Archive for category: Blog

During gestation, babies receive consistent, predictable positioning and sensory input from the womb. Positioning and sensory interventions in the NICU should ideally promote consistency in practice across caregivers, such as using dedicated tools that decrease variability in positioning technique. Having consistent, evidence-based positioning support tools can be viewed as an important step toward improving developmental care.

Our social media series Consistency Is Key covered three main areas of neonatal positioning that benefit greatly from consistent neurodevelopmental support. Find all of the slideshows in one place with additional information about Swaddling, Nesting, and Prone Support below:

Swaddling

Swaddling has been used for centuries to provide babies with warmth and calming containment. Hospitalized babies— especially those born preterm— need consistent, neurodevelopmentally-supportive positioning that aims to bridge the gap between the experience of the womb and the experience of the NICU.

Traditional swaddling with blankets may not provide the right type of support to optimize growth and development. High levels of variation can exist in blanket swaddling techniques, resulting in a variable experience and position for the baby.

Babies also need dynamic boundaries that allow for free movement and periods of active extension, followed by passive recoil to flexion at rest. Traditional blankets may be stiff, preventing free movement and failing to promote recoil to flexion.

An ideal swaddling aid should make it easy to provide the right position and sensations for each baby, without the influence of caregiver preference or technique on the outcome.

Learn more about the Dandle® WRAP Stretch.

Nesting

Positioning nests crafted, folded, or molded by hand are a long-standing tradition in NICU environments.

While these types of support can be effective with the right technique, the potential exists for high variability in positioning across caregivers, babies, and even shifts.

Nesting with products that provide close-fitting, easy-to-replicate positioning support will give the babies the redundancy and dynamic interplay characteristic of the womb. Womb-like positioning can promote deeper sleep, which benefits babies, their parents, and caregivers alike!

Learn more about the Dandle® ROO2.

Prone Support

Developmentally supportive prone positioning should facilitate a flexed posture, with the shoulders rounded, hips and knees flexed, and hands toward the face.

Prone supports that are built from blankets, burp cloths, pillowcases, or other flaccid materials may not be firm enough to promote and maintain proper prone positioning.

Learn more about the Dandy Prone Pad™.

To learn more about the 5 Tenets of Neurodevelopmentally Supportive Positioning™ check out the 5 Tenets Deep-Dive and/or download the Dandle•LION® Positioning Competency Toolkit.

In 2011, national legislation was passed designating the month of June as “National Cytomegalovirus (CMV) Awareness Month” and recommending that “more effort be taken to counsel women of childbearing age of the effect this virus can have on their children.” Even though congenital CMV is the leading viral cause of congenital disabilities and the leading non-genetic cause of childhood hearing loss, most adults have never heard of it. The National CMV Foundation was incorporated in 2014 with hopes of changing these statistics. The organization began with a mission to raise awareness and educate women of childbearing age about congenital CMV. A year later, the National CMV Foundation joined forces with three prominent CMV non-profit organizations: Maddie’s Mission, Stop CMV, and the Utah CMV Council to become the largest national advocacy organization focused on congenital CMV. The organization is focused on our vision to eliminate congenital cytomegalovirus (CMV) in the United States for the next generation. We are honored to share information about CMV for National CMV Awareness Month this month.

What is CMV?

Cytomegalovirus (sy·toe·MEG·a·low·vy·rus) or CMV, is a member of the herpes virus family. Coming into contact with the CMV virus is a common occurrence, typically harmless to the general population. A CMV infection causes cold-like symptoms, such as a sore throat, fever, fatigue, and swollen glands. These mild cytomegalovirus symptoms last for only a few short weeks and are rarely a cause for concern for healthy kids or adults.
 
It is important to note that the CMV virus can cause serious problems for people with weakened immune systems (immunocompromised) due to organ transplants, HIV/AIDS infection, chemotherapy, and specific medications, such as glucocorticoids, cytostatics, antibodies, and drugs acting on immunophilins.
 
The CMV virus can also cause severe disease in babies who were infected with CMV before birth (referred to as congenital CMV infection).
 
According to the Centers for Disease Control and Prevention (CDC), between 50 and 80 percent of people in the United States have had a CMV infection by the time they are 40 years old.
 
Once the CMV virus is in a person’s body, it stays there for life and can reactivate. A person can also be reinfected with a different strain of the virus.

