neonatal manual for standard newborn care
Contents
1. ea ie e a i a e EE iaaa 7 MeO dO OE a a a a a NaS 8 Apparatus ounsi a a i a a a a delet Man a a r te ete ciate 8 The Motion Watt heenrten iaaa E N A ER 8 Connectivity a B A E r a a Aaah ek Ae 9 Epochs amp Recording times Activity amp Light ccccccccssssssecececsssesssaeseeecsesesssnsaeeeeeeessessseaeeeesens 10 Experimental Protocol cccccccccccccccesssssnsecececeescsessaesececeesceesesaeseseeeesesesesseaeeeeeesesenesseaeeeeess 11 Assessment Kit aeir i TEE i E A EAEI aE AA Gee EE EAEE EA E AA EA EA 11 Set up and placement of the MotionwatchB sssessssssssseressssssrrenrrssssesrrersrssssrsrreenessssesereesnssssenet 11 Procedure on Return of the Motionwatch8 cc cccccccccsssssessseeeceeeesssessaeeeceesesssesseaeeeeees 13 Sleep wake cycle and daytime physical activity Analysis ccccsscccceessstececesseeeecesseeeeeeeeaes 15 Reference Satunnainen e a a e an ohadles a donates sete tonees 18 Credits This manual was prepared by members of the INTERGROWTH 21st Infant Development Group and reflects the general consensus reached during the Infant Development Group Meeting Oxford 23 March 2012 regarding the selection of tests to be included in the INTERGROWTH 21 Neurodevelopment Package The following people made important contributions to this final version for which we thank them Michelle Fernandes Group Coordinator Nuffield Department of Obstetrics and Gynaecology the John Radcliffe Hospi2. INTERGROWTH 21 International Fetal and Newborn Growth Standards for the 21 Century The International Fetal and Newborn Growth Consortium SLEEP WAKE CYCLE ASSESSMENT MANUAL December 2013 ag UNIVERSITY OF Var as ry Hag Es OXFORD Please read this manual carefully and refer to it throughout the study if any clarification is needed This Operations Manual was produced by the INTERGROWTH 21 Infant Development Group based on the 1 Meeting of the Group Oxford March 2012 This document reflects the consensus reached by members of the group regarding the selection of tests to be included in the INTERGROWTH 21 Neurodevelopment Package to be implemented by all centers taking part in the INTERGROWTH 21 follow up study INTERGROWTH 21 is a large project involving health institutions from eight geographically diverse countries It is therefore essential that all participating institutions follow a standardized neurodevelopment protocol Table of Contents EES e AEPS AAN ENAA PE rete te tes asad See eres et tla Me coe ETS eae ceed ena 4 SOUCO iesisnk ci besa Secesenk ebb a a eae ea UE See aa eee Sa CU DEGRA 8a 8 a a Sa CS 5 IACFORAUCUON oana tan tone tad ale ete id eel etl dae hat nee cle dace 6 The use of Actigraphy to measure sleep wake patterns and physical activity in the follow up study of the INTERGROWTH 21 Project i saranda Miata boalaihandabiathaauen 7 Rationale for the Measurement Of Sleep renia
3. Tri axial MEMs technology 0 01g to 8g range 3 11Hz CR2032 Lithium Coin Cell 6 Months run time simple user change 4Mbits non volatile 182 days recording 1min epoch AW mode uncompressed 3 Bar suitable for swimming Yes with visual feedback 2 5 15 30 60 sec in AW compatible mode Direct USB uses generic Windows drivers Micro USB cable All data in 50 sec approx Bespoke XL 12mm silicone 245mm overall length or 12mm nylon Integral Light Sensor Type Range Resolution Sampling Digital human eye response optimized Automatic ranging 0 to 64000lux 0 25lux 0 1000 lux range 1 sample per second averaged over epoch Connectivity and Battery The MotionWatch benefits from a Micro B USB port Fig 2 which can be directly plugged into a PC Fig 3 This allows the user to setup and download from the MotionWatch without the trouble and expense of a separate reader charger The battery is standard lithium CR2032 which can be easily changed by the user Both the MotionWatch battery and USB port can be accessed by simply twisting open the case Fig 2 Fig 3 Epochs amp Recording times Activity amp Light 10 Experimental Protocol Duration of administration in clinic 5 minutes Duration of sleep recording 5 days Epoch 15 seconds Duration of battery life 22 days Assessment Kit The assessment kit consists of 1 A MotionWatch A disposable strap A standard watch
