Intrauterine exposure to caffeine and inattention/overactivity in children

AIM

To determine the association between intrauterine exposure to timing and sources of caffeine and inattention/overactivity, suggesting ADHD in the child.

METHOD

This study used prospectively collected data from the large population-based study, The Norwegian Mother and Child Cohort Study (MoBa). Participants were 25 343 mothers and their 18-month-old children. Mothers reported on consumption of a number of caffeine sources at the 17th week and 30th week of gestation, as well as child inattention/overactivity at 18 months. Data were analysed using univariate analyses of covariance (ancova).

RESULTS

Once we controlled for confounders, there was a small effect of caffeine intake at 17th week of gestation on inattention/overactivity combined, and both 17th and 30th week of gestation on overactivity, when investigated separately from inattention. Surprisingly, the caffeine effect was only found for soft drinks, not tea or coffee.

CONCLUSION

Intrauterine exposure to soft drinks rather than coffee, the traditional focus, is associated with maternal reports of overactive behaviour in children aged 18 months.

Parental reported bullying among Nordic children: a population-based study

BACKGROUND

Bullying has been shown to be a serious problem amongst school children, but few studies have been population-based and included pre-school children.

METHODS

The study is part of a cross-sectional comparative study in 1984 and 1996, focusing on children's and their families' health and welfare in the Nordic countries. At each point of time parents of 3000 randomly selected children aged 2-17 years in each of five Nordic countries received a postal questionnaire. Altogether approximately 20,000 questionnaires were completed. The prevalence of bullying, risk factors for bullying and possible effect factors were analysed.

RESULTS

Parents reported bullying of their child in 15.1% of the cases. Bullying varied from 7.2% in Sweden to about 20% in Denmark and Finland. There was a small increase in bullying from 13.7% in 1984 to 16.4% in 1996. Bullying was most frequent in boys (OR: 1.4) and in children 2-6 and 7-12 years old (OR: 2.0 and 2.2 compared with older children). Children of single parents and of parents with low education had increased risks (OR: 1.4 and 1.4). Children with chronic conditions had higher risks for being bullied (OR: 2.3). In 1996 children with psychiatric/nervous problems and hyperactivity had high risks for being bullied (OR: 8.8 and 10.5) and for bullying others (3.9 and 3.5). Being bullied was associated with poor thriving and psychosomatic and psychological problems. No countries had national interventions before 1984, but Sweden had early focused on the problem and implemented a strong national policy before 1996. After 1996 national anti-bullying policies were strengthened in the Nordic countries, most in Sweden and Norway.

CONCLUSION

Bullying is common among Nordic children, including pre-school children. Bullying is a threat to children's health, and augments problems in children with chronic conditions. The low prevalence of bullying in Sweden may be a result from sustained, strong anti-bullying policies. There is still a need for continuing interventions.

[Nasal congestion and earache--upper respiratory tract infections in 4-year-old children]

BACKGROUND

Few population-based studies in Norway have addressed upper respiratory infections in children.

MATERIAL AND METHODS

A questionnaire concerning health, diseases and living condition was administered to parents of all four-year-old children in Vestfold county (n = 1912). Participation rate was 79%.

RESULTS

Close to one out of three of the children suffered from recurrent common cold (four episodes or more) during the last year. One third experienced otitis at least once, and one out of twenty experienced four episodes of otitis or more. Day-care centre attendance was the only significant risk factor for recurrent common cold (odds ratio 1.50; 95% CI 1.18-1.92) or otitis (odds ratio 1.42; 95% CI 1.12-1.77). The odds ratios were essentially unchanged after logistic regression analysis, when mother's education, housing, other children in the family, passive smoking, and history of breastfeeding were included in the analysis. Children with otitis or recurrent common cold consulted a doctor almost ten times as often as other children.

