Modern Neonatal Intensive Care Units Research Articles

Continuous Positive Airway Pressure vs. Nasal Intermittent Positive Pressure Ventilation in Preterm Neonates: What if Mean Airway Pressures were Equivalent?

Respiratory support for preterm neonates in modern neonatal intensive care unit is predominantly with the use of non-invasive interfaces. Continuous positive airway pressure (CPAP) and nasal intermittent positive pressure ventilation (NIPPV) are the prototypical and most commonly utilized forms of non-invasive respiratory support, and each has unique gas flow characteristics. In meta-analyses of clinical trials till date, NIPPV has been shown to likely reduce respiratory failure and need for intubation compared to CPAP. However, a significant limitation of the included studies has been the higher mean airway pressures used during NIPPV. Thus, it is unclear to what extent any benefits seen with NIPPV are due to the cyclic pressure application vs. the higher mean airway pressures. In this review, we elaborate on these limitations and summarize the available evidence comparing NIPPV and CPAP at equivalent mean airway pressures. Finally, we call for further studies comparing non-invasive respiratory support modes at equal mean airway pressures.

Understanding the Challenges Nurses Encounter with Monitoring Technologies in a NICU

A neonatal intensive care unit (NICU) provides an optimal environment for the care of preterm babies. Bedside nurses are fundamental to this care provided to preterm babies in the NICU. Modern NICUs are technology-intensive space, instrumented with several monitoring technologies to help the nurses track the babies in their care. These technologies help the nurses in a way that is essential for the successful operation of the NICU. To understand how these monitoring technologies function in the NICU from the viewpoint of the nurses, we conducted semi-structured interviews with seven nurses who work at a NICU in the US. We then performed a thematic analysis on the interviews and we found that, despite the utility of the monitoring technologies, they also pose several challenges to the nurses in performing their duties. More specifically, we discovered that: (1) all elements of the monitoring technologies posed a challenge in some way; (2) in a few specific situations, the nurses were able to make up for some of these challenges; and (3) the nurses suggested improvements to all elements of the monitoring technologies. Based on these findings, we describe six areas of future research that argue for the design of monitoring technologies as a way to empower nurses. These include: improved vital signs monitoring that facilitate kangaroo care, using voice to manage alarms, video feeds controlled by nurses in the patient rooms, giving more control over the alarm sounds to the nurses, having a common interface and leveraging augmented reality to help the nurses control the monitoring technologies.

The Process of Assembling A Prognosis in Nicu

The uncertainty of prognosis and the importance of prognosis are in tension with one another, especially in modern neonatal intensive care units (NICU). Prognosis, along with diagnosis, forms the cornerstone of making decisions. Reaching a shared consensus often happens without the participants being fully aware of the process. Child psychiatrists can be helpful in a team to make explicit where the team, the family and the outside specialist teams are up to in arriving at consensus and how they might move beyond times of impasse. Child psychiatrists have not traditionally had a large role in NICU except in relation to the adult mental health. This paper emerged from two child psychiatrists, both pediatric neuropsychiatrists, quietly “observing” and describing the everyday business of a NICU. It elucidates the process of how NICU clinicians in one children’s hospital, and the families they care for, arrive at a consensus despite the uncertainties and the complexities. What is extraordinary is that this process is usually managed without complication.

Accelerating Upstream Together: Achieving Infant Health Equity in the United States by 2030.

Accelerating Upstream Together: Achieving Infant Health Equity in the United States by 2030.

Mortality and Morbidity rounds in neonatology: Providers' experiences and perspectives.

To describe how Canadian level III neonatal intensive care units (NICU) organise mortality and morbidity rounds (M&MR) and explore clinicians' perspectives. This questionnaire study, including open-ended questions, examined the following domains: (1) M&MR format, (2) ethical issues and (3) limitations and perceived effectiveness. Sixteen out of twenty (80%) level III NICUs participated. All deaths and 64% of morbidities were discussed. M&MR occurred monthly (69%) with 3-5 patients discussed hourly (63%) and usually (75%) physician led. Wide variations of practice between centres existed for practical issues, such as administrative support and attendance. 44% of centres allowed nurses to participate. Goals reported by participants were also heterogeneous: reducing medical error (56%), educational (50%), improving communication (44%) and peer review (23%). Practical barriers were time (75%) and lack of resources/structure (25%). Four main themes were as follows: the role of M&MR, the ongoing blame culture, communication issues and the distinction between mortality and morbidity. Goals and format of M&MR vary widely. M&MR remains physician-centric, where the blame culture still endures. Neonatal M&MR models should be adapted to the modern NICU to ensure the M&MR stays relevant. It could also benefit from lessons learned in quality improvement.

