Hospital Nursery Research Articles

Mycobacterium tuberculosis Transmission in a Newborn Nursery and Maternity Ward--New York City, 2003

Evaluating young children recently exposed to airborne Mycobacterium tuberculosis is a public health priority. If infected, children aged <2 years are at high risk for severe tuberculosis (TB) disease (e.g., TB meningitis). In December 2003, infectious pulmonary TB disease was diagnosed in a foreign-born nurse working in the newborn nursery and maternity ward of a New York City hospital (hospital A); the nurse had declined treatment for latent TB infection (LTBI) after testing positive 11 years earlier. An investigation including medical evaluation of contacts in the nursery and maternity ward was conducted by the Bureau of TB Control (BTBC) at the New York City Department of Health and Mental Hygiene, hospital A, and CDC. This report summarizes the results of that investigation, which determined that approximately 1,500 patients had been exposed to the nurse but the majority could not be located for evaluation. Among those who were tested, four infants had positive tuberculin skin test (TST) results, likely attributable to recent transmission of M. tuberculosis. The findings emphasize the difficulty of conducting contact investigations in certain settings and the importance of effective LTBI testing and treatment programs for health-care workers (HCWs) to prevent TB disease and subsequent health-care--associated transmission.

Factors which contribute to time of first stool and first urine passage in Newborns

Purpose:To evaluate the factors which contribute to the time of the first stool and the first urine passage. Methods:We retrospectively reviewed a chart of 1,221 infants ≥34 weeks of gestational age admitted to the normal newborn nursery of Il Sin Christian Hospital, Busan, from November 2004 to April 2005. We compared the time to first stool and urine according to maternal factors(maternal age, parity, mode of delivery, meconium-stained amniotic fluid, and maternal diabetes) and infant factors (gender, Apgar score, gestational age, type of feeding during first 24 hours, age at the first feeding, number of feeds during the first 12 hours and age at discharge). Results:In total, 95.3 percent of our infants had passed their first stool by 24 hours and 99.8 percent of them had a stool by 36 hours. A total of 95.8 percent of our infants had passed urine by 24 hours of age and 98.3 percent of them by 36 hours. Comparing preterm and term infants, the time to first urine is 6.5±5.8 hours and 12.1±6.6 hours, respectively(P=0.000). The time to first stool is 20.7±13.5 hours and 10.0±6.3 hours, respectively(P=0.000) Early-fed infants were significantly earlier in time to first urine(P=0.023) and first stool(P=0.012). There was no statistically significant relationship between the number of feeds in 0-12 hours, mode of delivery, Apgar score, parity, gender, type of feeding, maternal diabetes and the time of the first urine and first stool. Conclusion:Gestational age, birth weight and age at first feeding were significantly related to the time of the first urine and first stool passage. When there is delayed passage of the first urine and first stool, we should consider close observation of other associated symptoms and other factors previously mentioned, to avoid extensive evaluation and intervention.

Echovirus Type 11: Outbreak of Hand-Foot-and-Mouth Disease in a Thai Hospital Nursery

Echovirus Type 11: Outbreak of Hand-Foot-and-Mouth Disease in a Thai Hospital Nursery

An Emptying Quiver: Antimicrobial Drugs and Resistance

An Emptying Quiver: Antimicrobial Drugs and Resistance

Infection Control Practices Reduce Nosocomial Infections and Mortality in Preterm Infants in Bangladesh

