Giving Voice to Parents in the Development of the Preemie Prep for Parents (P3) Mobile App Background: Parents at risk for preterm birth frequently receive prematurity education when the mother is hospitalized for premature labor. Parental ability to learn and consider the information is limited because of the stress of the hospitalization. A promising approach is dissemination of information to at-risk parents before the birth hospitalization. Purpose: This article describes formative research used to develop smartphone-based prematurity education app for parents at-risk for preterm birth. Methods: Stakeholders were parents with a prior preterm birth. Using stakeholder meeting transcripts, constant comparative analysis was used to reflect upon the parental voice. Results: The parents named the app, Preemie Prep for Parents (P3). Parent perspectives revealed desire for information in the following 5 categories. (1) Power in knowledge and control: parents want autonomy when learning information that may influence medical decision-making. (2) Content and framing of information: they desire information from a trusted resource that helps promote prenatal health and provides neonatal intensive care information. (3) Displaying content: parents want personalization, push notifications, photographs displaying fetal development, and easy-to-understand statistics. (4) Providing information without causing harm: they desire non–value-laden information, and they do not support “gamifying” the app to enhance utilization. (5) Decision making: parents want information that would benefit their decision making without assuming that parents have a certain outlook on life or particular values. Implications for Practice: These findings support the need for the P3 App to aid in decision making when parents experience preterm birth. Implications for Research: The findings highlight the need to study the effects of smartphone-based prematurity education on medical decision-making. Correspondence: Mir A. Basir, MD, MS, Department of Pediatrics, Medical College of Wisconsin, Ste CCC-410, 8701 Watertown Plank Rd, Milwaukee, WI 53226 (mbasir@mcw.edu). This project was supported by the National Center for Advancing Translational Sciences, National Institutes of Health (NIH) (grant no. UL1TR001436). Its content is solely the responsibility of the authors and do not necessarily represent the official views of NIH. The authors have no conflict of interest relevant to this article to disclose. © 2019 by The National Association of Neonatal Nurses

Kangaroo Mother Care in Hospitalized Low Birth-Weight Infants on Respiratory Support: A Feasibility and Safety Study Background: Low birth-weight (LBW) infants on respiratory support are often deprived of kangaroo mother care (KMC) due to fear of instability. Data on safety of KMC in these infants are lacking. Primary Objective: To determine the feasibility of KMC in LBW infants on continuous positive airway pressure or synchronized intermittent mandatory ventilation. Secondary Objectives: To compare vital signs (heart rate [HR], respiration, temperature, and SpO2) and ventilatory parameters (FIO2, peak inspiratory pressure [PIP], and positive end-expiratory pressure [PEEP]) before, during, and after KMC, and assess the mother's perception of the KMC intervention. Methods: LBW infants stable on respiratory support were given KMC for 1 hour. Vital signs and ventilator parameters were recorded before, every 15 minutes during and after KMC. Feasibility was defined as continuation of KMC for 1 hour without interruption, with stable vital signs (HR > 100/min, SpO2 > 90%, and temperature 36.5°C-37.5°C) and ventilator parameters (no change in PIP, PEEP, or increase in FIO2 not more than 0.1) without tube dislodgement. Results: Twenty LBW infants with a mean birth weight of 1390 ± 484 g were included. All infants completed 1-hour duration of KMC without interruption. No significant changes in temperature, respiratory rates, or saturations were noted. The HR and FIO2 were marginally higher during KMC than before or after (HR before 147.3 ± 11.5, during 150.8 ± 11, and after 147.3 ± 11.1, P = .04; FIO2 before 30.6 ± 8.1, during 31.8 ± 8.1, and after 30.7 ± 8.0, P = .034). No accidental extubation or dislodgement of lines occurred. Most mothers were happy. Implications for Practice: The vital signs were stable during KMC. KMC is feasible in infants receiving respiratory support. Implications for Research: Effectiveness of early initiation and prolonged duration of KMC. Correspondence: Suman PN Rao, MD, DM, Department of Neonatology, St John's Medical College Hospital, Sarjapur Rd, Koramangala, Bangalore 560034, India (raosumanv@gmail.com). Dr Bisanalli conceived, designed, collected, and drafted the manuscript; Dr Rao conceived, supervised the research, and edited the manuscript and act as a guarantor for this article; Ms Nesargi analyzed and edited the manuscript; and Dr Govindu helped with analysis and edited the manuscript. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.advancesinneonatalcare.org). © 2019 by The National Association of Neonatal Nurses

