Donna Dowling PhD, RN, and Shelley Thibeau, PhD, RNC-NIC ❍ Section Editors

Original Research

Gastric Residual Volumes Versus

Abdominal Girth Measurement in
Assessment of Feed Tolerance in Preterm
Neonates
A Randomized Controlled Trial
Shemi Thomas, MSc; Saudamini Nesargi, VDNB; Preena Roshan, BSc; Renjita Raju, BSc;
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Shiny Mathew, MSc; Sheeja P., MSc; Suman Rao, PN

ABSTRACT
Background:  Preterm neonates often have feed intolerance that needs to be differentiated from necrotizing enteroco-
litis. Gastric residual volumes (GRV) are used to assess feed tolerance but with little scientific basis.
Purpose:  To compare prefeed aspiration for GRV and prefeed measurement of abdominal girth (AG) in the time taken to
reach full feeds in preterm infants.
Methods:  This was a randomized controlled trial. Infants with a gestational age of 27 to 37 weeks and birth weight of
750 to 2000 g, who required gavage feeds for at least 48 hours, were included. Infants were randomized into 2 groups:
infants in the AG group had only prefeed AG measured. Those in the GRV group had prefeed gastric aspiration obtained
for the assessment of GRV. The primary outcome was time to reach full enteral feeds at 150 mL/kg/d, tolerated for at
least 24 hours. Secondary outcomes were duration of hospital stay, need for parenteral nutrition, episodes of feed intol-
erance, number of feeds withheld, and sepsis.
Results:  Infants in the AG group reached full feeds earlier than infants in the GRV group (6 vs 9.5 days; P = .04). No
significant differences were found between the 2 groups with regard to secondary outcomes.
Implications for Practice:  Our research suggests that measurement of AG without assessment of GRV enables preterm
neonates to reach full feeds faster than checking for GRV.
Implications for Research:  Abdominal girth measurement as a marker for feed tolerance needs to be studied in infants
less than 750 g and less than 26 weeks of gestation.
Key Words:  abdominal girth measurement, feed tolerance, gastric aspiration, NEC, preterm

BACKGROUND AND SIGNIFICANCE India is by evaluation of gastric residuals. There is no

Optimum nutrition is known to improve neurodevel-
opmental outcomes in preterm neonates.1,2 Despite
advances in parenteral nutrition, early enteral nutri-
tion remains the cornerstone of nutrition in neo-
nates.3 However, preterm infants are at risk for feed
intolerance (FI). The current method to assess FI in
Author Affiliations: Department of Paediatrics, St John’s College of
Nursing (Mrs Thomas, Drs Mathew and Sheeja, Ms Raju and Mrs
Roshan) Bangalore, Karnataka, India; and Department of Neonatology,
St John’s Medical College Hospital, Bangalore, Karnataka, India
(Dr Nesargi and Dr Rao).
Shemi Thomas, Renjita Raju, and Preena Roshan were responsible for
data collection and interpretation of data. Suman Rao, Saudamini
Nesargi, Shiny Mathew, and Sheeja P. were responsible for conceptual-
izing the study. Saudamini Nesargi was responsible for the initial draft
of the manuscript and subsequent revisions.
The authors declare no conflicts of interest.
Correspondence: Saudamini Nesargi, VDNB, Associate Professor,
Department of Neonatology, St John’s Medical College Hospital,
Sarjapur Main Rd, Koramangala, Bangalore 560034, India (saudamini_
nesargi@yahoo.com).
Copyright © 2018 by The National Association of Neonatal Nurses
DOI: 10.1097/ANC.0000000000000532
evidence that this is indicative of feed tolerance or
prevents necrotizing enterocolitis (NEC). Aspirating
gastric contents may damage the mucosa and lead to
a loss of gastric juices that are required for digestion.
Assessment of gastric residual has also been found to
increase the time taken to reach full enteral feeds.4
Abdominal girth (AG) measurement is an alterna-
tive method to assess feed tolerance and is used in
neonatal care around the globe as assessment param-
eter. Abdominal girth measurement is recommended
by the Government of India in the facility-based
newborn care manual.5 As the evidence for this is
not robust, this study was planned to compare GRV
and AG measurement in preterm neonates.
It is known that preterm infants are at risk for FI
but the exact incidence, definitions, and effects of a
delay in reaching full enteral feeds vary.6 The
PubMed database was searched using the terminol-
ogy “preterm, neonate, feed intolerance and enteral
nutrition.” No language restrictions were applied.
Thirty-three articles were found, the findings of
which are summarized later.

