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COINN
Position
Statements

  • WHAT IS A NEONATAL NURSE?
    COINN (Council of International Neonatal Nurses, Inc) acknowledges that limited resources and/or personnel may restrict opportunities to implement the recommendations and action points. However, to improve health outcomes, the global neonatal care community must strive to uphold these recommendations. SUMMARY A Neonatal Nurse specializes in the care of neonates across the continuum including the preterm, sick, at risk and well neonate to promote the best possible health outcomes. The family is central to the care of the neonate and should be involved and empowered as partners in care. COINN RECOMMENDATIONS AND ACTION POINTS: The Neonatal Nurse: Practices safe, contemporary evidence based neonatal care and support maternal needs. Provides education and support regarding neonatal health. Collaborates with interprofessional teams. Enhances communication within and related to neonatal care. Advocates for culturally sensitive and non-bias care Ensures the provision of family centred developmentally supportive care. Contributes to shaping neonatal health policy and guidelines and informing health systems. Acts as a role model and leader in neonatal care. Approved: COINN BOD: May, 2024
  • USE OF ARTIFICIAL INTELLIGENCE IN NEONATAL NURSING
    COINN (Council of International Neonatal Nurses, Inc) acknowledges that limited resources and/or personnel may restrict opportunities to implement the recommendations and action points. To improve health outcomes, the global neonatal care community must strive to uphold these recommendations. This position statement is applicable to any healthcare professional caring for the neonate and their family. SUMMARY In the evolving realm of healthcare communications, Artificial Intelligence (AI) is poised to bring about transformative changes. However, the incorporation of AI into healthcare practices should not deviate from the fundamental objectives of patient care; foundational principles such as compassion, trust, and caring form the core of relationships. The Council of International Neonatal Nurses, Inc. (COINN) strongly recommends that healthcare providers conscientiously assess how AI is integrated into their practice, considering its potential benefits and risks to both individual and population health outcomes. BACKGROUND AND FACTORS AI is a broad category encompassing algorithms guiding the behaviour of various entities such as software programs, machines, robotics, games, and hardware devices (Ali, et al., 2023), and plays a significant role in healthcare and education. It includes a diverse range of current, emerging, and future technologies designed to support healthcare professionals in patient care. Tools for monitoring vital signs, disease prediction (apnea of prematurity, bronchopulmonary dysplasia, respiratory distress syndrome), risk stratification (retinopathy of prematurity, intestinal perforation, jaundice), neurological diagnostic and prognostic support (electroencephalograms, sleep stage classification, neuroimaging), and novel image recognition technologies—which are especially helpful for early infection recognition—are among the current artificial intelligence applications in neonatology (Chioma et al, 2023). The ethical use of data, including big data, is crucial in influencing the functionality of AI and its impact on patients (O’Connor, et al., 2023). As novel AI technologies continue to emerge, it is imperative for healthcare professional to have guidance on the ethical, compassionate, safe, and evidence-based implementation of AI in healthcare. In fields like public health, research, and informatics nursing, an understanding of how AI can inadvertently overshadow minority health needs and perpetuate disparities is crucial. The judicious application of AI in neonatal care must align with and strengthen the core values and ethical responsibilities of healthcare professionals (Van Bulck, et al., 2023). Nurses especially, bear the responsibility of ensuring that advanced technologies do not compromise fundamental human interactions and relationships (Fernandes, et al., 2023). Healthcare professionals should be well-informed about AI to provide suitable education to neonatal families, to support safe use of AI for improved health outcomes. COINN RECOMMENDATIONS AND ACTION POINTS: Stay abreast of AI advancements and acknowledge its revolutionary impact on scientific communication. Engage in AI education and training initiatives available to enhance AI literacy and understanding of both its potential and associated risks. Integrate AI responsibly, transparently, and equitably, with a steadfast commitment to confidentiality. Ensure that AI practices align with the Code of Ethics. Advocate for neonatal families where the use of AI is contraindicated or unsafe. When AI is used, adaptation and nursing assessment individualized to the neonate and family is essential. REFERENCES Ali, S., Abuhmed ,T., El-Sappagh, S., Muhammad, K., et. al. (2023) Explainable artificial intelligence (XAI): what we know and what is left to attain trustworthy artificial intelligence. Information Fusion, 99:101805. DOI: https://doi.org/10.1016/j.inffus.2023.101805 Chioma, R., Sbordone, A., Patti, M. L., Perri, A., et. al.. (2023). Applications of artificial intelligence in neonatology. Applied Sciences, 13(5), 3211. https://doi.org/10.3390/app13053211 Fernandes, F., Santos, P., Sá, L., & Neves, J. (2023). Contributions of artificial intelligence to decision making in nursing: A scoping review protocol. Nursing Reports, 13(1), 67-72. DOI: https://doi.org/10.3390/nursrep13010007 O'Connor, S., Yan, Y., Thilo, F. J., Felzmann, H., et. al. (2023). Artificial intelligence in nursing and midwifery: A systematic review. Journal of Clinical Nursing, 32(13-14), 2951-2968. DOI: https://doi.org/10.1111/jocn.16478 Van Bulck, L., Couturier, R., & Moons, P. (2023). Applications of artificial intelligence for nursing: has a new era arrived? European Journal of Cardiovascular Nursing, 22(3), e19-e20. DOI: https://doi.org/10.1093/eurjcn/zvac097 Approved: COINN BOD: May, 2024
  • THE USE AND PROMOTION OF BREAST-MILK SUBSTITUTES
    COINN (Council of International Neonatal Nurses, Inc) acknowledges that limited resources and/or personnel may restrict opportunities to implement the recommendations and action points. To improve health outcomes, the global neonatal care community must strive to uphold these recommendations. This position statement is applicable to any healthcare professional caring for the small and sick newborns and their families. SUMMARY The Council of International Neonatal Nurses, Inc. (COINN) supports the aims of the World Health Organization (WHO) “International Code of Marketing of Breast-milk Substitutes” (WHO, 1981) and the World Health Assembly resolutions to promote and protect breastfeeding as the best form of nutrition for all neonates, especially sick and/or premature neonates. This statement supports a safe use of breast milk substitutes when required. BACKGROUND AND FACTORS In the 1970s, there was global recognition that unregulated marketing and inappropriate use of breast-milk substitutes (e.g., formula) contributed to an alarming decline in breastfeeding and widespread malnutrition and mortality. In response, the International Code of Marketing of Breast Milk Substitutes was adopted by the World Health Assembly. All healthcare professionals must provide consistent, evidence-based advice and support to mothers and caregivers on the value of supplying breast-milk as the optimum nutrition for the neonate. There is a requirement to protect breastfeeding, but when breastfeeding is not possible or where breast-milk substitutes, fortifiers or supplemental feeding is indicated, mothers and caregivers should receive education on the proper use of the breast-milk substitutes available. Healthcare professionals require up to evidence-based knowledge to meet their obligations and correctly advise and support parents and caregivers on infant nutritional alternatives. With the increased use of digital platforms, inappropriate and misguided online content can influence the public and make people susceptible to harmful marketing practices (Ching et al., 2021). Aggressive marketing of breast-milk substitutes, bottles, and teats (pacifiers) can threaten the successful establishment of breastfeeding (Van Tulleken et al., 2020). Sponsorship by breast-milk substitute companies for healthcare professional education, scientific meetings and the supply of promotional material is not encouraged by the WHO Code, The Baby-friendly Hospital Initiative (BFHI) nor the International Board of Lactation Consultant Examiners (IBLCE). Having evidence-based knowledge supports healthcare professionals to protect, promote, and support breastfeeding and the use of human milk. This knowledge enables healthcare professional to give clear, consistent, and accurate information about the importance of breastmilk. COINN RECOMMENDATIONS AND ACTION POINTS: Educational opportunities should be provided for healthcare professionals caring for neonates regarding the importance of breastmilk, feeding techniques, and safe practices (including infection control) regarding breast-milk substitutes. Competency assessments of the healthcare professional providing neonatal care should be undertaken to ensure safe use of breast-milk substitutes. Parents and caregivers of neonates should be provided with education regarding the safe preparation and use of breast-milk substitutes (e.g., parent craft classes). Clean areas should be available for the preparation of breast-milk substitutes to reduce the risk of infection and contamination. Evidence-based protocols should be provided which include guidance regarding ordering/purchasing, storage, preparation, administration and disposal of breast-milk substitutes. Acceptance of sponsorship through trade exhibition, financial support for education events, and/or the receiving of any nutritional alternatives or products (e.g., bottles) should only be accepted from companies that comply with the WHO Code and are products prescribed for medical indications. REFERENCES Australian College of Neonatal Nurses Inc. (2019) Breastfeeding and breast milk substitutes position statement. Retrieved from https://www.acnn.org.au/about/position-statements/Position statement-on-breastfeeding-and-breastmilk-substitutes.pdf. Ching, C., Zambrano, P., Nguyen, T. T., Tharaney, M., Zafimanjaka, M. G., & Mathisen, R. (2021). Old tricks, new opportunities: how companies violate the international code of Marketing of Breast Milk Substitutes and Undermine Maternal and child health during the COVID-19 pandemic. International journal of environmental research and public health, 18(5), 2381. International Board of Lactation Consultant Examiners. (2017) Minimising commercial influence on education policy. Retrieved from https://iblce.org/wp-content/uploads/2017/05/minimising commercial-influence-on-education-policy.pdf. New Zealand Nurses Organisation. (2019). Responsible income generation from sponsorship and advertising policy. Retrieved from https://www.nzno.org.nz. The Perinatal Society of Australia & New Zealand. (PSANZ). (2017) PSANZ policy on receiving sponsorship from companies marketing infant formula. Retrieved from https://www.psanz.com.au. van Tulleken, C., Wright, C., Brown, A., McCoy, D., & Costello, A. (2020). Marketing of breastmilk substitutes during the COVID-19 pandemic. The Lancet, 396(10259).e58. doi: 10.1016/S 0140- 6736(20)32119-X. Epub 2020 Oct 8. PMID: 33038948; PMCID: PMC7544448. World Health Organization. (WHO). (1981). International code of marketing of breast milk substitutes. Retrieved from https://www.who.int/publications/i/item/9241541601. World Health Organization. (WHO). (2009). Baby- friendly hospital initiative Retrieved from https://www.who.int/publications/i/item/9789241594950. Approved: COINN BOD: May, 2024
  • INTERNATIONAL RECRUITMENT OF NURSES
