Neonatal intensive care practices harmful to the developing brain

Nursing Interventions That Promote Sleep in Preterm Newborns in the Neonatal Intensive Care Units: An Integrative Review

Sleep is a crucial factor for the psychological and physiological well-being of any human being. In Neonatal Intensive Care Units, preterm newborns' sleep may be at risk due to medical and nursing care, environmental stimuli and manipulation. This review aims to identify the nurses' interventions that promote sleep in preterm newborns in the Neonatal Intensive Care Units. An integrative review was conducted following Whittemore and Knafl's methodology and the 2020 Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. The research was carried out on the electronic databases PubMed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and ScienceDirect, with a timeframe from 2010 to 2021. A total of 359 articles were initially identified. After selection and analysis, five studies were included in the sample. Interventions by nursing staff that promote sleep in preterm newborns in the Neonatal Intensive Care Units fall within three categories: environmental management, relaxation techniques and therapeutic positioning. Nurses play a vital role in implementing interventions that promote preterm newborns' sleep. They can positively affect preterm newborns' sleep by controlling environmental stimuli and applying relaxation techniques and therapeutic positioning to their care practices.

High-Risk Neighborhoods and Neurodevelopmental Outcomes in Infants Born Preterm

OBJECTIVE

To study the association between neighborhood risk and moderate to severe neurodevelopmental impairment (NDI) at 22-26 months corrected age in children born at <34 weeks of gestation. We hypothesized that infants born preterm living in high-risk neighborhoods would have a greater risk of NDI and cognitive, motor, and language delays.

STUDY DESIGN

We studied a retrospective cohort of 1291 infants born preterm between 2005 and 2016, excluding infants with congenital anomalies. NDI was defined as any one of the following: a Bayley Scales of Infant and Toddler Development-III Cognitive or Motor composite score <85, bilateral blindness, bilateral hearing impairment, or moderate-severe cerebral palsy. Maternal addresses were geocoded to identify census block groups and create high-risk versus low-risk neighborhood groups. Bivariate and regression analyses were run to assess the impact of neighborhood risk on outcomes.

RESULTS

Infants from high-risk (n = 538; 42%) and low-risk (n = 753; 58%) neighborhoods were compared. In bivariate analyses, the risk of NDI and cognitive, motor, and language delays was greater in high-risk neighborhoods. In adjusted regression models, the risks of NDI (OR, 1.43; 95% CI, 1.04-1.98), cognitive delay (OR, 1.62; 95% CI, 1.15-2.28), and language delay (OR, 1.58; 95% CI, 1.15-2.16) were greater in high-risk neighborhoods. Breast milk at discharge was more common in low-risk neighborhoods and was protective of NDI in regression analysis.

CONCLUSIONS

High neighborhood risk provides an independent contribution to preterm adverse NDI, cognitive, and language outcomes. In addition, breast milk at discharge was protective. Knowledge of neighborhood risk may inform the targeted implementation of programs for socially disadvantaged infants.

Paediatric dysphagia within the context of South Africa's quadruple burden of disease, seen at a tertiary level hospital

Purpose: To inform service provision, this study explored feeding and swallowing difficulties in children within the context of South Africa's quadruple burden of disease (BOD) (i.e. conditions characterised as communicable, non-communicable, maternal and/or perinatal and trauma).Method: A retrospective chart review of 1432 paediatric inpatients (under 12 years of age) who met the inclusion criteria of presenting with dysphagia and being referred for speech-language pathology services was conducted.Result: Participants with diagnoses within the maternal and/or perinatal BOD category were noted most frequently (61.2%), followed by non-communicable (59.7%), communicable (43.4%) and trauma (4.2%). The majority of participants were under 1 year of age (82.2%) and 56.2% presented with comorbidities in multiple BOD categories. Mortality was 5.9%, with a higher rate (67.7%) in more complex cases. Mortality was associated with non-communicable BOD (p = 0.001), and maternal and/or perinatal BOD (p = 0.003). Pharyngeal phase swallowing difficulties were a significant risk for mortality (OR = 2.96; 95% CI: 1.01-8.65, p = 0.047).Conclusion: The majority of children with dysphagia presented with multiple comorbidities and were at high risk for mortality. Education and service delivery models should be designed to improve health outcomes and reduce mortality rates.

Parent participation in the neonatal intensive care unit: Predictors and relationships to neurobehavior and developmental outcomes

OBJECTIVE

To 1) define predictors of parent presence, any holding, holding in arms, and skin-to-skin care in the NICU and 2) investigate the relationships between parent participation and a) early neurobehavior and b) developmental outcomes at age 4 to 5years among preterm infants.

METHODS

Eighty-one preterm infants born ≤32weeks estimated gestational age were prospectively enrolled within one week of life in a level III-IV NICU. Parent (maternal and paternal) presence and holding (including holding in arms and skin-to-skin care) were tracked throughout NICU hospitalization. Neurobehavior at term equivalent age and development at 4 to 5years were determined using standardized assessments.