Chlorhexidine Gluconate Utilization for Infection Prevention in the NICU: A Survey of Current Practice Background: Central-line-associated bloodstream infection (CLABSI) contributes to significant morbidity and mortality in the neonatal intensive care unit (NICU). Disinfection of skin is part of bundled cares aimed at prevention of CLABSI. While considered an essential component of insertion and maintenance bundles, the optimal solution to disinfect neonatal skin remains controversial. Purpose: The purpose of this project was to survey neonatal nurse practitioners and nursing leaders across NICUs regarding the current use of chlorhexidine gluconate (CHG) in term and preterm infants. Methods: This descriptive study involved the collection of survey data to determine NICU practices related to the use of CHG in their infant population. The sample was composed of nursing directors of NICUs and neonatal nurse practitioners who completed an electronic survey via a provided link. Findings/Results: Chlorhexidine was reported to be used in 53 (82.81%) of the NICUs and was the primary agent used to prepare the skin for central vascular catheter insertion (53.23%) followed by povidone-iodine (45.16%), and 70% isopropyl alcohol (1.61%). Gestational age or birth weight restrictions for CHG use were reported in 43 (82.69%) NICUs. Trends in the data demonstrated nursing's role in using CHG in the NICU. Adverse events reported from CHG included burns, redness, dermatitis, and other irritations. Concerns included risk of absorption, burns, skin irritation, lack of evidence, and overall safety. Implications for Practice: Systematic monitoring by nurse leaders is needed to identify evidence related to skin disinfection and CHG in neonates. Targeted education for nursing staff related to directed to developmental maturation of the skin, safe use of CHG, review of best evidence, rationale for usage of CHG, and potential iatrogenic effects is recommended. Implications for Research: Research is needed to evaluate the impact of educational offerings and surveillance for adverse events on CLABSI rates. Correspondence: Karen Beekman, MS, RNC-NIC, NNP-BC, ACCNS-N, Dayton Children's Hospital, One Children's Plaza, Dayton, OH 45404 (beekmankk@childrensdayton.org). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.advancesinneonatalcare.org). The authors declare no conflicts of interest. © 2019 by The National Association of Neonatal Nurses

Acute Kidney Injury Guidelines Are Associated With Improved Recognition and Follow-up for Neonatal Patients Background: Studies demonstrate that neonatal acute kidney injury (AKI) is associated with increased morbidity and mortality. Acute kidney injury survivors are at risk for renal dysfunction and chronic kidney disease and require long-term follow-up. Purpose: To maximize identification of AKI and ensure referral, we created guidelines for diagnosis, evaluation, and management of AKI. Methods/Search Strategy: Retrospective cohort study of neonatal intensive care unit patients treated before guideline implementation (cohort 1; n = 175) and after (cohort 2; n = 52). Outcome measures included AKI incidence, documented diagnosis, and pediatric nephrology consultation. Statistical methods included t tests, Fisher exact tests, and Wilcoxon rank sum tests. Findings/Results: We found 68 AKI episodes in 52 patients in cohort 1 and 15 episodes in 12 patients in cohort 2. Diagnosis and documentation of AKI improved after guideline implementation (C1:24/68 [35%], C2: 12/15 [80%]; P= .003) as did pediatric nephrology consultation (C1:12/68 [18%]; C2: 12/15 [80%]; P< .001) and outpatient referral (C1: 3/47 [6%], C2:5/8 [63%]; P< .01). Implications for Practice: Neonatal AKI guideline implementation was associated with improvements in recognition, diagnosis, and inpatient and outpatient nephrology consultation. Early recognition and diagnosis along with specialist referral may improve outcomes among neonatal AKI survivors, ensuring appropriate future monitoring and long-term follow-up. Implications for Research: Future research should continue to determine the long-term implications of early diagnosis of AKI and appropriate subspecialty care with follow-up. Correspondence: Katherine Vincent, NNP, Department of Pediatrics, Division of Neonatology, Medical University of South Carolina, 165 Ashley Ave, Charleston, SC 29425 (vincentk@musc.edu). All work for this study was performed at the Medical University of South Carolina in Charleston, Charleston, South Carolina. The data were presented as poster presentation at the Southern Society Pediatric Research 2018 Regional Meeting and at the 2018 3rd International Symposium on Acute Kidney Injury in Children and were presented as an oral presentation at the 2018 Darby Children's Research Institute and Pediatric Research Day and at the 2019 National Association of Neonatal Nurses Research Summit. The authors report no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.advancesinneonatalcare.org). © 2019 by The National Association of Neonatal Nurses