4. at this result will be expected to scale depending on the length of the epoch Fragmentation Index The sum of the Mobile time and the Immobile bouts lt 1min This is an indication of the degree of fragmentation of the sleep period and can be used as an indication of sleep quality or the lack of it The Copy Epoch Results and Copy Statistics will allow the transfer of either the detailed epoch by epoch results or the overall statistics easily into a spread sheet program or similar Simply click the button transfer to a spread sheet window on the computer and use the normal Windows paste function to create a table of your results 16 Categorization into Sleep or Wake In order to determine if in each epoch the wearer was most likely to be awake or asleep the activity data for the epoch and a number of surrounding epochs are scaled and added together and the result compared to a threshold If the total is greater than the threshold then the epoch is categorized as awake The scaling factors applied to surrounding epochs are shown below The threshold applied by default to the sum is 40 counts Preceding epochs Targetepoch Following epochs 60sec 1 25 1 5 1 1 5 1 25 epoch Categorization into Mobile or Immobile To categorize each epoch they are individually compared to a threshold as the table below The epoch is considered immobile if the activity in it is less than the thresho
5. battery A computer on which the MotionWare software has been set up A prepaid envelope if the method of return of the watch is via post OB WON Set up and placement of the Motionwatch8 Step 1 Explain procedure to the mother amp obtain consent Step 2 Load the neurodevelopment application on the iPad and enter the child s FGLS number date of birth and the researcher code A neurodevelopment home page for the child will pop up Access the sleep window for the child s neurodevelopment home page If another assessment from the package such as the vision or neurodevelopment assessment has been completed already the child will have a customized neurodevelopment home page already ready and there is no need to create a new one for the same child Step 3 Completion of sleep questionnaire There will be 5 questions pertaining to the child s sleep in the sleep window of the neurodevelopment home page of the iPad application Ask the parent these questions and record his her response using the picker Where a time is to be entered please use the hour minute hh mm format These six questions are 1 Does a person put the child to bed every night Options a Yes b No c Unable to assess If so at what time 2 Who wakes the child up every morning on weekdays Options a Mother wakes child b Child wakes up himself herself c Wakes up with an alarm d Unable to assess 3 At what time does the child usually wa
6. data All of these four times are also displayed in the information box below Once the desired sleep region is selected the software will automatically perform a categorisation of each epoch of the period between Fell Asleep and Woke Up as either Sleep or Wake and also as 15 either Mobile or Immobile and use these results to provide a number of measures from the period These are described below Bag pn Oo OND 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Time in bed The total elapsed time between the Lights Out and Got Up times Assumed sleep The total elapsed time between the Fell Asleep and Woke Up times Actual sleep time The total time spent in sleep according to the epoch by epoch wake sleep categorisation Actual sleep Actual sleep time expressed as a percentage of the assumed sleep time Actual wake time The total time spent in wake according to the epoch by epoch wake sleep categorisation Actual wake Actual wake time expressed as a percentage of the assumed sleep time Sleep efficiency Actual sleep time expressed as a percentage of time in bed Sleep latency The time between Lights Out and Fell Asleep Sleep bouts The number of contiguous sections categorised as sleep in the epoch by epoch wake sleep categorisation Wake bouts The number of contiguous sections categorised as wake in t
7. e for the participant to use Actigraphy was selected as the sleep measure of choice for the follow up study of the INTERGROWTH 21 project as it was found to meet the criteria mentioned above Polysomnography is more difficult to use for measuring sleep in children requires specialist training and equipment and a sleep lab It necessitates an overnight stay in the lab which would not be feasible for the participants of the INTERGROWTH 21 Project Subjective measures of infant sleep were not chosen as they were not found to be as reliable indicators of infant sleep as actigraphy and because their validity in international populations was not known Issues relating to the compliance of mothers in completing sleep diaries on a daily basis for their children presented difficulties to its use in the field Rationale for the Measurement of Sleep The acquisition of sleep consolidation occurs over the first 2 years of life The measurement of sleep patterns among children in the follow up study allows i To build a profile of sleep patterns night awakenings total duration of sleep daytime napping and sleep efficiency ii To assess group and individual variability a To compare sleep patterns across cultures b To compare sleep patterns in children born at term and preterm and in children with differential fetal growth patterns iii To explore associations between sleep disturbances and other neurodevelopmental outcomes in a large sa
