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Kinesthetic stimulation for preventing apnea in preterm infants

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Authors

David A Osborn1, David J Henderson-Smart2

Background - Methods - Results - Characteristics of Included Studies - References - Data Tables & Graphs


1Royal Prince Alfred Newborn Care, Royal Prince Alfred Hospital, Camperdown, Australia [top]
2NSW Centre for Perinatal Health Services Research, Queen Elizabeth II Research Institute, Sydney, Australia [top]

Citation example: Osborn DA, Henderson-Smart DJ. Kinesthetic stimulation for preventing apnea in preterm infants. Cochrane Database of Systematic Reviews 2002, Issue 2. Art. No.: CD000373. DOI: 10.1002/14651858.CD000373.

Contact person

David A Osborn

Royal Prince Alfred Newborn Care
Royal Prince Alfred Hospital
Missenden Road
Camperdown
New South Wales
2050
Australia

E-mail: david.osborn@email.cs.nsw.gov.au

Dates

Assessed as Up-to-date: 21 October 2009
Date of Search: 15 October 2009
Next Stage Expected: 15 October 2011
Protocol First Published: Issue 2, 1996
Review First Published: Issue 4, 1997
Last Citation Issue: Issue 2, 2002

What's new

Date / Event Description
15 October 2009
Updated

This updates the review "Kinesthetic stimulation for preventing apnea in preterm infants" published in The Cochrane Library, Issue 2, 2002 (Henderson-Smart 2002).

No new eligible studies found in an updated search October 2009.

History

Date / Event Description
12 March 2008
Amended

Converted to new review format.

06 February 2002
New citation: conclusions changed

Substantive amendment

Abstract

Background

Recurrent apnea is common in preterm infants, particularly at very early gestational ages. These episodes of loss of effective breathing can lead to hypoxemia and bradycardia, which may be severe enough to require resuscitation including use of positive pressure ventilation or other treatments. Physical stimulation is often used to restart breathing and it is possible that repeated stimulation, such as with an oscillating mattress (kinesthetic stimulation), might prevent apnea and its consequences.

Objectives

To determine the effect of prophylactic kinesthetic stimulation on apnea and bradycardia and use of intermittent positive pressure ventilation (IPPV) in preterm infants at risk for apnea?

Search methods

The standard search strategy of the Cochrane Neonatal Review Group was used. This included searches of the Oxford Database of Perinatal trials, Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2009), MEDLINE (1966 to October 2009), EMBASE, CINAHL (1982 to October 2009), previous reviews including cross references, abstracts, conferences and symposia proceedings, expert informants, journal hand searching mainly in the English language.

Selection criteria

All trials in preterm infants at risk of developing clinical apnea which utilized random or quasi-random allocation to treatment with an oscillating mattress (or other forms of repetitive kinesthetic stimulation) or control, were eligible.

Data collection and analysis

Standard methods of the Cochrane Collaboration and its Neonatal Review Group were used with separate evaluation of trial quality and data extraction by each author and synthesis of the data using relative risk.

Results

Three trials enrolling a total of 154 babies were included in this review. There was no evidence of effect on short-term outcomes (apnea /bradycardia, IVH, use of IPPV, sleep/wake cycles and neurological status at discharge) or long-term outcomes (in one trial - growth and development to one year).

Authors' conclusions

Implications for practice. Prophylactic use of kinesthetic stimulation cannot be recommended to reduce apnea/bradycardia in preterm infants.

Implications for research. There are currently no clear research questions regarding prophylactic use of kinesthetic stimulation to prevent apnea in preterm infants.

Plain language summary

Kinesthetic stimulation for preventing apnea in preterm infants

Lying preterm babies on oscillating mattresses has not been shown to help prevent apnea. Physical stimulation arouses babies experiencing apnea (episodes where breathing stops), and babies still in utero are naturally stimulated by their mothers' movements. Thus, it has been thought that keeping the baby moving might prevent apnea and promote growth and development. Oscillating (moving) mattresses have sometimes been used for babies born too early (preterm) who are at risk of apnea. However, the review found that this has not been shown to be effective.

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Background

Description of the condition

Apnea in infants has been defined as a pause in breathing of greater than 20 seconds or one of less than 20 seconds and associated with bradycardia and/or cyanosis (Nelson 1978). Recurrent episodes of apnea are common in preterm infants and the incidence and severity increases at lower gestational ages. Although apnea can occur spontaneously and be attributed to prematurity alone, it can also be provoked or made more severe if there is some additional insult such as infection, hypoxemia or intracranial pathology (Henderson-Smart 1995).

