Hospital Nursery Research Articles

Getting Enough: Mother’ Concerns About Breastfeeding a Preterm Infant After Discharge

To describe maternal concerns about breastfeeding a preterm infant in the postdischarge period and to delineate the strategies mothers used in managing these concerns. Naturalistic inquiry was used. A semistructured interview was conducted with the mother in the home 1 month after discharge of the infant. Twenty mothers of preterm infants; the infants had been in a level 3 hospital nursery, and the mothers had received individualized breastfeeding support services in the hospital. Three categories of maternal concerns emerged from the data: adequate milk consumption by infants; milk composition; and problems with the mechanics of breastfeeding a preterm infant. Mothers identified strategies for these concerns. The mothers' main concern was whether infants consumed an adequate volume of milk by breastfeeding alone. Strategies for managing concerns about getting enough included using supplemental and complemental feeding, using ongoing cues to tell that the infant is getting enough, and persevering with breastfeeding. Mothers of preterm infants have unique concerns about breastfeeding in the postdischarge period and need individualized interventions.

The Parent Health Belief Scales

Health locus of control (HLC) has been used to operationalize general health motivation. This study was undertaken to evaluate the internal consistency and construct validity of Tinsley and Holtgrave's Parent Health Belief Scales (PHBS) as a measure of maternal HLC toward their children's health. Five hundred mothers (71% of eligible consecutive admissions) of newborns admitted to the normal newborn nursery of a large municipal teaching hospital were interviewed 24 to 72 hours after delivery. Principal components factor analysis of the PHBS did not support the originally hypothesized three-dimensional factor structure of the PHBS. In addition, the original subscales did not have adequate internal consistency reliability. Further assessment of construct validity by comparison with maternal preventive health behaviors showed some evidence of construct validity for the scales when compared with breastfeeding behavior. When the three items written as reverse-coded Internality items are not reversed, a reliable seven-item Externality scale emerges which contains items originally thought to represent all three dimensions of HLC.

Neonatal Outcome in Infants With Evidence of Fetal Exposure to Opiates, Cocaine, and Cannabinoids

This study evaluated the neonatal outcome of infants with evidence of fetal exposure to cocaine, opiates, and cannabinoids. Subjects were from the newborn nursery of an inner-city university teaching hospital. Meconium from 141 infants admitted to the full-term nursery was analyzed for metabolites of opiates, cocaine, and cannabinoids. The population was 72% African-American; 82% had medical assistance; history of drug use was reported in the medical records in 18%; mean maternal age was 24.2 years; mean birth weight was 3,234 +/- 502 g; and neonatal abstinence syndrome was reported in 7%. Meconium analysis data showed the following: 52.5% were drug-free; cocaine was present in 31%, opiates in 18% (cocaine and/or opiates 39%), and cannabinoids in 17%. In 38 infants in whom urine toxicology was obtained for clinical indications, meconium was more sensitive than urine in detecting drug exposure (55.3% vs 31.5%). There was no significant difference between cocaine/opiate-exposed and drug-free infants in race, socioeconomic status, maternal age, birth weight, head circumference, length, and Apgar scores. Cocaine/opiate-exposed infants had greater length of stay and increased frequency of maternal sexually transmitted diseases during pregnancy, with a trend toward a higher percent with fetal distress.

Monitoring Premature Infants in Car Seats: Implementing the American Academy of Pediatrics Policy in a Community Hospital

In 1990, the American Academy of Pediatrics (AAP) Committee on Injury and Poison Prevention issued a policy statement which recommended that all infants born at less than 37 weeks gestational age be monitored in their car seat before discharge to identify infants at risk for apnea associated with car seat use. The objective of this report is to summarize the experience of a community hospital in implementing this recommendation, including: education of health professionals about the problem and its management, development of an effective hospital policy and procedure for testing at-risk infants, overcoming logistical difficulties for nursing staff who implement the policy, overcoming liability concerns, and summarizing the clinical results which we observed during a 15-month period. MetroWest Medical Center, Framingham Union Campus is a community hospital with a Level II Neonatal Unit with approximately 2200 deliveries annually. Hospital procedures and policies were developed to implement the AAP policy for safe transportation of premature infants. Consequently, infants less than 37 weeks gestation at birth were monitored for a 90-minute observation period for oxygen saturation, apnea, or bradycardia in the car seat that they would be going home in from the nursery. Policies and procedures for car seat monitoring were instituted successfully during 15-month period. Sixteen of 87 (18.4%) monitored infants 26 to 36 weeks gestation had abnormal results. In addition, one 37-week gestational newborn who was monitored because of duskiness during feeds also became apneic and bradycardic in the car seat. A car seat monitoring program can be incorporated effectively into a Level II community hospital nursery discharge plan provided that appropriate medical staff policies, nursing procedures, and administrative support to deal with the logistics of the program is established. Our monitoring results are consistent with previous reports that premature infants are at risk of desaturation in a car seat. In addition, we have demonstrated that a full-term neonate may also be at risk if other evidence of desaturation (eg, duskiness during feedings) is observed.

