Parents' Experiences and Perspectives of Their Child's Sleep Quality During Hospitalization

Sleep is essential for maintenance and restoration of health, yet studies exploring this in hospitalized children are scarce. In a qualitative study, we assessed the perceived quality of sleep, factors affecting sleep, and the role of health care professionals in the sleep environment for hospitalized children aged 1 to 12 years. Data were obtained from 11 semi-structured, audio-recorded, and verbatim-transcribed interviews with parents, and analyzed using a systematic thematic analysis. The interviews were coded based on iterative assessment of transcripts. Subsequently, categories and interpretative main themes were identified. Four themes emerged: (1) being informed, keeping informed; (2) coordination of care; (3) parents as main advocates for their child's sleep; and (4) environmental disturbers. Parents reported differences in their child's sleep quality during hospital compared with home. Sleep is substantially affected during hospitalization, prompting the need for interventions to improve the quality of sleep of children. Parents provided valuable suggestions for improvements.

Sleep assessment using EEG-based wearables - A systematic review

Polysomnography (PSG) is the reference standard of sleep measurement, but is burdensome for the participant and labor intensive. Affordable electroencephalography (EEG)-based wearables are easy to use and are gaining popularity, yet selecting the most suitable device is a challenge for clinicians and researchers. In this systematic review, we aim to provide a comprehensive overview of available EEG-based wearables to measure human sleep. For each wearable, an overview will be provided regarding validated population and reported measurement properties. A systematic search was conducted in the databases OVID MEDLINE, Embase.com and CINAHL. A machine learning algorithm (ASReview) was utilized to screen titles and abstracts for eligibility. In total, 60 papers were selected, covering 34 unique EEG-based wearables. Feasibility studies indicated good tolerance, high compliance, and success rates. The 42 included validation studies were conducted across diverse populations and showed consistently high accuracy in sleep staging detection. Therefore, the recent advancements in EEG-based wearables show great promise as alternative for PSG and for at-home sleep monitoring. Users should consider factors like user-friendliness, comfort, and costs, as these devices vary in features and pricing, impacting their suitability for individual needs.

Concordance between creatinine- and cystatin C-based eGFR in clinical practice

The mean of GFR-estimates based on serum creatinine (eGFR_crea) and cystatin C (eGFR_cys) has superior accuracy than each estimate alone. Recent studies have shown that agreement between eGFR_crea and eGFR_cys is an indicator for the accuracy of the mean of the two estimates. As long as the difference between the two (|ΔeGFR|) is below 40%, a high P₃₀ accuracy rate of more than 90% was documented in research settings using gold-standard GFR measurements. This was the case in approximately 80% of the measurements. The study was set out to explore |ΔeGFR| in a broader pediatric nephrological population and identify factors influencing the discrepancy between eGFR_crea and eGFR_cys. We retrospectively analyzed 1596 simultaneous cystatin C and creatinine measurements in 649 unique patients at the pediatric nephrology outpatient clinic of VU university medical center. The FASage equation was used to calculate eGFR_crea, FAScys for eGFR_cys. |ΔeGFR| was calculated as 100x(|eGFR_crea-eGFR_cys|)/(0.5x(eGFR_crea+eGFR_cys). ΔeGFR below 40% was considered high agreement. Patient characteristics like age, diagnosis, glucocorticosteroid use, eGFR, BMI and sex were analyzed for their effect on ΔeGFR below or above 40% using non-parametric tests and a potential explanation for measurements with low agreement was sought. Eighty-seven percent of the population had a |ΔeGFR| lower than 40%. Measurements with |ΔeGFR| above 40% were significantly more frequent from patients with neural tube defects. In 102 out of 208 measurements with low agreement, a potential explanation was found. In a broad pediatric nephrological population, |ΔeGFR| is below 40% in the vast majority of measurements. In this group, the mean of eGFR_crea and eGFR_cys can be used as an accurate estimate of GFR.

Preconception Lifestyle and Cardiovascular Health in the Offspring of Overweight and Obese Women

Women’s lifestyle has important implications for the development and health of their offspring. Yet little is known about the association between women’s preconception dietary intake and physical activity with cardiovascular health of the offspring. We therefore examined this association in a group of Dutch women with overweight or obesity (BMI ≥ 29 kg/m²) and infertility, who participated in a 6-month randomized preconception lifestyle intervention trial, and their offspring (n = 46). Preconception dietary intake and physical activity were assessed during the 6-month intervention using a food frequency questionnaire and the Short QUestionnaire to ASsess Health-enhancing physical activity (SQUASH), respectively. Offspring cardiovascular health (i.e., BMI, waist:height ratio, systolic and diastolic blood pressure, fat and fat free mass, and pulse wave velocity) was measured at age 3–6 years. Multivariable linear regression analyses were used to examine the associations between preconception lifestyle and offspring cardiovascular health. Higher preconception vegetable intake (per 10 g/day) was associated with lower offspring diastolic blood pressure (Z-score: −0.05 (−0.08; −0.01); p = 0.007) and higher preconception fruit intake (per 10 g/day) was associated with lower offspring pulse wave velocity (−0.05 m/s (−0.10; −0.01); p = 0.03). Against our expectations, higher preconception intake of sugary drinks was associated with a higher offspring fat free mass (0.54 kg (0.01; 1.07); p = 0.045). To conclude, preconception dietary intake is associated with offspring health.

The effects of intrauterine insemination and single embryo transfer or modified natural cycle in vitro fertilization on offspring's health-Follow-up of a randomized clinical trial

OBJECTIVE

Does ovarian hyperstimulation and/or the in vitro procedure of assisted reproduction affect neurodevelopmental and physical health of the offspring?

