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Background: Sound levels in the pediatric intensive care unit (PICU) are often above recommended levels, but few researchers have identified the sound sources contributing to high levels. Objectives: To identify sources of PICU sound exposure. Methods: This was a secondary analysis of continuous bedside video and dosimeter data (n = 220.7 hours). A reliable coding scheme developed to identify sound sources in the adult ICU was modified for pediatrics. Proportions of sound sources were compared between times of high (≥45 dB) and low (<45 dB) sound, during day (7 AM to 6:59 PM) and night (7 PM to 6:59 AM) shifts, and during sound peaks (≥70 dB). Results: Overall, family vocalizations (38% of observation time, n = 83.9 hours), clinician vocalizations (32%, n = 70.6 hours), and child nonverbal vocalizations (29.4%, n = 64.9 hours) were the main human sound sources. Media sounds (57.7%, n = 127.3 hours), general activity (40.7%, n = 89.8 hours), and medical equipment (31.3%, n = 69.1 hours) were the main environmental sound sources. Media sounds occurred in more than half of video hours. Child nonverbal (71.6%, n = 10.2 hours) and family vocalizations (63.2%, n = 9 hours) were highly prevalent during sound peaks. General activity (32.1%, n = 33.2 hours), clinician vocalizations (22.5%, n = 23.3 hours), and medical equipment sounds (20.6, n = 21.3 hours) were prevalent during night shifts. Conclusions: Clinicians should partner with families to limit nighttime PICU noise pollution. Large-scale studies using this reliable coding scheme are needed to understand the PICU sound environment. [ABSTRACT FROM AUTHOR]

Purpose: To characterize and quantify touch experienced by preterm infants in the NICU during essential nursing care, identify instances of skin-to-skin touch between infants and caregivers, and identify clinical/demographic variables associated with touch experiences. Design: Cross-sectional study. Sample: Preterm infants (N = 20) born 27–32 weeks post-menstrual age. Main Outcome Variable: Categories of touch during observations. Results: Touch experienced by infants during day and night shifts was primarily direct touch that was further categorized as general handling. During day shifts, 30 percent of direct touch was provided for comfort, but only 9.7 percent of touch was provided exclusively for comfort (i.e., without more intrusive touch). During night shifts, 10.6 percent of direct touch was provided for comfort, and 3 percent was categorized as exclusive comforting touch. Caregivers wore gloves for >89 percent of infant touch. Only the level of respiratory support was associated with touch categories during both shifts. [ABSTRACT FROM AUTHOR]

Inflammation often accompanies preterm birth and contributes to poor neurodevelopment in preterm infants. The purpose of this study was to describe postnatal cytokine trajectories among non-infected very preterm infants during the first weeks of life. Blood samples for cytokine analysis were collected weekly from infants born between 28 and 31 weeks post-menstrual age. We used linear mixed models to calculate slopes for each cytokine and allowed the slopes to differ by infant biological sex and post-menstrual age at birth. Levels of interleukin-6, interleukin-8, and interleukin-1 receptor antagonist decreased, on average, during the neonatal period. Monocyte chemoattractant protein-1 levels increased over time, and tumor necrosis factor-alpha levels were stable. Interleukin-6 and interleukin-8 slopes differed by post-menstrual age at birth but were unaffected by infant sex. Knowledge of average cytokine trajectories may be useful in identifying infants with unresolving inflammation that increases their risk for poor neurodevelopment. [ABSTRACT FROM AUTHOR]

Background and Purpose: Parents' competencies in coparenting are critical to adaptive and competent caregiving of an infant with complex congenital heart disease. To date, feasible interventions to support parents in working together—coparenting—for caregiving of these infants have not been developed and systematically examined. The purpose of this feasibility study was to examine the efficacy of the participatory teaching/learning intervention, Guided Participation (GP) on parent dyads' competencies in interactive problem-solving tasks in preparation for a randomized controlled trial. Methods: Nurse guides used GP to support mother and father couples in developing coparenting competencies through the first 6 months after birth. Couples, enrolled from two regional heart centers, were randomly assigned either to the usual care group (n = 10) or the GP group (n = 24). Intervention involved nurse guided GP in hospital and, following the infant's discharge, monthly telephone GP sessions between 2-months and 6-months infant age. In-home data collection visits at 2 and 6 months included video-recorded parent interaction problem-solving tasks with two goals, infant caregiving and the parent couple's relationship. The Iowa Family Interaction Rating Scales were used to score observed interactive competencies. Results: Retention was 82%, and results revealed small to moderate effect sizes for GP on problem-solving constructs for mothers and for the parent couple dyad. Implications for Practice: Our findings support further study in a fully powered randomized trial with a more diverse sample, handbook-enhanced GP, and examination of the effect on a broader spectrum of outcomes, including infant growth and development. [ABSTRACT FROM AUTHOR]

