Short developmental milestone risk assessment tool to identify Duchenne muscular dystrophy in primary care

BACKGROUND

In patients without a family history, Duchenne muscular dystrophy (DMD) is typically diagnosed at around 4-5 years of age. It is important to diagnose DMD during infancy or toddler stage in order to have timely access to treatment, opportunities for reproductive options, prevention of potential fatal reactions to inhaled anesthetics, awareness of a child's abilities needed for good parenting, and opportunities for enrolment in clinical trials.

METHOD

We aimed to develop a short risk assessment tool based on developmental milestones that may contribute to the early detection of boys with DMD in primary care. As part of the case-control 4D-DMD study (Detection by Developmental Delay in Dutch boys with DMD), data on developmental milestones, symptoms and therapies for 76 boys with DMD and 12,414 boys from a control group were extracted from the health records of youth health care services and questionnaires. Multiple imputation, diagnostic validity and pooled backward logistic regression analyses with DMD (yes/no) as the dependent variable and attainment of 26 milestones until 36 months of age (yes/no) as the independent variable were performed. Descriptive statistics on symptoms and therapies were provided.

RESULTS

A tool with seven milestones assessed at specific ages between 12 and 36 months resulted in a sensitivity of 79% (95CI:67-88%), a specificity of 95.8% (95%CI:95.3-96.2), and a positive predictive value of 1:268 boys. Boys with DMD often had symptoms (e.g. 43% had calf muscle pseudohypertrophy) and were referred to therapy (e.g. 59% for physical therapy) before diagnosis.

DISCUSSION

This tool followed by the examination of other DMD-related symptoms could be used by youth health care professionals during day-to-day health assessments in the general population to flag children who require further action.

CONCLUSIONS

The majority of boys (79%) with DMD can be identified between 12 and 36 months of age with this tool. It increases the initial a priori risk of DMD from 1 in 5,000 to approximately 1 in 268 boys. We expect that other neuromuscular disorders and disabilities can also be found with this tool.

Health status and public health needs in a Togolese child health care centre modelled after the Dutch system

BACKGROUND

The charity foundation Association Soutien Enfants Togo started a child health care (CHC) centre in Togo that was modelled after the Dutch high-quality CHC system to improve child health.

AIM

To describe health care data of children who visited the centre.

SUBJECTS AND METHODS

Data were routinely collected between October 2010-July 2017. Outcomes were completed vaccinations, growth, development, lifestyle, physical examination, and laboratory testing results.

RESULTS

In total, 8,809 children aged 0-24 years were available. Half (47.5%) of children aged 0-4 years did not receive all eligible free vaccinations from the government. The proportions of stunted children (all) or with a developmental delay (0-4 years) were 10.1% and 9.5%, respectively. In total, 40-50% of all children did not wash their hands with soap after toilet or before eating, or did not use clean drinking water. Furthermore, 5.1-6.6% had insufficient vision, high eye pressure or hearing loss. Sickle cell disease was detected in 5.3%.

CONCLUSION

A large group of children in need of prevention and early treatment were detected, informed and treated by the centre. Further research is needed to confirm if this strategy can improve children's health in Sub-Saharan Africa. Our data are available for further research.

Key developmental milestones helped to identify children with special educational needs and disabilities at an early stage

AIM

Responding to developmental delay promptly is important, as it helps children to reach their full potential. This study investigated how developmental milestones predicted primary school children with special educational needs and disabilities (SEND) at an early stage.

METHODS

We obtained data about 36 milestones between 12 and 45 months using the Dutch Development Instrument. Development, primary school classification and background characteristics were collected from the Dutch Preventive Child Healthcare system in Utrecht from 2008 to 2016. We investigated SEND classifications and the primary schools that the children attended at 4-12 years of age. The findings include area under the curve (AUC) data.

RESULTS

Data on 30 579 children in mainstream schools and 1055 children with SEND were available. Different milestones predicted SEND classifications. Fourteen milestones and parental education predicted attendance at special needs schools with smaller classes (AUC 0.913). Nine milestones, sex, migration background and parental education predicted attendance at schools for severe communication problems (AUC 0.963). Ten milestones and parental education predicted attendance at schools for severe learning difficulties (AUC 0.995). Milestones did not accurately predict attendance at schools for severe behavioural or psychiatric problems.

CONCLUSION

Milestones at 12-45 months predicted most SEND classifications at primary school age, except severe behavioural or psychiatric problems.

Birth weight discordance in very and extremely preterm twins and the risk of neonatal hearing loss

OBJECTIVE

Birth weight (BW) discordant twins have an increased risk of mortality and morbidity. We aimed to study the effect of BW discordance on the risk of neonatal hearing loss (NHL) in very and extremely preterm twins.

STUDY DESIGN

Results of the nationwide newborn hearing screening program in Dutch Neonatal Intensive Care Units and diagnostic examination were centrally registered between 2003 and 2021 and included in this study. We selected twins and singletons with a gestational age (GA) 24- < 32 weeks. Logistic regression analyses were applied to study the effect of BW discordance on the risk of NHL adjusted for BW, GA and sex. Singletons and concordant twins, defined as a BW discordance of ≤20 %, were used as two reference groups. BW discordance was further categorized as medium (>20-30 %) and high (>30 %).

RESULTS

In total, 3430 twins (2694 concordant, 428 medium and 308 high BW discordant), and 23,114 singletons were available. Smaller newborns of high BW discordant twins showed an increased risk of NHL compared to singletons (adjusted odds ratio with 95 % confidence interval was 3.56 (2.26-5.60)). Also, smaller newborns of medium and high BW discordant twins showed an increased risk of NHL compared to concordant twins (adjusted odds ratio with 95 % confidence interval were 1.97 (1.13-3.44) and 4.17 (2.56-6.82), respectively). No other statistically significant differences were found.

CONCLUSION

BW discordance increased the risk of NHL in the smaller of the twin born very or extremely preterm. This risk increased as the weight difference increased.

Health-Related Quality of Life in Patients With Early-Detected Central Congenital Hypothyroidism

CONTEXT

Central congenital hypothyroidism (CH) requires lifelong medical treatment. The majority of children with central CH have multiple pituitary hormone deficiencies (MPHD), but in some cases central CH is isolated. Most pituitary hormone deficiencies are associated with impaired health-related quality of life (HRQoL). However, studies on HRQoL in central CH are lacking.

OBJECTIVE

To evaluate HRQoL and fatigue in children and young adults with central CH, as well as parent perspectives.

DESIGN

Nationwide cross-sectional study comparing HRQoL between early-detected central CH patients and unaffected siblings with the Pediatric Quality of Life inventory (PedsQL™) and PedsQL Multidimensional Fatigue Scale. Participants ≥ 8 years old filled in self-reports; parents of participants aged 3 to 18 years filled in parent reports. Isolated central CH patients, MPHD patients, and siblings were compared using a linear mixed model and Tukey's post hoc test.

RESULTS

Eighty-eight patients and 52 siblings participated, yielding 98 self-reports and 115 parent reports. Isolated central CH patients (n = 35) and siblings showed similar scores on all subscales, both in the self-reports and parent reports. For MPHD patients (n = 53), self-reported scores were similar to those of siblings. Parent reported total HRQoL and fatigue scores were significantly poorer in MPHD patients compared with siblings (mean differences -10.2 and -9.4 points; P < 0.01), as were scores for physical functioning, social functioning and general fatigue.

CONCLUSION

Self-reported HRQoL scores in isolated central CH and MPHD patients were similar to siblings. However, parents reported significantly lower HRQoL and fatigue scores for MPHD patients, suggesting a difference in perceived limitations between MPHD patients and their parents.

Costs and effects of conventional vision screening and photoscreening in the Dutch preventive child health care system

Background

Little is known about costs and effects of vision screening strategies to detect amblyopia. Aim of this study was to compare costs and effects of conventional (optotype) vision screening, photoscreening or a combination in children aged 3–6 years.

Methods

Population-based, cross-sectional study in preventive child health care in The Hague. Children aged 3 years (3y), 3 years and 9 months (3y9m) or 5–6 years (5/6y) received the conventional chart vision screening and a test with a photoscreener (Plusoptix S12C). Costs were based on test duration and additional costs for devices and diagnostic work-up.

