A novel format for a growth chart

Variability in Definitions and Criteria of Extrauterine Growth Restriction and Its Association with Neurodevelopmental Outcomes in Preterm Infants: A Narrative Review

Extrauterine growth restriction (EUGR) has been used in the literature and clinical practice to describe inadequate growth in preterm infants. Significant variability is seen in the criteria for EUGR, with no standard definition reached to date. Moreover, no consensus on the optimal timing for assessment or the ideal growth monitoring tool has been achieved, and an ongoing debate persists on the appropriate terminology to express poor postnatal growth. To ensure an adequate understanding of growth and early intervention in preterm infants at higher risk, it is critical to relate the diagnostic criteria of EUGR to the ability to predict adverse outcomes, such as neurodevelopmental outcomes. This narrative review was conducted to present evidence that evaluates neurodevelopmental outcomes in preterm infants with EUGR, comparing separately the different definitions of this concept by weight (cross-sectional, longitudinal and "true" EUGR). In this article, we highlight the challenges of comparing various published studies on the subject, even when subclassifying by the definition of EUGR, due to the significant variability on the criteria used for each definition and for the evaluation of neurodevelopmental outcomes in different papers. This heterogeneity compromises the obtention of a single firm conclusion on the relation between different definitions of EUGR and adverse neurodevelopmental outcomes.

Metformin versus insulin therapy for gestational diabetes: Effects on offspring anthropometrics and metabolism at the age of 9 years: A follow-up study of two open-label, randomized controlled trials

AIMS

To compare anthropometrics, and lipid and glucose metabolism in the 9-year-old offspring of mothers treated with metformin or insulin for gestational diabetes mellitus (GDM).

MATERIALS AND METHODS

This was a Finnish two-centre, 9-year follow-up study of two open-label, randomized controlled trials comparing the effects observed in the offspring of mothers who received metformin and insulin treatment for GDM. Measurements included anthropometrics, blood pressure, lipoproteins, and oral glucose tolerance tests. This study was registered with ClinicalTrials.gov, number NCT02417090.

RESULTS

At the age of 9 years 172 children (55% of the original study cohort, 82 from the metformin and 90 from the insulin group) participated in the study. No differences were found between the 9-year-old offspring groups in anthropometric variables, including body mass index and waist-to-height ratio. The offspring in the metformin group had higher high-density lipoprotein (HDL) cholesterol concentrations (1.72 vs. 1.54 mmol/L; P = 0.039) but lower low-density lipoprotein cholesterol (2.39 vs. 2.58 mmol/L; P = 0.046) and apolipoprotein B concentrations (0.63 vs. 0.67 g/L; P = 0.043) than the offspring in the insulin group. The difference in HDL cholesterol concentration was found to be significant only in boys (P = 0.003). The 2-hour glucose value in the oral glucose tolerance test was 0.6-mmol/L lower in boys from the metformin group than in those from the insulin group (P = 0.015).

CONCLUSIONS

Metformin treatment for GDM is associated with similar offspring growth and glucose metabolism but a more favourable lipid profile at the age of 9 years as compared to insulin treatment.

Weight transitions and psychosocial factors: A longitudinal cohort study of Finnish primary school children with overweight

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Children most probably stayed in their initial weight category.

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Probabilities of transitioning across weight categories differ between genders.

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Girls of nuclear families transition to obesity at a lower rate than their peers.

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Experiences of crises and bullying are related to obesity development among boys.

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Multistate models are useful for analyzing childhood obesity development.

For targeted prevention and treatment of childhood obesity, primary health care needs methods to identify children potentially developing obesity. The objectives of this study were to examine transitions across weight categories and their association with psychosocial family- and school-related factors, data on which were retrieved from health records. This longitudinal cohort study comprised 507 Finnish children with overweight, identified from a random sample of 2000 sixth graders in Helsinki in 2013. We applied Markov multistate models to analyze the transition rates over six primary school years between BMI SDS categories of normal weight, overweight and obesity, as assessed by Finnish BMI-for-age reference, and to examine relations between transition rates and family- and school-related factors. Among 3116 pairs of consecutive growth measurements from 225 girls and 282 boys aged 6–14, 719 transitions from weight category to another occurred. The highest 1-year probabilities were 0.76 for girls to stay in overweight and 0.80 for boys to stay in obesity. Transitions from normal weight to overweight and from obesity to overweight were more probable than vice versa. Transitions from overweight into obesity were among girls associated with older age (HR 2.63) and divorced or single parents (HR 2.29), as well as among boys with experiences of crises (HR 2.40) and being bullied (HR 1.66). Factors identifiable in school health care and associated with the probability of transition towards obesity should be considered when planning individual support and intervention programs.

Distinct age-related patterns of overweight development to guide school healthcare interventions

AIM

We aimed to identify groups of primary school children with similar overweight development, reveal age-related patterns of overweight development in the resulting groups and analyse overweight-related school healthcare interventions.

METHODS

This retrospective longitudinal register study utilised electronic health records from six primary school years. From a random sample of 2000 sixth graders, we derived a study cohort of 508 children meeting criteria for overweight at least once during primary school. We investigated how many different groups (latent classes) of children with similar weight development would emerge by applying flexible latent class mixed models on body mass index standard deviation score. We also explored the resulting groups with respect to offered overweight-related interventions.

RESULTS

Per child, the data consisted in median 7 growth measurements over 5.4 years. We identified five overweight development groups for girls and four for boys. The groups converged temporarily around age 10 after which only some continued into obesity. School nurses and physicians offered overweight-related interventions to children with obesity, less to children gaining weight or with overweight.

CONCLUSION

Obesity prevention might benefit from awareness of typical overweight development patterns when designing intervention studies or planning and timing multidisciplinary school health check programmes.

Screening and treatment of obesity in school health care - the gap between clinical guidelines and reality

AIMS

School health care offers a natural setting for childhood obesity interventions. Earlier studies reveal inadequate screening and treatment in primary care. However, longitudinal studies in unselected populations are lacking. We aimed to examine how school nurses and physicians identified obesity, diagnosed it and offered interventions over primary school. We compared the results with Finnish recommendations.

METHODS

From our cohort of 2000 primary school sixth graders (aged 12-14), 172 were obese at least once during primary school. We manually collected retrospective electronic health record (EHR) data of these 'ever-obese' children.

RESULTS

Of the ever-obese children, 96% attended annual nurse assessments more than twice. School physicians met 53% of the ever-obese children at health checks at first grade and 93% at fifth grade. Of overweight-related extra visits to school nurses, 94% took place without parents. Parents were present in 48% of extra school physician visits. Only 29% of the 157 who became obese during the first five school grades received an obesity diagnosis. However, school physicians mentioned weight problems in EHR for 90% of the children and, similarly, school nurses for 99%. The majority received a treatment plan at least once. For 78%, at least one plan was made with the parents. Still, 28% missed nutrition plans, 31% exercise plans and 90% lacked recorded weight development targets.

CONCLUSIONS

The gap between clinical guidelines and reality in school health care could be narrowed by improving diagnosing and parent collaboration. Obstacles in parent involvement and work methods in school health care need further study.

Growth impairment and gonadal axis abnormalities are common in survivors of paediatric brain tumours

AIM

Childhood brain tumour survivors have a high risk of endocrine morbidity. This study evaluated the growth, pubertal development and gonadal function in survivors of childhood brain tumours and identified factors associated with the problems we observed.

METHODS

The 52 subjects (52% male) were diagnosed in 1983-1997 and treated for brain tumours at Tampere University Hospital, Finland. They were followed up at a mean age of 14.2 (3.8-28.7) years, a mean of 7.5 (1.5-15.1) years after diagnosis.

