Merenstein & Gardner’s Handbook of

Neonatal Intensive Care 8th Edition

Sandra Lee Gardner & Brian S. Carter &
Mary I Enzman-Hines & Jacinto A.
Hernandez - eBook PDF
Go to download the full and correct content document:
https://ebooksecure.com/download/merenstein-gardners-handbook-of-neonatal-inten
sive-care-ebook-pdf/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...

Merenstein & Gardner's Handbook of Neonatal Intensive

Care: An Interprofessional Approach, 9th Edition
Gardner Rn Ms Cns Pnp - eBook PDF

https://ebooksecure.com/download/merenstein-gardners-handbook-of-
neonatal-intensive-care-an-interprofessional-approach-9th-
edition-ebook-pdf/

(eBook PDF) Certification and Core Review for Neonatal

Intensive Care Nursing 5th Edition

http://ebooksecure.com/product/ebook-pdf-certification-and-core-
review-for-neonatal-intensive-care-nursing-5th-edition/

Core Curriculum for Neonatal Intensive Care Nursing 6th

Edition M. Terese Verklan - eBook PDF

https://ebooksecure.com/download/core-curriculum-for-neonatal-
intensive-care-nursing-ebook-pdf/

Criminal Law 13th Edition Thomas J. Gardner - eBook PDF

https://ebooksecure.com/download/criminal-law-ebook-pdf/
(eBook PDF) Criminal Law 12th Edition by Thomas J.
Gardner

http://ebooksecure.com/product/ebook-pdf-criminal-law-12th-
edition-by-thomas-j-gardner/

(eBook PDF) Criminal Law 13th Edition by Thomas J.

Gardner

http://ebooksecure.com/product/ebook-pdf-criminal-law-13th-
edition-by-thomas-j-gardner/

Greenspan’s Basic and Clinical Endocrinology 10th

Edition David G. Gardner - eBook PDF

https://ebooksecure.com/download/greenspans-basic-and-clinical-
endocrinology-ebook-pdf/

Obstetric Intensive Care Manual Fifth Edition (eBook

PDF)

http://ebooksecure.com/product/obstetric-intensive-care-manual-
fifth-edition-ebook-pdf/

(eBook PDF) Your College Experience: Strategies for

Success 13th Edition by John N. Gardner

http://ebooksecure.com/product/ebook-pdf-your-college-experience-
strategies-for-success-13th-edition-by-john-n-gardner/
Merenstein &
Gardner’s Handbook
of Neonatal Intensive
Care
EIGHTH EDITION

Sandra L. Gardner, RN, MS

Retired Clinical Nurse Specialist; Retired Pediatric Nurse Practitioner; Director, Professional
Outreach Consultation; Editor, Nurse Currents and NICU Currents, Aurora, Colorado

Brian S. Carter, MD, FAAP

Professor of Pediatrics, University of Missouri-Kansas City School of Medicine, Division of
Neonatology & Bioethics Center, Children’s Mercy Hospital-Kansas City, Kansas City, Missouri

Mary Enzman Hines, PhD, APRN, CNS, CPNP,

APHN-BC
Professor Emeritus, Beth El College of Nursing and Health Sciences, University of Colorado at
Colorado Springs
Certified Pediatric Nurse Practitioner, Rocky Mountain Pediatrics, Lakewood, Colorado

Jacinto A. Hernández, MD, PhD, MHA, FAAP

2
Professor Emeritus of Pediatrics, Section of Neonatology, Department of Pediatrics, University of
Colorado School of Medicine
Chairman Emeritus Department of Neonatology, Children’s Hospital Colorado, Aurora, Colorado

3
Table of Contents
Cover image

Title page

Newborn Metric Conversion Tables

Copyright

Dedication

Contributors

Reviewers

Preface

Introduction
Unit One. Evidence-Based Practice

1. Evidence-Based Clinical Practice

Finding High-Quality Evidence

Pressures to Intervene

Evaluation of Therapies

Qualitative Research Evaluating Experiences in the Neonatal Intensive Care Unit

Systematic Review in Perinatal Care and Evidence-Based Practice

Translating Evidence into Practice

Clinical Practice Guidelines

4
Unit Two. Support of the Neonate

2. Prenatal Environment: Effect on Neonatal Outcome

Physiology

Compromised Fetal Environment

Environmental Effects of Labor on the Fetus

Assessment of Fetal Well-Being

3. Perinatal Transport and Levels of Care

Regional Perinatal Referral and Transport System

Neonatal Transport

Family-Centered Care for Transport

Future of Neonatal Transport

4. Delivery Room Care

A Golden Opportunity

Physiology

Asphyxia and Apnea

Clamping of the Umbilical Cord

Resuscitation of the Newborn

Delivery Room Emergencies

Care During the Transition from the Delivery Room to the Nursery

Care of the Family and Perinatal Decision Making

5. Initial Nursery Care

Assessment and Care at Delivery

Evaluation and Care During the Transitional Period

Physical Assessment of the Newborn

Late-Preterm Infant

Care of the Well Newborn Infant

Parent Teaching

5
6. Heat Balance
Historical Milestones

Physiologic Considerations

Etiology of Heat Imbalances

Prevention of Heat/Cold Stress

Data Collection

Hypothermia

Hyperthermia

Parent Teaching

7. Physiologic Monitoring
Physiology

Noninvasive Monitoring

Data Collection

Interventions

Complications

Controversies

Parent Teaching

8. Acid-Base Homeostasis and Oxygenation

Physiology

Data Collection

Treatment

Complications

9. Diagnostic Imaging in the Neonate

Radiography

Fluoroscopy

Ultrasonography

Computed Tomography

Magnetic Resonance Imaging

Nuclear Scintigraphy

6
 Positron Emission Tomography

Interventional Radiology

Picture Archiving and Communication Systems

Family Education and Involvement

10. Pharmacology in Neonatal Care

Physiology

Data Collection

Drug Categories

Prevention of Therapeutic Mishaps

Methods of Administration

Parent Teaching

11. Drug Withdrawal in the Neonate

Physiology

Etiology of Neonatal Abstinence Syndrome

Prevention

Diagnosis

Treatment and Intervention

Parent Teaching

12. Pain and Pain Relief

Physiology and Pathophysiology

Neuroanatomy

Physiologic Responses

Etiology

Prevention

Data Collection

Treatment

End-of-Life Care

Complications

Parent Teaching

7
13. The Neonate and the Environment: Impact on Development
Developmental Tasks of the Neonate and Infant

Endowment

Environment

Interventions

Unit Three. Metabolic and Nutritional Care of the Neonate

14. Fluid and Electrolyte Management

Physiology

Etiology

Prevention

Data Collection

Treatment

Complications

Parent Teaching

15. Glucose Homeostasis

Fetal Physiology

Neonatal Physiology

Hypoglycemia

Hyperglycemia

Etiology of Hypoglycemia and Hyperglycemia

Prevention of Hypoglycemia and Hyperglycemia

Data Collection

Treatment

Complications

Parent Teaching

16. Total Parenteral Nutrition

Physiology

Indications

Data Collection

8
 Treatment

Complications

Parent Teaching

17. Enteral Nutrition

Physiology

Nutritional Requirements

Composition of Enteral Feedings

Feeding Techniques

Feeding Intolerance and Complications

The Preterm Infant

The Intrauterine Growth–Restricted Infant

Changes in Nutritional Requirements with Illness

Developmental Support

Family Support

Feeding the Preterm Infant After Hospital Discharge

18. Breastfeeding the Neonate with Special Needs

Physiology of Breastfeeding

Psychologic Values of Breastfeeding

Facilitating Successful Breastfeeding

Prevention of Breastfeeding Problems

Data Collection and Intervention

Complications of Breastfeeding

Parent Teaching

19. Skin and Skin Care

Physiology

Etiology

Prevention

Data Collection

Treatment

9
 Complications

Parent Teaching

Unit Four. Infection and Hematologic Diseases of the Neonate

20. Newborn Hematology

Red Blood Cells

Polycythemia and Hyperviscosity

Coagulation

Thrombosis

White Blood Cells

21. Neonatal Hyperbilirubinemia

Pathophysiology

Etiology of Hyperbilirubinemia

Mechanisms of Bilirubin Neurotoxicity

Prevention of Hyperbilirubinemia

Evaluation of the Infant with Hyperbilirubinemia

Treatment

Parent Teaching

Health Systems Approach to Bilirubin

22. Infection in the Neonate

Pathophysiology and Pathogenesis

Etiology

Specific Infectious Diseases

Parent Teaching

Unit Five. Common Systemic Diseases of the Neonate

23. Respiratory Diseases

General Physiology

General Etiologic Factors

General Prevention

10
 General Data Collection

General Treatment Strategies

General Complications

Parent Teaching

24. Cardiovascular Diseases and Surgical Interventions

Congenital Heart Disease: Overview

Specific Conditions

Parent Teaching

Future Research

25. Neonatal Nephrology

Normal Development

Clinical Assessment of Renal Disease in the Neonate

Acute Kidney Injury

Intrinsic Renal Parenchymal Abnormalities

Renal Vein Thrombosis

Hydronephrosis

Hypertension

Abdominal Masses

Renal Tubular Disorders

Urinary Tract Infection

Neurogenic Bladder

Nephrocalcinosis and Nephrolithiasis

Chronic Renal Failure

Nursing Care of the Neonate with Renal Failure

26. Neurologic Disorders

Congenital Malformations

Birth Injuries

Specific Birth Injuries

Hypotonia

11
 Neonatal Seizures

Hypoxic-Ischemic Encephalopathy

Intraventricular Hemorrhage

Pediatric Stroke

27. Genetic Disorders, Malformations, and Inborn Errors of Metabolism

Genetic Principles

Etiology

Data Collection

Treatment and Intervention

The Human Genome Project

Parent Teaching

28. Neonatal Surgery

Diaphragmatic Hernia

Esophageal Atresia and Tracheoesophageal Fistula

Congenital Chest Masses

Intestinal Malrotation and Volvulus

Intestinal Atresia

Necrotizing Enterocolitis

Meconium Ileus

Hirschsprung’s Disease

Anorectal Malformations

Omphalocele and Gastroschisis

Neonatal Tumors

Minimally Invasive Surgery

Parent Teaching

Unit Six. Psychosocial Aspects of Neonatal Care

29. Families in Crisis: Theoretical and Practical Considerations

Normal Attachment

Psychologic Adjustments to a Sick Newborn

12
 Communicating Medical Information: Evidence-Based Practice

Postpartum Mood Disorders

Adaptation to the Intensive Care Environment

30. Grief and Perinatal Loss

The Grief Process

Perinatal Situations in Which Grief is Expected

Stages of Grief

Symptoms of Grief

Male–Female Differences

Timing of Grief Resolution

Interventions

Children and Grief

Pathologic Grief

31. Discharge Planning and Follow-Up of the Neonatal Intensive Care Unit Infant
Planning for Discharge

Neurodevelopmental Follow-Up of High-Risk Infants

Complex Disorders of Brain Development

Perinatal Risk Factors for Neurodevelopmental Impairments

Specific Neurodevelopmental Outcomes

Tracking Health Outcomes: the Primary Care Provider

Long-Term Neurodevelopmental Follow-Up

32. Ethics, Values, and Palliative Care in Neonatal Intensive Care

Historical Overview

Definition of Bioethics

Theories of Ethics

Clinical Dilemmas in the Neonatal Intensive Care Unit

Decision Making in the Neonatal Intensive Care Unit

Ethics Committee or Palliative Care Consultation?

Communicating with Families

13
 Palliative Care in the Intensive Care Setting

Social Ethics

Glossary

Index

Newborn Metric Conversion Tables (Cont’d)

14
Newborn Metric Conversion
Tables
Temperature

Fahrenheit (F) to Centrigrade (C)

NOTE: °C = (°F – 32) × 5/9. Centrigrade temperature equivalents rounded to one decimal place by adding
0.1 when second decimal place is 5 or greater.
The metric system replaces the term “centrigrade” with “Celsius” (the inventor of the scale).
See inside back cover for additional tables.

15
Copyright

3251 Riverport Lane

St. Louis, Missouri 63043

MERENSTEIN & GARDNER’S HANDBOOK OF NEONATAL INTENSIVE CARE,

EIGHTH EDITION ISBN: 978-0-323-32083-2

Copyright © 2016 by Elsevier, Inc.

Copyright © 2011, 2006, 2002, 1998, 1993, 1989, 1985 by Mosby, Inc., an affiliate of
Elsevier Inc.

All rights reserved. No part of this publication may be reproduced or transmitted in any
form or by any means, electronic or mechanical, including photocopying, recording, or
any information storage and retrieval system, without permission in writing from the
publisher. Details on how to seek permission, further information about the Publisher’s
permissions policies and our arrangements with organizations such as the Copyright
Clearance Center and the Copyright Licensing Agency, can be found at our website:
www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright
by the Publisher (other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research
and experience broaden our understanding, changes in research methods, professional
practices, or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge
in evaluating and using any information, methods, compounds, or experiments
described herein. In using such information or methods they should be mindful of
their own safety and the safety of others, including parties for whom they have a
professional responsibility.

With respect to any drug or pharmaceutical products identified, readers are advised to
check the most current information provided (i) on procedures featured or (ii) by the
manufacturer of each product to be administered, to verify the recommended dose or
formula, the method and duration of administration, and contraindications. It is the

16
 responsibility of practitioners, relying on their own experience and knowledge of their
patients, to make diagnoses, to determine dosages and the best treatment for each
individual patient, and to take all appropriate safety precautions.

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or
editors, assume any liability for any injury and/or damage to persons or property as a
matter of products liability, negligence or otherwise, or from any use or operation of
any methods, products, instructions, or ideas contained in the material herein.

