“Prehab” for Preemies...Part IV: Prehab for Nurses 2 1 2 4/27/2021 2 Disclosures Directorof...

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“Prehab” for Preemies: The Protective Effects of an Exclusive Human Milk Diet Part I: “What’s Prehab?” and “Why Human Milk?”

Terry S Johnson, APN, NNP‐BC, ASPPS, CLEC, MN

Director, Education and Professional Development

Prolacta Bioscience

Course Overview

Part I: What’s Prehab and Why Human Milk

Part II: BPD and Late‐Onset Sepsis

Part III: ROP and NEC

Part IV: Prehab for Nurses

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Disclosures

Director of Education and Professional Development at Prolacta Bioscience

• I personally prepared this slide deck

• It is without commercial bias or influence and is evidence based

• I have received financial reimbursement for non‐marketed, non‐branded, non‐promotional educational presentations through the Abbott Nutrition Health Institute (ANHI)

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Terry S JohnsonAPN, NNP‐BC, ASPPS

Part I: Objectives

Define the term prehab

Identify the role of inflammation in the development of neonatal comorbidities

Discuss the benefits of human milk in reducing inflammation

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“Prehab”

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What is “Prehab”?• A preventive mechanism to decrease the risk of injury and/or to optimize your functional ability and quality of life

• Described as “prehabilitation” or “preventive rehab” with the goal of reducing the risk for injury

• Focuses on efforts to decrease the burden on individuals and the healthcare system

This Photo by Unknown Author is licensed under CC BY‐NC‐ND

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For millennia women have labored and delivered and

breastfed babies…

For 60+ years women have had more

complex pregnancies and deliveries…

For 60+ years babies have been born

smaller and younger and survived…

Evolutionary Biology

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Premature and low birth weight

Multisystem organ immaturity

Limited exposure to maternal microbiome

Reduced maternal antibody passage

Risk of pre‐/prolonged ROM Immature innate/adaptive immune systems

Resuscitation and stabilization Increased caloric expenditures Inadequate protein/mineral stores

Largest surface area with “other” – is the GI tract 7

Evolutionary Discordance

Cacho NT, Lawrence RM. Innate immunity and breast milk. Front Immunol. 2017;8:584. doi:10.3389/fimmu.2017.00584Jakaitis BM, Denning PW. Human breast milk and the gastrointestinal innate immune system. Clin Perinatol. 2014;41(2):423‐435. doi:10.1016/j.clp.2014.02.011

Innate Immunity• First line of defense at birth

• Provides immediate protection at a local/cellular level

• Acts with non‐specific responses

• Uses “pro‐inflammatory” mechanisms

• ↑ Vasodilata on, cellular ac va on, vascular permeability, coagulation

• Secondary collateral damage

Adaptive Immunity• Later developed immune response

• Requires exposure to antigens

• Amplifies with repeated exposure

• Highly specific response

• Relies on T & B cells and “memory”

• Elaborate cascade of responses

• More balanced response

• More modulated responses

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Neonatal Immune Responses

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Torrazza RM, Neu J. The altered gut microbiome and necrotizing enterolcolitis. Clin Perinatol. 2013;40(1)93‐108. doi:10.1016/j.clp.2012.12.009 Underwood MA, Umberger E, Patel R. Safety and efficacy of probiotic administration to preterm infants: ten common questions. Pediatr Res. 2020;88(Suppl 1):48‐55. doi:10.1038/s41390‐020‐1080‐6

Altered Microbiota Dysbiosis

Inflammation Dysregulation

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DYSBIOSISTerm/Well

Preterm/Sick?

Preterm Birth, the Microbiome, and the Origin of Dysbiosis

39 trillion microbial cells30 trillion human cells

2 million microbial genes23 thousand human genes

That’s a LOT of OTHER!

Bode L. Benefits of human milk and the role of oligosaccharides. Presentation at Spring National Advanced Practice Neonatal Nurses Conference; May 29 to June 1, 2019; Palm Springs, CA.

Neonatal Microbiome

Microbial Cells: Human/Self Microbial Genes: Human/Self

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Groer MW, Miller EM, D’Agata A, et al. Contributors to dysbiosis in very‐low‐birth‐weight infants. J Obstet Gynecol Neonatal Nurs. 2020;49(3):232‐242. doi:10.1016/j.jogn.2020.02.003

Dysbiosis is characterized by:

• Low diversity in the microbiome

• Overall reduction in beneficial and/or commensal bacteria

• ↑ Opportunistic pathogens of the gamma‐proteobacteria class

• These factors interact to produce inflammation in the gut, which further perpetuates dysbiosis

• The potential for dysbiosis, limited capacity for localization, and the potential initiation of systemic inflammation

Origin of dysbiosis in preterm infants:

• 37% of pregnant women receiveantibiotics during pregnancy

• 33% receive them in the intrapartum period

• Early or prolonged ROM; maternal stress

• Antenatal steroids → immune system

• 64% of preterm infants delivered via C/S

• 85% of all ELBW infants receive at least one course of broad‐spectrum antibiotics

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Preterm Birth and the Origin of Dysbiosis

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Is feeding Intolerance the mildest case of NEC?

Is NEC the worse case of feeding intolerance?

Incidence Estimate: NEC~5% of VLBW infants

Incidence Estimate: FIAs high as 36%

Horbar JD, Edwards EM, Green berg LT, et al. Variation in performance of neonatal intensive care units in the United States [published correction appears in JAMA Pediatr. 2017;171(3):306] JAMA Pediatr. 2017;171(3):e164396 doi:10.1001/jamapediatrics.2016.4396.

