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Background: As rates of substance use during pregnancy persist, the health and optimal development of infants with prenatal substance exposure remain a key priority. Nurses are tasked with identifying and reporting suspected cases of child maltreatment, including abuse and neglect, which is often assumed to be synonymous with substance use during pregnancy. While policies aimed at protecting infants from child abuse and neglect are well intentioned, literature regarding the short- and long-term social and legal implications of mandatory reporting policies is emerging., Purpose: In this article, we explore the intersections between the condition of substance use in pregnancy and policies related to mandatory reporting., Methods: We provide an overview of historical and current trends in mandatory reporting policies for nurses related to substance use in pregnancy and related ethical and social implications for mother-infant dyads., Results: Nurses often function at the intersection of healthcare and social services, underscoring the important role they play in advocating for ethical and equitable care for both members of the mother-infant dyad affected by substance use., Implications for Practice and Research: We offer recommendations for practice including the integration of respectful care and family-centered support for the mother-infant dyad affected by substance use. Cross-sectoral collaborations, inclusive of the family, are important to the advancement of evidence-based and equity-focused research, advocacy, and policy initiatives to support familial preservation and reduce mother-infant separation., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (Copyright © 2024 by The National Association of Neonatal Nurses.)

Background: Infants and families requiring neonatal intensive care unit (NICU) care often experience significant stress and trauma during the earliest period of the infant's life, leading to increased risks for poorer infant and family outcomes. There is a need for frameworks to guide clinical care and research that account for the complex interactions of generational stress, pain, toxic stress, parental separation, and lifelong health and developmental outcomes for infants and families., Purpose: Apply the Adverse Childhood Experiences (ACEs) framework in the context of the NICU as a usable structure to guide clinical practice and research focused on infant neurodevelopment outcomes and parental attachment., Methods: An overview of ACEs is provided along with a detailed discussion of risk at each level of the ACEs pyramid in the context of the NICU. Supportive and protective factors to help mitigate the risk of the ACEs in the NICU are detailed., Results: NICU hospitalization may be considered the first ACE, or potentially an additional ACE, resulting in an increased risk for poorer health outcomes. The promotion of safe, stable, and nurturing relationships and implementation of trauma-informed care and individualized developmental care potentially counter the negative impacts of stress in the NICU., Implications for Practice and Research: Nurses can help balance the negative and positive stimulation of the NICU through activities such as facilitated tucking, skin-to-skin care, mother's milk, and active participation of parents in infant care. Future research can consider using the ACEs framework to explain cumulative risk for adverse health and well-being in the context of NICU care., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 by The National Association of Neonatal Nurses.)

Competing Interests: The authors declare no conflicts of interest.

Background: While a growing body of literature has established the role of human milk as a mechanism of protection in the formation of the infant gut microbiome, it remains unclear the extent to which this association exists for infants with neonatal opioid withdrawal syndrome., Purpose: The purpose of this scoping review was to describe the current state of the literature regarding the influence of human milk on infant gut microbiota in infants with neonatal opioid withdrawal syndrome., Data Sources: CINAHL, PubMed, and Scopus databases were searched for original studies published from January 2009 through February 2022. Additionally, unpublished studies across relevant trial registries, conference proceedings, websites, and organizations were reviewed for possible inclusion. A total of 1610 articles met selection criteria through database and register searches and 20 through manual reference searches., Study Selection: Inclusion criteria were primary research studies, written in English, published between 2009 and 2022, including a sample of infants with neonatal opioid withdrawal syndrome/neonatal abstinence syndrome, and focusing on the relationship between the receipt of human milk and the infant gut microbiome., Data Extraction: Two authors independently conducted title/abstract and full-text review until there was consensus of study selection., Results: No studies satisfied the inclusion criteria, which resulted in an empty review., Implications for Practice and Research: Findings from this study document the paucity of data exploring the associations between human milk, the infant gut microbiome, and subsequent neonatal opioid withdrawal syndrome. Further, these results highlight the timely importance of prioritizing this area of scientific inquiry., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 by The National Association of Neonatal Nurses.)

