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COUNCIL OF INTERNATIONAL NEONATAL NURSING, INC (COINN)POSITION STATEMENT ON CARE OF THE LATE PRETERM INFANT COINN (Council of International Neonatal Nurses, Inc) 
Position: The United Nations Millennium Development Goal (MDG) 41 calls for a 2/3rd reduction in under five years of age mortality. One third of the infant/child deaths occur during the neonatal period. Of these, ¾ occur in the first week and about 1/3rd of these within the first 24 hours. Forty to seventy percent of these are preventable through basic inexpensive interventions aimed at a continuum of care from preconception through to postnatal care. 2 The causes of morbidity and mortality are mostly preventable (i.e., infections such as malaria, pneumonia, and tetanus and diarrhea). While progress has been made in reducing overall infant mortality, neonatal mortality remains high. 3, 4 All newborn babies therefore require a basic standard of care in order to prevent these deaths particularly within the first 24 hours of life. In the United States there was an increase of 18% in late preterm births from 1996 to 2006 representing 9.1% of all live preterm births.2 This late preterm population accounted for more than 70% of all the preterm births in the US in the 2006. 5, 6 The same trend is seen worldwide with approximately 1 million premature infants dying during the neonatal period many of which are late premature infants. 7 These infants are in fact, both physiologically and metabolically immature. Central nervous system function is also not at the level of term infants which reduces the self regulatory ability to adapt to the external stress. 8 In spite of their appearance to mimic full term infants, immaturity places them at higher risk for health issues associated with increased morbidity and mortality. Although, many of the term infant care principles apply to the late preterm infants care, high risk factors must be recognized at birth to identify, prevent and intervene for the common late preterm issues such as respiratory distress, apnea, inadequate thermoregulation, hypoglycemia, feeding difficulty, hyperbilirubinemia (or Jaundice), sepsis, and other potential problems. 9,10 The American Academy of Pediatrics (AAP) and American Congress of Obstetricians and Gynecologists (ACOG) 6th edition Guidelines for Perinatal Care recommend careful observation of a newborn during the first 6‐12 hours of transition period even for a well term infants. 8 The late preterm infants require additional vigilance. Globally the problem is not always separated from over all preterm birth rates. Care given with prevention in mind to the vulnerable late preterm newborn infants during the first few hours and days of their lives may have a profound significance to the United Nations Millennium Development Goals (MDGs). The Council of International Neonatal Nurses, Inc (COINN) is the international voice of neonatal nurses who provide care during this vulnerable period. In order to address identified gaps in current practice COINN (Council of International Neonatal Nurses, Inc) supports and recommends the following Guideline for Care of late preterm infants: A late preterm infant 34 0/7‐36 6/7 weeks’ gestation after the onset of the mother’s Last Menstrual Period‐LMP is physiologically and metabolically immature. The limited compensatory response to the external stressors must be recognized and should be cared for as immature regardless of the weight. The presence, at every delivery, of a nurse/doctor trained in neonatal resuscitation (skilled neonatal attendant) dedicated solely to care for the baby. Availability of an oxygen source, suction, bag and mask set up is essential. Provision of adequate thermal environment such as warmer. Immediate assessment of the newborn’s health status by a trained professional after delivery as drying, stimulation, and suctioning is provided for during the transition. On‐going maintenance of an appropriate thermal environment by placing a cap, light clothing and bundling, or skin to skin with mother. Temperature instability is one of the frequent diagnosis for the late preterm infant. Keep in mind that cold stress alone could lead to peripheral and pulmonary vascular constriction, hypoglycemia, or death if not minimized or prevented. Formal admission of individual infant as an individual patient to receive identification number. Recording of the newborn’s condition including gestational age, physical exam and vital signs at birth. Identify and document other risk factors besides late preterm at this time. These factors may include but are not limited to: Small for Gestational Age‐SGA, Infant of a Diabetic Mother‐IDM, maternal smoking, substance exposure, genetic anomalies, low Apgar score at 5 minutes and prenatal laboratory values for Syphilis, Hepatitis B, Human Immunodeficiency Virus‐HIV, Rubella status, and Herpes Simplex Virus (HSV). Make an appropriate reporting to the doctor of these findings. Give Vitamin K to prevent Vitamin K dependent Hemorrhagic disease and eye prophylaxis against gonococal ophthalmia within 1 hour after birth. Continued monitoring of vital signs, skin color, respiratory pattern, tone, peripheral circulation, level of consciousness and activity every 30 minutes until over all status is stable for 2 hours. During this time and throughout the hospital stay, family‐centered care practice such as on‐ going contact with the mother is encouraged for breast feeding initiation and bonding. However, excessive handling of the infant is not encouraged for the late preterm infant has limited compensatory mechanism for external stimulation. Excessive stimulation leads to excessive use of glucose, tiring and not being able to feed. Offer feeding as soon as possible. Glucose check within an hour is recommended for hypoglycemia is another frequently diagnosed condition. If the infant is unable to suck swallow and breathe effectively, physicians/doctors or nurse practitioners must be notified immediately to avoid hypoglycemia, dehydration, aspiration and other complications. Keep in mind that preterm infants’ serum glucose hits nadir (low point) at 1‐2 hour after birth. Each nursery‘s glucose protocol must be followed for continued glucose check. Continued observation for potential complications by assessing for the following, Temperature instability, Change in activity, Poor feeding, Poor skin color, Abnormal cardiac or respiratory rate and rhythm, Apnea, Abdominal distension or bilious vomiting, Excessive lethargy and sleeping, Delayed stooling or voiding, The importance of these changes in assessment findings should also be communicated to the parents while rooming‐in so that a trained staff is notified of any change, Trained staff should observe the infant periodically in mother’s room while rooming in according the institutional protocol, Infant with these findings should be evaluated by the medical team for specialized care may be necessary to properly care for the infant in a timely manner. 