Results

Two thousand, one hundred and forty-four children were included. The estimated costs per child screened were €17.44, €20.37 and €6.90 for conventional vision screening at 3y, 3y9m and 5/6y, respectively. For photoscreening, these estimates were €6.61, €7.52 and €9.40 and for photoscreening followed by vision screening if the result was unclear (combination) €9.32 (3y) and €9.33 (3y9m). The number of children detected with amblyopia by age were 9, 14 and 5 (conventional screening), 6, 13 and 3 (photoscreening) and 10 (3y) and 15 (3y9m) (combination), respectively. The estimated costs per child diagnosed with amblyopia were €1500, €1050 and €860 for conventional vision screening, €860, €420 and €1940 for photoscreening and €730 (3y) and €450 (3y9m) for the combination.

Conclusions

Combining photoscreening with vision screening seems promising to detect amblyopia in children aged 3y/3y9m, whereas conventional screening seems preferable at 5/6y. As the number of study children with amblyopia is small, further research on the effects of these screening alternatives in detecting children with amblyopia is recommended.

Cognitive and Motor Outcome in Patients with Early-Detected Central Congenital Hypothyroidism Compared with Siblings

CONTEXT

Early treatment of primary congenital hypothyroidism (CH) prevents irreversible brain damage. Contrary to primary CH, outcome studies on central CH are scarce. Most patients with central CH have multiple pituitary hormone deficiencies (MPHD); these patients are also at risk for neonatal hypoglycemia.

OBJECTIVE

To assess cognitive and motor outcome in patients with early-treated central CH detected by the Dutch neonatal screening.

METHODS

In this cross-sectional study, primary outcome full-scale intelligence quotient (FSIQ) was measured in patients with MPHD and patients with isolated central CH born between January 1, 1995, and January 1, 2015, with siblings as controls. Secondary outcomes were intelligence test subscales and motor function. Linear mixed models were used to compare both patient groups and siblings, followed by post hoc tests in case of significant differences.

RESULTS

Eighty-seven patients (52 MPHD; 35 isolated central CH) and 52 siblings were included. Estimated marginal means for FSIQ were 90.7 (95% CI 86.4-95.0) in patients with MPHD and 98.2 (95% CI 93.0-103.5) in patients with isolated central CH. While patients with MPHD scored lower FSIQs than siblings (mean difference -7.9 points, 95% CI -13.4 to -2.5; P = .002), patients with isolated central CH did not. Processing speed was lower in both patient groups than in siblings (mean differences -10.5 and -10.3 points). Motor difficulties occurred significantly more often in patients (33%) versus siblings (5%; P = .004).

CONCLUSION

In early-treated central CH, FSIQ is comparable with siblings in patients with isolated central CH, while patients with MPHD have a significantly lower FSIQ. This may be explained by disease-specific consequences of MPHD, such as neonatal hypoglycemia and more severe hypothyroidism.

Clinical and genetic characteristics of Dutch children with central congenital hypothyroidism, early detected by neonatal screening

OBJECTIVE

To evaluate clinical characteristics of patients with central congenital hypothyroidism (CH), detected in the Dutch neonatal screening program. This included patients with isolated central CH but the majority have multiple pituitary hormone deficiencies (MPHD).

DESIGN

Nationwide, cross-sectional study.

METHODS

Data was collected on clinical characteristics, endocrine tests and neuroimaging of central CH patients, detected by the Dutch neonatal screening and born between 1 January 1995 and 1 January 2015. Height and pubertal status were assessed during a study visit. Isolated central CH patients without a confirmed genetic diagnosis were offered genetic (re-)testing.

RESULTS

During the 20-year period 154 central CH patients were detected (incidence of permanent central CH 1:25 642). After excluding deceased (15), severe syndromic (7) and transient patients (6), 92 of 126 eligible patients were included (57 MPHD; 79% male). Sixty-one patients (50 MPHD) had been hospitalized before screening results were reported, but central CH was diagnosed on clinical grounds in only three of them (5%). MRI abnormalities consistent with pituitary stalk interruption syndrome were seen in 50 (93%) MPHD patients. Among isolated central CH patients, 27 (84%) had an IGSF1, TBL1X or IRS4 gene variant (53, 16 and 16%, respectively).

CONCLUSION

Many patients with central CH have neonatal health problems, especially MPHD patients. Despite hospital admission of two-thirds of patients, almost none were diagnosed clinically, but only after the notification of an abnormal screening result was received. This indicates that central CH, especially if isolated, is an easily missed clinical diagnosis.

Early developmental milestones in Duchenne muscular dystrophy

AIM

To investigate the differences in attainment of developmental milestones between young males with Duchenne muscular dystrophy (DMD) and young males from the general population.

METHOD

As part of the case-control 4D-DMD study (Detection by Developmental Delay in Dutch boys with Duchenne Muscular Dystrophy), data on developmental milestones for 76 young males with DMD and 12 414 young males from a control group were extracted from the health care records of youth health care services. The characteristics of DMD were acquired from questionnaires completed by parents. Logistic regression analyses were performed with milestone attainment (yes/no) as the dependent variable and DMD (yes/no) as the independent variable, with and without adjustment for age at visit.

RESULTS

The mean number of available milestones was 43 (standard deviation [SD]=13, range: 1-59) in the DMD group and 40 (SD=15, range: 1-60) in the control group. The presence of developmental delay was evident at 2 to 3 months of age, with a higher proportion of young males with DMD failing to attain milestones of gross/fine motor activity, adaptive behaviour, personal/social behaviour, and communication (range age-adjusted odds ratios [ORs]=2.3-4.0, p<0.01). Between 12 and 36 months of age, differences in the attainment of developmental milestones concerning gross motor activity increased with age (range age-adjusted ORs=10.3-532, p<0.001). We also found differences in developmental milestones concerning fine motor activity, adaptive behaviour, personal/social behaviour, and communication between 12 and 48 months of age (range age-adjusted ORs=2.5-9.7, p<0.01).

INTERPRETATION

We found delays in the attainment of motor and non-motor milestones in young males with DMD compared to the control group. Such delays were already evident a few months after birth. Developmental milestones that show a delay in attainment have the potential to aid the earlier diagnosis of DMD.

Evaluation of the Dutch neonatal screening for congenital adrenal hyperplasia

BACKGROUND

In 2002, a nationwide screening for congenital adrenal hyperplasia (CAH) was introduced in the Netherlands. The aim of our study is to evaluate the validity of the neonatal screening for CAH and to assess how many newborns with salt-wasting (SW) CAH have already been clinically diagnosed before the screening result was known.

METHODS

Retrospective, descriptive study. The following data of patients with positive screening results since implementation of the screening programme were collected (1 January 2002 up until 31 December 2013): gestational age, sex, diagnosis, clinical presentation and contribution of screening to the diagnosis.

RESULTS

In the evaluated period, 2 235 931 newborns were screened. 479 children had an abnormal screening result, 133 children were diagnosed with CAH (114 SW, 14 simple virilizing (SV)), five non-classic CAH. During this period, no patients with SW CAH were missed by neonatal screening (sensitivity was 100%). After exclusion of 17 cases with missing information on diagnosis, specificity was 99.98% and positive predictive value was 24.7%. Most false positives (30%) were attributable to prematurity. Of patients with SW CAH, 68% (71/104) patients were detected by neonatal screening and 33 (33/104) were clinically diagnosed. Of girls with SW CAH, 38% (14/37) were detected by neonatal screening and 62% (23/37) were clinically diagnosed.

CONCLUSION

The Dutch neonatal screening has an excellent sensitivity and high specificity. Both boys and girls can benefit from neonatal screening.

