NEWS FANNP. The Effects of Light on The Neonate

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FANNP NEWS December 2009 Vol. 20, No. 4 HIGHLIGHTED: THE EFFECTS OF LIGHT ON THE NEONATE HANDBOOK ON IDENTIFYING NEWBORN INFECTION NEAR-INFRARED SPECTROSCOPY USE IN NEONATOLOGY PLUS: FANNP CONFERENCE WRAP-UP CPR ABSTRACT POCKET NOTEBOOK LEGISLATIVE UPDATE EDUCATIONAL OFFERINGS BRING IT ON LETTER FROM THE PRESIDENT FANNP SCHOLARSHIP AND SPIRIT AWARD WINNERS The Publication of the Florida Association of Neonatal Nurse Practitioners The Effects of Light on The Neonate Louise Bowen, NNP-BC, MSN, CMTE, CNA-BC Bright lights in the NICU have been identified as a source of excessive stimulation in the neonate resulting in physiological instability. 1,2 Neonates, irrespective of gestational age, demonstrate changes in heart rate, oxygen saturation, blood pressure, and body movements in response to excessive stimulation. 3 The premature neonate, however, is more susceptible to the effects of increased stimulation than term neonates. Between 25 to 40 weeks gestation, there is a period of rapid brain growth 4 as well as changes in the respiratory and gastrointestinal systems as a result of environmental stimulation. 5,2 Excessive environmental stimulation such as bright lights may place the premature neonate at increased risk of insult or injury to their continuing development. 6,7 While in the hospital, the neonate is exposed to a variety of ambient and environmental light sources. Exposing the neonate to bright lights has been shown to increase heart and respiratory rates 8 and decrease oxygen saturations. 9 The effects of lighting on the neonate s physiological stability have been studied for over five decades, yet questions continue to be raised about light level exposure and the degree of influence on the neonate s development. Light in the Environment During the 1980s, light levels in NICUs ranged from 24 to 150 footcandles (ftc). 10 More recent studies have shown a decrease in light levels but ranges varied between different NICUs. Light levels ranged from 40 to 100 ftc during the day, reducing in units with cyclic lighting to 5 to 10 ftc at night. As expected, light levels were highest in areas of increased patient acuity. 11,12 The American Academy of Pediatrics recommends that ambient lighting at each neonate s bedside should range between 1 to 60 ftcs with the ability to adjust lighting. Preterm and critically ill neonates are exposed to other types of light sources including phototherapy lights (300-10,000 ftc) 13, heat lamps (1000 ftc) 14, and natural light from windows (1024 ftc). 15 During phototherapy, correctly placed eye shields reduced light from reaching the neonate s eyes by more than 90%. 16 However, one study found that more than 50 percent of the eye shields were in the incorrect position exposing the infant s eyes to the phototherapy lights. 17 Another study found infants that were positioned adjacent to the phototherapy lights received continuous light exposure of greater than 60 ftc. 18,19 Other studies have focused on the effects of phototherapy lights and the incidence of patient ductus arteriosus (PDA). 20 One study found that the lower-birthweight infants who had their chest shielded during phototherapy had less incidence of developing a PDA or developed it later and required less extensive treatment resulting in a shorter length of stay. Premature and critically ill neonates have routine eye examinations for ROP during their hospitalization. Exposure to the light from an ophthalmoscope set at maximum power for two minutes during the eye examination produces the same amount of light as 2000 ftc for three hours. 21 Pupillary dilatation for the exam may also increase sensitivity to light for as long as 18 hours. 11 Several studies have been conducted that compared the use of cycled versus continuous lighting in NICUs. 22,23 Cycled lighting involves changing the light intensity during a 24 hour period See Light on page 4 2 Letter from the President It is hard to believe that my 2-year term as president is drawing to an end. I am very excited to be turning the reins over to Ruth Bartleson who has been involved with FANNP for many years and will continue to meet the mission of FANNP. I am so blessed to be part of such an outstanding organization that just celebrated their 20th Anniversary. I am constantly amazed and energized when talking with FANNP members on projects they are working on, committees they are joining to bring NNPs to the national table and the networking opportunities with the National Association of Neonatal Nurse Practitioners. We have so much to be proud of! As we look to the New Year I would like to share a comment from Tara Woods, an NNP Student at UAB that sums up the role we play in the lives of our patients. She sent this to her fellow classmates in regards to Prematurity Day, I am very aware of what a blessing a healthy baby is I just want to tell you all I am very thankful for what you all do! As a