15. Education on prevention of infection Proper cord care, Hygiene practices for diaper change, Hand washing, Clean technique for breast feeding and formula preparation, Limiting visitors during the influenza season, Bathing instructions. 16. First bath should be given once the infant‘s thermal stability is ensued to prevent hypothermia. Late Preterm infants require vigilance with this intervention. Whole body bathing is not always necessary. Localized skin care or techniques that expose the skin minimally to remove blood and meconium may prevent the excessive heat loss thus prevents hypothermia. The skin barrier function for the first four weeks of life is somewhat unstable and offers protective immunity when not disrupted. 11,12 17. Immunization should be initiated before discharge and followed up according to the recommended schedule by follow up health professional. (Hepatitis B, Mumps, Measles, and Rubella (MMR), Haemophilus influenzae type b‐Haemophilus influenza (b‐HIB), Polio and other). 18. During the Respiratory Syncytial Virus (RSV) season, RSV vaccine is offered for preterm infants of 35 weeks or less with at least one risk factor (day care or having a sibling 5 years and younger). 10 19. Perform hearing screen. If the infant does not pass, make or asked the doctor for a referral for further examination. 20. Perform metabolic and genetic screen 24 hours after feeding initiated, if done before, another follow up must be arranged. 21. Identify a health care professional who will provide on‐going care of the infant with whom immediate follow up care can be arranged. Discharge summary or a form of written report is sent to the follow up health care professional with specific hospital course and follow up needs. 22. The infant should be carefully assessed with #13 in mind before discharge. Individualized decision should be made regarding the timing of discharge. 8,10 Feeding competency with 24 hours of successful feeding with demonstration of coordinated suck, swallow and breathing. Thermoregulation ability. Free from abnormal physical exam findings, (or immediate follow up plan available for a non emergent abnormal finding). Infants should be in stable condition for at least 12 hours prior to discharge. (Respiratory Rate less than 60/minutes, Heart Rate 100‐160/minutes, Temperature 36.5‐37.4 degrees C or 97‐98.6 degrees F in an open crib with appropriate clothing. At least one spontaneous stooling. To avoid severe hyperbilirubinemia, appropriate follow up plan is made based on the bilirubin level that should be checked on the day of discharge. Mother has been educated and demonstrated the understanding of feeding plan, hygiene, importance of follow up, recognition for status change including severe jaundice, dehydration, sepsis, thermoregulation, clothing, and safety issues (see 21). Absence of social risk factors that endanger the infant. Availability of a safety plan for the infant if there is risk factor. (see 21) Infant has demonstrated ability to tolerate car seat challenge without apnea, bradycardia or decreased oxygen saturation or skin color change. Follow the policy of the state or country regarding the genetic or metabolic screening. Perform the screening after full feeding is achieved. If one was done before 24 hours of initiation of feeding, another screening is needed at a follow up. The plan must be in place before discharge and should be communicated to the follow up professional. Infant passed Hearing screening or if did not pass, plan is made to repeat the screening. Infant’s weight loss must be assessed. Weight loss of more than 2‐3% per day or maximum of 7% by the time of discharge calls for an evaluation by a medical professional. Dehydration must be considered and feeding ability and volume of feeding must be carefully assessed before discharge decision is made. 23. Family environment should be assessed to ensure safeguarding infant upon discharge and maincare provider of the infant is provided with safety education. Completion of the parental education and parental demonstration of competency is documented. 8,9 Free from history of abuse or neglect, domestic violence, or parent with mental illness. Collaborate with the social service at the hospital and state child care service when indicated. Availability of a safety plan to safeguard infant from any identified social or environmental risk such as follow up social work visit. Presence of family support for the mother or the main care provider. Presence of a fixed home environment with heat, water and essential supplies. Identify community support as needed to address concerns. Parental understanding for the care of the infant outlined below and reinforce education, Prevention of hypothermia, Basic hygiene including bathing, cord care, diaper change, Current feeding plan, Comfortable and proficient with breast feeding, and also proper prep for formula, Importance of follow up care and definite plan for the next follow up, Newborn safety such as car seat, smoke fire alarms at home, danger of second hand smoking, and any other environmental hazards present, Prevention of SIDS (back to sleep, no soft pillows and excessive blankets), Appropriate layers of clothing for the infant, Preventive measures against infection (avoid public in flu season, hand washing for the family, avoid crowd during newborn period), Proper use of thermometer for axillary temperature, Administering any medication such as multivitamin or iron Education to identify risk factors given in #13 and provision of number/clinic name/doctor’s office contact information to call to report change of status, Contact for emergency needs is reviewed. Changes that the care provider must be able to recognize and report are: Increase in severity of Jaundice, Lethargy and poor feeding Vomiting, Poor skin color, Fever greater than 38 degrees C or 100.4 degrees F or below 36 degrees C or 96.8 degrees F, Respiratory distress–emergency, Apnea‐emergency. 