1. Section Editor(s): Dowling, Donna

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Decision-Making Influences: A Comparison Based on Infant Diagnosis

Kimberly A. Allen, MSN, RN; Sharron L. Docherty, PhD, CPNP; Debra H. Brandon, PhD, RN, CCNS, FAAN


BACKGROUND AND SIGNIFICANCE: Infants who would have previously died of complex life-threatening conditions are now surviving because of technological advances in treatments. However, there are still several diagnostic categories that experience high morbidity and mortality despite advances, including extremely premature infants and infants with hypoxic-ischemic encephalopathy (HIE). Infants with complex life-threatening conditions require parents and providers to make crucial decisions that affect the infants' duration and quality of life. Understanding the infant illness course and decision-making trajectory of parents and providers is vital. Extremely premature infant and infants with HIE may present different challenges for parents and providers making decisions about care and treatment. Parents and providers face similar decisions about whether to initiate treatment, whether to escalate treatment, or when to proceed to withdrawal or withholding support for infants. Yet there are differences: the timing of diagnosis, length of time to make critical decisions, and the appearance of the infant. Each of these differences can alter the communication between parents and providers and also impact parental understanding of the severity of the infant's illness. Specifically how each of these differences impacts parent and provider decision-making is unknown.


PURPOSE: The purpose of this study was to compare how influences on decision making differed between parents of infants with HIE and extremely premature infants changed during the initial hospitalization period.


DESIGN: Data analysis from 2 completed studies were used to compare the differences in parental decision making. The design of both studies was a longitudinal, multiple-case study used to understand how parents and health care providers make decisions for infants with life-threatening illnesses. A case was defined as an infant, at least 1 parent, and at least 2 health care providers. Only parents will be included in this analysis. The setting for both studies was a southeastern tertiary academic medical center. Infants, parents, and health care providers were recruited from the neonatal intensive care unit. A total of 12 cases of extremely premature infants and 11 cases of infants with HIE were recruited. Parents participated in open-ended interviews and self-report questionnaires at birth and following any life-threatening event until the infant was discharged from the hospital. The self-report questionnaires were the Parental Stressor Scale: Infant Hospitalization, the Spielberger State-Trait Anxiety Inventory-State subscale, and the Impact of Events Scale-Revised. Medical chart reviews were conducted to obtain infant length of stay, days of mechanical ventilation, technological support needs, days to full feeds, and physical/occupation/speech therapy needs.


ANALYSIS: To complete the comparison of infants with different life-threatening conditions, the analyses of case data of premature infants and HIE infants were used. The infant cases were compared across to identify commonalities and differences in parental influences on decision making. The influences of decision making were visually displayed to determine whether there were patterns. For example, parents with high levels of stress may not rely on provider information early in the decision-making trajectory and may have trouble communicating with providers during the hospitalization.


RESULTS: Parents of extremely premature infants and parents of infants with HIE faced similar types of decisions, but the timing of the decisions and influences were different. Parents of extremely premature infants usually had some warning prior to delivery that their infants might experience difficulties during delivery and in the weeks to months after birth; however, parents of infants with HIE rarely knew that problems might occur during delivery that could impact the infants' entire development. Generally, extremely premature infants had longer hospitalization periods than infants with HIE. During the first several day, parents of infants with HIE had higher anxiety, higher stress, and lower hope for the infant than parents of extremely premature infants. The possible reasons for differences between parents may be related to how the parents view the infant's illness trajectory.


Most parents of infants with HIE viewed the infant's illness trajectory as a disease-oriented injury. Parents who viewed HIE as a disease-oriented injury typically described the infant's complications in terms of organ systems and how the injury occurred during the intrapartum period. These parents generally reported receiving little information from providers about what happened during delivery and the first hours of the infant's life. In contrast, most parents of extremely premature infants often explained the infant's illness trajectory as a developmental injury. Parents reported that the infant needed to grow and develop and expected the infant to have significant improvement by their original due date.


KEY WORDS: decision making, healthcare providers, infant, neonatal intensive care unit, parents


Author Affiliations:Duke University School of Nursing, Durham, North Carolina.


This study was supported in part by 1F31 NR012083-01 from the National Institute for Nursing Research, NIH, and the American Nursing Foundation research grant to the first author and by 1R01-NR010548 from the National Institute for Nursing Research, NIH, to the second and third authors.


The authors declare no conflict of interest.


Correspondence: Kimberly A. Allen, MSN, RN, Duke University, DUMC 3322, 307 Trent Dr, Durham, NC 27710 ().


Practices to Avoid IV/Feeding Tube Misconnections in the NICU: A Survey

Sandra Sundquist Beauman, MSN, RNC-NIC, CNS


PURPOSE: To determine compliance with recommendations for and barriers to implementation of dedicated enteral systems when complete compliance is not present as perceived by neonatal intensive care unit (NICU) registered nurses (RNs).