INTERPRETATION

Day-care centre attendance has significant influence on the occurrence of upper respiratory infections in four-year-olds, but less influence than reported for younger children. Other environmental differences seem to be of little importance and do not represent any potential for prophylaxis.

Recurrent pain symptoms in children and parents

Recurrent pain in five different areas (stomach, arms & legs, head, back and neck & shoulders) in a population of 348 school children and their parents has been investigated. The study presented here is restricted to 229 mother-father-child trios. Forty-four percent of the children reported pain in at least one area compared to 60% of the mothers and 51% of the fathers. Headache and pains in arms and legs were most common in boys. The most frequent pain sites for girls were head and back. Overall, girls complained more than boys. No significant associations between complaints in parents and their children were demonstrated, analysed by logistic regression analysis. Furthermore, there was no significant association between the reported pain in the mother and father.

CONCLUSION

Children's pain did not associate with parental pain in this study. The results do not support previous hypotheses that recurrent pain clusters in families.

[Drug prescription to 4-year-old children in the county of Vestfold]

We carried out a study of four-year-old children's general health, diseases and use of medicines over a 12-month period in 1995-96. The study was based on a questionnaire administered in connection with the regular health controls. Questionnaires from 1,912 children were returned, representing 79% of children born during one year in the county. More than half the children had received medicine prescribed by a physician, corresponding to 557 preparations per 1,000 children. Some children had used several types of drugs, with a mean of 1.4 preparations per child. Antibiotics were prescribed to 63% of the children. Compared to what has been found in other studies, the use of prescribed medicine was moderate. More pharmacoepidemiological studies are needed to assess whether the use of medicine in children is at an acceptable level.

[Regional differences in the incidence of femoral neck fractures in Norway]

Studies reporting data from the late seventies indicated there were significant differences in the incidence of hip fracture from county to county in Norway. We used the most recent available data on the occurrence of hip fracture in 1994 and 1995 and analyzed regional variations in the incidence of hip fracture, standardized for age and sex, among people aged 65 years and over. In 1994 and 1995 16,779 hip fractures occurred in Norway among people aged 65 years and over, making an overall annual crude incidence rate of 12.1 per 1,000 population. Incidence rates varied from 8.1 for the county of Finnmark to 14.9 per 1,000 population for Oslo. Standardized rates per 1,000 aged 65 years and over varied from 9.2 in the county of Finnmark to 15.0 in Vestfold. There has been a clear regional pattern in the incidence rate. Oslo and the counties in the south and south-east had the highest incidence rate. Compared with reports from 1978 and 1979, the span of relative differences in the county incidence rates has narrowed. The sources of these differences are not explained.

[Health status survey in a district with many immigrant children]

In Norway, prophylactic child health care is organized through local mother and child clinics, each of which serves a given population. This study summarizes the findings from the routine check-up of four-year-olds in a district with a high proportion of immigrant families. The sample consisted of 70 children, 33 of them from immigrant families. The ordinary check-up was supplemented by information obtained by means of a questionnaire, which was filled in by the public health nurse and the doctor in consultation with the parents. A validated scale, or checklist (BCL), for ordinary behavioural problems among pre-school children was also included. The findings must be interpreted with caution, one reason being the large socio-economic differences between the immigrant and the Norwegian families included in the study. Nevertheless, the difference between the eating habits of the two groups of children was striking, in spite of the emphasis placed on diet at the clinic. Another important finding was the poor knowledge of Norwegian among the immigrant children, which was obviously associated with the poor language skills of the mothers. Therefore, an important element of the preventive health work among immigrant children should be to encourage the mothers to attend courses in Norwegian.

