Janet Pinelli

Efficacy and Safety of Sucrose for Procedural Pain Relief in Preterm and Term Neonates

BackgroundPreterm and acutely ill term neonates who are hospitalized in a neonatal intensive care unit are subjected to multiple frequent invasive and painful procedures aimed at improving their outcome. Although several trials to determine the efficacy of sucrose for managing procedural pain in preterm and acutely ill term neonates have been developed, these have generally lacked methodological rigor and have not provided clinicians with clear practice guidelines. ObjectivesTo compare the efficacy and safety of three interventions for relieving procedural pain associated with heel lances in preterm and term neonates, and to explore the influence of contextual factors including sex, severity of illness, and prior painful procedures on pain responses. MethodsIn a randomized controlled trial, 190 neonates were stratified by gestational age and then randomized to receive (a) sucrose and nonnutritive sucking (n = 64), (b) sucrose alone (n = 62), or (c) sterile water and nonnutritive sucking (control) (n = 64) to evaluate the efficacy (pain response as measured using the Premature Infant Pain Profile) (Stevens, Johnson, Petryshen, & Taddio, 1996) and safety (adverse events) following a scheduled heel lance during the first week of life. Stratification was used to control for the effects of age on pain response. ResultsSignificant differences in pain response existed among treatment groups (F = 22.49, p < .001), with the lowest mean Premature Infant Pain Profile scores in the sucrose and nonnutritive sucking group. Efficacy of sucrose following a heel lance was not affected by severity of illness, postnatal age, or number of painful procedures. Intervention group and sex explained 12% of the variance in Premature Infant Pain Profile scores. Few adverse events occurred (n = 6), and none of them required medical or nursing interventions ConclusionsThe combination of sucrose and nonnutritive sucking is the most efficacious intervention for single heel lances. Research on the effects of gestational age on the efficacy and safety of repeated doses of sucrose is required.

Self-Perceived Health-Related Quality of Life of Former Extremely Low Birth Weight Infants at Young Adulthood

OBJECTIVES. The goals were to compare the self-reported, health-related quality of life of former extremely low birth weight and normal birth weight infants at young adulthood and to determine whether there were any changes over time. METHODS. A prospective, longitudinal, population-based study with concurrent control subjects was performed. We interviewed 143 of 166 extremely low birth weight survivors (birth weight: 501–1000 g; 1977–1982 births) and 130 of 145 sociodemographically comparable, normal birth weight, reference subjects. Neurosensory impairments were present for 27% extremely low birth weight and 2% normal birth weight young adults. Health Utilities Index 2 was used to assess health status, and standard gamble technique was used to measure directly the self-reported, health-related, quality of life and 4 hypothetical health states. RESULTS. Extremely low birth weight young adults reported more functional limitations in cognition, sensation, mobility, and self-care, compared with control subjects. There were no differences between groups in the mean self-reported, health-related, quality of life or between impaired (n = 38) and nonimpaired (n = 105) extremely low birth weight subjects. However, with a conservative approach of assigning a score of 0 for 10 severely disabled, extremely low birth weight subjects, the mean health-related quality of life was significantly lower than control values. Repeated-measures analysis of variance to compare health-related quality-of-life measurements obtained for young adults and teens showed the same decline in scores over time for both groups. There were no differences between groups in the ratings provided for the hypothetical health states. CONCLUSIONS. At young adulthood, health-related quality of life was not related to size at birth or to the presence of disability. There was a small decrease in health-related quality-of-life scores over time for both groups.

Comparison of current health, functional limitations, and health care use of young adults who were born with extremely low birth weight and normal birth weight.

