Tesi sul tema "Infants (premature)"

Premature infants represent 7% of all births in the UK and have higher rates of vaccine preventable infections. National recommendations for vaccine schedules focus predominantly on term infants. We aimed to assess the immunogenicity of the UK immunisation schedule in preterm infants randomising infants to 3 different PCV13 primary schedules and using data from the randomized controlled trial and a pooled data metaanalysis of preterm vaccine studies to identify factors affecting vaccine responses. Methods 210 infants «35 weeks gestation) received DTaP-IPV-Hib vaccine at 2, 3 and 4 months of age and meningococcal C conjugate vaccine at 2 and 3 months alongside 3 different PCV13 vaccine schedules (Group1: 2 and 4 months, Group 2: 2, 3 and 4 months, Group 3: 2,4 and 6 months). At 12 months of age participants received MMR, PCV13 and Hib-MenC-TI vaccines. Antibody concentrations and Iymphocyte subpopulations were measured before and one month after primary and booster vaccinations. Results The median birth gestation was 29+6 weeks (range 23+2-34+6). Younger gestation was associated with lower antibody concentrations at baseline but had limited effect on vaccine responses. For PCV13, group 3 had the highest antibody concentrations post-primary and prior to booster vaccination but the lowest antibody concentrations after the booster. There was no consistent effect of chronic lung disease, growth restriction or the receipt of blood products, antenatal or postnatal steroids on vaccine responses. For all antibodies a longer duration of vaccine course or an older age at final immunisation was associated with improved immunogenicity. Increased CD19+was associated with improved PCV13 immunogenicity Conclusion Premature infants can mount satisfactory responses to all routine vaccines but the schedule followed for PCV13 vaccine will significantly influence when optimal protection occurs. Disease epidemiology must be considered when deciding which schedule to follow.

Background. Improvements in postnatal care provided in neonatal intensive care units have resulted in increasing survive percentage of children born at the limits of viability. A large number of premature infants experienced major impairment and/or minor neurodevelopmental disabilities, such as cognitive, psychiatric and motor disorders. The etiology of these developmental deficits still remains not completely understood, but they may be the result of neonatal brain injury as well of interruption of the normal process of brain maturation that occurs during the last trimester of pregnancy, a critical period of prenatal ontogenesis. Prediction of the outcome of individual preterm infants is difficult. Although a premature infant may be asymptomatic for abnormal clinical signs, he may exhibit subtle alterations in brain activity which often remain unrecognized. A neurophysiologic evaluation of brain activity in the third trimester of gestation would probably be of great benefit for early detection of pathological processes or subclinical alterations. Electroencephalogram and cortical auditory evoked potentials turned out to be simple and useful techniques in evaluation of brain maturation. Aims. We conducted cross-sectional and longitudinal investigations at early crucial phases of development (35 and 40 weeks post-conception) in order to identify differences in cerebral activity between premature infants born at different gestational ages and full-term neonates, using electroencephalogram (EEG) at rest and cortical auditory evoked potentials (CAEP). We further aimed to correlate the neonatal data with later neurodevelopment. Methods. The research is divided into three studies: Study 1: EEG spectral activity was recorded at 35 post-conception weeks in 40 premature infants and compared between groups of infants born at different gestational age (“extremely low gestational age”, ELGA: 23–27+6, ‘‘very low gestational age’’, VLGA: 28–31+6 and “low gestational age”, LGA: 34-35). The results were correlated with behavioral developmental scores obtained at 12 months corrected age from 20 infants. Study 2: a subgroup of 10 infants of Study 1 repeated the EEG recording at 40 post-conception age. EEG spectral activity of this subgroup was compared longitudinally and further the activity recorded at 40 GA were compared with those of a group of 10 full-term infants. Study 3: CAEP were recorded in active sleep at 35 post-conception weeks in response to an auditory stimulation in 36 premature infants and compared between groups of infants born at different gestational age (ELGA, VLGA, LGA). The results were correlated with behavioral developmental scores obtained at 12 months corrected age from 20 infants. Methodology Study 1 and 2. Electrical brain activity was recorded for 40 minutes on 5 bipolar channels. Data were transformed into the frequency domain using a Fast Fourier Transform algorithm. Frequency spectrum was divided into the following bands: δ (0.5-4 Hz, comprising δ1 0.5-1 Hz and δ2 1-4 Hz), θ (4-8 Hz), α (8-13 Hz) and β (13-20 Hz). Statistical analysis were performed on absolute and relative power values only on central sites (C3-C4, C3-T3, C4-T4). Methodology Study 3. 1000 Hz (paradigm 1) and 500 Hz (paradigm 2) auditory stimulations were performed on continuous EEG recording. Design consisted of 300 tones for each paradigm. Inter-stimulus interval randomly varied between 600 and 900 ms; 12 monopolar channels were recorded, referenced to the bilateral linked ear lobes. 600 ms epochs were divided for statistical analysis in time windows of 100 ms. Statistical analysis were performed only on central sites (Fz, Cz). Results. Study 1. On C3-C4, relative spectral power values differed significantly between ELGA and LGA groups. Infants born at lower gestational ages had a higher amount of power in the δ and a lower amount of α and β spectral power. The preliminary data on those infants attaining 12 months of corrected age showed that higher amount of δ and a lower amount of β and α resulted associated with poor relational skills and personal self autonomies. Study 2. At 40 post-conception age, premature infants showed on C3-C4 a decrease in δ activity and a mild, not significant, increase in higher frequencies; no significant differences in spectral power values were found with full-term neonates. Study 3. In response to 1000 Hz tones no waveforms became evident on Fz in ELGA infants, while LGA presented a wide and slow positive response; the groups differed significantly. VLGA’s grand average waveform resembled that of LGA group, but characterized by a high variability. Responses to 500 Hz resulted highly variable and not reliable. Conclusions. We found early subtle brain electrical alterations in premature infants experiencing different developmental pathways, suggesting a different cortical organization; these differences seem to be associated with later development. The potential of neurophysiological methodologies is to provide a useful indicator of good prognosis or poor developmental outcomes.
Premesse. Gli avanzamenti tecnologici che negli ultimi decenni hanno caratterizzato le cure perinatali e le tecniche di terapia intensiva neonatale hanno permesso la sopravvivenza di una percentuale sempre maggiore di neonati prematuri nati ad età gestazionali sempre più basse, ai limiti della sopravvivenza. Eppure, studi sullo sviluppo a breve e lungo termine hanno dimostrato che molti neonati prematuri riportano esiti maggiori e/o disordini evolutivi minori, come deficit cognitivi e neuropsicologici, disturbi psichiatrici/comportamentali e motori. La causa di tali disordini dello sviluppo rimane poco chiara, ma può essere il risultato di sofferenza cerebrale in epoca neonatale come anche dell’interruzione del normale processo di sviluppo che avviene nel terzo trimestre di gravidanza, un periodo estremamente critico per la maturazione cerebrale. Predire come sarà lo sviluppo di un neonato prematuro rimane attualmente molto difficile. Infatti, sebbene un neonato possa essere asintomatico per segni clinici indicativi di una condizione patologica in atto, possono essere presenti alterazioni subcliniche del funzionamento cerebrale che spesso non vengono riconosciute. Una valutazione neurofisiologica dell’attività cerebrale nel neonato prematuro può probabilmente essere di grande utilità nel precoce riconoscimento di processi patologici o di alterazioni subcliniche. L’elettroencefalogramma (EEG) e i potenziali evocati uditivi corticali (CAEP) si sono dimostrati tecniche semplici e valide nel valutare la maturazione cerebrale. Obiettivi dello studio. Abbiamo condotto delle valutazioni neurofisiologiche trasversali e longitudinali in due fasi precoci e cruciali dello sviluppo (35 e 40 settimane postconcezionali) allo scopo di identificare differenze nell’attività elettrica cerebrale fra prematuri nati ad età gestazionali diverse e neonati a termine, usando EEG a riposo e i CAEP. Tali indagini in epoca neonatale sono state poi correlate con lo sviluppo comportamentale a distanza. Metodi. La ricerca è stata articolata in tre studi: Studio 1: è stata eseguita l’analisi spettrale dell’EEG registrato a 35 settimane postconcezionali in 40 neonati prematuri; tale attività è stata comparata fra gruppi di neonati nati ad età gestazionali diverse (estremi prematuri, ELGA: 23–27+6, veri prematuri, VLGA: 28–31+6 e prematuri, LGA: 34-35). I risultati ottenuti in epoca neonatale sono stati correlati con l’indice di sviluppo comportamentale ottenuto ai 12 mesi di età corretta nei primi 20 bambini che hanno raggiunto tale età. Studio 2: un sottogruppo di 10 neonati dello Studio 1 ha ripetuto la registrazione EEG a 40 settimane postconcezionali; la potenza spettrale ottenuta dalle registrazioni EEG a 35 e 40 settimane postconcezionali è stata cofrontata longitudinalmente; successivamente l’attività spettrale ottenuta alle 40 settimane postconcezionali è stata confrontata con quella di 10 neonati a termine alla nascita. Studio 3: i CAEP sono stati registrati in sonno attivo a 35 settimane postconcezionali in 36 prematuri e comparati fra gruppi di neonati nati ad età gestazionali diverse (ELGA, VLGA, LGA). I risultati sono stati correlati con l’indice di sviluppo comportamentale ottenuto ai 12 mesi di età corretta nei primi 20 bambini che hanno raggiunto quest’età. Metodologia Studio 1 e 2. L’attività elettrica cerebrale è stata registrata per 40 minuti su 5 canali bipolari. I dati ottenuti sono stati trasformati nel dominio delle frequenze utilizzando una trasformazione Fast Fourier. Lo spettro di frequenza è stato diviso nelle seguenti bande: δ (0.5-4 Hz, composto da δ1 0.5-1 Hz e δ2 1-4 Hz), θ (4-8 Hz), α (8-13 Hz) e β (13-20 Hz). Le analisi statistiche sono state eseguite sui valori di potenza assoluti e relativi ottenute solo dai siti centrali (C3-C4, C3-T3, C4-T4). Metodologia Studio 3. Durante la registrazione continua dell’EEG i neonati sono stati stimolati con treni di toni a 1000 Hz (paradigma 1) e a 500 Hz (paradigma 2). Il disegno sperimentale prevedeva 300 toni per ciascun paradigma. L’intervallo inter-stimolo variava in maniera casuale fra 600 e 900 ms; sono stati registrati 12 canali monopolari, riferiti bilateralmente ai lobi degli orecchi. Le epoche di 600 ms sono state divise per l’analisi statistica in finestre temporali di 100 ms. Le analisi statistiche sono state eseguite solo sui siti centrali (Fz, Cz). Risultati. Studio 1. In C3-C4, i valori di potenza spettrale relativa differivano significativamente fra i gruppi di ELGA e LGA. I neonati nati alle età gestazionali più basse avevano una maggiore potenza relativa in δ e una minore in α e β. La correlazione di questi dati con lo sviluppo comportamentale dei primi bambini che hanno raggiunto i 12 mesi di età corretta ha mostrato come alte percentuali di potenza in δ e basse in β e α fossero associate ad abilità relazionali più povere ed autonomie personali meno mature. Studio 2. A 40 settimane postconcezionali i prematuri hanno mostrato in C3-C4 una riduzione di potenza δ relativa e un lieve, non significativo, aumento di potenza nelle alte frequenze; non sono state trovate differenze significative rispetto i neonati a termine. Studio 3. Nel paradigma a 1000 Hz non è stato possibile rilevare nessuna risposta ai suoni nei neonati ELGA, mentre nei LGA in Fz era evidente una lenta ed ampia onda positiva; la grande media dei due gruppi differiva significativamente in Fz. La grande media dei neonati VLGA assomigliava a quella dei LGA, ma era caratterizzata da un’alta variabilità. Le risposte a toni di 500 Hz sono risultate troppo variabili e non riproducibili. Conclusioni. Confrontando neonati prematuri che hanno sperimentato linee di sviluppo differenti, abbiamo trovato delle differenze sottili nell’attività elettrica cerebrale che suggeriscono un’alterazione dell’organizzazione corticale. Tali differenze sembrano inoltre associate allo sviluppo comportamentale nel primo anno di vita. Questi risultati suggeriscono che le tecniche neurofisiologiche possano essere molto utili nella prognosi dei neonati prematuri.

