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  • 1.
    Björkström, Markus V
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Hall, Lina
    Söderlund, Stina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Håkansson, Eva Grahn
    Umeå University, Faculty of Medicine, Department of Clinical Microbiology, Clinical Bacteriology.
    Håkansson, Stellan
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Domellöf, Magnus
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Intestinal flora in very low-birth weight infants2009In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 98, no 11, p. 1762-1767Article in journal (Refereed)
    Abstract [en]

    AIM: To study the early faecal microbiota in very low-birth weight infants (VLBW, <1500 g), possible associations between faecal microbiota and faecal calprotectin (f-calprotectin) and to describe the faecal microbiota in cases with necrotizing enterocolitis (NEC) before diagnosis. METHODS: Stool samples from the first weeks of life were analysed in 48 VLBW infants. Bacterial cultures were performed and f-calprotectin concentrations were measured. In three NEC cases, cultures were performed on stool samples obtained before diagnosis. RESULTS: Bifidobacteria and lactobacilli were often identified in the first stool sample, 55% and 71% of cases, respectively within the first week of life. A positive correlation between lactic acid bacteria (LAB) and volume of enteral feed was found. Other bacteria often identified were Escherichia coli, Enterococcus and Staphyloccus sp. F-calprotectin was not associated with any bacterial species. All NEC cases had an early colonization of LAB. Prior to onset of disease, all cases had a high colonization of non-E. coli Gram-negative species. CONCLUSION: In contrast to the previous studies in VLBW infants, we found an early colonization with LAB. We speculate that this may be due to early feeding of non-pasteurized breast milk.

  • 2. Darlow, Brian A
    et al.
    Lui, Kei
    Kusuda, Satoshi
    Reichman, Brian
    Håkansson, Stellan
    Swedish Neonatal Quality Register, Department of Pediatrics/Neonatal Services, Umeå University Hospital, Umeå, Sweden.
    Bassler, Dirk
    Modi, Neena
    Lee, Shoo K
    Lehtonen, Liisa
    Vento, Maximo
    Isayama, Tetsuya
    Sjörs, Gunnar
    Helenius, Kjell K
    Adams, Mark
    Rusconi, Franca
    Morisaki, Naho
    Shah, Prakesh S
    International variations and trends in the treatment for retinopathy of prematurity2017In: British Journal of Ophthalmology, ISSN 0007-1161, E-ISSN 1468-2079, Vol. 101, no 10, p. 1399-1404Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To compare the rates of retinopathy of prematurity (ROP) and treatment of ROP by laser or intravitreal anti-vascular endothelial growth factor among preterm neonates from high-income countries participating in the International Network for Evaluating Outcomes (iNeo) of neonates.

    METHODS: weeks' gestation who were admitted to neonatal units in Australia/New Zealand, Canada, Finland, Israel, Japan, Spain, Sweden, Switzerland, Tuscany (Italy) and the UK between 2007 and 2013. Pairwise comparisons of ROP treatment in survivors between countries were evaluated by Poisson and multivariable logistic regression analyses after adjustment for confounders. A composite outcome of death or ROP treatment was compared between countries using logistic regression and standardised ratios.

    RESULTS: Of 48 087 infants included in the analysis, 81.8% survived to 32 weeks postmenstrual age, and 95% of survivors were screened for ROP. Rates of any ROP ranged from 25.2% to 91.0% in Switzerland and Japan, respectively, among those examined. The overall rate of those receiving treatment was 24.9%, which varied from 4.3% to 30.4%. Adjusted risk ratios for ROP treatment were lower for Switzerland in all pairwise comparisons, whereas Japan displayed significantly higher ratios. Comparisons of the composite outcome between countries revealed similar, but less marked differences.

    CONCLUSIONS: Rates of any ROP and ROP treatment varied significantly between iNeo members, while an overall decline in ROP treatment was observed during the study period. It is unclear whether these variations represent differences in care practices, diagnosis and/or treatment thresholds.

  • 3. Di Renzo, G C
    et al.
    Melin, P
    Berardi, A
    Blennow, M
    Carbonell-Estrany, X
    Donzelli, G P
    Håkansson, Stellan
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Hod, M
    Hughes, R
    Kurtzer, M
    Poyart, C
    Shinwell, E
    Stray-Pedersen, B
    Wielgos, M
    El Helali, N
    Intrapartum GBS screening and antibiotic prophylaxis: a European consensus conference2015In: The Journal of Maternal-Fetal & Neonatal Medicine, ISSN 1476-7058, E-ISSN 1476-4954, Vol. 7-8, p. 766-782Article in journal (Refereed)
    Abstract [en]

    Abstract Group B streptococcus (GBS) remains worldwide a leading cause of severe neonatal disease. Since the end of the 1990s, various strategies for prevention of the early onset neonatal disease have been implemented and have evolved. When a universal antenatal GBS screening-based strategy is used to identify women who are given an intrapartum antimicrobial prophylaxis, a substantial reduction of incidence up to 80% has been reported in the USA as in other countries including European countries. However recommendations are still a matter of debate due to challenges and controversies on how best to identify candidates for prophylaxis and to drawbacks of intrapartum administration of antibiotics. In Europe, some countries recommend either antenatal GBS screening or risk-based strategies, or any combination, and others do not have national or any other kind of guidelines for prevention of GBS perinatal disease. Furthermore, accurate population-based data of incidence of GBS neonatal disease are not available in some countries and hamper good effectiveness evaluation of prevention strategies. To facilitate a consensus towards European guidelines for the management of pregnant women in labor and during pregnancy for the prevention of GBS perinatal disease, a conference was organized in 2013 with a group of experts in neonatology, gynecology-obstetrics and clinical microbiology coming from European representative countries. The group reviewed available data, identified areas where results were suboptimal, where revised procedures and new technologies could improve current practices for prevention of perinatal GBS disease. The key decision issued after the conference is to recommend intrapartum antimicrobial prophylaxis based on a universal intrapartum GBS screening strategy using a rapid real time testing.

  • 4.
    Ellberg, Lotta
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology. Umeå University, Faculty of Medicine, Department of Nursing.
    Högberg, Ulf
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Lundman, Berit
    Umeå University, Faculty of Medicine, Department of Nursing.
    Källén, Karin
    Department of Reproductive Epidemiology, Tornblad Institute, Lund University, Lund, Sweden.
    Håkansson, Stellan
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Lindh, Viveca
    Umeå University, Faculty of Medicine, Department of Nursing.
    Maternity care options influences readmission of newborns2008In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 97, no 5, p. 579-583Article in journal (Refereed)
    Abstract [en]

    Aim: To analyse morbidity and mortality in healthy newborn infants in relation to various routines of post-natal follow-up. Design: cross-sectional study. Setting: maternity care in Sweden. Population: healthy infants born at term between 1999 and 2002 (n = 197 898).

    Methods: Assessment of post-natal follow-up routines after uncomplicated childbirth in 48 hospitals and data collected from the Swedish Medical Birth Register, Hospital Discharge Register and Cause-of-Death Register. Main outcome measure: neonatal mortality and readmission as proxy for morbidity.