Description of the intervention

Various treatments for apnea in preterm infants have been used, including physical stimulation by nursing staff, pharmacological stimulation including methylxanthines (HendersonSmart 2005a) and continuous positive airway pressure (CPAP) (HendersonSmart 2005b). Kinesthetic stimulation using various forms of oscillating mattress has been used in treatment for apnea, and compared to use of methylxanthines which are the subject of other Cochrane reviews (Osborn 2005a; Osborn 2005b). This review examines the effects of kinesthetic stimulation for prevention of apnea in preterm infants.

How the intervention might work

Physical stimulation by nursing staff is commonly used to arouse the apneic infant and so stimulate breathing. This raises the question of whether frequent physical stimuli might prevent the occurrence or reduce the number of apneic events. Furthermore, some believe that the preterm infant is deprived of the frequent stimuli that would be felt in utero and that substituting these with an oscillating mattress to provide kinesthetic stimulation might improve growth and development.

Why it is important to do this review

If prolonged, apnea can lead to hypoxemia and reflex bradycardia which may require active resuscitative efforts to reverse. There are clinical concerns that these episodes might be harmful to the developing brain or cause dysfunction of the gut or other organs. Frequent episodes may be accompanied by respiratory failure of sufficient severity as to lead to intubation and the use of intermittent positive pressure ventilation (IPPV).

Objectives

To determine the effect of prophylactic kinesthetic stimulation on apnea and bradycardia and use of intermittent positive pressure ventilation (IPPV) in preterm infants at risk for apnea?

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Methods

Criteria for considering studies for this review

Types of studies

All trials utilizing random or quasi-random patient allocation.

Types of participants

Preterm or low birth weight infants at risk of developing recurrent apnea/bradycardia.

Types of interventions

Kinesthetic stimulation (various forms of oscillating mattresses or other repetitive stimulation involving moving the baby) used as prophylaxis for recurrent apnea.

Types of outcome measures

Primary outcomes
  1. Apnea/bradycardia [consistent with an evaluation of 'clinical apnea', as defined by the American Academy of Pediatrics (see above)];
  2. Use of IPPV.
Secondary outcomes
  1. Rate of intraventricular hemorrhage;
  2. Neurodevelopmental status at follow-up.

Search methods for identification of studies

Electronic searches

The search was updated October 2009 including searches of CENTRAL (The Cochrane Library, Issue 3, 2009), EMBASE, MEDLINE, PREMEDLINE and CINAHL, supplemented by searches of abstracts of the Society for Pediatric Research hand searched for the years 2005 to 2009 inclusive and the Perinatal Society of Australia and New Zealand years 2000 to 2009.

An updated search was performed of MEDLINE and PREMEDLINE, EMBASE, CINAHL and CENTRAL (October 2009) using the search terms ['kinesthetic or (water bed) or (air bed) or oscillating or rocking or (vertical pulsating)] and [infant or neonat*] and [apnoea or apnea].

Original search: The standard search strategy of the Cochrane Neonatal Review Group was used. This included searches of the Oxford Database of Perinatal Trials, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 4, 2004), MEDLINE (1966 to December 2004), EMBASE (1966 to December 2004) and CINAHL (1982 to December 2004) were searched. Abstracts of the Society for Pediatric Research were hand searched for the years 1996 to 2004 inclusive.

The Cochrane Controlled Trials Register was searched using search terms 'kinesthetic', 'water bed', 'air bed', 'oscillating', '(apnoea or apnea) and (infant or preterm or neonate or newborn)', 'rocking', and 'vertical pulsating'.

MEDLINE was searched using MeSH headings 'apnea and infant-premature'; and text words 'kinesthetic', 'water bed', 'air bed', 'oscillating', '(apnea or apnoea) and (infant or preterm or neonate or newborn)', 'rocking', and 'vertical pulsating'.

The Oxford Database of Perinatal Trials was searched using search term 'apnea'.

Searching other resources

Additional searches were performed of previous reviews including cross references, abstracts, conferences and symposia proceedings, expert informants, and journal hand searching mainly in the English language. Abstracts of the Society for Pediatric Research were hand searched for the years 1996 to 2009 inclusive.

