The life of a preterm infant admitted to a neonatal intensive care unit may be stressful from the moment of birth. Ever since Hans Selye’s initial characterisation of the biological stress response, cortisol has been frequently measured as an indicator of stress responsivity. However, research of the stress response and cortisol in infants, especially those who are preterm and/or ill, has been scarce basically because of methodological issues. The first aim with this thesis was to investigate the acute stress response, as measured by salivary cortisol and behaviour, for preterm infants, healthy infants, and infants at high psychosocial risk in response to certain defined handling procedures. The second aim was to investigate the stress response, as measured by salivary cortisol and psychometric measures, for parents present during the handling procedure of their infants. The intention was to perform all investigations in an as naturally occurring situation as possible, which means that the studied procedures would have been performed irrespectively of the research. The present thesis includes six original articles. The results of the first study demonstrate that it is feasible to collect sufficient amounts of saliva and to analyse salivary cortisol in neonates using the presented method of collection and analysis. The second study shows that preterm infants, usually cared for in incubators, show no signs of discomfort and have variable cortisol responses during skin-to-skin care with their mothers. The mothers, however, experience stress and low control before their first skin-to-skin care with their preterm infant and do not relax completely until after the session. In the third study we found that preterm infants have higher baseline salivary cortisol as compared to healthy full-term infants. Moreover, preterm infants have higher and sustained pain response during a nappy change as compared to healthy full-term infants. The results of the fourth study shows that infants younger than three months, living in psychosocial high-risk families, have increased cortisol responses during a nappy change, performed by the mother. However, support with the aim of improving mother-infant interaction, dampens the stress response. The results of the fifth study show that oral sweet-tasting solution in combination with a pacifier dampen the levels of the stress hormone cortisol in three months old infants during routine immunisation. Moreover, parents experience more self-rated emotional stress before immunisation if it is their first child who is being immunised. The sixth paper shows that the material used for saliva collection (cotton buds with wooden or plastic sticks) is of importance when saliva is collected but for practical reasons not centrifuged within 24 hours prior to cortisol analyse. The present thesis shows that it is practically feasible to collect saliva and to analyse the stress hormone cortisol in infants. The interpretation of infants’ and parents’ salivary cortisol responses to different handling procedures are discussed in relation to shortand long-term consequences, neonatal intensive care, preterm birth, attachment, mood, and pain.

Syfte: Att beskriva sjuksköterskans upplevelser och copingstrategier vid vård av barn med cancer samt beskriva de ingående artiklarnas datainsamlingsmetod. Metod: En beskrivande litteraturstudie med kvalitativ ansats. Totalt granskades elva artiklar, nio kvalitativa, en kvantitativ samt en med mixad metod. Artiklarna söktes via databaserna PubMed och Cinahl mellan åren 2005 till 2015. Huvudresultat: Fem teman identifierades: Sjuksköterskans upplevelser vid vård av barn med cancer, kommunikationssvårigheter med barnen och deras föräldrar, svårigheter inom yrket, samt den palliativa vården och döden, sjuksköterskans copingstrategier vid vård av barn med cancer. Sjuksköterskan upplevde hinder i kommunikationen relaterat till negativa prognoser för barnen samt om barnen var svåra att nå och inte ville kommunicera. Känslomässiga svårigheter uppstod ofta då sjuksköterskan skapat personliga band till barnen och deras familjer. Emotionella svårigheter sågs framförallt när barnens behandlingsfokus ändrades eller om barnen dog. Detta hanterade sjuksköterskorna med olika copingstrategier, exempelvis genom att prata med sina kollegor om sina upplevelser. Sjuksköterskorna upplevde även att de var tvungna att ta kontroll över sina egna känslor. I granskningen av de ingående artiklarnas datainsamlingsmetod framkom att artiklarna använt sig av semistrukturerade-, ostrukturerade och djupgåendeintervjuer, fokusgrupper, enkäter och en metod där deltagarna skriftligt besvara en fråga.   Slutsats: Sjuksköterskan på en pediatrisk onkologiavdelning möter dagligen svårt sjuka barn. Emotionella påfrestningar är något som sjuksköterskan måste hantera då de ofta möter svåra och sorgsna situationer. Dessa påfrestningar hanterar sjuksköterskan genom att använda sig av olika copingstrategier. Trots yrkets svårigheter upplever sjuksköterskan mycket glädje och tacksamhet i sitt arbete. / Aim: The aim of this literature study was to describe the nurse experience and coping strategies working with cancer ill children and to analyze the included articles data collection method. Method: A descripted literature study with qualitative approach. Eleven articles were included, nine qualitative, one quantitative and one with a mixed method. The articles were found through the database PubMed and Cinahl between the years 2005 to 2015. Result: Five main themes were found: The nurse experience of working with cancer ill children, communications difficulties with the children and their families, difficulties about the work, and palliative care and death, the nurse coping strategies of working with cancer ill children. The nurses handled it with different coping strategies such as talking with colleges about their experiences. The nurses also had to take control over their own emotions. The data collection methods the included articles used were; semi-structed-, unstructed-, depth- and focus- groups interviews, surveys. One method, participants were responding to one question. Conclusion: The nurse in pediatric oncology unit, daily faces seriously ill children. Emotional stress is something that the nurse must manage as he/she often faces difficulties and sad situations. The nurse manages these pressures by making use of different coping strategies. Despite these difficulties, the nurse experiences a lot of happiness and thankfulness in her profession.