[Academic degrees and changing ceremonies]

The traditions and ceremonies regarding doctoral dissertations in Europe date back to early medieval times, to the school of health at Salerno. The University of Oslo, founded in 1811, inherited the traditions from Denmark. Up to 1845, the dissertations were held in Latin, which was a burden on the candidates. The first four candidates who presented a thesis for a doctorate were all from the Faculty of Medicine. After 1845, the Norwegian language was permitted, but up to the end of the century there were still only few dissertations, and a doctorate degree was not highly valued. The number has since increased, and this degree is more highly esteemed. The ceremonies around the dissertations have also changed. The first promotions included solemn procedures in Latin, but later on the promotion ceremonies disappeared for 91 years. Promotion ceremonies reappeared in 1933, but changes have been observed more recently, probably related to changing cultural opinions and trends. The policy today seems to indicate a trend towards more ceremony, accompanied by festivity.

Development of stomach-ache and headache during middle childhood: co-occurrence and psychosocial risk factors

Development of somatic symptoms and associations with psychosocial risk factors were investigated in a longitudinal study of Norwegian children aged 4-10 years. Complaints of stomach-ache only were associated with emotionally well-adapted children, and mothers with low education and high emotional support. Children complaining of headache only behaved well as preschoolers, showed a tendency towards high achievement motivation at school and their mothers were employed outside the home. Children with the co-occurrence syndrome seemed to constitute a separate entity. They differed from the others as the syndrome was associated with previous behavioural and emotional problems, current emotional disturbances and mothers with less support. Family demographic stability, further child health problems and school factors were not associated with the co-occurrence syndrome.

[Cerebral palsy in the light of old and new research results--in what direction does the pendulum swing?]

Cerebral palsy is reviewed from Little's first description of spastic diplegia in 1843 to the results of the most recent studies. One central question concerns whether prenatal or perinatal causes are the most important for the development of cerebral palsy. Current research indicates that conditions prior to and during pregnancy probably play a more important role than earlier thought. For years it has been the belief that cerebral palsy is caused by mismanagement in the perinatal period. At the same time, it has been suggested that improved perinatal care would reduce the incidence of cerebral palsy. This has not been the case, and many studies indicate that, despite proper perinatal care, the incidence of cerebral palsy is increasing. Much research remains to be done to obtain an overall picture of the etiology of cerebral palsy before we can establish measures to prevent this complex and serious condition.

[Fall-related injuries among elderly at home]

The aim of this study was to describe the extent of the problem of injuries from falling among elderly people at home. The study is based on data from the National Injury Register, which contains information on all inpatients and outpatients treated for injuries by hospitals and emergency clinics in four Norwegian towns. This study included 594 cases of accidental fall-related injuries which occurred at home in 1992 among a total population of 23,942 persons aged 65 years and over living in two towns, Drammen and Stavanger. The incidence of fall-related injuries at home was 25 per 1,000. The incidence was higher among women than men (32 and 13 per 1,000 respectively). The ratio between falls to the same level and falls to lower levels was 2:1 in the age group 65-79 year and 4:1 in the age group over 80 years. The most common mechanisms causing injuries were loss of balance (46%), stumbling (19%) and sliding (12%). 60% of all patients sustained fractures (15 per 1,000). 50% of all patients were hospitalised. The findings show that possibilities exist for preventing these injuries. The strategies must be directed both at the home environment and at individual factors among the elderly population.

[In the beginning was the child...Is health and course of life determinated already in utero and during early childhood?]

This question has been asked in many medical journals in recent years. The British research group, DJP Barker and co-workers, has performed a series of studies where the delayed effects of the early environment have been documented. The studies comprise ecological, individual follow-up and case control studies, as well as studies of trends over time. They show associations between different measures of children's living conditions at birth and during the first year of life, and the prevalence of different diseases among adults, especially ischaemic heart disease. The Norwegian researchers Forsdahl and Waaler have also done early fundamental work in this field. The Barker group interprets their findings by suggesting that nutrition in foetal and early life is crucial. However, alternative interpretations of their findings have been suggested. The most important objection is perhaps that socio-economic conditions at birth tend to persist throughout life, and that these conditions are more decisive for adult health than the conditions associated with foetal life and birth. Longitudinal, prospective studies which could provide conclusive evidence are lacking.

