Trends in the prevalence of breastfeeding up to 6 months of age using structured data from routine child healthcare visits.

AIM: The Norwegian Action Plan for a Healthier Diet (2017-2021) set the target that 25% of infants should be exclusively breastfed for 6 months by 2022. Our aim was to determine trends in the prevalence and duration of breastfeeding in the municipality of Bergen. METHODS: Data on breastfeeding status in 2010-2018 were extracted from a standardised electronic medical record kept by public child health centres and recorded as exclusive, partial or none, at 6 weeks and 6 months of age. RESULTS: We found that 28,503 and 26,735 infants attended the 6-week and 6-month consultations, respectively. The prevalence of any breastfeeding was 92.0% at 6 weeks and 78.0% at 6 months with no trend over time between 2010 and 2018. The prevalence of exclusive breastfeeding at 6 weeks was 73.9% and stable over time, but it declined at 6 months, from 28.1% in 2010 to 11.1% in 2014 and remained stable thereafter. CONCLUSION: During 2010-2018, the prevalence of any and exclusive breastfeeding at 6 weeks and any breastfeeding at 6 months was stable. Exclusive breastfeeding at 6 months declined halfway through the study period, to a stable, but low, prevalence of 11.1% by 2014.

Early surfactant and non-invasive ventilation versus intubation and surfactant: a propensity score-matched national study.

OBJECTIVE: To compare outcome after less invasive surfactant administration (LISA) and primary endotracheal intubation (non-LISA) in infants born before gestational age (GA) 28 weeks. SETTING: All neonatal intensive care units (NICUs) in Norway during 2012-2018. METHODS: Defined population-based data were prospectively entered into a national registry. We compared LISA infants with all non-LISA infants and with non-LISA infants who received surfactant following intubation. We used propensity score (PS) matching to identify non-LISA infants who were similar regarding potential confounders. MAIN OUTCOME VARIABLES: Rate and duration of mechanical ventilation (MV), survival, neurological and gastrointestinal morbidity, and need of supplemental oxygen or positive pressure respiratory support at postmenstrual age (PMA) 36 and 40 weeks. RESULTS: We restricted analyses to GA 25-27 weeks (n=843, 26% LISA) because LISA was rarely used at lower GAs. There was no significant association between NICUs regarding proportions treated with LISA and proportions receiving MV. In the PS-matched datasets, fewer LISA infants received MV (61% vs 78%, p<0.001), and they had fewer days on MV (mean difference 4.1, 95% CI 0.0 to 8.2 days) and lower mortality at PMA 40 weeks (absolute difference 6%, p=0.06) compared with all the non-LISA infants, but only a lower rate of MV (64% vs 97%, p<0.001) and fewer days on MV (mean difference 5.8, 95% CI 0.6 to 10.9 days) compared with non-LISA infants who received surfactant after intubation. CONCLUSION: LISA reduced the rate and duration of MV but had no other clear benefits.

Modifiable and non-modifiable risk factors for obstetric anal sphincter injury in a Norwegian Region: a case-control study.

BACKGROUND: Obstetric anal sphincter injury (OASI) is a common and severe complication of vaginal delivery and may have short- and long-term consequences, including anal incontinence, sexual dysfunction and reduced quality of life. The rate of OASI varies substantially between studies and national birth statistics, and a recent meta-analysis concluded that there is a need to identify unrecognized risk factors. Our aim was therefore to explore both potential modifiable and non-modifiable risk factors for OASI. METHODS: We performed a case-control study in a single center maternity clinic in South-Eastern Norway. Data were extracted retrospectively from an institutional birth registry. The main outcome measure was the occurrence of the woman's first-time 3rd or 4th degree perineal lesion (OASI) following singleton vaginal birth after 30 weeks' gestation. For each woman with OASI the first subsequent vaginal singleton delivery matched for parity was elected as control. The study population included 421 women with OASI and 421 matched controls who gave birth during 1990-2002. Potential risk factors for OASI were assessed by conditional logistic regression analyses. RESULTS: The mean incidence of OASI was 3.4% of vaginal deliveries, but it increased from 1.9% to 5.8% during the study period. In the final multivariate regression model, higher maternal age and birthweight for primiparous women, and higher birthweight for the multiparous women, were the only non-modifiable variables associated with OASI. Amniotomy was the strongest modifiable risk factor for OASI in both primi- (odds ratio [OR] 4.84; 95% confidence interval [CI] 2.60-9.02) and multiparous (OR 3.76; 95% CI 1.45-9.76) women, followed by augmentation with oxytocin (primiparous: OR 1.63; 95% CI 1.08-2.46, multiparous: OR 3.70; 95% CI 1.79-7.67). Vacuum extraction and forceps delivery were only significant risk factors in primiparous women (vacuum: OR 1.91; 95% CI 1.03-3.57, forceps: OR 2.37; 95% CI 1.14-4.92), and episiotomy in multiparous women (OR 2.64; 95% CI 1.36-5.14). CONCLUSIONS: Amniotomy may be an unrecognized independent modifiable risk factor for OASI and should be further investigated for its potential role in preventive strategies.