An updated search was performed of abstracts of the Pediatric Academic Society Conference and Perinatal Society of Australia and New Zealand (2005-2009).

Data collection and analysis

Standard methods of the Cochrane Collaboration and its Neonatal Review Group were used. The methodological quality of each trial was reviewed by the second author blinded to trial authors and institution(s). Additional information was obtained from authors to clarify methodology and to allow reanalysis of the raw data (Korner 1975, Jones 1981).

Each author extracted the data separately, then compared and resolved differences.

The standard method of Neonatal Review Group was used to synthesize the data using relative risk.

Selection of studies

Trial eligibility was assessed independently by both review authors. DIfferences were resolved through consensus.

Data extraction and management

Each review author extracted the data separately into a standard data table, then compared and resolved differences. Trial details were entered into 'table of included studies' and data into 'data and analyses' using RevMan software.

Assessment of risk of bias in included studies

The methodological quality of each trial was reviewed by the second author blinded to trial authors and institution(s). Each review author extracted the data separately, then compared and resolved differences. Studies were assessed for selection bias (blinding of randomisation), performance bias (blinding of intervention), attrition bias (complete follow-up), and detection bias (blinding of outcome measurement). Each criterion were characterized as Yes, Can’t tell, No.

In addition, for the update in 2009, the following issues were evaluated and entered into the Risk of Bias Table:

  1. Sequence generation: Was the allocation sequence adequately generated?
  2. Allocation concealment: Was allocation adequately concealed?
  3. Blinding of participants, personnel and outcome assessors: Was knowledge of the allocated intervention adequately prevented during the study? At study entry? At the time of outcome assessment?
  4. Incomplete outcome data: Were incomplete outcome data adequately addressed?
  5. Selective outcome reporting: Are reports of the study free of suggestion of selective outcome reporting?
  6. Other sources of bias: Was the study apparently free of other problems that could put it at a high risk of bias?

Measures of treatment effect

The standard method of the Neonatal Review Group to synthesise data was followed, using the fixed effects model to calculate relative risk (RR), risk difference (RD) and mean difference (MD) or weighted mean difference (WMD) where appropriate.

Unit of analysis issues

The unit of analysis was intended to be the unit of randomisation. For crossover trials, the data were extracted from all exposure periods and combined where appropriate.

Dealing with missing data

Authors of studies with missing data were contacted.

Assessment of heterogeneity

Heterogeneity was examined statistically in the 2009 update using the chi2 test for heterogeneity for statistical significance and the I2 test to quantify heterogeneity. The degree of heterogeneity was graded as: 0% to 30%: might not be important; 31% to 50%: moderate heterogeneity; 51% to 75%: substantial heterogeneity; 76% to 100%: considerable heterogeneity.

Data synthesis

The analysis was performed using Review Manager software (RevMan 5). The standard method of the Neonatal Review Group to synthesise data was followed, using the fixed effects model where appropriate. For estimates of typical relative risk and risk difference, we used the Mantel-Haenszel method. For measured quantities, used the inverse variance method.

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Results

Description of studies

Results of the search

In the 2009 update, no additional eligible studies were found. Two additional studies (Ludington-Hoe SM 2004; Chin 2006) were entered into 'excluded studies'.

Details of the three included studies (Korner 1975; Jones 1981; Saigal 1986) have been entered into to the included studies table.

Included studies

Each trial used a different form of kinesthetic stimulation. Korner 1975 examined the effect of an irregularly oscillating water bed (16/min); Jones 1981 examined the effect of a regularly oscillating water bed (12 - 14/min); and Saigal 1986 examined the effect of a regularly oscillating air bed (14 - 16 /min).

Apnea/bradycardia events were recorded by the nursing staff (monitor alarms due to episodes of heart rate < 100 and/or breathing frequency < 20) in the study by Korner et al: by both nursing observations (monitor alarms due to episodes of heart rate < 100 and/or apnea >> 15 second duration) and blindly assessed polygraphic recordings in the study by Saigal et al; and by blindly assessed polygraphic recordings (bradycardia to 80 or less) in Jones' study.

Saigal 1986 employed the most precise methodology with clear predetermined clinically relevant end points; power calculations and follow-up data were reported. Jones 1981 set out to examine apnea of prematurity using a randomized cross over design and additional data were provided from the author's MD Thesis.

