Keskoslasten motorinen kehitys : Alberta Infant Motor Scale (AIMS) -testistöllä arvioituna

Opinnäytetyön tarkoituksena oli kuvata alle 1 500 gramman painoisena syntyneiden keskoslasten motorista kehitystä kolmen, kuuden ja kahdentoista kuukauden korjatussa iässä, sekä tuoda esille mahdollisia motorisen kehityksen yhteisiä piirteitä Alberta Infant Motor Scale (AIMS) -testistöllä arvioituna. Työ toteutettiin yhteistyössä Lasten ja nuorten sairauksien toimialan fysioterapian yksikön kanssa, jossa keskoslasten motorisen kehityksen arviointi AIMS-testistöllä oli toteutettu vuosina 2005 - 2006. Idea opinnäytetyöhön syntyi yhteisten keskusteluiden pohjalta fysioterapeuttien kanssa. Opinnäytetyön tavoitteena oli analysoida ja koota yhteenveto Lasten ja nuorten sairauksien toimialalle heidän tutkimastaan aineistosta. Työ oli luonteeltaan kuvaileva kvantitatiivinen tutkimus valmiiksi saadun aineiston pohjalta. Aineisto koostui yhteensä 109 keskoslapsen AIMS-testistön arviointilomakkeista. Keskoslapsista 54 oli kolmen kuukauden, 42 kuuden kuukauden ja 13 kahdentoista kuukauden korjatussa iässä. Tulokset analysoitiin käyttämällä SPSS 13.0 Windows Release-tilasto-ohjelmaa ja tulokset esitettiin taulukoiden ja kuvioiden avulla. Tiedonkeruumenetelminä käytimme kirjallisuuden lisäksi uusimpia tutkimusartikkeleita sekä asiantuntijahaastattelua. Kolmen kuukauden ikäisistä keskoslapsista 51 sijoittui AIMS-testistön motorista kehitystä kuvaaville käyrille. Kolme lasta jäi käyrien alapuolelle. Kuuden kuukauden ikäisten keskoslasten kokonaispistemäärissä oli enemmän hajontaa. 15 lasta jäi AIMS-testistön motorista kehitystä kuvaavien käyrien alapuolelle. Kahdentoista kuukauden ikäisistä lapsista yhdeksän sijoittui motorista kehitystä kuvaaville käyrille ja neljä lasta jäi käyrien alapuolelle. Yhteisenä piirteenä kaikilta kolmen kuukauden ikäisiltä ja 14 kuuden kuukauden ikäiseltä lapselta puuttui taito tukeutua yläraajoihin istuma-asennossa (Sitting With Propped Arms). Tutkimustulosten perusteella kolmen kuukauden ikäisten keskoslasten motorinen kehitys oli valtaosalla (51/54) ikätasoista. Kuuden ja kahdentoista kuukauden ikäisten keskoslasten motorisessa kehityksessä yksilölliset erot olivat suurempia. Tutkimusjoukkomme keskoslapsista motorinen kehitys oli ikätasoa heikompaa 22 keskoslapsella. Lasten ja nuorten sairauksien toimiala saa käyttöönsä työmme tulokset, joita voidaan hyödyntää keskoslasten motorisen kehityksen seurannassa sekä fysioterapian kehittämisessä. Työmme lisää AIMS-testistön tunnettavuutta ja siitä on myös laajemmin hyötyä lasten parissa työskenteleville fysioterapeuteille.

Early relationship between very preterm infant and mother: The role of infant, maternal and dyadic factors

