Insulin pump treatment (CSII) is considered the most physiological way to imitate the healthy body’s insulin profile in adolescents with diabetes. However, despite the use of CSII, achieving the recommended disease control is difficult for adolescents. The aim of this thesis was to explore aspects of self-management of diabetes in adolescents using insulin pumps in order to describe conditions contributing to the recommended disease control. Three methods of bolusing (normal, dual-wave and square-wave) in connection with pasta meals were tested in a crossover study among 15 adolescents with diabetes to assess whether one method was superior in managing glucose levels. A cross-sectional study among 90 adolescents being treated with CSII was conducted to investigate the management of CSII, including the administration of bolus doses. Two qualitative interview studies, based on the grounded theory method, were performed to gain insight into the processes involved in taking bolus doses and to investigate reasons for missed bolus doses and strategies for avoiding missing them. Twelve adolescents, four parents and one diabetes specialist nurse were interviewed. No method of bolusing was found to be superior in managing the glucose levels after these meals. The post-prandial glucose peaks were <10 mmol/L, in 48% of the cases, regardless of bolus methods. This indicates that adolescents can be encouraged to individually test which bolus method gives them the most normal post-prandial glucose levels. The cross-sectional study showed that adolescents were satisfied with CSII, but that 38% had missed more than 15% of the bolus doses the day under study. The frequency of bolus doses correlated with the disease control. Findings from the interview study revealed the need to clarify the responsibility for diabetes self-management in continuous negotiation between adolescents and parents to avoid insulin omission. The main reason for missed boluses was lost focus, and the strategies for remembering them were agreements involving reminders. The thesis describes that individual dose testing, clarification of responsibility and agreements involving reminders are conditions contributing to the recommended disease control. The thesis also describes that lost focus and a lack of responsibility can lead to insulin omission and be a hindrance to achieving disease control. / Anna Kernell avled maj 2010.

Introduction: Gut microbial composition has been associated with immune-mediated diseases. Breastfeeding yields a microbiota rich in bifidobacteria and promotes colonization by lactobacilli. Bifidobacteria and lactobacilli are considered health-promoting and are used as probiotics, i.e. live microbial food supplements which when ingested in adequate amounts confer a beneficial effect on the host. During weaning the developing gut immune system is exposed to an increasing variety of antigens from both foods and gut microbiota. Aims: We aimed to determine if daily feeding of 1x108 colony-forming units (CFU) of the probiotic Lactobacillus paracasei ssp. paracasei strain F19 (LF19) to healthy term infants from 4 to 13 months of age could maintain some of the beneficial effects conferred by breastfeeding on gut microbial composition, with possible effects on gut microbial function, T cell function, Th1/Th2 immune balance and eczema incidence. Study design: Infants were randomized to daily intake of cereals with (n=89) or without LF19 (n=90) from 4-13 months of age. Clinical outcome measures were monitored by diaries and a questionnaire. Stool and blood samples were obtained at 4, 6½, 9, 13 and 5½, 6½, 12 and 13 months of age, respectively. Stool samples were analyzed for lactobacilli counts by conventional culture methods and the presence of LF19 was verified by randomly amplified polymerase chain reaction (RAPD-PCR). Fecal short-chain fatty acid (SCFA) pattern, a proxy for gut microbial function, was determined by gas-liquid chromatography. After polyclonal or specific activation of T cells, the cytokine mRNA expression levels [interleukin 2 (IL2), IFN-, IL4 and IL10] were determined on isolated mRNA by quantitative real time reverse transcriptase-PCR. Serum concentrations of total and specific IgE antibodies, Haemophilus influenzae type b, diphtheria and tetanus toxoid specific IgG antibodies were analyzed by enzyme immunoassay. Results: Feeding LF19 maintained high fecal lactobacilli counts during weaning. Persistent colonization with LF19 induced differences in the fecal SCFA pattern. The cumulative incidence of eczema was lower in the probiotic group, in conjunction with a higher IFN-γ/IL4 mRNA ratio in polyclonally activated T cells. Even though there was an effect by LF19 on Th1/Th2 immune balance, there was no effect on IgE sensitization. Infants in both groups increased their capacity to express both Th1 and Th2 cytokines during the second half of infancy but the expression was still lower than that of adults. Infants in the probiotic group had lower IL2 levels after polyclonal T cell activation at 13 months of age compared with infants in the placebo group. Infants fed LF19 did not have fewer infections, but had fewer days with antibiotic prescription compared with infants fed placebo. In addition, compared to placebo, persistent colonization by LF19 enhanced specific vaccine responses to protein antigens during the course of vaccination. Conclusions: We conclude that feeding LF19 was safe, based on no observed adverse effects in our study. Infants in both groups demonstrated maturation of adaptive immune responses during weaning. Adding probiotics in complementary foods during weaning reduced the risk of eczema by 50%, with a concomitant shift towards an enhanced Th1/Th2 ratio. The reduction of eczema might be explained by probiotic effects on both T cell-mediated immune responses and reinforced gut microbial function.

