Blood pressure nomograms for children and adolescents, by height, sex, and age, in the United States

Australasian randomised trial to evaluate the role of maternal intramuscular dexamethasone versus betamethasone prior to preterm birth to increase survival free of childhood neurosensory disability (A*STEROID): study protocol

BACKGROUND

Both dexamethasone and betamethasone, given to women at risk of preterm birth, substantially improve short-term neonatal health, increase the chance of the baby being discharged home alive, and reduce childhood neurosensory disability, remaining safe into adulthood. However, it is unclear which corticosteroid is of greater benefit to mother and child.This study aims to determine whether giving dexamethasone to women at risk of preterm birth at less than 34 weeks' gestation increases the chance of their children surviving free of neurosensory disability at two years' corrected age, compared with betamethasone.

METHODS/DESIGN

Design randomised, multicentre, placebo controlled trial.Inclusion criteria women at risk of preterm birth at less than 34 weeks' gestation with a singleton or twin pregnancy and no contraindications to the use of antenatal corticosteroids and who give informed consent.Trial entry & randomisation at telephone randomisation eligible women will be randomly allocated to either the dexamethasone group or the betamethasone group, allocated a study number and corresponding treatment pack.Study groups women in the dexamethasone group will be administered two syringes of 12 mg dexamethasone (dexamethasone sodium phosphate) and women in the betamethasone group will be administered two syringes of 11.4 mg betamethasone (Celestone Chronodose). Both study groups consist of intramuscular treatments 24 hours apart.Primary study outcome death or any neurosensory disability measured in children at two years' corrected age.Sample size a sample size of 1449 children is required to detect either a decrease in death or any neurosensory disability from 27.0% to 20.1% with dexamethasone compared with betamethasone, or an increase from 27.0% to 34.5% (two-sided alpha 0.05, 80% power, 5% loss to follow up, design effect 1.2).

DISCUSSION

This study will provide high-level evidence of direct relevance for clinical practice. If one drug clearly results in significantly fewer deaths and fewer disabled children then it should be used consistently in women at risk of preterm birth and would be of great importance to women at risk of preterm birth, their children, health services and communities.

TRIAL REGISTRATION

TRIAL REGISTRATION NUMBER

ACTRN12608000631303.

The relation of serum nesfatin-1 level with metabolic and clinical parameters in obese and healthy children

BACKGROUND

Nesfatin-1, a recently discovered anorexigenic neuropeptide, is expressed in several tissues including pancreatic islet cells and central nervous system. This peptide seems to play an important role in hypothalamic pathways regulating food intake and energy homeostasis.

OBJECTIVE

We aimed to investigate the relation of serum nesfatin-1 level with metabolic and anthropometric parameters in obese children.

METHODS

The study included obese children with a body mass index (BMI) above the 95th percentile and healthy children with a BMI below the 85th percentile. The healthy and obese subjects had similar age and gender distribution. Fasting serum glucose, insulin, lipid profile, and nesfatin-1 levels were measured to evaluate metabolic parameters.

RESULTS

Obese group (n = 37) had significantly higher BMI, BMI-SDS (standard deviation score of BMI), triglyceride, insulin, and insulin resistance index by the homeostasis model assessment, systolic and diastolic blood pressure values compared with the control group (n = 31) (p < 0.05). Serum nesfatin-1 level of the obese subjects was significantly lower than that of the control subjects (p = 0.001). No statistically significant difference was found when nesfatin-1 levels were compared among obese patients regarding the presence of insulin resistance (p = 0.202). In the obese group, nesfatin-1 level was negatively correlated with BMI-SDS, but not with insulin resistance index (p = 0.02 and p = 0.361, respectively).

CONCLUSIONS

This is the first study to evaluate nesfatin-1 levels in relation with anthropometric and metabolic parameters in obese patients who had significantly lower nesfatin-1 levels. Our results underline that nesfatin-1 may play an important role in regulation of food intake in obese individuals.

Magnesium sulphate at 30 to 34 weeks' gestational age: neuroprotection trial (MAGENTA)--study protocol

Background

Magnesium sulphate is currently recommended for neuroprotection of preterm infants for women at risk of preterm birth at less than 30 weeks’ gestation, based on high quality evidence of benefit. However there remains uncertainty as to whether these benefits apply at higher gestational ages.

The aim of this randomised controlled trial is to assess whether giving magnesium sulphate compared with placebo to women immediately prior to preterm birth between 30 and 34 weeks’ gestation reduces the risk of death or cerebral palsy in their children at two years’ corrected age.

Methods/design

Design: Randomised, multicentre, placebo controlled trial.

Inclusion criteria: Women, giving informed consent, at risk of preterm birth between 30 to 34 weeks’ gestation, where birth is planned or definitely expected within 24 hours, with a singleton or twin pregnancy and no contraindications to the use of magnesium sulphate.

Trial entry & randomisation: Eligible women will be randomly allocated to receive either magnesium sulphate or placebo.

Treatment groups: Women in the magnesium sulphate group will be administered 50 ml of a 100 ml infusion bag containing 8 g magnesium sulphate heptahydrate [16 mmol magnesium ions]. Women in the placebo group will be administered 50 ml of a 100 ml infusion bag containing isotonic sodium chloride solution (0.9%). Both treatments will be administered through a dedicated IV infusion line over 30 minutes.

Primary study outcome: Death or cerebral palsy measured in children at two years’ corrected age.

Sample size: 1676 children are required to detect a decrease in the combined outcome of death or cerebral palsy, from 9.6% with placebo to 5.4% with magnesium sulphate (two-sided alpha 0.05, 80% power, 5% loss to follow up, design effect 1.2).

Discussion

Given the magnitude of the protective effect in the systematic review, the ongoing uncertainty about benefits at later gestational ages, the serious health and cost consequences of cerebral palsy for the child, family and society, a trial of magnesium sulphate for women at risk of preterm birth between 30 to 34 weeks’ gestation is both important and relevant for clinical practice globally.

Trial registration

Australian New Zealand Clinical Trials Registry - ACTRN12611000491965

Predicting metabolic syndrome in obese children and adolescents: look, measure and ask

OBJECTIVE

To verify in obese children whether or not the presence of (i) high waist-to-height ratio (WHtR), (ii) family history for type 2 diabetes (T2D) and (iii) acanthosis nigricans (AN), singularly or together, might predict the occurrence of metabolic syndrome or prediabetes.

METHODS

1,080 Italian obese children (567 females) were enrolled. Blood pressure, fasting plasma glucose, insulin, and lipids were measured, and oral glucose tolerance test (OGTT) was performed. The WHtR was calculated, family history for T2D was assessed, and the presence of AN was noticed. The odds ratios for showing metabolic syndrome and/or prediabetes according to the presence of these features were calculated.

RESULTS

The prevalence of metabolic syndrome was 29.2%. AN (OR1.81; p = 0.002) and WHtR higher than 0.60 (OR 2.24; p < 0.0001) were the clinical signs linked to higher risk for showing metabolic syndrome, and the odds raised significantly when these elements occurred simultaneously (OR 3.34; p < 0.0001). T2D family history (OR 2.36; p = 0.01) and WHtR higher than 0.60 (OR 2.32; p = 0.009) were the two features associated with increased odds of showing prediabetes.

CONCLUSIONS

Three simple actions, i.e., looking at the patient, asking about T2D family history, and measuring WHtR, may represent a powerful tool in the hands of pediatricians to identify obese children with high cardiovascular and metabolic risk.

Rapid cardiovascular effects of growth hormone treatment in short prepubertal children: impact of treatment duration

OBJECTIVE

Previous studies show that growth hormone (GH) treatment increases cardiac dimensions in short children with GH deficiency (GHD) and has diverse cardiac effects in children with idiopathic short stature (ISS). This study was performed to assess the effect of GH on the cardiovascular system in short children with a broad range of GH secretion and GH sensitivity/responsiveness.

DESIGN AND PATIENTS

In this prospective, multicentre study, short prepubertal children diagnosed with isolated GHD (89) or ISS (38) were followed during 2 years of GH treatment. They were randomized to receive either a standard (43 μg/kg/day) or an individualized GH dose (range 17-100 μg/kg/day) based on GH responsiveness estimated by a prediction model and distance to target height. Echocardiography, blood pressure and electrocardiography were performed at baseline, 3, 12 and 24 months.

RESULTS

Left ventricular mass (LVM) indexed to body surface area increased significantly during 2 years of GH treatment in both GHD and ISS irrespective of randomized dose. This change was already apparent at 3 months, when standard deviation scores (SDS) of wall thickness and diameter were increased. At 24 months, left ventricular diameter SDS remained increased, whereas myocardial thickness SDS returned to baseline values. There was no impairment of systolic or diastolic function. There was no correlation with treatment dose and LVM SDS at 24 months.

