- Email: [email protected]
Very Low Birth Weight Infant Care
letters (Continued from page 266)
born infants. Clin Pediatr 22(8):
intake and fluid and sodium losses. We vehemently disagree with Ms. McCormick’s approach t o infant stimulation of t h e VLBW. She recommends avoiding overstimulation in a hostile environment and reserving infant stimulation programs for t h e growing premature infant. Current behavioral theory and strategies emphasize reduction of negative stimulation, as well a s the integration of planned, positive infant stimulation into nursing care from birth. This is a vital point because nursing interventions can s h a p e the developmental outcome of these children. Historically, planned positive stimulation was not a nursing priority, and premature infants developed defensive coping mechanisms when confronted with any stimulation. Five years ago, the hyperirritable, inconsolable infant with BPD was frequently e n c o u n t e r e d . Recent changes in nursing practice have virtually eliminated the “BPD Personality.” We acknowledge t h e difficulty of thoroughly addressing all the issues impacting nursing care of the VLBW in a single article. We suggest the scope of this topic is better suited to a series of articles, where the clinical issues are examined in depth and alternative nursing approaches a r e explored.
533.
TONIBOSNYAKVENTO,R N , MS DENISE POIRIER MAGUIRE, R N , MS Neonatal Intensive Care Unit The Children’s Hospital Boston, Massachusetts REFERENCES 1. Robertson A, et al. Predicting need for exchange transfusion in new-
July/August 1985 JOCNN
2. Bryla D. Development, design, and sample composition, in National Institute of Child Health and Hu-
3.
4.
5.
6.
man Development. Randomized controlled trial of phototherapy for neonatal hyperbilirubinemia. Pediatrics February 1985 75(2): 387. Aperia A, Broberger 0, Zetterstom R. Implication of limitations of renal function for t h e nutrition of low birth weight infants. Acta Paediat Scand Suppl Symp Nutr Low Birth Weight Infants 1982;296:4952. Keenan W, et al. Morbidity and mortality associated with exchange transfusion. Pediatrics February 1985; 75(2):417. Lorenz M, Kleinman L, Kotagal U , Reller M. Water balance in very low birth weight infants: relationship to water and sodium intake and effect on outcome. Pediatrics 101(3):423-432. Als H. Towards of synactive theory of development: promise for the assessment and support of infant individuality. Infant Ment Health J. 1982.
Author’s reply: Thank you for your opinions regarding the care of the very low birth weight infant. I agree that a series of articles addressing the various principles of care would certainly have provided a more comprehensive approach. Because this was not a n option, however, my intent was to present a general overview that identified main priorities in nursing care. My recommendations on fluid management and hyperbilirubinemia were based on clinical experience and a review of t h e literature. It was not possible to address all approaches to management. T h e current references you provided should be helpful to interested neonatal readers. To facilitate this review, I would like to correct the inaccurate reference
by Lorenz, which is located in the Journal of Pediatrics, not Pediatrics. 1 d o not underestimate the positive effect of well planned, individualized stimulation programs that are implemented after assessment of each infant’s readiness for such interaction. I am concerned about the effects of overstimulation that can occur in the special care nursery, particularly with very low birth weight infants. Stimulation that is too complex, intense, or inappropriately timed can be a s harmful a s lack of stimulation; because the optimum level, amount, and type of stimulation have not been established, efforts to stimulate the preterm infant in order to compensate for a sensory-deprived environment can cause overstimulation.’ High-risk infants must first develop sufficient physical integrity and internal stability before they a r e able to use the caregiver support and input stimulation needed for developmental gains; caregiver interventions that foster the infant’s physical a s well a s socialinteractive development occur from the period when the infant is no longer acutely i l l and is able to breathe effectively and gain weight satisfactorily.’ Others believe that stimulation should be deferred for infants less than 34weeks gestation when physiologic disturbances occur and, particularly, following the first week of admission to prevent complications that can occur.“ Your reference by Als further elaborates that for some infants, elimination of stimulation may be necessary, with extreme caution rendered in caretaking abilities. “Quiet, protected, and contained time is of utmost importance.”“ (Continued on page 296)
295
(Continued from page 295)
REFERENCES Blackburn S. Fostering behavioral development of high risk infants. JOGNN 1983;12:3 76-86s. Gorski P, Davison M, Brazelton TB. Stages of behavioral organization in the high risk neonate. Sem Perinatal 1979;3:1 61-72. Powell KB. Developmental stimulation for preterm infants. Reaching Out 1985;7:1. Als H. Toward a synactuve theory of development: promise for the assessment and support of indi-
viduality. Infant Mental Health Journal 1982;3:4, 229-243.