Advances in Neonatal Care • Vol. 18, No. 4 • pp. E13-E19 E13

Copyright © 2018 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
E14 Thomas et al
Lucchini et al7 defined feed intolerance as the
presence of gastric residuals, abdominal distension,
and the onset of apnea and bradycardia. The defini-
tion of feed intolerance may have been best stated by
Moore as “the inability to digest enteral feeding,
presenting as increased gastric residual volumes
>50%, abdominal distension, emesis or both and a
disruption of the patients’ feeding plan.”8 The defi-
nition is important to differentiate the relatively
benign condition of FI from the far more cata-
strophic NEC. Very low birth-weight (VLBW)
infants are reported to have a higher incidence of
FI—64%, whereas only 27.5% of all preterm infants
have been reported to have FI.9 However, the inci-
dence of NEC is far lower than that of FI between
6% and 10% of VLBW infants.10
Clinicians often delay initiation and advancement of
enteral feeds fearing NEC.11 Therefore, a balance is
needed between “aggressive” advancement of enteral
nutrition and slower feeding advancements to defend
against the development of NEC. The short-term effects
of delaying enteral nutrition include extra uterine
growth restriction and increased use of parenteral nutri-
tion leading to liver disease and sepsis.7 The long-term
effects are primarily a poorer neurodevelopmental out-
come at 24 months.12,13 Recent recommendations sug-
gest that infants less than 1000 g should reach full
enteral feeds by 2 weeks of life and those between 1000
g and 1500 g should reach full feeds by the end of the
first week of life.14
Traditionally, gastric residual volumes (GRV)
have been an integral measure of FI. However, there
is no consensus in what constitutes an abnormal
residue. Some neonatal intensive care units (NICUs)
have empirically set residual volumes greater than
2 mL in infants less than 750 g and 3 mL in infants
between 750 g and 1000 g. Other NICUs consider
greater than 50% of the feed volume or 1/3 the feed
volume to be abnormal.7 A few authors do not rely
on GRV before each feed but those over an entire
day. Volume of concern varies between greater than
10% to greater than 70% of the total daily feed vol-
umes to be indicative of FI.15,16 The color of the gas-
tric aspirate also appears to be important as many
NICUs consider yellow, green, or hemorrhagic aspi-
rates, significant enough to withhold feeds.17 Deci-
sions to replace the gastric aspirate are not based on
evidence but rather on individual experience.4
Hodges and Vincent18 showed that only 4% of
NICU nurses replace gastric aspirates. This wide
variability in practices related to GRV results in ces-
sation of feeds, increased time to full enteral feeds,
and a loss of digestive enzymes and nutrients in the
gastric aspirates.14 The volume of the gastric residu-
als also changed with position, infants cared for in
the prone position have less residuals than those
cared for in the supine position.19 The use of a larger
gauge feeding tube also increases the GRV.20,21
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Copyright © 2018 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
What This Study Adds
• Assessment of abdominal girth (AG) measurement
alone is a preferable alternative to checking for gastric
residual volumes (GRV) while assessing for feed
tolerance.
• Assessment of AG only enables preterm infants to
reach full feeds faster.
• Assessment of AG only demonstrated a trend toward
decreased hospital stay.
Because of the lack of consistency about “signifi-
cant” GRV, Jadcherla and Kleigman11 have defined
FI as GRV occurring with either emesis or abdomi-
nal distension. Ng and Shah22 in their Cochrane
review have defined FI as only abdominal disten-
sion. An increase in AG of 2 cm is considered signifi-
cant.7 Hence, the objective of our study was to com-
pare GRV with measurement of AG in the time to
reach full enteral feeds in preterm neonates.
Methodology
This was a randomized controlled trial done in the
NICU of St John’s Medical College Hospital in Ban-
galore. The study was completed between October
2015 and February 2017. Infants between 26 and 37
weeks of gestation were assessed for eligibility.
Those with a birth weight of more than 750 g and
less than 2000 g and likely to require gavage feeds
for at least 48 hours of life were included in the
study. Extramural neonates who had not received
any feeds were also included. Infants with life-
threatening congenital anomalies and anomalies of
the gastrointestinal tract were excluded. A written
informed consent was obtained from either parent at
admission to the NICU. The study was approved by
the institutional ethics committee.
Infants included in the study were randomized to
1 of 2 groups—routine prefeed aspiration for GRV—
GRV (control) or prefeed AG—AG (intervention)
