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CONTRIBUTORS
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Beena D. Kamath-Rayne, MD, MPH
Associate Professor of Pediatrics Department of Pediatrics University of Cincinnati College of Medicine; Associate Professor of Pediatrics Perinatal Institute Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio
Megan Kirkley, MD, MPH
Assistant Professor Department of Pediatrics University of Colorado School of Medicine Aurora, Colorado; Neonatologist Department of Pediatrics Denver Health Medical Center Denver, Colorado
Betsy Knappen, MSN, APRN
Neonatal Nurse Practitioner Division of Neonatology Children’s Mercy Hospital Kansas City, Missouri
Lawrence C. Ku, MD
Assistant Professor Department of Pediatrics Duke University Durham, North Carolina
Robert M. Lawrence, MD, FAAP
Clinical Professor of Pediatrics Department of Pediatrics University of Florida San Diego, California
Ruth A. Lawrence, MD, DD (Hon), FAAP, FABM
Distinguished Alumna Professor of Pediatrics and
Obstetrics/Gynecology Division of Neonatology Department of Pediatrics; Director Breastfeeding and Human Lactation Study Center; Director Finger Lakes Children’s Environmental Health Center University of Rochester Rochester, New York
Harold N. Lovvorn III, MD
Associate Professor Pediatric Surgery Vanderbilt University Nashville, Tennessee
Carolyn Lund, RN, MS, FAAN
Neonatal Clinical Nurse Specialist Newborn Intensive Care Unit UCSF Benioff Children’s Hospital—Oakland Oakland, California; Associate Clinical Professor Department of Family Health Care Nursing University of California San Francisco, California
Anne L. Matthews, RN, PhD, FACMG
Professor Genetics & Genome Sciences Case Western Reserve University; Director Genetic Counseling Training Program Genetics & Genome Sciences Case Western Reserve University Cleveland, Ohio
Jane E. McGowan, MD
Professor Emeritus, Pediatrics Retired Associate Chair for Research Drexel University School of Medicine Philadelphia, Pennsylvania
Christopher McKinney, MD
Assistant Professor Pediatrics University of Colorado Anschutz Medical Campus Aurora, Colorado
Susan Niermeyer, MD, MPH, FAAP
Professor of Pediatrics University of Colorado School of Medicine Aurora, Colorado
CONTRIBUTORSx
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Michael Nyp, DO, MBA
Associate Professor Pediatrics Children’s Mercy—Kansas City; Associate Professor Pediatrics University of Missouri—Kansas City; Assistant Medical Director of the Donald W. Thibeault
Neonatal Laboratory Pediatrics Children’s Mercy—Kansas City Kansas City, Missouri; Clinical Assistant Professor Pediatrics University of Kansas Medical Center Kansas City, Kansas
Steven L. Olsen, MD
Neonatologist Division of Pediatrics Children’s Mercy Hospital Kansas City, Missouri
Alexandra Oschman, PharmD, BCPPS
Clinical Pharmacy Specialist Children’s Mercy Hospital Kansas City, Missouri
Annette S. Pacetti, BSN, MSN, NNP-BC
Neonatal Nurse Practitioner Division of Neonatology Monroe Carell Jr. Children’s Hospital at Vanderbilt Nashville, Tennessee
Eugenia K. Pallotto, MD, MSCE
Medical Director Intensive Care Nursery; Medical Director, Neonatal ECMO; Professor of Pediatrics Pediatrics/Neonatology Children’s Mercy Kansas City; UMKC School of Medicine Kansas City, Missouri
Alfonso F. Pantoja, MD
Neonatologist Division of Neonatology Saint Joseph Hospital; Neonatologist Colorado Permanente Medical Group Denver, Colorado
Webra Price-Douglas, PhD, NNP-BC, IBCLC
Coordinator Maryland Regional Neonatal Transport Program Johns Hopkins & University of Maryland Medical
Centers
Baltimore, Maryland
Daphne Reavey, ARNP, MSN, PhD