The purpose of this study was to assess if preterm infants receiving an intervention of intermittent human tactile contact would demonstrate clinical improvement over infants who did not receive the intervention. A quasi-experimental design was used with 26 infants between 28 and 32 weeks gestation. Hands were placed on the infants' heads and lower backs for a total of 36 minutes of tactile contact a day for 10 days. Findings indicated a significant gain in mean body weight for both groups between Day 0 and Day 10. Also, there was a significant decrease in mean hematocrit in the control group between Day 0 and Day 10. On Day 10, experimental infants had a significantly higher mean number of apneic and bradycardic episodes than control infants. There were no significant mean differences between the groups for body weight, body temperature stability, oxygen variance, or hematocrit. Data suggest that gentle human touch may be correlated with desireable outcomes. Further research is necessary.

Establishing breastfeeding in the infant born prematurely remains one of the most important challenges to neonatal midwives. Many obstacles stand in the way of mothers becoming successful in this art; probably the most notable being unit guidelines established through anecdotal rather than evidence based on information. Difficulties arise in gathering "evidence" and this may in some part account for the lack of literature on breastfeeding and the preterm infant. Earlier studies indicate that breastfeeding premature infants regulate feeding differently to bottle feeding infants but these qualitative data do not adequately describe feeding performance. A convenience sample of preterm infants was selected and variables associated with feeding measured. A pulse oximeter measured heart rate and oxygen saturation pre, during and post feed, whilst feeding variables of sucking, swallowing and breathing were monitored throughout feeding using pressure sensors and auscultation. The data were continuously collected and stored in a computer using the Snapshot programme. The findings of this study indicate that practice at feeding affects outcome, bursts become longer and pauses shorter, sucks and swallows/second increase with breaths/second being influenced by milk flow and swallow rate; that total feeding time is variable and not dependent on post menstrual age (PMA); that immature infants (those of 31 weeks PMA) are able to coordinate sucking, swallowing and breathing and produce rhythmic bursts and pauses and possibly adapt feeding performance according to physiological status; finally that suckling does not cause any obvious increase in heart rate and therefore cannot be considered as an energy consuming activity.

