NICU Setting Research Articles

Self-assessed Competence of Nurses in Critical Care Units in Malawi: A Cross-sectional Survey

Background: The birth of a premature infant and admission to the NICU is often unexpected and traumatic for families, leading to increased distress and can negatively impact parental-infant attachment. Appropriate interventions can help to lessen the negative impact of a NICU admission on families, improving parental mental health, reducing distress, enhancing parent- infant relationships, and improving the long-term physical, cognitive, emotional, and social development of the infant.
 Aims: The purpose of this study is to examine and evaluate research evidence on the effectiveness of current interventions for improving parental distress in the NICU. Methods: A rapid review was conducted utilizing a protocol based on the Virginia Commonwealth University guidance. Keyword searches were conducted on CINAHL, MEDLINE, and PsychINFO, and studies were selected according to pre-defined eligibility criteria, published between January 2015 and January 2020. The literature search included primary studies of interventions with parental stress and/or anxiety reduction as outcomes.
 Results: A total of 14 articles were included, evaluating the effectiveness of 13 different interventions, including narrative writing, art therapy, structured nursing interventions, anxiety counselling, spiritual care, organizational change, music therapy, relaxation, and mindfulness techniques. With the Pexception of three, all the studies found significant results in the reduction of stress and/or anxiety levels of the subjects, with mothers having overall higher levels of stress indicated by higher stress scores on standardized measurement tools.
 Conclusion: There is a need for ongoing assessment of parental distress and integration of appropriate interventions within the NICU settings. In this review, both individualized and group interventions including narrative writing, art therapy, music therapy, spiritual care, activity-based group therapy, music therapy, audio-assisted relaxation techniques, mindfulness based neurodevelopmental care, cognitive behavioral based counselling, family nurture intervention and a structured nursing intervention were shown to be effective in reducing parental stress and/or anxiety in the NICU. The small scale of the studies included in this review impact generalizability to a broader audience and emphasizes the need for larger scope, multi-center studies at an international level to build on and broaden our level of knowledge on how to better support families and reduce parental distress in the NICU.

Effectiveness of Current Interventions to Alleviate Parental Distress in the NICU: A Rapid Review

Background: The birth of a premature infant and admission to the NICU is often unexpected and traumatic for families, leading to increased distress and can negatively impact parental-infant attachment. Appropriate interventions can help to lessen the negative impact of a NICU admission on families, improving parental mental health, reducing distress, enhancing parent- infant relationships, and improving the long-term physical, cognitive, emotional, and social development of the infant.
 Aims: The purpose of this study is to examine and evaluate research evidence on the effectiveness of current interventions for improving parental distress in the NICU.
 Methods: A rapid review was conducted utilizing a protocol based on the Virginia Commonwealth University guidance. Keyword searches were conducted on CINAHL, MEDLINE, and PsychINFO, and studies were selected according to pre-defined eligibility criteria, published between January 2015 and January 2020. The literature search included primary studies of interventions with parental stress and/or anxiety reduction as outcomes.
 Results: A total of 14 articles were included, evaluating the effectiveness of 13 different interventions, including narrative writing, art therapy, structured nursing interventions, anxiety counselling, spiritual care, organizational change, music therapy, relaxation, and mindfulness techniques. With the Pexception of three, all the studies found significant results in the reduction of stress and/or anxiety levels of the subjects, with mothers having overall higher levels of stress indicated by higher stress scores on standardized measurement tools.
 Conclusion: There is a need for ongoing assessment of parental distress and integration of appropriate interventions within the NICU settings. In this review, both individualized and group interventions including narrative writing, art therapy, music therapy, spiritual care, activity-based group therapy, music therapy, audio-assisted relaxation techniques, mindfulness based neurodevelopmental care, cognitive behavioral based counselling, family nurture intervention and a structured nursing intervention were shown to be effective in reducing parental stress and/or anxiety in the NICU. The small scale of the studies included in this review impact generalizability to a broader audience and emphasizes the need for larger scope, multi-center studies at an international level to build on and broaden our level of knowledge on how to better support families and reduce parental distress in the NICU.

