The increased survival of preterm and very low birth weight infants in recent years has been well documented but continued surveillance is required in order to monitor the effects of new therapeutic interventions. Gestation and birth weight specific survival rates most accurately reflect the outcome of perinatal care. Our aims were to determine survival to discharge for a large Canadian cohort of preterm infants admitted to the neonatal intensive care unit (NICU), and to examine the effect of gender on survival and the effect of increasing postnatal age on predicted survival.
Outcomes for all 19,507 infants admitted to 17 NICUs throughout Canada between January 1996 and October 1997 were collected prospectively. Babies with congenital anomalies were excluded from the study population. Gestation and birth weight specific survival for all infants with birth weight
Multiple researchers have validated indicators and measures of infant pain. However, infants at risk for neurologic impairment (NI) have been under studied. Therefore, whether their pain responses are similar to those of other infants is unknown. Pain responses to heel lance from 149 neonates (GA>25-40 weeks) from 3 Canadian Neonatal Intensive Care units at high (Cohort A, n=54), moderate (Cohort B, n=45) and low (Cohort C, n=50) risk for NI were compared in a prospective observational cohort study. A significant Cohort by Phase interaction for total facial action (F(6,409)=3.50, p=0.0022) and 4 individual facial actions existed; with Cohort C demonstrating the most facial action. A significant Phase effect existed for increased maximum Heart Rate (F(3,431)=58.1, p=0.001), minimum Heart Rate (F(3,431)=78.7, p=0.001), maximum Oxygen saturation (F(3,425)=47.6, p=0.001), and minimum oxygen saturation (F(3,425)=12.2, p=0.001) with no Cohort differences. Cohort B had significantly higher minimum (F(2,79)=3.71, p=0.029), and mean (F(2,79)=4.04, p=0.021) fundamental cry frequencies. A significant Phase effect for low/high frequency Heart Rate Variability (HRV) ratio (F(2,216)=4.97, p=0.008) was found with the greatest decrease in Cohort A. Significant Cohort by Phase interactions existed for low and high frequency HRV. All infants responded to the most painful phase of the heel lance; however, infants at moderate and highest risk for NI exhibited decreased responses in some indicators.
The primary purpose was to determine the underlying structure of the vulnerable infant's response to an acute painful procedure. The secondary purpose was to explore the influence of context (e.g., risk for neurological impairment [NI] and gestational age [GA]). A descriptive cohort design determined contributions of selected indicators to the structure of infant pain. The magnitude of variance for 19 pain indicators was assessed using 3 exploratory factor analyses in 149 neonates. The basic exploratory factor structure included behavioural (e.g., facial actions) and physiological (e.g., oxygen saturation, heart rate) indicators. Facial actions accounted for the greatest variance across all factor solutions (29-39%). Physiological indicators explained 8 to 26% additional variance. There were no consistent differences in the factor structures when contextual factors were explored.
Faculty of Nursing and Maternal-Child Nursing Research Unit, Centre for Research in Women's Health, University of Toronto, 50 St George St, Toronto, Ontario, Canada M5S 3H4. ellen.hodnett@utoronto.ca
North American cesarean delivery rates have risen dramatically since the 1960s, without concomitant improvements in perinatal or maternal health. A Cochrane Review concluded that continuous caregiver support during labor has many benefits, including reduced likelihood of cesarean delivery.
To evaluate the effectiveness of nurses as providers of labor support in North American hospitals.
Randomized controlled trial with prognostic stratification by center and parity. Women were enrolled during a 2-year period (May 1999 to May 2001) and followed up until 6 to 8 postpartum weeks.
Thirteen US and Canadian hospitals with annual cesarean delivery rates of at least 15%.
A total of 6915 women who had a live singleton fetus or twins, were 34 weeks' gestation or more, and were in established labor at randomization.
Patients were randomly assigned to receive usual care (n = 3461) or continuous labor support by a specially trained nurse (n = 3454) during labor.
The primary outcome measure was cesarean delivery rate. Other outcomes included intrapartum events and indicators of maternal and neonatal morbidity, both immediately after birth and in the first 6 to 8 postpartum weeks.
Data were received for all 6915 women and their infants (n = 6949). The rates of cesarean delivery were almost identical in the 2 groups (12.5% in the continuous labor support group and 12.6% in the usual care group; P =.44). There were no significant differences in other maternal or neonatal events during labor, delivery, or the hospital stay. There were no significant differences in women's perceived control during childbirth or in depression, measured at 6 to 8 postpartum weeks. All comparisons of women's likes and dislikes, and their future preference for amount of nursing support, favored the continuous labor support group.
In hospitals characterized by high rates of routine intrapartum interventions, continuous labor support by nurses does not affect the likelihood of cesarean delivery or other medical or psychosocial outcomes of labor and birth.
Notes
Comment In: JAMA. 2003 Jan 8;289(2):175-6; author reply 17612517223
To determine whether healthcare professionals perceive the pain of infants differently due to their understanding of that infant's level of risk for neurological impairment.
Neonatal Intensive Care Units (NICU's) at two tertiary pediatric centers. Ninety-five healthcare professionals who practice in the NICU (50 nurses, 19 physicians, 17 respiratory therapists, 9 other) participated. They rated the pain (0-10 scale and 0-6 Faces Pain Scale), distress (0-10), effectiveness of cuddling to relieve pain (0-10) and time to calm without intervention (seconds) for nine video clips of neonates receiving a heel stick. Prior to each rating, they were provided with descriptions that suggested the infant had mild, moderate or severe risk for neurological impairment. Ratings were examined as a function of the level of risk described.
