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Hellström, S., Jonsdotter, A., Jonsson, M., Pettersson, K., Saltvedt, S., Herbst, A., . . . Carlsson, Y. (2023). A follow up on the feasibility after national implementation of magnesium sulfate for neuroprotection prior to preterm birth. Acta Obstetricia et Gynecologica Scandinavica, 102(12), 1741-1748
Open this publication in new window or tab >>A follow up on the feasibility after national implementation of magnesium sulfate for neuroprotection prior to preterm birth
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2023 (English)In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 102, no 12, p. 1741-1748Article in journal (Refereed) Published
Abstract [en]

Introduction

The risk for brain injury manifested as cerebral palsy is higher in very preterm born children than in term. Prenatal administration of magnesium sulfate (MgSO4) has been shown to be neuroprotective and reduces the proportion of very preterm born children later diagnosed with cerebral palsy. A Swedish national clinical practice guideline was implemented in March 2020, stipulating the administration of a single intravenous dose of 6 g MgSO4 1–24 h prior to delivery before gestational age 32+0, aiming for 90% treatment coverage. The aim of this study was to evaluate the feasibility of this new clinical practice guideline in the first year of its implementation.

Material and methods

Data on MgSO4 treatment were collected by reviewing the medical charts of women who gave birth to live born children in gestational age 22+0–31+6 during the period of March 1, 2020 to February 28, 2021, at five Swedish university hospitals. Women with pre-eclampsia, eclampsia, or high elevated liver enzymes low platelets (HELLP) were excluded.

Results

A total of 388 women were eligible and 79% received treatment with MgSO4. Of the 21% not receiving treatment, 9% did not receive treatment due to lack of knowledge about the clinical practice guideline, 9% were not possible to treat and 3% had missing data. The proportion treated increased from 72% to 87% from the first to the last 3 months. Of those treated, 81% received the drug within the stipulated timeframe (mean 8.7 h, median 3.4 h).

Conclusions

There was a positive trend over time in the proportion of women receiving MgSO4 treatment, but the a priori target of 90% was not reached during the first year of implementation. Our findings indicate that this target could be reached with additional information to clinicians.

Place, publisher, year, edition, pages
John Wiley & Sons, 2023
Keywords
cerebral palsy, extremely preterm, magnesium sulfate, neuroprotection, premature birth, preterm birth, very preterm
National Category
Pediatrics Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-523245 (URN)10.1111/aogs.14673 (DOI)001070018700001 ()37680134 (PubMedID)
Funder
Swedish Research Council, 2019-01320Linnéa och Josef Carlssons stiftelseWilhelm och Martina Lundgrens Vetenskapsfond, 2019-2941
Available from: 2024-02-16 Created: 2024-02-16 Last updated: 2024-02-16Bibliographically approved
Arwehed, S., Axelin, A., Björklund, L. J., Thernström Blomqvist, Y., Heiring, C., Jonsson, B., . . . Lehtonen, L. (2023). Nordic survey showed wide variation in discharge practices for very preterm infants. Acta Paediatrica
Open this publication in new window or tab >>Nordic survey showed wide variation in discharge practices for very preterm infants
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2023 (English)In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227Article in journal (Refereed) Epub ahead of print
Abstract [en]

Aim

We aimed to describe clinical practices and criteria for discharge of very preterm infants in Nordic neonatal units.

Methods

Medical directors of all 89 level-2 and level-3 units in Denmark, Finland, Iceland, Norway and Sweden were invited by e-mail to complete a web-based multiple-choice survey with the option to make additional free-text comments.

Results

We received responses from 83/89 units (93%). In all responding units, discharge readiness was based mainly on clinical assessment with varying criteria. In addition, 36% used formal tests of cardiorespiratory stability and 59% used criteria related to infant weight or growth. For discharge with feeding tube, parental ability to speak the national language or English was mandatory in 45% of units, with large variation among countries. Post-discharge home visits and video-consultations were provided by 59% and 51%, respectively. In 54% of units, parental preparation for discharge were not initiated until the last two weeks of hospital stay.

