Transcript The Premature Infant: Nursing

The Premature Infant:
Nursing Assessment
and Management,
2nd Edition
Lyn E. Vargo, PhD, NNP, RNC
Carol Wiltgen Trotter, PhD,
NNP, RNC
Slides prepared by Margaret Comerford Freda, EdD, RN, CHES, FAAN
Preterm Births United States
Percent
12.3
11.9
12
10.8
10.1
9.4
7.6
8
4
0
1981
1991
2001
2003
27 percent increase from 1981 to 2001
© 2006, March of Dimes
2007
March of
Dimes
Objective
2010
Healthy
People
Objective
Transition to Extrauterine Life
• Requires many physiologic changes for the
infant
• Nurses need to understand general
principles of delivery-room management,
resuscitation and thermoregulation for
premature infants.
© 2006, March of Dimes
Delivery-Room Management
Certification by the Neonatal Resuscitation
Program (NRP) of the American Heart
Association (AHA) and the American Academy
of Pediatrics (AAP) is essential for all nurses
who work with premature infants.
© 2006, March of Dimes
Delivery-Room Management Risks
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Tendency to have difficulty with transition
Vulnerable to cold stress
More lung immaturity and RDS
More intracranial hemorrhage
More hypoglycemia
Potential for oxygen-related injuries
High risk of developing NEC
© 2006, March of Dimes
Delivery-Room Management
Precautions
• Follow resuscitation from NRP guidelines.
• Avoid rough handling during resuscitation.
• Reduce heat loss even if resuscitation is
not required.
• Preterm infants may require endotracheal
intubation and surfactant administration
soon after birth.
© 2006, March of Dimes
Delivery-Room Management
Precautions (Continued)
• Administer medication slowly as
recommended by NRP guidelines.
• Follow glucose levels carefully. Glycogen
stores may be decreased. Infant may
experience hypoglycemia secondary to
perinatal compromise.
• Maintain normal oxygen range after
resuscitation.
© 2006, March of Dimes
Major Physiologic Problems
of the Premature Infant
• RDS, BPD, apnea of prematurity and
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chronic lung disease
PDA and hypotension
ROP
Immune-system immaturity that increases
the risk of infection
P-IVH
© 2006, March of Dimes
Additional Physiologic Problems
of the Premature Infant
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Skin immaturity and fragility
Thermoregulation
GI issues
Fluid and electrolyte imbalances related
to immature renal function
Acid-base disorders
Pain management
Developmental issues related to the CNS
Impact of the NICU environment
© 2006, March of Dimes
RDS
• Incidence 10% for all premature infants
• Incidence 50% for 26 week to 28 weeks
• Risk factors:
– Low gestational age
– Male
– Born to diabetic mothers
– Born after an asphyxial insult before birth
– Born after maternal-fetal hemorrhage
– Multiple gestation
© 2006, March of Dimes
RDS
(Continued)
Complex respiratory disease characterized
by diffuse alveolar atelectasis of the lungs,
primarily caused by a deficiency of
surfactant. This leads to higher surface
tension at the surface of alveoli, which
interferes with normal exchange of oxygen
and carbon dioxide.
© 2006, March of Dimes
NIH Recommendations
for Use of Antenatal Steroids
• Give to all pregnant women 24 to 34
weeks gestation who are at risk for
preterm delivery within 7 days:
– 2 doses of 12 mg of betamethasone IM 24
hours apart OR
– 4 doses of 6 mg of dexamethasone IM 12 hours
apart
• Repeat courses of corticosteroids should
not be given routinely in pregnant women.
© 2006, March of Dimes
Chain of Events with Surfactant
Delivery
© 2006, March of Dimes
Signs and Symptoms of RDS
• Difficulty in establishing normal respiration,
especially if infant has risk factors for RDS
• Expiratory grunting while the infant is not
crying
• Intercostal and sternal retractions due to
increased rib cage compliance and decreased
lung compliance
© 2006, March of Dimes
Signs and Symptoms of RDS (Continued)
• Nasal flaring
• Cyanosis
• Tachypnea
© 2006, March of Dimes
RDS Treatment
• Thermoregulation
• Fluid balance and nutrition
• Skin care
• Pain assessment
• Developmental care
• Family care
© 2006, March of Dimes
RDS Treatment
(Continued)
• Focus is to prevent and minimize atelectasis.