Background and Purpose: The prenatal preparing women do for infant caregiving is understudied. In this pilot, multimethods study, we examined motivation for preparing for infant caregiving of women in their third trimester of pregnancy expecting either a healthy infant or an infant with complex congenital heart disease (CCHD). Methods: Eleven women expecting a healthy infant and four expecting an infant with CCHD completed a questionnaire and were interviewed. Preparing was reported in context of expectations, intentions, and goals and in personal, family, and infant conditions. Motivation for preparing was expressed through an interview about caregiving issues women were working on. Intensity of motivation was estimated by self-report of the time infant caregiving issues were in thought or action. Effect sizes were calculated for between group differences in motivation intensity. Interview data were examined with directed content analysis. Results: Intensity of motivation was higher for women expecting an infant with CCHD for issues of Knowing What and How to prepare. Women expecting an infant with CCHD reported uncertainty about how they would feed their babies given their health condition. Interviews yielded new motivations encompassing issues of family and working with the parent partner. Implications: Assessment of issues women are working on prenatally, indicating motivations for preparing for infant caregiving, and of the intensity of motivations advances culturally-attuned and family-centered preparation. Knowledge of these issues and motivation intensity could orient clinical care to supporting women in developing well-informed expectations, intentions, and goals culturally suited to postnatal learning and infant needs. [ABSTRACT FROM AUTHOR]

Background: Developmental delay is a significant concern for infants born with complex congenital heart disease (CCHD). Environmental exposures (e.g., excessive light and sound exposure, sleep disruption) in neonatal intensive care are associated with poor developmental outcomes. However, the environmental experience of newborn infants in cardiac care is unknown. Objectives: The aim of the study was to examine the feasibility of continuous environmental data collection (i.e., light and sound exposure, sleep pattern) in pediatric cardiac care units and describe the environmental experience of three hospitalized infants with CCHD. Methods: A case series of three infants undergoing cardiac surgery for CCHD within the first month of life was performed. Measures of light, sound, and sleep were collected in 24-hour periods on three to four separate hospital days. For each day, light and sound meters were attached to the hospital bed, and an actigraphy band was placed on the infant's lower leg to measure sleep/wake states. Feasibility of continuous environmental data collection was assessed through acceptability of data collection for families and clinical staff, usability of data collection equipment for research staff, and study protocol adherence. Descriptive statistics were used to calculate the count and duration of episodes of excessive light and sound exposure, hourly levels of light and sound exposure, total sleep time, duration of individual sleep episodes, and number of arousals from sleep. Results: Although continuous environmental data collection was generally acceptable to families and clinical staff, multiple usability issues were identified by research staff, and study protocol adherence was variable. Missing data were a major limitation. User error during equipment setup was a main contributor to missing data. Infants experienced frequent episodes of sound exposure above recommended maximum levels, whereas light exposure generally remained below recommended maximum levels. Infant sleep patterns were highly fragmented, with frequent arousals and short duration of individual sleep episodes. Discussion: Lessons learned during preliminary data collection with the infants in this case series will inform methods and prevent missing data in future, large-scale studies of this vulnerable, hard-to-recruit population. Data reflect a cardiac care environment characterized by excessive sound exposure and highly disrupted sleep. These environmental stressors may affect developmental outcomes in infants with CCHD. [ABSTRACT FROM AUTHOR]