    Results: During the first 28 days, 2.1% of the infants were readmitted generally because of infections, jaundice and feeding-related problems. Infants born in hospitals with a routine neonatal examination before 48 h and a home care programme had a readmission rate [OR, 1.3 (95% CI, 1.16–1.48)] higher than infants born in hospitals with routine neonatal examination after 48 h and 24-h care. There were 26 neonatal deaths.

    Conclusion: Post-delivery care options and routines influence neonatal morbidity as measured by hospital readmission rate. A final infant examination at 49–72 h and an active follow-up programme may reduce the risk of readmission.

  • 5. Gemmell, L
    et al.
    Martin, L
    Murphy, K E
    Modi, N
    Håkansson, Stellan
    Swedish Neonatal Quality Register, Department of Pediatrics/ Neonatal Services, Umeå University Hospital, Umeå, Sweden.
    Reichman, B
    Lui, K
    Kusuda, S
    Sjörs, G
    Mirea, L
    Darlow, B A
    Mori, R
    Lee, S K
    Shah, P S
    Hypertensive disorders of pregnancy and outcomes of preterm infants of 24 to 28 weeks' gestation2016In: Journal of Perinatology, ISSN 0743-8346, E-ISSN 1476-5543, Vol. 36, no 12, p. 1067-1072Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To examine the relationship between hypertensive disorders of pregnancy (HDPs) and mortality and major morbidities in preterm neonates born at 24 to 28 weeks of gestation.

    STUDY DESIGN: weeks of gestation during 2007 to 2010 from 6 national neonatal databases. The incidence of HDP was compared across countries, and multivariable logistic regression analyses were conducted to examine the association of HDP and neonatal outcomes including mortality to discharge, bronchopulmonary dysplasia, severe brain injury, necrotizing enterocolitis and treated retinopathy of prematurity.

    RESULTS: The incidence of HDP in the entire cohort was 13% (range 11 to 16% across countries). HDP was associated with reduced odds of mortality (adjusted odds ratio (aOR) 0.77; 95% confidence interval (CI) 0.67 to 0.88), severe brain injury (aOR 0.74; 95% CI 0.62 to 0.89) and treated retinopathy (aOR 0.82; 95% CI 0.70 to 0.96), but increased odds of bronchopulmonary dysplasia (aOR 1.16; 95% CI 1.05 to 1.27).

    CONCLUSIONS: In comparison with neonates born to mothers without HDP, neonates of HDP mothers had lower odds of mortality, severe brain injury and treated retinopathy, but higher odds of bronchopulmonary dysplasia. The impact of maternal HDP on newborn outcomes was inconsistent across outcomes and among countries; therefore, further international collaboration to standardize terminology, case definition and data capture is warranted.

  • 6.
    Granlund, Margareta
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Microbiology, Clinical Bacteriology.
    Axemo, P
    Bremme, K
    Bryngelsson, A-L
    Carlsson Wallin, M
    Ekström, C-M
    Håkansson, Stellan
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Jacobsson, B
    Källén, K
    Spetz, E
    Tessin, I
    Antimicrobial resistance in colonizing group B Streptococci before the implementation of a Swedish intrapartum antibiotic prophylaxis program2010In: European Journal of Clinical Microbiology and Infectious Diseases, ISSN 0934-9723, E-ISSN 1435-4373, Vol. 29, no 10, p. 1195-1201Article in journal (Refereed)
    Abstract [en]

    The prevalence of antibiotic resistance and their genetic determinants in colonizing group B streptococci (GBS) sampled in a Swedish nationwide survey was examined. In five GBS isolates (1.3%), kanamycin/amikacin resistance and the presence of the aphA-3 gene was identified. Three of these isolates carried the aad-6 gene and were streptomycin-resistant. Screening with kanamycin and streptomycin 1,000-μg disks enabled a rapid and easy detection of these isolates. In all, 312/396 (79%) GBS were tetracycline-resistant and 95% of the examined isolates harbored the tetM gene. Among the 22 (5.5%) GBS resistant to erythromycin and/or clindamycin, the ermB gene was detected in nine isolates (41%) and erm(A/TR) in ten isolates (45%). A high level of erythromycin and clindamycin resistance with minimum inhibitory concentrations (MICs) >256 mg/L was found in four serotype V isolates that harbored ermB. The erythromycin/clindamycin resistance was distributed among all of the common serotypes Ia, Ib, II, III, IV, and V, but was not present in any of the 44 serotype III isolates associated to clonal complex 17. Screening for penicillin resistance with 1-μg oxacillin disks showed a homogenous population with a mean inhibition zone of 20 mm. A change in the present oxacillin breakpoints for GBS is suggested.

  • 7. Grunewald, Charlotta
    et al.
    Håkansson, Stellan
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Högberg, Ulf
    Luthander, Charlotte Millde
    Sandin-Bojö, Ann-Kristin
    Wiklund, Ingela
    Svensk förlossningsvård säkras i ett rikstäckande projekt: tvärprofessionell samverkan en grundpelare i »Säker förlossningsvård«2012In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 109, no 19, p. 956-959Article in journal (Refereed)
  • 8. Grunewald, Charlotta
    et al.
    Håkansson, Stellan
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Saltvedt, Sissel
    Källén, Karin
    Significant effects on neonatal morbidity and mortality after regional change in management of post-term pregnancy2011In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 90, no 1, p. 26-32Article in journal (Refereed)
    Abstract [en]

    Objective. To evaluate the effects on neonatal morbidity of a regional change in induction policy for post-term pregnancy from 43(+0) to 42(+0) gestational weeks (GWs).

    Design and setting. Nationwide retrospective register study between 2000 and 2007. Population. All singleton pregnancies with a gestational age of >41(+2) GW (n= 119,198).

    Methods. All Swedish counties were divided into three groups where study group allocation was designated by the proportion of pregnancies >42(+2) GW among all pregnancies of >41(+2) GW. Stockholm county formed a separate group. Main outcome measures. Perinatal morbidity.

    Results. In counties with the most active management, 19% of pregnancies >41(+2) GW were delivered at >42(+2) GW during 2000-2004 compared to 7.1% in 2005-2007. In the least active counties, corresponding figures were 21.0% compared to 19.4%. During 2005-2007, the odds ratios for meconium aspiration and 5-minute Apgar score of ≤6 in the least compared to most active counties, were 1.55 (95% CI: 1.03-2.33) and 1.26 (95% CI: 1.06-1.51). In Stockholm >42(+2) GW seen among pregnancies of >41(+2) decreased from 21.0% in 2000-2004 to 5.9% in 2005-2007. Reduced perinatal death risks by 48%, meconium aspiration of 51% and low Apgar scores by 31% in 2005-2007 compared with 2000-2004 were observed. Rates of operative deliveries at >41(+2) GW in Stockholm were unaltered.

    Conclusion. A significant reduction in perinatal morbidity was found, with no influence on operative delivery rates for post-term pregnancy in Stockholm. We advocate a nationwide change toward more active management of post-term pregnancies.

