Early-childhood linear growth faltering in low- and middle-income countries

Globally, 149 million children under 5 years of age are estimated to be stunted (length more than 2 standard deviations below international growth standards)1,2. Stunting, a form of linear growth faltering, increases the risk of illness, impaired cognitive development and mortality. Global stunting estimates rely on cross-sectional surveys, which cannot provide direct information about the timing of onset or persistence of growth faltering-a key consideration for defining critical windows to deliver preventive interventions. Here we completed a pooled analysis of longitudinal studies in low- and middle-income countries (n = 32 cohorts, 52,640 children, ages 0-24 months), allowing us to identify the typical age of onset of linear growth faltering and to investigate recurrent faltering in early life. The highest incidence of stunting onset occurred from birth to the age of 3 months, with substantially higher stunting at birth in South Asia. From 0 to 15 months, stunting reversal was rare; children who reversed their stunting status frequently relapsed, and relapse rates were substantially higher among children born stunted. Early onset and low reversal rates suggest that improving children's linear growth will require life course interventions for women of childbearing age and a greater emphasis on interventions for children under 6 months of age.

Obscuring effect of coding developmental disability as the underlying cause of death on mortality trends for adults with developmental disability: a cross-sectional study using US Mortality Data from 2012 to 2016

OBJECTIVE

To determine whether coding a developmental disability as the underlying cause of death obscures mortality trends of adults with developmental disability.

DESIGN

National Vital Statistics System 2012-2016 US Multiple Cause-of-Death Mortality files.

SETTING

USA.

PARTICIPANTS

Adults with a developmental disability indicated on their death certificate aged 18 through 103 at the time of death. The study population included 33 154 adults who died between 1 January 2012 and 31 December 2016.

PRIMARY OUTCOME AND MEASURES

Decedents with a developmental disability coded as the underlying cause of death on the death certificate were identified using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision code for intellectual disability, cerebral palsy, Down syndrome or other developmental disability. Death certificates that coded a developmental disability as the underlying cause of death were revised using a sequential underlying cause of death revision process.

RESULTS

There were 33 154 decedents with developmental disability: 7901 with intellectual disability, 11 895 with cerebral palsy, 9114 with Down syndrome, 2479 with other developmental disabilities and 1765 with multiple developmental disabilities. Among all decedents, 48.5% had a developmental disability coded as the underlying cause of death, obscuring higher rates of choking deaths among all decedents and dementia and Alzheimer's disease among decedents with Down syndrome.

CONCLUSION

Death certificates that recorded the developmental disability in Part I of the death certificate were more likely to code disability as the underlying cause of death. While revising these death certificates provides a short-term corrective to mortality trends for this population, the severity and extent of this problem warrants a long-term change involving more precise instructions to record developmental disabilities only in Part II of the death certificate.

Long-term effects of glucocorticoids on function, quality of life, and survival in patients with Duchenne muscular dystrophy: a prospective cohort study

BACKGROUND

Glucocorticoid treatment is recommended as a standard of care in Duchenne muscular dystrophy; however, few studies have assessed the long-term benefits of this treatment. We examined the long-term effects of glucocorticoids on milestone-related disease progression across the lifespan and survival in patients with Duchenne muscular dystrophy.

METHODS

For this prospective cohort study, we enrolled male patients aged 2-28 years with Duchenne muscular dystrophy at 20 centres in nine countries. Patients were followed up for 10 years. We compared no glucocorticoid treatment or cumulative treatment duration of less than 1 month versus treatment of 1 year or longer with regard to progression of nine disease-related and clinically meaningful mobility and upper limb milestones. We used Kaplan-Meier analyses to compare glucocorticoid treatment groups for time to stand from supine of 5 s or longer and 10 s or longer, and loss of stand from supine, four-stair climb, ambulation, full overhead reach, hand-to-mouth function, and hand function. Risk of death was also assessed. This study is registered with ClinicalTrials.gov, number NCT00468832.

FINDINGS

440 patients were enrolled during two recruitment periods (2006-09 and 2012-16). Time to all disease progression milestone events was significantly longer in patients treated with glucocorticoids for 1 year or longer than in patients treated for less than 1 month or never treated (log-rank p<0·0001). Glucocorticoid treatment for 1 year or longer was associated with increased median age at loss of mobility milestones by 2·1-4·4 years and upper limb milestones by 2·8-8·0 years compared with treatment for less than 1 month. Deflazacort was associated with increased median age at loss of three milestones by 2·1-2·7 years in comparison with prednisone or prednisolone (log-rank p<0·012). 45 patients died during the 10-year follow-up. 39 (87%) of these deaths were attributable to Duchenne-related causes in patients with known duration of glucocorticoids usage. 28 (9%) deaths occurred in 311 patients treated with glucocorticoids for 1 year or longer compared with 11 (19%) deaths in 58 patients with no history of glucocorticoid use (odds ratio 0·47, 95% CI 0·22-1·00; p=0·0501).

INTERPRETATION

In patients with Duchenne muscular dystrophy, glucocorticoid treatment is associated with reduced risk of losing clinically meaningful mobility and upper limb disease progression milestones across the lifespan as well as reduced risk of death.

FUNDING

US Department of Education/National Institute on Disability and Rehabilitation Research; US Department of Defense; National Institutes of Health/National Institute of Arthritis and Musculoskeletal and Skin Diseases; and Parent Project Muscular Dystrophy.

From Nonissue to Healthcare Crisis: A Historical Review of Aging and Dying With an Intellectual and Developmental Disability

Individuals with intellectual and developmental disabilities are living unprecedentedly longer lives primarily due to the long-term benefits of the deinstitutionalization movement and widespread improvements in health outcomes. However, the consequences of this protracted aging process are significant, complex, and often poor not only for the individuals and their caregivers but for the mainstream healthcare community. This article will explore, utilizing a constructionist perspective, how these challenges evolved from a nonissue to an impending crisis in less than 25 years. Additionally, present-day efforts by researchers, policymakers, and practitioners to address these challenges will be explored and recommendations will be made for future directions.

