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  • 1.
    Alm, Stina
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Stoltz Sjöström, Elisabeth
    Umeå University, Faculty of Social Sciences, Department of Food and Nutrition.
    Nilsson Sommar, Johan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Domellöf, Magnus
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Erythrocyte transfusions increased the risk of elevated serum ferritin in very low birth weight infants and were associated with altered longitudinal growth2019In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227Article in journal (Refereed)
    Abstract [en]

    Aim: There has been a lack of population‐based longitudinal data on serum ferritin in very low birth weight (VLBW) infants during hospitalisation. Our aim was to fill this gap in the knowledge and investigate risk factors for elevated serum ferritin and associations between erythrocyte transfusions and longitudinal growth.

    Methods: We retrospectively reviewed longitudinal data on 126 VLBW infants treated at Umeå University Hospital, Sweden, between 2010‐2013.

    Results: The infants’ mean gestational age and birth weight were 26.9 weeks and 899 grams. Most (91%) received erythrocyte transfusions and the majority had multiple erythrocyte transfusions. There was a significant correlation between serum ferritin and the volume of transfusions. Almost two‐thirds had at least one serum ferritin measurement of more than 350 µg/L, indicating iron overload. In those with complete anthropometric data (n=78) there was no significant effect of serum ferritin concentrations in relation to longitudinal growth, but there was a positive association between the erythrocyte transfusion dose and longitudinal growth in VLBW infants born before 25 weeks.

    Conclusion: This is the first population‐based study to investigate longitudinal data on serum ferritin in VLBW infants during hospitalisation. The unexpected positive finding in the subgroup born at less than 25 weeks needs further research with a larger cohort.

  • 2.
    Challis, Pontus
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Larsson, Linn
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Stoltz Sjöström, Elisabeth
    Umeå University, Faculty of Social Sciences, Department of Food and Nutrition.
    Serenius, Fredrik
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics. Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden.
    Domellöf, Magnus
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Elfvin, Anders
    Validation of the diagnosis of necrotising enterocolitis in a Swedish population-based observational study2019In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 108, no 5, p. 835-841Article in journal (Refereed)
    Abstract [en]

    Aim: The definition of necrotising enterocolitis (NEC) is based on clinical and radiological signs that can be difficult to interpret. The aim of the present study was to validate the incidence of NEC in the Extremely Preterm Infants in Sweden Study (EXPRESS)

    Methods: The EXPRESS study consisted of all 707 infants born before 27 + 0 gestational weeks during the years 2004–2007 in Sweden. Of these infants, 38 were recorded as having NEC of Bell stage II or higher. Hospital records were obtained for these infants. Furthermore, to identify missed cases, all infants with a sudden reduction of enteral nutrition, in the EXPRESS study were identified (n = 71). Hospital records for these infants were obtained. Thus, 108 hospital records were obtained and scored independently by two neonatologists for NEC.

    Results: Of 38 NEC cases in the EXPRESS study, 26 were classified as NEC after validation. Four cases not recorded in the EXPRESS study were found. The incidence of NEC decreased from 6.3% to 4.3%.

    Conclusion: Validation of the incidence of NEC revealed over- and underestimation of NEC in the EXPRESS study despite carefully collected data. Similar problems may occur in other national data sets or quality registers.

  • 3.
    Domellöf, Magnus
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Stoltz Sjöström, Elisabeth
    Umeå University, Faculty of Social Sciences, Department of Food and Nutrition. Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Enteral Iron Supplementation in Preterm Infants: Response to Letter to the Editor2017In: Journal of Pediatric Gastroenterology and Nutrition - JPGN, ISSN 0277-2116, E-ISSN 1536-4801, Vol. 64, no 1, p. e26-Article in journal (Refereed)
  • 4. Klevebro, Susanna
    et al.
    Westin, Vera
    Stoltz Sjöström, Elisabeth
    Umeå University, Faculty of Social Sciences, Department of Food and Nutrition.
    Norman, Mikael
    Domellöf, Magnus
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Edstedt Bonamy, Anna-Karin
    Hallberg, Boubou
    Early energy and protein intakes and associations with growth, BPD and ROP in extremely preterm infants2019In: Clinical Nutrition, ISSN 0261-5614, E-ISSN 1532-1983, Vol. 38, no 3, p. 1289-1295Article in journal (Refereed)
    Abstract [en]

    Background & aim: Extremely preterm infants face substantial neonatal morbidity. Nutrition is important to promote optimal growth and organ development in order to reduce late neonatal complications. The aim of this study was to examine the associations of early nutritional intakes on growth and risks of bronchopulmonary dysplasia (BPD) and retinopathy of prematurity (ROP) in a high-risk population.

    Methods: This population-based cohort study includes infants born before 27 0/7 weeks of gestational age without severe malformations and surviving ≥10 days. Intake of energy and protein on postnatal days 4–6 and association with weight standard deviation score (WSDS) from birth to day 7, as well as intakes of energy and protein on postnatal days 4–6 and 7 to 27, respectively, and association with composite outcome of death and BPD and separate outcomes of BPD and ROP were examined, and adjusted for potential confounders.

