Regional analysis on the occurrence of oral clefts in South America

Moderate altitude as a risk factor for isolated congenital malformations. Results from a case-control multicenter-multiregional study

BACKGROUND

Living in high-altitude regions has been associated with a higher prevalence of some birth defects. Moderate altitudes (1500-2500 m) have been associated with some congenital heart diseases and low birth weight. However, no studies have been conducted for other isolated congenital malformations.

OBJECTIVES

To estimate the prevalence at birth of isolated congenital malformations in low and moderate altitudes and to determine if moderate altitudes are a risk factor, such as high altitudes, for isolated congenital malformations adjusted for other factors.

METHODS

The study consisted of a case-control multicenter-multiregional study of 13 isolated congenital malformations. Cases included live births with isolated congenital malformations and controls at low (10-1433 m) and moderate altitudes (1511-2426 m) from a Mexican registry from January 1978 to December 2019. Prevalence per 10,000 (95% CI) per altitude group was estimated. We performed unadjusted and adjusted logistic regression models (adjusted for maternal age, parity, malformed relatives, socioeconomic level, and maternal diabetes) for each isolated congenital malformation.

RESULTS

Hydrocephaly and microtia had a higher at-birth prevalence, and spina bifida, preauricular tag, and gastroschisis showed a lower at-birth prevalence in moderate altitudes. Moderate altitudes were a risk factor for hydrocephaly (aOR 1.39), microtia (aOR 1.60), cleft-lip-palate (aOR 1.27), and polydactyly (aOR 1.32) and a protective effect for spina bifida (aOR 0.87) compared with low altitudes.

CONCLUSIONS

Our findings provide evidence that moderate altitudes as higher altitudes are an associated risk or protective factor to some isolated congenital malformations, suggesting a possible gradient effect.

Clusters of rare disorders and congenital anomalies in South America

Objective

To map geographic clusters of rare disorders and congenital anomalies reported in South America.

Methods

Qualitative systematic review conducted in Medline/PubMed, Lilacs, and Scielo electronic databases to identify studies meeting eligibility criteria. The strategy resulted in 1 672 unique articles, from which 164 were selected for full reading by a pair of reviewers.

Results

Fifty-five articles reported at least one cluster of genetic disorders or congenital anomalies in South American territory. From these papers, 122 clusters were identified, of which half (61) were related to autosomal recessive disorders. Sixty-five (53.3%) of the clusters were located in Brazil.

Conclusions

The results of the review reinforce that rare diseases and congenital anomalies can occur in a non-random way in space, which is discussed in the perspective of the complex history of formation, social organization, and genetic structure of the South American population. Mapping clusters in population medical genetics can be an important public health tool, given that such places concentrate cases of rare diseases that frequently require multiprofessional, specialized care. Therefore, these results can support important agendas in public health related to rare diseases and congenital anomalies, such as health promotion and surveillance.

Clinical and Descriptive Study of Orofacial Clefts in Colombia: 2069 Patients From Operation Smile Foundation

OBJECTIVE

To describe the population of patients with cleft lip and/or palate (CL/P) in terms of cleft phenotypes, gender, age, ethnic group, family history, clinical presentation (syndromic vs nonsyndromic), some environmental and behavioral factors, and some clinical features.

DESIGN

Descriptive retrospective study.

SETTING

Patients attending the genetics counseling practice in Operation Smile Foundation, Bogotá, Colombia, for over 8 years.

PARTICIPANTS

No screening was conducted. All patients requiring clinical genetics assessment in Operation Smile Foundation were included in the study.

RESULTS

Left cleft lip and palate (CLP) and nonsyndromic forms were the most frequent types of malformations in this population. Psychomotor retardation and heart disease were the most frequent comorbidities in these patients. A low proportion of mothers exposed to passive smoking during pregnancy was observed and low birth weight accounted for an important number of cases. Aarskog, velocardiofacial, and orofaciodigital syndromes were the most frequent syndromic forms of CLP in this population.

CONCLUSIONS

In this study, the most frequent type of CL/P was the nonsyndromic complete left CLP. Aarskog, velocardiofacial, and orofaciodigital syndromes were the most frequent syndromic forms of CL/P in this population.

Endocrine-Disrupting Chemicals and Disorders of Penile Development in Humans

This paper reviews the current knowledge on the environmental effects on penile development in humans. The specific focus is on endocrine-disrupting chemicals (EDCs), a heterogeneous group of natural or manmade substances that interfere with endocrine function, and whether they can induce hypospadias and micropenis in male neonates. Epidemiological data and animal observations first raised suspicions about environmental effects, leading to the testis dysgenesis syndrome (TDS) hypothesis. More recent research has provided stronger indications that TDS may indeed be the result of the direct or indirect effects of EDCs. Drawing on epidemiological and toxicological studies, we also report on the effects of maternal diet and substances like pesticides, phthalates, bisphenol A, and polychlorinated biphenyls. Proximity to contamination hazards and occupational exposure are also suspected to contribute to the occurrence of hypospadias and micropenis. Lastly, the cumulative effects of EDCs and the possibility of transgenerational effects, with the penile development of subsequent generations being affected, raise concerns for long-term public health.