[Risk assessment of pre-term infants]

Pre-term birth occurs when a baby is born before 37 weeks of gestation are completed. Many recent publications on neurodevelopmental and somatic outcome parameters of premature infants are of interest for insurance medicine. Infants born before the 28th week are called extremely pre-term. When examined at five years, 85% had already received or still needed special treatment or support. The results of examinations in early childhood have quite a low predictive value for the further development of the child. In the very and moderately pre-term stages, long-term risks are continuously declining with the length of gravidity. Even "late pre-term" birth (34 to 36 weeks of gestation) is associated with a nearly doubled rate of developmental impairment and chronic disease in childhood and adolescence. Various studies performed in early adulthood showed that former pre-term infants suffered more often from asthma and psychiatric disorders. On average, they also had higher blood pressure, lower insulin sensitivity, and a reduced exercise capacity. It remains to be evaluated how much these risk factors contribute to cardiovascular or pulmonary morbidity and mortality later in life. At least, general mortality after preterm birth seems to be increased up to the oldest age group statistically evaluated up to now, i.e. 18 to 36 years.

Frank-ter Haar syndrome protein Tks4 regulates epidermal growth factor-dependent cell migration

Mutations in the SH3PXD2B gene coding for the Tks4 protein are responsible for the autosomal recessive Frank-ter Haar syndrome. Tks4, a substrate of Src tyrosine kinase, is implicated in the regulation of podosome formation. Here, we report a novel role for Tks4 in the EGF signaling pathway. In EGF-treated cells, Tks4 is tyrosine-phosphorylated and associated with the activated EGF receptor. This association is not direct but requires the presence of Src tyrosine kinase. In addition, treatment of cells with LY294002, an inhibitor of PI 3-kinase, or mutations of the PX domain reduces tyrosine phosphorylation and membrane translocation of Tks4. Furthermore, a PX domain mutant (R43W) Tks4 carrying a reported point mutation in a Frank-ter Haar syndrome patient showed aberrant intracellular expression and reduced phosphoinositide binding. Finally, silencing of Tks4 was shown to markedly inhibit HeLa cell migration in a Boyden chamber assay in response to EGF or serum. Our results therefore reveal a new function for Tks4 in the regulation of growth factor-dependent cell migration.

Developing and refining the Taiwan Birth Cohort Study (TBCS): five years of experience

The Taiwan Birth Cohort Study (TBCS) is the first nationwide birth cohort database in Asia designed to establish national norms of children's development. Several challenges during database development and data analysis were identified. Challenges include sampling methods, instrument development and statistical approach to missing data. The purpose of this paper is to describe the pilot study underpinning the TBCS, testing of the TBCS developmental instrument and the resolution of methodological challenges. Bayesian analysis fill in missing data, three-step regression analysis for the investigation of mediating and moderating effect, the use of structural equation modeling in a large scale investigation, investigating direct and indirect effects, confounding factors and reciprocal relationships in children's development, and used latent growth model in longitudinal observations are described. The TBCS will provide ongoing longitudinal information regarding the predisposing and maintaining factors affecting the long term outcome of pediatric illnesses.

Ictal electroencephalograms in neonatal seizures: characteristics and associations

The characteristics of ictal electroencephalograms in 160 neonatal seizures of 43 babies were correlated with mortality and neurodevelopmental outcomes. Neonatal seizures are focal at onset, most frequently temporal, and often occur during sleep. Twenty-one percent of babies with seizures died, and 76% of survivors manifested neurodevelopmental impairment during 2-6-year follow-up. A low-amplitude ictal electroencephalogram discharge was associated with increased mortality, and a frequency of <2 Hz with increased morbidity. Status epilepticus, ictal fractions, multiple foci, and bihemispheric involvement did not influence outcomes. Of 160 seizures, 99 exhibited no associated clinical features (electrographic seizures). Neonatal seizures with clinical correlates (electroclinical seizures) exhibited a higher amplitude and frequency of ictal electroencephalogram discharge than electrographic seizures. During electroclinical seizures, the ictal electroencephalogram was more likely to involve larger areas of the brain and to cross the midline. Mortality and morbidity were similar in babies with electroclinical and electrographic seizures, emphasizing the need to diagnose and treat both types. Ictal electroencephalogram topography has implications for electrode application during limited-channel, amplitude-integrated electroencephalograms. We recommend temporal and paracentral electrodes. Video electroencephalograms are important in diagnosing neonatal seizures and providing useful information regarding ictal electroencephalogram characteristics.

Reducing and eliminating restraint of people with developmental disabilities and severe behavior disorders: an overview of recent research

This paper provides a brief overview of the most recent research (1999-2009) on restraint reduction and elimination efforts in the literature and also examines the characteristics of restraint along with the risks and benefits. Some earlier papers were included in this review because of their importance to the topic. The results of this literature review are discussed in terms of implications for practitioners and researchers.

[Very premature births: Dilemmas and management. Part 1. Outcome of infants born before 28 weeks of postmenstrual age, and definition of a gray zone]

With very preterm deliveries, the decision to institute intensive care, or, alternatively, to start palliative care and let the baby die, is extremely difficult, and involves complex ethical issues. The introduction of intensive care may result in long-term survival of many infants without severe disabilities, but it may also result in the survival of severely disabled infants. Conversely, the decision to withhold resuscitation and/or intensive care at birth, which is an option at the margin of viability, implies allowing babies to die, although some of them would have developed normally if they had received resuscitation and/or intensive care. Withholding intensive care at birth does not mean withholding care but rather providing palliative care to prevent pain and suffering during the time period preceding death. The likelihood of survival without significant disabilities decreases as gestational age at birth decreases. In addition to gestational age, other factors greatly influence the prognosis. Indeed, for a given gestational age, higher birth weight, singleton birth, female sex, exposure to prenatal corticosteroids, and birth in a tertiary center are favorable factors. Considering gestational age, there is a gray zone that corresponds to major prognostic uncertainty and therefore to a major problem in making a "good" decision. In France today, the gray zone corresponds to deliveries at 24 and 25 weeks of postmenstrual age. In general, babies born above the gray zone (26 weeks of postmenstrual age and later) should receive resuscitation and/or full intensive care. Below 24 weeks, palliative care is the only option offered in France at the present time. Decisions within the gray zone will be addressed in the 2nd part of this work.