Conclusion

Discharge readiness was based mainly on clinical assessment, with criteria varying among units despite similar population characteristics and care structures. This variation indicates a lack of evidence base and may unnecessarily delay discharge; further studies of this matter are needed. Earlier parental preparation and use of interpreters might facilitate earlier discharge.

Place, publisher, year, edition, pages
John Wiley & Sons, 2023
Keywords
early discharge, length of stay, neonatal home care, preterm infant, telemedicine
National Category
Pediatrics
Identifiers
urn:nbn:se:uu:diva-512706 (URN)10.1111/apa.16934 (DOI)001047084900001 ()37540833 (PubMedID)
Available from: 2023-09-28 Created: 2023-09-28 Last updated: 2023-09-28Bibliographically approved
Törn, A. E., Hesselman, S., Johansen, K., Ågren, J., Wikström, A.-K. & Jonsson, M. (2023). Outcomes in children after mild neonatal hypoxic ischaemic encephalopathy: A population‐based cohort study. British Journal of Obstetrics and Gynecology
Open this publication in new window or tab >>Outcomes in children after mild neonatal hypoxic ischaemic encephalopathy: A population‐based cohort study
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2023 (English)In: British Journal of Obstetrics and Gynecology, ISSN 1470-0328, E-ISSN 1471-0528Article in journal (Refereed) Epub ahead of print
Abstract [en]

Objective

To investigate whether mild neonatal hypoxic ischaemic encephalopathy (HIE) in term born infants is associated with cerebral palsy, epilepsy, mental retardation and death up to 6 years of age.

Design

Population-based cohort study.

Setting

Sweden, 2009–2015.

Population

Live term born infants without congenital malformations or chromosomal abnormalities (n = 505 075).

Methods

Birth and health data were retrieved from Swedish national health and quality registers. Mild HIE was identified by diagnosis in either the Swedish Medical Birth Register or the Swedish Neonatal Quality Register. Cox proportional hazards regression was used to estimate hazard ratios (HRs) with 95% confidence intervals (CIs).

Main outcome measures

A composite of the outcomes cerebral palsy, epilepsy, mental retardation and death up to 6 years of age.

Results

Median follow-up time was 3.3 years after birth. Of 414 infants diagnosed with mild HIE, 17 were classified according to the composite outcome and incidence rates were 12.6 and 2.9 per 1000 child-years in infants with and without HIE respectively. Infants with mild HIE was four times as likely to be diagnosed with the composite outcome (HR 4.42, 95% CI 2.75–7.12) compared with infants without HIE. When analysed separately, associations were found with cerebral palsy (HR 21.50, 95% CI 9.59–48.19) and death (HR 19.10, 95% CI 7.90–46.21). HRs remained essentially unchanged after adjustment for covariates.

Conclusions

Mild neonatal HIE was associated with neurological morbidity and mortality in childhood. Challenges include identifying infants who may develop morbidity and how to prevent adverse outcomes.

Place, publisher, year, edition, pages
John Wiley & Sons, 2023
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:uu:diva-504414 (URN)10.1111/1471-0528.17533 (DOI)000991569400001 ()37199188 (PubMedID)
Funder
Gillbergska stiftelsen
Available from: 2023-06-13 Created: 2023-06-13 Last updated: 2023-06-15
Naseh, N., Canto Moreira, N., Vaz, T. F., Gonzalez Tamez, K., Ferreira, H., Fredriksson Kaul, Y., . . . Hellström-Westas, L. (2022). Early Hyperglycemia in Very Preterm Infants Is Associated with Reduced White Matter Volume and Worse Cognitive and Motor Outcomes at 2.5 Years. Neonatology, 119(6), 745-752
Open this publication in new window or tab >>Early Hyperglycemia in Very Preterm Infants Is Associated with Reduced White Matter Volume and Worse Cognitive and Motor Outcomes at 2.5 Years
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2022 (English)In: Neonatology, ISSN 1661-7800, E-ISSN 1661-7819, Vol. 119, no 6, p. 745-752Article in journal (Refereed) Published
Abstract [en]

Introduction: Hyperglycemia in very preterm infants is associated with increased morbidity and mortality. We aimed to investigate potential associations between early hyperglycemia, neonatal cerebral magnetic resonance imaging (MRI), and neurodevelopment at 2.5 years.