Bone Mineral Metabolism in Full-Term Infants Fed Human Milk, Cow Milk—Based, and Soy-Based Formulas

To study the hypothesis that ingestion of a modified soy-based formula with an improved mineral suspension system may result in bone mineral content similar to that observed in infants fed human milk or cow milk-based formulas. Prospective, self-selected group of infants fed human milk randomized between the two formula-fed groups. University-based hospital nursery and follow-up. Fifty-six normal, healthy, full-term infants, free of major malformations or disorders, including 17 infants fed human milk, 19 infants fed a cow milk-based formula, and 20 infants fed a soy protein formula were followed up to 6 months' postnatal age. The soy-based formula studied was modified to improve the suspendability of the minerals. Infants were fed human milk or the study formula for the first 4 months, at which time beikost was permitted. Infants fed human milk received vitamin supplementation to provide 400 IU of vitamin D per day. Anthropometric variables, serum calcium, magnesium, phosphorus, alkaline phosphatase, and parathyroid hormone levels were measured at enrollment, and at 8, 16, and 24 to 26 weeks' postnatal age. Bone mineral content at the distal third radius site was measured with single photon absorptiometry at these times. Growth in the infants did not differ significantly among the groups. There was no significant difference in serum calcium, magnesium, alkaline phosphatase, or parathyroid hormone concentrations among the infants during the study. Serum phosphorus was significantly lower at 8 weeks in the group fed human milk than in that fed the cow milk-based formula. Bone mineral content at 16 and 24 to 26 weeks was higher in the group fed the soy-based formula than in that fed human milk, and bone width was also higher at 16 weeks in the infants fed the soy-based formula. Improving the suspendability of the mineral system in the soy formula results in bone mineralization in infants fed the soy-based formula similar to that measured in infants fed human milk and cow milk-based formula. We suggest that the suspendability of the minerals used is an important variable in the interpretation of the effect of feedings on the bone mineral status of infants.

Newborn discrimination of speech-like sounds

Knowledge of the development of auditory sensation and perception is of unquestionable theoretical and practical importance. A procedure for behaviorally assessing auditory perception in newborns, based on sucking, has been developed. Neonatal thresholds to tonal stimuli, obtained with this measure, have been reported [A. G. Shoup-Pecenka etal., J. Acoust. Soc. Am. 90, 2297 (A) (1991)]. For the present study, speech discrimination thresholds were assessed in the well-baby nursery of a county hospital. The stimuli used were a forward English /u/ and the same sound played backward, at various intensities (0, 5, 10, 15, and 20 dB re:normal adult threshold). These stimuli were chosen because newborns have been reported to discriminate between them at a suprathreshold level [A. Weintraub, 8th International Conference on Infant Studies (1992)]. Using a procedure similar to the one for obtaining tonal thresholds, the level at which the neonate could determine the difference between two speech sounds was determined and compared to the infant’s 1–3 kHz threshold. Results suggest that speech discrimination thresholds for newborns are comparable to those for adults.

IgM antibody to Treponema pallidum in cerebrospinal fluid of infants with congenital syphilis.

