Neonatology and Perinatology

Ke-Ni Tien has been in Neonatal Clinical Practice sine 1991, having worked in Taiwan and some of the Nation’s top ranked Neonatal Intensive Care Units. She currently serves as a Neonatal Nurse Practitioner (NNP) full-time with Cleveland Clinic Children’s and part-time with Johns Hopkins Children’s Center. Ke-Ni holds an earned Master of Science in Nursing from Arizona State University (2007) and is currently a Doctoral Candidate in Nursing Practice (DNP) with the University of Maryland. Her interests concentrate on the synthesis of neonatal research, education and quality improvement projects, transforming data driven interdisciplinary team approaches into tangible improvement outcomes.

Antibiotics are the most commonly prescribed medications in the neonatal population. Early antibiotic exposure is associated with asthma, allergic reaction, autoimmune disease, and obesity later in childhood. In this newborn setting, the providers most commonly refer to the 2010 CDC guideline for managing infants at risk for early-onset sepsis (EOS). However, the interpretation of the guideline varies among providers. Evidence suggests that implementing a neonatal earlyonset sepsis (EOS) calculator decreases the number of infants requiring antibiotic prophylaxis and reduces antibiotic exposure safely. The purpose of this quality improvement (QI) scholarly project was to implement the EOS calculator for infants ≥35 weeks gestational age (GA) with infection risk factors but well appearing in a newborn nursery (NBN) at an urban medical center setting in Maryland to reduce the need for laboratory evaluation and antibiotic exposure, as well as to standardize the practice. Focus-Analyze-Develop-Execute/Evaluate (FADE) was the quality improvement (QI) model used for this project. All infants born at ³ 35 0/7 weeks’ gestation (n= 190) at the study hospital were enrolled over 11 weeks, September 9, 2018, to November 22, 2018. A retrospective chart review was also conducted to establish a baseline of comparison (n= 144). Based on the data, 174 out of 190 infants (91.6%) were managed utilizing the EOS calculator from birth to 12 hours of life. Seven out of one hundred and seventy-four infants (4%) received sepsis laboratory evaluation, compared to 25 infants out of 144 (17.3%) before the implementation. The percentage of infants needing laboratory evaluation significantly decreased with the use of the EOS calculator (p < 0.05). The results of this project reveal a decrease in laboratory evaluation and prophylactic antibiotic use by utilizing the EOS calculator. The significant declines suggest that continued and widespread use of the EOS calculator has a significant impact on antibiotic usage in this well newborn nursery.

Gayatri Jape (MD, FRACP) is a consultant neonatologist at King Edward Memorial Hospital (KEMH) in Perth, Western Australia. She is a Clinical Senior Lecturer at the University of Western Australia. She has worked in Pediatrics and Neonatology since last 15 years in Australia and overseas. Dr Jape is involved in follow up of high risk preterm infants till five years of age as a part of the Neonatal Follow Up Program at KEMH. She is pursuing a PhD focussed on probiotics,nutrition and long term neurodevelopment in preterm infants. She led a randomized controlled trial on effect of single or three strain probiotic on enteral nutrition in extremely preterm infants (SiMPro, ACTRN12615000940572) which is currently in the long term follow up phase. Dr Jape has also completed her Graduate Certificate in Autism Diagnosis from UWA. She has published articles and is an international reviewer for good impact peer-reviewed journals.

Administration of oropharyngeal colostrum (OPC) is safe, feasible, and potentially beneficial in preterm infants. We aimed to assess the effects of OPC in preterm infants. A systematic review of randomized controlled trials (RCTs) and non-RCTs of OPC administration in preterm infants was conducted. We searched MEDLINE via PubMed and Ovid, EMBASE, Cochrane Central Register of Controlled Trials, Emcare databases, proceedings of Pediatric Academic Society meetings and grey literature in April 2018. Six RCTs (N=269) and four non-RCTs (N=737) were included. One RCT (n=40) focussed on enteral bovine colostrum and hence was excluded from our review. Five of the six RCTs had unclear risk of bias in many domains of assessment. Meta-analysis (random effects model) of RCT data showed no significant difference in ≥ stage 2 necrotizing enterocolitis [Relative Risk (RR): 0.83; 95% CI 0.39, 1.75; P=0.62], late onset sepsis [RR: 0.78 (95%CI 0.50, 1.22) P=0.28], all-cause mortality [RR: 0.74 (95%CI 0.27, 2.06); P=0.56]; duration of hospital stay [Mean Difference (MD): -1.65 days (95%CI: -10.09, 6.80); P=0.70] and time to full feeds [MD: -2.86 days (95% CI -6.49, 0.77); P=0.12]. Meta-analysis of data from non-RCTs also showed no benefit for any of these outcomes. OPC increased secretory IgA and lactoferrin levels (four RCTs), but did not alter oral microbiome (one RCT). There were no adverse effects (e.g. aspiration) of OPC. The overall quality of evidence (GRADE analysis) was very low. Adequately powered RCTs are needed to confirm the nutritional and immunomodulatory benefits of OPC in preterm infants.