The study by Korner 1975 was primarily concerned with examining the neurologic and behavioral maturation of the premature infant so there was no predetermined end point for apnea. A students T-Test had been used in the original paper, but the data were significantly skewed, especially for the control group. The raw data were kindly provided by the author of the latter trial that allowed calculation of dichotomous outcomes as for the other trials.

Excluded studies

The 15 excluded studies are listed in the Table of Excluded Studies. All but one were excluded because they did not report apnea/bradycardia as an outcome. None of these used oscillating mattresses. One (Clark 1989) used a rocking water mattress. The one study reporting apnea (Scafidi 1986) used a brief stimulation involving three five minute periods in which the limbs were moved three times per day. This was not considered to be consistent with repetitive stimulation aimed at preventing apnea. The main aim of this and other excluded studies was to improve growth and development and most used touch stimuli as the predominant intervention. This latter intervention is the subject of another Cochrane review (Vickers 2002).

The update search found 2 additional studies which examined the effect of co-bedding (Chin 2006) and kangaroo care (Ludington-Hoe SM 2004), both multicomponent interventions.

Risk of bias in included studies

Details of the methodological quality of each trial are given in the included studies table.

Allocation

The methods used for randomization were unclear in two studies (Korner 1975 and Jones 1981).

Blinding

Due to the nature of the treatment, this could not be blinded in any of the studies.

The primary outcomes of apnea/bradycardia were assessed blindly in Saigal 1986 and Jones 1981, but not in Korner 1975. All of the post-treatment assessments in Saigal 1986 were carried out blind.

Incomplete outcome data

Two infants were excluded after randomization in the Korner 1975 trial and Jones 1981 randomized three infants with clinical apnea (each acting as their own control) which are not analyzed here. In Saigal 1986, five infants were randomized but not included in the trial because there was no parental consent; all other treated and control infants were analyzed for neonatal outcomes and 75 and 76% in each group respectively were seen in follow up at one year.

Effects of interventions

Using categorical data on apnea/bradycardic episodes, neither the individual studies nor the meta-analysis showed a difference in the number of infants with more than four [typical RR 1.06 (0.82, 1.36)] (Outcome 1.1) or more than 10 [typical RR 0.84 (0.58, 1.23)] (Outcome 1.2) episodes per 24 hours at any time. There was no apparent heterogeneity between studies reporting apnea. There was no significant difference in the use of mechanical ventilation in the two groups (Outcome 1.3).

Saigal 1986 also examined the effect on intraventricular hemorrhage (IVH) and found no significant difference between groups (Outcome 1.4). Additional prescribed comparisons were made between the treatment and control groups in this study. These included weight and energy intake at various stages in the study, sleep state distribution on and after treatment, Albert Einstein Neurobehavioral Assessment Scale scores at term age, cardiovascular habituation to sound at three months past term age, and Bayley Scales of Infant Development at six and 12 months after term age. None were found to be different (Outcomes 1.5-1.7).

Discussion

Summary of main results

These trials do not indicate that prophylactic kinesthetic stimulation is of benefit to preterm infants in the prevention of recurrent apnea and bradycardia.

Only Saigal 1986 evaluated possible adverse effects such as disturbances in sleep/wake rhythms with kinesthetic stimulation and found none.

Overall completeness and applicability of evidence

The largest analysis included only 164 infants suggesting an inability to detect a moderate effect on apnea. However, there was no apparent heterogeneity between studies. A lack of effect of prophylactic kinesthetic stimulation in preterm infants at risk of apnea does not preclude a possible benefit of kinesthetic stimulation in the treatment of infants with established apnea of prematurity. This is the subject of separate reviews (Osborn 2005a, Osborn 2005b).

Kinesthetic stimulation and massage have been used to promote the growth and development of preterm infants and this is the subject of another Cochrane review (Vickers 2002).

Quality of the evidence

Only one study reported adequate allocation procedures, none blinding of intervention and two studies blinding of measurement of apnea.

Potential biases in the review process

Limitations of this review and meta-analysis are the combination of the results of trials that used different forms of kinesthetic stimulation, the use of different measures of apnea/bradycardia in each trial and the relatively small numbers of subjects. The exclusion of the Scafidi 1986 trial that used only brief periods of stimulation each day could be criticized (see Description of Studies section). They did report mean rates of apnea in the 10 day study period and found no difference between the stimulus and control groups.

