Hands-on approach during breastfeeding support in a neonatal intensive care unit: a qualitative study of Swedish mothers' experiences

BACKGROUND: Assisting mothers to breastfeed is not easy when babies experience difficulties. In a neonatal intensive care unit (NICU), nurses often help mothers by using hands-on-breast without their permission. Little is known about how mothers feel about this unusual body touching. To gain more knowledge from mothers who lived through this experience, this hands-on practice was studied in a NICU in Sweden. METHODS: Between January and June 2001, in-depth interviews were conducted with ten mothers of preterm or sick term infants and all of them experienced the hands-on approach. In this research, Radnitzky's seven principles of hermeneutic interpretation were applied in order to interpret the meaning of mothers' responses. This article presents results related to the period of initiation of breastfeeding. This qualitative study was based on a combination of the models of Gustafsson, Orem, and Aarts' Marte Meo. RESULTS: Five main themes were identified: Insult to integrity, Manipulating the baby, Understanding and adjustment, Breasts as objects, Alternatives to this practice. Hands-on help in the breastfeeding situation was experienced as unpleasant and the women experienced their breasts as objectified. The mothers accepted the hands-on help given by nursing staff, even though they considered it unpleasant. Most mothers expressed a need for assistance when starting breastfeeding, but could not suggest any alternative to hands-on help such as demonstrating with an artificial breast and a doll. CONCLUSION: The study provides information about how mothers experience unexpected hands-on help with breastfeeding in a NICU, which has not been described previously. Since most mothers in this study regarded this behavior as unpleasant and not helpful mostly because it was unexpected and unexplained, it would be important to either explain beforehand to mothers what type of physical approach could be attempted on their body or better, to avoid this type of approach completely

Less is more: Antibiotics at the beginning of life.

Antibiotic exposure at the beginning of life can lead to increased antimicrobial resistance and perturbations of the developing microbiome. Early-life microbiome disruption increases the risks of developing chronic diseases later in life. Fear of missing evolving neonatal sepsis is the key driver for antibiotic overtreatment early in life. Bias (a systemic deviation towards overtreatment) and noise (a random scatter) affect the decision-making process. In this perspective, we advocate for a factual approach quantifying the burden of treatment in relation to the burden of disease balancing antimicrobial stewardship and effective sepsis management

Analysis of Antibiotic Exposure and Early-Onset Neonatal Sepsis in Europe, North America, and Australia.

IMPORTANCE Appropriate use of antibiotics is life-saving in neonatal early-onset sepsis (EOS), but overuse of antibiotics is associated with antimicrobial resistance and long-term adverse outcomes. Large international studies quantifying early-life antibiotic exposure along with EOS incidence are needed to provide a basis for future interventions aimed at safely reducing neonatal antibiotic exposure. OBJECTIVE To compare early postnatal exposure to antibiotics, incidence of EOS, and mortality among different networks in high-income countries. DESIGN, SETTING, AND PARTICIPANTS This is a retrospective, cross-sectional study of late-preterm and full-term neonates born between January 1, 2014, and December 31, 2018, in 13 hospital-based or population-based networks from 11 countries in Europe and North America and Australia. The study included all infants born alive at a gestational age greater than or equal to 34 weeks in the participating networks. Data were analyzed from October 2021 to March 2022. EXPOSURES Exposure to antibiotics started in the first postnatal week. MAIN OUTCOMES AND MEASURES The main outcomes were the proportion of late-preterm and full-term neonates receiving intravenous antibiotics, the duration of antibiotic treatment, the incidence of culture-proven EOS, and all-cause and EOS-associated mortality. RESULTS A total of 757 979 late-preterm and full-term neonates were born in the participating networks during the study period; 21 703 neonates (2.86%; 95% CI, 2.83%-2.90%), including 12 886 boys (59.4%) with a median (IQR) gestational age of 39 (36-40) weeks and median (IQR) birth weight of 3250 (2750-3750) g, received intravenous antibiotics during the first postnatal week. The proportion of neonates started on antibiotics ranged from 1.18% to 12.45% among networks. The median (IQR) duration of treatment was 9 (7-14) days for neonates with EOS and 4 (3-6) days for those without EOS. This led to an antibiotic exposure of 135 days per 1000 live births (range across networks, 54-491 days per 1000 live births). The incidence of EOS was 0.49 cases per 1000 live births (range, 0.18-1.45 cases per 1000 live births). EOS-associated mortality was 3.20% (12 of 375 neonates; range, 0.00%-12.00%). For each case of EOS, 58 neonates were started on antibiotics and 273 antibiotic days were administered. CONCLUSIONS AND RELEVANCE The findings of this study suggest that antibiotic exposure during the first postnatal week is disproportionate compared with the burden of EOS and that there are wide (up to 9-fold) variations internationally. This study defined a set of indicators reporting on both dimensions to facilitate benchmarking and future interventions aimed at safely reducing antibiotic exposure in early life

