Neurodevelopmental problems, general health and academic achievements in a school-based cohort of 11-year-old Swedish children.

AIM: Assessing rates of neurodevelopmental problems (NDPs) in 11-year-old children and possible association with other health complaints and school performance. METHODS: In-school study of 11-year-old children as an add-on assessment to the 4th grade regular health check-up, comprising a structured physical neurodevelopmental examination, neuropsychological assessment, behavioural ratings, maternal interview, review of medical records and academic achievements. RESULTS: Out of 348 children recruited from eight schools, 223 (64%) participated. Any physical condition was found in 102/222 (46%), most commonly atopy (18%). One in five had a BMI z-score >2 standard deviations over the reference mean. One or more NDP was found in 86/221 (40%) children. The number of failed national tests correlated positively with NDP severity rated with the clinical global impression severity instrument (Spearman's r = 0.41, p < 0.001). The majority of participants with failed national tests, also had co-occurring health complaints (≥2 of: stomach or extremity ache, headache, difficulties sleeping, internalising symptoms or obesity) and NDPs. CONCLUSION: Health complaints, physical conditions and NDPs are very common in 11-year-old children and warrant adequately staffed, thoroughly equipped school healthcare services.

Family Transmission of COVID-19 Including a Child with MIS-C and Acute Pancreatitis.

INTRODUCTION: Spread of the novel coronavirus SARS-CoV-2, since at least December 2019, has caused a pandemic. SARS-CoV-2 causes the disease COVID-19, which can affect several human organs. Abdominal pain is one of the known symptoms, but little is known about acute pancreatitis as a complication. As well, knowledge about viral transmission in families is limited. This case report describes MIS-C and acalculous acute pancreatitis in a child who was a member of a family in which four of five members had COVID-19. CASE REPORT: A previously healthy family was infected by SARS-CoV-2 from an unknown source. The 13-year-old daughter was infected by SARS-CoV-2 and symptomatic during two periods, with an asymptomatic interval in-between. During the first period, she had transient and mild upper respiratory symptoms which was followed four weeks later by a secondary severe illness. At that point, there was inflammation in multiple organs and signs of Multisystem Inflammatory Syndrome in Children (MIS-C) and a Kawasaki-like disease with skin rash, scalded skin in hands and conjunctivitis. Myocarditis, bronchopneumonia, pancreatitis, and hepatopathy without encephalopathy were noted. She required assisted ventilation for 5 days. There were laboratory signs of disseminated intravascular coagulopathy. The multisystem inflammation was treated with intravenous immunoglobulin (IVIG) once a day for four days and immunotherapy (high dose methylprednisolone (IV) once a day, for 12 days, then tapered over 4 weeks, anakinra (IV) four times daily for 12 days), low molecular weight heparin for 22 days and salicylates for 6 weeks leading to full restoration of health. The two brothers and mother in the family had mild to moderate COVID-19 infections. The father was not affected despite close contact with his children. The household transmission and clinical course and outcome are described. No further known COVID-19 infection occurred in the neighborhood during or immediately after the family cluster was discovered. CONCLUSION: Penetrance and severity of COVID-19 can vary in family clusters. One adolescent showed a two-phase course with severe infection. This case report highlights MIS-C and acute pancreatitis as a complication associated with COVID-19 in children.

Body Mass Index and Association With Caries in School-Aged Children With Orofacial Cleft: A Case-Control Study.

OBJECTIVE: Data on the association between body mass index (BMI) and dental caries in children with orofacial clefts are sparse. Therefore, studies on the impact of BMI on caries frequency in children with cleft lip and/or palate (CL/P) are of importance. The aim of the current study was to investigate the association between BMI and frequency of dental caries in children with and without CL/P. Height, weight, and BMI in children with CL/P were also compared to controls. DESIGN: This study used a cross-sectional case-control design. PARTICIPANTS: One hundred and thirty-nine 5- and 10-year-old children with CL/P and 299 age-matched controls. MAIN OUTCOME MEASURES: Caries was recorded according to the International Caries Detection and Assessment System. Height and weight were recorded, and BMI was calculated as weight/height2. RESULTS: There was no correlation between BMI and caries frequency. Weight, height, and BMI were significantly lower in all children with CL/P compared to controls. After adjustment for international adoption, only BMI was significantly lower in CL/P children compared to controls. Non-adopted children with CL/P were significantly heavier and longer than adopted children with CL/P. CONCLUSIONS: Five- and 10-year-old children with corrected CL/P seemed to have a lower BMI than controls, but there was no association between BMI and caries frequency. Internationally adopted children with CL/P were lighter and shorter than non-adopted CL/P children and controls.