Övervikt och fetma hos barn är ett allvarligt och växande problem. Det är ett tillstånd som för med sig många olika sjukdomar och i och med att antalet överviktiga barn ökar hastigt kommer det att vara en stor belastning för den framtida hälso- och sjukvården. Prevalensen är särskilt stor i vissa delar av världen och inom vissa grupper i samhället. Föräldrar spelar en väsentlig roll i huruvida barnen lever hälsosamma liv eftersom de bär ansvaret för barnen. Syftet med denna litteraturstudie var att undersöka föräldrars påverkan i utvecklingen av övervikt och fetma hos barn och genom en systematisk bearbetning av litteraturen granskades och bearbetades slutligen 19 vetenskapliga artiklar till resultatdelen i studien. Socioekonomiska faktorer, faktorer inom familjen och föräldrars roll var tre teman som utmärkte sig där det under varje rubrik beskrivs hur föräldrar påverkar med att bidra till eller motverka riskfaktorer till en ohälsosam viktstatus hos barn. Föräldrar har ett behov av stöd i form av information och kunskap och hälso- och sjukvården bär ett stort ansvar i att stödja föräldrar, förebygga sjukdom och främja hälsa. / Overweight and obesity in children are serious conditions, with many negative consequences to the health of individuals and the health care system as a whole. The prevalence is particularly great in certain groups of people and the frequency of these conditions is increasing at an alarming rate. Parents, as the primary caregivers, play a vital role in determining whether or not their children lead a healthy lifestyle. The aim of this literature review was to establish the influence that parents have on the development of overweight and obesity in their children. 19 articles were systematically reviewed and the results showed three main areas of influence; socio-economic factors, factors within the family and the role of the parent. In each of these areas, risk factors of developing overweight and obesity in children were identified. In general, parents lack information about these conditions and are in need of support from nurses and other health care professionals, who in turn carry the responsibility to support the parents, promote good health and prevent disease.

Aim: The aim of this study was to describe the total energy expenditure (TEE) and physical activity levels (PAL) within a group of children with cystic fibrosis (CF) and to compare the results with a control group with healthy children. The aim also was to compare the rated activity levels between the groups as well comparing the difference between boys and girls within the groups. Method: The study included 30 participating children, divided into two groups with 15 participants in each group. One of the groups was a CF-group and the other a group of controls, matched for gender and age. Activity diaries were studied and data were presented decrepitly and analyzed with Wilcoxon rank sum test. Result: The result showed no difference between the groups while comparing TEE and PAL. Half of the participants in both groups (53,34 % and 46,67 %) reached a moderate or high physical activity level during the registration. No significance was proved between the groups as they rated their activity level, numbered 6-9, in their activity diaries. Neither could any differences be proved significant in rated activity between the boys and girls within the groups. Conclusion: The conclusion was that no significant differences appeared regarding TEE or PAL between the CF-group and the control group participating in this study. Neither were there any differences in activity level between boys and girls within the groups. / Syfte: Syftet med studien var att beskriva energiomsättning och fysisk aktivitetsnivå hos en grupp barn med cystisk fibros (CF) och jämföra resultatet med friska barn i en kontrollgrupp. Syftet var också att jämföra skattade aktivitetsnivåer mellan grupperna samt mellan flickor och pojkar inom de båda grupperna. Metod: I studien deltog 30 barn, indelade i två grupper om 15 deltagare. Grupperna var en CF-grupp och en kontrollgrupp matchad efter kön och ålder. Aktivitetsdagböcker granskades och data sammanställdes och data presenterades deskriptivt och analyserades med Wilcoxsons rangsummetest. Resultat: Resultatet visade att det inte fanns skillnad mellan de båda grupperna vid jämförelse av TEE och PAL. Ungefär hälften av alla deltagare (53,34 % resp. 46,67 %) nådde moderat eller hög aktivitetsnivå under de registrerade dagarna. Det förekom ingen signifikant skillnad mellan grupperna med avseende antal skattade 6-9:or i aktivitetsdagboken. Inte heller någon skillnad mellan könen inom de båda grupperna kunde påvisas. Slutsats: Slutsatsen var att det inte fanns någon signifikant skillnad beträffande energiomsättning eller fysisk aktivitet mellan barn med CF och friska barn som deltog i denna studie. Inte heller kunde någon skillnad i aktivitetsnivå mellan könen inom grupperna påvisas.

