Neonatal Intensive Care Unit Setting Research Articles

Barriers and Facilitators in Lactation Support for the Preterm Mother-Infant Dyad: An Integrated Approach.

Breastfeeding offers significant health benefits for both mothers and infants, particularly preterm infants, where it serves as a therapeutic strategy to reduce mortality and morbidities. However, breastfeeding practices are threatened globally by societal norms and systemic barriers at both micro and macro levels. This paper explores the complex interplay of these barriers and facilitators, focusing on the Neonatal Intensive Care Unit (NICU) setting. Preterm infants face specific feeding challenges due to immature physiological functions, yet evidence supports that strategies like cue-based feeding and individualized care can enhance feeding success and health outcomes. For mothers, initiating and maintaining lactation after preterm birth is critical but challenging, with early lactation support and achieving sufficient milk volume being key predictors of success. Partner support significantly influences lactation outcomes, although more inclusive research is needed for diverse family structures. In the NICU, a multidisciplinary approach to lactation care is vital, emphasizing the need for experienced staff and family-centered practices. NICU design, policies promoting parental presence, and adherence to Baby-friendly Hospital Initiative guidelines further support breastfeeding. This paper aims to provide directives for local breastfeeding policies through an integrated approach, considering societal attitudes and healthcare practices. The findings advocate for improved lactation support in NICUs, inclusive language and policies, and further research into diverse familial and gender roles in breastfeeding.

Current Evidence Regarding the Evaluation and Management of Neonatal Delirium.

Newborns and infants in the neonatal intensive care unit (NICU) may be at uniquely high risk of developing delirium. Because there is a dearth of NICU-focused literature, providers must rely on evidence derived from older children and infants in other care settings to guide management. The literature was rigorously reviewed to highlight evidence specific to newborns and infants and is summarized here. Delirium likely occurs in newborns and infants at similar or higher rates than what is seen in other care settings. Recent literature calls particular attention to the lack of assessment tools validated in a NICU setting. Evidence for the evaluation and management of delirium in the NICU is lacking. More study specific to the NICU is needed to build consensus toward best practice.

Effects of an App-Based Visitation Program for Mothers of High-Risk Infants in the Neonatal Intensive Care Unit: A Quasi-Experimental Study.

This study established an app-based visitation program for mothers of infants admitted to the neonatal intensive care unit (NICU)-constrained by COVID-19 visitation restrictions-and assessed its impact on neonatal perception, maternal-infant attachment, and parental stress. High-risk infants in the NICU encounter heightened challenges, exacerbated by COVID-19 restrictions, leading to heightened maternal stress, impaired neonatal perception, and hindered mother-infant attachment. A quasi-experimental study was conducted with 40 mothers (20 in the experimental group and 20 in the control group) unable to visit the NICU of a tertiary general hospital in South Korea. The experimental group utilized the Dodam-Dodam smartphone application, while the control group received neonatal information through telephone calls and text messages. Data collection occurred in July 2022 (control) and September 2022 (experimental) using research instruments (parent's neonatal perception, maternal-infant attachment, and parental stressor scale: NICU, visiting program satisfaction). Descriptive statistics and tests (χ2, Fisher's exact, Shapiro-Wilk, parametric independent t and paired t tests, and nonparametric tests: Mann-Whitney and Wilcoxon's signed-rank) were employed for analysis. The Dodam-Dodam application significantly impacted maternal-infant attachment parental stress scores and program satisfaction in the experimental group, except for neonatal perception. The Dodam-Dodam application was more efficacious than traditional visiting programs in enhancing maternal-infant attachment, increasing maternal satisfaction and reducing parental stress within NICU settings amid restricted visitation. Recommendations include app-based NICU visitation, exploring app variations, studying diverse populations, and providing optimal information provision.

A pilot study of a virtual reality-based simulation platform for Neonatal Resuscitation Program training.

