System Specific Effects of Therapeutic Hypothermia with Neonatal Encephalopathy: Pearls for Clinicians

Neonatal encephalopathy (NE) is defined as a condition of impaired neurological function often caused by a peripartum event that impairs gas exchange resulting in hypoxia, hypercapnia, cerebral ischemia, and metabolic acidosis. NE is a significant cause of neonatal morbidity and mortality. Therapeutic hypothermia (TH) is the standard of care for the treatment of moderate and severe NE and has significantly improved long-term outcomes for affected infants. There are extensive systemic physiologic effects associated with TH that clinicians need to be aware of to optimize care for these infants. There is a paucity of literature that comprehensively identifies causal relationships between the physiologic and biochemical effects of TH. This can leave neonatal clinicians devoid of a comprehensive understanding of the medical management of NE. Therefore, this article seeks to help fill this gap, improve clinician knowledge base, and ultimately improve the care of infants undergoing TH.

Neonatal Enterovirus: A Case Report in a Term Infant Requiring Air Evacuation

Enterovirus infections in neonates have the potential to cause a cascade of devastating clinical complications that can lead to death. Because of vague maternal symptom presentations, the diagnosis may not be obvious to antepartum adult providers. Clinicians evaluating infants in the newborn nursery and following initial hospital discharge must be alert for this potential infection. Common newborn issues, such as hyperbilirubinemia and weight loss, may be early signs of a more life-threatening diagnosis. Enterovirus infections may be responsible for a continuum of critical diagnoses in the neonate. Utilization of viral panels during the initial rule-out sepsis evaluation may provide rapid diagnosis and, ultimately, earlier response times to devastating clinical symptoms. Antepartum history and presenting features of enteroviral infections warrant rapid diagnosis with viral polymerase chain reaction detection panels to potentially reduce antibiotic usage and inpatient length of stay. The purpose of this case report is to review risk factors, presentation, and management of neonatal enterovirus infections. As this infant was born in a remote setting and required air evacuation, the logistics of this transport are also discussed.

Provision of Sedation and Treatment of Seizures During Neonatal Therapeutic Hypothermia

Hypoxic-ischemic encephalopathy (HIE) produces a high rate of long-term neurodevelopmental disability in survivors. Therapeutic hypothermia dramatically improves the incidence of intact survival, but does not eliminate adverse outcomes. The ideal provision of sedation and treatment of seizures during therapeutic hypothermia represent therapeutic targets requiring optimization in practice. Physiologic stress from therapeutic hypothermia may obviate some of the benefits of this therapy. Morphine is commonly utilized to provide comfort, despite limited empiric evidence supporting safety and efficacy. Dexmedetomidine represents an interesting alternative, with preclinical data suggesting direct efficacy against shivering during induced hypothermia and neuroprotection in the setting of HIE. Pharmacokinetic properties must be considered when utilizing either agent, with safety dependent on conservative dosing and careful monitoring. HIE is the leading cause of neonatal seizures. Traditional therapies, including phenobarbital, fosphenytoin, and benzodiazepines, control seizures in the vast majority of neonates. Concerns about the acute and long-term effects of these agents have led to the exploration of alternative anticonvulsants, including levetiracetam. Unfortunately, levetiracetam is inferior to phenobarbital as first-line therapy for neonatal seizures. Considering both the benefits and risks of traditional anticonvulsant agents, treatment should be limited to the shortest duration indicated, with maintenance therapy reserved for neonates at high risk for recurrent seizures.

Profile of at-risk newborns attended by nurses in outpatient follow-up clinic: a retrospective cohort study

OBJECTIVE

to analyze the cohort profile of at-risk newborns attended by nurses in a multidisciplinary follow-up clinic, with emphasis on the type of feeding and weight gain, after hospital discharge.

METHOD

retrospective cohort, whose population is composed of at-risk newborns attended in a 4-year period. Data came from medical records and attendance report, later exported to R Program. The outcome variables were number of the nursing consultation, type of feeding, daily weight gain and main guidelines. We used descriptive statistics, frequency distribution and applied Mann-Whitney, Chi-Square, Spearman correlation, Variance and Tukey analysis, with p <0.05 being significant.

RESULTS

a total of 882 consultations with 629 infants and families were analyzed. The frequencies of exclusive breastfeeding and weight gain increased as the consultations progressed. The infants who needed more consultations and with lower weight gain were those with lower gestational age (p = 0.001) and birth weight (p = 0.000), longer length of hospital stay (p <0.005), and diagnoses related to extreme prematurity (p <0.05), among others.