Entry into Practice: NAACOG’s Position Paraphrasing Webster, “editorial” used a s a noun is an article that gives the editor’s views o r those of the person o r persons in control of the publication. Within that definition, Sylvia Clark, in the role of guest editorialist, is exercising her prerogative to express her opinions. However, the other part of the definition requires that the readers of JOCNN be aware of t h e NAACOG philosophy, a s approved by t h e executive board (1984), which states In order to function effectively as a member of a multidisciplinary team in the complexity of a rapidly changing system, the nurse needs not only t h e traditional knowledge and skills, but also the knowledge of self and society that is inherent in a broad general education best obtained at the baccalaureate level.
This view was first put forward in a Statement on Education for Entry Into Practice approved by the executive board in December 1979. The statement goes on to say
296
The multiple levels of nursing education of t h e past have militated against attainment of the stature and credibility needed to establish nursing on an equal footing with other members of the health-care team and with those who make policy. I f nursing is to control its own destiny, it must assure that nurses of the future are prepared to meet the challenge and demands of that future. That future has now arrived.
HELENWOHLERT, RN NAACOG President Reexamining t h e Oral Contraceptive Issues: A n Update T h e outpouring of information about t h e safety and side effects of oral contraceptives, as well as controversy that continues concerning certain physiological effects, have prompted us to write a n update to the article that appeared in t h e JanuaryIFebruary issue (1985, pp. 30-36). After the issue was published, t h e Food and Drug Administration issued a bulletin concluding that no increased risk for breast cancer has been substantiated to date for any subgroup of users o r any particular oral contraceptive formulation.’3‘ A s we suggested in the article, t h e data so far are inconclusive. The cohort of women who began taking oral contraceptives in t h e late 1950s and early 1960s, with t h e high doses of hormones, a r e just becoming the high-risk group for breast cancer, so it is too early to predict whether they a r e at increased risk, protected, o r unaffected by their oral contraceptive use. The Pike study cited in our article has been withdrawn; that was the o n e piece of work t o
date suggesting a link with breast ~ancer.~ The protective effects of oral c o n t r a c e p t i v e s postulated by Burkman, Rubin, et aL4.5in relation to the occurrence of pelvic inflarnmatory disease may give women a false sense of security. A report suggesting that oral contraceptives may have the potential for enhancing chlamydia1 infections was published in April of this year.6 Reports of investigations of the effects of oral contraceptives on lipoprotein triglyceride and cholesterol levels and on carbohydrate metabolism continue to appear in t h e literature. As we reported in our article, some authors offer some suggestions regarding clinical management based on their findings. Others feel the data a r e inconclusive and that more investigation is needed. The conflicting opinions and findings from investigations to date point up t h e dilemma the clinician faces. Data are, indeed, far from conclusive, and there are n o absolutes to guide clinical practice. It is encouraging to realize that not all t h e effects associated with oral contraceptive use, aside from prevention of pregnancy, are negative. What clinicians a r e left with is a wide range of choices, reliance on the best evidence to date, and their own clinical judgment based on experience and individual case data. JOELLEN w . HAWKINS,RNC,
PHD,
FAAN
ROBERTAORNE,R N ,
MS
REFERENCES 1. FDAs Fertility and Maternal Health
Drugs Advisory Committee. February 1984. (Continued on page 307)
July/August 1985 JOCNN
born infants. Clin Pediatr 22(8):
intake and fluid and sodium losses. We vehemently disagree with Ms. McCormick’s approach t o infant stimulation of t h e VLBW. She recommends avoiding overstimulation in a hostile environment and reserving infant stimulation programs for t h e growing premature infant. Current behavioral theory and strategies emphasize reduction of negative stimulation, as well a s the integration of planned, positive infant stimulation into nursing care from birth. This is a vital point because nursing interventions can s h a p e the developmental outcome of these children. Historically, planned positive stimulation was not a nursing priority, and premature infants developed defensive coping mechanisms when confronted with any stimulation. Five years ago, the hyperirritable, inconsolable infant with BPD was frequently e n c o u n t e r e d . Recent changes in nursing practice have virtually eliminated the “BPD Personality.” We acknowledge t h e difficulty of thoroughly addressing all the issues impacting nursing care of the VLBW in a single article. We suggest the scope of this topic is better suited to a series of articles, where the clinical issues are examined in depth and alternative nursing approaches a r e explored.
