Karen A. Thomas

How the NICU environment sounds to a preterm infant: update.

PurposeTo replicate a previously published descriptive study of sound levels in the NICU. Study Design and MethodsA descriptive study of nursery ambient sound levels and sound levels associated with nursery equipment and care activities was conducted in a Level III NICU. Measurements were obtained using a sound level meter and evaluated in light of previous findings. ResultsContrasted with 16 years ago, room sound levels were reduced; however sound levels associated with caregiving, equipment, and activities continue to be high. Clinical ImplicationsSound levels continue to be a clinical challenge for NICU nurses. This study suggests some modification of care practices and equipment selection that could reduce sound levels and concludes that sound reduction is a continuing need in neonatal care.

Use of the parenting stress index in mothers of preterm infants.

PURPOSEThis report describes parenting stress experienced by mothers of preterm infants following hospital discharge. SUBJECTSTwenty-nine mothers and their preterm infants were included in the analysis. DESIGN AND METHODSThe study was conducted using a descriptive and exploratory single group design. The analysis included 29 mothers of preterm infants, mean gestational age 33.14 weeks, mean postnatal age 78.59 days, 6 to 10 weeks after discharge. Mothers were administered the Parenting Stress Index (PSI), a 101-item questionnaire that includes a total score and Parent and Child Domains. It also includes the following 13 scales: Adaptability, Acceptability, Demandingness, Mood, Distractibility/Hyperactivity, Reinforces Parent, Depression, Attachment, Restriction of Role, Sense of Competence, Social Isolation, Relationship with Spouse, and Parent Health. PRINCIPAL RESULTSA high rate of missing items was noted on the PSI. In particular, missing items occurred predominantly in the Child Domain. By following guidelines for scoring the PSI when items are missing, summary scores were calculated for 16 of the 29 participants. Total scores demonstrate the stress experienced by parents of preterm infants. Parent Domain scores were comparable with normative samples; however, Child Domain scores were above the 50th percentile for all child scales. CONCLUSIONSMothers of preterm infants experience stress that is largely attributable to the particular characteristics of low gestation infants. The PSI may provide insight into parenting stress; however, future research should examine missing items more closely.

NICU sound environment and the potential problems for caregivers

While concerns regarding the effects of the neonatal intensive care unit (NICU) sound environment have primarily centered on infants, caregivers are exposed to the same auditory stimuli. In a review of the literature on adult responses to sound, behavioral and physiological responses to sound as well as influence on job performance and communication are examined. Hearing damage among caregivers is unlikely given the sound levels of the typical NICU. The effect of the NICU sound environment on caregivers has received little attention in research; however, findings from other researches of responses to sound suggest that a variety of physiological and behavioral responses may occur in response to the NICU sound environment, and that the sound intensity of the NICU may interfere with communication and job performance.

Parental responses to first and recurrent febrile convulsions

Objective– To compare parental knowledge, attitudes, concerns, and first‐aid practices for children experiencing febrile convulsions (FC). Subjects and methods– A questionnaire was mailed to 326 FC parents from 11 emergency departments in southern Taiwan. Results– A total of 109 first‐ and 107 recurrent‐FC parents responded 1–3 months after the FC. Most incorrectly believed an electroencephalogram (EEG) or computed tomography (CT) was necessary; immunization should be postponed, and overestimated the risk of subsequent epilepsy. Parents were concerned about further attacks in the night, fever episodes, and frequently measured the childs body temperature. During the first episode, objects were inserted into the childs mouth and they were rushed to a hospital. One third lowered the childs body temperature, and 15% positioned the children on their side. For subsequent seizures, 80% anticipated rushing the child to a hospital, and 44% would put objects into the childs mouth. In comparison, although the recurrent‐FC parents had higher scores in knowledge and attitudes than the first‐FC parents, low knowledge scores (40% correct) were seen in both groups. No significant differences were found on parental concerns, performed/anticipated first aid for FC. Conclusion– Most FC parents had inadequate knowledge, high concerns, and improper first‐aid practices. This suggests that parents with either first‐ or recurrent‐FC children need information, emotional support, and first‐aid demonstrations.