Tracking of lung function from 10 to 35 years after being born extremely preterm or with extremely low birth weight.

BACKGROUND: Lifelong pulmonary consequences of being born extremely preterm or with extremely low birth weight remain unknown. We aimed to describe lung function trajectories from 10 to 35 years of age for individuals born extremely preterm, and address potential cohort effects over a period that encompassed major changes in perinatal care. METHODS: We performed repeated spirometry in three population-based cohorts born at gestational age ≤28 weeks or with birth weight ≤1000 g during 1982-85, 1991-92 and 1999-2000, referred to as extremely preterm-born, and in term-born controls matched for age and gender. Examinations were performed at 10, 18, 25 and 35 years. Longitudinal data were analysed using mixed models regression, with the extremely preterm-born stratified by bronchopulmonary dysplasia (BPD). RESULTS: We recruited 148/174 (85%) eligible extremely preterm-born and 138 term-born. Compared with term-born, the extremely preterm-born had lower z-scores for forced expiratory volume in 1 s (FEV1) at most assessments, the main exceptions were in the groups without BPD in the two youngest cohorts. FEV1 trajectories were largely parallel for the extremely preterm- and term-born, also during the period 25-35 years that includes the onset of the age-related decline in lung function. Extremely preterm-born had lower peak lung function than term-born, but z-FEV1 values improved for each consecutive decade of birth (p=0.009). More extremely preterm-than term-born fulfilled the spirometry criteria for chronic obstructive pulmonary disease, 44/148 (30%) vs 7/138 (5%), p<0.001. CONCLUSIONS: Lung function after extremely preterm birth tracked in parallel, but significantly below the trajectories of term-born from 10 to 35 years, including the incipient age-related decline from 25 to 35 years. The deficits versus term-born decreased with each decade of birth from 1980 to 2000.

Psychological health in preschool children with underweight, overweight or obesity: a regional cohort study.

Objective: To examine if underweight (UW), overweight (OW) or obesity (OB), or body mass index (BMI) expressed as its SD score (BMI SDS), were associated with psychological difficulties in preschool children. Design: Regional cohort study. Setting: Oppland County, Norway. Methods: At the routine school entry health assessment at 5-6 years of age, parents were invited to participate by local public health nurses. The parents completed questionnaires on sociodemographic, health and lifestyle factors of the child and the family, and on the child's neurocognitive development. They assessed psychological health with the Strengths and Difficulties Questionnaire (SDQ). Public health nurses measured weight and height on all eligible children and reported age, sex, height and weight anonymously for the children who declined to participate. Participants: We obtained information on 1088 of 1895 (57%) eligible children. The proportion of UW, OW and OB was slightly higher among the children who declined. Main outcome measures: SDQ subscale and Total Difficulties Scores. Results: The mean SDQ scores and proportion of scores ≥the 90th percentile had a curvilinear pattern from UW through normal weight (NW), OW and OB with NW as nadir, but the pattern was only significant for the mean Emotional problems, Peer problems and Total SDQ Scales, and for the Total SDQ Score ≥the 90th percentile (TDS90). After adjusting for relevant social, developmental, health and behavioural characteristics, TDS90 was only significantly associated with UW in multiple logistic regression analyses, and only with the lowest quartile of BMI SDS in a linear spline regression analysis. Conclusions: The study suggests that UW and low BMI, but not OW, OB or higher BMI, are independent risk factors for having psychological symptoms in preschool children.