Healthcare Provider Information and Resources

CMV can be a serious problem for babies who are infected before birth. This is referred to as congenital CMV and it occurs when a pregnant woman passes the virus to her unborn child. Congenital CMV can cause birth defects and developmental disabilities and more children will have disabilities due to congenital CMV than other well-known infections and syndromes, including Downs Syndrome, Fetal Alcohol Syndrome, Spina Bifida, and Pediatric HIV/AIDS. We have provided these resources for physicians, OB-GYNs, midwives, nurses, and clinicians to enable better identification, prevention, and treatment for congenital CMV.

In the United States, approximately 1 to 4% of women will have their first, primary CMV infection during pregnancy, and about 40% of these women who become infected with CMV for the first time during pregnancy will pass the virus to their babies. It is crucial that physicians and OB-GYN doctors share this information with women who are pregnant or preparing for pregnancy.

Looking for guidance on how to best counsel women about congenital CMV during pregnancy? The CDC offers a PDF download titled “CMV Facts for Pregnant Women and Parents” that may be helpful here.

About 1 out of every 200 babies (roughly 30,000 children annually) is born with congenital CMV making it the most common congenital viral infection in the United States. More than 6,000 children annually suffer permanent disability as a result. Severe complications from congenital CMV result in approximately 400 deaths nationwide per year.

Transmission

Transmission of CMV is very rare through casual contact. CMV is spread from one person to another, usually by direct and prolonged contact with bodily fluids, including saliva, urine, and breast milk.

CMV is common among healthy children 1 to 3 years of age who attend daycare and can easily spread CMV among their peers. CMV is not generally harmful to these children and most kids will not show any signs or symptoms of infection.

Contact with the saliva or urine of young children is a major cause of CMV infection among pregnant women, especially mothers, daycare workers, preschool teachers, therapists, and nurses. Women who are pregnant or plan to become pregnant should practice standard hygiene procedures around young children to reduce their risk of CMV infection because the virus can be transmitted to their unborn child.

Signs/Symptoms of CMV in the Pregnant Patient

Most people who contract CMV will show no symptoms and may not even know that they have been infected. Others may develop a mild illness and may have any of the following symptoms:

• High fever
• Fatigue
• General discomfort, uneasiness, or ill feeling
• Joint stiffness
• Muscle aches or joint pain 
• Night sweats
• Prolonged fever 
• Sore throat
• Swelling of the lymph nodes 
• Weakness
• Loss of appetite 
• Weight loss

Since these are also symptoms of other illnesses, most people may not realize that they have been infected with CMV. If you have a pregnant patient experiencing symptoms similar to a seasonal illness, order a test for CMV IgM and IgG antibodies.

Signs/Symptoms of CMV in Utero

If your patient is believed to have contracted CMV during their pregnancy, regular ultrasounds and/or amniocentesis are the preferred methods to determine if CMV has been passed to the baby in utero. The CDC includes information about the diagnosis, treatment, and ongoing monitoring in their PDF download, “Diagnose, treat, and monitor children with Congenital Cytomegalovirus (CMV) to help improve their health outcomes“. 

Signs of CMV infection in utero include the following:

• Placental thickening
• Organomegaly – abnormal enlargement of organs
• Hepatomegaly – abnormal enlargement of the liver
• Splenomegaly – abnormal enlargement of the spleen
• Pyelectasis – dilation of the renal pelvis, the funnel-like dilated proximal part of the ureter (muscular tubes that propel urine from the kidneys to the urinary bladder) in the kidney (also a marker for Down Syndrome)
• Megaloureter – abnormal dilation of the ureter
• Ascites – a gastroenterological term for an accumulation of fluid in the peritoneal cavity (is a potential space between the parietal peritoneum and visceral peritoneum, that is, the two membranes that separate the organs in the abdominal cavity from the abdominal wall)
• Fetal hydrops – accumulation of fluid in the fetal compartments
• Abnormality of amniotic fluid
• Microcephaly – small head circumference, more than two standard deviations smaller than average
• Cerebral ventriculomegaly – dilation of the lateral ventricles of the brain
• Intracranial calcifications – the build-up of calcium salts in the soft tissue of the brain
• Hyperdense image in thalamic arteries
• Periventricular echodensities
• Hepatic echodensities
• Intestinal echodensities
• Cystic structures in the germinal zone