OBJECTIVE. The objective of this study was to compare the current health status, physical ability, functional limitations, and health care use of extremely low birth weight and normal birth weight young adults. METHODS. A longitudinal study was conducted of a population-based cohort of 166 extremely low birth weight survivors (501–1000 g birth weight; 1977–1982 births) and a group of 145 sociodemographically comparable normal birth weight individuals. Current health status, history of illnesses, hospitalizations, use of health resources, and physical self-efficacy were assessed through questionnaires that were administered to the young adults by masked interviewers. RESULTS. Individuals completed the assessments at a mean age of 23 years. Neurosensory impairments were identified in 27% of extremely low birth weight and 2% of normal birth weight individuals. No differences were reported in the current health status for physical or mental summary scores. Extremely low birth weight young adults reported a higher prevalence of chronic health conditions in the past 6 months. A significantly higher proportion of extremely low birth weight individuals had functional limitations in seeing, hearing, and dexterity and experienced clumsiness and learning difficulties. Except for prescription glasses, medications for depression, and home-care services for extremely low birth weight individuals, there were no significant differences between groups in use of health care resources. Extremely low birth weight individuals had significantly weaker hand grip strength and lower scores for physical self-efficacy, perceived physical ability, and physical self-confidence. CONCLUSIONS. Extremely low birth weight young adults seem to enjoy similar current health status to their normal birth weight peers. However, they continue to have significantly poorer physical abilities and a higher prevalence of chronic health conditions and functional limitations. Contrary to expectations, they do not pose a significant burden to the health care system at young adulthood.

Effects of family coping and resources on family adjustment and parental stress in the acute phase of the NICU experience.

Purpose: To determine the relationship between family coping and resources and family adjustment and parental stress in the acute phase of the NICU experience. Design: Correlational study based on the Resiliency Model of Family Stress, Adjustment, and Adaptation. Main study instruments included the State Anxiety scale of the State-Trait Anxiety Inventory, the Family Inventory of Resources for Management, the Family Crisis Oriented Personal Evaluation Scales, and the General Functioning subscale of the McMaster Family Assessment Device. Sample: Data collected from 124 mother and father pairs within two to four days of their infant’s admission to the NICU. Main Outcome Variables: Family adjustment and parental stress. Results: Adequate resources were more strongly related to positive adjustment and decreased stress than were either coping or being a first-time parent. The relationships among the variables were generally the same for both parents. Mothers utilized more coping strategies than did fathers. Practice Recommendations: Families with limited resources should be identified early to facilitate their adjustment to the NICU.

Growth Trajectories of Extremely Low Birth Weight Infants From Birth to Young Adulthood: A Longitudinal, Population-Based Study

We compared sex-specific growth attainment of a population-based cohort of 147/166 (89%) extremely low birthweight (ELBW < 1000 g) and 131/145 (90%) sociodemographically comparable normal birthweight (NBW) cohort at young adulthood, and examined the pattern of growth trajectories and correlates of growth at ages 1, 2, 3, and 8 y, and teen and young adulthood (mean age, 23.3 versus 23.6 y). The proportion considered small for gestational age was ELBW 25% versus NBW 3%; and 26% versus 2% had neurosensory impairments. Weight for age z-scores for ELBW showed substantial decline to age 3 y, with subsequent significant catch-up to adolescence and smaller gains to adulthood. Height for age z-scores showed both sexes of ELBW were disadvantaged at every age compared with NBW and their expected mid-parental height. The BMI z-scores for ELBW showed a sustained incline from age 3 to adulthood, where both sexes normalized to above zero, and were comparable to their peers. ELBW children showed growth failure during infancy, followed by accelerated weight gain and crossing of BMI percentiles at adolescence, a pattern that may increase the risk of insulin resistance and coronary heart disease. However, normalization of BMI for both sexes at adulthood suggests that final growth was proportionate.

Resources to Enhance Evidence-based Nursing Practice

Evidence-based practice means integrating the best available research evidence with information about patient preferences, clinician skill level, and available resources to make decisions about patient care. Barriers to the use of research-based evidence occur when time, access to journal articles, search skills, critical appraisal skills, and understanding of the language used in research are lacking. Resources are available to overcome these barriers and support an evidence-based nursing practice. This article highlights available resources and describes strategies that nurses can use to develop and sustain an evidence-based nursing practice.

