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www.babyfirst.com
Clinical Knowledge.
Family Focus.
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Miss an Issue of NANN E-News?
You can access past issues of NANN E-News on NANN's Web site. Read an issue online in your browser, or download a pdf and read it at your leisure. Visit the NANN E-news page to see what you've missed! |
 Board Update
Lori Armstrong, MSN RN, NANN President
 The NANN board met via conference call on April 22. As mentioned in previous board updates, NANN has several new products in the hopper. We're pleased to announce that Developmental Care of Newborns and Infants, 2nd edition, and an online RNC review course will be available in the summer. Several other new products are scheduled for release soon after these, so watch the NANN Web site, NANN E-News, and NANN Central for updates. Increasing membership engagement is one of NANN's strategic goals, with several projects on the docket. The board approved a new style guide that will give a consistent visual look to all NANN's products and news vehicles and to the Web site. Watch for NANN's new style in the coming months. We discussed Neonatal Nurses Day and approved a proposal for reaching out to NANN members on September 15. The board also approved a chapter charter for the Central Florida Association of Neonatal Nurses. If you live in the Orlando area, we invite you to join them! A roster of chapter presidents can be accessed on the NANN Web site. Another of NANN's strategic goals concerns advocacy. NANN and NANNP members recently participated in efforts to address the requirement of the Centers for Medicare and Medicaid Services that only physicians direct respiratory care services, and a change in that policy has now been recommended. See Suzanne Staebler's article in this issue, and find information on other advocacy initiatives on the Advocacy page of NANN'S Web site, under "Call to Action." Last, plans for NANN's 26th Annual Educational Conference in Las Vegas are progressing rapidly. We think you will find this conference to be an exceptional educational opportunity, as well as inspirational and enjoyable. I hope to see you there! Please direct any questions to me at
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CE Course on SIDS Reduction
Sudden infant death syndrome (SIDS) is one of the leading causes of infant death in the United States. Even though no way to prevent SIDS completely is known, parents and caregivers can take certain actions to significantly reduce their babies' risk for SIDS.
Nurses play a critical role in communicating SIDS risk-reduction techniques, especially in hospital settings. To ensure that nurses have the most current and accurate information to communicate risk factors and answer parents' questions, the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) has created a continuing education (CE) program on SIDS risk reduction. The program is currently available free of charge. Nurses who successfully complete the course will earn 1.1 contact hours of CE credit from the Maryland Nurses Association, which is accredited by the American Nurses Credentialing Center Commission on Accreditation as a CE provider.
Click the button at left to download the online CE program, or call (800) 505-CRIB (2742) to order a printed version.
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Awards Nominations Due June 1
Don't miss an opportunity to recognize your colleagues or your local chapter. You'll find more information about NANN's awards, as well as the award applications, on NANN's Web site.
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NANN and NANNP Elections in June
Balloting for the NANN and NANNP annual elections will be open from June 1 through June 30, 2010. Please watch for an e-mail that will contain a link to the ballot and your ID and log-in password. If you are a NANNP member, you will have access to both the NANN and the NANNP ballots. If you do not have e-mail, voting instructions will be sent to you by U.S. postal mail.
NANN will elect a Secretary-Treasurer, a Director-at-Large, a Special Interest Group Director-at-Large, and--new this year--a Staff Nurse Director-at-Large. The NANNP ballot will include open positions for Council members in Districts 1, 2, and 4.
The futures of both NANN and NANNP depend upon leaders who have a clear vision for the organization and for neonatal nursing. Your vote will help determine the best leaders to fulfill those roles. Please vote!
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Member News
Congratulations to NANN member Laura Stokowski, MS RN, whose article in Medscape Nurses, "Will We Have a National Nurse?" was featured as the top story in the American Nurses Association's SmartBrief of March 23, 2010. According to the March 29 issue of National Nurse Newsletter, Laura's article on HR 4601, a bill to create an Office of the National Nurse, prompted many nurses to write in "requesting more information and asking how they could help support this important legislation to improve the public's health and increase the visibility of the nursing profession." Laura, who works at Inova Fairfax Hospital in Falls Church, VA, is cochair of NANN's Health Policy and Advocacy Committee.
