Kristina Thorngren-Jerneck

Low 5-minute Apgar score: a population-based register study of 1 million term births

OBJECTIVE To determine the rate of 5‐minute Apgar scores below 7 in term infants (at least 37 weeks) in Sweden during 1988–1997, evaluate the influence of obstetric risk factors on low 5‐minute Apgar scores, and to study the infant prognosis regarding infant mortality, neonatal neurologic morbidity, and outcome. METHODS Data were collected from the Swedish Medical Birth Registry 1988–1997, and the National Hospital Discharge Registry. Odds ratios (OR) and risk ratios were calculated. RESULTS Among 1,028,705 term newborns, 7787 (0.76%) had 5‐minute Apgar scores below 7. The annual rate of low Apgar scores decreased from 0.77% in 1988 to 0.63% in 1992, but thereafter increased to 0.82% in 1998. The highest OR was found for vaginal breech delivery (OR 6.7), birth weights above 5 kg (OR 6.3), and second born twins (OR 4.1). Primiparity, maternal age, smoking, post‐date pregnancy, epidural analgesia, male infant gender, and being born at night, were also significant risk factors for Apgar below 7 at 5 minutes. The infant mortality rate was 48 per 1000 (OR 14.4), and the ORs were 31.4 for a diagnosis with cerebral palsy, 7.9 for epilepsy, and 9.5 for mental retardation. CONCLUSION Several obstetric risk factors are associated with low 5‐minute Apgar score in term infants. Mortality and the risk of severe neurologic morbidity are increased in these infants.

The Microbiota of the Gut in Preschool Children With Normal and Excessive Body Weight

The aim of this study was to investigate the gut microbiota in preschool children with and without overweight and obesity. Twenty overweight or obese children and twenty children with BMI within the normal range (age: 4–5 years) were recruited from the south of Sweden. The gut microbiota was accessed by quantitative PCR (qPCR) and terminal restriction fragment length polymorphism and calprotectin was measured in feces. Liver enzymes were quantified in obese/overweight children. The concentration of the gram‐negative family Enterobacteriaceae was significantly higher in the obese/overweight children (P = 0.036), whereas levels of Desulfovibrio and Akkermansia muciniphila‐like bacteria were significantly lower in the obese/overweight children (P = 0.027 and P = 0.030, respectively). No significant differences were found in content of Lactobacillus, Bifidobacterium or the Bacteroides fragilis group. The diversity of the dominating bacterial community tended to be less diverse in the obese/overweight group, but the difference was not statistically significant. Concentration of Bifidobacterium was inversely correlated to alanine aminotransferase (ALT) in obese/overweight children. The fecal levels of calprotectin did not differ between the study groups. These findings indicate that the gut microbiota differed among preschool children with obesity/overweight compared with children with BMI within the normal range.

Perinatal factors associated with cerebral palsy in children born in Sweden.

OBJECTIVE: To identify perinatal factors associated with cerebral palsy (CP). METHODS: This was a case–control study based on the Swedish Medical Birth Registry and the Swedish Hospital Discharge Registry, including 2,303 infants born in Sweden 1984–1998 with a diagnosis of CP and 1.6 million infants without this diagnosis. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. RESULTS: Infants born preterm had a highly increased risk for CP, and constituted 35% of all cases; OR 34 (95% CI 29–39) in weeks23–27, OR 37 (95% CI 32–42) in weeks 28–29, OR 26 (95% CI 23–30) in weeks 30–31, and OR 3.9 (95% CI 3.4–4.4) in weeks 32–36. Boys had a higher risk (sex ratio 1.36:1), particularly before term (sex ratio 1.55:1). Other factors associated with CP were being small or large for gestational age at birth, abruptio placentae (OR 8.6, 95% CI 5.6–13.3), maternal insulin-dependent diabetes mellitus type 1 (OR 2.1, 95% CI 1.4–3.1), preeclampsia (OR 1.5, 95% CI 1.3–2.4), being a twin (OR 1.4, 95% CI 1.1–1.6), maternal age older than 40 years (OR 1.4, 95% CI 1.1–1.8) or 35–39 years (OR 1.2, 95% CI 1.1–1.4), primiparity (OR 1.2, 95% CI 1.1–1.3), and smoking (OR 1.2, 95% CI 1.1–1.3). In term infants, low Apgar scores were associated with a high risk for CP; OR 62 (95% CI 52–74) at score 6 at 5 minutes, OR 498 (95% CI 458–542) at score 3. Other factors associated with CP in term infants were breech presentation at vaginal birth (OR 3.0, 95% CI 2.4–3.7), instrumental delivery (OR 1.9, 95% CI 1.6–2.3), and emergency cesarean delivery (OR 1.8, 95% CI 1.6–2.0). CONCLUSION: Preterm birth entails a high risk for CP, but 65% of these children are born at term. Several obstetric factors and low Apgar scores are associated with CP. LEVEL OF EVIDENCE: II-2