CONCLUSION

nurses verified the importance of outpatient follow-up of at-risk newborns, especially in promoting breastfeeding and healthy growth.

National audit of neonatal units finds improvements in care

BABIES BORN early in the north of England are less likely to be breastfed than those in the south, making them more prone to infections.

Treatment for early-onset neonatal sepsis

Up to one in 10 neonates are investigated and treated for neonatal sepsis, although most are later found to be uninfected. This review discusses identifying and treating this emergency condition and how implementing NICE guidance could reduce treatment time in well babies and saveonatal sepsis resources without compromising care.

Neonatal pharmacology--pharmacokinetics

The goal of drug therapy is a defined clinical response. Drug therapy in the vulnerable preterm and term newborn population is complicated by developmental limitations that affect the pharmacokinetics of most drugs. It is important that, in any therapy, care providers maintain a keen awareness of the expected response while monitoring the infant's clinical response throughout drug administration. This column has addressed pharmacologic principles, especially the pharmacokinetics of drug therapy, to guide clinical assessments of patients' responses to drug therapy.

Nuchal Cord Management and Nurse-Midwifery Practice

Nuchal cord, or cord around the neck of an infant at birth, is a common finding that has implications for labor, management at birth, and subsequent neonatal status. A nuchal cord occurs in 20% to 30% of births. All obstetric providers need to learn management techniques to handle the birth of an infant with a nuchal cord. Management of a nuchal cord can vary from clamping the cord immediately after the birth of the head and before the shoulders to not clamping at all, depending on the provider's learned practices. Evidence for specific management techniques is lacking. Cutting the umbilical cord before birth is an intervention that has been associated with hypovolemia, anemia, shock, hypoxic-ischemic encephalopathy, and cerebral palsy. This article proposes use of the somersault maneuver followed by delayed cord clamping for management of nuchal cord at birth and presents a new rationale based on the available current evidence.

The dying neonate: family-centered end-of-life care

There is a need in the NICU for an end-of-life care guideline that nurses can follow when working with dying infants and their families. Maintaining intravenous access to relieve the infant's pain, communicating sensitively to the family, and creating precious, everlasting memories are goals that should be part of every dying infant's care. The nurse's ability to partner with the family in caring for the infant is integral to helping the family take the first steps in their grief journey. Evidence-based literature provides NICU nurses with the knowledge that they are the facilitators of end-of-life care for dying infants. New mothers and fathers are not aware of the caring parental tasks they can perform for their dying baby. They look to and depend on their infant's nurses to encourage them. The guideline included here provides nurses with a tool for ensuring that families have the opportunity to create memories that will not only help them with their immediate pain, but also comfort them for a lifetime.

Scalp IV or graduation tassel? Differing perspectives of the NICU experience

FAMILY-FRIENDLY/FAMILY-CENTERED care in the NICU contributes to positive patient outcomes, strong families, and excellence in care. Successfully integrating the patient’s family into the care team in the high-tech, high-stress NICU environment can pose many challenges to the nursing staff. A significant obstacle to successful family-professional partnerships is lack of understanding by NICU professionals of parental perspectives of the NICU experience. This column provides unique insight into the differing perspectives of one infant’s family and the NICU staff who cared for him.

[Perceptions of newborns' families about the communication of bad news]

The present study aims to describe how families perceive the communication of bad news about hospitalized newborns given by professionals. A qualitative and descriptive study was carried out with families of hospitalized newborns in the neonatal unit. Five mothers and one father were interviewed The thematic analysis of data revealed four categories: Message content in relation to clarity, detailing and not disclosed information. The way the news was transmitted: leads to ambiguity in reactions. Families' perceptions aboutprofessionals' attitudes to transmit the news: sometimes attitudes are different depending on the professional's experience and involvement with the customer. Use of communication strategies for message transmission: considered by the families as a mean to minimize the gravity of the baby's problem. The results pointed out the use of a non symmetrical communication between professional-family The adoption of a team practice, which incorporates it in its interventions, may meet the families' needs of information and social support.

News of the Academy of Neonatal Nursing

Come join us this spring in Boston, Massachusetts, for the 6th National Advanced Practice Neonatal Nurses Conference at the Westin Boston Waterfront, April 3–5, 2009. The Westin is just three miles from Logan International Airport. The Westin is not only convenient for those coming from out of town, it is a beautiful hotel loaded with amenities and located close to Boston’s historical landmarks, shopping, and restaurants.