RESULTS

We found that 30 (58%) participants had a lower height standard deviation score at follow-up than at diagnosis and short stature at follow-up was associated with tumour malignancy (p = 0.005), radiotherapy (p = 0.004), chemotherapy (p = 0.024), growth hormone deficiency (p < 0.001), hypogonadism (p = 0.044) and delayed puberty (p = 0.021). We found that five needed sex hormones to induce puberty, one had precocious puberty, 12 (23%) had growth hormone deficiency and eight (22%) of the 36 pubertal or postpubertal patients had hypogonadism. Testicular volume was low in 83% of late or postpubertal male survivors.

CONCLUSION

Growth impairment, growth hormone deficiency and hypogonadism were common in childhood brain tumour survivors and low testicular volume was also common in male survivors. Lifelong annual follow-up checks are indicated for survivors.

Development of overweight and obesity among primary school children-a longitudinal cohort study

BACKGROUND

School health care is crucial for obesity prevention. Data on constancy of childhood obesity are still scarce, but highly necessary for risk evaluation.

OBJECTIVES

We examined from electronic health records (EHRs) the continuity of obesity during primary school and searched for social and behavioural characteristics associated with childhood obesity.

METHODS

From randomly selected 2000 Finnish sixth graders (aged 12-14), we identified 402 'ever overweight' and 172 'ever obese' children who were overweight or obese at least once since their first grade. These cohort data of growth measurements and the content of all pre-seventh grade health checks were retrospectively analysed from EHRs.

RESULTS

Of the ever obese and ever overweight children, 69.3% (95% CI: 65.2-73.4%) continued to be overweight or obese in sixth grade. Of the ever obese children, nearly 40% were obese in first grade and 56% were obese or overweight in all six grades. Furthermore, 80% were obese or overweight already before school age. Obese children had experienced more bullying than overweight children (43.6% versus 30.8%, P = 0.003), had more frequently special needs for studying (25.6% versus 14.7%, P = 0.002) or had undergone a serious family crisis (20.3% versus 11.4%, P = 0.005).

CONCLUSIONS

Electronic data on children's growth and psychosocial characteristics are potentially useful when aiming for early action to counter obesity. Such routinely collected data appear to be underutilized and should be further exploited both in individual and population level to develop screening and treatment processes.

Severe Bronchopulmonary Dysplasia, Growth, Nutrition, and Adipokines at School Age

This study evaluated nutrition and growth in relation to plasma adipokine levels in 21 very-low-birth-weight (VLBW) children with radiographic bronchopulmonary dysplasia (BPD), 19 VLBW controls, and 19 term controls with a median age of 11.3 years. We took anthropometric measurements; assessed plasma levels of adipsin, resistin, adiponectin, and leptin; and analyzed the children’s 3-day food records. Children with BPD had a smaller age-adjusted head circumference and more microcephaly but no other significant growth differences. Daily recommended nutritional intake levels were poorly met but did not differ between the groups. Leptin levels correlated positively with the body mass index standard deviation score in VLBW children. No other associations between adipokine concentrations and growth were found. There were negative correlations between leptin concentrations and fat intake, resistin levels and carbohydrate intake, and adiponectin, adipsin, and leptin levels and energy intake.

Infant Growth after Preterm Birth and Mental Health in Young Adulthood

OBJECTIVES

Faster growth after preterm birth benefits long-term cognitive functioning. Whether these benefits extend to mental health remains largely unknown. We examined if faster growth in infancy is associated with better self-reported mental health in young adults born preterm at very low birth weight (VLBW) (< 1500 g).

STUDY DESIGN

As young adults, participants of the Helsinki Study of Very Low Birth Weight Adults self-reported symptoms of depression and attention deficit/hyperactivity disorder (ADHD) (n = 157) and other psychiatric problems (n = 104). As main predictors of mental health outcomes in linear regression models, we used infant weight, length, and head circumference at birth, term, and 12 months of corrected age, and growth between these time points. Growth data were collected from records and measures at term and at 12 months of corrected age were interpolated. Additionally, we examined the moderating effects of intrauterine growth restriction.

RESULTS

Size at birth, term, or 12 months of corrected age, or growth between these time points were not associated with mental health outcomes (p-values >0.05). Intrauterine growth restriction did not systematically moderate any associations.

CONCLUSIONS

Despite the high variability in early growth of VLBW infants, the previously described association between slow growth in infancy and poorer cognitive functioning in later life is not reflected in symptoms of depression, ADHD, and other psychiatric problems. This suggests that the development of cognitive and psychiatric problems may have dissimilar critical periods in VLBW infants.

Very low birth weight, infant growth, and autism-spectrum traits in adulthood

OBJECTIVES

We examined whether adults born preterm at very low birth weight (VLBW; <1500 g) differ from term-born adults in autism-spectrum traits, and whether among VLBW adults, growth in infancy is associated with these traits.

METHODS

A total of 110 VLBW and 104 term-born adults of the Helsinki Study of Very Low Birth Weight Adults completed the Autism-Spectrum Quotient yielding total, social interaction, and attention to detail sum scores. Growth in weight, length, and head circumference from birth to term and from term to 1 year of corrected age was determined as standardized residuals reflecting growth conditional on previous history.

RESULTS

VLBW adults scored higher than term-born controls on social interaction sum score, indicating higher autism-spectrum traits. In contrast, they scored lower on attention to detail sum score, indicating lower autism-spectrum traits. Within the VLBW group, faster growth in weight, length, and head circumference from birth to term was associated with lower total and social interaction sum scores. In this group, growth from term to 1 year was not associated with autism-spectrum traits.

CONCLUSIONS

Among those born preterm at VLBW, the risk for higher levels of autism-spectrum traits, particularly related to social interaction, may persist into adulthood. Faster growth from birth to term may ameliorate these effects, suggesting that targeted interventions could aid long-term neurodevelopment.

Infant growth after preterm birth and neurocognitive abilities in young adulthood

OBJECTIVES

To examine whether faster growth from birth to term (40 postmenstrual weeks) and during the first year thereafter was associated with better neurocognitive abilities in adults born preterm with very low birth weight (VLBW; <1500 g).

STUDY DESIGN

Weight, length, and head circumference data of 103 VLBW participants of the Helsinki Study of Very Low Birth Weight Adults were collected from records. Measures at term and at 12 months of corrected age were interpolated. The participants underwent tests of general neurocognitive ability, executive functioning, attention, and visual memory at mean age of 25.0 years.

RESULTS

Faster growth from birth to term was associated with better general neurocognitive abilities, executive functioning, and visual memory in young adulthood. Effect sizes in SD units ranged from 0.23-0.43 per each SD faster growth in weight, length, or head circumference (95% CI 0.003-0.64; P values <.05). After controlling for neonatal complications, faster growth in head circumference remained more clearly associated with neurocognitive abilities than weight or length did. Growth during the first year after term was not consistently associated with neurocognitive abilities.

CONCLUSIONS

Within a VLBW group with high variability in early growth, faster growth from birth to term is associated with better neurocognitive abilities in young adulthood. Neurocognitive outcomes were predicted, in particular, by early postnatal head growth.

Antenatal and postnatal growth and 5-year cognitive outcome in very preterm infants

OBJECTIVES

To study how antenatal growth affects cognitive outcome in very preterm infants and to determine whether there is an association between growth in any particular time period between birth and 5 years of age and cognitive outcome. Small for gestational age (SGA) and non-SGA infants were analyzed separately, because antenatal growth may affect postnatal growth.