monitoring. Randomization was completed using a
computer-generated random number table in
unequal block sizes ranging from 4 to 12 by the prin-
cipal investigator. The randomization was done
within 24 hours of feed initiation. Allocation con-
cealment was done using sequentially numbered
opaque sealed envelopes. Participant enrolment was
obtained by the study team. Only the primary inves-
tigator had access to the envelopes and was not part
of the clinical team. Blinding during the study proto-
col was not possible as GRV and AG need to be
documented as part of the input and output chart.
Our unit policy on feeding of preterm neonates
includes routine aspiration of the infant feeding tube
prior to the next feed. Routinely, AG is checked only
once every shift (8 hourly) or if the GRV are greater
than 10 mL/kg/d. Feeds are given every 2 hours,
either expressed milk from the infants’ own mother
 Gastric Residual Volumes Versus Abdominal Girth for Feed Tolerance in Preterm Neonates
or donor milk. The aspirated gastric contents are to
be replaced if not altered. Control group aspirates
were replaced per this protocol.
The intervention was checking of AG at baseline,
that is, before feeds were initiated and at 2 hourly
intervals, before the next feed. In infants random-
ized to the AG group, aspiration of the feeding tube
was not an aspect of the gastric assessment. Before
commencement of the study, all nurses completed
training on the measurement of AG. Girth was uni-
formly measured at the umbilicus using a flexible
measuring tape touching skin but not compressing
tissue.23 Feeds were withheld if there were signs of FI
or if the girth increased by 2 cm or more.7
Current Unit Policy on Feeding During This
Study
Feeding was initiated, advanced, stopped, and
restarted as per unit protocol derived by consensus
from a previous study.24 Trophic feeds, that is, 10 to
20 mL/kg/d at 2 hourly intervals of either colostrum
(if available) or donor human milk feeds are initi-
ated in hemodynamically stable infants preferably
on day 1 of life. Milk feeds consist of mother’s own
milk or donor milk. Feeds are advanced by 20 mL/
kg/d (in infants 750-1249 g and those with abnor-
mal antenatal Dopplers) or by 35 mL/kg/d (in
infants 1250-1499 g hemodynamically stable with
static or decreasing ventilatory requirements).
Infants weighing greater than 1500 to 2000 g may
be started on full feeds if they do not have abnormal
Dopplers, respiratory distress, asphyxia, or hemo-
dynamic instability. Feeds are withheld if there are
signs of FI, hemodynamic instability, suspected
NEC, or voluminous gastric residuals. Feeds are
restarted when all the aforementioned signs have
resolved. Parenteral nutrition is continued till 100
mL/kg/d of feeds is reached. Full feeds are defined
as 150 mL/kg/d. Feed intolerance is defined as the
presence of any one of the following 4 features—
abdominal distension of 2 cm or greater from the
previous measurement, or vomiting 2 or more epi-
sodes in the past 6 hours or blood-stained or bilious
aspirates, or more than 2 episodes of voluminous
gastric aspirates in a 6-hour period. Voluminous
gastric residuals are defined as more than 50% of
previous feed volume if 6 mL per feed or more, or 2
episodes of more than 50% in a 6-hour period, or a
single residue of 100% if feed volume is less than 6
mL per feed.
The primary outcome of this investigation was
the time to reach full feeds (150 mL/kg/d), tolerated
for at least 24 hours. Secondary outcomes were
number of episodes of FI, number of feeds that were
withheld, duration of hospital stay, duration of par-
enteral nutrition, incidence of late-onset sepsis (as
defined by a C-reactive protein (CRP)>1 mg/dL,
total leucocyte count <5000/cmm or >25,000/
Advances in Neonatal Care • Vol. 18, No. 4
Copyright © 2018 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
E15
cmm, abnormal absolute neutrophils count based on
Manroe or Mouzinho’s charts, thrombocytopenia,
or blood culture positive), and NEC stage 2 on mod-
ified Bells classification.
Data regarding feeds of the infant and demo-
graphic details were recorded from the medical
record. Demographic details included birth weight,
weeks of gestation, gender, small for gestational age
(SGA), maternal hypertension, abnormal antenatal
Doppler, antenatal magnesium sulfate and steroids,
mode of delivery, need for resuscitation, need for
ventilation, hemodynamically significant ductus
arteriosus, placement of umbilical arterial catheter,
and time of starting feeds.
Sample size was calculated to be 24 in each group,
assuming a difference in time to reach full feeds of 5
days, with a power of 80% and a .05 level of signifi-
cance.25 Statistical analysis was completed using the
t test or Mann-Whitney U test for continuous data
and the χ2 test or Fischer exact test for categorical
