POSITION: The Council of International Neonatal Nurses, Inc. (COINN) believes that every baby worldwide should have an optimal start in life and that parents are an integral part of this. It is undisputed that involvement of parents is of paramount importance and integrating infant and family-centered developmental care (IFCDC) as a core standard for neonatal care is essential– in particular for the most vulnerable infants such as preterm, sick, and low birthweight babies (European Foundation for the Care of Newborn Infants (EFCNI), 2021; Global Alliance for Newborn Health (GLANCE), 2021). The COVID-19 pandemic led to the implementation of a set of measures which included a restriction of parental presence, frequently leading to separation of parents and their babies. These measures in many areas have continued even though the pandemic is waning. Given the pandemic related challenges in neonatal care, we advocate for healthcare workers to listen to the parents’ experiences and to acknowledge their crucial role in the care of hospitalized babies worldwide. In addition, following the invitation by EFCNI and GLANCE to support their ‘zero-separation’ policy, we strongly support this essential initiative and to keep parents and their babies together.

Council of International Neonatal Nurses, Inc. (COINN) Position Statement on Pre-Service Orientation of Registered Nurses and Midwives to Neonatal Units The Council of International Neonatal Nurses, Inc. (COINN) recommends that nurse/midwife orientation includes a standardized orientation process which can be tailored to meet the individual nurse/midwife’s needs. The standardized orientation includes: didactic learning, neonatal skills, case discussions and scenarios, simulation with debriefing. These are considered to be essential to meet the neonatal nurse /midwifery competency standards, required to care for small and sick newborns. The orientation period should be individualized dependent on the knowledge and experience of the orientee but requires a minimum of a standardized 12-week orientation process. Ideally a dedicated experienced neonatal nurse should be assigned as a preceptor to each orientee. Adopted February 16, 2022

DEFINITION OF A NEONATAL NURSE A Neonatal Nurse is a nurse who specializes in the care of preterm and/or sick newborn infants and their families across the care continuum-hospital or community/follow up settings-during at least the neonatal period (first 28 days of life) to promote the best possible health outcomes. The Neonatal Nurse provides education regarding neonatal health issues; works in interprofessional teams to enhance communication and collaboration; provides and advocates for culturally sensitive, family centered, patient focused , developmentally supportive care; uses and contributes to evidence-based practice, changes care based on best practices, and conducts research to advance neonatal nursing science. Key roles for neonatal nurses include providing direct care to newborns and families, education, advocacy, research, participation in shaping neonatal health policy, and inpatient and health systems management. Approved by COINN (Council of International Neonatal Nurses, Inc) BOD April 29, 2014

Council of International Neonatal Nurses, Inc Position Statement on Violence Against Women, Children, and Families COINN (Council of International Neonatal Nurses, Inc) supports the recent commitment by world leaders to 17 global Sustainable Development Goals (SDGs) to achieve an end to extreme poverty, fight inequality and injustice and combat climate change in the next 15 years. Part of this work includes ending violence against women and girls, reducing all forms of violence everywhere and ending all forms of violence against children(1). COINN (Council of International Neonatal Nurses, Inc) champions the Global Strategy for Women’s, Children’s and Adolescents’ Health, 2016-2030 that “strives for a world in which every mother can enjoy a wanted and healthy pregnancy and childbirth, every child can survive beyond their fifth birthday, and every woman, child and adolescent can thrive to realize their full potential, resulting in enormous social, demographic and economic benefits”(2). Background Violence against women and children is partner or non-partner abuse, intimate partner violence, child abuse and neglect, elder abuse and neglect, dating violence, sexual violence, or violence in other family relationships(3). Violence can be instigated psychologically, physically, sexually, through neglect or financial and spiritual constraints. A global report released by the World Health Organization (WHO) in partnership with the London School of Hygiene & Tropical Medicine and the South African Medical Research Council provided figures on the first global systematic review of scientific data on the prevalence of two forms of violence against women: violence by an intimate partner (intimate partner violence) and sexual violence by someone other than a partner (non-partner sexual violence)(4). This review was based on data from 80 countries and main findings include: 35% of women worldwide have experienced either intimate partner violence or non-partner sexual violence in their lifetime. This is more than 1 in 3 women worldwide 42% of women experience injuries either physically or sexually by a partner 38% of all murders of women globally were committed by an intimate partner Women who have experienced violence are: 2 x more likely to experience depression 2 x more likely to have alcohol use disorders 1.5 x more likely to acquire HIV and sexually transmitted disease 16% more likely to have a premature or low-birthweight baby The risk factors for either becoming a victim or a perpetrator appear similar: low education, witnessing violence in the family, exposure to childhood abuse and attitudes accepting of violence and gender inequality(5). International studies reveal that a quarter of all adults report having been physically abused as children, with 1 in 5 women and 1 in 13 men reporting having been sexually abused as a child. Also many children were subjected to emotional abuse and neglect(5). The impact on a child where there is violence in the family leads to emotional and behavioural disturbances in later life and can continue the cycle of abuse, with them either continuing as a victim or becoming a perpetrator(5, 6). When stressors such as poverty and abuse are experienced, the impact on a family are felt by everyone, even an unborn child(7). It increases the risk for restricted foetal growth, premature birth and neonatal and infant death. During pregnancy, the foetus is exposed to signals from the mother’s emotions and early programming of the foetal brain can be negatively influenced with the potential for permanent changes to the stress regulation system(8). After birth, these changes are associated with greater reactivity to stress and long-term problems with emotional and cognitive functioning(6). Along with the risks from domestic violence and premature birth, the connections for parent infant attachment can also be affected(8, 9). Research from multiple disciplines indicates the importance of a positive start during pregnancy and the early years in order for children to have healthy outcomes across the life span(10, 11). Central to this positive start is the need for all infants and children to have the opportunity to develop a secure attachment with their parents as a foundation for their future development(7, 9). Key principles: COINN (Council of International Neonatal Nurses, Inc) supports and advocates for the following key principles: Nobody has the right to physically hurt another person and this includes children(3); Nobody has the right to have sexual contact with another person without that person’s permission(3); Nobody has the right to use intimidation or threats to control another person(3); Everybody has the right to live in a healthy family relationship based around trust and respect. A place they can feel safe and valued, no matter which country they come from(12); Women and Children Violence is unacceptable and impacts our most vulnerable. There is a need to make changes, to stand up and be counted and not accept family violence as something that is behind closed doors(3); It is up to every individual, community, society and country to engage others to speak up and support programmes that will allow women to say no more and teach parents about healthy relationships(9, 13). Summary statement: The above principles are the foundation for a life free of violence. Addressing the issue of women and children violence is an urgent priority. Nurses and National Nurses Associations have a responsibility to provide information and lobby for the elimination of family violence. COINN (Council of International Neonatal Nurses, Inc) is the international organization that represents the global community of neonatal nurses and their organizational partners. COINN (Council of International Neonatal Nurses, Inc) advances neonatal nursing care and the profession of neonatal nursing by speaking with one strong voice. Working together, we are able to contribute to the formulation of health policy, promote quality neonatal care and advance neonatal nursing knowledge while fostering high practice standards for neonatal nursing as a profession. This Position Statement represents the views of the Council of International Neonatal Nurses. This Statement was approved by the COINN (Council of International Neonatal Nurses, Inc) Board of Directors on March 16, 2016. This statement was coordinated by Ms Jacquie Koberstein. References: United Nations. Transforming out world: The 2030 Agenda for Sustainable Development. A/RES/70/1 https://sdgs.un.org/2030agenda [Accessed February 27, 2021]. Every Women Every Child (2015). Global Strategy for Women’s, Children’s and Adolescents’ Health, 2016-2030. Survive, Thrive, Transform http://www.everywomaneverychild.org/commitments/make-a-commitment. [Accessed October 23, 2015]. Ministry of Social Development (2015). Family Violence is not OK. http://www.areyouok.org.nz/ [Accessed October 23, 2015]. World Health Organization (2013). Global and regional estimates of violence against women. Prevalence and health effects of intimate partner violence and non-partner sexual violence http://www.who.int/reproductivehealth/publications/violence/9789241564625/en/ [Accessed October 23, 2015]. World Health Organization (2014). Child maltreatment fact sheet 150 http://www.who.int/mediacentre/factsheets/fs150/en/ [Accessed October 23, 2015]. The Body Shop International and UNICEF (2006). Behind Closed Doors:The Impact of Domestic Violence on Children http://www.unicef.org/media/files/BehindClosedDoors.pdf [Accessed October 23, 2015]. Nobilo H (2014). The experience of poverty for infants and young children. https://brainwave.org.nz/article/the-experience-of-poverty-for-infants-and-young-children/ [Accessed February 27, 2021]. Altarac M, Strobino D. Abuse during pregnancy and stress because of abuse during pregnancy and birthweight. Journal of the American Medical Women’s Association. 2002;57(4):208-14. Benoit D. Infant-parent attachment: Definition, types, antecedents, measurement and outcome. Paediatrics & Child Health. 2004;9(8): 541–45. Larson CP. Poverty during pregnancy: Its effects on child health outcomes. Paediatrics & Child Health. 2007;12(8):673–77. Perry B. Childhood Experience and the Expression of Genetic Potential: What Childhood Neglect Tells Us About Nature and Nurture. Brain and Mind. 2002;3:79-100. Revilla L (2014). Characteristics of family relationships. / www.livestrong.com/article/55800-characteristics-family-relationship/ [Accessed October 23, 2015]. World Health Organization (2014). Global status report on violence prevention 2014. http://www.who.int/violence_injury_prevention/violence/status_report/2014/en/. [Accessed october 23, 2015].

