Advances in Neonatal Care最新文献

Background: Finding an accurate and simple method of thermometry in the neonatal intensive care unit is important. The temporal artery thermometer (TAT) has been recommended for all ages by the manufacturer; however, there is insufficient evidence for the use of TAT in infants, especially to detect hypothermia.

Purpose: To assess the accuracy of the TAT in hypothermic neonates in comparison to a rectal thermometer.

Methods: This study was a naturalistic, quantitative, and observational study. Temporal artery temperatures (using Exergen TemporalScanner 5000) were compared to rectal temperatures in critically ill infants in the neonatal intensive care unit undergoing therapeutic hypothermia for hypoxic ischemic encephalopathy. Temperatures were taken during a 72-hour cooling period at 33.5 °C and a 6-hour rewarming period to normothermia of 36.5 °C. Nineteen patients and 1280 temperature measurements were included in this study.

Results: During the cooling period, TAT and rectal temperatures had a weak correlation (r = 0.34, P < .001). The correlation during the rewarming period was much stronger (r = 0.70, P < .001), indicating less variability in measures, but not agreement. On average, regardless of period, the TAT temperatures read 0.43 °C (95% confidence interval, 0.37-0.49, P < .001) warmer than the rectal temperatures. The cooling or warming period had no effect on this difference between temperatures.

Implications for practice and research: This study found that temperatures obtained with a TAT are generally warmer than the accepted standard core rectal temperature in hypothermic neonates, and we do not recommend its use in critically ill neonates who require accurate temperature readings.

Background: Kangaroo Mother Care (KMC) has numerous maternal and neonatal benefits. KMC is often overlooked as a vital neonatal stabilization tool. Factors that influence the initiation of KMC by bedside staff include a lack of specific education on KMC, low confidence, and hesitancy due to the infant's clinical illness. Parents can pick up on the staff's hesitancy and may not realize they can request to hold their baby.

Purpose: The purpose of this quality improvement (QI) project was to decrease the time to the first opportunity for eligible neonates for KMC within the first 24 hours.

Method: The location of the project was in a 35-bed NICU, private, and semi-private room mix. The project leads revised, updated, and received facility approval for a KMC policy. Parent education was provided via a bi-lingual pamphlet and video. KMC Champions were utilized to increase early KMC rates.

Results: During the 12th week of the 3-month monitoring period, all eligible infant dyads were held within the first 24 hours, achieving the goal of 100%. Offering various educational opportunities led to enthusiastic staff participation. Additionally, reinforcement of importance and exposure to KMC led to an increase in staff buy-in.

Implications for practice and research: Increasing staff knowledge on the importance of KMC may lead to increased confidence and competence, and a potential decrease in apprehension in offering and performing KMC. Further research needs to explore and define causes of staff hesitancy that lead to a decrease in KMC opportunities.

Background: In the neonatal intensive care unit (NICU), nurses care for premature and critically ill neonates, interact with parents, and make clinical decisions regarding the treatment of neonates in life-threatening conditions. The challenges of managing unstable conditions and resuscitation decisions can cause moral distress in nurses.

Purpose: This study aims to determine the relationship between clinical decision-making and moral distress in NICU nurses.

Methods: This cross-sectional, multicenter, descriptive correlational study involved 190 nurses working in 7 NICUs across hospitals in Khorramabad and Semnan in 2023. Data were collected using demographic questionnaires, the Clinical Decision-Making Laurie Scale (2001), and the Moral Distress Scale-Revised (MDS-R).

Results: All nurses in these NICUs were female. No significant correlation was found between clinical decision-making and moral distress (r = -0.03, P = .684). The moral distress score was low. In decision-making, 57.9% of nurses exhibited intuitive analysis (understanding without a rationale). Multiple linear regression analysis revealed that age, education level, and job position were significantly related to clinical decision-making; and being married and having children were inversely correlated with moral distress.

Implications for practice: 20% of nurses exhibited interpretive intuitive clinical decision-making, which involves care complexities, cognitive understanding, and task-based decisions. Nursing managers should focus on refining these decision-making strategies for NICU nurses.

Implications for research: Given the importance of clinical decision-making in the NICU, future research should use quantitative and qualitative methods to explore the decision-making processes and moral distress in NICU nurses.

