Sammanfattning Mål: Tidigare studier visar att delar av den fysiska och psykiska tillväxten och utvecklingen hos för tidigt födda barn kan påverkas av den förkortade graviditetsperioden. De odontologiska aspekterna av prematuritet har ännu inte till fullo studerats. Syftet med denna studie är att undersöka om tandmognaden påverkas av för tidig födsel och om enskilda tänder i högre utsträckning är mer påverkade.Material och Metod: I studien deltog 116 barn: 36 extremt för tidigt födda barn (extremely preterm - EPT), 38 mycket för tidigt födda barn (very preterm – VPT) och 42 fullgångna kontroller (controls – C). Panoramaröntgenbilder analyserades av fem kalibrerade observatörer, enligt en metod som utvecklats av Demirjian och Goldstein. Röntgenbilderna avidentifierades och mognadsgraden av de 7 permanenta tänderna i underkäkens vänstra sida (tand 31-37) bedömdes enligt ett 8-stegs system. De 7 bedömningarna adderades sedan till en tandmognadspoäng (maturity score) som motsvarade barnets tandmognadsgrad. Detta möjliggjorde jämförelser på såväl gruppnivå som tandnivå. Observatörernas tillförlitlighet och metodens reproducerbarhet utvärderades genom att 27 slumpvis utvalda röntgenbilder bedömdes ytterligare en gång. Statistiska analyser utfördes av studiens resultat samt av reproducerbarheten.Resultat: Resultatet, med hänsyn till variationer i observatörernas bedömningar, visade att EPT-gruppen hade en genomsnittlig tandmognadspoäng mellan 81.9 och 86.7, VPT 85.2-89.1 och kontrollgruppen 88.1-91.0. Samtliga fem observatörer uppvisade statistiskt signifikanta skillnader mellan EPT-gruppen och kontrollgruppen (p≤0.006). På tandnivå uppvisade alla observatörer en signifikant fördröjning (p≤0.002) av tandmognaden för tand 37 när EPT-gruppen jämfördes mot kontrollgruppen. Signifikanta skillnader mellan ett flertal andra tänder erhölls men konsensus mellan observatörerna saknades. Överensstämmelsen inom varje enskild observatör (intra-observer agreement) beräknades med ett Kappa-test, där resultaten varierade mellan 0.16-1.00. Kappa-beräkningen av reproducerbarheten mellan samtliga observatörer (inter-observer agreement) varierade mellan 0.31-0.71.Slutsats: Resultaten i denna studie tyder på en allmän försening av tandmognaden vid 9 års ålder hos de extremt för tidigt födda barnen (EPT), jämfört med fullgångna barn (C). En förkortad gestationsperiod tycks indikera en fördröjning av tandmognaden jämfört med tandmognaden hos fullgångna barn.

Globally, in both developed and developing countries, the twinning rates have increased since the early 70’s. A large proportion of twins are born preterm and/or small-for-gestational-age (SGA) and/or with a low birth weight. Several studies have been performed on the long-term effect of these non-optimal birth characteristics on future reproductive performance and morbidity. Yet, most studies exclude twins or higher order pregnancies and thus the findings are based on singleton pregnancies only. The aim of the present thesis was therefore to investigate the impact of non-optimal birth characteristics in terms of preterm birth, small-for-gestational age, and low birth weight, on the reproductive pattern and morbidity among twins and singletons Furthermore, the present thesis attempted to establish whether twins and singletons were affected in the same manner. The studies included in this thesis are prospective population-based register studies, including all men and women, alive and living in Sweden at age 13, who were born between 1973 and 1983 (1,000,037 singletons and 16,561 twins) for the first three studies with follow-up till the end of 2006 and 2009. The last study included all men and women, alive and living in Sweden at age 13, who were born between 1973 and 1993 (2,051,479 singletons and 39,726 twins) with follow-up till the end of 2012. In general, twins were found less likely to reproduce between 13 and 33 years of age compared with singletons. Stratifying data by different birth characteristics, it was found that twins had a lower likelihood of reproducing on several different birth characteristics (appropriate-for-gestational-age, normal birth weight, low birth weight, term birth, preterm birth). However, twins born very preterm had an increased likelihood of reproducing compared with singletons born very preterm. Not taking birth characteristics into account, twinning was associated with a higher degree of hospitalization. However, accounting for the diverging birth characteristics this difference diminished and for some diagnoses the relationship was reversed such that twins were actually less likely to be hospitalized compared with singletons. In terms of the heritability of non-optimal birth characteristics singleton mothers born preterm were more predisposed to give birth to a child that was preterm while singleton mothers born SGA more often gave birth to a child either born preterm or SGA. Among twins this heritability was not as evident. The only difference observed was among twin mothers born SGA who were more likely to give birth to a child born SGA. In the extended cohort comprising those born between 1973 and 1993, male and female twins were found to be less likely to become parents compared with singletons. No difference was found among women in terms of having a second child, while male twins were more likely to have a second child compared with male singletons. It was also found that the likelihood of becoming a first-time parent and second-time parent was positively associated with the number of siblings.