Neonatal Nurse Practitioner Division of Neonatology Children’s Mercy Hospital; Coordinator: Neonatal Nurse Practitioner Program Department of Nursing University of Missouri—Kansas City Kansas City, Missouri
Nathaniel H. Robin, MD, FACMG
Professor of Genetics Pediatrics and Otolaryngology University of Alabama at Birmingham Birmingham, Alabama
Mario Augusto Rojas, MD, MPH
Medical Director Neonatal Intensive Care Department of Pediatrics Division of Neonatology Valley Children’s Hospital Madera, California
Paul J. Rozance, MD
Professor of Pediatrics University of Colorado School of Medicine Aurora, Colorado
Mohan Pammi, MD, PhD, MRCPCH
Associate Professor Department of Pediatrics Baylor College of Medicine Houston, Texas
Tamara Rush, MSN, RN, C-NPT, EMT
Nurse Manager Brenner Children’s Hospital-Wake Forest Baptist Health Winston-Salem, North Carolina
CONTRIBUTORS
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xi
Danielle E. Soranno, MD
Assistant Professor of Pediatrics Bioengineering and Medicine University of Colorado Aurora, Colorado
John D. Strain, MD, FACR, CAQ
Pediatric Radiology, Neuroradiology Professor of Radiology Department of Radiology University of Colorado School of Medicine; Chairman, Department of Radiology Children’s Hospital Colorado Anschutz Medical Campus Aurora, Colorado
Julie R. Swaney, MDiv
Director Department of Spiritual Care Services University of Colorado Hospital Aurora, Colorado
Tara Swanson, MD
Director Fetal Cardiology Program Heart Center Children’s Mercy Hospital Associate Professor University of Missouri—Kansas City Kansas City, Missouri
David T. Tanaka, MD
Professor of Pediatrics Neonatologist Duke University Medical Center Durham, North Carolina
Elizabeth H. Thilo, MD
Associate Professor of Pediatrics Section of Neonatology University of Colorado School of Medicine; Neonatologist Division of Pediatrics Children’s Hospital Colorado Aurora, Colorado
Kristin Voos, MD
Director of Family Integrated Care Neonatal Intensive
Care Unit Associate Professor Pediatrics, Division of Neonatology Director of Neonatal-Perinatal Medicine Fellowship
Program Rainbow Babies and Children’s Hospital University Hospitals Cleveland Medical Center Cleveland, Ohio
Beth Boulden Warren, MD, MS
Center for Cancer and Blood Disorders Children’s Hospital Colorado University of Colorado Anschutz Medical Campus Aurora, Colorado
Jason P. Weinman, MD
Associate Professor Department of Radiology Children’s Hospital of Colorado; Associate Professor Department of Radiology University of Colorado School of Medicine Aurora, Colorado
Leonard E. Weisman, MD
Professor of Pediatrics Baylor College of Medicine; Neonatology Attending Pediatrics Texas Children’s Hospital Houston, Texas
Rosanne Woloschuk, RD
Clinical Dietitian The Kidney Center Children’s Hospital Colorado Aurora, Colorado
Jennifer Woo, PhD, CNM/WHNP-BC
Assistant Professor College of Nursing Texas Woman’s University Denton, Texas
Kelly Tracy, MS, RD, LD, CNSC
Nutrition Program Coordinator; Senior Clinical Nutrition Specialist Department of Nutrition Children’s Mercy Hospital Kansas City, Missouri
REVIEWERS
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Sandra Sundquist Beauman, MSN, RNC-NIC, CNS
Manager Clinical Trials Operations Department of Pediatrics University of New Mexico Health Sciences Center Albuquerque, New Mexico
Stephanie M. Blake, DNP, RN, NNP-BC
Neonatal Nurse Practitioner Division of Neonatology/Department of Pediatrics Duke University Medical Center Durham, North Carolina
Karen D’Apolito, PhD, APRN, NNP-BC, FAAN
Neonatal Nurse Practitioner Program School of Nursing Vanderbilt University School of Nursing Nashville, Tennessee
Joyce Foresman-Capuzzi, MSN, APRN, CCNS, CEN, CPN, CTRN, CPEN, CCRN, TCRN, AFN-BC, SANE-A, EMT-P, FAEN
