Preterm Birth Rates – Iceland
Rank: 167–Rate: 6.5% Estimated # of preterm births per 100 live births (USA – 12 %)
Iceland is a Nordic island country in the North Atlantic, with a population of 364,134 and an area of 103,000 km (40,000 sq mi), making it the most sparsely populated country in Europe. The capital and largest city is Reykjavík. Reykjavik and the surrounding areas in the southwest of the country are home to over two-thirds of the population. Iceland is volcanically and geologically active. The interior consists of a plateau characterised by sand and lava fields, mountains, and glaciers, and many glacial rivers flow to the sea through the lowlands. Iceland is warmed by the Gulf Stream and has a temperate climate, despite a high latitude just outside the Arctic Circle. Its high latitude and marine influence keep summers chilly, with most of the archipelago having a polar climate.
Health: Iceland has a universal health care system that is administered by its Ministry of Welfare paid for mostly by taxes (85%) and to a lesser extent by service fees (15%). Unlike most countries, there are no private hospitals, and private insurance is practically nonexistent. A considerable portion of the government budget is assigned to health care, and Iceland ranks 11th in health care expenditures as a percentage of GDP and 14th in spending per capita. Overall, the country’s health care system is one of the best performing in the world, ranked 15th by the World Health Organization. According to an OECD report, Iceland devotes far more resources to healthcare than most industrialised nations. As of 2009, Iceland had 3.7 doctors per 1,000 people (compared with an average of 3.1 in OECD countries) and 15.3 nurses per 1,000 people (compared with an OECD average of 8.4). Icelanders are among the world’s healthiest people, with 81% reporting they are in good health, according to an OECD survey.
Our focus in this month’s blog will highlight some of the unique challenges our preterm birth community faces during the current Covid-19 pandemic.
Big THANKS to our essential workers and community members who are respecting and following local Covid-19 protocols/orders. Together we are saving lives. Here in Seattle, WA. King 5 News staff working from their homes remind us that although times are tough, together we can get through this. Through their Neighbors Helping Neighbors virtual stories King 5 staff show us that it is heroic to not only care about others but to act accordingly. You are likely sharing similar do-good stories within your local communities. People everywhere are connecting with respect and kindness while offering diverse and creative ways to pitch in for our mutual good. We see through responsible media-sharing that as a community we are resilient and adaptable as we quickly learn to educate ourselves and our children using our in-home technology and resources. We have immersed ourselves in creating home offices, learning new software programs, and changing the ways we work in order provide meaningful services and goods. We are learning to cook and bake at home, and we have had time to garden, read, make home improvements and opportunity to ponder things that have special personal meaning in our lives! We will look back at this time with sorrow, gratitude, joy and relief. We may be thinking about how we can use this time to manifest our dreams moving forward. We will be stronger, more educated, with renewed clarity about the power of human kindness and our global and local reliance on each other.
From our third floor window, while a very inspired woodpecker hammers our wood/concrete siding in order to mark his territory, we greet you with our love, gratitude, and very best wishes!
Mothers and Fathers kept from seeing their premature babies due to Covid-19 – ITV News
The Covid-19 pandemic has led to time between babies and parents being rationed. In some cases, this means new mothers and fathers are having to wait days – and in some cases weeks – to see their newborns on the neonatal ward. Health officials say the strict measures are in place to protect babies born prematurely from the risk of infection. ITV News spoke to some of the parents who were forced to stay away from their ill newborns.
An Iceland Preemie Innovation
The company name Róró originates from the Icelandic word “ró” which means calmness and comfort. Róró is dedicated to helping babies and their caregivers feel better. It was founded in 2011 around a single idea: to make a product for babies that imitated closeness when their parents needed to be away. Indeed, the idea of the Lulla doll was born when our friend had her baby girl prematurely and had to leave her alone in the hospital every night for two weeks.
Lulla doll is a soother and sleep companion for preemies, babies, toddlers and beyond. It imitates closeness to a caregiver at rest with its soft feel and soothing sounds of real-life breathing and heartbeat. Lulla plays for 12 hours to provide comfort all night long. The doll is machine washable and comes with 2 AA batteries.
COVID-19 and the NICU Balancing Safety and Care
I dedicate this column to the late Dr. Andrew (Andy) Shennan, the founder of the perinatal program at Women’s College Hospital (now at Sunnybrook Health Sciences Centre). To my teacher, my mentor and the man I owe my career as it is to, thank you. You have earned your place where there are no hospitals and no NICUs, where all the babies do is laugh and giggle and sleep.
“There is no evidence of vertical transmission of novel coronavirus between mother and baby at this time. Infants born to COVID-19 infected mothers have not tested positive for the disease, nor has novel coronavirus been found in amniotic fluid or breast milk.” Rob Graham, R.R.T./N.R.C.P.
One cannot watch television or pick up a newspaper without being bombarded with COVID-19 stories and information. In our lifetimes, we haven’t seen anything like this; while the adult world is the focus of this pandemic, we in the NICU must contend with the risks associated with parental involvement in the care of their babies.
There is no evidence of vertical transmission of novel coronavirus between mother and baby at this time. Infants born to COVID-19 infected mothers have not tested positive for the disease, nor has novel coronavirus been found in amniotic fluid or breast milk. While this is ostensibly good news, it must be tempered with the fact that this is a hitherto unknown pathogen and that while our knowledge base is growing daily, there is still much we don’t know. It is my opinion that one cannot be too cautious dealing with COVID-19; better to modify the policy as evidence becomes available than to wait for evidence to form policy. Unfortunately, the latter approach has been most common and has likely led to the explosion in cases outside the Wuhan epicentre.
Many hospitals have prohibited visitors during this crisis. This approach is certainly prudent given the increasing evidence of asymptomatic transmission but may not be in the best interests of the neonatal population. Regardless, in Toronto, there are discrepancies between institutions. (A copy of Toronto’s guideline is attached. NOTE: this is an example and not intended as medical advice or protocol). A previous column (December 2019) discussed the relationship between respiratory care and neurodevelopmental outcome, including the benefits of direct parental involvement and kangaroo care. The clear benefits of parental contact must be weighed against the risks to the baby and those who care for it. The unit in which I am employed has limited visitation to one parent at a time. Overnight stays are permitted, parents are forbidden to leave the NICU area until leaving the hospital, and face masks must be worn at all times.
