ADVANCES IN NEONATAL CARE 对其发表的原创研究和临床实践文章采取了独特而动态的方法。解决每天面临的实践挑战——每年在二级和三级新生儿重症监护病房照顾 40,000 多名低出生体重婴儿——该杂志促进循证护理并改善最小患者及其家人的结果。同行评审的社论包括独特而详细的视觉和教学辅助工具，例如家庭教学工具箱、从研究到实践、培养临床专业知识和在线功能。每期都提供印刷和在线格式的继续教育 (CE) 文章。

Advances in Neonatal Care takes a unique and dynamic approach to publishing original research and clinical practice articles. The journal addresses the daily practical challenges faced in neonatal intensive care units, caring for over 40,000 low birth weight infants each year. By promoting evidence-based care, it aims to improve outcomes for these vulnerable patients and their families. Peer-reviewed editorials include unique and detailed visual and educational aids, such as family teaching toolkits, translation from research to practice, development of clinical expertise, and online features. Each issue provides continuing education (CE) articles in both print and online formats.

《Advances in Neonatal Care》采用独特而动态的方法，发表原创研究和临床实践文章。该杂志专注于解决新生儿重症监护病房中每天面临的实践挑战，每年照顾超过40,000名低出生体重婴儿。通过促进循证护理，该杂志致力于改善这些脆弱患者及其家庭的结果。同行评审的社论中包含独特而详细的视觉和教学辅助工具，例如家庭教学工具箱、从研究到实践的转化、临床专业知识的培养以及在线功能。每期杂志还提供印刷和在线格式的继续教育（CE）文章。

Advances in Neonatal Care

Background:The expression, storage, preparation, fortification, and feeding of breast milk are common ongoing activities in many neonatal intensive care units (NICUs) today. Errors in breast milk administration are a serious issue that should be prevented to preserve the health and well-being of NICU babies and their families. Purpose:This paper describes how a program to improve processes surrounding infant feeding was developed, implemented, and evaluated. Methods:The project team used a blended quality improvement approach that included the Model for Improvement, Lean and Six Sigma methodologies, and principles of High Reliability Organizations to identify and drive short-term, medium-term, and long-term improvement strategies. Findings/Results:Through its blended quality improvement approach, the team strengthened the entire dispensation system for both human milk and formula and outlined a clear vision and plan for further improvements as well. The NICU reduced feeding errors by 83%. Implications for Practice:Be systematic in the quality improvement approach, and apply proven methods to improving processes surrounding infant feeding. Involve expert project managers with nonclinical perspective to guide work in a systematic way and provide unbiased feedback. Create multidisciplinary, cross-departmental teams that include a vast array of stakeholders in NICU feeding processes to ensure comprehensive examination of current state, identification of potential risks, and “outside the box” potential solutions. Implications for Research:As in the realm of pharmacy, the processes involved in preparing feedings for critically ill infants should be carried out via predictable, reliable means including robust automated verification that integrates seamlessly into existing processes. The use of systems employed in pharmacy for medication preparation should be considered in the human milk and formula preparation setting.

Alexandra Luton

Patricia G. Bondurant

Amy Campbell

Claudia Conkin

Jae Hernandez

Nancy Hurst

Got (the Right) Milk? How a Blended Quality Improvement Approach Catalyzed Change