data. Statistical analysis was completed using SPSS
version 20.0.
RESULTS
During the study period, there were 754 infants born
who were between 26 and 37 weeks of gestation and
between 750 and 2000 g. A majority of these infants,
however, were not likely to need tube feeds for more
than 48 hours. Fifty-two infants randomized to each
arm of the study. The trial flow is shown in Figure
1.Table 1 shows the baseline characteristics includ-
ing birth weight, gestational age, and comorbid con-
ditions. None were significantly different between
the 2 groups. The mean birth weight was 1300 g and
mean gestation was 30 to 31 weeks.
Outcomes are shown in Table 2. The primary out-
come of the time to reach full feeds was significantly
lower in the infants who had only AG checked. These
infants reached full feeds 3 days earlier. The second-
ary outcome of duration of hospital stay was lower
in the AG group, but this difference did not reach
statistical significance. There were also fewer with-
held feeds in the AG group, but this was not statisti-
cally significant. In the GRV group, feeds were with-
held because of more than 50% aspirates of previous
feed volume, altered aspirates and bilious aspirates,
and twice due to emesis. In the AG group, feeds were
withheld because of emesis and one occasion when
AG increased by more than 2 cm. There was no mor-
tality in either group. One infant in the GRV group
developed NEC and required a colostomy.
DISCUSSION
This randomized controlled trial showed that mea-
suring AG as a marker for FI, instead of (or without)
assessing GRV enabled preterm infants to reach full
E16 Thomas et al
FIGURE 1
Trial flow. AG indicates abdominal girth; GRV, Gastric residual volumes.
feeds faster. The newborns ranged from 26 weeks to
37 weeks of gestation. Infants less than 26 weeks are
at a higher risk for FI and NEC but were excluded.
This was done to first establish efficacy of AG mea-
surement in slightly more mature neonates before it
is applied to the most vulnerable of infants. Preterm
infants older than 26 weeks were eligible for the
study, including the late preterm infants weighing
more than 1500 g. These late preterm infants were
randomized if they were likely to require gavage
feeds for more than the first 48 hours of life. Thus,
those who participated were sick infants who had
experienced asphyxia, hemodynamic compromise,
or were SGA. While NEC is primarily considered a
disease of prematurity—bigger infants who are SGA
and have polycythemia, asphyxia, early-onset sepsis,
congenital heart disease, or hypotension may
develop NEC.26,27
Several baseline characteristics were compared
between the 2 groups. These included SGA, mater-
nal pregnancy-induced hypertension, maternal mag-
nesium sulfate administration, abnormal fetal Dop-
plers, antenatal glucocorticoid administration, need
for resuscitation, ventilation, hemodynamically sig-
nificant ductus arteriosus, presence of an umbilical
arterial catheter, and the time at which feeds were
started. Small for gestational age, maternal preg-
nancy induced hypertension (PIH), abnormal fetal
Dopplers, need for resuscitation, HSPDA, ventila-
tion, and presence of an umbilical arterial
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Copyright © 2018 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
catheter—all cause hypoxia or ischemia of the gut.28
Magnesium sulfate administration to the mother
causes poor gut motility, thereby increasing FI. Ante-
natal glucocorticoids are protective against NEC.
Time of feed initiation is an important determinant
of time to reach full feeds—infants who receive early
enteral nutrition reach full feeds faster.29 Each of
these baseline characteristics is an independent risk
factor for FI and hence they were compared between
the 2 groups. We found no significant differences in
these baseline characteristics between the groups.
In the only other study we found, Kaur et al25 also
compared GRV and AG. Their results were similar
and the infants in the AG group reached full feeds
significantly earlier. Their population, however, dif-
fered in that they included only VLBW infants, but
excluded SGA infants, and those with asphyxia and
abnormal Dopplers. The present study includes this
“high-risk” population for NEC (30% had abnor-
mal Dopplers, 34% were SGA, and 46% required
resuscitation) and even in this group of infants, we
found that full feeds were reached earlier when only
AG was measured.
The primary concern about FI is differentiating
the progression to NEC. Some authors have shown
a correlation between the volume of aspirates and
NEC. Cobb et al30 in their retrospective case control
study with 51 VLBW infants found that GRV are
increased in infants who subsequently developed
NEC. The infants in their study had increased GRV
 Gastric Residual Volumes Versus Abdominal Girth for Feed Tolerance in Preterm Neonates E17