Bakgrund: Bland barn i Sverige så insjuknar varje år drygt 300 barn och ungdomar mellan 0–18 år av cancer. Den palliativa vården bygger på ett förhållningssätt som syftar på att förbättra livskvalitén för både patienter och familjer som drabbas av problem vid livshotande sjukdomar. Allmänhet i vården ses familjen har stor betydelse i omvårdnaden. Syfte: Syftet med studien var att beskriva föräldrars upplevelse av stöd från sjuksköterskor vid palliativ vård av barn med cancer. Syftet med studien var även att granska de i studien ingående artiklarnas datainsamlingsmetod. Metod: Föreliggande litteraturstudie har en deskriptiv design. Sökstrategin utgick från två databaser PubMed och Cinahl. Sökorden använda var Childhood cancer, parents, experience, support och palliative care. Tio artiklar valdes ut för granskning och bearbetning. Huvudresultat: I resultatet framkom fyra hörnstenar: kommunikation, delaktighet, kontinuitet samt relation, som är en grund för föräldrars upplevelse av stöd. Föräldrars upplevelser av stöd i mötet med vården av deras barn med cancer, kretsar kring vårdpersonalens förhållningssätt. En ärlig och god kommunikation, delaktighet, kontinuitet i vården samt relationen mellan familjen och vårdpersonalen upplevdes som viktigast bland föräldrar. Den metodologiska aspekten som valdes för att granskas i den här studien var datainsamlingsmetoden. Utefter granskning av artiklarnas datainsamlingsmetod har det hittats tre olika datainsamlingsmetoder i de olika artiklarna, semistrukturerade intervjuer, fokusgrupper och enkäter. Slutsatser: Kännedom bland sjuksköterskor och vårdpersonal om föräldrars upplevelse av stöd i mötet med vård av ett cancersjukt barn är viktigt för att kunna bygga upp en öppen, ärlig och mellanmänsklig relation. Kommunikation, delaktighet, kontinuitet och vårdrelationen utgör underlag för att kunna uppnå denna mellanmänskliga relation. / Background: In Sweden, more than 300 children and adolescents aged 0-18 years are affected by cancer each year. Palliative care is based on an approach aimed at improving the quality of life for both patients and their families facing the problems of life threatening diseases. In healthcare in general, the family is considered to be of high value in nursing. Aim: The purpose of this study was to describe parents' experience of support from nurses in palliative care for children with cancer. The purpose of the study was also to examine the data collection method of the articles included in the study. Method: This literature review has a descriptive design. The search strategy was based on two databases, PubMed and Cinahl. The keywords used were Childhood Cancer, parents, experience, support and palliative care. Ten articles were selected for review and processing. Result: Four cornerstones were identified in the results: communication, participation, continuity and relationship, which is the foundation for the parents' perception of support. Parents' perceptions of support in the meeting with the care of their child with cancer, revolves around nursing staff approach. An honest and good communication, participation, continuity of care and the relationship between the family and the caregivers were perceived as most important among parents. The methodological aspect that was selected for examination in this study, was the data collection method In the review of the articles data collection methods, three different methods were found in the various articles, semi-structured interviews, focus groups and surveys. Conclusions: The knowledge among nurses and health professionals about parents' experience of support in the care of a cancer sick child is important, in order to build an open, honest and interpersonal relationship. Communication, participation, continuity and care-relationship is the basis for achieving this interpersonal relationship.

