Mental and motor development and psychosocial adjustment of Chinese children with phenylketonuria

Neuropsychological and quality of life outcomes in PKU patients: expert recommendations of assessment tools in Brazil

BACKGROUND

 Phenylketonuria (PKU) is an inborn error of metabolism caused by deficient activity of phenylalanine hydroxylase. In Brazil, the National Neonatal Screening Program enables early treatment of patients with PKU, which prevents them from developing severe neurological damage and mental disabilities. However, between 20 and 30% of early-treated patients with PKU present focal cognitive deficits, including deficits in working memory, processing speed, and psychiatric symptoms such as anxiety, depression, and attention deficit hyperactivity disorder (ADHD). Therefore, age-specific neuropsychiatric and cognitive tests are important components of PKU patient care. To date, there are no officially approved guidelines or recommendations of tools in Portuguese validated for use in Brazil that could be applied to assess these parameters in patients with PKU.

OBJECTIVE

 To recommend tools validated for use in Brazil that can be used in daily clinical practice to assess quality of life and neuropsychological outcomes in patients with PKU.

METHODS

 Six Brazilian experts discussed about eligible tools based on their clinical experience, the feasibility of their use in clinical routines, and their availability in public health services. Before the meeting, an independent review of the literature was conducted to identify the currently validated tools in Brazil, using the MEDLINE and SciELO databases.

RESULTS

 The experts recommended nine tools to assess quality of life (Peds-QL, SF-36 or WHOQOL-bref), executive function (BRIEF or Bayley-III), IQ (SONR 2½-7[a] or WASI) and ADHD (MTA-SNAP-IV and ASRS).

CONCLUSION

 These instruments may be easily incorporated into clinical practice and improve the quality of multidisciplinary care of patients with PKU.

Paths of social-emotional development before 3 years old and child development after 5 years old: Evidence from rural China

BACKGROUND

Social-emotional development during the first three years of life is associated with later social-emotional development and cognitive development. In rural China, research has found large shares of children under age three are developmentally delayed, yet little is known about the paths of social-emotional development before age 3 or how developmental paths predict later social-emotional skills and cognitive skills.

AIMS

To investigate the paths of child social-emotional development during ages 0-3 and examine how different paths predict social-emotional development and cognitive development at preschool age.

METHODS

Three waves of longitudinal panel data from 1245 children in rural Western China was collected. Child social-emotional development was measured by the Ages and Stages Questionnaire: Social-Emotional. Child cognitive development was measured by the Bayley Scales of Infant Development and by the Wechsler Preschool and Primary Scale of Intelligence-Fourth Edition. Four paths of child social-emotional development were classified: "never" social-emotionally delayed; "persistently" social-emotionally delayed; "improving," or "deteriorating."

RESULTS

331 (27%) were never social-emotionally delayed; 373 children (30%) were persistently social-emotionally delayed; 149 children (12%) experienced improving social-emotional development; and 392 children (31%) experienced deteriorating social-emotional development. Children who were never social-emotionally delayed or who were on an "improving" path had higher social-emotional development at preschool age (p < .01). Children who were persistently social-emotionally delayed (p < .5) and on a deteriorating path (p < .01) had lower social-emotional development at preschool age. Children on the persistently delay path also were shown to have lower levels of cognitive development at preschool age (p < .01).

CONCLUSIONS

Different paths of child social-emotional development before age 3 are associated with different social-emotional and cognitive development at preschool age.

Stimulation and Early Child Development in China: Caregiving at Arm's Length

OBJECTIVE

To provide an empirical overview of the parenting landscape in rural China, focusing on 18- to 30-month-old children and their caregivers in rural Shaanxi province.

METHODS

We collected unique data on 1442 caregiver-toddler dyads in rural areas of Shaanxi province and examined caregiver attitudes toward parenting, sources of information about parenting, and interactive parenting practices, and how each of these differed across generations. We measured how parenting attitudes and sources of information informed parenting practices. Finally, we measured levels of child development in our sample and the association between parenting practices and children's developmental outcomes.

RESULTS

Most of the caregivers did not engage with children in a way that encouraged early development. Caregivers rarely told stories, sang, or used toys to play with their children. Grandmothers were more stressed by the children in their care and engaged significantly less than mothers did in the 3 stimulating interactions. Professional sources of information about parenting were underutilized by all caregivers. We found high rates of developmental delay in our sample and showed that these delays were associated with the lack of caregiver engagement.

