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My PhD investigated relationships between care provided for babies born between 27-31 weeks gestation in England and their outcomes. It comprised: a systematic review examining whether place of birth/care affects outcomes for babies born between 27-31 weeks; literature reviews exploring (a) heterogeneity in outcomes for this cohort, (b) heterogeneity of structure and process within neonatal units and (c) concepts around measurement of quality of care; a study exploring the relationship between quality of care and outcomes for these babies. Systematic review revealed a lack of evidence to guide optimisation of place of birth. Literature reviews demonstrated heterogeneity of outcomes related to degrees of fetal maturity between 27-31 weeks, and that variation in structure and process within neonatal units can impact outcomes. In exploring relationships between quality of care and outcomes, plans for data collection using questionnaires proved unsuitable during piloting. Data from the National Neonatal Research Database (NNRD) were therefore utilised. To analyse care provided I measured unit compliance with pre-determined, evidence-based standards (administration of antenatal steroids, normothermia on admission, early use of non-invasive ventilation, and appropriate nurse staffing ratio), and then assessed data completion and compliance with National Neonatal Audit Programme (NNAP) measures. I categorised neonatal units (n=113, 4986 babies) into two groups, and compared the top quartile with the rest, using multivariate analyses to look for associations with length of stay (LOS) and pre-discharge mortality. I found no difference in mortality, but demonstrated a mean reduction in LOS by one day for babies born in neonatal units within the top quartile for compliance with evidence-based and NNAP measures. This supports a relationship between quality of care and outcomes, and the hypothesis that units striving to comply with national guidance and provide evidence-based care have better outcomes. This has potential implications for patient-flow and cost-effectiveness in neonatal care.

This thesis comprises a series of studies initially focusing on the acid-base and glucose status of term and near-term infants at birth. It defines normal values and explores the influence on both short- and medium-term outcomes to elucidate prognosis and any interventions that might be warranted to improve this. The research then moves onto the oxygenation of preterm infants, firstly by examining the relationship between arterial partial pressure of oxygen (PaO2) and pulse oximeter oxygen saturations (SpO2), and then via case control studies examines the influence of oxygenation on important clinical outcomes (mortality and retinopathy of prematurity (ROP)). Acid-base status of term and near-term infants and likelihood of death and cerebral palsy The acid-base status of infants around birth can provide information about their past, current and future condition. Although umbilical cord blood pH less than 7.0 or base deficit equal to or greater than 12mmol/l is associated with increased risk of adverse outcome, there is uncertainty about the prognostic value of degree of acidosis as previous studies have used different variables, thresholds, outcomes, and populations. We aimed to describe the relationship between pH and base deficit around the time of birth, the immediate clinical condition of the infants after birth, the risk of neonatal encephalopathy, and the risk of death or survival with permanent disability at the age of 2 years. We conducted a retrospective review of routinely collected clinical data in all liveborn inborn infants of 35 weeks gestation or more delivered over an eight-year period at the Royal Infirmary of Edinburgh. Infants were included if their lowest recorded pH was less than 7 and/or highest base deficit equal to or greater than 12mmol/l on either umbilical cord blood and/or neonatal blood gas within one hour of birth. Two-year neurodevelopmental outcomes were collected from a targeted follow-up database. 56,574 infants were eligible. 507 infants (0.9%) met inclusion criteria. Poor condition at birth and all adverse outcomes increased with worsening acidosis. Combined outcome of death or cerebral palsy was 3%, 10% and 39% at lowest pH of 6.9-6.99, 6.8-6.89 and < 6.8 respectively, and 8%, 14% and 59% at a base deficit of 12-15.9, 16-19.9, and 20mmol/l or more respectively. We found that there is a dose-dependent relationship between the degree of acidosis within an hour of delivery, and the likelihood of adverse outcome within 2 years in infants born at 35 weeks gestation or more. This information may help to facilitate the setting of entry criteria in clinical trials and better inform medicolegal opinion as to the likely outcome had delivery been expedited and the severity of acidosis been reduced. Analysing the role of umbilical cord blood glucose in stratifying risk of impaired metabolic adaptation The normal range of blood glucose concentration in umbilical cord blood in contemporary obstetric practice is uncertain. Defining normal and abnormal values is important because hypoglycaemia can require prompt recognition and treatment. It is therefore a priority to conduct research to fully elucidate threshold values for hypoglycaemia in healthy and at-risk infants in order that clinicians can implement practices that prevent harm that can result from unrecognised or untreated hypoglycaemia, whilst minimising unnecessary interventions and admissions to neonatal units. We conducted a hypothesis generating exploratory study examining the frequency and associations of umbilical cord arterial glucose concentrations lower than the current operational thresholds defining neonatal hypoglycaemia. The aims of this study were firstly to define normative values of cord arterial blood glucose with centile thresholds for infants greater than 35 weeks gestational age at birth without hypoxic ischaemic encephalopathy (HIE) grade II and III in a centre in which umbilical cord sampling was routine for all deliveries, and secondly to explore whether umbilical cord arterial glucose less than the 10th centile is associated with risk factors for impaired metabolic adaptation. We gathered data in the Royal Infirmary of Edinburgh over a fifteen-month period. All umbilical cord blood gas measurements performed in infants of 35 weeks gestation or more were included. Centiles were defined for arterial cord blood glucose concentration, and electronic patient records were interrogated for gestation, birth weight, mode of delivery, diagnosis of HIE grade II or III and hyperinsulinism, neonatal unit admission, repeat blood glucose measurement in the first four hours after birth, and the presence of risk factors for metabolic maladaptation (intrauterine growth restriction < 2nd centile, maternal labetolol and maternal diabetes). 9793 umbilical cord blood samples were downloaded in infants greater than 35 weeks gestation. This represented 5612 infants, with 4181 infants having paired arterial and venous cord glucose values. The mean (SD) arterial and venous blood glucose values were 3.84 (1.22) and 4.53 (1.15) mmol/l respectively. In 4181 infants with both arterial and venous samples, the venous glucose level was a mean 0.75mmol/l higher than the arterial value (95% CI of the mean difference 0.73-0.77). 456 infants had arterial cord glucose below the 10th centile (2.5mmol), and 168 infants below the 5th centile (2.2mmol/l). 83 infants with arterial cord glucose below the 10th centile were admitted to the neonatal unit (18%). In infants with arterial cord glucose below the 10th centile, there were 130 repeat glucose samples within four hours (mean 2.586 mmol/l, SD 1.371, range 0-10.3). 68 infants (15%) with arterial cord glucose below the 10th centile had one or more risk factors for impaired metabolic adaptation. In infants diagnosed with HIE, there was a statistically significant difference in cord arterial glucose between those that died (mean 2.8mmol/l, SD 1.69) and those that survived to discharge (mean 5.1 mmol/l, SD 1.8) and between those diagnosed with grade II encephalopathy (mean 5.2 mmol/l, SD 1.90) compared to grade III (mean 3.3 mmol/l, SD 1.69). Infants delivered by Elective Caesarean section made up 52% of infants below the 10th centile for cord arterial glucose. We concluded that in this large dataset drawn from an unselected population of term and near-term infants without a diagnosis of HIE, the 10th centile for arterial cord glucose is 2.5 mmol/l and the 5th centile is 2.2 mmol/l. Although cord arterial glucose poorly stratifies those at risk of impaired metabolic adaptation, we recommend that initial cord arterial glucose is treated as a valid sample measured on a reliable device and therefore is included in the BAPM Framework for Practice operation threshold approach. Exploring the relationship between PaO2 and SpO2 in very low birth weight infants in the first week of life Titrating supplemental oxygen to SpO2 in neonates evolved with little supporting evidence. Prior to the widespread introduction of SpO2 targeting, recommended practice was to target transcutaneous or arterial partial pressure of oxygen to 6.7-10.7kPa (50-80mmHg). It is not known which approach is safer. Recent evidence shows that SpO2 targets below 90% increase mortality and NEC and higher targets increase ROP treatment but not blindness or disability. We aimed to explore the relationship between PaO2 and SpO2 in oxygen dependent preterm infants targeted to an SpO2 range 90-95% and to estimate the probability that individual SpO2 readings would allow a PaO2 outside the range 6.7-10.7kPa (50-80mmHg) previously recommended. Paired SpO2 and PaO2 data were collected from oxygen dependent babies with birth weight less than 1500g during the first seven days of life over a four-year period. 3748 data pairs were obtained from 140 very low birth weight infants. We found that at any SpO2 below 90% more than half of PO2 readings were below 6.7kPa (50mmHg). Low PaO2 (< 6.7kPa, 50mmHg) was more likely than high PaO2 (>10.7kPa, 80mmHg) at all SpO2 values below 98%. At SpO2 92-97% around 70% of specimens had PaO2 within between 6.7-10.7kPa (50-80mmHg) and high PO2 was less likely than low PO2. We concluded that an SpO2 target range of 90-95% permits many PaO2 values below 6.7kPa (50mmHg). High PaO2 readings are uncommon at SpO2 below 98%. We concluded that further studies examining an SpO2 target range of 92-97% may be beneficial as a higher range may confer additional survival advantage without significant hyperoxia, and this was incorporated into the recommendations for research as part of the NICE guideline NG124 Specialist neonatal respiratory care for babies born preterm.

