Supporting oral feeding in fragile infants: an evidence-based method for quality bottle-feedings of preterm, ill, and fragile infants.

Successful oral feeding of preterm and other ill and fragile infants is an interactive process that requires (1) sensitive, ongoing assessment of an infant's physiology and behavior, (2) knowledgeable decisions that support immediate and long-term enjoyment of food, and (3) competent skill in feeding. Caregivers can support feeding success by using the infant's biological and behavioral channels of communication to inform their feeding decisions and actions. The Supporting Oral Feeding in Fragile Infants (SOFFI) Method is described here with text, algorithms, and reference guides. Two of the algorithms and the reference guides are published separately as Philbin, Ross. SOFFI Reference Guides: Text, Algorithms, and Appendices (in review). The information in all of these materials is drawn from sound research findings and, rarely, when such findings are not available, from expert, commonly accepted clinical practice. If the quality of a feeding takes priority over the quantity ingested, feeding skill develops pleasurably and at the infant's own pace. Once physiologic organization and behavioral skills are established, an affinity for feeding and the ingestion of sufficient quantity occur naturally, often rapidly, and at approximately the same postmenstrual age as volume-focused feedings. Nurses, therapists, and parents alike can use the SOFFI Method to increase the likelihood of feeding success in the population of infants at risk for feeding problems that emerge in infancy and extend into the preschool years.

The SOFFI Reference Guide: text, algorithms, and appendices: a manualized method for quality bottle-feedings.

The Support of Oral Feeding for Fragile Infants (SOFFI) method of bottle-feeding rests on quality evidence along with implementation details drawn from clinical experience. To be clear, the SOFFI Method is not focused on the amount of food taken in but on the conduct of the feeding and the development of competent infant feeding behavior that, consequently, assures the intake of food necessary for growth. The unique contribution of the SOFFI method is the systematic organization of scientific findings into clinically valid and reliable, easily followed algorithms, and a manualized Reference Guide for the assessments, decisions, and actions of a quality feeding.A quality feeding is recognized by a stable, self-regulated infant and a caregiver who sensitively (responsively) adjusts to the infant's physiology and behavior to realize an individualized feeding experience in which the infant remains comfortable and competent using his nascent abilities to ingest a comfortable amount of milk/formula. The SOFFI Reference Guide and Algorithms begin with prefeeding adjustments of the environment and follow step by step through a feeding with observations of specific infant behavior, decisions based on that behavior, and specific actions to safeguard emerging abilities and the quality of the experience. An important aspect the SOFFI Reference Guide and Algorithms is the clarity about pausing and stopping the feeding on the basis of the infant's physiology and behavior rather than on the basis of the amount ingested. The specificity of each observation, decision, and action enables nurses at all levels of experience to provide quality, highly individualized, holistic feedings. Throughout the course of feeding in the NICU, the nurse conveys to parents the integrated details (observations, decisions, and actions) particular to their infant, thus passing on the means for parents to become competent in quality feeding, to enjoy feeding time into the future, and to gain in confidence as they watch their infants grow.

A comparison of antibiotic point prevalence survey data from four Irish regional/general hospitals.

INTRODUCTION: Point prevalence surveys (PPS) are increasingly used to examining and compare hospital antibiotic consumption. The aim of this study was to identify the (1) point prevalence of antibiotic use in one regional hospital and (2) compare PPS data from similar regional/general hospitals. METHODS: Data were collected on all inpatients with an active antibiotic prescription and on all prescriptions issued in the emergency department over a 24-h period. Point prevalence data were obtained from three other regional/general hospitals. RESULTS: The frequency of antibiotic use was hospital A = 29%, B = 38%, C = 34% and D = 37%. Overall, the most commonly prescribed antibiotic was co-amoxiclav (30%), followed by macrolides (12%). However, new generation broad-spectrum antibiotics, such as piperacillin/tazobactam or ciprofloxacin, were also commonly used. Prescribing for common conditions such as respiratory infection or cellulites showed diverse antibiotic selection. CONCLUSION: Point prevalence survey data using a standardised methodology could facilitate both local audit and national benchmarking to monitor antibiotic use.

Recommended permissible noise criteria for occupied, newly constructed or renovated hospital nurseries.

OBJECTIVE: To base permissible noise criteria for occupied, new nurseries on research findings. STUDY DESIGN: An interdisciplinary group of clinicians reviewed the literature regarding the effect of sound on the fetus, newborn, and preterm infant and based recommended criteria on the best evidence. An external panel subsequently reviewed the criteria. RESULTS: The recommended criteria: Patient bed areas and the spaces opening onto them shall be designed to produce minimal ambient noise and to contain and absorb much of the transient noise that arises within the nursery. The overall, continuous sound in any bed space or patient care area shall not exceed: (1) an hourly Leq of 50 dB and (2) an hourly L10 of 55 dB, both A-weighted, slow response. The 1-second duration Lmax shall not exceed 70 dB, A-weighted, slow response. CONCLUSION: The permissible noise criteria will protect sleep, support stable vital signs, and improve speech intelligibility for many infants most of the time.

