Merenstein & Gardner’s Handbook of

Neonatal Intensive Care 8th Edition

Sandra Lee Gardner & Brian S. Carter &
Mary I Enzman-Hines & Jacinto A.
Hernandez
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Merenstein &
Gardner’s Handbook
of Neonatal Intensive
Care
EIGHTH EDITION

Sandra L. Gardner, RN, MS

Retired Clinical Nurse Specialist; Retired Pediatric Nurse Practitioner; Director, Professional
Outreach Consultation; Editor, Nurse Currents and NICU Currents, Aurora, Colorado

Brian S. Carter, MD, FAAP

Professor of Pediatrics, University of Missouri-Kansas City School of Medicine, Division of
Neonatology & Bioethics Center, Children’s Mercy Hospital-Kansas City, Kansas City, Missouri

Mary Enzman Hines, PhD, APRN, CNS, CPNP,

APHN-BC
Professor Emeritus, Beth El College of Nursing and Health Sciences, University of Colorado at
Colorado Springs
Certified Pediatric Nurse Practitioner, Rocky Mountain Pediatrics, Lakewood, Colorado

Jacinto A. Hernández, MD, PhD, MHA, FAAP

2
Professor Emeritus of Pediatrics, Section of Neonatology, Department of Pediatrics, University of
Colorado School of Medicine
Chairman Emeritus Department of Neonatology, Children’s Hospital Colorado, Aurora, Colorado

3
Table of Contents
Cover image

Title page

Newborn Metric Conversion Tables

Copyright

Dedication

Contributors

Reviewers

Preface

Introduction
Unit One. Evidence-Based Practice

1. Evidence-Based Clinical Practice

Finding High-Quality Evidence

Pressures to Intervene

Evaluation of Therapies

Qualitative Research Evaluating Experiences in the Neonatal Intensive Care Unit

Systematic Review in Perinatal Care and Evidence-Based Practice

Translating Evidence into Practice

Clinical Practice Guidelines

4
Unit Two. Support of the Neonate

2. Prenatal Environment: Effect on Neonatal Outcome

Physiology

Compromised Fetal Environment

Environmental Effects of Labor on the Fetus

Assessment of Fetal Well-Being

3. Perinatal Transport and Levels of Care

Regional Perinatal Referral and Transport System

Neonatal Transport

Family-Centered Care for Transport

Future of Neonatal Transport

4. Delivery Room Care

A Golden Opportunity

Physiology

Asphyxia and Apnea

Clamping of the Umbilical Cord

Resuscitation of the Newborn

Delivery Room Emergencies

Care During the Transition from the Delivery Room to the Nursery

Care of the Family and Perinatal Decision Making

5. Initial Nursery Care

Assessment and Care at Delivery

Evaluation and Care During the Transitional Period

Physical Assessment of the Newborn

Late-Preterm Infant

Care of the Well Newborn Infant

Parent Teaching

5
6. Heat Balance
Historical Milestones

Physiologic Considerations

Etiology of Heat Imbalances

Prevention of Heat/Cold Stress

Data Collection

Hypothermia

Hyperthermia

Parent Teaching

7. Physiologic Monitoring
Physiology

Noninvasive Monitoring

Data Collection

Interventions

Complications

Controversies

Parent Teaching

8. Acid-Base Homeostasis and Oxygenation

Physiology

Data Collection

Treatment

Complications

9. Diagnostic Imaging in the Neonate

Radiography

Fluoroscopy

Ultrasonography

Computed Tomography

Magnetic Resonance Imaging

Nuclear Scintigraphy

6
 Positron Emission Tomography

Interventional Radiology

Picture Archiving and Communication Systems

Family Education and Involvement

10. Pharmacology in Neonatal Care

Physiology

Data Collection

Drug Categories

Prevention of Therapeutic Mishaps

Methods of Administration

Parent Teaching

11. Drug Withdrawal in the Neonate

Physiology

Etiology of Neonatal Abstinence Syndrome

Prevention

Diagnosis

Treatment and Intervention

Parent Teaching

12. Pain and Pain Relief

Physiology and Pathophysiology

Neuroanatomy

Physiologic Responses

Etiology

Prevention

Data Collection

Treatment

End-of-Life Care

Complications

Parent Teaching

7
13. The Neonate and the Environment: Impact on Development
Developmental Tasks of the Neonate and Infant