Authors' conclusions

Implications for practice

Prophylactic use of kinesthetic stimulation cannot be recommended to reduce apnea/bradycardia in preterm infants.

Implications for research

There are currently no clear research questions regarding prophylactic use of kinesthetic stimulation to prevent apnea in preterm infants.

Acknowledgements

Thanks to Annaliese Korner and Rosamond Jones who provided methodological information and raw data from their trials, and to Dr. Saroj Saigal who provided further details on concealment of randomization.

The Cochrane Neonatal Review Group has been funded in part with Federal funds from the Eunice Kennedy Shriver National Institute of Child Health and Human Development National Institutes of Health, Department of Health and Human Services, USA, under Contract No. HHSN267200603418C.

Contributions of authors

DO and DHS performed all aspects of the review and review updates collaboratively.
Eligibility, critical appraisal and data extraction were performed independently by both reviewer authors with differences resolved by consensus.

Potential conflict of interest

  • None noted.

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Characteristics of studies

Characteristics of Included Studies

Jones 1981

Methods

Randomised controlled trial, crossover design.

Participants

Preterm infants (n = 11, acted as own controls) < 33 weeks gestation with < 3 apnea/bradycardias /day, not on treatment. Three additional infants with apnea on theophylline also randomised but not analysed here.

Interventions

Regularly oscillating water bed (12 to 14 cycles/min). Cross over design with 4 hr control period on same mattress without oscillations.

Outcomes

Bradycardias to 80/min or less (also measured apneas > 9 sec and bradycardias to 60 or less - not analysed here).

Notes

Additional methodological information and data were obtained from author's MD thesis.

Risk of bias table
Item Judgement Description
Adequate sequence generation? Unclear

Method of randomisation unclear.

Allocation concealment? Unclear

Unclear.

Blinding? (Treatment) No

Unable to be blinded.

Blinding? (All outcomes) Yes

Outcome apnea/bradycardia blindly assessed.

Incomplete outcome data addressed? Yes

All infants assessed.

Free of selective reporting? Yes

Korner 1975

Methods

Randomised controlled trial, parallel design.

Participants

Preterm infants (n = 21) 27 to 34 weeks gestation (mean 32 for case and 31 for control), no severe RDS, not small for gestational age and no congenital abnormalities.

Interventions

Irregularly oscillating water bed (14 cycles/min) compared with standard mattress.

Outcomes

All apnea / bradycardia (< 100 bpm) episodes over days 5 to 9 after birth, regardless of severity.

Notes

Additional information on methodology and the raw data sheets were provided by the author.

Risk of bias table
Item Judgement Description
Adequate sequence generation? Unclear

Method of randomisation unclear.

Allocation concealment? Unclear

Unclear.

Blinding? (Treatment) No

No blinding of treatment.

Blinding? (All outcomes) No

Outcome assessment not blinded.

Incomplete outcome data addressed? Unclear

2 infants excluded (sepsis, meningitis).

Free of selective reporting? Yes

Saigal 1986

Methods

Randomised controlled trial, parallel design.

Participants

Preterm infants (n = 122) 750 - 1250 g birthweight, less than 5 days of age. Infants with grades 3 or 4 IVH or congenital abnormalities were excluded.

Interventions

Regularly oscillating air mattress (14 - 16 cycles / min) compared with standard mattress.

Outcomes

Apnea > 14 sec, bradycardia < 100 bpm, (polygraph recordings), IVH after enrollment, polygraph of infant sleep and behavior before and 24 hrs after treatment, Albert Einstein Neonatal Neurobehavioral Scale at term equivalent age, Bayley Scales of Infant Development and growth at 6 and 12 months (all post treatment assessments performed blind).

Notes
Risk of bias table
Item Judgement Description
Adequate sequence generation? Yes

Sealed, opaque envelopes.

Allocation concealment? Yes

Adequate.

Blinding? (Treatment) No

Unable to be blinded.

Blinding? (All outcomes) Unclear

Assessment of apnea/bradycardia and sleep behavior after treatment blinded.

Incomplete outcome data addressed? No

5 infants not assessed for apnea/bradycardia and other neonatal outcomes, 76% for neurodevelopment.

Free of selective reporting? Yes

Characteristics of excluded studies

Barnard 1983

Reason for exclusion

Unclear as to whether RCT or not. Apnea/bradycardia not reported.

