Debra Armentrout

Randomized, controlled trial of slow versus rapid feeding volume advancement in preterm infants.

Objectives. To determine whether infants who are fed initially and advanced at 30 mL/kg per day (intervention) take fewer days to get to full feedings than those who are fed initially and advanced at 20 mL/kg per day (control), without increasing their incidence of feeding complications and necrotizing enterocolitis (NEC). We also examined whether these infants regain birth weight earlier, have fewer days of intravenous fluids, and a have shorter hospital stay. Methods. A randomized, controlled, single-center trial was conducted in a Neonatal Intensive Care Unit of a community-based county hospital in Houston, Texas. Infants between 1000 and 2000 g at birth, gestational age ≤35 weeks, and weight appropriate for gestational age were allocated randomly to feedings of expressed human milk or Enfamil formula starting and advanced at either 30 mL/kg per day or 20 mL/kg per day. Infants remained in the study until discharge or development of stage ≥IIA NEC. Results. A total of 155 infants were enrolled: 72 infants in the intervention group and 83 in the control group. Infants in the intervention group achieved full-volume feedings sooner (7 vs 10 days, median), regained birth weight faster (11 vs 13 days, median), and had fewer days of intravenous fluids (6 vs 8 days, median). Three infants in the intervention group and 2 control infants developed NEC for an overall incidence of 3.2% (relative risk: 1.73; 95% confidence interval: 0.30–10.06). Conclusion. Among infants between 1000 and 2000 g at birth, starting and advancing feedings at 30 mL/kg per day seems to be a safe practice and results in fewer days to reach full-volume feedings than using 20 mL/kg per day. This intervention also leads to faster weight gain and fewer days of intravenous fluids.

Erythromycin fails to improve feeding outcome in feeding-intolerant preterm infants

Objective Approximately half of extremely low birth weight infants have feeding intolerance, which delays their achievement of full enteral feedings. Erythromycin, a motilin receptor agonist, triggers migrating motor complexes and accelerates gastric emptying in adults with feeding intolerance. Few studies have assessed the efficacy of this drug in preterm infants with established feeding intolerance. This study was designed to assess the efficacy of erythromycin in feeding-intolerant infants, as measured by gastric emptying, maturation of gastrointestinal motor patterns, and time to achieve full enteral feedings. Methods Subjects were 27 preterm infants who were admitted to the neonatal intensive care unit and who did not achieve full enteral feeding volumes (150 mL/kg/day) within 8 days of the initiation of feedings. In a controlled, randomized, double-blinded clinical trial, infants received intragastric erythromycin or placebo for 8 days without crossover. At study entry, the authors recorded motor activity in the antrum and the duodenum during fasting, in response to intragastric erythromycin (1.5 mg/kg) or placebo, and in response to feeding. Gastric emptying at 20 minutes and transit time from duodenum to anus were determined. Each infant then received erythromycin or placebo for 8 days, and feeding characteristics were prospectively tracked. Results Gastric emptying and characteristics of antroduodenal motor contractions were similar in the two groups, as were the transit times from duodenum to anus. Feeding outcomes were comparable in the two groups. Conclusion Intragastric erythromycin does not improve feeding tolerance in preterm infants with established feeding intolerance because it fails to improve gastrointestinal function in the short or long term.

Neonatal diabetes mellitus

Neonatal diabetes mellitus is an uncommon disorder of unknown cause that can be encountered in the first days to weeks of life. Two forms--transient and permanent--have been described. Signs and symptoms of both forms are identical with the ongoing need for insulin therapy past the neonatal period the only method to distinguish between them. This article describes the infant with transient neonatal diabetes and reviews the clinical characteristics of both the transient and permanent forms. The role of the nurse practitioner in the care and management of these infants is also addressed.

Simulation With Synergy and Community Energy

Neonatal nurse practitioners (NNPs) have a crucial role in the management and care of critically ill newborns and infants in the neonatal intensive care unit. Their role responsibilities range from daily management of care, oversight of unit and bedside education, execution of advanced procedures, and attendance at high-risk deliveries. During their educational program, there is a mix of didactic and clinical training. To ensure that their graduates are able to competently care for neonatal patients in the ever-advancing neonatal world, the NNP program at the University of Texas Medical Branch–Galveston (UTMB), has implemented simulation-based training into every clinical course. This article describes the history of simulation in the NNP program at UTMB, discusses the current use of simulation at UTMB, explores the synergistic use of undergraduate students in simulations at UTMB, and details the use of professional volunteers from the local medical community to execute the simulations and debriefing process.