before the onset of NEC.31 Conversely, Mihatsch17

TABLE 1. Baseline Characteristicsa
and Shulman32 in independent randomized studies
Characteristics GRV (n = 24) AG (n = 26) found no correlation between increased GRV and
Birth weight, gb 1336 ± 346 1312 ± 265.7 NEC. Mihatsch et al17 did a multiple regression
model and found no correlation of green GRV and
Gestation, wkb 30.8 ± 1.5 31.0 ± 1.4 amount of feeds on day 14. Apart from the quantity,
Male, n (%) 16 (61.5) 15 (62.5) the color of the GRV also influences decisions to
SGA, n (%) 8 (30.7) 9 (37.5) withhold feeds. In their study, only frankly hemor-
rhagic residuals were a predictor of NEC and not
PIH in mother, n (%) 12 (46.1) 12 (50)
those that were merely blood stained or bilious.17
Abnormal Doppler, 10 (38.4) 6 (25) In their article, Torrazza et al33 compared 61
n (%) VLBW infants between 24 and 32 weeks of gesta-
Antenatal steroids, 20 (76.9) 21 (87.5) tion, who were randomized into 2 groups—one
n (%) that had GRV measured and the second group
Antenatal magne- 14 (53.8) 16 (66.6) where GRV was not measured. The infants without
sium sulfate, n (%) GRV reached full feeds 6 days earlier. They found
Cesarean delivery, 14 (53.8) 18 (75) no differences in secondary outcomes of sepsis,
n (%) total parenteral nutrition days, or use of central
lines.33 Riskin et al,34 in a recently published study,
Need for resuscita- 10 (38.4) 13 (54.1)
tion, n (%)
compared routine versus selective aspiration for
gastric residuals. They studied nearly 500 preterm
Ventilation, n (%) 18 (69.2) 19 (79.1) infants and found that by restricting assessment of
HSPDA, n (%) 5 (19.2) 3 (12.5) gastric residuals to only those infants with other
Umbilical arterial 1 (3.8) 0 signs of FI, infants reached full feeds significantly
line, n (%) faster. They also had a lower incidence of NEC, but
Time of initiation of 23 (11.5-27.2) 12 (8.25-24)
this incidence was not significant. The neonates in
feeds, hc their study were similar to the present study in
terms of gestation age (∼32 weeks) but were larger
Abbreviations: AG, abdominal girth; GRV, gastric residual
volumes; HSPDA, hemodynamically significant patent ductus (birth weight: 1600 g).
arteriosus; PIH, pregnancy induced hypertension; SGA, small for These prospective studies have not found an asso-
gestational age.
aThere were no significant differences between the 2 groups in
ciation between bilious residuals and NEC14 Gastric
any of the baseline characteristics. residuals in preterm infants are physiological rather
bMean ± SD. than pathological. Preterms have reduced gut motil-
cMedian and interquartile range.
ity due to a low percentage of gastric electrical slow
wave, poor esophageal sphincter tone, and decreased
in the first 3 days of life and 3 days before the onset acid production, all which result in the presence of
of NEC. Their study, however, has been criticized on gastric residuals.4 This, however, is more a sign of
the choice of controls as there was considerable immaturity of the gastrointestinal tract rather than a
overlap between the 2 groups. Bertino et al31 in their sign of FI.6 One author has stated that “checking
study of 17 VLBW infants found that GRV were GRV is a practice searching for evidence!”35
significantly higher in infants who developed NEC. In one published guideline about feeding of pre-
Their findings, however, are limited by sample size term neonates, the authors have recommended that
and that these significant aspirates occurred 17 days GRV be assessed only after an infant reaches some

TABLE 2. Primary and Secondary Outcomes

GRV (n = 24), AG (n = 26),
Outcomes Median (IQR) Median (IQR) P
Time to reach full feeds, d 9.5 (6.75-13.0) 6 (5-7.75) .042
Episodes of feed intolerance 0.5 (0-1) 0 (0-1) .15
No. of feeds withheld 0 (0-15) 0 (0-1.25) .12
Duration of hospital stay, d 30 (14.25-38.75) 21 (13-27) .28
Duration of parenteral nutrition, d 5.5 (3-11.75) 5 (3-7) .21
Sepsis, n 5 4 .61
NEC 1 0
Abbreviations: AG, abdominal girth; GRV, gastric residual volumes; IQR, interquartile range; NEC, necrotizing enterocolitis.

