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NeoReviews

contents

NeoReviews

o ers 24 CME articles per year. A maximum of one

AMA PRA Category 1 Credit

TM is earned after achieving a

60% score on each designated quiz.

CME statements:

The American Academy of Pediatrics (AAP) is accredited by the Accreditation Council for Continuing Medical Education

(ACCME) to provide continuing medical education for physicians. The AAP designates this journal-based CME activity for a maximum of 1.00 AMA PRA Category 1 Credit TM . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This activity is acceptable for a maximum of 1.00 AAP credit. These credits can be applied toward the AAP CME/CPD* Award

available to Fellows and Candidate Members of the AAP.

The American Academy of Physician Assistants (AAPA) accepts certi cates of participation for educational activities certi ed

for

AMA PRA Category 1 Credit

TM from organizations accredited by ACCME. Physician assistants may receive a maximum of 1.00 hour of Category 1 Credit for completing this program.

This program is accredited for 1.00 NAPNAP CE contact hour; pharmacology (Rx) and psychopharmacology contact hours to be

determined per the National Association of Pediatric Nurse Practitioners (NAPNAP) Continuing Education Guidelines.

It has been established that each CME activity will take the learner approximately 1 hour to complete.

*Continuing Professional Development

How to complete this activity

NeoReviews

can be accessed and reviewed in print or online at http://neoreviews.aappublications.org. Learn ers can claim

credit monthly online upon completion of each CME article. The deadline for completing this activity is December 31, 2019.

Credit will be recorded in the year in which it is submitted. It is estimated that it will take approximately 1 hour to complete

each CME article. This activity is not considered to have been completed until the learner documents participation in that

activity to the provider via online submission of answers. Course evaluations are online.Editor-in-Chief: Alistair G.S. Philip, Palo Alto, CA

Deputy Editor:

Dara Brodsky, MD,

Boston, MA

Associate Editor:

Josef Neu, Gainesville, FL

Assistant Editor, CME:

Henry C. Lee, Palo Alto, CA

Editorial Fellow:

Alison Chu, Los Angeles, CA

EDITORIAL BOARD

Rita Dadiz, Rochester, NY

Sergio Golombek,

Valhalla, NY

Joseph R. Hageman, Evanston, IL

Ivan Hand,

Brooklyn, NY

Martin Keszler, Providence, RI

Karen M. Puopolo, Philadelphia, PA

Renate D. Savich, Jackson, MS

Michael P. Sherman,

Columbia, MO

Akshaya J. Vachharajani, St. Louis, MOThomas E. Wiswell, Honolulu, HISantina A. Zanelli, Charlottesville, VA

Founding Editor:

William W. Hay Jr,

Denver, CO

International Advisory Board:

Malcolm Battin,

Auckland, New Zealand

Matts Blennow,

Stockholm, Sweden

Jose Diaz Rossello,

Montevideo, Uruguay

Jeanie Cheong, Victoria, Australia

Lizhong Du, Hangzhou, Zhejiang, P.R. China

Janusz Gadzinowski,

Poznan, Poland

Gorm Greisen,

Copenhagen, Denmark

Hercilia Guimarães, Maia, Portugal

Kazushige Ikeda,

Tokyo, Japan

Helen Mactier,

Glasgow, Scotland

Jorge César Martinez,

Buenos Aires, Argentina

Frank Pohlandt,

Ulm, Germany

Francesco Raimondi,

Naples, Italy

Siddarth Ramji,

New Delhi, India

Eric Shinwell,

Jerusalem, Israel

Umberto Simeoni,

Marseille, France

Bo Sun, Shanghai, China

Cleide Trindade, Sao Paolo, Brazil

Maximo Vento,

Valencia, Spain

Andrew Whitelaw,

Bristol, United Kingdom

David Woods,

Cape Town, South Africa

Tsu-Fuy Yeh,

Taichung, Taiwan

Khalid Yunis,

Beirut, Lebanon

Liaison, NeoReviewsPlus Self-Assessment

William A. Engle,

Indianapolis, IN

Liaison, Council on International Neonatal Nurses:

Carole Kenner,

Ewing, NJ

Liaison, National Association for Neonatal Nurses:

Carol Wallman, Denver, CO

Managing Editor:

Luann Zanzola

Publications Editor:

Sara Strand

Pu blisher: American Academy of Pediatrics

Department of Publishing Director: Mark Grimes

Division of Journal Publishing Director:

Joseph Puskarz

NeoReviews"

(ISSN 1526-9906) is owned and controlled by the American Academy of Pediatrics. It is published monthly by the American Academy of Pediatrics, 141 Northwest Point Blvd., Elk Grove Village, IL 60007-1098. Statements and opinions expressed in NeoReviews" are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees. Recommendations included in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Subscription price for NeoReviews" for 2017: AAP/CPS Member $125; AAP National Affiliate Member $95; Nonmember $160; AAP In-Training Member, $95; Nonmember In-Training / Allied Health, $115; AAP Perinatal Section Member $115. Institutions call for pricing (866-843-2271). © AMERICAN ACADEMY OF PEDIATRICS, 2017. All rights reserved. Printed in USA. No part may be duplicated or reproduced without permission of the American Academy of Pediatrics. POSTMASTER: Send address changes to NEOREVIEWS", American Academy of Pediatrics, 141 Northwest Point Blvd., Elk Grove Village, IL 60007-1098.

