A few days ago Nick Hall from Graham’s Foundation posted the following question on Linkedin:
Private room vs open bay for the NICU. Can always get a quote from a parent saying it is great but….? At what cost? Impact on staff? Is parent time in those NICUs greater now? Other alternatives?
Included in the post was an article discussing the benefits of such a design. Below I will look at the benefits and risks and conclude with an answer to his last question.
The NICUs of the 1970s through late 1990s have been described as “barn like” or “open concept” but in recent years the belief that single patient rooms (SPR) would offer greater benefit to infants led to the adoption of such a unit design across North America. The imagined benefits would be related to improved parent comfort, creating a desire for families to spend more time with their children. As we move to a “family centred” approach to care, a key goal of all units should be to make their families as comfortable and stress free as possible in order to have a positive experience.
Detractors meanwhile, speak of concern regarding isolation of such infants when families do not visit and moreover a risk that such infants deprived of sensory experience will have impaired development. Last year a paper was published that did not help quell such fears; Alterations in Brain Structure and Neurodevelopmental Outcome in Preterm Infants Hospitalized in Different Neonatal Intensive Care Unit Environments (full article in link). This study which compared infants cared for in SPR to an open unit (the hospital in this study had a mixture of both in their NICU) found a worrisome finding at 2 year follow-up in that the infants in SPR had lower scores on language and a trend towards lower motor scores as well. Additionally, partly explaining such findings may have been differences noted at term equivalent age in both the structure and activity of the children’s brains compared to those cared for in an open environment. We were starting construction on a new NICU at the time this paper was published and I can tell you the findings sent shockwaves through our hospital as many wondered whether this was the right decision.
Devil Is in The Details
Looking further into this study, the urban population bore little resemblance to our own. In our hospital all women are taught how to perform skin to skin care and the majority of our mothers spend a great deal of time with their infants. To see how successful have a look at our recent Kangaroo Care drive results! The families in this study however the average hours per week of parent visitation over the length of stay ranged from 1.8-104 hours with a mean of 19+/- 19 hours. The average number of days held per week over the length of stay was 0-6 days with a mean of 2.4 +/-1.5 days. The average number of days held skin-to-skin over the length of stay ranged from 0-4 days, with a mean of 0.7 +/- 0.9 days. In short they were hardly there.
Second Study Finds The Opposite
Later on in 2014 a second study on this subject was published; Single-family room care and neurobehavioral and medical outcomes in preterm infants. Infants < 1500g who were admitted to an NICU between 2008 and 2012 were compared with respect to medical and neurobehavioral outcomes at discharge. Participants included 151 infants in an open-bay NICU and 252 infants after transition to a SPR NICU.
Statistically significant results (all Ps ≤.05) showed that infants in the SPR NICU weighed more at discharge, had a greater rate of weight gain, required fewer medical procedures, had a lower gestational age at full enteral feed and less sepsis, showed better attention, less physiologic stress, less hypertonicity, less lethargy, and less pain. Nurses reported a more positive work environment and attitudes in the SPR NICU.
This study in fact demonstrated greater maternal involvement in a SPR with improvement in outcomes across the board. It would seem then that in a SPR environment, provided there is enough family visitation and involvement this model truly is superior to the open concept. Furthermore despite concerns by some nurses that the loss of line of sight to their patients will make for a more stressful working environment this does not seem to be the case.
What About Families Who Cannot or Simply Aren’t Visiting Frequently?
The reality is that there are many reasons for parents to be absent for long periods during their newborns stay. Having a home outside of the city with other children to care for, work obligations, or loss of custody and abandonment due to apprehension are just some of these reasons. In our hospital, at least 15-20% of all patients admitted are from outside Winnipeg. The evidence as I see it supports the move to a SPR but what do we do for those children who need more visitation? The solution is a cuddler program.
As we prepare to move to the new hospital we are grateful for the generosity of our Children’s Hospital Foundation who secured a donor to pay for a coordinator of such a program. The coordinator’s responsibility will be to ensure that no infant goes beyond a set period of time without feeling the touch or hearing the sound of a voice. Such a program is in fact already in place at our other tertiary hospital and was featured in a lovely article attached here.
The SPR is the right design in my mind for families with many benefits that spring forth in such an environment. This need not be a win-lose scenario for your hospital. Do not underestimate the power of a cuddler and don’t hesitate to seek support to initiate such a program. It could mean the difference from going from good to great!
It’s the 5th International Kangaroo Care Day!