Birth prevalence of congenital anomalies in Argentina, according to socioeconomic level

Birth prevalence of congenital anomalies (CA) in Argentina is estimated around 1.7%. CA are the second leading cause of infant mortality. Poverty and other adverse socioeconomic conditions have been associated with birth defects. To describe the prevalence at birth of CA, according to the two proxy variables of socioeconomic level: the health subsector of the hospital where the cases were born (PUB-public versus PRI-private or social security) and its geographical location. The design of the study was ecological using the data of the National Network of Congenital Anomalies of Argentina (RENAC); from October 2010 to December 2018. CA birth prevalence was estimated using the Poisson regression. We used a logistic regression model to analyze the association birth prevalence to health subsector and geographical region. A total of 2,202,994 births were examined in the study period, with a global CA prevalence of 1.69% (95% CI 1.68-1.71). The highest prevalence was observed in PUB hospitals when comparing to PRI hospitals at the country level and in all regions. There were differences in the prevalence of selected congenital anomalies with a statistically significant association to PUB (observed in anencephaly, encephalocele, hydrocephalus, microcephaly, holoprosencephaly, microtia/anotia, cleft lip and palate, postaxial polydactyly, talipes equinovarus, talipes calcaneovalgus, and gastroschisis). The prevalence of critical heart defects and chromosomal anomalies was significantly higher in PRI hospitals. Although this is an ecological study with no information on socioeconomic status at individual level, we found an association between CA frequency and selected CA with the PUB subsector. Vulnerable populations affected with CA require a greater effort from policy makers and health care providers to allocate more resources and design strategies to access to health.

Orofacial clefts embryology, classification, epidemiology, and genetics

Orofacial clefts (OFCs) rank as the second most common congenital birth defect in the United States after Down syndrome and are the most common head and neck congenital malformations. They are classified as cleft lip with or without cleft palate (CL/P) and cleft palate only (CPO). OFCs have significant psychological and socio-economic impact on patients and their families and require a multidisciplinary approach for management and counseling. A complex interaction between genetic and environmental factors contributes to the incidence and clinical presentation of OFCs. In this comprehensive review, the embryology, classification, epidemiology and etiology of clefts are thoroughly discussed and a "state-of-the-art" snapshot of the recent advances in the genetics of OFCs is presented.

The Prevalence of Nonsyndromic Oral Clefts in Twins Compared to Singletons: The Association With Birth Weight

PURPOSE

To examine the prevalence of nonsyndromic oral clefts in twins compared to singletons in the United States and to evaluate the association between birth weight and nonsyndromic oral clefts.

DESIGN

A large population-based cross-sectional study was performed using the data from the US National Center for Health Statistics database in 2017.

PARTICIPANTS

Our sample consisted of 128 310 twins and 3 723 273 singletons.

METHODS

The variables collected were sociodemographic variables, environmental predictors, and clinical measures. Descriptive analysis, bivariate, and multivariate logistic regression were performed.

MAIN OUTCOME MEASURE

The main outcome variable in our study is nonsyndromic oral clefts.

RESULTS

The prevalence of nonsyndromic oral clefts was 5.22 per 10 000 in twins and 5.12 per 10 000 in singletons. Results show no significant risk of nonsyndromic oral clefts in twins compared to singletons (P = .92). There was a significant relationship between birth weight and infant diagnosed with nonsyndromic oral clefts (P = .01). Unadjusted odds ratio for birth weight was 2.52 (95% CI: 2.25-2.82). Adjusted odds for potential confounders such as mother's age, race, mother's education, gender of the infant, APGAR 5-minute score, gestational age, prenatal smoking, number of prenatal care visits, and mother's body mass index were resulted in similar but with a slightly lower odds of 2.11 (95% CI: 1.78-2.50).

CONCLUSION

Compared to singletons, twins did not have higher risk of nonsyndromic oral clefts. Infants with low birth weight were more prone to have nonsyndromic oral clefts.

Birth prevalence of congenital anomalies in the City of Buenos Aires, Argentina, according to socioeconomic level

The goal of our study is to describe the prevalence of congenital anomalies (CA) in hospitals of the City of Buenos Aires, Argentina, according to two proxy variables of the socioeconomic level: health subsector, public (PUB) versus private/social security (PRI), and geographical location, northern (N) versus southern (S). The source of data was the National Network of Congenital Anomalies of Argentina (RENAC) (period 2010-2016). From a total of 228,208 births, 4872 newborns with CA were detected (2.14%). The prevalence in PRI-N, PUB-N, PRI-S, and PUB-S hospitals were 1.59%, 1.91%, 2.20%, and 2.43%, respectively. Prevalence of neural tube defects, abdominal wall defects, and oral clefts was significantly higher in PUB than in PRI hospitals. Prevalence of critical heart defects was significantly lower in PUB-N and in PRI-S hospitals. Prevalence of anencephaly, encephalocele, hydrocephalus, microcephaly, gastroschisis, cleft lip and palate, ductus arteriosus, and bilateral renal agenesis was higher in PUB hospitals, both N and S, as well as microphthalmia/anophthalmia and ambiguous genitalia, spina bifida, anotia/microtia, postaxial polydactyly, and diaphragmatic hernia had higher prevalences in PUB-S hospitals. Omphalocele was more frequent in PUB-N hospitals. Results suggest that vulnerable populations in the public and southern subsectors of the city still require a greater support to reinforce resources and strategies that lead to greater equity in access to health.

Análise espacial das anomalias congênitas do sistema nervoso

Resumo Introdução A anomalia congênita do sistema nervoso ocorre durante o desenvolvimento embrionário. O território pode ser um fator determinante e esse conhecimento é importante para o planejamento de ações ou intervenções em saúde pública. Objetivo Detectar aglomerados espaciais da ocorrência das anomalias congênitas do sistema nervoso e caracterizá-las de acordo com as variáveis do Sistema de Informações sobre Nascidos Vivos. Método Estudo ecológico em que foram utilizados os dados do Sistema de Informações sobre Nascidos Vivos no Estado da Paraíba, período entre 2014 e 2016. Para a análise dos dados foram empregados a Razão de Incidências Espacial, a estatística Scan e o teste de Friedman. Resultados Foi constatado que nos anos de 2014 e 2016 os aglomerados espaciais estavam espalhados pelo Estado, enquanto no ano de 2015 ocorreu uma maior concentração desses ao noroeste do Estado. Conclusão A detecção dos aglomerados espaciais pode auxiliar os gestores na identificação de áreas prioritárias no cuidado à saúde de crianças com anomalias congênitas do sistema nervoso.

