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  • 1.
    Berg, Lisa
    et al.
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS).
    Rostila, Mikael
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS).
    Saarela, Jan
    Hjern, Anders
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). Karolinska Institutet, Sweden.
    Parental Death During Childhood and Subsequent School Performance2014In: Pediatrics, ISSN 0031-4005, E-ISSN 1098-4275, Vol. 133, no 4, p. 682-689Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: Parental death during childhood has been linked to increased mortality and mental health problems in adulthood. School failure may be an important mediator in this trajectory. We investigated the association between parental death before age 15 years and school performance at age 15 to 16 years, taking into account potentially contributing factors such as family socioeconomic position (SEP) and parental substance abuse, mental health problems, and criminality.

    METHODS: This was a register-based national cohort study of 772117 subjects born in Sweden between 1973 and 1981. Linear and logistic regression models were used to analyze school performance as mean grades (scale: 1-5; SD: 0.70) and school failure (finished school with incomplete grades). Results are presented as -coefficients and odds ratios (ORs) with 95% confidence intervals (CIs).

    RESULTS: Parental death was associated with lower grades (ORs: -0.21 [95% CI: -0.23 to -0.20] and -0.17 [95% CI: -0.19 to -0.15]) for paternal and maternal deaths, respectively. Adjustment for SEP and parental psychosocial factors weakened the associations, but the results remained statistically significant. Unadjusted ORs of school failure were 2.04 (95% CI: 1.92 to 2.17) and 1.51 (95% CI: 1.35 to 1.69) for paternal and maternal deaths. In fully adjusted models, ORs were 1.40 (95% CI: 1.31 to 1.49) and 1.18 (95% CI: 1.05 to 1.32). The higher crude impact of death due to external causes (ie, accident, violence, suicide) (OR: -0.27 [90% CI: -0.28 to -0.26]), compared with natural deaths (OR: -0.16 [95% CI: -0.17 to -0.15]), was not seen after adjustment for SEP and psychosocial situation of the family.

    CONCLUSIONS: Parental death during childhood was associated with lower grades and school failure. Much of the effect, especially for deaths by external causes, was associated with socially adverse childhood exposures.

  • 2. Ekeus, C.
    et al.
    Lindström, K.
    Lindblad, Frank
    Stockholm University, Faculty of Social Sciences, Stress Research Institute.
    Rasmussen, F.
    Hjern, Anders
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS).
    Preterm birth, social disadvantage, and cognitive competence in Swedish 18- to 19-year-old men2010In: Pediatrics, ISSN 0031-4005, E-ISSN 1098-4275, Vol. 125, no 1, p. e67-73Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: The aim was to study the impact of a range of gestationalages (GAs) on cognitive competence in late adolescence and howthis effect is modified by contextual social adversity in childhood.

    METHODS: This was a register study based on a national cohortof 119664 men born in Sweden from 1973 to 1976. Data on GA andother perinatal factors were obtained from the Medical BirthRegister, and information on cognitive test scores was extractedfrom military conscription at the ages of 18 to 19 years. Testscores were analyzed as z scores on a 9-point stanine scale,whereby each unit is equivalent to 0.5 SD. Socioeconomic indicatorsof the childhood household were obtained from the Populationand Housing Census of 1990. The data were analyzed by multivariatelinear regression.

    RESULTS: The mean cognitive test scores decreased in a stepwisemanner with GA. In unadjusted analysis, the test scores were0.63 stanine unit lower in men who were born after 24 to 32gestational weeks than in those who were born at term. The differencein global scores between the lowest and highest category ofsocioeconomic status was 1.57. Adjusting the analysis for thechildhood socioeconomic indicators decreased the effect of GAon cognitive test scores by 26% to 33%. There was also a multiplicativeinteraction effect of social adversity and moderately pretermbirth on cognitive test scores.

    CONCLUSIONS: This study confirms previous claims of an incrementalassociation of cognitive competence with GA. Socioeconomic indicatorsin childhood modified this effect at all levels of preterm birth.

