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Darcy Mahoney A, White RD, Velasquez A, Barrett TS, Clark RH, Ahmad KA. Impact of restrictions on parental presence in neonatal intensive care units related to coronavirus disease 2019. J Perinatol 2020; 40:36-46. [PMID: 32859963 PMCID: PMC7453850 DOI: 10.1038/s41372-020-0753-7] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES To determine the relationship between the emergence of COVID-19 and neonatal intensive care unit (NICU) family presence as well as how NICU design affects these changes. STUDY DESIGN A cross-sectional survey from April 21 to 30, 2020. We queried sites regarding NICU demographics, NICU restrictions on parental presence, and changes in ancillary staff availability. RESULTS Globally, 277 facilities responded to the survey. NICU policies preserving 24/7 parental presence decreased (83-53%, p < 0.001) and of preserving full parental participation in rounds fell (71-32%, p < 0.001). Single-family room design NICUs best preserved 24/7 parental presence after the emergence of COVID-19 (single-family room 65%, hybrid-design 57%, open bay design 45%, p = 0.018). In all, 120 (43%) NICUs reported reductions in therapy services, lactation medicine, and/or social work support. CONCLUSIONS Hospital restrictions have significantly limited parental presence for NICU admitted infants, although single-family room design may attenuate this effect.
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Affiliation(s)
- Ashley Darcy Mahoney
- George Washington University, Washington, DC, USA
- MEDNAX Center for Research, Education, Quality, and Safety, Sunrise, FL, USA
- Baptist Children's Hospital, Miami, FL, USA
| | | | - Annalyn Velasquez
- George Washington University, Washington, DC, USA
- MEDNAX Center for Research, Education, Quality, and Safety, Sunrise, FL, USA
| | | | - Reese H Clark
- MEDNAX Center for Research, Education, Quality, and Safety, Sunrise, FL, USA
| | - Kaashif A Ahmad
- MEDNAX Center for Research, Education, Quality, and Safety, Sunrise, FL, USA.
- Baylor College of Medicine, San Antonio, TX, USA.
- Pediatrix Medical Group of San Antonio, San Antonio, TX, USA.
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White RD. Next steps in Newborn Intensive Care Unit design and developmental care. J Perinatol 2020; 40:1. [PMID: 32859956 DOI: 10.1038/s41372-020-0748-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Robert D White
- Regional Newborn Program, Beacon Children's Hospital, South Bend, IN, USA.
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Abstract
The environment of care has a lasting impact on the patients, families, and caregivers who experience it. A newborn intensive care unit (NICU) is typically in use for 10-30 years, over which time decisions made during its design will have human and financial impacts far beyond the initial cost. Good planning is crucial, yet most participants in the planning process have little experience designing a NICU and may be driven as much by what they do not like in their existing NICU as by the evidence and experience reported by others. Standards generated by a group of experts in multiple disciplines can inform these planners, as well as the agencies developing building codes for NICUs. Now in its ninth iteration, these Recommended Standards continue to be refined as new evidence and experience accumulates, along with new guidance for couplet care in the NICU and for detection of latent safety risks prior to occupancy.
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Affiliation(s)
- Robert D White
- Regional Newborn Program, Beacon Children's Hospital, South Bend, IN, USA.
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Brons JA, Bierman A, White R, Benner K, Deng L, Rea MS. An assessment of a hybrid lighting system that employs ultraviolet-A for mitigating healthcare-associated infections in a newborn intensive care unit. Lighting Research & Technology 2020. [DOI: 10.1177/1477153520904107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Reducing healthcare-associated infections is critically important. A new hybrid lighting system technology, designed to provide both visible white light and disinfecting UV-A (λmax = 366 nm) radiation, was retrofitted into a modern hospital newborn intensive care unit. The UV-A dosing was set to levels calculated to be safe for human occupation (maximum of 10 W m−2 for 8 hours at eye level). Eight-hour exposures at 3 W m−2 on newborn intensive care unit counter surfaces were effective for suppressing selected pathogens identified by the Centers for Disease Control and Prevention as problematic for healthcare facilities. Professional staff accepted the hybrid lighting system, although its implementation in this newborn intensive care unit was not completely satisfactory. An analysis of photodegrading effects suggested that UV-A resistant equipment and furnishing may need to be installed with this technology. The present findings should form the foundation for the next generation of this lighting technology.