Heart rate during the first 24 hours in term-born infants.

OBJECTIVE: Heart rate (HR) is an important clinical parameter in newborn infants, but normal ranges are poorly defined. Our aim was to establish normal reference ranges and individual variations in HR as obtained by auscultation in healthy term-born infants during the first 24 hours of life. DESIGN: Observational study. SETTING: Single hospital in Norway. METHODS: HR was assessed by auscultation for 30 s at 2, 4, 8, 16 and 24 hours of age. Auscultation was validated against ECG recordings. SUBJECTS: Healthy term-born infants who were asleep or awake in a quiet resting state. MAIN OUTCOME MEASURES: Construction of percentile curves for resting HR. RESULTS: The study included 953 infants. The 50th percentile was 126 beats per minute (bpm) at age 2 hours and thereafter 120-122 bpm. The respective 2nd and 98th percentiles were 102 (thereafter 96-100) bpm and 162 (thereafter 150-156) bpm. The mean HR was 5.6 bpm higher when awake than asleep, 4.9 bpm higher when on the mother's chest than in the cot, 1.6 bpm higher in girls than in boys, and increased by 0.5 bpm per 0.1°C increase in rectal temperature. Mode of delivery, meconium staining, birth weight and maternal smoking during pregnancy were of no significance. For each infant, HR varied considerably during the first 24 hours (intraclass correlation 0.21 (95% CI 0.18 to 0.24), coefficient of variation 9.2%). CONCLUSIONS: The HR percentiles allow for a scientifically based use of HR when assessing newborn infants born at term.

Voice and Exercise Related Respiratory Symptoms in Extremely Preterm Born Children After Neonatal Patent Ductus Arteriosus.

Objective: To investigate voice characteristics and exercise related respiratory symptoms in extremely preterm born 11-year-old children, focusing particularly on associations with management of a patent ductus arteriosus (PDA). Study design: Prospective follow-up of all children born in Norway during 1999-2000 at gestational age <28 weeks or with birthweight <1,000 g. Neonatal data were obtained prospectively on custom-made registration forms completed by neonatologists. Voice characteristics and exercise related respiratory symptoms were obtained at 11 years by parental questionnaires. Result: Questionnaires were returned for 228/372 (61%) eligible children, of whom 137 had no history of PDA. PDA had been noted in 91 participants, of whom 36 had been treated conservatively, 21 with indomethacin, and 34 with surgery. Compared to the children treated with indomethacin or conservatively, the odds ratio (95% confidence interval) for the surgically treated children were 3.4 (1.3; 9.2) for having breathing problems during exercise, 16.9 (2.0; 143.0) for having a hoarse voice, 4.7 (1.3; 16.7) for a voice that breaks when shouting, 4.6 (1.1; 19.1) for a voice that disturbs singing, and 3.7 (1.1; 12.3) for problems shouting or speaking loudly. The significance of surgery per se was uncertain since the duration of mechanical ventilation was associated with the same outcomes. Conclusion: Extremely preterm born children with a neonatal history of PDA surgery had more problems with voice and breathing during exercise in mid-childhood than those whose PDA had been handled otherwise. The study underlines the causal heterogeneity of exercise related respiratory symptoms in preterm born children.

No significant associations between breastfeeding practices and overweight in 8-year-old children.

AIM: The aim was to examine if breastfeeding practices were associated with body mass index (BMI) and risk of overweight or obesity in third grade (8 years) of elementary school. METHODS: In a regional cohort, we related BMI z-scores and presence of overweight or obesity at 8 years of age with ever being breastfed and with duration of exclusive and partial breastfeeding after adjusting for potential confounders. Parents completed questionnaires on breastfeeding and sociodemographic and lifestyle factors at school entry, and public health nurses measured height and weight. For non-participants, the nurses anonymously reported these measurements together with sex and age. RESULTS: 90% of participants had been breastfed. In adjusted analyses, BMI z-scores were not significantly related to whether or not the child had been breastfed (P = .64), or to the duration of exclusive (P = .80) or partial breastfeeding (P = .94). Logistic regression also showed no significant association between breastfeeding measures and overweight or obesity. CONCLUSION: This study on 8-year-old Norwegian children did not support a commonly held notion that breastfeeding reduces the risk of overweight or obesity.