Methods: The study population included 69 infants with gestational age (GA) 22.3-31.9 weeks (n = 29 with GA <28 weeks), born 2011-2014. Plasma glucose concentrations during the first week were checked according to clinical routines. Hyperglycemia was defined as glucose concentrations above 8.3 mmol/L (150 mg/dL) and above 10 mmol/L (180 mg/dL), respectively, categorized as the highest glucose days 0-2, number of days above 8.3 and 10 mmol/L, and prolonged (yes/no) 2 days or more above 8.3 and 10 mmol/L. The MRI analysis included morphological assessment, regional brain volumes, and assessment of apparent diffusion coefficient (ADC). Neurodevelopmental impairment (NDI) developed in 13 of 67 infants with available outcomes, of which 57 were assessed with the Bayley-III. Univariate and multiple linear and logistic regressions were performed with adjustments for GA, birth weight z-scores, and illness severity expressed as days on mechanical ventilation.

Results: Hyperglycemia above 8.3 mmol/L and 10 mmol/L was present in 47.8% and 31.9% of the infants. Hyperglycemia correlated independently with lower white matter volume, but not with other regional brain volumes, and was also associated with lower ADC values in white matter. Hyperglycemia also correlated with lower Bayley-III cognitive and motor scores in infants with GA <28 weeks, but there was no significant effect on NDI.

Conclusion: Early hyperglycemia is associated with white matter injury and poorer neurodevelopment in very preterm infants.

Place, publisher, year, edition, pages
S. Karger, 2022
Keywords
Brain injury, Impairment, Insulin, Magnetic resonance imaging, Neurodevelopment
National Category
Pediatrics
Identifiers
urn:nbn:se:uu:diva-496804 (URN)10.1159/000524923 (DOI)000854938500001 ()36108597 (PubMedID)
Funder
Uppsala University
Available from: 2023-02-28 Created: 2023-02-28 Last updated: 2023-02-28Bibliographically approved
Ågren, J., Segar, J. L., Söderström, F. & Bell, E. F. (2022). Fluid management considerations in extremely preterm infants born at 22-24 weeks of gestation. Seminars in Perinatology, 46(1), Article ID 151541.
Open this publication in new window or tab >>Fluid management considerations in extremely preterm infants born at 22-24 weeks of gestation
2022 (English)In: Seminars in Perinatology, ISSN 0146-0005, E-ISSN 1558-075X, Seminars in perinatology, ISSN 0146-0005, Vol. 46, no 1, article id 151541Article, review/survey (Refereed) Published
Abstract [en]

Emerging data regarding the encouraging outcomes of extremely preterm infants from cen-ters taking active approaches to the care of these infants have prompted dialogue regarding optimal medical management. Among the multitude of decisions providers make in caring for extremely premature infants is the prescribing of parenteral fluids. Surprisingly, there are limited data to guide evidenced-based approaches to fluid and electrolyte management in this population. Immaturity of renal function and skin barriers contribute to the impaired capacity of the preterm infant to maintain salt and water homeostasis. This per-spective paper highlights developmental physiological properties of the kidney and skin, which the provider needs to understand to provide parenteral fluid therapy. Additionally, we provide recommendations for initial fluid and electrolyte management of the preterm infant based on novel data as well as the published literature.