• Minimize untoward effects of oxygen and
barotrauma or volutrauma.
• Treat underlying cardiovascular infectious
and other physiologic problems.
• Maintain a balanced physiologic
environment.
© 2006, March of Dimes
Surfactant Therapy
• Surfactant coats the inside of the alveoli.
It prevents collapse (atelectasis) and
keeps alveoli open at the end of
expiration.
• It is given via endotracheal tube.
• Prophylactic therapy appears more
beneficial than rescue therapy.
© 2006, March of Dimes
Surfactant Therapy
(Continued)
• Criteria for identifying at-risk infants who
would benefit from prophylactic
treatment are unclear.
• Multiple doses lead to improved clinical
outcomes.
© 2006, March of Dimes
Adjunct Treatments for RDS
CPAP
– A method of assisting lung expansion with
continuous distending pressure
– A valuable adjunct when spontaneous
breathing is adequate and pulmonary
disease is not excessive
– Increases transpulmonary pressure;
improves oxygenation and ventilation
– Reduces tachypnea and grunting
© 2006, March of Dimes
Adjunct Treatments for RDS
(Continued)
• HFV
– Allows the use of small tidal volumes (smaller
than anatomic dead space) and high frequencies.
– Rates of 150 to 3,000 breaths per minute can be
used depending on the type of HFV.
– HFV limits large tidal volumes and wide ventilator
pressure swings associated with volutrauma/
barotrauma caused by traditional mechanical
ventilation.
• Oscillation
© 2006, March of Dimes
RDS Nursing Care
Any nurse caring for an infant with RDS must:
– Be familiar with RDS pathophysiology
– Recognize symptoms of RDS
– Initiate interventions as indicated
© 2006, March of Dimes
RDS Nursing Care (Continued)
• Maintain paO2 and oxygen saturation levels.
• Recognize importance of weaning oxygen
and other ventilator parameters.
• Recognize complications arising from RDS,
intubation and mechanical ventilation.
• Utilize proper endotracheal suctioning
techniques.
© 2006, March of Dimes
RDS Nursing Care (Continued)
• Provide mouth and skin care.
• Maintain proper positioning.
• Provide adequate fluid and electrolyte
balance.
• Monitor blood glucose levels.
• Reduce environmental stressors.
• Provide parental support.
© 2006, March of Dimes
BPD
• A significant problem for premature
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•
infants
Uncommon after 32 weeks gestation
A secondary disease that develops in
neonates treated with positive pressure
ventilation and oxygen for primary lung
problems such as RDS
7,500 new cases every year in the United
States
10% die by 1 year of age
© 2006, March of Dimes
Signs and Symptoms of BPD
• Hypoxemia with prolonged oxygen
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•
•
•
requirement
Hypercapnia, tachypnea with increased work
of breathing
Episodic bronchospasm with wheezing
In severe cases, CHF with cor pulmonale
Abnormal postures of neck and upper trunk
© 2006, March of Dimes
Cascade of Events Occurring in
BPD
© 2006, March of Dimes
BPD Treatment
• Therapy is preventive and supportive.
• Preventive measures begin prenatally with
preventing prematurity and using a single
course of antenatal steroids.
• Includes early, careful management of RDS,
use of low ventilator pressures, and careful
use of oxygen and exogenous surfactant
treatment.
© 2006, March of Dimes
AAP/CPS Summary/Recommendations on
Postnatal Steroids
• Systemic administration of dexamethasone
to mechanically ventilated premature
infants decreases incidence of chronic lung
disease and extubation failure. Does not
decrease overall mortality.
• Dexamethasone treatment for VLBW infants
is associated with complications (impaired
growth and neurodevelopmental delay).
© 2006, March of Dimes
AAP/CPS Summary/Recommendations on
Postnatal Steroids (Continued)
• Use of inhaled corticosteroids to prevent
CLD has not shown benefits.
• Routine use of dexamethasone for the
prevention of BPD in VLBW infants is not
recommended.
• Postnatal use of systemic dexamethasone for
the prevention of BPD should be limited to
carefully designed randomized doublemasked controlled trials.
© 2006, March of Dimes
AAP/CPS Summary/Recommendations on
Postnatal Steroids (Continued)
Outside the context of a randomized
controlled trial, the use of postnatal
corticosteroids should be limited to
exceptional clinical circumstances (an infant
on maximal ventilatory support). Parents
should be fully informed about the shortand long-term risks and agree to treatment.
