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Objective To describe the neonatal health risks (hypothermia, hypoglycemia, hyperbilirubinemia, respiratory distress, the need for a septic workup, and feeding difficulties) experienced by late preterm infants (LPIs) from a large multisite study and determine how these risks were affected by gestational age at birth. Design Descriptive analysis of prospective data obtained as part of the AWHONN Late Preterm Infant Research‐Based Practice Project. Setting Fourteen hospitals located through the United States and Canada. Participants Late preterm infants (802) born at gestational ages between 34 0/7 and 36 6/7 weeks. Methods Nurses at each site obtained consent from the mother of the infant. The data about the infant were gathered from the infant's medical record. Results Thirty‐six percent of LPIs were initially cared for in a special care nursery; approximately one half of these infants were eventually transferred to a well‐baby nursery. Of the 64% of LPIs initially cared for in a routine nursery, 10% were transferred to a special care unit or neonatal intensive care unit (NICU). More than one half of LPIs experienced hypothermia, hypoglycemia, feeding difficulties, hyperbilirubinemia, and respiratory distress and/or needed a septic workup. The risk for these problems was higher in infants of younger gestational ages. Thirty‐two percent of the infants were bathed during the first 2 hours of life, and by 4 hours, more than two thirds had had their first bath. Fifty‐two percent received kangaroo care during the first 48 hours of life. Conclusion These findings support those of smaller studies indicating that LPIs are at high risk for developing health problems during their neonatal hospitalization. Nurses may be able to ameliorate some of these health problems through early identification of problems and simple, inexpensive interventions such as avoiding early bathing and promoting kangaroo care.

This article briefly reviews the history of ROP followed by a discussion of the pathogenesis of this complex disorder. We describe the International Classification System for ROP and identify risk factors and screening recommendations. Finally, we discuss some of the measures that have been used in an attempt to both prevent and treat ROP.

Often used interchangeably, chronic lung disease (CLD) or bronchopulmonary dysplasia (BPD) develops primarily in extremely low birth weight infants weighing1000 g who receive prolonged oxygen therapy and or positive pressure ventilation. CLD, which occurs in as many as 30 percent of infants born weighing1000 g, contributes significantly to the morbidity and mortality seen in very low birth weight infants. Despite extensive research aimed at identifying risk factors and devising preventative therapies, many questions about the etiology and pathogenesis of BPD remain. This article reviews the embryologic development of the lung and the pathogenesis of CLD or BPD. The authors discuss some of the measures that have been used in an attempt to both prevent and treat BPD.

Timely access to primary healthcare is becoming increasingly difficult for many Canadians. In a healthcare system created for managing acute illness and communicable disease, the complex care that millions of Canadians with chronic illnesses require is not being appropriately managed. The answer is not more healthcare dollars; it's better use of the funding already allocated. The key to delivering accessible, comprehensive and cost-effective care is effective collaboration among health professionals. The nurse practitioner role offers a unique skill set, incorporating health promotion and disease prevention into primary healthcare, complementing the roles of a variety of other health professionals. In spite of increasing interest and commitment to collaboration, numerous barriers remain. Perceived competition, leadership struggles and confusion about the role have hindered collaboration between nurse practitioners and physicians. Increased interest in interprofessional education has given rise to improved awareness and respect for the knowledge of other disciplines, raising hopes that fostering interdisciplinary working relationships will result in better client care. Nurse practitioners must take the lead in increasing the visibility of their role, improving public understanding and fostering collaborative relationships with other health professionals in order to provide the most effective care for Canadians.

Sacrococcygeal teratomas (SCTs) are the most common germinal cell neoplasms of the fetus and neonate. They originate during embryonic development when the primitive streak fails to differentiate among mesodermal, ectodermal, and endodermal tissues in the embryonic disc. This article discusses the fetal pathophysiology of SCTs and the impact of the condition on the newborn. Fetal SCTs can have life-threatening physiologic effects— such as premature labor, dystocia, and high-output cardiac failure—if not managed appropriately. Clinical manifestations, prenatal diagnosis, therapeutic approaches and treatment options for the fetus and newborn, and current research related to SCTs are addressed to aid practitioners caring for a fetus or infant diagnosed with an SCT.