S100 protein in serum as a prognostic marker for cerebral injury in term newborn infants with hypoxic ischemic encephalopathy

The astroglial protein S100 is an established biochemical marker for CNS injury in the adult. The aim was to investigate whether S100 in serum is a prognostic marker of cerebral injury in term newborn infants with hypoxic ischemic encephalopathy (HIE) after perinatal asphyxia. Serum S100 was measured on postnatal days 1-4 in 62 term infants with birth asphyxia. The infants were classified for HIE and had follow-up for at least 18 mo.Infants with moderate and severe HIE had significantly higher S100 levels on postnatal day 1 (p = 0.031) and day 2 (p = 0.008) than infants with mild or no HIE. The levels of S100 decreased on days 2 and 3 in all infants with HIE. The median S100 level on postnatal day 1 was higher in nine infants who died neonatally and in 10 infants who developed cerebral palsy (CP), compared with 43 infants with no signs of impairment at follow up, 14.0 (0.5-60.0) μg/L, 20.7 (0.2-64.0) μg/L and 5.5 (0.7-120.0) μg/L, respectively. A level of S100 above 12 μg/L the first day of life was significantly more frequent in infants who died or developed CP than in infants with no impairment at follow up (p = 0.02). Increased S100 levels were significantly inversely correlated with perinatal pH in the infants and associated with abnormal CTG at admission to the labor ward. Early determination of serum S100 may reflect the extent of brain damage in infants with HIE after asphyxia.

Long term outcome after umbilical artery acidaemia at term birth: influence of gender and duration of fetal heart rate abnormalities

Objective To study the outcome after acidaemia at term birth, and the relation to gender and duration of pathological fetal heart rate changes.

Mode of delivery in breech presentation at term: increased neonatal morbidity with vaginal delivery

Objective. To compare the neonatal outcome in planned vaginal delivery and planned cesarean section in term singleton pregnancies with breech presentation in a Scandinavian clinic with a high rate of vaginal breech delivery.

Cerebral glucose metabolism measured by positron emission tomography in term newborn infants with hypoxic ischemic encephalopathy

Total and regional cerebral glucose metabolism (CMRgl) was measured by positron emission tomography with 2-(18F) fluoro-2-deoxy-d-glucose (18FDG) in 20 term infants with hypoxic ischemic encephalopathy (HIE) after perinatal asphyxia. All infants had signs of perinatal distress, and 15 were severely acidotic at birth. Six infants developed mild HIE, twelve moderate HIE, and two severe HIE during their first days of life. The positron emission tomographic scans were performed at 4–24 d of age (median, 11 d). One hour before scanning, 2–3.7 MBq/kg (54–100 μCi/kg) 18FDG was injected i.v. No sedation was used. Quantification of CMRgl was based on a new method employing the glucose metabolism of the erythrocytes, requiring only one blood sample. In all infants, the most metabolically active brain areas were the deep subcortical parts, thalamus, basal ganglia, and sensorimotor cortex. Frontal, temporal, and parietal cortex were less metabolically active in all infants. Total CMRgl was inversely correlated with the severity of HIE (p < 0.01). Six infants with mild HIE had a mean (range) CMRgl of 55.5 (37.7–100.8) μmol·min-1·100 g-1, 11 with moderate HIE had 26.6 (13.0–65.1) μmol·min-1·100 g-1, and two with severe HIE had 10.4 and 15.0 μmol·min-1·100 g-1, respectively. Five of six infants who developed cerebral palsy had a mean (range) CMRgl of 18.1 (10.2–31.4) μmol·min-1·100 g-1 compared with 41.5 (13.0–100.8) μmol·min-1·100 g-1 in the infants with no neurologic sequela at 2 y. We conclude that CMRgl measured during the subacute period after perinatal asphyxia in term infants is highly correlated with the severity of HIE and short-term outcome.

