Background: Atopic disease is an increasing problem. Eczema affects 10-20% of young children, and 33-37% of children with eczema are food allergic. Among other factors, nitric oxide (NO) is thought to play a role in eczema and food allergy. Following the atopic march, pproximately 80% of children with atopic eczema will become sensitized to aeroallergens and develop asthma and/or allergic rhinitis. Skin prick test is used for investigating sensitization and is considered a safe method. However, systemic allergic reactions may appear when the test is performed. In diagnosing food allergy and for evaluating achievement of tolerance, the oral food challenge is the method of choice, and the double-blind placebocontrolled fashion is 'the gold standard'. Skin prick test: We examined six cases of generalized allergic reactions in connection with skin prick testing in order to identify risk factors, and thereby increase safety, and we investigated the necessity of performing skin prick tests in duplicate. We found that all six children with generalized reactions were <6 months of age. When analyzing skin prick tests in duplicate, we found only 1.3% that showed diverging results, and in infants <6 months even fewer, 0.9%. Food challenge: We developed recipes and a protocol for low-dose oral food challenge to milk and egg to be used in young children outgrowing their food allergy so as to facilitate early re-/introduction of small amounts of milk and egg. We performed 52 challenges, both open and double-blind placebo controlled. The recipes were validated for blinding. The lowdose challenge was tolerated well by the children and was easy to perform. Four children had a positive challenge outcome, all reacting to very small amounts of milk. All but two of the non-reacting children were able to introduce milk and egg into their diet. Nitric oxide and eczema: We investigated the effect of eczema treatment on the NO levels in urine. The sum of nitrite and nitrate was measured in urinary samples from 94 infants at two visits, with an interval of 6 weeks, and the results were compared with clinical data. The levels of NO products increased significantly when the eczema improved. The atopic march: The aim was to evaluate the atopic march in children with eczema, from referral at <2 years until 4½ years of age. We followed 123 children with eczema, 78 sensitized and 45 not sensitized to milk and/or egg, with respect to eczema severity, other allergic manifestations, development of airway sensitization, and achievement of food tolerance. The difference in severity of eczema at referral was significant when comparing food-sensitized with non-sensitized children. At follow-up, 62% were still affected by eczema, although 56% only mildly so. Tolerance was achieved in 81% of the children allergic to milk and 68% of those allergic to egg. Fifty-eight percent of the food-sensitized children and 26% of the non-sensitized children had become sensitized to aeroallergens, a significant difference. The difference in airway symptoms was not significant. Very few children were exposed to tobacco smoke in their homes. Conclusions: Increased precautions should be considered when performing skin prick tests in infants <6 months of age. The use of a single prick, to avoid the risk of summation of reactions, is justified when performing skin prick tests. We report recipes and a protocol for standardized open and double-blind placebo-controlled low-dose food challenge in young children, enabling the introduction of small amounts of egg and milk into the diet during tolerance development. NO products in urine increases when eczema improves. This might be due to a Th2/Th1 shift induced by the eczema treatment and skin healing, and the variation in NO response may be due to individual variations in NO-induced feedback downregulation of Th1 and Th2 proliferation. The prognosis for achieving clinical tolerance is very good in children early sensitized and allergic to milk and egg, but they will become significantly more often sensitized to aeroallergens.

