Chylothorax, a lymphatic flow disorder characterized by an abnormal circulation of lymph fluid into the pleural cavity, is the most common cause of pleural effusions during the neonatal period. This condition affects 1/15,000 neonates every year. Affected neonates often manifest with respiratory distress, electrolyte imbalances, sepsis, and even immunodeficiencies. Mortality risk is highest among neonates undergoing cardiac surgery as well as those with associated hydrops fetalis. Conservative treatment options include bowel rest with administration of parenteral nutrition, followed with medium-chain triglyceride enteral feedings, and octreotide therapy. Severe or persistent cases require surgical intervention. This can involve a unilateral or bilateral pleurectomy and thoracic duct ligation, with or without pleurodesis. Early identification and successful treatment of this condition is contingent upon awareness of the most current evidence and a timely cross-disciplinary approach to care.
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- Go to article: Maternal Obesity and Breastfeeding A Review of the Evidence and Implications for Practice
A myriad of factors influence the sub-optimal breastfeeding rates in the U.S. Among these factors is maternal obesity (BMI > 30 kg/m2), which has been found to negatively impact breastfeeding initiation and duration for some women. Obesity increases women’s risk for various complications throughout the perinatal period, which may impact breastfeeding and the long-term health and well-being of women and their children. However, adequate lactation support that upholds a respectful consciousness regarding the potential breastfeeding challenges of women with obesity can assist these women to successfully meet their breastfeeding goals. This review summarizes the literature on the impact of maternal BMI on breastfeeding duration, and maternal and infant risk factors that may complicate lactation for women with obesity. Recommendations for assessing and supporting the needs of mothers with obesity to best achieve their breastfeeding goals are provided.
- Go to article: Mitigating Infant Medical Trauma in the NICU: Skin-to-Skin Contact as a Trauma-Informed, Age-Appropriate Best Practice
Mitigating Infant Medical Trauma in the NICU: Skin-to-Skin Contact as a Trauma-Informed, Age-Appropriate Best Practice
Infant medical trauma in the NICU is associated with serious and lasting consequences. Skin-to-skin contact (SSC) of infants with their parents is a nursing intervention that provides significant benefits and can mitigate the negative consequences of the infant’s traumatic experiences in the NICU. The purpose of this article is to explain how SSC aligns with the concept of trauma-informed age-appropriate care (TIAAC) in the NICU. The evidence supporting SSC will be reviewed and discussed using TIAAC as a framework. SSC is an effective and evidence-based care strategy that reduces the infant’s traumatic NICU experiences by improving parental proximity, attachment, and lactation; decreasing stress and pain; improving physiologic stability; supporting sleep; and enhancing neurologic outcomes.
Maintenance of electrolyte balance in the neonate is challenging in the context of illness or prematurity. Imbalances in potassium and phosphorus can occur in neonates, ranging from benign and clinically insignificant to those that can be life-threatening. An individualized approach to fluid and electrolyte management is based on the neonate’s gestational age, day of life, maintenance needs, deficits, and ongoing losses. This article reviews normal and abnormal potassium and phosphorus values along with management strategies. Using a case scenario, the reader can apply concepts outlined in this article to management of critically ill neonates with electrolyte disturbances.
After losing an infant, grieving mothers may still have to cope with postpartum issues, including lactation. This article reviews and addresses care options for lactation concerns after pregnancy, neonatal, or infant loss. Currently, lactation care and advice after loss varies greatly. Lactation consultants are instrumental in providing mothers with anticipatory guidance and evidence-based care. Implementing system-wide training and education regarding this topic will help families receive the information they need to deal with the physiological aftermath of infant loss.
Cystic fibrosis (CF) is the most common genetic disorder in Caucasian individuals, with an incidence of 1/2,500–3,500 live births. When CF was first described in 1938, most children died in infancy. Currently, the average lifespan is 28–47.7 years. Although new breakthroughs have occurred, CF is still incurable. Both early diagnosis and treatment by multidisciplinary teams are essential to optimize short- and long-term outcomes. It is imperative for neonatal clinicians to keep up to date on the most current research, treatment, and management of CF to provide the best outcomes. This article offers clinicians an updated review of the pathophysiology and clinical manifestations of CF, as well as current evidence-based diagnostics and treatment regimens.
The “golden hour” is the critically important first 60 minutes in an extremely low birth weight neonate’s life that can impact both short- and long-term outcomes. The golden hour concept involves several competing stabilization priorities that should be conducted systematically by highly specialized health care providers in both the hospital and transport settings for improvement in patient outcomes. Current literature supports utilizing an experienced team in the golden hour process to improve patient outcomes through standardization, improved efficiency, and positive team dynamics. Although a variety of teaching methods exist to train individuals in the care of extremely low birth weight infants, the literature supports the incorporation of low- or high-fidelity simulation-based training. In addition, initial and ongoing educational requirements of individuals caring for a golden hour-eligible infant in the immediate post-delivery phase, as well as ongoing care in the days and weeks to follow, are justified. Instituting standard golden hour educational requirements on an ongoing basis provides improved efficiency in team function and patient outcomes. The goal of this literature review was to determine whether implementation of golden hour response teams in both the inpatient and transport setting has shown improved outcomes and should be considered for neonatal intensive care units admitting or transporting golden hour eligible infants.
Despite advances in perinatal care in the past decade, sepsis and its complications continue to present problems for the neonate, remaining a major cause of neonatal morbidity and mortality. Sepsis research is focusing on how the neonate (host) responds to bacteria. The newborn may develop a systemic reaction to bacteria that induces the release of substances known as inflammatory mediators. Termed the systemic inflammatory response syndrome (SIRS), this reaction is believed to be responsible for the signs and symptoms of sepsis. This article introduces the neonatal nurse to SIRS, providing an overview of various inflammatory mediators and cytokines, their clinical consequences, and potential new therapies in the management of SIRS.
Cloacal exstrophy is an extremely rare and devastating complex of congenital abnormalities resulting in multiple debilitating morbidities. Infants with this disorder require numerous surgical interventions to repair gastrointestinal, genitourinary, spinal, and orthopedic malformations. Treatment involves the combined efforts of many medical and nursing specialists. This article discusses the embryology, clinical presentation, and management (both early and long term) of cloacal exstrophy, with emphasis on gender reassignment issues and quality of life.
- Go to article: Developmentally Supportive Care in the Neonatal Intensive Care Unit: An Occupational Therapist’s Role
Developmentally Supportive Care in the Neonatal Intensive Care Unit: An Occupational Therapist’s Role
The role of a pediatric occupational therapist (OT) in the NICU is to provide comprehensive services, including evaluation, treatment, education, decision making, family support, and discharge planning. It may also include early intervention services or outpatient pediatric rehabilitation services. This article will address the need for developmentally supportive care in the NICU, and specifically addresses the role of an OT in this setting. It will explain how crucial collaboration between team members can be in providing quality, comprehensive care for these neonates. In addition, it will address the important role of the parent in this setting for developmentally supportive care while in the NICU and follow-up intervention upon discharge.
Calcium, the most abundant ion in the neonate, plays a role in bone formation, blood coagulation, muscle contractility, and nerve conduction. Calcium levels are regulated via a negative feedback loop by the parathyroid hormone, calcitonin, and vitamin D. Calcium levels in the neonate must be monitored carefully to avoid complications that affect the central nervous system as well as the cardiac and musculoskeletal systems.
- Go to article: Collaboration to Improve Neuroprotection and Neuropromotion in the NICU: Team Education and Family Engagement
Collaboration to Improve Neuroprotection and Neuropromotion in the NICU: Team Education and Family Engagement
The number of babies born extremely low birth weight surviving to be discharged home after experiencing the NICU continues to improve. Unfortunately, early sensory development for these babies occurs in an environment vastly different from the intended in-utero environment and places them at high risk of long-term neurodevelopmental and neurocognitive challenges. Our goal in the NICU must transition from simply discharge home to supporting the neurosensory development necessary for a thriving lifetime. To accomplish a goal of thriving families and thriving babies, it is clear the NICU interprofessional team must share an understanding of neurosensory development, the neuroprotective strategies safeguarding development, the neuropromotive strategies supporting intended maturational development, and the essential nature of family integration in these processes. We share the educational endeavors of 11 center collaboratives in establishing the foundational knowledge necessary to support preterm babies and their families.
- Go to article: Difference in Mortality and Morbidity Between Extremely and Very Low Birth Weight Neonates
Purpose: The aim of the present study was to evaluate the mortality and morbidity of extremely low (ELBW < 1,000 g) and very low birth weight neonates (VLBW: 1,000–1,500 g) hospitalized in a referral NICU of a Children’s hospital. Design: A retrospective study was conducted in records of the Neonatal Unit of a tertiary care Children’s hospital in Greece from January 2009 to March 2019. Sample: All neonates with birth weight ≤1,500 grams, who were all outborn, were reviewed. Main Outcome Variable: Mortality and morbidity, including respiratory distress syndrome, bronchopulmonary dysplasia, intraventricular hemorrhage, periventricular leukomalacia, necrotizing enterocolitis, early onset sepsis, late onset sepsis, retinopathy of prematurity (ROP), ROP treated with laser and neurological findings were investigated. Results: A total of 444 neonates (52 percent males) were analyzed. Among them, 187 (42 percent) were ELBW and 257 (58 percent) were VLBW. The mean gestational age was lower in ELBW neonates compared to VLBW (26.3 ± 2.3 vs. 29.7 ± 2.4 weeks, respectively; p < .001). Mortality was significantly higher in ELBW compared to VLBW neonates (26.7 percent vs. 7.0 percent, p < .001). Morbidity was significantly higher in ELBW compared to VLBW for respiratory distress syndrome (p < .001), bronchopulmonary dysplasia (p < .001), intraventricular hemorrhage (p < .001), periventricular leukomalacia (p < .001), necrotizing enterocolitis (p = .05), early onset sepsis (p < .001) and late onset sepsis (p = 0.001). Similarly, the incidence of ROP and ROP treated with laser was higher in ELBW compared to VLBW neonates (p < .001). Severe neurological findings during follow-up were more prevalent in ELBW compared to VLBW neonates. Finally, the incidence of eye disorders was higher in ELBW compared to VLBW (p = .05). Conclusion: Our results confirmed that ELBW have higher mortality and morbidity than VLBW neonates. Efforts should be made in order to ameliorate perinatal and neonatal care to reduce the burden of prematurity.
