Parental professional help-seeking for infant sleep.

AIMS AND OBJECTIVES: To explore the perceptions and experiences of parental professional help-seeking for infant sleep and sleep-related concerns. BACKGROUND: Infant sleep is a frequent concern for parents. However, very little is known about the reasons parents seek, do not seek or delay seeking professional attention about their concerns related to infant sleep. DESIGN AND METHODS: A qualitative study design was used. Twenty audio-taped interviews with parents of healthy 12-month-old infants were conducted at a university-affiliated hospital or parents' homes depending on where parents felt more comfortable discussing their personal views and medical help-seeking experiences. Thematic content analysis was performed to determine specific patterns and similarities within and between interview data. FINDINGS: Three main themes developed from the interviews were as follows: (i) uncertainty about infant sleep; (ii) I can handle infant sleep; and (iii) I am not satisfied with the professional services provided for infant sleep. Overall, parents knew little about or misunderstood infant sleep behaviours. Lack of proper information and knowledge about infant sleep influenced parents' motivation for professional help-seeking and help-receiving. Parents who have consulted a healthcare professional but received unsatisfactory responses, such as an ambivalent attitude or insufficient assessment, reported being less motivated or unwilling to seek medical help again. CONCLUSION: Our study demonstrates the complexity of parental professional help-seeking and receiving for infant sleep. Findings suggest that parents perceive a wide range of barriers that influence the likelihood that they will seek professional advice for infant sleep. RELEVANCE TO CLINICAL PRACTICE: Reducing knowledge barriers and providing adequate attention at all well-infant visits would facilitate parental use of healthcare services to manage problematic infant sleep behaviours.

Light and maternal influence in the entrainment of activity circadian rhythm in infants 4-12 weeks of age.

The influence of light and maternal activity on early infant activity rhythm were studied in 43 healthy, maternal-infant pairs. Aims included description of infant and maternal circadian rhythm of environmental light, assessing relations among of activity and light circadian rhythm parameters, and exploring the influence of light on infant activity independent of maternal activity. Three-day light and activity records were obtained using actigraphy monitors at infant ages 4, 8, and 12 weeks. Circadian rhythm timing, amplitude, 24-hour fit, rhythm center, and regularity were determined using cosinor and nonparametric circadian rhythm analyses (NPCRA). All maternal and infant circadian parameters for light were highly correlated. When maternal activity was controlled, the partial correlations between infant activity and light rhythm timing, amplitude, 24-hour fit, and rhythm center demonstrated significant relation (r = .338 to .662) at infant age 12 weeks, suggesting entrainment. In contrast, when maternal light was controlled there was significant relation between maternal and infant activity rhythm (r = 0.470, 0.500, and 0.638 at 4, 8 and 12 weeks, respectively) suggesting the influence of maternal-infant interaction independent of photo entrainment of cycle timing over the first 12 weeks of life. Both light and maternal activity may offer avenues for shaping infant activity rhythm during early infancy.

Sleep, Depression, and Fatigue in Late Postpartum.

PURPOSE: To study the relation of infant characteristics and home environment on maternal sleep, depression, and fatigue in late postpartum. STUDY DESIGN AND METHODS: Forty-two healthy mother-infant dyads completed a home-based study at infant age 32 weeks. Maternal measures included Patient Reported Outcomes Measurement Information System (PROMIS) sleep and wake disturbance, depression, and fatigue scales. Home regularity was assessed using the Confusion, Hubbub, and Order Scale (CHAOS). Infant sleep and regulation were measured respectively by the Brief Infant Sleep Questionnaire (BISQ) and Infant-Toddler Symptom Checklist (ITSC). RESULTS: Significant correlations among maternal sleep and wake disturbance, fatigue, and depression were detected (r = .519 to .746, p < .01), but not with infant variables. Home regularity was significantly related with maternal variables (r = .597 to .653, p < .01). CLINICAL IMPLICATIONS: Regularity of the home environment appears to contribute to maternal sleep, depression, and fatigue. Implications for intervention include establishment of daily routines and household management to improve regularity and consequently improve maternal outcomes.

