Neonatal Intensive Care Practices Research Articles

Need for national guidance regarding proactive care of infants born at 22-23 weeks' gestation.

With recent rapid improvements in neonatal intensive care, the limit of viability has shifted downward to 22-23 weeks' gestation. The younger the gestational age of preterm infants, the higher the risk of survival despite severe neurodevelopmental impairments. For infants born at 22-23 weeks' gestation, the limit of viability, neurodevelopmental outcomes, and survival rates may be determined by the quality of proactive care. Owing to the high risk of severe neurodevelopmental impairment in 22-23 weeks' gestation, proactive care is sometimes withheld according to ethical or legal considerations, and there are significant differences in the provision of proactive care and survival rates across countries or institutions. Additionally, there are differing or even lacking guidelines regarding the care of these infants across countries and institutions. Japan and Sweden are countries with well-established national guidance and proactive care for infants born at 22-23 weeks' gestation, resulting in higher survival rates among them. In Korea, where there is an extreme shortage of neonatologists, maternal transfer before delivery at 22-23 weeks' gestation to high-activity regions with appropriate neonatal intensive care unit resources, such as adequate personnel and facilities similar to the centralized care model seen in Sweden, is crucial for improving the survival rates of infants born at 22-23 weeks' gestation. The survival of these infants largely depends on the quality of proactive care provided. This rate is not static and can be improved through proactive case management based on national guidance and the implementation of enhanced neonatal intensive care practices, including centralization of care.

Implementation of a Level III neonatal intensive care unit was associated with reduced NICU mortality in a resource limited public tertiary care hospital in Guyana, South America.

Neonatal mortality is a significant contributor to child mortality, and there is increasing interest in low resource settings to implement neonatal intensive care practices to lower neonatal mortality. In Guyana, South America neonatal mortality remains relatively high. At Georgetown Public Hospital Corporation (GPHC), the only tertiary referral hospital in Guyana, a Level III NICU was developed starting in January, 2012 with full implementation in September, 2015. In this study, we report the association of the implementation of a Level III NICU with in-hospital neonatal survival at GPHC. Using an observational study design, available data were collected from January 1, 2015 through September 30, 2020. During the study period, there were 30,733 deliveries at GPHC and 4,467 admissions to the NICU at GPHC. There were no significant changes in the numbers of births or NICU admissions during the time of the study. The survival rate for patients admitted to the NICU was ~64% during the first 3 quarters of 2015 with most deaths were caused by sepsis or respiratory failure. By the last quarter of 2015, the NICU survival rate increased dramatically and has been sustained at ~87% (p<0.0001). The inborn mortality rate at GPHC, calculated as a percentage of all live births at GPHC, was 2.9% prior to the full implementation of the NICU and was 1.4% after the full implementation of the NICU (p<0.0001). These findings suggest that the implementation of a Level III NICU at GPHC was associated with an improvement in survival to NICU discharge in a resource limited setting.

Associations of molecular genetic predictors of type 2 diabetes mellitus with hyperglycemia in extremely low birth weight infants

Hyperglycemia in premature newborns is an independent risk factor for death, so blood glucose testing is widely used in the practice of neonatal intensive care units.Objective: to evaluate the associations of the frequency of carriage of allelic variants of polymorphic loci of genes predisposing to type 2 diabetes mellitus in newborns with extremely low body weight and hyperglycemia.Methods. The study design is prospective, controlled, single – center, non-randomized. Genomic DNA samples were studied in newborn infants with extremely low body weight (ELBW) (n = 105). Previously, we compared the distribution of allele frequencies of the studied genes between a group of newborns with ELBW and a population sample of adults (control). Then, the distribution of allele frequencies of the genes was compared depending on the presence of hyperglycemia in newborns with ELBW. For the analysis, loci with already known association with the development of type 2 diabetes mellitus were selected ‒ ADRB2 (rs1042713) and (rs1042714), ADRB3 (rs4994), GNB3 (rs5443), PPARA (rs4253778), PPARD (rs2016520), TCF7L2_IVS3 (rs7903146) and TCF7L2_IVS4 (rs12255372), PPARGC1A (rs8192678), MTHFR (rs1801131), PPARG (rs1801282), MTNR1B (rs10830963), SIRT1 (rs7069102).Results. In newborns with ELBW, we found a more frequent occurrence of the mutant allele A of the polymorphic locus rs8192678 in the PPARGC1A gene and the allele C of the polymorphic locus rs4253778 in the PPARA gene, in contrast to the adult population sample. But in newborns with ELBW, hyperglycemia is most likely associated with the carrier of the allele C rs1801282 of the PPARG gene (χ2 = 18.972, p &lt; 0.001) and the allele T rs7903146 in the TCF7L2 gene (χ2 = 11.496, p &lt; 0.001).Conclusions. The carriage of the allele С rs1801282 of the PPARG gene is characterized by the presence of a strong conjugation with hyperglycemia in newborns with extremely low body weight. It is desirable to monitor the level of glycemia in the conditions of neonatal intensive care units, taking into account the carriage of genes predisposing to hyperglycemia.