CONCLUSIONS

Irrespective of GH status, there was a rapid increase in LVM during GH treatment in short children. At 3 months, wall thickness and diameter were increased, whereas only diameter remained increased at 24 months.

Serum sphingolipids and inflammatory mediators in adolescents at risk for metabolic syndrome

The purpose of this study was to determine low-grade inflammation associated with obesity that is mediated partially by TNF-α, an adipocytokine which stimulates sphingomyelinase activity in adipocytes. Circulating ceramide (Cer) and sphingosine 1-phosphate (S1P) are elevated in genetically obese (ob/ob) mice. We aimed to determine whether serum sphingolipid concentrations correlate with measures of obesity, insulin resistance, and lipid profiles in overweight versus lean adolescents. This cross-sectional study recruited 30 healthy overweight (body mass index, BMI ≥ 85%) and 15 lean (BMI 10-84%) adolescents. Anthropometric measurements and fasting blood samples were collected at one clinic visit. Serum glucose, insulin, and fasting lipid profiles were measured. Serum adipocytokine concentrations were measured by ELISA or colorimetric assay and sphingolipids were measured by HPLC-mass spectrometry. Between group differences in serum sphingolipid concentrations were assessed. Correlations between sphingolipid concentrations and (i) body mass index, (ii) calculated homeostasis model assessment of insulin resistance (HOMA-IR), (iii) adipocytokines, and (iv) lipoproteins were determined. The results showed that significant differences in HOMA-IR (4.5 ± 3.2 vs. 1.2 ± 0.7), free fatty acids (0.8 ± 0.3 mmol/l vs. 0.4 ± 0.3 mmol/l), and adiponectin (6.4 ± 3.8 vs. 12.6 ± 9.9 μg/ml) were seen between groups (overweight vs. lean). There were significant correlations between Cer and TNF-α (r = 0.429), S1P and TNF-α (r = 0.288), Cer and adiponectin (r = 0.321), Cer:S1P and adiponectin (r = 0.324), Cer and HOMA-IR (r = 0.307), and Cer:S1P and LDL cholesterol (r = 0.453); these associations persisted after adjustment for BMI Z-score, sex, and Tanner stage. We concluded that elevated sphingolipid concentrations correlate with TNF-α, adiponectin, lipoprotein profiles, and HOMA-IR. Ceramide is associated with atherogenic lipid profiles and the development of insulin resistance in obese adolescents, similar to adults.

Monitoring of blood pressure among children and adolescents in a coastal province in China: results of a 2010 survey

BACKGROUND

Several studies have provided ample evidence that hypertension in adults has its onset in childhood; children and adolescents with elevated blood pressure (BP) are more likely to become hypertensive adults. The present study examined the prevalence of relatively high BP among children and adolescents in Shandong, China.

SUBJECTS AND METHODS

Data for this study were obtained from a large cross-sectional survey of schoolchildren carried out in 2010. A total of 38 860 students (19 481 boys and 19 379 girls) aged 7 to 17 years participated in this study. Relatively high BP status was defined as systolic blood pressure and/or diastolic blood pressure ≥95th percentile for age and gender.

RESULTS

Shandong children had a high BP level, with the 50th percentiles of systolic and diastolic blood pressure of children and adolescents aged 7 to 17 years in Shandong being above the reference values for Chinese children and adolescents by 3 to 12 mm Hg and 3 to 7 mm Hg for boys, and by 3 to 6 mm Hg and 3 to 5 mmHg for girls, respectively. The overall prevalence of relatively high BP was 26.22% for boys and 20.27% for girls.

CONCLUSION

There is a high prevalence of relatively high BP among children and adolescents in Shandong, China. It has become a threatening hazard to children and adolescents and should arouse special attention.

Quantifying the relationships of blood pressure with weight, height and body mass index in Chinese children and adolescents

AIM

The aim of this study was to quantify the relationships of height, weight and body mass index (BMI) with blood pressure (BP) levels in Chinese children and adolescents.

METHODS

Height, weight, BMI and BP measurements were obtained from a nationally representative sample of 231,227 children aged 7-18 years. Body size measurements were converted to age- and sex-specific standard deviation (SD) scores. The relationships between body size and BP measurements were assessed using linear regression analysis.

RESULTS

All body size measurements were significantly associated with BP levels. Systolic BP increased 4.14, 3.70 and 2.88 mmHg in boys and 2.98, 2.63 and 1.87 mmHg in girls, corresponding to 1 SD increase in weight, BMI and height, respectively. A similar pattern was also observed for diastolic BP. After adjustment for height, systolic BP increased substantially with increasing weight (3.96 mmHg/SD increase for boys and 2.92 mmHg for girls). With adjustment for weight, systolic BP increased slightly with 1 SD increase in height (0.27 mmHg for boys and 0.10 mmHg for girls). The strength of the association between a body size measurement and BP varied among different ages, peaked at 10-11 years in girls and around 12-14 years in boys.

CONCLUSIONS

Weight is the most powerful driving force of BP in children and adolescents, followed by BMI and height. Height has little impact on BP in children with a given weight, while weight has considerable impact on BP in children with a given height.

Body height and blood pressure regulation in humans during anti-orthostatic tilting

The hypothesis was tested that the cardiovascular changes during an upper body anti-orthostatic maneuver in humans are more pronounced in tall than in short individuals, because of the larger intravascular hydrostatic pressure gradients. In 34 males and 41 females [20–30 yr, body height (BH) = 147–206 cm], inter-individual multiple linear regression analyses adjusted for gender and body weight were conducted between changes in cardiovascular variables versus BH during tilting of the upper body from vertical to horizontal while keeping the legs horizontal. In all the subjects, tilting induced increases in stroke volume and arterial pulse pressure and a decrease in heart rate, which each correlated significantly with BH. In males ( n = 51, BH = 163–206 cm), 24-h ambulatory mean arterial pressure increased significantly with BH ( P = 0.004, r = 0.40, α = 0.15 mmHg/cm) so that systolic/diastolic blood pressure increased by 2/2 mmHg per 15 cm increase in BH. There was no significant correlation between mean arterial pressure and BH in females ( n = 53, BH = 147–193 cm). In conclusion, a larger BH induces larger cardiovascular changes during anti-orthostatic tilting, and in males 24-h ambulatory mean arterial pressure increases with BH. The lack of a mean arterial pressure to BH correlation in females is probably because of their lower BH and greater variability in blood pressure.

Body fat and blood pressure: comparison of blood pressure measurements in Chinese children with different body fat levels

Children in China are experiencing a rapid increase in the prevalence of obesity, which is associated with hypertension. To compare the effect of body fat on blood pressure (BP) with that of the normal physical growth, we compared BP levels in Chinese children with different body fat levels. In the present population-based study, 13 972 children in the highest-skinfold-thickness-quartile group were individually matched to 13 972 children in the lowest-skinfold-thickness-quartile group by height and weight. Similarly, 5103 children in the highest-waist-circumference-quartile group were matched to the same number of children in the lowest-waist-circumference-quartile group. The high- and low-fat groups had similar height and weight but the high-fat group had significantly higher skinfold and waist circumference measurements. The differences in systolic BP (SBP) between the high- and low-skinfold-thickness groups were small: 0·01 (95 % CI − 0·41, 0·44) mmHg in boys and 0·20 (95 % CI − 0·15, 0·54) mmHg in girls. The differences in diastolic BP (DBP) were also small (0·39 and 0·38 mmHg for boys and girls, respectively) but were statistically significant. The differences in both SBP and DBP between the high- and low-waist-circumference groups were small but not statistically significant. For a given body size as measured by height and weight, relative body fat had little impact on BP levels in these children. Fat mass and lean mass may have a similar quantitative impact on BP in healthy-weight children.

Serum chitotriosidase activity: is it a new inflammatory marker in obese children?

