level-III Neonatal Intensive Care Unit Research Articles

Incidence and Predictors of Bronchopulmonary Dysplasia Development and Severity Among Preterm Infants Born at 32 Weeks of Gestation or Less.

Background As the most common chronic lung disease (CLD) related to premature birth, bronchopulmonary dysplasia (BPD) is associated with long-term lung disease along with cardiovascular and neurodevelopmental disorders. However, data on the incidence and predictors of BPD in Qatar are lacking. Objectives In this study, we aimed to determine the incidence of BPD among infants born at ≤ 32 weeks gestational age (GA) at our neonatal unit, and identify risk factors for the development of BPD and moderate-severe BPD. Methods This was a retrospective observational cohort study conducted at a single site: a level-III neonatal intensive care unit (NICU) in Qatar. We included 1539 neonates born at ≤ 32 weeks of gestation with birth weights of ≤ 1500 grams who were admitted to the NICU between 2017 and 2020. Univariate and multivariate logistic regression analyses were performed to identify potential factors and predictors and their possible associations with the development of BPD and moderate-severe BPD. We also applied BPD classifications to determine the variability in the incidence of BPD in our cohort according to various definitions (2001 National Institute of Child Health and Human Development (NICHD) Diagnostic Criteria, 2016 Revisions of NICHD Criteria, and 2019 Neonatal Research Network Jensen Grading). Results A total of 451 infants (29.3%) had BPD (BPD group) while 1088 (70.7%) did not (non-BPD group), and the overall incidence of BPD was 29.3%. The most relevant risk factors associated with a higher risk of developing BPD identified in the multivariate logistic regression analysis were appropriate weight for gestational age (adjusted OR (aOR) 3.67, 95%CI 2.02-6.67, P < 0.001), presence of patent ductus arteriosus (PDA) (aOR 2.61, 95%CI 1.86-3.66, P < 0.001), late-onset sepsis (aOR 2.16; 95%CI 1.29-3.62; P = 0.003), and use of invasive ventilation (aOR 1.90; 95%CI 1.35-2.69; P < 0.001). The most relevant independent risk factors associated with a higher risk for developing moderate-severe BDP were postnatal steroids (aOR 7.12, 95%CI 3.77-13.44, P < 0.001), use of inhaled nitric oxide (aOR 3.65, 95%CI 1.48-9.01, P = 0.005), use of invasive ventilation (aOR 2.13, 95%CI 1.13-4.00, P = 0.019), late-onset sepsis (aOR 2.07, 95%CI 1.10-3.91, P = 0.025), and male sex (aOR 2.04, 95%CI 1.24-3.36, P = 0.005). The difference in the distribution of BPD severity across the three different definitions of NICHD was significant (P < 0.001). Conclusion The results of this study showed that the incidence of BPD remained high in infants born at ≤ 32 weeks of gestational age and birth weight <1500 g with appropriate weight for gestational age. The presence of PDA at birth or first echocardiography, late-onset sepsis, and use of invasive ventilation were significant risk factors for the incidence of BPD. The identification of risk factors will contribute to the implementation of lung-protective strategies for at-risk infants who may benefit from potential preventive therapy.

"My Brigham Baby" Application: A Pilot Study Using Technology to Enhance Parent's Experience in the Neonatal Intensive Care Unit.

This study aimed to describe the family psychosocial experience in a level-III neonatal intensive care unit (NICU), and to assess how it evolved after rollout of an educational smartphone application (App) called "My Brigham Baby." We surveyed 25 NICU parents pre-App rollout (before coronavirus disease 2019 [COVID-19] pandemic) and 25 parents post-App rollout (during pandemic). Collected data included parental self-reported discharge readiness, symptoms of stress and anxiety, and parenting skill confidence. Survey scores were assessed as total or mean scores, and by category of severity. Pre-and post-App parents had comparable demographics, and their infants had similar clinical characteristics during their NICU stay. Discharge readiness differed by group status (p = 0.02) and was characterized by a greater frequency in being "very ready" for discharge among the post-App rollout parent group compared with the pre-App group (56 vs. 20%, p = 0.027), and parenting confidence shifted toward more optimal scores post-App rollout. Parental stress and anxiety symptoms did not significantly differ between groups despite possible stress contagion from the COVID-19 pandemic. This pilot study suggests that technology Apps are feasible interventions within NICU settings and may enhance parental experiences related to NICU hospitalization. · Parents' experience increased psychological distress during the time their infant is cared for in the NICU, which has downstream consequences for the family unit.. · In our study, surveyed parents reported higher discharge readiness and parenting confidence shifted toward improvement after rollout of a family education and support smartphone application in a level-III NICU.. · This pilot study suggests that technology applications are feasible interventions that might enhance parental experiences during NICU hospitalization..