TANGO2 deficiency as a cause of neurodevelopmental delay with indirect effects on mitochondrial energy metabolism.

Exome sequencing has recently identified mutations in the gene TANGO2 (transport and Golgi organization 2) as a cause of developmental delay associated with recurrent crises involving rhabdomyolysis, cardiac arrhythmias, and metabolic derangements. The disease is not well understood, in part as the cellular function and subcellular localization of the TANGO2 protein remain unknown. Furthermore, the clinical syndrome with its heterogeneity of symptoms, signs, and laboratory findings is still being defined. Here, we describe 11 new cases of TANGO2-related disease, confirming and further expanding the previously described clinical phenotype. Patients were homozygous or compound heterozygous for previously described exonic deletions or new frameshift, splice site, and missense mutations. All patients showed developmental delay with ataxia, dysarthria, intellectual disability, or signs of spastic diplegia. Of importance, we identify two subjects (aged 12 and 17 years) who have never experienced any overt episode of the catabolism-induced metabolic crises typical for the disease. Mitochondrial complex II activity was mildly reduced in patients investigated in association with crises but normal in other patients. In one deceased patient, post-mortem autopsy revealed heterotopic neurons in the cerebral white matter, indicating a possible role for TANGO2 in neuronal migration. Furthermore, we have addressed the subcellular localization of several alternative isoforms of TANGO2, none of which were mitochondrial but instead appeared to have a primarily cytoplasmic localization. Previously described aberrations in Golgi morphology were not observed in cultured skin fibroblasts.

Role of iodine-containing multivitamins during pregnancy for children's brain function: protocol of an ongoing randomised controlled trial: the SWIDDICH study.

INTRODUCTION: Iodine is essential for normal brain development. Moderate and severe fetal iodine deficiency results in substantial to serious developmental delay in children. Mild iodine deficiency in pregnancy is associated with neurodevelopmental deficits in the offspring, but evidence from randomised trials is lacking. The aim of the Swedish Iodine in Pregnancy and Development in Children study is to determine the effect of daily supplementation with 150 µg iodine during pregnancy on the offspring's neuropsychological development up to 14 years of age. METHODS AND ANALYSIS: Thyroid healthy pregnant women (n=1275: age range 18-40 years) at ≤12 weeks gestation will be randomly assigned to receive multivitamin supplements containing 150 µg iodine or non-iodine-containing multivitamin daily throughout pregnancy. As a primary outcome, IQ will be measured in the offspring at 7 years (Wechsler Intelligence Scale for Children-V). As secondary outcomes, IQ will be measured at 3.5 and 14 years, psychomotor development at 18 months and 7 years, and behaviour at 3.5, 7 and 14 years. Iodine status (urinary iodine concentration) will be measured during pregnancy and in the offspring at 3.5, 7 and 14 years. Thyroid function (thyroid hormones, thyroglobulin), and deiodinase type 2 polymorphisms will be measured during pregnancy and in the offspring at 7 and 14 years. Structural MRI or other relevant structural or functional brain imaging procedures will be performed in a subgroup of children at 7 and 14 years. Background and socioeconomic information will be collected at all follow-up times. ETHICS AND DISSEMINATION: This study is approved by the Ethics Committee in Göteborg, Sweden (Diary numbers: 431-12 approved 18 June 2012 (pregnancy part) and 1089-16 approved 8 February 2017 (children follow-up)). According to Swedish regulations, dietary supplements are governed by the National Food Agency and not by the Medical Product Agency. Therefore, there is no requirement for a monitoring committee and the National Food Agency does not perform any audits of trial conduct. The trial will be conducted in accordance with the Declaration of Helsinki. The participating sites will be contacted regarding important protocol changes, both orally and in writing, and the trial registry database will be updated accordingly. Study results will be presented at relevant conferences, and submitted to peer-reviewed journals with open access in the fields of endocrinology, paediatrics and nutrition. After the appropriate embargo period, the results will be communicated to participants, healthcare professionals at the maternal healthcare centres, the public and other relevant groups, such as the national guideline group for thyroid and pregnancy and the National Food Agency. TRIAL REGISTRATION NUMBER: NCT02378246; Pre-results.