Maternal and infant activity: Analytic approaches for the study of circadian rhythm.

The study of infant and mother circadian rhythm entails choice of instruments appropriate for use in the home environment as well as selection of analytic approach that characterizes circadian rhythm. While actigraphy monitoring suits the needs of home study, limited studies have examined mother and infant rhythm derived from actigraphy. Among this existing research a variety of analyses have been employed to characterize 24-h rhythm, reducing ability to evaluate and synthesize findings. Few studies have examined the correspondence of mother and infant circadian parameters for the most frequently cited approaches: cosinor, non-parametric circadian rhythm analysis (NPCRA), and autocorrelation function (ACF). The purpose of this research was to examine analytic approaches in the study of mother and infant circadian activity rhythm. Forty-three healthy mother and infant pairs were studied in the home environment over a 72h period at infant age 4, 8, and 12 weeks. Activity was recorded continuously using actigraphy monitors and mothers completed a diary. Parameters of circadian rhythm were generated from cosinor analysis, NPCRA, and ACF. The correlation among measures of rhythm center (cosinor mesor, NPCRA mid level), strength or fit of 24-h period (cosinor magnitude and R(2), NPCRA amplitude and relative amplitude (RA)), phase (cosinor acrophase, NPCRA M10 and L5 midpoint), and rhythm stability and variability (NPCRA interdaily stability (IS) and intradaily variability (IV), ACF) was assessed, and additionally the effect size (eta(2)) for change over time evaluated. Results suggest that cosinor analysis, NPCRA, and autocorrelation provide several comparable parameters of infant and maternal circadian rhythm center, fit, and phase. IS and IV were strongly correlated with the 24-h cycle fit. The circadian parameters analyzed offer separate insight into rhythm and differing effect size for the detection of change over time. Findings inform selection of analysis and circadian parameters in the study of maternal and infant activity rhythm.

Mother-infant circadian rhythm: development of individual patterns and dyadic synchrony.

BACKGROUND: Mutual circadian rhythm is an early and essential component in the development of maternal-infant physiological synchrony. AIMS: The aim of this to examine the longitudinal pattern of maternal-infant circadian rhythm and rhythm synchrony as measured by rhythm parameters. STUDY DESIGN: In-home dyadic actigraphy monitoring at infant age 4, 8, and 12 weeks. SUBJECTS: Forty-three healthy mother-infant pairs. OUTCOME MEASURES: Circadian parameters derived from cosinor and non-parametric analysis including mesor, magnitude, acrophase, L5 and M10 midpoints (midpoint of lowest 5 and highest 10h of activity), amplitude, interdaily stability (IS), and intradaily variability (IV). RESULTS: Mothers experienced early disruption of circadian rhythm, with re-establishment of rhythm over time. Significant time effects were noted in increasing maternal magnitude, amplitude, and IS and decreasing IV (p<.001). Infants demonstrated a developmental trajectory of circadian pattern with significant time effects for increasing mesor, magnitude, amplitude, L5, IS, and IV (p<.001). By 12 weeks, infant phase advancement was evidenced by mean acrophase and M10 midpoint occurring 60 and 43 min (respectively) earlier than at 4 weeks. While maternal acrophase remained consistent over time, infants became increasingly phase advanced relative to mother and mean infant acrophase at 12 weeks occurred 60 min before mother. Mother-infant synchrony was evidenced in increasing correspondence of acrophase at 12 weeks (r=0.704), L5 (r=0.453) and M10 (r=0.479) midpoints. CONCLUSIONS: Development of mother-infant synchrony reflects shared elements of circadian rhythm.

Quantification of neonatal amplitude-integrated EEG patterns.

