Effect of Nesting and Swaddling on Sleep Duration of Preterm Neonate Hospitalized at Tertiary Care Centre of Eastern Nepal

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INTRODUCTION
According to the definition of the World Health Organization (WHO), preterm period refers to a baby born before complete 37 weeks of pregnancy [1][2].In 2012, globally 15 million babies were born premature, 37.6% were in South Asia and 14 % in Nepal.Among those, 1 million preterm babies die each year and babies who survive can face lifelong disabilities [1].Preterm neonates have immature organ systems that often need additional support to survive.There are five core major developmental cares: protected sleep, pain and stress assessment and management, developmental activities of daily living, familycentered care and the healing environment [3][4][5].It's determinant of mortality as well as morbidity, and is more vulnerable to organ injury, illness death and neurological developmental disabilities [6].
Adequate sleep is important for brain development in neonates where the need of neonatal sleep duration is 10-19 hours/24 hours and may be higher in prematurity [7,8].Swaddling is an ancient practice of encircling an infant in a restrict movement that is more effective for self-regulatory ability of neonates, where they spend more time sleeping [9,10].Nesting, as a component of developmental care, improves neonates sleep quality through preservation of neonates curved limb position that exhibit fewer motor responses to stimuli when keeping in cocoon [7,9,11].

METHODS
The Experimental study design (post-test control group design) was adopted as a consecutive sampling technique with random allocation.Sample size is calculate based on literature using the formula for comparison of two mean and samples consisted of 36 [12].Total 39 respondents were assessed for eligibility (preterm neonate, spontaneous breathing, no need of oxygen administration and ventilator support, no used of sedatives, no any congenital anomalies, not diagnosed with hyperbilirubinemia and septicemia) [13].Three samples were excluded as per the criteria, and 36 were included in study where random sampling was done by lottery method to allocate each subject into either intervention or control group.Eighteen pieces of paper each for experimental and control group was prepared, and put into a box and shuffled.Single piece of paper at a time was drawn as lottery before assigning the sample to the group without replacement method until researcher gets required number of samples.Ethical clearance was obtained from the Institutional Review Committee of BPKIHS (IRC/1044/017).Written assent was obtained from parents and confidentiality maintained throughout the study.The data were collected from 28 th December 2017 to 14 th February 2018.A semi structured questionnaire regarding socio-demographical characteristics and observation tool for sleep duration including clinical medical data form was used for data collection.Intervention: An interview was taken regarding sociodemographic variables, and medical history was obtained from patient chart.Intervention was done once, at least for 1 hour [14,15].For experimental group: Preterm neonate who meets the inclusion criteria within intervention group were fed according to pediatrician's advice; then after diaper were changed and neonate was swaddle on flannel smooth non allergic clothes below the neck by following 4 steps of swaddle [16].
Step 1: Folded the swaddle flannel into a triangle, and baby was placed in the center with shoulders just below the fold.
Step 2: Baby's right arm was placed alongside the body, slightly bent.Same sides of the swaddle (flannel) were taken and pulled it securely across baby's arm and chest, tucking the flannel under the baby.Left arm was kept free.
Step 3: Bottom of the swaddle was folded up over baby's feet.Then after point of the flannel was tuck into the top of the swaddle.
Step 4: Baby's left arm was placed alongside the body, slightly bent, then remaining swaddled, neonate was wrapped over arm and chest; at last, the remaining flannel were tuck under the baby to secure the swaddle.Then after, preterm neonates were kept within cocoon on supine position for nesting in radiant warmer.Then continuous video recording was done throughout the intervention (start of nesting to wake up of neonate) for 2 hours with the DSLR Camera Canon EOS 100D.(Table 1)  Manual/sleep-wake state characteristics scoring [17].For Control group -Similar procedure as in experimental group was done (Preterm neonate who met the inclusion criteria within control group were feed according to pediatrician's advice then after diaper were changed and kept for sleep in radiant warmer) except step wise swaddling and Nesting.  2 shows the baseline characteristics of participants.Nearly 3 in 10 participants (27.8%) were preterm neonate i.e. born between 28 to 32 weeks of gestation in both groups.There was no statistically significant difference in mean of gestation period between experiment and control group.One in two neonates fell within a weight range of 1000 to 1500 grams.The mean weight did not differ statistically significantly between the experimental and control groups.Nearly 7 in 10 neonates received their nutrition through breastfeeding in both groups.There was no proportion difference in breast feeding practices (66.7% vs 69.4%, p=0.72) and types of feeding (44.4% vs. 33.3%,p=0.49) between experimental and control group groups.
Table 3 shows that the mean sleeping duration was significantly higher in experiment group than in control groups (p=0.001).
Table 4 depicts that the association of sleep duration with other variables such as age of neonate, sex, gestational age, body weight, feeding type and feeding methods.There was no significant association in average sleep duration between experimental and the control groups across the studied variables in either of the groups (p>0.05).
Table 5 describe the multi variant linear regression was calculated to predict the effect of independent variables including nesting and swaddling in the dependent variable i.e. sleep duration.There is linear relationship of sleep duration with demography (age and sex) and with other variables (week of gestation, weight, type of feeding).About 68% of the variation in sleep duration could be explained by change in age, sex, week of gestation, weight, type of feeding and intervention and remaining percentage where other factors not include in model (R 2 =0.675,F change significant at (0.343).There is no significant relationship between sleep hour and age, sex, week of gestation, weight and type of feeding.However, we found statistically significant association between sleep duration and the intervention (p= 0.001).It means if intervention is done sleeping time is increased by 19.95 minutes.

