Umbilical Catheter Research Articles

"TPN-oma": A Rare Complication of Lipid Extravasation With Umbilical Venous Catheterization Misplacement.

"TPN-oma": A Rare Complication of Lipid Extravasation With Umbilical Venous Catheterization Misplacement.

Humidification Solution as a Source for Spreading Burkholderia cepacia in a Neonatal Intensive Care Unit

Abstract Burkholderia cepacia is an important opportunistic organism in hospitalized and immunocompromised patients especially in newborns. The natural ecology of these bacteria associated with plants is also a cause of infectious potential. The disease-causing potential of bacteria as a nosocomial pathogen may be due to its ability to survive in antiseptic solutions, contamination equipment. The patient was hospitalized for prematurity and respiratory distress syndrome. He was treated with surfactant intratracheally for the respiratory distress syndrome. Umbilical catheter was inserted. Ampicillin and gentamicin treatments were initiated. The patient who received respiratory support for a long time was given a steroid protocol because of bronchopulmonary dysplasia. Burkholderia cepacia was detected in the blood and tracheal aspirate cultures of the patient, whose infection markers increased and a new area of infection was detected on the chest radiograph. Colistin and ciprofloxacin treatments were given according to the culture antibiogram. Screening tests revealed B. cepacia colonization in incubator moistening solutions. All incubator humidification solutions in the hospital were changed. Burkholderia cepacia is a rare cause of nosocomial infection in intensive care units but resistant to many treatments. With its capability to colonize water and grow on microbicides, the presence of B. cepacia in a patient's blood warrants further investigation in institutions providing care.

AIUM Practice Parameter for the Performance of Duplex Sonography of Native Renal Vessels

AIUM Practice Parameter for the Performance of Duplex Sonography of Native Renal Vessels

Bilateral lower extremity ischemia due to a retained umbilical artery catheter in a preterm neonate.

The use of umbilical artery catheters is common in Neonatal Intensive Care Units, especially in low and very low birth weight neonates. Rarely, these can break or fracture, leading to a retained fragment, which can embolize or cause thrombosis. We pre sent a case of a very low birth weight, premature neonate, 940 grams, with a retained umbilical artery catheter that led to bilateral lower extremity ischemia. A laparotomy with aortotomy was per formed for retrieval of the catheter. Chronic occlusion of the aorta with collateralization is a long-term complication associated with this case.

Treatment for hypotension in the first 24 postnatal hours and the risk of hearing loss among extremely low birth weight infants.

Objective:To evaluate whether treated hypotension in the first 24 postnatal hours is associated with hearing loss in extremely low birth weight (ELBW) infants.Study Design:In a cohort of 735 ELBW infants, we identified 25 with sensorineural hearing loss at 12–24 months adjusted age. For each case we selected 3 controls with normal hearing. Logistic regression models were used to adjust for confounding variables.Results:60% of cases and 25% of controls were treated for hypotension. After adjusting for confounding variables (gestational age, antenatal glucocorticoids, 5 minute Apgar < 6, insertion of an umbilical catheter, treatment with high frequency ventilation, and major cranial ultrasound abnormality), treated hypotension was associated with an increased risk of sensorineural hearing loss (adjusted odds ratio: 3.6; 95% confidence interval: 1.3–9.7).Conclusions:Treated hypotension in ELBW infants in the first 24 hours of life is associated with an increased risk of sensorineural hearing loss.

Development and validation of a nomogram for predicting late-onset sepsis in preterm infants on the basis of thyroid function and other risk factors: Mixed retrospective and prospective cohort study

Preterm birth and infection are common causes of neonatal death. In this study, we aimed to develop a nomogram for assessing the individual prior probability of late-onset sepsis on the basis of risk factors in preterm infants. This study is a mixed retrospective and prospective cohort study conducted in three centers. Data from January 2014 to December 2017 was used for the development cohort, and data from January 2018 to December 2018 was used for the validation cohort. In the development cohort, we identified the predicting variables of late-onset sepsis in preterm infants, from which a nomogram was obtained. Then we built nomograms, for with and without thyroid function, to predict late-onset sepsis. The nomogram was validated in the validation cohort concerning discrimination and calibration. A total of 1256 and 452 preterm infants were included in the development and validation cohort, respectively. We found thyroid hypofunction in preterm infants could increase the incidence of late-onset infection. The prediction model incorporated thyroid function, birth weight, use of endotracheal intubation, and duration of umbilical venous catheters was validated and developed as a nomogram for predicting late-onset sepsis in preterm infants. Nomogram in this study may contribute to clinical assessment and treatment decisions.

