Preterm appropriate for gestational age infants: size at birth explains subsequent growth

AIM

 The aim was to evaluate growth and breastfeeding up to 18 months corrected age (CA) among preterm appropriate for gestational age (AGA) infants whose mothers initiated breastfeeding during the infants' hospital stay.

METHODS

 One hundred and twenty-seven preterm AGA infants with a median birth weight of 2320 (769-3250) g and gestational age 34.29 (25.00-35.86) weeks were evaluated up to a CA of 18 months. A retrospective, descriptive and comparative design was used. Data were obtained by chart review of hospital medical records and a questionnaire completed by the mothers.

RESULTS

The changes in standard deviation scores (SDS) during the infants' hospital stay were -0.9 for weight, -0.3 for length and -0.5 for head circumference (HC). Infants with higher SDS at birth showed more negative changes from birth to discharge. Median increments in SDS from discharge to a CA of 2 months were as high as, or higher than, the loss from birth to discharge.

CONCLUSION

 Preterm AGA infants with higher SDS for weight, length and HC at birth are at higher risk of inadequate growth during their hospital stay.

Can the TW3 bone age determination method provide additional criteria for growth hormone treatment in adopted girls with early puberty? A comparison of the Tanner-Whitehouse 3 method with the Greulich-Pyle and the Tanner-Whitehouse 2 methods

BACKGROUND/AIMS

Gonadotropin-releasing hormone analogues (GnRHa) are the accepted treatment of idiopathic central precocious puberty. As it has been found that growth velocity may be decreased with GnRHa treatment, clinical trials with GnRHa combined with growth hormone (GH) have been carried out. In a recent study 46 adopted girls with early or precocious puberty were randomly assigned to treatment with either GnRHa or GnRHa combined with GH, and followed to final height (FH). It was found that FH was significantly higher in the combined treatment group, 158.9 compared with 155.8 cm in the GnRHa treated group. In order to select the patients who could benefit from added GH, predictions of FH at the start of treatment according to the methods of bone age determination of Greulich-Pyle (GP) and Tanner-Whitehouse 2 (TW2) were compared. It was found that the GP method was the most useful method for patient selection. Recently, a revision of the Tanner-Whitehouse method, named Tanner-Whitehouse 3 (TW3), has been developed. The present study examined the usefulness of the TW3 method in selecting suitable patients for combined treatment.

METHOD

The TW3 method bone age determinations of the 46 girls were compared to the GP and TW2 method determinations, using the differences between actual FH and predicted adult height (PAH). Beside accuracy of prediction of FH, the criteria of efficiency of selection and replicability were applied in the comparison.

RESULTS

We found that the GP method, also when compared to the TW3 method, gave the most accurate prediction of the FH on only GnRHa treatment. This gives the best ground for selection of patients who can benefit from combined treatment. The GP method was also the most efficient in selecting patients, i.e., it could select the least number of patients that needed the combined treatment. The only drawback of the GP method was that it requires an experienced pediatric radiologist. Automated methods are being developed and may soon facilitate the use of the GP method for those less experienced. The FH after combined treatment could be predicted with an equation including PAH GP as well as PAH TW3 as variables.

CONCLUSION

The GP method remains the most useful method for selection of those patients who will benefit most from the addition of GH to GnRHa in the treatment of idiopathic central precocious or early puberty. FH prediction after combined treatment requires PAH GP as well as PAH TW3.

Gestational diabetes and offspring body disproportion

AIM

It has been demonstrated that females born large for gestational age (LGA) in weight but not length are at increased risk of being obese at childbearing age. We addressed the question whether women with gestational diabetes mellitus (GDM) are at increased risk of giving birth to such infants.

METHODS

Birth characteristics of 884,267 infants of non-diabetic mothers and 7817 of mothers with GDM were analysed. LGA was defined as birth weight or birth length >2 standard deviation scores for gestational age. Multiple logistic regression analysis was performed.

RESULTS

The odds ratio (OR) for a woman with GDM to give birth to an LGA infant that was heavy alone was four times increased (OR: 3.71, 95% CI: 3.41-4.04). Furthermore, in the population of mothers giving birth to LGA infants, the proportion heavy alone was 68% in the group of women with GDM compared with 64.4% in the group of non-diabetic women. The risks were independent of gender of the foetus.

CONCLUSION

Women with GDM have an almost four times higher risk of delivering an LGA infant that is heavy alone. The noted disproportion between weight and length in infants of such mothers may have an impact on the risk of later obesity.

Temporal trends of HLA genotype frequencies of type 1 diabetes patients in Sweden from 1986 to 2005 suggest altered risk

The aim of this study was to compare the frequency of human leukocyte antigen (HLA) genotypes in 1-18-year-old patients with type 1 diabetes newly diagnosed in 1986-1987 (n = 430), 1996-2000 (n = 342) and in 2003-2005 (n = 171). We tested the hypothesis that the HLA DQ genotype distribution changes over time. Swedish type 1 diabetes patients and controls were typed for HLA using polymerase chain reaction amplification and allele specific probes for DQ A1* and B1* alleles. The most common type 1 diabetes HLA DQA1*-B1*genotype 0501-0201/0301-0302 was 36% (153/430) in 1986-1987 and 37% (127/342) in 1996-2000, but decreased to 19% (33/171) in 2003-2005 (P \ 0.0001). The 0501-0201/0501-0201 genotype increased from 1% in 1986-1987 to 7% in 1996-2000 (P = 0.0047) and to 5% in 2003-2005 (P > 0.05). This study in 1-18-year-old Swedish type 1 diabetes patients supports the notion that there is a temporal change in HLA risk.

A unifying hypothesis on the development of type 1 diabetes and celiac disease: gluten consumption may be a shared causative factor

This paper presents a hypothesis of the aetiology of the increasing incidence of type 1 diabetes (T1D). This together with the global increased incidence of celiac disease (CD) and that these increases cannot be explained by genetic factors suggest a common environmental factor for these two diseases. Even though enterovirus (EV) infections are believed to trigger T1D and gluten is the trigger of CD, the increasing intake of gluten containing products all over the world could be the trigger for both diseases directly and indirectly. It has been shown that the duration of exposure to gluten is related to the prevalence of T1D. It has also been shown that T1D patients at onset have an inflammatory reaction in the gut. Hence, early diagnose of CD followed by elimination of dietary gluten will lead to a decreased incidence of T1D.

Recent enterovirus infection in type 1 diabetes: evidence with a novel IgM method

Enterovirus (EV) infection has been associated with Type 1 (T1D) diabetes and on a few occasions virus could be isolated at onset of the disease. Using two such isolates as antigens in a quantitative PCR enhanced immunoassay (T1D-EV-QPIA) we have measured IgM antibodies against such potentially diabetogenic viruses in serum from 33 newly diagnosed T1D children, 24 siblings, and 27 healthy children. Sera were also analysed with regard to autoantibodies against GAD65, the cytokine TNF-alpha and the chemokine IP-10. EV-RNA detection was performed on peripheral blood mononuclear cells (PBMC). IgM antibodies against this "new" EV antigen were more frequent in serum from T1D children than in serum from siblings and/or controls (P < 0.001). EV-RNA was detected more frequently in PBMC from T1D children than in healthy control children (P < 0.001) and also compared to the siblings (P < 0.003). The cytokine TNF-alpha was less frequently detected in serum from the T1D children compared with serum from siblings and/controls (P < 0.001). A positive correlation was found between the results obtained with the T1D-EV-QPIA and the EV-PCR (P < 0.001). These findings are in line with earlier findings of an increased frequency of enteroviral infections in newly diagnosed T1D patients. In addition, we found that T1D children at onset of the disease had lower frequencies of the chemokine TNF-alpha in their serum than age- and sex-matched controls had, suggesting an impaired immune response.

