Neonatal Intensive Care Environment Research Articles

Optimal presence: enhancing parent integration to maximize neurodevelopmental outcomes in preterm infants.

Preterm birth disrupts the natural progression of events in the parent-infant relationship and bestows many of the typical parent responsibilities to the clinical care team. In turn, the neonatal intensive care environment (NICU) introduces obstacles to parents that would not otherwise be encountered and forces parents to adapt to this artificial environment as they seek to bond with and care for their newborn. Facilitating parent presence at the bedside and incorporating them into the care of their preterm infant is critical for lessening the immediate burden to both the parent and offspring while also ensuring the best possible outcome for preterm infants. In this review, we explore the impact that parents exert on the neurodevelopmental outcome of preterm infants and identify several barriers and facilitators to parent presence.

Maternal Needs and Priorities in Neonatal Intensive Care Environment: A Cros- sectional study in the UAE


 
 
 Background: HospitalizaBon of neonates in the Neonatal Intensive Care Unit (NICU) pre- sents significant stress and adaptaBon challenges for mothers. Understanding their needs is crucial for opBmal care, as unmet needs can adversely affect both maternal and infant health outcomes.
 Purpose: This study aims to systemaBcally assess the maternal needs and prioriBes in the NICU seRng, emphasizing the significance of maternal well-being in neonatal care.
 Methods: Employing a cross-secBonal survey design, we engaged 200 mothers of hospi- talized neonates in Al Qassimi Women and Children Hospital, Sharjah. The Maternal Needs Inventory, comprising 25 items across five dimensions (Assurance, Proximity, InformaBon, Support, and Comfort), was uBlized. Mothers rated their needs and listed their top five prioriBes.
 Results: Assurance needs emerged as paramount, with 87.2% of mothers highlighBng them as criBcal. Comfort needs were deemed least important (52.4%). A significant associaBon was noted between maternal needs and certain demographic variables, underscoring the diversity of maternal experiences in the NICU.
 Conclusion: The Maternal Needs Inventory proves to be an effecBve tool in recognizing and addressing mothers’ needs in the NICU. Addressing these needs is vital for fostering a family-centered care approach, crucial for both maternal and neonatal well-being.
 
 

Effects of the neonatal intensive care environment on circadian health and development of preterm infants.

The circadian system in mammals ensures adaptation to the light-dark cycle on Earth and imposes 24-h rhythmicity on metabolic, physiological and behavioral processes. The central circadian pacemaker is located in the brain and is entrained by environmental signals called Zeitgebers. From here, neural, humoral and systemic signals drive rhythms in peripheral clocks in nearly every mammalian tissue. During pregnancy, disruption of the complex interplay between the mother's rhythmic signals and the fetal developing circadian system can lead to long-term health consequences in the offspring. When an infant is born very preterm, it loses the temporal signals received from the mother prematurely and becomes totally dependent on 24/7 care in the Neonatal Intensive Care Unit (NICU), where day/night rhythmicity is usually blurred. In this literature review, we provide an overview of the fetal and neonatal development of the circadian system, and short-term consequences of disruption of this process as occurs in the NICU environment. Moreover, we provide a theoretical and molecular framework of how this disruption could lead to later-life disease. Finally, we discuss studies that aim to improve health outcomes after preterm birth by studying the effects of enhancing rhythmicity in light and noise exposure.

Providers’ perspectives of the neonatal intensive care unit context and care provision for adolescent parents: an interpretive description