Do former preterm infants remember and respond to neonatal intensive care unit noise?

BACKGROUND: Previous studies have shown that 4-month-old infants have a decrease in heart rate, a component of the orienting reflex, in response to interesting auditory stimuli and an increase in heart rate to aversive auditory stimuli. OBJECTIVE: To compare the heart rate responses of former preterm and term infants at 4-5 months corrected age to a recording of NICU noises. METHODS: 13 former preterm infants and 17 full-term infants were presented NICU noise and another noise of similar level and frequency content in random order. Heart rate 10s prior to the stimulus and for 20s during the stimulus was analyzed. Group differences in second by second heart rate changes in response to the two noise stimuli were compared by analysis of covariance. RESULTS: Both the preterm and term newborns responded similarly to the NICU noise and the control noise. The preterm infants did not alter their heart rate in response to either stimulus. In contrast, the term infants displayed an orienting response to the second stimulus presented regardless of whether it was the NICU or control noise. CONCLUSIONS: Former preterm infants at 4-5 months corrected age have reduced responsiveness to auditory stimulation in comparison to 4- to 5-month-old term infants. Furthermore, they did not respond to the NICU noise as an aversive stimulus.

Effects of the neonatal intensive care unit on auditory attention and distraction.

A theory is proposed that attention to acoustic signals is important for normal development and varies with background masking sounds. Specifically, the theory states that distractibility increases with decreasing predictability of the acoustic environment and with decreasing age. Literature from premature neonates, normal infants, preadolescent children, children with attention deficit disorders, and adults is reviewed. One conclusion is that an environment perceived by adults as predictable may be distracting for preterm infants. One recommendation for future research is to include measures of background acoustic predictability as independent variables or covariates in developmental studies.

Planning the acoustic environment of a neonatal intensive care unit.

This article addresses general principles of designing a quiet neonatal intensive care unit (NICU) and describes basic aspects of room acoustics as these apply to the NICU. Recommended acoustical criteria for walls, background noise, vibration, and reverberation are included as appendices. Crowding in open, multiple-bed NICUs is the major factor in designs that inevitably produce noisy nurseries with limited space for parents. Quiet infant spaces with appropriate sound sources rely on isolation of the infant from facility and operational noise sources (eg, adult work spaces, supply delivery, and travel paths) and extended contact with family members.However, crowding has been an important influence on the clinical practice and social context of neonatology. It allows clinicians to rely on wide visual and auditory access to many patients for monitoring their well-being. It also allows immediate social contact with other adults, both staff and families. Giving up this wide access and relying on other forms of communication in order to provide for increased quiet and privacy for staff, infants, and parents is a challenge for some design teams. Studies of the effects of various nursery designs on infants, parents, clinicians, and the delivery of services are proposed as a means of advancing the field of design.

Changing levels of quiet in an intensive care nursery.

OBJECTIVES: To document low sound levels, the range and pattern of levels, and the relative effects of operational (staff and equipment generated) and facility (building generated) noise on the acoustic environment of a level III nursery. STUDY DESIGN: A quasi-experimental, prospective, longitudinal study of one bed space. Operational noise was reduced through staff behavior change while facility noise was reduced through renovation. RESULTS: Initial noise levels were typical of those in the literature and in recently measured nurseries. About 80% of sound levels were between 62 and 70 dBA. The lowest levels (L(min)) were 60 to 65 dBA. After staff behavior change, L(min) was about 56 dBA although the highest levels (L(max)) remained at 78 to 100 dBA. Levels following renovation were reduced to L(min)s of 47 to 51 dBA and L(max)s of 68 to 84 dBA, perceived as three or four times quieter than initially. CONCLUSIONS: Staff behavior as well as the acoustical characteristics of the facility determine the levels of noise and quiet in an intensive care nursery.

Antenatal hepatitis B screening - is there a need for a national policy?

Routine antenatal testing for hepatitis B carriage with maternal consent was introduced at the Rotunda in January 1998. The uptake of testing has been excellent; 99.98% of women presenting for antenatal care accepted hepatitis B (HBV) screening in the 30-months from January 1998 through June 2000. The prevalence of HBV carriage was 0.35% (58 pregnancies of 16,222 tested) increasing from 0.25% in 1998 (16 of 6227) to 0.45% in the first six months of 2000 (16 of 3484). Fifty-five women had 58 pregnancies (three women had two pregnancies). Two of these were e-antigen positive. HBV carrier status was previously unknown in 48 (87%). Two additional women had acute HBV infection in pregnancy. Forty-five infants have been born to mothers included in this screening programme. Audit of infant outcome reveals excellent compliance with immunisation and follow-up: 29 (64%) have completed the 3 dose HBV vaccination schedule to date. Thirteen infants (31%) are still attending; three are lost to follow-up including one whose family has emigrated. Routine antenatal screening for hepatitis B carriage is cost-effective and should be considered a standard of care in maternity practice.