Clinical Nurse Educator Nursing Lankenau Medical Center Wynnewood, Pennsylvania
Dolores Greenwood, MSN, RNC-NIC
Education Manager Stephen & Alexandra Cohen Newborn and Infant
Critical Care Unit Children’s Hospital Los Angeles Los Angeles, California
Carie Linder, MSN, APRN, NNP
Neonatal Nurse Practitioner Neonatal Intensive Care Unit Integris Baptist Medical Center Oklahoma City, Oklahoma
Christina Mahoney, RN, BSN, CCRN
RN Staff Nurse II, Charge RN NICU Boston Children’s Hospital Boston, Massachusetts
Diane McClure, DNP, CPNP, CCRN, APHN-BC, CCAP, CEIM
Neonatal Advanced Practice Nurse-Caritas Coach Maternal Child Health St. Joseph’s Healthcare System Paterson, New Jersey
Sarah Mears, MSN, BC-NNP
Neonatal Nurse Practitioner Intensive Care Nursery Duke University Medical Center Durham, North Carolina
Andrea C. Morris, DNP, RNC-NIC, CCRN, CNS
Neonatal Clinical Nurse Specialist Newborn Intensive Care Unit Citrus Valley Medical Center-NICU West Covina, California
Mindy Morris, DNP, NNP-BC, CNS
Consultant Neonatal Huntington Beach, California
Tonya Oliver, MSN, RN, NNP-BC
Neonatal Nurse Practitioner Neonatal Wake Forest Baptist Health, Duke University Winston-Salem, North Carolina
Tracy Ann Pasek, RN, MSN, DNP, CCNS, CCRN, CIMI
Clinical Nurse Specialist Pain/Pediatric Intensive Care Unit/Evidence-based
Practice and Research
Children’s Hospital of Pittsburgh of University of
Pittsburgh Medical Center
Pittsburgh, Pennsylvania
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REVIEWERS
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Sandra Priest, RN, MSN, NNP-BC
Assistant Professor Neonatal Nurse Practitioner Program, School of
Nursing University Texas Medical Branch Galveston, Texas
Patricia Scheans, DNP, NNP-BC
NNP, Clinical Support for Neonatal Care Women’s and Children’s Legacy Health Portland, Oregon
Timothy Matthew Snow, BSN, MSN
Neonatal Nurse Practitioner Wake Forest Baptist Health-Brenner Children’s Hospital Winston-Salem, North Carolina
PREFACE
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he concept of the team approach is import­ant in neonatal intensive care. Each health
T
the duties of his or her own role but must also understand the roles of other involved profession­als. Nurses, physicians, other health care providers, and parents must work together in a coordinated and efficient manner to achieve optimal results for patients in the neonatal intensive care unit (NICU).
the field of neonatal intensive care, we believe it is necessary that this book contain input from major fields of health care—nursing and medicine. Both nurses and physicians have edited and co-authored every chapter.
have been reviewed, revised, and updated for the ninth edition. Unit One presents evidence-based practice and the need to scientifically evaluate neo­natal therapies, emphasizing randomized controlled trials as the ideal approach. Units Two to Five are the clinical sections, which have been fully updated for this edition. The chapters within these sections include highlighted clinical directions for quick
care professional must not only perform
Because this team approach is so important in
The book is divided into six units, all of which
reference, Parent Teaching boxes to aid in discharge instructions, Critical Findings boxes to prioritize assessment data, and medication tables.
The combination of physiology and pathophys­iology and separate emphasis on clinical application in this text is designed for neonatal intensive care nurses, nursing students, medical students, and pediatric, surgical, and family practice housestaff. This text is comprehensive enough for nurses and physicians, yet basic enough to be useful to families and all ancillary personnel.