8. he epoch by epoch wake sleep categorisation Mean sleep bout The average length of each of the sleep bouts Mean wake bout The average length of each of the wake bouts Immobile mins The total time categorised as Immobile in the epoch by epoch mobile immobile categorisation Immobile time The immobile time expressed as a percentage of the assumed sleep time Mobile mins The total time categorised as mobile in the epoch by epoch mobile immobile categorisation Mobile time The mobile time expressed as a percentage of the assumed sleep time Immobile bouts The number of contiguous sections categorised as immobile in the epoch by epoch mobile immobile categorisation Mean immobile bout The average length of each of the immobile bouts Immobile bouts lt 1min The number of immobile bouts which were less than or equal to one minute in length Immobile bouts lt 1min The number of immobile bouts less than or equal to one minute expressed as a percentage of the total number of immobile bouts Total activity score The total of all the activity counts during the assumed sleep period Mean activity epoch The total activity score divided by the number of epochs in the assumed sleep period Note that this result will be expected to scale depending on the length of the epoch Mean nonzero activity epoch The total activity score divided by the number of epochs with greater than zero activity in the assumed sleep period Note th
9. he event marker before starting and after finishing the following activities i Feeding the child ii Changing nappies iii Bathing the child The parent should return the watch via post pre paid envelope on day 6 after starting the test Alternatively a member of the research team can be organised to collect the watch on day 6 from the mother s home 12 If the mother asks what to do if the child pulls the watch off tell the mother to press the event marker as soon as she realises this has happened If she attempts to put the watch back on the child ask her to press the event marker again If the mother says that the child refuses to keep the watch on and wants to return it before the 5 days are completed for example on day 2 ask her to do so by using the pre paid envelope and including a brief note to the study team to inform them of this Step 5 Offer mother the option of couriering watch back give pre paid envelope or dropping it off to the team after 5 days i e on DAY 6 after starting the test If the mother chooses to courier the watch back give her a pre paid envelope If the mother chooses to drop the watch back in person give her the name and number of who to contact on the day In both cases the mother need only courier back the Motionwatch8 sensor unit and not the strap Record the mode of delivery chosen by the mother in the sleep window of the neurodevelopment iPad application Procedure on Return of the Mot
10. ionwatch8 Step 1 Remove strap amp discard if still attached Step 2 Connect the Motionwatch8 to the laptop via the USB connector Check battery life if it is lt 20 change the battery after performing steps 3 to 7 below Do not change the battery before performing steps 3 to 8 Step 3 Click read data Once the data is read this can take up to 20 seconds click save recording Save the recording in as FGLS number sleep in the default folder setting C Program Files Application data Motionware Step 4 Log onto the live database Enter your username and password Go to the PIFS tab Under the Sleep Watch files headers click Upload Sleep watch files original A new window will open up On the upper right hand side click Upload A browsing window will open up where you will need to browse for and select the sleep file of choice Click Add and then click Upload Ensure that the Overwrite if file exists box is checked Step 5 Open the Motionware software by double clicking the desktop icon In the Recent Recordings window select the most recent recording by double clicking A window will open up showing the sleep data On the top right corner click the tab called Select all Another window will open up showing statistics On the left hand side will be a tab called Analysis Function under which will be a heading called Sleep Click on this Sleep function The sleep s
11. ke up every morning on weekdays 4 Does the child nap during the day Options a Yes b No c Unable to assess Does the child wake up in the middle of the night Options a Allthe time b Some of the time c Once ina while d Never e Unable to assess Step 2 Calibrating the MotionWatch The researcher must calibrate and set up the MotionWatch before the assessment This is done by Opening up the watch Putting a battery into the watch Connecting the watch to a computer on which the MotionWare software is loaded by a USB cable Clicking New Setup on the MotionWatch Manager The researcher must confirm that the battery life on the watch is gt 20 If it is lt 20 the battery will need to be changed Enter the child s FGLS number TWICE in the User patient ID field and the Full name field the child s gender and the child s date of birth Click Apply setup When Device setup OK please disconnect is displayed unplug the motion watch Step 3 Explain the process to the child highlight that the watch must be worn all the time for five full days Place watch on the non dominant hand of the child Fig 4 Step 4 Give instructions on use to both the parent and the child These are as follows 1 2 3 The child should wear the watch all the time for 5 days even while bathing The watch should not be covered with a heavy sleeve as far as possible The parent should press t