[Care practices for neonates while setting up a neonatal unit in a university hospital]

The hospitalization process of neonates makes them vulnerable to several care practices. The aim of this study was to get to know the care practices adopted by health professionals while setting up a neonatal unit at the Hospital de Clínicas of Porto Alegre, Rio Grande do Sul, Brazil. This is a qualitative study based on the New History Theory. The study collected data from October 2006 to January 2007. Fifteen health professionals responsible for the project and/or its implementation from 1972 to 1984 provided information. The thematic data analysis highlighted the concern among health professionals of making good use of technological advances, as well as unifying scientifically-based conducts. Besides, they tried to establish routines enabling neonate's parents to stay at the bedside during the whole hospitalization period. Finally, it was inferred that the main objective of these practices was to increase the survival of neonates.

Observational sickness assessment by the NICU staff nurses

OBJECTIVE

To see the level of agreement on subjectively assessed sickness by NICU staff nurse with doctor.

METHODS

Prospective study in NICU for three months. The nurses were asked to assess whether a baby is sick or not on the basis of observed physical variables. Both the nurses and the attending physician made their assessment on a progress sheet separately. Statistical analysis was carried out to see the agreement of the nurses with the doctors in respect to the sickness assessment, treatment, final outcome and the agreement between the symptoms picked up by the nurses and the doctors.

RESULTS

Out of 112 babies admitted, 90 were observed to be sick by the nurses out of which 85 were observed to be sick by the doctors (Kappa=0.4098). Considerable accuracy was noted on comparing symptoms picked up by the nurses and the doctors'. The Kappa value for respiratory, GI and neurological system was 0.4278,0.401 and 0.59 respectively. A significant correlation was seen between the two groups with regard to the treatment given (p value=0.0456).

CONCLUSION

Trained NICU staff nurse can identify sick neonate on observation.

An evaluation of bubble-CPAP in a neonatal unit in a developing country: effective respiratory support that can be applied by nurses

To describe the implementation of bubble-CPAP in a referral hospital in a developing country and to investigate: the feasibility of nurses implementing bubble-CPAP and the impact of bubble-CPAP on need for mechanical ventilation and mortality. Retrospective evaluation of prospectively collected data from two time periods: 18 months before and 18 months after the introduction of bubble-CPAP. The introduction of bubble-CPAP was associated with a 50 per cent reduction in the need for mechanical ventilation; from 113 of 1,106 (10.2 per cent) prior to bubble-CPAP to 70 of 1,382 (5.1%) after introduction of CPAP (chi2, p<0.001). In the 18 months prior to bubble-CPAP there were 79 deaths (case fatality of 7.1 per cent). In the 18 months after bubble-CPAP there were 74 deaths (CF 5.4 per cent), relative risk: 0.75 (0.55-1.02, chi2, p=0.065). Nurses could safely apply bubble-CPAP after 1-2 months of on-the-job training. Equipment for Bubble-CPAP cost 15 per cent of the cost of the cheapest mechanical ventilator. The introduction of bubble-CPAP substantially reduced the need for mechanical ventilation, with no difference in mortality. In models of neonatal care for resource-limited countries, bubble-CPAP may be the first type of ventilatory support that is recommended. Its low cost and safety when administered by nurses makes it ideal for this purpose. Bubble-CPAP has the potential for being available at even lower cost than the current commercially available bubble systems used in this study.

The role of the neonatal intensive care nurse in decision-making: Advocacy, involvement in ethical decisions and communication

Neonatal intensive care unit (NICU) nurses are often faced with complex clinical and ethical problems. Little is known about the role of the NICU nurse in ethical decision-making, or processes that inform decision-making in this setting. The purpose of this study was to explore and describe nurses' perceptions of their role as patient advocate, clinical situations that cause them concern and the extent of their involvement in ethical decision-making. A combined quantitative and qualitative research design was used. A questionnaire was administered to nurses working in the NICU of the sole perinatal tertiary referral centre of Western Australia, Australia. Findings showed that NICU nurses saw their role in ethical decision-making primarily as advocating for the best interests of the infant and family, that they used clinical knowledge and experience to guide ethical decision-making, they were able to clearly articulate ethical problems and respond to them according to the clinical scenario and, while being primarily assertive in presenting their views, some nurses took a more passive approach. These findings support the need for development of a multidisciplinary model for ethical decision-making, where the view of all team members are considered.