COUNCIL OF INTERNATIONAL NEONATAL NURSES, Inc. (COINN)Position Statement COINN (Council of International Neonatal Nurses, Inc) Position The Council of International Neonatal Nurses, Inc. (COINN) is the international voice of neonatal nurses who provide care during this vulnerable period. In order to address identified gaps in current practice COINN (Council of International Neonatal Nurses, Inc) supports and recommends the following basic care for well term babies: 1. The presence, at every delivery, of a nurse/doctor trained in neonatal resuscitation (skilled neonatal attendant) dedicated solely to care for the baby. 2. Initial evaluation and recording of the newborn’s condition including gestational age, physical exam and vital signs by a trained professional after delivery. Identify risk factors at this time. These factors may include but are not limited to: late preterm birth, Small for Gestational Age (SGA), Infant of a Diabetic Mother (IDM), maternal smoking, substance exposure, prenatal laboratory values for Syphilis, Hepatitis B, Human Immunodeficiency Virus- HIV, Rubella status, and Herpes Simplex Virus (HSV), and genetic anomalies. If late preterm, then the COINN (Council of International Neonatal Nurses, Inc) guideline for the late preterm infant should be followed. 3. Monitor vital signs, skin color, respiratory pattern, tone, peripheral circulation, level of consciousness and activity every 30 minutes until over all status is stable for 2 hours. 4. During this time and throughout the hospital stay, ongoing contact with the mother is encouraged for breastfeeding initiation and bonding. 5. Maintain the thermal environment to prevent hypothermia. Actions to be taken are: immediate drying after birth, provision of warmth, positioning and clothing, and skin-to skin care. 6. Continue observation for potential complications by assessing for the following, temperature instability, change in activity or poor feeding, poor skin color, abnormal cardiac or respiratory rate and rhythm, abdominal distension or bilious vomiting, excessive lethargy and sleeping, or delayed stooling or voiding. The importance of the assessment should be communicated to the parents so they are able to notify the trained staff immediately while rooming in. Trained staff should observe the infant periodically to assess and to reinforce education for the parents. The medical team should evaluate infant with abnormal findings for specialized care may be necessary to properly care for the infant. 7. Admission of each infant as an individual patient including the establishment of an individual record to document infant’s condition and progress. 8. The individual infant’s record should include the evidence that high risk factors have been assessed (maternal fever, infection, late preterm, Low Birthweight (LBW), Small for Gestational Age (SGA), maternal prenatal laboratory values for Syphilis, Hepatitis B, Human Immunodeficiency Virus-HIV, Group B Streptococcus (GBS), Rubella immune status, low Apgar score at 5 minutes, in utero substance exposure). High risk factors must be communicated to the appropriate medical personnel. For late preterm infants (older than 34 weeks, born before reaching 37 weeks), refer to COINN (Council of International Neonatal Nurses, Inc) late preterm position statement and guideline. 9. Collaborate with social service as indicated by the presence of high-risk social issues. 10. Initial feeding should be offered as soon as possible after delivery. If delayed feeding occurs or poor feeding is an issue, or the infant is Small for Gestational Age, Low Birth Weight, follow the protocol to evaluate the glucose. 11. Give Vitamin K to prevent Vitamin K dependent Haemorrhagic disease and eye prophylaxis against gonococcal ophthalmia within 1 hour after birth. 12. Careful timing for the bath often delaying up to 6 hours and once the infant is stable to prevent hypothermia. Low Birth Weight and Small for Gestational Age infants require vigilance with this intervention. Localized skin care or techniques that expose the skin minimally may prevent the excessive heat loss thus prevents hypothermia. Bathing should primarily be done to educate the mother on bathing her baby and to cleanse any remaining blood/meconium not removed at delivery. The skin barrier function for the first four weeks of life is somewhat unstable and offers protective immunity when not disrupted (Telofski, Morello, Mack Correa, & Stamatos (2012), The Royal Children Hospital’s Melbourne (2017). 13. Infant should be weighed daily on a same scale. 14. The infant must be immunized according to country requirements. 15. Perform hearing screen. If the infant does not pass, make or asked the doctor for a referral for further examination. 16. Perform metabolic and genetic screen 24 hours after feeding initiated, if done before, another follow up must be arranged. 17. Identify a health care professional who will provide an on-going care of the infant with whom immediate follow up care can be arranged. Discharge summary or a form of written report is sent to the follow up health care professional with specific hospital course and follow up needs. 18. The baby should be carefully assessed with #6 in mind before discharge. Discharge in less than 48 hours can be considered if the criteria are met for both infant and the mother/care taker (AAP and ACOG, 2017): Infant’s nursery course was uncomplicated after vaginal delivery. Gestational Age (GA) is 38-42 weeks. Infants should be in stable condition for at least 12 hours prior to discharge. (Respiratory Rate-RR less than 60 per minute, Heart Rate-HR 100-160 per minute, Temperature-T 36.5- 37.5 degrees C or 97.7-99.5 degrees F in an open crib with appropriate clothing. Has urinated and passed one stool. Free from abnormal physical assessment findings, (or follow up plan made for non-emergent abnormal findings). At least 2 successful feedings evidenced by coordinated suck, swallow and breathing. No evidence of significant jaundice at less than 24 hours of age (transcutaneous Bilirubin/serum bilirubin should be done before discharge). To prevent complications associated with severe indirect hyperbilirubinemia, plans should be made for a follow up evaluation within a 24-48 hours based on the bilirubin level at discharge. Care should be given especially for Low Birth Weight, Small for Gestational Age or infants with Coombs’s positive, breastfeeding infants and infants of first time mothers. 