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Aim Children with osteomyelitis present with a range of signs and symptoms and with varying degree of severity. The purpose of this study was to provide data on a population-based 10-year material of children with acute osteomyelitis. Methods All children, 0-14 years in Stockholm Region with acute osteomyelitis hospitalised in July 2005-June 2015, were retrospectively studied. Time to hospital presentation, disease localization, inflammation markers, imaging procedures, microbiology, severity classified by the presence of complications, surgical procedures, hospital length of stay and seasonal variation were recorded. Results There were 430 children with acute osteomyelitis; 61% were boys. The incidence per 100 000 person-years was 11.6; 9.3 in girls and 13.1 in boys. Median age at admission was 2.9 years with no peak later in childhood. Median time from first symptom to diagnosis was 4 days (range 1-21) and 48% of the cases were localised to femur or tibia. Mean C-reactive protein was 59 mg/L (range 1-376). Blood (n = 82) or tissue cultures (n = 54) were positive in 118 (28%) children. The most common pathogen was Staphylococcus aureus (n = 88) followed by Streptococcus pyogenes (n = 12). Surgery was performed in 71 children (17%). There was no mortality. Severe complications were seen in 14 (3.3%) children, five of whom were admitted to intensive care. Median hospital length of stay was 4 days (range 1-60). Conclusions Osteomyelitis in children is a diagnostic challenge with a low yield of positive bacterial cultures. Few children with uncomplicated disease need surgery, but the risk of severe complications is not negligible.

AIM We present our results using interferon-gamma release assays in any child

In Stockholm, Sweden, rotavirus vaccination was offered to children born after 1 March 2014. Our aim was to describe rates of hospitalisation due to community-acquired gastroenteritis before and after the introduction of the vaccine, and aetiology, underlying medical conditions and complications in admitted children.We retrospectively included patients from our catchment area hospitalised with a diagnosis of gastroenteritis during ten infection seasons 2008/2009-2017/2018, whereof six seasons prevaccination and four seasons postvaccination. We studied virus detection data and the patients' medical records.We included 3718 episodes in 3513 children. In 2967 (80%), stools were tested with virus isolation, ELISA, PCR, or bacterial culture; 479 (16%) tested negative. The incidence rates, with 95% confidence intervals, for children5 years hospitalised for rotavirus gastroenteritis were 2.9 (2.8-3.1) per 1000 person-years prevaccination and 0.65 (0.56-0.74) postvaccination, for a rate ratio (RR) of 0.22 (0.19-0.26,Rotavirus vaccination reduced the number of children5 years requiring hospital care for gastroenteritis. We saw no replacement of rotavirus by other viruses.

Objectives The aim of this study was to analyze the rate of admissions, the rate of serious complications (postseptal orbital complications and surgery) and the bacterial etiology of acute rhinosinusitis in hospitalized children under five years old in Stockholm County, eight years after the introduction of the pneumococcal conjugate vaccine (PCV). The secondary aim was to compare this period with the period four years prior to the vaccine's introduction. Methods This was a population-based, descriptive observational study with retrospectively collected data from 1 July 2008 to 30 June 2016 in Stockholm County. Hospital admissions of children with a discharge diagnosis of rhinosinusitis and related complications were reviewed and compared to the pre-PCV period of 2003–2007. Results A total of 215 children were admitted, for a yearly incidence of 18.8 per 100 000 children (22.8 for boys, 14.6 for girls). Computer tomography-verified postseptal orbital complications occurred in 29 cases (13.5%) and surgery was necessary in nine (4.2%). Pathogens other than Streptococcus pneumoniae were found in the cases with postseptal complication or surgery (Streptococcus pyogenes in four, Haemophilus influenzae in three and Staphylococcus aureus in one case). In comparison to the four years pre-PCV, the incidence of admission decreased from 43.81 to 20.31 and 17.45 per 100 000/year for the two four-year periods after vaccine introduction. The incidence of CT-verified postseptal complication increased slightly from 1.51 to 2.34 and 2.74 per 100 000/year. The incidence of surgeries increased marginally but continued to be very low, from 0.22 to 0.54 and 1.03 per 100 000/year. Conclusions Complications due to acute rhinosinusitis in children living in Stockholm County continues to be very rare after the introduction of pneumococcal vaccine. Hospitalization has decreased for children under five years old after PCV introduction, but the incidence or postseptal complications and surgery in the same population increased slightly. Predominantly bacteria other than Streptococcus pneumoniae was found. There is a need of larger studies to determine trends, and a need of prospective studies to elucidate the bacterial etiology, of serious complications due to acute rhinosinusitis in children.