A reliable pain assessment tool for clinical assessment in the neonatal intensive care unit

OBJECTIVE

The aim of this study was to validate a clinician-friendly pain assessment tool for all groups of critically ill infants cared for in the specific neonatal intensive care units (NICUs) studied.

DESIGN

A prospective study was undertaken to test the Pain Assessment Tool (PAT). Interrater reliability of the PAT score was assessed by two nurses who simultaneously determined an infant's PAT score. The PAT was validated against the CRIES score--crying, requires increased oxygen administration, increased vital signs, expression, sleeplessness--and the mother's assessment of her infant's discomfort using the Visual Analogue Scale (VAS).

SETTING

The NICUs at two children's hospitals.

PATIENTS

Participants were 144 preterm and term infants. Infants on a ventilator and those who had undergone surgery were included.

RESULTS

The interrater reliability of the PAT was .85 with a mean difference of 0.17 (standard deviation: 1.73). There was a strong correlation between the PAT and CRIES scores (r = 0.76) and a moderate correlation (.38) between the PAT score and the VAS scores of the infant's mother. The correlation coefficient between the PAT score and CRIES score was significant for all groups (p < .01).

CONCLUSIONS

The PAT score was shown in this study to be a valid, reliable, and clinician-friendly pain assessment measurement tool for all infants nursed in the NICU.

Utilizing an oral sucrose solution to minimize neonatal pain

ISSUES AND PURPOSE

To present an evidence-based practice protocol for oral sucrose administration to minimize neonatal procedural pain.

CONCLUSION

Examination of published research may provide additional modalities to expand an established pediatric pain-management program.

PRACTICAL IMPLICATIONS

The extensive research evaluating oral sucrose supports its inclusion in a pediatric pain-management program. A thorough implementation plan will allow new modalities to be included to optimize procedural pain relief for hospitalized neonates with minimal staff resistance and improved patient outcomes.

A history of neonatal group B streptococcus with its related morbidity and mortality rates in the United States

The history of neonatal sepsis related to early onset group B streptococcus (GBS) emerged in the early 1970s. The neonatal mortality rate was 55% for those neonates with invasive GBS disease. The first adopted guidelines by the medical community to prevent early onset GBS were developed in the 1990s. One year after implementation of the guidelines, the mortality rate dropped to approximately 5%. Despite the great accomplishments in reducing the mortality rate, GBS remains the number one cause of infant morbidity and mortality in the United States.

Strategic use of antibiotics in the neonatal intensive care unit

Infection is one of the most common causes of infant morbidity and mortality in the neonatal intensive care unit, despite the availability of various therapeutic medical interventions, such as mechanical ventilation, that allow premature infants a better chance of survival. In fact, many of these therapeutic interventions violate the natural protective barriers for infection. Fortunately, maternal and neonatal risk factors have been identified for early- and late-onset sepsis and the prevalence of highly suspected pathogens for each type of infection influences the empiric selection of antibiotics. In many institutions, the common pathogens have developed resistance to antibiotics. In others, the predominance of pathogens has shifted. Both challenges may warrant modification of traditional antibiotic regimens. Continual monitoring of pathogen shifts within an individual neonatal intensive care unit and application of various antibiotic characteristics are key elements of strategic, safe, and effective use of antibiotics in this patient population. Development of a protocol incorporating infection control measures and guidelines for judicious use of antibiotics can minimize the threat of antibiotic resistance.

Viral infection and antiviral therapy in the neonatal intensive care unit

Viral diseases are leading causes of mortality and morbidity among infants requiring care in the neonatal intensive care unit (NICU), with ongoing discoveries of new viral pathology likely to add to the burdens posed. Many viral diseases in NICU infants are undiagnosed or appreciated only late in the course because of subtle or asymptomatic presentation, confusion with bacterial disease, and failure to consider viral disease. We present an overview of viral disease in NICU infants, with emphasis on pharmacologic agents currently employed for prophylaxis and treatment of such diseases. Advances in molecular biology and popular demand to develop antiviral agents for viral diseases (eg, human immunodeficiency virus) offer great promise for the future.