Effect of video camera monitoring feedback on hand hygiene compliance in neonatal intensive care unit, an interventional study

BackgroundThe purpose of this study was to determine whether use of a video camera surveillance system for hand hygiene (HH) monitoring, video-based education, and feedback could improve the HH compliance in a neonatal intensive care unit (NICU). Methods and materialsThis was an interventional before-after trial conducted in a level-III NICU between July 2019 and June 2020. HH compliance was measured using randomly selected video-camera footage in the baseline, intervention, and maintenance periods. After the baseline, an intervention consisting of feedback and education with video scenarios was implemented. The primary outcome was change in HH compliance. The compliance rates were analyzed as an interrupted time series (ITS) with a segmented regression model adjusted for autocorrelation for each study period. ResultsWe identified a total of 8335 HH indications. There were non significant increases in the total compliance rate (9.0%, 95% CI -2% to 20%) at the time of intervention and in the compliance rate after intervention (0.26%, 95% CI -0.31% to 0.84%) per day. The hand hygiene compliance before patient contact significantly increased (19.8%, 95% CI, 4.8%-34.8%). Incorrect glove use improved non-significantly with the intervention (-3.4%, 95% CI -13.4% to 6.7%). ConclusionIn this study of HH monitoring using video-camera footage combined with an intervention including feedback and education, there were inconsistent improvements in HH compliance. However, these improvements were not sustained in the long term. Frequent feedback and education may be required to sustain high compliance.

"We Absolutely Had the Impression That It Was Our Decision"-A Qualitative Study with Parents of Critically Ill Infants Who Participated in End-of-Life Decision Making.

Guidelines recommend shared decision making (SDM) between neonatologists and parents when a decision has to be made about the continuation of life-sustaining treatment (LST). In a previous study, we found that neonatologists and parents at a German Level-III Neonatal Intensive Care Unit performed SDM to a variable but overall small extent. However, we do not know whether parents in Germany prefer an extent of more or sharing. We performed a qualitative interview study with parents who participated in our first study. We analyzed the semi-structured interviews with qualitative content analysis according to Kuckartz. The participation in medical decision making (MDM) varied across cases. Overall, neonatologists and parents conducted SDM in most cases only to a small extent. All parents appreciated their experience independent of how much they were involved in MDM. The parents who experienced a small extent of sharing were glad that they were protected by neonatologists from having to decide, shielding them from a conflict of interest. The parents who experienced a large extent of sharing especially valued that they were able to fulfil their parental duties even if that meant partaking in a decision to forgo LST. Other studies have also found a variety of possibilities for parents to partake in end-of-life decision making (EOL-DM). Our results suggest that parents do not have a uniform preference for one specific decision-making approach, but rather different parents appreciate their individual experience regardless of the model for DM. SDM is apparently not a one-size-fits-all approach. Instead, neonatologists and parents have to adapt the decision-making process to the parents' individual needs and preferences for autonomy and protection. Therefore, SDM should not be prescribed as a uniform standard in medico-ethical guidelines, but rather as a flexible guidance for DM for critically ill patients in neonatology.

Efficacy and Safety of Multiple Whole-Body Cleansing With Aqueous 0.5% Chlorhexidine in Stable NICU Preterm Infants—Randomized Controlled Trial