Introduction: Preterm birth is increasing worldwide and is a major cause of neonatal death. Survivors are at increased risk of neurodisability, cognitive, social and psychiatric disorders in later life. Alterations to the white matter can be assessed using diffusion tensor imaging (DTI) MRI and are associated with poor neurodevelopmental outcome. The pathogenesis of white matter injury is multifactorial and several clinical risk and resilience factors have been identified. DNA methylation (DNAm) is an epigenetic process which links stressful early life experience to later life disease and is associated with normal brain development, neuronal processes and neurological disease. Several studies have shown DNAm is altered by the perinatal environment, however its role in preterm white mater injury is yet to be investigated. Aims: 1. To examine the relationship between preterm birth and white matter integrity 2. To investigate the effect of neuroprotective treatments and deleterious clinical states on white matter integrity in preterm infants 3. To assess the best DTI method of quantifying white matter integrity in a neonatal population 4. To investigate the effect of preterm birth on DNA methylation and 5. To determine the clinical and imaging factors that contribute to the variance in DNA Methylation caused by preterm birth Methods: DTI data was acquired from preterm infants (< 32 weeks' gestation or < 1500 grams at birth) at term equivalent age (TEA) and term controls (> 37 weeks' gestation at birth). Region-of-interests (ROI) and tract-averaged methods of DTI analysis were performed to obtain measurements of fractional anisotropy (FA) and mean diffusivity (MD) in the genu of corpus callosum, posterior limb of internal capsule and centrum semiovale. Clinical data was collected for all infants and the effect of prematurity, neuroprotective agents and clinical risk factors on white matter integrity were analysed. 8 major white matter tracts were segmented using probabilistic neighbourhood tractography (PNT), a tract-averaged technique which also allowed the calculation of tract shape. The two DTI techniques were compared to evaluate agreement between results. DNA was collected from preterm infants and term controls at TEA, and a genome-wide analysis of DNAm was performed. DTI parameters from probabilistic neighborhood tractography (PNT) methodology and clinical risk and resilience factors were used to inform a principal components analysis to investigate the contribution of white matter integrity and clinical variables to variance in DNAm. Results: FA and MD were significantly affected by preterm birth on ROI analysis. In addition, DTI parameters were affected by clinical factors that included antenatal magnesium sulphate, histological chorioamnionitis and bronchopulmonary dysplasia. Evaluation of DTI methodology revealed good accuracy in repeated ROI measurements but limited agreement with tract-averaged values. Differential methylation was found within 25 gene bodies and 58 promoters of protein-coding genes in preterm infants, compared with controls. 10 of these genes have a documented association with neural function or neurological disease. Differences detected in the array were validated with pyrosequencing which captured additional differentially methylated CpGs. Ninety-five percent of the variance in DNAm in preterm infants was explained by 23 principal components (PC); corticospinal tract shape associated with 6th PC, and gender and early nutritional exposure associated with the 7th PC. Conclusions: Preterm birth is associated with alterations in white matter integrity which is modifiable by clinical risk factors and neuroprotective agents. ROI analysis may not provide sufficient representation of white matter tracts in their entirety. Prematurity is related to alterations in the methylome at sites that influence neural development and function. Differential methylation analysis has identified several promising candidate genes for future work and contributed to the understanding of the pathogenesis of preterm brain injury.

The evidence that breastfeeding reduces mortality and short and long-term morbidity among premature and small babies is well established but breastfeeding rates in neonatal units in the UK remain low. The aim of this study was to develop and evaluate an eLearning module that addresses the learning needs of neonatal clinicians to support breastfeeding on Neonatal Intensive Care Units (NICU). The module focussed on the knowledge areas of anatomy and physiology of lactation and expression. Mixed methodology was used to evaluate the eLearning module and inform its iterative development. This consisted of quasi-experimental pre-test/post-test studies using The Neonatal Unit Clinical Assessment Tool (NUCAT), an on-line objective knowledge test with self ratings of confidence to test the effects of the eLearning module on knowledge, confidence in knowledge and confidence in practice. Semi-structured interviews explored neonatal clinicians’ experiences of undertaking the eLearning module and their perceptions of the feasibility and applicability of the eLearning module as well as their opinions and experiences of breastfeeding support and training. In total 101 neonatal clinicians, including neonatal nurses, doctors, Advanced Neonatal Nurse Practitioners (ANNPs), nursery nurses and students undertook the initial NUCAT assessment of knowledge and confidence. A further 90 clinicians went on to complete the training and post intervention assessment, 60 repeated the post intervention assessment at 6-8 weeks. Baseline knowledge was greater in the area of breast milk expression than in the anatomy and physiology of lactation. Neonatal nurses were found to have greater baseline knowledge of breast milk expression than doctors or nursery nurses. Doctors/ANNPs were more knowledgeable about the anatomy and physiology of lactation. Following the training intervention doctors/ANNPs showed the greatest improvement in knowledge scores and nursery nurses the least. Knowledge and confidence was significantly increased immediately following the intervention and at 6-8 weeks in all groups. The semi-structured interviews conducted after the study showed the feasibility and applicability of the eLearning module for clinicians in NICU. On-line assessment and training provide a potentially effective multidisciplinary training method to improve breastfeeding knowledge and confidence. Nursery nurse may have differing learning needs and require further support and training.

Neonatal mortality in grey seals on the Isle of May breeding colony and in a rehabilitation centre were investigated by detailed systematic post-mortem examinations (n=59), on-site bacteriology and advanced molecular diagnostic techniques for specific pathogens. Causes of death on the breeding colony included starvation (30%), omphalitis-peritonitis (26%), septicaemia (22%), stillbirth (10%) and trauma (4%) and in the rehabilitation centre starvation (44%) and septicaemia (22%). Detailed key gross and histopathological findings and pathogens are described and include the first report of Listeria monocytogenes in any marine mammal. Phocid herpes virus 1 nucleic acids were detected in nasal swabs of 58% live, free-ranging grey seal pups (n=90) and 28% yearlings (n=19), suggesting recrudescence in the latter. Previously undetected in Scotland, phocid herpes virus 2 nucleic acids were identified only in yearlings (15%); sealpox was detected in a single live stranded grey seal pup and phocine distemper virus was not detected. Given their unique characteristics and potential for acting as sentinels of coastal marine health several pathogens of putative anthropogenic origin were investigated: Toxoplasma gondii, Neospora caninum, Salmonella spp. and Campylobacter spp. Toxoplasma gondii DNA was detected in 6% dead free-ranging grey seal pups (n=50) but N. caninum was not found. Salmonella (20%) and Campylobacter (50%) were isolated from rectal swabs of live and dead grey seal pups and Campylobacter was significantly associated with moderate to severe colitis implying pathogenicity. These findings imply a land-sea-land transfer of T. gondii and early exposure of pups to this parasite. Extensive genetic fingerprinting suggested an exchange of Salmonella between grey seal, cattle and human populations and that the Campylobacter isolates may share the same origin as human clinical isolates. This work provides a solid base line study of diseases present in grey seal pups and demonstrates that they are useful indicators of coastal marine microbial contamination.

The observed physiological dynamics of an infant receiving intensive care contain a great deal of information about factors which cannot be examined directly, including the state of health of the infant and the operation of the monitoring equipment. This type of data tends to contain both common, recognisable patterns (e.g. as caused by certain clinical operations or artifacts) and some which are rare and harder to interpret. The problem of identifying the presence of these patterns using prior knowledge is clinically significant, and one which is naturally described in terms of statistical machine learning. In this thesis I develop probabilistic dynamical models which are capable of making useful inferences from neonatal intensive care unit monitoring data. The Factorial Switching Kalman Filter (FSKF) in particular is adopted as a suitable framework for monitoring the condition of an infant. The main contributions are as follows: (1) the application of the FSKF for inferring common factors in physiological monitoring data, which includes finding parameterisations of linear dynamical models to represent common physiological and artifactual conditions, and adapting parameter estimation and inference techniques for the purpose; (2) the formulation of a model for novel physiological dynamics, used to infer the times in which something is happening which is not described by any of the known patterns. EM updates are derived for the latter model in order to estimate parameters. Experimental results are given which show the developed methods to be effective on genuine monitoring data.

Research has indicated that pain management practices amongst registered nurses is inadequate across all age groups; however, it is frequently noted that children receive less analgesia in comparable situations than adult clients leading to harmful and costly consequences. There is a distinct gap in nursing educational research understanding nursing student knowledge and attitudes towards neonatal and pediatric pain management practices. Using a convenience sample from a private, Christian-based university in the southeastern United States, this study used a quasi-experimental, one-group pretest/posttest design to understand the impact of elective nursing courses on undergraduate baccalaureate nursing student knowledge and attitudes towards neonatal and pediatric pain management practices using the Pediatric Healthcare Providers Knowledge and Attitude Survey Regarding Pain (PHPKAS). The research question states: To what extent do undergraduate baccalaureate nursing students neonatal and pediatric pain management knowledge and attitudes differ before and after three elective nursing courses already containing pain management education? A sample of 21 participants completed both the pretest and posttest surveys. Results from a paired samples t-test indicated there was not a significant difference in undergraduate nursing student knowledge and attitudes towards neonatal and pediatric pain management practices before and after elective nursing courses t[20]=.765; p=.227 (one tailed); thus, the researcher failed to reject the null hypothesis. Findings suggest that confusion exists towards the pain management practices, especially towards caring for children with cancer, the use of sedatives and narcotics, and common misconceptions regarding pain in neonates and pediatrics. The findings from this research can guide future pain management curricular content and educational research.

Full Study Title: Food Insecurity Screening of Families in a Level III Neonatal Intensive Care Unit Background: Early infancy food insecurity (FI) is linked to poor health later in life, and Neonatal Intensive Care Units (NICUs) are often overlooked. Routine FI screening can help identify and assist the families suffering from FI seen in the NICU before being discharged home. Purpose: The aim was to identify if families were assessed for FI by social workers or if they were more likely to report FI in a brief survey. Method: A randomized chart review of social work notes for 30 NICU patients at Regional One Health from January 2023 to June 2023 was conducted to determine if FI was screened. A three-question-FI screening tool was placed in all patient charts from October 2023 to December 2023. The NICU nurses and researcher asked admitted families to complete the survey during visits. Inclusion criteria included parents greater than or equal to 18 years old and English-speaking. Results: The chart review identified no explicit statements surrounding FI in the social work notes. The team anticipated 50 or more returned surveys throughout the study but received only 33 completed surveys. Thirty surveys were included in the study. Around 17% of families discussed receiving food assistance with social workers, whereas 39% reported FI via the survey. Conclusion: Screening via a brief survey was successful but not cohesive to the Regional One Health NICU. A different distribution method may offer better results.