Aim This study explored the differences in demographic and socioeconomic factors between children hospitalised due to four common viral infections. Methods Demographic data were obtained from Statistics Sweden on >3,000 children admitted to Astrid Lindgren Children's Hospital in 2009-2014 with rotavirus, influenza, respiratory syncytial virus (RSV), or chickenpox. We compared demographic and socioeconomic factors between case groups using logistic regression with rotavirus cases as reference. Results There were differences in the median age at admission; RSV cases were younger (0.4 years), influenza (2.4 years) and chickenpox cases (2.7 years) older than rotavirus cases (1.2 years). RSV, influenza and chickenpox cases lived in families with more children than rotavirus cases. RSV and influenza cases were more likely to have underlying chronic conditions. Mothers of RSV cases were more likely to be born in Sweden. Further socioeconomic differences were not robustly confirmed in sensitivity analyses. Conclusion We found a few differences in demographic factors between children hospitalised with the four common infections, which were mainly explained by the epidemiology and transmission patterns of these infections.

BACKGROUND The etiology of bloodstream infections (BSIs) changes over time due to updated immunization programs, new antibiotic-use strategies, changes in patient mix and travel. Continuous surveillance can guide empiric therapy and identify targets for prevention. METHOD We conducted a descriptive retrospective analysis among children

AIM Since the introduction in 1979 of rapid testing using immunofluorescence, we have collected information about children hospitalised for confirmed respiratory syncytial virus (RSV) infection in the northern Stockholm area. We here report hospitalisation rates, risk factors and complications in 2008-2016 compared with 1986-1998. METHODS Microbiological laboratory reports and retrospective chart review. Comparison of the two periods was complicated by changing testing routines, with a more sensitive method and increased testing of older children in the late period. RESULTS In infants, there was an 12.3% increase in the population-based rate of hospital admission for RSV infection from 12.2 to 13.7/1000. Including all children

We aimed to identify hospitalizations due to infectious diseases among asylum seekers and compare them to those of the resident population 1.6.2015–31.10.2016. Administrative numbers assigned to hospitalized non-resident children made them identifiable in the discharge register. The examined populations, expressed as person-years, were 334,573 residents and 7565 asylum seekers. There were 2500 episodes of infectious disease in 2240 resident children and 139 episodes in 121 asylum seekers. Among prevalent infections contracted before or during migration, there were 33 cases of tuberculosis, four of malaria, and one of louse-borne relapsing fever, all of which occurred in 13–17-year-old unaccompanied minors. Among younger asylum seekers, there were no significant differences in the spectrum of infectious discharge diagnoses compared to residents, but across all incident infections, 0–6-year-old asylum seekers had 3.2-fold and 7–12-year-old a 4.7-fold greater risk of being admitted. Screening for multidrug-resistant bacteria showed that 45/160 (28%) of the asylum seekers were colonized, but clinical infections caused by these species were rare.Conclusion: There was a high rate of hospitalizations for acute infectious diseases in asylum-seeking children, but the spectrum and severity of infections were similar to that in resident children. What is known:• Mental and physical health problems are common in immigrant children and adolescents.What is new:• Hospitalizations due to acute infections in asylum-seeking children and adolescents are common. In the context of this study, the severity and spectrum of infectious diseases seemed to be the same in the two groups; the increased hospitalization rate in asylum seekers may be due to social factors and perceived need for more support.

Few prospective cohort studies have estimated the overall impact of severe rotavirus gastroenteritis (RVGE) leading to hospitalization on families and society. We assessed human and economic resources needed to care for an affected average child aged5 years in Sweden.The study was conducted in Astrid Lindgren Children's Hospital which serves approximately 14% of all Swedish children5 years of age. All children admitted with acute gastroenteritis in the study period were tested for rotavirus. Health care consumption was collected prospectively and publically available unit costs used to calculate direct costs. Non-medical and indirect costs were collected in interviews with families using a standardized questionnaire during the hospital stay and approximately 14 days post-discharge.144/206 children (70%) with laboratory-confirmed RVGE were included. The median age was 14 months. The average total cost per hospitalized child was €3894, of which €2169 (56%) was due to direct healthcare-related costs (including Emergency Department visits and in-patient care), €104 (2%) to non-medical direct costs and €1621 (42%) to indirect costs due to productivity loss. Carers of children with severe RVGE were absent from work on average five days per study child: four days during hospitalization of affected child and one day due to gastroenteritis in the carer.Costs for RVGE are dominated by direct costs which are similar to some other countries in Europe, but indirect costs due to productivity loss are also important, and should be considered in decisions to introduce rotavirus vaccines into national vaccination programmes.

An immunocompetent six-year old child presented with a bronchial occluding mass that was diagnosed as an endobronchial Mycobacterium avium infection. The child was successfully treated with a combination of surgery and tuberculostatics.

