Objective This study aimed to determine the impact of neonatal intensive care unit (NICU) design and environmental factors on neonatal sound exposures. We hypothesized that monitoring with a smartphone application would identify modifiable environmental factors in different NICU design formats. Study Design Minimum, maximum, and peak decibel (dB) recordings were obtained using the Decibel X phone app, and the presence of noise sources was recorded in each patient space at three NICUs over a 6-month period (December 2017 to May 2018). Data were analyzed by Student's t-test and ANOVA with Bonferroni correction. Data were collected at the University of Maryland Medical Center single family room (SFR) level IV and St. Agnes Healthcare hybrid pod/single family room level III NICU, Baltimore, MD and at Prince George's Hospital Center open-pod design Level III NICU, Cheverly, MD. Results All recordings in the three NICUs exceeded the American Academy of Pediatrics (AAP) recommended <45 dB level. The maximum and peak dB were highest in the open pod format level III NICU. Conversations/music alone and combined with other factors contributed to increased sound exposure. Sound exposure varied by day/night shift, with higher day exposures at the level III hybrid and open pod NICUs and higher night exposures at the level IV SFR NICU. Conclusion Although sound exposure varied by NICU design, all recordings exceeded the AAP recommendation due, in part, to potentially modifiable environmental factors. A smartphone application may be useful for auditing NICU sound exposure in quality improvements efforts to minimize environmental sound exposure. Key Points

OBJECTIVE: Narrative medicine is a tool that may foster compassionate and empathetic practitioners. Pediatric residents completing their intensive care rotations in the Pediatric Intensive Care Unit (PICU) and Neonatal intensive Care Unit (NICU) may experience burnout and compassion fatigue making empathic communication and compassionate care challenging. Our goal was to examine how residents working in the NICU and PICU at one children’s hospital responded to a narrative medicine curriculum. METHODS: In this cross-sectional qualitative study, pediatric residents participated in two narrative medicine sessions during their NICU or PICU rotation. At the end of each NICU or PICU block, residents received an IRB-approved anonymous REDCap survey. The survey included four open-ended questions about the sessions. Responses were interpreted by NVivo 1.0 (QSR International). RESULTS: 22 of 36 residents (61%) responded to the survey. Residents noted the sessions provided worthwhile forums for self-reflection and release of emotion. Residents identified empathic witnessing to each other as a strength. The forum for group reflection and shared perspectives was empowering. Reflective writing was a valued skill. CONCLUSION: Pediatric residents rotating in the NICU and PICU endorsed narrative medicine sessions as a fulfilling and meaningful forum for them to share emotions and reflect on the experiences of their colleagues.

Objectives: Routine gastric aspirate (RGA) monitoring is a common yet controversial practice intended for early identification of gastrointestinal pathology in infants receiving gavage feeds. Our objectives were to evaluate the association of ceasing RGA monitoring on the incidence of necrotizing enterocolitis (NEC) as well as nutritional outcomes in a large population of very low birth weight (VLBW) and very preterm neonates. Methods: Retrospective record review of neonates born ≤32 weeks and/or VLBW from 2 cohorts: (1) during pre-feed RGA monitoring (September 2015 to June 2018) and ( 2) after cessation of RGA ("non-RGA") monitoring (July 2018 to December 2020). We compared incidence of NEC, time-tofull enteral feeds, central line duration, and duration of parenteral nutrition (PN) in bivariate and multivariable models accounting for changes in feeding protocols over time. Results: We identified 617 subjects, 53% in the RGA monitoring cohort (n = 327) and 47% in non-RGA cohort (n = 290). The non-RGA cohort had feeds initiated earlier (P < 0.0001), achieved full enteral feeds more rapidly (P < 0.0001), received a shorter duration of PN (P = 0.0003), and had shorter central access duration (P < 0.0001) without increasing NEC risk. In fact, the non-RGA cohort had a lower incidence of NEC (P = 0.0345) compared to the RGA cohort. Even after adjusting for changes in feeding protocols over time in a multivariable model, the RGA cohort had significantly higher odds of NEC. Conclusions: Pre-feed RGA monitoring in the absence of concerning clinical exam findings is not indicated for neonates receiving gavage feeds as it does not improve NEC incidence but instead may delay important nutritional outcomes such as feed initiation and central line removal.