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Affiliation(s)
- JA Brons
- Lighting Research Center, Rensselaer Polytechnic Institute, Troy, NY, USA
| | - A Bierman
- Lighting Research Center, Rensselaer Polytechnic Institute, Troy, NY, USA
| | - R White
- Memorial Hospital Beacon Health, South Bend, IN, USA
| | - K Benner
- GE Current, a Daintree company, Cleveland, OH, USA
| | - L Deng
- GE Current, a Daintree company, Cleveland, OH, USA
| | - MS Rea
- Lighting Research Center, Rensselaer Polytechnic Institute, Troy, NY, USA
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Schanler R, Groh-Wargo SL, Barrett-Reis B, White RD, Ahmad KA, Oliver J, Baggs G, Williams L, Adamkin D. Reply. J Pediatr 2019; 205:291-292. [PMID: 30503035 DOI: 10.1016/j.jpeds.2018.10.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 10/29/2018] [Indexed: 02/08/2023]
Affiliation(s)
- Richard Schanler
- Neonatal-Perinatal Medicine Cohen Children's Medical Center New Hyde Park, New York
| | | | | | - Robert D White
- Pediatrix Medical Group Memorial Hospital of South Bend South Bend, Indiana
| | - Kaashif A Ahmad
- Baylor College of Medicine Pediatrix Medical Group North Central Baptist Hospital San Antonio, Texas
| | | | | | | | - David Adamkin
- Department of Pediatrics University of Louisville Louisville, Kentucky
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Autmizguine J, Smith PB, Prather K, Bendel C, Natarajan G, Bidegain M, Kaufman DA, Burchfield DJ, Ross AS, Pandit P, Schell WA, Gao J, Benjamin DK. Effect of fluconazole prophylaxis on Candida fluconazole susceptibility in premature infants. J Antimicrob Chemother 2018; 73:3482-3487. [PMID: 30247579 PMCID: PMC6927883 DOI: 10.1093/jac/dky353] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 08/06/2018] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES Extremely premature infants are at high risk of developing invasive candidiasis; fluconazole prophylaxis is safe and effective for reducing invasive candidiasis in this population but further study is needed. We sought to better understand the effect of prophylactic fluconazole on a selection of fluconazole-resistant Candida species. METHODS We evaluated the susceptibility to fluconazole of Candida isolates from premature infants (<750 g birth weight) enrolled in a multicentre, randomized, placebo-controlled trial of fluconazole prophylaxis. Candida species were isolated through surveillance cultures at baseline (study day 0-7), period 1 (study day 8-28) and period 2 (study day 29-49). Fluconazole MICs were determined for all Candida isolates. RESULTS Three hundred and sixty-one infants received fluconazole (n = 188) or placebo (n = 173). After the baseline period, Candida colonization was significantly lower in the fluconazole group compared with placebo during periods 1 (5% versus 27%; P < 0.001) and 2 (3% versus 27%; P < 0.001). After the baseline period, two infants (1%) were colonized with at least one fluconazole-resistant Candida in each group. Median fluconazole MIC was similar in both treatment groups at baseline and period 1. However, in period 2, median MIC was higher in the fluconazole group compared with placebo (1.00 versus 0.50 mg/L, P = 0.01). There was no emergence of resistance observed and no patients developed invasive candidiasis with a resistant Candida isolate. CONCLUSIONS Fluconazole prophylaxis decreased Candida albicans and 'non-albicans' Candida colonization and was associated with a slightly higher fluconazole MIC for colonizing Candida isolates.
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Affiliation(s)
- Julie Autmizguine
- Department of Pharmacology and Physiology, Université de Montréal, Montreal, Canada
- Department of Pediatrics, Université de Montréal, Montréal, Canada
- Research Center, CHU Ste-Justine, Montréal, Canada
| | - P Brian Smith
- Department of Pediatrics, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Kristi Prather
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | | | | | | | | | | | - Ashley S Ross
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Paresh Pandit
- Children’s Hospital of Philadelphia at Vitua West Jersey Hospital Voorhees, Voorhees, NJ, USA
| | - Wiley A Schell
- Department of Medicine, Duke University, Durham, NC, USA
| | - Jamie Gao
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Daniel K Benjamin
- Department of Pediatrics, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
- Corresponding author. Duke University Medical Center, Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC 27705, USA. Tel:+1-919-668-7081; Fax: +1-919-668-7058; E-mail:
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Schanler RJ, Groh-Wargo SL, Barrett-Reis B, White RD, Ahmad KA, Oliver J, Baggs G, Williams L, Adamkin D. Improved Outcomes in Preterm Infants Fed a Nonacidified Liquid Human Milk Fortifier: A Prospective Randomized Clinical Trial. J Pediatr 2018; 202:31-37.e2. [PMID: 30195561 DOI: 10.1016/j.jpeds.2018.07.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 06/26/2018] [Accepted: 07/02/2018] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To compare growth, feeding tolerance, and clinical and biochemical evaluations in human milk-fed preterm infants randomized to receive either an acidified or a nonacidified liquid human milk fortifier. STUDY DESIGN This prospective, controlled, parallel, multicenter growth and tolerance study included 164 preterm infants (≤32 weeks of gestation, birth weight 700-1500 g) who were randomized to acidified or nonacidified liquid human milk fortifier from study day 1, the first day of fortification, through study day 29 or until hospital discharge. RESULTS There was no difference in the primary outcome of weight gain from study days 1 to 29 (acidified liquid human milk fortifier, 16.4 ± 0.4 g/kg/day; nonacidified liquid human milk fortifier, 16.9 ± 0.4 g/kg/day). However, in both the intention-to-treat and the protocol evaluable analyses, infants fed nonacidified liquid human milk fortifier had significantly greater weight gain from study days 1 to 15 (17.9 g/kg/day vs 15.2 g/kg/day; P = .001). Infants fed with acidified liquid human milk fortifier received more protein (4.26 vs g/kg/day 4.11 g/kg/day, P = .0099) yet had lower blood urea nitrogen values (P = .010). The group fed acidified liquid human milk fortifier had more vomiting (10.3% vs 2.4%; P = .018), gastric residuals (12.8% vs 3.7%; P = .022), and metabolic acidosis (27% vs 5%; P < .001) in the intention-to-treat analysis and more abdominal distension (14.0% vs 1.7%; P = .015) in the protocol evaluable analysis. CONCLUSIONS Infants fed an acidified liquid human milk fortifier had higher rates of metabolic acidosis and poor feeding tolerance compared with infants fed a nonacidified liquid human milk fortifier. Initial weight gain was poorer with the acidified liquid human milk fortifier. TRIAL REGISTRATION ClinicalTrials.gov: NCT02307760.