The effect of paternal factors on perinatal and paediatric outcomes: a systematic review and meta-analysis

BACKGROUND

Maternal factors, including increasing childbearing age and various life-style factors, are associated with poorer short- and long-term outcomes for children, whereas knowledge of paternal parameters is limited. Recently, increasing paternal age has been associated with adverse obstetric outcomes, birth defects, autism spectrum disorders and schizophrenia in children.

OBJECTIVE AND RATIONALE

The aim of this systematic review is to describe the influence of paternal factors on adverse short- and long-term child outcomes.

SEARCH METHODS

PubMed, Embase and Cochrane databases up to January 2017 were searched. Paternal factors examined included paternal age and life-style factors such as body mass index (BMI), adiposity and cigarette smoking. The outcome variables assessed were short-term outcomes such as preterm birth, low birth weight, small for gestational age (SGA), stillbirth, birth defects and chromosomal anomalies. Long-term outcome variables included mortality, cancers, psychiatric diseases/disorders and metabolic diseases. The systematic review follows PRISMA guidelines. Relevant meta-analyses were performed.

OUTCOMES

The search included 14 371 articles out of which 238 met the inclusion criteria, and 81 were included in quantitative synthesis (meta-analyses). Paternal age and paternal life-style factors have an association with adverse outcome in offspring. This is particularly evident for psychiatric disorders such as autism, autism spectrum disorders and schizophrenia, but an association is also found with stillbirth, any birth defects, orofacial clefts and trisomy 21. Paternal height, but not BMI, is associated with birth weight in offspring while paternal BMI is associated with BMI, weight and/or body fat in childhood. Paternal smoking is found to be associated with an increase in SGA, birth defects such as congenital heart defects, and orofacial clefts, cancers, brain tumours and acute lymphoblastic leukaemia. These associations are significant although moderate in size, with most pooled estimates between 1.05 and 1.5, and none exceeding 2.0.

WIDER IMPLICATIONS

Although the increased risks of adverse outcome in offspring associated with paternal factors and identified in this report represent serious health effects, the magnitude of these effects seems modest.

Plasma zinc levels in Ecuadorian mothers of infants with nonsyndromic cleft lip with or without cleft palate: A case series

BACKGROUND

Previous studies have reported an association between maternal zinc deficiency and increased risk of nonsyndromic cleft lip with or without cleft palate (NSCL/P) in offspring. A high prevalence of zinc deficiency and a high prevalence of NSCL/P have been reported in Ecuador. We postulated that mothers of infants with NSCL/P may have lower serum zinc levels than women from the general population.

METHODS

A case series study was conducted from November 2013 to July 2016. Thirty-five healthy mothers of infants with NSCL/P were selected during surgical missions conducted by Operación Sonrisa Ecuador. A single blood sample along with pertinent medical history was collected during personal interviews after 3.6 months postpartum. The prevalence of plasma zinc concentration (PZn) deficiency among the participants was determined and analyzed along with the prevalence of PZn deficiency in Ecuadorian women of reproductive age from the general population.

RESULTS

The mean PZn was 11.47 µmol/dm³ . The prevalence of PZn deficiency among the participants was 31.4% (95% CI: 17.1-48.6) and differed significantly from the prevalence of zinc deficiency observed among women from the general population (G²  = 8.66; p < .05).

CONCLUSIONS

The results showed that the prevalence of PZn deficiency is lower in a cohort of healthy mothers of infants with NSCL/P than in women from the general population in Ecuador. More studies are required to confirm these findings and evaluate other factors related to NSCL/P pathophysiology in the Ecuadorian population.

Individual deprivation, regional deprivation, and risk for oral clefts in Argentina

Objective. The aim of this study was to analyze the effects of individual low socioeconomic status (SES) and deprived geographical area (GA) on the occurrence of isolated cleft lip with or without cleft palate (CL±P) in Argentina.

Methods. This case-control study included 577 newborns with isolated CL±P and 13 344 healthy controls, born between 1992 and 2001, from a total population of 546 129 births in 39 hospitals in Argentina. Census data on unsatisfied basic needs were used to establish the degree of geographical area deprivation. An SES index for each individual was established, using maternal age, gravidity, low paternal and maternal education, and low-level paternal occupation. Logistic regression was used to assess the effects of low SES and of deprived GA on CL±P.

Results. A slightly increased risk of CL±P was observed in mothers with a low SES, while a deprived GA showed no effect. Native ancestry, acute maternal illnesses, and poor prenatal care were significant risk factors for CL±P for the mothers with low SES, after using propensity scores to adjust for the demographic characteristics in cases and controls.

Conclusions. Low individual SES slightly increased the risk for CL±P, but a deprived GA did not have that effect. There was no interaction between individual SES and deprived GA. Factors related to low individual SES—including poor prenatal care, low parental education, lack of information, and lifestyle factors—should be primarily targeted as risk factors for CL±P rather than factors related to a deprived place of residence.

Altitude as a risk factor for the development of hypospadias. Geographical cluster distribution analysis in South America

OBJECTIVE

Hypospadias is the most common congenital anomaly affecting the genitals. It has been established as a multifactorial disease with increasing prevalence. Many risk factors have been identified such as prematurity, birth weight, mother's age, and exposure to endocrine disruptors. In recent decades multiple authors using surveillance systems have described an increase in prevalence of hypospadias, but most of the published literature comes from developed countries in Europe and North America and few of the published studies have involved cluster analysis. Few large-scale studies have been performed addressing the effect of altitude and other geographical aspects on the development of hypospadias. Acknowledging this limitation, we present novel results of a multinational spatial scan statistical analysis over a 30-year period in South America and an altitude analysis of hypospadias distribution on a continent level.