Chitotriosidase (ChT) is an enzyme secreted by activated macrophages and involved in defense against, and in degradation of chitin-containing pathogens, such as fungi, nematodes, and insects. In addition, it plays an important role in the development of atherosclerosis related with systemic low-grade inflammation. To this effect of activity of ChT, we aimed to investigate serum ChT activity in obese subjects and to determine to relation with insulin resistance and high-sensitive C-reactive protein (hsCRP). A total of 73 obese subjects (10.9 +/- 2.6 years of age, 44 male patients) and 41 age and gender-matched healthy lean subjects (11.6 +/- 2.9 years of age, 18 male patients) were included in this study, between 2007 and 2008. The criterion for diagnosing obesity was defined as the body mass index (BMI) being over 97th percentile of the same gender and age. Fasting serum glucose, insulin, hsCRP and ChT levels were measured. We compared the differences in variables between obese and lean subjects with Student's t-test compared after ascertaining that the data were normally distributed. All data were expressed as mean +/- standard deviation. There was statistically significant increase in serum ChT activity of obese subjects, while there was statistically significant difference in serum hsCRP levels when compared to healthy lean subjects (30.0 +/- 17.9 and 23.0 +/- 17.8, p=0.045; 2.3 +/- 3.1 and 0.7 +/- 1.2, p=0.001). Obese subjects had significantly higher BMI-SDS, TG and HOMA-IR and lower HDL-C levels when compared with the healthy lean subjects (p<0.05). Correlation analysis showed no significant correlation between serum ChT activity and hsCRP, HOMA-IR and BMI-SDS (p>0.05). Although the data need to be validated by further investigation, the observations made in this study seem to indicate that serum ChT activity may not be a useful marker for monitoring systemic low-grade inflammation and insulin resistance in obese subjects.

The association between intima media thickness, central obesity and diastolic blood pressure in obese and overweight children: a cross-sectional school-based study

OBJECTIVE

To examine relationship between carotid intima-media thickness (IMT) and central obesity, cardiovasculary risk factors, and chronic inflammation markers in overweight and obese schoolchildren in Eastern Turkey.

METHODS

A cross-sectional school-based survey on 2765 schoolchildren was performed. We collected the clinical data (age, sex, percentage of body fat, and measured systolic blood pressure [BP] and diastolic BP, triglycerides, high- and low-density lipoprotein cholesterol, glucose, insulin, homocysteine and high-sensitivity C-reactive protein) in 67 obese and 24 overweight children. The control group was composed of nonobese children of similar age and sex.

RESULTS

Mean systolic and diastolic BP values in the cases of overweight and obese groups were higher than those in the control group cases (p=0.001). Obese and overweight children demonstrated a significantly thicker intima media as compared with the control group (p=0.001). Carotid IMT was significantly correlated to the body mass index (r=0.396, p=0.001), fat mass percentage (r=0.257, p=0.036), waist circumference (r=0.390, p=0.001), diastolic BP (r=0.266, p=0.030), glucose (r=0.250, p=0.042), and high-sensitivity C-reactive protein levels (r=0.269, p=0.001) in the obese group. In multiple linear regression analysis, carotid IMT correlated significantly to waist circumference (p=0.045), and diastolic BP (p=0.031) in obese group.

CONCLUSIONS

Obesity is related to cardiovascular risk factors leading to early atherosclerosis in schoolchildren. There is a relationship between atherosclerosis, and central obesity, diastolic BP, and chronic inflammation. Waist circumference measurement is more sensitive than other anthropometric measurements in predicting obesity and associated complications.

Distribution of skinfold thickness and blood pressure among children and adolescents in Shandong, China

This article reported the distribution of skinfold thickness (SFT) and blood pressure (BP) among children and adolescents in Shandong, China. A total of 8568 students (4333 boys and 4235 girls) aged 7-18 years participated in this study. Triceps and subscapular SFT and BP of all subjects were measured, the sum of Triceps and subscapular SFT (SSFT) was used as an indicator of the overall SFT. The overall prevalence of relative high BP was 24.07% for boys and 22.36% for girls. The prevalence of relative high BP was increasing with SSFT percentiles, this trend was obvious especially in upper percentiles of SSFT. The prevalence of relative high BP increased from 13.27% (boys) and 13.33% (girls) in <5th SSFT percentile group to 55.50% (boys) and 48.17% (girls) in ≥95th SSFT percentile group, which increased by 3.2 and 2.6 times. There is a higher level of SSFT and higher prevalence of relative high BP among children and adolescents in Shandong, China.

Secular trends of blood pressure, body mass index, lipids and fasting glucose among children and adolescents in Turkey

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

•  Turkey is in a state of rapid transition and urbanization. There is ample evidence for an increased cardiovascular risk over the past two decades in Turkey. •  Obesity, dyslipidemia and high blood pressure in children are markers of the future burden of cardiovascular disease and clustering of cardiovascular risk factors starts early in life. •  The patterns of cardiovascular risk factors in populations are not static over time and the secular trends in obesity and cardiovascular risk factors among children and adolescents of developing countries have not been completely defined.

WHAT THIS STUDY ADDS

•  The prevalences of obesity and high blood pressure have increased several folds among Turkish children and adolescents over the past two decades. •  The temporal trends in fasting glucose and lipids did not correlate with the increasing prevalence of obesity with the exception of HDL-C levels. •  Finally, the prevalence of metabolic syndrome has doubled in Turkish children and adolescents over the last two decades. Our findings indicate that there may be an increase in the future morbidity and mortality from cardiovascular disease, thrombosis, stroke and diabetes mellitus throughout the developing countries.

SUMMARY

Patterns of cardiovascular risk factors and metabolic syndrome risk criteria in populations are not static over time. We analyzed the trends in lipid levels, blood pressure, fasting glucose and body mass index over the last two decades among children and adolescents. Two different cross-sectional studies were examined among students (ages 8-18) in 1989 (n = 1385) and in 2008 (n = 1746). Using the international cut-off points and percentiles, we identified children and adolescents with elevated blood pressure, triglycerides, fasting glucose (≥100 mg dL(-1) ), body mass index and low high-density lipoprotein cholesterol (HDL-C) levels. The prevalence of obesity has increased several folds over the last two decades. According to the international criteria, 4.3% of children were obese and 15.2% were overweight in 2008 vs. only 0.6% obese and 4.3% overweight in 1989 (P < 0.001). The prevalence of elevated systolic blood pressure also increased significantly among 8-12-year-old boys and girls (28.5 vs. 15.7%, P < 0.001). The temporal trends in fasting glucose and lipids did not correlate with the increasing prevalence of obesity with the exception of HDL-C levels. Low HDL-C (≤ 10th percentile) was observed in 16.3% in 1989 vs. 21.6% in 2008 (P = 0.016). HDL-C levels decreased significantly among adolescent boys. Finally, the prevalence of metabolic syndrome by modified National Cholesterol Education Program (NCEP) criteria has doubled over the last two decades (2.2 vs. 4.5%, P < 0.001). Strategies for combating the future cardiovascular mortality should focus on the prevention of obesity, high blood pressure and metabolic syndrome among children and adolescents.

The relationship of body mass index distribution to relatively high blood pressure among children and adolescents in Shandong, China

BACKGROUND

Obesity and hypertension are both common health problems in children and adolescents; several studies have reported that obesity is associated with elevated blood pressure (BP) in both adults and children. However, no studies on the association between body mass index (BMI) distribution and prevalence of relatively high BP among children and adolescents have been reported in China.

AIM

The present study examined the relationship of BMI distribution to relatively high BP among children and adolescents in Shandong, China.

SUBJECTS AND METHODS

A total of 8568 students (4,333 boys and 4,235 girls) aged 7-18 years participated in this study. Height, weight and BP of all subjects were measured; BMI of adolescents was calculated from their height and weight. Relatively high BP status was defined as systolic blood pressure (SBP) and/or diastolic blood pressure (DBP) ≥ 95th percentile for age and gender. Prevalence of relatively high BP within each BMI percentile category was determined. Comparisons of BP among different BMI percentile groups were made.

RESULTS

The levels of SBP and DBP increased with age and were positively correlated with BMI in both boys and girls. The overall prevalence of relatively high BP was 24.07% for boys and 22.36% for girls. Prevalence of relatively high BP increased with BMI percentiles, this trend being especially obvious in the upper percentiles of BMI. An increasing trend was observed in SBP and DBP from BMI < 25th, 25th ≤ BMI < 50th, 50th ≤ BMI < 75th to BMI ≥ 75th percentile group.

CONCLUSION

There is a high prevalence of relatively high BP among children and adolescents in Shandong, China. The present findings emphasize the importance of prevention of overweight and obesity in order to prevent future related problems such as hypertension in children and adolescents.