["The patient slipped on the ice...". Non-traffic related fractures among pedestrians, occurrence and seasonal variations]

The epidemiology of non-traffic-related fractures among pedestrians in three Norwegian towns (Drammen, Harstad and Stavanger, 515,602 person years) during the period 1 January 1988 to 31 December 1990 was studied on the basis of data form The Norwegian Injury Register. 1,104 such fractures occurred during the study period (21 per 10,000). The incidence increased with age from 12 per 10,000 in the age group < or = 14 years, to 47 per 10,000 in the group > or = 65 years. 57% of all patients with fractures were under the age of 65. Higher incidence during the winter months was observed in all three towns during the whole period. The increase occurred in the age groups 25-64 and > or = 65 years, both in males and females, but not in the age groups < or = 14 or 15-24 years. In 1990 we obtained more accurate information on the injury incident. 39% of all the fractures were caused by slipping on ice or snow. 45% of these were fractures of the elbow or lower arm. There seems to be a substantial potential for targeted preventive measures.

Prevalence and persistence of stomach ache and headache among children. Follow-up of a cohort of Norwegian children from 4 to 10 years of age

Results from a prospective cohort of 136 children, from 4 to 10 years of age, indicated that stomach ache was almost as prevalent among preschool children as children of school age. Headache was almost absent among 4-year-olds but prevalent at 10 years of age. Generally, early pain complaints were persistent. The co-occurrence of stomach ache and headache increased from 4% of children at 4 years of age to 20% when they reached 10 years of age.

["Rough pleasures"--and the good outdoor life. Physicians as pioneers of the outdoor life]

From the middle of the last century, mountain tourism has become an important part of our national tradition and culture. The physical activity and the pleasure and relaxation achieved by walking in wild areas is believed to have beneficial effects on health. Several colleagues in the medical profession were early pioneers in mountain walking and in the discovery and description of former "white spots" on maps. They communicated their feeling and love for nature, and the pleasure gained from their eventful expeditions. They taught us respect and concern for our special environment, with its great opportunities for a variety of leisure time adventures.

[To put one's femininity at stake. Admission of women to medical studies; Marie Spångberg and other pioneers]

In 1993, 100 years have passed since the first woman graduated in medicine from the University of Oslo. Her name was Marie Spångberg. A long-lasting "battle" had previously taken place to allow women to enter the University and to study medicine in particular. The first proposal to the Storting (the Norwegian national assembly) on this matter was made by Mr. L. Smitt, who strongly argued for the admittance of women to medical studies at the University. The Storting agreed, but the Medical Faculty protested violently in a note which was regarded as one of the most reactionary statements of the time on the nature of women. However, on 23 June 1884, an Act allowing women to graduate in all University studies was finally passed. In spite of the earlier resistance from the Medical Faculty, the female students did not experience any discrimination of women during their studies. They did meet difficulties, however, after their graduation, both in continuing their education and in obtaining a position.

Immune-mediated hemolysis associated with the administration of a radiographic contrast medium

A female patient developed serious hemolysis in association with the injection of a radiographic contrast medium (RCM). Serologic investigation of her serum suggested complement-mediated hemolysis, induced by an RCM-dependent IgM antibody in her serum. The antibody was of high titer and low avidity. The antibody showed cross-reactions with related radiographic contrast media and reacted only with group I adult RBCs.

[Neonatal alloimmune thrombocytopenia. Serological studies]

Alloimmune neonatal thrombocytopenia is most often caused by immunization towards the platelet-specific, glycoprotein IIIa-associated antigen HPA-1a (previous nomenclature PlA1, Zwa), but other defined platelet-specific antigens may also be involved. An HPA-1a-negative mother carrying an HPA-1a-positive child occurs in 1/50 of all pregnancies. However, HPA-1a-immunization occurs only in 1/1000 of all pregnancies, and only a proportion of the children are clinically affected. If the mother is positive for HLA-B8/DR3 she is known to be at risk for immunization. The serological diagnosis of thrombocyte immunization requires careful typing and investigation of antibodies, and reliable typing reagents. The quantitation of the mother's antibody is of little predictive value for the child's outcome, but intrauterine cord sampling can be a useful tool for improving the prenatal diagnosis.