19. The family should be assessed to ensure the safeguarding of the infant and proper education is provided to the mother before discharge. The documentation for the parental education and demonstration of competency by the mother or the primary care provider is made: Free from history of abuse or neglect or domestic violence, parent with mental illness. Presence of family support for the mother. Presence of a fixed home environment with heat, water and essential supply. Identify community support as needed to address concerns. 20. Parental understanding for the basic care outlined below and reinforce education: Prevention of hypothermia. Basic hygiene including bathing, cord care, diaper change. Breast feeding, and also proper preparation for formula. Importance of follow up care and definite plan for the next follow up. Basic safety and prevention of Sudden Infant Death Syndrome (SIDS) (back to sleep, no soft bedding or excessive blankets). Newborn safety including car seat safety, smoke fire alarms for home, danger of second hand smoking, and any other environmental hazards (i.e. a need for boiling water for formula preparation). Preventive measures against infection (avoid public in flu season, hand washing for the care providers, avoid crowd during newborn period). Immunization schedule should be reviewed and need for follow up according to the recommended schedule by follow up health professional and country. (Hepatitis B, Mumps, Measles, and Rubella (MMR), Haemophilus influenza type b-Haemophilus influenza (b-HIB), Pneumococcal conjugate, Polio, Rotavirus and other). Proper use of thermometer for axillary temperature. Education to identify risk factors given in #6 and number for clinic to call to report change in jaundice, any lethargy and poor feeding, development of respiratory distress or fever greater than 38 degrees C or 100.4 degrees F (axillary, oral thermometer). Depending on the time of discharge, the bilirubin level, and other factors identified should be included in the decision for the timing of the follow up and the first appointment should be made and parent is aware of it before discharge. To avoid sever hyperbilirubinemia, follow up within 48-72 hours should be considered. The baby that has had early discharge (24 hours) should be assessed at 48 hours then 3 to 5 days after discharge, 2 weeks, and every 2-3 months for first 6 months. Background The United Nations Sustainable Development Goal (SDG) 3 calls for a reduction in newborn death to 12 deaths per 1000 births (United Nations, 2015). 2.7 million babies die in the first 28 days of life. The worldwide neonatal mortality rate fell by 47 per cent between 1990 and 2015 from 36 to 19 deaths per 1,000 live births (UNICEF, 2016). Most of the neonatal deaths occur in low-and middle-income countries. Of the noted neonatal death, almost one million occur on the first day of live and close to 2 million during the first week of life (UNICEF, 2016). The World Health Organization (WHO) strategy included sending skilled health care workers immediately after birth to evaluate the baby for infections or birth complications (World Health Organization, 2016). Progress has been made to combat the under five years of age group and the death rate has decreased from 5 million in 1990 to about 2.7 million in 2015 (United Nations, 2015). Too many infants are still dying when preventative measures are possible. Care given with prevention in mind to physiologically vulnerable newborn infants during the first few hours and days of their lives has a profound significance to the United Nations Sustainable Development Goal. The American Academy of Pediatrics (AAP) and American Congress of Obstetricians and Gynecologists (ACOG) 6th edition Guidelines for Perinatal Care recommend careful observation of a newborn during the first 6-12 hours of the transition period (AAP & ACOG, 2017). A recent rise in the births of late preterm infants in well baby nurseries adds to the complexity of providing adequate care (Loftin, Habli, Snyder, Cormier, Lewis, & DeFranco, 2010 & WHO, 2012). Please refer to the COINN (Council of International Neonatal Nurses, Inc) Position Paper regarding the Late preterm infants. References American Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologists (ACOG), (2017). Guidelines for perinatal care. 8th edition, Elk Grove Village, IL: AAP/ACOG. Loftin, R. W., Habli, M., Snyder, C. C., Cormier, C. M., Lewis, D. F., & DeFranco, E. A. (2010). Late Preterm Birth. Reviews in Obstetrics and Gynecology, 3(1), 10–19. Telofski, L. S., Morello III, P., Mack Correa, C. M., & Stamatos, G. N. (2012). The infant skin barrier: Can we preserve, protect and enhance the barrier? Dematology Research and Practice, 2012, p.18. Doi: http://dx.doi.org/10.1155/2012/198789 The Royal Children Hospital’s Melbourne (2017). Neonatal and Infant skin care. Retrieved from: https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Neonatal___infant_skin_care/ UNICEF. (2016). The neonatal period the most vulnerable time for a child. Retrieved from: https://data.unicef.org/topic/child-survival/neonatal-mortality/# United Nations Sustainable Development Goals (SDG). (2015). Retrieved from: http://www.un.org/sustainabledevelopment/sustainable-development-goals/ World Health Organization (2012). Born to soon: The global action report on preterm births. Retrieved from: http://www.who.int/pmnch/media/news/2012/preterm_birth_report/en/index3.html World Health Organization (2016). Newborns, reducing mortality. Retrieved from: http://www.who.int/mediacentre/factsheets/fs333/en/