The purpose of the study was to identify and compare characteristics of preterm infants' pulse rate, respiratory rate, stress related behavior and self comforting behavior in two situations: (1) the infant receiving routine nursing care in the environment of a neonatal intensive care nursery, and (2) the infant in the same environment after experiencing a gentle back massage. Specifically, the research question for this study was: what patterns of pulse rate, respiratory rate and behavior, are associated with massage? Preterm infants between 33 and 36 weeks gestational age were observed for a baseline period of 50 minutes, given a 10 minute back massage, and observed for an additional 50 minutes. Exploratory data analysis revealed changes in the pulse rate, and in the frequencies of stress related and self comforting behaviors after massage that were associated with gestational age. Younger infants displayed a decline in pulse rate and an increase in respiratory rate after massage when compared to baseline observations, whereas older infants showed an increase in pulse rate immediately following massage. Stress related behavior declined during the first 10 minutes after massage in all age groups. Most preterm infants in this sample did not manifest any stress related behavior for several minutes after the massage. The frequency of self comforting behaviors increased after infants experienced a massage. Behavioral patterns were coupled with physiological variables; the frequency of self comforting behaviors was reflected in the pattern of respiratory rate whereas the frequency of stress related behaviors was more closely coupled with pulse rate. As infants became more aroused, they used a greater variety of behaviors. The behavioral reportoire also increased with gestational age. Content analysis demonstrated that infants spent more time in quiet sleep after having a massage than before massage. There were more frequent changes between active and quiet sleep before massage than afterward among infants who were treated concurrently with ultraviolet light. There was a trend for infants of all ages to take less time to console themselves after having a massage than before. None of these observed differences was statistically significant. Rotational movements were noted among more mature infants and were associated with quiet sleep. Infant behaviors showed a general decrease in the amplitude of movement over time. Several infants appeared alert, opening their eyes and looking around after having a massage. In general, preterm infants in this sample manifested changes in arousal and in activity which were observed in the differences in their behavior and vital signs after having a massage.

The survival rate of premature infants is increasing. As such protective factors against cognitive and behavioural developmental impairments associated with prematurity need to be identified and understood in order to promote healthy infant development. Quality of parent-infant interaction may be a protective factor over and above other mediators such as sociodemographic and neonatal medical risks. Most research has considered the mothers' experience of having a premature infant and the quality of mother-infant interaction on infant outcomes. Evidence suggests that father involvement and interaction with the infant is also associated with improved developmental outcomes in later childhood. More research is needed of fathers' experiences of interactions with premature infants in order to promote early positive interactions, fostering healthy relationship and infant development. The current study used a qualitative design to investigate fathers' experiences of interacting with their premature infants on UK neonatal intensive care units and after discharge home. Telephone interviews were conducted with ten fathers from across the UK about their experiences of interacting with their premature infants. Thematic analysis identified six themes affecting fathers' experiences of interactions with their infant: i) Fragility of the infant - fathers were nervous and unsure about how to interact with their fragile babies, being scared of hurting them; ii) From self-conscious to self-confident interactions - fathers described the lack of privacy in the hospital contributing to them feeling self-conscious about attempting interactions with their infant, whereas they built confidence in interaction over time and felt interactions were more natural once in the freedom of their own home; iii) Medical equipment as barrier to interaction - the incubator and monitors around the infants acted as physical and emotional barriers to interaction, though the fathers recognised it was needed to keep their babies safe; iv) Passivity of baby - fathers struggled with interacting with their unresponsive infants and adapted their interactions to those which the passive infant did not need to participate in, such as singing to them; v) Not having the envisaged experience of fatherhood - fathers had to readjust their preconceived expectations of what the early days of fatherhood would be like had their infant been born full-term, to the new reality 0809, RES, Research Project, UofN: 4093405, UofL: 08127476 Pageiiof197 of having a premature baby; vi) Nature of information - although staff actively involved fathers in care-giving tasks and provided information about the infants' medical needs, little information was provided about non-care-giving interactions and fathers often had to ask what they could do with their baby. Fathers in this study described facing many challenges and barriers to interacting with their premature infants, and that these resulted in a delay in feeling like a father to the infant and in the development of the father-infant relationship. The findings have implications for the development of father- infant attachment which may influence infant development. The fathers described neonatal staff as excellent and supportive, though there appears to be a lack consistency of information to encourage fathers to interact with their premature infants from the earliest possible stages. Given the importance of this for positive infant outcomes, the experiences reported in this study may help inform support for fathers on UK NICUs to promote early interactions with their infant and foster healthy relationship and infant development.

It is generally acknowledged that infants born very preterm are at a high risk of developmental delay. It has been suggested that the first few months of life ex-utero might constitute a "sensitive period" during which growth rate could influence later outcome measures including cognitive development. This study investigated the early growth of a sample of 90 infants born very preterm and the developmental status (at 18 months of age) of 81 of those infants (mean gestational age 29.4 weeks; mean birth weight 1283g). Two main issues were addressed. One concerned the relative contribution of various early infant, maternal and medical factors to rate of growth up to 3-months corrected age. The other issue was the extent to which these early factors, as well as early growth rate, were predictive of developmental status at 18 months of age (again corrected for gestation), using the Mental Development Index of the Bayley Scales. Analyses revealed that there were few significant predictors of early growth among the variables that were examined. Infants who had required more intensive medical care during the neonatal period showed a slower growth rate than the more robust infants. Breast-fed infants grew slower from birth to term, but thereafter grew significantly better, resulting in no discernable difference over the whole 5-7 month period. None of the infant behavioural, maternal or social variables examined appeared to be related to early growth. Infants who were born lighter-for-gestation grew faster than the infants who were heavier for gestational age. At the 18-month follow-up assessment this very preterm sample performed poorly overall in comparison to published norms for full term infants. When regression analyses were performed, weight at 3-months of age was found to be predictive of developmental status at 18-months (even when concurrent weight was taken into account), whereas actually being born growth retarded was not found to be a risk factor for poorer developmental outcome. This supports the concept of a "sensitive period" during the first few months of life, when growth rate may influence developmental outcome. Other significant predictors of developmental outcome were gender, early brain scan and mean parental height.

The purpose of this study was to conduct a qualitative case study using secondary data on four mothers with premature infants in a home visitation intervention group. Three data points were collected on each mother and infant: the health of the infant, the quality of attachment as seen in play interactions, and maternal life circumstances such as depression, social support and use of community resources. The data was looked at prenatally up until the infants were 15 months old. The results indicated that all four infants were relatively healthy across the first year of their lives. Three out of the four mothers had a secure attachment with their premature infants at 12 months of age and one mother was at risk for an insecure attachment. All four mothers demonstrated some positive play interactions; however, one mother in particular demonstrated low involvement. Of the four mothers, one was highly depressed, and the other three mothers were minimally to moderately depressed. The four mothers were also in a marital or partner relationship, and all reported satisfaction in their support systems as well as very similar uses of community resources. The results of this study can be used to assist Home Visitors in understanding the need to help mothers improve their interactions with their premature infants and to encourage the Home Visitors to refer the mothers who show any signs of depression.
B.S.
Bachelors
Education and Human Performance
Teaching, Learning and Leadership

Thesis (Ph. D.)--University of Sydney, 2003.
Includes tables and questionnaires. Title from title screen (viewed Apr. 28, 2008). Submitted in fulfilment of the requirements for the degree of Doctor of Philosophy to the Centre for Perinatal Health Services Research, School of Public Health. Includes bibliography. Also available in print form.

Human milk fortification is recommended to meet the nutritional requirements of preterm infants. Most human milk fortifiers (HMFs) contain non-protein energy (NPE) predominantly as carbohydrate which may lead to high fat deposition relative to lean mass accretion. We hypothesized that fortifying human milk with a HMF containing NPE predominantly as fat (fatHMF) would result in a higher (1) lean mass accretion (percent lean mass) and (2) growth (anthropometry), compared to fortifying with an isocaloric, isonitrogenous HMF containing NPE predominantly as carbohydrate (carbHMF). In a double-blind randomized trial, 29 infants (≤32 weeks and appropriate for gestational age) admitted to the Neonatal Intensive Care Unit received either mother's milk fortified with the fatHMF (n = 14) or the carbHMF (n = 15). Body composition and growth measurements were performed at Baseline (at ≤10% of goal intake 150 ml/kg), Phase 1, and Phase 2 (3 weeks and 6 weeks, respectively, from starting HMF). Although neither percent lean (fat) mass nor growth were statistically different, by Phase 2 infants receiving fatHMF showed a 63% increase in percent fat mass, gained 1194 g in weight and 8.8 cm in length, whereas the carbHMF showed a 96% increase in percent fat mass, gained 1005 g in weight and 6.9 cm in length (p = 0.3586, 0.3815, and 0.1851 respectively). By Phase 2, the fatHMF infants gained 128 g in absolute dry lean tissue, whereas the carbHMF infants gained 99 g (p = 0.0362, Post hoc analysis). Differences of this magnitude are clinically important, but a larger study is required to demonstrate statistical significance.

