Prospective longitudinal comparative study showed that breastfeeding outcomes were comparable in preterm twins and singleton infants.

AIM: We compared milk volumes, skin-to-skin contact and breastfeeding by the mothers of very preterm twins and singleton infants born at 28-32 weeks of gestation. METHODS: This Norwegian longitudinal prospective comparative study was carried out in two neonatal intensive care units: one with single family rooms and one open bay unit. It comprised 49 singleton infants, 28 twins and their mothers. The mothers' milk volume and direct breastfeeding were recorded from birth until 4 months' of corrected age. They also answered the breastfeeding self-efficacy scale and skin-to-skin contact was recorded. RESULTS: The mothers of preterm twins produced doubled the volume of expressed milk at day 14, compared to the mothers of singletons (mean 816 ± 430 mL vs. 482 ± 372 mL, p < 0.05) and this difference was still sustained at 34 + 0 weeks/days (p < 0.02). Mothers of twins had their first breastfeeding attempt later than mothers of singletons (median of 133 h compared to 56 (p < 0.002). Preterm twins received less daily skin-to-skin contact (mean 157 ± 66 min each vs. 244 ± 109) (p < 0.001). There were no differences in receiving mother's own milk, exclusively direct breastfeeding or perceived breastfeeding self-efficacy. CONCLUSION: Breastfeeding was initiated as successfully in preterm twins as singletons as the mothers' milk production doubled.

Unwarranted geographic variation in paediatric health care in the United States and Norway.

AIM: We present the four US and Norwegian paediatric and neonatal health atlases and discuss the concept and causes of unwarranted geographic variation in paediatric health care. METHODS: The four atlases analyse data from both publicly owned health registers, registers of insurance claims and quality registers. Healthcare utilisation is counted per recipient in predefined hospital service areas, adjusted for relevant confounders and presented as extremal ratios between the highest and lowest rate. RESULTS: The atlases describe geographic variation in rates for primary health care, hospital admissions, outpatient visits, treatment procedures and diagnostic testing. A difference in extremal ratios from 2 to 4 between health service areas are common, and for some procedures extremal ratios is even higher. CONCLUSION: Variation in healthcare utilisation of the magnitude described in these four atlases cannot be explained by differences in population morbidity or patient preferences and are therefore characterised as unwarranted variation. Individual provider preferences or supply of resources such as hospital beds may explain the observed variation.

Impact of parents' education on variation in hospital admissions for children: a population-based cohort study.

OBJECTIVES: To assess the impact of parental educational level on hospital admissions for children, and to evaluate whether differences in parents' educational level can explain geographic variation in admission rates. DESIGN: National cohort study. SETTING: The 18 hospital referral areas for children in Norway. PARTICIPANTS: All Norwegian children aged 1-16 years in the period 2008-2016 and their parents. MAIN OUTCOME MEASURES: Age- and gender-adjusted admission rates and probability of admission. RESULTS: Of 1 538 189 children, 156 087 (10.2%) had at least one admission in the study period. There was a nearly twofold (1.9) variation in admission rates between the hospital referral areas (3113 per 100 000 children, 95% CI: 3056 to 3169 vs 1627, 95% CI: 1599 to 1654). Area level variances in multilevel analysis did not change after adjusting for parental level of education. Children of parents with low level of education (maternal level of education, low vs high) had the highest admission rates (2016: 2587, 95% CI: 2512 to 2662 vs 1810, 95% CI: 1770 to 1849), the highest probability of being admitted (OR: 1.18, 95% CI: 1.16 to 1.20), the highest number of admissions (incidence rate ratio: 1.05, 95% CI: 1.01 to 1.10) and admissions with lower cost (-0.5%, 95% CI: -1.2% to 0.3%). CONCLUSIONS: Substantial geographic variation in hospital admission rates for children was found, but was not explained by parental educational level. Children of parents with low educational level had the highest admission probability, and the highest number of admissions, but the lowest cost of admissions. Our results suggest that the variation between the educational groups is not due to differences in medical needs, and may be characterised as unwarranted. However, the manner in which health professionals communicate and interact with parents with different educational levels might play an important role.

Associations Between Single-Family Room Care and Breastfeeding Rates in Preterm Infants.

BACKGROUND: Hospitalization in neonatal intensive care units with a single-family room design enables continuous maternal presence, but less is known regarding the association with milk production and breastfeeding. RESEARCH AIM: To compare maternal milk production, breastfeeding self-efficacy, the extent to which infants received mother's milk, and rate of direct breastfeeding in a single-family room to an open bay neonatal intensive care unit. METHODS: A longitudinal, prospective observational study comparing 77 infants born at 28- 32° weeks gestational age and their 66 mothers (n = 35 infants of n = 30 mothers in single family room and n = 42 infants of n = 36 mothers in open bay). Comparisons were made on milk volume produced, the extent to which infants were fed mother's milk, and rate of direct breastfeeding from birth to 4 months' corrected infant age. Breastfeeding self-efficacy was compared across mothers who directly breastfed at discharge (n = 45). RESULTS: First expression (6 hr vs. 30 hr, p < .001) and first attempt at breastfeeding (48 hr vs. 109 hr, p < .001) occurred significantly earlier, infants were fed a greater amount of mother's milk (p < .04), and significantly more infants having single-family room care were exclusively directly breastfed from discharge until 4 months' corrected age; OR 6.8 (95% CI [2.4, 19.1]). Volumes of milk produced and breastfeeding self-efficacy did not differ significantly between participants in either units. CONCLUSION: To increase the extent to which infants are fed mother's own milk and are exclusively directly breastfed, the design of neonatal intensive care units should facilitate continuous maternal presence and privacy for the mother-infant dyad.