    Results: The cohort comprised 296 infants with a median gestational age of 25 3/7 weeks. Expressed as daily intakes, every additional 10 kcal/kg/d of energy during days 4–6 was associated with 0.08 higher WSDS on day 7 (95% CI 0.06–0.11; p < 0.001). Between days 7 and 27, every 10 kcal/kg/d increase in energy intake was associated with a reduced risk of BPD of 9% (95% CI 1–16; p = 0.029) and any grade of ROP with a reduced risk of 6% (95% CI 2–9; p = 0.005) in multivariable models. This association was statistically significant in infants with ≤10 days of mechanical ventilation. In infants with >10 days of mechanical ventilation, a combined higher intake of energy and protein was associated with a reduced risk of BPD.

    Conclusion: Early provision of energy and protein may reduce postnatal weight loss and risk of morbidity in extremely preterm infants.

  • 5.
    Larsson, Linn
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences.
    Challis, Pontus
    Umeå University, Faculty of Medicine, Department of Clinical Sciences.
    Späth, Cornelia
    Umeå University, Faculty of Medicine, Department of Clinical Sciences.
    Stoltz Sjöström, Elisabeth
    Umeå University, Faculty of Medicine, Department of Clinical Sciences.
    Domellöf, Magnus
    Umeå University, Faculty of Medicine, Department of Clinical Sciences.
    Blood transfusions are not a risk factor for necrotizing enterocolitis in extremely preterm infants2014Conference paper (Refereed)
  • 6. Lundgren, Pia
    et al.
    Stoltz Sjöström, Elisabeth
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Domellöf, Magnus
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Källen, Karin
    Holmström, Gerd
    Hård, Anna-Lena
    Smith, Lois E.
    Löfqvist, Chatarina
    Hellström, Ann
    WINROP identifies severe retinopathy of prematurity at an early stage in a nation-based cohort of extremely preterm infants2013In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 8, no 9, article id e73256Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To evaluate the ability of a postnatal weight-gain algorithm (WINROP) to identify sight-threatening retinopathy of prematurity (ROP type 1) in a nation-based extremely preterm infant cohort.

    METHODS: This study enrolled all 707 live-born extremely preterm (gestational age [GA] <27 weeks) infants, born 2004-2007 in Sweden; the Extremely preterm Infants in Sweden Study (EXPRESS). WINROP analysis was performed retrospectively in 407 of the infants using weekly weight gain to assess the preterm infant's risk of developing ROP type 1 requiring treatment. GA, birthweight (BW), and weekly postnatal weight measurements were entered into WINROP. WINROP signals with an alarm to indicate if the preterm infant is at risk for ROP type 1.

    RESULTS: In this extremely preterm population, WINROP correctly identified 96% (45/47) of the infants who required treatment for ROP type 1. The median time from alarm to treatment was 9 weeks (range, 4-20 weeks).

    CONCLUSIONS: WINROP, an online surveillance system using weekly weight gain, identified extremely preterm infants at risk for ROP type 1 requiring treatment at an early stage and with high sensitivity in a Swedish nation-based cohort.

  • 7. Lundgren, Pia
    et al.
    Stoltz Sjöström, Elisabeth
    Umeå University, Faculty of Social Sciences, Department of Food and Nutrition.
    Domellöf, Magnus
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Smith, Lois
    Wu, Carolyn
    VanderVeen, Deborah
    Hellström, Ann
    Löfqvist, Chatarina
    The specificity of the WINROP algorithm can be significantly increased by reassessment of the WINROP alarm2015In: Neonatology, ISSN 1661-7800, E-ISSN 1661-7819, Vol. 108, no 2, p. 152-156Article in journal (Refereed)
    Abstract [en]

    Background: Retinopathy of prematurity (ROP) is a sight-threatening disease affecting extremely preterm infants. The introduction of new ROP screening surveillance systems, with higher sensitivity and specificity than established ROP screening guidelines, has the potential to reduce the number of stressful eye examinations in these infants.

    Objectives: To improve the specificity of the WINROP (Weight, Insulin-like growth factor-I, Neonatal, ROP) surveillance system, identifying extremely preterm infants requiring treatment for ROP.

    Methods: Two cohorts that had previously been subjected to WINROP analyses were included and reevaluated in this study. The weight at WINROP alarm for extremely preterm infants, born at gestational age <27 weeks, was reevaluated and by establishing 'safe' WINROP alarm weight limits, an intersample reassessment of WINROP alarm was performed. The two cohorts were as follows: (1) the Extremely Preterm Infants in Sweden Study (EXPRESS) cohort, infants born in Sweden during 2004-2007 (n = 407), and (2) extremely preterm infants in a North American co-hort, born during 2006-2009 (n = 566).

    Results: In the EXPRESS cohort, 12.5% (40/319) of the infants who previously received a WINROP alarm were now reassessed as having no alarm; the specificity of WINROP in EXPRESS increased from 23.9% (86/360) to 35.0% (126/360). In the North American cohort, 15.4% (81/526) were reassessed as having no alarm; the specificity increased from 8.5% (38/447) to 26.6% (119/447). The sensitivity persisted as 97.5% in EXPRESS (45/47) and 98.3% (117/119) in the North American cohort.

    Conclusions: The specificity of the WINROP surveillance system for extremely preterm infants can be significantly improved by reassessment using the weight at WINROP alarm.

