Preterm Birth Rates – Ghana

Rank: 14 –Rate: 14.5% Estimated # of preterm births per 100 live births (USA – 12%)

Source: https://www.marchofdimes.org/mission/global-preterm.aspx#tabs-3

Ghana, officially the Republic of Ghana, is a country located along the Gulf of Guinea and Atlantic Ocean, in the subregion of West Africa. Spanning a land mass of 238,535 km² (92,099 sq mi), Ghana is bordered by the Ivory Coast in the west, Burkina Faso in the north, Togo in the east and the Gulf of Guinea and Atlantic Ocean in the south. Ghana means “Warrior King” in the Soninke language.

Ghana’s population of approximately 30 million spans a variety of ethnic, linguistic and religious groups.

Ghana is a unitary constitutional democracy led by a president who is both head of state and head of the government. Ghana’s growing economic prosperity and democratic political system have made it a regional power in West Africa. It is a member of the Non-Aligned Movement, the African Union, the Economic Community of West African States (ECOWAS), Group of 24 (G24) and the Commonwealth of Nations.

Ghana has a universal health care system strictly designated for Ghanaian nationals, National Health Insurance Scheme (NHIS).  Health care is very variable throughout Ghana and in 2012, over 12 million Ghanaian nationals were covered by the National Health Insurance Scheme (Ghana) (NHIS). Urban centres are well served, and contain most of the hospitals, clinics, and pharmacies in Ghana. There are over 200 hospitals in Ghana and Ghana is a destination for medical tourism. In 2010, there were 0.1 physicians per 1,000 people and as of 2011^[update], 0.9 hospital beds per 1,000 people.

 

COMMUNITY

The unsung hero in breast-milk

Date: Jan 16 , 2020 BY: Matilda Twumasi & Dr Freda Intiful

 

Breastfeeding a child after birth can be considered exciting, fascinating, interesting and tiring for mothers who have just given birth.Human breast milk is considered the best food and the gold standard for newborns and infants. It has been well documented that breastfed infants are better protected from infectious agents than formula-fed infants.This can be attributed to various factors present in milk. Oligosaccharides are one of the important factors.

Oligosaccharides

Milk oligosaccharides (HMOs) are complex sugars which form part of the functional ingredients of human breast milk.

They are the third most important solid component of breast milk (with the first and second being lactose and lipids respectively) which has positive short-and long-term effects on infants.

HMOs levels appear to be higher in first milk (colostrum, the yellowish creamy milk) after child birth and decrease as breastfeeding continues.

They have many benefits which put breastfed children at an advantage as compared to formula-fed infants.

The first of its benefits is its function on the gastrointestinal tract (GIT).

HMOs act as feed for digestive micro-organisms. HMOs have long been thought to stimulate the colonisation of beneficial microbes in the gastrointestinal tract of the infant.

Generally, breast-fed infants seem to have a less complex, more stable microbial community than formula-fed infants.

It is now well established that HMOs can serve as substrate for intestinal microbes.

Infections

The second of its benefits is its ability to protect against infections. Studies have shown that breast-fed infants have lower incidences of infectious diseases of the intestinal, urinary and respiratory tract.

Many pathogens first need to adhere to mucosal surfaces to invade the host to cause disease or initiate infection but some HMOs inhibit adhesion and enhance pathogen clearance which reduces infection.

Brain development

Thirdly, HMOs are also considered nutrients for brain development.

Studies have shown that breastfed preterm infants have superior developmental scores at 18 months of age and higher intelligence quotients at the age of seven.

Human milk is a rich source of sialic acid, and post-mortem analysis on human neonates showed that sialic acid concentrations are significantly higher in the brains of breastfed infants than infants fed with formula that contained lower amounts of sialic acid.

This shows that sialylated HMOs contribute to the majority of sialic acid in human milk that provides the developing brain with this seemingly essential nutrient and contribute to good developmental scores and intelligence quotients in breastfed infants.

HMOs represent the next frontier in neonatal nutrition as they constitute a major component of the immune-protection conferred by breast milk upon vulnerable infants.

The addition of HMOs to infant formula is currently not feasible due to the limited availability.

Cattle-milk-based infant formula contains very low levels of complex oligosaccharides, which make it difficult to be used as a substitute for that which comes from humans.

Perfect food

In an attempt to compensate for this deficiency, infant formula manufacturers are presently fortifying their products with enzymatically produced or plant-based, non-human oligosaccharides, including galactooligosaccharides (GOS) and fructooligosaccharides (FOS).

The effects of formula oligosaccharides on intestinal epithelium and barrier functions are controversial.

Some studies have reported that FOS supplementation in neonatal rats increased bacterial translocation without affecting barrier integrity.

Whether or not this is a potential health concern to the human infant remains to be clarified.

In conclusion, HMOs seem to have a wide spectrum of benefits for the breast-fed infant that go beyond the prebiotic aspects.

Adding “the real” HMOs to infant formula in similar complexity as found in breast milk will, at least for now, remain technically unfeasible.

However, with recent advances in glycan synthesis, one or more “authentic” HMOs might soon become available for clinical studies with infant health outcomes, but also to address basic measures such as HMO metabolism, bioavailability and kinetics.

Until then, breast milk still remains the most perfect food for the baby and mothers are encouraged to choose breastmilk over formula.

Source: https://www.graphic.com.gh/news/health/the-unsung-hero-in-breastmilk.html

Israeli gov’t provides support GHS in Neonatal care

By Florence Afriyie Mensah, GNA     –     Wednesday 10th July, 2019

Kumasi, July 10, GNA – The government of Israel as part of efforts to deepen relationship with the Ghana Health Service (GHS), has inaugurated two neonatal units in two health facilities in the Kumasi Metropolis.

The beneficiary hospitals are the Kumasi South and the Suntreso Government Hospitals.

Each of the 16 bed capacity for newborns, would provide essential services such as; Kangaroo Mother Care (KMC), clinical training for medical and physician assistants, while also serving as maternal and child health research hubs.

Ms. Shani Cooper, Israeli Ambassador to Ghana, who inaugurated the facilities at separate ceremonies in Kumasi on Wednesday, said the aim was to improve performance, reduce neonatal and maternal deaths in the Mother and Baby Units (MBU).

The units were created by an Israeli Physician, Dr. Miki Karplus in 2009 for the two hospitals, under the joint MASHAV and Soroka initiative.

So far, the two units have been able to register significant achievement with the introduction of new methodologies, computerized data collection system and a sharp decrease in maternal and neonatal mortality rate.

Additionally, the units have ensured permanent distant medical consultations between the Israeli team of doctors and their counterparts in the two facilities.

Ms. Cooper said the Israeli government had also helped to install at the facilities, bubble CPAP, infusion pumps, radiant warmers, oxihoods and phototherapy equipment, all being aids that promote effective delivery of neonatal services at the facilities.

She mentioned that a delegation from the Ghana health Service was already in Israel attending a conference on health technologies, adding that, her government remained committed to partner the Ghana government to speed up socio-economic development.

Dr. Ashura Bakari, Head of the MBU of the Sunterso Government Hospital, said the Hospital had an annual admission of more than 900 babies between ages of zero to two months.

He said neonatal deaths decreased from 23 in 2017 to 16 in 2018 at the facility and commended the Israeli government for the continued support to improve neonatal services at the two facilities.

Source: https://www.ghananewsagency.org/health/israeli-gov-t-provides-support-ghs-in-neonatal-care-152930

HEALTH CARE PARTNERS

esStudy provid data-based answer for preterm baby’s discharge from the NICU

Reviewed by James Ives, M.Psych. (Editor)Jan 16 2020

“When is my baby going home?” is one of the first questions asked by families of infants admitted to the neonatal intensive care unit (NICU). Now clinicians have a data-based answer. Moderate to late preterm babies (born at gestational age of 32 to 36 weeks) who have no significant medical problems on admission are likely to be discharged at 36 weeks of postmenstrual age (gestational age plus age since birth), according to a study published in the American Journal of Perinatology. Small for gestational age infants and those with specific diagnoses may stay longer.

For the first time, practitioners have tangible data on length of stay to counsel parents at the time of their preterm baby’s admission. Our results may decrease parent stress and help families prepare for their baby’s arrival home.”

Previously, length of stay predictors were signs of the infant’s physiological maturity, which were only available near the end of the hospital stay. Infants born at less than 37 weeks of completed gestation comprise almost 10 percent of births in the United States. Most preterm infants are born between 32 and 36 weeks of gestation.

To establish a reliable length of stay estimate at the time of a preterm baby’s admission, Dr. Higgins Joyce and colleagues from Lurie Children’s conducted a retrospective chart review over six years, encompassing 3,240 moderate to late preterm infants born in a large, urban NICU. They found that the mean length of stay for these infants was 17 days, ranging from 30 days for infants born at 32 weeks of gestation to about a week for infants born at 36 weeks.

“While these results come from just our hospital, we hope other centers can confirm that many parents of premature infants can anticipate having their babies home with them earlier than previously expected,” says senior author Patrick Myers, MD, neonatologist at Lurie Children’s and Assistant Professor of Pediatrics at Northwestern University Feinberg School of Medicine.

Source: Alanna Higgins Joyce, MD, MPH, lead author, hospitalist at Ann & Robert H. Lurie Children’s Hospital of Chicago and Assistant Professor of Pediatrics at Northwestern University Feinberg School of Medicine

Journal reference: Joyce, A. H., et al. (2020) When is My Baby Going Home? Moderate to Late Preterm Infants are Discharged at 36 Weeks Based on Admission Data. American Journal of Perinatology. doi.org/10.1055/s-0039-3401850.