Elevated systolic blood pressure in preterm very-low-birth-weight infants ≤3 years of life

Preterm, very-low-birth-weight neonates (≤1500 gm, VLBW) exhibit elevated systolic blood pressures (SBP) in adolescence and adulthood; however, the age of onset and causes are unknown. We assessed SBP in a cross-sectional study of VLBW infants at 1, 2 and 3 years of age (n = 40 per cohort). SBP was manually measured using Doppler amplification (observed), and calm values were compared to reference ranges used for clinical purposes (expected). SBP was converted to age-, gender- and height-specific z-scores (SBPz). Perinatal variables and growth parameters measured between 6 and 36 months were assessed as predictors of an elevated SBP. Observed SBP and SBPz exceeded the expected value at each age (P < 0.01); for example 1 year SBP was 94 ± 10 (standard deviation) vs. 85 ± 3 mmHg, respectively. Although the expected SBP rose from 85 ± 3 to 90 ± 3 mmHg with advancing age (P < 0.05), VLBW SBP was unchanged (P > 0.1), averaging 93 mmHg across ages. Height and weight z-scores were below expected (P < 0.01), while weight-for-height z-scores exceeded zero at 6, 12 and 24 months (P < 0.05). Male subscapular skinfold thickness:abdominal circumference ratio decreased with advancing age, paralleling the decreases in SBPz. The VLBW neonates demonstrated an elevated SBP as early as 1 year of age. Although predictive perinatal variables were not identified, gender-specific relationships between infant growth and SBP were observed.

Comparison of blood pressure levels among four age groups of Chinese children matched by height

Hypertension in children is frequently undiagnosed. Normal blood pressure is currently defined as a function of two continuous variables, age and height for each gender. Applying the current cutoff values to assess a child's blood pressure is time consuming. To separate the independent effect of age from that of height on blood pressure, we conducted a multiple group matched study to investigate if blood pressure levels in children with a given height distribution vary with age. An equal number of 2539 Chinese children from each of the four age groups (7, 8, 9 and 10 years) were individually matched by height, sex and geographic region. We used the matching technique to force the four age groups to have an identical height distribution. Systolic and diastolic blood pressures significantly increased with increasing age before matching. After matching, four groups had strikingly similar levels of blood pressures, and the differences among four groups were small and not statistically significant. Once height is taken into consideration, age has little impact on blood pressure. Our findings, if confirmed in children of other ages, suggest that blood pressure percentile charts can be considerably simplified by establishing normal percentiles according to height alone for each gender.

Determinants of blood pressure distribution in school children

BACKGROUND

Hypertension (potential risk for cardiovascular diseases) is a major health problem in developed and developing countries affecting approximately one billion individuals worldwide. Many of the risk factors associated with development of hypertension are preventable. Early identification of children at risk for hypertension is important to prevent serious complications. The present study aimed at determining the percentile of systolic blood and diastolic blood pressure and to investigate distribution of blood pressure and its association with anthropometric variables.

METHODS

A cross-sectional study among 701 school children (in the age group of 12-16 years), selected by stratified random sampling was conducted in Aligarh. Personal data were collected through a pre-tested questionnaire. Blood pressure, weight and height were measured through standardized techniques and quetelet index was used to determine BMI. The distributions of blood pressure by anthropometric characteristics were examined. Mean, standard deviation, chi square and correlation coefficient were used for statistical analysis using SPSS 12 software. High blood pressure was defined as systolic and/or diastolic blood pressure over the 95th percentile.

RESULTS

Out of 363 boys, 34 (9.36%) and out of 338 girls, 32 (9.46%) had hypertension with overall prevalence of 66 (9.4%) children. Mean systolic blood and diastolic blood pressure were higher as the range of weight, height and BMI increased and blood pressure of children showed positive correlation with anthropometrics characteristics.

CONCLUSIONS

It is therefore recommended that the children must be screened regularly for blood pressure to detect the prevalence so that remedial measure may be initiated as early as possible.

A survey of blood pressure in Lebanese children and adolescence

BACKGROUND

Blood pressure varies between populations due to ethnic and environmental factors. Therefore, normal blood pressure values should be determined for different populations.

AIMS

The aim of this survey was to produce blood pressure nomograms for Lebanese children in order to establish distribution curves of blood pressure by age and sex.

SUBJECTS AND METHODS

We conducted a survey of blood pressure in 5710 Lebanese schoolchildren aged 5 to 15 years (2918 boys and 2792 girls), and studied the distribution of systolic and diastolic blood pressure in these children and adolescents. Blood pressure was measured with a mercury sphygmomanometer using a standardized technique.

RESULTS

Both systolic and diastolic blood pressure had a positive correlation with weight, height, age, and body mass index (r= 0.648, 0.643, 0.582, and 0.44, respectively) (P < .001). There was no significant difference in the systolic and diastolic blood pressure in boys compared to girls of corresponding ages. However, the average annual increase in systolic blood pressure was 2.86 mm Hg in boys and 2.63 mm Hg in girls, whereas the annual increase in diastolic blood pressure was 1.72 mm Hg in boys and 1.48 mm Hg in girls. The prevalence of high and high-normal blood pressure at the upper limit of normal (between the 90(th) and 95(th) percentile, at risk of future hypertension if not managed adequately), was 10.5% in boys and 6.9% in girls, with similar distributions among the two sexes.

CONCLUSIONS

We present the first age-specific reference values for blood pressure of Lebanese children aged 5 to 15 years based on a good representative sample. The use of these reference values should help pediatricians identify children with normal, high-normal and high blood pressure.

Relation of subepicardial adipose tissue thickness and clinical and metabolic parameters in obese prepubertal children

BACKGROUND

The measurement of subepicardial adipose tissue thickness (SATT) has been found to be related to insulin resistance (IR) in adults. Until now, the association between SATT and IR has not been evaluated in obese prepubertal children. We aimed to determine the relation of SATT with clinical anthropometric and metabolic parameters and to provide cutoff value of SATT associated with IR in obese prepubertal children.

METHODS

Fifty-two obese (mean age: 9.5 ± 1.6 years, 29 female) and 31 lean prepubertal age- and gender-matched subjects (mean age: 9.2 ± 1.4 years, 12 female) were evaluated by echocardiography. SATT was measured by transthoracic echocardiography.

RESULTS

SATT (6.54 ± 1.38 mm) and homeostatic model assessment-insulin resistance (HOMA-IR) (3.2 ± 2) values of obese prepubertal subjects were significantly higher than those of the lean subjects (3.72 ± 0.57 mm and 1.6 ± 1) in the control group (both p < 0.001). Bivariate correlation analysis showed significant correlation between SATT, age, body mass index (BMI), waist circumference (WC), hip circumference (HC), waist-to-hip ratio (WHR), mid-arm circumference (MAC), triceps skin fold (TSF) thickness, insulin, and HOMA-IR (r = 0.547, r = 0.524, r = 0.543, r = 0.431, r = 0.289, r = 0.402, r = 0.400, r = 0.328, r = 0.289, p < 0.05, respectively). As an optimal cutoff point, an SATT of 4.33 mm determined IR with 93.3% sensitivity and 51% specificity.

CONCLUSIONS

Our study on obese prepubertal children showed that SATT was significantly correlated with age, BMI, WC, HC, MAC, TSF, insulin, and HOMA-IR.

New equations and a critical appraisal of coronary artery Z scores in healthy children

BACKGROUND

The aim of this study was to find the best model to obtain valid and normally distributed Z scores for coronary artery (CA) diameters in a large, heterogeneous population of healthy children.

METHODS

Echocardiography was performed on 1,033 healthy children. Several regression models were tested with height, weight, body surface area, and aortic valve diameter. The computed Z scores were tested for normal distribution and stability.

RESULTS

CA diameter was best predicted using regression with the square root of body surface area. The weighted least squares method yielded normally distributed and very stable Z-score estimates for all CA segments. In prepubertal children, aortic valve diameter was also a valid predictor of CA diameter.

CONCLUSIONS

This study shows two valid methods to estimate Z scores for CA size in children of all ages. Such Z scores are important for risk stratification in patients with Kawasaki disease.

Subepicardial adipose tissue thickness and its relation with anthropometric and clinical parameters in pubertal obese children

AIM

To determine the relation of echocardiographic subepicardial adipose tissue (SAT) thickness with anthropometric and clinical parameters in pubertal obese children.

SUBJECTS AND METHODS

A total of 52 obese pubertal subjects (13.1±1.56 yr, 27 male patients) and 39 age- and gender-matched lean pubertal subjects (13.0±1.28 yr, 16 male patients) were included in the study. Serum glucose, lipid profile, and insulin levels were measured during the fasting state. Each subject underwent a transthoracic echocardiography and the SAT thickness was measured during end-diastole from the parasternal long-axis views.

RESULTS

The obese pubertal subjects had significantly higher SAT, triceps skin fold (TSF) thickness (mm), waist (WC) and mid-arm circumference (MAC) values (cm) compared with lean pubertal subjects group (p<0.05). Correlation analysis showed that SAT thickness was significantly related with age, SD score-body mass index (SDS-BMI), BMI, WC, MAC, TSF, and homeostasis model assessment of insulin resistance (HOMA-IR) (p<0.05), whereas there was no significant relation of SAT with hip circumference and waist to hip ratio (p>0.05). As an optimal cut-off point, a SAT thickness of 5.25 mm determined IR with 92% sensitivity and 62.1% specificity.