We took the challenge this year again and I am happy to announce achieved even greater success than last time around! Since the last time we have purchased special clothing to facilitate the practice and with this new initiative perhaps it helped us reach new highs! Here are the results paraphrased from one of our very own!
At St. Boniface Hospital
“663 hours and 29 minutes. This means 2 hours and 4 minutes per patient per day.
The really great part of this is the involvement we had from L&D and LDRP. Both units kept log sheets and informed patients and visitors about the importance of Skin to Skin.
L&D logged 65 hours and 27 minutes for 58 patients which equals more than an hour per patient, their patients don’t stay as long.
LDRP logged a total of 268 hours and 47 minutes for 34 patients which is more than 8 hours of skin to skin per patient and baby. LDRP had some parents who did more than 15 hours during their hospital stay, one family logged 34 hours!
321 hours of KC in the 3 Neonatal Areas combined!
.5 hours per patient per day eligible for KC! (excludes those too sick)
How Does This Compare to Last Year (For St.B)?
Sunnybrook NICU in Toronto put out a challenge to promote Kangaroo Care for a two-week period to in the NICU. We took the challenge at St. Boniface Hospital and here are the results…
Our dates were from April 13-27.
We totaled 647 hours and 10 minutes, equals 27 days worth of skin to skin.
Total of 36 babies in the unit, another 14 infants that were held KC while in a C-section or being monitored by our Observation staff (these babies had TTN and were being transitioned KC in L&D and LDRP.
We had 9 long term micro premies that were in the unit at the time of the challenge, they averaged 33-69 hours during the two week period.
Not bad at all I say based on the number of babies we had! This represents an average of 18 hours of KC per baby over that time!
You have likely heard of Kangaroo Care and you may have even seen some children receiving it in your hospital. Why is this so important?
Kangaroo Care (KC) or Skin to Skin Care (STS) is an ideal method of involving parents in the care of their premature infant. It fosters bonding between parents and their hospitalized infant, encourages the family to be with their child and thereby exposes them to other elements of neonatal care that they can take part in. While we know that many units are practising Kangaroo Care there is a big difference between having KC in your unit and doing everything you can to maximize the opportunity that your families have to participate.
There is much more to KC than simply holding a baby against your chest. For a demonstration of KC please watch the accompanying video and show it to any one in your units that may need a visual demonstration. This excellent video is from Nationwide Children’s Hospital and walks you through all of the important steps to get it right and maximize benefit.
Before you reach the conclusion that KC only serves to enhance the parental experience it does so much more than that. The practice began in Bogota Columbia in 1979 in order to deal with a shortage of incubators and associated rampant hospital infections. The results of their intervention were dramatic and lead to the spread of this strategy worldwide. The person credited with helping to spread the word and establish KC as a standard of care in many NICUs is Nils Bergman and his story and commentary can be found here http://bit.ly/1cqIXlm
The effects of KC are dramatic and effective to reduce many important morbidities and conclusively has led to a reduction in death arguably the most important outcome. An analysis of effect has been the subject of several Cochrane Collaboration reviews with the most recent one being found here.
To summarize though, the use of KC or STS care has resulted in the following overall benefits to premature infants at discharge or 40 – 41 weeks’ postmenstrual age:
mortality (typical RR 0.68, 95% CI 0.48 to 0.96)
nosocomial infection/sepsis (typical RR 0.57, 95% CI 0.40 to 0.80)
hypothermia (typical RR 0.23, 95% CI 0.10 to 0.55)
KMC was found to increase some measures of infant growth, breastfeeding, and mother-infant attachment
To put this in perspective, medicine is littered with great medications that never achieved such impact as simply putting your child against your chest. This is another shining example of doing more with less. This is not to say that modern medicine and technology does not have its place in the NICU but KC is simply too powerful a strategy not to use and promote routinely in the NICU.
Please join me in championing this wonderful technique and make a difference to all of our babies!
A sample of our parent letter to promote KC is found in the link below.
Parent letter II
As those of you who have been following this blog are aware, I am always on the lookout for strategies that can help minimize blood work without sacrificing care in the NICU. At particular risk our the very premature infants in our units who for example at 1 kg have about 80-90 mL of blood. It does not take very many 0.5 – 1 mL “small” draws to create anemia. In a recent study (free article in link) of infants less than 1500g entitled A mathematical modeling approach to quantify the role of phlebotomy losses and need for transfusions in neonatal anemia, the authors studied 26 infants over a one month period. The results were staggering in that these infants experienced 138 +/- 21 blood draws with an average of nearly four transfusions per patient. While the authors do not specify what type of testing was done they did find a shocking statistic that 59% of the blood collected by weight of sample was discarded. This certainly stresses the point that we should aim to minimize the volume of sample collected in each case to that which is only necessary for the equipment to run. Furthermore, strategies to minimize sample draws should be utilized where possible and if accuracy permits point of care technology may further reduce volumes required and provide immediate results at the bedside. Lastly where possible, utilizing non-invasive technology to avoid blood draws needs to be explored when possible and was the subject of another post on Masimo non-invasive HgB measurement (http://wp.me/p5NWfD-1t).