IA-2 autoantibodies in incident type I diabetes patients are associated with a polyadenylation signal polymorphism in GIMAP5

In a large case-control study of Swedish incident type I diabetes patients and controls, 0-34 years of age, we tested the hypothesis that the GIMAP5 gene, a key genetic factor for lymphopenia in spontaneous BioBreeding rat diabetes, is associated with type I diabetes; with islet autoantibodies in incident type I diabetes patients or with age at clinical onset in incident type I diabetes patients. Initial scans of allelic association were followed by more detailed logistic regression modeling that adjusted for known type I diabetes risk factors and potential confounding variables. The single nucleotide polymorphism (SNP) rs6598, located in a polyadenylation signal of GIMAP5, was associated with the presence of significant levels of IA-2 autoantibodies in the type I diabetes patients. Patients with the minor allele A of rs6598 had an increased prevalence of IA-2 autoantibody levels compared to patients without the minor allele (OR=2.2; Bonferroni-corrected P=0.003), after adjusting for age at clinical onset (P=8.0 x 10(-13)) and the numbers of HLA-DQ A1*0501-B1*0201 haplotypes (P=2.4 x 10(-5)) and DQ A1*0301-B1*0302 haplotypes (P=0.002). GIMAP5 polymorphism was not associated with type I diabetes or with GAD65 or insulin autoantibodies, ICA, or age at clinical onset in patients. These data suggest that the GIMAP5 gene is associated with islet autoimmunity in type I diabetes and add to recent findings implicating the same SNP in another autoimmune disease.

SUMO4 M55V polymorphism affects susceptibility to type I diabetes in HLA DR3- and DR4-positive Swedish patients

SUMO4 M55V, located in IDDM5, has been a focus for debate because of its association to type I diabetes (TIDM) in Asians but not in Caucasians. The current study aims to test the significance of M55V association to TIDM in a large cohort of Swedish Caucasians, and to test whether M55V is associated in those carrying human leukocyte antigen (HLA) class II molecules. A total of 673 TIDM patients and 535 age- and sex-matched healthy controls were included in the study. PCR-RFLP was performed to identify the genotype and allele variations. Our data suggest that SUMO4 M55V is not associated with susceptibility to TIDM by itself. When we stratified our patients and controls based on heterozygosity for HLA-DR3/DR4 and SUMO4 genotypes, we found that presence of SUMO4 GG increased further the relative risk conferred by HLA-DR3/DR4 to TIDM, whereas SUMO4 AA decreased the risk. From the current study, we conclude that SUMO4 M55V is associated with TIDM in association with high-risk HLA-DR3 and DR4, but not by itself.

Milk for small infants

This study investigated weight patterns of infants born SGA, in relation to two different feeding regimens during hospital stay. We compared 21 SGA infants prescribed 200 mL/kg milk on day 2, with 21 infants, prescribed 170 mL/kg on day 9. The infants fed according to the proactive nutrition policy tolerated large volumes of milk and showed lower weight loss.

CONCLUSION

A proactive nutrition policy demonstrably reduces weight loss in SGA infants.

Females born large for gestational age have a doubled risk of giving birth to large for gestational age infants

AIM

To analyse if females born large for gestational age (LGA) have an increased risk to give birth to LGA infants and to study anthropometric characteristics in macrosomic infants of females born LGA.

METHODS

The investigation was performed as an intergenerational retrospective study of women born between 1973 and 1983, who delivered their first infant between 1989 and 1999. Birth characteristics of 47,783 females, included in the Swedish Birth Register both as newborns and mothers were analysed. LGA was defined as >2 SD in either birth weight or length for gestational age. The infants were divided into three subgroups: born tall only, born heavy only and born both tall and heavy for gestational age. Multiple logistic and linear regression analyses were performed.

RESULTS

Females, born LGA with regard to length or weight, had a two-fold (adjusted OR 1.96, 95% Cl 1.54-2.48) increased risk to give birth to an LGA infant. Females, born LGA concerning weight only, had a 2.6 (adjusted OR 2.63, 95%, 1.85-3.75) fold increased risk of having an LGA offspring heavy only and no elevated risk of giving birth to an offspring that was tall only, compared to females born not LGA. In addition, maternal obesity was associated with a 2.5 (adjusted OR 2.56, 95%, 2.20-2.98) fold increased risk of having an LGA newborn, compared to mothers with normal weight.

CONCLUSION

Females, born LGA, have an increased risk to give birth to LGA infants, compared to mothers born not LGA. Maternal overweight increases this risk even further.

Can bone age determination provide criteria for growth hormone treatment in adopted girls with early puberty?

In treatment of idiopathic central precocious puberty, GnRH analogues (GnRHa) have been accepted as the treatment of choice. Since growth velocity may be impaired with GnRHa treatment growth hormone (GH) treatment has been added in clinical trials. Recently, a study followed adopted girls with early or precocious puberty on GnRHa or combined GnRHa and GH treatment to final height. It was found that final height was significantly higher in the combined treatment group, although the difference was small. It was seen that patients that were extremely short at arrival and short at start of treatment seemed to be candidates for combined treatment. We have now analysed the data in order to define criteria for the sub-group in need of combined GnRHa-GH treatment in order to achieve normal final height, i.e. above -2 SDS. Bone ages of 46 patients at start of treatment, randomized to either GnRHa treatment or GnRHa treatment combined with GH, were examined blindly by the same radiologist and the PAH calculated. The methods according to Greulich-Pyle / Bayley-Pinneau (GP/BP) and Tanner-Whitehouse (TW2) were used. Predictions versus final height data were analysed. The accuracy of FH prediction was greatest for GnRHa treated group using the GP/BP method. The GP/BP method gave useful cut off limits for when combined treatment was necessary to possibly achieve normal height. If pre-treatment GP/PAH was > 157cm, the patients attained normal height with GnRHa treatment only. Ten out of 13 (77%) such girls could be correctly identified. Using TW2 with a cut off of 164 cm, 9 out of 13 could be selected. Using a multi regression equation of best fit the number of correctly selected cases for GnRHa treatment only, could not be further increased in this group. We conclude that bone age determination and adult height prediction with the Greulich-Pyle/Bayley-Pinneau method, provides useful criteria for selecting the subgroup of adopted girls with early puberty where combined treatment with GnRHa and GH is not necessary to reach normal final height.

Growth and breastfeeding among low birth weight infants fed with or without protein enrichment of human milk

The effect of protein enrichment of mother's milk on growth of low birthweight infants needs further exploration in order to optimize feeding strategies. The aim of this study was to describe feeding and growth of infants weighing <1,900 g at birth, up to a corrected age of 18 months, with or without protein-enriched breastmilk. A retrospective, descriptive, non-experimental design was used to describe the growth of 52 low birthweight infants. Data on their growth and feeding were collected from medical records at hospitals and child health care clinics. Despite more severe morbidity, the infants given protein-enriched milk showed similar growth as the other study infants. Standard deviation score for length at birth correlated positively with delta standard deviation score for length, from discharge to 12 and from discharge to 18 months corrected age. Duration of 'full' breastfeeding had a significant impact on subsequent improvement in SDS for weight. At discharge a smaller proportion of singletons fed with protein enriched milk were breastfed 'fully'. Infants who established breastfeeding at an early post-menstrual age were born with more optimal weight standard deviation score and had a better weight gain after discharge. We conclude that protein-enriched breast milk enables low birthweight infants requiring especially intensive care to attain growth at discharge comparable to that of healthier infants not given enriched milk. Low standard deviation score for length at birth may predict poor growth after discharge. However duration of 'full' breastfeeding had a significant impact on subsequent improvement in SDS for weight. Therefore it is important that mothers of LBW infants are given sufficient support of lactation and breastfeeding.