Bakgrund: Många föräldrar upplever det som jobbigt att närvara på operationssalen, bland det jobbigaste är att se barnet sövas och att därefter gå därifrån. Föräldrarna upplever känslor av hjälplöshet, avsaknad av psykologiskt stöd och bristande kontroll över situationen. Syfte: Att få fördjupad förståelse för föräldrars livsvärld och upplevelser av att inför en operation överlämna sitt barn till operationsteamet, samt hur bemötandet från operationsteamet påverkar dessa upplevelser. Metod: En kvalitativ intervjustudie med deskriptiv design och induktiv ansats. Sex föräldrar intervjuades med hjälp av en intervjuguide innehållande semi-strukturerade frågor. Insamlade data analyserades med kvalitativ innehållsanalys och resultatet tolkades ur ett livsvärldsperspektiv. Resultat: I resultatet framkom att föräldrarnas emotionella livsvärld till stor del upptogs av ovisshet och oro för att något skulle gå fel, rädsla för att komplikationer på ett negativt sätt skulle påverka barnets livskvalité i framtiden. Upplevelsen av att överlämna sitt barn till operationsteamet påverkades av vilka förväntningar föräldrarna hade samt deras tidigare erfarenheter gällande mötet med operationssjukvården. Föräldrarnas upplevelser på operationssalen bestod av en oro inför sövningen och de tyckte att det var psykiskt påfrestande att lämna barnet ensam på operationssalen. Däremot var deras generella upplevelse av överlämningen god. Personalens påverkan på föräldrarnas upplevelser var stor. Här framkom vikten av ett gott bemötande och en stödjande dialog samt hur erfaren föräldern uppfattade att personalen var. Slutsats: Föräldrarna upplevde överlämningen som psykiskt påfrestande men kände att det generellt sett gick bra. Personalens stöd och bemötande var viktigt och påverkade föräldrarnas upplevelse av överlämningen i hög grad. / ABSTRACT Background: Many parents find it difficult to be present in the operating theatre, particularly witnessing the child being anaesthetised before then having to leave. Parents experience feelings of helplessness, and a lack of psychological support or control over the situation. Aim: To gain deeper insight into the parental situation, experiences of handing over their child to a surgical team prior to operation, as well as how such teams’ treatment of parents affects their experience. Method: A qualitative interview study with a descriptive design and inductive approach. Six parents were interviewed with the support of an interview guide containing semi-structured questions. Quantitative content analysis was applied to gathered data and the results interpreted from a lifeworld perspective. Results: It was apparent that parents were emotionally occupied by uncertainty and fear about something going wrong, and concern that complications could negatively affect the child’s future quality of life. The handover experience to the surgical team was influenced by parental expectations and prior encounters with surgical care. Parental experiences in the operating theatre consisted of anxiety prior to anaesthetisation and the psychological impact of leaving the child in theatre. However, general handover experiences were good, with surgical teams having substantial influence. Apparent were the importance of considerate treatment, supportive dialogue, and how experienced parents perceived the staff to be. Conclusion: Parents experience handovers as mentally stressful but otherwise felt that they generally went well. How staff supported and treated them was important and substantially affected the parents’ perception of the handover procedure.

<p>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.</p> / <p>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.</p>