Library of Congress Cataloging-in-Publication Data

Merenstein & Gardner’s handbook of neonatal intensive care / [edited by] Sandra L.
Gardner, Brian S. Carter, Mary Enzman Hines, Jacinto A. Hernandez. -- Eighth edition.
p. ; cm.
Merenstein and Gardner’s handbook of neonatal intensive care
Preceded by Merenstein & Gardner’s handbook of neonatal intensive care / [edited by]
Sandra L. Gardner... [et al.]. 7th ed. c2011.
Includes bibliographical references and index.
ISBN 978-0-323-32083-2 (pbk. : alk. paper)
I. Gardner, Sandra L., editor. II. Carter, Brian S., 1957- , editor. III. Hines, Mary Enzman,
editor. IV. Hernandez, Jacinto A., editor. V. Title Merenstein and Gardner’s handbook of
neonatal intensive care.
[DNLM: 1. Intensive Care, Neonatal. 2. Infant, Newborn, Diseases--therapy. WS 421]
RJ253.5
618.92’01--dc23
2015006347

Executive Content Strategist: Lee Henderson

Content Development Manager: Jean Sims Fornango
Senior Content Development Specialist: Tina Kaemmerer
Publishing Services Manager: Catherine Jackson
Senior Project Manager: Carol O’Connell
Design Direction: Renee Duenow

Printed in China

Last digit is the print number: 9 8 7 6 5 4 3 2 1

17
Dedication

We dedicate this edition to the memory of Gerald B. Merenstein, MD—our

friend, colleague, and mentor who was also a wonderful husband, father, and
grandfather. As the inspiration for this text, Gerry contributed to the fields of
neonatal and pediatric care through his dedication to nurses, nurse practitioners,
child health associates, interns, residents, fellows, neonates, and their families. We
miss him every day and know that his empathy, knowledge, teaching, and
compassion influences all of us, as well as the newborns, children, and families
that he and we serve.

SLG BSC MEH JAH

In memory of Stephanie Marie Gardner, whose three days of life did have a
purpose.

SLG

To my family: Angel, Sean, Yvonne, Rebecca, and Jacquelyn; my mentors and

colleagues; and all of the children and families who have allowed me to share
with them both joyous and difficult times in their lives.

BSC

To my family James, Jennifer, Sean, Finnoula, Steve, and Sarah for their enduring
source of love, confidence, and encouragement and to all the families who have
informed by practice and knowledge about caring for fragile infants.

MEH

To all the newborn infants, their families, and dedicated caregivers; my beloved
wife Pam and sons Gabriel and Jacinto for their love and constant support.

JAH

In Memoriam

18
Jimmie Lynne Scholl Avery

L. Joseph Butterfield, MD

Lula O. Lubchenco, MD

William A. Silverman, MD

19
Contributors
Rita Agarwal, MD, FAAP, Professor of Anesthesiology, Director of Education, Pediatric
Anesthesia, Pediatric Anesthesia Program Director, Director of the Colorado Review of
Anesthesiology for Surgicenters and Hospital, Children’s Hospital Colorado, University
of Colorado Denver, School of Medicine, Aurora, Colorado

Marianne Sollosy Anderson, MD, Neonatologist, Sequoia Pediatrics, Kaweah Delta

Medical Center, Visalia, California

Jaime Arruda, MD, FACOG, Assistant Professor, Obstetrics and Gynecology,

University of Colorado Denver, Aurora, Colorado

James S. Barry, MD, Associate Professor of Pediatrics, Section of Neonatology,

Department of Pediatrics, University of Colorado Denver School of Medicine, Medical
Director, Neonatal Intensive Care Unit, University of Colorado Hospital Department of
Neonatology Children’s Hospital Colorado, Aurora, Colorado

Wanda Todd Bradshaw, MSN, RN, NNP-BC

Assistant Professor and Lead Faculty, NNP Specialty, Duke University School of Nursing,
Durham, North Carolina
Neonatal Nurse Practitioner, Moses Cone Health System, Greensboro, North Carolina

M. Colleen Brand, PhD, APRN, NNP-BC, Neonatal Nurse Practitioner, Texas

Children’s Hospital, Houston, Texas

Laura D. Brown, MD, Associate Professor of Pediatrics, Section of Neonatology,

Department of Pediatrics, University of Colorado Denver School of Medicine, Aurora,
Colorado

Jessica Brunkhorst, MD, Neonatology Fellow, Children’s Mercy Hospital, Kansas City,
Missouri

Brian T. Bucher, MD, Clinical Fellow, Pediatric Surgery, Department of Pediatric

Surgery, Vanderbilt, Nashville, Tennessee

Deanne Buschbach, RN, MSN, NNP, PNP, Clinical Operations Director for Advanced
Clinical Practice, Pediatric and Neonatal Critical Care APP Service, Pediatric Heart APP
Service, Duke University Medical Center, Durham, North Carolina

Melissa A. Cadnapaphornchai, MD, Associate Professor of Pediatrics and Medicine,

Pediatric Nephrology/The Kidney Center, University of Colorado Denver School of

20
Medicine and Children’s Hospital Colorado, Aurora, Colorado

Angel Carter, DNP, APRN, NNP-BC, Assistant Professor of Nursing, Assistant Chair
—BSN Degree Completion Program, Park University, Kansas City, Missouri

Brian S. Carter, MD, FAAP, Professor of Pediatrics, University of Missouri-Kansas City

School of Medicine, Division of Neonatology & Bioethics Center, Children’s Mercy
Hospital-Kansas City, Kansas City, Missouri

Susan B. Clarke, MS, RNC-NIC, RN-BC, CNS, Professional Development Specialist,

Continuing Education and Outreach, NRP Regional Trainer, Children’s Hospital
Colorado, Aurora, Colorado

C. Michael Cotten, MD, MHS, Associate Professor of Pediatrics, Medical Director,

Neonatology Clinical Research, Duke University, Durham, North Carolina

Heather Furlong Craven, MD, Associate Professor of Pediatrics, Division of

Neonatology, Medical Director of Neonatal Transport Services, Wake Forest School of
Medicine Brenner Children’s Hospital, Winston-Salem, North Carolina

Jane Davis, RNC, BSN, Level III Permanent Charge Nurse, Neonatal Intensive Care
Unit, University of Colorado Hospital, Aurora, Colorado

Jane Deacon, NNP-BC, MS, Neonatal Nurse Practitioner, Children’s Hospital

Colorado, Aurora, Colorado

David J. Durand, MD, Division of Neonatology, UCSF Benioff Children’s Hospital-

Oakland, Oakland, California

Jarrod Dusin, MS, RD, Clinical Dietitian Specialist, Children’s Mercy Hospital, Kansas
City, Missouri

Nancy English, PhD, RN, Fetal Concerns, Director and Coordinator, Colorado High
Risk Maternity and Newborn Program, University of Colorado Health Sciences, The
Children’s Hospital, Aurora, Colorado

Mary Enzman Hines, PhD, APRN, CNS, CPNP, APHN-BC

Professor Emeritus, Beth El College of Nursing and Health Sciences, University of
Colorado at Colorado Springs
Certified Pediatric Nurse Practitioner, Rocky Mountain Pediatrics, Lakewood, Colorado

Lori Erickson, RN, CPNP, APRN, Fetal Cardiac and Cardiac High Acuity Monitoring
APRN, Ward Family Heart Center, Children’s Mercy Hospital, Kansas City, Missouri

Ruth Evans, MS, APRN, NNP-BC, Neonatal Nurse Practitioner, Children’s Hospital
Colorado and University of Colorado Hospital, Aurora, Colorado

Loretta P. Finnegan, MD
President, Finnegan Consulting, LLC, Perinatal Addiction and Women’s Health, Avalon,
New Jersey
Founder and Former Director of Family Center, Jefferson Medical College of Thomas
Jefferson University, Philadelphia, Pennsylvania

21
Sandra L. Gardner, RN, MS, Retired Clinical Nurse Specialist; Retired Pediatric Nurse
Practitioner; Director, Professional Outreach Consultation; Editor, Nurse Currents and
NICU Currents, Aurora, Colorado

Edward Goldson, MD, Professor, Department of Pediatrics, University of Colorado

Denver School of Medicine, The Children’s Hospital, Aurora, Colorado

Linda L. Gratny, MD
Associate Professor of Pediatrics, University of Missouri-Kansas City School of Medicine
Neonatologist and Director, Infant Tracheostomy and Home Ventilator Program,
Children’s Mercy Hospital, Kansas City, Missouri

Marie Hastings-Tolsma, PhD, CNM, FACNM

Professor, Nurse Midwifery, Louis Herrington School of Nursing, Baylor University,
Dallas, Texas
Visiting Professor, University of Johannesburg, Johannesburg, South Africa

William W. Hay Jr. MD, Professor of Pediatrics, Section of Neonatology, Scientific

Director, Perinatal Research Center, Co-Director for Child and Maternal Health and the
Perinatal Research Center, Colorado Clinical and Translational Sciences Institute,
University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora,
Colorado

Kendra Hendrickson, MS, RD, CNSC, CSP, Clinical Dietitian Specialist, Neonatal
Intensive Care Unit, University of Colorado Hospital, Aurora, Colorado

Carmen Hernández, MSN, NNP-BC, Neonatal Nurse Practitioner, Rocky Mountain

Hospital for Children, Denver, Colorado

Jacinto A. Hernández, MD, PhD, MHA, FAAP

Professor Emeritus of Pediatrics, Section of Neonatology, Department of Pediatrics,
University of Colorado School of Medicine
Chairman Emeritus Department of Neonatology, Children’s Hospital Colorado, Aurora,
Colorado

Patti Hills, LMSW, LCSW, Fetal Health Center, NICU Social Worker, Children’s Mercy
Hospital, Kansas City, Missouri

Mona Jacobson, MSN, RN, CPNP-PC, Instructor in Pediatrics, Section of Child

Neurology, University of Colorado School of Medicine, Children’s Hospital Colorado,
Aurora, Colorado

M. Douglas Jones Jr. MD, Senior Associate Dean for Clinical Affairs, Professor, Section
of Neonatology, Department of Pediatrics, University of Colorado Denver School of
Medicine, Aurora, Colorado

Beena Kamath-Rayne, MD, MPH, Assistant Professor of Pediatrics, Perinatal Institute,

Division of Neonatology, Global Health Center, Cincinnati Children’s Hospital Medical
Center, Cincinnati, Ohio

Rhonda Knapp-Clevenger, PhD, CPNP

Director, Research and Pediatric Nurse Scientist, Center for Pediatric Nurse Research

22
and Clinical Inquiry
Clinical Research Director, Pediatric and Perinatal Clinical Translational Research
Centers, University of Colorado Denver, College of Nursing , Children’s Hospital
Colorado, Aurora, Colorado

Ruth A. Lawrence, MD, DD(Hon), FAAP, FABM, Distinguished Alumna Professor of

Pediatrics and Obstetrics/Gynecology, Northumberland Trust Chair in Pediatrics,
Director of the Breastfeeding and Human Lactation Study Center, University of
Rochester School of Medicine and Dentistry, Rochester, New York

Mary Kay Leick-Rude, RNC, MSN, PCNS, Clinical Nurse Specialist, Children’s Mercy
Hospital, Kansas City, Missouri

Harold Lovvorn III MD, FACS, FAAP, Assistant Professor of Pediatric Surgery,
Vanderbilt University Children’s Hospital, Nashville, Tennessee

Carolyn Lund, RN, MS, FAAN

Neonatal Clinical Nurse Specialist, ECMO Coordinator, Neonatal Intensive Care Unit,
UCSF Benioff Children’s Hospital-Oakland, Oakland, California
Associate Clinical Professor, Department of Family Health Care Nursing, University of
California, San Francisco, California

Marilyn Manco-Johnson, MD, Professor of Pediatrics, Section of Hematology,

University of Colorado Denver and The Children’s Hospital Colorado, Hemophilia and
Thrombosis Center, Aurora, Colorado

Anne Matthews, RN, PhD, FACMG, Professor, Genetics and Genome Sciences,
Director, Genetic Counseling Training Program, Case Western Reserve University,
Cleveland, Ohio

Jane E. McGowan, MD, Professor of Pediatrics, Associate Chair for Research, Drexel
University College of Medicine, Medical Director, NICU, St. Christopher’s Hospital for
Children, Philadelphia, Pennsylvania

Christopher McKinney, MD, Fellow, Pediatric Hematology, Center for Cancer and
Blood Disorders, Children’s Hospital Colorado, University of Colorado-Denver, Aurora,
Colorado

Mary Miller-Bell, PharmD, Clinical Research Pharmacist, Duke University Hospital,

Durham, North Carolina

Susan Niermeyer, MD, MPH, FAAP, Professor of Pediatrics and Epidemiology,

University of Colorado School of Medicine and Colorado School of Public Health,
Aurora, Colorado

Priscilla M. Nodine, PhD, CNM, Assistant Professor, Midwifery, College of Nursing,

University of Colorado Anschutz Campus, Aurora, Colorado

Michael Nyp, DO, MBA, Assistant Professor of Pediatrics, University of Missouri-

Kansas City, Division of Perinatal-Neonatal Medicine, Children’s Mercy Hospital, Kansas
City, Missouri

23
Steven L. Olsen, MD, Associate Professor of Pediatrics, University of Missouri-Kansas
City, Division of Neonatology, Children’s Mercy Hospital, Kansas City, Missouri

Annette S. Pacetti, RN, MSN, NNP-BC, Neonatal Nurse Practitioner, Monroe Carell, Jr.
Children’s Hospital at Vanderbilt, Nashville, Tennessee

Eugenia K. Pallotto, MD, MSCE, Associate Professor, University of Missouri-Kansas

City School of Medicine, Medical Director, NICU, Children’s Mercy Hospital, Kansas City,
Missouri

