Partera, Disparities, Clinical Pearl


Rank: 111 –Rate: 9%  Estimated # of preterm births per 100 live births (USA – 12 %, Global Average: 11.1%)

Bolivia, officially the Plurinational State of Bolivia, is a landlocked country located in western-central South America. The constitutional capital is Sucre, while the seat of government and executive capital is La Paz. The largest city and principal industrial center is Santa Cruz de la Sierra, located on the Llanos Orientales (tropical lowlands), a mostly flat region in the east of the country.

The country’s population, estimated at 11 million, is multiethnic, including AmerindiansMestizosEuropeansAsians, and AfricansSpanish is the official and predominant language, although 36 indigenous languages also have official status, of which the most commonly spoken are GuaraniAymara, and Quechua languages.

Modern Bolivia is a charter member of the UNIMFNAMOASACTOBank of the SouthALBA, and USAN. Bolivia remains the second poorest country in South America, though it has slashed poverty rates and has the fastest growing economy in South America (in terms of GDP). It is a developing country, with a high ranking in the Human Development Index. Its main economic activities include agricultureforestryfishingmining, and manufacturing goods such as textilesclothing, refined metals, and refined petroleum. Bolivia is very rich in minerals, including tinsilverlithium, and copper.


Between 2006 and 2016, extreme poverty in Bolivia fell from 38.2% to 16.8%. Chronic malnutrition in children under five years of age also went down by 14% and the child mortality rate was reduced by more than 50%, according to World Health Organization. In 2019 the Bolivian government created a universal healthcare system which has been cited as a model for all by the World Health Organization.



Wishing the very best to our Global Neonatal Womb Community from our home in Seattle, WA. USA.  In many ways the pandemic has provided and even demanded expansion of and collaboration towards our increased potential to access healthcare. At the same time, the gaps that exist in our global access to healthcare became more visible to the masses.  Our hope is that the exposure to broadened community perspectives will continue to promote collaborative efforts to create, sustain and grow universal healthcare access, replenish/build a supported, vibrant, and empowered healthcare provider community, and decrease preterm birth and maternal and child mortality worldwide.  We have a lot of work to do with pandemics, increasing climate change challenges and serious socio-economic barriers to address. Our preterm birth survivors need research, diagnostic/treatment options and provider development to address survivor needs. So, let’s get to it. We have what it takes.

This revolutionary Bolivian hospital is changing how women give birth

Javier Sauras/Narratively

July 14, 2016 – Michele Felix Javier and Bertelli Lill Sauras

Under the dim hospital light, a midwife, a doctor, a pregnant woman, and her mother silently ponder what they should do with a baby that fiercely resists coming out of the womb. The longer the labor, the more dangerous it gets, and it has been almost a full day since the woman arrived here at the hospital. In Bolivia, which has the second-highest maternal mortality rate in South America, such a delay is a mortal threat. But here, in the high Andean plateau, hours from any major hospital, the mother is in very good hands.

The pregnant woman never wanted to go to the hospital. The night before, her mother called Doña Leonarda, the midwife, or partera, to attend the delivery according to traditional Aymara customs. Doña Leonarda was working at the hospital today, so the woman reluctantly came here. Lying on her back, eyes wide open, the mother looks terrified. A young nurse turns to the physician, Dr. Henry Flores, and asks whether she should call the ambulance and take the woman to La Paz for a C-section.

“That would be unwise,” Flores answers in a smooth, low-pitch tone.

It would take more than two hours to get to the capital city and that could be too risky, too late for her. Her pain is increasing and she is already dilated. The doctor measures her contractions and tells the nurse to give the woman an IV solution. “It’s only vitamins,” Doña Leonarda says. But she knows better: they are dripping a painkiller into a plastic bag hanging from a pole — one of the few traces of modernity in this small chamber of the rural hospital. Three deep breaths later Dr. Flores makes a decision.

“Should we try the traditional way?” he asks the partera. “She is weak but she can do it,” Doña Leonarda answers.

Mother, partera, doctor, and nurse place a green mat on the floor of the hospital and gently move the woman over it. She is on her knees, her head on her mother’s hands; Doña Leonarda rolls up the woman’s skirt. It’s going to be a vertical delivery, virtually unheard of in Bolivian hospitals but the traditional method in the Andean region. It’s the way this pregnant woman was born herself, thirty years ago, just like her mother before her, and her grandmother, and so on. Dr. Flores learned the delivery method from the indigenous healers of El Altiplano — Bolivia’s Andean plateau — and he is one of the few doctors in the country who is confident enough to try it.

Here on the Bolivian side of El Altiplano, a vast plateau 13,000 feet above sea level, the difference between life and death wears a bowler hat and a rainbow skirt. Far from medical facilities, lacking academic training and marginalized by the public healthcare system, parteras provide the only help that most women get during childbirth. But their efforts are not enough. Hundreds of people die every year during labor, a curse that haunts one of the most vulnerable groups on Earth: rural, poor, indigenous women. Bolivia trails behind almost every other place in the Americas with 206 deaths per 100,000 live births. (The rate in the United States is just 14 deaths per 100,000.) This revolutionary hospital might be showing the way to put an end to this ongoing tragedy.

Dr. Flores, who runs the local hospital in Patacamaya, approached Leonarda Quispe 10 years ago to recruit her for the outpost, even though she had never set foot in medical school and she barely speaks Spanish. Born in a small indigenous Aymara community, Doña Leonarda, as people know her, has been delivering babies since she was 12. Nobody has ever died under her care, she says “neither a woman nor a newborn,” which might be a record for someone who has attended more than 10,000 childbirths. Seven years ago, Dr. Flores realized the partera was getting more calls than any of his obstetricians and came up with a surprisingly straightforward and inexpensive idea. His plan was to develop a new healthcare system that would attract the local population to the hospital by combining traditional indigenous practices and modern academic knowledge. Should it prove to be successful, it might be adapted and applied everywhere — not just in Bolivia, but around the globe.

In Dr. Flores’ hospital, parteras are welcomed and traditional indigenous doctors have their own offices, alongside skilled surgeons and trained specialists. Doña Leonarda and her husband, Don Vitaliano, are part of the staff; medical doctors like Flores often consult with them. Delivery rooms in Patacamaya’s hospital look like little rural houses: There are kitchens, windows with thick curtains, walls painted in warm colors, wooden furniture, and flurry blankets. Nothing is white or shiny. By the pale red cribs, a banner reads “Ususiñ Uta” (birthing chamber), although in the hospital everybody knows these spaces as “intercultural delivery rooms.”

Nearby, in the two-story brick house where Leonarda and Vitaliano live and run their own private practice, there are two bedrooms, plus an examination room filled with jars, syrups, ointments, a couple of tables, some notebooks, and a stretcher. As modest as the facility might look, Doña Leonarda and Don Vitaliano attract patients from as far as Chile, Brazil, Argentina, Peru, and even Spain.

Hidden in Leonarda’s pollera, a large cotton skirt typical of the Altiplano, a small cellphone insistently buzzes. “Another patient,” she says in Spanish while excusing herself with a gentle gesture of her hand before leaving the room. Wearing a pink sweater and a colorful skirt under a blue apron, she takes her bowler hat off for a second, revealing all of her braided black hair, almost three feet long. Don Vitaliano, a large man with gelled hair, the arms of a builder, and the smile of a high school student, stays behind. Ten years younger than his wife, he is her voice, her aide, and her driver. A Honda off-road motorcycle, the engine still warm, waits outside the house. They have just returned from the hospital, where they attended a delivery in the middle of the night.

It’s now seven in the morning. The previous night a woman called from La Paz to ask Doña Leonarda to attend her delivery. Leonarda told her to come here, to her private office in Patacamaya. But when the woman and her mother arrived in the early hours, Don Vitaliano had to convince them to meet his wife at the hospital, where she was still working, rather than at their place. It was a difficult task: They traveled three hours at night to give birth in a traditional environment, with a partera, far from medical doctors and their scary bright-white delivery rooms.

Convincing an indigenous woman to set foot in a hospital is like inviting her to take her life into her hands. “There are some diseases here, in the Altiplano, that urban doctors don’t want to treat,” Don Vitaliano says. Projecting his voice like a Roman orator, he explains the condition of sobreparto, a commonly reported postpartum condition among the Aymaras. Everybody in the rural area has heard about sobreparto and can describe its symptoms: headaches, swelling, fever, fatigue, and inability to perform complex tasks. But this malady is not recognized by modern medicine.

Therefore, it has no treatment. Indigenous women, however, are extremely scared of it. It attacks them when the rooms are frigid with tiles and metals and when nurses wash them with cold water. “Some mothers prefer to stay at home because they are afraid of getting cold,” Vitaliano says.

“When they go to hospitals they are not taken care of properly and, then, they get sick. Sometimes they don’t even speak the same language and doctors yell at them; they cannot talk to anyone and they are terrified.”

Narratively is a digital publication and creative studio focused on ordinary people with extraordinary stories.


Fatal police violence may be linked to preterm births in neighborhoods nearby

April 16, 2021  Author Dana Goin Postdoctoral Scholar, University of California, San Francisco

Building on generations of work by activists and organizers, there is currently a national reckoning with the impacts of police violence on Black communities underway in the United States. It’s well established that killings, injuries and intense surveillance by police can traumatize not only the direct victims, but their communities. But little research has been done to assess whether police violence has spillover effects on other facets of human health.

I am an epidemiologist who studies how the social and physical environment shapes maternal and infant health, and my research team and I wanted to investigate whether witnessing the police killing someone – or even living nearby or hearing about it afterward – could affect the outcome of a healthy pregnancy. Our latest research suggests the answer is yes.

Our new study, published in March in the journal Paediatric and Perinatal Epidemiology, found that Californians who were pregnant when fatal police violence occurred in their neighborhoods saw increases in preterm birth. For Black mothers, the associations were particularly high: When police killed a Black person in the neighborhood, the hazard of delivering early increased by 35% or 81%, depending on the data source.

Previous studies show stressful or traumatic events of any kind during pregnancy can be linked to increased risk for preterm birth. Because Black people are disproportionately victimized by police violence, and because there are stark racial and ethnic inequities in preterm births, we anticipated that exposure to fatal police violence during pregnancy might also influence preterm birth risk.

Examining the data

Our study used California birth records to estimate pregnancy duration for the almost 4 million births statewide from 2007 to 2015. We then looked at anyone who was pregnant when a police killing occurred in their neighborhood, and compared them to their neighbors who were not exposed during their pregnancies. There is no single comprehensive source of data on police killings. We therefore used two sources of information about fatal police violence: California death records and the Fatal Encounters database, a compilation of Americans killed during police interactions.

We observed that when people were exposed to fatal police violence sometime during their pregnancies, there was a small increase in the hazard of delivering prematurely. Using the California death records,  there was a 5% increased hazard of the baby being born between 34 and 36 weeks of gestation. There was a 3% increased hazard using the Fatal Encounters database. We didn’t observe associations between exposures to police violence and delivery even earlier, between 20 and 33 weeks of gestation.

Among Black women, we found that exposure to fatal police violence, especially when the victim was also Black, had an even stronger impact. When police killed a Black person in her own neighborhood, a Black mother’s hazard of delivering her child between weeks 32 and 33 increased 81% with the California death records. With the Fatal Encounters data, the hazard increased by 35%.

These findings are critical for a number of reasons. Preterm birth is the leading cause of infant death and may also carry implications for a child’s short- and long-term health. Mothers of preterm children may experience adverse mental health outcomes like increased anxiety and fatigue and use postnatal services less.

The cost of preterm birth is staggering, an estimated US$25.2 billion per year – about $65,000 per birth – with a substantial portion of that paid by Medicaid. For families, preterm birth can present additional financial hardships, including increased transportation costs for additional medical appointments and delayed return to work or missed work for employed parents.

The American Public Health Association provides detailed guidance on addressing police violence to improve health and health equity. This policy statement from public health researchers builds on work from community organizers and indicates what’s needed most is a shift in how government resources are allocated. It suggests that moving those resources away from criminalizing and policing marginalized communities to investing in their health, safety and well-being – through housing, food security, and quality health care and education systems – is the route to real change.


A little LOVE from Bolivian artist Bonny Lovy and Serkiel (Argentina)

Bonny Lovy Feat. Serkiel Amor Amor • 613,037 views • Bolivia & Argentina

Scope | Stanford Medicine's blog - Scope

Culture & Healthcare

Assault during pregnancy boosts risk of poor infant health

Author Beth Duff-Brown Published on September 17, 2020

Babies born to women who experienced an assault in their homes during pregnancy are more likely to be born prematurely and have a very low birth weight — which could lead to a lifetime of poor health and economic well-being, Stanford Health Policy research has found.

Health economist Maya Rossin-Slater, PhD, examined the effects of prenatal exposure to violent crime on infant health, using New York City crime records that are linked to birth records data. She and her colleagues found that in-utero assault significantly increases the incidence of adverse birth outcomes.

The findings were released in a NBER working paper last year; an updated version has since been accepted by the Review of Economics and Statistics.

In their analysis, the researchers found that assault during pregnancy leads to increases in the rates of very low birth weight (less than 3.3 lbs.) and low Apgar scores, a widely used metric for evaluating newborn health.

“Our results imply that interventions that reduce violence against pregnant women can have meaningful consequences not just for the women — and their partners — but also for the next generation and society as a whole,” Rossin-Slater said.

Findings timely due to COVID-19-related jump in domestic violence

Their research was conducted before the COVID-19 pandemic disrupted virtually every American household in a myriad of ways, including through an increase in domestic abuse. Rossin-Slater notes several studies  have identified an association between stay-at-home orders and an increase in 911 domestic-violence calls and incidents in which police have been called to the scene. And there are likely many more cases that are not captured in the data.

That makes understanding the ramifications of domestic violence even more important, researchers believe.

“Lower-income pregnant women are more likely to be domestic violence victims than their more advantaged counterparts, and COVID-19 likely amplifies this disparity through the shelter-in-place orders,” said Rossin-Slater. “And then, the children of women who experience this violence are as a result also at a disadvantage — and this disadvantage may affect them throughout their life and even into their own children’s life.”

The research team also calculated the collateral economic damage of assaults on pregnant women.

They estimated that the annual social cost of violence during pregnancy in the United States is $3.8 billion to $8.8 billion. Those costs result from the increased rate of adverse birth outcomes, which in turn lead to a higher rate of infant mortality, increased medical costs at and immediately following birth, increased costs associated with childhood and adult disability, decreases in adult income, and reductions in life expectancy.

“Measuring the social cost of crime — and especially violent crime — is crucial for policy debates about the judicial system and programs that impact criminal behavior more broadly,” the authors concluded.


Risk of developmental difficulties remains high among children born early

Preterm birth continues to pose a large burden for families, healthcare, and educational systems, say researchers

Date: April 28, 2021   Source: BMJ

Children born preterm (before 37 weeks of pregnancy) remain at high risk of developmental difficulties that can affect their behaviour and ability to learn, finds a study published by The BMJ today.

These difficulties were found not only in children born extremely preterm (22-26 weeks) but also in those born very and moderately preterm (between 27 and 34 weeks), say researchers.

Survival of preterm babies has increased worldwide. Children born early often have developmental issues, but studies have mainly focused on those born extremely preterm (22-26 weeks’ gestation) and less is known about children born very and moderately preterm (27-34 weeks’ gestation).

Given how important it is to identify children most at risk of developmental difficulties, researchers in France set out to describe neurodevelopment among children born before 35 weeks compared with children born at full term.

Their findings are based on 3,083 French children aged 5½ born after 24-26, 27-31, and 32-34 weeks gestation who were taking part in the EPIPAGE-2 study (designed to investigate outcomes of preterm children over the past 15 years) and a comparison group of 600 children born at full term.

Neurodevelopmental outcomes such as cerebral palsy, sensory impairments (blindness and deafness), and brain function (cognition), as well as behavioural difficulties and movement disorders, were assessed using recognised tests.

To further assess the family and social burden of prematurity, measures such as the need for extra support at school, visits to a psychiatrist, speech therapist or physiotherapist, and parental concerns about development, were also recorded.

After adjusting for other potentially influential factors, the researchers found that rates of neurodevelopmental disabilities increased as gestational age decreased.

For example, among the 3,083 children assessed, rates of severe to moderate neurodevelopmental disabilities were 28%, 19% and 12% and rates of mild disabilities were 39%, 36%, and 34% among children born at 24-26, 27-31 and 32-34 weeks, respectively.

Assistance at school was used by 27%, 14% and 7% of children born at 24-26, 27-31, and 32-34 weeks, respectively. And about half of children born at 24-26 weeks received at least one developmental intervention which fell to 26% for those born at 32-34 weeks.

Behaviour was the concern most commonly reported by parents.

Rates of neurodevelopmental disabilities were also higher in families with low socioeconomic status.

This is an observational study, so can’t establish cause, and the researchers point to some limitations that may have affected their results. However, by assessing a wide range of developmental and behavioural issues, they were better able to reflect the complexity of difficulties faced by these children and their families.

As such, they say their findings indicate that preterm birth “continues to pose a large burden for families, healthcare, and educational systems.”

Although rates of severe to moderate neurodevelopmental disabilities decreased with increasing gestational age, they point out that around 35% of the moderately to extremely preterm born children had mild disabilities requiring special care or educational services.

And a considerable proportion of parents had concerns about their child’s development, particularly about behaviour, which warrant attention, they add.

“Difficulties faced by these groups of children and their families should not be underestimated,” they conclude.



Exercise aids the cognitive development of children born preterm

Date: May 6, 2021    Source: University of Basel

Summary: A premature start in life can cause problems even into teenage years. A study indicates that training motor skills in these children helps even when they are older.

A premature start in life can cause problems even into teenage years. A study by the University of Basel and the University Children’s Hospital Basel (UKBB) indicates that training motor skills in these children helps even when they are older.

Children that are born before the 37th week of pregnancy remain under close medical supervision while they are young. Any cognitive limitations often disappear after a few years. However, children who come into the world even before the 32nd week of gestation still exhibit differences even into their teenage years. In a new study, researchers led by Dr. Sebastian Ludyga and Professor Uwe Pühse have demonstrated that these children have weaker impulse control compared with children born at term (after the 37th week of pregnancy). This can, for example, have disadvantages in school performance and is linked to behavioral problems and a higher susceptibility to addiction.

As the research team reports in the journal Developmental Cognitive Neuroscience, these differences in impulse control can be fully explained by the children’s motor skills. “In other words, premature children who had very well-developed motor skills were practically equal to children born at term when it came to impulse control,” explains Ludyga.

In their study, the researchers compared a group of 54 very preterm children aged 9 to 13 years with a control group of children of the same age who had been born at term. To test impulse control, the sports scientists conducted a “go/no go” test with the children. When given a signal, the young study participants had to push a button as quickly as possible. When given a different signal, they were not allowed to push the button — in other words, they had to suppress their impulse to move.

During the experiment, the researchers monitored certain brain activity parameters using an EEG (electroencephalogram) to determine how the children processed the stimulus. A comparison of the two groups showed that on average, the premature children found it more difficult to suppress the impulse to move due to impaired attention processes.

In further experiments, the researchers tested gross and fine motor skills, as well as ball handling. They found that the greater the deficit in motor skills, the more limited the impulse control in the children born very preterm.

“We conclude from these findings that targeted motor skills training could also reduce cognitive limitations,” explains Ludyga. The researchers now want to test this in a follow-up study.

Ludyga says that there are few support options for very premature children as they grow into teenagers unless they come under scrutiny for a different reason, such as ADHD or another illness: “Limited impulse control at this age, even if it sorts itself out later, can have negative consequences and restrict these children’s educational opportunities.”

In younger children in particular, the development of motor and cognitive skills are closely linked. The time window from 9 to 13 years is therefore a promising period in which to reduce cognitive deficits in children born very preterm.

University of Basel. “Exercise aids the cognitive development of children born preterm.” ScienceDaily. ScienceDaily, 6 May 2021. <>.


What Parents Want to Know after Preterm Birth

EDITORIALS| VOLUME 200, P10-11, SEPTEMBER 01, 2018 Edward F. Bell, MD Matthew A. Rysavy, MD, PhD Published: May 08, 2018

When faced with the birth of a child born very preterm, most parents’ first question is, “Will our baby live?” Then, “If so, how will she be?” or “What will his life be like?” And finally, “What will our lives look like now?” Generally, parents do not ask, “Will our child have neurodevelopmental impairment?” or “Will our child have a Bayley cognitive composite score less than 85?”

So why has “neurodevelopmental impairment” become the standard measure for neonatal studies? Why has it become central to the way we counsel patients’ families and discuss prognoses with them? Do our answers address the real concerns and needs of parents of infants born preterm?

The focus on certain aspects of neurological development as the primary outcome after preterm birth may be, in part, an accident of history. The largest and most rigorous study of infant outcomes in the 1960s, the same decade that the term neonatologist first came into use, was the Collaborative Perinatal Study, organized by the then National Institute of Neurological Diseases and Blindness. This study informed the methods for conducting follow-up assessments and provided a benchmark for subsequent outcome studies.

The term neurodevelopmental impairment, now in common use, came to incorporate the outcomes of such studies, including motor and sensory development, cerebral palsy, deafness, and blindness.

Is it possible that we present parents with information about neurodevelopmental impairment because it is what we measure? What outcomes are actually most important to parents?

In this volume of The Journal, Jaworski et al report the results of an analysis comparing parents’ reports of their prematurely born children’s well-being at 18- to 22-month follow-up with the categorization of neurodevelopmental impairment based on research definitions of the Canadian Neonatal Follow-Up Network.

The investigators evaluated 190 children born very preterm. They also asked the children’s parents an open-ended question, “What concerns you most about your child?” and asked the parents to “Please describe the best things about your child.”

The main result was that there was no association between the themes used by the parents in describing their children, which were predominantly positive, and the presence or degree of neurodevelopmental impairment. The rates of positive aspects and physical health concerns were similar among all groups, but the reporting of developmental concerns was most frequent among parents of children with mild or moderate impairment; two-thirds of parents of children in this group reported concerns about their children’s development. Parents of children with no impairment or severe impairment were less likely to report concerns—approximately one-half in each group. The result for the severely impaired children must be viewed with caution, as there were only 15 children in this group. Other limitations include the lack of data from the parents of 41% of the survivors eligible for follow-up and the absence of information about how parents of healthy children born at term would respond to the same questions.

The authors observed that parents’ concerns often were not included in the standard definition of neurodevelopmental impairment. Although development was of concern to many parents, many also worried about behavior, such as hyperactivity and aggression. Parents also worried about feeding issues and growth.

The overwhelming message is that many parents of infants born very preterm view their children as having a good personality, being happy, and making developmental progress. Nevertheless, one-half or more of parents in all groups were concerned about their child’s health and development. And, perhaps most important, there was no correlation between the parents’ perception of their child’s status and the degree of neurodevelopmental impairment as graded by standard testing.

This leads to the questions, “What is a satisfactory outcome?” and “Who should decide?” To answer the second question first, it seems that only the individual born prematurely can determine whether her outcome is satisfactory, and until she is old enough to express this for herself, her parents must speak for her. We have heard repeatedly that children and adults born prematurely and their parents are, as a rule, happy with their lives, at least as happy as their counterparts born at term.

 As healthcare providers, we should give up the idea that we are trying to protect families and children from unspeakable horrors when we warn them of the daunting risks of very preterm birth. This is not what they want to hear, and these dire forecasts do not give the whole picture.

 We should state the risks compassionately and accurately  and temper this worrisome news with the possibility of good outcomes as well as bad ones.

The study of Jaworski et al also raises questions about which long-term outcomes we should assess in neonatal studies. How can we conduct better research that addresses what parents and survivors of preterm birth find most important? Moreover, what is the best way to use this research to relay the results to those who can use them?

It is time to include in our research outcomes that are most important to parents. We have the rudiments of guidance in this task, but we could use more input from parents in defining outcomes that are of practical importance to them and their children. This may require developing new measurement tools.

This effort is not entirely new. A few of our pioneer follow-up investigators recognized this need and have addressed it well; yet, the opportunity remains for most of us to do much better. Jaworski et al contribute to a growing body of evidence that challenges the way we think about prognosis for infants born preterm. They remind us that we must ask parents, and whenever possible former patients, what outcomes are most important to them, and we must listen to their answers.


When the Stress of the NICU Goes Away, Trauma May Last

April 13, 2021

Newborn babies who need intensive or specialized medical attention are often admitted to the Neonatal Intensive Care Unit until they’re healthy enough to go home, but research has found that even after a baby comes home from the NICU, many parents find themselves dealing with their own long-lasting effects.

According to statistics kept by the March of Dimes, in 2019 there were 3,744 preterm births in Dallas County — or 10 percent of all live births. In Tarrant County, there were 2,874 preterm births, or 10.6 percent of all live births. About one in 10 babies is born prematurely each year in the United States, the March of Dimes says.

A preterm birth is a birth that occurs prior to 37 weeks of gestation. While preterm and premature are often used interchangeably, the World Health Organization says there are three levels of premature births—late preterm, or born after 32 weeks but before 37 weeks; very preterm, or born between 28 weeks and 32 weeks; and extremely preterm, or born before 28 weeks.

Even if their baby spends little time in the NICU, a parent can find themselves reacting to similar situations, smells or even sounds months after. Studies have found that post-traumatic stress disorder (PTSD) and/or acute stress disorder are not uncommon among parents of children who spent time in the NICU.

In a study published in Europe’s Journal of Psychology, researchers surveyed 21 Italian parent couples of preterm infants and 29 couples of full-term babies. All parents filled out the same questionnaires designed to measure how they were reacting to the stressors they were experiencing.

The study found that mothers and fathers of preterm infants reported more tension, depression, anger and fatigue than parents with full-term babies.

“Our findings suggest that parents of premature babies, in particular mothers, since the birth of their babies, are at risk of developing higher levels of anxiety, depression, anger and stress,” the article says. “Furthermore, the preterm infants’ external characteristics and signals associated with immaturity and severity of medical status could be a further stressor especially for mothers.”

similar study in Poland also found that parents of premature babies were at higher risk for PTSD.

Everything that can happen in a NICU—the health of the tiny infants, the noises, the uncertainty—can certainly provide the circumstances for developing PTSD, says Donald Hafer Jr., Ph.D., director of the Texas Health Behavioral Health Service Line, especially when you also consider the potential traumatic surroundings of the birth that brought the baby to the NICU to begin with.

PTSD, Hafer explains, is diagnosed after someone has been having symptoms for more than 30 days. “Acute Stress Disorder can be diagnosed from day one to day 30, and the criteria are pretty much the same,” he says.

“It always has to be tied to some event; it could be something that actually occurred to you, that you saw happen, or even that you heard about,” Hafer says. “You can develop this vicariously.

“And PTSD can show up later—it doesn’t always, but it could come even years later.”

There are four main ways PTSD symptoms may manifest:

  1. Reliving the event (nightmares, flashbacks or something that triggers a memory of a traumatic time);
  2. Avoiding situations that trigger memories of the traumatic event, or even avoiding discussing the event;
  3. Negative beliefs and feelings (anxiety about the future, difficulty in having positive or loving feelings toward people);
  4. Hyperarousal (feeling like you must be on the lookout for danger, trouble sleeping, trouble concentrating)But not everyone who spends time watching over their infant in the NICU will experience PTSD, Hafer says.

But not everyone who spends time watching over their infant in the NICU will experience PTSD, Hafer says.

“You can be there, seeing this traumatic experience, and for some people there’s trauma, and for some people there’s not,” he explains. “If you’re there and there’s a big code on a baby, whether it’s yours or not, that can be a traumatic experience.

“It really all depends,” he continues. “Not everyone with a NICU stay has the same experience. For some, it is a relatively short stay with minimal medical complications and for others, it turns into months of one crisis followed by another.”

Whether that trauma continues to affect someone can often depend on what a parent has dealt with in the past.

“Trauma for one person is not the same as for another, based on their past life experiences,” Hafer explains. “Seeing your child in NICU, or vicariously seeing another child go through a code may become a trauma trigger.”

Hafer says that treatment for PTSD can take many forms. For some, knowing their triggers and avoiding the ones they can is helpful. “You may or may not be able to avoid them,” he says.

Sometimes medication is helpful, especially if there is underlying depression or anxiety tied to the PTSD, Hafer says. Others find a more psychoanalytical route helpful.

“There are also effective strategies that are symptom-based—things like breathing training, cognitive therapy, and relaxation training—that help you cope with the symptoms,” he says. “Sometimes it’s a matter of self-talk, asking if you’re saying things to yourself that could be exacerbating your anxiety.”

And sometimes seeking out people that have been in the same boat is helpful, too. One study published in the Canadian Medical Association Journal found that 16 weeks after preterm birth, mothers who were matched with parents who had lived through the NICU experience already had less anxiety and depression and felt they had more social support.

But if a parent does feel that they are experiencing PTSD, help is available.

“You need to visit with a mental health professional who is familiar with treating PTSD,” Hafer says. “You can start by talking to your MD about a referral, or you can call Texas Health Behavioral Health and schedule a free hour-long screening at any of our 20 locations within 24 hours.”


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September 03, 2020– Natalie Clark   Photo: Flickr

Bolivia is the second poorest country in South America, performing poorly in education, life expectancy, economic strength and overall development. Most alarmingly, it lacks sufficient medical care due to a limited supply of adequate resources. Bolivia’s unique geography advances its tremendous healthcare challenges, causing children to be 10 times more likely to be born with congenital heart defects. These conditions are nearly impossible to treat without trained cardiologists and updated facilities, two things often inaccessible to most Bolivians. Thus, addressing heart disease in Bolivia is quite challenging as a result of these factors. However, Franz Freudenthal, inventor and cardiologist, is improving medical care with a simple technique that utilizes an indigenous hobby to heal holes in hearts.

What is PDA?

Patent Ductus Arteriosus (PDA) is a common congenital heart defect, particularly prevalent in certain parts of Bolivia. The defect is caused by an opening between two major blood vessels traveling away from the heart. The opening is crucial to a baby’s circulatory system before birth, but it should close almost immediately upon exiting the womb. PDA cases, however, present holes in the heart that remain open. Although the exact cause of congenital heart defects like PDA is typically unclear, decreased oxygen levels have a direct impact on fetal heart health. Because La Paz, Bolivia sits at 3,600 meters above sea level, where the atmosphere has lower oxygen levels than most parts of the world. Therefore, Bolivia’s altitude is the likely cause of irregular blood. Also, the mother’s inability to provide appropriate oxygen levels to her child can result in severe complications.

Breathlessness and failure to thrive are the most common symptoms in mild cases, but fatigue and failure to gain weight can also occur because harmed hearts must work three times harder to pump blood than healthy hearts. Children with severe cases of PDA are at a higher risk for pulmonary hypertension, arrhythmias, infective endocarditis, anticoagulation and congestive heart failure. However, each of these symptoms can be relieved by skilled women in the Andes Mountains’ high plains.

Ingenuity to Fight Heart Disease in Bolivia

Aymara women have been knitting clothes and blankets for centuries, but with help from Franz Freudenthal, they are now knitting heart-closure devices to mend PDA. The Nit Occlud is a hi-tech medical advancement modeled after an occluder, an industrially-produced device intended to block holes in babies’ hearts. Unlike a normal occluder, the Nit Occlud’s design cannot be mass-produced due to its intricate design. Therefore, Freudenthal had to search for an alternative production plan. The perfect method, he soon found, was the wonderful weaving skills of the Aymara women.

The Nit Occlud is composed of a super-elastic metal known as nitinol, a nickel-titanium alloy capable of memorizing its own shape. After a doctor inserts the device through the body’s natural channels, it travels through blood vessels, expands to its original shape, plugs the heart’s hole and permanently restores basic cardiac functionality.

Typical treatments for PDA include surgical procedures, cardiac catheterizations, or heart transplants, but these are not available Bolivia and are not welcomed by the Aymara people. Even though the Aymara people have recently adopted Catholicism, they still believe in the power of the Andes Mountains spirits and their effects on human souls. Keeping in mind that manipulating a heart – performing open-heart surgery or a transplant – is considered desecration according to the spirits, Freudenthal created a minimally invasive innovation to respect patient beliefs and to “make sure that no child is left behind.”

Making Impact

Although congenital heart defects remain the fourth leading cause of premature deaths in Bolivia, the rate has dropped 36% since 2007. Freudenthal’s Nit Occlud has saved more than 2,500 children in nearly 60 countries after experiencing immense success in Bolivia. The country is also succeeding in its fight against poverty. The number of Bolivians living on less than $3.20 a day is projected to decrease by 35% in the next 10 years. Additionally, more children are being vaccinated and more prenatal care opportunities are becoming available to mothers. With these advancements in healthcare and poverty reduction, the economy will soon flourish and rates of heart disease in Bolivia are sure to drop.


Higher levels of nitrate in drinking water linked to preterm birth, Stanford study finds

Women exposed to higher levels of nitrate in drinking water were more likely to deliver very early, according to a study of 1.4 million California births

Pregnant women exposed to too much nitrate in their drinking water are at greater risk of giving birth prematurely, according to a Stanford University study of more than 1.4 million California births.

Agricultural runoff containing fertilizer and animal waste can greatly increase the nitrate level in groundwater, which naturally contains a low level of the chemical.

“We found that higher concentrations of nitrate in drinking water during pregnancy were associated with an increased risk of spontaneous preterm birth, even at nitrate concentrations below the federal regulatory limit,” said Allison Sherris, a graduate student in the Emmett Interdisciplinary Program in Environment and Resources at Stanford. “That was surprising.”

The study, which published online May 5 in Environmental Health Perspectives, is the largest ever to connect nitrate exposure and premature birth. Sherris is the lead author. The senior author is Gary Shaw, DrPH, professor of pediatrics.

The research found that the risk of early preterm birth, in which an infant is born at least nine weeks early, more than doubled among women whose tap water had nitrate levels that exceeded the federal limit of 10 milligrams per liter compared with those whose tap water nitrate levels were less than 5 milligrams per liter. The risk was elevated by about half among women exposed to a moderate level of 5-10 milligrams per liter of nitrate in their water. Later preterm births, in which an infant arrives three to eight weeks early, were also associated with elevated nitrate, but the connection was less pronounced.

Early preterm births are fairly rare, composing less than 1% of all births, but are medically severe for affected infants. These preemies typically require long hospitalizations and can experience short- and long-term complications with vision, hearing, digestive function and neurological development.

“If we can prevent even a fraction of these births, that would be enormously beneficial,” Sherris said.

The federal safety limit of nitrate in drinking water was set after it was discovered that newborns drinking formula mixed with high-nitrate water can develop “blue baby” syndrome, in which infants’ blood carries too little oxygen. Both fetuses and young infants have a special oxygen-carrying protein in their blood called fetal hemoglobin, which is especially susceptible to damage by nitrate. 

“Our drinking water matters,” Shaw said. “Water is a very complicated thing to study, but it’s important to know if there are risks associated with what’s in our water.”

Analysis of sibling births

The study drew on records of more than 1.4 million births of sibling pairs who were born to about 650,000 women in California between 2000 and 2011. The siblings in the study were not twins or other multiples but had the same mother. Comparing siblings helped the researchers control for factors that might influence preterm birth independently of nitrate exposure, such as the mothers’ genetics, socioeconomic status and dietary habits.

“The within-mother approach gives us confidence in our findings,” Sherris said.

The researchers used public data on nitrate levels in local drinking water systems at the mothers’ homes to estimate their nitrate exposures during each pregnancy. Some women in the study had the same exposures for multiple pregnancies, whereas other women were exposed to different nitrate levels, either because the amount in their local drinking water changed, or because they moved between pregnancies.

Compared with women exposed to the lowest nitrate level of less than 5 milligrams per liter, the odds of spontaneous preterm birth occurring nine or more weeks early  was 47% higher in women exposed to 5-10 milligrams per liter, and 252% higher in women exposed to more than 10 milligrams per liter in drinking water.

The link between preterm births that happen four to eight weeks early and nitrate exposure was not as strong. This was not surprising, as other research has suggested that early and later preterm births may be biologically distinct phenomena with different causes.

The strongest effects of nitrate on prematurity risk were seen in California’s agricultural regions, including the San Joaquin Valley and the Inland Empire, the study noted.

A higher proportion of births in these areas are to Hispanic women than in other regions of the state, said Sherris, adding, “This is one of many environmental justice issues facing women in rural California.”

Further research may help inform whether stricter regulations are needed for nitrate levels in drinking water, the researchers concluded.


Telehealth for Prenatal Care Gets Seal of Approval From Patients, Providers

Majority say that telemedicine should continue post-pandemic by Amanda D’Ambrosio, Enterprise & Investigative Writer, MedPage Today  May 4, 2021

Patients and providers felt that prenatal care via telemedicine was safer, more accessible, and cost-effective during the COVID-19 pandemic, a survey found.

Three-quarters of patients stated that they felt safer using telehealth for their obstetrics care during the pandemic, with 18% responding that they would have forgone care if telehealth wasn’t available, reported Karampreet Kaur, a medical student at Vanderbilt University School of Medicine in Nashville.

More than 95% of healthcare providers also felt that providing prenatal care via telemedicine was safer than in-clinic for themselves, their patients, and their peers, she noted during a presentation at the American College of Obstetricians and Gynecologists (ACOG) virtual meeting.

“From our survey study, we found that overall both obstetrical patients and providers believe telehealth was a safe modality that improved access to obstetrics care during the COVID-19 pandemic,” Kaur said. “A majority believe that telehealth options should be considered for delivery of prenatal care independent of COVID-19.”

The survey results showed that telemedicine allowed patients to save money on transit and childcare, as well as reduce their missed wages. Future studies should include a more comprehensive cost analysis, to further understand savings associated with telehealth for both obstetrics patients and hospitals, she added.

Kaur’s group collected self-administered survey data from obstetrics patients and providers at Vanderbilt University Medical Center. They included clinicians, advanced practice providers, genetic counselors, social workers, and registered dietitians. The researchers received responses from patients from June 2020 to April 2021, but only collected answers from providers during the summer of 2020. All patients included in the survey had at least one prenatal appointment via telehealth.

The researchers obtained survey data from 167 patients, more than half of whom were ages 25 to 34. Around 70 providers responded to the survey, the majority being MDs or DOs.

Of all patients who responded to the survey, 44% last saw a generalist, 28% saw a maternal-fetal medicine specialist, 26% saw a genetics counselor, and just 1% saw a social worker. Approximately 84% of all telemedicine visits were conducted at home, while the remaining 16% were conducted at a clinic, most frequently after an in-person ultrasound appointment.

Around 75% of patients agreed that telehealth reduced their travel time, and almost half saved at least $35 in transportation, childcare, and missed wages. The researchers found that 95% of patients were satisfied with their telehealth obstetrics care, and 96% thought that the state of Tennessee should develop a permanent telehealth obstetrics program.

In their analysis of provider responses, Kaur’s group concluded that 94% of providers thought telehealth was an acceptable way to provide obstetrics services, 85% said that telehealth allowed for high-quality communication with their patients, and 96% agreed that telehealth improved patients’ access to obstetrics healthcare.

Nearly all providers who responded to the survey said that they’d be willing to use telehealth for obstetrics care outside of the pandemic, and that the Vanderbilt telehealth system was positive for the state of Tennessee.

Kaur acknowledged that this study was limited by both non-response bias and sampling bias. As the survey was administered electronically to patients on smartphones or computers, patients without access to these technologies may not have been able to respond.


Disparities in the follow-up of very preterm born children in Europe

Posted on 01 April 2021

With a letter issued in February 2021, a group of researchers presented an analysis of the cross-European disparities of routine follow-up services of children who were born very preterm (<32 weeks of gestational age (GA)). It was found that the mother’s sociodemographic characteristics and her perinatal situation were among the main factors regarding these disparities.

Aiming to describe the use of follow-up services in Europe, the research team collected data from obstetric and neonatal records from 19 regions across 11 European countries. A population-based analysis was conducted using standardised parental questionnaires. The goal was to evaluate the use of routine follow-up services on 3635 children born before 32 weeks of gestation and until their fifth birthday.

Despite the limitations concerning parental recall, the study presented interesting results, stating that 90.3% of the children had used follow-up services, and 27.3% continued with these until the age of five. A family’s lower socioeconomic status was associated with use of follow-up services. Mothers younger than 24 years and mothers born outside of Europe were two groups associated with never having used follow-up services. This underuse is concerning, as their children already belong to a vulnerable minority. Infants with perinatal risk factors such as low GA, small for GA or bronchopulmonary dysplasia (BPD), were among the group to continue follow-up services at older age. Interestingly, the group of male preterm babies used more follow-up services than the female group.

Given the importance of follow-up appointments in children born very preterm, and considering that the most affected groups shown in the study are already in a challenging life situation, the study highlights the need for standardisation in follow-up protocols and calls for action in this regard.

EFCNI was part of the SHIPS Research Group – one of the main data contributors and collaborators of this study.

Paper available to view at: British Medical Journal



New device uses harmless light particles for real-time monitoring of newborn babies’ brains

April 30,2021

An estimated 500,000 babies born around the world each year develop unnecessary brain damage that could be treated if caught in time – but monitoring these infants’ delicate brains is extremely difficult. However, spotting these underlying causes at a critical, early stage, a new photonics device currently in development aims to reduce unnecessary disabilities by improving the instant, real-time monitoring of newborn babies with harmless light particles.

No medical tools currently exist to create a harmless, real-time, continuously moving image inside newborn babies’ delicate brains.

MRI scans can provide an accurate picture inside adults but are highly unsuitable for newborn babies, given they require a patient to sit still while giving out harmful radiation.

Neurodevelopment disabilities like cognition or motor skill impairments that affect half a million infants globally every year – resulting from defective heart vessels – can be treated but are difficult to monitor and catch in time.

However, the ‘TinyBrains’ health consortium run in conjunction with ICFO – The Institute of Photonic Sciences in Barcelona is developing a new wearable device to help doctors see what is going on inside infants’ minds quicker than ever.

Putting near-infrared lasers and LEDs into a small, wearable cap that are combined with EEG electrodes, the scientists send harmless signals into the infant’s brain – working almost like an ultrasound scan, but using photonics (or light) to give much more information, a more detailed picture and an image of the underlying brain activity rather than the anatomy.

The signals can measure the cause of so many unnecessary neurodevelopment disabilities by keeping a close eye on any slight drops in critical oxygen levels to and from the brain instantaneously in real-time.

Heart defects and neurological complications

TinyBrains project coordinator, Professor Turgut Durduran, said: “A staggering 500,000 people suffer unnecessary disabilities that result from congenital heart defects (CHD) and other structural defects in the heart across the world, drastically affecting the life of the patient if they are not picked up soon after birth.

“At present, it is tough to monitor these at-risk populations both technically, because of the lack of appropriate tools, and also ethically because consent and risks have to be taken into consideration.”

Each year 3.4 million babies worldwide are born with a congenital disability, and of these, congenital heart defects (CHD) are the most frequent. About 40% of these infants need a cardiac surgical intervention during their first year of life with a subsequent stay in the intensive care unit.

Most of these babies survive to adulthood but risk suffering from deficits in their neurological development due to brain blood flow and perfusion alterations happening during the intervention. These alterations often result in learning disabilities, leading to low quality of life for these patients and their families, constituting a significant challenge to public health.

Scanning with light

The cap’s sensors connect to a portable unit and measure the cerebral metabolic rate of oxygen – or the oxygen saturation in the blood and the concentrations of oxy- and deoxy-hemoglobin – and build up a 3D color image in real-time.

“We are using high-density near-infrared spectroscopy (fNIRS) and diffuse correlation spectroscopy (DCS) to measure the oxygen saturation levels in the blood. By integrating both of them with an imaging device as the electroencephalography (EEG), the resulting 3D images have higher resolution, increase the brain specificity and penetration and for the first time, a spatial resolution to this class of measurements.” Turgut Durduran, Professor and Project coordinator, TinyBrains

By identifying brain function alterations during surgery and stays in intensive care units will allow doctors to analyze why brain disorders frequently occur in the postnatal period and to pinpoint the types of clinical interventions that can improve the neurological outcome of these infants and, ultimately, their quality of life, as infants, young persons and adults.