Salivary Cortisol Rhythms in Children With Cleft Lip and/or Palate: A Case-Control Study.

OBJECTIVE: Knowledge about the stress response in children with cleft lip and/or palate (CL/P) is sparse and the association between the stress response and health-related quality of life (HRQoL) is unknown. Consequently, investigations on the influence of CL/P on the stress response alone and its association with HRQoL are of importance. The purpose was to determine whether salivary cortisol concentration in children with CL/P differs from that in children without clefts (controls) and whether there are any differences in salivary cortisol concentrations between ages, gender, and type of cleft. Furthermore, the final aim was to determine the correlation between salivary cortisol concentration and HRQoL. DESIGN: The study used a cross-sectional case-control design. PARTICIPANTS: Ninety-one 5- and 10-year-old children with CL/P and 180 age-matched controls. MAIN OUTCOME MEASURES: Salivary samples were collected on 2 mornings and 1 evening for each child. Samples were analyzed using a commercial competitive radioimmunoassay and HRQoL was assessed using the KIDSCREEN-52. RESULTS: Salivary cortisol concentrations were similar in children with CL/P and controls. There was no difference in salivary cortisol concentrations between children with different types of cleft. There was no correlation between cortisol concentration and HRQoL. CONCLUSION: Five- and 10-year-old children with corrected CL/P seemed not to be more stressed than controls, and there were no correlation to HRQoL. The HRQoL levels - were comparable to that of a European norm population.

A comparison of health-related quality of life in 5- and 10-year-old Swedish children with and without cleft lip and/or palate.

BACKGROUND: The current understanding on health-related quality of life (HRQoL) in young Swedish children with cleft lip and/or palate (CL/P) is sparse, and therefore, research on impact of CL/P on HRQoL in children is needed. AIMS: To investigate HRQoL in 5- and 10-year-old Swedish children with CL/P in comparison with non-cleft controls. Also to analyse whether there were any differences in HRQoL between children with cleft lip (with or without cleft palate, CL ± P) and cleft palate only (CP) and/or gender differences. DESIGN: A total of 137 children with CL/P and 305 non-cleft controls participated. HRQoL was measured with KIDSCREEN-52. RESULTS: All children in the study exhibited HRQoL within or above the age-matched reference interval of the method with similar results in both groups; however, in the dimension 'social support and peers', the 10-year-old children with CL/P perceived lower HRQoL than the non-cleft controls, but it did not reach statistical significance. Type of cleft or gender did not influence HRQoL. CONCLUSIONS: Both 5- and 10-year-old Swedish children with CL/P had HRQoL in the normal reference interval. Their general life situations were well adjusted to their clefts, but the older children with CL/P felt more excluded and less supported by peers.

Hepatic Glycogen Storage Diseases Toward One Global Collaborative Network

Abstract The third international meeting of the Scandinavian Association for Glycogen Storage Disease focused on hepatic glycogen storage disease and was organized for health-care professionals, patient representatives, and representatives from the industry. This report highlights dilemmas in dietary management, differences in monitoring strategies, and challenges with rare disease care, research, and patient participation.

Evaluating the Impact of AAC Interventions in Reducing Hospitalization-related Stress: Challenges and Possibilities.