STUDY DESIGN

Infertile couples were randomly allocated to intrauterine insemination with controlled ovarian hyperstimulation (IUI-COH), modified natural cycle in vitro fertilization (IVF-MNC) or single embryo transfer IVF (IVF-SET). We compared neurodevelopmental and physical health in childhood (4-7 years). We used age-appropriate questionnaires to assess behavioral problems (Child Behavior Check List (CBCL)) and executive functioning (Behavior Rating Inventory of Executive Function (BRIEF)). We measured body mass index Z-score, waist- and hip-circumference, body fat percentage, blood pressure Z-scores, pulse wave velocity, glucose, insulin, insulin resistance, total cholesterol, high- and low-density lipoprotein cholesterol, triglycerides, and high sensitivity c-reactive protein. We compared groups by analysis of variance.

RESULTS

We examined 191 (57%) of the 333 children born in the study at a mean age of 5.5 years (range 4.0-7.6 years). We found no statistically significant differences between randomization groups in children's neurodevelopmental or physical health indices (all p-values > 0.05). Comparing the outcomes between actual method of conception, including a naturally conceived group, also did not show statistically significant differences.

CONCLUSIONS

Although this follow-up study was not powered on childhood outcomes and limited power due to attrition may have hampered detection of subtle effects, we found no indications of differences in neurodevelopmental and physical health between ovarian hyperstimulation and/or the in vitro procedure of assisted reproduction. Future trials should be powered on child outcomes, and aim to optimize follow-up rates to provide answers that are more definitive.

A National Process to Enhance the Validity of Entrustment Decisions for Dutch Pediatric Residents

BACKGROUND

Postgraduate medical education (PGME) has become increasingly individualized, and entrustable professional activities (EPAs) have been adopted to operationalize this. At the same time, the process and content to determine residents' progress using high-stakes summative entrustment decisions by clinical competency committees (CCCs) is not yet well established.

OBJECTIVE

We evaluated the experiences with a structured process for assessment of EPAs to attain uniform summative entrustment decisions for a national sample of pediatric residents.

METHODS

An EPA-based national PGME program for pediatric residents was introduced in the Netherlands, including a process of uniform summative entrustment decisions, termed the Evaluation and Assessment of Residents by Supervisors (EARS) procedure. To evaluate the program, we assessed survey data and information from invitational conferences.

RESULTS

Beginning in January 2017, 125 pediatric residents in all 8 Dutch residency regions started training in the EARS program. The program enabled robust summative entrustment decisions. Preliminary data suggested that faculty, despite increased preparation time, appreciated the comprehensive appraisal of resident qualifications. The EPA-based program was well accepted by residents. Fifty-one percent (57 of 112) had at least 2 EARS procedures per year, and for 75% (84 of 112) the level of supervision was often or always adjusted to their level of training.

CONCLUSIONS

A national EPA-based program provided a structured process for summative entrustment decisions by CCCs and enabled individualized stepwise progression of residents toward unsupervised practice. Broader application of these concepts may require adaptations to accommodate different health care systems and specialties.

Cardiorespiratory Fitness in Childhood and Adolescence Affects Future Cardiovascular Risk Factors: A Systematic Review of Longitudinal Studies

BACKGROUND

Although cardiorespiratory fitness (CRF) in childhood and adolescence may be linked to future cardiovascular health, there is currently limited evidence for a longitudinal association.

OBJECTIVES

To provide a systematic review on the prospective association between CRF in childhood and adolescence and cardiovascular disease (CVD) risk factors at least 2 years later.

METHODS

Using a systematic search of Medline, Embase, and SPORTDiscus, relevant articles were identified by the following criteria: generally healthy children and adolescents between 3 and 18 years of age with CRF assessed at baseline, and a follow-up period of ≥ 2 years. The outcome measures were CVD risk factors. We appraised quality of the included articles with STROBE and QUIPS checklists.

RESULTS

After screening 7524 titles and abstracts, we included 38 articles, assessing 44,169 children and adolescents followed up for a median of 6 years. Eleven articles were of high quality. There was considerable heterogeneity in methodology, measurement of CRF, and outcomes, which hampered meta-analysis. In approximately half of the included articles higher CRF in childhood and adolescence was associated with lower body mass index (BMI), waist circumference, body fatness and lower prevalence of metabolic syndrome in later life. No associations between CRF in childhood and adolescence and future waist-to-hip ratio, blood pressure, lipid profile, and glucose homeostasis were observed.

CONCLUSION

Although about half of the included articles reported inverse associations between CRF in childhood and adolescence and future BMI, body fatness, and metabolic syndrome, evidence for other CVD risk factors was unconvincing. Many articles did not account for important confounding factors such as adiposity. Recommendations for future research include standardizing the measurement of CRF, i.e. by reporting VO_2max, using standardized outcome assessments, and performing individual patient data meta-analyses.

Preconception lifestyle intervention reduces long term energy intake in women with obesity and infertility: a randomised controlled trial

Background

The preconceptional period may be an optimal window of opportunity to improve lifestyle. We previously showed that a 6 month preconception lifestyle intervention among women with obesity and infertility was successful in decreasing the intake of high caloric snacks and beverages, increasing physical activity and in reducing weight in the short term. We now report the effects of the preconception lifestyle intervention on diet, physical activity and body mass index (BMI) at 5.5 years (range = 3.7–7.0 years) after the intervention.

Methods

We followed women who participated in the LIFEstyle study, a multicentre RCT in which women with obesity and infertility were assigned to a six-month lifestyle intervention program or prompt infertility treatment (N = 577). Diet and physical activity 5.5 years later were assessed with an 173-item food frequency questionnaire (N = 175) and Actigraph triaxial accelerometers (N = 155), respectively. BMI was calculated from self-reported weight and previously measured height (N = 179). Dietary intake, physical activity, and BMI in the intervention and control group were compared using multivariate regression models. Additionally, dietary intake, physical activity and BMI of women allocated to the intervention arm with successful weight loss during the intervention (i.e. BMI < 29 kg/m² or ≥ 5% weight loss), unsuccessful weight loss and the control group were compared with ANCOVA.

