Prematurity in America
By now, you have probably seen the headlines: "Premature Births Fuel Infant Death Rates" (The New York Times) and "US Grapples With High Infant Mortality" (CBS News). These and many more news stories appeared in response to a report about infant mortality in the United States, released by the CDC in November 2009.1 The report reveals that in 2005 (the last year for which statistics are available) the United States fell to #30 in international rankings of infant mortality. Much of the higher infant mortality in the United States can be explained by the high percentage of preterm births, especially infants born between 34 and 37 weeks' gestation.
The report compares the United States with countries in Europe, which have a much lower preterm birth rate. In 2004, 1 in 8 infants born in the United States was born preterm, compared with 1 in 18 in Ireland and Finland. The report does not discuss the comparative influence of race on the infant mortality in the United States and Europe.
In addition to the CDC report, there are other new resources about prematurity of interest to perinatal professionals. The March of Dimes, which launched its prematurity campaign in 2003, recently released a "Whitepaper on Preterm Birth: Global and Regional Toll."2 The organization has also updated its yearly prematurity report cards, giving grades to each state on the basis of performance in reducing the risks associated with preterm birth and lowering the preterm birth rate.3 The national grade for 2009 was a "D." Only 7 states improved their performance from the previous year.
References
1. MacDorman MF, Mathews TJ. Behind international rankings of infant mortality: how the United States compares with Europe. NCHS Data Brief No. 23. 2009:1-8. [Context Link]
2. March of Dimes. March of Dimes Whitepaper on Preterm Birth: Global and Regional Toll. White Plains, NY: March of Dimes; 2009. http://www.marchofdimes.com/files/66423_MOD-Complete.pdf?src=PAM. Accessed November 21, 2009. [Context Link]
3. March of Dimes. US gets a D for preterm birth rate. http://www.marchofdimes.com/aboutus/49267_62035.asp. Published November 17, 2009. Accessed November 21, 2009. [Context Link]
Breastfeeding Report Cards
States also receive annual grades for how well they promote, protect, and support breastfeeding, based on specific outcome and process indicators. The percentage of women who breastfed their newborns at all, the percentage breastfeeding exclusively at 3 and 6 months, and the percentage at least partly breastfeeding at 6 and 12 months are compared. In addition, states are graded on factors such as percentage of breastfed babies who received formula before 2 days of life, the number of lactation consultants available, legislation about breastfeeding in public, and legislation about employer breastfeeding support. Each state also receives a score that reflects how well its birth facilities provide maternity care that supports breastfeeding. Birth facility policies and practices significantly affect whether a woman chooses to start breastfeeding and how long she continues to breastfeed. Several specific policies and practices, in combination, determine how much overall support for breastfeeding a woman who gives birth in a given facility is likely to receive and how likely her baby is to receive formula in the first 2 days.
State breastfeeding report cards can help states monitor their progress in breastfeeding issues and identify opportunities for growth in promotion, protection, and support of breastfeeding. Breastfeeding report cards for individual states are available at: http://www.cdc.gov/breastfeeding/data/report_card.htm.
Mentoring to Close the Talent Gap
The "talent gap" refers to the impending retirement of baby boomer nurses, and the effect that the loss of their collective wisdom might have on the profession of nursing. Because these nurses, most of whom will retire with 40-plus years of experience, will be replaced by new graduates, it will take years before the profession rebuilds the experience base that it has now. The best legacy that retiring nurses can leave the profession is their knowledge, and an ideal way to pass along this knowledge is on a one-to-one basis through mentoring, precepting, and coaching new graduate nurses in the NICU.
From the Journal of Perinatal and Neonatal Nursing, an article by Buffum and Brandon, "Mentoring New Nurses in the Neonatal Intensive Care Unit: Impact on Satisfaction and Retention," is highly recommended for experienced nurses who serve in mentoring roles or aspire to do so. The authors helpfully explain the differences among mentoring, precepting, and coaching, and describe how graduate nurses feel about being mentored. They also explain how the multigenerational workforce affects the mentoring relationship (the "generation gap"). The authors present the 5 levels of skill development of the new graduate nurse and discuss the advantages of a mentoring program to the unit, including cost savings.