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2010 March of Dimes Walk for Babies
The NANN national office staff, with colleagues and family members, raised $4,397 in the 2010 March of Dimes Walk for Babies on April 24, breaking all previous records. Twenty-three walkers raised $2,397, and $2,000 of that amount was matched by Association Management Center, NANN's management company, to bring the total to $4,397. Thanks to these walkers and to all across the country who supported this worthy cause.
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Chapter News
In March the Central California chapter (CCANN) held a conference titled "Haiti's Smallest Survivor"; Virginia Meade was the presenter. A garage sale held following the conference raised $1,760 for Haiti earthquake victims. In other news, the chapter is offering a $500 scholarship to an RN seeking higher education and will be giving support for 10 members to attend NANN's annual conference in Las Vegas.
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Student Members Catch a Break from NANN
To help foster a love of neonatal nursing in nursing students, the NANN Board of Directors has reduced the student membership rate to just $50 per year. New programs are in the works for students and should be rolled out late this year, so now is a great time for them to join. Do you know any nursing students? Invite them to check out the benefits of NANN membership and join today.
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NANN's Annual Conference
Don't miss out! Registration is now open for NANN's 26th Annual Educational Conference, the national conference for neonatal nurses. Scheduled for September 19-22 in Las Vegas, NV, this year's conference promises a whole host of educational and networking opportunities, and you can also earn up to 25 contact hours.
Come hear opening keynoter John Nance discuss what hospitals can learn from the aviation field. His 2008 book Why Hospitals Should Fly has been in great demand as healthcare reform unfolds. Mr. Nance will introduce revolutionary ideas that could change how you think about safety in your NICU.
In the closing keynote address Rick Kirschner, ND, will discuss how to bring out the best in people, whether your boss, your co-workers, or people who report to you. He'll deliver an information-packed session in his funny, enjoyable, and inimitable style.
Early registration (with a savings of $100) runs through August 20. Register today!
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Faces of Neonatal Nursing Photo Contest
Neonatal nursing has many faces: dedicated nursing professionals in the NICU, in transport, in home care, in academic settings, within local communities, on Capitol Hill; the faces of neonates from days to years old, growing and prospering; the faces of mothers, fathers, grandparents, and siblings. Celebrate neonatal nursing by participating in NANN's Faces of Neonatal Nursing photo contest! Capture a moment in a photograph and submit it with a narrative; multiple entries are permitted.
Photo submissions and narratives will be displayed in September at NANN's 26th Annual Educational Conference, where attendees will determine the winning photo by ballot vote. The submitter of the winning entry will receive a complimentary registration to NANN's 2011 annual conference, and the photo will be considered for use on the cover of an issue of Advances in Neonatal Care. All photos and narratives must be submitted in electronic format to
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by August 6, 2010. For contest rules and judging criteria, please visit the meetings page at www.nann.org.
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Preventing and Treating Diaper Dermatitis
Lauren Heimall, MSN RNC
 Diaper dermatitis (DD), an acute inflammatory reaction of diapered skin, is a common problem in the pediatric population. Although incidence is unknown, it is estimated to be present in approximately 25% of children seen as outpatients (Ward, Fleischer, Feldman, & Krowchuk, 2000) and accounts for more than 1 million office visits per year in the United States (Nield & Kamat, 2007). DD can occur in patients of various ages, but patients between 9 and 12 months of age have been found to be most at risk (Borkowski, 2004). The signs and symptoms range from generalized erythema to skin that breaks down and becomes an open wound. DD causes both discomfort for the patient and significant distress to caregivers.
The etiology of DD is multifactorial. Skin contact with urine and feces plays an important role because moisture trapped against the skin causes increased permeability and susceptibility to damage from friction. The skin therefore loses its ability to provide an effective barrier against irritants and microbes. In addition, skin normally has an acidic pH of 4.5-5.5. When urine is in contact with diapered skin, the skin pH increases, causing increased permeability and an activation of fecal enzymes, irritants known to cause skin destruction. A study of 1,601 infants found an elevated pH in diapered skin compared to nondiapered skin and found that the elevated pH was associated with greater severity of DD (Berg, Milligan, & Sarbaugh, 1994). Furthermore, as the stratum corneum becomes damaged, microbes are more likely to cause inflammation and lead to the development of a secondary infection. Ferrazzini and others (2003) found that children with DD were significantly more likely to be colonized with Candida albicans and that the severity of the DD correlated with the extent of colonization.