Chin 2006

Reason for exclusion

Randomised trial of cobedding of preterm infants - effects on growth and physiologic regulation. Multicomponent intervention, not only kinesthetic stimulation.

Clark 1989

Reason for exclusion

Rocking bed, measured weight gain and neurobehavior. Apnea/bradycardia not reported.

Deiriggi 1995

Reason for exclusion

Preterm infants, not a randomized trial. Examined heart rate and its variability before and on and after being placed on a non-oscillating water bed. Apnea/bradycardia not reported

Harrison 1996

Reason for exclusion

Gentle cutaneous stimulation rather than kinesthetic stimulation. Apnea/bradycardia not reported.

Hemingway 1991

Reason for exclusion

Non-oscillating water bed used to influence head moulding. No kinesthetic stimulation and apnea/bradycardia not reported.

Kadam 2005

Reason for exclusion

Randomised trial of kangaroo care in preterm infants reporting apnea. Multicomponent intervention, not only kinesthetic stimulation.

Kean 1999

Reason for exclusion

Cross over design with oxygen saturation as outcome. Apnea/bradycardia not reported.

Kramer 1976

Reason for exclusion

Rocking water bed and acoustic stimulation. Apnea/bradycardia not reported.

Kuhn 1991

Reason for exclusion

Quasi-randomized trial (enrolled in alternate weeks). Brief (5 min) limb movements plus 10 mins touch three times a day. Apnea/bradycardia not reported.

Ludington-Hoe 1994

Reason for exclusion

Single period of Kangaroo Care - not kinesthetic stimulation.

Ludington-Hoe SM 2004

Reason for exclusion

Randomised trial of kangaroo care in preterm infants reporting apnea. Multicomponent intervention, not only kinesthetic stimulation.

Rausch 1981

Reason for exclusion

Tactile and kinesthetic stimulation. Apnea/bradycardia not reported.

Rose 1980

Reason for exclusion

Tactile and vestibular stimulation. Behavioral outcomes. Apnea/bradycardia not reported.

Scafidi 1986

Reason for exclusion

Brief tactile and kinesthetic stimulation for 15 mins (kinesthetic for 5 min of this) 3 times per day.

White 1976

Reason for exclusion

Weight gain and feed intake main outcomes. Apnea/bradycardia not reported.

White-Traut 1988

Reason for exclusion

Behavioral outcomes. Apnea/bradycardia not reported.

White-Traut 1997

Reason for exclusion

Control and four treatment groups, one of which included vestibular stimulation, given for 15 minutes once per day for 4 days. Reported heart rate, respiratory rate, oxygen saturation and behavioral state. Apnea/bradycardia not reported.

White-Traut 1988a

Reason for exclusion

Pilot study to examine safety of Rice Infant Sensorimotor Stimulation Technique. Apnea/bradycardia not reported.

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References to studies

Included studies

Jones 1981

Published and unpublished data

* Jones RAK. A controlled trial of a regularly cycled oscillating waterbed and a non-oscillating waterbed in the prevention of apnoea in the preterm infant. Archives of Disease in Childhood 1981;56:889-91.

Jones RAK. Recurrent apnoea in preterm infants. MD Thesis, University of London 1981.

Korner 1975

Published and unpublished data

Korner AF, Kraemer HC, Haffner ME, Cosper LM. Effects of waterbed flotation on premature infants: a pilot study. Pediatrics 1975;56:361-7.

Saigal 1986

Saigal S, Watts JL, Campbell D. No immediate or long-term benefits with the use of an oscillating air mattress (OAM) in preterm infants: a randomized clinical trial. Pediatric Research 1986;20:384.

* Saigal S, Watts JL, Campbell D. Randomized clinical trial of an oscillating air mattress in preterm infants: Effect on apnea, growth, and development. Journal of Pediatrics 1986;109:857-64.

Watts JL, Saigal S, Campbell D. Randomized controlled trial of the prevention of apnea of prematurity by oscillating air mattress. Pediatric Research 1984;18:354.

Excluded studies

Barnard 1983

Barnard KE, Bee HL. The impact of temporally patterned stimulation on the development of preterm infants. Child Development 1983;54:1156-67.