Breast milk is the optimal form of nutrition for human newborns, offering a number of physical and psychosocial benefits to both mother and baby. In the case of premature infants, however, breast milk does not provide optimal levels of calcium and nutrients to facilitate growth. For these infants, a variety of additives to address these deficits have been formulated. Breast-milk additives have also been proposed as a way to ameliorate some of the risk factors and problems experienced by very-low–birth-weight infants. The volume and rigor of research addressing these additives and their effects on various components of human milk are variable. This article outlines the benefits and shortcomings of breast-milk feeding for premature neonates and reviews the research supporting various breast-milk additives. A discussion of potential problems related to additives and clinical implications of those problems follows. This article outlines the benefits and shortcomings of breast-milk feeding for premature neonates and reviews the research supporting various breast-milk additives. A discussion of potential problems related to additives and clinical implications of those problems follows.

Gastroschisis, one of the more common congenital abdominal wall defects, results in herniation of fetal abdominal viscera into the amniotic cavity. This article discusses theories about gastroschisis etiology, in utero diagnostic tools, delivery options, and postdelivery care. Included are detailed considerations regarding immediate interventions after delivery to support the infant’s thermal and fluid management needs and to protect the exposed bowel. Surgical options and postoperative care issues and complications are reviewed, as are respiratory distress and vena cava compression from increased abdominal pressure, nutritional support, and interventions related to the prevention of infection. Giving birth to an infant with gastroschisis is an upsetting experience for parents. Evidence suggests, however, that with today’s advances in neonatal care and nutrition and with meticulous attention, the survival rate for infants born with gastroschisis can be excellent.

The liver, the largest organ in the body, is critical to a number of key metabolic functions. It also plays an important role in removing the waste products of metabolism (particularly ammonia) and in detoxifying drugs and other substances such as endogenous hormones and steroid compounds. In addition, the liver plays a major role in the production of clotting factors, plasma proteins, bile salts, and bilirubin.Many neonates display signs of hepatic dysfunction such as hyperbilirubinemia, hepatomegaly, or elevated liver enzymes. These often occur secondary to systemic illness, such as sepsis or hypoxic injury, or following the use of drugs or parenteral nutrition to treat other problems. Although rare, primary liver disease does occur in neonates and must be recognized promptly, with treatment initiated in a timely manner to prevent unnecessary sequelae. This article, the third in a series on the liver, examines causes of liver dysfunction in neonates, beginning with an overview of jaundice and hepatomegaly and moving to a discussion of specific diseases.

The liver, the largest organ in the body, performs many essential functions, including the storage and filtration of blood, production of bile, regulation of plasma proteins and glucose, and biotransformation of drugs and toxins. Many neonates display signs of hepatic dysfunction such as hyperbilirubinemia, hepatomegaly, or elevated liver enzymes. Primary liver disease in neonates is rare; much of the liver dysfunction seen in the neonatal period is secondary to systemic illness such as sepsis or hypoxic injury. It is important for the clinician to have the skills and knowledge necessary to distinguish intrinsic liver disease from liver dysfunction resulting from extrahepatic causes. Early intervention to address the cause of dysfunction is critical to successful management of liver disease. This article reviews the assessment of liver function in neonates and examines the techniques used to diagnose liver dysfunction.

The liver is the largest organ in the body and is critical to a number of metabolic, regulatory, and detoxification processes. These include the production of bile, metabolic processing of nutrients, synthesis and regulation of plasma proteins and glucose, and biotransformation of drugs and toxins.

IN THE PREVIOUS COLUMN OF THIS series (October 2001), we reviewed the ins and outs of e-mail. An e-mail address is essential for staying in touch with colleagues around the world. An email address also opens the door to discussion groups, another avenue for keeping up with changing clinical trends. This column examines the workings of a discussion group and provides you with the addresses of several perinatal and neonatal groups.

