Health disparities in preterm births.

Introduction: Black African American (B/AA) women have a 2-fold to 3-fold elevated risk compared with non-Hispanic White (W) women for preterm birth. Further, preterm birth is the leading cause of mortality among B/AA infants, and among survivors, preterm infant adverse health outcomes occur disproportionately in B/AA infants. Racial inequities in maternal and infant health continue to pose a public health crisis despite the discovery >100 years ago. The purpose of this study was to expand on reported preterm infant outcome disparities. A life-course approach, accumulation of lifelong stress, including discrimination, may explain social factors causing preterm birth rate and outcome inequities in B/AA mothers. Methods: Anthropometric measures and clinical treatment information for 197 consented participants were milled from electronic health records across 4 years. The Neonatal Infant Stressor Scale was used to tally acute and chronic painful/stressful procedures. Neurobehavioral differences were investigated using the Neonatal Intensive Care Unit (NICU) Network Neurobehavioral Scale. Results: B/AA mothers gave birth to preterm infants earlier than W mothers. NICU hospitalization stays were extended more than 2 weeks for the significantly smaller B/AA preterm infants in comparison to the age-matched W preterm infants. A higher number of chronic lifesaving procedures with demonstrated altered stress response patterns were recorded for B/AA preterm infants. Discussion: This cross-sectional analysis of preterm birth rates and preterm infant developmental and neurodevelopmental outcomes are presented in the context of NICU stress and pain, with attendant implications for infant mortality and future health disparities. Preterm birth rate and outcome inequities further support the need to develop interventions and policies that will reduce the impact of discrimination and improve social determinants of health for Black, Indigenous, and other People of Color.

Conducting Neonatal Intensive Care Unit Research During a Pandemic: Challenges and Lessons Learned.

BACKGROUND: The coronavirus pandemic disrupted normal clinical operations and research. Nurse scientists conducting research studies in the neonatal intensive care unit experienced significant challenges to continuing their research studies amid national lockdowns and hospital visitation restrictions. OBJECTIVES: The purpose of this article is to describe the challenges encountered by nurse scientists conducting research studies in the neonatal intensive care unit during the pandemic, the creative solutions devised to overcome these barriers, and the lessons learned during this unprecedented time. METHODS: Using our pandemic area studies as exemplars, we highlight the barriers encountered in continuing our research in the intense environment of the neonatal intensive care unit. RESULTS: Visitor restrictions limited the presence of parents and researchers in the neonatal intensive care unit during the pandemic, causing disruptions to participant recruitment and data collection. Laboratory closures further limited research activities during the pandemic. Strategies to overcome these barriers include building formal collaborations among researchers and clinicians, creating the infrastructure to support virtual recruitment and electronic consent, and developing contingency plans for studies involving the analysis of biological samples. DISCUSSION: The neonatal intensive care unit is a unique environment because of vulnerable patient population and need for researchers to interact with parents to recruit study participants. Implementing the strategies developed during the coronavirus pandemic may allow for the continuation of research activities during future public health crises.

Multi-Omics Analysis on Neurodevelopment in Preterm Neonates: A Protocol Paper.

BACKGROUND: The gut microbiome is an important determinant of health and disease in preterm infants. OBJECTIVES: The objective of this article was to share our current protocol for other neonatal intensive care units to potentially expand their existing protocols, aiming to characterize the relationship between the intestinal microbiome and health outcomes in preterm infants. METHODS: This prospective, longitudinal study planned to recruit 160 preterm infants born <32 weeks gestational age or weighing <1,500 g and admitted to one of two Level III/IV neonatal intensive care units. During the neonatal intensive care unit period, the primary measures included events of early life pain/stress, gut microbiome, host genetic variations, and neurobehavioral assessment. During follow-up visits, gut microbiome; pain sensitivity; and medical, growth, and developmental outcomes at 4, 8-12, and 18-24 months corrected age were measured. DISCUSSION: As of February 14, 2020, 214 preterm infants have been recruited. We hypothesize that infants who experience greater levels of pain/stress will have altered gut microbiome, including potential adverse outcomes such as necrotizing enterocolitis and host genetic variations, feeding intolerance, and/or neurodevelopmental impairments. These will differ from the intestinal microbiome of preterm infants who do not develop these adverse outcomes. To test this hypothesis, we will determine how alterations in the intestinal microbiome affect the risk of developing necrotizing enterocolitis, feeding intolerance, and neurodevelopmental impairments in preterm infants. In addition, we will examine the interaction between the intestinal microbiome and host genetics in the regulation of intestinal health and neurodevelopmental outcomes.

