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vi C ontrib utors

Linda L. Gratny, MD Mona Jacobson, MSN, RN, CPNP-PC

Associate Professor of Pediatrics Instructor in Pediatrics
University of Missouri-Kansas City School of Medicine; Section of Child Neurology
Neonatologist and Director, Infant Tracheostomy and University of Colorado School of Medicine
Home Ventilator Program Children’s Hospital Colorado
Children’s Mercy Hospital Aurora, Colorado
Kansas City, Missouri
M. Douglas Jones, Jr., MD
Marie Hastings-Tolsma, PhD, CNM, FACNM Senior Associate Dean for Clinical Affairs
Professor, Nurse Midwifery Professor, Section of Neonatology
Louis Herrington School of Nursing Department of Pediatrics
Baylor University University of Colorado Denver School of Medicine
Dallas, Texas; Aurora, Colorado
Visiting Professor
University of Johannesburg Beena Kamath-Rayne, MD, MPH
Johannesburg, South Africa Assistant Professor of Pediatrics
Perinatal Institute, Division of Neonatology
William W. Hay Jr., MD Global Health Center
Professor of Pediatrics, Section of Neonatology Cincinnati Children’s Hospital Medical Center
Scientific Director, Perinatal Research Center Cincinnati, Ohio
Co-Director for Child and Maternal Health and the
Perinatal Research Center, Colorado Clinical and Rhonda Knapp-Clevenger, PhD, CPNP
Translational Sciences Institute Director, Research and Pediatric Nurse Scientist
University of Colorado School of Medicine and Center for Pediatric Nurse Research and Clinical Inquiry;
­Children’s Hospital Colorado Clinical Research Director, Pediatric and Perinatal
Aurora, Colorado Clinical Translational Research Centers
University of Colorado Denver, College of Nursing
Kendra Hendrickson, MS, RD, CNSC, CSP Children’s Hospital Colorado
Clinical Dietitian Specialist Aurora, Colorado
Neonatal Intensive Care Unit
University of Colorado Hospital Ruth A. Lawrence, MD, DD(Hon), FAAP, FABM
Aurora, Colorado Distinguished Alumna Professor of Pediatrics and
­Obstetrics/ Gynecology
Carmen Hernández, MSN, NNP-BC Northumberland Trust Chair in Pediatrics
Neonatal Nurse Practitioner Director of the Breastfeeding and Human Lactation
Rocky Mountain Hospital for Children Study Center
Denver, Colorado University of Rochester School of Medicine and ­Dentistry
Rochester, New York
Jacinto A. Hernández, MD, PhD, MHA, FAAP
Professor Emeritus of Pediatrics Mary Kay Leick-Rude, RNC, MSN, PCNS
Section of Neonatology Clinical Nurse Specialist
Department of Pediatrics Children’s Mercy Hospital
University of Colorado School of Medicine; Kansas City, Missouri
Chairman Emeritus Department of Neonatology
Children’s Hospital Colorado Harold Lovvorn III, MD, FACS, FAAP
Aurora, Colorado Assistant Professor of Pediatric Surgery
Vanderbilt University Children’s Hospital
Patti Hills, LMSW, LCSW Nashville, Tennessee
Fetal Health Center
NICU Social Worker
Children’s Mercy Hospital
Kansas City, Missouri
 Contrib u tors vii

Carolyn Lund, RN, MS, FAAN Priscilla M. Nodine, PhD, CNM

Neonatal Clinical Nurse Specialist
ECMO Coordinator
Neonatal Intensive Care Unit
UCSF Benioff Children’s Hospital-Oakland
Oakland, California;
Associate Clinical Professor
Department of Family Health Care Nursing
University of California
San Francisco, California
Marilyn Manco-Johnson, MD
Professor of Pediatrics, Section of Hematology
University of Colorado Denver and The Children’s
Hospital Colorado
Hemophilia and Thrombosis Center
Aurora, Colorado
Anne Matthews, RN, PhD, FACMG
Professor
Genetics and Genome Sciences
Director, Genetic Counseling Training Program
Case Western Reserve University
Cleveland, Ohio
Assistant Professor, Midwifery
College of Nursing
University of Colorado Anschutz Campus
Aurora, Colorado
Michael Nyp, DO, MBA
Assistant Professor of Pediatrics
University of Missouri-Kansas City
Division of Perinatal-Neonatal Medicine
Children’s Mercy Hospital
Kansas City, Missouri
Steven L. Olsen, MD
Associate Professor of Pediatrics
University of Missouri-Kansas City
Division of Neonatology
Children’s Mercy Hospital
Kansas City, Missouri
Annette S. Pacetti, RN, MSN, NNP-BC
Neonatal Nurse Practitioner
Monroe Carell, Jr. Children’s Hospital at Vanderbilt
Nashville, Tennessee

Jane E. McGowan, MD Eugenia K. Pallotto, MD, MSCE

Professor of Pediatrics Associate Professor
Associate Chair for Research University of Missouri-Kansas City School of Medicine
Drexel University College of Medicine Medical Director, NICU
Medical Director, NICU Children’s Mercy Hospital
St. Christopher’s Hospital for Children Kansas City, Missouri
Philadelphia, Pennsylvania
Mohan Pammi, MD, PhD, MRCPCH
Christopher McKinney, MD Associate Professor
Fellow, Pediatric Hematology Baylor College of Medicine
Center for Cancer and Blood Disorders Houston, Texas
Children’s Hospital Colorado
University of Colorado-Denver Alfonso Pantoja, MD
Aurora, Colorado Neonatologist
Saint Joseph’s Hospital
Mary Miller-Bell, PharmD Denver Colorado
Clinical Research Pharmacist
Duke University Hospital Julie A. Parsons, MD
Durham, North Carolina Associate Professor of Pediatrics and Neurology
Haberfield Family Endowed Chair in Pediatric
Susan Niermeyer, MD, MPH, FAAP Neuromuscular Disorders
Professor of Pediatrics and Epidemiology Child Neurology Program Director
University of Colorado School of Medicine and University of Colorado School of Medicine
Colorado School of Public Health Children’s Hospital Colorado
Aurora, Colorado Aurora, Colorado
viii C ontrib utors

Webra Price-Douglas, PhD, CRNP, IBCLC Danielle E. Soranno, MD

Maryland Regional Transport Program Assistant Professor of Pediatrics and Bioengineering
Baltimore, Maryland Pediatric Nephrology/The Kidney Center
University of Colorado Denver School of Medicine and
Daphne A. Reavey, PhD, RN, NNP-BC Children’s Hospital Colorado
Neonatal Nurse Practitioner Aurora, Colorado
Children’s Mercy Hospital
Kansas City, Missouri John Strain, MD, FACR, CAQ Pediatric Radiology, Neuroradiology
Professor of Radiology
Nathaniel H. Robin, MD, FACMG Department of Radiology
Professor of Genetics and Pediatrics University of Colorado School of Medicine;
University of Alabama at Birmingham Chairman, Department of Radiology
Birmingham, Alabama Children’s Hospital Colorado
Anschutz Medical Campus
Mario A. Rojas, MD, MPH Aurora, Colorado
Professor of Pediatrics
Division of Neonatal-Perinatal Medicine Julie R. Swaney, MDiv
Wake Forest University School of Medicine Manager, Spiritual Care Services
Winston Salem, North Carolina Associate Clinical Professor, Department of Medicine
University of Colorado Denver Anschutz Medical Campus
Jamie Rosterman, DO Aurora, Colorado
Neonatology Fellow
Children’s Mercy Hospital Tara M. Swanson, MD
Kansas City, Missouri Assistant Professor of Pediatrics
University of Missouri-Kansas City School of Medicine;
Paul Rozance, MD Director of Fetal Cardiology
Associate Professor of Pediatrics Children’s Mercy Hospital
Section of Neonatology Kansas City, Missouri
University of Colorado Denver School of Medicine
Children’s Hospital Colorado David Tanaka, MD
Aurora, Colorado Professor of Pediatrics
Neonatologist
Tamara Rush, MSN, RN, C-NPT, EMT Duke University Medical Center
Nurse Manager Durham, North Carolina
Brenner Children’s Hospital-Wake Forest Baptist Health
Winston-Salem, North Carolina Elizabeth H. Thilo, MD
Associate Professor of Pediatrics
Mary Schoenbein, BSN, RN, CNN Section of Neonatology
Perinatal Dialysis Nurse/The Kidney Center University of Colorado Denver School of Medicine;
Children’s Hospital Colorado Neonatologist
Aurora, Colorado University of Colorado Hospital and Children’s Hospital
Colorado
Alan R. Seay, MD Aurora, Colorado
Professor of Pediatrics and Neurology
University of Colorado School of Medicine Kristin C. Voos, MD
Children’s Hospital Colorado Neonatologist
Aurora, Colorado Children’s Mercy Hospital;
Associate Professor of Pediatrics
University of Missouri-Kansas City School of Medicine
Kansas City, Missouri

Susan M. Weiner, PhD, MSN, RNC-OB, CNS
Perinatal Clinical Nurse Specialist
Assistant Clinical Professor/Retired
Freelance Author/Editor
Philadelphia, Pennsylvania
Jason P. Weinman, MD
Assistant Professor of Radiology
University of Colorado School of Medicine
Medical Director Computed Tomography
Children’s Hospital Colorado
Aurora, Colorado
Contrib u tors ix
Leonard E. Weisman, MD
Professor of Pediatrics
Section of Neonatology
Baylor College of Medicine
Texas Children’s Hospital
Houston, Texas
Rosanne J. Woloschuk, RD
Clinical Dietitian
The Kidney Center
Children’s Hospital Colorado
Aurora, Colorado
 REVIEWERS
Nancy Blake, PhD, RN, NEA-BC, CCRN
Patient Care Services Director
Critical Care Services
Children’s Hospital Los Angeles
Los Angeles, California
Fran Blayney, RN-C, BSN, MS, CCRN
Education Manager
Pediatric Intensive Care Unit
Children’s Hospital Los Angeles
Los Angeles, California
Karen C. D’Apolito, PhD, NNP-BC, FAAN
Professor & Program Director
Neonatal Nurse Practitioner Program
Vanderbilt University School of Nursing
Nashville, Tennessee
Mary Dix, BSN, RNC-NIC
Staff Nurse
Neonatal Intensive Care Unit
PIH Health Hospital-Whittier
Whittier, California
Sharon Fichera, RN, MSN, CNS, NNP-BC
Neonatal Clinical Nurse Specialist
Children’s Hospital Los Angeles
Los Angeles, California
Joyce Foresman-Capuzzi, MSN, RN
Clinical Nurse Educator
Lankenau Medical Center
Wynnewood, PA
Delores Greenwood, MSN, RNC-NIC
Education Manager, Newborn and Infant Critical
Care Unit
Children’s Hospital Los Angeles
Los Angeles, California
x
Nadine A. Kassity-Krich, MBA, BSN, RN
Clinical Professor
Hahn School of Nursing
University of San Diego
San Diego, California
Lisa M. Kohr, RN, MSN, CPNP- AC/PC, MPH, PhD(c), FCCM
Pediatric Nurse Practitioner
Cardiac Intensive Care Unit
Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Carie Linder, RNC-NIC, MSN, APRN-BS
Neonatal Nurse Practitioner
Integris Baptist Medical Center
Oklahoma City, Oklahoma
Twila Luckett, BSN, RN-BC
Pediatric Pain Service
Monroe Carell Jr. Children’s Hospital at Vanderbilt
Nashville, Tennessee
Erin L. Marriott, MS, RN, CPNP
Pediatric Cardiology Nurse Practitioner
American Family Children’s Hospital
Watertown Regional Medical Center
Madison, Wisconsin
Andrea C. Morris, DNP, RNC-NIC, CCRN
Neonatal Clinical Nurse Specialist
Citrus Valley Medical Center-NICU
West Covina, California
Mindy Morris, DNP, NNP-BC, CNS
Neonatal Nurse Practitioner
Extremely Low Birth Weight Program Coordinator
Children’s Hospital of Orange County
Orange, California
 Review ers xi