Pienipainoisen keskosen ja äidin varhainen suhde: Lapsen, äidin ja dyadisten muuttujien vaikutus Tämän tutkimuksen tavoitteena oli tutkia keskosvauvan ja äidin varhaista suhdetta. Tutkimuksessa selvitettiin myös vauvan itkukäyttäytymisen, vauvan sylissä olon ja äidin masentuneisuuden yhteyttä äidin ja keskosvauvan varhaiseen suhteeseen. Tutkimusryhmät koostuivat 32:sta (tutkimus I-II) ja 38:sta (tutkimus III-IV) keskosena syntyneestä vauvasta (syntymäpaino < 1501 g tai GI < 32 viikkoa) sekä 46:sta täysiaikaisena syntyneestä terveestä verrokkivauvasta. Lapsen ja äidin vuorovaikutusta arvioitiin 6 ja 12 kuukauden iässä (korjattu ikä) PCERAmenetelmällä. Äidin mielikuvia lapsestaan tutkittiin WMCI-haastattelulla, kun lapsi oli 12 kuukautta. Baby Day Diary -menetelmää käytettiin vauvan itkukäyttäytymisen ja sylissä olon keston mittaamisessa vauvan ollessa 5 kuukautta. Äidin masentuneisuutta arvioitiin EDPS-lomakkeella, kun lapsi oli 6 kuukautta. Tulokset osoittivat, että turvallisten kiintymyssuhdemielikuvien määrä tai vuorovaikutuksen laatu eivät keskosvauvan äideillä eronneet täysiaikaisina syntyneiden vauvojen äitien vastaavista. Ryhmien välillä ei löytynyt eroja myöskään dyadisen vuorovaikutuksen laadussa. Keskosena syntyneet lapset olivat kuitenkin vetäytyvämpiä ja heillä oli laadullisesti heikommat keskittymisen ja leikin taidot vuorovaikutustilanteessa 12 kuukauden iässä täysiaikaisina syntyneisiin lapsiin nähden. Lisäksi äidin masentuneisuus ja lapsen pitkittynyt itkuisuus olivat negatiivisessa yhteydessä vuorovaikutuksen laatuun keskosvauvojen ryhmässä. Vauvan itkukertojen määrän, sylissä olon keston sekä äidin ja vauvan vuorovaikutuksen laadun välillä löytyi positiivinen yhteys ainoastaan keskosena syntyneiden lasten ryhmässä. Tulostemme perusteelle toteamme, että lapsen ennenaikainen syntymä itsessään ei näytä muodostavan riskiä äidin vuorovaikutuksen laadulle tai turvalliselle kiintymyssuhteelle. Yhdessä muiden riskitekijöiden kanssa keskosuus kuitenkin altistaa vauvat ja heidän äitinsä varhaisen vuorovaikutuksen ongelmille. Lisäksi tuloksemme viittaavat siihen, että vauvan itku ja siitä seuraava sylissä olo toimivat suojaavana mekanismina pienipainoisen keskosen ja äidin varhaisessa suhteessa.

Probiotic interventions in infancy: Benefit and Safety Assessment of Extended Applications

Immaturity of the gut barrier system in the newborn has been seen to underlie a number of chronic diseases originating in infancy and manifesting later in life. The gut microbiota and breast milk provide the most important maturing signals for the gut-related immune system and reinforcement of the gut mucosal barrier function. Recently, the composition of the gut microbiota has been proposed to be instrumental in control of host body weight and metabolism as well as the inflammatory state characterizing overweight and obesity. On this basis, inflammatory Western lifestyle diseases, including overweight development, may represent a potential target for probiotic interventions beyond the well documented clinical applications. The purpose of the present undertaking was to study the efficacy and safety of perinatal probiotic intervention. The material comprised two ongoing, prospective, double-blind NAMI (Nutrition, Allergy, Mucosal immunology and Intestinal microbiota) probiotic interventions. In the mother-infant nutrition and probiotic study altogether 256 women were randomized at their first trimester of pregnancy into a dietary intervention and a control group. The intervention group received intensive dietary counselling provided by a nutritionist, and were further randomized at baseline, double-blind, to receive probiotics (Lactobacillus rhamnosus GG and Bifidobacterium lactis) or placebo. The intervention period extended from the first trimester of pregnancy to the end of exclusive breastfeeding. In the allergy prevention study altogether 159 women were randomized, double-blind, to receive probiotics (Lactobacillus rhamnosus GG) or placebo 4 weeks before expected delivery, the intervention extending for 6 months postnatally. Additionally, patient data on all premature infants with very low birth weight (VLBW) treated in the Department of Paediatrics, Turku University Hospital, during the years 1997 - 2008 were utilized. The perinatal probiotic intervention reduced the risk of gestational diabetes mellitus (GDM) in the mothers and perinatal dietary counselling reduced that of fetal overgrowth in GDM-affected pregnancies. Early gut microbiota modulation with probiotics modified the growth pattern of the child by restraining excessive weight gain during the first years of life. The colostrum adiponectin concentration was demonstrated to be dependent on maternal diet and nutritional status during pregnancy. It was also higher in the colostrum received by normal-weight compared to overweight children at the age of 10 years. The early perinatal probiotic intervention and the postnatal probiotic intervention in VLBW infants were shown to be safe. To conclude, the findings in this study provided clinical evidence supporting the involvement of the initial microbial and nutritional environment in metabolic programming of the child. The manipulation of early gut microbial communities with probiotics might offer an applicable strategy to impact individual energy homeostasis and thus to prevent excessive body-weight gain. The results add weight to the hypothesis that interventions aiming to prevent obesity and its metabolic consequences later in life should be initiated as early as during the perinatal period.