EP091: Improving cytogenetic testing utilization in a tertiary care NICU through quality improvement

There is an increasing recognition of the importance of diagnosing genetic conditions with an ever-growing list of genetic testing options. Yet, most providers do not have genetics training and knowing the most appropriate test to order is challenging. Multiple cytogenetic studies are often ordered simultaneously in a NICU setting despite literature showing that a karyotype and microarray are rarely needed at the same time.

Utilisation of neonatologist-performed echocardiography in shock among neonatologists with interest in haemodynamic: International survey.

Neonatologist-performed echocardiography (NPE) is recommended during shock. We aimed to assess factors associated with NPE utilisation in the NICU and physiological information obtained during management of shock. An Internet-based survey, sent to neonatologists with interest in haemodynamics, studying NPE utilisation in shock management through a real clinical case and correlating its use with responders' training and NICU settings. Fifty-nine completed surveys were received from the United Kingdom: 38%, Western Europe: 32%, Canada: 23% and other countries: 7%. Whilst managing the given clinical case, 90% of responders expected first NPE to exclude congenital heart disease-although only 61% could exclude it confidently (71% in trained clinicians vs. 29% without training; p<0.01). NPE utilisation prior to initiate treatment was significantly correlated with mean number of neonatologists able to perform NPE in the NICU (4.9 vs. 2.9 neonatologists per unit; p=0.02). Similarly, for ongoing therapeutic guidance, NPE was more used in trained clinicians (p<0.01). 88% and 81% of responders studied a combination of multiple parameters to assess filling and systemic flow, respectively. Neonatologist-performed echocardiography during shock management differs with previous training and number of doctors able to perform echocardiography in NICU. This study highlighted the need for enhanced training implementation.

Readmission of late preterm and term neonates in the neonatal period

ObjectiveTo determine the incidence of hospital readmissions in late preterm and term neonates, the most common reasons for readmission, and analyze the risk factors for readmission in the neonatal period. MethodsNewborn infants admitted to a well-baby nursery ≥ 36 weeks gestation were included in this retrospective cohort study. Data for all infants born in a 3-year period and readmitted in the first 28 days of life were analyzed. Indication for readmission was one diagnosed during initial workup in the pediatric emergency room visit before readmission. ResultsThe final cohort consisted of 5408 infants. The readmission rate was 4.0% (219/5408). Leading readmission causes were respiratory tract infection (29.58%), jaundice (13.70%), and urinary tract infection (9.59%). The mean ± SD age of readmitted infants was 13.3 ± 7.1 days. The mean ± SD treatment duration of treatment was 5.5 ± 3.0 days. In the multivariate regression analysis, infants that were during the initial hospitalization transferred to special care/NICU had a lower chance of readmission during the neonatal period (p = 0.04, OR = 0.23, 95% CI 0.06–0.93). Infants with mothers aged from 19–24 years had a higher risk of readmission (p = 0.005, OR = 1.62, 95% CI 1.16–2.26). ConclusionsFinding that infants that were during the initial hospitalization transferred to special care or a NICU setting were less likely to require hospitalization in the neonatal period is an interesting one. Further research into how different approach in these settings reduce the risk of readmission is necessary.

Parent Activation in the Neonatal Intensive Care Unit.

Patient activation is the knowledge, skills, and confidence to manage one's health; parent activation is a comparable concept related to a parent's ability to manage a child's health. Activation in adults is a modifiable risk factor and associated with clinical outcomes and health care utilization. We examined activation in parents of hospitalized newborns observing temporal trends and associations with sociodemographic characteristics, neonate characteristics, and outcomes. Participants included adult parents of neonates admitted to a level-IV neonatal intensive care unit in an academic medical center. Activation was measured with the 10-item Parent version of the Patient Activation Measure (P-PAM) at admission, discharge, and 30 days after discharge. Associations with sociodemographic variables, health literacy, clinical variables, and health care utilization were evaluated. A total of 96 adults of 64 neonates were enrolled. The overall mean P-PAM score on admission was 81.8 (standard deviation [SD] = 18), 88.8 (SD = 13) at discharge, and 86.8 (SD = 16) at 30-day follow-up. Using linear mixed regression model, P-PAM score was significantly associated with timing of measurement. Higher P-PAM scores were associated with higher health literacy (p = 0.002) and higher in mothers compared to fathers (p = 0.040). There were no significant associations of admission P-PAM scores with sociodemographic characteristics. Parents of neonates who had a surgical diagnosis had a statistically significant (p = 0.003) lower score than those who did not. There were no associations between discharge P-PAM scores and neonates' lengths of stay or other indicators of illness severity. Parental activation in the NICU setting was higher than reported in the adult and limited pediatric literature; scores increased from admission to discharge and 30-day postdischarge. Activation was higher in mothers and parents with higher health literacy. Additional larger scale studies are needed to determine whether parental activation is associated with long-term health care outcomes as seen in adults. · Little is known about activation in parents of neonates.. · Activation plays a role in health outcomes in adults.. · Larger studies are needed to explore parent activation..

