Mozambique: Moçambique,  is a country located in southeastern Africa bordered by the Indian Ocean to the east, Tanzania to the north, Malawi and Zambia to the northwest, Zimbabwe to the west, and Eswatini and South Africa to the southwest. The sovereign state is separated from the ComorosMayotte and Madagascar by the Mozambique Channel to the east. The capital and largest city is Maputo.

Mozambique is endowed with rich and extensive natural resources, notwithstanding the country’s economy is based chiefly on fishery—substantially molluscscrustaceans and echinoderms—and agriculture with a growing industry of food and beverages, chemical manufacturing, aluminium and oil. The tourism sector is expanding. South Africa remains Mozambique’s main trading partner, preserving a close relationship with Portugal with a perspective on other European markets.

Since 2001, Mozambique’s GDP growth has been thriving, but the nation is still one of the poorest and most underdeveloped countries in the world, ranking low in GDP per capitahuman development, measures of inequality and average life expectancy.

The country’s population of around 30 million, as of 2022 estimates, is composed of overwhelmingly Bantu peoples. However, the only official language in Mozambique is the colonial language of Portuguese, which is spoken in urban areas as a first or second language by most, and generally as a lingua franca between younger Mozambicans with access to formal education. The most important local languages include TsongaMakhuwaSena, Chichewa, and Swahili.


MOZAMBIQUE: JAPAN Donates USD 20 Million to Improve Neonatal Care


The Japanese International Cooperation Agency (JICA) on Thursday pledged to disburse the sum of 20.1 million US dollars to finance the construction of a new neonatal care unit at the Maputo Central Hospital (HCM) in Mozambican.

To that end Minister of Foreign Affairs Veronica Macamo signed an agreement on behalf of the Mozambican Government and the Japanese Ambassador to Mozambique, Kimura Hajime.

The aim is to improve paediatric services provided by HCM the country’s largest public hospital.

Construction works are expected to start in 2024 and to be completed over a period of two years.

The new neonatal care unit building will provide for most of maternal and child care health services which are currently spread over a number of buildings such as maternity and paediatrics wards, among others. This is due to the lack of a single building to accommodate all services which will now be integrated in one single entity.

Speaking shortly after the signing ceremony, HCM’s general director Mouzinho Saide said that the new building will provide more space for incubators since one of the major cause of hospitalization in paediatrics wards was prematurity. It will also make for the installation of specialised operating theatres which will bring down waiting time.

The new infrastructure will also allow provision of accommodation for both babies and mothers in neonatology, which currently is not always possible. Furthermore, it will provide for more space for laboratories and training for health professionals.

“The unit will improve the Central Hospital’s capacity to provide for newborns and also render better services thanks to the provision of better equipment that will be installed”, he assured.

According to Saide, the donation comes on top of other ongoing projects in the health sectors in the country, also financed by the Japanese government seeking to achieve universal health coverage, with a special emphasis on the Mozambican President’s initiative: “One District, One Hospital”.

For his turn, the Japanese ambassador pointed out that the donation aims to improve paediatric services in Mozambique and reducing infant mortality through the construction of a neonatal care unit and provision of state-of-the-art hospital equipment to improve maternal and newborn health.

The diplomat also pointed out that Japan’s cooperation policy with Mozambique prioritizes human development, focused on improving public health as a condition for fighting poverty.

“We saw the need to improve the interconnection between neonatology, paediatrics and maternity services as a way to overcome obstacles in provision of neonatal care”, he said, adding that Mozambique has one of the highest birth rates in the world, hence the need to match the population growth.


New guidelines to care for premature babies

Nov,17,202022 KPIX | CBS NEWS BAY AREA

November 17th marks world prematurity day. Dr. Gary Darmstadt, professor of pediatrics and co-principal investigator of the Prematurity Research Center at Stanford Medicine, discusses the new World Health Organization’s updated guidelines for the care of premature and low birthweight babies.

WA Hospitals Close Labor and Delivery Units, Raising Fears For New Parents

May 14, 2023 at 6:00 am   By Elise Takahama  – Seattle Times staff reporter

Deciding where to have a baby is often intensely personal for new parents: Do you want to go to a hospital or give birth at home? Are you comfortable with the doctor? Is it close enough to make it in time if complications arise?

These choices — a decision about where and how to bring new life into the world — are dwindling for some expectant parents across Washington. Labor and delivery units, particularly in rural areas, have been among the first services to be cut as Washington hospitals face financial turmoil.

When Yakima County resident Emma Argo became pregnant with her third child last summer, she hoped to deliver at Astria Toppenish, a community hospital less than 10 minutes from her home in Zillah. She was taken aback when the hospital abruptly closed its labor and delivery unit in December, four months before her due date. After the closure, Argo said she felt an “emotional toll.”

“The time I should be spending packing a hospital bag or washing baby clothes is spent sorting this out,” she said a few weeks before giving birth. “It just feels like one more thing.”

Labor and delivery units have been on the front lines for cuts because they’re expensive for hospitals to operate. They require specialized staff, services like neonatal intensive care units are particularly costly, and government-paid insurance plans often don’t reimburse hospitals for the full cost of care.

At the same time, hospitals are desperate: Hospitals in the state had collectively lost about $2.1 billion by the end of 2022, largely due to dried-up federal pandemic relief, rising costs and low Medicaid reimbursement rates. But as labor and delivery units close, parents in those areas are left with fewer options — and the possibility that it could take them longer to access obstetric care in an emergency, when every second counts.

Reducing options for expectant parents in Southeast King County, MultiCare Covington Medical Center shuttered its birth center in September. The same happened at Forks Community Hospital on the Olympic Peninsula last December, about 60 miles from the nearest hospital birthing center in Port Angeles, though the hospital is working to restaff the unit.

Washington health care leaders have warned of hospitals’ financial problems for at least a year now, and other services have been cut in recent months: At Providence Everett, admissions to its pediatric inpatient unit have been paused since last fall. Astria Sunnyside lost its cardiology services in the winter. But the labor and delivery cuts may have sparked the most public pushback.

Some relief for pregnancy care is on its way after the state Legislature, which recently wrapped up its 2023 session, boosted Medicaid rates and funded a new doula program. At the same time, communities are scrambling to prevent these losses. 

“Losing hospital services is something every Washingtonian should be concerned about,” Cassie Sauer, CEO of the Washington State Hospital Association, said in a news conference in November. “When these resources leave a community, it’s nearly impossible to get them back.”

How we got here

Apple orchards, hops farms and rolling hills stretch over more than 4,000 square miles of Central Washington. At the northeast edge of the Yakama Reservation, the town of Toppenish is home to about 9,000 people in the lower Yakima Valley, with farmland surrounding a small downtown dotted with murals. The town’s hospital, Astria Toppenish, has been a community staple for decades, and its maternity center was well-loved.

The December 2022 closure came as a shock, said Dr. Jordann Loehr, an OB-GYN who used to deliver out of Astria Toppenish. 

“I still don’t understand this decision,” she said. “It’s heartbreaking to our community, many whose mothers, grandmothers and great grandmothers had their babies at Toppenish.”

According to the hospital, however, its labor and delivery unit had struggled all year. Astria Toppenish reported it brought on nearly 200% more travel nurses, contracted workers who typically move from hospital to hospital in response to demand and often get paid more than staff nurses. The hospital also saw increases in supply costs due to inflation. Efforts to hire permanent pediatricians, who also worked in the unit, were unsuccessful, the hospital said.

Astria Toppenish’s reimbursement rates for Medicaid services, temporarily boosted in 2020 thanks to a one-year budget provision, were slashed by a third the following year when lawmakers denied an extension, according to the hospital. The drop meant providers were not getting reimbursed for the complete cost of their services by federal Medicaid programs, and would ultimately lose money when treating Medicaid patients, who made up more than 75% of Astria Toppenish’s obstetrics clients.

For example, while a standard vaginal delivery, usually a one-day stay, costs about $8,000 to $10,000 per day, the hospital was only getting reimbursed about $3,765 for Medicaid patients, said Jane Winslow, an Astria Toppenish spokesperson. 

A cesarean, or C-section, usually costs about $35,000 for a three-and-a-half-day stay in the hospital, while the Medicaid reimbursement amounted to about $4,933, Winslow said, using an example of a “snapshot in time” from December 2022. 

By the end of the year, Toppenish’s labor and delivery services had lost $3.2 million, the hospital said.

“It is a very challenging service line to keep open when you’re facing the financial losses that many of the hospitals are right now,” said Chelene Whiteaker, senior vice president of government affairs at the Washington State Hospital Association. “You’re thinking, ‘If you keep that open, what else are you going to have to close instead?’”

Historically, obstetrics is considered a particularly resource-intensive field, said Dr. Tanya Sorensen, a maternal and fetal medicine doctor at Providence Swedish in Seattle, one of the more popular delivery units in the state. 

The field requires significant hands-on nursing, Sorensen said. Labor and delivery nurses usually spend more one-on-one time with their patients compared, for example, to a nurse caring for someone gradually recovering from surgery. 

Obstetrics also has become more specialized over the years, Whiteaker added: In the past, babies were commonly delivered by doctors who worked as general practitioners or family physicians. Now, it’s more typical for hospitals to employ doctors and other staff who are trained specifically in infant and pregnancy care and are prepared to address the wide variety of challenges that can arise in deliveries.

That means labor and delivery units need to have larger staffs with specialized experience — which costs more money. At the same time, hospitals, especially those in rural areas, are struggling to retain and recruit a limited number of health care workers, which means staffing costs overall have increased dramatically.

“We’re in a spot now where we’re using travel nurses, which are far more expensive, costing millions of dollars compared to our [permanent] nurses,” Sorensen said. “Swedish is able to cope with that … but if you’re a little community and trying to staff for a small labor and delivery unit, that becomes super challenging and super expensive.”

She’s particularly worried about the growing lack of obstetric care in Yakima Valley, she said, noting Swedish’s transfer rate from rural areas rose about 8% between 2021 and 2022.

“There’s a huge amount of concern about these obstetric deserts where there’s limited local care for pregnant women,” Sorensen said.

The fight back

Since several hospitals closed their labor and delivery units, few have provided updates on plans to bring services back. In the Yakima Valley, residents are determined to keep the issue from being forgotten.

At a town hall meeting in Toppenish in early January, the room was crowded with former hospital employees and patients hoping to voice their concerns about the labor and delivery closure. 

“I was a senior in high school and pregnant with my first child when I suffered a miscarriage and almost died,” Semone Dittentholer, a Wapato resident and Yakama tribal member, said at the podium, recalling her experience at Astria Toppenish more than 20 years ago. She knew her community suffered disproportionately worse birth outcomes, adding to her fear. 

“I was minutes from bleeding out,” she said. “There was no way I was going to make it to Yakima [Memorial],” the largest hospital in the county, about twice as far from her home as Astria Toppenish.

When Dittentholer arrived at Astria Toppenish, she couldn’t stop shaking and her skin was almost translucent. She was told she might not make it through the night. 

After hours in the maternity center, Dittentholer woke up, but her baby didn’t.  

“If it wasn’t for Toppenish labor and delivery, I wouldn’t have made it,” she told City Council members. “It makes me stressed and sad to think about all the women who couldn’t — and won’t be able to — make it out to Yakima.”

Since the closure of Toppenish’s maternity center, community members have continued to brainstorm ideas on how to return obstetric care to their area. They held community gatherings. They wrote to their City Council members. They advocated for new legislation. 

Then, last month, a group working on maternity solutions in Washington stumbled on an old state law that mentions “maternity care distressed areas.” Ears perked up.

According to the law, enacted in 1989 and revised in 2011, the Washington state Health Care Authority would pay for contracted maternity care providers, if an area is considered to be maternity care distressed — which could mean a higher-than-average percent of people in the area received late or no prenatal care or had to travel out of the area to receive maternity care.

“We’re not sure if this is going to apply to us yet,” Loehr said, “but if this ends up working in our favor and we could get some state relief, that would be big.”

Some relief is on the way for Toppenish. Gov. Jay Inslee last week approved legislation that will raise the hospital’s Medicaid rates starting next year. In the meantime, the hospital will receive a short-term grant this summer to “bridge the gap until that reimbursement kicks in,” Winslow said.

Still, it likely won’t be enough for the hospital to reopen its maternity center, Winslow said, adding that it’s an “exceptionally expensive service” and the extra funding will likely go toward maintaining existing services, like behavioral health, instead.

Loehr is also leading efforts to introduce a public hospital district to the area, a fairly common designation in Washington. The state has 56 public hospital districts, community-created entities authorized by the state to deliver health services. 

“We’re like a library district or a school district,” said Matthew Ellsworth, executive director of the Association of Washington Public Hospital Districts. “Local constituents voted to draw a circle around themselves and ultimately they can choose to tax themselves for revenue.”

Most public hospital districts in the state have hospitals, while a handful provide specific care, like emergency services, urgent care and nursing homes. Once a district is created, residents elect a board of commissioners to govern the district and decide which health-related projects to fund.

“To have health care decisions executed on a policy basis by elected officials is a big benefit,” Ellsworth said. “Ultimately, the people running your hospital are accountable to you. … But I don’t want it to be viewed as a panacea.”

For example, he said, “If you want to build a billion-dollar hospital, that’s not going to happen.” Tax revenue from public hospital district levies don’t come close to the amount needed to run a health care facility, he said. 

But in places like Vashon Island, the state’s newest public hospital district, residents were able to raise enough funds to preserve some clinical services. 

What’s at risk

Across the Puget Sound, similar challenges have complicated the search for pregnancy care. 

As of this year, only one hospital in Kitsap County — St. Michael Medical Center in Silverdale — is staffed to deliver babies. The Naval Hospital, near a base in Bremerton, closed the doors to its labor and delivery unit in April 2022, citing staffing and resource shortages. Peninsula Community Health Services, also in Bremerton, followed suit a few months later. 

Because of the growing gap in care, many patients have started to rely on local midwives, said Ashley Jones, a licensed midwife and executive director of True North Birth Center in Poulsbo, the only out-of-hospital birth center on the peninsula. The practice has seen a huge influx in patients since last July, Jones said. 

“The unfortunate thing is that I know there are those who do qualify (for a low-risk birth) who may actually choose our option and just don’t know about us,” Jones said. “We’re a big military community, so some people are coming from states like Virginia and Texas, or somewhere where midwifery is not as common may not even know that we’re an option.”

She’s hoping to continue to spread the word about her practice in case St. Michael’s obstetric unit does fill up. In the last year, many of Jones’ new patients transferred to her practice after experiencing or hearing stories of long waits at St. Michael, she said.

Because of recent changes to the state’s landscape of labor and delivery care, patient numbers have fluctuated at different hospitals, making clear trends in demand difficult to identify. 

While the number of MultiCare Yakima Memorial’s monthly deliveries has slowly increased since Astria Toppenish’s unit closure, signaling some absorption of patient volume, St. Michael hasn’t necessarily seen the same rise on the Kitsap Peninsula. 

St. Michael’s president, Chad Melton, says its unit does have room and staffing has “stabilized” in the past four to five months, though it still does partially rely on contract travel nurses. Demand has actually dropped from an average of about 200 deliveries a month during most of the pandemic to now about 130 per month. 

“It’s a service we need to provide,” Melton said. 

Meanwhile, patient demand at Kitsap OB-GYN, one of the few independent practices on the peninsula, has been growing for months, said administrator Megan McDermaid.

“There’s not a lot of choice in the county,” McDermaid said. 

Morgan Runge, 27, a mother of two who lives on Chinook Pass, said she’s concerned for other new parents in the Yakima area who now may be far from the nearest hospital, or may no longer have a choice in where they deliver their baby.

She said she felt fortunate to have options: She delivered her son at Astria Toppenish just days before its maternity center closed, instead of MultiCare Yakima Memorial. While Yakima was much closer to her home — about 30 minutes, compared to an hour’s drive to Toppenish — she was willing to make the hourlong trip because of a traumatic experience delivering her first child at Yakima Valley.

She was in labor the entire drive, she said. 

“It’s a terrifying thought that these types of services are drying up in some parts of our state,” she said.


Messias Maricoa – Cuidar De Mim (Official Music Vídeo

Messias Maricoa    #MessiasMaricoa #CuidarDeMim


CUAMM attended the Second National Paediatric Congress of Mozambique to follow the proceedings at close hand and observe the development of best practice for protecting children’s health.

In a country with only 68 paediatricians for over 12 million children, where over 90% of children never see a paediatrician, the question of children’s health is ever more pressing. The Second National Paediatric Congress of Mozambique, which took place from 25 to 28 October in the Mozambican capital Maputo, was therefore an important contribution to the national debate, which CUAMM was determined not to miss.

The event, organised by AMOPE(Associação Moçambicana de Pediatras – Mozambican Association of Paediatricians) under the heading Our Priority is the Health of Children and Young People”, was opened by Nazira Abdula, Mozambique’s Minister of Health. CUAMM was represented by Olga Denysyuk, a neonatologist working at Beira Hospital.

It offered an opportunity to discuss integrated care as a means of controlling the main diseases causing ill health and death in Mozambique’s children. To date, premature birth, asphyxia and infections have been the main causes of death in newborns, while HIV/AIDS, malaria, TB, malnutrition, respiratory disease and diarrhoea continue to affect very young children. While there are signs of progress, there is still much to do, as Valéria Chicamba, Director of the National Paediatric Programme, explained:

CUAMM is playing its part in guaranteeing health care for Mozambican children: we are improving the facilities at Beira Central Hospital’s Neonatology Department and enlarging the “kangaroo mother” therapy unit for premature babies, as well as providing equipment and on-the-job training for local staff.

Thirteen foreign paediatricians have been brought in to strengthen the 68-strong Mozambican team, bringing the total to 81. Moreover, there is a significant geographical imbalance, with 58 of these specialists concentrated in the capital Maputo, leaving just 23 paediatricians working in the remaining 10 Provinces. This hampers the struggle to reduce infant mortality, which now stands at a rate of 64 deaths for every 1,000 live births.



Supporting Parents of Sick or Premature Babies

Parents of sick or premature babies go through a lot of emotional ups and downs in the early weeks and months of their babies’ lives.

When they get practical help and emotional support from family and friends, parents often cope a lot better with the experience. And when they’re managing well, they’re better able to look after their babies.

Here’s how you can help.

1. Celebrate as you usually would when a baby is born

Offer congratulations, send a card or flowers, and ring the new parents. By celebrating the birth of their baby in this way, you’re helping them celebrate as well. Give a gift if this is what you’d usually do. Small gifts for the parents can help them feel nurtured too.

If you’re thinking of giving clothes for the baby, make sure they’re very easy to put on and take off – loose necklines and armholes are good. If the baby is premature, size 00000 clothes can also be useful, because many parents won’t have bought these smaller sizes. Baby clothes for later are wonderful too, because they help the parents think about the future, when their child is at home.

Another gift could be a voucher for hospital parking. Or you could give a voucher for a restaurant close to the hospital, so that parents can have a meal and some time together but not be far away from their baby.

“A lot of people sent flowers in the first few days after the birth. Most preemies spend at least two weeks in hospital or more, so it’s nice to get flowers or a gift a bit later. It’s a nice surprise and encouraging along the long journey”.
– Mother of 35-week premature baby

2. Offer practical help

Parents will be visiting the hospital as often and for as long as they can for days, weeks or months to come. This means that everyday chores are hard to fit in or don’t get done, which can be stressful.

Here are helpful things you could offer to do:

  • Mow the lawn or walk the dog.
  • Prepare meals or do the weekly grocery shopping.
  • Take older siblings to preschool or school or look after the other children in the evening.
  • Give parents a lift to the hospital – parking and transport can be very expensive.
  • Set up a messaging group or social media page, so that parents can send updates to just one source.

3. Support parents in whatever way they need

It’s OK to ask parents what they need. Some parents want to shut themselves off and cope with the situation alone or with a few close friends and family. Respect their wishes, but also let them know that you’re thinking of them. You could try to offer help at different times.

Some parents need a lot of people around for support. These parents might love having company at the hospital. You could offer to drive, have lunch or just sit with them. Some parents want to talk about things other than the baby. Parents’ needs can change as their baby grows and changes.

“I found the weeks my baby was in hospital a very lonely time. The friends who helped me most were those who offered specific things. They said things like, ‘I’ll drive you into the hospital tomorrow and stay with you for the day’, or ‘I’ll meet you there and we’ll have a bite of lunch together’. The friends who said, ‘Let me know if I can do anything’ didn’t help so much. They were just as sincere, but it was just easier if they offered something specific”.
– Mother of a 28-week premature baby

4. Stay in touch with parents

A text message, an email, a quick phone call or voice message, or even an old-fashioned card in the mail – these are simple ways to let parents know you’re thinking of them. They help parents feel supported and remembered.

Try to understand how stressed the parents are and avoid judging them if they forget a birthday, can’t get to a family gathering, or take less interest in what’s happening in your life. It’s not that they don’t care – it’s just that right now, all their energy and focus is on their baby.

“When you feel up to it, encourage loved ones to visit you at hospital. It’s good to have some time out, fresh air and different conversation, because the hospital becomes your life”. 
– Mother of 27-week premature baby

5. Say positive things about the baby

You can show your support by saying positive things like ‘Your baby is growing fast already’, or ‘They’re strong just like you’.

Avoid talking about setbacks that might happen or challenges that the baby could face, unless the parents bring it up with you. Also avoid giving advice about the baby.

6. Don’t expect to cuddle the baby

Sick or premature babies are very sensitive to touch, noise, infection and other things in their environment, so cuddling or touching is often limited or not allowed. Parents can also be very protective of their babies.

You might not even be able to see the baby, because there are usually limits on the number of visitors allowed at one time. Often it’s only 2. Sometimes only family is allowed – often this is only the baby’s parents. Each hospital has its own set of rules. Instead, you could ask to see some photos of the baby (if the parent feels up to sharing them) or have a coffee with the parents at the hospital café.

Don’t be surprised if you still can’t have a good cuddle when the baby goes home. Many babies are still easily overwhelmed and might need to be protected from too much handling and too many new people.

If you’re sick, you should avoid visiting a family with a baby in the neonatal intensive care unit (NICU) or the special care nursery (SCN). Sick or premature babies can get illnesses and infections very easily.

7. Listen to parents

Parents are likely to have mixed and powerful feelings about their sick or premature baby and their experiences of the birth or hospital. These might not surface for weeks, months or even years.

Be open, let them talk and avoid giving advice unless it’s asked for. Avoid comparing them with other parents who’ve had a hard time. If you listen more than talk and follow the lead of the baby’s parents, you’re more likely to be helpful.

8. Keep offering help after the baby comes home

Your family member or friend might be tied to the house for some weeks once the baby comes home. Having someone organise shopping or preschool and school runs can really help.


What are the risk factors for preterm labor and birth?

There are several risk factors for preterm labor and premature birth, including ones that researchers have not yet identified. Some of these risk factors are “modifiable,” meaning they can be changed to help reduce the risk. Other factors cannot be changed.

Health care providers consider the following factors to put women at high risk for preterm labor or birth:

  • Women who have delivered preterm before, or who have experienced preterm labor before, are considered to be at high risk for preterm labor and birth.1
  • Being pregnant with twins, triplets, or more (called “multiple gestations”) or the use of assisted reproductive technology is associated with a higher risk of preterm labor and birth. One study showed that more than 50% of twin births occurred preterm, compared with only 10% of births of single infants.2
  • Women with certain anomalies of the reproductive organs are at greater risk for preterm labor and birth than are women who do not have these anomalies. For instance, women who have a short cervix (the lower part of the uterus) or whose cervix shortens in the second trimester (fourth through sixth months) of pregnancy instead of the third trimester are at high risk for preterm delivery.

Certain medical conditions, including some that occur only during pregnancy, also place a woman at higher risk for preterm labor and delivery. Some of these conditions include3:

  • Urinary tract infections
  • Sexually transmitted infections
  • Certain vaginal infections, such as bacterial vaginosis and trichomoniasis
  • High blood pressure
  • Bleeding from the vagina
  • Certain developmental anomalies in the fetus
  • Pregnancy resulting from in vitro fertilization
  • Being underweight or obese before pregnancy
  • Short time period between pregnancies (less than 6 months between a birth and the beginning of the next pregnancy)
  • Placenta previa, a condition in which the placenta grows in the lowest part of the uterus and covers all or part of the opening to the cervix
  • Being at risk for rupture of the uterus (when the wall of the uterus rips open). Rupture of the uterus is more likely if you have had a prior cesarean delivery or have had a uterine fibroid removed.
  • Diabetes (high blood sugar) and gestational diabetes (which occurs only during pregnancy)
  • Blood clotting problems

Other factors that may increase risk for preterm labor and premature birth include:

  • Ethnicity. Preterm labor and birth occur more often among certain racial and ethnic groups. For example, infants of African American mothers are more likely to be born preterm than infants of white mothers. American Indian/Alaska Native mothers are also more likely to give birth preterm than are white mothers.4
  • Age of the mother.
    • Women younger than age 18 are more likely to have a preterm delivery.
    • Women older than age 35 are also at risk of having preterm infants because they are more likely to have other conditions (such as high blood pressure and diabetes) that can cause complications requiring preterm delivery.4
  • Certain lifestyle and environmental factors, including:3
  • Late or no health care during pregnancy
  • Smoking
  • Drinking alcohol
  • Using illegal drugs
  • Domestic violence, including physical, sexual, or emotional abuse
  • Lack of social support
  • Stress
  • Long working hours with long periods of standing
  • Exposure to certain environmental pollutants


App Helps Support Parents of NICU Babies No Matter Where They Are

April 3, 2023

At 23 weeks gestation, a rare pregnancy-related complication forced Meg Hamilton to have a caesarean section to save her life and give birth to her baby Will four months early.

Weighing 1 pound at birth, Will had a 50-50 survival chance, she and her husband, Dave Hamilton, say. Doctors expected him to spend at least four months in the neonatal intensive care unit (NICU) at Northwestern Medicine Central DuPage Hospital in Winfield, Illinois.

“It was traumatic,” recalls Meg Hamilton, who underwent in vitro fertilization to conceive the baby the Elmhurst, Illinois, couple considers a miracle.

As Will’s condition developed, updating about 70 members of the couple’s large family became overwhelming.

“There was a lot going on in a very short amount of time,” Dave Hamilton recalls. “We were looking for a way to communicate with everyone that was secure and also that we could invite people to. But there are some people that didn’t need to know the entire story. And there were some people that we did want to know the entire story.”

A smartphone app developed by a Northwestern University team offered most of the features the Hamiltons needed to track and update everyone on Will’s progress until his hospital discharge. The app, NICU2Home, provides updates on NICU newborns and allows parents to share as much information as they want and with whom.

Dr. Craig Garfield and engineer Young Seok Lee created the app to keep parents informed about their baby’s care no matter their location. Most parents don’t expect their baby to require intensive care, and they easily can become overwhelmed by the staggering amounts of information they receive during such a distressing period. So far, about 2,000 NICU parents have relied on the app for updates and information.

“What made us start to think about how we could do this was when smartphones really first came out, and I saw so many parents at the bedside with their phones while their baby was sleeping,” says Garfield, pediatrician and professor of pediatrics and medical social sciences at Northwestern University Feinberg School of Medicine. “We realized very early on that designing an app to deliver information that was personalized and specific for that particular baby in that particular situation that we could extract the exact information we wanted to send to those parents so as not to overwhelm them.”

After the app’s 2020 launch at Northwestern Medicine Prentice Women’s Hospital in Chicago, Garfield and Lee wanted to offer it at facilities with more diverse patient populations to determine whether it can help improve health outcomes and equity. They expanded their research at Central DuPage Hospital, Northwest Community Hospital in Arlington Heights, Illinois, and Rush University Medical Center in Chicago with support from Health Care Service Corporation (HCSC).

“These are our families that are generally not included in research or maybe kind of marginalized in society more generally, but they’re having babies prematurely,” Garfield says. “When HCSC was looking for solutions to help with health equity, we put in a proposal and HCSC was incredibly enthusiastic about it.”

HCSC leaders believe the NICU2Home app could help lower-income, urban and suburban NICU parents with transportation, work flexibility or child-care challenges. The app would allow parents to remain engaged and connected to their NICU baby, reducing the stress of trying to maintain a continuous beside presence.

“Part of what we’re trying to do is help support research that helps improve the care and the health outcomes for babies that are premature and also helping them in that transition to home process,” says Dr. Derek Robinson, a vice president and chief medical officer for HCSC’s Illinois plan. “We think this is a tremendous opportunity to address some of the disparities that impact the lived experience of the parents who are caring for these children.”

The app’s use could significantly enhance a parent’s ability to care for their newborn, based on a study published in the Journal of Pediatrics external link.

Garfield and Lee found that among Prentice NICU parents who used it, the app boosted their confidence in caring for their babies and continued to help them up to a month after their babies’ hospital discharges.

“Our hope is that the information that we provide in the app actually helps parents feel confident enough that they didn’t have to immediately run as soon as their babies showed one sign of something or the other into the doctor’s office,” Garfield says.

Lee, an adjunct professor at Northwestern University’s Feinberg School of Medicine with a Ph.D. in industrial engineering, wants to create apps to address other maternal infant care areas, including postpartum depression.

“I think still there are a lot of innovation we can create to address challenges,” he says, adding that he’d like to expand NICU2Home’s access nationwide.

Maintaining connection and reducing worry

Central DuPage Hospital’s NICU sometimes cares for babies from as far away as the Iowa state line. Access to the NICU2Home app may help reduce the anxiety and worry of parents who can’t always be at their baby’s side, says Dr. Jeffery Loughead, medical director for the hospital’s Lurie Children’s Program.

“Updating the families in a real-time basis is enormous,” he says. “It really allows them to touch base with their baby right away. Also, the educational features of the app allow the parents to be better informed as to what their baby is experiencing medically and what to expect developmentally at each gestational milestone.”

For the Hamiltons, having a secure place to share photos and post comments with family helped everyone stay connected during Will’s NICU stay.

“Posting and keeping track of his milestones was huge,” Meg Hamilton says. “It was great for us to have something to share with people and show how well he was doing.”

Her husband agrees.

“It was massive for our family to have that app as much as it was a convenience to us,” he says.



Supporting Robust Teamwork — Bridging Technology and Organizational Science

List of authors: Anna T. Mayo, Ph.D., Christopher G. Myers, Ph.D., John C. Bucuvalas, M.D., Sandy Feng, M.D., Ph.D.,  Courtney E. Juliano, M.D.

Health care organizations are meeting the demands associated with caring for patient populations with increasingly complex needs by leveraging larger teams that include clinicians with diverse and specialized expertise. Simultaneously, high turnover and labor shortages mean that facilities are often employing a more temporary and mobile workforce than in past eras. The result is that the structure of health care teams often defies decades of wisdom from team-design research about the conditions that support the best possible performance.

Rather than facilities having well-defined teams with clear boundaries dictating who is included, team boundaries are blurred, with individual clinicians having roles on multiple care teams whose compositions may evolve over time because of shift changes, the timing of rotations, and changing patient needs. Furthermore, instead of being part of stable teams with a history of working together, clinicians who share a patient often have limited, if any, history of collaboration. These features constrain coordination and communication within and across teams, hamper collective learning processes, and can result in suboptimal — and at times devastating — patient outcomes.

Recognizing the challenges posed by these conditions, many organizations have implemented costly technology to support collective work. Clinicians formerly communicated directly, but in recent years, the complexity of clinical work has increased concurrently with the adoption of various communication tools — from messaging applications to electronic medical record systems.

Although these technological solutions hold potential for facilitating communication, they often don’t address the fundamental human challenges involved in fostering effective teamwork, such as managing attention and relationships.

Implementing effective solutions for modern health care teams requires a deep understanding of human behavior, not just more advanced technologies. But the findings from decades of research in the organizational sciences and related fields (e.g., human-factors engineering and psychology), which has included rigorous studies of human behavior in health care settings, haven’t been incorporated into most health care research.1,2 We believe there are promising opportunities for integration across these fields. Recent findings from organizational science shed light on coordination and collective-learning constraints in health care. Integrating these findings with technology development could create powerful levers to support robust teamwork.

There are numerous challenges associated with promoting effective teamwork in health care. The shift toward communicating mostly asynchronously by means of notes and messaging platforms, with the occasional phone call or in-person conversation, was intended to facilitate communication among dispersed clinicians. But when someone is out of sight, they are often out of mind.

In keeping with substantial research on cross-boundary collaboration in organizations, one of us found in a recent study of medical inpatient teams at an academic medical center that teams tended to turn inward when conducting their work, excluding other clinicians who could play a critical role in delivering high-quality care, such as nurses, specialists, and pharmacists, as well as patients and their families.3 Even when information was gathered from outside the team (e.g., a consult occurred and a note was sent back), the team may not have provided other clinicians with all the relevant patient-level information, which limited the usefulness of their input. Moreover, inward-focused teams often failed to take the critical step of synthesizing the input they received from these out-of-sight people. This pattern of isolated work resulted in backtracking and delays when previously missing input from people outside the team came to light and necessitated reworking plans or when clinicians found that they had been oblivious to important decisions (e.g., when nurses were delayed in seeing electronic notices of “STAT” orders, thereby slowing medication delivery).

In the same study, however, about 25% of inpatient teams were found to dynamically integrate people with other roles into team processes as needed. To facilitate this integration, teams essentially shifted their boundaries over time: the boundary surrounding the core medical team expanded as its members gathered input from other clinicians, as well as patients and families, and met with them in real time, often in person, to collectively synthesize information and conduct complex decision making during rounds; the team boundary then contracted again when the core medical team huddled to delegate tasks internally and move on to its next patient. On the surface, these teams engaged in more time-consuming coordination-related work, but they capitalized on available expertise for each patient, and they backtracked less often and completed daily rounds faster than teams that didn’t consistently integrate people with other roles in real time. The patients assigned to these teams also had shorter lengths of stay than patients assigned to other teams.

The increasingly fluid structure of health care teams and the reliance on technology-mediated communication do not only affect the care of current patients; they can also erode opportunities for learning from others, which is a critical component of teamwork in health care and is necessary for improving care for future patients. For instance, the evolution of clinical technologies and their uses (e.g., the integration of robots in surgery) has altered trainees’ roles and professional routines, thereby reducing opportunities for trainees to learn by working with experts. Post-training learning opportunities are also being constrained by the increasingly mobile nature of the health care workforce, which undercuts the formation of key relationships that could otherwise be important sources of knowledge transfer.

Research on learning in organizations reveals the power of creating spaces for informal conversation or observing others and learning on the job, which could promote the knowledge sharing and learning necessary for collective work. For example, the constant reconfiguration of air medical transport crews restricts collaboration and interferes with traditional learning mechanisms, yet research by one of us has found that crew members use storytelling routines during downtime to learn from other crews’ experiences. This finding, along with a robust body of work on organizational learning, highlights that although didactic teaching is often emphasized in health care (particularly in academic medical centers), learning is a social process. Learning vicariously and learning by doing (together) are critical practices that organizations can support by means of dedicated efforts to bring professionals together to share experience and expertise.

Better understanding the human-focused constraints on — and opportunities for — teamwork in health care can help guide more effective technology-based interventions to track and increase coordination and learning. For instance, artificial intelligence that processes conversations in real time could support information management during team decision making, including by inviting input from people (e.g., nurses, specialists, or patients) who haven’t contributed to a discussion but probably should. Identifying patterns of clinician interactions (i.e., who is involved and when) that are associated with critical outcomes could also inform the development of better teamwork-related metrics and tools to encourage collaboration. Such tools could include algorithms that provide recommendations about interactions — prompting, for example, a primary care team to connect with a particular consultant. Similarly, scheduling technologies could draw on interaction and outcome data to create ideal care-team assignments, balancing the inclusion of members who are more familiar with each other (which could improve communication and collaboration) with those who are less familiar with each other and might provide new perspectives or stories related to their own disparate experiences (which would be in keeping with research on the potential value of working with multiple people in the same role — for example, residents working with a greater number of nurses — to enhance learning).

Of course, there are risks associated with deploying new technologies. Algorithms used to support human decision making can lack transparency, which, along with concerns about data security, can create distrust. They can also perpetuate bias, which is especially a risk when high-quality data aren’t available. These shortcomings could hamper innovation. Moreover, scaling solutions and integrating them across heterogeneous sites can be challenging. Here, too, research from organizational science and related fields could help organizations collect the right data and use meaningful metrics to identify important contextual factors that could inform modification and integration across sites and to better manage change and implement new solutions.

Calls to improve teamwork-related practices in health care aren’t new. Yet in today’s dynamic health care landscape, where team design often conflicts with best practices, we believe it’s critical that researchers, developers, and practitioners integrate insights from research in the organizational sciences with technology development to cultivate more robust teamwork.


Earlier fetal monitoring may reduce stillbirth rates without increasing neonatal morbidity

April 27, 2023

Key takeaways :

  • Fetal monitoring from 39 weeks may reduce stillbirth among South Asian-born women.
  • Stillbirth, early neonatal death and special care nursery admission decreased after initiation of fetal monitoring at 39 weeks.

Fetal monitoring from 39 weeks’ gestation may be an alternative to routine earlier labor induction to reduce stillbirth rates among certain women without causing increased neonatal morbidity, according to researchers.

The largest maternity service in Victoria, Australia, formerly began fetal monitoring at 41 weeks’ gestation. Because women of South Asian birth were at five times higher risk for stillbirth compared with Australian-born women by 41 weeks, the maternity service implemented a new guideline of twice weekly cardiotocography and measurement of amniotic fluid for all South Asian women in their practice at 39 weeks’ gestation.

Data were derived from Davies-Tuck ML, et al. Am J Obstet Gynecol. 2023;doi:10.1016/j.ajog.2023.02.028.

“A policy of offering fetal monitoring from 39 weeks for women of South Asian background allowed identification of fetal compromise and guided timing of birth where relevant to significantly reduce the rates of stillbirth at term. Through offering monitoring, the rates of stillbirth at term become equivalent to all other women at the service,” Miranda L. Davies-Tuck, PhD, head of the perinatal epidemiology and clinical trials at Hudson Institute of Medical Research, Clayton, Australia, told Healio. “Additionally, while the rate of induction initially increased, it did not continue to increase over the study period. Therefore, a fall in stillbirth was not achieved by continuing increases in inductions.”

This cohort study, published in the American Journal of Obstetrics and Gynecology, included 3,506 South Asian-born women who gave birth prior to these new recommendations and 8,532 who gave birth after these new recommendations were implemented. All women gave birth between 2016 and 2020. Researchers determined differences in stillbirth rates, neonatal deaths, perinatal morbidities and interventions after July 2017 and assessed changes in stillbirth rates and labor induction.

After these new recommendations were implemented, researchers observed a 64% reduction in term stillbirth among South Asian-born women, from 2.3 per 1,000 births to 0.8 per 1,000 births (P = .047). Early neonatal death rates (3.1 vs. 1.3 per 1,000; P = .03) and special care nursery admission (16.5% vs. 11.1%; P < .001) rates also decreased after these new recommendations were implemented.

Researchers observed no significant differences in admission to NICUs, Apgar score less than 7 at 5 minutes, birth weight or differences in trends of labor induction per month.

According to Davies-Tuck, future research should include qualitative work capturing the views of women themselves as well as a large, multisite randomized controlled trial of monitoring and targeted earlier birth compared with routine earlier induction of labor and to determine if this approach works for other groups experiencing high stillbirth rates at term.

“The findings of this work provide a strategy to reduce stillbirth at term for South Asian women and can represent an alternative to offering earlier induction of labor,” Davies-Tuck said.


Physical Examination of a Premature Infant

Stanford Medicine – Phillip Sunshine MD

The House is on Fire!! Responding to Unexpected Neonatal Events

Lisa Owens

Like firefighters, neonatologists must be ready to “put out a fire” anytime. While we are clinically prepared for the necessary interventions, we may feel less prepared for coding such events. Understanding what was done, what was submitted before the emergency, and which codes have procedures bundled or when 24-hour global codes apply can help.

Scenario #1

The hospital delivery team (NICU RN and RT) attends a routine C/ Section of a term infant as per hospital policy. At 15 minutes of life, the neonatologist on call receives a call from the RN because she is not comfortable taking the baby to the NBN. The Neo rushes to the DR and finds the infant in mild respiratory distress with oxygen saturations in the mid-80s. The baby does not appear distressed, the heart rate is in the 120s, and the pulses are equal throughout. The Neo applies CPAP and asks the OB about the significant pregnancy complications. The OB states that the mother had gestational DM. The Neo then orders a CXR to evaluate heart size, shape, and lung fields, which is unremarkable. At 25 minutes of life, the infant’s oxygen saturations are above 95%, and the CPAP is removed. The infant is observed for another 10 minutes and then cleared for transport to NBN. The Neo updates the parents and documents in the chart—total time 40 minutes.

The best CPT code for this encounter is:

A. 99464 Attendance at delivery

B. 99465 Delivery room resuscitation

C. 99221 Initial hospital care

D. 99252 Inpatient consult, 35 minutes

Correct answer: D. When a consult code is used, the documentation should reflect the request for a consult and the total time spent. CPT 2023 has revised the time requirements.

CPT Code Time (minutes)





With the updated CPT, the face-to-face time with the patient does not have to be documented separately, merely the total time.

Because the resuscitation was over, neither delivery room code was appropriate.

Despite the exam and history obtained, this does not meet the requirement for H&P. Therefore; answer C cannot be used.

Scenario #2

The neonatologist on call is requested to come to the Level II nursery. A 5-day-old 33-week infant receiving low flow oxygen via NC, approximately 100 ml/kg enteral feedings, and has a PIV for TPN running at approximately 50 ml/kg. She weighs 1750 grams today. She was seen by a member of the same physician group this morning. The nurse at the bedside tells you the baby has had increasing oxygen needs and abdominal distension throughout her shift and has passed a bloody stool. On exam, the abdomen is discolored and grossly distended, and during the exam, the infant has a significant apneic episode. The neonatologist intubates the infant, stops feeds, places a Replogle, and orders an X-ray showing diffuse pneumatosis. Labs are drawn, broad-spectrum antibiotics are

ordered, and the infant is transferred to the Level IV nursery across the hall, total time spent 75 minutes.