The breathing pattern of preterm infants is immature and is associated with a variety of reflexes. In a patient on the ventilator these reflexes interfere with spontaneous breathing. A better understanding of the immature control of breathing could lead to further improvements in ventilatory techniques. This thesis concerns studies of pulmonary stretch receptor (PSR) and phrenic nerve activity as part of the regulation of breathing in an animal model. During assist/control ventilation with three different inspiratory pressure waveforms in animals with healthy lungs, squarewave pressure waveform strongly inhibits spontaneous inspiratory activity. During partial liquid ventilation (PLV) in animals with healthy lungs, all PSRs studied maintained their phasic character, with increased impulse frequency during inspiration. PSR activity was not higher during PLV than during gas ventilation (GV), indicating that there was no extensive stretching of the lung during PLV. During proportional assist ventilation (PAV) the applied airway pressure is servo-controlled proportionally to the ongoing breathing effort, thereby interacting with the activity of PSRs. Peak PSR activity was higher and occurred earlier during PAV than during CPAP. The regulation of breathing is maintained during PAV in surfactant-depleted animals before and early after surfactant instillation, with a higher ventilatory response and a lower breathing effort than during CPAP in both conditions. Both lung mechanics and gas exchange influence the regulation of breathing. Inhibition of inspiratory activity occurred at a lower arterial pH and a higher PaCO2 during PLV than during GV in animals with surfactant-depleted lungs, which might be related to recruitment of a larger number of pulmonary stretch receptors during PLV. In summary, selected aspects of the regulation of breathing were studied in an animal model with different ventilatory techniques under different lung conditions similar to those that can occur in infants.

Bakgrund: Att vårdas på sjukhus kan vara en traumatisk upplevelse där inte enbart sjukdom orsakar lidande utan även den främmande fysiska vårdmiljön. När ett barn drabbas av sjukdom drabbas hela familjen vilket gör att föräldrarnas hälsa och upplevelser spelar stor roll för barnets återhämtning. Barn som själva varit patienter upplever att tillgång till familjen är en viktig faktor som stärker den egna hälsan. Det är därför viktigt att skapa en fysisk vårdmiljö som främjar en familjecentrerad vård, där föräldrarollen kan upprätthållas och föräldrarna kan bli en del av vårdteamet.  Syfte: Att belysa upplevelsen av den fysiska vårdmiljön hos familjer med sjuka barn som vårdas under långvarig sjukhusvård. Metod: Litteraturöversiktens resultat bygger på 15 vetenskapliga artiklar. Sökningen av artiklar utfördes systematiskt genom att använda specifikt utformade sökord i databaserna PubMed samt Cinahl. Utvalda artiklar analyserades sedan i en artikelmatris och innehållet kondenserades ner till teman där likheter och skillnader identifierades.  Resultat: I analysprocessen växte ett huvudtema fram; en främmande miljö. Detta huvudtema fick i sin tur fem underteman; medicinsk apparatur på gott och ont, avsaknad av avskildhet, tillfällig frihet från sjukhusmiljön, ljud, belysning och temperatur samt bekvämlighet. Slutsats: Familjers upplevelser av den fysiska vårdmiljön har en direkt påverkan på såväl familjers hälsa som den familjecentrerande vården. Vidare kan anpassningar i den fysiska vårdmiljön både minska vårdlidande och främja föräldrars delaktighet. Sjuksköterskan har även en viktig uppgift i att informera och instruera föräldrar om den fysiska vårdmiljön för främja den familjecentrerade vården. / Background: Being treated at a hospital can be a traumatic experience in which not only sickness causes care suffering but also the foreign physical health care environment. When a child suffers from illness, the whole family is affected, which means that the parents' health and experiences play a major role in the child's recovery. Children who have been patients themselves feel that access to their family is an important factor that strengthens both the child's health and the experience of being cared for in hospitals. It is therefore important to maintain a family-centered care that enables an environment in which the parental role can be maintained and where parents become part of the care team. Aim: To illustrate families of hospitalized children experiences of the physical health care environment.  Method: The results of the literature review are based on 15 research articles. The search for articles was carried out systematically using specifically designed search words in the PubMed and Cinahl databases. Selected articles were then analyzed in an article matrix and the content condensed to themes where similarities and differences were identified and presented.  