Parent experience of Beads of Courage program in a neonatal intensive care unit

AimThe neonatal intensive care unit can be a stressful environment for parents. The Beads of Courage program is an arts-in-medicine, psychosocial intervention, designed to strengthen and support children and families who are coping with serious or life-threatening illness. We hypothesised that the program would improve the parent experience in the neonatal unit. MethodsInfants less than 32 weeks' gestation were eligible for enrolment on the program. The study was conducted from 2016 to 2018. A 13 point questionnaire was sent to participating parents post discharge from the unit including a combination of Likert scale and open-ended questions. ResultsDuring the study period 123 infants were enrolled. Mean gestational age was 27.7(±2.2) weeks and median length of stay was 49 days (lower quartile 34; upper quartile 76). All respondents rated the program as “helpful and enjoyable” with 72.5% rating it “extremely helpful and enjoyable”, 85% felt the program made their stay in the neonatal unit easier. ConclusionThe Beads of Courage program was found to be an extremely popular initiative for parents in a neonatal unit setting and was found to be a useful adjunct to communication and inclusion of parents in the care of their infants. SummaryThe Beads of Courage program in a NICU setting was found to be very helpful for parents in improving awareness of procedures and understanding overall care of their infants. Parents felt their journey was made easier with the additional engagement and communication with being in the program.

Effect of Nursing Intervention Program related to Nursing Iatrogenic Events on Nurses Performance and Clinical Outcomes of Neonates at Neonatal Intensive Care Unit

Background: Iatrogenic events that cause harm to neonates in NICU is characterized as adverse events. Neonates are a particularly vulnerable population and may be at further risk of harm from medical errors because of their low birth weight, physiological immature, limited compensatory abilities and extensive exposure to medication in NICU. Nurses are the first line of defense to safeguard against iatrogenic errors. Aim of this study was to evaluated the effect of educational intervention program on nurses’ performance and clinical outcomes of neonates related to nurses’ iatrogenic at neonatal intensive care unit. Subjects and method The study was conducted at Neonatal Intensive Care Unit of Tanta University hospital. A quasi-experimental design was used. Sample All nurses (57) working in the previously mentioned setting were included the study and all neonates admitted within six months. Tools: Three tools were used to collect the required data; Structured Interview schedule, It was consisted of two parts, part one was biosocial data of nurses, neonate and part two was nurses' knowledge (tool I). Observation checklist to assess nurse's practice regarding iatrogenic errors at NICU (tool II). Neonate's clinical outcomes schedule to assess outcomes of neonate post program (tool III). Results of the study revealed that, before program the total knowledge scores of all nurses were poor while majority of them had good scores after implementing program. Total practice scores of all nurses were good also immediately and after one month. There were statistical significant difference between nursing knowledge, practice and biosocial data. The outcome of neonates showed an improvement in neonatal condition of discharge. Conclusion Intervention program was effective and improving nurses’ knowledge and practice as well as reducing iatrogenic errors at NICU. Recommendations were suggested that establish continuous monitoring system to assess nurses practice in NICU settings especially for iatrogenic errors

Transition to a Safe Home Sleep Environment for the NICU Patient.

