Publications by authors named "Joan R Smith"

25 Publications

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STEPP IN: Working Together to Keep Infants Warm in the Perioperative Period.

Pediatrics 2020 04 19;145(4). Epub 2020 Mar 19.

Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri.

Objectives: Reduce postoperative hypothermia by up to 50% over a 12-month period in children's hospital NICUs and identify specific clinical practices that impact success.

Methods: Literature review, expert opinion, and benchmarking were used to develop clinical practice recommendations for maintaining perioperative euthermia that included the following: established euthermia before transport to the operating room (OR), standardized practice for maintaining euthermia on transport to and from the OR, and standardized practice to prevent intraoperative heat loss. Process measures were focused on maintaining euthermia during these time points. The outcome measure was the proportion of patients with postoperative hypothermia (temperature ≤36°C within 30 minutes of a return to the NICU or at the completion of a procedure in the NICU). Balancing measures were the proportion of patients with postoperative temperature >38°C or the presence of thermal burns. Multivariable logistic regression was used to identify key practices that improved outcome.

Results: Postoperative hypothermia decreased by 48%, from a baseline of 20.3% (January 2011 to September 2013) to 10.5% by June 2015. Strategies associated with decreased hypothermia include >90% compliance with patient euthermia (36.1-37.9°C) at times of OR arrival (odds ratio: 0.58; 95% confidence interval [CI]: 0.43-0.79; < .001) and OR departure (odds ratio: 0.0.73; 95% CI: 0.56-0.95; = .017) and prewarming the OR ambient temperature to >74°F (odds ratio: 0.78; 95% CI: 0.62-0.999; = .05). Hyperthermia increased from a baseline of 1.1% to 2.2% during the project. No thermal burns were reported.

Conclusions: Reducing postoperative hypothermia is possible. Key practices include prewarming the OR and compliance with strategies to maintain euthermia at select time points throughout the perioperative period.
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http://dx.doi.org/10.1542/peds.2019-1121DOI Listing
April 2020

Preventable Harm Reduction: A Balancing Act to Zero Harm.

Authors:
Joan R Smith

J Perinat Neonatal Nurs 2019 Oct/Dec;33(4):283-284

St Louis Children's Hospital St Louis, Missouri.

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http://dx.doi.org/10.1097/JPN.0000000000000447DOI Listing
May 2020

Disparate Care in the NICU: An Opportunity for Improvement.

Authors:
Joan R Smith

J Perinat Neonatal Nurs 2019 Apr/Jun;33(2):103-104

St Louis Children's Hospital St Louis, Missouri.

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http://dx.doi.org/10.1097/JPN.0000000000000408DOI Listing
December 2019

Neonatal Nurses Transforming Care Through Innovation.

Authors:
Joan R Smith

J Perinat Neonatal Nurs 2019 Jan/Mar;33(1):7-8

St Louis Children's Hospital St Louis, Missouri.

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http://dx.doi.org/10.1097/JPN.0000000000000388DOI Listing
December 2019

Resiliency: A Core Competency in Today's NICU Nurse Leader.

J Perinat Neonatal Nurs 2018 Oct/Dec;32(4):295-296

St Louis Children's Hospital St Louis, Missouri.

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http://dx.doi.org/10.1097/JPN.0000000000000370DOI Listing
September 2019

An Innovative ECMO Staffing Model to Reduce Harm.

J Perinat Neonatal Nurs 2018 Jul/Sep;32(3):204-205

St Louis Children's Hospital St Louis, Missouri.

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http://dx.doi.org/10.1097/JPN.0000000000000355DOI Listing
September 2019

Manual Expression of Breast Milk: A Strategy to Aid in Breastfeeding Success.

J Perinat Neonatal Nurs 2018 Apr/Jun;32(2):102-103

St Louis Children's Hospital St Louis, Missouri.

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http://dx.doi.org/10.1097/JPN.0000000000000328DOI Listing
September 2019

The Art of Skillful Disclosure.

J Perinat Neonatal Nurs 2018 Jan/Mar;32(1):12-14

St Louis Children's Hospital, St Louis, Missouri.

