Gender differences in symptoms in partial responders to proton pump inhibitors for gastro-oesophageal reflux disease

BACKGROUND

Gender differences may exist in the symptom experience of patients with gastro-oesophageal reflux disease (GERD) who have a partial response to proton pump inhibitors (PPIs).

OBJECTIVE

The purpose of this study was to analyse gender differences in partial responders to PPIs.

METHODS

Patients with GERD who responded partially to PPIs (n = 580; NCT00703534) completed the Reflux Symptom Questionnaire 7-day recall (RESQ-7) and the Gastrointestinal Symptom Rating Scale (GSRS). Anxiety and depression were evaluated using the Hospital Anxiety and Depression Scale.

RESULTS

Women had significantly higher RESQ-7 domain scores than men for Heartburn (frequency: 4.3 vs 3.9; intensity: 3.1 vs 2.8), Burping (frequency: 4.9 vs 4.4; intensity: 3.1 vs 2.8) and Hoarseness, cough and difficulty swallowing (frequency: 2.6 vs 2.2; intensity: 1.8 vs 1.5), and had higher GSRS domain discomfort scores than men for Abdominal pain (3.51 vs 3.23), Indigestion (3.80 vs 3.45) and Constipation (2.69 vs 2.17) (all p < 0.05). Anxiety and depression were significantly more prevalent in women than in men.

CONCLUSION

In this population of partial responders, women had more frequent/intense heartburn and extra-oesophageal symptoms and more discomfort from abdominal pain, indigestion and constipation than men. Comorbid anxiety and depression may contribute to the increased symptom burden in women.

Secular trends in weight, height and BMI in young Swedes: the 'Grow up Gothenburg' studies

AIM

This study aims to document secular differences in anthropometry (level and variability of weight, height, BMI) in two cohorts born around 1990 and 1974 and examined as young adults.

METHODS

Descriptive results are presented for the complete cohorts. The final analysis age-matched the cohorts (mean, 18.8 years) and employed CDC z-scores to compare means and distributions of weight, height and BMI.

RESULTS

Z-scores for weight, height and BMI were higher in later-born (1990) boys, while in girls weight and height increased over this period without resulting in increased BMI. At the same time, in boys the BMI variances increased, confirming a simultaneous emergence of more overweight and more underweight. In girls, the BMI variance did not increase significantly. Sensitivity analyses, excluding subjects not born in Sweden, confirmed increasing BMI trends in boys.

CONCLUSION

This study documents that gender differences in the recent childhood obesity epidemic can also be observed in young Swedes as they enter adulthood. Comparing two cohorts of high school students born around 1974 or 1990, less favourable trends in weight status were seen in boys than in girls. Finally, secular increases in height, already observed earlier in the 20th century, continued in these more contemporary cohorts.

Preschool children born moderately preterm have increased waist circumference at two years of age despite low body mass index

AIM

To investigate the development of waist circumference (WC) in preschool children born preterm compared with a population-based reference.

BACKGROUND

Children born preterm are reported to be insulin resistant, despite being lean during early childhood. We hypothesize that the mechanism is through increased visceral adiposity.

METHODS

Data from 4446 preschool children (2169 girls/2277 boys) born in 2001-2006 from a population-based study were compared with longitudinal measurements of body mass index (BMI) and WC from a cohort of 152 children (64 girls/88 boys) born moderately preterm in 2002-2004 (gestational age, 32-37 weeks).

RESULTS

In the preterm children, the mean WC was 2.8 cm larger compared with the reference group (p < 0.001) at 2 years of age but not at 5 years of age. There was no significant difference in the mean BMI at 2 years of age. The preterm group was significantly leaner at 5 years of age, with a mean BMI of 15.13 compared with 15.98 in the reference group (p < 0.001).

CONCLUSION

Children born moderately preterm present as lean during early childhood but have an increased waist circumference in infancy, pointing towards a change in fat distribution with more abdominal fat. This may have implications for their metabolic status.

Early postnatal growth variables are related to morphologic and functional ophthalmologic outcome in children born preterm

AIM

To evaluate the association between gestational age (GA), early and late postnatal growth variables and ophthalmologic outcome in ex-preterm children. methods: Children (GA < 32 weeks, n = 66), previously examined regarding insulin-like growth factor 1 (IGF-1) serum concentrations in relation to ROP, underwent ophthalmologic examination at median 5.6 years. Weight, height, and head circumference (HC) were measured and expressed as SDS. Growth variables were analysed in relation to ophthalmologic outcome.

RESULTS

At follow-up 74% had some ophthalmologic abnormality and 17% had visual impairment. Poor visual acuity was correlated with low GA (r(s) = 0.29, p = 0.019), low weight at 32 weeks (r(s) = 0.30, p = 0.013), and low weight (r(s) = 0.37, p = 0.0025), height (r(s) = 0.41, p = 0.0007) and HC (r(s) = 0.55, p < 0.0001) at follow-up. Hyperopic children (25%) had low neonatal IGF-1 (p = 0.0096) and HC at follow-up (p = 0.022). Poor visual perception was correlated with low early weight (r(s) = 0.38, p = 0.0036) and HC at follow-up (r(s) = 0.39, p = 0.0024). Head circumference at follow-up was correlated with GA (r(s) = 0.40, p = 0.0012), neonatal IGF-1 (r(s) = 0.37, p = 0.0031), and early weight (r(s) = 0.27, p = 0.035).

CONCLUSIONS

In very preterm children, early and later postnatal growth is closely related to visual acuity and perception at follow-up. In addition, IGF-1 concentrations and early growth are correlated with head circumference and refraction at follow-up.

New insights into the development of retinopathy of prematurity--importance of early weight gain

Evidence is accumulating that one of the strongest predictors of retinopathy of prematurity (ROP), in addition to low gestational age, is poor weight gain during the first weeks of life. In infants born preterm, the retina is not fully vascularised. The more premature the child, the larger is the avascular area. In response to hypoxia, vascular endothelial growth factor (VEGF) is secreted. For appropriate VEGF-induced vessel growth, sufficient levels of insulin-like growth factor I (IGF-I) in serum are necessary. IGF-I is a peptide, related to nutrition supply, which is essential for both pre- and post-natal general growth as well as for growth of the retinal vasculature. In prematurely born infants, serum levels are closely related to gestational age and are lower in more prematurely born infants. At preterm birth the placental supply of nutrients is lost, growth factors are suddenly reduced and general as well as vascular growth slows down or ceases. In addition, the relative hyperoxia of the extra-uterine milieu, together with supplemental oxygen, causes a regression of already developed retinal vessels. Postnatal growth retardation is a major problem in very preterm infants. Both poor early weight gain and low serum levels of IGF-I during the first weeks/months of life have been found to be correlated with severity of ROP.

CONCLUSION

This review will focus on the mechanisms leading to ROP by exploring factors responsible for poor early weight gain and abnormal vascularisation of the eye of the preterm infant.

Paternal sperm concentration and growth and cognitive development in children born with a gestational age more than 32 weeks after assisted reproductive therapy

BACKGROUND

A possible impact of paternal sperm quality on the outcome in children born after assisted reproductive technologies, especially ICSI, has been discussed. The objective of this study was to assess whether sperm concentration has any influence on growth and cognitive development in children born with a gestational age more than 32 weeks after ICSI or IVF.

METHODS

Singleton children born after ICSI (n = 492) or IVF (n = 265) from five European countries were examined at age 5 years. The ICSI group was divided into five subgroups according to paternal sperm origin and sperm concentration: (1) epididymal and testicular sperm group, (2) ejaculated sperm < 1 x 10(6)/ml, (3) ejaculated sperm 1-4.99 x 10(6)/ml, (4) ejaculated sperm 5-19.99 x 10(6)/ml and (5) ejaculated sperm > or = 20 x 10(6)/ml. The IVF group was divided into two subgroups: (1) < 20 x 10(6)/ml and (2) > or = 20 x 10(6)/ml. Growth parameters at birth and age 5 were evaluated. Cognitive development was assessed with the Wechsler Preschool and Primary Scale of Intelligence-Revised.

RESULTS

No significant difference was found for gestational age, birth weight and birth weight standard deviation scores (SDS) between the ICSI and IVF sperm groups. No significant difference in height and weight at age 5 or SDS weight or height or BMIs at age 5 was found. There was no significant difference in total intelligence quotient (IQ)--performance or verbal IQ--between the groups.

CONCLUSION

We found no indication that growth and cognitive development in ICSI and IVF children differed depending on paternal sperm concentration.

Overuse of acid suppressive therapy in hospitalised patients with pulmonary diseases

OBJECTIVES

Overuse of acid suppressive therapy (AST) has been reported in hospitalised patients, but the use in specific patient categories is unexplored. We assessed the use of and indication for AST and upper endoscopic investigations in hospitalised patients on a pulmonary ward compared with patients on other wards.

METHODS

301 patients were enrolled in the study. 162 were hospitalised on a pulmonary ward with a control group consisting of 139 from both a surgical and general internal medicine ward. Adequate indications for AST were those strongly supported by medical literature.

RESULTS

Among the 301 patients enrolled, 132 (44%) used AST. 78 (59%) had no adequate indication for AST. On the pulmonary ward 79 (49%) patients used AST, compared to only 10 (20%) on the internal medicine ward (P < 0.05). On the pulmonary ward 68% of the patients had no adequate indication for AST, which was more common than inappropriate use of ASTon the control wards (P < 0.05). The most common inadequate indication for AST was peptic ulcer prophylaxis during corticoidsteroid therapy.

CONCLUSION

In hospitalised patients a significant overuse of AST was observed, particularly among pulmonary patients. More adequate use of AST can contribute to substantial savings for the health-care system.

Knee-heel length measurements in preterm infants: evaluation of a simple electronically equipped instrument

AIM

To compare and evaluate a mini-knemometer with a simple and inexpensive electronic caliper with regard to precision, handling error (technical error) and estimation of growth velocity.

METHODS

Thirty-five prematurely born infants, with a median gestational age of 29 (range 24-33) wk and a median birthweight of 960 (range 480-2,480) g, were measured on 409 different occasions with both instruments. On each occasion, five independent readings were made.

RESULTS

There was no significant difference in precision between the two instruments, when measuring growth velocity over a 4 wk period (median 0.41, range 0.10-0.59 mm d(-1)). The handling error in this study, calculated as the mean standard deviation, was 0.36 (SD 0.18, coefficient of variation 0.38%) mm for the simple electronic caliper and 0.59 mm for the mini-knemometer. Short-term growth was detectable within 2 d when growth velocity was normal.

CONCLUSION

Longitudinal measurement of lower leg length is a gentle and useful complementary method for assessing growth in preterm infants. An inexpensive electronic caliper is well suited for routine use in clinical practice, with measurements taken once or twice a week.

Swedish population-based longitudinal reference values from birth to 18 years of age for height, weight and head circumference

This study aimed to update growth reference values for height, weight and head circumference in order to reflect the changes in body size in the Swedish population during the past two decades. The data came from a large longitudinal growth study on 3650 full-term healthy Swedish children who were born between 1973 and 1975. All of these 1801 girls and 1849 boys had longitudinal data for height and weight from birth to final height. Comparison with previous Swedish growth reference values based on children born between 1955 and 1958 revealed that there have been secular changes in body size. For instance, at 18 y of age, the updated height and weight reference values are 180.4 cm for males and 167.7 cm for females, i.e. 1.9 cm taller and 5.7 kg heavier for males and 2.3 cm taller and 3.4 kg heavier for females compared with the previous reference values.

CONCLUSION

These new growth reference values provide current national standards for growth monitoring and evaluation since the year 2000.

Cerebral palsy in preterm infants: a population-based case-control study of antenatal and intrapartal risk factors

Previous studies have indicated that foetomaternal infection increases the risk of spastic cerebral palsy (CP) in term infants, whereas this association appears to be less evident in preterm infants. The aim of this study was to analyse infection-related risk factors for spastic CP in preterm infants. A population-based series of preterm infants with spastic CP, 91 very preterm (<32 wk) and 57 moderately preterm (32-36 wk), born in 1983-90, were included and matched with a control group (n = 296). In total, 154 maternal, antenatal and intrapartal variables were retrieved from obstetric records. In the entire group, histological chorioamnionitis/pyelonephritis, long interval between rupture of membranes and birth, admission-delivery interval <4 h and Apgar scores of <7 at 1 min just significantly increased the risk of CP, and Apgar scores of <7 at 5 and 10 min were strongly associated with an increased risk. Abruptio placentae, Apgar scores <7 at 1 min and pathological non-stress test (reason for delivery) were significant risk factors of CP only in the moderately preterm and hemiplegic groups, whereas fever before delivery was a significant risk factor in the very preterm and spastic diplegic groups. Antibiotics during pregnancy was associated with CP only in the spastic diplegic CP group.

CONCLUSION

Antenatal infections marginally increased the risk of CP. Low Apgar score and abruptio placentae were associated with CP, especially in moderately preterm infants with hemiplegic CP.

Variation in size at birth in infants born small for gestational age in Lithuania

The aim of this study was to describe the heterogeneity in body proportions of infants born small for gestational age (SGA), defined by birthweight, and to study the relationship of placental size with neonatal anthropometric measurements. Anthropometry was evaluated in 107 symmetrically and asymmetrically growth-retarded infants born SGA (birthweight <-2 SD) and compared with 181 appropriate-for-gestational age infants (AGA; birthweight and length +/- 2 SD). Study children were born at Kaunas University Hospital during the period from 1 January 1998 to 25 August 2000. Two-thirds of SGA children were light (SGA(W)) and one-third was both light and short (SGA(WL)) for gestational age. Infants in both SGA groups were significantly leaner than AGA children. SGA(WL) infants had significantly larger heads in relation to their length compared with SGA(W) and even AGA children, probably indicating a brain-sparing effect. SGA(WL) children had the lowest mean placental weight, but the highest placental weight to birthweight (PW/BW) ratio. The PW/BW ratio was inversely correlated with most infant measurements; the strongest negative relationship was observed with birthlength and lower leg length.

CONCLUSION

There is heterogeneity in children born SGA, defined by birthweight. It is suggested that the two SGA groups represent the continuum of intrauterine growth retardation, with an initial reduction in trophic growth and a subsequent retardation of linear growth. The PW/BW ratio is a strong indicator for impaired prenatal linear growth.

Prenatal cytokine exposure results in obesity and gender-specific programming

Prenatal events appear to program hormonal homeostasis, contributing to the development of somatic disorders at an adult age. The aim of this study was to examine whether maternal exposure to cytokines or to dexamethasone (Dxm) would be followed by hormonal consequences in the offspring at adult age. Pregnant rats were injected on days 8, 10, and 12 of gestation with either human interleukin-6 (IL-6) or tumor necrosis factor-alpha (TNF-alpha) or with Dxm. Control dams were injected with vehicle. All exposed offspring developed increased body weight (P < 0.05--0.001), apparently due to an increase of 30--40% in adipose tissue weight (P < 0.05--0.01). Corticosterone response to stress was increased in the IL-6 group (P < 0.05-0.01). Dxm-treated male rats exhibited blunted Dexamethasone suppression test results. In male rats, insulin sensitivity was decreased after IL-6 exposure (P < 0.01), whereas basal insulin was elevated in the TNF-alpha group (P < 0.01). In female rats, plasma testosterone levels were higher in all exposed groups compared with controls (P < 0.01--0.001), with the exception of Dxm-exposed offspring. Males in the TNF-alpha group showed decreased locomotor activity (P < 0.05), and females in the IL-6 group showed increased locomotor activity (P < 0.05). These results indicate that prenatal exposure to cytokines or Dxm leads to increased fat depots in both genders. In females, cytokine exposure was followed by a state of hyperandrogenicity. The results suggest that prenatal exposure to cytokines or Dxm can induce gender-specific programming of neuroendocrine regulation with consequences in adult life.

Association between urinary tract infection, renal damage and birth size

The aim of this study was to investigate whether birth size is associated with permanent renal damage in children with urinary tract infection (UTI). A cohort of 1221 children under 16 y of age was diagnosed with their first symptomatic UTI between 1970 and 1979. Of these, 74 had urographic renal scarring in childhood and 57 were re-examined as adults. The birth files of 48 of these patients (35F, 13M) were available, and birthweight and birthlength in relation to gestational age were analysed and compared with a Swedish reference population. Children who had renal damage without vesicoureteric reflux were significantly smaller at birth (median weight, -0.76 SDS) compared with both children who had renal damage and reflux (median weight, -0.01 SDS) and the reference population.

CONCLUSION

The demonstration of low birthweight among children with UTI and renal damage but no reflux suggests that low birthweight may be a risk factor for the development of renal damage.

Low IGF-I suppresses VEGF-survival signaling in retinal endothelial cells: direct correlation with clinical retinopathy of prematurity

Retinopathy of prematurity is a blinding disease, initiated by lack of retinal vascular growth after premature birth. We show that lack of insulin-like growth factor I (IGF-I) in knockout mice prevents normal retinal vascular growth, despite the presence of vascular endothelial growth factor, important to vessel development. In vitro, low levels of IGF-I prevent vascular endothelial growth factor-induced activation of protein kinase B (Akt), a kinase critical for endothelial cell survival. Our results from studies in premature infants suggest that if the IGF-I level is sufficient after birth, normal vessel development occurs and retinopathy of prematurity does not develop. When IGF-I is persistently low, vessels cease to grow, maturing avascular retina becomes hypoxic and vascular endothelial growth factor accumulates in the vitreous. As IGF-I increases to a critical level, retinal neovascularization is triggered. These data indicate that serum IGF-I levels in premature infants can predict which infants will develop retinopathy of prematurity and further suggests that early restoration of IGF-I in premature infants to normal levels could prevent this disease.

Cancer risk in Swedish women: the relation to size at birth

The relationship between fetal growth as indicated by weight and length at birth, and cancer risk in 1080 adult Swedish women was examined. Birth factors were retrieved from original midwife records for the years 1914, 1918, 1922 and 1930, and primary cancer cases were identified by matching with national and regional cancer registries through the year 1998. A positive and statistically significant increased risk for cancer was found with increasing birth weight or birth length for all site cancer and non-hormone related cancer, defined as all cancer sites excluding breast, uterus and ovary. Addition of factors suspected to influence cancer risk, maternal proteinuria, birth order, own parity and age at menarche, did not attenuate this relation. Previously only breast cancer has been reported to be related to size at birth in adult women and this is the first study to report that cancer sites other than the major hormone-related sites may be influenced by size at birth, as measured by either weight or length at birth; these findings warrant further investigation.

Blood pressure and hypertension in middle-aged women in relation to weight and length at birth: a follow-up study

OBJECTIVES

To examine the relationship between indicators at birth and adult blood pressure and risk for developing hypertension at two age levels.

DESIGN

Original midwife records of 438 women born at term participating in a prospective population study in Göteborg, Sweden with blood pressure and hypertension assessment at both 50 and 60 years of age.

RESULTS

Systolic blood pressure at both age levels showed a U-shaped relationship to weight and length at birth. Hypertension prevalence at 60 years was significantly and inversely related to both weight and length at birth, but not at 50 years. Significantly higher risk for hypertension was found in the lowest birth weight quintile [odds ratio (OR) = 2.0, 95% confidence interval (CI) 1.1-3.8] and lowest birth length tertile (OR = 1.8, 95% CI 1.1-3.0), in relation to the middle quintile/tertile, with or without adjustment for adult body size (as body mass index), at 60 years but not at 50 years. At 50 years, hypertension risk decreased by 3% (95% CI 0.92-1.01) for every 100 g increase in birth weight and 6% (95% CI 0.83-1.05) per cm birth length. At age 60 years, hypertension risk decreased by 4% (95% CI 0.92-0.99) per 100 g birth weight and 10% (95% CI 0.81-0.99) per cm length.

CONCLUSIONS

Size at birth was a predictor of hypertension risk in women at 60 years but not 50 years. This study supports the hypothesis that poor fetal growth, as measured by low weight or length at birth, may contribute to the development of hypertension in later life and that this relationship became stronger with age.

Poor agreement between self-reported birth weight and birth weight from original records in adult women

Data from an ongoing prospective population study of women in Göteborg, Sweden, were used to assess agreement between self-reported birth weight and birth weight obtained from original delivery records of women aged 44-60 years. Of the eligible population with traced delivery records (n = 693), only 28% (n = 192) could report their own birth weight. Spearman correlation between self-reported birth weight and birth weight from original records was r = 0.76. However, a difference plot, with limits of agreement at -1,028 to 1,038 g (95% confidence limits: lower limit, -1,157 to -901 g, upper limit, 910 to 1,166 g) revealed poor agreement between methods. Of the self-reported birth weights, 53% were in error by 250 g or more, and 31% were positively or negatively discordant by 500 g or more. Application in an analysis of cardiovascular risk factors in adulthood found conflicting results between self-reported and recorded birth weights. Low reporting rate, poor reporting accuracy, and misleading findings in application led to the conclusion that self-reported birth weights from middle-aged women would not be a satisfactory replacement for birth weights from original records.

Ocular fundus abnormalities in children born before 29 weeks of gestation: a population-based study

PURPOSE

Preterm birth has been found to be associated with increased morbidity of the central nervous and vascular tissues. To investigate the influence of preterm birth on the optic disc and retinal vessels, we examined the ocular fundus in school-aged children born very preterm.

METHODS

A prospective, population-based study was performed in 50 very preterm children (median age 7 years, range 5-9 years) with a median gestational age at birth of 27 weeks (range 24-28 weeks) and a median birth weight of 1055 g (range 450-1520 g). The ocular fundus was examined by ophthalmoscopy in 50 children, and the optic nerve and retinal vessel morphology was evaluated by digital image analysis of ocular fundus photographs in 45 of these children.

RESULTS

The median optic disc area was significantly smaller (p = 0.0002) in the preterm children compared with a reference group. There was no difference in cup area and, consequently, the rim area was significantly smaller (p = 0.0002) in the preterm children. Children with early signs of brain lesions commonly had a rim area below the median of the reference group. Preterm children also commonly had an abnormal retinal vascular pattern that was independent of a previous history of retinopathy of prematurity.

CONCLUSION

Very preterm birth was associated with subnormal optic disc and rim areas and an abnormal vascular pattern. The findings clearly demonstrate the effect of preterm birth on the development of these structures. The long term clinical prognosis of these findings has yet to be determined.

Sociodemographic characteristics influencing birth outcome in Sweden, 1908-1930. Birth variables in the Population Study of Women in Gothenburg

STUDY OBJECTIVE

To identify variables available in early Swedish delivery records and their relation to birth outcomes for home and hospital deliveries in Gothenburg at the early part of this century.

DESIGN

A retrospective recovery of original delivery records and social variables in a cross sectional population.

SETTING

Gothenburg, Sweden.

PARTICIPANTS

851 fullterm singleton female births with known gestational age born into five birth cohorts on selected dates (1908, 1914, 1918, 1922 and 1930).

MAIN RESULTS

Delivery site, maternal parity, gestational age, and social group were significant factors influencing birth outcome as birth weight and length. The mean birth weight and length of hospital born infants was consistently lower than for home deliveries across all cohorts. Site of delivery changed significantly during the period of births under study, 1908-1930.

CONCLUSIONS

In this study, which was based on original delivery records from the early part of this century, it was found that delivery site was an important factor influencing birth outcome across five birth cohorts. Utilisation of delivery services changed during the period of study. Thus, to avoid selection bias, the application of delivery records should reflect the birthing practice of the time period in question.

Visual function in school-aged children born before 29 weeks of gestation: a population-based study

The aim of this study was to assess visual function, including visual perception, in a geographically-based population of school-aged children, with a median age of 7.2 years (range 5.1 to 9.3 years), born before 29 weeks of gestation to mothers living in Goteborg, Sweden. Fifty-one preterm children participated in the study, six of whom had known brain lesions. Visual acuity, visual fields, stereoacuity, and visual perception were tested. The Test of Visual Perceptual Skills Revised (TVPS-R, Gardner 1996) was used to measure visual perception, and the results were compared with those of 50 term (control) subjects. Six percent of the preterm children were visually impaired, with a visual acuity of less than 0.3 (6/18), while 42% of all the preterm children and 34% of those without known brain lesions had a total score below the 5th centile of the reference material for the test, compared with 14% of the control subjects. In conclusion, visual-perceptual problems seem to be common among very preterm children and should be screened for and assessed before the children start school.

Reduced retinal vascularization in children with growth hormone deficiency

The neovascularization in diabetic retinopathy is believed to involve locally produced angiogenic factors. In addition, there are indications that GH may influence retinal vascularization. To investigate the role of GH in retinal vascularization, we examined the retinal vascular pattern in children with congenital GH deficiency. Retinal vessel morphology was evaluated by digital image analysis of ocular fundus photographs in 39 children (5 girls and 34 boys, aged 3.6-18.7 yr) with congenital GH deficiency, and it was compared to that of 100 healthy controls. Twenty children had received GH treatment (0.1 IU/kg daily). All children were born at term, and none of the children had any clinical signs of ocular disease or reduced vision. Children with GH insufficiencies, regardless of whether they were treated with GH, had a significantly lower number of vascular branching points than the reference group (P < 0.0001). Thirty-three percent of the GH-insufficient individuals had a number of vascular branching points less than or equal to the fifth percentile of the reference group. The reduced retinal vascularization observed in children with congenital GH deficiency suggests that GH may be of importance for angiogenesis.

Postnatal growth and health in children born after cryopreservation as embryos

BACKGROUND

There is uncertainty about the health of children born from in-vitro fertilisation (IVF) with cryopreserved embryos. We investigated the postnatal growth and health (up to 18 months) of these children compared with those born after standard IVF with fresh embryos and those from spontaneous pregnancies.

METHODS

255 children from cryopreserved embryos were matched by maternal age, parity, single or twin pregnancy, and date of delivery with 255 children born after IVF with fresh embryos, and 252 children from spontaneous pregnancies. The main endpoint was growth; secondary endpoints were the prevalence of chronic illness, major malformations, cumulative incidence of common diseases, and development during the first 18 months. Growth was assessed by comparison with standard Swedish growth charts and by standard deviation scores.

FINDINGS

Growth features were similar for both singletons and twins in the three groups. There were 6 (2.4%) of 255, 9 (3.5%) of 255, and 8 (3.2%) of 252 major malformations in the cryopreserved group, standard IVF, and spontaneous groups, respectively (p=0.6 between the cryopreserved and standard IVF group). The prevalence of chronic diseases did not differ between the three groups, with 18.0%, 15.3%, and 16.7% of children with a chronic illness in the cryopreserved group, standard IVF, and spontaneous groups, respectively.

INTERPRETATION

The cryopreservation process does not adversely affect the growth and health of children during infancy and early childhood. Minor handicaps, behavioural disturbances, learning difficulties, and dysfunction of attention and perception cannot be ruled out at this age.

Ocular fundus morphology in preterm children. Influence of gestational age, birth size, perinatal morbidity, and postnatal growth

PURPOSE

To determine the influence of gestational age, birth size, perinatal morbidity, and postnatal growth on fundus morphology in preterm children using digital image analysis of fundus photographs.

METHODS

Thirty-nine preterm children (mean postmenstrual gestational age, 29.1 weeks; range, 24.6 to 32) were included in the study. Thirty-nine healthy children, born at term, were used as control subjects. Fundus photographs were obtained at a mean age of 4.8 years (preterm) and 6.1 years (control subjects).

RESULTS

There was no difference in optic disc, excavation, or peripapillary crescent area between the two groups. In the group of preterm children, a large optic disc size was associated with a low birth weight (rs = -0.29, P = 0.07), duration of assisted ventilation (rs = 0.43, P = 0.006), and number of blood transfusions (rs = 0.33, P = 0.04). The girls born prematurely showed a negative relation between the length of gestation and the area of the optic disc (r2 = 0.28, P = 0.009). No such relation was found in boys. The preterm children had increased tortuosity of retinal vessels (P < 0.001 and P < 0.002 for arteries and veins, respectively) and reduced number of vascular branching points (P < 0.001) compared with those of the control subjects. There were no associations between these vascular abnormalities and the perinatal and postnatal variables studied.

CONCLUSIONS

No difference in optic disc morphology between preterm children and control subjects was found. However, preterm birth seems to affect the retinal vascular pattern close to the optic disc, independently of retinopathy of prematurity. Among the girls born preterm, optic disc size was negatively correlated to gestational age.

Overview of the safety of felodipine based on clinical trials in patients with hypertension

All clinical studies of at least 1 week's duration with felodipine in patients with hypertension were included in a safety analysis. The major finding was that felodipine does not increase mortality or the incidence of major cardiovascular events and that the data indicate a favorable effect.

Hypertension in pregnancy and size at birth

Low birth weight and high placental weight are associated with increased cardiovascular morbidity and mortality. Children born after hypertensive pregnancies have higher blood pressure than children born after normotensive pregnancies. Hypertension in pregnancy is considered a major risk factor for intrauterine growth retardation. The present study describes size at birth and perinatal characteristics in children born after hypertensive pregnancies. During five consecutive years 17,000 deliveries took place in the well defined geographic area of eastern Göteborg. Hypertension in pregnancy complicated 261 pregnancies. For comparison 260 normotensive pregnancies, matched for maternal age and time of delivery, were used. Standard deviation score for birth weight and length were calculated according to reference standards for birth weight (BWSDS) and length (BLSDS) based on all Swedish births 1977-1981 (n = 475,588). Children born after hypertensive pregnancies had lower birth weight, were shorter and had a shorter gestational period as compared with children born after normotensive pregnancies. Head circumference and placental weight did not differ and there were no significant differences in BWSDS. It is concluded that hypertensive pregnancies are characterized by lower birth weight and shorter gestational period. However, intrauterine growth retardation is not a general characteristic of hypertension in pregnancy.

Normal weight for length in newborn infants in whom growth hormone deficiency was later diagnosed. Swedish Paediatric Study Group for GH Treatment

A new model for evaluating leanness/fatness (LeanSDS) in the newborn infant has been used to examine body weight for length in a group of Swedish infants in whom idiopathic growth hormone deficiency (GHD n = 220) was later diagnosed. These infants have earlier been reported to be significantly shorter (median = -0.87 SDS; SDS; standard deviation scores) and lighter (median = -0.60 SDS) in relation to gestational age, than the most recent reference. A group of infants who later developed GHD due to organic etiologies (n = 92) had normal weight and length for gestational age at birth. Using the LeanSDS model (with intercept 0.0 and regression coefficient 0.7) revealed that these idiopathic GHD infants have weight that is normal for their length (mean LeanSDS = 0.11 +/- 0.08 (SEM); n.s.) why the abnormality is a reduced linear growth. These findings also indicate that birth length (linear growth) should be given increased attention when size at birth is evaluated.

Weight-for-length model in newborn Swedish infants

A new methodology for evaluation of weight in relation to length normalized for sex and gestational age (leanness/fatness) in the newborn infant is presented. Using standard deviation scores (SDS) for weight and length in a linear regression model, a new continuous variable called LEANSDS has been constructed with intercept = zero, regression coefficient = 0.7152, SD = 0.6988 and r2 = 0.51, irrespective of gender and gestational age within the range 34-43 weeks' gestation. The model is based on the Swedish 1986 Medical Birth Register and was tested on the 1985 year cohort. The reference material consisted of live-born, singleton infants considered "healthy". This new variable is independent of length. A chart is presented which simplifies visual evaluation. Using -2 SD as the cut-off limit, approximately one-third of light-for-dates infants are also lean, while two-thirds of the lean infants are not light for dates. Proportions of "not healthy" live-born infants and still births are given. Using another method, based on weight and length, and with some approximations needed for calculation of a comparable BW/BLSDS, the correlation was 0.9974, but this calculation is more elaborate and the comparable chart more complex. This method reveals the influence of gestational age on the relationship between weight and length, indicating a "prenatal puberty". Empirically, the logarithmic relationship found between weight and length indicates a ponderal index exponent of 2.4-2.5 instead of 3. LEANSDS, with its continuous nature, also gives the degree of deviation in each individual and in groups of infants, and can be added together and further analysed with improved sensitivity.

Metabolic consequences of different perioperative fluid therapies in the neonatal period

Carbohydrate and fat metabolism during and after anaesthesia and surgery was studied in 14 neonates with major congenital non-cardiac anomalies. They were either given a glucose solution until surgery or starved for at least 4 h before surgery. Ringer-acetate alone or Ringer-acetate plus 10% glucose was used for the intraoperative fluid therapy. After anaesthesia all neonates were given a 10% glucose solution. Concentrations of glucose, free fatty acids, triglycerides, lactate, pyruvate, alanine, glycerol and 3-hydroxybutyrate were measured at predetermined intervals pre-, intra- and postoperatively. Blood glucose concentrations rose during surgery both in neonates given glucose before and during surgery (n = 6) and in neonates not given glucose before and during surgery (n = 6). Increased intraoperative levels of free fatty acids and 3-hydroxybutyrate were found in neonates not given glucose before and during surgery. The triglyceride levels were equal in both groups. In two neonates given glucose before surgery and Ringer-acetate during surgery increased levels of 3-hydroxybutyrate were found, particularly in one patient who became hypoglycaemic. In conclusion, starved neonates without intraoperative glucose supply mobilized fat and maintained blood glucose concentrations.

Leukotriene B4 and C4 generation by human colostral macrophages in vitro

To investigate leukotriene (LT) generation by human colostral macrophages (CM phi), we evaluated calcium ionophore A23187-induced LTB4 and LTC4 production by CM phi obtained from mothers who had had preterm and term deliveries. As a comparison, we also investigated such production of these LTs by blood monocytes (BMo). LTB4 and LTC4 production by preterm CM phi did not significantly differ from that by term CM phi. LTB4 and LTC4 production by both preterm and term CM phi was significantly lower than that by BMo. The ratio of LTC4 to LTB4 did not differ significantly between preterm and term CM phi. The CM phi ratios were significantly lower than that of BMo. These findings suggest that human CM phi can generate LTB4 and LTC4 but that production, especially LTC4 production, is suppressed compared with that of BMo.

An update of the Swedish reference standards for weight, length and head circumference at birth for given gestational age (1977-1981)

An update of the Swedish reference standards for weight, length, and head circumference at birth, for each week of gestational age, is presented. It is based on the total Swedish cohorts of infants born 1977-1981 (n = 475,588). A "healthy population" (79%) was extracted, using prospectively collected data. Weekly (28-42 weeks) grouped data for length and head circumference were well approximated by the normal distribution, but the distributions for birthweight were positively skewed. The original skewed distributions for birthweight were transformed, using the square root, resulting in distributions close to the Gaussian. For smoothing purposes, the weakly values for the mean and the standard deviation were both fitted by a third degree polynomial function. These functions also make possible the calculation of the continuous variable, standard deviation score, for individual newborn infants as well as a comparison of distributions between groups of infants. The reference values and charts presented here have two major advantages over the current Swedish ones: the sample size used is now sufficiently large at the lower gestational ages, so that empirically found variations can be used, and the skewness of the birth weight distribution has been taken into account. The use of the reference standards presented here improves and facilitates evaluation of size deviation at birth.

Birth data for patients who later develop growth hormone deficiency: preliminary analysis of a national register. The Executive Scientific Committee of the Kabi International Growth Study and the Swedish Paediatric Study Group for Growth Hormone Treatment

This study analyses gestational age, mode of delivery and size at birth in children who later developed idiopathic or organic growth hormone deficiency (GHD). A data register of children on growth hormone (GH) treatment in Sweden was compared with the Swedish Medical Birth Register during a 14-year period (1973-1986) comprising 1.4 million newborn children. Size at birth was evaluated using a new Swedish reference standard based on data from around 500,000 newborn children. It was found that the children who later develop idiopathic GHD (IGHD) were born with a normal distribution of gestational age. They were more often born with breech delivery (7.1% versus 2.8%) or caesarean section (16.6% versus 10.4%) compared with normal children. The children's condition at birth was poorer than normal, as shown by the frequency of Apgar scores below 7 at 5 minutes (5.2% versus 1.2%). Finally, it was found that children who later develop IGHD (n = 220) had a median birth length of 0.87 SDS below the mean and a median birth weight of 0.60 SDS below the mean of the standard. In contrast, both the birth length and weight of the children who later develop organic GHD (OGHD) (n = 92) did not differ from that of the reference.

Parenteral nutrition in preterm neonates with and without carnitine supplementation

The effects of carnitine supplementation on fat and glucose metabolism and carnitine balance were studied in 12 preterm neonates receiving full or partial parenteral nutrition (PN) for 5 to 21 days. The gestational age ranged from 27 to 32 weeks and the birth weight from 790 to 2090 g. The neonates were assigned at random to receive either L-carnitine 10 mg/kg (n = 6) or saline (n = 6). In the carnitine group, increased concentrations in plasma of total and free carnitine were observed. Less than 50% of the given dose was recovered in urine. In the placebo group no changes in the total plasma carnitine concentration were seen. In all neonates plasma triglycerides, free fatty acids, glycerol, alanine, 3-hydroxybutyrate (BOB), glucose and lactate were measured at predetermined intervals. The only significant difference between the groups was higher BOB-concentrations in the carnitine group 2 days after the start of parenteral nutrition. Elevated BOB concentrations are an indicator of improved fatty acid oxidation in the carnitine group. In this study, only a temporary effect of the carnitine supplementation was found.