DESIGN/METHODS: A survey was developed and posted on an electronic survey system (Survey Monkey). The survey link was posted via e-mail and various Web sites targeted to neonatal nurses. Printed invitations were also sent to neonatal nurse managers and leaders who had attended a recent conference. A convenience sample of 76 RNs completed the survey through August 2011, and 92% of respondents were from a level III NICU. Descriptive statistics were used to analyze the data.


MAIN OUTCOME MEASURES/PRINCIPAL RESULTS: Seventy-four percent of the RNs reported that they were currently using a dedicated system, although it may not have been complete, according to responses, 20% said that they were involved or knew about a "near-miss," and 19% reported an error due to misconnection. Primary barriers to using dedicated systems were cost and "not seen as a priority." Other less frequently mentioned barriers included space to stock multiple syringes (enteral and parenteral) and concerns about back order situations. Use of oral syringes was also included. Three respondents indicated pharmacy sent oral medications in intravenous (IV) syringes and one indicated that oral syringes were not available.


CONCLUSIONS: Although more than two thirds of the RNs report using a dedicated system in their NICUs, the view that the use of enteral-only systems is not a priority must be addressed through education and regulatory standards. Neonates are a vulnerable patient population and at particularly high risk for complications and adverse outcomes. Additional implications for practice include the need for a comparison of costs for items currently used, that is, syringe pumps intended for IV fluids (many of which are costly "smart pumps") with feeding pumps now available on the market. A comparison of extension tubing intended for IV use versus the cost of enteral-only tubing is needed. In many cases, these may actually be less expensive. As more choices become available, price has decreased. Implications for manufacturers include making these items affordable and standardizing enteral connections so that in situations where back orders exist, alternative solutions can be easily available. Study limitations include the possibility of multiple responses from a single hospital and the relatively small number of responses overall.


KEY WORDS: enteral nutrition, gastric feeding tubes, infant, newborn, patient safety, safety management


Author Affiliation:CNS Consulting, Bernalillo, New Mexico. The author declares no conflict of interest.


Correspondence: Sandra Sundquist Beauman, MSN, RNC-NIC, CNS, Huntington Hospital, 1059 Evening Primrose Lane, Bernalillo, NM 87004 ().


Cerebral Oxygenation During Position Changes in Stable NICU Infants

Heather E. Elser, MSN, RN, NNP-BC, CNS; Diane Holditch-Davis, PhD, RN, FAAN; Janet Levy, PhD; Debra H. Brandon, PhD, RN, CCNS, FAAN


BACKGROUND AND SIGNIFICANCE: Infants cared for in the neonatal intensive care unit (NICU) are repositioned every 3 to 4 hours and position changes may alter cerebral blood flow from specific head or body positions. Cerebral oxygenation monitoring may be a useful method to indirectly measure cerebral blood flow during positioning.


PURPOSE: To examine cerebral oxygenation in stable NICU infants in order to assess the effects of 5 different standard positions used in caring for these infants.


METHODS: This pilot study included 9 stable, intensive care infants (5 boys and 4 girls, 67% black, 33% white) in a repeated-measure design. Gestational age at birth averaged 34.3 weeks (23.0-39.6 weeks); birth weight averaged 2.76 kg (0.56-3.90 kg). Infants were without congenital neurologic, cardiac, or gastrointestinal anomalies and weighed greater than 2.5 kg at the time of study.


The assessment for each infant lasted for a total of 90 minutes as the infant was laid flat in the supine position throughout 5 typical head position changes and 1 tilting change, each lasting 10 minutes. The infant was placed in the prone position for the last 30 minutes. A second assessment occurred 1 week later if the infant was not discharged.


ANALYSIS AND RESULTS: Mixed general linear models were used to compare cerebral oxygenation in the second supine, head midline position to 6 other positions. The 6 different comparisons were (1) the first supine, head midline position versus the second supine, head midline position; (2) the first turned head position versus the second supine, head midline position; (3) the second turned head position versus the second supine, head midline; (4) the third supine, head midline position versus the second supine, head midline position; (5) the second supine, head midline position versus a supine, head midline position elevated with a 15[degrees] elevation; and (6) prone position versus the second supine, head midline position.


Results showed that only the third supine, head midline position was significantly different from the second supine, head midline position. The supine, head midline position had significantly lower cerebral oxygenation over time than the same position at 0[degrees] elevation 20 minutes later (b = -0.22, P < .05).


IMPLICATIONS FOR PRACTICE AND RESEARCH: Higher cerebral oxygenation levels later in the positioning sequence may reflect the effects of manipulation and result in a lower capacity to metabolize oxygen from increased stimulation. Results are statistically significant but until these small changes are proven to be clinically significant, results remain informative at this time.