Cost-effectiveness of newborn screening for severe combined immunodeficiency

Severe combined immunodeficiency (SCID) is a condition that often results in severe infections and death at young age. Early detection shortly after birth, followed by treatment before infections occur, largely increases the chances of survival. As the incidence of SCID is low, assessing cost-effectiveness of adding screening for SCID to the newborn screening program is relevant for decision making. Lifetime costs and effects of newborn screening for SCID were compared to a situation without screening in the Netherlands in a decision analysis model. Model parameters were based on literature and expert opinions. Sensitivity analyses were performed. Due to earlier detection, the number of deaths due to SCID per 100,000 children was assessed to decrease from 0.57 to 0.23 and a number of 11.7 quality adjusted life-years (QALYs) gained was expected. Total yearly healthcare costs, including costs of screening, diagnostics, and treatment, were €390,800 higher in a situation with screening compared to a situation without screening, resulting in a cost-utility ratio of €33,400 per QALY gained.Conclusion: Newborn screening for SCID might be cost-effective. However, there is still a lot of uncertainty around the cost-effectiveness estimate. Pilot screening projects are warranted to obtain more accurate estimates for the European situation. What is Known: • Severe combined immunodeficiency (SCID) is a condition that often results in severe infections and death at a young age. • As the incidence of SCID is low, assessing cost-effectiveness of adding screening for SCID to the newborn screening program is needed. What is New: • Newborn screening for SCID is expected to reduce mortality from 0.57 to 0.23 per 100,000 children at additional healthcare costs of €390,800. The cost-utility ratio is €33,400 per QALY gained. • Due to large uncertainty around cost-effectiveness estimates, pilot screening projects are warranted for Europe.

Concise tool based on language milestones identifies children with specific language impairment at 24-45 months of age

AIM

This study aimed to develop a concise tool with acceptable predictive properties to identify young children with specific language impairment (SLI).

METHODS

In this nested case-control study children with SLI attending two special needs schools for severe speech and language difficulties in the Netherlands were matched by date of birth and sex with control children attending mainstream education. This study analysed the predictive validity for having SLI at a mean age of eight years and three months (range 4-11 years) using combinations of six language milestones that were registered at 24, 36 and 45 months and retrieved from the children's healthcare files in 2012.

RESULTS

We included 253 pairs of children with and without SLI. During a single visit, combinations of two milestones at one age achieved a specificity of at least 97% and sensitivities ranged from 32% to 64%. However, the concise tool, which combined five milestones at three different ages - 24, 36 and 45 months - had a specificity of 96% (95% confidence interval 94-99%) and a sensitivity of 71% (95% confidence interval 66-77%).

CONCLUSION

Combining milestones at different ages provided a concise tool that could help to detect children with SLI at a young age.

Children with specific language impairment are more likely to reach motor milestones late

BACKGROUND

Delayed language development without an obvious cause is considered an isolated developmental disorder and is called specific language impairment (SLI). SLI is probably the most prevalent developmental disorder in childhood with a generally cited prevalence of 7%. This study aimed to investigate whether SLI is always an isolated disorder or if children with SLI also have delayed motor development.

METHODS

We used data of an earlier study with a prospective nested case-control design in which developmental data were collected from child health care files. Cases were children (4-11 years) with diagnosed SLI. They were matched by sex and date of birth with control children attending mainstream education. Data of both groups on seven gross and six fine motor milestones which had been registered in the Dutch Developmental Instrument between the ages of 15-36 months were retrieved from child health care files. McNemar tests were performed to test for differences in reaching motor milestones at the age norm between the case and control group.

RESULTS

Data from 253 children in each group were available. A significant difference was found between both groups in the proportion failing to reach three of the seven investigated gross motor milestones at the age norm (p < 0.05). The proportion of children not reaching the motor milestone at the age norm was significantly higher for five of the six fine motor milestones in children with SLI compared with control children (p < 0.05).

CONCLUSIONS

More children with SLI are late in reaching motor milestones than children without SLI. This means that it is debatable whether SLI can be regarded as a "specific" impairment, which is not associated with other developmental problems. A broader developmental assessment is therefore indicated when diagnosing SLI.

Mortality in Children With Early-Detected Congenital Central Hypothyroidism

CONTEXT

Approximately 60% to 80% of patients with congenital central hypothyroidism (CH-C) have multiple pituitary hormone deficiencies (MPHDs), making CH-C a potentially life-threatening disease. Data on mortality in patients with CH-C are lacking.

OBJECTIVE

To study the mortality rate in pediatric patients with early-detected and treated CH-C in the Netherlands and to investigate whether causes of death were related to pituitary hormone deficiencies.

METHODS

Overall mortality rate, infant mortality rate (IMR), and under-5 mortality rate were calculated in all children with CH-C detected by neonatal screening between 1 January 1995 and 1 January 2013. Medical charts were reviewed to establish causes of death.

RESULTS

A total of 139 children with CH-C were identified, of which 138 could be traced (82 with MPHD, 56 with isolated CH-C). Total observation time was 1414 years with a median follow-up duration of 10.2 years. The overall mortality rate was 10.9% (15/138). IMR and under-5 mortality rate were 65.2/1000 (9/138) and 101.4/1000 (14/138), respectively, compared with an IMR of 4.7/1000 and under-5 mortality of 5.4/1000 live-born children in the Netherlands during the same time period (P < 0.0001). Main causes of death were severe congenital malformations in six patients, asphyxia in two patients, and congenital or early neonatal infection in two patients. Pituitary hormone deficiency was noted as cause of death in only one infant.

CONCLUSION

We report an increased mortality rate in patients with early-detected CH-C that does not seem to be related to endocrine disease. This suggests that mortality due to pituitary insufficiency is low in patients with early-detected and early-treated CH-C.

Tracking of thinness and overweight in children of Dutch, Turkish, Moroccan and South Asian descent from 3 through 15 years of age: a historical cohort study

BACKGROUND

Overweight is shown to track (= to maintain a relative position in a distribution) from childhood to adulthood, but is mostly studied in preobesogenic cohorts and in single ethnic groups. Little is known about tracking of thinness by ethnicity.

OBJECTIVES

to determine (differences in) tracking of BMI (class) from 3 through 15 years and the prediction of BMI class at 13-15 years of age in contemporary Dutch, Turkish, Moroccan and South Asian children living in the Netherlands.

METHODS

Historical cohort of 7625 children, born 1994-1997, with 24,376 measurements of BMI. BMI z-score and BMI class was analysed using universal criteria. South Asian children were also assessed using ethnic specific BMI criteria. Diagnostic odds ratios (OR) and test properties were calculated to estimate the ability of BMI class at 3-4 years to predict BMI class at 13-15 years.

RESULTS

Tracking of thinness between 3 and 15 years was stronger than that of overweight, as indicated by a generally higher diagnostic OR. BMI trajectories between 3 and 15 years of age of thin, normal weight and overweight adolescents were, although significantly different, quite similarly shaped in children of Dutch, Turkish and Moroccan descent. The South Asian BMI trajectory deviated considerably from the other ethnic groups, but the differences disappeared when South Asian specific BMI criteria were applied. A substantial proportion of overweight developed between 5-10 years, after which less children shifted to other BMI classes. A total of 55-78% of children with overweight at 3-4 years retained their overweight at 13-15 years, and 10-20% of 3-4 year olds with thinness remained thin.

CONCLUSIONS

In all ethnic groups, overweight and especially thinness highly tracked into adolescence. South Asian children differed from the other ethnic groups when universal BMI criteria were applied, but with South Asian specific BMI criteria tracking patterns became more concordant.

TSH and FT4 Concentrations in Congenital Central Hypothyroidism and Mild Congenital Thyroidal Hypothyroidism

CONTEXT

In central hypothyroidism (CeH), free thyroxine (FT4) concentrations are low, whereas thyrotropin (TSH) concentrations may be low, normal, or even slightly elevated due to reduced bioactivity. Congenital CeH (CCeH) may be isolated or part of multiple pituitary hormone deficiencies (MPHD).

OBJECTIVE

We tested our hypotheses that (1) TSH concentrations have a more U-shaped distribution in children with CCeH compared with children with a normally functioning hypothalamic-pituitary-thyroid axis and (2) TSH concentrations in children with CCeH with MPHD are higher compared with children with isolated CCeH. We also studied whether FT4 levels are helpful in distinguishing CCeH from mild congenital hypothyroidism of thyroidal origin (CH-T).

METHODS

Dutch neonatal screening TSH and first diagnostic TSH and FT4 were analyzed in all children diagnosed with permanent CCeH between 1995 and 2012. Controls were children with T4-binding globulin deficiency. FT4 concentrations in CCeH were compared with those in CH-T with TSH values in the same range as those of CCeH.

RESULTS

We studied 120 children with CCeH (isolated CCeH, n = 50; MPHD, n = 70) and 350 control subjects. Screening TSH concentrations were not significantly different (P = 0.055), but diagnostic TSH values were significantly different between the CCeH group and the control group (P = 0.037). TSH was significantly higher in MPHD compared with isolated CCeH (P = 0.004). FT4 concentrations were significantly lower in CCeH compared with mild CH-T (P < 0.0005).