Unit Six presents the psychosocial aspects of neonatal care. The medical, psychological, and social aspects of providing care for the ill neonate and family are discussed in this section. This section in particular will benefit social workers and clergy, who often deal with family members of neonates in the NICU.
In this handbook we present physiologic prin­ciples and practical applications and point out areas as yet unresolved. Material that is clinically
applicable is set in bold type so that it can be easily identified.
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INTRODUCTION
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n 1974 as the Perinatal Outreach Educator at the Children’s Hospital in Denver, Colorado,
I
I took a folder to Gerry Merenstein, MD, at Fitzsimmons Army Medical Center to discuss his lectures for the first outreach education program in La Junta, Colorado. When we finished, he removed from his desk drawer a 1-inch-thick compilation of the neonatal data, graphs, nomograms, and dia­grams he had created for the medical housestaff during his fellowship. Giving the document to me, he asked that I review it and let him know what I thought. Several weeks later, I told him it was good except there was no nursing care or input, which is essential in every NICU. So Gerry asked, “Want to write a book?”—and the idea for the Handbook was born!
With this ninth edition in 2020, we celebrate 35 years of publication of the Handbook of Neonatal Intensive Care. Gerry and I co-edited this book for 21 years until his death in December 2007. To fulfill my promise that Gerry’s name would always be on the book, the seventh and all subsequent editions are now known as Merenstein & Gardner’s Handbook of Neonatal Intensive Care. Instead of editing this edition alone or with another physician, I decided to convene an editorial team consisting of myself, a nurse colleague, and two neonatologists. Together we bring 180 years of clinical practice, research, teaching, writing, and consulting in neonatal, pedi­atric, and family care to this ninth edition.
In the eighth edition, we have the distinction of translation to Korean and Portuguese. We are still working on a Spanish translation because this was an ongoing wish of Gerry Merenstein. In addition, the Handbook is available on multiple e-platforms to facilitate use at the bedside. Multiple editions of the Handbook (first in 1985; fifth in 2002; seventh in 2011; and eighth in 2016) have won the American Journal of Nursing Book of the Year Award. The
eighth edition of the Handbook placed first in the Critical Care/Emergency Nursing category.
For our new audience and for our continuing loyal readers, this is my opportunity to introduce myself and all members of the editing team.
I am currently the Director of Professional Outreach Consultation (www.professionaloutreach-
consultation.org), a national and international con-
sulting firm established in 1980. I plan, develop, teach, and coordinate educational workshops on perinatal/neonatal/pediatric topics. I graduated from a hospital school of nursing in 1967 with a diploma, obtained my BSN at Spalding College in 1973 (magna cum laude), and completed my MS at the University of Colorado School of Nursing in 1975 and my PNP in 1978. I have worked in perinatal/neonatal/pediatric care since 1967 as a clinician (37 years in direct bedside care), practi­tioner, teacher, author, and consultant. In 1974, I was the first Perinatal Outreach Educator in the United States funded by the March of Dimes. In this role, I taught nurses and physicians in Colorado and the seven surrounding states how to recognize and stabilize at-risk pregnancies and sick neonates. I also consulted with numerous March of Dimes grantees to help them establish perinatal outreach programs. In 1978, I was awarded the Gerald Hencmann Award from the March of Dimes for “outstanding service in the improvement of care to mothers and babies in Colorado.” I am a founding member of the Colorado Perinatal Care Council (now the Colorado Perinatal Care Quality Collaborative). I am an active member of the Colorado Nurses Association/American Nurses Association, the Academy of Neonatal Nurses, and the National Association of Neonatal Nurses.