Calling themselves TinyBrains, the consortium took their inspiration from similar scope and technologies: a national project called PhotoDementia, a twenty-year collaboration with the Children’s Hospital of Philadelphia, and projects from the European Commission – BabyLux (which monitored cerebral oxygen metabolism and blood flow for Neonatology), and LUCA, a similar light-based technology to monitor thyroid nodule screening to improve thyroid cancer screening.

Although each technology is different, the underlying principles are the same: using photons, or harmless light, to make an instant, non-invasive scan deep within the body.

Concluding in 2024, the TinyBrains project will conduct future trials at the Children’s Hospital Sant Joan de Déu in Barcelona.


Follow-up after very preterm birth in Europe

Follow-up programmes aim to detect neurodevelopmental and health problems and enable early interventions for children born very preterm (<32 weeks of gestational age (GA)). Although the importance of post discharge follow-up is widely acknowledged, recommendations differ regarding eligibility criteria, frequency, duration and content, especially for follow-up beyond early childhood. We used data from a European cohort of children born very preterm to describe the use of routine follow-up services until 5 years of age.

The data were collected for the Effective Perinatal Intensive care in Europe and Screening to Improve Health in Very Preterm Infants studies, which constituted and followed up an area-based cohort of children born very preterm in 2011/2012 in 19 regions across 11 European countries. Perinatal data were collected from obstetric and neonatal records, and parents completed questionnaires at 2 and 5 years of age. Out of 7900 live births, 6792 were discharged from neonatal care, of whom 6759 were alive at 5 years and 3635 (53.8%) participated in the study.

Based on a question on the use of routine follow-up services for children born very preterm in the 5-year parental questionnaire, we classified children as having never used follow-up, no longer using follow-up or still using follow-up services. We described associations with family sociodemographic characteristics and perinatal risks and estimated adjusted risks using multinomial regression models with robust variance estimators for clustered samples and inverse probability weights using baseline characteristics to account for study attrition bias.

Of all children, 90.3% had used follow-up services, and 27.3% (10.9 to 58.4% by country) were still doing so at 5 years of age. Never using follow-up services was associated with maternal sociodemographic characteristics (younger age, low educational level and being born outside Europe) and lower perinatal risk. Continued follow-up at 5 years of age was related to perinatal risk factors (low GA, small for GA, bronchopulmonary dysplasia and male sex). Children with mothers born outside of Europe were less likely to continue follow-up. Adjustments for social and perinatal characteristics failed to explain differences between countries.

This study provides novel data on use of routine follow-up services after preterm birth based on a population-based design and standardised questions on follow-up from diverse European regions. Limits are reliance on parental recall and study attrition.

Children from socially disadvantaged families were more likely to never use follow-up services, corroborating previous studies. This is concerning, as these children are more vulnerable to the adverse neurodevelopmental consequences of preterm birth, and may benefit most from interventions. Variation between European countries in the percentage of children continuing follow-up at five persisted after accounting for perinatal risk factors, such as lower GA and neonatal morbidities. While differences are expected, given the heterogeneity in follow-up policies and programmes, the magnitude of these cross-country disparities, in tandem with marked social inequalities at follow-up entry, underscore the need for better evidence on optimal follow-up organisation and duration.


Clinical Pearl: A Day in the Life: A Preemie Experience

Catherine Ney, MS, CCLS, Joseph R. Hageman, MD/ NEONATOLOGY TODAY Peer Reviewed Research, News and Information

Have you, as a clinician, wondered what it is really like to be a premature infant being admitted to the Neonatal Intensive Care Unit? Even after spending time as a patient in the intensive care unit after a cardiac arrest, intubated, then post-operatively following a four-vessel bypass as I did in 2013, I do not think I really know what it is like for a preemie.

Catherine Ney, my co-author, and colleagues in the Developmental Care Committee have organized an excellent simulation for NICU nurses, neonatal and pediatric nurse practitioners, residents, fellows, and faculty with help from the experts in our Simulation Unit at the University of Chicago. The simulation explores aspects of an admission experience includes admission procedures highlighting the effects of the sensory experience (i.e., sound, noise, taste, smell, light, and positioning). Additional components to effectively simulate the neonate’s experience included the sensation of a weighted positioner on your chest and movement restrictions due to an overly tight swaddle and poor positioning. One of the adults assumes the role of the patient as the providers complete admission tasks with a follow-up discussion regarding the effects on development, potential pathological effects, and how it must feel for the baby.

A comprehensive introduction, led by our Neonatal Nurse Practitioner Chris Elsen, highlights premature development through a developmental care lens that helps focus our participants before their breakout simulation sessions.

Pat Byrnes-Bowen, our physical therapist, explains the stages of development in utero and, as a consequence of preterm birth, what that infant will no longer have an opportunity to experience. As providers in this space, she discusses how we can use various tools and techniques to make the infant’s extrauterine life as physically supportive as possible. Pat explains how positioning needs change and how important proper positioning can be to aiding in a successful life as a young child and adult.

Moving through our additional stations, participants discuss taste and smell with Julie Sadowski, Speech-Language Pathologist, and myself (Dr. H). In this session, participants learn about the aspects of development in utero that prepare infants for feeding later and how exposure to noxious smells can interfere with bonding and deter patient’s from positive oral experiences. This simulation allows participants to smell common items used on or near these patients at a high concentration. They are encouraged to smell various containers and identify alcohol wipes, adhesive remover, and perfume. Even in the age of mask-wearing, these smells permeate without losing their potency.

As participants enter the sound and vision station, they often notice an iPad set up with a decibel reader that is left on throughout the discussion. Catherine walks them through the developmental components of life in utero and the fascinating way the evolution of pregnancy prepares infants for the outside world. For most of our patient population, this natural experience is stripped away as they are thrust into a space that assaults their immature sensory systems. As the discussion moves toward sound, graphs are highlighted with decibel level readings of physical spaces on our unit compared to the recommended level of 45dB’s. The discussion in the room spikes to the mid 70dB range with just one person talking . As the participants digest these thoughts, the lights are dimmed, and they are encouraged to get comfortable in their chairs with eyes closed as they are about to enter the world of a preemie for a few moments. Recorded sounds are played, starting with a heartbeat track that is layered with common noises on the unit. Participants appear visibly shocked as these noises begin and have thoughtful comments during our discussion.

Prior to the final discussion, all participants are gathered for a presentation on mindfulness. Working in the health care field and in an intensive care unit demands more than clinical competence. Compassionate care supports a family-centered model but can be hard to sustain amid the daily challenges on our unit, not to mention the global pandemic. Participants are encouraged to explore the use of G.R.A.C.E. to help support their cultivation of compassionate care toward their patients and families and find ways to support their capacity to do so. We also discuss what the clinicians can do to be more sensitive to the infant’s senses and developmental needs, optimize their NICU experience, and minimize the negative effects of this experience.

We have had several nurses, NNPs, fellows, and attending neonatologists experience this simulation, and the feedback has been really positive thus far. We have a debrief and ask them what can be done to improve the experience and have received a lot of helpful feedback to refine the simulation.

This is by no means a unique simulation as other NICUs have been doing this for a number of years (Phillips, and Catherine has spoken with clinicians from other units about their programs.

We will continue to refine this Day in the Life simulation and plan to do some follow-up surveys for those clinicians who have been through this to see if it has affected their practice in the NICU. An educational handout with summaries of development and the senses is also provided for the attendees.

A Day in the Life: A Preemie Experience Educational Handout is available through the link below

Mop Rides the Waves of Life

Gotham Reads

Gotham Reads presents Jaimal Yogis, acclaimed writer, reading “Mop Rides the Waves of Life”. Going to school and navigating classmates can be hard—but all that goes away when little surfer Mop paddles out in the waves. With a few tips from his clever mom, Mop studies the wisdom of the water and learns to bring it into his life on land: taking deep breaths, letting the tough waves pass, and riding the good ones all the way. With newfound awareness and courage, Mop heads back to land—and school—to surf the waves of life. #GothamReads #JaimalYogis #MopRidesTheWavesOfLife

Kat’s Corner

How to Live Life to the Fullest and Enjoy Each Day

Anna Chui

Have you ever felt like others don’t understand your pain when they seem to be living a happy life? You’re not alone in feeling this way, but the truth is that happiness takes work, and learning how to live life to the fullest takes dedication and practice.

People who smile in public have been through every bit as much as people who cry, frown, and scream. They just simply found the courage and strength to smile through it and enjoy life in the best way possible.

Life is short, and we only live once. Learning to live life to the fullest is an important step in making the most of every day. Here are 9 ways you can try.

1. Decide What’s Important to You

Whether it’s taking care of your children, working hard on your career, writing a new blog post each day, or baking up fabulous creations, you get to decide how you enjoy spending your time. Your parents, friends, community, and society in general all have their opinions, but at the end of the day, you’re the only person who will be around for every moment of your life.

Do what makes you happy, and everything else will fall into place. This may not mean finding your perfect job if you’re limited by education, location, or job openings. However, you can still do what you love by engaging in hobbies, volunteer work, or mentoring. 

Want to discover what’s important for you? I recommend you make use of this 3-Step Guide To Break Free And Design the Life You Want. It’s a free guide to help you figure out what truly matters to you so you can align your everyday life with it and start to live the life you want. Grab your free guidebook here.

2. Take More Risks

Sometimes there’s danger involved in life, but every reward carries risk with it. If you never take risks, you’ll never get anywhere in life, and you certainly won’t learn how to live life to the fullest.

Staying in your comfort zone is the fastest way to become discontent[1]. Without stepping outside what you’re already comfortable with, you will cease to learn and stagnate in both your personal and professional life.

How Fulfilled Are You In Your Life?

While it may feel uncomfortable, taking a risk can be as simple as saying yes next time your friends want to go out instead of staying at home alone. It can mean going out on a blind date, buying plane tickets to a new city, or dragging out those paints that have been stuffed away for years. 

When people look back on their lives, they regret the chances they didn’t take more than the ones they did, so find something new to try today and set goals beyond what you currently believe possible.

3. Show Your Love to People You Care About

Family and friends will always appreciate hearing that you love and appreciate them in everyday life. It will brighten a stranger’s day to hear a random compliment. If you like someone’s shirt, tell them. If you notice that they’re doing a great job not losing their temper while their kid screams in the supermarket, let them know. 

If you have a romantic interest in someone, just go for it. There are a lot of ways it may end, and only one of them keeps them in your life forever. In the end, you may look back and wish you had asked them out. 

4. Live in the Present Moment

Your past is important to learn from. Your future is important to work towards. At the end of the day, though, the only thing that exists outside of your head is the present.

In order to ground yourself in the now, you can practice mindfulness, which involves learning to live in the moment by noticing what’s around you, how you’re feeling, why you’re feeling that way, etc. Meditation can also help with this as it helps you get in touch with your thoughts and feelings. 

Gratitude is another amazing tool for living in the present[2]. Each day, practice gratitude by writing down three to five things you’re grateful for. You’ll be amazed and how quickly this helps place you in the moment and start to live life to the fullest. 

5. Ignore the Haters

No matter what you decide to do with your life, there will always be someone around to point out the many ways you’ll fail or what you’re doing wrong with each step you take. 

Know that every winner loses, but not every loser wins. Successful people don’t start out successful. What makes them successful is that they keep pushing through failure.

Next time you run into a hater, work on placing boundaries and practice self-love to build your self confidence and make it impenetrable to the outside forces trying to break it down. 

Take a look at these 10 Famous Failures to Success Stories That Will Inspire You to Carry On.

6. Don’t Compromise Your Values

If something doesn’t feel right, don’t do it. Don’t compromise on your internal code of ethics, as this will leave you feeling empty and full of regret. 

Life doesn’t work like a movie. It’s filled with gray areas. Trust your instincts, and do whatever you want so long as you can look yourself in the mirror with appreciation and love. 

7. Be Kind to Others

Every day, you’ll see someone who could use help. While you may not be at a place to help them financially, offering a smile or a kind word can do wonders to help someone feel better about where they’re at in life[3]. When others see you practicing kindness, they’ll also be more likely to do so, which can help everyone learn how to live life to the fullest. 

You can also try these 29 Ways to Carry Out Random Acts of Kindness Every Day in order to live life to the fullest.

8. Keep Your Mind Open

Having an open mind is important for your growth. Just because you’re right about something doesn’t mean there aren’t other ways to look at it.

Listening to ideas you don’t agree with or understand keeps your brain active and healthy. You’ll continue to learn as long as you stay open to difficult conversations. Don’t assume you know everything about another person, as they always have more to teach you. 

Here’re 5 Ways to Cultivate a Growth Mindset for Self Improvement.

9. Take Action for What Matters to You

You’ll hear people say, “I had that idea,” every time you see someone create something great. Everyone had the idea for Facebook first. The reason Mark Zuckerberg got rich off of it is because he went out and did it while everyone else was talking about it.

Ideas are useless if you don’t act on them. Less thinking, more doing

The Bottom Line

Learning to live life to the fullest is a big step in discovering a path that will lead you to your greatest sense of happiness and accomplishment. We all need moments to rest and relish in a sense of contentment, but staying in one place too long will leave you feeling a lack in life. Discover what makes your life feel meaningful and go after it.


Jan 13,2018  Roman Bader

— THE ALTIPLANO PROJECT — Country: Bolivia Location: Uyuni, Potosi (The world´s largest salt flat located in the Altiplano region at a height of 3653 m with a surface of 10.582 km² Because we couldn´t find any information that somebody has ever tried to fly there with a paraglider without a motor, we started the Altiplano project. We developed a system to safely tow a paraglider behind a car into the air. The project started already in Germany where we did some tests. We used a 250 meter-long rope with a special strain. We had a breaking point on the paraglider and wipple trees on the car. The only problem was the big height. The Paraglider is really fast because of the thin air. After a few tests it was finally working. 🙂



Rank: 36  –Rate 13%   Estimated # of preterm births per 100 live births  (USA – 12 %, Global Average: 11.1%)

India: officially the Republic of India is a country in South Asia. It is the second-most populous country, the seventh-largest country by land area, and the most populous democracy in the world. Bounded by the Indian Ocean on the south, the Arabian Sea on the southwest, and the Bay of Bengal on the southeast, it shares land borders with Pakistan to the west; ChinaNepal, and Bhutan to the north; and Bangladesh and Myanmar to the east. In the Indian Ocean, India is in the vicinity of Sri Lanka and the Maldives; its Andaman and Nicobar Islands share a maritime border with ThailandMyanmar and Indonesia.

India has been a federal republic since 1950, governed in a democratic parliamentary system. It is a pluralistic, multilingual and multi-ethnic society. India’s population grew from 361 million in 1951 to 1.211 billion in 2011. During the same time, its nominal per capita income increased from US$64 annually to US$1,498, and its literacy rate from 16.6% to 74%. From being a comparatively destitute country in 1951, India has become a fast-growing major economy and a hub for information technology services, with an expanding middle class. It has a space programme which includes several planned or completed extraterrestrial missions. Indian movies, music, and spiritual teachings play an increasing role in global culture. India has substantially reduced its rate of poverty, though at the cost of increasing economic inequality. India is a nuclear-weapon state, which ranks high in military expenditure. It has disputes over Kashmir with its neighbours, Pakistan and China, unresolved since the mid-20th century. Among the socio-economic challenges India faces are gender inequalitychild malnutrition, and rising levels of air pollution. India’s land is megadiverse, with four biodiversity hotspots. Its forest cover comprises 21.4% of its area. India’s wildlife, which has traditionally been viewed with tolerance in India’s culture, is supported among these forests, and elsewhere, in protected habitats.

India has a universal multi-payer health care model that is paid for by a combination of public and private health insurances along with the element of almost entirely tax-funded public hospitals. The public hospital system is essentially free for all Indian residents except for small, often symbolic co-payments in some services. At the federal level, a national health insurance program was launched in 2018 by the Government of India, called Ayushman Bharat. This aimed to cover the bottom 50% (500 million people) of the country’s population working in the unorganized sector (enterprises having less than 10 employees) and offers them free treatment even at private hospitals. For people working in the organized sector (enterprises with more than 10 employees) and earning a monthly salary of up to Rs 21000 are covered by the social insurance scheme of Employees’ State Insurance which entirely funds their healthcare (along with pension and unemployment benefits), both in public and private hospitals. People earning more than that amount are provided health insurance coverage by their employers through the many public or private insurance companies. As of 2020, 300 million Indians are covered by insurance bought from one of the public or private insurance companies by their employers as group or individual plans. Unemployed people without coverage are covered by the various state funding schemes for emergency hospitalization if they do not have the means to pay for it. In 2019, the total net government spending on healthcare was $ 36 billion or 1.23 % of its GDP. Since the country’s independence, the public hospital system has been entirely funded through general taxation.



What Happened With Preterm Birth During the Pandemic?

Some mothers — and their babies — may have fared better than others

Email article by Amanda D’Ambrosio, Enterprise & Investigative Writer, MedPage  April 8, 2021

While pregnant women have been warned about their potential for more severe COVID-19 illness, a few early reports have suggested one positive finding for this population — that pandemic lockdown restrictions may have coincided with a decrease in preterm births.

Early studies have observed a decline in preterm birth rates during the lockdowns, highlighting a potential “silver lining” of the pandemic. But while these findings are encouraging, experts say there is still not enough data to know whether the reduction in preterm births was widespread, or what factors may have caused this outcome to drop in the first place.

“The jury is out, in terms of what’s the overall impact [of the pandemic] on preterm birth,” said Rahul Gupta, MD, MPH, chief medical and health officer at March of Dimes. While early data may provide some insight into lifestyle changes such as working from home and remote access to healthcare, Gupta said more information is needed before drawing conclusions about preterm birth reductions — and which populations were most affected.

Globally, preterm birth is the leading cause of death in children under 5 years old, according to the WHO. In the U.S., the preterm birth rate has been on a consistent upward trajectory, with 2019 being the fifth straight year in a row that the rate increased. Between 2018 and 2019, the preterm birth rate rose by 2%, according to the CDC.

Clinicians from Denmark and Ireland first began to notice a decline in preterm births last spring — specifically, those that were earliest and most critical. A preprint study from Denmark, which included more than 31,000 infants born between 2015 and 2020, showed around a 90% decrease in extremely preterm births (those born before 32 weeks’ gestation) during the lockdown period. In Ireland, another study published in BMJ Global Health observed a 73% reduction in extremely low birthweight deliveries, from January to April of last year.

Other studies have found that rates decrease for specific populations. A recent systematic review and meta-analysis in The Lancet Global Health found that while the overall preterm birth rate was not significantly different before and during the pandemic, the rate in high-income countries declined by 9%. Spontaneous preterm births in high-income countries saw an even greater reduction, falling by almost 20%.

“Interestingly, there are happy numbers mainly from high-income countries,” said the study’s lead author, Asma Khalil, MD, of St. George’s University Hospitals NHS Foundation Trust in London.

Some reports from the U.S. also reflected a decline, albeit a smaller one. Last April, Stephen Patrick, MD, MPH, of Vanderbilt University, wrote on Twitter that he noticed a lower number of infants in the neonatal intensive care unit (NICU) at his institution.

Last month, Patrick and colleagues published a study in JAMA Pediatrics showing the relationship between preterm birth and stay-at-home orders in Tennessee. Patrick’s team found that the risk of preterm birth fell nearly 15% during the lockdown period, after controlling for maternal age, race, education level, hypertension, and diabetes.

Naima Joseph, MD, MPH, a maternal-fetal medicine fellow at Emory University School of Medicine, said it could be that the decline is related to the environmental and lifestyle changes that occurred during the early months of the pandemic.

Alison Gemmill, PhD, of Johns Hopkins University, said that a number of changes during lockdown may have been associated with drops in the preterm birth rate. When most cars were off the roads, there may have been a decline in the number of preterm births associated with air pollution. Additionally, as pregnant people shifted to remote work and found themselves at home and off their feet, Gemmill said there may have been a decline in physical stress.

Another hypothesis, Gemmill added, is that the decrease in preterm births may have occurred simultaneously with an increase in stillbirths. Some reports have shown an increase in stillbirths during the pandemic (including Khalil’s analysis), but U.S. data has yet to confirm this increase.

Gemmill and colleagues published a study last week (which has not yet been peer-reviewed) showing that the preterm birth rate in the U.S. was one of several birth outcomes that was lower than expected in March and April of last year. But the group also observed that the rate dipped significantly again in November and December — coinciding with the months when infection rates climbed.

“Something is definitely going on,” Gemmill said in an interview. She added that the rates her group observed are crude, and do not describe how different demographic groups in the U.S. were affected. However, she said her research is “detecting a really important signal that doesn’t occur in birth outcomes research.”

Not all U.S. data confirm this pattern. A JAMA study of nearly 9,000 infants at the University of Pennsylvania showed that mothers in 2020 were at the same risk of preterm birth than they had been in years prior.

Gupta, of March of Dimes, stated that the U.S. is not a homogenous society, and preterm birth rates will look different across different populations. Black parents, for example, have a 50% higher chance of having a premature infant than white or Hispanic parents. And while preterm births may have coincided with remote work, that would not apply for the essential workers who continued their employment throughout lockdowns.

Regarding preterm birth outcomes during the pandemic, Gupta said that once scientists break down data by demographics, social determinants of health, and medical comorbidities, he expects there will be a “variety of outcomes.” There is no real-time, national birth surveillance data in the U.S. — so it will take time to understand these outcomes fully.

As far as the theories about which factors may have impacted preterm birth, Joseph said that “mostly, these data have led to more hypothesis generation than anything else more conclusive.”

Gupta agreed, adding that there is more research to be done about both the impacts of COVID-19 infection, as well as the indirect effects of the pandemic.

“I think we really have to better understand what factors during COVID — including lockdowns, unemployment, social interactions, mental health, adherence to medications, job loss — all played a role,” he said. “I think we should not take any of these one factors for granted.”



Our favorite rituals have stories to tell.

Strengthening personal rituals that we experience as grounding, foundational, and self-affirmative may help us navigate through these challenging times.

Rituals are a feature of all known human societies. They include not only the worship rites and sacraments of organized religions and cults, but also rites of passage, atonement and purification rites, oaths of allegiance, dedication ceremonies, coronations and presidential inaugurations, marriages, funerals and more.


Healthy rituals provide comfort, stability, connection and empower our personal and collective presence in the world. We all have rituals, although we may not see them as such. A child is born and with it are born many and diverse rituals of interaction between the child and those who care for it. When a loved one dies, time stops as we pick up the phone to check in or share a story with the deceased and suddenly remember that the ritual and rhythm of connecting with our loved one has also transpired, at least in that form.

Communities and cultures share rituals and in sharing may strengthen the ability of the community to heal, grow, and experience prosperity and wellness.  Rituals have the capacity to build resilience. Connecting with the self within the Source empowers our capacities to survive and thrive. It is a process of plugging in, recharging, transmitting and receiving.

 I like to pick up a local coffee early in the morning. I do not especially like coffee but I love the aroma of coffee beans that have ventured to my neighborhood from so many places in the world. My hands cherish the warmth of the cup they enfold. That  first sip of coffee in the morning is my Namaste, my deep breath, my bow to the Divine that connects All.  And then …. on with the day.

Your favorite ritual?

Joseph Campbell:

The function of ritual, as I understand it, is to give form to human life, not in the way of a mere surface arrangement, but in depth.

Mundan Ceremony

Approved by the BabyCenter India Medical Advisory Board

A mundan or tonsuring is an important ceremony for Hindus. It is also known as chaula or choodakarana. Mundan is shaving off baby’s first hair or the birth hair.

Muslims too shave or trim the baby’s hair and some Sikhs perform the kesi dahi ceremony. This is done by putting curd in the hair of the newborn baby boy.

Among Hindus, the mundan is performed during the first or third year of a child’s life. In some regions, the mundan is done only for the male child. However, in most families girls have a mundan too.

Why is a mundan performed?

In most communities a mundan or first haircut is done in the belief that it purifies the child. Many also believe that a mundan:

  • rids the baby of his past life’s negativity
  • bestows a long life and a good future
  • protects the child from the evil eye
  • cleanses the child’s body and soul
  • helps to keep the baby’s head cool, especially in hot summer months
  • helps relieve headache and pains caused by teething
  • improves the growth of the baby’s hair


Countries that are predominantly composed of nuclear family (father, mother and the children) units represent a limited portion of our global family. In most cultures extended families (grandparents, father, mother, children, aunts, uncles, cousins, other kin and even neighbors are considered to be “family”  and hold significant responsibility in supporting the care and development of the child. This joyous ceremony sweetly highlights the extended family engagement in a child’s life journey.

Ronav’s Mundan Ceremony

Jan 20, 2019


The Surgeon and the Mother

Heather Carmichael, M.D

This article was published on January 23, 2021, at

“Just that,” said the fox. “To me you are still nothing more than a little boy who is just like a hundred thousand other little boys. And I have no need of you. And you, on your part, have no need of me. To you, I am nothing more than a fox like a hundred thousand other foxes. But if you tame me, then we shall need each other. To me, you will be unique in all the world. To you, I shall be unique in all the world.”                                                              — Antoine de Saint-Exupéry

I did not get to hold you for the first 3 weeks of your life.

I knew this would happen. I was the surgeon, and I was prepared. You were born under the bright fluorescent lights of an operating room, delivered onto a sterile blanket on my belly. There, the intensivist began to work on you before you had taken your first breath. Before you had been separated from me, a tube was placed down your tiny throat. Before I had a chance to cry, you were whisked away to the adjacent room, where all the others — surgeons, intensivists, nurses, fellows, residents, respiratory therapists, students, your father — crowded around. And I was left alone, with the obstetrician and a nurse, waiting under the cold lights to deliver the placenta.

I was prepared. I was a surgeon, or at least a surgeon in training, and I knew this room. My hospital ID was tucked into the pocket of my bathrobe. I knew the timing of morning rounds, the hierarchy, the jargon. I had done this before. I knew how to neatly package my emotions in the glove compartment until the end of the day, avoiding any clutter that might get in the way of sound clinical judgment.

I knew, for example, that I shouldn’t cry in the exam room at my 20-week ultrasound when I heard that you had a congenital diaphragmatic hernia, that your stomach, intestines, spleen, and liver were all up in your chest. I bit back my tears until I reached the safety of my own car on the roof of the parking garage. I had done this before.

Sometime after the delivery, I was taken back to a recovery room. The nurse brought me a breast pump; a lactation consultant walked me through the pages of a pamphlet. I sat in the quiet dark, listening to the tick-tick-tick-tick of the machine counting out the requisite time. I thought about you, but I was the surgeon, and to me you were some other mother’s baby, one of many fighting for your life down that long, narrow hallway of the NICU. The nurse praised me for those few drops of colostrum, filling up the tiny syringe.

You needed to be put on ECMO, a machine to take over for your heart and lungs, sucking all the blood out of your miniature vessels and pumping it back in again. As a surgeon, I knew what this meant. I knew what would happen, the steps of the operation, the risks, the potential benefits, the alternatives, the lack of alternatives. I watched it happen through the glass door, across the hall by the nurses’ station, some strange dream. You under a sea of blue, the surgeon and the fellow with their heads bowed together over your tiny face. When it was over, I was instructed that I could touch your hands, your feet, gently cup the top of your head, but that I should not stroke your dark curls, or kiss your cheek, or squeeze your small fingers. I looked at your body, your eyes closed in a sedated sleep, but I did not experience those instant warm feelings of a mother gazing on her child.

Every 3 hours, I took out the pump and sat on the couch, tucked away in the back of your room, hidden by all the machines but with no true privacy. A steady stream of specialists, nurses, residents came through the glass doors, peering at your quiet form through the mass of wires, tubes, lines, and drains. The soft tick-tick-tick-tick of the pump was drowned out by the engine roar of the ventilator, like steady gunfire. There was no joy in this task, but there was some small comfort in its perfunctory nature, some sense of achievement from the steadily growing volumes collected with small syringes, containers, bottles that I could label and deposit neatly in plastic bags. It had the same routine, familiar steps, boxes to be checked. An echo of the way I kept my life organized at work.

When we were alone, I read to you. Here, there was some hesitation, some fear. I did not know if I wanted you to become a child, my child, whom I could love and therefore lose. It was easier to see you as a patient, to imagine that you were that other baby, the one I cared for in the same room just a few years earlier, when I was an intern diligently holding a retractor for the same operation you had at just 2 days old.

But slowly, over those first weeks, my surgical armor shifted, slipped, cracked. As you gradually opened your eyes and looked into mine, as I felt your tiny but firm hand clasp around my finger, you slowly claimed me as your own. Machines left the room, revealing the soft tick-tick-tick-tick of the breast pump, and the milk that I produced was drawn up neatly into syringes and slowly drained into the tube snaked across your face. Eventually, I could hold you, and bury my face in your hair, and smell your soft-sour scent.

And suddenly you were a child, my son. And I could love and therefore lose you.


Parents Are “Essential” Caregivers

Around the world, neonatal intensive care units (NICUs) had to adjust many of their routine practices due to coronavirus disease-2019 (COVID-19) while trying to continue to provide excellent care for newborns and their families. Prior to COVID-19, most NICUs used family-centered care as the framework to engage parents in infant caregiving. However, due to the need for urgent implementation of COVID-19 crisis management procedures in early 2020, family-centered policies regarding parental presence in the NICU were quickly modified to restrict parents’ presence at the bedside. New policies varied from unit to unit and even changed over time, as we learned more about how the virus spreads. Yet, as 2020 turned into 2021, many of the restrictive parent presence policies have been slow to return to prepandemic standards despite an increased understanding of the virus spread, implementing safety protocols for healthcare workers that could have been adapted for parents, and knowing that parents as caregivers are essential to excellent neonatal care. Infants develop best when they are emotionally and physically attached to their parents. Parent presence and participation in care results in improved outcomes for both newborns and parents. Randomized controlled trials that employed family-centered care interventions resulted in increased newborn weight gain, decreased readmissions, and decreased parental anxiety, depression, and stress.

During the pandemic, some of the reported restricted parental presence policies included: allowing only one parent to visit at a time; decreased mothers’ presence to 2 hours per day; and, limiting fathers’ presence to 1 hour per week. In one cross sectional survey of 277 NICUs, parental presence 24 hours per day 7 days per week decreased from 83% to 53%. These strict restrictions have led to parents requesting to be allowed back into NICUs.For example, after an informal survey of parents revealed concerns about family restrictions during the pandemic, the Vermont Oxford Family Faculty spoke out and stated that parents should be allowed back in the NICU to participate in care. Jennifer Canvasser, a former NICU parent who lost her son to necrotizing enterocolitis in 2012 and founder and director of The NEC Society, wrote about the importance of parental presence in the NICU to ensure shared decision-making at the bedside. Both the Vermont Oxford Family Faculty and Canvasser asked that partnerships with parents to be recognized during these complicated times. As NICUs grappled with these decisions, NICUs could have looked to use guidance from experts, such as the Institute for Patient and Family-Centered Care (IPFCC), to help make sure that parents were included in decisions at both the bedside and at the hospital level through the use of the IPFCC’s pandemic planning resources.

As in most pandemic work environments, extended use of technology is already in place in the NICU and new online platforms played a major role in connecting with families due to limited parental presence. Technology may have been an appropriate early solution to parent engagement as units learned about the pandemic, yet it was never meant to replace in-person visits. Seeing their newborn during physical separation may have been helpful to parents; however, it was insufficient. Parental presence as an active caregiver fosters infants’ security and parent–infant attachment.

As neonatal nurses we must continue to advocate for parents to be fully involved in their newborn’s care and ensure that parents feel supported throughout the NICU stay. That is why NANN has joined with the National Perinatal Association and the Association of Women’s Health Obstetric and Neonatal Nurses Association in the Consensus Statement on Family Presence in Neonatal Intensive Care Units.11 During the pandemic, the parent/caregiver role has not been seen as “essential” and parental presence in the NICU was not as hardwired into our culture as many would have liked to believe. We must now fully embrace parents as “essential caregivers” to the care of their infants in the NICU and avoid slipping back into the habit of labeling parents as visitors. Parents need supported in their need to be able to routinely participate in their newborn’s NICU care. We need to advocate for the holistic care of newborns, parents, and families to support our family-centered decisions at the unit, local, and national levels. Parents are essential; they must become the “constant” and not the “visitor.” It is now time for all neonatal clinicians to partner with parents so that infants and families can fully benefit from family-centered care.

Behr, Jodi Herron PhD, APRN, RNC-NIC, ACCNS-P; Brandon, Debra PhD, RN, CCNS, FAAN; Co-Editor; McGrath, Jacqueline M. PhD, RN, FNAP, FAAN; Co-Editor Parents Are “Essential” Caregivers, Advances in Neonatal Care: April 2021 – Volume 21 – Issue 2 – p 93-94 doi: 10.1097/ANC.0000000000000861


7 precautions to be taken by a high-risk pregnancy patient

By Dr Gandhali Deorukhkar –Wednesday, April 21, 2021

Accepting your condition is the first step to dealing with a high-risk pregnancy.

Given the current lifestyle and work culture, many women are undergoing high-risk pregnancies. If you are someone with a high-risk pregnancy, the emotional roller-coaster is a part of the package. Although anxiety and stress are inevitable, there is really no dire need to get too worked up about your high-risk pregnancy. With the development of amazing medical facilities and regular prenatal care, you can have a healthy baby with a safe outcome despite your high risk.

Here are 7 precautions you need to follow to have a healthy baby.


Accepting your condition is the first step to dealing with a high-risk pregnancy. Knowing that you have to handle a high-risk pregnancy makes you well aware and better prepared. You know what you are getting into. You understand all the essential complications well. If you remain in denial, then you cannot judge the red flags and you will miss out on essential treatment.


The key to handling a high-risk pregnancy is to trust your doctor. Have faith in your physician that they want the best for you and will advise the same. Reading articles on the internet or listening to other family and friends providing their unsolicited advice will only make things worse. You need to listen only to the expert. Avoid reading unnecessary information online and stop confusing your mind. Better option is to get all your queries solved by the gynaecologist herself.


Be consistent with your management plan. Take your medicines on time. Do not miss out on any of the supplements. All are essential and critical for the growth of your healthy baby. In case of any adverse side-effects, inform your physician right away. Do not hesitate to consult your physician for any complaint. Give a detailed history of all the issues that you are facing in your high-risk pregnancy.

Strict control

Diet is an essential part of a healthy lifestyle. Given your high-risk pregnancy, it is even more necessary to follow a healthy diet. Do not give in to all your cravings. Moderation is key. Control your portion size and limit your intake of fatty and sugar-filled foods. Junk food is completely off the table. In case you have conditions like gestational diabetes, you may have to go off of sugar entirely. Women with hypertension during pregnancy, which is known as eclampsia and pre-eclampsia, need to be careful about their salt intake. You may also be advised for complete bed rest owing to the severity of your condition. Hence, it is better to follow a strict diet plan to avoid all such added flavours of salt and sugar.

Exercise regime

Exercise helps your body stay fit mentally and physically. But if you have been diagnosed with a high-risk pregnancy and are suffering from a low-lying placenta, it is advised not to carry out yoga and antenatal exercises. Consult your gynaecologist about the exercises that are allowed for your case and follow them to the T.


Know your symptoms well. Understand the side-effects and symptoms of any complications that may arise, so that you are better prepared to inform your physician right away. If there is any kind of spotting or bleeding or any sudden pain with decreased baby movement, report to your gynaecologist right away. This way, you can avoid all complications at an earlier stage itself.


Be prepared with all the necessary essential items you require post-delivery. Pack your hospital bag well in advance as you never know when you may deliver with a high-risk pregnancy. Most cases have a proactive birth plan ready. But in case of an emergency, you are ready and good to go without the hassle of packing at the last minute.

Most importantly, have a strong support system with you. You need someone you can communicate with and share all your worries with. They just need to be there listening to you and helping you stay calm and relaxed. Listen to your body and your baby. They will guide you in the right direction. Maintain your regular visits to the gynaecologist and get all your doubts solved. Stay happy and keep smiling for a healthy pregnancy and complication-free delivery. Remember, a stress-free pregnancy is a happy pregnancy.

(The writer is Gynecologist, Wockhardt Hospital, Mumbai Central)



Two Indias: The structure of primary health care markets in rural Indian villages with implications for policy

Social Science & Medicine

Available online 15 June 2020, 112799


We visited 1519 villages across 19 Indian states in 2009 to (a) count all health care providers and (b) elicit their quality as measured through tests of medical knowledge. We document three main findings. First, 75% of villages have at least one health care provider and 64% of care is sought in villages with 3 or more providers. Most providers are in the private sector (86%) and, within the private sector, the majority are ‘informal providers’ without any formal medical training. Our estimates suggest that such informal providers account for 68% of the total provider population in rural India. Second, there is considerable variation in quality across states and formal qualifications are a poor predictor of quality. For instance, the medical knowledge of informal providers in Tamil Nadu and Karnataka is higher than that of fully trained doctors in Bihar and Uttar Pradesh. Surprisingly, the share of informal providers does not decline with socioeconomic status. Instead, their quality, along with the quality of doctors in the private and public sector, increases sharply. Third, India is divided into two nations not just by quality of health care providers, but also by costs: Better performing states provide higher quality at lower per-visit costs, suggesting that they are on a different production possibility frontier. These patterns are consistent with significant variation across states in the availability and quality of medical education. Our results highlight the complex structure of health care markets, the large share of private informal providers, and the substantial variation in the quality and cost of care across and within markets in rural India. Measuring and accounting for this complexity is essential for health care policy in India.

Full Article:


Reproductive risks in 35-year-old adults born very preterm and/or with very low birth weight: an observational study

Van der Pal, S.M., van der Meulen, S.A., Welters, S.M. et al. Reproductive risks in 35-year-old adults born very preterm and/or with very low birth weight: an observational study. Eur J Pediatr 180, 1219–1228 (2021).


Evidence suggests that increased survival over the last decades of very preterm (VPT; gestational age < 32 weeks)– and very low birth weight (VLBW; birth weight < 1500 g)–born infants is not matched by improved outcomes. The objective of our study was to evaluate the reproductive rate, fertility, and pregnancy complications in 35-year-old VPT/VLBW subjects. All Dutch VPT/VLBW infants born alive in 1983 and surviving until age 35 (n = 955) were eligible for a POPS-35 study. A total of 370 (39%) subjects completed a survey on reproductive rate, fertility problems, pregnancy complications, and perinatal outcomes of their offspring. We tested differences in these parameters between the VPT/VLBW subjects and their peers from Dutch national registries. POPS-35 participants had less children than their peers in the CBS registry. They reported more problems in conception and pregnancy complications, including a three times increased risk of hypertension during pregnancy.

Conclusion: Reproduction is more problematic in 35-year olds born VPT/VLBW than in the general population, possibly mediated by an increased risk for hypertension, but their offspring have no elevated risk for preterm birth.

What is known:
At age 28, the Dutch national POPS cohort, born very preterm or with a very low birth in 1983, had lower reproductive rates than the general Dutch population (female 23% versus 32% and male 7% versus 22%).
What is new:
At age 35, the Dutch POPS cohort still had fewer children than the general Dutch population (female 56% versus 74% and male 40% versus 56%). Females in the POPS cohort had a higher risk of fertility problems and pregnancy complications than their peers in the Dutch national registries, but their offspring had no elevated risk for preterm birth.


Improving thermoregulation in transported preterm infants


Infants born preterm (<37 weeks of gestation) or with a low birthweight (<2.5 kg) are at high risk for decreasing body temperature during transportation to the hospital. Hypothermia in preterm infants is a risk factor for increased mortality and morbidity (e.g. respiratory distress syndrome). Therefore, effective thermoregulation during transport is of outmost importance.

In the study by Glenn et al., interventions were developed to increase the efficacy of thermoregulation in transported newborn infants. Close collaboration with the transportation teams at the University Hospitals Rainbow Babies and Children’s Hospital in Cleveland, USA, was key, which lasted from January 2016 to December 2019. A total of 380 infants were included in the study, with a range in gestational age of 22 to 40 weeks and a weight range of 420g to 4220g. 229 of the infants were born preterm or with low birthweight.

The first 17 months of the study were used to gather baseline data, revealing an average of only 60% of preterm or low birthweight infants, who were admitted to the NICU with normal temperature (36.5°C – 37.5°C). Afterwards, together with a multidisciplinary team consisting of neonatologists, transport staff and paediatricians, Glenn et al. reviewed the transport protocols and chose a new set of interventions. These included controlling the heat of the transport incubator, using plastic wrap, exothermic warming mattresses, and temperature monitoring. For the intervention, the team used the Voyager Airborne Transport Incubator and Velcro closure wrap.

Furthermore, interventions included a check of temperature before the start of transport, and checking it continuously if it was outside the acceptable range. Feedback of the transport team indicated that most infants who arrive hypothermic at the NICU were already in this state at the beginning of transport. Staff members had difficulties normalising the temperature during transportation. Therefore, a supply checklist, increase of temperature in the operating room and immediate notification of the transport team of an upcoming delivery were implemented to address these difficulties. Additionally, and in response to the feedback, the heat of the transport incubator was made adjustable from 32-37°C depending on the infant’s weight and age (<1 day or >1 day) to meet their individual needs.

Overall, the interventions resulted in an increase by 36% (from 60% to 96%) of infants admitted within normal temperature range This could be achieved through educating staff on the importance of temperature control and by making only minor changes to thermoregulation. Especially when resources are low, interventions like using the plastic wrap are an effective way to prevent hypothermia in neonates during transport.

One of the limitations of this study is its dependency on the documentation of the transport staff. Thus, in some cases, performed interventions may not have been recorded. Nevertheless, the great increase in newborns who were admitted to the NICU within the goal temperature of 36.5°C to 37.5°C shows that the interventions were successful.

Paper available at: Journal of Perinatology

Full list of authors: Tara Glenn, Rhonda Price, Lauren Culbertson, Gulgun Yalcinkaya

DIO: 10.1038/s41372-020-0732-z


Scientific Duo Gets Back To Basics To Make Childbirth Safer

February 18, 2019

Their research is still in early stages, but Kristin Myers (left), a mechanical engineer, and Dr. Joy Vink, an OB-GYN, both at Columbia University, have already learned that cervical tissue is a more complicated mix of material than doctors ever realized. –Adrienne Grunwald for NPR

Brittney Crystal was just over 25 weeks pregnant when her water broke.

It was her second pregnancy — the first had been rough, and the baby came early.

To try to avoid a second premature birth, Dr. Joy-Sarah Vink, an obstetrician and co-director of the Preterm Birth Prevention Center at Columbia University Medical Center, arranged for Crystal to be transported by ambulance from her local Connecticut hospital to New York City, where Vink could direct her care.

Two weeks later Crystal started having contractions. She was given magnesium sulfate to stop them, and made it through the night. Crystal believed there was a future for her coming baby, whom she had named Iris.

“I went to the mirror and I talked to Iris,” Crystal says. “I said, ‘you know, this was a rough day. … You’re going to have them. But then the next day comes and the sun comes up and we move forward.’ “

That evening, however, the contractions started again. Crystal was whisked to an operating room for a Cesarean section. She was a little under 28 weeks pregnant.

“I think I knew before I opened my eyes that she had died,” Crystal says, her voice cracking as she reaches for a tissue.

Afterward, as she was recovering in the hospital and mourning the loss of Iris, Crystal and her family asked a lot of questions. Why can’t you seal up the amniotic sac if your water breaks early? Why can’t you reliably stop preterm labor?

“And that’s when Dr. Vink told us that, you know, rare diseases are being cured in this day and age, but we don’t know what triggers full-term labor,” Crystal recalls. “That just collectively blew away everyone in the room.”

It was surprising but true. When it comes to pregnancy, research on some basic questions stalled decades ago, Vink says. If a pregnancy is normal, that doesn’t matter much. But when things go wrong, those gaps in knowledge become issues of life and death.

“It’s mind-boggling that in this day and age, we still don’t understand [even] in a normal pregnancy how women go into labor — what triggers labor,” Vink says. “Because we don’t understand the normal fundamental mechanisms, we can’t identify how things go bad — and then how we fix it when things go bad.”

Crystal, for example, had undergone a procedure called cervical cerclage: Vink had stitched Crystal’s cervix closed in hopes of preventing it from opening too soon. The technique has been around for more than 40 years, and it’s about the only treatment available for what doctors call “an incompetent cervix.” But much of the time, it’s not enough to stop a premature birth.