  • 9. Gudmundsdottir, Anna
    et al.
    Johansson, Stefan
    Håkansson, Stellan
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Norman, Mikael
    Kallen, Karin
    Bonamy, Anna-Karin
    The Importance of Echocardiography and an Individual Approach to Patent Ductus Arteriosus Treatment in Extremely Preterm Infants2015In: Neonatology, ISSN 1661-7800, E-ISSN 1661-7819, Vol. 107, no 4, p. 257-257Article in journal (Refereed)
  • 10. Gudmundsdottir, Anna
    et al.
    Johansson, Stefan
    Håkansson, Stellan
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Norman, Mikael
    Källen, Karin
    Bonamy, Anna-Karin
    Timing of Pharmacological Treatment for Patent Ductus Arteriosus and Risk of Secondary Surgery, Death or Bronchopulmonary Dysplasia: A Population-Based Cohort Study of Extremely Preterm Infants2015In: Neonatology, ISSN 1661-7800, E-ISSN 1661-7819, Vol. 107, no 2, p. 87-92Article in journal (Refereed)
    Abstract [en]

    Background: The optimal timing of pharmacological treatment for patent ductus arteriosus (PDA) in extremely pre-term infants is unknown. Objective: To investigate whether timing of pharmacological PDA treatment is associated with a risk of secondary PDA surgery or death before 3 months of age, or bronchopulmonary dysplasia (BPD) in extremely preterm infants. Methods: In this population-based cohort of infants born before 27 gestational weeks in Sweden in 2004-2007, 290/585 infants (50%) received pharmacological PDA treatment. Cox proportional hazards regression estimated the hazard ratio (HR, with 95% confidence interval, Cl) of secondary PDA surgery or death as a composite outcome in relation to postnatal age at the start of pharmacological treatment: early (0-2 days); intermediate (3-6 days); late (>= 7 days). Furthermore, the odds ratio (OR, with 95% Cl) of BPD was estimated in relation to postnatal age at PDA treatment by conditional logistic regression. Results: The median postnatal age at the start of pharmacological PDA treatment was 4 days. 102 infants had secondary PDA surgery. Timing of PDA treatment was not associated with risk of PDA surgery or death; adjusted HRs were 0.89 (95% CI 0.57-1.39) after an intermediate start and 1.10(95% CI 0.53-2.28) after a late start, compared to an early start of treatment. Compared to the early start of PDA treatment, the intermediate start was not associated with any risk of BPD, while late PDA treatment was associated with a lower BPD risk; adjusted ORs were 0.83 (95% CI 0.42-1.64) and 0.28 (95% CI 0.13-0.61), respectively. Conclusion: Timing of pharmacological PDA treatment after extremely preterm birth is not associated with the risk of secondary PDA surgery or death. Moreover, expectant PDA management is not associated with an increased risk of BPD.

  • 11. Helenius, Kjell
    et al.
    Sjörs, Gunnar
    National Quality Registry for Neonatal Care, Department of Pediatrics/Neonatal Services, University Hospital of Umeå, Umeå, Sweden.
    Shah, Prakesh S
    Modi, Neena
    Reichman, Brian
    Morisaki, Naho
    Kusuda, Satoshi
    Lui, Kei
    Darlow, Brian A
    Bassler, Dirk
    Håkansson, Stellan
    National Quality Registry for Neonatal Care, Department of Pediatrics/Neonatal Services, University Hospital of Umeå, Umeå, Sweden.
    Adams, Mark
    Vento, Maximo
    Rusconi, Franca
    Isayama, Tetsuya
    Lee, Shoo K
    Lehtonen, Liisa
    Survival in very preterm infants: an international comparison of 10 national neonatal networks2017In: Pediatrics, ISSN 0031-4005, E-ISSN 1098-4275, Vol. 140, no 6, article id e20171264Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To compare survival rates and age at death among very preterm infants in 10 national and regional neonatal networks.

    METHODS: A cohort study of very preterm infants, born between 24 and 29 weeks' gestation and weighing <1500 g, admitted to participating neonatal units between 2007 and 2013 in the International Network for Evaluating Outcomes of Neonates. Survival was compared by using standardized ratios (SRs) comparing survival in each network to the survival estimate of the whole population.

    RESULTS: Network populations differed with respect to rates of cesarean birth, exposure to antenatal steroids and birth in nontertiary hospitals. Network SRs for survival were highest in Japan (SR: 1.10; 99% confidence interval: 1.08-1.13) and lowest in Spain (SR: 0.88; 99% confidence interval: 0.85-0.90). The overall survival differed from 78% to 93% among networks, the difference being highest at 24 weeks' gestation (range 35%-84%). Survival rates increased and differences between networks diminished with increasing gestational age (GA) (range 92%-98% at 29 weeks' gestation); yet, relative differences in survival followed a similar pattern at all GAs. The median age at death varied from 4 days to 13 days across networks.

    CONCLUSIONS: The network ranking of survival rates for very preterm infants remained largely unchanged as GA increased; however, survival rates showed marked variations at lower GAs. The median age at death also varied among networks. These findings warrant further assessment of the representativeness of the study populations, organization of perinatal services, national guidelines, philosophy of care at extreme GAs, and resources used for decision-making.

  • 12. Hines, Delaney
    et al.
    Modi, Neena
    Lee, Shoo K
    Isayama, Tetsuya
    Sjörs, Gunnar
    Swedish Neonatal Quality Register, Department of Pediatrics/Neonatal Services, Umeå University Hospital, Umeå, Sweden.
    Gagliardi, Luigi
    Lehtonen, Liisa
    Vento, Maximo
    Kusuda, Satoshi
    Bassler, Dirk
    Mori, Rintaro
    Reichman, Brian
    Håkansson, Stellan
    Swedish Neonatal Quality Register, Department of Pediatrics/Neonatal Services, Umeå University Hospital, Umeå, Sweden.
    Darlow, Brian A
    Adams, Mark
    Rusconi, Franca
    San Feliciano, Laura
    Lui, Kei
    Morisaki, Naho
    Musrap, Natasha
    Shah, Prakesh S
    Scoping review shows wide variation in the definitions of bronchopulmonary dysplasia in preterm infants and calls for a consensus2017In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 106, no 3, p. 366-374Article in journal (Refereed)
    Abstract [en]

    The use of different definitions for bronchopulmonary dysplasia (BPD) has been an ongoing challenge. We searched papers published in English from 2010 and 2015 reporting BPD as an outcome, together with studies that compared BPD definitions between 1978 and 2015. We found that the incidence of BPD ranged from 6% to 57%, depending on the definition chosen, and that studies that investigated correlations with long-term pulmonary and/or neurosensory outcomes reported moderate-to-low predictive values regardless of the BPD criteria.

    CONCLUSION: A comprehensive and evidence-based definition for BPD needs to be developed for benchmarking and prognostic use.