Source: https://www.news-medical.net/news/20200116/Study-provides-data-based-answer-for-preterm-babys-discharge-from-the-NICU.aspx

 

Tackling Physician Burnout and Moral Injury

January 8, 2020 Health Policy and Management, Psychology Katie Brind’Amour, PhD, MS, CHES

Across the United States, burnout and suicide rates for physicians have reached record highs, claiming the life of a doctor a day. What can be done to protect and improve the wellbeing of the people who care for everyone else?

Most doctors enter their profession knowing that it is demanding, but believing that it is also rewarding and meaningful work. “Demanding” may be putting it mildly, however. Health care providers sleep less than people in any other profession. Physician stress, depression and anxiety levels are on the rise, with more than half of clinicians reporting symptoms that qualify as emotional, physical and mental burnout. And sadly, between 300 and 400 physicians per year are lost to suicide.

But why do some physicians develop burnout, moral injury and long-term mental health conditions, while others don’t? Why is America losing a doctor every day to suicide? And what can be done about it?

Seeing the Problem

The health care system surrounding today’s clinicians encompasses much more than just providing care. Clinical work is part of a much larger picture that often includes electronic medical record management, office and insurance paperwork, highly complex regulatory requirements, satisfaction reviews, quality improvement and cost reduction responsibilities, continuing education, and multidisciplinary collaboration for complex patients. Clinicians are asked to accomplish more and more, often with no extra time or resources provided.

“Clinicians are increasingly torn by competing priorities, and they report they are constantly making trade-off decisions: having to choose between getting their administrative duties completed and providing more or better patient care,” says Brandon Kozar, PsyD, MBA, director of leadership coaching and development at Nationwide Children’s Hospital. “These are individuals who are in medicine because they want to help people, so this constant battle is demoralizing, guilt-inducing and makes them feel they aren’t in control of their professional lives. They lose the joy of practicing medicine.”

Resourcefulness and hard work cannot solve this dilemma, and their resiliency plummets. Over time, clinicians who feel that these forced trade-offs infringe on their ethical duties — that they are unable to uphold their entrenched moral desire to put patients’ wellbeing first — experience “moral injury,” a significant predictor of other serious mental health concerns, such as clinical depression, substance abuse, anxiety and suicidal ideation.

Burnout — a more common phenomenon, where emotional and physical exhaustion result from constant exposure to stressors and a decreased ability to cope with daily duties — and moral injury have important implications beyond the wellbeing of the affected individual clinicians. These problems may negatively impact patient care and outcomes. When doctors are exhausted mentally, emotionally and physically, they cannot provide optimal care. They become more likely to make mistakes. Substance abuse, sleep deprivation, anger control issues, relationship troubles and other problems arise, further increasing the risk to physicians and their patients.

Unfortunately, physicians and other health care workers often feel they have nowhere to turn for relief.

Understanding the Problem

Historically, clinicians have been known for a dogged commitment to their patients and their work, often at their own expense. Acknowledging emotions and troubles, admitting to being overwhelmed, and seeking help have been tantamount to inadequacy or unprofessionalism, and thus have carried a stigma.

Even in recent years, clinicians with depression or substance use disorders have faced loss of licensure, increased supervision, restriction of hospital privileges, and loss of privacy — making admission of difficulties a potential threat to their livelihood and status. And in part because of the profession’s reticence on the idea of mental health concerns affecting their own, suicide among physicians is believed to be underreported by pathologists trying to protect their deceased colleagues’ reputations.

To further complicate matters, many hospital program and department leaders are clinicians themselves, rather than business experts trained in human resource management and administrative processes. Running a business unit with significant fiduciary, regulatory and supervisory responsibilities may come naturally to some clinical directors, but others struggle to create environments that both support morale and enable engaged productivity. Emotional intelligence — the ability to recognize and empathetically respond to the emotions of the people around you — is perhaps under-appreciated in the selection of leadership, and clinicians and other staff pay the price.

“Some departments have greater rates of burnout and poor mental health than others, and the differences are not best predicted by workload,” says Dr. Kozar, referencing literature on emotional intelligence and clinical staff performance. “Instead, just the perception of being socially supported by peers, superiors or the organization dramatically influences how health care providers cope. Positive and supportive work environments that foster a sense of support and collegiality result in more productive work, more accurate differential diagnoses and less burnout.”

This goes beyond creating a feel-good culture to fostering an environment that systematically embraces a genuine concern for clinicians and other employees both in the adoption of workplace expectations and in the everyday manner of interpersonal interactions.

and administrative processes. Running a business unit with significant fiduciary, regulatory and supervisory responsibilities may come naturally to some clinical directors, but others struggle to create environments that both support morale and enable engaged productivity. Emotional intelligence — the ability to recognize and empathetically respond to the emotions of the people around you — is perhaps under-appreciated in the selection of leadership, and clinicians and other staff pay the price.

Some departments have greater rates of burnout and poor mental health than others, and the differences are not best predicted by workload,” says Dr. Kozar, referencing literature on emotional intelligence and clinical staff performance. “Instead, just the perception of being socially supported by peers, superiors or the organization dramatically influences how health care providers cope. Positive and supportive work environments that foster a sense of support and collegiality result in more productive work, more accurate differential diagnoses and less burnout.”

This goes beyond creating a feel-good culture to fostering an environment that systematically embraces a genuine concern for clinicians and other employees both in the adoption of workplace expectations and in the everyday manner of interpersonal interactions.

Fixing the Problem

There is no cut-and-dry solution to the problem of overwhelmed and under-supported physicians. But that has not stopped many institutions from trying to take an active step toward identifying burnout and distress, helping physicians in need, and preventing the problem in the first place.

At Nationwide Children’s, for instance, Dr. Kozar’s existence on staff is a primary example of the hospital’s intentional decision to protect its people. His role was created partly in response to the hospital’s Zero Hero program, designed to eliminate preventable harm, such as overtired staff and emotionally depleted clinicians. In addition, it was an attempt to formalize programs and a cultural shift toward de-stigmatizing mental health concerns, supporting employees and equipping them with resources and outlets to address their needs.

Dr. Kozar directs the hospital’s YOU Matter program, which offers emotional and mental health support to both clinical and non-clinical staff faced with work-related and potentially traumatic stressors, such as a patient death. The program has several components, including a peer support initiative, a critical response team, on-site Master’s-level clinical counselors exclusively for staff (focused in high-acuity settings such as the emergency department and intensive care units), and hospital rounds focused on discussing psychosocial impacts of participants’ work. In addition, hospital employees are eligible for confidential counseling sessions at no cost

(focused in high-acuity settings such as the emergency department and intensive care units), and hospital rounds focused on discussing psychosocial impacts of participants’ work. In addition, hospital employees are eligible for confidential counseling sessions at no cost.

“It might be due to the increasing visibility of mental health needs in society at large, but I think clinicians are becoming more accepting of the need to speak up and speak out about salient issues of burnout,” says Dr. Kozar. “The trick is to avoid framing all stress as evil. Stress actually can have many benefits both professionally and personally, and it isn’t realistic to totally eliminate it. Distress, however, is overwhelming and negative and needs to be reduced.”

Further efforts at Nationwide Children’s have included the implementation of business coaching for clinical department leaders to help them run better-organized programs and alleviate burnout. Stress management training for staff — in which the distinction between good and bad stress is emphasized — also reinforces the hospital’s culture of confronting the issue and treating each other with compassion. Staff trained as peer support personnel are taught to pay attention to the work experiences of their colleagues and to reach out to others on a regular basis.

“Human beings are social creatures — we do better when we work and operate in an environment where we are cared for,” says Dr. Kozar. “Instead of an environment where there’s nothing but a time crunched, task-oriented day where clinicians are drawn in every direction with no time to look out for each other, we’re focusing on building deliberate and strategic social support systems that can cultivate resiliency”.

How to Protect Clinician Well-being

The widespread problems of burnout and moral injury will not disappear overnight, but Dr. Kozar is confident that personal and institutional steps to counteract these problems can equip clinicians with the support and competencies they need in order to maintain resilience and protect their psyches.

“These are high-performing individuals,” Dr. Kozar says. “When you teach them to do something, they can implement it very effectively. You just have to make sure that you’re not training them to quash problems in one area only for them to pop up in another. The approach has to be comprehensive, which means it’s oriented at the institution’s programs and personal resiliency, not just workload.”

As many as a dozen hospitals per year come to Nationwide Children’s to learn about and implement programs similar to those managed by Dr. Kozar.

His recommended steps for physicians to take to prevent and address burnout and moral injury include:

1. Recognize as early as possible the signs of compassion fatigue (the “empathy well” has run dry), moral injury (value conflicts between what you are doing and what you believe is the right thing to do), and burnout (loss of pleasure, increasing cynicism, mental/emotional exhaustion).
2. Seek help early: Use your employee assistance program and/or seek counsel from a trusted colleague or supervisor.
3. Focus on what you can control (“I can’t change the medical health system, but I can control and improve this…”).
4. Promote and engage in social support (this is the single greatest protective factor against burnout and a primary source of life satisfaction).
5. Continue to cultivate resilience by focusing on your interpretation or framing of events and not just the events themselves. Remember: A + B = C (Activating event + Belief about that event = Consequence: How I feel and therefore behave).

