INDONESIA

Indonesia, officially the Republic of Indonesia  is a country in Southeast Asia and Oceania, between the Indian and Pacific oceans. It consists of more than seventeen thousand islands, including Sumatra, Java, Borneo (Kalimantan), Sulawesi, and New Guinea (Papua). Indonesia is the world’s largest island country and the 14th-largest country by land area, at 1,904,569 square kilometres (735,358 square miles). With over 267 million people, it is the world’s 4th-most-populous country as well as the most-populous Muslim-majority country. Java, the world’s most-populous island, is home to more than half of the country’s population.

The sovereign state is a presidential, constitutional republic with an elected legislature. It has 34 provinces, of which five have special status. The country’s capital, Jakarta, is the second-most populous urban area in the world. The country shares land borders with Papua New Guinea, East Timor, and the eastern part of Malaysia. Other neighbouring countries include Singapore, Vietnam, the Philippines, Australia, Palau, and India‘s Andaman and Nicobar Islands. Despite its large population and densely populated regions, Indonesia has vast areas of wilderness that support one of the world’s highest levels of biodiversity.

Government expenditure on HEALTHCARE is about 3.3% of GDP in 2016. As part of an attempt to achieve universal health care, the government launched the National Health Insurance (Jaminan Kesehatan Nasional, JKN) in 2014 that provides healthcare to citizens. They include coverage for a range of services from the public and also private firms that have opted to join the scheme. In recent decades, there have been remarkable improvements such as rising life expectancy (from 62.3 years in 1990 to 71.7 years in 2019) and declining child mortality (from 84 deaths per 1,000 births in 1990 to 25.4 deaths in 2017).  Nevertheless, Indonesia continues to face challenges that include maternal and child health, low air quality, malnutrition, high rate of smoking, and infectious diseases.

Source: https://en.wikipedia.org/wiki/Indonesia

 COMMUNITY

Warmer world linked to poor pregnancy results: Study

MARLOWE HOOD    AGENCE FRANCE-PRESSE  Paris, France  /  Wed, November 4, 2020

Women exposed to high temperatures and heatwaves during pregnancy are more likely to have premature or stillborn babies, researchers said Wednesday.

Such outcomes — closely linked to poverty, especially in the tropics — will likely increase with global warming, especially during more frequent and intense heatwaves, they reported in BMJ, a medical journal.

Even small increases “could have a major impact on public health as exposure to high temperatures is common and escalating,” the study concluded.

Each year, 15 million babies are born premature, the leading cause of death among children under five, according to the World Health Organization (WHO). 

That mortality is concentrated in the developing world, especially Africa. 

To quantify the impact of higher heat on pregnancy outcomes, an international team of researchers led by Matthew Chersich from Wits Reproductive Health and HIV Institute in Johannesburg looked at 70 peer-reviewed studies of 27 rich, poor and middle-income nations.

Of the 47 studies that concerned preterm births, 40 reported they were more common at higher temperatures.

The odds of a preterm birth rose, on average, by five percent per one degree Celsius (1C) increase, and by 16 percent during heatwave days, according to the new findings.

Global warming has seen Earth’s average temperature rise by 1C over the last century, with greater increases over large land masses.

The number of exceptionally hot days are expected to increase most in the tropics, according to the UN’s climate science advisory panel, the IPCC.

‘High risk’ for heat

Extreme heatwaves — made more dangerous by high humidity — are projected to emerge earliest in these regions as well.

Limiting global warming to 1.5C instead of 2C — goals consistent with the Paris Agreement — would mean around 420 million fewer people frequently exposed to extreme heatwaves, the IPCC said in a 2018 report.

The new study also found that stillbirths increased by five percent per 1C increase in temperature, with the link most pronounced in the last few weeks of pregnancy.

The impact of warmer days and heatwaves on low birth weight, which is associated with a host of health problems later in life, was smaller, but still significant, the researchers said.

As expected, adverse pregnancy outcomes associated with rising temperatures were strongest among poorer women.

Because other factors such as pollution might play a role in stillbirths and premature babies, the role of warmer temperatures is hard to pin down, the researchers acknowledged.

Nonetheless, the findings are strong enough to suggest that pregnant women “merit a place alongside the groups typically considered as at ‘high risk’ for heat-related conditions,” they concluded.

More research and targeted health policies should be a high priority, they added.

Source: https://www.thejakartapost.com/life/2020/11/04/warmer-world-linked-to-poor-pregnancy-results-study.html

Kat and I study global health issues and developments on an ongoing basis.  Based on the increasing and well documented climate change and global warming challenges that make national “borders” irrelevant in many ways,  and challenge the global community, much like the pandemic, to create ways of collaborating for global and good and even survival,  and considering the overwhelming scientific evidence that climate change and global warming pose a real and present danger, we call for global action and proactive changes. Our Neonatal Womb Warrior/Preterm Birth Community and our global community at large can and with increased necessity, must create progressive people/planet-oriented changes in order to provide a future for our children and our children’s children. 

The technology is here. The people are ready. Scientists have spoken. Progressive businesses are stepping forward. Now we need governments to take climate action!” – WWF International 

You must not gamble your children’s future on the flip of a coin. Instead, you mustunite behind the science. You must take action. You must do the impossible. Because giving up can never ever be an option- Greta Thunberg 

Few challenges facing America and the world are more urgent than combating climate change. The science is beyond dispute and the facts are clear – Barack Obama

Check Out: https://climate.nasa.gov/

Maternal smoking and preterm birth: An unresolved health challenge

Sarah J. Stock , Linda Bauld – Published: September 14, 2020 https://doi.org/10.1371/journal.pmed.1003386

Maternal exposure to tobacco smoke in pregnancy is a key modifiable risk factor for baby death and disability. Smoking is linked to preterm birth (birth before 37 weeks’ gestation), stillbirth, and neonatal mortality, as well as to miscarriage, fetal growth restriction, and infant morbidity . The worldwide prevalence of maternal smoking in pregnancy is 2%, with Europe having the highest prevalence at 8% . Although rates of maternal smoking in pregnancy are decreasing in many high-income countries , this decline is slower among women of lower socioeconomic status, contributing to health inequalities . In certain low- and middle-income countries, maternal smoking rates are static or rising .

In this issue of PLOS Medicine, two studies provide new insights into the implications of exposure to tobacco smoke in pregnancy for perinatal and childhood outcomes. Buyun Liu and colleagues studied preterm birth in relation to timing and intensity of maternal smoking in more than 25 million singleton mother–infant pairs using United States birth certificate data . The size of this “mega-cohort” allowed exploration of whether incremental increases of 1–2 cigarettes per day were associated with increases in preterm birth. Compared to nonsmokers, any maternal smoking during the three months prior to conception and continued into the first trimester of pregnancy was associated with increased preterm birth (odds ratio [OR] 1.17 [95% CI 1.16–1.19]). This risk increased if maternal smoking continued during the second trimester (OR 1.45 [1.45–1.46]). Women who quit smoking during pregnancy still had an increased risk of preterm birth, even if levels of smoking were low and they stopped early in pregnancy. For example, compared to nonsmokers, women who smoked 1–2 cigarettes a day and quit in the first trimester had an increased risk of preterm birth (OR 1.13 [1.10–1.16]). In contrast, if they quit smoking in the three months before pregnancy, even heavy smokers of 20 or more cigarettes per day had a similar risk of preterm birth to that of nonsmokers (OR 1.01 [0.99–1.03]). The authors conclude that there is no safe level for cigarette smoking in pregnancy.

Elise Philips and colleagues found a different pattern of smoking and preterm birth in an individual participant data meta-analysis of 220,000 births from 28 cohort studies, in which smoking status was determined from questionnaires . Compared to nonsmokers, mothers who smoked in the third trimester of pregnancy were at increased risk of preterm birth. However, the effect size was lower than in Liu’s study , with an OR of 1.08 (1.02–1.15). In contrast to Liu’s findings , smoking confined to the first trimester of pregnancy was not associated with preterm birth when compared to nonsmokers (OR 1.03 [0.85–1.25]). Furthermore, no dose response was seen with increasing or decreasing cigarette intake between first and third trimesters.

Philips and colleagues additionally explored the relationship between smoking and being small for gestational age (SGA) at birth and overweight in childhood . Whereas maternal first trimester smoking was associated with childhood overweight (OR 1.17 [1.02–1.35]) but not SGA (OR 0.99 [0.85–1.15]), smoking in later pregnancy was associated with both childhood overweight (OR 1.42 [1.35–1.48]) and SGA (OR 2.15 [2.07–2.23]). Reducing the number of cigarettes from first to third trimester lowered the risks of delivering SGA infants, but risks were still higher compared with nonsmoking mothers. Mothers who increased the number of cigarettes from first to third trimester had increased risk of an SGA infant compared with those who did not.

Several factors may explain the different patterns of association between smoking and preterm birth seen in the two studies. First, at 4.7%, the population risk of preterm birth in the Philips study, in which most of the cohorts were European , was less than half that of Liu’s US-based study (9.3%). Second, the sample size for analyses of cessation, increasing, or decreasing cigarettes smoked between first and third trimester was much smaller in Philips’ study and, at only 1% of the entire cohort (around 2,200 women with 120 preterm births), may not be representative at population level. The low numbers resulted from only around half of the included cohorts having data on both early and late pregnancy cigarette consumption. Third, in the Philips study, smokers who quit prepregnancy were included as nonsmokers, whereas in the Liu study, prepregnancy smokers were considered separately. Finally, cohorts in the Philips meta-analysis collected late pregnancy smoking data in the third trimester . This can be problematic, as most preterm births occur in the third trimester. Liu and colleagues restricted analysis to second-trimester smoking to avoid this.

Despite their differences, both studies add compelling evidence to the idea that there is a dose–response relationship between smoking in pregnancy and preterm birth. The more and the longer women smoke in pregnancy, the higher the associated morbidity. There will also be higher numbers of babies who die, as preterm birth is the major cause of neonatal mortality, and SGA is strongly associated with stillbirth. This message needs to be clearly conveyed to pregnant women and health professionals so that the relevance of surrogate health outcomes is not misinterpreted. Having a “small baby” may not be seen as a bad thing or even, erroneously, be considered advantageous for birth. Health messages should also be directed to wider audiences than just pregnant women and those that care for them. As beliefs about smoking are strongly influenced by family, friends, and peers, risk messages from social networks are frequently more effective than those delivered by health professionals .

Pregnancy is a time when interventions for smoking cessation might be most effective. It is purported that women are more likely to quit smoking in pregnancy than at any other period in their lives . There are certainly opportunities for improvement, with three-quarters of prepregnancy smokers continuing to smoke in early pregnancy and 85% of those that smoke in early pregnancy continuing into late pregnancy . Behavioral support for smoking cessation is recommended as part of antenatal care in many countries and endorsed by guidance from WHO. This should be delivered by staff who have received appropriate training but delivered in a flexible way, tailored to the needs of pregnant women. Some countries combine behavioral support with nicotine replacement therapy, which has been shown to be effective in the general adult population. However, single-product nicotine replacement therapy has not been shown to be effective during pregnancy , and research is now ongoing to explore this further .

Evidence from ongoing trials of promising adjuvant approaches, such as electronic cigarettes and financial incentives , may be key to improving quit rates but will require political will to implement if effective. There are, however, enormous potential benefits from reducing smoking in pregnancy, both in terms of women’s and children’s health and in savings to health services. In the United Kingdom alone, maternal and infant healthcare costs attributed to smoking are estimated at £20–£87.5 million per annum . A concerted effort across multiple sectors is required to prevent this harm and protect the health of future generations.

Citation: Stock SJ, Bauld L (2020) Maternal smoking and preterm birth: An unresolved health challenge. PLoS Med 17(9): e1003386. https://doi.org/10.1371/journal.pmed.1003386

Source: https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1003386

Global burden of preterm birth

Salimah R. Walani   First published: 10 June 2020   https://doi.org/10.1002/ijgo.13195

Abstract

Preterm birth is a live birth that occurs before 37 completed weeks of pregnancy. Approximately 15 million babies are born preterm annually worldwide, indicating a global preterm birth rate of about 11%. With 1 million children dying due to preterm birth before the age of 5 years, preterm birth is the leading cause of death among children, accounting for 18% of all deaths among children aged under 5 years and as much as 35% of all deaths among newborns (aged <28 days). There are significant variations in preterm birth rates and mortality between countries and within countries. However, the burden of preterm birth is particularly high in low‐ and middle‐income countries, especially those in Southeast Asia and sub‐Saharan Africa. Preterm birth rates are rising in many countries. The issue of preterm birth is of paramount significance for achieving United Nations Sustainable Development Goal 3 target #3.2, which aims to end all preventable deaths of newborns and children aged under 5 years by 2030.

Introduction

According to WHO, preterm birth is a live birth that occurs before 37 completed weeks of pregnancy. Preterm birth is further classified as extremely preterm (<28 weeks), very preterm (28 to <32 weeks), and moderate (32 to <34 weeks) to late preterm (34 to <37 weeks). Preterm birth may occur spontaneously or may be initiated by a provider through induction of labor or elective caesarean delivery which may or may not be medically indicated. A baby born after 37 weeks of pregnancy is not considered preterm; however, it is recommended that unless medically indicated a pregnancy should be allowed to continue until 39 completed weeks to ensure optimal health outcomes of the baby.

The true prevalence of preterm birth is not known due to lack of actual data in many countries, especially those in lower‐income categories. Estimates of preterm births for 184 countries using 2010 data showed that approximately 15 million babies are born preterm annually worldwide, indicating a global preterm birth rate of about 11%, ranging from 4% in Belarus to 18% in Malawi. Preterm birth rates are rising in most countries. A recent study examining the trends of preterm birth rates found that the global preterm birth rate rose from 9.8% in 2000 to 10.6% in 2014.

Preterm birth is the leading cause of childhood mortality. Approximately 1 million babies die every year due to complications of preterm birth. The issue of preterm birth is of paramount significance for achieving United Nations Sustainable Development Goal 3 target #3.2, which aims to end all preventable deaths of newborns and children aged under 5 years by 2030. Understanding the global burden of preterm birth and disparities in prevalence and mortality of this condition is critical for advocacy and allocation of resources for surveillance, research, prevention, and care related to preterm birth.

Prevalence

Of the 15 million preterm births every year, over 84% occur at 32–36 weeks of gestation. Only about 5% fall into the extremely preterm (<28 weeks) category and the other 10% are born at 28–32 weeks of gestation. Six countries—India, China, Nigeria, Pakistan, Indonesia, and the United States—account for 50% (~7.4 million) of the total preterm births in the world.

There are major variations in preterm birth rates by geographic region and level of income of a country. When countries are grouped by their World Bank income categories, it is found that approximately 90% of all preterm births occur in low‐ and middle‐income countries. The average preterm birth rate for low‐income countries is close to 12%, compared to 9.4% and 9.3% for middle‐ and high‐income countries, respectively. However, there are outliers. For example, Ecuador, a middle‐income county, has a preterm birth rate of 5%, which is lower than in many high‐income countries such as Germany (9.2%), Canada (7.8%), and Israel (8%).

Disparities in preterm birth rates by geographic regions are also very stark. Systematic review and modelling analysis from 2014 data showed that 80% of preterm births occur in countries in sub‐Saharan Africa and South Asia.³ However, there are remarkable variations in the rates within each region. For example, according to one estimate in sub‐Saharan Africa, the preterm birth rate in Uganda of only 6.6% is lower than that of many high‐income countries, including the United States, while Uganda’s neighboring country Tanzania has an estimated preterm birth rate of 16.6%. Within‐region differences are also evident in Europe, where preterm births are in the range of 5%–10%, despite similar development and healthcare infrastructures.

Disparities in preterm birth rates based on maternal education, race, and ethnic origin are also evident in some countries and regions. In the United States, for example, in 2016 the preterm birth rate was 14% among African‐American women compared to 9% among white women. An analysis of preterm birth rates across 12 European countries showed that preterm birth rates were generally higher among women with lower levels of education. In six of the twelve countries, these variations were statistically significant. The differences in preterm birth rates by maternal education were most significant in the Netherlands (P=0.001) and Norway (P=0.009). In the Netherlands, the preterm birth rate among women with a low level of education was 7.0%, compared to 4.9% in those with a high level of education. In Norway, the rates were 9.7% in women with a low level of education and 5.9% in women with a high level of education.

The causes of variations in preterm birth rates among countries and in groups within a country or a region are mainly unknown; however, risk factors associated with preterm birth are discussed in a study by Cobo.

Mortality

Of the 15 million babies born preterm every year worldwide, more than 1 million die before the age of 5 years due to preterm birth and its complications. There has been an overall decline in deaths in children aged under 5 years in the last two decades due to reductions in mortality related to infectious diseases such as pneumonia, diarrhea, malaria, and measles. As a result, complications related to preterm births are now the leading cause of death among children, accounting for 18% of all deaths in children aged under 5 years. The burden of preterm birth is particularly profound during the first 28 days of life (neonatal period), accounting for 35% of all neonatal deaths globally. As with the prevalence of preterm birth, there are huge variations among countries and regions in preterm birth mortality rates and absolute number of deaths due to complications related to preterm births. For example, preterm birth mortality accounts for close to 28% of all deaths in children aged under 5 years in North America and in Western Europe compared to approximately 13% in sub‐Saharan Africa and 25.5% in South Asia. However, the majority of all deaths due to preterm birth occur in sub‐Saharan African and South Asia. India, a country in South Asia, alone accounts for 330 000 (~33%) of the total global deaths due to preterm births. The high absolute number of deaths related to preterm births in some regions is partly due to their high overall rates of child mortality. In 2016, sub‐Saharan Africa had an average under‐five mortality rate of 79 deaths per 1000 live births compared to only 6 per 1000 live births in North America and Europe. Variations in survival gap is another important issue to be considered in relation to preterm birth mortality. In high‐income countries, where almost all births are attended by skilled staff, 50% of the babies born as early as 24 weeks survive, whereas in a low‐income country, even a baby born at 32 weeks has only a 50% chance of survival due to lack of available resources and/or low quality of specialized care needed to improve the survival of a baby born too soon.

Conclusions

Preterm birth is a major healthcare problem affecting 15 million births every year. It is the leading cause of mortality among children aged under 5 years, with a majority of deaths due to preterm birth occurring in the neonatal period.