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Affiliation(s)
- Richard J Schanler
- Neonatal-Perinatal Medicine, Cohen Children's Medical Center, New Hyde Park, NY.
| | | | | | - Robert D White
- Pediatrix Medical Group, Memorial Hospital of South Bend, South Bend, IN
| | - Kaashif A Ahmad
- Baylor College of Medicine, Pediatrix Medical Group, North Central Baptist Hospital, San Antonio, TX
| | | | | | | | - David Adamkin
- Department of Pediatrics, University of Louisville, Louisville, KY
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Paranka MS, Brown JM, White RD, Park MV, Kelleher AS, Clark RH. The impact of altitude on screening for critical congenital heart disease. J Perinatol 2018; 38:530-536. [PMID: 29379160 DOI: 10.1038/s41372-018-0043-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 12/07/2017] [Accepted: 01/02/2018] [Indexed: 02/08/2023]
Abstract
OBJECTIVES The objectives were to determine the frequency with which pulse oximetry identifies critical congenital heart defects in asymptomatic full-term and late preterm newborns using the AAP expert panel algorithm in a variety of different hospital settings and to evaluate the impact of altitude on the rate of positive screens. METHODS We conducted a prospective clinical study of implementation of a newborn pulse oximetry screening for congenital heart disease in 34 independent hospitals. Infants were eligible for enrollment if their gestational age was 35-44 weeks. RESULTS Of the 34 sites which enrolled infants into our study, 24 were located at or below 2000 feet; 5 were located between 4700 and 6000 feet and 5 were located above 6000 feet in altitude. We screened 6109 infants; 65 (1.1%) had a positive screen. There were no differences in median gestational age, birth weight, mode of delivery or race/ethnicity for infants with a positive screen compared to infants with a negative screen. Infants with positive screens were more often male and more often born at sites located at high altitudes. The frequency of a positive screen increased from 0.2% for infants born at sites at or less than 2000 feet to 6% for sites located above 6000 feet. We stopped enrollment at the site located at 8163 feet after enrolling 65 infants because 23 (35%) were positive. CONCLUSIONS Screening infants for critical cardiac defects at altitude is complicated by the increased false positive screens.
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Affiliation(s)
- Michael S Paranka
- Sky Ridge Medical Center, Lone Tree, Colorado, USA
- Aurora Medical Center, Aurora, Colorado, USA
| | | | | | - Matthew V Park
- Northwest Congenital Heart Care, Pediatrix, Cardiology, Tacoma, Washington, USA
| | - Amy S Kelleher
- The MEDNAX Center for Research, Education Safety and Quality, Sunrise, Florida, USA
| | - Reese H Clark
- The MEDNAX Center for Research, Education Safety and Quality, Sunrise, Florida, USA.
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Abstract
Several components of breast milk show circadian variability. It is likely that at least some of these macronutrients, hormones, and micronutrients produce circadian stimuli that enhance the well-being of breast-fed infants. Future research should determine whether high-risk infants benefit if breast milk is given during the same circadian phase as it was expressed.