得到了（正确的）牛奶吗？一种混合质量改进方法如何催化变革

CULTURALLY SENSITIVE, FAMILY-CENTERED CARE: UNIQUE NEEDS OF THE MILITARY FAMILIES SERVING ABROAD AN OVERVIEW OF THE NAVAL MEDICAL SERVICES The United States Navy (USN) currently has 328,267 active duty and 97,219 reserve members serving in various roles throughout the world.1 Navy Medicine, the healthcare division of the USN, operates 17 US Naval Hospitals (USNHs) worldwide, 2 of which are located in Japan. One is on mainland Japan in Yokosuka2 near Tokyo and the other is located on the southern island of Okinawa.3 USNH-Okinawa is the Navy Medicine's largest overseas military treatment facility providing direct patient care to over 47,000 personnel on Okinawa and nearly 189,000 in the Western Pacific region.4 The USNH-Okinawa has a level III, 12-bed neonatal intensive care unit (NICU).5 USNH-Yokosuka is the largest facility in mainland Japan providing a wide range of emergency, inpatient, and outpatient care for approximately 43,000 active duty members and their families. The geographic service area for USNH-Yokosuka and its branch clinics stretches from the northern tip of Japan, south to Iwo-Jima, and west to Diego Garcia, and essentially covers the entire Indo-Asia-Pacific region.6 USNH-Yokosuka does not offer specialized care for high-risk newborns or high-risk pregnancies, leaving a gap in neonatal care for this region. To meet the specialized needs of this population, USNH-Yokosuka has established a system to make high-risk services available through a joint partnership with civilian Japanese neonatal services in the region. The aim of this report is to highlight this collaborative partnership. In addition, the efforts of naval service leadership have been discussed to better understand the care of the high-risk newborns who require admission to the NICU and their families while serving our country overseas.Navy Nursing members, the author, and the Neonatal Nurse Leadership from Kanagawa Children's Medical Center in attendance at the US-Japan Joint Nursing Symposium 2018.NAVAL HOSPITAL-YOKOSUKA The Clinical Nurse Specialist for the Maternal and Infant Unit, Lieutenant Commander (LCDR) Michelle Westcott, RN, MSN, CNS, reports that USNH-Yokosuka provides routine prenatal, labor, delivery, and postpartum care. Highly skilled midwifery service provides quality care in partnership with the obstetrical team at Yokosuka Naval Medicine. The care of high-risk mothers and newborns, such as premature births, requires collaboration with the network of Japanese hospitals in the region that provide specialized NICU care. USNH-Yokosuka obstetrical team provides quality prenatal care by monitoring the suitability and safety of pregnant patients for delivery at USNH-Yokosuka. When problems are identified, arrangements for maternal transfers to USNH-Okinawa or back to the United States are made to achieve optimal patient outcomes. However, the dynamic nature of pregnancy and labor and delivery may prevent the opportunity to provide maternal transport to an appropriate military or US civilian facility. The USNH-Yokosuka transport team is used to transport high-risk mothers or moderately ill infants to Japanese accepting facilities. However, in emergent cases when mothers cannot be transported or following the delivery of an extremely preterm infant(s), Japanese teams are requested to transport the infant/infants to the outlying Japanese facility. These high-risk infants remain in the Japanese NICUs until they are stable, and then they are transferred back to USNH Yokosuka for newborn screening and a short period of observation before discharge home with their families. Although USNH-Okinawa has a 12-bed, level III NICU with neonatology service,5 the 1000-mile distance between USNH-Yokosuka and Okinawa is neither practical for families nor realistic for transport of high-risk infants in urgent or emergent situations. LCDR Westcott reports that annual transport needs vary; however, upwards of 20 cases including high-risk infants and high-risk pregnant mothers are transferred from USNH-Yokosuka to surrounding Japanese hospitals. The bed availability determines transfer location while also facilitating closeness for infants and families. The collaboration between the US and Japanese hospitals is not without challenges, increasing stressors for families that could have potential long-term consequences. CHALLENGES FOR THE NAVY FAMILIES AND ALSO FOR THE JAPANESE HEALTHCARE PROVIDERS Navy families are far removed from their own family support system during the time they serve their nation from posts abroad. Naval support systems are in place; however, not having your own immediate family and close friends nearby during a prolonged hospitalization with an ill child is a highly stressful experience both psychologically and physically. Although the Japanese hospitals where their infants are transported to may be in the “region,” the distance can still require extended driving times—as much as an hour or more. Frequent travel off-base to the foreign hospital is not included in typical training for the anticipated “overseas” experience for Navy service members or their families. It is also rare for Navy families serving in Japan to have language proficiency in the native language of Japanese. The Japanese hospital's standard practice does not typically include readily available English written materials, putting English-speaking patients and families at a disadvantage. It is common to find only a handful of nursing staff who may speak some English, but rarely at a proficient level. Some of the physician staff members may speak near-proficient English; however, his or her availability at the bedside is limited. A complex combination of barriers potentially creates further complications for Navy families, especially when the hospitalization is prolonged. Annual transports of up to 20 infants from USNH-Yokosuka to Japanese hospitals may not sound significant to readers whose practice carries out significant number of transports yearly; however, the impact of these transport cases, which originate from the Navy base, must be viewed in terms of the “total patient days of hospitalization,” and the