Background: Growing evidence supports the superior benefits of exposure to mother's own milk (MOM) in reducing prematurity-related comorbidities. Neonatal exposure to donor human Milk (DHM) is a suitable alternative when MOM is insufficient or unavailable. However, the same protective composition and bioactivity in MOM are not present in DHM. Additional evidence is needed to justify and inform evidence-based practices increasing MOM provision while optimizing adequate use of DHM for premature infants., Purpose: A systematic review of the literature was conducted to determine differences in neonatal outcomes among premature infants exposed to predominately MOM versus DHM., Methods/search Strategy: Databases including PubMed, CINAHL and Cochrane were searched (2020-2021) using the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis) guidelines. Evidence was classified using the John Hopkins evidence-based practice levels and quality of evidence., Results: Eleven studies met inclusion criteria. Studied neonatal outcomes included ( a ) growth parameters (n = 8), ( b ) neonatal morbidities (n = 6), and ( c ) gut microbiome (n = 4). Overall, evidence suggests DHM exposure is beneficial but not equivalent to MOM feeding. Compared with DHM, greater doses of MOM are ideal to enhance protection primarily related to infant growth, as well as gut microbiome diversity and richness., Implications for Practice: Standardized and evidence-based practices are needed to clearly delineate optimal use of DHM without undermining maternal and neonatal staff efforts to support and promote provision of MOM., Implications for Research: Additional evidence from high-quality studies should further examine differences in neonatal outcomes among infants exposed to predominately MOM or DHM in settings using standardized and evidence-based feeding practices., Competing Interests: The authors have no conflict of interest to disclose. Drs Cartagena, McGrath, and Parker, who are editors for Advances in Neonatal Care , were not involved in the editorial review or decision to publish this article. The entire process from submission, referee assignment, and editorial decisions was handled by other members of the editorial team for the journal., (Copyright © 2022 by The National Association of Neonatal Nurses.)

Competing Interests: The authors declare no conflicts of interest.

Background: Mother's own milk (MOM) is the gold standard of nutrition for premature infants. Yet, Hispanic and Black preterm infants are less likely than their White counterparts to receive MOM feedings. Evidence is lacking concerning potential modifiable factors and evidence-based strategies that predict provision of MOM among minority mothers of premature infants., Purpose: A review of the literature was conducted to answer the clinical question: "What evidence-based strategies encourage and improve mother's own milk expression in Black and Hispanic mothers of premature infants?", Methods/search Strategy: Multiple databases including PubMed, Cochrane, and CINAHL were searched for articles published in the past 10 years (2010 through May 2020), reporting original research and available in English. Initial search yielded zero articles specifically addressing the impact of lactation interventions on MOM provision in minority mothers. Additional studies were included and reviewed if addressed breastfeeding facilitators and barriers (n = 3) and neonatal intensive care unit breastfeeding support practices (n = 7)., Findings/results: Current strategies used to encourage and improve MOM expression in minority mothers are based on or extrapolated from successful strategies developed and tested in predominantly White mothers. However, limited evidence suggests that variation in neonatal intensive care unit breastfeeding support practices may explain (in part) variation in disparities and supports further research in this area., Implications for Practice: Neonatal intensive care unit staff should consider implementing scaled up or bundled strategies showing promise in improving MOM milk expression among minorities while taking into consideration the cultural and racial norms influencing breastfeeding decisions and practice., Implications for Research: Experimental studies are needed to evaluate the effectiveness of targeted and culturally sensitive lactation support interventions in Hispanic and Black mothers., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 by The National Association of Neonatal Nurses.)

Competing Interests: The authors declare no conflicts of interest.

Background: Smaller preterm infants often receive extra attention with implementation of additional thermoregulation interventions in the delivery room. Yet, these bundles of interventions have largely remained understudied in larger infants., Purpose: The purpose of this study was to evaluate initial (or admission) temperatures of infants born weighing 1500 g or more with diagnoses requiring admission to the neonatal intensive care unit (NICU)., Methods: Retrospective medical record review of 388 infants weighing 1500 g or more admitted to the NICU between January 2016 and June 2017., Result: In total, 42.5% of infants weighing 1500 g or more were admitted hypothermic (<36.5°C), 54.4% with a normothermic temperature, and 2.8% were hyperthermic. Of those infants admitted hypothermic, 30.4% had an admission temperature ranging from 36°C to 36.4°C and 12.1% had an admission temperature of less than 36°C. When compared with infants weighing less than 1500 g, who were born at the same institution and received extra thermal support interventions, there was a statistically significant difference (P < .001) between admission temperatures where infants less than 1500 g were slightly warmer (36.8°C vs 36.5°C)., Implications for Practice: Ongoing admission temperature monitoring of all infants requiring NICU admission regardless of birth weight or admission diagnosis is important if we are going to provide the best support to decrease mortality and morbidity for this high-risk population., Implications for Research: While this study examined short-term outcomes, effects on long-term outcomes were not addressed. Findings could be used to design targeted interventions to support thermal regulation for all high-risk infants., Conclusion: Neonates admitted to the NICU weighing 1500 g or more are at high risk for developing hypothermia, similar to smaller preterm infants., Competing Interests: No conflicts of interest declared for any authors. Dr McGrath, who is a Co-Editor for Advances in Neonatal Care and the coauthor and mentor to the primary author, was not involved in the editorial review or decision to publish this article. The entire process from submission, referee assignment, and editorial decisions was handled by other members of the editorial team for the journal., (Copyright © 2020 by The National Association of Neonatal Nurses.)