METHOD

A retrospective review was performed of the Latin American collaborative study of congenital malformations (ECLAMC). A total of 4,020,384 newborns was surveyed between 1982 and December 2011 in all participating centers. We selected all patients with hypospadias. All degrees of clinical severity were included in the analysis. Each participating center was geographically identified with its coordinates and altitude above sea level. A spatial scan statistical analysis was performed using Kulldorf's methodology and a prevalence trend analysis over time in centers below and above 2000 m.

RESULTS

During the study period we found 159 hospitals in six different countries (Colombia, Bolivia, Brazil, Argentina, Chile, and Uruguay) with 4,537 cases of hypospadias and a global prevalence rate of 11.3/10,000 newborns. Trend analysis showed that centers below 2000 m had an increasing trend with an average of 10/10,000 newborns as opposed to those centers above 2000 m that showed a reducing trend with an average prevalence of 7.8 (p = 0.1246). We identified clusters with significant increases of prevalence in five centers along the coast at an average altitude of 219.8 m above sea level (p > 0.0000). Reduction in prevalence was found in clusters located in two centers on the Andes mountains. Altitude of 2,000 m was associated with hypospadias (Figure), with an OR 0.59 (0.5-0.69). There are ethnic arguments to support our results supported by protective polymorphism distribution in high lands.

CONCLUSION

Altitude above 2,000 m is suggested to have a protective effect for hypospadias. Specific clusters have been identified with increased risk for hypospadias. Environmental risk factors in these areas need to be further studied given the association seen between altitude and the distribution of more severe cases.

Geographic clusters of congenital anomalies in Argentina

Geographical clusters are defined as the occurrence of an unusual number of cases higher than expected in a given geographical area in a certain period of time. The aim of this study was to identify potential geographical clusters of specific selected congenital anomalies (CA) in Argentina. The cases were ascertained from 703,325 births, examined in 133 maternity hospitals in the 24 provinces of Argentina. We used the spatial scan statistic to determine areas of Argentina which had statistically significant elevations of prevalence. Prenatal diagnosis followed by referral of high-risk pregnancies to high complexity hospitals in a hospital-based surveillance system can create artifactual clusters. We assessed the referral bias by evaluating the prevalence heterogeneity within each cluster. Eight clusters of selected CAs with unusually high birth prevalence were identified: anencephaly, encephalocele, spina bifida, diaphragmatic hernia, talipes equinovarus, omphalocele, Cleft lip with or without cleft palate (CL/P), and Down syndrome. The clusters of Down syndrome and CL/P observed in this study match the previously reported clusters. These findings support local targeted interventions to lower the prevalence of the CAs and/or further research on the cause of each cluster. The clusters of spina bifida, anencephaly, encephalocele, omphalocele, congenital diaphragmatic hernia, and talipes equinovarus may be influenced by prenatal diagnosis and referral to high complexity hospitals.

Environmental factors related to the occurrence of oral clefts in a Brazilian subpopulation

Background:

A cross-sectional study was conducted at the Craniofacial Rehabilitation Center in the General Hospital of the University of Cuiabá, Cuiabá city, Mato Grosso, Brazil.

Materials and Methods:

Poisson regression model was used to analyze the relationship between antenatal factors and the occurrence of oral clefts in 116 patients.

Results:

Oral clefts were more common in males (64.66%) and White race (46.02%). The mean age of the children was 21.91 months. The most common type of cleft was cleft lip and palate (CLP, 55.17%). Maternal and paternal smoking in the first trimester of pregnancy and parity were significantly associated with the occurrence of CLP. Parent's age, educational level, and occupation did not interfere in the occurrence of oral clefts. There was also no significant association between maternal illness, medication use, alcohol consumption, and maternal exposure to chemicals in the first trimester of pregnancy and the occurrence of clefts in this population.

Conclusion:

The analysis of the environmental factors present during the pregnancy of children with oral clefts revealed a significant association between parity (second onward), maternal smoking, and paternal smoking and the occurrence of CL and/or palate in this population.

Temporal trend in the reported birth prevalence of cleft lip and/or cleft palate in Brazil, 2000 to 2013

BACKGROUND

The birth prevalence of cleft lip with or without cleft palate (CL/P) in Brazil increased between the years from 1975 to 1994 but has not been evaluated for temporal trend since then.

METHODS

We used data from the Brazilian National Health Information System for the years 2000 through 2013. We calculated the reported CL/P birth prevalence each year per 10,000 live births and estimated the average increase in reported prevalence per year (and 95% confidence interval [CI]) by fitting a negative binomial regression model. We also estimated the temporal trend in each of the five Brazilian regions for this time period.

RESULTS

The overall reported birth prevalence was 4.85 (95% CI, 4.78-4.91) per 10,000 live births. The reported birth prevalence of CL/P increased over this time period, from 3.94 (95% CI, 3.73-4.17) per 10,000 in 2000 to 5.46 (95% CI, 5.20-5.74) per 10,000 in 2013. The temporal trend differed for different Brazilian geographic regions, being confined primarily to the Northeast (4.7% per year; 95% CI, 4.0%-5.5%), North (3.3% per year; 95% CI, 1.8%-4.7%), and Central (2.9% per year; 95% CI, 0.9%-4.9%) regions.

CONCLUSION

In recent years, there appears to be an upward trend in the reported prevalence of CL/P in Brazil, confined to the less developed regions of the country. The increase likely reflects improved surveillance; whether it also reflects etiologic differences is unknown. Birth Defects Research (Part A) 106:789-792, 2016. © 2016 Wiley Periodicals, Inc.

