Advances in Neonatal Care (Adv Neonatal Care)

Publisher: National Association of Neonatal Nurses, Lippincott, Williams & Wilkins

Journal description

This exciting full-color journal is dedicated to improving the outcomes of infants and their families. As the official journal of the National Association of Neonatal Nurses, Advances in Neonatal Care presents scientifically sound, clinically relevant articles focusing on the interdisciplinary aspects of care. A rich variety of thought-provoking articles and features not only keep readers up-to-date on this challenging and rapidly changing field, but also promote new approaches to controversial issues. Many articles are enhanced by unique, online only video features.

RG Journal Impact: 0.84 *

*This value is calculated using ResearchGate data and is based on average citation counts from work published in this journal. The data used in the calculation may not be exhaustive.

RG Journal impact history

2017 RG Journal impactAvailable summer 2018
2015 / 2016 RG Journal impact0.84
2011 RG Journal impact0.84
2010 RG Journal impact0.73
2009 RG Journal impact0.67
2008 RG Journal impact0.62
2007 RG Journal impact1.06
2006 RG Journal impact0.78
2005 RG Journal impact0.90
2004 RG Journal impact0.47
2003 RG Journal impact0.31

RG Journal impact over time

RG Journal impact
RG Journal impact over timeGraph showing a linear path with a yearly representation of impact points of the journal

Additional details

Cited half-life5.50
Immediacy index0.06
Article influencedata not available
WebsiteAdvances in Neonatal Care website
Other titlesAdvances in neonatal care
Material typePeriodical, Internet resource
Document typeJournal / Magazine / Newspaper, Internet Resource

Publisher details

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Publications in this journal

