Abstract
Nudging is a recent effective behavioral strategy
used to improve health outcomes. The principle
component of nudging is choice architecture which
alters the decisions we make while preserving the
individual’s freedom of choice. Nudging strategy
can be applied in NICU in scenarios of limit of
viability and ethical dilemmas whether to continue
life-sustaining treatment or not. This is effective to
promote breastfeeding, improve vaccination status in
children, reduce antibiotic over prescription in viral
illness, to reduce hospital discharge inconsistencies
and to promote hand washing. Nudging may not
be always morally neutral and context dependant.
Doctors need to develop new communication skills
to help parents clarify their values and chose shared
decision making procedure. Transparency about
nudging at the level of guidelines combined with
professional virtues is opted.
References
1. Kalyanaram G. Nudge: Improving
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Happiness20111Richard H. Thaler and
Cass R. Sunstein. Nudge: Improving
Decisions about Health, Wealth, and
Happiness. New Haven, CT: Yale
University Press 2008. 293 pp., ISBN:
978‐0300122237. International Journal
of Pharmaceutical and Healthcare
Marketing. 2011;5(4):349-352.
2. Ortmann A, Rydval O. Behavioral Game
Theory, Colin F. Camerer, 2003, Russell
Sage Foundation, New York, New York/
Princeton University Press, Princeton,
New Jersey, hardcover, 544 pages,
ISBN:0691090394. Journal of Economic
Psychology. 2004;25(5):671-674.
3. Velde F, Overgaard H, Bastien S. Nudge
strategies for behavior-based prevention
and control of neglected tropical
diseases: a scoping review and ethical
assessment. 2020;.
4. Kostick K, Trejo M, Volk R, Estep J,
Blumenthal-Barby J. Using Nudges to
Enhance Clinicians’ Implementation of
Shared Decision Making With Patient
Decision Aids. MDM Policy & Practice.
2020;5(1):238146832091590.
5. Thaler R, Sunstein C. Libertarian
Paternalism. American Economic
Review. 2003;93(2):175-179.
6. Raihani N. Nudge politics: efficacy and
ethics. Frontiers in Psychology. 2013;4.
7. Kelly A. Think Twice: Review of
Thinking, Fast and Slow by Daniel
Kahneman (2011). Numeracy.
2017;10(2).
8. Ploug T, Holm S. Doctors, Patients,
and Nudging in the Clinical Context—
Four Views on Nudging and Informed
Consent. The American Journal of
Bioethics. 2015;15(10):28-38.
9. Mercer B. Periviable Birth and the
Shifting Limit of Viability. Clinics in
Perinatology. 2017;44(2):283-286.
10. Stanak M, Hawlik K. Decision-making
at the limit of viability: the Austrian
neonatal choice context. BMC Pediatrics.
2019;19(1).
11. Mercer B. Periviable Birth and the
Shifting Limit of Viability. Clinics in
Perinatology. 2017;44(2):283-286.
12. Winyard A. The Nuffield Council
on Bioethics Report — Critical
care decisions in fetal and neonatal
medicine: Ethical issues. Clinical Risk.
2007;13(2):70-73.
13.Guillen U, Weiss E, Munson D,
Maton P, Jefferies A, Norman M et
al. Guidelines for the Management
of Extremely Premature Deliveries:
A Systematic Review. PEDIATRICS.
2015;136(2):343-350.
14.Liu J, Chen XX, Wang XL. Ethical issues
in neonatal intensive care units. J Matern
Fetal Neonatal Med. 2016;29(14):2322-6.
doi: 10.3109/14767058.2015.1085016.
Epub 2015 Sep 18. PMID: 26382713
15. Mills B, Janvier A, Argus B, Davis P,
Frøisland D. Attitudes of Australian
neonatologists to resuscitation of
~425~˷
Review Article Medical Journal of Pokhara Academy of Health Sciences Vol. 4 Issue 2 July-December 2021
extremely preterm infants. Journal
of Paediatrics and Child Health.
2015;51(9):870-874.
16. Weir M, Evans M, Coughlin K. Ethical
Decision Making in the Resuscitation
of Extremely Premature Infants: The
Health Care Professional’s Perspective.