Background There are few population-based studies of complications due to acute rhinosinusitis in children. The aim was to clarify the admission and complication rate and analyze bacterial cultures in children five to 18 years old in Stockholm, Sweden. Methods This was a population-based observational cohort study with retrospectively collected data from individual medical records, from 1 July 2003 to 30 June 2016 in Stockholm, Sweden. Hospital admissions of children with a discharge diagnosis of rhinosinusitis and related complications were reviewed. Results Incidence of admission due to acute rhinosinusitis was 7.8 per 100 000 children per year (boys 9.2, girls 6.2) and 61% of the admitted children were boys. A severe – postseptal orbital, intracranial or osseous – complication, was present in 34% of admissions (postseptal orbital 28%, intracranial 6%, osseous 4%), resulting in an incidence of 2.6 severe complications per 100 000 children per year (boys 3.6, girls 1.6). Orbital preseptal cellulitis was present in 88% of admissions. Incidence of surgery was 1.3 per 100 000 per year (boys 1.8, girls 0.8) and the percentage of admitted children that had surgery increased with age. S. pyogenes was the most common pathogen found in the whole cohort (29 admissions), while S. milleri was the most common pathogen found among the children with severe complication and surgery. Conclusions There is a relative high risk of severe complications in children between five to 18 years that are admitted due to acute rhinosinusitis. There is a need for prospective studies to further analyze the pathogens involved in complications due to acute rhinosinusitis.

Minors with a stated age18 years unaccompanied by a responsible adult form an increasing part of refugees to Europe. They are older than other asylum-seeking children and many come from countries with a high tuberculosis (TB) incidence. During the 2015 refugee crisis, 35,369 of 162,877 refugees (22%) seeking asylum in Sweden were unaccompanied minors, which gave us the opportunity to study their burden of TB infection and disease.Of the unaccompanied minors seeking asylum in Sweden during 2015, 2936 (8.3%) were allocated to northern Stockholm. Of these, 2422 were from countries with an incidence of TB exceeding 100/10Of those screened, 349 had a positive test and were referred to the northern paediatric TB clinic at Astrid Lindgren Children's Hospital. Of these, 16 had TB disease and 278 latent tuberculosis infection (LTBI), while we considered 53 uninfected. In addition, eight sought medical attention with symptomatic TB outside the screening system. Cohort rates were 6.8% of LTBI and 0.5% of TB in minors from Afghanistan and 26-32% of LTBI and 3.4-3.5% of TB among those from Eritrea, Ethiopia or Somalia.We conclude that TB infection and disease is common among asylum-seeking unaccompanied minors, especially among those from the Horn of Africa.

The burden of community-acquired pneumonia (CAP) in high-income countries is still significant. The introduction of pneumococcal conjugate vaccines (PCV) has reduced the overall need for hospitalization for CAP. However, it is not clear whether children with underlying disease also have benefitted from the PCV immunization programme. Children 0 to

Background Reports of the outcome of treatment of tuberculosis (TB) disease and infection (TBI) in children are scarce. Since 2010, we routinely use interferon-gamma release assays in addition to clinical history for the exclusion of TBI, although the safety of this approach has been questioned. We present the frequency of recurrent TB or progression to TB after treatment for TB disease or TB infection, respectively, and progression to disease in children considered TB uninfected at our pediatric TB clinic. Methods We included 4707 patients from 1990 to 2017. At the initial assessment, 96 (2.0%) had previously received TB treatment, 253 (5.4%) had TB disease, 1625 (35%) had TBI and 2733 (58%) children were considered uninfected. Patients were passively followed at our clinic, at the adult TB clinics in Stockholm and at the Swedish national TB registry. Results During a median follow-up time of 8.4 years, we found 36 cases of TB disease, with true relapses in 3/243 (1.2%) successfully treated TB patients. Preventive treatment of TBI reduced the risk of progression to TB by 85%, from 4.3% (15/349) to 0.6% (8/1262). In children considered uninfected, the risk of later developing TB was 0.07% (2/2733). Conclusions The effectiveness of TB management was acceptable. Our routine procedures for the exclusion of TBI appear safe.

BACKGROUND Antimicrobial resistance is increasing, and data on antimicrobial use in Swedish children are limited. We evaluated trends in antimicrobial use and attempted to identify targets for improving the quality of antimicrobial prescribing in a tertiary care center. METHODS One-day hospital-wide point prevalence surveys were conducted 8 times during 2003-2017 at Astrid Lindgren Children's Hospital. Children

During 2000 to 2018, 1831 children were screened as part of tuberculosis contact investigation at the Stockholm Northern Clinic. The risk of a child having a positive tuberculin skin test was 33% and positive interferon-gamma release assay 12%. The risk of tuberculosis disease was 6.1% (tuberculin skin test) and 13% (interferon-gamma release assay) in positive-testing children.

The number of patients infected with nontuberculous mycobacteria (NTM) is increasing and presents severe health problems. NTM infections in children are not uncommon and differ in several aspects from NTM infections in adults. In children, lymph nodes are most often infected, while lung infections dominate among adults. Thus, this chapter on NTM infections will focus on infections in children and pulmonary infections in adults. The reason why NTM diseases have been more commonly recognized is partly due to increased awareness and improved diagnostic methods. In addition, the number of patients with impaired resistance to infections has increased and such conditions are important risk factors for developing NTM disease. However, many NTM patients, particularly children, have no known predisposing condition. In addition, spontaneous resolution is common among children. Diagnosis and treatment are challenging since many patients suffer from other diseases and many NTM are resistant to commonly used drugs. Therapy is, therefore, generally complex and prolonged and side effects are common.