A family-oriented intervention programme to curtail obesity from five years of age had no effect over no intervention.

AIM: To examine the effect of a family-oriented multidisciplinary intervention programme to curtail weight increase in young children with obesity. METHODS: Children who weighed more than one kilogram above the 97th percentile for height at the preschool assessment in Oppland County, Norway, were identified. Parents residing in one part of the county were invited to participate in a group-based three-year intervention programme while the rest had no interventions. Body mass index (BMI) and family characteristics at entry and measurements at birth were explanatory variables, and change in BMI standard deviation score (SDS) the outcome measure. For the intervention group, outcome was also related to skinfold thicknesses, waist-to-height ratio and physical ability. RESULTS: The programme was completed by 31 families in the intervention and 33 in the control group. At entry, the respective median (interquartile) age was 5.83 (0.36) and 5.74 (0.66) years, and the BMI SDS 2.35 (1.06) and 1.95 (0.49), P = .012. The median decrease in BMI SDS was 0.19 in both groups. The decline increased with increasing BMI SDS at entry, but irrespective of group. Social or behavioural factor or other anthropometric measures were not associated with outcome. CONCLUSION: The intervention programme had no effect on BMI SDS.

Parent psychological wellbeing in a single-family room versus an open bay neonatal intensive care unit.

BACKGROUND: Studies of parents' psychological well-being in single-family rooms in neonatal intensive care units have shown conflicting results. AIMS: To compare emotional distress in the form of depression, anxiety, stress and attachment scores among parents of very preterm infants cared for in a single-family rooms unit vs an open bay unit. STUDY DESIGN: Prospective survey design. SUBJECT: Parents (132) of 77 infants born at 28 0/7-32 0/7 weeks of gestation in the two units. OUTCOME MEASURES: Duration of parental presence was recorded. Scores for depression (The Edinburgh Postnatal Depression Scale), anxiety (The State-Trait-Anxiety Inventory, Short Form Y), stress (The Parent Stressor Scale: neonatal intensive care unit questionnaire and The Parenting Stress Index-short form) and attachment (Maternal Postnatal Attachment Scale) measured 14 days after delivery, at discharge, expected term date and four months post-term. RESULTS: Parents were present 21 hours/day in the single-family room unit vs 7 hours/day in the Open bay unit. Ninety-three percent of the fathers in the single-family rooms unit were present more than 12 hours per day during the first week. Mothers in the single-family rooms had a significantly lower depression score -1.9 (95% CI: -3.6, -0.1) points from birth to four months corrected age compared to mothers in the Open bay unit, and 14% vs 52% scored above a cut-off point considered being at high risk for depression (p<0.005). Both mothers and fathers in the single-family rooms reported significantly lower stress levels during hospitalization. There were no differences between the groups for anxiety, stress or attachment scores after discharge. CONCLUSION: The lower depression scores by the mothers and lower parental stress scores during hospitalization for both parents supports that single-family rooms care contribute to parents' psychological wellbeing.

Sex-related change in BMI of 15- to 16-year-old Norwegian girls in cross-sectional studies in 2002 and 2017.

BACKGROUND: The prevalence of overweight and obesity (OWOB) has stabilized in some countries, but a portion of children with high body mass index (BMI) may have become heavier. This study aimed to describe the distributions of BMI and the point prevalence of OWOB in Norwegian adolescents in 2002 and 2017. METHODS: A cross-sectional study involving 15- to 16-year-old adolescents in Oppland, Norway, was undertaken in 2002 and 2017. We calculated their BMI, BMI z-scores (BMIz), and the prevalence of OWOB. RESULTS: The mean BMI increased from 20.7 to 21.4 (p < 0.001) for girls but remained unchanged at 21.5 vs 21.4 (p = 0.80) for boys. The prevalence of OWOB increased from 9 to 14% among girls (difference 5, 95% CI: 2, 8) and from 17 to 20% among boys (difference 3, 95% CI: - 1, 6%). The BMI density plots revealed similar shapes at both time points for both sexes, but the distribution for girls shifted to the right from 2002 to 2017. CONCLUSION: Contrary to previous knowledge, we found that the increase in OWOB presented a uniform shift in the entire BMI distribution for 15-16-year-old Norwegian girls and was not due to a larger shift in a specific subpopulation in the upper percentiles.