CONCLUSIONS

Our study showed that SAT thickness in obese pubertal children shows a good correlation with age, SDS-BMI, BMI, WC, MAC, TSF, and HOMA-IR. In addition, our results suggest that SAT thickness might be used as a supportive data for risk stratification of metabolic syndrome in obese children.

The incidence of asymptomatic hypertension in school children

BACKGROUND

Although hypertension is a well-documented risk factor for cardiovascular diseases, including myocardial infarction and stroke, in adults, only recently has knowledge about childhood hypertension increased significantly.

AIM

To determine the incidence of asymptomatic hypertension in school-age children.

SUBJECTS AND METHODS

Children in primary school were chosen with a randomized sampling method. During measurement of blood pressure, a calm, comfortable setting was provided. Blood pressure measurements were performed by only 1 researcher. For accurate measurement of blood pressure, recommended standards were followed.

RESULTS

A total of 1,963 children were included in the study. The incidence of systolic hypertension and diastolic hypertension were 7% and 2%, respectively. Obesity was present in 10.5% girls with hypertension and 13.9% of boys with hypertension.

CONCLUSION

Our findings indicate that hypertension is an important health problem in children, and its prevalence is quite high. Blood pressure measurements must be a part of routine clinical examinations. Further studies should be performed in high-risk populations to prevent hypertension and to establish methods of early diagnosis and treatment in children.

Bradycardia during induction of anesthesia with sevoflurane in children with Down syndrome

BACKGROUND

Bradycardia is a complication associated with inhaled induction of anesthesia with halothane in children with Down syndrome. Although bradycardia has been reported after anesthetic induction with sevoflurane in these children, the incidence is unknown.

OBJECTIVES

In this study we compared the incidence and characteristics of bradycardia after induction of anesthesia with sevoflurane in children with Down syndrome to healthy controls.

METHODS

We reviewed electronic anesthetic records of 209 children with Down syndrome and 268 healthy control patients who had inhaled induction of anesthesia with sevoflurane over an 8-year period. Data extracted from the medical record included demographics, history of congenital heart disease, heart rate, oxyhemoglobin saturation, expired sevoflurane concentrations, arterial blood pressure, and any treatment of bradycardia during the first 360 seconds after the start of induction of anesthesia. Bradycardia and hypotension were defined as heart rate and arterial blood pressure below the critical limits recommended for activating a pediatric rapid response team to the bedside of a hospitalized child for quick intervention. Factors associated with bradycardia were identified in a univariate analysis. A step-wise backward multiple logistic regression model was used to identify independent factors. Differences between the 2 groups were computed using Fisher's exact test or χ(2) tests for categorical data and t tests for continuous data.

RESULTS

Univariate analysis demonstrated that Down syndrome, low ASA physical status, congenital heart disease, and mean sevoflurane concentrations were factors associated with bradycardia. However, multivariate analysis showed that only Down syndrome and low ASA physical status remained as independent factors associated with bradycardia.

CONCLUSION

Bradycardia during anesthetic induction with sevoflurane was common in children with Down syndrome, with and without a history of congenital heart disease.

Importance of plasma N-terminal pro B-type natriuretic peptide, epicardial adipose tissue, and carotid intima-media thicknesses in asymptomatic obese children

This study aimed to analyze the variations of N-terminal pro B-type natriuretic peptide, epicardial adipose tissue thickness, and carotid intima-media thickness in childhood obesity. The study participants consisted of 50 obese children in the study group and 20 nonobese children referred for evaluation of murmurs who proved to have an innocent murmur and were used as control subjects. All the subjects underwent transthoracic echocardiographic examination for determination of left ventricular systolic function and mass index, myocardial tissue rates, and myocardial performance index. Epicardial adipose tissue thickness and carotid intima-media thickness also were measured during echocardiography. Serum N-terminal pro B-type natriuretic peptide levels were measured at the time of evaluation. The left ventricle mass index was 40.21 + or - 10.42 g/m(2) in the obese group and 34.44 + or - 4.51 g/m(2) in the control group (p > 0.05). The serum N-terminal pro B-type natriuretic peptide level was 109.25 + or - 48.53 pg/ml in the study group and 51.96 + or - 22.36 pg/ml and in the control group (p = 0.001). The epicardial adipose tissue thickness was 5.57 + or - 1.45 mm in the study group and 2.98 + or - 0.41 mm in the control group (p = 0.001), and the respective carotid intima-media thicknesses were 0.079 + or - 0.019 cm and 0.049 + or - 0.012 cm (p = 0.001). The left ventricular systolic and diastolic functions showed no statistically significant correlations with N-terminal pro B-type natriuretic peptide levels, carotid intima-media thickness, or epicardial adipose tissue thickness values. The results show that measurement of serum N-terminal pro B-type natriuretic peptide level, carotid intima-media thickness, and epicardial adipose tissue thickness in asymptomatic obese children is not needed.

Randomized GH trial with two different dosages in combination with a GnRH analogue in short small for gestational age children: effects on metabolic profile and serum GH, IGF1, and IGFBP3 levels

BACKGROUND

GnRH analogue (GnRHa) combined with GH treatment has been proposed to increase adult height. Effect on metabolic profile and GH, IGF1, and IGFBP3 levels in short small for gestational age (SGA) children is unknown.

OBJECTIVE

To assess fat mass and lean body mass SDS, percentage trunk fat, blood pressure (BP), insulin sensitivity (Si), beta-cell function (disposition index, DI), lipid profile, and GH, IGF1, and IGFBP3 levels during 2 years of combined treatment.

SUBJECTS

Forty-one pubertal short SGA children with a mean (+/-S.D.) age of 12.1 (+/-1.0) years.

DESIGN

Children received 3.75 mg of leuprolide acetate depot subcutaneously every 4 weeks, and they were randomly assigned to receive 1 mg (group A) or 2 mg (group B) of GH/m(2) per day.

RESULTS

Percentage trunk fat increased in both groups, but to a lower extent in group B. Lean body mass SDS increased only in group B. Changes in BP, Si, DI, and lipids were similar in both groups. Si significantly decreased, but DI remained unchanged. Lipids remained normal. GH and IGF1 levels were significantly higher in group B.

CONCLUSION

Our study is the first to report that 2 years of combined treatment with a GnRHa and either 1 or 2 mg GH/m(2) per day does not adversely affect body composition and metabolic profile of short SGA children who come under medical attention at the onset of puberty. There was a dose-dependent effect on fat mass SDS(height), percentage trunk fat, lean body mass SDS(height), and GH and IGF1 levels in favor of treatment with GnRHa and the higher GH dose of 2 mg/m(2) per day.

Dexmedetomidine hemodynamics in children after cardiac surgery

BACKGROUND

Dexmedetomidine has opposing effects on the cardiovascular system. Action in the central nervous system produces sympatholysis and a reduction in blood pressure, while peripherally it causes vasoconstriction leading to an increase in blood pressure. The purpose of our study is to define the concentration-response profile for these hemodynamic effects in children after cardiac surgery.

METHODS

A simultaneous pharmacokinetic-pharmacodynamic analysis of data from 29 children given a single bolus of dexmedetomidine 1-4 mcg.kg(-1) following cardiac surgery was undertaken using mixed effects modeling. There were four dexmedetomidine concentrations available from each patient, and mean arterial blood pressure (MAP) was recorded electronically every 5 min for 5 h after drug administration. A composite Emax model was used to relate mean arterial pressure changes to plasma dexmedetomidine concentration.

RESULTS

Children had a mean age of 2.67 years (range 4 days-14 years) and a mean weight of 12.34 (range 3.4-48.4) kg. The peripheral vasopressor effect was directly related to plasma concentration with an Emax(pos) of 50.3 (CV 44.50%) mmHg, EC(50pos) 1.1 (48.27%) microg.l(-1) and a Hill(pos) coefficient of 1.65. The delayed central sympatholytic response was described with an Emax(neg) of -12.30 (CV 37.01%) mmHg, EC(50neg) 0.10 (104.40%) microg.l(-1) and a Hill(neg) coefficient of 2.35. The equilibration half-time (T(1/2)keo) was 9.66 (165.23%) min.

CONCLUSIONS

Dexmedetomidine administered as a single bolus dose following cardiac surgery produces a biphasic effect on MAP. A plasma dexmedetomidine concentration of above 1.0 microg.l(-1) was associated with a 20% increase in MAP in this specific cohort. A dosage regimen involving a small bolus dose (0.5 microg.kg(-1)) followed by a continuous infusion should be used to avoid initial increases in MAP.

