Differences in breastfeeding rate between mothers delivering by caesarean section and those delivering vaginally.

Aim: The aim of the study was to analyse the impact of delivery on breastfeeding at 6 months, with special focus on caesarean section combined with established breastfeeding at 2 months. Methods: Delivery mode and breastfeeding at 2 and 6 months were studied in a database of 130,993 infants from two Swedish counties between 1990-2011. Results: The difference in breastfeeding rates at 6 months between children delivered by caesarean section and children delivered vaginally was smaller in a subpopulation of children with established breastfeeding at 2 months compared to all children. The impact of delivery method on breastfeeding at 6 months was independent of child gender, mother's first child, maternal smoking and maternal education. Conclusions: Breastfeeding in mothers giving birth by caesarean section is more likely to continue until (at least) 6 months if established early (at 2 months). It may be worthwhile to promote breastfeeding for mothers who deliver by caesarean section.

Clinical utility of the Structured Observation of Motor Performance in Infants within the child health services.

AIM: This study aimed to evaluate the clinical utility of the Structured Observation of Motor Performance in Infants (SOMP-I) when used by nurses in routine child healthcare by analyzing the nurses' SOMP-I assessments and the actions taken when motor problems were suspected. METHOD: Infants from three child health centers in Uppsala County, Sweden, were consecutively enrolled in a longitudinal study. The 242 infants were assessed using SOMP-I by the nurse responsible for the infant as part of the regular well-child visits at as close to 2, 4, 6 and 10 months of age as possible. The nurses noted actions taken such as giving advice, scheduling an extra follow-up or referring the infant to specialized care. The infants' motor development was reassessed at 18 months of age through review of medical records or parental report. RESULTS: The assessments of level of motor development at 2 and 10 months showed a distribution corresponding to the percentile distribution of the SOMP-I method. Fewer infants than expected were assessed as delayed at 4 and 6 months or deficient in quality at all assessment ages. When an infant was assessed as delayed in level or deficient in quality, the likelihood of the nurse taking actions increased. This increased further if both delay and quality deficit were found at the same assessment or if one or both were found at repeated assessments. The reassessment of the motor development at 18 months did not reveal any missed infants with major motor impairments. INTERPRETATION: The use of SOMP-I appears to demonstrate favorable clinical utility in routine child healthcare as tested here. Child health nurses can assess early motor performance using this standardized assessment method, and using the method appears to support them the clinical decision-making.

Relationship Between Breastfeeding and Early Childhood Obesity: Results of a Prospective Longitudinal Study from Birth to 4 Years.

AIM: To study a potential link between breastfeeding in infancy and obesity at age 4. MATERIALS AND METHODS: A total of 30,508 infants born during 2002-2007 from the databases of the Preventive Child Health Services in two Swedish counties and from national registers were studied. The outcome variable was obesity at age 4. Analyses were conducted by logistic regression models using the methodology of generalized estimating equations. Analyses were adjusted for child sex and maternal anthropometric and sociodemographic variables. RESULTS: In unadjusted analyses, any breastfeeding up to 9 months was linked to successively decreasing odds ratios (ORs) for obesity at age 4 (ORs 0.78-0.33), however, not significantly for 1 week and 2 months of breastfeeding. In adjusted analyses, the same pattern remained statistically significant for breastfeeding for 4 (OR 0.51), 6 (OR 0.55), and 9 (OR 0.47) months. Child sex, maternal education, maternal body mass index, and maternal smoking additionally influenced child obesity. CONCLUSION: Breastfeeding duration for at least 4 months may contribute independently to a reduced risk for childhood obesity at 4 years.

Motivational Interviewing to Prevent Childhood Obesity: A Cluster RCT.

OBJECTIVE: The objective was to evaluate a manualized theory-driven primary preventive intervention aimed at early childhood obesity. The intervention was embedded in Swedish child health services, starting when eligible children were 9 to 10 months of age and continuing until the children reached age 4. METHODS: Child health care centers in 8 Swedish counties were randomized into intervention and control units and included 1355 families with 1369 infants. Over ∼39 months, families in the intervention group participated in 1 group session and 8 individual sessions with a nurse trained in motivational interviewing, focusing on healthy food habits and physical activity. Families in the control group received care as usual. Primary outcomes were children's BMI, overweight prevalence, and waist circumference at age 4. Secondary outcomes were children's and mothers' food and physical activity habits and mothers' anthropometrics. Effects were assessed in linear and log-binominal regression models using generalized estimating equations. RESULTS: There were no statistically significant differences in children's BMI (ß = -0.11, 95% confidence interval [CI]: -0.31 to 0.08), waist circumference (ß = -0.48, 95% CI: -0.99 to 0.04), and prevalence of overweight (relative risk = 0.95, 95% CI: 0.69 to 1.32). No significant intervention effects were observed in mothers' anthropometric data or regarding mothers' and children's physical activity habits. There was a small intervention effect in terms of healthier food habits among children and mothers. CONCLUSIONS: There were no significant group differences in children's and mothers' anthropometric data and physical activity habits. There was, however, some evidence suggesting healthier food habits, but this should be interpreted with caution.