Neurological outcomes at 18 months of age after moderate hypothermia for perinatal hypoxic ischaemic encephalopathy: synthesis and meta-analysis of trial data

OBJECTIVE

To determine whether moderate hypothermia after hypoxic-ischaemic encephalopathy in neonates improves survival and neurological outcome at 18 months of age.

DESIGN

A meta-analysis was performed using a fixed effect model. Risk ratios, risk difference, and number needed to treat, plus 95% confidence intervals, were measured.

DATA SOURCES

Studies were identified from the Cochrane central register of controlled trials, the Oxford database of perinatal trials, PubMed, previous reviews, and abstracts. Review methods Reports that compared whole body cooling or selective head cooling with normal care in neonates with hypoxic-ischaemic encephalopathy and that included data on death or disability and on specific neurological outcomes of interest to patients and clinicians were selected. Results We found three trials, encompassing 767 infants, that included information on death and major neurodevelopmental disability after at least 18 months' follow-up. We also identified seven other trials with mortality information but no appropriate neurodevelopmental data. Therapeutic hypothermia significantly reduced the combined rate of death and severe disability in the three trials with 18 month outcomes (risk ratio 0.81, 95% confidence interval 0.71 to 0.93, P=0.002; risk difference -0.11, 95% CI -0.18 to -0.04), with a number needed to treat of nine (95% CI 5 to 25). Hypothermia increased survival with normal neurological function (risk ratio 1.53, 95% CI 1.22 to 1.93, P<0.001; risk difference 0.12, 95% CI 0.06 to 0.18), with a number needed to treat of eight (95% CI 5 to 17), and in survivors reduced the rates of severe disability (P=0.006), cerebral palsy (P=0.004), and mental and the psychomotor developmental index of less than 70 (P=0.01 and P=0.02, respectively). No significant interaction between severity of encephalopathy and treatment effect was detected. Mortality was significantly reduced when we assessed all 10 trials (1320 infants; relative risk 0.78, 95% CI 0.66 to 0.93, P=0.005; risk difference -0.07, 95% CI -0.12 to -0.02), with a number needed to treat of 14 (95% CI 8 to 47).

CONCLUSIONS

In infants with hypoxic-ischaemic encephalopathy, moderate hypothermia is associated with a consistent reduction in death and neurological impairment at 18 months.

Neurological outcomes at 18 months of age after moderate hypothermia for perinatal hypoxic ischaemic encephalopathy: synthesis and meta-analysis of trial data

OBJECTIVE

To determine whether moderate hypothermia after hypoxic-ischaemic encephalopathy in neonates improves survival and neurological outcome at 18 months of age.

DESIGN

A meta-analysis was performed using a fixed effect model. Risk ratios, risk difference, and number needed to treat, plus 95% confidence intervals, were measured.

DATA SOURCES

Studies were identified from the Cochrane central register of controlled trials, the Oxford database of perinatal trials, PubMed, previous reviews, and abstracts. Review methods Reports that compared whole body cooling or selective head cooling with normal care in neonates with hypoxic-ischaemic encephalopathy and that included data on death or disability and on specific neurological outcomes of interest to patients and clinicians were selected. Results We found three trials, encompassing 767 infants, that included information on death and major neurodevelopmental disability after at least 18 months' follow-up. We also identified seven other trials with mortality information but no appropriate neurodevelopmental data. Therapeutic hypothermia significantly reduced the combined rate of death and severe disability in the three trials with 18 month outcomes (risk ratio 0.81, 95% confidence interval 0.71 to 0.93, P=0.002; risk difference -0.11, 95% CI -0.18 to -0.04), with a number needed to treat of nine (95% CI 5 to 25). Hypothermia increased survival with normal neurological function (risk ratio 1.53, 95% CI 1.22 to 1.93, P<0.001; risk difference 0.12, 95% CI 0.06 to 0.18), with a number needed to treat of eight (95% CI 5 to 17), and in survivors reduced the rates of severe disability (P=0.006), cerebral palsy (P=0.004), and mental and the psychomotor developmental index of less than 70 (P=0.01 and P=0.02, respectively). No significant interaction between severity of encephalopathy and treatment effect was detected. Mortality was significantly reduced when we assessed all 10 trials (1320 infants; relative risk 0.78, 95% CI 0.66 to 0.93, P=0.005; risk difference -0.07, 95% CI -0.12 to -0.02), with a number needed to treat of 14 (95% CI 8 to 47).

CONCLUSIONS

In infants with hypoxic-ischaemic encephalopathy, moderate hypothermia is associated with a consistent reduction in death and neurological impairment at 18 months.

The effect of maternal child marriage on morbidity and mortality of children under 5 in India: cross sectional study of a nationally representative sample

OBJECTIVE

To assess associations between maternal child marriage (marriage before age 18) and morbidity and mortality of infants and children under 5 in India. Design Cross-sectional analyses of nationally representative household sample. Generalised estimating equation models constructed to assess associations. Adjusted models included maternal and child demographics and maternal body mass index as covariates. Setting India. Population Women aged 15-49 years (n=124 385); data collected in 2005-6 through National Family Health Survey-3. Data about child morbidity and mortality reported by participants. Analyses restricted to births in past five years reported by ever married women aged 15-24 years (n=19 302 births to 13 396 mothers).

MAIN OUTCOME MEASURES

In under 5s: mortality related infectious diseases in the past two weeks (acute respiratory infection, diarrhoea); malnutrition (stunting, wasting, underweight); infant (age <1 year) and child (1-5 years) mortality; low birth weight (<2500 kg). Results The majority of births (73%; 13 042/19 302) were to mothers married as minors. Although bivariate analyses showed significant associations between maternal child marriage and infant and child diarrhoea, malnutrition (stunted, wasted, underweight), low birth weight, and mortality, only stunting (adjusted odds ratio 1.22, 95% CI 1.12 to 1.33) and underweight (1.24, 1.14 to 1.36) remained significant in adjusted analyses. We noted no effect of maternal child marriage on health of boys versus girls. Conclusions The risk of malnutrition is higher in young children born to mothers married as minors than in those born to women married at a majority age. Further research should examine how early marriage affects food distribution and access for children in India.