Background: Premature infants may experience increased difficulty with nutrition and growth. Successful oral feeding is an important factor associated with discharge readiness. Despite the importance of feeding as a growth-fostering process, little empiric evidence exists to guide recommendations for early interventions., Purpose: Evaluate whether specific elements of sucking, during preterm initiation of oral feeding, predict sucking organization at corrected term age., Methods: Sucking performance of 88 preterm infants born between 24 and 34 weeks of post-menstrual age was measured at baseline and term (33-35 and 40 ± 1.5 weeks). Participants were divided into 4 groups (quartiles) based on initial measures of performance including number of sucks, number of bursts, sucks per burst, and maximum pressure. Stability in sucking organization was assessed by comparing changes in infant's quartile location from baseline to term., Results: A correlation between quartile location was observed for mean maximum pressure (PMAX): infants with PMAX in the lowest quartile (poorest performance) were significantly more likely to remain in the lowest quartile at term (P < .000); infants in the highest quartile (best performance) at baseline were significantly more likely to be in the highest quartile at term (P < .000)., Implication for Practice: Infants with the weakest sucking pressures at 34 weeks of post-menstrual age continue to be at risk for less than optimal feeding skills at 40 weeks of post-menstrual age. Early identification of at-risk infants may allow for effective interventions to potentially decrease long-term feeding problems., Implications for Research: Future research should focus on the development of personalized interventions to address attributes of problematic feeding such as sucking efficiency., (Copyright © 2020 by the National Association of Neonatal Nurses.)

Competing Interests: The authors declare no conflicts of interest.

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

Background/significance: Infants born extremely premature (<1500 g) often experience lengthy stays in the challenging environment of the neonatal intensive care unit (NICU) separated from their parents., Purpose: The purpose of this study was to explore nurses' knowledge, attitude, and use of maternal voice as a therapeutic intervention for preterm infants in the NICU., Methods: Neonatal nurses (n = 117) completed an online survey about the use of maternal voice in their individual units. Questions included: (1) previous knowledge surrounding use of maternal voice in the NICU; (2) their attitudes about using maternal voice recordings and/or live maternal speech as an intervention; (3) whether their unit had the necessary equipment and environment conducive to using the therapy; (4) average amount of time parents were in the NICU with their neonate; and (5) in what situations they would personally encourage the use of maternal recordings (during procedures, rounds, etc)., Results: Of those responding, 73.3% of nurse (n = 117) respondents agreed they were willing to incorporate maternal recordings into caregiving, with 80.8% indicating they were open to learning and employing different therapies to improve parental involvement in infant care., Implications for Practice: When the appropriate equipment is available, neonatal nurses are interested and willing to use alternative therapies that incorporate parental participation into direct caregiving as well as utilizing maternal voice recordings., Implications for Research: Further research with larger, more diverse samples is needed to determine the current knowledge, attitudes, and practices of maternal voice recordings by NICU nurses. Future research can also focus on barriers to utilization of the therapy during daily care.