The major concern when breastfeeding an infant of a COVID-19 infected mother or symptomatic parent under investigation is twofold: prevention of transmission to the infant and protection of those charged with the infant’s care. It is not breastmilk that is of concern, rather the potential infection of others via droplet. The safest approach here is to have parents wear masks to reduce the chance of droplet exposure during breastfeeding; however, the utility of regular surgical masks in preventing transmission of COVID-19 is questionable. The same applies to kangaroo care since exposure is identical. During skin to skin contact, consideration may be given to having the involved parent thoroughly clean the area of contact in addition to routine hygiene. Ideally those entering the room of a COVID-19 infected patient should wear a properly fitted N-95 mask, but the international breakdown of our supply chain has resulted in an acute shortage of PPE; thus surgical masks are being used as a substitute. There is much debate over the utility of these masks to protect caregivers but increasing evidence in their ability to reduce transmission.
The best way to contain an outbreak like this is to test and isolate. China and South Korea have amply demonstrated the efficacy of this approach. However, a combination of reagent supply shortage and a concurrent shortage of swabs (ironically mostly manufactured in Italy) have made this impossible as the pandemic spread to the rest of the world, and the fact that the number of infections outside the epicentre now greatly outnumber those within is a testament to the necessity of testing. Given the possibility of asymptomatic transmission, it would behoove us to assume infection in all until proven otherwise and act accordingly. This is a case of what we don’t know can indeed hurt us.
The risks associated with aerosol-generating medical procedures are well known, particularly in the adult population. It stands to reason that a premature infant generates less aerosol than an adult; however current guidelines call for the infant of a confirmed or suspected parent to be treated in the same manner as an adult patient. Compounding this is the unusually high viral titre with COVID-19 infection, potentially making droplets more likely to lead to infection.
In the adult population, when mechanical ventilation is required, lower tidal volumes (3-6mls/kg) and higher PEEP has been recommended, although recent anecdotal reports from the front lines are less clear. (These anecdotal reports are coming from Twitter® posts from ER physicians on the front line and as such do not constitute evidence). A letter to the editor of The American Journal of Respiratory and Critical Care Medicine, March 2020, suggests a different approach. One that is echoed by other anecdotal reports and describes an atypical ARDS picture associated with COVID-19. In this case, it is not a lack of recruitment that is the problem but rather uneven ventilation/perfusion matching. (10) HFO is potentially more prone to aerosol generation, and if used, airborne precautions are advised. (11) (This is an excellent reference for the management of all COVID-19 patients.) A filter on the expiratory limb of any ventilated patient may be considered provided it does not interfere with the normal operation of the machine and are changed in accordance with the manufacturer’s recommendations.
It is perhaps fortunate we have little data regarding neonatal infection with COVID-19. It seems that mechanical ventilation for symptomatic positive infants may only be required for other reasons (i.e., extreme prematurity as the limited number of cases seen thus far have not required intubation) and that neonates exhibit the same relatively mild symptoms of older children.(12) Recent reports of 2 infants succumbing to COVID-19 in the U.S. may be a harbinger of things to come.(13) It is my sincere hope this is not the case. Perhaps the most significant risk NICU staff face for infection are each other. Given the increasing rate of community-acquired infection and asymptomatic transmission, we are at the same or greater risk than the general population. Fomites are a known source of transmission (particularly plastic and stainless steel). (14) We are all potentially exposed this way, particularly when using public transit as grab bars, and handles are all made of plastic and stainless steel. The importance of meticulous, regular hand hygiene, and avoidance of touching the face cannot be emphasised enough.
The concept of social distancing is difficult to achieve in the NICU environment due to the necessity of close contact during procedures and the proximity of workstations. Staff are well-advised to wear face masks at all times as a matter of policy to mitigate the risk of infection. Patient assignments should be such that staff can be stationed as far away from each other as is practically possible. COVID-19 doesn’t discriminate based on credentials!
This pandemic will affect all of us one way or another. As NICU caregivers, we may be at reduced risk relative to our adult colleagues; however, as the crisis worsens, some of us may be seconded to adult areas. Now would be a good time for those assigned exclusively to the NICU to brush up on adult ventilation protocols. The Toronto Centre for Excellence in Mechanical Ventilation provides an excellent resource.
As evidence is gathered, the guidelines and recommendations we practice under are subject to change. Given limited numbers (although still increasing exponentially), the fact that there is presently no evidence to suggest vertical transmission or risks associated with breastmilk, for example, doesn’t necessarily mean risks do not exist. Healthy, younger patients are dying from COVID-19. While the mean age of infection is 45 years, the mortality rate for those <60 is approximately 0.32% compared to 6.4% in those >60 and 13.4% in those >80. (16) 0.32% seems pretty small, but this represents a 3-fold increase over that of seasonal flu in the general population.(17) We’re all playing Russian roulette; the only difference is the number of bullets in the gun. I, for one, prefer not to play.
Finally, while high-frequency jet ventilation (HFJV) is commonly used in the NICU setting, there is currently no commercially available adult jet ventilator in North America. There are a few machines available in Toronto cobbled together in labs at the University of Toronto years ago. These have been used as a last-ditch effort when other modes have failed. The Oscillate study of conventional (CV) vs. high-frequency oscillation (HFO) ventilation in adult respiratory distress syndrome (ARDS) found HFO detrimental, but similar research on HFJV has not been performed.(18) The benefits of HFJV in the neonatal population may well apply to the adult population; the high mortality rate from ARDS surely should provide an incentive to its study in this population. Now seems to be a good time.