Most basic knowledge about pregnancy comes from research performed in the 1940s, Vink says, and she’s working hard to update that information.

She’s focused first on the cervix, she says, because if doctors can get the cervix to stay closed in those final, crucial weeks of gestation, the baby won’t be born too soon, even if the amniotic sac breaks.

“So, what is the cervix made out of? What proteins are there, what cells are there? How are all these things interacting? How do they change in pregnancy?” she asks, laying out some of the unknowns. By the end of pregnancy, a woman’s cervix goes from being stiff, like the tip of a nose, to very soft. But how?

To help answer those questions, Vink and her graduate researchers are taking, for analysis, cervical tissue samples from women in her medical practice who are at different stages of pregnancy.

One of her first findings, she says, is that the cervix is not made mostly of collagen, as doctors long thought. It also has a lot of muscle, especially near the very top.

While Vink studies what the cervix is made of, one of her university colleagues, mechanical engineer Kristin Myers, is trying to determine how it works.

“I’m kind of an oddball in the department of obstetrics and gynecology,” Myers says. “I teach mechanics classes and design classes here at Columbia.”

Myers got her start as an undergraduate, doing materials research in the automobile industry. Back then she tested how tires respond to heat.

“So if you take rubber and you heat it up and you pull on it, it gets really, really soft — and then it breaks,” Myers says.

That reaction reminded her adviser of how a bulging aneurysm bursts. He suggested she focus her curiosity on the mechanics of the human body. When she arrived at MIT for her graduate studies, Myers worked with researchers who were interested in the mechanics of pregnancy.

“It’s an important area — an understudied area — and a basic part of pregnancy physiology,” says Dr. Michael House, an OB-GYN at Tufts Medical Center who also has a background in engineering. “There is just lots to learn.”

House has been a mentor to Myers and continues to collaborate with her. He says the focus on the cervix is particularly important, “because a cervix problem can affect the pregnancy very early.”

About 1 in 10 babies are born prematurely in the U.S. each year. If those babies are born close to term — after around 35 weeks — they can do quite well. But a woman with a problematic cervix can go into labor much sooner, which can lead to miscarriage or a baby born so early that the child may die or face lifelong health problems.

Myers is investigating several aspects of the biomechanics of pregnancy — from how much the uterus can stretch, to how much pressure pregnancy exerts on the cervix, to how much force a baby’s kick puts on the whole system.

“We’re building computational models of female pregnancy to answer those questions,” Myers says.

She has two labs at Columbia — one at the hospital and one in the engineering school. In the lab at the engineering school there are a variety of microscopes and scalpels and slides. There’s one machine that can inflate the uterine membranes like a balloon, and another, about the size of a microwave, that stretches uterine tissue between two grips.

“These [are] types of machines you’ll see in all different kinds of material testing labs,” Myers explains. “In civil engineering you can have one of these machines that is like two or three stories high and they’re testing the mechanical strength of, [say], railroad ties.”

She is measuring just how much the cervical tissue changes during pregnancy — starting out with the capability and consistency of a tendon, and becoming something more like a loose rubber band.

“We’ve mechanically tested various pregnant tissues and nonpregnant tissues of the cervix,” Myers says, “and its stiffness changes by three orders of magnitude.”

All those measurements go into a databank. And when women in Vink’s practice get an ultrasound, the technicians spend an extra few minutes measuring the mother’s anatomy, as well as the baby’s, and send that information to Myers, too.

Then the team uses their computer models to look at how the various factors — shape, stretch, pressure and tissue strength — interact as a woman moves toward labor and childbirth.

Their goal is to be able to examine a pregnant woman early on, and accurately predict whether she will go into labor too soon. It’s a first step, Vink hopes, toward better interventions to stop that labor.

That’s what Brittney Crystal is aiming for as well. After baby Iris died, Crystal started a foundation called The Iris Fund, which has raised more than $150,000 for Vink’s and Myers’ research.

“She didn’t get to have a life,” Crystal says. “But we really want her to have a very strong legacy.”


LuSi Video Brochure

Apr 16, 2021                          LuSi neosim

LuSi is a Lung simulator to train clinicians in the assessment of lung function and the application of respiratory therapy without risk to patients. LuSi responds to treatment without operator intervention and can simulate pathologies like RDS, lung collapse, weak muscular activity, pneumothorax, airway obstruction, etc. The vital signs parameters are calculated based on actually measured values such as pressure, flow and volume plus case-specific pathology like dead space, CO2 production and lung compliance. LuSi reacts to therapy without need for an operator – no technician is needed in the background to change oxygen saturation or arterial PCO2 – because LuSi is autonomous. The embedded real-time artificial intelligence makes her the only autonomous lung simulator in the world. LuSi can be used in the hospital setting or out of hospital in any training facility because it does not need CO2 gas nor actual monitoring equipment.


Who’s on First? Split and Shared Services in the NICU

Scott D. Duncan, MD, MHA Professor and Chief Division of Neonatal Medicine University of Louisville

The baseball analogy is appropriate in neonatology, as the provision of neonatal care is a team sport, including, but not limited to, physicians, advanced practice providers, nursing, nutritionists, pharmacists, respiratory therapists, speech therapists, physical therapists, and social workers. In many instances, the neonatologist’s role has undergone significant modifications, with an increasing role of advanced practice providers, as well as a reduction in trainee rotations and restrictions on work hours.


In the batter’s box, the delivery team attends the delivery of a 32- week gestation infant due to maternal gestational diabetes and pre-eclampsia. The delivery team includes two nurses, a respiratory therapist, and a neonatal nurse practitioner (NNP) as the team leader. In the delivery room, the infant requires intubation and positive pressure ventilation. The infant is admitted to the NICU on a ventilator. By 30 minutes of age, the infant demonstrates increasing respiratory distress, hypercarbia, and the CXR reveals severe RDS. The NNP orders surfactant therapy.

While making rounds with the fellow and resident team, the neonatologist asks the NNP about the patient. The NNP gives the neonatologist a verbal report and completes the electronic medical record’s history and physical (EMR). Following rounds, the neonatologist examines the infant and places a macro-based attestation used for resident documentation on the H&P, co-signs the note, and uses the charge capture feature on the EMR to place a 99468 code for the date of admission.

A Strikeout

Strike One – The neonatologist provided limited services in the assessment and care plan.

Strike Two – A NNP is not a trainee, and Physician at Teaching Hospital (PATH) guidelines do not apply for documentation and attestations.

Strike Three – The service for the day is an initial critical care charge, and split/shared services are prohibited with critical care delivery.


 In this Scenario, the neonatologist made multiple errors as related to split/shared services and supervision. A split/shared service is an encounter where a physician and the NNP from the same group and same specialty each personally perform a portion of an Evaluation and Management (E/M) visit. As applied to in-patient neonatology, the split/shared E/M rule applies only to selected E/M visits such as these in the hospital settings:

• hospital admissions (CPT® codes 99221-99223)

• subsequent hospital visits (CPT® Codes 99231-99233)

• discharge management (CPT® Codes 99238-99239).

In the case of critical care, split/shared services are not allowed. The guidance provided by the US Department of Health and Human Services states, “Critical care services are reflective of the care and management of a critically ill or critically injured patient by an individual physician or qualified non-physician practitioner for the specified reportable period of time. Unlike other E/M services where a split/shared service is allowed, the critical care service reported shall reflect the evaluation, treatment, and management of a patient by an individual physician or qualified non-physician practitioner [NPP] and shall not be representative of combined service between a physician and a qualified NPP.” (1)

Appropriate documentation must substantiate the nature of the admission. Per the recommendations of the AAP Committee on Coding and Nomenclature, (2) the medical record documentation should include:

• Documentation of the critical status of the infant

• Documentation of the bedside direction and supervision of all aspects of care

• Review of pertinent historical information and verification of significant physical findings through a medically indicated, focused patient examination

• Documentation of all services provided by members of the care team and discussion and direction of the ongoing therapy and plan of care for the patient

• Additional documentation of any major change in a patient course requiring significant hands-on intervention by the reporting provider

Split/shared services may be utilized for E/M services, hospital admissions, subsequent hospital visits, and discharge, as noted above. In these instances, the providers should each document their portion of the service provided. Charges may be placed using the following rules:

• When the physician provides any face-to-face portion of the encounter, use either provider’s NPI

• When the physician does not provide a face-to-face encounter, use the NNP’s NPI

Revised Scenario – a pinch hitter At the plate, the delivery team attends the delivery of an infant of 32-week gestation due to maternal gestational diabetes and preeclampsia. The delivery team includes two nurses, a respiratory therapist, and a neonatal nurse practitioner (NNP) as the team leader. In the DR, the infant requires PPV and intubation. The infant is brought to the NICU on assisted ventilation. By 30 minutes of age, the infant demonstrates increasing respiratory distress, hypercarbia, and the CXR reveals severe RDS.

While making rounds with the fellow and resident team, the neonatologist asks the NNP about the patient. The NNP gives the neonatologist a verbal report, and the neonatologist leads the rounding team to the patient’s bedside, where a complete examination is performed. The neonatologist orders surfactant replacement, and following rounds completes a history and physical, including the assessment and plan, in the EMR, independent of documentation by the NNP. The neonatologist uses the charge capture feature on the EMR to place a 99468 charge for the date of admission. A Home Run!


Preterm birth, neonatal therapies and the risk of childhood cancer

Laura K Seppälä1Kim Vettenranta2Maarit K Leinonen3Viena Tommiska4Laura-Maria Madanat-Harjuoja5doi: 10.1002/ijc.33376. Epub 2020 Nov 11.


Our aim was to study the impact of preterm birth and neonatal therapies on the risk of childhood cancer using a nationwide, registry-based, case-control design. Combining population-based data from Finnish Medical Birth Registry (MBR) and Finnish Cancer Registry, we identified a total of 2029 patients diagnosed with cancer under the age of 20 years and 10 103 age- and sex-matched controls over the years 1996 to 2014. Information on the prenatal and perinatal conditions was obtained from the MBR. Gestational age was categorized into early (<32) and late preterm (32-36) and term (≥37 weeks). Cancer risk among the preterm compared to term neonates was evaluated using conditional logistic regression. We identified 141 cancers among the preterm (20.8% of 678) vs 1888 cancers in the term children (16.5% of 11 454). The risk of any cancer was increased for the preterm (odds ratio [OR] 1.28, 95% confidence interval [CI] 1.06-1.57), especially for the early preterm (OR 1.84, 95% CI 1.16-2.92). The risk of acute myeloid leukemia (AML; OR 2.33, 95% CI 1.25-4.37), retinoblastoma (OR 3.21, 95% CI 1.22-8.41) and germ cell tumors (OR 5.89, 95% CI 2.29-15.18) was increased among the preterm compared to term. Germ cell tumors were diagnosed at a significantly younger age among the preterm. Neonatal therapies, for example, mechanical ventilation, were associated with an increased risk of childhood cancer independent of gestational age. Preterm, especially early preterm birth, is associated with an increased risk of childhood cancer, especially germ cell tumors and AML. Respiratory distress requiring neonatal intervention also appears to be associated with an increased risk.


Preterm Birth and the Development of Visual Attention During the First 2 Years of Life

A Systematic Review and Meta-analysis

Or Burstein, MA1Zipi Zevin, BA1Ronny Geva, PhD1,2

JAMA Netw Open. 2021;4(3):e213687. doi:10.1001/jamanetworkopen.2021.3687 – March 30, 2021

Key Points

Question  Is preterm birth associated with visual attention impairments in early life, and if so, in which attention functions?

Findings  This systematic review and meta-analysis of 53 studies including 2047 preterm-born and 1951 full-term–born neonates and infants found that preterm birth was significantly associated with impairments in visual attention functioning. Despite a short-term advantage in visual-following in preterm infants, deficits cascaded from basic orienting responses to focused attention during the first 2 years of life.

Meaning  The findings suggest that preterm birth is associated with challenges in the development of visual attention beginning in the early stages of life.


Importance  Preterm birth is associated with an increased risk for long-lasting attention deficits. Early-life markers of attention abnormalities have not been established to date but could provide insights into the pathogenesis of attention abnormalities and could help identify susceptible individuals.

Objective  To examine whether preterm birth is associated with visual attention impairments in early life, and if so, in which attention functions and at which developmental period during the first 2 years of life.

Data Sources  PubMed and PsycINFO were searched on November 17, 2019, to identify studies involving visual attention outcomes in infants born preterm vs full term.

Study Selection  Peer-reviewed studies from the past 50 years met the eligibility criteria if they directly assessed visual attention outcomes until the age of 2 years in generally healthy infants born preterm or full term. The selection process was conducted by 2 independent reviewers.

Data Extraction and Synthesis  The Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guideline was followed. Random-effects models were used to determine standardized mean differences. The risk of bias was assessed both within and between studies.

Main Outcomes and Measures  Five nascent indices of visual attention were analyzed, including very basic functions—namely, the abilities to follow and fixate on visual targets—and more complex functions, such as visual processing (ie, habituation), recognition memory (ie, novelty preference), and the ability to effortfully focus attention for learning.

Results  A total of 53 studies were included, with 69 effect sizes and assessing a total of 3998 infants (2047 born preterm and 1951 born full term; of the 3376 for whom sex was reported, 1693 [50.1%] were girls). Preterm birth was associated with impairments in various attention indices, including visual-following in infancy (Cohen d, −0.77; 95% CI, −1.23 to −0.31), latency to fixate (Cohen d, −0.18; 95% CI, −0.33 to −0.02), novelty preference (Cohen d, −0.20; 95% CI, −0.32 to −0.08), and focused attention (Cohen d, −0.28; 95% CI, −0.45 to −0.11). In the neonatal period, preterm birth was associated with superior visualfollowing (Cohen d, 0.22; 95% CI, 0.03 to 0.40), possibly owing to the additional extrauterine exposure to sensory stimulation. However, this early association waned rapidly in infancy (Cohen d, –0.77; 95% CI, –1.23 to –0.31).

Conclusions and Relevance  The findings suggest that preterm birth is associated with impingements to visual attention development in early life, as manifested in basic and then complex forms of attention. Advancements in neonatal care may underlie improvements found in the current era and accentuate several early protective factors.

Building capacities of Auxiliary Nurse Midwives (ANMs) through a complementary mix of directed and self-directed skill-based learning—A case study in Pune District, Western India

Shilpa KarvandeVidula PurohitSomasundari Somla GopalakrishnanB. Subha SriMatthews Mathai & Nerges Mistry Human Resources for Health volume 18, Article number: 45 (2020)


Auxiliary nurse midwives (ANMs) play a pivotal role in provision of maternal and newborn health at primary level in India. Effective in-service training is crucial for upgrading their knowledge and skills for providing appropriate healthcare services. This paper aims at assessing the effectiveness of a complementary mix of directed and self-directed learning approaches for building essential maternal and newborn health-related skills of ANMs in rural Pune District, India.


During directed learning, the master trainers trained ANMs through interactive lectures and skill demonstrations. Improvement and retention of knowledge and skills and feedback were assessed quantitatively using descriptive statistics. Significant differences at the 0.05 level using the Kruskal-Wallis test were analysed to compare improvement across age, years of experience, and previous training received. The self-directed learning approach fulfilled their learning needs through skills mall, exposure visits, newsletter, and participation in conference. Qualitative data were analysed thematically for perspectives and experiences of stakeholders. The Kirkpatrick model was used for evaluating the results.


Directed and self-directed learning was availed by 348 and 125 rural ANMs, respectively. Through the directed learning, ANMs improved their clinical skills like maternal and newborn resuscitation and eclampsia management. Less work experience showed relatively higher improvement in skills, but not in knowledge. 56.6% ANMs either improved or retained their immediate post-training scores after 3 months.

Self-directed learning helped them for experience sharing, problem-solving, active engagement through skill demonstrations, and formal presentations. The conducive learning environment helped in reinforcement of knowledge and skills and in building confidence. This intervention could evaluate application of skills into practice to a limited extent.


In India, there are some ongoing initiatives for building skills of the ANMs like skilled birth attendance and training in skills lab. However, such a complementary mix of skill-based ‘directed’ and ‘self-directed’ learning approaches could be a plausible model for building capacities of health workforce. In view of the transforming healthcare delivery system in India and the significant responsibility that rests on the shoulder of ANMs, a transponder mechanism to implement skill building exercises at regular intervals through such innovative approaches should be a priority.


Get easily out of breath? It may be because you were small at birth, study finds

January 31, 2020 Karolinska Institutet

Babies born with low birth weights are more likely to have poor cardiorespiratory fitness later in life than their normal-weight peers. That is according to a study by researchers at Karolinska Institutet in Sweden published in the journal JAHA. The findings underscore the importance of prevention strategies to reduce low birth weights even among those carried to at term delivery.

Having a good cardiorespiratory fitness — that is ability of the body to supply oxygen to the muscles during sustained physical activity — is important for staying healthy and can reduce the risk of numerous diseases and premature death. Alarmingly, cardiorespiratory fitness is declining globally, both for youths and adults. A recent study showed that the proportion of Swedish adults with low cardiorespiratory fitness almost doubled from 27 percent in 1995 to 46 percent in 2017.

Given its implications for public health, there has been a growing interest in understanding the underlying causes of poor cardiorespiratory fitness. Researchers have identified both physical inactivity and genetic factors as important determinants. Preterm delivery, and the low birth weight associated with it, has also been linked to low cardiorespiratory fitness later in life. In this study, the researchers wanted to examine if low birth weights played a role for cardiorespiratory fitness in individuals born after pregnancy of 37-41 weeks.

They followed more than 280,000 males from birth to military conscription at age 17-24 using Swedish population-based registers. At conscription, the men underwent a physical examination that included an evaluation of their maximal aerobic performance on a bicycle ergometer. The researchers found that those born with higher birth weights performed significantly better on the cardiorespiratory fitness test. For every 450 grams of extra weight at birth, in a baby born at 40 weeks, the maximum work capacity on the bicycle increased by an average of 7.9 watts.

The association was stable across all categories of body mass index (BMI) in young adulthood and was largely similar in a subset analysis of more than 52,000 siblings, suggesting that BMI and shared genetic and environmental factors alone cannot explain the link between birth weight and cardiorespiratory fitness.

“The magnitude of the difference we observed is alarming,” says Daniel Berglind, researcher at the Department of Global Public Health at Karolinska Institutet and corresponding author. “The observed 7.9 watts increase for each 450 grams of extra weight at birth, in a baby born at 40 weeks, translates into approximately 1.34 increase in metabolic equivalent (MET) which has been associated with a 13 percent difference in the risk of premature death and a 15 percent difference in the risk of developing cardiovascular disease. Such differences in mortality are similar to the effect of a 7-centimeter reduction in waist circumference.”

The researchers believe the findings are of significance to public health, seeing as about 15 percent of babies born globally weigh less than 2.5 kilos at birth and as cardiorespiratory fitness have important implications for adult health.

“Providing adequate prenatal care may be an effective means of improving adult health not only through prevention of established harms associated with low birth weight but also via improved cardiorespiratory fitness,” says Viktor H. Ahlqvist, researcher at the Department of Global Public Health and another of the study’s authors.


Pets have been shown to ease stress, anxiety, and provide emotional support to their owners/families.  Like many, as I have adjusted to the new normal of being at home 24/7. On days when the isolation of being separated from friends, mentors, colleagues, peers, and family has felt endless, our PTSD survivor cat Gannon has reminded me to be grateful for the little moments in time that bring joy into mundane daily tasks. While vaccination rollouts have ignited our hope for progressing towards increased in-person gathering,  we still have a way to go. When working out seems like a drag I nab Gannon, put him in his big outdoor see-through tent,  and enjoy his companionship and entertaining, hilarious behaviors. We are buddies.  Following our recent move to Seattle, Gannon (a house cat) has managed to make countless neighborhood friends with other cats without leaving the home. Throughout the day and especially at night, he entertains and socializes with frequent “visitors” through our various small and large windows. He prefers we leave the living room and adjoining office area by 11:30 PM so he can  enjoy his social time with his new friends who gather on the front porch. Observing him forming these mysterious connections fascinates me.  As we progress towards increased in-person socialization Gannon continues to inspire me to be open to forming  new and exciting friendships and reminds me that some barriers we anticipate are actually doors and windows we can open.

Adopting a pet may seem like a selfless act, but there are plenty of selfish reasons to embrace pet ownership. Research has shown that caring for a pet may provide numerous health benefits. An article by  John Hopkins Medical Director  Jeremy Barron, M.D reveals the positive effects a pet can have towards reducing stress, lowering blood pressure, increasing activity, and easing loneliness and depression.

Enjoy Dr. Barron’s pet suggestions

Meet Ishita Malaviya, India’s first woman surfer | Her Game

Mar 25, 2021 

When Ishita started surfing, there were no other known women surfers in India. Now, every boy and girl in her village has access to free surfing lessons. Watch her inspiring story.



Rank: 101  –Rate: 9.5%   Estimated # of preterm births per 100 live births (USA – 12 %, Global Average: 11.1%)

Rwanda, officially the Republic of Rwanda, is a landlocked country in the Great Rift Valley, where the African Great Lakes region and East Africa converge. One of the smallest countries on the African mainland, its capital city is Kigali. Located a few degrees south of the Equator, Rwanda is bordered by UgandaTanzaniaBurundi, and the Democratic Republic of the Congo. It is highly elevated, giving it the soubriquet “land of thousand hills”, with its geography dominated by mountains in the west and savanna to the east, with numerous lakes throughout the country. The climate is temperate to subtropical, with two rainy seasons and two dry seasons each year. Rwanda has a population of over 12.6 million[8] living on 26,338 km2 (10,169 mi) of land, and is the most densely populated mainland African country.

The population is young and predominantly rural. Rwandans are drawn from just one cultural and linguistic group, the Banyarwanda. However, within this group there are three subgroups. Christianity is the largest religion in the country; the principal language is Kinyarwanda, spoken by most Rwandans, with English and French serving as additional official languages. The sovereign state of Rwanda has a presidential system of government. Rwanda is one of only three countries in the world with a female majority in the national parliament, the two other countries being Bolivia and Cuba.

The quality of healthcare in Rwanda has historically been very low, both before and immediately after the 1994 genocide. In 1998, more than one in five children died before their fifth birthday, often from malaria.

President Kagame made healthcare one of the priorities for the Vision 2020 development programme, boosting spending on health care to 6.5% of the country’s gross domestic product in 2013, compared with 1.9% in 1996.

In recent years Rwanda has seen improvement on a number of key health indicators. Between 2005 and 2013, life expectancy increased from 55.2 to 64.0, under-5 mortality decreased from 106.4 to 52.0 per 1,000 live births, and incidence of tuberculosis has dropped from 101 to 69 per 100,000 people. The country’s progress in healthcare has been cited by the international media and charities. The Atlantic devoted an article to “Rwanda’s Historic Health Recovery”. Partners In Health described the health gains “among the most dramatic the world has seen in the last 50 years”.

Rwanda also has a shortage of medical professionals, with only 0.84 physicians, nurses, and midwives per 1,000 residents. The United Nations Development Programme (UNDP) is monitoring the country’s health progress towards Millennium Development Goals 4–6, which relate to healthcare.


UNICEF/UN0321627/Kanobana Jemimah, right, sits with two other mothers in the Kangaroo Care room. Gahini Hospital did not always have the best care, but with more medical equipment and better trained doctors through the clinical mentorship programme, mothers like Jemimah feel safer and happier giving birth here.

Born too early: Rwanda’s smallest babies/UNICEF Rwanda

In Gahini Hospital, two paediatric mentor-trainers from the United Kingdom are training Rwandan doctors and nurses to better care for newborn babies who are born premature. The Rwandan health professionals then pass this knowledge to their peers and to the mothers and fathers of these babies.


Sweet, powerful, inspirational, chart topper Rwandan gospel music 2021. Enjoy!

Aline Gahongayire – Izindi Mbaraga featuring Niyo Bosco (Official Video 2021)

•Premiered Mar 5, 2021  #NiyoBosco​ #AlineGahongayire​ #newmusic​

Commentary: Residency programs must address new interns’ divergent skills, experience

Jennifer R. Di Rocco, D.O., M.Ed., FAAP and Marissa H. Fakaosita, M.D., FAAP

March 17, 2021

We all have felt the strain of adapting to an ever-changing world of medical education during the COVID-19 pandemic.

Medical students and residents have been pulled from rotations, with some unable to experience core rotations in person or have experienced them much later in their clinical training, often at diminished capacity.

Standardized tests have been postponed or canceled, making it problematic for residency programs to evaluate candidates equally. Most visiting rotations were not possible, and interviews and hospital tours have been conducted exclusively on a virtual platform. This has made it exceedingly difficult to assess a candidate’s interpersonal skills and body language, which offer valuable, distinguishing information (Hammoud MM, et al. JAMA. 2020;324:29-30).

Residency programs and applicants alike have gone to great lengths to bolster their online presence. Yet, it feels like both sides are wearing blinders when making match lists outside of home institutions, as they base choices on virtual versions of people and places.

On Match Day 2021, filling an intern class and matching into an accredited residency program still will be the benchmark of a successful match. But where will we go from there?

Despite the numerous challenges and limitations that a virtual residency recruitment season brings, there are some benefits that could permanently transform what residency recruitment and the “interview trail” look like. Virtual recruitment naturally expands and diversifies a residency program’s applicant pool and allows for increased convenience in scheduling interviews. Further, the cost savings of forgoing travel allows for a more equal and consistent process for all applicants. Ultimately, remotely conducted meetings and interviews are not only modern, they have become the new normal. Programs that revert to a recruitment strategy that lacks any virtual component likely will be outliers.

Whatever results Match Day brings on March 19, each program will need to scrutinize its recruitment processes and strategies, looking forward to new national recommendations to shape the next match season.

Programs also will have to prepare for their new intern class. Students and residents in pediatrics have had much less clinical exposure in the inpatient and outpatient settings, with national volumes of pediatric patients being significantly lower during quarantine and school closure periods. Residency programs will need to accept that their intern class will have had widely variable clinical exposure and experience. Programs should look closely at transcripts and have discussions with incoming interns early in the academic year to appreciate their clinical exposure. Simulation-based learning exercises during intern orientation may help identify areas that need strengthening prior to the busy fall and winter seasons. Programs then should design individualized educational units to strengthen experiential learning and create tailored plans for resident success. Faculty also will need to adjust their expectations as we all strive to comprehend the practice gaps that may exist for our new interns and rising supervisory residents.

Competency-based assessment will be of the utmost importance as we won’t be able to measure time-based training in the same fashion, with interns starting the year with widely divergent skills and expertise. The Accreditation Council for Graduate Medical Education Pediatrics 2.0 Milestones are being finalized and hopefully will offer programs and residents a more streamlined, practical tool to assess these competencies.

This year’s match has presented many challenges, but some surprising benefits may change the way we interact with resident candidates moving forward. As we weather this storm in pediatric medical education, let us share ideas to prepare the next cohort of residents to become pediatricians during this uncertain time.

Dr. Di Rocco is an associate program director of the University of Hawaii Pediatric Residency Program and a pediatric hospitalist. Dr. Fakaosita is co-chair of the Recruitment and Selection Committee and directs the Individualized Educational Unit curriculum at University of Hawaii Pediatric Residency Program and is a pediatric hospitalist.

Copyright © 2021 American Academy of Pediatrics


Incivility and Bullying in the NICU

March 13, 2021

Nurses are known to be compassionate, caring, and committed to their patients. These same nurses can sometimes be harsh and uncaring toward their colleagues. In this episode, Jill and Beth Bolick address incivility and bullying in the NICU. Beth, Professor at Rush University Medical Center College of Nursing, is a national speaker on the topic of bullying and incivility. There are a variety of ways incivility and bullying seep into the NICU – from gossip, teasing, eye-rolling, withholding business information, to even physical altercations. Beth and Jill dive into how bullying goes beyond the dyad of just two colleagues and impacts your entire unit and even direct patient care. Listen in to learn more about how to create a unit that is more civil and welcoming to colleagues and patient families alike. 

Visit for some of the free resources Beth discusses.


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Our mission at Physician Support Lifeline is to offer free and confidential peer support to American physicians and medical students by creating a safe space to discuss immediate life stressors with volunteer psychiatrist colleagues who are uniquely trained in mental wellness and also have similar shared experiences of the profession.

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We hope ultimately to build a sustainable community of peer support and wellness for physicians and medical students across the United States.

Our Goals

  • To normalize pursuit of mental wellness by physicians and medical students
  • To encourage unity and empathy among physician colleagues
  • To provide a resource for physician and medical student emotional wellness to healthcare organizations and institutions


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Grandmothers -A Neglected Family Resource For Saving Newborn Lives

Across the globe, the well-being of newborns is significantly influenced by the knowledge and practices of family members, yet global health policies and interventions primarily focus on strengthening health services to save newborn lives. Predominant approaches to promote newborn survival in non-western cultures across the Global South are based on a western, nuclear family model and ignore the roles of caregivers within wider family systems, whose attitudes and practices are determined by culturally prescribed strategies. In this paper, [the author reviews] evidence of a neglected facet of newborn care, the role and influence of senior women or grandmothers.


  • Interventions to promote newborn health and survival in the Global South primarily focus   

on young mothers based on a Eurocentric view of nuclear family structure.

  • Evidences from studies in numerous cultural contexts across Africa, Asia and Latin America reveal the significant role and influence of experienced older women, or grandmothers, on newborn care within multi-generational family systems.
  • Research reviewed from non-western collectivist cultures across the Global South suggests that grandmothers play similar core roles with newborns through advising and direct caregiving while their culturally specific practices vary greatly.
  • Future newborn policies and research should be grounded in a family systems frame that reflects the structure and dynamics of families in non-western collectivist cultures.
  • Grandmothers’ knowledge is sometimes out of date, but given their proximity, authority and commitment to newborn survival they should be explicitly involved in newborn interventions in order to optimise this abundant local resource for newborn health and survival.

Full Article:

NICU nurses help dad pop the question | Humankind

Mar 26, 2021

The look on mom’s face when she walked in the room was one of absolute shock.

Yale study finds link between autism in children, premature birth of their parents

Researchers at the Yale School of Public Health conducted the first study revealing that the preterm birth and low birth weight of parents could mean a higher risk of their children being diagnosed with autism.

Sydney Gray – FEB 08, 2021

Autism spectrum disorder, or ASD, in children may be linked to the premature birth of their parents, according to a Yale School of Public Health study.

Assistant Professor of Epidemiology Zeyan Liew and graduate student Jingyuan Xiao GRD ’26 examined the medical records of nearly 400,000 mother-child and father-child pairs. The researchers found that children had nearly double the risk of ASD if their mothers and fathers were born at earlier than 32 gestational weeks compared to children whose parents were born at term. The study was published in the International Journal of Epidemiology on Jan. 7.

“The worldwide prevalence of autism spectrum disorder (ASD) is increasing, but scientific understandings regarding the etiology of this multifactorial and complex neurodevelopmental conditions are still limited,” Liew and Xiao wrote in an email to the News. “We conducted this study to evaluate whether adverse birth characteristics of the parents … could influence ASD risk in their offspring.”

The researchers analyzed data from a cohort of 230,174 mother-child and 157,926 father-child pairs in Denmark to examine the multigenerational risk factors that might contribute to the prevalence of ASD.

The scientists also collected data on the grandparents’ and parents’ sociodemographic factors, age when pregnant, geographical location and mental health to include in their statistical models. They said that Denmark’s national health care and centralized medical records system helped make this type of longitudinal family linkage research possible.

The researchers used a pregnancy term of 37 weeks and a birth weight of 2,500 grams as a baseline reference. They found that mothers and fathers who were born prematurely — at fewer than 37 weeks of gestation — or with a low birthweight had a 30 to 40 percent higher risk of having children with ASD. Meanwhile, parents born at fewer than 32 gestational weeks had nearly double the risk of later having children with ASD, compared to parents born at term.

In the past, many studies on ASD have focused on environmental risk factors such as prenatal exposure to air pollution. Additionally, studies of family members of children living with ASD have largely centered on siblings instead of multigenerational data, the scientists said.

“It is known that certain genetics and fetal exposure to environmental risk factors contribute to the risk of ASD, but these known factors don’t fully explain the occurrence of all ASD cases in populations,” wrote Xiao and Liew. “Recently, new hypotheses regarding multigenerational risk for ASD have been proposed in animal models, but epidemiological evidence is still lacking.”

The Autism Center for Excellence Program at Yale, or ACE, led by professor Katarzyna Chawarska, currently has ongoing projects examining the brain connectivity of school-age siblings of children with autism to better comprehend how this relates to the severity of autism symptoms. Another ACE project aims to identify genetic markers linked to autism by studying the biological differences during early development of the brain in sibling pairs where one or both siblings are diagnosed with ASD.

Chawarska said she was “peripherally” involved in contributing to Liew and Xiao’s study but declined to comment further.

Xiao and Liew noted that additional studies are required to elucidate how ASD is transmitted across generations.

“It might be important to study specific grandparental and environmental factors that can directly impact on parental in-utero development,” Xiao and Liew wrote.

The scientists explained that prior research on multigenerational factors and ASD suggests that grandmaternal smoking and the use of diethylstilbestrol — a compound given to pregnant women between 1938 to 1971 to prevent pregnancy complications — potentially hinder neurodevelopmental health in grandchildren.

Xiao and Liew said that future studies should follow the development of parents born with adverse birth characteristics, such as low birthweight or preterm birth, to identify other postnatal factors that may have contributed to ASD in their children. The researchers hope these paths for future investigation could be a means to mitigate ASD transmission pathways within families.

The Centers for Disease Control and Prevention estimates that 1 in 54 children has been diagnosed with ASD in the United States.

Sydney Gray |


Extreme Preemies Grow Up: Against the Odds

Mar 19, 2021          

    WGEM – Tri States News Leader


Quality Improvement Approach to Reducing Admission Hypothermia Among Preterm and Term Infants

Alicia Sprecher, Kathryn Malin, Deanna Finley, Paula Lembke, Sally Keller, Ann Grippe, Genesee Hornung, Nicholas Antos and Michael Uhing   Hospital Pediatrics March 2021, 11 (3) 270-276; DOI:


BACKGROUND: Newborns, particularly premature newborns, are susceptible to hypothermia when transitioning from birth to admission to the NICU, potentially leading to increased mortality and morbidity. Despite attention to this issue, our rate of admission hypothermia was 39.8%.

METHODS: We aimed to reduce the rate of admission hypothermia for all inborn infants admitted to our institution to <10%. We undertook a quality improvement effort that spanned from 2013 through 2019 in our level IV NICU. Current state analysis involved investigating patient risk factors for hypothermia and staff understanding of hypothermia prevention. Improvement cycles included auditing processes, an in-hospital relocation of our NICU, expanded use of chemical heat mattresses and polyethylene bags, and staff education. Improvement was evaluated by using Shewhart control charts.

RESULTS: We demonstrated a reduction in admission hypothermia from 39.8% to 9.9%, which was temporally related to educational efforts and expanded use of chemical heat mattresses and polyethylene bags. There was not an increase in admission hyperthermia over this time period. We found that our group at highest risk of admission hypothermia was not our most premature cohort but those infants born between 33 and 36 6/7 weeks’ gestation and those infants prenatally diagnosed with congenital anomalies.

CONCLUSIONS: Expanded use of polyethylene bags and chemical heat mattresses can improve thermoregulation particularly when combined with staff education. Although premature infants have been the focus of many hypothermia prevention efforts, our data suggest that older infants, and those infants born with congenital anomalies, require additional attention.

  • Copyright © 2021 by the American Academy of Pediatrics


A National Survey on Physician Trainee Participation in Pediatric Interfacility Transport

Pediatr Crit Care Med  – 2020 Mar;21

Elizabeth A Herrup Bruce L Klein Jennifer Schuette Philomena M Costabile Corina Noje


Objectives: To ascertain the national experience regarding which physician trainees are allowed to participate in pediatric interfacility transports and what is considered adequate education and training for physician trainees prior to participating in the transport of children.

Design: Self-administered electronic survey.

Setting: Pediatric transport teams listed with the American Academy of Pediatrics Section on Transport Medicine.

Subjects: Leaders of U.S. pediatric transport teams.

Interventions: None.

Measurements and main results: Forty-four of the 90 U.S. teams surveyed (49%) responded. Thirty-nine (89%) were university hospital-affiliated. Most programs (26/43, 60%) allowed trainees to participate in pediatric transport in some capacity. Mandatory transport rotations were reported for pediatric critical care (PICU) fellows (9/42, 21%), neonatology (neonatal ICU) fellows (6/42, 14%), pediatric emergency medicine fellows (4/41, 10%), emergency medicine residents (3/43, 7%), and pediatric residents (2/43, 5%). Fellow participation was reported by 19 of 28 programs (68%) with PICU fellowships, 12 of 25 programs (48%) with pediatric emergency medicine fellowships, and 10 of 34 programs (29%) with neonatal ICU fellowships. Transport programs with greater than or equal to 1,000 annual incoming transports were more likely to include PICU and pediatric emergency medicine fellows as providers (p = 0.04; 95% CI, 1.04-25.71 and p = 0.02; 95% CI, 1.31-53.75). Most commonly, trainees functioned as medical control physicians (86%), provided minute-to-minute medical direction for critically ill patients (62%), performed intubations (52%), and were code leaders for patients undergoing cardiopulmonary resuscitation during transport (52%). Most transport programs required pediatric residents, PICU, and pediatric emergency medicine fellows to complete a PICU rotation prior to participating in pediatric transports. The majority of transport programs did not use any metrics to determine airway proficiency of physician trainees.

Conclusions: There is heterogeneity with regard to the types of physician trainees allowed to participate in pediatric interfacility transports, the roles played by physician trainees during pediatric transport, and the training (or lack thereof) provided to physician trainees prior to their participating in pediatric transports.


Maternal participation on preterm infants care reduces the cost of delivery of preterm neonatal healthcare services


Thailand, with an annual incidence rate of 12% ranks high in incidence of preterm birth. Preterm infants require specialized care which can be lengthy and costly both in terms of psychological and emotional stress and healthcare services. The rapid rise of cost of healthcare services is a major concern for Thai government and public.


To assess and compare the growth patterns and cost of delivery of healthcare services of 50 preterm infants who were randomly assigned to either the control arm or the Maternal Participation Program (MPP) arm of the study.


25 infants in the control arm and 25 infants in the MPP arm were followed up from the day of transfer to the neonatal ward until they were discharged from the hospital. Data on clinical parameters and cost of healthcare delivery were collected by reviewing medical charts and from institutional financial databases. The principle of intention-to-treat analysis was used to analyze the data using the SPSS package (Version 23).


The average hospital stay (53 days vs. 60, P = .427) and days of oxygen delivery (21 days vs. 45, P = .047) for infants in the MPP arm were shorter than the control. At discharge from hospital, growth velocity of infants in the control arm had caught up with the MPP arm. Overall costs of healthcare delivery services for the preterm infants in control arm were 1.75 times higher than those in the MPP arm, with the procedural services as the costliest. Costs of drugs and the other ancillary services for the control arm was about 3-fold higher than for the MPP arm.


There were similar growth patterns and weight gain between the preterm infants in the control arm and the intervention arm. However, health care cost in preterm infants in the control arm was no statistically significant higher than those of the MPP arm. The difference of health care cost may arise from healthcare services and clinical interventions. Innovative and simple alternative strategy such as MPP can be an effective approach to curb the escalating cost of healthcare services.


Parents’ experiences of emotional closeness to their infants in the neonatal unit: A meta-ethnography

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Physical and emotional parent-infant closeness activate important neurobiological mechanisms involved in parenting. In a neonatal care context, most research focuses on physical (parental presence, skin-to-skin contact) aspects; insights into emotional closeness can be masked by findings that overemphasise the barriers or challenges to parenting an infant during neonatal care.


To explore existing qualitative research to identify what facilitates and enables parents’ experiences of emotional closeness to their infants while cared for in a neonatal unit.

Study design

A systematic review using meta-ethnographic methods. Search strategy involved searches on six databases, author runs, and backward and forward chaining. Reciprocal translation was used to identify and compare key concepts of parent-infant emotional closeness.


Searches identified 6992 hits, and 34 studies from 17 countries that involved 670 parents were included. Three overarching themes and associated sub-themes were developed. ‘Embodied connections’ describes how emotional closeness was facilitated by reciprocal parent-infant interactions, spending time as a family, and methods for parents to feel connected while physically separated. ‘Inner knowing’ concerns how knowledge about infant and maternal health and understanding the norms of neonatal care facilitated emotional closeness. ‘Evolving parental role’ relates to how emotional closeness was intertwined with parental identities of contributing to infant health, providing direct care, and being acknowledged as a parent.


Parent-infant closeness evolves and is facilitated by multifaceted biopsychosocial factors. Practice implications include creating private and uninterrupted family time, strategies for parents to maintain an emotional connection to their infant when separated, and neurobiology education for staff.



The Next Generation of NICU Staff

Kelly Welton, RRT-NPS

2020 wreaked havoc on all of us. Life’s rhythm as we knew it in 2019 got transformed as we learned a new way to do almost everything in 2020. Although Zoom and Amazon saved many people from unnecessary trips to the office and the store, one thing remained unchangeable: healthcare, specifically patient care, is a hands-on business. Since patient care is a hands-on profession, training requires a mentor to show us the how-tos. It is one thing to learn how to set up a ventilator or an IV pump; another thing entirely to troubleshoot one that’s not doing what you set it to do. Thanks to SARS-Covid-19 [CoVid], many respiratory therapy and nursing school programs closed. First, clinical sites closed their doors so as not to expose students to this new virus that was spreading fast. Then schools closed their doors to in-person instruction. Forced to learn online, recent graduating classes will only get their ‘hands-on ‘experience once hired.

In the hospitals, current staff who want to be trained to work in NICU often need approval from their manager. In Southern California, there were two programs available that provided in-depth NICU classes and clinical training. Both programs have subsequently closed, leaving nowhere for therapists to get basic NICU training. Managers are also tasked with being chronically short staffed, unable to let a staff member shadow a NICU RT for a day because they are desperately needed in the other hospital areas. This situation has been true for decades; however, CoVid demanded all-hands-on-deck, and there was no time for any RT not to carry a workload.

As an RT Educator, my role has been to find the areas in which staff need additional training. Whether it is low-use equipment or training in a new area, competency in not just knowledge. Critical thinking and troubleshooting are also ‘musts.’ Although the NICU was not left untouched by Covid, when the CoVid dust settles, many RT’s and RN’s will either leave the field or seek solace in a place that is not calling a code every hour and losing 3-4 patients per shift. When these seasoned therapists retire, who will be left to care for patients? For these reasons, the Academy of Neonatal Care was formed. Initially, AoNC was designed to be a hands-on workshop. Participants learn the foundation of neonatal respiratory care and participate in workshops practicing correct fitting of nasal prongs, changing Oscillator circuits, surfactant instillation, and more. Covid has now challenged AoNC as well to translate learning to an online format. Clinical competency software and the ability to present live online courses where students can ask questions in real-time help AoNC fill the void.

As a non-profit 501 (c) 3, the Academy of Neonatal Care’s goal is to teach the highest level of care to beginners in NICU and seasoned therapists. RN’s are welcome to join, as are physicians.

Our secondary goal is to reach out to NICU babies’ parents and family to support them while their baby is in our care. Lastly, as a non-profit, we will give back by contributing to community outreach and support healthy pregnancy and healthy baby efforts across the world.

With the release of a CoVid vaccine, we look forward to presenting live and in -person. AoNC’s platform continues to change with the times, but our ‘base camp’ remains the same. We built day one for beginner RT’s and RN’s who have wanted to learn NICU but have never been given a chance to get into a NICU with a preceptor.

Day 2 is designed for the RT that floats to NICU occasionally and wants a refresher to reinforce skills and knowledge.

Day 3 is designed for current NICU staff who want to expand their knowledge on subjects such as Jet ventilation, iNO, Transports, and more. The way we are going, we may soon have a full 5-day course!

Academy of Neonatal Care’s vision is that when the first three days are completed, the RT has a certificate from AoNC that says, “I finished the entire AoNC course, and am now ready to work with a preceptor.” That certificate carries significant weight with the participant’s employer or director, enough so that the manager would feel confidant pairing the RT with a mentor to help them assimilate into NICU.