Results

Although BMI did not differ between the intervention and control group 5.5 years after the intervention (− 0.5 kg/m² [− 2.0;1.1]; P = 0.56), the intervention group did report a lower energy intake (− 216 kcal/day [− 417;-16]; P = 0.04). Women in the intervention arm who successfully lost weight during the intervention had a significantly lower BMI at follow-up compared to women in the intervention arm who did not lose weight successfully (− 3.4 kg/m² [− 6.3;-0.6]; P = 0.01), and they reported a significantly lower energy intake compared to the control group (− 301 kcal [− 589;-14]; P = 0.04). Macronutrient intake, diet quality, and physical activity did not differ between the intervention and control group, irrespective of successful weight loss during the intervention.

Conclusions

In our study population, a preconception lifestyle intervention led to reduced energy intake 5.5 years later. Additionally, women allocated to the intervention group who were successful in losing weight during the intervention also had a lower BMI at follow-up. This shows the potential sustainable effect of a preconception lifestyle intervention.

Trial registration

This trial was registered on 16 November 2008 in the Dutch trial register; clinical trial registry number NTR1530.

Electronic supplementary material

The online version of this article (10.1186/s12966-018-0761-6) contains supplementary material, which is available to authorized users.

Maternal Prepregnancy Overweight and Obesity Are Associated with Reduced Physical Fitness But Do Not Affect Physical Activity in Childhood: The Amsterdam Born Children and Their Development Study

BACKGROUND

Maternal overweight/obesity during pregnancy increases offspring's risks of obesity and cardiovascular disease (CVD). A possible pathway is by reduced physical fitness and physical activity (PA) levels in children of overweight/obese mother. We assessed whether maternal prepregnancy overweight/obesity independently determines cardiorespiratory fitness (CRF), muscular strength, moderate-to-vigorous physical activity (MVPA), and sedentary behavior (SB) in 8- to 9-year-old children. We also assessed whether child's fat mass (FM) mediates these associations.

METHODS

One hundred ninety-four children of Dutch ethnicity aged 8.6 (± 0.4) years were randomly selected from a prospective birth cohort, the Amsterdam Born Children and their Development (ABCD) study. CRF was assessed by the 20-m multistage shuttle run test (20-m MSRT), muscular strength by hand dynamometry, and MVPA and SB by accelerometry. The association of prepregnancy body mass index (BMI) ≥ 25 kg/m² with these outcome measures was assessed by multivariable linear regressions.

RESULTS

Mean (± standard deviation) attained 20-m MSRT stage was 5.3 (± 1.7). Compared with children from normal weight women, children of women with prepregnancy overweight/obesity attained a 0.80 (95% confidence interval: 0.15-1.50) lower stage, adjusted for child's sex and MVPA. This association was not mediated by birthweight or child's FM at age 5 years. Maternal prepregnancy overweight/obesity was not associated with child's muscular strength, MVPA, or SB.

CONCLUSIONS

Maternal prepregnancy overweight/obesity was associated with reduced childhood CRF, but not with muscular strength, PA, or SB. Birthweight and FM at age 5 years did not mediate this association. Reduced CRF may partly explain the increased CVD risk in children of overweight/obese women.

Cardiometabolic Health in Relation to Lifestyle and Body Weight Changes 3⁻8 Years Earlier

The degree to which individuals change their lifestyle in response to interventions differs and this variation could affect cardiometabolic health. We examined if changes in dietary intake, physical activity and weight of obese infertile women during the first six months of the LIFEstyle trial were associated with cardiometabolic health 3⁻8 years later (N = 50⁻78). Lifestyle was assessed using questionnaires and weight was measured at baseline, 3 and 6 months after randomization. BMI, blood pressure, body composition, pulse wave velocity, glycemic parameters and lipid profile were assessed 3⁻8 years after randomization. Decreases in savory and sweet snack intake were associated with lower HOMA-IR 3⁻8 years later, but these associations disappeared after adjustment for current lifestyle. No other associations between changes in lifestyle or body weight during the first six months after randomization with cardiovascular health 3⁻8 years later were observed. In conclusion, reductions in snack intake were associated with reduced insulin resistance 3⁻8 years later, but adjustment for current lifestyle reduced these associations. This indicates that changing lifestyle is an important first step, but maintaining this change is needed for improving cardiometabolic health in the long-term.

Effects of a preconception lifestyle intervention in obese infertile women on diet and physical activity; A secondary analysis of a randomized controlled trial

BACKGROUND

Lifestyle changes are notoriously difficult. Since women who intend to become pregnant are more susceptible to lifestyle advice, interventions during this time window might be more effective than interventions during any other period in life. We here report the effects of the first large preconception lifestyle intervention RCT on diet and physical activity in obese infertile women.

METHODS

In total, 577 women were randomized between a six-month lifestyle intervention program (intervention group; N = 290) or prompt infertility treatment (control group; N = 287). Self-reported dietary behaviors and physical activity were assessed at baseline, three, six and twelve months after randomization. Mixed models were used to analyze differences between groups.

RESULTS

Compared to the control group, the intervention group reduced their intake of sugary drinks at three months (-0.5 glasses/day [95% C.I. = -0.9;-0.2]), of savory snacks at three (-2.4 handful/week [-3.4;-1.4]) and at six months (-1.4 handful/week [-2.6;-0.2]), and of sweet snacks at three (-2.2 portion/week [-3.3;-1.0]) and twelve months after randomization (-1.9 portion/week [-3.5;-0.4]). Also, the intervention group was more moderate to vigorous physically active at three months after randomization compared to the control group (169.0 minutes/week [6.0; 332.1]).