A soft, light-weight, beige, stuffed toy was placed in direct body contact with stable, 30-34 wk gestation infants. Length of hospitalization, l activity level, length of time to return to birth weight, and parent visiting rate were recorded for the randomly assigned 10 experimental and 10 control infants. Contrary to predictions, significant differences were found in the length of hospitalization and weight gain, with the control group being discharged sooner and returning to birth weight faster. No significant differences occurred in the parent visiting rate, and only minimal positive results were seen in the activity level for the experimental group. The disproportionate number of younger, smaller, sicker infants in the experimental group was believed to be a reason for these unexpected results.

Background. Due to the increase in the rate of premature birth in the U.K., research into investigating psychological distress in parents of premature infants is clinically important. It has been identified that there is an absence of research in the area of psychological distress (anxiety, depression and trauma) in parents, particularly in fathers' of premature infants. Attachment theory states that templates of personal attachment are repeated from parents to children. Parents who have difficulty in forming an attachment with their newborn may be more likely to be psychologically distressed. Aims. The principle aim of the study was to understand the relationship between personal attachment style, psychological distress and trauma and the process of attachment in the postnatal period in the parents of premature infants. It aimed (1) to examine the most common personal attachment style of parents of premature infants, (2) to investigate, changes in psychological distress (anxiety, depression and trauma) for parents post birth and 3-4 months later, (3) to investigate the relationship between psychological distress (anxiety, depression and trauma) and parents own personal attachment style, (4) to investigate any changes in parents attachment to their infant post birth and 3-4 months later, and (5) to investigate the relationship between parental attachment to their infant and psychological distress (anxiety, depression and trauma). Method. Thirty-Two mothers and twenty-one fathers were recruited through neonatal intensive care units in two regional hospitals after the birth of their premature infant. Participants were also contacted 3-4 months later, twenty-two mothers and thirteen fathers completing and returning postal questionnaires. Findings. The participant group reported low scores on both the anxious and avoidant subscales of the Experience of Close Relationship-Revised (ECR-R) Questionnaire. Therefore, indicating that the participant group are securely attached. Results revealed that overall; parents of premature infants had lower levels of anxiety and depression at Time 2 (3-4 months post-partum) in relation to Time 1 (after the birth of the infant). However, parents reported higher levels of posttraumatic stress symptoms at Time 2 in comparison to Time 1. Additionally, mothers of premature infants reported higher levels of psychological distress (anxiety, depression and posttraumatic stress symptoms) at both Time periods in comparison to fathers. Mothers' anxiety scores (as measured by the HADS) reached caseness at Time 1. However, mothers' scores reduced significantly at Time 2. In relation to personal attachment style and changes in level of psychological distress, findings indicated a relationship. Mothers with lower avoidant scores reported a decrease in scores on the EPDS from Time 2 to Time 1. With respect to the relationship between changes in parental post-natal attachment and psychological distress, the overall findings suggest lower scores in three components of the Parental Post-Natal Attachment Scale (Tolerance, Pleasure in Proximity and Acceptance) at Time 2 in comparison to Time 1. However, the findings suggest higher scores on the Competence component of the Parental Post-Natal Attachment Scale at Time 2 in comparison to Time 1. Additionally, the findings highlighted a significant relationship between differences in both mothers' Competence scores and HADS depression scores. The findings also propose a significant relationship between changes in both Pleasure in Proximity scores and HADS anxiety and depression scores Conclusion. The findings highlight the importance of assessing parents' levels of psychological distress after the birth of their infant. Additionally, the findings highlight the importance of including fathers' of premature infants in the post-care of their infants to encourage positive interactions with their infant and thereby enabling them to gain from being in close proximity to their infant. Therefore, the findings highlight the importance of continued care for parents post-discharge as the findings indicate that the parents experience difficulties at both follow-up and in NICU.

Thesis (M. Tech. (Clinical Technology)) -- Central University of technology, Free State, 2012
Introduction: Reference ranges for cardiac measurement are available for adults, children and term infants but the same cannot be said for preterm or small for gestational age (SGA) infants surviving as a result of modern intensive care units. No published data of reference ranges for preterm infants exists for the South African population. Infants with congenital heart disease are twice as likely to be small for their gestational age and these reference ranges may affect clinical management decisions, therapeutic response and prognosis of these neonates. The aim was thus to establish reference ranges for cardiac dimensions and functional values for preterm and low birth weight infants for central South Africa and compare them with international standards. Methods: A total of 290 infants of less than 34 weeks of age and weighing less than 2500g at birth were examined during a twelve month period by echocardiography during the first 0-28 days of life. The study assessed normative cardiac measurements divided in M-Mode, 2-D and functional measurement for these infants in 3 weight groups. Exclusion criteria were applied to any condition affecting the size and functionality of the cardiac system. The following dimensions were measured: Standard M-Mode values for the left ventricle, 2D measurements of valve mitral and tricuspid orifices, as well as functional assessments including Shortening fraction (SF %), Ejection fraction (EF %), and Muscle performance Index (MPI)-index of the Left and Right ventricle. Measurements were done by the leading edge methodology following the ASE recommendations. A longitudinal study was also done to examine changes in these indices over the first month- on day 14 and day 28 of life. Interobserver differences were calculated for the variability between measurements of a single scan- 25 babies were re-measured and produced good repeatability. Results: 290 infants were included to produce Referance ranges of measurements (means and standard deviations) for 3 weight groups namely: <0.999g, 1000-1499g, and 1500g – 2500g. The gestational age’s ranges between 26-38 weeks with a median of 31 weeks, gender distribution was almost equal with a slight female preponderance. Body surface area ranged from a minimum from 0.076 m² and a maximum of 0.184 m², the body weight ranged between a minimum of 690g and a maximum of 2500g with a median of 1360g. Discussion: The left ventricular diastolic and systolic, interventricular septum, posterior wall, aortic and left atrium dimensions showed a proportionate increase in diameter with an increase in body weight There were no differences in cardiac dimensions between Small for Gestational age” (SGA) versus “Average for Gestational age” (AGA). Gender and race played no role in any functional measurements or with the cardiac sizes. Weight correlated well with BSA and the data suggest that weight only can be used to develop tables for clinical use. Cardiac chambers increased with BSA and weight and functional measurements stayed the same throughout the weight groups. Systolic and global functions were remarkably similar and constant throughout weight categories. . The longitudinal study also confirmed that the values are applicable to all low birth weight infants up to 28 days of age. Differences existed between some of the average South African infant’s cardiac chambers and international values. The Inter Ventricular Septum (IVS) and Posterior Wall (PW) measured thicker and the Left Atrium larger. This could be due to numerous factors that should be investigated further. Conclusion: The study emphasized the profound effect of growth and weight gain on the cardiac structure and that population specific reference values should therefore be developed and used.

