Showing papers in "Advances in Neonatal Care in 2005"

A review of the literature examining the benefits and challenges, incidence and duration, and barriers to breastfeeding in preterm infants.

Abstract: Breastfeeding benefits preterm infants from a nutritional, gastrointestinal, immunological, developmental, and psychological perspective. Despite the benefits, the incidence and duration of breastfeeding preterm infants continues to be less than that of full-term infants. The lower incidence is probably related to breastfeeding challenges that preterm infants and parents face, including establishing and maintaining a milk supply and transitioning from gavage feeding to breastfeeding. In order to increase the incidence and duration of breastfeeding preterm infants, researchers must examine breastfeeding experiences longitudinally. This way, researchers and clinicians can begin to understand the barriers to breastfeeding at various time periods in the breastfeeding experience and begin implementing strategies to remove these barriers.

The primacy of work and fathering preterm infants: findings from an interpretive phenomenological study.

Abstract: Purpose To improve our understanding of fathers of preterm infants by examining their meanings of work and exploring the impact of their work on their early transition to fatherhood. Subjects The sample included 9 white fathers between the ages of 22 and 40 years, who had infants born between 25 and 32 weeks gestation. Design and methods This report explores one theme that emerged from a broader interpretive phenomenological study. Fathers were interviewed 6 to 8 times over a 6-month period, beginning within 1 month of the birth of their infant and continuing after neonatal intensive care unit (NICU) discharge. Interview guides were used only to initiate conversation; probing, clarifying questions helped fathers provide detailed stories of what they did, thought, and felt about specific situations. Transcriptions of all 63 interviews were treated as meaningful text and analyzed using interpretive methods. Principal results Fathers' narratives revealed the primacy of work in their lives; work remained a pivotal focus even after an early birth. Fathers returned to work quickly after their infant's birth. They approached their work with a renewed sense of fervor in order to provide financially for their families. They found comfort in their work because in the work setting they felt that they were the experts, as opposed to feeling like novices in the NICU. The most stressful aspect of the experience was juggling their time between work and the outside world. Conclusions Fathers may respond to the experience of having a premature infant very differently from mothers. Because fathers' stressors often lie outside the NICU, their stressors may be invisible to healthcare providers. A deeper understanding of fathering must consider the social, familial, and historical processes that shape fathering practices.

A retrospective study of length of hospital stay in infants treated for neonatal abstinence syndrome with methadone versus oral morphine preparations.

Abstract: PURPOSELength of hospital stay (LOS) of infants treated for neonatal abstinence syndrome (NAS) with methadone was compared to LOS of those treated with an oral morphine preparation (OMP, neonatal morphine solution, or deodorized tincture of opium).METHODSA retrospective review of medical rec

Qualitative analysis of barriers to breastfeeding in very-low-birthweight infants in the hospital and postdischarge.

Abstract: PURPOSE To determine barriers to the successful establishment and maintenance of breastfeeding in very-low-birthweight (VLBW) infants, both in the hospital and after discharge, and changes in barriers over time. SUBJECTS Sixty-four mothers of infants <1500 g birth weight who planned to breastfeed and were in the supplementary structured breastfeeding counseling intervention group. DESIGN This qualitative, longitudinal study is a secondary analysis of a previously reported randomized controlled trial of a breastfeeding support intervention that examined infants weighing <1500 g at birth. METHODS A qualitative technique, content analysis, was used to review, analyze, interpret, and categorize data for the current study. Data were extracted from the research records of the research lactation consultant that addressed all aspects of mothers' reported breastfeeding experiences. The principal investigator identified the main issues of the conversations, entered these into a summary chart, and then assigned appropriate categories. All categories are a reflection of maternal perception. Categorical data were analyzed descriptively using the crosstabs function. MAIN OUTCOME MEASURES Barriers to the successful establishment and maintenance of breastfeeding during discharge from the neonatal intensive care unit (NICU), at discharge home, and at 1, 3, 6, and 12 months corrected age, or until weaning from breastfeeding. Changes in breastfeeding barriers across the 6 time periods were also determined. PRINCIPAL RESULTS At NICU discharge, low milk volume was the greatest breastfeeding barrier. During the period from discharge home and at 1 month and 3 months, the infants' compromised physical status was the largest barrier to breastfeeding. Data from the 6- and 12-month time periods indicated that the provision of complementary feeding was the greatest barrier to breastfeeding; it was most prevalent in the period following NICU discharge and before discharge home. Across all time periods, nipple and breast problems were most prevalent at NICU discharge, whereas poor technique was a barrier at 1 month. Mothers' compromised emotional status was greatest at discharge from the NICU and diminished thereafter. CONCLUSIONS Results from this study indicate the need to address time-period-specific barriers encountered during the breastfeeding experience of mothers of VLBW infants.