day-to-day struggle and stress Navy families endure in a foreign culture. We must also consider the day-to-day efforts the Japanese care providers make attempting to meet both the medical needs of the infants and the support for the families. In the NICUs in North America, we strive to welcome NICU families who speak limited English or no English at all, who may not have lived in the United States for a long time, so that our care quality, both actual and perceived, is not negatively impacted. The NICU environment is often perceived as “foreign,” “unwelcoming,” or “intimidating” even in the absence of language or cultural barriers. Table 1 summarizes some of the barriers and challenges that present to Navy families as well as the challenges expressed by Japanese hospital healthcare providers when Navy families face crisis in the NICUs in Japan. TABLE 1. - Comparison of needs for Families and Healthcare Providers Naval Families Japanese Healthcare Providers Limited Japanese language ability for reading, writing, and understanding the necessary forms/documents that are presented on admission and throughout the NICU hospitalization. Require interpreter or staff fluent in English to discuss complex medical information. Language barriers (when translators are not available) prevent families from receiving frequent and timely updates regarding the infant(s) condition from the care providers. Difficulties for the families to verbally express their concerns or anxiety in a timely manner, or to ask simple questions about infant's physiology when questions arise. Potential delays in parental engagement with the infants' care, which may cause additional negative impact on parent–infant bonding. Challenges felt by the families related to the cultural differences in the norm of what family may desire in time of crisis, which can lead to a potential misunderstanding or additional stress. Differences in how family-centered care concept is approached by the Japanese NICUs and how cultural influence may shape the concept and attitude impacting the unit policies and practice standards in a way that is stressful for the Navy families (eg, limited or no visitation for sibling/grandparents and limited visitation hours). Difficulty understanding medication names or purposes for medications. Even a commonly known medication may have a unique name in Japan. Potential confusion for families caused by a translation done with inaccurate terminology leading the families to receive wrong information, thus causing significant distress (eg, healthcare providers may explain that “The pregnancy cannot continue due to the severe maternal eclampsia,” indicating the need for an emergency cesarean section by using words that can be easily taken to mean “termination of pregnancy.” This example was given from the actual experience of the third author.). The sense of “Our family represents the US Navy” may make Navy families feel that they have to be “tough” during the most difficult times. This may prevent the families from making efforts to express honest concerns in a timely manner. Difficulty for receiving facility to collect maternal history in a timely manner. Challenges in the provision of frequent and timely education to parents due to the language barrier, potentially leading to a delayed parental acquisition of knowledge and skills needed to build confidence as parents. Difficulty for the healthcare team to help develop parental sense of being a part of the care team. Difficulty extending emotional support in a meaningful manner due to the language barrier. Some of the Japanese hospitals rely on the external services for interpreters; however, these services must be scheduled in advance. Abbreviation: NICU, neonatal intensive care unit. CURRENT EFFORTS BEING MADE Navy leadership is aware of actual or potential obstacles that service members experience in the host country hospital. Currently, a bilingual Japanese civilian staff that has previous nursing experience is incorporated into the care team by USNH-Yokosuka to support the navy families who are hospitalized off-base. This member visits the Japanese NICUs once a week to serve as an interpreter, visit with, and encourage Navy families. On these visits, complex matters are discussed with the healthcare team to ensure accurate information is communicated to families while any special needs of the families can be relayed to the care providers. To support this partnership, Naval Hospital leadership initiated a US–Japan Joint Nursing Symposium, inviting the local Japanese nursing community to an annual face-to-face meeting. The objective of this joint meeting is to nurture the cross-cultural professional relationship and to develop opportunities to improve the partnership in coordination of care, to optimize the experiences of patients and families. USNH-Yokosuka hosted the 4th Annual US–Japan Joint Nursing Symposium on February 12, 2018, at the Admiral Arleigh A. Burke Officer's Club on the Naval Base in Yokosuka, Japan. Nearly 100 nurses (Japanese, navy, air force, and civilian U.S. nurses working in USNH Yokosuka) representing numerous area hospitals where Navy service members or their families have received care or collaborated with in the past attended the event. The US–Japan joint participants were able to share healthcare challenges, and be inspired by the collaborative nursing spirit that ties them together in spite of the differences in culture or language. Invited speakers were from both the maternal–infant and the pediatric specialty care areas. The former Commanding Officer of USNH, Captain Rosemary C. Malone, MD, delivered her opening message with words of sincere gratitude to the Japanese hospital representatives for this innovative partnership. LCDR Westcott presented her sincere and heart-felt words of “thank you” by recognizing each hospital that was represented at this symposium. Several Japanese presenters discussed the efforts as well as the immense sense of responsibility they felt as they cared for the Navy families and their infants. One presenter reported the efforts they have made to translate some of the materials into English, especially the initial