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Affiliation(s)
- Robert D White
- Pediatrix Medical Group, Regional Newborn Program, Beacon Children's Hospital , South Bend, Indiana
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White RD. NICU Design Issue. Newborn and Infant Nursing Reviews 2016. [DOI: 10.1053/j.nainr.2016.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Affiliation(s)
- R D White
- Pediatrix Medical Group Director, Regional Newborn Program, Memorial Hospital, South Bend, IN, USA
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White RD. Neuroprotective Core Measure 4: Safeguarding Sleep — Its Value in Neuroprotection of the Newborn. Newborn and Infant Nursing Reviews 2015. [DOI: 10.1053/j.nainr.2015.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Shepley MM, Smith JA, Sadler BL, White RD. The business case for building better neonatal intensive care units. J Perinatol 2014; 34:811-5. [PMID: 25359412 DOI: 10.1038/jp.2014.174] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Revised: 08/14/2014] [Accepted: 08/19/2014] [Indexed: 02/08/2023]
Affiliation(s)
- M M Shepley
- Department of Design Environmental Analysis, Cornell University, Ithaca, NY, USA
| | - J A Smith
- Smith Hager Bajo Inc., Ashburn, VA, USA
| | - B L Sadler
- Institute for Healthcare Improvement, La Jolla, CA, USA
| | - R D White
- Pediatrix Medical Group, Memorial Hospital, South Bend, IN, USA
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Benjamin DK, Hudak ML, Duara S, Randolph DA, Bidegain M, Mundakel GT, Natarajan G, Burchfield DJ, White RD, Shattuck KE, Neu N, Bendel CM, Kim MR, Finer NN, Stewart DL, Arrieta AC, Wade KC, Kaufman DA, Manzoni P, Prather KO, Testoni D, Berezny KY, Smith PB. Effect of fluconazole prophylaxis on candidiasis and mortality in premature infants: a randomized clinical trial. JAMA 2014; 311:1742-9. [PMID: 24794367 PMCID: PMC4110724 DOI: 10.1001/jama.2014.2624] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
IMPORTANCE Invasive candidiasis in premature infants causes death and neurodevelopmental impairment. Fluconazole prophylaxis reduces candidiasis, but its effect on mortality and the safety of fluconazole are unknown. OBJECTIVE To evaluate the efficacy and safety of fluconazole in preventing death or invasive candidiasis in extremely low-birth-weight infants. DESIGN, SETTING, AND PATIENTS This study was a randomized, blinded, placebo-controlled trial of fluconazole in premature infants. Infants weighing less than 750 g at birth (N = 361) from 32 neonatal intensive care units (NICUs) in the United States were randomly assigned to receive either fluconazole or placebo twice weekly for 42 days. Surviving infants were evaluated at 18 to 22 months corrected age for neurodevelopmental outcomes. The study was conducted between November 2008 and February 2013. INTERVENTIONS Fluconazole (6 mg/kg of body weight) or placebo. MAIN OUTCOMES AND MEASURES The primary end point was a composite of death or definite or probable invasive candidiasis prior to study day 49 (1 week after completion of study drug). Secondary and safety outcomes included invasive candidiasis, liver function, bacterial infection, length of stay, intracranial hemorrhage, periventricular leukomalacia, chronic lung disease, patent ductus arteriosus requiring surgery, retinopathy of prematurity requiring surgery, necrotizing enterocolitis, spontaneous intestinal perforation, and neurodevelopmental outcomes-defined as a Bayley-III cognition composite score of less than 70, blindness, deafness, or cerebral palsy at 18 to 22 months corrected age. RESULTS Among infants receiving fluconazole, the composite primary end point of death or invasive candidiasis was 16% (95% CI, 11%-22%) vs 21% in the placebo group (95% CI, 15%-28%; odds ratio, 0.73 [95% CI, 0.43-1.23]; P = .24; treatment difference, -5% [95% CI, -13% to 3%]). Invasive candidiasis occurred less frequently in the fluconazole group (3% [95% CI, 1%-6%]) vs the placebo group (9% [95% CI, 5%-14%]; P = .02; treatment difference, -6% [95% CI, -11% to -1%]). The cumulative incidences of other secondary outcomes were not statistically different between groups. Neurodevelopmental impairment did not differ between the groups (fluconazole, 31% [95% CI, 21%-41%] vs placebo, 27% [95% CI, 18%-37%]; P = .60; treatment difference, 4% [95% CI, -10% to 17%]). CONCLUSIONS AND RELEVANCE Among infants with a birth weight of less than 750 g, 42 days of fluconazole prophylaxis compared with placebo did not result in a lower incidence of the composite of death or invasive candidiasis. These findings do not support the universal use of prophylactic fluconazole in extremely low-birth-weight infants. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00734539.
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Affiliation(s)
| | - Mark L Hudak
- University of Florida College of Medicine-Jacksonville
| | - Shahnaz Duara
- University of Miami Miller School of Medicine, Miami, Florida
| | | | | | | | | | | | | | | | | | | | - M Roger Kim
- Brookdale University Hospital, Brooklyn, New York
| | - Neil N Finer
- University of California-San Diego Medical Center
| | | | | | - Kelly C Wade
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | | | | | | | | | - P Brian Smith
- Duke Clinical Research Institute, Durham, North Carolina
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Affiliation(s)
- R D White
- Pediatrix Medical Group, Newborn ICU, Memorial Hospital, South Bend, IN, USA
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Abstract
The objective of the study was to perform a literature review on the health consequences of working rotating shifts and implications for structural design. A literature search was performed in June 2012 and a selection of the most relevant peer-review articles was included in the present review. Shift workers are more likely to suffer from a circadian sleep disorder characterized by sleepiness and insomnia. Shift work is associated with decreased productivity, impaired safety, diminished quality of life and adverse effects on health. Circadian disruption resulting from rotating shift work has also been associated with increased risk for metabolic syndrome, diabetes, cardiovascular disease and cancer. This article summarizes the known health effects of shift work and discusses how light can be used as a countermeasure to minimize circadian disruption at night while maintaining alertness. In the context of the lighted environment, implications for the design of newborn intensive care units are also discussed.
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Affiliation(s)
- M G Figueiro
- Lighting Research Center, Rensselaer Polytechnic Institute, Troy, NY 12180, USA.