Signs/Symptoms of CMV in the Newborn

About 90 percent of babies born with congenital CMV will appear healthy at birth, and the vast majority will not have any visible symptoms or long-term issues. Many times, health problems or disabilities caused by congenital CMV infection can sometimes appear roughly two or more years after birth. Signs of CMV infection that may be present at birth:

• Premature birth
• Small size at birth
• Small for Gestational Age (SGA)
• Intrauterine Growth Restriction (IUGR)
• Red or purple spots on the body caused by broken blood vessels (Petechiae / Purpura)
• Yellow skin and eyes caused by increased bilirubin levels in the blood (Jaundice)
• Liver problems
• Lung problems
• Spleen problems
• Low blood platelet levels (Thrombocytopenia)
• Small head size / small brain (Microcephaly)
• Seizures

If your infant patient shows any of the signs and symptoms listed above, test the infant for congenital CMV infection using a saliva or urine PCR test. It is important to note that congenital CMV can only be accurately diagnosed if the newborn is tested within 21 days of life because, after 3 weeks, it is hard to determine if the baby could have contracted the infection through nursing or by exposure to siblings or others who may be shedding the virus. Please refer to the CDC for additional information regarding interpreting laboratory tests.

Treating Congenital CMV During Pregnancy

If you have a pregnant patient who has been diagnosed with CMV during pregnancy, there are treatments and trials available. Recent studies indicate that Cytomegalovirus Immune Globulin Intravenous (CMV-IGIV) treatment may reduce the risk of congenital infection and/or disease in an unborn baby when given to pregnant women experiencing a primary CMV infection.

If you would like more information about clinical trials and the treatment options available to your patient during their pregnancy, please contact us.

Treating Congenital CMV in Newborns

Emerging research shows that antiviral drugs, Ganciclovir or Valganciclovir, may help newborns born with symptomatic congenital CMV. These antiviral treatments may prevent or lessen the severity of hearing loss and may improve head and brain growth. Ganciclovir and Valganciclovir can also help combat immediate medical concerns caused by CMV, such as thrombocytopenia, organ failure (most commonly spleen and/or liver), hepatitis, and pneumonitis. Treatments generally last from six weeks to six months and are administered orally or through an IV or PICC line.

Both Ganciclovir and Valganciclovir can have serious side effects, so be sure to consult with a doctor before and during the treatment period. Newborns receiving these antiviral treatments should have their regular blood counts taken to avoid problems with severe neutropenia or anemia.

If you have a newborn patient born with congenital CMV and you would like more information about antiviral treatments, please contact us. Ongoing Interventions & Therapies If you have a newborn patient diagnosed with congenital CMV, be sure to refer the patient to have their hearing and vision checked regularly to identify any early onset of hearing or vision loss. Early diagnosis is critical to experiencing long-term developmental successes.

If you are concerned about potential seizure activity in the newborn, ask the parent to record the baby’s behavior for your review. They may need to schedule a consult with a pediatric neurologist. Additional monitoring, including EEG, may be suggested to properly diagnose whether the child is experiencing seizures.

Refer your newborn patients born with congenital CMV to your local Early Intervention (EI) program to determine whether the child should be evaluated for EI services.

This information was provided by Farah Armstrong, founder of Maddie’s Mission and a co-founder of the National CMV Foundation. A graduate of the University of Texas, Farah has a Bachelor’s degree in Mechanical Engineering, with 10 years of work experience as an engineer with BP in Houston and a field development engineer with FMC Technologies in Singapore. When her daughter Madeline was born, they discovered she was severely affected by CMV, and she passed away after 12 days of life. In her honor, Farah began Maddie’s Mission. Her extensive engineering background gives her great expertise in planning, budgeting, and executing detailed operations, bringing together large groups of people from different backgrounds.

Dandle•LION is proud to partner with expert clinicians to provide the best available education and evidence-based care strategies. This month, we are excited to introduce you to Dr. Elizabeth Jeanson PT, DPT, CNT,  DCS, NTMTC. Elizabeth is the Developmental Specialist and Neonatal Therapist in Neonatal Intensive Care at Sanford Children’s Hospital/USD Medical Center in Sioux Falls, South Dakota!