mother, it was the RNs and NNPs that provided me the support and daily encouragement to get thru the single most trying time of my life to date. It is what inspired me to do what I am doing now! So as your days get tough and you wonder why you are doing what you are doing just remember Jacqui Hoffman there are so many children out there that you helped give a chance at life! You made a difference and though you may not remember them; they do remember you I promise they do and they will forever! My girls don t remember their birth but they know their story and they see the pictures. They know those people helped God save them! I worked Sunday night and I called to tell my girls goodnight and I told them that I had to go to a delivery for a 24-weeker (and yes they know how small that is). Taylor said momma go help that baby livethat mommy is going to be so sad! It just melted my heart! I am very grateful to modern technology and medicine that allowed my girls to survive with a perfectly normal quality of life. But it was those at the bedside that did the real work! Just remember you are all special and what you do lasts forever!!! Have a safe and happy holiday and thank you for making a difference in the lives of our little patients. Jacqui Hoffman, MSN, ARNP, NNP-BC T H E F L O R I D A A S S O C I A T I O N O F N E O N A T A L N U R S E P R A C T I T I O N E R S BOARD OF DIRECTORS Jacqui Hoffman, Seminole, FL President Ruth Bartelson, Winter Park, FL President Elect Carol Botwinski, Largo, FL Past President Kim Irvine, Land O Lakes, FL Secretary Sheryl Montrowl, Gainsville, FL Treasurer Genieveve Cline Newsletter Editor MEMBERS AT LARGE Mary Kraus Pam Laferriere Diana Fuchs Genieveve Cline FANNP P.O. Box 14572, St. Petersburg, FL 3 FANNP Conference Wrap-up 20th Annual Neonatal Nurse Practitioner Symposium: Clinical Update and Review Marylee Kraus, MSN, NNP-BC, ARNP Another great conference took place in October at the Sheraton Sand Key! We had a wonderful turn out with great speakers and many opportunities for networking and just plain having fun! The Welcome reception and the Mardi Gras Party were well attended. We had several new events, one being the simulation of a live birth and resuscitation with a helpful discussion afterwards. The Roundtable proved to foster popular discussions on Role Transition and Mentoring Gen X and Y. The exhibitors were plentiful with lots of good information and ideas. I think in our cozier environment, it is easier to talk directly with them on a more personal level. Their presence allows our conference to be one of the best values around! We started what I hope proves to be another tradition of making an effort of going green, by having the conference materials online. We had already done online registration, and hopefully soon may have online evaluations and CEU certificates. Please feel free to offer suggestions and ideas for us to consider for future conferences. Announcing the 2009 Kim Nolan Spirit Award Recipient The 2009 Recipient of the Kim Nolan Spirit Award is Gail Harris. Gail Harris (Nimphius) was the founding member of FANNP in Gail was integral in securing funding and pulling together a group of NNPs from across the state in Orlando for the formative meeting. Gail was the association s first president and held many roles in FANNP until she relocated to Charlotte, North Carolina. During her career in Florida, Gail was a NNP at Bethesda Hospital in Boynton Beach. Gail is currently the NNP Coordinator at Levine Children s Hospital in Charlotte. Congratulations Gail! To nominate someone for the Kim Nolan Spirit Award for 2010, go to the website and download an application, or write to Paula Timoney, c/o FANNP, PO Box 14572, St. Petersburg, FL Thank you! The FANNP would like to thank the following companies for their generous support of its 20th National NNP Symposium: Flamingo Sponsors Abbott Nutritionals Children s Medical Center, Dallas Children s Hospital of Philadelphia Blue Heron Sponsors Linkous & Associates Pediatrix Medical Group Egret Sponsors ENSEARCH Management Consultants Nationwide Children s Hospital All Children s Hospital 4 LIGHT continued from page 1 versus leaving the same (or continuous) light intensity during the same period. These studies report that infants in NICUs with day-night cycled lighting had increased weight gain, earlier initiation of oral feedings, decreased number of days on the ventilator and under phototherapy, and enhanced motor coordination. In addition, studies have shown that by reducing light levels in NICUs, infants have less respiratory instability; 24 lower heart and respiratory rates; 8 reduced time on mechanical ventilation and oxygen support; 6 and lower activity levels. 