Background/significance: Premature infants often experience extended stays in the neonatal intensive care unit (NICU) as opposed to home with parents. This prolonged separation creates a strain for both parents and infants, decreasing attachment and parental caregiving. One strategy to combat this shared stress is increasing parental participation, particularly through the use of their voices whether parents are present or not., Purpose: This Evidence-Based Practice Brief column explores the connection between mother and child, specifically the effects of maternal voice on infant autonomic stability, weight gain, and behavioral states., Methods: A systematic search of CINAHL, PubMed, and PsycInfo was used to identify studies involving the use of maternal voice intervention with preterm infants in the NICU., Results: Fifteen studies were identified. Three intervention categories emerged: (1) live maternal speech, (2) recorded maternal speech (subcategories included whether intervention content was prescribed or not), and (3) recorded maternal speech that was combined with biological maternal sounds (heart rate). Within each category, studies were organized chronologically to reflect how knowledge has changed overtime., Implications for Practice: Maternal voice has physiological as well as behavioral and emotional effect on preterm infants. Several studies found that maternal voice increased autonomic stability improving (heart rate and respirations) as well as weight gain. No negative effects were identified. Given these findings, incorporating different types of maternal voice into routine care by the bedside nurse can assist the mother in feeling more involved in her infant's care without seemingly being a distraction or obstacle to providers., Implications for Research: A major limitation for generalizability was sample size; more research is needed with larger sample sizes replicating interventions types to discern best outcomes.Video Abstract available at https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?videoId=31&autoPlay=true.

Background: According to the Healthy People 2020 goals, the sustainability of breastfeeding duration rates within the United States has not been achieved. To increase these rates, it is important that women with breastfeeding difficulties receive the support needed to continue breastfeeding. When supplementation occurs, it is essential that the breastfeeding relationship be preserved. Various methods of supplementation are often recommended including use of the supplemental feeding tube device (SFTD)., Purpose: The question guiding this brief is "What evidence exists to support the use of an SFTD as a method of supplementation for breastfed infants?", Search Strategy: The PubMed and CINAHL databases were queried for original research published in English from 1990 through July 2016. Search terms included "supplemental feeding tube," "breastfeeding," "term infants," "premature infants," "Supplemental Nursing System," "Lact-aid," and "supply line.", Findings: Very limited research exists on the use of SFTDs as a method of supplementation for breastfed infants; however, existing research suggests that an SFTD may be useful as a supplementation method for breastfed infants. High-quality research is needed to evaluate the efficacy of using an SFTD for supporting exclusive and all breastfeeding rates., Implications for Practice: Nurses and providers need to be educated and trained in the use of SFTDs as well as all supplemental feeding methods. Information on efficacy and SFTD use should also be included in policies related to breastfeeding and human milk use., Implications for Research: Further research should determine best methods of supplementation for breastfed infants and should examine differences in breastfeeding rates when using the SFTD for supplementation.

Background: The benefits of breast milk are well described, yet the mechanistic details related to how breast milk protects against acute and chronic diseases and optimizes neurodevelopment remain largely unknown. Recently, breast milk was found to contain stem cells that are thought to be involved in infant development., Purpose: The purpose of this review was to synthesize all available research involving the characterization of breast milk stem cells to provide a basis of understanding for what is known and what still needs further exploration., Methods/search Strategy: The literature search was conducted between August and October 2015 using the CINAHL, PubMed, and reference list searching. Nine studies addressed characterization of human breast milk stem cells., Findings/results: Five research teams in 4 countries have published studies on breast milk stem cells. Current research has focused on characterizing stem cells in full-term breast milk. The amount, phenotype, and expression of breast milk stem cells are known to vary between mothers, and they have been able to differentiate into all 3 germ layers (expressing pluripotent characteristics)., Implications for Practice: There is much to learn about breast milk stem cells. Given the potential impact of this research, healthcare professionals should be aware of their presence and ongoing research to determine benefits for infants., Implications for Research: Extensive research is needed to further characterize stem cells in breast milk (full-term and preterm), throughout the stages of lactation, and most importantly, their role in the health of infants, and potential for use in regenerative therapies.

Background: Trauma is an innately subjective experience ensuing from a deeply distressing event. Research has demonstrated that while the environment of the neonatal intensive care unit (NICU) is capable of providing extraordinary lifesaving measures following birth, the experience may be disruptive to several key aspects of early development, placing infants at risk for adverse behavioral, cognitive, and emotional outcomes., Purpose: This article provides rationale for the concept of Infant Medical Trauma in the NICU (IMTN) as a means of describing this unique stress experience. A triad of cumulative early life NICU experiences (stress, parental separation, and pain) is proposed to influence an infant's swinging neurodevelopmental pendulum amid the potential outcomes of risk and resilience., Implications for Practice and Research: Creating language that describes the infant experience brings meaning and calls caregivers and parents to action to consider strategies that may improve long-term health. Actively seeking opportunities to decrease the allostatic load of at-risk infants may support an infant's pendulum to swing toward a path of resilience, thereby moderating his or her early life adverse experience.