Chin 2006

Chin SD, Hope L, Christos PJ. Randomized controlled trial evaluating the effects of cobedding on weight gain and physiologic regulation in preterm twins in the NICU. Advances in Neonatal Care 2006;6:142-9.

Clark 1989

Clark DL, Cordero L, Goss KC, Manos D. Effects of rocking on neuromuscular development in the premature. Biology of the Neonate 1989;56:306-14.

Deiriggi 1995

Deiriggi PM, Miles KE. The effect of waterbeds on heart rate in preterm infants. Scholarly Inquiry for Nursing Practice 1995;9:245-62.

Harrison 1996

Harrison L, Olivet L, Cunningham K, Bodin MB, Hicks C. Effects of gentle human touch on preterm infants: pilot study results. Neonatal Network 1996;15:35-42.

Hemingway 1991

Hemingway MM, Oliver SK. Water bed therapy and cranial molding of the sick preterm infant. Neonatal Network 1991;10:533-56.

Kadam 2005

Kadam S, Binoy S, Kanbur W, Mondkar JA, Fernandez A. Feasibility of kangaroo mother care in Mumbai. Indian Journal of Pediatrics 2005;72:35-8.

Kean 1999

Kean S. Effects on oxygen saturation levels of handling premature infants within the concepts of kinaesthetic infant handling: pilot study. Intensive & Critical Care Nursing 1999;14:214-25.

Kramer 1976

Kramer LI, Pierpont ME. Rocking waterbeds and auditory stimuli to enhance growth of preterm infants. Journal of Pediatrics 1976;88:297-9.

Kuhn 1991

Kuhn CM, Schanberg SM, Field T, Symanski R, Zimmerman E, Scafidi F, Roberts J. Tactile-kinesthetic stimulation effects on sympathetic and adrenocortical function in preterm infants. Journal of Pediatrics 1991;119:434-40.

Ludington-Hoe 1994

Ludington-Hoe SM, Thompson C, Swinth J, Hadeed AJ, Anderson GC. Kangaroo care: research results, and practice implications and guidelines. Neonatal Network 1994;13:19-27, 29-34.

Ludington-Hoe SM 2004

Ludington-Hoe SM, Anderson GC, Swinth JY, Thompson C, Hadeed AJ. Randomized controlled trial of kangaroo care: cardiorespiratory and thermal effects on healthy preterm infants. Neonatal Network - Journal of Neonatal Nursing 2004;23:39-48.

Rausch 1981

Rausch PB. Effects of tactile and kinesthetic stimulation on premature infants. Journal of Obstetric, Gynecologic, and Neonatal Nursing 1981;10:34-7.

Rose 1980

Rose SA, Schmidt K, Riese ML, Bridger WH. Effects of prematurity and early intervention on responsivity to tactual stimuli: a comparison of preterm and full-term infants. Child Development 1980;51:416-25.

Scafidi 1986

Field TM, Schanberg SM, Scafidi F, Bauer CR, Vega-Halr N, Garcia R, Nystrom J, Kuhn CM. Tactile/kinesthetic stimulation effects on preterm neonates. Pediatrics 1986;77:654-8.

* Scafidi FA, Field T, Schanberg SM, Bauer CR, Vega-Haghr N, Garcia R, Poirier J, Nystrom G, Kuhn CM. Effects of tactile/kinesthetic stimulation on the clinical course and sleep/wake behaviour of preterm neonates. Infant Behaviour and Development 1986;9:91-105.

White 1976

White JL, Labarba RC. The effects of tactile and kinesthetic stimulation on neonatal development in the premature infant. Developmental Psychobiology 1976;9:569-77.

White-Traut 1988

White-Traut RC, Goldman MBC. Premature infant massage: is it safe? Pediatric Nursing 1988;14:285-9.

White-Traut 1997

White-Traut RC, Nelson MN, Silvestri JM, Cunningham N, Patel M. Responses of preterm infants to unimodal and multimodal sensory intervention. Pediatric Nursing 1997;23:169-75.

White-Traut 1988a

White-Traut RC, Nelson MN. Maternally administered tactile, auditory, visual and vestibular stimulation: relationship to later interactions between mothers and premature infants. Research in Nursing & Health 1988;11:31-9.

Studies awaiting classification

  • None noted.

Ongoing studies

  • None noted.