Gastric lymphoma causing granulocytopenia and cold intolerance, with recovery after treatment

A 34-year-old man was found to have granulocytopenia with a white blood count of 2.3 x 10(9) l-1, consisting of 10% segmented neutrophils, 50% monocytes and 40% lymphocytes. A bone marrow aspirate showed 20% promyelocytes and 10% blasts with monoblastic features, and a smouldering myelomonocytic leukaemia was considered to be a possible diagnosis. In cold weather the patient experienced cold intolerance with acrocyanosis and small ulcerations on the ears. The test for heparin-precipitable protein ('cryofibrinogen') was strongly positive. During the following year, these signs and symptoms persisted, and the patient also developed constant moderate pain in the epigastric region. Gastroscopy revealed a large lymphoma of the stomach, which was a high-grade malignant centroblastic type of non-Hodgkin's lymphoma. After successful removal of the tumour, and six courses of potent cytostatic combinations, the patient recovered completely, and the granulocytopenia and cold intolerance disappeared.

[Compatibility problems in transfusion. Special reference to the delayed hemolytic transfusion reaction]

During 1988, our laboratory (The National Blood Group Reference Laboratory) detected clinically significant alloantibodies (excluding anti-D and anti-C + D) in samples from 72 patients from 24 different hospitals, transfusing about 40,000 units of red cells in this period of time. The simultaneous presence of autoantibodies complicated the serological diagnosis in a number of cases. Two patients had suffered acute haemolytic transfusion reactions due to antibodies not being discovered in the pretransfusion testing (anti-c and anti-Fya). 13 showed serological evidence of delayed haemolytic transfusion reaction not noted in the local hospital. We believe that delayed haemolytic transfusion reaction is seldom recognized. We stress the importance of quality control programmes in blood group serology.

Antibody dependent cell mediated cytotoxicity against anti-D sensitized human erythrocytes. Influence of various effector cells and enzyme treatment of the target cells

Antibody dependent cell mediated cytotoxicity (ADCC) was measured against anti-D sensitized erythrocytes using various mononuclear cell populations from peripheral blood in a chromium release assay. Adherent effector cells gave stronger cytotoxicity than unseparated and non-adherent cells, and were less dependent on pretreatment of the target cells with papain. However, close correlations were found between the cytotoxicity obtained with the various effector cell populations, indicating that either of them might be used for the purpose of establishing in vitro methods to determine the clinical significance of erythrocyte antibodies. The optimal choice of effector cells is discussed.

Fluorouracil (5-FU) induced acute immune haemolytic anaemia

A female patient on Fluorouracil (5-FU) therapy for rectal carcinoma developed acute intravascular haemolysis with her fifteenth drug injection; a similar episode occurred later after a controlled challenge with the drug. A 5-FU-dependent complement-activating IgM antibody, which reacted with RBC in an indirect antiglobulin test, was detected in her serum. The antibody did not react with cord RBC, but a blood group specificity could not be determined. An excess of 5-FU in the indirect antiglobulin tests resulted in inhibition of these reactions.

Hereditary thrombocytopenia with excessively prolonged bleeding time, corrected by infusions of platelet poor plasma

In a family with hereditary thrombocytopenia, transfused normal platelets as well as their own platelets had a shortened survival in the patients' circulation (11). On the other hand, the patients' platelets survived normally when transfused to a normal recipient. Platelet-associated immunoglobulins or circulating platelet antibodies were not detected (immunofluorescence method). About 200 ml platelet poor plasma (PPP) from each of 4 normal donors was infused daily for 5 consecutive d to 1 afflicted family member, causing a rise of platelet count from 65 X 10(9)/l to 163 X 10(9)/l and a decrease of bleeding time from 28 to 11 min 7 d after the PPP was discontinued. The platelet count then gradually decreased and was 65 X 10(9)/l with a bleeding time of 30 min 16 d after the PPP was discontinued. In a repeated PPP infusion experiment a similar response was evoked. It is concluded that the afflicted family members must have a deficiency of some plasma principle necessary to keep platelets fit and circulating.