Ethamsylate for the prevention of morbidity and mortality in preterm or very low birth weight infants

BACKGROUND

Ethamsylate decreases blood loss in certain clinical situations such as menorrhagia and following some surgical procedures. This potential to reduce bleeding has led to the hypothesis that it may have a role to play in reducing intraventricular haemorrhage in preterm infants.

OBJECTIVES

To determine if ethamsylate, when compared to placebo or no treatment, reduces morbidity and/or mortality in preterm infants.

SEARCH STRATEGY

We searched the Cochrane Neonatal Group Trials Register (24 August 2009), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2009, Issue 2), MEDLINE and EMBASE (January 1966 to July 2009) and the Oxford Database of Perinatal Trials.

SELECTION CRITERIA

Randomised controlled trials or quasi-randomised trials comparing ethamsylate with placebo or no treatment. The initial search for trials enrolling infants born less than 32 weeks gestation was subsequently expanded to include trials enrolling preterm infants < 35 weeks gestation or < 2000 grams birth weight. Studies were included if they reported on outcomes of all children until death or discharge home. Data from reports of neurodevelopmental follow-up were only included if at least 80% of participants were followed up.

DATA COLLECTION AND ANALYSIS

Both review authors independently assessed trial quality and extracted data. We calculated relative risk (RR) and risk difference (RD) together with 95% confidence intervals (CI) and used a fixed-effect model for meta-analysis.

MAIN RESULTS

Eight studies were identified but only seven trials enrolling 1410 preterm infants were located. There was no significant difference detected in neonatal mortality or neurodevelopmental outcome at two years between infants treated with ethamsylate and controls. Infants treated with ethamsylate had significantly less intraventricular haemorrhage than controls at < 31 weeks (typical RR 0.63, 95% CI 0.47 to 0.86) and < 35 weeks gestation (typical RR 0.77, 0.65 to 0.92). There was also a significant reduction in grade 3 and 4 intraventricular haemorrhage when all infants < 35 weeks gestation (typical RR 0.67, 95% CI 0.49 to 0.94) were analysed as a single group, but not for the group of infants < 32 weeks alone. There was a reduction in symptomatic patent ductus arteriosus at < 31 weeks gestation (typical RR 0.32, 95% CI 0.12 to 0.87). There were no adverse effects of ethamsylate identified from this systematic review.

AUTHORS' CONCLUSIONS

Preterm infants treated with ethamsylate showed no reductions in mortality or neurodevelopmental impairment despite the reduction in any grade of intraventricular haemorrhage seen in infants < 35 weeks gestation.

Impact of postnatal corticosteroid use on neurodevelopment at 18 to 22 months' adjusted age: effects of dose, timing, and risk of bronchopulmonary dysplasia in extremely low birth weight infants

OBJECTIVE

Postnatal steroid use decreases lung inflammation but increases impairment. We hypothesized that increased dose is associated with increased neurodevelopmental impairment, lower postmenstrual age at exposure increases impairment, and risk of bronchopulmonary dysplasia modifies the effect of postnatal corticosteroid.

METHODS

Steroid dose and timing of exposure beyond 7 days was assessed among 2358 extremely low birth weight infants nested in a prospective trial, with 1667 (84%) survivors examined at 18 to 22 months' postmenstrual age. Logistic regression tested the relationship between impairment (Bayley Mental Developmental Index/Psychomotor Developmental Index of <70, disabling cerebral palsy, or sensory impairment), total dose (tertiles: <0.9, 0.9-1.9, and >/=1.9 mg/kg), and postmenstrual age at first dose. Separate logistic regression tested effect modification according to bronchopulmonary dysplasia severity (Romagnoli risk > 0.5 as high risk, n = 2336 (99%) for days of life 4-7).

RESULTS

Three hundred sixty-six (16%) neonates were steroid-treated (94% dexamethasone). Treated neonates were smaller and less mature; 72% of those treated were at high risk for bronchopulmonary dysplasia. Exposure was associated with neurodevelopmental impairment/death. Impairment increased with higher dose; 71% dead or impaired at highest dose tertile. Each 1 mg/kg dose was associated with a 2.0-point reduction on the Mental Developmental Index and a 40% risk increase for disabling cerebral palsy. Older age did not mitigate the harm. Treatment after 33 weeks' postmenstrual age was associated with greatest harm despite not receiving the highest dose. The relationship between steroid exposure and impairment was modified by the bronchopulmonary dysplasia risk, with those at highest risk experiencing less harm.

CONCLUSIONS

Higher steroid dose was associated with increased neurodevelopmental impairment. There is no "safe" window for steroid use in extremely low birth weight infants. Neonates with low bronchopulmonary dysplasia risk should not be exposed. A randomized trial of steroid use in infants at highest risk is warranted.

Neurodevelopmental outcome at 2 years in 23 to 26 weeks old gestation infants

BACKGROUND

Assessment of neurologic and developmental outcome at 2 years age of infants with gestational age (GA)<27 weeks, born between 1996-2001.

PATIENTS

A total of 110 live-born preterm infants with GA<27 weeks.

METHODS

Main outcome criterions: Neurologic examination (according to Touwen) and classification of cerebral palsy by using the Gross Motor Function Classification System (GMFCS) at the corrected age of 1 and 2 years; assessment of mental and psychomotor development by using the Griffith Mental Development scales at the corrected age of 2 years; growth assessment at birth, 1 and 2 years.

RESULTS

Mortality was 52%. Regular follow up was performed in 48 (91%) of the 53 surviving infants. Neurologic outcome: at 1 year age: 2% nonambulant cerebral palsy, 25% mild neurologic signs and 73% normal; at 2 years age: 4% nonambulant cerebral palsy, 2% ambulant cerebral palsy, 4% mild neurologic signs and 90% normal neurology. Developmental outcome at 2 years age: 40% DQ>-1 SD, 6% DQ between -1 SD and -2 SD (mild delay), 35% DQ between -2 SD and -3 SD (moderate delay) and 19% DQ<-3 SD (severe delay). Overall disability was found in 64%, severe disability in 27% of the infants. Profound growth failure in weight and head circumference<3rd centile at 2 years age was recorded in 39 and 19% of the infants, respectively.

CONCLUSION

Developmental delay is very common in preterm infants<27 GA and exceeds the number of neurological disabilities (including cerebral palsy).