METHODS

Very low birth weight (<1501 g) infants born between 2001 and 2006 and infants born at <32 gestational weeks between 2004 and 2006 who were treated at Turku University Hospital (n = 181) were followed. Weight, length, and head circumference (HC) of the infants were measured at 9 time points between birth and 5 years. The growth was determined as a z score change between measurement points. Cognitive development was assessed at 5 years of age with the Wechsler Preschool and Primary Scales of Intelligence-Revised. The association between growth and full-scale IQ (FSIQ) was studied.

RESULTS

Growth in length and height was not associated with 5-year cognitive outcome. However, weight (r = 0.18, P = .04) and HC growth (r = 0.25, P = .01) between birth and 2 years of corrected age correlated to FSIQ in non-SGA children. In SGA children, HC growth (r = 0.33, P = .03) around term age correlated to FSIQ.

CONCLUSIONS

Cognitive outcome was similar in SGA and non-SGA very preterm infants. Growth affected cognition positively in both subgroups, but the critical time period was different.

Risk of metabolic bone disease is increased both during and after weaning off parenteral nutrition in pediatric intestinal failure

AIM

To assess bone health in pediatric intestinal failure (IF).

METHODS

A population-based cohort of 41 IF patients (age 9.9 years) underwent evaluation of bone mineral density (BMD), bone biochemistry, nutritional status and growth. Eleven patients remained on parenteral nutrition (PN) after 69 months. Thirty had weaned off PN 9.0 years earlier (mean), i.e. after 30 months on PN.

RESULTS

The majority of patients had lumbar spine or femoral BMD Z-score ≤-1.0 (70%), vitamin D deficiency (serum 25-hydroxyvitamin-D, S-25-OHD, <50 nmol/l, 41%) or secondary hyperparathyroidism (plasma parathyroid hormone >47 ng/l, 44%), equally during and after weaning off PN. Hyperparathyroidism was absent when S-25-OHD was >80 nmol/l. Until puberty, height (-1.4 to -0.8, age 1-12) and weight Z-scores (-1.3 to -0.5, age 1-16) were below the normal mean (p < 0.05). Small bowel length associated with S-25-OHD levels (r = 0.489, p = 0.013). In a multivariate model, time after weaning off PN (β = -0.597, p = 0.001), duration of PN (β = -0.466, p = 0.006) and calcium intake (β = -0.331, p = 0.035) predicted decreased lumbar spine BMD.

CONCLUSIONS

In pediatric IF, vitamin D insufficiency, secondary hyperparathyroidism and decreased BMD are common. BMD, vitamin D, calcium and nutritional status should be closely monitored during and after weaning off PN to ensure sufficient vitamin D and mineral substitution for normal growth and bone mass attainment.

Growth charts of human development

This article reviews and compares two types of growth charts for tracking human development over age. Both charts assume the existence of a continuous latent variable, but relate to the observed data in different ways. The D-score diagram summarizes developmental indicators into a single aggregate score measuring global development. The relations between the indicators should be consistent with the Rasch model. If true, the D-score is a measure with interval scale properties, and allows for the calculation of meaningful differences both within and across age. The stage line diagram describes the natural development of ordinal indicators. The method models the transition probabilities between successive stages of the indicator as smoothly varying functions of age. The location of each stage is quantified by the mid- P-value. Both types of diagrams assist in identifying early and delayed development, as well as finding differences in tempo. The relevant techniques are illustrated to track global development during infancy and early childhood (0–2 years) and Tanner pubertal stages (8–21 years). New reference values for both applications are provided.

Neurological development in 21 children on peritoneal dialysis in infancy

Few studies have focused on the neurodevelopment of infants on peritoneal dialysis (PD). Infants are the most demanding patient group on PD and thus are vulnerable to neurological sequelae. We studied 21 patients <2 years of age (mean 0.59 years) at onset of PD. They were evaluated by a neurologist, otologist, physiotherapist, and occupational therapist during PD. Neuropsychological tests were collected from all patients at least 5 years old, and the brain images were reviewed. Eleven patients (52%) had a pre- or neonatal problem or comorbidity as risk factor for their development at onset of PD. All infants tolerated PD well. At the end of the study, 71% had some neurological abnormality, 29% a major impairment (all with predialysis risk factors), and 43%  a minor one. Brain infarcts were detected in four patients (19%) and other ischemic lesions in three (14%). Three patients (14%) developed hearing defect. Mortality rate was 5%. PD is a safe treatment modality for end-stage renal failure in infants. Some patients had risk factors for development, but their neurological problems did not progress during PD. Patients without risk factors tolerated PD well without major neurological sequelae.

New Finnish growth references for children and adolescents aged 0 to 20 years: Length/height-for-age, weight-for-length/height, and body mass index-for-age

BACKGROUND AND OBJECTIVES

Growth curves require regular updates due to secular trends in linear growth. We constructed contemporary growth curves, assessed secular trends in height, and defined body mass index (BMI) cut-off points for thinness, overweight, and obesity in Finnish children.

MATERIAL AND METHODS

Mixed cross-sectional/longitudinal data of 73,659 healthy subjects aged 0-20 years (born 1983-2008) were collected from providers in the primary health care setting. Growth references for length/height-for-age, weight-for-length/height, and BMI-for-age were fitted using generalized additive models for location, scale, and shape (GAMLSS). BMI percentile curves passing through BMIs 30, 25, 18.5, 17, and 16 kg/m(2) at the age of 18 years were calculated to define limits for obesity, overweight, and various grades of thinness.

RESULTS

Increased length/height-for-age was seen in virtually all age-groups when compared to previous Finnish growth data from 1959 to 1971. Adult height was increased by 1.9 cm in girls and 1.8 cm in boys. The largest increases were seen during the peripubertal years: up to 2.8 cm in girls and 5.6 cm in boys. Median weight-for-length/height had not increased.

CONCLUSIONS

New Finnish references for length/height-for-age, weight-for-length/height, and BMI-for-age were constructed and should be implemented to monitor growth of children in Finland.

Bone and body segment lengthening and widening: a 7-year follow-up study in pubertal girls

During growth bone increases in length and width as does the body size. The aim of this paper was to examine the growth pattern of body height and weight, and the width and length of various body segments, and to establish the timing of peak growth velocity (PV) in relation to time of menarche in a cohort of Finnish girls followed from age 10 until 18. The study was a 7-year longitudinal cohort study. Widths and lengths of body segments and bones were measured from DXA scan images using bone landmarks in 396 girls aged 10 to 13 years at baseline, and in 255 mothers and 159 grandmothers. The girls' growth velocities (rate of change with time) peaked at 13.5 months prior to menarche for height, 14.4 months for weight, and 15.4 months for BMI. Shoulder width peaked at 18.2 months, lesser pelvis width at 13.5 months and greater pelvis width at 11.6 months prior to menarche. The PV of various body segment lengths showed that the femur peaked earliest at 20.7 months prior to menarche, followed by the humerus (at 18.0 months), radius (at 17.4 months), tibia (at 17.5 months), and trunk (at 11.8 months), respectively. All the long bones were linearly correlated with height while the flat and irregular bones had a nonlinear growth relationship with height (r(2)=0.73-0.88). By the age of 18 years the girls had reached their mothers' height (101%) and humerus, radius, femur and tibia lengths (100-101%), but not their mothers' shoulder, great pelvis and lesser pelvis widths (98%, 95% and 93%, respectively). Our data confirmed that, after bone elongation had ceased, segment width continued to increase, although at a slower speed, into early adulthood. The wide variations in growth velocity of these anthropomorphic measurements underscore the need to optimize nutrition and physical activity from early puberty onward in order to maximize bone development.