Background: Type 1 diabetes is a chronic disease for which there is currently no cure, and high quality care is essential if acute and long-term complications are to be avoided. Many children and adolescents have inadequate metabolic control with increased risk for complications later in life, and adolescent girls have reported low quality of life. Differences in metabolic control between treatment centres have been found but the reasons for this are unclear. Diabetes is a largely self-managed disease. Patient education is central to successful self-management but little is known about how to make best use of diabetes communities on the Internet and integrate them into a practitioner-driven service. Aim: The main objective of this thesis was to gain better understanding of how to improve the quality of diabetes care for children and adolescents, aiming to have near-normal blood glucose, to prevent both acute and late complications and to have good quality of life. Methods: The geographic populations of two paediatric centres (n=400) received validated questionnaires on perceived quality of care and Health-Related Quality of Life (HRQOL). An intervention with a web portal containing diabetes-related information and social networking functions was carried out within the same population. Clinical variables from 18 651 outpatient visits registered in the Swedish paediatric diabetes quality registry, SWEDIABKIDS were analysed. Using data from SWEDIABKIDS, five centres with the lowest mean HbA1c, five with the highest, and five with the largest decrease in centre mean HbA1c between 2003 and 2007 were identified. Team members (n=128) were asked about structure, process, policy, and the messages given to patients about important diabetes issues. Results: Specific areas that were identified as needing improvement included information about self-care, waiting time at outpatient clinics and for treatment, and access to care. Diabetes seemed to reduce HRQOL. Subjects with better metabolic control and with higher frequency of injections reported slightly higher HRQOL, as did those living with both parents compared to those with separated parents. Only 35% of children and adolescents with diabetes in Sweden had an HbA1c level below the treatment target value. Mean HbA1c showed a correlation with mean insulin dose, diabetes duration, and age. A difference between centres was found, but this could not be explained by differences in insulin dose, diabetes duration, or age. Adolescent girls reported lower HRQOL, as did parents of girls aged < 8 years. Girls also had poorer metabolic control, especially during adolescence. In teams with the lowest and the most decreased mean HbA1c, members gave a clear message to patients and parents and had a lower HbA1c target value. Members of these teams appeared more engaged, with a more positive attitude and a greater sense of working as a team. Members of teams with the highest mean HbA1c gave a vaguer message, felt they needed clearer guidelines, and had a perception of poor collaboration within the team. High insulin dose, large centre population, and larger teams also seemed to characterize diabetes centres with low mean HbA1c. The most frequently visited pages on the web portal were the social networking pages, such as blogs, stories and discussions, followed by the diabetes team pages. Those who used the portal most actively were younger, had shorter diabetes duration, and lower HbA1c, and were more often girls. The web portal was not found to have any significant beneficial or adverse effects on HRQOL, empowerment or metabolic control. Conclusions: The quality of diabetes care for children and adolescents in Sweden is not sufficiently good and needs to improve further if complications in later life are to be avoided. Psychosocial support for children and adolescents with diabetes should be appropriate for age and gender. The attitudes of the members in the diabetes care team and the message they give to patients and their parents seem to influence metabolic control in children and adolescents. A clear and consistent message from a unified team appears to have beneficial effects on metabolic control. A web portal that includes comprehensive information about diabetes, and the opportunity to communicate with other people with diabetes and with healthcare professionals may be a useful complement to traditional patient education tools. Members of the diabetes team should encourage its use.

The aim of child health care is to promote health and development for all children, to early identify problems that concern children´s growth and development and to prevent ill-health among children. Today in our society the proportion of children who are underweight are few. The aim with this study was to describe paediatric nurses experience in meeting with underweight children and their parents. Interviews were implemented and analyzed according to qualitative content analysis. Focus was placed on looking at differences and interpretations in the text content. The analyse resulted in six main categories, such as a need of sensitivity and a holistic view from the nurse, difficulties in handling the meeting because lack of tools. A positive experience which facilitated the meeting was the emotional sensitivity from the parents. In their work the nurses used different facilities. It was also described how the nurse influenced the meeting with the family. It would be desirable to have guidelines for how to handle underweight children. / Övergripande syftet för verksamheten inom barnhälsovården är att främja hälsa och utveckling hos alla barn, att tidigt kunna identifiera problem som rör barns tillväxt och utveckling samt att förebygga ohälsa hos barn. Andelen barn som är underviktiga i dagens samhälle är få. Syftet med studien var att beskriva BVC-sjuksköterskors efrarenheter i möten med underviktiga barn och deras föräldrar. Intervjuer genomfördes och analyserades enligt kvalitativ innehållsanalys. Fokus lades på att se skillnader och likheter i textinnehållet. Resultatet av analysen beskrevs i sex huvudkategorier. Det framkom att det krävdes en stor lyhördhet för de enskilda individerna av sjuksköterskan och att sjuksköterskan upplevde det som svårt att hantera mötet på grund av brist på redskap. Ändå upplevdes det som positivt då föräldrarna var lyhörda för sjuksköterskornas råd. Det framkom även att sjuksköterskorna upplevde en stor oro hos föräldrarna och att sjuksköterskorna arbetade utifrån en helhetssyn på barnen. I sitt arbete med det undervikitga barnet använde sig sjuksköterskan av olika hjälpmedel och de beskrev även hur sjuksköterskan påverkar mötet med familjen. Det vore önskvärt att det arbetades fram ett vårprogram med riktlinjer för omhändertagandet av underviktiga barn.