BackgroundThe neonatal intensive care unit (NICU) is a complex care environment, with the NICU patient population among the most vulnerable in a hospital setting. Adolescent parents are a unique group within the broader NICU parent population and admission of their infant to the NICU contributes to an already complex situation as adolescent pregnancy and parenting is often associated with a range of psychosocial challenges. How the NICU care context influences care provision for adolescent parents is a significant gap in the NICU parenting and support discourse. Therefore, this study aimed to explore health and social care providers’ perspectives of the NICU care context and how providers perceive the context as influencing the experiences of adolescent parents in the NICU.MethodsThis was a qualitative, interpretive description study design. In-depth interviews were conducted with providers, including nurses and social workers, caring for adolescent parents in the NICU. Data was collected between December 2019 and November 2020. Data were analyzed concurrently with data collection. Constant comparison, analytic memos, and iterative diagramming techniques were used to challenge developing analytic patterns.ResultsProviders (n = 23) described how the unit context influenced care provision as well as experiences for adolescent parents. We learned that having a baby in the NICU was perceived by providers as a traumatic experience for parents – impacting attachment, parenting confidence and competence, and mental health. Environmental factors – such as privacy and time – and perceptions that adolescent parents are treated differently in the NICU were also seen as influencing this overall experience.ConclusionsProviders involved in the care of adolescent parents in the neonatal intensive care unit described the distinctiveness of this group within the broader parent population and how quality of care may be impacted by contextual factors as well as experiences of age-related stigma. Further understanding of NICU experiences from the parents’ perspectives are warranted. Findings highlight opportunities for strengthened interprofessional collaboration and trauma- and violence-informed care strategies within the neonatal intensive care environment to mitigate the potential negative influence of this experience and improve care for adolescent parents.

Cradles of Life

Medical technologies have intervened on the critical post-natal time and space by augmenting and/or optimizing conditions intended to increase survival. As contested, contextual, and transformative spaces, incubators fulfill particular biological needs while also becoming sites where political realities, human emotion, ritual and symbolism converge upon vulnerability. I explore sociopolitical contexts of vulnerability and protection in global and cross-cultural context, while drawing on prior scholarship in anthropology of motherhood, material culture, as well as feminist and reproductive anthropology. Events in popular culture like the Danish Octo Project and Purple Butterfly Initiative provide insight into lived experience and everyday interactions with incubators and the neonatal intensive care environment. In response to popular assumptions of technological advancements in clinical medicine as apolitical apexes of innovation, we must complicate their technical utility with profoundly human experiences toward and around them. In doing so, we situate and implicate technology in political and discursive narratives and reflect on these objects as more than sums of their parts. This essay contributes to broader discussions about the materiality of medical technologies and their environments, and illuminates new possibilities to examine corollaries of grief, hope, maternalism, memory, and the resilience of human psyches and physiologies.

Concordance of temperature measurements on preterm and term infants using oesophageal (core), axilla & skin methods in a neonatal intensive care unit

Aimthe aim of this contemporary paper is to investigate agreement between the axilla, core (oesophageal) and skin method of temperature taking. DesignA comparative descriptive design with a non-probability convenience sample used to describe the difference in recorded temperature by each method in preterm and term infants, gestational age from 24 weeks to term +14 days. MethodAll infants born at 24 weeks and term plus 14 days gestation, admitted to NICU and received parental consent were enrolled in the study. Infants were nursed in various thermal environments.Oesophageal temperature was recorded using the InnerSense sensor/feeding tube (Philips Healthcare, axilla by the BD digital thermometer and skin temperature by the Philips skin temperature probe. ConclusionThe results of this study demonstrate that oesophageal and axilla temperature estimates are very similar, with most differences less than 0.5 °C (CC = 0.63). By contrast, a comparison of oesophageal and skin method temperature estimates shows a much weaker agreement (CC = 0.37).This study confirms that oesophageal temperature taken via the Philips InnerSense can be used safely, as it agrees with the axilla method.Infants nursed in the neonatal intensive care environment, especially when preterm or term with PPHN for example, have special requirements for temperature regulation and minimal handling.

The effects of education levels of developmental care in Australia: Perceptions and challenges