Measuring sound in hospital nurseries.

This article provides practical advice on how to document sound levels in a nursery: How do you use sound-level meters, noise dosimeters, and spectrum analyzers? Where is the best position for microphones in a sound survey? How do you present results to nursery staff? The goal is to provide informal instruction on how to use these devices and interpret their measurements. The intended audience is medical personnel, not engineers. A companion article in this issue provides background on the technical aspects of sound measurement. There is an appendix with hints about finding help and purchasing equipment.

Facility and operations planning for quiet hospital nurseries.

This article discusses architectural design and construction and recommends criteria for achieving quiet nursery environments. Designs for new construction or facility renovation should incorporate vibration and noise control methods appropriate to the occupants and activities of the proposed space. Noise and vibration are environmental factors within a hospital nursery that can affect infant health and development, staff and parent communications, operational efficiencies, and the fatigue/comfort level of all occupants. Facility noise and vibration levels set a threshold that will be increased by operational noise. It is important, therefore, that hospital administrators, clinicians, and facility managers assure that architects, engineers, and builders use appropriate acoustical design criteria, methods, and materials to control noise and vibration.

Physiological effects of sound on the newborn.

Excessive sound is an acknowledged problem in neonatal intensive care units (NICUs); however, there is relatively little objective information about the effects of sound on the newborn. The cardiovascular and respiratory systems have been the most extensively studied systems. The patterns of response in these systems may be influenced by a variety of factors, including: the intensity of the sound, the infant's behavioral state, the infant's maturity and postnatal age, and the perinatal history. This article reviews the known cardiovascular, respiratory, and other physiological effects of sound on neonates.

Evaluating studies of the behavioral effects of sound on newborns.

Studies of the effects of sound on newborns can provide good information of use in clinical practice even though most were not designed for that purpose. Unfortunately, however, some poor-quality research has yielded unfounded yet clinically popular results. The clinician, therefore, must be careful in assessing the validity and reliability of research as well as the applicability of its findings to the care of individual patients. This article offers a checklist for evaluating research using auditory stimuli with newborns. Caveats concerning the newborn's gestational age and behavior (e.g., state, movement, attention, and habituation) are discussed. Particular design problems related to sound measurements and stimuli are identified. Clinicians are cautioned about applying findings from studies of term newborns to the care of preterm infants.

Hearing and behavioral responses to sound in full-term newborns.

This article, addressed to clinicians caring for and interacting with newborns, summarizes information from the research literature about newborn infants' hearing and behavioral responses to sound. While the emphasis is on current knowledge, older studies show how the investigators' assumptions have influenced the questions they have asked. Although these studies do not make up a neat package of information for clinicians, they do reveal broad outlines of newborn hearing abilities and the affects of sound on sleeping, quieting from crying, habituating, and paying attention. The newborn's responses to and preferences for particular sounds such as speech, music, and heartbeats are reviewed. These studies present the term newborn as an active listener and learner who, despite a somewhat immature auditory system and a limited repertoire of behavioral responses, is highly discriminating regarding the sounds of speech and whose efforts at sleeping, quieting, and paying attention may be hindered by noise such as that commonly found in hospital nurseries.

The influence of auditory experience on the behavior of preterm newborns.

This review of the research literature is addressed to clinicians who care for, interact with, and advise parents of preterm newborns. In summary, research on the effects of sound on preterm infant behavior and development provide only a little reliable clinical guidance as many of the studies are flawed, some badly. Some studies use a high sound level (i.e., loud) stimulus yet fail to report effects of the stimulus on vital signs, movement, and behavioral state. Only a handful of studies report long term effects regardless of the length of exposure to the experimental stimulus. A consistent problem is that the ambient sound in the nursery research setting is neither described nor considered as a facet of the auditory stimulus yet all reports of ambient nursery sound show high levels without respite periods of quiet. Therefore, unless other documentation is provided, ambient nursery noise is likely an unreported confounding variable in these studies. The clinician is cautioned, therefore, to carefully evaluate any finding before implementing an intervention program of sound stimulation with preterm infants. There are many reports of efforts to reduce nursery noise by changing staff behavior but none describes more than marginal success. Given this general failure of noise reduction through behavior change, an alternative is proposed of achieving quiet by changing the crowded, reverberant nature of the physical space. Recommendations for care that can be drawn from this literature include measuring and reducing nursery noise, facilitating parents' efforts to talk and sing to their own babies, and limiting purposefully added sound stimulation to quite specific clinical situations.