Moderate prenatal alcohol exposure and psychomotor development at preschool age

Effects of prenatal alcohol exposure on cognitive and behavioral development: Findings from a hierarchical meta-analysis of data from six prospective longitudinal U.S. cohorts

BACKGROUND

Cognitive and behavioral sequelae of prenatal alcohol exposure (PAE) continue to be prevalent in the United States and worldwide. Because these sequelae are also common in other neurodevelopmental disorders, researchers have attempted to identify a distinct neurobehavioral profile to facilitate the differential diagnosis of fetal alcohol spectrum disorders (FASD). We used an innovative, individual participant meta-analytic technique to combine data from six large U.S. longitudinal cohorts to provide a more comprehensive and reliable characterization of the neurobehavioral deficits seen in FASD than can be obtained from smaller samples.

METHODS

Meta-analyses were performed on data from 2236 participants to examine effects of PAE (measured as oz absolute alcohol/day (AA/day)) on IQ, four domains of cognition function (learning and memory, executive function, reading achievement, and math achievement), sustained attention, and behavior problems, after adjusting for potential confounders using propensity scores.

RESULTS

The effect sizes for IQ and the four domains of cognitive function were strikingly similar to one another and did not differ at school age, adolescence, or young adulthood. Effect sizes were smaller in the more middle-class Seattle cohort and larger in the three cohorts that obtained more detailed and comprehensive assessments of AA/day. PAE effect sizes were somewhat weaker for parent- and teacher-reported behavior problems and not significant for sustained attention. In a meta-analysis of five aspects of executive function, the strongest effect was on set-shifting.

CONCLUSIONS

The similarity in the effect sizes for the four domains of cognitive function suggests that PAE affects an underlying component or components of cognition involving learning and memory and executive function that are reflected in IQ and academic achievement scores. The weaker effects in the more middle-class cohort may reflect a more cognitively stimulating environment, a different maternal drinking pattern (lower alcohol dose/occasion), and/or better maternal prenatal nutrition. These findings identify two domains of cognition-learning/memory and set-shifting-that are particularly affected by PAE, and one, sustained attention, which is apparently spared.

The Early Developmental Outcomes of Prenatal Alcohol Exposure: A Review

Aim: This paper systematically reviews the literature on the effects of prenatal alcohol exposure on early child development from birth to 5 years with the aim to synthesize the developmental outcomes associated with prenatal alcohol exposure, and inform further research to improve our knowledge of the manifestations of prenatal alcohol exposure. Methods: Electronic databases (MEDLINE, Psych INFO, and Psych ARTICLES) were searched to find papers on the developmental outcomes of prenatal alcohol exposure in neonates, infants and toddlers and pre-school aged children. Studies were selected based on participants self-reporting alcohol consumption during pregnancy (either prospectively or retrospectively) and/or children being diagnosed with FASD based on a standardized assessment that includes a dysmorphology examination. The search was limited to peer-reviewed, English language studies involving human subjects, up to 5.5 years old. Results: Out of the 1,684 titles screened, a total of 71 papers were identified as relevant and included in this review. The majority of studies were prospective longitudinal studies. A range of assessment modalities (or tools) was used to determine neurodevelopmental outcomes of prenatal exposure to alcohol in the age group under review, the most frequently described being the Bayley Scales of Infant and Toddler Development (BSID) (n = 19). Studies varied in terms of the dose, frequency, and timing of alcohol consumption during pregnancy and methodology used to assess alcohol consumption. Findings demonstrate extensive evidence for poor global developmental outcomes in children prenatally exposed to alcohol, particularly with moderate to severe levels of prenatal alcohol exposure. Conclusion: The outcomes related to lower levels of prenatal alcohol exposure as well as outcomes in specific developmental domains, are poorly understood. Further research should aim to clarify the more subtle or less easily measurable manifestations of prenatal alcohol exposure on early development when the potential for greatest impact of interventions is highest.