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http://dx.doi.org/10.1097/JPN.0000000000000313DOI Listing
September 2019

Cognitive Bias: A Potential Threat to Clinical Decision-Making in the Neonatal Intensive Care Unit.

Authors:
Joan R Smith

J Perinat Neonatal Nurs 2017 Oct/Dec;31(4):294-296

Director Clinical Quality, Safety & Practice Excellence St Louis Children's Hospital St Louis, Missouri.

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http://dx.doi.org/10.1097/JPN.0000000000000289DOI Listing
July 2019

Sustaining SLUG Bug CLABSI Reduction: Does Sterile Tubing Change Technique Really Work?

Pediatrics 2017 Oct;140(4)

Department of Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.

Objectives: To evaluate the ability to sustain and further reduce central line-associated bloodstream infection (CLABSI) rates in NICUs participating in a multicenter CLABSI reduction collaborative and to assess the impact of the sterile tubing change (TC) technique as an important component in CLABSI reduction.

Methods: A multi-institutional quality improvement collaborative lowered CLABSI rates in level IV NICUs over a 12-month period. During the 19-month sustain phase, centers were encouraged to monitor and report compliance measures but were only required to report the primary outcome measure of the CLABSI rate. Four participating centers adopted the sterile TC technique during the sustain phase as part of a local Plan-Do-Study-Act cycle.

Results: The average aggregate baseline NICU CLABSI rate of 1.076 CLABSIs per 1000 line days was sustained for 19 months across 17 level IV NICUs from January 2013 to July 2014. Four centers transitioning from the clean to the sterile TC technique during the sustain phase had a 64% decrease in CLABSI rates from the baseline (1.59 CLABSIs per 1000 line days to 0.57 CLABSIs per 1000 line days).

Conclusions: Sustaining low CLABSI rates in a multicenter collaborative is feasible with team engagement and ongoing collaboration. With these results, we further demonstrate the positive impact of the sterile TC technique in CLABSI reduction efforts.
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http://dx.doi.org/10.1542/peds.2016-3178DOI Listing
October 2017

Hand Hygiene: A Back to Basics Global Health Initiative.

Authors:
Joan R Smith

J Perinat Neonatal Nurs 2017 Jul/Sep;31(3):198-199

Director Clinical Quality, Safety & Practice Excellence St. Louis Children's Hospital St. Louis, Missouri.

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http://dx.doi.org/10.1097/JPN.0000000000000278DOI Listing
July 2019

Analgesia in the Premature Neonate: Walking the Tightrope Requires a Great Team.

J Perinat Neonatal Nurs 2017 Apr/Jun;31(2):99-100

Clinical Pharmacist, Neonatal ICU, St Louis Children's Hospital, St Louis, Missouri Assistant Professor, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri Director, Clinical Quality, Safety & Practice Excellence, St Louis Children's Hospital, Missouri.

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http://dx.doi.org/10.1097/JPN.0000000000000245DOI Listing
July 2019

Linking Patient and Worker Safety to Create a Safe and Healthy Working Environment.

Authors:
Joan R Smith

J Perinat Neonatal Nurs 2017 Jan/Mar;31(1):8-11

Clinical Quality, Safety & Practice Excellence St Louis Children's Hospital, Missouri.

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http://dx.doi.org/10.1097/JPN.0000000000000231DOI Listing
July 2017

Neonatal Nurses NICU Quality Improvement: Embracing EBP Recommendations to Provide Parent Psychosocial Support.

Adv Neonatal Care 2017 Feb;17(1):33-44

HS Pediatrics, David Geffen School of Medicine at UCLA, Pediatrics Department/Neonatology & Developmental Biology, Los Angeles, California (Dr Purdy); Pediatrics Department/Neonatology & Developmental Biology, David Geffen School of Medicine at UCLA, Los Angeles, California (Dr Melwak); Goldfarb School of Nursing at Barnes-Jewish College, Advanced Practice Clinical Scientist, St. Louis Children's Hospital, St Louis, Missouri (Dr Smith); School of Nursing, Health, and Exercise Science/The College of New Jersey, Ewing (Dr Kenner); Department of Nursing/University of Iowa Children's Hospital, Iowa City (Dr Chuffo-Siewert); Nurse Education Program, Elmira College, Elmira, New York (Dr Ryan); Drexel University, Philadelphia, Pennsylvania (Dr. Geller); and Division of Neonatology/St John's Regional Medical Center, Oxnard, California (Dr Hall).