DD commonly affects healthy children; however, acutely and chronically ill children may be at higher risk because they receive antibiotics and medications that can cause diarrhea or because they have an underlying diagnosis such as cancer, gastrointestinal anomalies, neurological disorders, or genetic syndromes. Age is another factor, with neonates being at an increased risk. Lund and others (2001) looked at 2,820 infants in 51 hospitals and found that well newborns had a better baseline skin condition compared to preemies. Malnutrition, more common in hospitalized children, can affect the immune system and alter wound healing, which may prolong episodes of DD (Haisfield-Wolfe & Rund, 2000).
A limited number of studies have investigated DD in hospitalized or ill children. Suddaby and others evaluated skin breakdown in 347 hospitalized pediatric patients and found the most common areas of breakdown to be the buttocks, perineum, and occiput (Suddaby, Barnett, & Facteau, 2005). DD was found to be more common in general medical-surgical patients, younger children, and those with diarrhea. Adalat, Wall, and Goodyear (2007) surveyed 532 diapered children who were hospitalized or visiting an outpatient clinic; 16% had DD with diarrhea identified as a significant risk factor. Noonan, Quigley, and Curley (2006) reported an overall DD prevalence rate of 16% with approximately 60% of 252 hospitalized children incontinent of urine and/or stool. Another survey examined 1,064 children from nine children's hospitals and found that the most common type of skin breakdown was excoriation or DD, affecting 42% of study participants (McLane, Bookout, McCord, McCain, & Jefferson, 2004). On the basis of these data, DD is clearly a problem in hospitalized patients.
The literature supports the identification of DD is a problem in the hospitalized child; however, the most effective prevention and treatment options remain unclear. Studies show that zinc oxide and petrolatum are effective barriers against potential skin irritants and maceration (Association of Women's Health, Obstetric and Neonatal Nurses [AWHONN], 2007; Hoggarth, Waring, Alexander, Greenwood, & Callaghan, 2005; Lund, Kuller, Lane, Lott, & Raines, 1999; Nield & Kamat, 2007). Baldwin et al. (2001) conducted studies with a disposable diaper that delivered a continuous zinc oxide- and petrolatum-based formulation to the skin and found that infants wearing this diaper had reduced diaper rash and erythema compared to the control group wearing a regular diaper. Studies have also shown the importance of treating fungal infections. Spraker et al. (2006) found that miconazole nitrate 0.25% ointment in a zinc oxide/petrolatum vehicle was an effective and well-tolerated treatment for candidal DD in neonates, infants, and young children.
Other factors to consider are the frequency of diaper changes, type of diaper used, bathing practices, and concomitant products. A Cochrane Review did not find definitive evidence to support or refute the use and type of disposable diapers for prevention of DD (Baer, Davies, & Easterbrook, 2006). However, multiple descriptive and expert opinion articles recommend using superabsorbent diapers containing absorbent gelling materials, which help keep moisture away from the skin (Davis, Leyden, Grove, & Raynor, 1989; Lund et al., 1999; Nield & Kamat, 2007; Scheinfeld, 2005). Diapers should be changed frequently, as often as every 2 hours or sooner if the diaper is wet or soiled (Atherton, 2004; AWHONN, 2007; Borkowski, 2004; Kazaks & Lane, 2000; Nield & Kamat; Visscher, 2009). Because preservatives in baby wipes have the potential to cause skin irritation, articles in the literature also recommend using soft cloths and water for cleansing the diaper area (AWHONN; Boiko, 1999; Borkowski; Nield & Kamat). The method of applying diaper-area products is also important. Taquino (2000) advises that, to prevent further skin damage, products be applied thickly and not rubbed off completely during diaper changes. It may be helpful to cover the thicker products, such as pastes, with a thin layer of petrolatum in order to prevent the diaper from sticking to the product (Borkowski). The practices described above often vary among nurses and caregivers, but consistent treatment should be the goal of care.