NeoReviews

" is supported, in part, through an educational grant from Abbott Nutrition, a division of Abbott Laboratories, Inc.

NeoReviews" Editorial Board Disclosures

The American Academy of Pediatrics (AAP) Policy on Disclosure of Financial Relationships and Resolution of Conflicts of Interest for AAP CME Activities is designed to ensure quality, objective, balanced, and scientifically rigorous AAP CME activities by identifying and resolving all potential conflicts of interest before the confirmation of service of those in a position to influence and/or control CME content. All individuals in a position to influence and/or control the content of AAP CME activities are required to disclose to the AAP and subsequently to learners that the individual either has no relevant financial relationships or any financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in CME activities. Commercial interest is defined as any entity producing, marketing, reselling or distributing health-care goods or services consumed by, or used on, patients. Each of the editorial board members, reviewers, question writers, and staff has disclosed, if applicable, that the CME content he/she edits/ writes/reviews may include discussion/reference to generic pharmaceuticals, off-label pharmaceutical use, investigational therapies, brand names, and manufacturers. None of the editors, board members, reviewers, question writers, or staff has any relevant financial relationships to disclose unless noted below. The AAP has taken steps to resolve any potential conflicts of interest.

Disclosures

€ Sergio Golombek, MD, MPH, disclosed that he is on the speaker bureau of IKARIA, Inc.; has a clinical trial relationship with Chiesi, Inc.; and is on the speaker bureau and has honoraria support from Prolacta Bioscience, Inc.

€ Carole Kenner, PhD, RN, disclosed that she had a grant for education/research from Novo Nordisk.

€ Martin Keszler, MD, has disclosed that he has a research grant for a multicenter clinical trial

and has received speaker honoraria from Draeger Medical, Inc.; and that he participates in Data Safety Monitoring Boards with Chiesi Pharmaceutical, Medipost America, Inc., and Therabron Therapeutics, Inc. Medipost America, Inc. € Josef Neu, MD, has disclosed he has research grants and serves on the Scientific Advisory Boards of Medala and Infant Bacterial Therapeutics. € Carol Wallman, DNP, APRN, NNP-BC, has disclosed she has stocks/bonds with Biogen and

CVS Health.

€ Thomas Wiswell, MD, disclosed that he is a member of a Data Safety Monitoring Board with Draeger Medical, Inc. COMMENTARY e1 Coming Down the Home Stretch

Alistair G.S. Philip

ARTICLES

e3 The Status of US Neonatal Nurse Practitioner

Education in 2015...2016

Roger E. Sheldon, Robin Bissinger, Carole Kenner,

Suzanne Staebler

e22 What"and Why"the Neonatologist Should

Know About Twin-To-Twin Transfusion

Syndrome

Joseph M. Bliss, Stephen R. Carr, Monique E. De Paepe,

Francois I. Luks

e33 Diabetes Mellitus in Pregnancy Desmond M. Sutton, Christina S. Han, Erika F. Werner e44 Primer on Microcephaly Alison Chu, Taylor Heald-Sargent, Joseph R. Hageman e52 Seizures in the Preterm Neonate

Lekha M. Rao, Charles J. Marcuccilli

e60 Legal Briefs: Did Vacuum Extraction Use

Cause Brain Injury?

Maureen E. Sims

INDEX OF SUSPICION IN THE NURSERY

e63 Case 1: Seizures and Rashes Do Run in the Family Amit Hochberg, Sylvia Foldi, Erez Nadir, Roni Shreter,

Muhammad Mahajnah, Michael Feldman

e67 Case 2: The Inconsolable Newborn

Marina Migliore

e70 Visual Diagnosis: Sudden Onset of Neurologic

Dysfunction in a Preterm Infant

Vidit Bhargava, Soham Dasgupta, Monica Hu , Sunil K. Jain e75 Strip of the Month: January 2017