Journal of Obstetrics and Gynaecology
Canada. 2011;33(1):49-56.
17.Janvier A, Barrington K, Farlow B.
Communication with parents concerning
withholding or withdrawing of lifesustaining interventions in neonatology.
Seminars in Perinatology. 2014;38(1):38-
46.
18.Stanak M. Nudging in Neonatology:
Practical Wisdom and Accountability for
Reasonableness. International Journal of
Technology Assessment in Health Care.
2019;35(1):5-9.
19.AAP Executive Committee Response.
PEDIATRICS. 2012;129(5):991-991.
20.Kramer M, Kakuma R. Optimal duration
of exclusive breastfeeding. Cochrane
Database of Systematic Reviews. 2012;.
21. Brown K. WHO/UNICEF Review
on Complementary Feeding and
Suggestions for Future Research:
WHO/UNICEF Guidelines on
Complementary Feeding. Pediatrics.
2000;106(Supplement_4):1290-1290.
22.Timing of initiation, patterns of
breastfeeding, and infant survival:
prospective analysis of pooled data from
three randomised trials. The Lancet
Global Health. 2016;4(4):e266-e275.
23. Dewey K, Cohen R, Brown K, Rivera
L. Effects of Exclusive Breastfeeding
for Four versus Six Months on
Maternal Nutritional Status and Infant
Motor Development: Results of Two
Randomized Trials in Honduras. The
Journal of Nutrition. 2001;131(2):262-
267.
24.Merewood, A, Mehta, SD, Chamberlain,
LB, Philipp, BL, Bauchner,
H. Breastfeeding rates in US BabyFriendly hospitals: results of a national
survey. Pediatrics. 2005;116: 628-634.
25.Pérez-Escamilla R, Chapman D.
Breastfeeding Protection, Promotion,
and Support in the United States. Journal
of Human Lactation. 2012;28(2):118-
121.
26.Rea, MF . A review of breastfeeding in
Brazil and how the country has reached
ten months’ breastfeeding duration
[article in Portuguese]. Cad Saude
Publica. 2003;19(Suppl 1):S37-45
27.Giubilini, A., Caviola, L., Maslen, H. et
al. Nudging Immunity: The Case for
Vaccinating Children in School and Day
Care by Default. HEC Forum 31, 325–
344 (2019). https://doi.org/10.1007/
s10730-019-09383-7
28.DiBonaventura M, Chapman G. Do
Decision Biases Predict Bad Decisions?
Omission Bias, Naturalness Bias, and
Influenza Vaccination. Medical Decision
Making. 2008;28(4):532-539.
29.Everett J, Caviola L, Kahane G,
Savulescu J, Faber N. Doing good by
doing nothing? The role of social norms
in explaining default effects in altruistic
contexts. European Journal of Social
Psychology. 2014;45(2):230-241.
30. Chapman G, Li M, Colby H, Yoon H.
Opting In vs Opting Out of Influenza
Vaccination. JAMA. 2010;304(1):43.
31.Reiter P, McRee A, Pepper J, Brewer N.
Default policies and parents’ consent for
school-located HPV vaccination. Journal
of Behavioral Medicine. 2012;35(6):651-
657.
32.Larson H, Jarrett C, Eckersberger E,
Smith D, Paterson P. Understanding
vaccine hesitancy around vaccines and
vaccination from a global perspective: A
systematic review of published literature,
2007–2012. Vaccine. 2014;32(19):2150-
2159.
Nudge Theory and Role of Nudging Strategies in Neonatology and Child Health. Paudel R et. al.
~426~˷
Review Article Medical Journal of Pokhara Academy of Health Sciences Vol. 4 Issue 2 July-December 2021
33.Navin M. The Ethics of Vaccination
Nudges in Pediatric Practice. HEC
Forum. 2016;29(1):43-57.
34. Berry JG, Blaine K, Rogers J, McBride
S, Schor E, Birmingham J, et al. A
framework of pediatric hospital
discharge care informed by legislation,
research, and practice. JAMA Pediatr.