Ahammad F, Begum T, Akter J, Nasrin E. Comparison of feeding intolerance between very preterm and moderate preterm neonates – a prospective cohort study. J Pediatr Neonatal Care. 2018;8(4):200‐203. doi:10.15406/jpnc.2018.08.00339

DYSBIOSIS

INFLAMMATION

The Potential Continuum of Dysbiosis

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SOURCE: Trindade CEP, Rugolo LMSS. Free radicals and neonatal diseases. NeoReviews. 2007;8(12);e522‐e532. doi:10.1542/neo.8‐12‐e522

Inflammation

Infection

Ischemia

Reperfusion

Increased ROS Production

Deficient Antioxidant Defenses

Cell/Tissue/Organ Injury

Retinopathy of PrematurityChronic Lung Disease/BPD

Periventricular LeukomalaciaIntraventricular HemorrhageNecrotizing EnterocolitisPatent Ductus Arteriosus

Cerebral Palsy

InflammationOxidative Stress

Oxygen Radical Disease of Neonatology

Human Milk Anti‐inflammatory/Anti‐oxidant

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The “Burdens of Prematurity”

The gut‐brain axis

14SOURCE: Sherman, M., Zaghouani, H. & Niklas, V. Gut microbiota, the immune system, and diet influence the neonatal gut–brain axis. Pediatr Res 77, 127–135 (2015). https://doi.org/10.1038/pr.2014.161

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The gut‐lung axis – BPD

15SOURCE: Piersigilli F, Van Grambezen B, Hocq C, Danhaive O. (2020). Nutrients and Microbiota in Lung Diseases of Prematurity: The Placenta‐Gut‐Lung Triangle. Nutrients. 12(2):469. https://doi.org/10.3390/nu12020469


The gut‐eye axis – ROP

16SOURCE: Floyd JL, Grant MB. The Gut‐Eye Axis: Lessons Learned from Murine Models. Ophthalmol Ther. 2020 Sep;9(3):499‐513. doi: 10.1007/s40123‐020‐00278‐2. Epub 2020 Jul 2. PMID: 32617914; PMCID: PMC7406577.

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Dysbiosis late‐onset sepsis axis

17SOURCE: Kleist SA, Knoop KA. Understanding the Elements of Maternal Protection from Systemic Bacterial Infections during Early Life. Nutrients. 2020; 12(4):1045. https://doi.org/10.3390/nu12041045

The four “Biologics” or “Immunizations” or “Benefits” of human milk

Womb Milk Amniotic Fluid Colostrum Breastmilk

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Evolutionary Model of Human Milk

Other

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Improved long‐term health outcomes• American Academy of Pediatrics [AAP] (2012)

• 22 reviews of 14 different disease states

• Progressing from infancy → adulthood

• Lowered risk if exposed to human milk

• Not even an “exclusive diet” of human milk

LIFESPAN

22 reviews of 14 disease states

American Academy of Pediatrics. Breastfeeding and the use of human milk. Section on Breastfeeding. Pediatrics. 2012;129(3):e827‐e841. doi:10.1542/peds.2011‐3552

“Milk is Medicine”

Condition % Lower Risk

NEC 77

SIDS 36

RSV 74

Recurrent Otitis Media 77

URTI 63‐72

Asthma 26‐40

Atopic Dermatitis 27‐42

Gastroenteritis 64

Inflammatory Bowel 31

Obesity 24

Celiac Disease 52

Type 1 Diabetes 30‐40

Leukemia (ALL/AML) 15029

Mother’s Own Milk Donor Human Milk HM‐Based Fortifiers HM‐Split Products

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All Human Sourced Nutrition

“Mother’s own milk, fresh or frozen, should be the primary diet, and it should be fortified appropriately for the infant born weighing less than 1.5 kg.”

American Academy of Pediatrics. Breastfeeding and the use of human milk. Section on Breastfeeding. Pediatrics. 2012;129(3):e827‐e841. doi:10.1542/peds.2011‐3552

Exclusive Human Milk Diet

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AAP Policy: 2017 “Human Milk is a Biological Product”

• What is a biological product?• Biological products, are medical products

• Biologicals are made from a variety of natural sources (human cells, tissue, animal, microorganism)

• Like drugs, some biologicals are intended to treat diseases and medical conditions

• Biologicals are used to prevent diseases

U.S. Food and Drug Administration. FDA Basics; What is a biological product? U.S. Department of Health and Human Services. Accessed April 21, 2021. http://www.fda.gov/AboutFDA/Transparency/Basics/ucm194516.htm.

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Human Milk is a Biological

Human Milk

Pediatric Red Book 2018• “Breastfeeding provides numerous health benefits to infants, including protection against morbidity and mortality.”

22SOURCE: Committee on Infectious Diseases; American Academy of Pediatrics; David W. Kimberlin, MD, FAAP; Michael T. Brady, MD, FAAP; Mary Anne Jackson, MD, FAAP; Sarah S. Long, MD, FAAP

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“The Burdens of Prematurity”23

Torrazza RM, Neu J. The altered gut microbiome and necrotizing enterolcolitis. Clin Perinatol. 2013;40(1)93‐108. doi:10.1016/j.clp.2012.12.009

Dysbiosis – Inflammation – Burdens of Prematurity

• Fewer days on TPN• Fewer central line days

Decreased inflammation

Decreased morbidities:BPD | NEC | Late‐onset Sepsis | ROP

Inflammation

Human Milk Benefits for the “Evolutionarily New Population”

24SOURCE: John, A., Sun, R., Maillart, L., Schaefer, A., Hamilton Spence, E., & Perrin, M. T. (2019). Macronutrient variability in human milk from donors to a milk bank: Implications for feeding preterm infants. PloS one, 14(1), e0210610. https://doi.org/10.1371/journal.pone.0210610

The growth and neurodevelopmental

needs of the “evolutionarily new population of very premature infants’” are best met by the

appropriate fortification of human milk.”

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Course Overview





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Part II: Objectives

Describe the lung‐gut axis and its role in the development of BPD

Identify two ways that human milk nutrition is thought to reduce the risk of BPD

Discuss the impact of human milk on the incidence of late‐onset sepsis

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“Prehab”

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Bronchopulmonary Dysplasia

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Neonatal Gut‐Lung Axis

Nutrition and BPD• Fluid, energy intake

• Amino‐acids, lipids and vitamins

• Parenteral/enteral routes

SOURCE:Piersigilli F, Van Grambezen B, Hocq C, Danhaive O. Nutrients and Microbiota in Lung Diseases of Prematurity: The Placenta‐Gut‐Lung Triangle. Nutrients. 2020; 12(2):469. https://doi.org/10.3390/nu12020469

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“Cardiorespiratory function is not only the foremost determinant of

life after premature birth, but also a major factor of long‐term outcomes. However, the path from

placental disconnection tonutritional autonomy is enduring and challenging for the preterm infant and, at each step, will have profound influences on

respiratory physiology and disease”

“…have direct implications on lung tissue composition and cellular functions, thus affect lung

development and homeostasis and contributing to acute and chronic respiratory disorders.”