  • 13.
    Hoffman, Karin
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Brömster, Therése
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Håkansson, Stellan
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    van den Berg, Johannes
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Monitoring of pain and stress in an infant with asphyxia during induced hypothermia: a case report2013In: Advances in Neonatal Care, ISSN 1536-0903, E-ISSN 1536-0911, Vol. 13, no 4, p. 252-261Article in journal (Refereed)
    Abstract [en]

    The purpose of this article was to study an infant who suffered from asphyxia undergoing induced hypothermia with regard to (1) describe the pain and stress as measured by physiological variables skin conductance algesimeter (SCA) and pain rating scales, (2) the correlation between SCA and pain rating scales, and (3) how temperature cycles in the cooling blanket affect the response of the sympathetic nervous system as measured by the SCA and physiological variables. A single prospective case study was used for this article. Data were recorded every 15 minutes for 96 hours. Each observation was categorized according to treatment phase: cooling 0 to 72 hours, rewarming, and controlled normal temperature up to 96 hours. Structured observations were carried out and all nursing care was documented. In addition, 5 periods with no other nursing interventions were identified in which data were recorded every minute for analysis. Skin conductance algimetry showed a variable response during treatment. During cooling, 68% of the 15-minute periods, signs of stress and pain were recorded. During rewarming, the corresponding figure was 83%. During the time sequences with normal temperature, 89% of the periods were associated with stress and pain. During 80% of the nursing procedures, the SCA showed stress and pain. There was no correlation between the pain-rating scales and SCA. When the cooling blanket temperature was lower than core temperature, the infant had more stress and pain according to SCA (P < .001) and an increase in heart rate and blood pressure (P < .001). In infants during induced hypothermia, SCA seem to detect pain and stress. Future evaluation of SCA for the detection of pain and stress during hypothermia treatment is necessary. Pain-rating scales do not appear reliable in this case report.

  • 14.
    Håkansson, Stellan
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Axemo, Pia
    Department of Obstetrics and Gynecology, Academic Hospital, Uppsala, Sweden.
    Bremme, Katarina
    Department of Women and Child Health, Karolinska Institute, Stockholm, Sweden.
    Bryngelsson, Anna-Lena
    Department of Obstetrics and Gynecology, University Hospital, Örebro, Sweden.
    Wallin, Marie Carlsson
    Department of Obstetrics and Gynecology, Ystad Hospital, Ystad, Sweden.
    Ekström, Carl-Magnus
    Department of Obstetrics and Gynecology, Vrinnevi Hospital, Norrköping, Sweden.
    Granlund, Margareta
    Umeå University, Faculty of Medicine, Department of Clinical Microbiology, Clinical Bacteriology.
    Jacobsson, Bo
    Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Göteborg, Sweden Read More: http://informahealthcare.com/doi/abs/10.1080/00016340701802888.
    Källén, Karin
    Department of Reproductive Epidemiology, Tornblad Institute, Lund University, Lund, Sweden.
    Spetz, Eva
    Department of Obstetrics and Gynecology, Östersund Hospital, Östersund, Sweden.
    Tessin, Ingemar
    Department of Pediatrics, Queen Silvia Children's Hospital, Göteborg, Sweden.
    Group B streptococcal carriage in Sweden: a national study on risk factors for mother and infant colonisation2008In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 87, no 1, p. 50-58Article in journal (Refereed)
    Abstract [en]

    Background: To study group B streptococcus (GBS) colonisation in parturients and infants in relation to obstetric outcome and to define serotypes and antibiotic resistance in GBS isolates acquired.

    Methods: A population-based, national cohort of parturients and their infants was investigated. During 1 calendar week in 2005 all women giving birth (n=1,754) were requested to participate in the study.

    Results: A total of 1,569 mother/infant pairs with obstetric and bacteriological data were obtained. Maternal carriage rate was 25.4% (95% confidence interval (CI): 23.3–27.6). In GBS-positive mothers with vaginal delivery and no intrapartum antibiotics, the infant colonisation rate was 68%. Some 30% of infants were colonised after acute caesarean section, and 0% were colonised after an elective procedure. Duration of transport of maternal recto/vaginal swabs of more than 1 day impeded culture sensitivity. Infant mMales were more frequently colonised than females (76.9 versus 59.8%, odds ratio (OR): 2.16; 95% CI: 1.27–3.70), as were infants born after rupture of membranes ≥24 h (p =0.039). Gestational age, birth weight and duration of labor did not significantly influence infant colonisation. Some 30% of parturients with at least one risk factor for neonatal disease received intrapartum antibiotics. The most common GBS serotypes were type III and V. Some 5% of the isolates were resistant to clindamycin and erythromycin, respectively.

    Conclusions: Maternal GBS prevalence and infant transfer rate were high in Sweden. Males were more frequently colonised than females. The sensitivity of maternal cultures decreased with the duration of sample transport. Clindamycin resistance was scarce. The use of intrapartum antibiotics was limited in parturients with obstetric risk factors for early onset group B streptococcal disease.

     

  • 15.
    Håkansson, Stellan
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Kaellen, Karin
    Bullarbo, Maria
    Holmgren, Per-Åke
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Bremme, Katarina
    Larsson, Åsa
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Norman, Margareta
    Noren, Hakan
    Ortmark-Wrede, Catharina
    Pettersson, Karin
    Saltvedt, Sissel
    Sondell, Birgitta
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Tokarska, Magdalena
    von Vultee, Anna
    Jacobsson, Bo
    Real-time PCR-assay in the delivery suite for determination of group B streptococcal colonization in a setting with risk-based antibiotic prophylaxis2014In: The Journal of Maternal-Fetal & Neonatal Medicine, ISSN 1476-7058, E-ISSN 1476-4954, Vol. 27, no 4, p. 328-332Article in journal (Refereed)
    Abstract [en]

    Objective: Intrapartum antibiotic prophylaxis (IAP) reduces the incidence of neonatal early onset group B streptococcal infections. The present study investigated if an automated PCR-assay, used bedside by the labor ward personnel was manageable and could decrease the use of IAP in a setting with a risk-based IAP strategy. Methods: The study comprises two phases. Phase 1 was a multicenter, randomized, controlled trial. Women with selected risk-factors were allocated either to PCR-IAP (prophylaxis given if positive or indeterminate) or IAP. A vaginal/rectal swab and superficial swabs from the neonate for conventional culture were also obtained. Phase 2 was non-randomized, assessing an improved version of the assay. Results: Phase 1 included 112 women in the PCR-IAP group and 117 in the IAP group. Excluding indeterminate results, the assay showed a sensitivity of 89% and a specificity of 90%. In 44 % of the PCR assays the result was indeterminate. The use of IAP was lower in the PCR group (53 versus 92%). Phase 2 included 94 women. The proportion of indeterminate results was reduced (15%). The GBS colonization rate was 31%. Conclusion: The PCR assay, in the hands of labor ward personnel, can be useful for selection of women to which IAP should be offered.

  • 16.
    Håkansson, Stellan
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Källen, Karin
    Center for Reproductive Epidemiology, Tornblad Institute, Lund University.
    High maternal body mass index increases the risk of neonatal early onset group B streptococcal disease2008In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 97, no 10, p. 1386-1389Article in journal (Refereed)
    Abstract [en]

    Objective: The aim of this study was to analyse the occurrence of neonatal early onset group B streptococcal (EOGBS) disease relative to maternal body mass index (BMI).