An Infant with Food Allergy and Eczema in the Family – The Mental and Economic Burden of Caring

Allergic diseases including food allergy and eczema in an infant in combination with the everyday activities of caring for a family will pose challenges to parents. Only fragments of these challenges are revealed to health care professionals. Families have varying mental, social and economic resources to help them care for an allergic infant, and all such resources are important in determining how families succeed in meeting these challenges and the quality of the infant’s care. This study evaluated the whole burden to the family caused by an infant's allergic disease during the first 24 months of life. As the primary caregiver during this period is usually the mother, her perspective was considered important. Ecocultural theory, which considers families as capable of modifying the positive and negative forces facing them, was taken as the frame of reference. Data were collected as part of an ongoing prospective mother-infant study, and the methods included severity scoring of atopic dermatitis, dietary records, health-related quality of life measurements and assessments of the use of health care services and medications for treating the infant’s eczema, food allergy and asthma. Interviews with mothers were analysed by deductive content analysis on the basis of ecocultural theory and the family empowerment model. The theme “Living an ordinary family life” guided the organization of family activities essential for treating the infant's food allergy and eczema. These activities were sources of both strain and support for the mothers, the allergy-related supporting factors being the mother’s own knowledge of the allergy, hopes for an improvement in the infant’s condition, social support and work. An infant’s food allergy at the age of one year caused considerable strain for the mother in cases where the introduction of new foods into the child’s diet was delayed. This delay was still causing the mother additional strain when the child was 24 months of age. The infants waking at night at the ages of 12 and 24 months because of itching related to eczema caused strain for the mothers. The infants’ health-related quality of life was impaired at ages of 6 and 12 months compared with healthy infants. The principal reasons for impairments were itching, scratching and sleep disturbances at 6 and 12 months and treatment difficulties at 6 months. Problems with getting to sleep were reported at all stages irrespective of eczema and were also present in healthy infants. The economic impact of the treatment of allergic diseases on families during the first 24 months was 131 EUR (2006 value) in cases of eczema and 525 EUR in cases of food allergy. From the societal perspective, the costs of food allergy were a median of 3183 EUR (range 628–11 560 EUR) and of eczema a median of 275 EUR (range 94–1306 EUR). These large variations in costs in food allergy and eczema indicate that disease varies greatly . In conclusion, food allergy and eczema cause extra activities and costs to families which arrange these disease-related activities in such a way that they support the leading family theme “Living an ordinary family life”. Health care professionals should consider this thematic character of family life and disease-related activities in order to ensure that new treatments are sustainable, meaningful and tailored to daily activities. In addition, those mothers who are experiencing difficulties with food allergic infants or infants with eczema should be recognized early and provided with individual encouragement and support from health clinics. In the light of the present results, early detection of symptoms and effective parental guidance can contribute to the well-being and health-related quality of life of the child and family.

Infant Colic Crying and Gastrointestinal Tract – Causes, Consequences and Cure

Despite over 50 years of investigation, the precise cause of infant colic crying remains unresolved and the long-term consequences unrevealed, and an effective treatment is lacking. Indeed, a more profound understanding of the complex nature of infants’ excessive crying is needed. The purpose of this series of studies was to investigate the association between gut microbiota composition and infant crying, to evaluate the impact of colic crying on children’s later health and to study the possibilities of treating and preventing excessive crying with pro- and prebiotics. The material comprised three on-going, prospective randomized controlled trials of the probiotic Lactobacillus rhamnosus GG (ATCC 53103, LGG) or a mixture of prebiotics administered in early infancy. The study populations consisted of term infants (n=89), preterm infants (n=94) and term colic infants (n=30). Early crying was found to be inversely associated with the number of Bifidobacterium and Lactobacillus. Furthermore, at the age of 13 years functional gastrointestinal disorders (FGID) were manifested more frequently among children with previous colic crying than in those without. In preterm infants pro- and prebiotic supplementation during the first months of life reduced the frequency of excessive crying when compared to placebo. In parallel, probiotic LGG in tandem with a cow’s milk elimination diet and behavioral counseling reduced the daily crying amount among term colic infants when compared to placebo. In conclusion, the composition of the gut microbiota is associated with infant crying and colic, and probiotic LGG might provide a safe and effective treatment or preventive option to alleviate excessive crying in early infancy in term and preterm infants. Furthermore, early colic crying might be associated with the later development of FGID.

The role of cathepsin K in lung development and newborn chronic lung injury.

