Camryn is an 82 day-old infant who was born at 26 weeks’ gestation. Her corrected age is 38 weeks, 3 days. Her birthweight was 985g (2#, 2 ¾ oz) and weight on 5/18/99 was 2600g (~5#, 12 oz) which is at the 25^th percentile. Camryn continues to try to wean off of her nasal CPAP (Constant Positive Airway Pressure). On 5/11 rales or gurgly sounds were heard in her lungs. Her fluid intake is being monitored closely. She demonstrated increased work of breathing and grunting on 5/13 and 5/14 so her time on NCPAP was increased. A chest x-ray revealed inflammation with increased swelling in her lungs. Currently she’s on NCPAP 50% of the time and hood or mask oxygen the other half of the time. During most of the observation she was on 60% mask oxygen. Microlipids have been added to her mother’s breast milk along with HMF to increase the calories to 25cal/oz. She receives 155cc/12 hours every 3-4 hours via NG. Camryn’s caffeine was discontinued on 5/6 as she hasn’t had any breathing pauses and dropping of her heart rate (apnea/bradycardic spells) since 4/27. Camryn continues on a prophylactic antibiotic, Ampicillen to prevent a urinary tract infection. She gets extra iron called Fer-in-sol. An eye exam revealed mild right retinopathy of prematurity (ROP) which is being monitored by an eye doctor. The last NIDCAP observation was completed 14 days ago.

Camryn was observed for a total of 46 minutes on 5/18/99. The nursery was very quiet at the beginning of the observation and there was minimal activity around Camryn’s bedspace. The sound level increased toward the end of the observation. Camryn was awake, swaddled in a blanket and held in her mother’s arms. The observation began with her mother changing her diaper on her lap. Camryn is able to tuck her legs when she’s on her back, now. She continues to need caregiver support or swaddling in order to tuck her arms or bring her hands to her face when on her back. During her diaper change she was able suck on her pacifier to keep herself organized. She continues to suck on her pacifier for long periods of time and sucked today for 16 minutes before she arched away and stuck out her tongue. She was hungry and her feeding wasn’t started during this time because she’s on a stricter schedule secondary to the monitoring of her fluids. By the time her feeding was started she was getting tired and her breathing was becoming more irregular, fluctuating from very fast (102 breaths/minute) to slow (32 breaths/minute). She demonstrated brief periods of discomfort during her feeding by coughing, grunting, and squirming. She comforts by having her hands touching her face or her mouth and when softly talked to. Camryn is awake for long periods; up to an hour at one time. 

Today, while awake, she looked around and periodically gazed at her mother’s face to make eye contact. Camryn’s skin color, which had been pale during most of the observation, became rather dusky at the last half of her feeding as she tried to go to sleep. Her oxygen saturation levels were dipping to the low 90’s and upper 80’s so her oxygen was turned up from 60 to 65%. A quiet environment helps support her transition from wakefulness to sleep. Today, she had some trouble transitioning to sleep as she squirmed, yawned and repeatedly opened her eyes while there were two periods of vacuuming and loud voices in the nursery. Camryn continues to work very hard to breathe and her head often bobs with each breath. If she gets uncomfortable or upset her breathing and oxygen saturation levels pay the price as her levels drop, her skin color becomes more red or dusky and she works harder to breathe.

I met with Corrine, Camryn’s mother on 5/18/99. We discussed the observation and recommendations. Her next goal for Camryn continues to be for Camryn to get off of NCPAP. She asked questions regarding Camryn’s future needs. She has done some nuzzling with Camryn at her breast, but said that she was cautious with this because of Camryn’s restricted fluid intake. We discussed the role of breathing during feeding by mouth.

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 step continues to be weaning off of nasal CPAP.
2. Camryn is working on sucking on her pacifier during her entire NG feeding and sustaining a relaxed, comfortable, awake state during feedings. She is ready to do some nuzzling and is well prepared for breast-feeding once her she’s off of NCPAP and her breathing slows.
3. Camryn is enjoying social interactions when she’s awake. She’s working on giving eye contact while listening to her parent or caregiver’s voice.

RECOMMENDATIONS:

Environment:

Continue to be mindful of the sound level in the nursery. Very loud sounds impact Camryn’s oxygen saturation levels, skin color and quality of restful sleep. Like all of us, she will rest most peacefully when it’s quiet and dark.

Bedspace and Bedding:

Consider covering Camryn’s bed with a darker blanket when she’s sleeping.

Caregiving Interaction:

	Please be mindful of the position of Camryn’s oxygen mask straps and adjust them so that they aren’t touching her face in a way that’s irritating to her.
	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/mouth.
	Continue to hold Camryn during her NG feedings and offer her pacifier. Consider dipping her pacifier in her mother’s milk to offer tastes. We want to maintain her readiness for breast-feeding. If Camryn gets uncomfortable during her feeding (squirms, coughs, grunts), she may need you to slow or stop her NG 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. Consider reading a short story to her. Adjust the interaction to make sure that she doesn’t get overwhelmed (blink repeatedly, close her eyes, look away etc.)