What and How?• Cross between 2 systems

• Premature birth causes interruption

• Lung development / maturation• Exposure to a highly oxidant

environment

• Disruption of the nascent microbiome

• Invasive procedures

• Exposure to hospital microbiota

• Broad‐spectrum antibiotics

• Inflammation modulation

Nutritional Interruption and BPD• Placental insufficiency

• Suboptimal oxygen/nutrient transfer

• Placenta directly influences lung development

• Intrauterine Growth Restriction• <30 weeks with abnormal fetal doppler and

growth 33% incidence BPD compared to 7%

• Overall IUGR 4‐fold ↑ in BPD

• Postnatal malnutrition + hyperoxia induces RV and PA remodeling

30SOURCE:Piersigilli F, Van Grambezen B, Hocq C, Danhaive O. Nutrients and Microbiota in Lung Diseases of Prematurity: The Placenta‐Gut‐Lung Triangle. Nutrients. 2020; 12(2):469. https://doi.org/10.3390/nu12020469

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Sherman MP, Zaghouani H, Niklas V. Gut microbiota, the immune system, and diet influence the neonatal gut‐brain axis. Pediatr Res. 2015;77(1‐2):127‐135. doi:10.1038/pr.2014.161

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Enteral Feeding and theNeonatal Gut‐Lung Axis

↑Ac va on of inflamma on↓ Lung barrier func on↑ Bacterial transloca on↑ Ac va on of HPA ↑ Physiologic stress → ↑ cor sol ↑ Triggering further pro/anti‐

inflammatory gut/lung activity ↑ Hypermetabolic state

Gut‐Lung Axis

SOURCE: Piersigilli F, Van Grambezen B, Hocq C, Danhaive O. (2020). Nutrients and Microbiota in Lung Diseases of Prematurity: The Placenta‐Gut‐Lung Triangle. Nutrients. 12(2):469. https://doi.org/10.3390/nu12020469

Dysbiosis: Inflammation and the Neonatal Gut‐Lung Axis

Neonatal Gut‐Lung Axis2

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Inflamed Neonatal Bowel1

Dysbiosis Related Inflammation

SOURCE: 2 Piersigilli F, Van Grambezen B, Hocq C, Danhaive O. Nutrients and Microbiota in Lung Diseases of Prematurity: The Placenta‐Gut‐Lung Triangle. Nutrients. 2020; 12(2):469. https://doi.org/10.3390/nu12020469

Global Immunologic

Organ

Dysbiosis Related Inflammation

SOURCE: 1. Groer MW, Miller EM, D’Agata A, et al. Contributors to dysbiosis in very‐low‐birth‐weight infants. J Obstet Gynecol Neonatal Nurs. 2020;49(3):232‐242. doi:10.1016/j.jogn.2020.02.003

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Neonatal Gut‐Lung Axis BPD main cause of CLD and respiratory morbidity/morbidity preterm infants

Central role played by inflammation

Antenatal exposures and postnatal• Respiratory + digestive mucosal surfaces

• Form a global immunological organ in which stimulation of one compartment can lead to changes in distal areas

Role of Human Milk• Antioxidant/anti‐inflammatory

• ↓ Inflamma on/oxida ve stress

“It is not surprising that a “simple” nutritional approach (to the prevention of BPD) such as exclusive human milk feeding has shown an efficacy comparable to single‐target drugs.”

33SOURCE:Piersigilli F, Van Grambezen B, Hocq C, Danhaive O. Nutrients and Microbiota in Lung Diseases of Prematurity: The Placenta‐Gut‐Lung Triangle. Nutrients. 2020; 12(2):469. https://doi.org/10.3390/nu12020469

Trends in Neurodevelopment Outcomes – Study Design

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SOURCE NEEDED

A retrospective multicenter cohort of 30,793 preterm infants

Born at a gestational age ≤ 32 weeks, between 2003 and 2012

Part of the Neonatal Research Network, Japan N=13,661 infants followed up with until age 3 Evaluated for neurodevelopmental outcomes,

including: Cerebral palsy (CP) Home oxygen therapy Visual, hearing, and cognitive impairments

Multivariable logistic regression analysis was performed

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Outcome Discussion

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Nutritional support remained correlated with long‐term neurodevelopmental outcomes

The AOR of time to establishment of enteral feeding (with 5‐day increments) for all disabilities suggested that the shorter the time to the establishment of full enteral feeding, the lower the prevalence of abnormal long‐term neurodevelopment outcomes

SOURCE NEEDED

• 9.0% less BPD1

• 16.5% less BPD2

• 8.6% less BPD3

• 15.0% less BPD4

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SOURCES: 1 Assad M, Elliott MJ, Abraham JH. Decreased cost and improved feeding tolerance in VLBW infants fed an exclusive human milk diet. J Perinatol. 2016;36(3):216‐220. doi:10.1038/jp.2015.168 2 Delaney Manthe E, Perks PH, Swanson JR. Team‐based implementation of an exclusive human milk diet. Adv Neonatal Care. 2019;19(6):460‐467. doi:10.1097/ANC.0000000000000676 3 Hair AB, Peluso AM, Hawthorne KM, et al. Beyond necrotizing enterocolitis prevention: improving outcomes with an exclusive human milk‐based diet [published correction appears in Breastfeed Med. 2017;12(10):663]. Breastfeed Med. 2016;11(2):70‐74. doi:10.1089/bfm.2015.0134 4 Huston R, Lee M, Rider E, et al. Early fortification of enteral feedings for infants <1250 grams birth weight receiving a human milk diet including human milk ‐based fortifier. J Neonatal Perinatal Med. 2020;13(2):215‐221. doi:10.3233/NPM‐190300

Reduction in BPD with an EHMD

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Late‐Onset Sepsis

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Dysbiosis – Inflammation – Burdens of Prematurity




Inflammation

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Neonatal Late‐Onset Sepsis

The “Burden of Sepsis”• Sepsis categorized into two types• Early‐onset sepsis occurs within 3 days after birth

• Late‐onset sepsis occurs between DOL 7 and 10 • Systemic spread of microbes from the intestines, skin of premature infants

• Role of indwelling catheters/tubes• Associations between dysbiosis and LOS• ↑ Risk use of broad‐spectrum antibiotics

• Lack of an accepted international consensus on the definition, diagnosis, and treatment of neonatal sepsis1

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The “Burden of Neonatal Sepsis”• Developed countries, 4/10 infants with sepsis die/experience major disability (ND)

• Preterm neonates ‐ highest incidence and mortality of sepsis among all age groups

• In the US, 36% of neonates born < 28 weeks have 1 or more BSI during their birth hospitalization with up to a 50% mortality

• Compared to term infants, sepsis in preterm infants is up to 1000‐fold more common

SOURCE: Kleist SA, Knoop KA. Understanding the Elements of Maternal Protection from Systemic Bacterial Infections during Early Life. Nutrients. 2020; 12(4):1045. https://doi.org/10.3390/nu12041045