Neurological and neuropsychological effects of low and moderate prenatal alcohol exposure

Several explanations for the diverse results in research on foetal alcohol spectrum disorders or alcohol-related neurodevelopmental disorder might be at hand: timing, amount and patterns of alcohol exposure, as well as complex epigenetic responses. The genetic background of the offspring and its interaction with other prenatal and post-natal environmental cues are likely also of importance. In the present report, key findings about the possible effects of low and moderate doses of maternal alcohol intake on the neuropsychological development of the offspring are reviewed and plausible mechanisms discussed. Special focus is put on the serotonergic system within developmental and gene-environment frameworks. The review also suggests guidelines for future studies and also summarizes some of to-be-answered questions of relevance to clinical practice. Contradictory findings and paucity of studies on the effects of exposure to low alcohol levels during foetal life for the offspring's neuropsychological development call for large prospective studies, as well as for studies including neuroimaging and multi-omics analyses to dissect the neurobiological underpinnings of alcohol exposure-related phenotypes and to identify biomarkers. Finally, it remains to be investigated whether any safe threshold of alcohol drinking during pregnancy can be identified.

A Qualitative Study of Substance use during Pregnancy: Implications for Reproductive Healthcare in Western Kenya

Women who use alcohol and drugs are often in their childbearing years, creating a need for integrated substance abuse and reproductive health services. However, our understanding of the social context and drivers of substance use during pregnancy, particularly in developing countries, is limited and largely unaddressed in clinical care. Our qualitative research explored the reproductive health of women of childbearing age who inject drugs and its implications for healthcare in Kisumu, Kenya. We used in-depth, semi-structured qualitative interviews with 17 women who inject drugs to explore reproductive health topics including knowledge, practices, and clinical interactions related to substance use during pregnancy. All but one woman had a prior pregnancy and two were pregnant during our study. Alcohol and drug use was prevalent throughout pregnancy, often described as a coping mechanism for stress. Women received mixed advice from family and social contacts regarding alcohol use during pregnancy, leading to differing perceptions of its health effects. Healthcare providers infrequently screened women for alcohol or drug use. Our analysis highlights the need for culturally appropriate alcohol and drug screening and counseling to be included in integrated reproductive health services in western Kenya.

The Long-Term Neurocognitive Consequences of Prenatal Alcohol Exposure: A 14-Year Study

Prenatal alcohol exposure, at doses not generally associated with maternal alcohol problems, produces a broad array of neurocognitive deficits in offspring even in the absence of effects on growth and morphology. This report presents a summary of neurobehavioral, growth, and morphology findings from long-term follow-up of a birth cohort of 500 from a population-based study that has revealed attention, memory, and information processing deficits from birth through 14 years. Also observed (from school age through 14 years) have been problems with antisocial and delinquent behaviors, and classroom learning and behaviors; some of these problems may be secondary to earlier neurocognitive disabilities. Continuing research in behavioral and neurobehavioral teratology provides important opportunities for the neurosciences and for improved health of future generations.

Gross motor deficits in children prenatally exposed to alcohol: a meta-analysis

BACKGROUND AND OBJECTIVES

Gross motor (GM) deficits are often reported in children with prenatal alcohol exposure (PAE), but their prevalence and the domains affected are not clear. The objective of this review was to characterize GM impairment in children with a diagnosis of fetal alcohol spectrum disorder (FASD) or "moderate" to "heavy" maternal alcohol intake.

METHODS

A systematic review with meta-analysis was conducted. Medline, Embase, Allied and Complementary Medicine Database, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, PEDro, and Google Scholar databases were searched. Published observational studies including children aged 0 to ≤18 years with (1) an FASD diagnosis or moderate to heavy PAE, or a mother with confirmed alcohol dependency or binge drinking during pregnancy, and (2) GM outcomes obtained by using a standardized assessment tool. Data were extracted regarding participants, exposure, diagnosis, and outcomes by using a standardized protocol. Methodological quality was evaluated by using Strengthening the Reporting of Observational Studies in Epidemiology guidelines.

RESULTS

The search recovered 2881 articles of which 14 met the systematic review inclusion criteria. The subjects' mean age ranged from 3 days to 13 years. Study limitations included failure to report cutoffs for impairment, nonstandardized reporting of PAE, and small sample sizes. The meta-analysis pooled results (n = 10) revealed a significant association between a diagnosis of FASD or moderate to heavy PAE and GM impairment (odds ratio: 2.9; 95% confidence interval: 2.1-4.0). GM deficits were found in balance, coordination, and ball skills. There was insufficient data to determine prevalence.

CONCLUSIONS

The significant results suggest evaluation of GM proficiency should be a standard component of multidisciplinary FASD diagnostic services.

