Special issue on developmental delay

A significant percentage of children, ages 0-5 years, present with developmental delays. Delays can be global (GDD), when two or more developmental areas manifest at least 6 months delays, or specific (SDD)when it relates to a single functional area. This special issue reviews etiologies as well as clinical and research uses of the term, focusing on the potential for arriving at earlier specific diagnoses in cases of CP, ADHD, ASD and language impairments (LI).

The functional profile of young adults with suspected Developmental Coordination Disorder (DCD)

We assessed the non-academic and academic functioning of young adults with DCD, and investigated the emotional influences and the role of strategy use within this population. A random sample of 2379 adolescents and young adults aged 19-25 (1081 males [45.4%]; mean age=20.68, SD=3.42) was used to develop the instruments. From this sample, three study groups were identified (n=429) based on the Adolescents & Adults Coordination Questionnaire: probable DCD (n=135; 67.2% males), suspected borderline DCD (n=149; 51.4% males) and control (145; 70.5% males). Participants completed the Daily Life Functions Questionnaire (assessing non-academic and academic functioning), the Recent Emotional State Test (assessing feelings resulting from task performance), the Internal Factors Attributed to Success Questionnaire and the Problem Solving Questionnaire to assess strategy and executive strategy use. A MANOVA revealed statistically significant differences between-groups (F[7,422]=16.19; p<.001; η=.197); post hoc analyses revealed differences for all measures (except the Problem Solving Questionnaire), with the probable DCD and suspected borderline DCD groups performing worse than controls. Severity of motor deficits was correlated with all outcomes except strategy use. Logistic regression revealed that non-academic functioning was the most significant predictor of group placement (B=-1.32; p<.001); academic functioning/handwriting was the second most significant predictor (B=0.44; p=.047). Deficits in motor coordination continue into adulthood and have an effect on academic and non-academic function, as well as on the emotional state of the individual.

Preliminary findings of the developmental effects of in utero exposure to topiramate

There are relatively few studies that have looked at the longer-term developmental effects of intra-uterine topiramate exposure. The purpose of this report is to describe preliminary findings of the developmental outcomes of a group of nine children of preschool age (3-6 years, 11 months), exposed in utero to topiramate (TX) monotherapy, as compared to a control group of 18 children. The groups were compared on developmental measures of visual, fine and gross motor function as well as measures of behavior and cognitive functions. Results showed that the TX group performed significantly worse than the control group for almost all measures, with the most clearly delineated differences in the area of cognitive functioning. While the study group is small, and only preliminary conclusions may be inferred, it appears that TX exposure may have subtle effects on the development of children in a range of areas including motor function, cognition, and behavior.

An association between Helicobacter pylori infection and cognitive function in children at early school age: a community-based study

Background

H. pylori infection has been linked to iron deficiency anemia, a risk factor of diminished cognitive development. The hypothesis on an association between H. pylori infection and cognitive function was examined in healthy children, independently of socioeconomic and nutritional factors.

Methods

A community-based study was conducted among 200 children aged 6-9 years, from different socioeconomic background. H. pylori infection was examined by an ELISA kit for detection of H. pylori antigen in stool samples. Cognitive function of the children was blindly assessed using Stanford-Benit test 5^th edition, yielding IQ scores. Data on socioeconomic factors and nutritional covariates were collected through maternal interviews and from medical records. Multivariate linear regression analysis was performed to obtain adjusted beta coefficients.

Results

H. pylori infection was associated with lower IQ scores only in children from a relatively higher socioeconomic community; adjusted beta coefficient -6.1 (95% CI -11.4, -0.8) (P = 0.02) for full-scale IQ score, -6.0 (95% CI -11.1, -0.2) (P = 0.04) for non-verbal IQ score and -5.7 (95% CI -10.8, -0.6) (P = 0.02) for verbal IQ score, after controlling for potential confounders.

Conclusions

H. pylori infection might be negatively involved in cognitive development at early school age. Further studies in other populations with larger samples are needed to confirm this novel finding.