Effects of family integrated care on weight gain in extremely preterm infants.

Family integrated care (FICare) is a model that integrates families as partners in the modern neonatal intensive care unit (NICU) care and which can improve the health outcomes of preterm infants. Our study aimed to explore the effect of FICare on extremely preterm infants. Overall, 182 preterm infants with complete data were collected from June 2017 to June 2018 in the Chongqing Health Center for Women and Children. Sixty-six of 182 infants were enrolled into the FICare group, and another 66 matched subjects were in the control group. SPSS v. 20.0 software (SPSS Inc., Chicago, IL, USA) was used for statistical analysis. The correlation between each factor and weight gain was analyzed by linear regression. The rate of weight gain during hospitalization (t=4.32), oxygen exposure time (Z=1.967), hospitalization expenses (t=3.03) and the incidence of retinopathy of prematurity (ROP) (χ2=4.805) were higher in the FICare group (P<0.05). Elevated birth weight was associated with a decrease of the weight growth rate (P<0.001). The growth rate of small-for-gestational-age (SGA) infants was higher than normal gestational age infants, P=0.011. Every one year of increase in maternal age (P=0.016), each additional day for restoration days of birth weight (P=0.023), and each increment of δZ score (P<0.001) increased the weight growth rate. The irregular use of hormones reduced the weight growth rate (P=0.023). Compared with the control group, the weight growth rate of FICare group increased (P<0.001). FICare can significantly improve the weight gain in preterm infants ≤32 weeks during hospitalization.

Incremental Improvements Can Reduce Alarm Fatigue in the Neonatal Intensive Care Unit.

Incremental Improvements Can Reduce Alarm Fatigue in the Neonatal Intensive Care Unit.

Acute Responses to Diuretic Therapy in Extremely Low Gestational Age Newborns: Results from the Prematurity and Respiratory Outcomes Program Cohort Study

To determine if daily respiratory status improved more in extremely low gestational age (GA) premature infants after diuretic exposure compared with those not exposed in modern neonatal intensive care units. The Prematurity and Respiratory Outcomes Program (PROP) was a multicenter observational cohort study of 835 extremely premature infants, GAs of 230/7-286/7 weeks, enrolled in the first week of life from 13 US tertiary neonatal intensive care units. We analyzed the PROP study daily medication and respiratory support records of infants ≤34 weeks postmenstrual age. We determined whether there was a temporal association between the administration of diuretics and an acute change in respiratory status in premature infants in the neonatal intensive care unit, using an ordered categorical ranking of respiratory status. Infants in the diuretic exposed group of PROP were of lower mean GA and lower mean birth weight (P < .0001). Compared with infants unexposed to diuretics, the probability (adjusted for infant characteristics including GA, birth weight, sex, and respiratory status before receiving diuretics) that the exposed infants were on a higher level of respiratory support was significantly greater (OR, >1) for each day after the initial day of diuretic exposure. Our analysis did not support the ability of diuretics to substantially improve the extremely premature infant's respiratory status. Further study of both safety and efficacy of diuretics in this setting are warranted. Clinicaltrials.gov: NCT01435187.