BACKGROUND: Amplitude-integrated EEG (aEEG) is increasingly used in research with premature infants; however, comprehensive interpretation is limited by the lack of simple approaches for reliably quantifying and summarizing the data. AIM: Explore operational measures for quantifying continuity and discontinuity, measured by aEEG as components of infant brain function. STUDY DESIGN: An exploratory naturalistic study of neonates while in the Neonatal Intensive Care Unit (NICU). One single channel aEEG recording per infant was obtained without disruption of nursing care practices. SUBJECTS: 24 infants with mean postmenstrual age (PMA) of 33.11 weeks (SD 3.49), average age of 2.62 weeks (SD 1.35) and mean birth weights of 1.39 kg (SD 0.73). OUTCOME MEASURES: Quantification of continuity and discontinuity included bandwidth and lower border of aEEG, calculated proportion of time with signal amplitude below 10 µV, and peak counts. Variance of bandwidth and lower border denoted cycling. RESULTS: Group mean bandwidth was 52.98 µV (SD 27.62). Median peak count in 60 second epochs averaged 3.63 (SD 1.74), while median proportion < 10 µV was 22% (SD 0.20). The group mean of lower border within-subject aggregated medians was 6.20 µV (SD 2.13). Group mean lower border standard deviation was 3.96 µV. Proportion < 10 µV showed a strong negative correlation with the natural log of the lower border median (r = -0.906, p < .0001) after controlling for PMA. CONCLUSIONS: This study introduces a novel quantification process by counting peaks and proportion of time < 10 µV. Expanded definitions and analytic techniques will serve to strengthen the application of existing scoring systems for use in naturalistic research settings and clinical practice.

Parents' responses to stress in the neonatal intensive care unit.

Background Parents' stress resulting from hospitalization of their infant in the neonatal intensive care unit (NICU) produces emotional and behavioral responses. The National Institutes of Health-sponsored Patient Reported Outcomes Measurement Information System (PROMIS) offers a valid and efficient means of assessing parents' responses. Objective To examine the relationship of stress to anxiety, depression, fatigue, and sleep disruption among parents of infants hospitalized in the NICU. Methods Thirty parents completed the Parental Stressor Scale (PSS:NICU) containing subscales for NICU Sights and Sounds, Infant Behavior and Appearance, and Parental Role Alteration, and the PROMIS anxiety, depression, fatigue, and sleep disturbance short-form instruments. Results PSS total score was significantly correlated with anxiety (r = 0.61), depression (r = 0.36), and sleep disturbance (r = 0.60). Scores for NICU Sights and Sounds were not significantly correlated with parents' outcomes; however, scores for Alteration in Parenting Role were correlated with all 4 outcomes, and scores for Infant Appearance were correlated with all except fatigue. Conclusion Stress experienced by parents of NICU infants is associated with a concerning constellation of physical and emotional outcomes comprising anxiety, depression, fatigue, and sleep disruption.

Sleep disturbances and depressive symptoms in healthy postpartum women: a pilot study.

In this pilot study we examined the relationship between objective and subjective sleep disturbances and depressive symptoms in 22 healthy primiparous postpartum women within 3 months after delivery. We found that none of the women in our study had clinically significant depression scores on the Edinburgh Postnatal Depression Scale; nonetheless, a variable duration of night-time sleep from night to night during the 7-day monitoring period and reported awakening too early were significantly correlated with increased depressive symptoms. Results suggest that first-time mothers who complain of irregular night-time sleep duration and waking up too early should be screened and evaluated for potential postpartum depressive symptoms.

Daily sleep and fatigue characteristics in nulliparous women during the third trimester of pregnancy.