This pilot implementation study introduces a novel, neonatal-specific virtual reality (VR) simulation platform for resuscitation training and assesses its initial feasibility and reception in a neonatal intensive care unit setting. We developed a custom VR model simulating a resuscitation scenario for a 30-week neonate. Neonatal providers completed individualized training sessions and post-training surveys. Thirty-eight neonatal providers participated in the study. The VR platform was well-received, with 97% willing to use it again and 95% recommending it. Most participants (70.3%) found VR more realistic than traditional methods, with an average usefulness rating of 4.5/5. However, 40.5% reported adverse effects like eye strain and motion sickness. Feedback led to three significant VR platform upgrades. This study demonstrates strong enthusiasm for VR among neonatal providers. While promising, further research with larger samples and comparisons to traditional methods is needed to fully evaluate VR's effectiveness in neonatal resuscitation training.

A Scoping Review of Multimodal, Dyadic Early Relational Health Interventions in NICUs in the United States.

Early relational health (ERH) interventions can buffer toxic stress and improve the developmental trajectories of neonatal intensive care unit (NICU) infants. The purpose was to examine the current state of the science related to multimodal, dyadic ERH interventions implemented in the NICU setting in the United States and identify gaps in the current literature. PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and PsycInfo were searched in November 2022 and November 2023 for original studies and conference proceedings from 1970 to present in the English language. Gray literature searches were performed in February 2023 and December 2023. English language, original research, with a focus on multimodal, dyadic ERH interventions that took place primarily in a NICU in the United States were included. Outcome measures could be related to implementation, relational health, or physical and/or mental health outcomes of parent and/or infant. Eighteen of 2021 reviewed articles met the inclusion criteria. Data were extracted for author, year, intervention, purpose, methods, sample, paternal inclusion, dyadic components, non-dyadic components, and major outcomes/results and distilled for study characteristics, multimodal, dyadic intervention characteristics, and outcome measures. Several multimodal dyadic interventions exist to aid ERH in the NICU, providing evidence of improved outcomes for infants and families. More research is required using higher sample sizes and replication studies. ERH interventions show promise in improving neurodevelopmental, behavioral, and maternal mental health outcomes and should be considered for implementation into NICU services.

Embedding the ‘CoolCuddle’ intervention for infants undergoing therapeutic hypothermia for hypoxic-ischaemic encephalopathy in NICU: an evaluation using normalisation process theory

ObjectivesNewborn infants exposed to lack of oxygen and blood flow to the brain around birth may develop brain dysfunction (hypoxic-ischaemic encephalopathy—HIE). These infants undergo 72 hours of cooling therapy and...

Impact of daily music on comfort scores in preterm infants: a randomized controlled trial.

Premature birth heightens neurodevelopmental risks, theorized to partly stem from altered sensory inputs and disrupted sleep patterns. Modifying the acoustic milieu through music intervention (MI) offers promise to improve neonatal comfort, reduce sleep disturbances, and stabilize physiological parameters. This study explores the impact of non-pharmacological MI on these health indicators within the Neonatal Intensive Care Unit (NICU). A single-blinded RCT was conducted. Premature infants (34 > GA > 29 wks) were randomly assigned to either receive 8 min of daily MI or placebo for up to 15 days. Validated behavioral comfort scores were visually obtained by a blinded observer before and after intervention. Additionally, physiological signs (HR, RR, SatO2) were recorded. Differences between the groups were analyzed using χ² tests and t-tests. In total 56 preterm infants were included. After intervention, comfort levels increased significantly in the MI compared to placebo group (p = 0.000). Neonates receiving MI transitioned from wakefulness to a state of sleep significantly more compared to placebo (p = 0.002). Physiological parameters remained stable. This study adds to existing literature demonstrating that a music intervention in a NICU setting can enhance comfort and sleep of premature infants without adversely affecting physiological parameters. The study demonstrates that music interventions (MI) in a Neonatal Intensive Care Unit (NICU) setting can significantly increase comfort levels and positively impact the sleep of premature infants without negatively impacting their physiological parameters. This research increases evidence for non-pharmacological interventions, specifically music, as beneficial for the well-being of premature infants in NICU settings. It replicates and expands upon previous methodological designs, providing more robust evidence of MI's positive effects on this vulnerable population. The positive outcomes of music intervention could influence hospital policies by integrating non-pharmacological practices into standard neonatal care protocols to enhance developmental support for premature infants.