23. The initial follow up with a trained professional (home health, pediatrician, public health department, etc) should be arranged for the infant within 48‐72 hours after discharge if bilirubin follow up is necessary. The infant should be assessed at minimum after 6 days, 2 weeks, and every 2‐3 months for first 6 months. References United Nations Millennium Development Goals. (2009). Available: http://www.un.org/millenniumgoals/. March of Dimes (MOD). (2006). Late Preterm Birth: Every Week Matters. Available: http://www.marchofdimes.com/files/MP_Late_Preterm_Birth‐Every_Week_Matters_3‐24‐06.pdf. Lawn, J.E., Cousens, S., Zupen, J., for Lancet Neonatal Survival Steering Team. (2005). Neonatal Survival 1. 4 million neonatal deaths: When? Where? Why? Lancet, 365, 821‐822. The Millennium Development Goal Report 2009. Available: http://www.un.org/millenniumgoals/pdf/MDG_Report_2009_ENG.pdf March of Dimes. (MOD). Late preterm births. 1990‐2006. Available http://www.marchofdimes.com/peristats/level1.aspxdv=ls®=99&top=3&stop=240&lev=1& slev=1&obj=1 Engle, WA, Tomashek, KM, William, C, and the Committee on Fetus and Newborn.(2007). Late Preterm Infants: A population at risk. Pediatrics, 120(6). 1390‐1401. Global death toll: 1 million premature babies every year. White Plains, NY: March of Dimes (MOD). Available: http://www.eurekalert.org/pub_releases/2009‐10/modf‐gdt100209.php. American Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologists* (ACOG). (2007). Guidelines for perinatal care. 6th ed., Elk Grove Village, IL: AAP/ACOG. *now named the American Congress of Obstetricians and Gynecologists. Kruse, L. (2009). Late Preterm Infant Clinical Guideline. Oklahoma City, OK: University of Oklahoma Medical and the Oklahoma Healthy Mothers, Healthy Babies Coalition Infant Alliance. American Academy of Pediatrics (AAP). Committee on infectious diseases. Policy statement modified recommendations for use of palivizumab for prevention of respiratory syncytial virus infections. Published online Sept 7, 2009. Available: https://pediatrics.aappublications.org Dec 3, 2009. Bartels, N.G., Mleczko, A., Schink, T., Proquitte, H., Wauer, R.R., & Blume‐Peytavi, U. (2009). Influence of bathing or washing on skin barrier function in newborns during the first four weeks of life. Skin Pharmacology and Physiology, 22(5), 248‐257. Walker, L., Downe, S., & Gomez, L. (2005). Skin care in well term newborn: Two systematic reviews. Birth, 32(3), 224‐228. Acknowledgement: COINN (Council of International Neonatal Nurses, Inc) wishes to thank Lynda Kruse and University of Oklahoma Medical Center, Oklahoma City, OK and Bonnie Bellah of the Oklahoma Healthy Mothers, Healthy Babies Coalition Infant Alliance USA for generously allowing an adaptation of their clinical guideline for the late preterm infant to be used. COINN (Council of International Neonatal Nurses, Inc) acknowledges that some countries may not be able to implement the recommendations as written due to limited resources‐personnel, financial, and equipment. However, to improve health outcomes all the neonatal community must strive to uphold these recommendations.Determinations must be made within local and national organizations as to what constitutes basic, essential, and advanced care. Approved by COINN (Council of International Neonatal Nurses, Inc) Board of Directors January 2010 we/rd/ck/mb COINN –THE GLOBAL VOICE OF NEONATAL NURSESRepresenting over 50 countries and 15,000 nurses.

COUNCIL OF INTERNATIONAL NEONATAL NURSES, Inc. (COINN)Position Statement COINN (Council of International Neonatal Nurses, Inc) Position The Council of International Neonatal Nurses, Inc. (COINN) recognizes the critical contributions made by breastfeeding, breast milk, and mother-baby bonding, to not only enhance developmental outcomes but also child survival. Intergenerational cycles of poverty and health inequalities are also factors linked to not breastfeeding the infant. The highest risk of death is during the neonatal period. Positive survival and health outcomes result from relatively simple and safe measures such as breastfeeding. Keeping mothers and infants together as much as possible, providing breastfeeding counselling, assisting mothers to provide breast milk for their preterm unwell babies and supporting breastfeeding initiation, exclusivity and continuance, even in the workplace, are essential components for child survival. Supportive health care practices, such as these, are a prerequisite to reach optimal breastfeeding goals. That all infants should be exclusively breastfeed for a minimum of 6 months. Mothers living with HIV should breastfeed for at least 12 months and may continue to breastfeed for 24 months or beyond (similar to the general population) while being fully supported with ART adherence (WHO, 2016). Mothers known to be living with HIV should only give commercial infant formula as a replacement to their HIV-uninfected infant or infant who are of unknown HIV status if specific conditions are met: there is assured safe water and sanitation in the household and community; the mother or caregiver can reliably provide sufficient infant formula to support normal growth and development of the infant; the mother or caregiver can prepare the formula cleanly and frequently enough to ensure there is a low risk of diarrhea or malnutrition; the mother or caregiver can give infant formula exclusively for the first 6 months; the family supports the practice; the mother or caregiver can access health