In North America, an increasing number of babies are prenatally exposed to cocaine, yet the implications of cocaine use during pregnancy are not fully understood. The effects of cocaine are exerted primarily by its influence on aminergic receptors in the central and peripheral nervous systems. Developmental, physiological, and behavioral problems in infants and children are likely outcomes of maternal cocaine abuse, but these findings are confounded by concomitant use of other drugs such as marijuana and cocaine and by factors such as time, dosage, and route of cocaine intake. Different screening options exist for cocaine and its metabolites, including sampling of neonatal urine, hair and meconium need to be considered, as do the sensitivity and the ethical implications of such testing. Clinical management of cocaine-exposed infants requires attention to several issues, including: central nervous system irritation, cardiac anomalies, apnea, and feeding difficulties, as well as infant safety and follow-up postdischarge. Early detection and intervention remain the primary objectives of caring for cocaine-exposed infants.

The diagnosis of a neonatal malignancy, while rare, requires complex knowledgeable care from members of the health care team. The neonatal intensive care nurse plays an important role on that team. The types of malignancies found in neonates differ from those in older children, as do the neonate's responses to treatment. A review of the presentation, diagnosis, and management of the more common types of neonatal malignancies provides the context for consideration of the nurse's role in providing specialized care to neonates with cancer.

WE DON’T PRACTICE IN THE SAME WAY WE DID 25 YEARS ago. Then, we did a lot of things because that was the way we always did them, or because the unit policy said we must, or because someone just came back from a conference and that’s how they were doing it down there (up there, over there…). Today we implement practice changes based on a review of the existing evidence, based on the results of a meta-analysis, or as a result of multicentered benchmarking work.

Although the need for trained personnel to care for neonates with complex needs is recognized, there has been no systematic analysis of present or future personnel requirements. The Canadian Paediatric Society’s Neonatal-Perinatal Medicine Section sponsored a symposium on neonatal personnel, inviting four Canadian experts to address issues related to future needs. Areas addressed included neonatal nurse practitioners providing increased patient care in some parts of the country as resident involvement in neonatal intensive care decreases, the extended roles of other health care personnel and increased direct patient care by neonatologists. There is no approved method to determine personnel needs, but paediatric department heads have indicated that the number of neonatologists needed is substantially greater than available funding allows. Considering economic factors and the need to educate perinatal care providers, it is important to assess present and future needs to ensure that quality care can be provided.

With the growing emphasis on clinically based research as the foundation for nursing practice, the clinical nurse specialist (CNS) is in an ideal position to identify problems within the clinical arena and use research methods to support and advance practice. In the case of the Transition of the Preterm Infant to an Open Crib project sponsored by the Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN), CNSs served as site coordinators at most of the 10 implementation sites. The educational background of the CNS, combined with a grounding in clinical experience, was ideal for this role. This article discusses the role of the CNS in the implementation of a research utilization project using two case studies as examples.

SINCE ITS INCEPTION IN 1969, THE Internet has grown beyond all expectations, and today it plays a major role in our daily lives. In order to make the best use of limited time and resources, all members of your health care team should understand the strengths and weaknesses of the information superhighway.

Noninvasive ventilation (NIV) in the form of nasal continuous positive airway pressure (CPAP) was first introduced for use in newborns in the early 1970s. When mechanical ventilation for infants became available in the late 1970s, the use of CPAP declined. More recently, recognition that exposure to mechanical ventilation significantly increases a premature infant’s risk for developing chronic lung disease has resulted in renewed interest in the use of NIV.

These articles review the physiologic adaptations occurring during the transition from fetal to neonatal life and examine common red flags which may alert care providers to an infant experiencing delayed transition or an underlying disease process, congenital abnormality, or birth injury.

