The incidence of preterm birth in the United States has continued to increase since the early 1990s (Martin et al., 2009). The percentage of infants born with very low birth weight (VLBW) (less than 1,500 grams) has also increased during this period. Advances in neonatal care have allowed for improved survival of the most premature infants, but mortality and morbidity for VLBW infants remains high (Fanaroff et al., 1995; Martin et al.; Stoll et al., 2004). Morbidity and mortality remain higher for VLBW infants than for any other group of infants because of their innate vulnerability and exposure to risk factors in their environment. These vulnerabilities may be highest in the first hours of life when adaptation is critical and timing of care affects survival.  Delivery room (DR) management that focuses on adaptation of these infants, as well as early interventions that improve long-term outcomes, may emphasize the importance of this Golden Hour of care for improving outcomes in this extremely vulnerable population.

For VLBW infants, events occurring immediately after birth may be comparable to the "Golden Hour" referred to throughout the trauma literature (Sasada, Williamson, & Gabbott, 1994). In trauma cases, the term Golden Hour refers to the time between first encounter and admission to the emergency department. Neonatal healthcare providers are now asking, "Is there a Golden Hour of care for VLBW infants that begins with the first encounter at delivery and ends with admission to the neonatal intensive care unit (NICU)?"

The neonatal Golden Hour initiative was based on the systematic evaluation of the environmental needs and the timing of the care of the VLBW infant in the first hours of life. It moved beyond looking at changing one clinical outcome and instead looked at a process for providing care that was based on multiple evidence-based practice initiatives, or bundles, that could improve short- and long-term outcomes.

The Golden Hour bundle is a systematic evaluation of the scientific knowledge for each aspect of care for VLBW infants during resuscitation and stabilization. The Golden Hour bundle incorporates processes of neonatal resuscitation based on the Neonatal Resuscitation Program (NRP) guidelines and expands on these guidelines to ensure that the unique needs of the VLBW infant are addressed (American Academy of Pediatrics & American Heart Association, 2006). The Golden Hour bundle addresses unique strategies and evidence during the first minutes to hours after birth, highlighting four cornerstones of care: thermoregulation, cardiovascular stability, respiratory support, and nutritional requirements in the DR, during stabilization, and upon admission to the NICU. This article deals with just one aspect of the Golden Hour, thermoregulation. (For more information on the neonatal Golden Hour initiative, see the forthcoming October 2010 issue of Advances in Neonatal Care.)

Temperature control is essential to survival, and studies since the 1950s show that hypothermic infants are at increased risk for significant morbidities (Geary, Caskey, Fonseca, & Malloy, 2008). In VLBW infants, heat is lost rapidly at birth because of the cold external environment and innate immaturity. Despite ongoing work to reduce cold stress in VLBW infants in the DR, Vermont Oxford Network (2010) data demonstrate that almost one-third of VLBW infants have admission temperatures less than 36 degrees C. VLBW infants are unable to respond to thermal stress because of a diminished capacity to shiver or alter their body position due to their relatively immature skeletal muscles, lack of adequate brown-fat stores to fully use nonshivering thermogenesis, epidermal immaturity, and lack of keratin, leading to high transepidermal water loss.

Hypothermia occurring during the adaptation to extrauterine life presents increased demands for oxygen during a period when oxygen delivery may be compromised. Hypoxic infants use anaerobic metabolism, resulting in metabolic acidosis and pulmonary vasoconstriction, which ultimately leads to decreased cardiac output and shock. In addition, in VLBW infants increased glucose needs may be coupled with inadequate stores and a lack of dextrose delivery due to delays in intravenous access. The enormous water loss in these infants can lead to dehydration, electrolyte imbalance, weight loss, and thermal instability (Lorenz, Kleinman, Kotagal, & Reller, 1982). The mortality rates of low-birth-weight neonates can be reduced if healthcare providers take the necessary steps required to reduce heat loss and maintain temperature.

