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Noteworthy Professional News

Noteworthy Professional News

Editor(s): Stokowski, Laura A.

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doi: 10.1097/ANC.0000000000000098
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Immersion in water during labor, delivery, or both has been gaining popularity in many parts of the world, although no one knows exactly how prevalent “water birth” is in the United States. We do know that many hospitals and birth centers are equipped with tubs or are adding them to accommodate birth plan requests for immersion during labor.

The purported benefits of immersion during the first stage of labor are reduced pain, shorter labor, and less use of anesthesia, but no evidence indicates that it improves perinatal outcomes.1 The safety of immersion during the second stage of labor has not been established, has not been shown to benefit mother or fetus, and has resulted in case reports of serious adverse events in the newborn, including aspiration, drowning, infection, hyponatremia, perinatal depression, umbilical cord rupture (with neonatal hemorrhaging), and fatalities.2

Consequently, statements jointly released by the American Academy of Pediatrics1 and the American College of Obstetricians and Gynecologists3 conclude that immersion during the first stage of labor, if practiced, should not prevent or inhibit other elements of care, including appropriate fetal and maternal monitoring. In contrast, immersion during delivery of the neonate should be considered an experimental procedure and performed only within the context of an appropriately designed clinical trial. The bottom line? Don't do it.

1. American Academy of Pediatrics Committee on Fetus and Newborn and American College of Obstetricians and Gynecologists Committee on Obstetric Practice. Immersion in water during labor and delivery [published online ahead of print March 20, 2014]. Pediatrics.

2. Pinette MG, Wax J, Wilson E. The risks of underwater birth. Am J Obstet Gynecol. 2004;190:1211–1215.

3. American College of Obstetricians and Gynecologists. Immersion in water during labor and delivery. Committee Opinion No. 594. Obstet Gynecol. 2014;123:912–915.


After weeks or months in the highly supportive environment of the neonatal intensive care unit (NICU), when the time finally comes to go home, some families express hesitation about their ability to care for their preterm infants. It is not uncommon for parents to request a home apnea monitor, even when it is not indicated (or to jokingly ask the nurse to come home with them).

A comprehensive, well-planned discharge of the preterm infant helps ensure a safe and effective transition to home, with parents who are confident in their ability to care for their preterm infant. A new statement from the Canadian Paediatric Society1 provides guidance to healthcare professionals in planning discharge from the NICU to home of medically stable preterm infants born before 34 weeks' gestational age.

The statement covers the criteria for discharge readiness, including demonstration of functional maturation in the areas of physiological competencies of thermoregulation, control of breathing, respiratory stability, and feeding skills and weight gain. Supporting family involvement and providing education from the time of admission improve parental confidence and lessen their anxiety. Assessing the physical and psychosocial discharge environment, although not always easy to accomplish, is an important part of the discharge process.

The statement emphasizes the multidisciplinary team's responsibilities for discharge planning and concludes with specific evidence- and consensus-based discharge recommendations. These include criteria for assessing infant and family readiness for discharge, performing necessary predischarge evaluations, screening tests, and vaccinations, educating the parents to care for their infant, and ensuring that an appropriate follow-up plan is in place at the time of discharge.

1. Jeffries AL; Canadian Paediatric Society Fetus and Newborn Committee. Going home: facilitating discharge of the preterm infant. Paediatr Child Health. 2014;19:31–42.


Speaking of discharge, many parents continue to swaddle their infants for sleep after they leave the NICU. This makes sense, because their infants have been accustomed to weeks or months of being swaddled for sleep. Although primarily used for thermoregulation in the NICU, swaddling inhibits movement and calms fussy babies, making it easier to settle them to sleep in the supine position. Swaddling also obviates the need for blankets, which are unsafe in the sleeping environment of infants. In spite of these benefits, swaddling has not been recommended as a strategy for the prevention of sudden infant death syndrome1 and the potential risks associated with swaddling, have long been recognized.2

A recent study3 examined 36 swaddling incidents (ages 3 days to 15 months) reported to the Consumer Product Safety Commission, from 2004 to 2011. These included

  • 5 cases involving wearable blankets (1 death, 2 injuries, and 2 potential injuries);
  • 18 cases involving swaddle wraps (8 deaths and 10 potential injuries);
  • 1 death involving an unspecified product (either swaddle wrap or wearable blanket); and
  • 12 deaths involving swaddling in ordinary blankets.

In the cases of infant deaths involving wearable blankets or swaddle wraps, 7 of 10 infants were placed to sleep supine, but the swaddled infants rolled to the prone position (1 reportedly at 5 weeks of age) and death was attributed to positional asphyxia. Among infants who were swaddled in standard blankets, 6 died in a similar fashion. In some cases involving both swaddling blankets and standard blankets, parts of the blanket were found covering the dead infant's nose and mouth. Other risk factors were believed to contribute to infant deaths, including the use of soft bedding and hyperthermia from overbundling in an excessively warm environment.