Impairments in executive function have been posited to account for some of the poor cognitive and educational outcomes associated with very preterm birth. As part of a prospective, longitudinal study, this research examined executive function in a regionally representative sample of 103 children born very preterm and/or very low birth weight (<33 weeks GA / <1500g) and a comparison sample of 108 full term children at age 6 years (corrected for prematurity). The specific aims of the study were 1) to describe the performance of children born very preterm and full term on a range of executive function measures, 2) to identify the antecedent medical, neurological and socio-familial factors associated with executive function performance within the very preterm group, and 3) to examine linkages between children’s executive function performance and their academic achievement at age 6 years. Children underwent a comprehensive developmental assessment, including standardised tests of IQ and academic achievement in mathematics, reading and receptive language. Additionally, they completed a number of executive function tasks selected to assess verbal working memory (Digit Span), spatial working memory (Corsi Blocks), planning and problem-solving (Tower of Hanoi), selective attention (Visual Search), shifting and inhibitory control (Detour Reaching Box) and sustained attention and inhibition (Kiddie-Conner’s Continuous Performance Task; K-CPT). Parents and teachers of these children also completed the Behavioural Rating Inventory of Executive Function and teachers rated children’s performance in reading, arithmetic and comprehension in relation to their classroom peers. Results revealed a pervasive pattern of impairment across multiple measures of executive function in children born very preterm relative to their full term peers. Specifically, children born very preterm were less likely to be able to complete any backward Digit Span trials (p<0.05) and showed lower raw scores on this task (p<0.1) than children in the full term group. Children born very preterm showed lower spatial span scores on the Corsi Blocks Task (p<0.01). They also showed lower planning performance, as assessed by the Tower of Hanoi (p<0.05). Children born very preterm made more inhibitory control/shift errors on the Detour Reaching Box and demonstrated less accuracy in their Visual Search (p<0.001) than children born full term. Finally, they showed lower levels of sustained attention on the K-CPT (p<0.001). Parents, teachers and examiners rated these children as having greater difficulties across multiple areas of executive function. These differences remained significant after controlling for group differences in socioeconomic status and after exclusion of children with severe cognitive and motor impairments. Within the very preterm group, antecedent predictors of poorer working memory and planning performance included male gender (p<0.001), intrauterine infection (p<0.05) and severity of cerebral white matter abnormality on term-equivalent MRI (p<0.05). Lower gestational age (p<0.05) and male gender (p<0.001) were related to poorer executive attention performance. Familial predictors of poorer executive performance included instability in parenting (p<0.05), higher levels of parental intrusiveness (p<0.1) and lower levels of interactional synchrony (p<0.05) between parent and child, recorded at earlier follow-up points. Finally, children’s executive function performance was highly correlated with school achievement in reading, arithmetic and language comprehension (p<0.001). Findings suggest a global pattern of executive impairment amongst children born very preterm, with these difficulties placing children at risk for poor academic performance and learning difficulties. Findings also suggest that both neurological pathology and early parenting experiences are important mediators of the relationship between very preterm birth and poor executive function, highlighting the importance of these areas for early intervention.