Results: In the analysis process, a main theme emerged: a foreign environment. Which consisted of five sub-themes medical equipment for good and bad, lack of privacy, temporary freedom from the hospital environment, sound, lighting and temperature and uncomfortable interior. Conclusion: Families 'experiences of the physical health care environment have a direct impact on families' health as well as on family-centered care. The nursing profession needs more knowledge about how care suffering can be alleviated through adaptation of the physical care environment. Registered nurses have an important task to inform and instruct parents with hospitalized children about the physical health care environment.

Bakgrund: Sjuksköterskor inom pediatrisk verksamhet möter ofta barn i sitt arbete som upplever smärta och rädsla vid nålrelaterade procedurer (NRP). Inom pediatrisk verksamhet är det därför viktigt att arbeta efter Barnkonventionen som ser till barnets bästa. Barns hantering av smärta och rädsla vid NRP underlättas vanligen med hjälp av information, avledning och föräldrastöd. Den pediatriska omvårdnaden är många gånger komplex och kan vara en utmaning för den oerfarna sjuksköterskan. Erfarenhet och kunskap i arbetet med barn är viktigt för att omvårdnaden ska kunna utföras på ett sätt som skapar de bästa förutsättningarna för barnet.Motiv: I den pediatriska verksamheten anställs ofta grundutbildade sjuksköterskor eftersom det råder brist på specialistutbildade barnsjuksköterskor. Studier som utförts gällande barn som uttrycker rädsla för NRP fokuserar ofta på metoder som fungerar för att hjälpa dessa barn. Däremot är det svårare att finna studier kring hur sjuksköterskor med begränsad erfarenhet inom pediatrisk verksamhet bemöter och underlättar för dessa barn. Denna studie belyser därför sjuksköterskors erfarenheter och behov av stöd gällande barn som uttrycker rädsla för NRP.Syfte: Sjuksköterskors erfarenheter av att arbeta med barn som är rädda för nålrelaterade procedurer.Metod: Sjuksköterskor inom både öppen- och slutenvård med begränsad erfarenhet inom pediatrisk verksamhet deltog i enskilda semistrukturerade intervjuer. Intervjuerna analyserades med hjälp av en kvalitativ manifest innehållsanalys.Resultat: Resultatet ledde fram till tre huvudkategorier; ”Hantera känslosamma möten”, ”Skapa de bästa förutsättningarna för barnet” och ”Få erfarenhetsbaserad kunskap inom ett komplext område”.Konklusion: För att barn som uttrycker rädsla ska få så bra förutsättningar som möjligt vid en NRP är det viktigt att sjuksköterskan känner sig trygg i sin roll. Den oerfarna sjuksköterskan behöver introduceras och utbildas inom ämnet. Erfarenhet och kollegialt stöd gör det lättare för sjuksköterskan att lyckas med en NRP där barn uttrycker rädsla. / Background: Nurses within pediatric care often meet children who experience pain and fear during needle-related procedures (NRP). This makes it important to work according to the Convention on the Rights of the Child, which looks after the best interests of the child. Childrens’ management of pain and fear in NRPs is usually facilitated with information, distraction and parental support. Pediatric nursing can be complex which is challenging for the unexperienced nurse. Experience and knowledge are important when meeting a child tobe able to create the best conditions for the child.Motive: Nurses without further education are very common in pediatric care since there is a shortage of specially trained pediatric nurses. Previous studies on children expressing fear of NRP focus on methods to help these children. Research about how nurses with limited experience in pediatric care treat these children is more difficult to find. Therefore, this study highlights nurses’ experiences and need for support regarding children expressing fear during NRP.Aim: Nurses’ experiences of working with children with fear of needle-related procedures.Methods: Nurses with limited experience in pediatric care who worked in the outpatient or inpatient care participated in individual, semistructured interviews. The interviews were analyzed using a qualitative manifest content analysis.Result: The result led to three main categories; “Manage emotional encounters”, “Creating the best conditions for the child” and “Get experiential knowledge in a complex area”.Conclusion: It is important that the nurse feels comfortable to create the best conditions for children who express fear of NRPs. The unexperienced nurse needs to be introduced and trained in the subject. Experience and collegial support make it easier for the nurse to succeed with an NRP where the child express fear.