Background: Pain management is an essential component of care for pediatric patients following surgery. Massage reduces self-reported postoperative pain in adults with heart disease but has received little attention in postoperative pediatric patients with complex congenital heart disease (CCHD). Objectives: The aim of the study was to evaluate the effectiveness of massage compared to a rest period on postoperative pain scores and physiological responses in infants with CCHD. Methods: We used a two-group randomized clinical trial design with a sample of 60 infants with CCHD between 1 day and 12 months of age following their first cardiothoracic surgery. Both groups received standard postoperative care. Group 1 received a daily 30-minute restriction of nonessential caregiving (quiet time), and Group 2 received a daily 30-minute massage. Interventions continued for seven consecutive days. Pain was measured six times daily using the Face, Legs, Activity, Cry, Consolability Pain Assessment Tool (FLACC). Average daily doses of analgesics were recorded. Heart rates (HRs), respiratory rates (RRs), and oxygen saturations (SpO2) were recorded continuously. Daily averages, pre- and postintervention FLACC scores, and physiological responses were analyzed using descriptive statistics, generalized linear mixed models repeated measures, latent growth models, and/or regression discontinuity analysis. Fentanyl-equivalent narcotic values were used as a time-varying covariate. Results: Adjusted pain scores were lower for the massage group on all days except Day 7. Overall, there were no group effects on level of pain or differential rate of change in pain. However, the massage group had lower daily pain scores with small to medium effect size differences, largest at Days 4, 5, and 6, and lower average daily HR and RR. There was little difference between groups in SpO2. Infants demonstrated immediate effects of massage, with HR and RR decreasing and oxygen saturations increasing. Discussion: This study provides beginning evidence that postoperative massage may reduce pain and improve physiological parameters in infants with congenital heart disease. This nonpharmacological adjunct to pain management may provide a particular benefit for this population by reducing demand on the cardiorespiratory system. [ABSTRACT FROM AUTHOR]

Delirium is a complication of critical illness associated with poor outcomes. Although widely studied in adults, comparatively little is understood about delirium in pediatric intensive care units (ICUs). The purpose of this integrative review is to determine the extent and nature of current evidence, identify gaps in the literature, and outline future areas for investigation of pediatric ICU delirium. Eligible articles included research reports of delirium in pediatric ICU samples published in English since 2009. After an extensive literature search and consideration for inclusion/exclusion criteria, 22 articles were chosen for review. Delirium was highly prevalent in the ICU. Delirium episodes developed early in hospitalization, lasted several days, and consisted of hypoactive or mixed motor subtypes. Frequently identified independent risk factors included young age, developmental delay, mechanical ventilation, and benzodiazepine exposure. Pediatric delirium was independently associated with increased length of stay, costs, and mortality. The long‐term cognitive, psychological, and functional morbidities associated with pediatric delirium remain largely unknown. Few researchers have implemented interventions to prevent or manage delirium. There was little evidence for the efficacy or safety of pharmacological management. Multicomponent delirium bundles may significantly decrease delirium incidence. Key quality issues among studies included variation in delirium screening, low levels of evidence (i.e., observational studies), and limited ability to determine intervention efficacy in quasi‐experimental designs. Although the quantity and quality of pediatric delirium research has rapidly increased, further studies are needed to understand the long‐term effects of pediatric delirium and determine the efficacy and safety of interventions for prevention and management. [ABSTRACT FROM AUTHOR]

Purpose: Describe collaborative caregiving of the parents of an infant with congenital heart disease (CHD) with partner, health‐care clinicians, and substitute caregivers (SC). Design and Methods: In a national online survey, 53 mothers and 12 fathers described collaborative caregiving for infants after CHD intervention with respect to facets of Bowlby's concept of the internal working model of caregiving. Parents identified concern for 24 everyday common problems or goals (i.e., issues; 10 for partner, 9 for clinician, 5 for SC), rated issue importance and difficulty, indicated an intention for seeking and using help (help use), and identified help source. Results: All survey items were a concern to at least 11 parents. Most prominently, all five of the SC items were identified by at least 44% of the parents as a concern. Everyday, common problems and goals were generally reported to be more important than difficult. Two items identified as partner issues, "Talking about life change" and "Handling stress," were a concern for about 50% of parents and identified by at least 74% as very important and 72% as moderately to greatly difficult. Help use was highest for SC items followed by items related to the partner. The partner was most frequently identified as a help source. Practice Implications: Nurses are in a position to assess and support parent collaboration within partner, clinician, and SC relationships for everyday problems and goals. The survey questions, with further development and testing, could be used for clinician assessment and tailoring of intervention to support parents' collaborative caregiving for infants with CHD. [ABSTRACT FROM AUTHOR]