Place, publisher, year, edition, pages
ElsevierElsevier BV, 2022
Keywords
Prematurity, Insensible water loss, Transepidermal, Sodium, Hyperosmolarity, Electrolyte
National Category
Pediatrics
Identifiers
urn:nbn:se:uu:diva-467938 (URN)10.1016/j.semperi.2021.151541 (DOI)000750188000004 ()34848064 (PubMedID)
Available from: 2022-02-24 Created: 2022-02-24 Last updated: 2024-01-15Bibliographically approved
Karlsson, V., Thernström Blomqvist, Y. & Ågren, J. (2022). Nursing care of infants born extremely preterm. Seminars in Fetal & Neonatal Medicine, 27(3), Article ID 101369.
Open this publication in new window or tab >>Nursing care of infants born extremely preterm
2022 (English)In: Seminars in Fetal & Neonatal Medicine, ISSN 1744-165X, E-ISSN 1878-0946, Vol. 27, no 3, article id 101369Article in journal (Refereed) Published
Abstract [en]

With improving survival at the lowest gestations an increasing number of tiny and vulnerable infants are being cared for, and optimal outcomes require an approach to care that takes their specific characteristics into account. These include immature organ function and a risk for iatrogenic injury, and parental/familial strain due to the high degree of uncertainty, infant-mother separation, and long hospital stay. While the challenges in providing nursing care to these infants are obvious it is also clear that this field has tremendous potential to influence both short and long-term outcomes of this population. This mini-review discusses aspects of the nursing care provided to infants born at the very lowest gestations and their families, with focus on doing less harm by establishing an adequate care environment, actively promoting parental closeness and care-giving, and conservative skin care.

Place, publisher, year, edition, pages
ElsevierElsevier BV, 2022
Keywords
Insensible water loss, Skin to skin care, Immaturity, Family integrated care
National Category
Pediatrics
Identifiers
urn:nbn:se:uu:diva-481702 (URN)10.1016/j.siny.2022.101369 (DOI)000824410900007 ()35739009 (PubMedID)
Available from: 2022-08-16 Created: 2022-08-16 Last updated: 2024-01-15Bibliographically approved
Karlsson, V., Sporre, B., Fredén, F. & Ågren, J. (2022). Randomized controlled trial of low vs high oxygen during neonatal anesthesia: Oxygenation, feasibility, and oxidative stress. Pediatric Anaesthesia, 32(9), 1062-1069
Open this publication in new window or tab >>Randomized controlled trial of low vs high oxygen during neonatal anesthesia: Oxygenation, feasibility, and oxidative stress
2022 (English)In: Pediatric Anaesthesia, ISSN 1155-5645, E-ISSN 1460-9592, Vol. 32, no 9, p. 1062-1069Article in journal (Refereed) Published
Abstract [en]

Background To reduce risk for intermittent hypoxia a high fraction of inspired oxygen is routinely used during anesthesia induction. This differs from the cautious dosing of oxygen during neonatal resuscitation and intensive care and may result in significant hyperoxia. Aim In a randomized controlled trial, we evaluated oxygenation during general anesthesia with a low (23%) vs a high (80% during induction and recovery, and 40% during maintenance) fraction of inspired oxygen, in newborn infants undergoing surgery. Method Thirty-five newborn infants with postconceptional age of 35-44 weeks were included (17 infants in low and 18 in high oxygen group). Oxygenation was monitored by transcutaneous partial pressure of oxygen, pulse oximetry, and cerebral oxygenation. Predefined SpO2 safety targets dictated when to increase inspired oxygen. Results At start of anesthesia, oxygenation was similar in both groups. Throughout anesthesia, the high oxygen group displayed significant hyperoxia with higher (difference-20.3 kPa, 95% confidence interval (CI)-28.4 to 12.2, p < .001) transcutaneous partial pressure of oxygen values than the low oxygen group. While SpO2 in the low oxygen group was lower (difference - 5.8%, 95% CI -9.3 to -2.4, p < .001) during anesthesia, none of the infants spent enough time below SpO(2) safety targets to mandate supplemental oxygen, and cerebral oxygenation was within the normal range and not statistically different between the groups. Analysis of the oxidative stress biomarker urinary F-2-Isoprostane revealed no differences between the low and high oxygen group. Conclusion We conclude that in healthy newborn infants, use of low oxygen during general anesthesia was feasible, while the prevailing practice of using high levels of inspired oxygen resulted in significant hyperoxia. The trade-off between careful dosing of oxygen and risks of hypo- and hyperoxia in neonatal anesthesia should be further examined.