Growth retardation in Down syndrome in relation to insulin-like growth factors and growth hormone

Growth retardation is a cardinal characteristic of Down syndrome (DS). It is most pronounced from the age of 6 months, when growth starts to become growth hormone (GH) regulated. DS children have normal serum levels of GH. GH regulates the production of insulin-like growth factors (IGFs), which act as growth hormones. Therefore, the serum IGF pattern and the levels of their receptors were studied in fetuses with trisomy 21 and in patients with DS throughout life. Serum levels of IGF were determined by radioimmunoassays for insulin-like growth factors 1 and 2 (RIA-IGF-1 and RIA-IGF-2) showing normal serum RIA-IGF-2 levels throughout life. However, serum RIA-IGF-1 did not rise during childhood and remained at a low level throughout life. Determination of serum IGF by a radioreceptor assay (RRA-IGF), which detects both IGF-1 and IGF-2 as well as enhanced activity in the fetal circulation, showed a deficit in serum RRA-IGF in fetuses with trisomy 21, but at birth and throughout life elevated serum RRA-IGF levels. In spite of this, no differences were observed in fetal brain or liver binding sites for IGF-1, IGF-2, or insulin. Since in the RRA-IGF method IGF-1, IGF-2, and a fetal form of IGF-1 cross-react, it is possible that there is a delayed maturation with incomplete switching from production of the fetal form of IGF to production of the GH-regulated IGF-1 in DS. The deficit in IGF-1-like peptides might account for the growth retardation in DS. In order to study the effect of human growth hormone (hGH) therapy in DS, 5 growth-retarded children with DS were treated with hGH for 6 months. During this period the growth velocity doubled and the serum IGF-1 levels were restored to normal. Thus, DS children respond to hGH treatment.

Final height after combined growth hormone and GnRH analogue treatment in adopted girls with early puberty

BACKGROUND

Girls adopted from developing countries often have early or precocious puberty, requiring treatment with gonadotrophin-releasing hormone (GnRH) analogues. During such treatment, decreased growth velocity is frequent.

AIM

To study whether the addition of growth hormone (GH) to GnRH analogue treatment improves final height in girls with early or precocious puberty.

METHODS

Forty-six girls with early or precocious puberty (age < or =9.5 y) adopted from developing countries were randomized for treatment for 2-4 y with GnRH analogue, or with a combination of GH and GnRH analogue.

RESULTS

During treatment, the mean growth velocity in the GH/GnRH analogue group was significantly higher compared to the control group. Combined GH/GnRH analogue treatment resulted in a higher final height: 158.9 cm compared to 155.8 cm in the GnRH analogue-treated group. Three out of 24 girls (13%) in the combined group and nine of the 22 girls (41%) treated with GnRH analogue alone attained a final height below -2 standard deviation scores (SDS).

CONCLUSION

The difference between the two groups is statistically significant, and possibly of clinical importance. A future challenge is to identify a subgroup with clinically significant advantage of GH addition to GnRH analogue treatment. Being very short on arrival in Sweden and being short and young at start of treatment are possible indicators.

Cognitive and neuropsychological functioning in transnationally adopted juvenile delinquents

AIM

To evaluate cognitive and neuropsychological abilities of adopted delinquent adolescents in institutional care.

METHODS

Transnationally adopted adolescents admitted to institutional care (n = 20) and non-delinquent controls who were also transnationally adopted (n = 21) were compared concerning the Wechsler Intelligence Scale for Children and Adults (WISC and WAIS), the Wisconsin Card Sorting Test (WCST) and the Tower of London test (TOL). The adoptive parents answered questions about the adoption, early childhood and family circumstances by a questionnaire sent by mail.

RESULTS

The adopted delinquents had a significantly lower IQ and significantly lower results on several other measurements in the WISC/WAIS compared to the controls even after adjustment for age of arrival in the adoptive home. Both groups of adoptees scored low in the WISC/WAIS subscale of arithmetics when compared to the population mean. The TOL test showed that the delinquents were slower and made more errors than the controls.

CONCLUSION

The delinquent adoptees scored significantly lower on many variables in the WISC/WAIS. Both delinquent and non-delinquent adoptees had some difficulties with arithmetic. The weak performances in arithmetics might point to some weaknesses in the neuropsychological domain. These results probably have complex explanatory causes and need to be further evaluated.

Catch-Up Growth in Females Born Short for Gestational Age Reduces the Risk of Giving Birth to Short-for-Gestational-Age Infants

<i>Objectives: </i>The aim of the present study was to study the effect of catch-up growth on the offspring’s length at birth among females born short for gestational age. <i>Methods:</i> Data of 1,363 females born short for gestational age (<–2 standard deviation scores) were obtained from the Swedish Birth Register. The females were included in the register both as babies and mothers. The effect of catch-up growth on the offspring’s birth length was studied. <i>Results: </i>Short adult stature was associated with a threefold increase in the risk of giving birth to a short infant [OR 3.08 (CI 1.73–5.50)] and smoking increased the risk in a dose-dependent manner. Overweight was associated with a reduced risk [OR 0.46 (CI 0.22–0.96)] of giving birth to a short infant. <i>Conclusion:</i> Catch-up growth to normal adult stature among women born short for gestational age is associated with a reduced risk of giving birth to a short-for-gestational-age infant.

Intellectual and psychological performance in males born small for gestational age

All male singletons born without congenital malformations in Sweden between 1973 and 1978 and conscripted between January 1991 and January 1997 (n = 254426) were studied. Intellectual and psychological performance was tested at conscription. Males born small for gestational age (SGA) had lower results on both intellectual and psychological performance testing. Among males born SGA, low mean scores in both tests were constantly more common in those without catch-up growth than in those with catch-up growth. In conclusion, being born SGA is associated with an increased risk of subnormal intellectual and psychological performance. Catch-up growth is associated with a reduced risk of subnormal performance in males born SGA.

Birth characteristics and different dimensions of intellectual performance in young males: a nationwide population-based study

AIM

To study the effect of size at birth on different dimensions of intellectual capacity.

METHODS

The study comprised a population-based cohort including all male single births without congenital malformations in Sweden from 1973 to 1976, and conscripted before 1994 (n = 168 068). Information from the Swedish Birth Register was individually linked to the Swedish Conscript Register. The test of intellectual performance included four different dimensions: logical, spatial, theoretical and verbal capacity. These data were available for 80-86% of the males at conscription.

RESULTS

Compared with boys born appropriate for gestational age, males born small for gestational age (SGA) had an increased risk for subnormal performance in all four dimensions. Among males born SGA who were also of short adult stature at conscription, and in individuals born SGA with a head circumference <-- 2 SDS at birth, the risk of subnormal performance was most marked in the logical dimension (OR 1.52; CI 1.25-1.84 and 1.33; 1.15-1.55, respectively).

CONCLUSIONS

Being born small for gestational age is associated with increased risk of subnormal capacity in all four dimensions of intellectual performance. In SGA males, short adult stature, or a small head circumference at birth is especially associated with the risk of subnormal logical performance.