<p>While constituting a well functioning interface with the aqueous environment in utero, the skin offers a poor barrier after very preterm birth. As a result, transepidermal water loss (TEWL) is high, a fact which has important clinical consequences in these infants. To investigate the transport of water through perinatal skin and the potential role of aquaporin (AQP), a water channel protein, in this process, we determined TEWL in a group of extremely preterm infants, and in an experimental rat model we analyzed the expression and distribution of AQP in perinatal skin in relation to TEWL, skin surface hydration and water content. The effects of antenatal corticosteroids (ANS) and of restricted intake of fluids and nutrients on barrier characteristics of the perinatal skin and its AQP expression were also studied.</p><p>In infants born at 24 and 25 weeks of gestation TEWL was very high in the first days after birth and decreased with increasing postnatal age. At a postnatal age of 4 weeks, TEWL was still twice as high as previously reported in infants born at a gestational age of 25-27 weeks and four times higher than in infants born at term. In the rat model, immunohistochemical analysis revealed that AQP1 and AQP3 are abundantly expressed in the skin. AQP1 was expressed exclusively in dermal capillaries and AQP3 in basal layers of the epidermis. AQP1 and AQP3 mRNA as assessed by semiquantitative RT-PCR was higher in fetal than in adult skin. As in infants, TEWL and skin surface hydration were inversely related to gestational age in the rat. In preterm rat pups exposed to ANS, TEWL and skin surface hydration were lower than in unexposed controls, and AQP3 expression was selectively induced by ANS. In term newborn rat pups, restriction of fluid and nutrient intake resulted in a higher skin water content and higher TEWL early after birth, while at an age of 7 days TEWL was lower in fasting rat pups than in controls, although skin water content was still higher.</p><p>To conclude, TEWL is very high in extremely preterm infants early after birth and then decreases at a slower rate than previously reported for a group of slightly more mature infants. </p><p>This is the first time that the distribution and gene expression of AQP1 and AQP3 have been demonstrated in perinatal skin. The localization and expression of AQP in the skin might indicate that these water channels are involved in the regulation of skin hydration and transepidermal water transport in the fetus and newborn infant.</p>

<p>Children with myelomeningocele (MMC) usually have problems with daily life activities, but the background to their problems is not altogether obvious. An understanding of the possible causes of activity problems is a prerequisite for the effectiveness of physical therapy. The overall aim of the present studies was to identify impairments above the cele level, which might influence mobility in children with MMC (study I) and to analyse sitting posture (study II) and the movement characteristics of reaching movements (study III and IV). </p><p>In total, 41 children and young adults with MMC and without mental retardation were investigated. Study I comprised 32 children, 6-11 years. Mobility and the caregiver assistance required for mobility were quantified according to the Paediatric Evaluation of Disability Inventory (PEDI) and correlation between mobility and neurological impairment, hand function and cognitive function were calculated. The results showed that nine children achieved independent mobility and that there was a moderate and significant correlation between the need for physical assistance and high cele level, impaired hand function and impaired cognitive function. In those children who used a wheelchair, only poor hand strength was significantly correlated with the need for caregiver assistance.</p><p>Study II comprised 11 children, 10-13 years, and a control group of 20 healthy children. Sitting posture was investigated by using a force plate and analysed from the frequency and the amplitude of the postural sway. The reaction forces before and during rapid arm lift were also analysed. The result showed that children with MMC had significantly lower sway frequency compared to the controls. In both groups, the ground reaction forces were registered before the children lifted their arms. Study III and IV comprised 31 children and young adults, 9-19 years and 31 matched controls. Reaching movements were investigated with a digitising tablet, linked to a computer. The ability to program and execute reaching movements was analysed and also the ability to adapt reaching to new visuomotor conditions. The results showed that the MMC group had poorer precision, less straight movements and shorter deceleration phases as compared to the controls. In both groups the movements were pre-programmed. In addition, adaptation of reaching to new visuomotor conditions was poor in the MMC group as compared to the controls. </p><p>In conclusion we found that impairments above the cele level influenced mobility and the control of sitting posture in children with MMC. Reduced precision and co-ordination of reaching, and also difficulties with motor adaptation, could partly explain thier problems with hand activities. These findings need to be considered in therapy programs for children and young adults with MMC.</p>

<p>Glucose is the most important fetal nutrient and the production of this substrate increases in the pregnant woman. In the last trimester the increased insulin resistance directs energy substrates to the fetus. Fetal growth is sometimes disturbed, often without an obvious explanation.</p><p>After birth the newborn infant must produce its own glucose, primarily for the brain. Fatty acids from lipolysis are also important energy substrates. Hypoglycaemia can be a problem, occurring frequently in preterm infants and infants born small for gestational age (SGA). In addition, SGA infants are at risk of developing the metabolic syndrome in adulthood. Neonatal medication can influence energy metabolism. One such medication is theophylline, administered in preterm infants to prevent apnoea. </p><p>We investigated energy substrate production in women with normal and IUGR pregnancies, in preterm neonates, before and after theophylline treatment and in newborn SGA infants, using stable isotope-labelled compounds and gas chromatography-mass spectrometry. </p><p>We found that late pregnancy was associated with an almost twofold increase in the rate of lipolysis. This provides substrates for maternal energy metabolism, which may spare glucose for the fetus. Even though glucose production was comparable in the two groups of pregnant women, those with IUGR had a lower rate of lipolysis. A reduced supply of energy substrates could be one factor underlying IUGR. In spite of the insulin resistance of late pregnancy, insulin still had a regulatory role in energy substrate production in the women with normal pregnancies, but not in those with IUGR. </p><p>Although infants born preterm and/or SGA have limited energy stores, we demonstrated that they are capable of both lipolysis and glucose production. Theophylline had no adverse effects on energy substrate production. Data on insulin and IGFBP-1 in the SGA infants indicate that in such infants insulin sensitivity is increased peripherally but reduced in the liver.</p>