Predicting changes in language skills between 2 and 3 years in the EDEN mother-child cohort

Objective. To examine the factors predicting changes in language skills between 2 and 3 years. Methods. By using longitudinal data concerning 1002 children from the EDEN study, linear regression was used to predict 3-year language performance from 2-year language performance and the risk factors associated with language delays. Logistic regressions were performed to examine two change trajectories: children who fall below the 10th percentile of language skills between 2 and 3 years (declining trajectory), and those who rose above the 10th percentile (resilient trajectory). Results. The final linear model accounted for 43% of the variance in 3-year language scores, with 2-year language scores accounting for 22%. Exposure to alcohol during pregnancy, earlier birth term, lower level of parental education and lower frequency of maternal stimulation were associated with the declining trajectory. Breastfeeding was associated with the resilient trajectory. Conclusions. This study provides a better understanding of the natural history of early language delays by identifying biological and social factors that predict changes in language skills between the ages of 2 and 3 years.

Alcohol consumption among pregnant women in a Swedish sample and its effects on the newborn outcomes

BACKGROUND

Little is known about the effects of low levels of maternal alcohol intake on the neuropsychological development of the child. This study is part of an ongoing investigation on maternal drinking and presents data on demographic variables, maternal alcohol use, and birth outcomes from that study.

METHODS

The sample comprised 2,264 women from a Swedish antenatal clinic. Retrospective self-report data were collected on alcohol consumption before and during pregnancy, using the Alcohol Use Disorders Identification Test (AUDIT), and on nicotine use. Specific alcohol biomarkers for excessive drinking, carbohydrate-deficient transferrin (CDT) in serum and phosphatidylethanol (PEth) in whole blood, were determined during mid-pregnancy in a subsample of the women. Data on labor and early characteristics of the child were also assessed.

RESULTS

Before pregnancy, 89% of the women regularly consumed alcohol and 49% reported occasional or frequent binge drinking. Nicotine was used by 15% before and by 5% during pregnancy. During pregnancy, 12% continued using alcohol and 5% also admitted binge drinking. However, all alcohol biomarker values were below the reporting limits (CDT ≤ 1.7% disialotransferrin; total PEth < 0.1 μmol/L). Self-reported drinking during pregnancy was associated with a higher AUDIT score before pregnancy, nicotine use at the time of the first prenatal visit, older age, and previous legal abortions.

CONCLUSIONS

The AUDIT questionnaire and 2 specific alcohol biomarkers were used in routine maternity care to collect information about drinking during pregnancy and thereby to identify children at risk for alcohol-related complications. While the AUDIT results suggested that a significant number of women continued using alcohol during pregnancy, implying a risk for fetal disorders, the biomarkers showed negative test values thus indicating only modest drinking levels.

Alcohol, smoking, and drug use among Inuit women of childbearing age during pregnancy and the risk to children

BACKGROUND

Alcohol consumption during pregnancy, a known teratogen often associated with drug use and smoking is a well-known public health concern.

AIM

This study provides prevalence data for alcohol, smoking, and illicit drug use before, during, and after pregnancy among Inuit. Factors associated with alcohol use are also identified.

METHODS

Two hundred and eight Inuit women from Arctic Quebec were interviewed at mid-pregnancy, and at 1 and 11 months postpartum to provide descriptive data on smoking, alcohol, and drug use during pregnancy, and the year before and after pregnancy. Sociodemographic and family characteristics potentially associated with alcohol use were documented.

RESULTS

Ninety-two percent of the women reported smoking and 61% reported drinking during pregnancy. Episodes of binging during pregnancy were reported by 62% of the alcohol users, which correspond to 38% of pregnant women. Thirty-six percent of the participants reported using marijuana during pregnancy. Alcohol use and binge drinking during pregnancy were more likely to be reported by women who lived in less crowded houses, had a better knowledge of a second language, drank alcohol more often and in larger amounts prior to pregnancy, and used illicit drugs. Binge drinkers were more likely to be single women and to have had fewer previous pregnancies. Postpartum distress and violence were more likely to be experienced by women who used alcohol during pregnancy. Binge drinking during pregnancy was best predicted by drinking habits before pregnancy, maternal symptoms of depression, the use of illicit drugs during pregnancy, and the number of young children living with the mother.

CONCLUSIONS

These results confirm that alcohol is a major risk factor to maternal and child health in this population, underscoring the need for culturally relevant and effective prevention programs.

