Neonatal Care

Correlates and Trajectories of Preterm Infant Sucking Patterns and Sucking Organization at Term Age Background: Premature infants may experience increased difficulty with nutrition and growth. Successful oral feeding is an important factor associated with discharge readiness. Despite the importance of feeding as a growth-fostering process, little empiric evidence exists to guide recommendations for early interventions. Purpose: Evaluate whether specific elements of sucking, during preterm initiation of oral feeding, predict sucking organization at corrected term age. Methods: Sucking performance of 88 preterm infants born between 24 and 34 weeks of post–menstrual age was measured at baseline and term (33-35 and 40 ± 1.5 weeks). Participants were divided into 4 groups (quartiles) based on initial measures of performance including number of sucks, number of bursts, sucks per burst, and maximum pressure. Stability in sucking organization was assessed by comparing changes in infant's quartile location from baseline to term. Results: A correlation between quartile location was observed for mean maximum pressure (PMAX): infants with PMAX in the lowest quartile (poorest performance) were significantly more likely to remain in the lowest quartile at term (P < .000); infants in the highest quartile (best performance) at baseline were significantly more likely to be in the highest quartile at term (P < .000). Implication for Practice: Infants with the weakest sucking pressures at 34 weeks of post–menstrual age continue to be at risk for less than optimal feeding skills at 40 weeks of post–menstrual age. Early identification of at-risk infants may allow for effective interventions to potentially decrease long-term feeding problems. Implications for Research: Future research should focus on the development of personalized interventions to address attributes of problematic feeding such as sucking efficiency. Correspondence: Jacqueline M. McGrath, PhD, RN, FNAP, FAAN, UT Health San Antonio, School of Nursing, 7703 Floyd Curl Blvd, Room 2.202e, San Antonio, TX 78229 (mcgrathj@uthscsa.edu). There are no competing financial interests in relation to the work described. Dr McGrath, who is a coeditor for Advances in Neonatal Care and the coauthor and mentor to the primary author, was not involved in the editorial review or decision to publish this article. The entire process from submission, referee assignment, and editorial decisions was handled by other members of the editorial team for the journal. © 2020 by The National Association of Neonatal Nurses

Human Milk Expression, Storage, and Transport by Women Whose Infants Are Inpatients at a Tertiary Neonatal Unit in Melbourne, Australia: An Exploratory Study Background: Expression and storage of mothers' own milk at home and its transportation to hospital neonatal units are a common practice worldwide when newborns are inpatients. Studies assessing adherence to hospital protocols and guidelines for this are not widely published. Purpose: To explore the advice received and practices followed by mothers when expressing, storing, and transporting their milk from home to the hospital, with a substudy exploring the factors related to temperature maintenance of refrigerated milk at recommended values. Methods: Cross-sectional descriptive study at the neonatal intensive care unit of Mercy Hospital for Women, Melbourne, Australia. Mothers who were discharged home after birth of the infant, but whose infant(s) remained in the neonatal unit for 7 days or more participated. All participants completed a self-administered questionnaire. In the substudy, home refrigerator temperature and surface temperature of milk on arrival to the hospital were recorded. Results: The questionnaire was completed by 100 mothers; 38 participated in the substudy. Median travel time from home to the hospital was 32 minutes (range, 2-135 minutes). Lactation consultants were the largest group providing information, with 44 participants (45%) identifying them as the primary information source. Knowledge about recommended refrigerator storage times for expressed milk was correct in 53 mothers (54%). Coolness of milk was better maintained when transported in an insulated food container than nonuse (surface temperature: mean 9.1°C vs 12.2°C; P = .007). Distance and travel duration were not correlated with temperature. Implications for Practice: More diligent monitoring of conditions under which mothers' own milk is transported to hospital is required, and the use of an insulated food container for refrigerated/frozen milk, even for a short duration, should be strongly recommended. Staff to be trained and better equipped to provide uniform, concise information on expressed human milk management to mothers. Implications for Research: Further research to correlate factors associated with transporting human milk expressed at home and infant health outcome is needed. Correspondence: Ranmali Rodrigo, MD, DCH, MBBS, MRCPCH, Judith Lumley Centre, La Trobe University, Level 3, George Singer, Bldg, Bundoora, VIC 3086, Australia (ranmali_waduge@yahoo.com). Funding was received from the postgraduate student support grant, La Trobe University, in 2013 to purchase equipment. Conflict of Interest: None. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.advancesinneonatalcare.org). © 2020 by The National Association of Neonatal Nurses