Background: Single application of chlorhexidine soon after birth reduces skin colonization. The benefit is not sustained after 72 h and multiple repeated cleansing is suggested. Such interventions especially in preterm infants need evaluation. Objective: To evaluate efficacy and safety of multiple whole-body cleansing with aqueous 0.5% chlorhexidine during first week in preterm infants. Study Design: Randomized controlled trial with superiority design and triple blinding. Setting: Level-III neonatal intensive care unit of teaching hospital in India. Participants: A total of 120 hemodynamically stable preterm (28-34 weeks) infants without encephalopathy weighing ≥ 1,000 g admitted within 6 h of life. Intervention: Following stratified randomization (28-31 weeks n = 31; 32-34 weeks n = 89), 59 and 61 infants were cleansed with identically looking aqueous 0.5% chlorhexidine wipes and placebo (sterile-water wipes) respectively at 0, 48, and 96 h after recruitment and followed up until neonatal period. Outcomes: Primary outcome was skin colonization rate on day 7. Secondary outcomes include neonatal mortality, incidence of sepsis, adverse skin reactions, and hypothermic episodes and colony counts during first week. Results: We used intention to treat analysis. After multiple cleansings, skin colonization on day 7 with chlorhexidine was 50.9% (28/55) and sterile water was 92.8% (52/56). Risk reduction with chlorhexidine cleansing was 45% compared with sterile water (relative risk = 0.55; 95% confidence interval [CI]: 0.42,0.72). Absolute risk reduction = 41.95% (95% CI: 27.1, 56.78) and number needed to treat = 2.4 persons (95% CI: 1.8, 3.7). Neonatal mortality (10.1% vs 16.3%, P = .539), sepsis (10.1% vs 19.6%, P = .229) was not significant. None had adverse skin reactions. Temperature loss after wet cleansing was not different between chlorhexidine and water. Conclusion: Multiple whole-body cleansing with aqueous 0.5% chlorhexidine at 48 h interval during first week of life reduces skin colonization in preterm infants.

Characterization of Spirituality in Parents of Very Preterm Infants in a Neonatal Intensive Care Unit.

This study aimed to characterize the spiritual beliefs, practices, and needs of parents of very preterm infants, those born <32 weeks of gestation, in a level-III NICU and to characterize parental perception of the spiritual support received in the neonatal intensive care unit (NICU). Within 14 days of their infants' birth, parents underwent a recorded semistructured interview. Responses were organized into unique themes using standard qualitative methods. Parents completed the Spiritual Involvement and Beliefs Scale (SIBS) and Spiritual Needs Inventory (SNI). Twenty-six parents from 17 families were interviewed and provided SIBS and SNI surveys. Interviews yielded seven major themes describing parents' spirituality and support. Most parents identified themselves as spiritual (n = 14) or sometimes spiritual (n = 2). A high SIBS score was associated with Christian religion (p = 0.007) and non-White race (p = 0.02). The SNI showed ≥80% of parents reported a "frequent" or "always" need for laughter, being with family, thinking happy thoughts, and talking about day-to-day things. The most commonly mentioned sources of spiritual support were parents' connection with a higher power through their faith (n = 12) or religious activities (n = 8). Many parents reported receiving sufficient spiritual support outside of the hospital during their unique experience in the NICU. Parents of infants born <32 weeks of gestation in our NICU commonly self-identified themselves as spiritual. Many parents have similar spiritual needs which are often met by sources outside of the hospital. · Parents of infants born <32 weeks of gestation in our NICU commonly self-identify as spiritual.. · Many parents of preterm infants describe their spirituality as a personal experience.. · Many parents of preterm infants have similar spiritual needs.. · Many parents of preterm infants have their spiritual needs met outside of the hospital..

Neonatal nosocomial sepsis in Level-III NICU: Causative pathogens and their antimicrobial sensitivity.

Objective: To find out common organism causing nosocomial sepsis in neonatal intensive care unit (NICU) and their sensitivity to frequently used antibiotics. Study Design: Cross Sectional study. Setting: NICU Pediatric Department of Nishtar Hospital Multan. Period: May 2018 to April 2019. Material &amp; Methods: A total of 111 neonates of either gender admitted with blood culture proven sepsis were included in the study. For culture, blood samples were taken, ensuring standard antiseptic measures, either from a peripheral vein or an artery. Any growth of bacteria after incubation of 24 to 48 hours with only BACTEC and VITEK-2 technique were included, and their drug sensitivity recorded. Demographic data along with causative microorganisms, sensitivity and resistant patterns to frequently used drugs were recorded. Results: Out of 111 patients, 61 (55%) were male. Early onset sepsis (EOS) was present in 37 (33%) patients and 74 (66%) had late onset sepsis (LOS). Serratia species 33 (29.7%) and Staphylococcus epidermidis 31 (27.9%) were the commonest causative bacteria responsible for neonatal sepsis. Commonly involved microorganisms were highly resistant to frequently used antibiotics like ampicillin /amoxicillin, cefixime, ceftazidime. Conclusion: Nosocomial sepsis is a major health issue in NICU while and resistance of pathogens to commonly used antibiotics is alarming.

Development and validation of high definition phenotype-based mortality prediction in critical care units.