Prenatal alcohol exposure - a systematic review of the effects on child motor function

OBJECTIVE

To systematically review the available evidence on the effects of prenatal alcohol exposure on motor function in humans.

DESIGN

Systematic review.

POPULATION

Pregnant women and their offspring.

METHODS

The search strategy included Medline, Embase, The Cochrane Library and Scopus. The authors read titles and abstracts, and the articles that met the predefined criteria for inclusion were obtained and the full text read. The articles were assessed for quality using the Newcastle-Ottawa Quality Assessment Scale.

MAIN OUTCOME MEASURES

Motor function measured on standardized or validated tests.

RESULTS

The search resulted in 311 titles and abstracts, of which 39 were found relevant for inclusion. The findings of this review suggest a negative effect when the maternal consumption exceeded a certain level. Of all studies reporting a maternal intake of more than four drinks/day, only one study showed no effect on motor function, and of all studies reporting intake levels of less than 10 drinks/week, only one study showed deficit on the children's motor function.

CONCLUSIONS

While it appears consistent that high daily alcohol intake is associated with deficits in gross and fine motor function, and low weekly intake is not associated with such deficits, the issue of binge drinking is unsettled.

Effect of perinatal alcohol exposure on ibotenic acid-induced excitotoxic cortical lesions in newborn hamsters

Alcohol is one of the most common noxious substance to which fetuses are exposed. The aim of the study was to determine the effects of in utero alcohol exposure on excitotoxin-induced neuronal migration disorders. Female hamsters received alcohol (7%) for 3-5 mo or for the last 9-12 d of gestation. Alcohol diet was continued for 5 d during lactation in both groups. Drinking behavior was monitored. Peak plasma alcohol levels were 104+/-12 mg/dL and 225+/-6 mg/dL after 30 min for hamsters receiving an intragastric dose of 3 mL or 5 mL alcohol, respectively. At birth, pups received intrapallial injections ibotenic acid (1 ng, 100 ng, or 10 microg). Histology and N-methyl-D-aspartic acid (NMDA) receptor labeling by 3H-MK-801 in the pups cortices were studied. Short-term-alcohol-exposed pups had normal body and brain weights at birth, but their body growth was retarded postnatally. Ibotenic acid induced similar neuronal migration impairments in control and alcohol-exposed pups (nodular heterotopia in the white matter and/or deep cortical layers, subpial ectopia, and micro- or polymicrogyria). The size of lesions induced by 100 ng ibotenic acid was increased in alcohol-exposed pups; the 10 microg dose was lethal. The density of 3H-MK-801 binding sites was similar in the three groups, indicating that exacerbated ibotenic acid excitotoxicity in alcohol-exposed pups did not result from increased NMDA receptor density. This study shows that alcohol exposure at levels that do not induce neuron migration disorders is sufficient to enhance the effects of the hypoxia-ischemia mimicking effects of ibotenic acid.

Recognition of facial features of fetal alcohol syndrome in the newborn

The diagnosis of an infant, especially a newborn, with fetal alcohol spectrum disorder is difficult due to the fact that not all of the features are apparent at that time. Many cases are also missed due to inadequate knowledge of the mother's drinking pattern and because of the examining physician's lack of experience with the disorder. While conducting a study of the use of maternal blood markers to determine alcohol use in pregnancy, we have evaluated systematically the effects of alcohol on the newborn infant. We have developed a facial scoring system consisting of six of the features commonly seen in children with fetal alcohol syndrome (FAS) and present preliminary data about its use. By using a cutoff of four or more of these six features, there is a significant correlation with the presence of these features and the mother's self-reported alcohol use. In addition, there has been no significant difference in the frequency of positive scores between newborns of Caucasian or Black ancestry. We propose that this system may be useful in the assessment of newborn infants at high risk because of alcohol exposure during pregnancy.

Long-chain polyunsaturated fatty acids at birth and cognitive function at 7 y of age

OBJECTIVE

During the central nervous system (CNS) growth spurt, rapid accretion of long chain polyunsaturated fatty acids (LCPUFA) takes place. This particularly concerns docosahexaenoic acid (DHA, 22:6n-3) and arachidonic acid (AA, 20:4n-6), which are thought to play important roles in CNS development and function. The aim of this study was to investigate the relationship between cognitive performance at 7 y of age and LCPUFA levels in umbilical venous plasma phospholipids, representing the prenatal fatty acid availability, and in plasma phospholipids sampled at 7 y.

