Hospital-acquired skin lesions in the neonatal intensive care unit: A retrospective analysis of temporal trends and quality improvement strategies.

PURPOSE: Skin lesions in neonatal population are an emerging problem deserving attention from health care professionals. The purpose of this study is to retrospectively assess the incidence of hospital-acquired skin lesions during a 6-year period and to describe the characteristics of infants who developed them. DESIGN AND METHODS: This was a retrospective observational study conducted in a university-tertiary care center between 2015 and 2020. A descriptive analysis of the observed skin lesions is presented according to 2 time periods: 1) the implementation phase of a quality improvement program (2015-2019) and 2) the postimplementation phase (2020). RESULTS: Our findings showed an apparent increase in the incidence of all reported skin lesions throughout the study period. Pressure injuries were the most frequently reported skin lesions showing an increasing incidence over time which, however, was paralleled by a reduction in their severity. Among pressure injuries, device-related injuries were the most commonly observed (56.6% and 62.5% in the two periods, respectively) with nasal continuous positive airway pressure-related injuries accounting for 71.7% and 56.0% of lesions, respectively, and mainly affecting the nose root. The occipital area was the most frequently involved site in cases of conventional pressure injuries. CONCLUSION: Infants admitted to Neonatal Intensive Care Units may be at high risk of developing skin lesions. The adoption of appropriate preventative as well as treatment interventions could be effective in reducing the severity of pressure injuries. PRACTICE IMPLICATIONS: The implementation of quality improvement strategies may contribute to prevent skin injuries or lead to their early detection.

The hidden universe of human milk microbiome: origin, composition, determinants, role, and future perspectives.

Although traditionally considered sterile, human milk is currently recognized as an alive ecosystem that harbors not only bacteria, but also viruses, fungi and yeasts, and minor genera, collectively known as the human milk microbiome (HMM). The seeding of HMM is a complex phenomenon whose dynamics are still a matter of research. Many factors contribute to its determination, both maternal, neonatal, environmental, and related to human milk itself. The transmission of microorganisms to the infant through breastfeeding may impact its present and future health, mainly shaping the GI tract microbiome and immune system. The existence and persistence of HMM as a conserved feature among different species may also have an evolutionary meaning, which will become apparent only in evolutionary times. CONCLUSION: The complexities of HMM warrant further research in order to deepen our knowledge on its origin, determinants, and impact on infants' health. The practical and translational implications of research on HMM (e.g., reconstitution of donor human milk through inoculation of infant's own mother milk, modulation of HMM through maternal dietary supplementation) should not be overlooked. WHAT IS KNOWN: • Human milk harbors a wide variety of microorganisms, ranging from bacteria to viruses, fungi and yeasts, and minor genera. • Human milk microbiome is shaped over time by many factors: maternal, neonatal, environmental, and related to human milk itself. • The transmission of microorganisms through breastfeeding may impact the infant's present and future health. WHAT IS NEW: • We provide an overview on human milk microbiome, hopefully encouraging physicians to consider it among the other better-known breastfeeding benefits. • Further studies, with standardized and rigorous study designs to enhance accuracy and reproducibility of the results, are needed to deepen our knowledge of the human milk microbiota and its role in newborn and infant's health.

Near-infrared system's efficiency for peripheral intravenous cannulation in a level III neonatal intensive care unit: a cross-sectional study.

Venipuncture is a painful and invasive procedure for hospitalised newborns and represents a challenge for neonatal healthcare professionals. This study evaluated the most efficient cannulation method based on the proportion of success at the first attempt, standard care or near-infrared (NIR) device use, and pain assessment. An observational study with two arms was conducted in the neonatal intensive care unit (NICU) of a tertiary-care university hospital in Italy. All newborns undergoing peripheral vein cannulation and only nurses with more than 5 years of professional experience in the NICU were eligible for the first arm. Only newborns with a body weight of >2500 g at cannulation and all nurses working in the NICU were involved in the second arm. In the first arm of the study, no statistically significant differences between the NIR and control groups were found in terms of proportion of successful at the first attempt 60.6% (confidence interval [CI] 95%: 48.8; 72.4) vs. 56.1% (CI 95%: 44.1; 68.0) and the mean premature infant pain profile score 6.3 (CI 95%: 5.4-7.1) vs. 5.8 (CI 95%: 5.0-6.6). In the second arm, only among less experienced nurses (<1 year), we observed a significant increase in the proportion of success in the NIR group compared with the control group, nearly tripling the success rate (72.7% [54.1; 91.3] vs. 23.1% [0.2; 46.0]).  Conclusion: This study reported no differences between the NIR and control groups. The results also suggest that using a NIR device may be advantageous for healthcare professionals with less experience during first-time cannulation. What is Known: • Venipuncture is a painful procedure commonly used to place a peripheral venous catheter for administering nutrients or drugs. • Near-infrared light facilitates the visualisation of veins and consequently, the performance of cannulation in the paediatric population. What is New: • The near-infrared light device was not associated with fewer attempts and a lower premature infant pain profile score in placing venous access in newborns than the traditional method. • The near-infrared light device could help nurses with less professional experience place a peripheral venous catheter.