ObjectivesThe objectives of this study are to construct the high definition phenotype (HDP), a novel time-series data structure composed of both primary and derived parameters, using heterogeneous clinical sources and to determine whether different predictive models can utilize the HDP in the neonatal intensive care unit (NICU) to improve neonatal mortality prediction in clinical settings.Materials and MethodsA total of 49 primary data parameters were collected from July 2018 to May 2020 from eight level-III NICUs. From a total of 1546 patients, 757 patients were found to contain sufficient fixed, intermittent, and continuous data to create HDPs. Two different predictive models utilizing the HDP, one a logistic regression model (LRM) and the other a deep learning long–short-term memory (LSTM) model, were constructed to predict neonatal mortality at multiple time points during the patient hospitalization. The results were compared with previous illness severity scores, including SNAPPE, SNAPPE-II, CRIB, and CRIB-II.ResultsA HDP matrix, including 12 221 536 minutes of patient stay in NICU, was constructed. The LRM model and the LSTM model performed better than existing neonatal illness severity scores in predicting mortality using the area under the receiver operating characteristic curve (AUC) metric. An ablation study showed that utilizing continuous parameters alone results in an AUC score of >80% for both LRM and LSTM, but combining fixed, intermittent, and continuous parameters in the HDP results in scores >85%. The probability of mortality predictive score has recall and precision of 0.88 and 0.77 for the LRM and 0.97 and 0.85 for the LSTM.Conclusions and RelevanceThe HDP data structure supports multiple analytic techniques, including the statistical LRM approach and the machine learning LSTM approach used in this study. LRM and LSTM predictive models of neonatal mortality utilizing the HDP performed better than existing neonatal illness severity scores. Further research is necessary to create HDP–based clinical decision tools to detect the early onset of neonatal morbidities.

Evaluation of Morbidities and Complications of Neonatal İntensive Care Unit Patients with Respiratory Disorders at Different Gestational Ages.

Respiratory distress presented within the first few days of life is life-threatening and common problem in the neonatal period. The aim of this study is to estimate (1) the incidence of respiratory diseases in newborns and related mortality; (2) the relationship between acute neonatal respiratory disorders rates and gestational age, birth weight, and gender; and (3) the incidence of complications associated with respiratory disturbances. Only inborn patients with gestational age between 230/7 and 416/7 weeks having respiratory distress were included in the study. The data were collected from the medical records and gestational age was based on the menstrual dating. There were 8,474 live births between January 1, 2013, and June 30, 2013, in our hospital. A total of 1,367 newborns were hospitalized and oxygen therapy was applied in 903 of them because of respiratory distress. An acute respiratory disorder was found to be in 10.6% (903/8,474) among all live births. Mortality was 0.76% (66/8,474). The incidence of respiratory distress syndrome was 2.8% (n = 242). The occurrence of transient tachypnea of newborn was 3.1% (n = 270). Meconium aspiration syndrome, pneumonia, congenital diaphragmatic hernia, and pulmonary maladaptation and primary persistent pulmonary hypertension rates were 0.1, 0.7, 2.2, and 0%, respectively. Overall, 553 (61%) of the 903 newborns having respiratory diseases had complications. The occurrence of necrotizing enterocolitis, patent ductus arteriosus, bronchopulmonary dysplasia, intraventricular hemorrhage and air leak was 6.8, 19.8, 4.7, 24.9, and 5%, respectively. This study offers an epidemiological perspective for respiratory disorders from a single-center level-III neonatal intensive care unit. Although number of births, premature newborns, extremely low birth weight/very low birth weight infants, and complicated pregnancies increase in years, decreasing rates of mortality and complications are very promising. As perinatal and neonatal cares are getting better in every day, we think that more promising results can be achieved over the coming years. · Respiratory distress in the newborn is life-threatening.. · Pulmonary or extrapulmonary diseases may be underlying cause.. · More promising results can be achieved over the coming years with advanced care..

Timing of Antenatal Steroid Administration and Effects on the Newborn Infant: A Retrospective Study.