Reference
1. Buffum AB, Brandon DH. Mentoring new nurses in the neonatal intensive care unit: impact on satisfaction and retention. J Perinat Neonatal Nurs. 2009;23:357-362.
New Palliative Care Guidelines
The National Consensus Project for Quality Palliative Care has released the second edition of Clinical Practice Guidelines for Quality Palliative Care. The clinical practice guidelines are intended to be the blueprint with which to build optimal palliative care and to improve the quality of palliative care in the United States. The guidelines are congruent with the National Quality Forum's preferred practices for palliative and hospice care quality.
The guidelines provide a comprehensive description of what constitutes high-quality palliative care services for all patients, including children, and their families. It is a resource for practitioners who address the palliative care needs of patients and families, and an educational tool for those who are learning to do so. Real examples of how to use the clinical practice guidelines are provided in this new edition. The guidelines are a valuable resource for both new and existing palliative care programs and can be downloaded free of charge at http://www.nationalconsensusproject.org/guideline.pdf.
Infant Burns From Heel Warmers
A recent article posted on the Food and Drug Administration (FDA's) Medical Devices web site warns about the possibility of burns from infant heel warmers.1 These devices are disposable heat packs used to increase circulation in the infant's heel before performing a heelstick. Activating the pack produces a chemical reaction that heats the warmer to about 104[degrees]F (40[degrees]C) for a few minutes, before the heat starts to diminish. When the pack is applied to the heel, the heat increases capillary circulation. Although infant heel warmers are safe and effective when they are used according to the manufacturer's instructions, the FDA has received several reports about infants suffering first-, second-, and third-degree burns from these devices. In one case the device was reheated and reused, which the label warns against. In several other cases, the pack ruptured during activation and the contents splashed on the infant or the attending nurse. The article lists a number of precautions to avoid these types of incidents, such as the following:
* Check the infant's skin integrity before applying the heat pack. If the skin is compromised in any way, do not use it.
* Be especially careful while using the warmer on a premature infant.
* Do not activate the warmer near the infant or anyone's eyes.
* Use the device for 3 to 5 minutes or as directed by the manufacturer.
* Monitor the application site at least every 30 seconds while the warmer is in use.
* Do not wrap the warmer with any additional heat source, such as a warm washcloth.
* After removing the warmer, check the skin for blisters or erythema.
* Do not reuse the warmer, which is intended for one-time use. Reheating it could cause a burn.
* If the contents of the heel warmer leak onto the skin, wash immediately with mild soap and water and change affected clothing and bedding. If it contacts the eyes, flush thoroughly with water.
Reference
1. Food and Drug Administration. Medical devices. Use infant heel wamers with care. http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/TipsandArticlesonDevic. Accessed November 20, 2009. [Context Link]
Prenatal Pthalate Exposure Linked to Less Masculine Play in Boys
A study published in the International Journal of Andrology found that a fetus exposed in utero to a high concentration of phthalates is less likely, at preschool age, to play with male-typical toys and games, such as trucks and play-fighting. It is believed that pthalates, which have antiandrogenic properties, interfere with the testosterone necessary for normal masculine brain development.
Pthalates are chemicals, such as di(2-ethylhexyl) phthalate (DEHP) and dibutyl phthalate (DBP), that are used to soften plastics and are ubiquitous in the environment. They can be ingested through food and cooking, and they can be introduced to the body in soaps and lotions. Pthalates are known as "endocrine disrupters" and have been associated with genital defects, metabolic abnormalities, and reduced testosterone levels. Some pthalates have already been banned from use in certain infant toys, and many hospitals have moved to pthalate-free products, especially in the NICU where premature infants are believed to be extremely vulnerable to the effects of endocrine disrupters.
In the current study, researchers analyzed maternal urine at the 28th week of pregnancy for the concentrations of metabolites of DEHP and DBP. When the children were 3.5 to 6.5 years old (n = 145), their parents completed a Preschool Activities Inventory designed to discriminate play behavior within and between the sexes, addressing preferred types of toys, activities, and child characteristics. They found that higher concentrations of DEHP and DBP metabolites in mothers' prenatal urine were associated with less masculine play behavior scores. Pthalate exposure did not appear to affect the play of girls. Although additional research is needed to confirm these findings, a closer examination of the effect of pthalates on prenatal development is warranted.