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Fundação Oswaldo Cruz. Instituto Fernandes Figueira. Departamento de Ensino. Programa de Pós-Graduação em Saúde da Criança e da Mulher. Rio de Janeiro, RJ, Brasil
Objetivo do estudo é descrever sobre o neurodesenvolvimento de crianças nascidas pré-termo com idade gestacional inferior a 33 semanas nos primeiros dois anos de idade corrigida, avaliadas entre 18 e 24 meses de idade corrigida, através da Escala Bayley III. Estudo transversal realizado entre dezembro de 2010 e julho de 2011 em uma coorte de crianças nascidas pré-termo e acompanhadas no Ambulatório de Seguimento de Recém-nascidos de Risco do Departamento de Neonatologia do Instituto Fernandes Figueira. A coorte foi iniciada em 2005 com o objetivo de avaliar o desenvolvimento e o crescimento de prematuros nascidos com idade gestacional inferior a 33 semanas. Foram registradas informações sobre a história gestacional, do parto, dados antropométricos do recém-nascido, história neonatal, alimentar, sócio-econômica e familiar, evolução após a alta da Unidade Neonatal e os resultados obtidos na avaliação da Escala Bayley III. Foram avaliadas 104 crianças, sendo 45,2 % do sexo masculino e 21,2% pequenos para a idade gestacional, com a idade gestacional média de 29 semanas e 5 dias. A média do escore de linguagem (81,9) foi abaixo de -1 DP diferentemente da média dos escores cognitivo (93,7) e motor (91,1), que estavam entre ± 1 DP. Anormalidade no desenvolvimento da linguagem ocorreu em 50% das crianças, alteração motora em 25% e alteração cognitiva em 13%. Houve maior comprometimento na linguagem receptiva (3,3 pontos abaixo do padrão de referência). Não houve diferença no desenvolvimento motor, linguagem e cognitivo nas crianças PIG e AIG. O sexo masculino apresentou risco para o desenvolvimento anormal da linguagem e motor e a pneumonia foi fator de risco para escore baixo na linguagem. As razões de prevalência de escore cognitivo abaixo de 85, em relação a fatores de exposição perinatais e socioeconômicos, mostraram risco para pneumonia (RP 3,4 - IC 1,23-9,3) e APGAR inferior a 6 no quinto minuto (RP 3,6 - IC 1,07-12,0). Na avaliação do escore de linguagem, os fatores relacionados a resultados inferiores ao valor de 85 foram sexo masculino (RP 1,5 - IC 1,03-2,25), APGAR inferior a 6 no quinto minuto (RP 1,65 - IC 1,01-2,7) e pneumonia (RP 2,05 - IC 1,54-2,73), sendo a convivência com os pais um fator protetor (RP 0,48 - IC 0,23-0,98). Considerando o escore motor apenas o sexo masculino (RP 2,15 - IC 1,04-4,42) mostrou risco para anormalidade. Nenhum fator se mostrou significativo para anormalidade do escore cognitivo. Não houve influência da escolaridade paterna e materna, da presença da figura materna e da renda per capitanas médias dos resultados dos escores. A ausência da figura paterna mostrou risco para escore motor inferior a 85 (RP 2,96 - IC 1,55-5,6). Na análise multivariada nenhum fator se mostrou significativo para anormalidade do escore cognitivo. Em relação ao escore da linguagem, somente o sexo masculino e pneumonia mostraram risco para o desenvolvimento anormal, sendo que família do tipo única foi fator de proteção em relação à linguagem. Quanto ao risco para escore motor anormal somente foi significativo ser do sexo masculino. Na avaliação do desenvolvimento em pré-termos nascidos abaixo de 33 semanas de idade gestacional através da Escala Bayley III, o desenvolvimento da linguagem foi alterado, com escore abaixo da média, sendo 50% dos lactentes com atraso leve, porém as médias dos escores cognitivo e o motor foram normais. O desenvolvimento das crianças PIG e AIG foi semelhante nas 3 áreas estudadas e o sexo masculino foi fator de risco tanto para alteração motora quanto para linguagem. A média do escore bruto da linguagem receptiva foi inferior à média esperada para idade sem alteração na linguagem expressiva.
The purpose of the study is to describe the neurodevelopment of children born preterm with gestational age less than 33 weeks during the first two years corrected age, assessed between 18 and 24 months corrected age, with the Bayley Scale III. Cross-sectional study carried out between December 2010 and July 2011 in a cohort of children born preterm and followed up in the Follow Up Clinic of the Department of Neonatology of the Instituto Fernandes Figueira. This cohort was started in 2005 with the objective of assessing the development and growth of premature infants with gestational age less than 33 weeks. Information on history of pregnancy, birth, anthropometric data of the newborn, neonatal history, nutrition, socio-economic and family outcomes after discharge from the neonatal unit and the results obtained in the Bayley Scale III were recorded. 104 children were evaluated, with 45.2% male and 21.2% small for gestational age newborns, and the mean gestational age was 29 weeks and 5 days. The average language score (81.9) was below -1 SD differently from the average cognitive (93.7) and motor (91.1), which were within ± 1 SD. Abnormalities in language development occurred in 50% of children, motor disorders in 25% and cognitive impairment in 13% . There was greater impairment in receptive language (3.3 points below the standard). There was no difference in motor, language and cognitive development between SGA and AGA children. Male sex was risk for abnormal language and motor development, and pneumonia was a risk factor for low scores in language. The prevalence ratio for cognitive score below 85, in relation to perinatal and socioeconomic factors, showed risk for pneumonia (3.4 RP - CI 1.23 to 9.3) and APGAR less than 6 at the fifth minute (PR 3 , 6 - CI 1.07 to 12). In relation to language score below 85, the risk factors were male sex (PR 1.5 - CI 1.03 to 2.25), APGAR score less than 6 at the fifth minute (RP 1.65 - IC 1.01 to 2.7) and pneumonia (RP 2.05 - CI 1.54 to 2.73), and living with parents was a protective factor (RP 0.48 - CI 0.23 to 0.98). Considering the motor, score only male sex (PR 2.15 - CI 1.04 to 4.42) showed risk for abnormality. No factors were significant for abnormal cognitive score. There was no influence of maternal and paternal education, the presence of the mother and the income (per capita) in the average results of scores. The absence of a father figure showed risk for motor score less than 85 (PR 2.96 - CI 1.55 to 5.6). In the multivariate analysis, no factor was significant for abnormal cognitive score. In relation to language score, only male sex and pneumonia showed risk for abnormal development, and structured family was a protective factor in relation to language. The risk for abnormal motor score was significant only among males. In the assessment of development in preterm infants below 33 weeks gestational age using the Bayley Scale III, language development was altered with a score below the average, with mild delay in 50% of infants, but the mean cognitive and motor scores were normal. The development of AGA and SGA children was similar in the three areas studied and the male sex was a risk factor for both motor and language abnormality. The raw receptive language score was lower than expected for age with no abnormality in expressive language.