KEY WORDS: cerebral oxygenation, infant, position


Author Affiliations:Duke University School of Nursing, Durham, North Carolina.


The preparation of this article was supported by grant F31NR011269 from the National Institute for Nursing Research, National Institutes of Health, and a Clinical Translational Science Award.


The authors declare no conflict of interest.


Correspondence: Heather E. Elser, MSN, RN, NNP-BC, CNS, Duke University School of Nursing, DUMC 3322, Durham, NC 27710 ().


Coming to Consensus Among Experts About Necrotizing Enterocolitis Risk

Sheila M. Gephart, PhD, RN


PURPOSE: Risk factors for necrotizing enterocolitis (NEC) have been identified, but they are inconsistently reported and the level of agreement about NEC risk is unclear. The purpose of this study was to determine the level of agreement among experts about NEC risk and to measure the content validity index of GutCheckNEC, a neonatal risk index for NEC.


SUBJECTS: A purposive, snowball sampling technique was used to recruit experts (N = 35). Clinicians (neonatologists, pediatric surgeons, neonatal nurse practitioners, and expert nurses) and researchers participated (US: n = 31; International: n = 4).


DESIGN: A Delphi method, using electronic communication (E-Delphi), was undertaken. This consensus-building method was conducted online, using Survey Monkey, a study Web site, and e-mail communication.


METHODS: Experts rated each risk factor on a scale of 1 to 4 (1 = not relevant, 4 = relevant without revision). Feedback was given to the expert panel before they completed the subsequent survey. Three rounds were conducted over 7 weeks.


MAIN OUTCOME MEASURES: Items were retained or deleted if they met the criteria for consensus and/or stability. Consensus was defined as a percent agreement of >= 70% or a mean response of >= 3 or <= 2. Stability was defined as a change in mean response < 15%. Revisions and risk factors recommended by the experts were added to subsequent rounds. Thematic analysis of 284 comments was conducted.


PRINCIPAL RESULTS: Birth weight (lowest at highest risk), gestational age (youngest at highest risk), exclusive formula feeding, and rapid feeding advancement (>30 mL/kg per day) achieved the strongest consensus (>85%). High consensus (75%-85%) was met for fetal distress, intrauterine growth restriction, lack of unit-based adoption of standardized feeding guidelines, umbilical cord prolapse with perinatal asphyxia, Patent Ductus Arteriosus, mixture of formula with breast milk feeding, congenital heart disease, late-onset sepsis, greater than 2 infections prior to NEC, multiple antibiotic therapy, need for chest compressions at delivery, late-onset sepsis, and the institution as a risk factor. Experts agreed that exclusive human milk feeding, adoption of standardized feeding guidelines, and a single dose of antenatal steroids reduce risk. Twenty more items met consensus but achieved borderline agreement. The content validity index for the 43 retained items was 0.77. Two broad themes-individual vulnerability and variation within NICUs-were identified as contributors to NEC.


CONCLUSION: Level I evidence supports human milk feeding, standardized feeding guidelines, antenatal steroids, and preference of ibuprofen over indomethacin to close a Patent Ductus Arteriosus to prevent NEC. Research is under way to reduce the set of risk factors and test the prediction of GutCheckNEC.


KEY WORDS: E-Delphi, enterocolitis risk, GutCheckNEC, necrotizing neonatal intensive care unit, neonatal intensive care unit outcomes, quality of neonatal intensive care unit care


Author Affiliation:College of Nursing, University of Arizona, Tucson.


This work was supported in part by the National Institutes of Health and National Institute of Nursing Research (1F31NR012333-01A1) and the Friends of Yuma. The content is solely the responsibility of the author and does not necessarily represent the official views of the National Institute of Nursing Research or the National Institutes of Health.


The author declares no conflict of interest.


Correspondence: Sheila M. Gephart, PhD, RN, University of Arizona College of Nursing, PO Box 210203, Tucson, AZ 85721 ().


Development and Implementation of a Unit-Specific NICU Lactation Care Map

Shakira Lita Ismay Henderson, MS, MPH, RNC-NIC, IBCLC


INTRODUCTION: Transitioning the preterm infant to full (exclusive) breastfeeding is a challenge. Several sample feeding protocols to transition preterm infants to full breastfeeding have been published. However, the average percentage of preterm infants in the United States who are discharged breastfeeding exclusively is only 35%, compared with 75% in the healthy term infant population. Considering the documented benefits of breastfeeding to the preterm infant and mother, more evidence-based feeding protocols to transition the preterm infant prior to neonatal intensive care unit (NICU) discharge are imperative.