    COINN (Council of International Neonatal Nurses, Inc) acknowledges that limited resources and/or personnel may restrict opportunities to implement the recommendations and action points. However, to improve health outcomes, the global neonatal care community must strive to uphold these recommendations. This position statement is applicable to any healthcare professional caring for the small and sick newborns and their families. SUMMARY The Council of International Neonatal Nurses, Inc. (COINN) supports individual neonatal nurses’ rights to travel and work in other countries. COINN recognises that countries facing pressing health workforce challenges related to universal health coverage must be supported and provided with safeguards that discourage active and unethical international recruitment of nurses, and that high income countries must work to grow, sustain, and manage their own neonatal nursing workforce effectively to meet the increasing demand. BACKGROUND AND FACTORS Neonatal nursing is a growing speciality but affected by global nursing shortages. Migrant nurses constitute approximately one in eight of all nurses (WHO, 2020). International migration and mobility of health workers is longstanding, but now increasing in volume and growing in its complexity. The factors that drive this are labour market forces such as education, working conditions, and renumeration across countries. Migrant health workers also underpin an effective response to health emergencies. This was exacerbated during the COVID-19 pandemic and is likely to accelerate further over the next decade. While migration can occur among countries in the same region or context, there is an increasing trend for international recruitment from low and middle income countries. Recruitment to high income countries risks exacerbating shortages in the former. If not adequately managed, international mobility and migration of health workers from countries facing health worker shortages can weaken health systems, worsen health outcomes, and widen inequities (WHO, 2020; WHO, 2023). Nurses moving permanently or temporarily can experience positive professional work experiences which can aid professional development (Kamau et al., 2022). However, in some situations migrant nurses have been poorly treated, suffered exploitation and discrimination (Moyce et al., 2016). The WHO Global Code of Practice on the International Recruitment of Health Personnel is a key global governance instrument to manage international health worker migration and mobility. Its impact and implications must be kept at the forefront of international agendas to realize the global vision of “building a healthier world together” (WHO, 2020). COINN RECOMMENDATIONS AND ACTION POINTS: COINN supports ethical international recruitment from countries as per the WHO Global Code of Practice on the International Recruitment of Health Personnel (WHO, 2024) Nurses have the right to work in a safe working environment and one that adheres to the ICN Code of Ethics for Nurses, or if available the recruiting country’s national nursing code of ethics in addition to the United Nations (1948) Universal Declaration of Human Rights. Support individual nurses’ right to travel and work in other countries in a safe environment. An understanding of cultural differences and the need for cultural sensitivity in the new work environment must be considered and addressed to support integration. Support language acquisition to include written, verbal and comprehension. Ensure that adequate orientation and training is provided for a sufficient length of time to ensure competency in neonatal care provision. Strengthen education and training by providing opportunities for continued acquisition of knowledge and competency supported by the recruiting organisation/employer. Ensure that standards of practice are upheld by the employing institution. REFERENCES Kamau, S., Koskenranta, M., Kuivila, H., Oikarainen, A., et. al. (2022). Integration strategies and models to support transition and adaptation of culturally and linguistically diverse nursing staff into healthcare environments: An umbrella review. International Journal of Nursing Studies, 136: 104377. Moyce, S., Lash, R., & de Leon Siantz, M. L. (2016). Migration experiences of foreign educated nurses: a systematic review of the literature. Journal of Transcultural Nursing, 27(2): 181-188. World Health Organization. (WHO). (2020). State of the world’s nursing 2020: investing in education, jobs, and leadership. Geneva: World Health Organization. Licence: CC BY-NC-SA 3.0 IGO. World Health Organization. (WHO). (2023). WHO health workforce support and safeguards list 2023. Geneva: World Health Organization. Licence: CC BY-NC-SA 3.0 IGO. World Health Organization (WHO). (2024). Bilateral agreements on health worker migration and mobility: maximizing health system benefits and safeguarding health workforce rights and welfare through fair and ethical international recruitment. Geneva: World Health Organization. Licence: CC BY-NC-SA 3.0 IGO. Approved: COINN BOD: May, 2024
  • VIOLENCE AGAINST WOMEN AND CHILDREN
    COINN (Council of International Neonatal Nurses, Inc) acknowledges that limited resources and/or personnel may restrict opportunities to implement the recommendations and action points. However, to improve health outcomes, the global neonatal care community must strive to uphold these recommendations. SUMMARY Violence against women and children is an urgent priority to protect their rights to a safe and nurturing environment. Nurses, facilities and associations have a responsibility to provide information and advocate for the elimination of violence and to support healthy relationships. BACKGROUND AND FACTORS A positive start during pregnancy and the early years is crucial for children to have healthy outcomes across the life span (Lähdepuro, Lahti-Pulkkinen, Pyhälä, et al., 2022). A positive pregnancy is a time of heightened fetal receptivity to maternal and environmental signals which contribute to the neonate’s adaptation after birth (Davis & Narayan, 2020), as well as to develop a secure attachment with their parents as a foundation for their future development and relationships (Karakas & Dağlı, 2019; Van Ilzendoorn, 2022). The United Nations (1993, cited by World Health Organization, 2021) defines violence against women as “any act of gender-based violence that results in, or is likely to result in, physical, sexual, or mental harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life.” The World Health Organization (2023) designates violence against children to include all forms of violence against people under 18 years old. For infants and younger children, violence mainly involves child maltreatment (i.e. physical, sexual and emotional abuse and neglect) at the hands of parents and other authority figures. A global report released by the World Health Organization (WHO) provided figures on the prevalence of two forms of violence against women: violence by an intimate partner (intimate partner violence) and sexual violence by someone other than a partner (non-partner sexual violence). Findings include: • Nearly 30% of women worldwide have experienced either intimate partner violence or non partner sexual violence in their lifetime, or both. The situation can be exacerbated by a variety of factors such as humanitarian crises, poverty and displacement. • The impact of violence can have short and long term effects, specifically in pregnancy, which can lead to an increase risk of miscarriage, and preterm birth. COINN RECOMMENDATIONS AND ACTION POINTS: 1. Violence against women and children is unacceptable and impacts our most vulnerable population, and should be prevented (World Health Organization, 2020). 2. Children have the right to a safe place to live, and should be protected from harm. They should be provided with the necessary means for their growth, development and health. They are entitled to a clean environment and to be empowered for participation in society (Amnesty International, 2023). 3. Nurturing care of children is crucial in the early years to lay the foundations for healthy brain development with lifelong implications for learning, health and well-being (World Health Organization, 2023). 4. The principles of RESPECT to prevent violence against women should be implemented as suggested by the World Health Organization (2020): Relationship skills strengthened Empowerment of women Services ensured Poverty reduced Environments made safe Child and adolescent abuse prevented Transformed attitudes, beliefs and norms. 5. Advocate autonomy and support parents regarding healthy relationships (Amnesty International, 2023; World Health Organization, 2020). REFERENCES Amnesty International (2023). Children’s human rights. https://www.amnesty.org/en/what-we-do/child rights/ (Accessed 19 December 2023) Davis, E.P., & Narayan, A.J. (2020). Pregnancy as a period of risk, adaptation, and resilience for mothers and infants. Developmental Psychopatholoy, 32(5):1625-1639. Retrieved from: https://doi.org/10.1017%2FS0954579420001121 Karakas, N.M., & Dağlı, F.Ş.(2019). The importance of attachment in infant and influencing factors. Turkish Archives of Pediatrics, 54(2):76-81. Retrieved from: https://doi.org/10.14744%2FTurkPediatriArs.2018.80269. Lähdepuro, A., Lahti-Pulkkinen, M., Pyhälä, R., Tuovinen, S., et. al. (2022). Positive maternal mental health during pregnancy and mental and behavioral disorders in children: A prospective pregnancy cohort study. Journal of Child Psychology and Psychiatry, 64(5):807-816. Retrieved from: https://doi.org/10.1111/jcpp.13625. Van Ilzendoorn, M. (2022). Attachment. Encyclopedia on Early Childhood Development. Retrieved from: https://www.child-encyclopedia.com/attachment#why-it-important-form-secure-child-parent-bond-early childhood. World Health Organization (WHO). (2020). RESPECT women: preventing violence against women – implementation package. Retrieved from: https://www.unwomen.org/en/digital library/publications/2020/07/respect-women-implementation-package. World Health Organization (WHO). (2021). Global report on violence against women. Retrieved from: https://www.who.int/news-room/fact-sheets/detail/violence-against-women. World Health Organization (WHO). (2021). Violence against women. Retrieved from: https://www.who.int/news-room/fact-sheets/detail/violence-against-women. World Health Organization (WHO). (2023). New report calls for greater attention to children’s vital first years. Retrieved from: https://www.who.int/news/item/29-06-2023-new-report-calls-for-greater-attention to-children-s-vital-first-years. World Health Organization (WHO). (2023). Violence against children. https://www.who.int/health topics/violence-against-children#tab=tab_1. Approved: COINN BOD: May, 2024
  • THE USE OF SOCIAL MEDIA
    COINN (Council of International Neonatal Nurses, Inc) acknowledges that limited resources and/or personnel may restrict opportunities to implement the recommendations and action points. However, to improve health outcomes, the global neonatal care community must strive to uphold these recommendations. The position statements are applicable to any healthcare professional caring for neonates and their families. The statements interact with each other therefore, please read in conjunction with the associated position statements. SUMMARY The Council of International Neonatal Nurses, Inc. (COINN) recommends that all neonatal nurses and students must maintain professionalism in any social media postings. BACKGROUND AND FACTORS The use of social media is an important tool in today’s healthcare and can support engagement and education, however, there are risks associated with its use (Runyon, 2023). Any neonatal nurse using social media must consider its impact on the community and the profession (Glasdam, et al., 2022; Marsh, 2023). As members of a professional healthcare community neonatal nurses must understand the restrictions and guidelines around the sharing of information, commentary and photographs in social media (González-Luis, et al., 2022). Individuals, patients, and families can experience harm in relation to breached patient confidentiality, boundary issues or violations in professional relationships. The goals of COINN are to promote improved outcomes for neonates and support the education of those providing the care. COINN recognises the importance of social media in helping to achieving this. The following recommendations and action points apply to any use of social media. COINN RECOMMENDATIONS AND ACTION POINTS: Establish social media guidelines for individual units or departments to provide guidance to the team, including: Ensure best judgement is used prior to posting any material and consider if it might be inappropriate or harmful or might create a hostile environment. Respect diversity and differences of opinions. Consider copyright and intellectual property. Always maintain confidentiality. Do not respond to antagonistic or inflammatory dialogue. Maintain professional boundaries with families. REFERENCES Glasdam, S., Sandberg, H., Stjernswärd, S., Jacobsen, F. F., Grønning, A. H., & Hybholt, L. (2022). Nurses’ use of social media during the COVID-19 pandemic—A scoping review. PLoS One, 17(2), e0263502. Doi: https://doi.org/10.1371/journal.pone.0263502 González-Luis, H., Azurmendi, A., Santillan-Garcia, A., & Tricas-Saura, S. (2022). Nurses' freedom of expression: Rights, obligations and responsibilities. Journal of Nursing Management, 30(7), 2379-2382. Doi: https://doi.org/10.1111/jonm.13839 Marsh, A. (2023). What are UK nurses and midwives’ views and experiences of using social media within their role? A review. Bournemouth University. Retrieved from: https://eprints.bournemouth.ac.uk/38257/. Runyon, M. C. (2023). Bias of Some Perinatal Nurses Exposed on Social Media. MCN: The American Journal of Maternal/Child Nursing, 48(4), 231. Doi: 10.1097/NMC.0000000000000923. Approved: COINN BOD: May, 2024