  • Background: Premature infants are exposed to high levels of noise in the neonatal intensive care unit (NICU). Purpose: This study evaluated the effect of a relaxing music therapy intervention composed by artificial intelligence on respiratory rate, systolic and diastolic blood pressure, and heart rate. Methods: A double-blind, randomized, controlled trial was conducted in the NICUs of 2 general public hospitals in Andalusia, Spain. Participants were 17 healthy premature infants, randomly allocated to the intervention group or the control group (silence) at a 1:1 ratio. To be included in the study, the subjects were to be 32 to 36 weeks of gestation at birth (M = 32.33; SD = 1.79) and passed a hearing screening test satisfactorily. The intervention lasted 20 minutes, 3 times a day for 3 consecutive days, while infants were in the incubator. Infants' heart rate, respiratory rate, and blood pressure were assessed before and after each intervention session. Results: After each session, the respiratory rate decreased in the experimental group (main between-groups effect (F 1,13 = 6.73, P = .022, [eta]2partial = 0.34). Across the sessions, the heart rate increased in the control group (main between-groups effect, F1,11 = 5.09, P = .045, [eta]2partial = 0.32). Implications for Research: Future studies can use this music intervention to assess its potential effects in premature infants. Implications for Practice: Nurses can apply the relaxing music intervention presented in this study to ameliorate the impact of the stressful environment on premature infants.
  • The National Association of Neonatal Nurse Practitioners (NANNP) conducted its second workforce survey of certified neonatal nurse practitioners in the fall of 2016. National Association of Neonatal Nurse Practitioners partnered with the National Certification Corporation and the American Association of Nurse Practitioners to conduct this electronic survey, containing 69 questions and focusing on practice sites and total compensation packages (including benefits) and workforce deficits. Findings indicate a rising neonatal nurse practitioners (NNPs) position vacancy rate across the country. Regional salary data indicated that the southeast had lower compensation rates for NNPs, with regions 4 and 11 (South) having the lowest rates. A promising trend indicated that new graduate NNPs with a doctorate are earning more. The study findings indicate that tailoring benefit packages to the age and years of experience for the individual NNP may aid in recruiting and retaining NNPs in practice. For experienced NNPs, altered shift lengths (shorter), higher employer matching rates in retirement plans, and less employee cost sharing for health insurance benefits are more appealing strategies. It is critical for NNPs to continually evaluate the profession's workforce data. There are more than 205,000 nurse practitioners practicing in the United States, with neonatal NPs making up approximately 3% of the larger whole. Increased participation in future surveys will assist in creating sustainable solutions to the workforce crisis facing the profession.
  • Background: Current practice for diagnosing neonatal abstinence syndrome and guiding pharmacological management of neonatal drug withdrawal is dependent on nursing assessments and repeated evaluation of clinical signs. Purpose: This single-center quality improvement initiative was designed to improve accuracy and consistency of Finnegan scores among neonatal nurses. Methods: One-hundred seventy neonatal nurses participated in a single-session withdrawal-assessment program that incorporated education, scoring guidelines, and a restructured Finnegan scale. Nurses scored a standardized video-recorded infant presenting with opioid withdrawal before and after training. Results: Nearly twice as many nurses scored at target (Finnegan score of 8) posttraining (34.7%; mean error = 0.559, SD = 1.4) compared with pretraining (18.8%; mean error = 1.31, SD = 1.95; Wilcoxon, P < .001). Finnegan scores were significantly higher than the target score pretraining (mean = 9.31, SD = 1.95) compared with posttraining (mean = 8.56, SD = 1.40, Wilcoxon P < .001); follow-up assessments reverted to pretraining levels (mean = 9.16, SD = 1.8). Score dispersion was greater pretraining (variance 3.80) compared with posttraining (variance 1.96; Kendall's Coefficient, P < .001) largely due to score disparity among central nervous system symptomology. Implications for practice: Education, clinical guidelines, and a restructured scoring tool increased consistency and accuracy of infant withdrawal-assessments among neonatal nurses. However, more than 60% of nurses did not assess withdrawal to the target score immediately following the training period and improvements did not persist over time. Implications for research: This study highlights the need for more objective tools to quantify withdrawal severity given that assessments are the primary driver of pharmacological management in neonatal drug withdrawal.
  • Background: The basic principles of family-centered care in neonatal intensive care unit (NICU) include the unlimited presence of parents and their participation in infant's care. Nurses play a central role in encouraging parental attachment with their infant. Purpose: This study was carried out with the aim of understanding NICU nurses' lived experiences of family participation in family-centered care. Methods: This interpretative phenomenological study was conducted on the basis of Heideggerian philosophy. The data were collected using semistructured interviews and field notes and analyzed through the 7-stage Diekelmann, Allen, and Tanner approach. Findings: Two overarching themes emerged including "mother's centrality in the care chain" and "fathers; the lost ring in the care chain" each of which consisted of 3 and 4 subthemes, respectively. Interviews indicated that in Iran's NICUs, conditions for the presence of parents were appropriate for the mothers and they were encouraged to engage in family-centered care but the fathers' participation was limited due to traditional attitudes, cultural-religious background, and difficulties relating to the hospitals' organizational rules. Implications for practice: Fathers' participation in family-centered care seems to be enhanced through providing facilities, altering the organizational rules, attempting to modify traditional social attitudes, and educating parents and nurses. Implications for research: Future research should explore the experience of mothers and fathers of infants in NICU in Iran to achieve a comprehensive understanding of their role in family-centered care.
  • Background: Although oxygen is the most widely used therapeutic agent in neonatal care, optimal oxygen management remains uncertain. Purpose: We reviewed oxygen physiology and balance, key studies evaluating oxygen saturation targets, and strategies for oxygen use in the neonatal intensive care unit. Results: Oxygen is a potent vasodilator involved in the transition at birth to breathing. Supplemental oxygen is administered to reverse/prevent hypoxia; however, excessive oxygen can be toxic owing to the formation of reactive oxygen species. Current neonatal resuscitation guidelines recommend using room air for term infants in need of support, with titration to achieve oxygen saturation levels similar to uncompromised term infants. In premature infants, targeting a higher oxygen saturation range (eg, 91%-95%) may be safer than targeting a lower range (eg, 85%-89%), but more evidence is needed. In combined analyses, lower oxygen saturation levels increased mortality, suggesting that the higher target may be safer, but higher targets are associated with an increased risk of developing disorders of oxidative stress. Implications for practice: Need for supplemental oxygen should be assessed according to the American Heart Association guidelines. If appropriate, oxygen should be administered using room air, with the goal of preventing hypoxia and avoiding hyperoxia. Use of oximeter alarms may help achieve this goal. Pulmonary vasodilators may improve oxygenation and reduce supplemental oxygen requirements. Implications for research: Implementation of wider target ranges for oxygen saturation may be more practical and lead to improved outcomes; however, controlled trials are necessary to determine the impact on mortality and disability.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.
  • Background: Parents who experience a perinatal loss often leave the hospital with empty arms and no tangible mementos to validate the parenting experience. Opportunities to create parenting experiences with transitional objects exist following the infant's death. Purpose: This article offers suggestions for staff in units where infant loss is possible to best assist parents in optimal grieving through the offering of transitional bereavement objects. Methods/search strategy: CINAHL Complete, MEDLINE, and the Cochrane Database of Systematic Reviews were searched using the following key words-perinatal bereavement, grief, perinatal loss, transitional objects, bereavement photography-and the search was limited to 5 years and the English language. Findings/results: Recommendations exist and are well supported by leading neonatal and perinatal nursing and medicine organizations for the use of transitional objects to facilitate healthy grieving when parents experience perinatal loss. Transitional objects are mementos that validate the meaning of parenthood-even if the physical act of parenting was brief. Nursing and medical staff have significant roles in guiding parents to a healthy state of bereavement and ultimately managing long-term grief. Implications for practice: Transitional objects can be provided by staff that are low-cost or free, such as taking photographs for parents, or they can involve purchased products from perinatal bereavement programs. In the latter case, funding needs are a consideration for budgeting decisions. Implications for research: Immediately following a loss, parents experience a brief sense of healing after receiving mementos of their infant. However, further research is needed to assess long-term effects of receiving transitional objects following perinatal loss.