The effects of family resources, coping, and strains on family adjustment 18 to 24 months after the NICU experience.

PURPOSE To examine the relationship of family coping, resources, and strains on family adjustment over time following the NICU experience. DESIGN Longitudinal, correlational study based on the Resiliency Model of Family Stress, Adjustment and Adaptation. SAMPLE Data were collected, through mailed questionnaires, from 71 couples, 18 to 24 months following the birth of their infant. The data are a follow-up from a previous study conducted at the time of the infants birth. MAIN OUTCOME VARIABLES The dependent variable in the study was family adjustment, measured by the McMaster Family Assessment Device. The independent variables were family resources, as measured by the Family Inventory of Resource Management; family coping, as measured by the Family Crisis Oriented Evaluation Scales; family strain, as measured by the Family Inventory of Life Events and Changes; and parent gender, family system (first-time parent or not), and the childs health, as measured by the Demographic Information Questionnaire. RESULTS Family adjustment improved over time for mothers but decreased for fathers. Fathers of infants with ongoing health problems reported significantly poorer family adjustment. Family resources were related to family adjustment and decreased over time for both parents. Families used more coping mechanisms and different coping patterns over time.

Distilling the evidence on developmental care: a systematic review.

PURPOSETo determine whether developmental care interventions reduce neurodevelopmental delay, poor weight gain, length of hospital stay, length of mecharical ventilation, physiologic stress, and other clinically relevant adverse outcomes in preterm infants. SUBJECTSInfants born at less than 37 weeks postconceptional age. This review consisted of 31 studies in 4 categories of developmental care interventions, 19 subgroups, and multiple clinical outcomes. The total sample sizes in the individual studies ranged from 16 to 259; the sample size in 18 of the studies was less than 50. DESIGN AND METHODSA systematic review, based on the Cochrane Collaboration format, of all randomized trials in which elements of developmental care are compared with routine nursery care and that measured clinically relevant outcomes. Searches were made of MEDLINE from 1966 to July 2000. Additional databases were also searched electronically. Reference lists and bibliographles of relevant articles were hand-searched. Experts in the field were contacted. If more than one study in an outcome category existed, a meta-analysis was conducted. PRIMARY OUTCOME MEASURESOutcome measures included the following length of hospital stay, weight at discharge, neurodevelopment, physiologic parameters, feeding, growth, sleep/wake states, age at discharge, neonatal outcomes, cost of hospital stay, and death. PRINCIPAL RESULTSDevelopmental care interventions showed some benefit to preterm infants with respect to improved short-term growth outcomes, decreased respiratory support, decreased incidence of moderate to severe chronic lung disease, decreased length and cost of hospital stay, and improved neurodevelopmental outcomes to 24 months corrected age. These findings were based on 2 or 3 small trials for each outcome. Although a number of other benefits were shown, those results were from single studies with small sample sizes. The lack of blinding of the assessors of the outcome variables was a significant methodological flaw in half of the studies. The costs of the interventions and personnel were not considered in any of the studies. CONCLUSIONSIn most studies, the inclusion of multiple interventions made the determination of the effect of any single intervention difficult. Although there is evidence of some benefit of developmental care interventions overall and no major harmful effects reported, there were a large number of outcomes for which no or conflicting effects were shown. The single trials that did show a significant effect of an intervention on a major clinical outcome were based on small sample sizes, and the findings often were not supported in other small trials. Before a clear direction for practice can be supported, evidence showing more consistent effects of developmental care interventions on important short- and long-term clinical outcomes is needed. The economic impact of the implementation and maintenance of developmental care practices should be considered by individual institutions.

Risk-Scoring Tool for respiratory syncytial virus prophylaxis in premature infants born at 33-35 completed weeks' gestational age in Canada.