Hospitalization is a stressful context for all children and their families, but especially for children with communication difficulties. Effective communication using augmentative and alternative communication (AAC) strategies can play a critical role in preparing and supporting everyone involved in such situations to have discussions that minimize insecurity, allow children to express their concerns, and so decrease negative stress and anxiety. However, there is a critical need to identify robust and reliable ways of evaluating the effectiveness of interventions that seek to achieve this aim. This research note illustrates some of the challenges and problems that require attention and suggests possible new research tools, for example, the use of physiological measures. The evaluation of an AAC intervention on a day surgery ward is described and used to illustrate one potential physiological measure for evaluating the impact of an intervention.

Using Shoulder Straps Decreases Heart Rate Variability and Salivary Cortisol Concentration in Swedish Ambulance Personnel.

BACKGROUND: Previous research has shown that paramedics are exposed to risks in the form of injuries to the musculoskeletal system. In addition, there are studies showing that they are also at increased risk of cardiovascular disease, cancer, and psychiatric diseases, which can partly be explained by their constant exposure to stress. The aim of this study is to evaluate whether the use of shoulder straps decreases physical effort in the form of decreased heart rate and cortisol concentration. METHODS: A stretcher with a dummy was carried by 20 participants for 400 m on two occasions, one with and one without the shoulder straps. Heart rate was monitored continuously and cortisol samples were taken at intervals of 0 minutes, 15 minutes, 30 minutes, 45 minutes, and 60 minutes. Each participant was her or his own control. RESULTS: A significant decrease in heart rate and cortisol concentration was seen when shoulder straps were used. The median values for men (with shoulder straps) at 0 minutes was 78 bpm/21.1 nmol/L (heart rate/cortisol concentration), at 15 minutes was 85 bpm/16.9 nmol/L, and at 60 minutes was 76 bpm/15.7 nmol/L; for men without shoulder straps, these values were 78 bpm/21.9 nmol/L, 93 bpm/21.9 nmol/L, and 73 bpm/20.5 nmol/L. For women, the values were 85 bpm/23.3 nmol/L, 92 bpm/20.8 nmol/L, and 70 bpm/18.4 nmol/L and 84 bpm/32.4 nmol/L, 100 bpm/32.5 nmol/L, and 75 bpm/25.2 nmol/L, respectively. CONCLUSION: The use of shoulder straps decreases measurable physical stress and should therefore be implemented when heavy equipment or a stretcher needs to be carried. An easy way to ensure that staff use these or similar lifting aids is to provide them with personalized, well-adapted shoulder straps. Another better option would be to routinely sewn these straps into the staff's personal alarm jackets so they are always in place and ready to be used.

Comparing parent and teacher assessments of mental health in elementary school children.

BACKGROUND: Screening instruments are often used for detecting mental health problems in children and adolescents. The Strengths and Difficulties Questionnaire (SDQ) is one instrument for screening children's mental health. The SDQ can be used for assessment by different informants, i.e. parents, teachers and by 11-16 year olds for self-reporting. AIMS: The aim was to compare the precision and validity of parental and teacher SDQ assessments in elementary school children, and to analyze whether assessments were affected by the child's sex and by socio-demographic factors. METHODS: A total of 512 primary school students were included in a cross-sectional study. Exploratory factor analysis, sensitivity/specificity analysis, Cronbach's alphas, and logistic regression were applied. RESULTS: Parents rated 10.9% and teachers 8.8% of the children as high-risk individuals, but the overlap was low (32.1%). Cronbach's alphas were 0.73 and 0.71 for parents and teachers, respectively. However, factor analysis showed that the five-factor solution could be confirmed only for teacher ratings. Moreover, only the parents' ratings were affected by maternal educational level and parental country of birth when rating the same children as the teachers. CONCLUSIONS: Construct validity was only confirmed for teacher assessments. However, parental assessments might capture a dimension of a child's mental health that seems to be sensitive to socioeconomic factors, which could be important when addressing equity issues, and for the dialogue between parents and school.

Short- and long-term effects of tactile massage on salivary cortisol concentrations in Parkinson's disease: a randomised controlled pilot study.