Kelly Welton, RRT-NPS President, Academy of Neonatal Care @



Healthcare is the fastest-growing sector of the U.S. economy, employing over 18 million workers. Women represent nearly 80% of the healthcare work force. Healthcare workers face a wide range of hazards on the job, including sharps injuries, harmful exposures to chemicals and hazardous drugs, back injuries, latex allergy, violence, and stress. Although it is possible to prevent or reduce healthcare worker exposure to these hazards, healthcare workers continue to experience injuries and illnesses in the workplace. Cases of nonfatal occupational injury and illness with healthcare workers are among the highest of any industry sector.


The Persistent Pandemic of Violence Against Health Care Workers

December 11, 2020   Ashleigh Watson, MD , Mohammad Jafari, HBSc , Ali Seifi, MD

The American Journal of Managed Care, December 2020, Volume 26, Issue 12

The problem of violence against health care workers has escalated across the world, and tackling this issue requires the support of administrators.


Violence against health care workers is an ever-present threat that has been increasing over the past several years. The majority of physicians and nurses report that they have been victims of workplace violence at least once throughout their careers. Such violent attacks negatively affect the delivery, quality, and accessibility of health care. Certain factors such as substance abuse and intense emotions increase an individual’s risk of committing an act of workplace violence against a health care worker. Encountering violent individuals has legal implications and can compromise the moral framework of physicians. With action from institution administrations, advocates, leaders, and government, this issue that detrimentally affects health care can be combatted and reduced. By implementing required staff training, increasing security, strengthening the doctor-patient relationship, using medical chaperones, and reforming policy, positive changes can be made to protect health care workers and the health care system.

Takeaway Points

  • The support of health care administrators, leaders, and national advocates is essential and necessary for tackling health care workplace violence and protecting health care workers.
  • Hospitals need to implement required staff training, increase security, strengthen the doctor-patient relationship, use medical chaperones, and reform policy, among many constructive steps necessary to decrease the incidence of violence against health care workers.

The Occupational Safety and Health Administration defines workplace violence (WPV) as “any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site. It ranges from threats and verbal abuse to physical assaults and even homicide.” In 2014, it was reported that workers in the medical field encounter more nonfatal incidents of WPV than workers in any other profession. The risk of health care workers encountering violence in the hospital is ever present, and it appears that this violence is actually increasing. In this article, we will discuss the pandemic of violence and strategies that a physician can use to control explosive situations.

Violence against health care workers, especially in the hospital setting, is a global issue that affects both developed and developing countries. A comprehensive literature review shows that research studies have been conducted in the United States, United Kingdom, China, Iraq, Germany, Ethiopia, Jordan, Palestine, Nigeria, and many more nations, all indicating that the majority of physicians and health care workers have experienced some form of WPV. In fall 2014, a poll found that 71% of physicians in the United States had experienced at least 1 incident of violence at some point during their careers. Of the physicians in Michigan surveyed in 2002, 75% were victims of at least 1 incident of verbal threatening during a 12-month period, whereas 28.1% of respondents experienced physical assault. Nurses typically sustain the most WPV compared with other health care workers. A study in 2000 found that 82% of US nurses had been assaulted at least once during their careers, and 73% believed that assault was just part of their job. For physicians, the rate of violence is highest in the emergency department and among less-experienced physicians. Studies have shown that the most common acts of violence against nurses were shouting or yelling (60.0% by patients, 35.8% by visitors), swearing (53.5% by patients, 24.9% by visitors), and grabbing (37.8% by patients, 1.1% by visitors).

In 2016, 16,890 workers in the private industry experienced WPV that required days away from work. Of those victims, 70% worked in the health care and social assistance industry, according to the CDC.

The implications of WPV against health care workers are detrimental to not only the victimized individual but also the entire health care system. From physical injuries to psychological trauma, violence can lead to demotivation, poor job satisfaction, and early physician burnout. Overall, WPV affects the delivery of health care, decreasing quality and accessibility.

Numerous factors contribute to the escalating levels of violence against health care workers in the hospital setting. The majority of attacks come from patients or family members who have problems with substance abuse, a mental illness, or drug-seeking habits. Furthermore, the generalized fear, helplessness, and stress felt by individuals seeking medical attention and by their loved ones, especially when the patient is critically ill and there is frustration with the health care system, lead to increased risk of WPV in hospitals.2 These strong emotions and anger that individuals may harbor can emerge and be inappropriately directed toward health care workers. Additionally, a history of violence increases the risk that an individual will commit an act of WPV.

Currently, only 26 of 50 US states have any law to protect health care workers from assault, and the laws in the majority of these states protect only a small sector of the health care field. For example, penalties in Louisiana apply only to emergency department workers and those in Kansas apply only to mental health employees. In many states, the right to refuse treatment of abusive patients is allowed by law; however, under the Emergency Medical Treatment and Labor Act of 1986, emergency departments must treat all patients who present for care, regardless of abusive actions.

Encountering violent patients has serious ethical implications for physicians, potentially compromising the moral framework on which the practice of medicine was founded. The Hippocratic Oath clearly delineates that a physician should treat every patient, and no patient should go without the care they need. Physicians have an ethical obligation to practice nonmaleficence and beneficence regardless of minimal personal risk. However, if a patient or their family member is acting violently or aggressively at the hospital and abusing the physician, nurses, or other staff members, a personal decision can be made to refuse treatment during their violent episode. When contemplating refusing treatment, the welfare of the physician and staff must outweigh the responsibility to care for the patient. Complete termination of the patient-doctor relationship should be executed only in extreme circumstances, as abandonment of a patient is not ethically or legally permitted.

Physicians are also ethically obligated to respect patients as individuals and to exercise compassion and empathy in their interactions. When working with an abusive patient, physicians must block their personal emotions and assess some ethical challenges: Is the behavior voluntary? Does failure to assign responsibility to the patient undervalue them as an individual? Should they be held responsible for their actions or are they victims of their environment? The answers to these questions may differ with each incident, but they should be used to evaluate behavior and to judge the necessary steps for advancing with care.

Violence against health care workers at hospitals is a preventable problem, and the incidence rate can be diminished with collaboration, change, and reform. Required training that focuses on recognizing and responding to abusive patients and family members would better prepare health care workers to respond to violent individuals and mitigate escalation. Some hospitals use flagging systems that alert medical staff about patients’ histories of violence. This way, clinicians can be better prepared to defuse difficult situations. At the Portland Veterans Affairs Medical Center, for instance, the staff was alerted about patients with a history of violence; this resulted in reducing the number of violent attacks by 91.6%.

Increased security has also been proposed as a way to decrease WPV in health care environments. Henry Ford Hospital in Detroit, Michigan, recently installed metal detectors, and a New York City hospital also increased its security by effectuating an identification badge system, limiting patients and visitors to specific floors of the hospital. This effort reduced violent crimes by 65% over 18 months.

In addition, making subtle changes to the doctor-patient relationship may be advantageous in decreasing WPV. For instance, practicing increased empathy, shared understanding, and cooperation may help decrease patient and guest frustration, stress, and other potentially volatile emotions. This is evident from the results of a 2012 study concluding that nurse-patient relations have a significant impact on WPV and that empathic communication with patients can significantly reduce the chances of violent behavior. The use of a medical chaperone may also decrease the risk of WPV, potentially protecting the physician from abuse and violence. From personal experience, patients and families can experience less anger and frustration when health care professionals take some time to sit with them, show sympathy, listen, and potentially involve the palliative care team.

Motivating the leaders of health care institutions is instrumental in enacting positive change to combat the increasing levels of violence. If hospitals enforced a mandatory reporting policy in which the administration would fully support staff, WPV in the health care setting would be better documented and the necessary actions against offenders would be taken more effectively. Post event counseling should also be mandated, given the high percentage of health care workers who suffer from psychological trauma and decreased job satisfaction after experiencing WPV; efforts need to be taken to focus on the mental health and wellness of employees. In addition, the attitudes of both staff and society regarding WPV in health care settings need to be addressed. Violence should not be considered just “part of the job” from the perspective of health care workers, and society needs to know that it is unacceptable to treat health care workers in a violent or abusive manner.

The National Health Service of the United Kingdom launched its Zero Tolerance Policy in 1999 in hopes of protecting its employees and eliminating the “fear of violence, abuse, and harassment from patients or their relatives.” The Zero Tolerance Policy allows health care facilities to freely seek police assistance, remove violent patients from their practice if necessary, and encourage and enforce reporting of WPV.

The problem of violence against health care workers, especially in critical care units, prevails and escalates across the world. It has been confirmed time and again that the vast majority of physicians, nurses, and supporting staff fall victim to WPV during their careers. Patients, family members, and visitors commit these violent and abusive attacks due to substance abuse, mental illness, and/or powerful emotions that manifest themselves in destructive ways. Violence challenges the moral and ethical obligations of physicians, leading to difficult decisions that may need to be made to protect others. The power and support of administrators, leaders, and national advocates are essential and necessary for tackling this issue and protecting health care workers. Implementing required staff training, increasing security, strengthening the doctor-patient relationship, using medical chaperones, and reforming policy are constructive steps that will decrease the incidence of violence against health care workers.


Safe Health Workers, Safe Patients

The COVID-19 pandemic has unveiled the huge challenges and risks health workers are facing globally. Working in stressful environments makes health workers more prone to errors which can lead to patient harm. Health worker safety is a priority for patient safety. Speak up for health worker safety!

Social media & COVID-19: A global study of digital crisis interaction among Gen Z and Millennials

26 March 2021

WHO, Wunderman Thompson, the University of Melbourne and Pollfish share the outcomes of a global study investigating how Gen Z and Millennials get information on the COVID pandemic

The unfolding of the COVID-19 pandemic has demonstrated how the spread of misinformation, amplified on social media and other digital platforms, is proving to be as much a threat to global public health as the virus itself. Technology advancements and social media create opportunities to keep people safe, informed and connected. However, the same tools also enable and amplify the current infodemic that continues to undermine the global response and jeopardizes measures to control the pandemic.

Although young people are less at risk of severe disease from COVID-19, they are a key group in the context of this pandemic and share in the collective responsibility to help us stop transmission. They are also the most active online, interacting with an average number of 5 digital platforms (such as, Twitter, TikTok, WeChat and Instagram) daily.

To better understand how young adults are engaging with technology during this global communication crisis, an international study was conducted, covering approximately 23,500 respondents, aged 18-40 years, in 24 countries across five continents. This project was a collaboration between the World Health Organization (WHO), Wunderman Thompson, the University of Melbourne and Pollfish. With data collected from late October 2020 to early January 2021, the outcomes provide key insights on where Gen Z and Millennials seek COVID-19 information, who they trust as credible sources, their awareness and actions around false news, and what their concerns are. Some key insights uncovered include: Science content is seen as shareworthy

When asked what COVID-19 information (if any) they would likely post on social media, 43.9% of respondents, both male and female, reported they would likely share “scientific” content on their social media. This finding appears to buck the general trend on social media where funny, entertaining and emotional content spread fastest.

Awareness of false news is high but so is apathy

More than half (59.1%) of Gen Z and Millennials surveyed are “very aware” of “fake news” surrounding COVID-19 and can often spot it. However, the challenge is in recruiting them to actively counter it, rather than letting it slide, with many (35.1%) just ignoring.

Gen Z and Millennials have multiple worries beyond getting sick

While it is often suggested that young adults are ‘too relaxed’ and do not care about the crisis, this notion is not reflected in the data, with over 90% of respondents were very concerned or somewhat concerned about the risk of infection. Beyond getting sick themselves, the top concerns of respondents (55.5%) was the risk of friends and family members contracting COVID-19, closely followed by the economy crashing (53.8%).

WHO wants young people to be informed about COVID-19 information, navigate their digital world safely, and make choices to not only protect their health but also the health of their families and communities. These insights can help health organizations, governments, media, businesses, educational institutions and others sharpen their health communication strategies. Ensuring policy and recommendations are relevant to young people in a climate of misinformation, skepticism and fear. 

All key insights can be downloaded here and an Interactive Dashboard with a breakdown of all data has been developed. A detailed report and analysis will be published in April by the University of Melbourne.


Those of us who partake in utilizing social media are constantly being bombarded by a vast array of information. In reference to the WHO partnered Covid-19 social media study it was encouraging to learn that many of us who are Gen-Z and Millennials are interested, invested, and actively engaged in wanting up-to-date access to scientific information on our social media platforms. Knowing that many of us have expressed concern about the potential risk of Covid-19 negatively affecting the health, safety and well-being of us, our family, friends, loved ones and community is reassuring. Being able to actively engage in helping to educate each other, learn the facts and care for each other through social media sharing has helped many of us keep connected to the world around us, check in on friends and maintain relationships in a time where many of us may experience feeling isolation. Together, we can all do our part to better the health and safety of our community and world. Sending a big shout out to the researchers, social media services and advocates sharing credible resources and support services on their services to keep us educated and safe!

No surfing in Rwanda. Witness the beauty and joy expressed in the faces of our Rwandan family as they enjoy land-based action, moving like the ocean surf……

Sports and Culture Week / Kigali / Rwanda / One Team

Feb 19, 2020 – KIGALIAnton Sahler

ONE TEAM. We provide children and youths all over the world with access to sports. Through sports, we promote education, health and equality. We team up with our supporters, sports clubs, associations and enterprises as well as our local partners in the project countries. ONE TEAM




Rank: 16  –Rate: 14.4%   Estimated # of preterm births per 100 live births 

(USA – 12 %, Global Average: 11.1%)

Jordan: officially the Hashemite Kingdom of Jordan, is an Arab country in the Levant region of Western Asia, on the East Bank of the Jordan River. Jordan is bordered by Saudi ArabiaIraqSyriaIsrael and Palestine (West Bank). The Dead Sea is located along its western borders and the country has a 26-kilometre (16 mi) coastline on the Red Sea in its extreme south-west. Jordan is strategically located at the crossroads of Asia, Africa and Europe.  The capitalAmman, is Jordan’s most populous city as well as the country’s economic, political and cultural centre.

Jordan is classified as a country of “high human development” with an “upper middle income” economy. The Jordanian economy, one of the smallest economies in the region, is attractive to foreign investors based upon a skilled workforce. The country is a major tourist destination, also attracting medical tourism due to its well developed health sector. Nonetheless, a lack of natural resources, large flow of refugees and regional turmoil have hampered economic growth.


Life expectancy in Jordan was around 74.8 years in 2017. The leading cause of death is cardiovascular diseases, followed by cancer. Childhood immunization rates have increased steadily over the past 15 years; by 2002 immunisations and vaccines reached more than 95% of children under five. In 1950, water and sanitation was available to only 10% of the population; in 2015 it reached 98% of Jordanians.

Jordan prides itself on its health services, some of the best in the region. Qualified medics, a favourable investment climate and Jordan’s stability has contributed to the success of this sector. The country’s health care system is divided between public and private institutions. On 1 June 2007, Jordan Hospital (as the biggest private hospital) was the first general specialty hospital to gain the international accreditation JCAHO. The King Hussein Cancer Center is a leading cancer treatment centre. 66% of Jordanians have medical insurance.


Please join us in a Musical Moment….

Adham Nabulsi – Han AlAn (Official Music Video)

| أدهم نابلسي – حان الآن

Nov 20, 2020         Adham Nabulsi


Kat is a surviving twin, born at 24 weeks gestation. Her brother, my son, Cruz died at or shortly after birth. I was very surprised to learn that the tiny baby making a very big sound was a girl. Research related to neonatal outcomes for preemie twins is interesting. Further research into this fascinating subject will provide a foundation for both prevention and treatments supporting preemie survival and wellness.

Neonatal outcomes of extremely preterm twins by sex pairing: an international cohort study

Original research (11/12/20)  January 2021 – Volume 106 – 1


Objective Infant boys have worse outcomes than girls. In twins, the ‘male disadvantage’ has been reported to extend to female co-twins via a ‘masculinising’ effect. We studied the association between sex pairing and neonatal outcomes in extremely preterm twins.

Design Retrospective cohort study

Setting Eleven countries participating in the International Network for Evaluating Outcomes of Neonates.

Patients Liveborn twins admitted at 23–29 weeks’ gestation in 2007–2015.

Main outcome measures We examined in-hospital mortality, grades 3/4 intraventricular haemorrhage or cystic periventricular leukomalacia (IVH/PVL), bronchopulmonary dysplasia (BPD), retinopathy of prematurity requiring treatment and a composite outcome (mortality or any of the outcomes above).

Results Among 20 924 twins, 38% were from male-male pairs, 32% were from female-female pairs and 30% were sex discordant. We had no information on chorionicity. Girls with a male co-twin had lower odds of mortality, IVH/PVL and the composite outcome than girl-girl pairs (reference group): adjusted OR (aOR) (95% CI) 0.79 (0.68 to 0.92), 0.83 (0.72 to 0.96) and 0.88 (0.79 to 0.98), respectively. Boys with a female co-twin also had lower odds of mortality: aOR 0.86 (0.74 to 0.99). Boys from male-male pairs had highest odds of BPD and composite outcome: aOR 1.38 (1.24 to 1.52) and 1.27 (1.16 to 1.39), respectively.

Conclusions Sex-related disparities in outcomes exist in extremely preterm twins, with girls having lower risks than boys and opposite-sex pairs having lower risks than same-sex pairs. Our results may help clinicians in assessing risk in this large segment of extremely preterm infants.


Where Life Begins: Reducing Risky Births in a Refugee Camp

March 6, 2019 By Elizabeth Wang

Zaatari camp, the largest Syrian refugee camp in the world, sits less than 12 kilometers away from the border between Syria and northern Jordan. Rows of houses disappear into the desert, making it hard to tell where the camp begins and ends. Metal containers pieced together like patchwork are home to around 80,000 refugees. The remnants of tattered UNHCR tents cover holes in the walls. Almost seven years after the camp opened, this dusty sea of tin roofs has evolved into a permanent settlement.

When I entered Zaatari camp to begin my internship with the Women and Girls Comprehensive Center, I saw signs of resilience and humanity everywhere—colorful murals of smiling children, barefoot boys playing soccer, a wedding dress shop. Perhaps the greatest proof that life goes on can be found in the camp’s maternity wards, which see an average of 80 births per week, along with 14,000 consultations per week for expecting mothers. About 1 in 4 of the Syrian refugees living in Zaatari are women of reproductive age. According to UNFPA, 2,300 women and girls in Zaatari are pregnant at any one time. The extremely high fertility rate demonstrates how vital it is to facilitate access to quality reproductive and maternal health services during complex emergencies.

At the Women and Girls Comprehensive Center in Zaatari camp, which is run by the Jordan Health Aid Society and supported by UNFPA, refugee women of all ages receive services such as family planning, pre- and post-natal care, vaccinations, gynecological check-ups, and culturally sensitive information sessions. Every day, the clinic delivers five to seven babies. As of September 27, 2018, the clinic has had 10,089 safe deliveries and zero maternal mortalities, a stunning achievement that remains posted on a scoreboard outside the clinic’s gates.

Risky Pregnancies, Dangerous Deliveries

Despite this success, giving birth in Zaatari is not without dangers. The high prevalence of non-communicable diseases (such as anemia, diabetes, and hypertension) among Syrian refugees—and especially the inadequate management of these chronic conditions when they are fleeing conflict—increase health risks during and after pregnancy. Domestic and gender-based violence, which spike during complex emergencies, also cause extreme harm to women and girls. 

One of the greatest challenges facing the Women and Girls Comprehensive Center involves caring for pregnant adolescent girls and young women under 20 years old. Due to instability, displacement, and poverty, the rate of child marriage among Syrian refugees  is more than four times what it was in pre-crisis Syria. For Syrian refugees in Jordan specifically, the rate has doubled in the last four years. Consequently, many of these girls have multiple children before they even reach adulthood.

Seeing girls 16 years old and younger, in pain and alone in the delivery room, was one of the most difficult experiences of my time in Zaatari. As adolescents, they are much more likely to experience risky pregnancies, as well as premature birth and children with low birth weight, than women over the age of 20. Most of these girls are not aware of the risks of early marriage and pregnancy, and often do not feel safe during delivery.

At the center, refugees can access various forms of family planning, including birth control pills or IUDs. The midwives and doctors also host informational sessions on reproductive health topics, such as healthy prenatal behaviors and the risks of child marriage. The center’s oldest midwife, who everyone fondly refers to as “Mama,” makes home visits around the camp to discuss family planning and women’s health with families.

Despite the clinic’s efforts to encourage postponing and spacing pregnancies, the family planning services offered are not always used. Some women and girls are pressured by their husbands and families to avoid contraceptives and continue producing children without adequate time for recovery in between births. One patient I met at the clinic was famous in Zaatari, the midwife told me in a hushed voice, for having 12 children, all by cesarean section, over the course of 12 years. Women and girls who had IUDs placed often came back soon after to get them removed, per their husbands’ demands. Many Syrians feel obligated to have a lot of children to compensate for the family and friends killed in the war or to increase the likelihood that their children will survive.

Cultural Sensitivity Saves Lives

To save lives, we need to not only offer reproductive health services, but ensure they are culturally sensitive as well. Unlike other host countries, Jordan does not face large language or cultural barriers when providing care to Syrian refugees. Jordanians and Syrians speak similar Arabic and come from predominantly Muslim societies with shared values. This is an advantage for healthcare providers in Zaatari because they already have a good understanding of their patient population, which facilitates patient-provider trust and overall better quality care.

For example, when treating a woman who insisted on fasting for the religious holiday of Ramadan while pregnant, the Jordanian midwives were the best people for the job. As Muslim women themselves, they had a deep understanding of the woman’s motivations and could explain the serious health consequences of her decisions while still respecting the significance of the religious practice. By practicing empathy and non-judgment, they were able to help this woman find a balance between health and faith without alienating the patient and discouraging her from seeking care in the future.

New Beginnings

Early in my internship, we transported a woman in premature labor to a bigger hospital in Mafraq, the next closest city. As we all tried to maintain our balance in the back of the bumpy ambulance, the baby’s head began crowning. We pulled over to the side of the road and safely delivered her baby right there.

This is where life begins in Zaatari: in the back of dusty ambulances with missing windows, in delivery rooms with flies buzzing, in clinics where Jordanians and Syrians work together to protect women and children. Despite the enormous challenges facing these refugees and the healthcare workers seeking to help them, every day is the first day for another new life.

Elizabeth Wang is an intern with the Maternal Health Initiative. In 2018, she spent six months in Jordan studying humanitarian action, during which she interned at the Jordan Health Aid Society in both Amman and Zaatari camp. 

Sources: Al Jazeera, Conflict and Health, European Civil Protection and Humanitarian Aid Operations, National Public Radio, PRI, Save the Children, United Nations Population Fund, United Nations High Commissioner for Refugees, World Health Organization.

Countries prepared for the climate emergency have had fewer COVID deaths

Countries where individuals look after each other and the environment are better able to cope with climate and public health emergencies, research by King’s Business School has found.

The paper published in World Development explores the role of climate risk, preparedness and culture in explaining the cross-country variation in the Covid-19 mortality rates. The research highlights the crucial need for investment in both climate action and public health infrastructure as key lessons from the Covid-19 crisis, so countries can be better prepared for similar disasters in future.

The researchers used data from 110 countries empirically linking the Covid-19 mortality rates and a set of country-specific factors, consisting of pre-Covid-19 characteristics and a set of social, economic and health responses to the outbreak of the virus. Key findings include:

  • Individualistic societies fared significantly worse than collectivist ones in coping with Covid-19, resulting in much higher mortality rates. In the context of Covid-19, individualistic societies are known to be less engaged with social distancing and other measures as they are likely to be less concerned about the favourable impacts of such actions on others.
  • The greater the climate risk and the lower the readiness to climate change, the higher the risk of mortality from Covid-19.
  • Countries that were better prepared for the climate emergency were also better placed to fight the pandemic. The data showed that these had consistently lower fatality rates.
  • Public health capacity in terms of both health expenditures and number of hospital beds; the share of the elderly population; and economic resilience are important factors in fighting a pandemic

Gulcin Ozkan, Vice Dean (Staffing) and Professor of Finance at King’s Business School who is one of the authors of the research said: “Scientists have long established links between climate change and pandemics. Climate change is known to drive wild-life closer to people, which in turn, paves the way for viruses that are harmless in wild animals to be transmitted to humans with deadly consequences.

“In addition, the role of both extreme hot and cold weather in increasing mortality and of warmer climates in spreading diseases have been widely recognised. Given such significant role of climate change in health outcomes, and particularly in mortality, our research clearly establishes this link between climate risk, culture and the Covid-19 mortality rate.

“It’s time more countries take the climate emergency seriously and governments should invest in the infrastructure that could have prevented further deaths”.


Complications of premature birth decline in California

June 17, 2020

More of the youngest and smallest California preemies are going home from the hospital without any major complications, a Stanford study has found.

California’s most vulnerable premature babies are now healthier on average when they go home from the hospital, according to a new study led by researchers at the Stanford University School of Medicine and the California Perinatal Quality Care Collaborative.

Between 2008 and 2017, the proportion of the smallest and most premature California infants who survived until hospital discharge without major complications of their early birth increased from roughly 62% to 67%, and those with major complications had fewer of them.

The study was published online June 18  in Pediatrics.

“When a family takes their baby home from the hospital, we want them to have an infant that’s as healthy as possible,” said the study’s lead author, Henry Lee, MD, associate professor of pediatrics at Stanford. “Survival without major complications is one way we take into account that survival alone isn’t our only goal.”

The senior author is Jeffrey Gould, MD, professor of pediatrics and the Robert L Hess Endowed Professor.

About 1 in 12 California babies are born prematurely, arriving at least three weeks early, and about 1 in 100 are born 10 or more weeks before their due date. In the last 50 years, survival rates for very premature babies have greatly improved, Lee said, but some preemies continue to experience severe complications after birth, such as lung problems, infections, digestive disease, brain injury, brain hemorrhage and vision loss. Although prior studies had examined changes in the rates of individual complications of prematurity, none had addressed whether complications as a whole were declining among a large population of preemies in California.

Hospitals working together

California hospitals have been working together since 2007 to help neonatal intensive care units improve outcomes for babies. To promote this goal, they formed the California Perinatal Quality Care Collaborative. Headquartered at Stanford, the collaborative has conducted many projects to improve preemies’ health, such as studying best practices for resuscitating preemies in the delivery room and figuring out how to support breast-milk expression for mothers who deliver prematurely.

The new study focused on the smallest and most premature babies, those born 11 to 18 weeks early or who weighed 0.88 to 3.3 pounds at birth. It included 49,333 infants who were in the NICUs of 143 California hospitals between 2008 and 2017. The study did not include infants who died at birth or who had severe congenital abnormalities.

The researchers analyzed the infants’ medical records to look for the presence of major complications of premature birth. Between 2008 and 2017, the percentage of very premature or very small infants in California who survived without major complications improved from 62.2% to 66.9%. There was a significant decline in mortality of these infants over the same period. The complications whose incidence decreased most were necrotizing enterocolitis, a disease in which intestinal tissue dies, which declined 45.6%; and infections, which declined 44.7%.

Fewer complications per infant

Among preemies who did have complications, they had fewer of them. The number of infants in the study with four or more separate complications declined 40.2% between 2008 and 2017, the number with three complications declined 40.0% and the number with two complications declined 18.7%.

“It was really encouraging to me that we found that babies were less likely to have multiple morbidities,” Lee said, adding that this means care is improving across the board, even for the sickest preemies.

The performance of California’s neonatal intensive care units became more uniform for most complications of prematurity, with less variation between hospitals. However, there is still room for improvement; the study estimates that if all hospitals matched the performance of the top 25% of the state’s NICUs, an additional 621 California preemies would go home from the hospital without major complications each year.

The California Perinatal Quality Care Collaborative is helping health care providers at all NICUs learn from each other, Lee said. “We’ve started trying to see which hospitals are having very good outcomes, or have perhaps improved significantly over the last few years, so that we can disseminate the knowledge they have gained from their experience,” he said.

For families of premature babies, the new findings have a hopeful message. “It’s a hard situation when a family suddenly faces premature birth,” Lee said. “But we can tell them that we have taken care of many babies born at this age, and we’ve gotten better. That would hopefully be something of a reassurance.”

Other Stanford co-authors on the study are biostatistician Jessica Liu, PhD; Jochen Profit, MD, associate professor of pediatrics; and Susan Hintz, MD, professor of pediatrics and the Robert L. Hess Family Professor. Lee, Profit, Hintz and Gould are members of the Stanford Maternal & Child Health Research Institute. Lee is a member of Stanford Bio-X.

The study was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (grant R01 HD087425).



Prevalence of and Factors Associated With Nurse Burnout in the US

Megha K. Shah, MD, MSc1Nikhila Gandrakota, MBBS, MPH1Jeannie P. Cimiotti, PhD, RN2; et alNeena Ghose, MD, MS1Miranda Moore, PhD1Mohammed K. Ali, MBChB, MSc, MBA3

Author Affiliations Article Information February 4, 2021

JAMA Netw Open. 2021;4(2):e2036469. doi:10.1001/jamanetworkopen.2020.36469

Key Points

Question  What were the most recent US national estimates of nurse burnout and associated factors that may put nurses at risk for burnout?

Findings  This secondary analysis of cross-sectional survey data from more than 3.9 million US registered nurses found that among nurses who reported leaving their current employment (9.5% of sample), 31.5% reported leaving because of burnout in 2018. The hospital setting and working more than 20 hours per week were associated with greater odds of burnout.

Meaning  With increasing demands placed on frontline nurses during the coronavirus disease 2019 pandemic, these findings suggest an urgent need for solutions to address burnout among nurses.


Importance  Clinician burnout is a major risk to the health of the US. Nurses make up most of the health care workforce, and estimating nursing burnout and associated factors is vital for addressing the causes of burnout.

Objective  To measure rates of nurse burnout and examine factors associated with leaving or considering leaving employment owing to burnout.

Design, Setting, and Participants  This secondary analysis used cross-sectional survey data collected from April 30 to October 12, 2018, in the National Sample Survey of Registered Nurses in the US. All nurses who responded were included (N = 3 957 661). Data were analyzed from June 5 to October 1, 2020.

Exposures  Age, sex, race and ethnicity categorized by self-reported survey question, household income, and geographic region. Data were stratified by workplace setting, hours worked, and dominant function (direct patient care, other function, no dominant function) at work.

Main Outcomes and Measures  The primary outcomes were the likelihood of leaving employment in the last year owing to burnout or considering leaving employment owing to burnout.

Results  The 3 957 661 responding nurses were predominantly female (90.4%) and White (80.7%); the mean (weighted SD) age was 48.7 (0.04) years. Among nurses who reported leaving their job in 2017 (n = 418 769), 31.5% reported burnout as a reason, with lower proportions of nurses reporting burnout in the West (16.6%) and higher proportions in the Southeast (30.0%). Compared with working less than 20 h/wk, nurses who worked more than 40 h/wk had a higher likelihood identifying burnout as a reason they left their job (odds ratio, 3.28; 95% CI, 1.61-6.67). Respondents who reported leaving or considering leaving their job owing to burnout reported a stressful work environment (68.6% and 59.5%, respectively) and inadequate staffing (63.0% and 60.9%, respectively).

Conclusions and Relevance  These findings suggest that burnout is a significant problem among US nurses who leave their job or consider leaving their job. Health systems should focus on implementing known strategies to alleviate burnout, including adequate nurse staffing and limiting the number of hours worked per shift.


Clinician burnout is a threat to US health and health care. At more than 6 million in 2019,2 nurses are the largest segment of our health care workforce, making up nearly 30% of hospital employment nationwide.3 Nurses are a critical group of clinicians with diverse skills, such as health promotion, disease prevention, and direct treatment. As the workloads on health care systems and clinicians have grown, so have the demands placed on nurses, negatively affecting the nursing work environment. When combined with the ever-growing stress associated with the coronavirus disease 2019 (COVID-19) pandemic, this situation could leave the US with an unstable nurse workforce for years to come. Given their far-ranging skill set, importance in the care team, and proportion of the health care workforce, it is imperative that we better understand job-related outcomes and the factors that contribute to burnout in nurses nationwide.

Demanding workloads and aspects of the work environment, such as poor staffing ratios, lack of communication between physicians and nurses, and lack of organizational leadership within working environments for nurses, are known to be associated with burnout in nurses. However, few, if any, recent national estimates of nurse burnout and contributing factors exist. We used the most recent nationally representative nurse survey data to characterize burnout in the nurse workforce before COVID-19. Specifically, we examined to what extent aspects of the work environment resulted in nurses leaving the workforce and the factors associated with nurses’ intention to leave their jobs and the nursing profession.


Data Source

We used data from the 2018 US Department of Health and Human Services’ Health Resources and Service Administration National Sample Survey of Registered Nurses (NSSRN), a nationally representative anonymous sample of registered nurses in the US. The weighted response rate for the 2018 NNRSN is estimated at 49.0%.6 Details on sampling frame, selection, and noninterview adjustments are described elsewhere.7 Weighted estimates generalize to state and national nursing populations.6 The American Association for Public Opinion Research Response Rate 3 method was used to calculate the NSSRN response rate.6 This study of deidentified publicly available data was determined to be exempt from approval and informed consent by the institutional review board of Emory University. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cross-sectional studies

Variables and Definitions

Data were collected from April 30 to October 12, 2018. We generated demographic characteristics from questions about years worked in the profession, primary and secondary nursing positions, and work environment. We included the work environment variables of primary employment setting and full-time or part-time status. We grouped responses to a question on dominant nursing tasks as direct patient care, other, and no dominant task. We included 3 categories of educational attainment (diploma/ADN, BSN, or MSN/PhD/DNP degrees) and whether the respondent was internationally educated. Other variables included change in employment setting in the last year, hours worked per week, and reasons for employment change.

We categorized employment setting as (1) hospital (not mental health), (2) other inpatient setting, (3) clinic or ambulatory care, and (4) other types of setting. Workforce stability was defined as the percentage of nurses with less than 5 years of experience in the nursing profession.

We used 2 questions to assess burnout and other reasons for leaving or planning to leave a nursing position. Nurses who had left the position they held on December 31, 2017, were asked to identify the reasons contributing to their decision to leave their prior position. Nurses who were still employed in the position they held on December 31, 2017, and answered yes to the question “Have you ever considered leaving the primary nursing position you held on December 31, 2017?” were asked “Which of the following reasons would contribute to your decision to leave your primary nursing position?”

Statistical Analysis

Data were analyzed from June 5 to October 1, 2020. We used descriptive statistics to characterize nurse survey responses. For continuous variables, we reported means and SDs and for categorical variables, frequencies (number [percentage]). Further, we examined the overlap of the proportions who reported leaving or considered leaving their job owing to burnout and other factors. We then fit 2 separate logistic regression models to estimate the odds that aspects of the work environment, hours, and tasks were associated with the following outcomes related to burnout: (1) left job owing to burnout and (2) considered leaving their job owing to burnout. We controlled for nurse demographic characteristics of age, sex, race, household income, and geographic region and reported odds ratios (ORs) and 95% CIs. Two separate sensitivity analyses were performed: (1) we used a broader theme of burnout defined as a response of burnout, inadequate staffing, or stressful work environment for the regression models; and (2) we stratified the regression models by respondents younger than 45 years and 45 years or older to examine difference by age.

We used SAS, version 9.4 (SAS Institute, Inc), with statistical significance set at 2-sided α = .05. We used sample weights to account for the differential selection probabilities and nonresponse bias.


The 3 957 661 nurse respondents in 2018 were mostly female (90.4%) and White (80.7%). The mean (weighted SD) age of nurse respondents was 48.7 (0.04) years, and 95.3% were US graduates. The percentage of nurses with a BSN degree was 45.8%; with an MSN, PhD, or DNP degree, 16.3%; and 49.5% of nurses reported that they worked in a hospital. The mean (weighted SD) age of nurses who left their job due to burnout was 42.0 (0.6) years; for those considering leaving their job due to burnout, 43.7 (0.3) years (Table 1).

Of the total sample of nurses (N = 3 957 661), 9.5% reported leaving their most recent position (n = 418 769), and of those, 31.5% reported burnout as a reason contributing to their decision to leave their job (3.3% of the total sample) (eTable in the Supplement). For nurses who had considered leaving their position (n = 676 122), 43.4% identified burnout as a reason that would contribute to their decision to leave their current job. Additional factors in these decisions were a stressful work environment (34.4% as the reason for leaving and 41.6% as the reason for considering leaving), inadequate staffing (30.0% as the reason for leaving and 42.6% as the reason for considering leaving), lack of good management or leadership (33.9% as the reason for leaving and 39.6% as the reason for considering leaving), and better pay and/or benefits (26.5% as the reason for leaving and 50.4% as the reason for considering leaving). By geographic regions of the US, lower proportions of nurses reported burnout in the West (16.6%), and higher proportions reported burnout in the Southeast (30.0%) (Figure 1 and Figure 2). Figure 3 shows the overlap between leaving or considering leaving their position owing to burnout and other reasons. For both outcomes, the highest overlap response with burnout was for stressful work environment (68.6% of those who left their job and 63.0% of those who considered leaving their job due to burnout).

The adjusted regression models estimating the odds of nurses indicating burnout as a reason for leaving their positions or considering leaving their position revealed statistically significant associations between workplace settings and hours worked per week, but not for tasks performed, and burnout (Table 2). For nurses who had left their jobs, compared with nurses working in a clinic setting, nurses working in a hospital setting had more than twice higher odds of identifying burnout as a reason for leaving their position (OR, 2.10; 95% CI, 1.41-3.13); nurses working in other inpatient settings had an OR of 2.26 (95% CI, 1.39-3.68). Compared with working less than 20 h/wk, nurses who worked more than 40 h/wk had an OR of 3.28 (95% CI, 1.61-6.67) for identifying burnout as a reason they left their position.

For nurses who reported ever considering leaving their job, working in a hospital setting was associated with 80% higher odds of burnout as the reason than for nurses working in a clinic setting (OR, 1.80; 95% CI, 1.55-2.08), whereas among nurses who worked in other inpatient settings, burnout was associated with a 35% higher odds that nurses intended to leave their job (OR, 1.35; 95% CI, 1.05-1.73). Compared with working less than 20 h/wk, the odds of identifying burnout as a reason for considering leaving their position increased with working 20 to 30 h/wk (OR, 2.56; 95% CI, 1.85-3.55), 31 to 40 h/wk, (OR, 2.98; 95% CI, 2.24-3.98), and more than 40 h/wk, (OR, 3.64; 95% CI, 2.73-4.85).

The sensitivity analysis results in which a broader classification of burnout was used showed a similar relationship between odds of burnout and working more than 40 h/wk (OR, 3.86; 95% CI, 2.27-6.59) for those who left their job (OR, 2.66; 95% CI, 2.13-3.31). Stratification by those younger than 45 years and 45 years or older did not significantly change the findings. Figure 3 shows the overlap in nurses who reported burnout and other reasons for leaving their current position or considering leaving their current positions. The greatest overlap occurred in responses of burnout and stressful work environment (68.6% of those who reported leaving and 59.5% of those who considered leaving) and inadequate staffing (63.0% of those who reported leaving and 60.9% of those who considered leaving).


Our findings from the 2018 NSSRN show that among those nurses who reported leaving their jobs in 2017, high proportions of US nurses reported leaving owing to burnout. Hospital setting was associated with greater odds of identifying burnout in decisions to leave or to consider leaving a nursing position, and there was no difference by dominant work function.

Health care professionals are generally considered to be in one of the highest-risk groups for experience of burnout, given the emotional strain and stressful work environment of providing care to sick or dying patients.8,9 Previous studies demonstrate that 35% to 54% of clinicians in the US experience burnout symptoms.1013 The recent National Academy of Medicine report, “Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being,” recommended health care organizations routinely measure and monitor clinician burnout and hold leaders accountable for the health of their organization’s work environment in an effort to reduce burnout and promote well-being.1

Moreover, it appears the numbers have increased over time. Data from the 2008 NSSRN showed that approximately 17% of nurses who left their position in 2007 cited burnout as the reason for leaving, and our data show that 31.5% of nurses cited burnout as the reason for leaving their job in the last year (2017-2018). Despite this evidence, little has changed in health care delivery and the role of registered nurses. The COVID-19 pandemic has further complicated matters; for example, understaffing of nurses in New York and Illinois was associated with increased odds of burnout amidst high patient volumes and pandemic-related anxiety.

Our findings show that among nurses who reported leaving their job owning to burnout, a high proportion reported a stressful work environment. Substantial evidence documents that aspects of the work environment are associated with nurse burnout. Increased workloads, lack of support from leadership, and lack of collaboration among nurses and physicians have been cited as factors that contribute to nurse burnout. Magnet hospitals and other hospitals with a reputation for high-quality nursing care have shown that transforming features of the work environment, including support for education, positive physician-nurse relationships, nurse autonomy, and nurse manager support, outside of increasing the number of nurses, can lead to improvements in job satisfaction and lower burnout among nurses. The qualities of Magnet hospitals not only attract and retain nurses and result in better nurse outcomes, based on features of the work environment, but also improvements in the overall quality of patient care.

Self-reported regional variation in burnout deserves attention. The lower reported rates of nurse burnout in California and Massachusetts could be attributed to legislation in these states regulating nurse staffing ratios; California has the most extensive nurse staffing legislation in the US.20 The high rates of reported burnout in the Southeast and the overlap of burnout and inadequate staffing in our findings could be driven by shortages of nurses in the states in this area, particularly South Carolina and Georgia. Geographic distribution, nurse staffing, and its association with self-reported burnout warrant further exploration.

Our data show that the number of hours worked per week by nurses, but not the dominant function at work, was positively associated with identifying burnout as a reason for leaving their position or considering leaving their position. Research suggests nurses who work longer shifts and who experience sleep deprivation are likely to develop burnout. Others have reported a strong correlation between sleep deprivation and errors in the delivery of patient care.22,24 Emotional exhaustion has been identified as a major component of burnout; such exhaustion is likely exacerbated by excessive work hours and inadequate sleep.

The nurse workforce represents most current frontline workers providing care during the COVID-19 pandemic. Literature from past epidemics (eg, H1N1 influenza, severe acute respiratory syndrome, Ebola) suggest that nurses experience significant stress, anxiety, and physical effects related to their work.27 These factors will most certainly be amplified during the current pandemic, placing the nurse workforce at risk of increased strain. Recent reports suggest that nurses are leaving the bedside owing to COVID-19 at a time when multiple states are reporting a severe nursing shortage.2831 Furthermore, given that the nurse workforce is predominantly female and married, the child rearing and domestic responsibilities of current lockdowns and quarantines can only increase their burden and risk of burnout. Our results demonstrate that the mean age at which nurses who have left or considered leaving their current jobs is younger than 45 years. In the present context, our results forewarn of major effects to the frontline nurse workforce. Further studies are needed to elucidate the effect of the current pandemic on the nurse workforce, particularly among younger nurses of color, who are underrepresented in these data. Policy makers and health systems should also focus on aspects of the work environment known to improve job satisfaction, including staffing ratios, continued nursing education, and support for interdisciplinary teamwork.


Our study has some limitations. First, our findings are from cross-sectional data and limit causal inference; however, these data represent the most recent and, to our knowledge, the only national survey with data on nurse burnout. Second, our burnout measure is crude, and more extensive measures of burnout are needed. Third, 4 states did not have enough respondents to release data (Montana, Wyoming, North Dakota, and South Dakota). However, these data were weighted, and they represent the most comprehensive data available on the registered nurse workforce. Fourth, nonresponse analyses of these data reveal underestimation of certain races/ethnicities, specifically Hispanic nurses, and small sample sizes limited analyses of burnout by race/ethnicity. Fifth, the public use file of the NSSRN does not disaggregate the MSN, PhD, and DNP degrees in nursing practice categories. Given that these job tasks can vary, we addressed this limitation by examining dominant function at work. Last, the response rate was modest at 49.0% (weighted). Despite these limitations, this analysis is most likely the first to provide an updated overview of registered nurse burnout across the US.