NICU admission should not deter mothers from pursing their decision to breastfeed. Despite the existence of several sample NICU breastfeeding transition protocols, breastfeeding in the NICU remains an issue for improvement. This may be due to the fact that protocols are too general to meet the diverse needs of each NICU. The aims of this project are (a) to develop a unit-specific breastfeeding protocol to transition preterm infants to full breastfeeding and (b) to cite recommendations for unit-specific NICU breastfeeding protocol development and implementation.


METHODS: A multidisciplinary taskforce will be established for the project. The clinical excellence through evidence-based practice model will be used to develop a unit-specific lactation care map to transition premature infants to full breastfeeding. Critical appraisal components that will be assessed in development of this care map include evidence-based factors, patient factors, and clinical setting factors. In addition to the development of the tool, recommendations for unit-specific implementation will be cited.


CONCLUSIONS: Three lactation care maps were developed: lactation consultant, nurse, and mother. Recommendations for development and implementation of the care maps include (a) development of a multidisciplinary team, (b) use of at least 2 tools for literature assessment, (c) assessment of unit-specific needs, and (d) periodic revisions as practice or unit culture changes. Research is needed to test the effectiveness of lactation care maps in practice.


KEY WORDS: breastfeeding, care map, lactation


Author Affiliation:Research Department, South Miami Hospital, Florida.


The author declares no conflict of interest.


Correspondence: Shakira Lita Ismay Henderson, MS, MPH, RNC-NIC, IBCLC, Center for Research & Grants, 8500 SW 117th Rd, Miami, FL 33183 ().


The Tiny Babies Project: Parents' Perceived Needs at Discharge From the NICU

Donna M. LoSasso, DNP, RN, NNP-BC


BACKGROUND AND SIGNIFICANCE: Babies born prematurely and admitted to the neonatal intensive care unit (NICU) require complex and comprehensive health care once discharged home and into the community. The evidence in the literature is rich with the importance of a well-planned and coordinated discharge process for these babies and their families. Families are taught a myriad of feeding and medication procedures to care for their babies, and all of this information can be overwhelming. Despite the evidence, families continue to have unmet needs, and these needs need to be clearly understood so that they can be managed more effectively and discharge teaching and support can be optimized.


PURPOSE: The purpose of this project was to elicit parent perceptions of needs to successfully transition home with their baby. Information gathered was used to inform a larger-quality improvement project.


METHODS: Focus groups were conducted with parents who had babies in the NICU as well as with parents who had recently gone home with their baby from the NICU. The setting and moderator for the focus groups were selected to accomplish a neutral environment so parents could feel safe discussing thoughts and feelings.


RESULTS: A total of 14 participants composed the sample. Data collected from parents who had already gone home with their babies were not different from data collected from parents with babies still in the NICU, so all data were folded together for analysis. Four main categories emerged: best and worst experiences, taking care of baby, bringing baby home, and NICU nurses and physicians.


IMPLICATIONS: The findings from this project helped identify reasons families lack confidence in their ability to care for their babies during their first days at home. These findings help NICU staff provide anticipatory guidance and more effective support for families in ways that will reduce visits to the emergency department and panicky calls to the NICU.


KEY WORDS: discharge, high risk, infant, mother, NICU, parents, perceptions, transition


Author Affiliation:Johns Hopkins University School of Nursing, Baltimore, Maryland, and Baylor University Louise Herrington School of Nursing, Baylor Health Care Systems, and Pediatrix Medical Group, Dallas, Texas.


The author declares no conflict of interest.


Correspondence: Donna M. LoSasso, DNP, RN, NNP-BC, Baylor University Louise Herrington School of Nursing, 3700 Worth St, Dallas, TX 75246 ().


Bacterial Colonization of Nasogastric Tubes in the NICU and the Risk for Necrotizing Enterocolitis and/or Late-Onset Sepsis: Results of a Clinical Trial

Catherine Paoletti, RN


BACKGROUND: Premature infants are at high risk for acquiring Necrotizing Enterocolitis (NEC) and/or late-onset sepsis (L-OS), both associated with significant mortality/morbidity. Abnormal gastrointestinal colonization and an immature intestinal barrier place these infants at risk. It is unknown whether the long-term presence of a nasogastric tube (NGT/OGT) increases the risk as well. Some manufacturers recommend leaving NGTs in for up to 1 month, which has raised concerns among physicians and nurses regarding bacterial colonization and risk for infection.


PURPOSE: To determine whether NGT colonization is associated with a higher risk of acquiring NEC and/or L-OS.


DESIGN: A prospective, descriptive study.


SUBJECTS: Forty-six premature infants, born at less than 35 weeks' gestational age, hospitalized in the neonatal intensive care unit and requiring an NGT.


METHODS: For this institutional review board-approved study, serial NGT tips were obtained from subjects at 7 days postinsertion, using a sterile technique and following a strict research protocol. The NGT tip was immediately sent to the laboratory, and bacterial colonization was determined per standard microbiology protocol. The procedure was repeated every week with each NGT that was placed.