Endowment

Environment

Interventions

Unit Three. Metabolic and Nutritional Care of the Neonate

14. Fluid and Electrolyte Management

Physiology

Etiology

Prevention

Data Collection

Treatment

Complications

Parent Teaching

15. Glucose Homeostasis

Fetal Physiology

Neonatal Physiology

Hypoglycemia

Hyperglycemia

Etiology of Hypoglycemia and Hyperglycemia

Prevention of Hypoglycemia and Hyperglycemia

Data Collection

Treatment

Complications

Parent Teaching

16. Total Parenteral Nutrition

Physiology

Indications

Data Collection

8
 Treatment

Complications

Parent Teaching

17. Enteral Nutrition

Physiology

Nutritional Requirements

Composition of Enteral Feedings

Feeding Techniques

Feeding Intolerance and Complications

The Preterm Infant

The Intrauterine Growth–Restricted Infant

Changes in Nutritional Requirements with Illness

Developmental Support

Family Support

Feeding the Preterm Infant After Hospital Discharge

18. Breastfeeding the Neonate with Special Needs

Physiology of Breastfeeding

Psychologic Values of Breastfeeding

Facilitating Successful Breastfeeding

Prevention of Breastfeeding Problems

Data Collection and Intervention

Complications of Breastfeeding

Parent Teaching

19. Skin and Skin Care

Physiology

Etiology

Prevention

Data Collection

Treatment

9
 Complications

Parent Teaching

Unit Four. Infection and Hematologic Diseases of the Neonate

20. Newborn Hematology

Red Blood Cells

Polycythemia and Hyperviscosity

Coagulation

Thrombosis

White Blood Cells

21. Neonatal Hyperbilirubinemia

Pathophysiology

Etiology of Hyperbilirubinemia

Mechanisms of Bilirubin Neurotoxicity

Prevention of Hyperbilirubinemia

Evaluation of the Infant with Hyperbilirubinemia

Treatment

Parent Teaching

Health Systems Approach to Bilirubin

22. Infection in the Neonate

Pathophysiology and Pathogenesis

Etiology

Specific Infectious Diseases

Parent Teaching

Unit Five. Common Systemic Diseases of the Neonate

23. Respiratory Diseases

General Physiology

General Etiologic Factors

General Prevention

10
 General Data Collection

General Treatment Strategies

General Complications

Parent Teaching

24. Cardiovascular Diseases and Surgical Interventions

Congenital Heart Disease: Overview

Specific Conditions

Parent Teaching

Future Research

25. Neonatal Nephrology

Normal Development

Clinical Assessment of Renal Disease in the Neonate

Acute Kidney Injury

Intrinsic Renal Parenchymal Abnormalities

Renal Vein Thrombosis

Hydronephrosis

Hypertension

Abdominal Masses

Renal Tubular Disorders

Urinary Tract Infection

Neurogenic Bladder

Nephrocalcinosis and Nephrolithiasis

Chronic Renal Failure

Nursing Care of the Neonate with Renal Failure

26. Neurologic Disorders

Congenital Malformations

Birth Injuries

Specific Birth Injuries

Hypotonia

11
 Neonatal Seizures

Hypoxic-Ischemic Encephalopathy

Intraventricular Hemorrhage

Pediatric Stroke

27. Genetic Disorders, Malformations, and Inborn Errors of Metabolism

Genetic Principles

Etiology

Data Collection

Treatment and Intervention

The Human Genome Project

Parent Teaching

28. Neonatal Surgery

Diaphragmatic Hernia

Esophageal Atresia and Tracheoesophageal Fistula

Congenital Chest Masses

Intestinal Malrotation and Volvulus

Intestinal Atresia

Necrotizing Enterocolitis

Meconium Ileus

Hirschsprung’s Disease

Anorectal Malformations

Omphalocele and Gastroschisis

Neonatal Tumors

Minimally Invasive Surgery

Parent Teaching

Unit Six. Psychosocial Aspects of Neonatal Care

29. Families in Crisis: Theoretical and Practical Considerations

Normal Attachment

Psychologic Adjustments to a Sick Newborn

12
 Communicating Medical Information: Evidence-Based Practice

Postpartum Mood Disorders

Adaptation to the Intensive Care Environment

30. Grief and Perinatal Loss

The Grief Process

Perinatal Situations in Which Grief is Expected

Stages of Grief

Symptoms of Grief

Male–Female Differences

Timing of Grief Resolution

Interventions

Children and Grief

Pathologic Grief

31. Discharge Planning and Follow-Up of the Neonatal Intensive Care Unit Infant
Planning for Discharge

Neurodevelopmental Follow-Up of High-Risk Infants

Complex Disorders of Brain Development

Perinatal Risk Factors for Neurodevelopmental Impairments

Specific Neurodevelopmental Outcomes

Tracking Health Outcomes: the Primary Care Provider

Long-Term Neurodevelopmental Follow-Up

32. Ethics, Values, and Palliative Care in Neonatal Intensive Care

Historical Overview

Definition of Bioethics

Theories of Ethics

Clinical Dilemmas in the Neonatal Intensive Care Unit

Decision Making in the Neonatal Intensive Care Unit

Ethics Committee or Palliative Care Consultation?

Communicating with Families

13
 Palliative Care in the Intensive Care Setting

Social Ethics

Glossary

Index

Newborn Metric Conversion Tables (Cont’d)

14
Newborn Metric Conversion
Tables
Temperature

Fahrenheit (F) to Centrigrade (C)

NOTE: °C = (°F – 32) × 5/9. Centrigrade temperature equivalents rounded to one decimal place by adding
0.1 when second decimal place is 5 or greater.
The metric system replaces the term “centrigrade” with “Celsius” (the inventor of the scale).
See inside back cover for additional tables.