- Go to article: “Going Beyond the Call of Doula”: A Grounded Theory Analysis of the Diverse Roles Community-Based Doulas Play in the Lives of Pregnant and Parenting Adolescent Mothers
“Going Beyond the Call of Doula”: A Grounded Theory Analysis of the Diverse Roles Community-Based Doulas Play in the Lives of Pregnant and Parenting Adolescent Mothers
This article presents some of the most salient qualitative results from a larger program evaluation of pregnant and parenting adolescents who participated in a community-based doula program. Using grounded theory analysis, seven problem-solving strategies emerged that doulas apply in helping pregnant and parenting adolescents navigate multiple social and health settings that often serve as barriers to positive maternal- and child-health outcomes. The ethnographic findings of this study suggest that the doulas provide valuable assistance to pregnant and parenting adolescents by addressing social-psychological issues and socio-economic disparities. “Diverse role-taking” results in doulas helping pregnant adolescents navigate more successfully through fragmented social and health service systems that are less supportive of low-income adolescents, who are often perceived to be draining scarce resources. The findings have implications for the roles of community-based doulas assigned to low-income adolescents of color seeking to overcome obstacles and attain better educational and economic opportunities.
- Go to article: Knowledge, Attitudes, Practices, Barriers and Facilitators to Skin-To-Skin Contact Among Arabian Mothers and Health Care Providers in Arab Countries: A Systematic Scoping Review
Knowledge, Attitudes, Practices, Barriers and Facilitators to Skin-To-Skin Contact Among Arabian Mothers and Health Care Providers in Arab Countries: A Systematic Scoping Review
Skin-to-skin contact (SSC) occurs when a naked full-term neonate is placed on their mother’s bare abdomen or chest within 10 minutes of birth or soon after. Due to its multiple benefits for both the mother and the neonate, SSC is highly recommended by the World Health Organization. However, implementation of SSC in the Arab world is limited.
To undertake a systematic review to identify the knowledge, attitudes, practice, barriers and facilitators to SSC implementation among Arabian mothers and the health care providers in Arab countries.
A systematic scoping review using the JBI three-step search strategy was used to systematically review quantitative and qualitative evidence.
A total of eight studies were included. Around 82% of mothers would like to have more education about SSC. The majority of mothers (n = 254, 79%) expressed a positive attitude towards SSC, however more than three quarters did not correctly practice SSC. Among the healthcare providers, the mean knowledge score about SSC was 14.42 (95% CI = −0.21 to 29.06, I2 = 96%). This review found evidence for barriers to SSC implementation including lack of education, lack of guidelines and cultural beliefs.
Arabian mothers had positive attitudes towards SSC, but the practice was poor due to lack of education and the lack of protocols and guidelines. The knowledge and practice of Kangaroo Mother Care (KMC) were poor among health care providers (HCPs) despite holding a positive attitude. Assessment of knowledge, attitude, and practice among Arab mothers and HCPs is needed to develop a robust educational programme to raise awareness with regards to SSC.
Toxoplasma gondii, a parasite, has three modes of transmission: oral intake of raw or undercooked meat or contaminated fruits and vegetables, ingestion of materials contaminated with cat feces, and transplacental infection. The focus of this article is congenital toxoplasmosis, which is transmitted to the fetus across the placenta.
When primary infection of the mother occurs during pregnancy, there is a 40 percent chance of fetal infection; rate of transmission and severity of infection are related to gestational age at the time of infection. The brain and retina are often affected, and there can be a wide range of clinical disease. Amniocentesis or cordocentesis provides the most accurate diagnosis.
At birth, 80–90 percent of infants with congenital toxoplasmosis are asymptomatic. But further testing may reveal retinal and central nervous system abnormalities, and there is a risk of long-term sequelae. Chorioretinitis, hydrocephalus, intracranial calcifications, and convulsions are the typical presentation of classic congenital toxoplasmosis. Serology is the most common method of diagnosing neonatal infection, but more complex tests are also utilized. The prognosis for the untreated infant is poor; however, when antibiotic therapy is started early, the rate of sequelae is reduced significantly.
Resuscitations in the delivery room or the nursery cause significant stress for caregivers. Diligent preparation will improve the efficacy and safety of life-saving interventions and increase staff comfort. When establishment of an airway and delivery of positive pressure ventilation and chest compressions fail to result in return of spontaneous circulation, pharmacotherapeutic interventions should be considered. Epinephrine is first-line pharmacotherapy for severe bradycardia or cardiac arrest, increasing coronary arterial pressure and blood flow during chest compressions. Despite limited data regarding dosing and efficacy, the first dose of epinephrine may be delivered through the endotracheal tube during attainment of venous access (preferably a low-lying umbilical venous catheter in the delivery room). Intravenous dosing is preferred, and any facility caring for newborns must ensure optimized logistics including readily available dosing guidance and optimal flush volumes. After provision of epinephrine, additional medications may be considered, especially for resuscitations occurring outside of the immediate perinatal period, including normal saline, glucose, adenosine, atropine, and calcium. Clinicians must understand the indications, dosing, and monitoring parameters for these medications and ensure rapid availability for resuscitation. Every second truly counts in a neonatal resuscitation, and optimal understanding and preparation will ensure delivery of pharmacotherapy to optimize both patient outcomes and staff comfort.
This article presents a case study on the organization of maternity health care in Switzerland. Switzerland has a costly health care system with high intervention rates within an obstetric-led maternity care model. Evidence has shown that midwifery care is associated with lower cost, higher satisfaction rates among women, and less intervention. However, in this model, midwives are both marginalized and underused.
The article focuses on the distribution of power and knowledge between midwives, women, and the medical profession. The varying power structures that shape the maternity care system in Switzerland are examined, using a case study approach that draws on Foucault’s concepts of the gaze, surveillance, disciplinary power, and the docile body. This article critically analyzes the model of maternity care received by women in Switzerland and how it negatively impacts on both women’s personal and midwives’ professional autonomy while simultaneously driving up costs.
A better understanding of the underlying power structures operating within the maternity care system may facilitate the implementation of more midwifery-led care currently being endorsed by the Swiss Midwifery Association and some government agencies. This could result in reduced cost and lower intervention rates with reduced associated morbidity.
- Go to article: A Pilot Study of an Educational Intervention to Increase Postpartum Medical Visit Attendance in Home-Visited Mothers
A Pilot Study of an Educational Intervention to Increase Postpartum Medical Visit Attendance in Home-Visited Mothers
Socioeconomically disadvantaged women experience barriers to attending postpartum medical visits (PMV). This three-phase pilot study explored the feasibility, acceptability, and preliminary effectiveness of an educational intervention to increase PMV attendance in mothers enrolled in early childhood home visiting. Phases 1 and 2 occurred prior to the COVID-19 pandemic, and Phase 3 occurred during the pandemic. Home visitor implementation of the intervention with mothers was feasible and acceptable in all phases. All mothers who received the intervention reported PMV attendance. Overall, 81% of mothers reported they discussed all questions with healthcare providers at the PMV. These findings provide preliminary effectiveness for a brief educational intervention in increasing PMV attendance in home-visited mothers.
Hemoglobin plays an important physiologic role, one that begins early in fetal development. The focus of this article is hemoglobin physiology. Developmental erythropoiesis, developmental stages of hemoglobin, and postnatal erythropoiesis and hemoglobin production are discussed. The function of hemoglobin, its affinity for oxygen, and the clinical significance of the oxyhemoglobin dissociation curve are also explored.
Epilepsy affects approximately 1 percent of the population and roughly 1 million women of childbearing age. Estimates suggest that 0.3–0.7 percent of pregnancies occur in women with epilepsy. Epilepsy itself increases the risk of congenital malformation and medications add to this risk. Also, approximately one-half of the use of medications for epilepsy are used for other indications, possibly increasing exposure in some women. As controlled trials with these medications are not performed during pregnancy, data has been accumulated primarily through databases and case studies. This review is intended to update the practitioner about the use and concerns of antiepileptic medications in the presnant woman and the potential effects on the fetus and neonate.
Critical appraisal of the evidence is the third step in the evidence-based practice process. This column, the third in a multipart series to describe the critical appraisal process, focuses on critical appraisal of randomized control trials.
Simulation is an effective teaching methodology to enhance clinical thinking and reasoning skills among nursing students and practicing nurses. The opportunity to practice in a safe environment maintains a structure that promotes learning at all levels. There are various levels of fidelity as well as cost to facilitate simulation in the neonatal setting. This at times hinders the ability to incorporate simulation into educational practices. The purpose of this article is to provide a discussion on simulation practices in the neonatal setting, an overview of low-cost neonatal simulation exemplars, and implications for practice.
