Patricia J. Johnson

The history of the neonatal nurse practitioner: reflections from "under the looking glass".

The neonatal nurse practitioner (NNP) emerged in the 1970s. During the first two decades, nurses who functioned in this new advanced-practice role were forced to overcome interprofessional isolation, variable educational preparation, underutilization, and title ambiguity. However, after nearly 30 years of evolution influenced by the changing health care environment, technological advancements in newborn care, medical personnel shortages, and the advanced-practice nurse movement, the NNP is now a recognized member of the neonatal health care team nationwide. The NNP has achieved the level of provider status, but only after successfully overcoming many practice restrictions and restraints over the decades. This article chronicles the history of the NNP and recounts the external and internal elements that contributed to the development of this profession.

Caffeine citrate therapy for apnea of prematurity.

CA F F E I N E I S A D R U G commonly used in the neonatal intensive care unit. Given its frequent use, providers need to be well informed of the drug, its indications, mechanism of action, and pharmacokinetics. Caffeine has an important history of skeptics and variable practice preference, ultimately leading to fairly new evidence supporting its pharmacologic attributes for treatment of apnea of prematurity (AOP). Caffeine is also used to stimulate preextubation respiratory drive in the nursery and following anesthesia.1,2 The purpose of this column is to review the history of methylxanthine therapy as a treatment for AOP, examine the benefits of caffeine citrate (Cafcit®) as the methylxanthine of choice, including the pharmacology and pharmacokinetics of the drug, and review the current evidence-based practice for the use of Cafcit® in the treatment of AOP. AOP is a self-resolving disorder of developmental immaturity, but it has potential for serious clinical consequences including an increased risk of neurodevelopmental impairment.3,4 AOP, occurring in infants less than 37 weeks gestation, is defined as the cessation of breathing for greater than 20 seconds or cessation of breathing for 15 seconds, with associated bradycardia or cyanosis.5–8 The reported incidence of AOP varies, but it is clearly inversely related to gestational age. The incidence is 25 percent in newborns less than 2,500 g or those 34 weeks gestation at birth; but in newborns less than 34 weeks gestation, the incidence increases from 35 percent to as frequent as 85 percent depending on gestation. Ninety percent of the extremely low birth weight newborn population, less than 1,000 g, are reported to have AOP.6,9–11 AOP is a diagnosis of exclusion with no definitive diagnostic test beyond its observed occurrence. Alternative causes of AOP such as central nervous system (CNS) disorders, primary lung disease, anemia, sepsis, metabolic disturbances, cardiovascular abnormalities, or airway obstruction should be ruled out.5

Hydrocortisone for Treatment of Hypotension in the Newborn.

ABSTRACT Newborns, and especially premature newborns, are at significant risk for developing hypotension in the first week or two after birth. The etiology of hypotension in the newborn may vary, but the very low birth weight and extremely low birth weight preterm infants are less likely to respond to conventional cardiovascular support when they develop hypotension. This article reviews the least conventional treatment using hydrocortisone for hypotension that is refractory to conventional volume replacement and/or vasopressor medications with the underlying assumption that sick and premature newborns have a relative or measured adrenal insufficiency. The addition of hydrocortisone in the treatment of hypotension in the newborn is becoming more common but is not universally advocated. However, the supportive evidence is growing, and, as reviewed, use of hydrocortisone requires judicious and cautious regard.

Review of macronutrients in parenteral nutrition for neonatal intensive care population.

Parenteral nutrition (PN) has become essential in the management of sick and growing newborn populations in the NICU. In the past few decades, PN has become fundamental in the nutritional management of the very low birth weight infant (<1,500 g).1 Although the components in PN are commonly determined and ordered by the physician or neonatal nurse practitioner provider, the NICU nurse is responsible for confirming the components in the daily PN prior to infusion and is responsible for maintaining the infusion of PN. Nurses should understand the nutritional components of PN as well as the indications, side effects, and infusion limitations of each component. The purpose of this article is to review the macronutrients in PN, including carbohydrates, protein, and fat. A subsequent article will review the micronutrients in PN, including electrolytes, minerals, and vitamins.

Antibiotic resistance in the NICU.

Antimicrobial treatment is a mainstay therapy in the neo-natal intensive care unit (NICU). Given the lack of specificity for clinical symptoms of infection in the newborn and the overwhelming impact of infection with rapid multisystem dissemination, NICU providers tend to treat early while awaiting laboratory results. With the high vulnerability of our special population to a variety of potential infecting microbes, a combination of antibiotics is preferred for initial treatment. The selection of these antibiotics is based on the known or presumed environment of exposure. If the newborn is within a week of birth, we can reasonably expect the likely environment of exposure is the community or the mother. If the newborn is older or has undergone numerous procedures, we can presume the exposure is more likely to be hospital-based.

Sodium bicarbonate use in the treatment of acute neonatal lactic acidosis: benefit or harm?

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Normal saline bolus infusion for hypoperfusion in the newborn.

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The ongoing drug shortage problem affecting the NICU.

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The DNP* storm.

I DON’T REMEMBER THIS LEVEL OF PASSIONATE DISAGREEMENT over a nursing role since the birth of the neonatal nurse practitioner/clinician in the 1970s. At that time, a handful of nurse and physician visionaries saw the merits of advancing nursing practice in an acute setting; but most leaders in both organized nursing and medicine objected to the role’s potential to blur traditional professional lines.

Vitamin K prophylaxis in the newborn: indications and controversies.

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