Maternal type 1 and gestational diabetes: postnatal differences in insulin secretion in offspring at preschool age

BACKGROUND

It is well known that children born to mothers with diabetes in pregnancy are more likely to develop metabolic abnormalities in later life. Most prior studies have not differentiated between offspring of mothers with type 1 diabetes (T1DM) and gestational diabetes (GDM) or lack a control group of non-exposed offspring.

SUBJECTS

Offspring of T1DM (n = 16), GDM (n = 22) and mothers without diabetes (n = 25) born at Oulu University Hospital.

AIM

To assess insulin secretion and insulin resistance in the offspring of T1DM and GDM at preschool age in comparison with offspring of non-diabetic mothers.

METHODS

Anthropometric measurements and intravenous glucose tolerance testing were performed. First-phase insulin response (FPIR) and homoeostasis model assessment (HOMA) values were calculated. Pregnancy and birth data were analysed in relation to later metabolic parameters in all three groups using one-way analysis of variance (ANOVA) and analysis of covariance (ANCOVA).

RESULTS

At a mean age of 4.9 yr, offspring of T1DM had increased fasting serum insulin concentrations (p = 0.044), FPIR (p = 0.034) and HOMA-B values (p = 0.008) compared with offspring of GDM or with offspring of healthy controls (statistically non-significant). The GDM gained least weight during pregnancy, and when adjusted for maternal weight gain during pregnancy, there were no statistically significant differences between study groups.

CONCLUSIONS

Prenatal exposures to maternal type 1 and gestational diabetes may have different effects on postnatal glucose metabolism in the offspring assessed at a mean age close to 5 yr. Maternal weight gain in pregnancy may affect the postnatal glucose metabolism in the offspring.

Plant stanol ester spreads as components of a balanced diet for pregnant and breast-feeding women: evaluation of clinical safety

Clinical safety of consuming plant stanol ester spreads during pregnancy and lactation, the impact on maternal and infant serum and breast-milk cholesterol and the ratios (μmol/mmol of cholesterol) of synthesis and absorption markers were evaluated. Pregnant women (n21) were randomised to control and dietary intervention groups, the intervention including advice to follow a balanced diet and to consume spreads enriched with plant stanol esters. Participants were followed during and after pregnancy and their infants up to 1 year of age. A mean 1·1 (sd0·4) g consumption of plant stanols during pregnancy and 1·4 (sd0·9) g 1 month post-partum increased sitostanol and the markers for cholesterol synthesis, lathosterol, lathosterol/campesterol and lathosterol/sitosterol, and reduced a marker for cholesterol absorption, campesterol, in maternal serum. In breast milk, desmosterol was lower in the intervention group, while no differences were detected between the groups in infants' serum. Plant stanol ester spread consumption had no impact on the length of gestation, infants' growth or serum β-carotene concentration at 1 and 6 months of age, but the cholesterol-adjusted serum β-carotene concentration was lowered at 1 month in the intervention group. Plant stanol ester spread consumption appeared safe in the clinical setting, except for potential lowering of infants' serum β-carotene concentration, and was reflected in the markers of cholesterol synthesis and absorption in mothers' serum, encouraging further studies in larger settings.

Daily versus as-needed inhaled corticosteroid for mild persistent asthma (The Helsinki early intervention childhood asthma study)

OBJECTIVE

To compare the effect of inhaled budesonide given daily or as-needed on mild persistent childhood asthma. Patients, design and

INTERVENTIONS

176 children aged 5-10 years with newly detected asthma were randomly assigned to three treatment groups: (1) continuous budesonide (400 microg twice daily for 1 month, 200 microg twice daily for months 2-6, 100 microg twice daily for months 7-18); (2) budesonide, identical treatment to group 1 during months 1-6, then budesonide for exacerbations as needed for months 7-18; and (3) disodium cromoglycate (DSCG) 10 mg three times daily for months 1-18. Exacerbations were treated with budesonide 400 microg twice daily for 2 weeks.

MAIN OUTCOME MEASURES

Lung function, the number of exacerbations and growth.

RESULTS

Compared with DSCG the initial regular budesonide treatment resulted in a significantly improved lung function, fewer exacerbations and a small but significant decline in growth velocity. After 18 months, however, the lung function improvements did not differ between the groups. During months 7-18, patients receiving continuous budesonide treatment had significantly fewer exacerbations (mean 0.97), compared with 1.69 in group 2 and 1.58 in group 3. The number of asthma-free days did not differ between regular and intermittent budesonide treatment. Growth velocity was normalised during continuous low-dose budesonide and budesonide therapy given as needed. The latter was associated with catch-up growth.

CONCLUSIONS

Regular use of budesonide afforded better asthma control but had a more systemic effect than did use of budesonide as needed. The dose of ICS could be reduced as soon as asthma is controlled. Some children do not seem to need continuous ICS treatment.

High sucrose intake is associated with poor quality of diet and growth between 13 months and 9 years of age: the special Turku Coronary Risk Factor Intervention Project

BACKGROUND

Previous studies have suggested that interventions to lower dietary fat content and improved fat quality lead to a compensatory increase in sucrose content.

OBJECTIVE

The purpose of this work was to determine what associations exist between sucrose intake and intake of nutrients, intake of specific foods, and growth in children aged 13 months to 9 years of age in the prospective, randomized Special Turku Coronary Risk Factor Intervention Project.

SUBJECTS AND METHODS

Nutrient intake and food consumption were evaluated annually at ages 13 months through 9 years by using food records. Altogether, 543 children were divided into 3 groups according to mean sucrose intake: constantly high sucrose intake (highest 10%), constantly low sucrose intake (lowest 10%), and average sucrose intake (80%). Absolute and relative weights and heights were recorded at 7, 13, and 24 months of age and annually thereafter until 9 years old.

RESULTS

The high sucrose-intake group exceeded the recommended sucrose intake (<10% of energy intake, World Health Organization) already at the age of 2 years. Energy and total fat intake did not differ between the sucrose-intake groups. Children with low and average sucrose intake consumed more protein and had a better dietary fat quality than children with high sucrose intake. They also tended to receive more vitamin E, niacin, calcium, iron, zinc, and dietary fiber than children who consumed a high sucrose diet. Children in the low sucrose-intake group consumed more grains, vegetables, and dairy products than the other children. Sugar intake had no direct association with obesity, but weight, height, and BMI of children differed between the sucrose-intake groups between 7 months and 9 years of age.

CONCLUSIONS

In children aged 13 months to 9 years, long-term low sucrose intake is associated with better nutrient intake and growth than high sucrose intake.

Basal insulin switch from NPH to glargine in children and adolescents with type 1 diabetes

BACKGROUND

Insulin glargine is a long-acting insulin analogue increasingly used instead of neutral protamine Hagedorn (NPH) insulin in young subjects with type 1 diabetes.

OBJECTIVE

We evaluated the clinical course of diabetes in children and adolescents who were switched from NPH to insulin glargine.

METHODS

Between August 2003 and November 2004, a total of 76 subjects were switched to glargine in our clinic, treating 340 children with type 1 diabetes. All the subjects had been receiving insulin NPH, and their serum C-peptide levels had been non-detectable for at least 1 yr. Data were collected retrospectively, and 12-18 months after the change, experiences with glargine were inquired using a questionnaire. Seven subjects (9.2%) discontinued glargine before 12 months, and seven refused to participate.

RESULTS

Data for 62 subjects were analyzed. At the switch (0 months), their mean age was 12.7 yr (range 5.1-17.5), mean duration of diabetes was 6.7 yr (range 1.8-14.3), and mean hemoglobin A1c was (HbA1c) 9.2%. Twelve months later (+12 months), the mean HbA1c remained similar (9.2%), the proportion of long-acting insulin was smaller (47.7 vs. 58.1%; p < 0.001), and the daily insulin dose was lower (0.97 vs. 1.05 IU/kg; p < 0.001). The number of injections was lower at +12 months (17.7% with more than five injections vs. 64.5%; p < 0.001). No differences were seen in weight for height or the number of severe hypoglycemias. Most subjects who continued with glargine for > or =12 months considered glargine better than NPH.