care that offers comprehensive child health services (WHO, 2016). In situations where the HIV positive mother chooses to give mixed feedings it is recommended that she is on ARV medication and preferable breastfeed exclusively for minimum of 6 months. Research appears to indicate that this abrupt weaning even in HIV positive women may lead to adverse neonatal/infant outcomes. National and local health authorities should actively coordinate and implement services at health facilities, workplaces, communities and homes to promote and protect that ensure the right of for HIV positive mothers to breastfeed. During emergency situations and in the presence of an orphaned infant attempts should be made to administer HIV-negative donor human milk. In situations where the mother’s own milk is not available, the best option is donor human milk. While pasteurized donor milk from a regulated milk bank is preferred, it is often not available during a disaster. If formula is given, recommend ready-to-feed standard formula. Use concentrated or powdered formula only if bottled or boiled water is available. In emergency situations it may be preferable to re-initiate lactation in mothers who have been weaned over artificial feeding with infant formula. (United States Breastfeeding Committee, 2011; WHO Regional Office for Europe, 1997). COINN (Council of International Neonatal Nurses, Inc) supports the International Code of Marketing of Breastmilk Substitutes and subsequent, relevant World Health Assembly resolution. Background “In the battle to eradicate poverty, one small step would be to ensure that every newborn is breastfed. This would provide the best nutrition, the greatest infection protection, the most illness prevention, and the greatest food security and psychological protection for the infant” (Lawrence, 2007) Recommendations/Key Principles 1. The importance of breastfeeding and use of breast milk to child survival requires global coordinated health efforts to support breastfeeding. 2. Globally neonates (first 28 days of life) have the highest risk of death but a mortality gap exists between developing and developed countries, especially for countries experiencing conflicts or crises. 3. Infants born in less developed countries, who are not breastfed, have a six-fold greater risk of dying from infectious diseases in the first two months of life than those who are breastfed. 4. The Global Strategy on Infant and Young Child Feeding confirms that breastfeeding is a public health priority globally. 5. Initiation and support of breastfeeding are essential components of infant care in all settings including the woman’s workplace. 6. Protection and support of mother-baby bonding and breastfeeding, beginning shortly after birth, or as soon after birth as possible, [including situations where babies are born preterm or unwell and admitted to a neonatal or special care unit] are essential components for increased child survival. 7. Breastfeeding and breast milk provide optimal, species specific, nutrition and are an essential component of any program to improve child health. 8. Breastfeeding and breast milk save lives by protecting babies from infection and by modulation of the immature immune systems of babies. 9. The use of any breast milk substitutes in emergencies is a risk factor for neonates and infants due to unhygienic conditions, lack of water or clean water and lack of knowledge about safe preparation of these products. 10. “The world cannot afford to continue to lose one of its most valuable resources - its children." Carole Kenner (2007) COINN (Council of International Neonatal Nurses, Inc) acknowledges that some countries may not be able to implement the recommendations as written due to limited resources-personnel, financial, and equipment. However, to improve health outcomes all the neonatal community must strive to uphold these recommendations. Determinations must be made within local and national organizations as to what constitutes basic, essential, and advanced care. References American Academy of Pediatrics (2015). Infant feeding in Disasters and Emergencies. Retrieved from: http://www2.aap.org/breastfeeding/files/pdf/infantnutritiondisaster.pdf Davanzo, R. (2004). Newborns in adverse conditions: Issues, challenges and interventions. Journal of Midwifery & Women’s Health, 49, [4], Suppl 1: 29-35. Franz, A. N. (2015). Relactation in Emergencies. Retrieved from: http://corescholar.libraries.wright.edu/cgi/viewcontent.cgi?article=1167&context=mph Hanson, L. (2004). Immunobiology of human milk. How breastfeeding protects babies. Amarillo, Pharmasoft. Lawrence, R.A. (2007). The eradication of poverty one child at a time through breastfeeding: A contribution to the global theme issue on poverty and human development, October 22, 2007. Breastfeeding Medicine: The Official Journal of the Academy of Breastfeeding Medicine, 2: 193-194. Kenner, C. (2007). Working to save children’s lives. Council of International Neonatal Nurses Inc. http://www.coinnurses.org/news/savings_children_lives.htm. Kuhn, L., Aldrovandi, G. M., Sinkala, M., Kankasa, C., Semerau, K., Mwiya, M., Kasonde, P., Scott, N., Vwalika, C., Walter, J., Bulterys, M., Tsai, W-Y., & Thea, D. M. (2008). Effects of early abrupt weaning on HIV-free survival of children in Zambia. New England Journal of Medicine, 359: 130- 141 Savage, F., & Renfrew, M. J. (2008). Countdown to 2015 for maternal, newborn and child survival. Letter, The Lancet, 372: 369 United States Breastfeeding Committee. (2011). Statement on infant/young child feeding in emergencies. Retrieved from http://www.usbreastfeeding.org/d/do/416 World Health Organization (2016). Update of HIV and Infant Feeding. Retrieved from: http://apps.who.int/iris/bitstream/10665/246260/1/9789241549707-eng.pdf?ua=1 World Health Organization (1981). The International Code of Marketing of Breastmilk Substitutes. Full Code and relevant WHA resolutions are at: https://www.who.int/nutrition/publications/infantfeeding/9241541601/en/ World Health Organization (WHO), Regional Office for Europe. (1997). Infant feeding in emergencies; A guide for mothers. Copenhagen: World Health Organization.