Sleep problems, behavioural problems and respiratory health in children born extremely preterm: a parental questionnaire study.

OBJECTIVE: To explore whether children born extremely preterm (EPT) with different types of sleep problems had more behavioural and respiratory health problems than EPT children without sleep problems. DESIGN: Prospective, nationwide, questionnaire-based study. At 11 years of age, parents reported on four current sleep problems: difficulty falling asleep or frequent awakenings, snoring, daytime sleepiness and not recommended sleep duration (<9 hours). Behavioural problems were assessed by parents and teachers with the Strengths and Difficulties Questionnaire (SDQ). Parents assessed respiratory symptoms with the International Study of Asthma and Allergies in Childhood questionnaire and described use of asthma medication. SETTING: Norway. PATIENTS: EPT children. MAIN OUTCOME MEASURES: Specified sleep problems, behavioural problems and respiratory health. RESULTS: Data were obtained from 216 of 372 (58 %) of eligible children. All four specified sleep problems were associated with significantly higher parent-reported SDQ total-score (OR 1.1 for all), and except for not recommended sleep duration, also with higher teacher-reported SDQ total-score (OR 1.1 for all). Daytime sleepiness was strongly associated with wheezing last 12 months (OR 3.4), disturbed sleep due to wheezing (OR 3.9), wheeze during or after exercise (OR 2.9), use of inhaled corticosteroids or oral leukotriene modifiers (OR 3.4) and use of bronchodilators (OR 3.9). Snoring was associated with wheezing during or after exercise (OR 2.8) and current asthma (OR 4.2). CONCLUSION: EPT children with different types of sleep problems had more behavioural and respiratory health problems than EPT children without sleep problems.

Development and predictors of childhood mental health problems in former extremely preterm infants.

OBJECTIVE: To investigate development and predictors of mental health problems from five to eleven years of age in children born extremely preterm (EP). METHOD: In a national Norwegian cohort of children born before a gestational age of 28 weeks or with a birthweight <1000 g mental health was assessed by parents at five and eleven years of age using The Strengths and Difficulties Questionnaire. A Total Difficulties Score ≥ 90th percentile (TDS90) for a reference group was used as a measure of a mental health problem. Of 338 eligible EP children, 162 (48%) attended at both ages. RESULTS: The rate of TDS90 was 52 (32%) at five and 37 (23%) at eleven years of age (p = 0.025). Of the 52 children with TDS90 at five years, 25 had TDS90 at eleven years of age, and of 37 children with TDS90 at eleven, 25 had TDS90 at five years of age. Mental health problems and an IQ of 70-84 at five years were independent predictors of TDS90 at eleven years of age. CONCLUSION: The rate of mental health problems decreased from five to eleven years, but individual stability was moderate. Mental health problems and intellectual function in the lower normal range at preschool age were independent predictors of later mental health problems.

Comparison of physical activity and body composition in a cohort of children born extremely preterm or with extremely low birth weight to matched term-born controls: a follow-up study.

OBJECTIVES: To compare physical activity and body composition in a cohort of children born extremely preterm/extremely low birth weight (EP/ELBW) with term-born (TB) controls. METHODS: A regional cohort of children born during 1999-2000 at gestational age <28 weeks or with birth weight <1000 g and their individually matched TB controls were examined in 2010-2011. Information on physical activity was obtained from parental questionnaires, and body composition was determined by anthropometry and dual X-ray absorptiometry. RESULTS: Fifty-seven EP/ELBW and 57 TB controls were included at a mean age of 11.6 years. Compared with the TB children, the EP/ELBW-born children exercised less often (22% vs 44% exercised more than 3 days per week), had lower physical endurance and poorer proficiency in sports and play and were less vigorous during exercise (p<0.05). They also had lower values (mean; 95 % CI) for muscle mass (0.9; 0.3-1.5 kg), total bone mineral density z-score (0.30; 0.13-0.52 units) and fat mass ratio (0.14; 0.06-0.21 units). The association between physical activity and bone mineral and skeletal muscle mass accrual was significantly weaker for the EP/ELBW-born than the TB children. CONCLUSIONS: The EP/ELBW-born children were less physically active, had signs of an unfavourable body composition with less muscle mass and lower bone mineral density than the TB controls. The association between physical activity and the measures of body composition was weaker in the group of EP/ELBW-born children.

Single-family room design in the neonatal intensive care unit did not improve growth.

AIM: The aim was to compare growth in very premature infants cared for in a single-family room (SFR) and an open-bay (OB) unit. We recorded duration of parental presence and skin-to-skin contact as proxies for parental involvement in care of their infants. METHODS: We consecutively included infants with gestational ages 28 + 0 through 32 + 0 weeks at two hospitals in Norway, one SFR unit (n = 35) and one OB unit (n = 42). Weight, length, and head circumference were followed from birth to four months after term date. Both units adhered to the same nutritional protocol and methods of recording events. RESULTS: The SFR mothers spent a mean (standard deviation) of 111 (38) hours and the OB mothers 33 (13) hours with their infants during the first week and 21 (5) versus 7 (3) hours per day later. The respective duration of skin-to-skin care was 21 (10) versus 12 (8) hours during the first week and 4.2 (2) versus 3.0 (2) hours per day later. The differences were similar, but less pronounced for the fathers. The growth trajectories did not differ between the groups. CONCLUSION: SFR care was associated with more parental involvement, but not with better growth.

Survival and Impairment of Extremely Premature Infants: A Meta-analysis.

CONTEXT: Survival of infants born at the limit of viability varies between high-income countries. OBJECTIVE: To summarize the prognosis of survival and risk of impairment for infants born at 22 + 0/7 weeks' to 27 + 6/7 weeks' gestational age (GA) in high-income countries. DATA SOURCES: We searched 9 databases for cohort studies published between 2000 and 2017 in which researchers reported on survival or neurodevelopmental outcomes. STUDY SELECTION: GA was based on ultrasound results, the last menstrual period, or a combination of both, and neurodevelopmental outcomes were measured by using the Bayley Scales of Infant Development II or III at 18 to 36 months of age. DATA EXTRACTION: Two reviewers independently extracted data and assessed the risk of bias and quality of evidence. RESULTS: Sixty-five studies were included. Mean survival rates increased from near 0% of all births, 7.3% of live births, and 24.1% of infants admitted to intensive care at 22 weeks' GA to 82.1%, 90.1%, and 90.2% at 27 weeks' GA, respectively. For the survivors, the rates of severe impairment decreased from 36.3% to 19.1% for 22 to 24 weeks' GA and from 14.0% to 4.2% for 25 to 27 weeks' GA. The mean chance of survival without impairment for infants born alive increased from 1.2% to 9.3% for 22 to 24 weeks' GA and from 40.6% to 64.2% for 25 to 27 weeks' GA. LIMITATIONS: The confidence in these estimates ranged from high to very low. CONCLUSIONS: Survival without impairment was substantially lower for children born at <25 weeks' GA than for those born later.

Sleep Duration and Nocturnal Awakenings in Infants Born with Gestational Risk.

OBJECTIVE: Infants born with gestation-related risks (low birth weight (LBW), small for gestational age (SGA), and prematurely born infants) are faced with a cascade of developmental issues. The aim of this study was to investigate whether infants with gestation-related risks have different patterns of parent-reported sleep duration and nocturnal awakenings than children without these risk factors. METHODS: Information on sleep duration and nocturnal awakenings was obtained by parental report at age 6 and 18 months in the Norwegian Mother and Child Cohort Study, which is a population-based longitudinal pregnancy cohort study conducted at the Norwegian Institute of Public Health. Birth weight and gestational age were obtained from the Medical Birth Registry of Norway. Outcomes were related to birth weight, prematurity, and to being born SGA. RESULTS: A total of 75,531 mother-child dyads were included. Compared with children without gestational risks, children born SGA and with LBW had shorter sleep duration, whereas children born prematurely had longer sleep duration at both time points. The infants born SGA and with LBW, but not the prematurely born children, had fewer nocturnal awakenings at 6 months, but all had more awakenings at 18 months. CONCLUSION: Infants with gestation-related risks show distinct sleep patterns. We suggest that sleep assessment is included in the follow-up of high-risk infants. Future studies are needed to investigate the predictive value and functional importance of the sleep patterns for infants with gestation-related risks.