15
Copyright

3251 Riverport Lane

St. Louis, Missouri 63043

MERENSTEIN & GARDNER’S HANDBOOK OF NEONATAL INTENSIVE CARE,

EIGHTH EDITION ISBN: 978-0-323-32083-2

Copyright © 2016 by Elsevier, Inc.

Copyright © 2011, 2006, 2002, 1998, 1993, 1989, 1985 by Mosby, Inc., an affiliate of
Elsevier Inc.

All rights reserved. No part of this publication may be reproduced or transmitted in any
form or by any means, electronic or mechanical, including photocopying, recording, or
any information storage and retrieval system, without permission in writing from the
publisher. Details on how to seek permission, further information about the Publisher’s
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www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright
by the Publisher (other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research
and experience broaden our understanding, changes in research methods, professional
practices, or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge
in evaluating and using any information, methods, compounds, or experiments
described herein. In using such information or methods they should be mindful of
their own safety and the safety of others, including parties for whom they have a
professional responsibility.

With respect to any drug or pharmaceutical products identified, readers are advised to
check the most current information provided (i) on procedures featured or (ii) by the
manufacturer of each product to be administered, to verify the recommended dose or
formula, the method and duration of administration, and contraindications. It is the

16
 responsibility of practitioners, relying on their own experience and knowledge of their
patients, to make diagnoses, to determine dosages and the best treatment for each
individual patient, and to take all appropriate safety precautions.

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or
editors, assume any liability for any injury and/or damage to persons or property as a
matter of products liability, negligence or otherwise, or from any use or operation of
any methods, products, instructions, or ideas contained in the material herein.

Library of Congress Cataloging-in-Publication Data

Merenstein & Gardner’s handbook of neonatal intensive care / [edited by] Sandra L.
Gardner, Brian S. Carter, Mary Enzman Hines, Jacinto A. Hernandez. -- Eighth edition.
p. ; cm.
Merenstein and Gardner’s handbook of neonatal intensive care
Preceded by Merenstein & Gardner’s handbook of neonatal intensive care / [edited by]
Sandra L. Gardner... [et al.]. 7th ed. c2011.
Includes bibliographical references and index.
ISBN 978-0-323-32083-2 (pbk. : alk. paper)
I. Gardner, Sandra L., editor. II. Carter, Brian S., 1957- , editor. III. Hines, Mary Enzman,
editor. IV. Hernandez, Jacinto A., editor. V. Title Merenstein and Gardner’s handbook of
neonatal intensive care.
[DNLM: 1. Intensive Care, Neonatal. 2. Infant, Newborn, Diseases--therapy. WS 421]
RJ253.5
618.92’01--dc23
2015006347

Executive Content Strategist: Lee Henderson

Content Development Manager: Jean Sims Fornango
Senior Content Development Specialist: Tina Kaemmerer
Publishing Services Manager: Catherine Jackson
Senior Project Manager: Carol O’Connell
Design Direction: Renee Duenow

Printed in China

Last digit is the print number: 9 8 7 6 5 4 3 2 1

17
Dedication

We dedicate this edition to the memory of Gerald B. Merenstein, MD—our

friend, colleague, and mentor who was also a wonderful husband, father, and
grandfather. As the inspiration for this text, Gerry contributed to the fields of
neonatal and pediatric care through his dedication to nurses, nurse practitioners,
child health associates, interns, residents, fellows, neonates, and their families. We
miss him every day and know that his empathy, knowledge, teaching, and
compassion influences all of us, as well as the newborns, children, and families
that he and we serve.

SLG BSC MEH JAH

In memory of Stephanie Marie Gardner, whose three days of life did have a
purpose.

SLG

To my family: Angel, Sean, Yvonne, Rebecca, and Jacquelyn; my mentors and

colleagues; and all of the children and families who have allowed me to share
with them both joyous and difficult times in their lives.

BSC

To my family James, Jennifer, Sean, Finnoula, Steve, and Sarah for their enduring
source of love, confidence, and encouragement and to all the families who have
informed by practice and knowledge about caring for fragile infants.

MEH

To all the newborn infants, their families, and dedicated caregivers; my beloved
wife Pam and sons Gabriel and Jacinto for their love and constant support.