The best CPT code for the evening encounter is:

A. 99479 intensive care day 1500-2500 grams

B. 99468 Initial critical care < 29 days of life

C. 99469 Subsequent critical care < 29 days of life

D. 99291 Critical care time (99291), 31500 Intubation

Correct answer: B.

This infant was initially admitted to the Level II nursery. All admit codes can only be used once per admission, and since this infant has spent the entire admission in the intensive care unit, this transfer to critical care qualifies for a critical care admission code. The critical care codes are 24-hour global and bundled, meaning most procedures are included and cannot be billed separately. Since critical care had been provided (intubation, PPV,) this code could be used. However, the infant was transferred to Level IV and will be cared for there. Thus, the global code is more appropriate.

Scenario #3

The pediatrician on call is asked to come urgently to the Emergency Department. EMS has dropped off a newly born infant from a birthing center. The infant appears term, is pale, grunting, and is lethargic. Their heart rate is 190’s. The dad had accompanied the infant and said there was “a lot of blood” when the baby came out. The pediatrician suspects a cord accident or placental abruption. She quickly places a UVC (5 minutes), gives a bolus of NS over 10 minutes, and orders emergency blood. The respiratory distress worsens, and the pediatrician intubates the infant (5 minutes). The pediatrician calls the regional NICU (covered by a different group) for transfer. The total time spent was 80 minutes.

The best CPT code for this encounter is:

A. 99291 critical care (30-74 minutes), 99292 critical care (additional 30 minutes)

B. 99291,31500 (intubation), 31560 (UVC), 96360 (administration of IVF, 31-60 min)

C. 99291, 31500, 31560

D. 99468

Correct answer C. 

Procedures are not bundled with critical care time but must be subtracted from total critical care time. After subtracting procedural time, the critical care time does not exceed 74 minutes, and 99292 cannot be added as in answer A. If this infant had been admitted directly to NICU in this facility and the neonatologist and the pediatrician were in the same group, 99468 would be used, and separate codes from ED would not be entered. Since the infant is being transferred to a different facility and covered by a different group, the pediatrician can submit codes reflecting the work done in ED.

Unpredictability is the hallmark of Neonatology. When you think everything is under control, a fire breaks out somewhere, requiring your time and attention. Coding and documentation is the boring part of the job, but even firefighters have boring parts, too. I see them at the grocery store every time I go…

Let us be like firefighters: always look on the bright side and approach our work with a burning passion!



ADI and Infant Mortality Link Shed New Light on Maternal Health Crisis

Noting the link between neighborhood social vulnerability and NICU infant mortality gives another explanation for the nation’s maternal health crises.

By. Sarah Heath

May 15, 2023 – A new study in JAMA Network Open uncovered a link between social vulnerability and NICU morbidity and mortality, adding yet another layer to the maternal health crisis facing the United States.

Particularly, the study showed that a high score on the Area Deprivation Index (ADI) is a risk factor for NICU mortality among extremely premature infants born younger than 29 weeks gestation.

These findings come as the US continues to understand its maternal health crisis. The US has the highest maternal mortality rate of similarly developed nations and the steepest racial disparities in maternal and infant outcomes, previous research has found.

This latest study adds another foil to those figures, noting that greater neighborhood social vulnerability is a risk factor for poor NICU outcomes.

The researchers looked at four NICUs in the Midwest, Northeast, Mid-Atlantic, and South to garner insights about in-hospital morbidity and mortality for extremely premature infants staying in the NICU.

Across the nearly 3,000 infants included in the study, high ADI was linked to in-hospital mortality, the researchers found.

Particularly, ADI was higher among the 498 infants who died before NICU discharge, with the average ADI score being 71. This compares to an average ADI of 64 among infants who did not die prior to NICU discharge.

The researchers also observed a higher median ADI for those with late-onset sepsis or necrotizing enterocolitis (NEC) (68 versus 64) and those with severe intraventricular hemorrhage (IVH) (69 versus 64).

These figures were in line with the researchers’ hypothesis that higher ADI would be linked with worse NICU outcomes, likely because pregnant people from under-resourced neighborhoods may lack the prenatal care access that increases the chances of better birth outcomes.

“The mechanism by which area deprivation affects neonatal outcomes may include the effect of maternal adversity on the developing fetus,” the researchers explained. “Maternal stress and poor access to prenatal care have been linked with adverse birth outcomes. Lower maternal socioeconomic status increases the risk of preterm birth, and among those born prematurely, it increases the risk of adverse neurodevelopmental outcomes.”

These findings also add another layer to the racial health disparities evident in maternal and infant health outcomes. For one thing, Black race was linked to higher ADI; the median ADI among Black infants was 77 compared to 57 for White infants. In other words, Black infants were more likely to have a risk factor for NICU morbidity and mortality. However, Black race itself was not a predictor of NICU morbidity and mortality.

“As racial minority individuals proportionally endure more socioeconomic deprivation, it becomes essential to consider social disparities as a significant mediator of racial disparities,” the researchers offered.

The team added that it is often difficult to parse out the impacts that race and social disadvantage have on health outcomes, largely because the two pair together. That’s likely the result of institutional racism. For example, racist policies like redlining segregated racial minorities into under-resourced neighborhoods, meaning that Black people and other racial/ethnic minorities are more likely to live in places with higher ADI scores.

Generally, these findings provide an explanation for a phenomenon scientists already knew existed; Black babies have worse infant mortality rates than White babies. Per CDC figures, non-Hispanic Black babies face and infant mortality rate that is more than double that of non-Hispanic White babies, coming at 10.6 deaths per 100,000 live births and 4.5 deaths per 100,000 live births, respectively. For Hispanic babies, the infant mortality rate was 5 deaths per 100,000 live births.

Future public health investigation is necessary to determine how to mediate these barriers, the JAMA researchers indicated.


Infant Care Innovation Improves Outcomes for Preterm Infants

February 22, 2023 by Nicole Franco

A new feeding practice could become the standard of care in other neonatal ICUs.

If you visit an American neonatal intensive care unit (NICU), you will likely see a ward governed by strict routine. Nurses look after preterm babies (born at less than 37 weeks gestation) by ministering care at prescribed intervals. Even the feedings will be given, like clockwork, every three hours exactly.

However, according to Ani Jacob, DNP, clinical assistant professor in the College of Nursing and Public Health, this approach to preterm infant care does not reflect the latest research. Feeding preterm infants on a rigid schedule inevitably means babies must sometimes feed when they aren’t ready and therefore experience stress, which initial research indicates is associated with negative stress-related symptoms.

To see just how much the prevailing feeding practice was adversely affecting babies, a healthcare team including Dr. Jacob implemented a new practice at a hospital in Manhasset, New York. “Instead of feeding preterm infants at scheduled times or prescribed intervals, it’s important to feed them based on the signs and cues the infants show that indicate they’re hungry and ready to feed,” she said. She shared the benefits of this approach in an evidence-based practice project of cue-based feeding in the hospital’s NICU, published as “Implementation of Cue-Based Feeding to Improve Preterm Infant Feeding Outcomes and Promote Parents’ Involvement” (Journal of Obstetric, Gynecologic & Neonatal Nursing, May 2021).1

Preterm infants, Dr. Jacob explained, exhibit several cues that indicate they want to be fed. Some are visual: “First, the baby must be awake. Second, they should turn their head when you touch their cheek. And, third, if you put a nipple near the baby’s mouth, they should open their mouth to suck.” But vital signs are equally crucial cues, and ignoring them can have serious health consequences for a preterm infant. “If you feed babies when they aren’t ready,” she emphasized, “they may become stressed. Stress can elevate their heart rate, increase their rate of respirations and affect their level of oxygen saturation. If we continue to feed despite these stress signals, the baby may need to be rescued, which often involves more invasive—and more costly—procedures.”

When Dr. Jacob and her team implemented a cue-based feeding approach in the hospital’s NICU as part of their project, they found positive results across the board. “After changing our feeding practice, the babies exhibited fewer stress symptoms when feeding. The babies’ length of stay in the NICU also decreased because the reduction in stress led to better outcomes. So, while improving the level of care we delivered, we simultaneously lowered the average total cost of NICU care.”

The shift also led to another improvement that surprised Dr. Jacob and her team: Parents started to feel more comfortable caring for their babies. “Usually, parents are afraid of feeding preterm babies because these infants are so small and usually have compromised respiratory systems,” she said. “We taught parents to look for cues of feeding readiness by giving them handouts and encouraging them to identify when they think their baby is ready to eat. At the end of the project implementation, they were more comfortable caring for preterm babies because they felt they could interpret their baby’s cues at home.”

Now that their hospital has adopted cue-based feeding, Dr. Jacob and her team hope that the practice will become the standard of care in NICUs elsewhere. More importantly, though, the project imparted a broader lesson she believes all healthcare workers would do well to heed. “Too often in this field, we continue to provide care one way because that’s the way we were taught and know, instead of evidence-based care for better outcomes,” she concluded. “That’s a big problem. Instead, we should be looking for the best evidence that is out there, and then change our practice as we’ve done with cue-based feeding.”


© UNICEF/Raphael Pouget

Silent emergency’: Premature births claim a million lives yearly

9 May 2023 Health

A “silent emergency” that is claiming one million tiny lives born premature each year requires concerted action to swiftly improve children’s health and survival, according to a new report released by UN agencies and partners on Wednesday.

An estimated 13.4 million babies were born premature in 2020, with nearly a million dying from pre-term complications, according to Born too soon: Decade of action on preterm birth.

Produced by a range of agencies, including the UN Children’s Fund (UNICEF) and the World Health Organization (WHO), with its Partnership for Maternal, Newborn and Child Health (PMNCH), the report outlines a strategy forward to address this phenomenon, which has been long under-recognized in its scale and severity.

Progress is ‘flatlining’

Progress is flatlining for maternal and newborn health, as well as the prevention of stillbirths,” PMNCH Executive Director Helga Fogstad said.

Gains made are now being pushed back further through the devastating combination of COVID-19, climate change, expanding conflicts and rising living costs, she warned.

“By working together in partnership – governments, donors, the private sector, civil society, parents, and health professionals – we can sound the alarmabout this silent emergency,” she said.

This means bringing preterm prevention and care efforts to the forefront of national health and development efforts, building human capital by supporting families, societies, and economies everywhere, she added.

Born too soon

Preterm birth rates have not changed in any region in the world in the past decade, with 152 million vulnerable babies born too soon from 2010 to 2020, the report showed.

Preterm births occur earlier than 37 weeks of an expected 40-week full-term pregnancy.

The report included updated estimates from WHO and UNICEF, prepared with the London School of Hygiene and Tropical Medicine, on the prevalence of preterm births.

Leading cause of child deaths

Steven Lauwerier, Director of Health at UNICEF, noted that every preterm death, created “a trail of loss and heartbreak”.

Despite the many advances the world has made in the past decade, we have made no progress in reducing the number of small babies born too soon or averting the risk of their death. The toll is devasting. It’s time we improve access to care for pregnant mothers and preterm infants and ensure every child gets a healthy start and thrives in life.”

Preterm birth is now the leading cause of child deaths, accounting for more than one in five of all deaths of children occurring before their fifth birthday, the report said. Preterm survivors can face lifelong health consequences, with an increased likelihood of disability and developmental delays.

Too often, where babies are born, determines if they survive, the report found, noting that only 1 in 10 extremely preterm babies survive in low-income countries, compared to more than nine in 10 in high-income nations.

Gaping inequalities

The report showed gaping inequalities related to race, ethnicity, income, and access to quality caredetermine the likelihood of preterm birth, death, and disability, even in high-income countries.

Southern Asia and sub-Saharan Africa have the highest rates of preterm birth, accounting for more than 65 per cent of global cases.

Other factors are also making an impact, increasing risks for women and babies everywhere. For example, air pollution is estimated to contribute to six million preterm births each year, the report showed.

At the same time, nearly one in 10 preterm babies are born in the 10 most fragile countries affected by humanitarian crises, according to a new analysis in the report.

Parent-led activism

Across the world, groups for affected families of preterm birth have been at the forefront of advocating for access to better care and policy change and supporting other families, the report showed.

In addition, the past decade has also seen a growth of community activism on preterm birth and stillbirth prevention, driven by networks of parents, health professionals, academia, and civil society.

Life-saving strategy

UN agencies, including the UN Population Fund (UNICEF), WHO, and UNICEF, are calling for a set of actions to save lives: boost investments in newborn health, accelerate implementation of national policies, integrate efforts across sectors, and support locally led innovation and research to support improvements in quality of care and equity in access.

“Ensuring quality care for these tiniest, most vulnerable babies and their families is absolutely imperative for improving child health and survival,” said Anshu Banerjee, Director for Maternal, Newborn, Child and Adolescent Health and Ageing at WHO.

Progress must also advance in prevention, which means every woman must be able to access quality health services before and during pregnancy to identify and manage risks, she said.


Top 7 Medical Innovations In 2023 – The Medical Futurist

Jan 4, 2023     The Medical Futurist

At the beginning of every year, I come up with a few medical innovations I find to be important for the year ahead.

My Early Surprise: A Bedtime Story For Preemies by Sharifa Brown | #ReadAloud

Join me as we read, “My Early Surprise: A Bedtime Story For Preemies” by Sharifa Brown. Here we see firsthand the obstacles Baby Malik and his family faced during his early entrance into the world!

How To Make A Vision Board | 2021 SIMPLE

 Fine Tip Creative Studio

How to make a vision board? DIY Vision Board, Vision board ideas. Watch as we show you how to make a simple vision board for 2021 that actually works. Whether it’s a digital vision board, a poster board or images on your phone; Vision boards really work. Vision boards help you identify goals and resolutions. No need to over-explain on complicate this; It’s pretty simple. Like Mateo says, it’s like a post-it note. Vision boards are great for kids. You want to gather images and phrases that will remind you of goals, dreams, and things you want to accomplish in the next year. The most important part is to place it somewhere you will see it often. The constant reminder is where the magic lies. Also, keep in mind that the more specific you can be, the more clear your action plan can be. Make sure you take steps to plan how you will achieve your goals! The vision board is just a start, HAVE A PLAN!

#visionboard #visionboards #visionboardparty

Dreamy Mozambique surf trip – surfing & diving in beautiful Tofo & Tofino – Africa Travel – Pollywog

Jun 10, 2020     Pollywog surf

Pollywog surf travel presents Mozambique.

Mozambique is a dream tropical surf destination once simply must travel to. Just one of the many places to visit and surf in Africa and one of the many reasons why you should plan a surf trip to Africa. Africa is one of the last places on earth with pristine, untouched beaches and surf breaks, which makes it one of the best places to visit for a unique surf trip experience. In this video, we head up to Tofo in the middle of Moz with South African surfers Luke Patterson and Tanika Hoffman to find untapped, rustic beauty and experience the true essence of Africa and of course to score some epic waves and see some incredible marine wildlife along the way. The roads are mainly dirt, winding through endless palm trees. Even the roads in the village of Tofo are still dirt roads. It is pretty remote, but that adds to the charm. Still, the town has a great energy, with plenty of restaurants serving fresh fish and bars serving ice cold 2M beer! Surfing in Mozambique is a throwback to the past. The waves are largely uncrowded and the ocean is teeming with wildlife. The main wave is Tofino a right had point break that cooks when the conditions are right. It is a pretty consistent wave too and its possible to surf Tofino all year round. Tofino is probably the most famed wave in Mozambique, along with Ponto do Ouro. The winter months (May, June, July) bring the bigger swells from the south, but Mozambique often receives cyclone swells in the summer (Feb, March) which can create incredible surf conditions. Many South African surfers will drive the long journey chasing cyclone swells up the coast. Tofo, closer to town is a lot more sheltered and the more mellow wave is often good for longboarding or learning to surf. Tofo is also renowned for incredible diving, especially swimming with Whale sharks and Manta Rays.

Not Visiting, Passion, Cool Kids

Kazakhstan, officially the Republic of Kazakhstan, is a transcontinental landlocked country located mainly in Central Asia and partly in Eastern Europe. It borders Russia to the north and westChina to the eastKyrgyzstan to the southeastUzbekistan to the south, and Turkmenistan to the southwest, with a coastline along the Caspian Sea. Its capital is Astana, known as Nur-Sultan from 2019 to 2022. Almaty, Kazakhstan’s largest city, was the country’s capital until 1997. Kazakhstan is the world’s ninth-largest country by land area and the world’s largest landlocked country. It has a population of 19 million people and one of the lowest population densities in the world, at fewer than 6 people per square kilometre (15 people per square mile). Ethnic Kazakhs constitute a majority of the population, while ethnic Russians form a significant minority. Kazakhstan is a Muslim-majority country, although ethnic Russians in the country form a sizeable Christian community.

The Healthcare in Kazakhstan is a post-Soviet healthcare system under reform. The World Health Organization (WHO), in 2000, ranked the Kazakhstani healthcare system as the 64th in overall performance, and 135th by overall level of health (among 191 member nations included in the study).The Human Rights Measurement Initiative finds that Kazakhstan is fulfilling 79.7% of what it should be fulfilling for the right to health based on its level of income. When looking at the right to health with respect to children, Kazakhstan achieves 96.1% of what is expected based on its current income. In regards to the right to health amongst the adult population, the country achieves only 80.9% of what is expected based on the nation’s level of income. Kazakhstan falls into the “very bad” category when evaluating the right to reproductive health because the nation is fulfilling only 62.1% of what the nation is expected to achieve based on the resources (income) it has available.

Through the Looking Glass-Neonatal Womb Warriors-May, 2023


Preemies are people, people that make up over 11 % of our population globally.

Kathryn was born in 1991. At that time, the only publication available to parents in her birth hospital was a pamphlet targeting the needs of parents whose child had died or was dying. In our case, it was pertinent, as Cruz, Kathryn’s  twin, did pass following his birth. The community library had nothing for preterm birth families to reference. There were no support groups to provide direction. Enlightenment, a hard path, was a moment by moment experiential journey. Like many of you who may have experienced a preterm birth earlier in time, we lived, we endured, we moved forward, we survived and evolved.

On April 30, 1993 Tim Berners-Lee , a fellow at CERN, released the source code for the world’s first web browser and editor. The browser that he dubbed WorldWideWeb became the first royalty-free, easy-to-use means of browsing the emerging information network that developed into the internet as we experience it now (a magical moment!). Trillions of lights at our Preterm Birth Community fingertips, alive and expansive….. a magnificent opportunity to share, learn, connect, explore,  create and collaborate globally. 

In February 2016 we shared our first Neonatal Womb Warrior blog. Our outreach was and remains focused towards building a matrix globally that would empower the health and well-being of our preterm birth community, our Family, at large.  We are the resources we need! We believe that collaboration towards our mutual benefit and well-being is not only possible, but also “profitable” in every progressive and positive way. Three significant observations were foundational towards the development of our efforts to experience, understand, connect with and serve the Preterm Birth Community:

  • In comparison to 1991, preterm birth families had access to rich resources to help them navigate and empower their preterm birth journeys in many parts of the world.
  • Preterm birth community members were represented by many critical  partner affiliates including but not limited to preterm birth survivors, preterm birth families, healthcare providers, ancillary service providers, inventors, researchers, educators, community/governmental agencies, etc. With increasing necessity and requiring immediate attention within our preterm birth community was a need for appreciating, humanizing, supporting, and advancing/growing our healthcare partner community. We felt a need to explore, identify, and address any and all resistance presented that may deter us from our acknowledgment of the humanity and humane needs of our healthcare provider workforce.
  • Preemies are people who deserve and require healthcare and education complimentary to their entrance into life and their pathways throughout their life journeys.

We have a few observations and thoughts about the preterm birth community and it’s evolution we choose to share:

Resources to guide and support Preterm Birth parents/caregivers are currently abundant and growing in many places worldwide. In places globally that lack preterm birth support, education, and care including many rural communities like those in the USA, there is a need for resource development and access, as well as the implementation of comprehensive care planning and facilitation.

There remains at times within the Global healthcare community an attitude toward the preterm birth survivors that implies “ you are lucky to be alive, a lot of time and money were spent on you already, enough is enough, get over it”. This is especially apparent in the lack of resource development towards pre-verbal PTSD, a condition very relevant to the preterm birth survivor community, the non-development of preterm birth life span medical specialization and identification, and the lazy and likely misdiagnoses of preterm birth learning and psychosocial development based on research related to symptom expression as opposed to the gathering of objective information gained from the preterm birth survivor community itself during development over lifespans and based on research that provides an opportunity to explore brain development, socialization, health, etc. from a clean and relevant platform.

In 1991, and even in 2016, the  Preterm Birth Community was significantly compartmentalized. Doors were significantly closed between families, healthcare providers, researchers/inventors/suppliers/ancillary service providers,  and our preterm birth survivor members. Healthcare providers were and remain dehumanized to a significant extent by the Public. We believe that bringing attention to the humanity/personal experiences of our healthcare providers is required if we want access to healthcare for ALL of our community members. With more preterm births occurring globally and given the overwhelming shortages of and the current exodus of healthcare providers, now more than ever we are called to show our appreciation and offer support to our healthcare community partners. The hard cold fact is that without healthcare provider access and presence in our lives the number of our community members who would have/may die and the families damaged by the loss of a child is unfathomable (but we should try to “fathom” it) and unnecessary.

Dehumanization of any limits ALL. Numerous health care providers involved in preemie care reported that they had never or had rarely interacted with the preemie survivors they had so diligently and lovingly cared for.  There is sorrow in their reporting. We can fix that and each of us can choose to do so in some unique way.

When Kat and I first started the blog, some practitioners expressed alarm that we were sharing information with the Public that even they, preterm birth healthcare specialists, had not been aware of. Their fear of not being in control of the information and therefor their scope of responsibility was significant. From our perspective progressive change directed towards supporting our preterm birth community at large was a more compelling pathway. Discomfort and progression are well-orchestrated partners when moving towards positive advancement and change.  Opening doors and windows, letting in light and air, gives life opportunity and supports human advancement.

In 1991 when a NICU baby in the USA was discharged from the neonatologist, nurses, and staff to the care of a pediatrician, the pediatrician likely had little to no education regarding providing medical evaluation and care to a developing preterm birth survivor.  Preterm birth infants and children were treated with no targeted attention to their pathway into this human experience. The situation has not changed significantly although specialty training in becoming more available to medical residents, neonatologists, pediatricians, therapists, scientists, innovators and nurses. The nursing profession has been extremely proactive in this regard, especially within their specialty. While collaboration is advancing between healthcare specialties locally and globally, increased collaboration between neonatologists, medical residents, and nursing staff is imperative and encouraged.

Opportunity is something we create through our inner and interpersonal expansion of vision and the sharing of perspectives. We find our Neonatal Womb Warrior-Preterm Birth Family/Community to be inspired, optimistic, creative, while carrying a certain lightness of being  as we expand our horizons and explore the possibilities within our life stories.  We are grateful for your presence in our lives.

KAT’s Summary:

As a preemie survivor,  growing up as a pediatric and adult patient I experienced a lack of holistic clinical care wherein the impact and potential implications of my prematurity remained unacknowledged and/or simply side-lined to fulfilling a standard checklist. Within society and the medical community, certain ideologies, and theories pathologizing myself and other preemie survivors’ quality of life conditions and intellectual capabilities or classifications have often been mislabeled or placed into a box where the true etiology of our long-term health, mental and physical capacities are not fully realized.  For instance, I like many micro-preemies experienced “learning difficulties” due to dyslexia, and dyscalculia and was thought to experience challenges in feeling and outwardly expressing my emotions. However, when I reached my later twenties, I experienced an outburst of intellectual growth making me question my true neurodevelopment and that of other preemies who historically have been highlighted for experiencing the same “brain revolution.”  

For example, I am cautiously hesitant to buy into the common thought that preemies may have a higher rate of falling along the autism spectrum. Had I been born in 2019 vs 1991 I feel quite confident I would have fallen into this category. While I too agree that this domain of research is critical for those especially who meet all of the criteria, I believe firmly that there is vastly more research that needs to be performed so that the clinical and Public neonatal community does not limit itself and those of us born early into a categorical box that fails to address the full range of our developmental health as a whole.  

I highly encourage longitudinal research that thoroughly examines preterm birth survivor long-term development to fully examine our etiology and health development broadly. Studies ranging from 1 month-5 years of age are inadequate. Moreover, making strides to engage our clinical research & ancillary community in collaboratively establishing specialized pediatric and adult care for preemie survivors is critical towards advancing neonatal lifespan healthcare. We are living longer; we are surviving the odds at a rate higher than ever before. We are empowered to change the life course of millions. Let’s get to it!


America deliberately limited its physician supply—now it’s facing a shortage

Why we’re more worried than ever about a physician exodusDaily Briefing

Posted on February 16, 2022 Updated on March 18, 2023

Historically, the number of physicians in the United States has been deliberately limited in an attempt to avoid massive physician surpluses—but now, there is a growing shortage of doctors, which negatively affects the country’s health care system and people’s health, Derek Thompson writes for The Atlantic.

How the U.S. capped its physician supply

According to Thompson, the United States has one of the lowest number of physicians per capita, largely due to deliberate efforts to limit the overall physician workforce.

“There’s a huge scarcity of primary care doctors, like pediatricians, and many of us are operating in a scarcity framework without enough resources,” said Elizabeth Erickson, a professor at Duke University‘s School of Medicine.

In 1981, a report from the Graduate Medical Education National Advisory Committee concluded that the country would soon face a massive physician surplus and recommended actions to limit the number of new domestic physicians, as well as immigrant physicians. In response to the report, the federal government reduced funding for both medical school scholarships and residency training programs.

In addition, U.S. medical schools enacted a moratorium from 1980 to 2005, which limited the number of new medical schools and restricted medical school class sizes. Although the U.S. population grew by 60 million people during that period, the number of medical school graduates remained mostly stagnant and has not completely rebounded even after the moratorium ended, Thompson writes.

Separately, the process to become a physician in the United States is more arduous and expensive than other peer countries, particularly those in Europe. According to Thompson, the United States requires doctors to earn a four-year bachelor’s degree, as well as attend four years of medical school, but most European countries have one continuous six-year medical program instead. In addition, many medical school graduates have between $200,000 and $400,000 in student loans when they enter the workforce.

However, American doctors’ longer training periods have not translated into better health for Americans as a whole, Thompson writes. In fact, a recent study found that Americans die earlier than their European counterparts at every age and income level.

Ways to address the U.S. physician shortage

Growing the physician workforce over the next few years will be critical, Thompson writes, not only to deal with the effects of the current Covid-19 pandemic, but also to care for the United States’ older and aging population. In 2018, the Association of American Medical Colleges predicted that the United States would be short between 43,000 and 121,000 physicians by 2030.

According to Robert Orr, a policy analyst who studies health care policy at the Niskanen Center, one way to increase the number of physicians is to expand medical residency programs. “This might be the key bottleneck,” he said. More funding for residency programs would allow medical schools to grow, which will mean more medical students and, ultimately, more doctors.

Aside from just increasing the number of doctors, states could also increase the total supply of care available, Thompson writes. For example, states could allow more nurse practitioners to substitute for doctors and expand telemedicine services, particularly to rural and underserved areas.

The United States also needs to build its health care infrastructure, such as clinics and hospitals, as it works to expand its physician workforce. “We need a system of health care development banks that issue guaranteed loans for infrastructure projects,” Orr said. “That’s how the health care system was originally built up until the 1980s, with government-backed finance.”

Although Thompson notes that there are several potential downsides of having too many doctors, including lower physician wages and more student debt, he ultimately argues that “[s]ick, aging, and buckling under two years of pandemic mayhem, America desperately needs more physicians.” (Thompson, The Atlantic, 2/14; Orr, Niskanen Center, 9/8/2020)


Give Health Care Workers the Mental Health Support They Deserve

States must do more to help clinicians access mental health care. Their lives depend on it.

By Corey Feist, Arianna Huffington, Deborah Marcus, and Michelle A. Williams – Nov. 29, 2022, at 11:36 a.m.

Advocating for health care workers has become an essential part of our day-to-day. In March, we were proud to see the Dr. Lorna Breen Health Care Provider Protection Act enacted to provide $135 million for programs aimed at supporting the mental health and well-being of health workers. However, while this was a welcome first step, it’s only the beginning of the work needed to protect our clinicians.


Tackling Health Care Burnout

The next crucial step falls to the states: They must remove language in their licensing and credentialing processes that stigmatizes health care professionals who have sought treatment for mental health concerns.

Our research has identified 31 states, plus the District of Columbia, that may still use invasive or stigmatizing language requiring applicants to disclose any history of mental health concerns or to explain why they have taken breaks from work. Some require applicants to disclose any past psychiatric impairment, potentially going back decades, even to adolescence. These questions might violate the Americans with Disabilities Act. They certainly violate applicants’ privacy. And there is significant evidence that they deter clinicians from seeking the care they need – at tremendous risk to their well-being and their lives.

Indeed, a survey of more than 1,500 physicians conducted this year found that 80% agree there is stigma around doctors seeking mental health care. Nearly 40% reported that either they personally or a colleague they know has been scared to seek mental health care because that treatment would need to be disclosed on their licensure, credentialing or insurance applications.

This is unacceptable.

Like everybody, health workers deserve the right to pursue the care they need whenever they need it, without fear of losing their license or job. This is especially important now, as health care workers have reported sharp increases in emotional exhaustion due in large part to the extraordinary strain of caring for patients, while also enduring a surge of intimidation, threats and physical violence during the COVID-19 pandemic.

Mental health questions were often added to licensing applications out of a misplaced desire to protect the public from clinicians who might not be fit to give care. Yet there is no evidence that these questions serve that function.

On the contrary, the public interest is harmed by these questions, since we know that when doctors, nurses and other clinicians are afraid to seek the care they need, they may find themselves unable to work due to depression or burnout. Some may turn to drugs or alcohol. And tragically, some will turn to suicide. In fact, stigma associated with seeking – or even discussing – behavioral health care is a primary driver of suicide among the health care workforce.

The Dr. Lorna Breen Act is named after the sister-in-law of Corey Feist, a co-author of this piece. An emergency room physician, Lorna died by suicide in April 2020, after weeks of incredibly intense work caring for patients in the first wave of COVID-19. At one point during that surge, Lorna called her sister to confide that she was overwhelmed with exhaustion and grief – but she was fearful that she would lose her medical license or be ostracized at work if she acknowledged that she needed help.

In the years since Lorna’s death, we have heard from many families who have lost physician loved ones to suicide. We recently connected with an emergency medicine doctor in Florida who reported that four of her physician colleagues died by suicide this summer. In too many of these cases, the clinicians have acknowledged to friends or family that they are reluctant to get treatment because of the stigma around mental health issues.

One such tragedy involves Dr. Matthew Gall, a devoted oncologist who practiced medicine for 16 years in Minnesota, one of the states that until recently used invasive questions on licensing applications. In 2019, Matthew moved to North Carolina with his wife and their three children. The move to a new practice was difficult, and Matthew struggled with depression, yet he declined to seek help. His wife, Betsy, told an interviewer that her husband felt “ashamed and embarrassed” about his depression, and feared he would lose his medical license and his livelihood if he sought treatment. “He honestly thought that he’d no longer be able to be a practicing oncologist,” Betsy said. “The fear was real, and being a doctor meant everything to him.” Matthew died by suicide on Thanksgiving Day 2019.

A terrible irony in this tragedy is the fact that North Carolina does not actually ask intrusive questions about mental health treatments in its licensure process. But having just moved to the state, Matthew was not aware of that fact. Lorna, too, was unaware that New York does not use invasive questions.

These stories are painful. They are powerful reminders that we must work toward universal reform of licensure applications, as our team did in Minnesota, which updated its questions to be less stigmatizing after testimony from Lorna’s sister and brother-in-law. It’s also clear that simply changing the language on applications is not enough. We must also get the word out widely, so no clinicians ever fear they will lose their job if they seek the help they need. In addition, we must continue to change the culture inside health care systems so that physicians, nurses, pharmacists and other health care workers feel comfortable being open about their mental health concerns and their need for support.

We are fighting for those reforms through our campaign ALL IN: Well Being First for Healthcare, which brings together more than a dozen organizations including the American Medical Association, the American Hospital Association, the American Nurses Foundation and the Physicians Foundation. Thousands of individuals have joined us in contacting state medical boards to demand change.

We are also working to address clinician burnout through common-sense reforms that we expect will eliminate some of the bureaucracy that can consume so much of a clinician’s time and remove the joy from patient care.

Ensuring that health care workers can access necessary mental health care is critical for their well-being and for the health of our entire country. Let’s do our part to support them. Together, we can show our vital health care workforce that they aren’t alone in this fight for their lives.


*** One of the GREATEST vocalists we have ever experienced.  A CRUSHING performance! Don’t miss this truly amazing artist….

Dimash – SOS | 2021

  Dimash Qudaibergen

11,326,999 views Sep 21, 2021 #dimashkudaibergen #dimash #dq On January 16, the TIXR streaming platform hosted an online concert DIMASH DIGITAL SHOW, where the artist performed ‘SOS D’un Terrien En Détresse’. Dimash Qudaibergen performed the song “SOS” in the 1st round of the Chinese contest” I am a Singer ” in 2017. The next day, more than 600 million viewers learned about Dimash

Amid Healthcare’s Great Resignation, Burned Out Workers Are Pursuing Flexibility And Passion

Deb Gordon  Contributor

The Great Resignation—the mass exodus of unsatisfied workers—has hit few industries harder than healthcare. According to some reports, the field has lost an estimated 20% of its workforce, including 30% of nurses.

This year alone, nearly 1.7 million people have quit their healthcare jobs—equivalent to almost 3% of the healthcare workforce each month, according to the U.S. Bureau of Labor Statistics.

And a recent survey of 1,000 healthcare professionals showed that 28% had quit a job because of burnout.

These departures not only create current and fear of future staffing shortages, they raise another question: Where are all those highly skilled workers going?

Many healthcare workers who quit take other healthcare jobs, though sometimes under substantially different circumstances.

Lauren Berlin, RN, 45, has been a nurse in Wisconsin and Florida for 21 years, most recently employed as director of nursing for long-term care facilities. In that role, she says she was expected to be available at all times, every day of the year.

“My phone was never off,” she said. “I was burned out. I loved bedside nursing, but I desperately needed work-life balance.”

Berlin quit her full-time job and now takes shifts through CareRev, a staffing app which allows clinicians to sign up for shifts online based on their schedule, preferences, and availability.

This flexibility allows Berlin to focus on her other passion: coaching track and field in inner-city Milwaukee.

“If your home calendar is your priority, then you schedule your work shifts around your home calendar…You want to take a vacation? Go ahead, you don’t need to ask anyone,” Berlin said. “I work for myself, on my own terms.”

According to Will Patterson, CEO and founder of CareRev, Berlin reflects a growing trend among clinicians.

“Today’s worker expects greater flexibility. They expect to have a greater degree of freedom over when they work and for whom,” Patterson said. “Clinical professionals are no exception.”

A former trauma nurse, Patterson saw firsthand the impact of inflexible hospital scheduling, which could leave the ICU short-staffed when patient volume peaked.

“When you’re taking on responsibility for more lives than you can reasonably handle—for days at a time—you burn out quickly,” he said. “Now, after over two years of fighting the pandemic, that burnout is at an all-time high. And as the nurse shortage worsens, that burnout is only going to continue to accelerate.”

According to Patterson, many burned out clinicians haven’t lost their passion for healthcare, they just want more autonomy and work-life balance.

Lack of work-life balance caused Jill Bowen, 45, to quit her job as a director of physical therapy in the home health industry. Her productivity was measured by the number of visits completed with no credit for all the time she had to spend on phone calls, documentation, and scheduling.

“Payment, regulations, and all the red tape is the most stressful part of the job,” Bowen said. “When an agency is driven by profitability, marketing promises or non-compliant provider demands, clinicians are pressed to comply, and patient care suffers.”

Now, Bowen works as an implementation consultant with Axxess, a software company that serves home health agencies. She encourages other clinicians to recognize—and use—their transferrable skills.

There are lots of jobs available for people with the skills developed in the healthcare field,” Bowen said. “We have skills that can be transferred to other professional areas, such as being organized, effective communicators, and a team player.”

Some burned out workers are using their transferrable skills to launch their own ventures.

Taylor Bonacolta, 28, of Fort Myers, Florida, quit her job as a registered nurse in a pediatric intensive care unit a year ago due to the stresses of the pandemic combined with having two young children. Instead of getting another job, Bonacolta launched June and Lily, a business to provide support for new mothers.

“If there are any other healthcare workers out there considering quitting, I would remind them that there are so many different ways we can help others as nurses,” Bonacolta said.

The pandemic also prompted Jackie Tassiello, 34, to rethink her career. A licensed, board-certified art therapist in New Jersey, Tassiello was employed for almost four years in the pediatric cancer department at NewYork-Presbyterian Komansky Children’s Hospital. Before the pandemic, she often carried a caseload of 25 children in a day, all navigating cancer, blood disorders, or gastrointestinal diseases.

During the pandemic, Tassiello was redeployed to provide emotional support and meet basic needs for frontline medical staff working in Covid-19 units. She said she remembers seeing staff in hazmat suits responding to a patient in distress and thinking, “That could be me; that could be anyone I love.”

Those experiences caused Tassiello’s own priorities to change.

“I decided that I wanted to scale down in order to be more present. I also needed time off to recalibrate and heal,” she said.

Now running her own psychotherapy practice, Tassiello has some advice for healthcare organizations hoping to retain staff: “Hospitals need to solve issues at the core, not with gift cards and lunches,” she said. “There are systemic problems that no amount of bonuses can fix.”

Some healthcare workers are giving up clinical work altogether and turning to creative pursuits.

Cari Garcia, LCSW, 38, most recently worked as a psychiatric emergency room social worker in a large Florida hospital. She says she quit due to a toxic work environment, unsupportive administration, verbally and physically abusive patients, and pay that did not justify the level of stress she had to endure.

Garcia turned a food blog she’d run as a hobby for ten years into her primary source of income and now says she makes more money than she would as a social worker. Garcia encourages other healthcare workers considering quitting to take the leap.

“The minute you’re on the other side, you’ll ask yourself why you didn’t do it sooner,” she said. “I sleep better, I’m able to be present for my family, and my quality of life is through the roof.”

The Great Resignation isn’t just about clinicians. Christopher K. Lee, MPH, 31, had been working in healthcare management for more than a decade. Last month, he resigned from a senior manager role at UCLA Health after being required to be in the office every day since October 2021.

“I tried to make it work, but in March I decided I couldn’t do it anymore,” Lee said. “Like many people, during the pandemic I reflected on my priorities, and spending 3+ hours commuting a day no longer aligned with what I envisioned for my life.”

Now, Lee says he is writing a book about professional networking and doing advocacy work in teen and young adult mental health, projects he always wanted to do “someday.”

Lee said, “In the shadow of the pandemic, I decided: If I don’t do them now, what if I never get a chance?”


Nursing Post Pandemic: The Path Forward

Vallire Hooper, PhD, RN, CPAN, FASPAN, FAAN

J Perianesth Nurs. 2023 Feb; 38(1): 1–2.

Published online 2023 Jan 23. doi: 10.1016/j.jopan.2022.12.001

As we move into 2023, we are, I hope, moving into a brave new future. COVID-19, while still evolving and highly prevalent, is moving into more of an endemic, flu-like state as opposed to a pandemic presentation. The health care system, to include the nursing profession, however, has been left in a shambles. The reality, as we all know, is that the health care system was teetering on the edge of disaster prior to the onset of the pandemic. COVID-19 was essentially the “straw that broke the camel’s back.” This statement is particularly true for the nursing profession.

The nursing profession, and thus health care as we know it, is on the brink of implosion. Nurses of all ages are leaving at record numbers. Many are retiring, and taking decades of experience with them. Many newer nurses, however, are leaving the bedside within a year to two years of hire; some to advance their education and move out of the acute care setting, but many are leaving the profession entirely. The number of nursing students in the pipeline is in no way sufficient to fill the gap, and current nurse retention strategies are inadequate and outdated. The nursing profession, and particularly the future of health care in the acute care setting, is at a tipping point. If we, as the nursing profession, do not take the lead in staving off disaster, someone else will fix it for us, and we will likely not be happy with the results. Nurses, as a profession, must find a new path forward.

The numbers as they currently stand are not pretty, yet, not surprising. A Becker’s report published in October of 2022 reported some disturbing statistics:

  • Regional RN turnover percent rate changes from 2020 to 2021 ranged from 3.2% to 12.2%.
  • The overall nursing turnover rate in 2021 was 27.1%, up 8.4% over the previous year.
  • RN turnover rates in step down units, emergency departments, behavioral health, and telemetry increased from 101.3% to 111.4% over the last five years.
  • Average turnover cost for a nurse is $46,100.00, up 15%.
  • 60% of survey respondents reported an RN vacancy rate of 15%.
  • It now takes an average of 3 months to recruit an experienced RN.

A 2022 survey of physicians, registered nurses, and advanced practice providers showed that 25% of respondents were considering switching careers. To no surprise, 89% of those considering leaving the profession cited burnout as the primary reason. These statistics confirm what is now common knowledge: clinician burnout is a real threat to the stability of the US health care system. Wellbeing is also commonly acknowledged as the antithesis to that burnout. Yet how we define wellbeing, and how we enhance nursing wellbeing, is in need of some clarity and consensus building.

Wellbeing has many components: personal, spiritual, physical, mental, financial, etc, but what does well-being mean for the nurse? A recent concept analysis defined nurse wellbeing as “being the best “you” that you can be, and bringing the best “you” to your work, to your team, unit, and/or organization.3” On face value, this definition implies a personal perspective or ownership. It is “your” responsibility to attain wellbeing. Many nursing leaders and national nursing organizations have fallen victim to this attitude….if one only took better care of themselves, took time for meditation, attended wellness classes, etc, then the nurse could attain that ever elusive goal of wellbeing. The reality, however, is that nurse wellbeing cannot be obtained through individual pursuit. Nurse wellbeing is primarily a consequence of work environment issues, of having one’s basic human needs met in the work environment.