Mary Enzman-Hines, PhD, APRN, CNS, CPNP, APHN-BC, is currently Professor Emeritus at Beth­El College of Nursing at the University of Colorado
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INTRODUCTIONxvi
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in Colorado Springs and co-owner and certified Pediatric Nurse Practitioner at Integrative Pediatric Health Care in Englewood, Colorado (www.ip-
hcdenver.com). This is the first nurse practitioner
owned and operated practice in Colorado. Early in her nursing career, Mary worked in the NICU and PICU as a staff nurse, charge nurse, and nurse man­ager. After completing her PNP/CNS program and her master’s degree at the University of Colorado, Mary became the Neonatal and Pediatric Clinical Nurse Specialist at Denver Health and Hospital, where she created a beginning, intermediate, and advanced orientation for nurses in the NICU and PICU. At the University of Colorado, Mary accepted the practitioner/teacher role in maternal-child ser­vices, providing clinical care and mentorship in the NICU and pediatric units where nursing students were placed from the CU nursing program. When University Hospital and The Children’s Hospital combined their pediatric services, Mary became the Clinical Nurse Specialist in Research and Education and consulted in the NICU, PICU, and pediatric medical-surgical areas. In this role, she was a founding member of the interdisciplinary Pain Management Team and provided consultation throughout The Children’s Hospital for pain management issues. In 1996, Mary became a nursing faculty member at Beth-El College of Nursing and Health Sciences, where she created a student health center at the University of Colorado Colorado Springs and a school-based clinic for schoolchildren in Fountain, Colorado, while maintaining an active pediatric prac­tice at Colorado Springs Health Partners. Currently Mary provides pediatric care at her own practice and continues to teach courses to DNP students at the University of Northern Colorado as an adjunct fac­ulty. Mary is well published in the areas of pediatric, neonatal, and family health care, as well as in legal issues in maternal-child nursing. Mary is also a nurse researcher in the areas of pain, chronic illness, caring/ healing praxis, pediatric pain, holistic nursing, and technology in health care.
Brian S. Carter, MD, FAAP, is a graduate of David Lipscomb College in Nashville, Tennessee, and of the University of Tennessee’s College of Medicine in Memphis, Tennessee. Brian completed his residency in pediatrics at Fitzsimmons Army Medical Center in Aurora, Colorado. He completed his fellowship in neonatal-perinatal medicine at the University of Colorado Health Sciences Center in Denver. During the “Baby Doe” era, Brian trained
in bioethics, and, in addition to clinical neona­tology and neonatal follow-up, he has dedicated most of his academic career to the advancement of clinical ethics in neonatology and pediatric pal­liative care. Brian has been recognized nationally for his efforts in both of these fields. Currently he is William T. and Marjorie Sirridge Professor of Medical Humanities and Bioethics and Professor of Pediatrics at the University of Missouri–Kansas City School of Medicine. He also practices in the NICU/Follow-Up clinics and antenatal counseling at the Children’s Mercy Hospital in Kansas City, where he works in the Bioethics Center, serves on the Ethics Committee, and mentors students, residents, and fellows in the areas of clinical ethics, neonatology, pain management, and palliative care. Brian has previously co-edited the book Palliative
Care for Infants, Children, and Adolescents: A Practical Handbook, whose second edition was published
in 2011 by Johns Hopkins University Press. He has a forthcoming book on perinatal palliative care, co-edited with Rana Limbo, PhD, RN, and Charlotte Wool PhD, RN.
Susan Niermeyer, MD, MPH, FAAP, is Professor of Pediatrics at the University of Colorado School of Medicine and Colorado School of Public Health. She also serves as Senior Medical Advisor for newborn health to the United States Agency for International Development. Susan graduated from Vanderbilt University School of Medicine and completed training in pediatrics and neonatal-peri­natal medicine at the University of Colorado and Children’s Hospital Colorado. She earned an MS in Public Health in 2010 at the Colorado School of Public Health. Susan practices and teaches at Children’s Hospital Colorado and the University of Colorado Hospital as well as community hos­pital nurseries in the Denver area. She has served as co-chair of the American Academy of Pediatrics (AAP) Neonatal Resuscitation Program Steering Committee and editor of the International Liaison Committee on Resuscitation (ILCOR) neonatal resuscitation guidelines. She is editor of Helping Babies Breathe, the AAP educational program for neonatal resuscitation in resource-limited settings and a member of the Helping Babies Survive Planning Group. Susan’s research interests center on adaptation in the neonatal period, with a focus on delayed umbilical cord clamping and cardiopulmo­nary adaptation at high altitude. She has been hon­ored as a Career Teaching Scholar at the University
INTRODUCTION
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xvii
of Colorado and received the Avroy Fanaroff Neonatal Education Award from the AAP.