Dr. Kozar also suggests some opportunities for institutions to protect their employees from the potentially devastating problems of burnout and moral injury:

1. Recognize that burnout and the need to support and care for staff is a critical investment for their wellbeing as well as that of patients.
2. Assign a senior executive sponsor to support, fund and advocate for staff support programs –these initiatives deserve more than just staff-driven “culture club”-level support.
3. Train chiefs of medicine and other leaders on the 3Rs: How to Recognize, Respond and Refer physicians struggling with socioemotional issues.
4. Promote the purpose and joy of medicine: Have regular events in which physicians are exposed to past patients and families whom they have helped. Allow them the experience of someone expressing their gratitude and appreciation for what they did.
5. Remember to “Acknowledge the pain yet promote the gain.”
6. Teach leaders how to promote and support intrinsic motivation in staff: Autonomy, Mastery, and Purpose.
7. Hire leaders with above-average emotional intelligence. Poor or ineffective leadership is one of the main drivers of work-related burnout and dissatisfaction. As the saying goes, “Most people don’t leave their jobs, they leave their bosses” — so make sure the “bosses” are good not just at medicine, but at personnel management.

Source: https://pediatricsnationwide.org/2020/01/08/tackling-physician-burnout-and-moral-injury/

A Randomized Trial of Erythropoietin for Neuroprotection in Preterm Infants

January 16, 2020  By: Sandra E. Juul, M.D., Ph.D., Bryan A. Comstock, M.S., Rajan Wadhawan, M.D., Dennis E. Mayock, M.D., Sherry E. Courtney, M.D., Tonya Robinson, M.D., Kaashif A. Ahmad, M.D., Ellen Bendel-Stenzel, M.D., Mariana Baserga, M.D., Edmund F. LaGamma, M.D., L. Corbin Downey, M.D., Raghavendra Rao, M.D.,  for the PENUT Trial Consortium^*

 Abstract

Background

High-dose erythropoietin has been shown to have a neuroprotective effect in preclinical models of neonatal brain injury, and phase 2 trials have suggested possible efficacy; however, the benefits and safety of this therapy in extremely preterm infants have not been established.

Methods

In this multicenter, randomized, double-blind trial of high-dose erythropoietin, we assigned 941 infants who were born at 24 weeks 0 days to 27 weeks 6 days of gestation to receive erythropoietin or placebo within 24 hours after birth. Erythropoietin was administered intravenously at a dose of 1000 U per kilogram of body weight every 48 hours for a total of six doses, followed by a maintenance dose of 400 U per kilogram three times per week by subcutaneous injection through 32 completed weeks of postmenstrual age. Placebo was administered as intravenous saline followed by sham injections. The primary outcome was death or severe neurodevelopmental impairment at 22 to 26 months of postmenstrual age. Severe neurodevelopmental impairment was defined as severe cerebral palsy or a composite motor or composite cognitive score of less than 70 (which corresponds to 2 SD below the mean, with higher scores indicating better performance) on the Bayley Scales of Infant and Toddler Development, third edition.

Results

A total of 741 infants were included in the per-protocol efficacy analysis: 376 received erythropoietin and 365 received placebo. There was no significant difference between the erythropoietin group and the placebo group in the incidence of death or severe neurodevelopmental impairment at 2 years of age (97 children [26%] vs. 94 children [26%]; relative risk, 1.03; 95% confidence interval, 0.81 to 1.32; P=0.80). There were no significant differences between the groups in the rates of retinopathy of prematurity, intracranial hemorrhage, sepsis, necrotizing enterocolitis, bronchopulmonary dysplasia, or death or in the frequency of serious adverse events.

Conclusions

High-dose erythropoietin treatment administered to extremely preterm infants from 24 hours after birth through 32 weeks of postmenstrual age did not result in a lower risk of severe neurodevelopmental impairment or death at 2 years of age. (Funded by the National Institute of Neurological Disorders and Stroke; PENUT ClinicalTrials.gov number, NCT01378273. opens in new tab.)

Source: https://www.nejm.org/doi/full/10.1056/NEJMoa1907423

 

PREEMIE FAMILY PARTNERS

Buffalo NICU Nurse Writes Book for Preemies (wgrz.com)

Alyssa Veech   Published on May 10, 2019

Sisters of Charity Hospital nurse, Alyssa Veech, wrote “Small But Mighty” to help parents on the emotional journey of having a preemie in the NICU.

Preterm children have similar temperament to children who were institutionally deprived

Date: November 12, 2019 Source: University of Warwick

Summary:

A child’s temperament appears to be affected by the early stages of their life. Researchers have found children who were born very preterm (under 32 weeks gestation) or very low birthweight (under 1500g) had similar temperamental difficulties in controlling their impulses, to children who experienced institutional deprivation

The paper ‘A Comparison of the Effects of Preterm Birth and Institutional Deprivation on Child Temperament’, published today, 12 November in the journal Development and Psychopathology, highlights how different adverse experiences such as preterm birth and institutional deprivation affect children’s temperament in similar ways, resulting in greater risk for lower self-control.

The team of researchers, from the University of Warwick, University of Tennessee, University of Southampton and King’s College London looked at children who were born very preterm, or very low birth weight from the Bavarian Longitudinal study, and children who experienced at least six months of institutional deprivation — a lack of adequate, loving caregivers — in Romanian institutions from the English and Romanian Adoptees study, who were then compared to 311 healthy term born children and 52 non-deprived adoptees, respectively.

The researchers found that both groups of children had lower effortful control at 6 years.

This is the first study that directly compares the effects of severe preterm birth and extended institutional deprivation, and suggests that self-control interventions early in life may promote the development of children after both risk experiences.

Prof Dieter Wolke from the Department of Psychology at the University of Warwick comments: “Both, early care either in an incubator or deprivation and neglect in an orphanage lead to poor effortful control. We need to further determine how this early deprivation alters the brain.”

Lucia Miranda Reyes, from the Department of Child and Family Studies at the University of Tennessee comments: “These findings suggest that children’s poor effortful control may underlie long-term social problems associated with early adverse experiences; thus, improving their self-control may also help prevent these later problems.”

Source: https://www.sciencedaily.com/releases/2019/11/191112110211.htm

 

We are all in this together. This short video shares a powerful glimpse of our preterm birth journeys. The links below will provide families and caregivers with access to great support and the opportunity to give and give back. There are preterm birth support  groups around the world. We are listing a few that we know are fully committed to supporting the Neonatal Womb/preterm birth community world-wide.

Preemie Graduation | Canadian Premature Babies Foundation

Canadian Premature Babies Foundation – Published on Nov 13, 2019

Help premature babies and their parents reach the most important graduation of all.

Hand to Hold: https://handtohold.org/

Graham’s Foundation: https://grahamsfoundation.org/

March of Dimes: https://www.marchofdimes.org/nicufamilysupport/index.aspx

 

          Simple test predicts dangerous pregnancy disorder

Date: October 23, 2019      Source: Edith Cowan University

  Summary: Researchers have developed a simple, low-cost way to predict preeclampsia, a potentially deadly condition that kills 76,000 mothers and 500,000 babies every year.

Australian researchers have developed a way to predict the onset of a deadly pregnancy condition that kills 76,000 women and half a million babies each year, mostly in developing countries.

Researchers from Edith Cowan University in Perth Western Australia have developed a simple, low-cost way to predict preeclampsia, one of the leading causes of maternal-fetal mortality worldwide.

Preeclampsia can cause devastating complications for women and babies, including brain and liver injury in mothers and premature birth.

Survey gives early warning

ECU researchers assessed the health status of 593 pregnant Ghanaian women using the Suboptimal Health Questionnaire.

The Suboptimal Health Questionnaire was developed in 2009 by Professor Wei Wang from ECU’s School of Health and Medical Sciences. Combining scores for fatigue, heart health, digestion, immunity and mental health, the questionnaire provides an overall ‘suboptimal health score’ that can help predict chronic diseases.

Professor Wang’s PhD candidate Enoch Anto found that 61 per cent of women who scored high on the questionnaire went on to develop preeclampsia, compared with just 17 per cent of women who scored low.

When these results were combined with blood tests that measured women’s calcium and magnesium levels, the researchers were able to accurately predict the development of preeclampsia in almost 80 per cent of cases.

Mr Anto said preeclampsia was very treatable once identified, so providing an early warning could save thousands of lives.

“In developing nations, preeclampsia is a leading cause of death for both mothers and babies. In Ghana, it’s responsible for 18 per cent of maternal deaths,” Mr Anto said.

“But it can be treated using medication that lowers blood pressure once diagnosed.

“Both blood tests for magnesium and calcium and the Suboptimal Health Questionnaire are inexpensive, making this ideally suited to the developing world where preeclampsia causes the most suffering.”

Source: www.sciencedaily.com/releases/2019/10/191023093431.htm

 

NICU Technology Predicts Care

Hurley Medical Center / Hurley Children’s Hospital

Hurley’s NICU has been performing miracles for decades. With our growing technology, we are now able to do even more. Our doctors and nurses can now predict symptoms or problems BEFORE your baby experiences them. That gives us a jump on treating your baby. #HurleyCares #NHITweek @HIMSS

 

Environmental Research   Volume 176, September 2019,

Synergistic effects of prenatal exposure to fine particulate matter (PM_2.5) and ozone (O₃) on the risk of preterm birth:

A population-based cohort study

Abstract

Background

There is some evidence that prenatal exposure to low-level air pollution increases the risk of preterm birth (PTB), but little is known about synergistic effects of different pollutants.

Objectives

We assessed the independent and joint effects of prenatal exposure to air pollution during the entire duration of pregnancy.