Background: Increasingly, evidence supports oral feeding of very low birth-weight (VLBW) preterm infants exclusively at breast or with breast milk. Despite known breast milk benefits, outcomes related to exclusive breast milk provision are poor. Identifying factors that promote breast milk provision is critical., Purpose: Breastfeeding practices of mothers of VLBW infants admitted to neonatal intensive care unit were explored to identify factors associated with mode of feeding at discharge., Method: This retrospective study replicates previous work. Subjects were VLBW preterm infants consecutively admitted during a 24-month period. Primary outcomes included receiving any breast milk at discharge. Infant variables included gestational age, postmenstrual age of first direct breastfeeding, and comorbid conditions. Maternal variables included age and ethnicity. Nursing practice variables included first direct-to-breastfeeding, number of times to breast daily, and total direct-to-breastfeeding encounters 24 hours prior to discharge., Results: A total of 96 VLBW infants (28.7 ± 2.8 weeks' gestational age) met inclusion criteria. Of these, 48% received breast milk at discharge. Controlling for significant effect of length of stay, infants receiving first oral feed at breast were more likely discharged home receiving breast milk (adjusted odds ratio = 8.7; 95% confidence interval, 2.9-32.3; P < .0001). There were both an independent effect of first oral feed at breast and an interaction where infants of nonmarried women also benefited from the first oral feed at breast., Implications: Significant associations were found between first oral feeding at breast and infant receiving any breast milk at discharge. Targeting VLBW infants to receive first oral feeding at breast may yield the best outcome even among sickest and smallest infants.

Purpose: To examine the effect of skin-to-skin care (SSC) on stress perception between mothers who provided SSC to their late-preterm born infants and mothers who provided blanket holding., Design and Methods: This was a longitudinal 2-group randomized controlled trial of 40 infant-mother dyads recruited from a level 3 neonatal intensive care unit in the upper Midwest., Outcome Measure: Maternal stress was measured using the Parental Stressor: Neonatal Intensive Care Unit (PSS: NICU) scale pre- and post-SSC intervention. Demographic and other mother and infant covariates were extracted from medical records. Physiologic stability was measured by the Stability of the Cardiorespiratory System in Preterm Infants (SCRIP) score. Study personnel used daily logs to track frequency and duration of SSC and holding sessions., Results: The intervention and the control groups had similar pre- (mean ± standard deviation, 2.34 ± 0.86 for SSC and 2.94 ± 0.87 for holding) and post-intervention (mean ± standard deviation, 2.55 ± 0.95 for SSC and 2.78 ± 0.90 for holding) overall stress scores. Hours of SSC holding positively correlated with the change in stress scores for the entire scale (r = 0.58; P = .001), and for infant appearance (r = 0.58; P = .001) and parent role alteration (r = 0.48; P = .02) subscales. This relationship remained significant after controlling for the infant's length of stay and SCRIP score., Implications for Practice: Mothers who provide SSC may experience more stress related to a more facilitated progression in the mother and infant relationship., Implications for Research: The relationship between increased stress and the number of hours of SSC holding warrants further investigation.

Background: Over the past decades, advances in neonatal care have led to substantial increases in survival among preterm infants. With these gains, recent concerns have focused on increases in neurodevelopment morbidity related to the interplay between stressful early life experiences and the immature neuroimmune systems. This interplay between these complex mechanisms is often described as the brain-gut signaling system. The role of the gut microbiome and the brain-gut signaling system have been found to be remarkably related to both short- and long-term stress and health. Recent evidence supports that microbial species, ligands, and/or products within the developing intestine play a key role in early programming of the central nervous system and regulation of the intestinal innate immunity., Purpose: The purpose of this state-of-the-science review is to explore the supporting evidence demonstrating the importance of the brain-gut-microbiota axis in regulation of early life experience. We also discuss the role of gut microbiome in modulating stress and pain responses in high-risk infants. A conceptual framework has been developed to illustrate the regulation mechanisms involved in early life experience., Conclusions: The science in this area is just beginning to be uncovered; having a fundamental understanding of these relationships will be important as new discoveries continue to change our thinking, leading potentially to changes in practice and targeted interventions.