I have been asked to explore the possibility of using the LifePulse HFJV machine in larger patients. I shall keep readers apprised of any progress in that regard. We are facing the challenge of our careers and, indeed, our lives. The world is counting on us. Please, everyone, take care of yourselves and each other. While always important, it is now more so than ever. References: 1. https://www.frontiersin.org/articles/10.3389/ fped.2020.00104/full 2
A digital response to help ensure safer childbirths during COVID-19
A new initiative launched today by Maternity Foundation, University of Copenhagen and Laerdal Global Health in collaboration with International Confederation of Midwives (ICM) and UNFPA, the UN sexual and reproductive health agency, uses a digital tool to equip midwives in low-resource settings to protect themselves, mothers and newborns from the Coronavirus and to ensure that women continue to receive respectful quality of care during pregnancy and childbirth. During the current COVID-19 pandemic, women everywhere will continue to get pregnant and give birth. In low-resource countries and in humanitarian settings affected by conflict, pregnant women, new mothers, newborns and the health personnel providing them care face great risks in the new reality brought by the virus. Health systems are facing enormous pressure with lack of staff, resources and training to take necessary preventative measures against the virus. Midwives and other skilled health personnel providing care during childbirth need immediate support and tools to be able to still provide quality maternal care in the light of the pandemic. A new digital tool launched today aims to do just that.
In response to the global COVID-19 pandemic, Maternity Foundation, University of Copenhagen, and Laerdal Global Health in collaboration with International Confederation of Midwives (ICM) and UNFPA have partnered up to develop and disseminate an immediate and digital response for healthcare personnel – particularly midwives – to protect themselves, women and newborns from COVID-19.
The coalition is launching tools for capacity building and training for midwives through the Safe Delivery App, a mobile application developed by Maternity Foundation and University of Copenhagen, which provides visual, clinical and practical guidance on how to handle the most common childbirth complications. Through the Safe Delivery App, midwives can now get key information, animated video instructions, and check lists as well as guided training to support them to limit the spread of COVID-19 in the health facilities, including information on infection prevention, breastfeeding and vertical transmission.
The Safe Delivery App is a free application that is already being used by midwives and other skilled health personnel providing care during childbirth in over 40 countries worldwide. Thereby, the partners are leveraging an existing platform that is already reaching thousands of frontline health workers. All current users of the App will receive a pop-up message creating awareness about the new module and the importance of taking pre-cautions during COVID-19. It works offline once downloaded, making it easy to use in remote settings without a stable internet connection. The new COVID-19 content in the App is available in English as of today and will be available in French in a near future. The content of the Safe Delivery App is updated according to WHO standards and guidelines.
Laerdal Global Health has 10 years of experience of simulation-based training for midwives and other health care providers in low resource settings through the Helping Mothers Survive and Helping Babies Survive training programmes, implemented in over 80 countries. The current collaboration on merging scenarios for simulation into the Safe Delivery App will expand use of the App and support training in an efficient way, supporting the midwives where they are working.
In Moshi in northern Tanzania, senior nurse midwife at Mawenzi Regional Hospital Anne Shuma and her colleagues have just been introduced to the new COVID-19 module in the Safe Delivery App. The hospital is one of the hospitals in the country selected for receiving COVID-19 patients, and preparations are in full motion to prepare isolation centers, so they are ready when the first cases arrive. In the first week of April alone, they had 50 deliveries in the hospital.
“Going through the Safe Delivery App and the COVID-19 module made us realise that we were not prepared to receive pregnant women with suspected COVID-19. Immediately, we prepared a delivery kit and brought it to the isolation center and prepared a cube where suspected cases can give birth. We have now developed checklists based on the content in the App, so we are ready for when suspected cases come. It’s a very helpful tool for us midwives in an outbreak like this. It takes a concrete case and gives guidelines that are aligned with our national guidelines; procedures for handwashing and how to handle personal protective equipment. The App has opened our minds, we’re prepared now”, says Anne Shuma, who will spend the next weeks training fellow midwives and nurses in nearby clinics and hospitals to use the Safe Delivery App in their preparations for the COVID-19 response.
Dr. Natalia Kanem, Executive Director UNFPA: “The enormity of the COVID-19 crisis and its consequences is testing us all. As essential frontline health care workers, midwives must be protected and prioritized so that they can continue providing quality care to women and their newborns during the pandemic. UNFPA is pleased to collaborate with the Maternity Foundation, Laerdal, ICM and the Government of Denmark in developing innovative online resources to support midwives and other maternity care providers working in the field. These new digital tools will enable them to access the latest evidence-based approaches to care delivery in the context of COVID-19.”
Dr. Sally Pairman, CEO of the International Confederation of Midwives: “Midwives everywhere are frontline health care professionals in the face of the coronavirus, providing essential care to pregnant women and their babies during the childbirth continuum, despite the risk this presents to their own health. Many midwives have never had to work in pandemic situations before, and for everyone the coronavirus is new. In speaking with our Midwives’ Association members, we’ve been saddened by news of midwives dying from Covid19, simply because they were not adequately protected from the virus or did not have proper information on how to protect themselves. It’s essential that midwives and all other health professionals providing maternity care can access up-to-date and evidence-based advice on the changes they need to incorporate into their practice to keep women and their babies, and themselves, as safe as possible. The new modules in the Safe Delivery App will help guide midwives everywhere with advice they can count on.”
Chairman of Laerdal Global Health Tore Laerdal: “Our mission has always been helping save lives and now it has come even closer. During these extraordinary days, we work even harder towards our mission. There are hundreds of thousands of health workers who heroically continue to work through challenging situations and are in need of all the support we can offer. We hope our manikins and simulation solutions will be the helping hand that will support them in providing safe and respectful care.”CEO of Maternity Foundation, Anna Frellsen: “The direct and indirect consequences caused by the covid-19 pandemic can be fatal for mothers and newborns in many parts of the world. The Ebola outbreak in West Africa in 2013-16 showed a dramatic increase in maternal deaths because the health system was under too much pressure to fight the pandemic to also provide quality care. In a situation like this we need to respond fast and we need to do it together. By building on an existing digital platform and our global partners’ strong channels, we are now availing essential clinical guidelines instantly to midwives, even in some of the most vulnerable settings.”
