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Coming dissertations at MedFak

  • Targeting toddlers’ communication difficulties at the Swedish child health services – a public health perspective Author: Anna Fäldt Link: Publication date: 2020-11-18 13:54

    Communication is fundamental for human interaction. Communication difficulties have a negative impact on children’s learning, relations, and quality of life and are regarded as a public health problem. The Swedish child health services have a possibility to prevent communication difficulties and their consequences for the individual through universal interventions and identification of affected children. This thesis investigates interventions at the levels of universal prevention, identification, and indicated intervention for children with communication difficulties.

    Study I explored associations between family and child health centre characteristics and exposure to a universal preventive communication intervention. Questionnaires answered by 2326 mothers and 2077 fathers were analysed. Few parents reported that they had been exposed to the intervention. Positive associations were seen to high socioeconomic status and if the child was of low age at the start of the intervention or was oldest among siblings. Study II described the study design employed to investigate the identification and effects of an indicated intervention. Study III used a mixed-methods design to explore child health service nurses’ experiences and sense of competence when using the Infant-Toddler Checklist (ITC) at the 18-month health visit. The nurses considered the ITC to be a beneficial tool both in communicating with families and in identifying children with communication difficulties. The ITC seemed to enhance nurses’ and parents’ awareness of the child’s communication.

    In study IV, the psychometric properties of the ITC were analysed using data on 679 children. A sensitivity of 86% and specificity of 59% were found. These measures improved when combining the ITC with the child health service nurses’ informal developmental surveillance. Study V explored parents’ perceptions of the intervention ComAlong Toddler, consisting of five group sessions and two individual home visits. The parental intervention focused on responsive communication, enhanced milieu teaching and augmentative and alternative communication. Qualitative content analysis showed that parents appreciated the intervention and used the strategies taught. Parents described benefits of the combination of home visits and group sessions with peer learning through video recorded home assignments.

    In conclusion, the thesis shows that the ITC can be implemented in the child health services as the method identifies children with communication difficulties and seems to have preventive capabilities. ComAlong Toddler may help parents to implement communication-enhancing strategies with their children. When universal interventions are delivered through the child health services, implementation and distribution need to be carefully planned and carried out so that they reach all children.

  • Function and morbidity of the esophagus and respiratory system in the growing child with esophageal atresia Author: Felipe Donoso Link: Publication date: 2020-11-12 13:08

    Background: Esophageal atresia (EA) is a congenital malformation that consists of various degrees of discontinuity of the esophagus and affects about 1:3000 live births. EA is usually corrected at birth with survival rates over 90%, which has shifted the focus towards improvement of associated morbidity and health-related quality of life.

    The aims of this thesis were to investigate how morbidity in the esophagus and respiratory system in children with EA relates with diagnostic and function tests included in the follow-up programme after EA repair and evaluate the efficacy of the recommended proton pump inhibitor (PPI) prophylaxis.

    Methods: The study population consists of 169 children treated for EA in the Department of Pediatric Surgery at University Children’s Hospital, Uppsala between 1994 and 2018. The patients participated in the multidisciplinary follow-up programme that was established in 2011 for patients with EA. The thesis is based on four observational studies that investigated the outcome of the patients and generalisability of the results; risk factors for anastomotic strictures and the efficacy of PPI-treatment regimen in reducing its incidence; pulmonary function and risk factors for pulmonary function impairment; and association between ambulatory 24h pH test, endoscopic findings of esophagitis and hiatal hernia, symptoms of gastroesophageal reflux (GER), and histopathological esophagitis. The studies were approved by the Regional Committee for Medical Research Ethics.

    Results: The demographics and outcome of our study population are comparable with centres of higher caseload, showing low mortality rate but significant morbidity, especially considering anastomotic strictures and patients with long gap EA. Long gap EA, higher birth weight, and anastomotic tension were independent risk factors of anastomotic stricture formation. Prophylactic PPI-treatment did not reduce anastomotic strictures compared with symptomatic PPI-treatment. Respiratory morbidity and obstruction of the airways were common in children and adolescents after EA repair. The risk for pulmonary function impairment increased with lower birth weight and older age at follow-up. Neither ambulatory 24h pH-metry, clinical symptoms of GER nor endoscopic esophagitis were reliable tools to identify histopathological esophagitis in children and adolescents after EA repair and cannot replace esophageal biopsies.

    Conclusion: The poor correlation between clinical symptoms and morbidity of the esophagus and respiratory system justifies the need of clinical follow-up programmes in patients with EA. A general recommendation to stop prophylactic PPI-treatment after EA repair cannot be supported, however, sufficient evidence is available to support randomised controlled studies.

  • Care for the New-Born : Breastfeeding and Skin-to-Skin Contact Author: Paola Oras Link: Publication date: 2020-11-12 09:29

    Breastfeeding is associated with improved health in mothers and children and human milk is especially beneficial for preterm infants. The vast majority of pregnant women in Sweden intend to breastfeed, but breastfeeding rates are suboptimal, with even lower rates for preterm infants.

    The overall aim of this thesis was to describe breastfeeding patterns of preterm and term infants and to evaluate an intervention based on the Ten steps to successful breastfeeding on breastfeeding outcomes.

    In Paper I, mothers of preterm infants reported large variations in breastfeeding frequencies and patterns. The median breastfeeding frequencies from birth to six months ranged from 10–14 times per 24 hours with the majority practicing on demand breastfeeding.

    In Paper II the median daily duration of skin-to-skin contact in preterm infants during the hospital stay was associated with earlier breastfeeding attainment. Infants commenced full breastfeeding at a median postmenstrual age of 35+0 weeks (range 32+1 to 37+5). Breastfeeding duration was shorter than national statistics.

    Paper III describes the development and implementation of a breastfeeding support program for term and preterm infants using Intervention Mapping. The method was time-consuming, but allowed for a solid theoretical base, high involvement of stakeholders and was sufficiently comprehensive.

    Paper IV included term infants at age two months and their mothers and consisted of a baseline group and intervention group. Mothers reported large variations in breastfeeding frequencies and patterns. Mothers in the intervention group breastfed more frequently, in median 14 times compared to 11 times in the baseline group, and they also practiced on demand breastfeeding to a larger extent. Mothers with exclusive breastfeeding reported higher self -efficacy.

    This thesis provides a better understanding of breastfeeding patterns in preterm and term infants and it demonstrates that breastfeeding frequencies and on demand breastfeeding can be influenced with improved breastfeeding support. For preterm infants, breastfeeding attainment is facilitated by skin-to-skin-contact and they have the capability to breastfeed at a low postmenstrual age. This thesis also demonstrates a possible link between breastfeeding patterns and mothers’ ability to interpret infant cues. Intervention Mapping is a useful tool in the development of breastfeeding support programs.