Chronic lung diseases, specifically bronchopulmonary dysplasia (BPD), are still causing mortality and morbidity amongst newborn infants. High protease activity has been suggested to have a deleterious role in oxygen-induced lung injuries. Cathepsin K (CatK) is a potent protease found in fetal lungs, degrading collagen and elastin. We hypothesized that CatK may be an important modulator of chronic lung injury in newborn infants and neonatal mice. First we measured CatK protein levels in repeated tracheal aspirate fluid samples from 13 intubated preterm infants during the first two weeks of life. The amount of CatK at 9-13 days was low in infants developing chronic lung disease. Consequently, we studied CatK mRNA expression in oxygen-exposed wild-type (WT) rats at postnatal day (PN) 14 and found decreased pulmonary mRNA expression of CatK in whole lung samples. Thereafter we demonstrated that CatK deficiency modifies lung development by accelerating the thinning of alveolar walls in newborn mice. In hyperoxia-exposed newborn mice CatK deficiency resulted in increased number of pulmonary foam cells, macrophages and amount of reduced glutathione in lung homogenates indicating intensified pulmonary oxidative stress and worse pulmonary outcome due to CatK deficiency. Conversely, transgenic overexpression of CatK caused slight enlargement of distal airspaces with increased alveolar chord length in room air in neonatal mice. While hyperoxic exposure inhibited alveolarization and resulted in enlarged airspaces in wild-type mice, these changes were significantly milder in CatK overexpressing mice at PN7. Finally, we showed that the expression of macrophage scavenger receptor 2 (MSR2) mRNA was down-regulated in oxygen-exposed CatK-deficient mice analyzed by microarray analysis. Our results demonstrate that CatK seems to participate in normal lung development and its expression is altered during pulmonary injury. In the presence of pulmonary risk factors, like high oxygen exposure, low amount of CatK may contribute to aggravated lung injury while sustained or slightly elevated amount of CatK may even protect the newborn lungs from excessive injury. Besides collagen degrading and antifibrotic function of CatK in the lungs, it is obvious that CatK may affect macrophage activity and modify oxidative stress response. In conclusion, pulmonary proteases, specifically CatK, have distinct roles in lung homeostasis and injury development, and although suggested, broad range inhibition of proteases may not be beneficial in newborn lung injury.

Breastfeeding preterm infant from the delivery ward via nicu to home

The aim of this study was to examine how to support breastfeeding of preterm infants immediately after birth in the delivery ward, during their hospital stay in a neonatal intensive care unit (NICU), and at home after hospital discharge. Specifically, the role of early physical contact, maternal breastfeeding attitude, and an internet-based peer support group were investigated. The delivery ward practices concerning the implementation of early physical contact between a mother and her infant admitted to a NICU were examined by a structured survey in two hospitals. An Internet-based, breastfeeding peer-support intervention for the mothers of preterm infants was developed and tested in a randomized controlled design with one year follow-up. The main outcomes were the duration of exclusive and overall breastfeeding, expressing milk, and maternal attitude. In addition, the perceptions of mothers of preterm infants were investigated by analyzing the peer-support group discussions with a qualitative approach. The implementation of early physical contact was different between the two hospitals studied and was based more on hospital routines than the physiological condition of the infant. Preterm infants, who were born before a gestational age (GA) of 32 weeks, were hardly ever allowed to have early contact with their mothers. Both, a higher GA and early physical contact predicted earlier initiation and increased frequency of breastfeeding in the NICU. A maternal breastfeeding-favorable attitude predicted increased frequency of breastfeeding in the NICU and also a longer duration of overall breastfeeding. The actual duration of breastfeeding was, however, shorter than the mothers intended in advance. The internet-based, peer-support intervention had no effect on the duration of breastfeeding, expressing milk, or maternal attitude. The participating mothers enjoyed the possibility of sharing their experiences of preterm infants with other mothers in similar situations. Some of the mothers also experienced being given useful advice for breastfeeding. Based on the mothers’ discussions, a process of breastfeeding preterm infants was created. This included some paradoxical elements in the NICU where, for example, breast milk was emphasized over breastfeeding and support in the hospital varied. Hospital discharge was a critical point, when the mothers faced breastfeeding in reality. Over time, the mothers assimilated their breastfeeding experience into part of being a mother. The care practices related to early physical contact in delivery wards need to be re-evaluated to allow more infants to have a moment with the mother. Maternal attitude could be screened prenatally and attitude-focused interventions developed. Breastfeeding support in the NICU should be standardized. Internet-based breastfeeding peer-support intervention was feasible but additional research is needed.