CONCLUSIONS

A switch to insulin glargine retains a similar glycemic control and does not change the number of severe hypoglycemias.

Impact of repeated dietary counseling between infancy and 14 years of age on dietary intakes and serum lipids and lipoproteins: the STRIP study

BACKGROUND

Atherosclerosis development might be delayed or prevented by dietary measures. The aims of the present study were to evaluate the effect of low-saturated-fat, low-cholesterol dietary counseling on fat intakes, growth, serum cholesterol values, and pubertal development in children and adolescents.

METHODS AND RESULTS

In the randomized prospective Special Turku Coronary Risk Factor Intervention Project (STRIP), a low-saturated-fat, low-cholesterol diet was introduced to intervention infants (n=540) at 7 months of age, and control children (n=522) received an unrestricted diet. Dietary intakes, serum cholesterol values, somatic growth, and development were followed up throughout childhood and adolescence. Saturated fat intakes, serum total cholesterol, and low-density lipoprotein cholesterol values were lower (P<0.001) in the intervention than in control children during the 14 years, whereas high-density lipoprotein cholesterol values in the 2 study groups showed no difference. Boys had lower total and low-density lipoprotein cholesterol concentrations than girls throughout childhood (P<0.001), and the intervention effect on serum cholesterol concentration was larger in boys than girls. The 2 study groups showed no difference in growth, body mass index, pubertal development, or age at menarche (median, 13.0 and 12.8 years in the intervention and control girls, respectively; P=0.52). The cholesterol values decreased as puberty progressed. Mean concentrations of total and high-density lipoprotein cholesterol decreased from approximately 4.5 and approximately 1.4 mmol/L, respectively, in Tanner stage 1 (prepubertal) boys to approximately 3.9 and approximately 1.1 mmol/L in Tanner stage 4 (late pubertal) boys.

CONCLUSIONS

Repeated dietary counseling remains effective in decreasing saturated fat and cholesterol intake and serum cholesterol values at least until 14 years of age. Puberty markedly influences serum cholesterol concentrations.

Growth and growth hormone therapy in subjects with mulibrey nanism

OBJECTIVES

Mulibrey nanism is a monogenic disorder with prenatal-onset growth restriction, mild dysmorphic features, and a strong tendency for insulin resistance but no major neurologic handicap. Growth hormone therapy has been shown to promote short-term growth in children born small for gestational age, but the experience with long-term therapy is insufficient. Growth in patients with mulibrey nanism has not been analyzed previously in detail.

METHODS

We evaluated the natural growth pattern and long-term impact of growth hormone treatment in the largest cohort of subjects with mulibrey nanism to date. The study included 72 living subjects followed up to 30 years. Thirty (18 female) were treated with recombinant human growth hormone for a median period of 5.7 years. Patients were reviewed at baseline and every 6 to 12 months during the therapy. Evaluation included assessment of height, weight, and pubertal status and laboratory analyses. Glucose metabolism was evaluated by oral glucose-tolerance test.

RESULTS

The patients were born small for gestational age with immature craniofacial features. They experienced a continuous deceleration in height (median decrement of 1.1 SDS) and weight for height (median reduction of 17%) in infancy followed by an incomplete catch-up growth lasting up to school age. The final adult height averaged 136 cm in girls and 150 cm in boys. Growth hormone treatment improved the prepubertal growth but had only little impact on adult height (+5 cm). The treated subjects showed earlier bone maturation and growth arrest but not a significant increase in insulin resistance. On the contrary, the subjects who were treated with growth hormone were slimmer and had less metabolic syndrome as young adults.

CONCLUSIONS

The patients with mulibrey nanism showed a distinct postnatal growth pattern. The growth hormone treatment was safe and induced a good short-term effect, but the impact on the adult height remained modest.

High body mass index increases the risk for osteonecrosis in children with acute lymphoblastic leukemia

PURPOSE

The aim of the study was to determine the incidence of and clinical risk factors for radiographic osteonecrosis (ON) in children treated for acute lymphoblastic leukemia (ALL) using the Nordic ALL protocols.

PATIENTS AND METHODS

Ninety-seven consecutive patients with childhood ALL were studied prospectively by magnetic resonance imaging (MRI) of the lower extremities at the end of the treatment.

RESULTS

Twenty-three (24%) of the 97 patients had ON. Seven of the patients (30%) were symptomatic, and three patients (13%) required surgical interventions. Multiple logistic regression analysis showed that high body mass index (BMI; P = .04), female sex (P = .01), older age at diagnosis (P < .001), and higher cumulative dexamethasone dose (P = .03) were independent risk factors for radiographic ON. The cumulative prednisone dose did not differ significantly between the patients with and without ON. The incidence of radiographic ON decreased significantly, from 36% to 7%, when the duration of dexamethasone exposure during the delayed-intensification phase was shortened from 3 to 4 weeks to 2 weeks with a taper (P = .001).

CONCLUSION

ON as determined by MRI was found to be a common complication in children and adolescents after treatment with the Nordic ALL protocols. Revision of the ALL protocols by shortening the single exposure to dexamethasone has diminished the risk for ON remarkably. High BMI was identified as a new significant risk factor for ON.

Ketoacidosis at diagnosis of type 1 diabetes in children in northern Finland: temporal changes over 20 years

OBJECTIVE

To study the frequency of diabetic ketoacidosis (DKA) over a 20-year period among children diagnosed with type 1 diabetes in northern Finland.

RESEARCH DESIGN AND METHODS

The study population comprised 585 patients (328 boys) diagnosed with type 1 diabetes aged <15 years in the Department of Pediatrics, Oulu University Hospital, between 1 January 1982 and 31 December 2001. The data for clinical characteristics were collected retrospectively from the patients' case records. The earlier 10-year period (1982-1991) was compared with the later 10-year period (1992-2001). Two definitions for DKA were used: DKA(i) pH <7.30 or DKA(ii) pH <7.30 and/or bicarbonate <15 mmol/l.

RESULTS

During the later 10-year period, children less often had DKA at diagnosis [DKA(i) 15.2 vs. 22.4%, P = 0.028, and DKA(ii) 18.9 vs. 29.5%, P = 0.003]. The proportion of young children aged <5 years at diagnosis increased over time, but the frequency of DKA also was lower in this age-group during 1992-2001 compared with the earlier 10-year period [DKA(i) 17.7 vs. 32.1%, P = 0.052, and DKA(ii) 20.3 vs. 42.6%, P = 0.005]. In children aged <2 years at diagnosis, the frequency of DKA remained high during 1992-2001 [DKA(i) 39.1% and DKA(ii) 47.8%].

CONCLUSIONS

The overall frequency of DKA in children with newly diagnosed type 1 diabetes decreased over a 20-year period in northern Finland. However, children aged <2 years are still at high risk for DKA at diagnosis.