To characterize the neonatal IgG and IgM response to specific Treponema pallidum antigens in the cerebrospinal fluid (CSF) of infants with congenital syphilis. Cross-sectional survey. Newborn nursery and neonatal intensive care unit of a county hospital in Dallas, Tex. Twenty-one infants born to mothers with reactive serologic tests for syphilis were enrolled. Group 1 consisted of six infants with clinical and laboratory evidence of congenital syphilis; group 2, six asymptomatic infants born to mothers with untreated syphilis; and group 3, nine asymptomatic infants whose mothers were treated for syphilis before delivery. Random sample. Immunoblotting was used to examine the IgM and IgG reactivities of neonatal serum and CSF against T pallidum antigens. Among serum samples of all group 1 infants, a specific IgM response to T pallidum antigens with apparent molecular masses of 47, 45, and 17 kd was observed. Cerebrospinal fluid IgM reactivity to a 47-kd antigen of T pallidum was seen in four group 1 infants. Serum samples from two group 2 and three group 3 infants demonstrated IgM reactivity against the 47-kd antigen and, in some cases, against the 45-kd antigen of T pallidum. None of 15 group 2 and 3 infants had a positive CSF IgM immunoblot result. The IgG reactivity in CSF was similar in the three groups and was directed against T pallidum antigens with apparent molecular masses of 72, 59, 47, 45, 42, 37, 34, 17, and 15 kd. A specific IgM response to T pallidum antigens, particularly the 47-kd antigen, was detected in the CSF of some infants with clinical and laboratory evidence of congenital syphilis. The potential usefulness of this test for the diagnosis of congenital neurosyphilis merits further study.

The utilization of genetic counselors within a newborn screening program

Genetic counselors have participated in the Michigan Newborn Screening Program on a contractual basis since 1988. Their role includes newborn screening education and training, newborn nursery site visits, and monitoring newborn screening in hospitals. Their impact has been to improve the quality of newborn screening services by reducing errors and increasing completion of data fields on newborn screening cards, improving hospital nursery cooperation and problem solving, and enhancing health department response to specific problems.

Managing the Cleft Lip and Palate Patient

We have attempted to elucidate, first through an examination of the basic science of clefting and then through a description of the roles of the various members of the cleft palate team, an understanding of the multiplicity of problems faced by this heterogeneous group of children with cleft lip or palate. With an incidence of cleft of 1 in 700 births, all practicing pediatricians will at some time be faced with a patient with a cleft. Pediatric management begins in the hospital nursery by ruling out possible associated anomalies (e.g., congenital heart disease or urinary tract) or syndromes. At the same time, cleft palate nursers may be needed to overcome feeding problems. Simultaneously, counseling for the family begins with a positive attitude toward outcome and an initial explanation of the schedule of corrective procedures, i.e., lip repair at 3 months of age and palate repair at about 1 year. The counseling should incorporate an understanding of the cause of clefting, both its genetics and teratogenetics, and then proceed to noting the actual recurrence risks of 1% for a new cleft and 16% if there is a positive family history in a first-degree relative. The recurrence risks in recognized syndromes may follow mendelian patterns. Later, the pediatrician can help the family deal with multiple ear infections and the likely need for tympanostomy tubes, anticipating the need for tubes in a way that might facilitate placement at the time of anesthesia for the lip or the palate repairs. An understanding of the speech and language difficulties that may be encountered in later infancy may relieve parental anxiety. Later, after palate repair, knowledge of velopharyngeal incompetence may avert premature hypernasal speech problems caused by adenoidectomy, which should be avoided if at all possible. The pediatrician needs to be aware of the tooth malformations that accompany clefting of the alveolus as well as the increased susceptibility to caries, so that the family may be directed to early intervention by the pediatric dentist. With support by pediatrics of the efforts of pediatric dentistry, the child is then in optimal condition for orthodontics. Continually keeping the child's emotional adjustment in mind, the pediatrician can encourage the child and family, knowing that with palatal expansion techniques plus possible bone graft surgery to the cleft alveolus at about 9 years of age, the child may be orthodontically corrected to very near normal.(ABSTRACT TRUNCATED AT 400 WORDS)

Nursery crimes

Managers are axeing hospital nursery places again - ignoring equal opportunity policies in favour of short- sighted savings, warns Linda Nazarko