2014;168:955–66
35.Jack B, Greenwald J, Forsythe S,
O’Donnell J, Johnson A, Schipelliti
L, et al. Developing the tools to
administer a comprehensive hospital
discharge program: the reengineered
discharge (RED) program In: Henriksen
K, Battles J, Keye M, eds. Advances
in Patient Safety: New Directions
and Alternative Approaches. Vol. 3:
Rockville, MD: AHRQ Publication; No.
08-0034-3; 2008
36.Leets, Laura L et al. “Nudging Discharge
Readiness With a Poster: A Sequential,
Exploratory Mixed Methods Pilot Study
of Patient Caregivers.” Journal of patient
experience vol. 7,6 (2020): 1341-1348.
doi:10.1177/2374373520968976
37.Kripalani S, Jackson AT, Schnipper
JL, Coleman EA. Promoting effective
transitions of care at hospital discharge:
a review of key issues for hospitalists. J
Hosp Med. 2007;2:314–23
38.Sanders M, Stockdale E, Hume S, John
P. Loss aversion fails to replicate in the
coronavirus pandemic: Evidence from an
online experiment. Economics Letters.
2021;199:109433.
39.Dreibelbis R, Kroeger A, Hossain
K, Venkatesh M, Ram PK. Behavior
Change without Behavior Change
Communication: Nudging Handwashing
among Primary School Students in
Bangladesh. Int J Environ Res Public
Health. 2016;13(1):129. Published 2016
Jan 14. doi:10.3390/ijerph13010129
40.McDonagh MS, Peterson K, Winthrop
K, Cantor A, Lazur BH, Buckley DI.
Interventions to reduce inappropriate
prescribing of antibiotics for acute
respiratory tract infections: summary
and update of a systematic review. J
Int Med Res. 2018;46(8):3337-3357.
doi:10.1177/0300060518782519
41. Dooling KL, Shapiro DJ, Van
Beneden C, et al. Overprescribing
and inappropriate antibiotic selection
for children with pharyngitis in the
United States, 1997–2010. JAMA
Pediatrics 2014; 168: 1073–1074
42.Barlam TF, Morgan JR, Wetzler LM,
et al. Antibiotics for respiratory tract
infections: a comparison of prescribing
in an outpatient setting. Infect Control
Hosp Epidemiol 2015; 36: 153–159
43.Magin PJ, Morgan S, Tapley A, et
al. Changes in early-career family
physicians' antibiotic prescribing
for upper respiratory tract infection
and acute bronchitis: a multicentre
longitudinal study. Fam Pract 2016; 33:
360–367.
44.Meeker D, Knight TK, Friedberg MW,
Linder JA, Goldstein NJ Nudging
Guideline-Concordant Antibiotic
Prescribing: A Randomized Clinical
Trial. JAMA Intern Med. 2014
doi:10.1001/jamainternmed.2013.14191
45.Nudge vs Superbugs A behavioural
economics trial to reduce the
overprescribing of antibiotics June
2018 Nudge vs | Course Hero [Internet].
Coursehero.com. 2021 [cited 5 June
2021]. Available from: https://www.
coursehero.com/file/78357059/reportnudge-vs-superbugsdocx/
46.Persell SD, Doctor JN, Friedberg MW,
et al. Behavioral interventions to reduce
inappropriate antibiotic prescribing:
a randomized pilot trial. BMC Infect
Dis 2016; 16: 373
47.Litvin CB, Ornstein SM, Wessell
AM, et al. Use of an electronic health
record clinical decision support tool to
~427~˷
Review Article Medical Journal of Pokhara Academy of Health Sciences Vol. 4 Issue 2 July-December 2021
improve antibiotic prescribing for acute
respiratory infections: the ABX-TRIP
study. J Gen Intern Med 2013; 28: 810–
816
48.Pellegrino, E. D. 2009. Professing
Medicine, Virtue Based Ethics, and the
Retrieval of Professionalism. In Working
Virtue, eds. R. L. Walker, and P. J.