How to download the Safe Delivery App
- Search for Safe Delivery App in Google Play or App store
- Click Download – the App is free of charge
- Open the App and select language version – the COVID-19 content is in the global English version
- If you already have the Safe Delivery App on your phone, update it and the COVID-19 module will appear in the global English version
The full Infection Prevention video can be found here.
PREEMIE FAMILY PARTNERS
Vulnerable babies are being separated from their families because of corona virus
Published on Apr 19, 2020
Babies born sick and premature are being separated from their families because of hospital restrictions put in place during the corona-virus outbreak. Some hospitals are only allowing one parent to visit at a time and it’s even more difficult for siblings to meet their new relative.
Doctors are pessimistic about premature babies. Despite the evidence, we all are.
We tend to view them as “miracle babies,” or as the result of medical hubris.
By Sarah DiGregorio – Sarah DiGregorio is the author of “Early: An Intimate History of Premature Birth and What it Teaches Us About Being Human.” Feb. 21, 2020
In 2014, I was 28 weeks pregnant and sitting in a hospital bed, my husband beside me. My placenta was failing; to survive, our daughter would need to be delivered soon. She was smaller than average for this stage, an estimated 1.75 pounds.
The neonatal intensive-care unit (NICU) dispatched a neonatology fellow to help us understand what this meant. He started with our baby’s brain. When she was born, it might bleed, putting her at risk of death or cerebral palsy. Her lungs: They would certainly be immature, and she would probably have some degree of respiratory distress syndrome. Her heart might have a hole in it that would fail to close. Her intestines might develop an infection, possibly fatal, in which lengths of the bowel die. In the long term, premature babies are much more likely to experience developmental delays — the doctor guessed that our daughter had about a 50 percent chance of having a disability of some kind. She might lose some IQ points as a result of being premature, he added. The message was clear: Being born early was very, very bad, and our baby was likely to be fundamentally damaged, even in ways we would never definitively know.
It’s important that parents have the facts, and our doctor wanted us to know something true: Being born prematurely can affect a child’s health in many ways, and some of those complications can be fatal. The information he recited was medically accurate, though he probably inflated the likelihood of disability. (One benchmark is that, among babies born at 25 weeks, 13 percent develop a profound neurodevelopmental disability, and 29 percent develop a moderate one, according to data from the National Institute of Child Health and Human Development.)
The doctor’s laundry list also missed something important, something we really needed to hear at the time: The majority of babies born early, even very early, survive in good health. Their weeks, months and years ahead will not be easy. But there is also plenty of evidence for optimism.
Health-care providers have a well-documented and surprisingly durable pessimism about preemies. A 1994 survey in the American Journal of Obstetrics and Gynecology showed that doctors significantly underestimated their survival rates and overestimated their long-term disability rates. More than a decade later, a Pediatrics study of physicians, nurses and nurse practitioners echoed those findings, and showed that learning the true rates made doctors more likely to recommend resuscitation in theoretical borderline cases. Doctors are much sunnier about other patients: Research shows that internists and intensive-care unit physicians accurately assess the survival chances of adult patients admitted to the ICU.
This professional pessimism is matched by a broader cultural ambivalence. Our feelings about preterm infants are powerfully fraught. They suggest the thinness of the line between life and death; they symbolize the heights of human capability and the perils of going too far. We have two common narratives about premature infants: inspirational “miracle baby” stories and warnings of medical hubris. Record-setting “micro-preemies” who “defy the odds” and “fight for their lives” are regularly featured in tabloids and local TV broadcasts. Meanwhile, a 2017 Maclean’s article wondered, in the case of a very early birth, “to what extent should we intervene to prevent nature from taking that life before it becomes fully viable and conscious?” A Bloomberg Businessweek article, “Million-Dollar Babies,” asked, “Is there such a thing as too young?” Perhaps the general hand-wringing over such efforts made AOL’s chief executive blame the expensive medical care of “distressed babies” when he cut employee retirement benefits in 2014.
Our fascination with premature infants has always contained starry-eyed optimism about what could be done for them, along with uncertainty about whether the results were “worth” those efforts. That conflict goes back to the invention of the incubator in the 1880s, as Jeffrey Baker writes in “The Machine in the Nursery.” The medical establishment was slow to adopt the technology: The machine was expensive, and the value of the lives saved was seen as dubious. At the time, “Better Baby” contests were wildly popular, grading children on pseudoscientific traits like head measurements and awarding prizes to the “fittest” (i.e. large, able-bodied babies of white European heritage). Eugenicists argued that premature babies weren’t meant to survive; they would become a drain on society. The Buffalo Medical Journal wondered “whether the race as a whole does not suffer from the preservation of these weaklings to perpetuate their kind.” As a result, incubators remained a curiosity, touring world’s fairs and popping up in Coney Island as a boardwalk sideshow. People paid to gawk at preemies in their warm, glass-fronted boxes — they were objects of voyeuristic amazement, inspiring both hope and horror.
Even as cultural attitudes have progressed, some anxiety remains, often rooted in fears of disability. The 1985 book “Playing God in the Nursery” warned of “the dismal fate of a disturbing number of ‘salvaged’ babies’ ” who go on to lead “pathetic lives.” Two neonatologists called on fellow physicians to reexamine these beliefs in the Journal of Perinatology in 2013: “For the case of the preterm newborn, in particular, there may also be a sense that she is still ‘not meant to be here,’ ” they wrote. “If she survives with significant disability, the physicians might perceive that: But for our actions, there would be no disabled child.” The worry about gratuitous intervention, present in many medical decisions, seems especially acute when it comes to these patients.
All preterm babies are at increased risk for neurodevelopmental and learning disabilities when compared with term babies; the earlier the birth, the higher and more severe the risk. But these blanket assessments elide the fact that “disability” includes a whole range of experiences. Rigorous quality-of-life studies have found that as extremely premature babies grow into young adults, they rate their own health-related quality of life just as highly as a control group born at term. That includes former preemies who have a significant disability, such as cerebral palsy, vision problems or hydrocephalus — outcomes that providers seem to view more negatively than parents do. Neonatal providers often think that serious disabilities following from premature birth are worse than death, one study published in the Journal of the American Medical Association found. Most parents of babies born under 2.2 pounds feel differently — as do the grown ex-preemies themselves.