How to simplify the diagnostic criteria of hypertension in adolescents

Diagnosis of hypertension in adolescents is complicated because blood pressure values vary with age, gender and height. How can we simplify the diagnostic criteria for hypertension in adolescents? In 2006, anthropometric measurements were assessed in a cross-sectional population-based study of 3136 Han adolescents aged 13-17 years. Hypertension was defined according to the 2004 National High Blood Pressure Education Program Working Group definition. The following equations for blood pressure-to-height ratio (BPHR) were used: systolic BPHR (SBPHR)=SBP (mm Hg)/height (cm) and diastolic BPHR (DBPHR)=DBP (mm Hg)/height (cm). Receiver-operating characteristic curve analyses were performed to assess the accuracy of SBPHR and DBPHR as diagnostic tests for elevated systolic blood pressure (SBP) and diastolic blood pressure (DBP), respectively. After the cutoff points were determined, hypertension was defined by SBPHR/DBPHR, and the sensitivity and specificity were calculated. The accuracy of SBPHR and DBPHR (assessed by area under the curve) for identifying elevated SBP and DBP was >0.85 (0.989-1.000). The optimal thresholds of SBPHR/DBPHR for defining hypertension (stages 1 and 2) were 0.75/0.48 for boys and 0.78/0.51 for girls, and for defining hypertension (stage 2) were 0.81/0.57 for boys and 0.84/0.63 for girls. In identifying hypertension, the sensitivity and specificity were both >90% (91.0-99.1%). In identifying stage 2 hypertension, when the sensitivity was 100%, the specificity was 98.6% for boys and 99.1% for girls. BPHR is a simple, accurate and non-age-dependent index for screening hypertension in Han adolescents, especially for stage 2 hypertension.

Cardiovascular and metabolic risk profile and acylation-stimulating protein levels in children with Prader-Willi syndrome and effects of growth hormone treatment

CONTEXT

Reports on the cardiovascular and metabolic risk profile in children with Prader-Willi syndrome (PWS) and the effects of GH treatment are scarce. Acylation-stimulating protein (ASP) stimulates glucose uptake and triglyceride storage in adipose tissue.

OBJECTIVES

The aim was to study the metabolic and cardiovascular risk profile and ASP levels and to investigate the effects of GH treatment.

DESIGN

We conducted a randomized controlled GH trial. Infants and prepubertal children were assigned to receive GH (1 mg/m(2) . d) or to serve as controls for 12 and 24 months, respectively.

PATIENTS

Eighty-five children with PWS (mean +/- sd age of 4.9 +/- 3.0 yr) participated in the study.

MAIN OUTCOME MEASURES

We measured fat percentage (fat%) with dual-energy x-ray absorptiometry, blood pressure, fasting insulin and glucose levels, serum lipids, and ASP levels.

RESULTS

Mean +/- SD fat% was 28.4 +/- 6.2 in infants and 36.9 +/- 8.5 in prepubertal children. Fat% sd score (SDS) was above 2 SDS in 95% of prepubertal children. In addition, 63% of infants and 73% of prepubertal children demonstrated at least one cardiovascular risk factor, defined as hypertension or dyslipidemia. The metabolic syndrome was demonstrated in 5% of all children. Mean +/- sd baseline ASP was 107 +/- 45 nmol/liter (normal < 58 nmol/liter) and correlated with fat mass and TG levels. GH improved fat%SDS and the HDLc/LDLc ratio (P < 0.0001 and P = 0.04). GH had no effect on mean ASP levels in this population.

CONCLUSIONS

Many children with PWS had dyslipidemia and high ASP levels. GH improved fat% and high-density lipoprotein cholesterol/low-density lipoprotein cholesterol, but not ASP. High ASP levels may prevent complete normalization of fat%SDS during GH treatment but may contribute in keeping glucose and insulin levels within normal range.

Serum insulin-like growth factor-binding protein-2 levels and metabolic and cardiovascular risk factors in young adults and children born small for gestational age

BACKGROUND

IGF binding protein (IGFBP)-2 might protect against cardiovascular disease. Small for gestational age (SGA) birth could be associated with a higher risk for type 2 diabetes mellitus and cardiovascular disease in later life. No data are available on the relationship between serum IGFBP-2 levels and cardiovascular risk factors in young adults and children born SGA.

OBJECTIVE

The aim of the study was to determine circulating IGFBP-2 levels in subjects born SGA and to investigate the association with cardiovascular risk factors.

METHODS

IGFBP-2 levels were measured in sera from 151 young adults born SGA and 147 short SGA children. Age- and gender-adjusted sd scores (SDS) were calculated. We determined blood pressure, serum lipids, body composition by dual-energy x-ray absorptiometry, and glucose homeostasis by homeostasis model of assessment for insulin resistance or frequently sampled iv glucose tolerance test.

RESULTS

Serum IGFBP-2 SDS was significantly reduced in SGA young adults (with normal or short stature). Fat mass SDS was relatively high in SGA young adults and was reduced in short SGA children. Serum IGFBP-2 SDS in SGA young adults correlated positively with insulin sensitivity and negatively with fat mass SDS, insulin secretion (acute insulin response), fasting insulin, homeostasis model of assessment for insulin resistance, total cholesterol, triglycerides, and blood pressure SDS. The association between serum IGFBP-2 SDS and insulin sensitivity, blood pressure, total cholesterol, and triglyceride levels persisted after adjustment for known covariates including fat mass SDS. In short SGA children, IGFBP-2 SDS did not correlate with any of the cardiovascular risk factors.

CONCLUSION

In young adults who were born SGA, serum IGFBP-2 levels associate with cardiovascular risk markers.

International comparison of blood pressure and BMI values in schoolchildren aged 11-16 years

AIMS

This study comprised part of a larger cross-sectional survey performed in Hungary in the period 2005-2006, which was designed first to reveal the representative age-, gender- and height-specific percentile values for the systolic blood pressure (SBP) and the diastolic blood pressure (DBP) in Hungarian children aged 11-16 years. The second aim was to determine the prevalence of overweight and obesity.

METHODS

Analyses were performed on 14,290 Hungarian children aged 11-16 years. All blood pressure (BP) measurements were made with a validated, automated, digital device. The criteria recommended by international guidelines were used.

RESULTS

The prevalence of overweight and obesity among the Hungarian children was found to be 23.4% (3347 adolescents; International Obesity Task Force criteria). Previous studies have reported that the strongest correlation is observed between the BP values and weight, and our results are in accordance with this.

CONCLUSIONS

Regional differences in morphometry (different prevalences of overweight and obesity) and the genetic background, disparate eating habits and other cultural factors may account for the differences in BP levels during childhood. As the prevalence of overweight and obesity is increasing worldwide, it is important that countries carefully monitor the weight and BP status of their children and adolescents.

How do pediatric anesthesiologists define intraoperative hypotension?

INTRODUCTION

Although blood pressure (BP) monitoring is a recommended standard of care by the ASA, and pediatric anesthesiologists routinely monitor the BP of their patients and when appropriate treat deviations from 'normal', there is no robust definition of hypotension in any of the pediatric anesthesia texts or journals. Consequently, what constitutes hypotension in pediatric anesthesia is currently unknown. We designed a questionnaire-based survey of pediatric anesthesiologists to determine the BP ranges and thresholds used to define intraoperative hypotension (IOH).

METHODS

Members of the Society of Pediatric Anesthesia (SPA) and the Association of Paediatric Anaesthetists (APA) of Great Britain and Ireland were contacted through e-mail to participate in this survey. We asked a few demographic questions and five questions about specific definitions of hypotension for different age groups of patients undergoing inguinal herniorraphy, a common pediatric surgical procedure.

RESULTS

The overall response rate was 56% (483/860), of which 76% were SPA members. Majority of the respondents (72%) work in academic institutions, while 8.9% work in institutions with fewer than 1000 annual pediatric surgical caseload. About 76% of respondents indicated that a 20-30% reduction in baseline systolic blood pressure (SBP) indicates significant hypotension in children under anesthesia. Most responders (86.7%) indicated that they use mean arterial pressure or SBP (72%) to define IOH. The mean SBP values for hypotension quoted by SPA members was about 5-7% lower across all pediatric age groups compared to values quoted by APA members (P = 0.001 for all age groups).

CONCLUSIONS

There is great variability in the BP parameters used and the threshold used for defining and treating IOH among pediatric anesthesiologists. The majority of respondents considered a 20-30% reduction from baseline in SBP as indicative of significant hypotension. Lack of a consensus definition for a common clinical condition like IOH could have implications for patient care as well as future clinical research.