Methods

The study population consisted of the 2568 members of the Espoo Cohort Study, born between 1984 and 1990, and living in the City of Espoo, Finland. We assessed individual-level prenatal exposure to ambient air pollutants of interest at all the residential addresses from conception to birth. The pollutant concentrations were estimated both by using regional-to-city-scale dispersion modelling and land-use regression–based method. We applied Poisson regression analysis to estimate the adjusted risk ratios (RRs) with their 95% confidence intervals (CI) by comparing the risk of PTB among babies with the highest quartile (Q₄) of exposure during the entire duration of pregnancy with those with the lower exposure quartiles (Q₁-Q₃). We adjusted for season of birth, maternal age, sex of the baby, family’s socioeconomic status, maternal smoking during pregnancy, maternal exposure to environmental tobacco smoke during pregnancy, single parenthood, and exposure to other air pollutants (only in multi-pollutant models) in the analysis.

Results

In a multi-pollutant model estimating the effects of exposure during entire pregnancy, the adjusted RR was 1.37 (95% CI: 0.85, 2.23) for PM_2.5 and 1.64 (95% CI: 1.15, 2.35) for O₃. The joint effect of PM_2.5 and O₃ was substantially higher, an adjusted RR of 3.63 (95% CI: 2.16, 6.10), than what would have been expected from their independent effects (0.99 for PM_2.5 and 1.34 for O₃). The relative risk due to interaction (RERI) was 2.30 (95% CI: 0.95, 4.57).

Discussion

Our results strengthen the evidence that exposure to fairly low-level air pollution during pregnancy increases the risk of PTB. We provide novel observations indicating that individual air pollutants such as PM_2.5 and O₃ may act synergistically potentiating each other’s adverse effects.

Source: https://www.healthynewbornnetwork.org/country/ghana/

A Liftless Intervention to Prevent Preterm Birth and Low Birthweight Among Pregnant Ghanaian Women:

Protocol of a Stepped-Wedge Cluster Randomized Controlled Trial

JMIR Res Protoc 2018 Aug 23;7(8):e10095. Epub 2018 Aug 23. Institute of Public Health & Clinical Nutrition, School of Medicine, University of Eastern Finland, Kuopio, Finland.

Abstract

BACKGROUND:

Preterm birth (PTB) is a leading cause of infant morbidity and mortality worldwide. Every year, 20 million babies are born with low birthweight (LBW), about 96% of which occur in low-income countries. Despite the associated dangers, in about 40%-50% of PTB and LBW cases, the causes remain unexplained. Existing evidence is inconclusive as to whether occupational physical activities such as heavy lifting are implicated. African women bear the transport burden of accessing basic needs for their families. Ghana’s PTB rate is 14.5%, whereas the global average is 9.6%. The proposed liftless intervention aims to decrease lifting exposure during pregnancy among Ghanaian women. We hypothesize that a reduction in heavy lifting among pregnant women in Ghana will increase gestational age and birthweight.

OBJECTIVE:

To investigate the effects of the liftless intervention on the incidence of PTB and LBW among pregnant Ghanaian women.

METHODS:

A cohort stepped-wedge cluster randomized controlled trial in 10 antenatal clinics will be carried out in Ghana. A total of 1000 pregnant participants will be recruited for a 60-week period. To be eligible, the participant should have a singleton pregnancy between 12 and 16 weeks gestation, be attending any of the 10 antenatal clinics, and be exposed to heavy lifting. All participants will receive standard antenatal care within the control phase; by random allocation, two clusters will transit into the intervention phase. The midwife-led 3-component liftless intervention consists of health education, a take-home reminder card mimicking the colors of a traffic light, and a shopping voucher. The primary outcome are gestational ages of <28, 28-32, and 33-37 weeks. The secondary outcomes are LBW (preterm LBW, term but LBW, and postterm), compliance, prevalence of low back and pelvic pain, and premature uterine contractions. Study midwives and participants will not be blinded to the treatment allocation.

RESULTS:

Permission to conduct the study at all 10 antenatal clinics has been granted by the Ghana Health Service. Application for funding to begin the trial is ongoing. Findings from the main trial are expected to be published by the end of 2019.

CONCLUSIONS:

To the best of our knowledge, there has been no randomized trial of this nature in Ghana. Minimizing heavy lifting among pregnant African women can reduce the soaring rates of PTB and LBW. The findings will increase the knowledge of the prevention of PTB and LBW worldwide.

©Emma Kwegyir-Afful, Jos Verbeek, Lydia Aziato, Joseph D. Seffah, Kimmo Räsänen. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 23.08.2018.

Source: https://www.pubfacts.com/detail/30139723/A-Liftless-Intervention-to-Prevent-Preterm-Birth-and-Low-Birthweight-Among-Pregnant-Ghanaian-Women-P

 

WARRIORS:

GHANAIAN WISDOM

Study investigates health, well-being of adults who were born preterm at very low birth weight

Reviewed by Kate Anderton, B.Sc. (Editor)Nov 18 2019

The Finnish Institute for Health and Welfare (THL) is investigating the health and well-being of adults who were born preterm at very low birth weight in a series of studies that are unique worldwide.

The study initiated 15 years ago, will be continued when the same individuals, now aged between 35 and 40, are invited to participate.

The information obtained from the study will help with the development of the care and monitoring of premature babies and the reduction of any related health risks for adults.

The study involves the participation of those who were treated at birth between 1978 and 1985 in the infant intensive care ward at the Helsinki University Hospital and who were born either preterm at very low birth weight or, as a control group, were born at full term.

The health and well-being of these individuals as adults has been studied since 2004-2005.

The follow-up study is done in cooperation with an international partner, the Department of Medical Science at the Norwegian University of Science and Technology (NTNU). In Norway, a similar study is simultaneously being carried out using the same methodology as the Finnish study. The researchers will work together to process the data collected in the Finnish and Norwegian studies, which will improve the reliability and precision of the results.

The research includes a detailed health check-up and several questionnaire forms. The individuals’ health will be assessed using different indicators such as their body fat percentage and the results of a glucose tolerance test and a pulmonary function test.

Also, their psychological well-being will be studied using different tasks and questionnaire forms. A new component of the study is a detailed eye check-up and study of their motor skills.

In addition to NTNU, this study involves cooperation with the Helsinki and Uusimaa Hospital District’s Department of Eye Diseases, the University of Helsinki’s Department of Psychology, and the University of Oulu’s Faculty of Medicine.

“We aim to make participation in the research as easy and rewarding as possible. The participants receive for themselves the results of the measurements and check-ups, and thus acquire a broad overall picture of their state of health. The adults who were born preterm at very low birth weight have participated actively in the earlier studies, and we hope that as many as possible will participate this time as well.” Maarit Kulmala, Medical Researcher and Eye Disease Specialist

Infants with a birth weight of 1.5kg or less are classified as having very low birth weight. The systematic intensive care of preterm infants at very low birth weight began in the 1970s.

The majority of those born preterm at very low birth weight consider themselves to be healthy and live a normal life. Slightly less than 10% have some kind of illness or disability which is related to being born preterm and which affects their daily life and capacity to work.

In earlier studies, it was observed that there were health differences at young adulthood between those born full term and those born preterm at very low birth weight. Those born preterm had, for example, a higher incidence of risk factors related to cardiovascular diseases, such as high blood pressure.

They also clearly engaged less in physical exercise than those born full term. Furthermore, they experienced slightly more learning difficulties, depression and anxiety disorders. On the other hand, they fared better than those born full term in some areas, showing lower levels of allergic reactions, behavioural disorders and excessive alcohol consumption.

“We previously studied those born preterm during their young adulthood, aged around 20 to 25, at which point the body’s operating capacity is at its peak. Now we will be studying how their health and operating capacity develop with age: do the differences observed between those born preterm at very low birth weight and those born full term increase over time or even out? This follow-up study for later adulthood, those aged between 35 and 40, is the first of its kind in the world,” explains Professor Eero Kajantie, who is in charge of the study and also heads up the Adults Born Preterm International Collaboration (APIC).

Article Research Source: Finnish Institute for Health and Welfare

Source: https://www.news-medical.net/news/20191118/Study-investigates-health-well-being-of-adults-who-were-born-preterm-at-very-low-birth-weight.aspx

KAT’S CORNER

“Be an opener of doors”

― Ralph Waldo Emerson

Valentine’s Day is approaching and I am sending you all BIG LOVE everyday and everywhere. Remember this: choose to fall in love with You!

Surfing Power – The Pulse on JoyNews (3-4-18)

Apr 3, 2018  Busua’s young surfers aim for the world stage

Preterm Birth Rates – Australia

Rank: 139 –Rate: 7.6% Estimated # of preterm births per 100 live births (USA – 12%)

Source: https://www.marchofdimes.org/mission/global-preterm.aspx#tabs-3

Australia, officially the Commonwealth of Australia, is a sovereign country comprising the mainland of the Australian continent, the island of Tasmania, and numerous smaller islands. It is the largest country in Oceania and the world’s sixth-largest country by total area. The neighbouring countries are Papua New Guinea, Indonesia, and East Timor to the north; the Solomon Islands and Vanuatu to the north-east; and New Zealand to the south-east. The population of 26 million^[ is highly urbanised and heavily concentrated on the eastern seaboard.

Australia has a highly developed healthcare structure, though because of its vast size, services are not evenly distributed. Health care is delivered in Australia by both government and private companies which are often covered by Medicare. Health care in Australia is largely funded by the government at national, state and local governmental levels, as well as by private health insurance; but the cost of health care is also borne by not-for-profit organisations, with a significant cost being borne by individual patients or by charity. Some services are provided by volunteers, especially remote and mental health services.