Shifting the Paradigm for Establishing and Maintaining Milk Production in the Setting of Mother/Infant Separation.

Establishing lactation when mother and infant are separated, such as when the neonate is admitted to the neonatal intensive care unit (NICU), is challenging. The most common clinical advice is to express milk eight or more times per day, every 3 hours, around the clock. Sometimes, the first time that parents hear this is after the birth of their baby. This can be overwhelming and sometimes unachievable. A five-step paradigm shift is proposed that refocuses lactation care on providing evidence-based assistance and ongoing clinical education, and assessment beginning prenatally and extending past maternal discharge, to improve outcomes through curated support. Simple guidelines can begin with expressing milk at least five times a day by Day 5 of life (5 × 5), and expressing milk at least once between 0100 and 0500 (overnight pumping). With these measures, neonatal care in the NICU setting can provide personalized and achievable guidance on pumping schedules.

Exploring Computational Techniques in Preprocessing Neonatal Physiological Signals for Detecting Adverse Outcomes: Scoping Review.

Computational signal preprocessing is a prerequisite for developing data-driven predictive models for clinical decision support. Thus, identifying the best practices that adhere to clinical principles is critical to ensure transparency and reproducibility to drive clinical adoption. It further fosters reproducible, ethical, and reliable conduct of studies. This procedure is also crucial for setting up a software quality management system to ensure regulatory compliance in developing software as a medical device aimed at early preclinical detection of clinical deterioration. This scoping review focuses on the neonatal intensive care unit setting and summarizes the state-of-the-art computational methods used for preprocessing neonatal clinical physiological signals; these signals are used for the development of machine learning models to predict the risk of adverse outcomes. Five databases (PubMed, Web of Science, Scopus, IEEE, and ACM Digital Library) were searched using a combination of keywords and MeSH (Medical Subject Headings) terms. A total of 3585 papers from 2013 to January 2023 were identified based on the defined search terms and inclusion criteria. After removing duplicates, 2994 (83.51%) papers were screened by title and abstract, and 81 (0.03%) were selected for full-text review. Of these, 52 (64%) were eligible for inclusion in the detailed analysis. Of the 52 articles reviewed, 24 (46%) studies focused on diagnostic models, while the remainder (n=28, 54%) focused on prognostic models. The analysis conducted in these studies involved various physiological signals, with electrocardiograms being the most prevalent. Different programming languages were used, with MATLAB and Python being notable. The monitoring and capturing of physiological data used diverse systems, impacting data quality and introducing study heterogeneity. Outcomes of interest included sepsis, apnea, bradycardia, mortality, necrotizing enterocolitis, and hypoxic-ischemic encephalopathy, with some studies analyzing combinations of adverse outcomes. We found a partial or complete lack of transparency in reporting the setting and the methods used for signal preprocessing. This includes reporting methods to handle missing data, segment size for considered analysis, and details regarding the modification of the state-of-the-art methods for physiological signal processing to align with the clinical principles for neonates. Only 7 (13%) of the 52 reviewed studies reported all the recommended preprocessing steps, which could have impacts on the downstream analysis. The review found heterogeneity in the techniques used and inconsistent reporting of parameters and procedures used for preprocessing neonatal physiological signals, which is necessary to confirm adherence to clinical and software quality management system practices, usefulness, and choice of best practices. Enhancing transparency in reporting and standardizing procedures will boost study interpretation and reproducibility and expedite clinical adoption, instilling confidence in the research findings and streamlining the translation of research outcomes into clinical practice, ultimately contributing to the advancement of neonatal care and patient outcomes.

Bloodstream Infections in the Neonatal Intensive Care Unit: A Systematic Review of the Literature.