The skin is a potential source for invasive infections in neonates from developing countries such as Bangladesh, where the level of environmental contamination is exceedingly high. A randomized controlled trial was conducted from 1998 to 2003 in the Special Care Nursery of a tertiary hospital in Bangladesh to test the effectiveness of topical emollient therapy in enhancing the skin barrier of preterm neonates less than 33 weeks of gestational age. In the initial months of the study, the infection and mortality rates were noted to be unacceptably high. Therefore, an infection control program was introduced early in the trial to reduce the rate of nosocomial infections. After a comprehensive review of neonatal care practices and equipment to identify sources of nosocomial infections, a simple but comprehensive infection control program was introduced that emphasized education of staff and caregivers about measures to decrease risk of contamination, particularly hand-washing, proper disposal of infectious waste, and strict asepsis during procedures, as well as prudent use of antibiotics. Infection control efforts resulted in declines in episodes of suspected sepsis (47%), cases of culture-proven (61%) sepsis, patients with a clinical diagnosis of sepsis (79%), and deaths with clinical (82%) or culture-proven sepsis (50%). The infection control program was shown to be a simple, low-cost, low-technology intervention to reduce substantially the incidence of septicemia and mortality in the nursery.

MRSA--past, present, future

Infections with methicillin-resistant staphylococci (MRSA) remain a major concern. A Medline search reveals 175 publications in the past eight weeks and the BMJ has produced two editorials in the space of a year.1,2 For the reason, readers need look no further than the article by Dr David Thompson on p. 521.3 In the intensive care unit (ICU) of his hospital, MRSA were present for 16.9% of available bed-days.

Evaluation of Korean Newborns With the Brazelton Neonatal Behavioral Assessment Scale

To determine the unique responses of a group of Korean full-term newborns and to describe the pattern of behavior observed in the first few days of life. A descriptive study describing the behavioral patterns of Korean newborns using the Neonatal Behavioral Assessment Scale. Fifty newborns aged 1 to 3 days in a nursery of a large tertiary hospital in Daegu, Korea. Overall scores were at moderate levels in six clusters. These were (a) Response Decrement, (b) Social Interactive, (c) Motor System, (d) State Organization, (e) State Regulation, and (f) Autonomic System. Newborns showed good overall tone and activity level and low amount of irritable behavior. Although reflex responses were generally normal, Korean newborns showed particularly weak responses in standing and walking reflexes. Maternal variables such as employment and previous pregnancy history were related to the scores on the Neonatal Behavioral Assessment Scale. The results of the study indicate that Korean newborns showed a moderate level of autonomic stability and motor control and overall good state organization. These findings also provide some evidence that the mother's health status and lifestyle during the pregnancy may affect newborn behavior after birth.

2. Stastny, P. F., Ichinose, T. Y., Thayer, S. D., Olson, R. J., &amp; Keens, T .G. (2004). Infant sleep positioning by nursery staff and mothers in newborn hospital nurseries, Nursing Research, 53, 122-9*1

Sudden infant death syndrome (SIDS), the second most common cause of death in children 1 to 12 months of age, is the sudden death of an infant less than a year-old from an unknown cause. Research has shown that putting infants to sleep in the supine position (on their backs) dramatically decreases death from SIDS. Deaths from SIDS have decreased up to 50% in countries that have instituted programs encouraging putting infants to sleep on their backs. Even infants put to sleep on their sides are more than 6.5 times more likely to die from SIDS. In spite of the evidence and the recommendations by groups such as the American Academy of Pediatrics (“Back to Sleep”) that encourage placing infants on their backs to sleep, many parents still place their infants on their stomachs or sides, possibly due to fears that infants will aspirate if they sleep on their backs. Unfortunately, many health care providers, including nursery staff, do not recommend to parents that they place their infants to sleep on their backs.