Evaluation of diet and growth in children with and without atopic eczema: follow-up study from birth to 4 years

Current research into dietary factors contributing to the development of allergic diseases is directed towards new active approaches instead of passive elimination diets. The present study aimed to investigate the explanatory role of the diet in a probiotic intervention study on the appearance of atopic eczema (AE) in childhood and the safety of perinatal supplementation with probiotics (Lactobacillus rhamnosus strain GG; ATCC 53 103). A prospective follow-up study from birth to 48 months of children (n 159) with a family history of allergic disease was carried out. Outcome measures included growth, dietary intake assessed with 4 d food diaries and their association with AE by logistic regression models. Increased intakes of retinol, Ca and Zn, with perinatal administration of probiotics, reduced the risk of AE, whilst an increase in intake of ascorbic acid increased the likelihood of AE. Perinatal administration of probiotics was safe, as it did not influence the height (mean difference 0·04 (95 % CI −0·33, 0·40) sd scores, P=0·852) or the weight-for-height (mean difference −3·35 (95 % CI −7·07, 0·37)%, P=0·077) of the children at 48 months with and without perinatal administration of probiotics. Up to 48 months, AE did not affect height (mean difference −0·05 (95 % CI −0·42, 0·33) sd scores, P=0·815), but mean weight-for-height in children with AE was −5·1 % (95 % CI −8·9, −1·2 %) lower compared with children without (P=0·010). The joint effects of nutrients and probiotics need to be considered in active prevention and management schemes for allergic diseases.

Tracheal intubating conditions and pharmacodynamics following cisatracurium in infants and children undergoing halothane and thiopental-fentanyl anesthesia

BACKGROUND

The aims of the present study were to determine the tracheal intubating conditions, onset time, duration of action, and hemodynamic responses following the administration of cisatracurium 0.15 mg x kg(-1) to infants and children.

METHODS

One hundred and eighty-one infants and children aged 1 month to 12 years were randomized to two groups to receive anesthesia with nitrous oxide-oxygen-halothane (group H) or nitrous oxide-oxygen-thiopental-fentanyl (group TF). Intubation conditions were assessed 120 s after cisatracurium administration using a 4-part scale. Neuromuscular transmission was monitored by recording the evoked compound electromyogram of the adductor pollicis.

RESULTS

The proportion of patients with excellent or good intubating conditions was similar in both groups (88 of 90, 98% in group H; 85 of 90, 94% in group TF). However, there was a significantly greater proportion of excellent intubating conditions in group H (79 of 90, 88%) compared with group TF (65 of 90, 72%) (P = 0.01) and recovery time was significantly longer in group H compared with group TF (P < 0.001). There was also a higher proportion of excellent intubating conditions in infants compared with older subjects (P = 0.02) and a shorter onset time (P < 0.001) and longer recovery time (P < 0.001) in younger compared with older patients. Changes in heart rate and arterial pressure were negligible 1 min following the cisatracurium administration.

CONCLUSIONS

Cisatracurium 0.15 mg x kg(-1) produces acceptable intubating conditions at 120 s in the great majority of infants and children. Anesthesia background and age have significant effects on intubating conditions and duration of action of cisatracurium.

Development of overweight in an atherosclerosis prevention trial starting in early childhood. The STRIP study

CONTEXT

Recent data indicate a marked increase in the prevalence of obesity among school-aged children. Thus, efficacious programmes that prevent overweight development in children are urgently needed.

OBJECTIVE

To evaluate the impact of repeatedly given, individualised dietary and lifestyle counselling on the prevalence of overweight during the first 10 years of life.

DESIGN AND PARTICIPANTS

This study was a part of the Special Turku Coronary Risk Factor Intervention Project for Children (STRIP), which is a prospective, randomised trial aimed at reducing the exposure of the intervention children to the known risk factors of atherosclerosis. At the child's age of 7 months, 1062 children were assigned to an intervention group (n=540) or to a control group (n=522). The intervention children received individualised counselling focused on healthy diet and physical activity biannually. Height and weight of the children were measured at least once a year.

MAIN OUTCOME MEASURE

Prevalence of overweight and obesity among the intervention and control children by sex and age. Children were classified as overweight or obese if their weight for height was >20% or > or =40% above the mean weight for height of healthy Finnish children, respectively.

RESULTS

After the age of 2 years, there were continuously fewer overweight girls in the intervention group than in the control group. At the age of 10 years, 10.2% of the intervention girls and 18.8% of the control girls were overweight (P=0.0439), whereas 11.6% of the intervention boys and 12.1% of the control boys were overweight (P approximately 1.00). Only three children in the intervention group were obese at some age point, whereas 14 control children were classified as obese at some age point.

CONCLUSION

Individualised dietary and lifestyle counselling given twice a year since infancy decreases prevalence of overweight in school-aged girls even without any primary energy restrictions.

Nutrient intake, weight, and Leu7Pro polymorphism in prepro-neuropeptide Y in children

CONTEXT

The important role of neuropeptide Y (NPY) in the regulation of food intake and energy balance has been firmly documented in rodents, but human data are sparse. The recently identified functional Leu7Pro polymorphism in the signal peptide region of the prepro-NPY is a useful tool for the investigation of the role of NPY in men. Pro7 substitution has been associated with the following: plasma NPY concentration, the risk factors of cardiovascular disease, birth weight of children, serum triglyceride concentration, and the function of vascular endothelium.

OBJECTIVE

The objective of this study was to analyze the connection between Leu7Pro polymorphism and relative weight, nutrient intakes, and serum lipids in early childhood. We closely followed 647 healthy Finnish children participating in the Special Turku Risk Factor Intervention Project through their first 9 yr of life.

RESULTS

Leu7Pro polymorphism showed no relation to intakes of energy, macronutrients, or the relative weight in either gender. However, Pro7 substitution was associated with serum triglyceride concentration in boys at the ages of 5, 7, and 9 yr.

CONCLUSION

The functional Leu7Pro polymorphism is not likely to be involved in the regulation of adiposity or major nutrient preferences in childhood. In boys, the Pro7 variant may have impact on serum triglyceride concentration.

Impact of national fortification of fluid milks and margarines with vitamin D on dietary intake and serum 25-hydroxyvitamin D concentration in 4-year-old children

OBJECTIVE

To assess the impact of national fortification of fluid milks and margarines with vitamin D on dietary intake and on serum 25-hydroxyvitamin D concentration in Finnish 4-year-old children.

DESIGN, SUBJECTS AND METHODS

Two cohorts of children were studied during wintertime, one before (n=82) in 2001-2002 and the other after (n=36) the initiation of fortification in 2003-2004. Dietary intake was estimated by 4-day food records and serum 25-hydroxyvitamin D concentration was analyzed by radioimmunoassay.

RESULTS

The mean intake of vitamin D was higher the after initiation of fortification (mean (95% confidence interval (CI)); 4.5 (3.8-5.1) microg) than before it (2.1 (95% CI 1.8-2.3) microg; P<0.001), although there were no differences in consumption of the main food sources of vitamin D between the two cohorts. The difference between the cohorts was also evident when the intake of vitamin D was adjusted for energy intake (0.78 (95% CI 0.70-0.90) and 0.37 (95% CI 0.32-0.42) microg/MJ after and before fortification, respectively, P<0.001). After fortification, the mean intake approached that recommended, but was achieved by only 30.6% of the children. Equally, the serum 25-hydroxyvitamin D concentration was higher after fortification (64.9 (95% CI 59.7-70.1) nmol/l) compared to prior it (54.7 (95% CI 51.0-58.4) nmol/l; P=0.002).

CONCLUSIONS

The results indicate that the national fortification of fluid milks and margarines with vitamin D safely improved the vitamin D status of children. This approach, in view of the novel health effects beyond bone metabolism, encourages fortification of new food sources with vitamin D or use of vitamin D supplements particularly during wintertime.

Impact of anti-TNF treatment on growth in severe juvenile idiopathic arthritis

OBJECTIVES

To evaluate the impact of anti-tumour necrosis factor (TNF) treatment on growth and to identify the predictors for the change in growth in severe juvenile idiopathic arthritis (JIA).