Educational needs for practicing neonatal intensive care among Korean nursing students.

PurposeThis study was conducted to investigate the educational needs for practicing neonatal intensive care among Korean nursing students.MethodsAn explorative, sequential, mixed-methods design was used. Qualitative content analysis was conducted of in-depth interviews of six nursing students, five clinical practice faculty members, and five nurses in the neonatal intensive care unit. The results of a survey of 174 nursing students were analyzed quantitatively.ResultsNursing students, clinical practice faculty members, and nurses wanted opportunities for direct nursing practice and education in school during neonatal intensive care practice. In terms of specific educational content, nursing students expressed the highest observation-related educational needs for communication with medical team members, and they expressed the highest practice-related educational needs for operating medical equipment used for neonatal intensive care. The nursing students' needs with regard to the method of practice education were highest for orientation from the head nurses.ConclusionCommunication and operating medical equipment were found to be areas with high educational needs for practicing neonatal intensive care among Korean nursing students. Further research is needed to develop an educational framework and setting for practicing neonatal intensive care that would meet their needs.

Nutrition and the developing brain: the road to optimizing early neurodevelopment: a systematic review.

Neonatal intensive care practices have resulted in marked improvements in the survival of premature infants; however, they remain at significant risk for adverse neurodevelopmental outcomes. The impact of current nutritional practices on brain development following early extra-uterine exposure in premature infants is not well known. We performed a systematic review to investigate nutritional effects on postnatal brain development in healthy term and prematurely born infants utilizing advanced magnetic resonance imaging tools. Systematic screen yielded 595 studies for appraisal. Of these, 22 total studies were selected for inclusion in the review, with findings summarized in a qualitative, descriptive fashion. Fat and energy intake are associated with improved brain volume and development in premature infants. While breast milk intake and long-chain polyunsaturated fatty acid supplementation has been proven beneficial in term infants, the impact in preterm infants is less well understood.

Paediatric intensive care and neonatal intensive care airway management in the United Kingdom: the PIC-NIC survey.

In 2011, the Fourth National Audit Project (NAP4) reported high rates of airway complications in adult intensive care units (ICUs), including death or brain injury, and recommended preparation for airway difficulty, immediately available difficult airway equipment and routine use of waveform capnography monitoring. More than 80% of UK adult intensive care units have subsequently changed practice. Undetected oesophageal intubation has recently been listed as a 'Never Event' in UK practice, with capnography mandated. We investigated whether the NAP4 recommendations have been embedded into paediatric and neonatal intensive care practice by conducting a telephone survey of senior medical or nursing staff in UK paediatric intensive care units (PICUs) and neonatal intensive care units (NICUs). Response rates were 100% for paediatric intensive care units and 90% for neonatal intensive care units. A difficult airway policy existed in 67% of paediatric intensive care units and in 40% of neonatal intensive care units; a pre-intubation checklist was used in 70% of paediatric intensive care units and in 42% of neonatal intensive care units; a difficult intubation trolley was present in 96% of paediatric intensive care units and in 50% of neonatal intensive care units; a videolaryngoscope was available in 55% of paediatric intensive care units and in 29% of neonatal intensive care units; capnography was 'available' in 100% of paediatric intensive care units and in 46% of neonatal intensive care units, and 'always available' in 100% of paediatric intensive care units and in 18% of neonatal intensive care units. Death or serious harm occurring secondary to complications of airway management in the last 5 years was reported in 19% of paediatric intensive care units and in 26% of neonatal intensive care units. We conclude that major gaps in optimal airway management provision exist in UK paediatric intensive care units and especially in UK neonatal intensive care units. Wider implementation of waveform capnography is necessary to ensure compliance with the new 'Never Event' and has the potential to improve airway management.

Presence and pattern of scarring in children born very preterm

The long-term scarring burden of preterm infants undergoing modern neonatal intensive care is not known. This observational cohort study aimed to document the presence and pattern of scarring in children...

