Feature
NICU Nurses Influence on the Newborn Microbiome
By Amanda Williams, MSN APRN CNS ACCNS-N RNC-NIC C-ELBW C-NNIC C-ONQS NPD-BC
NICU nurses care for the most vulnerable and fragile population, babies at risk of long-term complications. Sick and premature newborns require specialized care to manage their underdeveloped systems and special needs, and NICU nurses are distinctly aware of the immaturity of their patients’ brain, lungs, kidneys, and guts in conjunction with their gestational age at birth.
However, there is one system we sometimes overlook: the microbiome.
Microbiome describes the bacteria, viruses, and fungi that live on and inside of the body. In recent years, research has highlighted the microbiome’s role as a foundational component of infant health, influencing immune function, gastrointestinal development, and even brain function. As NICU nurses, we must understand how our actions impact the microbiome to enhance care strategies and improve long-term outcomes for these vulnerable newborns.
After birth, the microbiome is vulnerable to changes in its environment. The first months of life are instrumental in shaping the development of the microbiome. NICU nurses should be mindful of the microbiome because it has a significant influence on immune health, gut health, and long-term health and because infants in the NICU are at risk of dysbiosis. Dysbiosis is an imbalance of commensal and pathogenic microorganisms and has been linked to numerous short-term conditions, including necrotizing enterocolitis (NEC) and late-onset sepsis, and to long-term health problems like asthma, allergies, and developmental delays.
Though nurses can’t influence some factors that have a significant impact on the microbiome (such as maternal prenatal health and mode of delivery), nurses should consider the factors they can influence that positively affect the microbiome, including supporting lactation; providing oral immune therapy; being stewards of antibiotics; and prioritizing skin-to-skin care.
Human milk is powerful, providing infants with multiple immunologic components that support their microbiome, including human milk oligosaccharides (HMOs), lactoferrin, immunoglobulin A, cytokines, and the milk’s own microbiota that changes to support the infant; additionally, more beneficial bacteria (Bifidobacteria) has been found in infants fed with human milk (especially from their own parent) (Carr et al., 2021). Some of the benefits of a human milk diet (including decreased risk of developing NEC or late onset sepsis) can be tied back to the positive effect human milk has on the microbiome. Though an infant’s own parent’s milk is the gold standard, pasteurized donor milk also is a valuable option when milk from a parent is unavailable. Both provide crucial immunological benefits and support a healthier microbiome.
Providing oral immune therapy with colostrum and human milk are additional ways NICU nurses can support the microbiome. Only the gut has larger colonies of bacteria than the mouth, and the mouth is instrumental to overall health (D'Agostino et al., 2022). “Oral care” is not the same as “oral immune therapy.” Infants in the NICU often have devices in their mouths and/or nose, such as feeding tubes and endotracheal tubes, which the body treats as foreign, creating a biofilm around them. When nurses provide oral care, we gently clean the mouth and remove the biofilm so that the colostrum or human milk we feed them can directly contact the epithelium (instead of biofilm). A 2020 study by Maffei et al. demonstrated that this method of administering human milk improves the absorption of critical immunologic components, directly benefiting immune and microbiome development. Understanding the distinction between oral care and oral immune therapy is crucial because the presence of biofilm can prevent full absorption, reducing the benefit on the infant’s immune and microbiome development.
The skin is another important microbial site, and the way nurses care for skin influences the microbiome development. complex biofilm of protein, lipids, and water, vernix has beneficial properties, from wound healing to anti-infective and antioxidant effects (Nishijima et al., 2019). Considering these effects, delayed bathing and leaving the vernix in place is supportive of the developing newborn’s microbiome. National skin care guidelines recommend the first bath be delayed until cardiorespiratory and thermal stability have been achieved, ideally between 6-24 hours of life in most infants while leaving vernix on the skin to allow for earlier skin acidification (Association of Women's Health, Obstetric and Neonatal Nurses & National Association of Neonatal Nurses, 2018). Delaying the first bath until after cardiorespiratory stability is achieved not only supports skin health but also fosters a more stable and diverse microbial environment, which is vital for the developing immune system.