Dysbiosis late‐onset sepsis axis

40SOURCE: Kleist SA, Knoop KA. Understanding the Elements of Maternal Protection from Systemic Bacterial Infections during Early Life. Nutrients. 2020; 12(4):1045. https://doi.org/10.3390/nu12041045

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The “Burden of Sepsis”

Pathophysiology of LOS• Responds to insult → inflamma on• Inflammation drives ↑ cytokine produc on• Causing cell/organ damage and death

• Pathophysiology with increased:• Vasodilatation• Cellular activation• Vascular permeability• Coagulation disturbances• Mitochondrial dysfunction

• Secondary collateral damage

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“Sepsis is mainly caused by host’s own uncontrolled

inflammation”

Add a footer

The “Burden of Sepsis”

Diagnosis and Treatment• Cultures, CBC , CRP, LP

• Emerging Biomarkers

• Antibiotics, follow cultures

• Non‐antimicrobial tx. strategies

• Oxygenation/ventilation

• Fluid resuscitation

• Multisystem support

• Restoring immune system balance

• Monitor for ND sequelae

LOS and Comorbidities

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SOURCE: Chen S., Shi Y. (2019) Progress of Research in Neonatal Sepsis. In: Fu X., Liu L. (eds) Severe Trauma and Sepsis. Springer, Singapore. https://doi.org/10.1007/978‐981‐13‐3353‐8_16

SOURCE: Zonnenberg, I. A., van Dijk‐Lokkart, E. M., van den Dungen, F., Vermeulen, R. J., & van Weissenbruch, M. M. (2019). Neurodevelopmental outcome at 2 years of age in preterm infants with late‐onset sepsis. European journal of pediatrics, 178(5), 673–680. https://doi.org/10.1007/s00431‐019‐03339‐2

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AAP Policy: 2017 “Human Milk is a Biological Product”

• What is a biological product?• Biological products, are medical products

• Biologicals are made from a variety of natural sources (human cells, tissue, animal, microorganism)

• Like drugs, some biologicals are intended to treat diseases and medical conditions

• Biologicals are used to prevent diseases

U.S. Food and Drug Administration. FDA Basics; What is a biological product? U.S. Department of Health and Human Services. Accessed April 21, 2021. http://www.fda.gov/AboutFDA/Transparency/Basics/ucm194516.htm.

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Human Milk is a Biological Product

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For every 10% increase in CMBD* 17.9% INCREASE in SEPSIS

SOURCE: Abrams SA, Schanler RJ, Lee ML, Rechtman DJ. Greater mortality and morbidity in extremely preterm infants fed a diet containing cow milk protein products. Breastfeed

Med. 2014;9(6):281‐285. doi:10.1089/bfm.2014.0024

EHMD and Remaining Sepsis Free

* CMBD (cow milk based diet)

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For every 10% increase in CMBD a 21% INCREASE in SURGICAL NEC

For every 10% increase in CMBD a 12% INCREASE in NEC

For every 10% increase in CMBD 17.9% INCREASE in SEPSIS


Med. 2014;9(6):281‐285. doi:10.1089/bfm.2014.0024

NEC SEPSISSURGICAL NEC

EHMD and “Dose Response”

For every 10% ↑ CMBD 17.9% ↑ late‐onset sepsis1

11.3% reduction in late‐onset sepsis2

10.5% reduction in late‐onset sepsis3

12.5% less late‐onset sepsis evaluations4

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1 Abrams SA, Schanler RJ, Lee ML, Rechtman DJ. Greater mortality and morbidity in extremely preterm infants fed a diet containing cow milk protein products. Breastfeed Med. 2014;9(6):281‐285. doi:10.1089/bfm.2014.0024 2 Hair AB, Peluso AM, Hawthorne KM, et al. Beyond necrotizing enterocolitis prevention: improving outcomes with an exclusive human milk‐based diet [published correction appears in Breastfeed Med. 2017;12(10):663]. Breastfeed Med. 2016;11(2):70‐74. doi:10.1089/bfm.2015.0134 3 O'Connor DL, Kiss A, Tomlinson C, Bando N, Bayliss A, Campbell DM, Daneman A, Francis J, Kotsopoulos K, Shah PS, Vaz S, Williams B, Unger S; OptiMoM Feeding Group. Nutrient enrichment of human milk with human and bovine milk‐based fortifiers for infants born weighing <1250 g: a randomized clinical trial. Am J Clin Nutr. 2018 Jul 1;108(1):108‐116. doi: 10.1093/ajcn/nqy067. Erratum in: Am J Clin Nutr. 2019 Aug 1;110(2):529. Erratum in: Am J Clin Nutr. 2020 May 1;111(5):1112. PMID: 29878061 4 Delaney Manthe E, Perks PH, Swanson JR. Team‐based implementation of an exclusive human milk diet. Adv Neonatal Care. 2019;19(6):460‐467. doi:10.1097/ANC.0000000000000676

Reduction in Late‐Onset Sepsis with an EHMD

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Human Milk Benefits for an “Evolutionarily New Population”





Course Overview





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Part III: ROP and NEC: “Burdens of Prematurity”

Objectives:

• Describe the concept of a “third wave” of retinopathy of prematurity

• Discuss the role of human milk on the development of the preterm infant microbiome

• List the benefits of human milk in reducing the incidence/severity of ROP

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“Prehab”

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What is “Prehab”?• A preventative mechanism to decrease the risk of injury and/or to optimize your functional ability and quality of life

• Also described as “prehabilitation or preventative rehab“ with the goal of reducing the risk for injury

• Prehab focuses on efforts to decrease the burden on individuals and the healthcare system

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“Prehab”

What is “Prehab”?• A preventative mechanism to decrease the risk of injury and/or to optimize your functional ability and quality of life

• Also described as “prehabilitation or preventative rehab“ with the goal of reducing the risk for injury

• Prehab focuses on efforts to decrease the burden on individuals and the healthcare system

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SOURCE: https://www.ivyrehab.com/news/what‐is‐prehab/#:~:text=Prehab%20is%20participation%20in%20therapy,balance%20and%20overall%20joint%20function. https://theprehabguys.com/what‐is‐prehab‐2/

Retinopathy of Prematurity

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“Eye development during the first trimester of pregnancy is like watching the grand finale of Fourth of July fireworks.”

Human embryo eye lid formation at 8 weeks gestation

“What’s Going On In There?”