Identifiering av fysisk barnmisshandel är en komplicerad uppgift och många misshandelsfall upptäcks inte av sjukvården. Det har skett en attitydförändring i samhället över tid, vilket har bidragit till en ökad anmälningsfrekvens av barnmisshandel. Fysisk barnmisshandel är när en vuxen vållar ett barn skada med eller utan tillhygge. Syftet med denna litteraturstudie var att belysa vilka kännetecken sjuksköterskan ska uppmärksamma vid kontakt med familjer för att upptäcka om barnet har utsatts för fysiskt våld. Med hjälp av tretton artiklar och en avhandling formades litteraturstudien. Resultatet visar att det finns ett stort antal varningssignaler som sjuksköterskan ska vara observant på vid misstanke av barnmisshandel. Dessa kännetecken varierar och kan vara allt från somatiska skador på barnet till föräldrarnas beteende i sociala sammanhang. Genom erfarenhet och utbildning inom området barnmisshandel, underlättas sjuksköterskans arbete i att särskilja situationer där ett barn blir misshandlat från en situation där ett barn skadas i samband med lek. Vidare forskning i ämnet barnmisshandel krävs för att stärka sjuksköterskeprofessionen och därmed fånga upp fler utsatta barn. / The disclosure of physical child abuse is a complex task for the medical care. A great number of cases are never revealed. There is a trend of an increased reporting frequency of child abuse, since the general attitude in the society has changed. Physical child abuse is defined as: An adult physically harming a child with or without an object. The purpose of this literature study was to summarize what nurses on the field should look for to discover physical child abuse. This paper was formed as a result of a literature study which included 13 articles and 1 thesis. The literature study resulted in identification of a large number of relevant warning signals of child abuse, for example somatic injuries and parental behaviour in social groups. To simplify the nurses' work of separating cases of child abuse from cases of normal accidents during play, existing experience within this area must be disseminated by education. Also, further research within this area is required to improve the nursing profession and help a larger fraction of exposed children.

Access technologies facilitate novel and alternative methods for individuals with disabilities to interact with their environment. Finding suitable access solutions for children with severe spastic quadriplegic cerebral palsy can be difficult because of their poor motor control and targeting abilities due to spasticity at the limbs, neck, and head. In this research a multiple camera tongue switch was developed for a 7 year-old case study participant with severe spastic quadriplegia. Remotely via video, this system reacts to tongue protrusions as cues for single-switch access. Having multiple cameras mitigates targeting problems with the head that conventional single camera systems would present. Results of a usability experiment with the participant show that good sensitivity (82%) and specificity (80%) can be achieved with a non-contact tongue protrusion access modality for a user with spastic quadriplegia. Moreover, the experiment verified that the extra cameras improve utility of video-based access technologies for the target population.

Access technologies facilitate novel and alternative methods for individuals with disabilities to interact with their environment. Finding suitable access solutions for children with severe spastic quadriplegic cerebral palsy can be difficult because of their poor motor control and targeting abilities due to spasticity at the limbs, neck, and head. In this research a multiple camera tongue switch was developed for a 7 year-old case study participant with severe spastic quadriplegia. Remotely via video, this system reacts to tongue protrusions as cues for single-switch access. Having multiple cameras mitigates targeting problems with the head that conventional single camera systems would present. Results of a usability experiment with the participant show that good sensitivity (82%) and specificity (80%) can be achieved with a non-contact tongue protrusion access modality for a user with spastic quadriplegia. Moreover, the experiment verified that the extra cameras improve utility of video-based access technologies for the target population.