METHODS

Data from 71 JIA patients (43 on etanercept, 28 on infliximab) were reviewed two years before and two years on the anti-TNF treatment. The patients had polyarticular disease course (48 polyarthritis, 19 extended oligoarthritis, two systemic arthritis, and two enthesitis related arthritis). At the initiation of the anti-TNF treatment, their mean age was 9.6 years and the mean duration of JIA, 5.7 years.

RESULTS

In the patients with delayed growth before anti-TNF treatment (n = 53), the growth velocity, measured as the change in height standard deviation score, accelerated +0.45 (95% confidence interval, 0.33 to 0.56) (p<0.001) during the anti-TNF treatment. In the patients with normal or accelerated growth before anti-TNF treatment (n = 18), the change in growth velocity was +0.05 (0.07 to 0.16) (p = 0.39). At two years on anti-TNF treatment, the growth velocity between these two groups was similar. No difference was found between the patients treated with etanercept or infliximab. A decelerating growth rate before the anti-TNF treatment was the strongest predictor for the observed increase in the growth velocity. The change in the inflammatory activity remained a significant predictor of the growth velocity even after the decrease in glucocorticoid dose was taken into account.

CONCLUSIONS

In the treatment of polyarticular JIA, the anti-TNF treatment not only suppresses inflammation but also restores growth velocity.

Insulin resistance syndrome in subjects with mutated RING finger protein TRIM37

We evaluated the glucose and lipid metabolism in 65 patients (aged 1.1-55 years) with mulibrey (muscle-liver-brain-eye) nanism (MUL), which is a monogenic disorder with prenatal-onset growth failure and typical clinical characteristics. MUL is caused by mutations in the TRIM37 gene, encoding a peroxisomal protein (TRIM37) with E3 ubiquitin-ligase activity. The subjects underwent clinical evaluation, abdominal ultrasonography, and laboratory measurements, including a 3-h oral glucose tolerance test. The results showed a dramatic change in glucose and lipid metabolism with age in MUL subjects. While the children had low fasting glucose and insulin levels, 90% of the adults had high fasting and postload insulin values (up to 1,450 mU/l). A 10-fold decrease in the fasting glucose-to-insulin ratio and a 4-fold decrease in whole-body insulin sensitivity index were observed. Insulin resistance, fatty liver, high serum leptin, hypertension, and acantosis nigricans were already evident in many slim prepubertal children. Half of the adults had type 2 diabetes, and an additional 42% showed impaired glucose tolerance. Seventy percent fulfilled the National Cholesterol Education Program criteria for metabolic syndrome. The peroxisomal targeting and the functional link of TRIM37 to the ubiquitin-proteosome pathway may provide novel clues to the development of metabolic syndrome.

Cardiovascular findings in very low birthweight schoolchildren with and without bronchopulmonary dysplasia

BACKGROUND

With the introduction of new therapies in peri- and neonatology, the clinical picture of bronchopulmonary dysplasia (BPD) seems to alter. The consequences of this "new BPD" are of interest.

AIM

To evaluate cardiovascular findings during the surfactant era in very low birthweight (VLBW, birth weight < 1500 g) schoolchildren with and without BPD.

METHODS

At 7-8 years of age, 34 VLBW children with BPD born in one hospital underwent blood pressure (BP) measurement, electrocardiography (ECG), two-dimensional Doppler and M-mode echocardiography, flow-volume spirometry and whole-body plethysmography. The age- and sex-matched control groups comprised 34 VLBW children without BPD (no-BPD group) and 34 term children (term group).

RESULTS

The mean(SD) diastolic BP was significantly higher in the no-BPD than in the BPD group (65(9) vs. 59(8) mm Hg, p < 0.05). No clinically significant tricuspid regurgitations were found. The groups did not differ with respect to right ventricular systolic time intervals corrected for heart rate. The results of all M-mode measurements were within normal range. Compared to term controls, the BPD cases had lower mean(SD) forced expiratory flow in 1 s (90(14)% vs. 99(11)% of ref., p < 0.05) and more often high ratio of residual volume to total lung capacity (15(52%) vs. 4(13%), p < 0.01). No clinically significant correlations were found between current lung function and echocardiographic findings.

CONCLUSION

In the surfactant era, school-aged VLBW survivors with and without BPD do not seem to evince indirect signs of elevated pulmonary pressure. The increased pulmonary vascular resistance associated with BPD appears to resolve with time more rapidly than abnormalities in respiratory function.

Factors associated with perceived health among 12-year-old school children. Relevance of physical exercise and sense of coherence

BACKGROUND

Poor perceived health during childhood may affect an individual's well-being throughout life. In adult studies, sense of coherence (SOC) has been shown to be associated with perceived health.

AIMS

The aim of this study was to determine which factors with an emphasis on SOC and physical exercise were associated with perceived health among 12-year-old children.

METHODS

A total of 1,231 12-year-old school children (83%) completed a questionnaire. Most of the 37 questions had multiple-choice types of response. The questions were largely based on those used in the Health Behaviour in School-aged Children (HBSC) study coordinated by the WHO. SOC was determined using the 13-item scale developed by Antonovsky. Factors used in calculating performance at school were marks (given by the teachers, range 4-10, 10 being the best) in mathematics, native language, and first foreign language. Statistical analysis involved the use of logistic regression models and the so-called generalized estimation technique because of the multi-level study design.

RESULTS

In a multivariate model adjusted for reported psychosomatic symptoms, insufficient physical exercise was clearly (OR 4.6) associated with poor perceived health. Other variables with significant associations (OR 1.4-1.7) were a mark below 9 in mathematics, belonging to the weakest SOC tertile, reporting of problems of perceived support from teachers, and reporting of various problems involving the class climate.

CONCLUSIONS

Among the studied variables physical exercise was the most strongly associated with perceived health, even when several social and psychological risk factors were included in the analysis. SOC and variables of social support were also of importance.

Serum leptin concentration poorly reflects growth and energy and nutrient intake in young children

OBJECTIVE

We studied whether the serum leptin concentration at age 2 years predicts changes in relative body weight by age 8 and whether the serum leptin concentration is associated with intake of energy and nutrients at age 5.

METHODS

A total of 156 8-year-old participants of the Special Turku Coronary Risk Factor Intervention Project were chosen to represent children whose relative weight decreased, was stable, or increased during the preceding 6 years. Their serum leptin concentrations were measured in samples collected when they were 2 years. Serum leptin was also measured in 100 5-year-old children in the Special Turku Coronary Risk Factor Intervention Project whose energy and nutrient intakes were analyzed using 4-day food records.

RESULTS

The boys whose relative weight decreased (n = 25), was stable (n = 28), or increased (n = 26) between 2 and 8 years of age had similar serum leptin concentrations at the age of 2 years. The girls whose relative weight decreased (n = 27) had higher serum leptin concentrations at 2 years than the girls whose relative weight remained stable (n = 26) but only when the leptin values were not adjusted for body mass index. The serum leptin concentration was higher in 5-year-old girls than in 5-year-old boys even when adjusted for body mass index. Serum leptin correlated with relative weight in girls and boys (r = 0.65 and r = 0.45, respectively). Serum leptin concentration adjusted for relative weight correlated poorly with intakes of energy, fat, saturated fat, carbohydrates, sucrose, and protein.

CONCLUSIONS

Serum leptin concentrations at age 2 poorly predicted changes in relative body weight during the following 6 years and poorly reflected the intake of energy or major nutrients at age 5.

Growth and adrenal androgen status at 7 years in very low birth weight survivors with and without bronchopulmonary dysplasia

AIMS

To evaluate whether 7 year old VLBW (very low birth weight, <1500 g) survivors with and without bronchopulmonary dysplasia (BPD) evince similar growth status and higher adrenal androgen (AA) levels than term controls, and whether AA levels are higher in VLBW children born small for gestational age (SGA) than in non-SGA cases.