Infant Sleep and Feeding Pattern: Effects on Maternal Sleep

Factors contributing to maternal sleep when infants are 4 to 10 weeks of age were examined. Twenty-four-hour sleep-wake diaries collected from 37 mother-infant dyads in the home environment were summarized to describe total, longest, and mean sleep period; synchrony of maternal and infant sleep; and feeding frequency and duration. Regression and post hoc analysis of variance were used to examine factors contributing to maternal and infant sleep. Maternal sleep is driven by infant sleep and feeding pattern. The minimum and maximum numbers of infant sleep episodes per day were 6 and 15, respectively, and mean infant total sleep was 13.47 hours (SD 1.73). Mean maternal total sleep was 7.18 hours (SD 1.51), with half of the mothers reporting less than 7 hours of sleep per 24 hours. Mean number of infant feedings was 11.14 (SD 3.27), with 11 infants (29.7%) receiving 13 or more feedings per 24 hours; minimum and maximum times per feeding were 15 and 41.7 minutes, respectively. Male infants had more sleep episodes, shorter sleep periods, and less sleep than females, and these gender differences resulted in shorter and more fragmented sleep for mothers. Findings suggest there is continued need for interventions to improve maternal sleep following childbearing.

Noninvasive measurement of body temperature in critically ill patients.

Elizabeth Bridges is an assistant professor at the University of Washington School of Nursing, a clinical nurse researcher at the University of Washington Medical Center in Seattle, and is director of Deployed Combat Casualty Research Team CJTF101 in Afghanistan. Karen Thomas, is a professor at the University of Washington School of Nursing. invasive methods (PA, esopha geal, or bladder), the following methods should be used in this order: rectal, oral, and tympanic. Axillary, temporal artery, and chemical dot thermometers are not recommended. In a subsequent series of letters to the editor, the author stated that temporal artery measurements were not recommended because Lawson et al found that 20% of the temporal artery temperature measurements were greater than ±0.5°C different from the concurrent PA temperature. However, as summarized in Table 1, the bias and precision of the oral and temporal artery methods were similar, and 19% of the oral measurements were also greater than ±0.5°C different from the concurrent PA temperature, suggesting that the 2 methods are comparable. Similarly, Fetzer and Lawrence recently compared ear-based and temporal artery temperature measurements and reported that the bias between the 2 methods was -0.4±0.64°C (95% CI, -1.29 to 1.21), which is less accurate and precise than either method compared with PA temperature measurement (Table 1). Unlike the studies outlined in Table 1, the difference between the ear-based and temporal artery methods reflects the error in both measurements, and we cannot say AElizabeth Bridges, RN, PhD, CCNS, and Karen Thomas, RN, PhD, reply:

Individual and Gender Differences Matter in Preterm Infant State Development

OBJECTIVE To further understand state development of preterm infants throughout hospitalization and the effects of selected infant characteristics on state development. DESIGN Secondary data analysis of a 2-group, experimental design study. SETTING Two nurseries in a Northwest medical center. PARTICIPANTS Ninety-seven hospitalized, medically stable, preterm infants. Fifty-one subjects were females. METHODS Two hundred and eighty-five real-time video recordings of infants performed during 4 hour interfeeding intervals. Sleep-wake states were coded at 15 second intervals. RESULTS Active sleep was the dominant state across postmenstrual ages. Although not statistically significant, preterm infants showed developmental changes in state organization with increased quiet sleep, drowsy, and awake, decreased active sleep, and more defined and less diffuse states over age. A significant gender effect was found, with males having less active sleep (p=.012), more drowsy (p=.03), more awake (p=.043), less defined (p=.002), and more diffuse (p=.001) states compared with females. CONCLUSION The predominance of active sleep during the preterm period reflects level of brain maturation. The results emphasize individual variations in state organization influenced by endogenous and environmental factors. Gender differences are potential sources of individual variation.