Background: Although the benefits of skin-to-skin care (SSC) are well documented in the literature, practices in the clinical setting remain inconsistent. Although nurses' reported knowledge about SSC has improved, confusion still exists regarding safety and appropriateness. Existing qualitative literature primarily focuses on parents' experiences; yet it is crucial to describe the essence of professional caregivers' experiences to enhance facilitation and implementation of SSC. Most studies surrounding the caregiver's perspective and SSC have focused on barriers that impede implementation or examined the experience from the organizational perspective and general group experiences rather than individual personal experiences with SSC., Purpose: This meta-ethnography integrated the findings from several discrete studies into a salient interpretative perspective, creating a relevant understanding of the process of SSC as a means of enhancing facilitation and implementation of SSC with hospitalized infants., Methods: An ethnographic meta-synthesis of qualitative literature was completed., Results: As a result of this synthesis, the caregivers' experiences were separated into themes to articulate the phenomena juxtaposed from the 8 original studies that influence facilitation of SSC for the parent-infant dyad. Qualitative data analysis uncovered 4 overarching themes: (1) varying thresholds of getting started; (2) defining adequate resources; (3) navigating the demands and complexity of the infant; and (4) balancing parental readiness with infant needs., Implications for Practice: This ethnographic meta-synthesis confirms nurses have good intentions in supporting SSC practices, yet struggle to meet competing demands in their daily practice., Implications for Research: Innovative and practical translations of SSC are needed to normalize SSC as the daily standard for premature infants.

Pain assessment and measurement are the cornerstones of pain management. Pain assessment connotes a comprehensive multidimensional description. Conversely, pain measurement provides a numeric quantitative description of each factor illustrating pain qualities. Pain scales provide a composite score used to guide practice and research. The type of infant pain instrument chosen is a significant factor in guiding pain management practice. The purpose of this review was to summarize current infant pain measures by introducing a conceptual framework for pain measurement. Although more than 40 infant pain instruments exist, many were devised solely for research purposes; several of the newly developed instruments largely overlap with existing instruments. Integration of pain management into daily practice remains problematic. Understanding how each instrument measures infant pain allows clinicians to make better decisions about what instrument to use with which infant and in what circumstances. In addition, novel new measurement techniques need further testing.

The purpose of this article is to introduce a model of neurodevelopmental risk and protection that may explain some of the relationships among biobehavioral risks, environmental risks, and caregiving behaviors that potentially contribute to neurobehavioral and cognitive outcomes. Infants born before 30 weeks of gestation have the poorest developmental prognosis of all infants. These infants have lengthy hospitalization periods in the neonatal intensive care unit (NICU,) an environment that is not always supportive of brain development and long-term developmental needs. The model supports the premise that interventions focused on neuroprotection during the neonatal period have the potential to positively affect long-term developmental outcomes for vulnerable very preterm infants. Finding ways to better understand the complex relationships among NICU-based interventions and long-term outcomes are important to guiding caregiving practices in the NICU.

Purpose: Risk of adverse outcome in late-preterm infants (born between 34 and 36 weeks and 6 days' gestation) is heightened for those living in geographic isolation (GI). We examined the relationships between GI and several mother and infant outcomes., Subjects and Design: This was a tricenter cross-sectional study of 38 English-speaking late-preterm infant/mother dyads admitted to neonatal intensive care in a predominately rural Midwestern state. Eligibility for the study included English-speaking mothers and their biologically born late-preterm infants with no known anomalies. METHODS AND MAIN OUTCOME: Outcomes included maternal knowledge of infant development (Knowledge of Infant Development Inventory) and competence (Competence in Preterm Infant Care questionnaire), maternal perception of vulnerability (Vulnerable Baby Scale ([VBS]), risk, and temperament (Pictorial Assessment of Temperament ([PAT]). Infant readmission and follow-up data were also examined. Potential covariates included any use of the Internet for healthcare information, demographic data, and mother and infant health history and were obtained from medical records and from the mother. Level of GI was determined by time and distance traveled (minutes) from the mother's primary residence to the closest regional healthcare center., Results: Study participants traveled 61 ± 58 miles and 72 ± 62 minutes on average. The Mean ± SD scores on assessment were as follows: Knowledge of Infant Development Inventory 77 ± 10, and Competence in Preterm Infant Care questionnaire 90 ± 14, VBS 27.5 ± 3.5, and PAT 17.5 ± 3. Bivariate associations were observed between distance and time and VBS scores (P = .03 for both). Multiple regression analysis showed significant relationship between time (P = .02) and PAT scores when maternal education (0.09) and the number of hours spent in the NICU (P = .01) were entered into the model. The association between time traveled and VBS scores became marginally significant when maternal age and Internet use were entered into the regression models. The odds for a mother to perceive her infant at risk for suboptimal outcomes were 6 times greater for each 1-hour additional travel time (odds ratio = 6.0; 95% confidence interval: 1.3-36; P = .001). There was no association between GI and readmission rate and follow-up care. Readmission rate was 8%, and anticipatory guidance was found to be inadequate., Conclusion: Remote access to appropriate healthcare services elicits more than legitimate concerns for the late preterm infant and warrants further investigation with consideration for how services might be more easily accessed for this at-risk group.

