Kim K. Doheny

Diminished vagal tone is a predictive biomarker of necrotizing enterocolitis-risk in preterm infants.

Necrotizing enterocolitis (NEC) is an acute neonatal inflammatory disease which may lead to intestinal necrosis, multisystem failure, and death. Currently, NEC is diagnosed by a combination of laboratory and radiographic tests conducted a posteriori i.e., when NEC is already clinically significant. Given the acute onset and rapid progression of NEC, a non‐invasive biomarker that allows early detection of patients at risk is required as a matter of urgency. We evaluated whether the high frequency (HF) component of heart rate variability (HRV), a measure of vagal efferent tonic cholinergic activity may be used as a predictive biomarker for NEC‐risk before the onset of clinical disease.

Analysis of acute pain scores and skin conductance measurements in infants

BACKGROUND Skin conductance (SC) has been previously used to measure acute post-operative pain in adults and older children (>1year old).We have investigated the ability of SC to predict the severity of post-operative pain scores in the exclusively infant population. METHODS Infants (ages 6-12months) scheduled for elective surgery were recruited for the study. Data for behavioral pain scores and SC values - frequency of electrodermal responses per second (EDR/s), peak and basal levels, were recorded in the post-anesthesia care unit (PACU). Blood samples were collected for genomic studies, including single nucleotide polymorphisms (SNP) in morphine opioid receptor (MOR) A118G and the catechol-O-methyltransferase (COMT) G1947A genes. RESULTS 31 infants, mean age 8.9months (±1.9); mean weight 8.5kg (±1.1) were included in the final study analysis. With every 0.1 unit increase in peak values noted on SC, the odds of higher pain scores were found to be 5% greater (p=0.03). For predictability of moderate to severe pain, the area under the curve, sensitivity and specificity were 0.64, 90.9% and 51.4% respectively for peak values and 0.66, 54.5% and 79.4% respectively for EDR/s values. Genotyping performed in 16 out of 31 infants demonstrated that the carriers of MOR 118G allele had consistently higher basal SC values in the PACU. CONCLUSION Peak SC values may serve as indicators of unmitigated pain. Further studies are needed to fully investigate the effect of MOR A118G SNP on the post operative pain scores and SC values in the larger infant population in order to validate both the clinical significance of the skin conductance for routine pain assessment in infants and the observed genetic effect.

Oropharyngeal Administration of Colostrum Increases Salivary Secretory IgA Levels in Very Low-Birth-Weight Infants

Aim Oropharyngeal administration of colostrum (OAC) has been proposed to provide mothers early milk to very low‐birth‐weight (VLBW) infants in the first few days of life. The aim of this study was to test the hypothesis that OAC would increase salivary secretory IgA (SsIgA). Patients and Methods Overall, 30 VLBW infants randomized to receive OAC or sterile water had salivary sampling for SsIgA on the day of life (DOL) 2, 7, and 14. The incidence of late‐onset sepsis (LOS) and necrotizing enterocolitis (NEC) was determined prospectively. Within and between‐group comparisons were made by paired and independent samples t ‐tests. Results Baseline characteristics were similar between groups. SsIgA was higher in OAC versus the control group (p < 0.05) on DOL 7, but not subsequently on DOL 14. There was no difference in LOS or NEC. Conclusion OAC increased SsIgA at DOL 7. A large, multicenter trial is needed to determine if OAC decreases LOS or NEC in VLBW infants.

Implementing and Sustaining Evidence Based Practice Through a Nursing Journal Club.

BACKGROUND The outcomes based emphasis in nursing and health care delivery requires identification of best available evidence in order to produce quality, safe, and effective patient care. Finding, critiquing, and ultimately implementing the best available evidence for practice is a formidable task for many clinical nurses. Development and implementation of a nursing journal club (NJC) became one organizations successful attempt to help clinical nurses better understand and use best available evidence in actual practice. METHODS The process and structure for the NJC evolved from an additional activity scheduled outside of work to a fully established endeavor of Nursing Research and Evidence Based Practice Council (NR&EBP). The Nursing Professional Practice Model was foundational to establishing the NJC as a formal component within the NR&EBP Council shared governance structure. Efforts to embed the NJC included taking advantage of resources available at an academic medical center and incorporating them into the council structure. RESULTS Successful outcomes of the NJC include a quarterly schedule, with topics selected in advance that are based on nursing department as well as organizational driven goals and initiatives. The structure and process in place has eliminated frequently mentioned deterrents to evidence based practice such as not enough time, lack of knowledge, or no immediate application to practice. CONCLUSIONS Incorporating the NJC as a component of NR&EBP Council has provided clinical nurses time away from clinical care that supports scholarship for nursing practice. Committed leadership and garnering of available resources have been key factors for success.

Skin conductance at baseline and postheel lance reflects sympathetic activation in neonatal opiate withdrawal

Skin conductance (SC) provides an objective measure of autonomic system regulation through sympathetic‐mediated filling of sweat glands. This study aimed to test the utility of SC to detect sympathetic activation in neonatal abstinence syndrome (NAS).