ReferencesAdalat, S., Wall, D., & Goodyear, H. (2007). Diaper dermatitis: Frequency and contributory factors in hospital attending children. Pediatric Dermatology, 24(5), 483-488. Association of Women's Health, Obstetric and Neonatal Nurses. (2007). Neonatal skin care evidence-based clinical practice guideline (2nd ed.). Washington, DC: Author. Atherton, D. J. (2004). A review of the pathophysiology, prevention and treatment of irritant diaper dermatitis . Current Medical Research and Opinions, 20(5), 645-649. Baer, E. L., Davies, M. W., & Easterbrook, K. J. (2006). Disposable nappies for preventing napkin dermatitis in infants. Cochrane Database of Systematic Reviews, 3.Baldwin, S., Odio, M. R., Haines, S. L., O'Connor, R. J., Englehart, J. S., & Lane, A. T. (2001). Skin benefits from continuous topical administration of a zinc oxide/petrolatum formulation by a novel disposable diaper. Journal of the European Academy of Dermatology and Venereology, 15(Suppl. 1), 5-11. Berg, R. W., Milligan, M. C., & Sarbaugh, F. C. (1994). Association of skin wetness and pH with diaper dermatitis. Pediatric Dermatology, 11(1), 18-20. Boiko, S. (1999). Treatment of diaper dermatitis. Dermatologic Clinics, 17(1), 235-241. Borkowski, S. (2004). Diaper rash care and management. Pediatric Nursing, 30(6), 467-470. Davis, J. A., Leyden, J. J., Grove, G. L., & Raynor, W. J. (1989). Comparison of disposable diapers with fluff absorbent and fluff plus absorbent polymers: Effects on skin hydration, skin pH, and diaper dermatitis. Pediatric Dermatology, 6(2), 102-108. Ferrazzini, G., Kaiser, R. R., Hirsig-Cheng, S. K., Wehril, M., Della Casa, V., Pohlig, G., et al. (2003). Microbiological aspects of diaper dermatitis. Dermatology, 206, 136-141. Haisfield-Wolfe, M. E., & Rund, C. (2000). A nursing protocol for the management of perineal-rectal skin alterations. Clinical Journal of Oncology Nursing, 4(1), 15-21. Hoggarth, A., Waring, M., Alexander, J., Greenwood, A., & Callaghan, T. (2005). A controlled, three-part trial to investigate the barrier function and skin hydration properties of six skin protectants. Ostomy/Wound Management, 51(12), 30-42. Kazaks, E. L., & Lane, A. T. (2000). Diaper dermatitis. Pediatric Clinics of North America, 47(4), 909-919. Lund, C., Kuller, J., Lane, A., Lott, J. W., & Raines, D. A. (1999). Neonatal skin care: The scientific basis for practice. Journal of Obstetric, Gynecologic and Neonatal Nursing, 28, 241-254. Lund, C. H., Kuller, J., Lane, A. T., Lott, J. W., Raines, D. A., & Thomas, K. K. (2001). Neonatal skin care: Evaluation of the AWHONN/NANN research-based practice project on knowledge and skin care practices. Journal of Obstetric, Gynecologic and Neonatal Nursing, 30, 30-40. McLane, K. M., Bookout, K., McCord, S., McCain, J., & Jefferson, L. S. (2004). The 2003 national pediatric pressure ulcer and skin breakdown prevalence survey: A multisite study. Journal of Wound, Ostomy, and Continence Nursing, 31(4), 168-178. Nield, L. S. & Kamat, D. (2007). Prevention, diagnosis, and management of diaper dermatitis. Clinical Pediatrics, 46(6), 480-486. Noonan, C., Quigley, S., & Curley, M. A. Q. (2006). Skin integrity in hospitalized infants and children: A prevalence study. Journal of Pediatric Nursing, 21(6), 445-453. Scheinfeld, N. (2005). Diaper dermatitis: A review and brief survey of eruptions of the diaper area. American Journal of Clinical Dermatology, 6(5), 273-281. Spraker, M. K., Gisoldi, E. M., Siegfried, E. C., Fling, J. A., de Espinosa, Z. D., Quiring, J. N., et al. (2006). Topical miconazole nitrate ointment in the treatment of diaper dermatitis complicated by candidiasis. Therapeutics for the Clinician, 77, 113-120. Suddaby, E. C., Barnett, S., & Facteau, L. (2005). Skin breakdown in acute care pediatrics. Pediatric Nursing, 31(2), 132-138, 148. Taquino, L. T. (2000). Promoting wound healing in the neonatal setting: Process versus protocol. Journal of Perinatal and Neonatal Nursing, 14(1), 104-118. Visscher, M. O. (2009). Recent advances in diaper dermatitis: Etiology and treatment. Pediatric Health, 3(1), 81-98. Ward, D. B., Fleischer, A. B., Feldman, S. R., & Krowchuk, D. P. (2000). Characterization of diaper dermatitis in the United States. Archives of Pediatric and Adolescent Medicine, 154, 943-946.