  • 8.
    Späth, Cornelia
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences.
    Domellöf, Magnus
    Umeå University, Faculty of Medicine, Department of Clinical Sciences.
    Stoltz Sjöström, Elisabeth
    Umeå University, Faculty of Social Sciences, Department of Food and Nutrition.
    Effects of two different parenteral nutrition regimen on plasma electrolyte concentrations in very low birth weight infantsManuscript (preprint) (Other academic)
    Abstract [en]

    Introduction: Recent studies demonstrated an increased prevalence of electrolyte imbalances in preterm infants who received enhanced amounts of energy and protein within the first days after birth. The aim of this study was to investigate the effect of two parenteral nutritional (PN) regimen, which differ in energy and protein content, on intakes and plasma concentrations of electrolytes in very low birth weight (VLBW, < 1500 g) infants.

    Methods: We collected daily nutritional, growth, and nutritional biomarker data retrospectively from clinical charts for VLBW infants born before (n = 81) and after (n = 53) the implementation of a concentrated PN regimen at the neonatal intensive care unit at Umeå University Hospital (Umeå, Sweden).

    Results: During the first postnatal week, intakes of energy, protein, sodium, potassium, calcium, and phosphorous were significantly higher in infants who received the concentrated PN regimen compared with infants who received the original PN regimen. The prevalence of hypernatremia, hypophosphatemia, and hypercalcemia did not differ significantly between the groups. However, infants who received concentrated PN were less likely to develop hypokalaemia during the first postnatal week compared with infants who received original PN (30 vs. 76%, P < 0.001).

    Conclusion: A concentrated, energy- and protein-optimized, PN regimen requires careful adjustments of electrolytes in VLBW infants. During the first three postnatal days, a minimum potassium intake of 1 mmol/kg/d might be necessary to prevent early hypokalaemia. The risk of early hypernatremia was not affected by different sodium intakes.

  • 9.
    Späth, Cornelia
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Stoltz Sjöström, Elisabeth
    Umeå University, Faculty of Social Sciences, Department of Food and Nutrition.
    Ahlsson, Fredrik
    Uppsala universitet.
    Ågren, Johan
    Uppsala universitet.
    Domellöf, Magnus
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Sodium supply influences plasma sodium concentration and the risks of hyper- and hyponatremia in extremely preterm infants2017In: Pediatric Research, ISSN 0031-3998, E-ISSN 1530-0447, Vol. 81, p. 455-460Article in journal (Refereed)
    Abstract [en]

    Background: Hyper- and hyponatremia occur frequently in extremely preterm infants. Our purpose was to investigate plasma sodium (P-Na) concentrations, the incidence of hyper and hyponatremia, and the impact of possible predisposing factors in extremely preterm infants.

    Methods: In this observational study, we analyzed data from the EXtremely PREterm (< 27 wk.) infants in Sweden Study (EXPRESS, n = 707). Detailed nutritional, laboratory, and weight data were collected retrospectively from patient records.

    Results: Mean ± SD P-Na increased from 135.5 ± 3.0 at birth to 144.3 ± 6.1 mmol/l at a postnatal age of 3 d and decreased thereafter. Fifty percent of infants had hypernatremia (P-Na >145 mmol/l) during the first week of life while 79% displayed hyponatremia (P-Na < 135 mmol/l) during week 2. Initially, the main sodium sources were blood products and saline injections/infusions, gradually shifting to parenteral and enteral nutrition towards the end of the first week. The major determinant of P-Na and the risks of hyper- and hyponatremia was sodium supply. Fluid volume provision was associated with postnatal weight change but not with P-Na.

    Conclusion: The supply of sodium, rather than fluid volume, is the major factor determining P-Na concentrations and the risks of hyper- and hyponatremia.

  • 10.
    Späth, Cornelia
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences.
    Stoltz Sjöström, Elisabeth
    Umeå University, Faculty of Medicine, Department of Clinical Sciences.
    Domellöf, Magnus
    Umeå University, Faculty of Medicine, Department of Clinical Sciences.
    Effects Of Early Sodium And Fluid Intakes On Sodium Levels And Weight Change In Extremely Preterm Infants2014Conference paper (Refereed)
  • 11.
    Späth, Cornelia
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences.
    Stoltz Sjöström, Elisabeth
    Umeå University, Faculty of Social Sciences, Department of Food and Nutrition.
    Ågren, Johan
    Ahlsson, Fredrik
    Domellöf, Magnus
    Umeå University, Faculty of Medicine, Department of Clinical Sciences.
    Associations between sodium supply, sodium imbalances and severe intraventricular haemorrhage in extremely preterm infants: A nested case-control studyManuscript (preprint) (Other academic)
    Abstract [en]

    Background: Severe intraventricular haemorrhage (IVH) is a serious neonatal morbidity among extremely preterm infants that has been associated with adverse neurodevelopmental consequences. We aimed to explore the associations between sodium supply, sodium imbalances and severe IVH.

    Methods: We used data from the EXtremely PREterm Infants in Sweden Study (EXPRESS) including all extremely preterm infants (< 27 weeks) born during 2004 and 2007 in Sweden (n = 707) and conducted a nested case-control study. For every infant with severe IVH (grades 3 to 4, n = 70) one control infant with a normal cranial ultrasound, a birthday closest to the case infant, and matched for hospital, sex, gestational age, and birth weight was selected.

    Results: Sodium supply was higher in infants with severe IVH compared with controls [Daily sodium supply until postnatal day 2: Mean ± SD (mmol/kg/d): 5.49 ± 2.53 vs. 3.95 ± 1.91, P = 0.009]. This association did not remain significant when we excluded the amount of sodium delivered from transfused blood products from total sodium supply. High concentrations of or large fluctuations in plasma sodium were not related to severe IVH.