Prediction of adult height and risk of overweight in females born small-for-gestational-age

The risk of short adult stature in women born small-for-gestational age (SGA) was estimated in this prospective cohort study of 43 872 singleton females, born between 1973 and 1983, who gave birth to a child between 1989 and 1999. The risk of overweight in females born SGA, with and without short adult stature, was also studied. All data on birth characteristics and adult height and weight were obtained from the Swedish Birth Register. SGA-born females were divided into being born short only for gestational age [birth length < -2 standard deviation scores (SDS)], born light for gestational age (birthweight < -2 SDS) or being born both short and light for gestational age. Short adult stature was defined as adult height below -2 SDS. Among females, being born SGA (<-2 SDS in birth length or birthweight) was associated with increased risk of short adult stature, compared with being born appropriate for gestational age. The risk varied substantially within different subgroups of females born SGA: being born short for gestational age was associated with an almost fivefold increased risk [odds ratio (OR) 4.89; 95% confidence interval (CI) 3.70, 6.47] of short adult stature, whereas being born light for gestational age was associated with an almost twofold increased risk [OR 1.95, 95% CI 1.43, 2.65]. Overall, females born SGA did not have increased risk of overweight compared with females with appropriate size at birth. However, among females born short for gestational age, short adult stature was associated with an increased risk of overweight in adulthood [OR 1.77, 95% CI 1.01, 3.12]. In conclusion, among females born SGA, of the birth characteristics, short birth length is associated with the highest increased risk of short adult stature. Spontaneous growth in height to normal adult stature reduced the risk of overweight in females born short for gestational age.

Insulin sensitivity and lipolysis in adolescent girls with poorly controlled type 1 diabetes: effect of anticholinergic treatment

OBJECTIVES

Increased GH secretion could be one factor behind the impaired glycaemic control often seen in adolescent girls with type 1 diabetes. Because GH induces insulin resistance, treatment with anticholinergic agents, such as pirenzepine (PZP), has been used to reduce GH secretion. However, in a previous study of adolescent girls with type 1 diabetes, we observed an improvement in glycaemic control during 12 weeks of PZP therapy despite unchanged excretion of GH in urine. Considering the complex mechanisms behind urinary GH excretion, the effects of PZP on pituitary GH secretion or secretory pattern cannot be excluded. Thus, to assess the effect of anticholinergic treatment on metabolic control in adolescent girls with diabetes, we have investigated GH secretion, insulin sensitivity and lipolysis before and during treatment with PZP.

PATIENTS

Eleven adolescent girls with type 1 diabetes and poor metabolic control were investigated before and after treatment with PZP, 100 mg orally, twice a day for 3 weeks.

DESIGN

Serum samples for analysis of haemoglobin A1c and IGF-I were obtained in addition to serum profiles of GH, insulin and IGFBP-1 before and after 3 weeks of PZP treatment. Effects on insulin sensitivity and lipolysis were also assessed.

MEASUREMENTS

IGFBP-1 was measured every hour, whereas serum GH and insulin were measured every 20 min for 24 h. Insulin sensitivity was analysed with the hyperinsulinaemic euglycaemic clamp technique. The rate of lipolysis was assessed under basal conditions following a constant rate infusion of [1,1,2,3,3-2H5]-glycerol. In five girls, lipolysis was also estimated during the hyperinsulinaemic euglycaemic clamp.

RESULTS

There was a significant reduction in haemoglobin A1c levels (9.9 +/- 0.2%vs. 9.1 +/- 0.2; P < 0.0001) during 3 weeks of PZP treatment. In additional, the glucose requirement during the euglycaemic hyperinsulinaemic clamp increased by more than 30% (72.5 +/- 4.9 vs. 96.8 +/- 8.5 mg/m2/min; P = 0.003). However, we could not demonstrate any significant changes in GH secretion (area under the curve, basal levels or peak amplitude) or in the GH secretory pattern (peak height, peak length or interpeak interval). Concordantly, the IGF-I levels were statistically unchanged, as were IGFBP-1 concentrations. The rate of lipolysis did not change under basal conditions (3.40 +/- 0.53 vs. 3.04 +/- 0.54 micro mol/kg/min, n = 11, P = 0.54) or during the hyperinsulinaemic euglycaemic clamp (1.58 +/- 0.21 vs. 2.08 +/- 0.26 micro mol/kg/min; n = 5, P = 0.32).

CONCLUSIONS

Our observations of an increased glucose requirement during the clamp as well as a decrease in haemoglobin A1c demonstrate improved insulin sensitivity in the adolescent girls with diabetes following pirenzepine therapy. The mechanism behind the improvement is not clear, as neither secretion nor the secretory pattern of GH changed significantly. The persistently high levels of GH might explain the unaltered rate of lipolysis despite the improved insulin sensitivity. The observed improvement in glycaemic control in adolescent girls with type 1 diabetes following pirenzepine therapy is promising, although more studies on this topic are needed.

Diabetes control deteriorates in girls at cessation of growth: relationship with body mass index

AIM

Diabetic patients, particularly girls, often experience poor metabolic control during puberty and adolescence. The aim of this study was to investigate metabolic control during adolescence, especially in relation to pubertal stages, growth, insulin treatment and body mass index (BMI).

METHODS

We studied the records of 38 (consecutive) girls with prepubertal onset of Type 1 diabetes mellitus. Data from the age of 10 to 18-20 years were obtained with regard to glycaemic control, growth, age at menarche, final height and BMI, and analysed in relation to both chronological age and age at menarche.

RESULTS

HbA1c was lowest 3 years before menarche; mean (+/- sd) 7.6 (+/- 1.2). After the pubertal growth spurt, there was a marked impairment of metabolic control, the highest level of HbA1c occurring 3 years after menarche. Mean age at menarche was 13.3 (+/- 1.1) years and mean linear growth after menarche only 4.7 cm, giving a final height of 164.9 (+/- 5.3) cm which is 2.7 cm below the Swedish mean. During adolescence the degree of correlation between BMI and HbA1c continuously increased, pointing out the effect of body fat on metabolic control in this age group. The level of HbA1c at 10 years of age could not predict the metabolic control after cessation of puberty, but prepubertal BMI appears to be a risk factor for both obesity and poor glycaemic control in late adolescence.

CONCLUSIONS

The highest HbA1c was found after cessation of growth. Prepubertal BMI is a possible predictor of metabolic control in adolescent diabetic girls.

Intellectual and psychological performance in males born small for gestational age with and without catch-up growth

Infants born small for gestational age (SGA) have an increased risk of neurologic and intellectual dysfunction. Most of these infants catch up in growth and attain normal height, although some do not. Whether catch-up growth influences intellectual function is not known. To analyze whether intellectual and psychological performance of males in early adulthood are associated with body size at birth or by catch-up growth in height among boys, a population-based cohort was studied. This cohort included all male singletons born without congenital malformations in Sweden from 1973 to 1978 and alive at 18 y (n = 276,033). Information from the Swedish Birth Register was individually linked to the Swedish Conscript Register. Of 254,426 conscripted males, information on intellectual and psychological performance was available for 97% and 91%, respectively. Low birth weight, short birth length, small head circumference at birth, and preterm birth increased the risk of subnormal intellectual and psychological performance. Among SGA-born males, the most important predictor was the absence of catch-up growth. Being born SGA is associated with increased risk of subnormal intellectual and psychological performance. The data strongly support the view that, for males born SGA, it is an advantage to have catch-up growth in length.