Pilot Study of Absolute Telomere Lengths in Preterm Infants.

BACKGROUND: Annually, approximately 15 million babies are born preterm (<37 weeks gestational age) globally. In the neonatal intensive care unit (NICU) environment, infants are exposed to repeated stressful or painful procedures as part of routine lifesaving care. These procedures have been associated with epigenetic alterations that may lead to an increased risk of neurodevelopmental disorders. Telomere length has been negatively associated with adverse life experiences in studies of adults. OBJECTIVES: This pilot study aimed to describe telomere length in a sample of preterm infants at NICU discharge and examine any associations with pain, feeding method, and neurodevelopment. METHODS: This descriptive pilot study sample includes baseline absolute telomere length (aTL) of 36 preterm infants immediately prior to discharge. Quantitative polymerase chain reaction was used to determine aTL. Infant demographics, pain/stress, type of feeding, antibiotic use, neurodevelopment, and buccal swab data were collected. Descriptive data analysis was used to describe the telomere length using graphs. RESULTS: Among our preterm infant samples, the mean aTL was far greater than the average adult telomere length. Although no significant associations were found between aTL and pain, feeding method, and neurodevelopment, a trend between sex was noted where male telomere lengths were shorter than females as they aged. DISCUSSION: This is one of few studies to evaluate preterm infant telomere length. Although other researchers have used relative telomere length, we used the more accurate aTL. We found nonsignificant shorter telomere lengths among males. Additional large-scale, longitudinal studies are needed to better identify the predictors of telomere length at the time of discharge from NICU.

Integrated Review of the Assessment of Newborns With Neonatal Abstinence Syndrome.

OBJECTIVE: To critically review and summarize current knowledge regarding the assessment of newborns with neonatal abstinence syndrome (NAS). DATA SOURCES: We searched the following databases for articles on the assessment of newborns with NAS that were published in English between January 2014 and June 2020: PubMed, CINAHL, and PsycINFO. Keywords and Medical Subject Heading terms used to identify relevant research articles included neonatal abstinence syndrome; Finnegan Scale; eat, sleep, console; epigenetics; genetics; pharmacokinetics; and measurement. We independently reviewed articles for inclusion. STUDY SELECTION: We retrieved 435 articles through database searches and 17 through manual reference searches; 31 articles are included in the final review. Excluded articles were duplicates, not relevant to NAS, qualitative studies, and/or of low quality. DATA EXTRACTION: We used the methodology of Whittemore and Knafl to guide this integrative review. We extracted and organized data under the following headings: author, year and country, purpose, study design, participants, measurement, biomarker (if applicable), results, limitations, recommendations, and intervention. DATA SYNTHESIS: The Finnegan Neonatal Abstinence Scale is the most widely used instrument to measure symptoms of NAS in newborns, although it is very subjective. Recently, there has been a transition from the Finnegan Neonatal Abstinence Scale to the eat, sleep, console method, which consists of structured assessment and intervention and has been shown to decrease length of hospital stay and total opioid treatment dose. Researchers examined biomarkers of NAS, including genetic markers and autonomic nervous system responses, on the variation in incidence and differential severity of NAS. In the included articles, women with opioid use disorder who were treated with naltrexone during pregnancy gave birth to newborns without NAS diagnoses. However, most women who were treated with buprenorphine gave birth to newborns with NAS diagnoses. CONCLUSION: NAS negatively affects newborns in a multitude of ways, and the objective assessment and measurement of the newborn's response to withdrawal remains understudied and needs further investigation.

At the intersection of science and theory: How the Nurse Role Integration Model reconciles the conflict.