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

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

COUNCIL OF INTERNATIONAL NEONATAL NURSES, Inc. (COINN)Position Statement COINN (Council of International Neonatal Nurses, Inc) Position COINN (Council of International Neonatal Nurses, Inc) supports the International Council of Nurses (ICN) (2007) position on ethical nurse recruitment. COINN (Council of International Neonatal Nurses, Inc) recognises that quality neonatal care cannot be given without an adequate supply of well qualified and educated nurses. COINN (Council of International Neonatal Nurses, Inc) supports an individual’s right to migrate to another country for better quality of life, working conditions, or other personal reasons. COINN (Council of International Neonatal Nurses, Inc) supports ethical recruitment for employment which provides adequate training, orientation and support or supervision. COINN (Council of International Neonatal Nurses, Inc) supports the World Health Organisation, Migration of Health Workers: the WHO Code of Practice and the Global Economic Crisis, (2014). Though not legally binding, has political weight and provides a benchmark by which international recruitment can be monitored. Background Maternal Child and Neonatal Nursing is a growing speciality area that is experiencing a nursing shortage and thus there is a need for recruitment. COINN (Council of International Neonatal Nurses, Inc) recognises that corporations are entering this critical healthcare delivery concern as brokers to recruit nurses on behalf of healthcare delivery systems and then arrange for their transportation to the country of need. Some of these agents are legitimate and others are bartering or trading nurses for a substantial sum of money. Middle and high resourced countries have increased their acquisition of nurses from low resourced countries, adding to the global shortage (Buchan, Parkin & Sochalski, 2003). The World Health Organization (WHO) (2017) projects a shortage of 18 million health workers. Given the growing global nursing shortage as documented by the ICN and other such organisations, the problem of bartering or trading nurses for profit is going to increase as well. Ideally westernised countries should be able to manage their workforce effectively and not be reliant on other countries. However, COINN (Council of International Neonatal Nurses, Inc) recognises that short term migration may be needed to meet the maternal child health care needs. This migration must be done with consideration of the potential “brain drain” from the country sending the nurses and the need for transition training in the country to which the nurse is migrating. When this migration is necessary there should be a limit on the number of nurses migrating, countries from which migration is acceptable and duration of time during which this migration is permitted so that this migration is not at the behest of a shortfall. Retention strategies should be employed so that nurses have incentives to stay in their own countries rather than migrate. These strategies could include but are not limited to: better working conditions, decreased number of hours, better patient to nurse ratios and better compensation – wages and benefits. Currently there are almost 60 million health workers globally, but they are unevenly distributed across countries and regions. Typically, they are scarcest where they are most needed, especially in the poorest countries. In any case, the total number is incapable of meeting the demands of many populations for access to the health care they require. Both developed and developing countries are struggling to cope with the huge challenges posed by the imbalance between increasing demand and faltering supply (WHO, 2013). The global drive towards achieving universal health coverage (UHC) by improving access to affordable and effective care for all, cannot be achieved without a well-trained workforce, and having “the right staff in the right place”. The Migration of Health Workers: the WHO Code of Practice and the Global Economic Crisis (2014) examines in depth the central and often-controversial issues of the international migration of health workers before and since the adoption of the WHO Global Code of Practice on the International Recruitment of Health Personnel. The Migration of Health Workers: the WHO Code of Practice and the Global Economic Crisis (2014) brings much-needed evidence and clarity to the changing patterns of migration over time, and the varied and changing reasons why health workers choose to migrate – or to stay in their own countries. Among these, the global financial crisis has influenced the trends and directions of health worker migration, and the impact of the crisis is reviewed at length. Against this global background, a range of better-informed policy responses is emerging locally, nationally and internationally. We must keep health workforce migration, its impact and implications at the forefront of multiple international agendas. Recommendations/Key Principles Guideline Principles for Ethical Migration include but are not limited to: 1. Active involvement by the employing institution or another governing body to ensure that standards of practice are upheld when no national regulatory bodies are in place. 2. If specialised knowledge is required such as neonatal or maternal child nursing, that adequate orientation and training is provided for a sufficient length of time to ensure competency. 3. Support for specialised evidence-based care in neonatology or maternal child health is available through nursing or medicine and that equipment is available if a nurse is recruited in this area of specialisation. Nurses (or alternate care providers) are appropriately trained in using, maintaining and checking equipment. 4. Strengthen education and training by continued acquisition of knowledge and demonstration of competency in neonatal or maternal child care is an expectation and is supported by the recruiting country. 5. Monitoring for quality of care provided and performance appraisal of the individual nurse must be ongoing in the areas of new-born, maternal and family care. 6. Consideration of cultural differences of the nurse and the need for cultural sensitivity in the new work environment must be addressed. 7. Language acquisition must be supported. This acquisition is to include written, verbal and comprehension. 8. Language fluency is critical before nurses start caring for patients. 9. Nurses have the right to work in a safe working environment and one that adheres to the ICN Code of Ethics for Nurses or if available the recruiting country’s national nursing code of ethics in addition to the United Nations (1948) Universal Declaration of Human Rights. 10. Active involvement by the employing institution or another governing body in the development of a national workforce plan. References Benton, D.C., & Ferguson, S.L. (2017). A wide-angle view of global nursing workforce and migration. Nursing Economics, 35(4), 170-177. Buchan, J. Parkin, T., & Sochalski, J. (2003) International Nurse Mobility: Trends and Policy Implications. Geneva, Switzerland: WHO, ICN, and Royal College of Nursing. ICN (2007.) Ethical Nurse Recruitment. Geneva, Switzerland: ICN. https://www.icn.ch/news/international-council-nurses-calls-ethical-recruitment-process-address-critical-shortage World Health Organisation. (2006). 5 th World Health Assembly, Provisional agenda item 11.12, May 4, 2006. http://www.who.int/gb/ebwha/pdf_files/WHA59/A59_18-en.pdf World Health Organisation. (2013). Guidelines on transforming and scaling up health professionals’ education and training. Geneva: World Health Organization http://whoeducationguidelines.org World Health Organisation (2014) Migration of Health Workers: the WHO Code of Practice and the Global Economic Crisis. Geneva: World Health Organisation https://www.who.int/hrh/migration/migration_book/en/ World Health Organisation (2017). Health workforce. http://www.who.int/hrh/news/2017/action-to-avertan18-million-health-worker-shortfall/en/