Self-Report and Biological Indexes of Work-Related Stress in Neonatal Healthcare Professionals: A Repeated-Measures Observational Study.

BACKGROUND: Healthcare providers working in neonatal intensive care units (NICUs) are considered at high risk for psychological work-related stress. PURPOSE: To evaluate both perceived and biological measures of work-related stress in neonatal healthcare professionals and to compare professionals working in the NICU with their colleagues working in less critical environments (ie, neonatal wards [NWs]). METHODS: The salivary cortisol level at the beginning (CORT-B) and at the end (CORT-E) of a daily work shift was collected once a week for 6 weeks and a psychological questionnaire was submitted to NW and NICU workers of a tertiary university center. RESULTS: No differences emerged in the overall cortisol secretion between professionals (NW 45 vs NICU 28), but the decrease in the mean cortisol values between CORT-B and CORT-E was less pronounced in NICU professionals (P < .001) who had greater psychological stress (P < .001). Lack of correlation between perceived and biological indexes was observed. IMPLICATIONS FOR PRACTICE: NICU professionals reported greater levels of self-perceived psychological stress, especially in terms of professional self-doubt and the complexity of interactions with infants and their parents.The disconnection between psychological and biological indexes raises the issue that work-related stress might be covert to the professionals themselves. Dedicated resources should be developed to address quality of life and the work environment of NICU professionals. IMPLICATIONS FOR RESEARCH: The absence of a correlation between perceived and biological indexes highlights the need to incorporate multidimensional physiological and biological measurements in evaluating burnout levels in neonatal healthcare providers.

Knowledge and attitude of health staff towards breastfeeding in NICU setting: are we there yet? An Italian survey.

The benefits of human milk in preterm infants, a population at high risk for developing adverse outcomes for which breast milk is a protective factor, are widely acknowledged. However, preterms' admission in a neonatal intensive care unit (NICU) and newborn's clinical conditions have been described as significant barriers, leading to lower rates of breastfeeding initiation and duration. Healthcare workers play a crucial role in encouraging breastfeeding. We conducted a cross-sectional survey among nurses working in six Italian NICUs, exploring their knowledge and attitude towards breastfeeding. Although the majority of nurses had a specific breastfeeding education, our results show still some variations among answers regarding aspects of breastfeeding support in this setting. Specifically, family-centered care, transition feeding to the breast, and skin-to-skin practice, despite being extensively addressed by the Neo Baby-Friendly Hospital Initiative, are the items that highlighted a range of answers that could result in conflicting information to mothers.Conclusion: By underlining the gaps of knowledge and attitude towards breastfeeding of nurses working in NICUs, this study provides an insight into what needs to be improved, with the aim of promoting higher rates of breastfeeding in the preterm population. What is Known: • Breastfeeding is particularly challenging in the preterm population, despite its universally recognized health benefits. • Improving healthcare professionals' knowledge and attitude towards breastfeeding has been shown to be crucial for promoting breastfeeding in NICUs. What is New: • Our results provide useful insight into nurses' knowledge and attitude towards breastfeeding in NICU settings. • By acknowledging strengths and weaknesses highlighted by this study, tailored strategies could be developed to improve health staff breastfeeding education and support to parents in NICU settings.

Clinical safety of 3-T brain magnetic resonance imaging in newborns.

BACKGROUND: The effects and potential hazards of brain magnetic resonance imaging (MRI) at 3 T in newborns are debated. OBJECTIVE: Assess the impact of 3-T MRI in newborns on body temperature and physiological parameters. MATERIAL AND METHODS: Forty-nine newborns, born preterm and at term, underwent 3-T brain MRI at term-corrected age. Rectal and skin temperature, oxygen saturation and heart rate were recorded before, during and after the scan. RESULTS: A statistically significant increase in skin temperature of 0.6 °C was observed at the end of the MRI scan (P<0.01). There was no significant changes in rectal temperature, heart rate or oxygen saturation. CONCLUSION: Core temperature, heart rate and oxygen saturation in newborns were not affected by 3-T brain MR scanning.