As more nurses embrace precision science, there is a tendency to utilize theoretical frameworks from other disciplines thus, placing nursing at risk of losing its autonomy and independence. The discipline has fallen prey to internal binary opposition, eliminating opportunities to engage in civil discourse. To explore how the roles nurses select might fit together in a theoretical framework and help nurses understand how the roles they choose to support their identity as nurses, this paper introduced a model of nursing that includes the bench scientists, the policy activists, and bedside nurses, using the Neuman Systems Model (NSM). The Nurse Role Integration Model (NRIM) espouses the basic tenets of NSM: prevention counteracts stressors from penetrating the client's lines of defense thus, reducing stress response. Primary prevention reflects the work of the nurse bench scientists, investigating the underlying mechanisms behind pathophysiology; secondary prevention is applied nurse scientists who build upon nurse researchers' work, identifying and testing potential interventions; tertiary prevention is nurse policy activists, the fulcrum, who leverage primary and secondary findings to argue policy change at all levels. Once policy change is adopted, bedside nurses are educated and implement the change. This lens provides an opportunity to create greater solidarity, strengthening the unity and autonomy of the discipline.

Vicarious Posttraumatic Growth in NICU Nurses.

BACKGROUND: When posttraumatic growth occurs in clinicians as a result of their caring for patients and families who are traumatized, it is termed vicarious posttraumatic growth. PURPOSE: (1) To determine the level of vicarious posttraumatic growth and the disruption of core beliefs in neonatal intensive care unit (NICU) nurses who have cared for critically ill infants and their families. (2) To explore those quantitative findings through nurses' qualitative descriptions of their growth. METHODS: A mixed method with a convergent parallel design was used to address the study aims. A targeted sample of neonatal nurses was recruited from the National Association of Neonatal Nurses (NANN) through the MyNANN Community message board. The sample consisted of 109 NICU nurses who completed the quantitative strand and 61 (55%) who completed the qualitative strand. Nurses completed the Posttraumatic Growth Inventory, the Core Beliefs Inventory, and described their experiences of any positive changes in their beliefs or life as a result of caring for critically ill infants. IBM SPSS 25.0 and Krippendorff's content analysis were used to analyze the quantitative and qualitative data, respectively. RESULTS: NICU nurses reported a moderate degree of vicarious posttraumatic growth and disruption of their assumptive world. Appreciation of Life was the Posttraumatic Growth Inventory dimension that reflected the highest growth and Spiritual Change the lowest. IMPLICATIONS FOR PRACTICE: Providing posttraumatic growth interventions has the potential to help NICU nurses find meaning through their experience. IMPLICATIONS FOR RESEARCH: Future surveys need to include a higher response rate to generalize the findings. A video abstract is available.Video Abstract available at: https://journals.na.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?autoPlay=false&videoId=36.

Oxytocin and early parent-infant interactions: A systematic review.

OBJECTIVES: Social relationships throughout lifespan are critical for health and wellbeing. Oxytocin, often called the 'hormone of attachment' has been suggested as playing an important role in early-life nurturing and resulting social bonding. The objective of this paper is to synthesize the associations between oxytocin levels and interactions between infants and parents that may trigger oxytocin release, and in turn facilitate attachments. METHODS: A comprehensive cross-disciplinary systematic search was completed using electronic databases. The inclusion criteria included studies that focused on mother-infant and father-infant interaction and measured both baseline and post-interaction oxytocin levels. RESULTS: Seventeen studies were included in the final systematic review. The reviewed studies used mother-infant and/or father-infant play and skin-to-skin contact between maternal-infant and paternal-infant dyads to examine the oxytocin role in early life bonding and parenting processes. Studies showed a positive correlation between parent-infant contact and oxytocin levels in infancy period. Increased maternal oxytocin levels were significantly related to more affectionate contact behaviors in mothers following mother-infant contact, synchrony, and engagement. Meanwhile, increased paternal oxytocin levels were found to be related to more stimulatory contact behaviors in fathers following father-infant contact. Oxytocin levels significantly increased in infants, mothers and fathers during skin-to-skin contact and parents with higher oxytocin levels exhibited more synchrony and responsiveness in their infant interactions. CONCLUSION: The review suggests that oxytocin plays an important role in the development of attachment between infants and parents through early contact and interaction. The complexities of oxytocinergic mechanisms are rooted in neurobiological, genetic, and social factors.

Synthesis of Mixed Research on Posttraumatic Stress Related to Traumatic Birth.