Morbidität und Mortalität extrem frühgeborener Kinder in Schleswig-Holstein

BACKGROUND

Regional, population-based outcome studies of extremely preterm infants may help to assess the quality of neonatal care across centres and explain variation.

PATIENTS AND METHODS

We included all extremely low gestational age infants (< 27 + 0 gestational age = ELGA) of six paediatric hospitals in Schleswig-Holstein born during 1997 to 1999. The surviving children were evaluated at the corrected age of three to six years with the developmental test ET 6-6. The end point major disability was determined as subnormal scores in the developmental test ET 6-6 (< 2 SD), or any of the following diagnoses: cerebral palsy, blindness, deafness, epilepsy and/or hydrocephalus requiring a shunt system.

RESULTS

130 infants with gestational age (GA) < 27 + 0 weeks were identified. 85 survived until discharge and 82 survived until follow-up. 63 children (77% of all possible cases) participated in the developmental test. Neonatal survival increased with gestational age: 0/1 GA = 22 weeks, 3/10 GA = 23 weeks, 12/25 GA 24 = weeks, 28/43 GA = 25 weeks, 42/51 GA = 26 weeks. At follow-up 24 children had a major disability, among those were 14 children with multiple major disabilities. There was no significant correlation between major disability and gestational age.

CONCLUSIONS

In a regional neonatal care system only infants of 25 to 26 weeks gestation but not those of lower GA show good survival rates. Major disability of extremely preterm infants seems to be independent of gestational age.

Causes of death in remote symptomatic epilepsy

OBJECTIVE

To determine the causes of death of individuals with developmental disabilities that occur more frequently among those with remote symptomatic epilepsy (i.e., epilepsy occurring in persons with developmental delay or identified brain lesions) than for those without.

METHODS

The authors compared causes of mortality in persons with (n = 10,030) and without (n = 96,163) history of epilepsy in a California population of persons with mild developmental disabilities, 1988 to 2002. Subjects had traumatic brain injury, cerebral palsy, Down syndrome, autism, or a developmental disability with other or unknown etiology. There were 721,759 person-years of data, with 2,397 deaths. Underlying causes of death were determined from the State of California's official mortality records. Cause-specific death rates and standardized mortality ratios (SMRs) were computed for those with and without epilepsy relative to subjects in the California general population. Comparisons were then made between SMRs of those with and without epilepsy, and CIs on the ratios of SMRs were determined.

RESULTS

Death rates for persons with epilepsy were elevated for several causes. The greatest excess was due to seizures (International Classification of Diseases-9 [ICD-9] 345; SMR 53.1, 95% CI 28.0 to 101.0) and convulsions (ICD-9 780.3; SMR 25.2, 95% CI 11.7 to 54.2). Other causes occurring more frequently in those with epilepsy included brain cancer (SMR 5.2, 95% CI 2.2 to 12.1), respiratory diseases (SMR 1.7, 95% CI 1.2 to 2.5), circulatory diseases (SMR 1.3, 95% CI 1.0 to 1.7), and accidents (SMR 2.7, 95% CI 1.9 to 3.7), especially accidental drowning (SMR 12.8, 95% CI 7.0 to 23.2).

CONCLUSIONS

Remote symptomatic epilepsy is associated with an increased risk of death. Seizures, aspiration pneumonia, and accidental drowning are among the leading contributors.

Fetal stroke

Fetal stroke, or that which occurs between 14 weeks of gestation and the onset of labor resulting in delivery, has been associated with postnatal epilepsy, mental retardation, and cerebral palsy. The entity is caused by antenatal ischemic, thrombotic, or hemorrhagic injury. We present seven new cases of fetal stroke diagnosed in utero and review the 47 cases reported in the literature. Although risk factors could not be assigned to 50% of the fetuses with stroke, the most common maternal conditions associated with fetal stroke were alloimmune thrombocytopenia and trauma. Magnetic resonance imaging was optimal for identifying fetal stroke, and prenatal imaging revealed hemorrhagic lesions in over 90% of studies; porencephalies were identified in just 13%. Seventy-eight percent of cases with reported outcome resulted in either death or adverse neurodevelopmental outcome at ages 3 months to 6 years. Fetal stroke appears to have different risk factors, clinical characteristics, and outcomes than other perinatal or childhood stroke syndromes. A better understanding of those risk factors predisposing a fetus to cerebral infarction may provide a basis for future therapeutic intervention trials. Ozduman K, Pober BR, Barnes P, Copel JA, Ogle EA, Duncan CC, Ment LR. Fetal stroke.

Excess mortality in remote symptomatic epilepsy

BACKGROUND

Published estimates of excess mortality associated with epilepsy vary greatly. How much, if any, of the excess is attributable to the seizures themselves as opposed to an underlying condition causing the epilepsy is not clear from the literature. This article offers evidence that epilepsy per se is associated with excess mortality. The excess varies according to severity and frequency of seizures.

MATERIALS AND METHODS

The authors studied mortality rates of developmentally disabled persons in California with and without epilepsy. In order to focus on the effect on mortality risk of epilepsy per se, they included only persons with good motor function (able to walk and climb stairs) and at worst moderate mental retardation (MR). The data were 506,204 person-years and 1523 deaths among 80,682 California subjects of age 5 to 65 years during the 1988-1999 study period. Mortality rates for persons with epilepsy were compared to rates for persons with no history of epilepsy.

RESULTS

Mortality rates were higher for persons with epilepsy than for those without. Excess death rates (EDRs) varied according to type and frequency of seizures. Combined EDRs were 6 (deaths per 1000 person-years) for persons with recent (< 12 months) history of status epilepticus, 5 for recent history of generalized tonic-clonic (GTC) seizures, 3 for recent history of seizures but no recent GTC seizures, and less than 1 for a history of seizures but no recent events.

CONCLUSIONS

The data presented here are evidence that epilepsy per se is associated with increased mortality. The EDRs reported here may be better measures of excess mortality due to epilepsy than previously published estimates.