Cord Blood Platelet Gel as a Treatment of Occipital Pressure Injuries in Newborns: Report of Two Cases.

BACKGROUND: A Pressure Ulcer (PU) is a severe event and could create discomfort to newborns. In newborns, one of mostly stricken location by PU is occipital area. Recent studies have highlighted that Cord Blood Platelet Gel (CBPG) might be a better alternative compared to traditional treatment. We report two cases of occipital PU treated with CBPG. CASE REPORT: Two male infants showing occipital PU were treated with standard local treatment, but no improvement was observed. After parental informed consent was obtained, CBPG application on PU was performed every 48 h. In these two cases of PU, a fast improvement in healing was observed since the first application of CBPG. The PU healed resulted in a scar after 53 and 50 days (Case 1 and Case 2, respectively) from development. No complications or infections were reported. CONCLUSIONS: CBPG contains many angiogenetic and growth factors, these characteristics make it indicated in treating soft tissue injuries. It would seem to be safe and an effective treatment of neonatal PUs reducing the time of the healing and the hospitalization and the infectious risks. Further studies are needed to evaluate long term aesthetic and functional results of PU treated with CBPG.

Exploring the Emotional Breastfeeding Experience of First-Time Mothers: Implications for Healthcare Support.

Background: Among breastfeeding determinants, the unique emotional breastfeeding experience has been poorly explored. The present study aimed to investigate the emotional breastfeeding experience in a cohort of first-time mothers. Materials and methods: We conducted a prospective observational study that enrolled primiparas having delivered singleton healthy term newborns, and exclusively breastfeeding at hospital discharge. At 3 months post-delivery mothers accessed an online questionnaire investigating their emotional breastfeeding experience. The chi-squared test was used to assess the association between the feelings experienced during breastfeeding and feeding outcomes at 3 months. Results: Out of the 421 enrolled mothers, 273 (65%) completed the questionnaire. At 3 months post-delivery exclusive breastfeeding was reported by a 66% of mothers, a 19% reported complementary feeding, and a 15% of mothers reported exclusive formula feeding. Breastfeeding experience was described as positive by 62% of mothers although breastfeeding difficulties were reported by 80% of the mothers. The mothers that had experienced fear, sadness, anger or concern during breastfeeding showed a significant higher exclusive formula feeding rate at 3 months post-delivery than those who did not (25.5 vs. 12.8%, p = 0.021; 28.6 vs. 13.4%, p = 0.02; 40 vs. 13.4%, p = 0.005; 20.5 vs. 11.8%, p = 0.049, respectively). An 85% of mothers stated that their breastfeeding experience was different from what they would have expected, blaming for this discrepancy the occurrence of difficulties during breastfeeding and the complexity of breastfeeding itself (50%), pain experience (8%), being dependent from the baby (6%), and breastfeeding failure (11%). A total of 25% of mothers, however, reported they found breastfeeding to be a much more positive experience than what they had expected. Conclusion: Breastfeeding care should include a tailored emotional support of first time-mothers in addition to the implementation of their breastfeeding knowledge and skills.

Knowledge of Health Professionals Regarding Vegetarian Diets from Pregnancy to Adolescence: An Observational Study.

The number of people adopting vegetarian diets is constantly increasing, and many among them are young parents who decide to share their diet with their children. The aim of this study was to investigate health professionals' knowledge regarding the adoption of vegetarian diets from pregnancy to adolescence. A cross-sectional survey was conducted. The administered questionnaire, which was based on the recommendations of the most up-to-date guidelines, included two macro areas: The first investigated the sociodemographic and professional profile of the interviewees and the second addressed the knowledge of the participants regarding vegetarian diets. A total of 418 health professionals in Italy were interviewed, of whom 65.8% were nursing staff. Among the participants, 79.9% had not attended a nutrition course in the previous five years. A correct definition of a vegetarian/vegan diet was provided by 34.1% of the participants. The answers regarding knowledge of nutrients were correct in 20% of cases, whereas correct answers to questions assessing knowledge of the risk and benefits of a vegetarian diet and the adoption of a vegetarian diet throughout the life cycle were given by 45% and 39.4% of the participants, respectively. A significant correlation between the items of the second macro area that investigated the knowledge and dietary habits of the participants was found for seven items. The results of the study indicate that health professionals do not have complete and exhaustive knowledge about vegetarian diets and lack information on health outcomes and the adoption of a vegetarian diet throughout the different life cycles and nutrients. Improving pre- and in-service learning opportunities in vegetarian nutrition for health professionals is strongly advisable.