AIM Increasing numbers of migrants to Sweden are screened for tuberculosis (TB), and a rational approach to screening is required. We evaluated positive tuberculin skin tests (TSTs) and interferon-gamma release assays (IGRAs) on paediatric migrants in relation to the TB incidence in the corresponding foreign-born populations in Stockholm. METHODS This study examined the characteristics of migrants under the age of 18 who were referred to a paediatric TB clinic at Karolinska University Hospital from 2008 to 2014 by primary care centres in Stockholm County. RESULTS We saw 943 TST-positive children with a median age of 14 years at the TB clinic and performed IGRAs on 557. IGRA positivity ranged from 64% in migrants from Somalia to 20% in those from the former Soviet Union and eastern Europe, with an estimated population level prevalence of 18.8% and 4.2%, respectively. These were significantly correlated to TB incidence in foreign-born Stockholm children. We diagnosed active TB in 20 screened migrants, and advanced, symptomatic TB was diagnosed in 10 recently arrived migrants without screening. CONCLUSION IGRAs showed higher specificity than TST in identifying tuberculosis. TB screening should focus on migrants from high-incidence countries, but this may be inadequate to detect advanced TB cases.

Aim This study explored the incidence and aetiology of bloodstream infections after patients received the pneumococcal conjugate vaccination and a risk-based intrapartum antibiotic prophylaxis against early onset sepsis caused by group B streptococcus. We also monitored clinically relevant antimicrobial resistance. Method We studied 3986 positive blood cultures from children up to 17 years of age at a paediatric hospital in Stockholm, Sweden, using data from medical records before and after the initiatives, to reduce early onset sepsis, were introduced in 2007 and 2008. Results Bloodstream infections caused by Streptococcus pneumoniae declined by 42% overall (5.6 to 3.2/100 000) and by 62% in previously healthy children under 36 months of age (24.2 to 9.2/100 000). Early onset sepsis caused by group B streptococcus declined by 60% (0.5 to 0.2/1000 live born children). Bacterial meningitis caused by these bacteria decreased by 70%. Staphylococcus aureus and various Gram-negative bacteria became the dominant pathogens, in both previously healthy children and those with underlying disease. Overall, antimicrobial resistance remained low between the two 5-year study periods. Conclusion Pneumococcal conjugate vaccination and risk-based intrapartum antibiotic prophylaxis against group B streptococcus effectively decreased the incidence of bloodstream infections. Empirical antibiotic therapy should target Staphylococcus aureus in both community and hospital-acquired invasive bacterial infections.

BACKGROUND AND OBJECTIVE: Streptococcus pneumoniae is a major cause of pneumonia and sinusitis. Pneumonia kills >1 million children annually, and sinusitis is a potentially serious pediatric disease that increases the risk of orbital and intracranial complications. Although pneumococcal conjugate vaccine (PCV) is effective against invasive pneumococcal disease, its effectiveness against pneumonia is less consistent, and its effect on sinusitis is not known. We compared hospitalization rates due to sinusitis, pneumonia, and empyema before and after sequential introduction of PCV7 and PCV13. METHOD: All children 0 to RESULTS: Hospitalizations for sinusitis decreased significantly in children aged 0 to CONCLUSIONS: PCV7 and PCV13 vaccination led to a 66% lower risk of hospitalization for sinusitis and 19% lower risk of hospitalization for pneumonia in children aged 0 to

Aim This Swedish study compared the discharge diagnosis codes used for children up to the age of five hospitalised for acute lower respiratory tract infections before and after the introduction of the pneumococcal conjugate vaccine in 2007. Methods The International Classification of Diseases - 10th revision codes were used. We compared the discharge diagnosis codes at the Astrid Lindgren Children's Hospital from 1 July 2005 to 30 June 2007 (n=1,127) and 1 July 2011 to 30 June 2013 (n=1,240) in relation to the diagnostic methods used. Results There was a 54% reduction in the rate of all-cause pneumonia from the first to the second period in infants up to the age of one, but some of this could have been due to the improved diagnosis of viral infections and us changing the code for respiratory syncytial virus infection from pneumonia to bronchiolitis. The overall rate of acute lower respiratory tract infections was unchanged. Conclusion We could not determine how much of the reduction in bacterial pneumonia in children under one was because of the introduction of the pneumococcal conjugate vaccine, based solely on discharge codes. Longitudinal register studies should take changes in diagnosis codes into account. This article is protected by copyright. All rights reserved.

The national Swedish immunisation programme includes vaccine against diphtheria, tetanus, polio, pertussis, Haemophilus influenzae type B, Pneumococcus as well as measles, mumps and rubella. Data were collected on hospital admissions for children 0- 17 years of age of vaccine-preventable diseases during 2008-2013 at Astrid Lindgren Children's Hospital, Stockholm. Patients were identified by discharge diagnosis codes as well as from the clinical microbiology laboratory. There were rare cases of measles and mumps, and only a few cases of invasive bacterial diseases. The dominating pathogens were influenza A and B, rotavirus and varicella zoster virus. Our national programme is effective, but vaccine preventable infections still cause significant morbidity in young children. An extended vaccine programme might significantly reduce the need of hospitalisations.