Prenatal origin of obesity and their complications: Gestational diabetes, maternal overweight and the paradoxical effects of fetal growth restriction and macrosomia

Pregestational (PGDM) and gestational (GDM) diabetes may be associated with a variety of fetal effects including increased rate of spontaneous abortions, intrauterine fetal death, congenital anomalies, neurodevelopmental problems and increased risk of perinatal complications. Additional problems of concern are fetal growth disturbances causing increased or decreased birth weight. Optimal control of maternal blood glucose is known to reduce these changes. Among the long lasting effects of these phenomena are a high rate of overweight and obesity at childhood and a high tendency to develop the "metabolic syndrome" characterized by hypertension, cardio-vascular complications and type 2 diabetes. Similarly, maternal overweight and obesity during pregnancy or excessive weight gain are also associated with increased obesity and complications in the offspring. Although there are different causes for fetal growth restriction (FGR) or for fetal excessive growth (macrosomis), paradoxically both are associated with the "metabolic syndrome" and its long term consequences. The exact mechanism(s) underlying these long term effects on growth are not fully elucidated, but they involve insulin resistance, fetal hyperleptinemia, hypothalamic changes and most probably epigenetic changes. Preventive measures to avoid the metabolic syndrome and its complications seem to be a tight dietary control and physical activity in the children born to obese or diabetic mothers or who had antenatal growth disturbances for other known or unknown reasons.

Is the association between Helicobacter pylori infection and anemia age dependent?

BACKGROUND

The relationship between H. pylori infection and anemia in childhood is still unclear. The aim of the study was to examine the association between H. pylori infection and anemia or iron deficiency in school-age children and in infants.

MATERIALS AND METHODS

Six- to 9-year-old Israeli Arab children (N = 202) and infants (N = 197) were examined for hemoglobin and ferritin levels. ELISA was used to detect H. pylori antigens in stool specimens collected from the participants. Household characteristics were obtained through personal interviews with the mothers.

RESULTS

The prevalence of anemia was 15.5 versus 5.5% in H. pylori-positive and -negative school-age children, respectively and 34.5 versus 29.8% in H. pylori-positive and -negative infants, respectively. The Mantel-Haenszel age-adjusted prevalence ratio (PR) and 95% confidence intervals (CIs) were 1.6 (95%CI 1.0, 2.6). In multivariate analysis controlling for socioeconomic variables, H. pylori infection was associated with 2.8 higher prevalence of anemia only in school-age children: adjusted PR 2.8 (95% CI 0.9, 9.3). The adjusted mean difference in hemoglobin levels between H. pylori infected school-age children and uninfected ones was -0.372 gr/dL (95% CI -0.704, -0.039) (p = .04). The respective mean ferritin difference was -6.74 μg/L (95% CI -13.38, -.011) (p = .04). Such differences were not found in infants.

CONCLUSIONS

H. pylori infection is associated with higher prevalence of anemia in school-age children independently of socioeconomic variables. Such association was not observed in infants. These findings are of clinical and public health importance.

The embryotoxicity of sera from patients with autoimmune diseases on post-implantation rat embryos in culture persists during remission and is not related to oxidative stress

We evaluated the embryolethality and embryotoxicity of sera from patients suffering from autoimmune diseases during remission on post-implantation rat embryos cultured on these sera and determined the association between the patients' clinical history, high blood levels of specific antibodies, medications, and oxidative stress parameters. One hundred and eighty, 10.5-day-old rat embryos were cultured in their yolk sacs in 33 sera of systemic lupus erythematosus (SLE)/antiphospholipid syndrome (APS) patients, and compared with 84 embryos cultured in rat sera and 88 embryos cultured in control human sera. The sera proved to be lethal and embryotoxic but not teratogenic resulting in smaller yolk sacs and embryos, lower protein level and lower developmental score. Significantly less embryos cultured in 'toxic' SLE/APS sera had peak 2 of low molecular weight antioxidants (LMWA) wave, implying a delayed maturation of the antioxidant defense. Lower peak 1 of LMWA correlated with a history of recurrent abortions. Embryonic levels of superoxide dismutase (SOD) and catalase (CAT) did not correlate with sera toxicity, patients' clinical history or specific antibodies. We conclude that SLE/APS patients' clinical remission did not prevent death or developmental delay accompanied by later appearance of peak 2 of LMWA in post-implantation rat embryo cultures. The normal levels of the antioxidant enzymes evaluated may indicate that sera toxicity is not related to oxidative stress.

Pregnancy outcome after in utero exposure to colchicine

OBJECTIVE

We sought to examine the fetal safety of colchicine.

STUDY DESIGN

This was a prospective observational comparative cohort study regarding colchicine exposure during pregnancy including contacts to 2 Teratology Information Services in Israel from 1994 through 2006.

RESULTS

In all, 238 colchicine-exposed pregnancies (97.0% first trimester) and 964 pregnancies with nonteratogenic exposure were followed up. Treatment indications were: familial Mediterranean fever (87.3%), Behçet disease (7.5%), or other (5.2%). The rate of major congenital anomalies was comparable between the groups (10/221 [4.5%] vs 35/908 [3.9%]; P = .648). There were no cytogenetic anomalies in the colchicine group. The median gestational age at delivery was earlier (39 [38-40] vs 40 [38-41] weeks; P < .001), the rate of preterm deliveries was higher (32/214 [15.0%] vs 51/867 [5.9%]; P < .001), and the median birthweight was lower (3000 [2688-3300] vs 3300 [2900-3600] g; P < .001) in the colchicine group.

