Perceptions of Neonatal Palliative Care: Similarities and Differences between Medical and Nursing Staff in a Level IV Neonatal Intensive Care Unit.

Background: A significant number of newborns are affected by life-limiting or life-threatening conditions. Despite this prevalence, there are inconsistencies in attitudes toward, and delivery of, neonatal palliative care. Implementing neonatal palliative care practice requires a multidisciplinary, collaborative effort. Objective: To examine institutional and individual barriers to and facilitators of neonatal palliative care from both medical and nursing perspectives. Design/Setting/Subjects: A prospective cross-sectional study design was used to collect data using the Neonatal Palliative Care Attitude Scale (NiPCAS) survey from medical providers and nurses in a 64-bed level IV neonatal intensive care unit in the United States. The response rate was 67%. Measurements: The NiPCAS survey included 26 attitudinal questions on a Likert scale. The instrument included three subscales: organization, resources, and clinician, in addition to other questions. Results: Six facilitators to neonatal palliative care were identified: (1) support of palliative care by the health care team, (2) support of palliative care by medical and nursing practice, (3) agreement that palliative care is as important as curative care, (4) parental involvement in decision making, (5) recognition of the importance of palliative care education, and (6) prioritizing pain relief. Three barriers to neonatal palliative care were highlighted: (1) a physical environment that is not conducive to providing palliative care, (2) technological obligations and parental demands, and (3) the societal belief that babies should not die. In addition, there were differences between medical and nursing staffs' attitudes on several topics. Conclusions: Several facilitators and barriers of neonatal palliative care were identified. There were similarities and differences in perceptions of neonatal palliative care between medical and nursing staff. Future work should be done to strengthen facilitators and to mitigate barriers.

CRIB scores as a tool for assessing risk for the development of pulmonary hypertension in extremely preterm infants with bronchopulmonary dysplasia.

OBJECTIVE: Bronchopulmonary dysplasia (BPD) increases the risk for developing pulmonary hypertension (PH). However, the risk factors associated with BPD-associated PH remain unclear. Our primary aim was to determine perinatal risk factors associated with the development of PH in infants with BPD. STUDY DESIGN: We retrospectively reviewed medical records of 303 infants born at ≤ 28 weeks' gestation. Infants were categorized as having no, mild, moderate, or severe BPD. PH was diagnosed by echocardiogram. Data were analyzed using Fisher exact test, two-sample t-test, and multivariable logistic regression. RESULTS: The incidence of PH in our cohort was 12%. Infants with PH had lower birth weights and gestational ages (p < 0.001). After controlling for confounding variables, severe BPD (p < 0.001), and higher Clinical Risk Index for Babies (CRIB) scores (p = 0.04) were associated with the development of PH. CONCLUSION: Severe BPD increases the risk for developing PH. Higher CRIB scores correlate with PH development in infants with BPD. We speculate that CRIB scores may allow for early categorization of preterm infants with a higher likelihood of developing PH.

Screening for Critical Congenital Heart Disease in Newborns.

CCHD affects more than 25% of neonates born with congenital heart disease. Patients with CCHD require timely intervention in the form of surgery or cardiac catheterization to survive. These interventions may improve survival and outcomes for these patients. There is strong evidence that performing newborn pulse oximetry screening after the first 24 hours of life may help to detect more than 1200 neonates in the United States each year with CCHD. Pulse oximetry screening for CCHD has been demonstrated to be reasonable to implement and seems to be cost-effective. There is evidence that asymptomatic patients with CCHD can be diagnosed before clinical presentation or cardiovascular collapse with this screening. Pulse oximeter screening has been endorsed by several national organizations as a valuable newborn screening tool. Implementation of pulse oximetry screening programs in a standardized manner with strong communication among all involved parties will likely improve outcomes as well. As we move forward, we as clinicians should work to have a centralized system of reporting positive CCHD results, prompt patient evaluation, and good follow-up for the families of those neonates with positive screening results. Achieving these objectives will likely help us to achieve the goal of improving outcomes of the most critical neonates with CCHD.