Necrotizing enterocolitis: improving survival within a single facility

Necrotizing enterocolitis (NEC), a disease associated with prematurity, carries a significant morbidity and mortality. This study was designed to evaluate our progress in dealing with NEC both medically and surgically in a single large neonatal intensive care unit (NICU). We also sought to confirm the relation of birth weight and particular indications for operation to outcome. Over 6 1/2 years, there were 7,807 admissions to a large NICU. Though there has been a steady increase in total admissions, especially of infants weighing less than 1,000 gm, survival has improved significantly in all groups (mean 89.1%). NEC occurred in 358 infants (4.6%), and 115 (32%) required surgical intervention. Infants weighing between 751 and 1,000 gm had the highest incidence of NEC. There has been a significant decrease in the mortality of both medically and surgically treated infants with NEC; in both cases, this decrease is weight-dependent. We found that using erythema and edema of the abdominal wall and a fixed-loop roentgenographic pattern as early indicators of necrotic bowel significantly improves survival in surgically treated infants.     

Neonatal transport in Georgia: implications for maternal transport in high-risk pregnancies

We analyzed population-based data from the Georgia Neonatal Surveillance Network from 1974 to 1978 to determine the effect of the hospital of delivery on the neonatal mortality rate (NMR) of infants later admitted to neonatal intensive case units (NICUs). The NMR of 3,524 infants transported from primary centers to NICUs was significantly higher [relative risk (RR) = 2.1; 95% CL = 1.9 to 2.3] than that of 10,764 infants born in tertiary centers and admitted directly to an NICU. This effect persisted even after adjustment for birth-weight differences (RR = 1.6; 95% CL = 1.5 to 1.8). The relative risk in favor of delivery in a tertiary center increased with increasing birth weight. However, the proportion of infants of less than 1,000 gm surviving was higher for transported infants and increased with distance transported. This finding suggests that, at these very low birth weights, the hardiest infants were selectively transported. A surprising finding was the very low proportion of low-birth-weight infants delivered in primary centers and transported to NICUs (eg, 32% of infants weighing between 1,001 and 1,200 gm). Our findings support previous reports that delivery in a hospital with an NICU is preferable to later neonatal transport and suggest that efforts to increase the rate of maternal transport in high-risk pregnancies can lead to a substantial reduction in infant deaths.     

Effectiveness of the neonatal transport team

This study was performed to determine the effectiveness of a hospital-based transport team in lowering mortality in newborns. The medical records of 603 outborn infants weighing from 500 to 2500 g and having primary respiratory disorders were reviewed. The infants were admitted to 1 of 3 regional neonatal centers between January 1, 1977 and September 30, 1980. The 2 centers without transport teams admitted 304 outborn infants, of whom 62 (20%) expired by 120 h of age. The center with a transport team admitted 184 team-transported infants and 115 nonteam-transported infants, of whom 38 (13%) expired by 120 h of age. Outborn infants admitted to the hospitals without a neonatal transport team had a 60% (p less than 0.01) greater mortality compared to those admitted to the hospital with a transport team. At the onset of intensive care, the babies transported to the nonteam hospitals had a greater incidence of hypothermia and acidosis which may be related to their increased mortality. We conclude that hospitals without the services of a neonatal transport team may have significantly more deaths among low birth weight infants with respiratory disease than comparable hospitals with neonatal transport teams.     

Assessing the effectiveness of neonatal intensive care

Although neonatal intensive care has been praised widely for individual successes, its effectiveness has not been established systematically or conclusively. The literature consists principally of reports from individual intensive care units with sample sizes too small for statistical validation or generalization. This study analyzes the results obtained by recalculating and pooling the isolated reports. In addition, the findings of the solitary clinical trial, some scattered epidemiologic data, and several analyses of regional birthweight-specific time series data are reviewed. Taken together, this constitutes a body of evidence that supports the conclusion that intensive neonatal medical care has played a significant role in bringing about the impressive reduction in infant mortality that has taken place in this country since 1965.     