Tracy Ann Pasek, RN, MSN, DNP, CCNS, CCRN, CIMI Nicole Van Hoey, PharmD
Clinical Nurse Specialist Medical Writer/Editor
Pain/Pediatric Intensive Care Unit Consultant
Children’s Hospital of Pittsburgh Arlington,Virginia
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania Winnie Yung, MN, RN
Registered Nurse
Patricia Scheans, DNP, NNP-BC Lucile Packard Children’s Hospital at Stanford
Clinical Support for Neonatal Care Palo Alto, California
Legacy Health
Portland, Oregon

Peggy Slota, DNP, RN, FAAN

Associate Professor
Director, DNP and Nursing Leadership Programs
Carlow University
Pittsburgh, Pennsylvania
 PREFACE
T he concept of the team approach is impor-
tant in neonatal intensive care. Each health
care professional must not only perform the
duties of his or her own role but must also understand
the roles of other involved ­ professionals. Nurses,
physicians, other health care providers, and parents
must work together in a coordinated and efficient
manner to achieve optimal results for patients in the
neonatal intensive care unit (NICU).
Because this team approach is so important in
the field of neonatal intensive care, we believe it is
necessary that this book contain input from major
fields of health care—nursing and medicine. Both
nurses and physicians have edited and co-authored
every chapter.
The book is divided into six units, all of which
have been reviewed, revised, and updated for the
eighth edition. Unit One presents evidence-based
practice and the need to scientifically evaluate neo-
natal therapies, emphasizing randomized controlled
trials as the ideal approach. Units Two through Five
are the clinical sections, which have been fully
updated for this edition. The chapters within these
xii
sections include highlighted clinical directions for
quick reference, Parent Teaching boxes to aid in dis-
charge instructions, and Critical Findings boxes to
prioritize assessment data.
The combination of physiology and pathophysi-
ology and separate emphasis on clinical application
in this text is designed for neonatal intensive care
nurses, nursing students, medical students, and pedi-
atric, surgical, and family practice housestaff. This
text is comprehensive enough for nurses and physi-
cians, yet basic enough to be useful to families and
all ancillary personnel.
Unit Six presents the psychosocial aspects of
neonatal care. The medical, psychological, and social
aspects of providing care for the ill neonate and fam-
ily are discussed in this section.This section in partic-
ular will benefit social workers and clergy, who often
deal with family members of neonates in the NICU.
In this handbook we present physiologic princi-
ples and practical applications and point out areas as
yet unresolved. Material that is clinically appli-
cable is set in purple type so that it can be
easily identified.
 INTRODUCTION
I n 1974 as the Perinatal Outreach Educator at
The Children’s Hospital in Denver, Colorado,
I took a folder to Gerry Merenstein, MD, at
Fitzsimmons Army Medical Center to discuss his
lectures for the first outreach education program in
La Junta, Colorado. When we finished, he removed
from his desk drawer a 1-inch thick compilation of
the neonatal data, graphs, nomograms, and diagrams
he had created for the medical housestaff during his
fellowship. Giving the document to me, he asked
that I review it and let him know what I thought.
Several weeks later, I told him it was good except
there was no nursing care or input, which is essential
in every NICU. So Gerry asked, “Want to write a
book?”—and the idea for the Handbook was born!
With this eighth edition in 2015, we celebrate 30
years of publication of the Handbook of Neonatal Intensive
Care. Gerry and I co-edited this book for 21 years until
his death in December 2007.To fulfill my promise that
Gerry’s name would always be on the book, the seventh
and all subsequent editions will be known as Meren-
stein & Gardner’s Handbook of Neonatal Intensive Care.
Instead of editing this edition alone or with another
physician, I decided to convene an editorial team con-
sisting of myself, a nurse colleague, and two neonatolo-
gists. Together we bring 170 years of clinical practice,
research, teaching, writing, and consulting in neonatal,
pediatric, and family care to this eighth edition.
We have the distinction in this new edition of trans-
lation into Spanish for our colleagues in Central and
South America and Spain. This was an ongoing wish
of Gerry Merenstein, and after much negotiation it
is finally a reality. Welcome to all our Spanish-reading
colleagues! In addition, the eighth edition is available
on multiple e-platforms to facilitate use at the bedside.
For our new audience, and for our continuing
loyal readers, this is my opportunity to introduce
myself and all the members of the editing team.
I am currently Editor of Nurse Currents and NICU
Currents (www.anhi.org) and the Director of Profes-
sional Outreach Consultation (www.professionalout-
reachconsultation.com), a national and international
consulting firm established in 1980. I plan, develop,
teach, and coordinate educational workshops on
perinatal/neonatal/pediatric topics. I graduated from
a hospital school of nursing in 1967 with a diploma,
obtained my BSN at Spalding College in 1973 (magna
cum laude), completed my MS at The University of
Colorado School of Nursing in 1975 and my PNP
in 1978. I have worked in perinatal/neonatal/pediatric
care since 1967 as a clinician (37 years in direct bedside
care), practitioner, teacher, author, and consultant. In
1974, I was the first Perinatal Outreach Educator in the
United States funded by the March of Dimes. In this
role I taught nurses and physicians in Colorado and the
seven surrounding states how to recognize and stabilize
at-risk pregnancies and sick neonates. I also consulted
with numerous March of Dimes grantees to help them
establish perinatal outreach programs. In 1978 I was
awarded the Gerald Hencmann Award from the March
of Dimes for “outstanding service in the improvement
of care to mothers and babies in Colorado.” I am a
founding member of the Colorado Perinatal Care
Council, a state advisory council to the Governor and
the State Health Department on perinatal/neonatal
health care issues, and I am the Treasurer and a member
of the Executive Committee. I am also an active mem-
ber of the Colorado Nurses Association/American
Nurses Association, the Academy of Neonatal Nurses,
and the National Association of Neonatal Nurses.
Mary Enzman Hines, RN, PhD, CNS, CPNP,
AHN-BC, is currently Professor Emeritus at Beth-El
College of Nursing at the University of Colorado in
Colorado Springs and certified Pediatric Nurse Prac-
titioner at Rocky Mountain Pediatrics, Lakewood,
Colorado. Early in her nursing career, Mary worked
in the NICU and PICU as a staff nurse, charge nurse,
and nurse manager. After completing her PNP/CNS
program and her master’s degree at the University of
Colorado, Mary became the Neonatal and Pediatric
Clinical Nurse Specialist at Denver Health and Hos-
pital, where she created a beginning, intermediate, and
advanced orientation for nurses in the NICU and
PICU. At the University of Colorado, Mary accepted
xiii
xiv Int r oduc t i o n
the practitioner/teacher role in maternal-child services,
providing clinical care and mentorship in the NICU
and pediatric units where nursing students were placed
from the CU nursing program. When University
Hospital and The Children’s Hospital combined their
pediatric services, Mary became the Clinical Nurse
Specialist in Research and Education and consulted in
the NICU, PICU, and pediatric medical-surgical areas.
In this role she was a founding member of the interdis-
ciplinary Pain Management Team and provided con-
sultation throughout The Children’s Hospital for pain
management issues. In 1996 Mary became a nursing
faculty member at Beth-El College of Nursing and
Health Sciences, where she created a student health
center at the University and a school-based clinic for
schoolchildren in Fountain, Colorado, while maintain-
ing an active pediatric practice at Colorado Springs
Health Partners. Currently Mary provides pediatric
care at Rocky Mountain Pediatrics and continues to
teach courses to DNP students at the University of
Northern Colorado as an adjunct faculty. Mary is well
published in the areas of pediatric, neonatal, and family
health care, as well as in legal issues in maternal-child
nursing. Mary is also a nurse researcher in the areas
of pain, chronic illness, caring/healing praxis, pediatric
pain, holistic nursing, and technology in health care.
Brian S. Carter, MD, FAAP, is a graduate of David
Lipscomb College in Nashville, Tennessee, and of
the University of Tennessee’s College of Medicine in
Memphis, Tennessee. Brian completed his residency
in pediatrics at Fitzsimmons Army Medical Center
in Aurora, Colorado. He completed his fellowship
in neonatal-perinatal medicine at the University of
Colorado Health Sciences Center in Denver. During
the “Baby Doe” era, Brian trained in bioethics and, in
addition to clinical neonatology and neonatal follow-
up, he has dedicated most of his academic career to
the advancement of clinical ethics in neonatology and
pediatric palliative care. Brian has been recognized
nationally for his efforts in both of these fields. Cur-
rently he is Professor of Pediatrics at the University
of Missouri-Kansas City School of Medicine, where
he serves on the Ethics Committee and mentors stu-
dents, residents, and fellows in the areas of clinical eth-
ics, neonatology, pain management, and palliative care.
Brian, Marcia Levetown, MD, and Sarah Friebert, MD,
co-edit the book Palliative Care for Infants, Children, and
Adolescents:A Practical Handbook, whose second edition
published in 2011 by Johns Hopkins University Press.
Jacinto A. Hernández, MD, PhD, MHA, FAAP, is
currently Professor Emeritus of Pediatrics and Neo-
natology at the University of Colorado Denver and
Chairman Emeritus of the Department of Neonatol-
ogy at Children’s Hospital Colorado, Aurora Colo-
rado. He is a graduate of the School of Medicine of
the University of San Marcos in Lima, Peru. Jacinto’s
postgraduate education includes a specialty in pediatrics
and a subspecialty in neonatology from the Children’s
Hospital National Medical Center and George Wash-
ington University in Washington, DC, and from the
University of Colorado Denver School of Medicine; a
PhD from the University of San Marcos; and a Master’s
in Health Administration from the University of Colo-
rado Denver School of Business. Jacinto has spent all of
his professional life in academic medicine, first at the
University of San Marcos as Associate Professor of Pedi-
atrics, and subsequently at the University of Colorado
Denver School of Medicine as Professor of Pediatrics.
As a physician and professor, his professional activities
have been carried out at The Children’s Hospital of
Denver in Aurora, Colorado, where he has been Direc-
tor of the Newborn Intensive Care Unit, Chairman of
the Department of Neonatology, an active staff neona-
tologist, and President of the Medical Staff. During his
career, Jacinto has distinguished himself both clinically
and academically, has written numerous publications in
the field of neonatal medicine, and has participated as
an invited professor at innumerable international events.
Jacinto has been recognized with numerous awards,
including the Career Teaching and Scholar Award, for
his scientific achievements, professional qualities, and
fruitful work as a superb clinical physician.
Borrowing from the words of Brian Carter in the
introduction to the sixth edition of the Handbook:
The goals of care should be patient- and family-
centered. It is the patient we treat, but it is the family,
of whatever construct, with whom the baby will go
home. Indeed, it is the family who must live with the
long-term consequences of our daily decisions in caring
for their baby.
These goals include the provision of skilled pro-
fessional care. An effective neonatal intensive care
team consists of educated professionals of many
disciplines—none of us can do it alone.
It has been my honor and privilege to work with
these co-editors, who are all patient- and family-
centered, and with the amazing editing team of Tina
Kaemmerer, Lee Henderson, and Carol O’Connell
for this eighth edition.
Sandra L. Gardner RN, MS, CNS, PNP
Senior Editor
 CONTENTS