Lauren Heimall is a clinical nurse specialist in the newborn/infant intensive care unit at Children's Hospital of Philadelphia, Philadelphia, PA.
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In the News: CMS Proposes Changes to Requirements for Respiratory Care Orders
Suzanne Staebler, DNP RN NNP-BC
A number of you participated in NANN's advocacy efforts to have the Centers for Medicare and Medicaid Services (CMS) reconsider its requirement that only physicians be allowed to direct respiratory care services. Although this rule allowed advanced practice registered nurses (APRNs) in all specialties to write respiratory care orders, it also mandated that the "responsible doctor of medicine or osteopathy must co-sign the order." For APRNs in 14 states that still require a physician "supervision or collaboration" relationship, this was a significant impediment to prompt access to appropriate care. NNPs caring for critically ill infants can write hundreds of respiratory orders a day, depending on the size of the unit and the acuity level of the patients. This policy, which promoted inefficiency and redundancy of provider activities, increased the complexity and eventual cost of providing care and placed patients at increased risk of experiencing delays in therapy and having poorer outcomes.
I am happy to report that in April, CMS proposed changes to the rule in section 482.57(b)(3) concerning the Medicare conditions of participation for hospitals relating to the types of practitioners who may provide rehabilitation services and respiratory care services (see the Fiscal Year 2011 Hospital Inpatient Prospective Payment System Proposed Rule Home Page on the CMS Web site). Finding the parameters for the ordering of these services to be "too narrow," and in the absence of "any documented studies indicating that qualified, licensed practitioners such as NPs and PAs [physician assistants] should be restricted from ordering these necessary services for their patients," CMS asserted that "we believe that the process of physician countersignature of orders written by qualified, licensed NPs and PAs, specifically for common hospital services such as rehabilitation and respiratory care services, is burdensome to practitioners (physicians as well as NPs and PAs) and the hospitals that they serve."
The update concludes, "We are proposing to revise the existing requirements at §482.57 to allow these practitioners, in addition to physicians as currently allowed, to order these services as long as such privileges are authorized by the medical staff and are in accordance with both hospital policies and procedures and CMS-1498-P 659, State laws."
If you sent a letter to CMS requesting a reevaluation of its stance on this regulation, please call or send an e-mail to thank those whom you contacted. This follow-up contact will help to "seal the deal" and make sure that these proposed changes are actually put in place in October 2010, when the 2011 fiscal year begins.
Suzanne Staebler is an APN clinical specialist at Texas Health Presbyterian Hospital, Plano, TX, and is cochair of NANN's Health Policy and Advocacy Committee. She may be reached at
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In the News: New Web Site for the Neonatal Community
Draeger and NICUniversity are supporting a new Web site dedicated to the neonatology community. This new site, called BabyFirst, can be accessed at www.babyfirst.com. The site features information for both the healthcare clinician and the families of neonatal patients. Nurses, physicians, and other clinicians in neonatal care can access lectures on such topics as thermoregulation, respiratory support, skin care, and developmental care. These video lectures are given by leaders in the neonatal field like Carolyn Lund, MSN RN FAAN, and Jay Greenspan, MD MBA. Links to numerous research abstracts and free full-text articles on the topics are also provided. Parents and families can access the site to obtain general information about having a baby in a NICU as well as a glossary of NICU terms, devices, and therapies. Testimonials from parents who have lived the NICU experience and a parents' blog are also available. |
In the News: Recall on Infant Sling Carriers
As neonatal nurses, we provide endless teaching to our families at the time of a baby's discharge. The basics include education on safe sleep, CPR, car seat safety, and shaken baby syndrome as well as on newborn care--bathing, swaddling, and diapering. Beyond this routine education that we give to parents, we often field numerous questions they have about bringing their baby home. We can never be expected to know everything, but keeping abreast of consumer product recalls may help us provide sound education to our patients' families.