RESULTS: A total of 46 infants served as subjects; 25 (54.35%) were males and 21 (45.65%) were females. Mean birth weight: 1399 g; SD = 479.08; range = 570 to 2465 g. Mean gestational age: 29 weeks; SD = 3.16; range = 23 to 28 weeks. A total of 146 specimens were collected from the 46 subjects. The majority (70%) of NGT cultures grew gram-negative organisms by 7 days postinsertion. Six subjects (13%) developed NEC and/or L-OS, for a total of 8 episodes among the 6 infants. In subjects with NEC and/or L-OS, 100% (6/6) had gram-negative colonization by 7 days post-insertion, compared with 80% for subjects without NEC or L-OS. Results were not statistically significant by 7 days post-insertion during week 1 or 2 in our sample. However, for some subjects the same gram-negative organism found on NGT culture also grew in blood and/or endotracheal tube aspirate culture and was associated with NEC/L-OS.


CONCLUSIONS: This pilot study was limited by a small sample size; however, results showed that NGTs become easily colonized with potentially pathogenic bacteria that may increase the risk for NEC and/or L-OS. On the basis of our findings, we speculate that there may be an association between NEC/L-OS and NGT colonization; therefore, we will not leave NGTs in for 30 days. Further research is warranted.


KEY WORDS: bacterial colonization, infection, nasogastric tube, necrotizing enterocolitis, premature infant, preterm, sepsis


Author Affiliation:Infant Special Care Unit, NorthShore University HealthSystem-Evanston Hospital, Illinois.


The author declares no conflict of interest


Correspondence: Catherine Paoletti, RN, North Shore University HealthSystem-Evanston Hospital, Infant Special Care Unit, 2650 Ridge Rd, Evanston, IL 60201 ().


Bottle-feeding Outcomes in Very Preterm Infants: Preliminary Effects of Positioning

Jinhee Park, PhD, RN; Suzanne M. Thoyre, PhD, RN; George Knafl, PhD; Brant Nix, BA BIO, BMET


PURPOSE: Oral feeding emerges during a dynamic process of the organization of inputs from subsystems within the infant and the environment. Very preterm (VP) infants (<= 30 weeks' gestational age) are at risk for impaired lung function, which significantly limits their organizational capacity and contributes to feeding difficulties. A head-elevated side-lying (HEL) position has recently been proposed as a strategy that may support breathing during feeding. The purpose of this study is to test the preliminary effects of the HEL position on the physiologic stability and feeding performance of VP infants when bottle-fed, compared with the head-elevated supine (HES) position.


PARTICIPANTS: Six VP infants were studied in a neonatal intensive care unit when they were orally feeding half of their prescribed milk for 3 consecutive days.


DESIGN: Within-subject cross-over design.


METHODS: Each infant was bottle-fed twice on 1 day, in both the HEL and HES positions in a random order. Heart rate (HR), oxygen saturation (SaO2), and respiratory characteristics were measured continuously 30 minutes before the feeding until the feeding was completed. Feeding performance was measured during the feeding. A 2-minute calm period before the feeding and the feeding period (not counting nonfeeding and burp periods) were used to calculate physiologic stability during the prefeeding and feeding periods, respectively.


MAIN OUTCOME MEASURES: Physiologic stability measures included a mean and variation for HR, SaO2, and respiratory characteristics (ie, interval between breaths, amplitude of breath, respiratory rate, and breathing pauses greater than 3 seconds). A functional variation of each variable was calculated by a coefficient of variation (ie, the ratio of standard deviation divided by the mean for the assigned period). In addition, the percentages of feeding time with the degrees of change in HR and SaO2 from the prefeeding period were calculated. Feeding performance measures included overall milk transfer, proficiency, efficiency, and duration of feeding.


RESULTS: Compared with the HES position, VP infants fed in the HEL position show significantly less variation in HR, less severe and fewer decreases in HR, shorter and more regular intervals between breaths, and breathing frequency that was closer to the prefeeding state. No significant findings for SaO2 and feeding performance were found.


CONCLUSIONS: The findings indicate that the HEL position may be a feeding strategy to support better regulation of breathing during feeding that allows VP infants to better maintain physiologic stability throughout the feeding.


KEY WORDS: bottle feeding, positioning, very preterm


Author Affiliations:School of Nursing, University of North Carolina at Chapel Hill.


This study is supported by Linda Warring Mathew's Research Fund, the Royster Society Fellowship, and a Sigma Theta Tau International Honor Society Alpha Alpha Chapter Small Research Grant.


The authors declare no conflict of interest.


Correspondence: Jinhee Park, PhD, RN, School of Nursing, University of North Carolina at Chapel Hill, Carrington Hall CB #7460, Chapel Hill, NC 27599 ().