  • PROMOTION OF SLEEP
    COINN (Council of International Neonatal Nurses, Inc) acknowledges that limited resources and/or personnel may restrict opportunities to implement the recommendations and action points. To improve health outcomes, the global neonatal care community must strive to uphold these recommendations. This position statement is applicable to any healthcare professional caring for the small and sick newborns and their families. SUMMARY The Council of International Neonatal Nurses, Inc. (COINN) recommends that a neonate’s sleep is to be protected and supported. Sleep is important for brain development, growth, healing, and general health. The protection of sleep post-delivery and during the period of hospitalization particularly for premature neonates, is a core component of neonatal care. BACKGROUND AND FACTORS Newborn term healthy neonates on average sleep 16–18 hour per day, with sleep states generally defined as quiet sleep and active sleep - precursors to non-rapid eye movement and rapid eye movement sleep states in adulthood (Bennet et al., 2018). Active sleep is considered the most important behavioural state for neonates (particularly premature neonates who spend 70-80% of their sleep time in this state). Active sleep plays a key role in organizing the central nervous system and is important for sensory input processing, consolidation and learning (Altimier & Phillips, 2016). During active sleep muscle tone is reduced with irregular breathing and heart rate, and spontaneous twitching and eye movements (Curzi Dascalova, 2001). Quiet sleep is necessary for energy restoration, tissue growth and repair, and the maintenance of homeostasis (Altimier & Phillips, 2016). In quiet sleep there is higher muscle tone, absence of eye movements, and regular heart rate and respiration (Bennet, Walker, & Horne, 2018). This state is limited for premature neonates due to immature physiological systems, reduced muscle tone, poor control of movements and limited ability for self-regulation. Distinctions of sleep states are difficult to determine before 30 weeks gestational age – prior to 30 weeks both sleep states are largely characterised as indeterminate sleep (Mirmiran, Maas, & Ariagno, 2003). Sleep is crucial to foster optimal brain development, cognition and behaviour, however, disruptions can occur from the first hours of life (Grigg-Damberger, 2016). Sleep quality can be impaired by the environment, including the light and noise of neonatal intensive care units (NICU) (van den Hoogen et al., 2017) and treatment such as respiratory support (Collins, Barfield, Davis, & Horne, 2015). Neonatal nursing care interventions, whilst critical, can lead to physiological instability, and can be stressful for neonates, which together with sleep interference risk negatively impacting their neuromotor, behavioural, growth milestones and sleep patterns (Sanders & Hall, 2018). It is a priority that neonatal teams understand the importance of sleep for the neonate’s wellbeing and that this is part of their education. It was recognised in a recent study that healthcare professionals view sleep as important but more theoretical knowledge would support strategies for implementation in practice (de Groot et al., 2023). Ultimately, optimizing opportunities for sleep gives neonates a better chance of healthy brain maturation (Bik et al., 2022) as sleep has a protective effect on brain development in premature neonates (Ednick et al., 2022). General strategies to protect sleep involve optimizing the environment, comfortable positioning, minimizing stress and pain, integrating families in care, protecting skin integrity, and ensuring adequate nutritional status. COINN RECOMMENDATIONS AND ACTION POINTS: Recognize the significance of promoting and protecting sleep as a keystone of the treatment of neonates in the neonatal intensive care unit (NICU.) Include sleep theory in neonatal education. Support neonatal sleep integrated teaching and education programs (e.g., e-learning, parent information, flyers) targeted to nurses, physicians, parents, visiting healthcare professionals and support personnel. Observe and record sleep and wake periods of neonates to assist with identifying sleep-wake patterns. Incorporate appropriate sleep measurements (e.g., validated observational scales, EEG, innovative non-obtrusive sleep measurements) into daily ward round assessments to increase awareness of sleep as a key factor in neonatal health. Establish good practice guidelines about elective care procedures which can be postponed during sleep (e.g., routine blood testing, routine x-rays, routine cardiac assessments). Avoid (where possible) disrupting neonatal sleep no less than 60 minutes after a previous sleep disruption. Schedule care / interventions for when the neonate is naturally awake (where possible) When required to wake the neonate, undertake this with gentle touch and quiet talking. Pay attention to intolerance of cares / interventions – provide clustered activities and care as tolerated. Practice regular scheduled unit-based quiet times/hours (dim lighting, quieter environment, reduced visitors) Promote opportunities for skin-to-skin contact (kangaroo care) and neonatal massage. Consider use of the following as appropriate to protect and support sleep: a. Headphones b. Alarm modifications c. Nesting aids d. Swaddling e. Non-nutritive sucking f. White noise g. Music therapy h. Eye masks i. Incubator covers. REFERENCES Altimier, L., & Phillips, R. (2016). The neonatal integrative developmental care model: advanced clinical applications of the seven core measures for neuroprotective family-centered developmental care. Newborn and infant nursing reviews, 16 (4), 230-244. Bennet, L., Walker, D. W., & Horne, R. S. (2018). Waking up too early–the consequences of preterm birth on sleep development. The Journal of physiology, 596(23), 5687-5708. Bik, A., Sam, C., de Groot, E. R., Visser, S. S., et. al. (2022). A scoping review of behavioral sleep stage classification methods for preterm infants. Sleep Medicine, 90, 74-82. 5 Collins, C. L., Barfield, C., Davis, P. G., & Horne, R. S. C. (2015). Randomized controlled trial to compare sleep and wake in preterm infants less than 32 weeks of gestation receiving two different modes of non-invasive respiratory support. Early Human Development, 91(12), 701-704. Curzi-Dascalova, L. (2001). Between-sleep states transitions in premature babies. Journal of Sleep Research, 10(2), 153-158. Ednick, M., Cohen, A. P., McPhail, G. L., Beebe, D., et. al. (2009). A review of the effects of sleep during the first year of life on cognitive, psychomotor, and temperament development. Sleep, 32(11), 1449-1458. Grigg-Damberger, M. M. (2016). The visual scoring of sleep in infants 0 to 2 months of age. Journal of clinical sleep medicine, 12(3), 429-445. de Groot, E. R., Ryan, M. A., Sam, C., Verschuren, O., et. al. (2023). Evaluation of Sleep Practices and Knowledge in Neonatal Healthcare. Advances in Neonatal Care, 10-1097. Mirmiran, M., Maas, Y. G., & Ariagno, R. L. (2003). Development of fetal and neonatal sleep and circadian rhythms. Sleep medicine reviews, 7(4), 321-334. Sanders, M. R., & Hall, S. L. (2018). Trauma-informed care in the newborn intensive care unit: promoting safety, security and connectedness. Journal of Perinatology, 38(1), 3-10. van den Hoogen, A., Teunis, C. J., Shellhaas, R. A., Pillen, S., et. al. (2017). How to improve sleep in a neonatal intensive care unit: a systematic review. Early human development, 113, 78-86. Approved: COINN BOD: May, 2024
  • RESEARCH INVOLVING NEONATES
    COINN (Council of International Neonatal Nurses, Inc) acknowledges that limited resources and/or personnel may restrict opportunities to implement the recommendations and action points. To improve health outcomes, the global neonatal care community must strive to uphold these recommendations. This position statement is applicable to any healthcare professional caring for the small and sick newborns and their families. SUMMARY COINN supports the Declaration of Helsinki (World Medical Association, 2013) agreement that states neonates belong to a vulnerable group and therefore encourage research to be conducted only if it benefits the neonates. Surrogates (parents / legal guardians) should give informed and voluntary consent on behalf of the neonates. All research must be approved by an appropriate ethical committee for the protection of the neonates and families. BACKGROUND AND FACTORS International collaboration to improve healthcare outcomes and safe practices for neonates and their families is encouraged through high quality and ethical research that informs clinical practice, education, and policy development. Research should benefit the neonates, and their unique needs should be respected. The role of the parents/legal guardians should be recognised in giving informed consent to ensure the best interest of the neonates. COINN RECOMMENDATIONS AND ACTION POINTS: Research involving neonates must be conducted in an ethical and morally appropriate manner. Research should be high quality and beneficial to neonates. International collaboration in research should be encouraged to improve neonatal outcomes. Research findings should be integrated into clinical practice, education programs and heath care policy. REFERENCE World Medical Association. (2013). World Medical Association declaration of Helsinki: Ethical principles for medical research involving human subjects. JAMA. Retrieved from https://jamanetwork.com/journals/jama/fullarticle/1760318. Approved: COINN BOD: May, 2024
  • CARE OF THE WELL TERM NEONATE