Background: Thrombocytopenia is common in sick preterm babies in the first day of life. Despite this, platelet production in thrombocytopenic preterm babies has rarely been assessed. Methods: To address this problem I have developed miniaturised assays to study circulating megakaryocyte (MK) progenitors (BFU-MK and CFU-MK), total cultured MK precursors and mature MK, by culturing mononuclear cells purified from 0.5-1ml of preterm peripheral blood. MK lineage colonies and cells are identified by a MK specific anti-glycoprotein IIb/IIIa antibody (CD61) by APAAP. Results: i) Normal values for these cells at birth were established in cord blood from healthy term and preterm babies. ii) Circulating BFU-MK/CFU-MK, total cultured MK precursors and mature MK were then prospectively studied in 63 preterm babies (gestational age 24-34 wks). iii) At birth 18 (69%) of the thromocytopenic babies were also neutropenic. Conclusion: These data indicate that the principal cause of the thrombocytopenia and neutropenia in the preterm babies studied was reduced platelet and neutrophil production occurring as a consequence of reduced numbers of MK and neutrophil progenitors respectively. Taken together these data suggest the haematological abnormalities characteristic of new-born born to mothers with PIH or with IUGR (thrombocytopenia, neutropenia and polycythaemia) are a consequence of dysregulation of fetal haemopoiesis occurring proximal to committed MK and neutrophil progenitors, most likely at the level of the primitive multipotent haemopoietic stem cell (CFU-GEMM). Finally the value of miniaturised MK progenitor and precursor assays in evaluating rare or unusual cases of neonatal thrombocytopenia has been demonstrated. In the three examples investigated this approach provided unique insights into the pathogenesis of the thromocytopenia in each case.

Introducción: Los avances tecnológicos han hecho que cada vez un mayor número de recién nacidos sobrevivan en casos que antes se consideraban inviables, pero aún falta información sobre estos cuidados en la UCIN. Es crucial brindar cuidados paliativos neonatales adecuados, enfocados tanto al neonato como a la familia. Objetivo: Analizar métodos e intervenciones que se realizan en la UCIN para proporcionar cuidados paliativos y ofrecer el mejor cuidado a neonatos y familias. Metodología: Se lleva a cabo una revisión bibliográfica en las bases de datos PubMed, CINAHL y PsycINFO. Se utilizan 10 artículos. Resultados: 4 categorías identificadas: 1. Organización en la UCIN, 2. Comunicación con las familias, 3. Implicación de las familias en el proceso de toma de decisiones, 4. Intervenciones de cuidados paliativos en la UCIN. Conclusión: Muestra de cómo se proporciona una atención paliativa en la unidad de cuidados paliativos neonatal, considerando aspectos de la práctica diaria. Resaltando el gran calibre de la relación profesional-familia, se identifican estrategias de comunicación y toma de decisiones.

Mycobacterium tuberculosis (Mtb) is the causative agent of tuberculosis (TB), a predominantly respiratory pathogen responsible for over ten million infections and one million deaths last year. Despite it being a primary objective of the World Health Organization (WHO) for several decades to irradicate TB, progress toward this objective has fallen short of the 2020 target to end TB by 2035. Meeting this goal will require advancements in diagnostic tools, education, healthcare access, and treatments and preventatives. Regarding prevention, the primary tool for this strategy is through vaccination. Currently, the only licensed vaccine for protection against TB is the century old bacillus Calmette Guérin (BCG). BCG is predominantly used where TB is endemic, where it is ideally given as near after birth as possible to offer protection. While this vaccine does protect young children against TB and its disseminated forms, its efficacy in older populations is highly variable, suggesting a poor ability to produce long-term immunity. Improving BCG or altogether developing a new, more protective vaccine is thus a logical route to controlling the TB epidemic. Unfortunately, no vaccine candidate to date has been successful. In the present dissertation, we proposed this failure arises from an incomplete appreciation for the unique immune environment of the neonate. Neonatal immunity is distinct from that of older age groups, be it in mice or humans. Therefore, studying vaccine responses in an age-appropriate model of vaccination could provide better representations of protection following immunization. To explore this, we developed a neonatal mouse model of vaccination and in vitro assessment. Following previous observations from our lab, we were interested in the influence of the cytokine interleukin (IL)-27. This cytokine is immunosuppressive and we have previously shown it is elevated in the neonatal period when children are being immunized with BCG. Here, we explored the role of IL-27 in the neonatal period following BCG vaccination using our neonatal mouse models of BCG administration and a mouse unresponsive to IL-27 as a result of deletion in its receptor (IL-27Rα-KO). We observed improved production of IL-12 from neonatal dendritic cells with greater stimulation of CD4+ T cells in the absence of IL-27. Furthermore, we showed where clearance of BCG in vitro and in vivo is improved in the absence of IL-27 signaling. Finally, we observed improved control of Mtb in our IL-27Rα-KO alongside a shift to increased production of inflammatory cytokines in the lungs. We conclude that the studies herein offer substantial support for the important negative contributions of IL-27 during neonatal vaccination and suggest that greater consideration be taken to the unique immune environment during early-life vaccination and the development of vaccines for this age group to better model anticipated responses.

Abstract: The obstruction of blood flow to regions of an infant brain leads to a reduction of oxygen and essential nutrients, causing what is known as hypoxic-ischemic (HI) damage to that region. Presently the only treatment available for affected neonates is hypothermia: head or whole-body cooling. Despite its limited effectiveness, hypothermia delays disease progression, thereby providing an opportunity for a supplement therapy to be beneficial within that time frame. It has long been the goal to combine hypothermia with pharmacology to improve the overall neuroprotective potential. Many drugs have shown promise in treating the HI damaged neonate brain, however, the systemic dosage used to achieve therapeutic concentrations in the brain lead to significant side-effects that have prevented their use in clinic. Self-assembling peptides can be engineered to respond to biological cues and deliver drugs in an on-demand manner. Although some classical pH sensitive polymer systems have been studied in the past, we focus on using relatively biocompatible elastin-like polypeptides (ELPs) as a self-assembling peptide that can be engineered to respond to pH and temperature to allow for localized release of drug. ELPs are biopolymers composed of repeating units of the pentapeptide sequence Val-Pro-Gly-X-Gly (VPGXG), where the variable residue X can be manipulated to trigger the phase transition at desired conditions. Once in nanoparticle form, appropriate drugs can be incorporated into the ELPs such that hypothermia and/or the pH changes that arise due to disrupted metabolism in the damaged tissue, would induce nanoparticle dissolution. Subsequently, the drug would be released at the site of injury in a safe and controlled manner. ELPs were synthesized from genetically engineered plasmids in recombinant Escherichia coli and purified from the bacterial lysate by inverse temperature cycling (ITC). Dexamethasone (DEX) was selected as the candidate anti-inflammatory drug for neonatal brain injury. Dynamic light scattering was used to characterize the temperature-dependent assembly of ELP nanoparticles containing DEX followed by the pH-dependent disassembly. The drug loading or encapsulation efficiency and the stability of the nanoparticles over time were determined using high-performance liquid chromatography. Next, the ELP-DEX nanoparticles were injected in a neonatal rat model of brain injury and focal brain cooling was applied. To test the ability of the ELP nanoparticles to deliver DEX to the injured brain, HPLC was used to detect and measure the amount of DEX in the brain tissue. On screening several valine, leucine, and histidine containing-ELPs in the guest position, we identified the construct (AG)40-(VH4)24 as the one that could undergo nanoparticle formation with DEX encapsulation under physiologically relevant pH 7.4 and temperature 37°C. This construct demonstrated assembly between 35 – 40 oC to form particles of size ~300 nm, and disassembly between 35 – 33 oC to

Couplet Care is an emerging model of care in neonatology where the strategy is to deliver intensive care to newborns and their postpartum mothers in a shared room. The evaluation of these environments for high-risk newborns through post-occupancy evaluations is essential for evidence-based design. However, there is little evidence available that demonstrates outcomes with couplet care. The Neonatal Experience Evaluation Toolkit used in this study was developed at Yale New Haven Hospital. It is an approach that measures the effect of exposure to couplet care on maternal-infant bonding during hospitalization. In this prospective cohort study, Memorial Hospital in South Bend, Indiana served as the data collection site. Participants (n=19) showed high satisfaction with care during the immediate postpartum period. Built environment characteristics at the room and unit levels emerged as factors impacting behavioral outcomes. Improvements in future iterations of couplet care are highlighted through design, operational policy, and technology recommendations.

