Norwegian Neonatal Intensive Care Units Research Articles

Parental reports of hospital- and community-based follow-up services, self-efficacy, and symptoms of depression a few months after discharge of a prematurely born child

BackgroundMany parents report the transition from hospital to home as challenging after the birth of a preterm-born child. This study investigates parental perceptions of community-based follow-up services after hospital discharge, alterations in parental self-efficacy during the early months at home, the prevalence of depressive symptoms among parents, and the relationship between these factors and both NICU experiences and children’s regulative behaviors.MethodsIn this second phase of a descriptive study, 110 parents returned a digital questionnaire when their child was four months corrected for prematurity. Parents were recruited while hospitalized with their child, in one of eight Norwegian neonatal intensive care units (NICUs). Thus, the study provides insight into follow-up services across a broad geographical range. Parents’ perception of self-efficacy was reported on the Karitane Parenting Confidence Scale, and depressive symptoms were evaluated with the Edinburgh Postnatal Depression Scale (EPDS). Children’s regulative behavior was reported on the 6-month version of the Ages and Stages Questionnaire: Social and Emotional (ASQ: SE). Using SPSS, associations between variables were investigated in multiple regression analysis in addition to descriptive analysis. Additionally, the examination of repeated measures of parental self-efficacy involved the application of linear mixed models.ResultsParents reported improved perception of self-efficacy from postdischarge to the children’s age of four months (F (1,167) = 1233.2, p < 0.001). On average, fathers’ self-efficacy improved more than that of mothers. Parents’ perception of being well informed prior to discharge from hospital predicted improved self-efficacy (F [1, 29] = 10.4, p = 0.003). Reports of depressive symptoms were at a similar level as previously reported among new parents, as 10.4% of mothers and 6.7% of fathers reported EPDS scores ≥ 10 points. Parents’ reports on ASQ: SE show that 15% of the children scored above the recommended cutoff score for three- to nine-month-old children. The parent-reported benefit of follow-up services showed considerable variation. The importance of specific knowledge about prematurity among public health nurses and physicians was frequently mentioned, and public health nurses were perceived as coordinators and mediators of various services.ConclusionsParents reported improved self-efficacy, and depressive symptoms at similar levels as new parents in general, a few months after discharge from hospital. Childrens’ regulatory behavior were reported at levels comparable with term-born infants.

Development of early life gut resistome and mobilome across gestational ages and microbiota-modifying treatments.

Gestational age (GA) and associated level of gastrointestinal tract maturation are major factors driving the initial gut microbiota composition in preterm infants. Besides, compared to term infants, premature infants often receive antibiotics to treat infections and probiotics to restore optimal gut microbiota. How GA, antibiotics, and probiotics modulate the microbiota's core characteristics, gut resistome and mobilome, remains nascent. We analysed metagenomic data from a longitudinal observational study in six Norwegian neonatal intensive care units to describe the bacterial microbiota of infants of varying GA and receiving different treatments. The cohort consisted of probiotic-supplemented and antibiotic-exposed extremely preterm infants (n=29), antibiotic-exposed very preterm (n=25), antibiotic-unexposed very preterm (n=8), and antibiotic-unexposed full-term (n=10) infants. The stool samples were collected on days of life 7, 28, 120, and 365, and DNA extraction was followed by shotgun metagenome sequencing and bioinformatical analysis. The top predictors of microbiota maturation were hospitalisation length and GA. Probiotic administration rendered the gut microbiota and resistome of extremely preterm infants more alike to term infants on day 7 and ameliorated GA-driven loss of microbiota interconnectivity and stability. GA, hospitalisation, and both microbiota-modifying treatments (antibiotics and probiotics) contributed to an elevated carriage of mobile genetic elements in preterm infants compared to term controls. Finally, Escherichia coli was associated with the highest number of antibiotic-resistance genes, followed by Klebsiella pneumoniae and Klebsiella aerogenes. Prolonged hospitalisation, antibiotics, and probiotic intervention contribute to dynamic alterations in resistome and mobilome, gut microbiota characteristics relevant to infection risk. Odd-Berg Group, Northern Norway Regional Health Authority.

Associations between unit workloads and outcomes of first extubation attempts in extremely premature infants below a gestational age of 26 weeks.