Information exchange is an essential component for all involved in the paediatric care encounter. Despite this, most of the research about information exchange concerns adults and the significance of the child’s existence in the encounter have not been given sufficient attention. Therefore, the overall aims of this thesis were twofold. Firstly, the aim was to identify, describe and generate concepts in information exchange between minors, parents/guardians and health care professionals in paediatric care situations. Secondly, the intention was to formulate a theoretical construction, a theory, of the phenomenon of information exchange in paediatric care situations. This thesis is based on four studies. In studies I, II and III grounded theory was used according to Glaser and data have been analyzed using the constant comparative analysis method. Data have been collected through observations and medical records (I, II and III) and also with additional follow-up interviews (III). In study IV, at first a qualitative content analysis of Løgstrup’s ethical demand was conducted and, second, a simultaneous concept analysis of the findings from studies I, II and III and the findings from the qualitative content analysis was carried out. There were a total of 67 participants in the three observational studies: 28 minors (I), 24 parents/guardians (II) and 15 health care professionals (III), who exchanged information in different paediatric care encounters. The information exchange interaction process was resolved by the minors “balancing the circumstances” (I), the parents/guardians used “firm handling” (II) and the health care professionals were “sharing and contributing the responsibility” (III). The qualitative content analysis of Løgstrup’s ethical demand provided the mediation and the social norms. The simultaneous concept analysis finally gave the advanced outcome to intergrade, which means to merge gradually with another through a continuous series of intermediates. At the same time as we intergrade in paediatric care, we protect the totality of minors, recognize the dependency of the parents/guardians and the social interplay by the health care professionals, the information exchange is improved. This thesis emphasizes the importance of health care professionals’ communication skills and the need for education and practice in this topic, in order to improve the information exchange with minors and their parents/guardians from an ethical viewpoint. The theory intergrade explains how this could be applied and implemented.

<p>The aim of child health care is to promote health and development for all children, to early identify problems that concern children´s growth and development and to prevent ill-health among children. Today in our society the proportion of children who are underweight are few.</p><p>The aim with this study was to describe paediatric nurses experience in meeting with underweight children and their parents. Interviews were implemented and analyzed according to qualitative content analysis. Focus was placed on looking at differences and interpretations in the text content. The analyse resulted in six main categories, such as a need of sensitivity and a holistic view from the nurse, difficulties in handling the meeting because lack of tools. A positive experience which facilitated the meeting was the emotional sensitivity from the parents. In their work the nurses used different facilities. It was also described how the nurse influenced the meeting with the family.</p><p>It would be desirable to have guidelines for how to handle underweight children.</p> / <p>Övergripande syftet för verksamheten inom barnhälsovården är att främja hälsa och utveckling hos alla barn, att tidigt kunna identifiera problem som rör barns tillväxt och utveckling samt att förebygga ohälsa hos barn. Andelen barn som är underviktiga i dagens samhälle är få.</p><p>Syftet med studien var att beskriva BVC-sjuksköterskors efrarenheter i möten med underviktiga barn och deras föräldrar. Intervjuer genomfördes och analyserades enligt kvalitativ innehållsanalys. Fokus lades på att se skillnader och likheter i textinnehållet. Resultatet av analysen beskrevs i sex huvudkategorier. Det framkom att det krävdes en stor lyhördhet för de enskilda individerna av sjuksköterskan och att sjuksköterskan upplevde det som svårt att hantera mötet på grund av brist på redskap. Ändå upplevdes det som positivt då föräldrarna var lyhörda för sjuksköterskornas råd. Det framkom även att sjuksköterskorna upplevde en stor oro hos föräldrarna och att sjuksköterskorna arbetade utifrån en helhetssyn på barnen. I sitt arbete med det undervikitga barnet använde sig sjuksköterskan av olika hjälpmedel och de beskrev även hur sjuksköterskan påverkar mötet med familjen.</p><p>Det vore önskvärt att det arbetades fram ett vårprogram med riktlinjer för omhändertagandet av underviktiga barn.</p>