Increased mortality in children and adolescents with developmental disabilities

A population-based cohort of 10-year-old children with mental retardation, cerebral palsy, epilepsy, hearing impairment or vision impairment, who were ascertained at 10 years of age in a previous study conducted in metro Atlanta during 1985-87, was followed up for mortality and cause of death information. We used the National Death Index to identify all deaths among cohort members during the follow-up period (1985-95). We estimated expected numbers of deaths on the basis of actual age-, race- and sex-specific death rates for the entire Georgia population for 1989-91. The objective was to quantify the magnitude of increased mortality and evaluate the contribution of specific disabilities to mortality among children and adolescents with one or more of five developmental disabilities. A total of 30 deaths were observed; 10.1 deaths were expected, yielding an observed-to-expected mortality ratio of almost three to one. The numbers of observed deaths exceeded those of expected deaths, regardless of the number of disabilities present, but the ratios were statistically significant (at the 95% confidence level) only in children with three or more co-existing disabilities. In general, the magnitude of the mortality ratios was directly related to various measures of the severity of the person's disability. An exception to this pattern was the elevated mortality from cardiovascular disease among cohort members with isolated mental retardation (three observed deaths vs. 0.2 expected). The specific underlying causes of death among other deceased cohort members included some that were the putative cause of the developmental disability (e.g. a genetic syndrome) and others that could be considered intercurrent diseases or secondary health conditions (e.g. asthma). Prevention efforts to decrease mortality in adolescents and young adults with developmental disabilities may need to address serious conditions that are secondary to the underlying disability (i.e. infections, asthma, seizures) rather than towards injuries, accidents and poisonings, the primary causes of death for persons in this age group in the general population.

Serial assessment of mortality in the neonatal intensive care unit by algorithm and intuition: certainty, uncertainty, and informed consent

OBJECTIVES

Does predictive power for outcomes of neonatal intensive care unit (NICU) patients get better with time? Or does it get worse? We determined the predictive power of Score for Neonatal Acute Physiology (SNAP) scores and clinical intuitions as a function of day of life (DOL) for newborn infants admitted to our NICU.

METHODS

We identified 369 infants admitted to our NICU during 1996-1997 who required mechanical ventilation. We calculated SNAP scores on DOL 1, 3, 4, 5, 7, 10, 14, 21, 28, and weekly thereafter until either death or extubation. We also asked nurses, residents, fellows, and attendings on each day of mechanical ventilation: "Do you think this child is going to live to go home to their family, or die before hospital discharge?"

RESULTS

Two thousand twenty-eight SNAP scores were calculated for 285 infants. On DOL 1, SNAP for nonsurvivors (24 +/- 8.7 [standard deviation]) was significantly higher than SNAP for survivors (13 +/- 6.1). However, this difference diminished steadily and by DOL 10 was no longer statistically significant (12.7 +/- 4.9 vs 10.0 +/- 4.8). On each NICU day, at all ranges of SNAP scores, there were at least as many infants who would ultimately survive as would die. Consequently, the positive predictive value of any SNAP value for subsequent mortality was <0.5 on all NICU days. Prediction profiles were obtained for 230 ventilated infants reflecting over 11 000 intuitions obtained on 2867 patient days. One hundred fifty-seven (81%) of 192 survivor profiles displayed consistent accurate prediction profiles-at least 90% of their NICU ventilation days were characterized by 100% prediction of survival. Twenty-five (13%) of 192 surviving infants survived somewhat unexpectedly; that is, after at least 1 day characterized by at least 1 estimate of "death." Thirty-three (60%) of the 55 nonsurvivors died before DOL 10. Eighty-two percent of the prediction profiles for these early dying infants were homogeneous, dismal, and accurate. Twenty-two (40%) of the 55 nonsurvivors died after DOL 10. Seventeen (78%) of these 22 late-dying infants were predicted to live by many observers on many hospital days. Sixty-one (30%) of 230 profiled patients had at least 1 NICU day characterized by at least 1 prediction of death; 26/61 (43%) of these patients were incorrectly predicted; that is, they survived. Seventeen infants who were predicted to die during but survived nonetheless were assessed neurologically at 1 year. Fourteen (82%) of these 17 were not neurologically normal-8 were clearly abnormal, 1 suspicious, and 5 had died.

CONCLUSIONS

If absolute certainty about mortality is the only criterion that can justify a decision to withhold or withdraw life-sustaining treatment in the NICU, these data would make such decisions difficult on the first day of life, and increasingly problematic thereafter. However, if we acknowledge that medicine is inevitably an inexact science and that clinical predictions can never be perfect, we can ask the more interesting question of whether good but less-than-perfect predictions of imprecise but ethically relevant clinical outcomes can still be useful. We think that they can-and that they must.

Long-term outcomes of childhood meningitis

Meningitis and meningococcal disease remain a major source of anxiety to paediatricians and parents alike. Survival rates have improved with rapid diagnosis and appropriate management. However, survivors remain at risk of long-term neurodevelopmental sequelae.

Developmental outcomes of newborn encephalopathy in the term infant

Newborn encephalopathy is a clinically defined condition of abnormal neurological behaviours in the newborn period. Though most cases have their origin in the preconceptional and antepartum period, newborn encephalopathy represents a crucial link between intrapartum events and permanent neurological problems in the child. The birth prevalence of newborn encephalopathy ranges from 1.8 to 7.7 per 1000 term live births according to the definition used and the population to which it is applied. Few studies have investigated the outcomes of newborn encephalopathy other than for cases solely attributed to intrapartum hypoxia. These adverse outcomes range from death to cerebral palsy, intellectual disability, and less severe neurological disabilities such as learning and behavioural problems. Outcomes following newborn encephalopathy may vary from country to country with 9.1% of affected babies dying in the newborn period in Western Australia and 10.1% manifesting cerebral palsy by the age of two. These compare to a case fatality of 30.5% in Kathmandu and a cerebral palsy rate of 14.5% by one year of age. The study by Robertson et al which followed children with hypoxic ischaemic encephalopathy found an incidence of impairment of 16% among survivors assessed at 8 years with 42% requiring school resource room help or special classes. This review emphasises the great need for comprehensive clinical and educational assessment as these infants approach school entry to enable appropriate educational provisions to be made.

