Nina Nelson

Lower stress responses after newborn individualized developmental care and assessment program care during eye screening examinations for retinopathy of prematurity: A randomized study

OBJECTIVE. Screening examination for retinopathy of prematurity is distressing and painful. The aim of the present study was to investigate whether a Newborn Individualized Developmental Care and Assessment Program intervention during a retinopathy of prematurity examination results in less adverse behavioral, pain, and stress responses as compared with standard care. METHODS. The first 2 eye examinations in 36 preterm infants were evaluated. The infants were randomly assigned at the first eye examination to receive either Newborn Individualized Developmental Care and Assessment Program care or standard care. At the second examination, crossover of subject assignment was performed. The assessments included behavioral responses; recordings of heart rate, respiration, and oxygenation; pain scores (premature infant pain profile); and salivary cortisol at defined time points up to 4 hours after the eye examination. The nursing support given during the eye examinations (intervention score) were scored using predefined criteria. RESULTS. Altogether, 68 examinations were evaluated. Newborn Individualized Developmental Care and Assessment Program care was associated with better behavioral scores during the examination but there was no difference in heart rate, respiratory rate, oxygenation, or premature infant pain profile score between the 2 care strategies before or after the eye examination. Salivary cortisol increased from baseline to 30 minutes after the eye examination independent of care strategy and decreased significantly between 30 and 60 minutes when infants were subjected to Newborn Individualized Developmental Care and Assessment Program care but not after standard care. During the study period the intervention score for standard care increased and approached the score for Newborn Individualized Developmental Care and Assessment Program care at the later eye examinations. CONCLUSION. A Newborn Individualized Developmental Care and Assessment Program-based intervention during eye examination does not decrease pain responses but results in faster recovery, as measured by lower salivary cortisol 60 minutes after the examination. The differences were seen despite the influence from the Newborn Individualized Developmental Care and Assessment Program intervention on the standard care treatment that occurred during the study period.

Does quantity have a quality all its own? Cumulative adversity and up- and down-regulation of circadian salivary cortisol levels in healthy children

Findings have been divergent regarding the direction of basal cortisol dysregulations resulting from stressor exposure, and seem to differ between young people and adults. Accumulated stress exposure has been suggested to be a risk factor for the development of hypocortisolism. This cross-sectional study aims to examine the impact of cumulative adversity, i.e., the number of adversities, on diurnal salivary cortisol levels, including the cortisol awakening response (CAR), in children without psychiatric disorder. The sample consisted of 130 children (mean age 12.8 years), representing one in each twin pair included in the population-based Child and Adolescent Twin Study in Sweden (CATSS). Information about socioeconomic disadvantage, negative life events and potentially traumatic life events were collected by telephone interview and questionnaires, with parents as informants. Salivary cortisol sampling was performed in the home during two school days: at awakening, +30 min post-awakening, and at bedtime. Results showed that the number of adversities was related to the CAR, diurnal decline and +30 min post-awakening cortisol levels. Children with a moderate amount of cumulative adversity displayed high cortisol measures, while those with a high amount (3 or more) of adversities instead showed levels similar to the non-exposed group, yielding an inverse U-pattern of the association between cortisol and adversity. These results indicate that the accumulation of adversity might be an explanation of patterns of basal cortisol up-regulation in children and that those most severely exposed can exhibit an early stage of down-regulation, an issue which should be further examined in longitudinal studies.

Diurnal cortisol levels and cortisol response in youths with obsessive-compulsive disorder.

Background/Aims: Recent results indicate a role of the hypothalamic-pituitary-adrenal (HPA) axis in the pathophysiology of obsessive-compulsive disorder (OCD). Although childhood onset is common, the HPA axis has scarcely been studied in young OCD subjects. Therefore, the present study aimed at examining basal and response levels of salivary cortisol in a sample of young OCD subjects. Methods: Twenty-three children and adolescents with DSM-IV OCD were compared to a reference group of school children (n = 240–336). The basal cortisol rhythm was measured through saliva samples 3 times/day. The cortisol response to a psychological stressor (exposure therapy in the OCD group and a fire alarm in the reference group) was also examined. Results: Compared to the reference group, OCD subjects displayed higher early-morning cortisol values (p = 0.005) with no difference between the late-morning and evening values. The cortisol levels in the OCD group diminished in response to the psychological stressor, compared to a positive response in the reference group (p < 0.001). No relation was found between cortisol and clinical parameters. Conclusion: These results support the idea that HPA hyperactivity, commonly found in adult OCD patients, is also present at an earlier stage of development, with specificity for the early-morning peak.