BACKGROUND: Parkinson's disease (PD) is a chronic neurodegenerative disorder with limited knowledge about the normal function and effects of non-pharmacological therapies on the hypothalamic-pituitary-adrenal (HPA) axis. The aim of the study was to analyse the basal diurnal and total secretion of salivary cortisol in short- and long-term aspects of tactile massage (TM). DESIGN: Prospective, Controlled and Randomised Multicentre Trial. SETTING AND INTERVENTIONS: Forty-five women and men, aged 50-79 years, were recruited. Twenty-nine of them were blindly randomised to tactile massage (TM) and 16 of them to the control group, rest to music (RTM). Ten interventions were given during 8 weeks followed by a 26 weeks of follow up. Salivary cortisol was collected at 8 am, 1 pm, 8 pm, and 8 am the next day, on five occasions. With the first and eighth interventions, it was collected immediately before and after intervention. MAIN OUTCOME MEASURES: The primary aim was to assess and compare cortisol concentrations before and immediately after intervention and also during the follow-up period. The secondary aim was to assess the impact of age, gender, body mass index (BMI), duration and severity of PD, effects of interventional time-point of the day, and levodopa doses on cortisol concentration. RESULTS: The median cortisol concentrations for all participants were 16.0, 5.8, 2.8, and 14.0 nmol/L at baseline, later reproduced four times without significant differences. Cortisol concentrations decreased significantly after TM intervention but no change in diurnal salivary cortisol pattern was found. The findings of reduced salivary cortisol concentrations immediately after the interventions are in agreement with previous studies. However, there was no significant difference between the TM and control groups. There were no significant correlations between cortisol concentrations and age, gender, BMI, time-point for intervention, time interval between anti-parkinson pharmacy intake and sampling, levodopa doses, duration, or severity of PD. CONCLUSIONS: Diurnal salivary cortisol rhythm was normal. Salivary cortisol concentrations were significantly reduced after the TM intervention and after RTM, but there were no significant differences between the groups and no sustained long-term effect. No associations were seen between salivary cortisol concentration and clinical and/or pharmacological characteristics. TRIAL REGISTRATION: ClinicalTrial.gov, NCT01734876 and FoU Sweden 108881.

Child drawings and salivary cortisol in children undergoing preoperative procedures associated with day surgery.

BACKGROUND: Perioperative procedures in children can impair their emotional status negatively with stress and/or anxiety. Cortisol concentrations and drawings could be helpful in gaining information about a child's levels of stress and/or anxiety when attending the hospital for surgery. PURPOSE: The purpose of this study was to determine the degree of anxiety and stress as well as to explore the association between objective measures of stress (cortisol concentration in saliva) and subjective assessment of hospital anxiety (children's drawings) as interpreted by the Swedish version of the Child Drawing: Hospital manual. METHODS: A total of 93 children scheduled for day surgery were included. Salivary cortisol was sampled preoperatively on the day of surgery at which time the children were also requested to make a drawing of a person at the hospital. RESULTS: Results showed no association between salivary cortisol concentration and the CD:H score. CONCLUSION: The drawings and salivary cortisol concentration preoperatively on the day of surgery reflect different components of the conditions of fear, anxiety, or stress emerging in the situation.

Cerebrospinal fluid brain injury biomarkers in children: a multicenter study.

BACKGROUND: Cerebrospinal fluid (CSF) biomarkers reflecting neuronal and astroglial injury, such as total tau (T-tau), glial fibrillary acidic protein (GFAP), and neurofilament light (NFL), have been extensively investigated in neurologic diseases in adults, but no large study has investigated these biomarkers in children. METHODS: This study presents a detailed evaluation of CFS T-tau, GFAP, NFL, and CSF:albumin ratio in a large cohort of pediatric patients. This is a retrospective multicenter study on pediatric patients aged <16 years (n = 607), where neuronal injury biomarkers T-tau, GFAP, NFL, and CSF albumin ratio were analyzed during 2000-2010 at the Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Sweden. The patients were grouped into eight categories: epilepsy, infectious and inflammatory central nervous system disorders, progressive encephalopathy, static encephalopathy, tumors, movement disorders, miscellaneous disorders, and a control group. RESULTS: T-tau, GFAP, and NFL were increased in progressive encephalopathy (P < 0.001), epilepsy (P < 0.001), and infectious and inflammatory central nervous system disorders (P < 0.001) compared with controls. T-tau was the biomarker with the highest diagnostic accuracy with the area under the curve of 0.83 (95% confidence interval (CI), 0.77-0.90; P < 0.0001) for progressive encephalopathy followed by epilepsy 0.80 (95% CI, 0.75-0.87; P < 0.0001). The combination of all four biomarkers further improved the area under the curve for the progressive encephalopathy 0.87 (95% CI, 0.77-0.89; P < 0.0001), followed by epilepsy 0.81 (95% CI, 0.74-0.80; P = 0.030). The combination of the biomarkers also separated progressive from static encephalopathy 0.88 (95% CI, 0.83-0.93; P < 0.0001). CONCLUSIONS: CSF T-tau, GFAP, and NFL are differently altered across different neurologic diseases in children. Importantly, the biomarker pattern distinguishes between progressive and static neurologic disorders.