40% Glucose Gel for the Treatment of Asymptomatic Neonatal Hypoglycemia Background: The Mother Infant Care Center at Fort Belvoir Community Hospital (FBCH) recently revised its asymptotic neonatal hypoglycemia (ANH) protocol and adopted 40% glucose gel into its treatment pathway. The previous protocol used infant formula as the primary intervention. Purpose: To evaluate the effectiveness of 40% glucose gel on exclusive human milk diet rates, time on protocol, level II Special Care Nursery (SCN) admission rates, length of stay (LOS), and total hospital costs for newborns with ANH at FBCH. Methods: Infants with ANH were treated with 40% glucose gel (n = 35) and compared with a historical group of infants with ANH (n = 29) who were treated with formula. Results: Exclusive human milk diet rates increased by 33.6%. The mean time on protocol dropped by 1.13 hours. The SCN admission rates dropped by 2.4% in the postimplementation group. The mean LOS was more than 12 hours less in the postimplementation group. The mean total cost per patient was $1190.60 lower after implementation of 40% glucose gel. Implications for Practice: The use of 40% glucose gel is a patient-focused, less-invasive, and cost-effective treatment of ANH. Implications for Research: More studies are needed to better define neonatal hypoglycemia. The use of 40% glucose gel is safe for use in infants with ANH; however, more studies are needed to examine its comprehensive benefits. Correspondence: LCDR Brandi L. Gibson, NC, USN, Duke University School of Nursing, 307 Trent Dr, Durham, NC 27710 (Gibson.brandi@rocketmail.com). All authors and coauthors of this article have read and approved the manuscript for publication and have all contributed equal substance to this work. No funding was required for this quality improvement project as it was conducted as part of the primary investigator's doctoral studies. Special acknowledgments recognize Mr Andrew Kim at Fort Belvoir Community Hospital for assisting with acquiring the cost data for the project and statistician Dr Julie Thompson at Duke for her assistance with data analysis on the project. Additional acknowledgments go to the neonatal nurse practitioners: Angela Wallace, Debbie Rosado, Christa Brown, Joan Hammond, and Tina Anderson for managing the daily data collection for our postimplementation group and championing this project. The views expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the US government. LCDR Gibson, NC, USN, and LT LeDuff, NC, USN, are military service members. This work was prepared as part of their official duties. Title 17, USC, §105 provides that "Copyright protection under this title is not available for any work of the US government." Title 17, USC, §101 defines a "US government work as a work prepared by a military service member or employees of the US government as part of that person's official duties." Written work prepared by employees of the federal government as part of their official duties is, under the US Copyright Act, a "work of the US government" for which copyright is not available. As such, copyright does not extend to the contributions of employees of the federal government. There are no conflicts of interest or financial disclosures. © 2020 by The National Association of Neonatal Nurses

What Do Neonatal Intensive Care Unit Policies Tell Us About Kangaroo Care implementation? A Realist Review Background: Kangaroo care (KC) is recommended for infants during their stay in the neonatal intensive care unit (NICU) due to the benefits to infant growth, stabilized vital signs, and parental bonding; however, literature primarily explores the physiologic benefits, barriers, and facilitators to KC practice. Little is known about the context and mechanisms of KC implementation. Purpose: This realist review is to explore what NICU policies tell us about practices to implement KC in the NICU. Methods: Policies were obtained via email, database, and search engines. Criteria were established to review each policy. Data were entered into a database then exported for frequency counts of identified characteristics. Results: Fifty-one policies were reviewed, which revealed inconsistencies in the implementation of KC practices. Inconsistencies include variability in infant postmenstrual ages and weight criteria, infant medical equipment in place during participation, duration and frequency of KC, KC documentation, and ongoing monitoring requirements. Implications for Practice: KC implementation varies widely across NICUs, even with similar infant populations. Exclusion of some infants from receiving KC may decrease the potential beneficial outcomes known to result from KC. Implications for Research: More research to understand KC best practice recommendations and implementation in the NICU is needed. Studies are needed to evaluate the duration and frequency of KC, as well as the benefits to infants and families to optimize KC in the NICU setting. Correspondence: Melissa Fluharty, BSN, RN, 4838 Buttercup Way, Summerville, SC 29485 (fluhart@musc.edu). The authors declare no conflicts of interest. © 2020 by The National Association of Neonatal Nurses