Nurse wellbeing emanates from a work environment in which one is adequately paid, protected, and supported. An environment where one’s workload is manageable and the nurse is able to provide the nursing care that the patient requires. An environment where the nurse can take a break without interruption, where the nurse has control of their schedule, where they are respected and have a sense of belonging, and where they feel protected and safe from harm. Nurses do not need wellbeing officers and classes. The evidence clearly supports that nurses are looking to be treated and supported as professionals….as the guardians of safe, quality health care. A work environment must be created in which nurse wellbeing can flourish. The work environment must support the basic needs of nurses. Nurse burnout does not result from an individual’s failure to pursue wellbeing; nurse burnout is a result of a failed health care system.

In my opinion, the first step down the pathway to a new nursing reality is in the recognition of the significant impact of nursing care that we provide impacts patient outcomes. This work begins in the C-suite. Nursing must no longer be considered as the primary cost center in the hospital. The care that nursing provides must no longer be wrapped up in the bed charge. Nursing must be recognized for what we are, the major revenue generator for the hospital. Without a nurse, there is not a hospital bed. The one and only reason that a patient is admitted to the hospital is because they require 24/7 nursing care. If a patient does not require 24 hour nursing care, then they can be managed via services in an outpatient setting. Nursing leaders and nursing administrators must own this power and make their voice known in the boardroom. They must support the bedside nurses they lead and no longer cave to pressures to “cut costs” in the nursing department. The nursing department is the center to which all other departments connect. We are the core that holds the acute care setting together. Nursing must own our positive impact on safe, quality patient outcomes and be reimbursed accordingly. Might this mean that nursing should be held accountable for critical nurse-sensitive quality measures? Yes. But this also means that nursing must be supported with adequate resources to deliver quality nursing care. Might nursing care delivery models need to be restructured to provide cost-effective care delivery at the bedside? Yes. Must federal policy and reimbursement structures be modified to reflect the criticality of nursing care to safe, patient care delivery? ABSOLUTELY!

The path forward to a new nursing reality will not be easy. It will not be without wrong turns, but we must traverse this long and difficult journey together. The new reality, the new future of nursing, will require significant changes in approaches to nursing leadership, nursing education, and the individual nurse’s approach to patient care. Nothing, and I mean nothing, will be the same as before the pandemic, but with hard work and collaboration, a new future can be obtained.



Is NICU Care Unnecessary for Some Premature Infants?

Apr 5, 2023 Michele Meyer

Findings reported this month in Pediatrics add to the evidence suggesting that neonatal intensive care units (NICUs) may be overused. Routine NICU care for low-acuity premature infants may be unnecessary and have a negative effect on breastfeeding, conclude the authors.

More than half (56%) of infants born at 35 weeks gestation are admitted to neonatal intensive care units (NICU). But is that precaution always medically needed — and could it cause harm among America’s 75,000 such early arrivals each year?

Even with rates of 20% for some areas, the number of NICU admissions has been increasing across all birth weights. That is “raising concern about NICU overuse,” said Andrea Wickremasinghe, M.D., neonatal specialist for Kaiser Permanente in Santa Clara, California.

Factors fueling such concerns include a California study showing that 34.5% of NICU admissions were for mild conditions, “and that hospitals with more NICU beds had an increased likelihood of NICU admissions,” she said.

To learn if rising NICU care for babies born at 35 weeks gestation is needed, Wickremasinghe and her colleagues studied chart data for 5,929 premature babies born from 2011 to 2021 at 13 Kaiser Permanente Northern California hospitals. They reported their results in the April 2023 issue of Pediatrics.

A normal pregnancy can range from 38 to 42 weeks. Infants born before 37 weeks are considered premature.

The study excluded premature babies with congenital anomalies or who needed antibiotics or respiratory support within two hours of birth. Instead, researchers focused on the remaining 15% of babies born at 35 weeks gestation.

Researchers found significant tradeoffs for those cared for in the NICU out of what they determined was “likely discretionary or hospital policy.”

Babies in NICU were hospitalized 58 hours longer than other newborns, and babies admitted to NICU within two hours of being born were over three times more likely (67% vs. 21%) to be hospitalized for four days or longer.

On the other hand, the babies taken care of the NICU babies were half as likely (3% vs. 6%) to be readmitted within a month of being discharged.

The study said many readmissions were for “transient conditions that are more prevalent in the first week after birth.” Those include jaundice (74.6%), hypothermia and failure to thrive.

“Many of these morbidities are mild and could be managed in a mother/baby unit,” Dr. Wickremasinghe said. Such babies then could benefit from being with their mothers versus being isolated in NICU.

Mothers are affected, too. Those with infants in NICU “were more likely to be stressed, depressed and anxious, all of which impact breast milk production” and, ultimately, the bonding created by breastfeeding.

By contrast, infants staying with their mothers instead of going to NICU caused less emotional and financial stress for their families.

The takeaway from Wickremasinghe and her colleagues: “Routine NICU admission may be unnecessary for low-acuity infants born at 35 weeks’ gestation.”


Parents Are Not Visiting. Parents Are Parenting

Bracht, Marianne RN, RSCN; Pediatrics; Franck, Linda S. PhD, RN, FRCPCH, FAAN; O’Brien, Karel MB, BCh, BAO, FRCPC, MSc; Pediatrics; Bacchini, Fabiana MSc, BJ

Advances in Neonatal Care 23(2):p 105-106, April 2023.

In their article “A Quality Improvement Project to Reduce Events of Visitor Escalation in the Intensive Care Nursery” (Vol 22, No. 1), the authors make repeated references to “visitors” to the neonatal intensive care nursery (NICU).

As seasoned healthcare professionals and advocates for parents of premature and sick infants, our position is this: Parents are not visitors. Parents are parents—their child’s first and most important caregiver.

Globally, healthcare organizations have traditionally positioned parents as visitors. This language is used not just in articles like this one but also frequently present in hospital documents, signage, and in the ways parents are spoken to and about in the hospital.

Preterm birth is traumatic. Often unexpected and unplanned, a preterm delivery to a medically fragile infant can leave a mother feeling like her body has failed. Parents are typically separated immediately from their infant, robbing them of that “moment” they have been waiting for—the moment they become parents. In the hours and days that follow, parents may not be allowed to hold or touch their infant. The clinical terms used to talk about their infant seem like a foreign language, everything is unfamiliar and sterile, and parents do not have any idea what to say, do, or ask. Parents of premature and sick infants are scared and anxious. They can feel powerless, alienated, alone—outsiders in their own infant’s life.

Therefore, language is so important. Calling parents visitors contributes to a culture of experts versus guests and us versus them.3 It evokes feelings for parents that this is the hospital’s infant, not your infant.4 Healthcare professionals decide who can touch and care for your infant, when, and for how long. The word “visitor” and how we use it to describe parents—in writing as well as verbally—is simply inaccurate. Parents are an infant’s primary caregiver. The words we use, as well as our tone, body language, and communication style, strongly affect how healthcare professionals see parents—and how parents see themselves. The culture of “allowing” parents’ permission to care for their premature or sick infants must shift.

Instead, healthcare providers’ words, actions, and knowledge should be a tool for helping parents learn to care for their sick newborn, build trust and rapport, and enable open communication.5 The first days and weeks in the NICU are formative for the parent–infant relationship and can make or break parents’ feelings of confidence, competence, and connection to their new infant. Parents must be at the center of a premature or sick infant’s care team.

Changing the language, we use, to talk about parents is a simple, cost-effective way to promote a culture of inclusion and involvement and improve outcomes. Looking at the wording in unit policies, notice boards, signage, parent education materials, staff presentations, in-services, training, and orientation is a good start.

Calling parents “visitors” is exclusionary. Parents are not visiting. Parents are parenting.


About 100,000 nurses left the workforce due to pandemic-related burnout and stress, survey finds

About 100,000 registered nurses in the US left the workplace due to the stresses of the Covid-19 pandemic, according to the results of a survey published Thursday by the National Council of State Boards of Nursing.

Another 610,388 registered nurses, who had more than 10 years of experience and an average age of 57, said they planned to leave the workforce by 2027 because of stress, burnout or retirement. The same was true of 189,000 additional nurses with 10 or fewer years of experience and an average age of 36.

The survey found that there were over 5.2 million active registered nurses and 973,788 licensed practical nurses or vocational nurses in the US in 2022. The researchers analyzed data from 29,472 registered and advanced nurses and more than 24,000 licensed practical or vocational nurses across 45 states. More than a quarter of those surveyed said they plan to leave the industry or retire in the next five years, the study says.

About 62% of the nurses surveyed said their workload increased during the pandemic, and 50.8% said they felt emotionally drained at work.

Almost half of nurses said they felt fatigued or burnt-out: 49.7% and 45.1%, respectively. These concerns were seen most in nurses with less than 10 years of experience.

Maryann Alexander, chief officer of nursing regulation at NCSBN and one of the authors of this study, said she is shocked by the findings of the study, especially related to younger nurses.

Soon, the industry will rely on nurses with less than 10 years of experience to act as mentors, managers and leaders in nursing care, Alexander said.

“It will send us into a health care crisis of huge proportions,” Alexander said.

She said that while it is common to see young nurses leaving the industry to go back to school and get more education, it is uncommon to see young nurses leaving due to stress and burnout.

“That is a huge cause for concern,” Alexander said.

This exhausted tone was a driving factor behind a strike in New York in January, when over 7,000 nurses took to the streets to call attention to staffing shortages and burnout.

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“We are sick and tired of the hospital only doing the bare minimum,” said Danny Fuentes, a union official who spoke to the crowd during the strike. “Time and time again, we are forced to take unsafe patient loads. We are humans, and we are burnt-out. And we are tired. And the hospital doesn’t seem to care. All they see are profits. We don’t want to be out here. We would much rather be with our patients. We need a fair contract to protect our patients.”

deals with the two hospitals involved, Mount Sinai Health System and Montefiore Health System. The union said the deal would provide enforceable “safe staffing ratios” for all inpatient units at Mount Sinai and Montefiore.

Montefiore agreed to financial penalties for failing to comply with agreed-upon staffing levels in all units.

The researchers on the new survey say their findings pose a threat to the US workforce, especially among younger and less experienced nurses. The National Council of State Boards of Nursing says hospitals and policymakers should be quick to enact solutions and address these challenges.



A New Patient Population for Adult Clinicians: Preterm Born Adults

Amy L. D’Agata Carol E. Green Mary C. Sullivan

Open Access Published: January 28, 2022DOI:

What if a single event could sway health, exercise capacity, learning style, social interactions, and even personal identities–yet individuals had no memory of the event? Adults born preterm are an under-recognized and vulnerable population. Multiple studies of individuals born prematurely, including our 35-year longitudinal study, have found important health concerns that adult healthcare providers should consider in their assessments. Concerns include increased rates of cardiovascular disease, metabolic syndrome, depression, anxiety and attention problems, lower educational attainment and frequency of romantic relationships.

 A Nordic study of over six million individuals found a linear relationship between gestational age and protection against early adult mortality, with preterm individuals showing 1⋅4 times increased likelihood of early mortality as full-term peers.

At the same time, surviving premature birth has become increasingly common. For the last several decades, nearly one in nine U.S. babies is born early, and now more than 95% survive.

 Global prevalence and survival data indicate more than 15 million preterm birth survivors annually reach adulthood.

 This suggests a new population of individuals with emerging healthcare needs for adult health providers.

Birth history should be part of every patients’ medical record.

 Due to the varied risks and prevalence of premature birth, all healthcare practitioners should be aware of the potential for long-term effects. With one in ten 30-year-old patients born preterm, clinical specialists who treat long-term complications of prematurity (i.e., neurology, psychiatry, cardiology) may have more preterm-born patients. Recognizing preterm birth as a cumulative, lifelong risk factor is the first step.

As clinicians and researchers, we have observed the medical community, like society at-large, tends to view prematurity as a health event localized to infancy-something kids outgrow. Ironically, some pediatric providers report limited training and understanding of health complications for children born preterm, and little evidence exists regarding adult practitioners’ knowledge to care for these adults.

 Preliminary adult primary care guidelines were recently created to screen and manage prematurity-related health complications.

Health risks from prematurity are also risks to equality and justice. Women who bear social risk factors are more likely to give birth early. This includes Black women, those living in socio-economically depressed areas, and women with two or more Adverse Childhood Experiences.

 The many arms of racism and caste-based inequalities can complicate and worsen the health of people already at risk from preterm birth.

Attention also needs to be drawn to the prematurity research community. To date, research has focused on younger age groups and predominantly White populations. Future research needs to seek out ethnically diverse populations and comprehensively examine potential life course complications of early birth. This is especially important when considering how socioeconomic factors may influence the allostatic load of individuals.

For many born preterm, prematurity is not just a health concern, it’s a matter of who they are. Their perception of health over time, or health related quality of life (HRQL), is a critical outcome. To date, this evidence varies with age, degree of prematurity and reporter; clinicians and parents tend to rate HRQL more negatively than survivors.

 Preterm-born individuals may not have event memories but, early birth repercussions can reverberate through family narratives and unique life experiences. Some identify as typically developed individuals who happen to have been born early, others as functional and well-adapted “preemies”, and others see prematurity as having colored their lives in negative ways.

 As prematurity researchers, we aim to uncover and bring awareness to the health outcomes and risks from early birth. A critical need exists for more evidence about adult health following preterm birth and yet, how do we protect individuals with statistically increased risk without unnecessarily pathologizing them?

In clinical practice and research settings, we can take the opportunity to listen to people who were too young as patients to speak for themselves but have riveting and complex stories about preterm birth’s effects. We are aware of just one other published qualitative study about the experiences of adults born preterm.

 Because most adult healthcare providers have yet to acknowledge and factor this experience into patient care, individuals born preterm are finding alternative avenues to be seen. Adults born preterm report seeking online community and support, connecting globally with people over shared early life experiences, while simultaneously making their needs and identities known.

As a research team, we strive to avoid labels for people born early but have nonetheless found that they are, in often subtle ways, a special group. They beat the odds as infants. Their birth and subsequent survival affected their families and communities in unprecedented ways. As clinicians and researchers, we can attend to the health risks of those born premature while acknowledging and celebrating their unique strengths and perspectives, often resulting from their early life experiences.


Health Topics: Positioning

The muscle tone is defined as the strength or tension of the muscle. Due to their immaturity, preterm babies usually have a lower muscle tone compared to term born babies. Maintaining a position can be quite challenging for a preterm baby. Movements are sometimes jerky and disorganised. Comfortable, supportive positioning and handling of the baby are important for the development of the skeletal and muscle system. Optimised positioning also helps to minimise stress, to promote breathing, digestion, and circulation, to preserve energy, and to promote the development of crawling, standing and walking.

So called nests can be built by folding rolled-up sheets or bedding into a wide, thick band long enough to surround the baby. A nest provides the baby with boundaries with a surface to touch and brace against. These boundaries are similar to the situation in the womb which makes the baby feel more secure. At the same time, the nest can help to keep legs and arms in a developmentally supportive position.

Lying positions for the baby: There are different comfortable lying positions for the baby:

The supine Position:

The supine position (i.e. lying on the back) is often used, if babies are unstable and need to be observed regularly. It facilitates access to the baby, for example to initiate procedures if necessary. This position is also recommended to use at home to ensure safe sleep. The caregivers usually support the baby’s head, shoulders and hips with additional pillows under the head and the shoulders.

The lateral Position:

The lateral position (lying on one side) supports a flexed position with bended arms and legs and allows the baby to adjust his or her own position. Usually, shoulders are rounded and relaxed, legs are bent with boundaries and hands can reach the mouth and face more easily. This position is often used to reduce stress during caregiving activities (e.g. mouth care, nappy change, or tube feeding), medical procedures, and lifting).

The prone Position:

The prone position (lying on the tummy/breast) may improve oxygen saturation, respiratory function, digestion, and sleep. Babies may lose less heat and energy. However, this position should only be used when the baby is monitored continuously and should not be used at home due to the risk of Sudden Infant Death Syndrome (SIDS).


A Stay in Neonatal Care – Preparing to Take Your Baby Home

The NICU Foundation

Oct 14, 2021

Funded by The NICU Foundation and created in partnership with The South West Neonatal Network, this animation was created to support parents, as they navigate their journey home following a stay in neonatal care with a premature or sick baby.


Epidemiology of Retinopathy of Prematurity in the US From 2003 to 2019

April 13, 2023

Key Points

Question  How have changes in the incidence of retinopathy of prematurity (ROP) varied across subpopulations and locations in the US between 2003 and 2019?

Findings  In this cohort study of 125 212 ROP discharges from over 23 million births, there was an 86% increase in ROP incidence found among the at-risk population. Incidence was persistently higher with a relatively greater increase in newborns who were database-reported as Black race, born in lower-income households, or born in the South or Midwest.

Meaning  This study found that ROP incidence nearly doubled in the US over the past 2 decades, particularly in traditionally underserved populations.


Importance  Retinopathy of prematurity (ROP) is a potentially blinding retinal disease with poorly defined epidemiology. Understanding of which infants are most at risk for developing ROP may foster targeted detection and prevention efforts.

Objective  To identify changes in ROP incidence in the US from 2003 to 2019.

Design, Setting, and Participants  This retrospective database cohort study used the Healthcare Cost and Utilization Project Kids’ Inpatient Databases. These nationwide databases are produced every 3 years, include data from over 4000 hospitals, and are designed to generate national estimates of health care trends in the US. Participants included pediatric newborns at risk for ROP development between 2003 and 2019. Data were analyzed from September 30, 2021, to January 13, 2022.

Exposures  Premature or low-birth-weight infants with relevant International Classification of Diseases, Ninth Revision or Tenth Revision codes were considered ROP candidates. Infants with ROP were identified using relevant codes.

Main Outcomes and Measures  ROP incidence in selected subpopulations (based on database-reported race and ethnicity, sex, location, income) was measured. To determine whether incidences varied across time or subpopulations, χ2 tests of independence were used.

Results  This study included 125 212 ROP discharges (64 715 male infants [51.7%]) from 23 187 683 births. The proportion of premature infants diagnosed with ROP increased from 4.4% (11 720 of 265 650) in 2003 to 8.1% (27 160 of 336 117) in 2019. Premature infants from the lowest median household income quartile had the greatest proportional increase of ROP diagnoses from 4.9% (3244 of 66 871) to 9.0% (9386 of 104 235; P < .001). Premature Black infants experienced the largest increase from 5.8% (2124 of 36 476) to 11.6% (7430 of 63 925; P < .001) relative to other groups (2.71%; 95% CI, 2.56%-2.87%; P < .001). Hispanic infants experienced the second largest increase from 4.6% (1796 of 39 106) to 8.2% (4675 of 57 298; P < .001) relative to other groups (−0.16%; 95% CI, −0.29% to −0.03%; P = .02). The Southern US experienced the greatest proportional growth of ROP diagnoses, increasing from 3.7% (3930 of 106 772) to 8.3% (11 952 of 144 013; P < .001) relative to other groups (1.61%; 95% CI, 1.51%-1.71%; P < .001). ROP diagnoses proportionally increased in urban areas and decreased in rural areas.

Conclusions and Relevance  This cohort study found that ROP incidence among premature infants increased from 2003 to 2019, especially among Black and Hispanic infants. Infants from the lowest-income areas persistently had the highest proportional incidence of ROP, and all regions experienced a significant increase in ROP incidence with the most drastic changes occurring in the South. These trends suggest that ROP is a growing problem in the US and may be disproportionately affecting historically marginalized groups.


A German study on the impact of stress on interparental relationship strain after preterm birth

A ReimerL MauseJ HoffmannA HagemeierN Scholten

European Journal of Public Health, Volume 32, Issue Supplement_3, October 2022, ckac130.204,

Published: 25 October 2022



Relationship satisfaction is an important predictor of well-being. Few studies address the effects of stress on interparental relationships of parents with preterm infants. However, the experience of a preterm birth represents an extreme, stressful event and therefore may place a strain on a relationship. Our aim is to examine the impact of postnatal stress on maternal and paternal perceptions of relationship strain.


As part of the Neo-CamCare project, a retrospective cross-sectional study was conducted targeting parents with infants with a birth weight below 1,500 g. Linear regression was used to analyse the influence of stress on relationship strain.


437 mothers and 301 fathers participated. Data indicate that interparental relationship strain experienced by fathers (M = 2.61, SD = 1.46) is lower than strain experienced by mothers (M = 3.43, SD = 1.7). The stress level due to the infant’s behaviour and appearance is lower in fathers (M = 2.53, SD = 0.95) than in mothers (M = 2.98, SD = 1.05). Stress due to parental role change is higher in mothers (M = 3.37, p = 1.04) than in fathers (M = 2.49, SD = 0.99). Regression analyses show that stress due to behaviour and appearance, as well as parental role change, can be associated with relationship strain in mothers. For fathers, only stress experienced due to the behaviour and appearance can be associated with relationship strain, whereas parental role change is not significant.


Our data illustrate that relationship strain can result from stress in mothers and fathers, indicating the need for stress prevention measures for both. Only mothers show relationship strain due to stress in their parental role. Although it is unclear what mechanisms underlie these findings, we assume that the maternal role is still primarily associated with child care. One way to relieve maternal stress could be to increase psychological support and the promotion paternal involvement in the postnatal period.

Key messages

  • Understanding the extent to which stress affects relationships helps to address mothers and father equally.
  • Based on the findings, parent-centred interventions can be developed to manage relationship strains.


The 14 Coolest Things Invented by Kids

Lisa Milbrand Updated: Jan. 20, 2023

You don’t have to be a grown-up to have a really great idea! Check out the amazing things the 18-and-under set dreamed up.

Inventions from imagination

 Every time you eat a Popsicle, decorate a Christmas tree, or put on earmuffs, you can thank the creativity of a kid or teenager! These kids had some brilliant ideas about how to fix common problems—or just make things more fun!—and they made them a reality. Here are some things you see all the time that were dreamed up by kids.


If you love to bounce, you can thank George Nissen. At age 16, he invented the trampoline after watching trapeze artists drop into the safety nets beneath them. He thought it would be cooler if they could bounce out of the net instead. The trampoline turns 90 years old this year; it was invented way back in 1930. Find out the most famous invention from your state.

Makin Bacon

A lack of paper towels helped inspire Abbey Fleck to create a new way to make crispy bacon fast. When her family didn’t have paper towels to soak up the excess grease from microwave-cooked bacon one Saturday morning in 1993, the eight-year-old decided to figure out a better way to cook bacon. After a little trial and error, she came up with the Makin Bacon, a microwave safe stand that allows you to drape bacon over it as you cook. The bacon is able to crisp up while the bacon fat pools in a bowl underneath it. Her brilliant idea helped make her a millionaire as a teenager.


In 1877, 15-year-old Chester Greenwood was tired of having cold ears when he went ice skating. So, he built a wire frame and had his grandmother help sew pieces of beaver skin to it to keep his ears warm. The muffs were a hit— especially with soldiers during World War I. Check out 20 other everyday things that were actually invented for World War I.

Christmas lights

Christmas trees used to be a big fire hazard, back in the day when lit candles adorned the trees. But in 1917, 15-year-old Albert Sadacca helped put an end to that by inventing less expensive strings of light bulbs to add pizazz to the holiday—without the potential for burning the house down. Get the inside scoop on some of the most ironic inventions ever.

Toy trucks

One of the very youngest inventors was Robert Patch, who was granted the patent for the toy truck when he was just six years old, back in 1963. He built his prototype out of bottle caps and cardboard, and his invention was meant to be taken apart and refashioned into different types of trucks, like a very early Transformer.


 Like many amazing foods, Popsicles were created by mistake. Eleven-year-old Frank Epperson accidentally left a cup filled with soda powder, water, and a stirring stick on his porch overnight, where it froze—and the delicious dessert was born. Nearly 20 years after his accidental discovery in 1905, he started selling his sweet treats. Now, we eat more than 2 billion every year. In fact, Popsicles are one of the items whose brand name has become synonymous with the thing itself—we call all frozen fruit pops “Popsicles,” even though “Popsicle” is a specific brand. Not bad for an 11-year-old!


The Man of Steel was first imagined by a pair of 17-year-olds, Jerry Siegel, and Joe Shuster, in 1933 and made his first appearance in comics in 1938. Some comic book historians believe the origin of the idea came from the death of Siegel’s father Mitchell in an armed robbery at his store.

Hot Seat

Alissa Chavez was upset about the stories of children who died when they were accidentally left in hot cars—and she wanted to do something to help prevent it. In 2014, at age 14, she came up with the idea of the Hot Seat, a small cushion with a sensor that’s placed in the car seat and connects to the parent’s smartphone. If the cushion senses that the smartphone has moved more than 20 feet from the car with the baby still in the seat, it sounds an alarm. Here are some more inventions that have changed the world in the last decade.

Early television

 One of the pioneers who helped bring us this life-changing technology was just 15 years old when he first dreamed it up. Philo T. Farnsworth created diagrams for an electronic television system in 1921, and it transmitted its first image six years later. Check out these world-changing ideas that came from dreams.

Water skis

 At 18, Ralph Samuelson wanted to combine his passion for snow skiing with his love of the water and aquaplaning. In 1922, he built his first water skis from strips of wood by softening the ends and bending them up.

Magnetic Locker Wallpaper

 If you’re big into locker decor, you can thank inventor Sarah Buckel for dreaming up this easy way to dress up your school storage back in 2006. As a 14-year-old, Sarah Buckel was tired of having to scrape her locker door clean of decorations at the end of every school year, so she came up with the idea of easy-to-swap Magnetic Locker Wallpaper instead. (It didn’t hurt that her dad was the chief operating officer of MagnaCard, which manufactured magnets!)


Joseph-Armand Bombardier, 15, strapped a car engine to four ski runners and a propeller to create the very first of these fun wintertime vehicles way back in 1922. He tinkered with it for years, before releasing the ultra-popular SkiDoo.

Swim fins

Noted inventor and Founding Father Benjamin Franklin was just 11 years old when he fashioned fins to make swimming easier. However, unlike today’s rubbery fins on your feet, his 1717 invention was hard paddles that were attached to your hands. Impress your friends with this bit of trivia next time you go snorkeling!


Toadstools and Fairy Dust

Try, try again. She can make a magnificent thing if she puts her engineering mind to it and doesn’t give up. Please join us for a dramatic read of The Most Magnificent Thing by Ashley Spires read by Miss Jill.

Hang Gliding Kazakhstan & Russia Championships 2016

056 views Sep 12, 2016  Stepan Zubashev

Чемпионаты Казахстана и России по дельтапланеризму 2016 в г. Алматы. Pilots: Zubashev Stepan, Nurbek Koibulatov, Dmitry Testov, Alexandr Barvinsky, Elena Barvinskaya. August 2016, Kazakhstan, Almaty. Music: Paper Navy – Swan Song, Audionautix – Atlantis


Venezuela is a country on the northern coast of South America, consisting of  continental landmass and many islands and islets in the Caribbean Sea. It has a territorial extension of 16,445 km (353,841 sq mi), and its population was estimated at 29 million in 2022. The capital and largest urban agglomeration is the city of Caracas.

The continental territory is bordered on the north by the Caribbean Sea and the Atlantic Ocean, on the west by ColombiaBrazil on the south, Trinidad and Tobago to the north-east and on the east by Guyana. The Venezuelan government maintains a claim against Guyana to Guayana Esequiba. Venezuela is a federal presidential republic consisting of 23 states, the Capital District and federal dependencies covering Venezuela’s offshore islands. Venezuela is among the most urbanized countries in Latin America; he vast majority of Venezuelans live in the cities of the north and in the capital.

Venezuela has a national universal health care system. The current government has created a program to expand access to health care known as Misión Barrio Adentro, although its efficiency and work conditions have been criticized. It has been reported that many Misión Barrio Adentro clinics have been closed, and (as of December 2014) it is estimated that 80% of Barrio Adentro establishments in Venezuela are abandoned.

Infant mortality in Venezuela was 19 deaths per 1,000 births for 2014 which was lower than the South American average. Child malnutrition (defined as stunting or wasting in children under the age of five) was 17%. Delta Amacuro and Amazonas had the nation’s highest rates. According to the United Nations, 32% of Venezuelans lacked adequate sanitation, primarily those living in rural areas. Diseases ranging from diphtheriaplaguemalaria, typhoid fever, yellow fevercholerahepatitis Ahepatitis B, and hepatitis D were present in the country. Obesity was prevalent in approximately 30% of the adult population in Venezuela.



Estimated # of preterm births: 9.73 per 100 live births

(USA 9.56-Global Average: 10.6)

Source- WHO 2014-


  We appreciate March of Dimes and the excellent and progressive work the March of Dimes performs locally and globally. The positive effects resulting from the March of Dimes intent and action, shared so generously with global Maternal and Child healthcare communities, and the continuous and positive impact the March of Dimes provides to educate and inspire individuals and organizations worldwide while generating increased support, education, and empowerment for women, children and families is simply…immeasurable and beautifully present. I share with heart-felt respect and gratitude the email we received (below) with our Neonatal Womb Warrior/Preterm Birth community.  Please enjoy the email and consider clicking on the link that follows in order to share your voice towards inspiring supportive action for the health and well-being of Moms, Children, and Families everywhere.  

  Add your voice today to the thousands of advocates calling for improved outcomes for moms, babies and families across the nation.    

March of Dimes Email to Kathy:

Dear Kathy,

Today, the Centers for Disease Control (CDC) and Prevention National Center for Health Statistics released the annual Maternal Mortality Rates in the United States Report and the data are alarming.   Since 2018, the maternal mortality rate increased nearly 89%. 

The maternal mortality rate for 2021 was 32.9 deaths per 100,000 live births compared to a rate of 23.8 in 2020. 

This is a 38% increase which is more than 2x the increase observed between 2019 and 2020. While rates of maternal mortality significantly increased between 2020 and 2021 for all race and Hispanic origin groups, the data show that significant racial and ethnic disparities in maternal mortality persist.

Maternal mortality rates for Black and Hispanic women significantly increased. In 2021, Black women were more than 2.5 times more likely to die than White and Hispanic women.  

 Since 2018, the maternal mortality rate increased nearly 89%. 

The maternal mortality rate for 2021 was 32.9 deaths per 100,000 live births compared to a rate of 23.8 in 2020. 

This is a 38% increase which is more than 2x the increase observed between 2019 and 2020. While rates of maternal mortality significantly increased between 2020 and 2021 for all race and Hispanic origin groups, the data show that significant racial and ethnic disparities in maternal mortality persist.

Maternal mortality rates for Black and Hispanic women significantly increased. In 2021, Black women were more than 2.5 times more likely to die than White and Hispanic women.  

Kathy, our nation is facing a maternal and infant health crisis. The U.S. remains among the worst developed nations for childbirth. The report released today only emphasizes that and is critical in raising awareness of the most pressing maternal and infant health issues families experience.

From helping to provide access to quality and equitable health care across the country to mobilizing our community to create lasting change for moms and babies through research and advocacy, March of Dimes is working to ensure all families can get the best possible start. 

Thank you for everything you do to fight for the health of all moms and babies.

Sincerely,  Dr. Elizabeth Cherot
                    Chief Medical & Health Officer
                    March of Dimes

P.S. Kathy, we’re calling for #BlanketChange to improve the health of all moms and babies.  Families in the U.S. need #BlanketChange. Help us achieve equity, access, and prevention for all moms and babies. Every family deserves to be healthy and receive the best possible start, regardless of income, race, gender or geography. But for too many in the United States, that isn’t the case. The U.S. is among the most dangerous developed nations for childbirth, and preterm birth–one of the leading causes of infant death–is at a 15-year high. The U.S. earned a D+ grade for preterm birth with the preterm birth rate increasing to 10.5%– the worst rate March of Dimes has ever reported. Maternal mortality has increased by 89% since 2018. While maternal mortality rates significantly increased for all races, clear and substantial racial and ethnic disparities continue to persist across key maternal health measures. Black women are 2.6 times more likely to die than White women and 2.5 times more likely to die than Hispanic women. The maternal and infant health crisis is worsening. March of Dimes is calling for #BlanketChange to improve the health of all moms and babies. Our agenda includes three key pillars: Equity: Eliminating racial and ethnic health disparities by focusing on prevention, treatment and social determinants of health to improve birth outcomes. Access: Improving unequal access to health care which contributes to the maternal and infant health crisis. Prevention: Expanding research and data collection on maternal mortality and morbidity to address preventable health conditions. Join us and tell your legislators we need #BlanketChange NOW.  Add your voice to the thousands of advocates calling for improved outcomes for moms, babies and families across the nation.

Add your voice today to the thousands of advocates calling for improved outcomes for moms, babies and families across the nation.  

At NICU Discharge, Considering Social Determinants of Health

A successful transition to home requires addressing a family’s environmental, financial, literacy, transportation, and social challenges.

Stefanie LaManna  September 10, 2022

  • Emma was born three months prematurely, with a variety of medical complications. After a long neonatal intensive care unit (NICU) stay, she is finally ready to go home—to a rural town more than an hour from the hospital.
  • Emma will need follow-up with multiple medical specialists, as well as physical therapy and speech-language treatment. She also needs her parents to manage her feeding tube, as she is unable to eat fully by mouth. Emma’s mother, Denise, quit her cashier job to care for her; her father, Tim, works long hours as a mechanic. Denise faces long hours caring for Emma alone, which feels overwhelming. The family is enrolled in Medicaid and the Special Supplemental Nutrition Program (WIC) in their state.

Nearly 50% of extremely preterm infants (those born at less than 28 weeks gestational age) who require prolonged NICU stays are re-hospitalized within the first two years of life (see sources). These medically complex infants need care from a variety of specialists to reduce the risk of re-hospitalization.

This interprofessional team is aware of the family’s socioeconomic and logistical barriers that may increase Emma’s risk—and they know how to incorporate these factors into discharge planning to ensure the family is prepared and well-supported for home.

Social determinants of health

A family’s socioeconomic status is one of the social determinants of health (SDOH)—the conditions in the family’s environment that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Per the U.S. Department of Health and Human Services, SDOH can be grouped into five domains: economic stability; education access and quality; health care access and quality; neighborhood and built environment; and social and community context.

SDOH affect people’s health and quality of life and may also lead to disparities and inequities in access to food, education, and health care (see last issue’s Leader article “Why Social Determinants of Health Matter So Much to Care.”

Emma and her family face barriers in each domain that may affect the transition to home.

Economic stability

Economic stability can influence a family’s ability to obtain specialty feeding supplies for their infant after NICU discharge, such as hypoallergenic formulas or specialty bottle systems. Even if one parent is steadily employed, frequent follow-up appointments and unanticipated medical expenses can strain family finances. Or perhaps a family member can no longer work because the family lacks access to medical daycare.

  • Denise is concerned that they cannot afford the bottle and nipple system that Emma has been using. The speech-language pathologist gives her extra nipples and bottles, as well as a gift card from the hospital’s charitable foundation to purchase extra supplies. The neonatologist and social worker collaborate to ensure that Emma’s specialty formula is available in her town and the physician writes a prescription for the formula so it will be covered by their medical assistance.

Education access and quality

A family’s access to education can affect their health literacy—the ability to understand basic health information needed to make appropriate health decisions. For example, almost half of adults who did not graduate from high school have low health literacy (see sources). People with low health literacy may have difficulty reading medication labels and dosages and formula-mixing instructions, or may find it challenging to report specifics such as their infant’s medications and feeding regimen to specialists and other medical staff.

  • Denise and Tim have learned to feed Emma using a feeding tube. Tim often gets frustrated figuring out how much formula to feed Emma and how to program the pump. The dietitian and NICU nurse collaborate to provide easy-to-follow, written instructions Tim can keep and easily access on his phone. 

Health care access and quality

Infants born extremely preterm or critically ill may require immediate transfer to a facility capable of handling their unique needs—which may be far from home or across state lines. After discharge, they usually have a variety of follow-up specialist appointments. Lack of transportation or inadequate insurance coverage may result in transferring care to specialists closer to home, though families may face long wait lists or delays in care.

It will be challenging for Denise and Tim to attend weekly appointments at the hospital, so the team transfers some of Emma’s care closer to her home—to a local pediatrician they provide with a comprehensive transition plan. The SLP connects Emma’s parents with a colleague who can provide feeding and swallowing treatment in their town, and refers the family to the state’s early intervention program so they can receive services in their home. The neonatologist schedules initial follow-ups with medical specialists on the same day so the family has only one trip to the hospital.

Neighborhood and built environment

Location, race, ethnicity, and socioeconomic status can affect environmental exposures, and poor communities are disproportionately affected by environmental conditions such as polluted air and water (see sources). A family living in a community with pollution may not have access to clean water to mix with formula or to wash feeding supplies, such as breast pump parts or bottles.

  • The dietitian and NICU nurse discuss formula-mixing instructions with Emma’s parents. They explain the importance of using sterile water (purchased from the store or boiled tap water) to decrease risk of infection. The social worker helps Denise apply for the supplemental nutrition assistance program (SNAP) to help pay for sterile water.

Social and community context

Parents of extremely preterm infants report higher levels of anxiety, depression, and parenting stress than parents of infants born at term, and a lengthy NICU stay can result in isolation from family and friends (see sources). Loved ones may not understand the implications of preterm birth and required medical supports on an infant’s development, or they may put well-intentioned pressure on an infant’s family to hasten discharge from the hospital, which may make for uncomfortable interactions.

  • Denise and Tim have no local family. Denise’s best friend has been supportive, but the friend’s son was born full-term, and Denise feels like she doesn’t understand the NICU experience. The patient advocate connects Denise with a virtual support group for NICU parents, in the hospital and after discharge. The social worker collaborates with their insurance company to secure nursing care for Emma so Denise has assistance while Tim is at work.

Discharge from the NICU is a significant milestone for an infant and family—but it can be a complex process with hurdles that make going home seem overwhelming. Considering a family’s unique SDOH during discharge planning can reduce health inequities and disparities, support a smooth transition to home, and ensure families have access to the resources to help them thrive.


Estoy Vivo Feat Chino y Nacho

Daniel elbittar

UNICEF supports the growth and development of babies born prematurely or underweight

28 June 2022

To contribute to the decrease in neonatal and infant morbidity and mortality and to promote breastfeeding, UNICEF supports the Kangaroo Method and its three fundamental pillars: kangaroo position, breastfeeding and outpatient follow-up

Children that are born before the 37 weeks or underweight face a risk such as mild alterations in their cognitive functions, delayed psychomotor development, vision loss, deafness, and even autism.

To mitigate these risks, UNICEF supports the early care of premature infants, and their families, through skin-to-skin contact from the moment of birth and according to the degree of prematurity or affectation, such practice is known as Kangaroo Mother Care Method. Thus, UNICEF, alongside health authorities, and multidisciplinary and family medical teams, work so every child enjoys their right to the highest possible level of health and quality services for the treatment of diseases, as it is established by the Convention on the Rights of the Child.

In the lactation center, mothers are assisted by a team of doctors, promoters, and nurses who guide and teach them the proper techniques for successful breastfeeding and how to preserve their breast milk. “Several promoters assist mothers from the moment they arrive at the emergency room. These new spaces reduce work for us since we now count on a mechanical device that helps women to prevent mastitis, hardening of their breasts, and those who have difficulty breastfeeding their baby. In this location, we set up the device (manual breast pump) and she feels relieved”, Indicates Elba Melchor, who is a promoter of humanized birth in the hospital.

In the outpatient consult, we offer medical assistance to monitor the growth and development of children until they are two years old,  and to continue educating family members on the care of their children. Likewise, medical advice on breastfeeding and complementary feeding, and immunizations, among other key aspects for the health of these children is provided to the mothers. This consult is of vital importance since it allows timely diagnosis and treatment of some pathologies that occur in these children, such as metabolic or gastrointestinal disorders, sensorineural disorders such as cerebral paralysis, blindness, deafness; language problems, among others.

This care design allows the inclusion of both parents, as well as the whole family together with a group of professionals from different disciplines such as doctors, nurses, physiotherapists, speech therapists, and social workers, among others, all integrated into an environment aimed at the care and stimulation of these children. 

In this consult, parents are reinforced with the importance of early attachment, through the kangaroo mother care method, and this way they are actively involved in the development of their baby.

Suarnny is 7 months old.  She was born at 35 weeks weighing 2.4 kilograms and then gradually lost weight. Today she has an expected development thanks to the accompaniment of the multidisciplinary team that has been with her watching over her development and growth process.

“The first days were tough, she had to be in an incubator for a month. In the hospital they encouraged me, they explained to me how to breastfeed her at the clinic and that I should talk to her and stimulate her. Little by little I was getting ahead, my girl was gradually gaining weight. I bring her monthly to her consultation”, indicates her mom Neyra.

Through their nutrition programme, in coordination with the health authorities and thanks to the contribution of international donors, UNICEF contributes to the reduction of infant mortality by improving the care of children born prematurely and underweight.



Clinical Pearl: Understanding the Impact of Neonatal Acute Kidney Injury

Kellie Barsotti, MD; Melanie Wielicka, MD  PhD

In recent years, we have significantly advanced our understanding of acute kidney injury (AKI) within the neonatal population. At birth, only about 4% of cardiac output reaches the kidneys; this is reflected in infants’ low glomerular filtration rate, especially those born prematurely. Any additional stressors such as hypoxia, hemodynamic instability, or infection, all of which we frequently encounter in preemies, have the potential to impact renal perfusion further and induce AKI. The incidence of AKI in infants born before 29 weeks gestation has been reported to be as high as 43%. Thus, significant efforts have been made to define neonatal AKI better and identify the risk factors and the related short and long-term outcomes.