JAH

In Memoriam

18
Jimmie Lynne Scholl Avery

L. Joseph Butterfield, MD

Lula O. Lubchenco, MD

William A. Silverman, MD

19
Contributors
Rita Agarwal, MD, FAAP, Professor of Anesthesiology, Director of Education, Pediatric
Anesthesia, Pediatric Anesthesia Program Director, Director of the Colorado Review of
Anesthesiology for Surgicenters and Hospital, Children’s Hospital Colorado, University
of Colorado Denver, School of Medicine, Aurora, Colorado

Marianne Sollosy Anderson, MD, Neonatologist, Sequoia Pediatrics, Kaweah Delta

Medical Center, Visalia, California

Jaime Arruda, MD, FACOG, Assistant Professor, Obstetrics and Gynecology,

University of Colorado Denver, Aurora, Colorado

James S. Barry, MD, Associate Professor of Pediatrics, Section of Neonatology,

Department of Pediatrics, University of Colorado Denver School of Medicine, Medical
Director, Neonatal Intensive Care Unit, University of Colorado Hospital Department of
Neonatology Children’s Hospital Colorado, Aurora, Colorado

Wanda Todd Bradshaw, MSN, RN, NNP-BC

Assistant Professor and Lead Faculty, NNP Specialty, Duke University School of Nursing,
Durham, North Carolina
Neonatal Nurse Practitioner, Moses Cone Health System, Greensboro, North Carolina

M. Colleen Brand, PhD, APRN, NNP-BC, Neonatal Nurse Practitioner, Texas

Children’s Hospital, Houston, Texas

Laura D. Brown, MD, Associate Professor of Pediatrics, Section of Neonatology,

Department of Pediatrics, University of Colorado Denver School of Medicine, Aurora,
Colorado

Jessica Brunkhorst, MD, Neonatology Fellow, Children’s Mercy Hospital, Kansas City,
Missouri

Brian T. Bucher, MD, Clinical Fellow, Pediatric Surgery, Department of Pediatric

Surgery, Vanderbilt, Nashville, Tennessee

Deanne Buschbach, RN, MSN, NNP, PNP, Clinical Operations Director for Advanced
Clinical Practice, Pediatric and Neonatal Critical Care APP Service, Pediatric Heart APP
Service, Duke University Medical Center, Durham, North Carolina

Melissa A. Cadnapaphornchai, MD, Associate Professor of Pediatrics and Medicine,

Pediatric Nephrology/The Kidney Center, University of Colorado Denver School of

20
Medicine and Children’s Hospital Colorado, Aurora, Colorado

Angel Carter, DNP, APRN, NNP-BC, Assistant Professor of Nursing, Assistant Chair
—BSN Degree Completion Program, Park University, Kansas City, Missouri

Brian S. Carter, MD, FAAP, Professor of Pediatrics, University of Missouri-Kansas City

School of Medicine, Division of Neonatology & Bioethics Center, Children’s Mercy
Hospital-Kansas City, Kansas City, Missouri

Susan B. Clarke, MS, RNC-NIC, RN-BC, CNS, Professional Development Specialist,

Continuing Education and Outreach, NRP Regional Trainer, Children’s Hospital
Colorado, Aurora, Colorado

C. Michael Cotten, MD, MHS, Associate Professor of Pediatrics, Medical Director,

Neonatology Clinical Research, Duke University, Durham, North Carolina

Heather Furlong Craven, MD, Associate Professor of Pediatrics, Division of

Neonatology, Medical Director of Neonatal Transport Services, Wake Forest School of
Medicine Brenner Children’s Hospital, Winston-Salem, North Carolina

Jane Davis, RNC, BSN, Level III Permanent Charge Nurse, Neonatal Intensive Care
Unit, University of Colorado Hospital, Aurora, Colorado

Jane Deacon, NNP-BC, MS, Neonatal Nurse Practitioner, Children’s Hospital

Colorado, Aurora, Colorado

David J. Durand, MD, Division of Neonatology, UCSF Benioff Children’s Hospital-

Oakland, Oakland, California

Jarrod Dusin, MS, RD, Clinical Dietitian Specialist, Children’s Mercy Hospital, Kansas
City, Missouri

Nancy English, PhD, RN, Fetal Concerns, Director and Coordinator, Colorado High
Risk Maternity and Newborn Program, University of Colorado Health Sciences, The
Children’s Hospital, Aurora, Colorado

Mary Enzman Hines, PhD, APRN, CNS, CPNP, APHN-BC

Professor Emeritus, Beth El College of Nursing and Health Sciences, University of
Colorado at Colorado Springs
Certified Pediatric Nurse Practitioner, Rocky Mountain Pediatrics, Lakewood, Colorado

Lori Erickson, RN, CPNP, APRN, Fetal Cardiac and Cardiac High Acuity Monitoring
APRN, Ward Family Heart Center, Children’s Mercy Hospital, Kansas City, Missouri

Ruth Evans, MS, APRN, NNP-BC, Neonatal Nurse Practitioner, Children’s Hospital
Colorado and University of Colorado Hospital, Aurora, Colorado

Loretta P. Finnegan, MD
President, Finnegan Consulting, LLC, Perinatal Addiction and Women’s Health, Avalon,
New Jersey
Founder and Former Director of Family Center, Jefferson Medical College of Thomas
Jefferson University, Philadelphia, Pennsylvania