Salivary cortisol and administration of concentrated oral glucose in newborn infants: improved detection limit and smaller sample volumes without glucose interference.

Newborn infants are subject to repetitive painful and stressful events during neonatal intensive care. When the baby attempts to cope with a stressful situation the hypothalamus‐pituitary‐adrenal axis is activated, releasing cortisol. The free cortisol response is optimally measured in saliva and saliva samples can be taken easily and without pain. However, saliva is very scarce in infants and saliva stimulants can interfere with analytical methods. Nowadays, sweet solutions are frequently administered to neonates prior to a disturbing procedure in order to reduce pain. The possible interference of sweet solutions with the measurement of salivary cortisol has not yet been documented. The aims of the present study were to further improve the detection limit of the radioimmunoassay used for cortisol analysis and to determine the degree of interference of high concentrations of glucose with the analytical method. By decreasing incubation temperature and prolonging the incubation time it was possible to improve the detection limit of the radio immunoassay (RIA) to 0.5 nmol/L at the same time as the sample volume was decreased to 10 μL saliva. Saliva was collected from full‐term and preterm babies and was sufficient for analysis in 113 out of 116 (97%) samples. Glucose in the concentrations and amounts commonly used for pain relief did not interfere with the RIA method. In conclusion, it is feasible to collect microlitre volumes of saliva and analyse even very low concentrations of cortisol in newborns. It is also possible to offer the baby oral glucose prior to a painful procedure and still reliably measure salivary cortisol.

Stress at three-month immunization: Parents’ and infants’ salivary cortisol response in relation to the use of pacifier and oral glucose

The aims of the present study were to investigate (1) whether the salivary cortisol response could be dampened during a routine three‐month immunization if the infant received sweet‐tasting solution in combination with a pacifier and (2) stress experienced by parents during immunization of the infant. Ninety‐eight infants were included into one of four intervention groups: ‘glucose and pacifier’, ‘water and pacifier’, ‘glucose’, or ‘water’. Saliva was collected before and 30min after the immunization. Infants’ crying‐time and parents’ self‐reported stress (VAS) were measured before and after immunization. Infants in the ‘pacifier and glucose’ group had a significantly smaller change in salivary cortisol than infants in the other groups (F3,72=3.1, p<0.05). In the ‘glucose and pacifier’ group the median salivary cortisol levels decreased 33% after the immunization. In the ‘water and pacifier’, ‘glucose’, and ‘water’ group median cortisol increased with 50%, 42%, and 8%, respectively. No significant differences in crying‐time were observed between the intervention groups. If the infant cried before the immunization, the crying‐time during the immunization was longer (p<0.01) and cortisol increased more (p<0.05). Median cortisol levels for parents decreased after the immunization (p<0.01). Median VAS increased 50% (p<0.0001) after immunization. First time parents rated higher stress on VAS before immunization (p<0.01). Parents’ change in cortisol and VAS were significantly related to infants’ crying time. In conclusion, the combination of oral glucose and pacifier dampen infants’ salivary cortisol in response to the three‐month immunization.

The long-term cost-effectiveness of fetal monitoring during labour : a comparison of cardiotocography complemented with ST analysis versus cardiotocography alone

Objective  To assess the cost‐effectiveness of the use of cardiotocography (CTG) complemented with fetal electrocardiography and ST analysis compared with the use of CTG alone in term deliveries when a decision has been made to use fetal monitoring with a scalp electrode.