Parental satisfaction with an early family intervention program

The objective of this study was to evaluate parental satisfaction with a family intervention program. The program provides help and support for parents with newborns who have specific health problems (e.g., cleft palate and/or lip; Down syndrome). Four family subscales, personal (emotional and cognitive), marital, parental, and extended family and others, were examined. The majority of parents were satisfied with the intervention. Most felt that the intervention had helped them to adapt to the unexpected situation. They received guidance in discerning and discussing their own emotions and those of their partner or spouse, and the help they received gave them confidence about the care their child would receive. Results revealed significant differences in satisfaction levels (depending on the sex of the parent), the child's diagnosis, and annual income. Mothers of newborns with Down syndrome were more satisfied than fathers with the personal-emotional support they received. Low-income families were more satisfied than those with higher incomes for all subscales. On the parental subscale, those whose child had a cleft lip/palate were more satisfied than those whose child had Down syndrome. The results raised several important questions about this type of early intervention program, which will require further in-depth investigation.

Neonatal nurse practitioners provide quality, cost-effective care

Loretta Ford, the pioneer of nurse practitioners, was the recipient of the Crystal Trailblazer Award from the American College of Nurse Practitioners in February 2003. In her acceptance speech, the stated that "in some ways, the profession had expanded beyond my wildest dreams," but cautioned against the medicalization of the NP role: "The profession is rooted in nursing ... and we enhance, advance, and influence through nursing." She added: "Medical and nursing interdependency sets the stage for the highest level of care. No one profession can deliver comprehensive health care themselves." NNPs, functioning collaboratively with neonatologists as part of a multidisciplinary team, illustrate the truth of Ford's words. They have clearly and unequivocally made significant strides during the past 20 years. Their achievements and contributions have been many but their potential has yet to be reached.

Polycythemia and hyperviscosity of the newborn

Polycythemia and hyperviscosity of the newborn are well-known conditions that are surrounded by controversy. The patient population most affected by polycythemia is the term or near-term infant. The true incidence of this condition is not known since the majority of infants are likely to be asymptomatic, normal newborns. Diagnosis is largely based on hematocrit values and symptoms, which can range from subtle to severe, and not on measures of viscosity. Hematocrits are not routinely drawn in this population, most likely related to the controversy surrounding the treatment of the asymptomatic infant. Presenting symptoms may be subtle and are not always attributed to polycythemia. Knowledge of the etiology, pathophysiology, and clinical signs and symptoms may contribute to the early identification and treatment of infants with polycythemia and hyperviscosity syndrome.

A focus of care for neonatal nursing: the relationship between neonatal nursing practice and outcomes. Part 2

A case study combining semi-structured interviews with documentary evidence was undertaken to ascertain whether neonatal nurses provide care in response to the developmental needs and consequent future quality of life of high risk babies (See Part 1 in May 2003 issue for the background, literature review and design of this study). Findings indicated that neonatal nurses are unable to focus their priorities for care on the long-term development of babies. Limited knowledge of, and unrealistic attitudes towards, potential outcomes posed a high challenge for nurses. Low staffing levels, reduced autonomy and conflicting responsibilities within the multidisciplinary team, were seen to be the main factors obstructing nurses in their caring roles. The overall picture was of a nursing service under pressure, with no continuous focus for care. Raising the profile of neonatology nationally may lead to the allocation of resources necessary to develop nursing practice in relation to outcomes. Creating a focus for care via a nursing model, with continuing infant development at its core, could enhance care provision and allow all babies to receive the optimal care to achieve their full potential.

The "geriatric" NICU patient

AT ONE END OF THE NICU spectrum of patients is the acutely ill premature or term baby. This is the patient who requires the fast-paced and intellectually stimulating nursing care that often attracts NICU nurses to the specialty. At the other end of the spectrum is the chronically ill baby. This is the patient who is past the acute stage but is in the NICU for much longer than anyone expected because of a chronic medical condition. This category of infants includes those with chronic lung disease, tracheostomies with or without ventilator dependence, short-bowel syndrome, and other conditions that require continued specialized care. As they grow, these infants present with conditions that would normally be dealt with on a regular pediatric floor, in the pediatrician’s or primary care physician’s office, or in a neonatal follow-up clinic.

Medication errors: analysis not blame

This article summarizes current knowledge regarding neonatal medication errors and explicates the key concepts of human error and system error. A case report illustrates the sources of error. Medication error analysis must go beyond the blaming of individuals for active errors and explore the latent errors that exist in a complex health care environment. Using correct language to describe and define medication error may facilitate the development of a nonpunitive culture and enable effective evaluation of the causes of error.

