Does preterm period sleep development predict early childhood growth trajectories?

OBJECTIVE: The current study examined the relationship between sleep state development across the preterm and early post-term periods and subsequent growth trajectories from 1 to 27 months corrected age. STUDY DESIGN: Retrospective analysis of data collected prospectively from 111 preterm infants (⩽34 weeks gestation) who participated in a multi-site longitudinal study. Separate longitudinal parallel process models were calculated for each sleep state (active and quiet sleep) and growth (weight, length and body mass index (BMI) Z-scores) variable to estimate the associations between their developmental trajectories. RESULTS: Significant associations were identified between the trajectories of quiet sleep and weight, active sleep and weight, quiet sleep and BMI, and active sleep and BMI. No statistically meaningful associations were identified between the trajectories of early childhood length and the preterm sleep states. CONCLUSION: Faster preterm period sleep development appears to predict more favorable early childhood growth trajectories, particularly for weight, indicating preterm sleep may be an important biomarker for subsequent growth outcomes.

Impact of a palliative care program on end-of-life care in a neonatal intensive care unit.

OBJECTIVE: Evaluate changes in end-of-life care following initiation of a palliative care program in a neonatal intensive care unit. STUDY DESIGN: Retrospective study comparing infant deaths before and after implementation of a Palliative Care Program comprised of medication guidelines, an individualized order set, a nursing care plan and staff education. RESULT: Eighty-two infants died before (Era 1) and 68 infants died after implementation of the program (Era 2). Morphine use was similar (88% vs 81%; P =0.17), whereas benzodiazepines use increased in Era 2 (26% vs 43%; P=0.03). Withdrawal of life support (73% vs 63%; P=0.17) and do-not-resuscitate orders (46% vs 53%; P=0.42) were similar. Do-not-resuscitate orders and family meetings were more frequent among Era 2 infants with activated palliative care orders (n=21) compared with infants without activated orders (n=47). CONCLUSION: End-of-life family meetings and benzodiazepine use increased following implementation of our program, likely reflecting adherence to guidelines and improved communication.

Evaluation of human milk fortification from the time of the first feeding: effects on infants of less than 31 weeks gestational age.

OBJECTIVE: To determine whether human milk fortification from the time of the first feeding significantly improves weight gain and bone mineral status in infants of <31 weeks estimated gestational age as compared with delayed or standard human milk fortification. STUDY DESIGN: This was a retrospective pre-post design. In all, 95 infants born at <31 weeks estimated gestational age were compared. There were 53 infants in the early fortification group (EFG) and 42 infants in the delayed fortification group (DFG). They were compared with regard to weight gain at 34 weeks postmenstrual age (PMA), and their serum levels of calcium, phosphorus and alkaline phosphatase levels were compared as an indicator of bone mineral status. The practice change of fortifying all human milk given to preterm infants at <34 weeks PMA commenced in June 2009. The usual practice of fortification took place once an infant had reached a feeding volume of 50 to 100 ml kg(-1) per day. The new practice fortified all human milk with a powdered human milk fortifier to 24 calories per ounce, starting with the first feeding, no matter how small the volume. RESULT: There were no differences in weight gain between the EFG and the DFG. The group that received fortification from the time of the first feeding were significantly less likely to have alkaline phosphatase levels >500 U l(-1) from 33 weeks PMA onward. There was no incidence of feeding intolerance with early fortification. CONCLUSION: Fortification of human milk from the time of the first feeding does not affect weight gain at 34 weeks PMA, but is related to a lower incidence of elevated alkaline phosphate levels and does not cause feeding intolerance.

Effectiveness of No-Sting skin protectant and Aquaphor on water loss and skin integrity in premature infants.

OBJECTIVE: The purpose of this study was to evaluate the effects of No-Sting skin protectant and Aquaphor, a water-based emollient, on skin integrity measured by Neonatal Skin Condition Score (NSCS) and transepidermal water loss (TEWL) in premature infants. In addition, with no data regarding the use of No-Sting in the neonatal population and its desirability because it requires less infant manipulation and less nursing time, it was important to evaluate the use of this product. STUDY DESIGN: In all, 69 premature infants born at <33 weeks gestation were randomly assigned to one of the two treatment groups: (1) No-Sting or (2) Aquaphor for a total of 14 days. RESULT: Gestational age and total fluid intake were related to NSCS whereas gestational age, incubator humidity levels and total daily fluid intake were significantly related to TEWL. Infants receiving Aquaphor had significantly higher NSCS, but the mean scores in both groups over the 14-day period were in the normal range (<4). There were no differences between Aquaphor and No-Sting in the rate of TEWL over the 14-day period. CONCLUSION: This study provides the first information regarding the use of No-Sting in the neonatal population. This skin protectant seems as effective as Aquaphor in decreasing TEWL and maintaining skin integrity, and is less resource intensive.

Nursing care and the development of sleeping and waking behaviors in preterm infants.

The relationship between nursing care and the development of sleep-wake behaviors of 71 medically high-risk preterms was examined. The development of preterm infants' sleep-wake states, jitteriness, and negative facial expressions were influenced not only by the presence of the nurse, but also by the type of caregiving the nurse provided. The infant was awake more often when with caregivers than when alone. Waking states increased over time only when the infant was with caregivers, whereas quiet sleep increased only when the infant was alone. Infant behaviors and sleep-wake development were related to the intrusiveness of care. For example, negative facial expressions and sleep-wake transitions increased over time during the most intrusive caregiving. The development of sleeping and waking in preterm infants appears to depend not only on biological maturation but also nursing stimulation. As long-term developmental effects of nurse caregiving are unknown, additional research is needed.

Toilet training for the child with chronic illness.

Toilet training is as necessary a developmental step for the child with chronic illness as it is for the healthy child. Helping families and children to achieve this task, despite the demands of the illness, may require modification of usual techniques. Assessment of readiness and impediments to toilet training along with suggested intervention approaches are addressed. Case examples demonstrate individualization to specific children's needs.