Mohan Pammi, MD, PhD, MRCPCH, Associate Professor, Baylor College of Medicine,
Houston, Texas

Alfonso Pantoja, MD, Neonatologist, Saint Joseph’s Hospital, Denver Colorado

Julie A. Parsons, MD, Associate Professor of Pediatrics and Neurology, Haberfield

Family Endowed Chair in Pediatric Neuromuscular Disorders, Child Neurology Program
Director, University of Colorado School of Medicine, Children’s Hospital Colorado,
Aurora, Colorado

Webra Price-Douglas, PhD, CRNP, IBCLC, Maryland Regional Transport Program,

Baltimore, Maryland

Daphne A. Reavey, PhD, RN, NNP-BC, Neonatal Nurse Practitioner, Children’s Mercy
Hospital, Kansas City, Missouri

Nathaniel H. Robin, MD, FACMG, Professor of Genetics and Pediatrics, University of

Alabama at Birmingham, Birmingham, Alabama

Mario A. Rojas, MD, MPH, Professor of Pediatrics, Division of Neonatal-Perinatal

Medicine, Wake Forest University School of Medicine, Winston Salem, North Carolina

Jamie Rosterman, DO, Neonatology Fellow, Children’s Mercy Hospital, Kansas City,
Missouri

Paul Rozance, MD, Associate Professor of Pediatrics, Section of Neonatology,

University of Colorado Denver School of Medicine, Children’s Hospital Colorado,
Aurora, Colorado

Tamara Rush, MSN, RN, C-NPT, EMT, Nurse Manager, Brenner Children’s Hospital-
Wake Forest Baptist Health, Winston-Salem, North Carolina

Mary Schoenbein, BSN, RN, CNN, Perinatal Dialysis Nurse/The Kidney Center,
Children’s Hospital Colorado, Aurora, Colorado

Alan R. Seay, MD, Professor of Pediatrics and Neurology, University of Colorado

School of Medicine, Children’s Hospital Colorado, Aurora, Colorado

Danielle E. Soranno, MD, Assistant Professor of Pediatrics and Bioengineering,

Pediatric Nephrology/The Kidney Center, University of Colorado Denver School of
Medicine and Children’s Hospital Colorado, Aurora, Colorado

John Strain, MD, FACR, CAQ Pediatric Radiology, Neuroradiology

24
Professor of Radiology, Department of Radiology, University of Colorado School of
Medicine
Chairman, Department of Radiology, Children’s Hospital Colorado, Anschutz Medical
Campus, Aurora, Colorado

Julie R. Swaney, MDiv, Manager, Spiritual Care Services, Associate Clinical Professor,
Department of Medicine, University of Colorado Denver Anschutz Medical Campus,
Aurora, Colorado

Tara M. Swanson, MD
Assistant Professor of Pediatrics, University of Missouri-Kansas City School of Medicine
Director of Fetal Cardiology, Children’s Mercy Hospital, Kansas City, Missouri

David Tanaka, MD, Professor of Pediatrics, Neonatologist, Duke University Medical

Center, Durham, North Carolina

Elizabeth H. Thilo, MD
Associate Professor of Pediatrics, Section of Neonatology, University of Colorado Denver
School of Medicine
Neonatologist, University of Colorado Hospital and Children’s Hospital Colorado,
Aurora, Colorado

Kristin C. Voos, MD, Neonatologist, Children’s Mercy Hospital;, Associate Professor of

Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri

Susan M. Weiner, PhD, MSN, RNC-OB, CNS, Perinatal Clinical Nurse Specialist,
Assistant Clinical Professor/Retired, Freelance Author/Editor, Philadelphia, Pennsylvania

Jason P. Weinman, MD, Assistant Professor of Radiology, University of Colorado

School of Medicine, Medical Director Computed Tomography, Children’s Hospital
Colorado, Aurora, Colorado

Leonard E. Weisman, MD, Professor of Pediatrics, Section of Neonatology, Baylor

College of Medicine, Texas Children’s Hospital, Houston, Texas

Rosanne J. Woloschuk, RD, Clinical Dietitian, The Kidney Center, Children’s Hospital
Colorado, Aurora, Colorado

25
Reviewers
Nancy Blake, PhD, RN, NEA-BC, CCRN, Patient Care Services Director, Critical Care
Services, Children’s Hospital Los Angeles, Los Angeles, California

Fran Blayney, RN-C, BSN, MS, CCRN, Education Manager, Pediatric Intensive Care
Unit, Children’s Hospital Los Angeles, Los Angeles, California

Karen C. D’Apolito, PhD, NNP-BC, FAAN, Professor & Program Director, Neonatal
Nurse Practitioner Program , Vanderbilt University School of Nursing, Nashville,
Tennessee

Mary Dix, BSN, RNC-NIC, Staff Nurse, Neonatal Intensive Care Unit, PIH Health
Hospital-Whittier, Whittier, California

Sharon Fichera, RN, MSN, CNS, NNP-BC, Neonatal Clinical Nurse Specialist,
Children’s Hospital Los Angeles, Los Angeles, California

Joyce Foresman-Capuzzi, MSN, RN, Clinical Nurse Educator, Lankenau Medical

Center, Wynnewood, PA

Delores Greenwood, MSN, RNC-NIC, Education Manager, Newborn and Infant

Critical Care Unit, Children’s Hospital Los Angeles, Los Angeles, California

Nadine A. Kassity-Krich, MBA, BSN, RN, Clinical Professor, Hahn School of Nursing ,
University of San Diego, San Diego, California

Lisa M. Kohr, RN, MSN, CPNP- AC/PC, MPH, PhD(c), FCCM, Pediatric Nurse
Practitioner, Cardiac Intensive Care Unit, Children’s Hospital of Philadelphia,
Philadelphia, Pennsylvania

Carie Linder, RNC-NIC, MSN, APRN-BS, Neonatal Nurse Practitioner, Integris Baptist
Medical Center, Oklahoma City, Oklahoma

Twila Luckett, BSN, RN-BC, Pediatric Pain Service, Monroe Carell Jr. Children’s
Hospital at Vanderbilt, Nashville, Tennessee

Erin L. Marriott, MS, RN, CPNP, Pediatric Cardiology Nurse Practitioner , American
Family Children’s Hospital, Watertown Regional Medical Center, Madison, Wisconsin

Andrea C. Morris, DNP, RNC-NIC, CCRN, Neonatal Clinical Nurse Specialist, Citrus
Valley Medical Center-NICU, West Covina, California

26
Mindy Morris, DNP, NNP-BC, CNS, Neonatal Nurse Practitioner, Extremely Low Birth
Weight Program Coordinator, Children’s Hospital of Orange County, Orange, California

Tracy Ann Pasek, RN, MSN, DNP, CCNS, CCRN, CIMI, Clinical Nurse Specialist,
Pain/Pediatric Intensive Care Unit, Children’s Hospital of Pittsburgh, University of
Pittsburgh Medical Center, Pittsburgh, Pennsylvania

Patricia Scheans, DNP, NNP-BC, Clinical Support for Neonatal Care , Legacy Health,
Portland, Oregon

Peggy Slota, DNP, RN, FAAN, Associate Professor, Director, DNP and Nursing
Leadership Programs, Carlow University, Pittsburgh, Pennsylvania

Nicole Van Hoey, PharmD, Medical Writer/Editor, Consultant, Arlington, Virginia

Winnie Yung, MN, RN, Registered Nurse, Lucile Packard Children’s Hospital at
Stanford, Palo Alto, California

27
Preface
The concept of the team approach is important in neonatal intensive care. Each health
care professional must not only perform the duties of his or her own role but must also
understand the roles of other involved professionals. Nurses, physicians, other health
care providers, and parents must work together in a coordinated and efficient manner to
achieve optimal results for patients in the neonatal intensive care unit (NICU).
Because this team approach is so important in the field of neonatal intensive care, we
believe it is necessary that this book contain input from major fields of health care—
nursing and medicine. Both nurses and physicians have edited and co-authored every
chapter.
The book is divided into six units, all of which have been reviewed, revised, and
updated for the eighth edition. Unit One presents evidence-based practice and the need
to scientifically evaluate neonatal therapies, emphasizing randomized controlled trials as
the ideal approach. Units Two through Five are the clinical sections, which have been
fully updated for this edition. The chapters within these sections include highlighted
clinical directions for quick reference, Parent Teaching boxes to aid in discharge
instructions, and Critical Findings boxes to prioritize assessment data.
The combination of physiology and pathophysiology and separate emphasis on
clinical application in this text is designed for neonatal intensive care nurses, nursing
students, medical students, and pediatric, surgical, and family practice housestaff. This
text is comprehensive enough for nurses and physicians, yet basic enough to be useful to
families and all ancillary personnel.
Unit Six presents the psychosocial aspects of neonatal care. The medical,
psychological, and social aspects of providing care for the ill neonate and family are
discussed in this section. This section in particular will benefit social workers and clergy,
who often deal with family members of neonates in the NICU.
In this handbook we present physiologic principles and practical applications and
point out areas as yet unresolved. Material that is clinically applicable is set in purple
type so that it can be easily identified.

28
Introduction
In 1974 as the Perinatal Outreach Educator at The Children’s Hospital in Denver,
Colorado, I took a folder to Gerry Merenstein, MD, at Fitzsimmons Army Medical Center
to discuss his lectures for the first outreach education program in La Junta, Colorado.
When we finished, he removed from his desk drawer a 1-inch thick compilation of the
neonatal data, graphs, nomograms, and diagrams he had created for the medical
housestaff during his fellowship. Giving the document to me, he asked that I review it
and let him know what I thought. Several weeks later, I told him it was good except there
was no nursing care or input, which is essential in every NICU. So Gerry asked, “Want to
write a book?”—and the idea for the Handbook was born!
With this eighth edition in 2015, we celebrate 30 years of publication of the Handbook of
Neonatal Intensive Care. Gerry and I co-edited this book for 21 years until his death in
December 2007. To fulfill my promise that Gerry’s name would always be on the book,
the seventh and all subsequent editions will be known as Merenstein & Gardner’s
Handbook of Neonatal Intensive Care. Instead of editing this edition alone or with another
physician, I decided to convene an editorial team consisting of myself, a nurse colleague,
and two neonatologists. Together we bring 170 years of clinical practice, research,
teaching, writing, and consulting in neonatal, pediatric, and family care to this eighth
edition.
We have the distinction in this new edition of translation into Spanish for our
colleagues in Central and South America and Spain. This was an ongoing wish of Gerry
Merenstein, and after much negotiation it is finally a reality. Welcome to all our Spanish-
reading colleagues! In addition, the eighth edition is available on multiple e-platforms to
facilitate use at the bedside.
For our new audience, and for our continuing loyal readers, this is my opportunity to
introduce myself and all the members of the editing team.
I am currently Editor of Nurse Currents and NICU Currents (www.anhi.org) and the
Director of Professional Outreach Consultation
(www.professionaloutreachconsultation.com), a national and international consulting
firm established in 1980. I plan, develop, teach, and coordinate educational workshops
on perinatal/neonatal/pediatric topics. I graduated from a hospital school of nursing in
1967 with a diploma, obtained my BSN at Spalding College in 1973 (magna cum laude),
completed my MS at The University of Colorado School of Nursing in 1975 and my PNP
in 1978. I have worked in perinatal/neonatal/pediatric care since 1967 as a clinician (37
years in direct bedside care), practitioner, teacher, author, and consultant. In 1974, I was
the first Perinatal Outreach Educator in the United States funded by the March of Dimes.
In this role I taught nurses and physicians in Colorado and the seven surrounding states
how to recognize and stabilize at-risk pregnancies and sick neonates. I also consulted

29
with numerous March of Dimes grantees to help them establish perinatal outreach
programs. In 1978 I was awarded the Gerald Hencmann Award from the March of Dimes
for “outstanding service in the improvement of care to mothers and babies in Colorado.”
I am a founding member of the Colorado Perinatal Care Council, a state advisory council
to the Governor and the State Health Department on perinatal/neonatal health care
issues, and I am the Treasurer and a member of the Executive Committee. I am also an
active member of the Colorado Nurses Association/American Nurses Association, the
Academy of Neonatal Nurses, and the National Association of Neonatal Nurses.
Mary Enzman Hines, RN, PhD, CNS, CPNP, AHN-BC, is currently Professor Emeritus
at Beth-El College of Nursing at the University of Colorado in Colorado Springs and
certified Pediatric Nurse Practitioner at Rocky Mountain Pediatrics, Lakewood, Colorado.
Early in her nursing career, Mary worked in the NICU and PICU as a staff nurse, charge
nurse, and nurse manager. After completing her PNP/CNS program and her master’s
degree at the University of Colorado, Mary became the Neonatal and Pediatric Clinical
Nurse Specialist at Denver Health and Hospital, where she created a beginning,
intermediate, and advanced orientation for nurses in the NICU and PICU. At the
University of Colorado, Mary accepted the practitioner/teacher role in maternal-child
services, providing clinical care and mentorship in the NICU and pediatric units where
nursing students were placed from the CU nursing program. When University Hospital
and The Children’s Hospital combined their pediatric services, Mary became the Clinical
Nurse Specialist in Research and Education and consulted in the NICU, PICU, and
pediatric medical-surgical areas. In this role she was a founding member of the
interdisciplinary Pain Management Team and provided consultation throughout The
Children’s Hospital for pain management issues. In 1996 Mary became a nursing faculty
member at Beth-El College of Nursing and Health Sciences, where she created a student
health center at the University and a school-based clinic for schoolchildren in Fountain,
Colorado, while maintaining an active pediatric practice at Colorado Springs Health
Partners. Currently Mary provides pediatric care at Rocky Mountain Pediatrics and
continues to teach courses to DNP students at the University of Northern Colorado as an
adjunct faculty. Mary is well published in the areas of pediatric, neonatal, and family
health care, as well as in legal issues in maternal-child nursing. Mary is also a nurse
researcher in the areas of pain, chronic illness, caring/healing praxis, pediatric pain,
holistic nursing, and technology in health care.
Brian S. Carter, MD, FAAP, is a graduate of David Lipscomb College in Nashville,
Tennessee, and of the University of Tennessee’s College of Medicine in Memphis,
Tennessee. Brian completed his residency in pediatrics at Fitzsimmons Army Medical
Center in Aurora, Colorado. He completed his fellowship in neonatal-perinatal medicine
at the University of Colorado Health Sciences Center in Denver. During the “Baby Doe”
era, Brian trained in bioethics and, in addition to clinical neonatology and neonatal
follow-up, he has dedicated most of his academic career to the advancement of clinical
ethics in neonatology and pediatric palliative care. Brian has been recognized nationally
for his efforts in both of these fields. Currently he is Professor of Pediatrics at the
University of Missouri-Kansas City School of Medicine, where he serves on the Ethics
Committee and mentors students, residents, and fellows in the areas of clinical ethics,
neonatology, pain management, and palliative care. Brian, Marcia Levetown, MD, and
Sarah Friebert, MD, co-edit the book Palliative Care for Infants, Children, and Adolescents: A
Practical Handbook, whose second edition published in 2011 by Johns Hopkins University
Press.
Jacinto A. Hernández, MD, PhD, MHA, FAAP, is currently Professor Emeritus of