METHODS

Assessment of height standard deviation score (SDs), body mass index (BMI), and serum androstenedione and dehydroepiandrostenedione sulphate levels in 31 VLBW children with BPD, 33 without BPD (no-BPD group), and 33 term controls.

RESULTS

Lower median (range) height SDs was found in BPD (-1.0 (-3.4 to 1.4) SD) and no-BPD (-0.9 (-2.9 to 2.2) SD) children than in term controls (0.3 (-1.5 to 1.9) SD). Low BMI (below 10th centile) was more common in both the BPD (18 (58%)) and no-BPD (16 (49%)) children compared to term cases (3 (9%)). The median (range) androstenedione levels tended to be higher in the BPD (0.8 (0 to 2.8) nmol/l) and no-BPD (0.8 (0 to 2.3) nmol/l) groups than in term controls (0.6 (0 to 1.8)). Higher median (range) dehydroepiandrostenedione sulphate levels were detected in the no-BPD compared to the term group (0.9 (0 to 4.1) v 0.3 (0 to 2.3) micro mol/l). VLBW children born SGA had higher AA levels compared to non-SGA cases.

CONCLUSIONS

At 7 years of age, VLBW children are shorter and tend to have higher AA levels than term controls, but VLBW children with and without BPD do not differ from each other in growth or AA status. Those born SGA have higher AA levels compared to non-SGA cases. The consequences of these findings to final height and to later metabolic and vascular health remain to be determined.

Growth, energy intake, and meal pattern in five-year-old children considered as poor eaters

OBJECTIVE

To investigate whether 5-year-old children considered poor eaters differ from their peers regarding growth, intake of energy and nutrients, or meal pattern. Study design Parental evaluations of children's (n=494) eating at age 5 years were collected using questionnaires, and energy and nutrient intakes and meal pattern of the children were assessed using 4-day food records. Weight and height were measured at birth and at ages 7 and 13 months, and 2, 3, 4, and 5 years. Of the children 30.2% (149) were poor eaters according to the parents. The rest of the sample (n=345) formed the comparison group.

RESULTS

Poor eaters were on average lighter and shorter at birth (P=.026 and P=.020, respectively), and at age 5 years (P<.001 for both weight and height) than the comparison children. At age 5 years the poor eaters on average received less of their daily total energy from warm meals (P=.044) and more from snacks (P=.013) than the comparison group, but the mean daily weight-adjusted intake of energy showed no difference between the groups (P=.153).

CONCLUSIONS

There appears not to be reason for serious concern about growth and diet of preschool-aged children considered as poor eaters by parents.

Pre- and post-discharge feeding of very preterm infants: impact on growth and bone mineralization

In this prospective study we examined (1) how the nutritional status of very preterm infants, judged by growth measures and biochemical values, evolved during the initial hospitalization; (2) the effect of feeding on growth after discharge from hospital; and (3) the risk factors associated with low lumbar bone mineral content (BMC) later in infancy. Sixty-four former preterm infants had their lumbar spine (L2-L4) BMC assessed by dual energy X-ray absorptiometry when they weighed between 5 and 7 kg. Predicted BMC values were calculated based on our previously reported reference lumbar BMC data. These values were used to convert the preterm infants' BMC values into percentages. The extremely preterm group (gestational age < or =28 weeks) had significantly more respiratory morbidity and longer duration of hospital stay than the more mature infants. Both groups developed growth retardation and malnutrition during the hospital stay. Exclusive breastfeeding after discharge from hospital supported linear catch-up growth and weight gain but was associated with a 7.0 (1.2-41.7)-fold risk of having low BMC values. The other factors associated with the risk of having low BMC values later in infancy were low serum phosphate levels at 6 weeks, with a 7.8 (1.6-37.0)-fold risk, and male gender, with a 4.3 (1.2-16.1)-fold risk. Appropriately designed interventional studies are needed to improve the growth and nutrition of these infants during initial hospitalization. In order to improve the postdischarge nutrition, we suggest that the amount and duration of multicomponent human milk fortification should be studied further to provide individualized nutrition throughout the catch-up growth period until the end of the first year of life.

Cardiovascular autonomic reactivity is decreased in adolescents with Type 1 diabetes

AIMS

To characterize autonomic nervous system function by means of the heart rate and blood pressure responses to various stimuli in relation to pubertal maturation in patients with Type 1 diabetes mellitus (DM).

METHODS

One hundred out of 138 eligible patients at the Out-patient Diabetes Clinic and 100 healthy control subjects were examined in terms of cardiovascular parameters at rest, during deep breathing and when standing. Heart rate variability was analysed with time domain,frequency domain and fractal dimension parameters. Tanner pubertal staging was performed before the examinations.

RESULTS

The time domain parameters of heart rate variability at rest or during standing did not significantly differ between the patients and controls in total or at pubertal stages. In the spectral analysis of heart rate variability the very low frequency band was decreased in the patients during standing (P = 0.023).The increase in the very low frequency (P = 0.013)and low frequency (P = 0.031) spectral powers upon changing from a supine position to standing was attenuated in the patients in total, while no significant differences were observed within the Tanner pubertal stages between patients and controls. Heart rate variability during deep breathing was decreased in the patients with distal polyneuropathy (P = 0.006).

CONCLUSIONS

Although cardiovascular integrity is in the main well preserved in adolescent patients with Type 1 DM, these patients are prone to attenuated autonomic nervous system reactivity.

Biochemical markers of bone metabolism in relation to adrenocortical and growth suppression during the initiation phase of inhaled steroid therapy

Growth suppression is usually most evident during the first year of inhaled steroid therapy. Steroid-induced changes in bone metabolism may contribute to this growth suppression. The aim of the present study was to evaluate the changes in biochemical markers of bone metabolism in relation to adrenal and growth suppression during the initiation phase of inhaled steroid therapy. Seventy-five school-aged children with new asthma were enrolled into budesonide (BUD, n = 30), fluticasone propionate (FP, n = 30) or cromone (CROM, n = 15) treatment groups. BUD dose was 800 microg/d during the first two months and 400 microg/d thereafter. The respective FP doses were 500 and 200 microg/d. Biochemical markers of bone metabolism were measured before treatment and after 2 and 4 mo of therapy. In the control (CROM) group, the mean concentrations of serum osteocalcin (OC), carboxyterminal propeptide of type I procollagen (PICP) (formation markers) and type I collagen carboxyterminal telopeptide (ICTP) (degradation marker) tended to increase. In the BUD group, OC and PICP decreased during the 4 mo by a mean of 23% (p < 0.001) and 15% (p < 0.05), respectively, while ICTP did not change significantly. In the FP group, OC and ICTP decreased during the first 2 mo by a mean of 19% (p < 0.01) and 21% (p < 0.01), respectively, returning to the pretreatment level at 4 mo, while PICP tended to increase during the 4 mo (14%, p = 0.12). In the steroid treated children whose height SD score decreased during the first 12 mo of therapy, both OC and PICP decreased during the first 4 mo by a mean of 20% (p < 0.01) and 21% (p < 0.001), respectively. In those children who had no growth suppression, the changes were not significant: -4% in OC and +13% in PICP. Furthermore, in children who developed evidence of adrenocortical suppression (on the basis of a low-dose ACTH test), OC decreased more (23%, p < 0.01) than in those with normal adrenocortical function (10%, p = 0.06). In conclusion, both inhaled BUD and FP caused dose-dependent effects on biochemical markers of bone metabolism. The children who developed growth or adrenocortical suppression were likely to have changes also in bone metabolism.