Robyn Stremler

Effectiveness of oral sucrose and simulated rocking on pain response in preterm neonates

Abstract Feeding and carrying have been interventions used by caregivers throughout history in relieving distress in infants. Recent studies on the food substance sucrose have elucidated the comforting effect of the taste component of feeding while studies of rocking have examined the comforting effect of the vestibular component of carrying. The purpose of this study was to determine the effectiveness of sucrose and simulated rocking alone and in combination on diminishing pain response in preterm neonates undergoing routine heelstick procedure in the neonatal intensive care unit (NICU). Preterm infants (n=85) between 25–34 weeks post‐conceptual age (PCA) and 2–10 days post‐natal age (PNA) were randomly assigned to one of four conditions for routine heelstick procedure. The conditions were (1) sucrose alone: 0.05 ml of 24% sucrose was placed on the anterior surface of the tongue just prior to the lancing of the heel; (2) simulated rocking alone: 15 min prior to and during the heelstick procedure, the infant was swaddled and put on an oscillating mattress; (3) combination of sucrose and simulated rocking; and (4) placebo: 0.05 ml sterile water administered just prior to heelstick. Physiological (heart rate) and behavioural (facial actions) responses from baseline across 90 s following heelstick were scored second‐to‐second. Facial actions were analysed with repeated measures MANCOVA and heart rate with repeated measures ANCOVA. Behavioural state and gestational age were covariates. The groups that received sucrose alone or in combination with simulated rocking showed less facial actions indicative of pain than the rocking alone or control group. The addition of rocking to the sucrose condition tended to further blunt the facial expression of pain, but this enhancement did not reach a significant level. Heart rate was not decreased by any intervention compared to the control condition. Although the simulated rocking did promote quiet sleep, which has been reported in earlier studies to blunt pain response, there was no difference between simulated rocking and control groups in either facial expressions indicative of pain or heart rate. The implication of these results is that sucrose, but not simulated rocking may be a means of diminishing pain from minor procedures in preterm infants. Further research is needed on the use of sucrose for more than one procedure as well as examining the contact component of natural rocking, as opposed to simulated rocking.

Effect of Repeated Doses of Sucrose during Heel Stick Procedure in Preterm Neonates

The purpose of this randomized clinical trial was to test the efficacy of repeated versus single dose sucrose to decrease pain from routine heel stick procedures in preterm neonates. Infants (n = 48) in the first week of life with a mean gestational age of 31 weeks received 0.05 ml of 24% sucrose solution or sterile water by mouth (1) 2 min prior to actual lancing of the heel; (2) just prior to lancing, and (3) 2 min after lancing. The single-dose group received sucrose for the first dose and water for the second and third dose; the repeated-dose group received sucrose three times, and the placebo group received only water. The Premature Infant Pain Profile (PIPP) scores were obtained for five 30-second blocks from lancing. Both sucrose groups had lower PIPP scores (single sucrose pain scores, 6.8–8.2, p = 0.07; repeated sucrose pain scores, 5.3–6.2, p < 0.01) than water (pain scores 7.9–9.1), and in the last block, the repeated dose had lower scores than the single dose (6.2 vs. 8.2, p < 0.05).

Effect on birth outcomes of a formalised approach to care in hospital labour assessment units: international, randomised controlled trial

Objective To determine if a complex nursing and midwifery intervention in hospital labour assessment units would increase the likelihood of spontaneous vaginal birth and improve other maternal and neonatal outcomes. Design Multicentre, randomised controlled trial with prognostic stratification by hospital. Setting 20 North American and UK hospitals. Participants 5002 nulliparous women experiencing contractions but not in active labour; 2501 were allocated to structured care and 2501 to usual care. Interventions Usual nursing or midwifery care or a minimum of one hour of care by a nurse or midwife trained in structured care, consisting of a formalised approach to assessment of and interventions for maternal emotional state, pain, and fetal position. Main outcome measures Primary outcome was spontaneous vaginal birth. Other outcomes included intrapartum interventions, women’s views of their care, and indicators of maternal and fetal health during hospital stay and 6-8 weeks after discharge. Results Outcome data were obtained for 4996 women. The rate of spontaneous vaginal birth was 64.0% (n=1597) in the structured care group and 61.3% (n=1533) in the usual care group (odds ratio 1.12, 95% confidence interval 0.96 to 1.27). Fewer women allocated to structured care (n=403, 19.5%) rated staff helpfulness as less than very helpful than those allocated to usual care (n=544, 26.4%); odds ratio 0.67, 98.75% confidence interval 0.50 to 0.85. Fewer women allocated to structured care (n=233, 11.3%) were disappointed with the amount of attention received from staff than those allocated to usual care (n=407, 19.7%); odds ratio 0.51, 98.75% confidence interval 0.32 to 0.70. None of the other results met prespecified levels of statistical significance. Conclusion A structured approach to care in hospital labour assessment units increased satisfaction with care and was suggestive of a modest increase in the likelihood of spontaneous vaginal birth. Further study to strengthen the intervention is warranted. Trial registration Current Controlled Trials ISRCTN16315180.