Reference
1. Swan SH, Liu F, Hines M, et al. Prenatal pthalate exposure and reduced masculine play in boys [Published online ahead of print November 16, 2009]. Int J Androl. doi: 10.1111/j.1365-2605.2009.01019.x [Context Link]
How Much O2 Does a Self-Inflating Bag Deliver Without a Reservoir?
It is widely accepted that a self-inflating neonatal resuscitation bag connected to a 100% oxygen source delivers approximately 40% oxygen, unless an oxygen reservoir is attached to the bag. The oxygen reservoir allows oxygen to collect in the bag's inlet area, which then mixes with room air to be drawn into the bag when the squeezed bag is released. In a benchtop study, Thio and colleagues1 determined how much oxygen is actually delivered with different brands of neonatal self-inflating bags used without oxygen reservoirs.
The researchers tested the smallest nondisposable self-inflating bags from Laerdal (Wappingers Falls, New York) and Ambu (Glen Burnie, Maryland), measuring the oxygen (O2) concentrations that were delivered. Bags were tested under a variety of conditions: more than 100 different combinations of oxygen flow rates (10, 5 to 1 liters per minute, LPM), ventilation rates (30, 60, or 100 inflations/minute), and peak inspiratory pressures (20-25 cmH2O, 35-40 cmH2O, or pop-off valve range, 55-60 cmH2O).
They found that delivered O2 concentration depended on gas flow rate, ventilatory rate, and the pressure used. At a pressure of 20-25 cmH2O, the mean delivered O2 concentration for both bags exceeded 70% at all gas flow rates except 1 LPM (where delivered O2 concentration was 60%-70%). When the pop-off valve was open at 35-40 cmH2O, at gas flow rates < 2 LPM, the O2 concentration fell to 30%-45%. The Ambu bag delivered slightly, but not clinically important, lower O2 concentrations.
The researchers concluded that when one of these bags is used, without an oxygen reservoir, during neonatal resuscitation, the delivered O2 concentration is higher than 70% for standard flow and pressure settings. Because some delivery rooms may lack oxygen blenders, clinicians should keep this in mind when using these bags, particularly with preterm infants. No other bag types or brands were tested, so these findings may not apply to other self-inflating bags. Additional research is needed to determine the true oxygen concentrations delivered with other neonatal self-inflating bags.
Reference
1. Thio M, Bhatia R, Dawson JA, Davis PG. Oxygen delivery using neonatal self-inflating resuscitation bags without a reservoir [published online ahead of print October 19, 2009]. Arch Dis Child. doi: 10.1136/adc.2009.166462.
Self-study Neonatal Resuscitation
Today's students are more comfortable with self-directed learning than students of previous generations. But, is there a limit to what can be taught to oneself? Can you teach yourself neonatal resuscitation?
Laerdal (Wappingers Falls, New York) has come up with an education tool that may allow us to answer this question. Known as Simply NRP, it is a self-directed program that uses a hands-on approach to teach the skills of lessons 1-4 of the Neonatal Resuscitation Program (Principles of Resuscitation, Initial Steps of Resuscitation, Bag-Mask Ventilation, and Compressions). The content is mapped directly to these 4 lessons, and learners are able to practice the skills associated with these lessons independently. The program comes with a DVD that demonstrates the skills, explains principles, and offers practice scenarios.
This program is an all-in-one package. It includes a maniken (NeoNatalie) and all the equipment necessary for a neonatal resuscitation, such as bag and mask, stethoscope, bulb syringe, suction tubing, endotracheal tubes, laryngoscope, and more. The maniken has a visible chest rise with positive pressure ventilation and a "compression clicker" for audio feedback during cardiac compressions. There is even an instrument panel so that learners will turn on oxygen flowmeters, radiant warmers, and suction controls. The learner who completes the self-study course will be ready to take the NRP mega-code test with a certified NRP instructor. For more information, see http://www.laerdal.com/doc/42925161/Simply-NRP.html.