Bakgrund: I världen är det mer än 21 miljoner barn i behov av palliativ vård, varav 550 i Sverige. Pediatrisk palliativ vård (PPV) fokuserar på att förbättra livskvaliteten hos det svårt sjuka barnet och barnets föräldrar. Att vara förälder till barn i palliativ vård är en svår situation. Syfte: Syftet med litteraturstudien var att beskriva föräldrars upplevelser av att leva med barn i behov av palliativ vård. Metod: Litteraturstudien är baserad på tio kvalitativa intervjustudier som granskades och analyserades. Artikelsökning skedde i vetenskapliga databaserna Cinahl, PubMed och Scopus. Resultat: Studiernas resultat analyserades och resulterade i två huvudkategorier och åtta underkategorier. Huvudkategorierna blev En förändrad vardag och Betydelsen av interaktion med vårdpersonal. I litteraturstudiens resultat framkommer föräldrars behov och emotionella reaktioner när deras barn vårdas palliativt. Konklusion: Barn i behov av palliativ vård till följd av obotlig sjukdom påverkar föräldrarna välbefinnande negativt. I mötet med föräldrar behöver sjuksköterskan möta varje enskild förälders behov för att kunna skapa förutsättningar för att bibehålla hälsa och välbefinnande. / Background: There are more than 21 million children in need of palliative care worldwide, including 550 in Sweden. Paediatric palliative care (PPC) focuses on improving the quality of life of the seriously ill child and the child's parents. It is a difficult situation to be the parent of a child who is in palliative care. Aim: The aim of the literature review was to describe parents' experiences of living with children who require palliative care. Methods: The literature study is based on ten qualitative interview studies that were reviewed and analysed. Articles were searched in the scientific databases Cinahl, PubMed and Scopus. Results: The results of the studies were analysed and resulted in two main categories and eight subcategories. The main categories were A changed daily life and The importance of interaction with healthcare professionals. The results of the literature study reveal parents' needs and emotional reactions when their child needs palliative care. Conclusion: Children in need of palliative care due to terminal illness, negatively affect the parents' well-being. In the meeting with parents, the nurse needs to meet each individual parent's wishes to create conditions for maintaining health and well-being.

Background: Palliative care is a collaboration between several different professions with relatives and patients as a central point. Children need individualized care where the needs are based on the child’s situation. Nursing care includes the person from the time the person is born until they die. Aim: The aim of the study was to describe parents experiences of having a child who recives palliative care. Method: The study was a descriptive literature study where eleven articles were compiled with parents' experiences of having a child who receives palliative care. Result: The results of the 11 articles are presented in four main themes: Parents' perceived feelings of having a child in palliative care, Relationships, Communication and Choice of environmental setting for pediatric palliative care. Four sub-themes are presented: Family relationships, healthcare staff and parent under Relationships and hospital and home health care under Choice of environmental setting for pediatric palliative care. Conclusion: Relatives are different and have different needs. It is therefore important that nurses work person-centred around both the patient and relatives, and listen to parents' wishes and needs. / Introduktion: Palliativ vård är ett samarbete mellan flera yrkesgrupper med närstående och patient som central utgångspunkt. Barn behöver en individanpassad vård där behoven utgår från barnets situation. Omvårdnad inkluderar personen från att personen föds till att de dör. Syfte: Litteraturstudiens syfte var att beskriva föräldrars erfarenheter och upplevelser av att ha ett barn som får palliativ vård. Metod: Studien är en beskrivande litteraturstudie där 11 artiklar har sammanställts med föräldrars erfarenheter och upplevelser av att ha ett barn som får palliativ vård. Resultat: Resultat: De elva artiklarna presenteras i fyra huvudteman: Föräldrars upplevda känslor av att ha ett barn i palliativ vård, relationer, kommunikation och valet av miljö för pediatrisk palliativ vård. Fyra underteman presenteras: Familjerelationer, sjukvårdpersonal och förälder under Relationer och sjukhus och hemsjukvård under Valet av miljö för pediatrisk palliativ vård. Slutsats: Anhöriga är olika och har olika behov. Det är därför av vikt att sjuksköterskor arbetar personcentrerat runt både patienten och anhöriga och lyssnar på föräldrars önskemål och behov.