End-of-life nursing education consortium (elnec)

Abstract: The End-of-Life Nursing Education Consortium (ELNEC) project is a national education initiative to improve palliative care and is a partnership between the American Association of Colleges of Nursing (AACN), Washington, DC and the City of Hope, Duarte, CA. The project provides undergraduate and graduate nursing faculty, CE providers, staff development educators, specialty nurses in pediatrics, oncology, critical care and geriatrics, and other nurses with training in palliative care so they can teach this essential information to nursing students and practicing nurses. The project, which began in February 2000, was initially funded by a major grant from The Robert Wood Johnson Foundation (RWJF). Additional funding has been received from the National Cancer Institute (NCI), American Association of Colleges of Nursing (AACN), US Cancer Pain Relief Committee, the Aetna, Archstone, California HealthCare, Cambia Health, Milbank, Oncology Nursing, Open Society, and Stupski Foundations and the Department of Veterans Affairs (VA).

The neurodevelopmental consequences of prenatal alcohol exposure.

Abstract: During pregnancy, ingestion of alcohol, a known teratogen, can cause harm to the fetus. Prenatal alcohol exposure is one of the leading causes of birth defects, developmental disorders, and mental retardation in children. The fetal central nervous system is particularly vulnerable to alcohol; this vulnerability contributes to many of the long-term disabilities and disorders seen in individuals with prenatal alcohol exposure. Diagnoses associated with prenatal alcohol exposure include fetal alcohol syndrome (FAS), partial fetal alcohol syndrome, fetal alcohol effects, alcohol-related neurodevelopmental disorder, and alcohol-related birth defects. Once diagnosed, early intervention improves the long-term outcome of affected children. Without documentation of maternal alcohol use, a diagnosis, and consequently treatment, is often difficult to attain. It is imperative that nurses, physicians, and other healthcare providers become comfortable with obtaining a history of, and providing anticipatory guidance and counseling about, alcohol use.

Impacting infant head shapes.

Abstract: Infant sleep position impacts the development of head shape. Changes in infant sleep position, specifically the movement toward supine sleep, have led to a redefinition of normal head shape for infants in the United States. Historically, a dolichocephalic (elongated) head shape was the norm. Currently the norm has changed to a more brachycephalic (shorter and broader) shape. Since the American Academy of Pediatrics' Back to Sleep Campaign, the incidence of positional plagiocephaly has increased dramatically with a concurrent rise in the incidence of torticollis. Infants who require newborn intensive care, particularly premature infants, are more prone to positional plagiocephaly and dolichocephaly. Both can be prevented or minimized by proper positioning. The infant with an abnormal head shape requires careful evaluation; treatment varies according to the etiology. Craniosynostosis, a less common but pathological etiology for plagiocephaly, should be considered in the diagnostic process. Successful treatment of positional plagiocephaly and dolichocephaly includes systematic positioning changes to overcome the mechanical forces of repetitive positioning, physical and/or occupational therapy to treat underlying muscle or developmental challenges, and in some cases, molding helmet therapy.