Borrowing from the words of Brian Carter in the
introduction to the sixth edition of the Handbook:
The goals of care should be patient- and family-cen­tered. It is the patient we treat, but it is the family, of whatever construct, with whom the baby will go home. Indeed, it is the family who must live with the long-term consequences of our daily decisions in caring for their baby.
These goals include the provision of skilled pro­fessional care. An effective neonatal intensive care team consists of educated professionals of many disciplines—none of us can do it alone.
It has been my honor and privilege to work with these co-editors, who are all patient- and fam­ily-centered, and with the amazing editing team of Laura Klein, Lee Henderson, and Carol O’Connell for this ninth edition.
Sandra L. Gardner, RN, MS,
Retired Clinical Nurse Specialist and Pediatric
Nurse Practitioner
Senior Editor
CONTENTS
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UNIT ONE
Evidence-Based Practice
1 Evidence- Based Clinical Practice, 1
Alfonso F. Pantoja and Mary Enzman-Hines
UNIT TWO
Support of the Neonate
2 Prenatal Environment: Effect on Neonatal
Outcome, 17
Jennifer Woo, Suzanne M. Carrington, and Anne Ambia
3 Perinatal Transport and Levels Of Care, 45
Mario Augusto Rojas, Amanda Flaherty, Heather Furlong Brown, and Tamara Rush
4 Care at Birth, 67
Susan Niermeyer and Susan B. Clarke
5 Immediate Newborn Care After Birth, 93
Sandra L. Gardner and Susan Niermeyer
6 Heat Balance, 137
Sandra l. Gardner and Betsy H. Cammack
7 Physiologic Monitoring, 165
Kristi Coe, Wanda T. Bradshaw, and David T. Tanaka
11 Drug Withdrawal in the Neonate, 250
Jodi Jackson, Betsy Knappen, and Steven L. Olsen
12 Pain and Pain Relief, 273
Sandra L. Gardner, Mary Enzman-Hines, and Rita Agarwal
13 The Neonate and the Environment Impact
on Development, 334
Sandra L. Gardner and Edward Goldson
UNIT THREE
Metabolic and Nutritional Care of the Neonate
14 Fluid and Electrolyte Management, 407
Michael Nyp, Jessica L. Brunkhorst, Daphne Reavey, and Eugenia K. Pallotto
15 Glucose Homeostasis, 431
Paul J. Rozance, Jane E. Mcgowan, Webra Price- Douglas, and William W. Hay Jr.
16 Total Parenteral Nutrition, 459
Steven L. Olsen, Alexandria Oschman, and Kelly Tracy
17 Enteral Nutrition, 480
Laura D. Brown, Kendra Hendrickson, Ruth Evans, Jane Davis, and William W. Hay JR.
8 Acid- Base Homeostasis and Oxygenation, 186
James S. Barry, Jane Deacon, Carmen Hernandez, and M. Douglas Jones, Jr.
9 Diagnostic Imaging in the Neonate, 201
Jason P. Weinman, Bridget M. Bronsert, and John D. Strain
10 Pharmacology in Neonatal Care, 226
Lawrence C. Ku, Chi Hornik, and Deanne Buschbach
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18 Breastfeeding the Neonate with Special
Needs, 534
Sandra L. Gardner, Ruth A. Lawrence, and Robert M. Lawrence
19 Skin and Skin Care, 602
Carolyn Lund and David J. Durand