Perinatal HIV-1 infection : Aspects on clinical presentation, viral dynamics and epidemiology

During the last 20 years HIV-1 infection has changed from being an unknown disease to being a widespread pandemic, in some areas affecting a large proportion of the human population. Mother-to-child transmission (MTCT) is the predominant route of transmission in children, who thus become infected during a period when their immune system is immature and developing. This thesis is based on a prospective follow-up of a population-based cohort of children to HIV-1-infected women in Sweden since the start of the HIV-1 epidemic. We followed a total of 419 mother-child pairs between 1982 and 2003, 355 of them prospectively. The MTCT rate decreased during the period from 24.7% 1984-93 to 5.7% 1994-98 and 0.7% 1999-2003. The proportion of children born to women who received antiretroviral treatment or prophylaxis increased from 2.3% to 91.5%, and the elective caesarean section rate from 8.0% to 80.1%. Seventy-two children, 31 of whom were born in Sweden, were vertically infected. Eleven infected children died. Ten out of 51 children living in Sweden in 2003 had had an AIDS diagnosis and 29 were on antiretroviral treatment. Eleven lived with a non-parental caregiver. In 24 prospectively followed HIV-1-infected children born during 1985-98, the disease progressed faster to severe immunodeficiency, AIDS or death in children with early symptoms related to HIV-1 than in those without early symptoms. Detectable virus during the first four days of life was not shown to affect disease progression. Two children developed symptoms suggestive of primary HIV-1 infection. HIV-1 RNA load was determined in 32 infected children. The median HIV-1 RNA level was highest at 1.5-3 months of age, decreased between 1 and 8 years and then increased slightly. This pattern was not seen in all individuals. Both symptomatic and asymptomatic children displayed a varying pattern of viral load. Stored samples from 24 infected children were analysed for genetic subtype and coreceptor use of the virus. The virus belonged to subtypes A, B, C, D, G and CRF01_AE. All isolates from the first year of life used chemokine receptor CCR5 as coreceptor. In virus from four patients, the coreceptor use changed from CCR5 to CXCR4. The change was associated with a decreased CD4+ cell count and disease progression, but appeared after immunological deterioration. Infectious viral loads by limiting dilution culture and days-to-culture positivity (infectious index) and HIV-1 RNA were determined in 16 children. Limiting dilution correlated to the infectious index. The median HIV-1 RNA and infectious indices of plasma and PBMC rose rapidly to 6-8 weeks of age to a plateau level. The median index in plasma declined to zero by 2 years of age in contrast to that in PBMC and to HIV-1 RNA. A high-peak plasma index correlated with clinical progression. Children who progressed to AIDS had higher median plasma indices than those who did not. In children displaying a coreceptor change in plasma, there was a simultaneous reappearance of infectious virus, which was not related to changes in RNA. In summary, the virological studies contribute to a better knowledge of the natural course and interaction between virus and host in perinatally HIV-1 infected children. The epidemiological study shows that good results can be achieved if prophylactic measures against MTCT of HIV-1 are used consistently, which highlights the importance of antenatal screening programmes

Neonatal adaptation in infants prenatally exposed to antidepressants--clinical monitoring using Neonatal Abstinence Score.

BACKGROUND: Intrauterine exposure to antidepressants may lead to neonatal symptoms from the central nervous system, respiratory system and gastrointestinal system. Finnegan score (Neonatal Abstinence Score, NAS) has routinely been used to assess infants exposed to antidepressants in utero. AIM: The purpose was to study neonatal maladaptation syndrome in infants exposed to selective serotonin reuptake inhibitors (SSRI) or serotonin-norepinephrine reuptake inhibitors (SNRI) in utero. METHOD: Retrospective cohort study of women using antidepressants during pregnancy and their infants. Patients were identified from the electronic health record system at Karolinska University Hospital Huddinge containing pre-, peri- and postnatal information. Information was collected on maternal and infant health, social factors and pregnancy. NAS sheets were scrutinized. RESULTS: 220 women with reported 3rd trimester exposure to SSRIs or SNRIs and who gave birth between January 2007 and June 2009 were included. Seventy seven women (35%) used citalopram, 76 used (35%) sertraline, 34 (15%) fluoxetine and 33 (15%) other SSRI/SNRI. Twenty-nine infants (13%) were admitted to the neonatal ward, 19 were born prematurely. NAS was analyzed in 205 patients. Severe abstinence was defined as eight points or higher on at least two occasions (on a scale with maximum 40 points), mild abstinence as 4 points or higher on at least two occasions. Seven infants expressed signs of severe abstinence and 46 (22%) had mild abstinence symptoms. Hypoglycemia (plasma glucose <2.6 mmol/L) was found in 42 infants (19%). CONCLUSION: Severe abstinence in infants prenatally exposed to antidepressants was found to be rare (3%) in this study population, a slightly lower prevalence than reported in previous studies. Neonatal hypoglycemia in infants prenatally exposed to antidepressant may however be more common than previously described