    COINN (Council of International Neonatal Nurses, Inc) acknowledges that limited resources and/or personnel may restrict opportunities to implement the recommendations and action points. To improve health outcomes, the global neonatal care community must strive to uphold these recommendations. This position statement is applicable to any healthcare professional caring for the well term infant and their families. SUMMARY The Council of International Neonatal Nurses (COINN) is the international voice of neonatal nurses who provide care during this vulnerable period. To address identified gaps in current practice COINN supports and recommends the following basic care for the well term infant. BACKGROUND AND FACTORS The United Nations Sustainable Development Goal (SDG) 3 calls for a reduction in newborn death to <12 deaths per 1000 births (United Nations, 2023a). The worldwide neonatal mortality rate fell by 51 per cent from 37 deaths per 1,000 live births in 1990 to 18 in 2021. This amounts to approximately 2.3 million neonates who died in the first 28 days of life in 2021 globally, or approximately 6 400 per day (UNICEF, 2023a). Disparities in neonatal mortality are still present across regions and countries, amidst the declining overall neonatal mortality rate. The region with the highest mortality rate remains sub Saharan Africa (i.e., West, Central, Eastern and Southern Africa regions) and South Asia, with respectively 27 and 23 deaths per 1000 live births (UNICEF, 2023a). Although progress has been made over the past decade, still too many neonates are dying when preventative measures are possible. The purpose of Every Newborn Action Plan (ENAP) is to provide countries with a roadmap to reduce preventable newborn deaths and stillbirths, and to reduce disability by 2030. One of the strategies is for every woman and newborn to receive early routine postnatal care within 2 days (UNICEF, 2023b). The World Health Organization (2017) published recommendations for neonatal health, including the care of the newborn immediately after birth, postnatal care, immunization, and management of illnesses. The American Academy of Pediatrics (AAP) and American Congress of Obstetricians and Gynecologists (ACOG) 8th edition Guidelines for Perinatal Care recommend careful observation of a newborn during the first 6-12 hours of the transition period (AAP & ACOG, 2017). COINN’s recommendations and action points for the care of the well term neonate are drawing from the above sources and additional evidence-based information. It is important to also take note of the position statement and recommendations related to preterm and sick neonates. COINN RECOMMENDATIONS AND ACTION POINTS: 2. At every delivery a healthcare professional skilled in neonatal resuscitation should be present and be dedicated solely to care for the neonate. 1. Essential care of the newborn (WHO, 2023) should be implemented and entails the following: • Immediate care at birth includes delayed/optimal cord clamping, thorough drying, assessment of breathing, skin-to-skin contact, and early initiation of breastfeeding Thermal care Resuscitation when needed Support for breast milk feeding Nurturing care Infection prevention Assessment of health problems Recognition and response to danger signs Timely and safe referral when needed. 3. Routine care should include prophylactic administration of Vitamin K and eye prophylaxis against gonococcal ophthalmia as recommended by local policies. 4. Bathing, skin care and cord care should be done according to evidence-informed guidelines. 5. The neonate must be screened and immunized according to the country’s requirements. 6. Each neonate should be admitted as an individual patient including the establishment of an individual record to document the neonate’s condition, progress and all actions taken. 7. Neonates should meet the discharge criteria prior to leaving the facility. 8. Breastfeeding initiation, attachment and bonding should be facilitated. 9. Refer to the position statement on sleep for neonates. REFERENCES Albahrani, Y., & Hunt, R. (2019). Newborn Skin Care. Pediatric Annals, 48(1), 11-15. Retrieved from: https://doi.org/10.3928/19382359-20181211-01. American Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologists (ACOG)*. (2017). Guidelines for perinatal care. 8th Edition, Elk Grove Village, IL: AAP/ACOG. *now named the American Congress of Obstetricians and Gynecologists. Retrieved from: https://www.aap.org/Guidelines for-Perinatal-Care-8th-edition-Paperback. American Academy of Pediatrics (AAP) Committee on Fetus and Newborn (2015). Hospital Stay for Healthy Term Newborn Neonates. Pediatrics, 135(5): 948–953. Available at: https://doi.org/10.1542/peds.2015-0699. Priyadarshi, M., Balachander, B., Gupta, S., & Sankar, M. J. (2022). Timing of first bath in term healthy newborns: A systematic review. Journal of Global Health, 12. Retrieved from: https://doi.org/10.7189%2Fjogh.12.12004 . Telofski, L. S., Morello III, P., Mack Correa, C. M., Stamatos, G. N. (2012). The neonate skin barrier: Can we preserve, protect and enhance the barrier? Dermatology Research and Practice, 2012, p.18. Doi: http://dx.doi.org/10.1155/2012/198789 . The Royal Children Hospital’s Melbourne (2017). Neonatal and Neonate skin care. Retrieved from: https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Neonatal___neonate_skin_care/. UNICEF (2023a). Neonatal mortality. Retrieved from: https://data.unicef.org/topic/child-survival/neonatal mortality/. UNICEF (2023b). Moving faster towards high-quality universal health coverage in 2020-2025. Retrieved from: https://data.unicef.org/resources/ending-preventable-newborn-deaths-and-stillbirths-by-2030/. United Nations Sustainable Development Goals (SDG). (2015). Retrieved from: http: http://www.un.org/sustainabledevelopment/sustainable-development-goals/. World Health Organization (2017). WHO recommendations on newborn health. Retrieved from: https://www.who.int/publications/i/item/WHO-MCA-17.07. World Health Organization (2023). Essential newborn care. Retrieved from: https://www.who.int/teams/maternal-newborn-child-adolescent-health-and-ageing/newborn health/essential-newborn-care. Approved: COINN BOD: May, 2024
  • PROVISION OF SAFE NEONATAL CARE
    COINN (Council of International Neonatal Nurses, Inc) acknowledges that limited resources and/or personnel may restrict opportunities to implement the recommendations and action points. However, to improve health outcomes, the global neonatal care community must strive to uphold these recommendations. This position statement is applicable to any healthcare professional caring for the small and sick newborns and their families. SUMMARY The Council of International Neonatal Nurses, Inc. (COINN) believes that neonatal nurses (and non specialist nurses providing neonatal care) play an integral role in caring and advocating for safe neonatal and maternal care. This should be high quality timely care, that meets the physical, emotional, spiritual, cultural, and social needs of the neonate and family. Nurses who care for neonates and their family should be provided appropriate education and training to deliver safe care suitable to their setting (Maleki et al., 2022). Neonatal nurses have a critical role in protecting the maternal/neonatal dyad (Lavallée et al., 2023) and in facilitating the attachment process through the quality of their care (Kim & Kim, 2022). BACKGROUND AND FACTORS All pregnant people are entitled to safe neonatal and maternal care however, this is not always available. Of an estimated 2.3 million neonatal deaths in 2021 (UNICEF, 2023a) and 1.9 million babies being stillborn in 2021 (UNICEF, 2023b), many are preventable with the delivery of high quality, evidence based interventions. Associated factors related to risk can include the availability of resources, access to care and workforce. In some cases, nurses may not be appropriately trained, resourced, or supported to be able to deliver safe neonatal and maternal care. Reducing inequities necessitates investment in all aspects of a health system including the workforce, infrastructure, commodities and supplies, service delivery, health information systems, financing and good leadership and governance (WHO. 2014; WHO, 2020). Safe and supporting working environments for neonatal nurses with appropriate training must be a priority for patient safety. A critical shortage of competent health workers remains a major challenge for the provision of quality care for mothers and neonates, particularly in low- and middle income countries (Bolan et al., 2021). Historic and persistent gender inequities can challenge the provision of safe neonatal and maternal care. With most nurses being women, gender discrimination risks constraining neonatal nurses’ decision-making and leadership abilities and can negatively impact the perceived role of the nurse (Gauci et al., 2022) and potentially the provision of safe neonatal and maternal care. Ensuring nurses are integral in interprofessional healthcare teams, will advance quality and safety, fostering a safe and fair working environment built on mutual respect and shared decision-making. Bias can affect the equitable delivery of safe neonatal and maternal care and is a factor that contributes to disparities in health and health care worldwide. Aspects of an individual’s identity (e.g., race, ethnicity, age, ability, weight, gender), can influence the care received. For example, racial bias/racism in neonatal and maternal care or associated health systems can cause harm (Howell et al., 2018). Steps must be taken to ensure individuals and organizations can combat the potential harm caused by implicit bias in health care. COINN RECOMMENDATIONS AND ACTION POINTS: Develop standardized orientation, training, and continual professional development for nurses caring for neonates and their mothers that anticipates complications and includes care for the small and/or sick neonate (refer to COINN Neonatal Competencies and other position statements). Ensure safe staffing levels and resources in line with the numbers and acuity of neonates being cared for. Involve neonatal nurses’ participation in multidisciplinary neonatal and maternal morbidity/mortality potential preventability reviews to support a comprehensive approach to quality improvement throughout the care continuum. Tackle gender bias and power imbalances to strengthen the nursing voice and participation in decision-making. Develop leadership opportunities and capacity to enhance safe neonatal and maternal care. Call for zero separation of mother and their neonates, recognize and empower families as partners in care. REFERENCES Bolan, N., Cowgill, K. D., Walker, K., Kak, L., Shaver, T., Moxon, S., & Lincetto, O. (2021). Human resources for health-related challenges to ensuring quality newborn care in low-and middle-income countries: a scoping review. Global Health: Science and Practice, 9(1), 160-176. Gauci, P., Peters, K., O’Reilly, K., & Elmir, R. (2022). The experience of workplace gender discrimination for women registered nurses: A qualitative study. Journal of Advanced Nursing, 78(6), 1743-1754. Howell, E. A., Brown, H., Brumley, J., Bryant, A. S., Caughey, A. B., Cornell, A. M., ... & Grobman, W. A. (2018). Reduction of peripartum racial and ethnic disparities: a conceptual framework and maternal safety consensus bundle. Journal of Obstetric, Gynecologic & Neonatal Nursing, 47(3), 275-289. Kim, S.Y. & Kim, A.R. (2022). Attachment- and Relationship-Based Interventions during NICU Hospitalization for Families with Preterm/Low-Birth Weight Infants: A Systematic Review of RCT Data. Int J Environ Res Public Health. 2022 Jan 20;19(3), 1126. doi: https://doi.org/10.3390/ijerph19031126. Lavallée, A., Côté, J., Luu, T.M., Bell, L., Grou, B., Blondin, S.E. & Aita, M. (2023). Acceptability and feasibility of a nursing intervention to promote sensitive mother-infant interactions in the NICU. Journal of Neonatal Nursing. 29(2), 296-301. https://doi.org/10.1016/j.jnn.2022.07.011. Maleki M, Mardani A, Harding C, Basirinezhad MH, Vaismoradi M. (2022). Nurses’ strategies to provide emotional and practical support to the mothers of preterm infants in the neonatal intensive care unit: A systematic review and meta-analysis. Women’s Health. 2022;18. doi:10.1177/17455057221104674 World Health Organization. (2014). Every newborn: an action plan to end preventable deaths. https://www.who.int/initiatives/every-newborn-action-plan World Health Organization. (2020). Every newborn progress report 2019. https://www.who.int/publications/m/item/every-newborn-progress-report-2019 UNICEF. (2023a). Neonatal mortality. https://data.unicef.org/topic/child-survival/neonatal mortality/ UNICEF. (2023b). Stillbirth. https://data.unicef.org/topic/child-survival/stillbirths/ Approved: COINN BOD: May, 2024
  • KEEPING BABIES AND PARENTS TOGETHER
    POSITION: The Council of International Neonatal Nurses, Inc. (COINN) believes that every baby worldwide should have an optimal start in life and that parents are an integral part of this. It is undisputed that involvement of parents is of paramount importance and integrating infant and family-centered developmental care (IFCDC) as a core standard for neonatal care is essential– in particular for the most vulnerable infants such as preterm, sick, and low birthweight babies (European Foundation for the Care of Newborn Infants (EFCNI), 2021; Global Alliance for Newborn Health (GLANCE), 2021). The COVID-19 pandemic led to the implementation of a set of measures which included a restriction of parental presence, frequently leading to separation of parents and their babies. These measures in many areas have continued even though the pandemic is waning. Given the pandemic related challenges in neonatal care, we advocate for healthcare workers to listen to the parents’ experiences and to acknowledge their crucial role in the care of hospitalized babies worldwide. In addition, following the invitation by EFCNI and GLANCE to support their ‘zero-separation’ policy, we strongly support this essential initiative and to keep parents and their babies together.