[Program designed for the parents of babies at risk: contribution to the training of the nursing student]

The present study is related to the academic education of nursing students who participated in a public service program designed for parents of high-risk newborns assisted in neonatal units. It is a descriptive study that has as its objective to analyze the contribution of such professional experience for those students. The subjects of this investigation were nursing students aged 18 to 22 years old. These students performed ludic, educational and leisure activities with parents of high-risk newborns assisted in a university school in the city of Ribeirão Preto. Data were collected by means of a questionnaires through which the subjects reported their experience in the project (advantages, disadvantages and contributions to their education). The answers were analyzed through the thematic analysis technique. Results showed that the program expanded students' view concerning nursing care and hospital care (beyond disease). It also improved interpersonal relationships; promoted the development of skills and the acquisition of knowledge and values. Thus contributing to students academic education and creativity.

Knowledge, assessment and management of pain related to nursing procedures used with premature babies: questionnaire study for caregivers

The aim of the study was to discover how much Finnish nursing staff know about the pain experienced by premature babies and about pain assessment. The types of helping methods used by caregivers in the nursing of premature babies were also studied. A semistructured questionnaire was sent in autumn 1995 to all registered nurses, practical children's nurses and medical laboratory technologists who take heel blood samples (n = 280) working in paediatric intensive care units in all Finnish university hospitals. The response rate was 70.4%. The structured questions were processed quantitatively at Kuopio University with the SPSS/PC+ data processing program (SPSS, Chicago, IL, USA), and the open questions were processed using quantitative content analysis. The results indicate that the respondents have rather extensive knowledge about the pain experienced by premature babies, pain assessment, pain management and about nursing and helping methods. Pain was assessed mostly on the basis of behaviour and physiological changes, and only infrequently on the basis of biochemical changes. The respondents described the helping methods they use in considerable detail. The most common was to increase the baby's feeling of security. The answers to the open questions revealed that the actions used by the respondents in pain assessment and pain management were not completely consistent with their knowledge. The results demonstrate that caregivers do not use their knowledge adequately in their pain management practices. Future studies should observe the three groups of caregivers in order to discover how they treat premature babies' pain.

[Pain assessment in newborn infants--a review of the literature]

While adults and children can express pain verbally it is not possible to appreciate pain immediately in neonates owing to their lack of language. Pain in the newborn must therefore be assessed indirectly and thus involves the use of physiological, behavioural and biochemical parameters. The present review of the literature describes the difficulties accompanying an objective appreciation of pain among the newborn, in particular in the case of premature babies. Most of the existing scales of pain have been developed for the purposes of research and their practical application in a regular clinical context has never been tested. Nurses and doctors are therefore still faced with the problem of having to use a small number of substantiated tools which, however, have hardly been tested in practice. This is all the more questionable since according to the literature the short and long-term consequences of continuous pain in neonates can include intraventricular haemorrhages, changes in feeding and sleeping patterns and damages to the delicate relationship between the infant and its parents.

Early-onset neonatal group B streptococcal infection: implications for practice

Group B streptococcus (GBS) is the leading bacterial infection associated with morbidity and mortality of newborns in the United States. Most neonatal infections can be prevented through the use of intrapartum antimicrobial prophylaxis in women who are at increased risk for transmitting infection to their newborns. However, prevention strategies have not been implemented widely or consistently, and the incidence of neonatal GBS disease has not declined. An understanding of GBS epidemiology, clinical presentation, and prevention strategies enhances the PNP's decision-making skills in the nursery and strengthens the PNP's ability to evaluate and compare new approaches to GBS prevention.

Comprehensive primary care follow-up for premature infants

Advances in perinatal and neonatal care have led to an increased incidence of survival of premature infants. Although most premature infants have normal outcomes, they are at increased risk for morbidity and mortality and require comprehensive primary care follow-up after they are discharged from the hospital. This article will review guidelines for general follow-up of premature infants and the associated problems related to prematurity. General follow-up is performed by the pediatric nurse practitioner, with subspecialty consultant referrals as needed. Knowledge of the problems of prematurity and treatment regimes will assist the pediatric nurse practitioner in providing high-quality care to these high-risk infants.

The hypothalamus

The hypothalamus is an integral part of the neuroendocrine system. The anatomy, embryologic development, and normal function of the hypothalamus are described here. Pathophysiology of congenital abnormalities and brain injury is discussed and a case study examined. In addition, nursing implications of caring for such an infant are addressed.