Management of congenital diaphragmatic hernia has changed dramatically over the past couple of decades. Until the early 1980s, it was felt that the abdominal contents should be returned to the abdomen as soon as possible to allow the lungs to expand. It is now known that it is not the defect that causes respiratory distress, but the infant’s hypoplastic lungs and accompanying pulmonary hypertension. Advances in treatment and technology have contributed to changes in management. Ultrasonography now allows for early prenatal detection. Prenatal treatment modalities include in utero tracheal ligation and maternal antenatal steroids. Postnatal modalities have expanded to include permissive hypercapnia, high-frequency ventilation, inhaled nitric oxide, pharmacologic support, exogenous surfactant, and extracorporeal membrane oxygenation. Liquid ventilation and lobar lung transplantation have also been tried. In spite of these advances, the overall survival rate remains about 63 percent.
Osteopenia, rickets, and fractures from nutrient deficiencies can occur during infancy, particularly in preterm infants. Bone mass accretion during the first year of life is equal to or greater than that achieved at any other stage of life, including adolescence. Optimizing calcium and bone status during infancy can have immediate benefits in maintaining calcium homeostasis and preventing disturbances in bone mineralization and can provide long-term benefits by helping infants to later reach their maximum genetic potential for peak bone mass, a prerequisite for the prevention of osteoporosis and its complications. Dietary calcium requirements during infancy generally reflect the need to achieve normal growth and bone mineralization because 99 percent of total body calcium is present in the skeleton. Knowledge of physiologic factors that determine infant calcium requirements and the bioavailability of calcium from various dietary sources is important to ensuring bone health during infancy. Also key are the practical issues related to optimizing calcium nutriture in infants born at term and prematurely.
Epidermolytic ichthyosis (EI) is a rare autosomal dominant genodermatosis that presents at birth as a bullous disease, followed by a lifelong ichthyotic skin disorder.1 Essentially, it is a defective keratinization caused by mutations of keratin 1 (KRT1) or keratin 10 (KRT10) genes, which lead to skin fragility, blistering, and eventually hyperkeratosis. Successful management of EI in the newborn period can be achieved through a thoughtful, directed, and interdisciplinary or multidisciplinary approach that encompasses family support. This condition requires meticulous care to avoid associated morbidities such as infection and dehydration. A better understanding of the disrupted barrier protection of the skin in these patients provides a basis for management with daily bathing, liberal emollients, pain control, and proper nutrition as the mainstays of treatment. In addition, this case presentation will include discussions on the pathophysiology, complications, differential diagnosis, and psychosocial and ethical issues.
- Go to article: Perinatal Music Therapy and Antenatal Music Classes: Principles, Mechanisms, and Benefits
Antenatal music activities are in the ascendant. Regarding evidence-based research, the article advocates 5 main aims: music therapeutic control of pre- and perinatal stress, anxiety, and depression; music-related mental and physical birth preparation comprising cognitive adjustment, emotional regulation, physical activity, relaxation and pain management, and social inclusion; music-associated bonding and self-efficacy; prenatal sound stimulation to trigger learning processes, pedagogical priming and brain maturation; music activities to facilitate the child’s acculturation and adaptive self-regulation. Underlying mechanisms such as neuroplasticity help to understand the multifaceted effects of music in pre- and perinatal care. Individual conditions and features of the mother and her child have to be taken into account and music interventions to be harmonized with complementary perinatal programs.
- Go to article: Central Diabetes Insipidus in a Preterm Neonate Unresponsive to Intranasal Desmopressin
Central or neurogenic diabetes insipidus (DI) is uncommon in the pediatric age group and rarely occurs in neonates. It should be suspected in any neonate presenting with excessive urine output and hypernatremia that persists despite increased fluid administration. Diabetes insipidus may be secondary to asphyxia, intraventricular hemorrhage, infection, and structural abnormalities or may be idiopathic or genetic. Diagnosis includes a careful history, laboratory testing, and magnetic resonance imaging. Management of neonatal DI involves a careful balance between fluid intake and pharmacologic treatment. In this article we report a case of an extremely low birth weight infant presenting with central DI possibly caused by abnormality of the pituitary gland. Persistent hypernatremia was the initial presentation. Increased fluids were given initially but were only partially helpful. Eventually subcutaneous desmopressin (DDAVP) was required. The infant was unresponsive to intranasal DDAVP and required subcutaneous DDAVP upon discharge.
BACKGROUND: Anxiety scores are higher in women being induced compared with women who are in spontaneous labor. There are limited published reports addressing anxiety associated with the induction of labor (IOL).
OBJECTIVES: The aim is to measure anxiety scores that are associated with IOL using two measuring scales and identify women’s characteristics and obstetrics variables that are associated with higher anxiety scores.
METHODS: A cross-sectional study was conducted between October 20, 2019, and October 20, 2020. Inclusion criteria required women to be 18 years or older, have a viable pregnancy, and have been admitted for IOL. Anxiety scores were measured using the visual analog scale for anxiety (VASA) first and then the State-Trait Anxiety Inventory (STAI). The factor analysis for mixed data was used to identify the independent variables that contributed the most to the variation among participants. These variables were then tested for association with the different anxiety variables using multivariate analysis of variance (MANOVA).
RESULTS: In this study, 300 women with a mean age of 28 years and a mean fetal gestational age of 39.4 weeks were recruited. A factor analysis with a principal component analysis method on the STAI state subscale revealed two components with high internal consistency, designated Component 1 and Component 2. Women had anxiety scores above the mean as measured on VASA (48.7%) and Component 1 (50.3%) and Component 2 (70.7%) of the STAI state subscale. There were statistically significant correlations between the two components of the STAI state subscale and VASA (Spearman’s rank correlation: VASA with STAI State Component 1 = −.239, p-value = 2.8 × 10−5; VASA with STAI State Component 2 = .296, p-value = 1.7 × 10−7). The three outcome anxiety variables (VASA and Components 1 and 2 of the STAI state subscale) in nonparametric MANOVA analysis showed significant associations with a prior history of subfertility (Wilk’s lambda test statistic = 3.668, df1 = 3, df2 = 296, p-value = .014) and higher parity (Wilk’s lambda test statistic = 2.100, df1 = 6, df2 = 590, p-value = .043).
CONCLUSION: High anxiety scores are prevalent among women who are being induced. The VASA and STAI state subscales are correlated, and VASA may be an alternative to the lengthy STAI. Antenatal identification of women at high risk may help in implementing strategies to reduce anxiety scores.
Breastfeeding should be encouraged for every baby with few exceptions, classic galactosemia being one of them. Classic galactosemia causes death in newborns and can be identified early with newborn screening, or through the careful assessments of physicians, midwives, and lactation consultants in the first 4 days of life. All practitioners that assess newborns within the first 4 days of life should have a clear understanding of when to halt breastfeeding and when to support continuation of breastfeeding while keeping babies safe.
Unplanned extubations (UEs) can have devastating effects on neonates. The purpose of this quality improvement project is to decrease the number of UEs in Lankenau Medical Center’s 22-bed Level III NICU. The UE rate had risen to 4.6 UEs per 100 ventilator days in 2016. Transitioning to a standardized bundle for intubated infants has decreased the UE rate to less than 2 per 100 ventilator days since 2018. The UE rate continues to be monitored for ongoing accountability and further staff education when rates increase.
- Go to article: Women’s Birth Preparedness and Complication Readiness in Nigeria: A Systematic Review and Meta-Analysis
Women’s Birth Preparedness and Complication Readiness in Nigeria: A Systematic Review and Meta-Analysis
INTRODUCTION: Globally, efforts are being made to reduce the menace of maternal death in order to achieve the sustainable development goal. Maternal death has been associated with inadequate Birth Preparedness and Complication Readiness (BPCR), especially in low- and middle-income countries. Therefore, this review assessed birth preparedness and complication readiness in Nigeria.
METHODS: A systematic review and meta-analysis of published research articles on birth preparedness and complication readiness in Nigeria were done using PubMed, EMBASE, and MEDLINE databases. All published articles from inception to November 2018 were included in the review. A total of 8,913 published articles were identified from an electronic search, and a total of 4,440 studies were included in this review, while only 12 articles met the inclusion criteria and were included in the meta-analysis.
RESULTS: The pooled prevalence of “good BPCR” for all studies yielded an estimate of 58.7% (95% CI 43.9%–72.7%). The I 2 statistic was 98%, indicating statistically significant heterogeneity among the studies. The percentage of women with good birth preparedness and complication readiness increases with the year of publication, such that women have tended to be more aware of good birth preparedness and complication readiness in recent years. More than half of the women had knowledge of obstetric danger signs (52.0%, 95% CI 39.5%–64.4%, 10 studies), arranged for transportation (59.5%, 95% CI 36.2%–80.7%, 11 studies), or saved money (63.4%, 95% CI 44.7%–80.2%, 11 studies) as part of the BPCR.
PROSPERO REGISTRATION NUMBER: The study protocol was registered with PROSPERO number CRD42019123220.
CONCLUSION: Women in Nigeria are better prepared for birth preparedness and complication readiness in recent years. Therefore, interventions to promote more adequate birth preparedness and complication readiness among women are recommended.
Delayed cord clamping is a collaboration between the obstetric team and the neonatal team. Although the optimal timing for clamping the umbilical cord after birth continues to be subject to study, delaying clamping for at least 30–60 seconds, with the newborn held at or below the level of the uterus/placenta supports normal physiology and has proven benefits. Practical issues such as thermoregulation and equipment can be overcome with team collaboration and prebriefing planning. Neonatal nurses who attend deliveries are perfectly poised to influence this practice and improve short- and long-term outcomes for their patients.