Aim To study the aetiology of bloodstream infections (BSI) in children 0–17 years, the influence of age and underlying co-morbidity on BSI rate, distribution of pathogens and outcome; and to provide data on antimicrobial susceptibility patterns. Methods A retrospective population-based study. Data on blood cultures were collected at yearly intervals during 1998–2008. Information about risk factors, focal infection and outcome was retrieved from the patient charts. Results We identified 1097 BSI. The incidence of BSI was 0.4/1000. The age-specific incidence was 2.3/1000 in neonates (0–28 days old) and 0.2/1000 in the age group 6–17 years. Staphylococcus aureus was the most common pathogen. The number of species causing BSI in previously healthy children was lower compared with children with co-morbidity. Most children requiring intensive care had a serious underlying illness. Antimicrobial resistance was rare and did not influence outcome. The case-fatality rate was 14.4% in neonates, 5.4% in children with co-morbidity and 1.7% in previously healthy children. Conclusion Mortality from BSI is low, and a limited spectrum of pathogens is isolated from previously healthy children compared with children with co-morbidity. When choosing empirical therapy for suspected BSI, age and presence of risk factors should be taken into account.

Aim This study described the epidemiology and clinical features of childhood tuberculosis (TB) in Stockholm over a 45-year period, when there was a resurge of tuberculosis concomitant with increased immigration. Methods We describe 220 children up to the age of 16 years with active TB, seen at the Astrid Lindgren Children's Hospital from 1971-2015. The study period was divided into three 15-year periods. Results Cases increased from 10 children in 1971-1985 to 76 in 1986-2000 and 134 in 2001-2015, with overall incidence increasing from

Aim Encephalitis is a rare, serious condition, and antiviral therapies, increased knowledge of inflammatory pathways and improved diagnostics have increased the therapeutic possibilities. We describe 40 years of childhood encephalitis in Sweden, covering the diagnostics, aetiology and outcomes. Methods We reviewed the clinical data that were available for all children discharged from the Karolinska University Hospital in Stockholm following treatment for encephalitis from 1970 to 2009. The hospital treated all children in the region with the condition during the study period. Results There were 408 episodes of encephalitis from 1970 to 2009 and the incidence was similar over the whole period, ranging from 6.4 to 8.7 per 100 000 child years. Although mortality markedly decreased from 10% in the first decade to zero in the last decade, and aetiologies shifted, no clear long-term improvements in outcome were seen. The need for intensive care was unchanged (18–20%) for each of the study intervals, possibly indicating that the severity of cases remained unaltered. Conclusion Understanding the pathophysiological mechanisms of encephalitis is vitally important for developing more efficient treatment regimens. As well as reporting the results of this 40-year study, this study considers possible explanations, addresses current therapeutic options and explores directions for central nervous system infection research.

Increasing international migration has changed the epidemiology of tuberculosis (TB) in Europe. Little is published on clinical manifestations and epidemiology in children in this new era.Clinical and laboratory data on all children with TB in Stockholm between 2000 and 2009 were entered into a database and retrospectively completed with information from case records. Population data, including parents' country of birth, were obtained from Statistics Sweden.TB was diagnosed in 147 children18 years of age (78 confirmed, 12 probable, 57 possible). Fifty-six children (38%) presented clinically, and 91 were identified by screening procedures. Ninety children (61%) were born in high-endemic countries and 38 in Sweden to parents from such countries. The incidence was 451/100,000 person years among children born in Somalia, 44 among those born in other high-endemic countries, and 13 among Swedish-born children with parents from high-endemic countries. All but 1 of the 19 Swedish-born children with Swedish parents belonged to a single outbreak. Median age was 12 years. Severe, adult-type TB was predominantly observed in adolescents, whereas young children presented mild, primary disease that was diagnosed at the time of screening. The 78 positive cultures were traced back to 67 strains. Resistance to any first-line drug was present in 25% of the strains, of which 4 were multidrug resistant.Active TB in Stockholm is common in children born in high-endemic countries, especially Somalia. The most severe cases are seen in adolescents. The high prevalence of antimicrobial resistance is a cause for concern.

Aim: To present our experience of nerve dysfunction following surgical treatment among 126 children with microbiologically verified non-tuberculous mycobacterial (NTM) lymphadenitis. Methods: We retrieved data from medical records, and a questionnaire with an invitation to a clinical follow-up was returned by 88 families. Results: The time from onset of symptoms to diagnosis was more than 3 months in 24% of subjects. Mycobacterium avium complex was isolated from 105, Mycobacterium malmoense from 12 and Mycobacterium scrofulaceum from one cervical lymph node. A total of 89% of the children underwent surgery and were examined in particular with regard to cranial motor nerve functions. Major persisting nerve dysfunction occurred in 3/51 (6%) children who underwent radical surgery, and minor dysfunction in seven (14%). In nine children, the marginal mandibular branch of the facial nerve was affected, and the accessory nerve was affected in one child. There were no neurological signs in 25 children treated with incision and drainage alone or in 12 followed with observation alone. Healing took >6 months in 2/76 (3%) surgically treated and 3/12 (25%) non-surgically treated children. Conclusion: Considering the risk of nerve dysfunction following extirpation, incision with drainage and observation alone should both be included among the management options for cervical NTM lymphadenitis in children.

