Kimberly A. Allen

Promoting and protecting infant sleep.

Sleep is essential to brain development and maturation in infants.1 Infants require extensive sleep for further development of the neurosensory systems; structural development of the hippocampus, pons, brainstem, and midbrain;2 and optimizing physical growth.3 Protecting infant sleep is a critical component of providing developmentally appropriate care for premature and full-term infants in the neonatal intensive care unit (NICU) because many of these infants are hospitalized during one of the most critical periods of brain development.4 To best provide developmentally appropriate care, identification of sleep-wake states is necessary.

Premedication for Neonatal Intubation: Which Medications are Recommended and Why?

Three decades ago, few scientists and health care providers believed infants and young children were able to localize and/or perceive painful stimuli.1 This assumption that infants and children did not feel pain led to infants undergoing surgical and other painful procedures (e.g., lumbar puncture, endotracheal intubation) without any medication for pain and anxiety.2 This assumption has now been proven to be untrue. Today, infants routinely receive analgesia and sedation for surgical procedures in the operating room, but the extent to which infants routinely receive medication for other painful procedures varies. A common, painful procedure for critically ill neonates is endotracheal intubation;3 however the administration of medications prior to intubation varies substantially. In the most recent survey from 2006 in the United States,4 only 44% of neonatology fellowship program directors reported routine use of analgesia and/or sedation before intubation. A survey of neonatal intensive care units (NICU) in the United Kingdom in 2009 reported that 90% of the units routinely administered premedication prior to elective intubations.5 Intubation can cause traumatic injury to the airway,6 as well as lead to physiologic instability during the procedure.7, 8 Despite the possible negative impact of intubation, the procedure is often necessary and many times life saving. Critically ill neonates are often intubated nonemergently in the NICU due to prematurity, need for prolonged ventilation, endotracheal tube change, or an unstable airway.9 In 2010, the American Academy of Pediatrics (AAP)10 recommended premedication be used for all intubations in neonates, except in the case of emergent intubation during resuscitation. The goal of premedication is to eliminate pain, discomfort, traumatic injury to the airway, and physiologic instability (e.g., bradycardia, hypotension/hypertension, decreased oxygen saturation) associated with endotracheal intubation procedure.10 To implement this recommendation in the NICU, written policies are needed to guide health care providers. However, the previous surveys found that the number of NICUs with written policies on premedication ranged from ‘few’ to 75% of units.4, 5 It is ideal when clinical pharmacists, neonatologists, and neonatal nurse practitioners work together in the design of premedication policies.11 However, since nurses often administer medications and act as advocates for their vulnerable patient; nurses also can also lead the way in collaborative policy development based on empirical evidence. Written policies when available and followed have the potential to reduce medication errors and improve the quality of care within the NICU. Therefore, the purpose of this integrated review is to explore current research evidence on medication(s) utilized for nonemergent intubation in preterm and term neonates. PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and the Cochrane database were searched to obtain English language publications from 1990 to November 2011. The year 1990 was chosen because this is when the health care literature began conducting clinical trials on patients receiving procedural sedation and analgesia.2 The inclusion criteria were clinical studies using medication(s) prior to neonatal (≤ 28 days of life) intubation. Studies were excluded if the average age of the participants was greater than 28 days of life, did not include humans, medications were no longer available in the United States, single case reports of infants with abnormal facies or rare diseases, and trials that focused on anesthetic gases due to lack of feasibility in the NICU. Sixteen studies met the inclusion criteria and included 436 neonates. The findings were organized by the classification of the medications administered (vagolytic agents, analgesia, sedation, and neuromuscular blocking agents) with advantages and disadvantages explained and current AAP recommendations and rationale provided. See Table 1 for a summary of medications utilized for premedication in nonemergent intubation. Table 1 Medications for Premedication for Nonemergent Intubation

Music Therapy in the Nicu: Is There Evidence to Support Integration for Procedural Support?

Optimizing physical and neurologic developmental goals are critical as many premature infants will survive throughout the neonatal intensive care period into childhood and adulthood. Receiving highly-technical and complex care in the neonatal intensive care unit (NICU) may cause harm through multiple factors that stress the immature physiology of the infant including exposing the infant to touch for assessments and invasive interventions often causing physiologic distress. Physical assessments and interventions are potential stressors that can change the stability of the infant leading to changes in vital signs1 that may require additional interventions to prevent further hypoxia and hypotension. If the hypoxia and hypotension continue, injury to the cerebral tissue may occur leading to alterations in the neurological system that may negatively affect short and long-term outcomes. Neuroprotective strategies to ameliorate the negative effects of stressors on the physiologic stability of the premature infant must be explored to prevent further consequences to these fragile infants.2 Music therapy is an emerging intervention that may help stabilize the negative physiologic changes during exposure to stressors in the NICU. Therefore, the purpose of this review was to determine what evidence exists to support the use of music therapy in the NICU during stressful events (e.g., endotracheal suctioning). This use of music therapy is different from music used on a short-term or continuous basis in the NICU, this review only examined the use of music therapy as adjunctive to procedures with preterm infants.