21
Sandra L. Gardner, RN, MS, Retired Clinical Nurse Specialist; Retired Pediatric Nurse
Practitioner; Director, Professional Outreach Consultation; Editor, Nurse Currents and
NICU Currents, Aurora, Colorado

Edward Goldson, MD, Professor, Department of Pediatrics, University of Colorado

Denver School of Medicine, The Children’s Hospital, Aurora, Colorado

Linda L. Gratny, MD
Associate Professor of Pediatrics, University of Missouri-Kansas City School of Medicine
Neonatologist and Director, Infant Tracheostomy and Home Ventilator Program,
Children’s Mercy Hospital, Kansas City, Missouri

Marie Hastings-Tolsma, PhD, CNM, FACNM

Professor, Nurse Midwifery, Louis Herrington School of Nursing, Baylor University,
Dallas, Texas
Visiting Professor, University of Johannesburg, Johannesburg, South Africa

William W. Hay Jr. MD, Professor of Pediatrics, Section of Neonatology, Scientific

Director, Perinatal Research Center, Co-Director for Child and Maternal Health and the
Perinatal Research Center, Colorado Clinical and Translational Sciences Institute,
University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora,
Colorado

Kendra Hendrickson, MS, RD, CNSC, CSP, Clinical Dietitian Specialist, Neonatal
Intensive Care Unit, University of Colorado Hospital, Aurora, Colorado

Carmen Hernández, MSN, NNP-BC, Neonatal Nurse Practitioner, Rocky Mountain

Hospital for Children, Denver, Colorado

Jacinto A. Hernández, MD, PhD, MHA, FAAP

Professor Emeritus of Pediatrics, Section of Neonatology, Department of Pediatrics,
University of Colorado School of Medicine
Chairman Emeritus Department of Neonatology, Children’s Hospital Colorado, Aurora,
Colorado

Patti Hills, LMSW, LCSW, Fetal Health Center, NICU Social Worker, Children’s Mercy
Hospital, Kansas City, Missouri

Mona Jacobson, MSN, RN, CPNP-PC, Instructor in Pediatrics, Section of Child

Neurology, University of Colorado School of Medicine, Children’s Hospital Colorado,
Aurora, Colorado

M. Douglas Jones Jr. MD, Senior Associate Dean for Clinical Affairs, Professor, Section
of Neonatology, Department of Pediatrics, University of Colorado Denver School of
Medicine, Aurora, Colorado

Beena Kamath-Rayne, MD, MPH, Assistant Professor of Pediatrics, Perinatal Institute,

Division of Neonatology, Global Health Center, Cincinnati Children’s Hospital Medical
Center, Cincinnati, Ohio

Rhonda Knapp-Clevenger, PhD, CPNP

Director, Research and Pediatric Nurse Scientist, Center for Pediatric Nurse Research

22
and Clinical Inquiry
Clinical Research Director, Pediatric and Perinatal Clinical Translational Research
Centers, University of Colorado Denver, College of Nursing , Children’s Hospital
Colorado, Aurora, Colorado

Ruth A. Lawrence, MD, DD(Hon), FAAP, FABM, Distinguished Alumna Professor of

Pediatrics and Obstetrics/Gynecology, Northumberland Trust Chair in Pediatrics,
Director of the Breastfeeding and Human Lactation Study Center, University of
Rochester School of Medicine and Dentistry, Rochester, New York

Mary Kay Leick-Rude, RNC, MSN, PCNS, Clinical Nurse Specialist, Children’s Mercy
Hospital, Kansas City, Missouri

Harold Lovvorn III MD, FACS, FAAP, Assistant Professor of Pediatric Surgery,
Vanderbilt University Children’s Hospital, Nashville, Tennessee

Carolyn Lund, RN, MS, FAAN

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

Jane E. McGowan, MD, Professor of Pediatrics, Associate Chair for Research, Drexel
University College of Medicine, Medical Director, NICU, St. Christopher’s Hospital for
Children, Philadelphia, Pennsylvania

Christopher McKinney, MD, Fellow, Pediatric Hematology, Center for Cancer and
Blood Disorders, Children’s Hospital Colorado, University of Colorado-Denver, Aurora,
Colorado

Mary Miller-Bell, PharmD, Clinical Research Pharmacist, Duke University Hospital,

Durham, North Carolina

Susan Niermeyer, MD, MPH, FAAP, Professor of Pediatrics and Epidemiology,

University of Colorado School of Medicine and Colorado School of Public Health,
Aurora, Colorado

Priscilla M. Nodine, PhD, CNM, 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

23
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

Eugenia K. Pallotto, MD, MSCE, Associate Professor, University of Missouri-Kansas

City School of Medicine, Medical Director, NICU, Children’s Mercy Hospital, Kansas City,
Missouri

Mohan Pammi, MD, PhD, MRCPCH, Associate Professor, Baylor College of Medicine,
Houston, Texas

Alfonso Pantoja, MD, Neonatologist, Saint Joseph’s Hospital, Denver Colorado

Julie A. Parsons, MD, Associate Professor of Pediatrics and Neurology, Haberfield

