Transcript The Premature Infant: Nursing Assessment and

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
© 2006, March of Dimes
Preterm Births United States
11.9
12
Percent
12.3
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
• Tendency to have difficulty with
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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 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 short- and 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
– 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
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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
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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
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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