In der Neonatologie ist die Verabreichung von Erythrozytenkonzentrat (EK) eine der häufigsten therapeutischen Maßnahmen. Ursachen dafür sind die Frühgeborenen-anämie und die iatrogen durch diagnostische Blutentnahmen hervorgerufene sekundäre Anämie. Obwohl ca. 80% der Frühgeborenen während des postnatalen stationären Aufenthaltes EK erhalten, gibt es noch immer keine einheitlichen Richtlinien zur Bluttransfusion bei Frühgeborenen. In der vorliegenden Studie sollte der Effekt einer EK-Gabe mit Hilfe der Messung der cerebralen und peripheren Gewebsoxygenierung (crSO2 und prSO2) erfasst werden. Und es wurde der Annahme nachgegangen, dass in der Neonatologie Subgruppen existieren, welche unterschiedlich von einer EK-Transfusion profitieren. Im Rahmen dieser Promotionsarbeit wurden Frühgeborene der neonatologischen Abteilung der Universitätsklinik und Poliklinik für Kinder- und Jugendmedizin Leipzig prospektiv analysiert. Es konnte gezeigt werden, dass bei allen untersuchten Patienten sowohl die cerebrale als auch die periphere Gewebsoxygenierung unter EK-Transfusion ansteigen und auch nach einem Intervall von 24 Stunden noch auf diesem gesteigerten Niveau konstant bleiben. Zudem konnte nachgewiesen werden, dass Kinder mit niedrigen crSO2-Ausgangswerten vor Transfusion mehr Sauerstoffsättigungsabfälle unter 80% (SaO2<80%) aufweisen. Nach Transfusion ist bei diesen Patienten zusätzlich ein stärkerer Rückgang der Anzahl der SaO2<80% zu beobachten. Somit ist die Gewebsoxygenierung möglicherweise ein sinnvoller Parameter für die Indikation zur EK-Transfusion, welcher bei der Erarbeitung neuer Transfusionsricht-linien in der Neonatologie mit einbezogen werden sollte.

Objectives: To explore why so few mothers breastfeed when their babies are admitted to neonatal intensive care unit (NICU), and to gain an understanding of the impact of this for the mothers and staff involved. DESIGN: This study adopted an ethnographic approach. The data collection involved 135 hours of participant observation over a 6-month period and 32 semi-structured interviews of 17 mothers, 10 nurses, and 5 physicians. Findings: Data from the participants’ interviews and the participant observation were analysed focusing on the two different perspectives; one relating to the mothers and the other to the staff members and their working conditions. The mothers’ experiences were revealed as a developing process as their feeling changed from fearful and terrifying toward becoming and feeling like a ‘real’ mother. Their experience of mothering and breastfeeding differed from their expectations in that breastfeeding became a complex process for some and impossible for others. Five distinct themes emerged; the first highlighted the crisis, which involved the mother's feelings of emotional instability, their strategies for coping such as not visiting the baby, and recognition of the NICU as a stressful environment. The second theme described issues relating to control and power. This involved the perception of having a lack of control and needing to seek permission, the use of language as a mechanism for control, and mothers being placed in a subordinate role. The third theme related to the separation, which included difficulties of acceptance, feeling like stranger and not being important, and the need for physical closeness. Acceptance and adaptation comprised the fourth theme in which gradual acceptance occurred and a spiritual aspect emerged. The final theme, becoming a mother, included issues such as the special moments, breastfeeding as a turning point, and practical and informational needs. Almost all the mothers in this study spoke about going through all these stages during their infants’ stay in the NICU. Analysis of these findings suggests that mothers who deliver prematurely, may have their rite of passage into motherhood interrupted, resulting in them being placed in a position of suspended liminality. v The data also suggest that while staff members agree with the benefits of breastfeeding for preterm infants, the actual implementation of a breastfeeding policy within the neonatal units is more problematic. Three key themes emerged from the analysis relating to the staff perspectives. The first described the contradiction that exists between the staff beliefs and behaviours in relation to breastfeeding and supporting mothers. Elements that comprised this theme were “breast milk is best”, perceiving breastfeeding promotion as a nicety not a necessity; lacking support for mothers, and abdication of responsibility. The second theme related to their working conditions: this included a lack of institutional support for the health care team, and barriers to support breastfeeding. The final theme of controlling relationships captured the essence of the practitioner: mother association. Together, these elements revealed a situation whereby staff appeared more preoccupied in addressing the task aspect of care for the babies than supporting mothers in feeding and subsequently mothering their preterm child. Conclusions: An understanding of the experiences of mothers of preterm infants who wish to breastfeed, and the connection that breastfeeding has to the process of becoming a mother, allows for the finding of more positive strategies to support mothers and breastfeeding within the NICU. This study reveals a new understanding of how breastfeeding is connected to the process of becoming a mother, within the context of two Jordanian NICUs. It also highlights the difficult working conditions for nurses within these units. It is anticipated that recognition of these findings may assist with service developments and lead to improvements in the NICU environment in Jordan, thus enhancing health care delivery in accordance with the individual needs of infants and their mothers.