Axillary and Thoracic Skin Temperatures Poorly Comparable to Core Body Temperature Circadian Rhythm: Results from 2 Adult Populations

Data from 2 separate studies were used to examine the relationships of axillary or thoracic skin temperature to rectal temperature and to determine the phase relationships of the circadian rhythms of these temperatures. In study 1, axillary skin and rectal temperatures were recorded in 19 healthy women, 21 to 36 years of age. In study 2, thoracic skin and rectal temperatures were recorded in 74 healthy women, 39 to 59 years of age. In both studies, temperatures were recorded continuously for 24 h while subjects carried out normal activities. Axillary and thoracic probes were insulated purposely to prevent ambient effects. Cosinor analysis was employed to estimate circadian rhythm mesor, amplitude, and acrophase. In addition, correlations between temperatures at various measurement sites were calculated and agreement determined. The circadian timing of axillary and skin temperatures did not closely approximate that of rectal temperature: the mean acrophase (clock time) for study 1 was 18:57 h for axillary temperature and 16:12 h for rectal; for study 2, it was 03:05 h for thoracic and 15:05 h for rectal. Across individual subjects, the correlations of axillary or thoracic temperatures with rectal temperatures were variable. Results do not support the use of either axillary or skin temperature as a substitute for rectal temperature in circadian rhythm research related to adult women.

Preterm infant thermal responses to caregiving differ by incubator control mode.

OBJECTIVE: To determine the influence of caregiving on preterm infant and incubator temperature and to investigate incubator control mode in thermal responses to caregiving.STUDY DESIGN: The intensive within-subject design involved continuous recording of infant and incubator temperature and videotaping throughout a 24-hour period in 40 hospitalized preterm infants. Temperature at care onset was compared with care offset, and 5, 10, 15, and 20 minutes following care offset using ANOVA-RM.RESULTS: Following caregiving, infant and incubator temperature differed significantly over time by incubator control mode. In air servo-control, infant temperature tended to decrease after caregiving, while in skin servo-control infant temperature remained relatively stable. With caregiving, incubator temperature remained consistent in air servo-control and increased in skin servo-control.CONCLUSIONS: The temperature effects of caregiving should be considered relative to maintenance of thermoneutrality and unintentional thermal stimulation.

Differential Effects of Breast‐ and Formula‐Feeding on Preterm Infants' Sleep‐Wake Patterns

Objective: To compare sleep-wake patterns of breastfed and formula-fed preterm infants. Design: Data were taken from an exploratory study of infant biorhythm maturation. Parents completed a 24-hour diary of infant Sleep, Awake, and Cry states and feedings, recorded at 30-minute intervals. Infant health data were collected from medical records and parents’reports. Setting: Infants were studied in the home after discharge from a neonatal intensive-care unit. Participants: The convenience sample included 12 breastfed and 25 formula-fed preterm infants (gestational age, 26–33 weeks; corrected postnatal age, 4–6 weeks). Groups were comparable in terms of gestational age, postnatal age, Apgar scores, maternal age, and home environment. Main Outcome Measure: The 24-hour recording period was divided into day (0600-1800) and night (1800-0600). Study variables were Day, Night, and 24-hour Sleep, Awake, and Cry. Results: Breastfed preterm infants exhibited more Day Cry and 24-hour Cry than did formulafed infants. Infants demonstrated a diumal pattern in Cry, Awake, and Sleep. Breastfed preterm infants cried approximately 1 hour per day more than formula-fed infants. Conclusion: Preterm breastfed infants experienced more cry than did formula-fed infants. The relationship between feeding method and sleepwake pattern has implications for supporting lactation as well as for research design.