A recent update from the U.S. Consumer Product Safety Commission (CPSC) released at the end of March 2010 announced a recall of more than 1 million infant slings in the United States following reports of three deaths of children ages 6 days to 3 months. The Infantino SlingRider and Wendy Bellissimo slings have been recalled because of suffocation hazards. The sling can cause suffocation when the fabric presses against the baby's face and restricts breathing. The sling also can cause the baby to be in a curled chin-to-chest position that can restrict the airway and limit the oxygen supply.
The CPSC has deemed that a mandatory standard for infant sling carriers is necessary. For more information, visit www.cpsc.gov.
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In the News: The Office of the National Nurse
The National Nursing Network Organization is currently lobbying for an Office of the National Nurse. What is the purpose of the National Nurse? The country already has a chief nursing officer (CNO) in the U.S. Public Health Service who serves as the Assistant Surgeon General. The National Nurse Act of 2010--HR 4601 will change the CNO position into a full-time position of the National Nurse within the Office of the Surgeon General.
This new National Nurse will continue to carry out the CNO's responsibilities while also working to improve the public's health and promote the nursing profession in these ways:
- supporting the Surgeon General's focus on prevention by promoting health awareness, increasing health literacy, and reducing health disparities
- developing nurses as community health advocates and educators
- promoting professional nursing by enhancing visibility and public recognition of nursing
- promoting health careers and increased resources.
The National Nurse Web site provides more information on the National Nurse Act as well as public and political responses to this movement.
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NANN Represented at March NIWI Program
Suzanne Staebler, DNP RN NNP-BC
The Nursing Organizations Alliance hosted the Nurse in Washington Internship (NIWI) program March 14-17 in Washington, DC. NIWI, open to any nurse interested in learning about the legislative process, aims to mentor and train nurses across specialties to play active roles in effecting change in policy. Arlene Lovejoy, a clinical nurse specialist at the University of Southern California Medical Center in Los Angeles, CA, and I attended as NANN's delegates:
While in Washington, I had the opportunity to speak with several legislative staff members about healthcare policy and appropriations funding for global nursing initiatives. I met with the staffs of two senators--John Cornyn (R-TX) and Kay Bailey Hutchinson (R-TX)--and met personally with Rep. Sam Johnson (R-TX). The healthcare reform bill was still being debated, so it was understandably difficult for representatives to make any commitments. I later followed up with staff members and representatives regarding a statement in the Congressional Record supporting nursing and the neonatal nursing specialty during National Nurses Week in May.
I was most excited about the opportunity to meet face to face with Texas representatives. Most legislators don't have a healthcare background, and most Americans know only what the press tells them, so this is why nurses are the best advocates for the people of the community.
The current healthcare system is extremely complex, and what most providers fear is that the system will implode. Having something written on paper doesn't guarantee that safe implementation will happen--possessing an insurance card is totally different from having access to a healthcare provider.
In my opinion, the biggest accomplishment for NIWI this year was helping legislators refocus on fundamental healthcare issues like the nursing shortage. At the current rate, U.S. healthcare institutions will have a 40% vacancy in nursing positions by 2020.
For me, NIWI was the experience of a lifetime. My next step is to make appointments with state representatives. And I hope eventually to be a person whom representatives call when they are evaluating changes to healthcare policy.
Suzanne Staebler is an APN clinical specialist at Texas Health Presbyterian Hospital, Plano, TX, and is cochair of NANN's Health Policy and Advocacy Committee.
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