Newly discovered genes and advances in genetic screening programs prompt many questions reflecting the kinds of ethical dilemmas that go hand in hand with life-changing discoveries. Neonatal genetic screening has been a standard of care for some time, but as our knowledge in the field of genetics expands, should we continue with the same approach? What newborn genetic screening tests should be mandatory, and what are the long-range consequences associated with testing? This article reviews genetic modes of inheritance, outlines and explains the most common newborn screening tests, and enumerates the ethical issues associated with these screening procedures. The role of the neonatal nurse in the newborn genetic screening process is discussed.
Maternal smoking during pregnancy and maternal smoking postnatally are important public health concerns worldwide. Smoking adversely affects the woman's general health and is causally related to pregnancy complications and serious health outcomes for the child, such as stillbirth, preterm delivery, low birth weight, and sudden infant death. The purpose of this research was to examine maternal smoking through a quantitative descriptive survey of 164 women, 120 who were pregnant and 44 who were postnatal. Women experienced barriers to quitting smoking, including dealing with stress, being exposed to smokers, not being ready to quit, not knowing how to quit, not looking for or not being able to find information about smoking or quitting smoking, and lacking adequate social and healthcare provider support. On the other hand, women revealed characteristics that suggest they might have had improved potential for quitting smoking, including having negative feelings about smoking, having cut down on smoking, smoking at a low level, having made quit attempts, thinking it would not be hard to quit smoking, being in the preparation stage of behavioral change, and thinking their healthcare providers (HCPs) would help them if they decided to quit. Taken together, those findings suggest that HCPs could offer important assistance to help women achieve smoking cessation. However, more research needs to be conducted to clarify the role and effectiveness of various HCPs in smoking cessation interventions and to identify measures to strengthen their provision of such interventions.
Congenital hypothyroidism (CH) is a disorder of thyroid hormone deficiency which develops secondary to incomplete thyroid development or inadequate thyroid hormone production. State-mandated newborn screening throughout the United States has increased the detection rate of CH, allowing for early intervention. Although the overall mortality rate of CH is low, delayed or omitted treatment can lead to devastating neurocognitive outcomes. As such, CH is regarded as the leading cause of preventable intellectual disability in children. Early identification, facilitated by astute neonatal nursing and medical care, is contingent upon an active working knowledge of the disease process and awareness of the limitations of the newborn screen.
If a tongue-tie is to be revised, what is the best technique for accomplishing that? There is some debate in the field about whether scissors or laser is most effective. Both techniques seem efficacious. This section also addresses which professionals should be performing the revision. Our panelists represent a wide range of disciplines, so some refer, and others perform the revisions themselves.
Parenteral nutrition (PN) is frequently required by extremely preterm infants due to gastrointestinal immaturity and complications of prematurity. Parenteral nutrition-associated cholestasis (PNAC) and intestinal failure-associated liver disease (IFALD) are common complications of prolonged PN. Plant-based intravenous lipid emulsions, containing proinflammatory omega-6 fatty acids and phytosterols, may contribute to these conditions as well as other comorbidities such as bronchopulmonary dysplasia and retinopathy of prematurity. Intravenous lipid emulsions containing animal-based fats, such as fish oil, contain fewer proinflammatory omega-6 fatty acids and more anti-inflammatory omega-3 fatty acids and antioxidants. SMOFlipid, recently Food and Drug Administration (FDA)-approved for adult use, is a blend of plant- and animal-based lipid emulsions with a favorable omega-6:omega-3 ratio that may prevent the development and progression of PNAC/IFALD in infants. Careful review of data supporting this alternative intravenous lipid emulsion is required prior to widespread use in neonatal intensive care.
IN THEIR EFFORTS TO IMPROVE THE health outcomes of neonates and infants in the Neonatal Intensive Care Unit (NICU), neonatal nurses should understand the potential for harm that plastic medical devices pose to infants. Di(2-ethylhexyl) phthalate (DEHP) is a plasticizer used to soften polyvinylchloride (PVC) that can leach from the plastic into the fluid or gas being delivered to the neonate. DEHP can harm the developing reproductive system. The U.S. Food and Drug Administration (FDA) has issued a public health notification recommendation that DEHP- free devices be considered for use in NICU patients.1 There are alternatives available. The purpose of this column is to inform neonatal nurses of the risk of DEHP exposure among infants and to make it simpler for them to implement change in reducing DEHP in their institution.
The historical evolution of infant feeding includes wet nursing, the feeding bottle, and formula use. Before the invention of bottles and formula, wet nursing was the safest and most common alternative to the natural mother’s breastmilk. Society’s negative view of wet nursing, combined with improvements of the feeding bottle, the availability of animal’s milk, and advances in formula development, gradually led to the substitution of artificial feeding for wet nursing. In addition, the advertising and safety of formula products increased their popularity and use among society. Currently, infant formula-feeding is widely practiced in the United States and appears to contribute to the development of several common childhood illnesses, including atopy, diabetes mellitus, and childhood obesity.
A descriptive study design was used to describe the decision of women having a cesarean surgery. The Cesarean Birth Decision Survey was used to collect data from 101 postpartum women who underwent a cesarean. Most of the surgeries were to primipara women who reported doctor recommendation and increased safety for the baby as the main reasons for the cesarean. Those women who had repeat cesarean surgery all cited their previous cesarean as the main reason for the current surgery. Women’s knowledge of cesarean surgery needs to be assessed early in pregnancy so that appropriate education may be provided. Accurate and ongoing information may decrease the number of women choosing a cesarean surgery.
Purpose: To compare kangaroo mother care (KMC) and conventional cuddling care (CCC) in premature and smallfor-gestational-age infants.
Design and Sample: Thirty mother-infant dyads in two Australian neonatal nurseries were randomly assigned to the KMC group or the CCC group. Both groups of mothers cuddled their babies for a minimum of two hours a day, five days a week while in the study, with the KMC group having skin-to-skin contact while the CCC group had contact through normal clothing.
Main Outcome Variable: The main outcome variables were infant weight gain, temperature maintenance during KMC and CCC, and length of hospital stay.
Results: The results showed no difference between groups on the Parental Stress Scale (NICU) or the Parental Expectations Survey. Infants in both groups experienced equivalent maintenance of or rise in temperature while out of the incubators, equal weight gain, equal length of stay in the hospital, and equal duration of breastfeeding.
Neonatal osteomyelitis is a rare and challenging diagnosis, particularly in the early onset period. Neonatal osteomyelitis is predominantly caused by Staphylococcus aureus with single bone involvement. Here, we report two cases of neonatal osteomyelitis in premature infants caused by Klebsiella pneumoniae with multiple bone lesions. Both cases presented with sepsis and meningitis and were initially diagnosed by incidental findings on plain films, with follow-up bone scan imaging. In both cases, diagnosis was timely and treatment was successful. These cases highlight the need to include neonatal osteomyelitis in the differential diagnosis when late-onset or prolonged neonatal sepsis is present, particularly because long-term outcome is dependent on rapid diagnosis and initiation of treatment.
Maintenance of electrolyte balance in the neonate is a challenge in the context of illness or prematurity. Neonatal providers’ approach to fluid management changes and adapts based on the newborn’s age, maintenance needs, deficits, and ongoing losses. Understanding the total body water content of the fetus and newborn is foundational to management of electrolyte disturbances. This article reviews common imbalances of sodium and chloride, identifies causes of imbalances, and discusses current evidence-based treatment options.
Aplasia cutis congenita (ACC) is a rare condition that presents at birth as an absence of skin that does not usually involve underlying structures. Occurring in 3/10,000 live births, ACC is evenly distributed between males and females; the risk of ACC increases to 7 percent in consanguineous marriages. Up to 86 percent of lesions are found on the scalp in the midline vertex position. Lesions can also be found on the trunk and limbs, as with Adams-Oliver syndrome or accompanying epidermolysis bullosa. ACC is associated with chromosomal abnormalities and 35–50 percent of the time with trisomy 13 (Patau syndrome). This case study presents an infant with multiple ACC lesions of the scalp. The pathophysiology, treatment, potential long-term complications, and nursing considerations are discussed.
Modern western society and media often present the mother’s choices for her birth as paramount. Various gurus provide the mother with often conflicting advice. But the reality is that childbirth often becomes a medicalized event with many interventions and less than ideal outcomes. In many instances, the choices are made to suit health professionals and hospital routines rather than the mother. All the aforementioned are based on ideas and assumptions which predate evidence-based medicine and recent neuroscience. In reproductive biology, the newborn is an active participant and agent in birthing (Alberts, 1994). Based on this, the perspective which has been lacking is what is best for the baby; our choices should be primarily based on the basic biological needs of the infant.
- Go to article: Fetal Middle Cerebral Artery and Umbilical Artery Pulsatility Index Doppler Associations With Pregnancy Risk and Neonatal Outcomes
Fetal Middle Cerebral Artery and Umbilical Artery Pulsatility Index Doppler Associations With Pregnancy Risk and Neonatal Outcomes
OBJECTIVE: To evaluate the role of the middle cerebral artery (MCA) to the umbilical artery (UA) blood velocity waveform’s pulsatility index (PI) screening in proximity to delivery as a predictor of high-risk pregnancy and neonatal outcomes.