A comparison of two mortality risk scores for very low birthweight infants: clinical risk index for babies and Berlin score

OBJECTIVE: To compare the performance of two mortality risk scores for very low birthweight (VLBW) infants. DESIGN AND SETTING: Cohort study in two university-associated neonatal tertiary care units. PATIENTS:. The clinical risk index for babies and the Berlin score were assessed in 343 VLBW infants (below 1500 g) admitted to one center and 257 infants admitted to a second center between 1992 and 1996. An additional 572 VLBW infants admitted at the former center during 1978-1987 and 294 during 1988-1991 were studied for changes in risk-adjusted mortality over time. MEASUREMENTS AND RESULTS: Goodness of fit was excellent for both scores in both centers. Ability of discrimination was similarly high for both scores. The area under the receiver operating characteristic curves for all 600 infants was 0.84 for the clinical risk index for babies, 0.82 for the Berlin score, and 0.77 for birthweight alone. Both scores discriminated less well in the present samples than they did in the populations in which they were developed. Applying the Berlin score in three periods revealed a continuous decrease in risk-adjusted mortality from 1978 to 1996, indicating improvement in neonatal care. CONCLUSIONS: Both scores predicted death in hospital with high accuracy and interhospital reliability. Decreasing mortality in VLBW infants during the past 20 years requires regular reevaluation of existing scoring systems to avoid overestimation of mortality risk.     

A meta-analysis of the efficacy of music therapy for premature infants

This meta-analysis on music research with premature infants in neonatal intensive care units (NICU) showed an overall large, significant, consistent effect size of almost a standard deviation (d =.83) (Cohen, 1998). Effects were not mediated by infants' gestational age at the time of study, birthweight, or type of music delivery nor by physiologic, behavioral, or developmental measures of benefit. The homogeneity of findings suggests that music has statistically significant and clinically important benefits for premature infants in the NICU. The unique acoustic properties that differentiate music from all other sounds are discussed and clinical implications for research-based music therapy procedures cited.     

Blood components in neonatal medicine

During a six-month period, 552 infants were admitted to a level III Neonatal Intensive Care Unit (NICU) and four level II units. Of the 953 cross matches of blood components requested from the blood bank, 83% were administered. Forty-four percent of the infants received multiple blood transfusions from multiple blood donors (mean 3.9 donors, range two to 11). Thirty-one percent received multiple transfusions from only one donor. The mean total volume of blood given was 22.5 ml (range 3 to 120 ml), exclusive of blood used for exchange transfusions. Seventy percent of the blood components were given to infants weighing less than 2,500 gm, and 44% were given to infants weighing less than 1,500 gm. Hospitals having only level II units must have the same blood banking facilities as hospitals with level III units, since 21% of the infants given transfusion received the blood component while receiving level II care.     

A review of preterm admissions into special care baby unit, in University of Maiduguri Teaching Hospital: a four year experience

There is little or no report of preterm (babies born less than 37 completed weeks of gestation) admission from this part of Sahel Savannah of Nigeria. This study of four-year period is presented to identify areas that require improvement, such as in the Labour ward and neonatal care. The case files of the 428 preterm newborns admitted into Special Care Baby Unit (SCBU) of the University of Maiduguri Teaching Hospital were reviewed. Preterms constituted 54.9% of the overall admissions, 53.4% being Low birth weight newborns (=2500 gm). Premature rupture of membrane, previous preterm deliveries, twin gestation and pregnancy induced hypertension were some of the common maternal factors that were associated with preterm deliveries. Birth asphyxia, Apnoea, Small for gestation age 9weight less than 10th centile), respiratatory distress were the main problem observed among the preterm newborns. Neonatal mortality rate was 349/1000 live birth; 62.1% of the death were preterm infants. Mortalities were common among babies weighing 1000 gm or less and also of babies of lower gestational age. We can improve on this, by implementing simple common measures such as educating our mothers on the need for good antenatal care and hospital deliveries, so that those with pregnancy induced hypertension, premature rupture of membrane, previous preterm delivery can be detected early and institute proper management.     

Viral infection and antiviral therapy in the neonatal intensive care unit

Viral diseases are leading causes of mortality and morbidity among infants requiring care in the neonatal intensive care unit (NICU), with ongoing discoveries of new viral pathology likely to add to the burdens posed. Many viral diseases in NICU infants are undiagnosed or appreciated only late in the course because of subtle or asymptomatic presentation, confusion with bacterial disease, and failure to consider viral disease. We present an overview of viral disease in NICU infants, with emphasis on pharmacologic agents currently employed for prophylaxis and treatment of such diseases. Advances in molecular biology and popular demand to develop antiviral agents for viral diseases (eg, human immunodeficiency virus) offer great promise for the future.     