Part 1: early recognition and treatment of birth trauma: injuries to the head and face

Abstract: The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Sentinel Event Alert from July 21, 2004 states that there have been 47 cases of birth trauma-related perinatal death or permanent disability reported for JCAHO review since 1996 This report clearly illustrates the importance of birth trauma in clinical practice for neonatal and perinatal nurses Estimates suggest that birth trauma occurs in 2% to 7% of all deliveries and is associated with an increase in both mortality and morbidity Birth trauma to the head may result in minor superficial extracranial injuries, such as caput succedaneum and cephalohematoma, or more serious and potentially life threatening lesions such as subgaleal hemorrhages The potential for deeper intracranial injury, such as subarachnoid or subdural hemorrhage exists; these may be isolated or associated with skull fractures and/or other extracranial injuries Injury to the eye, nasal structures, and paralysis of the vocal cords may also result from birth trauma during a difficulty delivery Part 1 of this 2-part article will focus on birth injuries to the head and face Part 2 of the series will review more systemic birth injuries that may involve abdominal organs, the spine and skeletal system, and peripheral and facial nerves

The clinical presentation of Ehlers-Danlos syndrome.

Abstract: Ehlers-Danlos syndrome (EDS), a heterogeneous group of inheritable connective tissue disorders, is attributed to mutations in connective tissue genes. These mutations cause defects in collagen. Collagen, a connective tissue protein that acts like glue, gives strength to the body and provides support and elasticity for movement. Thus, the altered gene affects the mechanical properties of skin, joints, ligaments, and blood vessels. Ehlers-Danlos syndrome is transmitted through autosomal dominant, autosomal recessive, or x-linked patterns of inheritance. The life expectancy of an affected infant varies with the type of EDS. This article provides an overview of the 6 major classifications of EDS, their unique clinical presentations, a focused physical assessment guide, considerations for nursing care, and resources for parents. Ehlers-Danlos syndrome can be a potentially debilitating syndrome. It requires preventative and protective measures starting at birth to preserve joint function to improve infant outcomes. Caring for patients with EDS requires an understanding of the potential associated complications to help minimize the physical and emotional impact of the syndrome and improve the quality of life for affected individuals.

Part 1. Injuries to the brachial plexus: mechanisms of injury and identification of risk factors.

Abstract: Upper-arm weakness (paresis) or paralysis indicates peripheral-nerve damage to the brachial plexus, a network of lower cervical and upper thoracic spinal nerves supplying the arm, forearm, and hand. Physical findings reflect muscle paralysis from spinal nerve roots. The mechanism of injury includes maternal, obstetric, and infant factors that apply traction on or compression to the anatomically vulnerable brachial plexus. Nerve regeneration can occur if nerve tissue components are preserved. Recovery is affected by multiple factors, including the type and site of injury, intervention timing, and developmental factors. The majority of injuries recover in days or months; however, residual deficits can persist. Part 1 of 2 of this article provides an overview of the neurophysiology of peripheral-nerve damage and nerve regeneration. The multifactorial etiology of brachial plexus injuries will be reviewed. Photographs and on-line video clips will enhance the description of the brachial plexus injury classifications and illustrate mechanisms of shoulder dystocia and obstetric relief maneuvers. A systematic approach to the physical examination will be explored in Part 2. Serial evaluation of motor function recovery is essential and is accomplished by appropriate referrals and follow-up. Part 2 will also describe treatment options and discuss anticipatory parent guidance.

A primer on Apnea of prematurity.

Abstract: Apnea, the cessation of respiratory airflow, can begin in many preterm infants in the first week of life and can last until the day of discharge or beyond. This article provides an overview of the complex anatomic, physiological, and developmental mechanisms related to immaturity of both the central nervous system and musculature of the pulmonary system, that contribute to apnea of prematurity. Apnea of prematurity is a diagnosis of exclusion; an array of other conditions and stimuli can also cause apnea, including infections, pulmonary disease, and intracranial pathology. The standard clinical management of apnea, including cutaneous stimulation, methylxanthine therapy, and continuous positive airway pressure or ventilatory support, are discussed as well as newer investigational therapies, such as olfactory stimulation. Emerging evidence on the long-term neurodevelopmental impact of apnea is reviewed. Nursing measures to prevent and manage apnea are reviewed with an emphasis on parent education and preparation for discharge. Apnea resolves in most preterm infants as they approach term corrected gestational age; however, if it does not, options include continued hospitalization or, for infants with stable apnea, discharge with a home apnea monitor.

Part 1. Understanding the embryology and genetics of cleft lip and palate.