Culture and Sensitivity Pattern of Sepsis in Ventilated Newborns

Introduction: Neonatal sepsis is a major cause of mortality and morbidity in modern neonatal intensive care units (NICU). Increasing trend of antibiotic resistance makes this problem more difficult to tackle, at present. Haemodynamically compromised neonates, particularly those requiring ventilator support, often suffer from multidrug resistant sepsis. The objectives of this study were to determine micro-organisms causing sepsis in those neonates requiring ventilator support and the sensitivity patterns of those micro-organisms.Material and Method: During 18 months of study period, 48 neonates, who had fulfilled the chosen inclusion criteria were included in this study. They were investigated with blood culture, urine culture, CSF culture, and endotracheal tube tip culture (taken within 48 hours of starting ventilation), as per relevance. Those who were found positive to any micro-organism, were also explored. They were studied further for antimicrobial sensitivity pattern. Data obtained from this study were analysed using SPSS-20.0.Results: 15(31.3%) neonates were found to be culture positive. Klebsiella sp. was most common (33.3%) organism isolated, followed by Pseudomonas aeruginosa (20%). Most common antibiotic found to be sensitive was Meropenem (86.67%), followed by Colistin and Tigecycline (80% each).Conclusion: Nowadays, all NICUs throughout the world face a common problem of multidrug resistant sepsis. There is always a doubt regarding choice of second line antibiotics, when one considers for upgradation. As per this study, authors considered Meropenem as second line antibiotic of choice, as other sensitive antibiotics like Colistin, Tigecycline wield more adverse effects on neonates.J Nepal Paediatr Soc 2016;36(1):34-37

Effect of Donor Milk on Severe Infections and Mortality in Very Low-Birth-Weight Infants

Infections and necrotizing enterocolitis, major causes of mortality and morbidity in preterm infants, are reduced in infants fed their own mother's milk when compared with formula. When own mother's milk is not available, human donor milk is considered a good alternative, albeit an expensive one. However, most infants at modern neonatal intensive care units are predominantly fed with own mother's milk. The benefits of add-on donor milk over formula are not clear. To determine whether providing donor milk instead of formula as supplemental feeding whenever own mother's milk is insufficiently available during the first 10 days of life reduces the incidence of serious infection, necrotizing enterocolitis, and mortality. The Early Nutrition Study was a multicenter, double-blind randomized clinical trial in very low-birth-weight infants (birth weight <1500 g) admitted to 1 of 6 neonatal intensive care units in the Netherlands from March 30, 2012, through August 17, 2014. Intent-to-treat analysis was performed. Infants received pasteurized donor milk or preterm formula during the first 10 days of life if own mother's milk was not (sufficiently) available. The primary end point was cumulative occurrence of serious infection (sepsis or meningitis), necrotizing enterocolitis, or mortality during the first 60 days of life. A total of 930 infants were screened for inclusion; 557 were excluded, resulting in 373 infants (183 receiving donor milk and 190 receiving formula) who were evaluated by intent-to-treat analysis (median birth weight, 1066 g; mean gestational age, 28.4 weeks). Own mother's milk comprised 89.1% and 84.5% of total mean intake during the intervention period for the donor milk and formula groups, respectively. The incidence of the combined outcome was not different (85 [44.7%] [formula] vs 77 [42.1%] [donor milk]; mean difference, 2.6%; 95% CI, -12.7% to 7.4%). The adjusted hazard ratio was 0.87 (95% CI, 0.63-1.19; P = .37). In the current study, pasteurized donor milk and preterm formula as supplemental feeding during the first 10 days of life yielded similar short-term outcomes in very low-birth-weight infants regarding safety and efficacy when own mother's milk availability was insufficient. Future studies investigating longer duration of use of human donor milk on short-term and long-term outcomes are necessary. trialregister.nl Identifier: NTR3225.

