Effects of biologic and experiential conditions on the pattern of growth in weight of premature and full-term infants.

In this exploratory study we examined the contribution of biologic and experiential conditions to the pattern of growth in weight for premature and full-term infants. The three components of the pattern were: (a) the infant's weight level; (b) the linear growth rate; and (c) the quadratic growth rate. Biologic conditions were maturity at birth and gender. Experiential conditions included variables in the mother's caregiving and the infant's feeding behavior, nutrient intake, and acuity of illness. At 1, 4, 8, and 12 months, premature infants (n = 61) weighed significantly less than full-term infants (n = 53), but neither linear nor quadratic rates of weight gain were significantly different from the rates for the full-term infants. Multilevel analytic models showed that female gender significantly affected weight level and linear and quadratic growth rates. Negative affect and behavior in both the mother and the infant significantly increased the linear rate of weight gain. The interaction of several experiential conditions with the two biologic conditions, birth maturity and gender, affected growth outcomes. Further exploration of the model with a larger sample is indicated to enable simultaneous testing of biologic and experiential conditions.

Stability of respiratory quotient and growth outcomes of very low birth weight infants.

Nutritional management of very low birth weight (VLBW) infants involves promoting growth at rates that mimic intrauterine rates. Nutritional intake at the recommended energy level to promote growth results in fat accretion at levels that exceed intrauterine rates for fat accretion. The respiratory quotient (RQ), the ratio of carbon dioxide produced to oxygen consumed during oxidation, provides a measure of the percentage of substrates used for energy. An RQ of greater than 0.9 indicates carbohydrate is used to meet energy needs, allowing the majority of fat intake to be stored as new tissue. The purpose of this study was to examine the stability of the RQ across time in relation to nutritional intake and growth in VLBW infants. Subjects were 9 enterally fed VLBW infants. Measurements to determine the RQ were obtained weekly for 3 weeks by indirect calorimetry. Nutritional intake and growth velocity were examined. There was no significant difference in the RQ across 3 weeks. The mean (+/- SD) RQs for each of the 3 weeks were 1.08 (+/- 0.04), 1.06 (+/- 0.05), and 1.06 (+/- 0.07), respectively. No significant differences were found across the 3 weeks for any of the macronutrient variables. Growth velocity for the period was 15.7 g/kg/day. By discharge from the NICU, 66% of the infants had weights less than the 10th percentile on an intrauterine growth reference. An RQ greater than 1.0 indicates VLBW infants are depositing excess fat. However, increased accretion rates of fat did not improve the growth outcomes of these VLBW infants.

Comparison of caloric intake and weight outcomes of an ad lib feeding regimen for preterm infants in two nurseries.

BACKGROUND: Effects on caloric intake and weight gain of an ad libitum (ad lib) feeding regimen for preterm infants may be specific to a special care nursery. OBJECTIVE: To explore across two nurseries the similarity of effect on caloric intake and weight gain of an ad lib feeding regimen compared with a prescribed regimen and the similarity of effect of caloric intake on weight gain. METHODS: All infants participating in the multi-site randomized clinical trial (RCT) of the ad lib feeding regimen were <35 weeks gestational age at birth and had birth weight appropriate for gestational age. Data on caloric intake and weight gain were collected at two nurseries (A, n=22; B, n=78) with the same feeding regimen protocols. Two strategies were used to explore similarity of regimen effect on caloric intake and weight gain. Repeated measures analysis of variance (ANOVA) was used to examine the effect on caloric intake and weight gain of time, feeding regimen, and time-by-regimen interaction for each nursery. RESULTS: In both nurseries, regimen effects were reasonably consistent for caloric intake and weight gain. Caloric intake was lower across nurseries for infants fed ad lib. After accounting for caloric intake, the ad lib regimen did not affect weight gain. The time-by-regimen interaction effect on caloric intake was significant in both nurseries. Caloric intake for infants fed ad lib increased significantly over 5 days. CONCLUSIONS: Despite differences between nurseries in infant characteristics and in protocol implementation, the feeding regimen effect was consistent for caloric intake and weight gain. Further support was found for the development of infant self-regulatory capacity.