OBJECTIVES: To examine the association among nighttime sleep and daytime napping behaviors, depressive symptoms, and perception of fatigue in pregnant women. DESIGN: A prospective descriptive study with within-subject design. SETTING: A university-affiliated hospital and participants' home environments. PARTICIPANTS: Thirty-eight third trimester nulliparous women completed sleep and depressive symptom questionnaires, wore a wrist actigraphy monitor for 7 consecutive days, and kept a concurrent diary reporting naps and rating their level of fatigue using a 0-10 visual analogue scale each morning, midday, afternoon, and evening. A generalized estimating equation regression model was applied to evaluate the time-dependent association. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Mean duration of total nighttime sleep by actigraphy was 386.3 ± 60.7 min, with 11 (28.9%) women having an average total nighttime sleep < 6 h. Nineteen women (50%) napped > 3 days, and only 2 women did not nap over the entire week. Antecedent night sleep duration had a significant inverse association with morning (P = 0.022) and afternoon fatigue (P = 0.009) of the subsequent day. Self-reported naps were significantly associated with midday fatigue (P = 0.003). More depressive symptoms predicted more severe fatigue throughout the day. CONCLUSIONS: Results suggest that interventions designed to increase sleep duration and decrease depressive symptoms have the potential to prevent, ameliorate, or reduce fatigue in pregnant women. Depressive symptoms during pregnancy likely share some psychological and behavioral tendencies with fatigue and/or sleep disturbance which may complicate the evaluation of intervention effect.

Light is beneficial for infant circadian entrainment: an actigraphic study.

AIM: This article is a report of an exploratory study of the relation between light exposure and circadian rest-activity patterns in infants. BACKGROUND: Ambient light is a major environmental stimulus for regulation of circadian rhythm of sleep and wake in adults, but few studies have been conducted to examine environmental light exposure in relation to rest-activity circadian rhythm parameters of infants. METHODS: An intensive within-subject design was used with a convenience sample of 22 infants (mean postnatal age 49·8 days) who wore a combined light and activity monitoring device for seven consecutive days at home. For each infant, light data (lux) were aggregated over the 7 days into categories of illumination and expressed in mean minutes/day. Circadian light and activity parameters, including mesor, amplitude, acrophase and R(2) cosinor fit, were determined using cosinor analysis. Associations between light exposure and circadian rest-activity rhythm parameters were examined using correlation and regression analyses. Data were collected between 2006 and 2007. RESULTS: Infants spent only one-eighth of their daytime hours in an environment with >100 lux light level. There was a relatively large statistically significant relation between the acrophase of light exposure and the acrophase of activity. Increased duration of daily exposure to >100 lux of illumination, and increased amplitude of circadian rhythm of light were associated with stronger circadian patterns of infant activity. CONCLUSION: Results suggest an association between light and activity patterns and that increasing duration of exposure to moderate light levels may be a simple and economical nursing intervention during the early postnatal weeks.

Electrode challenges in amplitude-integrated electroencephalography (aEEG): research application of a novel noninvasive measure of brain function in preterm infants.

Continuous real-time brain function monitoring of preterm infants offers a novel way to evaluate neurological development in neonatal intensive care. Direct measurement of brain function is difficult and complicated by vulnerabilities of the preterm infant population. This study illustrates the feasibility of using noninvasive hydrogel electrodes with amplitude-integrated electroencephalography (aEEG) as a simplified brain monitor in preterm infants. This article presents a systematic exploration of factors influencing the accuracy of aEEG measurement, especially skin preparation procedures and skin condition after electrode placement. The authors conducted aEEG recordings on 16 medically stable preterm infants at 31-36 weeks postmenstrual age in the neonatal intensive care unit between feedings and caregiving for approximately 3 hr. The authors systematically performed several strategies to improve electrode placement procedures and reduce skin impedance, including (a) examination of possible influences of environmental electrical equipment, (b) comparison of different hydrogel electrode types, (c) modification of skin preparation procedures, and (d) assessment of impacts of different skin conditions. The authors achieved improvements in the impedance value, length of uninterrupted recording, and percentage of the recording duration with measured impedance <20 kΩ (recommended acceptable limit). There was no report of skin irritation during or after the recording. The aEEG measurement at the bedside using hydrogel electrodes is noninvasive and feasible for reliable brain monitoring in preterm infants. This study demonstrated the importance of establishing systematic methods to ensure the accuracy and feasibility of physiologic measurements for nurse researchers.

Mother-infant activity synchrony as a correlate of the emergence of circadian rhythm.