Moderate Hypothermia: Is Selective Head Cooling or Whole Body Cooling Better?

Hypoxic ischemic encephalopathy (HIE) is one of the most serious birth complications affecting full term infants1 occurring in 1.5 to 2.5 per 1000 live births. 2, 3 HIE results in a brain injury from a hypoxic-ischemic event during the prenatal, intrapartum, or postnatal period preventing adequate blood flow to the infants brain.4 Infants with HIE experience associated morbidities and a significant mortality rate with 40-83% not surviving past 2 years of age or having severe disabilities.5-7 The long-term neurological consequences of HIE include mental retardation, epilepsy, and cerebral palsy.7

Pathophysiology and treatment of severe traumatic brain injuries in children

ABSTRACT:Traumatic brain injuries (TBIs) in children are a major cause of morbidity and mortality worldwide. Severe TBIs account for 15,000 admissions annually and a mortality rate of 24% in children in the United States. The purpose of this article is to explore pathophysiologic events, examine monitoring techniques, and explain current treatment modalities and nursing care related to caring for children with severe TBI. The primary injury of a TBI is because of direct trauma from an external force, a penetrating object, blast waves, or a jolt to the head. Secondary injury occurs because of alterations in cerebral blood flow, and the development of cerebral edema leads to necrotic and apoptotic cellular death after TBI. Monitoring focuses on intracranial pressure, cerebral oxygenation, cerebral edema, and cerebrovascular injuries. If abnormalities are identified, treatments are available to manage the negative effects caused to the cerebral tissue. The mainstay treatments are hyperosmolar therapy; temperature control; cerebrospinal fluid drainage; barbiturate therapy; decompressive craniectomy; analgesia, sedation, and neuromuscular blockade; and antiseizure prophylaxis.

Parent and Provider Decision-Making for Infants with Hypoxic-Ischemic Encephalopathy

Background: Hypoxic ischemic encephalopathy (HIE) is one of the most serious complications of full term birth that can lead to long-term neurological consequences or death. Parents and providers are faced with making complex decisions about which therapies to pursue within hours of birth. Purpose: The purpose of this study was to describe the decisions made for infants with HIE, who participated in the decision-making process, and what factors influenced the decision-making process. Design: A longitudinal, prospective, multiple case study design was used to study infant illness trajectories and parental responses (parental distress and hope) associated with caring for infants with HIE. Results: Two groups of parent decision-making emerged: standard care and experimental care. The decisionmaking groups appear to be dictated by the treatment the infants received within hours of birth. Parents within each group shared specific responses including similar hope and distress, which continued over the first 2 postnatal months. Conclusions: The results indicate that the type of medical therapy the infant receives determines the level of parental participation in decision-making. In the group of parents, in which providers obtained consent for study interventions parents had less hope for their infant even though the infant had a lower severity of illness compared to the infants receiving standard therapies. The reverse was true for parents of infants receiving standard therapy, parents were more hopeful even though their infants had a higher severity of illness.

The Risks and Benefits of Conducting Sensitive Research to Understand Parental Experiences of Caring for Infants With Hypoxic-Ischemic Encephalopathy.

ABSTRACT Aim: The aim of this report is to describe the parental experience of the emotional and physical risks and participant burden of participation in sensitive research about caring for an infant with hypoxic–ischemic encephalopathy. Background: Protecting the ethical rights of participants in research is a main focus of investigators. Evaluating the effect of current methods employed to protect participants in sensitive research is necessary to determine if the participants’ ethical rights are protected. Little research has addressed the parental perspective of participating in sensitive research. Design: The design of this study is a qualitative, descriptive methodology with structured interviews with parents. Methods: Participants were asked to describe their experience of participating in sensitive research. The qualitative data collected were analyzed using content analysis. Interviews were conducted between July 2010 and February 2012. Results: Thirteen parents of infants with hypoxic–ischemic encephalopathy were interviewed. Parents did not report harm or participant burden. Most of these parents found continued participation to be beneficial because they could express intense emotions in a nonjudgmental environment and also reflect on the milestones their child has reached since the traumatic birth experience. Conclusions: This study provides additional evidence to researchers regarding the risks and benefits to participants in sensitive research studies. Individuals are willing to participate in sensitive research, even during stressful times in their lives. The interviews allow participants an outlet to discuss thoughts and feelings and to reflect on past events and gain perspective. Participants do not report experiencing harm when participating in interviews about sensitive research.