30
Pediatrics and Neonatology at the University of Colorado Denver and Chairman
Emeritus of the Department of Neonatology at Children’s Hospital Colorado, Aurora
Colorado. He is a graduate of the School of Medicine of the University of San Marcos in
Lima, Peru. Jacinto’s postgraduate education includes a specialty in pediatrics and a
subspecialty in neonatology from the Children’s Hospital National Medical Center and
George Washington University in Washington, DC, and from the University of Colorado
Denver School of Medicine; a PhD from the University of San Marcos; and a Master’s in
Health Administration from the University of Colorado Denver School of Business.
Jacinto has spent all of his professional life in academic medicine, first at the University
of San Marcos as Associate Professor of Pediatrics, and subsequently at the University of
Colorado Denver School of Medicine as Professor of Pediatrics. As a physician and
professor, his professional activities have been carried out at The Children’s Hospital of
Denver in Aurora, Colorado, where he has been Director of the Newborn Intensive Care
Unit, Chairman of the Department of Neonatology, an active staff neonatologist, and
President of the Medical Staff. During his career, Jacinto has distinguished himself both
clinically and academically, has written numerous publications in the field of neonatal
medicine, and has participated as an invited professor at innumerable international
events. Jacinto has been recognized with numerous awards, including the Career
Teaching and Scholar Award, for his scientific achievements, professional qualities, and
fruitful work as a superb clinical physician.
Borrowing from the words of Brian Carter in the introduction to the sixth edition of the
Handbook:

The goals of care should be patient- and family-centered. It is the patient we treat, but it is
the family, of whatever construct, with whom the baby will go home. Indeed, it is the family
who must live with the long-term consequences of our daily decisions in caring for their baby.

These goals include the provision of skilled professional care. An effective neonatal
intensive care team consists of educated professionals of many disciplines—none of us
can do it alone.
It has been my honor and privilege to work with these co-editors, who are all patient-
and family-centered, and with the amazing editing team of Tina Kaemmerer, Lee
Henderson, and Carol O’Connell for this eighth edition.
Sandra L. Gardner, RN, MS, CNS, PNP
Senior Editor

31
UNIT ONE

Evidence-Based
Practice
OUT L INE
1. Evidence-Based Clinical Practice

32
1

Evidence-Based Clinical
Practice
Alfonso F. Pantoja, and Mary Enzman Hines

PURPLE type highlights content that is particularly applicable to clinical settings.

Globally, health care systems are experiencing challenges when evaluating therapies,
quality of care, and the risk of adverse events in clinical practice. Often health care
systems fail to optimally use evidence. This failure is either from underuse, overuse, or
misuse of evidence-based therapies and/or system failures.75 Evidence-based practice
(EBP) requires the integration of the best research evidence with our clinical expertise
and each patient’s unique values and circumstances.75 EBP approaches in all fields of
health care could prevent therapeutic disasters resulting from the informal “let’s-try-it-
and-see” methods of testing new therapies that are not recognized as risky. The epidemic
of retinopathy attributable to the indiscriminate use of supplemental oxygen; gray baby
syndrome attributable to the administration of chloramphenicol; kernicterus
attributable to the introduction of sulfonamides 65; and death due to liver toxicity of 40
premature newborns attributable to the administration of a parenteral form of vitamin E
(E-Ferol)71 are examples of these therapeutic misadventures in the field of neonatal care.
Silverman described how painfully slow health care providers were to embrace a culture
of skepticism and emphasizes, “We must insist on the highest standards of evidence in
studies involving the youngest human beings; and, since there is no short route to this
goal, we must prepare to be patient.”64 The use of experimentation and the scientific
method has ultimately led to our present views of how to ask and answer clinical
questions.56
Mistakes have also occurred at the other extreme, as well, resulting in a failure to
adopt therapies that are of proven benefit or an assumption that the risks associated
with changing practice justify complacency about current treatments. The significant
delay in the adoption of antenatal corticosteroids by the obstetric community to promote
fetal lung maturation19,68 is a good example of failure to use the available evidence. One of
the most important benefits of EBP is the constant questioning: “Have our current
clinical practices been studied in appropriately selected populations, of sufficient size to
accurately predict their efficacy, benefit, safety, side effects, and cost?”
EBP is a systematic way to integrate the best patient-centered, clinically relevant
research with our clinical expertise and with the unique preferences, concerns, and
expectations that each patient brings to a clinical encounter.75 Furthermore, EBP presents
an opportunity to enhance patient health and illness outcomes, increase staff
satisfaction, and reduce health care expenses. There is great interest in identifying

33
barriers and facilitators that could help in closing the knowledge-to-practice gap that is
inherent to the acceptance and adoption of EBP by all providers.76

Finding High-Quality Evidence

As new therapies are integrated into neonatal care, health care providers must continue
to increase existing knowledge of the health and health problems of newborns. Providers
need to formulate well-designed questions about the specific clinical encounter and
learn how to evaluate the quality of evidence regarding risks and benefits of new
practices. Most clinical questions arise through daily practice and often involve
knowledge gaps in background (general knowledge) and foreground (specific knowledge
to inform clinical decisions or actions). The knowledge needs will vary according to the
experience of the clinician.75
It is not the purpose of this chapter to provide a detailed review of the various research
designs that permit reliable scientific inference. Rather, our purpose is to promote the
propositions that (1) challenge clinical observations and wisdom by finding the current
best evidence and (2) careful assessment and critique of research that supports or
challenges the use of new and established clinical practices.
Clinical observations, although valuable in shaping research questions, are limited by
selective perception—a desire to see a strategy work or fail to work. At times, a single
case or case study may prompt us to question whether we should consider changing
current practice. In some situations, much can be learned from carefully maintained
databases. Such knowledge is gained only when we have formed databases with clear
intentions and have collected the necessary data.
Sinclair and Bracken67 described four levels of clinical research used to evaluate safety
and efficacy of therapies, based on their ability to provide an unbiased answer. In
ascending order, these are (1) single case or case series reports without controls, (2)
nonrandomized studies with historical controls, (3) nonrandomized studies with
concurrent controls, and (4) randomized controlled trials (RCTs). RCTs test hypotheses
by using randomly assigned treatment and control groups of adequate size to examine
the efficacy and safety of a new therapy. In theory, random assignment of the treatment
balances unknown or unmeasured factors that might otherwise bias the outcome of the
trial. A meta-analysis is a systematic review of the current literature that uses statistical
methods to combine the results of individual studies and summarizes the results
(http://neonatal.cochrane.org).18 Tyson79 has suggested criteria for identifying proven
therapies in current literature (Box 1-1). Ideally, therapeutic recommendations are
supported by evidence from systematic reviews of RCTs; however, such evidence is not
always available. It is then important to have a system to grade the strength of the
quality of the evidence found. An international collaboration has developed GRADE,
providing an explicit strategy for grading evidence and the strength of
recommendations.36 GRADE classifies the evidence into one of four levels: high,
moderate, low, and very low (Table 1-1). The strength of the recommendation is graded
as strong or weak. Factors that influence the strength of the recommendation include
desirable or undesirable effects, values, preferences, and economic implications (Figure
1-1).

34
TABLE 1-1
Levels of Evidence

LEVEL OF EVIDENCE THERAPY/PREVENTION/ETIOLOGY/HARM

1a Syste matic re vie ws of RCTs
1b Individual RCT with narrow confide nce inte rval

1c All or none
2a Syste matic re vie w of cohort studie s
2b Individual cohort study (including low-quality RCT [le ss than 80% follow-up])
3a Syste matic re vie w of case -control study
3b Individual case -control study
4 Case -controlle d studie s
5 Expe rt opinion without critical appraisal

RCT, Randomized controlled trial.

From Straus SE, Richardson WS, Haynes RB: Evidence-based medicine: how to practice and teach it, ed 4,
London, 2011, Harcourt.

B OX 1 - 1 P r o v e n T h e r a p ie s
Reported to be beneficial in a well-performed meta-analysis of all trials
or
Beneficial in at least one multicenter trial or two single-center trials
Modified from Tyson JE: Use of unproven therapies in clinical practice and research: how can we better serve
our patients and their families? Semin Perinatol 19:98, 1995.

Although conclusions drawn from quantitative studies (RCTs, meta-analysis of RCTs)

are regarded as the strongest level of evidence, evidence from descriptive and qualitative
studies should be factored into clinical decisions. Qualitative research provides guidance
in deciding whether the findings of quantitative studies could be replicated in various
patient populations. Qualitative research can also facilitate an understanding of the
experience and values of patients. The validity, importance, and applicability of
qualitative studies need to be evaluated in a similar way as quantitative studies.

35
 FIGURE 1-1 Evidence appraisal.
(Adapted from DiCenso A, Bayley L, Haynes RB: Accessing pre-appraised evidence: fine-tuning the 5S
model into the 6S model, Evid Based Nurs 12:99, 2009.)

Pressures to Intervene
RCTs of appropriate size are cited as providing the best evidence for guiding clinical
decisions; however, many take years to complete and publish. Providers find it difficult
to delay introduction of promising therapies. Bryce and Enkin12 discussed myths about
RCTs and rationales for not conducting them. One myth is that randomization is
unethical. This might be true in rare instances when an intervention is dramatically
effective and lifesaving. The more common situation is one where there is limited
evidence for a current or alternative strategy.
Pressure to intervene is, however, often overpowering. Believing that an infant is in
trouble, interventions occur through a cascade of interventions,49 one leading to the next
and each carrying risk. One of the most frequently cited examples is the epidemic of
blindness associated with the unrestricted use of oxygen in newborns.63,64 Oxygen, used
since the early 1900s for resuscitation and treatment of cyanotic episodes, was noted in
the 1940s to “correct” periodic breathing in premature infants. After World War II and
introduction of new gas-tight incubators, an epidemic of blindness occurred, resulting
from retrolental fibroplasia (RLF). Silverman63 pointed out that although many causes
were suspected, it was not until 1954 that a multicenter, controlled trial confirmed the
association between high oxygen concentrations and RLF. Frequently forgotten, however,
is that in subsequent years, mortality was increased in infants cared for with an equally
experimental regimen of strict restriction of oxygen administration and many survivors
had spastic diplegia. In the 1960s, the introduction of micro techniques for measuring
arterial oxygen tension permitted better monitoring of oxygen therapy, with a reduction
in mortality, spastic diplegia, and RLF, now called retinopathy of prematurity (ROP). Severe
ROP is currently limited to extremely low-birth-weight (ELBW) infants.63 Research
continues to explore causes, preventive measures, and treatments (see Chapter 31).
Large multinational, pragmatic RCTs to resolve the uncertainty surrounding the most
appropriate levels of oxygen saturation in premature infants have been recently

36
conducted and the results published.60,77,78 The publication of the results of the SUPPORT
trial77 brought about a significant debate about the ethical aspects of comparative
effectiveness research and parental informed consent when one of the elements of the
composite outcome was death before discharge.63 The practice of allowing very-low-birth-
weight (VLBW) infants to maintain lower O2 saturations during the first weeks of life
had been widely disseminated throughout the United States and the world due to
anecdotal reports of a significant decrease in the severity of ROP and blindness with this
approach.17 The SUPPORT77 and BOOST II78 trials showed a significant decrease in the
frequency of severe ROP and an increase in mortality rate in the low-saturation group.
However, another study with a similar design60 showed no significant effect on the rate
of death or disability at 18 months.
The desire to see an intervention “work” encourages practitioners and investigators to
seek early signs of benefit. Long-term effects are frequently overlooked. One reason is
that they may not be foreseen. Consider the example of diethylstilbestrol (DES). DES
administration to pregnant women was introduced in 1947 without clinical trials to
prevent miscarriage, fetal death, and preterm delivery.12,30 It was thought to be effective
after uncontrolled studies despite controlled trials summarized in an overview (meta-
analysis) by Goldstein et al34 (Table 1-2) that showed the opposite. Clearly, DES was not
effective, but it continued to be used until the 1970s, when the Food and Drug
Administration (FDA) finally disapproved its use. The unforeseen result was that female
children born to mothers who were given DES had structural abnormalities of the genital
tract, pregnancy complications, decreased fertility, and an increased risk for vaginal
adenocarcinoma in young women. Male children had epididymal cysts. This is not the
only example of physicians continuing to use therapies that have been shown in RCTs to
be of no benefit.15
The costs of long-term studies and follow-up surveillance are numerous. However,
when effects are measured later in life (e.g., psychological problems, ability to function in
school), the cost cannot determine study design. Even when randomized trials are
conclusive, unanswered questions remain: Will a technology or treatment have the same
effect in all settings? Has an “appropriate” target population been selected? Are there
long-term unforeseeable consequences?