    Method: A cohort of Swedish parturients with an early pregnancy BMI registered was investigated. Data were retrieved from population-based registers during 1997–2001, (n = 344 127, elective caesarean section excluded). Medical records of all infants with a diagnosis of EOGBS septicaemia (P36.0) were scrutinized for verification of the diagnosis. There were 136 cases with blood culture-positive septicaemia and 112 cases with clinical infection. Odds ratios (OR) and 95% confidence intervals (CI) were calculated using multiple logistic regression.

    Results: In obese parturients with BMI > 30, there was an 80% increased risk for verified neonatal EOGBS disease (OR 1.8, 95% CI 1.1–3.0). When cases with clinical sepsis were included a significant risk increment was also found in overweight women with BMI 25.0–29.9 (OR 1.5, 95% CI 1.1–2.0).

    Conclusion: Maternal obesity and overweight are risk factors associated with increased risk of neonatal EOGBS disease.

  • 17.
    Håkansson, Stellan
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Lilja, Maria
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Jacobsson, Bo
    Kaellen, Karin
    Reduced incidence of neonatal early-onset group B streptococcal infection after promulgation of guidelines for risk-based intrapartum antibiotic prophylaxis in Sweden: analysis of a national population-based cohort2017In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 96, no 12, p. 1475-1483Article in journal (Refereed)
    Abstract [en]

    IntroductionThis study aimed to investigate the incidence of neonatal early-onset group B streptococcal (GBS) infection in Sweden after promulgation of guidelines (2008) for risk factor-based intrapartum antibiotic prophylaxis, and evaluate the presence of risk factors and obstetric management in mothers. Material and methodsNational registers were searched for infants with early-onset GBS infection during 2006-2011. Medical records of cases and case mothers were abstracted. Verified cases of sepsis/meningitis and cases with clinical sepsis/pneumonia were documented, as well as risk factors in case mothers and timeliness of intrapartum antibiotic prophylaxis administration. ResultsThere were 227 cases with verified infection, with an incidence of 0.34 of live births during the whole period. There was a significant decrease after promulgation of guidelines, from 0.40 to 0.30 parts per thousand [odds ratio (OR) 0.75, 95% confidence interval (CI) 0.57-0.99]. A significant decrease in the number of cases with clinical GBS sepsis/pneumonia was also observed. In parturients with one or more risk factors, the incidence of any GBS infection was reduced by approximately 50% (OR 0.47, 95% CI 0.35-0.64), although there were many cases where the opportunity for timely administration of intrapartum antibiotic prophylaxis was missed. In infants of mothers without risk factor(s) there was no reduction in early-onset GBS morbidity. The mortality in verified cases was 4.8% (95% CI 2.1-7.6). ConclusionsThe introduction of national guidelines for risk-based intrapartum antibiotic prophylaxis coincided with a significant 50% risk reduction of neonatal early-onset GBS infection in infants of parturients presenting with one or more risk factors. A stricter adherence to guidelines could probably have reduced the infant morbidity further.

  • 18.
    Karlsson, Björn-Markus
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Lindkvist, Marie
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Lindkvist, Markus
    Karlsson, Marcus
    Lundström, Ronnie
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Håkansson, Stellan
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Wiklund, Urban
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Radiation Physics.
    van den Berg, Johannes
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Sound and vibration: effects on infants' heart rate and heart rate variability during neonatal transport2012In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 101, no 2, p. 148-154Article in journal (Refereed)
    Abstract [en]

    Aim: To measure the effect of sound and whole-body vibration on infants' heart rate and heart rate variability during ground and air ambulance transport.

    Methods: Sixteen infants were transported by air ambulance with ground ambulance transport to and from the airports. Whole-body vibration and sound levels were recorded and heart parameters were obtained by ECG signal.

    Results: Sound and whole-body vibration levels exceeded the recommended limits. Mean whole-body vibration and sound levels were 0.19m/s(2) and 73dBA, respectively. Higher whole-body vibration was associated with a lower heart rate (p<0.05), and higher sound level was linked to a higher heart rate (p=0.05). The heart rate variability was significantly higher at the end of the transport than at the beginning (p<0.01). Poorer physiologic status was associated with lower heart rate variability (p<0.001) and a lower heart rate (p<0.01). Infants wearing earmuffs had a lower heart rate (p<0.05).

    Conclusions: Sound and whole-body vibration during neonatal transport exceed recommended levels for adults and sound seem to have a more stressful effect on the infant than vibrations. Infants should wear earmuffs during neonatal transport because of the stress reducing effect.

  • 19. Kelly, L E
    et al.
    Shah, P S
    Håkansson, Stellan
    Department of Pediatrics/Neonatal Services, Swedish Neonatal Quality Register, Umeå University Hospital, Umeå, Sweden.
    Kusuda, S
    Adams, M
    Lee, S K
    Sjörs, G
    Department of Pediatrics/Neonatal Services, Swedish Neonatal Quality Register, Umeå University Hospital, Umeå, Sweden.
    Vento, M
    Rusconi, F
    Lehtonen, L
    Reichman, B
    Darlow, B A
    Lui, K
    Feliciano, L S
    Gagliardi, L
    Bassler, D
    Modi, N
    Perinatal health services organization for preterm births: a multinational comparison2017In: Journal of Perinatology, ISSN 0743-8346, E-ISSN 1476-5543, Vol. 37, no 7, p. 762-768Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To explore population characteristics, organization of health services and comparability of available information for very low birth weight or very preterm neonates born before 32 weeks' gestation in 11 high-income countries contributing data to the International Network for Evaluating Outcomes of Neonates (iNeo).

    STUDY DESIGN: We obtained population characteristics from public domain sources, conducted a survey of organization of maternal and neonatal health services and evaluated the comparability of data contributed to the iNeo collaboration from Australia, Canada, Finland, Israel, Italy, Japan, New Zealand, Spain, Sweden, Switzerland and UK.

    RESULTS: All countries have nationally funded maternal/neonatal health care with >90% of women receiving prenatal care. Preterm birth rate, maternal age, and neonatal and infant mortality rates were relatively similar across countries. Most (50 to >95%) between-hospital transports of neonates born at non-tertiary units were conducted by designated transport teams; 72% (8/11 countries) had designated transfer and 63% (7/11 countries) mandate the presence of a physician. The capacity of 'step-down' units varied between countries, with capacity for respiratory care available in <10% to >75% of units. Heterogeneity in data collection processes for benchmarking and quality improvement activities were identified.

    CONCLUSIONS: Comparability of healthcare outcomes for very preterm low birth weight neonates between countries requires an evaluation of differences in population coverage, healthcare services and meta-data.