CONCLUSION

Our study showed that obese infertile women who followed a six-month preconception lifestyle intervention program decreased their intake of high caloric snacks and beverages, and increased their physical activity. These changes in lifestyle may not only improve women's health but their offspring's health too.

Natural History of Vanishing White Matter

OBJECTIVE

To comprehensively describe the natural history of vanishing white matter (VWM), aiming at improving counseling of patients/families and providing natural history data for future therapeutic trials.

METHODS

We performed a longitudinal multicenter study among 296 genetically confirmed VWM patients. Clinical information was obtained via disease-specific clinical questionnaire, Health Utilities Index and Guy's Neurological Disability Scale assessments, and chart review.

RESULTS

First disease signs occurred at a median age of 3 years (mode = 2 years, range = before birth to 54 years); 60% of patients were symptomatic before the age of 4 years. The nature of the first signs varied for different ages of onset. Overall, motor problems were the most common presenting sign, especially in children. Adolescent and adult onset patients were more likely to exhibit cognitive problems early after disease onset. One hundred two patients were deceased. Multivariate Cox regression analysis revealed a positive relation between age at onset and both preservation of ambulation and survival. Absence of stress-provoked episodes and absence of seizures predicted more favorable outcome. In patients with onset before 4 years, earlier onset was associated with more severe disability and higher mortality. For onset from 4 years on, disease course was generally milder, with a wide variation in severity. There were no significant differences for sex or for the 5 eIF2B gene groups. The results confirm the presence of a genotype-phenotype correlation.

INTERPRETATION

The VWM disease spectrum consists of a continuum with extremely wide variability. Age at onset is a strong predictor for disease course. Ann Neurol 2018;84:274-288.

Women, their Offspring and iMproving lifestyle for Better cardiovascular health of both (WOMB project): a protocol of the follow-up of a multicentre randomised controlled trial

INTRODUCTION

Women, their Offspring and iMproving lifestyle for Better cardiovascular health of both (WOMB) project is the follow-up of the LIFEstyle study, a randomised controlled trial in obese infertile women, and investigates the effects of a preconception lifestyle intervention on later health of women (WOMB women) and their children (WOMB kids).

METHODS AND ANALYSIS

Obese infertile women, aged between 18 and 39 years, were recruited in 23 Dutch fertility clinics between June 2009 and June 2012. The 284 women allocated to the intervention group received a 6-month structured lifestyle programme. The 280 women in the control group received infertility care as usual. 4 to 7 years after inclusion in the trial, all women (n=564) and children conceived during the trial (24 months after randomisation) (n=305 singletons and age 3-5 years) will be approached to participate in this follow-up study (starting in 2015). The main focus of outcome will be cardiovascular health, but the dataset comprises a wide range of physical and mental health measures, diet and physical activity measures, child growth and development measures, biological samples and genetic and epigenetic information. The follow-up assessment consists of three stages that take place between 2016 and 2018, and includes (online) questionnaires, accelerometry and physical and behavioural measurements in a mobile research vehicle. A subsample of 100 women and 100 children are planned for cardiac ultrasound measurements.

ETHICS AND DISSEMINATION

The protocol of this follow-up study is approved by the local medical ethics committee (University Medical Centre Groningen). Study findings of the WOMB project will be widely disseminated to the scientific community, healthcare professionals, policy makers, future parents and general public.

TRIAL REGISTRATION NUMBER

The original LIFEstyle study is registered at The Netherlands Trial Registry (number 1530).

The Association of Birth Weight and Infant Growth with Energy Balance-Related Behavior - A Systematic Review and Best-Evidence Synthesis of Human Studies

BACKGROUND

Suboptimal prenatal and early postnatal growths are associated with obesity in later life, but the underlying mechanisms are unknown. The aim of this study was to systematically review the literature that reports on the longitudinal association of (i) birth size or (ii) infant growth with later (i) energy intake, (ii) eating behaviors, (iii) physical activity or (iv) sedentary behavior in humans.

METHODS

A comprehensive search of MEDLINE, EMBASE, PsycINFO and The Cochrane Library was conducted to identify relevant publications. We appraised the methodological quality of the studies and synthesized the extracted data through a best-evidence synthesis.

RESULTS

Data from 41 publications were included. The quality of the studies was high in three papers, moderate in 11 and low in the large majority (n = 27) of papers appraised. Our best-evidence synthesis indicates that there is no evidence for an association of birth weight with later energy intake, eating behavior, physical activity or sedentary behavior. We found moderate evidence for an association of extreme birth weights (at both ends of the spectrum) with lower physical activity levels at a later age. Evidence for the association of infant growth with energy balance-related behavior was generally insufficient.

CONCLUSIONS

We conclude that current evidence does not support an association of early-life growth with energy balance-related behaviors in later life, except for an association of extreme birth weights with later physical activity.

Associations of Infant Feeding and Timing of Weight Gain and Linear Growth during Early Life with Childhood Blood Pressure: Findings from a Prospective Population Based Cohort Study

Objective

Small birth size and rapid postnatal growth have been associated with higher future blood pressure. The timing of these effects, the relative importance of weight gain and linear growth and the role of infant feeding need to be clarified.

Methods

We assessed how blood pressure relates to birth weight, infant and childhood growth and infant feeding (duration of exclusive breastfeeding and timing of introduction of complementary feeding) in 2227 children aged 5 years from a prospective cohort study (Amsterdam Born Children and their Development). Postnatal growth was represented by statistically independent measures of relative weight gain (weight gain independent of height) and linear growth in four age periods during infancy (0–1 month; 1–3 months; 3–6 months; 6–12 months) and from 12 months to 5 years.