National surveys: a way to manage treatment strategies in Parkinson's disease? Pharmaceutical prescribing patterns and patient experiences of symptom control and their impact on disease.

BACKGROUND: The purpose of this study was to draw conclusions from patient-reported experiences in two national surveys from Scandinavia with the intention of comparing treatment strategies and increasing our knowledge of factors that affect the experiences of patients with Parkinson's disease (PD). METHODS: A total of 2000 individuals in Sweden and 1300 in Norway were invited to complete postal surveys covering PD-related issues. Patient experiences of diagnostic procedures, symptom control, and follow-up in PD and the effects on symptom-related quality of life were collected. Pharmaceutical prescription data on anti-PD drugs and administrative data were collected from national registries. RESULTS: The surveys were completed by 1553 (78%) of the Swedish cohort and 1244 (96%) of the Norwegian cohort. Only small differences were seen in disease duration and age distribution. Statistically as well as clinically significant differences in symptom control, diagnostic, and follow-up procedures, as well as in pharmacological treatment and impact on quality of life, were found between the national cohorts independent of disease duration. CONCLUSION: Information from separate national surveys has the potential to increase our knowledge of patient experiences in PD and can be used to compare, evaluate, educate, and guide health care staff and administrators in optimizing health care for patients with the disease.

Parkinson's disease patients' subjective descriptions of characteristics of chronic pain, sleeping patterns and health-related quality of life.

OBJECTIVE: Nonmotor symptoms are common in Parkinson's disease (PD). Health-related quality of life (HRQoL) is negatively affected by different factors, of which pain and sleep disturbances are important contributors. This study was performed to evaluate and describe subjective experiences of pain, sleeping patterns, and HRQoL in a cohort of PD patients with chronic pain. METHODS: A total of 45 participants with established PD for more than 2 years, and PD-related pain for the preceding three months, were recruited from three sites in Sweden. Data regarding time point for onset, duration and degree of pain parameters, body localization of pain, external influences, and treatments were obtained. HRQoL was evaluated with the Short Form-36(®) Health Survey, and sleeping patterns were registered with the Parkinson's disease Sleep Scale, both completed along with a questionnaire. RESULTS: In one-third of participants, pain preceded the PD diagnosis. Median pain score measured with a visual analog scale was 6.6 and 5.9 (for females and males, respectively) the week before the study. In almost half of the participants, pain was present during all their waking hours. Significantly more females described their pain as troublesome, while more males described their pain as irritating. Feelings of numbness and creeping sensations at night were strongly associated with the maximal visual analog scale scores. Polypharmacy was common; 89% used medication for anxiety/insomnia, and 18% used antidepressants. Only one-third of patients who reported pain relief with analgesics had these prescribed on their drug lists. Sleep was characterized by frequent awakenings. Urinary urgency and restless legs were frequently reported as troublesome. Patients rated HRQoL as significantly worse in all items compared with a healthy reference population matched for age and sex. CONCLUSIONS: Experiences of chronic PD-related pain are complex; there is substantial sleep fragmentation and negative impact on HRQoL.

Infant B cell memory differentiation and early gut bacterial colonization.