UNIT ONE 11. Drug Withdrawal in the Neonate, 199

Evidence-Based Practice Susan M. Weiner and Loretta P. Finnegan

1. Evidence-Based Clinical Practice, 1 12. Pain and Pain Relief, 218

Alfonso F. Pantoja and Mary Enzman Hines Sandra L. Gardner, Mary Enzman Hines, and Rita Agarwal

13. The Neonate and the Environment: Impact

UNIT TWO on Development, 262
Support of the Neonate Sandra L. Gardner, Edward Goldson, and Jacinto A. Hernández

2. Prenatal Environment: Effect on Neonatal

Outcome, 11 UNIT THREE
Priscilla M. Nodine, Marie Hastings-Tolsma, and Jaime Arruda Metabolic and Nutritional
Care of the Neonate
3. Perinatal Transport and Levels of Care, 32
Mario Augusto Rojas, Heather Furlong Craven, and Tamara Rush 14. Fluid and Electrolyte Management, 315
Michael Nyp, Jessica L. Brunkhorst, Daphne Reavey, and
4. Delivery Room Care, 47 Eugenia K. Pallotto
Susan Niermeyer, Susan B. Clarke, and Jacinto A. Hernández
15. Glucose Homeostasis, 337
5. Initial Nursery Care, 71 Paul J. Rozance, Jane E. McGowan, Webra Price-Douglas, and
Sandra L. Gardner and Jacinto A. Hernández William W. Hay, Jr.

6. Heat Balance, 105 16. Total Parenteral Nutrition, 360

Sandra L. Gardner and Jacinto A. Hernández
7. Physiologic Monitoring, 126
Wanda Todd Bradshaw and David T. Tanaka
8. Acid-Base Homeostasis and
Oxygenation, 145
James S. Barry, Jane Deacon, Carmen Hernández, and
M. Douglas Jones, Jr.
9. Diagnostic Imaging in the Neonate, 158
John D. Strain and Jason P. Weinman
10. Pharmacology in Neonatal Care, 181
Mary Miller-Bell, Charles Michael Cotten, and Deanne Buschbach
Steven L. Olsen, Mary Kay Leick-Rude, Jarrod Dusin, and
Jamie Rosterman
17. Enteral Nutrition, 377
Laura D. Brown, Kendra Hendrickson, Ruth Evans, Jane Davis,
Marianne Sollosy Anderson, and William W. Hay, Jr.
18. Breastfeeding the Neonate with Special
Needs, 419
Sandra L. Gardner and Ruth A. Lawrence
19. Skin and Skin Care, 464
Carolyn Lund and David J. Durand

xv
xvi C ontents

UNIT FOUR 26. Neurologic Disorders, 727

Infection and Hematologic Diseases Julie A. Parsons, Alan R. Seay, and Mona Jacobson
of the Neonate
27. Genetic Disorders, Malformations, and
20. Newborn Hematology, 479 Inborn Errors of Metabolism, 763
Marilyn Manco-Johnson, Christopher McKinney, Rhonda Anne L. Matthews and Nathaniel H. Robin
Knapp-Clevenger, and Jacinto A. Hernández
28. Neonatal Surgery, 786
21. Neonatal Hyperbilirubinemia, 511 Brian T. Bucher, Annette S. Pacetti, Harold N. Lovvorn III, and
Beena D. Kamath-Rayne, Elizabeth H. Thilo, Jane Deacon, and Brian S. Carter
Jacinto A. Hernández

22. Infection in the Neonate, 537 UNIT SIX

Mohan Pammi, M. Colleen Brand, and Leonard E. Weisman Psychosocial Aspects of Neonatal
Care
UNIT FIVE 29. Families in Crisis: Theoretical and Practical
Common Systemic Diseases of the Considerations, 821
Neonate Sandra L. Gardner, Kristin Voos, and Patti Hills

23. Respiratory Diseases, 565 30. Grief and Perinatal Loss, 865
Sandra L. Gardner, Mary Enzman Hines, and Michael Nyp Sandra L. Gardner and Brian S. Carter

24. Cardiovascular Diseases and Surgical 31. Discharge Planning and Follow-Up of the
Interventions, 644 Neonatal Intensive Care Unit Infant, 903
Tara Swanson and Lori Erickson Angel Carter, Linda Gratny, and Brian S. Carter

25. Neonatal Nephrology, 689 32. Ethics,Values, and Palliative Care in Neonatal
Melissa A. Cadnapaphornchai, Mary Birkel Schoenbein, Rosanne Intensive Care, 924
Woloschuk, Danielle E. Soranno, and Jacinto A. Hernández Julie R. Swaney, Nancy English, and Brian S. Carter
 UNIT ONE EVIDENCE-BASED PRACTICE
1 EVIDENCE-BASED
CLINICAL PRACTICE
ALFONSO F. PANTOJA AND MARY ENZMAN HINES
G lobally, health care systems are experiencing
challenges when evaluating therapies, qual-
ity of care, and the risk of adverse events
in clinical practice. Often health care systems fail
to optimally use evidence. This failure is either
from underuse, overuse, or misuse of evidence-based
therapies and/or system failures.75 Evidence-based
practice (EBP) requires the integration of the best
research evidence with our clinical expertise and
each patient’s unique values and circumstances.75
EBP approaches in all fields of health care could pre-
vent therapeutic disasters resulting from the informal
“let’s-try-it-and-see” methods of testing new thera-
pies that are not recognized as risky. The epidemic
of retinopathy attributable to the indiscriminate use
of supplemental oxygen; gray baby syndrome attrib-
utable to the administration of chloramphenicol;
kernicterus attributable to the introduction of sul-
fonamides65; and death due to liver toxicity of 40
premature newborns attributable to the administra-
tion of a parenteral form of vitamin E (E-Ferol)71
are examples of these therapeutic misadventures in
the field of neonatal care. Silverman described how
painfully slow health care providers were to embrace
a culture of skepticism and emphasizes, “We must
insist on the highest standards of evidence in stud-
ies involving the youngest human beings; and, since
there is no short route to this goal, we must prepare
to be patient.”64 The use of experimentation and the
scientific method has ultimately led to our present
views of how to ask and answer clinical questions.56
Mistakes have also occurred at the other
extreme, as well, resulting in a failure to adopt
PURPLE type highlights content that is particularly applicable to clinical settings.
therapies that are of proven benefit or an assump-
tion that the risks associated with changing
practice justify complacency about current treat-
ments. The significant delay in the adoption of ante-
natal corticosteroids by the obstetric community to
promote fetal lung maturation19,68 is a good example
of failure to use the available evidence. One of the
most important benefits of EBP is the constant
questioning: “Have our current clinical practices
been studied in appropriately selected popula-
tions, of sufficient size to accurately predict their
efficacy, benefit, safety, side effects, and cost?”
EBP is a systematic way to integrate the best
patient-centered, clinically relevant research
with our clinical expertise and with the unique
preferences, concerns, and expectations that
each patient brings to a clinical encounter.75 Fur-
thermore, EBP presents an opportunity to enhance
patient health and illness outcomes, increase staff sat-
isfaction, and reduce health care expenses. There is
great interest in identifying barriers and facilita-
tors that could help in closing the knowledge-
to-practice gap that is inherent to the acceptance
and adoption of EBP by all providers.76
FINDING HIGH-QUALITY
EVIDENCE
As new therapies are integrated into neonatal care,
health care providers must continue to increase
existing knowledge of the health and health prob-
lems of newborns. Providers need to formulate
1
2 UNIT ONE Evidence-Based Practice
well-designed questions about the specific clini-
cal encounter and learn how to evaluate the
quality of evidence regarding risks and benefits
of new practices. Most clinical questions arise
through daily practice and often involve knowl-
edge gaps in background (general knowledge) and
foreground (specific knowledge to inform clinical
decisions or actions).The knowledge needs will vary
according to the experience of the clinician.75
It is not the purpose of this chapter to provide
a detailed review of the various research designs
that permit reliable scientific inference. Rather, our
purpose is to promote the propositions that (1)
challenge clinical observations and wisdom by
finding the current best evidence and (2) careful
assessment and critique of research that supports
or challenges the use of new and established
clinical practices.
Clinical observations, although valuable in
shaping research questions, are limited by selec-
tive perception—a desire to see a strategy work
or fail to work. At times, a single case or case study
may prompt us to question whether we should con-
sider changing current practice. In some situations,
much can be learned from carefully maintained
databases. Such knowledge is gained only when we
have formed databases with clear intentions and
have collected the necessary data.
Sinclair and Bracken67 described four levels of
clinical research used to evaluate safety and effi-
cacy of therapies, based on their ability to provide
an unbiased answer. In ascending order, these are
(1) single case or case series reports without con-
trols, (2) nonrandomized studies with historical
controls, (3) nonrandomized studies with con-
current controls, and (4) randomized controlled
trials (RCTs). RCTs test hypotheses by using
randomly assigned treatment and control groups
of adequate size to examine the efficacy and
safety of a new therapy. In theory, random assign-
ment of the treatment balances unknown or unmea-
sured factors that might otherwise bias the outcome
of the trial. A meta-analysis is a systematic review
of the current literature that uses statistical meth-
ods to combine the results of individual stud-
ies and summarizes the results (http://neonatal.
cochrane.org).18 Tyson79 has suggested criteria
for identifying proven therapies in current litera-
ture (Box 1-1). Ideally, therapeutic recommenda-
tions are supported by evidence from systematic
reviews of RCTs; however, such evidence is
B O X
1-1
PROVEN THERAPIES
Reported to be beneficial in a well-performed meta-analysis of all trials
or
Beneficial in at least one multicenter trial or two single-center trials
Modified from Tyson JE: Use of unproven therapies in clinical practice and research: how
can we better serve our patients and their families? Semin Perinatol 19:98, 1995.
T A B L E
1-1 LEVELS OF EVIDENCE
LEVEL OF EVIDENCE THERAPY/PREVENTION/ETIOLOGY/HARM
1a Systematic reviews of RCTs
1b Individual RCT with narrow confidence interval
1c All or none
2a Systematic review of cohort studies
2b Individual cohort study (including low-quality
RCT [less than 80% follow-up])
3a Systematic review of case-control study
3b Individual case-control study
4 Case-controlled studies
5 Expert opinion without critical appraisal
From Straus SE, Richardson WS, Haynes RB: Evidence-based medicine: how to practice
and teach it, ed 4, London, 2011, Harcourt.
RCT, Randomized controlled trial.
not always available. It is then important to have
a system to grade the strength of the quality of the
evidence found. An international collaboration
has developed GRADE, providing an explicit
strategy for grading evidence and the strength of
recommendations.36 GRADE classifies the evi-
dence into one of four levels: high, moderate,
low, and very low (Table 1-1). The strength of the
recommendation is graded as strong or weak. Factors
that influence the strength of the recommendation
include desirable or undesirable effects, values, pref-
erences, and economic implications (Figure 1-1).
Although conclusions drawn from quantitative
studies (RCTs, meta-analysis of RCTs) are regarded
as the strongest level of evidence, evidence from
descriptive and qualitative studies should be factored
 CHAPT E R 1 Evidence-Based Clinical Practice 3