25 It is not just the amount of lighting that can be stressful to the neonate but also the sudden change in lighting. When light levels are rapidly increased, infants have responded with a sudden decrease in oxygen saturation especially in the lower gestational ages. 9 Physiological Factors The neonate s visual system is not fully developed at birth. The eye structure and peripheral retina in a term infant is well developed but vision is still immature and the macular region is not completely developed until age four. 26 Premature neonates are especially vulnerable to the potential negative consequences of light exposure with their thin eyelids that admit more light and large pupils that have a decreased ability to constrict and control light exposure. 27,28,29 Extremely premature infants have increased periods of eye opening despite the amount and intensity of light. 28 These infants are usually positioned supine which increases their exposure to overhead lighting. 15 Even though the eyelids of babies less than 23 to 24 weeks gestation are generally fused, their thin eyelids still allow light to penetrate. 26 Stress Response in The Neonate Cortisol is a corticosteroid hormone produced by the adrenal cortex and increases in response to psychological and physiological stress. 30 Critical illness or stress in the neonate increases cortisol production. 31 Several studies have shown a coorelation between bright lights and increased cortisol levels. 32 High cortisol levels in the premature neonate have been associated with severe intraventricular hemorrhage, morbidity, and death. 33 One study examining stress response in term babies showed lower cortisol levels prior to a procedure followed by a significant increase following the procedure. 34 As the response to stress triggers cortisol production, sustaining these increases can be detrimental and can lead to long-term adverse effects extending into adulthood. 31 Certain adult diseases, such cardiovascular, renal, type II diabetes, insulin resistance syndrome, and depression, have been correlated to fetal and neonatal cortisol exposure. 31,35,36 Practice Considerations Although there are recommendations for lighting levels and the use of cyclic lighting in NICUs there is no standard established. Developmental care protocols include a variety of interventions to manage the NICU environment. Light reduction is one of the components included in most developmental care protocols. 15 Previous studies highlight important issues for clinical practice and the need for further research. Neonatal health care professionals should be aware of the effects of ambient and environmental lighting on neonates. Each neonate should be assessed and cared for individually since reactions to environmental stimuli may vary. 9 The following are considerations for NICU light management: Be aware of the impact of overhead lighting as well as light exposure from windows Provide periods of dimmer lighting within a 24 hour period Position the neonate to not look directly into a light source Remember that premature infants tend to keep their eyes open more than term babies Be aware of how phototherapy lights can possibility increase light exposure to infants in surrounding beds Light sensitivity may be present in infants that have received medication to dilate the eyes in preparation for an ophthalmic examination. Consider placing a bili-mask or eye covering over the eyes for 4 hours to protect from direct light. Shielding the incubator with a blanket or cover to minimize light exposure is a common practice. The type of fabric, surface area covered, and level of ambient light impacts the amount of light reduction. Covers that are lighter in color, porous, and small in size will provide less light reduction than darker, tightly woven fabrics that are larger in size to cover more surface area. 37 Do not make rapid, abrupt changes in lighting intensity References 1. Als, H. (1982). Toward a synactive theory of development: Promise for the assessment and support of infant individuality. Infant Mental Health Journal, 3, Lotas, M.J. (1992). Effects of light and sound in the neonatal intensive care unit environment on the low-birth-weight infant. NAACOG S Clinical Issues, 3, Gibbins, S., Stevens, B., McGrath, P., Yamada, J., Beyene, J., Breau, L., et al. (2008). Comparison of pain responses in infants of different gestational ages. Neonatology, 93(1): Oehler, J.M. (1993). Developmental care of low birth weight infants. Nursing Clinics of North America, 28(2), Als, H., Lawhon, G., Brown, E., Gibes, R., Duffy, F.H., McAnulty, G., et al. (1986). Individualized behavioral and environmental care for the very low birth weight preterm infant at high risk for bronchopulmonary dysplasia: Neonatal intensive care unit and developmental outcome. Pediatrics, 78(6), Als, H., Lawhon, G., Duffy, F.H., McAnulty, G.B., Gibes-Grossman, R., & Blickman, J.G. (1994). Individualized developmental care for the very low-birth-weight preterm infant: Medical and neurofunctional effects. Journal of the American Medical Association, 272, Blackburn, S. (1998). Environmental impact of the NICU on developmental outcomes. Journal of Pediatric Nursing, 13, Shiroiwa, Y., Kamiya, Y., Uchibori, S., Inukai, K., Kito, H., Shitbata, T., et al. (1986). Activity, cardiac