Germ-free animal models have demonstrated that commensal bacterial colonization of the intestine induces B cell differentiation and activation. Whether colonization with particular bacterial species or groups is associated with B cell development during early childhood is not known. In a prospective newborn/infant cohort including 65 Swedish children, we examined the numbers and proportions of CD20(+), CD5(+), and CD27(+) B cells in blood samples obtained at several time points during the first 3 y of life using flow cytometry. Fecal samples were collected and cultured quantitatively for major facultative and anaerobic bacteria at 1, 2, 4, and 8 wk of life. We found that the numbers of CD20(+) B cells and CD5(+)CD20(+) B cells reached their highest levels at 4 mo, whereas CD20(+) B cells expressing the memory marker CD27 were most numerous at 18 and 36 mo of age. Using multivariate analysis, we show that early colonization with Escherichia coli and bifidobacteria were associated with higher numbers of CD20(+) B cells that expressed the memory marker CD27 at 4 and 18 mo of age. In contrast, we were unable to demonstrate any relation between bacterial colonization pattern and numbers of CD20(+) or CD5(+)CD20(+) B cells. These results suggest that the intestinal bacterial colonization pattern may affect the B cell maturation also in humans, and that an early gut microbiota including E. coli and bifidobacteria might promote this maturation.

The perioperative dialogue reduces postoperative stress in children undergoing day surgery as confirmed by salivary cortisol.

AIM: To evaluate the efficacy of 'the perioperative dialogue (PD)' by analyzing salivary cortisol, in 5- to 11-year-old children undergoing day surgery. BACKGROUND: To deal with anxiety prior to investigations and/or procedures, children need to be confident and informed about what is going to happen. Therefore, intervention strategies should be initiated before admission to hospital. METHODS AND MATERIALS: Children (n = 93), 79 boys and 14 girls, scheduled for elective day surgery requiring general anesthesia were randomly recruited into three groups: (i) standard perioperative care (n = 31), (ii) standard perioperative care including preoperative information (n = 31), and (iii) the PD (n = 31). Saliva was sampled for cortisol analysis at specific time points during the pre- and perioperative procedures. RESULTS: The children who received the PD had significantly lower (P = 0.003) salivary cortisol concentrations postoperatively. Moreover, it continuously decreased during the day of surgery compared with the other two groups (P < 0.01). Among the children who received analgesics, the PD group received significantly less morphine (P = 0.014) related to bodyweight: the mean dose was 0.1 mg·kg(-1) (n = 9) in the control group vs 0.04 mg·kg(-1) (n = 6) in the PD group. Irrespective of group, there was a positive correlation between the children's morphine consumption and salivary cortisol concentration (r = 0.56; P = 0.038). The W-B scale score was higher in the group that received morphine (median = 3 vs median=1; P = 0.001). CONCLUSIONS: The PD's caring, continuity, and on-going dialogues were associated with low concentrations of salivary cortisol postoperatively and reduced morphine consumption and thus appears to be a valuable complement to standard perioperative care in children undergoing day surgery.

Salivary cortisol for assessment of hypothalamic-pituitary-adrenal axis function.

OBJECTIVE: Cortisol is an important hormone/steroid in the regulation of intermediate metabolism and stress. It exists in free (unbound) and protein-bound forms in serum but only in a free form in saliva. The free form is the biologically active one. There is an advanced biofeedback system regulating the cortisol secretion/concentration by the hypothalamic-pituitary-adrenal axis. METHODS: There are many different methods to collect saliva, either directly from the mouth as an expectorate or indirectly by using swabs, capillary tubes or paper foams. The swab may be cotton-based, synthetic, with or without a plastic sheath. There are different methods for analysis - immunological, radioisotopic, mass fragmentographic and chromatographic. RESULTS: The diurnal variation in salivary cortisol concentrations in healthy school-aged boys and girls are described and show dependence to different degrees of age and sex. CONCLUSION: Sampling for salivary cortisol determination is a sensitive, specific and pain-free procedure and it is therefore very useful for following healthy and sick children before, during and after pharmacological interventions. Different conditions as time for sampling, interaction with other endogenous and exogenous steroids, and physical and psychological activity interact with the salivary cortisol concentration.