TABLE 1-2
Effects of Diethylstilbestrol (DES) on Pregnancy Outcomes

TYPICAL ODDS RATIO∗ 95% CONFIDENCE LIMITS

Miscarriage 1.20 0.89-1.62
Stillbirth 0.95 0.50-1.83
Ne onatal de ath 1.31 0.74-2.34
All thre e 1.38 0.99-1.92
Pre maturity 1.47 1.08-2.00
∗
An odds ratio is an estimate of the likelihood (or odds) of being affected by an exposure (e.g., a drug or
treatment), compared with the odds of having that outcome without having been exposed. Women
receiving DES did not have fewer stillbirths, premature births, or miscarriages than women who were
untreated.
Data from Goldstein PA, Sacks HS, Chalmers TC: Hormone administration for the maintenance of
pregnancy. In Chalmers I, Enkin M, Keirse M, editors: Effective care in pregnancy and childbirth, New York,
1989, Oxford University Press.

Evaluation of Therapies
37
The major cause of death in premature infants is respiratory failure from respiratory
distress syndrome (RDS) (see Chapter 23). Previously called hyaline membrane disease,
this syndrome of expiratory grunting, nasal flaring, chest wall retractions, and cyanosis
unresponsive to high oxygen concentrations was a mystery until the 1950s.64
The evaluation of various therapies for RDS contrasts the value of controlled and
uncontrolled trials. Sinclair66 noted that uncontrolled studies were more likely to show
benefit than controlled trials. In 19 uncontrolled studies, 17 popular therapies showed
“benefit.” In 18 controlled studies, only 9 demonstrated benefit. An untrained reviewer
of the research might base clinical practice on faulty conclusions of uncontrolled trials.

Surfactant Therapy
In contrast to many proposed treatments, surfactant therapy in premature infants has
been well studied in RCTs.3,37 Studies have evaluated the use of surfactant in treatment of
RDS, including the optimal source and composition of surfactant and prophylactic
versus rescue treatment. Morbidity (including pneumothorax, periventricular or
intraventricular hemorrhage, bronchopulmonary dysplasia [BPD], and patent ductus
arteriosus) and mortality rates in treatment and control groups have been compared.
Systematic reviews of surfactant therapy confirm the effect of surfactant therapy in
reducing the risk of morbidity and mortality.67,72 Although RCTs involving thousands of
newborns have clearly demonstrated the benefits of surfactant therapy, unanswered
questions remain. One of these questions is if prophylactic administration of surfactant
to an infant judged to be at risk of developing RDS was better than early selective use of
surfactant to infants with established RDS. Early trials demonstrated a decreased risk of
air leak and mortality with the prophylactic approach. However, recent RCTs that reflect
current practice (i.e., greater utilization of maternal steroids and routine postdelivery
stabilization on continuous positive airway pressure [CPAP]) do not support these
differences and actually demonstrate less risk of chronic lung disease or death when
using early stabilization on CPAP with selective surfactant administration to infants
requiring intubation59,77 (Figure 1-2).

38
 FIGURE 1-2 Table showing effect of prophylactic versus selective surfactant
administration on morbidity and mortality rates in preterm infants. (From Rojas-Reyes
X, Morley C, Soll R: Prophylactic versus selective use of surfactant in preventing morbidity and mortality in
preterm infants, Cochrane Database Syst Rev 3:CD000510, 2012.)

Corticosteroid Therapy
Misuse of corticosteroids in perinatal medicine illustrates the consequences of failure to
practice evidence-based medicine. Many practitioners initially declined to use antenatal
steroids to promote maturation of the immature fetal lung and prevent RDS despite
strong supportive evidence, demonstrating a failure to use a proven therapy.

Antenatal Corticosteroid Therapy: Single Course

Antenatal administration of corticosteroids to pregnant women who threatened to
deliver prematurely was first shown in 1972 to decrease neonatal mortality rate and the
incidence of RDS and intraventricular hemorrhage (IVH) in premature infants.44 In 1990,
Crowley et al21 used meta-analysis to evaluate 12 RCTs of maternal corticosteroid
administration involving more than 3000 women. The data showed that maternal
corticosteroid treatment significantly reduced the risk for neonatal mortality, RDS, and
IVH. Sinclair,68 using a “cumulative meta-analysis” approach of randomized trials,
clearly demonstrated that the aggregate evidence that was sufficient to show that this
treatment reduces the incidence of RDS and neonatal death was available for almost 20
years before the use of antenatal corticosteroids was widely accepted by the medical
community.
This led to the National Institutes of Health (NIH) consensus development conference
statement on “Effects of Corticosteroids for Fetal Maturation on Perinatal Outcomes.”50
Antenatal corticosteroid treatment of women at risk for preterm delivery between 24 and
34 weeks of gestation has been shown to be effective and safe in enhancing fetal lung

39
maturity and reducing neonatal mortality. Yet adoption by caretakers was inexplicably
slow.42

Antenatal Corticosteroid Therapy: Repeated Courses

At the same time, other practitioners administered repeated doses despite lack of
evidence of additional benefit and questions about safety, representing unproven use of a
proven therapy. Repeated courses of antenatal corticosteroids have been shown in
humans and animals to improve lung function and the quantity of pulmonary
surfactant.22,35 They may also have adverse effects on lung structure, fetal somatic
growth, and neonatal adrenocortical function, as well as poorly understood effects on
blood pressure, carbohydrate homeostasis, and psychomotor development.22,48 A 2000
NIH Consensus Development Conference found limited high-quality studies on the use
of repeated courses of antenatal steroids.51 The consensus statement discouraged routine
use of repeated courses of antenatal corticosteroids. Published preliminary reports of
infants exposed to multiple doses of antenatal steroids reaching school age are
emerging.6 A recent meta-analysis of infants exposed to more than one course of
antenatal corticosteroids concluded that “although the short-term neonatal benefits of
repeated courses of antenatal corticosteroids support their use, long-term benefits have
not been demonstrated and long-term adverse effects have not been ruled out. The
adverse effect of repeated doses of antenatal corticosteroids on birth weight and weight
at early childhood follow-up is a concern. Caution should therefore be exercised to
ensure that only those women who are at particularly high risk of very early preterm
birth are offered treatment with repeated courses of antenatal corticosteroids.”23 The
American College of Obstetricians and Gynecologists (ACOG) recommends a repeat
course of antenatal steroids if the fetus is less than 34 weeks of gestation and the
previous course of antenatal steroids was administered more than 14 days earlier.4

Postnatal Steroid Therapy

Postnatal glucocorticoids, administered to the infant after birth, have been widely used
despite weak evidence of long-term benefit and suggestions of possible harm,
illustrating use of an uncertain therapy.42 Despite early calls for caution in the use of
postnatal corticosteroids to decrease the risk for chronic lung disease and limit
ventilator time, they were used liberally in the 1990s.70,74 A number of years passed
before RCTs of postnatal corticosteroid administration included long-term follow-up.
Taken together, these studies showed positive short-term effects on the lungs. Studies
also showed increased blood pressure and blood glucose concentrations in the short
term; increased incidence of septicemia and gastrointestinal perforation in the
intermediate term; and with dexamethasone administered soon after birth, abnormal
neurodevelopmental outcome, including cerebral palsy, in the long term.25,37,43,74 An
increased risk for septicemia should have been anticipated, because it was first identified
in an RCT by Reese et al58 over 50 years earlier.
In 2002, the American Academy of Pediatrics (Committee on Fetus and Newborn) and
the Canadian Paediatric Society (Fetus and Newborn Committee) advised against the
use of systemic dexamethasone and suggested that “outside the context of a RCT that
include assessment of long-term development, the use of corticosteroids should be
limited to exceptional clinical circumstances (e.g., an infant on maximal ventilator
support and oxygen requirement).”2 A 2005 reanalysis of many of the same data by
Doyle et al25 suggests that relative risks and benefits of postnatal corticosteroids vary
with level of risk for BPD. When the risk for BPD or death is high, the risk for

40
developmental impairment from postnatal corticosteroids might be outweighed by
benefit.27,29 Watterberg et al83 suggested that hydrocortisone might have the benefits of
dexamethasone on the lungs without adverse neurologic effects. Following these
statements, the exposure of at-risk prematures decreased dramatically.81,82

Qualitative Research Evaluating Experiences in

the Neonatal Intensive Care Unit
The contribution of qualitative research to EBP is evident when “best evidence from
RCTs” may or may not work within the context of specific neonatal intensive care unit
(NICU) environments. The context can be quite variable and influenced by practitioners
and staff, the unit leadership, and family influence within the unit. The implementation
of family-centered care in the NICU has shown promising outcomes, including
minimizing parental stress related to the technology and complex care of a tiny, fragile
preterm infant.46 An environment of family-centered care has also contributed in a
positive way to the success of the implementation of clinical practice guidelines and
evaluating outcomes.26 Qualitative studies are useful when limited information exists
about a phenomenon or a deficiency is evident in the quality, depth, or detail of research
in a specific area of clinical practice. Qualitative research contributes to EBP in several
areas: (1) descriptions of patient needs and experiences; (2) providing the groundwork
for instrument development and evaluation; and (3) elaborating on concepts relative to
theory development.47
Systematic reviews and meta-analyses are emerging in qualitative literature
researching parental experiences in the NICU.33,52 In neonatology, qualitative studies
provide in-depth views of parental and provider experiences within the NICU setting to
humanize the health care of fragile infants. Parents of infants who require NICU care
begin an experience of parenthood in an unfamiliar and intimidating environment that
results in delayed attachment38,62; high levels of stress, including anxiety, depression,
trauma symptoms, and isolation (both physical and emotional) from their infant13,31; lack
of disclosure of their infant’s condition; and a lack of control.16 Mothers often experience
feelings of ambivalence, shame, guilt, and failure that the infant is in the NICU.61 Parents
also experience the tension between exclusion and participation in their infant’s care.84 In
contrast, parents describe factors that contribute to parental satisfaction in the NICU,
including assurance, caring communication, provision of consistent information,
education,20 environmental follow-up care, appropriate pain management,31 parental
participation in care, and emotional, physical, and spiritual support.20 Conversely, health
care professionals’ experiences of parental presence and participation in the NICU
revealed similar findings to those described by parents: the need to develop a caring
environment for parents to be present and take care of their child by guiding parents and
giving parents’ permission to care for their child, a need for personnel training in the art
of dealing with parents in crisis, identifying a balance between closeness and distance,
and dealing with parental worry.85,86
Quality care is a major issue currently evaluating the delivery of health care services,
yet little research has been conducted on what parents of premature infants perceive as
quality nursing care. Price57 used a qualitative approach to reveal the meaning of quality
nursing care from parents’ perspectives and identified concepts inherent in the process
of receiving quality nursing care. Four stages were identified: (1) maneuvering, (2) a
process of knowing, (3) building relationships, and (4) quality care. For parents,

41
nontechnical aspects of care, such as comforting infants after painful procedures, were
as important as the technical aspects of care. Another qualitative study revealed seven
categories that influence changes in practice: (1) staffing issues, (2) consistency in
practice, (3) the approval process for change, (4) a multidisciplinary approach to care, (5)
frequency and consistency of communication, (6) rationale for change, and (7) the
feedback process. Three categories further delineate quality care: human resources,
organizational structure, and communications.73

Systematic Review in Perinatal Care and

Evidence-Based Practice
Evidence-based practice is the integration of the best possible research evidence with
clinical expertise and patient needs.56,75 Examples from the literature, such as those cited
in the preceding sections, illustrate how the application of the principles of EBP offer a
strong argument countering those who assert that EBP is nothing more than “typical
practice using good clinical judgment.” Proponents of EBP argue that the principal four
steps of evidence-based practice—formulating a clinical question, retrieving relevant
information, critically appraising the relevant information, and applying the evidence to
patient care—provide a foundation for practice that leads to improved newborn
outcomes and avoidance of repeating medical disasters.
Believing that the results of perinatal controlled trials had to be summarized in a
manner useful to practitioners, Chalmers 14 and other perinatal professionals from
various countries developed a registry of RCTs. They reviewed a vast amount of literature
from published trials, sought out unpublished trials, and encouraged those who had
begun, but not completed, studies to make them known to the registry. Once gathered,
the studies’ findings were summarized in “overviews.”
A meta-analysis is a systematic review of the current literature that uses statistical
methods to combine the results of individual studies (preferably well-conducted RCTs
with similar characteristics of the participants and the treatments) and summarizes the
results.75 These results produce unbiased estimates of the effect of an intervention on
clinical outcomes and are distinguished from nonsystematic reviews in which author
opinions often are reported along with the evidence. Table 1-1 and Figure 1-2 were
developed after pooling the results of different studies.
From these systematic reviews, practitioners can learn the strengths or weakness of
clinical trials and evaluate the claims of benefit for implementing a strategy. The result
of the efforts of Chalmers et al was the 1989 publication of a remarkably useful book,
Effective Care in Pregnancy and Childbirth.15 At the end of the book, the authors reported
their own views of the reviewed treatments based on conclusions formed in the
preceding articles. They found that although some strategies and forms of care were
useful, others were questionable. Some interventions believed to be useful were not
useful, of little benefit, or, in fact, harmful. In 1991 a companion publication, Effective
Care of the Newborn Infant,67 compiled and reviewed neonatal RCTs.
Multiple networks have been developed to perform multicenter RCTs. This is
particularly useful, providing an opportunity to see whether treatments have similar
effects in different practice settings. It is also useful in that practitioners in individual
settings may not always see enough cases to reach robust conclusions. Rare conditions
and rare outcomes are better understood when trials are replicated or their findings are
pooled. Systematic reviews provide the opportunity to understand these findings in the
context of clinical practice.