The Effect of 2 Humidifier Temperature Settings on Inspired Gas Temperatures and the Physiological Parameters of Preterm Infants Receiving Mechanical Ventilation Therapy Background: The use of heated and humidified gas during mechanical ventilation is routine care in neonatal intensive care units. Giving gas at inadequate heat and humidity levels can affect neonatal morbidity and mortality. Purpose: To compare the effects of 2 humidifier temperature settings on the temperature and humidity of the inspired gas and the physiologic parameters in preterm newborns receiving mechanical ventilation. Methods: The research was conducted in a single-group quasi-experimental design. Proximal temperature was measured using a humidity heat transmitter. The humidifier temperature was set at 38°C (temperature I) and then at 39°C (temperature II). Results: The mean proximal temperatures were significantly lower than the values set in the humidifier (33.8 ± 1.20°C at temperature I, and 34.06 ± 1.30°C at temperature II, P < .001). However, the difference between the 2 proximal temperatures was not significant (P = .162). The incubator temperature was found to be effective on the proximal gas temperature (P < .05). It was found that only preterm infants in the temperature II group had a higher mean heart rate (P < .05). Implications for Practice: Incubator temperatures may have an effect on inspired gas temperature in preterm infants who are mechanically ventilated and caregivers should be aware of these potentially negative effects. Implications for Research: Future studies should focus on how to measure the temperature and humidity of gas reaching infants in order to prevent heat and humidity losses. Correspondence: Sema Bayraktar, PhD, MSc, RN, Department of Nursing, Faculty of Health Sciences, Bezmialem Vakif University, Silahtaraga caddesi, No:189 34065 Eyupsultan, Istanbul, Turkey (sema.byrktrr@gmail.com). The project was funded by the Research Fund of Istanbul University-Cerrahpasa: project no. 24657. The authors have no conflicts of interest to disclose. © 2020 by The National Association of Neonatal Nurses

Recovering Together: Mothers' Experiences Providing Skin-to-Skin Care for Their Infants With NAS Background: Over the past 2 decades, the prevalence of neonatal abstinence syndrome (NAS) has increased almost 5-fold. Skin-to-skin care (SSC), a method of parent–infant holding, is a recommended nonpharmacologic intervention for managing NAS symptoms. SSC has the potential to reduce withdrawal symptoms while positively influencing parent–infant attachment. Yet, little is known about the SSC experiences of mothers of infants with NAS. Purpose: The purpose of this study was to explore the SSC experiences of mothers of infants with NAS, including perceived barriers to SSC in the hospital and following discharge home. Methods: A qualitative descriptive design was used to obtain new knowledge regarding the experience of SSC of mothers of infants with NAS. Purposive sampling was used to recruit participants eligible for the study. We conducted semistructured individual interviews with postpartum mothers of infants with NAS. Data were analyzed using thematic analysis. Findings/Results: Thirteen mothers participated in the study. Four themes emerged from the data analysis: "a little nerve racking"; "she needed me, and I needed her"; dealing with the "hard times"; and "a piece of my puzzle is missing." SSC was described as a conduit for healing and bonding; in addition, several barriers to SSC were reported. Implications for Practice and Research: These findings highlight the inherent benefits of SSC for infants with NAS and demonstrate the unique challenges of these mother–infant dyads. Critical changes in hospital practices are needed to create an environment supportive of SSC for this patient population. In addition, research regarding implementation of interventions to increase SSC usage in this population is warranted. Correspondence: Kelly McGlothen-Bell, PhD, RN, IBCLC, School of Nursing, UT Health San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229 (mcglothen@uthscsa.edu). This work was funded by the Texas Health & Human Services Commission. The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Dr McGrath, who is a Co-Editor for Advances in Neonatal Care and the coauthor and mentor to the primary author, was not involved in the editorial review or decision to publish this article. The entire process from submission, referee assignment, and editorial decisions was handled by other members of the editorial team for the journal. © 2020 by The National Association of Neonatal Nurses