Background: Infants with complex congenital heart disease (CCHD) often develop neurodevelopmental disabilities. Cognitive abilities are associated with vagally mediated autonomic function. Skin-to-skin contact (SSC) interventions enhance infant neurodevelopment and autonomic function in other high-risk populations. Aim: To examine the effects of a neonatal SSC intervention on learning and autonomic function in 3-month-old infants: infants with CCHD who received neonatal SSC (n = 10), typically developing (TD) infants (n = 16), and infants with CCHD without SSC (n = 10). Methods: This secondary data analysis measured cognitive function using the mobile paradigm (MP), a classic measure of learning based on operant conditioning. Autonomic function was assessed with heart rate (HR) and HR variability (HRV). Data were analyzed with repeated-measures general linear mixed modeling with α =.10 for this exploratory study. Results: Learning rates were TD = 75%, cardiac-SSC = 70%, and cardiac-control = 40%. Learners demonstrated significant reductions in HRV during the MP; nonlearners exhibited no change. TD and cardiac-SSC groups exhibited increases in HR and reductions in HRV during the MP. No significant changes occurred in the cardiac-control group. Nonlinear HRV during the MP differed only in the TD group. Conclusions: Findings suggest improvements in cognitive and autonomic development in 3-month-old infants with CCHD who received neonatal SSC. Learning and autonomic function results in infants with CCHD who had not received SSC suggest reduced capacity to muster the physiologic resources to carry out this cognitive task. Findings provide preliminary evidence in support of implementation of SSC with infants with CCHD and support additional research. [ABSTRACT FROM AUTHOR]

This study described co-parenting motivations and quality of co-parenting features for parents of infants with complex congenital heart disease (CCHD), including differences over time by illness severity. Existing transcripts of parenting experience at infant age 1 and 12 months for 23 parent couples were analyzed using directed content analysis. Data were quantitized for additional description. Six co-parenting motivations and five co-parenting features were identified. Two co-parenting motivations had not been previously described: Developing the Co-Parenting Relationship and Maintaining the Couple Relationship. Variability in quality of co-parenting features was evident. However, the majority of parents showed high ratings. Motivations and quality of co-parenting features changed over time and were related to illness severity. Our findings increase the understanding of what parents are working on as a couple to parent an infant with CCHD and the quality of this co-parenting. Several questions for further study are presented. [ABSTRACT FROM AUTHOR]

Prematurity is the largest contributor to perinatal morbidity and mortality. Preterm infants and their families are a significant vulnerable population burdened with limited resources, numerous health risks, and poor health outcomes. The social determinants of health greatly shape the economic and psychosocial resources that families possess to promote optimal outcomes for their preterm infants. The purposes of this article are to analyze the resource availability, relative risks, and health outcomes of preterm infants and their families and to discuss why universal paid family leave could be one potential public policy that would promote optimal outcomes for this infant population. First, we discuss the history of family leave in the United States and draw comparisons with other countries around the world. We use the vulnerable populations conceptual model as a framework to discuss why universal paid family leave is needed and to review how disparities in resource availability are driving the health status of preterm infants. We conclude with implications for research, nursing practice, and public policy. Although health care providers, policy makers, and other key stakeholders have paid considerable attention to and allocated resources for preventing and treating prematurity, this attention is geared toward individual-based health strategies for promoting preconception health, preventing a preterm birth, and improving individual infant outcomes. Our view is that public policies addressing the social determinants of health (e.g., universal paid family leave) would have a much greater impact on the health outcomes of preterm infants and their families than current strategies. [ABSTRACT FROM AUTHOR]