CONCLUSION

The present study suggests that colchicine does not appear to be a major human teratogen, and, probably, has no cytogenetic effect.

Pregnancy outcome, thyroid dysfunction and fetal goitre after in utero exposure to propylthiouracil: a controlled cohort study

AIMS

Propylthiouracil (PTU) is presently considered to be the treatment of choice for hyperthyroidism in pregnancy. It is known to cross the human placenta, and therefore may affect the fetus. The major aims of this study were to evaluate the rate of major anomalies and to report the rate of fetal goitre, accompanied by hypothyroidism, in fetuses/ newborns of mothers after in utero exposure to PTU.

METHODS

Prospective observational controlled cohort study of PTU-exposed pregnancies of women counselled by the Israeli Teratology Information Service between the years 1994 and 2004 compared with women exposed to nonteratogens.

RESULTS

We followed up 115 PTU-exposed pregnancies and 1141 controls. The rate of major anomalies was comparable between the groups [PTU 1/80 (1.3%), control 34/1066 (3.2%), P= 0.507]. Hypothyroidism was found in 9.5% of fetuses/neonates (56.8% of whom with goitre). Hyperthyroidism, possibly resulting from maternal disease, was found in 10.3%. Goitres prenatally diagnosed by ultrasound were successfully treated in utero by maternal dose adjustment. In most cases neonatal thyroid functions normalized during the first month of life without any treatment. Median neonatal birth weight was lower [PTU 3145 g (2655-3537) vs. control 3300 g (2968-3600), P= 0.018].

CONCLUSIONS

PTU does not seem to be a major human teratogen. However, it could cause fetal/neonatal hypothyroidism with or without goitre. Fetal thyroid size monitoring and neonatal thyroid function tests are important for appropriate prevention and treatment.

Neurodevelopmental and psychological assessment of adolescents born to drug-addicted parents: effects of SES and adoption

OBJECTIVES

Prenatal exposure to heroin may have long-term consequences for development during early and middle childhood. The present research studied the cognitive, social, and emotional functioning of adolescents exposed to drugs prenatally, and investigated the extent to which the early adoption of children exposed prenatally to drugs would alleviate the possible effects of exposure.

METHODS

The study included 191 adolescents (12-16 years of age) and their parents in Israel, who had or had not been exposed prenatally to drugs and differing in socio-economic status (SES), and in adoptive status. They were administered five subtests of the Wechsler Intelligence Scale for Children (WISC-III), and the Youth Self-Report Form for assessing behavior problems that measures problems associated with attention deficit, self-esteem and risk-taking. Parents were administered the Child Behavior Checklist (CBCL) for assessing behavior problems, the Conners Rating Scale (CRS) for assessing attention deficit problems in their children and the Wender Utah Rating Scale (WURS), a self-report measure of ADHD-related problems.

RESULTS

Adolescents exposed to at least one risk factor (exposure to drugs, low SES, or adoption) performed more poorly than those exposed to none of these risk factors on the WISC-III subtests, the CBCL and the CRS. The effects of risk factors did not cumulate. Contrary to our hypothesis, adoption did not mitigate the effects of prenatal exposure to drugs: for cognitive functioning exposure to drugs was associated with poorer performance among the exposed High SES Adopted versus non-exposed High SES non-adopted children on three of the WISC-III subtests. Exposed low SES children living with their parents performed at the same relatively low level as non-exposed low SES controls. Exposure to drugs was associated with adult ADHD-related problems assessed by the WURS. There were no direct or interaction effects of exposure on neurological functioning, self-competence, behavior problems on the CBCL or risk-taking.

CONCLUSIONS

Children exposed to drugs of abuse prenatally, including those adopted away, and children who grow up in low SES backgrounds, may be at risk of relatively reduced cognitive functioning (though still within the normal range) in adolescence. Children exposed to drugs, who are from low SES backgrounds, or who are adopted, may be at risk for lower cognitive or social functioning than children who have not experienced such risks.

PRACTICE IMPLICATIONS

There is a need for implementing early monitoring and long-term intervention programs featuring encouragement of cognitive and social skills for children prenatally exposed to drugs in order to alleviate the possible long-term effects of exposure to risk.