Results

Lower birth weight was associated with higher childhood diastolic blood pressure (-0.38 mm Hg.SD^-1; P = 0.007). Faster relative weight gain and linear growth after 1 month were positively associated with systolic and diastolic blood pressure. Associations of linear growth with systolic blood pressure ranged from 0.47 to 1.49 mm Hg.SD^-1; P<0.01 for all. Coefficients were similar for different periods of infancy and also for relative weight gain and linear growth. Compared to breastfeeding <1 month, breastfeeding >1 month was associated with lower blood pressure (e.g. >6 months -1.56 mm Hg systolic blood pressure; P<0.001). Compared to >6 months, introduction of complementary feeding <6 months was associated with higher blood pressure (e.g. 4–6 months 0.91 mm Hg systolic blood pressure; P = 0.004).

Conclusions

After the age of one month faster growth in either weight or height is associated with higher childhood blood pressure. It is unknown whether faster weight gain and linear growth carry the same risk for adult hypertension and cardiovascular morbidity. Longer breastfeeding and delayed introduction of complementary feeding may be associated with lower adult blood pressure.

Predicting trajectories of behavioral adjustment in children diagnosed with acute lymphoblastic leukemia

Purpose

Previous research showed that children with cancer are at risk for developing behavioral adjustment problems after successful treatment; however, the course of adjustment remains unclear. This study focuses on adjustment trajectories of children during treatment for acute lymphoblastic leukemia (ALL) and aims to distinguish subgroups of patients showing different trajectories during active treatment, and to identify sociodemographic, medical, and psychosocial predictors of the distinct adjustment trajectories.

Methods

In a multicenter longitudinal study, 108 parents of a child (response rate 80 %) diagnosed with ALL were assessed during induction treatment (T0), after induction/consolidation treatment (T1), and after end of treatment (T2). Trajectories of child behavioral adjustment (Child Behavior Checklist; CBCL) were tested with latent class growth modeling (LCGM) analyses.

Results

For internalizing behavior, a three-trajectory model was found: a group that experienced no problems (60 %), a group that experienced only initial problems (30 %), and a group that experienced chronic problems (10 %). For externalizing behavior, a three-trajectory model was also found: a group that experienced no problems (83 %), a group that experienced chronic problems (12 %), and a group that experienced increasing problems (5 %). Only parenting stress and baseline QoL (cancer related) were found to contribute uniquely to adjustment trajectories.

Conclusions

The majority of the children (77 %) showed no or transient behavioral problems during the entire treatment as reported by parents. A substantial group (23 %) shows maladaptive trajectories of internalizing behavioral problems and/or externalizing behavioral problems. Screening for risk factors for developing problems might be helpful in early identification of these children.

Electronic supplementary material

The online version of this article (doi:10.1007/s00520-016-3289-9) contains supplementary material, which is available to authorized users.

The association of birth weight and postnatal growth with energy intake and eating behavior at 5 years of age - a birth cohort study

BACKGROUND

Low and high birth weight and accelerated postnatal weight gain are associated with an increased risk of obesity. Perinatal effects on energy intake and eating behavior have been proposed as underlying mechanisms. This study aimed to examine the independent associations of birth weight and postnatal weight and height gain with childhood energy intake and satiety response.

METHODS

In a birth cohort study, we used data from 2227 children (52% male), mean age 5.6 (±0.4) years. Mean daily energy intake and satiety response were parent-reported through validated questionnaires. Exposures were birth weight z-score and conditional weight and height gain between 0-1, 1-3, 3-6, 6-12 months and 12 months to 5 years. Conditional weight and height are residuals of current weight and height regressed on prior growth data, to represent deviations from expected growth. Analyses were adjusted for a set of potential confounding variables.

RESULTS

Conditional weight gain between 1-3, 3-6 months and 12 months to 5 years was significantly associated with energy intake, with 29.7 (95%-CI: 4.6; 54.8), 24.0 (1.8; 46.1) and 79.5 (29.4; 129.7) kcal/day more intake for each Z-score conditional weight gain between 1-3, 3-6 months and 12 months to 5 years, respectively. Conditional height gain between 0-1, 1-3 months and 12 months to 5 years was negatively associated with energy intake (β: -42.0 [66.6; -17.4] for 0-1 months, -35.1 [-58.4; -11.8] for 1-3 months and -37.4 [-72.4; -2.3] for 12 months to 5 years). Conditional weight gain in all periods was negatively associated with satiety response, with effect sizes from - 0.03 (-0.06; -0.002) in early infancy to -0.12 (-0.19; -0.06) in childhood. Birth weight was not associated with energy intake or satiety response.

CONCLUSIONS

Our findings suggest that accelerated infant and childhood weight gain are associated with increased energy intake and diminished satiety response at 5 years. Accelerated height gain seems to be beneficial for childhood energy intake. This perinatal 'programming' of energy intake and eating behavior provide a potential mechanism linking early life influences with later obesity and cardiovascular disease.

Hypothalamic-pituitary-adrenal (HPA) axis suppression after treatment with glucocorticoid therapy for childhood acute lymphoblastic leukaemia

BACKGROUND

Glucocorticoids play a major role in the treatment of acute lymphoblastic leukaemia (ALL). However, supraphysiological doses can suppress the hypothalamic-pituitary-adrenal (HPA) axis. HPA axis suppression resulting in reduced cortisol response may cause an impaired stress response and an inadequate host defence against infections, which remains a cause of morbidity and death. Suppression commonly occurs in the first days after cessation of glucocorticoid therapy, but the exact duration is unclear. This review is an update of a previously published Cochrane review.

OBJECTIVES

To examine the occurrence and duration of HPA axis suppression after (each cycle of) glucocorticoid therapy for childhood ALL.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 6, 2014), MEDLINE/PubMed (from 1945 to June 2014), and EMBASE/Ovid (from 1980 to June 2014). In addition, we searched reference lists of relevant articles, conference proceedings (the International Society for Paediatric Oncology and the American Society of Clinical Oncology from 2005 to 2013), and ongoing trial databases (the ISRCTN register and the NIH register via http://www.controlled-trials.com in June 2014).