Much attention has been devoted to the prevention of preterm birth through research and advocacy by organizations such as March of Dimes. However, there is substantial evidence that preterm birth rates are rising globally and in most countries. An analysis of high‐quality data from 38 countries, comparisons between 2000 and 2014, showed that preterm birth rates increased in 26 countries. Although due to scarcity of good‐quality surveillance and registry‐based data, the published prevalence rates from Asian and African countries must be interpreted with caution, the reports of disparities in preterm birth rates and mortality among regions and countries consistently show that the majority of preterm births and related mortality occurs in low‐ and middle‐income countries and the burden is particularly high in South Asia and sub‐Saharan Africa.

Source: https://obgyn.onlinelibrary.wiley.com/doi/full/10.1002/ijgo.13195

HAND METAL PROJECT

The project was conceived by friends and artists Iris Eichenberg and Jimena Ríos. Its aim is straightforward: for artists, jewelers, students, and professionals to craft medals that will honor the service and sacrifice of health workers. Infused with the gratitude of the ex-voto and the tribute of a medal, these hands have been made and collected since April 2020.

The design is drawn from a historical argentinian ex-voto. Authorship is secondary the medals are not about the maker, but about the receiver. To underscore the unity of this collaborative effort, participants copy a template of the hand, meant to be simple enough for all skill levels, and easily replicated into whatever metal is available. This singular hand design creates a collective voice, reinforcing the shared gratitude that is the project’s mission.

Jeweller

Our current battle with coronavirus is fought with an enemy invisible to the naked eye, its specter made all the more ominous by its intangibility—a danger you cannot see. By contrast, metal, especially jewelry, is known by its weight and shape against the body. When formed into a medal, it provides a physical testimony for both the unseen virus and invisible bravery of those who have fought it. Hands themselves have been powerfully present in this battle. They are symbols not only of how our bodies have become weapons to be washed, sanitized, and gloved, but also of their innate power to heal and to connect. For around 3000 jewelers that join the project, of course, they are the language of skill and expression embodied.

Source: https://handmedalproject.com/

INNOVATIONS

Medical Legal Forum: Simplified, Real-time, Free access to the Complete Medical Record in the NICU is Coming with Implementation of the 21st Century Cures Act

Parents of NICU patients have had the right to review their child’s medical records for many years, but in the past such efforts required trips to the medical records department in the sub-basement, long delays, and the significant costs of copying the records. In recent years with the shift to electronic medical records and the development of patient portals, families have had an easier time accessing some, but not all, medical records. This is about to change with the implementation of a rule from the Federal Office of the National Coordinator for Health IT requiring health systems to provide greater access to patient health records.

The rule is part of the implementation of the 21st Century Cures Act passed by Congress in 2016. The “Cures Act” was originally designed to accelerate medical product development and to bring new innovations to patients who need these products faster. The program also allowed patients to access all the health information in their electronic medical records without charge by their healthcare provider. The original deadline for the rule, November 2, 2020, was moved to April 5, 2021, due to the coronavirus pandemic. Patients will have access to the following types of clinical notes:

• Consultation notes • Discharge summary notes • History and physical • Imaging narratives •   

Laboratory report narratives • Pathology report narratives • Procedure notes • Progress notes

There are limited exceptions. These include certain psychotherapy notes by mental health professionals as well as information gathered for use in civil or criminal proceedings. A note can also be protected if it places the patient in potential danger, such as a discussion about domestic violence when the abuser can access the information. Additionally, certain health information for adolescents may be protected from access by the parents. It will be important to work with hospital legal and compliance experts to determine the specific application of the rule at your institution.

 An important second aspect of the rule is penalties for anti-competitive behavior and information blocking that impedes the exchange of medical information. For example, some health IT vendors had a “gag clause” prohibiting the sharing of screenshots. These non-disclosure clauses hinder efforts to improve safety and openly discuss safety concerns.

 The destruction of ‘data silos’ and mandated interoperability is designed to improve care and decrease costs by allowing patients to control their electronic health information, download the information to their smartphones, and examine the data with the apps of their choice. For years there has been an issue of who ‘owns’ patient health data, and this question has clearly been answered in favor of patients.

What impact will free, easy access to the medical record have in the NICU? Certainly, some additional education may be necessary. For example, many laboratory ‘normal’ values reflect data for adults, not neonates. Additionally, very sensitive maternal information, such as herpes status and pregnancy history, is part of the neonatal medical record as well. Ultimately the change will likely be very positive, as with most improvements in transparency. Indeed, while a busy NICU team is caring for multiple patients, a family is focused on just one patient and may catch and prevent errors of omission. Let us not forget that in 2013, the NICU Parent Network created the “NICU Parent’s Bill of Rights.” These ten statements are listed from the perspective of the NICU baby. An example of one statement is, “my parents are my voice and my best advocates; therefore, hospital policies, including visiting hours and rounding, should be as inclusive as possible.

The Cures Act “Final Rule,” which was issued on October 29, 2020, provides our healthcare system additional flexibility and clarifies privacy protections. Healthcare workers face quite a challenge. They must try to take the safest possible care of patients while working in extraordinarily complex systems. The High-Reliability theory offers insight into this dilemma. Increasing reliability has the potential to not only improve outcomes but also to decrease a hospital’s liability.

Breastmilk Harbors Antibodies to SARS-CoV-2

An abundance of immunoglobulin antibodies, and a paucity of viral RNA, in breastmilk offer evidence that women can safely continue breastfeeding during the pandemic.

Milk from lactating moms may hold potent antibodies to counter SARS-CoV-2 infections, according to a new study of 15 women. All of the samples from women who had recovered from COVID-19 and who were breastfeeding babies at the time had antibodies reactive to the virus’s spike protein, researchers report in the November issue of iScience. 

Detecting antibodies against the virus in breastmilk indicates that mothers could be passing viral immunity to their babies. Women can “feel pretty comfortable breastfeeding” during the pandemic, Christina Chambers, a perinatal epidemiologist at the University of California, San Diego, who not involved in the new study, tells The Scientist.

To date, there’s no evidence that a mother can transmit SARS-CoV-2 to her baby through breastmilk, Chambers says. She and others have tested breastmilk for SARS-CoV-2 RNA and found a few positive results, but no live virus. Her latest research also suggests that donor milk is safe for babies’ consumption, too, though she hasn’t assessed antibodies in donor milk banks she works with yet.

I think the potential is really great, if we get past this taboo that it’s breastmilk.

—Rebecca Powell, Icahn School of Medicine at Mount Sinai

Antibodies in breastmilk may be useful for more than protecting nursing infants from the virus. Antibodies extracted from milk—as opposed to the current practice of using convalescent serum—could also serve as a therapeutic for COVID-19. However, “people question that this is something that could really happen,” says study coauthor Rebecca Powell, an immunologist at the Icahn School of Medicine at Mount Sinai in New York City. Because there isn’t a wider understanding of the immune benefits of breastmilk, she says, the concept has not caught on in antiviral drug development.

Detecting breastmilk antibodies

Powell has been investigating human milk immunology for the past four years and was analyzing how the seasonal flu vaccine prompted an immune response in breastmilk when the coronavirus pandemic spread to New York City earlier this year. Switching to study the SARS-CoV-2 immune response in breastmilk was “a no brainer,” she says. “There’s so many unanswered questions in general about milk immunology, but to be able to study it with a novel pathogen was really important.” 

By early April, she and her colleagues had received approval to begin collecting milk samples from lactating mothers who had recovered from COVID-19. The researchers collected samples from eight women who had a SARS-CoV-2–positive PCR test and seven who had suspected cases of the disease but were not tested; all 15 were lactating at the time. The team then compared the samples to ones from different lactating mothers amassed before the pandemic began, first assessing them for the presence of immunoglobulin A (IgA) antibodies using an enzyme-linked immunosorbent assay (ELISA) and then checking the ability of any antibodies found to bind to the SARS-CoV-2 spike protein.

All the of samples from the women who had recovered from COVID-19 had specific SARS-CoV-2 binding activity, while the pre-pandemic samples had low levels of nonspecific or cross-reactive activity, the researchers report. They next tested the antibodies’ response to the receptor binding domain of the SARS-CoV-2 spike protein, and found that 12 out of 15 of the samples from previously-infected donors showed significant IgA binding activity. Some of those samples also included other reactive antibodies such as immunoglobulin G and immunoglobulin M. Compared with the controls, it was IgA and IgG levels that were the highest. 

The results align with a study published in September in the Journal of Perinatology that also detected high levels of IgA and some IgG and IgM that were reactive to the S1 and S2 subunits of the SARS-CoV-2 spike protein in a majority of milk samples collected during the pandemic. None of the breastmilk tested positive for SARS-CoV-2 with a PCR test, suggesting none of the mothers were infected at the time of sample collection. 

There was also no documentation of whether the 41 women who donated samples had ever been infected with the virus, notes study coauthor Veronique Demers-Mathieu, an immunologist at Medolac Laboratories in Boulder City, Nevada, so it’s unclear if these antibodies were the result of SARS-CoV-2 or another viral infection.

The team did collect general health information on the donors of the milk samples and found that S1 and S2 SARS-CoV-2–reactive IgG levels were higher in milk from women who had had symptoms of a viral respiratory infection during the last year than in milk from women who hadn’t had any symptoms of infection. IgG abundance was also higher in the samples from 2020 than from those taken in 2018, long before the pandemic started. The IgA and IgM antibody reactivity, however, didn’t appear to be specific to SARS-CoV-2 S1 and S2 and did not differ between the 2020 samples and the 2018 samples, meaning these responses could be the result of cross-reactivity from antibodies generated after exposure to other viruses. That suggests the antibodies secreted in breastmilk provide a broad immunity to breastfeeding infants, Demers-Mathieu says.

Benefits of breastmilk versus blood antibodies

One important feature of these antibodies, whether specific to the virus or not, is that they are secretory antibodies, Powell notes. The B cells that secrete antibodies into milk originate from the mucosal immune system in the mother’s small intestine. Those B cells travel through the blood to the mammary glands and secrete IgA that’s then shuttled from the mammary tissue to the milk via a transporter protein. Those proteins, called secretory components, leave pieces of themselves on the antibodies, wrapping around them and protecting them from being degraded in the infant mouth and gut. “Secretory antibody is found not only in milk, but in saliva and all other mucosal secretions,” Powell explains. “It’s not unique to milk, but it is not what you find in the blood.”

That difference could give breastmilk-derived antibodies an advantage over blood-based ones as far as therapeutic options go, she explains. Antibodies such as IgG that are extracted from serum and transfused into the blood of a sick person travel throughout the body and might not go where they are needed. But secretory antibodies, such as IgA from breastmilk, could be extracted and then inhaled into the respiratory tract—just where those antibodies are needed in COVID-19. Because of the protective secretory component they have, these antibodies can endure in the mucosa and target the virus, Powell explains.

“What we are finding in the milk is unique compared to what many people have already studied in the blood in terms of antibody response,” she says. Research suggests that blood-derived antibodies can last months. Secretory antibodies in breastmilk might last longer, Powell’s most recent data indicate, and that means there could be a longer window to collect antibodies from lactating donors after they’ve recovered from COVID-19.

Neither Demers-Mathieu’s nor Powell’s studies tested whether the breastmilk antibodies could neutralize SARS-CoV-2, which is a next step in both teams’ research. Powell has early results suggesting the breastmilk antibodies do neutralize the virus, and a company called Lactiga has partnered with her to continue developing the idea of extracting antibodies from breastmilk to counter COVID-19. 

“I think the potential is really great,” says Powell, “if we get past this taboo that it’s breastmilk.”

Source: https://www.the-scientist.com/news-opinion/breastmilk-harbors-antibodies-to-sars-cov-2-68162

Climate pregnancy threat: Study shows expectant mothers are negatively affected by climate change

Outcomes of the Neonatal Trial of High-Frequency Oscillation at 16 to 19 Years

August 13, 2020           N Engl J Med 2020; 383:689-691

To The Editor:

We previously reported superior lung function and teacher ratings of school performance in young persons who had received high-frequency oscillatory ventilation (HFOV) as neonates. In a multicenter, randomized trial, HFOV was compared with conventional ventilation that commenced within an hour of birth in infants born before 29 weeks of gestation. We hypothesized that the positive outcomes of HFOV would persist after the onset of puberty and now report the results of a reassessment of this cohort at the ages of 16 to 19 years.

Comprehensive lung-function assessments were undertaken and questionnaires completed regarding respiratory health, health-related quality of life, and lung function (see the Supplementary Appendix, available with the full text of this letter at NEJM.org). As in our previous assessment of children 11 to 14 years of age, the primary outcome was forced expiratory flow at 75% of the expired vital capacity (FEF₇₅). Because some children were unable to complete all the lung-function tests, we used multiple imputation with chained equations to impute missing data.

Table 1. Lung-Function Test Results According to Ventilation Group.

A total of 161 young people were evaluated, and 159 underwent lung-function assessment (Fig. S1 in the Supplementary Appendix). Baseline characteristics were similar among those who were assessed and those who were not (Table S1). Participant characteristics did not differ significantly between the ventilation groups when assessed as infants or at 16 to 19 years of age (Table S2). The results with respect to the primary outcome did not differ significantly between the ventilation groups at 16 to 19 years of age: mean (±SD) FEF₇₅ z score of −1.07±1.21 with conventional ventilation and −0.94±1.33 with HFOV (adjusted difference in mean z scores, 0.19; 95% confidence interval [CI], −0.18 to 0.56) (Table 1 and Table S3). These differences remained nonsignificant after multiple imputation (P=0.11) (Table S4). The majority of the mean FEF₇₅ results reported when participants were 16 to 19 years of age were below the lower limit of normal (59% with HFOV and 65% with conventional ventilation). Other measures of lung function also did not differ significantly between the ventilation groups (Table 1 and Table S3). However, 15% of participants in the HFOV group received a diagnosis of asthma, whereas only 3% of participants in the conventional ventilation group had such a diagnosis (adjusted difference, 11 percentage points; 95% CI, 3 to 23). Similarly, inhalers were prescribed for asthma treatment in 13% of those in the HFOV group as compared with 3% of those in the conventional ventilation group (adjusted difference, 11 percentage points; 95% CI, 2 to 21) (Table S5).

Our follow-up study of infants who had been enrolled in a randomized trial in which two types of ventilation were prescribed showed that the use of HFOV in the neonatal period was not associated with superior respiratory or functional outcomes at 16 to 19 years of age. Longer-term follow-up is required to determine whether there will be premature onset of chronic pulmonary disease in this vulnerable population.

Christopher Harris, M.R.C.P.C.H.; Alessandra Bisquera, M.Sc.: King’s College London, London, United Kingdom

Alan Lunt, Ph.D.; Imperial College, London, United Kingdom; Janet L. Peacock, Ph.D.:Dartmouth College, Hanover, NH;

Anne Greenough, M.D.: King’s College London, London, United Kingdom- anne.greenough@kcl.ac.uk

Supported by the National Institute for Health Research Biomedical Research Centre at Guy’s and St. Thomas’ National Health Service Foundation Trust and King’s College London.

Source: https://www.nejm.org/doi/full/10.1056/NEJMc2008677

HEALTH CARE PARTNERS

Optimal practice in neonatal parenteral nutrition: The role of quality improvement and risk management in providing high-quality parenteral nutrition

POSTED ON 06 OCTOBER 2020                                  

An interview with Professor Nicholas Embleton

In some infants, parenteral nutrition is the only way to provide the necessary nutrients for days or weeks. Being an invasive procedure, it also carries potential risks and therefore, requires certain infrastructure and thorough risk management paired with continuous quality assessment in order to ensure high quality of parenteral nutrition in daily practice. In this interview, Professor Nicholas Embleton from The Newcastle-upon-Tyne hospital & Newcastle University shares his view and experiences on means of quality improvement and how a blame-free culture can contribute to efficient risk management.

Question 1: Quality assessment and risk management rely on thorough and transparent reporting practices. Could you elaborate what in general makes the Briefing in a minute (BIM) an efficient method in Quality Improvement (QI) and Risk Management (RM)?

The great thing about BIM is that it is very quick to do, and you can do it repeatedly. We do every day after our morning teaching session, but you could do at every shift change i.e. twice per day. By the end of the week, you might have heard the same message 5 times, but then we have some fun, and we make a quiz “who can remember what the 4 items on BIM were this week?”. It allows us to communicate messages about QI or RM quickly.

Question 2: Concerning parenteral nutrition, which properties of the BIM are particularly advantageous in terms of quality improvement and risk management?

The ability to get a simple message communicated quickly – for example, we had an issue with placement of the filter in relation to the lipid infusion line. We realised some staff were placing the filter at the wrong location, which was leading to alarms. We were able to share that update really quickly. Although we meet as a whole team, shift handover happens separately for medical and nursing teams: the roles and responsibilities also differ. This means we have separate BIM for nursing and medical teams. The items discussed on BIM can be the same or different which allows us to ‘target’ different parts of a complex communication system.

Question 3: Can you say something about the implementation process of the BIM into daily work routines? Did it require training, for instance, to develop a routine in using simple, concise messages for the reporting?

We just started using it a few years ago, to be honest, I am not sure who had the original idea, but quite probably another hospital or department. It doesn’t require any training to use. You just need to give one person the responsibility of coordinating what will be the 3-4 items for that week. You can agree on those items at a departmental meeting, or you send an email to the senior team asking for specific items for BIM in that week. We write the items out and keep them in a folder – if you want you can look back at the last several weeks of BIM items. It is important that you don’t try and cover too much, so 3-4 items are about right. For more complex issues you need a different mechanism. So BIM cannot be used for teaching – it is not really an interactive event. But you could use BIM to say ‘we are using new filters for lipid; make sure you attend the training session before you start to use them’.

Question 4: To establish and to maintain a well-functioning risk management and reporting system, a blame-free culture is crucial. Yet, in healthcare, errors can range from minor mistakes to errors with tremendous consequences. How do you maintain and encourage open communication within your teams?

Establishing trust in the whole team is essential. Even when you know you didn’t mean to make the mistake, and even when it is not serious you can still feel bad. So developing a supportive team is crucial. We need to learn to look after our colleagues and stick together. That is all about being practical and recognising the real world: we are all human. It is not about ‘sticking together’ to hide mistakes away. At the end of the day, the motivation for working on a NICU is to make things better for the babies, so everyone wants to be involved in QI and RM. It is appropriate sometimes to maintain anonymity – if you made a ‘silly’ mistake, you don’t want to be ‘named and shamed’ at a large meeting, so we try hard to always maintain anonymity. It’s also important to recognise that as senior members of the team, we are much more confident in many respects – both in terms of knowledge and experience, but also more confident knowing that our colleagues will support us. More junior members may feel more worried and less confident. I might not perceive a small intravenous extravasation as being important, but the junior nurse responsible may feel really upset. Developing a friendly, supportive team and looking after each other is essential to good QI and RM. We are proud to have a ‘learning culture’ in our NICU. We accept that sometimes things will not go to plan. We deal with that by being honest and supportive. Parents appreciate honesty and deserve to be listened to. Parents appreciate it when a senior healthcare professional says “I am sorry this happened to your baby”. Saying sorry does not mean we made a mistake, it means we empathise and acknowledge that what happened to the baby has caused upset or harm. TEAM is the most important aspects of QI and RM.