  • PRE-SERVICE ORIENTATION OF REGISTERED NURSES AND MIDWIVES TO NEONATAL UNITS
    Council of International Neonatal Nurses, Inc. (COINN) Position Statement on Pre-Service Orientation of Registered Nurses and Midwives to Neonatal Units The Council of International Neonatal Nurses, Inc. (COINN) recommends that nurse/midwife orientation includes a standardized orientation process which can be tailored to meet the individual nurse/midwife’s needs. The standardized orientation includes: didactic learning, neonatal skills, case discussions and scenarios, simulation with debriefing. These are considered to be essential to meet the neonatal nurse /midwifery competency standards, required to care for small and sick newborns. The orientation period should be individualized dependent on the knowledge and experience of the orientee but requires a minimum of a standardized 12-week orientation process. Ideally a dedicated experienced neonatal nurse should be assigned as a preceptor to each orientee. Adopted February 16, 2022
  • NEONATAL NURSING EDUCATION
    COUNCIL OF INTERNATIONAL NEONATAL NURSES, Inc. (COINN)Position Statement COINN (Council of International Neonatal Nurses, Inc) Position COINN (Council of International Neonatal Nurses, Inc) believes that the survival and long-term outcomes for high-risk and/or sick newborns depends on the provision of skilled nursing care. COINN (Council of International Neonatal Nurses, Inc) supports the provision of neonatal nursing education that is resourced, evidence-based, focused on developing skills and a theoretical basis for practice, and delivered by appropriately qualified educators and clinicians. COINN (Council of International Neonatal Nurses, Inc) recognizes that different models of education must be available that take into account local capacity and requirements. Although differences exist within local and national organizations as to what constitutes basic, essential, and advanced care of the newborn, COINN (Council of International Neonatal Nurses, Inc) believes that neonatal nurses need skills to resuscitate newborns, and to care for preterm, small for gestational age, low birth weight, sick and critically ill newborns. COINN (Council of International Neonatal Nurses, Inc) acknowledges that, in some countries, the ability to educate neonatal nurses is hampered by limited resources - personnel, financial, and equipment. However, COINN (Council of International Neonatal Nurses, Inc) believes that in order to reduce newborn mortality and morbidity, neonatal nursing education is essential. Support and assistance for neonatal nursing training is required from health professionals, hospital management, academic institutions and regional and national governments in all countries. COINN (Council of International Neonatal Nurses, Inc) is committed to facilitating the education of neonatal nurses worldwide. Background The 2014 Lancet ‘Every Newborn’ Series highlights that the time of birth is the highest risk period of death for newborns, with more than 2.7 neonatal deaths occurring every year (Lawn, Blencowe, Oza, Lee, Waiswa, & Cousens, 2014). The three main causes of neonatal death globally are infection, intrapartum conditions and complications due to preterm birth; problems which are largely preventable (Premji, Spence, & Kenner, 2013). A rapid response by a skilled neonatal nurse is needed to resuscitate newborns, and to provide ongoing nursing care for preterm, small for gestational age, low birth weight and sick newborns, to prevent long-term consequences requiring costly treatment and diminish their capacity to work (Darmstadt,Kinney, Chopra, Cousens, Kak, Martines, & Lawn, 2014). To recognize, identify, and manage these newborns, nurses must have specialized training and education at a community, unit or institutional level. For over thirty years countries such as the United States, the United Kingdom, Australia, Canada, and New Zealand have recognized that neonatal nurses require specialty training either in the neonatal unit or at an academic institution resulting in a recognized qualification. The result in many countries has been recruitment and retention of nurses in the specialty as well as improved neonatal outcomes (Premji, Spence, & Kenner, 2013). Neonatal care should be provided by skilled health care workers and professionals as a first line defense in health care as this is most cost effective than emergency, critical, or long-term care (Mangham-Jefferies, Pitt, Cousens, Mills, & Schellenber, 2014).) Recommendations/Key Principles 1. COINN (Council of International Neonatal Nurses, Inc) is committed to the promotion of positive health outcomes for neonates, reducing mortality and morbidity, and creating a global community of well-educated, specialized nurses working together towards this goal. 2. COINN (Council of International Neonatal Nurses, Inc) supports the Every Newborn Action Plan (World Health Organization, 2014) in particular Goal 1: Ending preventable newborn deaths by increasing the coverage of skilled care at birth in health facilities, and improving the quality of newborn care by training health care workers in specific skills of caring for sick or small newborns. 3. COINN (Council of International Neonatal Nurses, Inc) supports the Sustainable Development Goals (SDGs) especially #3 to reduce the neonatal mortality rate to 12 deaths per 1000 live births (United Nations, 2015). 4. COINN (Council of International Neonatal Nurses, Inc) recognizes that there are differences in training and education around the world for nurses providing neonatal care, and asserts that neonatal nurses should receive formal preparation in programs of sufficient length and scope to facilitate evidence-based neonatal nursing practice. 5. COINN (Council of International Neonatal Nurses, Inc) believes that training should be progressive, supporting retention of nurses within the field by providing a clear career pathway. 6. COINN (Council of International Neonatal Nurses, Inc) believes that specialized, better educated nurses will be able to utilize, conduct and collaborate in research that will ultimately lead to better neonatal outcomes on national and global levels. 7. COINN (Council of International Neonatal Nurses, Inc) supports the development of a set of competencies for neonatal nurses which provide the basis for the outcomes of the education. 8. COINN (Council of International Neonatal Nurses, Inc) is committed to work with professional national and international organizations to support increased training and education of neonatal nurses References Darmstadt, G. L., Kinney, M. V., Chopra, M., Kak, L., Paul, V. K., Martines, J., Bhutta, Z., Lawn, J, E. , Lancet Every Newborn Study Group. (2014). Every Newborn 1: Who has been caring for the baby? Lancet, 384 (9938): 174-188. Lawn, J.E., Blencowe, H., Oza, S., You, D., Lee, A. C. C., Waiswa, P...Cosenns, S. N., Lancet Every Newborn Study Group. (2014). Every Newborn 2: Every Newborn: progress, priorities and potential beyond survival. Lancet, 384 (9938): 189-205. Mangharm-Jefferies, L., Pitt, C., Cousens, S., Mills, A., & Schellenberg, J. (2014). Cost-effectiveness of strategies to improve utilization and provision of maternal and newborn health care in low-income and lower-middle-income countries: a systematic review. BMC Pregnancy and Childbirth, 14 (243). Doi: 10.1186/1471-2393-14-243. Premji, S. S., Spencer, K., & Kenner, C. (2013). Call for neonatal nursing specialization in developing countries. Maternal Child Nursing, 38 (6): 336-342. United Nations (2015). Sustainable development goal: Goal 3: ensuring healthy lives and promote well-being for all at all ages. Retrieved from: http://www.un.org/sustainabledevelopment/health/ World Health Organization. (2014). Every newborn: an action plan to end preventable death. Retrieved from: https://www.who.int/maternal_child_adolescent/documents/every-newborn-action-plan/en/
  • CARE OF THE LATE-TERM INFANT
    COUNCIL OF INTERNATIONAL NEONATAL NURSING, INC (COINN)POSITION STATEMENT ON CARE OF THE LATE PRETERM INFANT COINN (Council of International Neonatal Nurses, Inc) 
Position: The United Nations Millennium Development Goal (MDG) 41 calls for a 2/3rd reduction in under five years of age mortality. One third of the infant/child deaths occur during the neonatal period. Of these, ¾ occur in the first week and about 1/3rd of these within the first 24 hours. Forty to seventy percent of these are preventable through basic inexpensive interventions aimed at a continuum of care from preconception through to postnatal care. 2 The causes of morbidity and mortality are mostly preventable (i.e., infections such as malaria, pneumonia, and tetanus and diarrhea). While progress has been made in reducing overall infant mortality, neonatal mortality remains high. 3, 4 All newborn babies therefore require a basic standard of care in order to prevent these deaths particularly within the first 24 hours of life. In the United States there was an increase of 18% in late preterm births from 1996 to 2006 representing 9.1% of all live preterm births.2 This late preterm population accounted for more than 70% of all the preterm births in the US in the 2006. 5, 6 The same trend is seen worldwide with approximately 1 million premature infants dying during the neonatal period many of which are late premature infants. 7 These infants are in fact, both physiologically and metabolically immature. Central nervous system function is also not at the level of term infants which reduces the self regulatory ability to adapt to the external stress. 8 In spite of their appearance to mimic full term infants, immaturity places them at higher risk for health issues associated with increased morbidity and mortality. Although, many of the term infant care principles apply to the late preterm infants care, high risk factors must be recognized at birth to identify, prevent and intervene for the common late preterm issues such as respiratory distress, apnea, inadequate thermoregulation, hypoglycemia, feeding difficulty, hyperbilirubinemia (or Jaundice), sepsis, and other potential problems. 9,10 The American Academy of Pediatrics (AAP) and American Congress of Obstetricians and Gynecologists (ACOG) 6th edition Guidelines for Perinatal Care recommend careful observation of a newborn during the first 6‐12 hours of transition period even for a well term infants. 8 The late preterm infants require additional vigilance. Globally the problem is not always separated from over all preterm birth rates. Care given with prevention in mind to the vulnerable late preterm newborn infants during the first few hours and days of their lives may have a profound significance to the United Nations Millennium Development Goals (MDGs). The Council of International Neonatal Nurses, Inc (COINN) is the international voice of neonatal nurses who provide care during this vulnerable period. In order to address identified gaps in current practice COINN (Council of International Neonatal Nurses, Inc) supports and recommends the following Guideline for Care of late preterm infants: A late preterm infant 34 0/7‐36 6/7 weeks’ gestation after the onset of the mother’s Last Menstrual Period‐LMP is physiologically and metabolically immature. The limited compensatory response to the external stressors must be recognized and should be cared for as immature regardless of the weight. The presence, at every delivery, of a nurse/doctor trained in neonatal resuscitation (skilled neonatal attendant) dedicated solely to care for the baby. Availability of an oxygen source, suction, bag and mask set up is essential. Provision of adequate thermal environment such as warmer. Immediate assessment of the newborn’s health status by a trained professional after delivery as drying, stimulation, and suctioning is provided for during the transition. On‐going maintenance of an appropriate thermal environment by placing a cap, light clothing and bundling, or skin to skin with mother. Temperature instability is one of the frequent diagnosis for the late preterm infant. Keep in mind that cold stress alone could lead to peripheral and pulmonary vascular constriction, hypoglycemia, or death if not minimized or prevented. Formal admission of individual infant as an individual patient to receive identification number. Recording of the newborn’s condition including gestational age, physical exam and vital signs at birth. Identify and document other risk factors besides late preterm at this time. These factors may include but are not limited to: Small for Gestational Age‐SGA, Infant of a Diabetic Mother‐IDM, maternal smoking, substance exposure, genetic anomalies, low Apgar score at 5 minutes and prenatal laboratory values for Syphilis, Hepatitis B, Human Immunodeficiency Virus‐HIV, Rubella status, and Herpes Simplex Virus (HSV). Make an appropriate reporting to the doctor of these findings. Give Vitamin K to prevent Vitamin K dependent Hemorrhagic disease and eye prophylaxis against gonococal ophthalmia within 1 hour after birth. Continued monitoring of vital signs, skin color, respiratory pattern, tone, peripheral circulation, level of consciousness and activity every 30 minutes until over all status is stable for 2 hours. During this time and throughout the hospital stay, family‐centered care practice such as on‐ going contact with the mother is encouraged for breast feeding initiation and bonding. However, excessive handling of the infant is not encouraged for the late preterm infant has limited compensatory mechanism for external stimulation. Excessive stimulation leads to excessive use of glucose, tiring and not being able to feed. Offer feeding as soon as possible. Glucose check within an hour is recommended for hypoglycemia is another frequently diagnosed condition. If the infant is unable to suck swallow and breathe effectively, physicians/doctors or nurse practitioners must be notified immediately to avoid hypoglycemia, dehydration, aspiration and other complications. Keep in mind that preterm infants’ serum glucose hits nadir (low point) at 1‐2 hour after birth. Each nursery‘s glucose protocol must be followed for continued glucose check. Continued observation for potential complications by assessing for the following, Temperature instability, Change in activity, Poor feeding, Poor skin color, Abnormal cardiac or respiratory rate and rhythm, Apnea, Abdominal distension or bilious vomiting, Excessive lethargy and sleeping, Delayed stooling or voiding, The importance of these changes in assessment findings should also be communicated to the parents while rooming‐in so that a trained staff is notified of any change, Trained staff should observe the infant periodically in mother’s room while rooming in according the institutional protocol, Infant with these findings should be evaluated by the medical team for specialized care may be necessary to properly care for the infant in a timely manner. 