admission consent forms. These materials will be used to facilitate communication with the Navy families at her institution. Japanese presenters also expressed the challenges they experienced when collecting maternal history or delivery information. It is not easy for the Japanese staff to review the history information sent with the patients from the Naval Hospital that is all written in English. One presenter stated that, in some emergency transports, all they know is “a baby is coming from the base” without a detailed history, making preparation a challenge. Wakako Eklund, DNP, NNP-BC, a NANN and NANNP member, was invited to present at this event. Her presentation, titled, “Our collaborative team of 29 NNPs and 10 Neonatologists!” described the common neonatal practices in the United States as Dr. Eklund practices in Nashville, Tennessee. She shared how a large geographic area is covered by the partnership of neonatologists and neonatal nurse practitioners in collaboration with area hospitals and their staff. She discussed the challenges in caring for non-English-speaking families whose infants are admitted to NICUs in the region. She also described that her Nashville practice has transported numerous infants from a military base in the region when higher level of NICU care was required and of the challenges that families face off-base. These challenges aligned with the collaborative practice between USNH-Yokosuka and area Japanese hospitals. Her message included the value of culturally sensitive and family-centered care, emphasizing how families' stress can be minimized by providing family support with various strategies especially when families do not speak English. She shared her own experience of caring for Japanese families with premature infants in the United States, and how intensely families seek someone of their own language/culture when in crisis for comfort or reassurance. This, she shared, is necessary for non-English-speaking families to feel confident in the care their infants are receiving, and to feel secure in an incredibly insecure moment in their lives. Navy nurses asked what more they can do to prepare the Navy families before they go to the Japanese hospitals, and they also expressed their observations of how the healthcare culture appeared to differ significantly between the United States and Japan. Dr. Eklund was able to visit with the nurse who makes the weekly visits to the NICU to meet with Navy families who are being cared for in the Japanese facilities. She learned from Japanese NICU nurses about the difficulty they experience as they take care of Navy families in a manner satisfying to both the Navy families and to the care providers. Not being able to fully engage with families in deep discussions with the simple verbal communication is challenging, and they shared concerns about not being able to adequately understand the families' feelings while the families were not adequately able to express their needs to the caregivers, thus potentially adding unnecessary stressors for all. Cristal Grogan, a former Navy wife who underwent an emergency cesarean section to deliver her son at 29 weeks' gestation while her husband was stationed in Spain, offers the following reflection based on her lived experience in a “foreign NICU.” Cristal is an active member of the “Premie Parent Alliance (PPA),”7 which is a dynamic network of former NICU parents, with the mission to advocate for the needs of NICU families by closely collaborating with the members of the neonatal, pediatric, and perinatal organizations. PPA is actively engaging in neonatal initiatives at the local, state, national, and also at an international front. My son had a complicated course in the NICU. But I truly believe that so much of the trauma we experienced as parents, and the PTSD [posttraumatic stress disorder] that I may always live with, could have been minimized by the simple ability to “speak” or “communicate intelligently” back and forth with the care team. The biggest stressor and the distress experienced as a result was mainly centered around the communication barrier, specifically the lack of access to interpreters. We had so many questions and we sensed that we were viewed as a burden to the NICU staff because of our lack of knowledge to speak the host-country's language, Spanish. Because of not being able to fully understand how my son's condition was improving, progressing, or regressing in concrete terms, I always feared the worst, traumatizing myself every day. My difficulty during those days negatively impacted my ability to bond with my dear son for well over a year post-discharge. It affected my mental health and my overall ability to care for my son, including breast feeding or to create special memories/moments with him during the early phase of his life. Today, it is known that PTSD is a reality to many NICU families even when there is no cultural or language barriers, and I understood later that my condition was far worse for a reason that was explainable. While we provide culturally sensitive care in the United States to non-English-speaking families from other cultural backgrounds, we must also remember some of our men and women who are serving abroad and experiencing culturally stressful hospitalization experiences. Dr. Eklund has contacted some of the Japanese hospital leadership to inquire how she could support such efforts as document translation, creation of English educational materials, or to participate in any future joint initiatives to facilitate any efforts using her language and neonatal expertise. She considers it an honor to have been a part of the 4th US–Japan Joint Nursing Symposium and to take part in any future efforts by keeping in touch with those NICU members in Japan where the Navy babies and their families are being cared for. She sensed a highly motivated collaborative spirit between the US Navy nurses and the Japanese nurses in attendance and is confident that the continued joint partnership between USNH-Yokosuka and the Japanese healthcare community in the region will continue to offer positive changes to the experiences of Navy families and their infants.

