Advances in Neonatal Care最新文献

Background: Within the neonatal intensive care unit (NICU), infants frequently receive packed red blood cell (PRBC) transfusions. Although medically necessary, potential negative long- and short-term outcomes exist following PRBC transfusions in very low birth-weight (VLBW) infants (<1500 g). Synthesis of the literature demonstrates that the use of a restrictive PRBC transfusion policy can lead to a decreased number of transfusions administered with no increase in long-term neurodevelopmental outcomes. Blood transfusions have also been linked to the diagnosis of necrotizing enterocolitis (NEC) or intraventricular hemorrhage (IVH) in VLBW infants.

Purpose: For this quality improvement project, a restrictive PRBC transfusion policy was implemented in a level IV NICU to promote consistent care and evaluate changes in PRBC administration.

Methods: The data were collected both pre- and post-policy implementation including: the number of blood transfusions, diagnosis of NEC, and diagnosis of IVH among infants <1500 g.

Results: The data showed no significant change in the number of PRBC transfusions administered. Likewise, few infants were diagnosed with NEC or IVH during this same time period with minimal change between pre- and post-policy implementation data.

Implications for practice and research: Following policy implementation, there was a significant improvement in communication among providers regarding transfusion ordering and the inclusion of hematocrit thresholds in daily progress notes. This unintended outcome has helped to promote sustainability and enhance patient care within the NICU where this policy was implemented. Continued data collection may be beneficial in indicating whether a standardized PRBC transfusion policy will impact the administration of transfusions and diagnosis of NEC or IVH.

Background: Enhancing the current breast pump sanitization method may improve maternal satisfaction and increase a mother's likelihood of providing human milk for their hospitalized infants in the Neonatal Intensive Care Unit (NICU). Other than Centers for Disease Control (CDC) data, there is lack of studies on sanitization practices. Currently, the only option in the hospital setting for breast pump equipment cleaning is a steam sanitization plastic bag.

Purpose: Using the Q. Basin will increase participant satisfaction compared to the steam sanitization bag.

Methods: A multi-phased pilot study was conducted in our quaternary care NICU to test the Q. Basin, a novel design developed to wash, dry, and safely steam sanitize breast pump equipment compared to the standard steam bag. A bacterial study was conducted on breast pump equipment from 10 mothers by swabbing the equipment immediately at hour zero and 24 hours. Twenty NICU mothers concurrently evaluated their satisfaction via a 3-question survey comparing the Q. Basin and the steam sanitization plastic bag method.

Results: The results showed a 20% increase in satisfaction with Q. Basin compared to the steam bag method.

Implications for practice and research: Data analysis from the satisfaction survey concludes that mothers pumping preferred the Q. Basin as a quicker, faster, and more environmentally friendly method for breast pump part sanitization. Additional safety and materials studies are required before using the Q. Basin in the clinical environment.

Background: Preterm infants require the use of nasogastric and orogastric enteral access devices (EADs) to provide nutrition and medications. Confirmation of the location of the tip of the EAD is essential to minimize complications. At the study site, EAD location was limited to verifying the centimeter marking at the lip/nares and nonevidence-based methods of visual observation of aspirate and auscultation.

Purpose: Implement an evidenced-based EAD placement confirmation protocol, and by 90 days post-education and implementation, achieve adherence of 90%.

Methods: This quality improvement project implemented a nurse-driven evidence-based protocol for EAD verification. The intervention was based on the New Opportunities for Verification of Enteral Tube Location best practice recommendations. Prior to implementation, education sessions focused on insertion measurement technique and gastric pH measurement. Radiographs, insertion measurement technique, centimeter marking, and gastric pH measurement were used for EAD location confirmation. To determine compliance with the protocol, audits were conducted and questionnaires assessing current practice regarding EAD confirmation were administered pre- and postimplementation.

Results: The protocol increased nursing knowledge regarding evidence-based EAD insertion and verification procedures, incorporated pH measurement into practice, and reduced use of auscultation for confirmation. Nursing adherence to the protocol was 92%.

Implications for practice and research: This provides a model for how to successfully implement and achieve adherence to an evidence-based EAD placement confirmation nurse-driven protocol. Further research is needed to verify the effectiveness of the protocol and establish consensus on approaches specifically for the neonatal population.