SELECTION CRITERIA

All study designs, except case reports and patient series with fewer than 10 children, examining the effect of glucocorticoid therapy for childhood ALL on the HPA axis function.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed the study selection. One review author performed the data extraction and 'Risk of bias' assessment, which another review author checked.

MAIN RESULTS

We identified eight studies (total of 218 children), including two randomised controlled trials (RCTs), that assessed the adrenal function. None of the studies assessed the HPA axis at the level of the hypothalamus, pituitary, or both. Due to substantial differences between studies, we could not pool results. All of the studies had some methodological limitations. The included studies demonstrated that adrenal insufficiency occurs in nearly all children in the first days after cessation of glucocorticoid treatment for childhood ALL. The majority of children recovered within a few weeks, but a small number of children had ongoing adrenal insufficiency lasting up to 34 weeks. In the RCTs, the occurrence and duration of adrenal insufficiency did not differ between the prednisone and dexamethasone arms. In one study, it appeared that treatment with fluconazole prolonged the duration of adrenal insufficiency. Furthermore, one of the studies evaluated the presence of infections or stress episodes, or both as a risk factor for adrenal insufficiency. The authors found no relationship between the presence of infection/stress and adrenal insufficiency.

AUTHORS' CONCLUSIONS

We concluded that adrenal insufficiency commonly occurs in the first days after cessation of glucocorticoid therapy for childhood ALL, but the exact duration is unclear. Since no data on the level of the hypothalamus and the pituitary were available, we cannot make any conclusions regarding those outcomes. Clinicians should consider prescribing glucocorticoid replacement therapy during periods of serious stress in the first weeks after cessation of glucocorticoid therapy for childhood ALL to reduce the risk of life-threatening complications. However, more high-quality research is needed for evidence-based guidelines for glucocorticoid replacement therapy.Special attention should be paid to patients receiving fluconazole therapy, and perhaps similar antifungal drugs, as this may prolong the duration of adrenal insufficiency.Finally, it would be relevant to further investigate the relationship between present infection/stress and adrenal insufficiency in a larger, separate study specially designed for this purpose.

Associations of infant feeding and timing of linear growth and relative weight gain during early life with childhood body composition

BACKGROUND

Growth and feeding during infancy have been associated with later life body mass index. However, the associations of infant feeding, linear growth and weight gain relative to linear growth with separate components of body composition remain unclear.

METHODS

Of 5551 children with collected growth and infant-feeding data in a prospective cohort study (Amsterdam Born Children and their Development), body composition measured using bioelectrical impedance analysis at the age of 5-6 years was available for 2227 children. We assessed how feeding (duration of full breastfeeding and timing of introduction of complementary feeding) and conditional variables representing linear growth and relative weight gain were associated with childhood fat-free mass (FFM) and fat mass (FM).

RESULTS

Birth weight was positively associated with both FFM and FM in childhood, and more strongly with FFM than FM. Faster linear growth and faster relative weight gain at all ages in infancy were positively associated with childhood FFM and FM. The associations with FM were stronger for relative weight gain than for linear growth (FM z score: β coefficient 0.23 (95% con 0.19 to 0.26), P<0.001 and 0.14 (0.11 to 0.17), P<0.001 per s.d. change in relative weight gain and linear growth between 1 and 3 months, respectively). Compared with full breastfeeding <1 month, full breastfeeding >6 months was associated with lower FM (FM z score: -0.17 (-0.28 to -0.05), P=0.005) and lower FFM (FFM z score: -0.13 (-0.23 to -0.03), P=0.015), as was the introduction of complementary feeding >6 months (FM z score: -0.22 (-0.38 to -0.07), P=0.004), compared with <4 months.

CONCLUSIONS

Faster infant weight gain is associated with a healthier childhood body composition when it is caused by faster linear growth. Full breastfeeding >6 months and introduction of complementary feeding >6 months are associated with lower childhood FM.

Neonatal diagnosis of Down syndrome in The Netherlands: suspicion and communication with parents

OBJECTIVES

To analyse which dysmorphic features are most recognised in newborns with Down syndrome (DS). Furthermore to evaluate the communication techniques used by clinicians to inform parents about the postnatal diagnosis and compare these to current best practice guidelines.

STUDY DESIGN

Prospective study of a birth cohort of newborns with DS born between 1 January 2003 and 31 December 2006 registered by the Dutch Paediatric Surveillance Unit (DPSU).

RESULTS

A total of 586 children with trisomy 21 were analysed. Most recognised dysmorphic features in DS newborns were 'upslanted palpebral fissures' (74.1%; n = 426), 'hypotonia' (73.7%; n = 424) and 'epicanthic folds' (68.5%; n = 394). The majority of parents were informed about the suspected diagnosis on the day of birth (76.5%; n = 390). Hospital deliveries had a significantly earlier suspected diagnosis (mean age 3-4 days) compared with home deliveries (mean age 7 days) (P < 0.05). In 10% (n = 44), paediatricians described dissatisfaction with the first conversation with parents. In 88.9% (n = 499) parents were both present when the diagnosis was told, however the child was not present during the conversation in 51.3% (n = 288). In 10.8% (n = 61) parents were not informed about local parent support groups or community resources.

CONCLUSION

DS is still often diagnosed after birth, usually on the first day of postnatal life. Most identified clinical features were upslanted palpebral fissures, epicanthic folds and hypotonia. Special attention for recognition of all present clinical features is needed for early diagnosis. Appropriate communication with the parents of the message that their child has DS can be difficult. Guidelines can help to make counselling easier and more effective, which in turn may increase parental satisfaction. Not all recommendations for the first conversation with parents were fully implemented in Dutch clinical practice.