12. ld For a 60 second epoch the activity threshold is 4 17 References 1 Sadeh A A Brief Screening Questionnaire for Infant Sleep Problems Validation and Findings for an Internet Sample Pediatrics 2004 113 6 e570 e7 2 Korte J Wulff K Oppe C Siegmund R Ultradian and circadian activity rest rhythms of preterm neonates compared to full term neonates using actigraphic monitoring Chronobiology International 2001 18 4 697 708 3 So K Michael Adamson T Horne RSC The use of actigraphy for assessment of the development of sleep wake patterns in infants during the first 12 months of life Journal of Sleep Research 2007 16 2 181 7 4 Inc CLaC cited Available from http www camntech com products motionwatch motionwatch 8 overview
13. mple Methodology Apparatus The MotionWatch The actigraph is a miniature wrist watch like device that monitors activity levels for continuous periods For the purpose of this study the actigraphs used will be MotionWatches 8 CamNtech Ltd Cambridge UK 2012 The MotionWatches Fig 1 use advanced accelerometer technology to measure physical activity The activity plots coupled with specialized software MotionWare Software and light sensing and event marking technology analyses data on a full range of sleep and circadian parameters The MotionWatch weighs 9 1 grams and measures 36mm x 28 mm x 9 4 mm It is waterproof and contains a CR2032 lithium coin battery with a recording life of 6 days for recording in 2 second epochs and 91 days for recording in 30 second epochs The watch is easy to wear and is waterproof it can be worn throughout the day with ease even during bathing The watch can be worn for prolonged periods 3 5 days with no inconvenience to the child or the mother Data can be downloaded from the watch using a simple USB device The watch can be reset by the click of a button on the software interface before being issued to another participant Fig 1 Technical Specifications Size mm Weight Sensor Battery Battery life Memory Waterproof Marker button Epoch Comms Download Strap MotionWatch 8 36 I x 28 2 w x 9 4 d excluding strap Weight 9 1 grams including battery excluding strap
14. o be fragmented as manifested by multiple and or prolonged night awakenings Moreover different patterns in sleep and different rates of establishment of circadian sleep wake behavior have been reported between preterm and full term neonates Night awakenings and sleep problems have not only been found to be associated with behavior problems and difficult temperament in children but if undetected and untreated can persist as sleep problems in adulthood A number of tests to assess sleep in children were considered based on literature reviews and discussion with experts These included l Subjective Methods of Assessment of Sleep i Sleep Diary This involved asking the mother to maintain a dairy recording the child s activities sleep and wake times and napping ii Sleep Questionnaire This involved mothers commenting on the quality and frequency of their child s sleep using a questionnaire such as the Brief Infant Sleep Questionnaire BISQ Il Objective Methods of Assessment of Sleep i Polysomnography Polysomnography PSG is the comprehensive recording of biophysical changes that occur during sleep It involves simultaneous recording of brain signals EEG heart signals electrocardiography ECG eye movements electrooculography EOG and muscle activity and movements electromyography EMG Data is recorded from multiple channels placed on the participant s head face limbs and chest The test is conducted in a slee
15. p lab where the participant is asked to sleep overnight ii Actigraphy Actigraphs are wrist watch like devices placed on the wrist or ankle to record movement Collected data are analyzed for periods of activity inactivity which are used to estimate wake sleep The technology is based on the premise that there is more activity during periods of wakefulness than sleep Actigraphy is a well established method of measuring sleep patterns and circadian rhythm in infants and young children The use of actigraphy to assess infant sleep disruptions normative development developmental changes and the efficacy of clinical interventions has also been well documented across all age groups Newer actigraphy watches contain light sensors to measure ambient light The use of Actigraphy to measure sleep wake patterns and physical activity in the follow up study of the INTERGROWTH 21 Project For the purpose of the INTERGROWTH 21 follow up study the following criteria were drawn up for the selection of a measure of sleep in children at 24 months Be suitable for use on children at 24 months of age Bean objective measure of sleep Yield information about night awakenings total duration of sleep daytime napping and sleep efficiency Yield information about motor activity during the day Be easy to administer without specialist training Be internationally valid Be rapid to administer lt 15 minutes Be easy and comfortabl