'Now I use words like asymmetry and unstable': nurses' experiences in using a standardized assessment for motor performance within routine child health care.

RATIONALE, AIMS AND OBJECTIVES: There is an increasing recognition that early intervention is important for children with motor disorders. The use of standardized assessment methods within the Swedish Child Health Services (CHS) may improve early identification of these children and thereby their development and quality of care. Given the key role of nurses within the CHS, we explored their experiences of using a structured assessment of motor performance (SOMP-I) in a clinical setting, and investigated possible barriers and facilitators for implementation of the method within the CHS. METHODS: The study was conducted in 2013 in Uppsala County, Sweden. Ten child health nurses participated in two focus group interviews, which were analysed using systematic text condensation. RESULTS: The analysis yielded three themes: (1) increased knowledge and professional pride - nurses described their desire to provide high-quality care for which SOMP-I was a useful tool; (2) improved parent-provider relationship - nurses felt that using SOMP-I involved both the parents and their infant to a greater extent than routine care; and (3) conditions for further implementation - nurses described that the time and effort needed to master new skills must be considered and practical barriers, such as lack of examination space, resource constraints and difficulties in documenting the assessment must be addressed before implementing the SOMP-I method in routine care. CONCLUSION: Child health nurses felt that the SOMP-I method fitted well with their professional role and increased the quality of care provided. However, significant barriers to implementing SOMP-I into routine child health care were described.

Can nurses be key players in assessing early motor development using a structured method in the child health setting?

RATIONAL, AIMS AND OBJECTIVES: Increasing evidence highlights the importance of early interventions for motor disorders in children. Given the key medical role of the nurse within the Swedish Child Health Service (CHS), we aimed to examine if nurses could apply a structured assessment of early motor development at the child health centre to enable early identification of children at risk. METHODS: Structured Observation of Motor Performance in Infants (SOMP-I) assesses infant's level of motor development and quality of motor performance using subscales converted to total scores. The total score for both level and quality can then be plotted within the SOMP-I percentile distribution at the child's age for comparison with a reference population. Fifty-five infants (girls: 30) were assessed according to SOMP-I at three child health centres. Assessments were performed by nurses (n = 10) in a clinical setting; one nurse performed the assessment while another nurse and a physiotherapist observed. RESULTS: Agreement for the assessment of level as a continuous variable was excellent [intraclass correlation coefficient (ICC) 0.97-0.98], but was lower for quality (ICC 0.02-0.46). When the children were categorized according to the percentile range categories, the assessors were in agreement for the majority of the children, with respect to both level (78-82%) and quality (78-87%). CONCLUSION: Despite brief experience with SOMP-I, the agreement was excellent when assessing the level of motor development, but was less satisfactory for the assessment of quality of motor performance. More extensive education and training may be necessary to improve the nurses' ability to assess quality, as this domain was an entirely new concept to the nurses. Further research is warranted to determine the applicability of SOMP-I as a standardized method for nurses to assess motor development within the CHS.

Primary prevention of childhood obesity through counselling sessions at Swedish child health centres: design, methods and baseline sample characteristics of the PRIMROSE cluster-randomised trial.

BACKGROUND: Childhood obesity is a growing concern in Sweden. Children with overweight and obesity run a high risk of becoming obese as adults, and are likely to develop comorbidities. Despite the immense demand, there is still a lack of evidence-based comprehensive prevention programmes targeting pre-school children and their families in primary health care settings. The aims are to describe the design and methodology of the PRIMROSE cluster-randomised controlled trial, assess the relative validity of a food frequency questionnaire, and describe the baseline characteristics of the eligible young children and their mothers. METHODS/DESIGN: The PRIMROSE trial targets first-time parents and their children at Swedish child health centres (CHC) in eight counties in Sweden. Randomisation is conducted at the CHC unit level. CHC nurses employed at the participating CHC received training in carrying out the intervention alongside their provision of regular services. The intervention programme, starting when the child is 8-9 months of age and ending at age 4, is based on social cognitive theory and employs motivational interviewing. Primary outcomes are children's body mass index and waist circumference at four years. Secondary outcomes are children's and mothers' eating habits (assessed by a food frequency questionnaire), and children's and mothers' physical activity (measured by accelerometer and a validated questionnaire), and mothers' body mass index and waist circumference. DISCUSSION: The on-going population-based PRIMROSE trial, which targets childhood obesity, is embedded in the regular national (routine) preventive child health services that are available free-of-charge to all young families in Sweden. Of the participants (n = 1369), 489 intervention and 550 control mothers (75.9%) responded to the validated physical activity and food frequency questionnaire at baseline (i.e., before the first intervention session, or, for children in the control group, before they reached 10 months of age). The food frequency questionnaire showed acceptable relative validity when compared with an 8-day food diary. We are not aware of any previous RCT, concerned with the primary prevention of childhood obesity through sessions at CHC that addresses healthy eating habits and physical activity in the context of a routine child health services programme. TRIAL REGISTRATION: ISRCTN16991919.