Background: The neonatal intensive care unit (NICU) can be a stressful environment for infants, their families, and the healthcare team. There is an immediate need for neonatal nurses to embrace and translate the new National Perinatal Association recommendations for psychosocial support of NICU parents into clinical practice to demonstrate best practices for infants, their families, and the whole team.

Purpose: To summarize the current evidence-based practice recommendations and to provide suggestions for team members to develop strategies to adopt and implement them through quality improvement (QI) projects.

Methods: Literature reviews were conducted by the original 6 National Perinatal Association workgroup teams and covered all levels of available evidence (eg, qualitative, quantitative, and clinical research, guidelines, and clinical and parental expertise). Evidence was synthesized to formulate this set of recommendations published in December 2015. We describe their applicability to the vital role of neonatal nurses, while elucidating QI projects that track measurements of change to translate these recommendations into practice.

Results: Neonatal nurses are in an ideal position to transform systems of support for NICU parents through the adoption of these recommendations at the bedside, and further to identify areas for QI to enhance implementation.

Implications For Practice: Neonatal nurses are integral to problem solving and identifying QI strategies for translating these recommendations into NICU clinical practice to improve parent psychosocial support.

Implications For Research: This article disseminates evidence and encourages scientific investigation into various methods of supporting emotional health of NICU parents to create better health outcomes.
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http://dx.doi.org/10.1097/ANC.0000000000000352DOI Listing
February 2017

Evidence-Based Practice and Quality Improvement in Nursing Education.

J Perinat Neonatal Nurs 2016 Jul-Sep;30(3):191-4

St. Louis Children's Hospital, St. Louis, Missouri (Drs Balakas and Smith); and Goldfarb School of Nursing at Barnes-Jewish College, St. Louis, Missouri (Dr Smith).

For more than a decade, nursing education has experienced several significant changes in response to challenges faced by healthcare organizations. Accrediting organizations have called for improved quality and safety in care, and the Institute of Medicine has identified evidence-based practice and quality improvement as 2 core competencies to include in the curricula for all healthcare professionals. However, the application of these competencies reaches far beyond the classroom setting. For nurses to possess the knowledge, skills, and attitudes to apply evidence-based practice and quality improvement to the real-world setting, academic-clinical institution partnerships are vital.
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http://dx.doi.org/10.1097/JPN.0000000000000197DOI Listing
July 2017

Determining Appropriate Sensory Exposures in the NICU: Too Much, Too Little, or Just Right?

Neonatal Netw 2016 ;35(2):63-5

Barnes-Jewish College of Nursing, 4483 Duncan Avenue, St. Louis, MO 63110, USA.

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http://dx.doi.org/10.1891/0730-0832.35.2.63DOI Listing
February 2017

SLUG Bug: Quality Improvement With Orchestrated Testing Leads to NICU CLABSI Reduction.

Pediatrics 2016 Jan 23;137(1). Epub 2015 Dec 23.

Children's Mercy Kansas City, Kansas City, Missouri; and Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri.

Objective: Reduce central line-associated bloodstream infection (CLABSI) rates 15% over 12 months in children's hospital NICUs. Use orchestrated testing as an approach to identify important CLABSI prevention practices.

Methods: Literature review, expert opinion, and benchmarking were used to develop clinical practice recommendations for central line care. Four existing CLABSI prevention strategies (tubing change technique, hub care monitoring, central venous catheter access limitation, and central venous catheter removal monitoring) were identified for study. We compared the change in CLABSI rates from baseline throughout the study period in 17 participating centers. Using orchestrated testing, centers were then placed into 1 of 8 test groups to identify which prevention practices had the greatest impact on CLABSI reduction.

Results: CLABSI rates decreased by 19.28% from 1.333 to 1.076 per 1000 line-days. Six of the 8 test groups and 14 of the 17 centers had decreased infection rates; 16 of the 17 centers achieved >75% compliance with process measures. Hub scrub compliance monitoring, when used in combination with sterile tubing change, decreased CLABSI rates by 1.25 per 1000 line-days.