Maurice L. Druzin, Nancy Peterson

Answer Key appears on page e83.Vol. 18 No. 1 January 2017

Coming Down the Home Stretch

As many readers know,NeoReviewsrst appeared in print form as an addendum toPediatrics in Reviewduring the last 6 months of 1999. Since January 2000, we have been an online-only journal, with rather limited content for therst 2 or 3 years. I joined the editorial group in 2001, became still in that position a decade later. Our goal has been to center each issue around a theme, with several of each months main articles covering many of the content specications of the Amer- ican Board of Pediatrics (ABP) Sub-board of Neonatal-Perinatal Medicine, to help our readers prepare for their ABP examinations. These themes also have tried to reect the proportions of various subspecialties appearing within the ABP ex- amination in neonatal-perinatal medicine (eg, respiratory disorders, cardiovascu- lar disorders, infectious diseases, neurology, etc), although some issues ended up asmiscellaneous!Ž In addition to the main articles, our content broadened over the years to include a number of regular sections, beginning withPerspectives,Žinitially Historical,then Internationaland Educational, andmost recently,Nursing.In the current issue, we include a piece that pertains to both Educational and Nursing aspects. Other sections that appeared sporadically were Pharmacology Reviews, Neonatal Informatics and, more recently, Complex Fetal Care. In addition, we began to include cases for Visual Diagnosis, Strip of the Month, Index of Suspicion in the Nursery, and Legal Briefs. These are now entrenched and have more recently been joined by Video Corner (uniquely suited to the online-only format), which allows us to present routine procedures as well as unusual clinical features. I stopped providing clinical care to neonates approximately 10 years ago and, despite attempting to stay abreast of recent developments, the ability to remaintuned inŽhas become increasingly difcult. One might use the old expression,The spirit is willing, but theesh is weak.ŽConsequently, this seems the appropriate time for me to step down as the editor-in-chief, and IplantodothisinJuly2017.Atthattime,Iwillpass the batonŽto my successor, Dara Brodsky, MD, who has served on the editorial board for several years and most recently has served as the deputy editor. I have no doubt that she will continue to move the journal forward and provide a fresher perspective. It has been a privilege to serve the AAP for more years than I originally intended, and I would like to acknowledge the signicant assistance I have the years have accumulated. In the early years of my career, it was an incredibly exciting time to be involved with neonatology. Many of the advances I witnessed have been

Commentary

Vol. 18 No. 1JANUARY 2017e1

documented in the Historical Perspectives that we pub- lished in the journal (also collected in the booksMilestones in Neonatal/Perinatal MedicineandPioneers in Neonatal/ Perinatal Medicinepublished by AAP in 2010 and 2015, respectively). For example, as a pediatric resident, I noted the mor- tality rate for a 1-kg infant was approximately 90%,

but within 30 years the survival rate for such an infantwas over 90%! While the pace of discovery has per-

haps slowed in recent years, continued modications and renements resulting from multicenter studies mean that care of the fetus and newborn will get even better in the years to come. I will be watching from the sidelines.

Alistair G.S. Philip, MD

Editor-in-Chief

e2NeoReviews

The Status of US Neonatal Nurse Practitioner

Education in 2015...2016

Roger E. Sheldon, MD, MPH,* Robin Bissinger, PhD, APRN,

Carole Kenner, PhD, RN, NNP,

x{

Suzanne Staebler, DNP, APRN, NNP-BC

*Department of Pediatrics, University of Oklahoma College of Medicine, Oklahoma City, OK

National Certication Corporation, Chicago, IL

Medical University of South Carolina, Charleston, SC x Council of International Neonatal Nurses, Yardley, PA School of Nursing, The College of New Jersey, Ewing, NJ **Nell Hodgson Woodruff School of Nursing at Emory University, Atlanta, GA

Education Gaps

Neonatologists and neonatal nurse practitioners (NNPs) may be unaware of the rising demand for NNPs, and the internal and external factors affecting NNP educational programs, which may hamper the ability of programs to educate NNPs and increase student enrollment.

Abstract

Numerous graduate nursing programs have been established across the United States in the last 30 years or more to prepare nurses for the expanded role of the neonatal nurse practitioner (NNP). These programs were initially hospital-based certicate programs open to nurses with diplomas or associate"sdegreesaswell as those with bachelor"s degrees, and they ranged from 6 to 9 months in length, including didactic and clinical components. In the 1980s, these NNP programs moved into schools of nursing and became part of the Master of Science in and lasting 1 to 2 additional years. In the past decade, many colleges of nursing have taken the position that the knowledge required and the responsibilities assumed by NNPs (and all other advanced practice nurses) are more consistent degree-typically requiring 3 or more additional years of study after the baccalaureate.DNPprogramsforNNPpreparationhave nowbeenestablishedin several locations, sometimes replacing existing MSN programs. Due to concerns over closure of NNP programs and the changes related to DNP preparation, we degrees. We describe the status of these programs in 2015, along sustain the future of this important specialty nursing practice. ObjectivesAfter completing this article, readers should be able to:

1. Describe the historical progression of neonatal nurse practitioner (NNP)

education and its current status.