Malassezia furfur Emergence and Candidemia Trends in a Neonatal Intensive Care Unit During 10 Years: The Experience of Fluconazole Prophylaxis in a Single Hospital Background: Because Candida spp is a major cause of mortality and morbidity in preterm infants, fluconazole prophylaxis has been suggested by some experts and hospital policy. In our hospital, fluconazole prophylaxis was used in eligible preterm infants and set as the neonatal intensive care unit (NICU) practice in 2014. Purpose: This study focused on fungal bloodstream infections and aimed to evaluate the benefit and harm of fluconazole prophylaxis. Methods/Search Strategy: This retrospective, descriptive study involved medical record reviews in our hospital from April 2005 to October 2016. NICU patients were included if Candida species, yeast-like organisms, or Malassezia species were cultured from their venous catheter tips or blood cultures. Findings/Results: After fluconazole prophylaxis, cases of Candida spp decreased and those of Malassezia furfur emerged. We reviewed 19 cases of catheter-related M furfur colonization and 1 case of M furfur fungemia. The gestational age was 27.3 ± 2.0 weeks and birth weight was 959.2 ± 229.8 g. Hyperalimentation with lipid infusion was used in all cases. All of the neonates survived with antifungal agent use. Implications for Practice: This study highlights that prophylactic fluconazole may be an associated factor of Malassezia colonization; M furfur remains a potential concern for fungemia in the care of premature infants and thus requires our attention. Implications for Research: Future studies should further investigate the incidence and impact of noncandidal fungal infections with fluconazole prophylaxis use in premature infants. Correspondence: Kuang-Che Kuo, MD, Division of Infectious Disease, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 123, Dapi Rd, Niaosong District, Kaohsiung City 833, Taiwan, ROC (light@cgmh.org.tw). The authors declare no conflicts of interest. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. © 2019 by The National Association of Neonatal Nurses

Improving Staff Knowledge and Attitudes Toward Providing Psychosocial Support to NICU Parents Through an Online Education Course Background: Provider–parent communication is a critical determinant of how neonatal intensive care unit (NICU) parents cope, yet staff feel inadequately trained in communication techniques; many parents are not satisfied with the support they receive from hospital providers. Purpose: This study evaluated whether NICU staff would demonstrate improved knowledge and attitudes about providing psychosocial support to parents after taking an online course. Methods: After providing demographic information, staff at 2 NICUs took a 33-item survey both before and after taking a 7-module online course “Caring for Babies and Their Families,” and again at 6-month follow-up. Scores (means ± standard deviation) from all time periods were compared and effect sizes calculated for each of the course modules. Results: NICU staff participants (n = 114) included nurses (88%), social workers (7%), physicians (4%), and occupational therapists (1%). NICU staff showed significant improvement in both knowledge and attitudes in all modules after taking the course, and improvements in all module subscores remained significant at the 6-month follow-up mark. Night staff and staff with less experience had lower pretest scores on several items, which improved on posttest. Implications for Practice: This course, developed by an interprofessional group that included graduate NICU parents, was highly effective in improving staff knowledge and attitudes regarding the provision of psychosocial support to NICU parents, and in eliminating differences related to shift worked and duration of work experience in the NICU. Implications for Research: Future research should evaluate course efficacy across NICU disciplines beyond nursing, impact on staff performance, and whether parent satisfaction with care is improved. Correspondence: Sue L. Hall, MD, 145 N. Crimea Street, Ventura, CA 93001 (suehallmd@gmail.com). This work was supported in part by unrestricted support from Medela, The Wellness Network, and Prolacta Bioscience. Dr. Hall is a consultant for The Wellness Network. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.advancesinneonatalcare.org). This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. © 2019 by The National Association of Neonatal Nurses