Neonatal Nurse Practitioner Use of Ultrasonography to Verify Umbilical Venous Catheter Placement in the Neonatal Intensive Care Unit.

Literature dating back to 1982 supports the use of ultrasound to confirm UVC position as a more reliable method compared to x-ray. The use of ultrasound to confirm UVC position remains infrequent in the NICU. To determine the feasibility of training an NNP in the acquisition and interpretation of a parasternal short-axis (PSAX) image of the heart to confirm UVC position. A retrospective review of 48 charts evaluated descriptive data using standard technique of an x-ray to confirm UVC placement. An NNP was trained to acquire and interpret a parasternal short-axis (PSAX) cardiac view by a pediatric cardiologist. The NNP independently and prospectively evaluated 21 neonates and determined whether the UVC was in satisfactory or unsatisfactory position. The same image was blindly over-read by the pediatric cardiologist. Agreement between the NNP and pediatric cardiologist interpretations as well as the pediatric cardiologist and radiologist interpretations was evaluated using the κ-test. Initial pediatric cardiology interpretation of UVC position showed the UVC to be malpositioned in 66% of neonates (n = 14). NNP and pediatric cardiology interpretations in UVC position had 86% agreement (κ-0.667). Pediatric cardiology (ultrasound) and radiology interpretations (x-ray) in UVC position had 86% agreement (κ-0.69). It is feasible to train NNPs to perform and accurately interpret a single PSAX ultrasound image to determine satisfactory UVC position. Increasing the use of ultrasound to determine satisfactory position of UVCs in the NICU can reduce unnecessary exposure to ionizing radiation in neonates.

Umbilical catheter-associated complications in a level IV neonatal intensive care unit.

To assess complication rates and risks associated with the use of umbilical catheters. An observational cohort study was conducted in a level IV neonatal intensive care unit over 11 years. Any neonate with an umbilical catheter placed during this period was included. Complication event rates over time were assessed via Poisson and Cox regressions. Fifty one of 2035 umbilical arterial catheters (2.5%) and 269 of 2017 umbilical venous catheters placed (13.3%) developed a complication. Positional issues comprised most umbilical venous catheter-associated complications (86.2%) and breaks/ruptures the majority in umbilical arterial catheters (41.2%). The cumulative incidence of a complication increased most notably after 10 days of umbilical arterial catheter use and 16 days of umbilical venous catheter use. Complications occurred in a relatively low percentage of umbilical catheters placed in our neonatal intensive care unit. Extended catheter dwell time remains a significant risk of developing a complication.

Current status of central vascular access devices in pediatric patients in 31 hospitals nationwide

Objective To explore the currents status of central vascular access devices (CVADs) in children's medical center in China and to provide a reference for the standardized use of CVADs and specialized nursing as well as a basis for pediatric intravenous therapy management. Methods Totally 31 hospitals of Futang Research Center of Pediatric Development, children's hospitals of the medical treatment alliance as well as women and children care centers and general hospitals with pediatric departments were selected by convenient sampling from July 23rd to 31st, 2018. All the pediatric patients using CVADs were investigated with the Central Vascular Access Device Questionnaire which was designed by the research group, and the incidence of complications was also observed. Totally 1 333 questionnaires were collected, among which 1 288 were valid, accounting for an effective recovery rate of 96.62%. Results There were 22 ClassⅢ and 9 ClassⅡ hospitals among the 31 hospitals. Among the 1 288 pediatric patients who used CVADs, 860 used peripherally inserted central catheters (PICC) , accounting for 66.77%; 342 used central venous catheters (CVC) , accounting for 26.55%; 77 used implantable venous access port (PORT) , accounting for 5.98%; and 9 used umbilical venous catheters, accounting for 0.70%. CVADs were mainly used in the Departments of Hematological Neoplasms, ICU, Intensive Care Unit Pediatric Surgery, Vasculocardiology and Neonatals. PICC, CVC and PORT were mainly applied to upper extremities (90.00%, 74 cases) , jugular vein (73.39%, 251 cases) and the breast (96.10%, 74 cases) respectively. In the maintenance of CVADs, there was the problem of co-existing dressings. Conclusions CVADs have been widely used in pediatric patients, and the choice of CVADs is relatively standardized. However, the maintenance of the catheters, the use of dressings, the selection of infusion connectors and the control of related complications still need to be strengthened. It is recommended that nursing professionals and nursing managers should further strengthen their knowledge about the placement and maintenance of CVADs, and intensify their management and supervision in accordance with international and national guidelines and standards for intravenous infusion therapy to further reduce the incidence of vascular access complications in pediatric patients. Key words: Hospitals, pediatrics; Complication; Central vascular access; Catheter maintenance; Current status survey