Eye Development & Vision The eye is an extension of brain tissue

Embryologic development begins on day 17

Retinal layers grow from neural ectoderm

Macula needs 4 to 5 months just to begin development, and matures 6 months after birth

SOURCE: Eliot, L (1999() What’s Going on in There? How the Brain and Mind Develop in the first Five Years of Life. New York, NY; Bantam Books.Jnah AJ & Trembath AN (Eds). Fetal and Neonatal Physiology for the Advanced Practice Nurse (2019). Singer Publishing Company; New York, NY.

“The brain devotes more of its territory to vision than all the

other senses combined.”

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Risk Factors for ROP

Risk Factors for ROP

SOURCE: Jnah AJ & Trembath AN (Eds). Fetal and Neonatal Physiology for the Advanced Practice Nurse (2019). Singer Publishing Company; New York, NY.

Prematurity Supplemental use of oxygen Low birth weight Hyperglycemia and insulin use Apnea Sepsis Blood transfusions Antioxidant deficiency Bronchopulmonary Dysplasia Patent ductus arteriosus Inflammation

Sherman MP, Zaghouani H, Niklas V. Gut microbiota, the immune system, and diet influence the neonatal gut‐brain axis. Pediatr Res. 2015;77(1‐2):127‐135. doi:10.1038/pr.2014.161

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Dysbiosis and the Neonatal Gut‐Eye Axis

↑Firmicutes/Bacteroidetes (F/B) ra o ↑ Inflammation in neonatal gut ↑ Thinning of gut mucosal layer↑ Disrup on of gut‐vascular barrier↑ Loss of physiologic barrier func on↑ Bacterial/byproducts transloca on ↑ Ac va on of HPA ↑ Physiologic stress → ↑ cor sol ↑ Induce pathological inflamma on↑ Hypermetabolic state

Neonatal Gut Eye Axis

SOURCE: Floyd, J.L., Grant, M.B. The Gut–Eye Axis: Lessons Learned from Murine Models. Ophthalmol Ther 9, 499–513 (2020). https://doi.org/10.1007/s40123‐020‐00278‐2https://doi.org/10.3390/nu12020469

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ROP and Inflammation

Sources of Inflammation• Perinatal inflammation

• >80% on infants <30 weeks have positive in situ bacteria

• Chorioamnionitis most common factor associated with PTB

• Neonatal Immune Responses• Innate and Adaptive responsivity• ↑ Inflamma on, oxida ve stress

• Systemic Inflammatory Response• Sepsis and reperfusion injuries

• Neonatal Co‐morbidities• NEC, BPD, ROP

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SOURCE: Hellström, A., Smith, L., & Dammann, O. (1991). Retinopathy of prematurity. Lancet (London, England), 337(8733), 83–84.Vento M, Aguar M, & BrugadaM (2008) Extremely premature infant overcoming inflammation and oxidative stress. Pediatric Health 2(4) https://doi.org/10.2217/17455111.2.4.397

ROP: “The Third Epidemic or Wave”

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“The Third Epidemic of ROP”• ↑ numbers and with ↓ GA• 65% of infants with BW <1250 g• 80% of those with BW < 1000g• Will develop some degree of ROP

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ROP Treatment Options

Photocoagulation

Laser Therapy• First line of defense in ROP

• Much like a retinal exam

• Local or general anesthesia

• Diode laser ophthalmoscope

• Multiple, tiny” burns in/along the periphery of the retina

Cryoplexy

Cryotherapy• Formerly the procedure of choice

• Uses cold temperatures to freeze parts of the affected retina via the outer wall of the eye

• Largely replaced by laser therapy

• Still useful when the retina can't be fully seen (hemorrhage)

SOURCE: https://www.childrenshospital.org/conditions‐and‐treatments/conditions/r/retinopathy‐of‐prematurity‐rop/treatments

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BOTH PHOTOCOAGULATION AND CRYOPLEXY DESTROY PART OF THE RETINA’S PERIPHERY AND RESULT IN LOSS OF VISION

ROP: Treatment Options

Anti‐Vascular Endothelial Growth Factor

VEGF• Signal protein that induces growth of blood

vessels in the developing eye

Anti‐VEGF• Works by ↓ VEGF production• Injected directly into the eye• Avastinmost researched in NICU

• Benefits in most severe cases of ROP• Shorter duration of anesthesia, NPO

Anti‐Vascular Endothelial Growth Factor

Anti‐VEGF Costs• Cost of drug < OR, anesthesia, etc.• Not every NICU (stepdown) offers it• ? Transport – away from family• May require anesthesia• Use of intubation/ventilation• ? Risk for cardiac hypertrophy, pulmonary

hypertension → infants with BPD

SOURCE: NIH/National Eye Institute. "Very low‐dose Avastin effective for preventing blindness in preterm infants: Very low doses effective for treating retinopathy of prematurity." ScienceDaily. ScienceDaily, 23 April 2020. <www.sciencedaily.com/releases/2020/04/200423130503.htm>. Wallace, DK,R aymond T. Kraker RT, Sreedman SF, , et al. Short‐term Outcomes After Very Low‐Dose Intravitreous Bevacizumab for Retinopathy of Prematurity. JAMA Ophthalmology, 2020; DOI: 10.1001/jamaophthalmol.2020.0334

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RISK OF ALTERATION IN CELLULAR GROWTH IN OTHER ORGANS

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ROP and Nutrition

Beneficial Role of Nutrition• Strong association SGA and ↑ risk of ROP

• Role of IGF‐1 and VEGF • ↑ Re nal vasculature/brain growth

• ↓ Results in halt of angiogenesis

• ↑ IGF‐1 improves retina vessel survival

• Prompts the onset of ROP

• IGF‐1 associated with weight gain• Early aggressive parenteral nutrition

• Early enteral feedings

• ↑ Use of MOM and HM

• ? Role of early fortification strategies

SOURCE: Lenhartova N, Matasova K, Lasabova Z, Javorka K, Calkovska A. Impact of early aggressive nutrition on retinal development in premature infants. Physiol Res. 2017 Sep 22;66(Suppl 2):S215‐S226. doi: 10.33549/physiolres.933677. PMID: 28937236. Hellström A, Smith LEH, Dammann O. Retinopathy of prematurity. Lancet. 1991;337(8733):83‐84.

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“Evidence is accumulating that one of the strongest predictors of ROP, in addition to low gestational age, is poor weight gain

during the first weeks of life.”

ROP and Nutrition

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Mean Daily Weight Gain by Chronological Age of 7483 Infants in the Postnatal Growth and Retinopathy of Prematurity Study

Is this baby having…Feeding Intolerance?

Slow to advance feedings?Slow to fortify feedings?

Not maximizing fortification?Start/stop feedings?