Consumer Product Safety Commission is a voluntary database, and without a firm denominator, we have no way of knowing the true rate of injury or death associated with the use of swaddling practices or products. Still, it is clear from this report that swaddling in ordinary blankets is not a safe practice beyond the immediate newborn period. Neonatal caregivers must teach parents how to use swaddling safely, the alternatives to swaddling, and the potential harms associated with inappropriate swaddling practices. It is also important to discuss when to discontinue swaddling. Although some physicians disagree about how long swaddling can safely continue, Dr Rachel Moon, who is also lead author of the American Academy of Pediatrics Safe Sleep guidelines4 and chair of the Task Force on sudden infant death syndrome, believes that babies should not be swaddled past 2 months of age.5 The safety of commercially available swaddling wraps and wearable blankets has not been established, and people who use them do so at their own risk.

1. Moon RY, American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment. Pediatrics. 2011;128:1030–1039.

2. van Sleuwen BE, Engelberts AC, Boere-Boonekamp MM, Kuis W, Schulpen TW, L'Hoir MP. Swaddling: a systematic review. Pediatrics. 2007;120:e1097–e1106.

3. Gerard CM, Harris KA, Thach BT. Spontaneous arousals in supine infants while swaddled and unswaddled during rapid eye movement and quiet sleep. Pediatrics. 2002;110:e70.

4. Meyer LE, Erler T. Swaddling: a traditional care method rediscovered. World J Pediatr. 2011;7:155–160.

5. Kennedy K. Unwrapping the controversy over swaddling. AAP News. 2-13;34. Accessed February 24, 2014.


Who knew that operant conditioning would work with premies?

This story is cool. It is so cool that it was picked up by many news agencies and disseminated widely on the Web, so you may already have heard about it.

Based on the idea that a mother's voice is a powerful auditory cue to her preterm baby, researchers at Vanderbilt University showed that a lullaby sung by a baby's mother could be used to teach the baby to suck harder and longer on a pacifier, thereby improving oral feeding skills.1 Pacifier-activated music players (PAM) were prerecorded with their mother's own voice singing either “Hush Little Baby” or “Snuggle Puppy.” These lullabies were chosen by investigator and music therapist Olena Chorna, because their melodies were simple, repetitive, and within a single octave range.2

The study was conducted in 94 infants who had reached 34 to 36 weeks' postmenstrual age, were stable, and had no residual respiratory issues. The infants had to be receiving more than 50% of their feedings by gavage in the 3 days before the beginning of the study. Infants were randomly assigned to receive 5 daily 15-minute sessions of nonnutritive sucking, either with PAM with mother's recorded voice or with no PAM. When PAM group infants sucked correctly on their pacifiers (reaching a preset threshold pressure), they were rewarded by hearing their mother singing. If they stopped sucking, the music would stop. The interventions took place 30 to 45 minutes before the infant's regular feeding time, and the clinical team was masked to group assignment.

The findings from this single study were very good. The PAM group had significantly increased oral feeding rates (2.0 vs 0.9 mL/min; P < .001), oral volume intake (91.1 vs 48.1 mL/kg per day; P = .001), oral feeds per day (6.5 vs 4.0; P < .001), and faster time-to-full oral feedings (31 vs 38 days; P = .04) compared with controls. Weight gain and cortisol levels during the 5-day protocol were not different between groups, with the latter suggesting that the intervention did not increase physiologic stress in the infants. Average hospital stays were 20% shorter in the PAM group, but the difference was not significant (P = .07).

The authors conclude that “PAM with mother's voice is a developmentally appropriate successful oral feeding strategy that provides positive auditory stimulation to infants while supporting active parental roles during infant hospitalization.” More studies are needed to better understand how this strategy works. Studies with larger samples and in multiple settings need to be conducted to understand how this added stimulation would benefit infants or not in different environments. Further research would support the development of recommendations about when and how to best use the intervention. It is important to note that the length of stay was not significantly different for infants who received the intervention, and thus understanding how the days to full feeding change did not affect discharge needs further exploration. Pacifier-activated lullaby (PAL) devices are commercially available through Powers Device Technologies, Inc.

1. Chorna OD, Slaughter JC, Wang L, Stark AR, Maitre NL. A pacifier-activated music player with mother's voice improves oral feeding in preterm infants. Pediatrics. 2014;133:462–468.

2. Culver A. Vanderbilt study shows mother's voice improves hospitalization and feeding in infants. Vanderbilt Res News. February 17, 2014. Accessed March 10, 2014.


A recent addition to the New England Journal of Medicine's Videos in Clinical Medicine series is courtesy of nurse practitioners Amy McCay, Elizabeth Elliott, and Marlene Walden, from Texas Children's Hospital.1 Long-term vascular access is often required in neonatal patients for the delivery of life-sustaining medications and nutrition. This high-quality video, which demonstrates placement of a peripherally inserted central catheter in a neonate, would be an excellent educational tool.


1. McCay AS, Elliott EC, Walden M. Videos in clinical medicine: PICC placement in the neonate. N Engl J Med. 2014;370:e17.
© 2014 by The National Association of Neonatal Nurses