15. Education on prevention of infection Proper cord care, Hygiene practices for diaper change, Hand washing, Clean technique for breast feeding and formula preparation, Limiting visitors during the influenza season, Bathing instructions. 16. First bath should be given once the infant‘s thermal stability is ensued to prevent hypothermia. Late Preterm infants require vigilance with this intervention. Whole body bathing is not always necessary. Localized skin care or techniques that expose the skin minimally to remove blood and meconium may prevent the excessive heat loss thus prevents hypothermia. The skin barrier function for the first four weeks of life is somewhat unstable and offers protective immunity when not disrupted. 11,12 17. Immunization should be initiated before discharge and followed up according to the recommended schedule by follow up health professional. (Hepatitis B, Mumps, Measles, and Rubella (MMR), Haemophilus influenzae type b‐Haemophilus influenza (b‐HIB), Polio and other). 18. During the Respiratory Syncytial Virus (RSV) season, RSV vaccine is offered for preterm infants of 35 weeks or less with at least one risk factor (day care or having a sibling 5 years and younger). 10 19. Perform hearing screen. If the infant does not pass, make or asked the doctor for a referral for further examination. 20. Perform metabolic and genetic screen 24 hours after feeding initiated, if done before, another follow up must be arranged. 21. Identify a health care professional who will provide on‐going care of the infant with whom immediate follow up care can be arranged. Discharge summary or a form of written report is sent to the follow up health care professional with specific hospital course and follow up needs. 22. The infant should be carefully assessed with #13 in mind before discharge. Individualized decision should be made regarding the timing of discharge. 8,10 Feeding competency with 24 hours of successful feeding with demonstration of coordinated suck, swallow and breathing. Thermoregulation ability. Free from abnormal physical exam findings, (or immediate follow up plan available for a non emergent abnormal finding). Infants should be in stable condition for at least 12 hours prior to discharge. (Respiratory Rate less than 60/minutes, Heart Rate 100‐160/minutes, Temperature 36.5‐37.4 degrees C or 97‐98.6 degrees F in an open crib with appropriate clothing. At least one spontaneous stooling. To avoid severe hyperbilirubinemia, appropriate follow up plan is made based on the bilirubin level that should be checked on the day of discharge. Mother has been educated and demonstrated the understanding of feeding plan, hygiene, importance of follow up, recognition for status change including severe jaundice, dehydration, sepsis, thermoregulation, clothing, and safety issues (see 21). Absence of social risk factors that endanger the infant. Availability of a safety plan for the infant if there is risk factor. (see 21) Infant has demonstrated ability to tolerate car seat challenge without apnea, bradycardia or decreased oxygen saturation or skin color change. Follow the policy of the state or country regarding the genetic or metabolic screening. Perform the screening after full feeding is achieved. If one was done before 24 hours of initiation of feeding, another screening is needed at a follow up. The plan must be in place before discharge and should be communicated to the follow up professional. Infant passed Hearing screening or if did not pass, plan is made to repeat the screening. Infant’s weight loss must be assessed. Weight loss of more than 2‐3% per day or maximum of 7% by the time of discharge calls for an evaluation by a medical professional. Dehydration must be considered and feeding ability and volume of feeding must be carefully assessed before discharge decision is made. 23. Family environment should be assessed to ensure safeguarding infant upon discharge and maincare provider of the infant is provided with safety education. Completion of the parental education and parental demonstration of competency is documented. 8,9 Free from history of abuse or neglect, domestic violence, or parent with mental illness. Collaborate with the social service at the hospital and state child care service when indicated. Availability of a safety plan to safeguard infant from any identified social or environmental risk such as follow up social work visit. Presence of family support for the mother or the main care provider. Presence of a fixed home environment with heat, water and essential supplies. Identify community support as needed to address concerns. Parental understanding for the care of the infant outlined below and reinforce education, Prevention of hypothermia, Basic hygiene including bathing, cord care, diaper change, Current feeding plan, Comfortable and proficient with breast feeding, and also proper prep for formula, Importance of follow up care and definite plan for the next follow up, Newborn safety such as car seat, smoke fire alarms at home, danger of second hand smoking, and any other environmental hazards present, Prevention of SIDS (back to sleep, no soft pillows and excessive blankets), Appropriate layers of clothing for the infant, Preventive measures against infection (avoid public in flu season, hand washing for the family, avoid crowd during newborn period), Proper use of thermometer for axillary temperature, Administering any medication such as multivitamin or iron Education to identify risk factors given in #13 and provision of number/clinic name/doctor’s office contact information to call to report change of status, Contact for emergency needs is reviewed. Changes that the care provider must be able to recognize and report are: Increase in severity of Jaundice, Lethargy and poor feeding Vomiting, Poor skin color, Fever greater than 38 degrees C or 100.4 degrees F or below 36 degrees C or 96.8 degrees F, Respiratory distress–emergency, Apnea‐emergency. 23. The initial follow up with a trained professional (home health, pediatrician, public health department, etc) should be arranged for the infant within 48‐72 hours after discharge if bilirubin follow up is necessary. The infant should be assessed at minimum after 6 days, 2 weeks, and every 2‐3 months for first 6 months. References United Nations Millennium Development Goals. (2009). Available: http://www.un.org/millenniumgoals/. March of Dimes (MOD). (2006). Late Preterm Birth: Every Week Matters. Available: http://www.marchofdimes.com/files/MP_Late_Preterm_Birth‐Every_Week_Matters_3‐24‐06.pdf. Lawn, J.E., Cousens, S., Zupen, J., for Lancet Neonatal Survival Steering Team. (2005). Neonatal Survival 1. 4 million neonatal deaths: When? Where? Why? Lancet, 365, 821‐822. The Millennium Development Goal Report 2009. Available: http://www.un.org/millenniumgoals/pdf/MDG_Report_2009_ENG.pdf March of Dimes. (MOD). Late preterm births. 1990‐2006. Available http://www.marchofdimes.com/peristats/level1.aspxdv=ls®=99&top=3&stop=240&lev=1& slev=1&obj=1 Engle, WA, Tomashek, KM, William, C, and the Committee on Fetus and Newborn.(2007). Late Preterm Infants: A population at risk. Pediatrics, 120(6). 1390‐1401. Global death toll: 1 million premature babies every year. White Plains, NY: March of Dimes (MOD). Available: http://www.eurekalert.org/pub_releases/2009‐10/modf‐gdt100209.php. American Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologists* (ACOG). (2007). Guidelines for perinatal care. 6th ed., Elk Grove Village, IL: AAP/ACOG. *now named the American Congress of Obstetricians and Gynecologists. Kruse, L. (2009). Late Preterm Infant Clinical Guideline. Oklahoma City, OK: University of Oklahoma Medical and the Oklahoma Healthy Mothers, Healthy Babies Coalition Infant Alliance. American Academy of Pediatrics (AAP). Committee on infectious diseases. Policy statement modified recommendations for use of palivizumab for prevention of respiratory syncytial virus infections. Published online Sept 7, 2009. Available: https://pediatrics.aappublications.org Dec 3, 2009. Bartels, N.G., Mleczko, A., Schink, T., Proquitte, H., Wauer, R.R., & Blume‐Peytavi, U. (2009). Influence of bathing or washing on skin barrier function in newborns during the first four weeks of life. Skin Pharmacology and Physiology, 22(5), 248‐257. Walker, L., Downe, S., & Gomez, L. (2005). Skin care in well term newborn: Two systematic reviews. Birth, 32(3), 224‐228. Acknowledgement: COINN (Council of International Neonatal Nurses, Inc) wishes to thank Lynda Kruse and University of Oklahoma Medical Center, Oklahoma City, OK and Bonnie Bellah of the Oklahoma Healthy Mothers, Healthy Babies Coalition Infant Alliance USA for generously allowing an adaptation of their clinical guideline for the late preterm infant to be used. COINN (Council of International Neonatal Nurses, Inc) acknowledges that some countries may not be able to implement the recommendations as written due to limited resources‐personnel, financial, and equipment. However, to improve health outcomes all the neonatal community must strive to uphold these recommendations.Determinations must be made within local and national organizations as to what constitutes basic, essential, and advanced care. Approved by COINN (Council of International Neonatal Nurses, Inc) Board of Directors January 2010 we/rd/ck/mb COINN –THE GLOBAL VOICE OF NEONATAL NURSESRepresenting over 50 countries and 15,000 nurses.
  • ETHICAL MIGRATION OF NEONATAL NURSES
    COUNCIL OF INTERNATIONAL NEONATAL NURSES, Inc. (COINN)Position Statement COINN (Council of International Neonatal Nurses, Inc) Position COINN (Council of International Neonatal Nurses, Inc) supports the International Council of Nurses (ICN) (2007) position on ethical nurse recruitment. COINN (Council of International Neonatal Nurses, Inc) recognises that quality neonatal care cannot be given without an adequate supply of well qualified and educated nurses. COINN (Council of International Neonatal Nurses, Inc) supports an individual’s right to migrate to another country for better quality of life, working conditions, or other personal reasons. COINN (Council of International Neonatal Nurses, Inc) supports ethical recruitment for employment which provides adequate training, orientation and support or supervision. COINN (Council of International Neonatal Nurses, Inc) supports the World Health Organisation, Migration of Health Workers: the WHO Code of Practice and the Global Economic Crisis, (2014). Though not legally binding, has political weight and provides a benchmark by which international recruitment can be monitored. Background Maternal Child and Neonatal Nursing is a growing speciality area that is experiencing a nursing shortage and thus there is a need for recruitment. COINN (Council of International Neonatal Nurses, Inc) recognises that corporations are entering this critical healthcare delivery concern as brokers to recruit nurses on behalf of healthcare delivery systems and then arrange for their transportation to the country of need. Some of these agents are legitimate and others are bartering or trading nurses for a substantial sum of money. Middle and high resourced countries have increased their acquisition of nurses from low resourced countries, adding to the global shortage (Buchan, Parkin & Sochalski, 2003). The World Health Organization (WHO) (2017) projects a shortage of 18 million health workers. Given the growing global nursing shortage as documented by the ICN and other such organisations, the problem of bartering or trading nurses for profit is going to increase as well. Ideally westernised countries should be able to manage their workforce effectively and not be reliant on other countries. However, COINN (Council of International Neonatal Nurses, Inc) recognises that short term migration may be needed to meet the maternal child health care needs. This migration must be done with consideration of the potential “brain drain” from the country sending the nurses and the need for transition training in the country to which the nurse is migrating. When this migration is necessary there should be a limit on the number of nurses migrating, countries from which migration is acceptable and duration of time during which this migration is permitted so that this migration is not at the behest of a shortfall. Retention strategies should be employed so that nurses have incentives to stay in their own countries rather than migrate. These strategies could include but are not limited to: better working conditions, decreased number of hours, better patient to nurse ratios and better compensation – wages and benefits. Currently there are almost 60 million health workers globally, but they are unevenly distributed across countries and regions. Typically, they are scarcest where they are most needed, especially in the poorest countries. In any case, the total number is incapable of meeting the demands of many populations for access to the health care they require. Both developed and developing countries are struggling to cope with the huge challenges posed by the imbalance between increasing demand and faltering supply (WHO, 2013). The global drive towards achieving universal health coverage (UHC) by improving access to affordable and effective care for all, cannot be achieved without a well-trained workforce, and having “the right staff in the right place”. The Migration of Health Workers: the WHO Code of Practice and the Global Economic Crisis (2014) examines in depth the central and often-controversial issues of the international migration of health workers before and since the adoption of the WHO Global Code of Practice on the International Recruitment of Health Personnel. The Migration of Health Workers: the WHO Code of Practice and the Global Economic Crisis (2014) brings much-needed evidence and clarity to the changing patterns of migration over time, and the varied and changing reasons why health workers choose to migrate – or to stay in their own countries. Among these, the global financial crisis has influenced the trends and directions of health worker migration, and the impact of the crisis is reviewed at length. Against this global background, a range of better-informed policy responses is emerging locally, nationally and internationally. We must keep health workforce migration, its impact and implications at the forefront of multiple international agendas. Recommendations/Key Principles Guideline Principles for Ethical Migration include but are not limited to: 1. Active involvement by the employing institution or another governing body to ensure that standards of practice are upheld when no national regulatory bodies are in place. 