Bedside sonography performed by neonatology residents to confirm central vascular catheter position in neonates – A Prospective Diagnostic Evaluation study

To evaluate the diagnostic accuracy and utility of bedside ultrasound (US) by neonatology residents to confirm position of umbilical venous catheter (UVC), umbilical arterial catheter (UAC), and peripherally inserted central catheter (PICC). In this prospective study, we included neonates who required UVC, UAC or PICC insertion. Two neonatology residents performed all bedside US examinations after a short period of training. Plain radiograph was taken as gold standard. Time taken for confirmation of catheter position by US and radiograph was recorded. We recruited 71 neonates for UVC and UAC, and 40 neonates for PICC. Sensitivity and specificity of US in identifying a malpositioned catheter was good for UVC (94% and 66.7% respectively) and UAC (86.7% and 94.5%). Agreement between radiograph and US was good for UVC [0.718 (0.512, 0.861); p < 0.001] and UAC [0.857 (0.682, 0.953); p < 0.001]. Sensitivity (47.8%) of US in identifying a malpositioned PICC was low, though specificity (82.4%) was good. Agreement between radiograph and US in identifying PICC position was poor [0.25 (-0.084, 0.545); p 0.024]. This was due to incorrect interpretation of catheter position on radiograph in some infants, which was confirmed by the radiologist. The median time taken for US was significantly less than time taken for radiograph in confirming the position of UVC (50 vs. 155 minutes; p < 0.001)), UAC (45 vs. 128 minutes; p < 0.001), and PICC (60 vs. 136 minutes; p < 0.001). US examination byneonatology residents has good diagnostic accuracy in confirming the position of UAC and UVC, and possibly PICC in neonates. The time taken to confirm catheter position by US is significantly less than radiograph.

Which long line do we use in very low birth weight neonates; umbilical venous catheter or peripherally inserted central catheter?

Umbilical venous catheters (UVC) and peripherally inserted central catheters (PICC) are commonly used in preterms. UVC is cheap, easy to insert but has shorter dwell time. UVC is replaced after 7 days due to the risk of complications. This is associated with increased cost, work, and risk of nosocomial infections. The aim of this study was to determine the antenatal and postnatal factors that predict the need for a central line for more than 7 days, thus helping select between UVC or PICC on day 1 of life in babies ≤1500 grams. We retrospectively collected antenatal and postnatal data of VLBW neonates over a period of 1 year who needed CL during their NICU stay. We then divided them into two cohorts. Group 1: CL ≤7 days. Group 2: CL > 7 days. Sepsis and catheter complications were lower with use of a single CL or duration being ≤7 days. Birth weight, incomplete/no antenatal steroids, need for resuscitation, low Apgar's, RDS, hs-PDA, and initiation of feeds beyond 24 hours of birth were significant. The score was devised based on factors found significant that had an acceptable AUC of 0.767 on ROC analysis with a score of 1 or above having 74.8% sensitivity and 67.7% specificity for prediction of need for CL > 7 days. Birth weight ≤1000 grams, incomplete steroids and need for resuscitation at birth were predictive of the need of CL beyond seven days, on day one of life.

Evaluation of the distance between the xiphoid process and the umbilicus: Is it appropriate for the measurement of the umbilical venous catheter length?