OBJECTIVE: To synthesize mixed-research results (quantitative and qualitative) on posttraumatic stress in women who experienced traumatic births. DATA SOURCES: PubMed, Scopus, and PsycINFO databases. STUDY SELECTION: Quantitative and qualitative studies were included if they were published in English from January 1, 2009, through December 31, 2018, and focused on posttraumatic stress in the postpartum period related to traumatic childbirth. DATA EXTRACTION: The final sample consisted of 59 studies: 4 qualitative and 55 quantitative. Both authors independently appraised each study using the Critical Appraisal Skills Programme. Quantitative studies were synthesized by narrative synthesis and vote counting, and qualitative studies were synthesized by content analysis. DATA SYNTHESIS: In the included studies, prevalence rates of elevated posttraumatic stress ranged from 0.8% to 26%. Significant predictors of posttraumatic stress that occurred before childbirth and those that were birth related were identified. Reports of six intervention studies to decrease posttraumatic stress symptoms after traumatic births were included. These interventions focused on postnatal debriefing, expressive writing, online cognitive behavioral therapy, a brief cognitive intervention, and the implementation of the nine instinctive stages of the infant during the first hour after birth. We created four themes from the findings of the qualitative studies: Distressing Symptoms, Detrimental Effect of Posttraumatic Stress on Women's Relationships With Their Infants and Partners, Critical Influence ofSupport, and Debriefing. CONCLUSION: When a woman experiences posttraumatic stress related to a traumatic birth, the entire family unit is vulnerable. Findings from quantitative predictor studies can be used to develop an instrument to screen women for risk factors for posttraumatic stress related to birth trauma. Primary interventions are needed to prevent women from experiencing traumatic births.

Associations between preterm infant stress, epigenetic alteration, telomere length and neurodevelopmental outcomes: A systematic review.

BACKGROUND: Every year, an estimated 15 million babies are born preterm (<37 weeks' gestational age [GA]) globally. These preterm infants are exposed to repeated stressful and often painful procedures as part of routine life-saving care within the neonatal intensive care unit (NICU). Preterm birth continues to be a major health issue associated with increased risk of neurodevelopmental and behavioral disorders such as cerebral palsy, cognitive impairment, autism spectrum disorders and psychiatric disease. OBJECTIVE: This paper identifies epigenetic alterations and incidence of telomere erosion that have been studied in preterm infants while in the NICU and as a long-term outcome measure. Better understanding of epigenetic alterations and telomere erosion might aid in early detection and prevention/alleviation of the negative effects of cumulative painful/stressful experiences in this population. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards were used to guide this review. Systematic searches of databases included PubMed, CINAHL, SCOPUS and PsychInfo. RESULTS: Twenty-one studies were included, appraised and then synthesized into a narrative summary. DISCUSSION: Several putative epigenetic markers were identified although there was a paucity of studies related to telomere length. The interaction of disease entity combined with therapeutic interventions intended to treat may inadvertently increase infant allostatic load or ability to adapt to stress. Future research should include not only human studies but leverage newly available large data sets to conduct additional analysis.

Allostatic Load and Biomarkers of Stress in the Preterm Infant: An Integrative Review.

BACKGROUND: Every year, an estimated 15 million babies are born preterm (<37 weeks' gestational age) globally. These preterm infants are exposed to repeated stressful and often painful procedures as part of routine life-saving care within the neonatal intensive care unit (NICU). Low thresholds for tactile and nociceptive input make it more difficult for neonates to discriminate between noxious and nonnoxious stimuli, which can result in continuous activation of stress responses in an attempt to achieve stability through adaptation, or allostasis. Rapidly reoccurring stressors can render stress-response systems over- or underactive, creating wear and tear, or allostatic load. A better understanding of biomarkers related to allostatic load might aid in early detection and prevention/alleviation of allostatic load in this population. PURPOSE: To identify stress biomarkers that have been studied in preterm infants at different time points in the NICU and as long-term outcome measures. METHOD/SEARCH STRATEGY: Systematic searches were conducted of PubMed, CINAHL, SCOPUS, and PsychInfo databases. FINDINGS/RESULTS: Twenty-one studies met inclusion criteria for this review. Several putative biomarkers were identified, including cortisol levels, epigenetic markers, brain microstructure, markers of oxidative stress, and the brain-gut-microbiome axis. CONCLUSION: The interaction of disease with therapeutic interventions may inadvertently increase infant allostatic load. In addition to human studies, future research should leverage newly available large data sets to conduct additional analyses.

Very preterm birth is associated with PLAGL1 gene hypomethylation at birth and discharge.