Over the past ten years, the neonatal modified Kidney Disease: Improving Global Outcomes (KDIGO) criteria have become the gold standard definition for neonatal AKI. It determines the severity of AKI based on the magnitude of the rise in serum creatinine from prior values and the decrease in urine output and may be used in patients <120 days of age. This definition, as many other ones used in pediatrics, was adapted mainly from an adult patient-driven one. For instance, it fails to account for the physiologic changes in neonatal creatinine, which initially reflects maternal creatinine. If maternal serum creatinine is low, it would be expected that in an extremely premature infant, their creatinine would increase over the first several days of life, which would not necessarily be representative of AKI.

Additionally, serum creatinine (SCr) is a marker of renal function, not injury. The initial insult must cause a significant decline in renal function in order to result in an increase in SCr, which can sometimes take several days. This issue leads to a delay in SCr increase in relation to the timing of the injury. Furthermore, the KDIGO criteria fail to account for the neonate’s chronological and post-menstrual age. Despite its flaws, this definition has provided a certain degree of standardization and has allowed us to describe neonatal AKI’s epidemiology and outcomes better.

The Assessment of Worldwide Acute Kidney Epidemiology in Neonates (AWAKEN) study included 24 centers and collected data from almost one thousand neonates admitted to neonatal intensive care units. It has demonstrated that the risk of AKI increases significantly with decreasing gestational age and that neonates with AKI have higher odds of death and prolonged hospitalization. It has also expanded upon the neonatal-modified KDIGO definition to address neonatal physiology and redefine absolute serum creatinine thresholds based on gestational age. Using mortality as a meaningful clinical outcome, they tested the hypothesis that ideal cutoffs for serum creatinine levels within the first week of life will differ by gestational age. Their data shows that absolute and percent serum creatinine cutoffs are higher in those neonates born at less than 29 weeks gestation, suggesting that the neonatal modified KDIGO definition does not adequately account for physiologic differences seen within the first week of life and also between neonates of different gestational ages. This project marks an important milestone in AKI research in that previously, we relied on retrospective, single-center studies and lacked meaningful data on AKI incidence and risk factors in patients categorized by gestational age and time point in their hospital course.

Last year, Aziz et al.’s smaller, single-center study provided supportive evidence for AKI being inversely proportional to both gestational age and birth weight and for an association between AKI and increased mortality in extremely low-birth-weight neonates. Interestingly, they suggested that while mortality is strongly associated with neonatal AKI, it does not directly result from it, and its amelioration does not reduce the risk of death in this population. In response to these findings, Askenazi et al. discussed in a commentary piece why this is less likely to be true. The authors note that there is a possibility of bias within the statistical approach of the initial study with the use of Shapley Additive Explanations Analysis (a structural model that shows the relative association of each measured variable with a given outcome) to determine the association between each variable and their relationship to mortality. Another reason this paper cites is the limitations of using the neonatal-modified KDIGO criteria in this patient population, especially in the first several days of life, some of which we have already discussed. Because of the potential for this miscalculation bias, many studies do not include serum creatinine from the first 48 hours of life, unlike Aziz et al. Since serum creatinine often does not increase for up to 48 hours following a renal insult, it becomes challenging to assess AKI›s relationship with mortality in this population when elevation in serum creatinine has been proven to lag behind the injury. As there seems to be a widespread consensus that serum creatinine is a suboptimal marker for monitoring neonatal renal function, identifying novel biomarkers that would allow for earlier identification and better classification of AKI continues to generate interest. Some of the ones that have been suggested thus far include urine neutrophil gelatinase-associated lipocalin, cystatin-c, and kidney injury molecule-1, although further work is needed before we will be able to use them in our clinical practice .


Venezuelan medical professionals step in to fill healthcare gaps in Peru

Among the 1.5 million Venezuelan refugees and migrants in Peru are doctors and nurses who want nothing more than the chance to serve.

By Jenny Barchfield in Lima, Peru  |  15 February 2023

There were times, during the darkest days of the pandemic, when the Venezuelan nurse started vaccinating at 7am and finished, many hundreds of patients later, only at midnight. 

“We didn’t get tired,” Edixioney recalled. “What we wanted was for people to be able to get vaccinated so that they wouldn’t have to go home, unvaccinated, after having wasted their time in line.”

For 39-year-old Edixioney, who left Venezuela to seek life-saving heart surgery for her daughter and spent her first months in Peru working in a restaurant, the chance to serve in her chosen profession feels like nothing short of a miracle.  

“Our thing is vaccinating,” said Edixioney, adding that she and the other Venezuelan nurses she works with at the Los Libertadores public health clinic in Lima’s San Martín de Porres neighbourhood will be eternally grateful for “the opportunity to earn a living doing what we love.”  

Peru is home to the second-largest population of Venezuelan refugees and migrants in the region, playing host to nearly 1.5 million of the total 7.1 million Venezuelan nationals who have left their country in recent years amid the ongoing social and economic crisis there. Many of them are educated professionals, including nurses, physical therapists, and physicians who, despite having skills that are highly sought after in their adopted country, have sometimes faced administrative hurdles that have make it difficult for them to practice in their adopted country.

That was initially the case for Néstor Márquez, a 53-year-old physician who settled in Lima in 2018. When he first arrived, Néstor was in no position to revalidate his medical licenses – a long and expensive process that can take upwards of a year and a half. His first priority was to save up enough money to be able to bring his wife and three young children to Peru. 

To do so, he traded the scrubs that had been his daily uniform during his decades-long medical career in Venezuela for a pair of comfortable shoes.

“I worked selling books at sidewalk stands…. I was a travelling book salesman,” said Néstor, a smile just visible from behind his surgical mask. “It helped me so much. With what I made selling books, I was able to bring my family.”

Now, thanks, in part, to an agreement between UNHCR, the UN Refugee Agency, and Peru’s Health Ministry, Néstor is working in physical therapy – the specialty he trained for back in Venezuela – at a new public clinic in North Lima. Under the deal, UNHCR funds the salary of the staff, nearly all of whom are Venezuelan nationals, for an initial three months while they are onboarded. 

Since it opened last year, residents from across the Peruvian capital have been flocking to the Los Olivos de Pro Rehabilitation Centre, seeking relief for ailments such as back pain, nerve damage, and long-lasting respiratory problems resulting from COVID-19. The team has also seen a surge in parents seeking speech therapy for young children who, kept inside during the pandemic at crucial stages in their development, are having a hard time communicating. 

Ironically, Néstor says that it was the coronavirus pandemic that helped Venezuelan health professionals in Peru, like him, get back to work.

In 2020, Peru’s healthcare workers were among the hardest hit by the coronavirus, which further depleted an already overburdened workforce. The pandemic created a dire need for qualified and experienced medical professionals, which prompted Peruvian authorities to fast-track medical licenses for qualified staff hailing from other countries who were already living in Peru. It was then that Néstor applied for and was granted the right to practice in Peru.

“For me, it’s like a dream come true to be here, in this place where there is so much need,” he said, gesturing toward the waiting area, where a little boy in a wheelchair and leg braces was awaiting his appointment. “Working here in this clinic allows me to carry out what I’ve spent my whole life thinking about and doing, surrounded by a group of extraordinary Venezuelan professionals.”

Asked whether any of the patients have balked at being cared for by the clinic’s near all-Venezuelan staff, Néstor said that, on the contrary “they are happy and grateful.”

Yesenia Ramos Sandóval, the mother of the little boy in the wheelchair, 7-year-old Jeremy, echoed that sentiment.

“We’re just so happy to be able to get Jeremy the therapy he needs,” said Yesenia, a 30-year-old native of the Peruvian capital, with a broad smile.


Moms’ and babies’ medical data predicts prematurity complications, Stanford Medicine-led study shows

Stanford Medicine scientists and their colleagues have shown they can tap mothers’ and babies’ medical records to better predict newborn health risks.

February 15, 2023 – By Erin Digitale

By sifting through electronic health records of moms and babies using a machine-learning algorithm, scientists can predict how at-risk newborns will fare in their first two months of life. The new method allows physicians to classify, at or before birth, which infants are likely to develop complications of prematurity.

A study describing the method, developed at the Stanford School of Medicine, was published online Feb. 15 in Science Translational Medicine.

“This is a new way of thinking about preterm birth, placing the focus on individual health factors of the newborns rather than looking only at how early they are born,” said senior study author Nima Aghaeepour, PhD, an associate professor of anesthesiology, perioperative and pain medicine and of pediatrics. The study’s lead authors are postdoctoral scholar Davide De Francesco, PhD, and Jonathan Reiss, MD, an instructor in pediatrics.

Traditionally defined as birth occurring at least three weeks early, premature birth is linked to complications in babies’ lungs, brains, vision, hearing and digestive system. Although earlier births generally carry higher risks, the timing of birth predicts only approximately how a specific infant will fare. Some infants who are born quite early develop no complications, while others born at the same stage of pregnancy become very ill or die.

“Preterm birth is the single largest cause of death in children under age 5 worldwide, and we haven’t had good solutions,” Aghaeepour said. “By focusing our research on predicting the health of these babies, we can optimize their care.”

Many complications of prematurity take days or weeks after birth to emerge, causing substantial damage to newborns’ health in the meantime. Knowing which infants are at risk could enable preventive measures.

“We look mainly at the baby to make treatment decisions in neonatology, but we are finding that we can get valuable information from the maternal health record, really homing in on how individual babies’ trajectories have been shaped by exposure to their specific maternal environment,” said study coauthor David Stevenson, MD, a neonatologist at Lucile Packard Children’s Hospital Stanford, professor of pediatrics and director of the March of Dimes Prematurity Research Center at the Stanford School of Medicine.

“This is a move toward precision medicine for babies,” he added.

The researchers linked electronic medical records for mothers at Stanford Health Care and for their babies at Stanford Medicine Children’s Health, covering 32,354 live births that occurred between 2014 and 2020. The mothers’ medical records included information from the pregnancy and, for those who had been patients at Stanford Medicine prior to pregnancy, health data from before they became pregnant. The infants’ records started with information recorded at birth, including weight; blood tests; and Apgar score, which is assessed in the delivery room one and five minutes after birth. The Apgar score incorporates factors such as the infant’s pulse, breathing and muscle tone.

Using a machine learning algorithm called a long short-term memory neural network, the researchers built a mathematical model from the medical records and tested whether it could predict 24 possible health outcomes for infants up to two months after birth.

“There is a computational challenge in using electronic health records because they are longitudinal and contain a large amount of data from each patient,” Aghaeepour said. “A long short-term memory neural network operates similarly to a person reading a book. When we’re reading, we don’t remember every word, but we remember the key concepts, read the next part, add more key concepts and carry that forward. The algorithm doesn’t memorize the entire electronic health record of every patient, but it can remember key concepts and carry those forward to the point where we make a prediction.”

At the time of birth, the machine learning model provided strong predictions for which infants would develop various conditions including bronchopulmonary dysplasia, a type of chronic lung disease; retinopathy of prematurity, a problem with the retina that can cause vision loss or blindness; anemia of prematurity; and necrotizing enterocolitis, a severe gastrointestinal complication often not diagnosed until weeks after birth, by which time interventions are complex and associated with poor outcomes.

The model also gave strong predictions a week before birth for multiple outcomes including mortality and retinopathy of prematurity, which can cause vision loss or blindness, as well as moderately strong predictions for 11 other conditions.

“I was surprised by how much predictive power we have before the baby is even born, and right at birth,” Aghaeepour said. “I did not expect to see that. I had thought accuracy would come several days after birth, once we had collected data from the baby.”

Some complications were not reliably predicted by the model, such as which infants would develop candidiasis, or yeast infections; polycythemia, a high concentration of red cells in the blood; or meconium aspiration syndrome, in which the infant inhales meconium, a sticky substance expelled from the fetal bowel, during birth.

The researchers validated that the strength of the predictions did not change over the years (comparing births from 2014 to 2018 with those from 2019 to 2020); they also validated some of the findings using an independent group of 12,258 mother-baby pairs from UC San Francisco.

The model’s predictions at birth provided more accurate information than currently used risk assessment tools such as Apgar scores and the National Institute of Child Health and Human Development risk score. These scores consider only the condition of the baby at birth and do not incorporate any information from the mother’s medical history, the researchers noted. However, additional studies in more diverse populations are needed before this machine-learning tool is ready to replace existing risk calculators at the bedside, the researchers said.

Mother’s health matters

The model revealed unexpected connections between certain health or social conditions in mothers and the health of their infants, according to the researchers.

For instance, mothers with anemia — a common pregnancy complication — were more likely to have newborns with anemia. These infants were also more likely to develop the bowel complication necrotizing enterocolitis, the study found.

“We need to explore what linkages explain these relationships at a biological level, as these might offer clues to how certain conditions occur,” Stevenson said. “That will allow us to intervene better to help those kids.”

The new algorithm was also able to link specific types of socioeconomic disadvantage in mothers with certain prematurity complications in their babies.

“If a mother was homeless, we found that the health impact on the baby would be different from the impact of incarceration, whereas under traditional paradigms both of these socioeconomic factors might be thought to have similar effects on prematurity risk,” Aghaeepour said.

Predictions from the model could help neonatologists better identify which patients will benefit from existing protocols to prevent birth complications, Stevenson said. For example, newborns who experience lack of oxygen during birth can now receive cooling protocols in early life, which lower their body temperature for a few days to prevent brain injury. Predictive scores may help identify additional infants who could be helped by cooling, he said.

The work needs to be replicated in larger, more diverse patient populations and folded together with other Stanford Medicine research that characterizes pregnancies according to thousands of biomarkers that change during gestation, the scientists said.


       An exodus of primary care doctors has officials re-imagining healthcare in South County

By Bill Seymour Special to the Independent    Feb 17, 2023

Dr. Sal Abbruzzese recently opened his internal medicine practice in South Kingstown, where he works with his wife, Sarah. Abbruzzese, who was the president of South County Hospital medical staff until he resigned in December, is the first doctor to open a solo practice in the area in several years and says Southern Rhode Island’s lack of primary care doctors is a problem that is only going to get worse. “It’s like watching a train crash,” he said this week.

Stephanie Nowell of Charlestown got very sick on January 6 with various symptoms, visited a walk-in clinic and received antibiotics that didn’t work for her.

She returned to the walk-in once more and was given additional antibiotics that helped. Her primary care doctor had left the practice to which Nowell belonged and she was having difficulty finding a new doctor.

“If I had a primary care doctor I could have consulted with, I think I could have gotten better faster,” she said.

It is tough to get an appointment with an internal medicine doctor in South County today. Waiting times could be long and a walk-in medical treatment center, pharmacy clinic or hospital emergency room — when it’s not really needed — may be the only place to go.

The difficulty of finding a primary care physician stems from an exodus of them from the practice of medicine. Many doctors point to a variety of reasons for leaving and less interest in young medical students wanting to pursue general medicine.

Among the reasons are too much stress, onerous requirements by medical systems seeking to cut costs, insurance companies wanting detailed records to qualify for payment, low pay and overall changes in the practice of internal medicine that make it less fulfilling as a career.

In their place are an increase of mid-level medical professionals — often called advanced practice providers — like nurse practitioners and physician assistants.

Now these professionals are getting their day in the sun with a rise in demand for their needed skills that also come with less cost in billing to insurance companies and less training for patients.

In several interviews with physicians about the shortage of primary care doctors, all are pointing to more demands in their jobs that take away from patient care as frustrations and stress build. Most would only speak anonymously because of fear of repercussions from hospital systems.

“It’s like watching a train crash. I know what’s coming and it’s going to be a worse crash,” said Dr. Sal Abbruzzese, former president of the South County Hospital medical staff who departed in December to open up a practice in Wakefield. It is the first time in many years that a doctor has opened a solo practice in the area, he said.

“I have people calling me, leaving wine on my doorstep with a note asking to be taken on, referrals from many other doctors who just can’t take on any more patients. It’s incredible, I’ve never seen such a thing,” said Abbruzzese who started work as a doctor more than 20 years ago.

Other doctors in the area interviewed echoed similar statements about the administrative headaches now forcing them to leave practice or open up “concierge” services where a patient pays a multi-thousand-dollar fee — sometimes upwards of $3,000 or more.

The high out-of-pocket cost brings for the few that can afford this convenience round-the-clock access and the kind of personal attention often missing now from many busy practices focusing on patient volume or through-put.

“Yes, I would say that people could soon be up the creek without a paddle if this continues,” said Dr. Gloria Sun, another physician who shelved her general practice career because of excessive demands and is now in a job at the University of Rhode Island student health services.

However, leaving was not easy, she said.

“It was very difficult for me. I feel like I’ve given up,” she added in a voice that slowly and softly let out the words. Her youthful brimming enthusiasm and idealism have faded to later-in-life resignation to dealing with the current medical industrial complex.

A spokesman for South County Health pointed to the mid-level professionals stepping in as an inevitability in the industry as more doctors leave both on the local and national scenes.

“In a primary care setting, advanced practice providers will fill an increasingly important role as the physician workforce ages into retirement and fewer new physicians choose to establish practices in Rhode Island,” explained Matt Moeller, SCH spokesman.

These mid-level APPs are licensed nurse practitioners, physician assistants, advanced practice registered nurses and others. To help ease the transition of doctor-only visits for patients, health systems are lumping the term “advanced practice provider” to mean both the doctor and the mid-levels together in a “team” approach.

Gone from reference often these days is your “personal physician” or your “primary care physician” known colloquially as your “PCP.”

Fewer Internists

Local doctors, who did not want their names used, said that the practice of medicine in profit-centered medical systems has beaten down many general medicine doctors.

They feel beleaguered by too much medical records paperwork, low pay, and hard-driving measures putting performance — the volume of patients seen — over patient care to make up for reduced insurance payments.

Alarm bells were sounded in the state more than two years ago, according to state Department of Public Health officials, as evidence mounted that thousands of doctors could potentially leave primary care practice by 2030.

The shortage of primary care doctors is also a national problem, too. Many want out because retirement looks far better than dealing with defeating requirements for endless after-hours of filling out patients’ detailed electronic medical records (EMR), they say.

Sun was one of them.

“I was spending up to three hours every night on paperwork. It’s just so all-consuming, even for a short and simple visit. EMR is what is killing medicine,” she said about records needing to be filled out in exacting detail so that insurance companies don’t lowball reimbursements already low on a profit scale for operations of medical practices and hospitals, say health care business managers.

Abbruzzese, 50, who last month opened his private practice, said that health systems are “running doctors out of town. They are not providing us with the tools we need. They want more and more and give less and less.”

For example, he referenced that various tests are available only on certain days, needed scans cannot be done on weekends, picc lines are inserted only on particular days and “even the cafeteria staff wasn’t around on weekends.”

Making matters worse, he and others added, is that the COVID pandemic has pushed doctors to the brink of sacrificing their own health and many died across the country in that service. It brought about a new reality of their limitations in today’s world of medicine.

“When we older doctors went into practice, we were told by our older doctors that this is a lifestyle — not a job — and this is your life now. Your job is to take care of your patients. That is slipping away from many of my colleagues’ abilities to do,” he said.

For instance, 57-year-old Sun’s colleagues and patients call her a devoted doctor. One patient who had cancer and lost her husband after an accident in which he was paralyzed from the neck down found a trusted medical advisor and friend in Sun.

“I just love her. Please tell her to take me. I can’t find anyone in the area,” the former patient said. It’s a sentiment that plies on Sun and other doctors interviewed who also have changed their medical career paths.

Sun, like many doctors her age, entered medicine to help people overcome or cope with diseases and be compassionate as much as possible in times of real need.

For those in medical school today that mission in primary care is an unappealing career. It’s akin to a caged mouse on a wheel being electronically stimulated to go faster and faster, some medical students have said.

Burnout comes quickly. This upcoming generation of doctors values the work-life balance, so the cage is out of the question for many, say young doctors preferring specialties that have a less hectic pace.

Who’s left to help?

More and more health systems are putting a stronger focus on mid-level advanced practice providers to step in as South County Health is doing. Thundermist Health Center reported it started with mid-levels before the primary care doctor shortage became the current topic of public and media attention.

In federally reported training standards, the National Institute of Health said physicians, physician assistants (PAs), nurse practitioners (NPs) and advanced practice registered nurses (APRNs) have vastly different requirements for admission to graduate programs, clinical exposure, and postgraduate training.

The National Institute of Health reported that nurse practitioners on average have about 500 clinical contact hours in training compared to 2,000 for a physician’s assistant and 5,000 or more for a doctor. Neither the NP nor the PA has a residency requirement in training as does the medical doctor, NIH said.

For specialty areas, the PA or NP also has no further training, but the doctor has three- and four-year programs with 13,500 to 18,000 clinical hours.

According to the Bureau of Labor Statistics Occupational Outlook, growth projections for advanced practice providers are much faster than the average for other professions.

The projected growth for advanced practice registered nurses over the ten-year period 2019-2029 is 45%. Over the same period, physician assistant jobs are projected to grow by 31%.

Thundermist has had a nurse practitioner fellowship for over five years for training in community health and integrates them into its healthcare teams, said Amanda Barney, spokeswoman for Thundermist, which has offices in Wakefield.

She said that at Thundermist there is roughly a 50-50 split in the number of doctors compared to other primary care specialists and APPs.

Moeller of South County Health did not give a ratio, but said that in 2022 SCH hired six new primary care providers, defined as either APPs or doctors. Barney did not have any immediate figures on her organization’s hiring numbers last year.

With retirements and turnover, he said, “we are net positive two primary care providers during that same time.” Nonetheless, there remains a need for local primary care services.

“South County Health estimates there is demand for 6-12 additional primary care providers in Washington County,” he added.

“We are in the final stages of rolling out a formal program for on-boarding and mentoring nurse practitioners early in their career that have an interest in primary care,” Moeller said.

Like Thundermist, SCH’s primary care nurse practitioners and other APPs work in teams that include physicians, pharmacists, nurses and possibly social workers as needed.  As with Thundermist, SCH also refers patients to specialists when needed.

More and increased training is underway as the need for them becomes more apparent.

“The mentorship program that South County Health is developing focuses on pairing new nurse practitioners with senior-level providers who have extensive experience navigating the healthcare landscape,” said Ian Clark, SCH vice president.

“It’s our hope this partnership will facilitate orienting those who are new to practice in Rhode Island to the intangibles, like working with our electronic health record, networking with other medical staff, and building a durable practice for long-term sustainability in the community,” he said.

“This program, we are confident, will allow us to increase the number of primary care nurse practitioners in our area and better meet the needs of the community,” Moeller added.

While APPs across the country are in many different medical services — oncology, orthopedics, surgery and neonatal — their use in primary care is also a boon for insurance and managed-care companies who may pay fees lower than they might for a medical doctor.

The State of Rhode Island licenses some advanced practice providers, like nurse practitioners, to also practice autonomously.

Increase Use of APPs

Last July a new survey of more than 60 organizations representing over 3,000 APPs nationwide found that three-fourths of diverse health systems have a strategy in place to increase the use of their APPs.

One of the largest studies focusing specifically on these roles, the 2022 Advanced Practice Provider Strategy & Oversight Survey provided key data points to help hospitals and medical groups.

These focus on better use of APPs while also spotlighting key areas for leaders to be aware of when pursuing an APP strategy, said the research firm the Coker Group.

This national healthcare advisory firm based in Alpharetta, Ga., found that organizations who said they are increasing APP involvement were responding to several market drivers, including the need to improve access to care including a shortage in primary care doctors, adapt to organizational growth, and improve the efficiency and quality of care.

These needs have been magnified nationally across healthcare following the COVID-19 pandemic and a growing labor shortage, it said.

“Our goal in creating this survey was to fill some of the gaps in data-driven information available and to better understand industry best practices,” said Matt Jensen, senior manager at the Coker Group.

“When organizations utilize APPs in the right way, they’re able to expand patient access, increase quality and drive performance. Across healthcare, however, hiring experienced APPs is extremely difficult, and the survey reflects that by showing just how many organizations are investing the time and resources required to onboard and train new APPs.”

It also pointed to challenges ahead, especially with resistant medical doctors who have concerns about APP training that is not as in-depth as full-scale medical school, internship, residency and fellowship that all bring over a decade of learning.

Roughly 67% of those polled said they allow their physicians to choose if they work with APPs for coverage of certain responsibilities. But about half of those physicians are hesitant to work with others, citing a heavy time commitment and a lack of incentive.

The experience of an APP also makes a difference in physicians’ use, with respondents indicating they spend more than 2.5 times the amount of time supervising APPs with less than two years of experience.

When asked about the barriers physicians have in a willingness to oversee APPs, the majority cited the time commitment and a lack of monetary incentive. While 46% of those overseeing APPs receive a fixed stipend for their supervision, 36% said there was no additional compensation.

Several local doctors did not want their names used when discussing the greater use of APPs. They acknowledged, however, that these advanced provider practitioners serve a vital role in handling minor issues.

“They are useful to support the practice and handle sinus infections, urinary tract infections and colds, but they need to know their limits,” one doctor said.

“You need to give new ones a lot of time — that you don’t have — to train them and this comes on top of all the other things, and a larger volume of patients that health systems want you to see. There aren’t the resources to help them,” a South Kingstown doctor added.

Abbruzzese was blunter.

“You get what you pay for, you get what you are trained in and it’s going to be a problem,” he said noting that doctors go through at least eight years of post-university training while for APPs it’s it far fewer.

“We’ll see what happens,” he said, while healthcare systems say they are putting bets on additional training and mentoring will add to the value of these professionals.



Courtesy Shakina Rajendram

Canadian siblings born four months early set record as the world’s most premature twins

By Paula Newton, CNN – March 9, 2023

CNN — 

For expectant parents Shakina Rajendram and Kevin Nadarajah, the doctor’s words were both definitive and devastating: Their twins were not “viable.”

“Even in that moment, as I was hearing those words come out of the doctor’s mouth, I could still feel the babies very much alive within me. And so for me, I just wasn’t able to comprehend how babies who felt very much alive within me could not be viable,” Rajendram recalled.

Still, she knew that there was no way she would be able to carry to term. She had begun bleeding, and the doctor said she would give birth soon. The parents-to-be were told that they would be able to hold their babies but that they would not be resuscitated, as they were too premature.

Rajendram, 35, and Nadarajah, 37, had married and settled in Ajax, Ontario, about 35 miles east of Toronto, to start a family. They had conceived once before, but the pregnancy was ectopic – outside the uterus – and ended after a few months.

As crushing as the doctor’s news was, Nadarajah said, they both refused to believe their babies would not make it. And so they scoured the Internet, finding information that both alarmed and encouraged them. The babies were at just 21 weeks and five days gestation; to have a chance, they would need to stay in the womb a day and a half longer, and Rajendram would have to go to a specialized hospital that could treat “micropreemies.”

The earlier a baby is born, the higher the risk of death or serious disability, the US Centers for Disease Control and Prevention says. Babies born preterm, before 37 weeks gestation, can have breathing issues, digestive problems and brain bleeds. Development challenges and delays can also last a lifetime.

The problems can be especially severe for micropreemies, those born before 26 weeks gestation who weigh less than 26 ounces.

Research has found that infants born at 22 weeks who get active medical treatment have survival rates of 25% to 50%, according to a 2019 study.

Rajendram and Nadarajah requested a transfer to Mount Sinai Hospital in Toronto, one of a limited number of medical centers in North America that provides resuscitation and active care at 22 weeks gestation.

Then, they say, they “prayed hard,” with Rajendram determined to keep the babies inside her just a few hours longer.

Just one hour after midnight on March 4, 2022, at 22 weeks gestation, Adiah Laelynn Nadarajah was born weighing under 12 ounces. Her brother, Adrial Luka Nadarajah, joined her 23 minutes later, weighing not quite 15 ounces.

According to Guinness World Records, the pair are both the most premature and lightest twins ever born. The previous record holders for premature twins were the Ewoldt twins, born in Iowa at the gestational age of 22 weeks, 1 day.

It is a record these parents say they want broken as soon as possible so more babies are given the opportunity to survive.

“They were perfect in every sense to us,” Rajendram said. “They were born smaller than the palm of our hands. People still don’t believe us when we tell them.”

‘They’re definitely miracles’

The babies were born at just the right time to be eligible to receive proactive care, resuscitation, nutrition and vital organ support, according to Mount Sinai Hospital. Even an hour earlier, the care team may not have been able to intervene medically.

“We just didn’t really understand why that strict cut off at 22, but we know that the hospital had their reasons. They were in uncharted territory, and I know that they had to possibly create some parameters around what they could do,” Rajendram said.

“They’re definitely miracles,” Nadarajah said as he described seeing the twins in the neonatal intensive care unit for the first time and trying to come to terms with what they would go through in their fight to survive.

“I had challenging feelings, conflicting feelings, seeing how tiny they were on one hand, feeling the joy of seeing two babies on the second hand. I was thinking, ‘how much pain they are in?’ It was so conflicting. They were so tiny,” he said.

These risks and setbacks are common in the lives of micropreemies.

Dr. Prakesh Shah, the pediatrician-in-chief at Mount Sinai Hospital, said he was straightforward with the couple about the challenges ahead for their twins.

He warned of a struggle just to keep Adiah and Adrial breathing, let alone feed them.

The babies weighed little more than a can of soda, with their organs visible through translucent skin. The needle used to give them nutrition was less than 2 millimeters in diameter, about the size of a thin knitting needle.

“At some stage, many of us would have felt that, ‘is this the right thing to do for these babies?’ These babies were in significant pain, distress, and their skin was peeling off. Even removing surgical tape would mean that their skin would peel off,” Shah told CNN.

But what their parents saw gave them hope.

“We could see through their skin. We could see their hearts beating,” Rajendram said.

They had to weigh all the risks of going forward and agreeing to more and more medical intervention. There could be months or even years of painful, difficult treatment ahead, along with the long-term risks of things like muscle development problems, cerebral palsy, language delays, cognitive delays, blindness and deafness.

Rajendram and Nadarajah did not dare hope for another miracle, but they say they knew their babies were fighters, and they resolved to give them a chance at life.

“The strength that Kevin and I had as parents, we had to believe that our babies had that same strength, that they have that same resilience. And so yes, they would have to go through pain, and they’re going to continue going through difficult moments, even through their adult life, not only as premature babies. But we believed that they would have a stronger resolve, a resilience that would enable them to get through those painful moments in the NICU,” Rajendram said.

There were painful setbacks over nearly half a year of treatment in the hospital, especially in the first few weeks.

“There were several instances in the early days where we were asked about withdrawing care, that’s just a fact, and so those were the moments where we just rallied in prayer, and we saw a turnaround,” Nadarajah said.

Adiah spent 161 days in the hospital and went home on August 11, six days before her brother, Adrial, joined her there.

Adrial’s road has been a bit more difficult. He has been hospitalized three more times with various infections, sometimes spending weeks in the hospital.

Both siblings continue with specialist checkups and various types of therapy several times a month.

But the new parents are finally more at ease, celebrating their babies’ homecoming and learning all they can about their personalities.

The twins are now meeting many of the milestones of babies for their “corrected age,” where they would be if they were born at full-term.

“The one thing that really surprised me, when both of them were ready to go home, both of them went home without oxygen, no feeding tube, nothing, they just went home. They were feeding on their own and maintaining their oxygen,” Shah said.

Adiah is now very social and has long conversations with everyone she meets. Their parents describe Adrial as wise for his years, curious and intelligent, with a love of music.

“We feel it’s very important to highlight that contrary to what was expected of them, our babies are happy, healthy, active babies who are breathing and feeding on their own, rolling over, babbling all the time, growing well, playing, and enjoying life as babies,” Rajendram said.

These parents hope their story will inspire other families and health professionals to reassess the issue of viability before 22 weeks gestation, even when confronted with sobering survival rates and risks of long-term disability.

“Even five years ago, we would not have gone for it, if it was not for the better help we can now provide,” Shah said, adding that medical teams are using life-sustaining technology in a better way than in previous years. “It’s allowing us to sustain these babies, helping keep oxygen in their bodies, the role of carbon dioxide, without causing lung injury.”

Adiah and Adrial’s parents say they’re not expecting perfect children with perfect health but are striving to provide the best possible life for them.

“This journey has empowered us to advocate for the lives of other preterm infants like Adiah and Adrial, who would not be alive today if the boundaries of viability had not been challenged by their health care team,” Rajendram said.


A NICU Baby Gives Hope to a Waiting Family

How a NICU team joined forces with social workers and an adoption agency to introduce a baby to her new family on Mother’s Day:

In April 2021, the sickest newborn in the neonatal intensive care unit (NICU) at Atrium Health Levine Children’s Hospital was born awaiting a family. She didn’t have a revolving door of visitors itching at the chance to hold her or anyone to make medical decisions for her. Her doctors didn’t know if the baby would survive her first week. 

Just two months later, that baby girl – Evelyn – was healthy, happy and at home with a new family. The NICU team joined forces with an adoption agency, a caring birth mom, and an adoptive family to help this baby heal in the hospital and to create a happily-ever-after for her beyond it.

This is a story about one of the happiest moms celebrating Mother’s Day this year, Laura Cobb, and the team who connected her to her daughter, Evelyn.

A Heartbreaking First Week

With no family available to make decisions for the sick newborn, the NICU doctors cared for baby Evelyn like they would any other, and charted the medical course for her based on the standard of care and best practices.

“We think about each baby in terms of, ‘If this was my child, what would I want this team to do?’” says Jessica Clarke-Pounder, M.D., a neonatologist at Levine Children’s Hospital. “We treat each baby how we would want our family members treated, with the same gravity to decision making that we would have with our own children.”

Evelyn faced multiple life-threatening challenges during her first few days. For one, she was born with an infection and was delivered by emergency C-section due to fetal distress which led to required resuscitation by the NICU team in the delivery room.  She was placed on therapeutic hypothermia protocol after delivery due to concern for brain injury.  The baby also had meconium aspiration, in which feces enters the lungs. Then, Evelyn developed pulmonary hypertension. Then, kidney failure. Evelyn’s body was essentially shutting down, and she required a heart/lung bypass machine – called ECMO, or extracorporeal membrane oxygenation – to keep her alive. Evelyn was so fragile that the pediatric surgical team performed the surgery to place her on the ECMO pump inside the NICU.

“Levine Children’s Hospital is the only center in this area that offers ECMO. If she was born anywhere else, she would’ve had to be transferred,” says Dr. Clarke-Pounder. “The pump saved her life.”

The NICU team offered the little girl more than decision making. The NICU team offered her love. Doctors and nurses, full of all faith backgrounds, prayed over this little girl to heal. They cuddled the baby every chance they could.

By the end of that first week, Evelyn stabilized and was healthy enough to come off the ECMO machine. Her birth mom chose to pursue adoption, and social workers and an adoption agency helped her find a forever family for her baby.

The Worst Day Becomes the Best Day

Mother’s Day used to be Laura Cobb’s most dreaded day of the year.

For seven years, Laura and her husband James tried to have a baby. They learned they couldn’t have biological children, and the adoption process was slow. Mother’s Day weekends were so painful that the couple turned off their phones and went on off-grid getaways to be alone. The Friday before Mother’s Day of 2021, however, Laura’s phone rang as she drove home from work. She decided to answer one last call before turning it off.

It was the adoption agency, who told Laura about a very sick baby in the NICU who needed a family. The baby was stable, but she could face developmental hurdles and possibly brain damage. The agency told Laura that she and her husband should talk and pray about it.

“My husband and I were like, ‘No, we’ve prayed enough! This is what we’ve been praying for! This is our daughter!’” Laura says, smiling and wiping tears at the memory. “We are her parents, that is it. And so, we met her the very next day.”

On the day before Mother’s Day, they met the 10-day-old baby. Evelyn wore the cutest pink outfit to meet her new parents. Laura later learned the outfit was a personal gift from someone who loved Evelyn, too: Dr. Clarke-Pounder.

“There are there lots of families that, for one reason or another, can’t be in the NICU. Families can feel a lot of guilt over that, but there are moms and dads who have limited time off from work, or babies who get transferred here from far away,” Dr. Clarke-Pounder says.  “Every baby who’s there, especially ones who don’t have families, we really take care of them as if they’re our family.”

A Big Team Supports a Little Baby

Laura and James joined an already large group of people who were part of Team Evelyn. There were NICU doctors, nurse practitioners, pediatric surgeons, respiratory therapists, ECMO therapists, gastrointestinal specialists, speech therapists, social workers, and an adoption agency.

People across many disciplines collaborated to create a seamless care plan to support this little girl.

While James needed to return to work, Laura came to the NICU daily to hold Evelyn, to sing to her, and to work with the therapists as they taught the little girl to take a bottle. 

“At first, I didn’t want to leave Evelyn because I didn’t want her to feel alone, but she wasn’t alone. She was so loved by the nurses and doctors, who were amazing. They were her family before we were,” Laura says. “And I felt taken care of by them just as much.”

About a month later, Evelyn learned how to take a bottle and she became strong enough to go home with the Cobbs. Before the family left the hospital together, the NICU team helped them make follow-up appointments with specialists and a pediatrician to help them transition to the next stage of their daughter’s care.

A Healthy Little Girl, a Grateful New Mom

Evelyn just celebrated her first birthday. She returns for developmental appointments at a neonatal follow up office, which works with her pediatrician to make sure she’s developing appropriately. All signs point to a healthy little girl, developing on schedule.

Laura says that the past year has shown her a capacity to love beyond what she’s ever known: for Evelyn, for Evelyn’s birth mother who continues to be a loving presence in her daughter’s life and for the NICU doctors and nurses.

Now, Laura’s preparing to celebrate her second happy Mother’s Day. 

“Because Mother’s Day weekend is the weekend we met Evelyn, it’s our family weekend,” Laura says. “It’s not about me. It’s about Evelyn, and it’s about honoring her birth mom. I’ve never met someone as strong and courageous and faith-filled as her birth mom – she’s amazing.”

The Cobbs remain in touch with Dr. Clarke-Pounder, sending her photos and updates of the baby she guided through those first few scary weeks.

“It was really special to me to see Evelyn progress from being the sickest baby in the NICU to becoming a baby who went home with a loving family,” Dr. Clarke-Pounder says. “It is really special when families are so impacted that they choose to stay in contact with us, and it’s really nice to see that our hard work has paid off.”

Laura kept the pink outfit that Dr. Clarke-Pounder gave Evelyn on the day the family met.

“One day I’m going to show Evelyn this outfit,” Laura says. “And I’m going to tell her, ‘This was from your doctor – she loved you before I even met you.’”


A NICU Baby Gives Hope to a Waiting Family – YOUTUBE


Norwegian paediatric residents surveyed on whether they would want life support for their own extremely preterm infant

Janicke SylternTrond Markestad 18 January 2023

Advances in perinatal and neonatal medicine have made it possible for preterm infants to survive at earlier ages. However, survival rates vary substantially between high-income countries and perinatal centres, suggesting that attitudes on providing life support differs. Survival rates for live-born infants vary, particularly at 22–23 weeks of gestation, but differences extend to 27 weeks when stillbirths are included. This suggests that proactive, life-saving prenatal care vary across a wider range of gestational ages. Differences may be due to variations in legislation or values, national or local consensuses by involved health professionals and how parents are included in decision making. Although there are multiple prognostic factors, the vulnerability of extremely preterm infants increases profoundly with decreasing gestational age in terms of survival, neonatal morbidity, burden of treatment and subsequent physical and mental health. Some European guidelines on resuscitating premature newborns have been developed by just perinatologists and neonatologists and they particularly vary on how active interventions should be at 22–25 weeks.

In Norway, guidelines based on the 1998 national consensus state that life support is standard care from 25 weeks. Infants born at 23–24 weeks should be individually assessed by neonatologists and consider the parents’ opinions. Life support at 22 weeks should be regarded as experimental. In practice, the so-called grey zone of 23–24 weeks has been narrowed down to 23 weeks, based on 2009–2014 data. This showed that 97% of infants born at 24 weeks were transferred to a neonatal intensive care unit, as were 74% born at 23 weeks and 19% born at 22 weeks. We have no data on how parents were involved in the decision-making process.

This study explored whether Norwegian paediatric residents would want life support to be provided if their own hypothetical preterm infant was born at 22–26 week of gestation. Short questionnaires, which were distributed after one-week compulsory national training courses in neonatology, were completed anonymously by 80/96 (83%) of participants, on paper in 2017 and 2019 and as an online Mentimeter survey (Mentimeter AB) in 2020. Most participants were in their thirties, with a median paediatric residency of 36 (range 3–84) months. The majority (94%) would not have wanted life support at 22 weeks, 73% at 23 weeks, 36% at 24 weeks and 8% at 25 weeks. One wanted life support before 24 weeks, 14% at 24 weeks, 59% at 25 weeks and 79% at 26 weeks. A particularly large percentage (50%) were unsure at 24 weeks (Table 1).

TABLE 1. How 80 Norwegian paediatric residents responded to whether they would want their hypothetical child to receive life support at 22–26 weeks of gestational age.

YesNot sureNo
22 weeks, n (%)1 (1)4 (5)75 (94)
23 weeks, n (%)0 (0)22 (28)58 (73)
24 weeks, n (%)11 (14)40 (50)29 (36)
25 weeks, n (%)47 (59)27 (34)6 (8)
26 weeks, n (%)63 (79)12 (15)5 (6)

The residents’ opinions were even more restrictive than the 1998 guidelines and deviated markedly from current Norwegian practice. This could challenge the golden rule of treating others as we would want to be treated. Although we cannot assume that others share our preferences, it seems unethical to impose what we would not want ourselves on them, without providing real choice. Most importantly, this hypothetical question may not predict what would happen in real life. However, the residents were at a common age for parenthood, knew the risks and burdens of treatment and had already had time to reflect on the issue during their clinical training and the newly completed course. In contrast, parents are generally unprepared and at the mercy of neonatal intensive care practices and how physicians provide information and frame alternatives.