The choice of tactics of treatment of patent ductus arteriosus in newborns with low and the critical birth weight

Questions diagnosis and tactics of treatment of patent ductus arteriosus in newborns with low and critical birth weight today are relevant to the practice of neonatal intensive care. The most unresolved issue is to identify the signs of hemodynamic significance of vice that often requires surgery. Thus, the objectification of assessing the severity of the newborn state with the CAP and the development of algorithms for early diagnosis and treatment is an actual problem.Purpose of the study. Develop and implement a diagnostic and treatment algorithm PDA in infants with low and critical body weight.Material and methods. During the years 2010-2013 was conducted a prospective controlled study. Study group consisted of 60 children with left-right shunt through the ductus arteriosus. A control group includ 30 premature newborn without blemish, a representative for gestational age and sex. Term gestation of newborn was 28,0 ± 2,0 weeks, the average weight of 1168,0 ± 377,0 grams.Results of the study. Was researching features of the central condition, brain, renal hemodynamics in neonates with critical body weight on the background of patent ductus arteriosus . The regularities and nature of the aforementioned disorders. Comparison of the clinical and laboratory characteristics of the organ dysfunctions with Doppler parameters obtained during the examination of the cardiovascular system of children with PDA allowed to substantiate new predictors of hemodynamic significance of vice, and to develop modern principles of diagnosis and intensive therapy of the disease. Based on these research was realized the basic and additional criteria for the hemodynamic significance of vice, which are summarized in the diagnosis and treatment algorithm.Conclusions. The application of the developed algorithm of diagnosis and treatment of PDA in infants with low and very low birth weight possible to achieve correction of the defect at 61.67%, which is 16,67% (p &lt;0,05) more compared to traditional approaches to treatment.

The ACO/Palliative Care Project: An Innovative Model for Upstream Palliative Care in a SNF (TH328)

Objectives Reflect on current neonatal intensive care practice for the seriously ill and or dying neonate. Explore the role of the primary palliative care clinician. Discuss palliative educational goals for intensive care clinicians. Introduction: This session will be an interactive discussion with presenters (parent, palliative care nurse scientist/educator/author/neonatologist/palliative care pediatric nurse consultant). Our assumption is that primary palliative care is integral to the life-supporting care of neonates and their families on admission to the neonatal intensive care unit (NICU). Background: In keeping with the recommendations of the 2014 Institute of Medicine’s Dying in America report, primary palliative care must be included in the basic curriculum for every clinician who cares for patients with advanced or serious illness. Clinicians practicing in the NICU fall squarely in this category as demonstrated by the life-supporting measures required by sick newborns while addressing the vulnerable traumatized emotional state of parents, especially mothers. Few parents are able to grasp the enormity of the situations they are now facing. Two-thirds of infant deaths (birth-1 year) occur in the neonatal period (birth-28 days). Other neonates remain with a significant degree of prognostic uncertainty, hovering between life and death for weeks or months. If an infant dies, parents are often unprepared and, in turn, the intensive care team is unprepared to respond to the intense suffering of parents.

Primary Palliative Care in the Neonatal Intensive Care Setting: What Is Possible? What Is Necessary? (TH327)

•Reflect on current neonatal intensive care practice for the seriously ill and or dying neonate.•Explore the role of the primary palliative care clinician.•Discuss palliative educational goals for intensive care clinicians. Introduction: This session will be an interactive discussion with presenters (parent, palliative care nurse scientist/educator/author/neonatologist/palliative care pediatric nurse consultant). Our assumption is that primary palliative care is integral to the life-supporting care of neonates and their families on admission to the neonatal intensive care unit (NICU). Background: In keeping with the recommendations of the 2014 Institute of Medicine’s Dying in America report, primary palliative care must be included in the basic curriculum for every clinician who cares for patients with advanced or serious illness. Clinicians practicing in the NICU fall squarely in this category as demonstrated by the life-supporting measures required by sick newborns while addressing the vulnerable traumatized emotional state of parents, especially mothers. Few parents are able to grasp the enormity of the situations they are now facing. Two-thirds of infant deaths (birth-1 year) occur in the neonatal period (birth-28 days). Other neonates remain with a significant degree of prognostic uncertainty, hovering between life and death for weeks or months. If an infant dies, parents are often unprepared and, in turn, the intensive care team is unprepared to respond to the intense suffering of parents. •What is the role of a primary palliative care clinician practicing in an intensive care setting?•Are there core primary palliative care educational outcomes that are specific to any intensive care settings?•Is the implementation of a primary palliative curriculum a possibility in the current intensive care environment? Summary: Session facilitators will summarize the discussion points and share with attendees via e-mail if requested.