Meta-
analysis
Systematic
reviews Filtered
information

ce
TRIP database Critically appraised

en
topics

vid
searches these

fe
simultaneously (evidence syntheses)

o
ty
Critically appraised individual

ali
Qu
articles (article synopses)

Randomized controlled trials (RCTs)

Unfiltered
Cohort studies
information
Case-controlled studies
Case series/Reports

Background information/Expert opinion

FI G URE 1-1 Evidence appraisal. (Adapted from DiCenso A, Bayley L, Haynes RB: Accessing pre-appraised evidence: fine-tuning the 5S
model into the 6S model, Evid Based Nurs 12:99, 2009.)

into clinical decisions. Qualitative research pro-
vides guidance in deciding whether the findings
of quantitative studies could be replicated in
various patient populations. Qualitative research
can also facilitate an understanding of the expe-
rience and values of patients. The validity, impor-
tance, and applicability of qualitative studies need to
be evaluated in a similar way as quantitative studies.
PRESSURES TO INTERVENE
RCTs of appropriate size are cited as providing
the best evidence for guiding clinical decisions;
however, many take years to complete and pub-
lish. Providers find it difficult to delay introduction
of promising therapies. Bryce and Enkin12 discussed
myths about RCTs and rationales for not conducting
them. One myth is that randomization is unethical.
This might be true in rare instances when an inter-
vention is dramatically effective and lifesaving. The
more common situation is one where there is limited
evidence for a current or alternative strategy.
Pressure to intervene is, however, often overpow-
ering. Believing that an infant is in trouble, interven-
tions occur through a cascade of interventions,49 one
leading to the next and each carrying risk. One of
the most frequently cited examples is the epidemic
of blindness associated with the unrestricted use of
oxygen in newborns.63,64 Oxygen, used since the
early 1900s for resuscitation and treatment of cya-
notic episodes, was noted in the 1940s to “correct”
periodic breathing in premature infants. After World
War II and introduction of new gas-tight incubators,
an epidemic of blindness occurred, resulting from
retrolental fibroplasia (RLF). Silverman63 pointed
out that although many causes were suspected, it
was not until 1954 that a multicenter, controlled trial
confirmed the association between high oxygen con-
centrations and RLF. Frequently forgotten, however,
is that in subsequent years, mortality was increased in
infants cared for with an equally experimental regi-
men of strict restriction of oxygen administration
and many survivors had spastic diplegia. In the 1960s,
the introduction of micro techniques for measuring
arterial oxygen tension permitted better monitor-
ing of oxygen therapy, with a reduction in mortality,
spastic diplegia, and RLF, now called retinopathy of
prematurity (ROP). Severe ROP is currently limited
to extremely low-birth-weight (ELBW) infants.63
Research continues to explore causes, preventive
measures, and treatments (see Chapter 31).
4 UNIT ONE Evidence-Based Practice
Large multinational, pragmatic RCTs to
resolve the uncertainty surrounding the most
appropriate levels of oxygen saturation in pre-
mature infants have been recently conducted
and the results published.60,77,78 The publication of
the results of the SUPPORT trial77 brought about a
significant debate about the ethical aspects of com-
parative effectiveness research and parental informed
consent when one of the elements of the composite
outcome was death before discharge.63 The practice
of allowing very-low-birth-weight (VLBW) infants
to maintain lower O2 saturations during the first
weeks of life had been widely disseminated through-
out the United States and the world due to anecdotal
reports of a significant decrease in the severity of
ROP and blindness with this approach.17 The SUP-
PORT77 and BOOST II78 trials showed a signifi-
cant decrease in the frequency of severe ROP
and an increase in mortality rate in the low-sat-
uration group. However, another study with a
similar design60 showed no significant effect on
the rate of death or disability at 18 months.
The desire to see an intervention “work”
encourages practitioners and investigators to seek
early signs of benefit. Long-term effects are fre-
quently overlooked. One reason is that they may
not be foreseen. Consider the example of diethyl-
stilbestrol (DES). DES administration to pregnant
women was introduced in 1947 without clinical tri-
als to prevent miscarriage, fetal death, and preterm
delivery.12,30 It was thought to be effective after
uncontrolled studies despite controlled trials sum-
marized in an overview (meta-analysis) by Goldstein
et al34 (Table 1-2) that showed the opposite. Clearly,
DES was not effective, but it continued to be used
until the 1970s, when the Food and Drug Adminis-
tration (FDA) finally disapproved its use.The unfore-
seen result was that female children born to mothers
who were given DES had structural abnormalities of
the genital tract, pregnancy complications, decreased
fertility, and an increased risk for vaginal adenocarci-
noma in young women. Male children had epididy-
mal cysts. This is not the only example of physicians
continuing to use therapies that have been shown in
RCTs to be of no benefit.15
The costs of long-term studies and follow-up
surveillance are numerous. However, when effects
are measured later in life (e.g., psychological prob-
lems, ability to function in school), the cost cannot
determine study design. Even when randomized tri-
als are conclusive, unanswered questions remain: Will
T A B L E EFFECTS OF DIETHYLSTILBESTROL (DES)
1-2 ON PREGNANCY OUTCOMES
TYPICAL ODDS 95% CONFIDENCE
RATIO* LIMITS
Miscarriage 1.20 0.89-1.62
Stillbirth 0.95 0.50-1.83
Neonatal death 1.31 0.74-2.34
All three 1.38 0.99-1.92
Prematurity 1.47 1.08-2.00
Data from Goldstein PA, Sacks HS, Chalmers TC: Hormone administration for the mainte-
nance of pregnancy. In Chalmers I, Enkin M, Keirse M, editors: Effective care in pregnancy
and childbirth, New York, 1989, Oxford University Press.
*An odds ratio is an estimate of the likelihood (or odds) of being affected by an exposure
(e.g., a drug or treatment), compared with the odds of having that outcome without hav-
ing been exposed. Women receiving DES did not have fewer stillbirths, premature births,
or miscarriages than women who were untreated.
a technology or treatment have the same effect in
all settings? Has an “appropriate” target population
been selected? Are there long-term unforeseeable
consequences?
EVALUATION OF THERAPIES
The major cause of death in premature infants is
respiratory failure from respiratory distress syndrome
(RDS) (see Chapter 23). Previously called hyaline
membrane disease, this syndrome of expiratory grunt-
ing, nasal flaring, chest wall retractions, and cyanosis
unresponsive to high oxygen concentrations was a
mystery until the 1950s.64
The evaluation of various therapies for RDS
contrasts the value of controlled and uncontrolled
trials. Sinclair66 noted that uncontrolled studies were
more likely to show benefit than controlled trials.
In 19 uncontrolled studies, 17 popular therapies
showed “benefit.” In 18 controlled studies, only 9
demonstrated benefit. An untrained reviewer of the
research might base clinical practice on faulty con-
clusions of uncontrolled trials.
Surfactant Therapy
In contrast to many proposed treatments, sur-
factant therapy in premature infants has been
 CHAPT E R 1 Evidence-Based Clinical Practice 5

well studied in RCTs.3,37 Studies have evaluated
the use of surfactant in treatment of RDS, includ-
ing the optimal source and composition of surfactant
and prophylactic versus rescue treatment. Morbidity
(including pneumothorax, periventricular or intra-
ventricular hemorrhage, bronchopulmonary dyspla-
sia [BPD], and patent ductus arteriosus) and mortality
rates in treatment and control groups have been
compared. Systematic reviews of surfactant therapy
confirm the effect of surfactant therapy in reducing
the risk of morbidity and mortality.67,72 Although
RCTs involving thousands of newborns have
clearly demonstrated the benefits of surfactant
therapy, unanswered questions remain. One of
these questions is if prophylactic administration of
surfactant to an infant judged to be at risk of devel-
oping RDS was better than early selective use of sur-
factant to infants with established RDS. Early trials
demonstrated a decreased risk of air leak and mortal-
ity with the prophylactic approach. However, recent
RCTs that reflect current practice (i.e., greater utili-
zation of maternal steroids and routine postdelivery
stabilization on continuous positive airway pressure
[CPAP]) do not support these differences and actu-
ally demonstrate less risk of chronic lung disease or
death when using early stabilization on CPAP with
selective surfactant administration to infants requir-
ing intubation59,77 (Figure 1-2).