Family Endowed Chair in Pediatric Neuromuscular Disorders, Child Neurology Program
Director, University of Colorado School of Medicine, Children’s Hospital Colorado,
Aurora, Colorado

Webra Price-Douglas, PhD, CRNP, IBCLC, Maryland Regional Transport Program,

Baltimore, Maryland

Daphne A. Reavey, PhD, RN, NNP-BC, Neonatal Nurse Practitioner, Children’s Mercy
Hospital, Kansas City, Missouri

Nathaniel H. Robin, MD, FACMG, Professor of Genetics and Pediatrics, University of

Alabama at Birmingham, Birmingham, Alabama

Mario A. Rojas, MD, MPH, Professor of Pediatrics, Division of Neonatal-Perinatal

Medicine, Wake Forest University School of Medicine, Winston Salem, North Carolina

Jamie Rosterman, DO, Neonatology Fellow, Children’s Mercy Hospital, Kansas City,
Missouri

Paul Rozance, MD, Associate Professor of Pediatrics, Section of Neonatology,

University of Colorado Denver School of Medicine, Children’s Hospital Colorado,
Aurora, Colorado

Tamara Rush, MSN, RN, C-NPT, EMT, Nurse Manager, Brenner Children’s Hospital-
Wake Forest Baptist Health, Winston-Salem, North Carolina

Mary Schoenbein, BSN, RN, CNN, Perinatal Dialysis Nurse/The Kidney Center,
Children’s Hospital Colorado, Aurora, Colorado

Alan R. Seay, MD, Professor of Pediatrics and Neurology, University of Colorado

School of Medicine, Children’s Hospital Colorado, Aurora, Colorado

Danielle E. Soranno, MD, Assistant Professor of Pediatrics and Bioengineering,

Pediatric Nephrology/The Kidney Center, University of Colorado Denver School of
Medicine and Children’s Hospital Colorado, Aurora, Colorado

John Strain, MD, FACR, CAQ Pediatric Radiology, Neuroradiology

24
Professor of Radiology, Department of Radiology, University of Colorado School of
Medicine
Chairman, Department of Radiology, Children’s Hospital Colorado, Anschutz Medical
Campus, Aurora, Colorado

Julie R. Swaney, MDiv, Manager, Spiritual Care Services, Associate Clinical Professor,
Department of Medicine, University of Colorado Denver Anschutz Medical Campus,
Aurora, Colorado

Tara M. Swanson, MD
Assistant Professor of Pediatrics, University of Missouri-Kansas City School of Medicine
Director of Fetal Cardiology, Children’s Mercy Hospital, Kansas City, Missouri

David Tanaka, MD, Professor of Pediatrics, Neonatologist, Duke University Medical

Center, Durham, North Carolina

Elizabeth H. Thilo, MD
Associate Professor of Pediatrics, Section of Neonatology, University of Colorado Denver
School of Medicine
Neonatologist, University of Colorado Hospital and Children’s Hospital Colorado,
Aurora, Colorado

Kristin C. Voos, MD, Neonatologist, 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

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

25
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

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

26
Mindy Morris, DNP, NNP-BC, CNS, Neonatal Nurse Practitioner, Extremely Low Birth
Weight Program Coordinator, Children’s Hospital of Orange County, Orange, California

Tracy Ann Pasek, RN, MSN, DNP, CCNS, CCRN, CIMI, Clinical Nurse Specialist,
Pain/Pediatric Intensive Care Unit, Children’s Hospital of Pittsburgh, University of
Pittsburgh Medical Center, Pittsburgh, Pennsylvania

Patricia Scheans, DNP, NNP-BC, Clinical Support for Neonatal Care , Legacy Health,
Portland, Oregon

Peggy Slota, DNP, RN, FAAN, Associate Professor, Director, DNP and Nursing
Leadership Programs, Carlow University, Pittsburgh, Pennsylvania

Nicole Van Hoey, PharmD, Medical Writer/Editor, Consultant, Arlington, Virginia

Winnie Yung, MN, RN, Registered Nurse, Lucile Packard Children’s Hospital at
Stanford, Palo Alto, California

27
Preface
The concept of the team approach is important 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 neonatal 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 sections include highlighted
clinical directions for quick reference, Parent Teaching boxes to aid in discharge
instructions, and Critical Findings boxes to prioritize assessment data.
The combination of physiology and pathophysiology and separate emphasis on
clinical application in this text is designed for neonatal intensive care nurses, nursing
students, medical students, and pediatric, surgical, and family practice housestaff. This
text is comprehensive enough for nurses and physicians, 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 family are
discussed in this section. This section in particular will benefit social workers and clergy,
who often deal with family members of neonates in the NICU.
In this handbook we present physiologic principles and practical applications and
point out areas as yet unresolved. Material that is clinically applicable is set in purple
type so that it can be easily identified.