Cerebral palsy and brain cooling

This month in The Journal there are 3 articles that discuss cerebral palsy (CP) and the use of hypothermia to decrease brain injury in newborns. Garfinkel et al used a Canadian CP registry to estimate that about 5% of CP could be prevented with the effective use of therapeutic hypothermia of asphyxiated term infants delivered in Canada. This low effectiveness results from the multiple factors pointed out in the editorial by Berg. Most cases of CP are not the result of the acute sentinel asphyxial events associated with deliveries, and many of the infants do not qualify for hypothermia treatment. Furthermore, the therapy is not highly effective. This discouraging overall effect of therapeutic hypothermia is compounded in low and middle-income countries (LMIC) as pointed out by the Commentary by Tagin et al. Hypoxic ischemic encephalopathy is responsible for an estimated 25% of all neonatal deaths worldwide, and asphyxia is responsible for a large number of fresh stillborns in LMIC countries. Although therapeutic hypothermia is an effective therapy in high resource environments, it has not been demonstrated to be effective in LMIC in a few trials. Although the therapy is relatively simple to deliver in any modern neonatal intensive care unit, there are multiple obstacles to its effective use in LMIC. Identification of the infant that qualifies for hypothermia treatment by the criteria used in high resource environments requires trained personnel and infrastructure, and, thus, is not easily accomplished. More lives could be saved by upgrading obstetric services to decrease stillborns and providing effective resuscitation, than by developing the infrastructure necessary for the rapid identification and treatment of the asphyxiated infant with hypothermia. Therapies to improve outcomes that are effective in one environment may not work in another. Even though therapeutic hypothermia is a major advance as the first treatment that can decrease brain injury in asphyxiated term infants, its overall impact on the incidence of CP and birth asphyxia will be small within the context of worldwide infant mortality. Article page 25▶ Article page 58▶ Editorial page 8▶ Cerebral Palsy after Neonatal Encephalopathy: How Much Is Preventable?The Journal of PediatricsVol. 167Issue 1PreviewTo determine the expected proportion of term cerebral palsy (CP) after neonatal encephalopathy (NE) that could theoretically be prevented by hypothermia and elucidate the perinatal factors associated with CP after NE in those who do not meet currently used clinical criteria required to qualify for hypothermia (“cooling criteria”). Full-Text PDF Neuroprotection for Perinatal Hypoxic Ischemic Encephalopathy in Low- and Middle-Income CountriesThe Journal of PediatricsVol. 167Issue 1PreviewPerinatal hypoxic ischemic encephalopathy (HIE) is associated with approximately one-quarter of global neonatal deaths.1 In 2010, there were an estimated 1.15 million cases of neonatal encephalopathy, of which 96% of were from low- and middle-income (LMI) countries.2 In the developed world, therapeutic hypothermia is now widely accepted as the standard of care for treating newborns with moderate to severe HIE.3 Therapeutic hypothermia has been found to reduce the risk of death or major neurodevelopmental disability at age 18 months (risk ratio [RR], 0.76; 95% CI, 0.69-0.84) and to increase survival with normal neurologic function (RR, 1.63; 95% CI, 1.36-1.95). Full-Text PDF Prevention of Cerebral Palsy: Which Infants Will Benefit from Therapeutic Hypothermia?The Journal of PediatricsVol. 167Issue 1PreviewCan cerebral palsy (CP) be prevented? The answer depends on the etiology of CP. Although the causes of CP are largely related to early brain injury, both the nature of that injury and the later manifestations can differ based on the gestational and postnatal ages at which the injury occurs, as well as its source. Full-Text PDF

The neonatal nurses' view of their role in emotional support of parents and its complexities

To explore the nurses' views of their role both in the neonatal intensive care unit and in the provision of interacting with, and emotionally supporting, families. The neonatal intensive care nurse has a large and complex clinical role and also a role of emotional supporter for parents in the neonatal intensive care unit. Identifying components of their role and recognising the elements within the nursery that obstruct or encourage this role can allow for modification of nurse education and peer support. Qualitative study based on semistructured interviews. Nine neonatal nurses from a single neonatal intensive care unit were interviewed and the data analysed thematically using NVIVO version 10. Participants viewed their role as an enjoyable yet difficult one, requiring seniority, training and experience. They provided support to parents by communicating, listening, providing individualised support and by encouraging parental involvement with their baby. Constructive elements that contributed to the provision of support included a positive neonatal intensive care unit environment and providing a parent support group. More obstructive elements were a lack of physical neonatal intensive care unit space, little time available for nurse-to-parent conversation and language and cultural barriers between nurses and parents. The role of the neonatal nurse in providing emotional support is complex and requires a high level of ongoing support and education for staff, and minimisation of physical and staff-related obstructions. The modern neonatal intensive care unit offers complex medical and nursing services and with this care comes higher needs from both babies and their parents. Neonatal intensive care unit nurses should be supported in their roles by having peer support available in the neonatal intensive care unit and education and training in emotional support and counselling skills. The nursing staff also require a comfortable and practical physical working space in which to assist parents to be with their baby.

Neonatal Radiation Exposure

Diagnostic radiology is essential in the care of neonates. Survival of extremely preterm neonates and neonates with multiple birth defects inevitably results in a number of diagnostic radiologic procedures being performed in modern neonatal intensive care units (NICUs). Harmful effects of radiation are well known. The number of radiographs performed on preterm neonates is described in several studies over the years. There is no estimate of the number of radiographs performed on neonates of all gestational ages admitted to a NICU. There are multiple dosimetry studies describing the radiation doses from plain chest and abdominal radiographs in preterm neonates. Some of the studies measure the doses imparted by contrast studies in neonates, not preterm neonates. Background natural radiation is estimated to be higher than the radiation from plain radiographs. The radiation from the contrast studies is not known. The article describes the units used to describe doses of radiation, the effects of radiation, and our experience with diagnostic radiographic procedures in neonates of all gestational ages.