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

COUNCIL OF INTERNATIONAL NEONATAL NURSES, Inc. (COINN) Policy Background COINN (Council of International Neonatal Nurses, Inc) should seek to grow its social media base and use this to engage with existing and potential members, donors, and stakeholders. At the same time, a professional balance must be adhered to which avoids placing the organization’s reputation at risk. COINN (Council of International Neonatal Nurses, Inc) seeks to encourage information and link-sharing amongst its membership, elected members and volunteers, and seeks to utilize the expertise of its elected members and volunteers in generating appropriate social media content. COINN (Council of International Neonatal Nurses, Inc) supports the use of Social Media such as Instagram, Twitter, Facebook, Google+, YouTube, and blogging and acknowledges that social media represents a growing form of communication for not-for-profit organizations, allowing them to engage their members and the wider public more easily than ever before. COINN (Council of International Neonatal Nurses, Inc) may choose to engage in social media such as: Twitter Facebook Google+ WordPress/Blogger You Tube/Vimeo iTunes/Podcasting Instagram WhatsApp COINN (Council of International Neonatal Nurses, Inc) recognizes that social media posts should be in keeping with the image that COINN (Council of International Neonatal Nurses, Inc) wishes to present to the public, and posts made through its social media channels should not damage the organization’s reputation in any way. Position COINN’s (Council of International Neonatal Nurses, Inc) social media use shall be consistent with the following core values: Integrity: COINN (Council of International Neonatal Nurses, Inc) will not knowingly post incorrect, defamatory or misleading information about its own work, the work of other organizations, or individuals. In addition, it will post in accordance with the organization’s Copyright and Privacy policies. Professionalism: COINN’s (Council of International Neonatal Nurses, Inc) social media represents the organization as a whole and should seek to maintain a professional and uniform tone. Elected members and volunteers may, from time to time and as appropriate, post on behalf of COINN (Council of International Neonatal Nurses, Inc) using its online profiles, but the impression should remain one of a singular organization rather than a group of individuals. Information Sharing: COINN (Council of International Neonatal Nurses, Inc) encourages the sharing and reposting of online information that is relevant, appropriate to its aims and of interest to its members. Recommendations/Key Principles The following principles apply to professional use of social media on behalf of COINN (Council of International Neonatal Nurses, Inc) as well as personal use of social media when referencing COINN (Council of International Neonatal Nurses, Inc): Members should be aware of the effect their actions may have on their images, as well as COINN’s (Council of International Neonatal Nurses, Inc) image. The information that employees post or publish may be public information for a long time. Members should be aware that COINN (Council of International Neonatal Nurses, Inc) may observe content and information made available by members through social media. Members should use their best judgment in posting material that is neither inappropriate nor harmful to COINN (Council of International Neonatal Nurses, Inc), its leaders or customers. Although not an exclusive list, some specific examples of prohibited social media conduct include posting commentary, content, or images that are defamatory, pornographic, proprietary, harassing, libellous, or that can create a hostile environment. Members are not to publish, post or release any information that is considered confidential or not public. Social media networks, blogs and other types of online content sometimes generate press and media attention or legal questions. Members should refer these inquiries to the COINN (Council of International Neonatal Nurses, Inc) board. If members find encounter a situation while using social media that threatens to become antagonistic, members should disengage from the dialogue in a polite manner and seek the advice of a board member. Members should get appropriate permission before you refer to or post images of current or former members, vendors or suppliers. Additionally, members should get appropriate permission to use a third party's copyrights, copyrighted material, trademarks, service marks or other intellectual property. Procedure Elected members and volunteers may, from time to time and where appropriate, post on behalf of COINN (Council of International Neonatal Nurses, Inc) using the organization’s online social media profiles. The Secretary or nominated representative has ultimate responsibility for: Ensuring appropriate and timely action is taken to correct or remove inappropriate posts (including defamatory and/or illegal content) and in minimizing the risk of a repeat incident. Ensuring that appropriate and timely action is taken in repairing relations with any persons or organizations offended by an inappropriate post. Moderating and monitoring public response to social media, such as blog comments and Facebook replies, to ensure that trolling and spamming does not occur, to remove offensive or inappropriate replies, or caution offensive posters, and to reply to any further requests for information generated by the post topic. It is important to maintain the balance between encouraging discussion and information sharing, and maintaining a professional and appropriate online presence. Social media is often a 24/7 occupation; as such, the Secretary to another appropriate staff member/volunteer as outlined above may delegate responsibilities. Process Before social media posts are made, volunteers and staff should ask themselves the following questions: Is the information I am posting, or reposting, likely to be of interest to COINN’s (Council of International Neonatal Nurses, Inc) members and stakeholders? Is the information in keeping with the interests of the organization and its constituted aims? Could the post be construed as an attack on another individual, organization or project? Would COINN’s (Council of International Neonatal Nurses, Inc) donors be happy to read the post? If there is a link attached to the post, does the link work, and have I read the information it links to and judged it to be an appropriate source? If reposting information, is the original poster an individual or organization that COINN (Council of International Neonatal Nurses, Inc) would be happy to associate itself with? Are the tone and the content of the post in keeping with other posts made by COINN (Council of International Neonatal Nurses, Inc)? Does it maintain the organization’s overall tone? If you are at all uncertain about whether the post is suitable, do not post it until you have discussed it with a representative of the COINN (Council of International Neonatal Nurses, Inc) Board. A few moments spent checking can save the organization big problems in the future. In the event of a damaging or misleading post being made, the Secretary should be notified as soon as possible, and the following actions should occur: The offending post should be removed. Where necessary an apology should be issued, either publicly or to the individual or organization involved. The origin of the offending post should be explored and steps taken to prevent a similar incident occurring in the future. The reputation of COINN (Council of International Neonatal Nurses, Inc) is first and foremost, and this involves maintaining a safe and friendly environment for its members. From time to time social media forums may be hijacked by trolls or spammers, or attract people who attack other posters or the organization aggressively. In order to maintain a pleasant environment for everybody, these posts need to be moderated. Freedom of speech is to be encouraged, but if posts contain one or more of the following, it is time to act: Excessive or inappropriate use of swearing. Defamatory, slanderous or aggressive attacks on COINN (Council of International Neonatal Nurses, Inc), other individuals, organizations, projects or public figures. Breach of copyrighted material not within reasonable use, in the public domain, or available under Creative Commons license. Breach of data protection or privacy laws including but not limited to use of an institution’s or patient’s family’s name or picture without consent. Repetitive advertisements. Topics which fall outside the realms of interest to members and stakeholders, and which do not appear to be within the context of a legitimate discussion or enquiry. If a post appears only once: Remove the post as soon as possible. If possible/appropriate, contact the poster privately to explain why you have removed the post and highlighting COINN’s (Council of International Neonatal Nurses, Inc) posting guidelines. If a poster continues to post inappropriate content, or if the post can be considered spam: Remove the post as soon as possible. Ban or block the poster to prevent them from posting again. Banning and blocking should be used as a last resort only, and only when it is clear that the poster intends to continue to contribute inappropriate content. However, if that is the case, action must be taken swiftly to maintain the welfare of other social media users.