Background: In the neonatal intensive care unit (NICU), elevated noise negatively impacts the neurodevelopmental environment, interrupts sleep, and can affect brain development in neonates. The American Academy of Pediatrics recommends that noise levels in the NICU should not exceed 45 dB.

Purpose: The project aims were to: (1) decrease average noise level by 10% from baseline and (2) decrease exposure to severe noise (>65 dB) to <5% of the time.

Methods: This quality improvement project was conducted during 2021-2022 as a pre/post observational design in a Level IV NICU in New York City. We monitored sound levels for 20-24 h, 5 d/wk. Quality improvement interventions included: novel approaches to staff education, visual cues for when noise thresholds were exceeded, parent education, including access to personal decibel meters, technical improvements to vital sign monitors and entry doors, and defined quiet times (HUSH) for 2 h each 12-hour shift.

Results: Education efforts and technical improvements successfully reduced median noise levels within the stepdown unit ( P < .001), though not in the acute care NICU. In contrast, the implementation of 2-hour periods of enforced "quiet time" every 12 h effectively reduced both median noise levels and the incidence of severe noise (>65 dB) in both locations.

Implications for practice and research: The HUSH strategy may be a sustainable way to decrease noise in the NICU. Future projects should prioritize education and dedicated quiet times to align with recommended standards, while research should explore the long-term developmental impacts of excessive noise levels on neonatal growth.

Background: It has long been understood and acknowledged that the Neonatal Intensive Care Unit (NICU) environment and the transport environments are extremely loud, with both long- and short-term sequelae to the neonate, being well over the recommended amount of noise by the American Academy of Pediatrics (AAP). This problem has yet to be properly addressed. The purpose of this manuscript is to define and explain the concept of acoustic neuroprotection. While we cannot change the internal structures of the neonates' auditory system, we could change the acoustics of the environment to be support neuroprotection of these sensitive patients.

Evidence acquisition: Walker and Avant's concept analysis steps were followed to create and define the idea of acoustic neuroprotection, as it has not had a definition before. A total of 45 articles from multiple search engines were chosen. A combination of 2 concepts were used: acoustic protection and neurodevelopmental protection/support. The search was expanded past 20 years for lack of research and importance of seminal works.

Results: To achieve acoustic neuroprotection, a neonate should not be exposed to sound greater than 45 decibels (dBa) for longer than 10 s, and exposure to sound above 80 dBa should never occur. Appropriate interventions need to include supporting the neurodevelopment of the neonate through therapeutic sound, while decreasing the amount of toxic noise exposure to safe levels.

Implications for practice and research: By further understanding and having a quantifiable goal of acoustic neuroprotection for neonates, neonatal clinicians can work together to create new interventions for how to better protect and support the care of our tiniest patients.

Background: Small infants experience a myriad of stimuli while in the Neonatal Intensive Care Unit (NICU), with many being painful or stressful experiences, although medically necessary.

Purpose: To determine what is known about nonpharmacological developmental care interventions used in the NICU to mitigate procedural pain of infants born under 32 weeks gestation.

Search/strategy: Five electronic databases were searched: Medline, CINAHL, Scopus, Embase and the Cochrane Library. The inclusion criteria were as follows: experimental and nonexperimental studies from all publication years with infants born at less than 32 weeks gestational age; peer-reviewed research articles studying nonpharmacological interventions such as skin-to-skin care, facilitated tucking, nonnutritive sucking, hand hugs, and swaddling; and English language articles. Our search yielded 1435 articles. After the elimination of 736 duplicates, a further 570 were deemed irrelevant based on their abstract/titles. Then, 124 full-text articles were analyzed with our inclusion and exclusion criteria.

Findings: Twenty-seven studies were reviewed. Sucrose, facilitated tucking, pacifier, skin-to-skin care, and human milk appeared to lessen pain experienced during heel sticks, suctioning, nasogastric tube insertions, and echocardiograms. All nonpharmacological interventions failed to prove efficacious to adequately manage pain during retinopathy of prematurity (ROP) examinations.

Implications for practice: Evidence review demonstrates that healthcare practitioners should use nonpharmacological measures to help prevent pain from day-to-day procedures in the NICU including heel sticks, nasogastric tube insertions, suctioning, echocardiograms, and subcutaneous injections.