    Conclusion: Although our results suggest a relationship between sodium supply and severe IVH via blood product transfusions, it is unclear whether this represents an effect of solute or volume load.

  • 12.
    Späth, Cornelia
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Zamir, Itay
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Stoltz Sjöström, Elisabeth
    Umeå University, Faculty of Social Sciences, Department of Food and Nutrition.
    Domellöf, Magnus
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Use of concentrated parenteral nutrition solutions is associated with improved nutrient intakes and postnatal growth in very low-birth-weight infants2020In: JPEN - Journal of Parenteral and Enteral Nutrition, ISSN 0148-6071, E-ISSN 1941-2444, Vol. 44, no 2, p. 327-336Article in journal (Refereed)
    Abstract [en]

    Background: Evidence showing the beneficial effects of enhanced parenteral nutrition (PN) to very low-birth-weight (VLBW,<1500 g) infants is accumulating. However, PN composition and its impact on growth outcomes are questioned. This study aimed to investigate the associations between administration of a concentrated PN regime and intakes of energy and macronutrients as well as postnatal growth in VLBW infants. 

    Methods: We compared 2 cohorts of VLBW infants born before (n = 74) and after (n =44) a concentrated PN regime was introduced into clinical use. Daily nutrition and fluid intake during the first 28 postnatal days and all available growth measurements during hospitalization were retrospectively collected from clinical charts. 

    Results: Infants who received concentrated PN compared with original PN had higher parenteral intakes of energy (56 vs 45 kcal/kg/d, P < 0.001), protein (2.6 vs 2.2 g/kg/d, P = 0.008), and fat (1.5 vs 0.7 g/kg/d, P < 0.001) during the first postnatal week. Changes in standard deviation scores for weight and length from birth to postnatal day 28 were more positive in the concentrated PN group (mean [95% CI]; weight change: –0.77 [–1.02 to –0.52] vs –1.29 [–1.33 to –1.05], P = 0.005; length change: –1.01 [–1.36 to –0.65] vs –1.60 [–1.95 to –1.25], P = 0.025). There were no significant differences in fluid intake and infant morbidity between the groups. 

    Conclusion: Our results suggest that concentrated PN is useful and seems to be safe for improving early nutrition and growth in VLBW infants.

  • 13.
    Stoltz Sjöström, Elisabeth
    Umeå University, Faculty of Social Sciences, Department of Food and Nutrition.
    Betydelse av tidig nutrition för hälsa hos barn och vuxna2016In: Nordisk Nutrition, ISSN 1654-8337, no 3/4, p. 35-37Article in journal (Other academic)
  • 14.
    Stoltz Sjöström, Elisabeth
    Umeå University, Faculty of Social Sciences, Department of Food and Nutrition.
    Betydelsen av tidigt näringsintag för tillväxt och hälsa hos extremt tidigt födda barn2015In: Dietistaktuellt, ISSN 1102-9285, Vol. XXIV, no 1, p. 10-13Article in journal (Other academic)
  • 15.
    Stoltz Sjöström, Elisabeth
    Umeå University, Faculty of Social Sciences, Department of Food and Nutrition.
    Nutritionsbehandling till prematurfödda barn avgörande för tillväxt och utveckling2018In: Nordisk Nutrition, ISSN 1654-8337, no 1, p. 30-32Article in journal (Other academic)
  • 16.
    Stoltz Sjöström, Elisabeth
    Umeå University, Faculty of Social Sciences, Department of Food and Nutrition.
    Nutrium-Express - Tidigt näringsintag hos extremt underburna barn2012In: Dietistaktuellt, ISSN 1102-9285, Vol. 21, no 1, p. 20-22Article in journal (Other (popular science, discussion, etc.))
  • 17.
    Stoltz Sjöström, Elisabeth
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Nutrium-EXPRESS studien: tidigt näringsintag hos extremt prematura barn2011In: Dietistaktuellt, ISSN 1102-9285, Vol. XX, no 1, p. 20-21Article in journal (Other (popular science, discussion, etc.))
  • 18.
    Stoltz Sjöström, Elisabeth
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    The impact of early nutrition on extremely preterm infants2014Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background Modern neonatal care has improved the survival rate of extremely preterm infants. These infants are at high risk of malnutrition and growth failure during 3-4 months of hospital care. The objectives of this study was to investigate nutritional intakes during hospitalization and explore associations between nutritional intakes, postnatal growth and retinopathy of prematurity (ROP). Perioperative nutrition in infants undergoing surgery for patent ductus arteriosus (PDA) was also investigated.

    Methods This is a population-based study of Swedish extremely preterm infants (<27 weeks) born during 2004-2007 (n=602). Detailed data on nutritional supply and anthropometric measurements during hospitalization were retrospectively retrieved from hospital records. Comprehensive data on cohort characteristics, neonatal morbidity and infant mortality were obtained from the Extremely Preterm Infants in Sweden Study (EXPRESS).