The timing of antenatal steroids (ANS) on short- and long-term effects on newborn infants was evaluated. This study was conducted at the University of Cincinnati Medical Center Level-III Neonatal Intensive Care Unit by reviewing the medical records of all women with history of ANS exposure from January 2015 to December 2018. We compared outcomes of newborns delivered within the ideal therapeutic window of 24 hours to 7 days (within window [WW]) after administration to those exposed and delivered outside the therapeutic window (outside window primary group [OWP]). Outcomes included anthropometrics, blood sugars, thyroid hormone profile, and neonatal morbidities. A total of 669 patients were identified as having received at least two doses of ANS. Two-thirds of them delivered within the ideal therapeutic window. Significant differences were found in anthroprometrics including lower birth weight, shorter length, and smaller head circumferences in those born within the window compared with those outside the window. Derangements in glucose homeostasis requiring treatment and elevations of thyroid stimulating hormone (TSH) were seen in infants born outside the ideal therapeutic window compared with those born within the therapeutic window. No differences were found in neonatal morbidities including severe intraventricular hemorrhage (sIVH), necrotizing enterocolitis (NEC), need for resuscitation, exogenous surfactant administration, continuous positive airway pressure (CPAP), mechanical ventilation, bronchopulmonary dysplasia (BPD), or periventricular leukomalacia (PVL). After controlling for selected covariates, only birth length was different between the groups. Effects on anthropometrics, glucose homeostasis, and thyroid function support the need to develop new or refine existing risk stratification systems to time the administration of antenatal steroids. Better targeting of women and fetuses may confer the benefits of systemic corticosteroids while mitigating the risks of adverse effects. · The timing of antenatal steroids on short and long-term effects on newborn infants was evaluated.. · Differences were found in anthroprometrics, glucoses, and thyroid function.. · No differences were found in neonatal morbidities..

Mortality Caused by Late-onset Sepsis in Very Low Birth Weight Infants: Risk Analysis and the Performance of Diagnostic Tools.

To assess the risk on late-onset sepsis attributed mortality in very low birth weight (VLBW) infants. Study Design: Observational study. Level-III Neonatal Intensive Care Unit, İstinye University, Antalya Medical Park Hospital, Turkey, between January 2014 and December 2018. Perinatal characteristics and clinical features of 198 septic preterm neonates were evaluated to predict sepsis-attributed mortality. ROC analysis was employed to drive optimal-cutoffs for laboratory parameters and logistic regression to calculate mortality risk factors using SPSS version-22 and MedCalc software. Mean gestational age was 28.91 ±2.67 weeks. Umbilical catheterisation was the principal risk factor for culture-positive sepsis (OR 2.860, 95%CI: 1.232-6.639). Outborn infants were more likely to deliver surfactant and longer intubation (p=0.013, and p=0.005, respectively), manifested frequent BPD (p=0.014), and at greater risk of proven sepsis and mortality (OR: 1.796, 95%CI: 1.011-3.191; OR: 1.950, 95%CI: 1.002-3.794). Low Apgar scores necrotising enterocolitis (NEC) and prolonged intubation were independent risk factors for mortality (OR: 13.840, 95%CI: 6.384-30.005; OR: 5.410, 95%CI: 2.113-13.849; OR: 10.037, 95%CI: 4.700-21.434). An increase in high-sensitivity C-reactive protein (hsCRP)-ratio >6.08-fold afforded good sensitivity and specificity (AUC: 0.914; sensitivity: 89.36%, specificity: 86.09%). Logistic regression of various combinations has shown a >6.08-fold change in hsCRP-ratio over 24-hours and platelet counts <88x109/L optimally predicted mortality (OR: 27.983, 95%CI: 9.704-80.697). Low Apgar scores, NEC and prolonged intubation are independent risk factors for mortality of VLBW infants. Birth in level III-IV NICUs featuring special neonatal care, avoidance of prolonged intubation, and timely prediction of fatal sepsis using hsCRP ratio and platelets could prevent sepsis-related mortality. Key Words: Sepsis, Very low birth weight, Infant formality, Apgar score.

MATERNAL VIRTUAL INFANT NUTRITION SUPPORT CLINIC FOR THE NEONATAL INTENSIVE CARE UNIT (MAVINS-NICU) - A QUALITATIVE STUDY