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

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

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

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

Parent-Infant Closeness, Parents' Participation, and Nursing Support in Single-Family Room and Open Bay NICUs.

This was a prospective survey study, comparing parent-infant closeness, parents' perceptions of nursing support, and participation in medical rounds in single-family room (SFR) and an open bay (OB) neonatal intensive care units. Nurses' assessments of provided support were also measured. In total, 115 parents of 64 preterm infants less than 35 weeks' gestational age and 129 nurses participated. Parents recorded the presence and skin-to-skin care. Parents were sent 9 text message questions in random order. Nurses answered corresponding Internet-based questions. SFR mothers were more present, 20 hours daily (median) versus 7 hours (P < .001), initiated skin-to-skin contact (SSC) at 4 versus 12 hours (P = .03), and preformed SSC 180 min/24 h versus 120 min/24 h for mothers in the OB unit (P = .02). SFR fathers were also more present, 8 versus 4 hours (P < .001), initiated SSC at 3 versus 40 hours (P = .004), and performed SSC 67 min/24 h versus 31 min/24 h (P = .05). SFR parents rated participation in medical rounds and emotional support higher than OB parents. Parental trust was rated higher by nurses in the OB unit (P = .02). SFR facilitated parent-infant closeness, parents' participation in medical rounds, and increased support from nurses.

A new proposal for priority setting in Norway: Open and fair.

Health systems worldwide struggle to meet increasing demands for health care, and Norway is no exception. This paper discusses the new, comprehensive framework for priority setting recently laid out by the third Norwegian Committee on Priority Setting in the Health Sector. The framework posits that priority setting should pursue the goal of "the greatest number of healthy life years for all, fairly distributed" and centres on three criteria: 1) The health-benefit criterion: The priority of an intervention increases with the expected health benefit (and other relevant welfare benefits) from the intervention; 2) The resource criterion: The priority of an intervention increases, the less resources it requires; and 3) The health-loss criterion: The priority of an intervention increases with the expected lifetime health loss of the beneficiary in the absence of such an intervention. Cost-effectiveness plays a central role in this framework, but only alongside the health-loss criterion which incorporates a special concern for the worse off and promotes fairness. In line with this, cost-effectiveness thresholds are differentiated according to health loss. Concrete implementation tools and open processes with user participation complement the three criteria. Informed by the proposal, the Ministry of Health and Care Services is preparing a report to the Parliament, with the aim of reaching political consensus on a new priority-setting framework for Norway.

Does skin-to-skin contact reduce stress during diaper change in preterm infants?

BACKGROUND: Skin-to-skin contact reduces pain response in preterm infants subjected to minor painful procedures, such as heel lance. Diaper change is a procedure performed several times daily in hospitalized preterm infants. Routine care giving tasks such as diaper change may be stressful for the infant. AIMS: The purpose of this study was to investigate whether diaper change induces stress and if skin-to-skin contact could reduce such stress, measured by changes in skin conductance. STUDY DESIGN: This was a randomized crossover pilot study in 19 preterm infants with gestational age between 28 and 34 weeks. The diaper change procedure was done twice in each infant, once during skin-to-skin contact, and once in incubator or bed with the mother present. OUTCOME MEASURES: During diaper change heart rate (HR), peripheral oxygen saturation (SpO2), and changes in skin conductance (SC) peaks per sec, using the Skin Conductance Algesimeter (SCA), were registered. RESULTS: The mean SC peaks/sec increased/decreased significantly under/after change of diapers which thereby underpins that this is a stressful procedure for the preterm infant. Skin-to-skin contact (SSC) entails significantly lower stress levels (p<0.05) compared to diaper changed in an incubator/bed measured by the SCA. CONCLUSIONS: Diaper change is a stressful procedure for preterm infants and may be ameliorated by skin-to-skin contact.

Improved cognitive development among preterm infants attributable to early supplementation of human milk with docosahexaenoic acid and arachidonic acid.

OBJECTIVE: The objective of our study was to evaluate the effect of supplementation with docosahexaenoic acid and arachidonic acid for human milk-fed preterm infants. The primary end point was cognitive development at 6 months of age. METHODS: The study was a randomized, double-blind, placebo-controlled study among 141 infants with birth weights of <1500 g. The intervention with 32 mg of docosahexaenoic acid and 31 mg of arachidonic acid per 100 mL of human milk started 1 week after birth and lasted until discharge from the hospital (on average, 9 weeks). Cognitive development was evaluated at 6 months of age by using the Ages and Stages Questionnaire and event-related potentials, a measure of brain correlates related to recognition memory. RESULTS: There was no difference in adverse events or growth between the 2 groups. At the 6-month follow-up evaluation, the intervention group performed better on the problem-solving subscore, compared with the control group (53.4 vs 49.5 points). There was also a nonsignificant higher total score (221 vs 215 points). The event-related potential data revealed that infants in the intervention group had significantly lower responses after the standard image, compared with the control group (8.6 vs 13.2). There was no difference in responses to novel images. CONCLUSIONS: Supplementation with docosahexaenoic acid and arachidonic acid for very preterm infants fed human milk in the early neonatal period was associated with better recognition memory and higher problem-solving scores at 6 months.