533.
TONIBOSNYAKVENTO,R N , MS DENISE POIRIER MAGUIRE, R N , MS Neonatal Intensive Care Unit The Children’s Hospital Boston, Massachusetts REFERENCES 1. Robertson A, et al. Predicting need for exchange transfusion in new-
July/August 1985 JOCNN
2. Bryla D. Development, design, and sample composition, in National Institute of Child Health and Hu-
3.
4.
5.
6.
man Development. Randomized controlled trial of phototherapy for neonatal hyperbilirubinemia. Pediatrics February 1985 75(2): 387. Aperia A, Broberger 0, Zetterstom R. Implication of limitations of renal function for t h e nutrition of low birth weight infants. Acta Paediat Scand Suppl Symp Nutr Low Birth Weight Infants 1982;296:4952. Keenan W, et al. Morbidity and mortality associated with exchange transfusion. Pediatrics February 1985; 75(2):417. Lorenz M, Kleinman L, Kotagal U , Reller M. Water balance in very low birth weight infants: relationship to water and sodium intake and effect on outcome. Pediatrics 101(3):423-432. Als H. Towards of synactive theory of development: promise for the assessment and support of infant individuality. Infant Ment Health J. 1982.
Author’s reply: Thank you for your opinions regarding the care of the very low birth weight infant. I agree that a series of articles addressing the various principles of care would certainly have provided a more comprehensive approach. Because this was not a n option, however, my intent was to present a general overview that identified main priorities in nursing care. My recommendations on fluid management and hyperbilirubinemia were based on clinical experience and a review of t h e literature. It was not possible to address all approaches to management. T h e current references you provided should be helpful to interested neonatal readers. To facilitate this review, I would like to correct the inaccurate reference
by Lorenz, which is located in the Journal of Pediatrics, not Pediatrics. 1 d o not underestimate the positive effect of well planned, individualized stimulation programs that are implemented after assessment of each infant’s readiness for such interaction. I am concerned about the effects of overstimulation that can occur in the special care nursery, particularly with very low birth weight infants. Stimulation that is too complex, intense, or inappropriately timed can be a s harmful a s lack of stimulation; because the optimum level, amount, and type of stimulation have not been established, efforts to stimulate the preterm infant in order to compensate for a sensory-deprived environment can cause overstimulation.’ High-risk infants must first develop sufficient physical integrity and internal stability before they a r e able to use the caregiver support and input stimulation needed for developmental gains; caregiver interventions that foster the infant’s physical a s well a s socialinteractive development occur from the period when the infant is no longer acutely i l l and is able to breathe effectively and gain weight satisfactorily.’ Others believe that stimulation should be deferred for infants less than 34weeks gestation when physiologic disturbances occur and, particularly, following the first week of admission to prevent complications that can occur.“ Your reference by Als further elaborates that for some infants, elimination of stimulation may be necessary, with extreme caution rendered in caretaking abilities. “Quiet, protected, and contained time is of utmost importance.”“ (Continued on page 296)
295
(Continued from page 295)
REFERENCES Blackburn S. Fostering behavioral development of high risk infants. JOGNN 1983;12:3 76-86s. Gorski P, Davison M, Brazelton TB. Stages of behavioral organization in the high risk neonate. Sem Perinatal 1979;3:1 61-72. Powell KB. Developmental stimulation for preterm infants. Reaching Out 1985;7:1. Als H. Toward a synactuve theory of development: promise for the assessment and support of indi-
viduality. Infant Mental Health Journal 1982;3:4, 229-243.