Review: Prophylactic versus selective use of surfactant in preventing morbidity and mortality in preterm infants
Comparison: 2 Prophylactic surfactant vs. treatment of established respiratory distress in preterm infants less than 30 weeks gestation
Outcome: 1 Neonatal mortality

Prophylactic Selective Risk Ratio Risk Ratio

Study or subgroup Weight
n/N n/N M-H, Fixed, 95% CI M-H, Fixed, 95% CI

1 Studies without routine application of CPAP

Bevilacqua 1996 28/136 46/132 17.6% 0.59 [ 0.39, 0.89 ]

Bevilacqua 1997 9/49 9/44 3.6% 0.90 [ 0.39, 2.06 ]

Dunn 1991 9/62 8/60 3.1% 1.09 [ 0.45, 2.63 ]

Egberts 1993 8/75 14/72 5.4% 0.55 [ 0.24, 1.23 ]

Kendig 1991 23/235 40/244 14.8% 0.60 [ 0.37, 0.97 ]

Merritt 1991 27/76 21/72 8.2% 1.22 [ 0.76, 1.95 ]

Walti 1995 15/134 23/122 9.1% 0.59 [ 0.33, 1.08 ]

Subtotal (95% CI) 767 746 61.8% 0.71 [ 0.58, 0.88 ]
Total events: 119 (Prophylactic), 161 (Selective)
Heterogeneity: Chi??  8.27, df  6 (P  0.22); I??  27%
Test for overall effect: Z  3.11 (P  0.0019)

2 Studies with routine application of CPAP

Dunn 2011 10/209 8/221 2.9% 1.32 [ 0.53, 3.28 ]

Support 2010 114/653 94/663 35.3% 1.23 [ 0.96, 1.58 ]

Subtotal (95% CI) 862 884 38.2% 1.24 [ 0.97, 1.58 ]

Total events: 124 (Prophylactic), 102 (Selective)
Heterogeneity: Chi??  0.02, df  1 (P  0.88); I??  0.0%
Test for overall effect: Z  1.73 (P  0.083)

Total (95% CI) 1629 1630 100.0% 0.91 [ 0.78, 1.07 ]

Total events: 243 (Prophylactic), 263 (Selective)
Heterogeneity: Chi??  18.64, df  8 (P  0.02); I??  57%
Test for overall effect: Z  1.11 (P  0.27)
Test for subgroup difference: Chi??  11.24, df  1 (P  0.00); I??  91%

0.2 0.5 1 2 5

Favors prophylactic Favors selective

FI G URE 1-2 Table showing effect of prophylactic versus selective surfactant administration on morbidity and mortality rates in preterm
infants. (From Rojas-Reyes X, Morley C, Soll R: Prophylactic versus selective use of surfactant in preventing morbidity and mortality in preterm
infants, Cochrane Database Syst Rev 3:CD000510, 2012.)
6 UNIT ONE Evidence-Based Practice
Corticosteroid Therapy
Misuse of corticosteroids in perinatal medicine
illustrates the consequences of failure to practice
evidence-based medicine. Many practitioners ini-
tially declined to use antenatal steroids to promote
maturation of the immature fetal lung and prevent
RDS despite strong supportive evidence, demon-
strating a failure to use a proven therapy.
ANTENATAL CORTICOSTEROID
THERAPY: SINGLE COURSE
Antenatal administration of corticosteroids to preg-
nant women who threatened to deliver prematurely
was first shown in 1972 to decrease neonatal mortal-
ity rate and the incidence of RDS and intraventric-
ular hemorrhage (IVH) in premature infants.44 In
1990, Crowley et al21 used meta-analysis to evaluate
12 RCTs of maternal corticosteroid administration
involving more than 3000 women. The data showed
that maternal corticosteroid treatment significantly
reduced the risk for neonatal mortality, RDS, and
IVH. Sinclair,68 using a “cumulative meta-analysis”
approach of randomized trials, clearly demonstrated
that the aggregate evidence that was sufficient to
show that this treatment reduces the incidence of
RDS and neonatal death was available for almost 20
years before the use of antenatal corticosteroids was
widely accepted by the medical community.
This led to the National Institutes of Health
(NIH) consensus development conference statement
on “Effects of Corticosteroids for Fetal Maturation
on Perinatal Outcomes.”50 Antenatal corticosteroid
treatment of women at risk for preterm delivery
between 24 and 34 weeks of gestation has been
shown to be effective and safe in enhancing fetal
lung maturity and reducing neonatal mortality. Yet
adoption by caretakers was inexplicably slow.42
ANTENATAL CORTICOSTEROID
THERAPY: REPEATED COURSES
At the same time, other practitioners administered
repeated doses despite lack of evidence of addi-
tional benefit and questions about safety, rep-
resenting unproven use of a proven therapy.
Repeated courses of antenatal corticosteroids have
been shown in humans and animals to improve lung
function and the quantity of pulmonary surfac-
tant.22,35 They may also have adverse effects on lung
structure, fetal somatic growth, and neonatal adre-
nocortical function, as well as poorly understood
effects on blood pressure, carbohydrate homeostasis,
and psychomotor development.22,48 A 2000 NIH
Consensus Development Conference found limited
high-quality studies on the use of repeated courses
of antenatal steroids.51 The consensus statement
discouraged routine use of repeated courses of
antenatal corticosteroids. Published preliminary
reports of infants exposed to multiple doses of ante-
natal steroids reaching school age are emerging.6 A
recent meta-analysis of infants exposed to more than
one course of antenatal corticosteroids concluded
that “although the short-term neonatal benefits of
repeated courses of antenatal corticosteroids support
their use, long-term benefits have not been demon-
strated and long-term adverse effects have not been
ruled out. The adverse effect of repeated doses of
antenatal corticosteroids on birth weight and weight
at early childhood follow-up is a concern. Caution
should therefore be exercised to ensure that only
those women who are at particularly high risk of
very early preterm birth are offered treatment with
repeated courses of antenatal corticosteroids.”23 The
American College of Obstetricians and Gyne-
cologists (ACOG) recommends a repeat course
of antenatal steroids if the fetus is less than 34
weeks of gestation and the previous course of
antenatal steroids was administered more than
14 days earlier.4
POSTNATAL STEROID THERAPY
Postnatal glucocorticoids, administered to the
infant after birth, have been widely used despite
weak evidence of long-term benefit and sug-
gestions of possible harm, illustrating use of an
uncertain therapy.42 Despite early calls for caution
in the use of postnatal corticosteroids to decrease
the risk for chronic lung disease and limit ventila-
tor time, they were used liberally in the 1990s.70,74 A
number of years passed before RCTs of postnatal
corticosteroid administration included long-term
follow-up. Taken together, these studies showed
positive short-term effects on the lungs. Studies also
showed increased blood pressure and blood glucose
concentrations in the short term; increased incidence
of septicemia and gastrointestinal perforation in the
intermediate term; and with dexamethasone admin-
istered soon after birth, abnormal neurodevelop-
mental outcome, including cerebral palsy, in the long
term.25,37,43,74 An increased risk for septicemia should
have been anticipated, because it was first identified
in an RCT by Reese et al58 over 50 years earlier.