Burnout continues to be reported by registered nurses across a variety of practice settings nationwide. How the COVID-19 pandemic will affect burnout rates owing to unprecedented demands on the workforce is yet to be determined. Legislation that supports adequate staffing ratios is a key part of a multitiered solution. Solutions must come through system-level efforts in which we reimagine and innovate workflow, human resources, and workplace wellness to reduce or eliminate burnout among frontline nurses and work toward healthier clinicians, better health, better care, and lower costs.


Babywearing” in the NICU

An Intervention for Infants With Neonatal Abstinence Syndrome

Williams, Lela Rankin PhD; Gebler-Wolfe, Molly LMSW; Grisham, Lisa M. NNP-BC; Bader, M. Y. MD

Editor(s): Cleveland, Lisa M. PhD, Section Editor Author Information Advances in Neonatal Care: December 2020 – Volume 20 – Issue 6 – p 440-449



The US opioid epidemic has resulted in an increase of infants at risk for developing neonatal abstinence syndrome (NAS). Traditionally, treatment has consisted of pharmacological interventions to reduce symptoms of withdrawal. However, nonpharmacological interventions (eg, skin-to-skin contact, holding) can also be effective in managing the distress associated with NAS.


The purpose of this study was to examine whether infant carrying or “babywearing” (ie, holding an infant on one’s body using cloth) can reduce distress associated with NAS among infants and caregivers.


Heart rate was measured in infants and adults (parents vs other adults) in a neonatal intensive care unit (NICU) pre- (no touching), mid- (20 minutes into being worn in a carrier), and post-babywearing (5 minutes later).


Using a 3-level hierarchical linear model at 3 time points (pre, mid, and post), we found that babywearing decreased infant and caregiver heart rates. Across a 30-minute period, heart rates of infants worn by parents decreased by 15 beats per minute (bpm) compared with 5.5 bpm for infants worn by an unfamiliar adult, and those of adults decreased by 7 bpm (parents) and nearly 3 bpm (unfamiliar adult).

Implications for Practice: 

Results from this study suggest that babywearing is a noninvasive and accessible intervention that can provide comfort for infants diagnosed with NAS. Babywearing can be inexpensive, support parenting, and be done by nonparent caregivers (eg, nurses, volunteers).

Implications for Research: 

Close physical contact, by way of babywearing, may improve outcomes in infants with NAS in NICUs and possibly reduce the need for pharmacological treatment.

***** See the video abstract BELOW for a digital summary of the study.



Dec 27, 2017   Ivanhoe Web

It’s a blinding eye disorder that affects as many as 16,000 preemies in the United States every year. See how a doctor in Oregon is pioneering ways to keep these babies from going blind.

***UPDATE: Michael F. Chiang, M.D., is now the Director of the National Eye Institute at the National Institutes of Health. A Very Interesting Interview can be found here:

Evaluation of the Neonatal Sequential Organ Failure Assessment and Mortality Risk in Preterm Infants With Late-Onset Infection

Noa Fleiss, MD1Sarah A. Coggins, MD2Angela N. Lewis, MD3; et alAngela Zeigler, MD4Krista E. Cooksey, BA3L. Anne Walker, BA5Ameena N. Husain, DO3Brenda S. de Jong, BSc6Aaron Wallman-Stokes, MD1Mhd Wael Alrifai, MD5Douwe H. Visser, MD, PhD6Misty Good, MD3Brynne Sullivan, MD4Richard A. Polin, MD1Camilia R. Martin, MD7James L. Wynn, MD8 Author Affiliations Article Information  Original Investigation Pediatrics  February 4, 2021. JAMA Netw Open. 2021;4(2):e2036518. doi:10.1001/jamanetworkopen.2020.36518

Key Points

Question  How useful is the neonatal Sequential Organ Failure Assessment for identification of preterm infants at high risk for late-onset, infection-associated mortality?

Findings  In this multicenter cohort study of 653 preterm infants with late-onset infection, the neonatal Sequential Organ Failure Assessment score was associated with infection-attributable mortality. Analyses stratified by sex or Gram stain of pathogen class or restricted to less than 25 weeks’ completed gestation did not reduce the association of the neonatal Sequential Organ Failure Assessment score with infection-related mortality.

Meaning  In a large, multicenter cohort, the single-center–validated neonatal Sequential Organ Failure Assessment score was associated with mortality risk with late-onset infection in preterm infants, implying generalizability.


Importance  Infection in neonates remains a substantial problem. Advances for this population are hindered by the absence of a consensus definition for sepsis. In adults, the Sequential Organ Failure Assessment (SOFA) operationalizes mortality risk with infection and defines sepsis. The generalizability of the neonatal SOFA (nSOFA) for neonatal late-onset infection-related mortality remains unknown.

Objective  To determine the generalizability of the nSOFA for neonatal late-onset infection-related mortality across multiple sites.

Design, Setting, and Participants  A multicenter retrospective cohort study was conducted at 7 academic neonatal intensive care units between January 1, 2010, and December 31, 2019. Participants included 653 preterm (<33 weeks) very low-birth-weight infants.

Exposures  Late-onset (>72 hours of life) infection including bacteremia, fungemia, or surgical peritonitis.

Main Outcomes and Measures  The primary outcome was late-onset infection episode mortality. The nSOFA scores from survivors and nonsurvivors with confirmed late-onset infection were compared at 9 time points (T) preceding and following event onset.

Results  In the 653 infants who met inclusion criteria, median gestational age was 25.5 weeks (interquartile range, 24-27 weeks) and median birth weight was 780 g (interquartile range, 638-960 g). A total of 366 infants (56%) were male. Late-onset infection episode mortality occurred in 97 infants (15%). Area under the receiver operating characteristic curves for mortality in the total cohort ranged across study centers from 0.71 to 0.95 (T0 hours), 0.77 to 0.96 (T6 hours), and 0.78 to 0.96 (T12 hours), with utility noted at all centers and in aggregate. Using the maximum nSOFA score at T0 or T6, the area under the receiver operating characteristic curve for mortality was 0.88 (95% CI, 0.84-0.91). Analyses stratified by sex or Gram-stain identification of pathogen class or restricted to infants born at less than 25 weeks’ completed gestation did not reduce the association of the nSOFA score with infection-related mortality.

Conclusions and Relevance  The nSOFA score was associated with late-onset infection mortality in preterm infants at the time of evaluation both in aggregate and in each center. These findings suggest that the nSOFA may serve as the foundation for a consensus definition of sepsis in this population.



Safe Rides Home for Smaller Babies

Special Interest Group Update

Heidi Heflin, MN RN CNS CPSTI     Laura Siemion, RNC-NIC BSN CPST

Helping caregivers select and properly use an appropriate child safety seat should be a part of every neonatal program (Bull & Chappelow, 2014; O’Neil et al., 2019). Child safety seats are highly effective in reducing the likelihood of death and injury in motor vehicle crashes, and for children less than 1 year old, a child safety seat can reduce the risk of fatality by 71% (Hertz, 1996).

Unfortunately, many babies may be poorly protected during their first car rides. One research study showed 93% of newborns left a university hospital inadequately buckled up (Hoffman et al., 2014). Although some nurses may feel uncomfortable addressing car seat safety, an unpublished 2020 national survey from NANN found that 112 of 113 nurse respondents said they had “addressed child passenger safety (CPS) for parents/caregivers during newborn hospitalization” within the past 6 months (Chappelow et al., 2020).

When it comes to preterm and low-birth-weight infants, special consideration must be given to transportation safety. In particular, the physiologic immaturity and low weight of these infants must be considered when selecting an appropriate type and model of child safety seat.

Motor vehicle injuries are a leading cause of death among children in the United States (National Center for Injury Prevention and Control, n.d.). Every day in 2018, three children were killed and an estimated 520 were injured in U.S. traffic crashes (National Center for Statistics and Analysis, 2020). Many deaths and injuries could be prevented with proper use of a child safety seat, which includes choosing a seat appropriate for the child.

To understand how child safety seats help prevent death, one must understand crash dynamics. The National Child Passenger Safety Certification Training (2020) describes that every vehicle crash is really three “crashes”. The first crash involves sudden deceleration of the vehicle, including hard braking, evasive maneuvers, and/or colliding with an external object. The second occurs as the occupant strikes something in the vehicle (in this case, a child hits the car safety seat shell and/or harness). The third crash involves the child’s internal organs continuing to move until they strike other organs or bones. A child safety seat decreases the severity of the second and third collisions by directing much of the crash energy into the child safety seat and away from the child.

A child safety seat is designed to protect a child in a crash or sudden stop in more than one way. It spreads crash forces across the strongest parts of the child’s body. For infants and young children, that means the seat must be placed with the child rear-facing so that, in a frontal collision, the force is dispersed over a wide area of the child’s back. The unproportionally large head, immature neck, and spine are protected by being encased in the child safety seat shell and by a snug-fitting harness securing the child at the shoulders and hips. A child safety seat helps the child’s body slow down more gradually than ‘the sudden stop,’ and prevents ejection from the car. Even at 30 mph, crash forces are severe. For instance, an unrestrained 10-lb baby in a 30-mph crash is thrown with 300 lbs of force.

The American Academy of Pediatrics (AAP) Policy Statement “Transporting Children with Special Health Care Needs” provides guidance for selecting child safety seats for infants with special healthcare needs and asserts that a conventional rear-facing child safety seat, which allows for proper positioning of the preterm infant, should be used if the infant can maintain healthy vital signs while seated in a semi-upright position (O’Neil et al. 2019).

Selecting the appropriate child safety seat can be daunting, especially since there are almost 350 models of child safety seats currently offered for sale in the United States (J. J. Stubbs, personal communication, October 1, 2020). Each offers slightly different features. An “appropriate” seat is one that properly fits the newborn, fits the vehicle, and is convenient to use on every ride (National Highway Traffic Safety Administration, 2020). The newborn’s weight, length, maturation, and associated medical conditions should all be considered when selecting a seat (Bull et al., 2009; reaffirmed 2018).

All child safety seats legally sold in the United States must meet Federal Motor Vehicle Safety Standard (FMVSS) No. 213, which establishes many child restraint system requirements, including those related to crash performance, flammability, and labeling. Child safety seat labeling can help determine if the seat is compliant and how to use it properly (National Highway Traffic Safety Administration, 2020). Requirements include a label on the plastic shell stating that the seat meets federal standards and a label with the date of manufacture. Model/manufacturer/”birthdate” labels should be used as a reference for investigating recalls.

Because child safety seat manufacturers generally set a specified lifespan (from 6 to 11 years) for their products, most models indicate an expiration date on labels or in the owner’s manual. Expired child safety seats should be destroyed or recycled, not used to transport a child.

The 2018 revised AAP policy statement, “Child Passenger Safety,” recommends that children ride rear-facing as long as possible, limited by the maximum weight and length allowed for use by their child safety seat instructions (Durbin et al., 2018).

Determining which seat fits by weight is a good first step to narrow selection. Most rear-facing-only (RFO) safety seats allow use by infants beginning at 4 lbs. At the time this article was written, three RFO seats allow use beginning at 3 lbs, and one may be used “from birth.” Larger convertible or all-in-one seats typically allow rear-facing use starting at 5 lbs, though several are available that start at 4 lbs and one allows use beginning at 3 lbs. After disqualifying seats based on weight, minimum height requirements can be used to immediately narrow options. See Table 1 to learn more about child safety seats for small babies.

A close-to-comprehensive product list of all seats on the market, including their weight minimum and maximum, can be found on AAP’s Healthy Children website. The list is updated annually but is not revised between updates, so some new models may not be reflected. A current list of all child safety seats that are rated for infants under 4 lbs can be found in the free handout #173 Automobile Restraints for Children with Special Needs: Quick Reference List found on the SafetyBeltSafe U.S.A. website. This list is updated as products are introduced or discontinued.

When choosing between an RFO or convertible child safety seat, note that either can provide optimum comfort, fit, and positioning for the preterm or low-birth-weight infant (Bull et al., 2009; reaffirmed 2018) if carefully selected. RFO seats are lighter weight, have a handle for carrying, and usually can be snapped in and out of a base that remains installed in the vehicle. Convertible seats are larger, heavier, and meant to stay in the car. Despite their larger overall size, some convertible models may be an option for preterm infants if the harness system fits properly. Models that allow use by 4-lb children tend to be adjustable for use by very small infants. Convertible seats have a longer period of usefulness, allowing forward-facing use by children weighing up to 40–85 lbs, depending on the seat. They are often a good choice for lower-income families and hospital distribution programs.

However, child safety seat fit is more complicated than just considering the allowable weight and height requirements of a product. Several features contribute to how well a seat fits a tiny baby. One thing to consider is where the shoulder harness goes through the seat relative to the child’s shoulders. When any infant is riding rear-facing, the harness straps must go through slots that are at or below the infant’s shoulders. Therefore, for a preterm infant, a seat with very low shoulder strap slots (roughly 5–6 in. up from the seat cushion), is essential (Safe Ride News Publications, 2020).

Some seats come with crash-tested and approved adjustment methods specifically for tiny babies, such as boosting inserts and alternative harness threading methods. A harness must be able to be tightened snugly over the child’s body, judged by ensuring the webbing cannot be pinched between thumb and forefinger. In addition, the buckle strap (or “crotch strap”) may have an adjustment to place it closer and/or make it shorter, preventing an infant from sliding down or slumping into an unsafe position (Bull et al., 2009; reaffirmed 2018).

In general, child safety seat instructions direct the user to which approved and recommended adjustments are necessary for a safe, snug harness fit. (Note: While adjustability may greatly enhance the performance of a child safety seat for a small infant, making the necessary adjustments can be complicated and overwhelming.) A child passenger safety technician (CPST), a nationally certified educator in the field of occupant protection, is a resource that can help train the neonatal team, keep them up to date (AAP et al., 2014), and assist with solving complex child safety seat problems.

Used seats are acceptable only if the parent or caregiver knows the seat’s history and that it has all pieces, including instructions. They must be certain that the seat has never been in a crash, is not expired, and has no unresolved recalls. Reused seats are often missing pieces, especially the inserts for newborns. Refer to the child safety seat instructions to account for every piece (National Highway Traffic Safety Administration, 2020).

Be aware that counterfeit seats are appearing with greater frequency at child safety seat installation stations, and they may be making their way to hospitals. These are often bought online at a “value” price and provide little or no protection in a crash. Sometimes it is difficult to identify a fake seat. Counterfeit child safety seats do not meet federal safety standards, often lack required labels on the seat shell and are made of inferior materials. Ask a CPST for help if you have doubts about whether a seat complies with federal safety standards.

Infants with certain temporary or permanent physical conditions may be at risk when placed in the semi-reclined position of a conventional seat and may travel more safely in a car bed certified to FMVSS 213 standards (Bull et al., 2009; reaffirmed 2018). To screen for tolerance in the semi-upright seating position, an infant should be observed in an appropriate child safety seat for valid results. To learn more about Car Seat Tolerance Screening (CSTS), refer to the AAP’s clinical report, Safe Transportation of Preterm and Low Birth Weight Infants at Hospital Discharge.

While some CPSTs are nurses, a nurse does not need to be a CPST to help protect infants in cars. To manage risk, a working group of experts convened by the National Highway Traffic Safety Administration (NHTSA) recommends that hospitals employ a CPST to train staff, assist in annual competency checks, and provide hands-on advice and guidance to families when questions arise beyond the nurse’s skill level (AAP et al., 2014). A CPST with additional certification through Safe Travel for All Children: Transporting Children with Special Health Care Needs would be an especially valuable resource.

One way to find CPSTs is to visit CPSTs can assist in the development of policies, procedures, and guidelines, train neonatal nurses on how to better protect their patients, and ensure that practices/institutions stay abreast of new products and updates to best practice recommendations. Additional sources for education, training, and resources for neonatal professionals and parents of preterm infants are listed at the end of this article. Neonatal nurses play a critical role in promoting CPS. They are a trusted source of information and have an established relationship with families in their communities. In an NHTSA motor vehicle occupant survey (2020), caregivers self-reported their behaviors, attitudes, and knowledge related to auto occupant safety, including the transport of children specifically. Of the responding caregivers, 48% indicated they received child restraint information and advice from a nurse or doctor.

The CPS field needs neonatal nurses as a vital link to caregivers. Ensuring that nurses know the basic criteria for child safety seat selection and use helps them to accurately educate parents, document child safety seat use upon discharge, and conduct car seat tolerance screenings. CPSTs welcome a nursing partnership to keep kids safe in cars.

Neonatal Passenger Safety Resources:

  • American Academy of Pediatrics (AAP) Healthy Children site: 
  • Automotive Safety Program:, information about transporting children who have certain medical conditions or have undergone procedures.
  • National Center for Safe Transportation of Children with Special Health Care Needs: 
  • Child Safety Seat Manufacturers’ sites: search by manufacturer name on search engine
  • National Child Passenger Safety Board:, the Safe Transportation of Children: Checklist for Hospital Discharge includes guidelines specific to neonates.
  • National Highway Traffic Safety Administration (NHTSA): 
  • Safe Kids Worldwide:, find a CPST with training in special transportation needs
  • Safe Ride News:, Selecting an Appropriate Child Safety Seat for a Tiny Baby fact sheet.
  • Safety Belt Safe U.S.A.:, offers caregiver and professional child passenger safety technician assistance call Safe Ride Helpline 800.745.SAFE (English), 800.747.SANO (Spanish).


What pregnant women should know about climate change

From low birthweight to preterm birth, pregnant women should know the potential health impacts of climate change. Learn how to keep yourself and your child healthy in a changing climate. This guide will explain how air pollution and heat matters to preterm birth and how you can keep you and your child healthy in a changing climate.

A Parents Guide to their Premature Babies Eyes

What is ROP? Retinopathy of prematurity (ROP) is a potentially blinding disease, which in the United States affects several thousand premature infants every year. It was unknown prior to 1942 because premature infants did not survive long enough to show the effects of ROP. With improvements in the medical care of the smallest premature infants, the rate and severity of ROP has increased. The diagnosis of ROP is made by an ophthalmologist who examines the inside of the eye. Premature infants qualify for eye examinations based on several factors, including the birth weight. Although, a high percentage of examined babies will show some degree of ROP, most will not require surgery. Nevertheless, premature babies require lifelong follow-up by an ophthalmologist because of their increased risk for eye misalignment, amblyopia, and the need for glasses to develop normal vision. Interested in learning more?

Please access the Parent Guide Below:


Video Abstract: “Babywearing” in the NICU: An Intervention for Infants with Neonatal Abstinence Syndrome

Video Author: Lisa M. Grisham   Published on: 07.28.2020

We describe the impact of infant carrying or “babywearing” on reducing distress associated with Neonatal Abstinence Syndrome among infants and caregivers. Heart rate was measured in a neonatal intensive care unit pre- (no touching), mid- (20 minutes into babywearing), and post-babywearing (5 minutes later). Across a 30-minute period, infants worn by parents decreased 15 beats per minute (bpm) compared to 5.5 bpm for infants worn by an unfamiliar adult, and adults decreased by 7 bpm (parents) and nearly 3 bpm (unfamiliar adult). Babywearing is a non-invasive and accessible intervention that can provide comfort for infants diagnosed with NAS.


Both preterm and post-term birth increases risk of Autism Spectrum Disorder

Posted ON 04 FEBRUARY 2021

The causes of autism spectrum disorder (ASD) are complex and remain unclear. A recent study, involving more than 3.5 million children, now shows that the risk of ASD may slightly increase for each week a baby is born before or after 40 weeks of gestation.

Autism spectrum disorder (ASD) is a neurodevelopmental disorder, affecting 1% to 2% of children worldwide. Children with this disease cannot initialize or take part in social communication and have repetitive behaviours. The reasons may be genetic and related to environmental factors, and there are still a lot of unsolved puzzles in this field.

A group of scientists analysed data of 3.5 million children born in Sweden, Finland or Norway between 1995 and 2015. The goal of the study was to explore a potential correlation between gestational age (at which week a child is born) and the risk of Autism Spectrum Disorder. The results show that the children born at term (in weeks 37-42) had the lowest risk rate of 0.83. This risk rate represents the percentage of babies with ASD in the specific group: a risk rate of 0.83 means that less than one baby born at term had ASD in the study population. For the babies born preterm in weeks 22-31, the risk rate for ASD was about 1.67, while for the babies born preterm in weeks 32-36 the risk rate was 1.08. Finally, post-term birth, in weeks 43-44, was associated with the highest risk rate observed (1.74).

The results suggest that preterm and post-term birth can be related to ASD. However, the main limitation of the study is the lack of information on the potential causes for either pre- or post-term birth. More research is required to clarify the link between pre- and post-term birth and ASD.

The study is based on nationwide data from Sweden, Finland, and Norway, made available from the European Union’s Horizon 2020 research and innovation program “RECAP preterm” (Research on European Children and Adults born preterm, Please see the following link for more information regarding the RECAP preterm project and EFCNI’s involvement:

Premature babies have a higher risk of dying from chronic disease as adults


Those that were born prematurely had a 40 percent higher risk of dying from chronic disease than the rest of the population, according to a new study.

A new study shows that people born prematurely have double the risk of dying from heart disease, chronic lung disease and diabetes as adults, compared to the rest of the population. The study includes 6.3 million people from Norway, Sweden, Finland and Danmark. It was led by professor Kari Risnes at the Norwegian University of Science and Technology, NTNU.

A full term pregnancy lasts 40 weeks. If a child is born before week 37, it’s considered premature.

The study shows that the general risk of death among people below the age of 50 is 2 in every 1000. For those born prematurely, this risk is 40 per cent higher.

Around 6 per cent of children in Norway are born before their full term.

“We already know that those who are born prematurely have a higher risk of dying as children and as young adults. Now we’ve shown the risk of death from chronic diseases before the age of 50,” Risnes says to NRK (link in Norwegian).

Doctors should now take into consideration whether someone was born prematurely when working with patients, according to Risnes.

“We already know that those who are born prematurely have a higher risk of dying as children and as young adults. Now we’ve shown the risk of death from chronic diseases before the age of 50,” Risnes says to NRK (link in Norwegian).

Doctors should now take into consideration whether someone was born prematurely when working with patients, according to Risnes.


Health Professional News

An inside look at the Children’s Minnesota neonatal transport program

For neonates, time is precious. Our neonatal transport team is able to transport newborns in need from any distance in the Upper Midwest. They receive specialized training to provide the safest transfer of patients, which can be done by ambulance, helicopter, fixed-wing plane or our critical care rigs. Transport service is available around the clock, seven days a week — the neonatal team is equipped to implement treatments such as nitric oxide and active cooling therapies immediately upon arrival at the hospital and during the transport.

“As medical director for the Children’s Minnesota neonatal transport team, I am extremely proud of the care our highly skilled team provides. Each year our team partners with referring hospitals around the Upper Midwest to transport hundreds of neonates to our Children’s Minnesota NICUs,” said Heidi Kamrath, DO, neonatal transport medical director and neonatologist. “We know that while most babies are born healthy, emergencies happen. Our neonatologists are accessible 24/7 by phone and virtual care where available for consultation. When transport is needed, our team is dedicated to providing high quality compassionate care to the families we serve.”

Meet two valuable members of the Children’s Minnesota neonatal transport team: Andy Rowe, RRT and Alison Olson, APRN, CNP. Andy is a respiratory therapist and critical care transport coordinator, and Alison is a neonatal nurse practitioner and transport team lead.

Read on as they provide information about their role and the highly complex, important program that they help lead to improve outcomes for newborns.

Q. What’s your background and what do you do on the team?

Andy: My training is in respiratory therapy and I’ve been with Children’s Minnesota for 11 years. For the past 5 years, I’ve been on the neonatal transport team and have managed the day to day operations since 2018. I love working on this well bonded team as we go into outlying communities with the opportunity to make a difference for neonatal patients, families and our referral hospitals.

Alison: I have worked in NICU for the past 10 years and have been a Neonatal Nurse Practitioner at Children’s Minnesota since 2017. I now serve as the NNP transport lead to guide policy and practice for the team as well as the care of neonatal patients requiring transfer from a community hospital to Children’s Minnesota when they require a higher level of care. My work helps assure quality and best outcomes for all newborns that come to the NICU at Children’s Minnesota.

Q. Can you tell me about the capabilities you carry with you when you transport a newborn?

Andy: We are prepared with all the capabilities of our Level IV NICU including high frequency ventilation, nitric oxide and active body cooling. Many preterm infants transported need high frequency ventilation (HFV). HFV can be very beneficial in reducing the risk for chronic lung disease for these fragile infants, by providing them with protective lung ventilation. For infants with respiratory failure such as severe hypoxia, respiratory distress syndrome, ELBW babies (23-26 weeks), persistent pulmonary hypertension of the newborn (PPHN), pneumothorax, meconium aspiration syndrome, we also carry inhaled nitric oxide (INO) on our transport incubators. The benefits of INO is that when inhaled, it relaxes and dilates the pulmonary vasculature allowing for improved oxygenation.

The sooner we can institute these techniques, the better the outcomes because it can prevent long term lung damage. Our goal is “out the door in 30 minutes of a call” and helps assure these care interventions can be applied as soon as possible!

Q. In addition to advanced respiratory care capability, you mentioned that you have “active” body cooling available on transport. For babies that have suffered hypoxic ischemic encephalopathy, is there criteria for when you may choose “passive” versus “active” body cooling?

Alison: When babies experience a hypoxic event or require resuscitation at delivery, community hospitals may start “passive” body cooling before we arrive. They may also be on the phone with Children’s Minnesota Physician Access or Neonatal Virtual Care for consult and continuing care guidance prior to our team arriving. Once we arrive, our transport team determines whether to use passive or active body cooling during transport.

Some of the decision making is based on proximity of the referring hospital because it takes some time to get the cooling machine set up and ready for cooling. If it is appropriate to initiate active body cooling, we use the Tecotherm Neo which is a blanket that is made up of tubes of water. The machine uses a thermometer to monitor the baby’s temp and sends that information to the blanket, adjusting the water temp as needed. It allows us to consistently cool the baby at a temperature of 33-34 degree Celsius quickly and safely. The treatment is continued once we reach Children’s Minnesota for 72 hours at which time we slowly bring their temperature back to normal as the treatment is completed. Total body cooling helps reduce secondary injury of the hypoxic insult and quick initiation is critical for best outcomes.


“The Future of Science is Appreciation of Disorder”- James Gleick


Over time, the science of Chaos has integrated into diverse sciences, providing broadened views, enhanced perspectives.

James Gleick on Chaos: Making a New Science

Mar 30, 2011

“Chaos is a kind of science that deals with the parts of the world that are unpredictable, apparently random . . . disorderly, erratic, irregular, unruly—misbehaved,” explains James Gleick, author of Chaos: Making a New Science. Gleick, one of the nation’s preeminent science writers, became an international sensation with Chaos, in which he explained how, in the 1960s, a small group of radical thinkers upset the rigid foundation of modern scientific thinking by placing new importance on the tiny experimental irregularities that scientists had long learned to ignore. Two decades later, Gleick’s blockbuster modern science classic is available in ebook form—now updated with video and modern graphics.


Over the past 5 months we have been living in chaos as we have experienced moving during the pandemic. In the process of selling our previous home we lived in an apartment for four months before settling into our new house.  As shown in the photo above moving into an old house built in 1918 has come with its bundle of chaos. From getting the entire house re-plumbed to considering new electricity and heat we are navigating new beginnings in a time of chaos.  One thing that has kept us centered is our  love and concern for our PTSD cat, Gannon.  Our efforts to provide him with familiar things and routines on a daily basis has calmed his fears and helped him to  experience a sense of normalcy, which has helped us to experience a sense of normalcy.  If we conscientiously choose to experience periods of peace and familiarity within this chaotic journey we are all on, we will always navigate home.

Foiling the Dead Sea

•Jul 19, 2018          Di Tunnington

The Dead Sea is the lowest place on earth, and 9 times saltier than the ocean. Taking the Hydrofoil out was a lot harder than I expected as the Salt caused drag for the foil! Check it out.

Celebration, Collaboration and a Cortex



Rank: 109  –Rate: 9.2   Estimated # of preterm births per 100 live births 

(USA – 12 %, Global Average: 11.1%)

Montenegro is a country in southeast Europe on the Adriatic coast of the Balkans. It borders Bosnia and Herzegovina to the north, Serbia to the east, Albania to the southeast, the Adriatic Sea and Croatia to the west. The largest and capital city Podgorica covers 10.4% of Montenegro’s territory and is home to 29.9% of the country’s population, while Cetinje has the status of old royal capital. Major group in the country are MontenegrinsSerbs form a significant minority at 28.7%, followed by BosniaksAlbanians and Croats.

Classified by the World Bank as an upper middle-income country, Montenegro is a member of the UN, NATO, the World Trade Organization, the Organization for Security and Co-operation in Europe, the Council of Europe, and the Central European Free Trade Agreement. Montenegro is a founding member of the Union for the Mediterranean. It is also in the process of joining the European Union.

According to the Health Consumer Powerhouse the country has “the most backward health system in Europe”. Public services are financed through the Health Insurance Fund. It is funded by payroll contributions of 10.5%. About 5% of the national budget is allocated to healthcare. Only €5 million was provided for all public hospital supplies in 2016, about a third of what was thought necessary. 72.5% of total health spending comes from the fund. Most of the rest is direct out-of-pocket payments.

The Ministry of Health in Montenegro guides a national health fund. Contributions of employer’s and employee’s entitles citizens to health care. This program covers most medical services, except from particular physicians.[32]



As we look forward to celebrating the beginning of our 6th year (February) of sharing this “blog” we thank all Neonatal Womb Warrior/Preterm Birth Community members for your presence, and for the courage, endurance, intelligence, creativity and compassion you share with All experiencing this challenging life journey. Knowing you are out there we feel a sacred kinship and energetic connection that only a soul-centered awareness can create. From deep within our hearts, with Joy and Gratitude, we  (Kat and Kathy) Thank You.

Queen Elizabeth II honours Inga Warren

Posted on 22 January 2021

© privat

This is one of the highest accolades given and is a wonderful recognition, justly deserved, of her work and dedication to babies and their families.

Inga Warren is a neonatal development specialist with extensive experience as an occupational therapist working with children of all ages and families. She teaches nurses, doctors and therapists to understand babies behaviour, their cues and body language, helping them to change practice and to involve parents in the care of their child. She is also the director of the UK NIDCAP (Newborn Individualized Developmental Care and Assessment Program )Training Centre.

Together with Monique Oude Reimer-van Kilsdonk, Inga Warren developed the FINE (Family and Infant Neurodevelopmental Education) programme – an educational pathway in infant and family-centred developmental care for all healthcare professionals working in neonatal care. She has been a supporter of EFCNI’s work for many years and was also very much involved in the European Standards of Care for Newborn health project where she contributed with her knowledge to the standard topic of Infant and family centred developmental care.


A large study of UK healthcare workers finds that immunity after coronavirus infection lasts for months, but those with antibodies may still be able to carry and spread the virus upon re-exposure.

Max Kozlov  Jan 14, 2021

Immune responses from a previous SARS-CoV-2 infection reduce survivors’ risk of reinfection by more than 83 percent for at least five months, according to preliminary data from a study of more than 20,000 UK healthcare workers published by Public Health England. The researchers caution that people previously infected may still be able to transmit the virus.

“Overall I think this is good news,” Imperial College London epidemiologist Susan Hopkins, a senior medical adviser to Public Health England (PHE), tells The Guardian. “It allows people to feel that prior infection will protect them from future infections, but at the same time it is not complete protection, and therefore they still need to be careful when they are out and about.”

Between June and November last year, the researchers monitored, through monthly serological tests and PCR tests twice a month, the infection rates in those who had been infected with the virus before June and those who had not. They found 44 potential reinfections, including 13 symptomatic cases, among the 6,614 who’d had the virus before, and 318 cases among the 14,173 who had no evidence of past infection. The authors concluded from these results that prior exposure to SARS-CoV-2 provides 94 percent protection against symptomatic reinfection, and 75 percent protection against asymptomatic reinfection.

The researchers also found that people who become reinfected can carry a high viral load in their noses and throats, even in asymptomatic cases, which correlates with a higher risk of spreading the virus to others, says Hopkins.

“Reinfection is pretty unusual, so that’s good news,” University of Pennsylvania immunologist John Wherry tells Nature. “But you’re not free to run around without a mask.”

“The immunity gives you a similar effect to the Pfizer vaccine and a much better effect than the AstraZeneca vaccine and that is reassuring for people. But we still see people who could transmit and so we want to strike a note of caution,” Hopkins tells The Guardian. In clinical trials, two doses of the Pfizer vaccine were 95 percent effective at preventing infection, compared with 62 percent from two doses of the Oxford/AstraZeneca vaccine. The Pfizer vaccine has been approved for emergency use in the UK, Canada, Mexico, the US, Switzerland, and the EU, while the Oxford/AstraZeneca vaccine has been approved for emergency use in the UK, Argentina, India, and Mexico. 

None of the individuals with potential reinfections had PCR-based evidence of a first infection, but all harbored antibodies against SARS-CoV-2 at the outset of the study, which has not yet been peer-reviewed or published in any medical journal. The authors tried to measure antibodies that were specific to SARS-CoV-2, but prior studies show that antibodies against other coronaviruses may cross-react to show a false positive result for SARS-CoV-2 antibodies, which is why the researchers termed these cases “possible reinfections.”

The PHE team does not yet have enough data to understand who might be at highest risk of reinfection. Francis Crick Institute immunologist George Kassiotis tells Nature that participants in the study were mainly women, and mostly under the age of 60. “This group is unlikely to experience the most severe form of COVID-19,” he says, “and may not be representative of the population as a whole.”

Correction (January 15): We omitted Mexico from the list of countries that have approved the Pfizer vaccine. The Scientist regrets the error.


Mapping neonatal and under 5 mortality in India

Published : May 11,  2020 Praaveen Kumar, Nalini Singhal

India is one of the world’s largest and most populous countries, made up of more than 700 diverse districts. Variations in mortality in the country are known at the macro level, and now the India State-Level Disease Burden Initiative Child Mortality Collaborators  have mapped neonatal and under-5 mortality rates from 2000 to 2017 for every district in India, going down to geospatial grids as small as 5 km × 5 km. In The Lancet, the study authors report that the under-5 mortality rate (U5MR) in India decreased from 83·1 deaths (95% uncertainty interval 76·7–90·1) in 2000 to 42·4 deaths (36·5–50·0) per 1000 livebirths in 2017, and the neonatal mortality rate (NMR) decreased from 38·0 deaths (34·2–41·6) to 23·5 deaths (20·1–27·8) per 1000 livebirths. U5MR varied 5·7 times between the various states and 10·5 times between the 723 districts in 2017, whereas NMR varied 4·5 times across the states and 8·0 times across the districts. Child and maternal malnutrition was the main risk factor, contributing to 68·2% (65·8–70·7) of under-5 deaths and 83·0% (80·6–85·0) of neonatal deaths in India in 2017, while 10·8% (9·1–12·4) of under-5 deaths could be attributed to unsafe water and sanitation and 8·8% (7·0–10·3) to air pollution. The authors found substantial variations between the states in the magnitude and rate of decline in neonatal and under-5 mortality, with higher variations between the districts. Additionally, inequality between districts has increased within the majority of the states.

The underlying system-based causes of neonatal and under-5 mortality need to be better understood. One size cannot fit all, especially in such a large country. Contextual microplanning is required at the lowest administrative unit level, which should be based on real data of deaths and their causes, available resources, and coverage and quality of services. The Article  describes important differences in local outcomes that can inform the designing of strategies with local stakeholders in areas such as education, provision of equipment (eg, incubators, neonatal radiant warmers, neonatal resuscitation bag and masks, autoclaves), and transportation of mothers and neonates to health facilities to accelerate the decrease in NMR and U5MR. Local health-care providers understand the challenges their areas face and thus might be able to provide solutions for sustainable improvements. A district-level perinatal–neonatal care model driven by local coordination committees composed of all stakeholders has been proposed.

Quality care, knowledge translation to caregivers, and local implementation for delivery of health care are all key to survival of children and mothers.

Focusing on local changes using local data can lead to improved outcomes, as has been shown in Canada.

Health is a state responsibility; however, in India planning typically occurs at the central level with very little involvement of lower level providers. This study provides valuable information to highlight the importance of standardised national perinatal–neonatal surveillance data that can be turned into actionable information for end users at the lowest administrative unit.

The authors have brought attention to the fact that, with current trends, India is unlikely to achieve the Sustainable Development Goal (SDG) 2030 NMR targets or either of the National Health Policy 2025 targets.

 To reach the SDG 2030 targets individually, 246 (34%) districts for U5MR and 430 (59%) districts for NMR would need a higher rate of improvement than they had up to 2017.

 Simply knowing the causes is not enough. Structural deficiencies remain, with glaring bottlenecks. To provide adequate care, India needs 20 000–30 000 level 3 neonatal intensive care unit (NICU) beds and 75 000–100 000 level 2 special newborn care beds.

 However, the numbers of beds available, especially level 3 NICU beds, are grossly inadequate.

 It remains common in government hospitals to have up to five sick newborn babies sharing a cot.

 In such scenarios, quality improvement efforts that target process improvement alone do not achieve their full potential benefits. The Indian Government’s flagship insurance scheme—the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana—holds great promise of rapidly expanding the pool of hospital beds by enrolling existing private health-care facilities. However, the effect on availability of level 3 NICU beds is yet to be seen. Upgrading and operationalising the underused newborn stabilisation unit beds across the country along with a functional back-referral system could substantially augment the number of level 2 beds available.

The variation in district-wise mortality and its relationship to social development has caught the attention of planners. The Aspirational Districts Programme launched in 2018 focuses on the 115 lowest-performing districts for all-round development through convergence, collaboration, and competition. Intersectoral and centre-state convergence addresses education, skills development, financial inclusion, water, air, infrastructure, and other determinants of health. Apart from state-wise and district-wise differences, another source of huge variation is urban slums. The mortality indicators in urban slums are even worse than in rural areas and they have their own unique set of problems.

The growing inequalities shown in this study  between 2000 and 2017, against a global aim of equity, are of concern and reflect the widening gap between the rich and the poor.

Finally, the estimates of the causes of neonatal deaths in the country need to be more robust for good planning. The study authors point out the limitations of verbal autopsy methods.

However, the medical certification of cause of death is not always credible, given the expertise of medical officers in the districts with limited laboratory support.

The authors make a strong case for local implementation and provide guidance to address gaps. In this direction, the Indian Government has launched programmes to improve nutritional outcomes for children, pregnant women, and lactating mothers; clean water and sanitation; and hygiene in public health facilities. With local input and planning, both U5MR and NMR can be brought down.


Thunderstorm in Montenegro| Soothing Thunder & Rain Sounds For Sleep| Relaxation| Studying| 10 Hours

Jan 6, 2021   Outdoor Therapy

Relax, Study or FALL ASLEEP FAST with the soothing sounds of this thunderstorm in Montenegro.


Beating the odds: The world’s most premature twins to celebrate 2nd birthday

Sarah Kay LeBlanc       Des Moines Register

DES MOINES, Iowa — Shorter than a Barbie doll and lighter than a football, Kambry Ewoldt entered the world fighting to survive.

Kambry and her identical twin sister, Keeley, were born Nov. 24, 2018, around the 22-week mark of the pregnancy of their mother, Jade Ewoldt. They weighed 15.8 ounces and 1 pound 1.3 ounces, respectively, and spent the first four months of their lives in the Neonatal Intensive Care Unit at the University of Iowa Stead Family Children’s Hospital before they could go home. 

Guinness World Records has recognized them as the world’s most premature twins

Today, the girls love singing “Baby Shark,” doing the Chicken Dance and painting pictures. They have their own personalities — Kambry is more of a tomboy and Keeley is very girly, Ewoldt said — and are excited to celebrate their second birthdays.

It’s a milestone they weren’t guaranteed.

‘Survival mode’

Ewoldt, already a mother of two, knew having twins meant it would be a high-risk pregnancy. 

At 16 weeks, doctors told Ewoldt her daughters had twin-to-twin transfusion syndrome, where they were sharing blood through blood vessels in the womb. If untreated, the syndrome can be deadly to babies.

″(TTTS) is also very rare,” Dr. Jonathan Klein, a neonatologist and medical director of the NICU at University of Iowa Stead Family Children’s Hospital, told The Associated Press in January 2019, about two months after the Ewoldt twins were born. “A lot of patients pass away before they are even born.”

At 17 weeks, Ewoldt underwent surgery at Cincinnati Children’s Hospital to seal and disconnect the twins’ aberrant vessels. 

Most mothers deliver their babies within 10 weeks of the surgery, and Ewoldt was no exception — Keeley and Kambry were born about a month later on Nov. 24.

For the next five months, Ewoldt was split between two worlds: the hospital and home. 

She made a two-hour round-trip commute almost every day from her home in Dysart — and her two older children, Koy and Kollins — to her newborn daughters. Constantly driving back and forth, she said, put her in “survival mode.”

“It was hard to leave the NICU knowing that I was having to compartmentalize life,” she said. “Leaving behind the twins, knowing I couldn’t take them home was painful and then (I was) going home to be with my other kids and shutting off thinking about the twins when I was with them.”

Stay safe and informed with updates on the spread of the coronavirus

As tiny infants, Kambry and Keeley were diagnosed with severe bronchopulmonary dysplasia, a chronic lung disease that makes breathing difficult. They have had to receive oxygen through nasal cannulas almost their entire lives, but were able to be taken off oxygen earlier this month. 

Klein told the Des Moines Register, part of the USA TODAY Network, that even though the babies missed most of their lung development in utero by being born so early, they have done “extremely well” in their development.

“I would consider anytime babies like this on the cusp of viability survive, that it’s a pretty amazing situation, and it’s a huge dedication to a large team,” he said. 

Life didn’t stop throwing obstacles in the Ewoldts’ path when Jade was able to bring her babies home. The twins are more susceptible to illness and last year had six hospital stays for the common cold. 

“Something you or I would get the sniffles over would put them in the ICU,” Ewoldt said. 

Although COVID-19 poses a significant risk to the twins, she said the family was already taking precautions against any sickness by staying indoors most of the time. It’s not perfect, but at least her family is together.

“I still feel torn between the two sets of kids, but at least I know, at the end of the day, the older kids get to do normal things where the twins get to stay healthy and I don’t have to decide between the two,” she said.

Giving thanks

November is a month full of meaning for the family. It’s the twins’ birthday month, and the birthday month for their older sister, Kollins, who will turn 5 on Nov. 30. World Prematurity Day, a day created by March of Dimes to support families of premature babies, was Nov. 17, and November is Prematurity Awareness Month.

It’s also the month Ewoldt said goodbye to her sister Baylee Hess, who died in a crash last year on Kollins’ birthday as she was driving to her parents’ house to watch movies with her mom. Hess, 26, collided with a tractor-trailer, and died at the scene.

As the family celebrates the twins at home this year, their birthday will be dedicated to Baylee, Ewoldt said. 

“This is a month of many emotions, but I want to practice Thanksgiving,” she wrote in a Nov. 1 Facebook post on her page called “Keeley and Kambry’s Tribe.” “I’m thankful for the uneven road that brought us here even when I do not understand.”

With nearly 10,000 Facebook followers, Ewoldt hopes their story can reach and support families going through similar struggles.

Years before she was pregnant with twins, without knowing the information may help save her future children, Ewoldt saw a story about a family that did not have the opportunity to intervene when they received a twin-to-twin transfusion syndrome diagnosis and lost their children. When she received the same diagnosis, that story affected her decisions, she said.  She hopes to pay it forward by sharing the knowledge she has gained.

“If our story can help save another baby, then it’s really important to continue to share,” she said.

Contributing: Associated Press

Source: World’s most premature twins to turn 2 in Iowa: Guinness World Records (

For premature babies

Dr. Nils Bergman, Jill Bergman

Kangaroo Mother Care (KMC) has often been used as a treatment for premature or preterm babies.

In a rural third world situation where no incubators are available this method of caring for preterm or low birth weight babies can be life-saving. This works because the baby on the mother’s chest does not get cold, so the lungs function better. The baby in skin-to-skin contact also feels safe with mum’s familiar heart beat and voice so they do not become stressed and the heart rate, blood pressure and breathing stabilize faster. On the mother’s chest the baby also stimulates the production of breastmilk. This milk is vital for providing the preterm baby with the exact food needed to grow her brain.