Abstract BACKGROUND Canadian exclusive breastfeeding rates at 6 months of age are only 24.2%, and are even lower in mothers of infants requiring Neonatal Intensive Care Unit (NICU) admission. An interactive website was developed that provides professional (articles, videos) and peer (discussion forum for peers, access to a lactation consultant) breastfeeding support to mothers of infants requiring NICU admission. OBJECTIVES The objective of the study is to outline maternal perceptions of the breastfeeding support website (MAVINS-NICU) in a level-III NICU setting. DESIGN/METHODS This study represents the qualitative research component of the MAVINS-NICU project. Semi-structured interviews were conducted antenatally with women at risk of delivering an infant requiring NICU admission (n=6), and postnatally with mothers of infants admitted to the NICU (n=7), regarding their experiences with the MAVINS-NICU website. Interviews were audio-recorded and transcribed by a professional transcriptionist. Analysis occurred in an iterative fashion using open and axial coding strategies to identify majors themes. RESULTS Several themes were identified: 1) Women seemed comforted that a reliable hospital-provided resource would be available to them after birth, “…I’m very happy that I’m going to have lots of support”; 2) Women felt overwhelmed after birth, but often accessed the website on their phone or read newly posted comments on the discussion forum in response to automatically generated weekly emails from the website, “I’m just, overwhelmed… because I’m [in the NICU a lot], I only have my phone and it’s just easier to look at the emails… [they] just pop up”; 3) Mothers felt extremely comforted by the peer support component of the website, “to see what other moms are going through … similar emotions or issues … to see that I’m not the only one [helps]”; 4) Mothers enjoyed remote access and quick online lactation consultant response times, “ … [you can] get help even when there’s no one around”, “I was really surprised … by how quickly I got responses”; 5) Majority of mothers expressed a sense of empowerment to provide breast milk with the help of MAVINS support, “…being able to breastfeed eventually is a big deal for me… [it made me feel] like I was accomplishing something”. CONCLUSION Mothers of infants admitted to the NICU found the MAVINS-NICU website very helpful and considered it part of their success in providing breast milk for their babies.

Nosocomial sepsis: evaluation of the efficacy of preventive measures in a level-III neonatal intensive care unit

Objective: To evaluate nosocomial infections preventive bundle, implemented in April 2010 in Centro Hospitalar de São João (CHSJ) Neonatal Intensive Care Unit (NICU) effectiveness. Methods: Newborns admitted to level-III NICU of CHSJ, between 1 April 2007 and 31 March 2013, with sepsis as discharge diagnosis, were selected and divided into two periods (Period 1 and 2, before and after new preventive bundle introduction). Data from the two periods were compared. Results: Nosocomial sepsis incidence density decreased significantly from 8.6 to 4.8 per 1000 patient days from Period 1 to 2. Nosocomial infections preventive bundle implementation led to a significant decrease in central line-associated bloodstream infections (CLABSI) rates from 14.1 to 10.4 per 1000 catheter days. Conclusions: Nosocomial infections preventive bundle implemented revealed efficient in decreasing the incidence density of nosocomial sepsis. However, CLABSI rates remain high. Physicians should be alert to the need to adhere to strict infection control protocols and institute effective measures for nosocomial infection surveillance.

Geographic Accessibility to Health Services and Neonatal Mortality Among Very-Low Birthweight Infants in South Carolina.

Introduction Mortality for infants born with very-low birthweight (VLBW, 500-1499 grams) is markedly higher than for babies born with normal birthweight (2500-4000 grams). Although these high-risk infants show better outcomes in advanced care settings, only 80% of VLBW infants born in South Carolina (SC) are delivered in hospitals with a level-III neonatal intensive care unit (NICU). The purpose of this research project was to assess geographic access to delivery hospitals and risk of neonatal death among singleton VLBW infants born in SC. Methods The linked birth and death records of a cross-sectional, population-based study of singleton VLBW infants born in SC between 2010 and 2012 were used (n=2030). We assessed the impact of travel time from maternal residence to delivery hospital. Logistic regression modeling was performed with adjustments for maternal, newborn, and hospital characteristics. Results The neonatal mortality rate among singleton VLBW infants was 11.03 deaths per 100 live births in 2010-2012. We did not find a significant association between travel time to delivery hospital and neonatal mortality after adjusting for confounders. However, we found that a 1-week increase in gestational age (odds ratio (OR): 0.61) and non-Hispanic black mothers (versus non-Hispanic white mothers) (OR: 0.68) were associated with lower odds of neonatal death, whereas non-NICU admission at birth (OR: 5.90) was associated with increased odds of death. The results of the sensitivity analyses including both singleton and multiple births did not yield significant results for travel time and neonatal mortality in VLBW infants. Discussion Although we found no significant association between travel time and neonatal mortality in singleton VLBW births in SC, we identified significant factors consistent with those found in previous studies that may affect neonatal mortality.