General AbstractPain is a major global health problem. While an immediate response to pain is necessary to protect the individual, ongoing persistent pain can be debilitating and without benefit. The underpinnings of the transition from acute to chronic pain, however, are unknown. Injury in early life causes pain, but the mechanisms that drive nociception in early life are distinct from adulthood. Despite this, much less attention focuses on the neonatal response to injury. The goal of this dissertation was to evaluate neonatal nociceptive mechanisms and how early life pain may result in a predisposition to chronic pain later in life. We first investigated patients and animal models before and immediately following pediatric surgery. Many children that undergo surgery report persistent pain, but why some patients are burdened with chronic post-surgical pain while others are not is not understood. We present a review of the genetic associations that may be relevant to identify at-risk populations. We continue to discuss not only how genetics may alter recovery from pediatric surgery, but also how early life injury may have long lasting effects to the epigenome of different cell types. In order to better understand the clinical problem, a preclinical rodent pediatric post-surgical pain model is introduced.The biological mechanisms following an early life surgery are distinct in early life, but many of the underlying differences are unknown. Therefore, we investigated a rodent model with a neonatal surgical incision. We found an injury-site growth hormone (GH)-dependent mechanism that is present in the neonate and not adult. We found that there is a tonic signaling tone of GH to the primary afferent in the naïve animal. After injury, GH is removed from the sensory neuron by macrophages to regulate immune-driven inflammation. The removal of GH signaling from sensory neurons results in primary afferent sensitization and behavioral phenotypes, all of which can be rescued by exogenous GH treatment. In our initial review, we found that early life injury can alter cell processes to later life injury, resulting in more pain in patients after subsequent injury. We found that GH treatment for an early life injury prevents this neonatal nociceptive priming from occurring. Finally, we continued to evaluate nociceptive priming and the role that the peripheral neuroimmune system may have in driving and maintaining this predisposition to persistent pain. We found that macrophages were both necessary and partially sufficient to drive a “primed” state. This may be due to a remodeling of the macrophage epigenome following an early life injury and this “memory” may be stored in the stem cells of the bone marrow. Targeting of this trained immunity may have potential to prevent behavioral neonatal nociceptive priming. These studies help us understand the risk that is involved with undertreated early life surgery. The data suggests that there is cellular memory that forms in the vulnerable systems activated by neonatal pain. The data present possible targets to prevent acute pain and the predisposition to chronic pain that occurs because of early life injury.

Abstract: This phenomenological study explores the lived experience of the nurse’s touch in the neonatal intensive care unit (NICU). Touch is deeply embedded within NICU nursing, sometimes so taken-for-granted as to seem invisible, but implied in nearly every nursing gesture and pursuit. Inserting an intravenous line, bathing a baby, assessing vital signs, holding and rocking a baby to sleep, and more; all are rich with the immediacy and intimacy of bodily contact and dependent on sensitive, capable gestures of touch. The manifold meanings of human touch may also go unrecognized, obscured within the tasks and work of nursing. Interpreting touch as simply the medium for nursing tasks may fail to capture the more originary meaning of touch between people as an ethical encounter, that quietly inheres in everyday moments of contact. In this study, I reflect on the nurse’s touch as a site of relation, revealing the felt sense of ethical demand experienced in the interface of touching contact. The project is situated in the qualitative research methodology phenomenology of practice (van Manen, 2014). Given to cultivating rich and ethically sensitive understandings of human life as it is lived, this form of interpretive inquiry is a strong fit with exploring the subtleties and sensualities of contact in an investigation of the embodied nature of the nurse’s touch. This inquiry is set primarily in the NICU where it is hard to imagine a human being that requires more delicate, nuanced, and skillful touch than the premature and ill newly born baby. By attempting to describe these practices and their possible meanings, my intention is to show that the ethical significance and contribution of touch might be realized as the corporeal wisdom of the nurse. This understanding may have a formative effect on our individual and professional consciousness, conversations, and curricula. Findings, insights, and explorations of the research are collected in three manuscripts. In the first paper, I consider the phenomenological interview as a means to gather detailed experiential description of the phenomenon under study. Using examples, I emphasize the methodological importance of detailed concrete descriptions of experience in phenomenological inquiry. I grapple with how to practice the phenomenological reduction during the interview, in service to setting aside preconceptions and assumptions about the focus of the study, including how to recognize concrete descriptions. In an important sense the researcher is trying to be invited into the participant’s world and to stand alongside them in a lived-through moment. In the second article, I have composed the research text around the following interpretive themes: the learning touch: finding a way to hold the baby; the marking touch: when touch lingers long after physical contact; the missing touch: or touching without physical contact; the gnostic touch: the possibility of knowing an other and ourselves; and the call of touch: drawn to hold. Exploring the touching gestures of the NICU nurse discloses the relational ethics at the heart of these caring practices. We reveal and appear to each other, baby to nurse and nurse to baby, through the proximity and closeness of touch. I explore further the experience of the nurse’s touch in the third manuscript, through phenomenological reflection on descriptive accounts of the nurse’s touch from poetry, fictional prose, neonatal nurse interviews, as well as scholarly and personal accounts. These examples help to cultivate insights into the nurse’s touch as a site for an ethical encounter, while contemplating the normative character of a good touch. The human connection of intimate contact -- both touching and being touched -- holds the possibility of transformation for the nurse.

The gut development of young calves is crucial for the producer and the calf's future. Many factors can affect the development of a young calf's gastrointestinal system, and there has been little research into the fecal microbiome development of calves from 0 to 12 weeks of age. To gain further insight into this process, development of the fecal microbiome in 12 dairy calves was investigated. Fecal bacterial composition was determined at four time points (weeks 0, 4, 8 and 12) using the 16S rRNA gene through PCR-amplification of the V1-V3 regions from fecal microbial genomic DNA, followed by Illumina MiSeq 2X300 sequencing. Four highly represented OTUs were found to have a peak of abundance at week 0 which was followed by significantly lower abundance at later time points (P < 0.05). Notably, OTU Bt-1063 peaked at week 0 (39.3% ± 3.6%) then declined at later time points with respective means of 2.3%, 0.1% and 0.05%. Seven other OTUs were found to peak at an intermediate time point (P < 0.05), including OTU Bt-1195 which was found in highest abundance at week 4 (4.5% ± 1.2%) compared to means with a range of 0.001% to 0.01% for the other time points. These results could allow for gut manipulation in the future which could improve the health and productivity of growing dairy calves.

An important component of nursing assessment of feeding tolerance in the neonatal intensive care unit (NICU) for both low-risk and high-risk babies, is the quantification of emesis volumes. While some nurses attempt to weigh the items saturated in emesis in order to quantify volume loss (QEV), there is no or limited consistency in this practice across nurses in this unit. Rather, volumes are “best-guessed” or estimated (EEV) and reported to the practitioner for decision-making. Often feed advances are paused or limited due to perceived feeding intolerance connected to emesis events in neonates. For this project, 158 NICU nurses at a large metropolitan children’s hospital in New York City were given a survey consisting of ten images of simulated emesis volumes on standard hospital linens and asked to estimate the emesis volumes (Appendix B). Nurses were also surveyed on demographics, their attitudes and beliefs related to emesis in neonates, and personal practices regarding this issue. Compiled data results revealed that nurses were able to correctly estimate the simulated emesis volume presented to them an average of 34.5% of the time, regardless of educational level, years of experience, or presence of certification in their specialty. It is clear that visual quantification of emesis volumes is a highly inaccurate method to assess feeding tolerance and guide feed advancement in the NICU. Further research is needed on how these methods affect time to full feedings and overall NICU length of stay.

Abstract: Extensive neonatal resuscitation that involves chest compressions is an uncommon event impacting approximately 0.1% of term newborns, and up to 15% of preterm newborns. Despite best resuscitation efforts birth asphyxia results in approximately one million deaths annually worldwide. Neonatal resuscitation research is still considered to be a field in its infancy when it comes to optimizing extensive resuscitation efforts. This is further complicated by the infrequent occurrence of extensive neonatal resuscitation, making it difficult to conduct rigorous clinical studies. However, optimizing neonatal resuscitation is an urgent issue as current extensive resuscitation practices are associated with poor survival and morbidity. Animal models make up the primary body of scientific knowledge when it comes to optimizing chest compression techniques. To this extent, the contents of this thesis explore whether continuous chest compressions with asynchronous ventilation (CCaV) with varying rates of chest compressions reduces the time to return of spontaneous circulation (ROSC) using a porcine model of neonatal asphyxia induced cardiac arrest. We hypothesize that CCaV with 120 CC/min will have reduced time to ROSC compared to CCaV with 100 CC/min or 90 CC/min. Thirty piglets of age 24-72h were surgically instrumented and allowed to recover to a stable baseline following surgery. Piglets in the intervention group were exposed to 30min of hypoxia followed by asphyxia until cardiac arrest, piglets in the sham-operated (n=6) group were not. Intervention piglets were randomized to receive CCaV with either 90 CC/min (n=8), 100 CC/min (n=8), or 120 CC/min (n=8) until ROSC or a maximum of 12min. Piglets that achieved ROSC were allowed to recover for 4h, after which, cerebral cortical tissues were harvested for bioassays. Time to ROSC was similar in all intervention groups (120s, 90s, and 90s for CCaV+120, CCaV+100, and CCaV+90 respectively, p=0.93). The number of piglets achieving ROSC (p=0.83), and survival to 4h after ROSC (p=0.50) was also similar across intervention groups. However, regional hemodynamic recovery at the end of experiment was significantly worse in CCaV with 90 CC/min and 100 CC/min compared to CCaV with 120 CC/min. A similar trend was observed with pro-inflammatory markers interleukin(IL)-1β, IL-6, and lactate in the frontoparietal cortex. Where CCaV with 90 CC/min and 100 CC/min had significantly worse cortical inflammatory and injury markers compared to CCaV with 120 CC/min.

Streptococcus agalactiae (Group B Streptococcus, GBS) is the most common neonatalpathogen capable of causing devastating disease in newborns, yet healthy adults are largelyunaffected. The cellular and molecular mechanisms for neonatal susceptibility to GBSpneumonia and sepsis are incompletely understood. Here we optimized a mouse model ofGBS pneumonia to test the role of alveolar macrophage (AM) maturation in hostvulnerability to severe disease. Compared with juvenile and adult mice, neonatal miceinfected with GBS had increased mortality and persistence of lung injury. In addition,neonatal mice were defective in GBS phagocytosis and killing. AM depletion and disruptionof AM differentiation in Csf2-/- mice both impaired GBS clearance. AM engage the heavilysialylated GBS capsule via the cell surface Siglec receptors Sialoadhesin (Sn) and Siglec-E.Newborn AM expressed significantly lower levels of Sn, although both newborn and adultAM expressed Siglec-E. Sn is exclusively expressed by CD11b lo and CD11b hi AM, whileSiglec-E is more commonly expressed by lung myeloid cells. AM Sn expression decreasedafter GBS infection in both adults and neonates, this decrease seemed to be mediated by theGBS Sia-Siglec-E ligation. The GBS Sia mutant, neuA, failed to decrease Sn expression ineither adults or neonates. Cell surface protein expression of Sn also decreased at 24 h afterGBS infection in the WT neonates, however, Sig-E-/- neonates maintained surface expression of Sn at 24 h of infection. We propose that a developmental delay in Sn expression on AMmay prevent effective killing and clearing of GBS from the newborn lung. Next weinvestigated the impact host Sia could have on AM development and responsiveness toinfection. While the fetal lung lacks expression of 2-3 Sia in the lung, the major sialylatedglycoprotein in the urine, Tamm-Horsfall Protein (THP), was found in the fetal lung. THP-/-neonates, at PND1, 2, and 8 all showed decreased expression of Siglec-E, and higherexpression of Siglec-F at PND2. We hypothesize that the developing fetus aspirates amnioticfluid, of which a major component is fetal urine containing THP, into the lung duringgestation bringing a source of Sia into the lungs and regulates fetal AM development andsuppresses inflammatory activity.