Inna Yoffe Vaisman has completed her MHA at the age of 26 years from Tel Aviv University. She is the Clinical Nurse Manager at Pediatric surgery department in Sheba Medical Center at Tel Hashomer, Israel.

Patient-centered care (PCC) is one of the main components of the IOM (2001) Quality Therapy, which addresses quality treatment according to the IOM Report (2001). Quality treatment respects the patient and addresses the patient's preferences, needs, and values, ensuring that patient values guide clinical decision-making. Preparing children for surgery reduces their anxiety level before and after surgery compared with unprepared children (Li & Lopez, 2008). The positive experience of the patient from the procedure is critical and influences the child's continued perception of his or her stay in the hospital. Therefore, it was decided to improve the pre-surgery procedure performed towards children's surgery in order to reduce the level of anxiety among children and their parents, to increase their sense of control and thereby to achieve cooperation between the child and his family.An intervention program was introduced that included age-appropriate structured instruction and a developmental stage of the "young patient".Raising awareness of the existing staff and preparing a training program for new nursing staff.Assessment of patient and family satisfaction before and after the intervention program.The intervention program contributed in a variety of ways to the general feeling of satisfaction with the preoperative process, and specifically to understanding the way in which the procedure was conducted and how the information about the planned operation was offered. The implications of the intervention program are very significant, as comprehensive adjusted training, patient empowerment, and empathic intervention have been shown to contribute to the sense of satisfaction and to generally improve the experience of hospitalization.

Ke-Ni Tien has been in Neonatal Clinical Practice sine 1991, having worked in Taiwan and some of the Nation’s top ranked Neonatal Intensive Care Units. She currently serves as a Neonatal Nurse Practitioner (NNP) full-time with Cleveland Clinic Children’s and part-time with Johns Hopkins Children’s Center. Ke-Ni holds an earned Master of Science in Nursing from Arizona State University (2007) and is currently a Doctoral Candidate in Nursing Practice (DNP) with the University of Maryland. Her interests concentrate on the synthesis of neonatal research, education and quality improvement projects, transforming data driven interdisciplinary team approaches into tangible improvement outcomes.

BACKGROUND: Antibiotics are the most commonly prescribed medications in the neonatal population throughout the country, especially in well appearing infants in the first few days of life (Polin, 2012; Tappero, 2004). Many undesirable consequences have been associated with unnecessary sepsis evaluations and antibiotic exposure. In our institution, those infants who were born to mothers with chorioamnionitis diagnoses, we obtained blood work at birth including complete blood count with differential (CBC/d), blood culture and initiated empiric antibiotics. Repeated CBC/d along with c-reactive protein (CRP) were collected at 24 hours of life. Additionally, infants who were born to mothers with prolonged rupture of membranes (PROM) also received the same laboratory evaluation without empiric antibiotics. METHODS: The Kaiser Early-Onset Sepsis (EOS) calculator was implemented on June 1, 2018 in the newborn nursery to newborns born to mothers with chorioamnionitis, PROM, and preterm infants born to mothers with unknown GBS or GBS+ but inadequately treated. RESULTS: W3e have effectively decreased the antibiotic usage rate (AUR), blood work evaluations, and the length of hospital stay since June 1, 2018. During the first three month period, our sepsis laboratory evaluation rate on asymptomatic infants with risk factors decreased from 100% to 15.7% and the empiric antibiotic use decreased from 100% to 2.9%. DISCUSSION: Initial challenges we encountered with planning and implementing the EOS calculator were concerns regarding a drastic practice change and the fear of missing treatment for possible sepsis. With careful interdisciplinary planning and education, ensuring proper team notification and consult for all infants at risk, usage of the EOS calculator and close follow-up, provider support gradually improved.