    Results During the first 70 days of life, intakes of energy, protein and several micronutrients, with the exception of iron and some vitamins, were less than estimated requirements, and infants showed severe postnatal growth failure. Energy and protein intake predicted growth in all anthropometric outcomes even when adjusting for severity of illness, and fat intake was positively associated with head growth. Low folate intake was positively correlated with poor weight and length gain while high iron intake, mainly explained by blood transfusions, was negatively associated with poor length gain. Furthermore, a low energy intake was associated with severe ROP (stage 3-5). An increased energy intake of 10 kcal/kg/d was associated with 24% decrease in severe ROP (p=0.01). During the first month, 99% of the infants were exclusively fed human milk. Infants who underwent surgery for PDA (n=140) were malnourished, with energy and macronutrient intakes below minimum estimated requirements before, during and after surgery.

    Conclusions The severe postnatal growth failure observed in Swedish extremely preterm infants may be prevented by improved intakes of energy, protein, fat and folate and a reduction of the number of blood transfusions. Human milk is the main enteral food source and analyses of human milk macronutrient contents facilitates individualized fortification. Provision of adequate energy intakes during the first four weeks of life may be an effective way to reduce the risk of severe ROP. Perioperative nutrition in infants undergoing PDA surgery needs to be improved. The study results have important implications for nutritional regimens, postnatal growth and health outcome in this new generation of survivors.

  • 19.
    Stoltz Sjöström, Elisabeth
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Lundgren, Pia
    Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.
    Öhlund, Inger
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Holmström, Gerd
    Department of Neuroscience, Ophthalmology, Uppsala University, Uppsala, Sweden.
    Hellström, Ann
    Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.
    Domellöf, Magnus
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Low energy intake during the first 4 weeks of life increases the risk for severe retinopathy of prematurity in extremely preterm infants2016In: Archives of Disease in Childhood: Fetal and Neonatal Edition, ISSN 1359-2998, E-ISSN 1468-2052, Vol. 101, no 2, p. F108-F113Article in journal (Refereed)
    Abstract [en]

    Objectives: Poor weight gain during the first weeks of life in preterm infants is closely associated with the risk of developing retinopathy of prematurity (ROP) and insufficient nutrition might be an important contributing factor. This study aimed to evaluate the effect of energy and macronutrient intakes during the first four weeks of life on the risk for severe ROP.

    Study design: Population-based study including all Swedish extremely preterm infants born before 27 gestational weeks during a 3-year period. Each infant was classified according to the maximum stage of ROP in either eye as assessed prospectively until full retinal vascularization. Detailed daily data of actual intakes of enteral and parenteral nutrition as well as growth data were obtained from hospital records.

    Results: Of the included 498 infants, 172 (34.5 %) had severe ROP (stages 3-5) and 96 (19.3 %) were treated. Energy and macronutrient intakes were less than recommended and the infants showed severe postnatal growth failure. Higher intakes of energy, fat and carbohydrates, but not protein, were significantly associated with a lower risk of severe ROP. Adjusting for morbidity, an increased energy intake of 10kcal/kg/d was associated with a 24 % decrease in severe ROP (p<0.01).

    Conclusions: We showed that energy intake during the first four weeks of life was an independent risk factor for severe ROP. This implies that provision of adequate energy from parenteral and enteral sources during the first four weeks of life may be an effective method for reducing the risk of severe ROP in extremely preterm infants.

  • 20.
    Stoltz Sjöström, Elisabeth
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Szymlek-Gay, Ewa A
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Öhlund, Inger
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Ahlsson, Fredrik
    Norman, Mikael
    Engström, Eva
    Hellström, Ann
    Fellman, Vineta
    Olhager, Elisabeth
    Domellöf, Magnus
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Micronutrient Intakes Affect Early Growth in Extremely Preterm Infants: Preliminary Results from a Swedish Cohort2011Conference paper (Refereed)
    Abstract [en]

    Background: Extremely preterm infants generally experience postnatal growth failure. It is still unclear if this is related to micronutrient intakes.

    Aim: To investigate the effect of micronutrient intakes (calcium, zinc, iron, phosphorus, sodium, potassium, chloride, magnesium, vitamin A, vitamin D, vitamin E, folate and vitamin B12) on growth during the first 28 days of life in extremely preterm infants.

    Method: From the EXPRESS cohort (all infants born < 27 gestational weeks between 2004-2007 in Sweden), those who survived the first 28 days were included (n=524). Daily parenteral and enteral intakes and anthropometric measurements were retrieved from hospital records.

    Results: Preliminary analyses of data from 333 infants (mean±SD gestational age 25.2±1.0 weeks, birth weight 753±168g) showed that macronutrient intakes were lower than recommended (energy 98±13kcal/kg/day, protein 2.9±0.4g/kg/day). Infants showed postnatal growth failure: mean standard deviation scores decreased by 2.2 for weight, 2.3 for length and 1.4 for head circumference. Intakes of micronutrients were generally low, e.g. adjusted enteral intakes of calcium were 66.6±21.4 mg/kg/day. The exception was iron, with a high parenteral intake of 2.7±1.6 mg/kg/day, mainly from blood transfusions. Adjusting for protein intake and other confounders, calcium intakes were positively correlated with head growth (r=+0.19, p=0.006) and iron intakes were negatively correlated with length gain (r=-0.18, p=0.009).

    Conclusions: Low calcium intakes and high iron intakes were associated with poor growth with regard to head circumference and length, respectively. If these results are confirmed, optimized micronutrient intakes may improve early growth in extremely preterm infants.