The federal government-administered Medicare insurance scheme covers much of the cost of primary and allied health care services. The government provides the majority of spending (67%) through Medicare and other programs. Individuals contribute more than half of the non-government funding.

Medicare is a single-payer universal health care scheme that covers all Australian citizens and permanent residents, with other programs covering specific groups, such as veterans or Indigenous Australians, and various compulsory insurance schemes cover personal injury resulting from workplace or vehicle incidents. Medicare is funded by a Medicare levy, which currently is a 2% levy on residents’ taxable income over a certain income. Higher income earners pay an additional levy (called a Medicare Levy Surcharge) if they do not have private health insurance. Residents with certain medical conditions, foreign residents, some low-income earners, and those not eligible for Medicare benefits may apply for an exemption from paying the levy, and some low-income earners can apply for reductions to the levy.

ACCESS to prenatal and maternal care is the key factor in preventing preterm birth. We have presented numerous studies and articles addressing this issue, and below are three additional articles  to reference. Access to healthcare reduces preterm birth,  maternal death, and overall health care costs. The US is lagging significantly behind other “developed” countries and many “developing” countries in preventing preterm birth, and this impacts all of us. Improving maternal health and preventing/reducing preterm birth is achievable for most of the world, so why does the US choose to be less than mediocre in this regard? We have the ability to change this,  and choosing not to change our global standing on these issues is a clear choice.

COMMUNITY

We are visiting our Neonatal Womb Warrior/Preterm Birth family in Australia this month. Our hearts feel great love for the Australian people and we know that their plight related to Global Climate Change is a real and expanding threat to all of us on this planet.  In order to support our global and local preterm birth communities we must recognize the realities and fluidity of climate change, the effects of climate change on our health and longevity, and discover and engage in activities to  support planetary well-being.

Reducing preterm birth amongst Aboriginal and Torres Strait Islander babies: A prospective cohort study, Brisbane, Australia

Abstract

Background-Prevention of avoidable preterm birth in Aboriginal and Torres Strait Islander (Indigenous) families is a major public health priority in Australia. Evidence about effective, scalable strategies to improve maternal and infant outcomes is urgently needed. In 2013, a multiagency partnership between two Aboriginal Community Controlled Health Organisations and a tertiary maternity hospital co-designed a new service aimed at reducing preterm birth: ‘Birthing in Our Community’.

Methods-A prospective interventional cohort study compared outcomes for women with an Indigenous baby receiving care through a new service (n = 461) to women receiving standard care (n = 563), January 2013–December 2017. The primary outcome was preterm birth (< 37 weeks gestation). One to one propensity score matching was used to select equal sized standard care and new service cohorts with similar distribution of characteristics. Conditional logistic regression calculated the odds ratio with matched samples.

Findings-Women receiving the new service were less likely to give birth to a preterm infant than women receiving standard care (6·9% compared to 11.6%). After controlling for confounders, the new service significantly reduced the odds of having a preterm birth (unmatched, n = 1024: OR = 0·57, 95% CI 0·37, 0·89; matched, n = 690: OR = 0·50, 95% CI 0·31, 0·83).

Interpretation-The short-term results of this service redesign send a strong signal that the preterm birth gap can be reduced through targeted interventions that increase Indigenous governance of, and workforce in, maternity services and provide continuity of midwifery care, an integrated approach to supportive family services and a community-based hub.

Source: https://www.sciencedirect.com/science/article/pii/S258953701930094X

Mapping integration of midwives across the United States: Impact on access, equity, and outcomes

• Published: February 21, 2018

Abstract-Poor coordination of care across providers and birth settings has been associated with adverse maternal-newborn outcomes. Research suggests that integration of midwives into regional health systems is a key determinant of optimal maternal-newborn outcomes, yet, to date, the characteristics of an integrated system have not been described, nor linked to health disparities.

Methods-Our multidisciplinary team examined published regulatory data to inform a 50-state database describing the environment for midwifery practice and inter-professional collaboration. Items (110) detailed differences across jurisdictions in scope of practice, autonomy, governance, and prescriptive authority; as well as restrictions that can affect patient safety, quality, and access to maternity providers across birth settings. A nationwide survey of state regulatory experts (n = 92) verified the ‘on the ground’ relevance, importance, and realities of local interpretation of these state laws. Using a modified Delphi process, we selected 50/110 key items to include in a weighted, composite Midwifery Integration Scoring (MISS) system. Higher scores indicate greater integration of midwives across all settings. We ranked states by MISS scores; and, using reliable indicators in the CDC-Vital Statistics Database, we calculated correlation coefficients between MISS scores and maternal-newborn outcomes by state, as well as state density of midwives and place of birth. We conducted hierarchical linear regression analysis to control for confounding effects of race.

Results-MISS scores ranged from lowest at 17 (North Carolina) to highest at 61 (Washington), out of 100 points. Higher MISS scores were associated with significantly higher rates of spontaneous vaginal delivery, vaginal birth after cesarean, and breastfeeding, and significantly lower rates of cesarean, preterm birth, low birth weight infants, and neonatal death. MISS scores also correlated with density of midwives and access to care across birth settings. Significant differences in newborn outcomes accounted for by MISS scores persisted after controlling for proportion of African American births in each state.

Conclusion-The MISS scoring system assesses the level of integration of midwives and evaluates regional access to high quality maternity care. In the United States, higher MISS Scores were associated with significantly higher rates of physiologic birth, less obstetric interventions, and fewer adverse neonatal outcomes.

Source: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0192523

Midwifery linked to better birth outcomes in state-by-state report cards

February 21, 2018  Source: Oregon State University-Original written by Michelle Klampe

Midwife-friendly laws and regulations tend to coincide with lower rates of premature births, cesarean deliveries and newborn deaths, according to a new US-wide ‘report card’ that ranks all 50 states on the quality of their maternity care.

The first-of-its-kind study found a strong connection between the role of midwives in the health care system — what the researchers call “midwifery integration” and birth outcomes. States with high midwifery integration, like Washington and Oregon, generally had better results, while states with the least integration, primarily in the Midwest and South, tended to do worse. The findings were published today in the journal PLOS ONE.

“Our findings suggest that in states where families have greater access to midwifery care that is well integrated into the maternity system, mothers and babies tend to experience improved outcomes. The converse was also demonstrated; where integration of midwives is poorer, so are outcomes,” said Melissa Cheyney, a licensed midwife, medical anthropologist and associate professor in Oregon State University’s College of Liberal Arts and one of the study’s co-authors.

As with most population health studies, the statistical association between the role of midwives and birth outcomes doesn’t prove a cause-and-effect relationship. Other factors, especially race, loom larger, with African-Americans experiencing a disproportionate share of negative outcomes. However, almost 12 percent of the variation in neonatal death across the U.S. is attributable solely to how much of a part midwives play in each state’s health care system.

“In communities in the U.S. that are under-served — where the health system is often stretched thin — this study suggests that expanding access to midwifery is a critical strategy for improving maternal and neonatal health outcomes,” said Saraswathi Vedam, an associate professor in the Department of Family Practice at the University of British Columbia, who led the team of U.S. epidemiology and health policy researchers responsible for the study.

About 10 percent of U.S. births involve midwives, far behind other industrialized countries, where midwives participate in half or more of all deliveries. Each state has its own laws and regulations on midwives’ credentialing, their ability to provide services at a client’s home or at birth centers, their authority to prescribe medication and the degree to which they are reimbursed by Medicaid.

“A large body of cross-cultural research has actually demonstrated similar relationships between midwifery care, systems integration and improved maternity care outcomes,” Cheyney said. “This study is important because it suggests that the same relationships hold true in the United States. There are significant policy implications stemming from this work.”

The research team created a midwifery integration score based on 50 criteria covering those and other factors that determine midwives’ availability, scope of practice and acceptance by other health care providers in each state.

Washington had the highest integration score, 61 out of a possible 100, followed by New Mexico at 59 and Oregon at 58. North Carolina had the lowest score, 17. The complete list, with links to each state’s report card, is available online at http://www.birthplacelab.org/how-does-your-state-rank/.

An interactive map created by the researchers reveals two clusters of higher midwifery integration — one swath stretching from the Pacific Northwest to the Southwest, and a cluster of Northeastern states.

Vermont, Maine, Alaska and Oregon had the highest density of midwives, as measured by the number of midwives per 1,000 births. The lowest midwifery integration was in the Midwest and Deep South.

The study used higher rates of vaginal birth and breastfeeding as positive maternity care outcomes. Higher rates of caesarean birth, premature births, low birth weight and newborn deaths were indicators of poor outcomes.

The Deep South, which not only had lower integration scores, but also higher rates of African American births, had the worst rates of premature birth, low birth weight and newborn mortality. The West Coast states of California, Oregon and Washington consistently scored well on those measures.

Source: https://www.sciencedaily.com/releases/2018/02/180221180521.htm

HEALTH CARE PARTNERS

Neonatal Provider Workforce-Erin L. Keels, Jay P. Goldsmith and COMMITTEE ON FETUS AND NEWBORN-Pediatrics December 2019, 144 (6) e20193147                              DOI: https://doi.org/10.1542/peds.2019-3147-                                                                                     Lead Authors: Erin L. Keels, DNP, APRN-CNP, NNP-BC

Abstract-This technical report reviews education, training, competency requirements, and scopes of practice of the different neonatal care providers who work to meet the special needs of neonatal patients and their families in the NICU. Additionally, this report examines the current workforce issues of NICU providers, offers suggestions for establishing and monitoring quality and safety of care, and suggests potential solutions to the NICU provider workforce shortages now and in the future

*** We are sharing two IMPORTANT sections (Potential Strategies To Address Workforce Shortage of Neonatal Providers  and Summary and Conclusions). We encourage you to review the full report.