About 4 million babies die each year in the first week of life, KMC could help 25% survive.

In a first world hospital setting KMC is also being used for premature babies. The same biology applies and means that the baby is more stable with all of the above benefits.

Any needed or available technology can be added when the baby is in skin to skin contact on mum’s chest.

For both contexts it is not just SURVIVAL of the preterm baby, but it is also the QUALITY of that survival in terms of brain growth, healthy brain wiring, emotional connectedness, bonding and attachment. KMC helps the physical, emotional, and social development to be the best it possibly can be!

When to do skin-to-skin contact:

  • Skin-to-skin contact should be for every baby at birth.
  • It is even more important for premature babies to help them stabilise.
  • You can do skin-to-skin contact when you are sleeping, or walking around.
  • You can do skin-to-skin contact with a baby on a ventilator or other machines

Some countries use Kangaroo Care only as an add-on to incubator care as a bit of cuddling for 10-60 minutes a day which helps mum and baby to bond together. This does help the mother produce more breast milk ! But if you hold your baby for less than an hour or full sleep awake cycle, it gives no benefit to the baby and might even do harm. Some places only allow you to hold your baby once she is “stable” and a particular weight and off all monitors and machines……………………advice???
Some say that the baby must stabilise in the incubator first and then have skin-to-skin contact. But this is a problem as babies do not stabilise in an incubator for days, they do stabilise in skin-to-skin contact.

Skin-to-skin contact should ideally be 24 hours a day so that your baby is never separated from you, her Mum. In this way stress is minimized. Some hospitals do not have enough space for mum’s to sleep in the hospital, but now that you know the importance of her brain wiring properly you will make it a priority to spend as much time as possible. The ideal is for mum and dad to take it in turns for the full 24 hours!

So take leave or get home help or whatever is needed to give your prem your support – she is fighting for her life and she needs you to help her. You will never regret this time that you spend with her.

The smaller the prem, the more they need their mother’s chest to stabilise even if they need medical technology as well.

KMC for Premature and Low Birth Weight Babies

The care of premature and low birth weight infants must be under the supervision of a qualified health professional if at all possible.

The KangaCarrier was originally designed to enable mothers of premature babies to be permanent incubators for their babies. Medical research has shown that maternal infant skin-to-skin contact is better than incubators for keeping babies warm, provides better breathing and heart rate, better breastfeeding and better growth. The problem is a mother has a preconceived idea of an incubator as something stuck in a hospital ward and not allowed to be moved or to be touched. The mother has been an incubator for nine months, and with the KangaCarrier she can now carry on being an incubator. Many premature and low birth weight babies will have special needs and require medical care, all these can be provided together with continuous skin-to-skin contact.

Skin-to-skin at birth

Immediately after birth, the low birth weight baby should be dried, placed on mother’s abdomen or chest, and covered with a cloth or blanket, just as described for a full term baby. Routine midwifery care and medical assessment should be completed speedily, with the newborn remaining on mother. Observations and monitoring will determine what medical support should be provided, and how this should be done.

This may in our current contexts require that the baby be separated, which must be accepted. A very premature infant may be too physically immature to exhibit the self-attachment behaviours of the full term baby, but the opportunity for early skin-to-skin contact is important nevertheless.

A premature baby will need help to breastfeed. Colostrum should be expressed and given by spoon or cup, or by gavage (tube) of necessary. For premature newborns, mothers should recline at an angle of 30 degrees, and should avoid moving about too much. This helps the baby’s breathing and sense of balance. Newborns should be stimulated as little as possible in this period.

After the first hour

Many premature babies will be stable in skin-to-skin contact after 90 minutes, often to the surprise of health professionals. Decisions need to be made about feeding and fluids and continued care. Oxygen by mask or by CPAP can easily be arranged while in skin-to-skin contact, drips and feeding tubes can be secured sideways.

If the baby is stable and the mother well, the KangaCarrier can be used just as described for full term babies. An important difference is that a premature baby should not be fed on demand, it needs to be fed far more frequently, every hour or two, day and night. This means loosening the wrapper regularly, so that mother can express breast milk. This is good for the baby and mother, though baby must never get cold.

The first six weeks

Many premature babies and low birth weight babies need intensive medical care, and may require care in incubators (6). Most neonatal intensive care units now allow mothers to start KMC for an hour or two a day, and build up the time successively as the baby gets better and the mother more confident. Even an hour a day has positive effects on baby, and just ten minutes a day can increase mother’s milk supply!

Once the baby is stable and gaining weight the KangaCarrier can be used day and night, both sleeping and walking. This is what it was originally designed for!

After six weeks

“How long should the premature baby stay this way?”

Again, no two babies are the same, and in this case the answer depends on a number of factors. But until the baby weighs 1800g, providing an ongoing heat source is physiologically essential, and even up to 2.2 kg a baby will easily become hypothermic. Beyond that weight, consider the baby as full term and apply the advice as above!

Once a baby reaches 4 kg or thereabouts, the KangaCarrier can be replaced by a sling or by the traditional African method of carrying on the back.

The benefits of KMC for premature babies

Skin-to-skin contact benefits for babies:

  • Better brain development
  • Better emotional development.
  • Less stress
  • Less crying
  • Less brain bleeds
  • More settled sleep
  • Babies are more alert when they are awake
  • babies feel less pain from injections
  • The heart rate stabilises
  • Oxygen saturation is more stable
  • Less apnea attacks
  • Breathe better
  • The temperature is most stable on the mother
  • Breastfeeding starts more easily
  • More breastmilk is produced
  • Gestation specific milk is produced
  • Faster weight gain
  • Baby can usually go home earlier

Skin-to-skin contact benefits for parents:

  • Parents become central to the caring team
  • Better bonding and interact with their child better
  • Emotional healing
  • Less guilt
  • Parents are calmer
  • Mum and dad are empowered and more confident
  • Parents are able to learn their baby’s unique cues for hunger
  • Parents and baby get more sleep
  • Parents, (especially mothers)are less depressed
  • Cope better in NICU
  • See baby as less “abnormal”


When a Baby’s Head is Misshapen: Positional Skull Deformities

When a baby spends a lot of time in one position, it can cause the shape of their head to change. This is called a positional skull deformity.

For about 20% of babies, a positional skull deformity occurs when they are in the womb or in the birth canal. More often, it happens in the first 4 to 12 weeks of life. This is when babies are not able to sit up or move on their own. By 6 months of age, many babies become more mobile and can turn their heads on their own more regularly.

What causes a baby’s head shape to change?

baby’s skull has soft, bony plates that haven’t yet fused together. The bony plates can move a bit, which helps the baby’s head to pass through the birth canal. The plates also allow room for the brain to grow during the first year of life.

There are many things that can cause a positional skull deformity, such as:

  • Preferred head position. Some babies like sitting or sleeping with their heads turned a certain way.
  • Not enough tummy time. Tummy time is for babies who are awake and being watched. It helps babies master basic milestones like head lifting, turning over, sitting up, and crawling.
  • Twin or triplet. Cramped or unusual positions in the womb can lead to changes in head shape.
  • Prematurity. Lying flat on their backs in the hospital can cause a preemie’s head to become misshapen. Preemies also have softer bones that are not as fully formed as the bones of full-term babies.
  • Birth complications. The baby’s position when moving through the birth canal can affect his or her head shape. Some other things that affect a baby’s head shape at birth are using forceps, vacuum extraction, or even a difficult labor.
  • Torticollis. An estimated 85% of babies with torticollis, a condition where the neck muscles are tight or imbalanced, have a positional skull deformity. Infants who have torticollis also will need physical therapy.

3 common misshapen head types

A baby’s head shape change usually is related to the position in which they spend the most time. Your pediatrician can determine whether your baby’s head shape is caused by a positional skull deformity or an uncommon but more serious condition called craniosynostosis. Common positional skull deformities do not require surgery.

  • Deformational brachycephaly is when the head is symmetrically (evenly) flat in the back and wide from side to side. The bone above the ears might seem to stick out. This is often seen in babies who spend a lot of time on their backs and do not get enough tummy time.
  • Deformational plagiocephaly is when the head is asymmetrically (unevenly) flat in the back on one side. The forehead may be more prominent causing the head to look like a parallelogram. The ear may also shift forward on the flat side. This is often seen in babies who prefer to sleep with their heads turned to one side and those with torticollis.
  • NICUcephaly is a common condition in preemies who spend their first few months of life in the neonatal intensive care unit (NICU). This positional skull deformity causes preemies to develop long, narrow heads.

A good time to check your baby’s head is after bath time when his or her hair is wet.

  • The back of your baby’s head should be evenly round.
  • Your baby’s ears should be even.
  • The width of your baby’s head and forehead should be even and balanced.

If you notice any changes or have any concerns, talk to your pediatrician.

What if my baby has a positional skull deformity?

The best treatment is to prevent a positional skull deformity. And when it is found early, simple changes to your baby’s position will help. For example:

  • Avoid too much time in a car seat, bouncy seat, baby swing, or other carrier. These positions put pressure on the back of your baby’s head.
  • Increase tummy time. It is important to put babies on their backs to sleep. But a baby needs supervised time on their tummy to play during the day. This also lets your baby exercise their neck, back, shoulders, arms and hips. Start with short spurts of time. Gradually work up to an hour per day in several short sessions.
  • Switch or alternate arms when holding and feeding your baby.
  • Alternate which end you of the crib you place your baby down for sleep.

Positional skull deformities do not affect brain growth or intellectual development. They are purely cosmetic, and the majority do not require surgery.

Early intervention & therapy

In some cases, your baby’s doctor may recommend treatment for positional skull deformity, particularly those with moderate or severe flattening.

Physical therapy. Your pediatrician may refer your baby for early intervention services and an evaluation from a pediatric physical therapist. The therapist will check your baby for delayed motor skills caused by poor head and neck control, and for torticollis. You will also learn stretching and positioning exercises to do with your baby at home. Depending on how severe the positional skull deformity is, your baby may need weekly therapy.

Helmet therapy. If your baby has moderate or severe flattening that does not respond to treatment by 5 or 6 months of age, he or she may need helmet therapy. Molding helmets work by re-shaping the baby’s head and are fitted by a specialist.

Surgery should only be considered when all other options have been exhausted, and after consulting with a neurosurgeon or pediatric plastic surgeon who specializes in these types of cases.

Remember: Talk with your pediatrician if you have any questions or concerns about your baby’s growth and de​​velopment.

Last Updated  8/31/2020 Source -American Academy of Pediatrics Section on Neurological Surgery and Section on Plastic and Reconstructive Surgery (Copyright © 2020)


NICU Collaboration During the COVID-19 Worldwide Pandemic: A Memory of Gratitude

Marana, Joseph MEd, MSN, RNC-NIC; Manager

Advances in Neonatal Care: December 2020 – Volume 20 – Issue 6 – p 424-425

Felicidades!” I exclaimed!  And right there, I saw it.

Through the muffled voice of wearing two masks, a distant image through the face shield I was wearing, I saw the look to his daughter. It was nearly imperceptible. It was the slightest hesitation. To stare, and see, his infant for the very first time. In the rush of moment, installing the car seat base in the heat of the afternoon, with his mother-in-law, his infant’s nurse, and myself holding the infant in the car seat, along with a few bags of supplies for the infant, he only took a fraction of a second to do it. But right there, in that moment, it felt like time stopped. The air felt heavy, the sounds drowned out to silence, and as I father myself I recognized in his face what this was. It was a look of love.

I have seen it many times before. The first time a father lays his eyes on his newborn infant is always different. It’s always new. Usually, it is during or immediately after delivery. It is often without speech. But even if a picture is worth a thousand words, the image every time is indescribable. It is love.

Typically, the birth of an infant, especially in an operating room (OR), is filled with lots of people. Nurses taking care of the mother and nurses taking care of the infant. Nurse practitioners right there to “catch” the infant and wrap in a blanket, obstetricians and their team at the surgical site, and anesthesiologists at the head of the bed. The father anxiously standing by, peering on toes next to neonatologists at the ready. In this particular case, with this specific infant, instead of the father being there, it was me. It was us.

She was the first infant born in our COVID OR, in the specifically built COVID unit. The OR had been equipped and prepared for weeks, if not months, but doctors and nurses, practitioners, and respiratory therapists to develop plans for deliveries just like this one was. We had spent days setting up machines, placing beds, and staging trays and lights. And then we spent days and weeks rearranging and adjusting it all again, as we talked through situations and scenarios. For days, we had mapped out who of our staff was going to be working, who was going to be going to the delivery, who was going to do what, who was going to be where. It was my plan to switch places with the nurse who was supposed to be going, to minimize her risk of exposure and, hopefully, her anxiety. But as the confident and dutiful nurse she has always been, she refused to do anything less than to be right there for the infant. So by the time the COVID-positive mother was brought in, they closed the doors and it was us two. Next to our neonatologist, the 3 of us were the neonatal intensive care unit (NICU) team ready to receive and, if necessary, stabilize and resuscitate this little baby girl.

The room was a flurry of action. With assured confidence and precision, I admired the Labor & Delivery staff who worked quickly and efficiently to make sure everything was set. It was as if they had done this thousands of times before. The thing was they had. Just never like this. In a negative pressure OR, with noisy HEPA filters, a smaller than usual space, and personal protective equipment (PPE) covering our mouths and noses, our eyes, our faces, our hair, bodies, and even shoes, all of us were uniformly protected from any chance of exposure. I remember looking at the mother’s face. Calm, eyes closed.

When the infant was born, instead of her father present, it was the physician and myself, alongside her nurse, the first to see her, the first to touch her, the first to talk to her. It was decided that she would be admitted to the NICU. So as I assisted in unplugging and unlocking the enclosed isolette to transport, I couldn’t help but recognize that unlike most deliveries, the mother would not get the chance to hold her infant right away. As we exited the room, despite all the other things going on, the Labor & Delivery staff moved poles and carts to clear a path. As we came out of the room, there were more of our team members outside, ready to assist with whatever they could. Our NICU charge nurse took the lead, as we took off and put on more PPE since we were leaving the room. Like this infant’s own personal entourage, we walked to the exit of the unit where more NICU nurses and Respiratory Therapy were there to receive the bed, attach our support “shuttle” for additional oxygen and power support, and bring the whole production down to the NICU.

The next few days were new to us. The entire multidisciplinary team worked seamlessly to make sure this mother and family were updated. One of our nurses created a new Skype account for the mother to be able to video call and see her infant using her cell phone. Our nurse practitioners and provider team kept in constant contact to communicate plans for discharge. Social work was involved, all of our managers stayed in touch, and we used a newly purchased car seat to test the infant in, and then give to the family so they would not need to bring one in from home. Our medical director was involved, our neonatal nurse practitioner administrator helped facilitate any needs, and Nursing had the constant resources from our leadership in Maternal Child Health, our director, and even our chief nursing officer.

When the day of discharge came, the whole team worked to coordinate times for pickup, who would be coming into the hospital to meet us, where they would park, where the father would wait. The infant’s nurse that day spent the entire shift preparing enough bottles, diapers, discharge information, and even clothing to be as ready to go out into the world as any newborn infant could be. We put on our PPE and together, she and I took the infant down to the emergency department (ED). I coordinated with the manager of the ED, who made sure we had a place to go, and what the best way to go would be, as well as the best route for us and the family. In the humid heat of the afternoon, I stood at the entrance alongside our COVID screeners, ready to meet the father and escort the grandmother in.

I knew it was them when they showed up, the anxious father and his excited mother-in-law. “Hola abuela!” I said, “Me llamo Joe, soy enfermero con to nueva nina!” (Hi grandma! I’m Joe, a nurse with your new baby girl!). As the father waited outside, the nurse and I walked the grandmother through discharge paperwork, and finally gave her the infant to see, hold and now feed, for the very first time. ED nurses and even physicians stopped in their tracks as they walked by, smiling at the beautiful infant in her grandmother’s arms. After just a few minutes, it was time to walk out. Back through the corridors, we all exited into the heat. Again, this little infant’s own personal entourage. I gave the father the base of the car seat and I could see him struggling, and sweating to get it secured in.

And as he turned, I extended the tiny infant in her car seat toward his waiting arms. “Felicidades!” I exclaimed. And right there, I saw it. In the heat of the outside, rather than the cool of the OR, into his hands instead of ours, this man recognized, and for the briefest of moments, stared at his new daughter for the first time. It doesn’t happen often, even for an NICU nurse to be there for both the delivery and also the discharge home, but this time it was me. In the moment that time stopped. In the moment of recognition, as a father myself in the eyes of another father, the look I have seen many times before, but new and amazing each time. It was a look of love.

For all of our planning, our weeks and days and sleepless nights. For our staff who worried but were always there. Through the stress of the world, for our team who demonstrated kindness and deep compassion. Through the endless meetings, the constant e-mails, through the questions and concerns and even through the tears, it was and always is moments like this that remind us of who we are.

Joseph Marana, MEd, MSN, RNC-NIC   Manager   Neonatal Intensive Care Unit & Pediatrics   Mercy Medical Center   Baltimore, Maryland

© 2020 The Author. Published by Wolters Kluwer Health, Inc. on behalf of the National Association of Neonatal Nurses


Psychological resilience during the COVID-19 lockdown

William D.S. Killgore, Emily C. TaylorSara A. Cloonan, and Natalie S. Dailey

Author information Article notes Copyright and License information Disclaimer

Psychiatry Res. 2020 Sep; 291: 113216.


Some individuals are more psychologically resilient to adversity than others, an issue of great importance during the emerging mental health issues associated with the COVID-19 pandemic. To identify factors that may contribute to greater psychological resilience during the first weeks of the nation-wide lockdown efforts, we asked 1,004 U.S. adults to complete assessments of resilience, mental health, and daily behaviors and relationships. Average resilience was lower than published norms, but was greater among those who tended to get outside more often, exercise more, perceive more social support from family, friends, and significant others, sleep better, and pray more often. Psychological resilience in the face of the pandemic is related to modifiable factors.


Neonatal data tech and video streaming help clinicians enhance care

The two technologies are linked with biomedical equipment, the EHR and the laboratory information system to help improve outcomes.   By Bill Siwicki June 19, 2020


“On average, a neonate undergoes 768 manipulations and 1,341 procedures during their hospital stay,” said Dr. Gautam Yadav, a pediatric physician at Kalawati Hospital in Rewari, in the Indian state of Haryana. “It is important to study the effect of these manipulations on the clinical outcome. We needed access to technology to noninvasively monitor critical patients in the NICU to ensure any early insights into patient condition.”


Kalawati Hospital sought out some unique technology from Child Health Imprints, a vendor of neonatal health data technology, along with live-streaming video technology from vendor Wowza.

The Child Health Imprints system includes a NEO device that fetches live physiological data from medical devices, and that combines with the Wowza live video-streaming technology that takes the data of the neonate through an attached camera. This data is made available to clinicians through a web platform, iNICU, for informed decision-making.

“With our technologies, video streaming of neonates is being annotated in real time with any changes in physiological or clinical state of patients.” Dr. Gautam Yadav, Kalawati Hospital

“The third layer, an analytics layer, has the capability of autonomously tagging the manipulations – touch-points to the neonate – in live videos, correlating the physiological signals and identifying the pattern of variability in physiological signal while the neonate is being manipulated,” Yadav explained. “Further, it also identifies the duration and frequency of these manipulations. The complete technology solution studies the impact of manipulations on neonatal care and its association with adverse outcomes.”


Kalawati Hospital has used the technology at the bedside of critical patients in the NICU. It is used by doctors and nurses for quality control and training.

“This technology is linked with data of various biomedical equipment in the NICU from GE, Philips, Draeger and Nihon Kohden,” Yadav explained. “It also is linked with the EHR and lab information system. The analysis layer of video streaming allows clinicians to see changes in physiological data – such as heart rate, respiratory rate and oxygen saturation – during different manipulations.”


Yadav offers four success-metric areas of using the combined neonatal data and video-streaming technologies that Kalawati Hospital is studying.

“It is hypothesized that in emerging countries, especially India, an oversight on nursing staff through an automated computer vision platform will have significant improvement in clinical outcomes,” he said. “We are still collecting data with live streaming and [an] integrated platform, and it will take us a few more months to publish improvement in clinical outcomes – on a statistically significant population – and get it peer reviewed.”

On another front is the movement index – tone and body postures. It is well documented that early symptoms of disease can be picked by monitoring body tone and movement indexes, he noted. Currently, this is done manually by doctors during daily rounds in two to three minutes. With the technologies, it is hoped that, with data across many NICU areas of both healthy and diseased patients, it will allow the platform to aid in early disease-identification in an autonomous manner, he said.

“Then there is the command center for remote management/telemedicine,” Yadav said. “Most of the telemedicine solutions do not have [the] synchronized temporal data of a patient’s physiology, video and its correlation with patient well-being. With our technologies, video streaming of neonates is being annotated in real time with any changes in [the] physiological or clinical state of patients. This will allow artificial intelligence and deep learning applications to further improve clinical outcomes.”

And finally, manipulation frequency and duration.

“We have been able to see the number and duration of manipulations – both invasive and noninvasive – on the neonates,” Yadav explained. “We have submitted the results in a peer-reviewed publication for sharing the same with other NICUs. This has allowed us to baseline data of our existing outcomes and enabled us to initiate quality improvement. This has also allowed us to build a staff education program for team members with non-planned care manipulations.”


“Video streaming in critical care can allow direct visualization to clinicians and help us in informed decision-making, including remote access,” Yadav said. “This has aided in better accuracy of manipulations and its relationship with vital sign data. This tool has allowed our clinical staff to determine their operational performance. It will potentially allow the NICU staff to determine if certain manipulations are associated with adverse outcomes.”


Dr. Nils Bergman – KMC: Physiological response, cultural & practical challenges in field settings

Läkare Utan Gränser
   Nov 14, 2016


Infographic: What Social Isolation Can Mean for the Brain

People who show low social engagement over long periods of time often show reductions in cognitive function. Studies of the brain may provide clues about this correlation.

Catherine OffordJul 13, 2020

Studies of animals and people experiencing isolation have identified several brain structures that appear to be affected by a lack of social interaction. Although these studies can’t identify causal relationships—and don’t always agree with one another—they shine a light on some of the mechanisms by which physical isolation, or feelings of loneliness, could impair brain function and cognition.


PREFRONTAL CORTEX: In some studies, people who are lonely have been found to have reduced brain volumes in the prefrontal cortex, a region important in decision making and social behavior, although other research suggests this relationship might be mediated by personality factors. Rodents that have been isolated from their conspecifics show dysregulated signaling in the prefrontal cortex.

HIPPOCAMPUS: People and other animals experiencing isolation may have smaller-than-normal hippocampi and reduced concentrations of brain-derived neurotrophic factor (BDNF), both features associated with impaired learning and memory. Some studies indicate that levels of the stress hormone cortisol, which affects and is regulated by the hippocampus, are higher in isolated animals.

AMYGDALA: About a decade ago, researchers found a correlation between the size of a person’s social network and the volume of their amygdala, two almond-shaped brain areas associated with processing emotion. More-recent evidence suggests the amygdalae are smaller in people who are lonely.

Read the full story.


Effectiveness of the Close Collaboration with Parents intervention on parent-infant closeness in NICU

Published: 11 January 2021  He, F.B., Axelin, A., Ahlqvist-Björkroth, S. et al. Effectiveness of the Close Collaboration with Parents intervention on parent-infant closeness in NICU. BMC Pediatr 21, 28 (2021).



Parent-infant closeness during hospital care of newborns has many benefits for both infants and parents. We developed an educational intervention for neonatal staff, Close Collaboration with Parents, to increase parent-infant closeness during hospital care. The aim of this study was to evaluate the effectiveness of the intervention on parent-infant closeness in nine hospitals in Finland.


Parents of hospitalized infants were recruited in the hospitals during 3-month periods before and after the Close Collaboration with Parents intervention. The data were collected using daily Closeness diaries. Mothers and fathers separately filled in the time they spent in the hospital and the time of skin-to-skin contact with their infant during each hospital care day until discharge. Statistical analyses were done using a linear model with covariates.


Diaries were kept before and after the intervention by a total of 170 and 129 mothers and 126 and 84 fathers, respectively. Either parent was present on average 453 min per day before the intervention and 620 min after the intervention in the neonatal unit. In the adjusted model, the increase was 99 min per day (p = 0.0007). The infants were in skin-to-skin contact on average 76 min per day before the intervention and 114 min after the intervention. In the adjusted model, skin-to-skin contact increased by 24 min per day (p = 0.0405).


The Close Collaboration with Parents intervention increased parents’ presence and skin-to-skin contact in nine hospitals. This study suggests that parent-infant closeness may be one mediating factor explaining benefits of parenting interventions.


Predicting premature births with a digital health tool


Preterm birth, or babies born before 37 weeks, is the leading cause of newborn death. Just as concerning are babies that are born very prematurely — at 28 weeks or less — who have these risks extend into the first year of life, including being at a higher risk of SIDs. Right now, the only way to predict preterm birth is by asking a pregnant woman if she’s given birth prematurely before.

“That approach only picks up 7% of preterm births,” says Dr. Avi Patil, CEO of Nixxi. His company has developed a digital health tool, called PopNatal, to more accurately predict preterm births. “Our rate is about 75% sensitivity to pick up women who will deliver prematurely.”

PopNatal tallies up more than 300 risk factors of preterm birth for each patient. These include being pregnant with twins, triplets or more; IVF conceptions; a short time period between pregnancies; high blood pressure; diabetes; the age of the mother; smoking; drinking; stress; working long hours with long periods of standing; and family history of preeclampsia. 

PopNatal consolidates those factors into an algorithm that determines whether a woman is at high risk or low risk of preterm birth. The form takes around 15 minutes to fill out, and Nixxi will send the results directly to your doctor within 72 hours.

PopNatal has been tested on thousands of pregnant women, and was developed by Patil, who is a high-risk obstetrician, and Dr. Chad Grotegut, a maternal-fetal medicine specialist. Between them, they have 27 years of experience in providing care to high-risk pregnancies.

They want it to be used broadly, not just by those with good health insurance. Currently, women who want to use it directly can access the tool online to get an individual risk assessment and companion report with guidance. Nixxi is also looking to work with health care providers.

Next up, Patil told CNET Nixxi is developing blood tests to pinpoint very high-risk women, and to pick up babies who have a higher risk of being in the NICU.


How it Works

Genetic Markers Linked to Preterm Birth Identified

December 3, 2020                                       Clinical OMICs

Research led by the University of Chicago has discovered two genes, HAND2 and GATA2, that could influence whether a woman gives birth prematurely or not.

“These genes are both important transcription factors that regulate the expression of several other genes,” said Ivy Aneas, Ph.D., a research associate at the University of Chicago and one of the lead researchers involved in the study.

HAND2 mediates the effect of progesterone on the uterine epithelium while GATA2 is involved in stem cell maintenance.”

The researchers hope that these results may help clinicians predict whether preterm birth is a likely pregnancy outcome and plan accordingly.

Previous studies have suggested that there is a genetic element to preterm birth, but a lack of knowledge about gene expression in placental and endometrial cells has made it hard to pinpoint these connections more accurately.

“When you’re studying a disease, there are typically a lot of genetic and tissue resources available in public databases,” said co-senior researcher Carole Ober, Ph.D., a professor at the University of Chicago. “But pregnancy related conditions, like preterm birth, get much less attention or funding, and as a result pregnancy-relevant tissues are not well represented in those databases.”

To investigate this further, Aneas and colleagues tested endometrial cells attached to the placenta after birth for markers of gene expression. They collected transcriptome data by sequencing the RNA, searched for epigenetic modifications and evaluated chromatin structural changes. They then compared these results with genome wide association data from 56,384 women collected in a study looking at pregnancy duration.

As reported in the journal Science Advances, the team found two new genes linked with preterm birth — HAND2 and GATA2, which are involved in the process of ‘decidualization’ when the endometrial cells prepare for pregnancy and placenta formation by implanting into the uterine wall.

From the data the researchers collected, they think HAND2 is directly linked with gestational duration and in endometrial cells they think GATA2 is the target of nearby genetic variants linked with preterm birth. Neither of these genes have previously been linked with pregnancy length.

“The fact that we identified a link between these two genes and the duration of gestation suggests that their roles in pregnancy may be more important than previously anticipated,” said co-first author Noboru Sakabe, Ph.D., a researcher at the University of Chicago.

The researchers caution that they only analyzed one type of cell taken from three individuals so their results need to be replicated. The cells were also collected after birth, so they acknowledge there may be changes that occur during pregnancy that were not reflected here.

“Future studies that include fetal cells from the placenta and uterine or cervical myometrial cells could reveal additional processes that contribute to gestational duration and preterm birth, such as those related to fetal signaling and the regulation of labor,” write the authors.


Kat’s Corner

Three invaluable tools to boost your resilience | BBC Ideas

•Jul 31, 2020   Dr Lucy Hone

Resilience (A Quote, A Song and a Picture)

Kathy’s Picks:

A Quote: Do not judge me by my success, judge me by how many times I fell down and got back up again.” Nelson Mandela

A Song: I Hope You Dance”by Lee Ann Womack   

And a picture:  


All of You Preemies out there

Kat’s Picks:

A Quote: “When we learn how to become resilient, we learn how to embrace the beautifully broad spectrum of the human experience.”― Jaeda DeWalt

A Song: “Hey World (Don’t Give Up)”—Michael Franti

And A Photo:

American poet Amanda Gorman reads a poem during the 59th Presidential Inauguration at the U.S. Capitol in Washington, Wednesday, Jan. 20, 2021. (AP Photo/Patrick Semansky, Pool)

Flysurfer Kiteboarding presents: Montenegro’s Hidden Coastline

Nov 20, 2015




Rank: 92  –Rate:10.2   Estimated # of preterm births per 100 live births 

(USA – 12 %, Global Average: 11.1%)

Jamaica is an island country situated in the Caribbean Sea. Spanning 10,990 square kilometres (4,240 sq mi) in area, it is the third-largest island of the Greater Antilles and the Caribbean (after Cuba and Hispaniola).[  Jamaica lies about 145 kilometres (90 mi) south of Cuba, and 191 kilometres (119 mi) west of Hispaniola (the island containing the countries of Haiti and the Dominican Republic); the British Overseas Territory of the Cayman Islands lies some 215 kilometres (134 mi) to the north-west.

With 2.9 million people, Jamaica is the third-most populous Anglophone country in the Americas (after the United States and Canada), and the fourth-most populous country in the Caribbean. Kingston is the country’s capital and largest city. The majority of Jamaicans are of Sub-Saharan African ancestry, with significant EuropeanEast Asian (primarily Chinese), IndianLebanese, and mixed-race minorities. Due to a high rate of emigration for work since the 1960s, there is a large Jamaican diaspora, particularly in Canada, the United Kingdom, and the United States. The country has a global influence that belies its small size; it was the birthplace of the Rastafari religion, reggae music (and associated genres such as dubska and dancehall), and it is internationally prominent in sports, most notably cricketsprinting and athletics.

Jamaica is an upper-middle income country with an economy heavily dependent on tourism; it has an average of 4.3 million tourists a year. Politically it is a Commonwealth realm, with Elizabeth II as its queen. Her appointed representative in the country is the Governor-General of Jamaica, an office held by Patrick Allen since 2009. Andrew Holness has served as Prime Minister of Jamaica since March 2016. Jamaica is a parliamentary constitutional monarchy with legislative power vested in the bicameral Parliament of Jamaica, consisting of an appointed Senate and a directly elected House of Representatives.

Healthcare in Jamaica is free to all citizens and legal residents at the public hospitals and clinics. This, in theory, includes the cost of prescribed medication. There are long queues at public health facilities. An audit in 2015 identified shortages of manpower, equipment, medications, wheelchairs, stretchers, gloves, beds, and other essential supplies. 3.3% of the national budget is spent on health services. In Jamaica there are over 330 health centres, 24 public hospitals, the University Hospital of the West Indies, a regional teaching institution partially funded by Regional Governments including Jamaica, 10 private hospitals and over 495 pharmacies. There are around 5,000 public hospital beds and about 200 in the private sector. 


Gov’t to Review Laws That Support Breastfeeding

*** We looked for an update to these actions and did not find formalized and related outcomes in Jamaica  yet related to the article below but the future likely holds support for improvement. This improvement in support for breastfeeding reflects a global need for progressive and related action.


Minister of Health and Wellness, Dr. the Hon. Christopher Tufton, says that stakeholders are being engaged to review and improve national laws that support breastfeeding.

In a message delivered by Public Health Nurse, Debbion Pinnock Harvey, at Westmoreland Public Health Services’ ‘Breastfeeding March and Road Show’ in Darliston on Tuesday (September 17), Dr. Tufton noted that the objective is to create a more enabling environment for mothers to breastfeed in order to improve the health of their babies.

“[This will] also ensure that workers in the informal economy and other vulnerable groups are recognised and protected by national laws. We also encourage employers to implement breastfeeding-friendly workplaces by establishing support facilities such as crèches, breastfeeding rooms and flexible work hours,” he noted.

Dr. Tufton said that the Ministry has spearheaded the development of the National Infant and Young Child Feeding Policy, which has the objective of creating “a sustainable environment that will contribute to a reduction in child mortality and morbidity and improvement in child health and nutrition”.

Meanwhile, the Ministry is encouraging greater family support for lactating mothers as the country marks National Breastfeeding Week 2019 from September 16 to 22.

“Although breastfeeding is the mother’s domain, with close support from fathers, partners, families, workplaces and communities, breastfeeding will improve,” Dr. Tufton said.

Breastfeeding is the responsibility of all, the Minister said. “Wherever you are, you can inform, anchor, engage and galvanise the message of breastfeeding as the fountain of life by raising awareness of the risks and disadvantages of artificial feeding and advocating for greater investment in breastfeeding programmes and policies,” he noted.

The Westmoreland Public Health Services ‘Breastfeeding March and Road Show’ was held under the theme, ‘Empower Parents: Enable Breastfeeding, Now and for the Future!’

The event featured health stakeholders from across the parish, who partnered with parents, schools and the police to make presentations on the benefits of breastfeeding.


Neonatology in Beirut, a Country Ravaged by a Financial, Political and Social Crisis

Carine Abi Gerges, MD – December, 2020

While 2020 has been a difficult year for most people, Lebanon has been particularly hit hard by the turn of the decade. In October 2019, thousands took to the streets to demand the overthrow of a corrupt regime. People protested for months while chanting ‘Kellon yaane kellon’ (All of them means all of them) in reference to the entire ruling class. Political and civil unrest rocked the country against the backdrop of an unprecedented economic and financial crisis: the Lebanese pound plummeted in a free-fall, eventually losing over 80% of its value with local banks imposing strict restrictions on cash withdrawals preventing depositors from accessing both their savings and salaries. The Coronavirus pandemic made matters substantially worse. The final blow, however, was the Beirut Port explosion on August 4th, 2020. One of the largest non-nuclear blasts ever recorded, it left 150+ dead with 6,000+ injured, 300,000+ homeless, and many more forever scarred by the detonation of almost three kilotons of ammonium nitrate neglectfully stored in the heart of the capital. Three months later, someone has yet to be held accountable.

The health sector, buckling under the pressure, was not spared and is barely holding in this untenable situation. Not long ago, Lebanon was the medical capital of the Middle East. In Beirut alone, over ten hospitals are fully equipped with neonatal intensive care units (NICU), serving as a referral hub for rural areas and serving hundreds of thousands of patients. Among the 70,000 babies born in Lebanon annually, 12% (9,000) are born prematurely. Additionally, around 9,000 premature births have been recorded among Syrian refugees since 2015, amounting to a total of at least 18,000 documented premature births per year . All patients require appropriate financial health coverage to support their medical management, very costly for admitted neonates.

 Prior to the financial crisis, less than half of Lebanese citizens had private or semi-public health insurance plans while the remaining half paid out-of-pocket, partly relying on the Ministry of Public Health (MoPH). As an increasing number of previously insured families lost their jobs and consequently their insurance coverage due to the crisis, many more now resort to an already overwhelmed MoPH to cover their hospital fees. However, some hospitals refuse to admit MoPH-covered patients due to years of accumulated unpaid dues from the government. Soon, only the upper class will be able to afford the estimated $30,000 in costs for the care of a premature baby.

The cost of NICU hospitalization depends on whether the hospital is public or private, as well as the baby’s condition. While most of Beirut’s patients are admitted with frequently encountered cases such as prematurity, hyaline membrane disease, necrotizing enterocolitis, and neonatal sepsis, some infants transferred from peripheral hospitals require acute care for rare metabolic and genetic diseases. Although not studied in this specific context, rural areas have a higher prevalence of births with inborn errors of metabolism, likely due to more frequent consanguineous marriage. With the population in these areas being largely working class, access to high-quality neonatal intensive care is particularly challenging, the crisis making it even worse.

Dany al-Hamod, the director of the NICU at Saint George Hospital University Medical Center (SGHUMC), describes a substantial increase in the number of families unable to afford hospital bills recently, forcing them to run from one non-governmental organization (NGO) to another to gather funds to avoid having to move their child to different facilities, or worse. The situation is even more dire for refugees. Lebanese is host to the second-largest Syrian refugee population and third largest Palestinian refugee population in the world. This population has increased in the last few years, partly due to the influx of over45,000 ‘twice-refugee’ Palestinians, once settled in Syria, fleeing to Lebanon to escape the civil war . Unable to be employed as a result of their refugee status, most do not have access to either public or private health coverage. Instead, they depend on humanitarian organizations to cover their healthcare needs, namely the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) and the United Nations High Commissioners for Refugees (UNHCR). These organizations have been essential to the survival of many newborns in this population, especially that they suffer a higher prevalence of neonatal complications due to inconsistent prenatal care, as well as higher rates of consanguinity . These organizations rely entirely on donations and grants, and their ability to cater to their beneficiaries has been severely impacted after the donations they depended on contracted as a result of the ongoing global economic crisis. The severe financial situation that the UNRWA is currently facing threatens millions of refugees and further limits their already minimal healthcare access .

The Carlos Slim Center for Children in the Beirut Governmental University Hospital (BGUH – Karantina) was renovated in 2016 by the NGO ASSAMEH – Birth and Beyond through multiple local and international donations, building the first fully-equipped public NICU. This center’s importance lies in its readiness to “care for those no one cares for.” While only 70% of admitted children are eligible for MoPH-coverage (10), specialized care at this public hospital is provided indiscriminately. Since 2017, six babies found in trash bins and more than twenty-two “undocumented” children have been taken in and treated by the Karantina team (2). Adding fuel to the fire, this center was heavily damaged by the Beirut Port explosion, nearing total collapse. Inside their incubators, babies sheltered from the debris were evacuated within 3 hours. “An apocalypse — one minute was worse than 20 years of war,” says Robert Sacy, head of the Pediatrics Department at the hospital and president of ASSAMEH – Birth and Beyond. What was once a haven for over 1,000 children per year has now been nearly razed to the ground. The remains of paintings of trees, suns, and smiles are now covered with blood on the few walls still standing. What was once joyful is now contaminated with death.

Making matters worse, a surge in the number of cases and ICUs at nearly full capacity, some project that the country might be heading towards an Italy-like scenario if serious long-term precautions measures are not implemented. The daily positivity rate fluctuates between 10 and 20%, and the death toll is 970+ since February 2020. The pandemic appears to be mostly affecting adults, with the case-fatality of children under nine years of age at 0.05% and only one recorded death(7).

Although it has been speculated that neonates, due to their immature respiratory physiology and the immune system, might be at a higher risk for COVID-19 related complications, a review of the literature shows no increased risk of severe disease in infected neonates. Conversely, Martin Filho et al. raised concern about how a cytokine storm in pregnant mothers might increase the likelihood of poor neonatal neurodevelopmental outcomes (6). Associate professor of Neonatology at the American University of Beirut Medical Center (AUBMC), Lama Charafeddine, denied that the pandemic had had any noticeable immediate effects on the rate of perinatal complications or congenital malformations or infections. She did contend, however, that it is too early to draw any conclusions regarding this matter. While COVID-19 does not significantly affect the neonatal and pediatric population, Antoine Yazbeck, head of Neonatology at Serhal Hospital, reports a drop in the overall quality of care and staff morale due to increasing physician burnout. Indeed, as of early November, numbers from the doctors’ syndicate and the order of nurses (5) show that a total of three doctors had died and seventeen admitted to intensive care units, with more than one hundred having been put under home quarantine and over 1,500 nurses having been infected. The pandemic has significantly affected the pediatric healthcare system’s overall capacity, draining it in such that neonatal care is becoming severely compromised.

For physicians around the world, and particularly in Lebanon, working conditions have become increasingly difficult. “We see 4-5 kids per day, on a good day”, reports Yazbeck, who has reported a ten-fold decrease in daily patient attendance to his clinic. Indeed, the pandemic has led many parents – those who have not migrated yet – to opt-out of vaccination programs and avoid routine follow-ups out of fear of exposure. Additionally, due to currency devaluation, consultation fees, still generally fixed at the same price in Lebanese pounds, are much less profitable to the physician (dropping from the equivalent of $60/patient to less than $12/ patient) while still being largely unaffordable for the larger patient population. Maroun Matar, head of the Neonatology Department at Lebanese American University Medical Center (LAUMC), also describes an 80% decrease in his monthly income despite raising his clinic fees by 10% whilst food products and basic necessities witness an inflation rate of more than 400% (3) and half the population is now under the poverty line. Highly qualified and trained physicians, overworked and underpaid, have decided to immigrate for better opportunities abroad. Indeed, over 400 physicians have immigrated in the last couple of months, with more expected to follow suit (8). This has pushed government officials to seek international aid to incentivize doctors to stay in the country by offering financial compensation (8). This exodus of physicians and the shortage of medications and medical equipment (hospital suppliers demanding to be paid in hard currency, largely unavailable on the market) has significantly reduced the quality of healthcare in Beirut, once a regional health hub in the Middle East.

It is crucial to bring to light the difficulties encountered by healthcare workers in developing countries to identify the various factors affecting the quality of care offered to patients. The pandemic has highlighted wide disparities and brought to the fore existing inequalities in developed countries, exposing the need to fill large healthcare delivery gaps to marginalized communities. In a country like Lebanon, shaken by financial precariousness, famine, civil unrest, a large explosion, a mass exodus, and a global pandemic, these disparities have become even more apparent and alarming. This eventful year has highlighted the lack of a national emergency preparedness plan, inadequate infection prevention and control practices, and the absence of an effective healthcare safety net for the uninsured in Lebanon. It is crucial to address these deficiencies for a better-equipped healthcare system in the face of the next blow in order to be able to, at least, give the newborns the gift of time.


Infant who survived in 1920s sideshow incubator dies at 96


Dr.Martin Couney, left, and an identified woman looking at a baby in an incubator

New York Public Library

MINEOLA, N.Y. — Lucille Conlin Horn weighed barely two pounds when she was born, a perilous size for any infant, especially in 1920. Doctors told her parents to hold off on a funeral for her twin sister who had died at birth, expecting she too would soon be gone.

But her life spanned nearly a century after her parents put their faith in a sideshow doctor at Coney Island who put babies on display in incubators to fund his research to keep them alive.

The Brooklyn-born woman who later moved to Long Island, New York, died Feb. 11 at age 96, according to the Hungerford & Clark Funeral Home. She had been suffering from Alzheimer’s disease.

Horn was among thousands of premature babies who were treated in the early 20th century by Dr. Martin Couney. He was a pioneer in the use of incubators who sought acceptance for the technology by showing it off on carnival midways, fairs and other public venues. He never accepted money from their parents, but instead charged oglers admission to see the tiny infants struggling for life.

Horn and her twin were born prematurely in Brooklyn. She told The Associated Press in a 2015 interview that when her sister died, doctors told her father to hold off on a funeral because tiny Lucille, would not survive the day.

“He said, ‘Well that’s impossible, she’s alive now. We have to do something for her,’” Horn said. “My father wrapped me in a towel and took me in a cab to the incubator; I went to Dr. Couney. I stayed with him quite a few days; almost five months.”

Couney, who died in 1950 and is viewed today as a pioneer in neonatology, estimated that he successfully kept alive about 7,500 of the 8,500 children that were taken to his “baby farm” at the Coney Island boardwalk. They remained there until the early 1940s, when the incubators became widely used in hospitals.