Talking to children about their HIV diagnosis: a discussion rooted in different global perspectives

An online meeting was arranged with four professionals representing four countries to debate current practices and future steps in naming HIV to children (disclosing HIV status). This article considers the evidence and reports on the commentary and debate from the meeting. Naming HIV to children remains a challenge. Although studies identify some of the facilitators and barriers to informing children of their HIV diagnosis, further review of practice is required. This article presents a global perspective of naming practices from different settings. The article comprises commentary and a report of the online debate, along with supporting evidence. The four participating authors concluded that health professionals must work in collaboration with families to support early naming of HIV to children or having an open discussion about HIV in clinics. Naming when a child is younger reduces self-stigma and empowers children and young people to adhere to their medication, make informed decisions and share their own diagnosis appropriately. The authors concluded that health professionals play a key role in educating colleagues and the public to reduce stigma and discrimination. Professionals working with children and families living with HIV require support and resources to instil confidence in naming and facilitate naming of HIV status to a child

R5 HIV-1 with efficient DC-SIGN use is not selected for early after birth in vertically infected children.

Binding of HIV to C-type lectin receptors may either result in enhanced trans-infection of T cells or virus degradation. We have investigated the efficacy of HIV-1 utilization of Dendritic Cell-Specific Intercellular adhesion molecule-3-Grabbing Non-integrin (DC-SIGN), a C-type lectin receptor, in the setting of intrauterine or intrapartum mother-to-child transmission. Viruses isolated from HIV-1 infected mothers, at delivery, and from their vertically infected children, early after birth and later in disease, were analysed for use of DC-SIGN, binding and ability to mediate trans-infection. DC-SIGN-use of the child's early virus tended to be reduced as compared with the corresponding maternal isolate. Furthermore, the children's late isolate displayed enhanced DC-SIGN utilization compared with the corresponding early virus. These results were also supported in head-to-head competition assays and suggest that HIV-1 variants displaying efficient DC-SIGN-use are not selected for during intrauterine or intrapartum mother-to-child transmission. However, viruses with increased DC-SIGN-use may evolve later in paediatric HIV-1 infections

Neonatal characteristics of infants exposed to antidepressants in utero, born 1 Jan 2007 to 30 June 2009 at Karolinska University Hospital.

<p>*gestational age <37+0.</p><p>**other antidepressants (n = 33): escitalopram (13 patients), venlafaxine (11), paroxetine (8) and duloxetine (1).</p>†<p>p 0.02, statistical test (logistic regression, adjusting for gestational age, maternal tobacco use, infant sex and 5 min Apgar).</p><p>Neonatal characteristics of infants exposed to antidepressants in utero, born 1 Jan 2007 to 30 June 2009 at Karolinska University Hospital.</p

Characteristics of study population, women with antidepressant treatment and delivery at Karolinska University Hospital Huddinge Jan 2007 to June 2009.

≠<p>one patient can have more than one diagnosis.</p>≠≠<p>other psychiatric diagnoses, all antidepressants (n): Phobia (4), Post-traumatic stress disorder (4), Eating disorder (9), Personality disorder (6), Obsessive compulsive disorder (7), Bipolar disorder type II (1), Attention deficit hyperactivity disorder (3).</p><p>*stated by mother at interview with midwife in prenatal care center, gestational week 10–14.</p><p>**other antidepressants (n = 33): escitalopram (13 patients), venlafaxine (11), paroxetine (8) and duloxetine (1).</p><p>***Highest dose in maternal care records during third trimester.</p><p>NA  =  not applicable.</p><p>Characteristics of study population, women with antidepressant treatment and delivery at Karolinska University Hospital Huddinge Jan 2007 to June 2009.</p

Analyses of Neonatal Abstinence Score in infants exposed to antidepressants in utero, born at Karolinska University Hospital Huddinge 1 Jan 2007 to 30 June 2009.

<p>*two or more scorings of 4–7.</p><p>**two or more scorings of 8 or above.</p><p>***Multiple ordinal regression, adjusted for infant sex and 5 min Apgar.</p>†<p>Chi square test.</p>††<p>Kruskal Wallis.</p>≠<p>other antidepressants (n = 33): escitalopram (13 patients), venlafaxine (11), paroxetine (8) and duloxetine (1).</p><p>Analyses of Neonatal Abstinence Score in infants exposed to antidepressants in utero, born at Karolinska University Hospital Huddinge 1 Jan 2007 to 30 June 2009.</p