Abstract: Craniofacial birth defects are the fourth most common congenital anomaly in newborns. Cleft lip and cleft palate (CL/CP) are the most common and immediately recognizable craniofacial anomalies. Some are diagnosed prenatally on ultrasound; more often, they are first noted in the delivery room. The infant may have a cleft that is unilateral, bilateral, complete, or incomplete, and it may involve the lip only, the palate only, or both. Cleft lip and/or cleft palate are often isolated nonsyndromic occurrences; however, when associated with other abnormal physical findings, a recognizable syndrome may be present. Part 1 of this 2-part article describes the incidence of CL/CP. The embryology of the face, lip, and palate are reviewed to enhance the understanding of the timing, complexity, and factors that may influence the development of this lesion. The emerging genetic links, environmental influences, and potential teratogens that may interact to contribute to CL/CP are discussed. Part 2 of this series will provide clinicians with tools to perform a focused risk assessment and obtain a detailed family and pregnancy history to evaluate for known associated risk factors for CL/CP. The article provides a guide for a systematic physical examination of infants with CL/CP. Careful assessment for other midline defects or physical findings consistent with associated syndromes is also discussed. Pictorial examples of a variety of forms of CL/CP are provided to enhance understanding of the spectrum of this defect. Treatment and long-term complications of CL/CP are reviewed with an emphasis on family support, identifying educational resources, and counseling.

Acculturation and stress in Chinese-American parents of infants cared for in the intensive care unit.

Abstract: PURPOSE To describe the stressful experiences of Chinese-American parents who have an infant in the intensive care unit (ICU), and to assess the influence of acculturation, parents' characteristics, and social supports on parental stress. DESIGN A cross-sectional, descriptive, correlational study. SAMPLE/SETTING A convenience sample of 30 Chinese-American families (30 mothers, 25 fathers) who had an infant hospitalized in 3 ICU sites in the San Francisco area. METHODOLOGY Measures included: (1) Infant's health data from the medical records and parents' demographic data, and (2) Parental Stressor Scale: Infant Hospitalization, Suinn-Lew Asian Self-Identity Acculturation Scale, and Family Support Scale. MAIN OUTCOME MEASURE The dependent variable was mothers' and fathers' stress levels. Independent variables included personal/family characteristics, acculturation, uncertainty regarding infants' illness, and social supports. PRINCIPAL RESULTS The ICU stressors were ranked by both mothers and fathers in the following order: infant's appearance, parental role alteration, staff communication and behaviors, and ICU environment. The combined effects of uncertainty about their infant's illness and its future impact, a strong belief in Asian family values, and lack of support from healthcare providers accounted for 26% and 55% of the variance in parental stress for mothers and fathers, respectively. CONCLUSIONS Findings from this study suggest implications for the education of both families and the ICU staffs.

Capillary refill time is an unreliable indicator of cardiovascular status in term neonates.

