Leslie A. Parker

Elevated sound levels within a busy NICU.

Purpose: Elevated sound levels in the NICU may contribute to undesirable physiologic and behavioral effects in preterm infants. This study describes sound levels in a busy NICU in the southeastern U.S. and compares the findings with recommended NICU noise level standards. Design: NICU sound levels were recorded continuously at nine different locations within the NICU. Hourly measurements of loudness equivalent (Leq) sound level, sound level exceeded 10 percent of the time (L10), and maximum sound level (Lmax) were determined. Sample: Sound levels were sampled from nine different locations within the NICU. Main Outcome Variable: Sound levels are described using the hourly, A-weighted Leq, L10, and Lmax. Results: The overall average hourly Leq (M = 60.44 dB, range = 55–68 dB), L10 (M = 59.26 dB, range = 55–66 dB), and Lmax (M = 78.39, range = 69–93 dB) were often above the recommended sound levels (hourly Leq <50 dB, L10 <55 dB, and 1-second Lmax <70 dB). In addition, certain times of day, such as 6–7 AM and 10 AM–12 noon, were noisier than other times of day.

Effect of early breast milk expression on milk volume and timing of lactogenesis stage II among mothers of very low birth weight infants: a pilot study

Objective:The purpose of this randomized pilot study was to collect preliminary data regarding the feasibility and effects of early initiation of milk expression on the onset of lactogenesis stage II and milk volume in mothers of very low birth weight (VLBW) infants.Study Design:Twenty women were randomized to initiate milk expression within 60 min (group 1) or 1 to 6 h (group 2) following delivery. Milk volume and timing of lactogenesis stage II was compared between groups using Wilcoxons rank sum tests.Result:Group 1 produced statistically significantly more milk than group 2 during the first 7 days (P=0.05) and at week 3 (P=0.01). Group 1 also demonstrated a significantly earlier lactogenesis stage II (P=0.03).Conclusion:Initiation of milk expression within 1 h following delivery increases milk volume and decreases time to lactogenesis stage II in mothers of VLBW infants.

Part 1: early recognition and treatment of birth trauma: injuries to the head and face.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Sentinel Event Alert from July 21, 2004 states that there have been 47 cases of birth trauma–related perinatal death or permanent disability reported for JCAHO review since 1996. This report clearly illustrates the importance of birth trauma in clinical practice for neonatal and perinatal nurses. Estimates suggest that birth trauma occurs in 2% to 7% of all deliveries and is associated with an increase in both mortality and morbidity. Birth trauma to the head may result in minor superficial extracranial injuries, such as caput succedaneum and cephalohematoma, or more serious and potentially life threatening lesions such as subgaleal hemorrhages. The potential for deeper intracranial injury, such as subarachnoid or subdural hemorrhage exists; these may be isolated or associated with skull fractures and/or other extracranial injuries. Injury to the eye, nasal structures, and paralysis of the vocal cords may also result from birth trauma during a difficulty delivery. Part 1 of this 2-part article will focus on birth injuries to the head and face. Part 2 of the series will review more systemic birth injuries that may involve abdominal organs, the spine and skeletal system, and peripheral and facial nerves.

Maternal voice and short-term outcomes in preterm infants.

This study explored effects of exposure to maternal voice on short-term outcomes in very low birth weight preterm infants cared for within an neonatal intensive care unit (NICU) without an ongoing program of developmental care. Using a comparative design, 53 infants born during their 27th to 28th postmenstrual week were sampled by convenience. Experimental groups were exposed to maternal voice during two developmental time periods. Group 1 listened to a recording of their mothers reciting a rhyme from 28 to 34 postmenstrual weeks. Group 2 waited 4 weeks and heard the recording from 32 to 34 weeks. The control group received routine care. The primary analysis of combined experimental groups compared to the control group revealed that the experimental infants experienced significantly fewer episodes of feeding intolerance and achieved full enteral feeds quicker compared to the control group. Further, in an analysis evaluating all three groups separately, it was noted that Group 1 experienced significantly fewer episodes of feeding intolerance compared to the control group. Study findings warrant further investigation of exposure to maternal voice and the developmental timing at which exposure is begun.

Neonatal intensive care unit sound levels before and after structural reconstruction.