Alcohol abuse in pregnant women: effects on the fetus and newborn, mode of action and maternal treatment

Offspring of mothers using ethanol during pregnancy are known to suffer from developmental delays and/or a variety of behavioral changes. Ethanol, may affect the developing fetus in a dose dependent manner. With very high repetitive doses there is a 6-10% chance of the fetus developing the fetal alcoholic syndrome manifested by prenatal and postnatal growth deficiency, specific craniofacial dysmorphic features, mental retardation, behavioral changes and a variety of major anomalies. With lower repetitive doses there is a risk of "alcoholic effects" mainly manifested by slight intellectual impairment, growth disturbances and behavioral changes. Binge drinking may impose some danger of slight intellectual deficiency. It is advised to offer maternal abstinence programs prior to pregnancy, but they may also be initiated during pregnancy with accompanying close medical care. The long term intellectual outcome of children born to ethanol dependent mothers is influenced to a large extent by the environment in which the exposed child is raised.

Are the cognitive functions of children with Down syndrome related to their participation?

AIM

There is a lack of investigation into the functional developmental profile of children with Down syndrome. On the basis of current international health paradigms, the purpose of this study was to assess the developmental profile of these children.

METHOD

Sixty children (33 males, 27 females) with Down syndrome (age range 6-16y; mean age 9y 3mo, SD 28.8mo), who had received standard, holistic, early intervention, were assessed. Of these, 42 (70%) had congenital anomalies, 12 had severe congenital heart defects. Participants were assessed on measures of cognitive function (Beery-Buktenica Developmental Test of Visual-Motor Integration; Stanford-Binet Intelligence Scale) and participation (Vineland Adaptive Behaviour Scales).

RESULTS

No difference was found on any measure on the basis of severity of congenital anomaly. Results showed improvements in age-related body function and correlations between specific body functions and participation. No decline in IQ was found with age, and significant correlations between IQ and all other measures were noted. Although sex differences were found in the body functions of short-term memory and motor function, no difference in measures of activity performance and participation was found.

INTERPRETATION

Our findings emphasize the need for paediatric Down syndrome intervention to encourage improved body functions while emphasizing the acquisition of functional skills that enable enhanced participation in age-appropriate activities.

Risk of preterm delivery and other adverse perinatal outcomes in relation to maternal use of psychotropic medications during pregnancy

OBJECTIVE

The purpose of this study was to determine the association of maternal psychotropic medication use during pregnancy with preterm delivery and other adverse perinatal outcomes.

STUDY DESIGN

A cohort of 2793 pregnant women in Washington State was interviewed, and their medical files were abstracted. Logistic regression models were constructed to assess odds ratios for perinatal outcomes by use of psychotropic medications.

RESULTS

Maternal use of benzodiazepine during pregnancy was associated with an increased risk of preterm delivery (adjusted odds ratio, 6.79; 95% confidence interval, 4.01-11.5) and with increased risks of low birthweight, low Apgar score, neonatal intensive care unit admissions, and respiratory distress syndrome. Selective serotonin receptor inhibitors were associated with preterm deliveries only among women who started treatment after the first trimester.

CONCLUSION

Benzodiazepine was associated highly with preterm delivery and other adverse perinatal outcomes. Well-conducted cohort studies are warranted to draw conclusions about risks and benefits of psychotropic medication use during pregnancy.

Amelogenin in cranio-facial development: the tooth as a model to study the role of amelogenin during embryogenesis

The amelogenins comprise 90% of the developing extracellular enamel matrix proteins and play a major role in the biomineralization and structural organization of enamel. Amelogenins were also detected, in smaller amounts, in postnatal calcifying mesenchymal tissues, and in several nonmineralizing tissues including brain. Low molecular mass amelogenin isoforms were suggested to have signaling activity; to produce ectopically chondrogenic and osteogenic-like tissue and to affect mouse tooth germ differentiation in vitro. Recently, some amelogenin isoforms were found to bind to the cell surface receptors; LAMP-1, LAMP-2 and CD63, and subsequently localize to the perinuclear region of the cell. The recombinant amelogenin protein (rHAM(+)) alone brought about regeneration of the tooth supporting tissues: cementum, periodontal ligament and alveolar bone, in the dog model, through recruitment of progenitor cells and mesenchymal stem cells. We show that amelogenin is expressed in various tissues of the developing mouse embryonic cranio-facial complex such as brain, eye, ganglia, peripheral nerve trunks, cartilage and bone, and is already expressed at E10.5 in the brain and eye, long before the initiation of tooth formation. Amelogenin protein expression was detected in the tooth germ (dental lamina) already at E13.5, much earlier than previously reported (E19). Application of amelogenin (rHAM(+)) beads together with DiI, on E13.5 and E14.5 embryonic mandibular mesenchyme and on embryonic tooth germ, revealed recruitment of mesenchymal cells. The present results indicate that amelogenin has an important role in many tissues of the cranio-facial complex during mouse embryonic development and differentiation, and might be a multifunctional protein.