Abstract: PURPOSE Decisions regarding the need for volume replacement in neonates often are made in the immediate newborn period. Capillary refill time (CRT) is used as an indicator of circulatory status; however, recent data show that CRT varies considerably with age, ambient and skin temperature, anatomical site of measurement, and duration of pressure. The purpose of this study was to (1) examine the relationship between CRT and heart rate (HR) and blood pressure (BP) in term neonates, and (2) evaluate the differences among CRT values measured at 3 body sites and with varying duration of cutaneous pressure. DESIGN This was a prospective, cross-sectional, correlational study. Subjects Forty-two appropriate-weight-for-gestational-age (AGA) neonates with birthweights, (M = 3407; SD = +/- 540 g), gestational ages (M = 39 weeks; SD = +/- 1 week), and sex (21 males, 21 females). Infants had no history of perinatal distress or maternal chorioamnionitis. METHODS Each neonate was studied prospectively 1 to 4 hours after birth. The infants were clothed with only a diaper and evaluated on a radiant warmer bed set to achieve an axillary temperature of 36.5 degrees to 37.0 degrees C. Capillary refill time was measured with a digital stopwatch at 3 sites: volar surface of finger (F), plantar surface of heel (H), and lower sternum (St), using brief (1- to 2-second) and extended (3- to 4-second) pressure. Heart rate was auscultated and counted for 60 seconds, and BP was measured by oscillometry. Relationships among variables were assessed by Pearson correlation coefficient, analysis of variance, and multiple regression analysis. The Bonferroni correction for multiple comparisons was applied. MAIN OUTCOME MEASURES Capillary refill time, blood pressure, and heart rate. PRINCIPAL RESULTS There was no significant site variation for CRT for either brief (2.4 +/- 0.6 to 2.9 +/- 1.0 seconds) or extended (3.8 +/- 0.8 to 4.3 +/- 0.8 seconds) pressure. However, regardless of site, CRT was greater when extended versus brief pressure was used (P < 0.001). There were no significant correlations between HR and CRT. There was a moderate, direct relationship between BP and CRT observed in the following anatomic sites: (1) sternum/extended pressure and systolic BP (SBP), diastolic BP, and mean BP (r = 0.35, P = 0.02; r = 0.49, P = 0.001; and r = 0.43, P = 0.005, respectively); (2) sternum/brief pressure and SBP (r = 0.31, P = 0.05); and (3) finger/extended pressure and SBP (r = 0.30, P = 0.05). CONCLUSIONS An unanticipated moderate, direct correlation between BP and CRT was observed; prolongation of CRT occurred with elevated blood pressure. This finding may have been secondary to increased circulating vasoactive substances in the newborn period; measurement of these substances was beyond the scope of this study. In addition, CRT was highly dependent on the duration of cutaneous pressure, regardless of the site. These 2 findings indicate that CRT may be an unreliable indicator of cardiovascular status in the term neonate during the first 4 hours after birth.

Ensuring safety for infants undergoing magnetic resonance imaging.

Abstract: and Introduction Abstract Magnetic resonance imaging (MRI) is a powerful and versatile diagnostic tool. Applications of MR technology are rapidly expanding for all patient populations, including infants receiving newborn intensive care. Millions of MR examinations have been conducted without incident or harm, yet rare accidents in the MR environment continue to occur. The infant is vulnerable to many of the potential hazards of MRI, including projectile accidents, radiofrequency electromagnetic field effects, noise hazards, physiologic instability, and adverse effects of transport, positioning, handling, and sedation. The MRI-compatible incubator is a promising means for safe imaging of smaller and less stable infants than previously possible. Proper education of staff and meticulous attention to detail in preparing the infants for MR examinations are the keys to safety during neonatal MRI.

Designing and evaluating parent educational materials.

Abstract: Families of infants in the neonatal intensive care unit (NICU) are continually seeking information about their infant. Communicating with and providing education to parents is a crucial focus for nurses, who are often challenged to provide families with culturally sensitive health informatio

Basic principles of noninvasive blood pressure measurement in infants.

Abstract: Correct measurement of blood pressure in infants is essential because blood pressure is an important indicator of cardiovascular status. This article provides a review of the fundamental principles of blood pressure measurement. Formulas to estimate mean arterial pressure are discussed along with an overview of pulse pressure. The advantages, challenges, and accuracy of the widely used oscillometric method of noninvasive blood pressure measurement are discussed. A step-by-step guide to noninvasive blood pressure measurement is outlined along with pragmatic strategies to ensure appropriate technique, thereby improving accuracy.

Recognition of Zellweger syndrome in infancy.

Abstract: At least 29 proteins are required for assembly of the peroxisome, a single-membrane organelle responsible for many metabolic processes. A defect in any of these proteins affects the numerous biochemical functions of the cell. Many genetic disorders are associated with peroxisome defects. Zellweger syndrome, a rare autosomal recessive disorder, is one of the disorders that result from a deficiency in the assembly of the peroxisome. Impaired metabolism results in the accumulation of toxic metabolites and damages developing neural cells. This article provides an overview of peroxisome function and its effect on central nervous system development. It highlights the presentation, clinical features, and nursing care of infants with Zellweger syndrome. A meticulous systematic physical assessment enhances early recognition of the physical features of this disorder. Although magnetic resonance imaging detects polymicrogyria, a manifestation of abnormal neuronal migration that is often associated with Zellweger syndrome, the diagnosis is confirmed biochemically. An emphasis on family support through genetic counseling and the integration of palliative resources to enhance quality of life for infants and families with this lethal condition is provided.