METHODS: The study used a nested case–control method, consisting of 34 women with high-risk pregnancies and 34 pregnant women who were classified as normal. The MCA/UA PI ratio was evaluated within 14 days before delivery. All subjects’ newborns were evaluated for neonatal outcomes, which included fetal distress, abnormal cardiotocography or fetal heart rate patterns, neonatal mortality, Apgar score, duration of hospitalization, and neonatal intensive care unit (NICU) admission. A cutoff point for MCA/UA PI ratio was assessed using the receiver operating characteristic curve. The correlations between the MCA/UA PI ratio and high-risk pregnancy and neonatal outcomes were assessed with multivariable linear regression based on the cutoff point obtained.
RESULTS: The MCA/UA PI ratio in high-risk pregnancy was significantly lower compared with normal pregnancy (p = .011). The MCA/UA PI ratio of ≤1.32 finding was 6.37 times higher in high-risk pregnancy (p = .017, AOR 6.37, 95% CI 1.40–28.97), 5.9 times higher in pregnancy with the neonate’s first-minute Apgar less than 7 (p = .031, AOR 5.90, 95% CI 1.18–29.61), and 18.62 times higher in neonates admitted to the NICU (p = .023, AOR 18.62, 95% CI 1.43–2702.94).
CONCLUSIONS: Low MCA/UA PI is associated with high-risk pregnancies and adverse neonatal outcomes, such as low first-minute Apgar score and NICU treatment.
- Go to article: Improving Exclusive Breastfeeding Behavior of Primipara Mothers With Lactation Education and Individualized Counseling Intervention
Improving Exclusive Breastfeeding Behavior of Primipara Mothers With Lactation Education and Individualized Counseling Intervention
New mothers often need support to establish and maintain breastfeeding, and they may find it difficult to access breastfeeding resources locally. Therefore, postpartum lactation education and counseling of primipara mothers were given by integrating into their routine follow-ups in the family health center. This study was conducted to determine the effect of lactation education and individual counseling intervention integrated into the routine follow-up visits of primipara mothers in family health centers on exclusive breastfeeding rates and breastfeeding behaviors during the first 6 months postpartum.
A two-factor, pretest–posttest, controlled, semi-experimental, prospective study was conducted. The study was conducted in three family health centers in a city on the north coast of Turkey. The interviews with the primipara mothers were performed between the 24th and 72nd hours and at the 1st, 3rd, 4th, 6th months postpartum.
The rates of giving exclusive breastfeeding to the infants in the first 6 months were 68% in the study group and 38% in the control group, exhibiting a statistically significant difference between the groups with regard to breastfeeding frequency (p =.001).
It was determined that the education and counseling integrated into the existing health system were effective in increasing the EBF rates and breastfeeding behaviors of primipara mothers in the first 6 months after birth.
Umbilical venous and arterial catheters are routinely used in the care of critically ill patients in neonatal intensive care settings. Providers caring for these vulnerable patients have a role in ensuring that catheter tips remain in an appropriate position. The ideal anatomic tip location for both types of umbilical catheters is reviewed, and the evaluation of this position via radiographic study is discussed. Umbilical venous catheters (UVCs) and umbilical arterial catheters (UACs) have their own different complications. Complications of a malpositioned catheter of either type can be life threatening; therefore, evaluation of catheter tip location is an important skill in the provision of neonatal intensive care.
In this column, the editor of The Journal of Perinatal Education discusses the need for continued education about promoting vaginal birth after cesarean. The editor also describes the contents of this issue, which offer a broad range of resources, research, and inspiration for childbirth educators in their efforts to promote, support, and protect natural, safe, and healthy birth.
Current evidence and professional organizations identify letting labor begin on its own as one of the most important strategies for promoting normal, physiologic birth. It also prevents iatrogenic prematurity and the need for high-tech medical interventions required for labor induction. Because the American College of Obstetricians and Gynecologists (ACOG) now states that it is reasonable for obstetric care providers to offer induction at 39 weeks to low-risk nulliparous women, it is more important than ever for childbirth educators to be familiar with best evidence on letting labor begin on its own.
- Go to article: Feature Article—Continuing Education Module—International Water-Birth Practices With Recommendations During a Global Pandemic
Feature Article—Continuing Education Module—International Water-Birth Practices With Recommendations During a Global Pandemic
The number of hospitals globally that offer water birth has increased exponentially during the past 10 years. This article examines some of the reasons for this increase as well as the objections to water birth by The American College of Obstetricians and Gynecologists, raised in their 2014 and 2016 opinion statements. The amount of research has also increased as more hospitals are keeping track of their data and publishing both prospective studies and retrospective analyses. The effects of water birth on the neonate are discussed through three meta-analyses from 2015, 2016, and 2018. The challenges and recommendations on continuing the use of water during labor and birth as a nonpharmacologic comfort measure even during a global pandemic are highlighted and supported by the best available evidence.
In this birth story, Katherine shares that she wanted an unmedicated birth. She planned a hospital birth with a midwife. During her pregnancy, she hired a doula and she and her husband, Corey, attended both natural childbirth classes and a natural comfort measures class. Katherine had an intense labor but was able to relax between contractions, and with the support of her husband and doula, she managed to cope with increasingly difficult contractions. Her commitment and hard work during labor, and the emotional and physical support she received, helped her achieve the unmedicated birth she wanted. Katherine and her husband welcomed their daughter, Clara Mae, into the world after 10.5 hours of labor.
- Go to article: Many Women and Providers Are Unprepared for an Evidence-Based, Educated Conversation About Birth
Findings from recent Canadian studies on the knowledge and beliefs about birth practices among first-time pregnant women and among obstetricians and other birth providers indicate that many women are inadequately informed and many providers deliver non-evidence-based maternity care. Consequently, informed decision making is problematic for pregnant women and their providers. New strategies are needed to inform pregnant women about key procedures and approaches that might be used in birth so they can have an educated, shared discussion with their provider and successfully advocate for their preferred birth experience. In addition, providers can be encouraged to supplement their knowledge with current, evidence-based maternity care practices. To avoid a lack of informed decision making and to ensure that natural, safe, and healthy birth practices are based on current evidence, pregnant women and providers must work together to inform themselves and to add childbirth to the women’s health agenda.
The clinical guidance for human milk (HM) feeding for sick and premature babies in Thailand was developed in 2013 to help improve their breastfeeding rates.
To expand breastfeeding (BF) for sick and premature babies using the clinical guidance, develop a monitoring system, and to integrate the practice into the national routine newborn care for sick babies.
Volunteer tertiary care hospitals were recruited to implement the clinical guidance. The development of a monitoring and evaluation system was done by the multidisciplinary team and volunteer hospitals. The integration into routine national care practice was done by including it in the national neonatal service plan of Thailand.
Thirty-eight pilot tertiary care hospitals volunteered for implementing the program. The proposed outcome indicators of rate of exclusive BF sick babies at hospital discharge and at 6 months of life for the volunteer hospitals were 62.97% and 41.76%, respectively. Since its integration into the national service plan in 2019, a total of 98 hospitals have been included in the program.
The integration of the clinical guidance into the national service plan is essential for sustaining BF of sick, premature babies in the country.
Editor’s note: One of the editorial goals for Clinical Lactation was to provide a forum where IBCLCs could respectfully discuss emerging, and sometimes controversial, issues that arise in our field. The issue of peer-to-peer milk sharing is one such issue. Social media has greatly facilitated this practice. Given the rise in milk-sharing behavior, it is appropriate for IBCLCs to acknowledge its existence, understand why it occurs, and decide on an appropriate course of action. This article presents a roundtable discussion of Karleen Gribble’s recent article, Biomedical Ethics and Peer-to-Peer Milk Sharing.
- Go to article: Retained Central Venous Lines in the Newborn: Report of One Case and Systematic Review of the Literature
Retained Central Venous Lines in the Newborn: Report of One Case and Systematic Review of the Literature
The use of percutaneously inserted central catheters (PICCs) is an established practice in most NICUs. With the widespread use of these catheters, an increasing number of PICC complications has been reported in neonates. We present one case of a PICC retained and tethered in the vein in a very low birth weight infant, as well as a systematic review of PICC retention cases. Ten previous cases of PICC retention in neonates were found. Among those cases, the most common associated factors were coagulase-negative staphylococcus catheter colonization/bacteremia and long duration of catheterization. Occlusion was not a useful sign for predicting catheter retention. Once retention was established, heparin or urokinase instillations were ineffective. Although surgical exploration was sometimes required, firm, continuous traction applied to the catheter over several hours or intermittent, moderately strong pulling maneuvers were successful in 44.4 percent of the cases in which they were performed. Traction did not show major side effects. Our case provides additional support for use of traction as the initial approach in the management of this rare complication.
- Go to article: Letter From the Editor: Web Wisdom, Birth or Other Life Transitions, and the Pursuit of Happiness
This perspective on “happiness as a way” rather than focusing on finding a path to happiness may be particularly relevant for new and expectant parents.
- Go to article: The Value of Using a Prenatal Education Planning Model: Application to an Aboriginal Community
A conceptual model for planning adolescent prenatal programs was developed that anticipated future trends, was easily modifiable, and fostered community self-direction (Loos & Morton, 1996). However, the model’s reliability with diverse groups in atypical settings required testing. Validation of its reliability focused on adolescent Aboriginal women living in an isolated northern community. Use of the model helped identify modifications in program design, implementation, and evaluation to meet the ethno-cultural, socioeconomic, and age-related needs differences of this population, suggesting that this model is an effective tool for program development.