Conclusions: This multicenter improvement collaborative achieved a decrease in CLABSI rates. Orchestrated testing identified infection prevention practices that contribute to reductions in infection rates. Sterile tubing change in combination with hub scrub compliance monitoring should be considered in CLABSI reduction efforts.
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http://dx.doi.org/10.1542/peds.2014-3642DOI Listing
January 2016

Orchestrated Testing.

Am J Med Qual 2017 Jan/Feb;32(1):87-92. Epub 2016 Jul 10.

11 Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA.

Health care quality improvement collaboratives implement care bundles to target critical parts of a complex system to improve a specific health outcome. The quantitative impact of each component of the care bundle is often unknown. Orchestrated testing (OT) is an application of planned experimentation that allows simultaneous examination of multiple practices (bundle elements) to determine which intervention or combination of interventions affects the outcome. The purpose of this article is to describe the process needed to design and implement OT methodology for improvement collaboratives. Examples from a multicenter collaborative to reduce central line-associated bloodstream infections highlight the practical application of this approach. The key components for implementation of OT are the following: (1) define current practice and evidence, (2) develop a factorial matrix and calculate power, (3) formulate structure for engagement, (4) analyze results, and (5) replicate findings.
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http://dx.doi.org/10.1177/1062860615609994DOI Listing
February 2018

Ensuring Quality in the NICU: Translating Research Into Appropriate Clinical Care.

J Perinat Neonatal Nurs 2015 Jul-Sep;29(3):255-61

Goldfarb School of Nursing at Barnes-Jewish College, St Louis, Missouri (Dr Smith); St Louis Children's Hospital and the Department of Nursing and Professional Practice, St Louis, Missouri (Dr Smith), St Louis Children's Hospital and the Department of Nursing and the Newborn Intensive Care Unit, St Louis, Missouri (Dr Smith and Mss Donze and Wolf); Departments of Neurology (Dr Smyser) and Pediatrics (Drs Smyser and Mathur), and Division of Newborn Medicine (Dr Mathur), Washington University School of Medicine, St Louis, Missouri; and George Warren Brown School of Social Work, Washington University, St Louis, Missouri (Dr Proctor).

Since the Institute of Medicine's landmark report To Err Is Human, extensive efforts to improve patient safety have been undertaken. However, wide-scale improvement has been limited, sporadic, and inconsistent. Implementation of evidence-based interventions remains a challenge, resulting in unwarranted variations in care. Three main categories of problems in healthcare delivery are defined as overuse, underuse, and misuse of medical services, resulting in inappropriate care, inefficiencies, and poor quality. Although broad acknowledgement that these categories of quality problems exist, there are limited standards for measuring their overall impact. This article aims to discuss the important role of implementation science in advancing evidence-based practice, using neonatal therapeutic hypothermia for the treatment of hypoxic-ischemic encephalopathy as an exemplar for examining appropriateness of care.
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http://dx.doi.org/10.1097/JPN.0000000000000122DOI Listing
December 2016

Interdisciplinary teamwork and the power of a quality improvement collaborative in tertiary neonatal intensive care units.

J Perinat Neonatal Nurs 2015 Apr-Jun;29(2):179-86

Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado (Drs Grover and Moran); Children's Mercy Hospital and the Department of Pediatrics, University of Missouri School of Medicine, Kansas City, Missouri (Dr Pallotto); Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania (Dr Brozanski and Ms Mingrone); Children's Healthcare of Atlanta at Egleston and Emory University School of Medicine, Atlanta, Georgia (Dr Piazza); Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania (Dr Chuo); Nationwide Children's Hospital, Columbus, Ohio (Dr McClead); Children's Hospital Association, Overland Park, Kansas (Ms Morelli); and St Louis Children's Hospital and Goldfarb School of Nursing at Barnes-Jewish College, St. Louis, Missouri (Dr Smith).