Of the nearly 3.8 million infants born in the United States in 2018, 8.3% had low birth weight (<2500 g [5.5 lb]) and 10% were born preterm (gestational age of <37 completed weeks). Many of these infants and others with congenital anomalies, perinatally acquired infections, and other disease require admission to a NICU. In the past decade, admission rates to NICUs have been increasing; it is estimated that between 10% and 15% of infants will spend time in a NICU, representing approximately 500 000 neonates annually. Approximately 3600 infants die annually in the United States from sleep-related deaths, including sudden infant death syndrome International Classification of Diseases, 10th Revision (R95), ill-defined deaths (R99), and accidental suffocation and strangulation in bed (W75). Preterm and low birth weight infants are particularly vulnerable, with an incidence of death 2 to 3 times greater than healthy term infants. Thus, it is important for health care professionals to prepare families to maintain their infant in a safe sleep environment, as per the recommendations of the American Academy of Pediatrics. However, infants in the NICU setting commonly require care that is inconsistent with infant sleep safety recommendations. The conflicting needs of the NICU infant with the necessity to provide a safe sleep environment before hospital discharge can create confusion for providers and distress for families. This technical report is intended to assist in the establishment of appropriate NICU protocols to achieve a consistent approach to transitioning NICU infants to a safe sleep environment as soon as medically possible, well before hospital discharge.

Music Is Life-Follow-Up Qualitative Study on Parental Experiences of Creative Music Therapy in the Neonatal Period.

Developmental problems in extremely preterm (EP) infants and the associated longitudinal burden for their families are major health issues worldwide. Approaches to social-emotional support such as family-integrating Creative Music Therapy (CMT) are warranted. We aimed: (1) to explore parental perspectives on the use of CMT with EP infants in the neonatal hospitalization period and (2) to examine the possible longitudinal influence of CMT. A qualitative design was used to examine the perspective of six families from various backgrounds. Semi-structured interviews were carried out when the infants reached school age. We used an inductive–deductive thematic analysis to identify three main themes, each with three sub-themes: (1) the positive impact of CMT on the infants, the parents, and bonding; (2) the attitude toward CMT, from being open-minded to recommending it as complementary therapy; and (3) the experience of overall healthy infant development despite unique developmental delay issues. The findings elucidate the positive and formative impact of CMT on both infants and parents in the stressful NICU setting and beyond. CMT may empower positive transformation in the parents through individualized early nurturing musical interactions, capacity building, and positive reinforcement. Further research may help to identify and implement potentially modifiable factors for improving health care in this vulnerable group through early family-integrating, resource-based approaches such as CMT.

Hearing Screening in Pediatric Primary Care.

1. Jordan K. Yoeli, MD*,† 2. Daniel Nicklas, MD*,† 1. *Children’s Hospital Colorado, Aurora, CO 2. †University of Colorado, Aurora, CO Screening for congenital and acquired deafness and hearing loss (HL) represents a significant responsibility for clinicians in all newborn units and medical homes. Approximately 1 to 3 infants of 1,000 born in a well infant nursery setting and 2 to 4 of 100 born in a NICU have significant bilateral HL. Outcomes in various developmental domains depend on the early recognition and subsequent intervention for HL. Developmental delay is present in 30% to 40% of children with HL; the goal of hearing screening (HS) and prompt intervention is to optimize a child’s language acquisition, cognitive development, literacy, social-emotional maturity and academic success. This article reviews the most up-to-date standards and practices to aid medical providers in the early detection and intervention for pediatric HL. In the United States, universal screening begins in the neonatal period. According to the American Academy of Pediatrics (AAP) Joint Commission on Infant Hearing (JCIH), all infants should be screened for congenital HL before 1 month of age. Most infants are screened in nursery or NICU settings, except for those born outside of a medical facility. For the latter population or for infants with no documented HS, screening should be completed by the medical home before 1 month of age. In a well nursery setting, most HSs are performed by otoacoustic emission (OAE) testing. During an OAE screen, a sensitive microphone in the ear canal records the cochlear responses (“acoustic emissions”) to acoustic stimuli, thereby testing the peripheral auditory system from the outer/middle ear (conduction zones) to the cochlear outer hair cells (sensory organ). A “pass” indicates that hearing is functional to the level of …

Associations between safety perceptions and medical error reporting among neonatal intensive care unit staff.