Sleep disturbance in family caregivers of children who depend on medical technology: A systematic review

PURPOSE Society relies on family caregivers of children who depend on medical technology (e.g. mechanical ventilation), to provide highly skilled and vigilant care in their homes 24 hours per day. Sleep disturbance is among the most common complaints of these caregivers. The purpose of this review is to systematically examine studies reporting on sleep outcomes in family caregivers of technology dependent children. METHODS All relevant databases were systematically searched: MEDLINE, EMBASE, PsycINFO and CINAHL. Given the heterogeneity of the studies, a qualitative analysis was completed and thus results of this review are presented as a narrative. RESULTS Thirteen studies were retrieved that met eligibility criteria for inclusion. All of the studies reported on family caregivers of children with medical complexity living at home. Moreover, all of the studies relied entirely on self-report, not objective sleep measures. No intervention studies were found. Sleep disturbance was found to be common (51-100%) along with caregiver reports of poor sleep quality. Sleep quantity was seldom measured, but was found in the few studies that did, to be approximately 6 hours, or less than recommendations for optimal health and daytime function. Multiple caregiver, child and environmental factors were also identified that may negatively influence caregiver sleep, health and daytime function. CONCLUSION Findings of this review suggest that family caregivers of children with medical complexity who depend on medical technology achieve poor sleep quality and quantity that may place them at risk of the negative consequences of sleep deprivation. Recommendations for practice include that health care providers routinely assess for sleep disturbance in this vulnerable population. The review also suggests that studies using objective sleep measurement are needed to more fully characterize sleep and inform the development of targeted interventions to promote sleep in family caregivers of technology dependent children.

Sleep, sleepiness, and fatigue outcomes for parents of critically ill children.

Objectives: To describe sleep quantity, sleep patterns, fatigue, and sleepiness for parents of critically ill hospitalized children. Design: Prospective observational study. Setting: Quaternary academic PICU. Participants: One hundred eighteen parents of 91 children recruited during their child’s PICU stay. Interventions: None. Measurements and Main Results: For 5 days and nights, parents wore an actigraph to determine objective sleep-wake times and reported sleep location, level of fatigue (Fatigue Visual Analogue Scale), and sleepiness (Stanford Sleepiness Scale). Mean amounts of nocturnal sleep were less than recommended for optimal health (398 min, fathers vs 422 min, mothers; p = 0.04). Parents woke frequently (7.8 wakes, fathers; 7.2 wakes, mothers) and spent over an hour awake at night (65 min, fathers; 60 min, mothers). On 130 nights (26%), parents slept less than 6 hours and 209 nights (44%) were evaluated as “worse” sleep than usual. Fifty-four parents (53%) experienced more than 30% difference in minutes of sleep between consecutive nights. Mean morning fatigue levels (41 mm, fathers vs 46 mm, mothers; p = 0.03) indicated clinically significant fatigue. Sleeping in a hotel, parent room, or residence was associated with 3.2 more wakes per night (95% CI, 0.61–5.78; p = 0.015) than sleeping in a hospital lounge or waiting room. Conclusions: We performed a prospective observational study of 118 parents of critically ill children using objective measures of sleep and validated scales to assess fatigue and sleepiness. We found that more than a quarter of nights met criteria for acute sleep deprivation, there was considerable variability in the amount of nocturnal sleep that individual participants slept on different nights, and sleep was fragmented with a large portion of the night spent awake. Future research should focus on interventions that improve parents’ ability to return to sleep upon awakening and maintain regular sleep-wake schedules.