Certainly in sick neonates whether they be term or preterm the drawing of blood gases to monitor ventilation contributes to the anemia of prematurity which often culminates in a transfusion. Sicker infants with greater lability due to respiratory compromise are deserving of optimal ventilation and this is achieved by monitoring pCO2 levels in arterial or venous samples. There have been different strategies employed to replace the sampling of CO2 by blood gas analysis which have not been very successful but there is one that I believe has promise that I will discuss at the end.
Transcutaneous pCO2 measurement was introduced in the 1980s. While this technology does allow measurement of pCO2 the variation between true arterial pCO2 and tcPCO2 can be wide making the technology difficult to implement on a consistent basis. In particular the accuracy in infants <28 weeks has been quite poor leading to increased numbers of arterial and venous samples to “check” ow closely the results correlate. As was described in 2005 by Aliwalas LL et al the technology in this group who actually have the highest number of blood draws does not meet the required standard to replace arterial pCO2 measurements (http://www.ncbi.nlm.nih.gov/pubmed/15496874)
Another method is of directly sampling exhaled CO2 in ventilated patients. Traditionally such measurements were taken with proximal gas sampling and in neonates in particular the results were discouraging. Problems encountered with proximal end tidal sampling were related to the lack of cuffed endotracheal tubes in part as the measured gas would be diluted with air in the presence of any leak around the tube leading to underestimation of true CO2 levels. Furthermore, in the presence of significant pulmonary disease the clearance of CO2 may be impaired such that the arterial pCO2 – ETCO2 difference may be quite large. For a review see the free article by Malloy and Deakins Are carbon dioxide detectors useful in neonates? The agreement between arterial and proximal sampling measured in this way has been quite variable and as such the technology has not really caught on to any great degree for monitoring ventilated infants. That being said it can be quite useful at determining if the endotracheal tube is in the trachea or esophagus. The presence of the waveform even if not yielding an accurate level confirms proper placement although where the tube sits in the trachea still needs confirmation.
The final method for sampling CO2 is the one which I believe holds the most promise for actually reducing blood draws and by extension risk of anemia and pain in the neonate. Kugelman and colleagues in Haifa, Israel published the following paper (free article in the link) A novel method of distal end-tidal CO2 capnography in intubated infants- comparison with arterial CO2 and with proximal mainstream end-tidal CO2. This creative study utilized a double lumen endotracheal tube which had been designed for surfactant installation and distal pressure measurement to instead sample pCO2 near the carina. This strategy was postulated to eliminate the issue with dilution of gas from proximal sampling and provide a closer measurement of true pCO2 when compared to arterial CO2 and proximal sampling. They studied 27 infants with varying degrees of pulmonary condition severity although most had RDS. When comparing the three methods of pCO2 measurement the following was found.
This demonstrates that while proximal measurement was quite poorly correlated with true arterial pCO2 the distal measurement was much more accurate. In fact the mean differences between arterial pCO2 and distal measurement was -1.5 mm Hg while that of proximal measurement -10.2 mm Hg albeit with wide confidence intervals. As found in other studies of proximal end tidal CO2 measurement, worse pulmonary disease correlated with worse accuracy as shown in table 2.
As the pCO2 rises above 60 the accuracy is less but remains much better than proximal measurements. Interestingly the same group has published an additional trial using high frequency ventilation and confirmed the measurements remain accurate. (http://www.ncbi.nlm.nih.gov/pubmed/22328495)
So what does the future hold? in VLBW infants one concern may be the internal diameter of the smallest double lumen tubes and the effect of upsizing to a larger tube and risk of subglottic stenosis. After a personal communication with Dr. Kugelman I understand that this has not been an issue in their unit as they tend to use these double lumen tubes in most if not all of the their infants. The accuracy is sufficient enough from my point of view that units should be able to implement this strategy at least in larger infants at first (those who would need a 3.0 ETT and larger) to see the effect on blood sampling. I suspect that one blood gas a day to determine accuracy in a given patient would be sufficient most of the time if the numbers were found to correlate well.