Determinants of quality of life during induction therapy in pediatric acute lymphoblastic leukemia

PURPOSE

Improvement in survival of pediatric acute lymphoblastic leukemia (ALL) has increased the attention to quality of life (QoL) . QoL is impaired during maintenance treatment, but little is known about QoL during induction therapy. Identification of patients with poor QoL during induction will provide opportunities for early interventions, and may subsequently improve future QoL. This national multi-center study aimed to assess QoL and its determinants during ALL induction treatment.

METHODS

Proxy reports of the Child Health Questionnaire (CHQ) and the PedsQL cancer version were collected. Child, treatment, and parental characteristics were analyzed as potential determinants in a multiple regression model.

RESULTS

One hundred thirty parents of children participated (response rate 82 %), median child age was 5.7 years and 48 % were female. QoL, as measured with the CHQ, was significantly lower than the norm, the effect sizes were large, and the differences were clinically relevant. Physical QoL was more often affected than psychosocial QoL. Regression models could be constructed for 4/ 10 CHQ scales and 6/ 8 PedsQL cancer scales, accounting for 7 to 36 % of the variance in scores. Impaired QoL was most often associated with older children, girls, and time since diagnosis. Also, father respondents seem to have a lower QoL perception compared to mother respondents although this needs to be confirmed in future research.

CONCLUSIONS

Specific counseling for subsets of patients with a higher risk of low QoL during the early phases of therapy is warranted.

Unsuccessful validation of 2004 model for predicting academic or behavioural limitations after childhood bacterial meningitis

AIM

In 2004, a model identifying children at risk of academic or behavioural limitations after bacterial meningitis (BM) was presented. Risk factors were male gender, low birthweight, lower educational level of the father, Streptococcus pneumoniae, lower cerebrospinal fluid (CSF) leucocyte count, delay between admission and start of antibiotics, dexamethasone <2 days, seizures and prolonged fever. The aim of this study was to validate that prediction model in an independent cohort.

METHODS

Academic or behavioural limitations were determined in 93 Dutch school-age BM survivors. Risk factors for limitations were obtained from medical files. Validation was performed by applying the model in the cohort, then assessing discrimination and goodness of fit. Multiple imputation techniques were used to deal with missing values.

RESULTS

Although fit of the model appeared good when it came to similarity of expected and observed cases (p-value of the Hosmer-Lemeshow test 0.24-0.57), discrimination was poor. Area under the curve (AUC) of the receiver operated characteristics (ROC) curve of the model was 0.83 (95% CI: 0.77-0.89) in the development cohort and 0.53 (95% CI: 0.41-0.65) in the validation cohort.

CONCLUSION

External validation of the model was unsuccessful. It is not suitable for implementation in practice.

Adequate endocrine and cardiovascular response to social stress in survivors of childhood acute lymphoblastic leukemia

Survivors of childhood ALL have been demonstrated to have increased morning cortisol levels compared to healthy controls. Information regarding the response of the HPA axis and the sympathetic nervous system to stress in childhood ALL survivors is not available. The present study aimed at assessing the endocrine and cardiovascular stress response in childhood ALL survivors and healthy controls by evaluating perceived stress on visual analog scales, by determining saliva cortisol, blood pressure and heart rate in response to the Trier Social Stress Test for Children (TSST-C). Fifty survivors who had completed their treatment for childhood ALL 57 (IQR 47.0-72.3) months before and 50 healthy age and sex matched controls were included. Exposure to the TSST-C induced a significant response of perceived stress, saliva cortisol and cardiovascular outcome variables in the total study group. These responses did not significantly differ between survivors of childhood ALL and healthy controls. We conclude that the endocrine and cardiovascular response to social stress are intact in survivors of childhood ALL.

Health status utilities in pediatrics: a systematic review of acute lymphoblastic leukemia

BACKGROUND

Measuring utilities and health-related quality of life (HRQL) in children is challenging due to their cognitive abilities and changing developmental stages.

PURPOSE

. To identify methodological issues on utility measurements in children, we performed a systematic review on utilities measured with a single instrument, the Health Utilities Index (HUI), in pediatric acute lymphoblastic leukemia (ALL). The secondary goal was to facilitate future cost-utility analyses without the need for time-consuming assessments. Data Sources. PubMed, Embase, Cochrane Library, CINAHL, and PsycINFO were searched from inception to June 2012. Studies had to report on utility scores in pediatric ALL, either on or after treatment, to be included.

RESULTS

. Fifteen studies were included. Most studies had methodological shortcomings, which mainly concerned

STUDY DESIGN

and definition and representativeness of the study group. Utility scores were dependent on treatment variables, and there generally was an improvement in HRQL as treatment or survivorship advanced. In general, proxy-respondents were less reliable for subjective phenomena than for observable conditions. HUI2 and HUI3 scores were not interchangeable. Limitations. Studies may have been missed because no validated search method for utility studies exists, due to language bias or the exclusion of non-peer-reviewed papers.

CONCLUSIONS

. Most studies in this review were methodologically suboptimal. Future developments should focus on including developmentally appropriate items for the whole pediatric age group. Adding disease-specific domains may enhance the sensitivity and responsiveness of instruments. Efforts should be undertaken to elicit valuation of health states from older children and teenagers as much as possible. For now, it remains difficult to make valid and informed decisions on the financing of interventions until health state valuation in children has become more methodologically robust.

Smoking overrules many other risk factors for small for gestational age birth in less educated mothers

BACKGROUND

Although there is convincing evidence for the association between small for gestational age (SGA) and socioeconomic status (SES), it is not known to what extent explanatory factors contribute to this association.

AIM

To examine to what extent risk factors could explain educational inequalities in SGA.