AUTHOR DISCLOSUREDrs Sheldon,

nonancial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

ABBREVIATIONS

AACN

American Association of Colleges

of Nursing

APRNadvanced practice registered

nurse

DNPDoctor of Nursing Practice

MSNMaster of Science in Nursing

NCCNational Certication Corporation

NICUneonatal intensive care unit

NNPneonatal nurse practitioner

SARAState Authorization ReciprocityAgreement

Vol. 18 No. 1JANUARY 2017e3

2. Dene trends in student enrollment, graduation rates, and program types

in NNP education.

3. Discuss the implications of NNP workforce needs and challenges for NICU

care and neonatal outcome nationally as numbers of infant patient-days rise.

4. Formulate strategies for mitigating these implications in ones own

practice.

INTRODUCTION

The practice of neonatal nurse practitioners (NNPs) has steadily evolved into a vital component of care in NICUs across theUnitedStates overthelast40years.(1)Amajority of level III and IV NICUs now use NNPs with anticipation of rising workforce needs in the future. (2) This trend, supported by neonatologists and the American Academy of Pediatrics, (3)(4) is part of the larger trend of advanced practice registered nurses (APRNs) providing care across many spe- cialties. NNPs are, however, distinct from most nurse practi- tioners in that they are highly focused not on primary care, but on the intensive, in-hospital care of critically ill newborn infants. Competence in this role requires extensive and uniquely specialized education and NICU clinical training. NNPs provide critical care around the clock including specialized history taking and physical examination, order- ing and interpreting tests, prescribing treatments, directing umbilical artery or vein catheterization, exchange transfusion, percutaneous central venous cannulation, and chest tube insertion. (5) In the late 1970s, certicate programs were developed to prepare nurses with a knowledge base and set of technical skills that were traditionally considered the purview of the physician. In the 1980s, masters degree programs (those granting the Master of Science in Nursing [MSN] degree) were established in nursing colleges in collaboration with other nurse practitioner programs. Currently all but 4 states require graduate degrees and national certication for APRN practice. (6) It is difcult to track programs because of the frequentux in their status of admitting students. In 2004, the American Association of Colleges of Nurs- ing (AACN) published a position paper advocating that entry into practice for APRNs be at the doctoral level, granting the

Doctorof Nursing Practice(DNP)degreeeffectivein2015.(7)(8)This recommendation was based on increasing program

content/requirements to prepare graduates to practice in the changing complexity of the health care system. AACNs goal was enhanced educational preparation that would lead to degree parity with other health professionals and assist graduates in assuming leadership roles in clinical practice, teaching, and policy development. In 2006, AACN pub- lished theEssentials of Doctoral Education for Advanced Nursing PracticeŽand anal report of theTask Force on the Roadmap to the DNP

Žwhich outlines the transition of

programs from MSN to DNP. (9) As this change has now begun to take effect, MSN pro- grams are decreasing in number because some have closed while others have morphed into DNP programs. (10) Increasing NNP workforce demand is partially due to changes in the Accreditation Council for Graduate Medical Educations pediatric residency training requirements. (11) Both a decrease in pediatric resident work hours and re- NNPs to provide care for this vulnerable population. At the same time, NICU patient days are also trending upward. (12) notable in NNP programs preparing DNPs, because many NNPs prepared in doctoral-level, nationally certied pro- grams choose practice over teaching fornancial reasons. According to NCCs data, only 3.3% of certied NNPs are prepared at the doctoral level, earning either the doctorate of philosophy (PhD) or DNP degrees. These faculty issues reduce the ability of programs to increase student numbers to meet the growing demand. Although the annual number of graduates has increased slowly since 2013, it has not returned to the number seen in 2012 and before. As the demand for NNPs increases, the shortage will continue to worsen unless the number of graduates is increased. In response to a lack of information about numbers of programs, and numbers of students and graduates, along with uncertainty about the programsexpected changes over the near future, we surveyed all the NNP programs known to e4NeoReviews the National Certication Corporation (NCC), the organization that offers the national certication examination for NNPs.

METHODS

We surveyed 38 NNP programs from which NCC had received applications, with 32 of these programs having 2015 graduates eligible for certication. Twenty-seven programs responded to the survey for a response rate of 71%. Responses were received between July and December of 2015. We called some of the nonresponding programs and added some incomplete infor- survey are shown in Appendix A.quotesdbs_dbs22.pdfusesText_28

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