COUNCIL OF INTERNATIONAL NEONATAL NURSES, Inc. (COINN)Position Statement COINN (Council of International Neonatal Nurses, Inc) Position COINN (Council of International Neonatal Nurses, Inc) supports the Declaration of Helsinki agreement that states neonates belong to a vulnerable group and encourage research to be done only if it cannot be carried out on a non-vulnerable group. COINN (Council of International Neonatal Nurses, Inc) supports research that is built on trust and openness. COINN (Council of International Neonatal Nurses, Inc) supports research that has been approved by RECs/IRBs for the protection of the neonate and family Background The Vision is to promote and facilitate international collaborative research to improve healthcare outcomes and safe practices for neonates and their families. Our aim is to support high quality research that informs clinical practice, education, and policy development and improves health outcomes of neonates that: respects the unique needs of the neonate. recognizes the role of the parents or care giver. takes into consideration the immediate and long-term welfare of the neonate. Recommendations/Key Principles To perform research in an ethical and morally appropriate manner. To lead, support, and promote high quality research that is of strategic importance to both COINN (Council of International Neonatal Nurses, Inc) and neonatal nursing worldwide. To lead, support and promote world-class nursing and multidisciplinary research programs that support effective models of evidence-based healthcare and development of a highly skilled health workforce. To strengthen the integration of research findings into clinical practice, education programs and heath care policy by effective knowledge implementation strategies. To increase research capacity by offering expert research guidance, mentoring, identifying, and supporting emerging research leaders. To expand collaborations with National and International partners from academic, industry, consumer and government sectors. To disseminate quality neonatal research and resultant change of practice to enhance the care of neonates and families worldwide. Ancillary conditions: In almost all circumstances the researchers should try to identify all ancillary conditions prior to commencing with the research. Identified ancillary conditions should have a plan of care developed before the research is begun. Possess the expertise sufficient to meet the need identified in a safe and effective manner. Possess the ability to apply that expertise without incurring inordinate costs. In the absence of other individuals or organizations that are able to meet the need, such as the local health system the researcher will attempt to address the issue. COINN (Council of International Neonatal Nurses, Inc) member participation Member participation in research is voluntary. Should a member NOT wish to be sent information or invitations to participate in research, please notify the secretary of COINN (Council of International Neonatal Nurses, Inc) at ceo@coinnurses.org RESEARCH PARTICIPATION When the COINN (Council of International Neonatal Nurses, Inc) board receives a request from researchers to access COINN (Council of International Neonatal Nurses, Inc) members to participate in research, the board assesses each research project individually. Should COINN (Council of International Neonatal Nurses, Inc) agree to a research request, COINN (Council of International Neonatal Nurses, Inc) will either distribute the information and invitation to members or formalize an agreement with the researcher regarding the privacy and use of member details for the purpose of distributing research invitations. Confidentiality of member’s details is maintained at all times. Should a member NOT wish to be sent information or invitations to participate in research, please notify the secretary of COINN (Council of International Neonatal Nurses, Inc) at ceo@coinnurses.org