Lyme Borreliosisis is a multi-organ infectious disease caused by the spirochete Borrelia burgdorferi. The spirochete is transmitted to humans by tick bites. Neuroborreliosis (NB) is a disseminated form of the disease, in which the spirochetes invade the nervous system. In children, subacute meningitis and facial nerve palsy are typical clinical manifestations of NB. The aim of this thesis was to study clinical, immunological and laboratory characteristics in children being evaluated for NB in a Lyme endemic area of Sweden, in order to identify factors of importance for prognosis and clinical recovery. A total of 250 patients and 220 controls were included during 1998-2005, with a prospective and a retrospective part. Less than half (41%) of children with signs and symptoms indicative of NB get the diagnosis confirmed by detection of Borrelia specific flagella antibodies in CSF (clinical routine method). Surprisingly few patients were diagnosed as having other infectious or neurologic diseases and consequently, many patients ended up with an uncertain diagnosis. However, four new Borrelia antigens (DbpA, BBK32, OspC, IR6) were evaluated and performed well in laboratory diagnostics. If they were combined in a panel, together with the flagella antigen, the sensitivity was 82% and the specificity 100%, leading to improved diagnostic accuracy in children with NB, as compared to using the routine flagella antibody test alone. Clinical recovery at the 6-month follow-up (n=177) was generally good and nonspecific symptoms, such as headache and fatigue, were not more frequently reported in patients than in controls. No patient was found to have recurrent or progressive neurologic symptoms. However, permanent facial nerve palsy was found in 22% of patients at the 2-year follow-up, with consequences such as eye-closing problems, excessive tear secretion, pronunciation difficulties and cosmetic complaints. When cellular immune responses were investigated, the number of Borrelia-specific IL-4 and IFN-γ secreting cells in CSF was found to be more prominent in children with NB than in controls. Furthermore, a much stronger IL-4 response in CSF was seen in children as compared to adults with NB. This cytokine profile of children with NB is believed to represent an effective and balanced type1/type2 response in a relevant compartment, and could contribute to the less severe course of the disease seen in children as compared to adults with NB. No prognostic factors were found to influence the outcome in patients with “Confirmed NB” or facial nerve palsy. Nor was any specific cytokine profile, or antibody response to new Borrelia antigens in CSF, correlated to a less favorable clinical outcome. An NB prediction score test, based on clinical variables at admission, is suggested to help physicians to determine whether to start early antibiotic treatment, before results from Borrelia antibody tests are available. Results in this thesis support the notion that mononuclear pleocytosis in CSF, in patients being evaluated for NB, indicates that they are true NB cases despite the fact that an antibody response cannot yet be visualized. with the routine flagella test. Consequently, early antibiotic treatment in NB seems to be the correct course of action and over-treatment is not a substantial problem. / Borrelia-infektion hos barn och vuxna är den vanligaste fästingburna infektionen i Sverige och orsakas av en bakterie som heter Borrelia burgdorferi. Den sprids till människa via fästingbett och kan orsaka besvär från hud, leder, hjärtmuskel och nervsystem. När nervsystemet är infekterat kallas det Neuroborrelios. Denna avhandling handlar om Neuroborrelios hos barn i syd-östra Sverige, ett område med hög Borrelia-förekomst. Jag har studerat symtom, laborativa provsvar och tillfrisknande hos 250 barn med misstänkt Neuroborrelios under åren 1998-2005 och jämfört med friska barn. Dessutom har jag tittat närmare på vissa signalsubstanser inom immunförsvaret i blod och ryggvätska och vilken roll signalsubstanserna spelar för förlopp och utläkning av infektionen. Avhandlingen innehåller också en utvärdering av fyra nya diagnostiska test vid misstänkt Neuroborrelios hos barn. Det visar sig att mindre än hälften (41%) av