Pharmacologic Management of Neonatal Abstinence Syndrome Using a Protocol Background: The opioid epidemic in the United States has reached unprecedented proportions with far-reaching impacts on the most vulnerable population. The number of neonates born addicted to opioids has grown exponentially over the last several decades, leading to increased neonatal intensive care unit admissions and rising healthcare costs. Recent studies have yielded mixed results regarding which medication is most effective at relieving the symptoms of opioid withdrawal and reducing the weaning timeframe for babies with neonatal abstinence syndrome (NAS). Purpose: To explore and compare the effectiveness of morphine versus methadone in the treatment for NAS using a standardized protocol. Method: A literature search of PubMed and CINAHL was performed. The search yielded 10 quantitative studies that were analyzed for potential practice changes. Conclusion: Based on current literature, following a standardized, stringent weaning protocol is more beneficial than the pharmacologic agent used. Studies reveal shorter weaning times and hospital stays in almost every group that followed rigid guidelines. Implication for Research: Although current studies are promising for the desired outcome, more research is needed to develop appropriate protocol-based weaning regimens for management of NAS. Implication for Practice: As the occurrence of NAS continues to rise, its management must vigorously meet the challenges of the diagnosis. Institutions should reevaluate their current protocols based on reassuring data showing that stringent guidelines using morphine or methadone can improve clinical outcomes, reduce hospital length, and lower healthcare costs. Correspondence: Lieutenant Brandi L. Gibson, MSN, RN, RNC-NIC, Nurse Corps, US Navy, Duke University School of Nursing, Box 3322, Durham, NC 27710 (Brandi.gibson@duke.edu). All the authors have read and approved this article for publication and have all contributed equal substance to this work. This manuscript has not been submitted for consideration by another journal. The views expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the US Government. LT Gibson is a military service member. This work was prepared as part of her official duties Title 17, USC, §105 provides that “Copyright protection under this title is not available for any work of the U.S. Government.” Title 17, USC, §101 defines a “U.S. Government work as a work prepared by a military service member or employees of the U.S. Government as part of that person's official duties.” Written work prepared by employees of the Federal Government as part of their official duties is, under the US Copyright Act, a “work of the United States Government” for which copyright is not available. As such, copyright does not extend to the contributions of employees of the Federal Government. The authors declare no conflicts of interest. © 2019 by The National Association of Neonatal Nurses

Use of Potassium Hydroxide (KOH) Test Reduces Antifungal Medication Prescription for Suspected Monilial Diaper Dermatitis in the Neonatal Intensive Care Unit: A Quality Improvement Project Background: Despite availability of rapid fungal potassium hydroxide (KOH) tests, many care providers rely on visual assessment to determine the diagnosis of monilial diaper dermatitis (MDD). Purpose: To determine whether a KOH test, when MDD is suspected, would result in more accurate diagnoses, with decreased antifungal medication prescription and exposure. Methods: Quality improvement project from 2016 through 2017 with protocol implemented in 2017 for treatment of MDD after positive KOH testing. If monilial rash suspected, after 2 negative KOH tests, then antifungal ordered (considered false negative). χ2 testing and cost determination were performed. Sample: Neonates in 2 level III neonatal intensive care units. Outcome Variables: KOH test results, use of antifungal medication, and cost. Results: The patient census included 1051 and 1015 patients in the year before and after the protocol initiation. The medical orders for antifungal medication decreased from 143 to 36 (P < .001; 95% odds ratio confidence interval, 2.24-4.38). There was a 75% reduction in both use and cost, as charged, of antifungal agents. Overall charges, including KOH test costs, decreased by 12%. Three infants received multiple negative KOH tests, then a positive one. These met the definition of false-negative tests, per protocol. There were no cases of fungal sepsis. Implications for Practice: Use of a quality improvement protocol, in which the use of KOH testing is required, before antifungal agents are prescribed, results in decreased exposure and costs. Implications for Research: To test the feasibility of bedside “point-of-care” KOH testing, and whether KOH testing and reduced antifungal medication use affects antimicrobial resistance or invasive fungal sepsis. Correspondence: Elena Bosque, PhD, ARNP, NNP-BC, Department of Neonatology, Seattle Children's Hospital, PO Box 5371/M1-12, Seattle, WA 98145 (elena.bosque@seattlechildrens.org). The authors declare no conflicts of interest. © 2019 by The National Association of Neonatal Nurses