Ivanhoe. London: Oxford University
Press
49.Draper H. Practical Decision Making in
Health Care Ethics: Cases and Concepts:
Raymond J Devettere, Washington DC,
Georgetown University Press, 2000,
639 pages, pound25.25, $35. Journal of
Medical Ethics. 2001;27(3):208-208.
50.Stanak M Professional ethics: The case
of neonatology. Med Health Care Philos.
(2018) doi: 10.1007/s11019-018-9863-
9.
Decisions about Health, Wealth, and
Happiness20111Richard H. Thaler and
Cass R. Sunstein. Nudge: Improving
Decisions about Health, Wealth, and
Happiness. New Haven, CT: Yale
University Press 2008. 293 pp., ISBN:
978‐0300122237. International Journal
of Pharmaceutical and Healthcare
Marketing. 2011;5(4):349-352.
2. Ortmann A, Rydval O. Behavioral Game
Theory, Colin F. Camerer, 2003, Russell
Sage Foundation, New York, New York/
Princeton University Press, Princeton,
New Jersey, hardcover, 544 pages,
ISBN:0691090394. Journal of Economic
Psychology. 2004;25(5):671-674.
3. Velde F, Overgaard H, Bastien S. Nudge
strategies for behavior-based prevention
and control of neglected tropical
diseases: a scoping review and ethical
assessment. 2020;.
4. Kostick K, Trejo M, Volk R, Estep J,
Blumenthal-Barby J. Using Nudges to
Enhance Clinicians’ Implementation of
Shared Decision Making With Patient
Decision Aids. MDM Policy & Practice.
2020;5(1):238146832091590.
5. Thaler R, Sunstein C. Libertarian
Paternalism. American Economic
Review. 2003;93(2):175-179.
6. Raihani N. Nudge politics: efficacy and
ethics. Frontiers in Psychology. 2013;4.
7. Kelly A. Think Twice: Review of
Thinking, Fast and Slow by Daniel
Kahneman (2011). Numeracy.
2017;10(2).
8. Ploug T, Holm S. Doctors, Patients,
and Nudging in the Clinical Context—
Four Views on Nudging and Informed
Consent. The American Journal of
Bioethics. 2015;15(10):28-38.
9. Mercer B. Periviable Birth and the
Shifting Limit of Viability. Clinics in
Perinatology. 2017;44(2):283-286.
10. Stanak M, Hawlik K. Decision-making
at the limit of viability: the Austrian
neonatal choice context. BMC Pediatrics.
2019;19(1).
11. Mercer B. Periviable Birth and the
Shifting Limit of Viability. Clinics in
Perinatology. 2017;44(2):283-286.
12. Winyard A. The Nuffield Council
on Bioethics Report — Critical
care decisions in fetal and neonatal
medicine: Ethical issues. Clinical Risk.
2007;13(2):70-73.
13.Guillen U, Weiss E, Munson D,
Maton P, Jefferies A, Norman M et
al. Guidelines for the Management
of Extremely Premature Deliveries:
A Systematic Review. PEDIATRICS.
2015;136(2):343-350.
14.Liu J, Chen XX, Wang XL. Ethical issues
in neonatal intensive care units. J Matern
Fetal Neonatal Med. 2016;29(14):2322-6.
doi: 10.3109/14767058.2015.1085016.
Epub 2015 Sep 18. PMID: 26382713
15. Mills B, Janvier A, Argus B, Davis P,
Frøisland D. Attitudes of Australian
neonatologists to resuscitation of
~425~˷
Review Article Medical Journal of Pokhara Academy of Health Sciences Vol. 4 Issue 2 July-December 2021
extremely preterm infants. Journal
of Paediatrics and Child Health.
2015;51(9):870-874.
16. Weir M, Evans M, Coughlin K. Ethical
Decision Making in the Resuscitation
of Extremely Premature Infants: The
Health Care Professional’s Perspective.
Journal of Obstetrics and Gynaecology
Canada. 2011;33(1):49-56.
17.Janvier A, Barrington K, Farlow B.
Communication with parents concerning
withholding or withdrawing of lifesustaining interventions in neonatology.
Seminars in Perinatology. 2014;38(1):38-
46.