CONCLUSION

TSH values in CCeH have a more U-shaped distribution compared with controls with the highest TSH concentrations in MPHD. FT4 levels were significantly lower in CCeH compared with CH-T.

Specific language impairment is associated with maternal and family factors

BACKGROUND

This study aimed to identify risk factors associated with specific language impairment (SLI).

METHODS

In a nested case-control design, 253 children attending special needs schools for severe speech and language difficulties in the Netherlands were matched for sex and date of birth with 253 children attending mainstream education. Data on perinatal, maternal and family issues were retrieved from well-child care files registered shortly after birth.

RESULTS

Children with SLI had younger mothers than children in the control group (mean 30 years 9 months vs. mean 31 years 9 months) (P = 0.02). Children with SLI were less frequently breastfed directly after birth (55% vs. 71%) (P = 0.0007) and were less frequently firstborns (33.3% vs. 46.2%) (P = 0.002). No statistically significant differences were found for any of the other risk factors.

CONCLUSIONS

A relationship was found between SLI and maternal age, being breastfed and place in the birth order. Perinatal risk factors do not seem to be strongly associated with SLI.

Transient hypothyroxinemia of prematurity and problem behavior in young adulthood

INTRODUCTION

Preterm newborns are at risk of developing transient hypothyroxinemia of prematurity (THoP), which has been associated with subsequent neurodevelopmental impairments. Behavioral outcomes at adult age after THoP have never been reported.

AIM

To examine whether there is an association between THoP and problem behavior at young adult age.

METHODS

This study was part of the follow-up of 19-year-old subjects born very preterm (i.e., <32 weeks) and/or with a very low birth weight (i.e.,<1500g) from the Project On Preterm and Small-for-gestational-age infants (POPS) cohort. We included 468 subjects of the POPS cohort; of whom 123 had THoP. Thyroxine (T4) concentrations were obtained through the national neonatal screening program for congenital hypothyroidism. THoP was defined as a T4 concentration <-3 SD (approximately 60nmol/L). At age 19, behavior was assessed using the Young Adult Self Report and the Young Adult Behavioral Checklist for parents.

RESULTS

THoP was associated with a 1.8 (95% confidence interval (CI): 1.01-3.4) -fold increased odds of self-reported Internalizing behavior, as well as with a 1.9 (95% CI: 1.1-3.1) -fold increased odds of parent-reported Total problem behavior. These relations persisted after correction for demographic and perinatal variables. Similar associations were absent for the other self-reported and parent-reported syndrome and problem scales.

CONCLUSIONS

THoP was associated with more internalizing and total problem behavior at age 19. While our observations warrant more awareness of problem behavior in preterm infants, at present, it is unclear whether these associations are causal and screening for THoP does not seem necessary.

Failure to meet language milestones at two years of age is predictive of specific language impairment

AIM

This study established predictive properties of single language milestones for specific language impairment (SLI) after the age of four, as these had not previously been reported in the literature.

METHODS

In this nested case-control study, children attending special needs schools for severe speech and language difficulties were matched with children attending mainstream schools. Data covering the ages of zero to four years were retrieved from well-child care clinics and the outcomes of 23 language milestones in the Dutch Developmental Instrument were analysed. The predictive properties were expressed as positive likelihood ratios, sensitivity and specificity.

RESULTS

We included 253 pairs of children with and without SLI, aged from four to 11 years. The mean age was eight years and three months, and 77% were boys. From the age of 18 months, cases and controls differed significantly on all milestones (p < 0.01). After 24 months, the language milestones had positive likelihood ratios that ranging from 6 to 108. In general, language milestones had a high specificity (range 77-100%), but the sensitivity was relatively low (range 0-68%).

CONCLUSION

Failure to meet language milestones from the age of 24 months was predictive of SLI, but the use of separate milestones had limited value due to low sensitivity.

No Association Between Transient Hypothyroxinemia of Prematurity and Neurodevelopmental Outcome in Young Adulthood

CONTEXT

Transient hypothyroxinemia of prematurity (THoP) has been associated with neurodevelopmental impairment in infancy and childhood. It is not known whether these relations persist into adulthood.

OBJECTIVE

The objective was to examine whether there is an effect of THoP on intelligence quotient (IQ) score and motor functioning at a young adult age.

DESIGN

This study was part of the 19-year follow-up of the Project On Preterm and Small-for-gestational-age birth (POPS) cohort, which included infants born very preterm (ie, <32 wk) and/or with a very low birth weight (ie, <1500 g).

SETTING

This was a multicenter study.

PATIENTS

There were 398 19-year-old participants of the POPS cohort, of whom 120 had THoP.

EXPOSURE

T4 concentrations were obtained through the national neonatal screening program for congenital hypothyroidism. THoP was defined as a total T4 concentration < -3 SD of the daily mean (approximately 60 nmol/L).

MAIN OUTCOME MEASURES

Main outcome measures were IQ and motor functioning, measured with the digital Multicultural Capacities Test-Intermediate Level and a revised version of Touwen's examination of minor neurological dysfunction, respectively.

RESULTS

THoP was not associated with IQ score (mean difference, 0 [95% confidence interval, -3.8 to 3.8] points) or motor function (mean difference, 0.6 [95% confidence interval, -1.3 to 2.5] points) after adjustment for demographic and perinatal characteristics.

CONCLUSIONS

No associations between THoP and neurodevelopmental outcome at age 19 years were found.

To screen or not to screen for adolescent idiopathic scoliosis? A review of the literature

OBJECTIVES

Over the years, there has been much debate about the desirability and efficacy of screening for adolescent idiopathic scoliosis. To analyse the current evidence from a public health point of view a renewed evaluation of the literature was performed.

STUDY DESIGN

Literature review.

METHODS

We performed two literature searches: from January 2000 to April 2015 for systematic reviews or guidelines on screening for adolescent idiopathic scoliosis and from January 2009 to April 2015 for all studies on adolescent idiopathic scoliosis and screening methods. We evaluated if screening for adolescent idiopathic scoliosis fulfils the criteria of the UK National Screenings Committee for appraising a screening programme.

RESULTS

Adolescent idiopathic scoliosis is a condition with an unpredictable natural history. The optimal age and frequency of screening are unknown; it is not possible to predict which patients will need (conservative or surgical) treatment. The Forward Bending Test has a positive predictive value of 2.6% and a sensitivity of 56% (95% CI 23-88%) for (conservative or surgical) treatment, and is therefore not valid enough for use in a screening programme. There seems to be sufficient evidence that brace treatment is effective for preventing progression of adolescent idiopathic scoliosis. It is not clear if screening is cost effective.

CONCLUSIONS

Despite evidence that brace treatment is effective for preventing progression of adolescent idiopathic scoliosis, the benefits from the screening programme do not outweigh the harms. From a Public Health point of view, there is not enough evidence to support a screening programme for adolescent idiopathic scoliosis.

Diagnostic accuracy of referral criteria for head circumference to detect hydrocephalus in the first year of life

BACKGROUND

Increased head circumference is often the first and main sign leading to the diagnosis of hydrocephalus. Our aim is to investigate the diagnostic accuracy of referral criteria for head circumference to detect hydrocephalus in the first year of life.

METHODS

A reference group with longitudinal head circumference data (n = 1938) was obtained from the Social Medical Survey of Children Attending Child Health Clinics study. The case group comprised infants with hydrocephalus treated in a tertiary pediatric hospital who had not already been detected during pregnancy (n = 125). Head circumference data were available for 43 patients. Head circumference data were standardized according to gestational age-specific references.

RESULTS

Sensitivity and specificity of a very large head circumference (>2.5 standard deviations on the growth chart) were, respectively, 72.1% (95% confidence interval [CI]: 56.3-84.7) and 97.1% (95% CI:96.2-97.8). These figures were, respectively, 74.4% (95% CI: 58.8-86.5) and 93.0% (95% CI:91.8-94.1) for a large head circumference (>2.0 standard deviation), and 76.7% (95% CI:61.4-88.2) and 96.5% (95% CI:95.6-97.3) for a very large head circumference and/or a very large (>2.5 standard deviation) progressive growth of head circumference.