and respiratory responses of blindfold preterm infants in a neonatal intensive care unit. Early Human Development, 14, Shogan, M.G. & Schumann, L.L. (1993). The effect of environmental lighting on the oxygen saturation of preterm infants in the NICU. Neonatal Network, 12, Hamer, R.D., Dobson, V., & Mayer, M.J. (1984). Absolute thresholds in human infants exposed to continuous illumination. Investigative Ophthalmology 5 and Visual Science, 25, Fielder, A.R. & Mosley, M.J. (2000). Environmental light and the preterm infant. Seminars in Perinatology, 24, Graven, S.W., Bowen, F.W., Brooten, D., Eaton, A., Graven, M.N., Hack, M., et al. (1992). The high-risk environment: Part 1 the role of the neonatal intensive care unit in the outcome of high-risk infants. Journal of Perinatology, 12, Glass, P. (1990). Light and the developing retina. Documenta Opthalmologica, 74, Floyd, A.M. (2005). Challenging design of neonatal intensive care units. Critical Care Nurse, 25, Kenner, C. & McGrath, J.M. (Eds.). (2004). Caregiving and the environment in developmental care of newborns & infants. Philadelphia: Mosby. 16. Porat, R., Brodsky, N., & Hurt, H. (1988). Effective eye shielding during phototherapy. Clinical Pediatrics, 28, Robinson, J., Moseley, M.J., Thompson, J.R., & Fielder, A.R. (1989). Eyelid opening in preterm neonates. Archives of Disease in Childhood, 64, Glass, P. (1988). Role of light toxicity in the developing retinal vasculature. Birth Defects, 24, Lemnos, J.A. & Lockwood, C.J. (Eds.) (2008). Guidelines for perinatal care (6 th ed.). Elk Grove, IL: American Academy of Pediatrics. 20. Rosenfeld, W., Sadheu, S., Brunot,V., Jhaveri, R., Zabaleta, I., & Evans, H. (1986). Phototherapy effect on the incidence of patient ductus arteriosus in premature infants: Prevention with chest shielding. Pediatrics, 78(1), Lanum, J. (1978). The damaging effects of light on the retina: Empirical findings, theoretical and practical implications. Survey of Ophthalmology, 22, Mann, N.P., Haddow,R., Stokes, L., Goodley, S., & Rutter, N. (1986). Effect of night and day on preterm infants in a newborn nursery: Randomized trial. British Medical Journal, 293, Miller, C.L., White, R., Whitman, T.L., O Callaghan, M.F., & Maxwell, S.E. (1995). The effects of cycled versus noncycled lighting on growth and development in preterm infants. Infant Behavior and Development, 18, Blackburn, S. & Patterson, D. (1991). Effects of cycled light on activity state and cardiorespiratory function in preterm infants. Journal of Perinatal and Neonatal Nursing, 4(4), Rivkees, S.A., Mayes, L., Jacobs, H., & Gross, I. (2004). Rest-activity pattern of premature infants are regulated by cycled lighting. Pediatrics, 113 (4), Birch, E.E. & O Connor, A.R. (2001). Preterm birth and visual development. Seminars in Neonatology, 6, Isenberg, S.J., Dang, Y., & Jotterand, V. (1989). The pupils of term and preterm infants. American Journal of Ophthalmology, 108, Robinson, J. & Fielder, A.R. (1990). Pupillary diameter and reaction to light in preterm neonates. Archives of Disease in Childhood, 65, Robinson, J. & Fielder, A.R. (1992). Light and the immature visual system. Eye, 6, Jett, P.L., Samuels, M.H., McDaniel, P.A., Benda, G.I., LaFranchi, S.H., Reynolds, J.W., et al. (1997). Variability of plasma cortisol levels in extremely low birth weight infants. Journal of Clinical Endocrinology and Metabolism, 82, Watterberg, K.L. (2004). Adrenocortical function and dysfunction in the fetus and neonate. Seminars in Neonatology, 9, Grauer. T.T. (1989). Environmental lighting, behavioral state, and hormonal response in the newborn. Scholarly Inquiry for Nursing Practice: An International Journal, 3(1), Aucott, S.W., Watterberg, K.L., Shaffer, M.L., & Donohue, P.K. (2008). Do cortisol concentrations predict short-term outcomes in extremely low birth weight infants? Pediatrics, 122(4), Gunnar, M.R., Malone, S., Vance, G., & Fisch, R.O. (1985). Coping with aversive stimulation in the neonatal period: Quiet sleep and plasma cortisol levels during recovery from circumcision. Child Development, 56(2), Reynolds, R.M., Walker, B.R., Syddall, H.E., Andrew, R., Wood, P.J., Whorwood, C.B., et al. (2001). Altered control of cortisol secretion in adult men with low birth weight and cardiovascular risk factors. The Journal of Clinical Endocrinology and Metabolism, 86(1), Thompson, C., Syddall, H., Rodin, I., Osmond, C., & Barker, D.J. (2001). Birth weight and the risk of depressive disorder in late life. British Journal of Psychiatry, 179, Lee, Y., Malakooti, N., & Lotas, M. (2005). A comparison of the light-reduction capacity of commonly used incubator covers. Neonatal Network, 24(2), Classified Advertising Classified advertising is available in FANNP Newsletters. For more information, please visit our website: Bring it On Answers (questions on page 12): Educational Offerings 2010 NEO The Conference for Neonatology February 10, 2010 Continuous Quality Improvement P
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