Place, publisher, year, edition, pages
John Wiley & SonsWiley, 2022
Keywords
F2-Isoprostanes, hyperoxia, neonatal anesthesia, oxidative stress, oxygenation
National Category
Pediatrics Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:uu:diva-483581 (URN)10.1111/pan.14519 (DOI)000824216300001 ()35791748 (PubMedID)
Funder
Gillbergska stiftelsen
Available from: 2022-08-31 Created: 2022-08-31 Last updated: 2024-01-15Bibliographically approved
Dickmark, M., Ågren, J., Hellström-Westas, L. & Jonsson, M. (2022). Risk factors for seizures in the vigorous term neonate: A population-based register study of singleton births in Sweden. PLOS ONE, 17(2), Article ID e0264117.
Open this publication in new window or tab >>Risk factors for seizures in the vigorous term neonate: A population-based register study of singleton births in Sweden
2022 (English)In: PLOS ONE, E-ISSN 1932-6203, Vol. 17, no 2, article id e0264117Article in journal (Refereed) Published
Abstract [en]

Background Neonatal seizures have been associated with increased mortality and impaired neurodevelopment and, knowledge about risk factors may be useful for prevention. Clear associations have been established between labor-related risk factors and seizures in asphyxiated neonates. However, there is limited information about why some vigorous term-born infants experience seizures. Objectives Our aim was to assess antepartum and intrapartum risk factors for seizures in vigorous term-born neonates. Methods This was a national cohort study of singleton infants born at term in Sweden from 2009-2015. Vigorous was defined as an Apgar score of at least 7 at 5 and 10 minutes. Data on the mothers and infants were obtained from the Swedish Medical Birth Register and the Swedish Neonatal Quality Register. A diagnosis of neonatal seizures was the main outcome measure and the exposures were pregnancy and labor variables. Logistic regression analysis was used and the results are expressed as adjusted odds ratios (aOR) with 95% confidence intervals (CI). Results The incidence of neonatal seizures was 0.81/1,000 for 656 088 births. Seizures were strongly associated with obstetric emergencies (aOR 4.0, 95% CI 2.2-7.4), intrapartum fever and/or chorioamnionitis (aOR 3.4, 95% CI 2.1-5.3), and intrapartum fetal distress (aOR 3.0, 95% CI 2.4-3.7). Other associated intrapartum factors were: labor dystocia, occiput posterior position, operative vaginal delivery, and Cesarean delivery. Some maternal factors more than doubled the risk: a body mass of more than 40 (aOR 2.6, 95% CI 1.4-4.8), hypertensive disorders (aOR 2.3, 95% CI 1.7-3.1) and diabetes mellitus (aOR 2.6, 95% CI 1.7-4.1). Conclusion A number of intrapartum factors were associated with an increased risk of seizures in vigorous term-born neonates. Obstetric emergencies, intrapartum fever and/or chorioamnionitis and fetal distress were the strongest associated risks. The presence of such factors, despite a reassuring Apgar score could prompt close surveillance.

Place, publisher, year, edition, pages
Public Library of Science (PLoS), 2022
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-472739 (URN)10.1371/journal.pone.0264117 (DOI)000777505200080 ()35176121 (PubMedID)
Available from: 2022-04-19 Created: 2022-04-19 Last updated: 2023-03-23Bibliographically approved
Spath, C., Stoltz Sjostrom, E., Ågren, J., Ahlsson, F. & Domellof, M. (2022). Sodium supply from administered blood products was associated with severe intraventricular haemorrhage in extremely preterm infants. Acta Paediatrica, 111(9), 1701-1708
Open this publication in new window or tab >>Sodium supply from administered blood products was associated with severe intraventricular haemorrhage in extremely preterm infants
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2022 (English)In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 111, no 9, p. 1701-1708Article in journal, Editorial material (Refereed) Published
Abstract [en]

Aim The aim of this study was to investigate the associations between sodium supply, fluid volume, sodium imbalances and severe intraventricular haemorrhage (IVH) in extremely preterm (EPT) infants.