CONCLUSIONS

A very large head circumference and/or a very large progressive growth of head circumference shows the best diagnostic accuracy to detect hydrocephalus at an early stage. Gestational age-specific growth charts are recommended. Further improvements may be possible by taking into account parental head circumference.

The severity of congenital hypothyroidism of central origin should not be underestimated

CONTEXT

Congenital hypothyroidism (CH) may be of thyroidal (CHT) or central origin (CHC). Worldwide, most neonatal screening programs are TSH-based and effectively detect CHT. Only a few screening programs measure total or free T4 and TSH simultaneously or stepwise, enabling detection of CHT as well as CHC. A frequently used argument against screening for CHC is its presumed mild hypothyroid character. In the recently published European Society for Paediatric Endocrinology (ESPE) CH consensus guidelines on screening, diagnosis, and management, severity of CH is classified based on initial free T4 (FT4) concentrations.

OBJECTIVE

Our objective was to assess disease severity of CHC compared with CHT in a Dutch cohort of CH patients.

METHODS

Pretreatment FT4 concentrations were analyzed in all children with CH detected by the Dutch neonatal T4+TSH+T4-binding-globulin (TBG) screening between 1995 and 2011. Disease severity was classified using the FT4-based ESPE classification.

RESULTS

Between 1995 and 2011, 1288 children were diagnosed with CH. Data of 1200 (143 CHC and 1057 CHT) were available for analysis. Based on FT4 concentrations, 4 children with CHC (2.8%) had severe, 75 (52.4%) moderate, and 64 (44.8%) mild CH. In the CHT group, 280 children (26.5%) had severe, 341 (32.3%) moderate, and 436 (41.2%) mild CH.

CONCLUSION

Our results indicate that, based on initial FT4 values, severe CH was much more prevalent in CHT compared with CHC. However, CHC itself should not be considered as only mild because more than half of CHC patients have moderate CH with initial FT4 below 10 pmol/L (0.78 ng/dl).

Facilitators and barriers to the successful implementation of a protocol to detect child abuse based on parental characteristics

To determine the critical facilitating and impeding factors underlying successful implementation of a method to detect child abuse based on parental rather than child characteristics known as the Hague Protocol. The original implementation region of the protocol (The Hague) was compared to a new implementation region (Friesland), using analysis of referrals, focus group interviews (n=6) at the Emergency departments (ED) and at the Reporting Centers for Child abuse and Neglect (RCCAN) as well as questionnaires (n=76) at the EDs. Implementation of the Hague Protocol substantially increased the number of referrals to the RCCAN in both regions. In Friesland, the new implementation region, the number of referrals increased from 2 out of 92,464 patients (three per 100,000) to 108 out of 167,037 patients (62 per 100,000). However in Friesland, child abuse was confirmed in a substantially lower percentage of cases relative to the initial implementation region (62% vs. 91%, respectively). Follow-up analyses suggest that this lower positive predictive value may be due to the lack of training for RCCAN professionals concerning the Hague Protocol. The focus group interviews and questionnaires point to time limitations as the main impediment for implementation, whereas an implementation coach has been mentioned as the most important facilitating factor for success. The Hague Protocol can be used to detect child abuse beyond the initial implementation region. However, training is essential in order to assure a consistent evaluation by the RCCAN.

Cost-effectiveness of newborn screening for cystic fibrosis determined with real-life data

BACKGROUND

Previous cost-effectiveness studies using data from the literature showed that newborn screening for cystic fibrosis (NBSCF) is a good economic option with positive health effects and longer survival.

METHODS

We used primary data to compare cost-effectiveness of four screening strategies for NBSCF, i.e. immunoreactive trypsinogen-testing followed by pancreatitis-associated protein-testing (IRT-PAP), IRT-DNA, IRT-DNA-sequencing, and IRT-PAP-DNA-sequencing, each compared to no-screening. A previously developed decision analysis model for NBSCF was fed with model parameters mainly based on a study evaluating two novel screening strategies among 145,499 newborns in The Netherlands.

RESULTS

The four screening strategies had cost-effectiveness ratios varying from €23,600 to €29,200 per life-year gained. IRT-PAP had the most favourable cost-effectiveness ratio. Additional life-years can be gained by IRT-DNA but against higher costs. When treatment costs reduce with 5% due to early diagnosis, screening will lead to financial savings.

CONCLUSION

NBSCF is as an economically justifiable public health initiative. Of the four strategies tested IRT-PAP is the most economic and this finding should be included in any decision making model, when considering implementation of newborn screening for CF.

Mainstream and special school attendance among a Dutch cohort of children with Down Syndrome

Object

To determine the level of mainstream education in a nationwide cohort of adolescents with Down Syndrome (DS), and to find characteristics related to mainstream or special school attendance.

Method

Dutch children with DS born in 1992, 1993 or 1994, were assessed when 16–19 years old. Parents scored school enrolment between the age of 4–18 years, general characteristics and the levels of intellectual disability using the Dutch Social Competence Rating Scale. Associations between disability and years in mainstream school were assessed by ordinal logistic regression, adjusting for sex and parental education.

Results

We collected data from 170 boys and 152 girls (response 63%); mean age 18.3 years (ranges 16.8–19.9). Intellectual disability was mostly moderate (43%). Most children (74%) entered mainstream education between 4 and 6 years of age. At 13 years 17% was in mainstream school and 7% stayed in up to 16 years. From the age of 8 years onwards the majority was in special education, while 6% never attended school. Girls were more often in mainstream school and stayed in longer. Level of disability was significantly associated with number of years in mainstream education.

Conclusion

Three out of four Dutch children with DS entered mainstream primary education, however late entry and high dropout are common.

[Haemoglobinopathy in the 21st century: incidence, diagnosis and heel prick screening]

OBJECTIVE

To determine the incidence of severe haemoglobinopathy, to evaluate the effect of heel prick screening, and to identify those children who do not benefit from this early diagnosis.

DESIGN

Prospective descriptive study.

METHOD

Registration of all symptomatic and asymptomatic children who between 2003-2009 were newly diagnosed with the a severe form of a hereditary disorder concerning the formation of the alpha haemoglobin chain (HbH disease), or the beta haemoglobin chain (sickle cell disease or beta thalassaemia major) in the Netherlands. Registration was done by collecting anonymised reports from the Dutch Paediatric Surveillance Unit and TNO, and by additional questionnaires.

RESULTS

During the study period, 48 children (range: 36-76) per year were diagnosed with severe haemoglobinopathy. The overall incidence was 2.5 per 10,000 live births. The incidence of sickle cell disease diagnosed by heel prick screening was 2.1 per 10,000 live births and of thalassaemia major 0.6 per 10,000 live births. In 7% of the children with sickle cell disease who were diagnosed without any form of screening, the diagnosis was made on (a life threatening) infection. Twenty-two percent of the children with a severe form of haemoglobinopathy were not born in the Netherlands. The parents of almost half of the children with sickle cell disease originally came from West- or Central Africa. The parents of children with thalassaemia major were mainly from Morocco or various Asiatic countries.

CONCLUSION

The number of children with severe haemoglobinopathy in the Netherlands has trebled since 1992. In order for all children to benefit from early diagnosis and preventive treatment, it is advisable that children who originate from risk areas should be tested for haemoglobinopathy when they first arrive in the Netherlands.

Declining and stabilising trends in prevalence of overweight and obesity in Dutch, Turkish, Moroccan and South Asian children 3-16 years of age between 1999 and 2011 in the Netherlands

OBJECTIVE

In many developed countries, overweight and obesity prevalence seems to stabilise. The aim of this study was to determine trends between 1999 and 2011 in overweight and obesity prevalence, and mean Body Mass Index (BMI) z-score in Dutch, Turkish, Moroccan and Surinamese South Asian children in the Netherlands.

DESIGN

A cross-sectional population-based study with 136 080 measurements of height and weight of 73 290 children aged 3-16 years. BMI class and BMI z-score were determined with the latest International Obesity Taskforce (IOTF) criteria, with overweight defined as an adult BMI equivalent ≥ 25 and obesity ≥ 30. Time trends per year were analysed using logistic and linear regression analyses.