© 2006, March of Dimes
BPD Nursing Care
• Prevent further lung damage.
• Wean ventilator and oxygen support
slowly.
• Recognize that stressful situations can
minimize hypoxemia-inducing events.
• Use sucrose with nonnutritive sucking
before painful procedures to decrease
pain.
© 2006, March of Dimes
BPD Nursing Care
(Continued)
• Preoxygenation (increasing FiO2 just
before suctioning) may help prevent
hypoxemia with suctioning.
• A consistent caregiver is helpful to parents.
• Use fortified breastmilk or premature
specialty formula for a consistent weight
gain of 10 g to 30 g per day.
• Kangaroo care promotes bonding.
© 2006, March of Dimes
Kangaroo Care
• Improvement in gas exchange and
temperature in premature infants
• No adverse affect on physiologic stability
• Improvement in lactation outcomes in
mothers wishing to breastfeed premature
infants
• Positive impact on the parenting process
© 2006, March of Dimes
Apnea of Prematurity
• 50% of NICU infants
• Periods of cessation of respiration for
longer than 10 seconds to 15 seconds
• Apneic episodes frequently accompanied
by cyanosis, bradycardia, pallor or
hypotonia
• Exact cause unknown but thought to be
due to immature CNS
© 2006, March of Dimes
Types of Apnea in Premature Infants
• Central:
Absent breathing movements/ effort
• Obstructive:
Breathing movements but no air flow
• Mixed:
Mixture of obstructive and central apnea
© 2006, March of Dimes
Apnea Treatment
• Cardiac and respiratory monitoring until no
apnea episodes for 5 to 7 days
• Neutral thermal environment
• Careful positioning; avoid flexion and
hyperextension of the neck
© 2006, March of Dimes
Apnea Treatment (Continued)
• Attention to gastric tube placement and
infusion rate during tube feeding
• Nasal CPAP
• Methyxanthines (oral to intravenous
aminophylline, theophylline and caffeine)
© 2006, March of Dimes
Apnea Nursing Care
• Assess infant’s color, perfusion, respiratory
rate, heart rate, position and oxygen
saturation.
• Document frequency and severity of episodes
and type and amount of stimulation required
to interrupt the event.
• Ensure bag and mask set-ups with oxygen
available at infant bedside.
© 2006, March of Dimes
PDA
• The most common cardiac complication
in premature infants
• Incidence inversely related to
gestational age
• Occurs in 45% of infants with a
birthweight <1,750 g
• Occurs in 80% of infants with a
birthweight <1,200 g
© 2006, March of Dimes
Signs and Symptoms of PDA
• Signs and symptoms of congestive heart
failure, increased need for oxygen and
inability to wean from ventilator
• Widened pulse pressure, an active
precordium, bounding peripheral pulses and
tachycardia with or without a gallop
• Echocardiogram most useful to evaluate
PDA
© 2006, March of Dimes
Left-to-Right Shunt Through PDA
© 2006, March of Dimes
PDA Treatment
• Treatment is controversial.
• Medical management with fluid restriction
and diuretics may be the initial approach.
• Indomethacin has been effective in closing
PDAs (dosage depends on weight,
gestation and renal function).
© 2006, March of Dimes
PDA Nursing Care
• Continually assess high-risk infants for pulse,
heart rate, pulse pressure, perfusion, and
auscultation for the presence of a murmur.
• Know dosage and contraindications for
indomethacin.
• Assess infant after indomethacin for ductal
closure, decreased urine output and
thrombocytopenia.
• Teach and reassure parents.
© 2006, March of Dimes
ROP
• A significant cause of blindness in children
initiated by delay in retinal vascular
growth
• The more premature the infant, the more
likely the infant is to have ROP.
• 82% of infants weighing <1,000 g at birth
develop ROP.
© 2006, March of Dimes
ROP (Continued)
• 47% of infants weighing 1,000 g to 1,500 g
at birth develop ROP.
• Other risk factors: prolonged mechanical
ventilation and oxygen administration,
hyperoxia, hypoxia, sepsis, acidosis, shock
© 2006, March of Dimes
Long-Term Consequences of ROP
• Myopia (nearsightedness)
• Strabismus (crossed eye)
• Amblyopia (lazy eye)
• Astigmatism
• Glaucoma
• Late retinal detachment
• Blindness
© 2006, March of Dimes
AAP: Screening Premature
Infants for ROP
• First exam occurs 4 to 6 weeks after birth
or 31 to 33 weeks postconceptional age.