Critically ill neonates are particularly susceptible to medical errors; however, few studies have evaluated NICU safety climate in the context of medical error reporting. This study aims to identify the association between perceptions of safety and culture among NICU staff with medical error reporting behaviours. This study used a convenience sample of 79 NICU staff members (38 Nurses and 41 Respiratory Therapists). Questionnaires consisted of demographic factors (years of experience, sex and education), the Safety Attitudes Questionnaire (SAQ) and hypothetical medical error reporting scenarios (categorized into minor harm or major harm). The SAQ consists of six domains: job satisfaction, teamwork climate, safety climate, perceptions of management, working conditions and stress recognition. Scores ranged from 0-5, with a 5 indicating a more positive perception. Logistic regression was used to determine statistically significant predictors for each individual harm scenario (odds of being very likely/likely to report vs. all other responses). Among those who completed the study, approximately 84.8% were female. Safety attitude domain scores were similar for both NICU respiratory therapists and nurses across all domains except for job satisfaction and stress. Respiratory therapists reported higher levels of job satisfaction compared to nurses (24 vs. 23, respectively, p=0.01). However, nurses reported higher levels of stress management compared to respiratory therapists (12 vs. 9, respectively, p<0.01). While we did not find a significant association between safety attitudes and hypothetical medical error reporting, NICU staff overall were more likely to report major medical errors compared to minor medical errors. This study suggests that safety climate may not play a significant role in promoting medical error reporting in the NICU setting. Interventions aimed at increasing medical error reporting should also incorporate established employees rather than targeting new employees only.

Utility of telemedicine to extend neonatal intensive care support in the community

Moderately ill preterm infants residing in medically underserved areas are frequently transferred to tertiary care NICUs that are mostly located in urban areas, resulting in mother-infant separation, high transportation costs, and the emotional costs of limited infant visitation. In 2012, The American Academy of Pediatrics revised neonatal care guidelines, adding in-house neonatal services to the scope of Level II NICUs. Limited availability of neonatologists in medically underserved areas has prompted innovative solutions like telemedicine to meet this requirement. Telemedicine consultations for pediatric transports have demonstrated improved patient outcomes compared with phone consultation, but evidence regarding telemedicine use for neonatal transport is mostly limited to simulation settings. Also, there are limited data on telemedicine use as a primary means to provide intensive care to neonates in Level I/II NICUs. Recently, two groups demonstrated the feasibility and safety of synchronous telemedicine to guide care for premature infants at lower level NICUs. This approach prevented unnecessary transfer and appeared to provide the same quality of care that the baby would have received at the tertiary care facility. As current evidence regarding the use of telemedicine to extend intensive care is based on single-center experiences, additional research and evaluation of the effectiveness of telemedicine for this application is required. This chapter describes the use of telemedicine to support physicians at lower level nurseries and the transport team with management of critical neonates, utility as primary means to provide care at lower level NICUs, barriers for implementation, and future opportunities to enhance telemedicine's impact in NICU settings.

Decision-Making for Extremely Preterm Infants With Severe Intraventricular Hemorrhage.