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Abstract
This is the eighth edition of the Recommended Standards for Newborn ICU Design. It contains substantive changes in recommendations for patient room size and feeding preparation areas, and a number of refinements of previous Recommended Standards with respect to family space, hand hygiene, lighting and other aspects of the newborn intensive care unit (NICU) design.
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Affiliation(s)
- R D White
- Regional Newborn Program Memorial Hospital, South Bend, IN, USA.
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Affiliation(s)
- Joy V Browne
- Departments of Pediatrics and Psychiatry, JFK Partners Center for Family and Infant Interaction, University of Colorado Anschutz Medical Campus, 13121 East 17th Avenue, Aurora, CO 80045, USA.
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Abstract
The environment of care has been recognized as an important factor in the healing process for centuries. This is true for all individuals but none more so than newborn infants, for whom the hospital is not only a place of healing but also where an extraordinary and unique period of growth and development must occur-it cannot wait until after the infant is well and discharged home. This article describes the optimal environment for developmental care in the neonatal intensive care unit.
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Affiliation(s)
- Robert D White
- Regional Newborn Program, Pediatrix Medical Group, Memorial Hospital, 615 North Michigan Street, South Bend, IN 46601, USA.
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Abstract
The newborn intensive care unit (NICU) is a life-defining place for many infants, families, and caregivers. The place in which such events occur is often remembered for its sights, sounds, and smells, but the physical environment of the NICU is far more than a memory tag; it can directly influence the quality of the experience for all of its inhabitants. A growing body of evidence demonstrates the profound impact of the physical environment on growth and development of the neonatal brain. The value of skin-to-skin care is now established. Psychology, sociology, and occupational health provide additional insight into the effect of the NICU setting on families and caregivers. Together, these lines of evidence point to the need for individualized environments. Single-family rooms are a growing trend in the NICU because they allow for individualized environments. Careful planning can avoid pitfalls and bring benefit to babies, families, and caregivers alike.
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Affiliation(s)
- Robert D White
- Regional Newborn Program, Pediatrix Medical Group, Memorial Hospital, South Bend, IN, USA.
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Abstract
The trend toward single-family room (SFR) design in the neonatal intensive care unit (NICU) has been driven by a growing understanding of the developmental needs of preterm infants, a desire to provide environments that support and encourage family participation, and infection control considerations. SFR design offers many potential benefits, but also requires substantial change in the NICU culture, as well as additional space and technology when compared to an open ward. The advantages and drawbacks of the SFR design are reviewed, and strategies are offered to assist those who are considering construction or renovation of an NICU.
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Affiliation(s)
- Robert D. White
- Address correspondence to Robert D. White, MD, Pediatrix Medical Group of Indiana, Memorial Hospital, 615 N. Michigan St., South Bend, IN 46601.
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Spitzer AR, White RD. Clinics in Perinatology. Neuroprotection in the Newborn. Preface. Clin Perinatol 2008; 35:xi-xii. [PMID: 19026330 DOI: 10.1016/j.clp.2008.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Abstract
The purpose of this study is to explore the implications of neonatal intensive care unit (NICU) single-family rooms (SFRs) relative to open-bay arrangements. A recent trend in the design of NICUs has been to increase the number of private patient rooms for neonates and their families. Several factors have contributed to the popularity of SFRs, including compliance with the Health Insurance Portability and Accountability Act, which mandates the need to provide patient privacy. Surveys of NICU medical staff ( N = 75) explored the preferences and experiences of individuals providing care in two facilities, an SFR NICU and a combination unit with open-bay infant stations and SFRs. The results of this study indicate that SFR NICU design may increase staff satisfaction and reduce staff stress.
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Steinbach M, Clark RH, Kelleher AS, Flores C, White R, Chace DH, Spitzer AR. Demographic and nutritional factors associated with prolonged cholestatic jaundice in the premature infant. J Perinatol 2008; 28:129-35. [PMID: 18059467 DOI: 10.1038/sj.jp.7211889] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The primary aim of this study was to determine if an association exists between amino-acid levels and development of cholestasis. The secondary aim of our amino-acid dose comparison trial was to identify factors associated with the development of prolonged cholestatic jaundice. STUDY DESIGN We compared demographic characteristics and amino-acid levels in neonates who developed cholestasis with those who did not. Parenteral-associated cholestatic liver disease was defined as a direct serum bilirubin above 5 mg per 100 ml any time during the first 28 days after birth in neonates with no history of biliary atresia or viral hepatitis. We obtained filter paper blood spots for amino acid and acylcarnitine measurements on the day of randomization and days 7 and 28 of age to identify a profile of values that could be used to identify neonates with evidence of abnormal liver function. RESULT We enrolled 122 neonates in our study; 13 (10.7%) developed cholestasis. Neonates who developed cholestasis were more immature, had lower birth weight, were exposed to parenteral nutrition for a longer period, had a higher cumulative dose of amino acids, were less often on enteral nutrition by day 7 of age, more often had a patent ductus arteriosus and severe intraventricular hemorrhage and were more commonly treated with steroids by 28 days of age. Amino acid and acylcarnitine values were not different for the two groups on the day of randomization. On day 7 (parenteral phase of nutrition), blood urea nitrogen, citrulline, histidine, methionine and succinyl carnitine were higher, and serine, glutamate and thyroxine levels were lower in the neonates who developed cholestasis than in who did not. CONCLUSION Cholestasis remains an important complication of parenteral nutrition, and several clinical and biochemical factors may be helpful in identifying high-risk patients.