Utilization of child health services, stress, social support and child characteristics in primiparous and multiparous mothers of 18-month-old children.

AIM: Traditionally, the child health services have laid emphasis on first-time mothers. Some researchers have argued that the needs of multiparous mothers must be considered equally important. The aim of this paper was to analyse parity-related characteristics in pairs of mothers and 18-month-old children. METHODS: The study was population-based and cross-sectional. 586 primiparous mothers and 821 mothers with at least one previous child completed a questionnaire. Additional information was extracted from the child health records by the nurses. Data were collected in 2002-2003 and 2004-2005. RESULTS: Compared to multiparous mothers, primiparous mothers had a higher utilization of child health services. Multiparous mothers scored higher on parental incompetence stress and felt that their work load was more demanding. Multiparous mothers reported less social support, particularly in practical respects such as baby-sitting. They considered their interaction with the child as less satisfactory than did primiparous mothers; their children participated less in shared reading and had a more restricted vocabulary. Fewer multiparous mothers assessed their own and their child's total situation as very good. CONCLUSIONS: The child health services should develop competence and methods to support multiparous mothers and alleviate their workload when caring for several children.

Infant gender and postpartum sadness in the light of region of birth and some other factors: a contribution to the knowledge of postpartum depression.

The purpose of this paper is to analyse postpartum depressive symptoms as related to baby gender, maternal region of birth, stress, perception of child difficult temperament and some demographic factors. The setting was 36 Swedish child health centres. Mothers of 1,848 19-month-old children completed a questionnaire, including an item about recall of postpartum sadness. A subsample of 360 answered the Edinburgh Postnatal Depression Scale (EPDS). Overall, significantly more mothers of boys than of girls recalled postpartum sadness. The same was found in mothers born in Sweden and in other regions, except for the Middle East (no significant result). Among those born in Sweden and in other regions, more mothers of boys than of girls scored ≥12 on the EPDS, except for Middle East mothers with the opposite pattern (no significant finding). More mothers of "difficult" boys than of "difficult" girls recalled postpartum sadness. Our findings are tentative but may inspire future research. Immigrant mothers in Sweden seem rather like the majority population, possibly with the exception of Middle East mothers. The significance of parents' knowledge of their child's gender in advance is an important area for research. Future parents could benefit from discussing gender expectations with a nurse or other professional.

Organizational differences in early child health care -- mothers' and nurses' experiences of the services.

AIM: The aim of this study was to evaluate parents' and nurses' perceptions of the child health services (CHS) in relation to whether the nurse worked exclusively with children (focused-child health centre, CHC) vs. with people of all ages (mixed-CHC). METHOD: Information about parents' perceptions about the CHS was acquired by a questionnaire intended for the mothers of 18-month-old children. One thousand thirty-nine answered in the baseline 2002-2003 and 996 in the follow-up 2004-2005. The nurses answered a special questionnaire aimed to obtain knowledge about their satisfaction with their work. Eighteen CHCs were chosen from the county of Uppsala and eighteen from other Swedish counties. The CHCs were chosen from areas with poor psycho-social status. The data were collected by questionnaires to mothers and nurses, and the analysis used the chi-square test, t-test and logistic regression. The study was approved by the Research Ethics Committees of the universities involved. RESULTS: Mothers were more satisfied, and the nurses found their work tasks easier, at CHCs where the child health nurse worked exclusively with children, compared with mothers and nurses belonging to CHCs where the nurses provided care to people of all ages. CONCLUSION: The findings indicated that nurses working exclusively with children, being able to concentrate their time and knowledge on a specialized field, develop a more solid child health competence. There are strong reasons to consider introducing 'exclusive' CHCs in psycho-socially vulnerable areas, which would probably make the services more effective. However, intensified education may modify the drawbacks of mixed-CHCs.