The relationship of a mother's working model of feeding to her feeding behaviour.

AIMS OF THE STUDY: This study aimed to examine the difference the attunement of a mother's working model of feeding to her infant makes for her positive feeding affect and behaviour, accounting for infant and mother conditions. BACKGROUND/RATIONALE: The concept of a mother's working model of feeding is derived from attachment theory. Caregiving, including feeding, is a component of this theory. The conditions that may influence the attunement of a mother's working model of feeding to her infant include infant birth maturity status (premature, full-term), age at assessment, and robustness, indexed by weight-for-age z score (WAZ). Mother conditions include symptoms of depression and feeding practice (breast feeding or exclusive bottle feeding). DESIGN/METHODS: Participants in this longitudinal study were 99 mothers and their infants (47 full-term, 52 premature, very low birth weight). After written informed consent was given, home assessments were made when infants were approximately 1, 4, 8 and 12 months old (adjusted age for premature infants). Working model attunement was assessed with a video-assisted interview. A mother's positive affect and behaviour, including sensitivity and responsiveness, were rated from videotaped feeding interaction. RESULTS/FINDINGS: Repeated measures analysis with a general linear mixed model showed a significant positive relationship with positive affect and behaviour for both working model attunement and the WAZ score and a significant negative relationship for symptoms of depression. Neither birth maturity status, infant age, nor feeding practice had a significant effect on mother's positive affect and behaviour during feeding. CONCLUSIONS: Nurses' efforts to enhance the attunement of a mother's working model of feeding may help mothers feed with greater positive affect and behaviour. Further study of how the attunement of a mother's feeding expectations and intentions are related to her symptoms of depression and with what she makes of the infant's growth and well-being is needed. The theoretical model needs testing with infants from the entire premature population.

The quality of mothers' solutions to child-rearing problems: what difference does setting internal or external to the family make?

In this study we examined the difference the setting of a child-rearing problem, either internal or external to the family, made for mothers' generation of solutions likely to assist a child's development of problem-solving competencies. In addition, the direct effect of a mother's personal resources (age, education, number of children parented, and verbal ability) and the direct and mediating effect of the extent to which a mother took the child's perspective on her generation of assistive solutions were explored. Adult mothers (n = 128) of children ranging in age from 1 month to 18 years were interviewed by telephone concerning eight hypothetical child-rearing problems. Mothers generated a greater proportion of assistive solutions and took the child's perspective more often for external problems than for internal problems. For internal problems, a mother's verbal ability made a significant contribution to the proportion of assistive solutions generated. For external problems, number of children made a significant negative contribution. For external problems, perspective taking had a mediating effect on the relationship of number of children with the proportion of assistive solutions generated. The nature of a mother's perspective taking and the function that it has in solution generation for child-rearing problems merit exploration.

The adaptiveness of mothers' working models of caregiving through the first year: infant and mother contributions.

How a mother's working model of caregiving develops through an infant's first post-term year has implications for the infant's health. Change in the adaptiveness of the working model of caregiving through the first year and influencing conditions (mother and infant) were examined for 33 premature infants and 44 full-term infants. Adaptiveness was coded from the transcription of a video-assisted interview at 1, 4, 8 and 12 months postterm age. Mother conditions included years of education, symptoms of depression, and evaluation of caregiving. Infant conditions included status at birth, birth weight, weight-for-age, and amenability of temperament. Hierarchical fixed occasions repeated measures analysis showed significant change in working-model adaptiveness with time. The highest adaptiveness scores were at 4 months and the lowest scores were at 8 months. At 8 months, mother's education had a significant positive effect on adaptiveness, mother's symptoms of depression had a negative effect, and infant weight-for-age had a positive effect. Further research is needed to learn what features of a mother's education enhance working model adaptiveness and to identify mechanisms that explain the effects of the infant's weight-for-age on adaptiveness.

Guided participation and development of care-giving competencies for families of low birth-weight infants.