Extremely premature infants are at great risk for poor neurodevelopmental outcomes, in part because neurologic structures designed to mature in the womb must now do so in the extrauterine environment. Reliable biomarkers of neurodevelopment are especially critical in this population, as behavioral measures can be unreliable due to immaturity of the premature infant nervous system. Oxytocin (OT) has the potential to be a marker of neurobiological processes that offer infant neuroprotection. However, no studies have measured OT in the plasma and urine of premature infants. The purposes of this study were to describe plasma and urine OT levels of premature infants through 34 weeks corrected gestational age (CGA), determine whether plasma and urine OT are correlated, and explore associations between infant demographics and OT trajectories. Plasma and urine from 37 premature infants, born at gestational ages 25-28 6/7 weeks, were longitudinally collected at 14 days of life, then weekly until 34 weeks CGA. Plasma OT decreased with age, at a rate of 15% per week, and exhibited strong stability within infants. Urine OT was not correlated with plasma OT and did not show a significant trend over time; thus, urine may not be a reliable, noninvasive measurement in this population. Apgar score was the only infant demographic characteristic associated with plasma OT. Given the novelty of this work, replication is needed to confirm these findings, and future research should explore potential mechanisms (e.g., stress, normal maturation, and social experiences) that contribute to declining plasma OT levels in premature infants. [ABSTRACT FROM AUTHOR]

Background: Infants with complex congenital heart disease (CCHD) demonstrate impaired autonomic nervous system (ANS) regulation, which may contribute to commonly observed impairments in feeding, growth, and development. Close mother-infant physical contact improves ANS function in other high-risk infant populations. Objective: Our purposes were to examine feasibility of a 2-week daily skin-to-skin contact (SSC) intervention and to describe change in ANS function in response to the intervention. Methods: Feasibility was assessed by recruitment and retention rates, safety, and acceptability. Autonomic nervous system function was measured with linear and nonlinear measures of heart rate variability (HRV) during a feeding before the 14-day SSC intervention and 3 times during a 4-week follow-up. Results: Recruitment rate was 72%; retention rate was 55.5%. Mothers were universally positive about SSC. Ten mothers and infants completed a daily mean of 77.05 minutes of SSC during the 14-day intervention with no adverse events. Baseline high-frequency HRV, reactivity to challenge, and recovery after challenge improved during the 6-week study. Nonlinear measures demonstrated abnormally high sympathetic activity, especially after feeding, in most infants. Conclusions: Skin-to-skin contact is feasible in infants with CCHD. Linear measures of HRV suggested improvements in ANS function with this intervention. This article is one of the first to describe nonlinear HRV measures in infants with CCHD. Additional research is needed to identify variations in linear and nonlinear effects based on specific cardiac conditions and with varying intervention doses and timing. This low-cost, low-risk intervention has the potential to improve outcomes in infants with CCHD. [ABSTRACT FROM AUTHOR]

Extremely premature infants, born 28 weeks gestation or less, are at high risk for impaired socioemotional development, due in part to exposure to early stressful social experiences that alter brain development. Understanding mediators that link experience with outcomes is necessary to assess premature infant responses to social experiences that are critical to brain development. The hormone oxytocin (OT), released during supportive interactions, has potential as a biomarker of the premature infant's responses to social experiences. The purpose of this study was to examine associations among infant plasma OT trajectories and maternal-infant social engagement behaviors during initial hospitalization. This study also examined demographic correlates of engagement behaviors in mothers and infants. Plasma from 28 extremely premature infants, born gestational ages 25-28 6/7 weeks, was collected at 14 days of life, then weekly until 34 weeks. Social engagement behaviors were measured by the Parent-Child Early Relational Assessment during a videotaped feeding when the infant was receiving one-quarter full oral feeds. Maternal-infant demographics were extracted from the medical record. Higher infant plasma OT was associated with lower infant social engagement, but no associations were found with maternal social engagement. Infant social engagement was positively related to maternal social engagement. Maternal parity was related to maternal social engagement, and infant demographics did not predict infant social engagement. The significant, yet negative, association between infant OT and engagement provides support for the measurement of OT as a neurobiological antecedent to infant social behaviors. Finally, this research suggests that during the earliest period of infant socio-behavioral development, premature infants are behaviorally reactive to the social engagement behaviors of their mothers. [ABSTRACT FROM AUTHOR]