Our findings agreed with other studies on whether informed healthcare personnel would want life support for their own infant. One found that only 54% of Norwegian paediatricians would want this at 24 weeks and another reported that 23/24 Australian neonatal nurses would not want this before 25 weeks. It seems unlikely that discrepancies between the attitudes of healthcare personnel and neonatal intensive care practices reflect different moral values of healthcare personnel and potential parents. It points towards different experiences and the burden and urgency when healthcare personnel and parents make difficult decisions. Although some parents of premature babies accept disabilities more than healthcare personnel, parents also worry about the short-term and long-term suffering of their baby and family and want to be involved in decision making.

Improved survival rates may encourage neonatologists to resuscitate ever more immature infants, but their decisions need to reflect society’s moral norms. We believe that national guidelines on challenging ethical medical dilemmas like this should not just be left to involved healthcare personnel. Relevant stakeholders should include professionals with experience from long-term follow-up, educators, ethicists, lawmakers and public representatives. Parents should be involved if decisions about providing life support fall within an agreed grey zone, where the child’s best interests are not clear. We believe that guidelines based on broad social support will increase social awareness about the ethical dilemmas of periviability and promote transparency. These are prerequisites for parents to become competent decision-making partners. We need to speak about values as well as medical facts and statistics. In our experience, parents need a trusting and open atmosphere to voice their doubts. Many of the paediatric residents we surveyed would have preferred a palliative approach for their own vulnerable infant and knowing this may encourage open dialogues about complex decisions at the margin of viability.


Strengthening neonatal and obstetric healthcare in the war-affected regions of Ukraine

9 Mar 2023 by Milena Chodoła and Dorota Zadroga

At the end of February, the Polish Medical Mission completed the first six months of the one-year project titled “Strengthening neonatal and obstetric healthcare in the war-affected regions of Ukraine”. Activities are being implemented in 10 neonatology hospitals in Ukraine, located in the cities of Kyiv, Dnipro, Chernihiv, Kharkiv, Chernivtsi, Zaporizhzhia, Poltava and Lviv. Cooperation with Ukrainian neonatologists in supporting this branch of medicine is a continuation of one of the leading projects of the Polish Medical Mission’s portfolio worldwide. The Polish association is carrying out similar activities in Colombia, Venezuela and Tanzania. The organization became involved in activities to help Ukraine’s healthcare system after the conflict began, providing specialized assistance to hospitals across the country.

In the first quarter of the project, starting September 1st 2022, a needs assessment on medical training for Neonatology and Neonatal Intensive Care Units (NICUs) was conducted in 10 hospitals. Based on it, a training plan (including the approach, methodology, scheme and work plan of trainers) was prepared, taking into account the current needs of each hospital. The process of purchasing specialized equipment has also begun — an advanced and high-quality neonatal resuscitation station, as well as a neonatal patient monitor (for measuring and analyzing vital signs) and a neonatal infusion pump were on the list for each institution. In accordance with the schedule, a complete plan of activities for the next second quarter of the project was developed by the end of November. Cooperation agreements with hospitals were signed and a project team of 27 staff members was recruited in Ukraine, including medical training coordinators, medical trainers, patient rights training coordinators, patient rights educators and administrative representatives of hospitals.

As part of the support for pregnant and postpartum patients, a series of onsite sessions raising awareness of patients’ rights, pregnancy and newborn care, will be held up monthly at each of the hospitals included in the project. Of the planned 80 trainings, 10 have already taken place, one at each facility. A total of 102 patients have taken part in them. There have also been two complementary online sessions (out of a planned 8) raising awareness about patients’ rights, pregnancy and newborn care for women who are patients or whose newborns are patients. A total of 42 female patients attended.

The second quarter was devoted to equipping hospitals and launching medical and patient rights trainings for health workers and awareness-raising sessions for patients. In each of the 10 hospitals, also stationary training sessions were being held for medical personnel in the use of neonatal resuscitation stations and neonatal patient monitors.

In December 2022, stationary medical training for staff of the neonatology and obstetrics departments began, ending in early February 2023. The project held one 4-day medical training in each of the 10 hospitals. A total of 346 doctors from Ukraine participated in all 10 medical trainings (the project’s indicators planned for a minimum of 100 doctors from 10 hospitals to participate in in-person medical trainings, more than tripling the expected result).

Prior to attending the in-person medical trainings for health workers in 10 hospitals, trainees filled out an anonymous knowledge test, which was repeated upon its completion. By compiling the results from the test before the training, as well as after the training, it was verified to what extent the trainees raised their level of knowledge. Approximately 95% of the participating doctors increased their level of knowledge in the topics that were covered in the training. They also filled out an anonymous questionnaire surveying their level of satisfaction with the training. Some 93% of the doctors gave the maximum score for the training, or 5 points; the remaining 7% of doctors rated the training on a scale of 4 to 4.9 points.

In the second half of January 2023, two online events were also organized on the Ukrainian medical platform Medvoice, streaming from January 17-19, while recordings of them are now available online. One, titled “Becoming a mom during wartime: important things to know”, is prepared for patients across Ukraine. The webinar has been replayed 780 times so far (February 28, 2023). The second is aimed at medical professionals, also across Ukraine, and was titled “Doctor-patient communication: foreign practices and Ukrainian realities”. So far, 1,607 doctors from Ukraine have registered, of which 995 doctors took the online course, passed the test and received a certificate. The events were held under the auspices of the National Health Service of Ukraine. In addition, the online course for doctors has been registered with the Ministry of Health of Ukraine, so doctors who participated and passed the online test received a certificate and official credits from the Ministry, which doctors collect to confirm the continuous development of their professional qualifications.

On February 16, 2023 the second online training on patient rights was held for the medical staff of the 10 neonatology hospitals participating in the project (a total of 8 such online trainings conducted at regular intervals are planned). A total of 50 doctors from 10 hospitals have already participated in these trainings. The purpose of the meetings run on the Zoom platform is to raise awareness among medical professionals about patient rights, legal liability of hospitals and doctors, communication with patients, and counteracting professional burnout and taking care of doctors’ well-being. It also demonstrates good practices used by Polish and EU doctors in the field of patient rights. Small groups allow participants to exchange insights and experiences, and to a greater extent assimilate the knowledge from the training.

Total numbers:

  • 10 NICUs in project
  • 995 trained medical staff representatives in online course on patient rights on Medvoice
  • 346 trained medical staff representatives in stationary medical training
  • 50 trained medical staff representatives in online trainings on patient rights
  • 780 patients in webinar on Medvoice
  • 144 patients in online and stationary awareness-raising sessions


Improvement of Maternal Morbidity and Mortality: Maternal Level of Care, Maternal Transport, and Regionalization

Mary Fang, BS M.D. Candidate

In my mind’s eye, I painted a picture of her experience flying here. She lay down to get her routine ultrasound done and watch the grayscale frames of the twins headknocking inside her uterus, eager to share some polaroids of her growing babes with her husband that evening, suddenly gazing back to the screen, which showed red and blue lines over her cervix she did not remember seeing or being told about previously. She was not going to go home that evening; she was going to the hospital via airlift from an island to the mainland major hospital. Mrs. Smith was tearful and expressed difficulty understanding why doctors recommended she stay in-patient in a hospital far from home for the remainder of her pregnancy, which she had just learned would end four weeks earlier than initially planned. She felt no change compared to before that ultrasound visit, where type I vasa previa and absent end diastolic flow of growth-restricted twin A were newly diagnosed. With the constellation of mo-di twins, vasa previa, and AEDF (absent end-diastolic flow), the possibility of her needing to be transported urgently or emergently was significant. However, with her now at a high-level care center, the transport would be up the elevator, not in an ambulance or aircraft, when life or death could be a matter of milliliters of fetal blood within minutes.

Perinatal care, comprised of the maternal-fetal/neonatal triad, has improved throughout the decades. However, the improvement is predominantly based on improved neonatal outcomes.  Implementing risk-appropriate neonatal care in the 1970s has significantly reduced neonatal and infant morbidity and mortality, especially among very low birthweight infants that receive appropriate care in at least a level III NICU.  However, the other side of the perinatal triad, the maternal side, continues to face rises in maternal mortality and morbidity in the U.S., especially among women of color. The longstanding neonatal model of levels of care has more recently inspired similar maternal levels of care models, whereby each level has a minimum ability related to staffing and resources. Appropriate level of maternal care spans the antenatal, perinatal, and postpartum periods. Efforts for assigning levels of maternal care at the national level are at their early stages, with mandatory versus voluntary efforts by the state. Efforts were piloted in 14 hospitals in 3 states in 2017. In Texas, the first iteration of maternity designation was codified in 2018, and all facilities in Texas were designated a level by September 2021 by the Department of State Health Services. Level 1 centers provide basic care to low to moderate-risk pregnant patients and detect, stabilize, and initiate management until the patient is transferred. Level 2 facilities provide specialty care, and level 3 facilities provide subspecialty care and are equipped to manage complex maternal and obstetric complications. Level 4 facilities are regional perinatal health care centers that are equipped to manage the most complex conditions and critically ill pregnant patients. There are challenges with adoption and acceptance in other states due to concern primarily for lower level hospitals and the process of applying, preparing prior to site review, the site review, and post-site report.

Despite the aforementioned concerns, regionalization through identifying high-level facilities and maternal transport is necessary to improve outcomes based on assigned risk. Maternal transport is one of the keystones for improving mortality or major morbidity through transferring care from a low-acuity to a high-acuity facility. These improved outcomes relate to preventing near-miss events, adverse outcomes that may have occurred in the absence of transport. However, maternal transport accessibility is not equal or equitable due to differences in time and distance from the nearest high-acuity center, inefficient identification of the nearest center, and/or lack of clear hospital protocols to appropriately transfer patients who require it. Improving equitable access to transfer to appropriate levels of care, especially highlighted in rural facilities, demands hospital-level quality improvement initiatives, including identifying patients who need transport and clear plans on the method of transport and distance. Reasons for maternal transfer fall into maternal and/or fetal/neonatal indications. While the most common reason is the lack of availability of appropriate-level neonatal care, maternal medical or surgical conditions or emergency care at a facility without obstetric services also require transfer. Improved maternal regionalization is another effort to facilitate the transfer of care via defining relationships between different level facilities and labeling the capabilities of a facility. Some instances may necessitate the identification of multiple higher-level facilities, depending on the facility’s capacity to accept new transfers. Mode-of-transport (i.e., ambulance versus airlift) is also an important consideration, reliant on distance, urgency, and availability of the transport means.

Fragmentation of perinatal care also contributes to increased morbidity and mortality. This discordance is multi-fold, with some facilities with appropriate high-level care for the maternal side but not the neonatal side, or vice versa, and hospitals without MFMs or neonatologists within a 10-mile radius.  This incongruity between appropriate maternal and neonatal care availability significantly affects outcomes for high-risk pregnancies. Studies have demonstrated improved outcomes for maternal transfer for neonatal indications prenatally versus postnatally. Improved regionalization can help increase the number of high-risk births occurring at the appropriate-level facility, avoiding separation of the mother and newborn after birth. This is achieved by better defining the scope of maternal and neonatal care concurrently to plan for delivery at a center that provides appropriate care for both the mother and the newborn.

Risk stratification and planning for delivery for high-risk pregnancies in advance require longitudinal care by a multidisciplinary team, including a maternal-fetal medicine specialist. Adequate prenatal care aids in the delivery plan by identifying and monitoring high-risk conditions. Unfortunately, there also exist disparities in the adequacy of prenatal care and, subsequently, differences in access to management by MFM. Co-morbidities that are unidentified or not adequately managed during pregnancy, including interval ultrasounds and antenatal testing, increase morbidity and mortality. In such cases, without access to routine prenatal care, presentations to care are often only to the emergency room, which might not be able to take care of the obstetric emergency, especially if it was undiagnosed beforehand due to lack of longitudinal obstetric care. An undiagnosed obstetric condition presenting for the first time in an emergent setting without appropriate resources and personnel can further delay transfer due to the stabilization requirement before transfer.  Perinatal health includes consideration of the maternal and fetal/neonatal perspectives. Conditions associated with maternal morbidity and mortality can directly impact fetal/neonatal outcomes and thus warrant high-level care antenatally with an MFM to make decisions about antenatal surveillance and include other specialists during the pregnancy.

Accurate risk stratification depends on identifying and controlling co-morbidities identified antenatally and informs management during the antenatal, perinatal, and postnatal/postpartum period, including assigning the appropriate level of care. As high-risk maternal patients are often associated with high-risk fetal/neonatal counterparts, planning care at a facility with level-appropriate care for both the mother and newborn improves outcomes. Maternal transport and regionalization, in addition to risk stratification, improve maternal morbidity and mortality with care at a facility equipped with resources and personnel to adequately and promptly respond appropriately. Lack of access to prenatal or MFM care and, thus, inappropriate diagnosis and management of maternal and/or fetal conditions underlie disparities in outcomes despite these improvements. Fortunately, identifying the barriers and inequities in accessing appropriate levels of care is ongoing, leading to the development of quality, evidence-based tools to lessen these gaps.


The connecting power of shared laughter | Karen Eddington | TEDxIdahoFalls

Shared laughter reverses the belief that we are alone. The most dangerous emotion we face is mental isolation. How would your life be different IF you felt connected? We can solve the struggle of when you are surrounded by people yet still feel alone. Karen Eddington is the author of Understanding Self-Worth and she uses her experience in stand-up comedy and improv to teach laughter as a form of self-care. This talk was given at a TEDx event using the TED conference format but independently organized by a local community. Learn more at

In times of stress and vulnerability practicing humor can be instrumental in helping us move through life’s challenges. Humor can help us connect with ourselves and others on a more intimate level. Being met with some challenges in my personal life recently, it’s the simple moments with close friends that have helped me see the humor within certain circumstances I am navigating. Finding ways to laugh about ourselves, the things we tend to take at times too seriously, and engaging with humor in our seemingly mundane moments can help us find the positive momentum we need to keep moving forward in a positive direction.  

Finding comfort in bringing laughter to those we hold close and appreciating the funny moments we share with ourselves and others is food for our souls. Who are some of the people and things in your life that bring you laughter? How does humor empower your relationship with yourself and others, and enhance your life journey?  

I believe by choosing joy, laughter, and engaging in some light-hearted fun through humor we can learn to embrace our grace. With April Fools around the corner my hope is that together we can bring a little more light into our world through the laughter we spark in each other.  

Surfing in Venezuela

Mark Angelo



Estimated # of preterm births: 8.84 per 100 live births (USA 9.56-Global Average: 10.6)

Source- WHO 2014-

Hungary is a landlocked country in Central Europe. Spanning 93,030 square kilometres (35,920 sq mi) of the Carpathian Basin, it is bordered by Slovakia to the north, Ukraine to the northeast, Romania to the east and southeast, Serbia to the south, Croatia and Slovenia to the southwest, and Austria to the west. Hungary has a population of 9.7 million, mostly ethnic Hungarians and a significant Romani minorityHungarian, the official language, is the world’s most widely spoken Uralic language and among the few non-Indo-European languages widely spoken in Europe. Budapest is the country’s capital and largest city; other major urban areas include DebrecenSzegedMiskolcPécs, and Győr.

Hungary is a middle power in international affairs, owing mostly to its cultural and economic influence. It is a high-income economy with a very high human development index, where citizens enjoy universal health care and tuition-free secondary education. Hungary has a long history of significant contributions to artsmusicliteraturesportsscience and technology. It is a popular tourist destination in Europe, drawing 24.5 million international tourists in 2019. It is a member of numerous international organisations, including the Council of EuropeNATOUnited NationsWorld Health OrganizationWorld Trade OrganizationWorld BankInternational Investment BankAsian Infrastructure Investment Bank, and the Visegrád Group.

Hungary maintains a universal health care system largely financed by government national health insurance. According to the OECD, 100% of the population is covered by universal health insurance, which is free for children, students, pensioners, people with low income, handicapped people, and church employees. Hungary spends 7.2% of GDP on healthcare, spending $2,045 per capita, of which $1,365 is provided by the government.

Hungary is one of the main destinations of medical tourism in Europe, particularly for dentistry, in which its share is 42% in Europe and 21% worldwide. Plastic surgery is also a key sector, with 30% of the clients coming from abroad. Hungary is well known for its spa culture and is home to numerous medicinal spas, which attract “spa tourism”.



Exposure to Air Pollution and Emergency Department Visits During the First Year of Life Among Preterm and Full-term Infants

Original Investigation  Environmental Health  February 22, 2023 Anaïs Teyton, MPH1,2,3Rebecca J. Baer, MPH4,5Tarik Benmarhnia, PhD3; et alGretchen Bandoli, PhD1,5 JAMA Netw Open.2023;6(2):e230262. doi:10.1001/jamanetworkopen.2023.0262

Key Points

Question  What is the association between fine particulate matter (PM2.5) exposure and emergency department (ED) visits during the first year of life, and are preterm infants more susceptible to PM2.5 exposure than full-term infants?

Findings  In this cohort study of 1 983 700 infants, a positive association was observed between PM2.5 exposure and all-cause, infection-related, and respiratory-related visits. Preterm and full-term infants were most susceptible to having an all-cause ED visit during their fourth and fifth months of life.

Meaning  These findings suggest that increased PM2.5 exposure was associated with an increased ED visit risk; thus, strategies aimed at reducing PM2.5 exposure for infants may be warranted.


Importance  Previous studies have focused on exposure to fine particulate matter 2.5 μm or less in diameter (PM2.5) and on birth outcome risks; however, few studies have evaluated the health consequences of PM2.5 exposure on infants during their first year of life and whether prematurity could exacerbate such risks.

Objective  To assess the association of PM2.5 exposure with emergency department (ED) visits during the first year of life and determine whether preterm birth status modifies the association.

Design, Setting, and Participants  This individual-level cohort study used data from the Study of Outcomes in Mothers and Infants cohort, which includes all live-born, singleton deliveries in California. Data from infants’ health records through their first birthday were included. Participants included 2 175 180 infants born between 2014 and 2018, and complete data were included for an analytic sample of 1 983 700 (91.2%). Analysis was conducted from October 2021 to September 2022.

Exposures  Weekly PM2.5 exposure at the residential ZIP code at birth was estimated from an ensemble model combining multiple machine learning algorithms and several potentially associated variables.

Main Outcomes and Measures  Main outcomes included the first all-cause ED visit and the first infection- and respiratory-related visits separately. Hypotheses were generated after data collection and prior to analysis. Pooled logistic regression models with a discrete time approach assessed PM2.5 exposure and time to ED visits during each week of the first year of life and across the entire year. Preterm birth status, sex, and payment type for delivery were assessed as effect modifiers.

Results  Of the 1 983 700 infants, 979 038 (49.4%) were female, 966 349 (48.7%) were Hispanic, and 142 081 (7.2%) were preterm. Across the first year of life, the odds of an ED visit for any cause were greater among both preterm (AOR, 1.056; 95% CI, 1.048-1.064) and full-term (AOR, 1.051; 95% CI, 1.049-1.053) infants for each 5-μg/m3 increase in exposure to PM2.5. Elevated odds were also observed for infection-related ED visit (preterm: AOR, 1.035; 95% CI, 1.001-1.069; full-term: AOR, 1.053; 95% CI, 1.044-1.062) and first respiratory-related ED visit (preterm: AOR, 1.080; 95% CI, 1.067-1.093; full-term: AOR,1.065; 95% CI, 1.061-1.069). For both preterm and full-term infants, ages 18 to 23 weeks were associated with the greatest odds of all-cause ED visits (AORs ranged from 1.034; 95% CI, 0.976-1.094 to 1.077; 95% CI, 1.022-1.135).

Conclusions and Relevance  Increasing PM2.5 exposure was associated with an increased ED visit risk for both preterm and full-term infants during the first year of life, which may have implications for interventions aimed at minimizing air pollution.


Considerations for Reducing Maternal Mortality

Elizabeth Filipovich, MPH

Maternal mortality in the United States is on the rise and has been for the past several decades. This trend stands out as other high-income countries, like the United Kingdom and Canada, have lower maternal mortality rates. Birthing people in the United States now experience worse mortality rates than the prior two generations. Maternal mortality ratios, or deaths per 100,00 live births, are used to illustrate the massive racial disparities among birthing people. Non-Hispanic Black birthing people have pregnancy-related mortality rates nearly 3x that of their white counterparts.

The Centers for Disease Control defines maternal mortality as “the death of a woman during pregnancy, at delivery, or soon after delivery.” Maternal deaths are further divided into two categories: pregnancy-related and pregnancy-associated deaths. Pregnancy-related deaths are defined as “the death of a woman while pregnant or within one year of the end of pregnancy, regardless of the outcome, duration, or site of pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.”

Pregnancy-associated but not related deaths are “the death of a woman while pregnant or within one year of pregnancy from a cause or cause unrelated to pregnancy. Often, when maternal mortality is researched and discussed, the body of work emphasizes pregnancy-related deaths. For example, the statistics used in the above paragraph reference pregnancy-related deaths exclusively. However, a better understanding of factors contributing to many accidental, pregnancy-associated but not related deaths is essential for effective methods to reduce the number of maternal deaths in the United States, regardless of cause or manner of death.

Well-documented maternal death causes include hemorrhage, cardiomyopathy, or other cardiac causes, and worsening underlying conditions or other medical causes often deemed pregnancy-related. Equally important are other causes of death, including accidental poisonings or overdoses, maternal suicides, or homicides. These are pregnancy-associated, not related, or not directly caused or exacerbated by pregnancy. The many touchpoints of care in the perinatal period provide opportunities for intervention and opportunities for improved perinatal care, particularly for birthing people who have a history of substance use disorder (SUD), history of anxiety, depression, or other mood disorders, or families who may be at risk for violence, instability, or other significant hardship.

Statewide and local Maternal Mortality Review Committees (MMRC) are convened to examine maternal death trends by comprehensively reviewing deaths that occur during or within one year of pregnancy. MMRCs are multidisciplinary and include representatives from a spectrum of perinatal care providers, including public health, obstetrics, maternal-fetal medicine, pediatrics, nursing, midwifery, community health organizations, mental and behavioral health, and patient/family advocacy groups. MMRCs meet to discuss cases and collaboratively create evidence-based recommendations to prevent future deaths. MMRCs provide critical evidence for legislatures, health systems, and public health leaders to endorse safety bundles and new laws to prevent future deaths.

While MMRCs retrospectively review maternal deaths to understand preventable causes of these deaths further, providers and clinicians across all disciplines, as well as the public, can proactively impact the alarming rate of maternal deaths in this country. Neonatal care providers have a critical role. Despite becoming increasingly standard practice to have postpartum follow-up visits before four weeks postpartum, this is not universally implemented. Even if a postpartum follow-up is scheduled, not all birthing people attend a follow-up visit, as evidenced by several studies documenting that 11-46% do not attend a postpartum visit. However, well-child visits are very well attended by postpartum people. By capitalizing on the touchpoint of the well-child visits, providers capture an opportunity for assessment and potential referral or intervention.

 Neonatal providers can contribute to reducing maternal mortality in several ways. Pediatric and family providers are often left out of the conversation, but the reality is that many providers for infants have more touchpoints with birthing people in the postpartum period than their prenatal providers. Pediatric visits for neonates and infants provide the opportunity for intervention that begins with a thorough assessment of the birthing person and include awareness of resources available to provide to patients, as well as understanding that wellness is facilitated by a host of factors extend beyond the physical health of the patient.

The scope of this newsletter article is not broad enough for the depth of discussion,  but rather draws attention to how social determinants of health contribute to maternal deaths and how providers can continue to care for their patients by addressing them. Providers should attempt to understand the environment of each family. By exploring significant relationships, one can understand the birthing person’s support systems, the likelihood of experiencing violence, housing circumstances, income stability, etc. By connecting identified birthing persons to support services and resources and following up on successive pediatric visits, perinatal providers can reduce maternal mortality. For more information on perinatal mood disorders, perinatal substance use, and many other resources for providers and families, please visit


Want to grab a little sunshine! Take a listen to this fun song!

VALMAR ft. Szikora Robi – Úristen

Valmar is a popular Hungarian artist/band. Szikora Róbert – Hungarian singer and songwriter.

Optimizing Temperature of Preterm Infants in the Delivery Room

Preventing heat loss in infants less than 1500 grams and/or less than 30 weeks’ gestational age.

Bundle care approach

                                                                 Preterm Baby Package    Jan 22, 2023


Recognizing Our Biases, Understanding the Evidence, and Responding Equitably

Application of the Socioecological Model to Reduce Racial Disparities in the NICU-McCarty, Dana B. DPT, PT Editor(s): Christine A., Fortney PhD, RN, Section Editor-Advances in Neonatal Care 23(1):p 31-39, February 2023.



Implicit bias permeates beliefs and actions both personally and professionally and results in negative health outcomes for people of color—even in the neonatal intensive care unit (NICU). NICU clinicians may naïvely and incorrectly assume that NICU families receive unbiased care. Existing evidence establishing associations between sex, race, and neonatal outcomes may perpetuate the tendency to deny racial bias in NICU practice.

Evidence Acquisition: 

Using the socioecological model as a framework, this article outlines evidence for racial health disparities in the NICU on multiple levels—societal, community, institutional, interpersonal, and individual. Using current evidence and recommendations from the National Association of Neonatal Nurses Position Statement on “Racial Bias in the NICU,” appropriate interventions and equitable responses of the NICU clinician are explored.


Based on current evidence, clinicians should reject the notion that the social construct of race is the root cause for certain neonatal morbidities. Instead, clinicians should focus on the confluence of medical and social factors contributing to each individual infant’s progress. This critical distinction is not only important for clinicians employing life-saving interventions, but also for those who provide routine care, developmental care, and family education—as these biases can and do shape clinical interactions.

TABLE 1. – NANN’s Racial Disparity in the NICU Position Statement Recommendations

Elevate awareness of racial disparities, inclusion, and cultural sensitivity by providing education in cultural competence, presenting published research on the issues, and having open discussions about the topics.
Encourage diversity in the workforce.
Examine personal bias and beliefs, some of which may be unconscious. Be self-aware and open to feedback and observations from others.
Examine individual NICU statistics to evaluate significant trends in gestational age, race, and patient outcomes.
Invite families to participate in the culture of the NICU by involving a diverse team of parents on committees, such as a quality improvement committee.
Regularly use interpreters when caring for families who do not speak English. Relying on other family members to interpret for parents may contribute to misinformation and a lack of appropriate education.
Provide written and electronic information in multiple languages whenever possible.
Consider all discharge requirements and available resources to transition families to the home environment.
Advocate for racial awareness and equality in your hospital and community. Connect with hospital administrators, community leaders, and elected officials to discuss health outcomes of racial disparities, and advocate for resources that positively impact the social determinants of health affecting maternal and infant health.



A hidden epidemic of fetal alcohol syndrome

New legislation could help bring awareness and resources to prevention, diagnosis, and treatment of fetal alcohol spectrum disorders-By Kirsten Weir Date created: July 1, 2022

Stress and alcohol use often go hand in hand, a concerning pattern on the heels of the COVID-19 pandemic. Researchers have found that alcohol use increased sharply during the pandemic, and there is some evidence that those patterns were present among pregnant women as well, said Ira Chasnoff, MD, a pediatrician and fetal alcohol spectrum disorder (FASD) researcher at the University of Illinois College of Medicine in Chicago. Experts worry that the trend could result in more babies being born with damage from prenatal alcohol exposure.

Even before the pandemic, FASD was a significant problem. Experts estimate that 2% to 5% of U.S. schoolchildren—as many as 1 in 20—may be affected by prenatal alcohol exposure, which can cause complications with growth, behavior, and learning. The effects on individuals and families, as well as the economic costs, are substantial.

Yet support for FASD research and services is limited. The National Institute on Alcohol Abuse and Alcoholism funds innovative research on FASD, said Christie Petrenko, PhD, a clinical psychologist and research associate professor at Mt. Hope Family Center, University of Rochester, and codirector of the FASD Diagnostic and Evaluation Clinic there. But a Substance Abuse and Mental Health Services Administration (SAMHSA)–funded FASD Center for Excellence program was shuttered in 2016, leaving a big gap between the research being done and practical solutions for children and families affected by FASD, she said. Now, there’s a bipartisan bill before Congress, the FASD Respect Act, which would support FASD research, surveillance, and activities related to diagnosis, prevention, and treatment. (APA has endorsed this bill.)

Such attention is sorely needed, and psychologists have a significant role to play in diagnosis, prevention, and treatment, Petrenko said. “Families are desperate for support.” Yet many people with FASD haven’t even received an accurate diagnosis, let alone appropriate treatments.

Clinicians should be aware that FASD often overlaps with mental health symptoms. These problems begin in early childhood and exist through adulthood, as described by Mary O’Connor, PhD, ABPP, founder of the UCLA Fetal Alcohol Spectrum Disorders Clinic (Current Developmental Disorders Reports, Vol. 1, No. 1, 2014). Her research has also found a higher incidence of suicidal ideation and behavior in adolescents with FASD (Birth Defects Research, Vol. 111, No. 12, 2019). And many adults with FASD who have mental health disorders aren’t getting treatment, said Susan Stoner, PhD, a research associate professor at the University of Washington School of Medicine and director of the Washington State Parent-Child Assistance Program, a program for pregnant and parenting women with substance use disorders (Alcoholism: Clinical and Experimental Research, Vol. 46, No. 2, 2022). “We found those with less severe FASD tend to have worse mental health than those with more severe FASD, which might be because those with more severe FASD are more likely to have a diagnosis and more likely to get support,” she said.

Understanding FASD

Many variables determine whether an infant will be born with FASD and how severe the disorder will be. Such factors include how much a pregnant person drinks, the rate at which they metabolize alcohol, and the stage of fetal development during alcohol exposure. “There are too many variables at play to estimate a safe level of drinking during pregnancy,” Stoner said. “The safest amount of alcohol during pregnancy is zero.”

Prenatal alcohol exposure can result in several conditions that fall under the FASD umbrella. These include fetal alcohol syndrome (FAS) and partial FAS, both of which can cause growth problems, central nervous system problems, and characteristic facial features (including small eye openings, flattening of the ridge between the nose and lip, and a thin upper lip), in addition to problems with learning and behavior. People with alcohol-related neurodevelopmental disorder (ARND) don’t have the characteristic facial features or growth deficiency of FAS, but they may have wide-ranging neurocognitive disabilities and problems with behavior and learning. These diagnoses overlap with a newer term—neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE)—a classification first included in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) as a condition requiring further study (Kable, J. A., et al., Child Psychiatry & Human Development, Vol. 47, No. 2, 2016).

Each of the disorders in the fetal alcohol spectrum can cause problems with self-regulation, executive functioning, social skills, and math skills. These deficits often interfere with children’s performance in school and their ability to make friends. Yet while FASD often causes learning difficulties, the symptoms can be unpredictable. “FASD is the most common preventable cause of intellectual disability in the world. But the majority of alcohol-exposed children have a normal IQ,” Chasnoff said. One notable feature of FASD is a gap between intelligence and adaptive functioning, he added. One of his teen patients, for example, has above average intelligence but is unable to read clocks or count money. “In children affected by alcohol exposure, adaptive functioning is significantly lower than IQ,” he said.

Behavioral problems associated with FASD are common, and often misunderstood, said Petrenko. “So many of the symptoms of FASD can look like intentionally willful or oppositional behavior, when really there are underlying neurodevelopmental explanations,” she said. An accurate diagnosis is the first step toward putting supports in place to address those neurodevelopmental challenges and help people with FASD thrive.

Diagnosis and treatment of FASD

The gold standard for FASD diagnosis is a multidisciplinary evaluation looking at physical features, neurobehavioral impairments, and any known history of prenatal alcohol exposure. The assessment typically involves a variety of specialists such as physicians, speech/language pathologists, psychologists, and geneticists. But those comprehensive evaluations are hard to come by. “There are very few FASD clinics that provide full-service diagnosis,” O’Connor said. “It’s estimated that about only 1% of people with prenatal alcohol exposure can get a diagnosis in that type of situation.”

As a result, many children with FASD are falling through the cracks. Chasnoff and colleagues collected data from 547 foster and adopted children and found that within this group 86.5% of youth with FASD had never been diagnosed or had been misdiagnosed (Pediatrics, Vol. 135, No. 2, 2015). “The great majority of children that are affected by alcohol are misdiagnosed and taking inappropriate medications or receiving ineffective therapy,” Chasnoff said. “FASD should be in the differential diagnosis for any child who presents with behavior problems. And while no single discipline can diagnose FASD, psychologists have a major role to play in the diagnosis.”

Psychologists are also instrumental in designing treatments for children with FASD. To date, only a handful of evidence-based interventions have been developed, each targeting different aspects of FASD. Parents and Children Together (PACT), developed by Chasnoff and colleagues, is a 12-week family intervention that works with children ages 6 to 12 years old and their parents or caregivers to improve self-regulation and executive function. PACT builds on techniques learned from treating traumatic brain injury and sensory processing disorders. The research has found that the intervention improves executive functioning and emotional problem-solving in children with FAS and ARND (Wells, A. M., et al., American Journal of Occupational Therapy, Vol. 66, No. 1, 2012).

The Math Interactive Learning Experience (MILE) program, developed by clinical psychologist Claire Coles, PhD, at Emory University, is a tutoring intervention designed to improve math knowledge and skills, a common area of struggle for children with FASD. A study showed that the 6-week intervention improved both math skills and behavior in alcohol-affected children ages 3 to 10 (Journal of Developmental & Behavioral Pediatrics, Vol. 30, No. 1, 2009).

Children with FASD often have trouble learning social skills as well. The Good Buddies program, developed by O’Connor and colleagues, is designed to teach those skills in a group format over 12 weeks to children ages 6 to 12. The program is derived from an evidence-based treatment for improving children’s friendships, adapted for the specific behavioral and cognitive deficits common in children with FASD (Laugeson, E. A., et al., Child and Family Behavior Therapy, Vol. 29, No. 3, 2007).

The Families Moving Forward Program, created by Heather Carmichael Olson, PhD, and colleagues at Seattle Children’s Research Institute, provides support for families of children with FASD and significant behavioral challenges. The program targets caregivers rather than children themselves and typically lasts about 9 months, in person or by telehealth. Studies have shown the efficacy of the program (Bertrand, J., Research in Developmental Disabilities, Vol. 30, No. 5, 2009), which is now used in multiple states and Canada. Petrenko is collaborating with Olson and colleagues to develop a mobile app, Families Moving Forward (FMF) Connect, to help more families access resources and support (JMIR Formative Research, Vol. 5, No. 12, 2021). The researchers are also adapting the program for children from birth to age 3.

With the right tools, children and adults with FASD can lead successful lives. “The biggest thing we’ve learned is the idea of reframing—looking at behavioral symptoms in a new way,” Petrenko said. Instead of treating a child as oppositional, for instance, reframing helps providers and parents understand that the child may be unable to do what they’re asked because of working memory deficits or other cognitive impairments. “By reframing these interpretations, you can put supports in place to help people be more successful,” she said.

Preventing FASD, attacking stigma

Efforts are also underway to prevent babies from being born with FASD. The Centers for Disease Control and Prevention promotes two strategies to reduce alcohol-exposed pregnancies. CHOICES is an evidence-based program that helps women make decisions around drinking and contraception (Floyd, R. L., et al., American Journal of Preventive Medicine, Vol. 32, No. 1, 2007). The other strategy, alcohol screening and brief intervention (SBI), is a preventive service that involves screening questions about drinking patterns, a short conversation with patients who drink more than recommended amounts, and referral to treatment when appropriate (Planning and Implementing Screening and Brief Intervention for Risky Alcohol Use [PDF, 2.11MB], Centers for Disease Control and Prevention, 2014). “These interventions could easily be incorporated as part of a psychologist’s practice,” O’Connor said. (See more on brief screening interventions.)

Other efforts are underway to reduce the number of children born with FASD. Stoner directs the Washington State Parent-Child Assistance Program (PCAP), a 3-year intensive case management program for mothers who have used alcohol or drugs during pregnancy. PCAP works with pregnant women to stop drinking and also continues to provide support after they give birth. The program connects mothers to social and health services to reduce the likelihood that their future children will be exposed to alcohol or drugs prenatally by reducing substance use or deferring pregnancy. PCAP has 15 sites in Washington covering 19 counties and 90% of the state population, Stoner said. While the program has had success, it was developed several decades ago, and its wide dissemination across the state makes it difficult to do a modern trial to evaluate its effectiveness. To develop that evidence base, Stoner and colleagues have launched a randomized controlled trial in Oklahoma, where they will compare outcomes for women in PCAP with those who receive services as usual.

While education and awareness of FASD have increased among physicians and mental health providers, many are still reluctant to speak with pregnant women about substance use, O’Connor said. Clinical psychologists can and should raise the topic with women in their care who are or might become pregnant. “Prevention can begin in the therapy room,” Stoner said. But it’s important to ask a woman about pregnancy and substance use in ways that encourage honesty and reduce stigma, O’Connor added. “So, for example, instead of asking, ‘Did you drink during pregnancy?’, it’s better to ask, ‘How often did you drink before you found out you were pregnant? And how much did you drink after?’” she said.

While careful conversation can help, stigma continues to be a challenge. Discomfort around the subject often prevents medical providers from asking women about alcohol use during pregnancy at all. Stigma also prevents women from seeking help for alcohol dependence and may prevent them from pursuing a FASD diagnosis for their child. Addressing negative perceptions about alcohol use during pregnancy is an important step toward reducing rates of FASD and improving lives for people with these conditions, Petrenko said. “People with FASD and their families are capable. They can thrive if we recognize their strengths and provide appropriate services and supports.


3 big factors that drive resident physician burnout


Jennifer Lubell Contributing News Writer-After surveying more than 20,000 physicians and other health professionals across the country, Mark Linzer, MD, has learned a great deal about the drivers of burnout—and possible remedies.

Physician burnout demands urgent action

The AMA is leading the national effort to solve the growing physician burnout crisis. We’re working to eliminate the dysfunction in health care by removing the obstacles and burdens that interfere with patient care.

“Feeling valued was a big mitigator, with burnout rates 30% lower if present. Teamwork was also a big mitigator, while work overload and fast-paced environments were key aggravators,” said Dr. Linzer. He was lead author of the study reporting on these findings that was published in JAMA Health Forum™.

Burnout is real. Rates skyrocketed at the end of 2021 to over 60%, noted Dr. Linzer, who is vice-chief of medicine at Hennepin Healthcare in Minneapolis and also directs the Institute for Professional Worklife there. Making changes at the residency training level is an important strategy for tackling burnout, he advised.

Research by Dr. Linzer and colleagues has revealed “several strong correlates of work conditions with resident burnout, which means there are many ways that programs can address this,” he said. Work-life factors such as teamwork, control of workload, fast-paced, chaotic environments, and time pressure can all affect burnout.

Researchers also identified three resident-specific items contributing to burnout:

  • Sleep impairment.
  • Program recognition of the resident.
  • Interruptions.

“One of our key findings is that work overload and sleep matter, even in the era of duty-hour restrictions,” noted Dr. Linzer.

Residency programs that take physicians’ well-being seriously are more attractive to residency applicants, he stressed. In an episode of “AMA Update,” Dr. Linzer discussed the innovative tool he uses to analyze resident burnout and specific actions residency program and health system leaders can take to increase well-being.

Mini Z research

Dr. Linzer developed the Mini Z measurement instrument, a tool that efficiently measures burnout. It takes two minutes to complete, reducing a six-page survey to a single page.

“Recent studies show it performs very well in measuring in terms of reliability and validity,” said Dr. Linzer. Mini Z versions exist for physicians, residents, nurses, leaders and other clinical staff.

Mini Z core items include three outcomes—satisfaction, stress and burnout, and seven predictors, including the main burnout causes of time pressure. There’s also the three C’s—control, chaos and culture—such as values alignment with leaders.

Translated into several languages, it’s used throughout the world.

Reducing physician burnout is a critical component of the AMA Recovery Plan for America’s Physicians.

Far too many American physicians experience burnout. That’s why the AMA develops resources that prioritize well-being and highlight workflow changes so physicians can focus on what matters—patient care.

Innovations to promote well-being

Evidence-based program interventions usually work best at mitigating and prevent resident physician burnout, advised Dr. Linzer. These may include jeopardy coverage for essential life events, a newsletter celebrating resident achievements, removal of after-hours consult pager call, an extra day off for senior residents on the wards, and care packages distributed through night teams.

“Faculty being on the alert for adverse work environments, such as excess admissions and inability for residents to unplug from the work environment and head home, or in people being distanced on rounds—so they’re not really connecting—might prompt faculty to go deeper and discuss with the resident or program director if they can help,” Dr. Linzer said.

Residency program leaders should also involve residents in data review and interventions. “This is a team effort,” he said. “Let the team guide what needs to be changed and where to go and then let you know if you got there.”

Learn more with the AMA STEPS Forward® toolkit, “Resident and Fellow Burnout: Create a Holistic, Supportive Culture of Well-Being.”

Experts weigh in on the joys and woes of virtual nursing

PULSE  By Hunter Boyce, The Atlanta Journal-Constitution Feb 22, 2023

Telehealth has reached new heights in popularity following a workforce-crippling pandemic. That being said, not all healthcare heroes are behind the concept of virtual nursing.

According to a survey by NSI Nursing Solutions, registered nurse turnover stood at roughly 27% in 2022. Meanwhile, RN vacancy rates were at 17.1%. According to Medpage Today, all of those nursing vacancies have hit the healthcare industry with a growing knowledge gap. Virtual nursing is partially designed to close that gap.

New nurses are “scared to death” of making a mistake when they first come onto the floor, Wendy Deibert, MBA, BSN, senior vice president of clinical solutions for Caregility, told Medpage Today.

“They’re thrown into a world… with not a lot of experience behind them,” she said. “So having a button on the wall where you can push… at a moment’s notice and get a nurse in that room to assist (is a huge help).

“I can zoom in to [see] exactly what they’re doing and give direction and support, so that they don’t feel like they’re out there on a limb by themselves. Not only does that boost their confidence, but it also really stops that turnover, because if they get too scared and do not feel supported, they’re not going to stay there.”