We wanted to elucidate the value of Borrelia antibodies in serum and cerebrospinal fluid (CSF) for the diagnosis of Lyme neuroborreliosis (LNB). We analyzed the serological findings, by anti-flagellin assay, in 267 patients with neurological symptoms from the Stockholm area, where Lyme borreliosis is endemic. In the 70 children with LNB, intrathecal Borrelia antibody production was diagnostic and found in 50 (71%). Sixteen (23%) showed an elevated antibody titer in serum only, and 4 (7%) had no serologic findings. Borrelia IgG in serum, with or without concomitant IgM, was a specific (98%), but insensitive (43%) marker of infection. Isolated, false-positive serum IgM titers were common and found in 10 of 67 children (15%) with viral meningitis, as well as in 28 of 111 (25%) with various neurological symptoms and normal CSF. The specificity of an isolated Borrelia IgM titer in serum was 81%, and the positive predictive value for Borrelia infection only 50% in our material. On the other hand, absence of antibodies in blood had a negative predictive value of 94%, which increased to 97% if also CSF findings were included. Intrathecal antibody production is strongly supportive of an LNB diagnosis. Conversely, isolated, elevated levels of Borrelia IgM in serum occur in up to onefourth of children with various neurological complaints, and should be interpreted with caution, especially in nonendemic areas.

The aim of this retrospective observational study was to evaluate age, length of hospital stay and development of complications in children hospitalized with community- or nosocomially- acquired rotavirus gastroenteritis (RV GE). In total, medical records of 984 children with RV GE were analysed retrospectively. The median age was 13.8 months (3 weeks to 99 months) in children with community acquired RV GE (n=723) and 9.0 months (range 3 weeks to 82 months) in children with nosocomially acquired RV GE (n=261). During this 11-y surveillance, only 2 children were admitted twice for a RV GE, suggesting development of subsequent protective immunity against severe rotavirus gastroenteritis after the first episode. Complications occurred in 16.5% of the children with community acquired RV GE and only in 1.9% of the nosocomially acquired RV GE. Identified complications in children with community acquired RV GE were: severe dehydration resulting in intensive care (1.7%), death (0.1%), hypertonic dehydration (9.1%), seizures (4.0%) and encephalitis with abnormal EEG (1.7%). The median age of children in need of intensive care was 9.1 months and in those developing hypertonic dehydration 10.8 months, both significantly lower than in children with no complications (p

Background Influenza remains a common reason for the hospitalization of children. There is a need for long term studies that are also population based. We describe the epidemiology of severe influenza in a defined population 1998–2014. Method Retrospective study of annually collected data of virologically confirmed influenza in hospitalized children 0–17 years living in the catchment area (230,000 children). We gathered information about comorbidity and complications from case records, and compared Influenza A, B and A(H1N1)pdm09 with respect to these factors. Results A total of 922 children with influenza were hospitalized. The mean rate remained unchanged at 22.5–24.2 per 100,000 children per year. There were two major outbreaks: influenza A(H3N2) in 2003–2004 and the A(H1N1) pandemic in 2009–2010. The proportion of children with influenza B increased from 8% during the first half of the study period to 28% during the second half. The highest admission rate was found in children

There are few independent, population-based reports that estimate the risk of hospitalization of respiratory syncytial virus (RSV)-infected infants before and during the palivizumab era. We present figures from the greater Stockholm area during the three seasons after the introduction of palivizumab and relate them to data based on 1400 hospitalizations for RSV disease in the same population area during 1987 through 1998.The number of births, neonatal complications and palivizumab prescriptions was obtained. We retrieved information about all infant hospitalizations for confirmed RSV infections with risk factors and complications. Chronic lung disease (CLD) in preterm infants was defined as oxygen dependency beyond 36 weeks of postconceptional age.Eight hundred eighteen infants (1.3% of the population) were hospitalized for confirmed RSV infection. The hospitalization rates were 3.7% (24 of 642) among preterm infants with gestational age33 weeks without CLD and 7.2% (14 of 195) in those with CLD. Palivizumab had been given to 235 infants, usually those with CLD and in need of continuous oxygen or steroid treatment or the6 month-old infants with extremely preterm birth (gestational age26 weeks). The risk of hospitalization for RSV disease was low, but this was the case also before the introduction of palivizumab.In countries with a low baseline risk of hospitalization for RSV infection, the benefit of palivizumab might not justify the cost of its widespread use. We advocate defining more rigorous prescription criteria.