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Affiliation(s)
- M Steinbach
- Pediatrix-Obstetrix Center for Research and Education and Pediatrix Analytical, Sunrise, FL, USA
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Abstract
Floors are a major element of newborn intensive care unit (NICU) construction. They provide visual cues, sound control, and with certain materials, some degree of physical comfort for workers. Flooring materials may entail a significant cost for installation and upkeep and can have substantial ecological impact, both in the choice of the flooring itself, as well as the substances used to clean it. In this article the important aspects to consider for each factor are explored and recommendations are offered for appropriate choices in various NICU areas.
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Affiliation(s)
- R D White
- Pediatrix Medical Group, South Bend, IN, USA.
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Abstract
Hypothermia remains a significant challenge in the initial care of premature infants. Although a number of prevention strategies have been identified, hypothermia is still a common event, especially in extremely low birth weight infants. Using data from four centers, we documented an incidence of hypothermia on admission to the neonatal intensive care unit from the delivery room of 31-78% for infants <1500 g birth weight. Increased efforts will be necessary to prevent early hypothermia in very preterm infants, especially with respect to the environmental conditions of the delivery room itself.
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Affiliation(s)
- D R Bhatt
- 1Kaiser Permanente, Fontana, CA, USA
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34
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Affiliation(s)
- R D White
- Memorial Hospital, South Bend, IN, USA.
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35
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Abstract
Theoretically, single patient room newborn intensive care units are designed to optimize the developmental outcomes of critically ill infants by providing individual patient environments with decreased stimulation and noise. This article reports the perceptions of 127 neonatal intensive care nurses after the move into a single room neonatal intensive care unit (NICU). The observations of the nurses were obtained using a questionnaire to identify some of the benefits, risks, and specific patient safety concerns related to the single room NICU design. The results suggest that in this setting the single patient room concept was deemed superior for patient care and parent satisfaction when compared to the large open unit. However, the nurses emphasize that the success of single room care model primarily depends on providing sufficient staff coverage, given the decreased patient visibility and greater distances between patients. Larger units also present unique communication, staff education, and quality improvement challenges. To further evaluate the impact of single room designs we evaluated data on important clinical issues, specifically noise levels and catheter-related infections provide objective measures of important improvements. Noise levels decreased from an average of 63 to 56 decibels and catheter-associated bloodstream infections fell from 10.1 per 1000 device days to 3.3 per 1000 device days in the 9 months after the move to single patient rooms. This article provides pragmatic design suggestions that should be prospectively considered to minimize staff isolation and stress.
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Affiliation(s)
- William F Walsh
- Vanderbilt University School of Medicine, Nashville, TN 37232-9550, USA.
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36
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Harris DD, Shepley MM, White RD, Kolberg KJS, Harrell JW. The impact of single family room design on patients and caregivers: executive summary. J Perinatol 2006; 26:S38-48. [DOI: 10.1038/sj.jp.7211583] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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37
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Abstract
Continuous electroencephalography can contribute useful information to clinical decision-making in neonatal care. Equipment is now reliable and user-friendly enough that its use can be taught to medical and nursing staff so that a 24-hour capability is achieved. It is possible to teach neonatologists, in a 1-day course, background knowledge on EEG and amplitude-integrated EEG (aEEG), recognition of aEEG patterns that have clinical significance, recognition of seizures using aEEG and "raw" EEG, the essentials of electrode placement for aEEG, and interpretation of findings in the clinical context. This must be followed up by background reading, frequent peer-review sessions on EEG recordings, and a reliable system for storing and access, as well as willingness to consult experienced operators elsewhere.
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MESH Headings
- Education, Medical, Continuing
- Education, Nursing, Continuing
- Electroencephalography/instrumentation
- Electroencephalography/methods
- Electroencephalography/standards
- Humans
- Intensive Care, Neonatal/standards
- Medical Audit
- Medical Staff, Hospital/education
- Monitoring, Physiologic/instrumentation
- Monitoring, Physiologic/methods
- Monitoring, Physiologic/standards
- Nursing Staff, Hospital/education
- Quality Assurance, Health Care
- Signal Processing, Computer-Assisted
- Workforce
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Affiliation(s)
- Andrew Whitelaw
- Neonatal Medicine, University of Bristol Medical School, Southmead Hospital, Bristol BS10 5NB, United Kingdom.