Who Is at Risk? High-Risk Infant Follow-up

Plans for discharge home from the neonatal intensive care unit (NICU) should begin with identification of which infants are at-risk for developing disability or early demise. As much as possible, this article serves as an evidenced-based review for identifying vulnerable infants in the NICU who are at higher risk for morbidity or early mortality. This article draws on the American Association of Pediatrics recommendations that highlight the responsibilities of the NICU team to recognize risk, plan discharge, and assist with transitioning care post discharge. Nurses, as professional team members, are ideal for identifying at-risk status, devising individualized discharge plans, and assuring referrals to high-risk infant follow-up (HRIF). HRIF programs bridge care pre and post NICU discharge to assure that infants with complex issues and special needs reach optimal health and developmental levels.     

Reducing toxic stress in the neonatal intensive care unit to improve infant outcomes

In 2011, the American Academy of Pediatrics (AAP) published a technical report on the lifelong effects of early toxic stress on human development, and included a new framework for promoting pediatric health: the Ecobiodevelopmental Framework for Early Childhood Policies and Programs. We believe that hospitalization is a specific form of toxic stress for the neonatal patient, and that toxic stress must be addressed by the nursing profession in order to substantially improve outcomes for the critically ill neonate. Approximately 4% of normal birthweight newborns and 85% of low birthweight newborns are hospitalized each year in the highly technological neonatal intensive care unit (NICU). Neonates are exposed to roughly 70 stressful procedures a day during hospitalization, which can permanently and negatively alter the infant's developing brain. Neurologic deficits can be partly attributed to the frequent, toxic, and cumulative exposure to stressors during NICU hospitalization. However, the AAP report does not provide specific action steps necessary to address toxic stress in the NICU and realize the new vision for pediatric health care outlined therein. Therefore, this paper applies the concepts and vision laid out in the AAP report to the care of the hospitalized neonate and provides action steps for true transformative change in neonatal intensive care. We review how the environment of the NICU is a significant source of toxic stress for hospitalized infants. We provide recommendations for caregiving practices that could significantly buffer the toxic stress experienced by hospitalized infants. We also identify areas of research inquiry that are needed to address gaps in nursing knowledge and to propel nursing science forward. Finally, we advocate for several public policies that are not fully addressed in the AAP technical report, but are vital to the health and development of all newborns.     

新生儿出生体重与NICU医院感染相关性研究

目的研究新生儿出生体重与新生儿重症监护病房(NICU)医院感染的关系,为有效防控提供依据。方法采用回顾性和前瞻性相结合调查方式,对2007-2008年度与2009-2010年度该医院NICU所有出院新生儿分段进行调查。结果该医院NICU在4年内,共监测4 811例出院新生儿,发生医院感染101例、106例次,新生儿医院感染率为2.10%、例次感染率为2.20%。新生儿出生体重≤1 000 g,日感染发生率为5.43‰;出生体重≥2 500g,日感染发生率为1.65‰。结论新生儿出生体重越低,医院感染发生率越高,低出生体重儿是医院感染的高危人群。     

The effect of an emotional support training program on acute stress disorder among mothers of preterm infants hospitalized in neonatal intensive care units

Many mothers experience acute stress disorder after hospitalized their infant in NICU. The objective was to assess the impact of an emotional support training program on acute stress disorder level among mothers of preterm infants admitted to a neonatal intensive care unit. A pretest-posttest experimental randomized controlled trial design using the Stanford Acute Stress Reaction Questionnaire was used on 48 mothers (24 each in two groups) of premature infants in a level III NICU in the largest public teaching hospital in Amman at Jordan. The results revealed statistically significant differences between the interventional and control group for mean post intervention scores [t (23) = 6.07, p = .01], with mean scores of 18.53 (9.33) and, 25.588 (4.99) respectively. Hence, the emotional support training programs effectively reduce acute stress disorder symptoms in mothers of premature infants in neonatal intensive care units.     

A review of term admissions to a neonatal intensive care unit – Are some more suited for a transitional unit?

AimThe increasing birth rate of term neonates and neonatal term admissions are placing unprecedented pressure on our neonatal resources. Transitional units may be a suitable alternative for low to moderate-risk neonates. This study reviewed admission trends of term neonates (37⁺⁰ to 41⁺⁶ weeks) admitted to the neonatal intensive care unit (NICU) at Royal Prince Alfred Hospital in Sydney, Australia.MethodsRetrospective cohort study using neonatal data from medical records. The primary outcome was to review the reasons for admission of term neonates to the NICU between 2015 and 2019. A secondary outcome was to determine term admissions suitable for a transitional unit model.Results2808 term neonates were admitted to the NICU, with respiratory distress accounting for most admissions (41%). Admissions potentially suitable for a transitional unit include hypoglycaemia, jaundice, thermoregulation and feeding issues, low birth weight and neonatal abstinence syndrome. These admissions account for over 30% of all term admissions to our NICU over the study period.ConclusionsSome low to moderate-risk term admissions may be suitable for transitional units. Implementation of transitional units may alleviate the demand on our neonatal health system and enable optimal family-centred care. Further large-scale studies of term neonates are warranted to explore the benefit of transitional care models in Australia and New Zealand.     