In her role as the developmental specialist, Elizabeth has the opportunity to implement developmental care protocols and practices for the unit and complete yearly developmental care quality improvement projects. In her role as a neonatal therapist Elizabeth is involved in direct patient care, family support, and education at the bedside. 

Over the past 22 years, both Sanford Children’s Hospital and DuPont Hospital for Children have benefited from Elizabeth’s expertise and passion. Elizabeth completed NIDCAP training and Infant Behavioral Assessment certification. She is NeoNatal Neurobehavioral Scale (NNNS) and Neonatal Touch and Massage Therapy (NTMTC) certified, as well as being a certified neonatal therapist (CNT). 

As a firm believer in sharing information and experiences, Elizabeth has presented nationally on topics including sensory development, positioning, nonpharmacologic pain management, change management, quality improvement, and Infant Driven Feeding™ Implementation. She is a NANT, Neonatal Touch and Massage, and Dr. Brown’s Medical lecturer. 

Elizabeth has published two articles in peer-reviewed journals: One to One Bedside Nurse Education as a Means to Improve Positioning Consistency in 2013 and Applying the Four Disciplines of Execution to Promote Culture Change in the NICU in 2020. Currently, Elizabeth is formulating a change process mentoring system and working towards creative integration of trauma-informed care into the daily interactions with infants and families in the NICU.

Working in the NICU is a highly unique form of nursing that branches out further into multiple specialties depending on the specific population of infants a nurse works with. There are many different certifications within NICU nursing that allow for more specialized care. Here are a few:

American Association of Critical-Care Nurses (AACN)

Critical-Care Registered Nurse (CCRN®)

This neonatal certification is for nurses “who provide direct care to acutely or critically ill neonatal patients regardless of their physical location.” Nurses who work in NICUs, cardiac care units, combined ICU/CCUs, medical/surgical ICUs, or other similar areas may be interested in this certification.

Find more information here.

Acute/Critical Care Knowledge Professional (CCRN-K)

This neonatal certification is for nurses “who influence the care delivered to acutely or critically ill neonatal patients but do not primarily or exclusively provide direct care.” Nurses who work as clinical educators, manager/supervisors, directors, or other similar areas may be interested in this certification.

Find more information here.

Neonatal Acute Care Clinical Nurse Specialist (ACCNS-N)

This is an entry-level advanced practice board certification “for clinical nurse specialists (CNSs) educated at the graduate level to provide advanced nursing care across the continuum of healthcare services—wellness through acute care—to meet the specialized needs of the neonatal patient population.”

Find more information here.

National Certification Corporation (NCC)

Registered Nurse Certified – Neonatal Intensive Care Nursing (RNC-NIC®)

According to the NCC summary, this certification “focuses on the care of the high-risk neonate. It demonstrates the specialty knowledge of Neonatal ICU nurses who provide care to acutely and critically ill neonatal patients and their families within an intensive care environment.” 

Find more information here.

Neonatal Neuro-Intensive Care (C-NNIC)

This certification “focuses on the neurological care of at-risk or impaired neonates within an intensive care environment” according to the NCC certification summary. It was created for those working in neonatal intensive care who want “to improve overall outcomes for these extremely vulnerable patients.”

Find more information here.

Neonatal Pediatric Transport (C-NPT®)

This certification provides designation for a paramedic, physician, respiratory therapist, neonatal nurse, nurse practitioner, nurse, or physician assistant to “provide stabilization and transport interventions to critically ill neonatal and pediatric patients in all types of settings” according to the NCC summary.

Find more information here.

Care of the Extremely Low Birth Weight Neonate (C-ELBW)

This subspecialty certification is designed for those who “provide care to acutely and critically ill extremely low birth weight neonates and their families within an intensive care environment to improve overall outcomes.”

Find more information here.

Low Risk Neonatal Intensive Care Nursing (RNC-LRN®)

This certification is for licensed registered nurses in the US and Canada who have a minimum of two years of specialized experience in “providing care to acutely and chronically ill neonatal patients and their families within level II, chronic care, special care, or step-down units.”

Find more information here.

Neonatal Nurse Practitioner (NNP-BC®)

This Core certification provides an entry-level, competency-based examination for licensed registered nurses in the US and Canada who have completed a US accredited nurse practitioner program to “provide care to acutely and critically ill neonatal patients and their families within hospitals or outpatient settings.”

Find more information here.