Hypertension in infancy: diagnosis, management and outcome

Advances in the ability to identify, evaluate, and care for infants with hypertension, coupled with advances in the practice of Neonatology, have led to an increased awareness of hypertension in modern neonatal intensive care units. This review will present updated data on blood pressure values in neonates, with a focus on the changes that occur over the first days and weeks of life in both term and preterm infants. Optimal blood pressure measurement techniques as well as the differential diagnosis of hypertension in the neonate and older infants will be discussed. Recommendations for the optimal immediate and long-term evaluation and treatment, including potential treatment parameters, will be presented. We will also review additional information on outcome that has become available over the past decade.

Influenza A/H1N1 Virus in Very Low-Birth-Weight Premature Infant: Case Report

Influenza is an uncommon illness among premature infants in developed modern neonatal intensive care units (NICUs), but if infants do manifest symptoms of this significant illness, they commonly present with an abrupt onset, with temperature instability and upper respiratory tract involvement and, commonly, clinical features similar to bacterial sepsis. Additionally, frequent manifestations include bronchiolitis and pneumonia. Influenza infection in premature infants is likely a result of reduced levels of passively transferred protective maternal antibodies. Timely supportive therapy, antiviral agents, and isolation of affected infants to prevent spread of infection may be sufficient protective measures in the NICU. We report a case of a 50-day-old very low-birth-weight premature infant with novel A/H1N1 influenza virus (swine flu). There were no obvious epidemiological conditions in the NICU among patients and staff. The unique presenting symptom was apnea, which required respiratory support by nasal intermittent positive pressure ventilation. Due to the current pandemic, neonatologists should be aware of possible infection of neonates with novel A/H1N1 influenza virus.

Infection control during administration of parenteral nutrition in preterm babies

Total parenteral nutrition (TPN) is standard practice for preterm babies in modern neonatal intensive care units.1 Although more difficult to site, peripherally inserted percutaneous central venous catheters need to be...

Addressing Hemolysis in an Infant Due to Mother–Infant ABO Blood Incompatibility

This issue of the Journal of the Medical Library Association (JMLA) honors the life of and contributions to medical librarianship of Estelle Brodman, PhD. Dr. Brodman's interests in medical bibliography, automation, international collaboration, education, the history of medicine, and the profession were far reaching, and her ideas reflected innovation and a strong desire to grow the profession and skills of medical librarians [1, 2]. Since that time, medical librarianship has continued to evolve, realizing many of the ideas Dr. Brodman and others advocated. For example, the availability of medical databases and widespread use of computers in libraries have improved library processes and the ability to quickly locate information. With her strong advocacy of lifelong learning, Dr. Brodman also serves as an important role model as a librarian/educator, and she would likely have been pleased to see the profession's emphasis on continuing education and research [3, 4]. As McClure noted in her discussion of Dr. Brodman as a historian, Dr. Brodman found that the study of history “often illuminates the meaning of the present and indicates logical possibilities for the future” [5]. The history of the development of neonatal critical care, like that of medical librarianship, has doubtless been influenced and evolved by pioneering thinkers. One such thinker and contemporary of Dr. Brodman, Mildred T. Stahlman, MD, was also a leader in education, practice, and research in her chosen field, neonatal critical care medicine. In 1961, Dr. Stahlman, known as the pioneer of modern neonatal intensive care, led a National Institutes of Health research project to explore the physiological aspects of the developing fetus and changes that occur at birth [6, 7]. At a critical point in her research, Dr. Stahlman made the groundbreaking decision to adapt a scaled-down respirator, a breathing machine originally developed for polio patients, to assist breathing in an infant born with severe hyaline membrane disease, a lung disease seen in premature infants whose lungs have not yet fully developed. The infant, who previously faced certain death, was able to survive with this first-ever respiratory therapy that gave a viable treatment option for preterm babies with underdeveloped lungs [6, 8]. This groundbreaking research led Dr. Stahlman to develop the first modern neonatal intensive care unit (NICU) at Vanderbilt University Medical Center [6]. Today, NICUs have become an essential part of health care in the United States for critically ill infants and their families, providing constant observation and care for these babies. Premature babies, infants born earlier than thirty-seven weeks gestation (the typical threshold for defining normal gestation) [9], represent a high percentage of those cared for by a NICU. These babies often have a variety of developmental issues requiring intensive treatment. Given the constantly evolving state of clinical research, NICU teams frequently encounter information needs requiring consultation of the medical literature.