DISCUSSION
The study revealed that the effect of nesting and swaddling experiment was significant on sleep duration of preterm neonate in experimental group.Kihara and Nakamura, in a study on the effect of swaddling and nesting on premature infants' behavioral condition and sleep, concluded that infants either in the nest or swaddled, had more prolong quiet sleep time (QST) [18].The study conducted by Franco et al. on the "Influence of Swaddling on Sleep and Arousal Characteristics of Healthy Infants" conclude that Swaddling promotes more-sustained sleep and reduces the frequency of spontaneous awakenings [19].Abdeyazda Z et.al. studied on effects of nesting and swaddling on the sleep duration of premature infants hospitalized in neonatal intensive care units, and concluded that both swaddling and nesting could significantly increase the duration of total sleep time (TST) and quite sleep time (QST), compared to the control (p<0.001)[7].
This study result suggests that the sleep duration of preterm neonate was not associated with other selected variables.This result is similar to the study conducted by Abdeyazda et.al.on effects of nesting and swaddling on the sleep duration of premature infants, which showed no significant difference in the mean of gestational age, postnatal age, weight between two groups (p->0.05[7]. Linear regression analysis showed that effect of intervention (i.e.nesting and swaddling) was significant in the sleep duration.

Figure 2 :
Figure 2: Flow diagram of study

Table 1 :
Sleep and wakefulness Behavioral characteristics of neonate (as per American Academy of sleep Medicine)

Table 4 :
Association of Sleep Duration of neonates with different variables (as per 1-hour video record

Table 5 :
Association between Sleep Duration and independent variable: A Multiple Regression Analysis Literature review of the available studies showed limited number of www.jkahs.org.npJKAHS | Vol.7 | No. 2 | Issue 20 | May-August 2024 studies on preterm neonate sleep possibly due to difficulty in sleep assessed in neonates.In addition, with extensive review of literature, authors found no study that compared the effect of two different cares at same time on preterm neonatal total sleep duration therefore the results of this study could not be compared with other similar studies.Hence this is a unique interventional study on the sleep pattern of preterm neonate, which can be valuable for healthcare workers as well as for general public.It can also be useful as a base for future study.The author would like to acknowledge to Department of Child Health Nursing, Department of Pediatric B.P. Koirala Institute of Health Sciences for validating the research questionnaire.I am grateful to Institutional Research Committee of BPKIHS for granting ethical clearance and approval.I would also like to acknowledge Professor Dr. Surya Raj Niraula, School of Public Health and Community Medicine, BPKIHS for valuable support on Statistical analysis and our sincere thanks to all the parents of participant neonates in this research study.Author Contributions Ms. Nirmala Kumari Pahadi (Conception and design, literature search, acquisition of data interpretation, Statistical analysis and interpretation, Manuscript preparation, revising the article, Guarantor) Prof.Mr. Ramanand Chaudhary (conception and design review, data interpretation, Statistical analysis and interpretation review, article review) Prof.Mr. Basant Kumar Karna (Concept and design review, final report review) Prof.Mr. Upendra Yadav (Concept and design review, final report review) Disclosure: This research was a part of principal investigator's (NKP) thesis work of MSc Nursing at BPKIHS.