A Clinical Trial of an Evidence-Based, Individualized, Breastfeeding Support Program for Mothers of Very-Low-Birth-Weight Infants

Holly Pilarek, BSN, RNC-NIC, IBCLC-RLC


BACKGROUND: Mothers of very-low-birth-weight (VLBW) infants encounter significant barriers to establishing and maintaining lactation during their infants' hospitalization. Breastfeeding success is dependent on appropriate lactation education, ongoing breastfeeding support, and an adequate milk volume at the infant's discharge. An abundant milk volume is dependent on (1) early initiation of milk expression postdelivery using a hospital-grade electric pump, (2) frequent pumping, (3) frequent skin-to-skin contact, (4) adequate sleep/hydration/nutrition/stress reduction for mother, (5) ongoing education and counseling, and (6) prompt intervention when lactation issues arise. Many mothers of VLBW infants believe that their infants will never be able to successfully breastfeed because of a premature birth. Maternal concerns related to inadequate milk volume and/or inadequate milk transfer during breastfeeding are the primary reasons for discontinuing breastfeeding. The purpose of this institutional review board-approved study was to determine whether an evidence-based, individualized, breastfeeding support program for mothers of VLBW infants (1) lengthens the duration of lactation, (2) improves milk volume at NICU discharge, and (3) enhances breastfeeding success at 2 weeks and 2 months after the NICU discharge.


DESIGN: A prospective, randomized clinical trial with longitudinal follow-up at 2 weeks and 2 months after the NICU discharge.


SUBJECTS: A convenience sample of 19 mothers who planned to provide breast milk for their VLBW infants.


METHODS: Mothers were approached and invited to participate within 24 hours after delivery. Once informed consent was obtained, mothers were enrolled in the study and randomly assigned to the treatment group (A) or control group (B). Group A mothers were paired with a designated "Breastfeeding (BF) Nurse" who followed a standardized, evidence-based program of individualized lactation support consisting of (1) counseling and early intervention beginning within 24 hours of delivery, (2) weekly phone and/or personal in-hospital contact during the infant's NICU stay, and (3) weekly postdischarge phone contact until 2 months after the NICU discharge. Group B mothers received standard lactation and breastfeeding support as per clinical practice.


RESULTS: Results were not statistically significant. However, in group A (treatment), 80% of mothers were still pumping at the infant's discharge, compared with only 55% in group B (control).


CONCLUSIONS: Preliminary results suggest that easy, feasible, cost-effective intervention is beneficial for these mothers who are at high risk for breastfeeding failure and may potentially lead to enhanced health outcomes for their infants as more mothers' milk may be available for a longer duration postbirth.


KEY WORDS: breast milk, breastfeeding, human milk, lactation, premature infant, very-low-birth-weight infant


Author Affiliation: NorthShore University Health System, Evanston Hospital, Illinois.


The author declares no conflict of interest.


Correspondence: Holly Pilarek, BSN, RNC-NIC, IBCLC-RLC, NorthShore Evanston Hospital, ISCU, 2650 Ridge Ave, Evanston, IL 60201 ().


Application of the M Technique in Hospitalized Very Preterm Infants: A Feasibility Study

Joan R. Smith, MSN, NNP-BC; Mary Raney, MSN, NNP-BC; Sandy Conner, BS, PT; Patricia Coffelt, MOT, OTR/L; Jacqueline McGrath, PhD, RN; Marco Brotto, PhD, RN; Terrie Inder, MD


PURPOSE: To explore the application of a novel relaxation method (the M Technique) in hospitalized very preterm infants in a level IIIC NICU.


DESIGN: A feasibility, observational intervention study.


SUBJECTS: Ten very preterm infants were enrolled to receive the treatment intervention. Eligible infants born less than 30 weeks' gestation received the intervention at 30 weeks postmenstrual age (PMA).


METHODS/MAIN OUTCOME MEASURES: On the basis of infant readiness, each infant received the M Technique for 5 minutes. Physiologic parameters (heart rate, respiratory rate, and oxygen saturations), behavioral variables (stress and relaxation cues), and infant behavioral state were measured 5 minutes before, during, and up to 10 minutes postintervention continuously.


RESULTS: Descriptive analysis revealed that baseline physiologic, behavioral state, and behavioral cue parameters changed during and after the M Technique delivery. A decrease in heart rate and respiratory rate occurred during the M Technique (P = .006 and P > .001, respectively) and a decrease in HR occurred at the end of the M Technique delivery (P = .02). In addition, an increase in SaO2 occurred during the M Technique and at 5 minutes after the M Technique delivery (P = .04 and P = .02, respectively). State scores decreased from baseline (mean = 5.1, range = 3-9) to postintervention (mean = 2.0, range = 1-4). As the intervention was delivered, more positive than negative behavioral cues were observed throughout, at the end, and after the M Technique delivery.