Childhood Acute Lymphoblastic Leukemia (ALL) is the most common childhood malignancy in the United States, accounting for approximately 30% of pediatric cancer diagnoses each year. Over the past several decades, the 5-year survival rate for ALL has risen to nearly 90% due to incorporation of modern treatment protocols that employ vincristine (VNC) as the frontline antineoplastic agent. Unfortunately, such improved outcomes have drawbacks, as VNC, along with several other chemotherapeutic agents produce neurotoxic effects and can result in chemotherapy-induced peripheral neuropathy (CIPN) in patient populations of all ages. While CIPN has been well studied clinically and experimentally in adults, little is known about the consequences of chemotherapy exposure in early life. Given that childhood ALL diagnoses typically occur around 2-3 years of age, a time at which the developing nervous system may be differentially vulnerable to peripheral insults, this dissertation characterizes for the first time, a rodent model of pediatric vincristine-induced peripheral neuropathy.

Abstract: The inertial filtration properties of neonatal infant nasal airways are the focus of this thesis. Nasal replicas based on computed tomography (CT) scan images of seven infants between the ages of 5 and 79 days were created using three-dimensional printing. Deposition of inertial sized aerosol particles in these models was measured using an electrical low pressure impactor (ELPI). The aerosol entering the nasal replica is characterized with the ELPI by sampling through a blank line. The reduction in concentration of aerosol after passing through the nasal replica is the deposited fraction. The ELPI bin geometric centres were used as a single particle size for deposition data. Deposition was recorded for particles with aerodynamic diameters between 0.53 and 5.54 μm. A filtration efficiency correlation was developed through non-linear least squares fitting. This correlation collapsed intersubject variability in the data onto a single curve capable of describing deposition in all the nasal replicas studied. A non-dimensional pressure drop, the Euler number, was required as an input variable in addition to the Reynolds and Stokes numbers to achieve satisfactory collapse of the data. These dimensionless parameters were evaluated with a characteristic dimension defined as the nasal airway volume divided by its surface area. An analysis of expected in-vivo intersubject variability of aerosol filtration was also performed. Further, the ability to scale a previously developed idealized infant nasal airway to produce a model which mimics nasal filtration in the neonatal population was explored. Inertial deposition in three scaled models of the original full scale geometry was measured using the same method used to quantify deposition in the nasal replica models. Comparison of deposition in the scaled idealized models to deposition in the replica models led to the identification of the appropriate scale factor. Non-linear least squares fitting produced a correlation which uses Reynolds and Stokes numbers to describe deposition in this geometry for all scales considered. It is hoped that the results of this thesis will aid future research into aerosol devices specifically for neonatal infants and their unique extrathoracic airways.

According to the AHA and the AAP, approximately 10% of newborns require some assistance to begin breathing at birth; less than 1% need extensive resuscitative measures to survive (2015). There is an abundance of evidence-based literature on the need for neonatal resuscitation readiness. However much of this literature is targeted toward teamwork efforts during the act of resuscitation. This DNP scholarly project is to take a step back to improve the actual set-up component required for neonatal resuscitation. There can be instances in which equipment is not properly set-up or the set-up is not appropriate for the gestational age of the newborn. Based on the PICO format the question for this project: Does initiating a comprehensive pre-resuscitation checklist increase neonatal resuscitation readiness? This can be the foundation for further studies on neonatal outcomes based on neonatal resuscitation and use of a neonatal resuscitation checklist on neonatal outcomes.

BACKGROUND: Donor breast milk is increasingly used as a supplemental feeding source for preterm infants when mother’s own milk supply is limited. Despite fortification, donor breast milk does not have the same nutritional content of a preterm infant’s own mother’s milk, and can be lacking in macronutrients needed for optimal growth. Air displacement plethysmography is validated for the measurement of neonatal body composition and can provide a snapshot of nutritional status that is predictive of later outcomes.OBJECTIVE: The goal of this study was to describe the body composition of very low birth weight infants fed donor breast milk and correlate the ratio of donor breast milk to maternal breast milk intake with lean and fat mass deposition.METHODS: Fat mass, lean mass, and body fat percentage were measured using air-displacement plethysmography. Nutritional intake details were recorded, and along with maternal characteristics, demographic data, and medical data, were used to develop a regression model that predicted body composition. RESULTS: Of the 67 enrolled infants, fat mass, lean mass, and body fat percentage were measured in 30 (45%) very low birth weight infants once they were stable on room air. Significant variables in the model for body fat percentage measured between 30+0 and 36+6 weeks corrected gestational age included sex, maternal age, and proportion of donor breast milk intake; together these explained 63% of variation in body fat percentage. Maternal height, maternal age, sex, and small for gestational age status were predictive of the variation in lean body mass, while proportion of donor breast milk intake was not a statistically significant characteristic in the lean body mass regression model.CONCLUSION: Donor breast milk intake is associated with less body fat deposition in very low birth weight infants.

Lysophosphatidic acid (LPA) is a signaling phospholipid that binds to G protein-coupled receptors designated LPA1-LPA6. It has several activities throughout the body, including modulating cellular survival and migration. LPA circulates in the blood bound to carriers such as albumin, and LPA concentrations are increased during cases of hemorrhage or trauma. In the nervous system, LPA helps modulate development and differentiation, but high concentrations of the lipid are often involved in pathology. Post-hemorrhagic hydrocephalus is one such disorder. Hydrocephalus results from an accumulation of cerebrospinal fluid (CSF) in the brain, which expands the fluid-filled ventricles, causing permanent brain damage. This disorder is often chronic and is treated by invasive neurosurgical procedures which drain excess CSF. Here we provide evidence that LPA, introduced to the CSF in the blood, may be a key mediator of post-hemorrhagic hydrocephalus. Animals were injected with LPA at postnatal day 8 and hydrocephalus was observed by measuring increased ventriculomegaly and intracranial pressure 7 days later. Histology and immunohistochemistry demonstrated that the ciliated ependymal cells which generate CSF flow were heavily disrupted 3-6 hours post-LPA exposure. However, development of hydrocephalus and degeneration of the ependymal monolayer was prevented by knockout of LPA1, and to a lesser extent by LPA3 knockout. Pretreatment with the LPA1 antagonist AM095 also protected LPA-injected animals from developing hydrocephalus, signifying that this is a receptor-mediated phenomenon that could be prevented by timely application of a pharmacological inhibitor. As there are currently no efficacious pharmacological treatments for hydrocephalus patients or methods used to prevent hydrocephalus post-hemorrhage, the identification of LPA1-expressing ependymal cells provides a novel target for therapeutic development.

In this modified single-subject design study, the researcher sought to find whether eight parents who were taught to use lullaby evidenced a change in attachment and parenting stress regarding their infant’s hospitalization and into transition to home. Using repeated measures over a period of approximately two months, each parent was asked to use infant directed lullaby with their infants and keep track of its use with a calendar. The Maternal Attachment Inventory and the Parenting Stress Index provided measurement of self-reported attachment and stress. An adapted intervention rating profile was used to determine the parent’s perceived acceptance of infant directed lullaby. Understanding possible connections between attachment and parenting stress with music, and as a music therapy intervention, is important for both researchers and clinicians in the field of music therapy. Teaching parents to use a simple and cost effective tool may provide families with more access to interventions similar to infant directed lullaby as well as provide support for families and their infants. Despite this study’s inconclusive findings, a new door for research in this settings has been opened regarding parent training and its effectiveness, which is important in that a therapist is not always able to be present to provide treatment particularly in the NICU setting and after they have been discharged home.

Breast milk is the gold standard for infant nutrition. In the past, infant formula was promoted as equal or superior to breast milk. However, research has shown that breastfeeding is the superior form of infant nutrition except in rare circumstances. Breast milk provides for all of a newborn’s caloric needs and has the correct balance of nutrients to promote proper development. In addition, breast milk provides protection against illnesses, supports an infant’s immune system, and promotes life-long health for the newborn. Mothers also experience personal benefits by breastfeeding such as decreased cancer risks, bonding with their babies, and faster postpartum weight loss. There are multiple reasons why a mother does not breastfeed or is unsuccessful in continuing breastfeeding, but receiving support and education can help a new mother be successful. The Baby Friendly Initiative has improved breastfeeding rates but further work still needs to be done to increase breastfeeding initiation and continuation in order to promote and increase both infant and maternal health.