  • 3. Hall, Matthew L.
    et al.
    Schönström, Krister
    Stockholm University, Faculty of Humanities, Department of Linguistics, Swedish as a Second Language for the Deaf.
    Spellun, Arielle
    Failure to Distinguish Among Competing Hypotheses2017In: Pediatrics, ISSN 0031-4005, E-ISSN 1098-4275, Vol. 140, no 5, article id e20172655CArticle in journal (Other academic)
  • 4. Lindström, Karolina
    et al.
    Lindblad, Frank
    Stockholm University, Faculty of Social Sciences, Stress Research Institute.
    Hjern, Anders
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS).
    Preterm Birth and Attention-Deficit/HyperactivityDisorder in Schoolchildren2011In: Pediatrics, ISSN 0031-4005, E-ISSN 1098-4275, Vol. 127, no 5, p. 858-865Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Previous studies have demonstrated an increased risk for attention-deficit/hyperactivity disorder (ADHD) in follow-up studies of preterm survivors from NICUs. In this study we analyzed the effect of moderate as well as extreme preterm birth on the risk for ADHD in school age, taking into account genetic, perinatal, and socioeconomic confounders.

    METHODS: Register study in a Swedish national cohort of 1 180 616 children born between 1987 and 2000, followed up for ADHD medication in 2006 at the age of 6 to 19 years. Logistic regression was used to test hypotheses. A within-mother-between-pregnancy design was used to estimate the importance of genetic confounding in a subpopulation of offspring (N = 34 334) of mothers who had given birth to preterm (≤34 weeks) as well as term infants.

    RESULTS: There was a stepwise increase in odds ratios for ADHD medication with increasing degree of immaturity at birth; from 2.1 (1.4–2.7) for 23 to 28 weeks' gestation, to 1.6 (1.4–1.7) for 29 to 32 weeks', 1.4 (1.2–1.7) for 33 to 34 weeks', 1.3 (1.1–1.4) for 35 to 36 weeks', and 1.1 (1.1–1.2) for 37 to 38 weeks' gestation compared with infants born at 39 to 41 weeks' gestation in the fully adjusted model. The odds ratios for the within-mother-between-pregnancy analysis were very similar. Low maternal education increased the effect of moderate, but not extreme, preterm birth on the risk for ADHD.

    CONCLUSION: Preterm and early term birth increases the risk of ADHD by degree of immaturity. This main effect is not explained by genetic, perinatal, or socioeconomic confounding, but socioeconomic context modifies the risk of ADHD in moderately preterm births.

  • 5.
    Liu, Can
    et al.
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). Karolinska Institutet, Sweden.
    Vinnerljung, Bo
    Stockholm University, Faculty of Social Sciences, Department of Social Work.
    Östberg, Viveca
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS).
    Gauffin, Karl
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS).
    Juarez, Sol
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS).
    Cnattingius, Sven
    Hjern, Anders
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). Karolinska Institutet, Sweden.
    Out-of-Home Care and Subsequent Preterm Delivery: An Intergenerational Cohort Study2018In: Pediatrics, ISSN 0031-4005, E-ISSN 1098-4275, Vol. 142, no 2, article id e20172729Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: Adverse early-life experience may affect preterm delivery later in life through priming of stress response. We aim to investigate the links between out-of-home care (OHC) experience in childhood, as a proxy of severe adversities, on subsequent risk of preterm delivery. METHODS: A register-based national cohort of all women born in Sweden between 1973 and 1977 (N = 175 821) was crosslinked with information on these women's subsequent deliveries as recorded in the Swedish medical birth register. During 1986-2012, 343 828 livebirths of these women were identified. The associations between women's OHC experience and her risk of preterm delivery were analyzed through logistic regression models, adjusting for women's own preterm birth, intrauterine growth, and childhood socioeconomic situation. RESULTS: Compared with women that never entered OHC, women with OHC experience up to and after age 10 were both associated with increased risks of preterm delivery (adjusted odds ratio [aOR] = 1.23 [95% confidence interval 1.08-1.40] and aOR = 1.29 [1.13-1.48], respectively). Women who experienced OHC before or at 10 years of age had increased risk of both spontaneous and medically indicated preterm delivery (aOR = 1.19 [1.03-1.38] and aOR = 1.27 [1.02-1.59], respectively). Women who experienced OHC after age 10 had a more pronounced risk of medically indicated preterm delivery (aOR = 1.76 [1.44-2.16]) than for spontaneous preterm delivery (aOR = 1.08 [0.92-1.27]). CONCLUSIONS: Women who were placed in OHC in childhood had increased risk of preterm delivery independent from their own perinatal history. Stress response, as 1 consequence of early life adversities, may take its toll on women's reproductive health and their offspring, calling for integrative efforts in preventing early life adversity.