We thank Professor Embleton for this insightful interview.

Professor Nicholas Embleton is Consultant Neonatal Paediatrician at the Newcastle-upon-Tyne hospital and a member of the expert panel for the topic of neonatal parenteral nutrition.

Source: http://www.enfci.org/news/optimal-practice-in-neonatal-parenteral-nutrition-the-role-of-quality-improvement-and-risk-management-in-providing-high-quality-parenteral-nutrition/

Midwife on a motorbike in Indonesia | UNICEF

Source: http://uni.cf/SaveNewbornLives

 Cannula With Long and Narrow Tubing vs Short Binasal Prongs for Noninvasive Ventilation in Preterm Infants

Noninferiority Randomized Clinical Trial

Ori Hochwald, MD¹; Arieh Riskin, MD²; Liron Borenstein-Levin, MD¹; et alIrit Shoris, RN²; Gil P. Dinur, MD¹; Waseem Said, MD²; Huda Jubran, MD¹; Yoav Littner, MD¹; Julie Haddad, MD¹; Malka Mor, RN¹; Fanny Timstut, RN¹; David Bader, MD²; Amir Kugelman, MD¹ Author Affiliations: JAMA Pediatr. Published online November 9, 2020. doi:10.1001/jamapediatrics.2020.3579  

Original Investigation   November 9, 2020

Key Points

Question  Is a cannula with long and narrow tubing inferior to short binasal prongs and masks in preterm infants who require nasal intermittent positive pressure ventilation?

Findings  In this noninferiority randomized clinical trial that included 166 preterm infants at 24 weeks’ to 33 weeks and 6 days’ gestation requiring nasal intermittent positive pressure ventilation, intubation within 72 hours occurred in 14% in the group using a cannula with long and narrow tubing and in 18% in the short binasal prongs and masks group (95% CI within the noninferiority margin). Moderate to severe nasal trauma was significantly less common in the group using cannulas with long and narrow tubing.

Meaning  Cannulas with long and narrow tubing were noninferior to short binasal prongs and masks in providing nasal intermittent positive pressure ventilation for preterm infants, while causing significantly less nasal trauma.

Abstract

Importance  Use of cannulas with long and narrow tubing (CLNT) has gained increasing popularity for applying noninvasive respiratory support for newborn infants thanks to ease of use, perceived patient comfort, and reduced nasal trauma. However, there is concern that this interface delivers reduced and suboptimal support.

Objective  To determine whether CLNT is noninferior to short binasal prongs and masks (SPM) when providing nasal intermittent positive pressure ventilation (NIPPV) in preterm infants.

Design, Setting, and Participants  This randomized controlled, unblinded, prospective noninferiority trial was conducted between December 2017 and December 2019 at 2 tertiary neonatal intensive care units. Preterm infants born between 24 weeks’ and 33 weeks and 6 days’ gestation were eligible if presented with respiratory distress syndrome with the need for noninvasive ventilatory support either as initial treatment after birth or after first extubation. Analysis was performed by intention to treat.

Interventions  Randomization to NIPPV with either CLNT or SPM interface.

Main Outcomes and Measures  The primary outcome was the need for intubation within 72 hours after NIPPV treatment began. Noninferiority margin was defined as 15% or less absolute difference.

Results  Overall, 166 infants were included in this analysis, and infant characteristics and clinical condition (including fraction of inspired oxygen, Pco₂, and pH level) were comparable at recruitment in the CLNT group (n = 83) and SPM group (n = 83). The mean (SD) gestational age was 29.3 (2.2) weeks vs 29.2 (2.5) weeks, and the mean (SD) birth weight was 1237 (414) g vs 1254 (448) g in the CLNT and SPM groups, respectively. Intubation within 72 hours occurred in 12 of 83 infants (14%) in the CLNT group and in 15 of 83 infants (18%) in the SPM group (risk difference, −3.6%; 95% CI, −14.8 to 7.6 [within the noninferiority margin], χ² P = .53). Moderate to severe nasal trauma was significantly less common in the CLNT group compared with the SPM group (4 [5%] vs 14 [17%]; P = .01). There were no differences in other adverse events or in the course during hospitalization.

Conclusions and Relevance  In this study, CLNT was noninferior to SPM in providing NIPPV for preterm infants, while causing significantly less nasal trauma.

Source: https://jamanetwork.com/journals/jamapediatrics/article-abstract/2772823

A Randomized Trial of Laryngeal Mask Airway in Neonatal Resuscitation

List of authors: Nicolas J. Pejovic, M.D., Ph.D., Susanna Myrnerts Höök, M.D., M.Med., Josaphat Byamugisha, M.D., Ph.D., Tobias Alfvén, M.D., Ph.D., Clare Lubulwa, M.D., M.Med., Francesco Cavallin, M.Sc., Jolly Nankunda, M.D., Ph.D., Hege Ersdal, M.D., Ph.D., Mats Blennow, M.D., Ph.D., Daniele Trevisanuto, M.D., and Thorkild Tylleskär, M.D., Ph.D.

Abstract

Background

Face-mask ventilation is the most common resuscitation method for birth asphyxia. Ventilation with a cuffless laryngeal mask airway (LMA) has potential advantages over face-mask ventilation during neonatal resuscitation in low-income countries, but whether the use of an LMA reduces mortality and morbidity among neonates with asphyxia is unknown.

Methods

In this phase 3, open-label, superiority trial in Uganda, we randomly assigned neonates who required positive-pressure ventilation to be treated by a midwife with an LMA or with face-mask ventilation. All the neonates had an estimated gestational age of at least 34 weeks, an estimated birth weight of at least 2000 g, or both. The primary outcome was a composite of death within 7 days or admission to the neonatal intensive care unit (NICU) with moderate-to-severe hypoxic–ischemic encephalopathy at day 1 to 5 during hospitalization.

Results

Complete follow-up data were available for 99.2% of the neonates. A primary outcome event occurred in 154 of 563 neonates (27.4%) in the LMA group and 144 of 591 (24.4%) in the face-mask group (adjusted relative risk, 1.16; 95% confidence interval [CI], 0.90 to 1.51; P=0.26). Death within 7 days occurred in 21.7% of the neonates in the LMA group and 18.4% of those in the face-mask group (adjusted relative risk, 1.21; 95% CI, 0.90 to 1.63), and admission to the NICU with moderate-to-severe hypoxic–ischemic encephalopathy at day 1 to 5 during hospitalization occurred in 11.2% and 10.1%, respectively (adjusted relative risk, 1.27; 95% CI, 0.84 to 1.93). Findings were materially unchanged in a sensitivity analysis in which neonates with missing data were counted as having had a primary outcome event in the LMA group and as not having had such an event in the face-mask group. The frequency of predefined intervention-related adverse events was similar in the two groups.

Conclusions

In neonates with asphyxia, the LMA was safe in the hands of midwives but was not superior to face-mask ventilation with respect to early neonatal death and moderate-to-severe hypoxic–ischemic encephalopathy. (Funded by the Research Council of Norway and the Center for Intervention Science in Maternal and Child Health; NeoSupra ClinicalTrials.gov number, NCT03133572. opens in new tab.)

Discussion

This randomized trial of the effectiveness and safety of the LMA in neonatal resuscitation conducted by midwives in a low-income country showed the LMA to be safe in the hands of midwives but to confer no benefit over the face mask with respect to the composite of early neonatal death or moderate-to-severe hypoxic–ischemic encephalopathy. The cuffless LMA that was used in this trial is designed to provide an efficient seal to the larynx without the inflatable cuff used in conventional LMAs. Positioning is easy, and the risk of tissue compression or dislodgement is low. Thus, the device provides a useful alternative to the face mask and endotracheal intubation, especially in settings where skills in performing positive-pressure ventilation or intubation are insufficient. A study in Uganda that used mannequins showed that after a brief training, midwives could easily insert this LMA, and it was more effective than the face mask in establishing positive-pressure ventilation in a mannequin. A phase 2, randomized, controlled trial at the same site showed that midwives could perform resuscitation in neonates effectively and safely with the cuffless LMA.

Data from previous trials have suggested that LMA use results in shorter ventilation times than use of a face mask and may reduce the hypoxic–ischemic insult. Resuscitations in these studies were conducted by physicians or supervised midwives. In the present trial, midwives used the LMA unsupervised, and the insertion technique could have been suboptimal, which may have affected the effectiveness of the LMA. The observation of a higher likelihood of treatment failure in the face-mask group than in the LMA group and the suggestion that rescue with the LMA might result in better outcomes than rescue with the face mask in the current trial are consistent with the results from previous trials. The frequency of failure with the face mask appeared to be lower than in our pilot trial; this may reflect improved skills regarding face-mask ventilation among midwives because of additional and repeated training during the trial.

Although our trial did not show superiority of the LMA over the face mask and the trial was not designed to assess noninferiority, the findings appear consistent with current ILCOR recommendations.²⁴ Thus, our findings suggest that the LMA can be safely used as an alternative device during newborn resuscitation, including when performed by trained midwives.

Most studies show that 3 to 6% of neonates require positive-pressure ventilation at birth. In our trial, 8.6% needed positive-pressure ventilation, and a large proportion of neonates were severely compromised; 61.2% had meconium-stained or foul-smelling amniotic fluid, and very early neonatal death occurred in 15.1%. This percentage is considerably higher than those in previous reports and could reflect the hospital demographics, with large numbers of late referrals and mainly neonates with severe asphyxia; previous reports that showed benefits of the LMA largely involved neonates who had mild asphyxia.  Differences between our trial population and those in previous trials are a potential explanation for the discrepancy between our results and the results of previous trials.

This trial extends our knowledge about LMA use among severely compromised neonates in a low-income setting — where more neonatal deaths occur than in higher-income settings and advanced resuscitation is often not available — by having a larger number of participants, relevant outcomes, rigorous methods (including video documentation), and a strong adherence to trial-group assignments with minimal loss to follow-up or exclusions. The trial also has some limitations. It was a single-site trial in a high-volume hospital, where fetal heart-rate monitoring was not routinely available, and there was inconsistent capacity of staff to provide advanced resuscitation; thus, the findings may not be generalizable to better-resourced settings. For trial conduct, we had additional staff on site. Crossovers, which occurred for safety reasons, were more frequent in the face-mask group than in the LMA group (10.9% vs. 3.5%), and this might have improved the outcomes of the neonates initially treated with the face mask. The neurologic outcome (hypoxic–ischemic encephalopathy) was based on the Thompson score without advanced examinations (e.g., electroencephalography or neuroimaging). In addition, it was an open-label trial, but hard outcomes were used and outcome assessors were not aware of the trial-group assignments.

In our trial, the LMA was safe in the hands of midwives but did not result in a lower incidence of early neonatal death or moderate-to-severe hypoxic–ischemic encephalopathy than face-mask ventilation among neonates with asphyxia.

Source: https://www.nejm.org/doi/full/10.1056/NEJMoa2005333

PREEMIE FAMILY PARTNERS

Breastfeed Your Baby to Reduce the Risk of SIDS

How Families Can Help Support Breastfeeding Moms

Breastfeeding moms can always use encouragement – here’s how you can help!

A breastfeeding mom needs lots of things – to stay hydrated, to eat extra calories, to get more sleep (hopefully!), and to build a successful nursing relationship with her little one. And she needs support from her loved ones and family! A supportive and encouraging partner, spouse, or family member can make all the difference in encouraging and helping a breastfeeding mom meet her goals. Here are some ways to help the breastfeeding mom in your life.

Supporting Mom’s Needs

When mom comes home with a new baby and is beginning her breastfeeding journey, there are several things that can be done to make things easier for her.

1. Create a comfortable home environment where she can practice and get used to breastfeeding and all that it physically and emotionally requires.
2. Run interference with phone calls and visits – and limit them if necessary.
3. Take on additional household chores like cooking, cleaning, and laundry.
4. Bring any needed items during a nursing session, like water, a snack, her phone, or a book.
5. Give supportive words or encouragement when she’s facing breastfeeding difficulties – and start the process to get additional help or support from your healthcare provider or a Lactation Consultant, if needed.

Bonding with Baby

Sometimes helping mom means taking over care for the little one and giving her some time to herself. And, since breastfeeding provides a unique opportunity for closeness between mom and baby, you’ll want to form your own special bond with the little one. Here are ways to interact one-on-one with baby and encourage your own special connection.

1. Make time for skin-to-skin contact when cuddling
2. Take over bath duties
3. Change diapers after each feeding
4. Burp the baby after a nursing session
5. Rock the baby to sleep
6. Walk with baby in the stroller or in a carrier
7. If your loved one is pumping, take over the night feeding by warming and feeding a previously expressed bottle of breast milk

If you’re unsure, just ask the breastfeeding mom in your life what would most help, and then do it! Even small tasks done every day can help over time to show that you support breastfeeding and make her feel more confident in her decision to nurse. It may not always be easy, but it’s always worth it! 

Source: https://www.medela.us/breastfeeding/articles/how-families-can-help-support-breastfeeding-moms

Mothers of premature babies struggle to get donor breast milk

Jack Shonkoff Discusses Early Childhood Development

Kat’s Korner

In regard to the video above I believe ACES is something some of us who are preemie infant survivors may connect with personally.

While our experience receiving life-saving care was essential for our long-term outcomes and wellness the process came undoubtedly for many of us with some difficult measures. As neonates many of us underwent traumatic experiences undergoing critical interventional care, significant time away from our caregivers/parents or human contact, and submersion in a prolonged high-stress environment.

 I encourage us as preemie infant survivors to explore the ACES model above and consider the ways our earliest human experiences may have impacted our development and has influenced our personal interaction with the world around us. Reflecting on the ways we may connect ACES to our human experience as preemie survivors may inspire us to discover new and exciting ways to approach enhancing our health and well-being.

I am calling for continuous research in this area of trauma informed care which may significantly influence the fields of neonatology and the health and well-being of our Neonatal Womb Warrior/Preterm Birth Survivor Community.

Surfing in Nias Utara (North of Nias)

Preterm Birth Rates – Samoa

Rank: 181 –Rate: 5.5% Estimated # of preterm births per 100 live births (USA – 12 %)
Source: https://www.marchofdimes.org/mission/global-preterm.aspx

Samoa officially the Independent State of  and until 1997 known as Western Samoa, is an island country consisting of two main islands, Savai’i and Upolu, two smaller inhabited islands, Manono and Apolima, and several small uninhabited islands including the Aleipata Islands (Nu’utele, Nu’ulua, Fanuatapu, and Namua). The capital city is Apia. The Lapita people discovered and settled the Samoan Islands around 3,500 years ago. They developed a Samoan language and Samoan cultural identity.
 
Samoa is a unitary parliamentary democracy with eleven administrative divisions. The sovereign state is a member of the Commonwealth of Nations. Western Samoa was admitted to the United Nations on 15 December 1976. The entire island group, which includes American Samoa, was called “Navigator Islands” by European explorers before the 20th century because of the Samoans’ seafaring skills. The country was governed by New Zealand until its independence in 1962.
 
The National Health Service is the main government provider of health services for Samoa. They operate all of the hospitals and health centres and the main provider for medical imaging services, the sole provider of medical laboratory testing, and our pharmacy services cater to a significant portion of national pharmaceutical needs.
 Source: https://en.wikipedia.org/wiki/Samoa

COMMUNITY

Scaling up breastfeeding policy and programs in Samoa: application of the Becoming Breastfeeding Friendly initiative

International Breastfeeding Journal volume 15, Article number: 1 (2020) Christina Soti-Ulberg, Amber Hromi-Fiedler, Nicola L. Hawley, Take Naseri, Analosa Manuele-Magele, John Ah-Ching, Rafael Pérez-Escamilla & on behalf of BBF Samoa Committee

Abstract

Background

Breastfeeding is a critical, evidence-based intervention that addresses malnutrition, improves early childhood development outcomes, and influences long-term maternal and infant health by reducing the non-communicable disease risk. Scaling up breastfeeding is an indisputably strong action countries can take to prevent suboptimal maternal and infant health outcomes. The Becoming Breastfeeding Friendly (BBF) initiative assists countries with scaling up breastfeeding policy and programs. BBF has been successfully implemented within Latin America, Africa, Europe and South-East Asian regions. This study assessed its application in Samoa.

Methods

In 2018, BBF was implemented in Samoa by a 20 member committee of breastfeeding experts who participated in collecting and utilizing national level data to score the degree of friendliness of Samoa’s breastfeeding environment, identify gaps, and propose policy recommendations to address those gaps. This eight-month process resulted in a public event where priority recommendations were widely disseminated to decision makers and actions agreed upon.

Results

The total BBF Index score for Samoa was 1.6 out of 3.0, indicating a moderate breastfeeding friendly environment for scaling up policies and programs that protect, promote, and support breastfeeding. Gear total scores indicated that seven of the eight gears were moderately strong within Samoa, while the eighth gear, funding and resources, was weakest in strength. Six prioritized recommendations emerged: 1) development and implementation of a National Breastfeeding Policy and Strategic Action Plan; 2) strengthening monitoring and evaluation of all breastfeeding activities; 3) ratifying the International Labour Organization’s Maternity Protection Convention 2000 (No 183); 4) identifying high-level advocates to champion and serve as role models for breastfeeding; 5) creation of a national budget line for breastfeeding activities; and 6) hiring of a national breastfeeding coordinator and trainer. Decision makers demonstrated commitment by signing the breastfeeding policy for hospitals ahead of the BBF dissemination meeting and electing to move forward with establishing lactation rooms within government ministries.

Conclusion

Implementation of BBF in Samoa yielded important policy recommendations that will address current gaps in national level breastfeeding support. The BBF consultation process can be successfully applied to other countries within the Western Pacific region in order to strengthen their breastfeeding programs.