Objective: Umbilical venous catheter is a commonly used intervention for total parenteral nutrition, antibiotic therapy, and investigations, especially in very low birth weight infants hospitalized in neonatal intensive care units. Catheter length can be calculated using several methods such as Dunn's method, Shukla–Ferrara's formula, and revised Shukla's formula. In this study, we evaluated with echocardiography whether the length of umbilical venous catheter inserted by measuring the upper limit of the xiphoid process and the lower limit of the umbilical ring is appropriate.Materials and Methods: A total of 12 premature infants with a birth weight ≤1500 g with umbilical venous catheter inserted were included in the study. The length of the umbilical venous catheter was determined by measuring the distance between the upper limit of the xiphoid process and the lower limit of the umbilical ring. Evaluation was performed first by chest X-ray followed by echocardiography. Results: On chest X-ray, the tip of the catheter appeared longitudinal below the diaphragmatic level in all infants. In none of the cases was the umbilical venous catheter found intracardiac when evaluated by echocardiography. The catheter tip was localized in the cavoatrial junction in four infants, thoracic inferior vena cava in five infants, and ductus venosus in three infants. Conclusion: In our study, we found that the length of umbilical venous catheter determined by measuring the distance between the upper limit of the xiphoid process and the lower limit of the umbilical ring did not lead to overadvancement, and this method can be used in practice. However, further studies with larger series are needed to draw more definitive conclusions on this issue.

The danger awaiting premature babies: Portal vein thrombosis.

Aim:Umbilical venous catheters are frequently used in the neonatal period. The incidence of umbilical venous catheter-related thrombosis is between 1.3% and 43% in ultrasound scans. This study aimed to determine the incidence and risk of portal vein thrombosis in patients who were hospitalized in the neonatal intensive care unit and underwent umbilical venous catheter insertion.Material and Methods:Premature infants (≤32 gestational weeks) who were hospitalized in a Level III neonatal intensive care unit and underwent umbilical vein catheter placement between 2016 and 2018, were included in the study. The demographic data, clinical risk factors for thrombosis, number of catheter days, catheter locations, times of detection of thrombosis using Doppler ultrasonography, treatment methods and durations, thrombosis follow-up and examinations were obtained retrospectively from the electronic patient files.Results:Ninety-six patients whose complete data could be reached were enrolled in the study. The mean gestational age of the patients was found as 29±2 weeks and the mean birth weight was 1353±369 g. Portal vein thrombosis was detected in 13.5% (n=13) of the patients. Five of the cases of portal vein thrombose were complete occlusion and eight were partial occlusion. All patients with complete occlusion and six patients with partial occlusion were treated with low-molecular-weight heparin for a mean duration of 31±13.8 days. Thrombosis disappeared in 7–120 days in all patients. A thrombophilia mutation was detected in six patients with thrombosis, four of whom had the PAI-1 4G / 5G mutation.Conclusion:Portal vein thrombosis which has a significant place among the causes of portal hypertension in childhood, is mostly asymptomatic in the neonatal period and cannot be recognized clinically. It is important to screen and follow up patients with umbilical vein catheters using Doppler ultrasonography in terms of PVT after catheter removal to prevent long-term complications.

Клинический случай ветряной оспы у беременной и внутриутробной ветряной оспы у новорожденного

In this article, we report a case of varicella in a pregnant woman and her newborn. The woman had moderate varicella infection at the 36th week of pregnancy. She delivered a full-term baby at 38th week, 13 days after first manifestations of varicella. Considering high risk of intrauterine infection, it was decided to prescribe acyclovir at a dose of 10 mg/kg per day divided into 3 portions given every 8 hours to prevent congenital varicella. We installed an umbilical catheter using aseptic technique for intravenous acyclovir infusions. Despite these measures, the newborn developed rash (rare erythematous elements up to 1 mm in diameter) on the chest and right shoulder on day 2. On days 3 and 4, the baby developed maculovesicular rash with a diameter of up to 2–3 mm. On day 5, the newborn demonstrated almost complete resolution of rash. Body temperature was normal. The baby was in good condition and active and was breast-fed. The baby received comprehensive therapy in addition to the causal treatment with acyclovir. This case demonstrates typical course of moderate varicella infection in a pregnant woman and intrauterine varicella in a newborn. The mother became ill shortly before giving birth and, therefore, produced specific antibodies that were transferred through the placenta, which ultimately mitigated varicella infection in the newborn. Key words: varicella, pregnant woman, newborn, acyclovir