  • 21.
    Stoltz Sjöström, Elisabeth
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Öhlund, Inger
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Ahlsson, Fredrik
    Domellöf, Magnus
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Intakes of micronutrients are associated with early growth in extremely preterm infants2016In: Journal of Pediatric Gastroenterology and Nutrition - JPGN, ISSN 0277-2116, E-ISSN 1536-4801, Vol. 62, no 6, p. 885-892Article in journal (Refereed)
    Abstract [en]

    Objectives: The aim of the study was to describe micronutrient intakes and explore possible correlations to growth during the first 70 days of life in extremely preterm infants.

    Methods: Retrospective population-based study including extremely preterm infants (<27 weeks) born in Sweden during 2004-2007. Detailed nutritional and growth data were derived from hospital records.

    Results: Included infants (n = 531) had a mean gestational age of 25 weeks and 2 days and a mean birth weight of 765 g. Estimated and adjusted intakes of calcium, phosphorus magnesium, zinc, copper, selenium, vitamin D, and folate were lower than estimated requirements, whereas intakes of iron, vitamin K, and several water-soluble vitamins were higher than estimated requirements. High iron intakes were explained by blood transfusions. During the first 70 days of life, taking macronutrient intakes and severity of illness into account, folate intakes were positively associated with weight (P = 0.001) and length gain (P = 0.003) and iron intake was negatively associated with length gain (P = 0.006).

    Conclusions: Intakes of several micronutrients were inconsistent with recommendations. Even when considering macronutrient intakes and severity of illness, several micronutrients were independent predictors of early growth. Low intake of folate was associated with poor weight and length gain. Furthermore, high iron supply was associated with poor growth in length and head circumference. Optimized early micronutrient supply may improve early growth in extremely preterm infants.

  • 22.
    Stoltz Sjöström, Elisabeth
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Öhlund, Inger
    Umeå University, Faculty of Medicine, Department of Clinical Sciences.
    Ahlsson, Fredrik
    Domellöf, Magnus
    Umeå University, Faculty of Medicine, Department of Clinical Sciences.
    Intakes Of Micronutrients Is Associated With Early Growth In Extremely Preterm Infants – A Population-based Study2014Conference paper (Refereed)
  • 23.
    Stoltz Sjöström, Elisabeth
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Öhlund, Inger
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Ahlsson, Fredrik
    Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden.
    Domellöf, Magnus
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Intakes of micronutrients is associated with early growth in extremely preterm infants: a population-based studyManuscript (preprint) (Other academic)
    Abstract [en]

    Objectives: To describe micronutrient intakes and explore possible correlations to growth during the first 70 days of life in extremely preterm infants.

    Methods: Retrospective population-based study including extremely preterm infants (<27 weeks) born in Sweden during 2004-2007. Detailed nutritional and growth data were derived from hospital records.

    Results: Included infants (n=531), had a mean gestational age of 25 weeks+2 days and a mean birth weight of 765 g. Intakes of calcium, phosphorus magnesium, zinc, copper, iodine, vitamin D and folate were lower than estimated requirements while intakes of iron, vitamin K and several water-soluble vitamins were higher than estimated requirements. High iron intakes were explained by blood transfusions. During the first 70 days of life, taking macronutrient intakes and severity of illness into account, folate intakes were positively correlated with weight (p=0.001) and length gain (p=0.003) and iron intake was negatively associated with length gain (p=0.006).

    Conclusions: Intakes of many micronutrients were insufficient. Even when considering macronutrient intakes and severity of illness, several micronutrients were independent predictors of early growth. Low intakes of folate were associated with poor weight and length growth. Further, high iron intakes were associated with poor length and head circumference growth. Optimized early micronutrient intakes may improve early growth in extremely preterm infants.

  • 24.
    Stoltz Sjöström, Elisabeth
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Öhlund, Inger
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Ahlsson, Fredrik
    Engström, Eva
    Fellman, Vineta
    Hellström, Ann
    Källén, Karin
    Norman, Mikael
    Olhager, Elisabeth
    Serenius, Fredrik
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics. Department of Women's and Children's Health, Uppsala University, Uppsala.
    Domellöf, Magnus
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Nutrient intakes independently affect growth in extremely preterm infants: results from a population-based study2013In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 102, no 11, p. 1067-1074Article in journal (Refereed)
    Abstract [en]

    Aim To explore associations between energy and macronutrient intakes and early growth in extremely low gestational age (ELGA) infants.

    Methods Retrospective population-based study of all ELGA infants (<27weeks) born in Sweden during 2004-2007. Detailed data on nutrition and anthropometric measurements from birth to 70days of postnatal age were retrieved from hospital records.

    Results Study infants (n=531) had a meanSD gestational age of 25.3 +/- 1.1weeks and a birth weight of 765 +/- 170g. Between 0 and 70 days, average daily energy and protein intakes were 120 +/- 11kcal/kg and 3.2 +/- 0.4g/kg, respectively. During this period, standard deviation scores for weight, length and head circumference decreased by 1.4, 2.3 and 0.7, respectively. Taking gestational age, baseline anthropometrics and severity of illness into account, lower energy intake correlated with lower gain in weight (r=+0.315, p<0.001), length (r=+0.215, p<0.001) and head circumference (r=+0.218, p<0.001). Protein intake predicted growth in all anthropometric outcomes, and fat intake was positively associated with head circumference growth.