Source: https://link.springer.com/article/10.1186/s13006-019-0245-6

To ALL of you sharing resources with our Global Community, and there are LOTS of you,

THANK YOU (Faʻafetai)  

Hinari Access to Research for Health programme

Hinari Access to Research for Health Programme provides free or very low cost online access to the major journals in biomedical and related social sciences to local, not-for-profit institutions in developing countries. Hinari was launched in January 2002, with some 1500 journals from 6 major publishers: Blackwell, Elsevier Science, the Harcourt Worldwide STM Group, Wolters Kluwer International Health & Science, Springer Verlag and John Wiley, following the principles in a Statement of Intent signed in July 2001. Since that time, the numbers of participating publishers and of journals and other full-text resources has grown continuously. Up to 165 publishers’ content are If your institution is in a Group A (free access) country, area, or territory, then Hinari is free. If your institution is in a Group B (low-cost access) country, area, or territory, Hinari costs US$ 1500 per institution per calendar year (from January through December). All eligible institutions registering from Group B countries, areas, or territories will receive a six month trial without payment.

If your institution is in a Group B (low-cost access) country, area, or territory, and cannot or chooses not to pay the annual fee, the institution will still be eligible for free access to a small number of information resources.

Samoa is on the A lists for free access to this services.

***Refugee Camps recognized by UNRWA or categorized by UNHCR as “planned/managed camps” are eligible for free Hinari access regardless of their geographical location.

Source: https://www.who.int/hinari/about/en/

Risk of Preterm Birth and Newborn Low Birthweight in Military Women with Increased Pregnancy-Specific Anxiety

Karen L Weis, USAF, NC, PhD, Katherine C Walker, MSN, RN, Wenyaw Chan, PhD, Tony T Yuan, PhD, Regina P Lederman, PhD, RN, FAAN – Military Medicine, Volume 185, Issue 5-6, May-June 2020, Pages e678– e685, https://doi.org/10.1093/milmed/usz399    Published: 06 December 2019

Abstract

Introduction

Prenatal maternal anxiety and depression have been implicated as possible risk factors for preterm birth (PTB) and other poor birth outcomes. Within the military, maternal conditions account for 15.3% of all hospital bed days, and it is the most common diagnostic code for active duty females after mental disorders. The majority of women (97.6%) serving on active duty are women of childbearing potential. Understanding the impact that prenatal maternal anxiety and depression can have on PTB and low birthweight (LBW) in a military population is critical to providing insight into biological pathways that alter fetal development and growth. The purpose of the study was to determine the impact of pregnancy-specific anxiety and depression on PTB and LBW within a military population.

Material and Methods

Pregnancy-specific anxiety and depression were measured for 246 pregnant women in each trimester. Individual slopes for seven different measures of pregnancy anxiety and one depression scale were calculated using linear mixed models. Logistic regression, adjusted and unadjusted models, were applied to determine the impact on PTB and LBW.

Results

For each 1/10 unit increase in the anxiety slope as it related to well-being, the risk of LBW increased by 83% after controlling for parity, PTB, and active duty status. Similarly, a 1/10 unit rise in the anxiety slope related to accepting pregnancy, labor fears, and helplessness increased the risk of PTB by 37%, 60%, and 54%, respectively.

Conclusions

Pregnancy-specific anxiety was found to significantly increase the risk of PTB and LBW in a military population. Understanding this relationship is essential in developing effective assessments and interventions. Results emphasize the importance of prenatal maternal mental health to fetal health and birth outcomes. Further research is needed to determine the specific physiological pathways that link prenatal anxiety and depression with poor birth outcomes.

Source: https://academic.oup.com/milmed/article/185/5-6/e678/5663471

PREEMIE FAMILY PARTNERS

In the NICU, both parents are essential and need to be at their child’s bedside

By Jennifer Canvasser, Kurlen Payton, and Elizabeth Rogers – July 13, 2020

Micah Canvasser, born at 27 weeks gestation, spent 299 days in a NICU. His parents were constantly at his bedside learning how to best contribute to their son’s care.

As Covid-19 surged through the United States this spring, Reina and James were told they could no longer stay with their severely ill newborn in the hospital’s neonatal intensive care unit and could visit for only a few hours — separately.

“My husband was allowed to visit for just one hour a week and had to prebook his time,” Reina (the parents’ names have been changed to protect their privacy) shared with one of us. “I was allowed to visit for two hours each day. Our baby sadly gained his wings seven days after he was born.”

The coronavirus pandemic has forced billions of people and institutions to make difficult decisions to prevent harm and save lives. Many of these decisions affected how patients experience health care. One particularly traumatizing change has been directed at parents of newborns receiving care in neonatal intensive care units (NICU).

That might be good for infection control, but it goes against everything we know about caring for sick newborns. Both parents (or a parent plus a support person) need access to their infant’s bedside often and at the same time. The risks of Covid-19 must be weighed against the known risks and harms of separating babies in the NICU from their parents.

In the NICU, parents are not visitors: They are essential members of the care team. Parents know their babies better than anyone else and are often the first to recognize when something is wrong. It is intuitive to understand that babies need their parents, yet this is also borne out in research. For vulnerable newborns, their mother’s milk is a lifesaving intervention. Infant skin-to-skin care with parents promotes growth and healthy development.

Shared decision-making is critical in the NICU, where parents and providers must work together to optimize decisions that can have lifelong health implications for the infant. Because things can change so rapidly in a sick newborn, parents need to be at their child’s bedside so they can be informed and participate in these vital health decisions. Limiting parents’ access harms the therapeutic alliance that needs to exist between NICU providers and parents.

Bonding during this developmentally fragile period is crucial. Limiting parents’ access disrupts the nurturing interactions that are necessary for an infant’s cognitive development and that are also essential to parents’ mental health. “Even though our daughter is now home, our NICU’s one-parent policy has left us with deep psychological scars,” a father shared with us.

The wide variation in Covid-19 visitor policies between hospitals fuels mistrust. NICU parents and providers have reported a range of policies: Some hospitals allow unrestricted access for two parents at the bedside, others allow just one parent to visit for only two hours a day, and there’s just about every possibility in between. Permitting just one parent at a time to be with their child is an unlikely Covid-19-reduction strategy, as most parents are in close contact outside of the hospital.

That might be good for infection control, but it goes against everything we know about caring for sick newborns. Both parents (or a parent plus a support person) need access to their infant’s bedside often and at the same time. The risks of Covid-19 must be weighed against the known risks and harms of separating babies in the NICU from their parents.

In the NICU, parents are not visitors: They are essential members of the care team. Parents know their babies better than anyone else and are often the first to recognize when something is wrong. It is intuitive to understand that babies need their parents, yet this is also borne out in research. For vulnerable newborns, their mother’s milk is a lifesaving intervention. Infant skin-to-skin care with parents promotes growth and healthy development.

Shared decision-making is critical in the NICU, where parents and providers must work together to optimize decisions that can have lifelong health implications for the infant. Because things can change so rapidly in a sick newborn, parents need to be at their child’s bedside so they can be informed and participate in these vital health decisions. Limiting parents’ access harms the therapeutic alliance that needs to exist between NICU providers and parents.

Bonding during this developmentally fragile period is crucial. Limiting parents’ access disrupts the nurturing interactions that are necessary for an infant’s cognitive development and that are also essential to parents’ mental health. “Even though our daughter is now home, our NICU’s one-parent policy has left us with deep psychological scars,” a father shared with us.

The wide variation in Covid-19 visitor policies between hospitals fuels mistrust. NICU parents and providers have reported a range of policies: Some hospitals allow unrestricted access for two parents at the bedside, others allow just one parent to visit for only two hours a day, and there’s just about every possibility in between. Permitting just one parent at a time to be with their child is an unlikely Covid-19-reduction strategy, as most parents are in close contact outside of the hospital.

We need to close this gap and ensure that all NICU families receive high-quality care by giving parents access to their medically fragile infants. Seemingly strict but malleable visitor policies are also inequitable in that families who advocate for themselves are often told that both parents can be at the bedside, while families with less ability to advocate for themselves are required to comply.

Parents’ basic rights to see and care for their own child are infringed upon when they are inaccurately categorized as visitors. Infants’ basic right to physically access both of their parents must also be considered. Health care providers and parents should work together at local and state levels to assure safe practices that honor the unique situation and needs of sick newborns.

Parents can be screened with the same protective procedures applied to all essential care team members who come in and out of the hospital every day. While certain parental restrictions may be justified in specific high-risk situations, extensive parental limitations should always be minimized. Efforts must be made to mitigate public health risks while maximizing parental rights.

Babies in the NICU need both of their parents at their bedsides, and their parents’ psychological well-being depends on being there. The way families experience care in the NICU remains with them for their lifetimes. When asymptomatic, two-parent access to their infant’s bedside should be the standard of care. Anything less is indefensible.

Jennifer Canvasser is the mother of a child who died from necrotizing enterocolitis after spending several months in the NICU and is the founder and director of the Necrotizing Enterocolitis (NEC) Society, a member of the Chan Zuckerberg Initiative’s Rare As One Network. Kurlen Payton is a neonatologist, interim director of the neonatal intensive care unit at Cedars-Sinai Medical Center in Los Angeles, and co-director of quality improvement collaboratives for the California Perinatal Quality Improvement Collaborative. Elizabeth Rogers is a neonatologist and director of the ROOTS Small Baby Program at UCSF Benioff Children’s Hospital in San Francisco. The authors thank Jochen Profit, a neonatologist and associate professor of pediatrics at Stanford University School of Medicine, for his help writing this article.

Source: https://www.statnews.com/2020/07/13/nicu-both-parents-essential-childs-bedside/

A Teen-Led, Volunteer-based NICU Reading Program: A Model for Supporting Family Reading and Family Integrated Care

Introduction: 

NICU babies are at high risk of neurodevelopmental impairment for multiple reasons, including prematurity, critical illness, and family emotional and economic stressors associated with hospitalization in the NICU. (1) Care in single-patient-room NICUs can compound the issues of sensory deprivation and contribute to speech and language deficits in NICU graduates. (2) Reading aloud with babies creates and strengthens neural connections that “promote … social-emotional development…and language and literacy skills during this critical period of early brain and child development.” (3) Providing parents and other caregivers books and encouraging them to read to their infants in the NICU is a low-cost intervention to increase infants’ speech and language interactions. Parent reading with their baby in the NICU supports family integrated care and bonding (4) and improves the NICU experience.

Babies With Books, a teen-led volunteer organization, began its first NICU Reading Program at Randall Children’s Hospital (RCH) in 2017.  The NICU Reading Program is a collaboration between teen volunteers and NICU providers, consisting of four discrete components – Admit Reading Packets, One-on-one Book Rounds, a Family Shared Reading Library, and literacy events and celebrations.  Admit Reading Packets contain a book, bookmark, and information on how and why to read aloud with babies beginning in the NICU. Teens source and assemble these admit packets, which are given by healthcare providers to each infant at NICU admission. One-on-one Book Rounds encourage and reinforce NICU reading. During book rounds, teen volunteers meet weekly with NICU families to  talk with them about how to read with their infant and why reading aloud to their babies beginning in the NICU is important. Some of this information was developed in collaboration with Reach Out And Read® (ROR).  Families are offered their choice of 3 books from a mobile book cart to read with their infant, keep in the NICU, and bring home at NICU discharge. The Family Shared Reading Library is a library located outside of the NICU (ex. in the NICU lobby or lounge) stocked with donated, gently used books. Literacy Events & Celebrations include NICU reada-thons, book nooks at NICU reunions, and other literacy promoting events that engage families in shared reading. In BWB’s first NICU read-a-thon at RCH, 45% of families participated, and all surveyed staff and families expressed high satisfaction. BWB has also hosted a “book nook” program at the RCH NICU reunion, during which we provided more than 200 donated books to NICU graduates and their siblings and read stories with them. Through this NICU Reading Program, BWB has served more than 850 NICU babies at RCH.

Books used in the Reading Program include a variety of high contrast board books, children’s stories, and “I love you” type books. Only new books are used with babies. Donated, gently used books may be used in the Family Shared Library and in “book nooks” at NICU reunions for NICU families and graduates. Books are available in multiple languages, and picture books are available for families whose primary language is not represented and for non-reading families. We recommend books by a wide range of authors that engage and represent the diversity of the NICU patient population.  Funding is through generous foundation grants as well as individual and corporate donations. We receive donated books from a local book bank and a used bookstore.

Like all hospital-based programs, BWB has been impacted by the COVID-19 pandemic.  The BWB teens have continued to source and assemble admit reading packets but do so offsite and deliver these to the hospital where they are stored for at least 72 hours prior to being given to NICU families. To assemble and deliver admit packets, volunteers must be symptom-free, wear masks, and adhere to strict hand hygiene. One-on-one volunteer-led book rounds have been paused during COVID-19 but can be performed by personnel with continued access to the NICU. Shared Family Reading Libraries are not recommended during COVID-19. Reada-thons remain a great way to support infants and families and build NICU morale during COVID-19.

Conclusion:  By engaging motivated, passionate, and creative teen volunteers in our BWB Reading Program, we provide valuable service to NICU babies and families with limited burden and cost to healthcare providers and hospitals.

Source:https://neonatologytoday.net/newsletters/nt-aug20.pdf

Preemie Siblings may feel abandoned, displaced, dis-empowered during and after the preterm birth experience within a family. Preterm birth changes everything for preemie families for a short or for a very long time. Preemie parents are often overwhelmed and immersed in a sea of chaos, destination unknown.  Family Partners,  please consider implementing the simple concepts shared in the article below in order to provide all family members with the support needed to move forward with purpose and intent upon a foundation of family trust. Simple inclusion of preemie siblings may dynamically and positively alter the course of their precious lives and ultimately reduce the stress the family unit experiences during this challenging time.

NICU: Helping Siblings Cope

When a baby is in the Neonatal Intensive Care Unit (NICU), the entire family can be affected. Here are some tips for helping siblings cope.

Northwestern Memorial Hospital – Patient Education – HEALTH AND WELLNESS

What Siblings Need

Routine

Help siblings maintain their regular routines as much as possible. Providing structure and normal daily activities will help siblings feel safe and supported when separated from parents and family.

Honesty

Be honest and use simple words they can understand when explaining why their brother/sister is in the hospital. This will help them feel less afraid.

Communication

Talk to siblings and help them understand what is happening. Allow siblings the chance to express their feelings and ask questions.

Behaviors to Watch For

It is not uncommon to notice a change in behavior in siblings when their brother/sister is in the hospital. Here are some typical reactions to watch for:

■ Guilt – Feeling that they did something to cause their sibling’s to be in the hospital.

■ Fear–Worrying that they or another loved one will get sick and have to go to the hospital.

■ Anger –Being angry about change in routine, separation from parents, less attention.

■ Loneliness – Feeling lonely when parents visit their brother/sister without them and wondering why they’re not getting as much attention as usual.

■ Confusion– Feeling confused about what will happen to their brother/sister, why they are there and when their life will return to “normal.” These feelings may be expressed in your child’s behavior.

Watch for:

■ Aggressive play or behavior

■ Increased need for attention/clinginess

■ Returning to younger behavior (bed wetting, temper tantrums, thumb sucking)

■ Changes in routine (sleeping and eating patterns)

How You Can Help

Siblings need lots of love and support when their brother or sister is in the NICU. Try to include your children as much as possible to answer questions and decrease fears.

Here are some resources and activities to use with siblings while supporting them.

Activities to Promote Positive Coping

■ Before visiting the hospital, make sure siblings know what to expect and remind them that it’s okay to ask questions.

■ Have the sibling choose a special item to bring to their sibling in the hospital (such as a favorite teddy bear, blanket or book).

■ Draw pictures or make decorations for the baby’s room (at home or in the NICU).

■ Write a letter to take to the baby.

■ Have the child draw a picture that they would like to share with their sibling.

■ Display a chart with different emotions or feelings on it in your home (you and your child can choose where to hang it). Ask the child each day how they are feeling and talk to them about why they are feeling that way. Always let them know that it is okay to talk and express all types of feelings.

Books You Can Read Together

■ “No Bigger Than A Teddy Bear” by Valerie Pankow

     A book for 3 to 7 year olds about what it is like to have a sibling in the NICU.

■ “My Brother is a Preemie” or “My Sister is a Preemie” by Joseph Vitterito

A book for 3 to 7 year olds that discusses what it is like to have a premature sibling in the NICU.

■ “What About Me? When Brothers and Sisters Get Sick” by Allan Peterkin

     A book for 5 to 10 year olds with hospitalized siblings.

■ “When Someone Has a Very Serious Illness” by Marge Eaton Heegaard

      A workbook for 7 to 13 year olds who have a sibling that is hospitalized or

     chronically ill.

■ “The Kissing Hand” by Audrey Penn

     A book about separation– this book is helpful if siblings are having a difficult time

     coping with separation from parents while they visit their child in the NICU.

■ “In My Heart” by Jo Witek

A book about emotions.file:///C:/Users/sacre/Downloads/northwestern-medicine-nicu-helping-siblings-cope-nmh%20(2).pdf

INNOVATIONS

Vanderbilt develops computational method to explore evolution’s influence on preterm birth

by Marissa Shapiro Jul. 24, 2020

Human pregnancy can easily be taken for granted as a natural and regularly occurring event, but it is the product of the complex, coordinated function of two bodies, mother and baby, that has evolved side by side with other important human adaptations. For the first time, researchers have established how a complex disorder associated with pregnancy – spontaneous preterm birth (sPTB) – has been shaped by multiple evolutionary forces.

The article, “Accounting for diverse evolutionary forces reveals mosaic patterns of selection on human preterm birth loci” was published in the journal Nature Communications on July 24.

Preterm or premature birth, medically defined as labor starting at 37 weeks of gestation or earlier (instead of the usual 40 weeks), affects more than 15 million pregnancies each year and is the leading cause of infant mortality worldwide. Both the associated medical conditions of the mother which cause sPTB and the outcomes of sPTB on an infant’s health have been well-defined. It is not well understood, however, how and why genetic factors influence sPTB and birth timing. A team of scientists led by Antonis Rokas, Cornelius Vanderbilt Chair in Biological Sciences and director of the Vanderbilt Evolutionary Studies Initiative and Tony Capra, associate professor of biological sciences, set out to demystify this element of pregnancy and human life.

The research, co-led by postdoctoral scholar Abigail LaBella and by M.D./Ph.D. candidate Abin Abraham, developed a computational approach to detect how evolution has shaped genomic regions associated with complex genetic traits, such as height or obesity. “Our approach integrates techniques developed in labs from all over the world to quantify how natural selection has influenced genomic regions involved with complex diseases,” said Capra. “We hypothesized that parts of our genome involved in disease might experience contrasting evolutionary pressures due to their involvement in multiple and different traits.”