Professionals' ratings of pain, distress, and time to calm did not vary significantly with level of risk, but ratings of the effectiveness of cuddling were significantly lower as risk increased [F (2,93) = 4.4, p = .02]. No differences in ratings were found due to participants' age, gender or site of study. Physicians' ratings were significantly lower than nurses' across ratings.
Professionals provided with visual information regarding an infants' pain during a procedure did not display the belief that infants' level of risk for neurological impairment affected their pain experience. Professionals' estimates of the effectiveness of a nonpharmacological intervention did differ due to level of risk.
To examine whether admission hospital type (13 perinatal centers vs 4 freestanding pediatric hospitals) was associated with differences in risk and illness severity adjusted mortality and morbidity among outborn preterm infants.
We developed and tested a new method, called the Evidence-based Practice for Improving Quality method, for continuous quality improvement.
We used cluster randomization to assign 6 neonatal intensive care units (ICUs) to reduce nosocomial infection (infection group) and 6 ICUs to reduce bronchopulmonary dysplasia (pulmonary group). We included all infants born at 32 or fewer weeks gestation. We collected baseline data for 1 year. Practice change interventions were implemented using rapid-change cycles for 2 years.
The difference in incidence trends (slopes of trend lines) between the ICUs in the infection and pulmonary groups was - 0.0020 (95% confidence interval [CI] - 0.0007 to 0.0004) for nosocomial infection and - 0.0006 (95% CI - 0.0011 to - 0.0001) for bronchopulmonary dysplasia.
The results suggest that the Evidence-based Practice for Improving Quality method reduced bronchopulmonary dysplasia in the neonatal ICU and that it may reduce nosocomial infection.
Notes
Cites: Pediatrics. 2000 Nov;106(5):1070-911061777
Cites: JAMA. 2008 Mar 12;299(10):1182-418334694
Cites: Pediatrics. 2001 Jan;107(1):14-2211134428
Cites: J Pediatr. 2001 Jan;138(1):92-10011148519
Cites: J Pediatr. 2001 Apr;138(4):525-3111295716
Cites: CMAJ. 2002 Jan 22;166(2):173-811826939
Cites: J Perinatol. 2002 Jan;22(1):26-3011840239
Cites: Pediatr Infect Dis J. 2002 Jun;21(6):505-1112182373
Cites: BMJ. 2004 Oct 30;329(7473):100415514344
Cites: Ann Surg. 1978 Jan;187(1):1-7413500
Cites: Pediatrics. 1984 Jul;74(1):127-336547526
Cites: Am J Infect Control. 1988 Jun;16(3):128-402841893
Cites: Pediatrics. 1988 Oct;82(4):527-323174313
Cites: Lancet. 1993 Jul 24;342(8865):193-88100927
Cites: Qual Manag Health Care. 1992 Fall;1(1):65-7410131648
Cites: JAMA. 1996 Mar 20;275(11):841-68596221
Cites: Jt Comm J Qual Improv. 1998 Mar;24(3):119-299568552
This paper is a report of a study to compare the importance and usefulness ratings of physiological and behavioural indicators of pain in neonates at risk for neurological impairment by nurse clinicians and pain researchers.
Neonates at risk for neurological impairment have not been systematically included in neonatal pain measure development and how clinicians and researchers view pain indicators in these infants is unknown.
Data triangulation was undertaken in three Canadian Neonatal Intensive Care Units using data from: (a) 149 neonates at high, moderate and low risk for neurological impairment, (b) 95 nurse clinicians from the three units where infant data were collected and (c) 14 international pain researchers. Thirteen indicators were assessed following heel lance in neonates and 39 indicators generated from nurse clinicians and pain researchers were assessed for importance and accuracy. Data were collected between 2004 and 2005.
Across risk groups, indicators with the highest accuracy for discriminating 'pain' among neonates were: brow bulge (77-83%), eye squeeze (75-84%), nasolabial furrow (79-81%), and total facial expression (78-83%). Correlations between nurse ratings and neonatal accuracy scores ranged from moderate to none (mild risk r = 0.52, P = 0.07; moderate r = 0.43, P = 0.15; high r = -0.12, P = 0.69). Researchers demonstrated a better understanding of the importance of pain indicators (mild risk, r = 0.91, P
To describe how (i) risk of neurological impairment (NI) and (ii) procedure invasiveness influence health professionals' assessment and management of procedural pain in neonates in the Neonatal Intensive Care Unit (NICU).
Prospective observational study.
Three tertiary level NICUs in Canada.
114 neonates, 25-40 weeks gestational age (GA) undergoing painful procedures.
Physical and behavioural pain indicators and pharmacological and nonpharmacological pain interventions.
114 neonates at high (Cohort A, n=35), moderate (Cohort B, n=25) and low (Cohort C, n=54) risk of NI were observed during 254 painful procedures performed by 147 health professionals. Physical pain indicators were used more frequently by health professionals to assess pain with Cohorts A and B than C (pA, B>C, p
The incidence of intraventricular hemorrhage (IVH), adjusted for known risk factors, varies across neonatal intensive care units (NICU)s. The effect of NICU characteristics on this variation is unknown. The objective was to assess IVH attributable risks at both patient and NICU levels.