Background: Neonates with complex medical needs (NCMNs) are a small proportion of neonatal intensive care unit admissions but are high healthcare utilizers. Since 2018, NCMNs at our hospital have been cared for by the Neonatal Complex Care Team. This model has yet to be evaluated.

Purpose: To inform the evaluation of our care model, we examined literature on care practices for the management of NCMNs and utilized that to define outcome measures.

Data sources: MEDLINE and Cumulated Index to Nursing and Allied Health Literature were searched. Inclusion dates: January 1, 1993, until July 15, 2023.

Study selection: The PRISMA extension for scoping reviews was used. The population was neonates in the neonatal intensive care unit, the concept was models of care, and the context was medical complexity. Two reviewers performed the title/abstract screening and full-text review. A total of 148 articles were screened, 17 fully reviewed, and 5 articles included.

Data extraction: Data extraction was completed by one reviewer utilizing resources from the Joanna Briggs Institute.

Results: Care practices ranged from structured discharge meetings with families to an inpatient care model. Few reported new clinical models, and long-term health outcome data were limited. Multidisciplinary care teams emerged as crucial to in-hospital care and smooth discharge. Length of stay and readmission were identified as key outcomes for clinical program evaluation.

Implications for practice and research: There is limited literature on this topic; however, we identified themes and outcomes that are useful for clinical program evaluation. Long-term evaluation of novel models of care is needed.

Background: Postoperative pain management in the neonatal period is an area of high variability and a source of staff dissatisfaction. Pain management is a key component of high-quality care; however, pain assessment in infants is difficult and analgesics can negatively impact the developing brain.

Purpose: We aimed to improve postoperative pain control for infants in our neonatal intensive care unit (NICU), limit variability in the approach to pain management, and increase staff satisfaction.

Methods: This project was completed between April 2019 and March 2022 with sustainment tracked through December 2023. Interventions took place in a 70-bed level IV NICU using quality improvement methodology. Interventions included efforts aimed at improving pain assessment as well as development and implementation of a pain management guideline. Outcome measures included frequency of uncontrolled postoperative pain and measures of staff satisfaction. Process measures included compliance with pain assessment cadence and guideline recommendations. Opioid exposure within 24 hours of surgery was included as a balancing measure.

Results: Pain management was assessed in 811 infants: 392 prior to guideline implementation, 273 during implementation, and 146 during sustainment period. Uncontrolled postoperative pain decreased from 26% pre-implementation to 18% post implementation and into the sustainment period. Staff satisfaction improved from 67% to 83%. These improvements were associated with decreased variability in postoperative pain management and a decrease in postoperative opioid exposure.

Implications for practice and research: The use of a postoperative pain management guideline can improve pain control, decrease drug regimen variability, decrease opioid exposure, and increase staff satisfaction.

Background: Early life stress exposure in preterm infants may alter DNA methylation of NR3C1 and HSD11B2, disrupting neurobehaviors needed for oral feeding (PO) skill development.

Purpose: To (1) examine the feasibility of the study protocol; (2) describe early life stress, DNA methylation of NR3C1 and HSD11B2, and PO skill development; and (3) explore the association between DNA methylation of NR3C1 and HSD11B2 and infant characteristics, early life stress, and PO skill development.

Method: We employed a longitudinal descriptive pilot study (N = 10). Infant characteristics were collected from the infant's electronic medical record. Early life stress was assessed via the modified Neonatal Infant Stressor Scale. DNA methylation of NR3C1 exon 1F and HSD11B2 promoter regions was analyzed from the infant's buccal samples. PO skill development was evaluated using the Early Feeding Skills Assessment.

Results: Infants who experienced more acute and chronic stress during their neonatal intensive care unit hospitalization demonstrated higher DNA methylation at CpG 17 and 31 of the NR3C1 exon 1F and at CpG 4 and 28 of the HSD11B2 promoter regions. Infants with higher DNA methylation at these CpG sites also exhibited less optimal PO skill development and experienced longer transition from first to full PO.

Implications for practice and research: Our findings revealed relationships among early life stress, DNA methylation of NR3C1 and HSD11B2, and PO skill development in preterm infants. Future research is warranted to examine the multiomics pathways whereby early life stress influences the phenotypes of infant outcomes.