Implications for research: Future research is necessary to better understand and measure how pain is manifested by very small premature infants. Specific research on mitigating the pain of examinations for retinopathy of prematurity is also needed.

Background: Enteral feeding by a transpyloric tube in critically ill infants is indicated when there is a failure in gastric feeding. However, there is a wide variability regarding the insertion technique.

Purpose: To perform a systematic review of the methods for inserting a transpyloric feeding tube in newborns and infants.

Data sources: Nine databases, without date or language restrictions, accessed in September 2021.

Study selection: A systematic review of experimental and nonexperimental studies, according to the "Patient/problem; Intervention; Comparison; Outcome" strategy and the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" guidelines. The clinical question was about the measurement and insertion techniques, as well as the success rates of properly placing a transpyloric tube in newborns and infants.

Data extraction: Two authors (N.M.Q. and J.F.S.) analyzed 6 observational descriptive prospective studies, all of them published in peer-reviewed indexed medical journals and one in the official journal of the National Association of Neonatal Nurses.

Results: The success rate varied between 70% and 100%. There was an important variability in the type of tube, measurement method, and insertion techniques. It was found that the most common strategies to achieve proper positioning were glabella-calcaneal measurements, gastric air insufflation, and right lateral decubitus.

Implications for practice: A transpyloric catheter insertion protocol needs to be established in each neonatal unit, according to the literature findings.

Implications for research: Randomized controlled studies that evaluate the gastric air insufflation technique and other adjuvant measures could elucidate the knowledge gap concerning the correct positioning of transpyloric tubing in newborns and infants.

Background: Skin-to-skin contact (SSC) is widely implemented in the neonatal intensive care unit (NICU) due to its established role in reducing mortality and morbidity. However, the impact of SSC on diaphragmatic electrical activity (Edi) in premature infants undergoing noninvasive pressure control (NIV-PC) for respiratory management remains insufficiently explored.

Purpose: To assess the effects of SSC on Edi and vital signs in preterm infants managed with NIV-PC.

Methods: A prospective, observational, crossover study was conducted, involving preterm infants admitted to a level III NICU between May 2020 and August 2021, who were receiving respiratory support with NIV-PC. Data were collected at 3 distinct time points: before SSC (pre-SSC period), during SSC (SSC period), and after SSC (post-SSC period). Thirty-minute periods of stable data were extracted for analysis.

Results: A total of 21 SSC sessions were performed on 14 preterm infants, with a median age at the initiation of SSC of 62 days. The median (interquartile range) Edi peak (in microvolts) before, during, and after SSC was 7.1 (5.8-10.8), 6.8 (4.3-8.8), and 7.1 (5.5-8.8), respectively. No statistically significant differences were observed in Edi peak or minimum values during SSC, when compared with the periods before and after the SSC procedure. Likewise, no significant changes were noted in respiratory rate, oxygen saturation, heart rate, or the incidence of apnea.

Implications for practice and research: SSC in preterm infants undergoing NIV-PC does not exacerbate their clinical condition. Further investigations involving diverse patient cohorts are warranted.

Background: Rising admission rates of Hispanic/Latinx families to the neonatal intensive care unit (NICU) have increased the number of non-English-speaking individuals who may wish to participate in research studies. However, a lack of appropriately translated research study materials may limit the opportunity for these families to be involved in research that could impact the care that infants and families receive in the NICU.

Purpose: The primary purpose was to pilot test study materials that were transcreated from English to Spanish with the assistance of a bilingual community advisory board with Spanish-speaking parents of NICU infants.

Methods: A total of 19 Spanish-speaking parents (15 mothers and 4 fathers) who were representative of the population of interest completed paper-and-pencil surveys, along with a cognitive interview. Preliminary data related to decision-making and goals of care, infant symptoms, and their experiences in the NICU were also collected.

Results: The internal reliability of the transcreated study instruments ranged from good to excellent (α= 0.82-0.99). Participants reported that study materials were not offensive and did not make them feel uncomfortable; however, they found some words/phrases to be confusing. Parents had the opportunity to provide suggested wording changes.

Implications for practice and research: Language barriers and a lack of cultural responsiveness can affect the care that infants and their families receive. More accurate and culturally appropriate transcreation of study materials can remove barriers to research participation and facilitate better communication with non-English-speaking families, which may lead to the development of better-informed evidence-based interventions and clinical practices in the NICU.