  • 20. Koller-Smith, Louise I. M.
    et al.
    Shahr, Prakesh S.
    Ye, Xiang Y.
    Sjörs, Gunnar
    Wang, Yueping A.
    Chow, Sharon S. W.
    Darlow, Brian A.
    Lee, Shoo K.
    Håkansson, Stellan
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Lui, Kei
    Comparing very low birth weight versus very low gestation cohort methods for outcome analysis of high risk preterm infants2017In: BMC Pediatrics, ISSN 1471-2431, E-ISSN 1471-2431, Vol. 17, article id 166Article in journal (Refereed)
    Abstract [en]

    Background: Compared to very low gestational age (<32 weeks, VLGA) cohorts, very low birth weight (<1500 g; VLBW) cohorts are more prone to selection bias toward small-for-gestational age (SGA) infants, which may impact upon the validity of data for benchmarking purposes. Method: Data from all VLGA or VLBW infants admitted in the 3 Networks between 2008 and 2011 were used. Two-thirds of each network cohort was randomly selected to develop prediction models for mortality and composite adverse outcome (CAO: mortality or cerebral injuries, chronic lung disease, severe retinopathy or necrotizing enterocolitis) and the remaining for internal validation. Areas under the ROC curves (AUC) of themodels were compared. Results: VLBW cohort (24,335 infants) had twice more SGA infants (20.4% vs. 9.3%) than the VLGA cohort (29,180 infants) and had a higher rate of CAO (36.5% vs. 32.6%). The two models had equal prediction power for mortality and CAO (AUC 0.83), and similarly for all other cross-cohort validations (AUC 0.81-0.85). Neither model performed well for the extremes of birth weight for gestation (<1500 g and >= 32 weeks, AUC 0.50-0.65; >= 1500 g and >= 32 weeks, AUC 0.60-0.62). Conclusion: There was no difference in prediction power for adverse outcome between cohorting VLGA or VLBW despite substantial bias in SGA population. Either cohorting practises are suitable for international benchmarking.

  • 21. Luthander, Charlotte Millde
    et al.
    Kallen, Karin
    Nyström, Monica E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Departmentof Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institute, Stockholm.
    Hogberg, Ulf
    Håkansson, Stellan
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Harenstam, Karin P.
    Grunewald, Charlotta
    Results from the National Perinatal Patient Safety Program in Sweden: the challenge of evaluation2016In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 95, no 5, p. 596-603Article in journal (Refereed)
    Abstract [en]

    Introduction: We studied the effects of the national Perinatal Patient Safety Program in Sweden, addressing local improvement measures, changes in the proportion of low Apgar score and the number of settled injury claims due to asphyxia.

    Material and methods: Final reports on achieved improvements from all Swedish obstetric units were analyzed and categories of the improvement measures taken in perinatal risk areas were established. Data on all term newborns during 2006–12 were obtained from the Medical Birth Registry. Incidence of 5-min Apgar score <7 was analyzed before, during and after the intervention. The odds ratio for low Apgar score in period ÍII vs. period I was calculated. Patient injury claims from The Swedish National Patient Insurance Company (LÖF) were analyzed.

    Results: Numerous local improvement initiatives were reported. The incidence of 5-min Apgar score <7 on a national level remained unchanged during the study periods. The units with the highest rate of Apgar score <7 showed a significant decrease in Apgar score of 4–6 after the intervention, whereas units with the lowest rate of Apgar score <7 showed a significant increase in Apgar score <7 after the intervention. A decline in settled claims due to substandard care was observed (7.5%, 2012–14; p for trend 0.049).

    Conclusion: The national incidence of low Apgar score remained unchanged but a reduction of settled claims of severely asphyxiated neonates was observed. The study highlights the need for robust designs when evaluating large-scale initiatives for improving patient safety at delivery, along with the difficulties in performing them.

  • 22. Martin, Lisa J
    et al.
    Sjörs, Gunnar
    Reichman, Brian
    Darlow, Brian A
    Morisaki, Naho
    Modi, Neena
    Bassler, Dirk
    Mirea, Lucia
    Adams, Mark
    Kusuda, Satoshi
    Lui, Kei
    Feliciano, Laura San
    Håkansson, Stellan
    Swedish Neonatal Quality Register, Department of Pediatrics/Neonatal Services, Umeå University Hospital, Umeå, Sweden.
    Isayama, Tetsuya
    Mori, Rintaro
    Vento, Max
    Lee, Shoo K
    Shah, Prakesh S
    Country-Specific vs. Common Birthweight-for-Gestational Age References to Identify Small for Gestational Age Infants Born at 24-28 weeks: an International Study2016In: Paediatric and Perinatal Epidemiology, ISSN 0269-5022, E-ISSN 1365-3016, Vol. 30, no 5, p. 450-461Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Controversy exists as to whether birthweight-for-gestational age references used to classify infants as small for gestational age (SGA) should be country specific or based on an international (common) standard. We examined whether different birthweight-for-gestational age references affected the association of SGA with adverse outcomes among very preterm neonates.

    METHODS: Singleton infants (n = 23 788) of 24(0) -28(6) weeks' gestational age in nine high-resource countries were classified as SGA (<10th centile) using common and country-specific references based on birthweight and estimated fetal weight (EFW). For each reference, the adjusted relative risk (aRR) for the association of SGA with composite outcome of mortality or major morbidity was estimated.

    RESULTS: The percentage of infants classified as SGA differed slightly for common compared with country specific for birthweight references [9.9% (95% CI 9.5, 10.2) vs. 11.1% (95% CI 10.7, 11.5)] and for EFW references [28.6% (95% CI 28.0, 29.2) vs. 24.6% (95% CI 24.1, 25.2)]. The association of SGA with the composite outcome was similar when using common or country-specific references for the total sample for birthweight [aRRs 1.47 (95% CI 1.43, 1.51) and 1.48 (95% CI 1.44, 1.53) respectively] and for EFW references [aRRs 1.35 (95% CI 1.31, 1.38) and 1.39 (95% CI 1.35, 1.43) respectively].

    CONCLUSION: Small for gestational age is associated with higher mortality and morbidity in infants born <29 weeks' gestational age. Although common and country-specific birthweight/EFW references identified slightly different proportions of SGA infants, the risk of the composite outcome was comparable.

  • 23. Persson, Martina
    et al.
    Shah, Prakesh S.
    Rusconi, Franca
    Reichman, Brian
    Modi, Neena
    Kusuda, Satoshi
    Lehtonen, Liisa
    Håkansson, Stellan
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Yang, Junmin
    Isayama, Tetsuya
    Beltempo, Marc
    Lee, Shoo
    Norman, Mikael
    Association of Maternal Diabetes With Neonatal Outcomes of Very Preterm and Very Low-Birth-Weight Infants: an International Cohort Study2018In: JAMA pediatrics, ISSN 2168-6203, E-ISSN 2168-6211, Vol. 172, no 9, p. 867-875Article in journal (Refereed)
    Abstract [en]

    IMPORTANCE: Diabetes in pregnancy is associated with a 2-times to 3-times higher rate of very preterm birth than in women without diabetes. Very preterm infants are at high risk of death and severe morbidity. The association of maternal diabetes with these risks is unclear.

    OBJECTIVE: To determine the associations between maternal diabetes and in-hospital mortality, as well as neonatal morbidity in very preterm infants with a birth weight of less than 1500 g.

    DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study was conducted at 7 national networks in high-income countries that are part of the International Neonatal Network for Evaluating Outcomes in Neonates and used prospectively collected data on 76 360 very preterm, singleton infants without malformations born between January 1, 2007, and December 31, 2015, at 24 to 31 weeks' gestation with birth weights of less than 1500 g, 3280 (4.3%) of whom were born to diabetic mothers. EXPOSURES Any type of diabetes during pregnancy.

    MAIN OUTCOMES AND MEASURES: The primary outcome was in-hospital mortality. The secondary outcomes were severe neonatal morbidities, including intraventricular hemorrhages of grade 3 to 4, cystic periventricular leukomalacia, retinopathy of prematurity needing treatment and bronchopulmonary dysplasia, and other morbidities, including respiratory distress, treated patent ductus arteriosus, and necrotizing enterocolitis. Odds ratios (ORs) with 95% confidence intervals were estimated, adjusted for potential confounders, and stratified by gestational age (GA), sex, and network.

    RESULTS: The mean (SD) birth weight of offspring born to mothers with diabetes was significantly higher at 1081 (262) g than in offspring born to mothers without diabetes (mean [SD] birth weight, 1027 [270] g). Of 76 360 infants, 25 962 (34%) and 33 598 (44%) were born before 28 weeks of gestation to mothers with and without diabetes, respectively. Mothers with diabetes were older and had more hypertensive disorders, antenatal steroid treatments, and deliveries by cesarean delivery than mothers without diabetes. Infants of mothers with diabetes were born at a later GA than infants of mothers without diabetes. In-hospital mortality (6.6% vs 8.3%) and the composite of mortality and severe morbidity (31.6% vs 40.6%) were lower in infants of mothers with diabetes. However, in adjusted analyses, no significant differences in in-hospital mortality (adjusted OR, 1.16 (95% CI, 0.97-1.39) or the composite of mortality and severe morbidity (adjusted OR, 0.99 (95% CI, 0.88-1.10) were observed. With few exceptions, outcomes of infants born to mothers with and without diabetes were similar regardless of infant sex, GA, or country of birth.

    CONCLUSIONS AND RELEVANCE: In high-resource settings, maternal diabetes is not associated with an increased risk of in-hospital mortality or severe morbidity in very preterm infants with a birth weight of fewer than 1500 g.

  • 24. Refsum, Erle
    et al.
    Håkansson, Stellan
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Mortberg, Anette
    Wikman, Agneta
    Westgren, Magnus
    Intracranial hemorrhages in neonates born from 32 weeks of gestation - low frequency of associated fetal and neonatal alloimmune thrombocytopenia: a register-based study2018In: Transfusion, ISSN 0041-1132, E-ISSN 1537-2995, Vol. 58, no 1, p. 223-231Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is a rare condition, with an estimated incidence of one in 1000 to 2000 live births. Predominantly, FNAIT is due to maternal alloantibodies that target paternally derived human platelet antigen (HPA) 1a. The most feared complication is an intracranial hemorrhage (ICH). The aim of this study was to determine the frequency of associated maternal platelet (PLT) alloimmunization in a population of neonates born from 32 weeks of gestation and diagnosed with an ICH.

    STUDY DESIGN AND METHODS: The Swedish Neonatal Quality (SNQ) register was used to identify neonates diagnosed with an ICH born between 2003 and 2012. Mothers were invited to donate peripheral blood, to investigate their HPA-1a antigen status, and test for anti-HPA and anti-HLA Class I alloantibodies. Clinical data for the neonates were retrieved from the SNQ register and available clinical records.

    RESULTS: Of 286 registered neonates, 278 mothers were contacted. Of 105 analyzed maternal samples, two (1.9%) were HPA-1a antigen negative. Antibody analyses revealed in total three (2.9%) mothers with anti-HPA: one mother (0.94%) with anti-HPA-1a and two mothers (1.9%) with anti-HPA-5b, of whom one had concurrent anti-HPA-15a. Twenty-four percent tested positive for anti-HLA Class I antibodies. A total of 8.5% of neonates (5/59) with PLT counts available in clinical records were severely thrombocytopenic, with PLT counts of less than 50 × 109/L.

    CONCLUSIONS: This retrospective cohort revealed a wide range of factors associated with ICH in neonates born from 32 weeks of gestation and suggests PLT alloimmunization to be a less common contributor than anticipated.

  • 25. Shah, Prakesh S.
    et al.
    Lee, Shoo K.
    Lui, Kei
    Sjors, Gunnar
    Mori, Rintaro
    Reichman, Brian
    Håkansson, Stellan
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Feliciano, Laura San
    Modi, Neena
    Adams, Mark
    Darlow, Brian
    Fujimura, Masanori
    Kusuda, Satoshi
    Haslam, Ross
    Mirea, Lucia
    The International Network for Evaluating Outcomes of very low birth weight, very preterm neonates (iNeo): a protocol for collaborative comparisons of international health services for quality improvement in neonatal care2014In: BMC Pediatrics, ISSN 1471-2431, E-ISSN 1471-2431, Vol. 14, p. 110-Article in journal (Refereed)
    Abstract [en]

    Background: The International Network for Evaluating Outcomes in Neonates (iNeo) is a collaboration of population-based national neonatal networks including Australia and New Zealand, Canada, Israel, Japan, Spain, Sweden, Switzerland, and the UK. The aim of iNeo is to provide a platform for comparative evaluation of outcomes of very preterm and very low birth weight neonates at the national, site, and individual level to generate evidence for improvement of outcomes in these infants. Methods/design: Individual-level data from each iNeo network will be used for comparative analysis of neonatal outcomes between networks. Variations in outcomes will be identified and disseminated to generate hypotheses regarding factors impacting outcome variation. Detailed information on physical and environmental factors, human and resource factors, and processes of care will be collected from network sites, and tested for association with neonatal outcomes. Subsequently, changes in identified practices that may influence the variations in outcomes will be implemented and evaluated using quality improvement methods. Discussion: The evidence obtained using the iNeo platform will enable clinical teams from member networks to identify, implement, and evaluate practice and service provision changes aimed at improving the care and outcomes of very low birth weight and very preterm infants within their respective countries. The knowledge generated will be available worldwide with a likely global impact.

  • 26. Shah, Prakesh S.
    et al.
    Lui, Kei
    Sjors, Gunnar
    Mirea, Lucia
    Reichman, Brian
    Adams, Mark
    Modi, Neena
    Darlow, Brian A.
    Kusuda, Satoshi
    Feliciano, Laura San
    Yang, Junmin
    Håkansson, Stellan
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Mori, Rintaro
    Bassler, Dirk
    Figueras-Aloy, Josep
    Lee, Shoo K.
    Neonatal Outcomes of Very Low Birth Weight and Very Preterm Neonates: An International Comparison2016In: Journal of Pediatrics, ISSN 0022-3476, E-ISSN 1097-6833, Vol. 177, p. 144-152Article in journal (Refereed)
    Abstract [en]

    Objective To compare rates of a composite outcome of mortality or major morbidity in very-preterm/very low birth weight infants between 8 members of the International Network for Evaluating Outcomes.