Perinatal complications and socio-economic differences in cerebral palsy in Sweden – a national cohort study

BackgroundThere is a controversy regarding the existence of a socio-economic gradient for cerebral palsy. Perinatal emergencies and preterm birth increase the risk for the offspring to develop cerebral palsy. The aim of this study was to investigate the association of socio-economic indicators with cerebral palsy (CP) and the role of perinatal health as mediator of this association.MethodsRegister study of a national cohort of 805,543 children born 1987–93, including 1,437 children with cerebral palsy that were identified in hospital discharge data from national registers. Socio-economic indicators of the household were taken from the Census of 1985. Logistic regression and chi-square analyses of linearity were used to test hypotheses.ResultsThere was a linear association between the incidence of CP (excluding cases caused by registered injuries or malformations) as well as of major perinatal indicators and the socio-economic status (SES) of the household of the mother (p < 0.001). Children in households with low SES had a higher odds ratio of CP (OR 1.49 [95% C.I. 1.16–1.91]) compared with high SES after adjustment for demographic confounders. This OR decreased to 1.36 (1.05–1.71) after adjustment for perinatal indicators with preterm birth as the most important mediating variable.ConclusionThis study suggests that there is a continuous socio-economic gradient for CP in Sweden. Further studies in more complete populations of children with cerebral palsy are needed to confirm this. Perinatal complications seem to mediate some of this gradient.

Reduced postnatal cerebral glucose metabolism measured by PET after asphyxia in near term fetal lambs

The effects of fetal asphyxia on cerebral function and development, involve the transition from fetal to neonatal life. Changes in cerebral glucose metabolism may be an early postnatal indicator of fetal asphyxia. The objective is to develop an experimental lamb model involving the transition from fetal to neonatal life and to examine the effect of fetal asphyxia with cerebral hypoxic ischemia on early postnatal cerebral glucose metabolism. Fetal asphyxia was induced by total umbilical cord occlusion in eight near‐term fetal lambs (134–138 days) with the ewe under isoflurane‐opiate anesthesia. The mean occlusion time until cardiac arrest was 14.5 (4.2) min (SD). Lambs were immediately delivered and standardized resuscitation was instituted after 2 min asystole. At 4 hr postnatal age, [18‐F]Fluoro‐2‐deoxy‐glucose (18‐FDG) was injected intravenously in eight asphyxiated lambs and in eight controls. Cerebral glucose metabolism was examined by positron emission tomography (PET). As a result the mean arterial blood pressure, acid‐base values, blood glucose and serum lactate at 4 hr postnatal age did not differ significantly between lambs subjected to umbilical cord occlusion and controls. EEG was abnormal in all lambs subjected to cord occlusion and normal in the controls at 4 hr postnatal age. Global cerebral metabolic rate (CMRgl) as determined by PET was significantly lower in lambs subjected to cord occlusion mean/median (SD) 22.2/19.6 (8.4) μmol/min/100 g) than in controls mean/median (SD) 37.8/35.9 (6.1); P < 0.01). Global CMRgl is significantly reduced in newborn lambs 4 hr after fetal asphyxia induced by umbilical cord occlusion. A reduction in CMRgl is an early indicator of global hypoxic cerebral ischemia.

Body mass index (BMI) and dental caries in 5-year-old children from southern Sweden.

OBJECTIVES The aim of the present survey was to study the association between dental caries and body mass index (BMI) in Swedish preschool children (born in 1999). METHODS A population-based and cross-sectional study design was used comprising all 920 5-year-old children in a defined area in and around the city of Lund. Anthropometric measures for the calculation of BMI were retrieved for each child from recordings at Child Health Care Centers (CHC). The occurrence of caries and fillings in the primary dentition, defined as deft (decayed, extracted, or filled primary teeth) and dt (decayed primary teeth), was collected from the childrens dental records. RESULTS The mean BMI was 16.1 (no differences between boys and girls). About 19.2% were overweight, of which 5.1% were obese. Overweight or obese children did not have higher deft or dt than others. However, children with low BMI (below -1 SD of national mean values for Swedish 5-year-olds) had statistically significantly higher deft and dt than children with normal BMI. CONCLUSIONS Children with low BMI may be at risk of caries development. Low BMI may be associated with eating habits endangering dental health.