  • Background: Secondary traumatic stress is an occupational hazard for healthcare providers who care for patients who have been traumatized. This type of stress has been reported in various specialties of nursing, but no study to date had specifically focused on neonatal intensive care unit (NICU) nurses. Purpose: (1) To determine the prevalence and severity of secondary traumatic stress in NICU nurses and (2) to explore those quantitative findings in more depth through nurses' qualitative descriptions of their traumatic experiences caring for critically ill infants in the NICU. Methods: Members of NANN were sent e-mails with a link to the electronic survey. In this mixed-methods study, a convergent parallel design was used. Neonatal nurses completed the Secondary Traumatic Stress Scale (STSS) and then described their traumatic experiences caring for critically ill infants in the NICU. SPSS version 24 and content analysis were used to analyze the quantitative and qualitative data, respectively. Results: In this sample of 175 NICU nurses, 49% of the nurses' scores on the STSS indicated moderate to severe secondary traumatic stress. Analysis of the qualitative data revealed 5 themes that described NICU nurses' traumatic experiences caring for critically ill infants. Implications for practice: NICU nurses need to know the signs of secondary traumatic stress that they may experience caring for their critically ill infants. Avenues for dealing with the stress should be provided. Implications for research: Future research with a higher response rate to increase the external validity of the findings to the population of neonatal nurses is needed.
  • Background: Premature and other at-risk infants can experience cardiorespiratory problems when positioned in their car seats. The American Academy of Pediatrics recommends that all premature and at-risk infants undergo a period of observation in their car seat to monitor for apnea, bradycardia, and oxygen desaturation before hospital discharge. This Infant Car Seat Challenge (ICSC) is used to determine readiness for infant travel in a car seat. Infants failing the ICSC are discharged home in car beds and referred for a follow-up screen in the outpatient clinic. Purpose: The purpose of this study was to identify predictors for infants failing the follow-up ICSC after hospital discharge. Methods/search strategy: A retrospective, cross-sectional study design was used to examine charts of 436 infants referred from across New England, to Boston Children's Hospital's, Center for Healthy Infant Lung Development clinic between August 2008 and May 2015 for a follow-up ICSC. Findings/results: Infants who failed the follow-up ICSC had statistically significant lower weights (0.27 ± 0.14 kg, difference ± standard error, P = .03) and younger postmenstrual ages (0.9 ± 0.4 weeks, P = .03). History of a cardiac condition (odds ratio, 3.6; 95% confidence interval, 1.5-8.5; P = .005) and respiratory illness (odds ratio, 2.1; confidence interval, 1.1 to 4.2; P = .03) were significant predictors of ICSC failure. Implications for practice: A follow-up ICSC is recommended for the safe transition of infants from a car bed to a car seat. Implications for research: Further research is needed to investigate the causes of ICSC failure among high-risk infant populations.
  • Background: Parental presence in the neonatal intensive care unit (NICU) is essential for families to participate in infant care and prepare them to transition from hospital to home. Nurses are the principal caregivers in the NICU. The nurse work environment may influence whether parents spend time with their hospitalized infants. Purpose: To examine the relationship between the NICU work environment and parental presence in the NICU using a national data set. Methods: We conducted a cross-sectional, observational study of a national sample of 104 NICUs, where 6060 nurses reported on 15,233 infants cared for. Secondary analysis was used to examine associations between the Practice Environment Scale of the Nursing Work Index (PES-NWI) (subscale items and with a composite measure) and the proportion of parents who were present during the nurses' shift. Results: Parents of 60% (SD = 9.7%) of infants were present during the nurses' shift. The PES-NWI composite score and 2 domains-Nurse Participation in Hospital Affairs and Manager Leadership and Support-were significant predictors of parental presence. A 1 SD higher score in the composite or either subscale was associated with 2.5% more parents being present. Implications for practice: Parental presence in the NICU is significantly associated with better nurse work environments. NICU practices may be enhanced through enhanced leadership and professional opportunities for nurse managers and staff. Implications for research: Future work may benefit from qualitative work with parents to illuminate their experiences with nursing leaders and nurse-led interventions in the NICU and design and testing of interventions to improve the NICU work environment.
  • Background: Feeding interventions for preterm infants aim to reduce the physiologic stress of feeding to promote growth. Heart rate variability (HRV) is a potential noninvasive measure of physiologic stress that may be useful for evaluating efficacy of feeding interventions. Purpose: To evaluate whether HRV is a sensitive measure of physiologic stress compared with standard physiologic outcomes in the context of a feeding intervention study. Methods: This was a secondary analysis of a within-subjects, cross-over design study comparing usual care feeding with a gentle, coregulated (CoReg) feeding approach in 14 infants born less than 35 weeks' postmenstrual age. HRV indices were calculated from electrocardiogram data and compared with standard physiologic outcomes, including oxygen saturation (Spo2), respiratory rate (RR), apnea, heart rate (HR), and bradycardia. Data were analyzed using linear mixed modeling. Results: Infants fed using the CoReg approach had fewer apneic events and higher RR, suggesting they were able to breathe more during feeding. No statistically significant differences were found in SpO2, HR, bradycardia, or high frequency power (the most commonly reported measure of HRV). Infants fed using the usual care approach had significantly higher SD12, a measure of HRV indicating randomness in the HR, which is a potential indicator of elevated stress. Implications for practice: SD12 was more sensitive to stress than SpO2, HR, and bradycardia. The utility of HRV as a measure of feeding outcomes in clinical practice needs further exploration. Implications for research: Further exploration of HRV as an intervention outcome measure is needed, particularly evaluating nonlinear indices, such as SD12.
  • Background: Effective basic newborn resuscitation is an important strategy to reduce the incidence of birth asphyxia and associated newborn outcomes. Outcomes for newborns can be markedly improved if health providers have appropriate newborn resuscitation skills. Purpose: To evaluate the skills of midwives in newborn resuscitation in delivery rooms in Jordan. Methods: Data were collected from observation of 118 midwives from National Health Service hospitals in the north of Jordan who performed basic newborn resuscitation for full-term neonates. A structured checklist of 14 items of basic skills of resuscitation was used. Descriptive statistics were used to analyze the data. Results: The results highlighted the lack of appropriate performance of the 8 necessary skills at birth by midwives. About 17.8% of midwives had performed the core competencies at birth (ie, assessing breathing pattern/crying, cleaning airways) appropriately and met the standard sequence. Less than half of midwives assessed skin color (40.7%) and breathing pattern or crying (41.5%) appropriately with or without minor deviations from standard sequences. Of the 6 skills that had to be performed by midwives at 30 seconds up to 5 minutes after birth, 4 skills were not performed by about one-quarter of midwives. Implications for practice and research: The midwives' practices at the 2 hospitals of this study were not supported by best practice international guidelines. The study showed that a high proportion of midwives had imperfect basic newborn resuscitation skills despite a mean experience of 8 years. This highlights the critical need for continuing medical education in the area of basic newborn resuscitation. The results highlight the need for formal assessment of midwives' competence in basic newborn resuscitation. National evidence-based policies and quality assurance are needed to reflect contemporary practice.
  • Background: Preterm infants often receive blood transfusions during hospitalization. Although transfusions are intended to enhance oxygen delivery, previous studies found decreases in tissue and mesenteric oxygen saturation during and after blood transfusions without changes in vital signs and hemoglobin oxygen saturation. Purpose: To study the effect of blood transfusions on regional mesenteric tissue oxygen saturation (rSO2), hemoglobin saturation of oxygen (SpO2), and heart rate (HR) in premature infants. Method: A prospective, observational, nonrandomized study using a repeated-measures design was done to evaluate changes in physiologic variables (HR, SpO2, rSO2) before, during, and after a blood transfusion in premature infants. Results: A convenience sample of 30 infants with a mean gestational age of 25.5 (2.1) weeks was recruited. Repeated-measures analysis of variance found no significant differences in HR (P = .06) and SpO2 (P = .55) over time. However, significant differences occurred in rSO2 over the 3 time periods (P < .001). The rSO2 increased during the transfusion from 40.3% to 41.5%, but decreased to 34.9% in the posttransfusion period. Pairwise comparisons revealed statistically significant mean rSO2 differences between pretransfusion and posttransfusion (P < .001), and during transfusion to posttransfusion (P < .001) periods. Implications for research: This study supports previous findings of perfusion changes during blood transfusions in preterm infants. Implications for practice: Measuring mesenteric tissue oxygenation during blood transfusion in very low-birth-weight infants can potentially add another physiologic parameter to guide further clinical assessment and interventions during transfusions.
  • Background: Transient asymptomatic neonatal hypoglycemia (TANH) is common as infants transition from their mother's energy stores to their own. There is little evidence supporting the blood glucose threshold that indicates a need for treatment although sustained hypoglycemia has been correlated with negative neurodevelopmental consequences. Treatment of TANH includes a stepwise approach from supplemental enteral feedings, buccal glucose gel, intravenous dextrose infusion, and/or transfer to special care units including neonatal intensive care units. Purpose: The purpose of this evidence-based practice brief is to review current evidence on 40% buccal glucose gel administration as a treatment strategy for TANH. Methods/search strategy: CINAHL, Cochrane, Google Scholar, and PubMed were searched using the key words and restricted to English language over the last 7 years. Findings/results: The use of buccal dextrose gel for TANH may reduce neonatal intensive care unit admissions, reduce hospital length of stay and cost, support the mother-infant dyad through reduced separation, support exclusive breastfeeding, and improve parental satisfaction without adverse neurodevelopmental consequences. Implications for practice: Timely collection of blood glucose levels following intervention is critical to support clinical decisions. Clinicians should offer family education regarding the rationale for serial glucose monitoring and treatment indications including buccal glucose administration. Clinical protocols can be revised to include use of buccal dextrose gel. Implications for research: There is a need for rigorous long-term studies comparing treatment thresholds and neurodevelopmental outcomes among various treatment strategies for TANH.
  • Background: Although technological advances have improved devices used to maintain the temperatures of 500- to 1500-g infants, managing the thermal environment remains challenging. Purpose: To evaluate the effects of 2 methods of thermal support provided by a hybrid incubator during routine care in the first week of life. Methods: This descriptive, comparative study evaluates changes in temperature, humidity, heart rate, and oxygen saturation in the incubator versus radiant warmer (canopy) modes of hybrid warmers using data downloaded from the incubator and the monitor. The impact of the Boost Curtain on temperature when opening the portholes during the incubator mode was also examined. Mixed-effects linear models and the log-rank test were used to analyze patient data to determine the effect of thermal support on temperature and humidity changes during care, as well as during the postcare period. Results: Entering the incubator through the portholes improved temperature control compared with using the canopy mode. The Boost Curtain resulted in an overall temperature stability and heat gain. Implications for practice: Nurses caring for premature infants in hybrid incubators should minimize incubator openings and utilize portholes rather than the canopy whenever practical. The Boost Curtain should be used when opening the portholes during the incubator mode. Implications for research: Comparing time, accuracy, and tolerance of procedures in the canopy versus incubator modes would improve nurses' ability to determine the best approach for different clinical scenarios.
  • Background: Diuretics are among the most frequently prescribed medications in the neonatal intensive care unit (NICU), despite minimal data regarding the safety and efficacy of their use in the neonatal population. Off-label diuretic therapy is used in preterm and full-term infants to both optimize kidney function and improve respiratory status. Purpose: This article examines the literature specific to the impact of diuretic therapy in the NICU and compares the benefits versus risks of utilization as they pertain to the prevention and treatment of renal and pulmonary dysfunction in this population. Methods/search strategy: A comprehensive literature search of online databases was performed, utilizing: CINAHL via EBSCO, PubMed, and ProQuest. Full-text, peer-reviewed, clinical trials, and review articles published in the English language between 2005 and 2015 were searched. Findings/results: Diuretics rank as the seventh most frequently prescribed medication in the NICU. More than 8% of all NICU patients and 37% of infants born at less than 32 gestational weeks and weighing less than 1500 g are exposed to diuretics. Benefits include lung fluid resorption acceleration, improved urine output, fluid retention counteraction, and augmentation of physiologic weight loss. Implications for practice: Diuretics are currently utilized in the NICU at an alarming rate, without adequate clinical trials regarding their safety and efficacy of use. Implications for research: Updated studies are needed regarding short- and long-term outcomes of diuretic use, as well as overall general outcome data regarding the impact and evaluation of diuretic usage in the NICU population.
  • Background: More than 95% of higher-order multiples are born preterm and more than 90% are low birth weight, making this group of infants especially vulnerable to sudden infant death syndrome (SIDS). Emerging evidence suggests that families with twins face challenges adhering to the American Academy of Pediatrics (AAP) recommendations to reduce SIDS risks. Adherence to the AAP recommendations in families with higher-order multiples has not been described. Purpose: This study describes SIDS risk reduction infant care practices for higher-order multiples during the first year of life. Methods: Mothers caring for higher-order multiple-birth infants were recruited from an online support group. An online survey was used to assess infant care practices when the infants were first brought home from the hospital as well as at the time of the survey. Results: Ten mothers of triplets and 4 mothers of quadruplets responded. Less than 80% of the mothers practiced "back to sleep" immediately postdischarge. Supine sleep positioning decreased over time, particularly during daytime naps. Only 50% of the infants shared the parents' bedroom and approximately 30% bed-shared with their siblings. Sleep-time pacifier use was low. Implications for practice: Safe sleep education must include specific questions regarding home sleeping arrangements, encouragement of breast milk feedings, supine positioning, and pacifier use at every sleep for higher-order multiple infants well before discharge in order for parents to plan a safe sleep environment at home. Implications for research: Prospective studies to identify barriers and facilitators can inform future strategies supporting adherence to safe sleep practices for higher-order multiple infants.
  • Background: Standardized late preterm infant (LPI) discharge criteria ensure best practice and help guide the neonatal provider to determine the appropriate level of care following birth. However, the location can vary from the well newborn setting to the neonatal intensive care unit (NICU). Purpose: The purpose of this review is to examine differences in LPI discharge criteria between the well newborn setting and the NICU by answering the clinical questions, "What are the recommended discharge criteria for the LPI and do they differ if admitted to the well newborn setting versus the NICU?" Search strategy: Databases searched include CINAHL, TRIP, PubMed, and the Cochrane Library. Focusing first on the highest level of evidence, position statements, policy statements, and clinical practice guidelines were reviewed, followed by original research. Results: There were few differences shown between settings. Discharge criteria included physiological stability and completed screenings for hearing loss, hyperbilirubinemia, car seat safety, hypoglycemia, critical congenital heart disease, and sepsis. Parent education is provided on umbilical cord care, feeding, elimination, and weight gain norms. Recommended maternal assessment included screenings for depression, drug use, safe home environment, and presence of social support. In general, research supported protecting the mother-infant dyad. Implications for practice and research: Developing a standardized approach for discharge criteria for LPIs may improve outcomes and reduce maternal stress. Research is needed to compare health and cost outcomes between settings.
  • Background: Neonatal abstinence syndrome (NAS) is a growing problem in the United States, affecting 32,000 infants annually. Although breastfeeding would benefit infants with NAS, rates among these mothers are low. Purpose: The purpose of this quality improvement project was to increase breastfeeding rates and decrease hospital length of stay (LOS) for infants with NAS through prenatal breastfeeding initiatives. Method: A pre-/postquality improvement design was used to assess the relationship between breastfeeding initiatives on breastfeeding rates and LOS in infants with NAS. A 3-class curriculum was offered to pregnant women at risk for delivering an infant with NAS. Chart review was completed for all infants evaluated for NAS in a hospital at baseline (n = 56), after Baby Friendly Status (BFS) (n = 75), and after BFS plus breastfeeding education (n = 69). Results: Although not statistically significant, the BFS plus breastfeeding education cohort had the largest percentage of exclusively breastfed infants during hospitalization (24.6%) and at discharge (31.9%). There was a statistically significant decrease in LOS (P< .001) between cohorts. Implications for practice: The small sample made it not possible to infer direct impact of the intervention. However, results suggest that prenatal education may contribute to an increase in the numbers of infants with NAS who receive human milk and a decrease in hospital LOS. Implication for research: Refinement of best practices around breastfeeding education and support for mothers at risk of delivering an infant with NAS is recommended so that breastfeeding may have the greatest impact for this subgroup of women and their infants.
  • Background: Structured training courses have shown to improve patient outcomes; however, guidelines are inconsistently applied in up to 50% of all neonatal resuscitations. This is partly due to the fact that psychomotor skills needed for resuscitation decay within 6 months to a year from the completion of a certification course. Currently, there are no recommendations on how often refresher training should occur to prevent skill decay. Purpose: Improve provider proficiency and confidence in the performance of neonatal resuscitation with a focus on chest compression effectiveness. Methods: The study recruited neonatal intensive care unit providers (n = 25). A simulation-based Neonatal Resuscitation Program (NRP) curriculum was developed and executed. Training sessions were delivered utilizing in situ simulations at varying time intervals. Pre- and postconfidence surveys and practicum skill scores were collected and evaluated by a content expert. Categorical data were summarized by frequency and percentage and tested for distributional equality via Pearson chi-square tests or Fisher exact tests depending on cell sample size distribution. All statistical tests were 2-sided with P < .05 considered statistically significant. Results: Provider overall confidence and rate of chest compressions improved; however, there was no statistically significant difference between groups. Rolling refresher training at varied time intervals did not demonstrate statistically significant differences in chest compression quality among NRP providers. Implications for practice: Rolling refresher training more frequently than every 6 months may not provide added benefit to NRP providers. Implications for research: Additional research is needed to determine optimal refresher training frequency to prevent skill decay.
  • Background: Previous research has reported that infants fed donor milk grow slower than those fed formula. However, most of the trials used unfortified donor milk, which limits the ability to generalize the results to current clinical practice. Purpose: To evaluate the impact of early human milk feeding (donor milk and/or mother's own milk) with standard fortification on in-hospital growth of very low-birth-weight infants. Methods: This pre-/postretrospective study included selected newborn infants less than 1500 g admitted to a level IV neonatal intensive care unit before and after the introduction of a policy providing donor milk when mother's own milk was not available in sufficient quantity to meet her infant's need. When enteral feeds reached 80 mL/kg per day, all human milk was fortified. Results: Seventy-two “before” (any formula-fed) and 114 “after” (human milk-fed) infants were enrolled in this study. Infant characteristics and neonatal morbidity were similar in both groups. Outcomes revealed that an initial human milk diet with standard fortification was associated with significantly higher early extrauterine weight gain and head growth in very low-birth-weight infants than a formula-fed diet. Implications for Practice: Very early initiation of fortified breast and/or donor milk feeding can help promote in-hospital head growth and weight gain of preterm infants. Formula may not be appropriate for early use among preterm infants. Implications for Research: Further large-scale clinical trials are needed to determine the best initiation and composition of enteral feeding for preterm infants.
  • Background: Maintaining normothermia and prevention of hypothermia are critical determinants of morbidity and mortality in infants. Noninvasive monitoring of skin temperature using skin temperature probes (STPs) has been a practice in neonatal intensive care units (NICUs) for decades. Incubators and radiant warmers use feedback mechanisms from the STP readings to determine the heat output to maintain normothermia. Placing the STP on an ideal site on the infant's body is essential for optimum servo control of the temperature. More importantly, where is the ideal site for the STP placement? Clinical practice guidelines (CPGs) vary on information regarding the site and proper placement of the STPs. The literature is analyzed to identify evidence for the ideal STP placement on infants in NICUs. Purpose: To review the literature for evidence for ideal placement for skin temperature probe placement on an infant. Search strategy: OVID/MEDLINE, CINAHL, Cochrane databases, and CPGs were searched to identify research, literature reviews, and guidelines for ideal sites for STP placement. Twenty documents were reviewed. Results: Guidelines vary in suggested sites for STP placement. The majority of the studies compared temperature measurement between abdomen and axilla. Although a Cochrane review found abdominal skin as an ideal site, other studies did not find any difference between axially and abdominal skin temperature measurements. Implications for practice and research: Placing the STP on an ideal site is essential for accurate and safe monitoring of skin temperature in infants. NICU nurses are uniquely positioned to undertake research to identify the ideal site for STP placement to guide safe practice and impact optimal neonatal outcome.
  • Background: Newborn screening programs provide testing for all newborns born in this country for conditions that can potentially cause death or disability. Currently each state is responsible for its programs and the number of disorders screened varies from state to state. The current universal recommended metabolic screening panel may include 32 to 58 disorders. Expansion of the programs has impacted the role of nurses in the neonatal intensive care units (NICUs). Nurses are responsible for facilitating the screening process, educating the family, and assisting with follow-up. In addition, they are the first-line defense for emotional, spiritual, and social support. Purpose: To review of the expansion of this program over time and discuss challenges the NICU nurse encounters. Methods/search strategy: Research literatures along with the national recommendation by governmental and professional agencies were reviewed to obtain evidence on current practice recommendations. Findings/results/implications for practice and research: NICU nurses face several challenges with the expansion of newborn screening programs. This includes gaining knowledge to answer questions posed by empowered parents and educate them appropriately; ensuring quality of the process that minimizes errors and optimal communication; and, addressing ethical concerns about the storage and subsequent use of specimens. New and ongoing research can measure and ensure provision of quality services provided through the NICUs globally.
  • Background: Respiratory syncytial virus (RSV) is the leading viral cause of death in infants younger than 1 year. In July 2014, the American Academy of Pediatrics (AAP) Committee on Infectious Diseases concluded that the "limited clinical benefit" for infants born at more than 29 weeks' gestation, together with the associated high cost of the immunoprophylaxis, no longer supported the routine use of palivizumab (Synagis). Purpose: To evaluate the impact of the newly adopted AAP palivizumab prophylaxis administration on health and subsequent hospital costs of infants born between 29 and less than 32 weeks' gestation. Methods: A retrospective cohort analysis from a single institution across the duration of the study comparing the clinical and financial outcomes of infants (aged < 32 weeks) treated under the 2009 AAP guidelines (PRE) and infants (aged >29 weeks) managed after the 2014 AAP guidelines (POST) took effect. Results: RSV-positive admissions were greater in the POST cohort versus the PRE cohort (P = .04). There were no readmission deaths due to RSV infection in either cohort. The number needed to treat to avoid a single RSV-positive hospitalization was 20 infants at an estimated palivizumab cost of $90,000 to avoid an estimated hospital cost of $29,000. Implications for practice: Assessment of individual risk factors and their ability to predict severe RSV risk/disease, thus, would allow providers greater flexibility in determining need for prophylaxis therapy. Implications for research: Longitudinal evaluation of financial and clinical outcomes is needed to determine the impact of the 2014 AAP revised regulatory guidelines.
  • Background: Preterm birth has been linked to increased parental stress, depression, and anxiety. Although the rate of neonatal morbidity and mortality decreases with increasing gestational age, recent research has revealed that there is no threshold age for risk or parental concern. Purpose: This study examines parental concern about medical and developmental outcomes of their premature infant. Methods: Parents of 60 premature infants were surveyed in a follow-up clinic regarding their level of concern about 11 morbidities and their child's gestation-adjusted age; these were compared with the infant's inpatient chart. "Concern scores" were tallied and compared across gestational age groups and knowledge of gestation-adjusted age using Chi-square tests of independence. Findings: Many parents reported concerns about morbidities that were unsupported by their child's diagnoses. Across parents of extremely, very, and moderate-late preterm children, the mean concern scores were 13.9, 15.7, and 19.7, respectively. Overall, 62% of parents incorrectly reported the gestation-adjusted age of their child. Parents who were correct were significantly more likely to correctly anticipate abnormal developmental patterns (70%) and growth patterns (65%) than those who were incorrect (33% and 31%, respectively). Implications for research: Future research should focus on whether NICU graduate parental stress levels are directly linked to the severity of their child's condition, and how physicians can help decrease NICU graduate parental stress. Implications for practice: Parental anxiety regarding all gestational age neonatal intensive care unit infant outcomes can be decreased by a thorough explanation of gestation-adjusted age and a discussion of expected prematurity-related issues.
  • Background: Patients in the neonatal intensive care unit are a vulnerable population with specific nutritional requirements, which include increased protein and caloric needs for adequate growth. Some infants cannot tolerate gastric feeds and need to have postpyloric feeds to grow. Placement of a postpyloric tube can be done by gastric insufflation. Gastric insufflation is a technique where air is inserted into the stomach as a nasogastric tube is advanced through the pylorus to the duodenum. There is research to support this technique in pediatrics, but scant evidence exists for placement of postpyloric tubes in the infant population. Purpose: The aim of this quality improvement practice project was to determine whether the current practice for postpyloric tube placement by the bedside nurses in the neonatal intensive care unit is safe and effective. Methods: Data were prospectively collected on 38 infants requiring placement of 60 postpyloric tubes over an 8-week period. Results: The results indicate a success rate of 95.6% for tube placement when a subset of infants diagnosed with congenital diaphragmatic hernia (CDH) (n = 15) was excluded. Six (40%) of the 15 infants with CDH had postpyloric tubes placed successfully. Nursing years of experience did not affect successful postpyloric tube placement. Implications for practice: The postpyloric tube placement policy was modified as a result of findings from this project. Placement of a postpyloric tube with one attempt by the bedside nurse was safe and effective in most preterm infants in our care excluding patients with CDH. The new policy reduced infants' exposure to radiation due to a decrease in the number of x-rays in comparison to interventional radiology placement. Implications for research: Further research should be done by units that primarily care for low birth-weight premature infants.
  • Background: Research concludes that there is a need for educational programs for grandmothers, as well as networking opportunities; educational programs for other extended family members have long been sought by parents, relatives, and nurses in neonatal intensive care unit. Purpose: To describe the effect of having premature infants' extended families participating in family-centered care (FCC) groups in the neonatal intensive care unit. An intervention based on dialogue, including topics as own reactions, general knowledge about the premature infants, parenthood, and how the extended families can support the new families during hospitalization and after discharge. Methods: A qualitative content analysis of 2 focus group interviews involving 16 purposefully sampled extended family members, who had participated in 1½ hours of FCC group interventions. Findings: The overall theme was: Accepting the individuality of the infant and providing the family with realistic expectations for the future. This theme emerged during the analysis of 4 categories: knowledge sharing, same basis for understanding, access to the immediate family, and competent supporting role. The interrelationship between the categories also emerged, surprisingly, during the analysis. Implications for practice: Extended family members should be recognized as an essential part of the new family's life from the time of the premature infant's admission to neonatal intensive care unit. Family-centered care group interventions should be integrated into ward practice and policy. Implications for research: The study reinforces the need for further research, utilizing both qualitative and quantitative methods, into age and ethnicity aspects of FCC group interventions. There is also a need to compare the new parents' perceived level of stress and support from the FCC group intervention in relation to participating and nonparticipating extended families.
  • Background: Many neonatal intensive care unit (NICU) parents experience emotional distress leading to adverse infant outcomes. Parents may not cope positively in stressful situations, and support programs often are underutilized. Purpose: To determine coping mechanisms utilized by NICU parents, and types of support programs parents are likely to attend. To determine whether sociodemographic and length-of-stay differences impact coping mechanisms utilized, and types of support programs preferred. Methods: A correlational cross-sectional survey design was used. The 28-item Brief COPE tool, questions about demographics and preferred support program styles, was distributed to a convenience sample of NICU parents in a level IV NICU in the southeastern United States. Results: One hundred one NICU parents used coping mechanisms, with acceptance emotional support, active coping, positive reframing, religion, planning, and instrumental support being the most common. Preferred support classes were infant development and talking with other NICU parents. Caucasians more commonly coped using active coping, planning, emotional support, acceptance, instrumental support, and venting compared with other races. Women utilized self-blame coping mechanisms more often compared with men. Younger parents were more likely to use venting and denial coping mechanisms. Parents with a shorter stay utilized self-distraction coping and preferred the class of talking with other parents. Implications for Practice: Support program preference, type of coping mechanism utilized, and sociodemographic factors may be used to guide the creation of NICU support programs. Implications for Research: Additional studies are needed to determine whether support program offering according to preferences and sociodemographic characteristics increases attendance and decreases emotional distress. Copyright © 2017 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
  • Background: Neonatal nurse practitioner (NNP) workload is not well studied, and metrics specific to NNP practice are lacking. Factors such as changes in resident duty hours, increasing neonatal intensive care unit admissions, and a shortage of NNPs contribute to NNP workload. Increased workload has been shown to be detrimental to providers and can affect quality of care. Purpose: This study quantified NNP workload using a subjective workload metric, the NASA Task Load Index, and a newly developed objective workload metric specific to NNP practice. Methods: The NNP group at a level IV academic medical center was studied. The sample included 22 NNPs and 47 workload experiences. Results: A comparison of scores from the NASA Task Load Index and objective workload metric showed a moderate correlation (r = 0.503). Mental demand workload scores had the highest contribution to workload. Feelings of frustration also contributed to workload. Implications for practice: The NASA Task Load Index can be utilized to measure the workload of NNPs. The objective workload metric has potential to quantify NNP workload pending further validation studies and is a simple, straightforward tool. Implications for research: Additional research is needed regarding NNP workload and methods to quantify workload. Larger studies are needed to validate the objective workload metric.
  • Background: Growth and nutrition are critical in neonatal care. Whether feeding guidelines improve growth and nutrition and reduce morbidity is unknown. Purpose: Feeding guidelines for very low birth-weight (VLBW) infants were implemented in our neonatal intensive care unit (NICU) to start and achieve full enteral feeds sooner, and increase weight gain over the first month. Methods: Feeding guidelines for VLBW infants were implemented in January 2014, stratified by birth weight (<750, 750-1000, and 1000-1500 g). After trophic feedings, enteral feedings were advanced by 20 to 30 mL/kg/d.Data were analyzed for 2 years prior (baseline) and 6 months after (guideline) guidelines were implemented and included days to initiation of enteral feeds, days on total parenteral nutrition (TPN), and weight gain over the first month. Potential concomitant factors that could affect feeding tolerance were examined including indomethacin or dopamine treatment, delivery room cardiopulmonary resuscitation, and growth restriction. Results: A total of 95 infants with a birth weight of less than 1500 g were included (59 baseline and 36 guideline). Days to start enteral feeds decreased by 47% (P < .01) and days on TPN decreased by 25% (16 days vs 11 days; P < .01). Weight gain over the first month of life increased by 15% (p < .05). Dopamine and indomethacin use decreased during the study period, and small for gestational age infants were overrepresented in the guideline group. Implications for practice/research: Establishment of feeding guidelines for VLBW infants in our NICU reduced the days to start feeds and days on TPN while increasing weight gain over the first month. Improving growth and nutrition and reducing need for TPN in this vulnerable population may ultimately prevent infection and improve neurodevelopmental outcomes.
  • Background: Necrotizing enterocolitis (NEC) can become severe quickly, making early recognition a priority and understanding the occurrence of abdominal and clinical signs of impending NEC important. Purpose: The purpose of this study was to examine relationships of abdominal signs up to 36 hours before diagnosis of NEC within subgroups treated medically, surgically, or those who died. Methods: A 3-site, descriptive correlational case-control design with retrospective data collection was used matching each NEC case to 2 controls (N = 132). Results: NEC cases were exposed to less human milk and fed later. Among them, 61% (n = 27) had at least 1 abdominal sign 36 hours before diagnosis, with fewer numbers having 2 (18%; n = 8) or 3 (5%; n = 2). At 36 hours before NEC, abdominal distension, duskiness, higher gastric residual, and greater count of abdominal signs were associated with severe NEC. No medical NEC cases had abdominal signs 36 or 24 hours before diagnosis. Highest severity of NEC was related to more abdominal signs at the times leading up to and at diagnosis of NEC. Gastric residuals were largely unrelated to NEC except for the most severe NEC at 36 hours before diagnosis. Implications for practice: Communicating a count of abdominal signs may support earlier recognition and treatment of NEC. Implications for research: More research is needed to explore timing for clinical worsening of status (eg, surgical and NEC leading to death) and to study effective clinical approaches targeting early recognition to support timely action.
  • Background: The traumatic experiences of parents of babies treated with therapeutic hypothermia (TH) have been described. No research has assessed neonatal intensive care unit (NICU) nurse experience in providing care to hypothermic babies and emotional support to their parents. Purpose: To assess NICU nurse attitudes to the provision of TH with respect to perceptions about baby pain/sedation, need for nurse and parent education, decision making about initiation of TH, and barriers to best care. Methods: A survey was electronically sent to 219 nurses at 2 affiliated academic level III NICUs: 1 rural and 1 urban location. There were 17 questions where responses were selected from a preset list and 7 opportunities for nurses to provide free text responses. Findings: The response rate was 38% (N = 83). Overwhelming similarities between the urban and rural institutions were found with NICU nurses expressing understanding of the indications for initiating TH, agreement that TH improves long-term outcomes and that the benefits of TH outweigh the risks. Nurses at the urban institution more frequently expressed concerns surrounding inadequate treatment of baby pain/sedation, and nurses at both institutions strongly emphasized the need for more nurse and parent education about TH and improved timeliness of decision making for initiation of TH. Implications for practice: NICU nurses specifically want to learn more about outcomes of babies after treatment with TH and feel that parents need more education about TH. Implications for research: Research is urgently needed to better understand the implications of TH treatment for parent-baby bonding.
  • Background: Premature infants have an increased risk for developing skin breakdown. Perceivably noninvasive interventions may have detrimental effects on the infant's skin. Purpose: This case presentation describes an extreme case of nasal breakdown associated with nasal continuous positive airway pressure (nCPAP). Methods: Highlighted is the vital importance of proper placement, along with appropriate apparatus size, in the efforts to prevent skin breakdown. Ensuring that pressure points are avoided is imperative to prevent nCPAP-related injuries, along with treating the area in the event of skin denudation. A literature search was conducted to determine best practice options to prevent these injuries. Findings: There is little information in the literature to guide treatment and prevention of this type of breakdown. Implications for practice: Avoidance of pressure in a localized area is the most commonly found recommendation. Implications for research: There are extensive opportunities for adding to our current knowledge in terms of prevention and treatment of skin breakdown associated with device utilization in the neonatal intensive care unit, especially with the increasing use of nCPAP.
  • Background: The incidence of hemodynamically significant patent ductus arteriosus (hsPDA) increases with decreasing gestational age and is associated with many common morbidities of extreme prematurity. Controversies remain surrounding the definition of hsPDA, the population of infants requiring treatment, the appropriate timing and method of treatment, and the outcomes associated with PDA and its therapies. Purpose: This integrative literature review focuses on diagnostic and treatment recommendations derived from the highest levels of evidence. Search strategy: PubMed and CINAHL were searched using key words "neonatal" and "patent ductus arteriosus" to discover the highest levels of evidence surrounding diagnosis, treatment methods, and outcomes. Findings/results: The lack of consensus surrounding the diagnosis and clinical significance of PDA hinders meta-analysis across studies and confounds understanding of appropriate management strategies. Novel biomarkers, pharmaceutical choices, and transcatheter closure methods are expanding diagnostic and treatment options. Implications for practice: Infants weighing less than 1000 g are at highest risk. Prophylactic closure is no longer recommended, although early asymptomatic therapy is still preferred by some to avoid prolonged pulmonary overcirculation or decreased renal and gut perfusion. Conservative treatment measures such as fluid restriction and diuretic administration have not consistently proven effective and are in some instances detrimental. Cyclooxygenase inhibitors are effective but have adverse renal and mesenteric effects. Oral ibuprofen is associated with lower instance of necrotizing enterocolitis. Implications for research: Well-defined staging criteria would aid in comparison and meta-analysis. Trials that include a control group that receives no therapy may help separate the outcomes associated with prematurity from those associated with PDA.
  • Background: Palliative care is a holistic framework that is designed to improve quality of life by identifying and treating distressing symptoms of life-threatening or complex conditions. Neonatal palliative care (NPC) has potential benefits for parents, staff, and patients, yet evidence suggests that implementation and utilization of organized NPC services are low. Purpose: The purpose of this study is to answer the clinical question: In neonatal intensive care, what evidence can be used to guide implementation of palliative care protocols? Search strategy: A literature search was conducted using CINAHL (Cumulative Index of Nursing and Allied Health Literature), PubMed, and the Cochrane Library databases. Publications with a focus on neonates, neonatal intensive care unit, and implementation or evaluation of a palliative care protocol, team, or educational intervention were retained. Results: The search yielded 17 articles that fit with the following themes: NPC protocols or teams (n = 8), healthcare team needs (n = 3), and barriers to implementation (n = 6). Approaches to NPC implementation were varied, and outcome data were inconsistently reported. Healthcare team members cited a need for education and consistent, ethical delivery of NPC. Common barriers were identified as lack of NPC education, poor communication, and lack of adequate resources such as staff and space. Implications for practice and research: Successful team approaches included standardized order sets to initiate NPC, NPC education for staff, and references to NPC guidelines or protocols. Barriers such as lack of interdisciplinary cooperation, lack of appropriate physical space, and lack of education should be addressed during program development. Further research priorities for NPC include seeking parent perceptions, shifting focus from mostly end-of-life to an integrated model, and collecting outcome data with rigor and consistency.
  • Background: Nurses have a primary role in promoting neonatal skin integrity and skin care management of the critically ill neonate. Adhesive products are essential to secure needed medical devices but can be a significant factor contributing to skin breakdown. Current literature does not offer a definitive answer regarding which products most safely and effectively work to secure needed devices in the high-risk neonatal population. Purpose: To determine which adhesive method is best practice to safely and effectively secure lines/tubes in the high-risk neonate population. Findings/results: The only main effect that was significant was age group with mean skin scores. Subjects in the younger group (24-28 weeks) had higher skin scores than in the older group (28-34 weeks), validating that younger gestations are at higher risk of breakdown with the use of adhesives. Implications for practice: The findings did not clearly identify which product was superior to secure tubes and lines, or was the least injurious to skin of the high-risk neonate. Neither a transparent dressing only or transparent dressing over hydrocolloid method clearly demonstrated an advantage in the high-risk, preterm neonate. Anecdotal comments suggested staff preferred the transparent dressing over hydrocolloid method as providing better adhesive while protecting skin integrity. The findings validated that younger gestations are at higher risk of breakdown with the use of adhesives and therefore require close vigilance to maintain skin integrity.
  • Background: The high prevalence of prematurity and low birth-weight places twin infants at increased risk for sudden unexpected infant death (SUID) and/or sudden infant death syndrome (SIDS). Risk for these SUID and SIDS is affected by a combination of nonmodifiable intrinsic risk factors and modifiable extrinsic stressors including infant care practices related to sleep. Although adherence to the full scope of American Academy of Pediatrics (AAP) 2011 recommendations is intended to decrease risk, these recommendations are aimed at singleton infants and may require tailoring for families with multiple infants. Purpose: The study describes infant care practices reported by mothers of twins in the first 6 months postpartum. Methods: Mothers caring for twin infants (N = 35) were surveyed online both longitudinally (at 2, 8, 16, and 24 weeks after infant hospital discharge) and cross-sectionally. AAP recommendations (2011) guided survey content. Results: The degree of adherence to AAP recommendations varied over time. For example, mothers of twins reported 100% adherence to placing twins supine for sleep initially, but many reported putting babies on their stomachs for naps as twins became older. Sharing a parent's bedroom decreased over time as did frequency of crib sharing. Fewer than half of mothers offered a pacifier most or all of the time for sleep. Implications for practice: Opportunities exist for development of an educational program geared specifically for postpartum parents of twins. Implications for research: Barriers affecting adherence to AAP recommendations and effectiveness of educational programs addressing needs of this unique population need further exploration.
  • Background: Hemophagocytic lymphohistiocytosis (HLH) is a rare disease that can be triggered by cytomegalovirus, a relatively common infectious exposure to neonates. The clinical presentation is common to many acute illnesses seen in extreme premature infants; however, there are key clinical and laboratory findings that can lead to the diagnosis. Purpose: We present a case of an extreme premature infant of 25 weeks' gestation who developed cytomegalovirus-induced HLH. Using the current published protocols that are used in pediatric cancer can be adapted for use in a premature infant, which led to remission of HLH and eventual discharge from the neonatal intensive care unit. Implications for practice: There are published treatment protocols used in pediatric oncology that when initiated early can lead to favorable outcomes and remission in even the most fragile neonates. Implications for research: Additional studies are needed on the pharmacokinetics, dosing, and side effects on medications used for treatment of HLH in preterm infants. Additional research is needed to improve the clinician's ability to reach the diagnosis as well as define treatment strategies that provide optimal outcomes.
  • Background: Early initiation of therapeutic hypothermia (TH) for the treatment of hypoxic ischemic encephalopathy (HIE) has been shown to improve outcomes. Many of these patients require transport to treatment facilities. At the time of the study, there were no servo-controlled devices approved for flight that allowed for active cooling of the neonate during air transport. Purpose: To introduce a clinical bundle for safe, active, or passive cooling and to achieve targeted, accurate temperature control with application for air or ground transport. Methods: After meeting criteria, a facsimile is sent to the referring center with instructions for passive cooling. Strict protocols are initiated, guiding the transport team in reaching and maintaining target temperature range of 33°C to 35°C. Results: From June 2010 to January 2014, a total of 22 neonates who qualified for TH were transported using the care bundle. Eight were actively cooled, whereas 14 were passively cooled. Of note, 8 infants required warming for temperatures below the acceptable range. The average temperature before turning off the warmer at the referral center was 36.0°C (SD = 1.1). The average temperature upon arrival of the transport team was 34.9°C (SD = 1.4). The average temperature upon arrival to the receiving facility was 33.5°C (SD = 0.7). Implication for practice: By utilizing a care bundle for the initiation of TH on transport, neonates can be safely delivered to a treatment center with an average temperature well within treatment range, all while avoiding extreme fluctuations. Implications for research: The number of qualified participants limited the study. Future research should focus on the effectiveness of the bundle in larger treatment populations, with inclusion of additional transport teams.
  • Background: Applied mechanical vibration in pediatric and adult populations has been shown to be an effective analgesic for acute and chronic pain, including needle pain. Studies among the neonatal population are lacking. According to the Gate Control Theory, it is expected that applied mechanical vibration will have a summative effect with standard nonpharmacologic pain control strategies, reducing behavioral and physiologic pain responses to heel lancing. Purpose: To determine the safety and efficacy of mechanical vibration for relief of heel lance pain among neonates. Methods: In this parallel design randomized controlled trial, eligible enrolled term or term-corrected neonates (n = 56) in a level IV neonatal intensive care unit were randomized to receive either sucrose and swaddling or sucrose, swaddling, and vibration for heel lance analgesia. Vibration was applied using a handheld battery-powered vibrator (Norco MiniVibrator, Hz = 92) to the lateral aspect of the lower leg along the sural dermatome throughout the heel lance procedure. Neonatal Pain, Agitation, and Sedation Scale (N-PASS) scores, heart rate, and oxygen saturations were collected at defined intervals surrounding heel lancing. Results: Infants in the vibration group (n = 30) had significantly lower N-PASS scores and more stable heart rates during heel stick (P = .006, P = .037) and 2 minutes after heel lance (P = .002, P = .016) than those in the nonvibration group. There were no adverse behavioral or physiologic responses to applied vibration in the sample. Implications for practice and research: Applied mechanical vibration is a safe and effective method for managing heel lance pain. This pilot study suggests that mechanical vibration warrants further exploration as a nonpharmacologic pain management tool among the neonatal population.

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