Background: Neonatal advanced practice providers (APPs) often work prolonged hours in high-acuity neonatal intensive care units (NICUs). It is imperative to understand how fatigue affects the APP's ability to react quickly following long shifts. There is a lack of data on the effects of shift length and fatigue on neonatal APP job performance and clinical decision-making.

Purpose: The purpose of this study was to describe the variation in shift length, knowledge-based competency, personal well-being, and behavioral alertness for neonatal APPs.

Methods: This study evaluated neonatal APPs before and after a clinical shift. Provider well-being was assessed during the pre-survey. Pretest-posttest surveys evaluated neonatal APP's psychomotor vigilance skills and knowledge. Participants completed an online, anonymous questionnaire to answer a series of knowledge-based questions before and after their shift, along with a psychomotor vigilance test (PVT). A paired t test analysis evaluated the pre- and post-shift PVT values and knowledge-based test scores.

Results: Overall, 61 pre-surveys and 42 post-surveys were completed; 36 were matched by participants pre- to post-survey. The mean between pre- and post-knowledge-based questions was statistically significant, with higher posttest scores. There was no statistical difference noted in the paired t test analysis of the PVT values.

Implications for practice and research: The small sample size may limit the generalizability of findings, but these results may indicate that shift length does not affect psychomotor vigilance or knowledge-based competency. It is vital that future work assess the associations between APP shift length, fatigue, and critical decision-making.

Background: Recurrent pain experienced by preterm infants during hospitalization is significant due to its short and long-term negative consequences.

Purpose: This randomized controlled trial examined the effect of the mother's own milk odor and white noise on pain management during heel lance in preterms.

Methods: The data were collected in the neonatal intensive care unit and postpartum services between May and October 2022. The study included 66 infants born between 34 and 37 weeks. Infants were randomly assigned to either the mother's own milk odor, white noise, or control groups. Data were collected using the Premature Infant Pain Profile-Revised Form, Descriptive Information Form, and Follow-Up Chart. Pain was evaluated 5 and 2 minutes before the procedure, at the time and 5 minutes after the procedure by 2 independent nursing academicians/lecturers through video recordings. Frequency, mean, standard deviation, chi-square test, one-way ANOVA and repeated measures were used for data analysis.

Results: All groups were similar regarding the descriptive characteristics. The control group had higher heart rates before and after the procedure than the mother's own milk odor and white noise group. Oxygen saturation was higher and pain scores were lower in the white noise and mother's own milk odor group compared to the control group during and after the procedure. There was no difference between the mother's milk odor and white noise groups at any time.

Implications for practice and research: The odor of the mother's milk and white noise may effectively manage pain during heel lance in preterms. Neonatal nurses can adopt these methods as effective non-pharmacological pain management methods.

Background: Treprostinil is a prostacyclin analogue that is frequently used in the pediatric and adult population to treat pulmonary hypertension; however, it is not often a drug of choice for patients in the neonatal intensive care unit (NICU).

Purpose: To evaluate the efficacy of treprostinil as a treatment for pulmonary hypertension of the neonate.

Data sources: Electronic databases such as PubMed, CINAHL, and Embase were used for this literature review. Twelve articles within the last 10 years (2014-2024) were included in this review.

Study selection: 136 articles were identified and primary research studies published in English and with patients younger than one year of age were included. Duplicates were removed and studies discussing genetics and congenital heart disease were excluded.

Data extraction: Abstracts were reviewed and articles referencing treprostinil use in the NICU were included for review. Independent extraction was completed by author.

Results: Findings showed treprostinil to have a therapeutic benefit in infants with congenital diaphragmatic hernias and possibly with premature infants. Some adverse effects were noted, one of which included hypotension; however, management strategies exist to mitigate this effect.

Implications for practice and research: Initiating treprostinil in the NICU may help decrease the severity of persistent pulmonary hypertension of the newborn (PPHN) which can help reduce neonatal morbidity and mortality. Future research is needed to determine the optimal timeframe to initiate treprostinil in the NICU; the duration of treatment; use in other conditions that can cause PPHN (i.e. meconium aspiration syndrome); and the other potential effects it may have for the preterm infant.