Camryn is a 96 day-old infant who was born at 26 weeks’ gestation. Her corrected age is 40 weeks. Her birth-weight was 985g (2#, 2 ¾ oz) and weight on 6/1/99 was 3040g (6#, 11 oz) which is at the 42^nd percentile. Her length is 46 cm (18") which is at the 14^th percentile and her head circumference is 34.75 cm (13½") which is at the 77^th percentile. Camryn is getting closer to weaning off of her nasal CPAP (Constant Positive Airway Pressure). Since 5/29 she is on NCPAP for 2-hours/12 hour shift and the rest of the time she’s on nasal cannula oxygen. During the observation today she was on 73% nasal cannula oxygen. Since 5/25, her mother’s breast milk has been fortified to increase the calories to 30 calories/oz. She gets extra iron called Fer-in-sol. An order was written to try breast feeding on 6/1/99. She receives 180-200cc/12 hour shift. Her NG feedings are every 2-4 hours. Camryn had one breathing pause and dropping of her heart rate (apnea/bradycardic spell) on 5/27. Camryn continues on a prophylactic antibiotic, Ampicillen to prevent a urinary tract infection. She was started on the diuretics, Aldactone and Diuril to limit fluid retention. Her eye exam revealed mild right retinopathy of prematurity (ROP) which continues to improve since the initial diagnosis. The last NIDCAP observation was completed 14 days ago.

Behavioral Summary

Camryn was observed for a total of 40 minutes on 6/1/99. She was observed for 2 minutes lying on her side in her bed wrapped in a blanket before Camryn’s mother gave her a bath, which took almost 11 minutes. Then she nuzzled and practiced breast-feeding for the remainder of the observation. Camryn was awake during the entire observation. Initially she was unsettled and fussed while her mother removed the tape from her NG tube and got her ready for her bath. Camryn is using grasping and holding on as a way to settle herself and even grabbed her mother’s hair today. Once in the tub she completely relaxed as her mother held her in a semi-reclined position. Camryn will gaze at her mother’s face at times such as this when she’s relaxed. With any movement in the tub while her mother washed her body, she would startle and preferred to keep her feet braced against the edge of the tub with her arms resting on her chest. She was pale and webbed prior to the bath and became red anytime she fussed. Sometimes her extremities were somewhat dusky. After her bath, she was a more even pale color. The few times during the observation that her mother needed to leave Camryn’s bedside, she was careful to position Camryn on her side where she could easily keep her hands near her face and rest her feet together.

Camryn is developing a better ability to keep her arms and legs tucked when she’s on her back for short periods such as diaper changes. When brought to her mother’s breast, her eyes were open wide and she held onto her mother’s finger. She did more licking and suck searching as she was positioned so her head and body were more rounded. Even when Camryn is getting tired, she’ll continue to root and suckle at her mother’s breast so she needs imposed breaks to make sure she won’t get tired out. Signs that she’s getting tired include: Arms falling into an extended position, mouth hanging open at rest, arching away from the breast, a glazed over look, a change from pale to dusky, and an increase in her work of breathing such as head bobbing. Camryn continues to work very hard to breathe and demonstrates great fluctuations in her breathing, anywhere between 37 and 102 breaths/minute. Her fast breathing will make it more challenging for her to coordinate swallowing and this was seen today when she got a swallow of milk and immediately pulled away, a little overwhelmed. She will need time to learn to coordinate her suck/swallow/breathe pattern. Her heart rate is steady and fast between 168-180 beats/minute and her oxygen saturation levels are predominately between 91-96%.

After the observation today I talked with the lactation consultant, nurse and Corinne, Camryn’s mother. We discussed the observation and recommendations. Corinne didn’t have any concerns and was pleased to be able to begin working with Camryn on breast-feeding.

1. Camryn is working on improving her lung function, using less energy to breathe, and on developing an even breathing pattern. Her next step is to completely wean off of nasal CPAP and to begin learning to coordinate her swallowing with breathing as she begins to breast-feed.
2. Camryn is ready to learn to breast-feed. She’s working on getting a good latch and maintaining relaxed wakefulness while she learns to coordinate her breathing with swallowing.
3. Camryn is working on developing her endurance for the work of breast-feeding so that she’s not worn out afterwards.
4. Camryn continues to enjoy social interaction when she’s awake and relaxed. She is not as easily overwhelmed with eye contact and enjoys being talked to.

RECOMMENDATIONS:

Environment:

Continue to be mindful of the sound level in the nursery especially when Camryn is participating in a caregiving interaction like a bath or trying to breast-feed.

Bedspace and Bedding:

Consider the position of stuffed animals or pictures that Camryn may be looking at so that they are at chest level (not above her head) and she won’t have to arch in order to look.

Caregiving Interaction:

Building endurance is an issue for Camryn and she needs our help in order to pace herself. Please watch her for signs of fatigue during all caregiving interactions, especially during breast-feeding. These signs include: Arms falling into an extended position, mouth hanging open at rest, arching away from the breast, a glazed over look, a change from pale to dusky, and an increase in her work of breathing such as head bobbing.

Breast-feeding recommendations: 1) Try to time breast feeding attempts so that Camryn is not worn out from having had other procedures or caregiving interactions prior to the attempt such as a bath, NG tube placement, etc. Instead time the attempts when she’s well rested, relaxed and awake. 2) Limit talking so that she can concentrate on learning to breast-feed. 3) Swaddling her will give her breathing and trunk muscles extra support and help her keep her body rounded/tucked. 4) Per the lactation consultant, pump before an attempt to limit the initial milk flow. 5) Watch for signs of fatigue as stated above and stop the feeding to avoid getting Camryn exhausted and worn out. Pay particular attention to her breathing.

Caregiving Interaction Recommendations (cont.):

• NG recommendations: 1) Continue to support Camryn in demanding her feedings a her schedule will allow. We want to support her relaxed wakefulness at every feeding.  2) Continue to offer her pacifier, allow her to nuzzle or be held skin to skin during NG feedings.
• Continue to swaddle Camryn (keep her arms and legs tucked) during movement transitions. Move her slowly as she often will startle, especially when in the tub or if laid onto her back.
• Continue to 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. She can also keep her feet touching each other in this position.
• Continue to stay with Camryn after caregiving until she’s settled into a restful sleep.