Steve Polega, BSN, RN, chief nursing officer of University of Michigan Health-West, however, believes utilizing virtual nursing is a lost cause.

“As a nurse of 25 years, I believe that nursing is a calling and a gift,” he told Becker’s Hospital Review. “It is a huge responsibility to be trusted by our patients and families to be the eyes, ears and caring hands at the bedside. Nursing is all about connecting with people. To earn that trust, I believe that you need to be at the bedside. Nursing is about that kind touch, that smile, those reassuring things that we can do for patients and families.

“It is very challenging to have that real human connection through virtual care. I think we all lose if this trend continues. We have to optimize our technologies to make our nurses more efficient and effective, but at the end of the day, nurses put the humanity into care and need to be present and at the bedside.”

It’s a point that perhaps needs to be put to the test.

Saint Luke’s Health System of Kansas City took advantage of an opportunity to significantly implement virtual nursing in 2019, before the pandemic. The hospital constructed a 33 bed nursing unit at one of its four facilities, utilizing a new care model and workflow.

“It was important that the model had an impact for both the nursing staff and the patient experience,” Jennifer Ball, RN, BSN, MBA, director of virtual care at Saint Luke’s Health System, told the American Nurses Association. “We looked at what could be taken off the plate of the bedside RN and completed by a nurse on camera in the patient room. We included tasks such as admission database, discharge teaching, medication reconciliation, completing procedure checklists, second nurse sign off for meds/skin checks, general education/teaching for the patients, contacting families, answering questions, and the list goes on.

“When these items are completed by the virtual RN, that frees up the time of the bedside RN to have more time to manage physical needs of the patents, answer call lights sooner, and generally have more time with the patients.”

The unit opened in Feb. 2021 and has since experienced several workflow changes. According to Ball, the unit’s operation since its opening has allowed for a few lessons.

“You can never have too much education, training, and information shared,” she said. “Staff have to be flexible, like change, and be willing to try new things. Start your planning early, be wiling to adjust things, and figure out your technology early on. Get everyone involved from the beginning: other disciplines and staff that will be interacting with the new care model.”



A day in the neonatal follow-up clinic

Nov 23, 2022 CanadianPreemies

What to expect and how to prepare for a neonatal follow-up appointment with your baby born preterm.


All babies, whether born preterm or term, need to have regular visits with a paediatrician for check-ups and immunisations. Preterm babies will probably need to have more regular and thorough follow-up visits beyond what is usually recommended for babies. The purpose of follow-up visits lies in the surveillance of the baby’s progress in growth and development and looking out for potential problems as early as possible.

In general, follow-up visits are scheduled at 4, 8, 12, 18, 24 and 36 weeks corrected age in the baby’s first year, meaning the age if the baby had been born at the expected time.

Usually these visits are there for assessing and tracking the baby’s growth and discussing feedings and sleeping patterns. The developmental level of the baby regarding sensors and the baby’s physical state is evaluated, as well as checks for jaundice are performed. The doctor will also provide the recommended immunisations for the baby. Any questions parents may have about the baby’s health are discussed.

Some countries offer structured preventive early intervention programmes for very preterm infants such as the ToP programme in the Netherlands. It is funded by the Dutch health insurance, consequently every very preterm infant and parent can get this support after discharge. Parents should always take the chance to consult the health care team before going home about specialised care programmes.

Last but not least follow-up practices or clinics are also forums for exchange with doctors and other parents on their baby’s behavior and on recommendations what to do about it.

Parents are often faced with an ‘information flood’ which can be challenging for them to absorb. Information is often new and specific, and parents – commonly worried about their preterm baby – may be overwhelmed.

Tips to help get the most out of follow-up appointments

Starting a file

It can be very helpful to write down the advice given in a file. This will support parents to run a commentary on the baby’s progress which they ca refer to later. In connection with immunisations and vaccinations the GP or paediatrician will record all vaccinations given to the baby in an international immunisation card. It is important and helpful to keep the record for future medical treatment of the baby to track the vaccination history.

Asking questions

Even if parents may suspect their questions to be amateurish, no health care professional will expect parents to understand the various possible health conditions entirely. It is better to ask twice than to leave a visit with uncertainties.

Managing appointments continuously but not too tightly

Sometimes, follow-up appointments for preterm babies can mount up and families may have more than one fixed date in a week. They can take up a lot of time and be very tiring, especially if families have to travel long distances. If it becomes difficult to manage the number of appointments, asking the health visitor to re-organise some of them, if possible, is a reasonable move in order to keep everyday life manageable.

*** The European Foundation for the Care of Newborn Infants (EFCNI) is the first pan-European organisation and network to represent the interests of preterm and newborn infants and their families.


NICU Follow-up Program – Brigham and Women’s Hospital

May 18, 2022   Brigham And Women’s Hospital

The Neonatal Intensive Care Unit (NICU) Follow-up Program at Brigham and Women’s Hospital provides close, frequent monitoring for babies who spent time in the NICU. Care is provided from discharge until kindergarten using a comprehensive, team-based approach to ensure the child is meeting all developmental milestones.

Premature twin separated from his sibling, has only lived in hospital for first three years of life

 KMOV St. Louis     Mar 26, 2019

March of Dimes 2022 Report Card Shows US Preterm Birth Rate Hits 15-year High Rates Increase for Women of All Races, Earning D+Grade

     November 15, 2022

March of Dimes, the nation’s leader in mom and baby health, released its 2022 Report Card today, revealing that the U.S. preterm birth rate increased to 10.5% in 2021 – a significant 4% increase in just one year and the highest recorded rate since 2007.1 Despite reporting a slight decline last year, the preterm birth rate has steadily increased since 2014, earning the country a D+ grade in the Report Card.  The data also shows persistent racial disparities across maternal and infant health measures that were compounded by the COVID-19 pandemic, making the U.S. among the most dangerous developed nations for childbirth.

The report shows that the number of preterm births increased from 364,487 to 383,082 for women of all races. Black and Native American women are 62% more likely to have a preterm birth and their babies are twice as likely to die as compared to White women. In 2021, preterm birth rates for Black mothers increased from 14.4% to 14.7% and increased from 11.6% to 12.3% for Native American/Alaskan Native mothers.  What’s more, while Asian women saw a 3% decline in births, they had the largest increase (8%) in preterm births compared to all other women.

Several factors may contribute to the high rate of preterm births, including inadequate prenatal care and preexisting maternal health conditions such as hypertension and diabetes.  Over 21.1% of Black women and 26.8% of American Indian/Alaskan Native women in the U.S. do not receive adequate prenatal care. The pandemic has further exacerbated the struggle for parents to access maternal care from hospitals and other prenatal providers.

“This year’s report sheds new light on the devastating consequences of the pandemic for moms and babies in our country,” said Stacey D. Stewart, President and CEO of March of Dimes. “While fewer babies are dying, more of them are being born too sick and too soon which can lead to lifelong health problems. Pregnant women with COVID have a 40% higher risk of preterm birth and we know more women are starting their pregnancies with chronic health conditions which can further increase their risk of complications.  It’s clear that we’re at a critical moment in our country and that’s why we’re urging policymakers to act now to advance legislation that will measurably improve the health of moms and babies.” 

The report also reveals that low-risk Cesarean births remain alarmingly high, with the highest rates among Black mothers (31.2%). Overall Cesarean delivery rates increased from 31.8% to 32.1% in 2021 and represent nearly one third of all births. While Cesarean birth is lifesaving in medically necessary situations, this form of delivery is a major surgery and does have immediate and long-term risks.  With about eight in 10 maternal deaths now preventable according to the CDC, reducing rates of Cesarean births may reduce adverse maternal health outcomes associated with medically unnecessary Cesarean birth.

“We know that the pandemic impacted the way that providers delivered care. Low staffing, resource issues, and fears around COVID-19 transmission put added pressure on providers to get patients delivered and out of maternity units in a timely fashion, and may have also contributed to increases in use of obstetric interventions such as inductions and Cesareans,” said Dr. Zsakeba Henderson, Senior Vice President and Interim Chief Medical and Health Officer at March of Dimes. “These interventions have also been shown to contribute to the rise in preterm births, especially late preterm births.”

For this reason, March of Dimes is working to reduce adverse outcomes driven by non-medically indicated inductions and Cesareans.

March of Dimes recognizes that the maternal and infant health crisis does not have one root cause or a singular solution. Present day structures and systems rooted in racist, biased and unfair policies and practices over centuries contribute to and magnify racial differences in access to resources, social conditions and opportunities.

To better understand and address the social drivers to healthcare, this year’s report includes the Maternal Vulnerability Index (MVI) – a new measure of the contextual, clinical, and social determinants of health that impact pregnant people and their babies. Developed by Surgo Ventures, the MVI is the first county-level, national-scale, open-source tool to identify where and why moms in the U.S. are vulnerable to poor health outcomes. It explores 43 indicators across six themes, including reproductive health care, physical health, mental health and substance use, general health care, socioeconomic determinants, and environmental factors. The MVI shows that while some parts of the country are more vulnerable, 4 out of 5 counties have some aspect of maternal health that can be improved. Black women in the lowest vulnerability counties are still at higher risk of death and poor outcomes than White women living in the highest vulnerability counties.

Supplemental Report Cards also provide an in-depth analysis of the national and state maternal and infant health data found in the report. New this year, the reports include a summary of March of Dimes programmatic initiatives and legislative advocacy efforts in each state.

2022 March of Dimes Preterm Birth Grades

Each year, the March of Dimes releases its Report Card with grades for individual states, Washington, D.C., Puerto Rico and the 100 cities with the greatest number of births. Between 2020 and 2021, 45 states, Washington D.C. and Puerto Rico experienced an increase in preterm birth rates.

  • 9 states and Puerto Rico earned an “F” (Alabama, Arkansas, Georgia, Kentucky, Louisiana, Mississippi, Oklahoma, South Carolina, West Virginia)  
  • 4 states earned a “D-” (Missouri, Nevada, Tennessee, Texas) 
  • 6 states earned a “D” (North Carolina, Nebraska, Florida, Indiana, Delaware, Wyoming)  
  • 5 states earned a “D+” (Ohio, Illinois, Michigan, Maryland, South Dakota)  
  • 2 states and Washington D.C. earned a “C-“(Hawaii, Alaska) 
  • 11 states earned a “C” (Arizona, Colorado, Iowa, Kansas, Montana, New Mexico, New York, Pennsylvania, Utah, Virginia, Wisconsin)  
  • 5 states earned a “C+” (North Dakota, Connecticut, Maine, Minnesota, Rhode Island) 
  • 4 states earned a “B-” (New Jersey, Massachusetts, California, Idaho,) 
  • 2 states earned a “B” (Washington, Oregon) 
  • 1 state earned a “B+” (New Hampshire) 
  • 1 state earned an “A-” (Vermont) 

Actions to Address the Crisis

Alongside the release of the report, March of Dimes is delivering the Mamagenda for #BlanketChange, an emergency call-to-action to Congress to improve the health of moms and babies. The Mamagenda calls for immediate action to advance policies that support equity, access and prevention, advocating for the enactment of the Black Maternal Health Act of 2021 (H.R. 959/S. 346) and the Pregnant Workers Fairness Act (H.R. 1065/S.1486) to help prevent racial and ethnic discrimination in maternity care, expand access to midwifery care, provide reimbursements for doula support, and more.  It calls for adopting Medicaid expansion and permanently extending Medicaid postpartum coverage to 12 months as authorized under the American Rescue Plan Act. Additionally, the Mamagenda calls for funding for Maternal Mortality Review Committees and Perinatal Quality Collaboratives that work to improve data collection for maternal deaths and make improvements in quality of care and maternal and infant health outcomes.

Visit to learn more and join the growing number of partners committed to improving maternity care for all.



Babies born in rural settings are more likely to experience trauma during birth, and one way Mayo Clinic is addressing this

By Elizabeth Zimmermann – January 25, 2022

Birth trauma rates are one of the measures of hospital quality used by the Joint Commission. Recent Mayo Clinic-led research, published in the Maternal and Child Health Journal, shows that babies born at rural hospitals are more likely to experience a birth-related injury than those born in urban hospitals.

This disparity is of concern to researchers and clinicians.

To address gaps and disparities in care, the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery works with the medical practice to investigate factors that contribute to high quality, high value care.

“In order to provide care that meets the needs of patients and the overall population, there is a need to understand current outcomes, in the context of current care settings and processes,” says Aaron Spaulding, Ph.D., a health services researcher at Mayo Clinic in Jacksonville, Florida, and the study’s senior author.

This is not Dr. Spaulding’s first study into the disparities of care and outcomes that are multi-faceted and not easily assessed. Within the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, he has led several multiinstitutional collaborations investigating differences in hospital quality outcomes between geographical settings, including the current study.

“Our work in this area seeks to understand better how communities in which hospitals reside influence hospital outcomes and vice versa,” he says. “We are led by the belief that many policies attempt to use a one-size-fits-all mentality which may be inappropriate and may punish or reward hospitals based on aspects they have little control over.”

Dr. Spaulding and his team hope that as they gain a better understanding of the association between communities and their hospitals, they will find better opportunities for policy or practice interventions that can make a difference. 

Babies in distress

In the current study, Dr. Spaulding, along with Hanadi Hamadi, Ph.D.; Jing Xu, Ph.D.; and Farouk Smith all of the University of North Florida, Jacksonville; and Aurora Tafili, University of Alabama at Birmingham; used Florida hospitals’ inpatient data from 2013 to 2018. Originally collected by the Florida Agency for Health Care Administration, the study data included information from 125 inpatient hospitals across the state. It included information for 1,192,336 singleton births and noted up to 31 diagnoses present on admission, as well as up to 31 injury-related diagnoses for the births.

“The most notable finding of the study is that no matter your race, a rural location was associated with an increased odds of birth trauma compared to an urban location,” says Dr. Spaulding.

His team is especially concerned about people of Hispanic ethnicity receiving care at a rural location, he continues, since the greatest birth trauma risk was among rural Hispanic or Latino babies.

The dataset they used only included Florida, however many states make this type of data available, which could be used for a similar analysis. It would not be unreasonable to assume that many states would show disparities between urban and rural outcomes much like those the researchers found in Florida, he says.

Teleneonatology consult allows specialist to see what the local care team is seeing, and to direct lifesaving care for infants in distress.

A possible solution to rural health care disparities at birth

Telemedicine has taken hold as a viable means by which people can access care not available in their geographic area. Mayo Clinic has been steadily implementing and evaluating a wide range of solutions to connect with patients wherever they are, and whenever they need that connection.

For babies born in rural settings or even urban hospitals with no access to neonatologists — pediatricians specializing in medical care for newborns (neonates) — Mayo’s Teleneonatology Program may bridge an essential gap, leading to better outcomes following birth-related traumas like those noted in Dr. Spaulding’s study.

“With this technology, we can be at the bedside of any newborn in need of critical care,” says Jennifer Fang, M.D., medical director of Mayo Clinic’s Teleneonatology Program.

In another recent publication, Dr. Fang describes how she and her colleagues are able to use telemedicine to remotely respond to newborn emergencies. In the paper, she notes the significant improvements in outcomes since teleneonatology consultations were integrated into the family birth centers and emergency departments of nineteen participating community hospitals. These include advancements in quality, safety and provider experience.

During a teleneonatology consult, a neonatologist at Mayo Clinic in Rochester, Minnesota, connects with the local care team in real time, via a telemedicine platform incorporating high resolution, secure audio and video capabilities.

“We are able to see and assess the infant, and guide the local doctors and nurses through resuscitation, including positive pressure ventilation, advanced airway placement and umbilical catheter placement, when needed” says Dr. Fang.

“As one of the acute care telemedicine services developed at Mayo Clinic, we were looking for a way to help more babies – even before they arrive to the neonatal ICU,” she says.

“Before our teleneonatology program we would try to help via a phone call with the care team during a particularly complex delivery. But nothing compares to being able to visualize the baby, to see what the local team is seeing, and how the newborn responds in the minutes after birth and following interventions.” Says Dr. Fang.

Other research has shown that approximately 10% of newborns require breathing assistance after delivery, and one in 1,000 require extensive resuscitation. These babies are much more likely to die in when delivered in hospitals with lower levels of neonatal care. Mayo’s Teleneonatology Program aims to reduce that risk.

In Dr. Fang’s paper, she reviews some of Mayo’s program results, including:

  • Substantially higher quality resuscitation for infants whose care team used the service.
  • Safer care — as demonstrated by significant reduction in birth injury cases.
  • Willingness to use the capability is good. In fact, 99% of providers would use teleneonatology support again — and recommend it to their colleagues.

Mayo’s various telemedicine capabilities are enabled by Mayo Clinic’s Center for Digital Health. Much of the research validating and evaluating new telemedicine and remote care capabilities is done in collaboration with the Mayo Clinic Kern Center for the Science of Health Care Delivery.

Next steps for researchers

Dr. Spaulding’s team continues to work on topics assessing disparities, geographic location and care outcomes. Also in an effort to understand factors that contribute to healthier infants, they are assessing the value of designation under the Baby-Friendly Hospital Initiative. They hope to determine which hospital and community characteristics are associated with hospital attainment of the designation.

On a broader scope, he and his colleagues seek to better understand the effect of community characteristics and health care outcomes. For example, his team is evaluating the presence of Magnet-designated hospitals and differences in associated health care outcomes between Magnet and non-Magnet-designated hospitals. (Read a related publication, “The influence of community health on hospitals attainment of Magnet designation: Implications for policy and practice.”)

“We hope to develop further our understandings of how community characteristics influence health outcomes and how hospital characteristics affect community health,” says Dr. Spaulding. 

Dr. Fang agrees that more research will be helpful for her program in particular.

“If we could get this program into every rural setting, I am confident we would see positive health outcomes for babies,” she says. “Research can help us determine costs and savings (a cost analysis of teleneonatology performed by the Division of Neonatal Medicine and the Kern Center is currently under review for publication), as well as quantifiable public health outcomes that can help shift perceptions among the people and agencies who oversee policies, payment, and care offerings at local, regional, state and national levels.”

In general Drs. Fang and Spaulding both agree that it is high time the health care community pays attention to diversity and inclusion research and the associated attempts to improve care for all. This research sheds light on the importance of the community in which one lives, which impacts health from the cradle to the grave.

“We hope that our research can help further clarify areas of needed policy and practice intervention,” concludes Dr. Spaulding. “Improved measurement of disparities and comparisons between communities and geographic locations will provide us with better tools to fight unequal access to quality care.”


Implementation of A Neurodevelopmental Care Bundle to Promote Optimal Brain Development in the Premature Infant

Author: Pamela S Hackman, MSN, RNC-NIC, C_ELBW Registered Nurse Hershey Medical Center Children’s Hospital, Hershey PA 629 Thoreau Drive 7173301589

Background and Purpose: When an infant is born prematurely, the external environment, routine or emergent nursing care actions performed on the infant can be detrimental. Neonatal nurses are keenly aware the premature infant is at risk for developing behavioral, cognitive, and physical impairments which can be short term or last a lifetime.  The purpose of a neuroprotective care bundle is two-fold:  First, for nurses, the bundle optimizes the health and well-being of the infant by incorporating seven core measures:   healing environment, partnering with families, positioning, and handling, safeguarding sleep, minimizing stress and pain, protecting skin, and optimizing nutrition. Second, for families, therapeutic touch, and skin-to-skin contact cultivates positive neurodevelopmental outcomes, nurturing and health for the infant as well as enhances the bonding experience for the family. Comprehensive, evidence-based research was conducted looking at the role of developmental care and prematurity and how it can correlate to a healthy environment for the premature infant. Result of that research indicates that decreasing negative effects of extrauterine life, decreasing touch times, and implementing a Neuroprotective care bundle in the neonatal intensive care unit can be modified to simulate an intrauterine environment, thereby promoting optimal brain development and outcomes for that infant.

Materials and Methodology: A quantitative research study was conducted in a level 4 neonatal intensive care unit with an average admission rate between 350-400 infants per year, with approximately 120 of those infants are born prematurely. Research was conducted over a twelve-week period. Eighteen premature infants 23-32 weeks gestation were tracked for the first 7 days of life. 

A Pareto chart was developed. Information on the chart included: birthweight, and gestational age. The chart was divided into 4-hour increments for a 24-hour (1day total). A list of variables disturbances to the infant included such interventions as opening the top of the isolette for CXR, or other medical test, opening the port holes to the isolette for attaining vital signs including blood pressure, diaper change, repositioning, suctioning, heel stick for blood, parental interaction with infant, answering an apnea, bradycardia, or desaturation alarm, consoling a crying infant, and assessment by medical team. The goal of the project was for the nurse to check off each intervention during an identified time slot. Data was collected for 7 days.

At the end of twelve weeks, each variable in the time interval and tic mark for that time was tabulated. Then all interventions were added together for each day.  To find out the average number of times an infant was disturbed, the total number of disturbances per day divided by 7 for the total study period was identified. This information indicated the number of times in a day that an infant was disturbed. Further calculation was done to figure out the number of times per day the infant was disturbed by dividing total number of interventions per day by 24 (hours in a day).

Results: Main outcome results indicated an infant was disturbed between 89 to 242 times during the first week of like. Further breakdown indicated that infants were disturbed 3.7 to 10.1 times per hour.  Barriers recognized when research study complete included: staff unaware of study so did not complete project, despite education and communication to all staff members. Multiple shifts did not have documentation complete. Documentation of tic mark for variable but no tic mark for opening port holes (assumption made here). No report of position change. No documentation noted on one patient for one shift. One patient did not have documentation for 2.5 days. Not all activities/interventions were captured. Too busy/ high acuity/ did not understand project request. Multiple pts/activities due at the same time. Totally dependent on RN to document data. Some variables were documented but no documentation for opening the port holes or popping the top of isolette that needed to happen first before taking care of the infant (assumption made here when looking at the intervention completed). Despite interventions being missed in the total tabulation of disturbances to the infant, the study was an eye-opening experience for the nurse to see the total number of times an infant is disturbed per day and per hour. The number of disturbances to the premature infant is detrimental to their health and something that is not often thought about when caring for the infant. Based on the limited results of this study, the intensive care unit in which this study was conducted is currently looking at interventions that promote the developing behavioral, cognitive, and physical needs of the premature infant by instituting specific touch times with infant that correlate with the infant’s wake cycle, implementation of a neurodevelopmental care bundle and promoting a family centered approach to care. To assimilate the intrauterine environment a neurodevelopmental care bundle ought to be utilized.  

Conclusion: A family- care, neuroprotective and developmentally supportive care approach, in conjunction with standard of care practices, promote brain development and a healthy environment.   The implementation of a neurodevelopmental care bundle provides an opportunity to promote optimal brain development as the infant grows in the intensive care, thereby, fostering a positive experience for the family, decreasing length of stay, decreasing hospital cost, and improving medical outcomes.

 Learning Objectives: At the end of this presentation the learner will be able to:

1. Identify the how the implementation of a neurodevelopmental care bundle promotes the developing behavioral, cognitive, and physical aspects of the premature infant.

2. Identify external environmental factors that are detrimental to the premature infant and how the intrauterine environment can be assimilated in the external environment.

3. Identify the positive outcomes of promoting a neurodevelopmental care bundle. 


Mayo Clinic Teleneonatology Program: Simulated Teleneonatology Consult

Mayo Clinic Jun 14, 2017    Mayo Clinic

The Power of Pets Health Benefits of Human-Animal Interactions

Nothing compares to the joy of coming home to a loyal companion. The unconditional love of a pet can do more than keep you company. Pets may also decrease stress, improve heart health, and even help children with their emotional and social skills.

An estimated 68% of U.S. households have a pet. But who benefits from an animal? And which type of pet brings health benefits?

Over the past 10 years, NIH has partnered with the Mars Corporation’s WALTHAM Centre for Pet Nutrition to answer questions like these by funding research studies.

Scientists are looking at what the potential physical and mental health benefits are for different animals—from fish to guinea pigs to dogs and cats.

Possible Health Effects

Research on human-animal interactions is still relatively new. Some studies have shown positive health effects, but the results have been mixed.

Interacting with animals has been shown to decrease levels of cortisol (a stress-related hormone) and lower blood pressure. Other studies have found that animals can reduce loneliness, increase feelings of social support, and boost your mood.

The NIH/Mars Partnership is funding a range of studies focused on the relationships we have with animals. For example, researchers are looking into how animals might influence child development. They’re studying animal interactions with kids who have autismattention deficit hyperactivity disorder (ADHD), and other conditions.

“There’s not one answer about how a pet can help somebody with a specific condition,” explains Dr. Layla Esposito, who oversees NIH’s Human-Animal Interaction Research Program. “Is your goal to increase physical activity? Then you might benefit from owning a dog. You have to walk a dog several times a day and you’re going to increase physical activity. If your goal is reducing stress, sometimes watching fish swim can result in a feeling of calmness. So there’s no one type fits all.”

NIH is funding large-scale surveys to find out the range of pets people live with and how their relationships with their pets relate to health.

“We’re trying to tap into the subjective quality of the relationship with the animal—that part of the bond that people feel with animals—and how that translates into some of the health benefits,” explains Dr. James Griffin, a child development expert at NIH.

Animals Helping People

Animals can serve as a source of comfort and support. Therapy dogs are especially good at this. They’re sometimes brought into hospitals or nursing homes to help reduce patients’ stress and anxiety.

“Dogs are very present. If someone is struggling with something, they know how to sit there and be loving,” says Dr. Ann Berger, a physician and researcher at the NIH Clinical Center in Bethesda, Maryland. “Their attention is focused on the person all the time.”

Berger works with people who have cancer and terminal illnesses. She teaches them about mindfulness to help decrease stress and manage pain.

“The foundations of mindfulness include attention, intention, compassion, and awareness,” Berger says. “All of those things are things that animals bring to the table. People kind of have to learn it. Animals do this innately.”

Researchers are studying the safety of bringing animals into hospital settings because animals may expose people to more germs. A current study is looking at the safety of bringing dogs to visit children with cancer, Esposito says. Scientists will be testing the children’s hands to see if there are dangerous levels of germs transferred from the dog after the visit.

Dogs may also aid in the classroom. One study found that dogs can help children with ADHD focus their attention. Researchers enrolled two groups of children diagnosed with ADHD into 12-week group therapy sessions. The first group of kids read to a therapy dog once a week for 30 minutes. The second group read to puppets that looked like dogs.

Kids who read to the real animals showed better social skills and more sharing, cooperation, and volunteering. They also had fewer behavioral problems.

Another study found that children with autism spectrum disorder were calmer while playing with guinea pigs in the classroom. When the children spent 10 minutes in a supervised group playtime with guinea pigs, their anxiety levels dropped. The children also had better social interactions and were more engaged with their peers. The researchers suggest that the animals offered unconditional acceptance, making them a calm comfort to the children.

“Animals can become a way of building a bridge for those social interactions,” Griffin says. He adds that researchers are trying to better understand these effects and who they might help.

Animals may help you in other unexpected ways. A recent study showed that caring for fish helped teens with diabetes better manage their disease. Researchers had a group of teens with type 1 diabetes care for a pet fish twice a day by feeding and checking water levels. The caretaking routine also included changing the tank water each week. This was paired with the children reviewing their blood glucose (blood sugar) logs with parents.

Researchers tracked how consistently these teens checked their blood glucose. Compared with teens who weren’t given a fish to care for, fish-keeping teens were more disciplined about checking their own blood glucose levels, which is essential for maintaining their health.

While pets may bring a wide range of health benefits, an animal may not work for everyone. Recent studies suggest that early exposure to pets may help protect young children from developing allergies and asthma. But for people who are allergic to certain animals, having pets in the home can do more harm than good.

Helping Each Other

Pets also bring new responsibilities. Knowing how to care for and feed an animal is part of owning a pet. NIH/Mars funds studies looking into the effects of human-animal interactions for both the pet and the person.

Remember that animals can feel stressed and fatigued, too. It’s important for kids to be able to recognize signs of stress in their pet and know when not to approach. Animal bites can cause serious harm.

“Dog bite prevention is certainly an issue parents need to consider, especially for young children who don’t always know the boundaries of what’s appropriate to do with a dog,” Esposito explains.

Researchers will continue to explore the many health effects of having a pet. “We’re trying to find out what’s working, what’s not working, and what’s safe—for both the humans and the animals,” Esposito says.

The Power of Pets | NIH News in Health

Dogs or cats with SUPERPOWER?!

Dec 5, 2018     CurioSips

Dogs or cats with SUPERPOWER?! We all have had that one time at least that our pet goes crazy and scratches us for no reason! Or when your cat starts staring at the window but there is nothing there? That is what happens at my house every single day! No matter how exaggerated these things seem, if this happens in your house as well, it might be that your pet is truly haunted, didn’t you think?


Kat’s Update:

When the pandemic hit, I was in the second year towards pursuing my medical education. Due to the impact of the pandemic on medical education and clinical surgery education in particular, I chose to defer and postpone my medical studies. 

In order to progress my knowledge, engagement, and expertise in global surgery and the medical community I have continued to participate in ongoing academic and independent research. Over the past two years, I have had the privilege and pleasure of presenting my research at 8 conferences in over 3 countries, expanding my professional network and growing my passion for advocacy and promotion of surgical care globally.

During the past year, I chose to pursue my MSc in London with a focus on global surgery and research pertaining to surgical system strengthening in austere environments. The opportunity to learn from and study alongside my fellow global surgery pathway cohort members and our respective global health cohort has allowed me to build strong relationships and gain close colleagues from over 15 nations.  

Perhaps the most impactful aspect of my program was the gift of gaining unimaginably strong friendships with four of my colleagues, each of whom are physicians from different countries (England, Ireland, Colombia, Ethiopia), all of whom embrace career aspirations in various areas of global surgery/medicine including obstetrics, neurosurgery, otolaryngology, and anesthesia. Each of these individuals has inspired me to become more present, gracious, composed, and joyous in my life and interaction with others. 

To my brilliant, compassionate, strong, and resilient friends Oscar, Martina, Heaven, and Tina THANK YOU for sharing your wisdom, hopes, dreams, and kind hearts! Your support and friendship have strengthened my ongoing intention towards completing my medical education. I look forward to the day I can join you all in service as a physician.

To my amazing cohort, I am GRATEFUL for the various perspectives, intellect, care, love, joy, passion, fire,  fun, and the positive challenges you have each provided us as a whole in order for us all to grow, develop, and strive to become better global citizens.

Beloved Neonatal Womb Warrior Brothers and Sisters! Your unique and personal journeys will create joyful and meaningful opportunities for magnificent manifestations and personal growth. Please take a moment or two to breath, relax, acknowledge, and experience the gratitude you feel towards those in your lives who gift you with their presence and spectacular beingness……

In 2023, I look forward to continued engagement in professional research with the goal of strongly contributing to the mission of those I have the pleasure of working alongside and towards creating a tangible impact in the communities and lives we seek to serve.

Kathy and Kat: Our precious and powerful Neonatal Womb Warrior/Preterm Birth Family! Our hearts are continually vitalized by your powerful presence. Every month you educate, challenge us towards change, surprise, and enchant us through your intellect, humanity, and courage. As we voyage forward into this next year, the seventh year of our Neonatal Womb Warrior collaboration; let us live wholeheartedly, let us remember the moments in life which empower our presence, the people in our lives who light up our world, that we are capable of living our dreams, and that with open hearts we belong to each other!

Let us go forward fully and fiercely, immersed within the journeys of our destinies…….

Pets! They are just full of surprises! The highlighted  video shows us a primary example of the kind of lighthearted fun and joy pets bring us each day! 

In my experience with our cat, Gannon, he has often taken us off-guard by scattering his numerous toys in odd places and through occasionally pouncing on our feet from underneath a bed as we pass. Perhaps the most fulfilling surprise he has graced us with is his requirement that when we show him affection, we must allow him to give it back (licking/cleaning and gripping our hands, snuggling).

Throughout the years each of our pets has brought us great joy and a sense of belonging in our lives. Pets are not just family; for me they are guardian angels who help me navigate the world and provide opportunities to learn more about myself and my relationships with others. The countless pets in our neighborhood have certainly helped me develop newfound friendships and participate in important, unexpected, and depth-filled conversations with others. There have been a scattering of belly laughs and a few occasional tears, focused on owner love for their pet!

 It’s never a dull moment when the pets are front and center. My hope is the comfort, love, and even those pesky and annoying challenges they bring about in our daily lives may help encourage us to send out unconditional love into the world in the ways in which they do every day.  

Do you have a pet? What do the pets in your life inspire?

Surf Team Hungary – 1. Rész

Peiman Lotfi       Sep 30, 2013

We have chosen a serious challenge for the 2013 surfing season, because this year the first Hungarian surfing team was assembled, which for the first time in history will compete in the European Championship (Eurosurf 2013) held this year in the Azores Islands. Unfortunately, the team was not able to enter the originally planned full team, as some key surfers could not come, especially Miki Rigler, but we still have 4 competitors in the “Open Men” category. By name, András Ajtai, Lotfi Peiman, Dávid Liptay and Krisztián Kövesdán. In the first part, we introduce our players and learn about the history of participation in the European Championship.

Fostering, Follow-up, Mortality


Estimated Number Of Preterm Birth Rates –  11.97 per 100 live births

(Global Average: 10.6, USA: 9.56)

Ethiopia, officially the Federal Democratic Republic of Ethiopia, is a landlocked country in the Horn of Africa. It shares borders with Eritrea to the northDjibouti to the northeastSomalia to the east and northeastKenya to the southSouth Sudan to the west, and Sudan to the northwest. Ethiopia has a total area of 1,100,000 square kilometres (420,000 square miles). As of 2022, it is home to around 113.5 million inhabitants, making it the 13th-most populous country in the world and the 2nd-most populous in Africa after Nigeria. The national capital and largest city, Addis Ababa, lies several kilometres west of the East African Rift that splits the country into the African and Somali tectonic plates.

The World Health Organization‘s 2006 World Health Report gives a figure of 1,936 physicians (for 2003), which comes to about 2.6 per 100,000. A brain drain associated with globalization is said to affect the country, with many educated professionals leaving Ethiopia for better economic opportunities in the West.

Ethiopia’s main health problems are said to be communicable (contagious) diseases worsened by poor sanitation and malnutrition. Over 44 million people (nearly half the population) do not have access to clean water. These problems are exacerbated by the shortage of trained doctors and nurses and health facilities.

The state of public health is considerably better in the cities. Birth ratesinfant mortality rates, and death rates are lower in cities than in rural areas due to better access to education, medicines, and hospitals. Life expectancy is better in cities compared to rural areas, but there have been significant improvements witnessed throughout the country in recent years, the average Ethiopian living to be 62.2 years old, according to a UNDP report. Despite sanitation being a problem, use of improved water sources is also on the rise; 81% in cities compared to 11% in rural areas. As in other parts of Africa, there has been a steady migration of people towards the cities in hopes of better living conditions.

Source- WHO 2014-


Neonatal mortality in neonatal intensive care unit hospitals in Ethiopia remains unacceptably high: a systematic review and meta-analysis: Magnitude and determinants of neonatal mortality in NICU

Gizachew Tadele Tiruneh , Tesega Mengistu Birhanu, Abdurahaman Seid, Mahteme Haile Workneh, Dareskedar GetieTenagnework Antefe Abebe, Ambanesh Necho Mulat, Taye Zeru Tadege, Kassahun Alemu Gelaye, Tadesse Awoke Ayele


Background: In Ethiopia, the neonatal mortality rate has not shown significant changes over time and is among the highest in the world. This review aimed to explore the pooled magnitude and determinates of neonatal mortality in the neonatal intensive care unit hospitals in Ethiopia.

Methods: The research team retrieved global peer-reviewed journal articles available as electronic databases including PubMed, Popline, and Scopus databases. Random-effects meta-analysis model was used to pool the estimates of the magnitude of mortality among studies. The results were presented as the pooled estimates (odds ratio and proportion) with 95% confidence intervals, at less than 0.05 significant levels. 

Results: In this review, 10 studies were included with a total of 8,729 neonates. Of these, 1,779 (20.4%) neonates died in the neonatal intensive care unit. The pooled neonatal mortality rate was 19.0% (95% CI: 14.0-25.0).  The neonatal mortality is three times higher among early age (OR: 2.80; 95% CI: 1.45-5.40) and preterm newborns (OR: 3.27; 95% CI: 2.12-5.07) than their counterparts. Early age of the newborn, prematurity, low birth weight, perinatal asphyxia, mode of delivery, hypothermia, late initiation of breastfeeding, and having antenatal care visits were the main determinants for neonatal mortality. 

Conclusion: Neonatal mortality in the intensive care unit is high. It is unacceptably high amongst early and preterm neonates. Special care for preterm and early age newborns, timely initiation of breastfeeding, exclusive breastfeeding, and appropriate mode of delivery, essential obstetric and newborn care, and promoting antenatal visits are recommended to reduce neonatal mortality.


Saving babies’ lives in Ethiopia

Paul Driscoll  Aug 5, 2021

It was Rahel Beyan’s lifelong ambition to nurse people back to health. In Tigray, Ethiopia, where she lives, she’s been working as a nurse alongside VSO volunteer Miriam Etter to improve conditions at Suhul Hospital – making her dream a reality.

Maternova Enters Distribution Agreement for Preemie-Test, the First Medical Device Capable of Accurately Assessing a Newborn’s Gestational Age

Hand-held, noninvasive device uses light to identify preterm newborns by analyzing the photobiological properties of the baby’s skin

July 27, 2022

PROVIDENCE, R.I.–(BUSINESS WIRE)–​Maternova Inc., empowering global health through innovative solutions, today announced that they have signed an agreement with BirthTech Lda, Portugal, to distribute its Preemie-Test in multiple geographies around the world. The Preemie-Test is the first medical device clinically proven to accurately assess the gestational age of a newborn, which is the major marker of neonatal survival. Maternova has an exclusive distribution agreement across Africa, Asia (except India) and Latin America (except Brazil) and non-exclusive rights in Brazil, India, the United States and Europe. Initial areas of regulatory approval and marketing focus for the Preemie-Test are Peru, Colombia, Philippines, Bangladesh and specific states in India.

Immediately after childbirth, a newborn with unknown or unreliable gestational age often requires resuscitation and hospitalization. Without this critical care, preterm newborns are at risk of mortality or serious, life-long health problems. According to the WHO, every year around 15 million babies are born too early and one million die due to prematurity complications. While most of these lives could be saved with prompt prematurity identification, in the absence of a prenatal ultrasound (often too expensive and not accessible), there has been no reliable method for pregnancy dating.

“The commercial launch of the Preemie-Test is a significant milestone in providing a new way of measuring gestational age and addressing a crucial need in low-resource settings,” said Rodney Guimarães, PhD, BirthTech CEO and the inventor of the device. “With a shared commitment to maternal and infant healthcare, we are proud to work with Maternova and believe its unique distribution network will help us quickly place this cost-effective solution into the hands of healthcare professionals from midwives to obstetricians.”

“I am delighted we were selected to commercialize and distribute the Preemie-Test,” said Meg Wirth, founder and president of Maternova. “Demand for effective and affordable maternal, newborn and child health innovations continues to grow across the globe. The Preemie-Test answers the call for a highly accurate solution that can be used in time-sensitive situations where self-sufficiency and portability are essential to newborn lives.”

Maternova is an exhibitor at the Florida International Medical Expo (FIME 2022) being held at the Miami Beach Convention Center from July 27-29. Representatives, including the inventor of the device, will be at booth V64 to demonstrate the Preemie-Test.

About the Preemie-Test

  • Portable, hand-held device
  • Rapid, accurate results
  • Easy to use
  • Noninvasive
  • Affordable

The Preemie-Test is the first medical device capable of accurately assessing gestational age within +/- 4 days immediately after an infant is born. The hand-held device features a probe containing light emitters and receivers that is applied against the newborn’s foot and, using mathematical algorithms, can estimate dating in a matter of seconds. This noninvasive optoelectronic device measures the thickness of the skin through backscattering of light using a light-emitting diode, and the battery lasts up to three years allowing hundreds to thousands of measurements. Support is available through a mobile app.

Multiple clinical trials to date have validated the effectiveness and 96% accuracy of the Preemie-Test in Brazil, Portugal, Mozambique, India and Malawi. According to ANVISA, the Brazilian regulatory health agency, this medical device is categorized as Class II Safety: Noninvasive and Medium Risk.

***WE really appreciated access to this Associated Video:


SOL ABA – Yene Nesh – የኔ ነሽ – ملكتي – New Ethiopian music 2022 – (Official video)

#Ethiopianmusic #Sol_Aba #eritreanmusic 1,611,376 views Dec 9, 2022 BAHGNA TV Ethiopian amharic music /Yene Nesh/ 2022/2023 bahgnatv production – Yene Nesh – amharicmusic


National Prevalence of Social Determinants of Health Screening Among US Neonatal Care Units

NOVEMBER 01 2022 

Erika G. Cordova-Ramos, MD; Stephen Kerr, MPH; Timothy Heeren, PhD; Mari-Lynn Drainoni, PhD; Arvin Garg, MD, MPH; Margaret G. Parker, MD, MPH


The extent that universal social determinants of health (SDH) screening in clinical encounters, as recommended by the American Academy of Pediatrics, has been implemented in inpatient pediatric settings is unknown. We aimed to determine the national prevalence and predictors of standardized SDH screening in US level 2 to 4 neonatal care units (NICUs), describe characteristics of SDH screening programs, and ascertain beliefs of clinical leaders about this practice in the NICU setting.


We randomly selected 100 hospitals with level 2 to 4 NICUs among each of 5 US regions (n = 500) and surveyed clinical leaders from January to November 2021 regarding standardized SDH screening. Responses were weighted for number of level 2 to 4 NICUs in each region and nonresponse.


Overall response rate was 34% (28%–40% by region). Twenty-three percent of US level 2 to 4 NICUs reported standardized SDH screening. We found no associations of hospital characteristics, such as region, size, or safety-net status, with implementation of this practice. Existing programs conducted systematic screening early in the hospitalization (84%), primarily led by social workers (92%). We identified practice variation regarding the type of screening tool, but there was substantial overlap among domains incorporated in the screening. Reported barriers to implementation included perceived lack of resources, inadequate referrals, and lack of an inpatient screening tool.