SOURCE: Binenbaum G, Bell EF, Donohue P, Quinn G, Shaffer J, Tomlinson LA, Ying GS; G‐ROP Study Group. Development of Modified Screening Criteria for Retinopathy of Prematurity: Primary Results From the Postnatal Growth and Retinopathy of Prematurity Study. JAMA Ophthalmol. 2018 Sep 1;136(9):1034‐1040. doi: 10.1001/jamaophthalmol.2018.2753. PMID: 30003216; PMCID: PMC6142979.

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Prevention and Reduction of ROP

Bio‐factors in Human Milk• Carotenoids, retinol

• α and γ tocopherol

• Superoxide dismutase

• Glutathione peroxidase

• Catalase

• Antioxidants

• Growth factors (VEGF and IGF‐1)

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SOURCE : Raghuveer TS & Zackula R (2020). Strategies to Prevent Severe Retinopathy of Prematurity: A 2020 Update and Meta‐analysis. NeoReviews2020;21;e249 DOI:10.1542/neo.21‐4‐e249.

SOURCE: Fang JL, Sorita A, Carey WA, Colby CE, Murad MH, and Alahdab F (2016). Interventions to prevent Retinopathy of Prematurity: A Meta‐Analysis originally published online March 9, 2016; Pediatrics http://pediatrics.aappublications.org/content/early/2016/03/07/peds.2015‐3387

2016 Summary of the Evidence• Meta‐analysis of 2 cohort studies on the

effect of breast milk versus formula feeds found a 60% reduction in the risk of severe ROP in human milk fed

• Some variability between studies in reporting enteral feed type, volume, exclusivity, duration

Prevention and Reduction of ROP

64SOURCE : Raghuveer TS& Zackula R (2020). Strategies to Prevent Severe Retinopathy of Prematurity: A 2020 Update and Meta‐analysis. NeoReviews 2020;21;e249 DOI:10.1542/neo.21‐4‐e249

“There is evidence that human milk, vitamin A, omega‐3 fatty

acids, and vitamin E can decrease the risk of ROP and are

recommended in addition to adequate oxygen saturation

monitoring.”

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Prevention of ROP:

Interventions to Reduce ROP

65SOURCE : Raghuveer TS & Zackula R (2020). Strategies to Prevent Severe Retinopathy of Prematurity: A 2020 Update and Meta‐analysis. NeoReviews 2020;21;e249 DOI:10.1542/neo.21‐4‐e249.

Role of Diet in ROP

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Diet includes use of Cow Milk‐Based Products Diet composed of exclusive Human Milk‐Based Products

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Reduction in ROP with EHMD• 3.8% less ROP (Hair AB et al 2016)

• Up to 26% less ROP (Assad M et al 2016)

• 8.6% less ROP (O’Connor et al et al 2018)

• 13.5% less ROP (Delaney Manthe E et al 2019)

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1 Hair AB, Peluso AM, Hawthorne KM, et al. Beyond necrotizing enterocolitis prevention: improving outcomes with an exclusive human milk‐based diet [published correction appears in Breastfeed Med. 2017;12(10):663]. Breastfeed Med. 2016;11(2):70‐74. doi:10.1089/bfm.2015.0134 2. Assad M, Elliott MJ, Abraham JH. Decreased cost and improved feeding tolerance in VLBW infants fed an exclusive human milk diet. J Perinatol. 2016;36(3):216‐220. doi:10.1038/jp.2015.168 3. O'Connor DL, Kiss A, Tomlinson C, et al. Nutrient enrichment of human milk with human and bovine milk‐based fortifiers for infants born weighing <1250 g: a randomized clinical trial [published corrections appear in Am J Clin Nutr. 2019;110(2):529 and Am J Clin Nutr. 2020;111(5):1112]. Am J Clin Nutr. 2018;108(1):108‐116. doi:10.1093/ajcn/nqy067 4. Delaney Manthe E, Perks PH, Swanson JR. Team‐based implementation of an exclusive human milk diet. Adv Neonatal Care. 2019;19(6):460‐467. doi:10.1097/ANC.0000000000000676 3 4

Human Milk and Co‐Neonatal Morbidities

Necrotizing Enterocolitis

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Dysbiosis – Inflammation –Burdens of Prematurity




Inflammation

Exclusive Human Milk Diet and Reduction in NEC

Overview of NEC

• “Pathophysiology complex and multifactorial” 1

• “Affects ~5‐7% of LBW infants with a mortality rate of 20%‐30%” 2

• “No current method of with sufficient sensitivity and specificity for early diagnosis” 3

• “One of leading causes of neonatal mortality and longterm morbidity” 4

• “Major player in economics of hospital care” 5

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SOURCE: 1,2, 4,5 Kim S & Claud EC (2019). Necrotizing enterocolitis pathophysiology: how microbiome data alter our understanding. Clin Perinatol 46;:9‐38. doi.org/10.1016/j.clp.2018.10.0033 , 3 Goldstein GP & Sylvester KG(2019). Biomarker discovery and utility in Necrotizing enterocolitis. Clin Perinatol 46:1‐17. doi.org/10.1016/j.clp.2018.10.001

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Torrazza RM, Neu J. The altered gut microbiome and necrotizing enterolcolitis. Clin Perinatol. 2013;40(1)93‐108. doi:10.1016/j.clp.2012.12.009 Underwood MA, Umberger E, Patel R. Safety and efficacy of probiotic administration to preterm infants: ten common questions. Pediatr Res. 2020;88(Suppl 1):48‐55. doi:10.1038/s41390‐020‐1080‐6

Altered Microbiota Dysbiosis

Inflammation Dysregulation

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DYSBIOSISTerm/Well

Preterm/Sick?

Preterm Birth, the Microbiome, and the Origin of Dysbiosis

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Is feeding Intolerance the mildest case of NEC?

Is NEC the worse case of feeding intolerance?

Incidence Estimate: NEC~5% of VLBW infants

Incidence Estimate: FIAs high as 36%

Horbar JD, Edwards EM, Green berg LT, et al. Variation in performance of neonatal intensive care units in the United States [published correction appears in JAMA Pediatr. 2017;171(3):306]. JAMA Pediatr. 2017;171(3):e164396 doi:10.1001/jamapediatrics.2016.4396.