Worldwide, more than 1 million infants die as a result of premature birth. In the United States, where 1 in 10 births occurs preterm, premature birth is the leading cause of infant mortality. Premature infants have high rates of mortality and morbidity, with the highest rates seen in those infants born extremely preterm -- prior to 30 weeks gestation. Severe morbidity in these infants often contributes to life-long health problems. Maternal hypertension (HTN) is one contributor to preterm birth and also contributes to fetal growth restriction, resulting in birth weights which are small for gestational age (SGA, and generally within the lowest 10th percentile). Within this high risk population, SGA infants have increased risk of mortality compared to appropriate for gestational age infants. Therefore the impact of maternal HTN on neonatal outcome might be presumed to be negative. Previous studies however, have been contradictory, with both higher and lower rates of infant mortality reported in infants born to mothers with HTN, as well as differing reports analyzing the relationship between serious morbidity and maternal HTN. Utilizing the Vermont Oxford Network Very Low Birth Weight database, a collaborative database of Level III Neonatal Intensive Care Units across the world, 88,275 North American infants born between 22+0 and 29+6 weeks gestational age between 2008 and 2011 were identified. This dissertation explores the relationship between maternal HTN and gestational age at time of birth within this population, and the reported rates of morbidity and mortality in infants born prior to 30 weeks gestation. The independent contributions of maternal HTN with neonatal morbidity and mortality in our population were estimated using logistic regression and adjusting for factors previously known to be associated with risk, including birth weight, antenatal steroid exposure, infant sex, maternal race/ethnicity, prenatal care, inborn/outborn status, and birth year. We hypothesized that mortality rates would be lower for infants born to mothers with HTN compared to those born due to other factors, when corrected for the noted confounding variables and surviving infants would have better prognoses, as evidenced by lower rates of severe morbidity, including bronchopulmonary dysplasia, intraventricular hemorrhage, periventricular leukomalacia, necrotizing enterocolitis, and infection. Within the higher-risk SGA population, we hypothesized that mortality rates would be higher than observed in appropriately grown infants, but decreased in those born to mothers with HTN, despite the association between maternal HTN and SGA. This dissertation begins with an explanation of current knowledge about preterm birth, maternal HTN, and their associations. Chapter 2 focuses on the relationship between maternal HTN and infant mortality in extremely preterm infants. Chapter 3 examines the risk associated with severe morbidities in surviving infants. In addition, we also use a combined morbidity risk assessment score which has previously been used to determine future risk of long term disability. In Chapter 4, SGA infants are separately evaluated for their risk of mortality and the association with maternal HTN. These analyses support the high mortality and morbidity rates seen in extremely preterm infants. Maternal HTN, after adjustment, results in reduced risk of both mortality and severe morbidities in infants compared to infants born to mothers with other underlying contributors to preterm birth. This suggests that clinical practices and parental counseling should reflect differing risk profiles in sub-populations of extremely preterm infants.