A retrospective study of breastfeeding outcomes in an Australian neonatal intensive care unit

BackgroundThe World Health Organisation (WHO) and a substantial body of literature recommend breastfeeding from birth until at least 6 months of age. The nutritional, gastrointestinal, immunological, neurodevelopmental and psychosocial benefits of breastfeeding have been shown for term and preterm infants. Meeting the WHO recommendations for breastfeeding is problematic in the cohort of infants requiring hospitalisation in a neonatal intensive care unit (NICU) for management of complex medical and surgical conditions.MethodA retrospective audit of medical records of all infants admitted to the neonatal unit of the Royal Children's Hospital, Melbourne, Australia between 2001 and 2003 was conducted.ResultsOne thousand, one hundred and sixty-three babies were admitted during the audit period. Babies discharged directly home were of significantly greater gestational age, higher birthweight and had a shorter length of stay than those babies transferred to another facility (P < 0.05). Fifty-six percent of the cohort was receiving breast milk on discharge from the neonatal unit. Babies exclusively breastfed on discharge were of greater gestational age and had a shorter length of stay in the NICU than those babies discharged on a combination of breast milk and formula, or formula alone (P < 0.001). Babies transferred to another facility, rather than discharged directly home, were less likely to be breastfed and more likely to receive enteral nutrition via intragastric tube feeds or a combination of bottle and tube feeds.ConclusionBirthweight, gestational age, and length of stay in a neonatal intensive care unit are factors likely to influence breastfeeding in the cohort of babies requiring tertiary level care.     

我国17省市儿科ICU调查

目的 分析近10年我国儿科重症监护病房(ICU)状况、存在问题并提出建议。方法 向全国近40所儿科床位100张以上的医院发出调查表。结果 分布于17省市的27所医院回复，内科ICU共44个：儿童重症监护(PICU)18个、新生儿重症监护(NICU)20个、P及NICU6个。ICU平均床位12(6-40)张，每张床位有0．43(0．43-1．25)台呼吸机，0．56(0．2—1．4)台多功能监护仪。床位和医师及护士比分别为1：0．75和1：1．37。51．9％的医院开展转运。2000年共收治病人15805人，病死率4．6％(0．9％—10．4％)，体重轻于1000g和1000-1500g的早产儿存活率分别为42.2％、75．1％，心肺复苏存活率71．4％。结论 我国三级医院儿科ICU正稳步发展，与92年比较，人员、设备有所改善。转运工作未广泛开展，一些ICU床位被非危重病人占据。建议ICU建立分级管理制度，积极开展转运，开展前瞻性危重评分预测死亡，以对ICU治疗效果作出更科学的评估。     

Neonatal nurses’ perceptions of supportive factors and barriers to the implementation of skin-to-skin care in extremely low birth weight (ELBW) infants - A qualitative study

There is currently a lack of evidence around perceptions of implementation of skin-to-skin care (SSC) in infants weighing <1000 gms amongst neonatal nurses. Majority of published work mainly focuses on infants weighing <2500 gms.AimThis study aimed to investigate neonatal nurses’ perceptions of supportive factors and barriers to the implementation of SSC in extremely low birth weight (ELBW) infants in a tertiary level neonatal intensive care unit (NICU) in London.MethodsA broad qualitative approach that included semi-structured interviews with seven neonatal nurses was used.ResultsAll seven nurses interviewed supported SSC in ELBW infants. There was a general consensus on barriers of its implementation. Humidity was perceived as a significant barrier for SSC in ELBW infants. Other barriers included concerns for infant safety, insufficient training, increased workload, lack of clear guidelines and management support.ConclusionsThis study identified supportive factors and barriers of SSC in ELBW infants in a tertiary neonatal unit. It ascertained the facilitation of parental readiness, development of clear guidelines, provisions of continuing education as well as organisational support as supportive factors in the implementation of SSC in ELBW infants. Furthermore, humidity was perceived as an additional barrier for SSC in these infants.