Significant gaps in healthcare quality and outcomes can be reduced via quality improvement collaboratives (QICs), which improve care by leveraging data and experience from multiple organizations.The Children's Hospital Neonatal Consortium Collaborative Initiatives for Quality Improvement team developed an infrastructure for neonatal QICs. We describe the structure and components of an effective multi-institutional neonatal QIC that implemented the "SLUG Bug" project designed to reduce central line-associated bloodstream infections (CLABSIs).The operational infrastructure of SLUG Bug involved 17 tertiary care neonatal intensive care units with a goal to reduce CLABSI in high-risk neonates. Clinical Practice Recommendations were produced, and the Institute of Healthcare Improvement Breakthrough Series provided the framework for the collaborative. Process measures studied the effectiveness of the collaborative structure.CLABSI rates decreased by 20% during a 12-month study period. Compliance bundle reporting exceeded 80%. A QIC score of 2.5 or more ("improvement") was achieved by 94% of centers and a score 4 or more ("significant improvement") was achieved by 35%.Frequent interactive project meetings, well-defined project metrics, continual shared learning opportunities, and individual team coaching were key QIC success components. Through a coordinated approach and committed leadership, QICs can effectively implement change and improve the care of neonates with complex diagnoses and rare diseases.
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http://dx.doi.org/10.1097/JPN.0000000000000102DOI Listing
December 2016

From the editors.

J Perinat Neonatal Nurs 2015 Apr-Jun;29(2):93-4

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http://dx.doi.org/10.1097/JPN.0000000000000094DOI Listing
December 2016

Impact of a Neonatal-Bereavement-Support DVD on Parental Grief: A Randomized Controlled Trial.

Death Stud 2015 Jan-Jun;39(1-5):191-200. Epub 2014 Dec 20.

a Edward Mallinckrodt Department of Pediatrics , Washington University School of Medicine , St. Louis , Missouri , USA.

This study tested the effect of a neonatal-bereavement-support DVD on parental grief after their baby's death in a Neonatal Intensive Care Unit compared with standard bereavement care (controls). Following a neonatal death, the authors measured grief change from a 3- to 12-month follow-up using a mixed-effects model. Intent-to-treat analysis was not significant, but only 18 parents selectively watched the DVD. Thus, we subsequently compared DVD viewers with DVD nonviewers and controls. DVD viewers reported higher grief at 3-month interviews compared with DVD nonviewers and controls. Higher grief at 3 months was negatively correlated with social support and spiritual/religious beliefs. These findings have implications for neonatal-bereavement care.
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http://dx.doi.org/10.1080/07481187.2014.946628DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4382412PMC
September 2015

A randomized-controlled trial pilot study examining the neurodevelopmental effects of a 5-week M Technique intervention on very preterm infants.

Adv Neonatal Care 2014 Jun;14(3):187-200

Division of Nursing and Newborn Intensive Care, St Louis Children's Hospital, Missouri (Dr Smith); School of Nursing, University of Connecticut, Nursing Research, Connecticut Children's Medical Center, Hartford (Dr McGrath); School of Nursing and Medicine, University of Missouri Kansas City (Dr Brotto); and Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, Massachusetts (Dr Inder).

Purpose: To systematically test the cumulative effect of the M Technique on infant neurodevelopment in hospitalized very preterm infants.

Design: A pilot randomized controlled trial (RCT).

Subjects: Twenty very preterm infants (<30 weeks gestation with average birth weights <1000 g) were randomly assigned to nontreatment or treatment groups. The study period began once the infants reached 30 weeks postmenstrual age (PMA).

Methods: Each infant received standard neonatal intensive unit (NICU) care or standard NICU care plus a 7-minute M Technique session, 6 times per week for 5 weeks. Neurobehavioral development (using the NICU Network Neurobehavioral Scale [NNNS]) and growth velocity (difference in infant weight at the beginning and end of protocol) were compared between the 2 groups. Physiologic parameters (heart rate, respiratory rate, and oxygen saturations) and infant behavioral states were measured 5 minutes before, during, and up to 10 minutes postintervention continuously on all infants in the treatment group at 3 different gestational time points (30, 32, and 34 weeks PMA) over the 5-week period.

