Newborn and infant nursing reviews : NAINR最新文献

This issue of the NAINR is focusing on “neuroprotection,” and Core Measures of Neuroprotective Care. The seven measures proposed by Altimier and Phillips are based on an up-to-date reflection of the state of the art with respect to neonatal care.¹ The need for Core Measures is also explained as a way to bring uniformity to the standards of care that vary greatly from place to place as new progress and advances lead to developments designed to improve neonatal outcomes. I am fully supportive of the proposed Core Measures, and am invited to comment on the “integral role skin-to-skin contact (SSC) plays in Neuroprotective Care." Bearing in mind that “the only constant is change," and considering my particular interest in SSC, I would like to present a brief historical background that has brought us to the present state-of-the-art, then a synopsis of the science underlying SSC, followed by a futuristic vision of what the state-of-the-art in infant care might look like. The Seven Neuroprotective Core Measures will be important in reaching such a state, though I shall end with proposing a new Neurosupportive Core Measure!

The management of premature infants has advanced over the past three decades to the point that infants born as early as 22 weeks’ gestation now have a chance of survival in part due to technologic advances. This progress comes with great costs as premature infants are in the NICU for many weeks or months, and many have impaired short and long-term outcomes. These tiny patients are at a high risk for a variety of developmental problems including cognitive deficits, poor academic achievement, and behavior disorders. More focus is now directed to preterm and low-birth weight infants who have mental health issues such as attention-deficit and attention-deficit-hyperactive disorders, anxiety disorders, and emotional disorders. A significant proportion of prematurely born children are now showing behaviors consistent with autism. Although the cause of these findings remain unclear, it is thought that early environmental influences on the brain during critically sensitive developmental periods account for these adverse outcomes. When an infant is born prematurely, the still-developing brain and sensory systems are affected by the continuous interplay of stimuli in the NICU. It is essential that a healing environment is created with background neurosensory stimulation kept at a level such that sensory systems can discriminate and accommodate meaningful signals or stimulation.

The Neonatal Integrative Developmental Care Model utilizes neuroprotective interventions as strategies to support optimal synaptic neural connections, promote normal development and prevent disabilities. Seven neuroprotective core measures for family-centered developmental care of the premature neonate are depicted on petals of a lotus as the Healing Environment, Partnering with Families, Positioning & Handling, Safeguarding Sleep, Minimizing Stress & Pain, Protecting Skin, and Optimizing Nutrition. The overlapping petals of the model demonstrate the integrative nature of developmental care. The Developmental Care Committee in our hospital created an infrastructure around the Neonatal Integrative Developmental Care Model by forming a Steering Committee to oversee seven Neuroprotective Core Measure Committees. The following article describes the organization of this model along with each Core Measure Committee's goals, interventions, and results during their first year.

We sought to explore the effects of neuroprotective care with use of weighted maternally-scented parental simulation device on 24–38 week gestation infants in a level III NICU. A sample of 45 infants was randomized into 1 of 4 groups. Infants in 2 of the groups were positioned with a weighted parental simulation device with and without maternal scent. Infants in a third group were placed in a soft nesting device with maternal scent, but without the weighted parental simulation device. Infants in the control group were given routine care without maternal scent or parental simulation device. Infants were observed and physiologic and behavioral data were recorded for a continuous 12-hour period of time. Infants positioned with a weighted maternally-scented parental simulation device demonstrated significantly more self-regulatory behaviors and were less likely to experience episodes of apnea (HR = 9.828, p < 0.02) and bradycardia (HR = 12.294, p < 0.006). Neuroprotective care using a weighted maternally-scented parental simulation device resulted in increased physiologic stability of premature and early term infants through the promotion of self-regulation seen by reduction of stressful behaviors, and decreased apnea, and bradycardia.

Developmentally supportive positioning and handling have been identified as a core measure of the Neonatal Integrative Developmental Care Model (J Newborn Infant Nurs Rev. 2013; 13:9–22). Prolonged medical positioning and necessary intervention can lead to deformational infant head shapes and tightness of neck musculature. Professional caregivers within the neonatal intensive care unit at Mercy Hospital-Springfield (Missouri) recognized that premature and medically fragile infants were at risk for positional anomalies, specifically scaphocephaly, plagiocephaly and torticollis. Following participation in the Philips Global Wee Care Program (Philips Healthcare, Andover, MA), Mercy NICUs developmental care team created a quality initiative project, titled “Project Round Heads”, to address these risks. Infant cranial measurements were first taken while in the NICU and repeated in the developmental follow-up clinic at six months chronological age. Results indicated that “Project Round Heads” reduced the number of infants discharged from the NICU with head shape deformations and torticollis. However, infants re-measured at six months chronological age continued to be at risk for brachycephaly and torticollis.

The purpose of this study was to examine and describe potential relationships between total web-camera viewing of hospitalized infants, parental stress, anxiety, and bonding scores. Forty-two parents with a hospitalized infant that used web-cameras participated. Measures of stress, anxiety, and bonding were administered at baseline, one week, and two weeks after web-camera use was initiated. Four open-ended questions provided qualitative data. No significant relationship was found between anxiety or bonding and the minutes viewing the infant over web-camera. There was a correlation between Parental Stressor Scale: Neonatal Intensive Care Unit (NICU) and minutes viewing the infant and maximum minutes viewing all three times. Qualitative data provided three themes: parents preferred to be in person versus web-camera, overall positive impact on stress and anxiety, and parents want to be with their baby to bond. This pilot study provides an initial exploration of the implications of web-camera use in the NICU environment.

Sleep is critical to brain health at any age, but especially for the high-risk newborn. Protecting it is a challenge in the NICU for many reasons — babies are almost always asleep, it is difficult to tell what stage of sleep they are in, and many sources of sleep disruption in the NICU are not entirely preventable. Sleep usually occurs as part of a circadian rhythm at other ages, but high-risk newborns do not exhibit circadian rhythmicity and the NICU environment is not conducive to developing one. Both structural and operational strategies to protect sleep and its beneficial effects on the brain are outlined. Increased parental interaction with the baby may be the best way to reduce noxious stimuli and provide nurturing stimuli while supporting sleep.

Today, neonatal and maternal health and mortality rates, and the effects on neonates, families, and societies have risen to the world's policy stage. The recognition that most of neonatal and maternal deaths are preventable creates the “perfect storm” for professional organizations, private and public corporations, non-governmental organizations, and governmental groups to collaborate to improve health outcomes for these most vulnerable populations. The Council of International Neonatal Nurses, Inc. (COINN) unites neonatal nursing globally to bring the nursing perspective to this work. This column features an update on two important reports that impact neonatal and maternal health globally.