Bloodstream infections represent a significant concern in neonatal intensive care units (NICUs), constituting a leading cause of morbidity and mortality among neonates. This study aimed to elucidate the etiology, prevalence, and antimicrobial resistance patterns of bloodstream infections in NICU settings. A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines using the PubMed database to source relevant studies published between 2019 and 2023. Keywords related to bloodstream infections, neonates in NICUs, pathogens, resistance, and susceptibility were employed. Out of the 73 identified articles, eight met the inclusion criteria. Findings revealed a predominance of late-onset sepsis in hospitalized neonates, with Escherichia coli, Klebsiella pneumoniae, coagulase-negative staphylococci, Group B Streptococcus, Acinetobacter species, Serratia marcescens, Staphylococcus aureus, and Enterobacter cloacae being the most commonly isolated pathogens. Antimicrobial susceptibility profiles demonstrated resistance among bacteria to ampicillin, gentamicin, and penicillin, while fungi exhibited resistance to amphotericin B, fluconazole, flucytosine, itraconazole, and voriconazole. These findings underscore the persistent challenge of bloodstream infections in the NICUs, particularly late-onset sepsis, emphasizing the importance of early detection and appropriate antimicrobial therapy in neonatal care management.

The Impact of Maternal Risk Factors on Neonatal Morbidity and Mortality in a Tertiary Care Neonatal Intensive Care Unit (NICU): An Observational Study.

Neonatal morbidity and mortality continue to be major public health issues globally, especially for infants admitted to neonatal intensive care units (NICUs). This study aims to investigate the incidence of morbidities among neonates born to high-risk mothers and to evaluate the impact of various maternal risk factors on neonatal morbidity and mortality in the NICU setting. This prospective observational study was conducted on 1,000 newborns up to 28 days of life, all with maternal risk factors, born in our tertiary care center, and admitted to the NICU. Most NICU admissions occurred during the 34-36 weeks of gestation, comprising 412 (41.20%) of the total admissions. Additionally, there was a female predominance, with 552 cases, representing 55.20% of the admissions. Most of the NICU patients came from rural background 594 (59.40%) and belonged to socioeconomic status (SES) IV 764 (76.40%). Higher percentages of neonatal morbidities were observed among children of illiterate and primarily educated mothers, amounting to 913 cases (91.30%). After evaluating patients in the NICU, we found that mortality was 172 (17.20%). Mothers with previous bad obstetric histories were at greater risk of poor neonatal outcomes. Cesarean sections were more commonly associated with NICU admissions, accounting for 555 cases (55.50%).The primary risk factors included pregnancy-induced hypertension, previous lower segment cesarean section, fetal distress, and premature rupture of membranes. Significant neonatal morbidities included respiratory distress syndrome (RDS) due to prematurity 79 (45.9%), intrauterine growth retardation19 (11.0%), meconium aspiration syndrome 16 (9.3%), birth asphyxia, sepsis 29 (16.8%), and congenital anomalies 12 (6.9%). RDS was identified as the leading cause of morbidity. The present study highlights several critical factors associated with NICU admissions and neonatal morbidities, underscoring the need for targeted interventions to improve neonatal health outcomes.

Cost-effectiveness of a new multi-lumen infusion device to reduce central-venous-line-associated bloodstream infections in neonates

A new medical device was developed for multi-infusion in neonatal intensive care units (NICUs) with the aim of addressing issues related to drug incompatibilities and central-line-associated bloodstream infections (CLABSIs). To assess the cost-effectiveness of implementing this new perfusion system in an NICU setting. This single-centre, observational study was conducted in all infants admitted to the NICU within 3 days of birth, and who required a central venous line, to evaluate the cost and effectiveness before (2019) and after (2020) implementation of the new perfusion system. Costs were calculated from the hospital perspective, and the incidence of CLABSIs was examined over a time horizon from NICU admission to discharge. Resource utilization was measured (infusion device, infection-treating drugs and biological analyses), and corresponding costs were valued using tariffs for 2019. The incremental cost-effectiveness ratio (ICER) was calculated, expressed as Euros per CLABSI avoided, and one-way and multi-variate sensitivity analyses were conducted. Among 609 infants selected, clinical characteristics were similar across both periods. The CLABSI rate decreased significantly (rate ratio 0.22, 95% confidence interval 0.07-0.56), and total costs reduced from €65,666 to €63,932 per 1000 catheter-days (P<0.001) after implementation of the new perfusion system, giving an ICER of €251 saved per CLABSI avoided. The majority of sensitivity analyses showed that the new intervention remained economically dominant. This single-centre study showed a significant decrease in the incidence of CLABSIs after implementation of the new perfusion system, without incurring additional costs. Further prospective multi-centre randomized studies are needed to confirm these results in other NICUs.