Neonatal hypoxic-ischaemic (HI) brain injury can lead to a range of neurological impairments and in some cases result in death. Maternal comorbidities such as obesity are associated with an increase in the incidence of birth related difficulties leading to HI. Currently, there are limited treatments for HI, hence the need to investigate alternative strategies. Postconditioning (PostC) with mild hypoxia after HI can reduce brain damage however, the mechanisms underlying this protection and effects on functional deficits are unknown, and were investigated in this thesis. Sprague Dawley (SD) rat pups were exposed to HI on postnatal day (P) 7 and to PostC (8% oxygen, 1hr/day for 5 days) or ambient conditions (N), starting 24 hours after HI. To investigate cellular responses, brain tissue loss, caspase-3 activation, microglial phenotype, gliosis and inflammation were examined using histological staining, immunohistochemistry and enzyme-linked immunosorbent assays. Markers of brain injury, inflammation and apoptosis were increased in the ipsilateral hemisphere after HI, and these were reduced by PostC. Short- and long-term behavioural deficits were observed in righting-reflex, footfault and novel object recognition tests following HI, and PostC prevented these deficits. The effects of maternal obesity on HI injury in offspring were also studied. Female SD rats were allocated to high fat (HFD) or Chow diet and mated with lean male rats. Offspring were assigned to HI or C groups on P7. Short-term behavioural tests were conducted and brains from offspring were analysed for brain tissue loss, microglial and astrocytic responses using histology and immunohistochemistry. Brain injury size was approximately doubled in HFD+HI compared to Chow+HI pups. Increased gliosis and microglial activation accompanied the exacerbated injury response in HFD+HI pups. A shift in microglial morphology from predominantly ramified to amoeboid in both HFD groups indicated a pro-inflammatory effect of maternal diet in the brains of offspring. The results of this thesis have provided a better understanding of the protective effect of PostC and the detrimental contribution of maternal obesity to neonatal HI. This lays the foundation for a potential intervention strategy which may be used to improve the wellbeing and clinical outcomes of children with HI brain injury.

Abstract: Short bowel syndrome (SBS) occurs when a significant length of intestine is surgically resected for both congenital and acquired intestinal abnormalities and remains a significant cause of morbidity and mortality in neonates. With an insufficient amount of intestine available for nutrient absorption, neonates with SBS are dependent on parenteral nutrition (PN) for survival but many continue to develop and succumb to PN-associated complications such liver disease and sepsis. In order for these children to survive, the remnant intestine must adapt and improve nutrient absorption over time. Glucagon-like peptide-2 (GLP-2) is a distal intestinal-derived peptide that is trophic to the intestine and stimulates intestinal adaptation after major resection. Diseases that lead to SBS in neonates, such as necrotizing enterocolitis, most commonly affect and require removal of the distal intestine, including ileum. Thus, GLP-2 may be the limiting factor for adaptation in human neonates with SBS. Furthermore, the intestinotrophic effects of GLP-2 may be augmented by the simultaneous delivery of either enteral nutrition (EN) or epidermal growth factor (EGF). We thus hypothesized that GLP-2 therapy stimulates intestinal growth and function in neonatal SBS, and that the intestinotrophic effects of GLP-2 are augmented when given in combination with either EN or EGF therapy. For these studies, neonatal piglets were block-randomized to either a 75% mid-intestinal resection (JI model) with jejunoileal anastomosis (leaving equal lengths of jejunum and ileum) or 75% distal-intestinal resection (JC model) (removing all ileum) with jejunocolic anastomosis or sham (no resection) control. Piglets also received a jugular venous catheter and a gastrostomy tube for the provision of PN and EN, respectively. Piglets were subsequently maintained for 7 days. In the first study, piglets received either intravenous GLP-2 (42 μg/kg/day) or saline control and either remained on total PN (0% EN) or received EN at 40% of nutritional requirement. In the second study, piglets received saline control, intravenous GLP-2 (42 μg /kg/day), enteral EGF (80 µg/kg/day), or combined GLP-2 and EGF and all piglets received EN at 20% of nutritional requirement. Structural adaptation was assessed by the change in intestinal length, mucosal and intestinal weight, and histopathology. Functional adaptation was assessed by measuring several parameters: the relative gene expression of nutrient transporters, digestive enzymes and tight junction proteins, measurement of intestinal permeability using the Üssing chamber apparatus, fat absorption and weight gain. In the first study, we observed that in piglets maintained on total PN in the absence of treatment, the JI model demonstrated intrinsic structural adaptation, including increased intestinal weight and villus height, while the JC model did not. In this group that was not enterally fed, GLP-2 treatment induced histological adaptation in the JC model. In contrast, enteral feeding at 40% of nutritional requirement resulted in intestinal lengthening and increased intestinal weight in the JI model, while increased diarrhea and decreased weight gain were observed in the JC model. GLP-2 treatment in this fed group of piglets had no effect in the JI model but increased villus height in the JC model. We did not observe differences in the gene expression of nutrient transporters or tight junction proteins. In the second study, combined EGF and GLP-2 treatment increased intestinal length by 15%, regardless of surgical anatomy. Both GLP-2 alone and combination therapy increased intestinal weight in the JC model, and jejunal mucosal weight and villus height in both JI and JC models. Combination therapy decreased intestinal permeability to both mannitol and polyethylene glycol in both surgical models. There was no difference in fat absorption or weight gain. Our results demonstrate the beneficial effects of exogenous GLP-2 treatment in the JC model, which anatomically represents most human infants with SBS. In contrast, the JI model demonstrated greater structural adaptation in response to enteral feeding. We further demonstrated a beneficial effect of combined GLP-2 and EGF treatment on increasing intestinal length and absorptive surface area in both models, which may lead to improved nutrient absorption. The benefit of decreased intestinal permeability with combination therapy translates to strengthened barrier function and decreased risk for bacterial translocation. GLP-2 therapy may thus benefit human infants with SBS, who commonly experience small intestinal bacterial overgrowth. Moving forward, our studies provide important preclinical data with regards to the translation of trophic peptide therapies in neonatal SBS.

Purpose: This research study sought to explore whether fetal total brain volume (TBV) determined by using conventional fetal MR imaging is associated with postnatal preoperative brain injury in neonates with critical congenital heart disease (CHD). A secondary aim was to investigate the trajectory of brain growth from the fetal to neonatal time period in this same patient population. Methods: Twenty subjects had complex CHD diagnosed in utero and required postnatal neonatal surgery at University of California, San Francisco (UCSF) from 2010-2016. Fetal and neonatal MRI scans from 12 of the 20 eligible subjects were processed and analyzed in this study. These scans and clinical data are a part of an ongoing study to investigate the effects of CHD on brain injury and neurodevelopmental outcome at UCSF. Results: This study revealed a strong linear relationship between fetal TBV and gestational age (p=0.0012). Subjects with preoperative brain injury tended to have a smaller mean fetal TBV (187.8 cm^3, 95%CI: 156.9-218.7) as compared to those without preoperative brain injury (225.2 cm^3, 95%CI: 189.8-260.6; p=0.165). There was also a trend towards decreasing TBV with a higher brain injury severity (BIS) score (BIS 0, TBV 225.1 ± 38.3 cm^3; BIS 1, TBV 210.9 cm^3; BIS 2, TBV 199.2 cm^3; BIS 3, TBV 176.4 ± 26.6 cm^3; p=0.06). The rate of increase in TBV from the fetal to neonatal time period was similar in those with and without preoperative brain injury (p=0.33).Conclusions: These preliminary findings suggest a potential relationship between in-utero brain growth and the risk of neonatal preoperative brain injury in patients with critical CHD. A larger sample size will be analyzed to further assess this relationship.

Premature birth (< 37 weeks of gestational age) is a leading contributor to neonatal morbidity and mortality worldwide. A major challenge in managing neonatal health is to provide adequate and appropriate nutrition such that growth and development are supported in a manner as close to in utero as possible. However, it is difficult to establish postnatal nutritional delivery in premature infants due to their inability to ingest nutrients. Enteral feeding is the gold standard for such patients, but their small size and fragility present significant challenges in nasogastric and particularly nasojejunal (NJ) feeding tube placement. Inadvertent feeding tube placement in the respiratory tract is common and can lead to pneumothorax.There are several methods to ensure correct placement of NJ tubes, but fluoroscopic guidance is the only real-time visualization methodology used clinically. Fluoroscopic placements are limited by the lack of soft tissue contrast and the exposure of the neonate to ionizing radiation. Frequently, NJ feeding tubes are displaced due to coughing, vomiting, and/or baby movement resulting in repeated tube placements and a significant cumulative X-ray dose.Magnetic resonance (MR) has the significant advantage of not requiring exposure of the neonate to ionizing radiation, allowing for repeated procedures and imaging when required. Additionally, MR imaging is superior to fluoroscopy in anatomical resolution and soft-tissue visualization. This dissertation investigates the hypothesis that magnetic resonance can be used to guide nasojejunal feeding tube placements in neonates providing improved device visualization over fluoroscopic methods without ionizing radiation if certain challenges are overcome. These challenges include: 1) the size mismatch between an adult-sized MR scanner and the neonate, 2) inaccuracies in active MR tracking caused by non-ideal conditions, 3) radiofrequency heating of conducting wires used to connect MR tracking coils to the MRI system, and 4) design of NJ tubes which can be reliably placed under MR-guidance.This research addressed the aforementioned challenges in an attempt to make a neonatal MR-guided NJ feeding tube placement a reality. First, two novel small-footprint neonatal MRI scanners were designed and built. These scanners allowed for the first time the ability to perform MR-guided interventions on neonates. Second, the accuracy and precision of MR device tracking was improved with two novel methods: centroid pixel and micro-transmit tracking. These methods are important when an interventional device encounters non-ideal conditions within the body. Third, several innovative methods to reduce radiofrequency (RF) heating of the conducting wires used to connect MR tracking coils to the MRI system were designed and evaluated experimentally. Fourth, a novel MR-guidable feeding tube and guidewire with integrated MR tracking coils were designed, built, and evaluated. Lastly, the feasibility of a MR-guided neonatal NJ feeding tube placement was assessed experimentally with an animal model.The research performed in this dissertation demonstrated the feasibility and benefits offered by an MR-guided approach to NJ feeding tube placement. The ability to acquire high-quality MR images of soft tissue without ionizing radiation coupled with accurate three-dimensional device tracking promises to have a powerful and sustained impact on future neonatal interventions.