He also put infants on display at the World’s Fair and other public venues during his career. There is no estimate on how many still are alive today.

Horn worked as a crossing guard and then as a legal secretary for her husband. She is survived by three daughters and two sons. She said she met Couney when she was about 19 and thanked him for what he had done.

“I’ve had a good life,” she said in 2015.

After a funeral Tuesday, she was buried at the Cemetery of the Evergreens in Brooklyn, next to her twin sister.


Disaster Preparedness in Neonatal Intensive Care Units

Wanda D. Barfield, Steven E. Krug, COMMITTEE ON FETUS AND NEWBORN and DISASTER PREPAREDNESS ADVISORY COUNCIL – Pediatrics May 2017, 139 (5) e20170507; DOI:


Disasters disproportionally affect vulnerable, technology-dependent people, including preterm and critically ill newborn infants. It is important for health care providers to be aware of and prepared for the potential consequences of disasters for the NICU. Neonatal intensive care personnel can provide specialized expertise for their hospital, community, and regional emergency preparedness plans and can help develop institutional surge capacity for mass critical care, including equipment, medications, personnel, and facility resources.


Model of decision-making based on available supplies: example using respiratory support. The figure shows a model of decision-making based on available supplies, personnel, patient acuity, and surge capacity for pediatric EMCC. CPAP, continuous positive airway pressure; ECMO, extracorporeal membrane oxygenation. Reproduced with permission from Bohn D, Kanter RK, Burns J, Barfield WD, Kissoon N. Supplies and equipment for pediatric emergency mass critical care. Pediatr Crit Care Med. 2011;12(suppl 6):S120–S127. Copyright © 2011 Wolters Kluwer Health.


Infants in the NICU are highly vulnerable in a disaster because of their need for specialized and highly technical support. As such, NICU preparedness is required for optimal disaster response.

  1. Preparation before a disaster event is critical to optimizing outcomes of NICU patients during public health emergencies and disasters. Health care institutions and providers are strongly encouraged to know and prepare for the most likely disaster scenarios in their communities (eg, hurricane, earthquake, or flood) and also to consider unanticipated events (eg, bioterrorism) that could create a mass casualty event and similarly affect surge capacity and capabilities.
  2. It is important for NICU teams to fully participate in the emergency- and disaster-planning activities of their facility, health care system, or regional, state, and local emergency management agency. Teams should be part of the periodic disaster simulation drills that are now required in every hospital. NICU teams should actively participate in the design of hospital drills to address the unique needs of NICU patients in situations involving “shelter-in-place,” relocation, and/or evacuation. The use of an incident command structure within the NICU, facility, and community is important to maintain structure and an organized response.
  3. Neonatal care systems (providers, administration, information technology, and equipment) can develop appropriate staffing support for safe and effective operations during disasters. NICU care providers, in collaboration with their hospital facility, community practitioners, network, and region, need to identify the surge capacity to provide 3 times the baseline critical care resources and sustain this for 10 days during a major public health disaster. An effective response to specific disaster threats, including maintenance of adequate surge capacity, relies on sufficient supplies of age- and size-appropriate MCMs.
  4. During a disaster, neonatal care providers can maintain situational awareness for decision-making, including patient volume and severity of illness, available equipment, medication, and staffing, transport, evacuation, recovery, and crisis standards of care. Maintaining flexibility is important in adjusting to new situations. Advance planning and coordination with local and state public health and emergency management agencies will additionally support situational awareness and timely decision-making. A process of ethical decision-making and altered standards of care needs to be included in disaster planning.
  5. In addition to the needs of patients, NICU providers may need to consider the medical and psychosocial needs of postpartum mothers and families. To the extent it is feasible, parents and families should remain in contact with patients. Families may have unique needs and/or require assistance in unusual ways during a large-scale disaster. In addition, plans should be made to recognize and respond to the needs of NICU staff, including self-care and support.
  6. Although some guidance in this report is based on systematic reviews (eg, H1N1 and mass critical care), much is based on lessons learned from previous disaster events. Preparedness is an ongoing process that changes on the basis of learned experience and evidence. NICU providers should continue to research best practices, neonatal medications and dosing, and the effects of altered standards of care in disasters.


*** Our Neonatal Womb Warrior Family and global Maternal and Child health at large are substantially and increasingly affected by the direct effects and challenges climate change and natural disasters invoke on our communities. We are closely exploring these issues and the opportunities offered towards supporting positive change/response to these changes.  Education remains foundationally essential towards formulating progressive strategies to interact with the challenges climate change and natural disasters offer. Like the Covid pandemic, physical borders cannot prevent local impacts of increased levels of climate change and natural disasters; and global collaboration towards addressing the associated needs through targeted and effective action in relationship to these elements is vitally essential.

Natural disasters are occurring more frequently with increased ferocity, UN says

  1. Extreme weather events are occurring more often, experts have warned.
  2. In the last 20 years, 7,348 major disaster events were recorded globally, claiming 1.23 million lives.
  3. These events cost $2.97 trillion in economic losses with 8 out of the 10 most-affected countries in Asia.

Extreme weather events have increased dramatically in the past 20 years, taking a heavy human and economic toll worldwide, and are likely to wreak further havoc, the United Nations warned.

Heatwaves and droughts will pose the greatest threat in the next decade, as temperatures continue to rise due to heat-trapping gases, experts said.

China (577) and the United States (467) recorded the highest number of disaster events from 2000 to 2019, followed by India (321), the Philippines (304) and Indonesia (278), the U.N. said in a report issued the day before the International Day for Disaster Risk Reduction. Eight of the top 10 countries are in Asia.

Some 7,348 major disaster events were recorded globally, claiming 1.23 million lives, affecting 4.2 billion people and causing $2.97 trillion in economic losses during the two-decade period.

Drought, floods, earthquakes, tsunamis, wildfires and extreme temperature events caused major damage.

“The good news is that more lives have been saved but the bad news is that more people are being affected by the expanding climate emergency,” Mami Mizutori, the U.N. Secretary-General’s Special Representative for Disaster Risk Reduction, told a news briefing.


This chart shows how much more common natural disasters are becoming


Your Premature Baby’s Development and Medical Follow-Ups

by  Sara Novak    Medically Reviewed by Lauren Crosby, M.D., F.A.A.P. on

March 3, 2020

When it comes to premature babies’ development, parents need a big dose of patience. Thankfully, most preemies catch up with the full-term crowd by toddlerhood.

Premature babies are born weeks and sometimes months before their actual due date, often before their nervous systems have fully developed. As a result, they can fall behind full-term babies after they’re born. That doesn’t mean that they won’t develop into perfectly normal and healthy kids, but it does mean that their timelines can be a little different from those of full-term babies.

How will my preemie’s development differ from that of full-term babies? Premature babies develop at a different rate than other babies, and just because your child has passed her due date doesn’t mean she’s all caught up.

Calculate her corrected age. When you’re considering your premature baby’s development it’s important to consider not just the day she was born, but also the original date she was supposed to be born. Calculating your baby’s corrected age can give you a more accurate understanding of whether she is developing at pace. For example, if your baby is 6 months old, subtract the number of weeks your baby was preterm in order to figure out her corrected age. This means that you can’t expect a 6-month-old preterm baby to sit up at the same time a 6-month-old full-term baby would, because they aren’t the same age developmentally. This “corrected age” is used during the first two years of life. By the time premature children are 2 years old, most have caught up on their milestones (so you won’t need to continue to recalculate your little one’s age).

Fine and gross motor skills could take longer. Preemies often take a little extra time to develop both gross- and fine-motor skills and hit baby and toddler milestones such as rolling over, sitting up and taking that first step. Later on, preemies are more likely than full-termers to have learning disabilities, so being aware of what’s normal and what’s not is vital to getting her the help she needs as soon as possible.

Worry less about dates and more about progress. Full-term babies are more likely to be tied to timelines when compared to preemies. With premature babies there’s less of an emphasis on timelines and more on ensuring they are progressing — from pulling up to standing to walking.

What medical follow-ups will I need for my premature baby

First and foremost, keep in regular contact with your baby’s pediatrician. That doctor will be seeing your baby for years to come, so it’s important to involve him or her from the start, even if you’re taking your child to other specialists.

  1. Make an appointment for a checkup soon after your baby’s release from the hospital. Most doctors will want to see a preemie within a day or two of homecoming. That way, your practitioner can get baseline readings on your premature baby’s weight and general health in order to keep close tabs on him. Note: Make sure you have a discharge summary from the neonatal intensive care unit (NICU), along with a record of your baby’s immunizations in the hospital.
  2. Schedule dental exams. Premature babies are more likely to suffer from delayed tooth growth and discolored teeth. Schedule your baby’s first dental exam either when your baby sprouts a tooth or when he turns 1.

Other tips on how to handle your premature baby’s development: Of course, it’s easier said than done, but try not to make your baby’s prematurity the only thing you think about. Enjoy and appreciate her for the amazing little person she is — and not as you would a delicate piece of china. It might help to remember these tips:

  1. Whatever she’s going through might have nothing to do with prematurity. When you’re parenting a preemie, it’s easy to attribute every small bump in the road to your baby’s premature status. But sometimes a baby’s cold is just a cold. And maybe she’s colicky because she’s got colic, not because she was born early.
  2. Follow your gut. No one knows your baby better than you. If something isn’t quite right, you’re most likely going to be the one to notice first, so don’t underestimate your intuition. Talk to your doctor if something seems off.

You’ve already been on a roller coaster of emotions waiting round the clock for the newest member of your family to finally be released from the hospital. It can be easy to transition that stress to your preemie’s development at home. Patience is a virtue that can’t be underestimated when it comes to your preemie’s development. And don’t worry: She’s going to catch up before you know it!


The NICU Doc Who Works in the NICU and Surrounds Your Baby -Jun 26, 2020

Wanna know who are all the people who surround your baby in the NICU? Want to know who are all the people that work in the NICU? It takes a village to take care of babies. In the NICU, there are medical students, residents, fellows, nurses, neonatal nurse practitioners, neonatologists, and many more. In this video, you can find out all the different people in the neonatal intensive care unit. And in the end, you will learn about someone you would not expect to find in the NICU.

For Family and Friends

Being a parent of an infant in the Neonatal Intensive Care Unit (NICU) is very different than having a newborn at home. When you have a newborn you are trying to squeeze tasks in around their changing, feeding and sleeping schedule. When your child is in the NICU, household tasks get crammed into the brief periods between sleeping, pumping, sterilizing, working, perhaps eating and trips to the NICU. If you are lucky, you have a short trip to the hospital and are able to return home easily, but that often means you are getting home in the wee hours of the morning. If you live further away, you may end up seeking out overnight accommodations.

Regardless of your proximity to the hospital, all parents have one thing in common; they are barely home and when they are at home they are physically and mentally exhausted.

Many people offer help to parents of infants in the NICU by saying “Let me know if you need some help”. This is great and lets the parents know they are not alone. The problem is that parents are often reluctant to admit they need help, or they just don’t know what help they need. The best thing you can do is to make a specific offer to help them. Parents, you just need to accept those offers.

If you are not sure of what things you can do to help here are some ideas:

  1. If they have other children, pets or aging parents, offer to take care of them.
  2. Make them a home cooked meal in a container they don’t have to wash and return to you.
  3. Arrange to drop by and help with the housework.
  4. Offer to pick up their laundry and return it washed and folded.
  5. Help with the house, cut the lawn, shovel the driveway, and/or make the house look lived in.
  6. Pick up their mail and sort addressed mail from unaddressed mail so they can quickly look at bills and important items.
  7. Do some grocery shopping for them.
  8. Ask them “What can I do to help you ? “
  9. Drive parents back and forth to the hospital.
  10. Respect the parents’ wishes about how they want to mark the birth. Some may wish to celebrate. Others may want to wait until the baby is home. It is for the parents to decide and for you to support their wishes.
  11. Learn about prematurity, but don’t feel the need to share what you’re learning with the parents. Be careful about what resources you use, especially if you’re researching online.
  12. Try not to be offended if parents exclude you temporarily. The NICU can be difficult and some people turn inwards in order to cope.
  13. Shop for necessities when the baby is discharged from the hospital.
  14. Respect the rules of the NICU. Don’t visit if you’re sick or if people close to you are sick.
  15. Respect the privacy of other parents and their babies.
  16. Offer to communicate with other family and friends so that the parents don’t have to spend all their time updating everyone.
  17. Coordinate other offers of help so that the parents don’t need to organize who does what.
  18. Resist the urge to compare the new baby with other babies. Please don’t make comments on size or weight, and please don’t talk about other birth experiences unless you have personal experience as a parent of a premature baby.
  19. Keep offering help when the baby is home. The first few months can be isolating and difficult and parents can really use continued assistance.
  20. When a baby goes home, remember that preemies, especially during the winter months, are at risk for infections and sickness. Never visit the parents and baby at home if you’re sick, and respect their wish to keep their baby healthy. They are not being over-protective. They are being good parents.

These things will help to relieve the pressure that they are under and allow them to focus on caring for their child.

Note: these points are also things that would be appreciated by any new parent or anyone with a critically ill family member.


Life After The NICU | Meet Dr. Nathalie Maitre,

Dr. Nathalie Maitre is a neonatologist and developmental specialist who is the Director of the NICU Follow-up Program and NICU Music Therapy Program at Nationwide Children’s Hospital. She works with a diverse team of scientists, engineers and therapists who all believe strongly in the need to identify children at high-risk for disabilities as early as possible, in order to optimize recovery after the neonatal period.

Break Time for Nursing Mothers

Federal law (USA) requires employers to provide reasonable break time for an employee to express breast milk for her nursing child for one year after the child’s birth each time such employee has need to express the milk (Section 7 of the FLSA). Employers are also required to provide a place, other than a bathroom, that is shielded from view and free from intrusion from coworkers and the public, which may be used by an employee to express breast milk.

General Guidance

  1. WHD Fact Sheet #73, Break Time for Nursing Mothers under the FLSA (Spanish Version)
  2. Break Time for Nursing Mothers Frequently Asked Questions (FAQs)
  3. Break Time for Nursing Mothers under the FLSA (Microsoft® PowerPoint®)
  4. Break Time for Nursing Mothers Poster (Spanish)
  5. Break Time for Nursing Mothers Employee Rights Card
  6. FLSA Handy Reference Guide
  7. How to File a Complaint



Panelists discuss how to manage wellness during pandemic winter

Trisha Korioth    Staff Writer    December 02, 2020   Pediatrician Wellness

Be honest. How much time are you spending on self-care right now? For many pediatricians, the answer is “Not enough.”

To be effective in practice, pediatricians must take care of themselves, according to panelists at an AAP town hall, Physician Resilience in the Time of COVID-19.

Anne R. Edwards, M.D., FAAP, AAP chief population health officer, led panelists in a discussion on how to address high stress levels, communicate and connect, give and get help, replenish resilience and maintain a growth mindset.

Connect with others

The pandemic has caused patient volume to drop and forced practices into new routines. Robert J. Riewerts, M.D., FAAP, of Southern California Permanente Medical Group and KP Care Management Institute, noted a silver lining. Phone time at his practice increased from between 3% and 7% to about 40% as pediatricians reached out to check in on patients and families.

Early in the pandemic, Dr. Riewerts’ group also arranged weekly discussions with expert to allay concerns about the virus. Pediatricians unaccustomed to seeking support from colleagues were encouraged to reach outside their comfort zone.

“This year, physicians are being stretched to the limits in all kinds of specialties,” he said. Supporting one another can help pediatricians model a positive example for their patients.

Routine team check-ins can build support within practices and hospitals, according to Riva Kamat, M.D., FAAP, co-lead of the AAP Section on Hospital Medicine Subcommittee on Provider Wellness and a hospitalist at Inova Fairfax Hospital for Children.

Dr. Kamat suggests asking colleagues if they are feeling stressed. “Then let them, what I call, ‘slime you.’ Let them share what’s bothering them.”

Because most problems cannot be solved in one vent session, Dr. Kamat said it is important to stay connected with the person. She asks colleagues how they would like her to check in again, such as by text or a phone call. Her institution also uses accountability partners to ensure people are taking care of themselves.

COVID-19 has isolated us in every way, said Melanie L. Brown, M.D., M.S.E., FAAP, chair of the AAP Section on Integrative Medicine Executive Committee and member of the Wellness Advisory Group. But that shouldn’t stop pediatricians from maintaining connections. This can be done locally or through AAP connections such as Extension for Community Healthcare Outcomes groups, collaboration sites and COVID-19 discussion boards ( login required).

“Being able to find connections with other like-minded colleagues, you’re also modeling for other people the importance of them also finding connections,” she said.

Refuel resilience

The dark days of winter can be challenging for many, which is why pediatricians should take time to figure out what refuels their resilience and identify barriers preventing them from replenishing it, said Christine Moutier, M.D., chief medical officer, American Foundation for Suicide Prevention.

“Sometimes, we react in ways that we are pleased with and other days we don’t. We don’t have to feel like that is fate,” she said. “We can actually make small tweaks that allow us to have whatever that substance is, that reservoir of resilience, that will allow us to keep drawing from that moment by moment.”

Ideas include meditating, journaling, exercising, getting outdoors and confiding with like-minded colleagues.

Dr. Moutier also cautions not to make major life decisions when extremely stressed. Pediatricians should be aware of tendencies toward anxiety or depression, shed stigmas and be proactive.

Manage your mindset

When stress reaches a boiling point, Dr. Moutier suggests trying the “Put It In Perspective” approach to redirect thoughts from irrational to rational. The approach, developed by Martin E.P. Seligman, director, University of Pennsylvania Positive Psychology Center, includes four steps:

  1. Ask yourself: What is the worst possible situation?
  2. Force yourself to think about the best outcome.
  3. Then consider what is most likely to happen.
  4. Finally, develop a plan for the most realistic scenario.

When problems fester, Dr. Moutier said, “Give yourself the gift of just a moment of time that’s set aside to work that through. Any time and effort we spend on that is going to bear fruit for us.”

Dr. Brown added, “Taking care of yourself is not selfish. It’s what’s needed in order for you to go out and then care for others.”


  1. Connecting with the Experts: A COVID-19 Townhall Series
  2. AAP Physician Health and Wellness webpage
  3. American Medical Association’s Steps Forward series


Life of a COVID-19 Nurse at Harborview’s ICU | UW Medicine

UW Medicine

Working 84-hour weeks. Isolating from children and partners. Comforting patients who are dying alone. Tending to a beloved teammate’s battle with a life-threatening illness. At Harborview Medical Center’s COVID-19 ICU, these are the new challenges that nurses take on every day during the coronavirus pandemic. Despite the stress and uncertainty, they find strength in the importance of their work. “I knew what I was getting into, and I chose it,” one nurse explains. “I was meant to be a nurse.”

 *** The pandemic has hit our healthcare provider community/workforce, already globally experiencing a severe provider shortage crisis, hard and will significantly set back the development of new providers available to care for our extensive family members. The road to becoming a  physician, nurse and within so many related healthcare provider specialties is often a very long hard journey, now expanded in length (months to years) due in part to a shortage of clinical opportunities to train. Please support our global healthcare community. Lives depend on it!

Still Want to Be a Doctor Post COVID-19?

How the pandemic could influence the next generation of healthcare professionals

by Jessica Gold, MD, and David Rettew, MD May 4, 2020

Every applicant to medical school has to write a personal statement. It does not have a prompt, but the understood question has always been, “Why do you want to be a doctor?”

Being a physician has always been considered a noble and honorable profession, but ever since COVID-19, physicians, along with the nurses and other healthcare professionals working on the front lines, have become bona fide heroes. The public now sees these courageous men and women risking their lives for others (sometimes without the protective equipment they need) while isolating themselves from their own families to do so.

In photos, their battle-tested faces reveal compassion and fatigue, but, perhaps more than anything, resolve. These pictures and the accounts that come with them have commanded respect and admiration, and have elevated medical professionals to new heights.

But with this adulation has come an enormous cost. As of last month, more than 200 doctors and nurses across the world have died from the novel coronavirus. Such grim numbers have shocked both the public and those already in or considering a career in healthcare. Yes, these careers involve hard work, life or death levels of responsibility, and many stressful situations, but actual danger — that’s only been there in the fine print and has been mostly avoidable for those wishing to do so, at least for those practicing in the U.S.

Until now.

In New York City hospitals and other places that have treated high numbers of COVID-19 patients, many doctors who might have reasonably believed that their career paths would have circumvented close contact with deadly viruses are finding themselves being called into action. Psychiatry residents are working in ICUs, and outpatient primary care doctors are getting enlisted to staff overflow units and field hospitals. For more risk-averse people thinking that being a physician was a cerebral and predictable line of work, it may be time to look elsewhere.

According to the Association of American Medical Colleges (AAMC), the number of applicants to medical school has been a roller coaster over the past 40 years. Since about 2003, however, there has been a steady increase in numbers. The current rise in applicants has occurred through both economic booms and recessions and has occurred despite what many have observed as an erosion in the level of trust and prestige afforded to physicians due to factors such as ties to the pharmaceutical industry and the public’s increasing attraction to “alternative” types of treatment. This rediscovered respect for doctors could make the number of applicants rise even more steeply, but there’s certainly no guarantee.

“I think with COVID-19, we just don’t know,” says Geoffrey Young, PhD, who is the AAMC’s senior director of Student Affairs and Programs and has worked on three medical school admission committees. He does not, however, predict that the current pandemic will scare off a significant amount of applicants as many applicants “at their core, have a service orientation” and “have a desire to have a positive impact on the environment around them,” he said.

For these individuals, “it’s not just a profession, it’s a calling,” Young said, noting that he wonders if there well could be an influx of medical school applications similar to the increase of people joining the armed forces after 9/11. This makes sense, as physicians have, especially lately, often been compared to soldiers, with their healthcare workspaces likened to battlefields.

On social media, a number of actual and future medical students have weighed in on this conversation. The opinions are expectedly mixed, but the majority view the pandemic as a reason to enter medicine if mostly to become an advocate for changing the system.

For example, one medical student in emergency medicine (EM) wrote, “Perhaps this reflects my bias, as someone aspiring to EM, but I feel like this is going to inspire a lot of people. Particularly people who know things could have gone better, need to go better, and want to work on making that possible.”

Another first-year medical student agreed, stating that “the next generation of doctors … tend to be enraged by the status quo. If they had an existing predilection to medicine, they’ll be even more enticed because of the opportunity for radical change.” A third-year in New York added, “I know we all see an issue and think we can change it, but this really is unprecedented and if this isn’t time to try to push the field in the right direction idk what is.”

A few premedical undergraduate students agreed, voicing that their interest and desire to go into medicine had increased as a result of COVID-19. One noted, “This has motivated me even more to be a doctor — we clearly need more physician-activists and more healthcare workers in positions of power.” A mom of a 16-year-old interested in medicine contributed by stating, “My 16-year-old daughter has always flip-flopped on [the] idea of going into medicine (infectious disease specifically) & she is now more energized & feels more sure this is what she wants to do. (I realize she’s 16 & may change, but…) I think it feels more meaningful now than ever.”

One physician poignantly wrote on Twitter, “My hope is that the outpouring of support will restore the feelings of the honorable profession that it is, rather than having people feel like replaceable worker bees. More inspiration, less desperation. One thing[s] for sure — expect change.”

Some, however, have begun to question their specialty choice or motivation for medicine altogether. A fourth-year medical student wrote, “I can imagine the numbers for Emed and IM going down for the next few years, people are naturally going to want to avoid the frontlines. Also, this might affect applications to med school as a whole. These are unprecedented times and people are rightfully spooked …Fear drives people’s actions more than anything else. Also, who wants to be in a position where you’re begging your employer for proper gear, and might be reprimanded for speaking out.”

A third-year added, “It was discouraging for ME (and I’m an MS3!) to see the mistreatment of my future colleagues … I think this will discourage those who are in it for monetary reasons or familial pressure but fuel the flame for those w/humanitarian goals.”

The last comment speaks to the possibility that while the number of applicants may not vary significantly due to the pandemic, the characteristics of those applicants will. While applicants to healthcare professions are hardly monolithic when it comes to their personality or motivations, a study in PLoS One from 2016 found that most medical students fit one of two personality profiles. One was labeled “resilient” and described students who were vigorous and industrious but a bit more on the materialistic side. The other was labeled “conscientious” and included those with higher levels of anxiety.

People with either of these profiles could get pulled in different directions when it comes to how attractive a career in medicine appears post-COVID-19. Noted personality researcher and psychiatrist Robert Cloninger, MD, PhD, who was the senior author of this study, speculates that those with the resilient profile may be “more likely to risk a dangerous job” but are also “unlikely to do things involving sacrifice for others.”

The second profile, by contrast, could be further inspired by the pandemic to help others but more concerned about their own safety. Putting it all together, it would certainly be reasonable to expect a decrease in applicants looking for secure and safe ways to make a good living and an increase in those who, as they say, like to run towards the fire.

Of course, there’s nothing wrong with the applicant pool we already have, who tend to be smart, dedicated, and compassionate people — many of whom are looking for that magic balance of a meaningful career and good job stability and security. That said, the stirring demonstrations of bravery, sacrifice, and persistence coming from the physicians and other healthcare professionals who have answered the call against the coronavirus is going to be a tough act to follow. Many of course will try, and the new crop that does may well be even more prepared to step up to our next major healthcare threat while simultaneously changing the way that healthcare is delivered.

In the years to come, there may well be a number of applicant essays that read “I want to be a doctor because of COVID-19.”



Preterm children’s long-term academic performance after adaptive computerized training: an efficacy and process analysis of a randomized controlled trial

Published: 12 September 2020Julia JaekelKatharina M. HeuserAntonia ZapfClaudia RollFrancisco Brevis NuñezPeter BartmannDieter WolkeUrsula Felderhoff-Mueser & Britta Huening



Adaptive computerized interventions may help improve preterm children’s academic success, but randomized trials are rare. We tested whether a math training (XtraMath®) versus an active control condition (Cogmed®; working memory) improved school performance. Training feasibility was also evaluated.


Preterm born first graders, N = 65 (28–35 + 6 weeks gestation) were recruited into a prospective randomized controlled multicenter trial and received one of two computerized trainings at home for 5 weeks. Teachers rated academic performance in math, reading/writing, and attention compared to classmates before (baseline), directly after (post), and 12 months after the intervention (follow-up). Total academic performance growth was calculated as change from baseline (hierarchically ordered—post test first, follow-up second).


Bootstrapped linear regressions showed that academic growth to post test was significantly higher in the math intervention group (B = 0.25 [95% confidence interval: 0.04–0.50], p = 0.039), but this difference was not sustained at the 12-month follow-up (B = 0.00 [−0.31 to 0.34], p = 0.996). Parents in the XtraMath group reported higher acceptance compared with the Cogmed group (mean difference: −0.49, [−0.90 to −0.08], p = 0.037).


Our findings do not show a sustained difference in efficacy between both trainings. Studies of math intervention effectiveness for preterm school-aged children are warranted.


  1. Adaptive computerized math training may help improve preterm children’s short-term school performance.
  2. Computerized math training provides a novel avenue towards intervention after preterm  birth.
  3. Well-powered randomized controlled studies of math intervention effectiveness for preterm school-aged children are warranted.


What Keeps Neonatal Nurses Up at Night and What Gets Them Up in the Morning?

Walden, Marlene PhD, APRN, NNP-BC, CCNS, FAAN; Janssen, Dalton W. MSN, RNC-NIC; Lovenstein, Austin MA, BS

Editor(s): Dowling, Donna PhD, RN, Section Editors; Schierholz, Elizabeth PhD, MSN, NNP-BC, Section Editors

Advances in Neonatal Care: December 2020 – Volume 20 – Issue 6 – p E102-E110



Occupational stress in neonatal nursing is a significant professional concern. Prolonged exposure to morally distressing patient care experiences and other healthcare issues may lead to worry among nurses. When worry becomes excessive, nurses and advanced practice registered nurses may lose joy that gives meaning to their work. Enhancing meaning in work may have a positive impact on nurse satisfaction, engagement, productivity, and burnout.


To explore neonatal nurses’ top professional satisfiers and top professional worries and concerns.


A descriptive study was conducted in a convenience sample of neonatal nurses to identify the top professional satisfiers that get them up in the morning and the top professional worries and concerns that keep them awake at night.


Complete data were available for 29 neonatal nurses. The top professional satisfiers were caring for infants and families, making a difference, witnessing resilience, intellectual challenge of specialty, positive working relationships with colleagues, and educating parents and families. The top professional worries and concerns were staffing, missed care, workload, making a mistake, and failure to rescue.

Implications for Practice: 

Healthcare and professional organizations must develop strategies to address occupational stress in today’s complex healthcare environment. Identifying professional worries and concerns may help nurses navigate challenging and distressing situations. Furthermore, understanding nurses’ professional satisfiers may promote personal and professional resiliency and help organizations create healthier workplace environments.

Implications for Research: 

Future studies are needed to test effective interventions that may promote professional satisfaction and help neonatal nurses cope with occupational stressors.

Preterm autism spectrum disorder risk linked to changes in cerebellar white matter

Children’s National Hospital   Nov 8, 2019

A study in experimental models suggests that allopregnanolone, one of many hormones produced by the placenta during pregnancy, is so essential to normal fetal brain development that when provision of that hormone decreases – as occurs with premature birth – offspring are more likely to develop autism-like behaviors. Lead study author Claire-Marie Vacher, Ph.D., explains the work of the Neonatology and Neonatal Neurology and Neonatal Neurocritical Care teams at Children’s National.

Family history is a predictor of current preterm birth

American Journal of Obstetrics & Gynecology MFM

Available online 11 November 2020, 100277 Original Research

This work was presented as a poster (number 674) at the Society for Maternal-Fetal Medicine Pregnancy Meeting, Dallas, TX, February 3, 2018.

Author links open overlay panel  AmandaKoireMD, PhDabDerrick M.ChuMD, PhDbcdKjerstiAagaardMD, PhDbcde


Reliable prediction of spontaneous preterm birth remains limited, particularly for nulliparous and multiparous women without a personal history of preterm birth. Although previous preterm birth is a risk factor for recurrent preterm birth, most spontaneous preterm births occur in women with no previous history of preterm birth.


This study aimed to determine whether patients’ self-reported maternal family history of preterm births among siblings and across 3 generations was an independent risk factor for spontaneous preterm births after controlling for potential confounders.

Study Design

This was a retrospective analysis of a prospectively acquired cohort using a comprehensive single, academic center database of deliveries from August 2011 to July 2017. The objective of the current analysis was to evaluate the risk of preterm birth among women with and without a family history of preterm birth. All subjects in the database were directly queried regarding familial history across 3 generations, inclusive of obstetrical morbidities. Index subjects with probable indicated preterm birth (eg, concurrent diagnosis of preeclampsia; hemolysis, elevated liver enzymes, and low platelet count; or placenta previa or placenta accreta) were excluded, as were nonsingleton pregnancies. Univariate and multivariate analyses with logistic regression were used to determine significance and adjusted relative risk.


In this study, 23,816 deliveries were included, with 2345 (9.9%) born prematurely (<37 weeks’ gestation). Across all subjects, preterm birth was significantly associated with a maternal family history of preterm birth by any definition (adjusted relative risk, 1.44; P<.001), and the fraction of preterm birth occurring in women with a positive family history increased with decreasing gestational age at which the index subjects of preterm birth occurred. For nulliparous women, a history in the subject’s sister posed the greatest risk (adjusted relative risk, 2.25; P=.003), whereas for multiparous women with no previous preterm birth, overall family history was most informative (P=.003). Interestingly, a personal history of the index subject herself being born preterm presented the greatest individual risk factor (adjusted relative risk, 1.94; P=.004).


Spontaneous preterm birth in the current pregnancy was significantly associated with a maternal family history of preterm birth among female relatives within 3 generations and notably sisters. The risk persisted among gravidae without a previous preterm birth, demonstrating the capacity for familial history to independently predict risk of spontaneous preterm birth even in the context of a negative personal history. This study provides evidence that self-reported maternal family history is relevant in a US population cohort and across more distant generations than has previously been reported.


Sensory processing patterns of young adults with preterm birth history

Ayla Günal ,Serkan Pekçetin &Çiğdem Öksüz

Pages 288-292 | Received 05 May 2020, Accepted 14 Sep 2020, Published online: 24 Sep 2020



This study aimed to evaluate the sensory processing abilities of young adults with a history of preterm birth and the factors affecting these abilities.

Materials and methods

Thirty-seven young adults with preterm birth history were included. After recording their sociodemographic data, sensory processing functions were evaluated using the Adolescent/Adult Sensory Profile. The participants’ data were compared to normative samples.


Mean score was 43.51 ± 8.29 for sensory sensitivity, 44.45 ± 9.19 for sensation avoiding, 33.43 ± 8.45 for low registration, and 47.97 ± 9.91 for sensation seeking. Compared to normative samples, 78% of participants in sensation avoiding quadrant, 62% of participants in sensory sensitivity quadrant, 40% of participants in low registration quadrant and sensation seeking quadrant had atypical scores. When sensory profile scores were analysed according to mode of birth, percentages of typical sensory sensitivity and sensation avoiding were low in both the normal vaginal and caesarean delivery subgroups. When analysed by gestational age at birth, ratios of abnormality in sensation avoiding were similar between individuals with very early, early, and late preterm delivery history. Statistically significant difference was found in low registration and sensation avoiding quadrants according to mode of birth (p < .05). There were no statistically significant sex-based and gestational age at birth differences in any of the four quadrants of the sensory profile in the preterm group (p > .05).


These results showed that young adults with preterm birth history have differences in sensory processing compared to the general population and should be evaluated for sensory processing patterns.



Kat’s Corner

We are a powerful and motivated community seeking health and well-being in turbulent times.

As a global community 2020 offered challenges that, like a NICU/preterm birth experience, we likely did not anticipate.  We have all endured these challenges, making significant transitions while living through a global pandemic. While 2020 has separated many of us in our professional and personal realms it has also inspired us to create new solutions to a variety of complex problems.

Our hearts wept knowing many of our new family members were  initially faced with prolonged separation from their babies as the pandemic emerged. Data analyses and intelligent planning eventually led to dynamic policies that offered balance and supportive care to the neonates (our brothers and sisters), their families and caregivers.

We consistently and enthusiastically search for resources that target and provide effective treatment for preverbal trauma survivors (a large part of our population). Resources for identifying, acknowledging, and providing effective treatment for preemie preverbal trauma survivors is currently dim. CALL TO ACTION 2021: We ask that the Global Healthcare Community increase attention and research while cultivating effective treatment options towards the mental health and well-being specific to our pre-verbal PTSD Warrior needs in 2021, with increased necessity!

For the families and community members: your stories, voices and engagement is vital to the progression towards health for our entire Community.  Warriors: seek,  with compassion, your preterm birth stories from family members. The process of sharing the experience may be healing for you as well as for your family members.

To our courageous healthcare workers, we hope that 2021 will bring about improved systems of logistical, technological, social, and resource support to empower you in the work you do each day to support the lives of those that you care for.  Most of all, we Thank You for your service and wish for you abundant health and healing.

WARRIORS: Let’s take on this New Year with deep intentions to make it a Great one!

Feel The Rhythm with Shama Beckford and Ivah Wilmot

Feb 23, 2018   SURFER

They say you can’t teach style. They’re right, of course, but oh do we wish they were wrong. If silky surf aesthetics could be easily taught, then Jamaican standouts Shama Beckford and Ivah Wilmot would be welcome in front of the class. In this edit, we get a closer look at the approaches of these two magnetic surfers, whether their laying down buttery lines at Lower Trestles or over concrete in a skatepark. Beckford and Wilmot bring a unique flair to everything they do both in and out of the water, which surfing can always use more of. Keep an eye on these two up-and-coming Caribbean islanders, and be sure to take notes.

Cures Act, Climate, Breast is Best


Indonesia, officially the Republic of Indonesia  is a country in Southeast Asia and Oceania, between the Indian and Pacific oceans. It consists of more than seventeen thousand islands, including SumatraJavaBorneo (Kalimantan), Sulawesi, and New Guinea (Papua). Indonesia is the world’s largest island country and the 14th-largest country by land area, at 1,904,569 square kilometres (735,358 square miles). With over 267 million people, it is the world’s 4th-most-populous country as well as the most-populous Muslim-majority country. Java, the world’s most-populous island, is home to more than half of the country’s population.

The sovereign state is a presidentialconstitutional republic with an elected legislature. It has 34 provinces, of which five have special status. The country’s capital, Jakarta, is the second-most populous urban area in the world. The country shares land borders with Papua New GuineaEast Timor, and the eastern part of Malaysia. Other neighbouring countries include SingaporeVietnam, the PhilippinesAustraliaPalau, and India‘s Andaman and Nicobar Islands. Despite its large population and densely populated regions, Indonesia has vast areas of wilderness that support one of the world’s highest levels of biodiversity.

Government expenditure on HEALTHCARE is about 3.3% of GDP in 2016. As part of an attempt to achieve universal health care, the government launched the National Health Insurance (Jaminan Kesehatan Nasional, JKN) in 2014 that provides healthcare to citizens. They include coverage for a range of services from the public and also private firms that have opted to join the scheme. In recent decades, there have been remarkable improvements such as rising life expectancy (from 62.3 years in 1990 to 71.7 years in 2019) and declining child mortality (from 84 deaths per 1,000 births in 1990 to 25.4 deaths in 2017).  Nevertheless, Indonesia continues to face challenges that include maternal and child health, low air quality, malnutrition, high rate of smoking, and infectious diseases.



Warmer world linked to poor pregnancy results: Study

MARLOWE HOOD    AGENCE FRANCE-PRESSE  Paris, France  /  Wed, November 4, 2020

Women exposed to high temperatures and heatwaves during pregnancy are more likely to have premature or stillborn babies, researchers said Wednesday.

Such outcomes — closely linked to poverty, especially in the tropics — will likely increase with global warming, especially during more frequent and intense heatwaves, they reported in BMJ, a medical journal.

Even small increases “could have a major impact on public health as exposure to high temperatures is common and escalating,” the study concluded.

Each year, 15 million babies are born premature, the leading cause of death among children under five, according to the World Health Organization (WHO). 

That mortality is concentrated in the developing world, especially Africa. 

To quantify the impact of higher heat on pregnancy outcomes, an international team of researchers led by Matthew Chersich from Wits Reproductive Health and HIV Institute in Johannesburg looked at 70 peer-reviewed studies of 27 rich, poor and middle-income nations.

Of the 47 studies that concerned preterm births, 40 reported they were more common at higher temperatures.

The odds of a preterm birth rose, on average, by five percent per one degree Celsius (1C) increase, and by 16 percent during heatwave days, according to the new findings.

Global warming has seen Earth’s average temperature rise by 1C over the last century, with greater increases over large land masses.

The number of exceptionally hot days are expected to increase most in the tropics, according to the UN’s climate science advisory panel, the IPCC.

‘High risk’ for heat

Extreme heatwaves — made more dangerous by high humidity — are projected to emerge earliest in these regions as well.

Limiting global warming to 1.5C instead of 2C — goals consistent with the Paris Agreement — would mean around 420 million fewer people frequently exposed to extreme heatwaves, the IPCC said in a 2018 report.

The new study also found that stillbirths increased by five percent per 1C increase in temperature, with the link most pronounced in the last few weeks of pregnancy.

The impact of warmer days and heatwaves on low birth weight, which is associated with a host of health problems later in life, was smaller, but still significant, the researchers said.

As expected, adverse pregnancy outcomes associated with rising temperatures were strongest among poorer women.

Because other factors such as pollution might play a role in stillbirths and premature babies, the role of warmer temperatures is hard to pin down, the researchers acknowledged.

Nonetheless, the findings are strong enough to suggest that pregnant women “merit a place alongside the groups typically considered as at ‘high risk’ for heat-related conditions,” they concluded.

More research and targeted health policies should be a high priority, they added.


Kat and I study global health issues and developments on an ongoing basis.  Based on the increasing and well documented climate change and global warming challenges that make national “borders” irrelevant in many ways,  and challenge the global community, much like the pandemic, to create ways of collaborating for global and good and even survival,  and considering the overwhelming scientific evidence that climate change and global warming pose a real and present danger, we call for global action and proactive changes. Our Neonatal Womb Warrior/Preterm Birth Community and our global community at large can and with increased necessity, must create progressive people/planet-oriented changes in order to provide a future for our children and our children’s children. 

The technology is here. The people are ready. Scientists have spoken. Progressive businesses are stepping forward. Now we need governments to take climate action!” – WWF International 

You must not gamble your children’s future on the flip of a coin. Instead, you mustunite behind the science. You must take action. You must do the impossible. Because giving up can never ever be an option- Greta Thunberg 

Few challenges facing America and the world are more urgent than combating climate change. The science is beyond dispute and the facts are clearBarack Obama

Check Out:

Maternal smoking and preterm birth: An unresolved health challenge

Sarah J. Stock , Linda Bauld – Published: September 14, 2020

Maternal exposure to tobacco smoke in pregnancy is a key modifiable risk factor for baby death and disability. Smoking is linked to preterm birth (birth before 37 weeks’ gestation), stillbirth, and neonatal mortality, as well as to miscarriage, fetal growth restriction, and infant morbidity . The worldwide prevalence of maternal smoking in pregnancy is 2%, with Europe having the highest prevalence at 8% . Although rates of maternal smoking in pregnancy are decreasing in many high-income countries , this decline is slower among women of lower socioeconomic status, contributing to health inequalities . In certain low- and middle-income countries, maternal smoking rates are static or rising .

In this issue of PLOS Medicine, two studies provide new insights into the implications of exposure to tobacco smoke in pregnancy for perinatal and childhood outcomes. Buyun Liu and colleagues studied preterm birth in relation to timing and intensity of maternal smoking in more than 25 million singleton mother–infant pairs using United States birth certificate data . The size of this “mega-cohort” allowed exploration of whether incremental increases of 1–2 cigarettes per day were associated with increases in preterm birth. Compared to nonsmokers, any maternal smoking during the three months prior to conception and continued into the first trimester of pregnancy was associated with increased preterm birth (odds ratio [OR] 1.17 [95% CI 1.16–1.19]). This risk increased if maternal smoking continued during the second trimester (OR 1.45 [1.45–1.46]). Women who quit smoking during pregnancy still had an increased risk of preterm birth, even if levels of smoking were low and they stopped early in pregnancy. For example, compared to nonsmokers, women who smoked 1–2 cigarettes a day and quit in the first trimester had an increased risk of preterm birth (OR 1.13 [1.10–1.16]). In contrast, if they quit smoking in the three months before pregnancy, even heavy smokers of 20 or more cigarettes per day had a similar risk of preterm birth to that of nonsmokers (OR 1.01 [0.99–1.03]). The authors conclude that there is no safe level for cigarette smoking in pregnancy.

Elise Philips and colleagues found a different pattern of smoking and preterm birth in an individual participant data meta-analysis of 220,000 births from 28 cohort studies, in which smoking status was determined from questionnaires . Compared to nonsmokers, mothers who smoked in the third trimester of pregnancy were at increased risk of preterm birth. However, the effect size was lower than in Liu’s study , with an OR of 1.08 (1.02–1.15). In contrast to Liu’s findings , smoking confined to the first trimester of pregnancy was not associated with preterm birth when compared to nonsmokers (OR 1.03 [0.85–1.25]). Furthermore, no dose response was seen with increasing or decreasing cigarette intake between first and third trimesters.

Philips and colleagues additionally explored the relationship between smoking and being small for gestational age (SGA) at birth and overweight in childhood . Whereas maternal first trimester smoking was associated with childhood overweight (OR 1.17 [1.02–1.35]) but not SGA (OR 0.99 [0.85–1.15]), smoking in later pregnancy was associated with both childhood overweight (OR 1.42 [1.35–1.48]) and SGA (OR 2.15 [2.07–2.23]). Reducing the number of cigarettes from first to third trimester lowered the risks of delivering SGA infants, but risks were still higher compared with nonsmoking mothers. Mothers who increased the number of cigarettes from first to third trimester had increased risk of an SGA infant compared with those who did not.