Methods We used data from the EXtremely PREterm infants in Sweden Study (EXPRESS) cohort consisting of all infants born at 22 to 26 gestational weeks from 2004 to 2007 and conducted a nested case-control study. For every infant with severe IVH (grade 3 or peri-ventricular haemorrhagic infarction), one IVH-free control infant with the birthday closest to the case infant and matched for hospital, sex, gestational age and birth weight was selected (n = 70 case-control pairs).

Results Total sodium supply and fluid volume were higher in infants with severe IVH compared with controls [daily total sodium supply until postnatal Day 2: mean +/- SD (mmol/kg/day): 5.49 +/- 2.53 vs. 3.95 +/- 1.91, p = 0.009]. These differences were accounted for by sodium and fluid from transfused blood products. High plasma sodium concentrations or large sodium fluctuations were not associated with severe IVH.

Conclusion Our results suggest a relationship between sodium-rich transfusions of blood products and severe IVH in EPT infants. It is unclear whether this is an effect of sodium load, volume load or some other transfusion-related factor.

Place, publisher, year, edition, pages
John Wiley & SonsWiley, 2022
Keywords
intraventricular haemorrhage, preterm infants, sodium imbalances, sodium supply, transfusions
National Category
Pediatrics
Identifiers
urn:nbn:se:uu:diva-485092 (URN)10.1111/apa.16423 (DOI)000808547100001 ()35615868 (PubMedID)
Funder
Swedish Research Council, 2016-02095European CommissionSwedish Nutrition Foundation (SNF)
Available from: 2022-09-20 Created: 2022-09-20 Last updated: 2024-01-15Bibliographically approved
Diderholm, B., Normann, E., Ahlsson, F., Sindelar, R. & Ågren, J. (2022). The Impact of Restricted versus Liberal Early Fluid Volumes on Plasma Sodium, Weight Change, and Short-Term Outcomes in Extremely Preterm Infants. Nutrients, 14(4), Article ID 795.
Open this publication in new window or tab >>The Impact of Restricted versus Liberal Early Fluid Volumes on Plasma Sodium, Weight Change, and Short-Term Outcomes in Extremely Preterm Infants
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2022 (English)In: Nutrients, E-ISSN 2072-6643, Vol. 14, no 4, article id 795Article in journal (Refereed) Published
Abstract [en]

The optimal fluid requirements for extremely preterm infants are not fully known. We examined retrospectively the fluid intakes during the first week of life in two cohorts of extremely preterm infants born at 22-26 weeks of gestation before (n = 63) and after a change from a restrictive to a more liberal (n = 112) fluid volume allowance to improve nutrient provision. The cohorts were similar in gestational age and birth weight, but antenatal steroid exposure was more frequent in the second era. Although fluid management resulted in a cumulative difference in the total fluid intake over the first week of 87 mL/kg (p < 0.001), this was not reflected in a mean weight loss (14 +/- 5% at a postnatal age of 4 days in both groups) or mean peak plasma sodium (142 +/- 5 and 143 +/- 5 mmol/L in the restrictive and liberal groups, respectively). The incidences of hypernatremia (>145 and >150 mmol/L), PDA ligation, bronchopulmonary dysplasia, and IVH were also similar. We conclude that in this cohort of extremely preterm infants a more liberal vs. a restricted fluid allowance during the first week had no clinically important influence on early changes in body weight, sodium homeostasis, or hospital morbidities.

Place, publisher, year, edition, pages
MDPI AG, 2022
Keywords
extremely preterm infant, fluid allowance, dehydration
National Category
Nutrition and Dietetics Pediatrics
Identifiers
urn:nbn:se:uu:diva-469556 (URN)10.3390/nu14040795 (DOI)000761414000001 ()35215444 (PubMedID)
Available from: 2022-03-14 Created: 2022-03-14 Last updated: 2023-08-28Bibliographically approved
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Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0002-9510-048x

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