This work was done in cooperation with Louis J. Muglia, co-director of the Perinatal Institute at Cincinnati Children’s and president and CEO of the Burroughs Wellcome Fund and Ge Zhang, associate professor at Cincinnati Children Hospital Medical Center and collaborator at the March of Dimes Prematurity Research Center-Ohio Collaborative. Zhang and Muglia recently completed the largest genome-wide association study (GWAS) on sPTB which identified multiple genomic regions associated with this complex disease. “Preterm birth is a global health concern, affecting ten percent of pregnancies in the United States. Understanding the evolution of genomic regions associated with spontaneous preterm birth is a major step forward in how we understand the foundations of human life and provide the best possible care to mother and child,” said Muglia.

Using this GWAS, the researchers found that genomic regions associated with sPTB have experienced multiple types of natural selection. From this information researchers can hypothesize why these risk-related genomic regions remain in human populations and what their potential functions may be. “While we knew of a few examples of selection like negative selection acting on genes associated with spontaneous preterm birth, we uncovered that every type of selection we tested had acted on at least one genomic region. Our initial figures looked like a mosaic made up of all the different metrics we had tested,” says Rokas.

The team’s results suggest that genomic regions associated with sPTB have experienced diverse evolutionary pressures, such as population-specific selection, and provide insights into the biological functions some of these regions. “It is difficult to study pregnancy in humans and we lack good models for laboratory studies,” LaBella explains. “We still have much to learn about the mechanisms through which human pregnancy is initiated.” For example, the group uncovered differences in a region near the gene OPRL1, involved in both the relaxation of maternal tissues and pain perception during childbirth, that are specific to certain human populations. Population-specific differences in this region may contribute to the uneven risk of sPTB between human populations. “This work is a part of a burgeoning field of evolutionary medicine, one of the types of interdisciplinary research that many of the investigators of the Vanderbilt Evolutionary Studies Initiative are engaged in,” says Rokas.

Both Abraham and LaBella plan to continue to foster collaboration between medicine and evolution in their future research. “Having this pipeline at our disposal opens up a range of new, exciting questions such as asking whether diseases of pregnancy, which involve two genomes, that of mom and baby, experience different evolutionary pressures than other complex genetic diseases,” says Abraham.

This work will be critical for researchers studying the genetics of pregnancy-associated disorder and is of broad interest to scientists researching human evolution, human population genomics and how evolutionary analyses relate to complex diseases like cancer and heart disease.

The research was supported by the March of Dimes Prematurity Research Center-Ohio Collaborative, the Burroughs Wellcome Fund and National Institutes of Health grants R35GM127087 and T32GM007347.

Source: https://news.vanderbilt.edu/2020/07/24/vanderbilt-develops-computational-method-to-explore-evolutions-influence-on-preterm-birth/

Caring For Babies And Their Families: Providing Psychosocial Support In The NICU”: An Innovative Online Educational Tool To Empower Neonatal Nurses To Support NICU Families

Hall, Sue L. MD; Sorrells, Keira BS; Eklund, Wakako Minamoto DNP, APRN, NNP-BC Editor(s): Eklund, Wakako DNP, NNP-BC, Section Editors; Smith, Heather E. PhD, RN, NNP-BC, CNS, Section Editors Advances in Neonatal Care: August 2020 – Volume 20 – Issue 4 – p 263-264

Parents whose newborns are hospitalized in the neonatal intensive care unit (NICU) nearly always experience stress. These parents have a higher prevalence of both postpartum depression (PPD) and posttraumatic stress disorder (PTSD) than new parents of infants born healthy, related in part to their perceptions of their experiences surrounding the birth of their infant or their NICU experiences that are traumatic. Prevalence of PPD among NICU mothers is 25% to 63% and for NICU fathers, approximately 36%, while rates of PTSD among NICU parents have been reported as 15% to 53% for mothers and 8% to 33% for fathers.

A comprehensive evidence-based program is now available to empower neonatal nurses to support NICU families. The program is designed to psychosocially minimize the occurrence of both PPD and PTSD, and to optimize infant and family outcomes. This online continuing education (CE) program is entitled “Caring for Babies and Their Families: Providing Psychosocial Support in the NICU,” and it represents an exemplar for interprofessional collaboration in which family and other stakeholders improve education for neonatal health professionals, and ultimately the care in neonatal settings.

My NICU Network was launched in January, 2018, with a mission of becoming the preeminent provider of compelling perinatal education on psychosocial support created with interprofessional collaboration. My NICU Network was recently expanded to become My NICU Network-My Perinatal Network (MNN-MPN), and is a collaborative endeavor between the National Perinatal Association and the NICU Parent Network. The goal is to provide online evidence-based education and “hands-on” bedside tools to empower healthcare staff working with mothers and infants. The focus of the education is to strengthen the critical parent–infant bonds and family functioning, and to improve developmental outcomes in the infant and mental health outcomes in their parents.

The 3 key guiding principles of course development are: (1) supporting NICU parents is equally as important to providing medical care to their baby; (2) healthcare staff must also be emotionally supported, so that they will have the emotional capacity to support the patients and parents in their care; and (3) interprofessional collaboration models are the foundation to fully realize family-centered care. These principles have been central to program development from inception to conclusion of this project. Stakeholders who are recipients of care (NICU parent leaders) collaborated every step of the way in designing and implementing these educational programs. The courses are rich with parent stories, audio clips, and videos that illustrate learning points. Parents helped to create the courses, conducted the surveys from which parent stories have been gleaned; contributed resources including web links and downloads to be available for the learners who take the course; have been instrumental in the development of the course’s trauma-informed care scripts. There are examples of what providers should not say to parents, how the parent interprets what the provider has said, and what is a better way to communicate the idea based on principles of trauma-informed care. Other parents have reviewed and provided feedback, which was used to refine the course content. All of this parental input has been the key to success of the program, as parents’ testimonials bring the evidence from the literature to life. As one nurse stated after taking the program: “It was very eye opening to see things through the eyes of the parents.” Few educational programs exist that include NICU parent leaders at every level from content development to content delivery, making this a truly unique and comprehensive educational experience.

All of the educational programs of MNN-MPN are based on principles of trauma-informed care, and NICU programs are based on the “Interdisciplinary Recommendations for Psychosocial Support of NICU Parents.” All are also available for CE credits. A study has demonstrated the efficacy of the initial learning program to improve nurses’ knowledge and attitudes toward providing psychosocial care. The program consists of 7 courses including: communication skills, providing emotional support, peer-to-peer support, family-centered developmental care, palliative and bereavement care, discharge planning and follow-up, and caring for the caregiver (staff support).

To date, over 700 NICU staff have completed the program, including the majority of nursing staff in 14 NICUs across the country. The goal for an entire NICU staff completing the program together is to transform the culture in the NICU to become more family-centered, and to mitigate long-term parental emotional complications such as PPD and PTSD. A condensed version of this program, called the Advanced NICU Provider Program, offers 2 CE credits for neonatologists and neonatal nurse practitioners. In mid-2020, 2 additional programs will be launched:

1. “Caring for Pregnant Patients and Their Families: Providing Psychosocial Support During Pregnancy, Labor and Delivery” (for maternity care staff), and
2. “Giving Birth During the Coronavirus Pandemic: Using Trauma-informed Care to Support Patients, Their Families, and Staff Through This Crisis” (for both NICU and maternity care staff).

NICU parents need, desire, and benefit from the emotional support from the nurses. Nursing interventions may mitigate the evolution of parents’ typically expected distress upon entering the NICU, preventing it from developing into full-blown depression or PTSD. Neonatal nurses who are at the bedside daily form more intimate relationships with infants and their families than other health professionals and are in a position to make a positive impact when well-equipped with strategies to address their complex psychosocial needs. NICU families value nurses; one study reported how the quality of relationship parents have with the nurses supported parental ability to cope and bond with their infants in the NICU.

One of the most critical goals for neonatal nurses is to improve the parent–infant bond in NICU to optimize families’ mental health/resilience, so that they can emerge as the empowered, confident, and knowledgeable advocates for their fragile infants who can achieve optimal development. Utilizing an innovative educational model, created through involvement of family stakeholders, can give nurses the tools they need to achieve this very important goal for the families in their care. For more information, please visit www.mynicunetwork.com or www.myperinatalnetwork.org.

Source:https://journals.lww.com/advancesinneonatalcare/Fulltext/2020/08000/Noteworthy_Professional_News.2.aspx

Decolonizing Parents Cuts NICU Staph Transmission Risk

Nicola M. Parry, DVM – January 13, 2020

Treating colonized parents of neonates hospitalized in the neonatal intensive care unit (NICU) may reduce the risk of parents spreading Staphylococcus aureus to the infants, a recent study published online December 30 in JAMA has shown.

“Treating parents of neonates in the NICU with intranasal mupirocin and 2% chlorhexidine-impregnated cloths compared with placebo reduced the risk of a neonate acquiring S aureus colonization with strains that were the same as S aureus strains identified from the parent(s) at time of study enrollment,” write Aaron M. Milstone, MD, MHS, from Johns Hopkins University, Baltimore, Maryland, and colleagues.

“In this trial, more than half of neonates who acquired S aureus had the same strain as their parent(s).”

According to the authors, neonates have an immature microbiome at the time of their admission to the NICU and rarely are already colonized by S aureus. Instead, they become colonized in the NICU after exposure to the organism from colonized or infected people and contaminated objects in the environment.

Staphylococcus aureus remains a common cause of outbreaks and healthcare-associated infections in NICUs and can seriously impact affected infants, with long-term sequelae such as poor neurodevelopmental and growth outcomes.

Although infection prevention strategies in NICUs typically center on healthcare workers and the physical environment as reservoirs for exposure of infants to S aureus, parents may also serve as an important reservoir for transmission of the bacterium.

With this in mind, Milstone and colleagues conducted their double-blinded, randomized controlled trial across two tertiary care NICUs to investigate whether treating parents would reduce the risk of their infants becoming colonized with S aureus.

The Treating Parents to Reduce Neonatal Transmission of Staphylococcus aureus (TREAT PARENTS) trial enrolled 236 infants. It included infants who had not had a previous culture positive for S aureus, had at least a 5-day NICU stay, were no more than 7 days old if admitted to the NICU from an outside location, and had at least one parent who tested positive for S aureus at screening.

The study’s primary endpoint was infants’ acquisition within 90 days of the same S aureus strain that their parent had. Secondary outcomes included infants’ acquisition of any strain of S aureus and neonatal S aureus infections.

Parents in the study received 5 days of treatment. They were randomly assigned to intranasal mupirocin and topical bathing with 2% chlorhexidine-impregnated cloths (n = 117) or placebo treatment with petrolatum intranasal ointment and nonmedicated soap cloths (n = 119).

Of the 236 enrolled infants, 208 (55% male; 76% singleton births; mean birthweight 1985 grams; 76% vaginal births) were included in the analytic sample, although 18 of these were lost to follow-up.

A total of 190 infants were included in the final analysis: 89 in the intervention group and 101 in the placebo group. Of these, 74 (38.9%) acquired S aureus colonization by 90 days, 42 (56.8%) of whom had a strain concordant with a parental baseline strain.

According to the researchers, fewer (n = 13; 14.6%) infants in the intervention group than in the placebo group (n = 29; 28.7%) acquired concordant S aureus colonization (risk difference, –14.1%; hazard ratio [HR], 0.43).

Similarly, fewer infants in the intervention group acquired any S aureus strain
(n = 28; 31.4% vs n = 46; 45.5%; HR, 0.57).

One infant (1.1%) in the intervention group and 1 (1.0%) in the placebo group developed a S aureus infection before colonization. Skin reactions in parents occurred commonly in both groups (4.8% vs 6.2%).

“This trial suggests that parents are a major reservoir from which neonates acquire S aureus in the NICU,” the authors write.

“Treating colonized parents may reduce risk of S aureus transmission to neonates, but these findings are preliminary and require further research for replication and to assess generalizability.”

This study “offers a novel and promising strategy to address a highly relevant, often intractable, clinical problem”, and “provides an explanation why interventions that primarily target patients and health care workers can fail to eradicate MSSA [methicillin-susceptible S aureus] in the NICU,” pediatric infectious disease specialists Philip Zachariah, MD, MSc, and Lisa Saiman, MD, MPH, write in an accompanying editorial.

However, they highlight some features of the study that indicate a need for further investigation before this strategy could be widely adopted by other NICUs. For example, both study NICUs already used active surveillance and decolonization protocols for both MSSA and MRSA, which limits generalizability of this treatment strategy.

In addition, the study was not powered to detect differences in infections or mortality, the editorialists say. Scalability is another concern, they add, noting that the study took 4 years to complete and that 92.7% of infants who were screened for eligibility failed to meet its inclusion criteria.

“Cost-effectiveness will also need to be determined,” Zachariah and Saiman add. Zachariah is from Columbia University Irving Medical Center, New York City, and Saiman is from NewYork-Presbyterian Hospital in New York City.

Nevertheless, the editorialists conclude that regardless of whether future research will support integration of this strategy into routine care, “Milstone and colleagues have made an important advance into this difficult area with the promise of having a meaningful benefit on neonatal care.”

This study was supported by the Agency for Healthcare Research and Quality. Three authors report receiving grants from the Centers for Disease Control and Prevention, the National Institutes of Health, Sage Products Inc, Singulex Inc, Curetis Inc, Accelerate Inc, and GenMark. The same three authors report personal fees from Becton Dickinson, Novartis, Theravance, Basilea, Pattern Diagnostics, and GenMark. The remaining authors and the editorialists have disclosed no relevant financial relationships.

JAMA. Published online December 30, 2019. Abstract, Editorial

Source: https://www.medscape.com/viewarticle/923668#vp_2

HEALTH CARE PARTNERS

How Premature Birth Shapes Future Heart Health

Meredith S. Campbell, MD, Editorial Fellow, Pediatrics, Neonatal-Perinatal Medicine Fellow, Vanderbilt University Medical Center, Nashville, TN          July 07, 2020

Advancements in neonatal care have led to a growing cohort of preterm-born individuals that have now reached adulthood. While population-based birth cohorts have provided us with a better understanding of long-term complications of premature birth such as risk for neurodevelopmental impairment, much less is known about potential cardiac consequences.

In a newly released review article in Pediatrics (10.1542/peds.2020-0146), Dr. Fernando Telles and colleagues present the first meta-analysis to compare cardiac structure and function between former preterm and term infants from the time of birth to young adulthood. A total of 32 observational studies were included in the review to quantify the impact of preterm birth on the heart across developmental stages. The results were intriguing—former preterm individuals have persistently lower left ventricular diastolic function, right ventricular systolic impairment, and an accelerated rate of left ventricular hypertrophy. The authors proposed that these cardiac alterations may make the heart more vulnerable to secondary insults, which may explain why preterm birth is a risk factor for early heart failure and long-term risk of ischemic heart disease.

As we dig deeper into what’s different about the hearts of those born preterm, further longitudinal studies are needed to determine how cardiac remodeling in preterm infants progresses over time. This is particularly important in the adolescent age range, for which there is a paucity of data. While this article adds to our understanding of how premature birth shapes future heart health, a number of questions and research gaps regarding the long-term cardiac outcomes after preterm birth remain including the need for earlier detection of former preterm individuals at higher risk for cardiac issues, screening guidelines, preventative strategies, and a plan for better clinical monitoring. Additional research will hopefully allow us to get to the heart of the matter.

Source: https://www.aappublications.org/news/2020/07/07/premature-birth-heart-health-pediatrics

Trauma-informed Care in the NICU

Caring Essentials Collaborative, LLC – Mar 9, 2018

Mary Coughlin MS, NNP, RNC-E presents a quick overview of the biological relevance of this paradigm for hospitalized newborns, infants and families.

Premature babies experience high exposure to noise in the incubator

by Medical University of Vienna– JULY 20, 2020

What do premature babies hear while lying in an incubator? That is the question addressed by an interdisciplinary team from the Medical University of Vienna, led by Vito Giordano (neuroscientist at the Division of Neonatology, Pediatric Intensive Care and Neuropediatrics at the Comprehensive Center for Pediatrics (CCP) of Medical University of Vienna), by musicologist/acoustician Christoph Reuter and by music physiologist Matthias Bertsch from the University of Music and the Performing Arts in the recent study, “The Sound of Silence,” published in the journal Frontiers in Psychology

This study shows that premature babies are exposed to a high level of noise in the incubator, particularly if they are on respiratory support in the neonatal intensive care unit (NICU).

According to data from the World Health Organization (WHO), approximately 15 million babies a year are born prematurely, the proportion varying between 5% and 18% depending on the country of origin. Despite general improvements in intensive care medicine, many premature babies face life-long impairments. The intrauterine hearing experience differs strongly from the extrauterine auditory load encountered in a neonatal intensive care unit (NICU).

“It is primarily low frequency noises (note: below 500 Hz) that are transmitted and filtered through the mother’s body. Several studies have indicated that the noise level inside the NICU repeatedly far exceeds the recommended threshold of 35 dB. Signals from monitoring equipment, loud talking, sudden opening of doors or medical procedures result in a high level of background noise and reach peak values well above 100 dB,” explains Giordano.

However, high noise levels can lead to hearing impairment or even hearing loss—the incidence being between 2% and 10% in very premature babies, as opposed to only 0.1% -0.2% in infants born at term. “Premature babies in an incubator lack the natural filtering and absorption of background noise that occurs in the mother’s womb. New acoustic stimuli and/or noises have a marked impact upon postnatal maturation of the auditory system, as pointed out by the Medical University Vienna expert. However, silence, which leads to deprivation, a feeling of isolation, is just as harmful as loud stimuli. The problem is not essentially new: nowadays, educational concepts and visual indicators to reduce noise are already standard in neonatal wards.

The aim of the recently published study was firstly to record the dynamics of sounds inside an incubator and secondly to enable others to understand the hearing experience of premature babies. “Everyone, especially clinicians, nurses, music therapists and parents are now able to imagine what it sounds like inside the incubator by listening to examples of the sounds themselves. Inside it sounds quite different from outside, since the incubator acts as a bass booster, i.e. lower frequencies below 250 Hz are significantly louder,” explains music physiologist Matthias Bertsch.

The results of the study show that the incubator has a “protective effect,” especially against medium- and high-frequency sounds, but amplifies lower frequency sounds. Moreover, the incubator lid has practically no protective effect against noise, there is an increase in high-frequency sounds when access doors are left open, and there is a high noise level generated by a respiratory support device. “What listeners find particularly surprising is how loud these respirators can become inside the incubator, even if the air-flow is only slightly increased. At a high flow-rate with the associated roaring sound, the increase is such that it equates to the noise of a vacuum cleaner at a distance of one meter (75 dB),” the study authors explain. Neonatologists are therefore advised to set the air flow of respiratory support devices to the necessary minimum.