Drawing the line in the Edinburgh Postnatal Depression Scale (EPDS): a vital decision.

BACKGROUND: The Edinburgh Postnatal Depression Scale (EPDS) is widely used in early child health care. This study examined the appropriateness of the recommended EPDS cut-off score 11/12. METHODS: Two main analyses were performed: 1. Associations between EPDS scores and maternal health behaviour, stress, life events, perceived mother-child interaction quality and child behaviour. 2. Screening parameters of the EPDS, i.e., sensitivity, specificity and positive predictive value. EPDS scores were available for 438 mothers and maternal questionnaires for 361 mothers. RESULTS: Already in the EPDS score intervals 6-8 and 9-11, there were notable adversities, according to maternal questionnaires, in stress, perceived quality of mother-child interaction, perceived child difficultness and child problem behaviours. Using maternal questionnaire reports about sadness/distress postpartum as standard, the recommended EPDS cut-off score 11/12 resulted in a very low sensitivity (24%). The cutoff score 6/7 yielded a sensitivity of 61%, a specificity of 82% and a positive predictive value of 61%. CONCLUSIONS: In terms of both clinical relevance and screening qualities, an EPDS cut-off score lower than 11/12 seems recommendable.

Child health and maternal stress: does neighbourhood status matter?

The purpose of this cross-sectional questionnaire study was to explore neighbourhood-level differences in health behaviour, maternal stress and sense of coherence, birth weight, child health and behaviour, and children's television watching habits. In total, 2006 pairs of Swedish mothers and children, aged approximately 20 months, from the general population participated in the study. A total of 1923 lived in neighbourhoods of average socioeconomic status in six counties, and 83 in a high-status neighbourhood in one of the counties. Data were collected in 2002-2003 and 2004-2005 through the Child Health Services. Socio-demographic confounders were adjusted for in multiple logistic regressions (maternal age, country of birth, education, marital status and parity). Compared with their counterparts in average neighbourhoods, mothers in the high-status neighbourhood were less frequently smokers and had been breastfeeding their children more. They felt less stress from social isolation and had a higher sense of coherence. All these differences except lower social isolation were non-significant after adjusting for socio-demographic characteristics. Privileged mothers felt more restricted by their parenting tasks (unadjusted comparison), and more privileged children were frequent television watchers. Child birth weight, health and behaviour were no better in the privileged than in average neighbourhoods. This paper adds to previous knowledge by showing that status-based geographic differences in important parenting and health parameters can be non-significant in an equitable society such as Sweden, where all families with young children have access to free high-quality health services. Individual characteristics could provide better explanations than neighbourhood status.

How can we identify vulnerable mothers who do not reach the cut off 12 points in EPDS?

The aim was to investigate the correspondence between 352 mother's self-reports about postpartum distress in a questionnaire including an item about distress 18 months after birth and their earlier scores within, on average, 2.5 months of childbirth from a screening with the Edinburgh Postnatal Depression Scale (EPDS). Mothers who did not reach the EPDS score of 12 points, but reported that they had been sad/depressed after childbirth, were similar in socio-demographic variables to mothers with no outcomes in sadness/depression issues. In items related to negative parenting and perceptions of the child, they presented the same picture as those with high EPDS scores who also reported having been depressed. These results suggest that EPDS does not identify all vulnerable mothers. Complementary methods for detecting mothers at risk of stress and depression need to be developed.

[Surname as a marker of ethnicity. A study from child health services shows that immigrant respective Swedish families seem to be isolated in different ways]. / Efternamn som markör för etnicitet. Studie inom barnhälsovården visar att invandrarfamiljer och svenska familjer tycks vara isolerade på olika sätt.

A practical method was tested for identifying ethnicity through family names in the absence of precise demographic information. In a questionnaire study of children covered by the Swedish child health services in some different counties, all potential participants (the children's mothers) were classified as "Swedish" or "non-Swedish" using family names. Inter-rater reliability was assessed by comparing the scores of two independent raters (Cohen's kappa: 0.89). Cases in which the raters did not agree were settled through discussion. The method's validity was roughly measured by comparing assigned classifications against ethnicity information provided by the 63.8 percent of the mothers who returned the questionnaire (1039 of 1628). Assigned and self-reported classifications were the same in 86.5 percent of the cases. Information from child health services about mothers who had agreed to participate in the study revealed health-related differences between those who returned the questionnaires and those who did not. The family name classification method indicated an ethnic selectivity in drop-out rates, which was helpful in interpreting these health differences.