2. If specialised knowledge is required such as neonatal or maternal child nursing, that adequate orientation and training is provided for a sufficient length of time to ensure competency. 3. Support for specialised evidence-based care in neonatology or maternal child health is available through nursing or medicine and that equipment is available if a nurse is recruited in this area of specialisation. Nurses (or alternate care providers) are appropriately trained in using, maintaining and checking equipment. 4. Strengthen education and training by continued acquisition of knowledge and demonstration of competency in neonatal or maternal child care is an expectation and is supported by the recruiting country. 5. Monitoring for quality of care provided and performance appraisal of the individual nurse must be ongoing in the areas of new-born, maternal and family care. 6. Consideration of cultural differences of the nurse and the need for cultural sensitivity in the new work environment must be addressed. 7. Language acquisition must be supported. This acquisition is to include written, verbal and comprehension. 8. Language fluency is critical before nurses start caring for patients. 9. Nurses have the right to work in a safe working environment and one that adheres to the ICN Code of Ethics for Nurses or if available the recruiting country’s national nursing code of ethics in addition to the United Nations (1948) Universal Declaration of Human Rights. 10. Active involvement by the employing institution or another governing body in the development of a national workforce plan. References Benton, D.C., & Ferguson, S.L. (2017). A wide-angle view of global nursing workforce and migration. Nursing Economics, 35(4), 170-177. Buchan, J. Parkin, T., & Sochalski, J. (2003) International Nurse Mobility: Trends and Policy Implications. Geneva, Switzerland: WHO, ICN, and Royal College of Nursing. ICN (2007.) Ethical Nurse Recruitment. Geneva, Switzerland: ICN. https://www.icn.ch/news/international-council-nurses-calls-ethical-recruitment-process-address-critical-shortage World Health Organisation. (2006). 5 th World Health Assembly, Provisional agenda item 11.12, May 4, 2006. http://www.who.int/gb/ebwha/pdf_files/WHA59/A59_18-en.pdf World Health Organisation. (2013). Guidelines on transforming and scaling up health professionals’ education and training. Geneva: World Health Organization http://whoeducationguidelines.org World Health Organisation (2014) Migration of Health Workers: the WHO Code of Practice and the Global Economic Crisis. Geneva: World Health Organisation https://www.who.int/hrh/migration/migration_book/en/ World Health Organisation (2017). Health workforce. http://www.who.int/hrh/news/2017/action-to-avertan18-million-health-worker-shortfall/en/
  • CHILD, HEALTH, POVERTY AND BREASTFEEDING
    COUNCIL OF INTERNATIONAL NEONATAL NURSES, Inc. (COINN)Position Statement COINN (Council of International Neonatal Nurses, Inc) Position The Council of International Neonatal Nurses, Inc. (COINN) recognizes the critical contributions made by breastfeeding, breast milk, and mother-baby bonding, to not only enhance developmental outcomes but also child survival. Intergenerational cycles of poverty and health inequalities are also factors linked to not breastfeeding the infant. The highest risk of death is during the neonatal period. Positive survival and health outcomes result from relatively simple and safe measures such as breastfeeding. Keeping mothers and infants together as much as possible, providing breastfeeding counselling, assisting mothers to provide breast milk for their preterm unwell babies and supporting breastfeeding initiation, exclusivity and continuance, even in the workplace, are essential components for child survival. Supportive health care practices, such as these, are a prerequisite to reach optimal breastfeeding goals. That all infants should be exclusively breastfeed for a minimum of 6 months. Mothers living with HIV should breastfeed for at least 12 months and may continue to breastfeed for 24 months or beyond (similar to the general population) while being fully supported with ART adherence (WHO, 2016). Mothers known to be living with HIV should only give commercial infant formula as a replacement to their HIV-uninfected infant or infant who are of unknown HIV status if specific conditions are met: there is assured safe water and sanitation in the household and community; the mother or caregiver can reliably provide sufficient infant formula to support normal growth and development of the infant; the mother or caregiver can prepare the formula cleanly and frequently enough to ensure there is a low risk of diarrhea or malnutrition; the mother or caregiver can give infant formula exclusively for the first 6 months; the family supports the practice; the mother or caregiver can access health care that offers comprehensive child health services (WHO, 2016). In situations where the HIV positive mother chooses to give mixed feedings it is recommended that she is on ARV medication and preferable breastfeed exclusively for minimum of 6 months. Research appears to indicate that this abrupt weaning even in HIV positive women may lead to adverse neonatal/infant outcomes. National and local health authorities should actively coordinate and implement services at health facilities, workplaces, communities and homes to promote and protect that ensure the right of for HIV positive mothers to breastfeed. During emergency situations and in the presence of an orphaned infant attempts should be made to administer HIV-negative donor human milk. In situations where the mother’s own milk is not available, the best option is donor human milk. While pasteurized donor milk from a regulated milk bank is preferred, it is often not available during a disaster. If formula is given, recommend ready-to-feed standard formula. Use concentrated or powdered formula only if bottled or boiled water is available. In emergency situations it may be preferable to re-initiate lactation in mothers who have been weaned over artificial feeding with infant formula. (United States Breastfeeding Committee, 2011; WHO Regional Office for Europe, 1997). COINN (Council of International Neonatal Nurses, Inc) supports the International Code of Marketing of Breastmilk Substitutes and subsequent, relevant World Health Assembly resolution. Background “In the battle to eradicate poverty, one small step would be to ensure that every newborn is breastfed. This would provide the best nutrition, the greatest infection protection, the most illness prevention, and the greatest food security and psychological protection for the infant” (Lawrence, 2007) Recommendations/Key Principles 1. The importance of breastfeeding and use of breast milk to child survival requires global coordinated health efforts to support breastfeeding. 2. Globally neonates (first 28 days of life) have the highest risk of death but a mortality gap exists between developing and developed countries, especially for countries experiencing conflicts or crises. 3. Infants born in less developed countries, who are not breastfed, have a six-fold greater risk of dying from infectious diseases in the first two months of life than those who are breastfed. 4. The Global Strategy on Infant and Young Child Feeding confirms that breastfeeding is a public health priority globally. 5. Initiation and support of breastfeeding are essential components of infant care in all settings including the woman’s workplace. 6. Protection and support of mother-baby bonding and breastfeeding, beginning shortly after birth, or as soon after birth as possible, [including situations where babies are born preterm or unwell and admitted to a neonatal or special care unit] are essential components for increased child survival. 7. Breastfeeding and breast milk provide optimal, species specific, nutrition and are an essential component of any program to improve child health. 8. Breastfeeding and breast milk save lives by protecting babies from infection and by modulation of the immature immune systems of babies. 9. The use of any breast milk substitutes in emergencies is a risk factor for neonates and infants due to unhygienic conditions, lack of water or clean water and lack of knowledge about safe preparation of these products. 10. “The world cannot afford to continue to lose one of its most valuable resources - its children." Carole Kenner (2007) COINN (Council of International Neonatal Nurses, Inc) acknowledges that some countries may not be able to implement the recommendations as written due to limited resources-personnel, financial, and equipment. However, to improve health outcomes all the neonatal community must strive to uphold these recommendations. Determinations must be made within local and national organizations as to what constitutes basic, essential, and advanced care. References American Academy of Pediatrics (2015). Infant feeding in Disasters and Emergencies. Retrieved from: http://www2.aap.org/breastfeeding/files/pdf/infantnutritiondisaster.pdf Davanzo, R. (2004). Newborns in adverse conditions: Issues, challenges and interventions. Journal of Midwifery & Women’s Health, 49, [4], Suppl 1: 29-35. Franz, A. N. (2015). Relactation in Emergencies. Retrieved from: http://corescholar.libraries.wright.edu/cgi/viewcontent.cgi?article=1167&context=mph Hanson, L. (2004). Immunobiology of human milk. How breastfeeding protects babies. Amarillo, Pharmasoft. Lawrence, R.A. (2007). The eradication of poverty one child at a time through breastfeeding: A contribution to the global theme issue on poverty and human development, October 22, 2007. Breastfeeding Medicine: The Official Journal of the Academy of Breastfeeding Medicine, 2: 193-194. Kenner, C. (2007). Working to save children’s lives. Council of International Neonatal Nurses Inc. http://www.coinnurses.org/news/savings_children_lives.htm. Kuhn, L., Aldrovandi, G. M., Sinkala, M., Kankasa, C., Semerau, K., Mwiya, M., Kasonde, P., Scott, N., Vwalika, C., Walter, J., Bulterys, M., Tsai, W-Y., & Thea, D. M. (2008). Effects of early abrupt weaning on HIV-free survival of children in Zambia. New England Journal of Medicine, 359: 130- 141 Savage, F., & Renfrew, M. J. (2008). Countdown to 2015 for maternal, newborn and child survival. Letter, The Lancet, 372: 369 United States Breastfeeding Committee. (2011). Statement on infant/young child feeding in emergencies. Retrieved from http://www.usbreastfeeding.org/d/do/416 World Health Organization (2016). Update of HIV and Infant Feeding. Retrieved from: http://apps.who.int/iris/bitstream/10665/246260/1/9789241549707-eng.pdf?ua=1 World Health Organization (1981). The International Code of Marketing of Breastmilk Substitutes. Full Code and relevant WHA resolutions are at: https://www.who.int/nutrition/publications/infantfeeding/9241541601/en/ World Health Organization (WHO), Regional Office for Europe. (1997). Infant feeding in emergencies; A guide for mothers. Copenhagen: World Health Organization.
  • BREASTFEEDING
    COUNCIL OF INTERNATIONAL NEONATAL NURSES, Inc. (COINN) Position Statement COINN (Council of International Neonatal Nurses, Inc) Position COINN (Council of International Neonatal Nurses, Inc) advocates for breastfeeding within the first hour of life and exclusive breastfeeding for the first six months of life for all newborn infants, when safe to do so. COINN (Council of International Neonatal Nurses, Inc) supports the World Health Assembly resolutions; the UNICEF and World Health Organization Baby-Friendly Hospital and Community Initiative; the enforcement of the International Code of Marketing of Breastmilk Substitutes and the provision of paid maternity leave and workplace breastfeeding initiatives. COINN (Council of International Neonatal Nurses, Inc) recognizes the critical impact of breastfeeding and expressed breast milk complementary feeding, to not only enhanced short and long-term health and developmental outcomes, but also to child survival. COINN (Council of International Neonatal Nurses, Inc) acknowledges that current practices in some countries need to be changed to support breastfeeding. For example, not all women are granted maternity leave of more than a few weeks, or have adequate places to use a breast pump, or breastfeed. Therefore, to improve health outcomes for neonates, it is important for parents, communities, healthcare workers, professional colleges, support organizations, education providers, health systems and governments to work together to strive to uphold these key principles and advocate for positive environments and leave policies that support breastfeeding. Background Globally more than 6 million children die before their 5th birthday with a significant portion of the deaths occurring in Sub-Sahara Africa and Southern Asia (United Nations, 2015). The Sustainable Development Goal (SDG) 3 calls for preventable deaths of newborns and children under 5 years to drop to as low as 12 per 1,000 live births and the under 5 mortality to at least 25 per 1000 (United Nations, 2015). High coverage with optimal breastfeeding practices has potentially the single largest impact on child survival of all preventive interventions (Azuine, Murray, Alsafi, & Singh, 2015). Evidence demonstrates that breastfeeding is effective at decreasing neonatal and child mortality (Gates & Binagwaho, 