“We feel it is important to raise awareness of the problem, not only with acoustic noise level tables but with understandable audible results,” the authors highlight. The consequences of early exposure to noise can be wide-ranging, e.g. impaired ability to discriminate speech compared to children born at term, which was demonstrated in a parallel study of the same study group. This was conducted in July 2019 under the supervision of neurolinguist Lisa Bartha-Doering at the Comprehensive Center for Pediatrics (CCP) and published in the journal Developmental Cognitive Neuroscience.

“These study findings show that it is important to invest in new technologies,” Angelika Berger, Head of the Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, explains, “and our research teams are currently working on such new technologies in order to improve the acoustic comfort and long-term outcome of our smallest patients.”

Source: https://medicalxpress.com/news/2020-07-premature-babies-high-exposure-noise.html

Six Tips for Managing Stress and Improving Self-Care in a COVID-19 Environment

Duke School Of Nursing    Apr 9, 2020 Duke University School of Nursing Assistant Professor Sean Convoy discusses suggestions for managing stress and improving self-care in a COVID-19 environment.

WARRIORS:

Warriors have the capacity to capitalize on the challenges Covid-19 presents by focusing on what we choose to experience within the  containments required to support our mutual health and well-being at this time. I challenge us to recognize the value of the here and now and not only recreate our relationships with ourselves during this moment in time but affirm our intention to prosper and grow ourselves. Don’t wait! Within the quiet isolation and uprooted rhythms of our pre-Covid-19 lives there is an open door to our hearts, and our souls.  In this moment, let’s leave the longing for what was and  follow our intuition towards lives of happiness and fulfillment beyond our imaginations. Take time to let go, to heal, to replenish and re-invent (re-discover) the wholeness of each of us! We have offered many self-empowerment resources over the past (almost 5) years. Here  are a couple of additional self-empowerment resources for our older Warriors to consider.  I like the kinesthetic experience the Toltec Path to Recapitulation offers, and am looking forward to exploring the ideas and wisdom offered through the books mentioned below.

Recapitulation: Release your past and reclaim trapped energy

Mar 16, 2016
All Things Perceptual Recapitulation: how to, from beginning to end, obtain a perfect recapitulation of your life, freeing you from the bonds of your life experiences, replenishing you with boundless energy and making you light and flexible in your spirit. The Legend of the perfect recapitulation and the Toltec theory of near immortality as a warrior of the third attention!

8 Self-Empowerment Books to Help You Take Back 2020

Take a break from the everyday unrest of this year to be inspired by the stories of others who have faced adversity and overcame it.

Peter Daisyme – August 28, 2020

It doesn’t matter who you ask — 2020 has been an exhausting year. Between a global pandemic, political unrest and an unprecedented economic downturn, it’s easy to feel downtrodden.

While there’s no easy way to get out of this funk, it never hurts to listen to the perspectives of others. By reading books focused on self-empowerment and overcoming adversity, you can feel prepared to take on whatever the world has to throw at you in 2020 and beyond. Here are some of the top choices out there right now.

1. Learn, Improve, Master: How to Develop Any Skill and Excel at It by Nick Velasquez

With lots of people having more free time than ever on their hands, many are taking this opportunity to pick up new skills. But doing so is often easier said than done. Learn, Improve, Master doesn’t teach the basics of any one skill; it gives you the tools you need to learn things more quickly and fully in the future. Nick Velasquez’s new book is a valuable investment for anyone looking to continually grow and evolve over time.

2. Grit: The Power of Passion and Perseverance by Angela Duckworth

The title here says it all. In Angela Duckworth’s Grit, the secret to success can be found entirely in one’s own dedication and work ethic. Duckworth looks at standouts everywhere from West Point to the National Spelling Bee and has found one thing in common: sheer determination. If you’re looking to learn how to take your career to the next level through hard work, this book is the one for you.

3. Responsibility Rebellion: An Unconventional Approach to Personal Empowerment by Kain Ramsay

It can seem like we achieve some of the greatest joys in life by avoiding responsibility — goofing off, taking vacations and ignoring the real problems at the heart of it all. Responsibility Rebellion turns this logic on its head by arguing that getting ahead in life isn’t about ignoring the underlying issues. It’s about facing them head on. Kain Ramsay’s unconventional approach to success may surprise some, but the results are hard to ignore. 

4. Across That Bridge: A Vision for Change and the Future of America by John Lewis

The death of John Lewis sent the country into a national state of mourning, but his influence doesn’t have to end there. Across That Bridge is a powerful collection of his thoughts, memories and reflections on what it was like to fight during the Civil Rights Movement and how people can use that spirit to continue to fight for justice today. The book is no easy read, but the wisdom contained therein is well worth it.

5. The Empowerment Paradox: Seven Vital Virtues to Turn Struggle Into Strength by Ben Woodward

Why is it that many of people’s biggest, most life-changing revelations often come after moments of deep pain and tragedy? There’s no easy answer to this question, but The Empowerment Paradox is a powerful look into what we might learn from it. Ben Woodward offers a unique perspective on how we might take some of the difficulties we face and turn them into personal progress.

6. Ignite Your Career!: Strategies and Tactics to Unleash Your Potential by Kris Holmes

This year’s college graduates are currently facing more uncertainty in the job market than any generation before them, and there’s no clear end in sight. Kris Holmes’s new book may have been written before the pandemic struck, but the advice is more relevant than ever. Ignite Your Career! is a must-have for any first-time job seekers.

7. Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones by James Clear

Less than two years old, Atomic Habits is already something of a modern classic. James Clear uses his book to give a clear, simple guide for remaking your life, starting with the small stuff. If you want a big change to come into your life, beginning with daily habits might just be the method that works best.

8. Boot Straps & Bra Straps: The Formula to Go from Rock Bottom Back into Action in Any Situation by Sheila Mac 

The pandemic has been hard on businesspeople of all shapes and sizes, but there’s no doubt that women have faced a particularly poignant challenge. Boot Straps & Bra Straps is a how-to guide for any woman hoping to bring her career to the next level without sacrificing any of herself in the process. Sheila Mac has already been through it all herself, meaning that her book has a lifetime’s worth of wisdom for you to glean from.

They may not have all the answers, but books are a good place to start when it comes to empowering yourself. By picking a couple of the options off of this list, you can introduce yourself to a whole world of ideas that you can use to learn and grow.

KAT’S CORNER

AND for our younger Neonatal Womb Warriors: Ruby Finds a Worry by Tom Percival Ruby’s Worry (Read Aloud) | Storytime

Feb 10, 2020        Toadstools and Fairy Dust

Please join us for a dramatic read of Ruby Finds a Worry, Ruby’s Worry by Tom Percival read by Miss Jill. Great story about feelings and overcoming anxiety and worry and what to do.

The Samoan Surfers

Apr 27, 2013  Iva Motusaga

The Motusaga Wave Riders

ICELAND

Preterm Birth Rates – Iceland

Rank: 167–Rate: 6.5% Estimated # of preterm births per 100 live births (USA – 12 %)

Iceland is a Nordic island country in the North Atlantic, with a population of 364,134 and an area of 103,000 km (40,000 sq mi), making it the most sparsely populated country in Europe. The capital and largest city is Reykjavík. Reykjavik and the surrounding areas in the southwest of the country are home to over two-thirds of the population. Iceland is volcanically and geologically active. The interior consists of a plateau characterised by sand and lava fields, mountains, and glaciers, and many glacial rivers flow to the sea through the lowlands. Iceland is warmed by the Gulf Stream and has a temperate climate, despite a high latitude just outside the Arctic Circle. Its high latitude and marine influence keep summers chilly, with most of the archipelago having a polar climate.

Health: Iceland has a universal health care system that is administered by its Ministry of Welfare paid for mostly by taxes (85%) and to a lesser extent by service fees (15%). Unlike most countries, there are no private hospitals, and private insurance is practically nonexistent. A considerable portion of the government budget is assigned to health care,  and Iceland ranks 11th in health care expenditures as a percentage of GDP and 14th in spending per capita. Overall, the country’s health care system is one of the best performing in the world, ranked 15th by the World Health Organization. According to an OECD report, Iceland devotes far more resources to healthcare than most industrialised nations. As of 2009, Iceland had 3.7 doctors per 1,000 people (compared with an average of 3.1 in OECD countries) and 15.3 nurses per 1,000 people (compared with an OECD average of 8.4). Icelanders are among the world’s healthiest people, with 81% reporting they are in good health, according to an OECD survey.

COMMUNITY

Our focus in this month’s blog will highlight some of the unique challenges our preterm birth community faces during the current Covid-19 pandemic.

Big  THANKS  to our essential workers and community members who are respecting and following local Covid-19 protocols/orders. Together we are saving lives.  Here in Seattle, WA. King 5 News staff working from their homes remind us that although times are tough, together we can get through this. Through their Neighbors Helping Neighbors virtual stories King 5 staff show us that it is heroic to not only care about others but to act accordingly. You are likely sharing similar do-good stories within your local communities.  People everywhere are connecting with respect and kindness while offering diverse and creative ways to pitch in for our mutual good. We see through responsible media-sharing that as a community we are resilient and adaptable as we quickly learn to educate ourselves and our children using  our in-home technology and resources. We have immersed ourselves in creating home offices, learning new software programs, and changing the ways we work in order provide meaningful services and goods.  We are learning to cook and bake at home, and we have had time to garden, read, make home improvements and opportunity to ponder things that have special personal meaning in our lives! We will look back at this time with sorrow, gratitude, joy and relief.  We may be thinking about how we can use this time to manifest our dreams moving forward. We will be stronger, more educated, with renewed clarity about the power of human kindness and our global and local reliance on each other.

From our third floor window, while a very inspired woodpecker hammers our wood/concrete siding in order to mark his territory, we greet you with our love, gratitude, and very best wishes!

Mothers and Fathers kept from seeing their premature babies due to Covid-19 – ITV News

ITV News

The Covid-19 pandemic has led to time between babies and parents being rationed. In some cases, this means new mothers and fathers are having to wait days – and in some cases weeks – to see their newborns on the neonatal ward. Health officials say the strict measures are in place to protect babies born prematurely from the risk of infection. ITV News spoke to some of the parents who were forced to stay away from their ill newborns.

An Iceland Preemie Innovation

The company name Róró originates from the Icelandic word “ró” which means calmness and comfort. Róró is dedicated to helping babies and their caregivers feel better. It was founded in 2011 around a single idea: to make a product for babies that imitated closeness when their parents needed to be away. Indeed, the idea of the Lulla doll was born when our friend had her baby girl prematurely and had to leave her alone in the hospital every night for two weeks.

Lulla doll is a soother and sleep companion for preemies, babies, toddlers and beyond. It imitates closeness to a caregiver at rest with its soft feel and soothing sounds of real-life breathing and heartbeat. Lulla plays for 12 hours to provide comfort all night long. The doll is machine washable and comes with 2 AA batteries.

Watch How the Lulla Doll Works

COVID-19 and the NICU Balancing Safety and Care

I dedicate this column to the late Dr. Andrew (Andy) Shennan, the founder of the perinatal program at Women’s College Hospital (now at Sunnybrook Health Sciences Centre). To my teacher, my mentor and the man I owe my career as it is to, thank you. You have earned your place where there are no hospitals and no NICUs, where all the babies do is laugh and giggle and sleep.

“There is no evidence of vertical transmission of novel coronavirus between mother and baby at this time. Infants born to COVID-19 infected mothers have not tested positive for the disease, nor has novel coronavirus been found in amniotic fluid or breast milk.”  Rob Graham, R.R.T./N.R.C.P.

One cannot watch television or pick up a newspaper without being bombarded with COVID-19 stories and information. In our lifetimes, we haven’t seen anything like this; while the adult world is the focus of this pandemic, we in the NICU must contend with the risks associated with parental involvement in the care of their babies.

There is no evidence of vertical transmission of novel coronavirus between mother and baby at this time. Infants born to COVID-19 infected mothers have not tested positive for the disease, nor has novel coronavirus been found in amniotic fluid or breast milk. While this is ostensibly good news, it must be tempered with the fact that this is a hitherto unknown pathogen and that while our knowledge base is growing daily, there is still much we don’t know. It is my opinion that one cannot be too cautious dealing with COVID-19; better to modify the policy as evidence becomes available than to wait for evidence to form policy. Unfortunately, the latter approach has been most common and has likely led to the explosion in cases outside the Wuhan epicentre.

Many hospitals have prohibited visitors during this crisis. This approach is certainly prudent given the increasing evidence of asymptomatic transmission but may not be in the best interests of the neonatal population. Regardless, in Toronto, there are discrepancies between institutions. (A copy of Toronto’s guideline is attached. NOTE: this is an example and not intended as medical advice or protocol). A previous column (December 2019) discussed the relationship between respiratory care and neurodevelopmental outcome, including the benefits of direct parental involvement and kangaroo care. The clear benefits of parental contact must be weighed against the risks to the baby and those who care for it. The unit in which I am employed has limited visitation to one parent at a time. Overnight stays are permitted, parents are forbidden to leave the NICU area until leaving the hospital, and face masks must be worn at all times.

The major concern when breastfeeding an infant of a COVID-19 infected mother or symptomatic parent under investigation is twofold: prevention of transmission to the infant and protection of those charged with the infant’s care. It is not breastmilk that is of concern, rather the potential infection of others via droplet. The safest approach here is to have parents wear masks to reduce the chance of droplet exposure during breastfeeding; however, the utility of regular surgical masks in preventing transmission of COVID-19 is questionable. The same applies to kangaroo care since exposure is identical. During skin to skin contact, consideration may be given to having the involved parent thoroughly clean the area of contact in addition to routine hygiene. Ideally those entering the room of a COVID-19 infected patient should wear a properly fitted N-95 mask,  but the international breakdown of our supply chain has resulted in an acute shortage of PPE; thus surgical masks are being used as a substitute. There is much debate over the utility of these masks to protect caregivers but increasing evidence in their ability to reduce transmission.

The best way to contain an outbreak like this is to test and isolate. China and South Korea have amply demonstrated the efficacy of this approach. However, a combination of reagent supply shortage and a concurrent shortage of swabs (ironically mostly manufactured in Italy) have made this impossible as the pandemic spread to the rest of the world, and the fact that the number of infections outside the epicentre now greatly outnumber those within is a testament to the necessity of testing. Given the possibility of asymptomatic transmission, it would behoove us to assume infection in all until proven otherwise and act accordingly. This is a case of what we don’t know can indeed hurt us.

The risks associated with aerosol-generating medical procedures are well known, particularly in the adult population. It stands to reason that a premature infant generates less aerosol than an adult; however current guidelines call for the infant of a confirmed or suspected parent to be treated in the same manner as an adult patient. Compounding this is the unusually high viral titre with COVID-19 infection, potentially making droplets more likely to lead to infection.

In the adult population, when mechanical ventilation is required, lower tidal volumes (3-6mls/kg) and higher PEEP has been recommended, although recent anecdotal reports from the front lines are less clear. (These anecdotal reports are coming from Twitter® posts from ER physicians on the front line and as such do not constitute evidence). A letter to the editor of The American Journal of Respiratory and Critical Care Medicine, March 2020, suggests a different approach. One that is echoed by other anecdotal reports and describes an atypical ARDS picture associated with COVID-19. In this case, it is not a lack of recruitment that is the problem but rather uneven ventilation/perfusion matching. (10) HFO is potentially more prone to aerosol generation, and if used, airborne precautions are advised. (11) (This is an excellent reference for the management of all COVID-19 patients.) A filter on the expiratory limb of any ventilated patient may be considered provided it does not interfere with the normal operation of the machine and are changed in accordance with the manufacturer’s recommendations.

It is perhaps fortunate we have little data regarding neonatal infection with COVID-19. It seems that mechanical ventilation for symptomatic positive infants may only be required for other reasons (i.e., extreme prematurity as the limited number of cases seen thus far have not required intubation) and that neonates exhibit the same relatively mild symptoms of older children.(12) Recent reports of 2 infants succumbing to COVID-19 in the U.S. may be a harbinger of things to come.(13) It is my sincere hope this is not the case. Perhaps the most significant risk NICU staff face for infection are each other. Given the increasing rate of community-acquired infection and asymptomatic transmission, we are at the same or greater risk than the general population. Fomites are a known source of transmission (particularly plastic and stainless steel). (14) We are all potentially exposed this way, particularly when using public transit as grab bars, and handles are all made of plastic and stainless steel. The importance of meticulous, regular hand hygiene, and avoidance of touching the face cannot be emphasised enough.

The concept of social distancing is difficult to achieve in the NICU environment due to the necessity of close contact during procedures and the proximity of workstations. Staff are well-advised to wear face masks at all times as a matter of policy to mitigate the risk of infection. Patient assignments should be such that staff can be stationed as far away from each other as is practically possible. COVID-19 doesn’t discriminate based on credentials!

This pandemic will affect all of us one way or another. As NICU caregivers, we may be at reduced risk relative to our adult colleagues; however, as the crisis worsens, some of us may be seconded to adult areas. Now would be a good time for those assigned exclusively to the NICU to brush up on adult ventilation protocols. The Toronto Centre for Excellence in Mechanical Ventilation provides an excellent resource.

As evidence is gathered, the guidelines and recommendations we practice under are subject to change. Given limited numbers (although still increasing exponentially), the fact that there is presently no evidence to suggest vertical transmission or risks associated with breastmilk, for example, doesn’t necessarily mean risks do not exist. Healthy, younger patients are dying from COVID-19. While the mean age of infection is 45 years, the mortality rate for those <60 is approximately 0.32% compared to 6.4% in those >60 and 13.4% in those >80. (16) 0.32% seems pretty small, but this represents a 3-fold increase over that of seasonal flu in the general population.(17) We’re all playing Russian roulette; the only difference is the number of bullets in the gun. I, for one, prefer not to play.

Finally, while high-frequency jet ventilation (HFJV) is commonly used in the NICU setting, there is currently no commercially available adult jet ventilator in North America. There are a few machines available in Toronto cobbled together in labs at the University of Toronto years ago. These have been used as a last-ditch effort when other modes have failed. The Oscillate study of conventional (CV) vs. high-frequency oscillation (HFO) ventilation in adult respiratory distress syndrome (ARDS) found HFO detrimental, but similar research on HFJV has not been performed.(18) The benefits of HFJV in the neonatal population may well apply to the adult population; the high mortality rate from ARDS surely should provide an incentive to its study in this population. Now seems to be a good time.