OBJECTIVE: Entrainment to the day-night cycle is critical for infant sleep and social development. Synchronization of infant circadian systems with the social 24-hr day may require maternal activity signals as an entraining cue. This descriptive and exploratory research examines the activity level and circadian pattern in mothers and infants. METHOD: Twenty-two healthy mothers and their infants (postnatal age 49.8 ± 17.1 days) wore actigraph monitors for seven days. Daytime (06:00-21:59) and nighttime (22:00-05:59) activity levels and circadian parameters of rest-activity patterns (i.e., mesor, amplitude, acrophase, and 24-hr cosinor fit) were calculated. RESULTS: Mothers and infants were significantly more active during the day than at night. The goodness-of-fit index for the model (R2) indicates that circadian rhythm accounted for a mean of 29 ± 10% and 12 ± 8% of the variability in maternal and infant activity, respectively. Acrophase of activity occurred at 15:46 ± 1:07 for the mothers and 15:20 ± 1:21 for the infants. The mean within-dyad correlation of activity counts was r = .46 ± .11, and the within-dyad correlation was associated with the amplitude (r = .66, p < .01) and 24-hr cosinor fit of infant activity (r = .67, p < .01). CONCLUSIONS: Our findings suggest maternal rhythms as a possible exogenous influence on shaping an infant's emerging rhythms and synchronizing them with the external light-dark cycle. Strong pattern synchrony between maternal and infant activity may support infant circadian entrainment and enhance a regular 24-hr sleep-wake schedule during the early postnatal weeks.

NICU procedures are getting sweeter: development of a sucrose protocol for neonatal procedural pain.

Neonates in the neonatal intensive care nursery experience multiple, painful, tissue-damaging procedures daily. Pain among neonates is often underestimated and untreated, producing untoward consequences. A literature review established strong evidence supporting the use of sucrose as an analgesic for minor procedural pain among neonates. A review of unit practices and nurses' experiential evidence initiated the production of a standardized protocol in our unit at the University of Washington Medical Center NICU in Seattle.Nursing practices surrounding sucrose use differed widely in dose, timing, and patient application. We carefully evaluated evidence documenting the effectiveness as well as the safety of sucrose administration and wrote a protocol and practice standards for our primarily premature patient population. This article describes the development and execution of a standardized, nurse-implemented, sucrose protocol to reduce procedural pain.

Seasonal mapping of NICU temperature.

PURPOSE: To create a thermal map of ambient air, radiant, and evaporative temperatures and humidity throughout the NICU nursery by season across a calendar year. SUBJECTS: Each cubicle of the 32-bed NICU, distributed across 5 rooms, in a level III nursery was measured. METHODS: Temperatures were recorded at a consistent time on one day during January, April, July, and October. MAIN OUTCOME MEASURES: : An electronic monitor (QUESTemp ° 34; Quest Technologies, Oconomowoc, Wisconsin) was used to measure dry bulb, wet bulb, and globe thermometer temperatures. RESULTS: Analysis of variance revealed statistically significant (P ≤ .000) differences in season, room, and season by room interaction. Room ambient air temperatures differed by less than 2 ° F across season. Radiant temperature paralleled air temperature. Humidity, the predominant difference across season, produced evaporative temperatures considerably lower than room air temperature, and the gradient between mean nursery dry bulb temperature and wet bulb temperature was 9.3 ° F in summer and 16.8 ° F in winter. CONCLUSIONS: The thermal map revealed seasonal thermal differences, particularly in humidity level and evaporative temperature. Room temperature alone does not reflect the total thermal environment. Recommendations include periodic assessment of nurseries along with air, evaporative, and radiant temperatures as well as humidity to fully appreciate the impact of the thermal environment on infants.

Seasonal mapping of NICU temperature.