Palliativ vård infaller då en patient är obotligt sjuk och närmar sig livets slutskede. Vården bör vara inriktad på att främja livskvalitet och lindra patientens mångsidiga lidande. Barn som vårdas för obotlig sjukdom kräver personcentrerad vård där föräldrar och anhöriga inkluderas och blir delaktiga. Sjuksköterskan bör vidare bemöta patientens och anhörigas unika livsvärld för att skapa möjlighet till vårdande möten. Att vårda ett döende barn i hemmiljö avviker från den naturliga vårdrelationen som sjuksköterskan har med patienten och är mycket komplext för sjuksköterskan. Syftet med litteraturöversikten är att belysa sjuksköterskans upplevelse av att vårda barn i ett palliativt skede i hemmiljö. Litteraturöversikten utgår från kvalitativa och kvantitativa artiklar och dess analys samt kvalitetsgranskning grundar sig på Fribergs analysprocess. Studiens resultat har genererat fyra teman som tillsammans sammanfattar sjuksköterskans erfarenheter av att vårda palliativt sjuka barn i hemmiljö: förtroendefulla relationer, emotionella reaktioner, etiska och moraliska dilemman samt utmaningar och strategier. Resultatet speglar vikten av betydelsefulla relationer, vilka komplexa emotionella reaktioner som uppstår hos sjuksköterskan samt mängden av upplevda etiska och moraliska dilemman vid pediatrisk palliativ vård i hemmiljö. Vidare visar resultaten att sjuksköterskor identifierat många brister i hälso- och sjukvårdens resurser men att sjuksköterskor trots det hittar styrka och finner mening i arbetet. Genom kontinuerliga utbildningar och tillgång till rätt resurser skapas grundläggande förutsättningar för sjuksköterskan gällande pediatrisk palliativ vård i hemmiljö. Genom att belysa de komplexa situationer sjuksköterskan erfar i pediatrisk palliativ vård kan förbättringsområden identifieras. / Palliative care occurs when a patient is terminally ill and approaching the end of life. Care should be aimed at promoting quality of life and alleviating the patient's multifaceted suffering. Children who are treated for an incurable disease require person-centered care where parents and relatives are included and become participants. The nurse should also respond to the unique life situation of the patient and relatives in order to create opportunities for caring encounters. Caring for a terminally ill child deviates from the natural care relationship that the nurse has with the patient. The purpose of the literature review is to shed light on nurses' experiences of caring for children in a palliative stage in a home environment. The literature review is based on qualitative and quantitative research and the analysis and quality review is based on Friberg's analysis process. The results of the study have generated four themes that together summarize nurses' experiences of caring for terminally ill children in the home environment: trusting relationships, emotional reactions, ethical and moral dilemmas as well as challenges and strategies. The result reflects the importance of significant relationships, the complex emotional reactions that arise in the nurse, and the amount of perceived ethical and moral dilemmas in pediatric palliative care in the home environment. Furthermore, the results show that nurses have identified many shortcomings in health care resources, but that despite this, nurses find strength and meaning in their work. Through continuous training and access to the right resources, basic prerequisites are created for the nurse regarding pediatric palliative care in a home environment. By highlighting the complex situation the nurse experiences in pediatric palliative care, areas for improvement can be identified.