Infant Sleep Location: Bed Sharing, Room Sharing and Solitary Sleepingat 6 and 12 Weeks Postpartum

Objectives: Parents may have their infant sleep with them in the same bed (bed sharing [BS]), in the same room, but a separate bed (room sharing [RS]), or a separate room in a separate bed (solitary sleeping [SS]); prevalence estimates of these choices are limited. Little is known regarding the effects of infant sleep location (ISL) on infant or maternal sleep or other health outcomes. Methods: Healthy first-time mothers (n=246) in an RCT of a sleep intervention provided information regarding planned and actual ISL at 6 and 12 weeks postpartum when maternal and infant sleep were measured using actigraphy. Other outcomes included subjective maternal sleep disturbance, breastfeeding exclusivity, fatigue, and depressive symptomatology. Results: Most women (65%) planned RS with their infant; the next most common plan was to use both BS and RS (22%). The most common usual ISL was RS, with 46% of infants RS at 6 weeks and 39% at 12 weeks. Usual BS was common; at 6 weeks 17% of families were usually BS and 12% at 12 weeks. BS to any extent was quite common at 6 (51%) and 12 weeks (41%) postpartum. At 6 weeks, usually BS mothers had shorter stretches of sleep than those usually SS (130 mins vs 156 mins ; p=0.03) and more awakenings than those usually RS and SS (11.2 vs 8.9 vs 8.3; p=0.001). At 12 weeks, mothers who were usually RS had shorter stretches of sleep than those usually SS (164 mins vs 192 mins; p=0.04). There were no significant differences between ISL groups on any other outcomes. Conclusion: There is variation in ISL choice, and ISL changes across the first three months postpartum. Given our findings that ISL has effects on objective maternal sleep outcomes, further prospective, longitudinal research on the effects of ISL on a broad range of health outcomes for infant, mother and partner across the first postpartum year is needed.

A Sleep Hygiene and Relaxation Intervention for Children With Acute Lymphoblastic Leukemia: A Pilot Randomized Controlled Trial.

Background: Sleep disturbance and fatigue are common and distressing pediatric cancer-related outcomes. Sleep hygiene education and relaxation techniques are recommended to improve sleep in healthy children and adult cancer survivors. No studies have tested these interventions to improve sleep and fatigue for children with acute lymphoblastic leukemia (ALL) in the home setting. Objectives: The aim of this study is to establish the feasibility and acceptability of a sleep hygiene and relaxation intervention to improve sleep and fatigue for children receiving maintenance chemotherapy for ALL. The childs fatigue and sleep data were collected to inform sample size calculations for a future trial. Methods: In this pilot randomized controlled trial, 20 children were allocated randomly to the sleep intervention or control group. The sleep intervention group received a 60-minute educational session to discuss sleep and fatigue in children with cancer and strategies to improve sleep, including use of 2 storybooks to teach deep breathing and progressive muscle relaxation. Objective sleep data were collected using actigraphy and fatigue was measured using the Childhood Cancer Fatigue Scale. Results: The intervention was acceptable to families, and feasibility of the intervention and data collection was clearly established. Although not statistically significant, increases in mean nighttime sleep and decreases in mean wake time after sleep onset in the sleep intervention group represented clinically important improvements. Conclusions: This pilot study demonstrated the feasibility and acceptability of a sleep hygiene and relaxation intervention for children undergoing maintenance chemotherapy for ALL. Implications for practice: Given the clinically important improvements in sleep observed, replication in a larger, adequately powered randomized controlled trial is merited.

T-O-125 INFANT SLEEP LOCATION: BED SHARING, ROOM SHARING AND SOLITARY SLEEPING AT 6 AND 12WEEKS POSTPARTUM

Objectives: Parents may have their infant sleep with them in the same bed (bed sharing (BS)), in the same room, but a separate bed (room sharing (RS)), or a separate room in a separate bed (solitary sleeping (SS)); prevalence estimates of these choices are limited. Little is known regarding the effects of infant sleep location (ISL) on infant or maternal sleep or other health outcomes. Methods: Healthy first-time mothers (n=246) in an RCT of a sleep intervention provided information regarding planned and actual ISL at 6 and 12 weeks postpartum when maternal and infant sleep were measured using actigraphy. Other outcomes included subjective maternal sleep disturbance, breastfeeding exclusivity, fatigue, and depressive symptomatology. Results: Most women (65%) planned RS with their infant; the next most common plan was to use both BS and RS (22%). The most common usual ISL was RS, with 46% of infants RS at 6 weeks and 39% at 12 weeks. Usual BS was common; at 6 weeks 17% of families were usually BS and 12% at 12 weeks. BS to any extent was quite common at 6 (51%) and 12 weeks (41%) postpartum. At 6 weeks, usually BS mothers had shorter stretches of sleep than those usually SS (130 mins vs 156 mins ; p=0.03) and more awakenings than those usually RS and SS (11.2 vs 8.9 vs 8.3; p=0.001). At 12 weeks, mothers who were usually RS had shorter stretches of sleep than those usually SS (164 mins vs 192 mins; p=0.04). There were no significant differences between ISL groups on any other outcomes.