Potential Strategies To Address Workforce Shortage of Neonatal Providers-Strategies to address provider workforce shortages in the NICU can include attempting to reduce the workload (i.e., reduce the number of patients admitted to the NICU and/or shorten the length of stay) and/or increase the number of providers. In addition to declining birth rates in the United States, new care strategies may potentially change the acuity and locations where newborn infants receive their care and, over time, may lead to a redistribution and change the workloads of the NICU provider workforce. These emerging care strategies include limiting elective cesarean deliveries to 39 weeks’ gestation or greater; treating infants with neonatal abstinence syndrome outside of the NICU; reducing the need for antibiotic administration and, therefore, length of hospital stay for mothers with intraamniotic inflammation or infection; reducing NICU admissions for treatment of hypoglycemia with intravenous glucose administration by using dextrose or glucose gel; and reducing length of NICU stay through quality improvement strategies, such as decreasing the incidence of central line–associated bloodstream infections.

Strategies to increase the NICU provider workforce have mostly been concentrated on increasing the use of pediatric hospitalists, NNPs, and PAs. Workforce surveys conducted by the NANNP have delineated the existing and future NNP workforce needs. The authors noted that education, recruitment, and retention of NNPs were key areas of focus to increase supply.

Education for NNPs has evolved over 5 decades from certificate programs, to bachelor’s and master’s degrees in nursing, to the doctorate of nursing practice degree, which could slow the NNP pipeline further. Barriers to obtaining this education are lack of higher degree (i.e., doctorate of nursing) programs, funding of faculty, access to preceptors, and federal and state regulations. Regulations posed by the US Department of Education related to long-distance learning have had an effect on NNP education and have contributed to a drop in enrollment in states with significantly restrictive requirements. Collaboration among educational institutions may be a strategy to overcome restrictive regulations and minimize costs and faculty needs. Locally, neonatal programs and hospitals can increase efforts to recruit more neonatal nurses within the workplace to pursue higher education as an NNP and offer tuition reimbursement or scholarships to assist with the financial burden. This strategy capitalizes on the professional expertise of neonatal nurses, facilitating success and easing the transition into the APRN role. A shortage of university nursing faculty is another limitation of enrollment in academic programs. The NANNP has led a strategy to support NNP programs to prepare expert NNP clinicians to become educators in clinical faculties. It is hoped that this effort to increase faculty will enable an increase in the student cohort size and consequently increase the numbers of newly graduated NNPs in the workforce.

Recruitment of NNPs is vital to the NICU provider workforce. Practicing NNPs should contribute to recruitment efforts by serving as clinical preceptors for NNP students. Mentoring programs for novice NNPs have been shown to be valuable recruitment tools for NNP practices and hospitals. Offering longer orientation or residency programs is attractive to new graduates as well.

Retention of NNPs in the workforce is another important aspect of maintaining the NNP supply. With an aging workforce, any additional reduction in manpower from burnout and early retirement will compound the workforce deficit and increase demand. The scope of responsibility for NNPs includes the NICU provider role along with other roles, such as transport NNP, educator, delivery room resuscitation, cross-coverage for physician housestaff, and well-infant consultations, etc.25 Adequate staffing ratios are required to balance the needs of the unit with safe and effective care to neonates. Consideration of patient load and acuity will help reduce burnout and increase job satisfaction. In hospitals that maintain 24-hour work shifts, ensuring downtime for NNPs is critical to safe and competent care. Other strategies may include creating shorter shift lengths and devising creative scheduling techniques to offer better work-life balance in an attempt to increase longevity of the NNP role.

AC PNPs, acting within their scope of practice, can be used as NICU providers for term and older infants, such as those with surgical conditions and chronic medical conditions. PC PNPs, working within their scope of practice, could be used to perform well-newborn and other types of consultations, discharge education, care coordination, and neurodevelopmental follow-up. This team-based collaborative model capitalizes on the unique skill sets of each provider. However, the PNP workforce pipeline suffers from many of the same or similar issues as the NNP pipeline, and it is likely that applying some of the above recruitment and retention strategies may help. Additionally, some PNPs may consider achieving additional certification as an NNP through a post–master’s certification academic program.

Efforts to increase the PA workforce in the NICU have included the addition of postgraduate training programs, and more hospitals are hiring PAs and providing onboarding for those without specific NICU experience. As the total population of PAs continues to increase, offering optional rotations through the NICU during student coursework and clinical rotations, creating more postgraduate training opportunities in neonatology for PAs, and formalizing neonatal PA orientation programs may increase the numbers of these providers in neonatology. Reynolds and Bricker note that PAs “represent a historically underutilized resource to resolve neonatology’s workforce issues.”

Pediatric hospitalists have completed a formal pediatrics residency program and are licensed physicians who can be used as NICU providers within their scope of practice. Hospitalists can currently achieve board certification through the ABP in the field of general pediatrics20 and, if eligible, may also soon be able to obtain board certification in PHM. The AAP Section on Hospital Medicine and its Neonatal Hospitalists Subcommittee are developing and reviewing content on delivery room care and common neonatal conditions for PHM fellowship programs and for the PHM board certification process. Recruitment and retention of pediatric hospitalists who are focused on newborn care and work as providers in the NICU may be helpful to the overall NICU provider workforce. The scope of responsibility for pediatric and neonatal hospitalists may include clinical responsibilities for delivery room resuscitation, transport, cross-coverage for housestaff, well-newborn consultation and care, and the care of selected newborn infants in the intermediate and intensive care nurseries. In addition, many pediatric hospitalists also serve as educators, researchers, and leaders of committees and quality improvement activities. Adequate staffing ratios are important to the practice environment and are required to balance the needs of the unit with safe and effective care to neonates. Consideration of patient load, acuity, and need for academic and professional development will help reduce burnout and increase longevity and job satisfaction of pediatric and neonatal hospitalists.

In addition to the pipeline, recruitment, and retention strategies mentioned previously, efforts should also be focused on effective use and quality-outcomes metrics of all neonatal providers to improve effectiveness and efficiency issues and to improve the quality of care delivered to the neonate who is hospitalized

Summary and Conclusions-

• The NICU provider workforce consists of a variety of professionals in varied stages of their careers with a wide range of degrees, training, experience, skills, and competencies.
• Increasing collaboration of neonatologists with other NICU providers (pediatric hospitalists, APRNs, and PAs) and physician trainees will be necessary to meet the needs of the NICU population going forward.
• The skill level, experience, and competency of neonatology physician trainees (residents and fellows) and NICU providers (PAs, pediatric hospitalists, and PNPs) can be variable, although the training model for NNPs is well developed and may serve as a model for other NICU providers.
• All neonatal providers should possess a basic set of knowledge, procedural, and behavioral-based competencies to provide safe and effective care.
• It is the responsibility of the medical and nursing leadership of the NICU, with the assistance of the hospital credentialing committee, to develop and periodically review competency criteria for all NICU providers.
• Competency criteria, such as those developed by the AAP, ACGME, AAPA, and NONPF, can help guide the development and evaluation of NICU providers to provide high-quality, safe, and cost-effective care to the high-risk NICU population.
• Strategies to increase the overall NICU provider workforce should be evaluated and thoughtfully employed at the national and state levels to remove barriers to education, training, and practice.
• Ultimately, the attending neonatologist is responsible for the care given by NICU providers under his or her supervision and/or collaboration. He or she should be involved in the development and periodic review of competency criteria and should ensure that malpractice liability protection, of the institution or obtained personally, covers adverse events that may involve members of the neonatal care team.

Source: https://pediatrics.aappublications.org/content/144/6/e20193147

    

Hospital transfer of premature newborns linked to heightened risk of brain injury

Ensuring extremely premature babies are born in the right place is the best approach, say researchers -16/10/2019

Transferring extremely premature babies from a lower (“non-tertiary”) level neonatal care unit to a higher (“tertiary”) level unit in the first 48 hours after birth is associated with an increased risk of severe brain injury, finds a study published by The BMJ today.

Keeping these infants at lower level units after birth is also associated with a higher risk of death, compared with birth in a tertiary facility.

The findings are based on more than 17,000 births in England between 2008 and 2015, and suggest that neonatal services should be designed to ensure, whenever possible, that extremely preterm infants are born in a tertiary care setting.

About one in 20 premature infants in high income countries are born extremely prematurely (at less than 28 weeks of pregnancy) and are at high risk of death, severe illness, and long term disability.

Studies from the 1980s found that transporting preterm infants from non-tertiary to tertiary care shortly after birth (known as “early postnatal transfer”) was linked to worse outcomes than preterm infants born in a tertiary setting.

But results from recent studies have been inconclusive, and care for the most premature babies before and after birth has changed considerably since many of these studies were done.

In England, early postnatal transfer continues to increase since neonatal care was reorganised in 2007, so it’s important to understand any effects associated with this.

To explore this further, researchers based in Finland and the UK analysed data for 17,577 extremely premature infants (born at less than 28 gestational weeks) in NHS hospitals in England between 2008 and 2015.

Infants were grouped based on birth hospital and transfer within 48 hours. Factors that could have influenced the results, like gestational age and whether antenatal steroids were given, were also taken into account by forming matched groups of babies.

Compared with controls (tertiary birth; not transferred), infants born in a non-tertiary hospital and transferred to a tertiary hospital had no significant difference in risk of death before discharge but higher risk of severe brain injury and lower chance of survival without severe brain injury.