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

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

COUNCIL OF INTERNATIONAL NEONATAL NURSES, Inc. (COINN) Education Committee Mandate To provide a forum for the discussion of current and common issues surrounding the development and deliverance of neonatal education, on a local, national and international scale To share ideas, innovations and projects surrounding neonatal education to enable members to learn from each other To encourage the development and/or to assist in the adaptation of, programs and educational material that are relevant and feasible across the spectrum of country’s/region’s available resources To share expertise and to lend support to anyone undertaking education or research projects within the field of neonatal care To foster and support multi-centre interdisciplinary collaboration in neonatal education and research, especially on an international level To raise the profile of neonatal education and research locally, nationally and internationally To raise the profile of COINN (Council of International Neonatal Nurses, Inc) and the COINN (Council of International Neonatal Nurses, Inc) Education Committee by having a presence/ representation at relevant conferences and meetings Chair The Chair of the COINN (Council of International Neonatal Nurses, Inc) Education Committee is a Registered Nurse or Nurse Practitioner volunteer member chosen among the COINN (Council of International Neonatal Nurses, Inc)-Education Committee members at the first meeting in July of a new term, when a Chair is needed. The Chair will usually serve a term of two years. An alternate Chair may be chosen if desired by the COINN (Council of International Neonatal Nurses, Inc) Education Committee membership or if the Chair is unable to serve his/her full term. Organization of the Committee The COINN (Council of International Neonatal Nurses, Inc) Education Committee will be organized as follows: One Chair One Co-Chair Members from a minimum of six different countries/regions Administrative assistance will be provided by COINN (Council of International Neonatal Nurses, Inc) with respect to the provision of communication resources/forums and other resources as able Authority and Accountability The COINN (Council of International Neonatal Nurses, Inc) Education Committee operates as a special committee under the leadership and oversight of the COINN (Council of International Neonatal Nurses, Inc) Executive Board. Membership on the COINN (Council of International Neonatal Nurses, Inc) Education Committee is open to anyone with a professional or academic interest in neonatal education. This includes, but is not limited to, physicians, nurses, midwives, medics, respiratory therapists, speech and language therapists, dieticians, physiotherapists, occupational therapists, psychologists, play specialists, HCAs and any other member of the neonatal multi-disciplinary team. Conflict of Interest Prospective members of the COINN (Council of International Neonatal Nurses, Inc) Education Committee will be asked to declare any potential or real conflict(s) of interest before agreeing, and being granted, membership on the Committee. If a potential conflict of interest is suspected or found, the applicant will be granted a special meeting with the COINN (Council of International Neonatal Nurses, Inc) Executive Board to explore the matter further, with a decision to be made by the Executive Board about future membership on the Committee. Roles & Responsibilities To work collaboratively to determine educational priorities by gathering information from stakeholders To develop short term and long term goals for the ongoing development of educational resources and projects, in conjunction with the goals and direction of the COINN (Council of International Neonatal Nurses, Inc) Executive Board To develop and maintain a work plan that clearly states the inputs, outputs, and measurable outcomes expected to ensure the goals set by the COINN (Council of International Neonatal Nurses, Inc) Educational Committee are being met In order to ensure accountability and transparency, the COINN (Council of International Neonatal Nurses, Inc) Education Committee will produce a report outlining their projects and progress, which will be presented to the COINN (Council of International Neonatal Nurses, Inc) Executive Board twice a year To maintain an awareness of the educational issues and opportunities available, and to disseminate this information as needed To offer recommendations to the COINN (Council of International Neonatal Nurses, Inc) Executive Board, as needed To draft and write educational resources/documents/policies, for the COINN (Council of International Neonatal Nurses, Inc) Executive Board to review Meetings The COINN (Council of International Neonatal Nurses, Inc) Education Committee will meet every second month (6 times/year) by teleconference/online forum, as organized by the Chair. The COINN (Council of International Neonatal Nurses, Inc) Education Committee may request an optional face-to-face, with the location, date and time to be determined by the Committee in consultation with COINN (Council of International Neonatal Nurses, Inc) Executive Board. Meetings that fall outside of the regularly scheduled meetings may be conducted, as requested by the Chair, for urgent and time sensitive matters. Preferred Representation Representation from a minimum of six (6) different countries/regions is preferred (excluding the Chair) up to a maximum of ten (10) different countries/regions Though the Committee is open to all members of the neonatal healthcare team, a maximum of 20 people should be considered in order to facilitate participation Whenever possible, a mixture of clinical/bedside nurses, educators, nurse practitioners and adjunct team members, is desired When deemed appropriate, the COINN (Council of International Neonatal Nurses, Inc) Education Committee may invite others to meet with the Committee, through the Chair, on a consulting basis in order to either supplement the work being done by the Committee, or to provide subject matter expert input, for a limited term Terms of Appointment One term of appointment is deemed to be a period of two years. A member’s Term of Appointment ends when a new member is appointed to replace the out-going member. COINN (Council of International Neonatal Nurses, Inc) Education Committee members are expected to serve one term to a maximum of two terms. To ensure continuity of business, the COINN (Council of International Neonatal Nurses, Inc) Executive Board requests that no more than 50% of COINN (Council of International Neonatal Nurses, Inc) Education Committee members’ Terms of Appointment be slated to end in any given year. Two months prior to the end of a member’s term, the COINN (Council of International Neonatal Nurses, Inc) Executive Committee may elect to issue a general call for new members via its website inviting interested and eligible nurses to apply to serve as new volunteer COINN (Council of International Neonatal Nurses, Inc) Education Committee members Review of applicants and subsequent selection of prospective new members will be done by the continuing members of the COINN (Council of International Neonatal Nurses, Inc) Education Committee in consultation with the COINN (Council of International Neonatal Nurses, Inc) Executive Board Expenses The costs associated with the telephone/on-line meetings will be borne by COINN (Council of International Neonatal Nurses, Inc) All other incidental expenses such as photocopy requirements and paper, will be borne by the COINN (Council of International Neonatal Nurses, Inc) Education Committee members, unless prior arrangements have been made with the COINN (Council of International Neonatal Nurses, Inc) Executive Board Goals, Plans and Annual Review The COINN (Council of International Neonatal Nurses, Inc) Education Committee may develop its own goals, plans, and work schedule to achieve its mandate/work, in consultation with the COINN (Council of International Neonatal Nurses, Inc) Executive Board. Annually in September, the Committee will review its goals, plans, operations and achievements in relation to its Terms of Reference and Mandate in order to make or recommend adjustments where needed. This process will ensure the work of the Committee is aligned with the vision and work of the COINN (Council of International Neonatal Nurses, Inc) Executive Board The Terms of Reference will be reviewed every 3 years by the Committee, and amended as needed.