Hand — Washing in a neonatal intensive care unit: Comparative effectiveness of chlorhexidine gluconate 4% w/v and triclosan 1% w/v

o 1. To evaluate the effects of triclosan on the methicillinresistant Staphylococcus aureus (MRSA) rates in a neonatal intensive care nursery. 2. To measure the amount of skin damage caused by handwashing with triclosan. A seven-week controlled prospective study between two hospital wards using different hand wash products, combined with clinical information on MRSA rates during the previous 10 months. All neonates and nursing staff in the intensive care and special care nurseries of a major metropolitan Australian hospital. The average weekly ‘new case’ MRSA rate was reduced from 3.4 per cent to 0.14 per cent (p>0.0001) in the experimental ward whilst no significant changes occurred in the control ward. Staff reported less skin damage and a higher rate of acceptance with the trial product. Results from the seven-week trial support wider use of the product and more extensive follow-up evaluation.

Neonatal rotavirus infections.

Rotavirus (RV) infections in newborns differ from those in older infants; the majority of RV infections that occur in neonates are mild or asymptomatic. Generally, fewer than one-third of RV-infected neonates have diarrhea, although rates have reached 77% in some hospital nursery populations. Cases with severe diarrhea, necrotizing enterocolitis, bowel perforation, and death have been reported, but such cases are very rare. Infection usually occurs during the first week of life and generally invokes a mucosal antibody response without a concomitant serologic antibody response. Neonatal RV infections appear to incite an immune response that affords significant protection against severe RV-associated diarrhea, although not necessarily against a symptomatic RV infection later in life. Strains that cause neonatal infections differ from those that infect older infants; the outer-capsid protein VP4 is highly conserved in "nursery" RV strains, a property that probably plays a key role in their attenuated virulence. Immaturity of proteolytic enzymes in the neonatal gut and presence of secretory anti-RV IgA and trypsin inhibitors in breast milk are other factors that could account for the asymptomatic nature of RV infections in newborns. Natural "nursery" strains of RV are currently being evaluated as vaccine candidates.

Development of Circadian Sleep-Wake Rhythms in Preterm and Full-Term Infants

We have compared the roles of neurologic maturity and environmental time cues in the development of the entrained circadian sleep-wake rhythm in the preterm and term human infant. The preterm infants (n = 19) spent some time after birth in a hospital nursery with no environmental time cues, whereas the term infants (n = 22) were exposed from birth to a cyclical light and dark environment with one major caregiver. The circadian sleep-wake rhythm in the preterm infants entrained after a similar time of exposure to an environment with daily time cues but at an earlier postconceptional age when compared with the term group. We conclude, therefore, that it is the length of exposure to environmental time cues, rather than neurologic maturity, that determines the entrainment of the circadian rhythm of sleep and wakefulness in the human infant.

Latch Assessment Documentation in the Hospital Nursery

Latch Assessment Documentation in the Hospital Nursery

Bacterial Meningitis in Neonates and Children

A high index of suspicion of meningitis is needed when evaluating neonates and young infants because clinical findings can be minimal and are often subtle and nonspecific. Analysis of the CSF constitutes the most effective method to document meningeal bacterial infection, although overlap with normal CSF values can occur, especially in newborns and very young infants. The introduction of highly active third-generation cephalosporins (ceftriaxone, cefotaxime) and their safety and efficacy in treating a broad array of bacterial pathogens that cause meningitis in all age groups has simplified selection of initial antibiotic therapy. In neonates, however, conventional antibiotic therapy with ampicillin and an aminoglycoside is appropriate because of its proven record of safety and efficacy, and because routine use of cephalosporins in the hospital nursery could lead to selection of resistant strains among gram-negative enteric bacilli. Despite the availability of modern intensive care management of infants and children with bacterial meningitis and the advent of potent antibiotics, case fatality rates and morbidity remain high. Because of this, recent research has focused on the complex interaction between bacteria and the host and on means to attenuate the meningeal inflammatory response. The clinical benefits demonstrated recently with the use of dexamethasone therapy in infants and children with bacterial meningitis underscore the importance of anti-inflammatory therapy to reduce audiologic and neurologic sequelae. Future studies of new methods to modulate meningeal inflammation such as the use of monoclonal antibodies directed against cytokines or of agents that interfere with leukocyte-endothelial interactions are indicated. The implication of routine H. influenzae type b immunization in young infants with the conjugated vaccines and optimal intrapartum prophylaxis against group B streptococcal disease in newborns will have an important impact on the incidence of meningitis in infants and children.