BackgroundDevelopmental care consists of a range of clinical, infant-focused, and family-focused interventions designed to modify the neonatal intensive care environment and caregiving practices to reduce stressors on the developing brain. Since the inception of developmental care in the early 1980s, it has been recommended and adopted globally as a component of routine practice for neonatal care. Despite its application for almost 40 y, little is known of the attitude of neonatal nurses in Australia towards the intervention. Aims and objectivesThe objective of this study was to establish Australian neonatal nurse perceptions of developmental care and explore associations between developmental care education levels of the nurses and personal beliefs in the application of developmental care. DesignThis involves a cross-sectional survey design. MethodsAn online questionnaire was completed by 171 neonatal nurses. Participants were members of the Australian College of Neonatal Nursing (n = 783). Covariate associations between key components of developmental care and respondents' geographical location, place of employment, professional qualifications, and developmental care education level were analysed. The reporting of this study is in accordance with the Enhancing the Quality and Transparency of Health Research Checklist for Reporting Results of Internet E-Surveys. ResultsDifferences were observed between groups for geographical location, place of employment, and professional qualification level. Rural nurses were less likely to support the provision of skin-to-skin care (odds ratio [OR]: 0.6, 95% confidence interval [CI]: 0.2–1.8) than nurses in a metropolitsan unit. Nurses working in a neonatal intensive care unit and nurses with postgraduate qualifications were more likely to support parental involvement in care ([OR: 2.3, 95% CI: 0.9–6.2] and [OR: 2.1, 95% CI: 0.6–7.4], respectively). Rural respondents were more likely to have attended off-site education (OR: 3.6, 95% CI: 1.3–9.9) than metropolitan respondents. ConclusionThe application of developmental care in Australia may be influenced by inadequate resources and inequitable access to educational resources, and similar challenges have been reported in other countries. Overcoming the challenges requires a focused education strategy and support within and beyond the neonatal intensive care unit.

SP6 Building on the druggle: personalised feedback to improve and maintain good prescribing practice

BackgroundInspired by work from a number of other centres,1 2 a weekly ‘Druggle’ was set up on our 28 cot tertiary, level 3 neonatal intensive care unit in June 2018. The Druggle is a short pharmacist-led briefing in the clinical area involving doctors and nurses, focussing on prescribing and administration issues and errors. Over the first year a concurrent zero tolerance audit shows an improvement in prescribing practice, with an increased number of charts with zero errors (63% in June 2018, 95% in June 2019). Despite the improvements in prescribing practice, average attendance at the Druggle has fallen from 17 people per week to 7 over the year. It was decided to consider personalised feedback on prescribing as a potential new mechanism to improve and maintain prescribing standards.AimTo investigate if structured, personalised feedback to prescribers on a neonatal unit could be an innovative way of improving prescribing standards and patient safety. The project was set up to gain an insight into prescribers attitudes towards prescribing feedback and to see what impact that feedback might have on their attitudes after it had been carried out.MethodAll prescribers on the unit were invited to complete an online questionnaire which included questions on previous experience of feedback and attitudes towards structured, personalised prescribing feedback. Participants were also able to express their interest in participating in a feedback session.A selection of prescribers who had chosen to participate were then monitored and contacted to arrange a feedback session. This comprised of a short interview style session based on Pendleton’s rules for feedback3 in which pictures of their prescriptions were appraised and a structured feedback form completed by the pharmacist was reviewed. The feedback form was split into sections covering legibility, accuracy and completeness, with each section having a non-numerical scoring system, together with practical examples and suggestions for improvement.After the feedback session, prescribers were asked to complete a feedback response form which allowed them to express how useful they found the feedback, whether they felt it would change their practice and to give comments.ResultsThe initial questionnaire was completed by a wide variety of prescribers including different grades of doctor and advanced neonatal nurse practitioners (ANNPs) with a range of 0–15 years of neonatal prescribing experience. 45% of respondents had never received personalised prescribing feedback, and 90% of respondents said they would welcome it. Comments included a desire for positive feedback as well as suggestions for how to improve. Feedback sessions are still ongoing, and initial results of the post-feedback questionnaire are positive – mean score of 4.3/5 for usefulness of feedback to practice. Comments include ‘This has been the single most useful feedback for my prescribing practice to date’ – ST5 Doctor.ConclusionProviding personalised feedback to prescribers is welcomed and should be explored more widely. Initial results show that prescribers find personalised feedback useful and they can use it as a basis for reflecting on prescribing practice.ReferencesReece A, Hill A, Platt B, et al. G171 Improving situation awareness in prescribing: A medication safety huddle – the DRUG-gle (Druggle). Arch Dis Child 2016;101:A89.Bell C, Jackson J, Shore H. P3 S.a.f.e. – the positive impact of ‘druggles’ on prescribing standards and patient safety within the neonatal intensive care environment. Arch Dis Child, 2018;103:e2.Pendleton D, Schofield T, Tate P, et al. The consultation: an approach to learning and teaching. Oxford: Oxford University Press, 1983.