Reanalysis of the Data of the Article “Impaired Lung Function After Intubation and Mechanical Ventilation for Surgical Ligation of the Ductus Arteriosus in Preterm Infants” by Dzukou et al

We read with interest the article “Impaired Lung Function After Intubation and Mechanical Ventilation for Surgical Ligation of the Ductus Arteriosus in Preterm Infants” by Dzukou et al.1 Lung parenchymal damage during intermittent positive-pressure ventilation (IPPV) secondary to the activation of inflammatory cascades2 and an increase in permeability of the alveolar-capillary barrier and increased vascular transmural pressure have been described.3 The findings of this article are of far-reaching clinical importance and potentially change neonatal intensive care practice.

Neonatal intensive care practices and the influence on skin condition

Premature skin has a thinner epidermis with a poorly formed stratum corneum (SC) barrier compared to full term skin. Poor skin integrity increases the risk of exposure to irritants and infectious agents. Interventions that facilitate skin maturation are essential. The objective was to examine the effects of prematurity and time from birth on SC maturation and to identify factors that impact skin condition. A retrospective review was conducted among 130 NICU patients. Skin regions were evaluated for erythema, rash, integrity and function. The effects of gestational age, time from birth, stool exposure, nutrition and diagnosis were examined. Three groups emerged: (i) premature and <38 weeks adjusted age; (ii) premature and >38 weeks adjusted age; and (iii) full term. Surprisingly, the premature infants exhibited lower perineal irritation and greater SC integrity (lower transepidermal water loss) than full terms (P < 0.05). Group 2 had a longer time before the first skin-stool contact. Chest skin pH showed maturational changes for Group 1 (P < 0.05) but did not change for premature Group 2 who was older at enrollment. Erythema was lower for infants using elemental formulas or total parenteral nutrition. Premature infants with early stool contact and high exposure, full term infants, and patients with congenital diaphragmatic hernia or trisomy 21 are at high risk for skin compromise and may benefit from prophylactic interventions to minimize compromise. Low stool exposure and greater time before the first stool contact appear to be protective against skin compromise.

Neonatal Intensive Care: A Global Perspective of Similarities and Differences in Selected Neonatal Intensive Care Units in Brazil, Chile, the United States, and Zambia

Nurses working in neonatal intensive care units (NICUs) worldwide share common goals of providing high quality care and promoting healthy outcomes for high-risk newborns and their families. There are wide differences across the globe, however, in the specific challenges that NICU nurses face in meeting these common goals and in the ways in which nursing care is provided to address these challenges. Neonatal nurses have much to learn from one another by sharing their common and unique challenges and solutions to those challenges. This article describes the practice of neonatal intensive care nursing in 4 NICUs located in Brazil, Chile, the United States, and Zambia to highlight both similarities and differences in the practice of neonatal nursing in diverse global settings. The article concludes with a discussion of the similarities and differences in challenges faced by nurses in these 4 units and recommendations about ways to address these challenges to promote equity and health for all across the globe.

Neonatal intensive care practices harmful to the developing brain

There has been a marked increase in the survival of extremely low birth weight (ELBW) infants, but these babies have a long stay in the NICU. Strategies to decrease their neurodevelopmental impairment become very important. The maximum development of the brain occurs between 29-41 weeks. From the warm, dark, acquatic econiche, where the baby hears pleasant sounds like the mother's heart beat, the baby suddenly finds itself in the dry, cold, excessively bright, noisy, environment of the NICU. Noise, bright light, painful procedures, and ill-timed caregiving activities, adversely affect the infant's development. Excessive radiation from X-rays of babies on the ventilator and CT scans also affect the brain. Medications like steroids for chronic lung disease also cause damage to the brain. Aminoglycides and frusemide are known to cause hearing impairment. Hence a developmentally supportive, humanized care will go a long way in enhancing the developmental outcome of these babies.