Analysis of the genetic ancestry of patients with oral clefts from South American admixed populations

Increased susceptibility to cleft lip, with or without cleft palate (CL±P) has been observed in South America, as related to Amerindian ancestry, using epidemiological data, uniparental markers, and blood groups. In this study, it was evaluated whether this increased risk remains when Amerindian ancestry is estimated using autosomal markers and considered in the predictive model. Ancestry was estimated through genotyping 62 insertion and deletion (INDEL) markers in sample sets of patients with CL±P, patients with cleft palate (CP), and controls, from Patagonia in southern Argentina and Belém in northern Brazil. The Amerindian ancestry in patients from Patagonia with CL±P was greater than in controls although it did not reach statistical significance. The European ancestry in patients with CL±P from Belém and in patients with CP from Belém and Patagonia was higher than in controls and statistically significant for patients with CP who were from Belém. This high contribution of European genetic ancestry among patients with CP who were from Belém has not been previously observed in American populations. Our results do not corroborate the currently accepted risks for CL±P and CP estimated by epidemiological studies in the North American populations and probably reflect the higher admixture found in South American ethnic groups when compared with the same ethnic groups from the North American populations.

Descriptive analysis of high birth prevalence rate geographical clusters of congenital anomalies in South America

BACKGROUND

The birth prevalence rate (BPR) of congenital anomalies (CAs) is heterogeneous and exhibits geographical and sociocultural variations throughout the world. In South America (SA), high birth prevalence regions of congenital anomalies have been observed. The aim of this study was to identify, describe, and characterize geographical clusters of congenital anomalies in SA.

METHODS

This observational descriptive study is based on clinical epidemiological data registered by the Latin-American Collaborative Study of Congenital Malformations network. Between 1995 and 2012, a total of 25,082 malformed newborns were ascertained from 2,557,424 births at 129 hospitals in SA. The spatial scan statistic was used to determine geographical regions with high BPR of CAs. The BPR was obtained with a Poisson regression model. Odds ratios were estimated for several risk factors inside the geographical clusters.

RESULTS

We confirmed the existence of high BPR regions of CAs in SA. Indicators of low socioeconomic conditions, such as a low maternal education, extreme age childbearing, infectious diseases, and medicine use during pregnancy were detected as risk factors inside these regions. Native and African ancestries with high frequency of consanguineous marriages could explain partially these high BPR clusters.

CONCLUSION

The recognition of clusters could be a starting point in the identification of susceptibility genes associated with the occurrence of CA in high BPR regions.

A descriptive epidemiology study of oral cleft in sergipe, Brazil

Introduction The nonsyndromic orofacial cleft is the fourth most common birth defect, but in Brazil, data about the cleft epidemiology are not accurate.

Objective This study aimed to describe the epidemiologic characteristics of oral cleft cases at Specialized Society Attending Cleft Patient in Sergipe State.

Methods Data were obtained from patients' medical records in relation to the following characteristics: age; gender; race; origin; cleft type; additional malformations and/or complications; prenatal accomplishment; treatment applied. For diagnosis analysis, it was noted if mothers had received prenatal care and if they had ultrasonography performed and if the cleft was viewed in it.

Results We observed a prevalence of male gender (54%). Age between 0 and 4 years old was most prevalent (53%), and pheoderma race was observed in 47%. Transincisive foramen cleft was found in 52.3% of the individuals. The prevalence of pre- and transincisive foramen cleft was higher in men (66.3 and 55.7%), women accounted for 65.0% of postincisive foramen, and atypical facial cleft (0.3%) occurred in one case. Associated malformations and complications were present in 12% of patients. Prenatal care was reported by 48% of the mothers.

Conclusion In this study male gender was the most affected, and 0 to 4 years was the most frequent age group. Transincisive foramen cleft type was most frequently encountered. Prenatal care was reported by most mothers. So, this study found that early treatment is a reality in SEAFESE (Service Specializing in Cleft Care of Sergipe), and consequently the chances of successful integration of the child to society will be better.

Parental health and social support in the first trimester of pregnancy and the risk of oral clefts: a questionnaire-based, case-control study

BACKGROUND

Nonsyndromic oral clefts are complex in cause and have multiple genetic and environmental risk factors. This retrospective, questionnaire-based, case-control study investigated the relationship between oral clefts and parental mental and physical health and social support.

METHODS

Three hundred forty-seven parents of children with nonsyndromic oral clefts and 420 controls were included. Maternal and paternal health during the first trimester was assessed using interviews and questionnaires modeled from the Cornell Medical Index and the Social Support Rating Scale. Case-control analyses were performed using t tests, chi-square tests, and logistic regression.

RESULTS

Parental age, household income, and subsisting on farming were significantly different for cases and controls. The Cornell Medical Index for cases was significantly worse compared with controls for physical and psychological health. Logistic regression showed that nine factors were significantly associated with oral clefts: paternal respiratory health (OR, 1.56; p = 0.03), maternal gastrointestinal health (OR, 1.71; p < 0.01), maternal musculoskeletal health (OR, 1.50; p < 0.01), paternal nervous system health (OR, 2.82; p < 0.01), maternal frequency of illness (OR, 2.21; p = 0.01), maternal diseases (OR, 2.44; p < 0.01), maternal health habits (OR, 1.73; p < 0.01), paternal feelings of inadequacy (OR, 2.28; p = 0.03), and maternal anger (OR, 2.28; p < 0.01) in the first trimester. Weaker social support from the community was associated with oral clefts (p < 0.01).

CONCLUSION

Maternal and paternal health and social support may affect a family's risk of having a child with a cleft.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Risk factors involved in orofacial cleft predisposition - review

Clefts that occur in children are a special topic. Avoiding risk factors, and also an early diagnosis of cleft possibility can result in minimizing or avoiding them. If on the other hand when clefts occur they require a long-term, multistage specialized treatment. Etiology of clefts seems to be related to many factors. Factors such as genetic, environmental, geographic and even race factors are important. Identification of risk factors can lead to prevention and prophylactic behaviors in order to minimize its occurrence. Exposure to environmental factors at home and work that lead to cleft predisposition should not be disregarded. It seems that before planning a family it would be wise to consult with doctors of different specializations, especially in high-risk families with cleft history in order to analyze previous lifestyle. Clefts are very common in hereditary facial malformations and are causing a lot of other irregularities in the head and neck region. In this paper after a brief papers review authors present socio-geographic, environmental and also work place related factors that are influencing pregnant women condition and should be taken under serious consideration.