The concept of guided participation is central to theory for supporting families in developing competencies for care of their low birth-weight infants. Guided participation is a process through which an experienced person helps another person who has less experience to become competent in practices that are personally and socially meaningful practices of everyday life. A practice is made up of socially formed activities directed to accomplishing a recurring goal. For a parent, infant care-giving encompasses protecting, comforting and nurturing activities, including feeding. For premature infants, a mother's care-giving begins during the neonatal intensive care unit stay and continues, after the infant's discharge from hospital, in the home. Care-giving competencies are addressed through guided participation of a mother in her care-giving practice. In this process, her working model of herself as parent, her infant, and feeding is constructed and revised through the guided participation process. In this paper, a general theory of guided participation that could be used to promote care-giving competencies is described. Two cases from a pilot study are presented to illustrate the application of the theory to a mother's feeding practice with infants who were born prematurely and who developed problems with feeding during the first year of life. These cases indicate that guided participation offers a means of precisely tailoring support for care-giving to the mother's needs and goals for development of competencies. Further research on how guided participation is best introduced to families of varying resources and life circumstances, how it is best implemented across settings as the infant moves from hospital to home, and how nurses can apply its principles with available resources and opportunities is needed.

Mothers' help seeking as care initiated in a social context.

PURPOSE: To develop from the literature a rationale for a theoretical model of help seeking by mothers of young infants and to explore this model for two mothers. SIGNIFICANCE: Components of the help that mothers of young infants often seek concerning caregiving are specified and linked in the theoretical model. This type of model is needed to support research and development of theory concerning help seeking. ORGANIZING FRAMEWORK: Working model includes: (a) the meaning to the mother of a caregiving situation; (b) her goals in seeking help; (c) formal and informal sources of help; and (d) a mother's expectations about accessibility of help and her willingness to seek help. SCOPE AND SOURCES: Forty-six mothers of healthy, full-term infants completed a self-report form 3 months after the infant's birth. Responses of two mothers are used to illustrate the model. DATA EXTRACTION: Mothers used categorical options to describe the four working model components for four hypothetical infant-care situations derived from mothers' reports in an earlier study. Mothers used ordinal rating scales to describe their help seeking in general. FINDINGS: The two mothers expected help sources to be accessible and were willing to seek help for caregiving from all types of help sources. Although both viewed themselves as having little need of help, both reported they would seek help for all the hypothetical problems. However, the women differed in what they wanted from help and from whom they would seek it and in variability in several working model components across caregiving situations. CONCLUSIONS: Examination of the two mothers' responses suggests that the theoretical model provides a base for study of mothers' help seeking. Maternal experience and environmental and personal conditions may shape working model components. Further model development may require a narrative approach to learn about conditions associated with help seeking as well as to obtain a full sense of the meaning and expectation components of the working model. IMPLICATIONS: Knowledge of a mother's working model of help seeking can aid clinicians in responding sensitively to requests for help and in supporting a mother in seeking help.

Education for the nursing of children and their families: standards and guidelines for prelicensure and early professional education.

To strengthen the preparation of nurses for care of children and families, standards and guidelines for prelicensure and early professional education were developed by a working group with broad-based input. Assumptions, theory, practice, and research underlying the standards and guidelines concerned the nature of health care, knowledge, teaching, learning, and evaluation. The 11 standards are presented and guidelines are illustrated. How they are implemented will depend on local resources and philosophies. Continued dialogue among nurse educators is needed to refine and develop the standards and guidelines.

A computerized method of describing phase-related interactive events: infant feeding as an example.

A generalizable, computerized method has been designed to describe in detail interactive events that occur within phases of a process involving two or more interactants. The objectives of the method are: (A) visual discernment of patterns of events within and across phases through graphically displayed data and (B) summarization of events within phases for comparison of events across phases. Stages of the implementation of these objectives are illustrated with data obtained from observations of mother-infant feeding interaction. The method provides a means for an investigator to structure the exploration of patterns of behaviors in the context of the social activity in which the behaviors occur and to develop hypotheses about the data.

Mothers' parenting self-appraisals: the contribution of perceived infant temperament.