Improving the Efficiency and Effectiveness of Parent Education in the Neonatal Intensive Care Unit Background: March of Dimes partners with hospitals across the country to implement NICU Family Support (NFS) Core Curriculum, a program providing education to parents in neonatal intensive care units (NICUs) across the country. Purpose: This NFS project's goal was to increase the efficiency and effectiveness of NICU parent education by establishing consistency, improving quality, and identifying best practices. Methods/Search Strategy: A 5 topic curriculum was developed and implemented across NFS program sites. The project studied 4 main outcomes of interest related to efficiency and effectiveness: increase in parenting confidence, parent learning, knowledge change, and satisfaction. Data were collected from speakers and attendees immediately following educational sessions. Analytical approaches included descriptive statistics such as frequency, percentage, and response rate, and inferential approaches such as t test, χ2, and analysis of variance. Findings/Results: Findings suggest that the NFS Core Curriculum improved both program efficiency and effectiveness. Sessions fully implemented according to recommended strategies had better outcomes than sessions not fully implemented according to recommended strategies (P < .0001). Across the 3648 attendees at 41 sites, 77% of parents reported learning “a lot” at the session they attended and 85% of attendees reported increased confidence. Attendees also reported positive knowledge change and high satisfaction. Implications for Practice: Parent education best practices identified through this initiative can be utilized for future NFS Core Curriculum topics and potentially generalized to all NICU parent education and family education in other hospital intensive care units. Implications for Research: Content and best practices identified through this project will require regular review to ensure medical accuracy and appropriateness of best practices as the physical design of NICUs evolves. Correspondence: Lori G. Gunther, MS, March of Dimes, 1550 Crystal Dr, Ste 1300, Arlington, VA 22202 (loriggunther@gmail.com). The authors declare no conflicts of interest. © 2019 by The National Association of Neonatal Nurses

Systematic Review of the Effects of Skin-to-Skin Care on Short-Term Physiologic Stress Outcomes in Preterm Infants in the Neonatal Intensive Care Unit Background: Infants in the neonatal intensive care unit (NICU) are exposed to many stressors. There is growing evidence that chronic stress early in life has long-term neurodevelopmental implications. Skin-to-skin care (SSC) is an intervention used to reduce stress in the NICU. Clinical Question: In premature infants in the NICU, what is the available evidence that SSC improves short-term physiologic stress outcomes compared with incubator care? Search Strategy: PubMed and CINAHL were searched for terms related to SSC, stress, physiology, and premature infants. Of 1280 unique articles, 19 were identified that reported on research studies comparing SSC with incubator care in the NICU and reported stress-related physiologic outcome measures. Results: Although there have been some mixed findings, the research supports that SSC improves short-term cardiorespiratory stress outcomes compared with incubator care. The evidence is clearer for studies reporting stress hormone outcomes, with strong evidence that SSC reduces cortisol and increases oxytocin levels in preterm infants. Implications for Practice and Research: SSC is safe and has stress-reducing benefits. SSC should be considered an essential component to providing optimal care in the NICU. More research is needed to determine the timing of initiation, duration, and frequency of SSC to optimize the stress-reducing benefits. Future research should include the most fragile infants, who are most likely to benefit from SSC, utilize power analyses to ensure adequate sample sizes, and use sophisticated data collection and analysis techniques to more accurately evaluate the effect of SSC on infants in the NICU. Correspondence: Britt Frisk Pados, PhD, RN, NNP-BC, Boston College William F. Connell School of Nursing, Maloney Hall 268, 140 Commonwealth Ave, Chestnut Hill, MA 02467 (britt.pados@bc.edu). Institution Where Work Occurred: Boston College. The authors declare no conflicts of interest. © 2019 by The National Association of Neonatal Nurses