Extremely preterm infants are at increased risk for developing an intraventricular hemorrhage in the first few days of life. Higher grades of intraventricular hemorrhage, referred to as severe intraventricular hemorrhage (sIVH), are associated with increased risk of adverse outcomes such as cerebral palsy, other neurodevelopmental impairments, and even death.1,2 Infants who develop sIVH often have significant cardiorespiratory disease as well. These concurrent clinical factors make it difficult to determine if early death after a diagnosis of sIVH is directly related to the hemorrhage, other clinical factors, or a decision to withdraw support.In this issue of Pediatrics, McCauley et al3 examine whether sIVH is independently associated with death. They analyzed retrospective data from >32 000 infants born at 22 to 29 weeks’ gestation during a 14-year period and hospitalized in one of 242 Pediatrix Medical Group NICUs. In multivariate analysis, the authors found that infants who required mechanical ventilation soon after birth and were subsequently diagnosed with sIVH were less likely to have been exposed to antenatal steroids, more premature, and more likely to require high frequency ventilation and at least 1 vasopressor in the first few days of life. These infants died earlier than those without sIVH (median 7.5 vs 13.5 days), and in infants who survived beyond 30 days of age, sIVH was associated with a greater mortality risk. Using a Cox proportional hazards model, the authors concluded that sIVH was independently associated with mortality in their cohort. Additionally, the authors interpreted regional differences in survival as suggesting that the presence of sIVH played a major role in the decision-making process to withdraw care, regardless of the overall severity of illness.When a critically ill preterm infant develops sIVH, the risk of death, as well as the potential for significant long-term neurodevelopmental challenges, should be discussed with the parents. These discussions allow parents to work with the medical team to determine if continuing, limiting, or withdrawing life-sustaining medical treatment (LSMT) is in the best interest for their child. Each situation is unique, because each family has their own set of values and desires regarding the quality of life they envision for their infant and family. These conversations with families are often not well documented in the medical record, and therefore, when doing a retrospective review, it can be difficult to ascertain a specific reasoning for a parent’s decision to continue, limit, or withdraw support.4Decision-making for a critically ill preterm infant is challenging for both parents and providers. The recommended approach in this situation is shared decision-making between the parents and medical team.5–7 It is, therefore, unclear why McCauley et al speculate that the increased mortality rate among infants with sIVH is the result of provider’s influence, because they did not collect data regarding provider–parent interactions preceding the infant’s death. They also did not collect data on the clinical course leading up to the infant’s death, so it is unknown how many of these deaths were the direct result of withdrawal of support, limitation of support, the infant’s underlying physiologic instability, or some combination thereof.The authors conclude that regional differences in survival suggest that provider and/or parental decision-making influenced the decision to withdraw LSMT for patients with sIVH. They base this conclusion on the fact that providers’ beliefs and practices have been shown to underlie regional variation in the intensity of care for adult patients with end-stage disease processes; it would be important to know the extent to which this applies or does not apply in the NICU setting. Until we do, the authors’ conclusion remains highly speculative.No one has a crystal ball to predict what the future will hold for an infant with sIVH, and despite a wealth of data regarding outcomes, each case is uniquely different. The fact that extremely preterm infants with sIVH have a greater mortality risk has been well-recognized for many years, and in their study, McCauley et al suggest that sIVH is an independent risk factor. However, the authors’ speculation that this is primarily due to limitation or withdrawal of LSMT is arguable; the current study is limited by its retrospective design, restricted data set, and post hoc analysis. Nevertheless, the authors raise several important questions. How prevalent is limitation of LSMT in infants with sIVH, how are those decisions being made, and how informed are the parents when making such decisions, given the limited prognostic value of cranial ultrasound findings? Some questions may be difficult or even impossible to answer, because of the limitations of medical documentation and the complexity of such decision-making. As McCauley et al conclude, better prognostic tools will help. More important, providers must strive to be transparent and objective when helping parents make such difficult decisions.

Impact of Probiotic B. infantis EVC001 Feeding in Premature Infants on the Gut Microbiome, Nosocomially Acquired Antibiotic Resistance, and Enteric Inflammation.

Background: Preterm birth is a major determinant of neonatal survival and morbidity, but the gut microbiome and associated enteric inflammation are also key factors in neonatal development and the risk of associated morbidities. We prospectively and longitudinally followed two cohorts of preterm infants, one of which was fed activated Bifidobacterium longum subsp. infantis (B. infantis) EVC001 8 × 109 CFU daily, and the other was not fed a probiotic. Hospital feeding protocol assigned all infants born at <1500 g and/or < 32 weeks corrected gestational age to the probiotic feeding protocol, whereas infants born at >1500 g and/or >32 weeks corrected gestational age were not fed a probiotic. Fecal samples were opportunistically collected from 77 infants throughout the hospital stay, and subjected to shotgun metagenomic sequencing and quantification of enteric inflammation. De-identified metadata was collected from patient medical records.Results: The gut microbiome of preterm infants was typified by a high abundance of Enterobacteriaceae and/or Staphylococcaceae, and multivariate modeling identified the probiotic intervention, rather than degree of prematurity, day of life, or other clinical interventions, as the primary source of change in the gut microbiome. Among infants fed B. infantis EVC001, a high abundance of total Bifidobacteriaceae developed rapidly, the majority of which was B. infantis confirmed via subspecies-specific qPCR. Associated with this higher abundance of Bifidobacteriaceae, we found increased functional capacity for utilization of human milk oligosaccharides (HMOs), as well as reduced abundance of antibiotic resistance genes (ARGs) and the taxa that harbored them. Importantly, we found that infants fed B. infantis EVC001 exhibited diminished enteric inflammation, even when other clinical variables were accounted for using multivariate modeling.Conclusion: These results provide an important observational background for probiotic use in a NICU setting, and describe the clinical, physiological, and microbiome-associated improvements in preterm infants associated with B. infantis EVC001 feeding.