Objectives Upon completion of this activity, the learner will be able to: 1.Discuss the difference between malformations, deformations, disruptions and dysplasia. 2.Recognize the importance of assessing for the presence of minor congenital anomalies in the newborn. 3.Understand the potential significance of selected minor congenital anomalies and why their presence may require further investigation. Continuing Nursing Education (CNE) Credit A total of 2 contact hours may be earned as CNE credit for reading "Physical Assessment of the Newborn: Minor Congenital Anomalies" and for completing an online post-test and participant feedback form. To take the test and complete the participant feedback form, please visit http://journalscne.awhonn.org/. Certificates of completion will be issued on receipt of the completed participant feedback form and processing fees. AWHONN is accredited as a provider of continuing nursing education by the American Credentialing Center's Commission on Accreditation. Accredited status does not imply endorsement by AWHONN or ANCC of any commercial products displayed or discussed in conjunction with an educational activity. AWHONN also holds California and Alabama BRN numbers: California CNE provider #CEP580 and Alabama #ABN0058.

2009 WHEN WE FIRST STARTED OUR nursing careers in local NICUs, we didn’t even think about what neonatal care would be like in 2009! (Would there even be premies any more?) We took care of 30-week premature infants that we were happy “made it.” Developmental care was birthing itself; fabulous research was being done. It was an incredible job—taking care of premature infants. As the years went by, premies became smaller; technology became “bigger”; fertility drugs seemed to help create more multiple pregnancies: smaller, earlier births; and it seemed that more cesarean sections were needed.

Given its central role in the production and maturation of thymocytes, congenital anomalies of the thymus invariably result in some degree of impairment in immune function. The thymus is the largest lymphoid organ relative to body size during fetal life, and is chiefly concerned with the production of immunocompetent T-cells, with their repertoire of helper, cytotoxic, suppressor, and inducer functions in the immune system. In this context, congenital anomalies of the thymus may have a profound impact on neonatal health.

One of the most common and concerning complications seen in low-birth-weight infants is chronic lung disease. A variety of factors have been implicated in the etiology of chronic lung disease including lung inflammation and injury. Noninvasive ventilation (NIV), a term applied to a variety of devices capable of supporting neonatal ventilation without the use of an endotracheal tube, is receiving increasing attention as means to reduce damage often incurred with mechanical ventilation. This article will review the history of continuous positive pressure ventilation and will provide an overview of some of the other types of NIV being used in neonates. The literature supporting the use of NIV is reviewed, and nursing care of the infant receiving NIV is examined.

Editor’s Note: This information is excerpted from the chapter, “Intrauterine Infections,” in the new book: Infection in the Neonate: A Comprehensive Guide to Assessment, Management, and Nursing Care. Ordering information can be found on the facing page, or you may order online at: www.neonatalnetwork.com/nicuink.

PERHAPS NOTHING HAS CHANGED THE face of communication more in the past ten years than the widespread use of electronic mail, or e-mail. More than 80 million Americans use e-mail, sending more than nine billion messages each day.1 Imagine sending a message to 2, 10, or 200 colleagues down the hall, across the country, or around the world. The message is transmitted instantly and received within seconds—all without postage or long-distance charges. No more telephone tag!

This article reviews the embryology, physiology, and pathophysiology of the thymus. The anatomy of this lymphoid organ, the significance of the presence or absence of the thymus radiographically, and the role of the thymus in immunity are also reviewed. Finally, the pathologic presentation of thymic hypoplasia (DiGeorge syndrome) is discussed. Despite advances in modern science, little was known about the thymus, one of the body’s key organs in the immune system, until 1961, when Dr. Jacques Miller performed thymectomies in mice. Then it became evident that the thymus played a key role in the body’s defense against infection. Since that time, researchers have continued to examine the role of the thymus from fetal life through adulthood.

The transition from fetus to neonate is a time of significant physiologic adaptation. In addition to the normal physiologic tasks of transition, some neonates must also cope with underlying congenital abnormalities, birth injury, or disease. Careful assessment and astute nursing care are needed during the period of transition to ensure that the neonate who is experiencing problems with transition is recognized and appropriate interventions are initiated. This article examines the physiology of transition and discusses factors placing the neonate at risk of illness. A plan of care for neonates experiencing symptoms of underlying disease during transition is presented.