16. tal University of Oxford Oxford UK Alan Stein Senior Advisor Section of Child and Adolescent Psychiatry Department of Psychiatry Warneford Hospital University of Oxford Oxford UK Charles Newton Senior Advisor Department of Psychiatry Warneford Hospital University of Oxford Oxford UK and Senior Clinical Research Fellow KEMRI Wellcome Trust Research Programme Kilifi Kenya Katharina Wulff Expert Advisor Associate Professor Nuffield Department of Clinical Neurosciences the John Radcliffe Hospital University of Oxford Oxford UK Source 1 The Actiwatch User Manual v 7 2 Document No 30096 July 2009 CamNtech Ltd Cambridge CB23 3UY UK 2 So K Michael Adamson T Horne RSC The use of actigraphy for assessment of the development of sleep wake patterns in infants during the first 12 months of life Journal of Sleep Research 2007 16 2 181 7 Further information Dr Michelle Fernandes E michelle fernandes obs gyn ox ac uk T 44 0 1865222936 2012 INTERGROWTH 21 Project The Nuffield Department of Obstetrics amp 5Gynaecology The John Radcliffe Hospital Oxford OX3 9DU United Kingdom www intergrowth 21st org uk Introduction The consolidation of sleep during the night which is referred to as sleeping during the night is a rapid maturational process during the first year of life However as many as 30 of all toddlers do not achieve sleep consolidation and their sleep continues t
17. tatistics will be displayed At the bottom of the Sleep Statistics window is a button called Copy Statistics Select it by clicking once Step 6 Access the live database and click the PIFS tab Under the Sleep watch files tab there is a text box called MotionWare statistics data Paste the statistics from the clipboard there using either Ctrl V or right click paste Then click save Motionware statistics Step 7 Exit from the live database 13 Step 8 Delete the files from the default folder setting C Program Files Application data Motionware Exit the Motionware program Step 9 If the battery life is gt 20 take the battery out and store it separately This is done by Twisting open the case Sliding out the battery Sliding in the new battery and clicking it into place Replacing the main case and snapping it shut Step 10 If the battery life is found to be lt 20 discard the battery and keep a new one ready in the storage case for the watch so that it is easily accessible for the next researcher to use when calibrating the watch for a new participant Step 11 Clean the exterior of the device with antibacterial wipes Fig 4 14 Sleep wake cycle and daytime physical activity Analysis The sleep analysis function is designed to provide a number of objective sleep measures from overnight actigraphy data It uses the Actiwatch compatible activity counts to apply existing algori
18. thms for measures on actigraphy data It can be easily applied either to normal overnight periods or used to examine any sleep period from an altered phase recording such as a shift worker Simply select a region from the main Actogram window which includes a little daytime on each side then fine tune the markings in the analysis window Fig 5 Sleep Analysis Lights Out 00 20 00 Got Up 08 55 00 Fell Asleep 00 30 00 Woke Up 08 53 00 Time in bed 08 35 Assumed sleep 08 23 Actual sleep time 08 12 Actual sleep 97 8 Actual wake time 00 11 Actual wake me Sleep efficiency 95 5 Sleep latency 00 10 Sleep bouts a Wake bouts 10 Mean sleep bout 00 54 40 Mean wake bout 00 01 06 Immobile mins 463 Immobile time 3 92 0 Mobile mins 40 Mobile time 8 0 Immobile bouts 32 Mean immobile bout 00 14 28 Immobile bouts lt 1min 6 Immobile bouts lt 1min 18 8 Total activity score 1385 Mean activity epoch 275 Mean nonzero activity epoch 34 63 Fragmentation Index 26 7 Copy Epoch Results l Copy Statistics Fig 5 After a sleep region has been opened in the analysis window and the sleep function selected it will look similar to the screenshot above Now the Lights Out and Got Up markers can be dragged to the appropriate positions in the data and the thinner red markers inside then which denote Fell Asleep and Woke Up will be automatically adjusted from the combination of markings and the activity
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