Efficacy and safety of long-term continuous growth hormone treatment in children with Prader-Willi syndrome

BACKGROUND

Children with Prader-Willi syndrome (PWS) have abnormal body composition and impaired growth. Short-term GH treatment has beneficial effects.

OBJECTIVES

The aim of the study was to investigate effects of long-term continuous GH treatment on body composition, growth, bone maturation, and safety parameters.

SETTING

We conducted a multicenter prospective trial.

DESIGN

Fifty-five children with a mean +/- sd age of 5.9 +/- 3.2 yr were followed during 4 yr of continuous GH treatment (1 mg/m(2) . d). Data were annually obtained in one center: fat percentage (fat%) and lean body mass (LBM) by dual-energy x-ray absorptiometry, height, weight, head circumference, bone age, blood pressure, and fasting IGF-I, IGF binding protein-3, glucose, insulin, glycosylated hemoglobin, total cholesterol, high-density lipoprotein, and low-density lipoprotein. sd scores (SDS) were calculated according to Dutch and PWS reference values (SDS and SDS(PWS)).

RESULTS

Fat%SDS was significantly lower after 4 yr of GH treatment (P < 0.0001). LBMSDS significantly increased during the first year (P = 0.02) but returned to baseline values the second year and remained unchanged thereafter. Mean +/- sd height normalized from -2.27 +/- 1.2 SDS to -0.24 +/- 1.2 SDS (P < 0.0001). Head circumference SDS increased from -0.79 +/- 1.0 at start to 0.07 +/- 1.1 SDS after 4 yr. BMISDS(PWS) significantly decreased. Mean +/- sd IGF-I and the IGF-I/IGF binding protein-3 ratio significantly increased to 2.08 +/- 1.1 and 2.32 +/- 0.9 SDS, respectively. GH treatment had no adverse effects on bone maturation, blood pressure, glucose homeostasis, and serum lipids.

CONCLUSIONS

Our study in children with PWS shows that 4 yr of continuous GH treatment (1 mg/m(2) . d) improves body composition by decreasing fat%SDS and stabilizing LBMSDS and head circumference SDS and normalizes heightSDS without adverse effects. Thus, long-term continuous GH treatment is an effective and safe therapy for children with PWS.

Sex hormones and metabolic syndrome in children and adolescents

Cardiovascular risk starts early in life, yet the patterns of changes in metabolic syndrome (MS) during puberty and normal development have not been completely defined. Sex hormones are shown to play a pivotal role in the modulation of insulin resistance and MS. Our aim is to clarify the relation between sex hormones and MS in normal children and adolescents. This is a cross-sectional study of 365 (8-12 and 14-18 years old) school students. We analyzed the associations of sex hormones (testosterone, free androgen index, estradiol, free estradiol index [FEI], and sex hormone-binding globulin [SHBG]) with cardiovascular risk factors and MS. Prevalence of MS varied depending on the definition, and 33 (9%) students had MS based on at least 1 definition of MS. Frequency of MS doubled among 14- to 18-year-old adolescents compared with 8- to 12-year-old children (12.4% vs 5.6%, P = .02). Adolescent boys and girls with MS had significantly lower SHBG levels compared with controls. Adolescent boys with MS also had significantly higher FEI levels compared with controls. Logistic regression analysis was performed to find the predictors of MS. Among covariates of age, estradiol, testosterone, free androgen index, and FEI, SHBG was the only significant predictor of MS (B = -0.3, odds ratio = 0.8, 95% confidence interval for odds ratio are 0.64 and 0.92, P = .005, Nagelkarke R(2) = 0.48) in adolescent boys. In conclusion, sex hormone levels and androgen/estrogen balance may play an important role in determining MS and future cardiovascular risk among children and adolescents.

The relationship of insulin resistance with SNP 276G>T at adiponectin gene and plasma long-chain polyunsaturated fatty acids in obese children

This study examined the association of insulin resistance with single-nucleotide polymorphism (SNP) 276G>T at adiponectin gene and the plasma long-chain polyunsaturated fatty acids (LCPUFAs) profile in obese children. One hundred thirty-one normolipidaemic obese children aged 8-13 y (53 girls and 68 boys) entered the study. The prevalence of T allele carriers at SNP276 was 48.8%. Mean [SD] values of fasting insulin and homeostasis model assessment-insulin resistance (HOMA-IR) index in noncarriers versus carriers of T allele were 12.4 [6.4] versus 20.6 [6.3] muU/mL (p = 0.039) and 2.6 [1.4] versus 4.5 [1.7] (p = 0.032). Mean [SD] values of plasma C18:3n - 3, C20:5n - 3/C20:4n - 6, and n - 6/n - 3 LCPUFA in phospholipids in noncarriers versus carriers of T allele were 0.10 [0.04] versus 0.08 [0.03] % (p = 0.013), 0.04 [0.01] versus 0.03 [0.01] % (p = 0.045), and 4.4 [0.7] versus 4.9 [0.9] % (p = 0.005), respectively. Insulin resistance was independently associated with SNP 276G>T (p = 0.002) and n - 6/n - 3 LCPUFA (p = 0.042) in plasma phospholipids, and interaction was found between SNP 276G>T and n - 6/n - 3 LCPUFA (p = 0.046). These findings suggest that obese children carriers of the SNP 276G>T may be at increased risk of metabolic complications compared with noncarriers, possibly due in part to a different plasma phospholipids profile.

Obesity and metabolic changes are common in young childhood brain tumor survivors

BACKGROUND

A population based cross-sectional study was used to examine the prevalence of metabolic syndrome and its components in childhood brain tumor survivors.

PROCEDURE

Fifty-two survivors were examined at a mean age of 14.4 years (range 3.8-28.7). Lipid and glucose metabolism, thyroid function, and plasma uric acid were evaluated. Fat mass and fat percentage were assessed by dual-energy X-ray absorptiometry (DXA). Metabolic syndrome was defined on International Diabetes Federation criteria.

RESULTS

Ten (19%) patients were overweight and four (8%) were obese. According to DXA, 16/46 (35%) patients were obese. Central obesity was found in 11 (21%) patients. Cranial irradiation, hypothalamic/hypophyseal damage, growth hormone (GH) deficiency and impaired mobility were associated with overweight/obesity and central obesity. Thirteen (25%) subjects had hypercholesterolemia, 14 (27%) had raised low-density lipoprotein cholesterol (LDL-C), 12 (23%) had raised blood pressure, four (8%) had metabolic syndrome, two (4%) had hyperinsulinemia and five (10%) had hyperuricemia. Cranial irradiation was associated with hypercholesterolemia (P = 0.019), raised LDL-C (P = 0.028), raised blood pressure (P = 0.040), and metabolic syndrome (P = 0.018). Impaired mobility was associated with hypercholesterolemia (P = 0.034). Hypothalamic/hypophyseal damage was associated with metabolic syndrome (P = 0.003) and hyperuricemia (P = 0.011) as was GH deficiency (P = 0.034 and P = 0.008). GH supplementation alleviated adverse metabolic outcomes among brain tumor survivors with GH deficiency.

CONCLUSIONS

Obesity/overweight, dyslipidemia, hypertension, metabolic syndrome, and hyperuricemia were common in young childhood brain tumor survivors. Cranial irradiation, hypothalamic/hypophyseal damage, growth hormone deficiency, and/or impaired mobility were associated with higher risk for obesity and metabolic changes among these patients.

The effect of growth hormone treatment on metabolic and cardiovascular risk factors is similar in preterm and term short, small for gestational age children

CONTEXT

We previously reported that short, small for gestational age (SGA) children who were born preterm have a lower body fat percentage and a higher blood pressure, insulin secretion and disposition index than short SGA children born at term. Whether preterm birth also influences these parameters during GH treatment is unknown.

OBJECTIVE

To compare blood pressure, insulin sensitivity, beta-cell function and body composition during 4 years of GH treatment, between preterm and term short SGA children.

PATIENTS

A total of 404 prepubertal non-GH-deficient short SGA children were divided into 143 preterm (< 36 weeks) and 261 term children.

OUTCOME MEASURES

Height, blood pressure (n = 404), body composition measured by dual energy X-ray absorptiometry (DXA) (n = 138) and insulin sensitivity and beta-cell function calculated from a frequent sampling intravenous glucose tolerance test (FSIGT) with tolbutamide (n = 74) or from the homeostasis model assessment of insulin resistance (HOMA-IR) (n = 204).

RESULTS

In preterm and term children, GH treatment resulted in a similar decrease in systolic and diastolic blood pressure, body fat percentage, limb fat/total fat ratio and insulin sensitivity, and a similar increase in insulin secretion and disposition index. Lean body mass (LBM) corrected for gender and height increased in term children and did not change in preterm children. Multiple regression analysis revealed that this difference in GH effect on LBM was not associated with gestational age.