RESULTS

The median number of days per week parents were documented to be present over NICU hospitalization was 4.0 (IQR=2.4-5.8) days; days held per week 2.8 (IQR=1.4-4.3) days [holding in arms days per week was 2.2 (IQR=1.2-3.2) days and parent skin-to-skin care days per week was 0.2 (IQR=0.0-0.7) days]. More parent presence was observed among mothers who were Caucasian, married, older, or employed and among those who had fewer children, familial support and provided breast milk (p<0.05). More holding was observed in infants with fewer medical interventions (p<0.05) and among those who were Caucasian, had a father who was employed, had fewer children and family support (p<0.05). More parent holding in the NICU was related to better reflex development at term age (p=0.02). More parent skin-to-skin care was related to better infant reflexes (p=0.03) and less asymmetry (p=0.04) at term and better gross motor development (p=0.02) at 4-5years.

DISCUSSION

Social and medical factors appear to impact parent presence, holding, and skin-to-skin care in the NICU. Parent holding is related to better developmental outcomes, which highlights the importance of engaging families in the NICU.

Effectiveness of interventions during NICU hospitalization on the neurodevelopment of preterm infants: a systematic review protocol

BACKGROUND

Previous systematic reviews have examined preterm infants' long-term neurodevelopment after neonatal intensive care unit (NICU) discharge, although none have explored the effectiveness of interventions on preterm infants' neurodevelopment during NICU hospitalization. The aim of this review is to evaluate whether interventions, i.e., sensory stimulation, parental involvement, and control of environment, improve preterm infants' neurodevelopment during their NICU hospitalization.

METHODS

Experimental studies such as randomized controlled/clinical trials (RCTs) and cluster RCT will be included in this systematic review. Selected studies will be published in English or in French, in the past 15 years from 2002 to 2017. The following electronic databases will be searched to locate relevant studies: CINAHL, MEDLINE, PubMed, EMBASE (OVID), Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science. For all steps in selecting studies, agreement will be reached between two experts in neonatology. Data extraction will be performed independently by the two same experts and will then be compared. The Cochrane assessment tool will be used to screen the studies for risk of bias. A meta-analysis will be performed if the included studies are sufficiently homogeneous. Results will be analyzed using a standardized mean difference (with a 95% confidence interval). Statistical heterogeneity will be evaluated using the χ 2 test at the significance level of 0.1 and the I 2 with the classification suggested by PRISMA-P. If possible, subgroup analyses will be carried out considering preterm infants' gestational age, length of NICU hospitalization, and the characteristics of the intervention such as who delivered it, the type, the dose, the frequency, and the duration. Data synthesis will be performed using the RevMan 5.1 software. Publication bias and selection of variables in publication will be examined using the graphical method of funnel plot and with the statistical test of Egger. Quality of the evidence of all outcomes will be assessed using the Grades of Recommendations Assessment, Development and Evaluation (GRADE) Working Group.

DISCUSSION

The results of this systematic review will highlight which interventions are effective for promoting preterm infants' neurodevelopment during NICU hospitalization and will contribute to the body of knowledge in neonatal care by providing guidance for NICU clinical practice and research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017047072.

A Strategy to Reduce Critical Cardiorespiratory Alarms due to Intermittent Enteral Feeding of Preterm Neonates in Intensive Care

Background

Many preterm infants require enteral feeding as they cannot coordinate sucking, swallowing, and breathing. In enteral feeding, milk feeds are delivered through a small feeding tube passed via the nose or mouth into the stomach. Intermittent milk feeds may either be administered using a syringe to gently push milk into the infant’s stomach (push feed) or milk can be poured into a syringe attached to the tube and allowed to drip in by gravity (gravity feed). This practice of enteral feeding is common in neonatal intensive care units. There is, however, no evidence in the literature to recommend the use of one method of feeding over the other.

Objective

The aim of this study was to investigate which of the two methods of feeding is physiologically better tolerated by infants, as measured by the incidence of critical cardiorespiratory alarms during and immediately after feeding.

Methods

We conducted a prospectively designed observational study with records of all feeding episodes in infants of gestational age less than 30 weeks at birth and with a minimum enteral intake of 100 mL/kg/day. In total, 2140 enteral feeding episodes were noted from 25 infants over 308 infant-days with records for several characteristics of the infants (eg, gestational age), feeding (eg, the position of infants), and of nursing-care events before feeding (eg, diapering). Logistic regression with mixed effects was used to model cardiorespiratory alarms for the push and gravity methods of feeding.

Results

After adjustments were made for all confounding variables, the position of infants was found to be statistically significant in changing the outcome of critical alarms for the two methods of feeding (P=.02). For infants in the lateral position, push feeds led to 40% more instances of one or more critical cardiorespiratory alarms in comparison with the gravity method. Both methods of feeding created a statistically comparable number of alarms for infants in the prone position.