SOMO PEOPLE MARK THE BEGINNING OF A NEW YEAR in September when the kids (or the academics) go back to school. Others look at the calendar and celebrate the New Year as the ball drops in Times Square. Still others use different calendars to mark the passage of time. Regardless of when the year starts for you, the mid-winter break is a good time to take stock of where you are, both personally and professionally. As you prepare to unfold the calendar for 2007 you might pause to think about where your practice will take you in the next year. Whoever said “life is a journey, not a destination” was certainly right when it comes to nursing practice. To make the most of the journey, we need to be open to new experiences and opportunities. You never know what door might open when you choose to turn a key. I am not one to make New Year’s resolutions, but I am promising to try to live by this motto, especially as I set off on a six month sabbatical from my day job at the University where I teach. It is my plan to take the time to think about the journey that is my neonatal practice and to explore some new roads along the way.

THE BUSINESS OF PUTTING TOGETHER A JOURNAL THAT is relevant, interesting, and scholarly has become increasingly more challenging and complex. Pressure from funding agencies to make government-sponsored research results freely accessible, the increasing movement towards online access to articles, and a general need to attend to the bottom line in a shrinking market for print journals, has resulted in two troubling events that I would like to share with you. The details of the first, the severing of ties between the American Journal of Nursing (AJN) and the American Nurses Association (ANA), are outlined in the accompanying letter that was sent to ANA by members of the International Association of Nurse Editors. In the second case, the editor-in-chief and the senior deputy editor of the Canadian Medical Association Journal (CMAJ), the journal of the Canadian Medical Association (CMA) were fired in February of this year. The reason for the firing—editorial freedom. The editors of the CMAJ commissioned a story on women’s experiences in obtaining the morning-after pill from pharmacies in Canada. When the Canadian Pharmacists Association heard about the story, they complained to the publisher of CMAJ who asked the editors to withhold the story.1 The editors chose to publish a negotiated revision but were fired for irreconcilable differences.2

EVIDENCE-BASED MEDICINE (EBM) HAS BEEN DEFINED as “the conscientious, explicit, and judicious use of current evidence in making decisions about the care of individual patients.”1

MANY OF YOU ATTENDING THIS MEETING, SOME FOR the first time, will be reading this editorial at the National Neonatal Nurses Meeting in Chicago. You might wonder, as I used to, how this meeting gets put together. Why Chicago and not your hometown? Why some of the same old speakers, or, why not more of the big names?

“I’D LIKE TO WRITE AN ARTICLE, BUT I DON’T KNOW where to start.” This is a common theme in e-mails I get from prospective authors. Fair enough; the process of getting an article from conception to publication can appear daunting. This is one of the reasons that Neonatal Network® is committed to working with new authors, helping translate their curiosity and expertise into solid, practical articles that can benefit neonatal nurses. This is balanced by articles from seasoned researchers and authors who also choose Neonatal Network® as a vehicle for disseminating new knowledge and ensuring that this knowledge is available to the practice community.

Despite tremendous advances in technology, sepsis remains a major threat in neonatal intensive care. The incidence of neonatal infection ranges from 7.3 to 16 per 1,000 live births. Nurses play an important role in the recognition and treatment of the septic infant. An understanding of the classification, epidemiology, and signs and symptoms of bacterial and fungal sepsis will better position the nurse to identify the infant at risk for sepsis and to initiate supportive care.

IN THIS DAY AND AGE EVERYONE HAS CHOICES. BECAUSE YOU are reading this editorial, I’m going to assume that you have made the choice to spend at least some of your scarce leisure or work time maintaining your competence by reading your professional journal. Putting together a peer-reviewed journal is a responsibility that we take seriously. It is our mission at Neonatal Network® and The Academy of Neonatal Nursing to provide nursing education that is up-to-date, evidence-informed, at a reasonable cost.

RUNNING A MARATHON IS ALL ABOUT PUSHING THE human body farther than its meant to go: Beyond the point where glycogen is available, beyond the point where muscles cease complaining and just plain cramp up. Doing a Google search on “pushing yourself” yields all kinds of references to running, training, triathlons, just about any type of physical training imaginable.