Part 2. Distinguishing physical characteristics and management of brachial plexus injuries.

Abstract: Brachial plexus injuries (BPI) are usually readily apparent at or shortly after birth. Failure of caregivers to recognize and appropriately treat BPI may contribute to the risk of life-long neuromuscular dysfunction for the infant and represents a serious medical-legal liability for the delivery provider. This article is the second in a series on BPI and provides a standard classification and a systematic guide to physical examination of the infant with suspected BPI. Conditions that mimic BPI are discussed along with diagnostic studies used to confirm this disorder. The natural history and predictors of outcome are presented along with a sample treatment protocol. Pictures and video clips are provided to enhance the reader's understanding of the consequences of this injury and the potential for improvement with surgical treatment. Useful Internet resources for parents, focused discharge planning, and guidelines for appropriate monitoring and follow-up are provided. Advantages of early referral and management by a multidisciplinary team at a brachial plexus specialty center are discussed.

Beyond newborn screening: early diagnosis and management of hearing loss in infants.

Abstract: As a result of the 1993 National Institutes of Health Consensus Statement recommending hearing screening for all infants before discharge from the newborn nursery, there are an increasing number of newborns identified with hearing impairment requiring follow-up services. Research has shown that hearing-impaired infants who receive intervention by the time they are 6 months adjusted gestational age are likely to develop language that is equal to their normal-hearing peers. Newborn hearing screening will not attain its goal of early intervention for hearing loss unless a comprehensive follow-up program is in place. The neonatal nurse plays an important role in the follow-up program by providing information to parents and stressing the importance of follow-up. Follow-up for infants identified through the screening process includes rescreening within 4 to 6 weeks of discharge and a full diagnostic evaluation for infants who fail the rescreening. The diagnostic evaluation includes Auditory Brainstem Response (ABR), Otoacoustic Emissions (OAE), and middle ear assessment. The course of treatment or therapy and the type of amplification chosen for hearing-impaired infants depends on the type and degree of hearing loss as well as the communication mode chosen by the family. The ultimate goal of early audiological diagnosis of hearing loss is to begin treatment as soon as possible to minimize delays in speech/language and academic development. This article focuses on what needs to happen after newborn hearing screening to ensure early and optimal intervention for hearing-impaired infants.

A case of shaken baby syndrome after discharge from the newborn intensive care unit.

Abstract: Preterm infants may be at higher risk of physical abuse after hospital discharge. Nonaccidental or inflicted head neurotrauma is the most common cause of mortality and morbidity in physical-abuse cases, and shaken baby syndrome (SBS) is the most common form of abuse. In the majority of the cases, parents who shake their infant do not intend to harm the infant. This article presents a report of a former preterm infant who presented to the pediatrician's office with a maternal report of an accidental fall. Shaken baby syndrome was suspected based on bilateral subdural hemorrhages of varying ages, which were inconsistent with the history provided. The differential diagnosis and systematic clinical evaluation for SBS are provided, and medical and nursing management is discussed. Patient care, advocacy, and mandatory reporting are reviewed. The newborn intensive care unit caregivers' role in preventing SBS in this high-risk population, including specific parent teaching and anticipatory guidance, is reviewed with an emphasis on teaching all caregivers about the dangers of shaking an infant.

Pilot survey of NICU nurses' interest in the neonatal nurse practitioner role.