Los neonatos pretérmino presentan múltiples factores para padecer una desregulación del metabolismo de la glucosa, sobre todo en los primeros días de vida. Parece que los sistemas hormonales y enzimáticos para la regulación de la glucemia son inmaduros en estos pacientes incluso a la edad de término.Nuestra hipótesis es que en los recién nacidos muy prematuros (RNMP), el riesgo de presentar oscilaciones marcadas de la glucemia persiste en el momento del alta hospitalaria, lo que podría afectar a su desarrollo psicomotor. En nuestro estudio objetivamos la existencia de episodios de hiperglucemia e hipoglucemia asintomáticos en este grupo de pacientes sin poder determinar un perfil hormonal característico mediante monitorización subcutanea continua de glucosa (monitor ciego). No encontramos variables clínicas que puedan ser consideradas como factores de riesgo para presentar hipoglucemias pero parece que el retraso de crecimiento intrauterino (RCIU) y el sexo femenino son factores de riesgo para padecer hiperglucemias. Sobre este aspecto del estudio, decir a modo de conclusión que hemos demostrado que los RNMP al llegar a la edad de término, estando clínicamente estables y con nutrición enteral total, siguen siendo una población vulnerable a presentar anormalidades en la regulación de la glucemia (46.7% de la cohorte global presentan algún episodio de anormalidad de la glucosa), presentando hiper y/o hipoglucemias prolongadas (tiempo en hipoglucemia (media ± DE): 2.9 ± 2.8 horas/paciente afecto/periodo monitorización (PM); tiempo en hiperglucemia (media ± DE): 4.0 ± 4.0 horas/paciente afecto/PM) y repetidas (el 50% de los pacienets que presentan altersciones d elos niveles de glucosa tienen 2 ó más episodios). También construimos una curva de respuesta normal a la ingesta y realizamos diferentes curvas según tipo de alimentación y patrón de crecimiento intrauterino y extrauterino. Mediante estas curvas, objetivamos que aquellos pacientes con RCIU presentaron niveles significativamente inferiores que aquellos pacientes con un crecimiento correcto tanto al inicio como durante la toma, pero no en el momento de finalizar la toma ni en el periodo post-toma. Este hecho llama la atención ya que es en este último periodo cuando tienen lugar la mayoría de los episodios de hiperglucemia y la explicación que encontramos fue que existe una mayor variabilidad en las cifras de glucosa los estos RCIU. También demostramos que los pacientes alimentados mediate lactancia materna presentan cifras medias de glucosa significativamente superiores durante todo el ciclo de alimentación en comparación con los pacientes alimentados mediante leche de fórmula (LF). Este hecho podría ser explicado por el perfil hormonal de estos pacientes, ya que aquellos alimentados con LF presentan una insulinemia mayor con una concentración inferior de cuerpos cetónicos, lo que podría favorecer la entrada de glucosa al interior de la célula y, por consiguiente, daría lugar a unas cifras más bajas de glucosa a nivel del intersticio. Asimismo, vemos que la monitorización continua de glucosa es un método seguro, exacto y que este grupo de pacientes vulnerable tolera bien. Además, tiene un alto porcentage de lecturas congruentes con el método de referencia de este estudios (glucemia capilar), ya que tan sólo el 1 .7% de lecturas aisladas hubieran llevado a tratamiento incorrecto del paciente pero se debe tener en cuenta que, probablemente, al analizar las tendencias de la monitorización continua, los errores de tratamiento hubieran sido menores.
Disturbances in glucose homeostasis are prevalent disorders in Very Preterm (VPT) infants. In spite of evidence of frequent abnormal glucose levels in VPT infants during the first days of life and of delayed maturation of the metabolic pathways involved, there is a lack of data regarding the prevalence of glucose abnormalities in preterm babies at the time they leave hospital. Further knowledge in this area would be clinically relevant, given that both hypo and hyperglycemia have been associated to adverse outcomes. Therefore, we sought to determine if very preterm babies are capable of independently maintaining normal glucose levels at or near term postmenstrual age. To address this problem, we performed subcutaneous continuous glucose monitoring (blind monitoring) in a population of stable VPT babies who were about to be discharged home. In our study, we have shown that VPT infants continue to present abnormal glucose values (46.7% of the cohort), especially hyperglycemia, by the time of hospital discharge, being all of these episodes asymptomatic, persistent (hypoglycemia mean ± SD: 2.9 ± 2.8 hours/affected patient/monitoring period and hyperglycemia mean ± SD: 4.0 ± 4.0 hours/affected patient/monitoring period) and frequent (50% of the babies with abnormal glucose levels presented more than 2 episodes). We couldn’t demonstrate any specific hormonal profile in those patients with glucose abnormalities. No specific factors identify babies at higher risk for hypoglycemia, while intrauterine growth restriction (IUGR) and female gender seemed to predispose to hyperglycemia. Also, we represented with a chart the normal response to enteral nutrition in this population and we also constructed different charts in relation to intrauterine and extrauterine growth pattern and type of enteral feed. We demonstrated that those patients with IUGR had significant lower glucose values at the beginning and during the feed but they had no differences at the end and in the post-feed period; this profile could be explained because of a greater variability in glucose values in IUGR patients. In those patients nourished with mother milk, the glucose values in all the studied period were significantly higher than those of formula feed infants. This find could be related to the hormonal profile of these babies that consist in lower insulin with higher ketone bodies levels if we compare these molecules in relation to formula fed babies.

There is sparse literature about HIV transmission in preterm infants. Eighty-two HIV-exposed preterm infants received birth polymerase chain reactions (PCRs). Five (6.1%) were HIV positive with all 5 mothers receiving inadequate antiretrovirals. Of the PCRnegative infants, 9 died and 87% of the survivors received further PCR testing which remained negative. With correct care, intrapartum transmission of HIV can virtually be eliminated.

[Truncated abstract] There is a large body of evidence describing the benefits and risks, to the human fetus, of antenatal glucocorticoid treatment, but no published research on the effects on lactation. The withdrawal of progesterone, in the presence of high levels of endogenous glucocorticoids and prolactin, triggers the onset of copious milk secretion (lactogenesis II) at the end of pregnancy. The alteration of lactogenesis II by exogenous glucocorticoids could potentially have adverse impacts on postnatal nutrition in both term and preterm infants. I aimed to determine the effects of maternal antenatal glucocorticoid treatment on lactogenesis II in both ewes and women. I found profound adverse effects on lactation in ewes, and similar but more subtle effects on lactation in women . . . This thesis represents the first investigation of the effects of antenatal glucocorticoid treatment on lactogenesis II in both ewes and women. I found that, in ewes, antenatal glucocorticoid treatment stimulated premature lactogenesis II, and this was caused by disruptions to hormonal regulation during pregnancy. This event was followed by profound delays in lactogenesis II after term parturition. More subtle effects in women suggest that antenatal glucocorticoid treatment did not have a major, prolonged impact on postnatal lactogenesis II. Very preterm gestational age strongly predicted delays in lactogenesis II stressing the importance of assistance for these mothers when they are establishing lactation.