Perceived Maternal Needs and Priorities in Neonatal Intensive Care Environment

Perceived Maternal Needs and Priorities in Neonatal Intensive Care Environment

Sentimentos maternos frente à hospitalização do filho prematuro: análise de conteúdo

Aim: understand the feelings experienced by the mother when having her premature child hospitalized in the Neonatal Intensive Care Unit (NICU). Method: Descriptive research of a qualitative nature, performed with 11 mothers, through a semi-structured interview. The Content Analysis framework was adopted. Results: three thematic categories were identified: Suffering from the hospitalization of the premature child; Premature child care: trust in the team; Experiencing the impact of the neonatal intensive care environment. Discussion: mothers were faced with feelings such as fear, guilt over suffering and possible loss of the child, and reported feeling powerless and unable to care for the child at this time, which increased their anguish. Conclusion: mothers, when faced with the premature child in the NICU, experienced different feelings, feeling incapable and, often, moving away from the newborn. However, they reported confidence and security in the care of professionals with their children, valuing both technical aspects and interpersonal relationships.

Music From the Very Beginning-A Neuroscience-Based Framework for Music as Therapy for Preterm Infants and Their Parents.

Human and animal studies demonstrate that early auditory experiences influence brain development. The findings are particularly crucial following preterm birth as the plasticity of auditory regions, and cortex development are heavily dependent on the quality of auditory stimulation. Brain maturation in preterm infants may be affected among other things by the overwhelming auditory environment of the neonatal intensive care unit (NICU). Conversely, auditory deprivation, (e.g., the lack of the regular intrauterine rhythms of the maternal heartbeat and the maternal voice) may also have an impact on brain maturation. Therefore, a nurturing enrichment of the auditory environment for preterm infants is warranted. Creative music therapy (CMT) addresses these demands by offering infant-directed singing in lullaby-style that is continually adapted to the neonate’s needs. The therapeutic approach is tailored to the individual developmental stage, entrained to the breathing rhythm, and adapted to the subtle expressions of the newborn. Not only the therapist and the neonate but also the parents play a role in CMT. In this article, we describe how to apply music therapy in a neonatal intensive care environment to support very preterm infants and their families. We speculate that the enriched musical experience may promote brain development and we critically discuss the available evidence in support of our assumption.

A comparison of the direct cost of care in an open-bay and single-family room NICU

This research examined the proposition that the direct costs of care were no different in an open-bay (OPBY) as compared with a single-family room (SFR) neonatal intensive care (NICU) environment. This was a sequential cohort study. General linear models were implemented using clinical and cost data for all neonates admitted to the two cohorts studied. Costs were adjusted to year 2007 U.S. dollars. Models were constructed for the unadjusted regression and subsequently by adding demographic variables, treatment variables, length of respiratory support and length of stay. With the exception of the last, none were found to achieve significance. The full model had R(2)=0.799 with P=0.0095 and predicted direct costs of care less in the SFR NICU. For the time, location and administrative practices in place, this study demonstrates that care can be provided in the SFR NICU at no additional cost as compared with OPBY NICU.

Very preterm birth: maternal experiences of the neonatal intensive care environment

Examine sources, predictors and child outcomes associated with neonatal intensive care unit (NICU)-related stress for mothers of infants born very preterm (VPT). Participants were 133 mothers of VPT infants admitted to a regional level-III NICU. At term equivalent, mothers completed the Parental Stressor Scale: NICU and were interviewed about their psychological well-being and family circumstances. Infant clinical data were also collected. At corrected age 4 years, 49 children were assessed for cognition, language and socio-emotional development. Mothers reported moderate to low stress, with parental role alteration considered most stressful and parent-staff communications least stressful. Predictors of overall stress included maternal educational underachievement, stressful life events, postnatal depression and infant unsettled-irregular behavior. NICU-related stress was associated with child anxiety and poorer language development. Parental well-being is an important focus of care in the neonatal setting. Strategies are needed to optimize early engagement and reduce stress levels to assist improved child outcomes.