COUNCIL OF INTERNATIONAL NEONATAL NURSES , Inc. (COINN) Position Statement COINN (Council of International Neonatal Nurses, Inc) Position COINN (Council of International Neonatal Nurses, Inc) supports the practice of Kangaroo Mother Care (KMC) in all areas of a Neonatal Intensive Care Unit or Special Care Baby Unit. Kangaroo Mother Care is defined as “Care of the stabilized preterm or low birthweight infant carried skin-to-skin with the mother and exclusive breastfeeding or feeding with breastmilk.” (WHO 2003; Conde-Aguedelo and Díaz-Rossello 2016). Key Components (Conde-Aguedelo and Díaz-Rossello, 2016) Kangaroo position, or continuous skin-to-skin contact between infant and mother or another caregiver. Exclusive breastfeeding, or feeding with breastmilk, when possible. Timely discharge from hospital with close follow-up. COINN (Council of International Neonatal Nurses, Inc) supports the continued practice of KMC at home. “Humanising the practice of neonatology, promoting breastfeeding and shortened hospital stays without compromising survival” (Charpak et al. 2001). Background Doctors Rey and Martinez in Bogota, Colombia as an alternative to inadequate or insufficient incubator care developed KMC for stable preterm babies (WHO 2003). KMC (continuous and intermittent) offers benefits to preterm and low birthweight infants in all settings. Compared to incubator care alone, KMC is a safe and effective method to reduce the risk of neonatal mortality, irrespective of weight or gestational age (WHO 2003, Conde-Aguedelo and Díaz-Rossello 2016, Boundy et al. 2016, Lawn et al. 2010). KMC provides the infant with thermal support, protection from infection, appropriate stimulation, and a nurturing environment (Boundy et al. 2016, Chan et al. 2016, Charpak et al. 2005). Long-term social and behavioral protective effects have also been reported (Charpak et al. 2017). WHO Recommendations (WHO 2015) Kangaroo mother care is recommended for the routine care of newborns weighing 2000 grams or less at birth, and should be initiated in health-care facilities as soon as the newborns are clinically stable. Newborns weighing 2000 grams or less at birth should be provided as close to continuous kangaroo mother care as possible. Intermittent kangaroo mother care, rather than conventional care, is recommended for newborns weighing 2000 grams or less at birth, if continuous kangaroo mother care is not possible. Guidelines for KMC practice should be developed to specifically and contextually suit the facility and environment where they are to be used. Procedure Individual assessment of each baby is necessary prior to initiating KMC, but general guidelines are presented below: Stablised preterm or low birthweight baby admitted to a neonatal intensive care unit or special care baby unit. Full term, well baby. To assist with maternal attachment when separation of mother and baby has occurred. To support lactation and establish breastfeeding. (A) Contraindications for KMC Individual assessment of each baby is necessary, but general guidelines to avoid KMC are presented below: Medically unwell, unstable baby who may be ventilated, have pneumothoraxes, or be extremely low birthweight. Immediate post-surgical baby. KMC may commence/recommence once medically stabilized. (B) Requirements for KMC (WHO 2003) Mother, or another caregiver. A comfortable reclining chair, if possible. Optional carrying sling or kangaroo wrap. Blanket to cover the baby’s back. Infant hat or cap. Adequately trained personnel with special skills to monitor mother and infant. Supportive environment. Privacy screens when practiced in open units, if possible. (C) What parents and family members need to know about KMC KMC is safe. KMC is beneficial. The baby will stay warm. KMC will stabilize heart and respiratory rate and increase oxygenation levels. Enhances lactation, breastfeeding, and immunological effects. (D) Obstacles to KMC Lack of a policy or guidelines for practice: Development of a KMC policy is necessary for individual facilities undertaking KMC. A KMC framework and practice guidelines are essential to give staff confidence in implementing KMC and the collaborative creation of a policy gives value to the practice within individual settings. Lack of an education programme: Staff require KMC education and guidance to enable competent and confident practice. Novice staff will benefit from the supportive mentoring of experienced staff members. Communication: Parents may not be aware of the benefits and safety of KMC. Staff will need to disseminate KMC information which is easily understandable and up to date. Lack of facilities for mothers: Facilities may not have enough beds for mothers to room-in close to their baby in the NICU or special care nursery. If this is the case then KMC is even more important as it will enable the mother and baby to achieve the full benefits of their time together. Facilities without adequate rooming-in facilities should consider working towards minimizing mother-baby separation as a future goal of optimal care. References Boundy, E.O., Dastjerdi, R., Spiegelman, D., Fawzi , W.W., Missmer, S.A., Lieberman, E., et al. (2016). Kangaroo Mother Care and Neonatal Outcomes: A Meta-analysis. Pediatrics 137(1): 1-16. Chan, G.J., Valsangkar, B., Kajeepeta, S., Boundy, E.O., & Wall, S. (2016). What is kangaroo mother care? Systematic review of the literature. Journal of Global Health 6(1), 010701. http://doi.or/10.7189/jogh.06.010701. Charpak, N., Ruiz-Pelaez J.G., Figeuroa de Calume, Z., & Charpak, Y. (2001). A randomised, controlled trial of Kangaroo Mother Care: Results of follow-up at 1 year of corrected age. Pediatrics 108(5):1072- 1079. Charpak, N., Ruiz, J.G., Zupan, J., Cattaneo, A., Figueroa, Z., Tessier, R., et al. (2005). Kangaroo Mother Care: 25 years after. Acta Paediatrica. 94(5): 514-22. Charpak, N., Tessier, R., Ruiz, J.G., Hernandez, J.T., Uriza, F., Villegas, J., et al. (2017). Twenty-year follow-up of kangaroo mother care versus traditional care. Pediatrics. 139(1), e20162063. Conde-Aguedelo, A., & Díaz-Rossello, J.L. (2016). Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database of Systematic Reviews. 8(Art. No.: CD002771). Lawn, J.E. Mwansa-Kambafwile, J., Horta, B.L., Barros, F.C., & Cousens, S. (2010). 