Overview There are numerous studies in the current literature focusing on the intense emotions experienced by parents, following the birth of a preterm infant, (i.e., born prior to 37 weeks gestational age [GA]). Research findings have helped us understand the fear and anxiety they feel while attempting to navigate the neonatal intensive care unit (NICU) environment. What happens in those early weeks and months at home after discharge, however, is surprisingly absent from the literature. It is well known that preterm infants are readmitted to the hospital during the first few months after discharge at a rate of 10% - 35%, for an average 4.7 - 11.7 day stay and a cost of approximately $376 million (Underwood, 2007; Escobar, et al., 2005). The most common reasons for readmission are respiratory, feeding and jaundice problems (Spicer, et al., 2008; Underwood, 2007; Escobar, et al., 2005; Brissaud, et al., 2005). What we don’t yet know is what transpired during those early days and weeks at home and how mothers established their day-to-day routines. This missing information could foster a better understanding of family needs and promote the development of strategies to share with mothers prior to discharge, with the result being healthier transitions for both mothers and infants and a possible reduction in the inflated readmission rates for this cohort. The purpose of this research was to help bridge the gaps in the literature on the topic of transitioning a preterm infant to home following NICU discharge. Eight mothers who met the criteria of having a preterm infant born between 24 and 34 weeks GA, admitted to a NICU for a week or more, and who had been discharged to home for 6 months or less, were purposefully chosen from a convenience sample. Each mother was interviewed and asked to describe those first few months at home, e.g., how she met her infant’s needs, what she learned, and how she learned it. Two follow up questions were included and asked the mother what she would like us (HCPs) to know about her experience, and what she would say to other mothers whose infants were still in the NICU. Most mothers spoke at length of the fear they felt when bringing their infants home, and how inadequate they felt trying to provide care that had heretofore been provided by a team of specialists. They described the 2 difficulty and confusion associated with getting their infants to sleep in a quiet home environment until they thought to duplicate the noises of the NICU, and how the monitors, which all infants wore home from the NICU, were both friend and foe, alerting them to potential problems, but awakening the entire household in the process. Each mother also spoke of her determination to do whatever was necessary to ensure that her infant was not rehospitalized, and how thankful she was that her infant had made it to this point. Although each mother described a different approach to meeting the challenges associated with her infant, there was a consistency in the overall challenges each mother experienced. Most mothers wanted HCPs to know they were thankful for the part each had played in saving their infant’s life but they also wanted to impart their parental wisdom on the best ways to give information to a parent, the need for uniformity in what they called the “rules” of the NICU, and how a little encouragement from any HCP was sorely needed by most parents. These mothers were excited to be taking part in this study. They wanted to feel that something they saw, felt or did would make a difference for another mother with an infant in the NICU. Each thanked me for allowing them to share their experiences with me. The references for this document will appear at the end of each section.

Neonatal Intensive Care Units have experienced profound advances in technology and treatment modalities over the last two decades. Infants born at the edge of viability are now surviving despite prolonged hospitalizations. These infants born preterm are prone to a high degree of stress from life sustaining and routine interventions. Much focus has been directed toward addressing noxious environmental factors such as noise, light, and infectious disease; however, little has been done to examine the stress experienced by the professional caregiver who work in these environments. Environmental press theory, which focuses on the interplay between human beings and their surroundings, is explored as a way to provide insight into understanding and mitigating the stress experienced by health care providers working in the newborn intensive care. A proposal for a research study with a cross-over design was approved to study the effect of “four handed care” on infants’ physiologic responses (oxygenation, heart rate, and stress) and behavioral responses (state, stress and defense, self-regulatory and approach behaviors) to and recovery from endotracheal suctioning when compared to routine care. Results of this study demonstrated no significant differences were noted when heart rate (HR) or oxygen saturation (SpO2) taken at baseline were compared to HR and SpO2 obtained during and after suctioning while in the routine care condition. In the four-handed care condition, mean SpO2 increased from pre-observation 95.49 to during observation saturation 97.75 (p = 0.001). Salivary cortisol did not differ between groups at baseline or post-suctioning. There was no significant difference in behavior state between the two conditions at any time point. More stress and defense behaviors were seen post-suctioning when infants received routine care as opposed to four-handed care (p = .001) and more self-regulatory behaviors were exhibited by infants during (p = .019) and after suctioning (p = .016) when receiving four-handed care as opposed to routine care. There was no statistical difference in the number of monitor call-backs post-suctioning. In conclusion, four-handed care during suctioning was associated with a decrease in stress and defense behaviors and an increase in self-regulatory behaviors. These findings, while based on a small sample, provide modest evidence that the four-handed care intervention for suctioning should receive further testing. Interventions such as four-handed care that are theoretically developmentally supportive of the sick preterm infant, need further research attention before recommending widespread adoption.