Implementing a Hospital-Based Safe Sleep Program for Newborns and Infants Background: An unsafe sleep environment remains the leading contributor to unexpected infant death. Purpose: To determine the effectiveness of a quality improvement initiative developed to create a hospital-based safe sleep environment for all newborns and infants. Methods: A multidisciplinary team from the well-baby nursery (WBN) and neonatal intensive care unit (NICU) of a 149-bed academic, quaternary care, regional referral center developed and implemented safe sleep environments within the hospital for all prior to discharge. To monitor compliance, the following were tracked monthly: documentation of parent education, caregiver surveys, and hospital crib check audits. On the inpatient general pediatric units, only hospital crib check audits were tracked. Investigators used Plan-Do-Study-Act (PDSA) cycles to evaluate the impact of the initiative from October 2015 through February 2018. Results: Safe sleep education was documented for all randomly checked records (n = 440). A survey (n = 348) revealed that almost all caregivers (95.4%) reported receiving information on safe infant sleep. Initial compliance with all criteria in WBN (n = 281), NICU (n = 285), and general pediatric inpatient units (n = 121) was 0%, 0%, and 8.3%, respectively. At 29 months, WBN and NICU compliance with all criteria was 90% and 100%, respectively. At 7 months, general pediatric inpatient units' compliance with all criteria was 20%. Implications for Practice: WBN, NICU and general pediatric inpatient unit collaboration with content experts led to unit-specific strategies that improved safe sleep practices. Implications for Research: Future studies on the impact of such an initiative at other hospitals are needed. Correspondence: Patricia A. Patrick, DrPH, Westchester Institute for Human Development, 20 Plaza West, Cedarwood Hall, Valhalla, NY 10595 (ppatrick@wihd.org). The authors declare no conflicts of interest. © 2020 by The National Association of Neonatal Nurses

Availability of Donor Human Milk Decreases the Incidence of Necrotizing Enterocolitis in VLBW Infants Background: Human milk feeding is associated with decreased risk of necrotizing enterocolitis (NEC). Purpose: To determine whether a quality improvement project in New Jersey neonatal intensive care units (NICUs) to promote human milk (HM) feedings would be associated with a decrease in NEC. Methods: Fourteen New Jersey NICUs engaged in efforts to reduce infection and promote HM feeding in very low birth-weight (VLBW) infants. Donor human milk (DHM) availability and NEC rates were assessed. Results: From 2009 to 2016, NICUs with DHM increased from 0 to 7. VLBW infants discharged on any HM increased from 35% in 2007 before the formation of the New Jersey NICU Collaborative to more than 55% in 2016. Time to first oropharyngeal colostrum decreased from 37 to 30 hours from 2014 to 2016. HM at first feeding increased from 71% in 2013 to 82% in 2016. There was an increase in the percentage of feeds that were HM over the first 7 days of feeding. Analyses of data from 9400 VLBW infants born between 2009 and 2016 showed that the incidence of NEC when DHM was not available was 5.1% (367/7182) whereas the incidence when DHM was available (64/2218) was significantly lower (2.9%; P < .0001). Implications for Practice: These findings show advantages of feeding HM and effectiveness of forming an NICU collaborative for improving care for preterm infants. Implications for Research New research projects should measure the quantity of HM consumed daily during the entire NICU stay and assess the timing and amount of HM consumption in relationship to incidence of NEC and infection in neonates. Correspondence: Morris Cohen, MBBCh, Division of Neonatal Medicine, Children's Hospital of New Jersey, Newark Beth Israel Medical Center, 201 Lyons Ave, C-10, Newark, NJ 07112 (morris.cohen@rwjbh.org). The authors have no conflicts of interest relevant to this article to disclose. The Vermont Oxford Network had no role in the concept, design, analysis, or formulation of this research. The discussion and views belong solely to the coauthors and do not represent the opinions of the Vermont Oxford Network. © 2020 by The National Association of Neonatal Nurses