Rapid identification and subsequent contextualization of an outbreak of methicillin-resistant Staphylococcus aureus in a neonatal intensive care unit using nanopore sequencing.

Outbreaks of methicillin-resistant Staphylococcus aureus (MRSA) are well described in the neonatal intensive care unit (NICU) setting. Genomics has revolutionized the investigation of such outbreaks; however, to date, this has largely been completed retrospectively and has typically relied on short-read platforms. In 2022, our laboratory established a prospective genomic surveillance system using Oxford Nanopore Technologies sequencing for rapid outbreak detection. Herein, using this system, we describe the detection and control of an outbreak of sequence-type (ST)97 MRSA in our NICU. The outbreak was identified 13 days after the first MRSA-positive culture and at a point where there were only two known cases. Ward screening rapidly defined the extent of the outbreak, with six other infants found to be colonized. There was minimal transmission once the outbreak had been detected and appropriate infection control measures had been instituted; only two further ST97 cases were detected, along with three unrelated non-ST97 MRSA cases. To contextualize the outbreak, core-genome single-nucleotide variants were identified for phylogenetic analysis after de novo assembly of nanopore data. Comparisons with global (n=45) and national surveillance (n=35) ST97 genomes revealed the stepwise evolution of methicillin resistance within this ST97 subset. A distinct cluster comprising nine of the ten ST97-IVa genomes from the NICU was identified, with strains from 2020 to 2022 national surveillance serving as outgroups to this cluster. One ST97-IVa genome presumed to be part of the outbreak formed an outgroup and was retrospectively excluded. A second phylogeny was created using Illumina sequencing, which considerably reduced the branch lengths of the NICU isolates on the phylogenetic tree. However, the overall tree topology and conclusions were unchanged, with the exception of the NICU outbreak cluster, where differences in branch lengths were observed. This analysis demonstrated the ability of a nanopore-only prospective genomic surveillance system to rapidly identify and contextualize an outbreak of MRSA in a NICU.

Exploring Current Practices, Challenges, and Innovations in the Nutrition and Feeding of Neonates, Including the Use of Human Milk, Fortifiers, and Formula: A Clinical Study

ABSTRACT Background: Neonatal nutrition plays a crucial role in the growth and development of infants, particularly in the neonatal intensive care unit (NICU) where specialized care is essential. This study aims to explore current practices, challenges, and innovations in the nutrition and feeding of neonates, focusing on the utilization of human milk, fortifiers, and formula. Materials and Methods: A retrospective clinical study was conducted at a tertiary care NICU over a period of two years. Data were collected from medical records of neonates admitted to the unit. Information regarding feeding practices, types of milk (human milk, fortified human milk, or formula), fortification protocols, and associated clinical outcomes were analyzed. Results: A total of 150 neonates were included in the study. The majority (85%) received some form of human milk during their NICU stay, with 60% exclusively receiving human milk. Among those receiving human milk, 40% required fortification with a human milk fortifier due to inadequate growth parameters. Formula supplementation was necessary in 25% of cases due to maternal lactation insufficiency or medical contraindications to human milk. The mean duration of parenteral nutrition was 10 days, with a median time to full enteral feeds of 14 days. Infants receiving exclusively human milk demonstrated a lower incidence of necrotizing enterocolitis (NEC) compared to those receiving formula (5% vs. 12%, P &lt; 0.05). Conclusion: Human milk remains the preferred source of nutrition for neonates in the NICU setting, associated with lower rates of NEC and improved clinical outcomes. However, fortification with human milk fortifiers or supplementation with formula is often necessary to meet the nutritional requirements of preterm infants. Further research is needed to optimize fortification protocols and improve long-term outcomes in this vulnerable population.