Background Immunological studies have indicated that the effectiveness of AS03 adjuvanted monovalent influenza A(H1N1)pdm09 vaccine (Pandemrix®) may be of longer duration than what is seen for non-adjuvanted seasonal influenza vaccines. Sixty-nine percent of children 6 months–18 years of age in Stockholm County received at least one dose of Pandemrix® during the 2009 pandemic. We studied the effectiveness of the vaccine during the influenza seasons 2010–2011 and 2012–2013 in children hospitalized with virologically confirmed influenza. The season 2011–2012 was not included, since influenza A(H3N2) was the predominant circulating strain. Methods In a retrospective case-control study using a modified test-negative design we compared the percentage vaccinated with Pandemrix® among children diagnosed with influenza A(H1N1)pdm09 (cases), with that of those diagnosed with influenza A(H3N2) or influenza B (controls) during the two seasons. We excluded children born after July 1, 2009, since only children who were 6 months of age or older received the pandemic vaccine in October–December 2009. Results During the 2010–2011 season, 3/16 (19%) of children diagnosed with influenza A(H1N1)pdm09, vs. 32/41 (78%) of those with influenza A(H3N2) or influenza B had been vaccinated with Pandemrix® in 2009. The odds ratio, after adjustment for sex, age and underlying diseases, for becoming a case when vaccinated with Pandemrix® was 0.083 (95%CI 0.014, 0.36), corresponding to a VE of 91.7%. During the season 2012–2013, there was no difference between the two groups; 59% of children diagnosed with influenza A(H3N2)/B and 60% of those with influenza A(H1N1)pdm09 had been vaccinated with Pandemrix® in 2009. Conclusion The AS03 adjuvanted monovalent influenza A(H1N1) pdm09 vaccine (Pandemrix®) was effective in preventing hospital admission for influenza A(H1N1)pdm09 in children during at least two seasons.

The aim of this prospective cohort study was to estimate the burden of severe disease caused by rotavirus-induced gastroenteritis in Swedish children aged5 y.Rotavirus-positive children admitted to hospitals serving 3 geographical regions with 155,838 children aged5 y, were offered inclusion in this 1-year study. Rotavirus strains identified were genotyped using multiplex PCR. Disease progression was documented through interviews and chart reviews.In total, 604 children with rotavirus-induced gastroenteritis were included in the study. Forty-nine of 604 (8.1%) fulfilled the criteria for nosocomial infection. The minimum incidence was 388 per 100,000, with significant variability between study regions, ranging from 280 to 542 per 100,000. In all regions, the peak season occurred in February-April, but the season start varied, with first cases observed in October in the eastern region and December in the northern region. Genotypes identified differed between the regions: G1[P8] was most prevalent in all regions (77%), while the most varied pattern was observed in the western region, with G1[P8] observed in 61%, G4[P8] in 13%, G9[P8] in 10%, G2[P4] in 8%, and G3[P8] in 8% of the children. The median age of hospitalized children was 14 months and the median total duration of diarrhoea was 6.9 days. Sixty-eight percent reported a temperature38.5°C upon admission. Complications occurred in10% of the children, with hypertonic dehydration (32/604) and seizures (10/604) occurring most frequently.Rotaviruses may cause severe febrile acute gastroenteritis leading to dehydration requiring acute rehydration in hospital. In addition, further complications occurred in10% of hospitalized children.

When the tuberculosis epidemic reached its peak in central Europe in the 1900s (not until the 2000s in sub-Saharan Africa), both contained and disseminated tuberculosis was mainly regarded as a childhood disease. From 1920, before the use of the Bacillus Calmette–Guérin (BCG) vaccine and the possibility of drug treatment, there was a drastic decline in the rate of tuberculosis incidence in the Western world. In 1970, the case rate had declined in Sweden from 500/100,000 individuals to 1/100,000 individuals. We recently studied childhood tuberculosis in the Stockholm area from 1971 to 2015. During this period the case rate had increased from 1/100,000 individuals to 8/100,000 individuals. A major contributing factor has been increased immigration and, more recently, from high incidence countries. While there are very few cases in Swedish children whose parents are also born in Sweden, the case rate is still high in foreign-born children, for example, 450/100,000 foreign-born Somali children. At the beginning of the past 45years, sentinel (infected in Sweden with no known source person) cases were a reality but they are rarely seen today. This may be attributed to better organization, contact tracing, screening, and early diagnosis in the adult population.

We examined the incidence of subsequent wheezing in 292 children, hospitalized for influenza A or respiratory syncytial virus (RSV) lower respiratory tract infection, during two consecutive seasons (November-December, 1993 and March-April, 1995). Questionnaires concerning episodes of wheezing and known risk factors for wheezy bronchitis were mailed to parents 1 year after hospitalization. Sixty per cent of parents reported two or more episodes of wheezing following either influenza A or RSV. Hospitalization as a result of wheezing was necessary in 15% of the patients. The severity of the primary infection, as indicated by the need for treatment in the intensive care unit (ICU), was correlated with later wheezing. No additional significant risk factors predicting later wheezing could be identified.