Avoiding unnecessary antibiotic exposure also supports the developing microbiome. Prolonged and unnecessary exposure to antibiotics alters the newborn microbiome, putting infants at increased risk for late onset sepsis and NEC. How can nurses impact unnecessary antibiotic exposure? One way is by preventing blood culture contamination. Nurses are in the important position of drawing blood cultures in many NICUs and carry the responsibility of understanding the importance of proper blood culture collection technique to prevent blood culture contamination. Contaminated blood cultures can lead to unnecessary antibiotic exposure and extended NICU stays. To reduce patients’ exposure to antibiotics, NICU nurses should work together to create standardized checklists and monitor their rates of blood culture contamination. By standardizing blood culture collection protocols and utilizing checklists to reduce contamination, NICU teams can minimize unnecessary antibiotic exposure, thereby protecting the delicate balance of the newborn microbiome (Fischer et al., 2023).
Parent involvement and supporting frequent skin-to-skin (STS) care also has been shown to promote neonatal stability, reduce mortality, and develop a more diverse microbiome for infants in the NICU. STS care has been shown to increase the microbial diversity in premature infants across body sites. Studies have shown infants who are held skin to skin had a more mature oral microbiome compared to infants who were not held skin to skin (Hendricks-Muñoz et al., 2015). Other studies have shown infants receiving high exposure of STS contact (defined as >60 minutes) showed greater microbial richness in the stool and distinct microbial compositions in both oral and intestinal microbiomes compared to those with low STS exposure (defined as <40 minutes; Hamidi et al., 2023). The clinical implications of these studies have been shorter NICU length of stay and enhanced microbial communities which can be hypothesized to improve long-term outcomes for infants in the NICU. Nurses play an essential role in educating and encouraging parents to participate in STS care, emphasizing its importance not only for bonding but also for promoting a healthy, diverse microbiome.
As NICU nurses, we have the unique opportunity to influence the early development of the newborn microbiome. By incorporating microbiome-supporting practices into our daily care routines, we can improve both immediate and long-term health outcomes for the infants we care for. Further research is needed to explore the full potential of microbiome-based interventions in NICU care. NICU nurses can play a vital role in this process by advocating for research initiatives and sharing their experiences with implementing these strategies. Through ongoing research and a commitment to promoting a healthy microbiome, we can continue to improve the lives of premature and critically ill newborns.
References
Association of Women's Health, Obstetric and Neonatal Nurses & National Association of Neonatal Nurses. (2018). Neonatal skin care evidence-based clinical practice guideline (4th ed.). https://apps.nann.org/store/product-details?productId=59314045
Carr, L. E., Virmani, M. D., Rosa, F., Munblit, D., Matazel, K. S., Elolimy, A. A., & Yeruva, L. (2021). Role of human milk bioactives on infants' gut and immune health. Frontiers in Immunology, 12, 604080. https://doi.org/10.3389/fimmu.2021.604080
D'Agostino, S., Ferrara, E., Valentini, G., Stoica, S. A., & Dolci, M. (2022). Exploring oral microbiome in healthy infants and children: A systematic review. International Journal of Environmental Research and Public Health, 19(18), 11403. https://doi-org.mlprox.csmc.edu/10.3390/ijerph191811403
Fischer, A. M., Mitchell, J. L., Stanley, K. C., & Javed, M. J. (2023). A quality improvement project to reduce antibiotic exposure in premature neonates. Hospital Pediatrics, 13(5), 435–448. https://doi-org.mlprox.csmc.edu/10.1542/hpeds.2022-006644
Hamidi, M., Cruz-Lebrón, A., Sangwan, N., Blatz, M., & Levine, A. (2023). Maternal vertical microbial transmission during skin-to-skin care. Advances in Neonatal Care, 23, 555-564. https://doi.org/10.1097/ANC.0000000000001109
Hendricks-Muñoz, K., Xu, J., Parikh, H., Xu, P., Fettweis, J., Kim, Y., Louie, M., Buck, G., Thacker, L., & Sheth, N. (2015). Skin-to-skin care and the development of the preterm infant oral microbiome. American Journal of Perinatology, 32(12), 1205-1216. https://doi.org/10.1055/s-0035-1552941
Maffei, D., Brewer, M., Codipilly, C., Weinberger, B., & Schanler, R. J. (2020). Early oral colostrum administration in preterm infants. Journal of Perinatology: Official Journal of the California Perinatal Association, 40(2), 284-287. https://doi-org.mlprox.csmc.edu/10.1038/s41372-019-0556-x
Nishijima, K., Yoneda, M., Hirai, T., Takakuwa, K., & Enomoto, T. (2019). Biology of the vernix caseosa: A review. The Journal of Obstetrics and Gynaecology Research, 45(11), 2145-2149. https://doi.org/10.1111/jog.14103