    Conclusion Extremely low gestational age infants received considerably less energy and protein than recommended and showed postnatal growth failure. Nutrient intakes were independent predictors of growth even after adjusting for severity of illness. These findings suggest that optimized energy and macronutrient intakes may prevent early growth failure in these infants.

  • 25.
    Stoltz Sjöström, Elisabeth
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Öhlund, Inger
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Tornevi, Andreas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Domellöf, Magnus
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Intake and macronutrient content in human milk given to extremely preterm infantsManuscript (preprint) (Other academic)
    Abstract [en]

    Background: Human milk (HM) is the preferred basis of nutrition for infants, including those born prematurely. Information on macronutrient content in HM is necessary to optimize nutritional support of preterm infants.

    Objectives: To describe the types and amounts of enteral feeds given to Swedish extremely preterm infants during hospitalization and to investigate the energy and macronutrient content in HM given to these infants.

    ­Methods: A population-based study of Swedish extremely preterm infants (n=586) born before 27 gestational weeks. Data on ingested volumes of different milks during hospitalization and analyses of macronutrient content in HM samples were obtained from hospital records. Nutritional content of HM was determined by mid-infrared spectrophotometry analysis.

    Results: During the first four weeks of life, 99% of the infants were exclusively fed HM and at four weeks of life, 70% of the infants received only mother’s own milk (MOM). Nutritional content in 821 MOM samples were analyzed. Protein content in MOM decreased significantly from 2.2g to 1.2g/100 mL during the first 112 postpartum days, while fat and energy content were highly variable within and between MOM samples. Additionally, 354 samples of donor milk were analyzed. Content of protein, fat and energy in pooled donor milk (n=129) were lower compared to single donor milk.

    Conclusions: Swedish extremely preterm infants receive MOM to a large extent during hospitalization. Protein, carbohydrates and energy in MOM changed significantly with time. Weekly analyses of MOM during the first month of lactation would allow a more individualized nutritional support to these vulnerable infants.

  • 26.
    Stoltz Sjöström, Elisabeth
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Öhlund, Inger
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Tornevi, Andreas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Domellöf, Magnus
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Intake and macronutrient content of human milk given to extremely preterm infants2014In: Journal of Human Lactation, ISSN 0890-3344, E-ISSN 1552-5732, Vol. 30, no 4, p. 442-449Article in journal (Refereed)
    Abstract [en]

    Background: Human milk (HM) is the preferred basis of nutrition for infants, including those born prematurely. Information on HM macronutrient content is necessary to optimize nutritional support of preterm infants. Objectives: This study aimed to describe the types and amounts of enteral feeds given to Swedish extremely preterm infants during hospitalization and to investigate the energy and macronutrient contents in HM given to these infants. Methods: A population-based study of Swedish extremely preterm infants (n = 586) born before 27 gestational weeks was conducted. Data on ingested volumes of different milk during hospitalization and analyses of macronutrient content in HM samples were obtained from hospital records. Nutritional content of HM was determined by mid-infrared spectrophotometry analysis. Results: During the first 4 weeks of life, 99% of the infants were exclusively fed HM, and at 4 weeks of life, 70% of the infants received only mother’s own milk (MOM). Nutritional content in 821 MOM samples was analyzed. Protein content in MOM decreased significantly from 2.2 to 1.2 g/100 mL during the first 112 postpartum days, whereas fat and energy content were highly variable within and between MOM samples. In addition, 354 samples of donor milk were analyzed. Content of protein, fat, and energy in pooled donor milk (n = 129) was lower compared to single donor milk. Conclusion: Swedish extremely preterm infants receive MOM to a large extent during hospitalization. Protein, carbohydrates, and energy in MOM changed significantly with time. Weekly analyses of MOM during the first month of lactation would allow more individualized nutritional support for these vulnerable infants.

  • 27. Westin, Vera
    et al.
    Klevebro, Susanna
    Domellöf, Magnus
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Vanpée, Mirelille
    Hallberg, Boubou
    Stoltz Sjöström, Elisabeth
    Umeå University, Faculty of Social Sciences, Department of Food and Nutrition.
    Improved nutrition for extremely preterm infants: a population based observational study2018In: Clinical Nutrition ESPEN, ISSN 2405-4577, Vol. 23, p. 245-251Article in journal (Refereed)
    Abstract [en]

    Background and aims Extremely preterm (EPT) infants are at high risk for malnutrition due to immaturity and medical complications and they often accumulate nutritional deficits and experience growth faltering during treatment at neonatal intensive care units (NICUs). Enhanced intake of energy and protein during the first weeks of life improves weight gain and head circumference growth. The optimal nutritional strategy for these infants' health and long-term development remains unknown. Nutritional regiments have been identified as a potential area for improvement in Swedish NICUs. The aim of this study was to evaluate changes in nutritional intake over time during the first 56 postnatal days in EPT (<27 gestational weeks; n = 316) infants, who were treated in NICUs during 2004–2011 in Stockholm, using a population-based study approach.

    Methods Several different nutritional interventions were implemented over the 8-year period. Nutrition and growth data were obtained retrospectively from hospital records. All intakes of enteral and parenteral nutrients were retrieved daily during the first 28 postnatal days and on days 35, 42, 49 and 56.