<p><b>Background. </b>Newborn infants, especially preterm infants, have an increased susceptibility to serious and overwhelming bacterial as well as fungal infections. Symptoms of septicaemia in especially the very preterm neonates are vague and unspecific. No really good biochemical parameter exists today that can confirm or exclude the existence of neonatal septicaemia. The access to such a test in neonates would be most valuable, not only to assure early institution of effective antibiotic therapy when needed, but also to avoid unnecessary use of antibiotics, thereby reducing the risk of further development of antimicrobial resistance. </p><p><b>Aim. </b>To investigate the possible use of the expression of the phagocyte receptor CD64 (FcγRI) on neutrophils for early diagnosis of bacterial infections with special reference to neonatal septicaemia. </p><p><b>Results. </b>Neutrophils from preterm and term newborn infants, older infants, children, and adults examined during the early phase of a bacterial infection showed a significantly higher expression of CD64 compared with non-infected controls (p<0.001). Neutrophils from even extremely preterm infants expressed CD64 to the same extent as did neutrophils from children and adult patients. The expression of CD64 was not affected by the respiratory distress syndrome (RDS) or by such factors as premature rupture of the membranes, gestational age, steroid treatment before delivery, method of delivery, birth weight or postnatal age.</p><p>Major surgery in adults (total hip replacement) did not affect the CD64 expression to an extent comparable to that found during bacterial infections. Indirectly CD64 was found to be at least equal to CRP for differentiation between Influenza A infection and bacterial infections in adults.</p><p><b>Conclusion.</b> CD64 was found to be a specific and reliable marker for early detection of bacterial infections in preterm and term newborn infants, as well as after surgery. For differentiation between bacterial and viral infections it is probably at least as effective as CRP.</p>

<p>In a Manila hospital, 204 mothers were randomized into three groups: two intervention groups receiving home-based counseling visits, one of them (n=68) by counselors trained to use a locally developed, two-tiered program of breastfeeding counseling, and the other by counselors trained in general childcare (n=67), were compared with a control group of mothers (n=69) who did not receive any counseling. All infants were scheduled for seven visits to the hospital for follow-up. During hospital visits, maternal and infant body measurements were made and an independent interviewer asked the mothers individually to recall how the infant had been fed. One study physician, blind to participant groups, was consulted at all scheduled and unscheduled infant visits.</p><p>At six months, 44% of the breastfeeding-counseled mothers, 7% of the childcare-counseled mothers and none of the mothers in the control group were exclusively breastfeeding. Twenty- four mothers breastfed exclusively during the first six months, of whom 22 received breastfeeding counseling and 2 had no breastfeeding counseling. Among 24 infants who were exclusively breastfed from birth to six months there were no episodes of diarrhea. All infants had gained in weight, length and head circumference. Mean maternal weight loss at six months was similar whether her breastfeeding was exclusive or partial.</p><p>The reasons why mothers without breastfeeding counseling introduced non-breast milk feeding before six months reflected lack of knowledge and support. Breastfeeding support during the first six months focusing on how to prevent and solve breastfeeding problems, particularly during the first two weeks, will enable mothers to choose to breastfeed exclusively up to six months. </p><p>This study has provided fundamental evidence of successful intervention by breastfeeding counseling to achieve six months of exclusive breastfeeding among term, low-birthweight infants. The locally developed training program in breastfeeding counseling, which successfully prepared volunteers to counsel mothers at home, could be incorporated into primary health care in the Philippines. Mothers who received breastfeeding counseling appreciated how this helped them to achieve their breastfeeding goals for the first six months. Improved breastfeeding practices as a result of breastfeeding counseling provided infants with protection from diarrhea and respiratory infections, contributing to their health and development.</p>