PURPOSE: To create a thermal map of ambient air, radiant, and evaporative temperatures and humidity throughout the NICU nursery by season across a calendar year. SUBJECTS: Each cubicle of the 32-bed NICU, distributed across 5 rooms, in a level III nursery was measured. METHODS: Temperatures were recorded at a consistent time on one day during January, April, July, and October. MAIN OUTCOME MEASURES: An electronic monitor (QUESTemp degrees 34; Quest Technologies, Oconomowoc, Wisconsin) was used to measure dry bulb, wet bulb, and globe thermometer temperatures. RESULTS: Analysis of variance revealed statistically significant (P < .000) differences in season, room, and season by room interaction. Room ambient air temperatures differed by less than 2 degrees F across season. Radiant temperature paralleled air temperature. Humidity, the predominant difference across season, produced evaporative temperatures considerably lower than room air temperature, and the gradient between mean nursery dry bulb temperature and wet bulb temperature was 9.3 degrees F in summer and 16.8 degrees F in winter. CONCLUSIONS: The thermal map revealed seasonal thermal differences, particularly in humidity level and evaporative temperature. Room temperature alone does not reflect the total thermal environment. Recommendations include periodic assessment of nurseries along with air, evaporative, and radiant temperatures as well as humidity to fully appreciate the impact of the thermal environment on infants.

6-sulfatoxymelatonin collected from infant diapers: feasibility and implications for urinary biochemical markers.

The purpose of this study was to assess feasibility and acceptability of using a diaper pad for collection of in-home infant urinary samples and to test the accuracy of diaper pad extraction for 6-sulfatoxymelatonin and creatinine, which was used to correct assay results for urinary volume. To assess feasibility and acceptability, urine samples from 20 infants were collected over a 24-hr day using a cotton pad inserted in the diaper. The accuracy of diaper pad extraction was evaluated in the laboratory using urine samples collected from 11 adult volunteers and assayed using enzyme immunosorbent assay (EIA). Urine samples were divided, one aliquot was assayed without extraction, and one aliquot was instilled into a diaper pad, extracted, and assayed. Mothers found diaper pad collection acceptable and easy to perform. Of 144 infant urinary samples obtained in the home environment, 59% were usable for assay purposes, and the remaining either were contaminated with stool or were of insufficient volume. While creatinine values from diaper pad extracted and nonextracted samples were highly correlated (r(2) = .947), those of creatinine-corrected 6-sulfatoxymelatonin were not (r(2) = .216). Diaper pad collection procedures altered 6-sulfatoxymelatonin values. Implications for measurement of urinary biochemical substances and statistical analysis are discussed.

Accurate assessment of mother & infant sleep: how many diary days are required?

PURPOSE: The purpose of the study was to determine the number of days of diary data collection needed to reliably measure mother and infant sleep-wake pattern. STUDY DESIGN AND METHODS: Twenty healthy adult mothers and their healthy term gestation infants age 4 to 10 weeks postnatal participated in a single group, cross-sectional design. Mothers completed a paper and pencil sleep-wake diary divided into 15-minute time periods. Data were collected in the home environment over a 4-day period. Mother and infant sleep and wake as well as infant feeding and cry were summarized and compared using between 1 and 4 days of data. Reliability was evaluated by correlating results obtained using from 1 to 4 days of data. RESULTS: Mean values for mother and infant sleep and activity variables did not differ significantly by day. Correlation among values calculated using increases in number of days of data showed adequate reliability (r > or = 0.80) when 3 days of data were used. CLINICAL IMPLICATIONS: Clinical measures should be valid and reliable. Due to day-to-day changes in maternal and infant sleep-wake pattern, a diary collected over 1 day may not provide adequate sleep information. These study findings indicate that 3 days of diary data are sufficient to reliably measure mother and infant sleep patterns. When using a diary to assess maternal and infant sleep-wake pattern in clinical practice or in clinically-based research, a 3-day period is suggested.

When neonatal ICU infants participate in research: special protections for special subjects.

Neonatal ICU research poses unique concerns for infants and parents. Children are considered a vulnerable research population. Federal regulations specify special protections when children participate in research. These regulations determine the types of research approvable for children based on the balance of risks and benefit. Risk also determines whether one or both parents' consent is required for their infant's participation in research.