Outcome of creating clustering nursing care and healing environment on premature infants’ behavioural outcomes

We conducted a quasi-experimental study in two neonatal intensive care units (NICUs) from January to July 2021, focusing on the effects of clustering nursing care and creating a healing environment...

Serratia marcescens Burden in a Neonatal Intensive Care Unit: Colonization Rate, Clinical Infections and Strain Relatedness

Background: Serratia marcescens (S. marcescens) is an environmentally associated organism known for causing healthcare associated infections and outbreaks in neonatal intensive care units (NICUs). The colonization or infection rates in NICU settings remain uncertain. This study aims to evaluate the rate of baseline colonization and clinical infection and relatedness of S. marcescens isolates. Methods: Prospective surveillance of rectal colonization and clinical infection of S. marcescens was conducted on patients admitted to the NICU at Mount Sinai Hospital in Toronto, Ontario, from March 1, 2023, to September 30, 2023. The NICU is a 57 bed unit with all private rooms. Monthly point prevalence assessments by rectal screening were performed, alongside active surveillance for clinical infections associated with S. marcesens. Isolates from screening or clinical samples underwent assessment for relatedness using pulse field gel electrophoresis (PFGE). Results: Over the 7 month study period, 12 different patients (5.4%) were colonized/infected with S. marcescens. Among these, 10 patients (4.5%) were identified through rectal screening (316 rectal swabs were collected from 224 patients) and two patients (0.9%) exhibited positive clinical specimens (urine and endotracheal aspirate) in association with pyelonephritis and ventilator-associated pneumonia, respectively. Of the two clinical cases, one case showed a negative preceding rectal swab and the other detected through a clinical sample before the point prevalence date. The age at which a positive S. marcescens swab or positive clinical specimen was identified ranged from 4 to 66 days (median=18 days, IQR 5-38.8) (Figure 1). Sixty seven infants had repeated screening. Three out of 67 (4.5%) were colonized with S. marcescens, the timing and sequence of positive and negative testing are presented in Figure 2. Females demonstrated a higher positivity rate compared to males [9.1% (9/99) vs 2.4% (3/125), p=0.04, respectively]. PFGE analysis of all 12 (100%) isolates revealed a polyclonal pattern. Most cases were detected from March to May in 9/12 cases (75%). Ten different strains were identified. Notably, two strains demonstrated clusters of two cases each, one during March and the other during May (Figure 3). No mortality was reported among the cases. Conclusions: The study highlights the polyclonal nature of S. marcesens and raises questions about the utility of point prevalence in anticipating clinical cases or patient-to-patient transmission, especially in patients with clinical infection where there were no preceding positive screening tests.

Antimicrobial Stewardship: A Correct Management to Reduce Sepsis in NICU Settings.

The discovery of antimicrobial drugs has led to a significant increase in survival from infections; however, they are very often prescribed and administered, even when their use is not necessary and appropriate. Newborns are particularly exposed to infections due to the poor effectiveness and the immaturity of their immune systems. For this reason, in Neonatal Intensive Care Units (NICUs), the use of antimicrobial drugs is often decisive and life-saving, and it must be started promptly to ensure its effectiveness in consideration of the possible rapid evolution of the infection towards sepsis. Nevertheless, the misuse of antibiotics in the neonatal period leads not only to an increase in the development and wide spreading of antimicrobial resistance (AMR) but it is also associated with various short-term (e.g., alterations of the microbiota) and long-term (e.g., increased risk of allergic disease and obesity) effects. It appears fundamental to use antibiotics only when strictly necessary; specific decision-making algorithms and electronic calculators can help limit the use of unnecessary antibiotic drugs. The aim of this narrative review is to summarize the right balance between the risks and benefits of antimicrobial therapy in NICUs; for this purpose, specific Antimicrobial Stewardship Programs (ASPs) in neonatal care and the creation of a specific antimicrobial stewardship team are requested.