Abstract: Purpose This descriptive, qualitative pilot study explored the interest and perceptions of neonatal intensive care unit (NICU) nurses regarding the neonatal nurse practitioner (NNP) role. Motivating factors to become an NNP, challenges facing NNPs, and rewards of the NNP role from the perspectives of NICU nurses were explored. Subjects The convenience sample was obtained using 2 survey techniques. The first sample group included nurses who were employed in Level III NICUs located within 2 major Midwestern cities. In order to confirm the data and to expand the scope, the second sample group was recruited from NICU nurses who were attending a regional educational conference. All participants were currently employed NICU nurses and were therefore potential NNP students. Combining the participants of both enrollment techniques resulted in a potential of 696 subjects. Design and methods A simple self-administered survey was used to collect data. Narrative data were qualitatively analyzed. Demographic data and categorical items were quantified. Results This study achieved a total 30% response rate (n = 209). Of the total participants, only 32% of Level III NICU nurses were interested in becoming an NNP. Analysis of the data revealed 6 major categories (themes) of reasons why nurses were not interested in the NNP role. The themes most often mentioned by the participants were (1) obligations to family and/or work (46%) and (2) too much responsibility in the NNP role (30%). The data also revealed several different rewards and challenges for those in the NNP role as well as factors that may motivate nurses to become an NNP. Conclusions Given the current NNP shortage, an increase in the supply of NNPs for the workforce is imperative. Current enrollment in NNP academic programs does not appear to be meeting the demand. Exploring the factors that influence enrollment in NNP programs from the perspective of potential NNP students is the first step towards increasing the supply of NNPs. The majority of participants were not interested in becoming an NNP for a variety of reasons. Negative perceptions of the NNP role were identified. Solutions posed from these results may provide scientifically sound solutions to help ease the shortage of NNPs. The findings of this naturalistic inquiry may be used to develop an instrument to measure interest in the NNP role.

Development, implementation, and evaluation of a community- and hospital-based respiratory syncytial virus prophylaxis program.

Abstract: PURPOSE To implement and deliver a respiratory syncytial virus prophylaxis (RSVP) program in response to the Canadian Pediatric Society recommendations. METHODS A novel program was designed to provide inpatient RSVP for at-risk infants cared for in 1 tertiary care newborn intensive care unit (NICU). This inpatient program was part of a coordinated approach to RSVP, designed and implemented by 3 hospitals. An RSVP program logic model was created and used by a multidisciplinary team to evaluate the in-house program and identify areas of program activity requiring improvement. RESULTS Following the 2000 to 2001 RSV season, a compliance and outcomes audit was performed in the tertiary center; 193 infants were enrolled in the RSVP program and 162 infants had received RSVP in the NICU [Mean = 1.64 doses]. Telephone follow-up with the parents of discharged infants identified that 159 infants (98%) had successfully completed their full course of RSVP. Using the RSVP program logic model, 5 areas for program improvement were identified including infant recruitment, patient transfer/discharge processes, product procurement, preparation/distribution/administration of doses, and healthcare team communication. CONCLUSIONS Interdisciplinary collaboration is an important factor in the success of the RSVP program and has supported a consistent model of care for the delivery of RSVP. The program logic model provided a useful structure to systematically review the RSVP program in this organization.

Part 2. Physical assessment of the infant with cleft lip and/or palate.

Abstract: Cleft lip and cleft palate (CL/CP) are the most commonly occurring craniofacial birth defects. Although some CL/CPs are detected on prenatal ultrasound, the majority are immediately recognized in the delivery room. Part 1 of this 2-part article, "Understanding the Embryology and Genetics of Cleft Lip and Palate," presented the embryology of the face, lip, and palate to help the clinician understand the timing, complexity, and factors that may influence the development of these defects. Part 2 provides clinicians with the tools needed to obtain a detailed family and pregnancy history to evaluate for known associated risk factors. It provides a guide for a systematic physical assessment of the infant with CL/CP along with key areas of assessment for other midline defects or physical findings consistent with associated syndromes. Pictures of a variety of types of CL/CP are included to enhance understanding of these defects. Treatment and long-term complications of CL/CP are reviewed with an emphasis on family support, identifying educational resources, and counseling.

A case report of the transport of an infant with a tension pneumopericardium.

Abstract: Neonatal pneumopericardium is a potentially fatal complication of positive-pressure ventilation and has become rare with the advent of surfactant replacement therapy. The clinical diagnosis, stabilization, treatment, and nursing care of an infant with pneumopericardium has not previously been discussed in the nursing literature. In this case report, delays in the recognition and definitive treatment of the pneumopericardium were encountered, resulting in the transport of an infant with a tension pneumopericardium and pneumoperitoneum. Root-cause analysis is used to identify contributing factors and examine system changes necessary to prevent the transport of another patient with a similar potentially life-threatening condition. Pneumopericardium should be suspected in any infant with an acute deterioration, especially in the presence of normal, equal breath sounds and muffled heart sounds, because prompt recognition and definitive treatment may be life-saving.