Cerebral vascular regulation and brain injury in preterm infants

Cerebrovascular lesions, mainly germinal matrix hemorrhage and ischemic injury to the periventricular white matter, are major causes of adverse neurodevelopmental outcome in preterm infants. Cerebrovascular lesions and neuromorbidity increase with decreasing gestational age, with the white matter predominantly affected. Developmental immaturity in the cerebral circulation, including ongoing angiogenesis and vasoregulatory immaturity, plays a major role in the severity and pattern of preterm brain injury. Prevention of this injury requires insight into pathogenesis. Cerebral blood flow (CBF) is low in the preterm white matter, which also has blunted vasoreactivity compared with other brain regions. Vasoreactivity in the preterm brain to cerebral perfusion pressure, oxygen, carbon dioxide, and neuronal metabolism is also immature. This could be related to immaturity of both the vasculature and vasoactive signaling. Other pathologies arising from preterm birth and the neonatal intensive care environment itself may contribute to impaired vasoreactivity and ineffective CBF regulation, resulting in the marked variations in cerebral hemodynamics reported both within and between infants depending on their clinical condition. Many gaps exist in our understanding of how neonatal treatment procedures and medications have an impact on cerebral hemodynamics and preterm brain injury. Future research directions for neuroprotective strategies include establishing cotside, real-time clinical reference values for cerebral hemodynamics and vasoregulatory capacity and to demonstrate that these thresholds improve long-term outcomes for the preterm infant. In addition, stimulation of vascular development and repair with growth factor and cell-based therapies also hold promise.

Supporting identification of neonatal conjugated jaundice

Case presentation We present a case of a 36 week old baby born in poor condition requiring intubation at 2 hours of life and required at least> 8 ml/hr of intravenous dextrose infusion to optimise blood glucose levels. Along with congenital hyperinsulinism and other complications of prematurity. he developed a conjugated jaundice.. Whilst there was a daily enquiry as to the colour of the baby9s stools, these were reported normal by several staff members. 8 days later, there was a biochemical cholestatic picture, despite still being asymptomatic. One of the authors reviewed the stools, which were pale cream / grey in colour and thought to be suspect. On further questioning, his stools had appeared this way for 10 days. He was investigated extensively and after an episode of sepsis, transferred to the regional Liver unit, where he was diagnosed with billary sludging. He is now doing well and has been discharged. Discussion Whilst it did not have a major impact on the outcomes in this case, there was clearly a problem with the subjective interpretation of suspect stools. This was amongst a variety of professionals, including junior medical and neonatal nursing staff. Within the hospital environment this may be less important to identify, but within the community setting, recognition of suspect stools is a key screening tool. Previous reports in neonates in the context of bilious vomiting has previously identified variations in the subjective interpretation of samples and suggested the utility of objective vomitus colour charts1. Our experience in this case suggests that a similar problem may exist with regards recognition of suspect stools and a similar resource for objective identification should be used. The Children9s liver foundation has produced such materials to support frontline workers (figure 1), which is available in a variety of forms. Conclusions Within a neonatal intensive care environment, there was lack of recognition of stools that were suspect of a cholestatic jaundice. In line with previous research in neonates, we would suggest the utility of objective resources to standardise the identification process with the aim of supporting high quality screening both inside and outside of hospital.

Treatment of suspected neonatal sepsis with a central line in-situ – do we always need vancomycin?

BackgroundCoagulase negative staphylococcus (CONS) is the commonest cause of central line related neonatal sepsis. There is a perception that the majority of CONS strains are resistant to usual anti-staphylococcal regime...

Spectral Analysis of Electroencephalography in Premature Newborn Infants: Normal Ranges

Continuous EEG monitoring has not been used widely in neonatal intensive care, especially in the care of extremely premature infants, probably in part because of a lack of a reliable quantitative method. The purpose of this study was to quantify the EEG of the very premature infants just after birth by using spectral analysis and to describe the characteristics of the spectral signal when infants were clinically stable. Digital EEG recordings were performed on 53 infants who were < or =30 wk gestation for 75 min each day during the first 4 d after birth. Artefact was rejected manually after visual inspection of trace. The EEG was analyzed by manual measurement of interburst interval and automatically by spectral analysis using Fast Fourier Transformation. Spectral analysis generated the normal ranges of the relative power of the delta (0.5-3.5 Hz), theta (4-7.5 Hz), alpha (8-12.5 Hz), and beta (13-30 Hz) frequency bands, spectral edge frequency, and symmetry. The median (range) relative power of the delta band increased significantly from 68% (62-76%) on day 1 to 81% (72-89%) on day 4 (p=0.001). The interburst intervals became progressively shorter between days 1 [14s (10-25)] and 3 [8s (6-12)]; there were no significant differences between days 3 and 4. The relative power of the delta band seemed to be the most useful and repeatable spectral measurement for continuous long-term monitoring. However, automatic artefact rejection software needs to be developed before continuous quantitative EEG monitoring can be used in the neonatal intensive care environment.