Several factors may explain the different patterns of association between smoking and preterm birth seen in the two studies. First, at 4.7%, the population risk of preterm birth in the Philips study, in which most of the cohorts were European , was less than half that of Liu’s US-based study (9.3%). Second, the sample size for analyses of cessation, increasing, or decreasing cigarettes smoked between first and third trimester was much smaller in Philips’ study and, at only 1% of the entire cohort (around 2,200 women with 120 preterm births), may not be representative at population level. The low numbers resulted from only around half of the included cohorts having data on both early and late pregnancy cigarette consumption. Third, in the Philips study, smokers who quit prepregnancy were included as nonsmokers, whereas in the Liu study, prepregnancy smokers were considered separately. Finally, cohorts in the Philips meta-analysis collected late pregnancy smoking data in the third trimester . This can be problematic, as most preterm births occur in the third trimester. Liu and colleagues restricted analysis to second-trimester smoking to avoid this.

Despite their differences, both studies add compelling evidence to the idea that there is a dose–response relationship between smoking in pregnancy and preterm birth. The more and the longer women smoke in pregnancy, the higher the associated morbidity. There will also be higher numbers of babies who die, as preterm birth is the major cause of neonatal mortality, and SGA is strongly associated with stillbirth. This message needs to be clearly conveyed to pregnant women and health professionals so that the relevance of surrogate health outcomes is not misinterpreted. Having a “small baby” may not be seen as a bad thing or even, erroneously, be considered advantageous for birth. Health messages should also be directed to wider audiences than just pregnant women and those that care for them. As beliefs about smoking are strongly influenced by family, friends, and peers, risk messages from social networks are frequently more effective than those delivered by health professionals .

Pregnancy is a time when interventions for smoking cessation might be most effective. It is purported that women are more likely to quit smoking in pregnancy than at any other period in their lives . There are certainly opportunities for improvement, with three-quarters of prepregnancy smokers continuing to smoke in early pregnancy and 85% of those that smoke in early pregnancy continuing into late pregnancy . Behavioral support for smoking cessation is recommended as part of antenatal care in many countries and endorsed by guidance from WHO. This should be delivered by staff who have received appropriate training but delivered in a flexible way, tailored to the needs of pregnant women. Some countries combine behavioral support with nicotine replacement therapy, which has been shown to be effective in the general adult population. However, single-product nicotine replacement therapy has not been shown to be effective during pregnancy , and research is now ongoing to explore this further .

Evidence from ongoing trials of promising adjuvant approaches, such as electronic cigarettes and financial incentives , may be key to improving quit rates but will require political will to implement if effective. There are, however, enormous potential benefits from reducing smoking in pregnancy, both in terms of women’s and children’s health and in savings to health services. In the United Kingdom alone, maternal and infant healthcare costs attributed to smoking are estimated at £20–£87.5 million per annum . A concerted effort across multiple sectors is required to prevent this harm and protect the health of future generations.

Citation: Stock SJ, Bauld L (2020) Maternal smoking and preterm birth: An unresolved health challenge. PLoS Med 17(9): e1003386.


Global burden of preterm birth

Salimah R. Walani   First published: 10 June 2020


Preterm birth is a live birth that occurs before 37 completed weeks of pregnancy. Approximately 15 million babies are born preterm annually worldwide, indicating a global preterm birth rate of about 11%. With 1 million children dying due to preterm birth before the age of 5 years, preterm birth is the leading cause of death among children, accounting for 18% of all deaths among children aged under 5 years and as much as 35% of all deaths among newborns (aged <28 days). There are significant variations in preterm birth rates and mortality between countries and within countries. However, the burden of preterm birth is particularly high in low‐ and middle‐income countries, especially those in Southeast Asia and sub‐Saharan Africa. Preterm birth rates are rising in many countries. The issue of preterm birth is of paramount significance for achieving United Nations Sustainable Development Goal 3 target #3.2, which aims to end all preventable deaths of newborns and children aged under 5 years by 2030.


According to WHO, preterm birth is a live birth that occurs before 37 completed weeks of pregnancy. Preterm birth is further classified as extremely preterm (<28 weeks), very preterm (28 to <32 weeks), and moderate (32 to <34 weeks) to late preterm (34 to <37 weeks). Preterm birth may occur spontaneously or may be initiated by a provider through induction of labor or elective caesarean delivery which may or may not be medically indicated. A baby born after 37 weeks of pregnancy is not considered preterm; however, it is recommended that unless medically indicated a pregnancy should be allowed to continue until 39 completed weeks to ensure optimal health outcomes of the baby.

The true prevalence of preterm birth is not known due to lack of actual data in many countries, especially those in lower‐income categories. Estimates of preterm births for 184 countries using 2010 data showed that approximately 15 million babies are born preterm annually worldwide, indicating a global preterm birth rate of about 11%, ranging from 4% in Belarus to 18% in Malawi. Preterm birth rates are rising in most countries. A recent study examining the trends of preterm birth rates found that the global preterm birth rate rose from 9.8% in 2000 to 10.6% in 2014.

Preterm birth is the leading cause of childhood mortality. Approximately 1 million babies die every year due to complications of preterm birth. The issue of preterm birth is of paramount significance for achieving United Nations Sustainable Development Goal 3 target #3.2, which aims to end all preventable deaths of newborns and children aged under 5 years by 2030. Understanding the global burden of preterm birth and disparities in prevalence and mortality of this condition is critical for advocacy and allocation of resources for surveillance, research, prevention, and care related to preterm birth.


Of the 15 million preterm births every year, over 84% occur at 32–36 weeks of gestation. Only about 5% fall into the extremely preterm (<28 weeks) category and the other 10% are born at 28–32 weeks of gestation. Six countries—India, China, Nigeria, Pakistan, Indonesia, and the United States—account for 50% (~7.4 million) of the total preterm births in the world.

There are major variations in preterm birth rates by geographic region and level of income of a country. When countries are grouped by their World Bank income categories, it is found that approximately 90% of all preterm births occur in low‐ and middle‐income countries. The average preterm birth rate for low‐income countries is close to 12%, compared to 9.4% and 9.3% for middle‐ and high‐income countries, respectively. However, there are outliers. For example, Ecuador, a middle‐income county, has a preterm birth rate of 5%, which is lower than in many high‐income countries such as Germany (9.2%), Canada (7.8%), and Israel (8%).

Disparities in preterm birth rates by geographic regions are also very stark. Systematic review and modelling analysis from 2014 data showed that 80% of preterm births occur in countries in sub‐Saharan Africa and South Asia.3 However, there are remarkable variations in the rates within each region. For example, according to one estimate in sub‐Saharan Africa, the preterm birth rate in Uganda of only 6.6% is lower than that of many high‐income countries, including the United States, while Uganda’s neighboring country Tanzania has an estimated preterm birth rate of 16.6%. Within‐region differences are also evident in Europe, where preterm births are in the range of 5%–10%, despite similar development and healthcare infrastructures.

Disparities in preterm birth rates based on maternal education, race, and ethnic origin are also evident in some countries and regions. In the United States, for example, in 2016 the preterm birth rate was 14% among African‐American women compared to 9% among white women. An analysis of preterm birth rates across 12 European countries showed that preterm birth rates were generally higher among women with lower levels of education. In six of the twelve countries, these variations were statistically significant. The differences in preterm birth rates by maternal education were most significant in the Netherlands (P=0.001) and Norway (P=0.009). In the Netherlands, the preterm birth rate among women with a low level of education was 7.0%, compared to 4.9% in those with a high level of education. In Norway, the rates were 9.7% in women with a low level of education and 5.9% in women with a high level of education.

The causes of variations in preterm birth rates among countries and in groups within a country or a region are mainly unknown; however, risk factors associated with preterm birth are discussed in a study by Cobo.


Of the 15 million babies born preterm every year worldwide, more than 1 million die before the age of 5 years due to preterm birth and its complications. There has been an overall decline in deaths in children aged under 5 years in the last two decades due to reductions in mortality related to infectious diseases such as pneumonia, diarrhea, malaria, and measles. As a result, complications related to preterm births are now the leading cause of death among children, accounting for 18% of all deaths in children aged under 5 years. The burden of preterm birth is particularly profound during the first 28 days of life (neonatal period), accounting for 35% of all neonatal deaths globally. As with the prevalence of preterm birth, there are huge variations among countries and regions in preterm birth mortality rates and absolute number of deaths due to complications related to preterm births. For example, preterm birth mortality accounts for close to 28% of all deaths in children aged under 5 years in North America and in Western Europe compared to approximately 13% in sub‐Saharan Africa and 25.5% in South Asia. However, the majority of all deaths due to preterm birth occur in sub‐Saharan African and South Asia. India, a country in South Asia, alone accounts for 330 000 (~33%) of the total global deaths due to preterm births. The high absolute number of deaths related to preterm births in some regions is partly due to their high overall rates of child mortality. In 2016, sub‐Saharan Africa had an average under‐five mortality rate of 79 deaths per 1000 live births compared to only 6 per 1000 live births in North America and Europe. Variations in survival gap is another important issue to be considered in relation to preterm birth mortality. In high‐income countries, where almost all births are attended by skilled staff, 50% of the babies born as early as 24 weeks survive, whereas in a low‐income country, even a baby born at 32 weeks has only a 50% chance of survival due to lack of available resources and/or low quality of specialized care needed to improve the survival of a baby born too soon.


Preterm birth is a major healthcare problem affecting 15 million births every year. It is the leading cause of mortality among children aged under 5 years, with a majority of deaths due to preterm birth occurring in the neonatal period.

Much attention has been devoted to the prevention of preterm birth through research and advocacy by organizations such as March of Dimes. However, there is substantial evidence that preterm birth rates are rising globally and in most countries. An analysis of high‐quality data from 38 countries, comparisons between 2000 and 2014, showed that preterm birth rates increased in 26 countries. Although due to scarcity of good‐quality surveillance and registry‐based data, the published prevalence rates from Asian and African countries must be interpreted with caution, the reports of disparities in preterm birth rates and mortality among regions and countries consistently show that the majority of preterm births and related mortality occurs in low‐ and middle‐income countries and the burden is particularly high in South Asia and sub‐Saharan Africa.



The project was conceived by friends and artists Iris Eichenberg and Jimena Ríos. Its aim is straightforward: for artists, jewelers, students, and professionals to craft medals that will honor the service and sacrifice of health workers. Infused with the gratitude of the ex-voto and the tribute of a medal, these hands have been made and collected since April 2020.

The design is drawn from a historical argentinian ex-voto. Authorship is secondary the medals are not about the maker, but about the receiver. To underscore the unity of this collaborative effort, participants copy a template of the hand, meant to be simple enough for all skill levels, and easily replicated into whatever metal is available. This singular hand design creates a collective voice, reinforcing the shared gratitude that is the project’s mission.


Our current battle with coronavirus is fought with an enemy invisible to the naked eye, its specter made all the more ominous by its intangibility—a danger you cannot see. By contrast, metal, especially jewelry, is known by its weight and shape against the body. When formed into a medal, it provides a physical testimony for both the unseen virus and invisible bravery of those who have fought it. Hands themselves have been powerfully present in this battle. They are symbols not only of how our bodies have become weapons to be washed, sanitized, and gloved, but also of their innate power to heal and to connect. For around 3000 jewelers that join the project, of course, they are the language of skill and expression embodied.



Medical Legal Forum: Simplified, Real-time, Free access to the Complete Medical Record in the NICU is Coming with Implementation of the 21st Century Cures Act

© N.Embleton Jonathan Fanaroff, MD, JD, Robert Turbow, MD, JD Gilbert Martin, M

Parents of NICU patients have had the right to review their child’s medical records for many years, but in the past such efforts required trips to the medical records department in the sub-basement, long delays, and the significant costs of copying the records. In recent years with the shift to electronic medical records and the development of patient portals, families have had an easier time accessing some, but not all, medical records. This is about to change with the implementation of a rule from the Federal Office of the National Coordinator for Health IT requiring health systems to provide greater access to patient health records.

The rule is part of the implementation of the 21st Century Cures Act passed by Congress in 2016. The “Cures Act” was originally designed to accelerate medical product development and to bring new innovations to patients who need these products faster. The program also allowed patients to access all the health information in their electronic medical records without charge by their healthcare provider. The original deadline for the rule, November 2, 2020, was moved to April 5, 2021, due to the coronavirus pandemic. Patients will have access to the following types of clinical notes:

• Consultation notes • Discharge summary notes • History and physical • Imaging narratives •   

Laboratory report narratives • Pathology report narratives • Procedure notes • Progress notes

There are limited exceptions. These include certain psychotherapy notes by mental health professionals as well as information gathered for use in civil or criminal proceedings. A note can also be protected if it places the patient in potential danger, such as a discussion about domestic violence when the abuser can access the information. Additionally, certain health information for adolescents may be protected from access by the parents. It will be important to work with hospital legal and compliance experts to determine the specific application of the rule at your institution.

 An important second aspect of the rule is penalties for anti-competitive behavior and information blocking that impedes the exchange of medical information. For example, some health IT vendors had a “gag clause” prohibiting the sharing of screenshots. These non-disclosure clauses hinder efforts to improve safety and openly discuss safety concerns.

 The destruction of ‘data silos’ and mandated interoperability is designed to improve care and decrease costs by allowing patients to control their electronic health information, download the information to their smartphones, and examine the data with the apps of their choice. For years there has been an issue of who ‘owns’ patient health data, and this question has clearly been answered in favor of patients.

What impact will free, easy access to the medical record have in the NICU? Certainly, some additional education may be necessary. For example, many laboratory ‘normal’ values reflect data for adults, not neonates. Additionally, very sensitive maternal information, such as herpes status and pregnancy history, is part of the neonatal medical record as well. Ultimately the change will likely be very positive, as with most improvements in transparency. Indeed, while a busy NICU team is caring for multiple patients, a family is focused on just one patient and may catch and prevent errors of omission. Let us not forget that in 2013, the NICU Parent Network created the “NICU Parent’s Bill of Rights.” These ten statements are listed from the perspective of the NICU baby. An example of one statement is, “my parents are my voice and my best advocates; therefore, hospital policies, including visiting hours and rounding, should be as inclusive as possible.

The Cures Act “Final Rule,” which was issued on October 29, 2020, provides our healthcare system additional flexibility and clarifies privacy protections. Healthcare workers face quite a challenge. They must try to take the safest possible care of patients while working in extraordinarily complex systems. The High-Reliability theory offers insight into this dilemma. Increasing reliability has the potential to not only improve outcomes but also to decrease a hospital’s liability.


Breastmilk Harbors Antibodies to SARS-CoV-2

An abundance of immunoglobulin antibodies, and a paucity of viral RNA, in breastmilk offer evidence that women can safely continue breastfeeding during the pandemic.

Milk from lactating moms may hold potent antibodies to counter SARS-CoV-2 infections, according to a new study of 15 women. All of the samples from women who had recovered from COVID-19 and who were breastfeeding babies at the time had antibodies reactive to the virus’s spike protein, researchers report in the November issue of iScience

Detecting antibodies against the virus in breastmilk indicates that mothers could be passing viral immunity to their babies. Women can “feel pretty comfortable breastfeeding” during the pandemic, Christina Chambers, a perinatal epidemiologist at the University of California, San Diego, who not involved in the new study, tells The Scientist.

To date, there’s no evidence that a mother can transmit SARS-CoV-2 to her baby through breastmilk, Chambers says. She and others have tested breastmilk for SARS-CoV-2 RNA and found a few positive results, but no live virus. Her latest research also suggests that donor milk is safe for babies’ consumption, too, though she hasn’t assessed antibodies in donor milk banks she works with yet.

I think the potential is really great, if we get past this taboo that it’s breastmilk.

—Rebecca Powell, Icahn School of Medicine at Mount Sinai

Antibodies in breastmilk may be useful for more than protecting nursing infants from the virus. Antibodies extracted from milk—as opposed to the current practice of using convalescent serum—could also serve as a therapeutic for COVID-19. However, “people question that this is something that could really happen,” says study coauthor Rebecca Powell, an immunologist at the Icahn School of Medicine at Mount Sinai in New York City. Because there isn’t a wider understanding of the immune benefits of breastmilk, she says, the concept has not caught on in antiviral drug development.

Detecting breastmilk antibodies

Powell has been investigating human milk immunology for the past four years and was analyzing how the seasonal flu vaccine prompted an immune response in breastmilk when the coronavirus pandemic spread to New York City earlier this year. Switching to study the SARS-CoV-2 immune response in breastmilk was “a no brainer,” she says. “There’s so many unanswered questions in general about milk immunology, but to be able to study it with a novel pathogen was really important.” 

By early April, she and her colleagues had received approval to begin collecting milk samples from lactating mothers who had recovered from COVID-19. The researchers collected samples from eight women who had a SARS-CoV-2–positive PCR test and seven who had suspected cases of the disease but were not tested; all 15 were lactating at the time. The team then compared the samples to ones from different lactating mothers amassed before the pandemic began, first assessing them for the presence of immunoglobulin A (IgA) antibodies using an enzyme-linked immunosorbent assay (ELISA) and then checking the ability of any antibodies found to bind to the SARS-CoV-2 spike protein.

All the of samples from the women who had recovered from COVID-19 had specific SARS-CoV-2 binding activity, while the pre-pandemic samples had low levels of nonspecific or cross-reactive activity, the researchers report. They next tested the antibodies’ response to the receptor binding domain of the SARS-CoV-2 spike protein, and found that 12 out of 15 of the samples from previously-infected donors showed significant IgA binding activity. Some of those samples also included other reactive antibodies such as immunoglobulin G and immunoglobulin M. Compared with the controls, it was IgA and IgG levels that were the highest. 

The results align with a study published in September in the Journal of Perinatology that also detected high levels of IgA and some IgG and IgM that were reactive to the S1 and S2 subunits of the SARS-CoV-2 spike protein in a majority of milk samples collected during the pandemic. None of the breastmilk tested positive for SARS-CoV-2 with a PCR test, suggesting none of the mothers were infected at the time of sample collection. 

There was also no documentation of whether the 41 women who donated samples had ever been infected with the virus, notes study coauthor Veronique Demers-Mathieu, an immunologist at Medolac Laboratories in Boulder City, Nevada, so it’s unclear if these antibodies were the result of SARS-CoV-2 or another viral infection.

The team did collect general health information on the donors of the milk samples and found that S1 and S2 SARS-CoV-2–reactive IgG levels were higher in milk from women who had had symptoms of a viral respiratory infection during the last year than in milk from women who hadn’t had any symptoms of infection. IgG abundance was also higher in the samples from 2020 than from those taken in 2018, long before the pandemic started. The IgA and IgM antibody reactivity, however, didn’t appear to be specific to SARS-CoV-2 S1 and S2 and did not differ between the 2020 samples and the 2018 samples, meaning these responses could be the result of cross-reactivity from antibodies generated after exposure to other viruses. That suggests the antibodies secreted in breastmilk provide a broad immunity to breastfeeding infants, Demers-Mathieu says.

Benefits of breastmilk versus blood antibodies

One important feature of these antibodies, whether specific to the virus or not, is that they are secretory antibodies, Powell notes. The B cells that secrete antibodies into milk originate from the mucosal immune system in the mother’s small intestine. Those B cells travel through the blood to the mammary glands and secrete IgA that’s then shuttled from the mammary tissue to the milk via a transporter protein. Those proteins, called secretory components, leave pieces of themselves on the antibodies, wrapping around them and protecting them from being degraded in the infant mouth and gut. “Secretory antibody is found not only in milk, but in saliva and all other mucosal secretions,” Powell explains. “It’s not unique to milk, but it is not what you find in the blood.”

That difference could give breastmilk-derived antibodies an advantage over blood-based ones as far as therapeutic options go, she explains. Antibodies such as IgG that are extracted from serum and transfused into the blood of a sick person travel throughout the body and might not go where they are needed. But secretory antibodies, such as IgA from breastmilk, could be extracted and then inhaled into the respiratory tract—just where those antibodies are needed in COVID-19. Because of the protective secretory component they have, these antibodies can endure in the mucosa and target the virus, Powell explains.

“What we are finding in the milk is unique compared to what many people have already studied in the blood in terms of antibody response,” she says. Research suggests that blood-derived antibodies can last months. Secretory antibodies in breastmilk might last longer, Powell’s most recent data indicate, and that means there could be a longer window to collect antibodies from lactating donors after they’ve recovered from COVID-19.

Neither Demers-Mathieu’s nor Powell’s studies tested whether the breastmilk antibodies could neutralize SARS-CoV-2, which is a next step in both teams’ research. Powell has early results suggesting the breastmilk antibodies do neutralize the virus, and a company called Lactiga has partnered with her to continue developing the idea of extracting antibodies from breastmilk to counter COVID-19. 

“I think the potential is really great,” says Powell, “if we get past this taboo that it’s breastmilk.”


Climate pregnancy threat: Study shows expectant mothers are negatively affected by climate change

Jun 24, 2020
New research shows climate change has an adverse effect on pregnancy outcomes, with African American mums at higher risk.

Outcomes of the Neonatal Trial of High-Frequency Oscillation at 16 to 19 Years

August 13, 2020           N Engl J Med 2020; 383:689-691

To The Editor:

We previously reported superior lung function and teacher ratings of school performance in young persons who had received high-frequency oscillatory ventilation (HFOV) as neonates. In a multicenter, randomized trial, HFOV was compared with conventional ventilation that commenced within an hour of birth in infants born before 29 weeks of gestation. We hypothesized that the positive outcomes of HFOV would persist after the onset of puberty and now report the results of a reassessment of this cohort at the ages of 16 to 19 years.

Comprehensive lung-function assessments were undertaken and questionnaires completed regarding respiratory health, health-related quality of life, and lung function (see the Supplementary Appendix, available with the full text of this letter at As in our previous assessment of children 11 to 14 years of age, the primary outcome was forced expiratory flow at 75% of the expired vital capacity (FEF75). Because some children were unable to complete all the lung-function tests, we used multiple imputation with chained equations to impute missing data.

Table 1. Lung-Function Test Results According to Ventilation Group.

A total of 161 young people were evaluated, and 159 underwent lung-function assessment (Fig. S1 in the Supplementary Appendix). Baseline characteristics were similar among those who were assessed and those who were not (Table S1). Participant characteristics did not differ significantly between the ventilation groups when assessed as infants or at 16 to 19 years of age (Table S2). The results with respect to the primary outcome did not differ significantly between the ventilation groups at 16 to 19 years of age: mean (±SD) FEF75 z score of −1.07±1.21 with conventional ventilation and −0.94±1.33 with HFOV (adjusted difference in mean z scores, 0.19; 95% confidence interval [CI], −0.18 to 0.56) (Table 1 and Table S3). These differences remained nonsignificant after multiple imputation (P=0.11) (Table S4). The majority of the mean FEF75 results reported when participants were 16 to 19 years of age were below the lower limit of normal (59% with HFOV and 65% with conventional ventilation). Other measures of lung function also did not differ significantly between the ventilation groups (Table 1 and Table S3). However, 15% of participants in the HFOV group received a diagnosis of asthma, whereas only 3% of participants in the conventional ventilation group had such a diagnosis (adjusted difference, 11 percentage points; 95% CI, 3 to 23). Similarly, inhalers were prescribed for asthma treatment in 13% of those in the HFOV group as compared with 3% of those in the conventional ventilation group (adjusted difference, 11 percentage points; 95% CI, 2 to 21) (Table S5).

Our follow-up study of infants who had been enrolled in a randomized trial in which two types of ventilation were prescribed showed that the use of HFOV in the neonatal period was not associated with superior respiratory or functional outcomes at 16 to 19 years of age. Longer-term follow-up is required to determine whether there will be premature onset of chronic pulmonary disease in this vulnerable population.

Christopher Harris, M.R.C.P.C.H.; Alessandra Bisquera, M.Sc.: King’s College London, London, United Kingdom

Alan Lunt, Ph.D.; Imperial College, London, United Kingdom; Janet L. Peacock, Ph.D.:Dartmouth College, Hanover, NH;

Anne Greenough, M.D.: King’s College London, London, United Kingdom-

Supported by the National Institute for Health Research Biomedical Research Centre at Guy’s and St. Thomas’ National Health Service Foundation Trust and King’s College London.



Optimal practice in neonatal parenteral nutrition: The role of quality improvement and risk management in providing high-quality parenteral nutrition

POSTED ON 06 OCTOBER 2020                                  

An interview with Professor Nicholas Embleton

In some infants, parenteral nutrition is the only way to provide the necessary nutrients for days or weeks. Being an invasive procedure, it also carries potential risks and therefore, requires certain infrastructure and thorough risk management paired with continuous quality assessment in order to ensure high quality of parenteral nutrition in daily practice. In this interview, Professor Nicholas Embleton from The Newcastle-upon-Tyne hospital & Newcastle University shares his view and experiences on means of quality improvement and how a blame-free culture can contribute to efficient risk management.

Question 1: Quality assessment and risk management rely on thorough and transparent reporting practices. Could you elaborate what in general makes the Briefing in a minute (BIM) an efficient method in Quality Improvement (QI) and Risk Management (RM)?

The great thing about BIM is that it is very quick to do, and you can do it repeatedly. We do every day after our morning teaching session, but you could do at every shift change i.e. twice per day. By the end of the week, you might have heard the same message 5 times, but then we have some fun, and we make a quiz “who can remember what the 4 items on BIM were this week?”. It allows us to communicate messages about QI or RM quickly.

Question 2: Concerning parenteral nutrition, which properties of the BIM are particularly advantageous in terms of quality improvement and risk management?

The ability to get a simple message communicated quickly – for example, we had an issue with placement of the filter in relation to the lipid infusion line. We realised some staff were placing the filter at the wrong location, which was leading to alarms. We were able to share that update really quickly. Although we meet as a whole team, shift handover happens separately for medical and nursing teams: the roles and responsibilities also differ. This means we have separate BIM for nursing and medical teams. The items discussed on BIM can be the same or different which allows us to ‘target’ different parts of a complex communication system.

Question 3: Can you say something about the implementation process of the BIM into daily work routines? Did it require training, for instance, to develop a routine in using simple, concise messages for the reporting?

We just started using it a few years ago, to be honest, I am not sure who had the original idea, but quite probably another hospital or department. It doesn’t require any training to use. You just need to give one person the responsibility of coordinating what will be the 3-4 items for that week. You can agree on those items at a departmental meeting, or you send an email to the senior team asking for specific items for BIM in that week. We write the items out and keep them in a folder – if you want you can look back at the last several weeks of BIM items. It is important that you don’t try and cover too much, so 3-4 items are about right. For more complex issues you need a different mechanism. So BIM cannot be used for teaching – it is not really an interactive event. But you could use BIM to say ‘we are using new filters for lipid; make sure you attend the training session before you start to use them’.

Question 4: To establish and to maintain a well-functioning risk management and reporting system, a blame-free culture is crucial. Yet, in healthcare, errors can range from minor mistakes to errors with tremendous consequences. How do you maintain and encourage open communication within your teams?

Establishing trust in the whole team is essential. Even when you know you didn’t mean to make the mistake, and even when it is not serious you can still feel bad. So developing a supportive team is crucial. We need to learn to look after our colleagues and stick together. That is all about being practical and recognising the real world: we are all human. It is not about ‘sticking together’ to hide mistakes away. At the end of the day, the motivation for working on a NICU is to make things better for the babies, so everyone wants to be involved in QI and RM. It is appropriate sometimes to maintain anonymity – if you made a ‘silly’ mistake, you don’t want to be ‘named and shamed’ at a large meeting, so we try hard to always maintain anonymity. It’s also important to recognise that as senior members of the team, we are much more confident in many respects – both in terms of knowledge and experience, but also more confident knowing that our colleagues will support us. More junior members may feel more worried and less confident. I might not perceive a small intravenous extravasation as being important, but the junior nurse responsible may feel really upset. Developing a friendly, supportive team and looking after each other is essential to good QI and RM. We are proud to have a ‘learning culture’ in our NICU. We accept that sometimes things will not go to plan. We deal with that by being honest and supportive. Parents appreciate honesty and deserve to be listened to. Parents appreciate it when a senior healthcare professional says “I am sorry this happened to your baby”. Saying sorry does not mean we made a mistake, it means we empathise and acknowledge that what happened to the baby has caused upset or harm. TEAM is the most important aspects of QI and RM.

We thank Professor Embleton for this insightful interview.

Professor Nicholas Embleton is Consultant Neonatal Paediatrician at the Newcastle-upon-Tyne hospital and a member of the expert panel for the topic of neonatal parenteral nutrition.


Midwife on a motorbike in Indonesia | UNICEF

Unicef Aug,2,2018
Widyani has saved countless lives in her 22 years as a midwife, and now, with the help of a UNICEF-supported training project, Widyani and her team can save even more.


 Cannula With Long and Narrow Tubing vs Short Binasal Prongs for Noninvasive Ventilation in Preterm Infants

Noninferiority Randomized Clinical Trial

Ori Hochwald, MD1Arieh Riskin, MD2Liron Borenstein-Levin, MD1; et alIrit Shoris, RN2Gil P. Dinur, MD1Waseem Said, MD2Huda Jubran, MD1Yoav Littner, MD1Julie Haddad, MD1Malka Mor, RN1Fanny Timstut, RN1David Bader, MD2Amir Kugelman, MD1 Author Affiliations: JAMA Pediatr. Published online November 9, 2020. doi:10.1001/jamapediatrics.2020.3579  

Original Investigation   November 9, 2020

Key Points

Question  Is a cannula with long and narrow tubing inferior to short binasal prongs and masks in preterm infants who require nasal intermittent positive pressure ventilation?

Findings  In this noninferiority randomized clinical trial that included 166 preterm infants at 24 weeks’ to 33 weeks and 6 days’ gestation requiring nasal intermittent positive pressure ventilation, intubation within 72 hours occurred in 14% in the group using a cannula with long and narrow tubing and in 18% in the short binasal prongs and masks group (95% CI within the noninferiority margin). Moderate to severe nasal trauma was significantly less common in the group using cannulas with long and narrow tubing.

Meaning  Cannulas with long and narrow tubing were noninferior to short binasal prongs and masks in providing nasal intermittent positive pressure ventilation for preterm infants, while causing significantly less nasal trauma.


Importance  Use of cannulas with long and narrow tubing (CLNT) has gained increasing popularity for applying noninvasive respiratory support for newborn infants thanks to ease of use, perceived patient comfort, and reduced nasal trauma. However, there is concern that this interface delivers reduced and suboptimal support.

Objective  To determine whether CLNT is noninferior to short binasal prongs and masks (SPM) when providing nasal intermittent positive pressure ventilation (NIPPV) in preterm infants.

Design, Setting, and Participants  This randomized controlled, unblinded, prospective noninferiority trial was conducted between December 2017 and December 2019 at 2 tertiary neonatal intensive care units. Preterm infants born between 24 weeks’ and 33 weeks and 6 days’ gestation were eligible if presented with respiratory distress syndrome with the need for noninvasive ventilatory support either as initial treatment after birth or after first extubation. Analysis was performed by intention to treat.

Interventions  Randomization to NIPPV with either CLNT or SPM interface.

Main Outcomes and Measures  The primary outcome was the need for intubation within 72 hours after NIPPV treatment began. Noninferiority margin was defined as 15% or less absolute difference.

Results  Overall, 166 infants were included in this analysis, and infant characteristics and clinical condition (including fraction of inspired oxygen, Pco2, and pH level) were comparable at recruitment in the CLNT group (n = 83) and SPM group (n = 83). The mean (SD) gestational age was 29.3 (2.2) weeks vs 29.2 (2.5) weeks, and the mean (SD) birth weight was 1237 (414) g vs 1254 (448) g in the CLNT and SPM groups, respectively. Intubation within 72 hours occurred in 12 of 83 infants (14%) in the CLNT group and in 15 of 83 infants (18%) in the SPM group (risk difference, −3.6%; 95% CI, −14.8 to 7.6 [within the noninferiority margin], χ2 P = .53). Moderate to severe nasal trauma was significantly less common in the CLNT group compared with the SPM group (4 [5%] vs 14 [17%]; P = .01). There were no differences in other adverse events or in the course during hospitalization.

Conclusions and Relevance  In this study, CLNT was noninferior to SPM in providing NIPPV for preterm infants, while causing significantly less nasal trauma.


A Randomized Trial of Laryngeal Mask Airway in Neonatal Resuscitation

List of authors: Nicolas J. Pejovic, M.D., Ph.D., Susanna Myrnerts Höök, M.D., M.Med., Josaphat Byamugisha, M.D., Ph.D., Tobias Alfvén, M.D., Ph.D., Clare Lubulwa, M.D., M.Med., Francesco Cavallin, M.Sc., Jolly Nankunda, M.D., Ph.D., Hege Ersdal, M.D., Ph.D., Mats Blennow, M.D., Ph.D., Daniele Trevisanuto, M.D., and Thorkild Tylleskär, M.D., Ph.D.



Face-mask ventilation is the most common resuscitation method for birth asphyxia. Ventilation with a cuffless laryngeal mask airway (LMA) has potential advantages over face-mask ventilation during neonatal resuscitation in low-income countries, but whether the use of an LMA reduces mortality and morbidity among neonates with asphyxia is unknown.


In this phase 3, open-label, superiority trial in Uganda, we randomly assigned neonates who required positive-pressure ventilation to be treated by a midwife with an LMA or with face-mask ventilation. All the neonates had an estimated gestational age of at least 34 weeks, an estimated birth weight of at least 2000 g, or both. The primary outcome was a composite of death within 7 days or admission to the neonatal intensive care unit (NICU) with moderate-to-severe hypoxic–ischemic encephalopathy at day 1 to 5 during hospitalization.


Complete follow-up data were available for 99.2% of the neonates. A primary outcome event occurred in 154 of 563 neonates (27.4%) in the LMA group and 144 of 591 (24.4%) in the face-mask group (adjusted relative risk, 1.16; 95% confidence interval [CI], 0.90 to 1.51; P=0.26). Death within 7 days occurred in 21.7% of the neonates in the LMA group and 18.4% of those in the face-mask group (adjusted relative risk, 1.21; 95% CI, 0.90 to 1.63), and admission to the NICU with moderate-to-severe hypoxic–ischemic encephalopathy at day 1 to 5 during hospitalization occurred in 11.2% and 10.1%, respectively (adjusted relative risk, 1.27; 95% CI, 0.84 to 1.93). Findings were materially unchanged in a sensitivity analysis in which neonates with missing data were counted as having had a primary outcome event in the LMA group and as not having had such an event in the face-mask group. The frequency of predefined intervention-related adverse events was similar in the two groups.


In neonates with asphyxia, the LMA was safe in the hands of midwives but was not superior to face-mask ventilation with respect to early neonatal death and moderate-to-severe hypoxic–ischemic encephalopathy. (Funded by the Research Council of Norway and the Center for Intervention Science in Maternal and Child Health; NeoSupra number, NCT03133572. opens in new tab.)


This randomized trial of the effectiveness and safety of the LMA in neonatal resuscitation conducted by midwives in a low-income country showed the LMA to be safe in the hands of midwives but to confer no benefit over the face mask with respect to the composite of early neonatal death or moderate-to-severe hypoxic–ischemic encephalopathy. The cuffless LMA that was used in this trial is designed to provide an efficient seal to the larynx without the inflatable cuff used in conventional LMAs. Positioning is easy, and the risk of tissue compression or dislodgement is low. Thus, the device provides a useful alternative to the face mask and endotracheal intubation, especially in settings where skills in performing positive-pressure ventilation or intubation are insufficient. A study in Uganda that used mannequins showed that after a brief training, midwives could easily insert this LMA, and it was more effective than the face mask in establishing positive-pressure ventilation in a mannequin. A phase 2, randomized, controlled trial at the same site showed that midwives could perform resuscitation in neonates effectively and safely with the cuffless LMA.

Data from previous trials have suggested that LMA use results in shorter ventilation times than use of a face mask and may reduce the hypoxic–ischemic insult. Resuscitations in these studies were conducted by physicians or supervised midwives. In the present trial, midwives used the LMA unsupervised, and the insertion technique could have been suboptimal, which may have affected the effectiveness of the LMA. The observation of a higher likelihood of treatment failure in the face-mask group than in the LMA group and the suggestion that rescue with the LMA might result in better outcomes than rescue with the face mask in the current trial are consistent with the results from previous trials. The frequency of failure with the face mask appeared to be lower than in our pilot trial; this may reflect improved skills regarding face-mask ventilation among midwives because of additional and repeated training during the trial.

Although our trial did not show superiority of the LMA over the face mask and the trial was not designed to assess noninferiority, the findings appear consistent with current ILCOR recommendations.24 Thus, our findings suggest that the LMA can be safely used as an alternative device during newborn resuscitation, including when performed by trained midwives.

Most studies show that 3 to 6% of neonates require positive-pressure ventilation at birth. In our trial, 8.6% needed positive-pressure ventilation, and a large proportion of neonates were severely compromised; 61.2% had meconium-stained or foul-smelling amniotic fluid, and very early neonatal death occurred in 15.1%. This percentage is considerably higher than those in previous reports and could reflect the hospital demographics, with large numbers of late referrals and mainly neonates with severe asphyxia; previous reports that showed benefits of the LMA largely involved neonates who had mild asphyxia.  Differences between our trial population and those in previous trials are a potential explanation for the discrepancy between our results and the results of previous trials.

This trial extends our knowledge about LMA use among severely compromised neonates in a low-income setting — where more neonatal deaths occur than in higher-income settings and advanced resuscitation is often not available — by having a larger number of participants, relevant outcomes, rigorous methods (including video documentation), and a strong adherence to trial-group assignments with minimal loss to follow-up or exclusions. The trial also has some limitations. It was a single-site trial in a high-volume hospital, where fetal heart-rate monitoring was not routinely available, and there was inconsistent capacity of staff to provide advanced resuscitation; thus, the findings may not be generalizable to better-resourced settings. For trial conduct, we had additional staff on site. Crossovers, which occurred for safety reasons, were more frequent in the face-mask group than in the LMA group (10.9% vs. 3.5%), and this might have improved the outcomes of the neonates initially treated with the face mask. The neurologic outcome (hypoxic–ischemic encephalopathy) was based on the Thompson score without advanced examinations (e.g., electroencephalography or neuroimaging). In addition, it was an open-label trial, but hard outcomes were used and outcome assessors were not aware of the trial-group assignments.

In our trial, the LMA was safe in the hands of midwives but did not result in a lower incidence of early neonatal death or moderate-to-severe hypoxic–ischemic encephalopathy than face-mask ventilation among neonates with asphyxia.



Breastfeed Your Baby to Reduce the Risk of SIDS

Dec 10, 2018
Many moms and moms-to-be know that breastfeeding offers many benefits for moms and babies. But they may not know that breastfeeding also reduces baby’s risk for Sudden Infant Death Syndrome (SIDS). Watch this 79-second video to learn how to practice safe sleep for baby when breastfeeding. A handout is also available at To watch other Safe to Sleep® videos visit….

How Families Can Help Support Breastfeeding Moms

Breastfeeding moms can always use encouragement – here’s how you can help!

A breastfeeding mom needs lots of things – to stay hydrated, to eat extra calories, to get more sleep (hopefully!), and to build a successful nursing relationship with her little one. And she needs support from her loved ones and family! A supportive and encouraging partner, spouse, or family member can make all the difference in encouraging and helping a breastfeeding mom meet her goals. Here are some ways to help the breastfeeding mom in your life.

Supporting Mom’s Needs

When mom comes home with a new baby and is beginning her breastfeeding journey, there are several things that can be done to make things easier for her.

  1. Create a comfortable home environment where she can practice and get used to breastfeeding and all that it physically and emotionally requires.
  2. Run interference with phone calls and visits – and limit them if necessary.
  3. Take on additional household chores like cooking, cleaning, and laundry.
  4. Bring any needed items during a nursing session, like water, a snack, her phone, or a book.
  5. Give supportive words or encouragement when she’s facing breastfeeding difficulties – and start the process to get additional help or support from your healthcare provider or a Lactation Consultant, if needed.

Bonding with Baby

Sometimes helping mom means taking over care for the little one and giving her some time to herself. And, since breastfeeding provides a unique opportunity for closeness between mom and baby, you’ll want to form your own special bond with the little one. Here are ways to interact one-on-one with baby and encourage your own special connection.

  1. Make time for skin-to-skin contact when cuddling
  2. Take over bath duties
  3. Change diapers after each feeding
  4. Burp the baby after a nursing session
  5. Rock the baby to sleep
  6. Walk with baby in the stroller or in a carrier
  7. If your loved one is pumping, take over the night feeding by warming and feeding a previously expressed bottle of breast milk

If you’re unsure, just ask the breastfeeding mom in your life what would most help, and then do it! Even small tasks done every day can help over time to show that you support breastfeeding and make her feel more confident in her decision to nurse. It may not always be easy, but it’s always worth it! 


Mothers of premature babies struggle to get donor breast milk

      Namibian Broadcasting Corporation

Jack Shonkoff Discusses Early Childhood Development

Jun 1, 2018 – The Duke Endowment
Noted child development expert Jack Shonkoff says constant, unrelenting negative experiences – toxic stress – in early childhood affect a developing brain in ways that can herald lifelong learning and behavior problems.

Kat’s Korner

In regard to the video above I believe ACES is something some of us who are preemie infant survivors may connect with personally.

While our experience receiving life-saving care was essential for our long-term outcomes and wellness the process came undoubtedly for many of us with some difficult measures. As neonates many of us underwent traumatic experiences undergoing critical interventional care, significant time away from our caregivers/parents or human contact, and submersion in a prolonged high-stress environment.

 I encourage us as preemie infant survivors to explore the ACES model above and consider the ways our earliest human experiences may have impacted our development and has influenced our personal interaction with the world around us. Reflecting on the ways we may connect ACES to our human experience as preemie survivors may inspire us to discover new and exciting ways to approach enhancing our health and well-being.

I am calling for continuous research in this area of trauma informed care which may significantly influence the fields of neonatology and the health and well-being of our Neonatal Womb Warrior/Preterm Birth Survivor Community.

Surfing in Nias Utara (North of Nias)

Oct 2, 2019
Nias is one of the well known surfing destination in the world. Most of the surfers go to the south side of Nias. This time Wet Traveler was invited by the Ministry of Tourism of The Republic of Indonesia to make a promotional video for Surfing in Nias Utara. Tell us what do you think about this place. Especially if you have your own experience there.

Polyvagal Theory, Community Collaboration, Stories


Preterm Birth Rates – Portugal

Rank: 138 –Rate: 7.7% Estimated # of preterm births per 100 live births (USA – 12 %)

Portugal, officially the Portuguese Republic is a country located mostly on the Iberian Peninsula, in southwestern Europe. It is the western most sovereign state of mainland Europe, being bordered to the west and south by the Atlantic Ocean and to the north and east by Spain. Its territory also includes the Atlantic archipelagos of the Azores and Madeira, both autonomous regions with their own regional governments. The official and national language is Portuguese.

Portugal ranks 12th in the best public health systems in the world, ahead of other countries like the United KingdomGermany or Sweden. The Portuguese health system is characterized by three coexisting systems: the National Health Service (Serviço Nacional de Saúde, SNS), special social health insurance schemes for certain professions (health subsystems) and voluntary private health insurance. The SNS provides universal coverage. In addition, about 25% of the population is covered by the health subsystems, 10% by private insurance schemes and another 7% by mutual funds.



TAG: PORTUGALCovid Story 5

Posted on June 13, 2020

Joana Mendes, São Francisco Xavier Hospital, Lisbon, Portugal

I am a NICU nurse since I left nursing school. It was my big and only passion. I work now for about 18 years with babies and families. My main areas of expertise are ethics and palliative care. When Covid-19 was spreading quickly in Europe, I was doing a pediatric palliative care clinical practice in Cardiff. One of the first challenges, was returned home safely, when boarders where closing, all over the world. I got to Portugal 2 days just before the lockdown. The news, papers and social posts on internet, arriving from China, Italy and Spain, were really scary. Portuguese boards (medical, nursing and even veterinary’s) asked for health care professionals, from all backgrounds and scenarios, to come and help in human medicine, especially in adult emergency department and intensive care, if needed. They even asked the retired ones to volunteer. And they came. Neonatal nurses knew in advance, one could be mobilized anywhere, anytime. If the situation turned really bad, some would have to go and work in adult department. It sounded very unreal. Some of us when to the pediatric emergency department, whe