Ahammad F, Begum T, Akter J, Nasrin E. Comparison of feeding intolerance between very preterm and moderate preterm neonates – a prospective cohort study. J Pediatr Neonatal Care. 2018;8(4):200‐203. doi:10.15406/jpnc.2018.08.00339

DYSBIOSIS

INFLAMMATION

The Potential Continuum of Dysbiosis

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Dysbiosis: Inflammation and the Neonatal Gut

Non‐inflamed neonatal bowel

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Inflamed neonatal bowel

Protective Role of Human MilkDysbiosis Related Inflammation

SOURCE: Groer MW, Miller EM, D’Agata A, et al. Contributors to dysbiosis in very‐low‐birth‐weight infants. J Obstet Gynecol Neonatal Nurs. 2020;49(3):232‐242. doi:10.1016/j.jogn.2020.02.003

“Dose response” of an EHMD (

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For every 10% increase in CMBD a 21% INCREASE in SURGICAL NEC

For every 10% increase in CMBD a 12% INCREASE in NEC

For every 10% increase in CMBD 17.9% INCREASE in SEPSIS


Med. 2014;9(6):281‐285. doi:10.1089/bfm.2014.0024

NEC SEPSISSURGICAL NEC

EHMD and “Dose Response”

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Feeing Protocols

SOURCES: B Jasani B & Patole S (2017) Journal of Perinatology; 00, 1. Kamitsuka MD, Horton MK, Williams MA. The incidence of necrotizing enterocolitis after introducing standardized feeding schedules for infants between 1250 and 2500 grams and less than 35 weeks of gestation. Pediatrics. 2000;105(2):379‐384. doi:10.1542/peds.105.2.379

The risk of NEC was reduced 84% after the introduction of

feeding protocols

The incidence of NEC was

reduced by 77% with the use of an Exclusive HumanMilk Diet

FEEDING PROTOCOL EXCLUSIVE HUMAN

MILK DIET

EHMD and Feeding Protocol

Exclusive Human Milk Diet and Reduction in NEC

Reduction in NEC with an EHMD• Sullivan1 et al (2010)

• Abrams2 et al (2014)

• Hair AB3 et al (2016)

• Assad M4 et al (2016)

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SOURCE: 1. Sullivan S, Schanler RJ, Kim JH, et al . J Pediatr. 2010 Apr;156(4):562‐7.e1. doi: 10.1016/j.jpeds.2009.10.040. Epub 2009 Dec 29. PMID: 20036378. 2. Abrams SA, Schanler RJ, Lee ML, Rechtman DJ. Breastfeed Med. 2014;9(6):281‐285. doi:10.1089/bfm.2014.0024 3. Hair AB, Peluso AM, Hawthorne KM, et al. Breastfeed Med. 2017;12(10):663]. Breastfeed Med. 2016;11(2):70‐74. doi:10.1089/bfm.2015.0134 4 . Assad M, Elliott MJ, Abraham JH. J Perinatol. 2016;36(3):216‐220. doi:10.1038/jp.2015.168 3

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Human Milk Benefits for an “Evolutionarily New Population”





Course Overview





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Part IV: Objectives

Define the terms legitimate and illegitimate stressors

Identify two practices to integrate into your workday that lower your stress

Discuss the concept of “Body Burden” on caregivers

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“Prehab”

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“Rehab”

What is “Rehab”?• The action of restoring someone to healthor normal life

• Restoration especially by therapeutic meansto and improved condition of function

• Care that can help you get back, keep, orimprove abilities that you need for daily life• These abilities may be physical, mental,and/or cognitive (or emotional and spiritual)

81SOURCE: Medline Plus. Definition of Rehabilitation. Accessed April 23, 2021. https://medlineplus.gov/rehabilitation.htmlMerriam Webster. Definition of Rehabilitation. Accessed April 23, 2021. https://www.merriam‐webster.com/dictionary/rehabilitationOxford English Dictionary. Accessed April 23, 2021. https://languages.oup.com/google‐dictionary‐en/

Support in the Workplace

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The past year has been anything but ordinary—the COVID‐19 pandemic,

civil unrest, natural disasters, and more have tested our resilience.

SOURCE: Mental Health First Aid. Accessed April 23, 2021. https://www.mentalhealthfirstaid.org/

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“The coronavirus has brought

unexpected and extremely heavy

emotional stress to the nursing practice that even veteran nurses have never experienced.”

SOURCE: Arnetz JE, Goetz CM, Arnetz BB, Arble E. Nurse reports of stressful situations during the COVID‐19 pandemic: qualitative analysis of survey responses. Int J Environ Res Public Health. 2020;17(21):8126. doi:10.3390/ijerph17218126


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The “Parallel Pandemic”

Psychological trauma among HCPs

“Trauma and Exhaustion”

HCPs accounted for 10% to 20% of all COVID‐19 cases early in pandemic

Long‐standing stigma about seeking mental healthcare for HCPs

https://www.nytimes.com/2021/02/04/health/health‐care‐workers‐burned‐out‐quitting.html

SOURCE: Dzau VJ, Kirch D, Nasca T. Preventing a parallel pandemic ‐ a national strategy to protect clinicians' well‐being. N Engl J Med. 2020;383(6):513‐515. doi:10.1056/NEJMp2011027 Relias Media. The ‘Parallel Pandemic’: Clinicians May Face Post‐Traumatic Stress. Accessed April 23, 2021. https://www.reliasmedia.com/articles/146385‐the‐parallel‐pandemic‐clinicians‐may‐face‐post‐traumatic‐stress

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Preventing a Parallel Pandemic—A National Strategy to Protect Clinicians’ Well‐Being

Organizational level• Integrate the work of chief wellness officers or clinician well‐being programs into COVID‐19 “command centers” or other organizational decision‐making bodies for the duration of the crisis

• Ensure the psychological safety of clinicians through anonymous reporting mechanisms that allow them to advocate for themselves and their patients without fear of reprisal

• Sustain and supplement existing well‐being programs

85SOURCE: Dzau VJ, Kirch D, Nasca T. Preventing a parallel pandemic ‐ a national strategy to protect clinicians' well‐being. N Engl J Med. 2020;383(6):513‐515. doi:10.1056/NEJMp2011027

Preventing a Parallel Pandemic—A National Strategy to Protect Clinicians’ Well‐Being

National level• Allocate federal funding to care for clinicians who experience physicaland mental health effects of COVID‐19 service

• Allocate federal funding to set up a national epidemiologic tracking program to measure clinician well‐being and report on the outcomes of interventions

86SOURCE: Dzau VJ, Kirch D, Nasca T. Preventing a parallel pandemic ‐ a national strategy to protect clinicians' well‐being. N Engl J Med. 2020;383(6):513‐515. doi:10.1056/NEJMp2011027

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Leadership Challenges in 2020Support in the Workplace

