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Newborn-15- Paper Draft CC
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RECOVER 2.0 Worksheet
QUESTION ID: Newborn-15
PICO Question:
In newborn dogs and cats that require resuscitation (P), how does the use of no external physical stimulation (I), compared with tactile stimulation (e.g., rubbing) (C), improve outcome (O)?
Outcomes:
PaCO2, Oxygenation, Surrogate marker(s) of perfusion, Hospital length of stay, Favorable neurologic outcome, Survival to Discharge
Prioritized Outcomes (1= most critical; final number = least important):
- Favorable neurologic outcome
- Survival to discharge
- Surrogate markers of perfusion
- Oxygenation
- PaCO2
- Hospital length of stay
Domain chairs: Christopher Byers, Autumn Davidson; this Evidence Summary and final edit by Kate Farrell and Manu Boller
Evidence evaluators: Susanna Solbak, Eric Schroeder
Conflicts of interest: None reported
Search strategy: See attached document
Evidence Review:
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Study Design |
Reduced Quality Factors
0 = no serious, - = serious,
- - = very serious |
Positive Quality Factors
0 = none, + = one, ++ = multiple |
Dichotomous Outcome Summary |
Non-Dichotomous Outcome Summary
Brief description |
Overall Quality
High, moderate, low, |
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No of studies |
Study Type |
RoB |
Indirectness |
Imprecision |
Inconsistency |
Large Effect |
Dose-Response |
Confounder |
# Intervention with Outcome |
# Control with Outcome |
RR (95% CI) |
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Outcome: Favorable neurologic outcome, Survival to discharge, Surrogate markers of perfusion, PaCO2, Hospital length of stay - No information in the SoF, 0 studies identified. |
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0 |
N/A |
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None |
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Outcome: Oxygenation |
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2 |
ES |
- |
- - |
0 |
0 |
0 |
0 |
0 |
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Very low |
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1 |
OS |
- - |
- |
- |
0 |
0 |
0 |
0 |
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Very low |
PICO Question Summary
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Introduction |
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Human newborn resuscitation guidelines suggest stimulating newborn infants immediately after birth if they are apneic/not crying or are hypotonic (Wyckoff 2020, Guinsburg 2022). Expert consensus in human literature estimates that approximately 10% of newborns will require and respond to drying and stimulation to help initiate breathing and to assist in the transition from intrauterine to extrauterine life (Wyckoff 2020, Ersdal 2012). However, despite universal recommendations, almost no information is available on efficacy of these stimulation methods in any species, including newborn puppies and kittens. |
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Consensus on science |
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Outcomes 1-3: Favorable neurologic outcome, Survival to discharge, Surrogate markers of perfusion
For the critical outcomes of survival to discharge and favorable neurologic outcome, as well as the important outcome of surrogate markers of perfusion, we identified no studies addressing the question.
Outcome 4: Oxygenation
For the important outcome of oxygenation, we identified 1 observational study in people (very low quality of evidence, downgraded for very serious risk of bias and serious indirectness) (Baik-Schneditz 2018/paper 1790) and 2 experimental studies (very low quality of evidence, downgraded for serious risk of bias, very serious indirectness and imprecision) that addressed the question.( Scarpelli 1977/paper 1787, Faridy 1983/paper 1786) In the observational study, preterm newborn infants displayed a significant increase in SpO2 after tactile stimulation compared to before (from a median of 61.9% to 70.7%, p<0.001), but this was not observed in term newborns. (Baik-Schneditz 2018/paper 1790) This study lacked a control group without tactile stimulation, such that the effect of the intervention itself cannot be assessed. In one experimental lamb study, scratching and rubbing the skin of the lower leg of mature fetal lambs in utero induced sustained spontaneous regular breathing. (Scarpelli 1977/paper 1787). After the sciatic nerve was cut in these lambs, there was no breathing response to electrical stimulation, scratching, rubbing, or vibration of the skin, demonstrating the apparent role of the peripheral somatic nerve in the afferent pathway of this respiratory reflex. (Scarpelli 1977/paper 1787) This did not, however, affect oxygenation, as PaO2 and other parameters remained constant. In one experimental study in rats, maternal rats were observed to hold the head of newborns, clean their nares/mouth, and provide additional assistance or stimulation as needed in the form of licking, biting, pushing, or rolling (Faridy 1983/paper 1786). Rat pups removed from the mother to prevent cleaning/stimulation developed respiratory distress and cyanosis, though oxygenation was not further assessed (Faridy 1983/paper 1786).
Outcomes 5-6: PaCO2, Hospital length of stay
For the important outcomes of PaCO2 and hospital length of stay, we identified no studies addressing the question.
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Treatment recommendation |
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In newborn puppies and kittens that require resuscitation, we recommend the use of tactile stimulation (e.g., rubbing, drying) immediately after birth without delaying essential interventions such as PPV (strong recommendation, very low quality of evidence).