28
Introduction
In 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 Merenstein & Gardner’s
Handbook of Neonatal Intensive Care. Instead of editing this edition alone or with another
physician, I decided to convene an editorial team consisting of myself, a nurse colleague,
and two neonatologists. 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 translation 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 Professional Outreach Consultation
(www.professionaloutreachconsultation.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

29
Another random document with
no related content on Scribd:
 “WHY.”

I’m sad, for, loving thee, I know full well

That this world’s talk, with its calumnious spell,
Will never spare thy fresh youth’s opening flower.
For every happy day and sunny hour,
Fate will exact in grief and tears his pay.
I’m sad because I see my loved one gay!
 MOSCOW.

Moscow, I love thee with a filial love,

Strong, burning, tender, which a Russian knows!
I love the holy gleam thy brows above,
Thy battled Kremlin in its calm repose.
In vain the foreign Potentate[6] essayed,
Great Russian giant of a thousand years,
To cope with thee, and, by deceit betrayed,
To make thee bow thy soul to craven fears.
In vain the Stranger spurred; you reared; he fell!
The world grew silent ’neath his mighty spell;
Whilst thou alone didst live, my stately one,
Thou heir to glories ours, and ours alone!
Thou livest still, and every stone of thine
Doth tell of generations tales divine.

FOOTNOTES:
[6] Napoleon.
FROM PUSHKIN.
 ⁂

I wander down the noisy streets,

I enter crowded fanes,
I join in youthful revelries,
I give my fancy reins.

I say, “The years are flying fast,

And seen we scarce are here,
Before we reach eternal tombs;
For each the hour is near.”

I glance upon the lonely oak,

The patriarch of the wood,
And think, “He’ll live through my brief day,
He through my father’s stood.”

I fondly kiss the little child,

And, kissing, think, “Good-bye!
I’m giving up my place to you.
You bloom; ’tis mine to die.”

Thus every day, thus every hour,

I’m wont with thought to spend,
And strive to guess the birthday-date
Of my approaching end.

Ah! where will Fate send Death to me?

Abroad? in war? on deep?
Or will a neighbouring valley hold
My cold dust in its keep?
Yet, though I know my lifeless form
Must rot where’er I die,
I’d fondly wish near my loved home,
In my own land, to lie.

There, round the entrance to the grave,

Let young life freely play,
And careless Nature calmly smile
With ageless beauty gay!
 ANACREONTIC.

We know the steed of mettle

By the breed-marks branded on it;
We know the haughty Highlander
By his plumed and towering bonnet;
And I know the happy lovers
By the love-light in their eyes,
Where, its tale of joyance telling,
The languid flame doth rise.
 (TO HIS WIFE.)

No! not for me the wild tumultuous gladness,

The rapturous rush, the transports, and the madness,
The moans, the cries, the young Bacchante makes,
When, clinging close in coilings like a snake’s,
With wounding kiss, and gush of hot caresses,
For the last moments’ thrills she quiveringly presses.

Far dearer thou, my gentle one, to me,

And happy I—distracted more by thee—
When yielding to long prayers with gentle grace,
You press me softly in your meek embrace;
Modestly cold, to love with passion fraught
You scarce respond; you conscience seem of naught;
Yet warm and warmer glowing, till at last,
As ’twere against your will, you share my blast.
 ⁂

Let me not lose my senses, God;

Better the pilgrim’s scrip and rod,
Or toil and hunger sad.
Not that I prize this mind of mine,
Or that my reason to resign
I should not be right glad,
If only then they’d set me free.
At large! How sportively I’d flee
To where the dark wood gleams!
I’d sing in raving ecstasies,
Forgetting self in fantasies
Of changeful wondrous dreams.
To the wild waves I’d lend an ear,
And glancing upward, full of cheer,
Would scan the open sky;
And strong and free I’d rush amain,
A whirlwind sweeping o’er the plain,
Crashing through woods I’d fly.
But there’s the rub! You lose your sense—
Are dreaded like a pestilence,
And clapped in prison drear.
They chain you to the idiot’s yoke,
And, through the cage-bars, to provoke
The wild beast they draw near.
No more the nightingale to hear
At midnight singing sweet and clear,
Nor greenwood’s rustling strains,
But only brother-madmen’s cries,
The nightly keeper’s blasphemies,
And shrieks, and clang of chains.
 ⁂

I’ve overlived aspirings,

My fancies I disdain;
The fruits of hollow-heartedness,
Sufferings alone remain.

’Neath cruel storms of Fate,

Withers my crown of bay,
A sad and lonely life I lead,
Waiting my latest day.

Thus, struck by latter cold,

While howls the wintry wind,
Trembles upon the naked bough
The last leaf left behind.
 PETER THE GREAT.

With autocratic hand

He boldly sowed the light;
He did not scorn his native land—
He knew her destined might.
A carpenter, a seaman,
A scholar, hero, he,
With mighty genius on the throne,
A labourer was incessantly.
 THE PROPHET.