La present tesi es centra en analitzar aquells factors que poden incidir en el desenvolupament cognitiu en infants prematurs o a terme, i que han requerit que fossin ingressats a una Unitat de Cures Intensives Neonatals (UCIN). S’incorporaren a l’estudi tots aquells infants nascuts entre l’1 de gener de 2001 i 31 de desembre de 2008, quedant una mostra de 440 nens de les següents edats gestacionals: prematurs extrems (n = 30), molt prematurs (n = 125), prematurs moderats (n = 124), prematurs tardans (n = 130), i a terme complerts (n = 31). S’avaluaven els nens entre les 34 i 46 setmanes d’edat postmenstrual amb l’Escala de Brazelton (NBAS), i es va fer un seguiment als 3, 6, 9, 12, 18, 24 i 30 mesos administrant les Escales Bayley, i en els 3, 4, 5, 6 i 7 anys amb els tests Terman-Merrill i WPPSI-III. Els objectius generals que es marcaren foren: (a) descriure la morbiditat, comorbiditat i seqüeles associades a l’infant i comparar-les en funció de variables sociodemogràfiques i clíniques, (b) descriure el desenvolupament des del naixement fins als 4 o 7 anys en funció de variables sociodemogràfiques i clíniques (c) determinar els factors de risc que influeixen al desenvolupament i la comorbiditat, i (d) determinar els factors protectors que influeixen al desenvolupament i la comorbiditat. S’ha trobat que: els nadons que han patit estrès a la UCIN tenen puntuacions de QI(z) més baixes al llarg del període estudiat; la toxicitat neurobiològica de l’estrès afecta a tots els nadons ingressats a la UCIN i pot ser contrarrestada per les Cures Centrades en el Desenvolupament i la Família (CCD); la reducció de la sobreestimulació lumínica s’ha manifestat amb una reducció de les retinopaties; els nadons que van patir algun dels elements que configuraven el factor de risc d’estrès a la UCIN, si no varen rebre les CCD tenen puntuacions en la NBAS menys elevades en els clústers sistema motor, regulació d’estats, i estabilitat del sistema nerviós autònom, i més elevada en l’organització d’estats; els nadons que no varen rebre les CCD tenen un risc moderat de patir trastorns de la regulació que es superior als que sí varen rebre les CCD. El curs de desenvolupament cognitiu està més marcat per les setmanes de gestació que pel pes i la patologia soferta; en les proves cognitives les nenes puntuen més alt, però els nens augmenten el seu QI(z) en major mesura que no pas les nenes; en l’infant de famílies amb baixos nivells econòmics i educatius es minva el seu QI(z) a partir de l’exploració en el període de 10 a 18 mesos endavant; el grup de procedència autòctons tenen una puntuació tipificada del QI una mica més elevada en l’índex de desenvolupament que els estrangers, i en els períodes d’avaluació la diferencia és significativa en els períodes de 19 a 30 mesos i 31 a 59 mesos; els nadons que prenen llet de fórmula són els que més augmenten el diferencial del seu QI(z) en l’índex de desenvolupament, però els que són alletats amb llet materna són els que tenen puntuacions més elevades de QI(z) en tots i cadascun dels períodes d’avaluació. Pel que respecta a la comorbiditat, els grups de procedència tenen associacions significatives amb els trastorn psicofuncionals, on els autòctons tenen més incidència, i el trastorn de la relació parental, on els estrangers pateixen més aquest trastorn. L’efecte de l’impacte negatiu en el desenvolupament cognitiu degut als factors socials apareix en el període de 10 a 18 mesos, com són els trastorns de la relació parental i el nivell socioeconòmic baix, i en els 19 a 30 mesos si els pare i/o mare són estrangers; en els nadons i les famílies hi ha una relació entre estar ingressat a la UCIN i patir trastorns de la relació parental; que un professional passi la NBAS davant els pares suposa que apareguin menys trastorn de la relació parental; els trastorns de la relació parental estan associats amb els trastorns psicofuncionals i els trastorns emocionals; a més visites efectuades en el PSD més detecció de trastorns psicofuncionals i de trastorns emocionals.
his thesis focuses on analyse the causes that can affect cognitive development in premature and full term new-borns who have been admitted to a Neonatal Intensive Care Unit (NICU). Also, in the study are included children born between the 1st January 2001 and the 31st December 2008, altogether it consists of a sample of 440 new-born babies from the following gestational age: extremely premature (n = 30), very premature (n = 125), moderate premature (n = 124), late premature (n = 130) and full term (n = 31). Evaluates children between the age of 34 and 46 post-menstrual weeks using the Brazelton Scale (NBAS). It then follows them up at 3, 6, 9, 12, 18, 24 and 30 months using the Bayley scales, and then when they are 3, 4, 5, 6 and 7 years old using the Terman-Merrill tests and the WPPSI-III. The main objectives to achieve were: (a) To describe morbidity, comorbidity and side effects associated with a child and then compare them based on clinical and socio-demographic variables; (b) to describe the development from birth up to 4 or 7 years of age based on clinical and socio-demographic variables; (c) to identify the risk factors that influence the development and comorbidity and; (d) to identify the protective factors that influence the development and the comorbidity. The results display that children who have suffered stress in a Neonatal Intensive Care Unit (NICU) have lower IQ scores (z) in the period of this study; the neurobiological toxicity caused by the stress affects all children admitted to the NICU, and it could be neutralised with healing based on physiological development and care, and assisting the family. For instance, reducing overstimulation of light has shown to reduce retinopathy; the children who suffered some elements of the stress risk factor in the NICU, if they did not have the Family-Focused Developmental Care (FFDC), were found to have had lower scores in the NBAS in the clusters motor system, regulation of states and stability of the autonomous nervous system and higher scores in the organization of states. It is also found that babies who did not receive the FFDC had a moderate risk of suffering from regulated disorders in comparison than those who received it. The course of cognitive development is more affected by the weeks of gestation than the weight and pathology. In cognitive tests, girls scored higher but boys increased their IQ(z) to a greater extent than girls. It was found that children in families with low economic and educational levels, had a decrease in the IQ(z) from the exploration to the period of 10 to 18 months. The locals had IQ scores slightly higher on the development index than foreigners, and the difference is significant between the periods of 19 to 30 months and 31 to 59 months. Concerning the comorbidity factor, local groups have significant associations with psycho-functional disorders while foreigners suffer more from parental relationship disorders. There are more chances for a baby to be breast-fed after being born if the baby has more weeks of gestation, for it gains more weight and consequently it has more protective factors. With less weeks of pregnancy, the risk factors are higher and the probability of artificial feeding increase. The effect of the negative impact on cognitive development is due to social factors, such as relationships and low socioeconomic status, that appear in the period of 10 to 18 months. Also, the impact of whether the one of the parents or both are foreigners appears between 19 to 30 months. There is a relationship between being admitted to the NICU and children and families that have disrupted parental relationship. The administration of the NBAS by a professional with the parents present, has resulted with less parental relationship disorder. Keeping in mind, disorders associated with parental relationships are fundamentally psycho-functional and emotional disorders. Thus, this study has shown the more visits to the Tracking Development Program the more detection of psycho- functional and emotional disorders.

Orientador: Antonieta Keiko Kakuda Shimo
Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas
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Resumo: Este estudo foi desenvolvido pela necessidade de conhecermos melhor a mulher-mãe que, logo após o parto, além de ter seu filho levado para a Unidade de Tratamento Intensivo Neonatal (UTIN) por ter nascido prematuramente e precisar de cuidados especiais, tem a responsabilidade de suprir suas necessidades nutricionais. Trata-se de um estudo exploratório descritivo, com abordagem qualitativa e que tem como objetivo desvelar os fatores que influenciam o processo de manutenção da lactação em mães de recém-nascido pré-termo (RNPT) internado na UTIN de um hospital filantrópico do Estado de São Paulo, identificando as barreiras e fatores facilitadores para a manutenção da lactação e sua rede de apoio social. Os atores sociais de nossa pesquisa foram mães de RNPT internados na UTIN do hospital em estudo, as quais foram previamente orientadas pelos profissionais do Banco de Leite sobre como proceder para estimular e manter a lactação. A amostra foi definida por saturação de dados e a coleta foi realizada no Banco de Leite Humano (BLH) e na UTIN, utilizando-se dos seguintes instrumentos: a) entrevista semi-estruturada; b) observação participante; c) diário de campo. A análise dos dados foi realizada através do Discurso do Sujeito Coletivo. Nas entrevistas realizadas com as dezenove mulheres-mães, observamos que os principais problemas encontrados para manter a lactação foram a dificuldade no manejo da ordenha, mesmo com a bomba tira-leite; dor nos mamilos ao retirar o leite; dificuldade para levar o leite ao BLH; desconhecimento quanto à freqüência da retirada do leite; desconhecimento da importância do leite materno; estresse, ansiedade, tristeza causada por não ter o bebê em seus braços; falta de apoio dos profissionais e da família. Os fatores que facilitam a produção láctea foram abordados, podendo-se citar, entre eles, a possibilidade de permanência das mães na UTIN, assim como estas obterem informações sobre o estado de saúde de seu bebê; o apoio dos profissionais do BLH; a realização da ordenha com bomba tira leite; a mulher ser encorajada pelo marido; fazer o método canguru e ter conhecimento sobre como ordenhar a mama e sobre o processo de produção láctea. Em relação à rede de apoio, pode-se concluir que o marido ou companheiro é o principal incentivador e quem ajuda nos afazeres de casa. Assim, concluímos que o profissional de saúde tem um importante papel no incentivo ao aleitamento, exercendo a sua paciência, sabendo ouvir sem pré-julgamentos, revendo normas que dificultam a proximidade entre mãe e filho e utilizando o seu conhecimento para apoiar a mulher-mãe que, muitas vezes, não tem a quem recorrer e precisa de uma palavra de incentivo
Abstract: This study was developed in order to understand and know better the mother-woman, who right after the childbirth, not only has her son taken to the Neonatal Intensive Care Unit (NICU) for having been born prematurely and consequently needs special cares, but also has to supply her nutritional needs. This is a descriptive exploratory study, with a qualitative approach which is aimed to unveiling the factors that influence the breastfeeding maintenance process in mothers of pre-term newly born (PTNB), who stay in the NICU of a philanthropic hospital in Sao Paulo state, by identifying the obstacles and the factors that cooperate for breastfeeding maintenance and her social net support. The social partakers of our research were PTNB mothers in the NICU of the hospital in study, who were previously guided by Human Milk Bank (HMB) professionals about how to act for stimulating and keeping the breastfeeding on. The sample was defined by data saturation and the collection was done at the Milk Bank (MB) and NICU making use of the following tools: a) Semi-structured interview; b) Partakers¿ observation; c) Field diary. The data analysis was carried out through the Colletive Speech. In the interviews put into practice with the nineteen mother-women, we realized that the main existing problems in keeping the breastfeeding were: difficulty in drawing the milk from the breast, even making use of a nursing milk pump; pain on the nipples when removing the milk; difficulty in taking the milk to MB; lack of knowledge of how often the milk should be removed and its importance; stress; anxiety; sadness for not having the baby in their arms and lack of support from professionals and family. The factors that cooperate for breastfeeding maintenance were the possibility of having the mothers together with the babies in the NCTI and keeping them informed about their babies¿ health; more support from MB professionals; the use of a nursing milk pump; more encouragement by the husband/partner; the kangaroo method and more knowledge of how to draw the milk and of the breastfeeding process. As the net support, we concluded that the husband/partner is the most important person to motivate the mothers and help with household chores. Thus we came to the conclusion that health professionals have an important role in encouraging their patients to breastfeed, working with their patience, listening to them without pre-judgment, reviewing rules that make it difficult for the mothers to be near their babies and making use of their vast knowledge to support the mother-woman, who, very often, doesn¿t have someone to run to and needs a comfort word
Mestrado
Enfermagem e Trabalho
Mestre em Enfermagem