The prolonged neonatal hospitalization provides opportunities to systematically address SDH. Yet, only 23% of US level 2 to 4 NICUs have implemented this practice. To scale-up implementation, quality improvement may support adaptation of screening and referral processes to the NICU context.


Fostering Resilience to Very Preterm Birth Through the Caregiving Environment

Trecia A. Wouldes, BA, MA, PhD1 – October 21, 2022 JAMA Netw Open. 2022;5(10):e2238095. doi:10.1001/jamanetworkopen.2022.38095

Preterm birth remains an important public health challenge for improving the quality of immediate and long-term care of the child and their family. Nearly 1 in 10 live births worldwide are preterm, with higher rates in marginalized populations and developing countries.1 Advances in medical intensive care of these infants mean more infants born very preterm and extremely preterm are surviving. The preponderance of research on children born very preterm has revealed the linkages between numerous risks and acute and long-term adverse health and developmental outcomes for the children, and social and psychological challenges for the families.2 Although children born earlier in gestation are at increased risk for poor outcomes, there is wide variability, with many children doing well. Therefore, research that can identify the protective factors or identify who, when, or under what circumstance some preterm children thrive is essential for informing interventions to assist those preterm children who are at risk of ongoing emotional problems. Very preterm (<32 weeks’ gestational age) and very low birth weight (<1500 g) children are more at risk than their full-term peers for developing internalizing symptoms (eg, anxiety and/or depression). Emerging evidence suggests that maternal sensitivity is a long-term resilience factor in the development of internalizing problems in early adolescence in very preterm children.

McLean et al provide further evidence that supportive parenting of infants born very preterm is associated with more optimal emotional outcomes across early and middle childhood. They report the findings from a prospective, longitudinal cohort study of 186 very preterm neonates (24-32 weeks’ gestational age) recruited from the level III neonatal intensive care unit (NICU) at BC Women’s Hospital in Vancouver, Canada. This report aimed to investigate whether neonatal pain-related stress experienced by neonates in the NICU was associated with trajectories of internalizing behaviors at ages 1.5 (159 children), 3.0 (169 children), 4.5 (162 children), and 8.0 (153 children) years and whether supportive parenting behaviors and lower self-reported parental stress at ages 1.5 and 3 years attenuated this association. Cumulative pain and stress was defined as the number of invasive procedures performed in the NICU. The main outcome was parent reports of child internalizing behaviors measured with the Child Behavior Checklist at every follow-up. At ages 1.5 and 3 years, parental stress was obtained from the Parenting Stress Index, and parent-child interactions were obtained from videotapes of a 5-minute teaching task coded by independent examiners using the Emotional Availability Scale–IV. After accounting for gestational age at birth and neonatal clinical factors, greater exposure to neonatal pain-related stress, related to invasive procedures from birth to NICU discharge, was associated with increased internalizing symptoms across follow-up. At 1.5 years, internalizing behaviors were within the normative range; however, by age 8 years, parent reports indicated that 24 of 153 children (16%) had symptoms that put them in the clinical range for internalizing behaviors. Latent profile analyses of parenting behaviors observed in parent-child interactions at ages 1.5 and 3 years and parenting stress at 3 years identified 3 profiles: average support with average stress, high support with low stress, and low support with high stress. Higher parenting stress at 1.5 years contributed to parent reports of greater internalizing problems across development to age 8 years. At age 3 years, the profile of high support and lower stress was associated with a reduction in the development of parent reports of internalizing behavior across development to age 8 years. Parents in this group demonstrated more behaviors that were characterized as sensitive, nonhostile, and nonintrusive and provided more structure in parent-child interactions.

The Bidirectional Nature of Parenting

Although sensitive supportive parenting in the general population is important for a child’s development, it is even more critical for preterm-born children. However, the communication abilities, atypical behavior, and regulation systems of very preterm-born children can affect the quality of these interactions. McLean et al found at 3 years, but not 1.5 years, children exhibited lower parent-reported internalizing behaviors related to supportive parenting interactions, even after accounting for child behavior in parent-child interactions in a teaching task.

Supportive parenting interactions rely on several social and psychological determinants of the mother-infant dyad, including maternal culture, depression, socioeconomic status, substance use disorders, the home environment, and whether the child was unplanned or unwanted.5 The prevalence rates of posttraumatic stress or acute stress disorders in mothers of preterm infants in the NICU range from 23% to 28%. Several factors contribute to the traumatic stress experienced by parents of preterm infants in the NICU; however, the most stressful aspects of the NICU experience reported by parents were the physical separation from their infant and their feelings of a loss of control and helplessness in their inability to shield their infant from the numerous painful procedures.7 The findings of McLean et al4 show that reduced parental stress and sensitive supportive parenting may temper the association between the effects of neonatal pain-related stressors in the NICU and internalizing behaviors throughout early and middle childhood. Therefore, interventions that help reduce stress should be part of postnatal care for mothers of very preterm children.

Where to Now?

Many of the stressors experienced by neonates and parents in the NICU and after discharge from the hospital have been addressed by interventions in the NICU, such as the Newborn Individualized Developmental Care and Assessment Program. This intervention is designed to identify both what is supportive and regulating, and what is disruptive to infant neurodevelopment. Further approaches include the redesign and reorganization of the NICU environment from large, open bays with multiple babies close to each other, to single-family rooms combined with neuroprotective approaches that emphasize developmentally appropriate care. The transition to single-family rooms aims to protect the infant from intrusive environmental stimuli of open bay NICUs while facilitating parental care and around-the-clock family presence.

Notwithstanding the advances made in caring for these vulnerable infants in the NICU, there are important questions left to answer. Preterm birth is increasing worldwide,1 but most studies on very preterm infants have involved White Western populations. The cohort in the study by McLean et al was predominantly a more mature, well-educated sample of parents (60% White and 84% with partial or complete university degree or postgraduate degree) with universal access to health care. Culture, poverty, and maternal mental well-being strongly influence parenting; therefore, more research is needed to determine who and under what social and psychological circumstances parents of children born very preterm require parenting support.

In addition, parental perceptions and attitudes toward the child born very preterm may be distorted and impact the developing parent-child relationship, particularly in circumstances where the pregnancy was unintended or unwanted. With the recent legal constraints to obtaining terminations for unintended or unwanted pregnancies, maternal mental health, stress, and the financial burden of very preterm birth is likely to escalate, particularly in already marginalized populations. Therefore, research is needed to understand what the potential impact of the lack of access to termination of an unwanted pregnancy will have on parenting very preterm infants.


Futility and Withdrawal of Intensive Care in Term Infants with Brain Injury

Ciara Terry, MRCPI , Breda C Hayes MD, FRCPI

Neonatal brain injury is a major challenge in modern perinatal care, including obstetric and neonatal care. Advances in the care of the newborn, including resuscitation improvements and the introduction of therapeutic hypothermia (TH) for the management of neonatal encephalopathy, have allowed us to sustain and improve life for babies that previously may have been deemed too unwell to continue life-sustaining treatments. From an obstetric perspective, there has been an increase in the detection of serious fetal anomalies with better antenatal scanning regimes and the use of MR imaging in fetal medicine to detect congenital brain malformations.

The decision to redirect the focus of care to comfort-only measures usually follows a detailed neurological examination of the baby in conjunction with neuroimaging (typically MR imaging) aided by EEG monitoring when available. Congenital causes of severe brain dysfunction, such as severe congenital brain malformations (e.g., giant encephalocele, lobar holoprosencephaly) leading to a plan for palliative care following delivery, are encountered. However, most term babies where palliative care is initiated do so following acquired perinatal brain injury. Major conditions that lead to the development of perinatal brain injury include hypoxic ischaemic encephalopathy (HIE), perinatal stroke, perinatal central nervous system infection, and intracranial haemorrhage. Hypoglycaemia can result in brain injury or potentiate injury due to other causes, e.g., HIE.

 HIE is one of the commonest reasons for acquired brain injury in the normally formed term newborn. The incidence of HIE is approximately 1.5 per 1000 births, and globally there are 700,000 cases of death or disability from birth asphyxia annually. Therapeutic hypothermia (TH) has resulted in significant improvements in the outcomes of neonates with HIE. However, greater than 40% of neonates who undergo TH will still have impaired neurological outcomes at school-going age. TH does not improve outcomes in babies with severe HIE.

A perinatal stroke is a cerebrovascular event occurring between 20 weeks gestation and up to 28 days after birth. Prevalence has been estimated at 1/1600 to 1/5000 live births and is recognised as the second most common cause of neonatal seizures after neonatal encephalopathy accounting for up to 20% of neonatal seizures . Presentation is usually in the first three days after birth. The outcome of neonates with perinatal stroke is difficult to predict.

Intracranial haemorrhage in term infants is rare but can result in significant neuro disability. Intracranial haemorrhage can be epidural, subdural, subarachnoid haemorrhage, or intracerebral.

Central nervous system infections, including meningitis and encephalitis, can be bacterial, viral, or fungal in aetiology. The incidence of early-onset meningitis is approximately 0.39 per 1000 live births. Herpes virus infection is the most common non-bacterial cause of central nervous system infection, with an estimated incidence of 1 in 50,000 live births, and can lead to severe neurodevelopmental delay.

Being told that their newborn has a brain injury is amongst the most devastating news that parents can receive. Existing data suggests that parents of encephalopathic neonates experience predictable communication difficulties. Medical information is complex and uncertain prognosis is challenging. It is well-accepted that parents value participation in medical decision-making. Parent-centered decision-making is preferred in the NICU when discussing longer term goals and potential harm. The fundamental goal of shared decision-making is to open the process to benefit from both the physician’s and the parent’s respective experiences, knowledge, and beliefs. This does not imply a value-neutral role for clinicians but instead requires a more delicate balancing as an advocate for the baby while respecting parental views. Parents who perceive a shared role in end-of-life decision-making may experience less long-term grief than parents who perceive either making the decision on their own or having no involvement. Palliative care teams are an important source of added support to all caregivers. Attempting prognostication in neonatal encephalopathy is essential to help parents formulate their concept of best interest for their newborn. However, estimating prognosis is complicated by the wide range of potential neurodevelopmental outcomes, evolving course, and role of extrinsic factors like access to rehabilitation. Even in cases of anticipated death, infants may unexpectedly survive. In the face of uncertainty, describing the best case, worst case, and most likely outcome is an effective strategy to characterize the potential range of outcomes.

Clinical history, neurologic examination, serum biomarkers, neurophysiology [amplitude-integrated electroencephalography (aEEG) or EEG], near-infrared spectroscopy, and magnetic resonance imaging have all been studied as predictors of severe neurologic injury and poor outcome, although none is 100% predictive. Serial evaluation over time facilitates discussion regarding anticipated poor prognosis and decision-making for transition to comfort care. Serial assessments with a particular test are more predictive than a single observation. The time over which a test remains abnormal together with the trend over time yields the best information(9). Thus far, brain monitoring in the form of aEEG and conventional EEG seems to be the best objective tools to identify the highest-risk patients. Specifically, a severe depression or burst suppression pattern which persists is suggestive of poor outcome. Magnetic resonance imaging (MRI) is known to retain its predictive abilities when performed in the window of 5-10 days after birth. Where MRI is performed, the pattern and extent of injury remain important predictors of outcome even after TH. However, MRI is sometimes not possible due to clinical instability or accessibility. In these cases, cranial ultrasound is important and predictive if it shows hyperechogenic subcortical grey matter structures (basal ganglia and thalamus) and/or focal parenchymal lesions. The presence of cystic lesions early in the neonatal course is also predictive of poor outcome and helps to identify prenatal injury. Many scoring systems are available and can be applied to help predict outcomes, including the Barkovich and the Rutherford scoring system. The Weeke scoring system is a comprehensive scoring system that assesses several different functional areas of the brain, including motor, visual, and memory. Complete and careful neurological examination remains of critical importance. In predictive models, time to improvement in stage and time to reach no or mild HIE were important predictors of death/disability. The advent of bedside aEEG allows neonatologists to continuously trend the background pattern and hence the degree of recovery alongside serial clinical examination during TH. In cases where clinical examination and EEG are in keeping with profound injury, and there is no sign of improvement over 24-48 hours, MRI brain does not add greatly to prognostication. However, MRI should be considered in this setting if the baby has received anti-epileptic medications, which may affect the reliability of both clinical examination and EEG findings.

The term life-limiting condition refers to any illness for which there is no reasonable hope of cure and where the child is unlikely to survive beyond early adulthood. Many of these conditions cause a progressive deterioration leaving the child increasingly dependent on their family or carers. Such illnesses have been categorised into four categories . The fourth category includes conditions leading to severe disability and the likelihood of premature death, such as severe cerebral palsy and multiple disabilities following brain injury.

Decisions that involve the withdrawal or withholding of life-sustaining treatment should have the child’s best interest as the central focus(7). A futile intervention is different from an intervention that is not pursued because it is not perceived to be in the overall best interests of the child.  With shared decision-making, medical facts must be reflected alongside the family’s preferences, values, and goals. Even when care is not futile, care may be against the child’s best interests when the likely harms outweigh possible benefits (6). Perinatal palliative care input is paramount in the care of the term neonate with significant brain injury. Palliative care stages have been defined in the British Association of Perinatal Medicine Framework for Clinical Practice in Palliative Care. This describes a transition period from routine or intensive care to palliative care. Supportive care includes considerations for oral nutrition, hydration, and analgesia. The overall goal of palliative care is to achieve the best quality of life for patients and their families.

In conclusion, decisions around the futility of care and redirection to comfort measures for newborns with brain injury is a complex decision that should only occur following a process of shared decision-making involving all caregivers for the baby. Certainty about prognosis is not possible despite advances in medical care, but clear and honest discussions with parents are paramount to the decision-making process. The involvement of palliative care physicians is recommended in patients with severe brain injury leading to a life-limiting condition.


More male midwifes in Ethiopia | METROPOLIS

 Metropolis  Jan 31, 20

In Ethiopia, a large proportion of midwives are men. Like Gashaw, who lost a beloved neighbor during childbirth. Metropolis is a video project by Dutch broadcast organizations HUMAN and VPRO, that started in 2008. Metropolis is made by a global collective of young filmmakers and TV producers, reporting on remarkable stories from their own country or city. More videos and full episodes on


Without additional support, families of preemies can fall through the cracks

Families of prematurely born babies are calling for increased paid leave, insurance, and mental health support to manage the emotional and economic impacts.

Pamela Appea – March 30th, 2022

Brooke Jones was in her late 20s when she became pregnant with her first child. Employed full-time as a medical assistant in Connecticut, Jones fully expected to work right up until her due date. Jones described her pregnancy as “normal” and didn’t believe she had any symptoms that were significantly worrisome. But that changed when a routine ultrasound at 25 weeks revealed that her amniotic fluid levels were dangerously low. Shortly after, medical professionals realized Jones’ blood pressure had spiked “through the roof,” she told Prism. She was diagnosed with preeclampsia and was admitted to the closest hospital for immediate treatment. 

“They told me I might give birth that day,” Jones said. She was subsequently transferred to Yale New Haven Children’s Hospital, where she was treated for a host of other complications, including fluid buildup in her lungs, which meant Jones had to go on medical leave immediately. “I was on autopilot,” she said.  

After two weeks of strict hospital bedrest, Jones gave birth to her baby boy at 27 weeks via an emergency C-section. A micro preemie, he weighed only 1 pound, 8 ounces at birth. Earlier in her pregnancy, Jones had carefully thought about her maternity-leave schedule, finances, childcare logistics, and more, but suddenly she needed a whole new plan. 

But as Jones discovered, balancing medical care, a lack of work leave and the need for aftercare support and mental health counseling as a caregiver often proves challenging for families with preemies. Jones’ son spent four months in the neonatal intensive care unit (NICU), where doctors treat sick and premature newborns, but her maternity leave only lasted six weeks after he was born, so she had to go back to work long before he was released from the hospital.  

In search of emotional and mental health support

Women of color like Jones, who is Black, compose a significant number of parents who give birth prematurely. According to the March of Dimes, over 380,000 babies are born preterm every year in the U.S. about 1 in 10 of every live birth. Black and Indigenous women are 60% more likely to give birth preterm than white women.

For the families of preemies, the whole birth experience can be fraught. Often, preemie caregivers aren’t given a lot of time to process that their baby may have short- and long-term medical, developmental, and other complications that require a NICU stay, high-risk surgeries, and other medical procedures. 

Additionally, caregivers can feel overwhelmed and experience a wide range of postnatal mental health issues, including depression, anxiety, guilt, and NICU-specific PTSD. 

“The caregivers’ primary need is emotional support. Prematurity is something that is a surprise, and it has a very traumatic effect on the family,” said Tina Tison, executive director of the Tiny Miracles Foundation. The Connecticut-based nonprofit partners with several hospital NICUs in the area to provide counseling, mentoring, and socio-emotional support to preemie caregivers. Jones received peer mentor support and financial assistance from The Tiny Miracles Foundation after the birth of her son, including during his lengthy four-month hospitalization in the NICU.

“Any caregiver takes comfort in knowing that they are not alone,” said Tison. 

Aftershocks of the pandemic continue to impact caregivers well after their baby has been discharged from the NICU, according to Dr. Angelica Moreyra, an expert in perinatal mental health at the Children’s Hospital in Los Angeles. 

“There is currently an enhanced need for advocacy for our families that we serve due to environmental stressors that create barriers for caregiver presence in the unit such as public transit … changes in school and child care options, increased financial, occupational, and housing instability, and more,” Moreya told Prism. “When caregivers encounter barriers in being able to present in the unit, it impacts the nature of our services, as we are focused on supporting bonding/attachment between caregivers.” 

Balancing work and care

Apart from the mental and emotional strain, the economic impact of having a preemie can also be significant. According to the March of Dimes, the average NICU bill starts at $65,000. But depending on surgeries, medical procedures, and other complications, many families are expected to pay hospital bills that are hundreds of thousands of dollars or higher. For many, access to health insurance or emergency state health insurance for preemies is crucial. However, more than 2.2 million women in the U.S. live in “maternity care deserts” where families often lack access to necessary prenatal care or don’t have health insurance to cover the costs. 

Prematurely born babies are eligible to receive Medicaid and Supplemental Security Income through Social Security. Regardless of a parent’s income level, state insurance typically covers nearly all of the child’s NICU hospital bills, surgeries, post-discharge medical treatment, and other medical and mental health services for both the caregiver and the baby during their first year.  Speech, occupational therapy, physical therapy, and other rehabilitative services are typically covered either through insurance, early intervention, and occasionally through Department of Education public education services after the age of 3-5, depending on the state. However, the process for access to these services is fraught with governmental red tape, making it difficult for caregivers to access.

Even as families face mounting expenses, without extra paid leave caregivers of preemies can find it difficult to hold onto a full-time job given the need for medical appointments, early intervention services, special education services, evaluations, operations, and other treatments for medical issues preemies may struggle with even after “graduating” from the NICU. While Jones’ son’s medical bills and her mental health care were covered by state insurance, her husband ultimately left his job to manage their son’s care and medical appointments.

Working toward policy shifts

As Jones and her husband have looked toward the future and considered having another baby, they’ve become doubtful about the financial feasibility. Without the same state Medicaid services, more paid family leave, and the ability to take time off work for medical appointments, Jones said she was unsure they could afford another child. Her family is far from alone, and advocates for families of preemies argue that a number of policy changes need to be put in place to provide caregivers the support they need, including ensuring universal access to public health insurance programs and a minimum of 12 weeks of paid family leave, with more for families of babies with more significant health and developmental needs. March of Dimes is also pushing for the elimination of racial and geographic disparities in prenatal care and expanded access to coverage for doula and midwifery support to offer caregivers more options both during and after birth. 

If she could wave a magic wand around government policy changes for family caregivers, Jones told Prism: “Let us have our time as caregivers with our children. For me, I only got six weeks. Some people are allowed more time. But as a law, I wish it was implemented to give mothers and fathers the [paid] time we need with our kids.”


Common NICU Discharge Tests

While you’re learning all you can about your baby’s care, the discharge coordinator or case manager is planning your baby’s final tests and making preparations for discharge. Common discharge tests are explained here, but not all NICU babies require all of the tests discussed. Ask your baby’s nurse what to expect as discharge draws near.

Eye exam

If your baby was 30 weeks’ gestation or less or weighed less than 1,500 grams (3 pounds, 5 ounces) at birth, they will have an eye examination at between 4 and 7 weeks of age. Babies born after 30 weeks’ gestation and weighing between 1,500 and 2,000 grams may also have this type of eye examination if they had an especially difficult NICU course. Follow-up exams will be scheduled if the findings of the first exam warrant them. The exam is to identify any changes in the eye tissue caused by retinopathy of prematurity.

Hearing test

Hearing tests—also called audiology screenings—are done in most nurseries before discharge. Electronic sound and response monitoring determine if your baby can hear. Environmental conditions, such as surrounding noise or a crying baby, can cause inconclusive results, however. If this happens, a retest should be scheduled in a more controlled environment. If your baby responds to your voice or to noise-making toys held where they can’t see them, there is usually no reason for concern.

After discharge, your child’s hearing should be monitored by your health care provider at periodic health exams. If you are concerned about your baby’s hearing, never hesitate to insist on a more extensive hearing exam. These are available at a pediatric audiologist’s office or in pediatric outpatient rehabilitation centers.

Newborn metabolic screening

Every baby is tested soon after birth to identify some rare but potentially serious or life-threatening conditions. The number of tests varies by state. Newborn metabolic testing can yield inconclusive results if the baby is very premature, is critically ill or needed a blood transfusion prior to metabolic testing. If the screening test suggests a problem, your baby’s doctor will speak directly with you and will order follow-up testing. Become aware of the screening test results prior to discharge from the NICU and communicate the findings with your community pediatrician.

Blood count

A final hematocrit or hemoglobin and reticulocyte level are usually done the week of discharge. Although it’s unlikely, your baby might be anemic and either need a blood transfusion or iron medication to help their bones make new red blood cells. If so, follow-up lab tests will usually be done in the pediatrician’s office or an outpatient clinic.

Sleep study (pneumogram)

Infants with continuing apnea and bradycardia may have a special test to help determine the cause of these episodes. Depending on your region of the country, the test is called a sleep study, a pneumocardiogram, or a pneumogramPhilosophies vary regarding the use of pneumograms, and not all NICUs use them. A pneumogram does not answer every question about the baby’s apnea and bradycardia, and interpretations of the test vary regionally. The American Academy of Pediatrics (AAP) states that “pneumograms are of no value in predicting sudden infant death syndrome (SIDS) and are not helpful in identifying patients who should be discharged with home monitors.”

Cranial ultrasound

If your baby was born younger than 30 weeks’ gestation, she has probably had several ultrasounds of her head to detect intraventricular hemorrhage. Some NICUs will perform a cranial ultrasound or other brain imaging study near the time of hospital discharge for babies weighing less than 1,000 grams at birth. Your neonatologist may also suggest magnetic resonance imaging near your baby’s original due date to help predict the need for early intervention services and ensure the best possible developmental outcome. Sometimes a different brain imaging technique may show abnormalities that a screening ultrasound will not. This does not mean that the initial ultrasounds were misinterpreted, but merely that each test has limitations.
 Last Updated 1/24/2023:

Father’s Perspective on Breast Feeding: A Cross-Sectional Questionnaire Based Study

Aparna VelmuruganPrahankumar RajendranManaikandan Mani



Despite global efforts to promote exclusive breastfeeding, the rates in India have been in the sub-optimal range. Higher levels of paternal support and encouragement are linked to better maternal confidence in breastfeeding. This study was aimed to assess the knowledge, attitude, and practice of fathers of infants towards the importance of breastfeeding practices.


Fathers of infants visiting the Pediatric OPD, were interviewed with a structured, pre-tested questionnaire after obtaining written informed consent. This is a cross-sectional study where 158 fathers were given the questionnaire on knowledge, attitude, and practice about breastfeeding along with the sociodemographic details. The sections of the questionnaire were scored using the five-point Likert scale.


Among the 158 fathers who participated in the study, majority (51%) had moderate scores in knowledge, attitude, and practice about breastfeeding. Around 131 fathers (83%) have not received any counseling about support and their role in breastfeeding and majority (58%) fathers felt the need to get education and training regarding parenting skills. Around 66% of the fathers were aware of the ideal duration of exclusive breastfeeding. About 35% of the fathers were not comfortable letting their wives breastfeed the child in public places. Around 25% of the participants had the idea that breastmilk production is reduced after child delivery through Cesarean section.


Fathers should have active participation during maternal check-ups, delivery, and antenatal counselling. This will help a better bonding and may lead to successful and prolonged breastfeeding. Educating fathers may help in increasing breastfeeding rates and duration.


Eleni Gebremedihin


Variation in NICU Head CT Utilization Among U.S. Children’s Hospitals

RESEARCH ARTICLE| JANUARY 09 2023 Megan M. Shannon, MDHeather H. Burris, MD, MPHDionne A. Graham, PhD


Evaluate nationwide 12-year trend and hospital-level variation in head computed tomography (CT) utilization among infants admitted to pediatric hospital NICUs. We hypothesized there was significant variation in utilization.


We conducted a retrospective cohort study examining head CT utilization for infants admitted to the NICU within 31 United States children’s hospitals within the Pediatric Health Information System database between 2010 and 2021. Mixed effects logistic regression was used to estimate head CT, head MRI, and head ultrasound utilization (% of admissions) by year. Risk-adjusted hospital head CT rates were examined within the 2021 cohort.


Between 2010 and 2021, there were 338 644 NICU admissions, of which 10 052 included head CT (3.0%). Overall, head CT utilization decreased (4.9% in 2010 to 2.6% in 2021, P < .0001), with a concomitant increase in head MRI (12.1% to 18.7%, P < .0001) and head ultrasound (41.3% to 43.4%, P < .0001) utilization. In 2021, significant variation in risk-adjusted head CT utilization was noted across centers, with hospital head CT rates ranging from 0% to 10% of admissions. Greatest hospital-level variation was noted for patients with codes for seizure or encephalopathy (hospital head CT rate interquartile range [IQR] = 11.6%; 50th percentile = 12.0%), ventriculoperitoneal shunt (IQR = 10.8%; 50th percentile = 15.4%), and infection (IQR = 10.1%; 50th percentile = 7.5%).


Head CT utilization within pediatric hospital NICUs has declined over the past 12-years, but substantial hospital-level variation remains. Development of CT stewardship guidelines may help decrease variation and reduce infant radiation exposure.

Source:Variation in NICU Head CT Utilization Among U.S. Children’s Hospitals – PubMed (

Keypoints in movement analysis graphically displayed

Artificial intelligence and video as a resource to timely discover anomalies in premature babies

               Published November 15, 2022

Due to an increased risk of various problems concerning growth, movement and development, premature babies are in need of special care. According neonatologist and professor of Pediatrics at the UMC Groningen, Arie Bos, it is important for early detection to discover possible anomalies on time in these premature babies, to minimize the consequences at a later age. In a movement analysis based on video images, such anomalies could be better assessed with the assistance of artificial intelligence.

At the University Medical Center Groningen (UMCG) 80 to 120 premature babies are admitted anually to the hospital from the provinces Groningen, Friesland, Overijssel and Drenthe. The babies end up on the Intensive Care Neonatology, which is the only intensive care unit for neonates out of eight hospitals in the Northern Netherlands. Due to a premature birth of ten weeks or more before the due date, these babies need special care. When the neonates are no longer in need of intensive care, they are transferred to one of the eight regional hospitals. There, the care is taken over by a pediatrician and the child is closer to the parents.

Periodic check

Periodic checks are of great importance in the case of an extreme preterm. Parent and child will visit the outpatient neonatology clinic of the UMCG during prebooked appointments to discover potential areas of concern in the development at an early stage. This consists of five moments in total, the first of which takes place when the baby is six months old and the last taking place when the child is eight years old.

The NeoLifeS cohort

To learn more about the development and most sufficient treatment of premature babies, the need arose for a central database of all the hospitals. In 2016, Bos together with his colleagues started NeoLifeS, a cohort with the purpose to identify problems and risk factors, and to improve the care for prematures. Premature babies are more at risk of various issues with growth, movement and development – including spasticity.

Within this cohort, data is collected on health and development issues of premature babies. The database contains information on the brain, lungs, eyes, respiration, the gastrointestinal system, infections, the placenta and on the start and course of the pregnancy of mother and child. Bos: “By systematically collecting and assessing clinical data of all the hospitals, of completed questionnaires by parents, and of movement patterns of the baby at three months past the calculated age, we can improve our intensive care for premature babies even further. After all, we want a bright and healthy future for these vulnerable kids.”

Since the start in 2016, after receiving permission from the parents, all clinical data of prematures has been collected from the moment of birth and stored in one databank. At present, the databank contains the data on 340 babies that were born before 30 weeks and/or weighed less than 1000 grams.

Movement analysis with own smartphone

Babies are often allowed to go home with the new parents if they are as old as they would originally be on the mother’s due date. This almost always occurs from one of the regional hospitals. Afterwards, it is essential that measurements are put in place to record the movements of the baby. Throug these measurement moments the baby is monitored for, amongst other things, spasticity. Spasticity occurs regularly and is often caused by a brain haemorrhage as a complication of preterm birth.

At the moment, spasticity is often only discovered after eighteen months. In the past this occured under the watchful eye of the specialist at the hospital, however, now, it can take place in a home environment, as the baby’s movements can be viewed with a smartphone. This new situation results in less stress for both parent and child, which ultimately provides a more reliable image.

Based on the video images, it is possible to determine whether there is a normal development or a potential anomaly as soon as three motngs. In this case, a rehabilitation specialist can be quickly called in for issues regarding arm and hand functions as a consequence of spasticity and these effects can be minimized when the child is older.

Timely recognition of certain patterns

The recorded video images are subsequently sent to the UMCG, where the NeoLifeS-team starts an analysis. The researchers watch approximately six to eight videos an hour, whereby it only takes 5 to 10 minutes of video to determine whether there is a case of normal or abnormal movement patterns and whether there is a need for closer examination. If it is suspected that there is a higher risk of a deviation in the motor development (especially spasticity), a consultation with the parents and the regional pediatrician is advised to refer to a rehabilitation center.

Bos explains: “The movement patterns at the age of three months is extremely important. With children that develop normally, you will see small, moderate speed, dancelike movements of the entire body, so in the shoulders, arms, hips, legs, torso and neck; then here, then there. Children who have a spastic movement disorder later on, do not display these movements at all. This knowledge has existed for a while, but only in the last few years we have discovered that by starting targeted therapy early, we can greatly improve the future results of children with spasticity.”

Technology as an essential factor

Neolook Solutions supports NeoLifeS with the development and expansion of the used movement analysis, which is internationally known as the General Movement Assessment (GMA). Marco D’Agata, Managing Director at Neolook Solutions: “UMCG is the national academic expertise center for the General Movement Assessment. If we want the GMA to be accessible for those thousands of children who are at risk every year in the Netherlands, just like in other countries, than we better work together with existing parties such as NeoLifeS.”

Neolook thinks ahead: where previously the specialist received the parents in the hospital or the nurse came by the house to record the video, it is now possible to virtually visit the parents. A livestream provides the nurse or the specialist with a direct view of the child. This takes less time and causes less stress for both the parent and the child. The video is then safely stored at the UMCG for the team of NeoLifeS to watch and analyse the video at a suitable moment.

Innovation with Artificial Intelligence

The next step in the process is to apply artificial intelligence. By visualizing the movements in the video with so-called ‘key points’ (key points which together form a wire figure of the child), potential deviations can be recognized by artificial intelligence software. Artificial intelligence makes it possible to automatically detect certain patterns in the movement of new-born babies. The application of the abovementioned form of artificial intelligence in the movement analysis of NeoLifeS can enable the specialists whom assess the movements to be more efficient and better supported in the assessment process.

The results from the recording are graphically displayed for the specialist, with any peculiarities being highlighted. Thus, the specialist can immediately investigate possible anomalies. The application of artificial intelligence in the movement analysis therefore supports the specialists in their tasks and speeds up the assessment process.

 D’Agata: “You cannot use just any livestream. Parents need to be coached live, because the quality has to be good. Then, we can overlay the 23 key points on the small body, mapping simple and complex movements for the specialist.”

At the moment, NeoLifeS works on the direct application of AI on livestream videos in an international consortium. It is therefore possible to act more rapidly, leading to earlier detection of potential anomalies in premature babies.

More about cohorts and biobanks

Currently, there are 175 cohorts and biobanks at the UMCG. These cohorts and biobanks collect data over extended periods, as well as body materials for future medical scientific research. The Cohort and Biobank Coordination Hub (CBCH) unites all these cohorts and biobanks, supports researchers and stimulates new research and cooperations.


Telemedicine Improves Rate of Successful First Visit to NICU Follow-up Clinic

January 2023 Lilly Watson, BAChristopher W. Woods, MSN, RN, NNP-BCAnya Cutler, MS, MPHJohn DiPalazzo, MPH, MSAlexa K. Craig, MD, MS, MSc



NICU graduates require ongoing surveillance in follow-up clinics because of the risk of lower cognitive, motor, and academic performance. We hypothesized that multiple programmatic changes, including availability of telemedicine consultation before hospital discharge, would improve NICU follow-up clinic attendance rates.


In this retrospective study, we included infants who survived and were premature (≤29 6/7 weeks/<1500 g) or had brain injury (grade III/IV intraventricular hemorrhage, stroke or seizure, hypoxic ischemic encephalopathy). We compared rates of follow-up for the early cohort (January 2018-June 2019; no telemedicine) with the late cohort (May 2020-May 2021; telemedicine available); and performed a mediation analysis to assess other programmatic changes for the late cohort including improved documentation to parents and primary care provider regarding NICU follow-up.


The rate of successful 12-month follow-up improved from 26% (early cohort) to 61% (late cohort) (P < .001). After controlling for maternal insurance, the odds of attending a 12-month follow-up visit were 3.7 times higher for infants in the late cohort, for whom telemedicine was available (confidence interval, 1.8-7.9). Approximately 37% of this effect was mediated by including information for NICU follow-up in the discharge documentation for parents (P < .001).


Telemedicine consultation before NICU discharge, in addition to improving communication regarding the timing and importance of NICU follow-up, was effective at improving the rate of attendance to NICU follow-up clinics.


 Surakshit Sagar India undertakes a massive 75-day campaign to clean up 75 beaches

As highlighted in the video above, I believe that learning how to hold our ground and maintain a positive perspective when difficult and unexpected situations arise in life may allow us to learn new ways to overcome difficult situations, cope with our emotions, and build our resilience.  

Recently, I was met with an unexpected and very challenging situation in my personal life that has required an internal response of focus on building my personal resilience in order to best move forward with the task at hand.  

As preemie survivors and global neonatal community members we are innately resilient, learning to overcome the challenges in life we have been dealt. As we know, it isn’t about what happens to us in life, it is about how we respond.  

As surfers are pushed to be present in the moment in order to ride the waves they chase, we too learn to surf the waves of life.  

What have the challenges in your life taught you to overcome and revealed to you about yourself? How have such experiences helped you develop your character, integrity, and sense of self so that you may rise on the other side as a stronger, more composed, and introspective individual?  

Moving into 2023 my hope is that the collective challenges we have experienced as a global community over the past few years and the challenges we face as individuals may compel us to stand grounded and even more composed as we work to pursue excellence in our lives and strive to give the best of ourselves to ourselves, to our family, to our friends, to our mentors, to our communities and to our world.  

Wishing you and our global neonatal community fruitful abundance and enhanced resilience for 2023! 

I did Paragliding in Ethiopia….**Just Awesome**

Ferils Mad World  Apr 5, 2022  #addisababa #ferilsmadworld

Hey, Ferfam I had a wonderful experience doing the paragliding activity organized by #greathikers in Ethiopia. We traveled to Sandafa city which is on the outskirts of #addisababa. It was such a beautiful experience, gliding in the air like a bird, It is a once-in-a-lifetime experience. The activity is done by a professional from Bulgaria, and it’s such a smooth ride. Watch the vlog on #ferilsmadworld and don’t forget to shower your love


Saudi Arabia


Estimated Number Of Preterm Birth Rates –  3.96per 100 live births

(Global Average: 10.6, USA: 9.56)

Source- WHO 2014-

Saudi Arabia, officially the Kingdom of Saudi Arabia (KSA), is a country in Western Asia. It covers the bulk of the Arabian Peninsula, and has a land area of about 150,000 km2 (830,000 sq mi), making it the fifth-largest country in Asia, the second-largest in the Arab world, and the largest in Western Asia and the Middle East. It is bordered by the Red Sea to the west; JordanIraq, and Kuwait to the north; the Persian GulfQatar and the United Arab Emirates to the east; Oman to the southeast; and Yemen to the south. Bahrain is an island country off the east coast. The Gulf of Aqaba in the northwest separates Saudi Arabia from Egypt. Saudi Arabia is the only country with a coastline along both the Red Sea and the Persian Gulf, and most of its terrain consists of arid desert, lowland, steppe, and mountains. Its capital and largest city is Riyadh. The country is home to Mecca and Medina, the two holiest cities in Islam.

Saudi Arabia is considered both a regional and middle power.[35][36] The Saudi economy is the largest in the Middle East; the world’s eighteenth-largest economy by nominal GDP and the seventeenth-largest by PPP. As a country ranks 35th, very high, in the Human Development Index, it offers a tuition-free university education, no personal income tax, and a free universal health care system. Saudi Arabia is home to the world’s third-largest immigrant population. It also has one of the world’s youngest populations, with approximately 50 per cent of its population of 34.2 million being under 25 years old.[ In addition to being a member of the Gulf Cooperation Council, Saudi Arabia is an active and founding member of the United NationsOrganisation of Islamic CooperationArab LeagueArab Air Carriers Organization and OPEC.

Health care in Saudi Arabia is a national health care system in which the government provides free health care services through a number of government agencies. Saudi Arabia has been ranked among the 26 best countries in providing high quality healthcare.


Meaningful Manifestations for 2023

As we celebrate the year of 2022 and TRANSITION into the New Year, we would like to share a few of our aspirations for advancements within our global neonatal community for 2023.  Feeling passion, we desire:

  • Enhanced efforts to drive strong and focused innovation in preterm birth technology, preterm birth research and  prevention, targeted diagnostic and treatment options, and effective healthcare  workforce development.
  • Collaborative global engagement focused towards provider/patient education and support, preemie-focused developmental and time sensitive interventional care, the development of  Preterm Birth Community lifespan wellness,  and focused health care/resource  access for our global pre-term birth survivor community (10-12% of our total global population). 
  • Comprehensive research and associated development of effective diagnostics and impactful treatment for preterm birth related preverbal PTSD effecting  preterm birth survivors of all ages.
  • Longitudinal research targeted towards investigation of the gestational neurological development of the preterm birth population, with increased identification of gestational development and advanced cohort/diagnostic classifications in order to improve diagnostics, treatment planning, and best practices supporting neonatal health outcomes. 
  • Expansion of healthcare provider specialization in medical and mental health care targeting pediatric and adult preterm birth survivor needs and resources.  
  • Advancements towards holistic, comprehensive, and accurate diagnostic care management of preemie neurological development, health and wellness conditions free from potentially harmful bias and assumptions that similar symptom presentation in preterm neonates vs. non equates  to similar  diagnoses, etiology, treatment and time sensitive interventions.  


We stand firmly in the expectation that as innovation, technology, diagnostics, research, integrated care management, and global collaboration expands within the preterm birth community we will witness improvements in the quality of life for all members of our global preterm birth family.

Kathy, Kat, and our cat Gannon anticipate that 2023 will lead to the joyful amplification and manifestation of our shared hopes, wishes, dreams and more within the Global Neonatal Womb/Preterm Birth Community! Wishing us all a Joyful, Love-filled, Healthy, Satisfying,  and Adventurous 2023!  


Lack of innovation in neonatal respiratory care is the biggest problem for both preterm and term neonates: to be remembered on World Prematurity Day

Daniele De Luca   09 NOV 2022

This is an editorial commissioned to the President of the European Society for Pediatric and Neonatal Intensive Care, on the occasion of World Prematurity Day 2022. It celebrates this important event by summarizing how the most crucial (and forgotten) problem in neonatal respiratory care is the lack of active translational research. Translational research is pivotal in this context, as it allows to understand the diseases, diagnose them, and imagine new strategic pathways. The lack of translational research means no innovation, and this is jeopardizing the possibility to improve healthcare for both preterm and term critically ill neonates. Historical and more recent examples of the problem are given, together with some basic suggestions to move forward.

On November 17 every year, many countries celebrate World Prematurity Day. Purple is the color of the initiative; thus, hospitals and monuments are highlighted, whereas gadgets and people show something with this color. Since 2011, this fruitful initiative succeeded in raising the attention on the problems related to prematurity, particularly on the care of preterm babies and the important role of parents. This is a commendable and needed initiative. In fact, neonatal care risks being perceived as something taken for granted in the Western world, where birth rates and infant mortality are low and the main current health problems, particularly in the COVID-19 era, are those of the adult age and elderly.

However, we cannot forget that preterm neonates are not the only ones at risk, and, as a matter of fact, the most crucial issue for neonatal medicine has been forgotten. In fact, although many focus on preterm developmental care and parental role, we must admit that neonatology has not meaningfully improved its global clinical results, as there have not been many relevant innovations in the last two decades.

This is particularly true for neonatal respiratory critical care which is, together with hemodynamics, the core problem to be addressed for most patients in life-threatening situations. After the introduction of prenatal steroids and surfactants, we have seen no other game changers for preemies. The situation is even worse for term neonates since the last improvement has been represented only by the introduction of whole body hypothermia for perinatal asphyxia. Thus, we still lack effective drugs and clear diagnostic-therapeutic strategies for bronchopulmonary dysplasia as well as for other disorders more typical of term neonates, such as refractory pulmonary hypertension or congenital diaphragmatic hernia and other congenital lung disorders.