42
 About the same time the Chalmers et al book was published, the Cochrane
Collaboration was established, again largely through the efforts of Ian Chalmers
(www.cochrane.org/index0.htm). The Cochrane Collaboration is a worldwide group with
53 Collaborative Review Groups whose members prepare, maintain, and disseminate
systematic reviews based primarily on the results of RCTs. These reviews are published
electronically in the Cochrane Library, which contains the Cochrane Database of
Systematic Reviews (CDSR: www.cochrane.org/reviews/index.htm), along with editorial
comments on these reviews. Comments come from an international group of individuals
and institutions dedicated to summarizing RCTs relevant to health care. In addition to
the Collaborative Review Groups, there are now 14 Cochrane Centers in the world. These
centers provide support for the review groups. The Neonatal Group is based at the
University of Vermont.51 Cochrane Neonatal Reviews are available at the National
Institute of Child Health and Human Development (NICHD) Cochrane Neonatal
Internet home page; approximately 260 overviews are listed
50
(http://neonatal.cochrane.org).
Additional sources of high-grade integrative literature are also available to the
practicing clinician. Critical appraisal of published research takes considerable time,
and several groups assemble high-grade literature using a uniform methodology that is
typically described to readers as a supplementary article.9,10 Reading this article once can
inform the practitioner if the method used to assemble a review or guideline is
sufficiently rigorous. Also, a number of sites do not produce integrative literature but
collect it from a number of sources. Some of these sites discuss the quality of the
information presented. If we cannot appraise the method used to collect this information,
we should always proceed with caution. Additional reliable sites include the following:
• The Database of Abstracts of Reviews of Effectiveness (DARE)
(www.crd.york.ac.uk/CRDWeb), a collection of international reviews including those
from the Cochrane Collaboration. Reviewers at the National Health Service Centre for
Reviews and Dissemination at the University of York, England, provide quality
oversight, including detailed structured abstracts that describe the methodology,
results, and conclusions of the reviews. The quality of the reviews is discussed along
with implications for health care.
• The National Guidelines Clearinghouse (www.guideline.gov), maintained by the U.S.
Department of Health and Human Services, Agency for Healthcare Research and
Quality (AHRQ), that was originally created in partnership with the American Medical
Association (AMA) and the American Association of Health Plans (AAHP). This site
provides a wide range of clinical practice guidelines from institutions and
organizations. Structured abstracts facilitate critical appraisal, and abstracts on the
same topic can be compared on a side-by-side table, allowing comparisons of
relevance, generalizability, and rigor of research findings. Links also are provided to
the full text of each guideline, when available.
Conducting systematic reviews is time consuming; thus not many are available. Often,
the power of RCTs, especially in neonatology, is low. The evidence in published studies
does not always apply to our specific patient. In addition, locating relevant evidence is
time consuming and may require access to online resources and a higher level of
information-seeking skills than are available. Finally, although recognizing that medical
expertise and scientific knowledge are crucial components of neonatal care, these
rigorous, objective, scientific evaluations create the potential to overlook valuable
experiential knowledge of the NICU provided by practitioners and parents.
Reasons to use an evidence-based approach have been well documented. According to
Asztalos,5 there are basically two reasons to try to keep up with the literature: (1) to

43
maintain clinical competence, and (2) to solve specific clinical problems. Phillips and
Glasziou56 suggest that clinicians seek information “just in time” (as a clinician seeing
patients) and “just in case” (an almost impossible task to keep up with information
pertinent to a particular clinical specialty). The former can be achieved by actively
searching for information in filtered, summarized clinical point-of-care resources.
FirstConsult (www.firstconsult.com/php/437124517-76/home.html), DynaMed
(https://dynamed.ebscohost.com), and UpToDate (www.uptodate.com/home) fall into
this category. The latter, “just in case” learning, also called surveillance of the literature,
is best achieved by using technology tools to survey the current original literature. These
tools include Evidence-Updates from the BMJ (http://group.bmj.com/products/evidence-
centre/evidence-updates), auto-alerts, and RSS feeds in PubMed or online databases and
journals. Learning about these ever-changing resources is a challenge. Many hospitals
and clinics are beginning to include a clinical librarian or informationist as part of the
health care team.7-9,45,69,80
Newer and practical resources to support evidence-based health care decisions are
rapidly evolving. Large multicenter RCTs answer important clinical questions and
provide more robust evidence synthesis and synopsis services that are currently
integrated into electronic medical records. DiCenso et al24 propose a hierarchic
organization of preappraised evidence linking evidence-based recommendations with
individual patients. This 6S model describes the levels of evidence building from original
single studies at the foundation, and building up from syntheses (systematic reviews, such
as Cochrane reviews); synopses (succinct descriptions of selected individual studies or
systematic reviews, such as those found in the evidence-based journals); summaries,
which integrate the best available evidence from the lower layers to develop practice
guidelines based on a full range of evidence (e.g., Clinical Evidence, National Guidelines
Clearinghouse); to the peak of the model, systematic reviews, where the individual
patient’s characteristics are automatically linked to the current best evidence that
matches specific circumstances. Practitioners should start by looking at the highest-level
resources available for the problem that prompts research. These resources have gone
through a filtering process to generate evidence that is rigorous and exhibited over
multiple studies. Evidence-based clinical information systems integrate and concisely
summarize all relevant and important research evidence about a clinical problem, are
updated as new research evidence becomes available, and automatically link (through
an electronic medical record) specific patient circumstances to the relevant
information. Figure 1-1 depicts elements of the 6S model.
At the end of this chapter is a list of additional evidence-based practice resources. To
use these resources effectively, individuals must become familiar with the principles and
value of evidence-based patient care.

Translating Evidence into Practice

Literature demonstrates that EBP interventions can produce changes in clinicians’
knowledge and skills. Even when it is difficult to demonstrate, EBP may induce changes
in health care provider behaviors and attitudes.75 Changes in clinical outcomes are more
difficult to demonstrate. In neonatology, the extent to which Cochrane reviews are used
and are in agreement with clinical practice guidelines have been found to be
disappointingly low.11 A quality chasm of evidence exists in NICUs.28 Enormous
variations in the use of established therapies exist, so it is not surprising that multiple
neonatal networks throughout the world have demonstrated an unexplained center-to-
center variability in outcomes.32,40,41 There are reports of how EBP can be practiced

44
successfully at the single NICU level.53 However, the implementations of “bundles” of
evidence-based practices by multiple NICUs using collaborative quality improvement
efforts have reported meaningful results.54,55 Cluster randomized trials performed at
regional or national levels using different strategies have led to significant changes in
practice.1,39

Clinical Practice Guidelines

Clinical practice guidelines are systematically defined statements that assist providers
and patients with decisions about appropriate health care for specific clinical
circumstances.75 Valid clinical guidelines create components from evidence derived from
systematic reviews and all relevant literature. Two essential components should be
considered when considering the use of select guidelines: evidence and detailed
instructions for application. In addition, “killer Bs” affect the instructions for application
(Box 1-2). Detailed guides for assessing the validity of clinical guidelines have been
developed. The AGREE Collaboration has developed an instrument for assessing the
validity of the clinical guidelines, including items focusing on six domains: (1) scope and
purpose, (2) stakeholder involvement, (3) rigor of development, (4) clarity of
presentation, (5) applicability, and (6) editorial independence
(www.agreecollaborative.org).

B OX 1 - 2 T h e K ille r B s
Burden: Is the burden of illness (frequency in our community, or our patient’s pretest
probability or expected event rate [PEER]) too low to warrant implementation?
Beliefs: Are the beliefs of individual patients or communities about the value of the
interventions or their consequences incompatible with the guideline?
Bargain: Would the opportunity cost of implementing this guideline constitute a bad
bargain in the use of our energy or our community’s resources?
Barriers: Are the barriers (geographic, organizational, traditional, authoritarian, legal,
or behavioral) so high that it is not worth trying to overcome them?
From Straus SE, Richardson WS, Haynes RB: Evidence-based medicine: how to practice and teach it, ed 4, London, 2011,
Harcourt.

As stated by Silverman65:

Since ours is the only species on the planet that has achieved rates of newborn survival
which exceed 90 percent, it seems to me we must demand the highest order of evidence
possible before undertaking widespread actions that may affect the full lifetimes of
individuals in the present, as well as in future generations. Here a strong case can be made
for a slow and measured pace of medical innovation.

References
1. Acolet D, Allen E, Houston R, et al. Improvement in neonatal intensive care unit
care: a cluster randomized control trial of active dissemination of
information. Arch Dis Child Fetal Neonatal Ed. 2011;96:F434.
2. American Academy of Pediatrics. Committee on Fetus and Newborn: Postnatal
corticosteroids to treat or prevent chronic lung disease in preterm