In 2002, the American Academy of Pediat-
rics (Committee on Fetus and Newborn) and the
Canadian Paediatric Society (Fetus and Newborn
Committee) advised against the use of systemic
dexamethasone and suggested that “outside the con-
text of a RCT that include assessment of long-term
development, the use of corticosteroids should be
limited to exceptional clinical circumstances (e.g.,
an infant on maximal ventilator support and oxy-
gen requirement).”2 A 2005 reanalysis of many of
the same data by Doyle et al25 suggests that relative
risks and benefits of postnatal corticosteroids vary
with level of risk for BPD. When the risk for BPD
or death is high, the risk for developmental impair-
ment from postnatal corticosteroids might be out-
weighed by benefit.27,29 Watterberg et al83 suggested
that hydrocortisone might have the benefits of dexa-
methasone on the lungs without adverse neurologic
effects. Following these statements, the exposure of
at-risk prematures decreased dramatically.81,82
QUALITATIVE RESEARCH
EVALUATING EXPERIENCES IN
THE NEONATAL INTENSIVE
CARE UNIT
The contribution of qualitative research to EBP is
evident when “best evidence from RCTs” may
or may not work within the context of specific
neonatal intensive care unit (NICU) environ-
ments. The context can be quite variable and influ-
enced by practitioners and staff, the unit leadership,
and family influence within the unit. The imple-
mentation of family-centered care in the NICU
has shown promising outcomes, including min-
imizing parental stress related to the technol-
ogy and complex care of a tiny, fragile preterm
infant.46 An environment of family-­ centered
care has also contributed in a positive way to
the success of the implementation of clinical
practice guidelines and evaluating outcomes.26
Qualitative studies are useful when limited informa-
tion exists about a phenomenon or a deficiency is
evident in the quality, depth, or detail of research
in a specific area of clinical practice. Qualitative
research contributes to EBP in several areas:
(1) descriptions of patient needs and experiences;
(2) providing the groundwork for instrument
development and evaluation; and (3) elaborating
on concepts relative to theory development.47
CHAPT E R 1 Evidence-Based Clinical Practice 7
Systematic reviews and meta-analyses are emerg-
ing in qualitative literature researching parental
experiences in the NICU.33,52 In neonatology,
qualitative studies provide in-depth views of parental
and provider experiences within the NICU setting
to humanize the health care of fragile infants. Par-
ents of infants who require NICU care begin an
experience of parenthood in an unfamiliar and
intimidating environment that results in delayed
attachment38,62; high levels of stress, including
anxiety, depression, trauma symptoms, and iso-
lation (both physical and emotional) from their
infant13,31; lack of disclosure of their infant’s
condition; and a lack of control.16 Mothers often
experience feelings of ambivalence, shame, guilt, and
failure that the infant is in the NICU.61 Parents also
experience the tension between exclusion and par-
ticipation in their infant’s care.84 In contrast, par-
ents describe factors that contribute to parental
satisfaction in the NICU, including assurance,
caring communication, provision of consistent
information, education,20 environmental follow-
up care, appropriate pain management,31 paren-
tal participation in care, and emotional, physical,
and spiritual support.20 Conversely, health care
professionals’ experiences of parental presence and
participation in the NICU revealed similar findings
to those described by parents: the need to develop
a caring environment for parents to be present and
take care of their child by guiding parents and giving
parents’ permission to care for their child, a need for
personnel training in the art of dealing with parents
in crisis, identifying a balance between closeness and
distance, and dealing with parental worry.85,86
Quality care is a major issue currently evaluating
the delivery of health care services, yet little research
has been conducted on what parents of premature
infants perceive as quality nursing care. Price57 used
a qualitative approach to reveal the meaning of
quality nursing care from parents’ perspectives
and identified concepts inherent in the process
of receiving quality nursing care. Four stages
were identified: (1) maneuvering, (2) a process
of knowing, (3) building relationships, and (4)
quality care. For parents, nontechnical aspects
of care, such as comforting infants after painful
procedures, were as important as the technical
aspects of care. Another qualitative study revealed
seven categories that influence changes in practice:
(1) staffing issues, (2) consistency in practice, (3) the
approval process for change, (4) a multidisciplinary
8 UNIT ONE Evidence-Based Practice
approach to care, (5) frequency and consistency of
communication, (6) rationale for change, and (7) the
feedback process. Three categories further delineate
quality care: human resources, organizational struc-
ture, and communications.73
SYSTEMATIC REVIEW IN
PERINATAL CARE AND
EVIDENCE-BASED PRACTICE
Evidence-based practice is the integration of the best
possible research evidence with clinical expertise and
patient needs.56,75 Examples from the literature, such
as those cited in the preceding sections, illustrate
how the application of the principles of EBP offer
a strong argument countering those who assert that
EBP is nothing more than “typical practice using
good clinical judgment.” Proponents of EBP argue
that the principal four steps of evidence-based
practice—formulating a clinical question, retriev-
ing relevant information, critically appraising the
relevant information, and applying the evidence
to patient care—provide a foundation for prac-
tice that leads to improved newborn outcomes
and avoidance of repeating medical disasters.
Believing that the results of perinatal controlled
trials had to be summarized in a manner useful to
practitioners, Chalmers14 and other perinatal profes-
sionals from various countries developed a registry
of RCTs. They reviewed a vast amount of literature
from published trials, sought out unpublished tri-
als, and encouraged those who had begun, but not
completed, studies to make them known to the reg-
istry. Once gathered, the studies’ findings were sum-
marized in “overviews.”
A meta-analysis is a systematic review of the
current literature that uses statistical methods to
combine the results of individual studies (prefer-
ably well-conducted RCTs with similar charac-
teristics of the participants and the treatments)
and summarizes the results.75 These results pro-
duce unbiased estimates of the effect of an interven-
tion on clinical outcomes and are distinguished from
nonsystematic reviews in which author opinions
often are reported along with the evidence. Table
1-1 and Figure 1-2 were developed after pooling the
results of different studies.
From these systematic reviews, practitioners
can learn the strengths or weakness of clini-
cal trials and evaluate the claims of benefit for
implementing a strategy. The result of the efforts
of Chalmers et al was the 1989 publication of a
remarkably useful book, Effective Care in Pregnancy
and Childbirth.15 At the end of the book, the authors
reported their own views of the reviewed treatments
based on conclusions formed in the preceding arti-
cles. They found that although some strategies and
forms of care were useful, others were questionable.
Some interventions believed to be useful were not
useful, of little benefit, or, in fact, harmful. In 1991 a
companion publication, Effective Care of the Newborn
Infant,67 compiled and reviewed neonatal RCTs.
Multiple networks have been developed to per-
form multicenter RCTs. This is particularly useful,
providing an opportunity to see whether treatments
have similar effects in different practice settings. It is
also useful in that practitioners in individual settings
may not always see enough cases to reach robust
conclusions. Rare conditions and rare outcomes
are better understood when trials are replicated
or their findings are pooled. Systematic reviews
provide the opportunity to understand these find-
ings in the context of clinical practice.
About the same time the Chalmers et al book was
published, the Cochrane Collaboration was estab-
lished, again largely through the efforts of Ian
Chalmers (www.cochrane.org/index0.htm). The
Cochrane Collaboration is a worldwide group
with 53 Collaborative Review Groups whose
members prepare, maintain, and disseminate sys-
tematic reviews based primarily on the results of
RCTs. These reviews are published electronically in
the Cochrane Library, which contains the Cochrane
Database of Systematic Reviews (CDSR: www.
cochrane.org/reviews/index.htm), along with edito-
rial comments on these reviews. Comments come
from an international group of individuals and
institutions dedicated to summarizing RCTs rel-
evant to health care. In addition to the Collab-
orative Review Groups, there are now 14 Cochrane
Centers in the world. These centers provide support
for the review groups. The Neonatal Group is based
at the University of Vermont.51 Cochrane Neonatal
Reviews are available at the National Institute
of Child Health and Human Development
(NICHD) Cochrane Neonatal Internet home
page; approximately 260 overviews are listed
(http://neonatal.cochrane.org).50
Additional sources of high-grade integrative
literature are also available to the practicing clini-
cian. Critical appraisal of published research takes

considerable time, and several groups assemble high-
grade literature using a uniform methodology that
is typically described to readers as a supplementary
article.9,10 Reading this article once can inform the
practitioner if the method used to assemble a review
or guideline is sufficiently rigorous. Also, a number
of sites do not produce integrative literature but col-
lect it from a number of sources. Some of these sites
discuss the quality of the information presented. If
we cannot appraise the method used to collect this
information, we should always proceed with cau-
tion. Additional reliable sites include the following:
• The Database of Abstracts of Reviews of Ef-
fectiveness (DARE) (www.crd.york.ac.uk/
CRDWeb), a collection of international re-
views including those from the Cochrane
Collaboration. Reviewers at the National
Health Service Centre for Reviews and Dis-
semination at the University of York, England,
provide quality oversight, including detailed
structured abstracts that describe the method-
ology, results, and conclusions of the reviews.
The quality of the reviews is discussed along
with implications for health care.
• The National Guidelines Clearinghouse (www.
guideline.gov), maintained by the U.S. De-
partment of Health and Human Services,
Agency for Healthcare Research and Qual-
ity (AHRQ), that was originally created in
partnership with the American Medical Asso-
ciation (AMA) and the American Association
of Health Plans (AAHP). This site provides a
wide range of clinical practice guidelines from
institutions and organizations. Structured ab-
stracts facilitate critical appraisal, and abstracts
on the same topic can be compared on a side-
by-side table, allowing comparisons of rel-
evance, generalizability, and rigor of research
findings. Links also are provided to the full
text of each guideline, when available.
Conducting systematic reviews is time consum-
ing; thus not many are available. Often, the power of
RCTs, especially in neonatology, is low.The evidence
in published studies does not always apply to our spe-
cific patient. In addition, locating relevant evidence
is time consuming and may require access to online
resources and a higher level of information-seeking
skills than are available. Finally, although recognizing
that medical expertise and scientific knowledge are
crucial components of neonatal care, these rigorous,
objective, scientific evaluations create the potential
CHAPT E R 1 Evidence-Based Clinical Practice 9
to overlook valuable experiential knowledge of the
NICU provided by practitioners and parents.
Reasons to use an evidence-based approach have
been well documented. According to Asztalos,5 there
are basically two reasons to try to keep up with the
literature: (1) to maintain clinical competence,
and (2) to solve specific clinical problems. Phil-
lips and Glasziou56 suggest that clinicians seek infor-
mation “just in time” (as a clinician seeing patients)
and “just in case” (an almost impossible task to keep
up with information pertinent to a particular clinical
specialty). The former can be achieved by actively
searching for information in filtered, summarized
clinical point-of-care resources. FirstConsult (www.
firstconsult.com/php/437124517-76/home.html),
DynaMed (https://dynamed.ebscohost.com), and
UpToDate (www.uptodate.com/home) fall into this
category.The latter, “just in case” learning, also called
surveillance of the literature, is best achieved by
using technology tools to survey the current origi-
nal literature. These tools include Evidence-Updates
from the BMJ (http://group.bmj.com/products/
evidence-centre/evidence-updates), auto-alerts, and
RSS feeds in PubMed or online databases and jour-
nals. Learning about these ever-changing resources is
a challenge. Many hospitals and clinics are begin-
ning to include a clinical librarian or informa-
tionist as part of the health care team.7-9,45,69,80
Newer and practical resources to support evi-
dence-based health care decisions are rapidly evolv-
ing. Large multicenter RCTs answer important
clinical questions and provide more robust evidence
synthesis and synopsis services that are currently
integrated into electronic medical records. DiCenso
et al24 propose a hierarchic organization of preap-
praised evidence linking evidence-based recom-
mendations with individual patients. This 6S model
describes the levels of evidence building from origi-
nal single studies at the foundation, and building up
from syntheses (systematic reviews, such as Cochrane
reviews); synopses (succinct descriptions of selected
individual studies or systematic reviews, such as those
found in the evidence-based journals); summaries,
which integrate the best available evidence from
the lower layers to develop practice guidelines based
on a full range of evidence (e.g., Clinical Evidence,
National Guidelines Clearinghouse); to the peak of
the model, systematic reviews, where the individual
patient’s characteristics are automatically linked to
the current best evidence that matches specific cir-
cumstances. Practitioners should start by looking
10 UNIT ONE Evidence-Based Practice
at the highest-level resources available for the
problem that prompts research. These resources
have gone through a filtering process to generate
evidence that is rigorous and exhibited over mul-
tiple studies. Evidence-based clinical information
systems integrate and concisely summarize all
relevant and important research evidence about
a clinical problem, are updated as new research
evidence becomes available, and automatically
link (through an electronic medical record) spe-
cific patient circumstances to the relevant infor-
mation. Figure 1-1 depicts elements of the 6S model.
At the end of this chapter is a list of addi-
tional evidence-based practice resources. To use
these resources effectively, individuals must become
familiar with the principles and value of evidence-
based patient care.
TRANSLATING EVIDENCE
INTO PRACTICE
Literature demonstrates that EBP interventions
can produce changes in clinicians’ knowledge
and skills. Even when it is difficult to demon-
strate, EBP may induce changes in health care
provider behaviors and attitudes.75 Changes in
clinical outcomes are more difficult to dem-
onstrate. In neonatology, the extent to which
Cochrane reviews are used and are in agreement
with clinical practice guidelines have been found
to be disappointingly low.11 A quality chasm of
evidence exists in NICUs.28 Enormous variations
in the use of established therapies exist, so it is not sur-
prising that multiple neonatal networks throughout
the world have demonstrated an unexplained center-
to-center variability in outcomes.32,40,41 There are
reports of how EBP can be practiced successfully at
the single NICU level.53 However, the implementa-
tions of “bundles” of evidence-based practices
by multiple NICUs using collaborative quality
improvement efforts have reported meaningful
results.54,55 Cluster randomized trials performed at
regional or national levels using different strategies
have led to significant changes in practice.1,39
CLINICAL PRACTICE
GUIDELINES
Clinical practice guidelines are systematically
defined statements that assist providers and patients
B O X
1-2 THE KILLER Bs