The objective was to explore whether high workloads in neonatal intensive care units were associated with short-term respiratory outcomes of extremely premature (EP) infants born <26 weeks of gestational age. This was a population-based study using data from the Norwegian Neonatal Network supplemented by data extracted from the medical records of EP infants <26 weeks GA born from 2013 to 2018. To describe the unit workloads, measurements of daily patient volume and unit acuity at each NICU were used. The effect of weekend and summer holiday was also explored. We analyzed 316 first planned extubation attempts. There were no associations between unit workloads and the duration of mechanical ventilation until each infant's first extubation or the outcomes of these attempts. Additionally, there were no weekend or summer holiday effects on the outcomes explored. Workloads did not affect the causes of reintubation for infants who failed their first extubation attempt. Our finding that there was no association between the organizational factors explored and short-term respiratory outcomes can be interpreted as indicating resilience in Norwegian neonatal intensive care units.

Implementing music therapy in a Norwegian neonatal intensive care unit.

Neonatal intensive care unit (NICU) music therapy is an emerging discipline. There is a growing evidence base supporting its use, with an emphasis on the immediate and short-term positive effects on infants' physiological responses and parents' experiences. To explore the implementation of music therapy aligned with standards of neonatal care and as an integral part of the care routinely provided in a Norwegian NICU. Parents of infants hospitalised in the NICU were offered music therapy sessions based on the First Sounds: Rhythm, Breath and Lullaby model. Before discharge from the NICU, parents were asked to complete an electronic survey about their experiences of music therapy. Nurses' feedback and observations were also elicited and collected. A total of 16 parents completed the survey. Overall, their experiences of music therapy were positive, and they noted several benefits for themselves and their infant. In addition, nurses observed that parents' interactions with their infant increased after participation in music therapy. However, nurses reported it was challenging to invite parents to participate in music therapy at a time of uncertainty, anxiety and grief. Nurses also found it challenging to disseminate information about music therapy to parents from other cultures. Furthermore, it was identified that most parents learned about the music therapy sessions from the music therapist, rather than from NICU medical or nursing staff, which indicates that music therapy was not fully integrated among the unit's multidisciplinary team. Music therapy can reinforce family-centred care and promote parent-infant bonding, but additional efforts are required to integrate it into the care routinely provided by the NICU multidisciplinary team.

Active antibiotic discontinuation in suspected but not confirmed early-onset neonatal sepsis-A quality improvement initiative.

To study whether a simple targeted intervention could reduce unwarranted antibiotic treatment in near-term and term neonates with suspected, but not confirmed early-onset sepsis. A quality improvement initiative in three Norwegian neonatal intensive care units. The intervention included an inter-hospital clinical practice guideline for discontinuing antibiotics after 36-48hours if sepsis was no longer suspected and blood cultures were negative in neonates≥34+0weeks of gestation. Two units used procalcitonin in decision-making. We compared data 12-14months before and after guideline implementation. The results are presented as median with interquartile ranges. A total of 284 infants (2.5% of all births≥34+0weeks of gestation) received antibiotics before and 195 (1.8%) after guideline implementation (P=.0018). The two units that used procalcitonin discontinued antibiotics earlier after guideline implementation than the unit without procalcitonin. Neonates not diagnosed with sepsis were treated 49 (31-84) hours before and 48 (36-72) hours after guideline implementation (P=.68). In all infants, including those diagnosed with sepsis, antibiotic treatment duration was reduced from 108 (60-144) to 96 (48-120) hours (P=.013). Antibiotic treatment duration for suspected, but not confirmed early-onset sepsis did not change. However, treatment duration for all infants and the proportion of infants commenced on antibiotics were reduced.

Highlights in this issue

Measles is one of the most contagious infectious diseases. Before the introduction of an efficient vaccine, it is estimated that there were 30 million cases and two million deaths each year, mostly among children in low-income countries. During the 1980s, measles was almost eliminated in many European countries. An editorial by Leif Dotevall 1 discusses the paradoxical and painful resurgence of measles in Europe in the last few years and highlights the need to regain confidence in immunisation. In a double-blind randomised study, Wejryd et al. gave 134 extremely low-birthweight infant oil drops containing the probiotic Lactobacillus reuteri DSM 17938 or a placebo. They did this once a day until the infants reached 36 weeks of gestation 2. The authors found that the probiotic did not reduce the time it took the infants to reach full enteral feeds. However, the infants who received the probiotic supplements had a better head growth rate during the first month of life. Claris 3 comments on the findings. This issue includes three reviews on paediatric hypertension. Wühl 4 shows that hypertension in childhood obesity was associated with significantly increased cardiovascular morbidity and mortality and states that early diagnosis and treatment for blood pressure control and weight reduction are essential. Meanwhile, Krmar 5 reviewed the prevalence of white-coat hypertension from a paediatric perspective and reports that this condition was best diagnosed in children by using ambulatory blood pressure monitoring over a 24-hour period. Carlström 6 studied hydronephrosis, and the risk of later hypertension, and points out that today's nonoperative management of hydronephrosis should be reconsidered to reduce the risk of developing elevated blood pressure or hypertension later in life. In 2014, an outbreak of group B streptococcus caused severe late-onset septicaemia in five very preterm infants and colonisation in 10 more infants in a neonatal intensive care unit (NICU) in Sweden. Åberg et al. 7 analysed the course of the outbreak, to find tools that stopped it from happening again. Meanwhile, Rønning et al. 8 adopted a similar approach to investigate an outbreak caused by antibiotic-susceptible Klebsiella oxytoca in a Norwegian NICU. The authors concluded that appropriate microbiological molecular screening methods and strict infection control measures are important, in order to control an outbreak. Readers may also be interested in the paper by Özenci and Schubert 9, which evaluated the implementation of an earlier, and more targeted, treatment of neonatal sepsis. The number of child deaths fell in Sweden from 2000 to 2014, but as many as 25% were from badly defined external causes or unknown causes, according to a study by Otterman et al. 10. A sizeable number of deaths were registered without death certificates, especially for infants. The authors conclude that systematic death reviews could yield information that could prevent future deaths. Palusci 11 comments on the findings. Readers may also be interested in the paper by Lykke et al. 12 on child mortality rates in Denmark, which we published in 2018, and the accompanying editorial by Kreicbergs 13, who discussed why and where children die. Figures 1–5. Istockphoto.com.

Validation of the Neonatal Satisfaction Survey (NSS-8) in six Norwegian neonatal intensive care units: a quantitative cross-sectional study

BackgroundThe experience of having their new-borns admitted to an intensive care unit (NICU) can be extremely distressing. Subsequent risk of post-incident-adjustment difficulties are increased for parents, siblings, and affected families. Patient and next of kin satisfaction surveys provide key indicators of quality in health care. Methodically constructed and validated survey tools are in short supply and parents’ experiences of care in Neonatal Intensive Care Units is under-researched. This paper reports a validation of the Neonatal Satisfaction Survey (NSS-8) in six Norwegian NICUs.MethodsParents’ survey returns were collected using the Neonatal Satisfaction Survey (NSS-13). Data quality and psychometric properties were systematically assessed using exploratory factor analysis, tests of internal consistency, reliability, construct, convergent and discriminant validity. Each set of hospital returns were subjected to an apostasy analysis before an overall satisfaction rate was calculated.ResultsThe survey sample of 568 parents represents 45% of total eligible population for the period of the study. Missing data accounted for 1,1% of all returns. Attrition analysis shows congruence between sample and total population. Exploratory factor analysis identified eight factors of concern to parents,“Care and Treatment”, “Doctors”, “Visits”, “Information”, “Facilities”, “Parents’ Anxiety”, “Discharge” and “Sibling Visits”. All factors showed satisfactory internal consistency, good reliability (Cronbach’s alpha ranged from 0.70–0.94). For the whole scale of 51 items α 0.95. Convergent validity using Spearman’s rank between the eight factors and question measuring overall satisfaction was significant on all factors. Discriminant validity was established for all factors. Overall satisfaction rates ranged from 86 to 90% while for each of the eight factors measures of satisfaction varied between 64 and 86%.ConclusionThe NSS-8 questionnaire is a valid and reliable scale for measuring parents’ assessment of quality of care in NICU. Statistical analysis confirms the instrument’s capacity to gauge parents’ experiences of NICU. Further research is indicated to validate the survey questionnaire in other Nordic countries and beyond.

Uniform national guidelines do not prevent wide variations in the clinical application of phototherapy for neonatal jaundice.

This study compared the use of phototherapy for neonatal jaundice in all 21 Norwegian neonatal intensive care units (NICUs) from 2013-2014 to improve practice. Information on all types of phototherapy devices was collected, and irradiance was measured from random units at 20 cm and 50 cm from the light source. We gathered information on local practice rules, including the use of single, double or triple phototherapy, how infants were positioned, the frequency of blood sampling, rules for using reflective surfaces and interrupting phototherapy. In every NICU, we asked one nurse with more than five years of experience and one with less than one year to set up phototherapy equipment, then measured the irradiance and distance. Photodiodes were the most common of the eight types of phototherapy devices used. Rules for the distance from the device to the infant varied from 10 to 40 cm and in practice they varied from 15 to 48 cm, with irradiance ranging from 11.1-56.1 W/m2 . There were significant variations between NICUs with regard to the overall treatment duration and duration in most birthweight categories. There were considerable variations in phototherapy practices among Norwegian NICUs. In particular, the significant variations in duration need to be addressed.

Phototherapy is commonly used for neonatal jaundice but greater control is needed to avoid toxicity in the most vulnerable infants.

Limited information is available about how guidelines on phototherapy for neonatal jaundice are applied in practice and toxicity is a concern. We studied the use of phototherapy in relation to birthweight and gestational age (GA) in Norwegian neonatal intensive care units (NICUs). The study population was all 5382 infants admitted to the 21 NICUs in Norway between September 1, 2013 and August 31, 2014. Data were recorded daily in the Norwegian Neonatal Network database and anonymised data on patient characteristics, diagnoses, duration, the ages at the start and discontinuation of phototherapy were analysed. More than a quarter (26.6%) of all infants admitted to Norwegian NICUs during the study period received phototherapy. The use of phototherapy was inversely related to GA and birthweight. More than 80% of the preterm infants under 28 weeks of GA received phototherapy. The duration was significantly longer in the lowest birthweight and GA groups and decreased with increasing birthweight and GA. Phototherapy is proved to be a strong candidate for the most common therapeutic modality in NICU infants. However, in the light of reported toxicity in the smallest, most vulnerable infants, we recommend increased emphasis on quality control.

Patient acuity and nurse staffing challenges in Norwegian neonatal intensive care units.

To describe fluctuations in patient numbers, patient acuity and the need for nurses in neonatal intensive care units based on population data. Neonatal intensive care units are difficult to staff appropriately due to fluctuations in patient volume and acuity. Staffing guidelines have been developed and applied in some countries to offer the neonatal population safe patient care. National data were used to describe patient load and acuity for two consecutive years. The need for nurses was calculated by combining these data with guidelines for nurse staffing. A total of 11.3% of all neonatal patients in Norway were categorised as intensive care patients. There were no differences in the need for nurses in weekends vs. weekdays or during summer holidays vs. days in the rest of the year. Small units have increased variability in staffing needs, and sufficient staffing is more challenging compared to that of larger units. Planning for reduced staffing for weekends and summer seasons is ineffective. Staffing planned for most of the days in a year instead of the median need for nurses will result in a greater increase in the need for nurses in small units compared to larger units.

N-BiPAP treatment in infants with respiratory distress syndrome: A population study

BackgroundSince November 1st 2008, our Norwegian neonatal intensive care unit has used nasal biphasic positive airway pressure (n-BiPAP) instead of invasive mechanical ventilation as first-line treatment after nasal continuous positive airway pressure (n-CPAP) failure in infants with respiratory distress syndrome (RDS). AimTo assess utility of a national patient register to compare outcomes of infants in our unit before and after November 1st 2008 as well as to hospitals that did not utilize n-BiPAP during the observation period. Study designA retrospective study, using a national patient register and a difference-in-difference (DID) statistical approach, adjusting for confounders. SubjectsInfants with RDS admitted to hospital 2002–2010. Outcome measuresWe compared our unit before and after November 1st 2008 and to other hospitals with regards to morbidity, mortality, and number of hospital days (NHD). ResultsInfants with RDS in our unit had a significantly lower risk of bronchopulmonary dysplasia (BPD) (odds ratio (OR) 0.59, p<0.05), retinopathy of prematurity (ROP) (OR 0.57, p<0.05), and intraventricular hemorrhage (IVH) (OR 0.37, p<0.001); as well as the combined outcome of periventricular leukomalacia (PVL), necrotizing enterocolitis (NEC), ROP, IVH, and/or BPD (OR 0.53, p<0.05) after November 1st 2008 and compared to other hospitals. PVL, NEC, and mortality did not change. NHD was reduced by 8. ConclusionIncreasing use of n-BiPAP was associated with reduced morbidity and NHD in infants with RDS. Using a patient register and DID analyses may be a health economic and ethically sound way of generating hypotheses and knowledge about disease and treatment.

Persistence of a pKPN3-like CTX-M-15-encoding IncFIIK plasmid in a Klebsiella pneumonia ST17 host during two years of intestinal colonization.

ObjectivesTo characterize the CTX-M-15-encoding plasmid in a Klebsiella pneumoniae ST17 strain, responsible for an outbreak at a Norwegian neonatal intensive care unit and subsequent colonization of affected children for up to two years. To identify plasmid-mediated features relevant for the outbreak dynamics, and to investigate the plasmids capability of horizontal transfer, its segregational stability and plasmid-mediated fitness costs.MethodsPlasmid profiling was performed by S1-nuclease PFGE, PCR-based replicon typing and Southern blot-hybridization. The complete sequence of the CTX-M-15-encoding plasmid was obtained by 454 sequencing. Plasmid self-transferability was investigated by broth- and filter mating, segregational stability was explored by serial passage, and plasmid-conferred fitness costs were examined in pairwise head-to-head competitions and by growth rate comparisons.ResultsCTX-M-15 was encoded by a ~180 kb IncFIIK plasmid in K. pneumoniae ST17. S1-nuclease PFGE profiles of the first and the last CTX-M-15-producing K. pneumoniae isolates, recovered from the four children colonized the longest, suggested that the plasmid was stably maintained during intestinal carriage of up to two years. The DNA sequence of the pKPN3-like plasmid, pKp848CTX, uncovered a Tn3-like antibiotic resistance region and multiple heavy metal- and thermoresistance determinants. Plasmid pKp848CTX could not be transferred to Escherichia coli in vitro and we found no evidence to support horizontal plasmid transfer in vivo. Segregational plasmid loss ranging from 0.83% to 17.5% was demonstrated in evolved populations in vitro, but only minor fitness costs were associated with plasmid-carriage.ConclusionsPlasmid pKp848CTX encodes phenotypic traits, which may have had an impact on the fitness and survival of the K. pneumoniae ST17 strain in the outbreak setting. The antibiotic resistance plasmid pKp848CTX was stably maintained during two years of intestinal colonization, conferring negligible fitness cost to its host, and thus seem well adapted to its K. pneumoniae host.

1847 Clinicans Documentation of Oxygenation and Ventilation in Premature and Sick Newborns in a Norwegian Neonatal Intensive Care Unit (NICU)

Background and AimsClinical practice concerning oxygen assessment and administration varies between nurses. Ventilator management, pulse oximetry alarm settings and monitoring also varies greatly. Clinicians would benefit from analysis of what...

First outbreak of extended‐spectrum β‐lactamase‐producing Klebsiella pneumoniae in a Norwegian neonatal intensive care unit; associated with contaminated breast milk and resolved by strict cohorting

Neonatal intensive care units (NICUs) are vulnerable to nosocomial outbreaks caused by multiresistant Enterobacteriaceae, but no reports of NICU outbreaks of extended-spectrum β-lactamase (ESBL) producing Klebsiella pneumoniae have previously been published from countries with a low level of antimicrobial resistance such as the Scandinavian countries. We describe a clonal outbreak of CTX-M-15 -producing Klebsiella pneumoniae affecting 58 infants in the neonatal intensive care unit at Stavanger University Hospital, Norway, during a period of 4months, 2008-2009. The clone spread widely and rapidly in the NICU, and extensive interventions were required to terminate the outbreak. In contrast to previous outbreaks, only one infant acquired a systemic infection caused by the outbreak strain, probably due to a favourable epidemic strain lacking the most common virulence factors. A probable index case was identified, due to multiple positive breast milk samples collected from the infant's mother before and after the infant's transfer from another hospital. Breast milk samples from 3/18 (17%) mothers of colonized infants were positive for ESBL-producing K. pneumoniae. Vertical transmission of ESBL-producing bacteria has been shown previously,&#146;but the possibility of transmission of ESBL-producing K. pneumoniae through expressed breast milk is reported here for the first time. The increasing occurrence of ESBL-producing&#146;Enterobacteriaceae should therefore encourage changes in diagnostic routines for bacterial screening of breast milk.