  • 6. Nagy, Zoltan
    et al.
    Ashburner, John
    Andersson, Jesper
    Jbabdi, Saad
    Draganski, Bogdan
    Skare, Stefan
    Böhm, Birgitta
    Smedler, Ann-Charlotte
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Forssberg, Hans
    Lagercrantz, Hugo
    Structural Correlates of Preterm Birth in the Adolescent Brain2009In: Pediatrics, ISSN 0031-4005, E-ISSN 1098-4275, Vol. 124, no 5, p. e964-e972Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: The Stockholm Neonatal Project involves a prospective,cross-sectional, population-based, cohort monitored for 12 to17 years after birth; it was started with the aim of investigatingthe long-term structural correlates of preterm birth and comparingfindings with reports on similar cohorts.

    METHODS: High-resolution anatomic and diffusion tensor imagingdata measuring diffusion in 30 directions were collected byusing a 1.5-T MRI scanner. A total of 143 adolescents (12.18–17.7years of age) participated in the study, including 74 formerlypreterm infants with birth weights of 1500 g (range: 645–1486g) and 69 term control subjects. The 2 groups were well matchedwith respect to demographic and socioeconomic data. The anatomicMRI data were used for calculation of total brain volumes andvoxelwise comparison of gray matter (GM) volumes. The diffusiontensor imaging data were used for voxelwise comparison of whitematter (WM) microstructural integrity.

    RESULTS: The formerly preterm individuals possessed 8.8% smallerGM volume and 9.4% smaller WM volume. The GM and WM volumesof individuals depended on gestational age and birth weight.The reduction in GM could be attributed bilaterally to the temporallobes, central, prefrontal, orbitofrontal, and parietal cortices,caudate nuclei, hippocampi, and thalami. Lower fractional anisotropywas observed in the posterior corpus callosum, fornix, and externalcapsules.

    CONCLUSIONS: Although preterm birth was found to be a risk factorregarding long-term structural brain development, the outcomewas milder than in previous reports. This may be attributableto differences in social structure and neonatal care practices.

  • 7. Rangmar, Jenny
    et al.
    Hjern, Anders
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). Karolinska Institutet, Sweden.
    Vinnerljung, Bo
    Stockholm University, Faculty of Social Sciences, Department of Social Work.
    Strömland, Kerstin
    Aronson, Marita
    Fahlke, Claudia
    Psychosocial Outcomes of Fetal Alcohol Syndrome in Adulthood2015In: Pediatrics, ISSN 0031-4005, E-ISSN 1098-4275, Vol. 135, no 1, p. E52-E58Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND OBJECTIVE: Primary disabilities in children prenatally exposed to alcohol have a major impact on their daily life. It is suggested that these issues persist into adulthood, but few studies have addressed the outcome in adults with prenatal exposure, especially those with fetal alcohol syndrome (FAS). The aim of this follow-up study was to investigate outcome variables, such as education, employment, health, and criminal acts, in 79 adults diagnosed with FAS. METHODS: We carried out a national register-based study of 79 adults with an FAS diagnosis, at a mean age of 32. Education, social adjustment, and mental health outcomes were analyzed and compared with 3160 comparison individuals matched on age, gender, and place of birth. RESULTS: The FAS group was much more likely to have received special education (25% vs 2%), be unemployed (51% vs 15%), and receive a disability pension (31% vs 3%) than the comparisons, but the levels of criminal offenses were similar. The FAS group had higher hospital admission rates for alcohol abuse (9% vs 2%) and psychiatric disorders (33% vs 5%) and was more likely to be prescribed psychotropic drugs (57% vs 27%). CONCLUSIONS: Swedish children with FAS have quite diverse psychosocial outcomes in adulthood, considerably worse than for majority population peers. Potential risk and protective factors within the FAS group deserve study to enable development of effective interventions.

  • 8.
    Tännsjö, Torbjörn
    Stockholm University, Faculty of Humanities, Department of Philosophy.
    Should Parents of Neonates With Bleak Prognosis Be Encouraged to Opt for Another Child With Better Odds? On the Notion of Moral Replaceability2018In: Pediatrics, ISSN 0031-4005, E-ISSN 1098-4275, Vol. 142, p. S553-S557Article in journal (Refereed)
    Abstract [en]

    The notion of moral exchangeability is scrutinized and its proper place in neonatal care is examined. On influential moral outlooks, the neonate is morally exchangeable. On these views, if the parents are prepared to let go of the neonate with a poor prognosis and opt instead for another child who is healthy, this may be the morally right thing for them to do, and neonatal care ought to ease their choice.