“It was all taken away”: Lactation, embodiment, and resistance among mothers caring for their very-low-birth-weight infants in the neonatal intensive care unit

The prevalence of infants born before 37 weeks of gestation continues to rise in the United States. Advances in neonatology have led to improved survival rates among preterm infants, including those born at a very-low-birth-weight (VLBW). Exclusive human milk feeding is a therapeutic intervention for VLBW preterm infants, and mothers are encouraged to provide their own milk. Yet, it is well-established that mothers and infants may face extraordinarily complicated lactation and infant feeding challenges in NICU settings, many of which emanate from birth trauma. The purpose of this study is to gain a deeper understanding of the ways in which the hyper-medicalized management of preterm birth and infant feeding in NICU environments affect mothers' postpartum health and well-being. Seventeen mothers of VLBW preterm infants were interviewed August 2016–June 2017 within three years of their infant's NICU discharge about their feeding decisions and experiences. Narrative analysis yielded five themes: (1) the physical and emotional trauma of giving birth prematurely impacted mothers' lactation experiences; (2) separation from their infants intensified mothers' suffering and disrupted lactation; (3) mothers experienced being marginalized in their infant's NICU care; (4) mothers practiced embodied forms of resistance to cope with both trauma and marginalization; and (5) skilled support was central to mothers' positive lactation experiences in the NICU. We draw upon feminist theory in the anthropology of reproduction to examine the fundamental hierarchies of power in U.S. neonatal critical care systems that fracture mothers' interembodied relationships to their newborns, exacerbate lactation failure, and engender traumatic postpartum neglect. Moreover, we theorize mothers' expressions of suffering in the context of preterm birth and lactation insufficiency as idioms of distress engendered by the violence of neglectful care. Narrative inquiry is instrumental to designing structural transformations in the systems of care available to mothers of preterm infants who are admitted to a NICU.

Bacterial Content of Fortified and Unfortified Holder Pasteurized Donor Human Milk During Prolonged Refrigerated Storage.

To assess the microbial growth in unfortified and fortified Holder pasteurized donor human milk (HPDHM) during 96 hours of refrigerated storage in a clinical setting. Thirty-six unfortified samples and 77 fortified samples of HPDHM were prepared in a neonatal intensive care milk preparation room and stored in the NICU refrigerator at 4°C to simulate a real-life feeding environment. One milliliter aliquots were removed at 24-hour intervals and cultured in duplicate for bacterial growth on solid blood agar medium. Viable bacterial colonies were characterized using standard microbiological methods. 96.5% of milk samples manipulated in a vertical laminar flow hood were negative for bacterial growth. In the remainder 3.5% of the samples, the maximum growth was 1 colony forming unit/0.1 ml plated. Higher colony counts were observed when the laminar hood was not used. In all cases, the colonies represented common skin bacteria and demonstrated an inconsistent and unsustained growth. Fortifier status and storage time were not significantly associated with increased bacterial growth (P > 0.05). Unfortified and fortified HPDHM remain largely free of bacterial growth for up to 96 hours of refrigerated storage in NICU settings. Sample handling techniques are important for preventing microbial contamination.

Outcome analysis of Neonates admitted to Neonatal Intensive Care Unit of a Border District of Uttar Pradesh

Background: As per the Child Mortality Report 2018 by UNICEF the current neonatal mortality rate in India stands at 24 per 1000 live births with it being more than the national average for Uttar Pradesh. The neonatal morbidity and outcome pattern in terms of discharge or otherwise shows considerable national, state, district and sub- district variations due to a multitude of diverse factors contributing to it at various levels. Aim &amp; Objective: The aim of the study was to explore the mortality rate and outcome in NICU setting, and factors influencing the outcomes. Methods and Material: This government NICU based follow-up study comprised of data analysed from 450 neonates through a semi-structured questionnaire using face to face interview technique. Data was evaluated in SPSS and; independent t test and chi square test were applied. Statistical analysis used: Data was evaluated in SPSS and; independent t test and chi square test were applied. Results: For morbidity low birth weight (LBW) (14.4%) and for mortality LBW/prematurity (56%) were the most common causes. The discharge rate was 64.4%. Good outcome in the form of successful discharge was statistically significant with birth weight (p=0.000), gestational age (0.001), length of stay at NICU (p=0.003) male sex (p=0.003) and feeding of newborn (p=0.002) Conclusions: The study enunciates a high discharge rate in tertiary care government NICU with a mixed morbidity and mortality profile. The causes are mainly preventable and hence can be largely mitigated through dedicated ante natal, intra natal and post-natal care.