'Kangaroo mother care' to prevent neonatal deaths due to preterm birth complications. International Journal of Epidemiology. 39, i144-54. World Health Organization. Kangaroo mother care: a practical guide. (2003). Geneva: World Health Organization. Available at: http://www.who.int/maternal_child_adolescent/documents/9241590351/en/. Accessed: 10 March 2017. World Health Organization. (2015). WHO recommendations on interventions to improve preterm birth outcomes. Geneva: World Health Organization. Available at: http://apps.who.int/iris/bitstream/10665/183037/1/9789241508988_eng.pdf. Accessed 10 March 2017 Selected Bibliography Anderson, G.C. (1991). Current knowledge about skin-to-skin (kangaroo) care for preterm infants. Journal of Perinatology. X1(3): 216-226. Bergh, A-M,. Kerber, K., Abwao, S., Johnso.n Jd-G., Aliganyira, P., Davy, K., et al. (2014). Implementing facility-based kangaroo mother care services: lessons from a multi-country study in Africa. BMC Health Services Research. 14(293): 1-10. Bergman, J., & Bergman, N. (2005). Kangaroo Mother Care; Support for parents and staff of premature infants. Available at: http://www.kangaroomothercare.com. Blaymore-Bier,,J..A. (1996). Comparison of skin-to-skin contact with standard contact in low birth weight infants who are breastfed. Archives of Pediatrics and Adolescent Medicine. 150: 1265-1269. Blencowe, H., Kerac, M., & Molyneux, E. (2009). Safety, effectiveness and barriers to follow-up using an 'early discharge' Kangaroo Care policy in a resource poor setting. Journal of Tropical Pediatrics. 55(4): 244- 8. Cattaneo, A., Davanzo, R., Uxa, F., & Tamburlini, G. (1998). Recommendations for the implementation of Kangaroo Mother Care for low birthweight infants. Acta Paediatrica. 87: 440-445. Cattaneo, A., Davanzo, R., Worku, B., Surjono, A., Echeverria, M., Bedri, A., Haksari, E., Osorno, L., Gudetta, B., Setyowireni, D., Quintero, S., & Tamburlini, G. (1998). Kangaroo Mother Care for low birthweight infants: A randomised controlled trial in different settings. Acta Paediatrica. 87: 976- 985. Charpak, N., Ruiz-Pelaez, J., & Charpak, Y. (1994). Kangaroo-mother programme: An alternative way of caring for low birth weight infants? One year mortality in a two-cohort study. Pediatrics. 94: 804- 810. Charpak, N., Ruiz-Pelaez, JG., Figueroa de C, Z., & Charpak, Y. (1997). Kangaroo mother versus traditional care for newborn infants <2000 grams: A randomized, controlled trial. Pediatrics. 100: 682-688. Feldman, R., Weller, A., Sirota, L., & Eidelman, A.I. 2003. Testing a family intervention hypothesis: The contribution of mother-infant skin-to-skin contact (Kangaroo Care) to family interaction, proximity and touch. Journal of Family Psychology. 17(1): 94-107. Feldman, R. (2004). Mother-infant-skin-to-skin contact: Theoretical, clinical and empirical aspects. Infant and Young Child. 17: 145-161. Ferber, S.G., & Makhoul, I.R. (2004). The effect of skin-to-skin contact (Kangaroo Care) shortly after birth on the neurobehavioural responses of the term newborn: A randomised, controlled trial. Pediatrics. 113(4): 858-865. Hurst, N.M. (1997). Skin-to-skin holding in the neonatal intensive care unit influences maternal milk volume. Journal of Perinatology. 17: 213-217. Ludington-Hoe, S.M., Anderson, G.C., Simpson, S., Hollingstead, A., Argote, L.A., & Rey, H. (1999). Birthrelated fatigue in 34-36-week preterm neonates: Rapid recovery with very early Kangaroo (Skin- to-Skin) Care. Journal of Obstetric, Gynaecologic and Neonatal Nursing. 28(1): 94-103. Nyqvist, K. H. (2004). Invited response to 'How can Kangaroo Mother Care and high technology care be compatible?' Journal of Human Lactation. 20(1): 72-74. Nyqvist, K.H., Anderson, G.C., Bergman, N., Cattaneo, A., Charpak, N., Davanzo, R., et al. 2010. Towards universal Kangaroo Mother Care: recommendations and report from the First European conference and Seventh International Workshop on Kangaroo Mother Care. Acta Paediatrics. 99(6): 820-6. Seidman, G., Unnikrishnan, S., Kenny, E., Myslinski, S., Cairns-Smith, S., Mulligan, B., et al. (2015). Barriers and enablers of kangaroo mother care practice: a systematic review. PLoS One. 10(5):e0125643. Tessier, R., Cristo, M., Velez, S., Giron, M., Nadeau, L., Figueroa de Calume, Z., Ruiz-Palaez, J.G., & Charpak, N. (2003). Kangaroo Mother Care: A method for protecting high-risk low-birth-weight and premature infants against developmental delay. Infant Behavior & Development. 26: 384-397. ​​​​​

World Patient Safety Day Joint Statement International Council of Nurses and The Council of International Neonatal Nurses, Inc. To mark World Patient Safety Day, 17 September 2021, the International Council of Nurses (ICN) and the Council of International Neonatal Nurses, Inc. (COINN) urge all stakeholders to heed the campaign call and “Act now for safe and respectful childbirth!”. TO READ MORE https://www.icn.ch/system/files/documents/2021-09/ICN%20COINN%20Joint%20Statement%20WPSD%202021%20final.pdf

COUNCIL OF INTERNATIONAL NEONATAL NURSES, Inc. (COINN)Position Statement COINN (Council of International Neonatal Nurses, Inc) Position COINN (Council of International Neonatal Nurses, Inc) believes that the survival and long-term outcomes for high-risk and/or sick newborns depends on the provision of skilled nursing care. COINN (Council of International Neonatal Nurses, Inc) supports the provision of neonatal nursing education that is resourced, evidence-based, focused on developing skills and a theoretical basis for practice, and delivered by appropriately qualified educators and clinicians. COINN (Council of International Neonatal Nurses, Inc) recognizes that different models of education must be available that take into account local capacity and requirements. Although differences exist within local and national organizations as to what constitutes basic, essential, and advanced care of the newborn, COINN (Council of International Neonatal Nurses, Inc) believes that neonatal nurses need skills to resuscitate newborns, and to care for preterm, small for gestational age, low birth weight, sick and critically ill newborns. COINN (Council of International Neonatal Nurses, Inc) acknowledges that, in some countries, the ability to educate neonatal nurses is hampered by limited resources - personnel, financial, and equipment. However, COINN (Council of International Neonatal Nurses, Inc) believes that in order to reduce newborn mortality and morbidity, neonatal nursing education is essential. Support and assistance for neonatal nursing training is required from health professionals, hospital management, academic institutions and regional and national governments in all countries. COINN (Council of International Neonatal Nurses, Inc) is committed to facilitating the education of neonatal nurses worldwide. Background The 2014 Lancet ‘Every Newborn’ Series highlights that the time of birth is the highest risk period of death for newborns, with more than 2.7 neonatal deaths occurring every year (Lawn, Blencowe, Oza, Lee, Waiswa, & Cousens, 2014). The three main causes of neonatal death globally are infection, intrapartum conditions and complications due to preterm birth; problems which are largely preventable (Premji, Spence, & Kenner, 2013). A rapid response by a skilled neonatal nurse is needed to resuscitate newborns, and to provide ongoing nursing care for preterm, small for gestational age, low birth weight and sick newborns, to prevent long-term consequences requiring costly treatment and diminish their capacity to work (Darmstadt,Kinney, Chopra, Cousens, Kak, Martines, & Lawn, 2014). To recognize, identify, and manage these newborns, nurses must have specialized training and education at a community, unit or institutional level. For over thirty years countries such as the United States, the United Kingdom, Australia, Canada, and New Zealand have recognized that neonatal nurses require specialty training either in the neonatal unit or at an academic institution resulting in a recognized qualification. The result in many countries has been recruitment and retention of nurses in the specialty as well as improved neonatal outcomes (Premji, Spence, & Kenner, 2013). Neonatal care should be provided by skilled health care workers and professionals as a first line defense in health care as this is most cost effective than emergency, critical, or long-term care (Mangham-Jefferies, Pitt, Cousens, Mills, & Schellenber, 2014).) Recommendations/Key Principles 1. COINN (Council of International Neonatal Nurses, Inc) is committed to the promotion of positive health outcomes for neonates, reducing mortality and morbidity, and creating a global community of well-educated, specialized nurses working together towards this goal. 2. COINN (Council of International Neonatal Nurses, Inc) supports the Every Newborn Action Plan (World Health Organization, 2014) in particular Goal 1: Ending preventable newborn deaths by increasing the coverage of skilled care at birth in health facilities, and improving the quality of newborn care by training health care workers in specific skills of caring for sick or small newborns. 3. COINN (Council of International Neonatal Nurses, Inc) supports the Sustainable Development Goals (SDGs) especially #3 to reduce the neonatal mortality rate to 12 deaths per 1000 live births (United Nations, 2015). 4. COINN (Council of International Neonatal Nurses, Inc) recognizes that there are differences in training and education around the world for nurses providing neonatal care, and asserts that neonatal nurses should receive formal preparation in programs of sufficient length and scope to facilitate evidence-based neonatal nursing practice. 5. COINN (Council of International Neonatal Nurses, Inc) believes that training should be progressive, supporting retention of nurses within the field by providing a clear career pathway. 6. COINN (Council of International Neonatal Nurses, Inc) believes that specialized, better educated nurses will be able to utilize, conduct and collaborate in research that will ultimately lead to better neonatal outcomes on national and global levels. 7. COINN (Council of International Neonatal Nurses, Inc) supports the development of a set of competencies for neonatal nurses which provide the basis for the outcomes of the education. 8. COINN (Council of International Neonatal Nurses, Inc) is committed to work with professional national and international organizations to support increased training and education of neonatal nurses References Darmstadt, G. L., Kinney, M. V., Chopra, M., Kak, L., Paul, V. K., Martines, J., Bhutta, Z., Lawn, J, E. , Lancet Every Newborn Study Group. (2014). Every Newborn 1: Who has been caring for the baby? Lancet, 384 (9938): 174-188. Lawn, J.E., Blencowe, H., Oza, S., You, D., Lee, A. C. C., Waiswa, P...Cosenns, S. N., Lancet Every Newborn Study Group. (2014). Every Newborn 2: Every Newborn: progress, priorities and potential beyond survival. Lancet, 384 (9938): 189-205. Mangharm-Jefferies, L., Pitt, C., Cousens, S., Mills, A., & Schellenberg, J. (2014). Cost-effectiveness of strategies to improve utilization and provision of maternal and newborn health care in low-income and lower-middle-income countries: a systematic review. BMC Pregnancy and Childbirth, 14 (243). Doi: 10.1186/1471-2393-14-243. Premji, S. S., Spencer, K., & Kenner, C. (2013). Call for neonatal nursing specialization in developing countries. Maternal Child Nursing, 38 (6): 336-342. United Nations (2015). Sustainable development goal: Goal 3: ensuring healthy lives and promote well-being for all at all ages. Retrieved from: http://www.un.org/sustainabledevelopment/health/ World Health Organization. (2014). Every newborn: an action plan to end preventable death. Retrieved from: https://www.who.int/maternal_child_adolescent/documents/every-newborn-action-plan/en/