Bladder capacity and renal concentrating ability in enuresis: pathogenic implications

PURPOSE

We compared bladder volume and renal concentrating capacity in dry children and 2 distinct groups of children with enuresis to hypothesize about the pathogenesis of various types of enuresis.

MATERIALS AND METHODS

A total of 55 dry children and 100 with enuresis underwent an overnight thirst provocation test to assess renal concentrating capacity and completed a 2-day voiding chart to assess functional bladder capacity. The enuretic children were subdivided into 27 desmopressin responders and 73 desmopressin nonresponders before study inclusion.

RESULTS

The desmopressin responder group had lower average renal concentrating capacity +/-1 standard deviation than dry children and desmopressin responders (856 +/- 158 mOsm./kg. versus 939 +/- 147 and 962 +/- 151, respectively, p <0.05). Analogously average daytime urine production in the desmopressin responder group was greater than in dry children and desmopressin responders (22.2 +/- 10.2 ml./kg. body weight versus 15.4 +/- 7.3 and 15.3 +/- 7.2, respectively, p <0.01). Average functional bladder capacity expected for age was less in desmopressin nonresponders than in dry children and responders (52.2% +/- 19.9% versus 79.2% +/- 30.4% and 69.5% +/- 25.7%, respectively, p <0.001).

CONCLUSIONS

Desmopressin responders produced larger amounts of less concentrated urine than the other children, while desmopressin nonresponders had smaller bladder capacity than the other groups. These results support the idea that enuretic children who respond favorably to desmopressin treatment have polyuria, whereas children with therapy resistant enuresis have detrusor hyperactivity.

Anticholinergic treatment improves glycaemic control in adolescent girls with insulin-dependent diabetes mellitus

Metabolic control often deteriorates during puberty in girls with insulin-dependent diabetes. It is well accepted that there is an abnormality in the growth hormone (GH)-insulin-like growth factor-I (lGF-I) axis in these girls, resulting in reduced IGF-I levels and elevated GH. As GH antagonizes insulin, attempts have previously been made to reduce excess GH secretion through anticholinergic treatment. However, most of these studies have been performed on adult patients. The aim of the present study was to evaluate the effects of 12 wk of oral anticholinergic treatment with Pirenzepine, 100 mg twice daily, in 16 adolescent girls with diabetes. Serum samples of IGF-I, glycated haemoglobin and fasting IGF-binding protein 1 were analysed at initiation and after 3, 8 and 12 wk of Pirenzepine therapy. Nocturnal urinary GH excretion was also examined. Glycated haemoglobin declined significantly after 3 wk of Pirenzepine therapy (9.8 +/- 0.18 vs 9.2 +/- 0.17; p < 0.001) and was still improved at the end of the study. Unexpectedly, nocturnal urinary GH excretion did not change. Serum IGF-I continuously increased during the study, while IGF-binding protein 1 levels were not significantly altered.

CONCLUSION

Anticholinergic treatment with Pirenzepine improves glycaemic control in adolescent girls with diabetes. Although nocturnal urinary GH excretion was unchanged there may still be changes in pituitary GH secretion to explain the improvement. Effects of Pirenzepine on gastrointestinal motility can represent other possible mechanisms behind the improved metabolic control.

Profound changes in the GH-IGF-I system in adolescent girls with IDDM: can IGFBP1 be used to reflect overall glucose regulation?

Disturbances in the relations between insulin, growth hormone (GH) and insulin-like growth factor I (IGF-I) may be a major cause behind deteriorated metabolic control in adolescent girls with type I diabetes. These patients have increased GH secretion and low IGF-I concentrations. The aim of this study was to identify possible endocrine mechanisms behind good and poor glycaemic control in such girls, focusing on the insulin-GH-IGF-I axis. Ten girls with well-controlled insulin-dependent diabetes mellitus (IDDM), hemoglobin A1c (HbA1c) 6.5+/-0.4% (normal range 3.9-5.2%) and nine healthy controls were investigated and compared with 11 girls with poor glucose regulation, HbA1c 10.9+/-0.4%, and their corresponding controls. Serum profiles of glucose, insulin, GH and IGF-binding protein 1 (IGFBP1) were analysed in addition to IGF-I and HbA1c. Two interesting observations were made. GH concentrations were equally elevated in the two diabetic groups regardless of metabolic control (mean 24 h GH - girls with poorly controlled diabetes 10.0+/-1.0 mU/L vs 9.8+/-1.7 - girls with well-controlled diabetes; p=ns). Likewise, the IGF-I concentrations were reduced to the same extent (233+/-19 vs 242+/-23 microg/L; p=0.75). Secondly, despite similar insulin concentrations (mean 24 h insulin - girls with poorly controlled diabetes 22.9+/-2.6 and girls with well-controlled diabetes 27.3+/-2.9 mU/L, respectively; p=0.26), there was a marked difference in IGFBP1 concentrations between the two groups with IDDM (mean IGFBP1 - girls with poorly controlled diabetes 70.5+/-9.1 microg/L vs girls with well-controlled diabetes 28.6+/-3.3; p<0.001). Despite equally elevated GH concentrations that may induce insulin resistance, the markedly lower concentrations of IGFBP1 in the well-controlled group indicate a higher hepatic insulin sensitivity in these girls compared with those with a poor control. Furthermore, in spite of similar total IGF-I concentrations, the lower IGFBP1 concentrations may result in higher IGF-I bioactivity in the well-controlled group. This may be reflected in better growth of the well-controlled group whose height of 168.7+/-0.9 vs 163.6+/-1.2 cm was significantly different (p<0.004). IGFBP1 may be a marker of overall insulinization in adolescents with type 1 diabetes, independent of the absolute insulin dose used for therapy.

Prepubertal growth and growth hormone secretion in children after treatment for hematological malignancies, including autologous bone marrow transplantation

Prepubertal growth standards were used to assess growth in 20 children who had undergone autologous bone marrow transplantation (ABMT) as part of their treatment for hematological malignancy. Most of the patients (16 of 20) were transplanted after a relapse of their disease. A negative change in height standard deviation score (H-SDS) was seen only in the group of patients (n = 7) who had received both cranial irradiation therapy (CRT) and 7.5-Gy single-fraction total body irradiation (TBI). Height changes in this group were observed from the time of diagnosis. In contrast, the groups of patients conditioned with chemotherapy only (n = 3) or both chemotherapy and TBI, without preceding CRT (n = 10), did not demonstrate a significant loss in H-SDS. Weight related to height demonstrated large individual differences over time. Spontaneous growth hormone (GH) secretion, as measured by a four-point sleep curve, was followed longitudinally and an increasing proportion of patients with low peak levels was seen in all patient groups. In summary, prepubertal growth was suppressed only in patients who received cranial irradiation before ABMT. Despite low GH peak levels, normal prepubertal growth was found in patients with no CRT before ABMT.

Intellectual and physical performance and morbidity in relation to height in a cohort of 18-year-old Swedish conscripts

To test whether short stature in young men without malformations or chronic childhood diseases is associated with intellectual and physical performance and morbidity, a large cohort of apparently healthy 18-year-old Swedish men was analysed. The original cohort consisted of all men born in 1976 and conscripted in 1994 (n = 38, 900). After exclusion due to growth-affecting disorders or missing data, 32,887 subjects were available for analysis. Short conscripts (height below or equal to -2 SD scores) demonstrated increased overall morbidity compared with taller conscripts (above -2 SD scores). Specifically, short conscripts had more psychiatric and musculoskeletal diagnoses and were more often considered psychologically unsuitable for military service. Mean intellectual performance increased continuously with height; the mean 'standard nine' score was 4.22 for the short men and 5.17 for the rest (p < 0. 001). Short conscripts scored less well than taller conscripts in assessment of psychological functioning during mental stress, and were evaluated as less suitable for leadership positions. Maximal working capacity per kilogramme body weight correlated negatively with height (p < 0.001). In conclusion, short stature was associated with increased morbidity and psychological problems and with lower mean intellectual performance. To what extent this association is direct or indirect needs further evaluation.