barnen med misstänkt Neuroborrelios får diagnosen säkerställd med det befintliga Borrelia-testet (baserat på ett protein som kallas flagellin) som används rutinmässigt. Dock förblir diagnosen oklar för många barn (59%). De fyra nya Borrelia-testen (baserade på protein som kallas DbpA, BBK32, OspC och IR6) visar sig fungera bra och om man kombinerar dem med befintligt Borrelia-test, kan man säkerställa Neuroborrelios hos 82% av barnen med misstänkt infektion. Jag hoppas att dessa nya Borrelia-test i framtiden kan leda till förbättrad diagnostik hos barn som utreds för misstänkt Neuroborrelios. Immunförsvarets signalsubstanser, som analyserades i ryggvätska och blod, visade sig ha en viss profil hos barn med Neuroborrelios jämfört med barn utan Borrelia-infektion, men även jämfört med vuxna med Neuroborrelios. De immunologiska T cellerna producerade två olika sorters signalsubstanser, som kallas ”Interferon-γ” och ”Interleukin-4”. Denna immunologiska profil verkar fördelaktig och kan möjligen bidra till den i allmänhet goda utläkning av Neuroborrelios som man ser hos barn jämfört med vuxna. De vanligaste symtomen vid en Borrelia-infektion i nervsystemet är huvudvärk, trötthet, dålig aptit, feber och ont i nacken. Ansiktsförlamning är det vanligaste specifika neurologiska symtomet. Antibiotikabehandling ges till 69% av barnen och vid en 6 månaders uppföljning rapporterar patienterna god utläkning av de olika symtomen. Inget barn hade återkommande eller allvarliga neurologiska symtom vid uppföljningen. Däremot, barn med ansiktsförlamning visade sig få kvarstående besvär i viss utsträckning. När de undersöktes 2 år efter sin ansiktsförlamning förekom mild till måttlig kvarstående förlamning i 22% av fallen. Patienterna uppgav besvär av ökat tårflöde, sluddrigt tal, svårigheter med att stänga ögat och dessutom rapporterade många patienter att snedheten i ansiktet var kosmetiskt störande. Inga specifika symtom, laborativa prov, immunologiska signalsubstanser eller diagnostiska test visade sig vara kopplade till ökad risk för kvarstående besvär efter Neuroborrelios i allmänhet och inte eller hos patienter med ansiktsförlamning. En checklista har utarbetats med olika symtom som är typiska för barn med Neuroborrelios. Den föreslås kunna användas som beslutsunderlag för start av tidig antibiotikabehandling, redan innan svar på Borrelia-testen finns tillgängliga.

The overarching aim of this thesis is to illuminate the experience of illness and the meaning of fear of medical care through children’s narratives. A purposive sample of 22 children and youths, aged from 2 to 18 years, narrated through play and conversation their experiences of illness and of their fear of contact with medical care. The data were analysed using thematic qualitative content analysis and the phenomenological hermeneutic method. In childhood, the experience of being ill seems to vary with the child’s age. At the ages of 7 to 10 years, the child’s way of thinking can colour the experience;imagination can produce both problems and opportunities. Children seem to combine imagination and reality, and contrasts in the experience coexist such as being scared/confident, sad/cosy and hurt/having fun. At the age of 11 to 18,being ill seemed to imply being lost, hurt and in need of comfort from themselves and others. Medical care can be frightening to children and what is fearful can differ with age. To a 2-year-old child, medical care seemed to be dangerous; to children aged 7 to 11 years, it seemed threatening, like a monster. To the 2-year-old child, there seemed to be a conflict between, on the one hand, living up to expectations by ‘being good’ and hiding their feelings or, on the other hand, communicating their fear. The narrations by children in the 7–11 year age group, point to the importance of empathy when caring for children, i.e., to be receptive of the child’s fear in order to help the child through and out of the fear. To be afraid for a two-yearold was to have one’s trust broken yet still be searching for a trustful relationship. However, if the child is received along with the fear, this opened up an opportunity for the child to develop courage and to gain control over the fear when under gentle care. The results of this research revealed the possibility of using play to create stories in a creative relationship with the child. To express one’s inner feeling is a gift of trust, a gift of hospitality. Thus when caring for children we can be the ones who are receiving that gift. We can accept the offer of being a guest in the child’s world.