Infants’ sleep problems, especially, nighttime awakenings, are common concerns of parents and may have developmental implications for infants, particularly infants born prematurely. Between one quarter and one third of all children aged six months to five years of age experience sleeping problems. Many factors have been associated with the development of these problems, although none has been shown to be causal. Although theorists have hypothesized that insecure attachment between a mother and her child may lead to intense maternal involvement at bedtime (e.g., active physical comforting), which may be linked to the infant’s inability to develop sleep self-initiation skills, mothers’ styles of attachment with their infants, particularly an anxious style, have not been researched. France and Blampied’s model of infant sleep was used as the guiding framework to examine relationships between mothers’ attachment and bedtime behaviour and premature infants’ sleep. Using a cross-sectional design, data were collected from a community-based sample of 105 mothers of premature infants aged 5-6 months (gestationally corrected age). Boys represented 61% of the sample and 63% of the infants were first-born children. The main outcome measures were infants’ nighttime awakenings (frequency and duration) and mothers’ perceptions of the quality of their infants’ sleep. The mothers reported that 55% of their children had sleep problems (17% were considered serious). The reported mean frequency of awakening was 2.1 times per night and the mean duration was 45.7 minutes. Preterm infants’ nighttime awakening was associated with their mothers having an anxious style of attachment and intense involvement at bedtime. The mother’s style of attachment (anxious) and a maternal history of sleep problems were predictors of the duration of infants’ nighttime awakening. Intense maternal involvement and the infant’s birth order were significant predictors of the infants’ frequency of nighttime awakenings. This study directs healthcare providers to focus on maternal factors such as having an anxious style of attachment and over involvement in bedtime settling when assessing infants’ sleep problems. More research is warranted to explain the mechanisms of these associations and to determine whether they are causal in nature.

The purpose of this study was to (a) describe the physiological and behavioural responses of premature infants to a tissue-damaging stimulus and (b) determine how severity of illness and behavioural state influenced these responses. A convenience ample of 124 premature infants between 32 and 34 weeks gestational age was obtained from one neonatal unit in a Montreal teaching hospital. Physiological (heart rate, oxygen saturation, intracranial pressure) and behavioural (facial expression and cry) data were collected during the baseline, warming, stick and squeeze phases of a routine heelstick procedure. Behavioural state and severity of illness were assessed using instruments by Prechtl (1974) and Georgieff, Mills and Bhatt (1989). Demographic data were collected from the medical record. Data analysis was performed utilizing repeated measures multivariate analysis of variance (RM MANOVA), multivariate analysis of variance (MANOVA) and repeated measures multivariate analysis of covariance (RM MANOVA). There were significant differences in physiological and behavioural parameters between baseline and stick including: (a) an increase in maximum heart rate, (b) a decrease in minimum oxygen saturation, (c) an increase in intracranial pressure and (d) an increase in the proportion of all facial actions. For those infants who cried during both the stick and squeeze phase, the fundamental frequency, harmonic structure and peak spectral energy were significantly increased during the stick as compared to the squeeze. Behavioural state was found to modify the facial expression variables and severity of illness modified the acoustic cry variables. An interaction between behavioural state and severity of illness influenced maximum heart rate. There was no significant relationship between physiological and behavioural outcomes. Both categories of outcomes provide important but different information about the premature infant's response to a tissue-damaging stimulus. A multidimen

Prematurity is a common health issue worldwide. In Hong Kong, the rate of prematurity is in an increasing trend, from 4.7% in 1999 to 5.1% in 2004 (Tertiary-wide Obstetric & Gynecology Audit Report, 2004). Preterm infants are usually required to hospitalize in neonatal intensive care unit (NICU) which expose them to certain stressors such as noise, caregiver procedure, medical manipulations and pain (Harrison et al., 2003). Stress would lead to certain illnesses likes metabolic and cardiovascular disorders (Caldji, Diorio, & Meaney, 2000). Facing stress of preterm infants not only affects the developmental and neurodevelopment outcome but also increase the morbidity and mortality (Mitchell & Boss, 2002). Preterm birth is a complicated health problem which affects the infant itself and also increase the burden to society as it costs nearly US$26 billion dollars per year for both inpatient and outpatient care (Richard & Adrienne, 2007). Although there were many known benefits of massage therapy in premature infants and the safety of practicing was being acknowledged, massage therapy is still not being practiced in Hong Kong health care settings. Massage therapy was effective in reducing signs of stress on premature infants and could be performed by parents safely as evidenced by six researches (Dieter, Field, Hernandez-Reif, Emory, & Redzepi, 2003; Hernandez-Reif, Diego, & Field, 2007; Lee, 2005; Kuhn, Schanberg, Field, Symanski, Zimmerman, Scafidi, & Roberts, 1991; Smith, Kux, Haley, Beechy, & Moyer-Mileur, 2012; Wheeden, Scafidi, Ironson, Valdeon, & Bandstra, 1993). Based on the evidence, a new evidence-based practice was developed for reducing signs of stress of premature infant by using massage therapy in NICU. Implementation potential was reviewed in relation to target setting, transferability of findings and cost-benefit analysis. Implementation plan was developed. Stakeholders were identified and communication process was discussed in details. Pilot testing would be carried out to assess the feasibility of implementing the guideline. Finally, evaluation on patient, parents and healthcare providers’ outcome were required in implementing this new change smoothly.
published_or_final_version
Nursing Studies
Master
Master of Nursing