EFFECT OF KANGAROO MOTHER CARE (KMC) ON THE FORMATION OF MATERNAL-INFANT ATTACHMENT BETWEEN MOTHERS AND PREMATURE BABIES: A LITERATURE REVIEW

Background: Nursing care of premature babies in the Neonatal Intensive Care Unit (NICU) setting can inhibit the maternal-infant attachment. One of the evidence-based interventions for premature babies is Kangaroo Mother Care (KMC). KMC needs to be further studied and researched through a review of previous articles to ensure the effectiveness of that implementation. However, there is a very limited review that specifies the effect of KMC on the formation of maternal-infant attachment. Objective: This study was conducted to assess the effect of KMC on maternal-infant attachment between mothers and premature babies. Design: The design of this study uses a literature review. Data Sources: Initial searches of journal articles were performed on the Pubmed, ScienceDirect, and CINAHL search databases. The study found 676 articles but only 7 journal articles that met the search inclusion criteria. Review Methods: A literature review procedures were used to collect library data, reading and taking notes, as well as critical assessment of managing research materials. Results: The results of this review showed that KMC has been shown to have a positive impact on improving attachment status and resulting in a lower risk of bonding failure between mothers and premature babies. Conclusion: It is recommended that health workers can provide treatment using KMC as an intervention to improve the formation of maternal-infant attachment between mothers and premature babies. The policies related to the implementation of KMC as standard operating procedures are also important.

A Narrative Review of NICU Implementation of Evidence-Based Early Relational Health Interventions.

Early relational health (ERH) interventions in the neonatal intensive care unit (NICU) buffer infants from toxic stress effects. Implementation science (IS) can guide successful uptake of evidence-based practice (EBP) ERH interventions. It is unknown if implementors of ERH interventions currently use the resources of IS to improve implementation. A narrative review of recent literature on implementation of ERH EBPs was completed to understand (a) which ERH interventions are currently being implemented in NICUs globally, (b) whether clinical implementors of ERH interventions have adopted the resources of IS, (c) existence of implementation gaps, and (d) implementation outcomes of ERH interventions in contemporary literature. Scopus, PubMed, and CINHAL were searched for original research regarding implementation of dyadic ERH interventions using key words related to IS and ERH. For inclusion, ERH EBPs had to have been implemented exclusively in NICU settings, contained data addressing an IS domain, printed in English within the last 5 years. Twenty-four studies met inclusion criteria. Studies were distilled for intervention, IS domains addressed, location, aims, design, sample, and outcomes. Eleven ERH interventions were described in the literature. Few studies utilized the resources of IS, indicating variable degrees of success in implementation. Discussions of implementation cost were notably missing. Implementors of ERH interventions appear to be largely unfamiliar with IS resources. More work is needed to reach clinicians with the tools and resources of IS to improve implementation outcomes.

The Effectiveness of Hammock Positioning in Regulating Behavioral Patterns in Preterm: A Systematic Review

Background- Preterm newborns benefit from supportive developmental techniques such as hammock placement, which give them a sense of being in the womb that promotes calm, relaxation, and deep restful sleep. Objective- To identify and synthesize the available evidence on the effect of hammock positioning in regulating behavioral patterns and sleep in preterm infants admitted to the NICU Data Sources: We searched the Google Scholar, Pubmed, and Scopus databases for reports of primary research studies using a three-step strategy. We also searched for and reviewed the reference lists of retrieved articles. Methods: We included data from randomized controlled trials, Quasi-experimental and Comparative study measuring the effects of hammock positioning on physiological stress outcomes, defined as oxygen saturation, body temperature, heart rate and respiratory rate, Sleep-wakefulness, and behavioral pattern. The PRISMA model was used to conduct data extraction. We performed a narrative synthesis of all studies when data were available from multiple studies. Results: Five studies were eligible for inclusion. Infants who received hammock positioning has shown to have a higher mean heart rate, oxygen saturation and temperature, Sleep-wakefulness and improved behavioral patterns. Conclusions: Current evidence suggests that hammock positioning in the neonatal intensive care unit setting is a safe method that may significantly affect some of the physiological parameters of stress, improved behavioral patterns and Sleep-wakefulness in preterm infants. However, due to clinical heterogeneity, further studies are needed to assess the effects of physiological stress in the neonatal intensive care unit on the development of preterm infants.