CONCLUSION

Our findings suggest that the major economic and social shifts occurring in rural China have not led to a widespread prevalence of stimulative parenting practices. Although caregivers report positive attitudes toward child-rearing, reliable sources of scientific information are lacking. Our results show a troubling generational disconnect between the information-seeking behaviors and parenting practices of rural caregivers.

The relationship between birth season and early childhood development: Evidence from northwest rural China

OBJECTIVE

To examine the correlation between birth season and early childhood development.

BACKGROUND

Almost all previous studies that examine the effect of birth season on early childhood development were conducted in developed countries with a limited sample size. The present study was conducted in poor, rural areas of western China, a developing region with a continental monsoon climate.

METHOD

We administered a hemoglobin test to 650 infants (52% boys), aged 8-10 months, using a Hemocue Hb 201+ finger prick system, and assessed the cognitive and psychomotor development of sample infants using Bayley Scales of Infant Development.

RESULTS

Infants born in winter have higher Hb concentrations (t = 3.63, p < 0.001) compared to infants born in summer. Similarly, cognitive development scores (t = 5.17, p < 0.001) and psychomotor development scores (t = 10.60, p < 0.001) were significantly higher among winter-born infants.

CONCLUSION

The findings point to the involvement of birth season in early childhood development and suggest that aspects of the environment shape the experiences that contribute to early childhood development. Policy suggestions such as providing infants with ample opportunities for movement and stimulation during the cold season are discussed.

Approach to Children with Aggressive Behavior for General Pediatricians and Hospitalists: Part 1-Epidemiology and Etiology

Children and adolescents are increasingly presenting to the hospital and emergency department with aggressive behavior and psychiatric emergencies. The rise in pediatric mental health problems, coupled with a lack of much needed resources, necessitates that pediatricians safely diagnose and treat patients presenting with aggressive behavior. In this article, we discuss the broad differential diagnosis that should be considered when initially evaluating a patient presenting with aggression or altered mental status; underlying causes include predisposing factors, comorbid conditions, and acute organic causes involving almost every organ system. Emergency and hospital physicians should tailor their examination and testing individually based on the patient's history and presentation. [Pediatr Ann. 2018;47(10):e402-e407.].

The complete European guidelines on phenylketonuria: diagnosis and treatment

Phenylketonuria (PKU) is an autosomal recessive inborn error of phenylalanine metabolism caused by deficiency in the enzyme phenylalanine hydroxylase that converts phenylalanine into tyrosine. If left untreated, PKU results in increased phenylalanine concentrations in blood and brain, which cause severe intellectual disability, epilepsy and behavioural problems. PKU management differs widely across Europe and therefore these guidelines have been developed aiming to optimize and standardize PKU care. Professionals from 10 different European countries developed the guidelines according to the AGREE (Appraisal of Guidelines for Research and Evaluation) method. Literature search, critical appraisal and evidence grading were conducted according to the SIGN (Scottish Intercollegiate Guidelines Network) method. The Delphi-method was used when there was no or little evidence available. External consultants reviewed the guidelines. Using these methods 70 statements were formulated based on the highest quality evidence available. The level of evidence of most recommendations is C or D. Although study designs and patient numbers are sub-optimal, many statements are convincing, important and relevant. In addition, knowledge gaps are identified which require further research in order to direct better care for the future.

The effect of a micronutrient powder home fortification program on anemia and cognitive outcomes among young children in rural China: a cluster randomized trial

BACKGROUND

Anemia early in life has been associated with delayed cognitive and motor development. The WHO recommends home fortification using multiple micronutrient powders (MNPs) containing iron as a strategy to address anemia in children under two. We evaluated the effects of a program freely distributing MNP sachets to caregivers of infants in rural China.

METHODS

We conducted a cluster-randomized controlled trial in Shaanxi province, enrolling all children aged 6-11 months in target villages. Following a baseline survey, investigators randomly assigned each village/cluster to a control or treatment group. In the treatment group, caregivers were instructed to give MNPs daily. Follow-up was after 6, 12, and 18 months of intervention. Primary outcomes were hemoglobin concentrations and scores on the Bayley Scales of Infant Development.

RESULTS

One thousand, eight hundred and-two eligible children and their caregivers were enrolled. At baseline 48% (870) of children were anemic and 29% (529) were developmentally delayed. Six hundred and-ten children (117 villages) were assigned to the control group and 1192 children (234 villages) were assigned to the treatment group. Assignment to the treatment group was associated with an improvement in hemoglobin levels (marginal effect 1.77 g/L, 95% CI 0.017-3.520, p-value = 0.048) and cognitive development (marginal effect 2.23 points, 95% CI 0.061-4.399, p-value = 0.044) after 6 months but not thereafter. There were no significant effects on motor development. Zero effects after the first 6 months were not due to low compliance, low statistical power, or changes in feeding behavior. Hemoglobin concentrations improved in both the treatment and control groups over the course of the study; however, 22% (325) of children remained anemic at endline, and 48% (721) were cognitively delayed.

CONCLUSIONS

Providing caregivers with MNP sachets modestly hastened improvement in hemoglobin levels that was occurring absent intervention; however, this improvement did not translate into improved developmental outcomes at endline.

TRIAL REGISTRATION

ISRCTN44149146 ; prospectively registered on 15th April 2013.

The relationship between infant peer interactions and cognitive development: Evidence from rural China

Social interactions in infancy have implications for long-term outcomes. This study uses data from a sample of 1412 rural Chinese infants aged 6–12 and 24–30 months to examine the relationship between peer interactions and cognitive development. Over 75% of the infants in this sample had less than three peers and around 20% had no peers in both periods. The prevalence of cognitive delays is high within this sample and increases as infants age. Multivariate analysis reveals that peer interaction is significantly associated with cognitive development. Heterogeneous analysis suggests that peer interactions and mental development may be related to the child’s primary caregiver and the distance from the child’s household to the center of their village.

Reciprocal moderation by Toxoplasma gondii seropositivity and blood phenylalanine - tyrosine ratio of their associations with trait aggression

We previously reported that trait aggression, proposed as an endophenotype for suicidal behavior, is positively associated with Toxoplasma gondii (T. gondii) seropositivity in females, but not in males. Additionally, older males seropositive for T. gondii had lower scores on measures of trait aggression, including self-aggression. Trait aggression may be influenced by dopaminergic signaling, which is known to be moderated by gender and age, and potentially enhanced in T. gondii positives through the intrinsic production of dopamine by the microorganism. Therefore, we investigated associations between trait aggression and interactions between T. gondii enzyme-linked immunoabsorbant assay (ELISA) IgG titer-determined seropositivity and high-performance liquid chromatography- (HPLC-) measured blood levels of dopamine precursors phenylalanine (Phe), tyrosine (Tyr), and their ratio in a sample of 1000 psychiatrically healthy participants. Aggressive traits were assessed using the questionnaire for measuring factors of aggression (FAF), the German version of the Buss-Durkee hostility questionnaire. We found that 1) the decrease in trait aggression scores in T. gondii-positive older males was only present in individuals with a low Phe:Tyr ratio, and 2) that there was a positive correlation between Phe:Tyr ratio and total aggression and selected subscales of aggression in T. gondii-positive males, but not in T. gondii-negative males. These findings point toward a gender-specific reciprocal moderation by Phe:Tyr ratio and T. gondii seropositivity of their associations with aggression scores, and lead to experimental interventions geared to manipulating levels of dopamine precursors in selected T. gondii positive individuals with increased propensity for aggression.

Parent Coping and the Behavioural and Social Outcomes of Children Diagnosed with Inherited Metabolic Disorders

OBJECTIVE

To explore the level of coping and management of parents of children with inherited metabolic disorders (IMD) and the relationship with children's cognitive, behavioural and social functioning.

METHODS

Parents of children (n = 22) with confirmed IMD (glutaric aciduria type I, methylmalonic aciduria, propionic aciduria, isovaleric aciduria, glycogen storage disease, maple syrup urine disease, ornithine transcarbamylase or very long-chain acyl-CoA dehydrogenase deficiency) completed standardised questionnaires regarding psychological distress, coping and family management. Children completed cognitive assessments and parents rated their behavioural and social functioning on standardised questionnaires. Scores were compared with normative data.

RESULTS

Most parents were coping well; 4/22 reported high levels of psychological distress. Exploratory analysis found that parent coping variables were correlated to the child's internalising symptoms, whereas family management was related to children's externalising behaviours and social skills. No relationship was found between parent variables and cognitive functioning.

CONCLUSIONS

Parental coping and family management impact on the child's internalising symptoms and externalising behaviours, respectively. Early identification of issues in these domains may enhance referral for therapeutic interventions and family support programmes.

Psychiatric disorders in adolescent and young adult patients with phenylketonuria

BACKGROUND AND OBJECTIVES

Psychiatric symptoms are a challenging aspect in adolescent and adult early treated phenylketonuric (ETPKU) patients. To assess the occurrence of psychiatric disorders we explored the presence of symptoms requiring intervention and further investigated the link between psychiatric disorders, the quality of biochemical control and cognitive functioning.

PATIENTS AND METHODS

Forty-six ETPKU patients (aged 12 to 44) and 30 age-matched healthy controls were subjected to cognitive and psychiatric assessment by means of self-report questionnaires and psychiatric interview. Psychiatric diagnoses, if detected, were made according to DSM-5 criteria. Concomitant IQ, historical and concurrent biochemical metabolic controls were included in the statistical analysis.

RESULTS

Twenty-five out of 46 ETPKUs showed clinical scores on at least one scale of the psychiatric assessment (7/30 in controls); anxiety and withdrawal were the most frequent self-reported symptoms. Seventeen patients (and no controls) met criteria for a psychiatric diagnosis, most of them belonging to the Anxiety Disorders category. The occurrence of psychiatric symptoms was not associated with the life-long and concurrent quality of metabolic control but patients with good metabolic control (≤ 500 μM) in the first 11 years of life showed higher frequency of psychiatric diagnosis (Fisher's exact p=.0300).

DISCUSSION/CONCLUSION

ETPKUs show a higher than normal vulnerability to psychiatric disorders, which cannot be explained by the usual biochemical alterations influencing intellectual outcome. Our data support the hypothesis that the burden of the disease acts as psychological stress for children and their families. Possible involvement of neuromediators in the pathogenesis of these complex symptoms requires further investigation.

Micronutrient deficiencies and developmental delays among infants: evidence from a cross-sectional survey in rural China

OBJECTIVES

Research increasingly indicates the importance of the nutritional programming that occurs in the first 2-3 years of life. Quality nutrition during this brief window has been shown to have large and significant effects on health and development throughout childhood and even into adulthood. Despite the widespread understanding of this critical window, and the long-term consequences of leaving nutritional deficiencies unaddressed, little is known about the status of infant nutrition in rural China, or about the relationship between infant nutrition and cognitive development in rural China.

DESIGN, SETTING AND PARTICIPANTS

In April 2013 and October 2013, we conducted a survey of 1808 infants aged 6-12 months living in 351 villages across 174 townships in nationally designated poverty counties in rural areas of southern Shaanxi Province, China.

MAIN OUTCOME MEASURES

Infants were administered a finger prick blood test for haemoglobin and assessed according to the Bayley Scales of Infant Development. They were also measured for length and weight. Caregivers were administered a survey of demographic characteristics and feeding practices.

RESULTS

We found that 48.8% of sample infants were anaemic, 3.7% were stunted, 1.2% were underweight and 1.6% were wasted. Approximately 20.0% of the sample infants were significantly delayed in their cognitive development, while just over 32.3% of the sample infants were significantly delayed in their psychomotor development. After controlling for potential confounders, infants with lower haemoglobin counts were significantly more likely to be delayed in both their cognitive (p<0.01) and psychomotor development (p<0.01).

CONCLUSIONS

The anaemia rates that we identify in this study classify anaemia as a 'severe' public health problem according to the WHO. In contrast, there is virtually no linear growth failure among this population. We find that low haemoglobin levels among our sample population are associated with significant cognitive and psychomotor delays that could eventually affect children's schooling performance and labour force outcomes.

TRIAL REGISTRATION NUMBER

ISRCTN44149146.

Neurodevelopmental profiles of children with glutaric aciduria type I diagnosed by newborn screening: a follow-up case series

Glutaric aciduria type I (GA-I) is an inherited metabolic disorder that may lead to severe motor disorder and cognitive impairment. GA-I is now included in the newborn screening programme in many countries as early detection allows for prompt treatment and effectively reduces the risk of poor developmental outcome. Information regarding the long-term neurodevelopmental outcome of children with GA-I treated early is sparse.We recruited children with a confirmed diagnosis of GA-I diagnosed via newborn screening, treated in our centre and >3 years of age (n = 6). Children were assessed at two time points using a comprehensive neuropsychological test battery. Four of these had been the subject of a previous report. All participants were male, 3-6 years at the initial assessment and 6-12 years of age at the follow-up assessment.Fine motor skills were below average in all patients. Speech, which was affected in all four patients reported previously, improved following speech therapy. IQ scores remained generally stable within the normal range. Executive functioning was average to high average in four patients. Behaviour, as assessed through parental questionnaires, was problematic in two patients. Compounding factors included child neglect, family history of autism and multiple admissions to hospital (n = 1 in each).GA-I affects fine motor skills and speech, regardless of early treatment, but not IQ scores. Patients with GA-I should be referred for assessment and appropriate early intervention. Further research is needed to correlate specific neuropsychological deficits with neuroimaging.