A paucity of prenatal data is available concerning prenatal experiences of primigravid women compared with those of multigravid women. Therefore, the objectives of this study were twofold: to compare prenatal personal (demographic and other descriptive elements, including self-esteem) and psychosocial variables (maternal-fetal attachment, marital satisfaction) and to describe perceived pregnancy experiences for both primigravid and multigravid women. Both quantitative and qualitative data were collected using a descriptive mixed-methods design. The data were part of a larger, longitudinal study focused on adjustment to parenthood in military and civilian couples. Married pregnant women who resided on the east and west coasts of the United States were recruited from prenatal care facilities. Participants included 50 pregnant primigravid and 50 multigravid married women recruited during the last trimester of a healthy, uncomplicated pregnancy. The main outcome measures included personal and psychosocial variables (demographics, self-esteem, maternal-fetal attachment, marital satisfaction) and perceived pregnancy experiences. Multigravid women had significantly lower levels of maternal-fetal attachment (p < .00) and marital satisfaction (p < .00) than did primigravid women during their third trimester of pregnancy. The pregnant women’s responses clearly reveal that unique and distinct differences exist between the needs of primigravid women and those of multigravid women. Innovative prenatal educational interventions tailored to meet the distinct needs of primigravid and multigravid women are suggested.
- Go to article: Neonatal Peripherally Inserted Central Catheters: Recommendations for Prevention of Insertion and Postinsertion Complications
Neonatal Peripherally Inserted Central Catheters: Recommendations for Prevention of Insertion and Postinsertion Complications
Peripherally inserted central catheters (PICCs) continue to be necessary in neonatal care. They benefit many premature infants and those needing long-term intravenous access. An experienced inserter, early recognition of PICC candidates, early PICC placement, knowledge of anatomy, and correct choice of vein all increase placement success. As with any invasive procedure, there are risks. These include pain, difficulty advancing the catheter, damage to vessels, catheter malposition, and bleeding. Utilizing assessment skills, following the product manufacturer’s instructions, and carefully placing the catheter should minimize most of these risks. Additional risks include postinsertion complications such as occlusions, thrombosis, catheter failure, infection, and catheter malposition. Proper nursing care—which includes controlling infection, properly securing the catheter, and changing the dressing as needed—is key to preventing complications and maintaining the PICC until treatment has been completed.
Pain and its management hold a central place in health care. The pain associated with pregnancy and giving birth is unique in that it is a normal, physiologic phenomenon that is affected by cultural mores, personal experience, and internalized sensations. There are numerous nonpharmacologic tools available to treat discomfort during pregnancy and childbirth. Some methods of nonpharmacologic relief are underutilized, due to the lack of knowledge of the evidence. Childbirth educators, doulas, nurses, and midwives are a prime source of knowledge for birthing families to learn a variety of comfort techniques during pregnancy and labor. The purpose of this article is to discuss the use of transcutaneous electrical nerve stimulation (TENS) as a nonpharmacologic comfort technique.
The purpose of this systematic review was to explore and describe the experience of parents with an infant in the newborn intensive care unit (NICU). A literature search covering the period 1998‐2008 was conducted. Fourteen articles reporting qualitative studies describing parental experiences and meeting the inclusion criteria were evaluated and themes were identified. Findings revealed that parents with an infant in the NICU experience depression, anxiety, stress, and loss of control, and they vacillate between feelings of inclusion and exclusion related to the provision of health care to their neonate. Nursing interventions that promote positive psychosocial outcomes are needed to decrease parental feelings of stress, anxiety, and loss of control. Interventions need to focus on family-centered and developmentally supportive care.
Fragile X syndrome is the most common inherited condition causing mental retardation in males. Females with the full mutation expansion can have milder signs of the disorder. Families with members who have been diagnosed with fragile X syndrome face concerns about the health of their newborn infant, decisions regarding family planning, and questions about the possibility that other family members could have this disorder. Neonatal nurses participate in assessment, health care management, counseling, and referral of the families regarding this syndrome.
Beginning with this issue, I am the new editor for the “News of The Academy of Neonatal Nursing.” Before introducing myself, let me first say thank you to Chuck Rait for his leadership and unending commitment to The Academy and to neonatal nursing. Chuck has been wearing many hats since launching this new association. In order to focus on other issues, Chuck is turning this column editorship over to me.
This article reports the findings from a mixed-methods study on factors that influence women’s decisions about birth, with the view that women’s decision making about birth can affect the use of cesarean surgery. Data was collected from focus groups and structured postpartum interviews and was analyzed using the Consensual Qualitative Research method. The findings relate specifically to the factors reported as influential in making decisions about birth including how the women categorized, prioritized, and/or favored certain types of knowledge about modes of birth. Four major information categories were identified but only stories about birth and/or attending a birth appeared to have a lasting effect on birth choices. These findings have implications for prenatal and perinatal education and nursing practice.
- Go to article: Congenital Melanocytic Nevus: Considerations for Neonatal Clinicians and a Parent Perspective
Congenital melanocytic nevus (CMN) or nevi, also known as dark moles, are present at birth. While small CMN are quite common, large and giant nevi are rare and can be associated with significant psychological distress and the potential for further clinical sequelae. Neonatal clinicians can offer anticipatory guidance to families through distribution of resources and navigation to additional consultants.
BREAST MILK, THE MAINSTAY OF infant nutrition, provides the appropriate nutrients for optimal growth and development for most babies. Several conditions in women and infants preclude breastfeeding, however, and identifying these conditions early on is important. Women who are unable to breastfeed because their infants are ill and/or premature yet wish to establish lactation for their hospitalized newborns need instruction and support if they are to succeed. It is the responsibility of the discharging hospital to have personnel who are specifically trained to provide an individualized plan of care for each mother (Table 1). Written instructions for handling, storing, and preparing expressed breast milk are an essential part of such plans. The discharge plan for each mother should include specific recommendations related to the mother: medical/surgical history, expression techniques, and collection and storage procedures. Completion of the plan should incorporate the infant’s current medical condition and neurologic status, with particular emphasis placed on enhancing the quality of the maternalchild interaction.
Purpose: To compare the amount of time required to collect a blood specimen, the number of heel punctures required, and the rate of hematology re-collections required when using a Monolet lancet vs a Tenderfoot Preemie device.
Design: Randomized, two-group, quasi-experimental.
Sample: Neonates with a birth weight >800 gm were eligible to participate in the study. Twenty subjects were randomized to the Monolet lancet (control) group and 20 to the Tenderfoot Preemie (experimental) group. A total of 157 blood specimens was collected, 89 of which were for hematology testing.
Results: For this sample population of preterm infants, less collection time was required, fewer heel punctures were necessary, and a lower re-collection rate occurred with use of the Tenderfoot Preemie than with use of the Monolet lancet.
- Go to article: Delphi Expert Parent Study: Factors Needed for 21st Century Pre- and Perinatal Parenting Programs
Using Delphi methodology, the current study utilized a panel of “expert” parents (N = 23 after three rounds) to examine nine content-based and logistical factors perceived to be important when developing pre-and perinatal (PPN) parenting programs for the modern day. The aim was to attain consensus on 235 items generated from literature and panelists. Consensus was reached on 126 items (53.62%). The most notable related to needs-based content, barriers to fathers' attendance, and groups of parents who may benefit most from programs. Consistent with the literature, clarity was not achieved for appropriate timing and length of programs. With the diversity of recommendations, next steps involve developing a range of programs that use randomized clinical trials with control groups, effective sample sizes, and are pre-and posttested.
Intraventricular hemorrhage (IVH) in the term infant is an uncommon and unexpected diagnosis. This article examines the frequency of IVH in the term newborn; the pathogenesis behind IVH; the presentation according to the location, extent, and cause of the hemorrhage; the diagnosis, associated complications, management, and outcomes of infants with IVH; and nursing responsibilities. A case study is offered of a term infant who presented with seizures after a normal labor and delivery, was found to have bilateral Grade III hemorrhages, and proceeded to develop posthemorrhagic hydrocephalus. Her management and outcome to date are discussed.
Purpose: Discharging infants from the NICU is complex, requiring the coordination of multiple aspects of care. Patient follow-up includes transferring medical care to primary care providers (PCP) who initially may have to rely on parents/caregivers for details about the child’s history and current needs. Improving communication between the NICU and primary care offices within this pediatric health system was a goal of the organization, especially as value-based care was launched. Design: A pilot program was introduced in which families, PCP, and NICU providers for medically complex infants were offered the opportunity to participate in video conference calls. Sample: Infants selected for this pilot were those discharging from a Level IV NICU for the first time with medical complexity, such as those who would require care from multiple specialists, those with nasogastric feeding tubes, gastrostomy feeding tubes, and/or requiring oxygen post-discharge. The agenda during calls consisted of a review of the infant’s birth, NICU course, and post-discharge needs. Participants were encouraged to provide detail and ask clarifying questions. Main Outcome Variable: Outcomes of this project included the evaluation of satisfaction with newer phone call methods for all participants and tracking readmission rates for those infants whose families experienced the video conference call. Results: High satisfaction levels were recorded among stakeholders as evidenced by 77 percent of parents and NICU providers being “very satisfied” or “completely satisfied” and 96 percent of primary care physicians being “very satisfied” or “completely satisfied.” The rate of 30-day readmission for those who participated in the pilot was 23 percent and those readmissions were not unexpected. Conclusion: Involving families and accepting primary care physicians into the discharge communication are satisfying to stakeholders and allow participants the opportunity to have bidirectional conversations regarding the unique care needs of infants discharged from the NICU with special needs.