Infants born in a non-tertiary hospital and not transferred had higher risk of death but no difference in risk of severe brain injury or survival without severe brain injury, compared with controls.

No differences in outcomes were found for infants transferred between tertiary hospitals (for non-medical reasons, such as insufficient capacity) and controls.

All these results were largely unchanged after further sensitivity analyses, suggesting that the findings withstand scrutiny.

This is an observational study, and as such, can’t establish cause, and the authors cannot rule out the possibility that some of the outcomes may have been due to other unmeasured (confounding) factors.

Nevertheless, they say this is one of the largest and most robust studies to focus on major outcomes among the highest risk infants in the context of modern neonatal care, and the results are in line with previous work in this field.

As such, they conclude: “Extremely preterm birth in a non-tertiary setting is associated with a higher risk of death and lower survival without severe brain injury compared with infants born in a tertiary neonatal setting.” They also recommend perinatal health services “promote pathways that facilitate delivery of extremely preterm infants in tertiary hospitals in preference to postnatal transfer.”

This view is supported by US researchers in a linked editorial, who say transfer before not after birth is the best approach for women at risk of preterm labour.

Professor Colm Travers from the University of Alabama at Birmingham and colleagues point out that antenatal transfer is well established in some US states, Australia and Scandinavia, where up to 95% of at risk infants are transferred before birth.

“Improved regionalization of perinatal care, prioritizing early and clear transfer pathways for women with threatened preterm labor should increase survival and reduce major lifelong morbidities among extremely preterm infants,” they conclude.

Source: https://www.bmj.com/company/newsroom/hospital-transfer-of-premature-newborns-linked-to-heightened-risk-of-brain-injury/

Retinopathy of prematurity – not only an acute condition? An interview with Professor Armin Wolf

POSTED ON 16 DECEMBER 2019 -Interview with Professor Armin Wolf, Deputy Hospital Director, Eye Hospital, Ludwig-Maximilians-University Munich

Retinopathy of Prematurity (ROP) is a condition that is found in the eyes of very preterm born babies. It is characterised by changes in the developing blood vessels of the retina (the light-sensitive layer in the back of the eye that sends visual signals to the brain). If detected timely, it can usually be treated and a blindness can be prevented. Still, it is a condition of the eye that can have long-term effects. We would like to learn a bit more about these long-term effects of ROP today.

Question: Professor Wolf , is follow-up for their eyes important for all preterm born patients, or only for a certain group (e.g. children who have been treated for ROP)? And why?

We know from various studies there are risk factors for developing ROP in a preterm infant. However, we know only little about the sequelae of this eye condition with the child growing older. Therefore, there is a screening for the child until it reaches its normal gestational age. Thereafter, controls are recommended according to findings. However, if we look at the sequelea that occur in adult age, it seems not to be dependent on whether the patient was treated during the critical time of ROP development. Nevertheless, we have to take into account that treatment of ROP has not always been the same within the last 40 years, thus we will need to continue studies on the late courses of former ROP, often referred to as adult ROP.

 Question: How long should the eyes of these babies be checked for and how often?

According to the current German guidelines for screening for ROP a continuous follow-up after reaching normal gestational age is recommended for preterm children with a birth weight of less than 1500g or a gestational age of less than 32 weeks. For children with a gestational age of 32 to 36 weeks a regular follow-up is recommended until the 6^th year. Every eye – and every patient with ROP is different, therefore it has to be decided based on every case. Especially if there are additional health problems, follow-up may need to be performed at shorter periods as it is not always easy to asses retinal status.

With new medical treatment modalities, we have seen late reactivation of ROP in very few cases, however, these cases must be identified. Currently, we have very little data from long-term follow-up of ROP patients. We are aware that they are at higher risk for retinal detachment, glaucoma and other ocular pathologies, however, we have too little data to draw conclusions. It seems that an eye that has gone through the active phase of ROP during early childhood, independent from treatment, seems to be a ”special eye also in the light of future treatment. Therefore, a treating surgeon will always need to know about the patient having been a preterm infant, and it seems that the birth weight does play a role in the individual risk.

Question: What is done during an eye follow-up examination after the baby has reached its due date and does it hurt?

Basically speaking, these examinations aim at examining the same structures that are examined during the active phase of ROP after birth at the NICU. In these examinations, pupil is dilated and the fundus (the back of the eye) is examined. Most of these patients are used to ophthalmic examinations, therefore, it is usually possible in a standard examination at the ophthalmologist. Only in few cases or if there is a possibly relevant finding during a standard examination, the examination has to be performed under full anesthesia to rule out relevant findings.

Testing the visual acuity and determining the refraction (i.e. the glasses the patient needs to wear), as well as examining the need to patch one eye to assure equal bilateral development are also part of these routine examinations. Invasive examinations are usually not necessary.

Question: Who can check the eyes of these babies and later children?

In general, these examinations may be done by any ophthalmologist. However, if the ophthalmologist feels uncomfortable or if there was an ROP diagnosis, a specialised ophthalmologist for retina or a specialized center may be senseful.

Question: Regarding follow-up, what is your advice for children who developed ROP?

We tend to look at ROP patients especially in their young ages.  At this age, follow-up is mandatory. However, with children growing up, preterm birth tends to be “forgotten”, and at later age there are only few patients that have regular follow-up examinations. I recommend to stick to lifelong follow-up with intervals depending on the clinical findings to avoid complications such as retinal detachments. In an uncomplicated ROP for example I do follow-up examinations year-wise.

 Source: https://pediatrics.aappublications.org/content/144/6/e20193147

PREEMIE FAMILY PARTNERS

Fathers in neonatal units: Improving infant health by supporting the baby-father bond and mother-father co-parenting.

INTERNATIONAL WORKING GROUP

The Family Initiative has convened the International Neonatal Fathers Working Group, involving 11 researchers and practitioners who have championed better engagement and support for fathers whose infants are being cared for in neonatal units.

​RESEARCH REVIEW-The Family Initiative has been tracking and reporting on research on fathers in neonatal care since 2015 on FamilyIncluded.com. It became apparent that some interesting and new ideas were emerging in newly published articles. In response to this, the Family Initiative approached all the authors and proposed a joint effort to report on all the new evidence.

We have since published an article in the Journal of Neonatal Nursing – Fathers in neonatal units: Improving infant health by supporting the baby-father bond and mother-father co-parenting.

This discusses the findings from 50 pieces of research in recent years on fathers in neonatal units.

The principle finding is that understanding and supporting father-infant attachment and supporting co-parenting improves the health of the baby and helps both parents to care for the baby and for each other.

WHAT NEONATAL FATHERS SAY

These are quotations from the published research that we reviewed.

“I did a bit of kangaroo with him and when I looked at him….wow! I’m going to be paternal, I know.”

“When I first saw M., it was magic, a miracle! I was all alone in the bloc.”

“The first time I held him skin-to-skin, it was really, like, wow! It was like a communion.”
“I looked at my son and then my daughter and then my wife and I just felt, damn I’m so happy.”
“I have never been this stressed before….I take care of the other children at home and of my job, but I also need to be here – I want to be here as well.”
“As a father, you feel left out.”
“I don’t want to be weak in front of my wife. I don’t think she knows how bad I am hurting right now.”

“I have to cheer her up, but no one helps me. It is difficult to bear. I do not show that I am burnt out; instead, I suppress my feelings.”
“I wouldn’t want my wife asking me how I feel.”
“Everybody around the situation is focused on mom/baby. Dads are left to worry about everything and everyone. As a dad, you may feel lonely.”
“It would have been helpful to have maybe more contact with NICU fathers such as men with children who were either currently or had been in the NICU at some point.”

RECOMMENDATIONS FOR PRACTICE-We make three key recommendations to improve infant health on the basis of the evidence:

• Support the father-baby bond in the same way the mother-baby bond is supported.
• Pay attention to the differences between mothers and fathers, both within individual families and also in relation to different gendered social expectations experienced by each.
• Support team parenting, or co-parenting, between the mother and father.

We also make 12 practical recommendations for practice:

• Assess the needs of mother and father individually.
• Consider individual needs and wants in family care plans.
• Ensure complete flexibility of access for fathers to the neonatal unit.
• Gear parenting education towards co-parenting.
• Actively promote father-baby bonding, particularly skin-to-skin, even in the presence of the mother.
• Be attentive to fathers hiding their stress from both professionals and their partners.
• Inform fathers directly not just via the mother.
• Facilitate peer-to-peer communication for fathers.
• Differentiate and analyse by gender in service evaluations.
• Train staff to work with fathers and to support co-parenting.
• Develop a father-friendly audit tool for neonatal units.
• Organise an international consultation to update guidelines for neonatal care, including those of UNICEF.

GENDER DIFFERENCES-The research identifies three ways in which fathers start from a different place from mothers:

 Fathers are often not considered “natural” careers like mothers are, a view that is strongly challenged by biological, neurobiological and psychological evidence.

Fathers are often expected to continue working and to look after older siblings.

Fathers are under strong social pressure to appear strong and to hide their distress.
Father-baby contact, particularly skin-to-skin, stimulates strong hormonal changes in men – more oxytocin, more prolactin, less testosterone. All these are linked to caring activity (as in mothers). Neurobiological changes also take place triggering ‘emotional empathy’ and ‘socio-cognitive’ networks in the father’s brain (as in the mother’s). When these two networks are strongly activated, the baby is likely to have stronger emotion regulation and social skills four years later.

Source: https://www.familyinitiative.org.uk/neonatal-fathers

Historical background to maternal-neonate separation and neonatal care.