CONCLUSION: In this feasibility study, the M Technique can be delivered without adverse effects to very preterm infants who are 30 weeks' PMA and with evidence of positive physiological and behavioral impact. Additional research is needed with a larger, randomized design to determine short- and long-term effects specifically related to neurological outcomes.


KEY WORDS: infant behavior, neonatal intensive care unit, theraeutic touch, very preterm infant


Author Affiliations:Division of Nursing and Newborn Intensive Care (Ms Smith and Ms Raney), and Division of Therapy Services (Ms Conner and Ms Coffelt), St Louis Children's Hospital, Missouri; School of Nursing, Virginia Commonwealth University, Richmond (Dr McGrath); School of Nursing and Medicine, University of Missouri Kansas City (Dr Brotto); and Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri (Dr Inder).


This research was supported in part by the St Louis Children's Hospital Foundation.


The authors declare no conflict of interest.


Correspondence: Joan R. Smith, MSN, NNP-BC, Division of Nursing and Newborn Intensive Care, St Louis Children's Hospital, St Louis, MO 63110 ().


A Standardized Nurse-Driven Adjusted Treatment Plan to Reduce Prevalence and Severity of Diaper Rash

Bette Schumacher, MS, CNS, RN


INTRODUCTION: Diaper rash is a common problem for the infant population, and the neonatal intensive care unit (NICU) is not exempt. The initial prevalence of diaper rash (redness, rash, or denudement) in a large level IIIb NICU in the Midwest was 37% with a 7% denudement. A nursing survey completed through the nursing performance improvement council demonstrated widely varying practices for assessment, cleansing, prevention, and treatment practices. Most registered nurses (58%) who responded indicated that they did not use protective emollient unless ordered and nearly all (90%) relied on physician orders to guide this practice. The purpose of this project was to (1) impact the prevalence of diaper rash in the NICU by changing practice culture related to perineal skin care practices and (2) standardize nursing assessment and treatment.


METHODS: The Iowa Model was used to change practices in the NICU. A Patient Intervention Comparison Outcome-also called PICO-question was posed, "For premature infants, does the use of a risk adjusted treatment based on skin condition scoring reduce the prevalence and severity of diaper rash?" Skin team nurses were the champions for the change along with a pharmacist and a neonatologist. A literature review was completed and a product trial of 2 emollients and a commercial wipe were implemented. A risk-adjusted treatment plan, using scoring from the Neonatal Skin Condition Score (NSCS), was developed. Providers were educated and data were collected through prevalence surveys by the unit skin team nurses. Each infant was examined and scored using the NSCS with focused attention to documentation of any redness, rash, or denudement. Prevalence surveys were completed quarterly for 4 years and is ongoing. Data were analyzed using descriptive statistics.


RESULTS: After the first year of using the standardized assessment and treatments based on NSCS, the prevalence of denudement decreased in the NICU from 7% to 1%. White petrolatum, an inexpensive emollient, was effective for about half of the infants; the remaining infants required a different product. The current formulary of products available for use is limited and identified as a barrier to change.


CONCLUSIONS: Prevention strategies such as emollients provide positive outcomes in neonates. Research is recommended to determine what factors affect infants' stooling patterns, such as formula additives and the effect of different skin-protective agents. Determining product effectiveness for different populations of infants is also recommended.


KEY WORDS: diaper rash, infant, intensive care units, neonatal, skin care


Author Affiliation:Sanford USD Medical Center Boekelheide, Sioux Falls, South Dakota.


The author declares no conflict of interest.


Correspondence: Bette Schumacher, MS, CNS, RN, Sanford USD Medical Center Boekelheide, NICU, 1305 W 18th St, PO Box 5039, Sioux Falls, SD 57117 ().


Mothers' Emotional Experiences on the Neonatal Intensive Care Unit

Rebecca Chuffo Siewert, DNP, ARNP, NNP-BC; Lisa Segre, PhD


INTRODUCTION: Whereas depression affects approximately 19% of all postpartum women, mounting evidence indicates increased risk for mothers of preterm infants, with prevalence estimates ranging from 28% to 67%. The current approach to management of maternal symptoms related to maternal depression in the neonatal intensive care unit (NICU) ranges from total lack of assessment to screening and referral. But for NICU mothers, following through on referrals is especially difficult and usually becomes a secondary priority. The purpose of this research study is to evaluate the effectiveness of an empirically supported nurse-delivered depression treatment, Listening Visits (LV), in improving depression outcomes among depressed mothers with newborns hospitalized on the neonatal intensive care unit.