I would welcome feedback from people who work in units where this strategy has been utilized. How effective is it? Did it reduce your blood gas draws or increase them due to unreliability? Have you seen a rise in subglottic stenosis? Please send your feedback to either this site or at my Facebook page at www.facebook.com/AllThingsNeonatal.
Thus far in my career, I have been called to the bedside to look at a female ex-preterm infant several times due to the complaint of swelling that usually extends from the lower abdomen to the upper thighs. Usually the clitoris and hood are swollen as well and at times raises the suspicion of cliteromegaly. The enlarged clitoris then prompts the question of whether the patient could be virilized from Congenital Adrenal Hyperplasia or perhaps even be male in extreme cases. As I think back on some of these babies, nursing often has expressed concerns that the infants are uncomfortable and have either been treated with furosemide (unsuccessfully) or pain medication for the perceived discomfort.
As you might expect from the first paragraph I believe I have found the answer which came to me through a circuitous route. We had a patient in the hospital recently whose phallus was small for his gestational age. After consulting the Pediatric Endocrinologist on service we performed a hormonal workup which excluded hypogonadotropic hypogonadism (small phallus due to a lack of male hormones) and insensitivity to testosterone. Our Neonatal service was advised that this child would likely experience penile growth during “Mini Puberty” I don’t know about you but I had never heard of the term so I began a search that culminated in me writing this post to hopefully bring others up to speed.
Mini puberty is secondary to the normal rise in testosterone that occurs after delivery. In utero both estrogen and testosterone inhibit GNRH with estrogen from the placenta being the most potent inhibitor. Once the placenta is removed this inhibition is lost leading to LH and FSH levels rising which peak between the 4th to 10th week that finally begin to decline after 7 months of age. The level of testosterone similarly peaks by 3 months and reaches pre-pubertal levels by 6-9 months. During this time there is an increase in testicular volume and less so penile length but a patient such as ours might reach a normal length with such stimulation if the length was not extremely short before “Mini Puberty”.
In female infants it is somewhat different in that pre-pubertal levels of estradiol are reached by two months of age. Given the lack of stimulation from excessive levels of estradiol how can we tie this back to the question of genital swelling?
In 1985 Sedin G et al published a case series of 4 premature infants who demonstrated swelling of the lower abdomen, labia and upper thighs. In each case the etiology was found to be the same; estradiol producing ovarian cysts. In one case the cyst was removed and with it the edema resolved and in the other cases progesterone was utilized to suppress production of Gonadotropin Releasing Hormone (GNRH) and with it production of FSH and LH, thereby reducing the estradiol levels. Ultrasound in each case also revealed uterine enlargement consistent with over stimulation. What is it that causes this phenomenon is unknown for sure but it is certainly curious that the condition only seems to affect preterm infants born at < 29 weeks. Furthermore the timing of the edema is consistently at 36 – 39 weeks CGA. Sedin postulates that the reason for this is that the hypothalamic pituitary axis is immature in these preterm infants and does not provide the negative feedback to reduce LH and FSH compared to the term infant in which such sensitivity is present.
Additionally another theory is that vascular endothelial growth factor released from ovarian granulosa and thecal cells may be involved. Since the report by Sedin, Starzyk et al have reported an additional 9 patients with such edema and ovarian cysts http://www.ncbi.nlm.nih.gov/pubmed/19039238
I suspect that many Neonatal units across the World have encountered such patients and tried a collection of treatments including furosemide or other diuretics along with fluid restriction. Unfortunately there has not been widespread description of such patients and it is my hope that with this post, awareness will increase of both “Mini Puberty” and “Genital Edema in females”. What is really needed in the latter is consultation with Endocrinology to perform provocative Hypothalamic Pituitary Axis testing and an ultrasound to confirm the presence of uterine hypertrophy and cysts. Treatment with progesterone or some other inhibitor of the GNRH will likely bring about resolution in a timely fashion without exposing the infant to a multitude of testing. Lastly such infants are often described as appearing uncomfortable which may be related to the ovarian cysts or the swelling but in either case adequate analgesia should be provided.
This truly is a post that I hope is shared with others so that we can increase awareness as there are certain to be cases in units right now that might do well to understand this condition.
To quote Malcolm Gladwell, I think I witnessed a “Tipping Point” yesterday. The standard of practice for determining the presence or absence of pneumonia and pneumothorax has always been a chest radiograph. Determination of fluid collections by ultrasonography in the chest or abdomen, the domain of the Pediatric Radiologist.