I have been asked to explore the possibility of using the LifePulse HFJV machine in larger patients. I shall keep readers apprised of any progress in that regard. We are facing the challenge of our careers and, indeed, our lives. The world is counting on us. Please, everyone, take care of yourselves and each other. While always important, it is now more so than ever. References: 1. https://www.frontiersin.org/articles/10.3389/ fped.2020.00104/full 2

Source: https://www.cdc.gov/coronavirus/2019-ncov/

A digital response to help ensure safer childbirths during COVID-19

A new initiative launched today by Maternity Foundation, University of Copenhagen and Laerdal Global Health in collaboration with International Confederation of Midwives (ICM) and UNFPA, the UN sexual and reproductive health agency, uses a digital tool to equip midwives in low-resource settings to protect themselves, mothers and newborns from the Coronavirus and to ensure that women continue to receive respectful quality of care during pregnancy and childbirth. During the current COVID-19 pandemic, women everywhere will continue to get pregnant and give birth. In low-resource countries and in humanitarian settings affected by conflict, pregnant women, new mothers, newborns and the health personnel providing them care face great risks in the new reality brought by the virus. Health systems are facing enormous pressure with lack of staff, resources and training to take necessary preventative measures against the virus. Midwives and other skilled health personnel providing care during childbirth need immediate support and tools to be able to still provide quality maternal care in the light of the pandemic. A new digital tool launched today aims to do just that.

In response to the global COVID-19 pandemic, Maternity Foundation, University of Copenhagen, and Laerdal Global Health in collaboration with International Confederation of Midwives (ICM) and UNFPA have partnered up to develop and disseminate an immediate and digital response for healthcare personnel – particularly midwives – to protect themselves, women and newborns from COVID-19.

The coalition is launching tools for capacity building and training for midwives through the Safe Delivery App, a mobile application developed by Maternity Foundation and University of Copenhagen, which provides visual, clinical and practical guidance on how to handle the most common childbirth complications. Through the Safe Delivery App, midwives can now get key information, animated video instructions, and check lists as well as guided training to support them to limit the spread of COVID-19 in the health facilities, including information on infection prevention, breastfeeding and vertical transmission.

The Safe Delivery App is a free application that is already being used by midwives and other skilled health personnel providing care during childbirth in over 40 countries worldwide. Thereby, the partners are leveraging an existing platform that is already reaching thousands of frontline health workers. All current users of the App will receive a pop-up message creating awareness about the new module and the importance of taking pre-cautions during COVID-19. It works offline once downloaded, making it easy to use in remote settings without a stable internet connection. The new COVID-19 content in the App is available in English as of today and will be available in French in a near future. The content of the Safe Delivery App is updated according to WHO standards and guidelines.

Laerdal Global Health has 10 years of experience of simulation-based training for midwives and other health care providers in low resource settings through the Helping Mothers Survive and Helping Babies Survive training programmes, implemented in over 80 countries. The current collaboration on merging scenarios for simulation into the Safe Delivery App will expand use of the App and support training in an efficient way, supporting the midwives where they are working.

In Moshi in northern Tanzania, senior nurse midwife at Mawenzi Regional Hospital Anne Shuma and her colleagues have just been introduced to the new COVID-19 module in the Safe Delivery App. The hospital is one of the hospitals in the country selected for receiving COVID-19 patients, and preparations are in full motion to prepare isolation centers, so they are ready when the first cases arrive. In the first week of April alone, they had 50 deliveries in the hospital.

“Going through the Safe Delivery App and the COVID-19 module made us realise that we were not prepared to receive pregnant women with suspected COVID-19. Immediately, we prepared a delivery kit and brought it to the isolation center and prepared a cube where suspected cases can give birth. We have now developed checklists based on the content in the App, so we are ready for when suspected cases come. It’s a very helpful tool for us midwives in an outbreak like this. It takes a concrete case and gives guidelines that are aligned with our national guidelines; procedures for handwashing and how to handle personal protective equipment. The App has opened our minds, we’re prepared now”, says Anne Shuma, who will spend the next weeks training fellow midwives and nurses in nearby clinics and hospitals to use the Safe Delivery App in their preparations for the COVID-19 response.

Dr. Natalia Kanem, Executive Director UNFPA: “The enormity of the COVID-19 crisis and its consequences is testing us all. As essential frontline health care workers, midwives must be protected and prioritized so that they can continue providing quality care to women and their newborns during the pandemic. UNFPA is pleased to collaborate with the Maternity Foundation, Laerdal, ICM and the Government of Denmark in developing innovative online resources to support midwives and other maternity care providers working in the field. These new digital tools will enable them to access the latest evidence-based approaches to care delivery in the context of COVID-19.”

Dr. Sally Pairman, CEO of the International Confederation of Midwives: “Midwives everywhere are frontline health care professionals in the face of the coronavirus, providing essential care to pregnant women and their babies during the childbirth continuum, despite the risk this presents to their own health. Many midwives have never had to work in pandemic situations before, and for everyone the coronavirus is new. In speaking with our Midwives’ Association members, we’ve been saddened by news of midwives dying from Covid19, simply because they were not adequately protected from the virus or did not have proper information on how to protect themselves. It’s essential that midwives and all other health professionals providing maternity care can access up-to-date and evidence-based advice on the changes they need to incorporate into their practice to keep women and their babies, and themselves, as safe as possible. The new modules in the Safe Delivery App will help guide midwives everywhere with advice they can count on.”

Chairman of Laerdal Global Health Tore Laerdal: “Our mission has always been helping save lives and now it has come even closer. During these extraordinary days, we work even harder towards our mission. There are hundreds of thousands of health workers who heroically continue to work through challenging situations and are in need of all the support we can offer. We hope our manikins and simulation solutions will be the helping hand that will support them in providing safe and respectful care.”CEO of Maternity Foundation, Anna Frellsen: “The direct and indirect consequences caused by the covid-19 pandemic can be fatal for mothers and newborns in many parts of the world. The Ebola outbreak in West Africa in 2013-16 showed a dramatic increase in maternal deaths because the health system was under too much pressure to fight the pandemic to also provide quality care. In a situation like this we need to respond fast and we need to do it together. By building on an existing digital platform and our global partners’ strong channels, we are now availing essential clinical guidelines instantly to midwives, even in some of the most vulnerable settings.”

How to download the Safe Delivery App

• Search for Safe Delivery App in Google Play or App store
• Click Download – the App is free of charge
• Open the App and select language version – the COVID-19 content is in the global English version
• If you already have the Safe Delivery App on your phone, update it and the COVID-19 module will appear in the global English version

The full Infection Prevention video can be found here.

Source: https://www.healthynewbornnetwork.org/news-item/a-digital-response-to-help-ensure-safer-childbirths-during-covid-19/

PREEMIE FAMILY PARTNERS

Vulnerable babies are being separated from their families because of corona virus

Published on Apr 19, 2020

Babies born sick and premature are being separated from their families because of hospital restrictions put in place during the corona-virus outbreak. Some hospitals are only allowing one parent to visit at a time and it’s even more difficult for siblings to meet their new relative.

Doctors are pessimistic about premature babies. Despite the evidence, we all are.

We tend to view them as “miracle babies,” or as the result of medical hubris.

By Sarah DiGregorio – Sarah DiGregorio is the author of “Early: An Intimate History of Premature Birth and What it Teaches Us About Being Human.” Feb. 21, 2020

In 2014, I was 28 weeks pregnant and sitting in a hospital bed, my husband beside me. My placenta was failing; to survive, our daughter would need to be delivered soon. She was smaller than average for this stage, an estimated 1.75 pounds.

The neonatal intensive-care unit (NICU) dispatched a neonatology fellow to help us understand what this meant. He started with our baby’s brain. When she was born, it might bleed, putting her at risk of death or cerebral palsy. Her lungs: They would certainly be immature, and she would probably have some degree of respiratory distress syndrome. Her heart might have a hole in it that would fail to close. Her intestines might develop an infection, possibly fatal, in which lengths of the bowel die. In the long term, premature babies are much more likely to experience developmental delays — the doctor guessed that our daughter had about a 50 percent chance of having a disability of some kind. She might lose some IQ points as a result of being premature, he added. The message was clear: Being born early was very, very bad, and our baby was likely to be fundamentally damaged, even in ways we would never definitively know.

It’s important that parents have the facts, and our doctor wanted us to know something true: Being born prematurely can affect a child’s health in many ways, and some of those complications can be fatal. The information he recited was medically accurate, though he probably inflated the likelihood of disability. (One benchmark is that, among babies born at 25 weeks, 13 percent develop a profound neurodevelopmental disability, and 29 percent develop a moderate one, according to data from the National Institute of Child Health and Human Development.)

The doctor’s laundry list also missed something important, something we really needed to hear at the time: The majority of babies born early, even very early, survive in good health. Their weeks, months and years ahead will not be easy. But there is also plenty of evidence for optimism.

Health-care providers have a well-documented and surprisingly durable pessimism about preemies. A 1994 survey in the American Journal of Obstetrics and Gynecology showed that doctors significantly underestimated their survival rates and overestimated their long-term disability rates. More than a decade later, a Pediatrics study of physicians, nurses and nurse practitioners echoed those findings, and showed that learning the true rates made doctors more likely to recommend resuscitation in theoretical borderline cases. Doctors are much sunnier about other patients: Research shows that internists and intensive-care unit physicians accurately assess the survival chances of adult patients admitted to the ICU.

This professional pessimism is matched by a broader cultural ambivalence. Our feelings about preterm infants are powerfully fraught. They suggest the thinness of the line between life and death; they symbolize the heights of human capability and the perils of going too far. We have two common narratives about premature infants: inspirational “miracle baby” stories and warnings of medical hubris. Record-setting “micro-preemies” who “defy the odds” and “fight for their lives” are regularly featured in tabloids and local TV broadcasts. Meanwhile, a 2017 Maclean’s article wondered, in the case of a very early birth, “to what extent should we intervene to prevent nature from taking that life before it becomes fully viable and conscious?” A Bloomberg Businessweek article, “Million-Dollar Babies,” asked, “Is there such a thing as too young?” Perhaps the general hand-wringing over such efforts made AOL’s chief executive blame the expensive medical care of “distressed babies” when he cut employee retirement benefits in 2014.

Our fascination with premature infants has always contained starry-eyed optimism about what could be done for them, along with uncertainty about whether the results were “worth” those efforts. That conflict goes back to the invention of the incubator in the 1880s, as Jeffrey Baker writes in “The Machine in the Nursery.” The medical establishment was slow to adopt the technology: The machine was expensive, and the value of the lives saved was seen as dubious. At the time, “Better Baby” contests were wildly popular, grading children on pseudoscientific traits like head measurements and awarding prizes to the “fittest” (i.e. large, able-bodied babies of white European heritage). Eugenicists argued that premature babies weren’t meant to survive; they would become a drain on society. The Buffalo Medical Journal wondered “whether the race as a whole does not suffer from the preservation of these weaklings to perpetuate their kind.” As a result, incubators remained a curiosity, touring world’s fairs and popping up in Coney Island as a boardwalk sideshow. People paid to gawk at preemies in their warm, glass-fronted boxes — they were objects of voyeuristic amazement, inspiring both hope and horror.

Even as cultural attitudes have progressed, some anxiety remains, often rooted in fears of disability. The 1985 book “Playing God in the Nursery” warned of “the dismal fate of a disturbing number of ‘salvaged’ babies’ ” who go on to lead “pathetic lives.” Two neonatologists called on fellow physicians to reexamine these beliefs in the Journal of Perinatology in 2013: “For the case of the preterm newborn, in particular, there may also be a sense that she is still ‘not meant to be here,’ ” they wrote. “If she survives with significant disability, the physicians might perceive that: But for our actions, there would be no disabled child.” The worry about gratuitous intervention, present in many medical decisions, seems especially acute when it comes to these patients.

All preterm babies are at increased risk for neurodevelopmental and learning disabilities when compared with term babies; the earlier the birth, the higher and more severe the risk. But these blanket assessments elide the fact that “disability” includes a whole range of experiences. Rigorous quality-of-life studies have found that as extremely premature babies grow into young adults, they rate their own health-related quality of life just as highly as a control group born at term. That includes former preemies who have a significant disability, such as cerebral palsy, vision problems or hydrocephalus — outcomes that providers seem to view more negatively than parents do. Neonatal providers often think that serious disabilities following from premature birth are worse than death, one study published in the Journal of the American Medical Association found. Most parents of babies born under 2.2 pounds feel differently — as do the grown ex-preemies themselves.

The truth is that the successful treatment of premature babies is one of the great triumphs of modern medicine. Before the widespread adoption of the incubator (and back when babies were usually studied by weight rather than gestational age), an 1883 study found, only about 35 percent of babies born under 4.4 pounds survived. But it isn’t just the incubator: With the subsequent development of respiratory support, intravenous nutrition and a host of other treatments, outcomes have improved dramatically. Infants born at the edge of viability, between 22 and 25 weeks, do, unfortunately, face substantial risk of death. But the vast majority of premature babies — more than 80 percent — are born after 32 weeks, and those born at 26 weeks and above are now quite likely to survive. According to the most recent available data from the Centers for Disease Control and Prevention, 87 percent of infants born at 26 weeks survive, and outcomes improve with each week of development.

Health-care providers are uniquely positioned to reframe our understanding of premature birth. They can answer parents’ questions, rather than leading with negative (and often hypothetical) predictions, and they can ground the discussion in the latest research. That evidence-based optimism might seep into the wider conversation. At the very least, it would make a difference to families, whose numbers are growing: More than 1,000 babies are born prematurely in the United States every day, and that figure has been rising for the past four years.

Families of premature babies are often deeply grateful to the providers who saved their children’s lives, and I am no exception. The doctor who recited that laundry list may have just been following hospital protocol. He probably had the best intentions; he may have been trying to manage his own emotions and expectations. But our counseling session hit me so hard not just because it laid out all the worst-case scenarios: It also seemed to say that my daughter would not have a wide-open future. She would forever be measured against an ideal that she was born short of and could never grow into.

And yet, in the time since, I have never wished my daughter, now age 5, were different. I speak from a position of tremendous luck: Her IQ is “normal,” whatever that means; she has a pulmonologist monitoring her persistent asthma and receives physical and occupational therapies for minor motor delay. Some of her fellow former preemies have fewer challenges; others have far more. But I don’t contemplate who she may have been, and I can’t wish away those difficulties without, in some real sense, wishing her away, exactly as she is.

We have a powerful collective fantasy of newborn perfection. We associate babies with possibility; we believe they could grow up to be anything, do anything. The truth is that no one, anywhere, has unlimited potential, not even at the very start of their life. But that fantasy can lend early births an unnecessarily tragic aspect — a sense of brokenness, of damage, even before parents have a chance to hold their infants. And often, we have plenty of reason to hope.

Source: https://www.washingtonpost.com/outlook/doctors-are-pessimistic-about-premature-babies-despite-the-evidence-we-all-are/2020/02/20/c4cefe50-4c44-11ea-9b5c-eac5b16dafaa_story.html

Does COVID-19 affect pregnancies?

UW Medicine – Mar 24, 2020

Much is still unknown about the virus that causes COVID-19. Dr. Kristina Adams Waldorf, professor of obstetrics and gynecology at University of Washington School of Medicine, shifted her lab’s focus to research what effects the virus may have on a pregnancy or a newborn. Scientists are investigating such questions as whether the infection can affect a fetus’ growth or whether it heightens the risk for preterm birth, stillbirth, and other conditions. This kind of research can help determine clinicians’ responses to pregnancies that also involve COVID-19.

INNOVATIONS

Will Simplifying the Finnegan Neonatal Abstinence Scoring Tool Improve Outcomes for Infants With Opioid Exposure?

Ju Lee Oei, MD^1,2; Trecia Wouldes, PhD³

It has been known for decades that opioid withdrawal in neonates has the potential to be fatal. Unfortunately, newborn withdrawal symptoms can be nonspecific, and identifying and differentiating infants with drug withdrawal from those with other illnesses, such as infection or neurologic problems, can be difficult, especially when maternal history is not forthcoming. Loretta Finnegan and colleagues devised the 21-point Finnegan Neonatal Abstinence Scoring Tool (FNAST) in 1975 based on observations of 55 full-term infants with narcotic exposure who were born at the Philadelphia General Hospital. The neonates were all admitted to a nursery and scored every hour for the first 24 hours, then every 2 hours on day 2, and then every 4 hours after that. They were formula fed and treated with a repertoire of agents that are no longer used as first-line treatments, including phenobarbital, paregoric, chlorpromazine, and diazepam. The FNAST is now the most widely used tool to screen, assess, and treat infants suspected of having drug withdrawal, but it is notoriously difficult to administer and is fraught with subjective differences.

In the study by Devlin et al, the authors attempted to shorten and simplify the FNAST by incorporating observational data from several infant cohorts (N = 424), including infants who did not require medications for neonatal abstinence syndrome (NAS). They dichotomized items that were previously expressed in grades of severity and removed items that were not observed frequently or were extremely heterogeneous, including convulsions, high-pitched crying, and hyperactive reflexes. The result was an assessment scale made up of 8 items, from which scores of 4 and 5 yielded closest agreement with FNAST treatment thresholds of 8 and 12, respectively (weight κ = 0.55; 95% CI, 0.48-0.61).

The simplicity of this tool is attractive. However, before it can be embraced in clinical care, several questions remain to be answered. First, only 1 score was used to determine treatment. Withdrawal symptoms typically evolve as the infant ages, and whether the associations between the 8 chosen items and NAS remain consistent with time needs to be assessed. The rare or uncommon items, such as seizures, were removed, but this may have limited the ability of the scale to detect severe but rare manifestations of withdrawal that require urgent treatment rather than continued observation. Critical events, such as seizures, may not have been common in the cohort studied by Devlin et al⁴ because the infants, unlike historical examples, were already monitored and treated preemptively with supportive care.

Nevertheless, the most significant knowledge gaps with the use of this and other scales is the lack of information regarding long-term outcomes. No prospective, well-controlled longitudinal studies have been conducted to associate prenatal drug exposure as well as assessment and treatment for NAS with later neurodevelopmental outcomes. Every single drug that causes NAS and every single medication that is used to treat withdrawal is neurotoxic. For example, opioids interfere with neurotransmitter homeostasis, promote cell death by apoptosis, and reduce brain growth and neuronal differentiation.⁵ Conversely, without treatment, severe withdrawal could lead to serious complications, such as dehydration, malnutrition, seizures, and even death.