RESULTS

The prevalence of overweight in Dutch children declined from 13% to 11% (OR 0.960; 95% CI 0.954 to 0.965), but increased in Turkish children from 25% to 32% (OR 1.028; 95% CI 1.020 to 1.036). In Moroccan and Surinamese South Asian children, overweight rates were stable, but obesity prevalence decreased (OR 0.973; 95% CI 0.957 to 0.989, OR 0.964; 95% CI 0.943 to 0.985, respectively) as well as the mean BMI z-score (B=-0.010; 95% CI -0.014 to -0.006, B=-0.010; 95% CI -0.016 to -0.004). In Turkish children, trends limited to the period 2007-2011 showed no statistically significant relationship for all outcome measures.

CONCLUSIONS

The decrease in obesity prevalence in Dutch, Moroccan and Surinamese South Asian children suggests that overweight children became less adipose. The stabilising trend in overweight and obesity prevalence in Turkish children since 2007 may signify a levelling off for this ethnic group.

[Neonatal screening for congenital hypothyroidism: more than 30 years of experience in the Netherlands]

OBJECTIVE

To describe the Dutch neonatal screening programme for congenital hypothyroidism (CH).

DESIGN

Descriptive study.

METHOD

Data on neonatal screening for CH in the period 1 January 1981 through 31 December 2011 were obtained from the Department for Vaccine Supply and Prevention Programmes of the Dutch National Institute for Public Health and the Environment (RIVM), laboratories and paediatricians to whom babies with abnormal screening results were referred. The screening procedure has been amended several times. In the period 1981-1994, only T4 and TSH were measured in heel prick blood, for example. From 1995, thyroxine-binding globulin (TBG) was added to the screening protocol.

RESULTS

The participation rate was 99.7%. Before 1995 the sensitivity, specificity and positive predictive value were 94%, 99.51% and 6%, respectively. From 1995 these percentages were 98%, 99.85% and 21%, respectively. The total prevalence of CH was 1:2670 (prevalence of CH of thyroidal origin was 1:3100 and CH of central origin was 1:21,600). The percentages of patients with severe CH treated before day 15 in the periods 1981-1990, 1991-2000 and 2001-2011 were 24% (63/263), 63% (170/269) and 96% (176/184), respectively.

CONCLUSION

The sensitivity and specificity of the screening procedure has considerably increased since 1995 compared with the period before 1995. In recent years patients with severe CH were treated considerably earlier than in the first years of the screening. Neonatal screening for CH may be considered as an important success for public health care.

Practical and social skills of 16-19-year-olds with Down syndrome: independence still far away

Survival of children with Down syndrome (DS) has improved considerably, but insight into their level of daily functioning upon entering adulthood is lacking. We collected cross-sectional data from a Dutch nationwide cohort of 322 DS adolescents aged 16-19 (response 62.8%) to assess the degree to which they master various practical and social skills, using the Dutch Social competence rating scale and the Children's Social Behavior Questionnaire. Up to 60% mastered some of the skills required for independent functioning, such as maintaining adequate standards of personal hygiene and preparing breakfast. Less than 10% had achieved basic skills such as basic cooking and paying in a shop. It is difficult for DS people to master all the skills necessary to live independently. Ninety percent of adolescents with DS experience significant problems in social functioning.

A new protocol for screening adults presenting with their own medical problems at the Emergency Department to identify children at high risk for maltreatment

Identifying child abuse and neglect solely on the grounds of child characteristics leaves many children undetected. We developed a new approach (Hague protocol) based on characteristics of parents who attend the Emergency Department (ED) because they have the following problems: (1) intimate partner violence, (2) substance abuse, or (3) suicide attempt or other serious psychiatric problems. The goal of this protocol is to enable the Reporting Center for Child Abuse and Neglect (RCCAN) to rapidly assess family problems and offer voluntary community based support to these parents. The aim of this study is to assess whether this protocol for screening adults presenting for care in the Emergency Department can identify children at high risk for maltreatment. A before and after study was conducted at 9 EDs in 3 regions in the Netherlands (one intervention region and 2 control regions). During the period January 2006 to November 2007, prior to the introduction of the Hague protocol, from a total of 385,626 patients attending the ED in the intervention region 4 parents (1 per 100,000) were referred to the RCCAN. In the period after introduction of the protocol (December 2007 to December 2011), the number rose to 565 parents from a total of 885,301 patients attending the ED (64 per 100,000). In the control region, where the protocol was not implemented, these figures were 2 per 163,628 (1 per 100,000) and 10 per 371,616 (3 per 100,000) respectively (OR=28.0 (95 CI 4.6-170.7)). At assessment, child abuse was confirmed in 91% of referred cases. The protocol has a high positive predictive value of 91% and can substantially increase the detection rate of child abuse in an ED setting. Parental characteristics are strong predictors of child abuse. Implementing guidelines to detect child abuse based on parental characteristics of parents attending the adult section of the ED can increase the detection rate of child abuse and neglect allowing appropriate aid to be initiated for these families.

Problem behavior of individuals with Down syndrome in a nationwide cohort assessed in late adolescence

OBJECTIVE

To assess problem behavior in adolescents with Down syndrome and examine the association with sex and severity of intellectual disability.

STUDY DESIGN

Cross-sectional data of a Dutch nationwide cohort of Down syndrome children aged 16-19 years were collected using a written parental questionnaire. Problem behavior was measured using the Child Behavior Checklist and compared with normative data. The degree of intellectual disability was determined using the Dutch Social competence rating scale.

RESULTS

The response rate was 62.8% (322/513), and the mean age 18.3 years (SD ± 0.8). The total score for problem behavior was higher in adolescents with Down syndrome than in adolescents without Down syndrome (26.8 vs 16.5; P < .001). Overall, 51% of adolescents with Down syndrome had problem scores in the clinical or borderline range on 1 or more Child Behavior Checklist subscales; this is more than twice as high as adolescents without Down syndrome. Adolescents with Down syndrome had more internalizing problems than their counterparts without Down syndrome (14% and 9%, respectively, in the clinical range); the percentages for externalizing problems were almost equal (7% and 9%, respectively, in the clinical range). The highest problem scores in adolescents with Down syndrome were observed on the social problems and thought problems subscales (large to very large standardized differences). Male sex and/or more severe mental disabilities were associated with more behavioral problems.

CONCLUSIONS

Serious problem behavior is more prevalent in adolescents with Down syndrome. This demonstrates the need for a focus on general behavior improvement and on the detection and treatment of specific psychopathology in individuals with Down syndrome.

At what age is hydrocephalus detected, and what is the role of head circumference measurements?

To investigate at what age hydrocephalus is detected and to assess the role of head circumference measurements in detecting hydrocephalus, we performed a retrospective chart review in children with hydrocephalus treated in a tertiary paediatric hospital in the Netherlands. The study group contained 146 patients; 38 patients (31%) were referred because of abnormalities in head circumference. Eighty-nine per cent of the patients were detected in the first year of life. After this period, no patients were referred because of an abnormal head circumference. Therefore, head circumference measurements seem to have little value for detecting hydrocephalus after the first year of life.

Evaluation of treatment thresholds for unconjugated hyperbilirubinemia in preterm infants: effects on serum bilirubin and on hearing loss?

Background

Severe unconjugated hyperbilirubinemia may cause deafness. In the Netherlands, 25% lower total serum bilirubin (TSB) treatment thresholds were recently implemented for preterm infants.

Objective

To determine the rate of hearing loss in jaundiced preterms treated at high or at low TSB thresholds.

Design/Methods

In this retrospective study conducted at two neonatal intensive care units in the Netherlands, we included preterms (gestational age <32 weeks) treated for unconjugated hyperbilirubinemia at high or low TSB thresholds. Infants with major congenital malformations, syndromes, chromosomal abnormalities or toxoplasmosis, rubella, cytomegalovirus, herpes, syphilis, and human immunodeficiency infections were excluded. We analyzed clinical characteristics and TSB levels during the first ten postnatal days. After two failed automated Auditory Brainstem Response (ABR) tests we used the results of the diagnostic ABR examination to define normal, unilateral, and bilateral hearing loss (>35 dB).

Results

There were 479 patients in the high and 144 in the low threshold group. Both groups had similar gestational ages (29.5 weeks) and birth weights (1300 g). Mean and mean peak TSB levels were significantly lower after the implementation of the novel thresholds: 152±43 µmol/L and 212±52 µmol/L versus 131±37 µmol/L and 188±46 µmol/L for the high versus low thresholds, respectively (P<0.001). The incidence of hearing loss was 2.7% (13/479) in the high and 0.7% (1/144) in the low TSB threshold group (NNT = 50, 95% CI, 25–3302).