Adverse experiences early in life have the potential to disrupt normal brain development and create stress response channels in preterm infants that are different from those observed in term infants. Animal models show that epigenetic modifications mediate the effects of maternal separation and environmental stress on susceptibility to disease and psychobehavioral problems later in life. Epigenetic research has the potential to lead to the identification of biological markers, gene expression profiles, and profile changes that occur overtime in response to early-life experiences. Combined with knowledge gained through the use of advanced technologies, epigenetic studies have the promise to refine our understanding about how the brain matures and functions from multiple perspectives including the effect of the environment on brain growth and maturation. Such an understanding will pave the way for care practices that will allow the premature brain to develop to its full capacity and will lead to the best possible outcomes. Neonatal epigenetic research is emerging and rapidly advancing. As scientists overcome biological, technical, and cost-related challenges, such research has a great potential in determining key environmental factors that affect the preterm genome, allowing for targeted interventions. The purpose of this article is to explore existing literature related to epigenetic mechanisms that potentially mediate the effects of the environment on preterm infant brain development.

Necrotizing enterocolitis (NEC) is the most common cause of gastrointestinal-related morbidity and mortality in the neonatal intensive care unit (NICU). Its onset is sudden and the smallest, most premature infants are the most vulnerable. Necrotizing enterocolitis is a costly disease, accounting for nearly 20% of NICU costs annually. Necrotizing enterocolitis survivors requiring surgery often stay in the NICU more than 90 days and are among those most likely to stay more than 6 months. Significant variations exist in the incidence across regions and units. Although the only consistent independent predictors for NEC remain prematurity and formula feeding, others exist that could increase risk when combined. Awareness of NEC risk factors and adopting practices to reduce NEC risk, including human milk feeding, the use of feeding guidelines, and probiotics, have been shown to reduce the incidence of NEC. The purpose of this review is to examine the state of the science on NEC risk factors and make recommendations for practice and research.

Retinopathy of prematurity (ROP) remains a concern for many preterm infants. Early detection and timely treatment have been shown to be effective in improving visual outcomes; moreover, it is crucial that a series of indirect ophthalmic examinations be performed until an infant is considered no longer at risk for the disease. The purpose of this systematic review is to summarize and evaluate the published evidence regarding characteristics and effectiveness of pain management interventions during the ROP examination. Implications for practice are discussed and suggestions for further research are made. Despite the general consensus that ROP examination is a painful procedure with considerable amount of discomfort, evidence shows that pain management during the ROP examination is inadequate. Although there are currently clear recommendations and guidelines for performing the ROP examination, there are no standard protocols for pharmacological and nonpharmacological pain management during the ROP examination. This is an area where much work is still needed to address the needs of the infant during this critical examination.

Free radical production occurs continuously in all cells as a by-product of cell metabolism. In tandem, the human body has developed endogenous antioxidant systems as well as taken advantage of dietary exogenous antioxidants to process and detoxify free radicals appropriately. However, certain conditions may increase free radical production beyond the body's endogenous and exogenous antioxidant systems. The neonatal period is a vulnerable time for free radical damage and injury, particularly for preterm infants whose antioxidant defense systems have not fully matured. Endogenous and passively acquired exogenous antioxidant defense systems do not accelerate in maturation until late in the third trimester. To explore the complexities of these concepts, this article includes a description, an evolutionary perspective of oxygen, and a basic background on free radical chemistry in biology. In addition, this chemistry is applied to the etiology of many of the most common diseases seen in the neonatal period. Finally, the current research addressing clinical strategies in this area is critically appraised. Implications for practice and directions for further research are presented with an emphasis on strategies that support the prudent use of oxygen therapies.