Mothers' Psychological Distress and Feeding of Their Preterm Infants.

To examine the change in psychological distress of mothers of preterm infants and its association with maternal feeding behaviors as the infant transitions to full oral feeding. This descriptive exploratory study used a subset of data from a study of the effects of a coregulated feeding intervention for 34 mothers and hospitalized preterm infants in a Level-III neonatal intensive care unit (NICU). Maternal psychological distress was measured by maternal worry (Child Health Worry Scale), depression (Center for Epidemiology-Depression Scale), and role stress (Parental Stress Scale: NICU-Role Alteration) at three time points: within 1 week prior to the first oral feeding (T1), and at achievement of half (T2) and full oral feeding (T3). Feedings were videotaped at T2 and T3. An observational coding system measured maternal feeding behaviors. Linear mixed modeling evaluated the change in maternal psychological distress and its association with mothers' feeding behaviors as the infant transitioned to full oral feeding. Maternal depressive symptoms were highest at T1 and declined over time. Maternal worry and role stress were also highest at T1 but remained stable from T2 to T3. Increased maternal psychological distress, particularly depressive symptoms and role stress, were associated with less use of developmentally supportive feeding behaviors, that is, minimizing tactile stimulation, providing steady touch to contain or stabilize the infant, and regulating milk flow. Supporting maternal psychological well-being while infants are learning to feed orally may be an appropriate target for interventions to support mother-infant early feeding interactions.

Manifestations of Cow's-Milk Protein Intolerance in Preterm Infants.

Cow's-milk protein intolerance (CMPI) is poorly recognized in preterm infants. This study examined the clinical events that preceded the diagnosis of CMPI in preterm infants. This was a retrospective study of infants in a level-III neonatal intensive care unit of those who received parenteral nutrition (PN) support during a 12-month period. Parameters assessed included birth weight (g), diagnosis, duration and frequency on PN, type of enteral feeds at initiation, and achievement of enteral autonomy. CMPI was diagnosed based on persistent feeding intolerance that resolved after change of feeds from intact protein to a protein hydrolysate or crystalline amino acid formula. Three hundred forty-eight infants with birth weight (median/range) 1618 g (425-5110) received PN. Fifty-one (14%) infants required multiple courses of PN, and 19 of 348 (5%) were diagnosed with CMPI. The requirement for multiple courses on PN versus single course was associated with a high likelihood of CMPI: 14 of 51 versus 5 of 297, P < 0.001. Nine of the 14 infants identified with CMPI were initially diagnosed with necrotizing enterocolitis (NEC) after a median duration of 22 days (19-57) on intact protein feeds. After recovery from NEC, they had persistent feeding intolerance including recurrence of "NEC-like illness" (N = 3) that resolved after change of feeds to a protein hydrolysate or crystalline amino acid formula. The requirement for multiple courses of PN because of persistent feeding intolerance after recovery from NEC and recurrence of "NEC-like illness" may be a manifestation of CMPI in preterm infants.

Appropriateness of care and moral distress among neonatal intensive care unit staff: repeated measurements.

Perceived constraints to providing patient care in their own morally justified way may cause moral distress (MD) in neonatal nurses and physicians. Negative long-term effects of MD include substandard patient care, burnout and leaving the profession. To assess the immediate impact of perceived inappropriate patient care on nurses' and physicians' MD intensity, and explore a possible moderating effect of ethical climate. In a repeated measures design, after baseline assessment, each participant completed self-report questionnaires after five randomly selected shifts. Data were analysed with logistic and Tobit regression. Data were collected among 117 of 147 eligible nurses and physicians (80%) in a level-III neonatal intensive care unit in the Netherlands. At baseline, overall MD was relatively low; in nurses, it was significantly higher than in physicians. Few morally distressing situations were reported in the repeated measurements, but distress could be intense in these cases; nurses' and physicians' scores were comparable. Physicians were significantly more likely than nurses to disagree with their patients' level of care (p = 0·02). Still, perceived overtreatment, but not undertreatment, was significantly related to distress intensity in both professional groups; ethical climate did not moderate this effect. Substandard patient care due to lack of continuity, poor communication and unsafe levels of staffing were rated as more important causes of MD than perceived inappropriate care. Although infrequently perceived, overtreatment of patients caused considerable distress in nurses and physicians. Our unit introduced multidisciplinary medical ethical decision making 5 years ago, which may partly explain the low MD at baseline. MD might be prevented by improved continuity of care, safe levels of staffing and better team communication, along with other targeted interventions with demonstrated effectiveness, such as palliative care programs and facilitated ethics conversations.