Umblikal Kateter İlişkili Portal Ven Trombozu: Bir Merkez Deneyimi

Amaç: Yenidoğan yoğun bakım ünitelerinde giderek artan sıklıkta invaziv girişimler yapılmaktadır. Özellikle preterm bebeklere sıklıkla umblikal kateterler takılmaktadır. Bu çalışmanın amacı kliniğimizde takılan umblikalkateterlerin portal ventrombozu (PVT) ile ilişkisini ve risk faktörlerini belirleyebilmektir.Materyal ve metod: Retrospektif olarak 01 Ekim 2017-31 Aralık 2018 tarihleri arasında kliniğimiz yenidoğan yoğun bakım ünitesinde izlenen gestasyon yaşı 32 hafta ve altında olan, umblikal kateter takılan ve en az 6 saat boyunca kateter takılı olan preterm bebekler çalışmaya dahil edildi. Umblikal ven kateteri (UVK) takılan hastaların taburculuk öncesi PVT açısından yapılan portal venöz doppler ultrasonografi (USG) sonuçları ile perinatal risk faktörleri ve kateter ile ilgili özellikler değerlendirildi.Bulgular: 142 hastaya UVK takıldı. 118 hastanın doppler USG sonucuna ulaşıldı. On beş (%9,9) hastada doppler USG ile PVT saptandı. PVT saptanan hastaların hiçbirinde klinik bulgu yoktu. PVT saptanan hastaların ortalama gestasyon yaşı ve doğum ağırlığı, PVT saptanmayan hastalardan daha düşüktü. On dört hastada portal venin sol dalında tromboz saptanırken, bir hastada ana portal vende tromboz saptandı.Tromboz saptanan bir hastada annede gestasyonel diyabet mevcuttu. PVT saptanan hastaların geç neonatal sepsis ve bronkopulmoner displazi oranları daha yüksekti, hastanede yatış süresi daha uzundu. Yine bu grupta kateterin alçak yerleşim oranı daha fazla, kateter kalış süresi ise diğer gruba göre daha uzundu. Sonuç: Umblikal ven kateterizasyonu PVT gelişimi için önemli bir risk faktörüdür. UVK takılan, özellikle düşük doğum ağırlıklı hastalar PVT açısından portal doppler USG ile değerlendirilmelidir.

Application of a modified electrocardiogram-guided technique for umbilical venous catheterisation in neonates: A retrospective trial.

To investigate the effectiveness and safety of modified electrocardiogram (ECG)-guided technique in umbilical venous catheterisation in neonates. Sixty-six critically ill neonates underwent umbilical venous catheterisation with (ECG group) or without (control group) ECG guidance from January 2017 to March 2019. We retrospectively analysed and compared the rate of correct tip placement on first try, unplanned extubation rate and incidence of catheter-related complications between the two groups. There were 33 patients in each group. The ECG group showed significantly higher rate of correct tip placement on first try (P < 0.001), lower unplanned extubation rate (P < 0.001), but identical incidence of catheter-related complications (P = 0.492) comparing with the control group. The ECG-guided technique is an effective and safe method for umbilical venous catheterisation. The connecting method we modified made this technique more practical and can be promoted to areas without access to specific ECG adaptors.

Ultrasound-guided umbilical venous catheterisation: A cost-effectiveness analysis

IntroductionAlthough the use of ultrasound for the insertion of central catheters has proven to be cost-effective in adults, it is not known if this is the case in the neonatal population. This study compared the cost-effectiveness of ultrasound-guided umbilical venous catheterisation with conventional catheterisation in a neonatal intensive care unit of a Public University Hospital. Patients and methodsA retrospective observational study was conducted on newborns that required an umbilical venous catheter before completing their first 24h of extra-uterine life. Two retrospective cohorts were formed, including one with ultrasound-guided catheterisation and the other with conventional catheterisation. The effectiveness was measured using 2 variables: placement of ideal position and insertion without complications. The cost of human and material resources (consumable and non-consumable), the cost-effectiveness ratio, and the incremental cost-effectiveness ratio were estimated, as well as carrying out a sensitivity analysis. ResultsCatheter obstruction was more frequent in guided catheterisation than in conventional catheterisation (7.7% vs. 0%, P=.04) and catheter dysfunction was higher in the latter (79% vs. 3.8%, P<.0001). The cost-effectiveness ratio of the guided catheterisation was €153.9, and €484.6 for the conventional one. The incremental cost-effectiveness ratio was €45.5. The sensitivity analysis showed a €2.6 increase in the cost-effectiveness ratio of the guided catheterisation and €47 in the conventional one. ConclusionsThe use of ultrasound to guide umbilical catheterisation is more efficient than conventional catheterisation since, despite using more economic resources, it offers greater effectiveness.