Epidemiology of Orofacial Clefts in the East of Ireland in the 25-Year Period 1984–2008

Objective

To describe the epidemiology of orofacial clefts in the east of Ireland.

Design and Setting

A descriptive epidemiologic study on 851 cases of orofacial cleft identified over a 25-year period from 1984 to 2008 from more than 500,000 births.

Results

There were 438 (51.5%) cases of cleft lip with or without cleft palate and 413 (48.5%) cases of cleft palate. The total birth prevalence was 16.0 per 10,000 births for all orofacial clefts, 8.2 for cleft lip with or without cleft palate, and 7.8 for cleft palate. Of all cases, 63.7% (542/851) occurred as isolated anomalies, 21.5% (183/851) were associated with multiple anomalies, and 14.8% (126/851) were associated with a syndrome or chromosomal anomaly. A significantly increasing trend over the 25-year period was observed for cleft lip with or without cleft palate associated with syndromes or chromosomal anomalies among mothers younger than 35 years but not in those older than 35 years.

Conclusion

A slightly higher rate of orofacial clefts was observed in the east of Ireland than was observed in European and multinational studies during the study period, and there were higher rates of cleft palate. The rising trend in the proportion of mothers aged 35 years or older in Ireland is not contributing significantly to orofacial clefts associated with chromosomal syndromes.

Is Gravidity 4+ a Risk Factor for Oral Clefts? A Case-Control Study in Eight South American Countries Using Structural Equation Modeling

Background

There is disagreement about the association between cleft lip with or without cleft palate and multigravidity, which could be explained by differences of adjusting for maternal age, Amerindian ancestry, and socioeconomic status.

Objective

The aim was to evaluate gravidity 4+ (four or more gestations) as a risk factor for cleft lip with or without cleft palate in South America.

Design

We used a matched (1:1) case-control study with structural equation modeling for related causes. Data were obtained from 1,371,575 consecutive newborn infants weighing ≥500 g who were born in the hospitals of the Estudio Colaborativo Latinoamericano de Malformaciones Congénitas (ECLAMC) network between 1982 and 1999. There were a total of 1,271 cases with cleft lip with or without cleft palate (excluding midline and atypical cleft lip with or without cleft palate). A total of 1,227 case-control pairs were obtained, matched by maternal age, newborn gender, and year and place of birth. Potential confounders and intermediary variables were analyzed with structural equation modeling.

Results

The crude risk of gravidity 4+ was 1.41 and the 95% confidence interval was 1.14 to 1.61. When applying structural equation modeling, the effect of multigravidity on the risk of cleft lip with or without cleft palate was 1.22 and the 95% confidence interval was 0.91 to 1.39.

Conclusions

Multigravid mothers (more than four gestations) showed no greater risk of bearing children who had cleft lip with or without cleft palate than mothers with two or three births. Therefore, the often observed and reported association between multigravidity and oral clefts likely reflects the effect of other risk factors related to low socioeconomic status in South American populations.

Alterations and chromosomal variants in the Ecuadorian population

Medical genetics is a field marked by fast progress. Even though it was at one point confined to a group of relatively rare diseases, today it has become a central component in the understanding of disorders and it is the subject of interest for all medical specialties. This paper, shares data on the chromosomal alterations and variations that have been diagnosed in Ecuadorian patients since 1998. A total of 2,636 individual cases have been analyzed by G-banding technique until February 2012. The present work shows this collection of data and the important findings that have appeared throughout these years in hopes that it can contribute to have a deeper understanding of the incidence of chromosomal aberrations and alterations in the Ecuadorian population.

Cleft lip and palate: recommendations for dental anesthetic procedure based on anatomic evidences

Patients with cleft lip and palate usually present dental anomalies of number, shape, structure and position in the cleft area and the general dentist is frequently asked to restore or extract those teeth. Considering that several anatomic variations are expected in teeth adjacent to cleft areas and that knowledge of these variations by general dentists is required for optimal treatment, the objectives of this paper are: 1) to describe changes in the innervation pattern of anterior teeth and soft tissue caused by the presence of a cleft, 2) to describe a local anesthetic procedure in unilateral and bilateral clefts, and 3) to provide recommendations to improve anesthetic procedures in patients with cleft lip and palate. The cases of 2 patients are presented: one with complete unilateral cleft lip and palate, and the other with complete bilateral cleft lip and palate. The patients underwent local anesthesia in the cleft area in order to extract teeth with poor bone support. The modified anesthetic procedure, respecting the altered course of nerves in the cleft maxilla and soft tissue alterations at the cleft site, was accomplished successfully and the tooth extraction was performed with no pain to the patients. General dentists should be aware of the anatomic variations in nerve courses in the cleft area to offer high quality treatment to patients with cleft lip and palate.

Congenital malformations in Ecuadorian children: urgent need to create a National Registry of Birth Defects

AIM

This study sets out (a) to estimate the prevalence of admissions by birth defects, using the official database of hospitals of Ecuador; and (b) to set the basis for a new National Register of Birth Defects in Ecuador that works as a program for the clinical and epidemiological investigation of risk factors in the etiology of congenital anomalies in Ecuadorian hospitals, using a case-control methodological approach. This is the first report in their class.

METHODS

The data used in this study are derived from the National Register of Hospital Admission/Discharges of the Instituto Nacional de Estadísticas y Censos; data of the Ministry of Public Health were also used. Ecuador does not have an official Medical Birth Registry or a Congenital Malformations Registry.