Exploring the Gap Between Needs and Practice in Facilitating Breastfeeding Within the Neonatal Intensive Care Setting: An Italian Survey on Organizational Factors.

Introduction: The system-level factors of the neonatal intensive care unit work environment contribute to breastfeeding promotion in the preterm population. The aim of this study was to investigate the operative policies related to breastfeeding support in a sample of Italian Neonatal Intensive Care Units. Materials and Methods: A multicenter cross-sectional survey was conducted, including a sample of 17 head nurses. The items of the questionnaire investigated the following areas: breastfeeding policies, staff education, family centered care, and breastfeeding promotion and support both in the neonatal intensive care units and after discharge. Results: Written breastfeeding policies were available for staff in all the neonatal intensive care units, most commonly addressing procedures related to skin-to-skin contact, human milk expression, and preterm infant breastfeeding. Most of the neonatal intensive care units correctly advised the mothers to initiate milk expression within 6 h from delivery and to pump milk at least 6 times/days. Breastfeeding training for the nursing staff was planned in the majority of the neonatal intensive care units although according to different schedules. With regard to the family centered care implementation, time restrictions were present in seven neonatal intensive care units, mostly occurring during the night shift, and the morning hours concomitantly with medical rounds. Moreover, in the majority of the investigated neonatal intensive care units, the parents were asked to leave the ward when their infant underwent a major invasive procedure or during the nurse/physician shift change report. With regard to breastfeeding promotion and support, eight neonatal care units had a multidisciplinary team with several health care professionals and 10 provided information about community-based support services. Most of the units assessed breastfeeding after discharge. Conclusion: Based on the present findings, enrolled Neonatal Intensive Care Units appear to provide breastfeeding-supportive environments with special regard to breastfeeding policies, milk expression practices, interprofessional collaboration, and continuity of care. Health care professionals should exert efforts to ensure continuous and updated breastfeeding staff education and promote parent-infant closeness and family centered care.

Successful Extracorporeal Membrane Oxygenation After Incidental Azygos Vein Cannulation in a Neonate With Right-Sided Congenital Diaphragmatic Hernia Interruption of the Inferior Vena Cava and Azygos Continuation.

Incidental azygos vein cannulation has been reported in a few cases of neonatal extracorporeal membrane oxygenation (ECMO). This complication is described in the literature mainly in pathological conditions wherein increased central venous pressure dilates the superior vena cava (SVC), i.e., right congenital diaphragmatic hernia (CDH) or pulmonary hypertension. Azygos vein cannulation should always be suspected in cases of impaired venous return and circuit failure. Although rare, it hinders proper venous aspiration of the ECMO circuit and generally requires repositioning or replacement of the venous cannula or conversion to central cannulation. In this report, we describe a newborn with severe right CDH who required ECMO assistance, wherein incidental cannulation of the azygos vein resulted in successful functioning of the circuit because of the concomitant presence of isolated interruption of the inferior vena cava and azygos continuation. To the best of our knowledge, this is the first report of successful neonatal ECMO despite azygos vein cannulation in a patient with such rare physiology.

Surgical Expertise in Neonatal Extracorporeal Membrane Oxygenation (ECMO): A Single Center Experience.