45
Another random document with
no related content on Scribd:
Atherton. Simply a mystical Robinson Crusoe. The book relates
how a child was exposed in an ark upon the sea, drifted to a
Fortunate Island in the Indian Ocean, was there suckled by a roe,
dresses himself with skins and feathers, builds a hut, tames a horse,
rises to the discovery of ‘One supreme and necessarily self-existent
Being,’ and does, at last, by due abstinence and exclusion of all
external objects, attain to a mystical intuition of Him—a
contemplation of the divine essence, and a consciousness that his
own essence, thus lost in God, is itself divine:—all this, by the
unaided inner Light. A Mussulman hermit who is landed on the
island, there to retire from mankind, finds him; teaches him to speak;
and discovers, to his devout amazement, that this Ebn Yokhdan has
attained, first by deduction from the external world, and then,
abandoning that, by immediate intuition, to the very truth concerning
God which he has learnt through the medium of the Koran—the tee-
totum mysticism of spinning dervishes included.[374]
Gower. Barclay, citing his Arab, points the moral as teaching ‘that
the best and most certain knowledge of God, is not that which is
attained by premises premised, and conclusions deduced; but that
which is enjoyed by conjunction of the Mind of Man with the
Supreme Intellect, after the mind is purified from its corruption and is
separated from all bodily images, and is gathered into a profound
stillness.’[375]
Willoughby. And the simple-hearted apologist of the Friends never
suspected that this story was a philosopher’s conjecture—Abu
Tophail’s ideal of what the inner light might be supposed to teach a
man, in total seclusion?
Atherton. Not he. At any rate, Yokhdan figures in the first half-
dozen editions of the Apology. I believe, in none later.
Gower. A curious sight, to see the Arabian Sufi and the English
Quaker keeping company so lovingly.
Willoughby. And yet how utterly repugnant to our English natures,
that contemplative Oriental mysticism.
Gower. In practice, of course. But in the theory lies a common
ground.
Atherton. Our island would be but a spare contributor to a general
exhibition of mystics. The British cloister has not one great mystical
saint to show. Mysticism did not, with us, prepare the way for the
Reformation. John Wycliffe and John Tauler are a striking contrast in
this respect. In the time of the Black Death, the Flagellants could
make no way with us. Whether coming as gloomy superstition, as
hysterical fervour, or as pantheistic speculation, mysticism has found
our soil a thankless one.
Gower. I should like to catch a Hegelian, in good condition, well
nourished with the finest of thrice-bolted philosophic grain, duly
ignorant of England, and shut him up to determine, from the depths
of his consciousness, what would be the form which mysticism must
necessarily assume among us.
Atherton. He would probably be prepared to prove to us à priori
that we could not possibly evolve such a product at all.
Gower. Most likely. The torches of the Bacchantes, flung into the
Tiber, were said still to burn; but what whirling enthusiast’s fire could
survive a plunge into the Thames? There could be nothing for it but
sputtering extinction, and then to float—a sodden lump of pine and
pitch, bobbing against the stolid sides of barges.
Willoughby. The sage might be pardoned for prophesying that our
mysticism would appear in some time of religious stagnation—a
meteoric flash spasmodically flinging itself this way and that, startling
with its radiance deep slimy pools, black rich oozing reaches of
plurality and sinecure. Remembering the very practical mysticism of
the Munster Anabaptists, he might invest our mystical day-star with
such ‘trains of fire and dews of death;’ or depict it as a shape of
terror, like his who ‘drew Priam’s curtain at the dead of night;’
heralding horrors; and waking every still cathedral close to dread the
burning fate that befell, ‘the topless towers of Ilium.’
Atherton. It certainly would have been hard to foresee that
mysticism in England would arise just when it did—would go so far,
and no farther:—that in the time of the Commonwealth, when there
was fuller religious freedom by far, and, throughout the whole middle
class, a more earnest religious life than at any former period of our
history,—when along the ranks of triumphant Puritanism the electric
light of enthusiasm played every here and there upon the steel which
won them victory, and was beheld with no ominous misgiving, but
hailed rather as Pentecostal effluence,—that, at such a juncture,
Quakerism should have appeared to declare this liberty insufficiently
free, this spirituality too carnal, this enthusiasm too cold,—to profess
to eject more thoroughly yet the world, the flesh, and the devil,—to
take its place in the confused throng contending about the ‘bare-
picked bone’ of Hierarchy, and show itself not to be tempted for a
moment by wealth, by place, by power,—to commit many follies, but
never a single crime,—to endure enumerable wrongs, but never to
furnish one example of resistance or revenge.
Willoughby. Well done, old England! It is gratifying to think that, on
our shores, mysticism itself is less fantastic than its wont,—labours
benignly, if not always soberly; and is represented, not by
nightmared visionaries, or fury-driven persecutors, but by the holy,
tender-hearted, much-enduring George Fox. The Muggletonians,
Fifth-Monarchy men, and Ranters of those days were the
exceptional mire and dirt cast up by the vexed times, but assuredly
not the representatives of English mysticism.
Atherton. The elements of Quakerism lie all complete in the
personal history of Fox; and the religious sect is, in many respects,
the perpetuation of his individual character;—the same intellectual
narrowness, incident to an isolated, half-disciplined mind, and the
same large, loving heart of charity for all men. Remember how he
describes himself as ‘knowing pureness and righteousness at eleven
years of age;’ carefully brought up, so that from his childhood all vice
and profaneness were an abomination to him. Then there were his
solitary musings and sore inward battles, as he walked about his
native Drayton many nights by himself: his fastings oft; his much
walking abroad in solitary spots many days; his sitting, with his Bible,
in hollow trees and lonesome places, till night came on. Because the
religious teachers to whom he applied in his temptations to despair
were unhappily incompetent to administer relief, he concludes too
hastily that the system of ministerial instruction is more often a
hindrance than a help to ‘vital godliness.’ Because ‘priest Stevens’
worked up some of his remarks in conversation into his next
Sunday’s sermon,—because the ‘ancient priest’ at Mansetter, to
whom he next applied, could make nothing of him, and in despair
recommended tobacco and psalm-singing (furthermore violating his
confidence, and letting young George’s spiritual distresses get wind
among a bevy of giggling milk-lasses),—because, after travelling
seven miles to a priest of reputed experience at Tamworth, he found
him after all ‘but like an empty hollow cask,’—because horticultural
Dr. Cradock of Coventry fell into a passion with him for accidentally
trampling on the border of his flower-bed,—because one Macham, a
priest in high account, offered him physic and prescribed blood-
letting,—therefore the institution of a clerical order was an error and
a mischief, mainly chargeable with the disputings of the church, and
the ungodliness of the world. So, in his simplicity, he regarded it as a
momentous discovery to have it opened to him ‘that being bred at
Oxford or Cambridge was not enough to fit and qualify men to be
ministers of Christ.’[376]
Gower. We may hold that without joining the Society of Friends.
Atherton. In like manner he argues that because believers are the
temple of the Spirit, and many venerate places superstitiously, or
identify church-going with religion, therefore ‘steeple-houses’ are a
sinful innovation, diffusing, for the most part, darkness rather than
light. Because it appeared to him that in his study of the Scriptures
he knew Christ ‘only as the light grew’—by inward revelation—‘as he
that hath the key did open,’ therefore the doctrine of the inward Light
is proclaimed to all as the central principle of Redemption.
Gower. True. This proneness to extremes has led his followers
often to attach undue importance to the mere externals of a protest
against externalism. Those peculiarities of dress and speech are
petty formalities unworthy of their main principle. In his ‘Epistle to
gathered Churches into outward forms upon the Earth,’ Fox can see
scarce a vestige of spiritual religion anywhere beyond the pale of the
Society of Friends.
Atherton. Yet ascetic and narrow on many points as he
unquestionably was, and little disposed to make concession to
human weakness, in practical charity he was most abundant.
Oppression and imprisonment awakened the benevolent, never the
malevolent impulses of his nature,—only adding fervour to his plea
for the captive and the oppressed. His tender conscience could know
no fellowship with the pleasures of the world; his tender heart could
know no weariness in seeking to make less its sum of suffering. He
is a Cato-Howard. You see him in his early days, refusing to join in
the festivities of the time called Christmas; yet, if a stranger to the
mirth, never to the mercy, of that kindly season. From house to
house he trudges in the snow, visiting poor widows, and giving them
money. Invited to marriage merry-makings, he will not enter the
house of feasting; but the next day, or soon after, we find him there,
offering, if the young couple are poor, the effectual congratulation of
pecuniary help. In the prison-experiences of George Fox are to be
found the germs of that modern philanthropy in which his followers
have distinguished themselves so nobly. In Derby Jail he is
‘exceedingly exercised’ about the proceedings of the judges and
magistrates—concerning their putting men to death for cattle, and
money, and small matters,—and is moved to write to them, showing
the sin of such severity; and, moreover, ‘what an hurtful thing it was
that prisoners should lie so long in jail; how that they learned
badness one of another in talking of their bad deeds; and therefore
speedy justice should be done.’[377]
Willoughby. How the spirit of benevolence pervades all the
Journals of the early Friends. Look at John Woolman, who will
neither write nor have letters written to him by post, because the
horses are overwrought, and the hardships of the postboys so great.
When farthest gone in rhapsody, this redeeming characteristic was
never wanting to the Quakers. It may be said of some of them, as
was said of dying Pope—uttering, between his wanderings, only
kindness—‘humanity seems to have outlasted understanding.’
Atherton. As to doctrine, again, consider how much religious
extravagance was then afloat, and let us set it down to the credit of
Fox that his mystical excesses were no greater. At Coventry he finds
men in prison for religion who declared, to his horror, that they were
God. While at Derby, a soldier who had been a Baptist, comes to him
from Nottingham, and argues that Christ and the prophets suffered
no one of them externally, only internally. Another company, he says,
came to him there, who professed to be triers of spirits, and when he
questioned them, ‘were presently up in the airy mind,’ and said he
was mad. The priests and magistrates were not more violent against
him than the Ranters, who roved the country in great numbers,
professing to work miracles, forbidding other enthusiasts to preach,
on pain of damnation; and in comparison with whom, Fox was
soberness itself. Rice Jones, the Ranter, from Nottingham,
prophesies against him with his company. At Captain Bradford’s
house, Ranters come from York to wrangle with him. In the Peak
country they oppose him, and ‘fall a-swearing.’ At Swanington, in
Leicestershire, they disturb the meeting—hound on the mob against
the Friends; they sing, whistle, and dance; but their leaders are
confounded everywhere by the power of the Lord, and many of their
followers, says the Journal, ’were reached and convinced, and
received the Spirit of God; and are come to be a pretty people, living
and walking soberly in the truth of Christ.’[378] Such facts should be
remembered in our estimate. Fox’s inner light does not profess to
supersede, nor does it designedly contradict, the external light of
Revelation.
But hand me his Journal a moment. Here is a curious passage. It
shows what a narrow escape Fox had of being resolved into an
English Jacob Behmen.
He says, ‘Now (he was about four-and-twenty at the time) was I
come up in spirit, through the flaming sword, into the paradise of
God. All things were new; and all the creation gave another smell
unto me than before, beyond what words can utter. I knew nothing
but pureness and innocency and righteousness, being renewed up
into the image of God by Christ Jesus; so that I say I was come up to
the state of Adam which he was in before he fell. The creation was
opened to me; and it was showed me how all things had their names
given them, according to their nature and virtue. And I was at a stand
in my mind whether I should practise physic for the good of mankind,
seeing the nature and virtues of the creatures were so opened to me
by the Lord. But I was immediately taken up in spirit to see into
another or more stedfast state than Adam’s in innocency, even into a
state in Christ Jesus, that should never fall. And the Lord showed me
that such as were faithful to Him in the power and light of Christ,
should come up into that state in which Adam was before he fell; in
which the admirable works of the creation, and the virtues thereof
may be known, through the openings of that divine word of wisdom
and power by which they were made. Great things did the Lord lead
me into, and wonderful depths were opened unto me, beyond what
can by words be declared; but as people come into subjection to the
Spirit of God, and grow up in the image and power of the Almighty,
they may receive the word of wisdom that opens all things, and
come to know the hidden unity in the Eternal Being.‘[379]
Here he has arrived on life’s road where two ways meet;—had he
taken the wrong alternative, and wandered down that shadowy and
mysterious theosophic avenue, ignorant that it was no thoroughfare,
what a different history! Imagine the intrepid, heart-searching
preacher—the redoubted ‘man in leather breeches’—transformed
into the physician, haply peruked and habited in black, dispensing
inspired prescriptions, and writing forgotten treatises on Qualities
and Signatures, Sympathies and Antipathies. What a waste of that
indomitable energy!
Willoughby. How destructive to human life might his very
benevolence have proved.
Gower. Whatever direction the mysticism of a man like Fox might
have taken, it must have been always actively benevolent. His
mysticism is simple—no artificial stages of abstraction, mounting
step by step above the finite, to a solitary superhuman sanctity. It is
beneficent—his many and various spiritual distresses were permitted
by God, he tells us, ‘in order that he might have a sense of all
conditions—how else should he speak to all conditions?‘[380]
Willoughby. Truly, metaphysical refinements and Platonic
abstraction could have no charm for this most practical of mystics.
What a contrast here is his pietism to that of Zinzendorf—as
abundant in sentiment as Fox is devoid of it.
Gower. Nicholas of Basle is more like Fox than any of the German
mystics—much more so than Tauler.
Atherton. Fox is, as you say, eminently practical in one sense, yet
not enough so in another. In one respect Behmen and Law are more
practical than he, because more comprehensive. They endeavour to
infuse a higher spiritual life into forms and communities already
existing. Fox will have no steeple-houses, vestments, forms of
prayer, no ministry, regularly paid and highly educated. Such a code
is not practical, for it rests on an abstraction: it does not legislate for
men as they are. Formalism does not lie in these outward things
themselves—it consists in the spirit in which they are used. Here,
you see, the mystic, who will always go beneath the surface to the
reality, is too superficial. Formalism cannot be expelled by any such
summary process. The evil lies deeper.
Willoughby. So with the asceticism of the Friends. The worldly spirit
is too subtile to be exorcised by a strict outward separation between
church and world. How much easier is total abstinence from scenes
of amusement than temperance in money-getting.
Gower. Yet I know men and women who pique themselves on their
separateness from the world, because they were never seen at a
concert, whose covetousness, insincerity, or censorious speech,
proclaim them steeped in worldliness to the very lips.
Willoughby. What say you, Atherton, to the doctrine of the
Universal Light? In their theory on this matter the mystics seem to
divide into two classes. With the mystics of the fourteenth century
there is still left in fallen man a native tendency Godward, on which
grace lays hold. With Behmen and Fox, on the contrary, the inward
Seed is a supernatural gift, distinct from conscience, reason, or any
relics of natural goodness—the hidden word of promise, inspoken
into all men, in virtue of the redeeming work of Christ.[381]
Atherton. I do not believe that fallen man required a divine
bestowment of this kind—a supernatural soul within the soul, to give
him a moral sense, and make him responsible. But I am so far a
believer in the doctrine that I would not go beyond what is written,
and rigidly confine all the benefits of Christ’s redemption to those
only who have had access to the Christian Scriptures. The words of
the Apostle are still applicable,—‘Is he the God of the Jews only, is
he not of the Gentiles also?’ I cannot suppose that all Pagan minds,
past and present, have been utterly and for ever abandoned by the
Divine Spirit, because the dispensation under which they have been
placed is so much less privileged than our own. God has light
enough to be Himself, in the twilight, even as in the noonday. Did He
rule the rising and falling of ancient nations, working all things toward
the fulness of time;—did He care for the bodies of those heathen,
with seedtime and harvest for his witness, and shall we suppose that
He debarred Himself from all access to their souls?
Willoughby. Yet no doctrine we can hold on this question materially
lessens the mystery of that dark fact—the prevalence of Evil.
Atherton. I am afraid not. Whether we call that better part of man
the light of nature, conscience, or the internal Word, we must admit
that it accomplished next to nothing for the restoration of the vast
majority. We must not judge of the moral effects of heathendom by
the philosophic few merely; we must remember the state of the
superstitious many. And mysticism will be the first to admit that an
inoperative Christ (like that of the Antinomian, for example) is a
deceptive phantom or a vain formula.
Our own position, however, is the same, let our theory or our hope,
concerning others, be what it may. Whatever it may be possible
(under the constitution of our nature) for the Spirit of God to make
known inwardly to that man who is shut out from external teaching, it
is quite certain that we shall receive no inward communications of
gracious influence, while we neglect those outward means which are
of divine appointment.

Note to page 300.

The full title of the work referred to runs as follows: The Improvement
of Human Reason, exhibited in the Life of Hai Ebn Yokhdan: written
in Arabick about 500 years ago, by Abn Jaafer Ebn Tophail. In which
is demonstrated by what methods one may, by the mere Light of
Nature, attain the knowledge of things Natural and supernatural;
more particularly the knowledge of God and the affairs of another
Life. Newly translated from the original Arabick by Simon Ockley, &c.
1708.
Ockley adds an Appendix, to guard the book from abuse by the
Quakers, wherein he proposes to examine ‘the fundamental error’ of
his author—viz. that ‘God has given such a power or faculty to man
whereby he may, without any external means, attain to the
knowledge of all things necessary to salvation, and even to the
Beatifick Vision itself, whilst in the state.’
The following is a specimen of the mystical progress which our
Arabian Defoe describes his Crusoe as making,—precisely that with
which Ebn Tophail was well acquainted, but which no real solitary
Ebn Yokhdan could ever have struck out for himself.
‘He began, therefore, to strip himself of all bodily properties, which
he had made some progress in before, during the time of the former
exercise, when he was employed in the imitation of the heavenly
bodies; but there still remained a great many relicks, as his circular
motion (motion being one of the most proper attributes of body), and
his care of animals and plants, compassion upon them, and industry
in removing whatever inconvenienced them. Now, all these things
belong to corporeal attributes, for he could not see these things at
first, but by corporeal faculties; and he was obliged to make use of
the same faculties in preserving them. Therefore he began to reject
and remove all those things from himself, as being in nowise
consistent with that state which he was now in search of. So he
continued, after confining himself to rest in the bottom of his cave,
with his head bowed down and his eyes shut, and turning himself
altogether from all sensible things and the corporeal faculties, and
bending all his thoughts and meditations upon the necessarily self-
existent Being, without admitting anything else besides him; and if
any other object presented itself to his imagination, he rejected it
with his utmost force; and exercised himself in this, and persisted in
it to that degree, that sometimes he did neither eat nor stir for a great
many days together. And whilst he was thus earnestly taken up in
contemplation, sometimes all manner of beings whatsoever would
be quite out of his mind and thoughts, except his own being only.
‘But he found that his own being was not excluded from his thoughts;
no, not at such times when he was most deeply immersed in the
contemplation of the first, true, necessarily self-existent Being; which
concerned him very much,—for he knew that even this was a
mixture in this simple vision, and the admission of an extraneous
object in that contemplation. Upon which he endeavoured to
disappear from himself, and be wholly taken up in the vision of that
true Being; till at last he attained it; and then both the heavens and
the earth, and whatsoever is between them, and all spiritual forms,
and corporeal faculties, and all those powers which are separate
from matter, and all those beings which know the necessarily self-
existent Being, all disappeared and vanished, and were as if they
had never been; and amongst these his own being disappeared too,
and there remained nothing but this one, true, perpetually self-
existent Being, who spoke thus in that saying of his (which is not a
notion superadded to his essence):—“To whom now belongs the
kingdom? To this One, Almighty God.”[382] Which words of his Hai
Ebn Yokhdan understood and heard his voice; nor was his being
unacquainted with words, and not being able to speak, any
hindrance at all to the understanding him. Wherefore he deeply
immersed himself into this state, and witnessed that which neither
eye hath seen nor ear heard, nor hath it ever entered into the heart
of man to conceive.’—§§ 83, 84.
 CHAPTER II.