RESULTS

A total of 51,375 discharges by congenital malformations were registered in a 7-year period. Of these, 16,679 admissions were of children aged less than 1 year of age, with a birth prevalence rate (BPR) of 72.33/10,000 births. 77% of the congenital defects registered comprise the 50 most common birth defects observed in this age group. Cleft lip was the most prevalent birth defect in children less than 1 year of age and the second most common defect in children 1 to 5 years of age. Unilateral cleft lip shows a BPR of 4.57/10,000 births; cardiac birth defects as a group have a BPR of 4.2; hydrocephalus a BPR of 3.77; and Down's syndrome a BPR of 3.70. Undescended testicle was the most prevalent birth defect in children between 1 to 5 years. 9384 children under 1 year of age were male (55.9%) and 7053 were female (42.1%). BPR in males was 40.45 and in females 30.40.

CONCLUSION

This report documents the prevalence estimates for birth defects reported in the hospital discharge data. These estimates are important to 1) plan for health-care and education needs of the Ecuadorian population, 2) identify increased occurrences of birth defects in specific geographic regions, 3) serve as a reference point for assessment of provincial surveillance systems, 4) evaluate national public health interventions, 5) compare Ecuador prevalence estimates with those of other countries, and 6) help determine the appropriate allocation of resources for basic and public health research. There is an urgent need to establish a National Registry of Birth Defects involving different sources of information such as prenatal medical records, birth records and medical records during the first year of life at an early stage, and surveys on cytogenetic prenatal diagnostic surveys and cytogenetics of therapeutic abortions.

Parental age as a risk factor for non-syndromic oral clefts: a meta-analysis

OBJECTIVES

A meta-analysis was conducted to assess the relationship between parental age and the occurrence of non-syndromic oral clefts. The questions addressed if younger or older mothers and fathers have an increased risk of having a child with non-syndromic oral clefts.

DATA

Data from cohort studies, case-control, cross-sectional and prevalence studies in which the association between parental age and oral clefts was investigated were analysed. Only studies on oral clefts not associated with syndromes or other anomalies were considered.

SOURCES

An electronic literature search were conducted in Medline, Embase, LILACS, SciELO, SCOPUS and the Cochrane library databases to identify original research published until November 2010. References of the selected articles were also searched.

STUDY SELECTION

The initial database search identified 4623 citations and according to eligibility criteria 80 articles were submitted to quality assessment. In 13 studies measures of association could be extracted for meta-analysis.

CONCLUSION

Our findings suggest that fathers forty years of age or older had a 58% higher probability of having a child with cleft palate compared to those aged between 20 and 39 years. The probability of mothers aged between 35 and 39 years having a child with cleft palate was 20% higher in comparison with those between 20 and 29 years-old, whilst for those aged 40 years or more this probability was 28% higher compared to those aged between 20 and 29 years. Mothers aged 40 years or over were 1.56 times more likely to have a newborn with cleft lip with or without palate compared to those aged between 20 and 29 years. No evidence of association between early maternal and paternal age with occurrence of oral clefts was observed.

Sentinel phenotype for rubella embryopathy: time-space distribution in Brazil

The dyad comprising eye anomalies and congenital heart defects in the same newborn has been proposed as the best sentinel phenotype for the early detection of rubella embryopathy. Time-space birth prevalence distributions of the eye-heart dyad were described in 36 Brazilian hospitals from the Latin-American Collaborative Study of Congenital Anomalies - ECLAMC network, for the period 1994-2008. Seventy dyad cases observed among 554,531 births showed seasonal variation (Χ2 = 5.84; p < 0.05), suggesting an environmental etiology, with an increase in cases in October-March and acrophase in December. The secular distribution of dyad prevalence rates was consistent with the distribution of rubella cases in Brazil, showing a decrease from 1994 to 2004, followed by an increase until 2008. Two geographic clusters were identified, one with high and the other with low dyad prevalence. In the high prevalence cluster, a secular increase was observed, starting in 1999, matching the rubella epidemic waves observed in Brazil in 1998-2000 and 2006.

Levantamento epidemiológico dos pacientes portadores de fissura de lábio e/ou palato de um centro especializado de Belo Horizonte

OBJETIVO: traçar o perfil epidemiológico dos pacientes com fissura de lábio e/ou palato de um centro especializado de Belo Horizonte. MÉTODO: os dados referentes ao ano de entrada no centro, tipo de fissura, gênero, cidade de origem e idade foram obtidos de planilha do Excel contendo o cadastro dos pacientes. A análise estatística foi realizada por meio do teste qui-quadrado, com nível de significância de 5%. RESULTADOS: a amostra foi composta por 1.219 pacientes, sendo 593 pacientes cadastrados em 2005, 273 em 2006, 222 em 2007 e 131 em 2008. Da amostra total, 49% apresentavam fissura transforame incisivo, 26% pós-forame, 19% pré-forame, 2% pré e pós-forame e 3% outros tipos de má formação craniofacial. Quanto ao gênero, 54% eram do gênero masculino e 46% do feminino. Quanto à origem, 33% eram moradores de Belo Horizonte, 28% de outras cidades da Região Metropolitana de Belo Horizonte, 38,5% do interior de Minas Gerais e 0,5% de outros Estados. Quanto à idade, esta variou de zero a 64 anos (mediana=6,0), com 40% chegando até três anos, 45,5% entre três e 18 anos e 14,5% acima de 18 anos. Segundo o ano de entrada, em 2005 prevaleceu a faixa de seis a 12 anos (29%) e nos anos seguintes a faixa de até um ano (38%, 36% e 43%). CONCLUSÃO: neste centro, a maior parte dos casos apresenta fissura do tipo transforame, é do gênero masculino, oriunda do interior do estado de Minas Gerais e formada por bebês e crianças.