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Justification of treatment recommendation |
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While the characteristics and effectiveness of newborn tactile stimulation are rarely described in human or animal literature, it remains one of the most common interventions provided to newborns. Evidence examining the question is scarce and of very low quality and virtually absent for newborn puppies and kittens, but the preponderance suggests benefit. One additional observational study that was not captured in the original search, likely as it did not address one of the predetermined outcomes, includes 245 preterm infants and showed that tactile stimulation significantly reduces the risk for intubation (RR 0.41, 95% CI 0.20-0.85).( Dekker 2017) The intervention is of high feasibility and low risk as long as it is executed in a gentle, non-traumatic manner, and does not delay the institution of other life-saving interventions (e.g., PPV). Thus, the committee recommends its routine use immediately after birth.
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Knowledge gaps |
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There is no information on the optimal methods and timing of physical stimulation in newborns puppies or kittens, in addition to no information regarding efficacy of providing stimulation in these animals.
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Additional citations for this section:
● Ersdal HL, Mduma E, Svensen E, Perlman JM. Early initiation of basic resuscitation interventions including face mask ventilation may reduce birth asphyxia related mortality in low-income countries: a prospective descriptive observational study. Resuscitation. 2012;83:869– 873.
● Wyckoff MH, Wyllie J, Aziz K, de Almeida MF, Fabres JW, Fawke J, Guinsburg R, Hosono S, Isayama T, Kapadia VS, Kim HS, Liley HG, McKinlay CJD, Mildenhall L, Perlman JM, Rabi Y, Roehr CC, Schmölzer GM, Szyld E, Trevisanuto D, Velaphi S, Weiner GM; Neonatal Life Support Collaborators. Neonatal Life Support 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation. 2020 Nov;156:A156-A187. doi: 10.1016/j.resuscitation.2020.09.015. Epub 2020 Oct 21. PMID: 33098917.
● Guinsburg R, de Almeida MFB, Finan E, Perlman JM, Wyllie J, Liley HG, Wyckoff MH, Isayama T. Tactile Stimulation in Newborn Infants With Inadequate Respiration at Birth: A Systematic Review. Pediatrics. 2022 Apr 1;149(4):e2021055067. doi: 10.1542/peds.2021-055067. PMID: 35257181.
● Dekker J, Martherus T, Cramer SJE, van Zanten HA, Hooper SB, Te Pas AB. Tactile Stimulation to Stimulate Spontaneous Breathing during Stabilization of Preterm Infants at Birth: A Retrospective Analysis. Front Pediatr. 2017 Apr 3;5:61. doi: 10.3389/fped.2017.00061. PMID: 28421171; PMCID: PMC5377072.
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● Scarpelli 1977/paper 1787 (ES)
○ Mature fetal lambs (n=6) were investigated in utero
○ Scratching and rubbing the skin of the lower leg invariably induced sustained spontaneous regular breathing, which lasted a few seconds to 5 minutes (short-lived compared to electrical stimulation), whereas vibration of the skin had no effect
○ After the sciatic nerve was cut, there was no breathing response to electrical stimulation, scratching, rubbing, and vibration of the skin, demonstrating the apparent role of the peripheral somatic nerve in the afferent pathway of the respiratory reflex.
○ Evidence to support the clinical observation that cutaneous stimulation is effective for the treatment of apnea of prematurity
○ No changes in arterial blood pressure, PO2, PCO2, pH, body temp
○ A further animal study showed that somatic sensory stimulation significantly increased respiratory activity in mature apnoeic lambs
● Faridy 1983/paper 1786 (ES)
○ This observational study describes that Immediately after birth, the maternal rat holds the head of the newborn with both paws, cleans and sucks the nares and the mouth of the newborn.
○ It further describes that if, immediately after birth, a pup (rat) is removed from the mother, and prevented from being cleaned, it will develop respiratory distress with physical signs of mouth breathing, chest and abdominal, gasping and cyanosis.
○ This study also describes other types of tactile stimulation, such as when necessary, she presses the pup's chest with one paw for a few seconds, licks the spine from caudal to cervical region, which causes extension of the body and expansion of the chest, or bites the tail, which makes the newborn squeak, in addition to periodic pushing, rolling, licking, and biting. These observations are however not reported in relation to outcome measures for the neonate.
● Pietravalle 2018/paper 1789 (Obs) ???
○ Observational study in human neonates, received stimulation for apnea, hypotonia, or both
○ Low number of infants (9%) that responded to some form of tactile stimulation (stimulation considered as effective when it provided a complete newborn recovery, avoiding the need for PPV)
■ Techniques: rubbing thorax, abdomen, back, trunk, flicking feet
○ Recommended stimulation techniques were rarely performed, thus preventing any meaningful conclusions on efficacy; low adherence to the international guidelines in term of initiation, duration and method of stimulation
○ NO CONTROL, others got PPV
● Baik-Schneditz 2018/paper 1790 (Obs)
○ Preterm human neonates displayed a significant increase in SpO2 after tactile stimulation (from a median of 61.9% to 70.7%, p<0.001), compared to before tactile stimulation had been performed, but this was not observed in term human neonates.
○ 25 term, 18 pre-term infants born by C-section
In another human observational study, a low number of infants (9%) responded to tactile stimulation and avoided the need for positive pressure ventilation (Pietravalle 2018/paper 1789). However, there was no control group, recommended stimulation techniques were rarely performed, and oxygenation was not directly assessed (Pietravalle 2018/paper 1789).
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