Conclusions

Implementation of lower treatment thresholds resulted in reduced mean and peak TSB levels. The incidence of hearing impairment in preterms with a gestational age <32 weeks treated at low TSB thresholds was substantially lower compared to preterms treated at high TSB thresholds. Further research with larger sample sizes and power is needed to determine if this effect is statistically significant.

Measuring free thyroxine levels in neonatal heel-prick samples

The Dutch neonatal screening scheme for Congenital Hypothyroidism (CH) is primarily based on the determination of thyroxine (T4) in filter paper blood spots. In the lowest 5% of T4 values, thyroxine binding globulin (TBG) is measured in order to be able to correct for occasional low TBG levels. However, because the commercial TBG kit has been withdrawn from the market, alternative strategies are needed to be explored including the assessment of free T4. We evaluated the Neonatal Free Thyroxine (fT4) enzyme immunoassay (EIA) kit of Bio-Rad. FT4 as measured in a daily run of random samples correlated with T4. We also observed a correlation between fT4 and T4, and between fT4 and T4/TBG ratio in blood spots with low T4 concentrations. The correlation between fT4 and T4 in blood spots of proven CH-patients was highly significant. ROC curves were constructed for the fT4 assay and the T4/TBG ratio based on 27 CH patients and 215 controls with a complete set of data. The curves of both assays seemed to be rather similar. We conclude that the validity of the fT4 and the T4/TBG-approach seems to be the same. A study with a larger sample size giving the same or even more favorable results for the fT4-approach is necessary before we will change the present CH protocol.

PKU: high plasma phenylalanine concentrations are associated with increased prevalence of mood swings

In phenylketonuria, knowledge about the relation between behavior and plasma phenylalanine is scarce. The aim of this study was to determine whether high phenylalanine is associated with disturbed behavior noticed by the patient and or close environment (parents or partners). 48 early treated PKU patients (median age 8.5, range 0-35 years) participated (median phenylalanine concentration in total sample 277 (range 89-1171) μmol/l; and in patients <12 years 238 (range 89-521) μmol/l). After sending blood samples, patients or close environment were interviewed with a standardized questionnaire whether they noticed hyperactivity, annoying behavior, mood swings and introvert or extravert behavior. The interviewer as well as the respondents were blinded with regard to the phenylalanine concentration.

RESULTS

Patients reported less deviant behavior compared to close environment. Mood swings were positively associated with phenylalanine concentrations in the total group (P=0.039) and patients <12 years (P=0.042). The relationships between temporary high phenylalanine concentrations and hyperactivity, annoying behavior, introvert and extravert behavior were not statistically significant.

CONCLUSION

there is a positive association between phenylalanine concentrations and mood swings.

Ten-year quality assurance of the nationwide hearing screening programme in Dutch neonatal intensive care units

AIM

To evaluate 10-year quality assurance of newborn hearing screening (NHS) in Dutch neonatal intensive care units (NICU).

METHODS

Results of the two-stage automated auditory brainstem response (AABR) screening and diagnostic examination in NICU graduates were centrally registered between October 1998 and December 2008. This registration facilitates screening, tracking and follow-up after abnormal screening results. Outcome measures are referral rates, prevalence rate of hearing loss and (trends of) coverage rates and timeliness of follow-up.

RESULTS

Thirty-two thousand one hundred and two infants have been screened. Referral rates were 9.2% at the first and 26.3% at the second stage. Hearing loss was diagnosed in 728 infants (2.2%). Coverage rates were 98.7% at the first, 92.1% at the second stage, 92.3% for the diagnostic examination and 97.9% for the complete programme. After correction for gestational age, 95.8% of the infants had their first AABR<1 month, 81.8% of the referred infants had their second AABR<6 weeks and 67.1% were diagnosed<3 months. There was a positive trend in referred infants that had their second AABR<6 weeks (p=0.004) as well as in infants diagnosed<3 months (p<0.001).

CONCLUSION

The NHS in Dutch NICUs is effective. Timely identification of hearing loss is improving over time.

One-third of the new paediatric patients with sickle cell disease in The Netherlands are immigrants and do not benefit from neonatal screening

OBJECTIVES

To estimate the prevalence of children with sickle cell disease (SCD) in The Netherlands. To estimate the annual number of children newly diagnosed as having SCD and the proportion with diagnoses through neonatal screening To estimate the proportion of children with SCD receiving paediatric care in a comprehensive care setting.

DESIGN

Data from two sources, a survey of paediatric practices (n=107) and a laboratory database (n=20), were analysed by the capture-recapture method.

PARTICIPANTS

Children with SCD aged <18 years, either born before 2003 or newly diagnosed as having SCD between 2003 and 2007.

MAIN OUTCOME MEASURES

Prevalence, annual number of children newly diagnosed as having SCD, proportion of children with diagnoses through neonatal screening, proportion of children receiving paediatric care.

RESULTS

The prevalence of SCD in children living in The Netherlands on 1 January 2003 was 1:5152 (95% CI 1:4513 to 1:6015). In the next 4 years, the annual incidence was 1:2011 (95% CI 1:1743 to 1:2376). Nearly one-third (27%) of the children newly diagnosed as having SCD immigrated to The Netherlands after birth and would, therefore, be missed by the neonatal screening programme. Approximately 60% of all children with SCD were not reported by paediatricians.

CONCLUSION

The number of children with SCD in The Netherlands is much higher than previously estimated, and the majority of these children seem not to be reviewed regularly by a paediatrician. Children born abroad (27% of new cases) do not benefit from neonatal screening and are at high risk of life-threatening complications before SCD is diagnosed. As this introduces disparities in healthcare, the initiation of adequate measures should be considered.

Risk indicators for hearing loss in infants treated in different neonatal intensive care units

AIM

To assess which infants' characteristics and specialized procedures are risk indicators for unilateral or bilateral hearing loss (HL) and to evaluate whether these risk indicators are associated with variation in prevalence of HL between Neonatal Intensive Care Units (NICUs).

METHODS

For 2002-2005, data from the NICU hearing screening database in the Netherlands were matched with the national neonatology database in which all NICU infants with their patient characteristics and specialized procedures are registered. Multivariate logistic regression analyses were performed to assess risk indicators for HL and to explain differences in prevalence rates between NICUs.

RESULTS

A total of 10 830 infants were available for analyses. The prevalence of HL was 1.8% and ranged from 0.7 to 3.7% between NICUs. Infants' characteristics that significantly increased the risk of HL were the presence of craniofacial anomalies, chomosomal/syndromal anomalies, central nervous system conditions, circulatory system conditions and intra-uterine infections. The specialized procedures involving > or =12 days of intensive care and high frequency oxygenation ventilation were independent risk indicators for HL. Approximately 20% of the variance can be explained by the studied risk indicators. Differences in prevalence rates between NICUs were slightly reduced after adjustment for these risk indicators. NICUs with the highest prevalence rates of HL were situated in the largest cities in the Netherlands with a mixed population because of immigration. Therefore, ethnicity may be a risk indicator.

CONCLUSIONS

Several independent risk indicators for HL were found, but they could not explain all differences in prevalence rates of HL between NICUs.

[Guideline for preventive child health care: 'Detection and referral criteria in short stature']

The main goal of this guideline for preventive child health care (PCHC) is to improve early detection of disorders that induce short stature. Based on research, evidence-based referral criteria for children aged 0-10 years with a short stature were formulated. These criteria are important for all professionals working with children, such as PCHC, general practitioners and paediatricians. Previous referral criteria dated 1997 and titled 'Diagnostics of short stature in children' had a very low specificity and were therefore considerably revised. They should no longer be applied. The guideline also provides information on the cause of short stature, psychosocial aspects and the use of growth hormone.