Burden: Is the burden of illness (frequency in our community, or our
patient’s pretest probability or expected event rate [PEER]) too low
to warrant implementation?
Beliefs: Are the beliefs of individual patients or communities about the
value of the interventions or their consequences incompatible with
the guideline?
Bargain: Would the opportunity cost of implementing this guideline
constitute a bad bargain in the use of our energy or our community’s
resources?
Barriers: Are the barriers (geographic, organizational, traditional,
authoritarian, legal, or behavioral) so high that it is not worth trying
to overcome them?
From Straus SE, Richardson WS, Haynes RB: Evidence-based medicine: how to practice
and teach it, ed 4, London, 2011, Harcourt.
with decisions about appropriate health care for
specific clinical circumstances.75 Valid clinical guide-
lines create components from evidence derived from
systematic reviews and all relevant literature. Two
essential components should be considered when
considering the use of select guidelines: evidence
and detailed instructions for application. In addition,
“killer Bs” affect the instructions for application (Box
1-2). Detailed guides for assessing the validity of clinical
guidelines have been developed. The AGREE Col-
laboration has developed an instrument for assess-
ing the validity of the clinical guidelines, including
items focusing on six domains: (1) scope and purpose,
(2) stakeholder involvement, (3) rigor of development,
(4) clarity of presentation, (5) applicability, and (6) edi-
torial independence (www.agreecollaborative.org).
As stated by Silverman65:
Since ours is the only species on the planet that has achieved
rates of newborn survival which exceed 90 percent, it seems
to me we must demand the highest order of evidence possible
before undertaking widespread actions that may affect the
full lifetimes of individuals in the present, as well as in
future generations. Here a strong case can be made for a slow
and measured pace of medical innovation.
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For a full list of references,
scan the QR code or visit
http://booksite.elsevier.com/
9780323320832.