Nosocomial outbreak of neonatal gastroenteritis caused by a new serotype 4, subtype 4B human rotavirus

A nosocomial outbreak of rotavirus gastroenteritis involving 52 newborns occurred between June and September 1988 at the University Children's Hospital of Freiburg, Federal Republic of Germany. Stools from 27 representative patients were examined for rotavirus serotypes, using a monoclonal antibody-based enzyme-linked immunosorbent assay. The electropherotype was also examined by polyacrylamide gel electrophoresis of genomic RNA. As many as 18 patients were found to be infected by serotype 4, subtype 4B strain, and in all of them the same electropherotype was detected. Although rotavirus from the remaining nine patients could not be typed, the electropherotype in four was identical to that of the serotype 4, subtype 4B strain. Thus, most of the patients in the outbreak were infected by the same rotavirus strain. Retrospective epidemiological studies showed that the 4B strain began to circulate at the hospital in January 1988, whereas only rotavirus serotypes 1, 3, and 4A were detected in 1985-1987. The primary case of the outbreak was presumably a newborn with acute gastroenteritis, admitted to the hospital from a small maternity unit in the same urban area. During the outbreak, 12 of 44 healthy newborns in the nurseries of the Children's Hospital and other maternity hospitals were found to be asymptomatic rotavirus carriers, and in three of the newborns the same 4B strain was detected. This is the first reported outbreak caused by a serotype 4, subtype 4B strain.

The relation of obstetrical volume and nursery level to perinatal mortality.

We investigated the relation of hospital delivery volume and nursery technology level to perinatal outcome in 226,164 White singleton births in Washington State, 1980-83. Level III facilities (neonatal intensive care unit) were defined by the state licensing commission. We defined the Level II (intermediate) and Level I (normal newborn) facilities using published criteria. Infants under 2000 gm born in Level III facilities had half the risk of perinatal death compared to those born in a Level I or II facility. No significant improvement was noted among level or volume groupings for normal birthweight infants. A loglinear regression model of hospital perinatal death rates showed that when birthweight and maternal risk were controlled, obstetrical volume added minimal explanatory power to level of nursery care.

Acute Diarrheal Disease in Children under Five Years of Age in the Eastern Province of Saudi Arabia

A follow-up study was conducted in 859 children younger than 5 years who were treated for acute diarrhea at the Diarrhoea Control Center, Dammam, during 1408H (1987-1988). The purpose of the study ...

The “kangaroo-mother” method: Evaluation of an alternative model for the care of low birth weight newborns in developing countries

The “kangaroo-mother” method, that is nursing babies by continuously keeping them wrapped at the mother's breasts, has been proposed as an “appropriate technology” for the care of low birth weight (LBW) newborns in developing countries. We evaluated the effectiveness of this method as an alternative hospital care model in the Special Care nursery of the Central Hospital of Mapto, Mozambique. One hundred LBW newborns (mean birth weight 1329 g, SD ± 208 g) were consecutively admitted to the “kangaroo-mother” section of the unit at the mean postnatal age of 11.6 days. Ninety-five of them were discharged alive after a mean period of 16.3 days of “kangaroo” nursing. During this period they were exclusively breast fed and their mean weight gain was 12.8 g/day. Besides being very effective in improving survival, this method favored the development of early mother-infant relations, which are certainly very important for the long term well-being of the child.

Anonymous HIV Testing on Newborns

To the Editor.— We read with interest the report by Novick et al 1 regarding the prevalence of human immunodeficiency virus (HIV) infection in parturient women in New York State. In Italy, where cases of acquired immunodeficiency syndrome (AIDS) among women and children represent 17.7% and 3.2%, respectively, of all patients with AIDS reported, we carried out a program similar to that described by Novick et al. Using blood samples collected on adsorbent paper during June through December 1988 for the routine detection of hereditary metabolic disorders, we examined for the presence of anti-HIV antibodies (HIV-Ab) 23 492 consecutive newborn babies from 63 hospital nurseries in nine Italian regions. At the National Blood Transfusion Center of the Italian Red Cross, one blood-saturated disk was punched out from each collection paper, without identification of the patient. The sample was eluted in phosphate-buffered saline as described previously 2 and screened for HIV-Ab