Laboratory and hospitalization data from two children's hospitals with large primary catchment areas and national laboratory and hospitalization data for children under 4 y of age with acute diarrhoea were compiled to estimate the number of hospitalizations and the cost burden associated with rotavirus diarrhoea in Sweden. According to our estimates 1500-1700 rotavirus-associated hospitalizations occur annually in Sweden in children under 4 y of age (3.7 hospitalizations/1000 children/y). This number represents 2.3% of admissions for all diagnoses in children of this age group. The cost of these hospitalizations is 13.5-15 million Swedish crowns (US$1.8-2 million). Serotyping by PCR for two years revealed that serotype 1 (G1) was the most common (49% and 58%, respectively) identified. Serotypes 2-4 were identified in the following proportions G2 (23% and 5%), G3 (21% and 0%) and G4 (7% and 16%). The national laboratory report data for 1993-96 show that as much as 7-13% of rotavirus infections occur in elderly people.

Objective To describe the role of Norwalk-like virus in pediatric diarrhea, since relatively little is known about it in this age group. Methods We reviewed all 77 hospitalized cases of diarrhea related to Norwalk-like virus at St Goran's Children's Hospital from 1987 to 1993. Electron microscopy of feces was used routinely, and performed at the former Central Microbiology Laboratory of the Stockholm County Council. Results Forty-seven children (61%) had nosocomial diarrhea. Their median age was 9 months. Most nosocomial cases occurred singly or in small clusters during periods when there were also community-acquired cases. However, during the first half of 1992, there was a larger cluster of eight community-acquired and 19 nosocomial cases. Both vomiting and diarrhea were present in the majority of patients. The symptoms were typically mild, and only 14% needed intravenous fluids. Five of 17 children examined repeatedly excreted virus after the symptoms had subsided. We used detection of Norwalk-like virus in fecal samples as an indication of infectiousness and then observed no further nosocomial spread. There was a seasonal variation with a predilection for the winter months. Conclusion Norwalk-like virus should also be considered as a cause in cases of nosocomial diarrhea in young children.

81 cases of tuberculosis infection (17) and disease (64), seen between 1977 and 1995 at St Göran's Children's hospital, Stockholm, Sweden are reviewed. The incidence of tuberculosis disease increased from 1 to 6/10(5) children/y. The increase was due to immigration from high-prevalence countries, with an incidence of 20/10(5) in a partly segregated suburb. Most of the children were foreign-born. Of the 31 0-4-y-old cases, 19 were born in Sweden, and 7 had received BCG vaccination. For Swedish-born children with Swedish-born parents, the incidence of tuberculosis disease remained stable at0.5. 50 patients were symptomatic when first seen (60% pulmonary tuberculosis, 8% military tuberculosis, 25%, cervical adenitis, 15% other extrapulmonary tuberculosis). There was 1 death, and in 2 children complicated tuberculosis courses. Side effects of drug therapy were seen in 5% of the children. In conclusion, tuberculosis remains an important differential diagnosis in children of immigrants from high-prevalence countries for at least 5 y after settlement in Sweden. The practice of delaying BCG vaccination of them until 6 months of age can be disputed.

At St. Göran's Children's Hospital (a tertiary center), we perform electron microscopy of feces in most cases of nosocomial gastroenteritis. From September 1987 through April 1992 we identified 32 episodes of calicivirus infection, 25 of which were nosocomial and, except for one outbreak, sporadic. Systematic study of the nosocomial outbreak of calicivirus gastroenteritis from November 1991 to January 1992, revealed calicivirus in the stools of 8 of 23 children with diarrhea and 0 of 10 without diarrhea. In 3 of 7 sampled after cessation of diarrhea, calicivirus excretion continued for 3 to 6 days. We found no calicivirus in 42 staff members or 9 members of infected patients' families. Nosocomial transmission of calicivirus can occur among infants.

Newborn infants are rapidly colonized by both aerobic and and anaerobic bacteria, initially with about 50% of each type. Several factors related both to the infant and its environment influence the composition of the intestinal microflora quantitatively as well as qualitatively. Major ecological disturbances are observed in newborn infants treated with antimicrobial agents. One way of minimizing the ecological disturbances, which may be seen in infants treated in neonatal intensive care units, is to provide them with fresh breast milk from their mothers and to use antimicrobial therapy only under strict clinical indications.

We examined the fecal microflora of 1-3-month-old infants during treatment with phenoxymethylpenicillin, amoxycillin, pivampicillin, cefaclor, cefadroxil, loracarbef, erythromycin or cotrimoxazole. Escherichia coli increased during treatment with penicillins or cephalosporins, but was not affected by erythromycin or cotrimoxazole. Other enterobacteria were acquired or increased during treatment with all agents except cotrimoxazole. Enterococci persisted or increased during phenoxymethylpenicillin, cephalosporin or cotrimoxazole treatment, whereas erythromycin and the other penicillins suppressed them. Bacteroides, bifidobacteria and lactobacilli were suppressed to undetectable levels in most infants during treatment with all agents, except phenoxymethylpenicillin and loracarbef.