PurposeThis study compared sound levels before and after structural reconstruction within an NICU. Study Design and MethodsUsing a descriptive design, sound level recordings (in decibels, A-weighted scale) of the Leq, L10, and Lmax were measured continuously for 8 hours (0600-1400) before and after reconstruction in an NICU located in north central Florida. ResultsLevels before reconstruction were Leq M = 60.44 dB, L10 M = 59.26 dB, and Lmax M = 78.39 dB. The average overall sound levels after reconstruction were Leq M = 56.4 dB, L10 M = 60.6 dB, and LmaxM = 90.6 dB. Although an approximate 4-decibel decrease in the Leq sound level after reconstruction was noted, a similar decrease in the L10 and Lmax did not occur. Furthermore, sound levels after reconstruction in the NICU still exceeded recommended levels (Leq < 50 dB, L10 < 55 dB, and Lmax < 70 dB). Clinical ImplicationsFindings from this study demonstrated the positive impact that reconstruction can have on sound levels (4 dB Leq decrease); however, additional interventions may be needed to meet the current standards for noise reduction in an NICU.

Gastric Residual Evaluation in Preterm Neonates: A Useful Monitoring Technique or a Hindrance?

It is routine practice in most neonatal intensive care units to measure the volume and color of gastric residuals (GRs) prior to enteral bolus feedings in preterm very low birth weight infants. However, there is paucity of evidence supporting the routine use of this technique. Moreover, owing to the lack of uniform standards in the management of GRs, wide variations exist as to what constitutes significant GR volume, the importance of GR color and frequency of GR evaluation, and the color or volume standards that dictate discarding or returning GRs. The presence of large GR volumes or green-colored residuals prior to feeding often prompts subsequent feedings to be withheld or reduced because of possible necrotizing enterocolitis resulting in delays in enteral feeding. Cessation or delays in enteral feeding may result in extrauterine growth restriction, a known risk factor for poor neurodevelopmental and growth outcomes in preterm very low birth weight infants. Although some neonatal intensive care units are abandoning the practice of routine GR evaluation, little evidence exists to support the discontinuation or continuation of this practice. This review summarizes the current state of GR evaluation and underlines the need for a scientific basis to either support or refute the routine evaluation of GRs.

Part 2: Birth trauma: injuries to the intraabdominal organs, peripheral nerves, and skeletal system.

Part 1 of this 2-part article, “Early Recognition and Treatment of Birth Trauma: Injuries to the Head and Face” provided readers with basic concepts related to birth trauma to the head and face. Part 2 focuses on the pathophysiology, etiology, diagnosis, treatment, and prognosis of birth injuries to the intraabdominal organs, the peripheral nerves, the spinal cord, and the skeletal system. Risk factors for birth injury to these areas are discussed along with key issues related to the nursing care of affected infants.

The value of routine evaluation of gastric residuals in very low birth weight infants

Objective:Little information exists regarding gastric residual (GR) evaluation prior to feedings in premature infants. The purpose of this study was to compare the amount of feedings at 2 and 3 weeks of age, number of days to full feedings, growth and incidence of complications between infants who underwent RGR (routine evaluation of GR) evaluation versus those who did not.Study Design:Sixty-one premature infants were randomized to one of two groups. Group 1 received RGR evaluation prior to feeds and Group 2 did not.Result:There was no difference in amount of feeding at 2 (P=0.66) or 3 (P=0.41) weeks of age, growth, days on parenteral nutrition or complications. Although not statistically significant, infants without RGR evaluation reached feeds of 150 ml kg−1 per day 6 days earlier and had 6 fewer days with central venous access.Conclusion:Results suggest RGR evaluation may not improve nutritional outcomes in premature infants.

Kangaroo care for adoptive parents and their critically ill preterm infant

In this case study kangaroo care (KC) was facilitated for an adoptive mother and father who were planning to attend the birth of the infant they had arranged to adopt. Unexpectedly, the birth mother delivered at 27 weeks gestation. The infant was critically ill and required mechanical ventilation. However, in this neonatal intensive care unit where all adoptive parents and parents of mechanically ventilated infants are offered KC, these adoptive parents began KC on Day 3 while their infant daughter was still mechanically ventilated. She thrived thereafter and the entire experience was profoundly beneficial for this beginning family both at the hospital and after discharge home.

Aspiration and evaluation of gastric residuals in the neonatal intensive care unit: state of the science.

The routine aspiration of gastric residuals (GR) is considered standard care for critically ill infants in the neonatal intensive care unit (NICU). Unfortunately, scant information exists regarding the risks and benefits associated with this common procedure. This article provides the state of the science regarding what is known about the routine aspiration and evaluation of GRs in the NICU focusing on the following issues: (1) the use of GRs for verification of feeding tube placement, (2) GRs as an indicator of gastric contents, (3) GRs as an indicator of feeding intolerance or necrotizing enterocolitis, (4) the association between GR volume and ventilator-associated pneumonia, (5) whether GRs should be discarded or refed, (6) the definition of an abnormal GR, and (7) the potential risks associated with aspiration and evaluation of GRs. Recommendations for further research and practice guidelines are also provided.