Outcome in prenatally diagnosed fetal agenesis of the corpus callosum

This study of the outcome and prognostic factors in prenatally diagnosed agenesis of the corpus callosum (ACC) was undertaken to see if there are any differences between subgroups, what relationship they have to neurodevelopmental outcome and whether this information aids the counselling of parents of fetuses with the condition. The outcome of 14 prenatally diagnosed fetuses with ACC and 61 postnatally diagnosed patients was assessed in terms of clinical problems, developmental milestones and neurological signs; each patient was then given a score out of 10, 0 being a normal outcome and 10 being the worst outcome, i.e. death or termination of pregnancy. Comparing patients diagnosed pre- and postnatally, several similarities were found indicating that the postnatal group can provide useful information about the prenatal group. There was a higher incidence of ACC in males than females. In the prenatally diagnosed patients complete ACC was more common than partial ACC, although this might be because partial ACC was easily missed. Complete ACC has a worse prognosis than partial ACC (p = 0.001), and when associated with other anomalies, especially of the central nervous system, the outcome is very bad (p < 0.01). The only neurodevelopmentally normal patients were in the isolated partial ACC group. This study highlights the need to perform a detailed review of fetal anatomy and the desirability of determining the karyotype of the fetus in all newly diagnosed cases of ACC so that as much information as possible is available before parents are counselled about the likely outcome.

Effect of micronutrient supplementation on linear growth of children

This review summarizes the results of published, randomized clinical trials that have examined the impact of administration of micronutrients, singly or in combination to infants, preschool and school children on linear growth. Supplementation of single micronutrients resulted in small or no benefits on linear growth. A meta-analysis of zinc supplementation trials confirmed that zinc has a significant but small impact (0.22 sd units) on length gain in children 0-13 years of age. However, a recent study reported a substantially greater benefit (>1 sd) in stunted and non-stunted breast-fed infants 6-12 months of age. With iron supplementation, a beneficial effect was found only in anemic children. Vitamin A supplementation trials have reported little or no benefit on linear growth. Data currently available suggest some impact in children with clinical or biochemical vitamin A deficiency, but this issue needs confirmation. Few studies could be identified where a combination of micronutrients was given as a supplement or as fortified food; in the latter set of studies energy availability was assured. The impact on length without multiple micronutrient supplementation was no greater than that observed with single micronutrients. In conclusion, zinc and iron seem to have a modest effect on linear growth in deficient populations. Vitamin A is unlikely to have an important effect on linear growth. Limited available evidence does not allow us to conclude whether a combination of micronutrients, with or without additional food, would have a greater impact than that seen with zinc alone.

[Outcome of 249 premature infants, less than 29 weeks gestational age]

The aim of this paper was to report the vital and neurological outcome of 249 preterm infants of less than 29 weeks born between 1990 and 1996, and included in a prospective study until two years of age.

RESULTS

The initial mortality rate was 19%. This was related to gestational age and severe transfontanellar ultrasonographically (TFU) detected abnormalities. The rate of follow-up at two years of age was 98%. Neurological sequelae amounted to 12.8%, including four cases of deafness. The possibility of survival without neurological sequelae increased from 52% at 24-25 weeks to 72% at 26-28 weeks of gestational age (p < 0.005). The presence of sequelae was significantly related to severe cranial ultrasonographically-detected abnormalities, to parental social level, and to early neonatal anemia. Normal TFU and/or isolated periventricular hyperechogenicity could not exclude the presence of neurological sequelae which, however, appeared to be less severe than at the onset.

CONCLUSION

Gestational age, severe TFU abnormalities and neonatal anemia play a major role in the rate of mortality and in the neurological sequelae in preterm infants, and can influence the decisions concerning the treatment of this pediatric population.

Aging in individuals with lifelong disabilities

The major research data and findings related to aging among persons with developmental disabilities are discussed. Differences between the aging processes noted in the general population and individuals who have developmental disabilities are highlighted. Topics addressed include prevalence of developmental disabilities and mortality rates for individuals with developmental disabilities. The effects of aging on the senses, the neuromusculoskeletal system, and the cardiopulmonary system are presented along with the clinical implications of these changes in individuals with developmental disabilities who are aging.

Mortality of persons with developmental disabilities after transfer into community care: a 1996 update

More than 2,000 persons with developmental disabilities have recently been transferred from California institutions into community care. Using data on 1,878 clients moved between April 1993 and December 1995, Strauss et al. (1998) found a corresponding increase in mortality rates. In the present report we update that study by analyzing 1996 data. There were 36 deaths, an 88% increase in risk-adjusted mortality over that expected in institutions, p < .01. We again found that persons transferred later were at higher risk than those moving earlier, even after adjustment for differences in risk profiles. In the highest functioning group, the community mortality rate was tripled. Death certificate information was also analyzed.

Outcome of very preterm birth: children reviewed with ease at 2 years differ from those followed up with difficulty

AIM

To determine whether those most easily reviewed in a population prevalence study differ from those followed up only with difficulty.

METHODS

All babies born before 32 weeks of gestation in the North of England in 1983, 1990, and 1991 were traced, and all the survivors assessed at two years by one of two independent clinicians.

RESULTS

818 of the 1138 live born babies survived to discharge. There was some non-significant, excess disability in the 5% of long term survivors who were difficult to trace because of social mobility, but eight times as much severe disability in the 1% (9/796) in care and in the 5% (38/796) whose parents initially failed to keep a series of home or hospital appointments for interview, and five times as much emergent disability in the 2.7% (22/818) who died after discharge but before their second birthday. Had the babies who were seen without difficulty been considered representative of all the babies surviving to discharge, the reported disability rate would have been two thirds what it really was (6.9% instead of 11.0%).

CONCLUSIONS

Population prevalence studies that ignore those who seem reluctant to cooperate risk serious ascertainment bias.

An extended Kaplan-Meier estimator and its applications

We develop an extension of the Kaplan-Meier estimator for the case of multiple live states. The method can be used to construct prognostic charts for tracking individuals initially in a given condition. It is also the key component in constructing a longitudinal version of the multistate life table.