The reasons behind this lack of innovation are many. The regulatory procedures are too strict, time-consuming, and do not consider the peculiarities of the newborn patient and the rarity of his diseases. They are supposed to protect the patient from “wrong” innovations, but they forgot to protect him from the lack of innovation, i.e., the unavailability of drugs or medical devices. Surfactant was intensively studied in the 1980s, following animal and bench experiments performed by Mary Allen Avery and Bengt Robertson. Most likely, this would be extremely difficult, if not impossible, with current regulations, and, if these basic experiments would have been needed today, no surfactant would be available.

The neonatal market is smaller than that represented by several adult medicine specialties, and the relatively low neonatal mortality has decreased the interest of many public grant programs; as a combination of these two factors, neonatal research often lacks specific funding and this is particularly true for respiratory research. Most of the neonatal ventilation research is done without public or industry fundings ; in other words, without the charities and the dedication of researchers, we would not have several respiratory support techniques such as the newest noninvasive ventilation modalities. Other cases are less lucky: some respiratory drugs [including potentially life-saving pulmonary vasodilators do not achieve enough clinical evidence, because they are not suitable from a marketing point of view (i.e., low price, rare use) despite strong translational and clinical data supporting them.

Nonetheless, we shall admit that, besides these problems, the difficulties in finding new solutions for neonatal respiratory care are also due to our own carelessness about what has been learned in close fields, such as anesthesiology, intensive care medicine, regenerative medicine, transplantation surgery, and other fields of adult healthcare. Neonatal respiratory care, and neonatology in general, has suffered a lack of cross-disciplinary awareness that has prevented or delayed important advancements. The reason behind this was the supposition that the neonate was completely distinct from all other patients; newborn physiology may be different in some aspects, but this cannot prevent to recognize similitudes and take advantage from experience accumulated in other fields. In 1964, Gilbert Hualt provided mechanical ventilation for the first time to a newborn infant with congenital tetanus. Without his vision, the introduction of neonatal ventilation would have been delayed; ironically, this technique is now considered the basis of intensive care. How many of us have the same vision regarding strategies, tools, and research lines investigated in adult respiratory care? I still remember a professor stating, no more than 15 years ago, that applying ECMO to neonates was technically impossible. Lung transplantation in neonates and infants is still regarded as an extreme procedure, but some centers practice it with satisfactory results. Are we enough interested in artificial organs and regenerative medicine applied to neonatal respiratory disorders?

The examples are countless and the combination of all these factors leaves many neonatal disorders without a full understanding of their pathobiology and orphan of diagnostic-therapeutic tools; this creates relevant clinical unmet needs. 

Despite all of these problems, some innovations have been achieved, such as the recognition of neonatal acute respiratory distress syndrome (an entity that was forgotten for several decades;  and the implementation of point-of-care lung ultrasound, following the adult intensive care experience (although its diffusion is still variable among countries. Nonetheless, translational research is essential if we really want to fill the many clinical unmet needs. Translational projects are important to understand the mechanisms of disease, how to “intercept” them with diagnostic tools, how to personalize the treatment as much as possible and to discover new therapeutic possibilities. Thus, neonatal translational research, particularly in the respiratory field, must receive greater attention, be facilitated in the regulatory process, and take advantage from quicker industry-academy and cross-disciplinary collaborations. The work might not be exclusively unidirectional. As neonates today are the patients of tomorrow, good results achieved by neonatal research can impact on patient health for several decades ahead. Although we celebrate World Prematurity Day, we shall remember that the actual main problem, both for preterm and for full-term neonates, is that there is no future without active research.


US gets D+ grade for rising preterm birth rates, new report finds

By Jacqueline Howard, CNN   Published 8:00 AM EST, Tue November 15, 2022

The US preterm birth rate peaked in 2006 at 12.8%, according to data from the National Center for Health Statistics.

Since then, some March of Dimes reports have found US preterm birth rates much higher than 10.5%, but those rates were based on calculations that have since been updated, according to March of Dimes.

“There are too many babies being born too soon: 1 in 10. If you were to have 10 babies in front of you and one of them is having to face the complications that comes with prematurity, that’s unacceptable, and we need to do better,” Henderson said, adding that those 1 in 10 are more likely to be Black, American Indian or Alaska Native.

March of Dimes data in the new report shows that infants born to Black and Native American mothers are 62% more likely to be born preterm than those born to White women.

States with the highest and lowest rates

The new March of Dimes report also highlighted state-by-state differences in the rate of babies born prematurely across the country.

The report grades a preterm birth rate less than or equal to 7.7% as an A and a preterm birth rate greater than or equal to 11.5% as an F.

The national preterm birth rate of 10.5% is graded as a D+.

No state has achieved an A rate, and only one has a state-level preterm birth rate that would be graded as an A-: Vermont, which has the lowest preterm birth rate in the US at 8%.

Meanwhile, nine states and one territory have preterm birth rates that received an F grade: Georgia and Oklahoma with 11.9%; Arkansas, Kentucky and Puerto Rico with 12%; South Carolina with 12.1%; West Virginia with 12.8%; Alabama with 13.1%; Louisiana with 13.5%; and Mississippi with the highest preterm birth rate of all states at 15%.

“The areas that have the worst grades are the same areas we’ve been seeing consistently for a long time, and it’s past time for us to do what we need to do to make health better and make our country a better place to give birth and be born,” Henderson said. “It’s unfortunate that we don’t have policies in place to protect the most vulnerable in our country, and without protecting our moms and babies, we can’t secure the health of everyone else.”

To address these state-by-state disparities in preterm births and help improve the national preterm birth rate as a whole, March of Dimes has been advocating for certain policies, Henderson said, including the Black Maternal Health “Momnibus” Act of 2021, a sweeping bipartisan package of bills to provide pre- and postnatal support for Black mothers – but most of the bills in the package are still making their way through Congress.

March of Dimes also has been urging more states to adopt legislation expanding access to doulas and midwives, among other maternal health care services, and reduce the prevalence of maternity care deserts across the country.

How Covid-19 plays a role

There are many potential factors contributing to the nation’s rising preterm birth rate, and Henderson said the Covid-19 pandemic remains one of the biggest.

“We cannot forget about the impact of the Covid-19 pandemic and recognize that there is likely a huge contribution of that, knowing that Covid-19 infection increases the risk of preterm birth,” she said. “But we also know that this pandemic brought many other issues to the forefront, knowing that issues around structural racism and barriers to adequate prenatal care, issues around access, were brought to the forefront during this pandemic as well.”

She added that many mothers in the United States are starting pregnancies later in life, and there has been an increase in mothers with chronic health conditions, who are at higher risk of having to give birth early due to pregnancy complications.

Pregnant women with Covid-19 may be at increased risk of preterm delivery, CDC study suggests

Henderson also said that preterm birth is one of the top causes of infant deaths and disproportionately affects babies born to women of color.

“The United States is one of the worst places to give birth and be born among industrialized countries, unfortunately. When we look at maternal deaths and infant deaths, we’re at the bottom of the pack among countries with similar profiles in terms of gross domestic product,” Henderson said. “It’s because of our disproportionate numbers of preterm births –particularly for populations that are disproportionately impacted, such as Black families and American Indian and Alaskan Native families – that our rates are so much higher than other countries.”

An ‘urgent public health issue’

Globally, about 10% of births are preterm worldwide – similar to the US preterm birth rate.

About 15 million babies are born preterm each year, amounting to more than 1 in 10 of all births around the world, according to the World Health Organization, which has called prematurity an “urgent public health issue” and “the leading cause of death of children under 5.”

Separate from the March of Dimes report, WHO released new guidelines Tuesday on how nations can improve survival and health outcomes for babies born too early, at 37 weeks of pregnancy or less, or too small, at 5½ pounds or less.

These WHO recommendations advise that skin-to-skin contact, also known as kangaroo mother care, be provided to a preterm infant immediately after birth, without any initial time spent in an incubator.

“Previously, we recommended that kangaroo mother care to only be for babies that were completely stable,” said pediatrician Dr. Karen Edmond, medical officer for newborn health at WHO, who was the lead on the new guidelines.

“But now we know that if we put babies in skin-to-skin contact, unless they are really critically ill, that this will vastly increase their chances of surviving,” she said. “So what’s new is that we now know that we should provide kangaroo mother care immediately after birth, rather than waiting until the baby’s stable.”

Edmond added that immediate kangaroo mother care can help infants better regulate their body temperature and help protect against infections, and she said that these guidelines are for on-the-ground health care providers as well as families.

The new WHO guidelines also recommend that emotional, financial and workplace support be provided for families of babies born too early or at low birth weights.

“Preterm babies can survive, thrive, and change the world – but each baby must be given that chance,” WHO Director-General Tedros Adhanom Ghebreyesus said in a news release.

“These guidelines show that improving outcomes for these tiny babies is not always about providing the most high-tech solutions,” he said, “but rather ensuring access to essential healthcare that is centered around the needs of families.”


RedOne ft. Enrique Iglesias, Aseel and Shaggy | Don’t You Need Somebody

platinumrecordsmusic  236,826,729 views Jul 27, 2016

* Aseel Omran (Arabicأسيل عمران) is a Saudi Arabian singer

Consider What Happens When We Don’t Care for NICU Parents

Here’s how hospitals can support parental mental health

by Alexa Grooms, BSN, RN December 23, 2022

Evidence shows opens in a new tab or window it is the emotional opens in a new tab or window, rather than the medical, complications of pregnancy that are most impactful on the long-term well-being of the parent and child. These emotional complications, known as perinatal mood and anxiety disorders (PMADs), may occur during pregnancy until the first few years after giving birth. PMADs include the most widely known postpartum depression, as well as the lesser-known postpartum anxiety, panic disorder, postpartum obsessive-compulsive disorder, post-traumatic stress disorder, and postpartum psychosis.

Neonatal intensive care unit (NICU) parents are particularly vulnerable to PMADs. Parents rarely expect their child to require intensive care, and the journey is emotional and unpredictable. Studies most often focus on mothers, or the birthing parent, rather than fathers or the supporting parent. However, we know that NICU parents have 28-70% higher opens in a new tab or window incidences of depression. At a minimum, being separated from your child can cause distress and impaired bonding.

As a NICU nurse, I can testify that staff know parent mental health is pervasive. So why aren’t we addressing it? Unfortunately, few of us have the tools, resources, and confidence to intervene. After all we were hired to take care of babies, and adults can be intimidating, especially on such a stigmatizing topic. However, hospitals and healthcare professionals must ask ourselves: What are we missing if we do not also care for the family? Parents are the key to their child’s emotional and cognitive wellness and the effects last a lifetime, for the positive or negative. Mood disorders can be debilitating both for the individual and the family.

This year, a cross-sectional study opens in a new tab or window by Cooper Bloyd, MD, MS, and fellow researchers surveyed which NICUs were incorporating mental health screening and treatment following the 2015 release of the National Perinatal Association guidelines. Among respondents, 44% routinely screened parents for disorders, most often depression. They also found that 47% offered mental health education to families, and between 3-11% employed some type of mental health specialist in their unit. The figures, they acknowledged, were likely high because of low study participation and the respondents wanting to advertise their practices.

As the National Perinatal Association outlines opens in a new tab or window, mental health initiatives can be implemented with families via universal distress screening; “layered levels of support” through education, especially peer support groups; and employment of mental health professionals. Here are my recommendations for how these may be best incorporated into standard care.

Incorporate Universal Screening

Screening can be integrated by making it part of the admission and discharge educational packages. For example, when parents are filling out initial admission forms or upon discharge when families either transfer to another facility or go home with their follow-up pediatrician appointments. There are also opportunities to screen families during infant care milestones, such as 100 days in the NICU. Whenever possible, screening can be placed alongside standard information such as safe sleep and feeding education to minimize stigma. The Edinburgh Postnatal Depression Scale is a validated screening tool specific to postpartum depression. Other useful screening tools may include the PHQ-2 for depression or PTSD-5 for trauma. Positive results should trigger follow up with a unit-based mental health provider such as a social worker, psychologist, psychiatrist, psychiatric nurse practitioner, or nurse with extensive perinatal mental health training.

This year, a cross-sectional study opens in a new tab or window by Cooper Bloyd, MD, MS, and fellow researchers surveyed which NICUs were incorporating mental health screening and treatment following the 2015 release of the National Perinatal Association guidelines. Among respondents, 44% routinely screened parents for disorders, most often depression. They also found that 47% offered mental health education to families, and between 3-11% employed some type of mental health specialist in their unit. The figures, they acknowledged, were likely high because of low study participation and the respondents wanting to advertise their practices.

As the National Perinatal Association outlines opens in a new tab or window, mental health initiatives can be implemented with families via universal distress screening; “layered levels of support” through education, especially peer support groups; and employment of mental health professionals. Here are my recommendations for how these may be best incorporated into standard care.

Incorporate Universal Screening

Screening can be integrated by making it part of the admission and discharge educational packages. For example, when parents are filling out initial admission forms or upon discharge when families either transfer to another facility or go home with their follow-up pediatrician appointments. There are also opportunities to screen families during infant care milestones, such as 100 days in the NICU. Whenever possible, screening can be placed alongside standard information such as safe sleep and feeding education to minimize stigma. The Edinburgh Postnatal Depression Scale is a validated screening tool specific to postpartum depression. Other useful screening tools may include the PHQ-2 for depression or PTSD-5 for trauma. Positive results should trigger follow up with a unit-based mental health provider such as a social worker, psychologist, psychiatrist, psychiatric nurse practitioner, or nurse with extensive perinatal mental health training.

Additional follow up could also take the form of obstetricians reaching out to patients prior to the 6-week postpartum follow up. Screening and support should also include pediatrics, as pediatricians are in a unique position to continuing assessing the child’s development and parent-child relationship.

Education for Parents and Staff

There are many opportunities to enhance parent and staff education. Parent support groups are especially therapeutic. Parents should be welcomed in by other parents as they go through this unexpected journey together. Veteran NICU families often play an important role in facilitating and leading these groups. Parents who pump also find exceptional reward and meaning in donating breast milk back to other NICU infants.

In terms of staff, mental health education should be ongoing, as going into pediatrics means partnering with families. Patient psychosocial history and discussion about how to support families should be incorporated into daily provider rounds.

Seeing It Through With Usable Referrals

Parents who want or require psychiatric care after discharge must be referred. Most importantly, these referrals must be usable. I will argue that hospitals must guarantee NICU parents’ appointments or spots in follow up care. We cannot build the trust of these families only to refer them to help that is a dead end. Hospitals will argue it is impossible to guarantee appointments, as demand for psychiatric care is high. However, hospitals must recognize the risk of both child and parent hospital readmission if they aren’t connected to care. There is also the added benefit of building patient loyalty. Labor and delivery are where most families first interact with medical care, and a good experience can lead them to return for future care.

Of course, adding mental health staff and resources will come at a cost. As cost is an understandable concern, the value of these services can be demonstrated first in low- to zero-cost quality improvement or nurse residency projects before investing dollars. Once value is demonstrated, hospitals can leverage funding from Magnet or Baby Friendly Hospital designation budgets. Applications for these hospital designations are lengthy but worth pursing as funds are allocated for pilot projects such as these.

Final Thoughts

It is clear NICU parents need our help. My recommendations are clear and feasible, and unit staff can help integrate them into standard care practices. Hospitals have a responsibility to be part of the solution and allocate funding from existing initiatives to offset costs. Staff must be educated to support parents, and hospitals must create systems within existing infrastructure to address mental health concerns. We can no longer omit parents’ health when we care for their child.



The NICU: The palliative care team would ask us, “How do you feel about what you just heard?”

Courageous Parents Network Nov 6, 2019

The palliative care team would ask us, “How do you feel about what you just heard?” Parents of a baby son who was born with Arteriovenous Malformation (AVM) and died at age 3 months, talk about how the palliative care team interacted with and supported them, and helped manage their son’s pain and consider the future. “They really saw us as people and as parents. It was an awesome help to have them there.”

Holding Your Baby in Intensive Care

Published on Jun 19, 2022

“Yes, your baby can be held today!”

Hearing these words can trigger strong emotions. Every parent is eager to hold their baby. But holding a baby who is very small or on a breathing machine with lots of tubes and wires can be scary (even for experienced parents). Below are some common questions parents have about holding their baby in intensive care and our recommendations.

“I know I will want to hold my baby, but isn’t it better to just let my baby rest in bed?”

Babies are born needing your touch. Your touch is very different than touch from the hospital sta­ff.

When you hold your baby, you help your baby:

  • Get to know you and develop an attachment
  • Maintain body temperature
  • Develop and grow brain connections
  • Learn language
  • Develop muscles and strength
  • Gain weight
  • Feel less pain
  • Cry less
  • Stabilize breathing and heart rate
  • Sleep better
  • Reduce stress
  • Feel safe and protected

Holding your baby also helps you:

  • Feel more confident as a parent
  • Feel connected to your baby
  • Reduce stress
  • Produce milk for your baby, if you pump

“Holding my baby for the first time feels like a big deal. How can I prepare when it is time to hold my baby?”

  • Request a comfortable chair with arms and a footrest.
  • Choose a time when you can take your time and are not rushed.
  • Go to the restroom, and make sure you eat beforehand.
  • For moms who pump, pump before holding your baby.
  • Have a water bottle nearby in case you become thirsty.

“I want to hold my baby, but I don’t know whether it is safe, and I feel nervous. What are some tips?”

  • It’s never too early to start a conversation with your nurse about when your baby will be ready to be held. If your baby is not yet ready, ask your nurse, “What are some signs that tell me my baby is ready to be held?”
  • Talk to your baby’s therapists (e.g., occupational therapists, physical therapists) about suggestions for how to hold your baby.
  • Ask your baby’s nurse for ideas about how to make your baby comfortable.
  • Remember that sometimes babies have a little stress while being moved out of bed but then become very comfortable in your arms.
  • All babies (not just premature babies) benefit from skin to skin holding, which is called kangaroo care. Kangaroo care has amazing benefits for children and parents and is encouraged whenever possible. To learn more about kangaroo care, please see the Skin to Skin Care (Kangaroo Care) handout in the patient family education manual (13:B:08).
  • Before holding your baby, take some calming deep breaths.
  • Ask the social worker or psychologist for tips on how to feel more comfortable holding your baby.
  • Remember that the more you hold your baby, the easier and more comfortable it will become!

My baby’s team says my baby is not yet ready to be held. What else can I do?”

If your baby is not ready to be held, your touch is still important!

  • “Hand hugs” are a great option when your baby is not yet ready to get out of bed. This will also support your baby’s growth and your relationship.
  • Gentle, constant touch to your baby’s head, chest or feet can have a calming effect.
  • If your baby is in a warmer bed or isolette, ask for a taller chair so you can sit comfortably next to your baby and be together.


Mom shares story of premature baby now hospitalized with RSV

CBS 8 San Diego

Nov 17, 2022 – Nov 17, 2022

On World Prematurity Day, a Southern California mom is sharing her story about having a premature baby who is now hospitalized with RSV. The three-month-old has been at Children’s Health of Orange County for more than three weeks, but his story is similar to other families whose children are being treated right here in San Diego.

Respiratory syncytial virus (RSV

Respiratory syncytial virus (RSV) What is RSV Respiratory syncytial virus (abbreviated as RSV) is a virus that can cause cold-like symptoms but can also lead to severe breathing difficulties or even a severe infection of the lung. Almost all children have already once been infected with RSV by their second birthday. Since there are a lot of different forms of RSV, one can be infected several times in life.1 At risk for an RSV infection Everybody can be infected by RSV. Usually people don’t really note this, but have a cold or sniffle and recover within a few days. But the virus can also cause a very severe infection. Certain people are at risk for a more severe infection and may require hospitalisation, need of oxygen therapy and long-term damages like asthma.

Symptoms of an infection with RSV:

 The symptoms of an infection with RSV are similar to common cold symptoms, like runny nose, coughing or wheezing (a whistling sound during breathing) and a decreased appetite. An adult infected with RSV can show symptoms, but does not have to, while children usually do show symptoms. Especially in very young children the symptoms might consist of irritability and decreased activity and appetite. Also breaks in breathing (apnoea) might occur. Fever can be a symptom, but is not always present. At the beginning, the symptoms might be relatively low pronounced, but especially in people at risk for a more severe infection it can lead to hospitalisation and severe inflammation of the small airways in the lung (bronchiolitis) and infection of the lungs (pneumonia).1 Ways of transmission of the virus The virus is mainly spread by droplets from a person who is infectious to another person. This means by sneezing or coughing of an infected person into the air. When a person inhales these droplets or when they touch the mouth, nose or eye, this can lead to an infection. Also a direct or indirect contact with nasal or oral secretions from a contagious person can lead to an infection. Be aware that also kissing can lead to a transmission of the virus. Another possible form of being infected with RSV is by touching something (surfaces, toys, doorknobs, gloves,…) that an infectious person had touched before and then rubbing eyes or nose. People who are infected with the virus, but do not show symptoms or only light symptoms can still be contagious for others.

At Risk for Severe Infection:

– preterm babies young children (particularly up to 6 months)

– children with heart or lung disease (especially up to 2 years)

– certain congenital anomalies (for example trisomy 21)

 – children with a neuromuscular disease (for example children who cannot swallow easily or have – – problems clearing mucus secretions)

– elderly people who have a weak immune system

Additional Risk Factors for the babies:

– multiple birth

– male siblings in early childhood

–  passive smoking close domestic conditions

– malnutrition

– lack of breastfeeding

– family history of allergic diseases or asthma

You can help protect your baby by taking some precautions:

 The virus is able to survive quite a long time on hands (about half an hour), tissues (up to an hour) and toys/surfaces (several hours).

 Therefore the following precautions and recommendations are very important to be followed:

 Don’t share your mug, plate or cutlery with others Avoid rubbing your nose or eyes If possible, avoid interaction with high-risk children if you have cold-like symptoms When coughing or sneezing cover your mouth and nose with a tissue and throw it away afterwards Stay at home when you have cold-like symptoms Don’t kiss high-risk children while you or they show cold-like symptoms High-risk children should spend little time in potentially infectious places (for example child-care centres) Don’t smoke near your child. Wash your hands after smoking Breastfeeding reduces the risk for an infection with RSV Wash your hands frequently and wipe hard surfaces with soap and water (15-20 seconds!) or disinfectant.

Treatment of RSV Most people who are infected with RSV only show a mild form of infection and usually do not need treatment at all. For the ones suffering from a more severe form of the disease, there is no causal therapy and only the symptoms can be treated by for example lowering fever and drinking enough. Some children may even require hospitalisation and need help with breathing.4 Vaccination against RSV At the moment there is no vaccine that can help prevent RSV infection.3 Nevertheless, there may be options to prevent contracting the virus. And of course, you can help avoid RSV infection by following the already mentioned tips for hygiene! For further questions please ask your paediatrician.

A Stay in Neonatal Care – Preparing to Take Your Baby Home

The NICU Foundation Oct 14, 2021

Funded by The NICU Foundation and created in partnership with The South West Neonatal Network, this animation was created to support parents, as they navigate their journey home following a stay in neonatal care with a premature or sick baby.

*** Ask your healthcare provider what community resources are available to support you, your family, and your baby. Knowing resources in advance will empower your ability to be proactive and prepared!


Stanford Fetal Therapy VR: An inside look at complex fetal conditions

Stanford Medicine Children’s Health Apr 29, 2022

Stanford Fetal Therapy VR gives patients and doctors an unprecedented view of two complex fetal conditions—spina bifida and twin-to-twin transfusion syndrome—and how we can treat them using cutting-edge surgical techniques.

Clinical outcomes for babies born between 27 31 weeks of gestation: Should they be regarded as a single cohort?

Abdul Qader Tahir Ismail a,b,*, Elaine M. Boyle a, Thillagavathie Pillay a,c, For the OptiPrem Study Team

Journal of Neonatal Nursing 29 (2023) 27–32

  1. Introduction

 Within the UK, babies born below 27 weeks of gestation are recommended to be born in maternity services attached to neonatal intensive care units (NICU). For those babies born between 27 and 31 weeks of gestation, care can be delivered in maternity services attached to either a NICU or a local neonatal unit (LNU). While the first recommendation is evidence based (Marlow et al., 2014; Watson et al., 2014), our systematic review found a paucity of evidence for optimal location of birth and care for babies born between 27 and 31 weeks (Ismail et al., 2020).

 This reflects a more general lack of research aimed at babies born between 27 and 31 weeks of gestation. During our systematic review we found that most of the data available for this population comes from subgroup analyses in studies of larger gestational age ranges (Ismail et al., 2020; Lasswell et al., 2010). Of these, most report outcomes for this group as a whole rather than by gestational week (Watson et al., 2014). Neonatal research is logistically difficult, especially in relation to very preterm babies, as the population size decreases with each extra gestational week of prematurity. Therefore, it is common practice to cohort babies. While not ideal, this makes more sense for certain gestational age ranges than others.

 Babies born between 27 and 31 weeks do not form a ‘natural’ cohort as do those born extremely preterm. There is a significant degree of heterogeneity in the clinical presentation between babies born at either end of this spectrum. Over this five-week period the foetus is undergoing significant growth and developmental changes in-utero. In this review we describe the limited available literature on the variation in clinical presentation and outcomes for babies born between 27 and 31 weeks of gestation in the context of fetal developmental biology and preterm birth. In doing so, we highlight the importance of future research reporting gestation specific outcomes for preterm babies in general, but especially this cohort.

  • Survival and key morbidities for babies born at 2731 weeks

Table 1 and Fig. 1 summarises outcomes for major neonatal morbidities by each week between 27 and 31 weeks of gestation. They include international mortality data from national statistical bodies. An identical trend is evident for all, demonstrating increasing incidence with decreasing gestational age and substantially different outcomes for the most preterm babies within this gestational age range compared to the most mature. There is, on average, a greater than 4-fold difference in mortality between babies born at 27 weeks of gestation compared to 31 weeks, and a 4-fold increase in rates of survival to discharge without morbidity for babies born at 30 weeks compared to 27 weeks.

  • Understanding postnatal outcomes through the lens of foetal development

 The medical and nursing care required for babies in this group is likely to be more intense for those at the lower than the higher end of the gestational age spectrum, based on their degree of immaturity, and existence of co-morbidities.

  • Respiratory system

Babies born at the lower end of this gestational age range are often first supported with non-invasive ventilation (NIV) if they display sufficient respiratory drive and have a good heart rate. Those that do not will be intubated and invasively ventilated within delivery suite, and a proportion of those who initially managed on NIV may require subsequent intubation and ventilation due to significant apnoea and/or respiratory failure. These babies may benefit from a dose of surfactant and regular caffeine, with the aim to extubate onto NIV as soon as appropriate, to minimise ventilator associated lung injury while still providing an adequate level of support, which may be required for several weeks. In contrast, the majority of babies born at the upper end of this gestational age range will only require a brief period of NIV, usually in the form of high flow nasal prong oxygen or continuous positive airway pressure (CPAP) support.

How can we understand this in the context of foetal development? In-utero breathing stimulates lung growth (Harding and Hooper, 1985). By 24–28 weeks, fetal breathing movements occur for 10–20% of the time, increasing to 30–40% by 30 weeks (Fraga and Guttentag, 2012). Correspondingly, during the saccular stage of fetal lung development (24–26 weeks to 36–38 weeks), surface area for gas exchange increases as does vascularisation and surfactant production. Following preterm birth, this immaturity of central respiratory drive manifests as periods of hypoventilation and apnoea, the incidence falling from 54% at 30–31 weeks to 7% at 34–35 weeks (Henderson-Smart, 1981). In those born at 24–27 weeks, apnoeic episodes are more likely to continue for longer compared to those born ≥28 weeks (Eichenwald et al., 1997). Therefore, respiratory compromise, the need for mechanical ventilation and intensive care support is more likely with increasing prematurity, with the incidence of RDS at 60–80% for babies born at 26–28 weeks, falling to 15–30% by 32–36 weeks [14]. The more immature the lung, the greater the risk of ventilator associated lung injury, abnormal development, and chronic lung disease (CLD) [15]. Its incidence is nine times greater in babies born at 27 weeks than at 31 weeks of gestation (Bolisetty et al., 2015; Egreteau et al., 2001).

  • Cardiovascular system

Babies born at 27 weeks of gestation who are difficult to successfully extubate will often be found to have a haemodynamically significant patent ductus arteriosus (PDA) on echocardiography (although clear evidence is lacking for a causal relationship – (El-Khuffash et al., 2019; Benitz et al., 2016)). Management protocols vary unit to unit, but many will commence pharmacological treatment with ibuprofen, or more recently paracetamol. If this is unsuccessful, and on serial echocardiograms there is evidence of developing heart failure, the baby will be referred for surgical ligation. While some babies born at 31 weeks may have clinical signs of a PDA (i.e., a murmur, easily palpable femoral pulses), it is unlikely to be haemodynamically significant and can be left to close on its own. If at the time of discharge these signs are still present, an echocardiogram can provide a definitive diagnosis to arrange appropriate follow-up.

Following preterm birth, constriction of the ductus arteriosus is less likely to occur because of reduced vessel tone and pulmonary clearance of prostaglandins, to which the ductus in preterm babies is more sensitive (Clyman, 2012). This explains the increase in incidence of patent ductus arteriosus (PDA) at day 7 of life with reducing gestation (68%, 33%, and 2% at 26–27 weeks, 28–29 weeks, and ≥30 weeks, respectively) (Clyman, 2012), and a 10-fold increase in the likelihood of requiring surgery for a clinically significant PDA in those born at 27 weeks gestation when compared to those at 31 weeks (Bolisetty et al., 2015).

  • Ocular system

 Babies born at the lower end of this gestational age range most often require supplemental oxygen as part of their respiratory support. This is recognition receptors (including toll like receptors) continue development until 33 weeks, however, for up to 28 days after preterm birth at <30 weeks, toll like receptor responses are significantly reduced (Marchant et al., 2015). Regarding the complement system, average levels of terminal pathway components, C5, C6, and C8 in preterm babies are at 60–73%, 36–39%, and 29%, respectively, compared to adult levels (McGreal et al., 2012). Considering overall functional capacity, CH50 assay results increase from 32 to 36% at 26–27 weeks, to 52–81% at term.

Physical and external contributing factors, such as skin barrier integrity, repeated invasive procedures and indwelling plastic catheters, are also related to degree of prematurity.

3.6. Renal system

 Babies born at the lower end of this gestational age range receive a significant proportion of their hydration/nutrition intravenously, while simultaneously exposed to nephrotoxic drugs, e.g., gentamicin for treatment of suspected EOS, ibuprofen for treatment of a haemodynamically significant PDA, and vancomycin for treatment of CLABSI, warranting close monitoring of their electrolytes, renal function, and fluid balance. In contrast, babies born at the upper end of this gestational age range relatively quickly establish enteral feeds and much less frequently require treatment with nephrotoxic drugs.

The incidence of renal failure is 2-fold higher for a baby born at 27 weeks compared with 30 weeks of gestation (Walker et al., 2011; Jetton et al., 2017). Two thirds of new nephrons form between 28 and 36 weeks, after which no new glomeruli develop (Stritzke et al., 2017; Hinchliffe et al., 1991). Following preterm birth, nephrogenesis can continue for up to 40 days (Rodriguez et al., 2004; Black et al., 2013), but a significant proportion of new glomeruli have cystic dilatation of the Bowman’s capsule (Sutherland et al., 2011).

3.7. Neurological system

 As routine, babies born at the lower end of this gestational age range will have a cranial ultrasound scan (CrUSS) within the first few days of life, which will be repeated two to three times within the first month. It is not uncommon to diagnose uni/bilateral grade I-II intraventricular haemorrhage (IVH) and increased echogenicity in the periventricular areas even in those babies without any discernible risk factors except prematurity. However, for the more unwell (who may have required a degree of resuscitation, intubation and invasive ventilation, periods of hypoxaemia, hyper/hypocapnia and acidosis, and hypotension requiring fluid expansion and inotropic support), more severe grades of IVH (III/IV) and cystic periventricular leukomalacia (PVL) are more common. This would necessitate increasing the frequency of scanning to monitor for complications (e.g., post-haemorrhagic hydrocephalus) and plan for longer term neurodevelopmental follow-up and support. Babies born at the upper end of this gestational age range are much less likely to experience this degree of homeostatic disturbances and so are routinely scanned once within the first week of life and may not have a second scan until term equivalent or ready for discharge.

This variation in scanning frequency is based on the inverse correlation gestational age at birth has with risk of IVH (Brouwer et al., 2008; Synnes et al., 2001). Babies born at 27–28 weeks have a 2-fold increased risk of developing intraventricular haemorrhage (IVH) of any grade, compared to those born at 31 weeks (Brouwer et al., 2008; Synnes et al., 2001). Severe IVH (stage III/IV) is three times more common in those born at 27 weeks than 31 weeks.

The germinal matrix has a dense supply of fragile blood vessels that are prone to rupture with fluctuations in cerebral blood flow, causing the bulk of what is described in the literature as IVH. The risk is increased due to immature cerebral autoregulation, in which hypoxaemia, hypercapnia, hypocapnia, and acidosis cause pressure passivity (Soul et al., 2007; Tsuji et al., 2000). This, combined with increasing severity of respiratory illness and homeostatic disturbances in the more preterm baby, may explain the inverse correlation of IVH with gestational age.

The trend is similar for periventricular leucomalacia (PVL) (Luan-ying, 2011). Non-cystic PVL is characterised by hypomyelination (Volpe, 2009). By 28–30 weeks, increasing differentiation of oligodendrocyte progenitors (pre-OL) coincides with the start of myelination (Jakovcevski et al., 2009; Tau and Peterson, 2010), stimulated by microglia that are also proliferating (Menassa and Gomez-Nicola, 2018; Gould and Howard, 1991; Billiards et al., 2006). Hypoxia, infection or inflammation cause pathogenic activation of microglia and death of pre-OL cells through release of reactive nitrogen and oxygen species (RNS/ROS) (Merrill et al., 1993; Haynes et al., 2003).

Preterm babies with severe IVH (grade III/IV) and cystic PVL are at increased risk of cerebral palsy (Himmelmann and Uvebrant, 2014). There is a nearly 2-fold increase in incidence of cerebral palsy for a baby born at 27 weeks compared with 31 weeks of gestation, but the absence of cranial ultrasound abnormalities does not always mean normal neurodevelopment for babies born preterm. In utero, cortical volume increases from 13% at 28 weeks to 53% at 34 weeks. Babies born preterm have reduced growth trajectories of their cerebrum, cerebellum, and brainstem compared to the foetus within the last trimester (Bouyssi-Kobar et al., 2016). Each extra week of maturity at birth between 27 and 32 weeks is associated with an increased IQ of 2.5 points (Johnson, 2007).

  • Implications for practice

The degree of clinical support that a preterm baby may receive is graded into intensive care, high dependency and special care (BAPM, 2011). Most babies born at the lower end of this gestational age spectrum require some degree of intensive care support, based on the clinical manifestations of their prematurity. In contrast, the majority of ‘well’ preterm babies at the upper end may never require intensive care support, but rather high dependency and special care support. This dichotomy in their clinical presentation means that grouping them into a single cohort may have the following consequences:

 a) Cohorting this group in terms of decision-making regarding place of birth and care may mean over utilisation of intensive care support for those babies at the upper end of the spectrum. This in turn may limit intensive care availability for those babies who need it, especially in resource and cost constrained environments.

 b) Grouping them as a single cohort in the literature makes it more likely significant outcomes for babies at the lower end of this spectrum will be obscured.

5. Conclusion

 This review highlights the variation and range of clinical profiles and associated outcomes for babies born between 27 and 31 weeks of gestation, and how these relate to key aspects of organ/system development occurring in-utero during this 5-week period. The data summarised in Table 1 and graphically represented in Fig. 1 consistently demonstrate a gradient of risk across multiple outcomes with rates of mortality and morbidity increasing from birth at 31 to 27 weeks. Outcomes at the two extremes of this range may differ significantly, yet babies born between 27 and 31 weeks of gestation are often regarded as a single entity with respect to place of birth and care, and for research purposes. In future studies relating to very preterm birth, understanding gestation specific morbidities and outcomes may be more informative, compared to outcomes as a single collective group. This may be a useful concept for policy makers involved in preterm health service delivery, and might allow more finely tuned, appropriate utilisation of resources for this group of babies.

Full Report, Data, Charts/References


AAP Issues Reports on Point-of-care Ultrasonography Applications in the NICU


Point-of-Care Ultrasonography (POCUS) can be performed at the bedside of patients in neonatal intensive care units (NICU). If performed in a timely fashion, POCUS has the potential for enhancing quality of care and improving outcomes. The clinical report, “Use of Point-of-Care Ultrasonography in the NICU for Diagnostic and Procedural Purposes,” along with an accompanying technical report, are published in the December 2022 Pediatrics (published online Nov. 28). Although the performance and interpretation of ultrasonography have traditionally been limited to pediatric radiologists and pediatric cardiologists, POCUS refers to ultrasonography performed at the bedside by non-radiology and non-cardiology practitioners in the NICU for diagnostic, therapeutic, and procedural purposes. The reports, written by the Committee on Fetus and Newborn and the Section on Radiology, state that the technology is increasingly used worldwide. Yet, there are no published guidelines on implementation of point-of-care ultrasonography programs in U.S. neonatal intensive care units. The AAP suggests institutional guidelines for the use of point-of-care ultrasonography and other steps to help overcome barriers in use of the technology.



Healthcare providers should consider RSV in patients with respiratory illness, particularly during the RSV season.

Respiratory syncytial virus (RSV) was discovered in 1956 and has since been recognized as one of the most common causes of childhood illness. It causes annual outbreaks of respiratory illnesses in all age groups. In most regions of the United States, RSV circulation starts in the fall and peaks in the winter, but the timing and severity of RSV season in a given community can vary from year to year. Scientists are developing several vaccines, monoclonal antibodies, and antiviral therapies to help protect infants and young children, pregnant people (to protect their unborn babies), and older adults from severe RSV infection.

Clinical Description and Diagnosis

In Infants and Young Children

RSV infection can cause a variety of respiratory illnesses in infants and young children. It most commonly causes a cold-like illness but can also cause lower respiratory infections like bronchiolitis and pneumonia. One to two percent of children younger than 6 months of age with RSV infection may need to be hospitalized. Severe disease most commonly occurs in very young infants. Additionally, children with any of the following underlying conditions are considered at high risk:

  • Premature infants
  • Infants, especially those 6 months and younger
  • Children younger than 2 years old with chronic lung disease or congenital heart disease
  • Children with suppressed immune systems
  • Children who have neuromuscular disorders, including those who have difficulty swallowing or clearing mucus secretions

Infants and young children with RSV infection may have rhinorrhea and a decrease in appetite before any other symptoms appear. Cough usually develops one to three days later. Soon after the cough develops, sneezing, fever, and wheezing may occur. In very young infants, irritability, decreased activity, and/or apnea may be the only symptoms of infection.

Most otherwise healthy infants and young children who are infected with RSV do not need hospitalization. Those who are hospitalized may require oxygen, intubation, and/or mechanical ventilation. Most improve with supportive care and are discharged in a few days.

In Older Adults and Adults with Chronic Medical Conditions

Adults who get infected with RSV usually have mild or no symptoms. Symptoms are usually consistent with an upper respiratory tract infection which can include rhinorrhea, pharyngitis, cough, headache, fatigue, and fever. Disease usually lasts less than five days.

Some adults, however, may have more severe symptoms consistent with a lower respiratory tract infection, such as pneumonia. Those at high risk for severe illness from RSV include:

  • Older adults, especially those 65 years and older
  • Adults with chronic lung or heart disease
  • Adults with weakened immune systems

RSV can sometimes also lead to exacerbation of serious conditions such as:

  • Asthma
  • Chronic obstructive pulmonary disease (COPD)
  • Congestive heart failure

Clinical Laboratory Testing

Clinical symptoms of RSV are nonspecific and can overlap with other viral respiratory infections, as well as some bacterial infections. Several types of laboratory tests are available for confirming RSV infection. These tests may be performed on upper and lower respiratory specimens.

The most commonly used types of RSV clinical laboratory tests are

  • Real-time reverse transcriptase-polymerase chain reaction (rRT-PCR), which is more sensitive than culture and antigen testing
  • Antigen testing, which is highly sensitive in children but not sensitive in adults

Less commonly used tests include:

  • Viral culture
  • Serology, which is usually only used for research and surveillance studies

Some tests can differentiate between RSV subtypes (A and B), but the clinical significance of these subtypes is unclear. Consult your laboratorian for information on what type of respiratory specimen is most appropriate to use.

For Infants and Young Children

Both rRT-PCR and antigen detection tests are effective methods for diagnosing RSV infection in infants and young children. The RSV sensitivity of antigen detection tests generally ranges from 80% to 90% in this age group. Healthcare providers should consult experienced laboratorians for more information on interpretation of results.

For Older Children, Adolescents, and Adults

Healthcare providers should use highly sensitive rRT-PCR assays when testing older children and adults for RSV. rRT-PCR assays are now commercially available for RSV. The sensitivity of these assays often exceeds the sensitivity of virus isolation and antigen detection methods. Antigen tests are not sensitive for older children and adults because they may have lower viral loads in their respiratory specimens. Healthcare providers should consult experienced laboratorians for more information on interpretation of results.

Prophylaxis and High-Risk Infants and Young Children

Palivizumab is a monoclonal antibody recommended by the American Academy of Pediatrics (AAP) to be administered to high-risk infants and young children likely to benefit from immunoprophylaxis based on gestational age and certain underlying medical conditions. It is given in monthly intramuscular injections during the RSV season, which generally starts in the fall and peaks in the winter in most locations in the United States.


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Kiteboarding Saudi Arabia I had the chance to go kiting at two amazing spots in Saudi Arabia. Let me take you to this unusual place. Enjoy!