Culturally Competent Nursing Care

Culturally Competent Nursing Care

URINARY LEVELS OF DI-2-ETHYLHEXYL PHTHALATE METABOLITES IN NICU INFANTS

ISEE-191 Rationale: Di -2 -ethylhexyl phthalate is commonly used as a plasticizer in multiple medical products containing poly vinyl chloride and may represent between 20–40% of the finished weight of the plastic. Medical devices containing DEHP are in extensive use in modern NICU’s. The lipophilic nature of DEHP and its non-covalent binding to PVC allow it to leach from products being used. This is of concern, since in developing and adult laboratory animals, the metabolites have demonstrated multiple organ system toxicities, most notably hepatic and reproductive. We performed a cross-sectional study to assess the relationship of exposure to DEHP containing medical devices with internalized dose of DEHP in neonates as reflected by levels of MEHP (mono ethylhexyl phthalate) a principal urinary metabolite of DEHP. Methods: The study sample comprised (54) randomly selected infants enrolled nearly evenly from two Level III Boston hospital nurseries during the time period March 1– April 30, 2003. Subjects were in the NICU at least 3 days before observation, and had a corrected gestational age of ≤ 44 weeks. LOW, MEDIUM, and HIGH DEHP exposure classification categories were determined apriori, with the LOW exposure group containing subjects receiving primarily bottle and/or gavage feedings; the MEDIUM exposure group receiving enteral feedings, intravenous hyperalimentation, and/or nasal continuous positive airway pressure (CPAP); and the HIGH exposure group receiving umbilical vessel catheterization, endotracheal intubation, intravenous hyperalimentation and an indwelling gavage tube. Neonatal urine samples were collected from each infant using a standardized protocol and measured for MEHP by liquid chromatography (HPLC) and tandem mass spectroscopy (MS/MS). Results: MEHP levels tended to be greater among male infants and among infants with lower gestational age and longer stays in the NICU. MEHP levels were substantially higher with increasing exposure class: for the LOW, MEDIUM, and HIGH exposure classes, mean (sd) MEHP levels were, in ng/mL, 9.3 (9.8), 41 (55), and 139 (189), respectively (p=0.004, ANOVA of log-transformed values). Although further adjustment for institution and infant’s sex attenuated these differences somewhat (p=0.09), infants in the HIGH exposure class still demonstrated significantly higher MEHP levels than infants in the LOW exposure class (p=0.03). Conclusion: Use of DEHP-containing medical devices leads to demonstrable urinary levels of metabolites in NICU infants.

Rest-Activity Patterns of Premature Infants Are Regulated by Cycled Lighting

Many hospitalized premature infants are exposed to continuous dim lighting rather than to cycled lighting. However, we do not know whether dim lighting or low-intensity cycled lighting is more conducive to the development of rest-activity patterns that are in phase with the solar light-dark cycle. Thus, we examined the effects of nursery lighting conditions on the development of activity patterns in premature infants. Premature infants who were born at <32 weeks' postmenstrual age and were medically stable in neonatal intensive care unit rooms were randomly assigned between 32 and 34 weeks' postmenstrual age to either continuous dim lighting (<25 lux; duration 24 days; control group; n = 29) or cycled lighting (239 +/- 29 lux, 7:00 AM to 7:00 PM; <25 lux, 7:00 PM to 7:00 AM; duration: 25 days; experimental group; n = 33). Activity was continuously monitored from enrollment until approximately 1 month after discharge from the hospital. Weight and head circumference were also assessed up to 6 months after discharge from the hospital. Over the first 10 days at home, distinct day-night differences in activity were not seen in control subjects (D day-night: N 1.07 +/- 0.02), but experimental group infants were more active during the day than at night (day-night: 1.25 +/- 0.03). It was not until 21 to 30 days after discharge that day-night activity ratios in control infants matched those seen in experimental group infants shortly after discharge, yet even at this age, experimental group infants (day-night: 2.13 +/- 0.19) were considerably more active during the day than at night as compared with control subjects (day-night: 1.43 +/- 0.09). Exposure of premature infants to low-intensity cycled lighting in the hospital nursery induces distinct patterns of rest-activity that are apparent within 1 week after discharge. In comparison, the appearance of distinct patterns of rest and activity are delayed in infants who are exposed to continuous dim lighting in the hospital. These observations show that day-night rhythms in activity patterns can be detected shortly after discharge to home in premature infants and that the circadian clock of developing infants is entrained by cycled lighting.