• Two exams after pupillary dilation using
indirect ophthalmoscopy if:
– Weight at birth <1,500 g or gestational age
<28 weeks
– High-risk event and weight at birth 1,501 g to
2000 g or gestational age 29 to 36 weeks
© 2006, March of Dimes
ROP Treatment
• ROP progresses at different rates in
different infants.
• The goal of treatment for ROP is
prevention of blindness.
• Surgical therapies—Laser photocoagulation
and cryotherapy
© 2006, March of Dimes
Characteristics of Neonatal Sepsis
Early Onset
<7 days
Late Onset
 7 days to 3
months
Late, Late
Onset
>3 months
Intrapartum
complications
Often present
Usually absent
Varies
Transmission
Vertical; organisms
often acquired from
mother’s genital tract
Vertical or via
postnatal
environment
Usually postnatal
environment
Clinical
manifestations
Fulminant course,
multisystem
involvement,
pneumonia
Insidious, focal
infection, meningitis
common
Insidious
Case-fatality
rate
5 percent to 20 percent
5 percent
Low
M.S. Edwards, 2002a. Reprinted with permission.
© 2006, March of Dimes
Deficiencies in Neonatal Host Defenses
that Predispose to Infection
• Anatomic barriers—Injuries during delivery
(skin abrasions)
• Invasive procedures in the nursery (umbilical
artery catheters, endotracheal tubes)
© 2006, March of Dimes
Deficiencies in Neonatal Host Defenses
that Predispose to Infection, Continued
Phagocytic cells
– Small PMN leukocyte storage pool
– Decreased PMN leukocyte adherence
– Decreased PMN leukocyte and monocyte
chemotaxis
– Decreased phagocytosis in stressed neonates
– Decreased PMN leukocyte intracellular killing
in stressed neonates
© 2006, March of Dimes
Deficiencies in Neonatal Host Defenses
that Predispose to Infection, Continued
• Complement
– Decreased levels of complement
– Decreased expression of complement receptors
• Cellular immunity
– Possible defects in T-cell immunoregulation
© 2006, March of Dimes
Deficiencies in Neonatal Host Defenses
that Predispose to Infection, Continued
Humoral immunity
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Decreased IgA, IgM
Decreased IgG in premature neonates
Impaired antibody function
Decreased levels of fibronectin
Decreased levels of cytokine (interferon,
tumor necrosis factor)
© 2006, March of Dimes
Meningitis
• Severely debilitating illness in VLBW infants
• Caused by the same pathogens that cause
sepsis
• Incidence of culture-proven meningitis: 1.8%
• Occurs in neonates with lower mean birthweights and gestational ages
• Residual major neurologic abnormalities and
subnormal scores on MDI on the Bayley Scales
of Infant Development
© 2006, March of Dimes
Meningitis (Continued)
• Most common etiology is hematogenous
spread from the bloodstream to the
meninges.
• Can be early- or late-onset
• Mortality is usually higher with early onset
disease.
© 2006, March of Dimes
Signs and Symptoms of Meningitis
• Lethargy
• Hypotonia
• Temperature instability
• Increased oxygen requirements
• Apnea
• Bradycardia
• Feeding intolerance
• Seizures
© 2006, March of Dimes
Pneumatocele
© 2006, March of Dimes
Pneumonia in a Premature Infant
© 2006, March of Dimes
Pneumonia
• Developed:
– In utero through transplacental transfer of
organisms and aspiration of pathogens from
amniotic fluid of mothers with chorioamnionitis
– During/After delivery through aspiration of
infected materials
– Postdelivery through inhalation of particles from
individuals or equipment; through contaminated
endotracheal tubes; through hematogenous
spread from pathogens in the bloodstream
• Most common cause is GBS.
© 2006, March of Dimes
Signs and Symptoms of Pneumonia
Early signs are the same as for sepsis:
• Lethargy or irritability
• Poor feeding
• Temperature instability
• Poor color
• Respiratory signs--tachypnea, apnea, cyanosis,
retractions, grunting, nasal flaring and retractions
© 2006, March of Dimes
Treatment of Sepsis, Meningitis
and Pneumonia
• Early identification of neonate at risk is
essential for prevention of morbidity and
mortality.