GROWING UP IN IRELAND: FACTORS IMPACTING SLEEP PATTERNS OF PRETERM INFANTS By Joanne Fallon MS, OT, PhD A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy at Virginia Commonwealth University Virginia Commonwealth University, 2015. Major Director: Shelly J. Lane, PhD, Professor, Department of Occupational Therapy Preterm infants represent the largest child patient group in the European Union (EU), accounting for 5.5-11.4% of all births (European Foundation for the Care of Newborn Infants, 2011b). Preterm birth is defined as birth prior to 37 weeks gestation. Infants born late preterm (34-36 weeks) are considered more similar to early preterm (> 34 weeks) than to full-term infants, despite previously regarded as near-term (Raju Higgins, Stark, & Leveno, 2006). For preterm infants, sleeping functions are critical as they demonstrate the ability to adjust to biological and social rhythms and support emotional regulation, learning, and memory. Many studies have focused on sleep patterns of full-term infants; however, few have investigated preterm infants and none have compared early and late preterm infants with a population from the Republic of Ireland. The purpose of this study was to identify infant and parent characteristics that promote optimal sleep in preterm infants and to establish whether the parent-infant relationship mediates this association. A secondary purpose was to test the transactional model of sleep. Parent report of infant sleep was taken from a recent population-based dataset from the Republic of Ireland. A comparison of the day and nighttime sleep patterns of early and late preterm infants found no difference between groups. There was also no difference in infant temperament, breast-feeding, parental stress, depression, or sociodemographics. A difference was found between groups in infant development, weight at 9 months, and age infant began solid foods. This finding was not surprising as infants born early preterm are at greater at greater risk of developmental delay and disability. Results of this study suggest that the paternal-infant relationship has a mediating impact on the relationship between infant temperament and nighttime waking in the early preterm group only, while the maternal-infant relationship has a mediating role in both groups. These findings add to the body of knowledge on the transactional model of sleep, and are the first to identify infant temperament and the paternal-infant relationship as important factors. Implications of these results are discussed in the context of the transactional model of sleep and recommendations for future research are presented.

MOTHER-INFANT SYNCHRONY DURING INFANT FEEDING By Barbara A. Reyna, PhD A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy at Virginia Commonwealth University. Virginia Commonwealth University, 2010. Major Director: Rita H. Pickler, PhD Endowed Nursing Alumni Professor Department of Family and Community Health Nursing, School of Nursing Synchrony between a mother and her infant is fundamental to their developing relationship. Feeding is an essential activity that provides an opportunity for interaction between a mother and her infant and may lead to synchronous interaction. The purpose this study was to develop and test a coding system, the Maternal-Infant Synchrony Scale (MISS), for assessing synchrony of feeding interaction between a mother and her preterm infant. The secondary aims were to: (1) describe mother and preterm infant synchrony during feeding; (2) examine mother-infant synchrony during feeding over time; (3) examine the mediating effects of infant severity of illness, behavior state, birth gestation, and birth weight, and maternal depression, and maternal responsiveness and sensitivity on mother-infant synchrony; and (4) test the criterion-related validity of the synchrony scale. A descriptive, longitudinal design using data collected during an earlier study was employed; a sample dataset from 10 mother-infant dyads that completed three data collection points (30 observations total) was used. Data were also collected on maternal depression and responsiveness and sensitivity and dyadic tension and reciprocity. For this analysis, scores for infant severity illness and behavior state were computed. The Noldus Observer XT 8.0 (Noldus Information Technology b.v., 2006) was used for data review and coding. The MISS was created by determining the frequency of select behaviors and the percentage of time behaviors occurred during the feeding; changes in behaviors over the three observations periods were calculated. Mothers were attentive and focused during feedings. The influence of infant maturation on feeding behaviors was evident across observations; infant attempts at interaction (gazing at mother) were greater than the mother attempts to engage her infant. MISS scores were not significantly different over the observations, the selected mediators had no significant effect on synchrony, and the criterion validity for the MISS was not established. This study revealed behaviors that are descriptive of the interaction and can be used to develop interventions that would support the developing relationship. Use of the MISS with a larger sample size and a cohort of healthy, term newborns is needed to establish the MISS as a valid and reliable measure of synchrony.