Conclusions

This study provides objective data that may assist in optimizing enteral feeding protocols for premature infants. The incidence of critical cardiorespiratory alarms for infants in the lateral position can be lowered by the use of gravity instead of push feeding. No differences were observed between the two types of feeding when infants were in the prone position.

A targeted noise reduction observational study for reducing noise in a neonatal intensive unit

BACKGROUND

Excessive noise in neonatal intensive care units (NICUs) can interfere with infants' growth, development and healing.Local problem:Sound levels in our NICUs exceeded the recommended levels by the World Health Organization.

METHODS

We implemented a noise reduction strategy in an urban, tertiary academic medical center NICU that included baseline noise measurements. We conducted a survey involving staff and visitors regarding their opinions and perceptions of noise levels in the NICU. Ongoing feedback to staff after each measurement cycle was provided to improve awareness, engagement and adherence with noise reduction strategies. After widespread discussion with active clinician involvement, consensus building and iterative testing, changes were implemented including: lowering of equipment alarm sounds, designated 'quiet times' and implementing a customized education program for staff.

INTERVENTIONS

A multiphase noise reduction quality improvement (QI) intervention to reduce ambient sound levels in a patient care room in our NICUs by 3 dB (20%) over 18 months.

RESULTS

The noise in the NICU was reduced by 3 dB from baseline. Mean (s.d.) baseline, phase 2, 3 and 4 noise levels in the two NICUs were: LAeq: 57.0 (0.84), 56.8 (1.6), 55.3 (1.9) and 54.5 (2.6) dB, respectively (P<0.01). Adherence with the planned process measure of 'quiet times' was >90%.

CONCLUSIONS

Implementing a multipronged QI initiative resulted in significant noise level reduction in two multipod NICUs. It is feasible to reduce noise levels if QI interventions are coupled with active engagement of the clinical staff and following continuous process of improvement methods, measurements and protocols.

Sustaining a "culture of silence" in the neonatal intensive care unit during nonemergency situations: a grounded theory on ensuring adherence to behavioral modification to reduce noise levels

The aim of this study was to generate a substantive theory explaining how the staff in a resource-limited neonatal intensive care unit (NICU) of a developing nation manage to ensure adherence to behavioral modification components of a noise reduction protocol (NsRP) during nonemergency situations. The study was conducted after implementation of an NsRP in a level III NICU of south India. The normal routine of the NICU is highly dynamic because of various categories of staff conducting clinical rounds followed by care-giving activities. This is unpredictably interspersed with very noisy emergency management of neonates who suddenly fall sick. In-depth interviews were conducted with 36 staff members of the NICU (20 staff nurses, six nursing aides, and 10 physicians). Group discussions were conducted with 20 staff nurses and six nursing aides. Data analysis was done in line with the reformulated grounded theory approach, which was based on inductive examination of textual information. The results of the analysis showed that the main concern was to ensure adherence to behavioral modification components of the NsRP. This was addressed by using strategies to “sustain a culture of silence in NICU during nonemergency situations” (core category). The main strategies employed were building awareness momentum, causing awareness percolation, developing a sense of ownership, expansion of caring practices, evolution of adherence, and displaying performance indicators. The “culture of silence” reconditions the existing staff and conditions new staff members joining the NICU. During emergency situations, a “noisy culture” prevailed because of pragmatic neglect of behavioral modification when life support overrode all other concerns. In addition to this, the process of operant conditioning should be formally conducted once every 18 months. The results of this study may be adapted to create similar strategies and establish context specific NsRPs in NICUs with resource constraints.

Parents of preterm-born children; sources of stress and worry and experiences with an early intervention programme - a qualitative study

Background

Preterm-born children are at increased risk of adverse developmental outcomes, and their parents may experience increased stress levels. The Mother–Infant Transaction Program (MITP) is an early intervention that aims to enhance the parent–infant relationship and child development. The present study investigated differences in parents’ experience of stress and concerns about caring for their preterm-born child according to whether they participated in the programme. Parental satisfaction with the intervention was also explored.

Methods

As part of a follow-up study at 36 months, a randomized controlled trial of the MITP—14 parents of 11 children from the intervention group, and 17 parents of 14 children from the control group were interviewed by the use of semi-structured focus group interviews. The interviews were analysed thematically.

Results

The intervention parents reported that the knowledge, advice, guidance and emotional support given during the intervention made them feel less stressed and more confident, competent and secure caring for their preterm born child than they would otherwise have been. The control parents described feeling less involved and emotionally supported, and seemed more anxious about their child’s development than the intervention parents. All parents were vigilant and alert to their child’s needs and monitored developmental milestones carefully.

Conclusion

This qualitative exploration of the influences of the MITP revealed a positive impact of the intervention and seems to be an important educational and supportive initiative. Thus, reducing parental stress and enhancing confidence in the parental role.