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

Position The Council of International Neonatal Nurses, Inc. (COINN) recommends that a neonate’s sleep is to be protected and supported. Sleep is important for brain development, growth, healing, and general health. The protection of sleep post-delivery and during the period of hospitalization particularly for premature neonates, is a core component of neonatal care. Background and Factors Newborn term healthy neonates on average sleep 16–18 hour per day, with sleep states generally defined as quiet sleep and active sleep - precursorsto non-rapid eye movement and rapid eye movement sleep states in adulthood (Bennet et al., 2018). Active sleep is considered the most important behavioural state for neonates (particularly premature neonates who spend 70-80% of their sleep time in this state). Active sleep plays a key role in organizing the central nervous system and is important for sensory input processing, consolidation and learning (Altimier & Phillips, 2016). During active sleep muscle tone is reduced with irregular breathing and heart rate, and spontaneous twitching and eye movements (Curzi-Dascalova et al., 1988). Quiet sleep is necessary for energy restoration, tissue growth and repair, and the maintenance of homeostasis (Altimier & Phillips, 2016). In quiet sleep there is higher muscle tone, absence of eye movements, and regular heart rate and respiration (Bennet et al., 2018). This state is limited for premature neonates due to immature physiological systems, reduced muscle tone, poor control of movements and limited ability for self-regulation. Distinctions of sleep states are difficult to determine before 30 weeks gestational age – prior to 30 weeks both sleep states are largely characterised as indeterminate sleep (Mirmiran et al., 2003). Sleep is crucial to foster optimal brain development, cognition and behaviour, however, disruptions can occur from the first hours of life (Grigg-Damberger, 2016). Sleep quality can be impaired by the environment, including the light and noise of neonatal intensive care units (NICU) (van den Hoogen et al., 2017) and treatment such as respiratory support (Collins et al., 2015). Neonatal nursing care interventions, whilst critical, can lead to physiological instability, and can be stressful for neonates, which together with sleep interference risk negatively impacting their neuromotor, behavioural, growth milestones and sleep patterns (Sanders & Hall, 2018). It is a priority that neonatal teams understand the importance of sleep for the neonates wellbeing and this is part of their education. It was recognised in a recent study that healthcare professionals view sleep as important but more theoretical knowledge would support strategies in practice (Groot et al., 2023). Ultimately, optimizing opportunities for sleep gives neonates a better chance of healthy brain maturation (Bik et al., 2022) – sleep has a protective effect on brain development in premature neonates (Ednick et al., 2022). General strategies to protect sleep involve optimizing the environment, comfortable positioning, minimizing stress and pain, integrating families in care, protecting skin integrity, and ensuring adequate nutritional status. COINN Recommendations and Action Points 1. Recognize the significance of promoting and protecting sleep as a keystone of the treatment of neonates in the NICU. 2. Include sleep theory in neonatal education. 3. Support neonatal sleep integrated teaching and education programs (e.g., e- learning, parent information, flyers) targeted to nurses, physicians, parents, visiting healthcare professionals and support personnel. 4. Observe and record sleep and wake periods of neonates to assist with identifying sleep-wake patterns. 5. Incorporate appropriate sleep measurements (e.g., validated observational scales, EEG, innovative non-obtrusive sleep measurements) into daily ward round assessments to increase awareness of sleep as a key factor in neonatal health. 6. Establish good practice guidelines about elective care procedures which can be postponed during sleep (e.g., routine blood testing, routine x-rays, routine cardiac assessments). 7. Avoid (where possible) disrupting neonatal sleep no less than 60 minutes after a previous sleep disruption. 8. Schedule care / interventions for when the neonate is naturally awake (where possible) 9. When required to wake the neonate, undertake this with gentle touch and quiet talking where possible. 10. Pay attention to intolerance of cares / interventions – provide clustered activities and care as tolerated. 11. Practice regular scheduled unit-based quiet times/hours (dim lighting, quieter environment, reduced visitors) 12. Promote opportunities for skin-to-skin contact (kangaroo care) and neonatal massage. 13. Consider use of the following as appropriate to protect and support sleep: a. Headphones b. Alarm modifications c. Nesting aids d. Swaddling e. Non-nutritive sucking f. White noise g. Music therapy h. Eye masks i. Incubator covers. Disclosure COINN (Council of International Neonatal Nurses, Inc) acknowledges that limited resources and/or personnel may restrict opportunities to implement the recommendations and action points. However, to improve health outcomes, the global neonatal care community must strive to uphold these recommendations. Acknowledgement Thank you to Professor Agnes van den Hoogen, Dr. Deanne August , and the *COINN Education Committee for the development of this statement. References Altimier, L., & Phillips, R. (2016). The neonatal integrative developmental care model: advanced clinical applications of the seven core measures for neuroprotective family- centered developmental care. Newborn and infant nursing reviews, 16 (4), 230-244. Bennet, L., Walker, D. W., & Horne, R. S. (2018). Waking up too early–the consequences ofpreterm birth on sleep development. The Journal of physiology, 596(23), 5687-5708. Bik, A., Sam, C., de Groot, E. R., Visser, S. S., Wang, X., Tataranno, M. L., ... & Dudink, J. (2022). A scoping review of behavioral sleep stage classification methods for preterm infants. Sleep Medicine, 90, 74-82. Collins, C. L., Barfield, C., Davis, P. G., & Horne, R. S. C. (2015). Randomized controlled trial to compare sleep and wake in preterm infants less than 32 weeks of gestation receiving two different modes of non-invasive respiratory support. Early Human Development, 91(12), 701-704. Curzi-Dascalova, L. (2001). Between-sleep states transitions in premature babies. Journal of Sleep Research, 10(2), 153-158. Ednick, M., Cohen, A. P., McPhail, G. L., Beebe, D., Simakajornboon, N., & Amin, R. S. (2009). A review of the effects of sleep during the first year of life on cognitive, psychomotor, and temperament development. Sleep, 32(11), 1449-1458. Grigg-Damberger, M. M. (2016). The visual scoring of sleep in infants 0 to 2 months of age. Journal of clinical sleep medicine, 12(3), 429-445. de Groot, E. R., Ryan, M. A., Sam, C., Verschuren, O., Alderliesten, T., Dudink, J., & van den Hoogen, A. (2023). Evaluation of Sleep Practices and Knowledge in Neonatal Healthcare. Advances in Neonatal Care, 10-1097. Mirmiran, M., Maas, Y. G., & Ariagno, R. L. (2003). Development of fetal and neonatal sleep and circadian rhythms. Sleep medicine reviews, 7(4), 321-334. Sanders, M. R., & Hall, S. L. (2018). Trauma-informed care in the newborn intensive care unit: promoting safety, security and connectedness. Journal of Perinatology, 38(1), 3-10. van den Hoogen, A., Teunis, C. J., Shellhaas, R. A., Pillen, S., Benders, M., & Dudink, J. (2017). How to improve sleep in a neonatal intensive care unit: a systematic review. Early human development, 113, 78-86. *COINN Education Committee Contributors: Tracey Jones, Chair, Wakako Eklund, Judy Hitchcock, Carin Maree, Ann Martin, Aya Nakia, Linda Ng, Debra Nicholson, Julia Petty, Lynne Wainwright Adopted: September 5, 2023 Next Review: 2026 2110 Yardley Road, Yardley, PA 19067, USA Email: ceo@coinnurses.org Website: www.coinnurses.org “COINN – the Global Voice of Neonatal Nurses” A not for profit – 501C3.