The truth is that the successful treatment of premature babies is one of the great triumphs of modern medicine. Before the widespread adoption of the incubator (and back when babies were usually studied by weight rather than gestational age), an 1883 study found, only about 35 percent of babies born under 4.4 pounds survived. But it isn’t just the incubator: With the subsequent development of respiratory support, intravenous nutrition and a host of other treatments, outcomes have improved dramatically. Infants born at the edge of viability, between 22 and 25 weeks, do, unfortunately, face substantial risk of death. But the vast majority of premature babies — more than 80 percent — are born after 32 weeks, and those born at 26 weeks and above are now quite likely to survive. According to the most recent available data from the Centers for Disease Control and Prevention, 87 percent of infants born at 26 weeks survive, and outcomes improve with each week of development.
Health-care providers are uniquely positioned to reframe our understanding of premature birth. They can answer parents’ questions, rather than leading with negative (and often hypothetical) predictions, and they can ground the discussion in the latest research. That evidence-based optimism might seep into the wider conversation. At the very least, it would make a difference to families, whose numbers are growing: More than 1,000 babies are born prematurely in the United States every day, and that figure has been rising for the past four years.
Families of premature babies are often deeply grateful to the providers who saved their children’s lives, and I am no exception. The doctor who recited that laundry list may have just been following hospital protocol. He probably had the best intentions; he may have been trying to manage his own emotions and expectations. But our counseling session hit me so hard not just because it laid out all the worst-case scenarios: It also seemed to say that my daughter would not have a wide-open future. She would forever be measured against an ideal that she was born short of and could never grow into.
And yet, in the time since, I have never wished my daughter, now age 5, were different. I speak from a position of tremendous luck: Her IQ is “normal,” whatever that means; she has a pulmonologist monitoring her persistent asthma and receives physical and occupational therapies for minor motor delay. Some of her fellow former preemies have fewer challenges; others have far more. But I don’t contemplate who she may have been, and I can’t wish away those difficulties without, in some real sense, wishing her away, exactly as she is.
We have a powerful collective fantasy of newborn perfection. We associate babies with possibility; we believe they could grow up to be anything, do anything. The truth is that no one, anywhere, has unlimited potential, not even at the very start of their life. But that fantasy can lend early births an unnecessarily tragic aspect — a sense of brokenness, of damage, even before parents have a chance to hold their infants. And often, we have plenty of reason to hope.
Does COVID-19 affect pregnancies?
UW Medicine – Mar 24, 2020
Much is still unknown about the virus that causes COVID-19. Dr. Kristina Adams Waldorf, professor of obstetrics and gynecology at University of Washington School of Medicine, shifted her lab’s focus to research what effects the virus may have on a pregnancy or a newborn. Scientists are investigating such questions as whether the infection can affect a fetus’ growth or whether it heightens the risk for preterm birth, stillbirth, and other conditions. This kind of research can help determine clinicians’ responses to pregnancies that also involve COVID-19.
Will Simplifying the Finnegan Neonatal Abstinence Scoring Tool Improve Outcomes for Infants With Opioid Exposure?
It has been known for decades that opioid withdrawal in neonates has the potential to be fatal. Unfortunately, newborn withdrawal symptoms can be nonspecific, and identifying and differentiating infants with drug withdrawal from those with other illnesses, such as infection or neurologic problems, can be difficult, especially when maternal history is not forthcoming. Loretta Finnegan and colleagues devised the 21-point Finnegan Neonatal Abstinence Scoring Tool (FNAST) in 1975 based on observations of 55 full-term infants with narcotic exposure who were born at the Philadelphia General Hospital. The neonates were all admitted to a nursery and scored every hour for the first 24 hours, then every 2 hours on day 2, and then every 4 hours after that. They were formula fed and treated with a repertoire of agents that are no longer used as first-line treatments, including phenobarbital, paregoric, chlorpromazine, and diazepam. The FNAST is now the most widely used tool to screen, assess, and treat infants suspected of having drug withdrawal, but it is notoriously difficult to administer and is fraught with subjective differences.
In the study by Devlin et al, the authors attempted to shorten and simplify the FNAST by incorporating observational data from several infant cohorts (N = 424), including infants who did not require medications for neonatal abstinence syndrome (NAS). They dichotomized items that were previously expressed in grades of severity and removed items that were not observed frequently or were extremely heterogeneous, including convulsions, high-pitched crying, and hyperactive reflexes. The result was an assessment scale made up of 8 items, from which scores of 4 and 5 yielded closest agreement with FNAST treatment thresholds of 8 and 12, respectively (weight κ = 0.55; 95% CI, 0.48-0.61).
The simplicity of this tool is attractive. However, before it can be embraced in clinical care, several questions remain to be answered. First, only 1 score was used to determine treatment. Withdrawal symptoms typically evolve as the infant ages, and whether the associations between the 8 chosen items and NAS remain consistent with time needs to be assessed. The rare or uncommon items, such as seizures, were removed, but this may have limited the ability of the scale to detect severe but rare manifestations of withdrawal that require urgent treatment rather than continued observation. Critical events, such as seizures, may not have been common in the cohort studied by Devlin et al4 because the infants, unlike historical examples, were already monitored and treated preemptively with supportive care.
Nevertheless, the most significant knowledge gaps with the use of this and other scales is the lack of information regarding long-term outcomes. No prospective, well-controlled longitudinal studies have been conducted to associate prenatal drug exposure as well as assessment and treatment for NAS with later neurodevelopmental outcomes. Every single drug that causes NAS and every single medication that is used to treat withdrawal is neurotoxic. For example, opioids interfere with neurotransmitter homeostasis, promote cell death by apoptosis, and reduce brain growth and neuronal differentiation.5 Conversely, without treatment, severe withdrawal could lead to serious complications, such as dehydration, malnutrition, seizures, and even death.