    Study design We included 58 004 infants born weighing < 1500 g at 24 degrees-31(6) weeks' gestation from databases in Australia/New Zealand, Canada, Israel, Japan, Spain, Sweden, Switzerland, and the United Kingdom. We compared a composite outcome (mortality or any of grade >= 3 peri-intraventricular hemorrhage, periventricular echodensity/echolucency, bronchopulmonary dysplasia, or treated retinopathy of prematurity) between each country and all others by using standardized ratios and pairwise using logistic regression analyses.

    Results Despite differences in population coverage, included neonates were similar at baseline. Composite outcome rates varied from 26% to 42%. The overall mortality rate before discharge was 10% (range: 5% [Japan]-17% [Spain]). The standardized ratio (99% CIs) estimates for the composite outcome were significantly greater for Spain 1.09 (1.04-1.14) and the United Kingdom 1.16 (1.11-1.21), lower for Australia/New Zealand 0.93 (0.89-0.97), Japan 0.89 (0.86-0.93), Sweden 0.81 (0.73-0.90), and Switzerland 0.77 (0.69-0.87), and nonsignificant for Canada 1.04 (0.99-1.09) and Israel 1.00 (0.93-1.07). The adjusted odds of the composite outcome varied significantly in pairwise comparisons.

    Conclusions We identified marked variations in neonatal outcomes between countries. Further collaboration and exploration is needed to reduce variations in population coverage, data collection, and case definitions. The goal would be to identify carepractices and health care organizational factors, which has the potential to improve neonatal outcomes.

  • 27. Smith, Lucy K.
    et al.
    Morisaki, Naho
    Morken, Nils-Halvdan
    Gissler, Mika
    Deb-Rinker, Paromita
    Rouleau, Jocelyn
    Håkansson, Stellan
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Kramer, Michael R.
    Kramer, Michael S.
    An International Comparison of Death Classification at 22 to 25 Weeks' Gestational Age2018In: Pediatrics, ISSN 0031-4005, E-ISSN 1098-4275, Vol. 142, no 1, article id e20173324Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To explore international differences in the classification of births at extremely low gestation and the subsequent impact on the calculation of survival rates.

    METHODS: We used national data on births at 22 to 25 weeks' gestation from the United States (2014; n = 11144), Canada (2009-2014; n = 5668), the United Kingdom (2014-2015; n = 2992), Norway (2010-2014; n = 409), Finland (2010-2015; n = 348), Sweden (2011-2014; n = 489), and Japan (2014-2015; n = 2288) to compare neonatal survival rates using different denominators: all births, births alive at the onset of labor, live births, live births surviving to 1 hour, and live births surviving to 24 hours.

    RESULTS: For births at 22 weeks' gestation, neonatal survival rates for which we used live births as the denominator varied from 3.7% to 56.7% among the 7 countries. This variation decreased when the denominator was changed to include stillbirths (ie, all births [1.8%-22.3%] and fetuses alive at the onset of labor [3.7%-38.2%]) or exclude early deaths and limited to births surviving at least 12 hours (50.0%-77.8%). Similar trends were seen for infants born at 23 weeks' gestation. Variation diminished considerably at 24 and 25 weeks' gestation.

    CONCLUSIONS: International variation in neonatal survival rates at 22 to 23 weeks' gestation diminished considerably when including stillbirths in the denominator, revealing the variation arises in part from differences in the proportion of births reported as live births, which itself is closely connected to the provision of active care.

  • 28.
    Törnell, Siv
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Ekeus, C.
    Hultin, Magnus
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Håkansson, Stellan
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Thunberg, Johan
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Högberg, U.
    Low Apgar score, neonatal encephalopathy and epidural analgesia during labour: a Swedish registry-based study2015In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 59, no 4, p. 486-495Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Maternal intrapartum fever (MF) is associated with neonatal sequelae, and women in labour who receive epidural analgesia (EA) are more likely to develop hyperthermia. The aims of this study were to investigate if EA and/or a diagnosis of MF were associated to adverse neonatal outcomes at a population level. METHODS: Population-based register study with data from the Swedish Birth Register and the Swedish National Patient Register, including all nulliparae (n = 294,329) with singleton pregnancies who gave birth at term in Sweden 1999-2008. Neonatal outcomes analysed were Apgar score (AS) < 7 at 5 min and ICD-10 diagnosis of neonatal encephalopathy (e.g. convulsions or neonatal cerebral ischaemia). Multivariate logistic regression was used to calculate adjusted odds ratios (AOR) with 95% confidence intervals (CI). RESULTS: EA was used in 44% of the deliveries. Low AS or encephalopathy was found in 1.26% and 0.39% of the children in the EA group compared with 0.80% and 0.29% in the control group. In multivariate analysis, EA was associated with increased risk with low AS, AOR 1.27 (95% CI 1.16-1.39), but not with diagnosis of encephalopathy, 1.11 (0.96-1.29). A diagnosis of MF was associated with increased risk for both low AS, 2.27 (1.71-3.02), and of neonatal encephalopathy, 1.97 (1.19-3.26). CONCLUSION: Diagnosis of MF was associated with low AS and neonatal encephalopathy, whereas EA was only associated with low AS and not with neonatal encephalopathy. The found associations might be a result of confounding by indication, which is difficult to assess in a registry-based population study.

  • 29.
    van den Berg, Johannes
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Olsson, Linn
    Umeå University, Faculty of Medicine, Department of Nursing.
    Svensson, Amelie
    Umeå University, Faculty of Medicine, Department of Nursing.
    Håkansson, Stellan
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Adverse events during air and ground neonatal transport: 13 years' experience from a neonatal transport team in Northern Sweden2015In: The Journal of Maternal-Fetal & Neonatal Medicine, ISSN 1476-7058, E-ISSN 1476-4954, Vol. 28, no 10, p. 1231-1237Article in journal (Refereed)
    Abstract [en]

    Objective: To study the prevalence of adverse events (AEs) associated with neonatal transport, and to categorize, classify and assess the risk estimation of these events.

    Methods: Written comments in 1082 transport records during the period 1999-2011 were reviewed. Comments related to events that infringed on patient and staff safety were included as AEs, and categorized and further classified as complaint, imminent risk of incident/negative event, actual incident or actual negative event. AEs were also grouped into emergency or planned transports, and risk estimation was calculated according to a risk assessment tool and defined as low, intermediate, high or extreme risk.

    Results: AEs (N = 883) were divided into five categories: logistics (n = 337), organization (n = 177), equipment (n = 165), vehicle (n = 129) and medical/nursing care (n = 75). Eighty-five percent of AEs were classified as incidents or negative events. The majority of AEs were estimated to be of low or intermediate risk in both planned and emergency transports. AEs estimated to be of high or extreme risk were significantly more frequent in emergency transports (OR = 10.1; 95% CI: 5.0-20.9; p < 0.001).

    Conclusion: AEs are common in both planned and emergency neonatal transport, often related to imperfect transport logistics or equipment failure. AEs of high or extreme risk were more frequent in emergency transports.

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