Camryn is a 54 day-old infant who was born at 26 weeks’ gestation. Her corrected age is 34 weeks, 3 days. Her birthweight was 985g (2#, 2 ¾ oz) and weight on 4/20/99 was 1745g (3#, 13½ oz) which is approximately the 25^th percentile. On 4/11 Camryn finished 10 doses of a steroid medication called Dexamethasone to improve her lung function. The following day, Zantac, an antacid, was discontinued. She’s been on nasal CPAP (Constant Positive Airway Pressure) with a pressure of 5 and 56% oxygen. On 4/18 she began brief breaks from the CPAP and used mask or hood oxygen. She can use the mask or hood for up to six hours today. She received 75% oxygen while using the mask during the observation today. Camryn continues to receive Caffeine, a medication to help regulate her breathing so that she doesn’t experience breathing pauses with dropping of her heart rate (apnea/bradycardic spells). She had an episode on 4/12, 4/19 and today. Camryn is on a prophylactic antibiotic, Ampicillen to prevent a urinary tract infection. She gets extra iron called Fer-in-sol. She is receiving breast milk that’s fortified with HMF to increase the calories to 24 cal/oz. She receives 125-135cc/12 hours every 2-4 hours. Camryn is demanding some of her feedings.

Camryn was observed for a total of 42 minutes on 4/20/99. The nursery was crowded. The constant hum of a ventilator could be heard at Camryn’s bedspace. The observation began with Camryn’s mother’s hands assisting Camryn with keeping her arms and legs tucked as Camryn lay on her right side in her incubator fluctuating between periods of aroused agitation and exhaustion. It was time for her OG feeding and her mother was awaiting assistance with transferring Camryn to her chest for skin to skin holding. Camryn was working hard to breathe. Her breathing was irregular and fluctuated between slow and fast. Her lower ribs pulled in with each breath. Her oxygen saturation levels were predominately in the 70’s and 80’s with some fluctuations up or down. Her oxygen saturation monitor constantly alarmed. She was dusky and looked tired as her mouth hung open. She would settle for brief periods and hold onto her mother’s hand and clasp her feet together on her own. She flailed and became very aroused, upset, and weakly cried without the support of her mother. She had high side rolls that were securely positioned so that they touched her body and she didn’t arch her head and body during these periods of high motor activity. She was able to extend her feet over the roll at the foot of her bed as she searched for something to brace her feet against when without the support of her mother’s hands. Twelve minutes into the observation, a respiratory therapist arrived to transfer Camryn onto her mother’s chest. Camryn’s respiratory therapist removed her nasal CPAP and placed her on 75% mask oxygen. Camryn immediately settled down when placed onto her mother’s chest. Her oxygen saturation levels improved (91-98%) with less frequent and shorter periods where she would dip below 90. Her skin color also improved, as she was an even pale red. Camryn’s nurse arrived and suctioned Camryn’s nose. Camryn coughed and protested by fussing and arching away. Her oxygen saturation levels dipped briefly into the 60’s and 70’s. She immediately calmed down again and opened eyes as her OG feeding was started. She sucked vigorously on her pacifier for six minutes and slowed down toward the end of her feeding. While awake, she blinked her eyes, lifted her eyebrows and frowned. She tried to pull away from her pacifier, squirmed and her saturation levels dipped to 71% as she appeared to be getting full from her feeding. She was starting to drift off to sleep as she continued to receive her OG feeding. During the entire observation Camryn’s heart rate was fast between 172-191 beats/minute.

Both of Camryn’s parents continue hold her skin to skin on a daily basis. I met with both of her parents on 4/20/99 to discuss her progress. Both feel that Camryn is doing less arching. They agree that if her pacifier is offered when she’s already upset, that she’ll often become even more agitated. Mother discussed thinking about bringing Camryn home and the oxygen support that Camryn will need for her breathing. Discussed my recommendations with both parents.

INFANT’S CURRENT GOALS:

1. Camryn is working on improving her lung function, using less energy to breathe, and on developing an even breathing pattern. She’s working on developing and maintaining an even skin color with even oxygen saturation levels. Her next steps are to be increasing her time off of nasal CPAP.
2. Camryn is working on sucking on her pacifier and being relaxed and awake during her OG feedings as she prepares for breast-feeding.
3. Camryn is working on being relaxed during caregiving interactions or when awaiting her OG feeding. She continues to rely on the support of her caregivers when she’s unsettled and agitated. With support she is able to remain calm by using tucking of her arms and legs, holding on with her hands and bracing her feet.
4. Camryn is working on socially interacting by exploring her parent’s or caregiver’s face when she’s in a relaxed awake state.

RECOMMENDATIONS:

Environment:

Camryn is awake more often. Continue to adjust the lighting in response to Camryn’s cues. She may peek or blink a lot if the lighting is too bright for her.

Bedspace and Bedding:

Camryn is doing less arching. Continue to support her with rolls that go from the top of her head down to her feet and are tucked in close to her on each side. In order to brace her feet, she needs a very high foot roll or she’ll extend her feet over it.

Caregiving Interaction:

	Consider responding as quickly as possible to Camryn when she’s starting to wake up and demand her feeding. She experiences periods of agitation and needs hands on support to stay calm when she’s hungry. When she’s upset, she often will refuse her pacifier and accept it only AFTER she’s calm and relaxed. It taxes her breathing and is tiring for her to get upset.
	As you hold Camryn while she sucks on her pacifier during her OG feedings, consider removing her pacifier from her mouth when she stops sucking for longer than a minute or starts to squirm or pull away. She may needs short rest breaks and then offer the pacifier again to see if she wants it.
	If Camryn isn’t awake and being held during an OG feeding, continue to stay with her while she’s in her incubator and support her during the feeding. If she gets uncomfortable, she may need you to slow or stop her feeding momentarily before resuming it again.
	Continue to stay with Camryn after caregiving until she’s settled into a restful sleep.
	As Camryn is awake for longer periods, offer her something interesting to look at like your face, a picture or a stuffed animal. She also seems to respond positively when people talk softly to her.