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EVIDENCE-BASED PRACTICE
RESOURCES
Databases of Evidence and Search Engines
ACP Journal Club (http://annals.org/journalclub.aspx): Evidence-
based evaluative summaries of articles taken from 100 clinical
journals, written by MDs and others, with comments from MDs.
Campbell Collaboration (www.campbellcollaboration.org): An inde-
pendent, international, nonprofit organization that aims to help
people make well-informed decisions about the effects of inter-
ventions in the social, behavioral, and educational arenas. The vi-
sion of the Campbell Collaboration is to bring about positive
social change and to improve the quality of public and private
services across the world by preparing, maintaining, and dissemi-
nating systematic reviews of existing social science evidence. The
Campbell Collaboration’s substantive priorities include, but are
not confined to, education, social welfare, and crime and justice.
Cochrane Library (www.thecochranelibrary.com): Premier evidence-
based medicine resource composed of the following:
Database of Systematic Reviews containing systematic reviews and meta-
analyses conducted by Cochrane Study Groups.
Database of Reviews of Effects including systematic reviews and meta-
analyses from non-Cochrane sources, many with structured abstracts with
comments on the reviews.
Center Register of Controlled Trials: Indexes many trials not included
in MEDLINE.
Cochrane Neonatal National Institutes of Child Health and Human
Development (NICHD) Cochrane Neonatal (www.nichd.nih.
gov/cochrane): Resource for systematic reviews of child health
topics.
HTA and NHS EED (www.crd.york.ac.uk/CRDWeb/SearchPage.
asp): This is the HTA web-based site that features the NHS Eco-
nomic Evaluation Database focused on the economic evaluation
of health care interventions and technical literature in the United
Kingdom.
ClinicalTrials.gov (http://clinicaltrials.gov/ct/gui): Provides regu-
larly updated information about federally and privately supported
clinical research in human volunteers. Gives information about a
trial’s purpose, who may participate, locations, and phone num-
bers for more details.
Current Controlled Trials (www.controlled-trials.com): Allows users
to search, register, and share information about randomized con-
trolled trials.
Health Services/Technology Assessment Texts (HSTAT) (http://
hstat.nlm.nih.gov): A free, Web-based resource of full-text docu-
ments that provide health information and support health care
decision making. HSTAT’s audience includes health care provid-
ers, health service researchers, policy makers, payers, consumers,
and the information professionals who serve these groups.
NHS Centre for Reviews and Dissemination (www.york.ac.uk/inst/
crd): Resource for systematic reviews of health economics and
technology assessment. Also maintains the DARE, Health Tech-
nology Assessment, and NHS Economic Evaluation databases
included in Cochrane.
TRIP Database (www.tripdatabase.com): Locates high-quality, ev-
idence-based medical literature using this metasearch engine.
Some resources in the results list may require subscription.
WHO Clinical Trial Search Portal (www.who.int/trialsearch): Ena-
bles researchers, health practitioners, consumers, journal editors,
and reporters to search more easily and quickly for information
on clinical trials.
References 10.e3
Databases of Guidelines
CMA Infobase, Clinical Practice Guidelines (www.cma.ca): Click on
Clinical Resources tab; requires membership. Excellent access to
guidelines and other point-of-care resources.
Guidelines International Network (G-I-N) (www.g-i-n.net): Guide-
lines organized by health topic. Links to worldwide sources of
guidelines.
National Guideline Clearinghouse (www.guideline.gov): Use “De-
tailed Search” link on left for more specific searches. A U.S. re-
source for evidence-based clinical practice guidelines. A display
tool allows side-by-side comparison of guidelines.
NHS National Institute for Clinical Excellence (NICE) (www.nice.
org.uk): Evidence-based guidance on technology use, clinical
care, and interventional procedures.
Scottish Intercollegiate Guidelines Network (SIGN) (www.sign.
ac.uk): Use link on left to view guidelines by topic. Distribution
point for Scottish national clinical guidelines.
U.S. Preventive Services Task Force (USPSTF) (www.ahrq.gov/
clinic/uspstfix.htm): A collection of materials related to the
work of an independent panel of experts in primary care and
prevention that systematically reviews the evidence of effec-
tiveness and develops recommendations for clinical preventive
services.
Evidence-Based Practice Resources
Centre for Evidence-Based Medicine (Oxford, United Kingdom)
(www.cebm.net): Major website for learning about, practicing,
and teaching EBM. The Toolbox provides valuable resources for
learning and practice.
Centre for Evidence-Based Medicine (Toronto, Canada) (www.
cebm.utoronto.ca): In addition to learning resources, this site pro-
vides focused syllabi for specialties and a glossary.
Centres for Health Evidence (www.cche.net): Based in Alberta, Can-
ada, this center provides resources and support for evidence-based
practice.
Cochrane Collaboration (www.cochrane.org): This international
nonprofit and independent organization is dedicated to making
up-to-date, accurate information about the effects of health care
readily available worldwide through systematic reviews of medi-
cal research.
Evidence-Based Medicine Tool Kit (www.ebm.med.ualberta.ca): A
collection of tools for identifying, assessing, and applying relevant
evidence for better health care decision making.
JAMAevidence (www.JAMAevidence.com): Excellent self-paced
learning modules based on the JAMA Users’ Guide series, featur-
ing interactive activities designed to reinforce learning.
Pediatric Critical Care Evidence-Based Medicine Resources
(http://pedsccm.org/EBJournal_Club_intro.php): An online
collection of resources and training tools for the pediatric pro-
fessional.
Student’s Guide to the Medical Literature (http://140.226.6.124/SG):
A guide suitable for anyone new to evidence-based medicine,
written by a former UCD-AMC medical student for other stu-
dents.
Understanding Evidence-Based Healthcare: A Foundation for Ac-
tion (http://us.cochrane.org/understanding-evidence-based-
healthcare-foundation-action): A Web course created by the
U.S. Cochrane Center that is designed to help the user under-
stand the fundamentals of evidence-based health care concepts
and skills.
10.e4 References
Texts
Craig J, Smyth R: The evidence-based practice manual for nurses, ed 3,
New York, 2011, Churchill Livingstone.
Dawes M, Davies P, Gray A: Evidence based practice: a primer for health
care professionals, ed 2, New York, 2005, Churchill Livingstone.
Dicenso A, Guyat G, Ciliska D: Evidence based nursing: a guide to clinical
practice, St Louis, 2004, Mosby.
Friedland DJ, Go AS, Davoren JB, et al: Evidence-based medicine: a frame-
work for clinical practice, Stamford, Conn, 1998, Appleton-Lange.
Greenhalgh T: How to read a paper: the basics of evidence-based medicine,
ed 4, London, 2010, BMJ.
Malloch K, Porter-Grady T: Introduction to evidence-based practice in nurs-
ing and health care, ed 2, Boston, 2009, Jones & Bartlett.
Melnyk B, Fineout-Overholt E: Evidence based practice in nursing
and healthcare, ed 2, Philadelphia, 2011, Lippincott Williams &
Wilkins.
Riegelman RK: Studying a study and testing a test: how to read the medical
evidence, ed 5, Boston, 2004, Little, Brown.
Sackett DL, Richardson WS, Rosenberg W, et al: Evidence-based medi-
cine: how to practice and teach EBM, Edinburgh, 2000, Churchill
Livingstone.
Straus SE, Glasziou P, Richardson WS, et al: Evidence-based medicine:
how to practice and teach it, ed 4, London, 2011, Harcourt.
Straus SE,Tetroe J, Graham ID: Knowledge translation in health care: mov-
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Kramer MS: Randomized trials and public health interventions: time
to end the scientific double standard [Review], Clin Perinatol
30:351, 2003.
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maintains an updated and selective, but substantial, list of referenc-
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 UNIT TWO SUPPORT OF THE NEONATE
PRENATAL ENVIRONMENT
2 Effect on Neonatal Outcome
PRISCILLA M. NODINE, MARIE HASTINGS-TOLSMA, AND JAIME ARRUDA
T he human fetus develops within a complex
maternal environment. Structurally defined
by the intrauterine/intraamniotic compart-
ment, the character of the prenatal environment is
determined largely by maternal variables. The fetus
depends totally on the maternal host for respiratory
and nutritive support and is significantly influenced
by maternal metabolic, cardiovascular, and environ-
mental factors. In addition, the fetus is limited in its
ability to adapt to stress or modify its surroundings.
This creates a situation in which the prenatal
environment exerts a tremendous influence on
fetal development and well-being. This influ-
ence lasts well beyond the period of gestation, often
affecting the newborn in ways that have profound
significance for both immediate and long-term
outcome.
There is great utility in identifying maternal fac-
tors that adversely affect the condition of the fetus.
Providers of obstetric care have long used this
information to identify the “at-risk” population
and design interventions that prevent or reduce the
occurrence of fetal and neonatal complications. It is
equally important that neonatal care providers
obtain a clear picture of the prenatal environ-
ment and use this information before birth to
anticipate the newborn’s immediate needs and
make appropriate preparations for resuscitation
and initial nursery care. After birth, an awareness
of the likely sequelae of environmental compromise
PURPLE type highlights content that is particularly applicable to clinical settings.
helps focus ongoing assessment and aids in clinical
decision making.
The purpose of this chapter is to help neonatal
care providers evaluate maternal influences on the
prenatal environment, identify significant environ-
mental risk factors, and anticipate the associated
neonatal problems. Maternal factors and environ-
mental influences are important determinants in
neonatal outcome.
PHYSIOLOGY
Two variables have a critical influence on fetal
well-being throughout gestation: uteroplacental
functioning and inherent maternal resources. The
interplay of these factors is a major determinant of
fetal oxygenation, metabolism, and growth. Altera-
tions in the development and function of the pla-
centa also influence fetal growth and development.
The fetus may be affected to the point that survival
is threatened. Likewise, extrauterine well-being may
be compromised.
The placenta has a dual role in providing nutri-
ents and metabolic fuels to the fetus. First, placental
secretion of endocrine hormones, chiefly human
chorionic somatomammotropin, increases through-
out pregnancy, causing progressive changes in mater-
nal metabolism. The net effect of these changes is
an increase in maternal glucose and amino acids
11
12 UNIT T WO Support of the Neonate
available to the fetus, especially in the second half
of pregnancy. Second, the placenta is instrumental
in the transfer of these (and other) essential nutri-
ents from the maternal to the fetal circulation and,
conversely, of metabolic wastes from the fetal to the
maternal system. Adequate maternal and fetal blood
flow through the placenta is essential throughout the
entire pregnancy.
Fetal respiration also depends on adequate pla-
cental function. Respiratory gases (oxygen and car-
bon dioxide) readily cross the placental membrane
by simple diffusion, with the rate of diffusion deter-
mined by the Po2 (or Pco2) differential between
maternal and fetal blood.
Although the placenta mediates the transport
of respiratory gases, carbohydrates, lipids, vitamins,
minerals, and amino acids, the maternal reservoir is
their source. Maternal-fetal transfer depends on the
characteristics and absolute content of substances
within the maternal circulation, the relative effi-
ciency of the maternal cardiovascular system in per-
fusing the placenta, and the function of the placenta
itself. The fetal environment can be disrupted by
inappropriate types or amounts of substances (e.g.,
ethanol) in the maternal circulation, decreases or
interruptions in placental blood flow (e.g., placental
abruption), or abnormalities in placental function
(e.g., small placenta). Maternal nutrition, exercise,
and disease can impair placental uptake and transfer
of substances across the placenta to the fetus.
COMPROMISED FETAL
ENVIRONMENT
Maternal Disease
DIABETES
The prevalence of diabetes mellitus and gestational
diabetes mellitus (GDM) is increasing worldwide.
Diabetes is the most common endocrine disorder
affecting pregnancy, having doubled in the past
decade with approximately 4% to 10% of pregnant
women in the United States diagnosed with GDM
annually.21 This increase is likely fueled by the obe-
sity epidemic. Despite major reductions in mortality
rates over the past several decades, the infant of a dia-
betic mother (IDM) continues to have a consider-
able perinatal disadvantage. The physiologic changes
in maternal glucose use that accompany pregnancy,
coupled with either a preexisting hyperglycemia
(as found in types 1 and 2 diabetes) or an inability
to mount an appropriate insulin response (as seen in
patients with gestational diabetes), result in a signifi-
cantly abnormal fetal environment. This is because
of the increased level of maternal glucose, often in
concert with episodic hypoglycemia, as well as high
levels of triglycerides and free fatty acids. Early in
pregnancy, this environment may have a teratogenic
effect on the embryo, accounting for the dramatic
increase in spontaneous abortions and congenital
malformations in the offspring of diabetic women
with poor metabolic control.7 During the second
and third trimesters, the mechanics of placental
transport dictate that fetal glucose levels depend on,
but are slightly less than, maternal levels.11 Assuming
adequate placental function and perfusion, eleva-
tions in maternal glucose lead to fetal hyperglycemia
and increased fetal insulin production. Repeated or
continued elevations in blood glucose result in fetal
hyperinsulinism, alterations in the use of glucose and
other nutrients, and altered patterns of growth and
development.7,11
Fetal macrosomia (greater than the 90th per-
centile for weight) occurs in 25% to 42% of dia-
betic pregnancies because of hyperinsulinemia.
These macrosomic infants suffer increased morbid-
ity and mortality rates from unexplained death in
utero, birth trauma, hypertrophic cardiomyopathy,
vascular thrombosis, neonatal hypoglycemia, hyper-
bilirubinemia, erythrocytosis, and respiratory dis-
tress.54 Although intrauterine fetal death (IUFD) is
at an increased risk for those pregnant women with
preexisting or overt diabetes, the most contempo-
rary literature does not support an increased risk
for IUFD for those with true GDM.54 Macroso-
mic infants have increased risk for shoulder dystocia
during vaginal birth, as well as brachial plexus injury,
facial nerve palsy, dysfunctional labor patterns, and
operative vaginal birth.
In addition to the basic metabolic disturbances,
diabetes predisposes the pregnant woman to several
other complications, including gestational hyperten-
sion, preeclampsia, renal disease, and vascular disease.
As a consequence, the fetus may be compromised
further by chronic hypoxia and other insults, which
can lead to intrauterine demise, prematurity, growth
restriction, cardiovascular problems, respiratory dis-
tress syndrome (RDS), and long-term neurologic
problems.7 In terms of predicting perinatal morbidity
and mortality, the prognostically bad signs of preg-
nancy include diabetic ketoacidosis, hypertension,
 C H A P T E R 2 Prenatal Environment: Effect on Neonatal Outcome
pyelonephritis, and maternal noncompliance,
though risk of adverse neonatal outcome occurs
on a continuum with no clear threshold.7
In preparing for the delivery of an IDM, the
neonatal team should consider the classification of
maternal diabetes (type 1 or 2, or gestational). In
addition, the quality of metabolic control through­­­
out the pregnancy and labor, maternal complica-
tions, and the duration of the pregnancy should
be considered, along with indicators of fetal
growth and well-being. In cases where oral
antihypertensive agents have been used, there
should be careful assessment of the neonate
because sulfonylurea (i.e., glyburide) may cause
neonatal jaundice. Glyburide crosses the pla-
centa, as does metformin, with the potential to
affect neonatal physiology.12 Both of these medi-
cations are thought to be safe for the neonate
during lactation (see Chapter 18).
THYROID DISEASE
Thyroid disorders during pregnancy are relatively
common. The thyroid hormones triiodothyronine
(T3) and thyroxine (T4) cross the placenta in small
amounts, though the significance of the transfer
has not been well elucidated. The fetus depends on
maternal T4 in the first trimester of pregnancy. At
8 to 10 weeks’ gestation, the fetal thyroid begins to
concentrate iodine and produce T4. During the sec-
ond and third trimester, the fetus is independent of
maternal status. At approximately 24 weeks, thyroid-
stimulating immunoglobulins (TSIs) or thyroid-
stimulating hormone (TSH) receptor Abs, which
are classes of immunoglobulin G (IgG), cross the
placenta and stimulate fetal thyroid. Iodine is readily
transferred from mother to fetus. The fetal thyroid
gland concentrates iodine and synthesizes its
own hormones as early as 10 to 12 weeks’ ges-
tation; this is independent of maternal thyroid
function. Maternal thyroid hormones are believed
to be important for fetal neurologic development
in the first trimester and untreated hypothyroid-
ism has been associated with a decrease in intelli-
gence quotient (IQ) of offspring.44 Subclinical and
overt hypothyroidism should be treated because
they may result in increased neurodevelopmen-
tal delay in offspring, pregnancy loss, prematu-
rity, preeclampsia, low birth weight, and placental
abruption.44 Treatment with replacement hormone
during pregnancy is well tolerated by the fetus and
reduces these risks.1
13
Maternal hyperthyroidism presents a different
situation. Thyroid-stimulating antibodies, commonly
found in patients with Graves’ disease, as well as
many of the drugs used to treat hyperthyroidism,
cross the placenta and can have a significant effect
on the fetus. Antibodies, including long-acting thy-
roid stimulant and TSI, can increase fetal thyroid
hormone production. High levels are associated
with fetal and neonatal hyperthyroidism. Untreated
maternal thyrotoxicosis has been linked to preterm
delivery, intrauterine growth restriction (IUGR),
low birth weight, and stillbirth. In rare cases, the
offspring of women with Graves’ disease may
themselves have this condition. In fetuses and
newborns, this is evidenced by elevations in
heart rate, growth restriction, prematurity, goi-
ter, and congestive heart failure.44 Administra-
tion of antithyroid medication to the mother can
decrease thyroid hormone production in both the
mother and the fetus but may result in fetal hypo-
thyroidism and goiter.1
Another maternal antibody, TSH-binding inhibi-
tor immunoglobulin, also crosses the placenta and
can prevent the expected fetal thyroid response to
TSH. The result is a transient fetal and neonatal
hypothyroidism. Iodine deficiency in the mother is
another cause of fetal and neonatal hypothyroidism
and, in its severe form, leads to cretinism because of
the fetus’s dependence on maternal iodine reserves.1
PHENYLKETONURIA
Phenylketonuria (PKU) is an inherited disorder in
which an enzymatic defect precludes conversion
of the essential amino acid phenylalanine to tyrosine.
This metabolic derangement is evidenced by
an accumulation of excessive amounts of phe-
nylalanine and alternative pathway byproducts
in the blood, and these are toxic to the central
nervous system. Historically, PKU resulted in vir-
tually certain mental retardation; affected individuals
often were institutionalized and rarely reproduced.
With the advent of universal neonatal screening
in the United States since the 1960s and effective
dietary treatment to prevent hyperphenylalaninemia
during infancy and early childhood, genetically
affected persons may avoid the devastating effects of
this disease, have relatively normal development, and
become pregnant. For women who do conceive,
PKU poses a significant environmental risk for their
developing fetus.The care of these women and their
infants presents a unique perinatal challenge.
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 DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI

Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
 FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)

The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
 Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA

I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
 The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.

MAKONDE LOCK AND KEY AT JUMBE CHAURO

 This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
 “We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
 Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
 BRAZIER

Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT

SMOOTHING WITH MAIZE-COB

CUTTING THE EDGE

 FINISHING THE BOTTOM

LAST SMOOTHING BEFORE

BURNING

FIRING THE BRUSH-PILE

 LIGHTING THE FARTHER SIDE OF
THE PILE

TURNING THE RED-HOT VESSEL

NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
 Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK

DRAWING THE BARK OFF THE LOG

REMOVING THE OUTER BARK

 BEATING THE BARK

WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT

MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN