Outside looking in: the lived experience of adults with prematurely born siblings.

Siblings have unique relationships; however, not all sibling relationships are typical. In North America, the preterm birth rate ranks second only to Africa in a global climate of rising preterm birth rates. A paucity of literature exists for sibling relationships when one sibling is born prematurely. In this hermeneutic phenomenological study, we explored the lived experience of adult siblings with prematurely born, young adult brothers and sisters who subsequently developed disabilities. The 28 siblings, interviewed with open-ended questions, represented 47 families with extremely-low-birth-weight young adults with neurodevelopmental disabilities born between 1977 and 1982. Existential reflection guided by van Manen's human science approach assisted the analysis of tape-recorded conversations. A structure of meaning entitled "outside looking in" emerged to illustrate the extraordinary relationships forged by the adult siblings with their brothers and sisters throughout their years together.

Transition of extremely low-birth-weight infants from adolescence to young adulthood: comparison with normal birth-weight controls.

CONTEXT: Traditionally, educational attainment, getting a job, living independently, getting married, and parenthood have been considered as markers of successful transition to adulthood. OBJECTIVE: To describe and compare the achievement and the age at attainment of the above markers between extremely low-birth-weight (ELBW) and normal birth-weight (NBW) young adults. DESIGN, SETTING, AND PARTICIPANTS: A prospective, longitudinal, population-based study in central-west Ontario, Canada, of 166 ELBW participants who weighed 501 to 1000 g at birth (1977-1982) and 145 sociodemographically comparable NBW participants assessed at young adulthood (22-25 years). Interviewers masked to participant status administered validated questionnaires via face-to-face interviews between January 1, 2002, and April 30, 2004. MAIN OUTCOME MEASURES: Markers of successful transition to adulthood, including educational attainment, student and/or worker role, independent living, getting married, and parenthood. RESULTS: At young adulthood, 149 (90%) of 166 ELBW participants and 133 (92%) of 145 NBW participants completed the assessments at mean (SD) age of 23.3 (1.2) years and 23.6 (1.1) years, respectively. We included participants with neurosensory impairments (ELBW vs NBW: 40 [27%] vs 3 [2%]) and 7 proxy respondents. The proportion who graduated from high school was similar (82% vs 87%, P = .21). Overall, no statistically significant differences were observed in the education achieved to date. A substantial proportion of both groups were still pursuing postsecondary education (47 [32%] vs 44 [33%]). No significant differences were observed in employment/school status; 71 (48%) ELBW vs 76 (57%) NBW young adults were permanently employed (P = .09). In a subanalysis, a higher proportion of ELBW young adults were neither employed nor in school (39 [26%] vs 20 [15%], P = .02 by Holm's correction); these differences did not persist when participants with disabilities were excluded. No significant differences were found in the proportion living independently (63 [42%] vs 70 [53%], P = .19), married/cohabitating (34 [23%] vs 33 [25%], P = .69), or who were parents (16 [11%] vs 19 [14%], P = .36). The age at attainment of the above markers was similar for both cohorts. CONCLUSION: Our study results indicate that a significant majority of former ELBW infants have overcome their earlier difficulties to become functional young adults.

Kangaroo care is effective in diminishing pain response in preterm neonates.

OBJECTIVE: To test the efficacy of maternal skin-to-skin contact, or kangaroo care (KC), on diminishing the pain response of preterm neonates to heel lancing. DESIGN: A crossover design was used, in which the neonates served as their own controls. Subjects Preterm neonates (n = 74), between 32 and 36 weeks' postmenstrual age and within 10 days of birth, who were breathing without assistance and who were not receiving sedatives or analgesics in 3 level II to III neonatal intensive care units in Canada. INTERVENTIONS: In the experimental condition, the neonate was held in KC for 30 minutes before the heel-lancing procedure and remained in KC for the duration of the procedure. In the control condition, the neonate was in the prone position in the isolette. The ordering of conditions was random. MAIN OUTCOME MEASURES: The primary outcome was the Premature Infant Pain Profile, which is composed of 3 facial actions, maximum heart rate, and minimum oxygen saturation changes from baseline in 30-second blocks. Videotapes, taken with the camera positioned on the neonate's face so that an observer could not tell whether the neonate was being held or was in the isolette, were coded by research assistants who were naïve to the purpose of the study. Heart rate and oxygen levels were continuously monitored into a computer for later analysis. A repeated-measures analysis of covariance was used, with order of condition and site as factors and severity of illness as a covariate. RESULTS: Premature Infant Pain Profile scores across the first 90 seconds from the heel-lancing procedure were significantly (.002

Comparison of capillary blood sampling using an automated incision device with and without warming the heel.

OBJECTIVE: To determine if heel warming prior to heelstick increases the volume of blood collected compared to no warming. STUDY DESIGN: Randomized controlled trial involving 100 preterm and term infants requiring capillary blood sampling (CBS), randomized to receive warming (Control) (n=50) or nonwarming (Experimental) (n=50). RESULTS: This sample of infants showed no benefit of warming the heel prior to CBS. Volume of blood, collection time, crying time, and repeat procedures were not different between groups. More infants in the Control group received squeezing during the procedure compared to the Experimental group. CONCLUSION: Heel warming prior to CBS may be an unnecessary technique in preterm and term infants that expends nursing time and hospital financial cost.

Nonnutritive sucking in high-risk infants: benign intervention or legitimate therapy?

OBJECTIVE: To review the available research evidence on the effects of nonnutritive sucking (NNS) in high-risk full-term and preterm infants in neonatal nurseries. DATA SOURCES: Electronic searches of MEDLINE (1976-2001) and CINAHL (1982-2001) databases, as well as the Cochrane Library. Reference lists of all relevant articles were also reviewed. STUDY SELECTION: Experimental and quasi-experimental studies that included hospitalized full-term and preterm infants, where NNS by pacifier was compared to no pacifier. DATA EXTRACTION: Results of studies were reviewed by two of the authors. DATA SYNTHESIS: As an intervention to promote behavioral outcomes and gastrointestinal function or feeding, there is little evidence to support the use of NNS in preterm and high-risk full-term infants. NNS has been linked to reduced length of hospital stay and improved pain management. CONCLUSIONS: Although harmful effects have not been specifically studied, NNS in preterm and high-risk full-term infants does not appear to have any short-term negative effects. No long-term data on the effects of NNS in high-risk full-term and preterm infants are presently available. Based on the results of this review, it would seem reasonable for nurses to utilize pacifiers for pain management in high-risk full-term and preterm infants.

Impact of extreme prematurity on family functioning and maternal health 20 years later.

OBJECTIVE: The goal was to examine the impact of illness on families and the long-term effects on the health of parents of young adults (YAs) who were born with extremely low birth weight (ELBW), compared with normal birth weight (NBW) control subjects. METHODS: A longitudinal cohort study was performed. Participants were mothers of eligible ELBW and NBW YAs. Information was obtained with well-validated questionnaires. RESULTS: At young adulthood, 130 (81%) of 161 ELBW group and 126 (89%) of 141 NBW group mothers participated. There were no significant differences in scores between groups with respect to marital disharmony, family dysfunction, maternal mood, state anxiety, social support, depression, and maternal physical and mental health. The finding of no differences was unchanged when 27 YAs with neurosensory impairment (NSI) were excluded, except for family dysfunction scores, which were paradoxically lower for families with YAs with NSI. Although the impact scores revealed that significantly more parents of ELBW YAs were negatively affected with respect to their jobs and educational or training opportunities, mothers of ELBW YAs reported that the experience of caring for their child brought their family closer together and that relatives and friends were more helpful and understanding, compared with mothers of NBW YAs. Significantly more mothers of ELBW YAs with NSI, compared with those without NSI, felt better about themselves for having managed their child's health. CONCLUSION: It seems that, by young adulthood, there is a minimally negative long-term impact of having an ELBW child in the family, regardless of the presence of NSI.

Risk-Scoring Tool for respiratory syncytial virus prophylaxis in premature infants born at 33-35 completed weeks' gestational age in Canada.

OBJECTIVE: To study the impact of the Risk-Scoring Tool (RST) as a strategy for targeting prophylaxis effectively in 33-35-week gestational age (GA) Canadian infants who range from low to high risk by evaluating the subsequent incidence of respiratory syncytial virus (RSV) infections resulting in emergency room (ER) visits and hospitalization. DESIGN: Prospective, descriptive study. SETTING: McMaster Children's Hospital and St Joseph's Healthcare in Hamilton, Ontario. PARTICIPANTS: Premature infants between 33 and 35 weeks' completed gestation who were less than 6 months' chronological age at the start of, or during, the local 2005-2008 RSV winter seasons. METHODS: A validated, Canadian RST was used to calculate a total risk score based on seven risk factors. Only infants at moderate (RST score 49-64) and high risk (RST score 65-100) received palivizumab at monthly intervals from November to April and were followed during the respective RSV seasons. All parents received information on RSV prevention at hospital discharge. Parents of all recruited infants were contacted by telephone in May at the end of each season, and medical records were checked to determine ER visits for RSV-related respiratory tract infections and RSV hospitalization. Means, standard deviations, ranges, and percents were used to describe the variables for patients enrolled in the study. RESULTS: Over 3 years, 430 infants were recruited. Of these, 346 (81%), 57 (13%), and 27 (6%) were in the low-, moderate- and high-risk categories, respectively, based on their risk scores. A total of 78 (18.1%) infants received full courses of palivizumab. Six out of 57 (10.5%) infants in the moderate-risk group did not receive prophylaxis, while all 27 high-risk group infants received palivizumab. Seven (1.6%) infants were RSV-positive and five (low-risk) infants were hospitalized. One high-risk, RSV-positive infant, was seen in the ER, and discharged home. There were no statistical differences in the number of infants with RSV-related ER visits and hospitalizations within the risk category groups (p = 0.43). The limitations of this study include the observational design and the relatively small sample size. CONCLUSIONS: The RST is a practical, easy-to-use instrument to guide judicious RSV prophylaxis for moderate-high-risk, 33-35-week GA infants. It is cost-effective, reducing hospitalization in infants who are most 'at-risk', while avoiding prophylaxis in a large segment (81.9%) of this GA cohort who are considered low risk for RSV infection.

Predictive value of the respiratory syncytial virus risk-scoring tool in the term infant in Canada.

BACKGROUND: Palivizumab prophylaxis against respiratory syncytial virus (RSV) infection has been widely adopted for high-risk infants during the RSV season, based on country-specific guidelines. OBJECTIVE: To determine if a validated, risk-scoring tool (RST), can be applied to term, RSV-positive infants seen in the emergency room (ER) to predict need for hospitalization, in order to target prophylaxis cost effectively at a selected group of children. DESIGN: Retrospective, descriptive study. SETTING: McMaster Children's Hospital in Hamilton, Ontario, Canada. PARTICIPANTS: A total of 72, consecutive, term, RSV-positive cases were identified retrospectively, from November through April during the 2006-2007 RSV season. METHODS: A questionnaire/chart review was conducted on 68 of 72 cases, to determine risk categories based on the RST. Four, trained abstractors, extracted pertinent data from the medical records of RSV-positive patients. Means, standard deviations (SD), and percents were used to describe the study variables for hospitalized and ER patients discharged home. Chi-square tests were used to compare infants' risk factors to hospitalization. ANOVA was used for comparisons within and between risk groups and RST scores. A p-value of <0.05 was considered statistically significant. RESULTS: The majority of infants scored in the low-risk category (n = 44), versus moderate (n = 16) or high risk (n = 8). Within the low-risk category, 27 (61%) of children were admitted to hospital compared to 17 (39%) who were treated in the ER and discharged home. The mean RST scores for those admitted to the pediatric intensive care unit/ward, the ward only, or those discharged home from the ER were 48.3 (n = 10), 41.0 (n = 36), and 36.5 (n = 22), respectively (p = 0.17). The mean number of risk factors for those discharged home versus hospitalized patients was 2.5 (1.3) and 2.97 (1.13), respectively (p = 0.15). Only two of eight cases in the high-risk group required intensive care. CONCLUSIONS: Overall, the risk-scoring tool did not discriminate between low versus moderate- to high-risk RSV-positive term infants who require hospitalization which has cost implications, since universal prophylaxis of this cohort would be financially prohibitive. A larger study is necessary to establish risk factors that more accurately determine RSV hospitalization among term infants.

Development and evaluation of an instrument to measure parental satisfaction with quality of care in neonatal follow-up.

OBJECTIVE: The goal of this study was to develop and subsequently evaluate the psychometric properties of a new discriminative instrument to measure parental satisfaction with the quality of care provided in neonatal follow-up (NFU) programs. METHOD: The methodological framework for developing and evaluating measurement scales described by Streiner and Norman (Health Measurement Scales: A Practical Guide to Their Development and Use. 3rd ed. New York: Oxford University Press; 2003) was used for the study. Informing the phases of the research was a sample of 24 health care professionals and 381 parents who use NFU services. RESULTS: A comprehensive list of items representing the construct, parental satisfaction with quality of care, was generated from published reliable and valid instruments, research studies, focus groups with health care experts, and focus groups with parents. Using a clinimetric approach, the 62 items generated were reduced to 39 items based on parents' ratings of importance and refinement of the items by the research team. After content validation and pretesting, the instrument was tested with parents and underwent item-analysis. The resulting 16-item instrument was composed of 2 subscales, Process and Outcomes. Evaluation of the instrument's psychometric properties indicated adequate test-retest reliability (intraclass correlation coefficient = 0.72) and internal consistency (Process subscale, alpha = 0.77; Outcomes subscale, alpha = 0.90; overall instrument, alpha = 0.90), as well as good content and construct validity. A confirmatory factor analysis supported the multidimensionality of the construct. CONCLUSION: This new instrument provides clinicians and policy-makers with a tool to assess parental satisfaction with the quality of care in NFU, so areas of dissatisfaction can be identified and changes implemented to optimize service provision.

Health status and health service utilization of infants and mothers during the first year after neonatal intensive care.

PURPOSE: To describe the self-reported health status of mothers and maternal report of their infants' health problems at 3, 6, and 12 months after the infant's discharge from the neonatal intensive care unit (NICU) and to describe the self-reported utilization of health resources and services during the first year of the infants' life. SUBJECTS: One hundred fifty-two mothers of 165 infants who were admitted to the NICU. DESIGN: Descriptive longitudinal study that was part of a larger project that investigated changes in family function during the first year after the birth of an infant requiring neonatal intensive care. METHODS: Mothers were asked to complete the study questionnaires at 3, 6, and 12 months after the infants' discharge from the NICU. MAIN OUTCOME MEASURES: Maternal health status (1 question from the Short Form-12 Health Survey); health service utilization of mothers and their infants (components of the Health and Social Service Utilization Questionnaire adapted for postpartum women and their newborn infants); and mother's report of infant's health problems and infant's re-hospitalization(s) (form developed for current study). PRINCIPAL RESULTS: The majority of mothers described their current health to be excellent or very good (73%, 64%, and 73%, at 3, 6, and 12 months, respectively). Approximately half of the mothers indicated that their infants had a variety of health problems during each of the 3 time periods after NICU discharge. Use of health services was reported by the largest proportion of mothers in the 3 months after discharge, with physicians being the most heavily used group at each of the 3 time periods (72%, 36%, and 45% at 3, 6, and 12 months, respectively). According to maternal report, few infants were readmitted to hospital at any time period (14%, 6%, and 10% at 3, 6, and 12 months, respectively). CONCLUSIONS: Few mothers of high-risk infants in the current study reported poor health. About half of the sample reported their infants to have health problems during the first year of life. Mothers reported use of more health services during the first 3 months following their child's discharge than during the latter part of the first year. Mothers also reported using more health services for their infants in this time period compared with the later time periods. By maternal report, few infants were rehospitalized in any time period.

Parent as proxy reporting: implications and recommendations for quality of life research.

Improved disease management in children has resulted in an increased interest in the quality of life in children. Quality of life research in children may enlist either the substitute or complementary perspective. Much of the quality of life literature has been guided by the substitute perspective, which infers that parents may best report their child's quality of life. However, the complementary perspective values both parent and child perspectives equally. The purpose of this article was to critically review the quality of life literature with respect to children with diabetes. Limitations in the literature were addressed as conceptual and methodological, demographic, and underlying proxy perspectives. Benefits and limitations of quality of life measurements and perspectives were also discussed. Recommendations and future implications for quality of life research in children extend current understanding from both substitute and complementary perspectives.

Comparison of current health, functional limitations, and health care use of young adults who were born with extremely low birth weight and normal birth weight.

OBJECTIVE: The objective of this study was to compare the current health status, physical ability, functional limitations, and health care use of extremely low birth weight and normal birth weight young adults. METHODS: A longitudinal study was conducted of a population-based cohort of 166 extremely low birth weight survivors (501-1000 g birth weight; 1977-1982 births) and a group of 145 sociodemographically comparable normal birth weight individuals. Current health status, history of illnesses, hospitalizations, use of health resources, and physical self-efficacy were assessed through questionnaires that were administered to the young adults by masked interviewers. RESULTS: Individuals completed the assessments at a mean age of 23 years. Neurosensory impairments were identified in 27% of extremely low birth weight and 2% of normal birth weight individuals. No differences were reported in the current health status for physical or mental summary scores. Extremely low birth weight young adults reported a higher prevalence of chronic health conditions in the past 6 months. A significantly higher proportion of extremely low birth weight individuals had functional limitations in seeing, hearing, and dexterity and experienced clumsiness and learning difficulties. Except for prescription glasses, medications for depression, and home-care services for extremely low birth weight individuals, there were no significant differences between groups in use of health care resources. Extremely low birth weight individuals had significantly weaker hand grip strength and lower scores for physical self-efficacy, perceived physical ability, and physical self-confidence. CONCLUSIONS: Extremely low birth weight young adults seem to enjoy similar current health status to their normal birth weight peers. However, they continue to have significantly poorer physical abilities and a higher prevalence of chronic health conditions and functional limitations. Contrary to expectations, they do not pose a significant burden to the health care system at young adulthood.

Growth trajectories of extremely low birth weight infants from birth to young adulthood: a longitudinal, population-based study.

We compared sex-specific growth attainment of a population-based cohort of 147/166 (89%) extremely low birthweight (ELBW < 1000 g) and 131/145 (90%) sociodemographically comparable normal birthweight (NBW) cohort at young adulthood, and examined the pattern of growth trajectories and correlates of growth at ages 1, 2, 3, and 8 y, and teen and young adulthood (mean age, 23.3 versus 23.6 y). The proportion considered small for gestational age was ELBW 25% versus NBW 3%; and 26% versus 2% had neurosensory impairments. Weight for age z-scores for ELBW showed substantial decline to age 3 y, with subsequent significant catch-up to adolescence and smaller gains to adulthood. Height for age z-scores showed both sexes of ELBW were disadvantaged at every age compared with NBW and their expected mid-parental height. The BMI z-scores for ELBW showed a sustained incline from age 3 to adulthood, where both sexes normalized to above zero, and were comparable to their peers. ELBW children showed growth failure during infancy, followed by accelerated weight gain and crossing of BMI percentiles at adolescence, a pattern that may increase the risk of insulin resistance and coronary heart disease. However, normalization of BMI for both sexes at adulthood suggests that final growth was proportionate.

Self-perceived health-related quality of life of former extremely low birth weight infants at young adulthood.

OBJECTIVES: The goals were to compare the self-reported, health-related quality of life of former extremely low birth weight and normal birth weight infants at young adulthood and to determine whether there were any changes over time. METHODS: A prospective, longitudinal, population-based study with concurrent control subjects was performed. We interviewed 143 of 166 extremely low birth weight survivors (birth weight: 501-1000 g; 1977-1982 births) and 130 of 145 sociodemographically comparable, normal birth weight, reference subjects. Neurosensory impairments were present for 27% extremely low birth weight and 2% normal birth weight young adults. Health Utilities Index 2 was used to assess health status, and standard gamble technique was used to measure directly the self-reported, health-related, quality of life and 4 hypothetical health states. RESULTS: Extremely low birth weight young adults reported more functional limitations in cognition, sensation, mobility, and self-care, compared with control subjects. There were no differences between groups in the mean self-reported, health-related, quality of life or between impaired (n = 38) and nonimpaired (n = 105) extremely low birth weight subjects. However, with a conservative approach of assigning a score of 0 for 10 severely disabled, extremely low birth weight subjects, the mean health-related quality of life was significantly lower than control values. Repeated-measures analysis of variance to compare health-related quality-of-life measurements obtained for young adults and teens showed the same decline in scores over time for both groups. There were no differences between groups in the ratings provided for the hypothetical health states. CONCLUSIONS: At young adulthood, health-related quality of life was not related to size at birth or to the presence of disability. There was a small decrease in health-related quality-of-life scores over time for both groups.

Knowledge translation to advance the nurse practitioner role in British Columbia: researchers and decision-makers conduct policy-relevant research to guide legislative and regulatory development and the design of a nurse practitioner education program.

This project brought together a team of researchers and decision-makers to conduct policy-relevant research to support the introduction of advanced nursing practice roles in British Columbia. All team members, including decision-makers, were actively involved in the conceptualization, design, data collection, analysis and interpretation of the study. This level of engagement, coupled with ongoing knowledge translation (KT) activities, led to the implementation by stakeholders of a majority of the study's recommendations. The results have since been used to guide legislative and regulatory development and to design a nurse practitioner education program.

A review of the literature examining the benefits and challenges, incidence and duration, and barriers to breastfeeding in preterm infants.

Breastfeeding benefits preterm infants from a nutritional, gastrointestinal, immunological, developmental, and psychological perspective. Despite the benefits, the incidence and duration of breastfeeding preterm infants continues to be less than that of full-term infants. The lower incidence is probably related to breastfeeding challenges that preterm infants and parents face, including establishing and maintaining a milk supply and transitioning from gavage feeding to breastfeeding. In order to increase the incidence and duration of breastfeeding preterm infants, researchers must examine breastfeeding experiences longitudinally. This way, researchers and clinicians can begin to understand the barriers to breastfeeding at various time periods in the breastfeeding experience and begin implementing strategies to remove these barriers.

Qualitative analysis of barriers to breastfeeding in very-low-birthweight infants in the hospital and postdischarge.

PURPOSE: To determine barriers to the successful establishment and maintenance of breastfeeding in very-low-birthweight (VLBW) infants, both in the hospital and after discharge, and changes in barriers over time. SUBJECTS: Sixty-four mothers of infants <1500 g birth weight who planned to breastfeed and were in the supplementary structured breastfeeding counseling intervention group. DESIGN: This qualitative, longitudinal study is a secondary analysis of a previously reported randomized controlled trial of a breastfeeding support intervention that examined infants weighing <1500 g at birth. METHODS: A qualitative technique, content analysis, was used to review, analyze, interpret, and categorize data for the current study. Data were extracted from the research records of the research lactation consultant that addressed all aspects of mothers' reported breastfeeding experiences. The principal investigator identified the main issues of the conversations, entered these into a summary chart, and then assigned appropriate categories. All categories are a reflection of maternal perception. Categorical data were analyzed descriptively using the crosstabs function. MAIN OUTCOME MEASURES: Barriers to the successful establishment and maintenance of breastfeeding during discharge from the neonatal intensive care unit (NICU), at discharge home, and at 1, 3, 6, and 12 months corrected age, or until weaning from breastfeeding. Changes in breastfeeding barriers across the 6 time periods were also determined. PRINCIPAL RESULTS: At NICU discharge, low milk volume was the greatest breastfeeding barrier. During the period from discharge home and at 1 month and 3 months, the infants' compromised physical status was the largest barrier to breastfeeding. Data from the 6- and 12-month time periods indicated that the provision of complementary feeding was the greatest barrier to breastfeeding; it was most prevalent in the period following NICU discharge and before discharge home. Across all time periods, nipple and breast problems were most prevalent at NICU discharge, whereas poor technique was a barrier at 1 month. Mothers' compromised emotional status was greatest at discharge from the NICU and diminished thereafter. CONCLUSIONS: Results from this study indicate the need to address time-period-specific barriers encountered during the breastfeeding experience of mothers of VLBW infants.

The effects of family resources, coping, and strains on family adjustment 18 to 24 months after the NICU experience.

PURPOSE: To examine the relationship of family coping, resources, and strains on family adjustment over time following the NICU experience. DESIGN: Longitudinal, correlational study based on the Resiliency Model of Family Stress, Adjustment and Adaptation. SAMPLE: Data were collected, through mailed questionnaires, from 71 couples, 18 to 24 months following the birth of their infant. The data are a follow-up from a previous study conducted at the time of the infant's birth. MAIN OUTCOME VARIABLES: The dependent variable in the study was family adjustment, measured by the McMaster Family Assessment Device. The independent variables were family resources, as measured by the Family Inventory of Resource Management; family coping, as measured by the Family Crisis Oriented Evaluation Scales; family strain, as measured by the Family Inventory of Life Events and Changes; and parent gender, family system (first-time parent or not), and the child's health, as measured by the Demographic Information Questionnaire. RESULTS: Family adjustment improved over time for mothers but decreased for fathers. Fathers of infants with ongoing health problems reported significantly poorer family adjustment. Family resources were related to family adjustment and decreased over time for both parents. Families used more coping mechanisms and different coping patterns over time.

Incidence and duration of breastfeeding for term infants in Canada, United States, Europe, and Australia: a literature review.

BACKGROUND: Analysis of differences in the incidence and duration of breastfeeding across countries may provide information about practices that encourage breastfeeding. This comparative review examines variation in the incidence and duration of breastfeeding for term infants that has been reported in studies from Canada, the United States, Europe, and Australia. METHODS: Searches were conducted in PubMed, MEDLINE (from 1966), CINHAL (from 1982), and the Cochrane Database of Systematic Reviews. Studies were limited to nonexperimental and observational research that addressed term infants (>37 weeks gestational age), performed in developed countries, written in the English language, and published since 1990. Additional studies were located from reference lists of meta-analyses, systematic reviews, and previous articles. All studies that met study criteria were included in the review, regardless of the quality of methodology. RESULTS: Although studies had methodological limitations that precluded conducting a formal systematic review or meta-analysis, this comparative review revealed consistent differences among countries. For example, Europe and Australia reported a higher initiation and duration of breastfeeding term infants compared with Canada and the United States. CONCLUSIONS: Studies that examined reasons for a higher incidence and duration of breastfeeding term infants consistently document that women who initiate and continue to breastfeed are older, married, better educated, and have higher family incomes than women who do not breastfeed.