Results: Mann-Whitney U analyses revealed no differences between the 2 groups on all 12 NNNS summary score domains but a difference in growth velocity between the 2 groups (P = 0.005). Repeated-measures analysis of variance revealed significant physiologic differences of mean heart rate, respiratory rate, and SaO2 (F = 41.116, P < 0.0005) and behavioral states (F = 38.564, P < 0.0005) from baseline to 10 minutes after the M Technique intervention across all 3 time points. State scores decreased from baseline (M = 6.11) to post intervention (M = 1.4) at all 3 time points.

Conclusions: This pilot RCT demonstrates the utility of the M Technique in hospitalized very preterm infants starting at 30 weeks PMA with notable evidence of positive weight, physiological, and behavioral state adaptations. Additional research is needed with a larger, randomized design to determine short- and long-term effects specifically related to neurological outcomes.
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http://dx.doi.org/10.1097/ANC.0000000000000093DOI Listing
June 2014

Application of the M Technique in hospitalized very preterm infants: a feasibility study.

Adv Neonatal Care 2012 Oct;12 Suppl 5:S10-7

Division of Nursing and Newborn Intensive Care, St Louis Children's Hospital, Missouri 63110, USA.

Purpose: To explore the application of a novel relaxation method (the M Technique) in hospitalized very preterm infants in a level IIIC neonatal intensive care unit.

Design: A feasibility, observational intervention study.

Subjects: Ten very preterm infants were enrolled to receive the treatment intervention. Eligible infants born less than 30 weeks' gestation received the intervention at 30 weeks' postmenstrual age.

Methods: Based on infant readiness, each infant received the M Technique for 5 minutes. Physiologic parameters (heart rate, respiratory rate, and oxygen saturations), behavioral variables (stress and relaxation cues), and infant behavioral state were measured 5 minutes before, during, and up to 10 minutes after the intervention, continuously.

Results: Descriptive analysis revealed that baseline physiologic, behavioral state, and behavioral cue parameters changed during and after the application of the M Technique. A decrease in heart rate and respiratory rate occurred during the M Technique (P = .006, P > .001 respectively) and a decrease in heart rate occurred at the end of the M Technique session (P = .02). In addition, an increase in SaO2 occurred during and at 5 minutes following the M Technique session (P = .04, P = .02, respectively). State scores decreased from baseline (mean = 5.1; range, 3-9) to after the intervention (mean = 2.0, range 1-4). As the intervention was delivered, more positive than negative behavioral cues were observed throughout, at the end, and after the M Technique session.

Conclusion: In this feasibility study, the M Technique can be delivered without adverse effects to very preterm infants who are 30 weeks' postmenstrual age. Additional research is needed with a larger, randomized design to determine short- and long-term effects specifically related to neurologic outcomes.
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http://dx.doi.org/10.1097/ANC.0b013e31826743eaDOI Listing
October 2012

Fathers' perceptions of supportive behaviors for the provision of breast milk to premature infants.

Adv Neonatal Care 2006 Dec;6(6):341-8

St. Louis Children's Hospital, One Children's Place, NICU/5E-10, St. Louis, MO 63110, USA.

Purpose: To explore fathers' perceptions of behaviors used to support the provision of breast milk to hospitalized premature infants.

Subjects: Sixteen English-speaking fathers who, each were at least 15 years of age, had a hospitalized premature infant between 24 and 32 weeks gestation and a partner who had decided to provide breast milk.

Design: As part of a larger, exploratory study, a qualitative descriptive study was conducted to analyze fathers' perceived contributions to the process of providing breast milk.

Methods: Fathers were interviewed with a semi-structured interview guide. All interviews were audiotaped, and verbatim transcripts were analyzed by using qualitative descriptive methods.

Main Outcome Measure: Supportive behaviors as identified by fathers of hospitalized premature infants.

Principal Results: Fathers described 3 types of behaviors used to support the provision of breast milk to their hospitalized premature infants: assistance with the pumping process, assumption of additional daily domestic responsibilities, and provision of moral support.

Conclusions: Results from this study suggest several significant behaviors that fathers perceived they performed to support their partners' efforts to provide breast milk to their hospitalized premature infants.
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http://dx.doi.org/10.1016/j.adnc.2006.08.005DOI Listing
December 2006