2014). Exclusive breastfeeding could prevent 823,000 childhood deaths and 20,000 maternal deaths per year (Lancet, 2016). Infants less than six months of age who are not breastfeed have and 3-5 times (boys) and 4-1 times (girls) increase in mortality compared to the infants who had been breastfeed (Victoria et al., 2016). The children who are breastfeed for short periods of time or not at all have a higher incidence of infectious morbidity and mortality, more dental malocclusions and lower intelligence (Victoria et al., 2016). Promoting skin-to-skin and early initiation of breastfeeding lowers neonatal mortality and waiting after the first hour to initiate breastfeeding doubled the risk of the neonate dying (Khan, Vesel, Bahl, & Martines, 2015). The striking feature of all of this is that despite knowing the potential of breastfeeding in reducing neonatal and infant mortality; breastfeeding rates have remained stagnant at 37per cent of children less than six months of age being exclusively breastfed (Victoria et al., 2016). Recommendations/Key Principles Promotion, protection and support for breastfeeding at local, national and international levels. Increased global attention, media coverage and funding for breast feeding initiatives acknowledging, highlighting and supporting the critical role breastfeeding plays in reducing child deaths and providing short and long term benefits for maternal health. Promotion of The International Code of Marketing of Breastmilk Substitutes and subsequent, relevant, World Health Assembly resolutions. Support the UNICEF and World Health Organization Baby-Friendly Hospital and Community Initiative. The provision of paid maternity leave in line with the International Labour Organization (ILO) minimum recommendations and workplace breastfeeding initiative. Professional and lay support for breastfeeding mothers, including: The attendance of a skilled birth attendant at every birth to ensure the initiation of breast feeding within one hour of birth Professional support by health providers to extend the duration of any breastfeeding and this must be facilitated by allocating adequate resources to long-term health worker training, recruitment, support and retention Support in the community by lay counsellors to increase the initiation and duration of exclusive breastfeeding 7. Where possible mother and child should not be separated and kangaroo mother care should be facilitated. 8. Exclusive breastfeeding for all infants for the first six months of life. ‘Exclusive breastfeeding’ is defined as giving no other food or drink – not even water – except breast milk. It does, however, allow the infant to receive oral rehydration salts (ORS), drops and syrups (vitamins, minerals and medicines). 9. Infants not able to breastfeed should be fed breast milk (mother’s own or donated) via tube, cup, syringe or spoon. Bottle-feeding should not be offered. 10. From six months of life the provision of nutritionally adequate and safe foods that complement breastfeeding. 11. The continuation of breastfeeding up to two years or beyond. 12. Community /country relevant policies regarding feeding HIV exposed babies-either exclusive breastfeeding with anti-retroviral (ARV) therapy or avoidance of all breast feeding. In low resource settings even when ARVs are not available, mothers should be counselled to exclusively breastfeed in the first six months of life and continue breastfeeding thereafter unless environmental and social circumstances are safe for, and supportive of, replacement feeding. References Azuine, R. E., Murray, J., Alsafi, N., & Singh, G. K. (2015). Exclusive Breastfeeding and Under-Five Mortality, 2006-2014: A Cross-National Analysis of 57 Low- and-Middle Income Countries. International Journal of MCH and AIDS, 4(1), 13–21. Gates, M., & Binagwaho, A. (2014). Newborn health: a revolution in waiting. Retrieved from: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60810-2/fulltext Khan, J., Vesel, L., Bahl, R., & Martines, J. C. (2015). Timing of breastfeeding initiation and exclusivity of breastfeeding effects on neonatal mortality and morbidity – a systematic review and meta-analysis. Maternal Child Health, 19(3), 468-79. Doi:10.1007/s10995-014-1526-8. Lancet (2016). Breastfeeding: achieving the new normal. Lancet, 387(10017), 404. Retrieved from: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)00210-5/fulltext Victoria, C, S., Bahl, R., Barros, A. J., Giovanny, V. A. F., Horton, S., Krasevec., J., & Rollins, N. C. (2016). Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet, 387(10017), 475- Retrieved from: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)01024-7/fulltext
  • KANGAROO MOTHER CARE
    COUNCIL OF INTERNATIONAL NEONATAL NURSES , Inc. (COINN) Position Statement COINN (Council of International Neonatal Nurses, Inc) Position COINN (Council of International Neonatal Nurses, Inc) supports the practice of Kangaroo Mother Care (KMC) in all areas of a Neonatal Intensive Care Unit or Special Care Baby Unit. Kangaroo Mother Care is defined as “Care of the stabilized preterm or low birthweight infant carried skin-to-skin with the mother and exclusive breastfeeding or feeding with breastmilk.” (WHO 2003; Conde-Aguedelo and Díaz-Rossello 2016). Key Components (Conde-Aguedelo and Díaz-Rossello, 2016) Kangaroo position, or continuous skin-to-skin contact between infant and mother or another caregiver. Exclusive breastfeeding, or feeding with breastmilk, when possible. Timely discharge from hospital with close follow-up. COINN (Council of International Neonatal Nurses, Inc) supports the continued practice of KMC at home. “Humanising the practice of neonatology, promoting breastfeeding and shortened hospital stays without compromising survival” (Charpak et al. 2001). Background Doctors Rey and Martinez in Bogota, Colombia as an alternative to inadequate or insufficient incubator care developed KMC for stable preterm babies (WHO 2003). KMC (continuous and intermittent) offers benefits to preterm and low birthweight infants in all settings. Compared to incubator care alone, KMC is a safe and effective method to reduce the risk of neonatal mortality, irrespective of weight or gestational age (WHO 2003, Conde-Aguedelo and Díaz-Rossello 2016, Boundy et al. 2016, Lawn et al. 2010). KMC provides the infant with thermal support, protection from infection, appropriate stimulation, and a nurturing environment (Boundy et al. 2016, Chan et al. 2016, Charpak et al. 2005). Long-term social and behavioral protective effects have also been reported (Charpak et al. 2017). WHO Recommendations (WHO 2015) Kangaroo mother care is recommended for the routine care of newborns weighing 2000 grams or less at birth, and should be initiated in health-care facilities as soon as the newborns are clinically stable. Newborns weighing 2000 grams or less at birth should be provided as close to continuous kangaroo mother care as possible. Intermittent kangaroo mother care, rather than conventional care, is recommended for newborns weighing 2000 grams or less at birth, if continuous kangaroo mother care is not possible. Guidelines for KMC practice should be developed to specifically and contextually suit the facility and environment where they are to be used. Procedure Individual assessment of each baby is necessary prior to initiating KMC, but general guidelines are presented below: Stablised preterm or low birthweight baby admitted to a neonatal intensive care unit or special care baby unit. Full term, well baby. To assist with maternal attachment when separation of mother and baby has occurred. To support lactation and establish breastfeeding. (A) Contraindications for KMC Individual assessment of each baby is necessary, but general guidelines to avoid KMC are presented below: Medically unwell, unstable baby who may be ventilated, have pneumothoraxes, or be extremely low birthweight. Immediate post-surgical baby. KMC may commence/recommence once medically stabilized. (B) Requirements for KMC (WHO 2003) Mother, or another caregiver. A comfortable reclining chair, if possible. Optional carrying sling or kangaroo wrap. Blanket to cover the baby’s back. Infant hat or cap. Adequately trained personnel with special skills to monitor mother and infant. Supportive environment. Privacy screens when practiced in open units, if possible. (C) What parents and family members need to know about KMC KMC is safe. KMC is beneficial. The baby will stay warm. KMC will stabilize heart and respiratory rate and increase oxygenation levels. Enhances lactation, breastfeeding, and immunological effects. (D) Obstacles to KMC Lack of a policy or guidelines for practice: Development of a KMC policy is necessary for individual facilities undertaking KMC. A KMC framework and practice guidelines are essential to give staff confidence in implementing KMC and the collaborative creation of a policy gives value to the practice within individual settings. Lack of an education programme: Staff require KMC education and guidance to enable competent and confident practice. Novice staff will benefit from the supportive mentoring of experienced staff members. Communication: Parents may not be aware of the benefits and safety of KMC. Staff will need to disseminate KMC information which is easily understandable and up to date. Lack of facilities for mothers: Facilities may not have enough beds for mothers to room-in close to their baby in the NICU or special care nursery. If this is the case then KMC is even more important as it will enable the mother and baby to achieve the full benefits of their time together. Facilities without adequate rooming-in facilities should consider working towards minimizing mother-baby separation as a future goal of optimal care. References Boundy, E.O., Dastjerdi, R., Spiegelman, D., Fawzi , W.W., Missmer, S.A., Lieberman, E., et al. (2016). Kangaroo Mother Care and Neonatal Outcomes: A Meta-analysis. Pediatrics 137(1): 1-16. Chan, G.J., Valsangkar, B., Kajeepeta, S., Boundy, E.O., & Wall, S. (2016). What is kangaroo mother care? Systematic review of the literature. Journal of Global Health 6(1), 010701. http://doi.or/10.7189/jogh.06.010701. Charpak, N., Ruiz-Pelaez J.G., Figeuroa de Calume, Z., & Charpak, Y. (2001). A randomised, controlled trial of Kangaroo Mother Care: Results of follow-up at 1 year of corrected age. Pediatrics 108(5):1072- 1079. Charpak, N., Ruiz, J.G., Zupan, J., Cattaneo, A., Figueroa, Z., Tessier, R., et al. (2005). Kangaroo Mother Care: 25 years after. Acta Paediatrica. 94(5): 514-22. Charpak, N., Tessier, R., Ruiz, J.G., Hernandez, J.T., Uriza, F., Villegas, J., et al. (2017). Twenty-year follow-up of kangaroo mother care versus traditional care. Pediatrics. 139(1), e20162063. Conde-Aguedelo, A., & Díaz-Rossello, J.L. (2016). Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database of Systematic Reviews. 8(Art. No.: CD002771). Lawn, J.E. Mwansa-Kambafwile, J., Horta, B.L., Barros, F.C., & Cousens, S. (2010). 'Kangaroo mother care' to prevent neonatal deaths due to preterm birth complications. International Journal of Epidemiology. 39, i144-54. World Health Organization. Kangaroo mother care: a practical guide. (2003). Geneva: World Health Organization. Available at: http://www.who.int/maternal_child_adolescent/documents/9241590351/en/. Accessed: 10 March 2017. World Health Organization. (2015). WHO recommendations on interventions to improve preterm birth outcomes. Geneva: World Health Organization. Available at: http://apps.who.int/iris/bitstream/10665/183037/1/9789241508988_eng.pdf. Accessed 10 March 2017 Selected Bibliography Anderson, G.C. (1991). Current knowledge about skin-to-skin (kangaroo) care for preterm infants. Journal of Perinatology. X1(3): 216-226. Bergh, A-M,. Kerber, K., Abwao, S., Johnso.n Jd-G., Aliganyira, P., Davy, K., et al. (2014). Implementing facility-based kangaroo mother care services: lessons from a multi-country study in Africa. 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Kangaroo Mother Care for low birthweight infants: A randomised controlled trial in different settings. Acta Paediatrica. 87: 976- 985. Charpak, N., Ruiz-Pelaez, J., & Charpak, Y. (1994). Kangaroo-mother programme: An alternative way of caring for low birth weight infants? One year mortality in a two-cohort study. Pediatrics. 94: 804- 810. Charpak, N., Ruiz-Pelaez, JG., Figueroa de C, Z., & Charpak, Y. (1997). Kangaroo mother versus traditional care for newborn infants <2000 grams: A randomized, controlled trial. Pediatrics. 100: 682-688. Feldman, R., Weller, A., Sirota, L., & Eidelman, A.I. 2003. Testing a family intervention hypothesis: The contribution of mother-infant skin-to-skin contact (Kangaroo Care) to family interaction, proximity and touch. Journal of Family Psychology. 17(1): 94-107. Feldman, R. (2004). Mother-infant-skin-to-skin contact: Theoretical, clinical and empirical aspects. Infant and Young Child. 17: 145-161. Ferber, S.G., & Makhoul, I.R. (2004). 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Towards universal Kangaroo Mother Care: recommendations and report from the First European conference and Seventh International Workshop on Kangaroo Mother Care. Acta Paediatrics. 99(6): 820-6. Seidman, G., Unnikrishnan, S., Kenny, E., Myslinski, S., Cairns-Smith, S., Mulligan, B., et al. (2015). Barriers and enablers of kangaroo mother care practice: a systematic review. PLoS One. 10(5):e0125643. Tessier, R., Cristo, M., Velez, S., Giron, M., Nadeau, L., Figueroa de Calume, Z., Ruiz-Palaez, J.G., & Charpak, N. (2003). Kangaroo Mother Care: A method for protecting high-risk low-birth-weight and premature infants against developmental delay. Infant Behavior & Development. 26: 384-397. ​​​​​
  • THE CRITICAL ROLE OF NURSES IN SAFE MATERNAL AND NEWBORN CARE
    World Patient Safety Day Joint Statement International Council of Nurses and The Council of International Neonatal Nurses, Inc. To mark World Patient Safety Day, 17 September 2021, the International Council of Nurses (ICN) and the Council of International Neonatal Nurses, Inc. (COINN) urge all stakeholders to heed the campaign call and “Act now for safe and respectful childbirth!”. TO READ MORE https://www.icn.ch/system/files/documents/2021-09/ICN%20COINN%20Joint%20Statement%20WPSD%202021%20final.pdf
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