• Develop a culture of prevention of
infection in NICU.
• Eradicate the pathogen with medications.
• Minimize sequelae.
© 2006, March of Dimes
Nursing Care of Sepsis, Meningitis
and Pneumonia
• Monitor respiratory status, oxygen
support, mechanical ventilation.
• Watch for worsening apnea/bradycardia.
• Suctioning PRN
• Volume replacements PRN with isotonic
solutions
© 2006, March of Dimes
Nursing Care of Sepsis, Meningitis
and Pneumonia, Continued
• Blood products PRN
• Minimal handling to avoid extra stress
• Watch for seizures.
© 2006, March of Dimes
NEC
• The most common neonatal intestinal
emergency
• Characterized by intestinal ischemia, most
often involving the terminal ileum
• Pathogenesis is uncertain.
• Three major factors: bowel wall ischemia;
bacterial invasion of the bowel wall; enteral
feedings
© 2006, March of Dimes
Pathogenesis of NEC
© 2006, March of Dimes
Three Stages of NEC
1. Generalized symptoms of early sepsis, including
temperature instability, lethargy, apnea and
bradycardia, feeding intolerance, abdominal
distention, and stools that test positive for occult
blood
2. Severe abdominal distention and tenderness,
visible bowel loops, grossly bloody stools,
metabolic acidosis, poor perfusion and a mottled
skin color
3. Fulminant signs of SIRS, including shock, mixed
acidosis, DIC and neutropenia
© 2006, March of Dimes
NEC Treatment
• Goals:
– Stabilize the neonate.
– Treat the infection.
– Rest the intestinal tract.
• Discontinue feedings.
• Initiate IV access for fluids and antibiotics.
• NG tube to decompress GI tract
© 2006, March of Dimes
NEC Nursing Care
• Monitor vital signs.
• Monitor blood gases and pH.
• Examine for abdominal distention,
tenderness, emesis, bloody stools,
temperature instability, metabolic
acidosis, apnea, bradycardia.
• Support parents.
• Encourage mother to pump breasts and
freeze breastmilk.
© 2006, March of Dimes
Intrapartum Antibiotic Prophylaxis
to Prevent Perinatal GBS
Vaginal and rectal GBS screening cultures at 35 to 37 weeks gestation
for all pregnant women (unless patient had GBS bacteriuria during the
current pregnancy or a previous infant with invasive GBS disease).
Intrapartum prophylaxis indicated
Intrapartum prophylaxis not indicated
• Previous infant with invasive GBS disease
• GBS bacteriuria during current pregnancy
• Positive GBS screening culture during current
pregnancy (unless a planned cesarean
delivery, in the absence of labor or amniotic
membrane rupture, is performed)
• Unknown GBS status (culture not done,
incomplete or results unknown) and any of
the following:
• Previous pregnancy with positive GBS
screening culture (unless a culture was also
positive during the current pregnancy)
• Planned cesarean delivery performed in the
absence of labor or membrane rupture
(regardless of maternal GBS culture status)
• Negative vaginal and rectal GBS screening
culture in late gestation during the current
pregnancy, regardless of intrapartum risk
factors
– Delivery at <37 weeks gestation
– Amniotic membrane rupture ≥18 hours
– Intrapartum temperature ≥100.4°F
(≥38.0°C)†
© 2006, March of Dimes
GBS Prophylaxis for Women with
Threatened Preterm Delivery
© 2006, March of Dimes
Prevention of Early-Onset GBS
Disease in the Newborn
© 2006, March of Dimes
PBPs for Prevention of
Nosocomial Infections in NICUs
• Increased compliance with hand-hygiene
standards
• Improved accuracy of the diagnosis of
bacteremia
• Reduced line and line connection (hub)
bacterial contamination
© 2006, March of Dimes
PBPs for Prevention of Nosocomial
Infections in NICUs (Continued)
• Maximal barrier precautions for central
line placement
• Decreased
– Number of skin punctures
– Duration of IV lipid infusion
– Duration of central venous line use
© 2006, March of Dimes
IVH/PVH
• 50% will die.
• Occurs in 25% to 30% of all VLBW infants
discharged from Level III NICUs
• Associated primarily with prematurity
• Infants <28 weeks gestation are at greatest
risk.