During fetal to neonatal circulatory transition, the mammalian heart undergoes an elaborate maturation process involving structural, morphological, and hemodynamic changes that ultimately lead to functional maturation of left and right ventricular chambers as they synchronize to support the systemic and the pulmonary circuits respectively. Perturbation of this process may have major implications in congenital heart defects (CHDs) and pediatric heart diseases. Transcriptome programming is the driving force of cardiac development and pathological remodeling in heart. Although recent progress of deep RNA sequencing technology has revealed much of the landscape of transcriptome regulation in cardiac development and diseases, transcriptome changes during chamber specific maturation or remodeling in neonatal heart in health and disease conditions remain understudied.During the past three years we have made systematic multidisciplinary efforts to address this critical gap of knowledge. We implemented deep RNA-sequencing to establish genome wide transcriptome profiles at single exon resolution in newborn mouse heart during maturation. Our studies reveal that transcriptome maturation during perinatal circulatory transition is a highly dynamic process which is precisely regulated in spatial and temporal manners, affecting transcriptional regulation, molecular signaling, the long noncoding RNAs (lncRNAs) and alternative RNA splicing. Some of these regulatory mechanisms may have potential implications in cardiac maturation, stress response, and neonatal heart diseases. The data provide a comprehensive spatial and temporal landscape of lncRNAs in neonatal heart, revealing their tight regulation and putative function. Among them, several cardiac specific lncRNAs are significantly conserved in human infantile hearts, providing the basis for future investigations in neonatal heart maturation and pathology. Moreover, we discovered chamber specific regulation of Wnt signaling and cellular proliferation programs. From functional studies, we establish for the first time a previously unrecognized significant role of Wnt11 signaling in neonatal heart growth and maturation. More remarkably, we establish that altered regulation of Wnt-mediated signaling in heart of infants with cyanotic CHDs comparing to noncyanotic CHDs, suggesting a potential contribution of Wnt signaling in heart response to chronic hypoxemia. Discovering the functional role of Wnt signaling and exploring the translational implication in early postnatal heart maturation and diseases by establishing the CHD Bio Core at UCLA represent major components of my thesis project.

The World Health Organization (2013) states palliative care for children should begin at diagnosis which may even occur prenatally. Neonatal palliative care is variable due to the high technological, curative environment in the newborn intensive care unit, and the uncertain prognoses of infants born at the edge of viability. The purpose of this EBP project was to determine the influence of establishing a neonatal palliative care protocol on nurses’ perceived barriers to palliative care and moral distress. Corley’s Moral Distress theory and Stetler’s Model were used as guides for the framework of the project. The protocol, based on guidelines supported by the American Academy of Pediatrics and the National Association of Neonatal Nurses, included forming a care team for the infant and family and educational sessions for the nurse based on the End of Life Nursing Education Curriculum. Pre-invention and post-invention surveys were administered which measured perceived barriers and moral distress. The pre intervention and the post-intervention groups differed by gender (X2(1) = 4.483, p

Abstract: Cardiovascular dysfunction in asphyxiated neonates leads to significant morbidity and mortality and the hemodynamic support is limited to the use of catecholamines. In a pilot study, we showed that low-dose vasopressin improved myocardial tissue lactate levels, suggesting decreased anaerobic metabolism. We postulated that starting this infusion earlier would benefit systemic hemodynamics. The aim was to compare the systemic and regional hemodynamic effects of vasopressin and dobutamine, a synthetic beta-adrenoreceptor agonist commonly used clinically. This study is the first to demonstrate that a low-dose vasopressin infusion used in the setting of a neonatal swine model of hypoxia-reoxygenation improves cardiac output and mesenteric perfusion, with results comparable to those of dobutamine. Improved myocardial biomarkers and evidence of decreased mesenteric oxidative stress confirmed our results. We did not demonstrate a benefit to the combined used of vasopressin and dobutamine. We conclude that low-dose vasopressin may be useful in the treatment of perinatal asphyxia.

When a woman discovers that she is pregnant, she begins a process of internal work to develop her mother role. This process has been outlined in the literature for the delivery of a healthy full-term baby, however little is known about the process for mothers of medically fragile babies. A threatened pregnancy and subsequent delivery of a medically fragile baby involves a different process of internal work by the mother to prepare for her role. Mothers with a baby in the Neonatal Intensive Care Unit (NICU) experience stress, uncertainty, and anxiety potentially causing a permanent impact on the successful development of her role. It is the purpose of this dissertation to explore the process of mother role development among those first-time mothers having a baby in the NICU. This study was conducted using a qualitative grounded theory method. Data collection consisted of personal journals, in-person interviews, researcher notes and observation. The specific aims include (1) describing the disruption in the individual’s preconceived idea of being a mother, (2) exploring specific strategies that support the mother in the development of her role while in the NICU, (3) describing the mother’s perception of her role during physiologic changes in her baby, (4) examining the mother’s evaluation of her mother-role success, (5) developing a deeper understanding of the process of developing the role of mother while in the NICU, and (6) constructing a theoretical model to illustrate the process of becoming a mother while in the NICU.

Congenital hypothyroidism (CH) is a condition of severe thyroid hormone (TH) deficiency present at birth. The current treatment is clear, and straightforward - a daily oral dose of thyroxine (T4). But, knowing precisely how much T4 to give and how to adjust dosages over time is an unsolved major treatment issue. Too much can produce side effects throughout life; too little is not enough to sustain normal growth and development. We developed and quantified a non-linear, multi-compartmental CH neonate model, as an adaptation of an existing simulator of feedback control of human TH levels in children and adults. Using a simulation approach, we found that simulated L-T4 plus L-T3 treatment is better than L-T4 alone treatment and the best treatment for CH babies is 1st 8 mcg/kg L-T4, followed by 0.5 mcg/kg/day L-T4, with 0.10 mcg/kg/day L-T3 over the first month of life - the period for which we had reliable data.

Abstract: In this qualitative study, methods adapted from the field of ecologic restoration were used to explore seven registered nurses’ perceptions of one Neonatal Intensive Care Unit (NICU) as a place to provide neonatal palliative and end of life care. The study was conducted in two phases. In phase one, data was collected during a unit photo walkabout. A photo-elicitation focus group followed. Transcribed data were coded for themes related to physical spaces, practices and culture that influenced care, and current resources available to support care. Key findings from this study included: participants faced challenges providing palliative and end of life care in a busy NICU, there is a need for continued education in palliative and end of life care principles and the importance of providing grief and bereavement support to families.This improved understanding is a step towards setting goals aimed at improving care for dying neonates and their families.

Abstract: The surgical repair of congenital heart defects (CHDs) often requires a bloodless/motionless field achieved by arresting the neonatal heart and exposing it to a period of ischemia. Metabolic manipulation, such as suppression of fatty acid (FA) oxidation, improves post-ischemic functional recovery in adult hearts. However, the metabolic profile of a neonatal heart differs dramatically from that of an adult. The neonatal heart is highly dependent on FA oxidation while glucose metabolic rates remain low until weaning. Since the neonatal myocardium is a FA-centered metabolism, then, unlike the adult heart, augmenting FA oxidation may improve its post-ischemic function recovery by increasing ATP available to the myocardium. In these studies, hearts were isolated from relevant neonatal rabbit models to study insulin’s effect, neonatal volume-overload hypertrophy, neonatal cardiac hypertrophy treated with a peroxisome proliferator activated-receptor-Α (PPARΑ) agonist. The hearts were perfused ex vivo to assess changes in cardiac metabolism and post-ischemic functional recovery associated with each treatment. The results demonstrate that high fat alters the neonatal heart’s response to insulin to increase FA oxidation and improve post-ischemic functional recovery. In contrast, neonatal cardiac hypertrophy downregulates FA metabolism and is associated with poor post-ischemic functional recovery. The administration of a PPARΑ agonist upregulated the FA metabolic pathway; therefore, FA metabolism increased and rescued the metabolic phenotype associated with cardiac hypertrophy and normalized post-ischemic functional recovery. In conclusion, augmenting FA oxidation with clinical levels of insulin in the normal neonatal heart and or a PPARΑ agonist in hypertrophied neonatal hearts improves post-ischemic functional recovery and may be a viable therapy of ischemia-reperfusion protection.

There is a worldwide consensus that the incidence of asthma and allergy is exhibiting a rising trend in western societies. There is also epidemiological evidence that New Zealand children raised on farms are less likely to experience asthma than those in urban environments. The aims of this study were to firstly set up a sheep model for the study of asthma and secondly, examine the effect of intrauterine and neonatal inoculation of an asthma-causing allergen [house dust mite (HDM) - Dermatophagoides pteronyssinus] or helminth antigen [Trichostrongylus colubriformis L₃ (TCL₃)] on the development of experimentally induced ‘asthma’ in sheep. Feti or neonates of twin-bearing ewes (n=22) were treated with TCL₃, HDM or PBS (control) given by lavage following hysterectomy (prenatal). At ten months of age, these lambs with additional control lambs (n=6) were sensitized by the subcutaneous inoculation of HDM and later challenged intra-bronchially with HDM, using a fibre-optic bronchoscope. At birth, lambs treated in utero with HDM antigen had the highest levels of HDM-specific IgE compared with lambs treated prenatally with TCL₃ or PBS. HDM-specific IgE levels for the different treatment groups decreased significantly over the 4 week postnatal period but not their HDM-specific IgG₁.Twin lambs (control and treated) showed similar levels of specific–HDM antibody after suckling from the same ewe. At 10 months of age following sensitization and challenge, there were no significant differences among white blood cells of the peripheral blood but cytology of bronchoaveolar lavage fluid following challenge showed that treatment with HDM antigen had a significant (P=0.003) effect on increasing lymphocyte percentage in the left lung of the experimental sheep but not in the right (PBS treated) lung. The atopic TCL₃ and PNTCL₃ sheep had significantly less eosinophils (P=0.05) in the left (treated) lung compared with the right (control) lung BAL, 24 h and 48 h after challenge. The atopic sheep from the other groups did not show any significant differences between their left and right lungs. Gross pathology of the sheep lung showed hepatisation of both treated and control lungs of the sheep with a trend for the animals treated prenatally (with either TCL₃ or HDM, or their controls) to have less extensive lung changes. Histological examination indicated that prenatal (TCL₃) or neonatal (PNTCL₃) exposure to helminth antigen compared with HDM and control resulted in less inflammation of the lung tissue after sensitization and challenge with HDM antigen. This study showed that research sheep can be used as a model for asthma studies and that exposure of lambs to a helminth antigen in utero or as neonates suppress inflammatory responses to asthma-causing allergen in the lungs, later in life.

The admission of an infant to the Neonatal Intensive Care Unit (NICU) has the potential to produce significant stress for the mothers of these infants. Researchers suggest that this may contribute to difficulties with coping following discharge. Past research on this topic has been primarily focused on Caucasian women. Approximately 9% of the U.S. population is of Mexican heritage; therefore, this population is significantly underrepresented in the existing literature. For this reason, the purpose of this grounded theory study was to identify the basic social processes used by English-speaking mothers of Mexican heritage who have experienced the admission of an infant to the NICU. Maximum variation sampling was utilized to recruit 15 English-speaking mothers of Mexican heritage who were at least 18 years of age and had experienced the admission of an infant to the NICU. The women were recruited from various locations in San Antonio, Texas. Data collection was conducted through audio-taped, semi-structured individual interviews and transcribed field notes. Data analysis consisted of constant comparison, open coding of data, and theoretical coding. This investigation resulted in the substantive theory making sure my baby is cared for by being there for my baby. The process began with the unexpected event of having an infant in the NICU and played out in the context of opposing forces: trying to be the mother or making meaningful connections. The mothers developed strategies for managing this situation by balancing responsibilities, leaving part of me with my baby, and watching over. The process concluded with one of two consequences: bringing my baby home or losing my baby. The theory that emerged from this study offers insight for researchers, nurse educators, and neonatal nurses who provide care for English-speaking, Mexican-heritage mothers and their infants as well as for the care of all NICU mothers and their infants.

Emphasis on infant pain management has recently become prominent in the medical field. Though it was once thought that infants do not feel pain or remember pain, this thinking has changed due to recent research on the subject. This research has found that infants’ underdeveloped nervous systems actually leads to increased pain rather than decreased pain as previously thought. Research has also found that there are long-term developmental risks associated with prolonged or unmanaged pain in infancy. However, this has not been applied to clinical practice. Studies show that infants are still being under-medicated, if medicated at all, for painful or invasive procedures. Infants in the neonatal intensive care unit are at a high-risk for complications related to unmanaged pain because of the frequency and abundance of invasive procedures performed on this unit. Reasons for this include lack of physician education on this subject, risk for adverse effects with opioid administration, and lack of adequate pain assessment tools for infants. There are some interventions that can be implemented to improve pain management in infants, which include non-pharmacological methods and educating medical staff on this subject.

Abstract: Background: Perinatal ischemic brain injury leads to developmental disability (DD), which accounts for 30% of disabilities in children. Antepartum risk, or risk occurring prior to birth occurs in more than 90% of cases. This study investigated whether maternal ingestion of a natural health product (broccoli sprouts) would provide neuroprotection in an intrauterine model of HI. Methods: Intrauterine ischemia was induced by bilateral uterine artery ligation (BUAL) on E20 of gestation. Rats were fed broccoli sprouts (200 mg) from E15 until postnatal day 14 (PD14). Rat pups underwent neurobehavioural testing from birth to PD21 and were then sacrificed for neuropathologic assessment on PD21. Results: BUAL ligation resulted in growth restriction (IUGR) of the fetuses, which persisted throughout the study (p < 0.001). Reflex testing indicated IUGR pups were developmentally delayed compared to controls (p < 0.001). Open field testing on PD21 indicated hyperactivity in IUGR animals compared to controls (p < 0.001). Histological assessment showed a reduction in pyramidal cells in CA1 and CA3 of IUGR hippocampi and in myelin basic protein (MBP) immunohistochemistry signal. Broccoli sprout supplementation improved some reflex and behavioural measures, increased cell counts in CA1 and CA3 as well as MBP signal in growth restricted animals. Conclusions: Supplementation with broccoli sprouts during the last trimester of gestation and the first 2 weeks of life in the rat lessened the effects of chronic intra-uterine ischemia. These findings suggest a novel approach to the prevention of DD associated with perinatal HI.

Abstract: Islet transplantation has the potential to be an effective treatment for patients with type 1 diabetes. However, a shortage of human donor islets and the need for continuous immunosuppressive therapy currently limit this therapy to patients with brittle type 1 diabetes. Neonatal pigs may provide an unlimited source of islets for transplantation; however, the barrier of islet xenograft rejection must still be overcome. Understanding the mechanism of neonatal porcine islet (NPI) rejection will help to develop targeted therapies to prevent rejection. This thesis studied the early immune cells and molecules involved in NPI xenograft rejection, compared the role of NK cells in two models of islet xenotransplantation and investigated the role of T cell co-stimulatory and adhesion pathways in NPI xenograft rejection. Targeting these aspects of the immune response to NPI xenografts with short-term therapies may play a role in improving NPI xenograft acceptance and induce long-term xenograft survival.

During neonatal development estrogen plays a major role in the ultimate expression of male behavior. Studies using knockout mice and selective agonists indicate that actions of estrogen differ depending upon the estrogen receptor subtype (ERα or ERβ). Effects also vary depending both upon the timing of exposure (critical period) and the age at which effects are tested, with most studies examining the effects of early exposure on subsequent adult or juvenile response. The goal of this study was to examine the effects of estrogen, on the behavioral response of males during the neonatal period. The prairie vole was used as the system because it is highly social, estrogen has been associated with the expression of high levels of male prosocial behavior, and in neonatal male inhibition of conversion of testosterone to estrogen increased pup directed aggression. We found that there was no behavioral change in males when subjected to aromatase inhibition through the use of the selective inhibitor ATD over controls. Males given an estrogen receptor (ER) α agonist, PPT, showed increased locomotor activity in an open field test, as well as a social recognition deficit as measured through the amount of time spent sniffing an unfamiliar individual in a novel interaction test. They also exhibited an increase in c-Fos activity in the dorsal thalamic nucleus over sesame oil control. Treatment animals given the selective ERβ agonist DPN showed no behavioral changes, but showed a similar change in c-Fos activity in the dorsal thalamic nucleus.

To study early events of neonatal Herpes Simplex Virus (HSV) encephalitis and its sequelae we induced a controlled infection in the brains of mice using HSVgH-, a genetically modified Disabled Infective Single Cycle virus. Neonatal Balb/C mice were infected with various amounts of HSVgH- virus by intracerebral injection. Results showed that the survival of infected mice was dependent on the amount of virus injected. Infection with 200,000 plaque forming units (pfu) of HSVgH- virus resulted in 0% survival, whereas 25,000 pfu resulted in 75% survival. If the mice died, 98% of the deaths occurred between 3 and 7 days after infection. Replication competent virus was recovered from 20% of mice brains infected with 25,000 pfu of HSVgH-. Neutralizing antibodies were not detected 6 weeks post infection in sera of mice, which survived infection with 25,000 pfu of HSVgH-. LacZ histochemistry and immunoperoxidase staining using anti-HSV and anti-beta-galactosidase antibody revealed that the infection was limited to the site of injection. Tissue destruction was observed at the site of inoculation 3 days post infection using cresyl violet staining. At 3 days post infection adjacent sections showed positive cells for viral antigens and apoptotic cells in the infected area. Immunoperoxidase staining using antibodies to surface markers showed microglial activation beginning on day 1 and astrocyte proliferation beginning on day 3-post infection. B and T lymphocytes were not detected on day 1 through 7-post infection. This controlled experimental HSV infection suggests a limited non-specific early host response of innate immunity and absence of adaptive immunity in the neonate to HSV encephalitis.

Rehospitalization for graduates of newborn intensive care units (NICU) is not uncommon. According to Zotkiewicz (1996:355), "a baby born weighing 3 pounds, 5 ounces (1500 grams) has a 30 to 50 percent greater chance of being rehospitalized within the first year of life than does a term infant of normal weight". Respiratory infections are the most frequent cause of rehospitalization for these infants (Zotkiewicz, 1996:356). Other reasons for readmission might include feeding difficulties, more frequent episodes of apnea, inability of parents to provide a prescribed treatment, or vision or hearing impairments (Zotkiewicz, 1996:356). The purpose of this study is to understand mothers' opinions about the issues that led to the rehospitalization of their infant. A convenience sample (n=8) was used for this study. The subjects were mothers of infants who were discharged from the Regional Center for Newborn Intensive Care (RCNIC) on durable medical equipment or home nursing care and were rehospitalized within two months. Data was collected via audiotaped recordings close to or soon after the time of discharge. Data were analyzed using content analysis and found to fit the following categories: the reason for each infant's rehospitalization, home preparation, maternal support and maternal challenges. The findings of this study showed that mother's had enough knowledge to know that their infant was not doing well, the infants were readmitted for worsening medical conditions, mother's felt well-prepared to care for their infant upon discharge from the hospital, mothers were not prepared to have their infant rehospitalized on a unit other than the NICU. In addition, mothers had difficulty accepting an infant with special health care needs and there is an inability to obtain reliable nursing care at home.Practice implications from this study are (1) mother's need to participate in their infant's care early in the hospitalization (2) mother's need to be prepared to have their child readmitted to another unit other than the NICU (3) mothers need emotional support to adjust to caring for an infant with special health care needs, (4) a thorough assessment of the availability of home nursing care should be conducted prior to discharge.