Making Meaning of Pumping for Mothers of Infants With Congenital Diaphragmatic Hernia

To describe the process of initiation and maintenance of milk supply and potential transition to direct breastfeeding among mother/infant dyads with infants with congenital diaphragmatic hernia (CDH). A Level-III neonatal intensive care unit. Eleven mother/infant dyads with infants with CDH. Prospective, longitudinal qualitative descriptive design. Semistructured interviews were conducted over the course of the NICU stay. Conventional content analysis was used. Human milk oral care emerged from the interview data as a strong facilitating factor to encouraging mothers to continue pumping during hospitalization. Four main themes emerged regarding the importance and value of human milk oral care for the mothers in relation to pumping and maintenance of milk supply: (a) It motivates me; (b) I'm a part of my baby getting better; (c) We do it together, and (d) We're getting somewhere. The findings of this study reflect the importance and value of human milk oral care as a driving factor to motivate mothers to maintain milk supply during the critical time when the infant with CDH is not able to take in enteral nutrition and throughout the hospital stay.

Prospective surveillance of antibiotic use in the neonatal intensive care unit: results from the SCOUT study.

Prolonged or unnecessary antibiotic use is associated with adverse outcomes in neonates. Our objectives were to quantify all antibiotic use in a Level-III neonatal intensive care unit and to identify scenarios where their use could be reduced. Surveillance and evaluation of all antibiotic use provided to every infant admitted to a Level-III neonatal intensive care unit from 10/3/11 to 11/30/12 was performed. Types of antibiotics, reasons for their initiation, discontinuation and duration, as well as clinical, laboratory and outcome data were recorded. Antibiotic use was quantified by days of therapy (DOT) per 1000 patient-days (PD). A total of 1607 infants were included. The total antibiotic use was 9165 DOT (343.2 DOT/1000 PD; 5.7 DOT/infant). Seventy-two percent of infants received 1 (43%) or more (29%) courses of antibiotics. Gentamicin (46%), ampicillin (39%) and oxacillin (8%) were the most frequently used agents. Ninety-four percent of antibiotic use (323 DOT/1000 PD) was empiric therapy for suspected infection. Sixty-three percent (216.2 DOT/1000 PD) was discontinued at approximately 48 hours when cultures were sterile (68%>48 hours, 32%≤48 hours). Twenty-six percent of all antibiotic use (89.4 DOT/1000 PD) was therapy for ≥5 days despite sterile cultures; pneumonia (16%) and "culture-negative" sepsis (8%) were the major contributors. Five percent (17.4 DOT/1000 PD) of antibiotic use was for culture-proven sepsis, 5% (16.6 DOT/1000 PD) was penicillin prophylaxis for group B Streptococcus and 1% (3.5 DOT/1000 PD) was preprocedural prophylaxis. Narrow-spectrum therapy accounted for >92% of antibiotic use and would not be monitored by most stewardship programs. Only 5% of antibiotic usage was due to culture-proven infection. Pneumonia and "culture-negative" sepsis were frequent reasons for prolonged therapy; further study of these conditions may allow reduction in treatment duration.

Barriers and Facilitators to Implementing the Baby-Friendly Hospital Initiative in Neonatal Intensive Care Units

To explore manager, educator, and clinical leader perceptions of barriers and facilitators to implementing Baby-Friendly practice in the neonatal intensive care unit (NICU). Qualitative, descriptive design. Two university-affiliated level-III NICUs in Canada. A purposive sample of 10 medical and nursing managers, nurse educators, lactation consultants, and neonatal nurse practitioners. In-depth, semistructured interviews transcribed and analyzed using qualitative content analysis. Participants valued breastfeeding and family-centered care yet identified numerous contextual barriers to Baby-Friendly care including infant health status, parent/infant separation, staff workloads and work patterns, gaps in staff knowledge and skills, and lack of continuity of breastfeeding support. Facilitators included breastfeeding education, breastfeeding champions, and interprofessional collaboration. Despite identifying numerous barriers, participants recognized the potential value of expanding the Baby-Friendly Hospital Initiative (BFHI) to the NICU setting. Recommendations include promoting BFHI as a facilitator of family-centered care, interdisciplinary staff education, increasing access to lactation consultants, and establishing a group of NICU champions dedicated to BFHI implementation.