Perceptions of Parents, Nurses, and Physicians on Neonatal Intensive Care Practices

Perceptions of Parents, Nurses, and Physicians on Neonatal Intensive Care Practices

Perceptions of Parents, Nurses, and Physicians on Neonatal Intensive Care Practices

To identify satisfaction with neonatal intensive care as viewed by parents and healthcare professionals and to explore similarities and differences between parents and healthcare professionals. A 3-round Delphi method to identify neonatal care issues (round 1) and to determine the importance of these issues (rounds 2 and 3) was conducted among nurses (n = 84) and physicians (n = 14), followed by an exploratory survey among parents (n = 259). Main outcome measures were 92 neonatal care-related items. Sixty-eight nurses and 13 physicians completed all 3 rounds. The first round yielded 419 neonatal care related statements, which were clustered into 92 items. The survey was completed by 148 (57%) parents. Parents rated 25 of 92 care items significantly higher than did the professionals (effect size of Cohen's d, 0.31 to 1.14, P <or= .02). Two items related to medication administration had the largest effect size. Professionals rated 7 items significantly higher than did parents (Cohen's d, -0.31 to -0.58, P <or= .04). One of these was assigning a physician and a nurse to the parents. Three were related to multicultural care. This study revealed disparities between parents and neonatal intensive care unit staff on a number of care issues reflecting incongruity in recognizing parents' desires.

Measuring developmentally appropriate practice in neonatal intensive care units

Neonatal intensive care units (NICUs) impose stressors on development. Comparative studies have focused mostly on the units' medical qualities and less on their developmental 'ecology'. The aim of the study was to develop a tool for measuring the various domains of a developmentally appropriate practice in the NICU environment, and to assess its implementation in Israel. A questionnaire, designed for NICU senior staff members, was completed by 76 respondents representing 24 NICUs in Israel. The tool that measures developmentally appropriate practice as applied in the NICU environment includes the following three domains: (a) parental and family involvement, (b) environmental control and (c) individualized care and assessment. These measures jointly produce the developmentally appropriate neonatal intensive-care practice (DANIP) index. High variability was found in the application of procedures and programs considered developmentally appropriate. Units with a relatively large multidisciplinary team scored high. Overall, the NICUs in Israel did not consistently follow an integrated form of the developmental care as provided by the Neonatal Individualized Developmental Care and Assessment Program. It was found that individualized care and assessment was significantly and positively linked to control of the environment (r=0.53, P<0.01) and to parental and family involvement (r=0.76, P<0.01); the latter two scales were not associated. Of the three DANIP domains, parental involvement was salient. Although the staff highly appreciated the importance of environmental control and individualized care, application was limited. The DANIP index provides a good starting point for comparative studies.

With Hope and Imagination: Imaginative Moral Decision-Making in Neonatal Intensive Care Units

Although the role of imagination in moral reasoning is often neglected, recent literature, mostly of pragmatist signature, points to imagination as one of its central elements. In this article we develop some of their arguments by looking at the moral role of imagination in practice, in particular the practice of neonatal intensive care. Drawing on empirical research, we analyze a decision-making process in various stages: delivery, staff meeting, and reflection afterwards. We show how imagination aids medical practitioners demarcating moral categories, tuning their actions, and exploring long-range consequences of decisions. We argue that imagination helps to bring about at least four kinds of integration in the moral decision-making process: personal integration by creating a moral self-image in moments of reflection; social integration by aiding the conciliation of the diverging perspectives of the people involved; temporal integration by facilitating the parties to transcend the present moment and connect past, present, and future; and epistemological integration by helping to combine the various forms of knowledge and experience needed to make moral decisions. Furthermore, we argue that the role of imagination in these moral decision-processes is limited in several significant ways. Rather than being a solution itself, it is merely an aid and cannot replace the decision itself. Finally, there are also limits to the practical relevance of this theoretical reflection. In the end, it is up to care professionals as reflective practitioners to re-imagine the practice of intensive care and make the right decisions with hope and imagination.

The impact of neonatal intensive care practices on the developing brain

The impact of neonatal intensive care practices on the developing brain

Response to “Giving ‘Moral Distress’ a Voice: Ethical Concerns Among Neonatal Intensive Care Unit Personnel” by Pam Hefferman and Steve Heilig and “Neonatal Viability in the 1990s: Held Hostage by Technology” by Jonathan Muraskas et al. (CQ Vol 8, No 2)

The Spring 1999 issue of Cambridge Quarterly (Volume 8, Number 2) adds to the growing body of academic inquiry into the goals of neonatal intensive care practices. Muraskas and colleagues thoughtfully presented the possibility of nontreatment for neonates born at or under 24 weeks gestation. Jain, Thomasma, and Ragas explained that quality of future life must not be ignored in clinical deliberation. And Hefferman and Heilig described once again the dilemmas nurses face when caring for potentially devastated neonates kept alive by technology. These authors take brave steps by publicly questioning the trend of intensive medical support for most every American-born product of conception. But many questions addressing the goals of neonatal intensive care remain, and few authors have actually tried to distill these goals.