Maternal risk factors and immediate outcome of late preterms

Background: This study was conducted to analyse the immediate outcome of late preterm babies and also to evaluate the various maternal risk factors in these babies so that close monitoring of these babies for the complications is done and immediate problems can be addressed.Methods: Prospective observational study done in level 3 NICU setting for 6 months. All babies born between 34-36/7 weeks are included in the study and they constitute the cases. Term (above 36 weeks 6 days gestation) newborns babies born during the study period are controls. Maternal history is taken in detail. Risk factors during pregnancy including maternal age, gravida, mode of delivery, medical conditions and birth details. Baby details like gestational age, sex, birth weight, and neonatal morbidities are recorded. The babies are either shifted to NICU or to mother’s side based depending on the baby’s condition. All of them are followed up till discharge.Results: 89 late preterm babies born in the hospital during the study period are included in the study. Out of 89 babies 45are females constituting 50.6% and 44are male babies constituting 49.4%. 20 (22.5%) babies had gestational age between 34-35 weeks.29 babies (32.5 %) had gestational age between 35-36 weeks and 40 babies (45%) are between 36-37 weeks of gestation. 47 babies (52.9%) have birth weight between 1.5-2.49 kg.42 babies (47.1%) have birth weight between 2.5-3.5 kg. The number of babies born by LSCS were 48 (54%) and 41 babies 46% are born through vaginal route.42 babies constituting 48.3% are appropriate for gestational age and 43 babies (49.4%) are small for gestationalage.34 (39.1%) babies required NICU admission and 55 (60.9%) babies did not require NICU admission. Among the maternal risk factors PIH was the commonest risk factor in 22babies (24.7 %), followed by PROM13 (14.6 %), oligohydramnios 6 (6.7 %) ,twin gestation 6 (6.7 %), MSAF 3 (3.4%), IDM 3 (3.4%), Antepartum hemorrhage 3 (3.4%), eclampsia 1 (1.1%) and maternal cardiac disease 1.1%. Neonatal morbidities are 25 late preterm babies had jaundice (28.7%) followed by RDS in 15 (17.2%), sepsis in 9 (10.3%), NEC 2 (2.3%), Hypoglycemia 5 (5.6%) late preterm babies required ventilation/ CPAP constituting 5.7%. Surfactant was used in 2 late preterm babies 2.3%. 87 babies (97.8%) got discharged and mortality is 2.2%.Conclusions: Late prematurity is associated with significant neonatal morbidity.

Racial/Ethnic Disparities in Neonatal Intensive Care: A Systematic Review.

Racial and ethnic disparities in health outcomes of newborns requiring care in the NICU setting have been reported. The contribution of NICU care to disparities in outcomes is unclear. To conduct a systematic review of the literature documenting racial/ethnic disparities in quality of care for infants in the NICU setting. Medline/PubMed, Scopus, Cumulative Index of Nursing and Allied Health, and Web of Science were searched until March 6, 2018, by using search queries organized around the following key concepts: "neonatal intensive care units," "racial or ethnic disparities," and "quality of care." English language articles up to March 6, 2018, that were focused on racial and/or ethnic differences in the quality of NICU care were selected. Two authors independently assessed eligibility, extracted data, and cross-checked results, with disagreements resolved by consensus. Information extracted focused on racial and/or ethnic disparities in quality of care and potential mechanism(s) for disparities. Initial search yielded 566 records, 470 of which were unique citations. Title and abstract review resulted in 382 records. Appraisal of the full text of the remaining 88 records, along with the addition of 5 citations from expert consult or review of bibliographies, resulted in 41 articles being included. Quantitative meta-analysis was not possible because of study heterogeneity. Overall, this systematic review revealed complex racial and/or ethnic disparities in structure, process, and outcome measures, most often disadvantaging infants of color, especially African American infants. There are some exceptions to this pattern and each area merits its own analysis and discussion.