Entry into Practice: NAACOG’s Position Paraphrasing Webster, “editorial” used a s a noun is an article that gives the editor’s views o r those of the person o r persons in control of the publication. Within that definition, Sylvia Clark, in the role of guest editorialist, is exercising her prerogative to express her opinions. However, the other part of the definition requires that the readers of JOCNN be aware of t h e NAACOG philosophy, a s approved by t h e executive board (1984), which states In order to function effectively as a member of a multidisciplinary team in the complexity of a rapidly changing system, the nurse needs not only t h e traditional knowledge and skills, but also the knowledge of self and society that is inherent in a broad general education best obtained at the baccalaureate level.
This view was first put forward in a Statement on Education for Entry Into Practice approved by the executive board in December 1979. The statement goes on to say
296
The multiple levels of nursing education of t h e past have militated against attainment of the stature and credibility needed to establish nursing on an equal footing with other members of the health-care team and with those who make policy. I f nursing is to control its own destiny, it must assure that nurses of the future are prepared to meet the challenge and demands of that future. That future has now arrived.
HELENWOHLERT, RN NAACOG President Reexamining t h e Oral Contraceptive Issues: A n Update T h e outpouring of information about t h e safety and side effects of oral contraceptives, as well as controversy that continues concerning certain physiological effects, have prompted us to write a n update to the article that appeared in t h e JanuaryIFebruary issue (1985, pp. 30-36). After the issue was published, t h e Food and Drug Administration issued a bulletin concluding that no increased risk for breast cancer has been substantiated to date for any subgroup of users o r any particular oral contraceptive formulation.’3‘ A s we suggested in the article, t h e data so far are inconclusive. The cohort of women who began taking oral contraceptives in t h e late 1950s and early 1960s, with t h e high doses of hormones, a r e just becoming the high-risk group for breast cancer, so it is too early to predict whether they a r e at increased risk, protected, o r unaffected by their oral contraceptive use. The Pike study cited in our article has been withdrawn; that was the o n e piece of work t o
date suggesting a link with breast ~ancer.~ The protective effects of oral c o n t r a c e p t i v e s postulated by Burkman, Rubin, et aL4.5in relation to the occurrence of pelvic inflarnmatory disease may give women a false sense of security. A report suggesting that oral contraceptives may have the potential for enhancing chlamydia1 infections was published in April of this year.6 Reports of investigations of the effects of oral contraceptives on lipoprotein triglyceride and cholesterol levels and on carbohydrate metabolism continue to appear in t h e literature. As we reported in our article, some authors offer some suggestions regarding clinical management based on their findings. Others feel the data a r e inconclusive and that more investigation is needed. The conflicting opinions and findings from investigations to date point up t h e dilemma the clinician faces. Data are, indeed, far from conclusive, and there are n o absolutes to guide clinical practice. It is encouraging to realize that not all t h e effects associated with oral contraceptive use, aside from prevention of pregnancy, are negative. What clinicians a r e left with is a wide range of choices, reliance on the best evidence to date, and their own clinical judgment based on experience and individual case data. JOELLEN w . HAWKINS,RNC,
PHD,
FAAN
ROBERTAORNE,R N ,
MS
REFERENCES 1. FDAs Fertility and Maternal Health
Drugs Advisory Committee. February 1984. (Continued on page 307)
July/August 1985 JOCNN