Influence of fluid regimens on perioperative blood-glucose concentrations in neonates

Blood concentrations of glucose were measured during surgery and during the first 8 h after operation in 30 neonates undergoing major surgery during the first week of life. Fifteen of the neonates were given Ringer-acetate as the only crystalloid peroperative fluid; to the other 15, 10% glucose i.v. was administered during surgery. In the Ringer-acetate group, mean (SD) blood concentration of glucose increased from 3.1 (2.0) to 4.3 (2.4) mmol litre-1 during surgery. The corresponding increase in the glucose-supplemented group was 3.4 (1.5) to 6.3 (2.2) mmol litre-1. In the Ringer-acetate group, peroperative blood concentrations of glucose were found to be low if a preoperative glucose infusion was interrupted at the start of anaesthesia. Hypoglycaemia occurred in both groups, but more often in the group given Ringer-acetate only (3/15 vs 1/15). Hypoglycaemia was found only in neonates less than 48 h of age and during the first 1 h of anaesthesia only. Monitoring of blood concentrations of glucose and adjustment of the glucose infusion appears to be desirable during and after surgery in neonates.

Modelling of reference values for size at birth

Data from the Swedish Medical Birth Registration, 1977-1981 were used to apply methods of constructing reference standards for size at birth. Using clinical information a 'healthy' sub-population was extracted. The conditional distributions of birthweight (BW) and birthlength (BL) for each week of Gestational age, and the conditional distribution of birthweight given birthlength were modelled using truncated Normal distributions, after making use of Box-Cox power transformations. Spline functions were then used in conjunction with a multiplicative method to obtain appropriate percentage point curves. Examples of this analysis are given.

Carnitine in maternal and neonatal plasma

Total plasma carnitine was analysed in 19 women, with uncomplicated pregnancies, who underwent elective caesarean section, and in their neonates. The women were given a balanced glucose (glucose group) or saline (saline group) infusion, group allocation being on a random basis. The carnitine levels in maternal or infant plasma did not differ between these two groups. At delivery, the mean maternal carnitine value, 17.4 +/- 1.25 mumol/l, was lower than the mean infant value, 25.9 mumol/l +/- 2.67 (mean +/- SE, p less than 0.005) and lower than the mean value in non-pregnant, fertile women, i.e. 40.9 +/- 1.22 mumol/l. The mean carnitine value in the unfed neonate had not changed when the infant was 4 hours old. A positive correlation was found between carnitine levels in maternal and infant plasma (p less than 0.01). At delivery, the levels of non-esterified fatty acids and 3-OH-butyrate in infant plasma were different in the two groups, but not at 4 hours of age. The results suggest that the maternal carnitine level is the most important factor governing plasma carnitine levels in the neonate.

A methodology for evaluating size at birth

Data from the Swedish Medical Birth Registration, 1977-78, were utilized to develop methods of calculating reference standards for evaluating size at birth. Using the clinical information available, a 'healthy' sub-group was extracted. The individual distributions of birthweight (BW), birth length (BL) and birth headcircumference (BHc) at each week of gestational age (GA) were modelled following some truncation of their ranges. Application of the Box-Cox power family of transformations was generally found to improve the normality of the data. Certain percentages (such as 2.28, 50 and 97.72) were linked through a smoothing device. Features of the results include a positively skewed BW distribution in most GA weeks, a normal positively skewed BW distribution in most GA weeks, a normal distribution of BL and BHc at term, a larger relative variation in BW at lower GA than at term, and a distinct sigmoid shape of the median and other BW curves. Compared with five commonly quoted standards, the present data show the least deceleration in the fullterm region. Disregarding the clinical information, 'primary' sub-groups were also extracted using decomposing techniques. These gave rise to similar BW/GA relationships. Using data from the WHO comparative study, the method just mentioned was applied to standardize BW and BW-specific early neonatal mortality rates. This resulted in an improved description of biological events.

Perinatal risk factors in the aetiology of hearing loss in preschool children

In order to assess the importance of pertinent perinatal risk factors in causing hearing loss (HI), a retrospective evaluation was made of the records of 146 affected children born in the city of Göteborg between 1970 and 1979. The incidence among six-year-olds born between 1970 and 1974 was 3.8 per 1000 newborns. If only HI of more severe degree was taken into account (above 40dB in the best ear), the remaining incidence was 1.4/1000. Sensorineural HI (SNHI) accounted for 87 per cent of the cases. A positive hereditary tendency for HI was found in 55 per cent. In 61 per cent the origin of the HI was presumably prenatal, either positive heredity alone or in the form of facio-auricular anomalies, syndromes and toxic influences (infection and alcohol) during early pregnancy. Postnatal infections (meningitis, parotitis and secretory otitis media) could be ascertained as causes in about 20 per cent of the cases. For 12 per cent no aetiology could be determined. Perinatal aetiology was probable or possible in about 10 per cent of the children. The frequency of SNHI was found to be increased among survivors of neonatal intensive care, VLBW, LBW and SFD infants. Caesarean section, ventouse and breech delivery were not associated with increased rates, nor were hyperbilirubinaemia, exchange transfusion or birth asphyxia. No cases could be traced to aminoglycoside treatment. Neonatal sepsis/meningitis may have been the cause in two of the 146 cases. Hypoxia as a consequence of apnoea and respiratory distress syndrome necessitating mechanical ventilation appeared to be the major risk-factor in the neonatal period. However, in comparison with genetic predisposition, potentially damaging perinatal factors appeared to be of minor importance.