Camryn is a 68 day-old infant who was born at 26 weeks’ gestation. Her corrected age is 36 weeks, 3 days. Her birthweight was 985g (2#, 2 ¾ oz) and weight on 5/4/99 was 2150g (4#, 11 ¾ oz) which is approximately the 18^th percentile. Albuterol and Cromolyn nebulizer treatments were tried from 4/24-4/26 to see if her lung function would improve. She had a blood transfusion on 4/26. From 4/27-4/30 Camryn received additional doses of a steroid medication called Dexamethasone to improve her lung function. Ramitidine, an antacid, was started the same day and discontinued on 5/3. She continues to be weaned from her nasal CPAP (Constant Positive Airway Pressure) and is down to 2 hours/12 hour shift as tolerated. The rest of the time, she’s on mask or hood oxygen of 69%. 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). Her most recent episodes were on 4/20 and 4/27. Camryn continues 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 155-165cc/12 hours every 2-4 hours via NG. Camryn is demanding some of her feedings. The last NIDCAP observation was completed 14 days ago.

Camryn was observed for a total of 40 minutes on 5/4/99. The nursery was very quiet at the beginning of the observation and there was very little activity around Camryn’s bedspace. The sound level increased toward the end of the observation. Camryn was in a light sleep and lay in her open crib on her back under hood oxygen with her head turned to the right and her arms extended at her side. On her back, she is unable to bring her hands to her face and keep her arms tucked. She is able to turn her head and keep her legs tucked with the support of a high roll at the foot of her bed so that she can brace her feet. She continued to use bracing while her mother changed her diaper. She fussed in her sleep as her nurse took her vital signs. Camryn has difficulty with transitions in and out of her bed. After her mother removed her sleeper and lifted her out of her crib, Camryn flailed, startled and cried. Her mother laid Camryn on her lap as she got situated with Camryn’s mask oxygen. Camryn is vulnerable to skin color changes and poor oxygen saturation levels when she’s upset or if her oxygen mask isn’t directly over her nose. She’ll quickly change from pale to dusky. She recovers quickly once calm and with her oxygen mask in place. While positioned on her mother’s chest, Camryn steadily sucked on her pacifier while receiving her NG feeding of 55cc breast milk. She worked hard at trying to wake up, yet wasn’t able to achieve a relaxed awake state today. Drowsily, she blinked repeatedly, frowned or lifted her eyebrows as if to help get her eyes open. She was still and comfortable at her mother’s chest. After 10 minutes Camryn arched away from her pacifier and looked tired as her mouth hung open. She gradually did less peeking and went to sleep as she continued to receive her NG feeding. Camryn’s oxygen saturation levels were in the high 80’s initially and improved to the low 90’s while being held skin to skin on her mother’s chest. Her breathing was irregular and fastest, in the mid 70’s, while she was in her crib. When held skin to skin during her feeding, her breathing showed greater fluctuations, anywhere from 30 to 70 breaths/minute. Her heart rate was steady in the 150’s to 160’s with the exception of increasing to 182 during the transfer from her bed to her mother’s chest.

Both of Camryn’s parents continue to hold her skin to skin on a daily basis. I met with Camryn’s mother on 5/4/99 and we discussed Camryn’s next steps and vulnerabilities. Her mother agreed that Camryn has difficulty with transitions and we discussed ways to support her. She reported that Camryn is inconsistent with sucking on her pacifier at all feedings. She usually does it for at least one feeding/day. Her mother is ready for Camryn to do more nuzzling in preparation for breast-feeding. Her mother stated that she has noticed that not everyone is consistent with making sure Camryn’s roll at the foot of her bed is high enough and that Camryn continues to extend her feet over it when it’s too low.

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 weaned off of nasal CPAP.
2. Camryn is working on demanding every NG feeding and on achieving relaxed wakefulness during her feedings as she prepares for breast-feeding. She can suck on her pacifier well and is ready to do some nuzzling.
3. Camryn is working on being relaxed during transitions in and out of her crib.
4. Camryn is working on achieving relaxed wakefulness for brief social interactions. She’s working on exploring her parent or caregiver’s face or listening to a person’s voice without becoming overwhelmed.

RECOMMENDATIONS:

Environment:

Continue to grade the amount of talking and eye contact with Camryn based on what she can handle. She may need it very quiet with no expectation of eye contact until she’s clearly in a relaxed awake state.

Bedspace and Bedding:

• Camryn continues to need a very high foot roll or she’ll extend her feet over it.

Caregiving Interaction:

• Camryn has difficulty with transitions in/out of her crib. Consider swaddling her to keep her contained before lifting her out of her crib. Try holding her close to your body so that she feels secure. If you lay her on your lap, consider placing her on her side so that she can keep her arms tucked and close to her face.
• Please position Camryn on her side as much as possible both at rest and during caregiving interactions so that she can tuck her arms and keep her hands by her face.
• Continue to hold Camryn during her NG feedings and offer her pacifier. Continue to respect Camryn’s indication that she doesn’t want her pacifier or that she’s done sucking on her pacifier. She will often pull away by arching or turning her head. Consider removing her pacifier from her mouth when she stops sucking for longer than a minute. 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, watching her closely to make sure that she doesn’t get overwhelmed (blink repeatedly, close her eyes, look away etc.) She also seems to respond positively when people talk softly to her.