Preterm infants’ behaviors and skin conductance responses to nurse handling in the NICU

Abstract Stress response patterns are indicative of the neonates unique ability to cope with environmental demands and can be evaluated through autonomic and behavioral response parameters. Objective: To characterize stress responses during tactile stimulation to standard nurse handling in the NICU, and their association with severity of illness in preterm infants. Methods: Thirty preterm neonates were studied at postnatal day 4–5 during standard nurse caregiving. Heart rate (HR), respiratory rate (RR), skin conductance responses per second (SCR/s), and NIDCAP® stress behaviors were recorded before and during care. Non-parametric tests were used to assess differences from before to during care. Pearson’s correlations were used to determine the association of biological and behavioral variables to the score for neonatal acute physiology (SNAP), a severity of illness index. Results: HR, RR, SCR/s and NIDCAP® behaviors (motor and attentional cues, and ability to self-console) increased from before to during the care (p < 0.01). NIDCAP® behaviors showed a significant negative association to the SNAP score (R = −0.45, p < 0.05). Conclusions: HR, RR, SCR/s and NIDCAP® behaviors significantly increased during care. NIDCAP® stress behaviors were influenced by the severity of illness of the infant, while SCR/s was not influenced by severity of illness.

Heightened sympathetic arousal is demonstrated by skin conductance responsivity to auditory stimuli in a small cohort of neonates with opiate withdrawal

To determine the effects of auditory stimulus on skin conductance (SC) in infants with severe neonatal abstinence syndrome (NAS) that required morphine treatment (MT) compared with NAS infants that did not require morphine treatment (non-MT). We prospectively enrolled opiate-exposed term infants without polysubstance exposure. Skin conductance responses to an auditory stimulus (ringing a bell for 3s) near the time of discharge were obtained. Skin conductance was measured before, during, and after the stimulus. Non-parametric tests were used to determine between group and within phase differences. Infants were off MT at the time of SC measurement in response to an auditory stimulus. In a 2-group comparison of MT vs. non-MT infants, there was significantly higher SC responsivity to an auditory stimulus (p <0.05) in the MT group as compared with the non-MT group near discharge. The mean +SE peak morphine dose was 0.85+0.20mg/kg/day in the MT group. The mean Length of Stay (LOS) was 32 vs. 7 (p <0.05) days respectively, for the MT vs. the non-MT group. Our preliminary data suggest that in infants with severe NAS symptoms, higher sympathetic arousal in response to an auditory stimulus persists at discharge, underscoring the need for ongoing evaluation and specialized care at home.

Electrical Grounding Improves Vagal Tone in Preterm Infants

Background: Low vagal tone (VT) is a marker of vulnerability to stress and the risk of developing necrotizing enterocolitis in preterm infants. Electric fields produced by equipment in the neonatal intensive care unit (NICU) induce an electric potential measurable on the skin in reference to ground. An electrical connection to ground reduces the skin potential and improves VT in adults. Objectives: We aimed to measure the electric field strengths in the NICU environment and to determine if connecting an infant to electrical ground would reduce the skin potential and improve VT. We also wished to determine if the skin potential correlated with VT. Methods: Environmental magnetic flux density (MFD) was measured in and around incubators. Electrical grounding (EG) was achieved with a patch electrode and wire that extended to a ground outlet. We measured the skin potential in 26 infants and heart rate variability in 20 infants before, during, and after grounding. VT was represented by the high-frequency power of heart rate variability. Results: The background MFD in the NICU was below 0.5 mG, but it ranged between 1.5 and 12.7 mG in the closed incubator. A 60-Hz oscillating potential was recorded on the skin of all infants. With EG, the skin voltage dropped by about 95%. Pre-grounding VT was inversely correlated with the skin potential. VT increased by 67% with EG. After grounding, the VT fell to the pre-grounding level. Conclusion: The electrical environment affects autonomic balance. EG improves VT and may improve resilience to stress and lower the risk of neonatal morbidity in preterm infants.

Exploring Preterm Mothers' Personal Narratives: Influences and Meanings

In this article we report on a study exploring personal narratives of mothers of former preterm infants and the attributed meaning related to that experience over time. Using narrative inquiry as the research method, in-depth, unstructured interviews were conducted with 6 preterm mothers. Findings reveal that a preterm mothers experience is informed by contextual, intrapersonal, and interpersonal dynamics, some predating the birth often with effects that continue for years beyond it. By learning a preterm mothers unique experience and its attributed meaning, nurses can better understand the resulting effect on maternal/family health and well-being and tailor nursing interventions accordingly.

Stress Adaptation Upregulates Oxytocin within Hypothalamo-Vagal Neurocircuits

Stress plays a pivotal role in the development and/or exacerbation of functional gastrointestinal (GI) disorders. The paraventricular nucleus of the hypothalamus (PVN) contains neurons that are part of the hypothalamic-pituitary-adrenal axis as well as preautonomic neurons innervating, among other areas, gastric-projecting preganglionic neurons of the dorsal vagal complex (DVC). The aim of the present study was to test the hypothesis that stress adaptation upregulates oxytocin (OXT) within PVN-brainstem vagal neurocircuitry. The retrograde tracer cholera toxin B (CTB) was injected into the DVC of rats which, after post-surgical recovery, were pair-housed and exposed to either homo- or heterotypic stress for five consecutive days. Fecal pellets were counted at the end of each stress load. Two hours after the last stressor, the whole brain was excised. Brainstem and hypothalamic nuclei were analyzed immunohistochemically for the presence of both OXT-immunopositive cells in identified preautonomic PVN neurons as well as OXT fibers in the DVC. Rats exposed to chronic homotypic, but not chronic heterotypic stress, had a significant increase in both number of CTB+ OXT co-localized neurons in the PVN as well as density of OXT-positive fibers in the DVC compared to control rats. These data suggest that preautonomic OXT PVN neurons and their projections to the DVC increase following adaptation to stress, and suggest that the possible up-regulation of OXT within PVN-brainstem vagal neurocircuitry may play a role in the adaptation of GI responses to stress.