THIS TITLE EITHER HARKENS BACK TO YOUR favorite Disney ride or makes you want to close the journal right now. What brings me to write under such a corny banner? Well, it started when my 15-year-old was telling me about the philanthropy committee she sits on at school and the report she was writing outlining which charities she thought the school’s fundraising should support. This followed hot on the heels of a story in the local paper about a high school that had worked for four years to build a school in Africa. All this led me to think about philanthropy in nursing and what our role might be in the global village.

ACCORDING TO WEBSTER’S NEW COLLEGIATE Dictionary, a hero is “someone who is admired for his achievements and qualities or one that shows great courage.” Since the onslaught of Hurricane Katrina, we have heard many stories of heroism—stories about rescues, giving, and surviving against formidable odds. As with any event of this magnitude, there are many more unsung heroes—people who quietly go about doing what needs to be done because that’s what they do. People who stayed behind in empty cities to take care of patients who couldn’t leave, and people who sat by the bedside to keep ventilators running, vitals signs monitored, and treatments given. People who accepted admission after admission, sometimes without full paperwork. People who are the men and women of the NICUs in Mississippi, Louisiana, Alabama, and Texas—the neonatal nurses, neonatologists, RTs, and others who worked tirelessly to ensure the safety and well-being of their patients.

“WHAT GOES AROUND comes around,” isn’t that the old saying? Others use phrases like “what’s old is new and what’s new is old” to describe the cyclical patterns we see in life. You know—bell bottoms and belly buttons come and go, short hair, long hair, horned-rim glasses or not. We are always hearing of new trends that really aren’t new at all and in some ways, can make us feel really quite old.

MAJOR MILESTONES SUCH AS birthdays and anniversaries provide us with an opportunity to look back and reflect on what has gone before us. They are also a perfect time to look to the future. This special anniversary issue of Neonatal Network® features many reflections of the past twenty years of neonatal care—although for many of us, our history of caring for babies goes back much farther. Do we start with the opening of the first NICU in 1965, or do our influences reach back much farther to the work of some of the early pioneers in neonatal care? Do we mark our beginnings with the development of the first infant incubator (Stéphane Tarnier, Paris France) in 1878, or with the work of another Parisian, Pierre-Constant Budin who in the late 19th century developed many of the principles that formed the basis of neonatal medicine?

(2000) Cochrane Database Syst Rev (4). Symington A, Pinelli J. . Developmental care for promoting development and preventing morbidity in preterm infants. . ; . :CD001814 (latest version 28 July 2000). . QUESTION: Does developmental care (ie, interventions designed to modify the neonatal intensive care unit [NICU] environment and thereby minimise the stress experienced by preterm infants) reduce adverse outcomes in preterm infants? Studies were identified by searching Medline (1966 to July 2000), CINAHL, and the Cochrane Library ; English language conference and symposia proceedings from 1990 to July 2000; bibliographies of retrieved articles; and by contacting experts. Randomised trials were included if they compared elements of developmental care with routine nursery care in infants

(1999) Pediatrics 104, 22; Kothadia JM, O'Shea TM, Roberts D . , et al. . Randomized placebo-controlled trial of a 42-day tapering course of dexamethasone to reduce the duration of ventilator dependency in very low birth weight infants. . Jul; . : . –27 . [OpenUrl][1][Abstract/FREE Full Text][2] (1999) Pediatrics 104, 15. O'Shea TM, Kothadia JM, Klinepeter KL . , et al. . Randomized placebo-controlled trial of a 42-day tapering course of dexamethasone to reduce the duration of ventilator dependency in very low birth weight infants: outcome of study participants at 1-year adjusted age. . Jul; . : . –21 . [OpenUrl][3][Abstract/FREE Full Text][4] QUESTION: Among very low birthweight infants, does a 42 day course of dexamethasone reduce duration of assisted ventilation and affect developmental outcome at age 1 year? Randomised (allocation concealed*), unblinded, placebo controlled trial with follow up at age 1 year. 2 neonatal intensive care units (NICUs) in North Carolina, USA. 118 infants (53% boys, 61% white) who were 15–25 days old and had birth weight