AIM: Recent findings show that DNA methylation is susceptible to very preterm (VPT) birth and to the experience of the early stay in the neonatal intensive care unit. The aim of the study was to compare PLAGL1 methylation between VPT and full-term (FT) infants at birth as well as between VPT infants at discharge and FT infants at birth. METHODS: DNA was collected from cord blood of 56 VPT and 27 FT infants at birth and from peripheral blood in VPT infants at neonatal intensive care unit discharge. Sociodemographic and neonatal variables were considered. RESULTS: PLAGL1 methylation at birth and at discharge were highly correlated in VPT infants. Lower methylation emerged in VPT infants at birth and discharge compared to FT counterparts. CONCLUSION: PLAGL1 hypomethylation emerged as a potential epigenetic mark of VPT birth. Future research is warranted to assess the functional consequences of PLAGL1 diminished methylation in VPT infants' development.

Influence of anthropometric parameters on breastmilk provision in preterm infants.

OBJECTIVE: To explore how growth trends may relate to maternal provision of breastmilk to preterm infants in the Neonatal Intensive Care Unit (NICU). DESIGN: Non-experimental, retrospective, descriptive. SETTING: Level III, 40-bed suburban neonatal intensive care unit (NICU). PARTICIPANTS: 94 preterm infants (<37 post-menstrual age) admitted to the NICU between September 2011 and May 2013. METHODS: This retrospective chart review explored the relationship between infant growth during hospitalization and maternal provision of breastmilk at discharge. Growth data were collected including standard weekly growth measurements from birth through hospital discharge. In addition, average growth over time or growth velocity was assessed for weight (g/kg/d), head circumference (cm/d) and length (cm/d). Growth parameters at birth and discharge were plotted using the Olsen 2010 Growth Calculator for Preterm Infants to obtain standardized assessments of growth percentiles. Key growth factors were examined against the primary investigational outcomes of continued breastmilk provision at discharge and length of hospital stay. Variables included infant characteristics, number of daily direct-to-breast feedings (identified as traditional oral breastfeeding), and maternal characteristics. Statistical tests included student t-test and chi square. Logistic regression models were used to evaluate data and multiple regression was used to examine growth variables. RESULT: In this cohort, 44% of mothers continued to provide breastmilk at the time of infant discharge. Growth velocity was a significant predictor of continued provision of breastmilk at discharge (p=0 0.002, OR 1.39). Ponderal index, combined with other variables were highly predictive of length of stay (p<0.001, R2=0.858). Those infants whose first oral feed was direct-to-breast (versus bottle) were more likely to still be receiving breastmilk at discharge (adj OR 5.3). CONCLUSION: First oral feed being direct-to-breast and higher growth velocity are supportive of continued breastmilk provision throughout hospitalization. These results highlight a need for additional breastfeeding support for mother-infants dyads who provided a bottle as the first oral feed or with poorer growth progression.

Noise in the Neonatal Intensive Care Unit: What Does the Evidence Tell Us?

BACKGROUND: In 2014, more than 10% of all births in the United States were preterm (born at <37-weeks' gestation). These high-risk infants will often spend weeks to months within the neonatal intensive care unit (NICU), where noise levels can easily reach 120 decibels adjusted (dBA) on a regular and sometimes consistent basis. The American Academy of Pediatrics recommends that NICU sound levels remain below 45 dBA to promote optimal growth and development. PURPOSE: The purpose of this evidence-based brief is to critically appraise the literature concerning preterm infant response to noise within the NICU as well as the use of noise interventions to improve health outcomes for the vulnerable preterm infant population. METHODS/SEARCH STRATEGY: Systematic searches of databases included the Cochrane Library, CINAHL, PubMed, and Science Direct. Included studies were appraised and then synthesized into a narrative summary. FINDINGS/RESULTS: Twenty studies met inclusion criteria for this review. While there are numerous methods that have been shown to reduce noise levels within the NICU, most NICU noise levels remain consistently above the American Academy of Pediatrics recommendations. Studies that assessed interventions found that staff reeducation was critical to sustaining appropriate noise levels. IMPLICATIONS FOR PRACTICE: Implementing interventions with rigorous attention to initial and continued staff education with engagement and ownership is recommended. This review identifies gaps in intervention studies targeting vulnerable NICU populations. IMPLICATIONS FOR RESEARCH: While noise interventions show promise in the NICU, additional focused research is needed to further strengthen the evidence and inform clinical practice.