Other references

Additional references

Henderson-Smart 1995

Henderson-Smart DJ. Recurrent apnoea. In: Ed Yu VYH, editor(s). Bailliere's Clinical Paediatrics. Vol. 3 No. 1 Pulmonary Problems in the Perinatal Period and their Sequelae. London: Bailliere Tindall, 1995:203-22.

HendersonSmart 2005a

Henderson-Smart DJ, Steer P. Methylxanthine treatment for apnea in preterm infants. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD000140. DOI: 10.1002/14651858.CD000140 .

HendersonSmart 2005b

Henderson-Smart DJ, Subramaniam P, Davis PG. Continuous positive airway pressure versus theophylline for apnea in preterm infants. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD001072. DOI: 10.1002/14651858.CD001072 .

Nelson 1978

Nelson NM. Members of the task force on prolonged apnea of the Americal Academy of Pediatrics. Pediatrics 1978;61:651-2.

Osborn 2005a

Osborn DA, Henderson-Smart DJ. Kinesthetic stimulation for treating apnea in preterm infants. Cochrane Database of Systematic Reviews 2002, Issue 2. Art. No.: CD000499. DOI: 10.1002/14651858.CD000499 .

Osborn 2005b

Osborn DA, Henderson-Smart DJ. Kinesthetic stimulation versus theophylline for apnea in preterm infants. Cochrane Database of Systematic Reviews 2002, Issue 2. Art. No.: CD000502. DOI: 10.1002/14651858.CD000502 .

Vickers 2002

Vickers A, Ohlsson A, Lacy JB, Horsley A. Massage for promoting growth and development of preterm and/or low birth-weight infants. Cochrane Database of Systematic Reviews 2002, Issue 2. Art. No.: CD000390. DOI: 10.1002/14651858.CD000390.pub2 .

Other published versions of this review

Henderson-Smart 1997

Henderson-Smart DJ, Osborn DA. Prophylactic kinesthetic stimulation in preterm infants at risk of apnea. Cochrane Database of Systematic Reviews 1997, Issue 4. Art. No.: CD000373. DOI: 10.1002/14651858.CD000373 .

Henderson-Smart 1999

Henderson-Smart DJ, Osborn DA. Prophylactic kinesthetic stimulation in preterm infants at risk of apnea. Cochrane Database of Systematic Reviews 1999, Issue 2. Art. No.: CD000373. DOI: 10.1002/14651858.CD000373 .

Henderson-Smart 2002

Henderson-Smart DJ, Osborn DA. Prophylactic kinesthetic stimulation in preterm infants at risk of apnea. Cochrane Database of Systematic Reviews 2002, Issue 2. Art. No.: CD000373. DOI: 10.1002/14651858.CD000373 .

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Data and analyses

1 Kinesthetic stimulation vs control

Outcome or Subgroup Studies Participants Statistical Method Effect Estimate
1.1 Apnea / bradycardia > 4 / day 3 165 Risk Ratio (M-H, Fixed, 95% CI) 1.06 [0.82, 1.36]
1.2 Apnea / bradycardia > 10 / day 3 165 Risk Ratio (M-H, Fixed, 95% CI) 0.84 [0.58, 1.23]
1.3 Use of IPPV 2 144 Risk Ratio (M-H, Fixed, 95% CI) 3.20 [0.34, 29.94]
1.4 IVH grade 3 or 4 1 122 Risk Ratio (M-H, Fixed, 95% CI) 1.33 [0.38, 4.73]
1.5 Neurological abnormality at 1 yr 1 92 Risk Ratio (M-H, Fixed, 95% CI) 0.73 [0.22, 2.41]
1.6 Mental Development Index at 1 yr 1 92 Mean Difference (IV, Fixed, 95% CI) 3.10 [-5.07, 11.27]
1.7 Psychomotor Development Index at 1 yr 1 92 Mean Difference (IV, Fixed, 95% CI) 4.90 [-1.45, 11.25]

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Sources of support

Internal sources

  • Neonatal Medicine, Royal Prince Alfred Hospital, Sydney, Australia
  • NSW Centre for Perinatal Health Services Research, Sydney, Australia

External sources

  • No sources of support provided.

This review is published as a Cochrane review in The Cochrane Library, Issue 1, 2010 (see http://www.thecochranelibrary.com External Web Site Policy for information). Cochrane reviews are regularly updated as new evidence emerges and in response to feedback. The Cochrane Library should be consulted for the most recent version of the review.