Reliability and Validity of the Arabic Version of the Parental Stressor Scale and Nurse Parental Support Tool: Opening Up Research on Parental Needs in Neonatal Intensive Care Units in Egypt Background: The admission of a newborn infant to a neonatal intensive care unit (NICU) due to preterm birth or high-risk conditions, such as perinatal injury, sepsis, hypoxia, congenital malformation, or brain injury, is a stressful experience for mothers. There is currently a lack of research on maternal perceived stress and support in Egyptian NICUs and no validated Arabic tool to investigate this further. Purpose: To determine the reliability and validity of the Arabic language versions of the Parental Stressor Scale: NICU (PSS:NICU) and the Nurse Parental Support Tool (NPST). Methods: Egyptian mothers completed the PSS:NICU and the NPST at the time of their infants' discharge from the NICU. Reliability was assessed with Cronbach α and Spearman-Brown coefficient. The multifactorial structure of the PSS:NICU Arabic version was tested. Associations with sociodemographic and clinical variables were explored with bivariate correlations and t tests. Results: Sixty-eight mothers of preterm (PT) infants and 52 mothers of ill full-term (IFT) infants completed the study. Mothers of PT and IFT infants did not differ for sociodemographic variables. High internal consistency (α range between .93 and .96) emerged for both tools. Spearman-Brown coefficients ranged between 0.86 and 0.94. The multidimensional structure of the PSS:NICU was confirmed and 3 core dimensions explained up to 71.48% of the variance. Perceived nursing support did not diminish the effects of stress in mothers of infants admitted to the NICU, regardless of PT or IFT infants' status. A longer NICU stay was associated with greater stress in mothers of PT infants. The presence of comorbidities was significantly associated with stress of mothers of IFT infants. Implications for Research: Future research is needed to develop evidence-based support for mothers whose infants are admitted to a NICU in Egypt. The availability of validated and reliable PSS:NICU and NPST scales in Arabic will facilitate cross-country and cross-cultural research on maternal stress in the NICU. Implications for Practice: Neonatal care nurses in Egypt will be able to increase their understanding of the stressors experienced by mothers of infants admitted to the NICU. This will in turn enable the introduction of neonatal care policies aimed at reducing specific stressors and provide improved maternal support. Correspondence: Dina Rabie, MD, Faculty of Medicine, Ain Shams University, Abbassia Square, Ramses, Cairo, Egypt (d_essam_rabie@outlook.com). Drs Dina Rabie and Livio Provenzi are co-first authors. LP contributed to conception and design, analysis and interpretation of data, and drafting of the article. DR contributed to data acquisition and interpretation of data. NM contributed to interpretation of data. RM contributed to conception and design and interpretation of data. All the authors contributed to revising the manuscript and approved final version for submission. The authors declare no conflicts of interest. © 2020 by The National Association of Neonatal Nurses

Eat, Sleep, Console and Adjunctive Buprenorphine Improved Outcomes in Neonatal Opioid Withdrawal Syndrome Background: The worsening opioid crisis has increased the number of infants exposed to maternal opioids. Standard treatment of newborns exposed to opioids prenatally often requires prolonged hospitalization and separation of the mother–infant dyad. These practices can potentially increase severity of withdrawal symptoms, interrupt breastfeeding, and disturb mother–infant bonding. Use of the Eat, Sleep, Console (ESC) model may ameliorate symptoms, decrease mother–infant separation, and decrease hospital length of stay. Purpose: To manage opioid exposed infants in a more holistic manner to decrease neonatal intensive care unit (NICU) admissions, reduce the need for pharmacotherapy, and evaluate response and total length of treatment after a unit protocol change from morphine to buprenorphine. Methods: Implemented ESC model, optimized nonpharmacologic bundle, and prescribed buprenorphine therapy instead of morphine as needed for adjunctive therapy. Results: Admissions of opioid-exposed infants from the Mother–Baby Unit (MBU) to the NICU decreased by 22%, and the number of infants who required pharmacotherapy was reduced by 50%. The average length of pharmacotherapy fell from 14 to 6.5 days. Implications for Practice: The successful implementation of the ESC model helped keep the mother–infant dyad together, reduced admissions to the NICU, and lessened the need for pharmacotherapy. The change to buprenorphine further reduced our average length of treatment. Implications for Research: Investigation of monotherapy with buprenorphine needs to be evaluated as a valid treatment option. The buprenorphine dosing and weaning chart will need to be revised and modified if indicated. Correspondence: Sarrah Hein, PharmD, BCPPS, Pharmacy Department, Akron Children's Hospital Mahoning Valley, 6505 Market St, Boardman, OH 44512 (shein@akronchildrens.org). Conflict of Interest: None declared for the listed authors. © 2020 by The National Association of Neonatal Nurses

#

Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

Telephone consultation 11855 int 1193,