Wakako M. Eklund

Michelle Westcott

Cristal Grogan

Noteworthy Professional News

值得关注的专业新闻

Moniaci, Valerie K. APRN, NNP-BC; Bellflower, Bobby DNSc, NNP-BC, FAANP Author Information

Valerie K. Moniaci

Bobby Bellflower

NANN's Thermoregulation in the Care of Infants Guideline for Practice Executive Summary

NANN 婴儿护理中的体温调节指南执行摘要

Hemophagocytic lymphohistiocytosis (HLH) is a rare disease resulting from an abnormal proliferation of histiocytes within the body's tissues leading to an ineffective immune response. Typically, HLH is characterized by fever, hepatosplenomegaly, cytopenia, hypertriglyceridemia, hypofibrinogenemia, and hemophagocytosis. However, the premature infant with HLH may present differently making diagnosis of the disease cumbersome. If an infant is born with ascites, cytopenias, hypofibrinogenemia, and hepatosplenomegaly, a diagnosis of HLH cannot be ruled out. In addition, premature infants oftentimes will not present with fever because they are kept normothermic from ambient sources. Reports of premature infants with HLH in the literature are rare. This is a case presentation of a 27-week-gestation female with a family history of HLH.

Amanda G. Woods

Christopher W. Woods

Hemophagocytic Lymphohistiocytosis in the Premature Neonate

早产儿中的噬血细胞性淋巴组织细胞增多症

Familial hemophagocytic lymphohistiocytosis is a rare and inherited disease that affects both males and females equally and is most often fatal if not treated. Diagnosis is challenging because it mimics severe sepsis by demonstrating hepatomegaly, splenomegaly, persistent fever, central nervous system involvement, and cytopenias. The etiologies of hemophagocytic lymphohistiocytosis have been well established through the identification of 3 causative genetic mutations. Therapies for hemophagocytic lymphohistiocytosis focus on restoring health by diminishing the disease sequelae with a goal of hematopoietic stem cell transplant, the only known curative therapy for hemophagocytic lymphohistiocytosis. Current research is being conducted to identify other causative genetic mutations and newer, more effective treatment modalities.

Brian F. Whaley

Familial Hemophagocytic Lymphohistiocytosis in the Neonate

新生儿家族性噬血细胞性淋巴组织细胞增生症

Background: Recurrent pain experienced by preterm infants during hospitalization is significant due to its short and long-term negative consequences. Purpose: This randomized controlled trial examined the effect of the mother’s own milk odor and white noise on pain management during heel lance in preterms. Methods: The data were collected in the neonatal intensive care unit and postpartum services between May and October 2022. The study included 66 infants born between 34 and 37 weeks. Infants were randomly assigned to either the mother’s own milk odor, white noise, or control groups. Data were collected using the Premature Infant Pain Profile—Revised Form, Descriptive Information Form, and Follow-Up Chart. Pain was evaluated 5 and 2 minutes before the procedure, at the time and 5 minutes after the procedure by 2 independent nursing academicians/lecturers through video recordings. Frequency, mean, standard deviation, chi-square test, one-way ANOVA and repeated measures were used for data analysis. Results: All groups were similar regarding the descriptive characteristics. The control group had higher heart rates before and after the procedure than the mother’s own milk odor and white noise group. Oxygen saturation was higher and pain scores were lower in the white noise and mother’s own milk odor group compared to the control group during and after the procedure. There was no difference between the mother’s milk odor and white noise groups at any time. Implications for Practice and Research: The odor of the mother’s milk and white noise may effectively manage pain during heel lance in preterms. Neonatal nurses can adopt these methods as effective non-pharmacological pain management methods.