Prevalence at Birth of Cleft Lip with or without Cleft Palate: Data from the International Perinatal Database of Typical Oral Clefts (IPDTOC)

As part of a collaborative project on the epidemiology of craniofacial anomalies, funded by the National Institutes for Dental and Craniofacial Research and channeled through the Human Genetics Programme of the World Health Organization, the International Perinatal Database of Typical Orofacial Clefts (IPDTOC) was established in 2003. IPDTOC is collecting case-by-case information on cleft lip with or without cleft palate and on cleft palate alone from birth defects registries contributing to at least one of three collaborative organizations: European Surveillance Systems of Congenital Anomalies (EUROCAT) in Europe, National Birth Defects Prevention Network (NBDPN) in the United States, and International Clearinghouse for Birth Defects Surveillance and Research (ICBDSR) worldwide. Analysis of the collected information is performed centrally at the ICBDSR Centre in Rome, Italy, to maximize the comparability of results. The present paper, the first of a series, reports data on the prevalence of cleft lip with or without cleft palate from 54 registries in 30 countries over at least 1 complete year during the period 2000 to 2005. Thus, the denominator comprises more than 7.5 million births. A total of 7704 cases of cleft lip with or without cleft palate (7141 livebirths, 237 stillbirths, 301 terminations of pregnancy, and 25 with pregnancy outcome unknown) were available. The overall prevalence of cleft lip with or without cleft palate was 9.92 per 10,000. The prevalence of cleft lip was 3.28 per 10,000, and that of cleft lip and palate was 6.64 per 10,000. There were 5918 cases (76.8%) that were isolated, 1224 (15.9%) had malformations in other systems, and 562 (7.3%) occurred as part of recognized syndromes. Cases with greater dysmorphological severity of cleft lip with or without cleft palate were more likely to include malformations of other systems.

How valid are the rates of Down syndrome internationally? Findings from the International Clearinghouse for Birth Defects Surveillance and Research

Rates of Down syndrome (DS) show considerable international variation, but a systematic assessment of this variation is lacking. The goal of this study was to develop and test a method to assess the validity of DS rates in surveillance programs, as an indicator of quality of ascertainment. The proposed method compares the observed number of cases with DS (livebirths plus elective pregnancy terminations, adjusted for spontaneous fetal losses that would have occurred if the pregnancy had been allowed to continue) in each single year of maternal age, with the expected number of cases based on the best-published data on rates by year of maternal age. To test this method we used data from birth years 2000 to 2005 from 32 surveillance programs of the International Clearinghouse for Birth Defects Surveillance and Research. We computed the adjusted observed versus expected ratio (aOE) of DS birth prevalence among women 25-44 years old. The aOE ratio was close to unity in 13 programs (the 95% confidence interval included 1), above 1 in 2 programs and below 1 in 18 programs (P < 0.05). These findings suggest that DS rates internationally can be evaluated simply and systematically, and underscores how adjusting for spontaneous fetal loss is crucial and feasible. The aOE ratio can help better interpret and compare the reported rates, measure the degree of under- or over-registration, and promote quality improvement in surveillance programs that will ultimately provide better data for research, service planning, and public health programs.

The impact of altitude on infant health in South America

Several studies report that altitude reduces birth weight. However, much remains unknown about effects in various altitude ranges and about the heterogeneity in altitude effects by fetal health endowments. This study estimates the effects of altitude in South America on the means and quantiles of birth weight and gestational age separately for two large samples born at altitude ranges of 5 to 1,280 m and 1,854 to 3,600 m. The study finds significant negative altitude effects on birth weight and gestational age in the low-altitude sample and on birth weight in the high-altitude sample. Altitude effects are larger for infants with very low fetal health endowments. The study finds differences in the effects of several inputs such as socioeconomic status and maternal fertility history and health between the two altitude samples. The study highlights the importance of adverse altitude effects on infant health when evaluating the costs and returns of policies that change the number of individuals who reside at higher altitude in both low and high altitude ranges.

Small area estimation of sparse disease counts using shared component models-application to birth defect registry data in New South Wales, Australia

In the field of disease mapping, little has been done to address the issue of analysing sparse health datasets. We hypothesised that by modelling two outcomes simultaneously, one would be able to better estimate the outcome with a sparse count. We tested this hypothesis utilising Bayesian models, studying both birth defects and caesarean sections using data from two large, linked birth registries in New South Wales from 1990 to 2004. We compared four spatial models across seven birth defects: spina bifida, ventricular septal defect, OS atrial septal defect, patent ductus arteriosus, cleft lip and or palate, trisomy 21 and hypospadias. For three of the birth defects, the shared component model with a zero-inflated Poisson (ZIP) extension performed better than other simpler models, having a lower deviance information criteria (DIC). With spina bifida, the ratio of relative risk associated with the shared component was 2.82 (95% CI: 1.46-5.67). We found that shared component models are potentially beneficial, but only if there is a reasonably strong spatial correlation in effect for the study and referent outcomes.

Whorl patterns on the lower lip are associated with nonsyndromic cleft lip with or without cleft palate

Nonsyndromic cleft lip with or without cleft palate (CL/P) is a common birth defect due to both genetic and environmental factors. Whorl lip print patterns are circular grooves on the central upper lip and/or the left and right lower lip. To determine if whorls are more common in families with CL/P than in controls, the Pittsburgh Orofacial Cleft Study collected lip prints from over 450 subjects, that is, individuals with CL/P, their relatives, and unrelated controls-from the U.S., Argentina, and Hungary. Using a narrow definition of lower-lip whorl, the frequency of whorls in the U.S. sample was significantly elevated in cleft individuals and their family members, compared to unrelated controls (14.8% and 13.2% vs. 2.3%; P = 0.003 and 0.001, respectively). Whorls were more frequent in CL/P families from Argentina than in CL/P families from the U.S. or Hungary. If these results are confirmed, whorl lip print patterns could be part of an expanded phenotypic spectrum of nonsyndromic CL/P. As such, they may eventually be useful in a clinical setting, allowing recurrence risk calculations to incorporate individual phenotypic information in addition to family history data.