18.Stanak M. Nudging in Neonatology:
Practical Wisdom and Accountability for
Reasonableness. International Journal of
Technology Assessment in Health Care.
2019;35(1):5-9.
19.AAP Executive Committee Response.
PEDIATRICS. 2012;129(5):991-991.
20.Kramer M, Kakuma R. Optimal duration
of exclusive breastfeeding. Cochrane
Database of Systematic Reviews. 2012;.
21. Brown K. WHO/UNICEF Review
on Complementary Feeding and
Suggestions for Future Research:
WHO/UNICEF Guidelines on
Complementary Feeding. Pediatrics.
2000;106(Supplement_4):1290-1290.
22.Timing of initiation, patterns of
breastfeeding, and infant survival:
prospective analysis of pooled data from
three randomised trials. The Lancet
Global Health. 2016;4(4):e266-e275.
23. Dewey K, Cohen R, Brown K, Rivera
L. Effects of Exclusive Breastfeeding
for Four versus Six Months on
Maternal Nutritional Status and Infant
Motor Development: Results of Two
Randomized Trials in Honduras. The
Journal of Nutrition. 2001;131(2):262-
267.
24.Merewood, A, Mehta, SD, Chamberlain,
LB, Philipp, BL, Bauchner,
H. Breastfeeding rates in US BabyFriendly hospitals: results of a national
survey. Pediatrics. 2005;116: 628-634.
25.Pérez-Escamilla R, Chapman D.
Breastfeeding Protection, Promotion,
and Support in the United States. Journal
of Human Lactation. 2012;28(2):118-
121.
26.Rea, MF . A review of breastfeeding in
Brazil and how the country has reached
ten months’ breastfeeding duration
[article in Portuguese]. Cad Saude
Publica. 2003;19(Suppl 1):S37-45
27.Giubilini, A., Caviola, L., Maslen, H. et
al. Nudging Immunity: The Case for
Vaccinating Children in School and Day
Care by Default. HEC Forum 31, 325–
344 (2019). https://doi.org/10.1007/
s10730-019-09383-7
28.DiBonaventura M, Chapman G. Do
Decision Biases Predict Bad Decisions?
Omission Bias, Naturalness Bias, and
Influenza Vaccination. Medical Decision
Making. 2008;28(4):532-539.
29.Everett J, Caviola L, Kahane G,
Savulescu J, Faber N. Doing good by
doing nothing? The role of social norms
in explaining default effects in altruistic
contexts. European Journal of Social
Psychology. 2014;45(2):230-241.
30. Chapman G, Li M, Colby H, Yoon H.
Opting In vs Opting Out of Influenza
Vaccination. JAMA. 2010;304(1):43.
31.Reiter P, McRee A, Pepper J, Brewer N.
Default policies and parents’ consent for
school-located HPV vaccination. Journal
of Behavioral Medicine. 2012;35(6):651-
657.
32.Larson H, Jarrett C, Eckersberger E,
Smith D, Paterson P. Understanding
vaccine hesitancy around vaccines and
vaccination from a global perspective: A
systematic review of published literature,
2007–2012. Vaccine. 2014;32(19):2150-
2159.
Nudge Theory and Role of Nudging Strategies in Neonatology and Child Health. Paudel R et. al.
~426~˷
Review Article Medical Journal of Pokhara Academy of Health Sciences Vol. 4 Issue 2 July-December 2021
33.Navin M. The Ethics of Vaccination
Nudges in Pediatric Practice. HEC
Forum. 2016;29(1):43-57.
34. Berry JG, Blaine K, Rogers J, McBride
S, Schor E, Birmingham J, et al. A
framework of pediatric hospital
discharge care informed by legislation,
research, and practice. JAMA Pediatr.
2014;168:955–66
35.Jack B, Greenwald J, Forsythe S,
O’Donnell J, Johnson A, Schipelliti
L, et al. Developing the tools to
administer a comprehensive hospital
discharge program: the reengineered
discharge (RED) program In: Henriksen
K, Battles J, Keye M, eds. Advances
in Patient Safety: New Directions
and Alternative Approaches. Vol. 3:
Rockville, MD: AHRQ Publication; No.