Introduction: The surgical technique for peripheral cannulation aimed at providing extracorporeal membrane oxygenation (ECMO) is well described. Training methods for surgeons still need proper standardization, especially in newborn patients. This study aims to evaluate the surgical training outcomes of a neonatal ECMO team. Materials and Methods: A 4 year training program (2014-2018) was developed to achieve the skills in the surgical technique for neonatal veno-arterial ECMO. Surgeons with experience in neonatal and vascular surgery were selected for the training. The training consisted of educational sessions, high-fidelity simulations, in vivo swine model procedures, international fellowship, and periodical simulations. The preliminary clinical experience in surgical neonatal ECMO management (2016-present) was analyzed by recording the following data: indications for ECMO and patients' data; effectiveness of cannulations (number; perioperative complications of cannulation; major surgical events during ECMO); efficacy of decannulation (number and perioperative complications). Results: 12 neonates (5 females) fitted the ELSO criteria for ECMO. Nine newborns were affected by CDH; 1 by H1N1 flu-related pneumonia; 1 by meconium aspiration syndrome and one by Respiratory Syncytial Virus related bronchiolitis. Mean weight at cannulation was 3,281 g (range 2,330-3,840 g); mean gestational age was 36 weeks. No procedure was aborted, and no intra-operatory mortality was recorded. Mean operative time was 86 ± 30 min. The caliber of the carotideal cannulas ranged from 8F (8 patients) to 10F (2 patients); the caliber of the jugular cannulas were: 8F cannula (2 patients), 10F (6 patients), and 12F (2 patients). Four complications occurred: a case of air in the circuit, two cases of azygous vein cannulation and a partial dislocation of the venous cannula during the daily care maneuvers. All of them were promptly recognized and successfully treated. The mean ECMO duration was 7.1 ± 4.2 days (range 2-16 days). Seven patients (78%) were decannulated effectively. Mean decannulation time was 53 min (range 45-80 min). No complications occurred during the decannulation process. No ECMO-related deaths were recorded. Conclusions: Neonatal respiratory ECMO still represents a challenge. Experienced neonatal surgeons can manage the neck vascular cannulation. The codified procedure must be adhered to after appropriate training and following a proper learning curve.

Robotic Therapy: Cost, Accuracy, and Times. New Challenges in the Neonatal Intensive Care Unit.

Background: The medication process in the Neonatal Intensive Care Unit (NICU), can be challenging in terms of costs, time, and the risk of errors. Newborns, especially if born preterm, are more vulnerable to medication errors than adults. Recently, robotic medication compounding has reportedly improved the safety and efficiency of the therapeutic process. In this study, we analyze the advantages of using the I.V. Station® system in our NICU, compared to the manual preparation of injectable drugs in terms of accuracy, cost, and time. Method: An in vitro experimental controlled study was conducted to analyze 10 injectable powdered or liquid drugs. Accuracy was calculated within a 5% difference of the bottle weight during different stages of preparation (reconstitution, dilution, and final product). The overall cost of manual and automated preparations were calculated and compared. Descriptive statistics for each step of the process are presented as mean ± standard deviation or median (range). Results: The median error observed during reconstitution, dilution, and final therapy of the drugs prepared by the I.V. Station® ranged within ±5% accuracy, with narrower ranges of error compared to those prepared manually. With increasing preparations, the I.V. Station® consumed less materials, reduced costs, decreased preparation time, and optimized the medication process, unlike the manual method. In the 10 drugs analyzed, the time saved from using the I.V. Station® ranged from 16 s for acyclovir to 2 h 57 min for teicoplanin, and cost savings varied from 8% for ampicillin to 66% for teicoplanin. These advantages are also capable of continually improving as the total amount of final product increases. Conclusions: The I.V. Station® improved the therapeutic process in our NICU. The benefits included increased precision in drug preparation, improved safety, lowered cost, and saved time. These advantages are particularly important in areas such as the NICU, where the I.V. Station® could improve the delivery of the high complexity of care and a large amount of intravenous therapy typically required. In addition, these benefits may lead to the reduction in medication errors and improve patient and family care; however, additional studies will be required to confirm this hypothesis.

Breastfeeding Difficulties and Risk for Early Breastfeeding Cessation.

Although breast milk is the normative feeding for infants, breastfeeding rates are lower than recommended. We investigated breastfeeding difficulties experienced by mothers in the first months after delivery and their association with early breastfeeding discontinuation. We conducted a prospective observational study. Mothers breastfeeding singleton healthy term newborns at hospital discharge were enrolled and, at three months post-delivery, were administered a questionnaire on their breastfeeding experience. Association among neonatal/maternal characteristics, breastfeeding difficulties and support after hospital discharge, and type of feeding at three months was assessed using multivariate binary logistic regression analysis. We enrolled 792 mothers, 552 completed the study. Around 70.3% of mothers experienced breastfeeding difficulties, reporting cracked nipples, perception of insufficient amount of milk, pain, and fatigue. Difficulties occurred mostly within the first month. Half of mothers with breastfeeding issues felt well-supported by health professionals. Maternal perception of not having a sufficient amount of milk, infant's failure to thrive, mastitis, and the return to work were associated with a higher risk of non-exclusive breastfeeding at three months whereas vaginal delivery and breastfeeding support after hospital discharge were associated with a decreased risk. These results underline the importance of continued, tailored professional breastfeeding support.