Growth hormone therapy in young children with Down syndrome and a clinical comparison of Down and Prader-Willi syndromes

The genetic disorders Prader-Willi syndrome and Down syndrome have a number of features in common, for example, both growth and mental retardation. Growth hormone (GH) treatment is becoming part of the clinical management of children with Prader-Willi syndrome, but in children with Down syndrome, such therapy is still on a research level. In this review, we compare the clinical phenotypes of the two syndromes, and report the effects of long-term GH treatment on the linear growth and psychomotor development of 15 young children with Down syndrome (mean age at start of treatment, 7.4 months). The mean height of the treated children with Down syndrome increased significantly from -1.8 to -0.8 SDS (Swedish standard) during the 3 years of GH therapy (P < 0.001). The mean height of a corresponding control group fell from -1.7 to -2.2 SDS. After the cessation of treatment, growth velocity declined in the treated group. Growth of the head did not increase during GH treatment. There was no effect on mental or gross-motor development, although some improvement in fine-motor development was noted in the GH-treated group (P < 0.01). At present, treatment with GH is not recommended in children with Down syndrome who have not been diagnosed with GH deficiency. Long-term studies with an emphasis also on the metabolic effects of GH therapy are necessary before routine treatment can be considered in such children.

Enuresis--background and treatment

Nocturnal urinary continence is dependent on 3 factors: 1) nocturnal urine production, 2) nocturnal bladder function and 3) sleep and arousal mechanisms. Any child will suffer from nocturnal enuresis if more urine is produced than can be contained in the bladder or if the detrusor is hyperactive, provided that he or she is not awakened by the imminent bladder contraction. Urine production is regulated by fluid intake and several interrelated renal, hormonal and neural factors, foremost of which are vasopressin, renin, angiotensin and the sympathetic nervous system. Detrusor function is governed by the autonomic nervous system which under ideal conditions is under central nervous control. Arousal from sleep is dependent on the reticular activating system, a diffuse neural network that translates sensory input into arousal stimuli via brain stem noradrenergic neurons. Disturbances in nocturnal urine production, bladder function and arousal mechanisms have all been firmly implicated as pathogenetic factors in nocturnal enuresis. The group of enuretic children are, however, pathogenetically heterogeneous, and two main types can be discerned: 1) Diuresis-dependent enuresis - these children void because of excessive nocturnal urine production and impaired arousal mechanisms. 2) Detrusor-dependent enuresis - these children void because of nocturnal detrusor hyperactivity and impaired arousal mechanisms. The main clinical difference between the two groups is that desmopressin is usually effective in the former but not in the latter. There are two first-line therapies in nocturnal enuresis: the enuresis alarm and desmopressin medication. Promising second-line treatments include anticholinergic drugs, urotherapy and treatment of occult constipation.

Desmopressin resistant enuresis: pathogenetic and therapeutic considerations

PURPOSE

We tested the role of the bladder in the pathogenesis of desmopressin resistant enuresis by evaluating the influence of urine production on the timing of the enuretic event and the response to anticholinergic medication.

MATERIALS AND METHODS

We gave 33 children with monosymptomatic nocturnal enuresis resistant to the standard 0.4 mg. oral dose of desmopressin 0.4 and 0.8 mg. desmopressin and placebo tablets for 5 nights each in a double-blind crossover fashion. The time of enuresis or nocturia was documented. All 9 children who had at least 1 dry treatment period during the randomized portion of the study then received open label treatment with 0.8 mg. desmopressin. Nonresponders to this regimen and the remainder of the children were offered anticholinergic treatment.

RESULTS

Average time between bedtime and voiding was 5.0, 5.6 and 5.0 hours during the nights with placebo, and 0.4 and 0.8 mg. desmopressin, respectively (p = 0.12). Of the 9 children subsequently treated with 0.8 mg. desmopressin 5 became completely dry. Of the remaining 28 children given anticholinergic treatment 20 responded.

CONCLUSIONS

Antidiuresis does not delay the enuretic event in children with desmopressin resistant enuresis. This finding and the favorable response to anticholinergic medication favor the hypothesis that these children have nocturnal bladder instability. A subgroup of enuretic children responds to high but not normal doses of desmopressin.

Prediction of male adult stature using anthropometric data at birth: a nationwide population-based study

Short stature and excess weight in adulthood are both associated with an increased risk of health problems. In a population-based investigation, data on birth length, birth weight, and gestational age for males born in Sweden in 1976 were used to predict the risk of being short or overweight in adulthood. The Swedish Birth Register was used to identify singleton males, born to Nordic mothers, who were without malformations and alive at 18 y of age. After individual record linkage between the Birth Register and the Swedish Conscript Register, information about height and weight at 18-21 y was obtained for 90% (n = 39901) of the birth cohort. Logistic regression analyses were used to estimate the risk of being short or overweight at conscription. The odds ratio (OR) was used to estimate relative risk. At conscription, mean height (+/-SD) was 179.5+/-6.6 cm, mean weight 72.1+/-11.2 kg, and mean body mass index 22.3+/-3.1 kg/m2. The risk of short adult stature (<166.3 cm) was associated with being short for gestational age (OR = 5.9), having a low birth weight for gestational age (OR = 1.7), and being born at a gestational age below 32 wk (OR = 2.6). The risk of being overweight (body mass index > +2 SD) was primarily associated with a high ponderal index (> +2 SD; OR = 1.8). In conclusion, anthropometric birth data are better predictors of short stature than of being overweight in adulthood. Among anthropometric data at birth, birth length is the most important predictor of adult height.

Influence of perinatal factors on the onset of puberty in boys and girls: implications for interpretation of link with risk of long term diseases

The authors examined the hypothesis that perinatal factors influence the onset of puberty. Children born as singletons in Uppsala, Sweden, in 1973-1977 were followed for height development before and during their school years (through 16 years of age). In all, 62 children born after preeclampsia, 129 born prematurely, 90 born small for gestational age, 175 born large for gestational age, 49 born short for gestational age, and 38 born tall for gestational age were compared with 688 "normal" children. Differences in age and height at puberty onset and age at menarche were analyzed using the t test and analyses of covariance. For boys, the mean age at puberty onset did not differ between normal boys and those with perinatal factors. Boys born small or short for gestational age were 4 cm shorter than normal boys, and those born large for gestational age were 3 cm taller than normal boys. Among girls, patterns for differences in height were similar. Girls born small for gestational age were 5 months younger than normal girls at the onset of puberty and menarche. Patterns of early childhood growth seemed to explain the relations between these perinatal factors and height and age at puberty. The authors conclude that body size at birth affects stature at puberty; in girls, smallness for gestational age is associated with earlier puberty. Associations between intrauterine exposures and disease risk may be confounded by, or mediated through, effects on adolescence.