Current trends in paediatric tracheostomies

In the 1970s, the most common indication for tracheostomy in children was acute inflammatory airway obstruction. Modern neonatal intensive care units have turned long-term intubation into an alternative to tracheostomy. Long-term intubation itself has become the most important indication for tracheostomy combined with subglottic stenosis. Retrospective analysis in a tertiary referral center. A total of 38 patients who underwent tracheostomy for respiratory failure and upper airway obstruction from 1 November 1998 to 30 November 2004. Total complication rate was 42.1%. In children under 1 year of age the complication rate was 47.4%, in children over 1 year the complication rate was 26.3%. Decannulation was attempted in 12 patients with a cannulation time of 22 months. Long-term intubation and its sequelae have now become one of the most important indication for tracheostomy. The change of indication has also entailed a decrease of the average age of children who require tracheostomy. A longer period before decannulation and a lower average age have changed the complication rate of tracheostomy in paediatric patients.

Noise in contemporary neonatal intensive care

Weekly sound surveys (n = 63) were collected, using 5 s sampling intervals, for two modern neonatal intensive care units (NICUs). Median weekly equivalent sound pressure levels (LEQ) for NICU A ranged from 61 to 63 dB (A weighted), depending on the level of care. NICU B L(EQ) measurements ranged from 55 to 60 dB (A weighted). NICU B was recently built with a focus on sound abatement, explaining much of the difference between the two NICUs. Sound levels exceeded 45 dB (A weighted), recommended by the American Academy of Pediatrics, more than 70% of the time for all levels of care. Hourly L(EQ)s below 50 dB (A weighted) and hourly L10s below 55 dB (A weighted), recommended by the Sound Study Group (SSG) of the National Resource Center, were also exceeded in more than 70% of recorded samples. A third SSG recommendation, that the 1 s L(MAX), should not exceed 70 dB (A weighted), was exceeded relatively infrequently (< 11% of the time). Peak impulse measurements exceeded 90 dB for 6.3% of 5 s samples recorded from NICU A and 2.8% of NICU B samples. Twenty-four h periodicities in sound levels as a function of regular staff activities were apparent, but short-term variability was considerable.

Periventricular Hemorrhagic Infarction: Risk Factors and Neonatal Outcome

The aim of this study was to define the incidence, clinical associations, and short-term outcome of periventricular hemorrhagic infarction in the modern neonatal intensive care unit. From 5774 infants (birth weight<2500 gm), periventricular hemorrhagic infarction diagnosed by cranial ultrasound was identified and confirmed. gestational age-matched control infants were identified with normal cranial ultrasounds and detailed clinical data were obtained in both groups. Periventricular hemorrhagic infarction was confirmed in 58 infants. Incidence was 0.1% (1500-2500 gm), 2.2% (750-1500 gm), and 10% (<750 gm). Data across 6 study years reveal increased incidence in infants<750 gm. Compared with control infants, infants with periventricular hemorrhagic infarction had significantly greater association with assisted conception, intrapartum factors (emergency cesarean section, low Apgar scores), early neonatal complications (patent ductus arteriosus, pneumothorax, pulmonary hemorrhage), blood gas disturbances, and need for pressor, volume infusion, and respiratory support. Neonatal mortality of this group was 40% (n=23). Survivors had longer duration of mechanical ventilation and critical care stay compared with control subjects. Thirty-seven percent of survivors required cerebrospinal fluid shunt placement. Periventricular hemorrhagic infarction remains an important neurologic complication of prematurity. A growing population of survivors is apparent among infants with birth weight<750 gm. Multiple hemodynamic factors associated with periventricular hemorrhagic infarction cluster in the intrapartum and early neonatal periods.