DESIGN

As part of a follow-up study, the cognitive performance of 306 children, born at term, was assessed at 7 y of age with the Kaufman Assessment Battery for Children. Backward stepwise regression analysis was used to study the relationship between the outcomes and LCPUFA status. Social class, maternal intelligence and parenting skills were included as covariables, among others.

RESULTS

Results show no significant association with either DHA or AA at birth and the cognitive performance at 7 y of age. The LCPUFA levels at 7 y were not associated with these outcomes either. Consistent with the literature, significant relationships were found between cognitive outcome measures and maternal education, maternal intelligence and the child's birthweight.

CONCLUSIONS

In conclusion, our results do not provide evidence for a positive association between cognitive performance at 7 y and LCPUFA status at birth or at 7 y of age.

Prenatal ethanol exposure, generalized learning impairment, and medial prefrontal cortical deficits in rats

Prenatal ethanol exposure may cause neurological damage and subsequent mental retardation in humans, with learning deficits similar to those following damage to the prefrontal cortex. This study examined cognitive dysfunction and cortical damage after prenatal exposure to ethanol using a chronic administration model. Pregnant Sprague-Dawley rats received one of three diets during gestation: a liquid diet containing 35% ethanol-derived calories (ETOH), an isocaloric liquid diet (ISO), or standard chow (CHOW). Subjects were obtained from ETOH dams with blood alcohol concentrations (BACs) above 90 mg/dl and corresponding ISO and CHOW controls (one male pup/litter; n=6 pups/group). At approximately 90 days of age, subjects began training on a series of unique auditory discrimination problems using a successive go/no-go procedure. A criterion of 85% accuracy determined when a rat continued to the next problem. Subjects completed a varying number of problems within a 30-session limit, after which all rats were tested on a tone/click discrimination and reversal. Subjects were then sacrificed and neuronal number in the medial prefrontal cortex (mPFC) was estimated by the optical fractionator method. Prenatal ethanol exposure induced significant cell loss in the mPFC, which was associated with significantly impaired reversal learning. Poor performance by ETOH subjects on the tone/click reversal indicates a transfer of training deficit that may reflect failures of inhibitory control.

Maternal substance use during pregnancy and developmental outcome at age three

PURPOSE

The data from the National Maternal and Infant Health Survey (NMIHS) and its 3-year follow-up offer a unique opportunity to study the effects of substance (alcohol, marijuana, and tobacco) use during gestation on development at age three in a nationally representative sample. Using this data, the relationship of development (language, gross motor, fine motor, and adaptive behavior) and specific behaviors (eating problems, length of play, activity level, difficulty of management, level of happiness, fearfulness, ability to get along with peers, tantrums, eating nonfood) and maternal drinking, marijuana use, and cigarette smoking was studied in a sample of live births who had been followed up at age three.

METHODS

The data were analyzed using a cumulative logit model of ordinal responses.

RESULTS

Higher activity level, greater difficulty of management, tantrums, eating problems, and eating nonfood were related to maternal drinking during pregnancy. Increased fearfulness, poorer motor skills, and shorter length of play were associated with maternal marijuana use during pregnancy. Less well developed language, higher activity level, greater difficulty of management, fearfulness, decreased ability to get along with peers, and increased tantrums were associated with maternal cigarette smoking during pregnancy. The preponderance of significant effects involved the behaviors studied rather than the developmental indices.

IMPLICATIONS

It may be that the effects of substance use during pregnancy, especially more subtle ones, show up in behavior before they can be measured by developmental scales.

Neuroanatomical and neurophysiological mechanisms involved in central nervous system dysfunctions induced by prenatal alcohol exposure

One of the most severe consequences of maternal ethanol consumption is the damage to the developing central nervous system, which is manifested by long-term cognitive and behavioral deficits in the offspring. Prenatal exposure to ethanol affects many crucial neurochemical and cellular components of the developing brain. Ethanol interferes with all of the stages of brain development, and the severity of the damage depends on the amount of ethanol intake and level of exposure. Experimental observations also indicate that the toxic effects of ethanol are not uniform: some brain regions are more affected than others and, even within a given region, some cell populations are more vulnerable than others. The neocortex, the hippocampus, and the cerebellum are the regions in which the neurotoxic effects of ethanol have been associated with the behavioral deficits. At the cellular level, ethanol disrupts basic developmental processes, including interference with division and proliferation, cell growth, and differentiation and the migration of maturing cells. Alterations in astroglia development and in neuronal-glial interactions may also influence the development of the nervous system. An impairment of several neurotransmitter systems and/or their receptors, as well as changes in the endocrine environment during brain development, are also important factors involved in the behavioral dysfunctions observed after prenatal ethanol exposure. Finally, some molecular mechanisms of ethanol-induced behavioral dysfunctions will be discussed.