- Go to article: The Psychological Experience of Physiological Childbirth: A Protocol for a Systematic Review of Qualitative Studies
The Psychological Experience of Physiological Childbirth: A Protocol for a Systematic Review of Qualitative Studies
PURPOSE: The purpose of this systematic review of the literature is to look at the current evidence of the psychological experience of physiological childbirth.
BACKGROUND: Childbirth is a dynamic process in which the fetal and maternal physiology interacts with the woman’s psychosocial context, yet this process is predominantly evaluated using objective, physical measures. Simultaneously, childbirth is also a profound psychological experience with a deep impact in women that is physical, psychological, and social. The description of the psychological processes and experiences that happen during physiological childbirth will likely improve the care women receive during childbirth as health care professionals and carers will have a greater understanding of the process.
METHODS/DESIGN: The electronic databases MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, PsycARTICLES, SocINDEX, and Psychology and Behavioral Sciences Collection will be searched using the EBSCOhost platform to identify studies that meet the inclusion criteria. No language or publication date constraints will be applied. Articles that pass the 3-stage screening process will then be assessed for risk of bias and have their reference lists hand searched.
DISCUSSION: By synthesizing the results of the studies, this systematic review will help illuminate gaps in the literature, direct future research, and inform policymakers.
Hypoxic-ischemic encephalopathy (HIE) is characterized as brain injury that results from lack of oxygen or blood flow to the brain in the perinatal period. Neonatal whole-body hypothermia and selective head cooling are becoming increasingly common care practices across the U.S. and Canada for infants with moderate-to-severe HIE because of the demonstrated ability of these approaches to reduce reperfusion injury to the brain. Health care professionals must develop a clinical care path for these fragile infants. For best results, induced hypothermia should be initiated within six hours of birth; therefore, care must be organized and provided without delay. This article provides bedside clinicians with care recommendations for infants being treated with these new interventions.
As a midwife, delivering hundreds of babies a year in a busy city hospital, I rarely have the opportunity to reconnect with what made me pursue the path of midwifery. This is the story of the birth of my niece.
The use of peer support as a tool to increase breastfeeding exclusivity and duration can be facilitated by innovative community strategies. This is especially important in a binational environment where healthcare clients are served by providers on both sides of the U. S.–Mexico border. A successful adoption of the Baby Café model of peer-to-peer breastfeeding support, developed in the U.K., has been carried out by the El Paso Baby Café and its sister Baby Cafés in Ciudad Juárez and Northern Chihuahua, Mexico.
Providing care to neonates with bowel obstruction requires a basic understanding of gastrointestinal (GI) anatomy and functional landmarks as well as knowledge of the pathophysiology associated with intestinal blockage. Early recognition and prompt diagnosis necessitate astute assessment of common presenting symptoms and accurate interpretation of diagnostic investigations. Initial medical management is focused primarily on gastric decompression and maintenance of fluid and electrolyte balance. This article describes features of the neonatal GI tract and discusses common causes of neonatal bowel obstruction.
Ms. Shirland raises a valid concern regarding safe securement of the neonatal PICC catheter and its role in preventing catheter fracture and catheter embolism. Ms. Paulson and Ms. Miller’s response is appreciated [see the author’s response in Neonatal Network, November/December 2008, p. 427]. In Dislodgement Rates and Impact of Securement Methods for Peripherally Inserted Central Catheters (PICCs) in Children, Frey and Schears report methods of PICC securement include transparent dressings, skin closure strips, sutures, and catheter-specific securement devices.1 However, a specific procedure for the appropriate placement of the skin closure strips is not delineated. In PICC Complications in Neonates and Children, Frey describes catheter fracture, where the damage was caused by a “sterile-tape thread” in a skin closure strip.2 Given the extended dwell time expected with PICC catheters, placement of skin closure strips including sterile tape fibers directly overlying the catheter would, in combination with infant mobility, support the possibility of external forces (fibers, adhesive agent, activity) causing severance of the catheter over time, which cannot be discounted. In cases of catheter embolism, catheter fragments required cardiac catheterization for retrieval.2
Guaiac testing the stool of very low birth weight (VLBW; <1,500 g) preterm infants has been a standard of care for many neonatal intensive care units (NICUs) and considered a diagnostic tool that could potentially provide early warning of gastrointestinal disturbances, feeding intolerance (FI), or necrotizing enterocolitis (NEC). Evidence to either support or eliminate testing stool for occult blood from standard care practices is lacking. Support to eliminate testing is often based on the knowledge that neonatal treatment interventions—such as gastric tube placement, intubation, and/or suctioning—may often result in occult blood in stools. However, there is also reasonable concern that occult blood may indicate a cascade of pathophysiological events, which may lead to FI and NEC, is in progress.
Feeding intolerance remains one of the most consistent reasons VLBW preterm infants experience poor weight gain and extended hospital stays. Every nursing assessment is strategic to the early identification of contributing factors to either the development of FI or NEC. Including low-cost, noninvasive diagnostic tools to augment the findings of the nursing assessment can only help guide health care providers in appropriate decision making related to the feeding plan.
In 1996, the World Health Organization set out guidelines for normal birth. Because that time birth in the United States has continued to be intervention intensive, the cesarean rate has skyrocketed and maternal mortality, although low, is rising. At the same time, research continues to provide evidence for the benefits of supporting the normal physiologic process of labor and birth and the risks of interfering with this natural process. This article reviews the current state of U.S. maternity care and discusses research and advocacy efforts that address this issue. This article describes optimal care in childbirth and introduces the Lamaze International Six Healthy Birth Practices.
When we asked for mothers to tell us their stories of tongue-tie, responses flooded in. A theme in many of these stories is health-care providers not listening when mothers said they were in pain. The mothers’ related stories of painful nipples, babies breastfeeding “all the time,” and failure to thrive because of low milk production. Mothers’ voices were not heard because health-care providers minimized their concerns. Most of these mothers persisted with breastfeeding despite the problems. Eventually, the tongue-ties were correctly identified and revised, and the difficulties resolved. Other mothers were not able to continue breastfeeding. A smaller percentage of mothers described revisions that had harmful effects on their babies and that did not fix the breastfeeding problems. (Editor’s Note: We, unfortunately, received too many stories to include in this issue, but we will include all of them in the Clinical Lactation Monograph.)
- Go to article: Bone Mineral Metabolism in the Neonate: Calcium, Phosphorus, Magnesium, and Alkaline Phosphatase
CALCIUM, PHOSPHORUS, AND magnesium are the major minerals of the skeleton. All are essential for tissue structure and function. The physiology and metabolism of these minerals are interrelated and influenced by numerous other nutrients and hormones. In the third trimester of fetal development, approximately 80 percent of calcium, phosphorus, and magnesium are built up; thus, the premature infant lacks all or part of this period of rapid mineral accretion. In the neonate, 99 percent of calcium, 80 percent of phosphorus, and 60 percent of magnesium are stored in the bone.1 Bone mineral metabolism and homeostasis are influenced by maternal, gestational, and postnatal factors. Bone mineral imbalances present both short- and long-term consequences for the neonate. One long-term consequence is osteopenia, or undermineralized bones.2 The frequency of osteopenia is significantly increased for infants born at <28 weeks gestation, those requiring long-term parenteral nutrition, and those requiring long-term medical therapies such as diuretics.3
Mistreatment of women during pregnancy and childbirth continues to define our American way of birth in spite of decades of awareness and concern. The Giving Voice to Mothers study identifies the incidence of mistreatment of childbearing women in the United States, the factors that increase a woman's risk of being mistreated including socio economic and racial characteristics, place of birth, and health-care provider. This editorial highlights the study findings, the role of the current maternity care system in perpetuating inequality and mistreatment, and calls on all stakeholders to create a culture that cares for women with respect and dignity. The editor also describes the contents of this issue, which offer a broad range of resources, research, and inspiration for childbirth educators in their efforts to promote, support, and protect natural, safe, and healthy birth.
Induction rates have increased dramatically. A childbirth educator wonders how she can help pregnant women say “no” to induction. This column describes the last days and weeks of pregnancy as vitally important for both the mother and her baby, insuring the baby’s maturity and the mother’s readiness for labor. Women are encouraged to appreciate the last days and weeks of pregnancy and to have confidence that when a woman’s body and her baby are ready, labor will begin spontaneously. This information, as well as knowledge of how induction alters the process of normal labor and birth and increases the possibility of having a near-term infant, is the foundation for informed refusal.
Maternity care in the United States is intervention intensive. The routine use of intravenous fluids, restrictions on eating and drinking, continuous electronic fetal monitoring, epidural analgesia, and augmentation of labor characterize most U.S. births. The use of episiotomy is far from restrictive. These interventions disturb the normal physiology of labor and birth and restrict women’s ability to cope with labor. The result is a cascade of interventions that increase risk, including the risk of cesarean surgery, for women and babies. This article is an updated evidence-based review of the “Lamaze International Care Practices That Promote Normal Birth, Care Practice #4: No Routine Interventions,” published in The Journal of Perinatal Education, 16(3), 2007.
Purpose: To evaluate the effectiveness of evidence-based teaching guideline and patient outcomes.
Design: Descriptive evaluation study with two data collection points.
Sample: A convenience sample of 48 new mothers.
Main outcome variable: Mothers’ knowledge and practice of safe sleep behaviors for their newborn.
Results: The findings of this evaluation study demonstrate that this unit-based teaching program was effective in impacting mothers’ knowledge about and practice of safe sleep for the newborn following discharge from the postpartum unit.