Advances in Neonatal Care • Vol. 18, No. 4

Copyright © 2018 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
E18 Thomas et al

Summary of Recommendations for Practice and Research

What we know:
What needs to be studied:
What we can do today:
•  Checking for GRV delays time to reach full feeds.
•  There is not enough robust evidence to suggest that increased GRV predicts NEC.
•  AG measurement is safe and helps preterm neonates reach full enteral feeds
earlier.
•  The effect of AG measurement on hospital stay, infections, and NEC.
•  Use AG measurement to assess feed tolerance and not check for GRV. Conduct
larger trials with smaller neonates.

feeds. They, however, recommend that AG not be
checked mainly due to a paucity of data.14
Among the secondary outcomes, the duration of
hospital stay was lower in the AG group. This differ-
ence was not statistically significant as the study was
not adequately powered to assess this outcome and the
interquartile range was very wide. Kaur et al25 found a
significant decrease in the need for parenteral nutrition
and length of hospital stay, and the current study did
not find any difference in the incidence of sepsis, need
for parenteral nutrition, episodes of FI, or number of
feeds withheld. It was also encouraging that none of
the infants in the AG group developed NEC.
The strengths of this study are that it is a random-
ized controlled trial and that a feeding protocol was
followed for all infants, thereby minimizing the vari-
ability of feeding decisions in clinical practice. The
limitations are that the smallest infants at highest
risk for FI were not included. The results were not
stratified by gestation or birth weight as we did not
have adequate power for stratification. In addition,
there were 39 infants who were not approached for
consent because of non-availability of the PI and the
need for an extension for the ethical approval.
Implications for Practice
Our research suggests that measurement of AG only
without checking GRV enables preterm neonates to
reach full feeds faster than routinely checking for
GRV. With this study, we have demonstrated feasi-
bility and safety of AG measurement. At first, nurses
in the unit were hesitant to stop checking for GRV
but once the study was completed, they were con-
vinced that deleting this practice will decrease time
to full feeds and may decrease hospital stay.
Implications for Research
Abdominal girth measurement alone as a marker for
feed tolerance needs to be studied in infants weighing
less than 750 g and less than 26 weeks of gestation.
Studies should also be adequately powered to detect
a difference in need for parenteral nutrition, hospital
stay, cost, and safety.
CONCLUSION
Measurement of AG alone without measurement of
GRV compared with the use of routine monitoring of
gastric residual volumes for the assessment of feed tol-
erance results in earlier full enteral feeds in preterm neo-
nates. It may also decrease duration of hospital stay.
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Call for Manuscripts for Ethical Issues in Neonatal Care Section

Share your expertise with your colleagues!

Please consider submitting a manuscript related to ethical issues in
neonatal care that affect your neonatal clinical practices.
Section Overview: The ethics section highlights dilemmas healthcare
providers face in the care of the neonate. Articles may be research based,
opinion pieces, or debates about choosing a course of action. Dilemmas
may be related to challenges in the care for the mother and the fetus or
infant. Controversies in social impact of maternal behavior on the pregnancy
are included. Nurses’ feelings about provision of care to neonates who are
very young, sick, or genetically impaired are reported. Reports on special programs to pro-
vide palliative, hospice or end of life care to newborns are of interest. Concept analysis of
terms that impact neonatal caregiving may be submitted. Book reviews of material related
to ethics are published. Foreign authors are invited to report complexities in their home
countries.
For more details on manuscript submissions. Please see the author guidelines for
Advances in Neonatal Care available at http://edmgr.ovid.com/anc/accounts/ifauth.htm
Please contact the Section Editor, Kathy Ahern, PhD, RN, badiped@gmail.com, with
any ideas or questions.

Advances in Neonatal Care • Vol. 18, No. 4

Copyright © 2018 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.