CONCLUSION

The effect of GH treatment on metabolic and cardiovascular risk factors is similar in preterm and term short, SGA children.

Phenotypical aspects of maturity-onset diabetes of the young (MODY diabetes) in comparison with Type 2 diabetes mellitus (T2DM) in children and adolescents: experience from a large multicentre database

AIMS

To analyse and compare clinical characteristics in young patients with maturity-onset diabetes of the young (MODY) and Type 2 diabetes mellitus (T2DM).

METHODS

We conducted an observational investigation using the DPV-Wiss database containing clinical data on 40 757 diabetic patients < 20 years of age from Germany and Austria.

RESULTS

Three hundred and thirty-nine cases were clinically categorized as MODY (0.83%); 562 patients were diagnosed as T2DM (1.4%). In 20% of cases, the diagnosis of MODY was based on clinical findings only. Of the 272 subjects where genetic testing was available, 3% did not carry mutations in the three examined MODY genes. Glucokinase-MODY was commoner than HNF1A-MODY and HNF4A-MODY. Age at diagnosis was younger in MODY patients. The body mass index of T2DM was significantly higher compared with all MODY subgroups. Macrovascular risk factors such as dyslipidaemia and hypertension were commoner in T2DM, but 23% of MODY patients had dyslipidaemia and 10% hypertension. Glycaemic control was within the therapeutic target (HbA(1c) < 7.5%) in 86% of MODY and 70% of T2DM patients.

CONCLUSIONS

The prevalence of MODY in children and adolescents in Germany and Austria is lower than that of T2DM in this age group. Dyslipidaemia and hypertension are less frequent in MODY compared with T2DM patients, but do occur.

Insulin-like growth factor-binding protein-1: serum levels, promoter polymorphism, and associations with components of the metabolic syndrome in short subjects born small for gestational age

CONTEXT

IGF binding protein (IGFBP)-1 is the only acute regulator of IGF-I bioavailability. Its production is suppressed by insulin, and low levels are associated with hyperinsulinemia and cardiovascular disease risk in adults. Data on IGFBP-1 levels in short, small for gestational age (SGA) subjects are scarce, and associations with IGFBP1 promoter single nucleotide polymorphisms have not been established.

OBJECTIVE

The aim of the study was to determine IGFBP-1 levels in short SGA subjects compared with those in controls, to assess genotype frequency of the -575 G/A single nucleotide polymorphism, and to determine its impact on IGFBP-1 levels.

SUBJECTS

A total of 272 short subjects born SGA and 330 subjects with normal stature (245 children, 85 young adults) participated in the study.

OUTCOME MEASURES

We measured fasting levels of IGFBP-1, IGF-I, insulin and lipid parameters, and body composition.

RESULTS

IGFBP-1 sd score (SDS) was comparable to controls in lean, short, SGA children but significantly lower in short SGA adults with normal fat mass (P < 0.001). IGFBP-1 SDS correlated significantly with insulin levels, systolic blood pressure SDS, and various lipid parameters. Baseline IGFBP-1 SDS was lowest in SGA children with -575 GG genotype and significantly higher in SGA children with one or two copies of the A allele. In response to a given insulin level, children with the AA genotype had a significantly higher IGFBP-1 SDS compared to children with the GG genotype.

CONCLUSION

Normal IGFBP-1 levels in lean, short, SGA children may reflect a normal metabolic state, despite reported hyperinsulinemia. IGFBP-1 is modulated by polymorphic variability and seems to be an additional player in the complex interaction between the IGF-IGFBP axis, glucose homeostasis, and lipid metabolism.

Incidence and risk factors for preincision hypotension in a noncardiac pediatric surgical population

BACKGROUND

Routine monitoring of blood pressure is an essential part of perioperative care in adults and children. It is however not known whether intraoperative hypotension (IOH) is clinically important in the 'healthy' pediatric patient. This may be partly due to the lack of data on the incidence and consequences of IOH in this group of patients. We utilized the Brain Trauma Foundation definition of hypotension to describe the incidence of preincision hypotension (PIH) in a large pediatric noncardiac surgical population and identified risk factors for the occurrence PIH.

METHODS

We examined the electronic perioperative records of all children aged 1-17 years undergoing general anesthesia for noncardiac surgeries between January 2005 and June 2007 in our institution. Frequency and factors associated with PIH were computed. Binary logistic regression with forward step-wise algorithm was used to examine factors associated with PIH.

RESULTS

There were 22,263 children of whom 57.6% were males. Most (94.9%) cases were elective, American Society of Anesthesiologists (ASA) I-II (79.5%) procedures. Inhalational induction was predominantly used in this cohort (67%) although 33% of patients had propofol either as a sole induction agent or as part of a 'co-induction' regime. Single or multiple episodes of PIH occurred in 35.8% of patients. PIH was more common in patients with ASA > or = III (P < 0.001); those with preoperative hypotension (P < 0.001); and following intravenous induction (P < 0.001) as well as propofol co-induction (P < 0.001). On multivariate analysis the following were significant predictors of PIH: baseline hypotension, propofol co-induction, age, ASA > or = III, and long preincision period.

CONCLUSION

Preincision hypotension is common in the pediatric surgical population undergoing general anesthesia. Factors independently predictive of PIH included high ASA status, pre-existing hypotension, propofol co-induction prolonged preincision period and adolescent age group. The importance of blood pressure monitoring, prompt recognition of hypotension and use of appropriate intervention is emphasized.

Threshold value of subepicardial adipose tissue to detect insulin resistance in obese children

AIM

Until now, the association between subepicardial adipose tissue (SAT), insulin resistance and intima-media thickness (IMT) has not been evaluated in obese children. In this study, we evaluated whether echocardiographic SAT is related to insulin resistance and IMT in obese children.

SUBJECTS AND METHODS

A total of 46 obese subjects (10.2+/-2.5 years of age, 25 male patients) and 30 age- and gender-matched lean subjects (10.8+/-3.1 years of age, 13 male patients) were included in this study. The criterion for diagnosing obesity was defined as the body mass index (BMI) being over 97% percentile of the same gender and age. Serum triglyceride (TG), low- and high-density lipoprotein, cholesterol, glucose and insulin levels were measured during the fasting state. Each subject underwent a transthoracic echocardiogram and the SAT thickness was measured during end-diastole from the parasternal long-axis views.

RESULTS

The obese subjects had significantly higher SAT thickness and IMT values compared with the subjects in the control group (5.7+/-1.4 vs 3.0+/-0.7 mm, 0.78+/-0.15 vs 0.51+/-0.11 mm, P=0.001, respectively). Simple linear regression analysis showed no significant correlation between SAT and insulin resistance (r=0.170, P=0.253), whereas there was significant correlation between SAT and BMI, age and IMT (r=0.625, P=0.02, r=0.589, P=0.001, r=0.343, P=0.02, respectively). As an optimal cutoff point, a SAT thickness of 4.1 mm determined insulin resistance with 90% sensitivity and 61% specificity.

CONCLUSIONS

Our study showed that SAT was significantly correlated with age, BMI and IMT, but not insulin resistance. However, our findings suggest that a 4.1 mm cutoff of SAT thickness might be used as a simple, inexpensive and non-invasive screening method because of its ability to predict insulin resistance with high sensitivity in obese children.

Prevalência de hipertensão arterial e fatores associados em estudantes de Ensino Médio de escolas públicas da Região Metropolitana do Recife, Pernambuco, Brasil, 2006

O objetivo deste estudo foi identificar a prevalência de hipertensão arterial sistêmica e fatores associados à saúde em adolescentes, por meio de estudo epidemiológico transversal de base populacional, realizado no período de abril a setembro de 2006, empregando amostragem estratificada segundo porte da escola e turnos. Utilizando-se o questionário Global School-based Student Health Survey, 1.878 estudantes de 29 escolas públicas da Região Metropolitana do Recife, Pernambuco, Brasil, foram investigados quanto a: idade; sexo; índice de massa corporal; consumo de frutas, verduras, álcool e tabaco; e pressão arterial, admitindo os parâmetros da Task Force Report on High Blood Pressure in Children and Adolescent, de 1996, para pressão arterial, do Centers for Disease Control and Prevention para estado nutricional. As prevalências de hipertensão arterial (medida apenas uma vez), sobrepeso e obesidade igualaram-se a 17,3%, 6,9% e 3,7%, respectivamente. Comportaram-se como fatores associados para hipertensão arterial: sexo masculino, obesidade, sobrepeso e falta de atividade física. Concluiu-se que o conhecimento dos fatores associados para hipertensão arterial em adolescentes poderá subsidiar campanhas de educação para a saúde.