Certainly, the work of Devlin et al highlights that much more needs to be known about how an infant responds postnatally to intrauterine drug exposure and the optimum screening, diagnostic, and treatment strategies. Perhaps the ultimate goal should not be to decide whether to treat an infant with medication but to prevent poor outcomes, including neurologic harm and death. Adopting simple measures will only be effective if they are systematically accepted by clinicians, parents, guardians, and caretakers, which is often not the case. For example, standardized protocols for identifying and treating women with opioid use disorder and for assessing and treating infants at risk of NAS have been shown to be beneficial in reducing length of hospitalization and rates of NAS treatment even without changing assessment scales.
Finally, we need to acknowledge that infants, especially those affected by multiple drugs, may need more than 1 type of assessment. The FNAST was based on infants withdrawing from narcotics, most notably heroin and methadone. Today, pregnant women with a drug use disorder usually use multiple drugs, which may obfuscate the clinical presentation of the infant. Incorporating items from other scales, such as the NICU Network Neurobehavioral Scale, which incorporates physiological parameters with interactive capabilities in an assessment method, may provide useful diagnostic information even for infants without opioid exposure and may even prognosticate not only for the short term but also, importantly, for longer-term outcomes.
Published: April 8, 2020. doi:10.1001/jamanetworkopen.2020.2271
Advanced Wireless Neonatal Body Monitors to Improve Outcomes
Babies that end up in the neonatal intensive care unit (NICU) or pediatric intensive care unit (PICU) are monitored via a complex collection of sensors, each of which has a wire connected to a patient monitor. While necessary, all this technology makes it difficult for parents to bond with their children and for clinicians to access their patients.
Northwestern University engineers have developed flexible, wireless sensor patches that are able to collect the same vital signs as wired devices while offering an entire set of additional capabilities that existing commercial devices lack.
The new sensors are able to track the heart rate, respiration rate, temperature, and blood oxygenation as well as conventional sensors, and they also allow for monitoring of body movement and orientation, recording heart sounds, crying, and other audio biomarkers, and even provide a pretty accurate estimate of systolic blood pressure.
The sensors are powered by internal batteries and are pretty cheap to manufacture, and so should be applicable for use in low resource areas and varying clinical settings. Additionally, the same sensors can be used to monitor pregnant women and potentially hospitalized adults as well.
Following comprehensive testing at two hospitals in Chicago, the results of which have just been published in journal Nature Medicine, the sensors are already being evaluated for use on newborns in a hospital in Kenya and one in Zambia.
HEALTH CARE PARTNERS
At Mayo Clinic, Bringing Neonatologists to the Point of Care with Telemedicine
The health system has co-developed a tele-neonatology program designed to close a gap in care that has existed when neonatologists aren’t physically available.
Rajiv Leventhal– Oct 29th, 2019
According to researchers at the Rochester, Minn.-based Mayo Clinic, 10 percent of all newborn infants will require assistance at birth, while approximately 1 in 1,000 newborns will require advanced resuscitation after delivery—an intervention after a baby is born to help it breathe and to help its heart beat.
When these high-risk deliveries occur in a local referral center, such as the aforementioned Mayo Clinic, newborn outcomes can be optimized under the care of a multidisciplinary team that has frequent experience with neonatal resuscitation.
Conversely, if a similar high-risk delivery occurs in a community hospital, the local providers may face unique challenges when responding to delivery room emergencies, Mayo Clinic researchers pointed out. As such, the health system recently co-developed a Newborn Resuscitation Telemedicine Program (NRTP) in collaboration with telehealth solutions company InTouch Health.
At Mayo Clinic, the organization’s main hub in Rochester has Level III and Level IV regional NICUs (neonatal intensive care units)—Level IV being the highest level of neonatal care—but there are also 10 Mayo Clinic health system sites that range from having just Level 1 well baby nurseries up to Level II intermediate specialty care nurseries. On top of that, Mayo Clinic has eight emergency departments (EDs) that are a part of either critical access hospitals or standalone EDs where there are no labor or delivery services, explains Beth Kreofsky, operations manager for the new tele-neonatology program at Mayo Clinic.
“So when mothers present to these sites, they may not always have access to a neonatologist. Six years ago, our team identified—with the assistants of our Mayo Clinic health system pediatric teams and family medicine providers—that there was a need to have a neonatologist available for assistance at the bedside in critical care situations where newborn resuscitation was needed,” Kreofsky recalls.
This disparity based on birth location was what motivated Christopher E. Colby, M.D., chair of neonatal medicine at Mayo Clinic’s Rochester campus to explore the use of telemedicine for newborn resuscitation, according to health system officials who noted that Dr. Colby’s first consultation was for an extremely preterm baby with an unknown gestational age due to limited prenatal care.
In this scenario, the local physician was unsure if the newborn was viable and if resuscitation was indicated. After examining the baby via video, Dr. Colby determined the neonate was likely 26 to 28 weeks gestation and proceeded to guide the resuscitation and stabilization. After a short time in the Mayo Clinic NICU, the baby was transferred back to the local Level II nursery. From there, the healthy infant was discharged home, health system officials explained.
The telemedicine program that has now been established enables nine board certified Rochester-based neonatologists to consult with local care teams in 10 health system sites. Prior to using telemedicine, only 43 percent of newborns in Mayo Clinic health system sites had access to a neonatologist if they required advanced resuscitation, officials pointed out, and as Kreofsky explains it, in these situations, local care teams would activate Mayo Clinic’s transport services and be asked to connect by phone to a neonatologist to assist in the service.
“Now we have added the video component onto that workflow so our neonatologists can see what the infants look like and what the physician at the local hospital is seeing, and can then provide appropriate recommendations. This is [compared with the prior approach of] not being able to see what’s going on and conducting what essentially [amounted] to a phone consult,” Kreofsky says.