External causes of death among persons with developmental disability: the effect of residential placement

The authors analyzed death rates from external causes (accidents, injuries, homicides, etc.) for persons with developmental disability in California. There were 520 such deaths during the 1981-1995 study period, based on 733,705 person-years of exposure; this represents all persons who received any services from the state. Compared with the general California population, persons with developmental disability were at lower risk of homicide, suicide, and poisonings (standardized mortality ratios, 0.31-0.68), but higher risk of pedestrian accidents, falls, fires, and, especially, drowning (standardized mortality ratio=6.22). A major focus of the study was comparisons between different residential settings. Persons in semi-independent living had significantly higher risk than did those in their family home or group homes, with homicides rates being three times higher and pedestrian accidents rates being doubled, while persons in institutions had much lower risks with respect to most causes. Of the 28 deaths due to drug and medication overdoses, 79 percent occurred in supported living or small-group homes. Avoidable deaths could be reduced by making direct care staff more aware of the risks and better trained in acute care, along with improved monitoring of special incidents.

Adverse outcome after multiple pregnancy

There is increasing interest in the outcomes of multiple pregnancies as their numbers rise, mainly owing to advances in fertility-enhancing techniques. In addition, the numbers of multiple births surviving the perinatal period is increasing with the increasing survival of very tiny babies. In order to investigate these outcomes or to evaluate procedures that may improve them, it is important to consider a number of methodological issues that affect the comparability of data both between and within populations. How a birth and a multiple birth are defined, data sources, whether multiple pregnancies or individual births are being counted and the identification of multiple gestations by zygosity and chorionicity will all affect the reported outcome rates. In light of this, perinatal mortality and neurodevelopmental disabilities are examined as adverse outcomes of multiple pregnancies.

Prognosis for survival and improvement in function in children with severe developmental disabilities

OBJECTIVE

To derive prognostic data for survival and clinical improvement in children with severe developmental disabilities.

STUDY DESIGN

A 13-year follow-up study of several cohorts of children initially evaluated before their first birthday. The outcomes studied were survival and improvement in condition. Methods were used to overcome limitations in previously published work on the same California data base. Of the 11,912 children who received services from the California Department of Developmental Services between January 1980 and December 1993, we focused on three cohorts defined according to mobility and need for tube feeding.

RESULTS

Children who were tube fed and unable to lift their heads by ages 3 to 12 months were at high risk for early death, with a median remaining life expectancy of 3.2 years. Of those who survived an additional 2 years, the condition of about one third improved. A substantial majority of those who either showed improvement or died had done so by that age.

CONCLUSION

By age 5 years, the prognoses for survival and improvement have to a large extent been clarified. For children who survive to age 5 years, even those in the lowest functioning cohort have a 60% chance of surviving an additional 5 years. Detailing the probabilities of various outcomes at various ages should be useful to parents, pediatricians, and others concerned with children with developmental disabilities.

[Neonatal, neurologic and psychosocial findings in higher order multiple births. Follow-up for 3 to 10 years]

We examined the outcome of 9 triplet, 3 quadruplet, 1 quintuplet and 1 sixtuplet pregnancies delivered between 1979-1989 at the perinatal center of the RWTH Aachen. The course of pregnancy and neonatal period were retrospectively analysed. The follow-up program covered at least 3, up to a maximum of 10 years. 12 families could be interviewed concerning psychosocial effects. The neonatal mortality was 4%. Neonatal morbidity; hyaline membrane disease (n = 18), intraventricular hemorrhage (n = 9), pneumothorax (n = 7), patent ductus arteriosus (n = 7), bronchopulmonary dysplasia (n = 8). At the age of 2 years 63% of the children were considered to be normal on developmental assessment, 17% showed mild, 20% severe developmental delay. With 3 to 10 years 83% were normal, 17% severely handicapped. In total 20% of the children died or showed severe handicap. Higher order multiple pregnancies make great demands on the perinatal medicine and lead in spite of an improved prognosis to a remaining burden for the children and their parents.

Tubefeeding and mortality in children with severe disabilities and mental retardation

OBJECTIVE

To study the contribution of tubefeeding to mortality for children with severe disabilities and mental retardation. Previous research has suggested an association between tubefeeding and mortality. However, risk has never been determined using population-based data or defined in regard to patient variables.

METHODS

Retrospective analysis of a comprehensive statewide data set comprised of 4921 children with severe disabilities and mental retardation living in community and congregate care settings. The outcome measure was mortality; primary study variables included the presence of a feeding tube, measures of functional independence, type of residence, and medical comorbidity.

RESULTS

There were four findings. First, the use of a feeding tube was associated with virtually every disability. Second, when no study variables were controlled, statistically significant differences in mortality rates were noted between children who were tubefed and those who were not. The relative risk of mortality associated with use of a feeding tube was 2.1. Third, the use of a feeding tube was associated with a reduction in relative risk of mortality in children with tracheostomy (relative risk of mortality: .55). However, this association did not achieve statistical significance. Fourth, when study variables were controlled in a multivariate analysis, feeding tube use was associated with no identifiable increase in mortality among children with very severe disabilities, but was associated with an approximated doubled mortality rate among those with less severe disabilities.

CONCLUSIONS

We hypothesize that the increased mortality associated with tubefeeding may be attributable to a differential increase in pulmonary disease secondary to overly vigorous nutritional maintenance and subsequent aspiration after tube placement. For children with tracheostomy this risk may be reduced. If tracheostomy proves to be associated with a relatively more favorable outcome for tubefeeding, we hypothesize that it would reflect the benefits of tracheostomy in allowing access to the airway for suctioning and ventilation. Given the observed higher mortality rates among the less severely disabled children who are tubefed and the substantial costs associated with tubefeeding, a prospective, controlled study may be clinically indicated, ethically justifiable, and economically warranted.

Developmental and behavioral issues in childhood injury prevention

Injuries are the most important cause of mortality, morbidity, and disability during childhood and adolescence. Injuries with the greatest impact on the behavioral and emotional development of the child are head injuries and severe burns, both of which can markedly impact on subsequent development. Important risk factors for injury are gender, age, socioeconomic status, developmental status, behavior problems, substance abuse by parent and adolescent, and parents' perceptions of injury risk. These factors interact to increase or decrease the risk of injury in any given child and are much more meaningful than the futile search for the "accident-prone" individual. These factors must be taken into consideration when planning intervention strategies to ensure optimal effectiveness of intervention.