© 2006, March of Dimes
IVH/PVH
(Continued)
• Small (Grades I and II)
– Grade I hemorrhage is an isolated germinal matrix
hemorrhage.
– Grade Il is an IVH with normal ventricular size.
• Moderate (Grade III) is an IVH with acute
ventricular dilation.
• Severe (Grade IV) is an IVH with parenchymal
hemorrhage.
© 2006, March of Dimes
Venous Drainage of Cerebral
White Matter
© 2006, March of Dimes
Signs and Symptoms of IVH/PVH
• Can be subtle; sometimes only decreased
hematocrit or hemoglobin levels
• May evolve over several hours and include
decreased activity, hypotonia, altered
consciousness, respiratory disturbances
• Can develop rapidly, with seizures,
decerebrate posturing, fixed pupils
© 2006, March of Dimes
IVH/PVH Treatment and
Nursing Care
• Optimal treatment is prevention.
• Minimize brain tissue destruction.
• Minimize pain and stress.
• Minimize crying, suctioning, rapid bolus
infusions.
© 2006, March of Dimes
IVH/PVH Treatment and
Nursing Care (Continued)
• Maintain neutral thermal environment.
• Elevate head 30º.
• Use sucrose pacifiers, topical anesthetics
for procedures.
• Provide parental support.
© 2006, March of Dimes
PBPs for Prevention of IVH and PVL
• Administer antenatal steroids.
• Optimize peripartum management.
• Administer antenatal antibiotics for preterm
rupture of the membranes.
• Delivery-room resuscitation by neonatologists
and an experienced team
© 2006, March of Dimes
PBPs for Prevention
of IVH and PVL (Continued)
• Maintain the baby’s temperature >36°
centigrade.
• Maintain cardiorespiratory stability while
administering surfactant.
• Optimize direct clinical management by
neonatologists.
• Implement measures to minimize pain and
stress responses.
© 2006, March of Dimes
PBPs for Prevention
of IVH and PVL (Continued)
• Use developmental care.
• Judiciously use narcotic sedation (low dose,
continuous).
• Avoid early lumbar puncture (72 hours old).
• Use optimal positioning.
© 2006, March of Dimes
PBPs for Prevention
of IVH and PVL (Continued)
• In terms of fluid volume treatment of
hypotension, there is no evidence
demonstrating benefit of using MAP 30
rather than MAP > estimated gestational age
weeks.
• Use postnatal indomethacin judiciously.
• Optimize respiratory management.
• Use postnatal dexamethasone judiciously.
© 2006, March of Dimes
Goals of Nursing Care to Promote
Parental Attachment
• Opening the intensive care nursery to parents
• Transporting the mother to be near her infant
• Maternal day care for premature infants
• Rooming in for parents
• Individualized nursing care plans
• Early discharge
© 2006, March of Dimes
Goals of Nursing Care to Promote
Parental Attachment (Continued)
• Listening to parents during the infant’s
hospitalization and after discharge
• Parent support groups
• Programmed contact and reciprocal
interaction
• Transporting the healthy premature infant
to the mother
© 2006, March of Dimes
Goals of Nursing Care to Promote
Parental Attachment (Continued)
• Home-based interventions for young
parents
• Discussion with parents after discharge
• Kangaroo care
• Nurse home visitation
© 2006, March of Dimes
March of Dimes
Prematurity Campaign
Multi-year, multimillion-dollar campaign to
help families have healthier babies by:
• Funding research to find causes of premature
birth
• Educating women about risk reduction
• Providing support to families
© 2006, March of Dimes
March of Dimes
Prematurity Campaign (Continued)
• Expanding access to health care coverage
for prenatal care
• Helping providers learn ways to help
reduce risk of early delivery
• Advocating for access to insurance to
improve maternity care and infant health
outcomes
© 2006, March of Dimes
March of Dimes
NICU Family Supportsm
• Provides emotional and informational
resources to families with a newborn in
the NICU
• In more than 50 NICUs in the United States
by 2007
• marchofdimes.com/prematurity/nicu
© 2006, March of Dimes
March of Dimes
Share Your Story
• Online community for families with a child
in the NICU
• Users share NICU experiences, participate
in online discussions and meet other NICU
families.
• More than 10,000 registered members
• marchofdimes.com/share
© 2006, March of Dimes