This can be especially beneficial in rural settings where neonatal resuscitations are typically attended by general pediatricians or family practitioners. “While clinicians may have completed Neonatal Resuscitation Program training, knowledge and technical skills decline within four to six months, if not used regularly. Maintaining high proficiency in the face of low volumes presents inevitable challenges for rural providers. Telemedicine serves as a mechanism to address barriers in access to subspecialty care, support neonatal resuscitation in remote sites, and improve care for critically ill outborn neonates,” Kreofsky and her Mayo Clinic colleagues wrote in a study that evaluated the tele-neonatology program.
The study also examined the effectiveness of two telemedicine technologies used to provide NRTP consults: the InTouch Health Lite device compared with a wired telemedicine cart. As Kreofsky explains, if a mother needs to be moved to a different room, say for a C-section, the wired cart solution requires unplugging the device and removing it from the wall to a place where a network jack could be found. And if the physician gets disconnected during that transition, he or she would have to reconnect once the network is reestablished on that device.
But the InTouch technology, on the other hand, allows the physician to stay connected as the patient is being transitioned, meaning the transition is “more seamless and you don’t have to worry about unplugging anything or reestablishing connections in this scenario,” says Kreofsky.
Kreofsky also clarifies that when a tele-neonatology service does occur, neonatologists are able to partner with the local family medicine physician and pediatrician to assist with guidance and recommendations, but it’s the bedside physician who is still in control of all the care that’s happening on site. “So while a neonatologist cannot physically get their hands on a patient, he or she can assist with recommendations on how neonatal resuscitation program standards are followed throughout a resuscitation,” Kreofsky explains.
During the 20-month study period, 118 NRTP consultations were performed across Mayo Clinic sites, resulting in:
- 96 percent first connection attempt rate—the ability of the device to connect to the network on the first try.
- 93 percent incident resolve rate—the ability of the provider to easily resolve any issues with the device before patient care is impacted.
- Results of the NRTP device can be compared to a traditional wired cart, which saw a 73 percent connection attempt rate and a 68 percent incident resolve rate.
Kreofsky also notes that more recent satisfaction survey results found that 99 percent of the local care teams who have been surveyed agreed that they would use tele-neonatology again and would recommend it to others. Further, 100 percent of Mayo Clinic’s local care teams surveyed agreed that the consulting neonatologist provided, brief, clear, and specific information for the team, and worked collaboratively with them locally via telemedicine.
According to Jennifer L. Fang, M.D., with neonatal medicine at Mayo Clinic in Minnesota, the next step is to study the impact telemedicine has on the quality of newborn resuscitations. “While we and our colleagues in the health system believe telemedicine is improving delivery room care, we need to design a study to better answer that question,” she said.
A simple solution for healthier premature babies?
CBC News: The National – Published on Feb 12, 2018
Is there a simple solution to improve the health of premature babies? A new Canadian-led study suggests there is. The study’s results showed that by simply getting a premature baby’s parents involved in the care process sooner, the baby gained 15 per cent more weight. There was also another effect — the parents also showed less stress.
Kat has been teaching virtual fitness classes from home during Covid-19 Stay at Home restrictions. Kat’s voice was significantly impacted from long term intubation as a 24 week micro-preemie. Back in 1991 the intubation equipment was quite large and the roof of her mouth is a deep cavern. Her voice is smokey in her normal tone and she is often asked if she is a smoker (she is not). Kat has always had difficulty talking loudly and she will not be pursuing a singing career. I stay upstairs while she teaches her classes and have had the opportunity to re-notice how challenging it is for her to shout out directions and encouragement while teaching HITT fitness (Strong Nation) classes throughout each 60 minute session. This is not a big problem that needs fixing, just an interesting preemie outcome. I wish I would have been more aware of this impairment issue when Kat was a kid and her coaches yelled at her to yell louder!
Voice Abnormalities and Laryngeal Pathology in Preterm Children
PMID: 29962214 DOI: 10.1177/0003489418776987
Introduction: The prevalence of voice abnormalities in children born prematurely has been reported to be as high as 58%. Few studies have examined these abnormalities with laryngoscopic or videostroboscopic findings and characterized their laryngeal pathologies.
Objective: To review voice abnormalities in patients with a history of prematurity and characterize the etiology of their voice problems. A secondary objective is to see if there is a correlation between the findings and the patient’s intubation and surgical history.
Methods: A retrospective chart review was conducted of all preterm patients seen in voice clinic at a tertiary pediatric hospital. Demographic data, diagnoses, and office laryngoscopies were reviewed as well as any speech therapy evaluations and/or medical and surgical treatments.
Results: Fifty-seven patients were included. Mean age at presentation was 5.1 (±4.3) years. Mean gestational age was 27.8 (±3.7) weeks. Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) perceptual evaluations included a mean overall dysphonia severity of 46.6 (±24.2). Patients who had undergone prolonged intubation (⩾28 days) in the NICU or had prolonged NICU stays (>12 weeks) had significantly higher overall dysphonia severity scores. Thirty-three patients with vocal fold hypo- or immobility had significantly greater voice deviance in breathiness, loudness, and overall severity compared to those without vocal fold immobility. Of all patients, 35% were recommended surgical intervention and 49% voice therapy.
Conclusion: Intubation greater than 28 days and prolonged NICU stays are associated with more severe dysphonia in premature patients. There should be a low threshold for clinical evaluation of dysphonia in this unique patient population. ***Dysphonia= impairment of the voice
Covid-19: A Collective Hero’s Journey Dr. Arielle Schwartz
“Covid-19 has led many of us around the world to experience feelings of shock and confusion. This collective crisis has disrupted our orientation to the world as we have known it. We have been thrust into a process of self-discovery and a requisite redefining of our lives. It is impossible to go back to the old ways of living.” ~Dr. Arielle Schwartz
American mythologist, Joseph Campbell (2008), describes personal transformation as a hero’s journey. The hero must enter the darkness, face challenges, slay the dragon, retrieve the treasure, and emerge stronger. Here, we understand that challenging life events can serve as a call to enter the hero’s journey. You may feel as though you have been thrown into an abyss. The dragons you must slay are the inner demons. You walk into the darkness in order retrieve the treasures that exist within you, such as inner strength, wisdom, and hope. You emerge with an enhanced sense of meaning and purpose, which become the gifts that you have to offer to the world.