Neonatal salivary cortisol in response to heelstick: method modifications enable analysis of low concentrations and small sample volumes

Measuring cortisol in saliva offers important advantages compared to measurement in plasma or serum. However, the sampling procedure and also the detection limit cause problems, especially in paediatric and neonatal care. We describe a simple and efficient sampling procedure, together with a modification of a radioimmunoassay, which enables analysis of low (down to 1 nmol/L) concentrations of salivary cortisol (10 times lower detection limit than in the original procedure). This setting was used in studying salivary cortisol concentrations before and after heelstick on healthy newborn infants. A significant rise (median 81%; p<0.01) in salivary cortisol as response to this invasive stressor was noted.Measuring cortisol in saliva offers important advantages compared to measurement in plasma or serum. However, the sampling procedure and also the detection limit cause problems, especially in paediatric and neonatal care. We describe a simple and efficient sampling procedure, together with a modification of a radioimmunoassay, which enables analysis of low (down to 1 nmol/L) concentrations of salivary cortisol (10 times lower detection limit than in the original procedure). This setting was used in studying salivary cortisol concentrations before and after heelstick on healthy newborn infants. A significant rise (median 81%; p<0.01) in salivary cortisol as response to this invasive stressor was noted.

Sociocultural Disadvantage, Traumatic Life Events, and Psychiatric Symptoms in Preadolescent Children

Previous research has demonstrated impact of psychosocial adversity on the mental health of children. This cross-sectional study examined specific influences of psychosocial adversity on internalizing versus externalizing symptoms, as explained by relative neighborhood disadvantage, sociocultural disadvantage, and exposure to interpersonal and non-interpersonal traumatic life events. Participants included 258 children aged 6 to 12 years from two Swedish elementary schools located in two socioeconomically distinct neighborhood settings. Information was obtained from their parents by means of questionnaires (a demographic form including information about parental occupation and country of origin, the Strengths and Difficulties Questionnaire and the Life Incidence of Traumatic Events checklist). Neighborhood differences in mental health were explained by variability in psychosocial adversity. While controlling for gender, age, and the other symptom dimension, sociocultural disadvantage was associated with internalizing but not with externalizing symptoms. In contrast, traumatic life events and especially interpersonal traumas were related to externalizing but not to internalizing symptoms. These findings provide some support for specificity of psychosocial adversities in the impact on child mental health.

Neonatal reference values for ionized calcium, phosphate and magnesium. Selection of reference population by optimality criteria

Thirty-one full-term newborn babies were investigated in order to establish reference values for ionized calcium. Only children fulfilling certain optimality criteria (with best possible maternal and infant conditions and uncomplicated pregnancy and delivery) were included. All infants were breast fed. Capillary blood for analysis of ionized calcium was collected by heel puncture on day 1 (6-36 h post partum, p.p.), day 3 (60-84 h p.p.) and day 5 (108-132 h p.p.). Ionized calcium was measured with a semi-automatic electrode system ICA 1 (Radiometer A/S, Copenhagen, Denmark). The reference ranges (mean +/- 2 SD) for days 1, 3 and 5 were 1.05-1.37, 1.10-1.42 and 1.20-1.48 mmol/l, respectively. The mean ionized calcium concentration on day 1 was significantly lower than on days 3 and 5. Reference values are also given for total calcium, magnesium and phosphate. We emphasize that it is impossible to calculate ionized calcium from total calcium or vice versa.

Saliva collection using cotton buds with wooden sticks: a note of caution.

The aims of the present study were to investigate whether the cotton‐tipped applicators (cotton buds) used to collect saliva in infants can be stored un‐centrifuged prior to cortisol analysis, and to test whether there is any difference in results between wooden and plastic‐shafted sticks. Saliva was collected from 10 healthy adults using 6 cotton buds, i.e. 3 with wooden sticks and 3 with plastic sticks. The samples were then centrifuged at three different time‐points: immediately after collection, after 24 h and after 48 h. Using cotton buds with wooden sticks, median salivary cortisol was significantly lower after 24 h (40 %) (p<0.001) and after 48 h (49 %) (p<0.001) of storage than it was of the samples centrifuged immediately. There was no significant difference between the samples centrifuged immediately and those centrifuged after 24 h and 48 h when saliva was collected using the cotton buds with plastic sticks. It is concluded that cotton buds with wooden sticks should not be used in studies of salivary cortisol unless it is possible to centrifuge the saliva immediately. Moreover, it is inadvisable to alternate between cotton buds with wooden and plastic sticks in the same study when collecting saliva for analysis of cortisol.