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38
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Benjamin DK, Schelonka R, White R, Holley HP, Bifano E, Cummings J, Adcock K, Kaufman D, Puppala B, Riedel P, Hall B, White J, Cotton CM. A blinded, randomized, multicenter study of an intravenous Staphylococcus aureus immune globulin. J Perinatol 2006; 26:290-5. [PMID: 16598296 DOI: 10.1038/sj.jp.7211496] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Very low birth weight (VLBW) infants are vulnerable to nosocomial infections and subsequent morbidity; including infections caused by Staphylococcus aureus: 85% of nosocomial S. aureus infections are caused by capsular polysaccharide (CPS) types 5 and 8. Altastaph is a polyclonal investigational human immunoglobulin G (IgG) with high levels of opsonizing S. aureus CPS types 5 and 8 IgG. METHODS A Phase 2 clinical trial to assess the safety and kinetics of Altastaph in VLBW infants. Neonates in this multicenter study were randomized to receive two identical 20 ml/kg i.v. infusions of either 0.45% NaCl placebo or 1000 mg Altastaph/kg. Each infant was followed for 28 days after the second infusion or until discharge. Serum S. aureus CPS types 5 and 8 IgG levels were measured preinfusion and at various times after each infusion. RESULTS Of 206 neonates, 158 received both infusions. Adverse events were similar in the two treatment groups. Six subjects (3% in each group) discontinued owing to an adverse event. Geometric mean anti-type 5 IgG levels were 402 and 642 mcg/ml 1 day following infusion of the first (day 0) and Second (day 14) doses, respectively, in neonates < or =1000 g and slightly higher in neonates 1001 to 1500 g. Trough levels before second infusion were 188 mcg/ml. Type 8 IgG levels were similar. Geometric mean IgG levels among placebo recipients were consistently <2 and <5 mcg/ml for types 5 and 8 in both weight groups. Three episodes of S. aureus bacteremia occurred in each arm. CONCLUSIONS Infusion of Altastaph in VLBW neonates resulted in high levels of specific S. aureus types 5 and 8 CPS IgG. The administration of this anti-staphylococcal hyperimmune globulin was well tolerated in this population.
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Affiliation(s)
- D K Benjamin
- Duke University Department of Pediatrics, Durham, NC 27710, USA.
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39
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Capparelli EV, Bloom BT, Kueser TJ, Oelberg DG, Bifano EM, White RD, Schelonka RL, Pearlman SA, Patti J, Hetherington SV. Multicenter study to determine antibody concentrations and assess the safety of administration of INH-A21, a donor-selected human Staphylococcal immune globulin, in low-birth-weight infants. Antimicrob Agents Chemother 2005; 49:4121-7. [PMID: 16189088 PMCID: PMC1251526 DOI: 10.1128/aac.49.10.4121-4127.2005] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Nosocomial or late-onset sepsis is a common complication among premature infants, with a frequency inversely correlated with birth weight. Increased susceptibility to infection is due in part to an immature humoral (antibody-mediated) immune response. This study investigated the pharmacokinetics (PKs) and safety of a donor-selected specific intravenous immune globulin (IVIG) preparation, INH-A21 (Veronate), for prevention of sepsis in premature infants. Thirty-six infants weighing between 500 and 1,250 g during the first postnatal week were eligible to begin a series of up to four intravenous infusions of 500 or 750 mg/kg of body weight INH-A21. Blood samples were analyzed for antibodies against the Ser-Asp dipeptide repeat G (SdrG) and clumping factor A (ClfA) surface proteins of staphylococci. Sparse sampling and population PK analyses were performed to derive PK parameters. Following administration of the 500- and 750-mg/kg doses, the estimated average steady-state levels of anti-ClfA were 6.1 U/ml and 9.2 U/ml, respectively, and those of anti-SdrG were 5.2 U/ml and 7.7 U/ml, respectively. The elimination half-lives for anti-ClfA and anti-SdrG were 719 h and 701 h, respectively, and the clearances were 0.18 ml/h and 0.21 ml/h, respectively. In the final model, the values of the PK parameters were independent of gestational age. Both doses of INH-A21 were well tolerated, and the safety profile was similar to those of other IVIG preparations. These results suggest that a shorter dosing interval should be utilized between the first and second doses to achieve and maintain higher titers of anti-ClfA and anti-SdrG antibodies. Further studies examining INH-A21 for the prevention of late-onset sepsis in infants within the weight range studied are warranted.
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40
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Abstract
Nosocomial sepsis is a serious problem for neonates who are admitted for intensive care. It is associated with an increase in mortality, morbidity, and prolonged length of hospital stay. Thus, both the human and fiscal costs of these infections are high. Although the rate of nosocomial sepsis increases with the degree of both prematurity and low birth weight, no specific lab test has been shown to be very useful in improving our ability to predict who has a "real" blood-stream infection and, therefore, who needs to be treated with a full course of antibiotics. As a result, antibiotic use is double the rate of "proven" sepsis and we are facilitating the growth of resistant organisms in the neonatal intensive care unit. The purpose of this article is to describe simple changes in process, which when implemented, can reduce nosocomial infection rates in neonates and improve outcomes.
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Affiliation(s)
- Reese Clark
- Pediatrix Medical Group Inc., 1301 Concord Terrace, Sunrise, FL 323325-2825, USA
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41
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Abstract
Nosocomial sepsis is a serious problem for neonates who are admitted for intensive care. As it is associated with increases in mortality, morbidity, and prolonged length of hospital stay, both the human and fiscal costs of these infections are high. Although the rate of nosocomial sepsis increases with the degree of both prematurity and low birth weight, no specific lab test has been shown to be very useful in improving our ability to predict who has a "real" blood-stream infection and, therefore, who needs to be treated with a full course of antibiotics. As a result, antibiotic use is double the rate of "proven" sepsis and we are facilitating the growth of resistant organisms in the neonatal intensive care unit. The purpose of this article is to review the topic of nosocomial infections in neonates.