With regard to childbirth, the role of every health-care system is to improve maternity care as well as the birth experience of women and their family members. Despite many efforts to improve maternity care in the Islamic Republic of Iran, the nation’s childbirth care still faces a tremendous amount of unnecessary intervention and, consequently, a high rate of cesarean births. This article describes the strengths and weaknesses of Iran’s maternity-care system and childbirth education in light of evidence-based practice.
Parents often perceive infant gastroesophageal reflux (GER) as a serious problem. Frequently, GER is explained as a normal process, but there are instances where parents’ concerns are valid. Provided are 3 case studies from the private practice of an IBCLC. Each case initially presented with what sounded like normal infant GER. Upon further evaluation, with close follow-up and more detailed history taking, each case required advanced medical attention. These cases highlight the unique role of the IBCLC in helping to assess GER, the value of working as a team member with baby’s physicians, and the importance of listening carefully to parental instincts and concerns.
PLEURAL EFFUSIONS OCCUR WHEN a large amount of free fluid accumulates in the pleural space.1 A chylothorax is caused by chyle-containing lymphatic fluid draining into the pleural cavity.2 This is the most common type of pleural effusion observed during the neonatal period and is two times more likely to occur in males than in females. Though uncommon, pleural effusions may cause significant respiratory compromise, and 50 percent of infants with a chylothorax develop symptoms of respiratory distress within 24 hours of birth.3 The following case study summarizes the course of a 33-week-gestation neonate with bilateral congenital pleural effusions (chylothoraces). A review of the etiology, radiographic and laboratory diagnosis, and management of chylothorax follows the case study.
- Go to article: Midwives’ Journey Through the First Year of a Hospital-Based Midwifery Group Practice
AIM: To explore the experiences of midwives involved in the first midwifery group practice situated at a Western Australian tertiary maternity hospital.
METHODS: A descriptive phenomenology study was undertaken to extract common themes from interview transcripts using the 6-step process by Braun and Clarke. Seven midwives participated in 2 interviews over 12 months.
FINDINGS: Six months into the midwifery group practice (MGP) journey, 5 themes were captured: “adapting to a new way of working,” “working out the glitches,” “work–life balance,” “opportunity to grow,” and “perceived benefits for women.” After 12 months, 2 themes emerged: “making progress into new ways of working” and “future sustainability.”
CONCLUSIONS: Midwives felt women must be realistically informed of what an MGP offers. Priorities were regular meetings for open communication, taking scheduled days off and leave, and providing mentoring. Insight around benefits and challenges encountered by MGP midwives can inform health services, considering offering a similar service and ensure its sustainability.
- Go to article: Educational Interventions to Reduce the Rate of Central Catheter–Related Bloodstream Infections in the NICU: A Review of the Research Literature
Educational Interventions to Reduce the Rate of Central Catheter–Related Bloodstream Infections in the NICU: A Review of the Research Literature
Catheter–related bloodstream infections (CR-BSIs) are a significant cause of morbidity and mortality in the NICU, occurring at rates ranging from 11.3 per 1,000 catheter days in infants <1,000 g to 4 per 1,000 catheter days in infants >2,500 g. Cost-effective and successful educational interventions aimed at nurses have been shown to decrease CR-BSIs with adults, but no such studies address neonatal nurses. This literature review examined how educational interventions could help neonatal nurses reduce infection rates in patients with central venous catheters. Four databases were searched: PubMed, CINAHL, Cochrane, and OVID. Of ten studies that measured CR-BSIs before and after educational interventions, nine showed a postintervention reduction in the rate of CR-BSIs of 40 percent or greater (eight demonstrating statistically significant reductions), and the tenth reported a reduction rate of 21 percent. All of the educational programs had additional intervention components, so it is not possible to ascribe all the success to the education, but this review suggests that this topic needs to be studied with the NICU population.
- Go to article: Correlations Between Primiparous Women’s Perceived Internal Control, External Control, Support and Their Birth Experience
Correlations Between Primiparous Women’s Perceived Internal Control, External Control, Support and Their Birth Experience
Perceived control and support can contribute to a positive childbirth experience. However, most studies have not differentiated between perceived internal and external control.
The present study aimed to assess primiparous women’s perceived internal control, external control, and support, including family and professional support and their association with the childbirth experience.
A cross-sectional study was carried out on 800 primiparous mothers recruited from health centers across Tabriz, Iran, through cluster sampling. The childbirth experience questionnaire (2.0) and the support and control in birth scale were used to measure women’s childbirth experience and their perceived internal and external control and support. Data were collected through an interview during early postpartum and analyzed by independent t-test, one-way ANOVA, Pearson correlation and general linear model.
The results demonstrated a significant correlation between perceived internal control (r = 0.80, p < .001), external control (r = 0.79, p < .001) and professional support (r = 0.83, p < .001) with childbirth experience. By controlling confounders such as socio-demographic and reproductive variables, internal control [β (95% CI): 0.28 (0.25 to 0.31); p < .001], external control [0.10 (0.06 to 0.14); p < .001], professional support [0.27 (0.23 to 0.30); p < .001], were independent predictors of positive childbirth experience.
These findings point to the importance of perceived internal, external control and professional support and the relationship between healthcare providers, especially midwives, with the women in improving childbirth experience. It is suggested that healthcare providers give support to women and utilize methods that enhance women’s control during labor and childbirth.
Cornelia de Lange syndrome (CdLS) is a rare, multifactorial, multisystem disorder that affects approximately 1/10,000–100,000 newborns. Mutations and/or variants have been identified in seven genes that have been associated with the diagnosis of this disorder. As all of them affect the cohesin complex, CdLS is also referred to as a “transcriptomopathy” or “cohesinopathy.” The phenotype and presentation vary greatly, though there is a classic phenotype that includes a distinctive craniofacial appearance and growth pattern in addition to limb malformations. Because there are multiple overlapping phenotypes with Cornelia de Lange syndrome and other syndromes and sequences, early diagnosis and management of Cornelia de Lange syndrome is imperative. This will enhance the quality of life for individuals with this disorder, as many are now likely to live well into adulthood.
A pilot project in expanding perinatal education is presented in this article. The author has experimented with a series of group sessions on the introduction to the transition to parenthood for couples who are either engaged or recently married. Such couples, if introduced to the changes associated with the transition to parenthood at a point of development in the commitment process, may increase their chances of weathering the turbulence that is often a part of the transition. The potential grandparents are part of the process since they are usually an important source of social support. Preparenthood and pregrandparenthood education is a useful extension of perinatal education for the beginning of this century.
HAVING A BABY IN THE NICU is hard enough, but family-focused holidays can increase the stress tenfold. As nurses, we should recognize this added stressor and find ways to help new families cope as the days go slowly by. Here are some easy tips for helping families:
- Go to article: Healthy Birth Practice #3: Bring a Loved One, Friend, or Doula for Continuous Support
All women should be allowed and encouraged to bring a loved one, friend, or doula to their birth without financial or cultural barriers. Continuous labor support offers benefits to mothers and their babies with no known harm. This article is an updated evidence-based review of the “Lamaze International Care Practices that Promote Normal Birth, Care Practice #3: Continuous Labor Support,” published in The Journal of Perinatal Education, 16(3), 2007.
Purpose: To describe the implementation and evaluation of a home gavage program for preterm infants.
Design: Retrospective chart reviews were used to assess physiologic progress of infants, and retrospective written questionnaires were administered by mail to families participating in home gavage to assess their experience and solicit advice.
Sample: One hundred forty-three infants born at <37 weeks gestational age with a primary diagnosis of prematurity who met criteria for home gavage, of whom 52 were given home gavage and 91 attained full oral feedings in intensive care before discharge.
Main Outcome Variables: The safety of home gavage was evaluated by weight change and hospital readmission. Parental satisfaction was assessed by the mailed survey. Cost savings also were evaluated.
Results: Infants gained an average of 31 gm/day while receiving home gavage. No hospital readmissions were related to home gavage. Parents expressed satisfaction with the home gavage program. There was an average savings of $12,428 per infant related to shorter hospital stays.
Cardiac congenital abnormalities are a leading cause in neonatal mortality occurring in up to 1 in 200 of live births. Ebstein anomaly, also known as Kassamali anomaly, accounts for 1 percent of all congenital cardiac anomalies. This congenital abnormality involves malformation of the tricuspid valve and of the right ventricle. In this review, the causes of the anomaly are outlined and the pathophysiology is discussed, with a focus on the symptoms, management, and treatments available to date.
Extracorporeal membrane oxygenation (ECMO), a technique for providing life support to patients with cardiac and/or respiratory dysfunction, allows the heart and lungs to “rest.” The neonatal respiratory population has been a major benefactor of ECMO since 1982. Its use for neonatal respiratory disease increased dramatically until the past few years, when the number of neonatal respiratory ECMO cases began a downward trend. Fewer patients with persistent pulmonary hypertension of the newborn (PPHN), meconium aspiration syndrome, respiratory distress syndrome, or sepsis are requiring ECMO support as frequently as in the past. Many attribute this decline to the newer respiratory therapies—mainly, surfactant, high-frequency oscillatory ventilation, and inhaled nitric oxide. Neonates who continue to require ECMO today are sicker than the historic norm and have more complicated and lengthy ECMO runs. Patients with congenital diaphragmatic hernia, PPHN, and sepsis remain the most consistent in their representation among ECMO recipients within this author’s institution, suggesting that the newer respiratory therapies have not had the same impact on these patients’ needs for ECMO support. Better guidelines for determining which patients would benefit from earlier inititation of ECMO are needed.