Prior to birth, healthcare providers must have strict guidelines for environmental temperature and humidity. Surfaces that come in contact with the infant or are close by, including the towel used to catch and dry the infant, must be prewarmed. Strategies for drying must ensure that the two or three cell layers of the poorly supported epidermis are not removed. It is essential for caregivers to understand that radiant heaters (often the sole source of thermal care in the DR) cannot achieve a positive energy balance to warm the premature infant immediately after birth and that the use of occlusive wraps in the DR for infants less than 29 weeks' gestation significantly improves admission temperatures (Knobel, Wimmer, & Holbert, 2005; McCall, Alderdice, Halliday, Jenkins, & Vohra, 2005; Vohra, Frent, Campbell, Abbott, & Whyte, 1999; Vohra, Roberts, Zhang, Janes, & Schmidt, 2004; Watkinson, 2006). The wrap serves as a shield for the infant, forming a barrier that keeps higher ambient air humidity around the infant. Healthcare providers must learn techniques for effectively wrapping the infant so that unwrapping is unnecessary, even for procedures such as placement of umbilical lines. Healthcare providers must understand that 50% of a VLBW infant's total heat loss is through the head and that hats have a minimal effect in reducing heat loss and do not prevent evaporative heat loss (Belghazi et al., 2006; McCall et al.). Placing the wrap under the hat may decrease thermal losses. It is essential that one team member have a lead role in thermal care of the VLBW infant at birth and that thermal care be incorporated into ongoing neonatal resuscitation.

For VLBW infants, healthcare decisions made in the first hours of life may determine subsequent decades of survivor-experienced morbidity. Recent comparative effectiveness research suggests that we can improve care by decreasing practice variability and reducing the use of harmful therapies. Neonatal healthcare providers must implement evidence-based practices and use all available research and current NRP guidelines to address the needs of vulnerable infants even before they are born. The Golden Hour bundle provides a framework for this process.

References

American Heart Association & American Academy of Pediatrics. (2006). Textbook of neonatal resuscitation (5th ed.). Elk Grove Village, IL: Authors.

Belghazi, K., Tourneux, P., Elabbassi, E., Ghyselen, L., Delanaud, S., & Libert, J. (2006). Effect of posture on the thermal efficiency of a plastic bag wrapping in a neonate: Assessment using a thermal "sweating" mannequin. Medical Physics, 33, 637-644

Fanaroff, A. A., Wright, L. L., Stevenson, D. K., Shankaran, S., Donovan, E. F., Ehrenkranz, R. A., et al. (1995). Very-low-birth-weight outcomes of the National Institute of Child Health and Human Development Neonatal Research Network, May 1991 through December 1992. American Journal of Obstetrics and Gynecology, 173(5), 1423-1431.

Geary, C., Caskey, M., Fonseca, R., & Malloy, M. (2008). Decreased incidence of bronchopulmonary dysplasia after early management changes, including surfactant and nasal continuous positive airway pressure treatment at delivery, lowered oxygen saturation goals, and early amino acid administration: A historical cohort study. Pediatrics, 121, 89-96.

Knobel, R. B., Wimmer, J. E., & Holbert, D. (2005). Heat loss prevention for preterm infants in the delivery room. Journal of Perinatology, 25, 304-308.

Lorenz, J. M., Kleinman, L. I., Kotagal, U. R., & Reller, M. D. (1982). Water balance in very low-birth-weight infants: Relationship to water and sodium intake and effect on outcome. Journal of Pediatrics, 101(3), 423-432.

Martin, J. A., Hamilton, B. E., Sutton, P. D., Ventura, S. J., Menacker, F., Kirmeyer , S., et al. (2009). Births: Final data for 2006. National Vital Statistics Reports, 57(7). Hyattsville, MD: National Center for Health Statistics. Retrieved July 9, 2010, from www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_07.pdf.

McCall, E., Alderdice, F., Halliday, H., Jenkins, J., & Vohra, S. (2005). Interventions to prevent hypothermia at birth in preterm and/or low birth weight babies. Cochrane Database Systematic Review, 1, CD004210.

Sasada, M., Williamson, K., & Gabbott, D. (1994). The golden hour and pre-hospital trauma care. Injury, 25, 1-4.

Stoll, B. J., Hansen, N. I., Adams-Chapman, I., Fanaroff, A. A., Hintz, S. R., Vohr, B., et al. (2004). Neurodevelopmental and growth impairment among extremely low-birth-weight infants with neonatal infection. Journal of the American Medical Association, 292(19), 2357-2365.

Vermont Oxford Network (2010). Nightingale Database. Retrieved June 30, 2010, from https://nightingale.vtoxford.org/.

Vohra, S., Frent, G., Campbell, V., Abbott, M., & Whyte, R. (1999). Effect of polyethylene occlusive skin wrapping on heat loss in very low birth weight infants at delivery: A randomized trial. Journal of Pediatrics, 134, 547-551.