COUNCIL OF INTERNATIONAL NEONATAL NURSES, Inc. (COINN) Position Statement COINN (Council of International Neonatal Nurses, Inc) Position COINN (Council of International Neonatal Nurses, Inc) advocates for breastfeeding within the first hour of life and exclusive breastfeeding for the first six months of life for all newborn infants, when safe to do so. COINN (Council of International Neonatal Nurses, Inc) supports the World Health Assembly resolutions; the UNICEF and World Health Organization Baby-Friendly Hospital and Community Initiative; the enforcement of the International Code of Marketing of Breastmilk Substitutes and the provision of paid maternity leave and workplace breastfeeding initiatives. COINN (Council of International Neonatal Nurses, Inc) recognizes the critical impact of breastfeeding and expressed breast milk complementary feeding, to not only enhanced short and long-term health and developmental outcomes, but also to child survival. COINN (Council of International Neonatal Nurses, Inc) acknowledges that current practices in some countries need to be changed to support breastfeeding. For example, not all women are granted maternity leave of more than a few weeks, or have adequate places to use a breast pump, or breastfeed. Therefore, to improve health outcomes for neonates, it is important for parents, communities, healthcare workers, professional colleges, support organizations, education providers, health systems and governments to work together to strive to uphold these key principles and advocate for positive environments and leave policies that support breastfeeding. Background Globally more than 6 million children die before their 5th birthday with a significant portion of the deaths occurring in Sub-Sahara Africa and Southern Asia (United Nations, 2015). The Sustainable Development Goal (SDG) 3 calls for preventable deaths of newborns and children under 5 years to drop to as low as 12 per 1,000 live births and the under 5 mortality to at least 25 per 1000 (United Nations, 2015). High coverage with optimal breastfeeding practices has potentially the single largest impact on child survival of all preventive interventions (Azuine, Murray, Alsafi, & Singh, 2015). Evidence demonstrates that breastfeeding is effective at decreasing neonatal and child mortality (Gates & Binagwaho, 2014). Exclusive breastfeeding could prevent 823,000 childhood deaths and 20,000 maternal deaths per year (Lancet, 2016). Infants less than six months of age who are not breastfeed have and 3-5 times (boys) and 4-1 times (girls) increase in mortality compared to the infants who had been breastfeed (Victoria et al., 2016). The children who are breastfeed for short periods of time or not at all have a higher incidence of infectious morbidity and mortality, more dental malocclusions and lower intelligence (Victoria et al., 2016). Promoting skin-to-skin and early initiation of breastfeeding lowers neonatal mortality and waiting after the first hour to initiate breastfeeding doubled the risk of the neonate dying (Khan, Vesel, Bahl, & Martines, 2015). The striking feature of all of this is that despite knowing the potential of breastfeeding in reducing neonatal and infant mortality; breastfeeding rates have remained stagnant at 37per cent of children less than six months of age being exclusively breastfed (Victoria et al., 2016). Recommendations/Key Principles Promotion, protection and support for breastfeeding at local, national and international levels. Increased global attention, media coverage and funding for breast feeding initiatives acknowledging, highlighting and supporting the critical role breastfeeding plays in reducing child deaths and providing short and long term benefits for maternal health. Promotion of The International Code of Marketing of Breastmilk Substitutes and subsequent, relevant, World Health Assembly resolutions. Support the UNICEF and World Health Organization Baby-Friendly Hospital and Community Initiative. The provision of paid maternity leave in line with the International Labour Organization (ILO) minimum recommendations and workplace breastfeeding initiative. Professional and lay support for breastfeeding mothers, including: The attendance of a skilled birth attendant at every birth to ensure the initiation of breast feeding within one hour of birth Professional support by health providers to extend the duration of any breastfeeding and this must be facilitated by allocating adequate resources to long-term health worker training, recruitment, support and retention Support in the community by lay counsellors to increase the initiation and duration of exclusive breastfeeding 7. Where possible mother and child should not be separated and kangaroo mother care should be facilitated. 8. Exclusive breastfeeding for all infants for the first six months of life. ‘Exclusive breastfeeding’ is defined as giving no other food or drink – not even water – except breast milk. It does, however, allow the infant to receive oral rehydration salts (ORS), drops and syrups (vitamins, minerals and medicines). 9. Infants not able to breastfeed should be fed breast milk (mother’s own or donated) via tube, cup, syringe or spoon. Bottle-feeding should not be offered. 10. From six months of life the provision of nutritionally adequate and safe foods that complement breastfeeding. 11. The continuation of breastfeeding up to two years or beyond. 12. Community /country relevant policies regarding feeding HIV exposed babies-either exclusive breastfeeding with anti-retroviral (ARV) therapy or avoidance of all breast feeding. In low resource settings even when ARVs are not available, mothers should be counselled to exclusively breastfeed in the first six months of life and continue breastfeeding thereafter unless environmental and social circumstances are safe for, and supportive of, replacement feeding. References Azuine, R. E., Murray, J., Alsafi, N., & Singh, G. K. (2015). Exclusive Breastfeeding and Under-Five Mortality, 2006-2014: A Cross-National Analysis of 57 Low- and-Middle Income Countries. International Journal of MCH and AIDS, 4(1), 13–21. Gates, M., & Binagwaho, A. (2014). Newborn health: a revolution in waiting. Retrieved from: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60810-2/fulltext Khan, J., Vesel, L., Bahl, R., & Martines, J. C. (2015). Timing of breastfeeding initiation and exclusivity of breastfeeding effects on neonatal mortality and morbidity – a systematic review and meta-analysis. Maternal Child Health, 19(3), 468-79. Doi:10.1007/s10995-014-1526-8. Lancet (2016). Breastfeeding: achieving the new normal. Lancet, 387(10017), 404. Retrieved from: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)00210-5/fulltext Victoria, C, S., Bahl, R., Barros, A. J., Giovanny, V. A. F., Horton, S., Krasevec., J., & Rollins, N. C. (2016). Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet, 387(10017), 475- Retrieved from: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)01024-7/fulltext