Presence of Bisphenol A and Parabens in a Neonatal Intensive Care Unit: An Exploratory Study of Potential Sources of Exposure

Newborns in neonatal intensive care units (NICUs) are in contact with a variety of medical products whose production might include synthetic chemicals with hormonal activity. Our aim was to assess the content of bisphenol A (BPA) and parabens (PBs) and the hormone-like activities of a subset of medical products commonly used in NICUs in prolonged intimate contact with NICU newborns. Fifty-two NICU items were analyzed, determining the concentrations of BPA and PBs [methyl- (MeP), ethyl- (EtP), propyl- (PrP), and butylparaben (BuP)] and using the E-Screen and PALM-luciferase assays to measure the in vitro (anti-)estrogenic and (anti-)androgenic activity, respectively, of the extracts. Items found to have elevated BPA/PB content or hormone-like activities were further extracted using leaching methodologies. BPA was found in three-fifths and PBs in four-fifths of tested NICU items, and and of extracts evidenced estrogenic and anti-androgenic activity, respectively. The highest BPA content was found in the three-way stopcock (), followed by patterned transparent film dressing, gastro-duodenal feeding tubes, sterile gloves, single-lumen umbilical catheters, and intravenous (IV) infusion extension sets (concentrations ranged from 100 to BPA). A total PB concentration () was observed in several items, including light therapy protection glasses, patterned transparent film dressing, winged IV catheters, IV infusion extension sets, and textile tape. The highest estrogenic activity [ estradiol equivalent ()] was found in small dummy nipples, three-way stopcocks, and patterned transparent film dressing and the highest anti-androgenic activity [ procymidone equivalent units per gram ()] in small dummy nipples and three-way stopcocks. According to these findings, neonates might be exposed to multiple sources of BPA and PBs in NICUs via inhalation, dermal, oral, and IV/parenteral routes. There is a need to address the future health implications for these extremely vulnerable patients and to adopt precautionary preventive measures as a matter of urgency. https://doi.org/10.1289/EHP-embargotest.

Impact of an Educational Program on Pediatric Nurses Knowledge Regarding Non-Pharmacological Pain Management in Neonatal Intensive Care Units

Background: Newborns in the neonatal intensive care units (NICU) can be exposed to many painful procedures and treatments. Aim: This study was to improve nurses’ practice regarding non-pharmacological management of pain in newborns in neonatal intensive care units. Subjects and Method: A quasi-experimental research design was utilized in this study. The subjects of the study consists of all the nurses working in the NICUs in Port Said hospitals (N=40) affiliated to the Ministry of Health, including El-Nasr general hospital, Port Said general hospital, Port Fouad general hospital and El-Tadamon health insurance hospital. The data were collected using a observational checklists Conclusion: the nurses had statistically significant improvements in applying non-pharmacological pain management during painful procedures in newborns included; venous and arterial puncture, cannulation and umbilical catheter insertion. However, there were inadequate total scores regarding nurses' practice. Recommendation: continuous training courses should be provided to nurses in order to keep their practice regarding non-pharmacological pain management up to date. Also, nurses should be encouraged to attend national and international conferences and workshops about non-pharmacological management for newborns

Impact of an Educational Program on Pediatric Nurses’ Practice Regarding Non-Pharmacological Pain Management in Neonatal Intensive Care Units

Background: Newborns in the neonatal intensive care units (NICU) can be exposed to many painful procedures and treatments. Aim: This study was to improve nurses’ practice regarding non-pharmacological management of pain in newborns in neonatal intensive care units. Subjects and Method: A quasi-experimental research design was utilized in this study. The subjects of the study consists of all the nurses working in the NICUs in Port Said hospitals (N=40) affiliated to the Ministry of Health, including El-Nasr general hospital, Port Said general hospital, Port Fouad general hospital and El-Tadamon health insurance hospital. The data were collected using a observational checklists Conclusion: the nurses had statistically significant improvements in applying non-pharmacological pain management during painful procedures in newborns included; venous and arterial puncture, cannulation and umbilical catheter insertion. However, there were inadequate total scores regarding nurses' practice. Recommendation: continuous training courses should be provided to nurses in order to keep their practice regarding non-pharmacological pain management up to date. Also, nurses should be encouraged to attend national and international conferences and workshops about non-pharmacological management for newborns