METHODS: All NICU mothers of a Midwest Level III Children's Hospital were invited to participate in a study of mothers' emotional experiences on the NICU. Interested women were enrolled into phase 1, in which they completed self-report forms assessing their levels of depression and anxiety. Women with elevated scores on the Edinburgh Postnatal Depression Scale (EPDS) (>= 12) were offered LV. Those opting for LV received up to six 50-minute sessions from a neonatal nurse practitioner. Pre-, post-, and follow-up assessments evaluated depression status, life satisfaction, and treatment acceptability.


ANALYSIS/RESULTS: Student t tests will be used to assess whether there is significant reduction in depression symptom scores on the EPDS-comparing pre-LV with both posttreatment and follow-up scores. Random regression analyses will be used to assess change over the repeated measurements including all clients with a baseline measurement. Descriptive statistics will be used to examine satisfaction with treatment as indicated by participants on the Client Satisfaction Scale as well as their qualitative responses on the Views Toward Listening Visits scale.


CONCLUSIONS/IMPLICATIONS FOR PRACTICE AND RESEARCH: Mothers of NICU patients are at higher risk for postnatal depression. These mothers frequently face considerable stress regarding concerns about complex medical issues, financial concerns, and social isolation. Because LV can be delivered by nurses, this type of intervention has significant potential to increase the accessibility of depression treatment to NICU mothers. Although LV have empirical support from European-based studies, this is the first study to look at effectiveness of LV with NICU mothers in the United States. This innovative depression treatment has the potential to help ensure that depressed mothers of NICU infants have access to an effective form of depression treatment.


KEY WORDS: depression treatment, EPDS (Edinburgh Postnatal Depression Scale), listening visits, newborn intensive care unit, postpartum depression


Author Affiliations:University of Iowa Children's Hospital and College of Nursing (Dr Siewert), and College of Nursing (Dr Segre), University of Iowa, Iowa City.


The authors declare no conflict of interest.


Correspondence: Rebecca Chuffo Siewert, DNP, ARNP, NNP-BC, University of Iowa Children's Hospital, 200 Hawkins Dr, Iowa City, IA 52242 ().


Implementation and Evaluation of "Golden Hour" Practice in Infants Born Less Than 33 Weeks' Gestation

Brenda Wallingford, DNP, APRN, NNP-BC


BACKGROUND OF PROBLEM: Prematurity is associated with long-term morbidities that include chronic lung disease (CLD), neurodevelopmental impairments (cognitive and motor delays), and visual disturbances. Consistencies in delivery room stabilization practices and in the first hour after birth, the "golden hour," have been shown to improve patient care outcomes. Review of Vermont Oxford Network data, for this Midwest level III neonatal intensive care unit (NICU), noted increased levels of CLD in infants born at less than 33 weeks' gestation. Initial analysis of delivery room practices with these infants showed great variance based upon each provider's experience and knowledge.


PURPOSE OF CHANGE: This project was to identify and implement methods that would improve delivery room practices and potentially reduce the incidence of CLD in this NICU.


PRACTICE CHANGE METHODS: This quality improvement project for the development and implementation of "golden hour" stabilization practices was guided by the use of Neuman's Systems Model, Clinical Excellence Through Evidence-Based Practice model, and the "golden hour" principles. Fruition of "golden hour" practice evolved after extensive literature review and collaboration among the neonatology and nurse practitioner teams. Our "golden hour" involved specific interventions in respiratory management, oxygen targeting, thermal regulation, and teamwork. Compliance with "golden hour" practice change has been tracked since implementation in March 2011 via delivery room documentation, debriefing, and chart review. Examination of compliance occurred at 3 months, 6 months, and 1 year. These intervals allowed time for adjustments to the "golden hour" practice and reevaluation.


RESULTS: Eighty-four infants received the "golden hour" practice. There has been high compliance (>90%) with respiratory management strategies that included application of an inspiratory hold, continuous postive ariway pressure (CPAP), and conversion to T-piece resuscitation device for ventilation as well as improvement in oxygen targeting. Admission temperatures within the euthermic range have improved from 31.9% in 2010 to 84%. Qualitative data show 95% staff satisfaction due to improved communication and teamwork. Implementation of the "golden hour" practices has reduced the incidence of CLD by 66%.


CONCLUSION: Implementation of "golden hour" practice has reduced the incidence of CLD by improvement in respiratory and thermal management as well as improved staff communication and teamwork in deliver room care of infants born less than 33 weeks' gestation in our NICU. Generalizability of our "golden hour" practice is limited because of practice variances among different NICUs.


KEY WORDS: chronic lung disease, delivery room, golden hour practice, infant, NICU


Author Affiliation:Alegent Health Systems, Nebraska Medical Center, Omaha, and Bellevue Medical Center, Nebraska.


The author declares no conflict of interest.


Correspondence: Brenda Wallingford, DNP, APRN, NNP-BC, Alegent Health Systems, 7500 Mercy Rd, Omaha, NE 68124 ().