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Affiliation(s)
- Reese Clark
- Pediatrix Medical Group, Inc., 1301 Concord Terrace, Sunrise, FL 33323-2825, USA
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42
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Abstract
With the advent of neonatal intensive care, medical professionals inserted themselves between the baby and its family. Even for healthy newborn, the mother could only get to her infant with permission from the medical staff and then only for limited periods and in a very restricted manner. Family-centered care restored the family's right to full access to their baby, but as generally practiced(and certainly as NICUs are currently designed) medical professionals still view the infant as a solitary individual who sleeps most of the time in a bed. Future NICU design should recognize that the baby must spend most of its time in its mother's arms to get the full benefit of her sensory environment as experienced throughout our evolution. NICUs must therefore be planned to facilitate this extended proximity as much as possible (ie, not just providing for parents at the bedside with the bed as the locus of care, but transforming the preferred and predominant locus of care from the bed to the parents' arms, with the design changes inherent to that concept). Designing our units to facilitate this interaction will not assure that it will always occur, but it will guarantee that we have not created permanent structural features that interfere with this crucial relationship.
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Affiliation(s)
- Robert D White
- Department of Pediatrics, Indiana University School of Medicine, Notre Dame, IN 46656, USA.
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43
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Abstract
Meeting the varied lighting needs of infants, caregivers, and families has become more complex as our understanding of visual development and perception and the effect of light on circadian rhythms advances. Optimal lighting strategies are discussed for new unit construction, as well as modifications to consider for existing units. In either case, the key concept is that lighting should be provided for the individual needs of each person, rather than the full-room lighting schemes previously used. Ideas gleaned from nonhospital settings, re-introduction of natural light into the neonatal intensive care unit, and new devices such as light-emitting diodes will dramatically change the lighting and visual environment of future neonatal intensive care units.
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Affiliation(s)
- Robert D White
- Department of Pediatrics, Indiana University School of Medicine, Notre Dame, IN 46656, USA.
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Abstract
The provision of individual rooms for NICU patients has several attractive benefits, including the ability to provide the appropriate environmental stimuli for each child, and increased privacy and accessibility for families. This concept can put serious strain on caregivers, however, by isolating them from one another and from the multiple infants for whom they may have responsibility, and places additional financial and space demands on the institution. These problems are not insurmountable, however, and use of individual rooms for at least some patients is feasible and probably desirable if certain considerations are addressed in the planning and design process.
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45
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Miceli PJ, Goeke-Morey MC, Whitman TL, Kolberg KS, Miller-Loncar C, White RD. Brief report: birth status, medical complications, and social environment: individual differences in development of preterm, very low birth weight infants. J Pediatr Psychol 2000; 25:353-8. [PMID: 10880066 DOI: 10.1093/jpepsy/25.5.353] [Citation(s) in RCA: 114] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To assess whether medical complications mediate the relationship between birth status (i.e., birth weight and gestational age) and developmental outcome of preterm, very low birth weight (VLBW) infants, as well as the role of the early social environment (maternal distress and social support) in infant development. METHOD Birth status and medical complication information was collected during the child's NICU stay. Maternal distress was assessed with the Beck Depression Inventory and the Parenting Stress Index at 4 months corrected infant age. Social support was measured with the Dunst Scales at 4 months corrected age. Child development measures were collected at 4 and 13 months corrected age (Bayley MDI and PDI), and at 36 months chronological age (PPVT-R and Achenbach CBCL). RESULTS Medical complications mediated the birth status-outcome relationship at 4 and 13 months, but not at 36 months. The 36-month outcomes were predicted by 4-month maternal distress and social support. CONCLUSIONS Prematurity and VLBW are indirectly related to early developmental outcome through their association with medical complications. However, by 36 months, developmental outcomes are more closely related to aspects of the early social environment than to early physiological factors.
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Affiliation(s)
- P J Miceli
- Department of Psychology, University of Notre Dame, Indiana 46556, USA.
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46
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White RD. Recommended standards for newborn ICU design. Committee to establish recommended standards for newborn ICU design. J Perinatol 1999; 19:S1-12. [PMID: 10685312 DOI: pmid/10685312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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47
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White RD. Enhanced neonatal intensive care design: a physiological approach. J Perinatol 1996; 16:381-4. [PMID: 8915938 DOI: pmid/8915938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- R D White
- Regional Newborn Program, Memorial Hospital of South Bend, IN 46601, USA
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48
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Miller CL, White R, Whitman TL, O'Callaghan MF, Maxwell SE. The effects of cycled versus noncycled lighting on growth and development in preterm infants. Infant Behav Dev 1995. [DOI: 10.1016/0163-6383(95)90010-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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49
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White R, Whitman T. Design of ICUs. Pediatrics 1992; 89:1267. [PMID: 1594388 DOI: pmid/1594388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
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50
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