Event-related potential correlates of selective processing in early- and continuously-treated children with phenylketonuria: effects of concurrent phenylalanine level and dietary control

This study focused on important characteristics of attentional (selective) processing in children with early-treated phenylketonuria (PKU). Seven to 14-year-old children with PKU were allocated to high phenylalanine (Phe) and low Phe groups and compared with control children on amplitudes and latencies of early and late event-related potential (ERP) components elicited during a selective processing task. These components are thought to measure early sensory processes (stimulus encoding/perception) and later selection processes (target detection). The effects of concurrent Phe level and dietary control on brain activity and behavioural performance were studied. Results showed that children with PKU with high Phe levels were less accurate and made more false alarms than controls and children with PKU with low Phe levels. Both children with PKU and controls displayed the expected early fronto-central selection negativity and a late positive peak over posterior sites associated with sensory aspects of the selective attention task. However, in contrast with controls, children with PKU showed an absence of condition differences for selection positivity over anterior sites associated with target detection. Negative and positive selection potentials over fronto-central sites were dependent on concurrent and historical Phe levels, whereas sensory potentials depended more strongly on historical Phe levels. It is concluded that both sensory and selection aspects of attention are affected by Phe levels. The relative predictive strength of historical Phe levels suggests that high Phe levels during sensitive periods for brain maturation may have long-lasting influences on selective attention.

Trends in overweight and obesity prevalence in Dutch, Turkish, Moroccan and Surinamese South Asian children in the Netherlands

OBJECTIVE

To determine trends in the prevalence of overweight and obesity in children in The Hague (the Netherlands) from 1999 through 2007.

DESIGN

Population-based study of a series of cross-sectional assessments of height and weight from electronic health records.

SETTING

Child Health Care (Municipal Health Service), The Hague.

PARTICIPANTS

50,961 children aged 3-16 years, with Dutch (59%), Turkish (17%), Moroccan (13%) or Surinamese South Asian (11%) ethnicity, representative of the four major ethnic groups in The Hague, with 85,234 weight and height measurements recorded in 1999-2007.

MAIN OUTCOME MEASURES

(Trends in) the prevalence of overweight (excluding obesity) and obesity as defined by the International Obesity Taskforce cut-off points, using logistic regression with year as independent variable.

RESULTS

From 1999 through 2007 there was a decrease in the prevalence of overweight in Dutch girls from 12.6% to 10.9% (OR 0.96; 95% CI 0.95 to 0.98) and an increase in Turkish boys from 14.6% to 21.4% (OR 1.08; 95% CI 1.04 to 1.11). Obesity prevalence rose significantly in Turkish boys from 7.9% to 13.1% (OR 1.04; 95% CI 1.01 to 1.06) and in Turkish girls from 8.0% to 10.7% (OR 1.04; 95% CI 1.01 to 1.08). Dutch boys, and Moroccan and Surinamese South Asian boys and girls showed no significant trends.

CONCLUSIONS

The declining prevalence of overweight in Dutch girls may indicate reversal of previous trends in the Netherlands. However, in Turkish children overweight prevalence and obesity is high and increasing. Further public health action is necessary, especially for Turkish children.

A nationwide study on hospital admissions due to dehydration in exclusively breastfed infants in the Netherlands: its incidence, clinical characteristics, treatment and outcome

AIMS

To estimate the incidence and clinical characteristics in hospital admissions due to dehydration or undernutrition and their laboratory evaluation and treatment outcome in exclusively breastfed infants.

METHODS

All hospital admissions during the first 3 months of life assessed by the Dutch Paediatric Surveillance Unit (DPSU) between mid 2003 and mid 2005.

RESULTS

Nationwide 158 cases reported, correspond to an incidence of 58/y/100,000 breastfed infants; it is lower for severe dehydration at risk for hypernatraemia; 20/y/100,000. Sixty-five per cent of cases were <2 weeks old, their median weight loss was 9.3% and median age at admission 5 days; Serum sodium value was measured in only 12% of all cases. Insufficient volume intake and inadequate growth were most frequently reported (61% and 41%). Lethargy, jaundice or clinical dehydration was scored in 11-25%, seizures or shock in 3%. A breast pump at home was used in only 31%. In the hospital breast pumps were available (82%) as lactation consultants (73%). For treatment 65% was offered formula, in 30% by nasogastric drip. Most admissions lasted up to 3 days, all recovered fully and 33% were breastfed exclusively at discharge.

CONCLUSION

The incidence of severe dehydration in the Netherlands is relatively low. With extended use of breast pumps at home it could be lower. To prevent complications, we recommend applying a reference weight chart, a full clinical examination and more extensive screening of serum sodium and glucose.

The short- and long-term effects of simple behavioral interventions for nocturnal enuresis in young children: a randomized controlled trial

OBJECTIVE

To assess the short- and long-term effects of 3 simple behavioral interventions to overcome nocturnal enuresis in young children.

STUDY DESIGN

We performed a randomized controlled trial in children aged four to five years with mono-symptomatic nocturnal enuresis (n = 570). The children were placed in one of four groups: (1) lifting to urinate and ask for a password; (2) the same as group 1, without a password; (3) using a reward system; or (4) a control group. Each participant was asked to carry out the appointed intervention for 6 months or until 14 consecutive dry nights occurred, which was the continence criterion. A follow-up was performed approximately 3 years after the study.

RESULTS

After 6 months, lifting the child to the toilet without the use of a password was the only intervention that resulted in significantly more dry children (37%) than the control group (21%). Three years later, both lifting groups had the highest (78%) and the control group the lowest (69%) percentage of dry children.

CONCLUSIONS

The intervention lifting to urinate without the use of a password leads to more dry children compared with no active treatment in children aged 4 to 5 years with nocturnal enuresis.

Phenylalanine tolerance can already reliably be assessed at the age of 2 years in patients with PKU

BACKGROUND

The clinical severity of phenylalanine hydroxylase deficiency is usually defined by either pre-treatment phenylalanine (Phe) concentration or Phe tolerance at 5 years of age. So far, little is known about the course of Phe tolerance or the ability of both pre-treatment Phe and Phe tolerance at early age to predict Phe tolerance at later age.

AIM

This study was conducted to investigate the course of the individual Phe tolerance and to assess the predictive value of both the pre-treatment Phe concentration and Phe tolerance at 1 and 6 months and 1, 2, 3 and 5 years for Phe tolerance at 10 years of age.

METHOD

Data on blood Phe concentration, prescribed Phe intake and weight of 213 early and continuously treated Dutch PKU patients up to 10 years of age were collected. Data acquired under good metabolic control were used in the study. Tolerance was expressed in mg/day and mg/kg per day.

RESULTS

Data at 1 and 6 months and at 1, 2, 3 and 5 years of 61, 58, 59, 57, 56 and 59 patients were included for comparison with the Phe tolerance at 10 years. Phe tolerances (mg/kg per day) at 2, 3 and 5 years showed a clear correlation with the tolerance at 10 years of age (r = 0.608, r = 0.725 and r = 0.661). Results for tolerance expressed as mg/day were comparable. Pre-treatment Phe concentrations did not correlate significantly with the tolerance.

CONCLUSION

Pre-treatment Phe is unreliable but Phe tolerance is a reliable predictor of the tolerance at 10 years of age, starting at 2 years of age.

Screening rules for growth to detect celiac disease: a case-control simulation study

Background

It is generally assumed that most patients with celiac disease (CD) have a slowed growth in terms of length (or height) and weight. However, the effectiveness of slowed growth as a tool for identifying children with CD is unknown. Our aim is to study the diagnostic efficiency of several growth criteria used to detect CD children.

Methods

A case-control simulation study was carried out. Longitudinal length and weight measurements from birth to 2.5 years of age were used from three groups of CD patients (n = 134) (one group diagnosed by screening, two groups with clinical manifestations), and a reference group obtained from the Social Medical Survey of Children Attending Child Health Clinics (SMOCC) cohort (n = 2,151) in The Netherlands. The main outcome measures were sensitivity, specificity and positive predictive value (PPV) for each criterion.

Results

Body mass index (BMI) performed best for the groups with clinical manifestations. Thirty percent of the CD children with clinical manifestations and two percent of the reference children had a BMI Standard Deviation Score (SDS) less than -1.5 and a decrease in BMI SDS of at least -2.5 (PPV = 0.85%). The growth criteria did not discriminate between the screened CD group and the reference group.

Conclusion

For the CD children with clinical manifestations, the most sensitive growth parameter is a decrease in BMI SDS. BMI is a better predictor than weight, and much better than length or height. Toddlers with CD detected by screening grow normally at this stage of the disease.