Yesterday however, I was introduced to the use of bedside Point of Care Ultrasound (POC U/S) for the diagnosis of all of these aforementioned conditions. I spent the morning at a course on POC U/S for the Neonatologist and with that became comfortable much sooner than I expected with making such diagnoses based on some very straightforward criteria. Now before you think I am getting ahead of myself, I do not believe for a second that I am now competent to use U/S to replace radiographs as the “gold standard” in my practice. It has led me to consider though how one might go about reaching this level of confidence but I will share more on that later.
An example of how one can use ultrasound to exclude a pneumothorax is shown here https://www.youtube.com/watch?v=ws7DI4ZGQCo. The presence of bilateral “lung sliding” of the parietal and visceral pleura accompanied by “comet trails” excludes a pneumothorax. The absence of these findings is suggestive of a pneumothorax although other pathological findings can be present necessitating a chest x-ray. Think of how many times a patient develops a sudden increase in FiO2 and you do a chest x-ray to exclude a pneumothorax before increasing PEEP. This could change with acquisition of such technology.
The first question to really ask before taking the leap to replace or augment the classic chest radiograph is to look at the literature. With respect to the Neonate, the body of literature is not large but there are a couple of recent papers that are worth mentioning. The first is by Pereda MA et al. Lung Ultrasound for the Diagnosis of Pneumonia in Children: A Meta-analysis. (http://1.usa.gov/1CM24Sv) The review examined 9 studies of which 2 were in the neonatal population. The findings were intriguing. The sensitivity was 96% and specificity 93% when compared to the “Gold Standard” of either CXR or CXR with clinical diagnosis. To put this into context, there were 765 children who would have had thousands of x-rays during their hospital stay. This technology could reduce the number to ionizing radiation exposure by an extraordinary amount given the accuracy of the test compared to standard x-rays. The benefit of such reduction can be immediately appreciated when one considers that children are at an increased risk of malignancy compared to adults from ionizing radiation. Free supporting publication here.
The second paper to highlight is by Lovrenski J. Lung Ultrasonography of pulmonary complications in preterm infants with respiratory distress syndrome. Free supporting publication here
In this paper 120 patients with respiratory distress syndrome had U/S performed in the first 24 hours of life and then follow-up as indicated. Of this sample, 47 had complications including hemorrhage, pneumothorax, pneumonia, atelectasis and bronchopulmonary dysplasia. Of this group 45 were detected by ultrasound with the only two failures being small pneumothoraces. There were 512 ultrasounds performed compared to 612 clinically indicated chest x-rays during the same period. Again the potential reduction in ionizing radiation is astounding!
To be clear I am not suggesting that we do away with the chest x-ray but rather there is a great potential for reducing the need for the urgent chest x-ray when patient status changes. Depending on the situation in the unit you work in, an x-ray from the time it is ordered till the time it is performed and processed can be 15-30 minutes or more. The time it takes to perform a bedside ultrasound exam is 2-3 minutes at most making this modality at least in my mind a great first line option.
As I mentioned earlier though I am not an expert but merely an enthusiastic Neonatologist. This is not meant to replace the Pediatric Radiologist and in fact I would like to stress that I believe it is best suited to questions in which a binary yes/no answer is being asked. Does the patient have a pneumothorax, atelectasis, fluid in the abdomen or chest; all yes/no. Does the patient have a tumour in the liver and if so what type? That is a different kettle of fish and deserving of a Pediatric Radiologist’s opinion.
How do we go from “good to great” and utilize this technology accurately and safely. Clearly we are in need of practice, which can only come through training by qualified people who have demonstrated proficiency in the field. Thankfully in our situation we have access to individuals who have taught courses internationally and are willing to provide the training locally to us. Our strategy will include monthly U/S rounds supervised by these two experts who will provide a small group of us “superusers” with the training and ultimately confidence to put this into routine clinical practice. As confidence rises, the use of POC U/S to obtain vascular access will develop as will performance of such procedures as a bladder tap under direct visualization to improve our success rate. I suspect new uses will develop over time as we are at the forefront of this technology. There are courses offered abroad but like the paucity of Neonatal research in the area there are very few if any such programs for the Neonate specifically.
What I can say for sure is that the benefits of POC U/S are vast and I believe our patients will benefit both during their hospital stay and into adulthood due to the reduction in ionizing radiation that I see coming for these fragile infants. I for one am excited and energized by the future of this field and look forward to an expanding body of literature on the topic.