250 Health Promoting Effects of a Family Focused Care Programme in a Norwegian Neonatal Intensive Care Unit

250 Health Promoting Effects of a Family Focused Care Programme in a Norwegian Neonatal Intensive Care Unit

Development of parent–nurse relationships in neonatal intensive care units – from closeness to detachment

This paper is a report of a study to explore the development of relationships between parents and nurses in a neonatal intensive care unit. As increasingly smaller premature babies survive, the prolonged hospitalization that follows makes relationships between parents and nurses crucial. A collaborative partnership in which all the family members' needs are acknowledged is suggested as the best approach. A hermeneutic approach was adopted, using overt participant observation (160 hours) and in-depth interviews to study interactions between parents and nurses. The participants were six mothers, six fathers, and six nurses from a 13-bed Norwegian neonatal intensive care unit. Data were obtained over 27 weeks from 2003 until 2004. A partnership between parents and nurses developed in three phases: the acute critical phase, the stabilizing phase, and the discharge phase. The stabilizing phase seemed the most challenging. As exhausted parents expressed the importance of maintaining the trusting relationship with their primary nurses to become confident when assuming more responsibility and adjusting to the new situation, nurses purposely withdrew and reduced their contact with parents, facilitating their independence and confidence as caretakers. Parents and nurses rarely seemed to discuss with each other the discrepancy in their understanding of the detachment process. Acknowledging the need for parents and nurses to discuss the processes of involvement and detachment may contribute positively to the development of family-centred care in neonatal intensive care units.

The opinions of clinical staff regarding neonatal procedural pain in two Norwegian neonatal intensive care units

Aim: Neonates are subjected to numerous painful procedures without sufficient pain management. The aim of this study was to describe the opinions of Norwegian physicians, nurses and nurse assistants who care for neonates, regarding procedural pain in neonates. Methods: A replication of a previous questionnaire study was conducted in two Norwegian neonatal intensive care units (NICU's). The questionnaire aimed at evaluating procedure painfulness, the current use of pharmacological agents and comfort measures and the optimal use of both. Results: Ninety members of the clinical staff participated, which is a response rate of 87%. Opinions on how procedural pain is currently and optimally managed differed significantly. Although most respondents rated a majority of the listed procedures as being more than moderately painful, pharmacological agents were rarely used, except for the insertion of a chest tube and endotracheal intubation. Comfort measures were also believed to be underutilized, but not to the same degree as pharmacological agents. Conclusion: Procedural pain in neonates is not sufficiently managed and both pharmacological agents and comfort measures are underutilized, according to clinicians at two Norwegian NICU's.

The opinions of clinical staff regarding neonatal procedural pain in two Norwegian neonatal intensive care units

Neonates are subjected to numerous painful procedures without sufficient pain management. The aim of this study was to describe the opinions of Norwegian physicians, nurses and nurse assistants who care for neonates, regarding procedural pain in neonates. A replication of a previous questionnaire study was conducted in two Norwegian neonatal intensive care units (NICU's). The questionnaire aimed at evaluating procedure painfulness, the current use of pharmacological agents and comfort measures and the optimal use of both. Ninety members of the clinical staff participated, which is a response rate of 87%. Opinions on how procedural pain is currently and optimally managed differed significantly. Although most respondents rated a majority of the listed procedures as being more than moderately painful, pharmacological agents were rarely used, except for the insertion of a chest tube and endotracheal intubation. Comfort measures were also believed to be underutilized, but not to the same degree as pharmacological agents. Procedural pain in neonates is not sufficiently managed and both pharmacological agents and comfort measures are underutilized, according to clinicians at two Norwegian NICU's.