Adapting the neonatal intensive care environment to decrease noise.

A protocol of environmental noise reduction was developed and tested over a 14-month period in a 70-bed tertiary care neonatal intensive care unit (NICU). Evidence-based research and a detailed sound assessment guided the development of the protocol. Modifications of caregiving activities and categorized changes in the physical environment were specific to the NICU tested; however, guidelines for adapting the protocol to other NICUs are explained as well as methods for implementation to promote staff awareness and cooperation are reviewed.

Role and experience determine decision support interface requirements in a neonatal intensive care environment

The aim of this paper is to describe a novel approach to the analysis of data obtained from card-sorting experiments. These experiments were performed as a part of the initial phase of a project, called NEONATE. One of the aims of the project is to develop decision support tools for the neonatal intensive care environment. Physical card-sorts were performed using clinical “action” and patient “descriptor” words. Thirty-two staff (eight junior nurses, eight senior nurses, eight junior doctors, and eight senior doctors) participated in the actions card-sorts and the same number of staff participated in separate descriptors card-sorting experiments. To check for consistency, the card-sorts were replicated for nurses during the action card-sorts. The card-sort data were analysed using hierarchical cluster analysis to produce tree-diagrams or dendrograms. Differences were shown in the way various classes of staff with different levels of experience mentally map clinical concepts. Clinical actions were grouped more loosely by nurses and by those with less experience, with a polarisation between senior doctors and junior nurses. Descriptors were classed more definitively and similarly by nurses and senior doctors but in a less structured way and quite differently by junior doctors. This paper presents a summary of the differences in the card-sort data for the various staff categories. It is shown that concepts are used differently by various staff groups in a neonatal unit and that this may diminish the effectiveness of computerised decision aids unless it is explored during their development.

Neonatology In Singapore: The Way We Were, The Way Forward

Singapore has a maternity hospital since 1924, but for many decades the newborns could only receive basic care. Neonatal and perinatal mortality rates were high. Marked improvement in neonatal care began from the 1980s when many neonatal departments were set up to provide intensive care. Improved socioeconomic status, better healthcare facilities, effective infection control, immunisation programmes and availability of potent antibiotics contributed to the decline of perinatal and neonatal mortality. Following the implementation of the glucose-6-phosphate dehydrogenase (G6PD) deficiency screening programme, severe neonatal jaundice and kernicterus were largely reduced. Exchange blood transfusions initiated in the 1960s and phototherapy in the 1970s had saved many babies. Kernicterus is almost not seen now. With more neonatal-trained staff, organised resuscitation teams, advances in respiratory management and better monitoring equipment, more babies have survived. Closer cooperation between obstetricians and neonatologists was a great leap forward towards perinatal medicine. Physicians should endeavour to reduce the incidence and prevalence of birth defects and metabolic errors. Perinatal asphyxia should be promptly detected and managed effectively, including neuroprotective strategies. There should be markers to predict the outcome of asphyxiated babies for decision-making. Neonatologists should be mindful of safe introduction of new technologies and rapid diagnostic techniques for infections, including group B streptococcal screening and chemoprophylaxis when required. Other current issues include prevention of major morbidities, preservation of brain function, improved neurodevelopmental outcome of premature babies, use of blood substitutes, optimal nutrition, fetal surgery, evidence-based medicine, better information systems, avoidance of medication errors, adequate sedation and pain relief of the baby, and the use of nitric oxide. One should bear in mind the need to enhance the neonatal intensive care environment, improve non-invasive monitoring and minimise invasive procedures. Physicians should prioritise neonatal care for their country and utilise less costly neonatal care. Ethical issues in neonatology that arise following advancement in neonatal care deserve attention. Advances in life sciences, such as the completion of the human genome project, cloning of tissues and organs, human stem cell research and technology, gene therapy, deoxyribonucleic acid vaccines and nanomedicine, should benefit neonatology.