ABSTRACT Objective: To study the impact of the Risk-Scoring Tool (RST) as a strategy for targeting prophylaxis effectively in 33–35-week gestational age (GA) Canadian infants who range from low to high risk by evaluating the subsequent incidence of respiratory syncytial virus (RSV) infections resulting in emergency room (ER) visits and hospitalization. Design: Prospective, descriptive study. Setting: McMaster Childrens Hospital and St Josephs Healthcare in Hamilton, Ontario. Participants: Premature infants between 33 and 35 weeks’ completed gestation who were less than 6 months’ chronological age at the start of, or during, the local 2005–2008 RSV winter seasons. Methods: A validated, Canadian RST was used to calculate a total risk score based on seven risk factors. Only infants at moderate (RST score 49–64) and high risk (RST score 65–100) received palivizumab at monthly intervals from November to April and were followed during the respective RSV seasons. All parents received information on RSV prevention at hospital discharge. Parents of all recruited infants were contacted by telephone in May at the end of each season, and medical records were checked to determine ER visits for RSV-related respiratory tract infections and RSV hospitalization. Means, standard deviations, ranges, and percents were used to describe the variables for patients enrolled in the study. Results: Over 3 years, 430 infants were recruited. Of these, 346 (81%), 57 (13%), and 27 (6%) were in the low-, moderate- and high-risk categories, respectively, based on their risk scores. A total of 78 (18.1%) infants received full courses of palivizumab. Six out of 57 (10.5%) infants in the moderate-risk group did not receive prophylaxis, while all 27 high-risk group infants received palivizumab. Seven (1.6%) infants were RSV-positive and five (low-risk) infants were hospitalized. One high-risk, RSV-positive infant, was seen in the ER, and discharged home. There were no statistical differences in the number of infants with RSV-related ER visits and hospitalizations within the risk category groups (p = 0.43). The limitations of this study include the observational design and the relatively small sample size. Conclusions: The RST is a practical, easy-to-use instrument to guide judicious RSV prophylaxis for moderate–high-risk, 33–35-week GA infants. It is cost-effective, reducing hospitalization in infants who are most ‘at-risk’, while avoiding prophylaxis in a large segment (81.9%) of this GA cohort who are considered low risk for RSV infection.

Effect of breastmilk consumption on neurodevelopmental outcomes at 6 and 12 months of age in VLBW infants.

PURPOSETo determine the influence of breastmilk consumption, as a dose response, in very low-birth-weight (VLBW) infants (<1,500 g) on neurodevelopmental outcomes at 6 and 12 months corrected age, and to determine the influence of selected sociodemographic and infant variables on neurodevelopmental outcomes. SUBJECTSVLBW infants (n = 148) who were fed mothers milk or formula by parental choice. DESIGNProspective cohort with longitudinal follow-up at 6 and 12 months corrected age. METHODSSelf-administered questionnaires given to mothers at study entry, before discharge, and at 3-, 6-, and 12-month follow-up visits. During hospitalization, mothers recorded the 24-hour volume of expressed milk once per week. At each follow-up visit, the volume of a single feeding was assessed by pre- and postbreastfeeding test weights of infants measured on an electronic scale accurate to 1.0 g. The amount of breastfeeding was also assessed by feeding records and mothers report. MAIN OUTCOME MEASURESThe Bayley Scales of Infant Development (2nd Edition), the Mental Development Index (MDI), and the Psychomotor Development Index (PDI). PRINCIPAL RESULTSAfter controlling for specific sociodemographic and infant variables, this study of VLBW infants showed no statistically significant effect of predominantly breastfeeding compared with predominantly formula feeding on neurodevelopmental outcomes to 12 months corrected age. The most significant predictor of MDI scores at 6 and 12 months corrected age was birth weight, in which higher birth weights predicted higher MDI scores. CONCLUSIONSDespite the lack of statistically significant differences, the findings suggest a small but consistent advantage in developmental scores in infants who were fed their mothers milk compared with those who were predominantly formula fed. Supporting parents to breastfeed preterm infants may maximize the potential advantages of early nutrition in the neurodevelopmental outcome of VLBW infants.