Growth hormone treatment during suppression of early puberty in adopted girls. Swedish Growth Hormone Advisory Group

Girls adopted from developing countries often have early or precocious puberty, requiring treatment with gonadotropin-releasing hormone (GnRH) analogues. During such treatment decreased growth velocity is frequent. The aim of this investigation was to study whether the addition of growth hormone (GH) to GnRH analogue treatment improves height velocity and final height in girls with early or precocious puberty. Forty-six girls with early or precocious puberty adopted from developing countries were randomized for treatment with GnRH analogue or a combination of GH and GnRH analogue. After 2 y of treatment the mean growth in the GH/GnRH analogue group was significantly higher, 14.6 cm, compared to 10.9 cm in the control group. The increase in bone age did not differ, while the difference in predicted adult height increased by 2.7 cm in favour of the combination group. Although data on final height are not yet available, combined GH/GnRH analogue treatment for 2 y resulted in a higher growth velocity and predicted final height compared to GnRH analogue treatment alone.

Prevalence of coeliac disease in Turner syndrome

This study was undertaken to investigate the prevalence of coeliac disease in children and adolescents with Turner syndrome. Eighty-seven children and adolescents with Turner syndrome were screened for IgA-antiendomysium antibodies (EMA) and IgA-antigliadin antibodies (AGA), 5% (4/87) being found to be EMA-positive, and 15% (13/87) to have AGA levels above normal. Of the 10 patients who were either AGA- or EMA-positive and further investigated with intestinal biopsy, four manifested villous atrophy (i.e. all three of the EMA-positive patients, but only one of the seven AGA-positive patients). The results suggest EMA-positivity to be a good immunological marker for use in screening for coeliac disease, and such screening to be justified in patients with Turner syndrome.

Depth of sleep and sleep habits among enuretic and incontinent children

In order to evaluate differences in sleep factors between children with wetting problems and dry children, questionnaire data were obtained from 1,413 schoolchildren between the ages of 6 and 10 y. The analyses were performed using logistic regression, and adjusted odds ratios (ORs) were calculated to approximate the relative risk. Current enuresis was associated with a subjectively high arousal threshold, pavor nocturnus, nocturia and confusion when awoken from sleep (ORs 2.7, 2.4, 2.1 and 3.4, respectively), whereas children with current incontinence often experienced bedtime fears, onset insomnia or nocturia (ORs 2.4, 2.3 and 2.7, respectively). Children exhibiting urinary urgency were overrepresented among both children with current enuresis (OR 2.5) and those with current incontinence (OR 17.2). It is concluded that impaired arousal mechanisms and bladder instability are aetiological factors underlying nocturnal enuresis.

Sleep of children with enuresis: a polysomnographic study

OBJECTIVE

To evaluate relationships between bladder voiding and sleep in children with enuresis.

METHODS

Polysomnographic recordings were obtained from 25 children, aged 7 to 17 years, with monosymptomatic nocturnal enuresis. During 52 recorded nights, 37 enuretic events were detected. Responders (n = 7) and nonresponders (n = 16) to desmopressin treatment were compared.

RESULTS

The mean latency between sleep onset and the first bladder voiding was 3 hours 20 minutes (SD = 2 hours 5 minutes). The number of voidings were 19, 7, 10, and 1 occurring during stages 2, 3, and 4, and rapid-eye movement sleep, respectively. Desmopressin responders were found to void during the early or late part of the night, whereas the voidings of the nonresponders were dispersed evenly throughout the night (chi2 = 8.09).

CONCLUSIONS

The enuretic event is a predominantly non-rapid eye movement sleep phenomenon. Responders and nonresponders to desmopressin treatment void during different parts of the night.

Growth hormone treatment in young children with Down's syndrome: effects on growth and psychomotor development

BACKGROUND

Learning disability and short stature are cardinal signs of Down's syndrome. Insulin-like growth factor I (IGF-I), regulated by growth hormone (GH) from about 6 months of age, may be involved in brain development.

AIMS

To study long term effects of GH on linear growth and psychomotor development in young children with Down's syndrome. Study design-Fifteen children with Down's syndrome were treated with GH for three years from the age of 6 to 9 months (mean, 7.4). Linear growth, psychomotor development, skeletal maturation, serum concentrations of IGF-I and its binding proteins (BPs), and cerebrospinal fluid (CSF) concentrations of IGF-II were studied.

RESULTS

The mean height of the study group increased from -1.8 to -0.8 SDS (Swedish standard) during treatment, whereas that of a Down's syndrome control group fell from -1.7 to -2.2 SDS. Growth velocity declined after treatment stopped. Head growth did not accelerate during treatment. No significant difference in mental or gross motor development was found. The low concentrations of serum IGF-I and IGFBP-3 became normal during GH treatment.

CONCLUSIONS

GH treatment results in normal growth velocity in Down's syndrome but does not affect head circumference or mental or gross motor development. Growth velocity declines after treatment stops.

Effect of growth hormone (GH) during puberty in GH-deficient children: preliminary results from an ongoing randomized trial with different dose regimens

This paper reports results from an ongoing, randomized, multicentre national trial. The aim is to elucidate whether a dose of growth hormone (GH) of 0.2 IU/kg (0.07 mg/kg), given either as once-daily or twice-daily injections during puberty, is more effective than a once-daily dose of 0.1 IU/kg/day (0.03 mg/kg/day) in improving final height in children with GH deficiency (GHD). The twice-daily regimen comes closer to the spontaneous GH secretion pattern in puberty. Ninety-two children with GHD who had been receiving GH therapy for at least 1 year, and with spontaneous puberty or who were prepubertal and due to be started on replacement therapy to induce puberty, were randomly assigned to receive GH as follows: group A, 0.1 IU/kg/day (0.03 mg/kg/day), administered once daily; group B, 0.2 IU/kg/day (0.07 mg/kg/day), administered once daily; and group C, 0.2 IU/kg/day (0.07 mg/kg/day), divided into two equal injections given at 12-hour intervals. Pubertal height gain was 0.7, 0.7 and 1.3 SDS for groups A, B and C, respectively. The gain in height during puberty was thus most marked in group C. Mean final height, when corrected for parental height, was between 0 and 1 SDS in all treatment groups. All but seven children reached a final height within +/- 2 SD of the general population. There was a wide range of final heights in all three treatment groups. This variation in response suggests the need to individualize treatment in order to achieve an appropriate final height for most individuals.

Osmoregulation and desmopressin pharmacokinetics in enuretic children

OBJECTIVE

The aim was to compare responders and nonresponders to antienuretic treatment with desmopressin with respect to pharmacokinetics and renal effects of the drug.

METHODS

Twelve children, aged 7.6 to 16.2 years, with nocturnal enuresis were examined. Six patients were nonresponders and 6 were responders to desmopressin treatment. The children were given 2 mg of desmopressin intravenously and plasma concentrations of the drug were monitored overnight. Urine parameters were followed for 24 hours after desmopressin administration. Ten patients also underwent a thirst provocation test.

RESULTS

Desmopressin pharmacokinetics did not differ between the groups. Neither nocturnal urine production nor morning urine osmolality after desmopressin injection differed between responders and nonresponders, whereas the responders produced significantly larger amounts of significantly less concentrated urine during the day after the injection compared with the nonresponders (urine production, 2.02 +/- 0.84 and 0.77 +/- 0.20 mL/kg/h; urine osmolality, 558 +/- 271 and 883 +/- 134 mOsm/kg). Nonresponders voided with smaller bladder volumes (2.43 +/- 0.68 mL/kg body weight) than responders (4.70 +/- 1.21 mL/kg). The responders produced significantly less concentrated urine than the nonresponders during the thirst provocation test (607 +/- 185 and 922 +/- 217 mOsm/kg, respectively).

CONCLUSION

Intravenous desmopressin pharmacokinetics and desmopressin renal effects did not differ between responders and nonresponders to desmopressin treatment. Nonresponders had a smaller spontaneous bladder capacity and responders produced less concentrated urine.