Vohra, S., Roberts, R. S., Zhang, B., Janes, M., & Schmidt, B. (2004). Heat Loss Prevention (HeLP) in the delivery room: A randomized controlled trial of polyethylene occlusive skin wrapping in very preterm infants. Journal of Pediatrics, 145(6), 750-753.

Watkinson, M. (2006). Temperature control of premature infants in the delivery room. Clinics in Perinatology, 33, 43-53.

Robin Bissinger is director of graduate education, associate professor, and NNP program director at the Medical University of South Carolina, Charleston, SC, and is the president of the National Certification Corporation. She is the guest editor of the October 2010 issue of Advances in Neonatal Care on the Golden Hour and was also recently elected to represent NANN and NANNP in the American Nurses Association Congress for Nursing Education and Practice.

On December 3, 2009, the Endocrine Disruption Prevention Act of 2009 (HR 4190, S 2828) was introduced in Congress. The bill would authorize an ambitious research program in endocrine disruption at the National Institute of Environmental Health Sciences. Health concerns related to endocrine-disrupting chemicals (EDCs) matter to those who work with neonates because of their possible effect on neonatal development, particularly the development of male reproductive organs. Two EDCs of particular concern for infants are bisphenol A, found in baby bottles and infant incubators, and phthalates, found in many flexible plastic products such as intravenous tubing and in shampoos and lotions.

Because this issue affects our neonatal patients, NANN's Health Policy and Advocacy Committee has been monitoring developments and seeking to educate members about the proposed legislation. A call for action has been posted on NANN's Web site, and members are encouraged to contact their elected officials in Washington and express their views about the Endocrine Disruption Prevention Act. At the Endocrine Disruption Exchange Web site (www.endocrinedisruption.com), you can learn more and find help in contacting your congressional representatives. Look for an article on EDCs by Laura Stokowski, cochair of NANN's Health Policy and Advocacy Committee, in the summer 2010 issue of NANN Central.

Sharon L. Fitzpatrick, BSN RNC; Elizabeth Hawn, BSN RNC-NIC NE-BC; Nancy Schult, BA RNC-NIC; Laurie Young, MSN/MBA RN

The NICU Leadership Forum was developed to provide inspiration, practical solutions, and networking opportunities for NICU nursing leaders throughout the country. NANN is one of many sponsors of the forum, which is open to managers and directors from all Level II and Level III NICUs across the country. The 2010 meeting, "Striving for Excellence," was held in Marco Island, FL. We attended this year with the help of a NANN scholarship, for which we are truly grateful.

The conference included didactic presentations, small breakout sessions on particular topics, panel discussions, and highly interactive discussions on topics concerning cutting-edge technology, quality improvement, safety, leadership, and management, and the meeting is structured in a way that promotes networking among the attendees. The NICU Leadership Forum has also developed an e-mail discussion group and mailing list so that managers and directors have an opportunity for ongoing discussion, information sharing, and networking throughout the year. These have been extremely valuable tools for attendees.

We found sessions on many topics relevant to the healthcare climate of our respective institutions. One of the most enlightening sessions, "How to Practice Accountability So That Excellence Happens," was presented by Eileen Dohmann, MBA BSN RN NEA-BC, vice president of nursing at Mary Washington Hospital in Fredericksburg, VA. Dohmann spoke about maintaining accountability in nursing and getting people to do what they say they will do. In an accountability culture, she said, learning and results are expected and valued, and results are generated by a disciplined method. The tools for accountability, we learned, are using accountability language, calling for the results you want, hearing the "yes" or the "no," stopping and resetting the work to be done and the mindset of the group doing the work, tapping the forward energy of what can be done (avoiding a focus on what can't be done), and "flipping the negative energy."

This conference provides useful information about many practical challenges faced by NICU leaders, and the opportunity for networking and obtaining support from other leaders is invaluable. Participants are reminded that leaders often share the same daily struggles and joys. Having the opportunity to discuss solutions with other leaders and hear about other ways to look at situations has allowed us to grow as leaders.

The NICU Leadership Forum provides incredible camaraderie and practical information for leading NICUs today and in the future. We thank NANN for making it possible for us to attend and encourage others to take advantage of this opportunity for professional growth.

Sharon L. Fitzpatrick is a nurse manager in the special care nursery at Winchester Hospital, Winchester, MA. Elizabeth Hawn is director of maternal child services at Martin Memorial Health System, Stuart, FL. Nancy Schult is a patient care manager in the NICU at Children's Hospitals and Clinics of Minnesota. Laurie Young is a nurse manager at Regions Hospital, Saint Paul, MN.