Burcu Otlu

Figen I. Esenay

Use of Mothers Milk Odor and White Noise on Pain Management in Preterm Infants

母乳气味与白噪音在早产儿疼痛管理中的应用

Background: Treprostinil is a prostacyclin analogue that is frequently used in the pediatric and adult population to treat pulmonary hypertension; however, it is not often a drug of choice for patients in the neonatal intensive care unit (NICU). Purpose: To evaluate the efficacy of treprostinil as a treatment for pulmonary hypertension of the neonate. Data Sources: Electronic databases such as PubMed, CINAHL, and Embase were used for this literature review. Twelve articles within the last 10 years (2014-2024) were included in this review. Study Selection: 136 articles were identified and primary research studies published in English and with patients younger than one year of age were included. Duplicates were removed and studies discussing genetics and congenital heart disease were excluded. Data Extraction: Abstracts were reviewed and articles referencing treprostinil use in the NICU were included for review. Independent extraction was completed by author. Results: Findings showed treprostinil to have a therapeutic benefit in infants with congenital diaphragmatic hernias and possibly with premature infants. Some adverse effects were noted, one of which included hypotension; however, management strategies exist to mitigate this effect. Implications for Practice and Research: Initiating treprostinil in the NICU may help decrease the severity of persistent pulmonary hypertension of the newborn (PPHN) which can help reduce neonatal morbidity and mortality. Future research is needed to determine the optimal timeframe to initiate treprostinil in the NICU; the duration of treatment; use in other conditions that can cause PPHN (i.e. meconium aspiration syndrome); and the other potential effects it may have for the preterm infant.

Diana Lee

Treprostinil Use in the NICU

硝普钠在新生儿重症监护室的使用

Background: In 2020, the rate of newborns diagnosed with neonatal abstinence syndrome (NAS) in the United States was 6.3 for every 1000 newborn hospitalizations. Resources used to care for this population, particularly NICU beds, are being overwhelmed. In 2020, the state of Ohio saw a rate of 9.5 newborns with NAS for every 1000 newborn hospitalizations. Purpose: To determine if using the Eat, Sleep, Console (ESC) model of care to guide management of neonates with NAS instead of the Finnegan Scale would reduce the number of admissions of neonates diagnosed with NAS to the neonatal intensive care unit (NICU). Methods: The PDSA (Plan, Do, Study, Act) method was used in the planning and implementation of this pilot quality improvement project. Education regarding the ESC model of care was provided to the Mother/Infant Unit (MIU), with ongoing education and resources provided and readily available on the unit. Results: Fifteen neonates were managed with ESC. Of the 5 who would have been admitted to the NICU for pharmacological treatment if Finnegan Scores were the determining factor for admission, 2 were discharged home from the MIU having been managed with ESC. Implications for practice and research: The use of the ESC model of care can be a useful tool in the management and assessment of neonates with NAS. Resource allocation for care of this population must be assessed to provide optimal non-pharmacological interventions.

Allison Zara Kelly

Gail A Bagwell

Penni Coates-Huffman

Our First Steps

我们的第一步

Background: Nonpharmacological methods such as white noise and therapeutic touch can be used in pain management in neonates. Purpose: This randomized controlled study evaluated the effects of white noise and therapeutic touch during heel lance procedures on pain, comfort levels, and physiological parameters in healthy neonates. Methods: This parallel, randomized controlled study was conducted in the Obstetrics and Gynecology Service of a regional hospital. The sample comprised 160 neonates with gestational ages of &gt;35 weeks randomly assigned to 4 groups (white noise [WN], therapeutic touch [TT], white noise + therapeutic touch [WT], and control [CG] group). Pain and comfort levels were evaluated according to the Neonatal Infant Pain Scale, and the COMFORTneo Scale. The primary outcomes were pain and comfort levels, and the secondary outcomes were heart rate and SpO 2 levels. The Kruskal-Wallis test was used to compare the scale scores among groups. Results: There were significant differences among groups in terms of Neonatal Infant Pain Scale and COMFORTneo scores ( P &lt; .05). The pain scores for the white noise, therapeutic touch, and white noise + therapeutic touch groups were 4.2 ± 2.0, 5.2 ± 1.6, and 3.3 ± 1.7, respectively. There was a significant difference in average heart rate during the heel lance procedure among the groups ( P &lt; .05). Pain scores of the intervention groups were lower compared to the control group. Implications for Practice and Research: The combination of white noise and therapeutic touch was more effective in reducing pain and increasing comfort levels. Nurses could reduce procedural pain by applying these pain relief methods.

Abbreviation	Adv. Neonatal. Care.
Journal Impact	1.65
Quartiles(Global)	NURSING(Q2)

ISSN	1536-0903, 1536-0911
h-index	52

Publication Information	Publisher: Lippincott Williams and Wilkins Ltd.，Publishing cycle: ，Journal Type: journal，Open Access Journals: No
Basic data	Year of publication: 2002，Proportion of original research papers: 85.39%，Self Citation Rate:12.50%， Gold OA Rate: 5.47%

Advances in Neonatal Care

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