SAUDE E DOENÇA: O QUE PENSAM E SENTEM AS CRIANÇAS HOSPITALIZADAS E SUAS MÃES ACOMPANHANTES

As reações infantis frente à novidade da estimulação física e social que a hospitalização proporciona podem ser de afastamento e isolamento; por outro lado, pode incentivar a interação social, levando a criança a explorar e a se comunicar com outros pacientes e adultos (Zannon, 1981). Foi realizado um estudo cujos objetivos foram identificar o que pensam e sentem as criança internadas e suas mães acompanhantes em relação à experiência sobre saúde e doença, e compreender o significado destas experiências em enfermaria pediátrica. Participaram da pesquisa 66 sujeitos, 33 crianças hospitalizadas na faixa etária de 6 a 12 anos e 33 mães acompanhantes da enfermaria pediátrica de um hospital geral. O instrumento utilizado foi o desenho de tres elementos flor, animal e pessoa em duas situações, saúde e doença, e do que se faz quando seestá doente. Saúde e doença foram associadas às condições corporais, com ênfase na forma, às possibilidades e às restrições de atividade física e a sentimentos decorrentes destas experiências. Diante da doença a atitude mais frequente foi a procura pelo atendimento médico. A experiência concreta da criança hospitalizada, muitas vezes, não está de acordo com o caráter negativo atribuído à internação infantil. A presença de sensações agradáveis significa que a hospitalização pode ser também uma experiência produtiva e positiva para a criança internada. A apropriação deste tipo de vivência permite uma assistência mais integrada por parte da equipe pediátrica.

Infection and colonization by Staphylococcus aureus in a high risk nursery of a Brazilian teaching hospital.

Neonates are susceptible to nosocomial infections due to immunological immaturity, prolonged hospital stay and the use of invasive procedures. We evaluated the incidence of infections and the prevalence of colonization by MRSA (Methicillin-resistant Staphylococcus aureus) and MSSA (Methilin-susceptible Staphylococcus aureus), as well as colonization risk factors. Staphylococcal infections were observed by analyzing medical records in the HICS (Hospital Infection Control Service) and the HRN (High Risk Nursery). Additionally, four inquiries concerning colonization prevalence were made for S. aureus, from January/2000 to December/2002. Clinical specimens from the nostrils, mouth and anus were cultivated in mannitol-salt agar plates and identification was made through standard methods. The frequency of neonates colonized by S. aureus was 49%. MSSA was more prevalent (57%) than MRSA (43%). Risk factors related to the acquisition of MRSA were: low weight and antibiotic use., Hospital stay was the only variable significantly associated with colonization by S. aureus. The incidence of infections by S. aureus during the last three years was 2.18% (159 cases). Nine of them (5.5%) were associated with MRSA and 150 (94.5%) with MSSA. Staphylococcal infections were considered as invasive (sepsis) and non-invasive (conjunctivitis, cutaneous), corresponding to 31% and 69%, respectively. The MRSA phenotype in infection was rare compared with methicillin-susceptible samples, although S. aureus, MRSA and MSSA colonization rates were high.

Human rotavirus strains bearing VP4 gene P[6] allele recovered from asymptomatic or symptomatic infections share similar, if not identical, VP4 neutralization specificities

A rotavirus VP4 gene P[6] allele has been documented in a number of countries to be characteristically associated with an endemic predominantly asymptomatic infection in neonates in maternity hospital nurseries. The mechanisms underlying the endemicity and asymptomatic nature of such neonatal infections remain unknown. Rotavirus strains sharing this same P genotype, however, have more recently been recovered from an increasing number of symptomatic diarrheal episodes in infants and young children in various parts of the world. Previously, we have shown that an asymptomatic P[6] rotavirus neonatal infection is not associated with a unique VP7 (G) serotype but may occur in conjunction with various G types. Although amino acid sequence comparisons of the VP4 gene between selected “asymptomatic” and “symptomatic” P[6] rotavirus strains have been reported and yielded information concerning their VP4 genotypes, serotypic comparisons of the outer capsid spike protein VP4 of such viruses have not been studied systematically by two-way cross-neutralizations. We determined the VP4 neutralization specificities of four asymptomatic and four symptomatic P[6] strains: two each of asymptomatic and symptomatic strains by two-way tests, and two each of additional asymptomatic and symptomatic strains by one-way tests. Both asymptomatic and symptomatic P[6] strains were shown to bear similar, if not identical, VP4 neutralization specificities. Thus, P[6] rotavirus strains causing asymptomatic or symptomatic infections did not appear to belong to unique P (VP4) serotypes. In addition, a close VP4 serotypic relationship between human P[6] rotavirus strains and the porcine P[6] rotavirus Gottfried strain was confirmed.