Stressful Situations During COVID‐19• Explore perceptions of sources of stress

• Cross‐sectional online survey

• Sample of 695 US nurses in May 2020

• Emerging themes• Exposure/infection—self

• Illness/death—others

• Workplace

• Personal protective equipment/supplies

• Unknowns

• Opinions/politics

SOURCE: Arnetz JE, Goetz CM, Arnetz BB, Arble E. Nurse reports of stressful situations during the COVID‐19 pandemic: qualitative analysis of survey responses. Int J Environ Res Public Health. 2020;17(21):8126. doi:10.3390/ijerph17218126

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Leadership Challenges in 2020Support in the Workplace

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Prioritize psychological safety• Psychologically safe environment

• Empowered to speak up

• Safe discussing

• Supported by their manager/team

• Zero tolerance for bullying

• Model support and connection

• No fear of blame or retaliation

Actions• Implement a psychologically safe

work environment

• Implement a zero‐tolerance policy related to disruptive behavior

• Implement a professional code of conduct

• Educational and behavioral interventions to support staff/leaders

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SOURCE: Relias Media. Seven ways to support nurses during COVID‐19 and beyond. Accessed April 23, 2021. https://www.relias.com/blog/seven‐ways‐support‐nurses‐covid‐19‐and‐

beyond


Understand impacts of moral injury

• HCPs facing morally challenging issues

• Burdens on front‐line clinicians

• Risk of mental health challenges

• Long lasting effect on sense of self

• Extremely complex phenomena

Actions• Introduce or review the concept

of moral injury with the team

• Could start as part of a huddlebut may warrant a larger forumfor discussion

• Employee assistance program

• Ethics committee services

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SOURCE: Relias Media. Seven ways to support nurses during COVID‐19 and beyond. Accessed April 23, 2021. https://www.relias.com/blog/seven‐ways‐support‐nurses‐covid‐19‐and‐

beyond

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Reduce the mental health stigma• HCPs↑ for mental health symptoms

• HCPs less likely to seek treatment

• HCPs and “mental health stigma”

• PTSD expectation after COVID‐19

• “Parallel pandemic”

Actions• Engage conversation around “stigma”

• “Stigma free”

• Pledge to Be StigmaFree | NAMI: National Alliance on Mental Illness

91SOURCE: Relias Media. Seven ways to support nurses during COVID‐19 and beyond. Accessed April 23, 2021.

https://www.relias.com/blog/seven‐ways‐support‐nurses‐covid‐19‐and‐beyond


Promote Self‐Care• COVID‐19 has added a complicated layer of stress/anxiety

• ↑ risk for depression, anxiety, PTSD

• ↑ risk for violence in workplace• Patients, families, domestic

• Inform what resources are available

• Ease of access, anonymity

Resources on tips for self‐care • Crisis hotlines (national/organizational)

• Provide support 24/7

Actions• Zero‐tolerance policy

• Open lines of communication

• Raise awareness

• Streamline reporting processes

• “Mental Health First Aid”• https://www.mentalhealthfirstaid.org/

• Encourage the practice self‐care techniques

92SOURCE: Relias Media. Seven ways to support nurses during COVID‐19 and beyond. Accessed April 23, 2021.

https://www.relias.com/blog/seven‐ways‐support‐nurses‐covid‐19‐and‐beyond

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Legitimate and Illegitimate Stressors

Illegitimate Stressors

Legitimate Stressors

Stressors In Caring Professions

BSOURCE: enner P, Wrubel J. The primacy of caring: stress and coping in health and illness. California: Addison‐Wesley Publishing Company;1989.

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Legitimate stressors• Result from the pain and suffering

• Dealing with human tragedy

• Infinite need

• Ignorance, violence, poverty

• Death and dying

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SOURCE: Benner P, Wrubel J. The primacy of caring: stress and coping in health and illness. California: Addison‐Wesley Publishing Company;1989.

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Illegitimate Stressors• Result from circumstances that prevent adequate caring• Limited resources

• Staffing shortages

• Fear and risk

• Work overload

• Inadequate reimbursement

And this year it has been an unimaginable amount of both

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SOURCE: Benner P, Wrubel J. The primacy of caring: stress and coping in health and illness. California: Addison‐Wesley Publishing Company;1989.

Themes for HCPs• Compassion fatigue syndrome

Perinatal Substance Abuse

Exhausted, depleted, numb

“Delivering self as product

Vertically ill Horizontally ill

Compassion Fatigue and Resiliency

Themes for HCPs• Resiliency Programs

• Mindfulness‐based stress reduction (MBSR)

• Roots are in spiritual teachings,the program itself is secular

• Kabat‐Zinn founded (MBSR) Clinic atthe UMASS Medical Center

• Promote focusing on the presentmoment without judgment

SOURCE: Sweigart E. Compassion fatigue, burnout, and neonatal abstinence syndrome. Neonatal Netw. 2017;36(1):7‐11. doi: 10.1891/0730‐0832.36.1.7

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Strategies for HCPs• Resiliency programs

• Time devoted to “recharging”

• Regular exercise

• Healthy eating habits

• Check in with your body

• Strategies include: • Self‐regulation

• Intentionality

• Self‐validation

• Social connection

• Self‐care

• Resiliency programs (cont)• Body burden

• Eat, sleep, console

• It can work for all of US, too

• Especially now

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Themes for HCPs• Resiliency programs

• MBSR

• Roots are in spiritual teachings,the program itself is secular

• Kabat‐Zinn founded (MBSR)Clinic at the UMASS Medical Center

• Promote focusing on the presentmoment without judgment



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Themes for HCPs• Resiliency strategies

• Check in with your body

• Time devoted to “recharging”

• Regular exercise

• Healthy eating habits

• Strategies include:

• Self‐regulation

• Intentionality

• Self‐validation

• Social connection

• Self‐care

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Leadership Challenges in 2020

“We are not all in the same boat. We are all in the same storm.”

—Damian BarrApril 21, 2020

“Let everyone navigate their route with respect, empathy, and responsibility.”

Resiliency in the Storm

SOURCE: Barbara Kelley https://www.directoryofillustration.com/artist.aspx?AID=6123

SOURCE: Wall Street Journal. What comes after the Coronavirus storm? Accessed April 23, 2021. https://www.wsj.com/articles/what‐comes‐after‐the‐coronavirus‐storm‐

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Speaker Contact Information:Terry S Johnson, APN, NNP‐BC, ASPPS, CLEC, MNDirector, Education and Professional DevelopmentProlacta BioscienceEmail: [email protected]: 630.881.2606

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