Is growth hormone hypersecretion in diabetic adolescent girls also a daytime problem?

OBJECTIVES

Glycaemic control often deteriorates during puberty in girls with insulin dependent diabetes mellitus (IDDM). This may be due in part to the normal psychosocial changes associated with adolescence. Puberty is, however, also characterized by rapid somatic development, orchestrated by hormonal changes. Some of these hormones play a major role in glucose homeostasis. We have examined the insulin-GH-IGF-I axis in 11 adolescent girls with poorly controlled insulin dependent diabetes and compared the data with those of 10 non-diabetic girls matched for age, pubertal stage and body mass index (BMI).

METHODS

Serum profiles of glucose, insulin, GH and IGF binding protein 1 (IGFBP1) were analysed in addition to IGF-I in serum and nocturnal urinary excretion of GH.

MEASUREMENTS

Serum glucose, insulin and IGFBP1 were measured every hour for 24 h, whereas GH in serum was measured every 30 minutes during the same period. Nocturnal urinary GH was analysed as a mean of three consecutive nights.

RESULTS

The insulin profiles of the IDDM patients were flat with low post-prandial peaks, corresponding to only one-third of the peaks of the non-diabetic girls. The integrated insulin levels, both during 24-h sampling and during daytime, were significantly lower in the diabetic group. There were no differences during night-time. The diabetic patients had elevated mean baseline levels of serum GH (IDDM 2.8 +/- 0.5 mU/l, controls 0.7 +/- 0.2; P < 0.001), a higher 24-h mean serum GH level (9.8 +/- 1.7 mU/l vs. 4.4 +/- 0.7; P < 0.001), significantly more peaks and a urinary GH excretion twice as high as in the non-diabetic group. An interesting observation was the finding of marked differences in daytime GH concentrations between the groups, both regarding overall integrated levels (GH AUC 103 +/- 15.8 and 35.9 +/- 7.1 mU/l x 12 h, respectively; P < 0.005) as well as baseline levels (3.8 +/- 0.6 mU/l vs. 0.7 +/- 0.2; P < 0.001). In contrast, during night-time only the mean basal levels of GH differed. The level of IGF-I was reduced in the diabetic group compared with the healthy controls (IDDM 233 +/- 19 micrograms/l vs. controls 327 +/- 21; P < 0.005). In addition, the IDDM patients had significantly increased concentrations of IGFBP 1, but kept a normal diurnal rhythm with a pronounced night peak.

CONCLUSION

Hypoinsulinaemia in adolescent IDDM patients, particularly in the portal hepatic circulation, results in decreased IGF-I and increased IGFBP 1 production in the liver. High levels of IGFBP 1 may, in turn, reduce the bioactivity of IGF-I even further. Low levels of IGF-I will lead to increased GH secretion. Earlier studies on the relationship between GH and diabetic control have focused on elevated GH levels during the night. In this study we have observed markedly elevated levels of GH also during daytime in adolescent IDDM patients. This indicates increased insulin resistance and insulin demand also during the day in diabetic subjects. The increased insulin resistance may result in hyperglycaemia leading to additional insulin resistance. A vicious circle may thus be induced, accelerating metabolic impairment in poorly controlled adolescent IDDM girls.

Sleep and night-time behaviour of enuretics and non-enuretics

OBJECTIVE

To investigate connections between nocturnal enuresis and sleep factors such as the subjective depth of sleep and classical parasomnias.

PATIENTS, SUBJECTS AND METHODS

One hundred school children aged 6-10 years answered a questionnaire, with their parents, and the same questions were asked of a group of 29 children of the same age suffering from severe nocturnal enuresis.

RESULTS

There were significant differences in arousability, with the enuretic group being 'deep sleepers', and in the prevalence of onset insomnia, nightmares, interrupted sleep and bedtime struggles, which were all less common among the enuretics. The prevalence of classical parasomnias did not differ between the groups.

CONCLUSION

A high arousal threshold is one of the pathogenetic factors underlying nocturnal enuresis and we propose that this group of therapy-resistant enuretic children might not only sleep more deeply than their nonenuretic peers, but perhaps have 'better' sleep.

[Enterovirus infections in new disguise]

Enteroviruses (Coxsackie A and B, echovirus, poliovirus) belong to a group of small RNA-viruses, picomavirus, which are widespread in nature. Enteroviruses cause a number of wellknown diseases and symptoms in humans, from subclinical infections and the common cold to poliomyelitis with paralysis. The development of polio vaccines is the greatest accomplishment within the field of enterovirus research and the background work was awarded the Nobel prize in 1954. New knowledge implies that enteroviruses play a more important part in the morbidity panorama than was previously thought. Chronic (persistent) enteroviruses were formerly unknown. Serologic and molecular biology techniques have now demonstrated that enteroviral genomes, in certain situations, persist after the primary infection (which is often silent). Persistent enteroviral infection or recurrent infections and/or virus-stimulated autoimmunity might contribute to the development of diseases with hitherto unexplained pathogenesis, such as post polio syndrome, dilated cardiomyopathy, juvenile (type 1) diabetes and possibly some cases of chronic fatigue syndrome.

Prevalence of diabetic retinopathy in children and adolescents with IDDM. A population-based multicentre study

Vision-threatening diabetic retinopathy can be prevented if it is diagnosed before becoming too advanced. Since diabetic retinopathy has been reported to occur only rarely before the end of pubertal development, children and adolescents are seldom included in screening programmes. We invited 780 children and adolescents with insulin-dependent diabetes mellitus diagnosed before the age of 15.0 years (disease duration of < 12 years) and who were older than 9.0 years at the time of examination from eight regions of Sweden. Retinal examination was performed with stereoscopic fundus photograph. The photograph were rated according to a modified Airlie House classification. The dropouts (223/780, 28.6%) were significantly older and with a longer duration of diabetes than the examined children (p < 0.001 and 0.001, respectively). Photographs from 557 patients aged (median [interquartile range]:14.6 [12.4-17.0]) years and with a diabetes duration of 8.0 (5.5-9.9) years were evaluated. Retinopathy was demonstrated in 81 patients (14.5%):66 with background retinopathy, 2 with microaneurysms and hard exudates, 12 with preproliferative retinopathy, 1 with proliferative retinopathy. Preproliferative retinopathy was diagnosed in a 12.8-year-old girl in pubertal stage 3 and an 11.8-year-old boy in pubertal stage 2, and proliferative retinopathy was found in a 21.5-year-old girl. Retinopathy was demonstrated in 6% and 18% of patients in pubertal stages 1 and 5, respectively. The overall prevalence of retinopathy in this population may even be higher since the dropouts were older and had a longer duration of diabetes. Since background and preproliferative retinopathy were found in children before puberty, we recommend including children and adolescents in screening programmes for diabetic retinopathy from the age of 10 years.

Serum lipoproteins and apolipoproteins in children during the first five years of diabetes

Serum lipoproteins and apolipoproteins were followed in 34 children during a period of 5 years from the onset of diabetes. The group did not differ in these respects from a healthy control group after 5 years of disease. The variation in serum triglycerides and very-low-density lipoprotein (VLDL) triglycerides was more pronounced, some patients having high values. Serum triglycerides and VLDL lipids were significantly correlated to subcutaneous fat, measured as triceps and subscapular skinfolds. None of the patients had albuminuria, so lipid levels could not be related to renal albumin excretion. There was no significant correlation between any serum lipid and haemoglobin A1c.