Tactile stimulation in response to apnoea of prematurity - comparison between low- and high- resource settings

BACKGROUND Infants born before 28 weeks frequently have episodes of apnoea, but it can also affect term infants secondary to pathologies such as asphyxia, intracranial haemorrhage, convulsions and intoxication. In preterm infants, apnoea spells are due to immaturity of the development of the central respiratory drive, delayed chemoreceptor response, stimulation of reflexes (catheters, food...), respiratory muscle weakness, altered neurotransmitters, and genetic factors. Apnoea prevention and therapy include caffeine, Nasal Continuous Positive Airway Pressure (NCPAP), mechanical ventilation and blood transfusions (controversial). At birth, one of the key steps in apnoea episodes (primary apnoea) is tactile stimulation, but this procedure is most frequently applied in the neonatal intensive care unit (NICU). Tactile stimulation is performed in various modalities, as there are no guidelines recommending a specific technique. A previous study reports great heterogeneity of tactile stimulation technique among nurses in a NICU in the Netherlands, but there are no studies that have evaluated tactile stimulation in the NICU in low-resource countries. OBJECTIVE The aim of the study was to assess the methods of tactile stimulation in response to apnoea of prematurity of neonatal medical staff in low- and high- resource settings. METHODS The study was conducted in high-resource NICUs (University Hospital of Padova and Fondazione Poliambulanxa Hospital of Brescia) and low-resource NICUs (University Hospital of Tengandogo, Burkina Faso, Saint Camillo Hospital of Ouagadogou, Burkina Faso and the University Hospital of Maputo, Mozambique). The study design was an observational manikin study that assessed different modalities of tactile stimulation in a preterm infant and compared differences between low- and high- resource countries. The setting involved a preterm manikin placed supine in an incubator with a blanket under the shoulders to maintain a neutral position. The manikin's chest movements were controlled by the observer using an air pump. The scenario involved the researcher simulating an apnoea spell and asking participants to apply tactile stimulation to the manikin. RESULTS The study involved 112 health professionals who administered 26 different methods of tactile stimulation. The most frequent stimulation modalities were back rub (57%), feet massage (35%) and feet rub (25%). Stimulation techniques were found to be dependent on centre’s preferences and attitudes. In low-resource countries, health care providers stimulated more frequently chest (56%) and feet (56%) and back (39%), whereas in high-resource countries preferred feet stimulation (88%) and back stimulation (81%) and did not often stimulate chest (p<0.0001); in low-resource countries the most frequent technique was rub (48%) followed by press (44%) and massage (31%); also in high-resource countries used rub (79%) and massage (53%) most frequently, but they often used tickle stimulation (p<0,004). CONCLUSIONS The results of this multicentre study showed that medical staff uses many techniques to counter an apnoeic spell in preterm infants. The methods of stimulation are hospital-dependent and change according to the learning (during a training event or during clinical activity). There are also differences in procedure between operators in low- and high- resource settings. It is reasonable to assume that this variability is due to the lack of detailed and extensive guidelines. In order to identify the most effective technique of tactile stimulation in newborns, future clinical studies are needed.