    The notion of moral exchangeability has a different place in different moral theories. Three theories are examined: deontological ethics (insisting on the sanctity of innocent human life), according to which there is no place for the replacement of 1 child for another. It is different, however, with utilitarianism and in the moral rights theory based on self-ownership. According to utilitarianism, we are all replaceable. According to the moral rights theory, neonates are replaceable to the extent that they have not developed personhood. Even a deontological ethicist of a Kantian bent would concur here with the moral rights theory.

    Because influential moral theories imply that the neonate is morally exchangeable, it is reasonable within neonatal care, as a general rule, to grant the parents a veto against any attempts to save a child with a poor prognosis. In particular, if the parents are prepared instead to have another, healthy child, this is to be recommended. However, this rule cannot be strict. In rare cases, it is necessary to yield to parents who insist that their neonate be saved despite a poor prognosis.

  • 9. Vogt, Hartmut
    et al.
    Lindström, Karolina
    Bråbäck, Lennart
    Hjern, Anders
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS).
    Preterm birth and inhaled corticosteroid use in 6- to 19-year-olds:  A Swedish national cohort study2011In: Pediatrics, ISSN 0031-4005, E-ISSN 1098-4275, Vol. 127, no 6, p. 1052-1069Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Preterm birth is associated with respiratory morbidity later in life, including asthma. Previous studies have mainly focused on asthma in early childhood in children born extremely preterm. In this study, we examined the risk of asthma in a national cohort of schoolchildren grouped according to degree of immaturity expressed as completed gestational weeks at birth.

    METHODS: This was a register study in a Swedish national cohort of 1 100 826 children 6 to 19 years old. Retrieval of at least 1 prescription of inhaled corticosteroids (ICS) during 2006 was used as the main indicator for asthma. Logistic regression was used to test hypotheses, with adjustment for multiple socioeconomic and perinatal indicators.

    RESULTS: Degree of immaturity, expressed as completed gestational weeks at birth, had an inverse dose-response relationship with ICS use. Compared with children born between 39 and 41 weeks' gestation, the odds ratio for ICS use increased with the degree of prematurity, from 1.10 (95% confidence interval: 1.08–1.13) for children born in weeks 37 to 38, to 2.28 (95% confidence interval: 1.96–2.64) for children born in weeks 23 to 28, after adjustment for confounders. The increase in ICS use with decreasing gestational age at delivery was similar in boys and girls, and declined with older age.

    CONCLUSION: Preterm birth increased the risk of ICS use in these 6- to 19-year-olds by degree of immaturity, from extremely preterm to early term birth.

  • 10. Xi, Bo
    et al.
    Zhang, Meixian
    Zhang, Tao
    Liang, Yajun
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Jining Medical University, China.
    Li, Shuangshuang
    Steffen, Lyn M.
    Hypertension Screening Using Blood Pressure to Height Ratio2014In: Pediatrics, ISSN 0031-4005, E-ISSN 1098-4275, Vol. 134, no 1, p. E106-E111Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: The definition of hypertension in children is too complex to be used by medical professionals and children and their parents because of the age-, gender-, and height-specific blood pressure (BP) algorithm. The aim of this study was to simplify the pediatric BP percentile references using BP to height ratio (BPHR, equal to BP/height) for screening for prehypertension and hypertension in Chinese children. METHODS: Data were obtained from the China Health and Nutrition Survey, which was conducted from 1991 to 2009 and included 11 661 children aged 6 to 17 years with complete data on age, gender, height, and BP values. Receiver operating characteristic curve analysis was performed to assess the performance of systolic BPHR (SBPHR) and diastolic BPHR (DBPHR) for screening for pediatric prehypertension and hypertension. RESULTS: The optimal thresholds for defining prehypertension were 0.81 in children aged 6 to 11 years and 0.70 in adolescents aged 12 to 17 years for SBPHR and 0.52 in children and 0.46 in adolescents for DBPHR, respectively. The corresponding values for hypertension were 0.84, 0.78, 0.55, and 0.50, respectively. The negative predictive values were much higher (all >= 99%) for prehypertension and hypertension, although the positive predictive values were relatively lower, ranging from 13% to 75%. CONCLUSIONS: BPHR index is simple and accurate for screening for prehypertension and hypertension in Chinese children aged 6 to 17 years and can be used for early screening or treating Chinese children with hypertension.

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