Polycythemia in the newborn.

Neonatal polycythemia, a venous hematocrit >65%, occurs in 1% to 5% of the total newborn population. Polycythemia can result from an excess production of red blood cells (active form) or from an increase in fetal blood volume (passive form). Clinical manifestations of polycythemia are caused by an increase in whole blood viscosity with a subsequent decrease in blood flow to organ systems. However, little information exists in the nursing literature concerning neonatal polycythemia. This article addresses the two categories of polycythemia and their etiologies; the involved pathophysiology; clinical manifestations of affected organ systems; supportive and specific therapies that can be used to treat polycythemic infants; the prognosis for polycythemic infants; and the difficulty healthcare providers face in deciding whether to treat this disorder. In addition, a case of a symptomatic infant who was treated with a partial exchange transfusion is presented.

Initial Development of C.A.T.E.S.: A Simulation-Based Competency Assessment Instrument for Neonatal Nurse Practitioners.

Abstract Purpose: Determine content validity of global statements and operational definitions and choose scenarios for Competency, Assessment, Technology, Education, and Simulation (C.A.T.E.S.), instrument in development to evaluate multidimensional competency of neonatal nurse practitioners (NNPs). Design: Real-time Delphi (RTD) method to pursue four specific aims (SAs): (1) identify which cognitive, technical, or behavioral dimension of NNP competency accurately reflects each global statement; (2) map the global statements to the National Association of Neonatal Nurse Practitioners (NANNP) core competency domains; (3) define operational definitions for the novice to expert performance subscales; and (4) determine the essential scenarios to assess NNPs. Sample: Twenty-five NNPs and nurses with competency and simulation experience Main outcome variable: One hundred percent of global statements correct for competency dimension and all but two correct for NANNP domain. One hundred percent novice to expert operational definitions and eight scenarios chosen. Results: Content validity determined for global statements and novice to expert definitions and essential scenarios chosen.

Neonatal blood component therapy.

Blood transfusion therapy plays an important role in the care and management of ill newborns, yet the indications for blood product administration remain controversial. The article reviews basic definitions, indications for blood product transfusion, and risks and difficulties involved in transfusion therapy. Descriptions, indications, ABO/Rh compatibility, shelf life, necessary equipment, dose, rate, and general considerations for various blood product components are included.

Cultivating Future Scholars

nursing role goes back over four decades with many of its original pioneers still employed in clinical and academic settings. however, the “graying of the workforce” has led many to question who will take over the reins of leadership both clinically and edu-cationally so that advance practice neonatal nursing maintains its scholarly foundation. emerging from the early hospital-based cer-tificate programs, as well as volunteer trans-port teams of the 1970s, it became apparent that the educational preparation for the evolving neonatal nurse practitioner (nnp) role needed to be based within a university setting. With the 1980s came national cer-tification of nnps through the national certification corporation (ncc) as well as the formation of their own specialty-specific organization, the national association of neonatal nurses, which further legiti-mized nnp education to be at the graduate level.

Not ready for prime time: transitional events in the extremely preterm infant.

Successful transition from intrauterine to extrauterine life involves significant physiologic changes. The majority of these changes occur relatively quickly during those first moments following delivery; however, transition for the extremely preterm infant occurs over a longer period of time. Careful assessment and perceptive interventions on the part of neonatal care providers is essential as the extremely preterm infant adjusts to life outside the womb. This article will focus on respiratory, cardiovascular, gastrointestinal, and neurologic transitional events experienced by the extremely premature infant.

Gastroesophageal reflux in infants

Spitting is a common occurrence in infants and is usually of no consequence. When regurgitation is accompanied by the return of gastric acids into the esophagus, however, it is considered to be gastroesophageal reflux. Failure to thrive, esophagitis, aspiration, chronic respiratory disease, and apnea can all be associated with pathologic gastroesophageal reflux. This paper discusses the causes, symptoms, and treatment modalities for pathologic gastroesophageal reflux. Health care practitioners can play a major role in providing direct care as well as coordinating and evaluating treatment interventions for infants with gastroesophageal reflux. In addition, health care providers can supply the families of these infants with the necessary education and emotional support required to care for their infant.