By Marilynn Larkin
NEW YORK (Reuters Health) - Holding infants intubated in an intensive care unit (ICU) to increase early mobility was well tolerated by the infants and well received by nurses and parents, researchers say.
"The risks of holding infants on life support for respiratory failure are low, and there may be benefits for both infants and families," Dr. Laura Ortmann of Children's Hospital and Medical Center in Omaha, Nebraska, told Reuters Health by email. "Thus, doctors should consider letting families hold their infants while they are in the ICU."
"Some family and staff are nervous to hold infants while they are on the ventilator," said Dr. Ortmann, who was at Children's Mercy Hospital in Kansas City during the study. "That's one of the reasons we did this study - to show that it can be safely done and to encourage doctors and nurses to consider offering holding to families."
"It can be scary the first time," she acknowledged. "But once a parent gets to hold their sick baby, they don't want to put them down."
Dr. Ortmann and colleagues studied infants less than six months of age intubated for respiratory failure secondary to either viral or bacterial lower respiratory tract disease with an expected duration of mechanical ventilation of more than 48 hours.
The holding intervention involved a caretaker holding the infant at least twice a day for at least an hour once the infant was medically stabilized. Infants were screened daily to assess whether they met 10 criteria for physiologic tolerance of the intervention on that day.
The study was not randomized because the researchers believed parents would be unlikely to consent to a study in which they could be randomized to not hold their infant. Instead, the team used data from patients admitted in the previous two years to create a historical control group with the same inclusion and exclusion criteria, matched 1:1 by age and Pediatric Index of Mortality 2 risk of mortality percentage.
The standard of care for historical controls was for intubated infants to remain in bed; holding was rare. Nurse-to-patient ratios were not different between time periods.
As reported online December 1 in Critical Care Nurse, 24 infants undergoing 158 holding interventions were studied. The mean holding duration was 99 minutes.
Twenty holding interventions were terminated early, most commonly because of infant agitation. The 24 historical controls had one unplanned extubation and two arterial catheter removals. The intervention group had no unplanned extubations, inadvertent central catheter removals or urinary catheter removals, but there was one arterial catheter removal that was not associated with holding.
Vital signs before and during holding were similar between the groups. There were no between-group differences in duration of intubation: 7.3 days for controls versus 6.0 days for the intervention group. Similarly, there were no between-group differences in length of intensive care unit stay (9.1 vs. 9.0 days) or of hospital stay (11.5 vs. 12.5 days).
The authors conclude, "Holding intubated infants in the intensive care unit was well tolerated, without an increase in adverse events."
Dr. Ortmann said, "The intervention would be appropriate for any culture and country. Here at Children's Hospital and Medical Center, we are in the process of rolling out a comprehensive mobility program in our ICU that will include encouraging the holding of infants."
"We know that too much bed rest is bad for adults, and the same is true for children," she noted. "Admissions to a pediatric ICU are also psychologically hard for the parents of a sick child. Holding infants in the ICU can help both the infants and the parents during this scary time."
Dr. Arun Chopra, director of Pediatric Critical Care at NYU Langone's Hassenfeld Children's Hospital in New York City, commented by email, "This study was likely too small to demonstrate any small benefits for the children involved; however, the authors did comment on the positive effects on the parents."
"Because it is a single-center study, with selected patients, it isn't clear that this would be safely repeatable," he told Reuters Health. "However, based on the publication, it seems that it is feasible, and with careful implementation would likely be successful elsewhere. This study will likely lead to repeat trials that are powered to look for patient benefits."
"Beyond the science," he added, "parents holding their children has benefit to both parent and child, and if this can be done safely should be considered for more patients."
Crit Care Nurse 2019.