Certainly, the work of Devlin et al highlights that much more needs to be known about how an infant responds postnatally to intrauterine drug exposure and the optimum screening, diagnostic, and treatment strategies. Perhaps the ultimate goal should not be to decide whether to treat an infant with medication but to prevent poor outcomes, including neurologic harm and death. Adopting simple measures will only be effective if they are systematically accepted by clinicians, parents, guardians, and caretakers, which is often not the case. For example, standardized protocols for identifying and treating women with opioid use disorder and for assessing and treating infants at risk of NAS have been shown to be beneficial in reducing length of hospitalization and rates of NAS treatment even without changing assessment scales.

Finally, we need to acknowledge that infants, especially those affected by multiple drugs, may need more than 1 type of assessment. The FNAST was based on infants withdrawing from narcotics, most notably heroin and methadone. Today, pregnant women with a drug use disorder usually use multiple drugs, which may obfuscate the clinical presentation of the infant. Incorporating items from other scales, such as the NICU Network Neurobehavioral Scale, which incorporates physiological parameters with interactive capabilities in an assessment method, may provide useful diagnostic information even for infants without opioid exposure and may even prognosticate not only for the short term but also, importantly, for longer-term outcomes.

Published: April 8, 2020. doi:10.1001/jamanetworkopen.2020.2271

Source: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2764194

Advanced Wireless Neonatal Body Monitors to Improve Outcomes

Babies that end up in the neonatal intensive care unit (NICU) or pediatric intensive care unit (PICU) are monitored via a complex collection of sensors, each of which has a wire connected to a patient monitor. While necessary, all this technology makes it difficult for parents to bond with their children and for clinicians to access their patients.

Northwestern University engineers have developed flexible, wireless sensor patches that are able to collect the same vital signs as wired devices while offering an entire set of additional capabilities that existing commercial devices lack.

The new sensors are able to track the heart rate, respiration rate, temperature, and blood oxygenation as well as conventional sensors, and they also allow for monitoring of body movement and orientation, recording heart sounds, crying, and other audio biomarkers, and even provide a pretty accurate estimate of systolic blood pressure.

The sensors are powered by internal batteries and are pretty cheap to manufacture, and so should be applicable for use in low resource areas and varying clinical settings. Additionally, the same sensors can be used to monitor pregnant women and potentially hospitalized adults as well.

Following comprehensive testing at two hospitals in Chicago, the results of which have just been published in journal Nature Medicine, the sensors are already being evaluated for use on newborns in a hospital in Kenya and one in Zambia.

Source: https://www.medgadget.com/2020/03/advanced-wireless-neonatal-body-monitors-to-improve-outcomes.html

HEALTH CARE PARTNERS

At Mayo Clinic, Bringing Neonatologists to the Point of Care with Telemedicine

The health system has co-developed a tele-neonatology program designed to close a gap in care that has existed when neonatologists aren’t physically available.

Rajiv Leventhal– Oct 29th, 2019

According to researchers at the Rochester, Minn.-based Mayo Clinic, 10 percent of all newborn infants will require assistance at birth, while approximately 1 in 1,000 newborns will require advanced resuscitation after delivery—an intervention after a baby is born to help it breathe and to help its heart beat.

When these high-risk deliveries occur in a local referral center, such as the aforementioned Mayo Clinic, newborn outcomes can be optimized under the care of a multidisciplinary team that has frequent experience with neonatal resuscitation.

Conversely, if a similar high-risk delivery occurs in a community hospital, the local providers may face unique challenges when responding to delivery room emergencies, Mayo Clinic researchers pointed out. As such, the health system recently co-developed a Newborn Resuscitation Telemedicine Program (NRTP) in collaboration with telehealth solutions company InTouch Health.

At Mayo Clinic, the organization’s main hub in Rochester has Level III and Level IV regional NICUs (neonatal intensive care units)—Level IV being the highest level of neonatal care—but there are also 10 Mayo Clinic health system sites that range from having just Level 1 well baby nurseries up to Level II intermediate specialty care nurseries. On top of that, Mayo Clinic has eight emergency departments (EDs) that are a part of either critical access hospitals or standalone EDs where there are no labor or delivery services, explains Beth Kreofsky, operations manager for the new tele-neonatology program at Mayo Clinic.

“So when mothers present to these sites, they may not always have access to a neonatologist. Six years ago, our team identified—with the assistants of our Mayo Clinic health system pediatric teams and family medicine providers—that there was a need to have a neonatologist available for assistance at the bedside in critical care situations where newborn resuscitation was needed,” Kreofsky recalls.

This disparity based on birth location was what motivated Christopher E. Colby, M.D., chair of neonatal medicine at Mayo Clinic’s Rochester campus to explore the use of telemedicine for newborn resuscitation, according to health system officials who noted that Dr. Colby’s first consultation was for an extremely preterm baby with an unknown gestational age due to limited prenatal care.

In this scenario, the local physician was unsure if the newborn was viable and if resuscitation was indicated. After examining the baby via video, Dr. Colby determined the neonate was likely 26 to 28 weeks gestation and proceeded to guide the resuscitation and stabilization. After a short time in the Mayo Clinic NICU, the baby was transferred back to the local Level II nursery. From there, the healthy infant was discharged home, health system officials explained.

The telemedicine program that has now been established enables nine board certified Rochester-based neonatologists to consult with local care teams in 10 health system sites. Prior to using telemedicine, only 43 percent of newborns in Mayo Clinic health system sites had access to a neonatologist if they required advanced resuscitation, officials pointed out, and as Kreofsky explains it, in these situations, local care teams would activate Mayo Clinic’s transport services and be asked to connect by phone to a neonatologist to assist in the service.

“Now we have added the video component onto that workflow so our neonatologists can see what the infants look like and what the physician at the local hospital is seeing, and can then provide appropriate recommendations. This is [compared with the prior approach of] not being able to see what’s going on and conducting what essentially [amounted] to a phone consult,” Kreofsky says.

This can be especially beneficial in rural settings where neonatal resuscitations are typically attended by general pediatricians or family practitioners. “While clinicians may have completed Neonatal Resuscitation Program training, knowledge and technical skills decline within four to six months, if not used regularly. Maintaining high proficiency in the face of low volumes presents inevitable challenges for rural providers. Telemedicine serves as a mechanism to address barriers in access to subspecialty care, support neonatal resuscitation in remote sites, and improve care for critically ill outborn neonates,” Kreofsky and her Mayo Clinic colleagues wrote in a study that evaluated the tele-neonatology program.

The study also examined the effectiveness of two telemedicine technologies used to provide NRTP consults: the InTouch Health Lite device compared with a wired telemedicine cart. As Kreofsky explains, if a mother needs to be moved to a different room, say for a C-section, the wired cart solution requires unplugging the device and removing it from the wall to a place where a network jack could be found. And if the physician gets disconnected during that transition, he or she would have to reconnect once the network is reestablished on that device.

But the InTouch technology, on the other hand, allows the physician to stay connected as the patient is being transitioned, meaning the transition is “more seamless and you don’t have to worry about unplugging anything or reestablishing connections in this scenario,” says Kreofsky.

Kreofsky also clarifies that when a tele-neonatology  service does occur, neonatologists are able to partner with the local family medicine physician and pediatrician to assist with guidance and recommendations, but it’s the bedside physician who is still in control of all the care that’s happening on site. “So while a neonatologist cannot physically get their hands on a patient, he or she can assist with recommendations on how neonatal resuscitation program standards are followed throughout a resuscitation,” Kreofsky explains.

During the 20-month study period, 118 NRTP consultations were performed across Mayo Clinic sites, resulting in:

• 96 percent first connection attempt rate—the ability of the device to connect to the network on the first try.
• 93 percent incident resolve rate—the ability of the provider to easily resolve any issues with the device before patient care is impacted.
• Results of the NRTP device can be compared to a traditional wired cart, which saw a 73 percent connection attempt rate and a 68 percent incident resolve rate.

Kreofsky also notes that more recent satisfaction survey results found that 99 percent of the local care teams who have been surveyed agreed that they would use tele-neonatology again and would recommend  it to others. Further, 100 percent of Mayo Clinic’s local care teams surveyed agreed that the consulting neonatologist provided, brief, clear, and specific information for the team, and worked collaboratively with them locally via telemedicine.

According to Jennifer L. Fang, M.D., with neonatal medicine at Mayo Clinic in Minnesota, the next step is to study the impact telemedicine has on the quality of newborn resuscitations. “While we and our colleagues in the health system believe telemedicine is improving delivery room care, we need to design a study to better answer that question,” she said.

Source: https://www.hcinnovationgroup.com/population-health-management/telehealth/article/21112281/at-mayo-clinic-bringing-neonatologists-to-the-point-of-care-with-telemedicine

A simple solution for healthier premature babies?

CBC News: The National –  Published on Feb 12, 2018

Is there a simple solution to improve the health of premature babies? A new Canadian-led study suggests there is. The study’s results showed that by simply getting a premature baby’s parents involved in the care process sooner, the baby gained 15 per cent more weight. There was also another effect — the parents also showed less stress.

Kat has been teaching virtual fitness classes from home during Covid-19 Stay at Home restrictions. Kat’s voice was significantly impacted from long term intubation as a 24 week micro-preemie. Back in 1991 the intubation equipment was quite large and the roof of her mouth is a deep cavern. Her voice is smokey in her normal tone and she is often asked if she is a smoker (she is not). Kat has always had difficulty talking loudly and she will not be pursuing a singing career. I stay upstairs while she teaches her classes and have had the opportunity to re-notice how challenging it is for her to shout out directions and encouragement while teaching HITT fitness (Strong Nation) classes throughout each 60 minute session. This is not a big problem that needs fixing, just an interesting preemie outcome. I wish I would have been more aware of this impairment issue when Kat was a kid and her coaches yelled at her to yell louder!

Voice Abnormalities and Laryngeal Pathology in Preterm Children

Anne Hseu  ¹ , Nohamin Ayele  ¹ , Kosuke Kawai  ¹ , Geralyn Woodnorth  ¹ , Roger Nuss  ¹

PMID: 29962214 DOI: 10.1177/0003489418776987

Abstract

Introduction: The prevalence of voice abnormalities in children born prematurely has been reported to be as high as 58%. Few studies have examined these abnormalities with laryngoscopic or videostroboscopic findings and characterized their laryngeal pathologies.

Objective: To review voice abnormalities in patients with a history of prematurity and characterize the etiology of their voice problems. A secondary objective is to see if there is a correlation between the findings and the patient’s intubation and surgical history.

Methods: A retrospective chart review was conducted of all preterm patients seen in voice clinic at a tertiary pediatric hospital. Demographic data, diagnoses, and office laryngoscopies were reviewed as well as any speech therapy evaluations and/or medical and surgical treatments.

Results: Fifty-seven patients were included. Mean age at presentation was 5.1 (±4.3) years. Mean gestational age was 27.8 (±3.7) weeks. Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) perceptual evaluations included a mean overall dysphonia severity of 46.6 (±24.2). Patients who had undergone prolonged intubation (⩾28 days) in the NICU or had prolonged NICU stays (>12 weeks) had significantly higher overall dysphonia severity scores. Thirty-three patients with vocal fold hypo- or immobility had significantly greater voice deviance in breathiness, loudness, and overall severity compared to those without vocal fold immobility. Of all patients, 35% were recommended surgical intervention and 49% voice therapy.

Conclusion: Intubation greater than 28 days and prolonged NICU stays are associated with more severe dysphonia in premature patients. There should be a low threshold for clinical evaluation of dysphonia in this unique patient population. ***Dysphonia= impairment of the voice

Source: https://pubmed.ncbi.nlm.nih.gov/29962214/

WARRIORS:

Covid-19: A Collective Hero’s Journey Dr. Arielle Schwartz

Posted on March 28, 2020 by Arielle Schwartz

“Covid-19 has led many of us around the world to experience feelings of shock and confusion. This collective crisis has disrupted our orientation to the world as we have known it. We have been thrust into a process of self-discovery and a requisite redefining of our lives. It is impossible to go back to the old ways of living.” ~Dr. Arielle Schwartz

American mythologist, Joseph Campbell (2008), describes personal transformation as a hero’s journey. The hero must enter the darkness, face challenges, slay the dragon, retrieve the treasure, and emerge stronger. Here, we understand that challenging life events can serve as a call to enter the hero’s journey. You may feel as though you have been thrown into an abyss. The dragons you must slay are the inner demons. You walk into the darkness in order retrieve the treasures that exist within you, such as inner strength, wisdom, and hope. You emerge with an enhanced sense of meaning and purpose, which become the gifts that you have to offer to the world.

A Collective Hero’s Journey

Campbell described the hero’s journey as a “monomyth,” which serves as a blueprint for many of our fairytales, books, and movies. The monomyth is described as a cycle that begins with a phase of freedom and innocence. This period of ease is tragically disrupted by a crisis that sends the hero into exile.

Here we are. There is no turning back. Covid-19 has changed our world. But, we are in this together. To overcome the challenges that are set before us, we must seek out resources needed to face our fears and inner demons. We must go within to gather our strength and to rise up in the midst of crisis. We are being asked to become the best version of ourselves.

This doesn’t mean that we won’t feel pain. Attending to our sadness, anger, fear is the path forward. Attend with love. Reach out…we are not meant to move through this alone. Perhaps, that is part of the lesson. We are a collective. We are deeply connected to each other. We are here to give and receive from each other.

Crisis as Catalyst

Perhaps our current world crisis has been the catalyst. Or, maybe your hero’s journey began long ago as a result of childhood trauma. No matter the origin, a hero’s journey can guide our process by encouraging us to transform our pain into a source of wisdom.

You might have uncomfortable places that you don’t like to acknowledge or feel. As a result, you might want to reject the call to enter the hero’s journey. The desire to avoid peering into the darkness is normal. It is human instinct to move away from pain. However, learning to turn toward discomfort is necessary and important. Even though you might want to run away, explore the resources that help you to step forward toward the discomfort. Remote psychotherapy, online support groups, journaling, time in nature, or mindful embodiment practices can all help you lean into discomfort at a pace that is right for you.

Living in Two Worlds

The challenge set before us is to learn to live in two worlds—that is, to maintain a connection to our inner, spiritual self while simultaneously living in the outer world. This dual connection helps us learn to live on a threshold where we can acknowledge our pain as a source of compassion.

At times, we might wonder how to live in a world that has betrayed us and that could betray us again. We grow by increasing our ability to hold the complexity of the human experience. This world contains experiences of harm and loss; however, this is also a world of love and care.

Transformed by a hero’s journey, we have an opportunity to grow ourselves into mature adults, capable of holding complex feelings and ideas in a world that can cause harm. There is a great maturity in being able to hold the truth that hurtfulness and happiness can coexist around and within you. We can learn to hold dichotomies, polarities, and contradictions. Experiences of pain are an inevitable part of life; opening our hearts involves the risk of pain. However, life can have excruciatingly painful moments and still be magnificently beautiful. Living on the threshold allows us to walk through the world with an effortless grace that emanates from within.

Emerging into Wholeness

Walk slowly and gently as you face your fears.

In time, we can all learn to trust our capacity to enter the darkness and return to the light. Successfully navigating the hero’s journey gives us the opportunity to discover that we are more powerful than we previously realized.

As a result, the here’s journey allows us to feel more grounded, real, and whole because – in truth – this transformation is about revealing who we truly are.

Together, let us remember that there is an inseparable relationship between our own personal happiness and the wellbeing of others.

Source: https://drarielleschwartz.com/covid-19-a-collective-heros-journey/#.XpjBAEBFxhE

(Kathy) I spent time with Joseph Campbell at Esalen Institute (late 1970’s/early 1980’s). His informal meal gatherings were enlightening and soul-challenging. He was an understated yet powerful speaker who mastered the dynamics of human behavior, subconscious motivations and pathways to transformation. Who in your life inspires transformation?

KAT’S CORNER

Covid-19 requires that we look beyond our preterm birth community this month into our broader communities so we can all be empowered through our shared resources and information. How Covid-19 will affect maternal outcomes and our preterm birth communities will be somewhat identified over time. Please reach out to your local healthcare providers for guidance and support and consider reviewing fluid resources such as WHO regarding Covid-19 pregnancy and childbirth information:                   Source: https://www.who.int/news-room/q-a-detail/q-a-on-covid-19-and-pregnancy-and-childbirth

Communities worldwide are navigating with limited resources the creation/expansion of medical, social, economic, governing, inter-governmental, technological, educational, interpersonal and personal best practices to maximize the health and wellness of their community members, patients, essential workforce and healthcare/wellness providers. The global health care provider shortage crisis is now critically exacerbated by our global pandemic experience.

Providing communities with factual, science-based information and resources is a critical component in building trust and reducing fear during crisis in a society that has access to multiple “news” resources at their fingertips. Addressing and advancing mental health holistically in our communities strengthens our ability to save lives, limit loss, and prevents fear-based violence. Media that offers not only factual information but also provides a community with guidelines for engaging in meaningful action supports mental wellness during times of crisis.

THANK YOU to the media members who have reached out to challenge us, give our actions meaning and power, who have focused on what good we can accomplish together while building hope and expressing our fears and gratitude.

As time transpires and we are able to review pertinent essential data including community engagement strategies, socioeconomic factors, local and global resources we will have an opportunity to build better societal strategies to serve our diverse communities. Borders do not exist for climate change and environmental disasters or for pandemic types of     human-centric challenges. Technology has the capacity to collect, provide, analyze, and disperse critical data that through collaboration and intent will allow all of us to respond to our personal, community, and global health care challenges with effective, fluid, time-sensitive, immediate and long-term action based planning.

It is essential that we work together in order to support and empower a healthy and sustainable planet. Covid-19 offers, and in some ways forces us to see in action the possibilities positive collaborative engagement provides. Our thanks to all of you who are choosing to stay informed, conduct your lives with intelligence and humane purpose, who live with integrity and a vision of good. Together we can create a safer, life affirming, dynamic and responsible global/local community for all.

Under An Arctic Sky – Official Trailer #1

Jan 17, 2017

With three hours of light each day, brutal winter storms and freezing temperatures, Iceland is far from the ideal surf trip. However, this didn’t stop photographer Chris Burkard and filmmaker Ben Weiland from rounding up a crew of surfers to seek out unknown waves in the islands remote north… all during the worst storm to hit Iceland’s shores in 25 years.