A Collective Hero’s Journey
Campbell described the hero’s journey as a “monomyth,” which serves as a blueprint for many of our fairytales, books, and movies. The monomyth is described as a cycle that begins with a phase of freedom and innocence. This period of ease is tragically disrupted by a crisis that sends the hero into exile.
Here we are. There is no turning back. Covid-19 has changed our world. But, we are in this together. To overcome the challenges that are set before us, we must seek out resources needed to face our fears and inner demons. We must go within to gather our strength and to rise up in the midst of crisis. We are being asked to become the best version of ourselves.
This doesn’t mean that we won’t feel pain. Attending to our sadness, anger, fear is the path forward. Attend with love. Reach out…we are not meant to move through this alone. Perhaps, that is part of the lesson. We are a collective. We are deeply connected to each other. We are here to give and receive from each other.
Crisis as Catalyst
Perhaps our current world crisis has been the catalyst. Or, maybe your hero’s journey began long ago as a result of childhood trauma. No matter the origin, a hero’s journey can guide our process by encouraging us to transform our pain into a source of wisdom.
You might have uncomfortable places that you don’t like to acknowledge or feel. As a result, you might want to reject the call to enter the hero’s journey. The desire to avoid peering into the darkness is normal. It is human instinct to move away from pain. However, learning to turn toward discomfort is necessary and important. Even though you might want to run away, explore the resources that help you to step forward toward the discomfort. Remote psychotherapy, online support groups, journaling, time in nature, or mindful embodiment practices can all help you lean into discomfort at a pace that is right for you.
Living in Two Worlds
The challenge set before us is to learn to live in two worlds—that is, to maintain a connection to our inner, spiritual self while simultaneously living in the outer world. This dual connection helps us learn to live on a threshold where we can acknowledge our pain as a source of compassion.
At times, we might wonder how to live in a world that has betrayed us and that could betray us again. We grow by increasing our ability to hold the complexity of the human experience. This world contains experiences of harm and loss; however, this is also a world of love and care.
Transformed by a hero’s journey, we have an opportunity to grow ourselves into mature adults, capable of holding complex feelings and ideas in a world that can cause harm. There is a great maturity in being able to hold the truth that hurtfulness and happiness can coexist around and within you. We can learn to hold dichotomies, polarities, and contradictions. Experiences of pain are an inevitable part of life; opening our hearts involves the risk of pain. However, life can have excruciatingly painful moments and still be magnificently beautiful. Living on the threshold allows us to walk through the world with an effortless grace that emanates from within.
Emerging into Wholeness
Walk slowly and gently as you face your fears.
In time, we can all learn to trust our capacity to enter the darkness and return to the light. Successfully navigating the hero’s journey gives us the opportunity to discover that we are more powerful than we previously realized.
As a result, the here’s journey allows us to feel more grounded, real, and whole because – in truth – this transformation is about revealing who we truly are.
Together, let us remember that there is an inseparable relationship between our own personal happiness and the wellbeing of others.
(Kathy) I spent time with Joseph Campbell at Esalen Institute (late 1970’s/early 1980’s). His informal meal gatherings were enlightening and soul-challenging. He was an understated yet powerful speaker who mastered the dynamics of human behavior, subconscious motivations and pathways to transformation. Who in your life inspires transformation?
Covid-19 requires that we look beyond our preterm birth community this month into our broader communities so we can all be empowered through our shared resources and information. How Covid-19 will affect maternal outcomes and our preterm birth communities will be somewhat identified over time. Please reach out to your local healthcare providers for guidance and support and consider reviewing fluid resources such as WHO regarding Covid-19 pregnancy and childbirth information: Source: https://www.who.int/news-room/q-a-detail/q-a-on-covid-19-and-pregnancy-and-childbirth
Communities worldwide are navigating with limited resources the creation/expansion of medical, social, economic, governing, inter-governmental, technological, educational, interpersonal and personal best practices to maximize the health and wellness of their community members, patients, essential workforce and healthcare/wellness providers. The global health care provider shortage crisis is now critically exacerbated by our global pandemic experience.
Providing communities with factual, science-based information and resources is a critical component in building trust and reducing fear during crisis in a society that has access to multiple “news” resources at their fingertips. Addressing and advancing mental health holistically in our communities strengthens our ability to save lives, limit loss, and prevents fear-based violence. Media that offers not only factual information but also provides a community with guidelines for engaging in meaningful action supports mental wellness during times of crisis.
THANK YOU to the media members who have reached out to challenge us, give our actions meaning and power, who have focused on what good we can accomplish together while building hope and expressing our fears and gratitude.
As time transpires and we are able to review pertinent essential data including community engagement strategies, socioeconomic factors, local and global resources we will have an opportunity to build better societal strategies to serve our diverse communities. Borders do not exist for climate change and environmental disasters or for pandemic types of human-centric challenges. Technology has the capacity to collect, provide, analyze, and disperse critical data that through collaboration and intent will allow all of us to respond to our personal, community, and global health care challenges with effective, fluid, time-sensitive, immediate and long-term action based planning.
It is essential that we work together in order to support and empower a healthy and sustainable planet. Covid-19 offers, and in some ways forces us to see in action the possibilities positive collaborative engagement provides. Our thanks to all of you who are choosing to stay informed, conduct your lives with intelligence and humane purpose, who live with integrity and a vision of good. Together we can create a safer, life affirming, dynamic and responsible global/local community for all.
Under An Arctic Sky – Official Trailer #1
Jan 17, 2017
With three hours of light each day, brutal winter storms and freezing temperatures, Iceland is far from the ideal surf trip. However, this didn’t stop photographer Chris Burkard and filmmaker Ben Weiland from rounding up a crew of surfers to seek out unknown waves in the islands remote north… all during the worst storm to hit Iceland’s shores in 25 years.