Bergman NJ. Department of Neonatology, Karolinska Institute, Stockholm, Sweden.

Abstract

Maternal-neonate separation after birth is standard practice in the modern obstetric care. This is however a relatively new phenomenon, and its origins are described. Around 1890, two obstetricians in France expanded on a newly invented egg hatchery as a method of caring for preterm newborns. Mothers provided basic care, until incubators became part of commercial exhibitions that excluded them. After some 40 years hospitals accepted incubators, and adopted the strict separation of mothers from babies observed at the exhibitions. The introduction of artificial infant formula made the separation practical, and this also became normal practice rather than breastfeeding. Incubators and formula were unquestioned standard practices before randomized controlled trials were introduced, and therefore never subjected to such trials. The introduction of Kangaroo Care began 40 years ago in Colombia, now as a novel intervention. Recent trials do in fact show that maternal-neonate separation is detrimental to mothers and babies. Recent scientific discoveries such as the microbiome, epigenetics, and neuroimaging provide the scientific explanations that have not been available before, suggesting that skin-to-skin contact and breastfeeding are defining for the basic reproductive biology of human beings.

© 2019 Wiley Periodicals, Inc.

Source:https://www.researchgate.net/publication/333514198_Historical_background_to_maternal-neonate_separation_and_neonatal_care

Family Support Linked to Resilience in Kindergarteners Born Preterm

October 10, 2019 Center for Biobehavioral Health, Neonatology  Adelaide Feibel,

Despite known adverse outcomes associated with prematurity, a large minority of kindergarteners born preterm exhibit none of them.

For years, medical researchers have dedicated countless hours to studying the adverse outcomes of premature births.

But in their attempts to illuminate the incidence of cognitive, behavioral and learning deficits in preterm and low-birth-weight infants, researchers have failed to address an equally important question: Why do some preterm infants manage to develop normally, despite the high-risk nature of their births?

1. Gerry Taylor, PhD, principal investigator in the Center for Biobehavioral Health in the Abigail Wexner Research Institute at Nationwide Children’s Hospital, seeks to rectify this omission from the developmental literature in a study published earlier this year in the Journal of the International Neuropsychological Society.

The study, which analyzed the development of 146 extremely low-birth-weight and preterm kindergarten children and 111 of their normal-birth-weight peers from the Cleveland, Ohio, metropolitan area, found that 45% of the children in the preterm group were “resilient” to the biological risks of being preterm, meaning they displayed age-appropriate behavior and academic learning. In comparison, 73% of the control group displayed these same characteristics.

“What about the kids that do well? How do they escape the negative consequences of this quite high-risk condition? No one has really focused on that part of the population,” Dr. Taylor says. “I see resilience as the flip side of the coin of looking at the effects of brain-related risk factors in children and their development.”

By measuring both the “proximal” family environment, such as the level of stimulation at each child’s home and the quality of the relationship between the mother and child, and more “distal” social risks such as median neighborhood income, the research team discovered that resilient preterm children were more likely to have grown up in “advantaged” family environments. Such environments are those that provide ample learning opportunities for their children, where parent-child relationships are positive and supportive, and where the parents themselves do not feel highly burdened or distressed.

According to Dr. Taylor, the development literature tends to apply the concept of “resilience” to children exposed to social risks, such as high poverty, who achieve well academically and are free of significant behavior problems. In his current position, he is interested in extending the concept of resilience to children at biological risk. Children at biological risk include not only those born preterm but also those with a broader group of neurodevelopmental conditions, such as traumatic brain injury and other acquired brain insults, congenital heart disease, epilepsy and muscular dystrophy. Dr. Taylor hopes to learn more about why many children with these conditions do well and he believes that this knowledge will help find ways to enhance the development of all at-risk children.

“This is something we need to be focusing on as much as the negative outcomes,” Dr. Taylor says. “We have different things to learn from the kids that do well.”

Reference: Taylor HG, Minich N, Schluchter M, Espy KA, Klein N. Resilience in extremely preterm/extremely low birth weight kindergarten children. Journal of the International Neuropsychology Society. 2019 Apr;25(4):362-374.

Source: https://pediatricsnationwide.org/2019/10/10/family-support-linked-to-resilience-in-kindergarteners-born-preterm/

INNOVATIONS

Naturally boost Oxycontin levels for Neonatal Bonding | Living Healthy Chicago

LivingHealthyChicago  Published on Mar 11, 2019

Oxytocin is naturally occurring hormone that plays a role in social bonding. Today Jackie learns about scent clothes that are helping babies who spend time in the NICU bond with their parents! Find out why scent cloth hearts are making a big difference for the very youngest of patients.

Sewing students create fabric hearts for babies in neonatal intensive care

CBC News · Posted: Apr 04, 2019 2:35 PM MT | Last Updated: April 4, 2019

Junior high fashion studies students at Lakeland Ridge School in Sherwood Park hold up examples of fabric hearts they’ve sewn. (Caroline McKay)

Fashion studies students at Lakeland Ridge School have a lot of heart when it comes to helping families with newborns in hospital.

The junior high students have been sewing fabric hearts to give to the Misericordia Community Hospital for its neonatal intensive-care unit.

Source: https://www.cbc.ca/news/canada/edmonton/fabric-hearts-newborn-babies-students-sherwood-park-1.5084978

Bonding Heart – For Neonatal Units In Hospitals

Make a heart, with tips to help you secure a lovely shape, going around curves and corners, includes pivoting. Use 100% Cotton for the babies please, and something soft that will go against a baby’s soft, delicate skin x

If you are interested in making hearts, please send them with your contact details or drop them off at Sheffield Hospitals Charity, Wycliffe House, Northern General Hospital, Sheffield, S5 7AT.

 

WARRIORS:

KAT’S CORNER

Wishing you great Peace, Joy and Health this New Year, my Warrior family. I started the year baking a Banoffee pie, something I had never heard of, but a friend of mine had mentioned it was one of his favorites! I looked at recipes and chose one. The recipe called for a  graham cracker crust, which was not baked, only chilled. My gut said this didn’t seem right, but I choose to follow the recipe. I prepared the dolce de leche, whipped cream, and bananas to perfection. After chilling everything as directed I went to serve the pie and it was a crumbly mess! Chilled, unbaked graham cracker crust was a bust. Should have listened to my gut……

Throughout history people have sold a lot of “recipes” for life . Road signs and guidelines can be helpful. Let’s choose to listen to our guts, tap into and trust our inner wisdom, and create and enjoy unique, passionate, fulfilling lives! Cheers!

Premature birth linked to increased risk of chronic kidney disease into later life

Given high levels of preterm birth, findings have important public health implications, say researchers –01/05/2019

Preterm and early term birth are strong risk factors for the development of chronic kidney disease (CKD) from childhood into mid-adulthood, suggests a study from Sweden published by The BMJ today.

Given the high levels of preterm birth (currently 10% in the US and 5-8% in Europe), and better survival into adulthood, these findings have important public health implications, say the researchers.

Preterm birth (before 37 weeks of pregnancy) interrupts kidney development and maturity during late stage pregnancy, resulting in fewer nephrons forming (filters that remove waste and toxins from the body).

Lower nephron number has been associated with the development of high blood pressure and progressive kidney disease later in life, but the long-term risks for adults who were born prematurely remain unclear.

So a team led by Professor Casey Crump at the Icahn School of Medicine at Mount Sinai in New York, set out to investigate the relation between preterm birth and risk of CKD from childhood into mid-adulthood.

Using nationwide birth records, they analysed data for over 4 million single live births in Sweden during 1973-2014. Cases of CKD were then identified from nationwide hospital and clinic records through 2015 (maximum age 43 years).

Overall, 4,305 (0.1%) of participants had a diagnosis of CKD, yielding an overall incidence rate of 4.95 per 100,000 person years across all ages (0-43 years).

After taking account of other factors that might be important, they found that preterm birth (less than 37 weeks) was associated with a nearly twofold increased risk of CKD into mid-adulthood (9.24 per 100,000 person years). Extremely preterm birth (less than 28 weeks) was associated with a threefold increased risk of CKD into mid-adulthood (13.33 per 100,000 person years).

A slightly increased risk (5.9 per 100,000 person years) was seen even among those born at early term (37-38 weeks).

The association between preterm birth and CKD was strongest up to age 9 years, then weakened but remained increased at ages 10-19 years and 20-43 years.

These associations affected both males and females and did not seem to be related to shared genetic or environmental factors in families.

This is an observational study, and as such, can’t establish cause, and the researchers acknowledge some limitations, such as a lack of detailed clinical data to validate CKD diagnoses and potential misclassification of CKD, especially beyond childhood.

However, the large sample size and long-term follow up prompt the researchers to conclude that preterm and early term birth “are strong risk factors for the development of CKD from childhood into mid-adulthood.”

People born prematurely “need long term follow-up for monitoring and preventive actions to preserve renal function across the life course,” they add.

And they call for additional studies to assess these risks in later adulthood, and to further explain the underlying causes and clinical course of CKD in those born prematurely.

Source:https://www.bmj.com/company/newsroom/premature-birth-linked-to-increased-risk-of-chronic-kidney-disease-into-later-life/

Redefining Happiness | Street Philosophy With Jay Shetty

Published on Sep 15, 2016-Motivational philosopher Jay Shetty urges us to redefine happiness.

Disabled Surfing Australia – Gerroa 2016

Published on Mar 24, 2016-Filmed on the 20th March 2016, with hundreds of volunteers and officials helping dozens of surfing enthusiasts enjoy the beautiful waters of 7 Mile Beach, Gerroa.