08-0034-3; 2008
36.Leets, Laura L et al. “Nudging Discharge
Readiness With a Poster: A Sequential,
Exploratory Mixed Methods Pilot Study
of Patient Caregivers.” Journal of patient
experience vol. 7,6 (2020): 1341-1348.
doi:10.1177/2374373520968976
37.Kripalani S, Jackson AT, Schnipper
JL, Coleman EA. Promoting effective
transitions of care at hospital discharge:
a review of key issues for hospitalists. J
Hosp Med. 2007;2:314–23
38.Sanders M, Stockdale E, Hume S, John
P. Loss aversion fails to replicate in the
coronavirus pandemic: Evidence from an
online experiment. Economics Letters.
2021;199:109433.
39.Dreibelbis R, Kroeger A, Hossain
K, Venkatesh M, Ram PK. Behavior
Change without Behavior Change
Communication: Nudging Handwashing
among Primary School Students in
Bangladesh. Int J Environ Res Public
Health. 2016;13(1):129. Published 2016
Jan 14. doi:10.3390/ijerph13010129
40.McDonagh MS, Peterson K, Winthrop
K, Cantor A, Lazur BH, Buckley DI.
Interventions to reduce inappropriate
prescribing of antibiotics for acute
respiratory tract infections: summary
and update of a systematic review. J
Int Med Res. 2018;46(8):3337-3357.
doi:10.1177/0300060518782519
41. Dooling KL, Shapiro DJ, Van
Beneden C, et al. Overprescribing
and inappropriate antibiotic selection
for children with pharyngitis in the
United States, 1997–2010. JAMA
Pediatrics 2014; 168: 1073–1074
42.Barlam TF, Morgan JR, Wetzler LM,
et al. Antibiotics for respiratory tract
infections: a comparison of prescribing
in an outpatient setting. Infect Control
Hosp Epidemiol 2015; 36: 153–159
43.Magin PJ, Morgan S, Tapley A, et
al. Changes in early-career family
physicians' antibiotic prescribing
for upper respiratory tract infection
and acute bronchitis: a multicentre
longitudinal study. Fam Pract 2016; 33:
360–367.
44.Meeker D, Knight TK, Friedberg MW,
Linder JA, Goldstein NJ Nudging
Guideline-Concordant Antibiotic
Prescribing: A Randomized Clinical
Trial. JAMA Intern Med. 2014
doi:10.1001/jamainternmed.2013.14191
45.Nudge vs Superbugs A behavioural
economics trial to reduce the
overprescribing of antibiotics June
2018 Nudge vs | Course Hero [Internet].
Coursehero.com. 2021 [cited 5 June
2021]. Available from: https://www.
coursehero.com/file/78357059/reportnudge-vs-superbugsdocx/
46.Persell SD, Doctor JN, Friedberg MW,
et al. Behavioral interventions to reduce
inappropriate antibiotic prescribing:
a randomized pilot trial. BMC Infect
Dis 2016; 16: 373
47.Litvin CB, Ornstein SM, Wessell
AM, et al. Use of an electronic health
record clinical decision support tool to
~427~˷
Review Article Medical Journal of Pokhara Academy of Health Sciences Vol. 4 Issue 2 July-December 2021
improve antibiotic prescribing for acute
respiratory infections: the ABX-TRIP
study. J Gen Intern Med 2013; 28: 810–
816
48.Pellegrino, E. D. 2009. Professing
Medicine, Virtue Based Ethics, and the
Retrieval of Professionalism. In Working
Virtue, eds. R. L. Walker, and P. J.
Ivanhoe. London: Oxford University
Press
49.Draper H. Practical Decision Making in
Health Care Ethics: Cases and Concepts:
Raymond J Devettere, Washington DC,
Georgetown University Press, 2000,
639 pages, pound25.25, $35. Journal of
Medical Ethics. 2001;27(3):208-208.
50.Stanak M Professional ethics: The case
of neonatology. Med Health Care Philos.
(2018) doi: 10.1007/s11019-018-9863-
9.
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