Reduced DHA transfer in diabetic pregnancies: mechanistic basis and long-term neurodevelopmental implications.

Infants born to diabetic mothers have a higher frequency of impaired neurodevelopment. The omega-3 or n-3 fatty acid docosahexaenoic acid (DHA) is an important structural component of neural tissue and is critical for fetal brain development. Maternal DHA supplementation during pregnancy is linked to better infant neurodevelopment; however, maternal-fetal transfer of DHA is reduced in women with diabetes. Evidence of mechanisms explaining altered maternal-fetal DHA transfer in this population is limited. This review explores existing evidence underpinning reduced maternal-fetal DHA transfer in maternal fuel metabolism in this population. Further research is necessary to evaluate the role of peroxisome proliferator-activated receptors in modulating placental fatty acid binding and maternal-fetal DHA transfer. Considerations for clinical practice include a diet high in DHA and/or provision of supplemental DHA to obstetric diabetic patients within minimum guidelines.

Caregiving Factors Affecting Breastfeeding Duration Within a Neonatal Intensive Care Unit.

BACKGROUND: Increasingly, evidence supports oral feeding of very low birth-weight (VLBW) preterm infants exclusively at breast or with breast milk. Despite known breast milk benefits, outcomes related to exclusive breast milk provision are poor. Identifying factors that promote breast milk provision is critical. PURPOSE: Breastfeeding practices of mothers of VLBW infants admitted to neonatal intensive care unit were explored to identify factors associated with mode of feeding at discharge. METHOD: This retrospective study replicates previous work. Subjects were VLBW preterm infants consecutively admitted during a 24-month period. Primary outcomes included receiving any breast milk at discharge. Infant variables included gestational age, postmenstrual age of first direct breastfeeding, and comorbid conditions. Maternal variables included age and ethnicity. Nursing practice variables included first direct-to-breastfeeding, number of times to breast daily, and total direct-to-breastfeeding encounters 24 hours prior to discharge. RESULTS: A total of 96 VLBW infants (28.7 ± 2.8 weeks' gestational age) met inclusion criteria. Of these, 48% received breast milk at discharge. Controlling for significant effect of length of stay, infants receiving first oral feed at breast were more likely discharged home receiving breast milk (adjusted odds ratio = 8.7; 95% confidence interval, 2.9-32.3; P < .0001). There were both an independent effect of first oral feed at breast and an interaction where infants of nonmarried women also benefited from the first oral feed at breast. IMPLICATIONS: Significant associations were found between first oral feeding at breast and infant receiving any breast milk at discharge. Targeting VLBW infants to receive first oral feeding at breast may yield the best outcome even among sickest and smallest infants.

A Meta-ethnography: Skin-to-Skin Holding From the Caregiver's Perspective.

BACKGROUND: Although the benefits of skin-to-skin care (SSC) are well documented in the literature, practices in the clinical setting remain inconsistent. Although nurses' reported knowledge about SSC has improved, confusion still exists regarding safety and appropriateness. Existing qualitative literature primarily focuses on parents' experiences; yet it is crucial to describe the essence of professional caregivers' experiences to enhance facilitation and implementation of SSC. Most studies surrounding the caregiver's perspective and SSC have focused on barriers that impede implementation or examined the experience from the organizational perspective and general group experiences rather than individual personal experiences with SSC. PURPOSE: This meta-ethnography integrated the findings from several discrete studies into a salient interpretative perspective, creating a relevant understanding of the process of SSC as a means of enhancing facilitation and implementation of SSC with hospitalized infants. METHODS: An ethnographic meta-synthesis of qualitative literature was completed. RESULTS: As a result of this synthesis, the caregivers' experiences were separated into themes to articulate the phenomena juxtaposed from the 8 original studies that influence facilitation of SSC for the parent-infant dyad. Qualitative data analysis uncovered 4 overarching themes: (1) varying thresholds of getting started; (2) defining adequate resources; (3) navigating the demands and complexity of the infant; and (4) balancing parental readiness with infant needs. IMPLICATIONS FOR PRACTICE: This ethnographic meta-synthesis confirms nurses have good intentions in supporting SSC practices, yet struggle to meet competing demands in their daily practice. IMPLICATIONS FOR RESEARCH: Innovative and practical translations of SSC are needed to normalize SSC as the daily standard for premature infants.