By spiritual thirst opprest,

I hied me to the desert dim,
When lo! upon my path appeared
The holy six-winged seraphim.
My brow his fingers lightly pressed,
Soothing my eyelids into rest:
Open my inward vision flies,
As ope a startled eaglet’s eyes.
He touched my ears, and they were filled
With sounds that all my being thrilled.
I felt a trembling fill the skies,
I heard the sweep of angels’ wings,
Beneath the sea saw creeping things,
And in the valleys vines arise.
Over my lips awhile he hung,
And tore from me my sinful tongue—
The babbling tongue of vanity.
The sting of serpent’s subtlety
Within my lips, as chilled I stood,
He placed, with right hand red with blood.
Then with a sword my bosom cut,
And forth my quivering heart he drew;
A glowing coal of fire he put
Within my breast laid bare to view.
As corpse-like on the waste I lay,
Thus unto me God’s voice did say—
“Prophet, arise! confess My Name;
Fulfil My will; submit to Me!
Arise! go forth o’er land and sea,
And with high words men’s hearts inflame!”
 ⁂

Play, my Kathleen;
No sorrow know.
The Graces flowers
Around thee throw.
Thy little cot
They softly swing,
And bright for thee
Dawns life’s fresh spring.
For all delights
Thou hast been born;
Catch, catch wild joys,
In life’s young morn!
Thy tender years
To love devote;
While hums the world,
Love my pipe’s note.
 A MONUMENT.[7]

I’ve raised myself no statue made with hands;

The People’s path to it no weeds will hide.
Rising with no submissive head, it stands
Above the pillar of Napoleon’s pride.
No! I shall never die; in sacred strains
My soul survives my dust, and flies decay—
And famous shall I be, while there remains
A single Poet ’neath the light of day.
Through all great Russia will go forth my fame,
And every tongue in it will name my name;
And by the nation long shall I be loved,
Because my lyre their nobler feelings moved;
Because I strove to serve them with my song,
And called forth mercy for the fallen throng.
Hear God’s command, O Muse, obediently,
Nor dread reproach, nor claim the Poet’s bay;
To praise and blame alike indifferent be,
And let fools say their say!

FOOTNOTES:
[7] Like our Shakespeare, Pushkin knew his own merits.
 THE POET.

Until Apollo calls the Bard

To share the holy sacrifice,
Plunged in the petty cares of life
The Poet’s spirit lies.

Silent and still his sacred lyre,

His soul to sleep a prey,
Amongst earth’s worthless sons he seems
More worthless, p’raps, than they.

But once the sacred summons rings

And strikes his eager ears,
The Poet’s soul, like eagle roused,
On upward pinion steers.

Then earthly pleasures cease to charm;

He scorns the babbling crowd;
No more beneath their Idol’s feet
His haughty head is bowed.

He flies—and wild and stern his moods,

His notes, now grave, now gay—
To shores where lonely billows play,
To depths of whispering woods.
FROM NADSON.
 ⁂

Pity the stately cypress trees;

How freshly green they spring!
Ah! why amidst their branches, child,
Have you put up your swing?
Break not a single fragrant bough.
Oh, take thy swing away
To heights where thick acacias bloom;
Mid dusty olives play!
Thence you can see the Ocean,
And, as your swing ascends,
Through greening boughs a sunny glimpse
The sea in laughter sends
Of white sails in the distance dim,
Of white gulls far away,
Of white flakes foaming on the sands,
A fringe of snowy spray.
FROM NEKRASOF.
 TE DEUM.

In our village there’s cold and there’s hunger;

Through the mist the sad morn rises chill;
Tolls the bell—the parishioners calling
From afar to the church on the hill;
Austere and severe and commanding
Pealed that dull tone thro’ the air.
I spent in the church that wet morning;
I can never forget the scene there.
For there knelt the village hamlet,
Young and old in a weeping crowd;
To be saved from the grievous famine
The people prayed aloud.
Such woe I had seldom witnessed,
Such agony of prayer,
And unconsciously I murmured,
“O God, the people spare!”

“Spare their friends, too, in Thy mercy!

Oh, hear our heartfelt cry!
For those who strove to free the serf
We lift the prayer on high;
For those who bore the battle’s brunt
And lived to win the day,
For those who’ve heard the serf’s last song,
To Thee, O God, we pray.”
 THE PROPHET.

Ah! tell me not he prudence quite forgot;

That he himself for his own fate’s to blame.
Clearer than we, he saw that man cannot
Both serve the good and save himself from flame.

But men he loved with higher, broader glow;

His soul for worldly honours did not sigh;
For self alone he could not live below,
But for the sake of others he could die.

Thus thought he—and to die, for him, was gain.

He will not say that “life to him was dear;”
He will not say that “death was useless pain;”
To him, long since, his destiny was clear.
 ⁂

Offer my Muse a friendly hand,

For I can sing no other song.
Who feels no woe, nor flames at wrong,
Loves not his Fatherland.