Noise levels, spectra, and operational function of an occupied newborn intensive care unit built to meet recommended permissible noise criteria

A group of clinical experts developed recommended permissible noise criteria for newly constructed or renovated hospital nurseries [Philbin et al., J. Perinatol. 19, 559–563 (2000); R. White, ibid. 23, S1–22 (2003)]. These criteria are based principally on research regarding wake-up thresholds for term newborns and speech interference levels for adults. These criteria are: The overall continuous A-weighted, slow response, sound level at any bed or patient care area shall not exceed: (1) an hourly Leq of 50 dB, (2) an hourly L10 of 55 dB, and (3) a 1-s Lmax of 70 dB. A new hospital building was designed to meet these criteria by using specific acoustical criteria for the structure and space arrangement [J. B. Evans and M. K. Philbin, J. Perinatol. 20, S105–S112 (2000)]. Acoustical criteria for sound isolation, background NC, structural vibration, and reverberation will be presented along with space arrangements that ensure staff efficiency, clinical safety, and family privacy. Post-occupancy measurements of sound levels and spectra along with photographs of a nursery in operation will be presented to illustrate how an ICU can have a quiet, highly functioning intensive care environment while meeting the operational goals and acoustical criteria.

The Lived Experience of Nurses Caring for Newborns With Sepsis

To describe the lived experience of nurses who care for newborns with sepsis. Phenomenology, a qualitative study using open-ended, tape-recorded interviews, followed by a focus group discussion. The data were analyzed using Colaizzi's step-by-step procedure, resulting in an essential structure of the experience. The nursery and neonatal intensive-care unit of a large community hospital in the southwestern United States. Eleven registered nurses who cared for newborns in both a transitional nursery and the neonatal intensive-care unit were interviewed individually or in a focus group. Three major themes were generated from the data: (a) "Dealing With Death and the Blessings of Life," (b) "Sepsis: The Cancer in the NICU," and (c) "Losing the Dream: Parents' Reactions." The nurses had feelings of helplessness and frustration while caring for these sick newborns. Nurses described the changes in newborns' condition as sepsis developed, the actions taken to reverse the downhill course, and the experiencing of the outcome. Nurses perceived that parents responded with overwhelming fear, guilt, and loss of control. The nurse caring for the infant with sepsis experiences many different emotions, reactions, and perceptions. These findings can assist nurses to have a better understanding of the role of the nurse and the emotional burden of working in the NICU.

Hyperbilirubinemia in healthy neonates with glucose-6-phosphate dehydrogenase deficiency.

A cohort study was carried out to assess the association between glucose-6-phosphate dehydrogenase (G6PD) deficiency, diagnosed by quantitative enzyme assay, and neonatal hyperbilirubinemia, defined as serum total bilirubin >/=15 mg/dl, in the well-baby nursery of Chang Gung Children's Hospital. Among 42,110 inborn infants, 757 male (3.54%) and 326 female (1.57%) newborns were G6PD-deficient. Compared to the occurrence of hyperbilirubinemia in G6PD-normal newborns (1.41% in male, 1.44% in female) in the well-baby nursery, a significantly higher incidence was observed in both G6PD-deficient male (11.36%) and female (7.06%) newborns. Further analyses demonstrated that the enzyme activity of G6PD in G6PD-deficient male newborns with hyperbilirubinemia (1.56+/-1.37 U/g Hb) were significantly lower than the subjects without hyperbilirubinemia (2.01+/-1.7 U/g Hb). No significant difference was observed in G6PD-deficient female newborns with hyperbilirubinemia (6.91+/-2.76 U/g Hb) compared to those without hyperbilirubinemia (7.81+/-2.84 U/g Hb). These data suggest that the G6PD-deficient neonates are at increased risk for hyperbilirubinemia even in the nursery free from agents that can potentially cause hemolysis to G6PD-deficient red cells. The lower G6PD enzyme activity was associated with the neonatal hyperbilirubinemia in G6PD-deficient male neonates.

Reasons hospitals give for not offering hepatitis B vaccine to low-risk newborns.

After a temporary suspension of hepatitis B vaccination (HBV) for low-risk newborns in July 1999, some hospitals still do not offer HBV to these infants. A semi-structured telephone survey of medical directors from a national random sample of 296 hospital nurseries was completed from August 2000 to April 2001 and analyzed using qualitative techniques. Directors of 201 of 290 eligible nurseries (71%) participated. Twenty-ight nurseries have never offered HBV to low-risk newborns ("Never Offered HBV") and 37 nurseries had offered HBV to low-risk newborns before July 1999, but discontinued this practice after the temporary suspension ("Discontinued HBV"). Common reasons for not offering HBV to low-risk newborns were difficulty with reimbursement and convenience of outpatient administration. In addition, directors of "Never Offered HBV" nurseries cited low disease incidence in their patient population, whereas directors of "Discontinued HBV" cited preference for the combination hepatitis B-Haemophilus influenza type b vaccine as important factors. Multi-faceted interventions may be necessary to increase HBV use in the nursery.

Effect of State Vaccine-Financing Strategy on Hepatitis B Immunization in Hospital Nurseries

Changes in recommendations for newborn hepatitis B vaccination offer an opportunity to examine the association between newborn hepatitis B vaccination in hospital nurseries and state vaccine-financing strategies, which include the Vaccines for Children (VFC) program alone, an enhanced VFC program, and universal purchase. We conducted a cross-sectional telephone survey of nursery directors from a national random sample of 290 hospital nurseries. Directors at 207 (71%) of 290 eligible nurseries responded. After the end of the temporary suspension of the hepatitis B vaccine birth dose, 59 (29%) of the 207 nurseries did not return to their previous policy and adopted a less strict policy for offering this vaccination to low-risk infants. In logistic regression analysis, compared with nurseries in states with VFC-only financing, nurseries in states with universal purchase financing were more likely to return a strict policy of routinely offering hepatitis B vaccination (odds ratio [OR], 0.09; 95% confidence interval [CI], 0.11-0.78), and nurseries in states with enhanced VFC financing were less likely to return to a strict policy of routinely offering hepatitis B vaccination (OR, 3.00; 95% CI, 1.14-7.88). The presence of residents or students in the nursery was associated with a lower likelihood of not returning to a strict policy of routinely offering hepatitis B vaccination (OR, 0.32; 95% CI, 0.10-0.97). State vaccine-financing strategy for the birth dose of hepatitis B vaccine is associated with nursery policy to routinely offer this vaccine in the nursery. The temporary change in national hepatitis B vaccination recommendations in 1999 served as a window of opportunity for the adoption of new hospital nursery policies and showed the effects of state vaccine financing on the adoption of newborn immunization recommendations.

Commentary Cultural Brokerage in the Newborn Nursery

Cultural issues play an important part in our daily lives. Often, the cultural practices of immigrants differ from those of the U.S. community in which they now live. The cultural misunderstandings that can result occur in a variety of situations. This is the story of one such misunderstanding that happened a few years ago at a small suburban hospital nursery in a northeastern state.