Pulmonary reaction associated with transfusion of plasma containing anti-5b

A patient developed an acute respiratory distress syndrome with lung infiltrates during a transfusion of plasma. The transfused plasma was shown to contain a potent leucocyte agglutinating antibody of IgG type with anti-5b specificity, reactive with the patient's cells. A review of the literature on similar transfusion-related syndromes showed an association with more of less well-defined white cell antibodies, mainly in the donors' plasma. The majority of donors were multiparous women. The anti-5b in our donor was demonstrated only by granulocyte agglutination technique, as previously described antibodies in the five system. A long incubation procedure (20-25 h) seemed to be optimal for granulocyte agglutination.

Chloroquine removal of HLA antigens from platelets for the platelet immunofluorescence test

Chloroquine-treated platelets did not react with HLA antisera in a platelet suspension immunofluorescence test (PSIFT), while the reactions with platelet-specific antibodies (P1A1, Baka) seemed even stronger after treatment. The method might be useful in discerning HLA and platelet-specific antibodies without absorption procedures. The treatment causes death of a proportion of the cells, with nonspecific fluorescence making the reading difficult. This may be circumvented by using special phase-contrast lenses.

An international reference typing for Ch and Rg determinants on rare human C4 allotypes

Red cells, serum and plasma samples of 20 individuals, selected for their C4 allotypes, were distributed from Bonn to five laboratories, for investigation of their Chido (Ch) and Rodgers (Rg) determinants. One anti-Ch (M.H.) and one anti-Rg(Prest.) were distributed, but the individual laboratories also used their own reagents and their own typing methods. There was general agreement in interpretation of the majority of samples. Partial inhibition for Ch and Rg was detected. Two samples gave anomalous results; one sample with C4 A1,3 BQO, QO had Ch determinants on the red cells and in plasma (partial inhibition), and another sample with C4 A3,4 B5, QO apparently lacked Ch determinants on the red cells and in plasma. Heterogeneity of anti-Ch and anti-Rg was suggested in testing red cells, perhaps, reflecting a quantitative effect. This heterogeneity was confirmed by inhibition studies. The capacity of some reagents to detect partial inhibition probably reflects qualitative as well as quantitative differences.

Paroxysmal cold haemoglobinuria. The most frequent acute autoimmune haemolytic anaemia in children?

Paroxysmal cold haemoglobinuria (PCH) is a disease which today is met mainly in its acute form in children. The diagnosis is revealed by a careful serological examination. Case reports of four children with PCH are given in this paper. They all showed typical clinical pictures of PCH, and displayed the expected serological findings, including a bithermic autoantibody (haemolysin), the Donath-Landsteiner antibody. Children with PCH often require immediate transfusion therapy, but certain precautions should be taken regarding transfusion policy in these patients. When the acute phase is overcome, the prognosis is excellent.

Neonatal alloimmune thrombocytopenia. Case reports, diagnostic and therapeutic considerations

Two families are presented, where the mothers have given birth to children with neonatal alloimmune thrombocytopenia (NAITP) due to immunization towards the platelet specific antigen PIA1, which is responsible for most of the cases with NAITP. Anti-PIA1 has previously been difficult to demonstrate, but current techniques, such as the platelet suspension immunofluorescence test (PSIFT) used here, have made routine laboratory diagnosis possible. Both mothers in these families were HLA-B8 positive. This antigen shows strong association with PIA1 immunization.