And to such Enthusiasm as is but the triumph of the soul of man,

inebriated, as it were, with the delicious sense of the divine life,
that blessed Root, and Original of all holy wisdom and virtue, I
am as much a friend as I am to the vulgar fanatical Enthusiasm a
professed enemy.—Henry More.

Willoughby. There is no mysticism in the doctrine of an immediate

influence exercised by the Spirit of God on the spirit of man.
Atherton. Certainly not. It would be strange if the Creator, in whom
we live and move, should have no direct access to the spirits of his
own creatures.
Gower. Does not your admission indicate the line between the true
and the false in that aspiration after immediate knowledge,
intercourse, or intuition, so common among the mystics? It is true
that the divine influence is exerted upon us directly. But it is not true
that such influence dispenses with rather than demands—suspends
rather than quickens, the desires and faculties of our nature. So it
appears to me at least.
Atherton. And to me also.
Willoughby. And again (to continue your negatives, Gower) it is not
true, as some of the mystics tell us, that we can transcend with
advantage the figurative language of Scripture; or gaze directly on
the Divine Subsistence,—that we can know without knowledge,
believe without a promise or a fact, and so dispense, in religious
matters, with modes and media.
Atherton. Agreed. For ourselves, I believe we shall always find it
true that the letter and the spirit do reciprocally set forth and
consummate each other,—
 ‘Like as the wind doth beautify a sail,
And as a sail becomes the unseen wind.’

We see truth in proportion as we are true. The outward written word

in our hands directs us to the unseen Word so high above us, yet so
near. The story of Christ’s life and death is our soul’s food. We find
that we may—we must, sit in spirit at his feet, who so spake, so
lived, so died. And, having been with him, we find a new power and
attraction in the words; we are led by the Spirit of Christ in the
keeping of those commandments, concerning which he said, ‘The
words I speak unto you, they are spirit and they are life.’
Willoughby. So Plotinus is right, in a sense, after all;—like only can
know like. Our likeness to Christ is our true knowledge of him.
Atherton. Yes. But we become partakers of the unseen life and
light of God only through the manifestation of that life and light,
Christ Jesus. It is on this point that the theology of Fox is so
defective.
Willoughby. His doctrine that the influence of the Spirit is
perceptible, as well as immediate, is still more questionable, surely?
Gower. Perceptible! aye, and physically perceptible, he will have it,
in some cases,—manifested in a tremulous agitation of the frame.
Willoughby. True. The convulsive movements among the
Protestant peasantry of the Cevennes are a similar instance. This
spasmodical religious excitement is in a high degree infectious when
many are assembled together.
Atherton. Yet we should not reject the doctrine of perceptible
spiritual guidance because it is so liable to abuse. My objection is
that I have never seen satisfactory proof adduced. Do not let us
think, however, that we escape from the danger of self-delusion by
denying this doctrine, and can afford to be careless accordingly. You
often see persons who would think the Quaker belief a dangerous
superstition, unscrupulously identifying their personal or party
interests with the cause of God, as though they believed themselves
divinely commissioned, and could not possibly be liable to deception.
Willoughby. Here you see the value of the Quaker doctrine
concerning stillness and quiet. The soul must be withdrawn in a
silent waiting, and so hearken for the divine voice. The impulses
which stir in the unallayed tumult of the feelings are the promptings
of passion or of self, not of God. Wherever the belief in perceptible
guidance is entertained, this practice of tranquil tarrying should
accompany it, as its proper safeguard.
Atherton. The Quakers are wrong, I think, in separating particular
movements and monitions as divine. But, at the same time, the
‘witness of the Spirit,’ as regards our state before God, is something
more, I believe, than the mere attestation to the written word.
Willoughby. The traditional asceticism of the Friends is their fatal
defect as a body.
Atherton. And their proneness to hazard good principles by
pushing them to some repulsive extreme. Thus, they propose to
abolish physical force by yielding everything to it;—to put an end to
war by laying Europe at the feet of a great military power,—by
apologizing for the oppressor and reviling those who resist him.
Gower. I believe the man who says to me, I am trying to love my
neighbour as myself: I suspect him who professes to love him better.
His profession is worse than worthless unless he be consistent, and
will allow himself to be swindled with impunity.
Atherton. We may well be suspicious when we see this super-
Christian morality defended by arguments which can only be valid
with the meanest and most grovelling selfishness. Such ethics are, in
promise, more than human; in performance—less.
Willoughby. But, leaving this question, I am sure no sect which
systematically secludes itself from every province of philosophy,
literature, and art, can grow largely in numbers and in influence in a
state of society like ours.
Gower. Our English Platonists contrast strongly, in this respect, with
George Fox and his followers.
Willoughby. How incomprehensible must have been the rude
fervour and symbolic prophesyings of the Quakers to the refined
scholarship and retiring devotion of men like More and Norris, Gale
and Cudworth. But can you call them mystics?
Atherton. Scarcely so, except in as far as Platonism is always in a
measure mystical. A vein of mysticism peeps out here and there in
their writings. Cold rationalism they hate. They warm, with a ready
sympathy, to every utterance of the tender and the lofty in the
aspirations of the soul. But their practical English sense shows itself
in their instant rejection of sentimentalism, extravagance, or
profanity. This is especially the case with More—as shrewd in some
things as he was credulous in others, and gifted with so quick an eye
for the ridiculous.
Gower. Delightful reading, those racy pages of his, running over
with quaint fancies.
Atherton. More’s position as regards mysticism is, in the main, that
of a comprehensive and judicial mind. He goes a considerable
distance with the enthusiast,—for he believes that love for the
supreme Beautiful and Good may well carry men out of themselves;
but for fanatical presumption he has no mercy.[383]
Willoughby. The Romanist type of mysticism would be the most
repugnant of all, I should think, to these somewhat free-thinking
English scholars.
Atherton. So I have found. More has no notion of professing to give
up his reason, like Poiret; still less of awaiting a suspension of our
powers, like John of the Cross. He believes that ‘the Spirit doth
accomplish and enlarge our humane faculties.’[384]
Gower. Yet Norris is less remote than More from the Romish
mysticism, is he not? I mean that his Platonism seemed to me a little
more monastic, and less philosophical.
Atherton. He has, it must be confessed, his four gradations of love
—akin to the class-religion of the Romish Church;—as though a
certain degree were incumbent on all Christians, but higher stages of
devout affection (above mere duty) were set before the eminently
religious.[385] Yet let us do full justice to the good sense of that
excellent man. The Quietist doctrine of unconsciousness appears to
him an unnatural refinement. He cannot conceive how it should be
expected that a man was to be ‘such an America to himself,’ as not
to know what his own wishes and attainments are. The infused virtue
of the Spanish mystics appears to his discriminating eye ‘as great a
paradox in divinity, as occult qualities in philosophy.‘[386]
Willoughby. And none of them, I think, distress themselves, as did
Fénélon, about purely disinterested love.
Atherton. They are too close followers of Plato to do that. They do
not disguise their impatience of the bodily prison-house. Neither
have they any love for the divine ignorance and holy darkness of
Dionysius. They are eager to catch every ray of knowledge—to know
and to rejoice, to the utmost that our mortality may, upon its
heavenward pilgrimage.[387]
 BOOK THE TWELFTH
EMANUEL SWEDENBORG
 CHAPTER I.

What if earth
Be but the shadow of heaven, and things therein
Each to other like, more than on earth is thought.

Milton.

Here follow extracts from a section in Atherton’s Note-book, entitled

‘Remarks on Swedenborg.’

The doctrine of Correspondence is the central idea of

Swedenborg’s system. Everything visible has belonging to it an
appropriate spiritual reality. The history of man is an acted
parable; the universe, a temple covered with hieroglyphics.
Behmen, from the light which flashes on certain exalted
moments, imagines that he receives the key to these hidden
significances,—that he can interpret the Signatura Rerum. But
he does not see spirits, or talk with angels. According to him,
such communications would be less reliable than the intuition he
enjoyed. Swedenborg takes opposite ground. ‘What I relate,’ he
would say, ‘comes from no such mere inward persuasion. I
recount the things I have seen. I do not labour to recall and to
express the manifestation made me in some moment of ecstatic
exaltation. I write you down a plain statement of journeys and
conversations in the spiritual world, which have made the greater
part of my daily history for many years together. I take my stand
upon experience. I have proceeded by observation and induction
as strict as that of any man of science among you. Only it has
been given me to enjoy an experience reaching into two worlds
—that of spirit, as well as that of matter.’
A mysticism like that of Tauler strives, and strives in vain, to
escape all image and ‘figuration.’ A mysticism like that of
Swedenborg clothes every spiritual truth in some substantial
envelope, and discerns a habitant spirit in every variety of form.
The follower of Plato essays to rise from the visible to the
invisible. But he spurns each ladder in succession by which he
has ascended. The follower of Swedenborg seeks a similar
ascent; but he never flings away, as common, the husk which
guards the precious spiritual kernel. He will not shun the
material, or diminish his relations to it. Rather will he surround
himself by those objects and those ties of earth which, spiritually
regarded, speak constantly of heaven. To look thus on life, I
need not enter the school of Swedenborg.
But in this freedom from asceticism,—this tendency to see the
spiritual, not beyond, but in, the natural,—the mysticism of
Swedenborg, like that of Behmen, has advanced far beyond its
mediæval type. Religion no longer plays the despot toward
science; the flesh is no longer evil; this beautiful world no longer
yielded over to that father of lies who called it his.
As regards the scriptures, I find Swedenborg less one-sided than
mystics like Frank, Weigel, or the more extreme among the
Quakers. He displays no inclination to depreciate the letter of
scripture in favour of the inward teaching of the Word. Without
this ‘book-revelation,’ he tells us, man would have remained in
gross ignorance concerning his Maker and his future destinies.
The literal sense of the word is the basis of the spiritual and
celestial sense; and the word, for this very reason, holy in every
syllable. He sets up no doctrine based on arbitrary or fantastical
interpretations. His doctrinal system is drawn from the literal
sense, and calmly, if not always satisfactorily deduced, by
citation, exegesis, and comparison of passages, without any
mysticism whatever. Thus the balance between the letter and the
spirit is maintained in his theology with a fairness almost
unparalleled in the history of mysticism.[388]
According to Swedenborg, all the mythology and the symbolisms
of ancient times were so many refracted or fragmentary
correspondences—relics of that better day when every outward
object suggested to man’s mind its appropriate divine truth. Such
desultory and uncertain links between the seen and the unseen
are so many imperfect attempts toward that harmony of the two
worlds which he believed himself commissioned to reveal. The
happy thoughts of the artist, the imaginative analogies of the
poet, are exchanged with Swedenborg for an elaborate system.
All the terms and objects in the natural and spiritual worlds are
catalogued in pairs. This method appears so much formal
pedantry. Our fancies will not work to order. The meaning and
the life with which we continually inform outward objects,—those
suggestions from sight and sound, which make almost every
man at times a poet,—are our own creations, are determined by
the mood of the hour, cannot be imposed from without, cannot
be arranged like the nomenclature of a science. As regards the
inner sense of scripture, at all events, Swedenborg introduces
some such yoke. In that province, however, it is perhaps as well
that those who are not satisfied with the obvious sense should
find some restraint for their imagination, some method for their
ingenuity, some guidance in a curiosity irresistible to a certain
class of minds. If an objector say, ‘I do not see why the ass
should correspond to scientific truth, and the horse to intellectual
truth,’ Swedenborg will reply, ‘This analogy rests on no fancy of
mine, but on actual experience and observation in the spiritual
world. I have always seen horses and asses present and
circumstanced, when, and according as, those inward qualities
were central.’[389] But I do not believe that it was the design of
Swedenborg rigidly to determine the relationships by which men
are continually uniting the seen and unseen worlds. He probably
conceived it his mission to disclose to men the divinely-ordered
correspondences of scripture, the close relationship of man’s
several states of being, and to make mankind more fully aware
that matter and spirit were associated, not only in the varying
analogies of imagination, but by the deeper affinity of eternal law.
In this way, he sought to impart an impulse rather than to
prescribe a scheme. His consistent followers will acknowledge
that had he lived in another age, and occupied a different social
position, the forms under which the spiritual world presented
itself to him would have been different. To a large extent,