To learn how a mother's perception of her infant's temperament contributes to her appraisal of her parenting and of her problem-solving competence during the first 3 months postpartum, we explored a conceptual model, including infant gender and maternal attributes (education and parity) and the personal and social context of the parenting experience (infant centrality and life change), in a sample of 117 mothers. The set of temperament variables contributed to the variance in both parenting evaluation and problem-solving competence at 1 and 3 months. The pattern of infant temperament variables contributing to maternal self-appraisal variables at 1 and at 3 months suggests change in the temperament variables that are salient to mothers as the infants grow older.

Influences on mothers' use of clinician help in the infants' first three months.

Factors that influenced use of physician and nurse help were explored for 49 mothers of healthy, term-born infants for two study periods in the first three months. These factors were concepts pertinent to mothers' internal working models of help use, their resources, perceived problem-solving competence, and clinical evaluation of maternal competence in use of help. Variables contributing to the frequency with which help was used and to the ratio of that help to other communal help sources differed for nurse and physician help and for the time period. For physicians, the number of infant caretaking issues a mother identified contributed to the frequency of help use in both study periods. The problem-solving help nurses gave emerged as a critical help in the second study period. The ratio of help from nurses to that from other sources was higher when mothers identified reassurance from the nurse as a critical help and, in addition, as the infant grew older, when the nurse's evaluation of the mother's use of help was more positive. In contrast, throughout the first three months, the more infant care experience a mother had, the higher the proportion of help from physicians relative to communal sources of help. The findings suggest that nurses and physicians may have complementary functions when a mother uses help.

Nipple feeding for preterm infants with bronchopulmonary dysplasia.

OBJECTIVE: To examine the influence of an infant's physical condition on nipple-feeding practices and the contribution of the infant's age at complete nipple feeding to dietary intake and somatic growth outcomes. DESIGN: A retrospective, correlational study. SETTING: Two Level III nurseries. PARTICIPANTS: Records of 55 preterm infants with bronchopulmonary dysplasia. MAIN OUTCOME MEASURES: The infant's intake of kcal/kg on Day 1 of complete nipple feeding and the weight gain per day between complete nipple feeding and discharge. RESULTS: Gestational age and days on mechanical ventilation, continuous positive airway pressure, or supplementary oxygen influenced age at start and at completion of nipple feeding (p < .05). The infant's weight when nipple feeding was introduced was the primary determinant of age at introduction of nipple feeding (B = .50, p < .001). The physical condition variables did not influence the transition time from introduction of nipple feeding to complete nipple feeding. Neither the physical condition variables nor the feeding practice variables contributed to caloric intake. Weight gain between the time of complete nipple feeding and hospital discharge was less for infants who were on supplementary oxygen longer and who were older when completely nipple fed (p < .01).

Anticipatory guidance of parents of new infants: potential contribution of the internal working model construct.

Although anticipatory guidance for parents of young children has been well subscribed to as a clinical strategy for over half a century, it has little theoretical substance to guide its practice and to direct research that would develop and test the practice. The assumptions and definitions of the traditional practice of anticipatory guidance focus on providing information about what to expect and how to deal with unwanted or challenging events or conditions related to developmental or life change. In this paper, the potential contributions of social cognition theory, including the construct of internal working models, to the theory of anticipatory guidance are explored and implications of the revised theory are illustrated.

Transition to being the mother of a new infant in the first 3 months: maternal problem solving and self-appraisals.

This study explored components of a model of transition to being the mother of a new infant during an infant's first 3 months. Personal and situational conditions and maternal problem-solving factors (issue formulating and the use of help with issues) that may influence transition markers (maternal appraisal of problem-solving competence and evaluation of parenting) were examined for two study periods: the first 30 days postpartum and the next 60 days. For the second study period, variables contributing to maternal attention to infant growth, development and temperament (knowing issues) were also explored. Questionnaires and a daily log kept by 62 mothers of healthy term infants were data sources. Everyday supports (situational condition) contributed to use of lay help for the second period. Caretaking issues positively influenced use of clinician help throughout the study. The number of knowing issues a mother formulated contributed positively to problem-solving competence and to parenting evaluation; the use of problem-solving help had no effect. More clinician help received during the first month meant higher need for maternal action for both knowing and caretaking issues in the second and third months. Further study of the mechanisms of these relationships and examination of factors contributing to shifts in the transition process are needed.