Prenatal alcohol exposure and development at preschool age: main results of a French study

Very high levels of alcohol consumption during pregnancy are harmful for the central nervous system of the child and affect morphogenesis and growth. The aim of this study was to investigate the effects of moderate prenatal alcohol exposure on development at preschool age in a longitudinal study. Pregnant women were interviewed on their alcohol consumption during pregnancy at their first visit to the maternity hospital of Roubaix, France. The development of their 160 children was assessed at the age of 4 1/2. Multiple regression analyses indicated that consumption of 1.5 oz of absolute alcohol (approximately 3 drinks) or more during pregnancy was significantly related to a decrease of 7 points on the general cognitive index of the McCarthy scales, after controlling for confounders. This level of consumption was also related to a higher score on minor neurological anomalies, a lower height of the child, and a higher score on facial features. This level of 1.5 oz of absolute alcohol/day should not be interpreted as a biological threshold, because the study does not allow conclusions to be drawn regarding the effects of lower levels of alcohol consumption. Alcohol consumption during pregnancy can affect the development of the child, at levels well below those associated with fetal alcohol syndrome.

A review of the neurobehavioral deficits in children with fetal alcohol syndrome or prenatal exposure to alcohol

Fetal alcohol syndrome is a devastating developmental disorder caused by prenatal exposure to high amounts of alcohol. In addition to structural abnormalities and growth deficits, fetal alcohol syndrome is associated with a broad spectrum of neurobehavioral anomalies. This paper reviews the behavioral and cognitive effects of prenatal alcohol exposure. More than 20 years of research are discussed, with a focus on IQ, activity, attention, learning, memory, language, motor, and visuospatial abilities in children prenatally exposed to varying amounts of alcohol, including those with fetal alcohol syndrome.

Moderate Alcohol Consumption and Psychological Stress during Pregnancy Induce Attention and Neuromotor Impairments in Primate Infants

This study examined the effect of moderate alcohol and/or psychological stress during prenancy on off-spring growth and behavior in 33 rhesus monkey infants (Macaca mulatta). Infants were derived from 1 of 3 groups of female: (1) alcohol-consuming,0.6g/Kg, Daily throughou gestation (equivalet, to 1-2 drinks), beginning 5 day prior to breeding;(2) alcohol-consuming (as above) and exposed to mild psychological stress(removal from home cage and exposed to 3 random noise bursts); (3) sucrose-consuming, equivolemic, and equicaloric to the alcohol solution.Beginning on day 4 postpartum, intantrs underwent brief weekly separations from their mother for assessment of growth, behavior, and facial dimensions. Results indicated that moderate alcohol consumption throughout pregnancy was sufficient to affect attention and neuromotor functioning, even though the infants were normol in birthweight, gestational length, and facial dimensions, Moreover, alcohol-induced neuromotor impairments were exacerbated by maternal exposure to psychological stress, and males from the alcohol/stress condition had reduced birthweights. Finally, although all females consuming alcohol produced viable offspring, alcohol accompanie by stress during gestation resulted in 23% fetal losses (abortion and stillbirths).

Hepatitis C infection after blood product transfusion

HCV infection has been demonstrated in multiply transfused children who received blood products or transplanted organs before universal screening in 1990. The risk of active infection is related to the number of transfusions or pooled blood products. Accurate diagnosis of infection is dependent on utilisation of third generation RIBA and identification of HCV RNA by RT-PCR. The natural history of HCV in childhood is undetermined and prospective long term studies should be undertaken. It is likely that about develop chronic hepatitis with progression at some time to cirrhosis and have an increased risk of developing liver cancer. Treatment with interferon alfa may be effective in up to 50% of children and only those children with documented infection with HCV RNA should be selected for treatment. In order to answer important questions about natural history, outcome, and the necessity and efficacy of treatment response, treatment for these children should only be as part of scientifically conducted studies on a multicentre basis.