    Results Energy intake (median) increased from 77 kcal/kg/d during the 2004–2005 period to 98 kcal/kg/d during the 2010–2011 period on days 4–6. Median protein intake increased from 2.4 g/kg/d during 2004–2005 to 3.6 g/kg/d during 2010–2011. Energy and protein intake during postnatal days 0–6 increased continuously over the 8 years and protein intake increased during all 56 postnatal days. Full enteral feeds were reached earlier and the proportion of enteral feeds during the first week was higher during 2008–2009 compared to all other years. A significant improvement in growth was primarily noted by comparing the 2004–2005 period to subsequent years.

    Conclusions Neonatal nutrition improved significantly in Stockholm from 2004 to 2011. Above all, parenteral nutrition was initiated more promptly during the first week and was provided at higher quantities. However, many of the EPT infants born during the later years still did not reach the recommended macronutrient intake levels. A significant weight gain improvement was observed between 2004–2005 and 2006–2011.

  • 28.
    Westin, Vera
    et al.
    Karolinska Institutet, Stockholm.
    Stoltz Sjöström, Elisabeth
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Ahlsson, Fredrik
    Uppsala University, Uppsala.
    Domellöf, Magnus
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Norman, Mikael
    Karolinska Institutet, Stockholm.
    Perioperative nutrition in extremely preterm infants undergoing surgical treatment for patent ductus arteriosus is suboptimal2014In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 103, no 3, p. 282-288Article in journal (Refereed)
    Abstract [en]

    AIM: To evaluate perioperative nutrition in extremely preterm infants undergoing surgery for patent ductus arteriousus (PDA).

    METHODS: Population-based study of extremely preterm infants born in Sweden during 2004-2007 and operated on for PDA. Data on perioperative nutrition was obtained from hospital records. All enteral and parenteral nutrients and blood products were used to calculate daily nutritional intakes, starting three days before and ending three days after surgery. Data are mean (95% confidence intervals).

    RESULTS: Study infants (n=140) had a mean gestational age of 24.8 weeks and mean birth weight was 723 gram. Energy and macronutrient intakes were below minimal requirements before, during and after PDA surgery. On the day of surgery, energy intake was 78(74-81) kcal/kg/d, protein 2.9(2.7-3.2) g/kg/d, fat 2.5(2.3-2.7) g/kg/d and carbohydrate intake was 10.7(10.2-11.2) g/kg/d. Nutrition did not vary in relation to GA, but infants operated early (0-6 days after birth) received poorer nutrition than infants operated at older age. Fluid intake was 164(159-169) mL/kg/d, and it did not vary during the week of surgery.

    CONCLUSIONS: Perioperative nutrition in extremely preterm infants undergoing PDA surgery in Sweden is suboptimal and needs to be improved. The significance of malnutrition for outcome after PDA surgery remains unclear and requires further investigation.

  • 29.
    Zamir, Itay
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Stoltz Sjöström, Elisabeth
    Umeå University, Faculty of Social Sciences, Department of Food and Nutrition.
    Abrahamsson, T.
    Ahlsson, F.
    Hallberg, B.
    Pupp, I.
    Stjernkvist, K.
    Serenius, F.
    Domellöf, Magnus
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Early-life hyperglycemia in extremely preterm infants affects neurodevelopment at 6 years of age2016In: EUROPEAN JOURNAL OF PEDIATRICS, ISSN 0340-6199, Vol. 175, no 11, p. 1440-1440Article in journal (Refereed)
  • 30.
    Zamir, Itay
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Tornevi, Andreas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Abrahamsson, Thomas
    Ahlsson, Fredrik
    Engström, Eva
    Hallberg, Boubou
    Hansen-Pupp, Ingrid
    Stoltz Sjöström, Elisabeth
    Umeå University, Faculty of Social Sciences, Department of Food and Nutrition.
    Domellöf, Magnus
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Hyperglycemia in extremely preterm infants: insulin treatment, mortality and nutrient intakes2018In: Journal of Pediatrics, ISSN 0022-3476, E-ISSN 1097-6833, Vol. 200, p. 104-110Article in journal (Refereed)
    Abstract [en]

    Objective: To explore the prevalence of hyperglycemia and the associations between nutritional intakes, hyperglycemia, insulin treatment, and mortality in extremely preterm infants.

    Study design: Prospectively collected data from the Extremely Preterm Infants in Sweden Study (EXPRESS) was used in this study and included 580 infants born <27 gestational weeks during 2004-2007. Available glucose measurements (n = 9850) as well as insulin treatment and nutritional data were obtained retrospectively from hospital records for the first 28 postnatal days as well as 28- and 70-day mortality data.

    Results: Daily prevalence of hyperglycemia >180 mg/dL (10 mmol/L) of up to 30% was observed during the first 2 postnatal weeks, followed by a slow decrease in its occurrence thereafter. Generalized additive model analysis showed that increasing parenteral carbohydrate supply with 1 g/kg/day was associated with a 1.6% increase in glucose concentration (P < .001). Hyperglycemia was associated with more than double the 28-day mortality risk (P < .01). In a logistic regression model, insulin treatment was associated with lower 28- and 70-day mortality when given to infants with hyperglycemia irrespective of the duration of the hyperglycemic episode (P < .05).

    Conclusions: Hyperglycemia is common in extremely preterm infants throughout the first postnatal month. Glucose infusions seem to have only a minimal impact on glucose concentrations. In the EXPRESS cohort, insulin treatment was associated with lower mortality in infants with hyperglycemia. Current practices of hyperglycemia treatment in extremely preterm infants should be reevaluated and assessed in randomized controlled clinical trials.

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