STUDY DESIGN

In this study fully completed data were available for 3793 pregnant women of Dutch origin from a population-based cohort (ABCD study). Path-analysis was conducted to examine the role of explanatory factors in the relation of maternal education to SGA.

RESULTS

Low-educated pregnant women had a higher risk of SGA offspring compared to the high-educated women (OR 1.98, 95% CI 1.35-2.89). In path-analysis, maternal cigarette smoking and maternal height explained this association. Maternal age, hypertension, chronic disease, late entry into antenatal care, neighborhood income, underweight, environmental cigarette smoking, drug abuse, alcohol use, caffeine intake, fish intake, folic acid intake, anxiety, and depressive symptoms did not play a role in the association between maternal education and SGA birth.

CONCLUSION

Among a large array of potential factors, the elevated risk of SGA birth among low-educated women appeared largely attributable to maternal smoking and to a lesser extent to maternal height. To reduce educational inequalities more effort is required to include low-educated women especially in prenatal intervention programs such as smoking cessation programs instead of effort into reducing other SGA-risk factors, though these factors might still be relevant at the individual level.

BMI may underestimate the socioeconomic gradient in true obesity

BACKGROUND

Body mass index (BMI) does not make a distinction between fat mass and lean mass. In children, high fat mass appears to be associated with low maternal education, as well as low lean mass because maternal education is associated with physical activity. Therefore, BMI might underestimate true obesity in children of low-educated mothers.

OBJECTIVE

To investigate the associations of maternal education with fat mass index (FMI), lean mass index (LMI) and BMI.

METHODS

In total, 1965 Dutch children from a prospective cohort, aged 5.7 years (standard deviation 0.5), had available data on body composition based on bioelectrical impedance analysis.

RESULTS

Maternal education was not associated with BMI after adjustment for confounders. In contrast, children of low-educated mothers had a higher FMI (β 0.28 95% confidence interval [CI] 0.07; 0.49) and a lower LMI (β -0.18 95% CI -0.33; -0.03) compared with children of high-educated mothers.

CONCLUSIONS

This suggests that BMI underestimates the educational gradient of childhood obesity.

Measuring cardiac autonomic nervous system (ANS) activity in children

The autonomic nervous system (ANS) controls mainly automatic bodily functions that are engaged in homeostasis, like heart rate, digestion, respiratory rate, salivation, perspiration and renal function. The ANS has two main branches: the sympathetic nervous system, preparing the human body for action in times of danger and stress, and the parasympathetic nervous system, which regulates the resting state of the body.

ANS activity can be measured invasively, for instance by radiotracer techniques or microelectrode recording from superficial nerves, or it can be measured non-invasively by using changes in an organ's response as a proxy for changes in ANS activity, for instance of the sweat glands or the heart. Invasive measurements have the highest validity but are very poorly feasible in large scale samples where non-invasive measures are the preferred approach. Autonomic effects on the heart can be reliably quantified by the recording of the electrocardiogram (ECG) in combination with the impedance cardiogram (ICG), which reflects the changes in thorax impedance in response to respiration and the ejection of blood from the ventricle into the aorta. From the respiration and ECG signals, respiratory sinus arrhythmia can be extracted as a measure of cardiac parasympathetic control. From the ECG and the left ventricular ejection signals, the preejection period can be extracted as a measure of cardiac sympathetic control. ECG and ICG recording is mostly done in laboratory settings. However, having the subjects report to a laboratory greatly reduces ecological validity, is not always doable in large scale epidemiological studies, and can be intimidating for young children. An ambulatory device for ECG and ICG simultaneously resolves these three problems.

Here, we present a study design for a minimally invasive and rapid assessment of cardiac autonomic control in children, using a validated ambulatory device ^1-5, the VU University Ambulatory Monitoring System (VU-AMS, Amsterdam, the Netherlands, www.vu-ams.nl).

The association of maternal prenatal psychosocial stress with vascular function in the child at age 10-11 years: findings from the Avon longitudinal study of parents and children

OBJECTIVE

To investigate whether (1) maternal psychosocial stress (depression/anxiety) during pregnancy is associated with offspring vascular function and (2) whether any association differs depending on the gestational timing of exposure to stress. We also investigated whether any association is likely to be due to intrauterine mechanisms by (3) comparing with the association of paternal stress with offspring vascular function and (4) examining whether any prenatal association is explained by maternal postnatal stress.

METHODS AND RESULTS

Associations were examined in a UK birth cohort, with offspring outcomes (systolic and diastolic blood pressure, SBP and DBP, endothelial function assessed by brachial artery flow-mediated dilatation (FMD); arterial stiffness assessed by carotid to radial pulse wave velocity (PWV), brachial artery distensibility (DC), and brachial artery diameter (BD) assessed at age 10-11 years (n = 4,318). Maternal depressive symptoms and anxiety were assessed at 18 and 32 weeks gestation and 8 months postnatally. Paternal symptoms were assessed at week 19. With the exception of DBP and BD, there were no associations of maternal depressive symptoms with any of the vascular outcomes. Maternal depressive and anxiety symptoms were associated with lower offspring DBP and wider BD, though the latter attenuated to the null with adjustment for confounding factors. Paternal symptoms were not associated with offspring outcomes. Maternal postnatal depressive symptoms were associated with lower offspring SBP.

CONCLUSIONS

We found no evidence to support the hypothesis that maternal stress during pregnancy adversely affects offspring vascular function at age 10-12 years via intrauterine mechanisms.

Independent validation of an existing model enables prediction of hearing loss after childhood bacterial meningitis

OBJECTIVE

This study aimed external validation of a formerly developed prediction model identifying children at risk for hearing loss after bacterial meningitis (BM). Independent risk factors included in the model are: duration of symptoms prior to admission, petechiae, cerebral spinal fluid (CSF) glucose level, Streptococcus pneumoniae and ataxia. Validation helps to evaluate whether the model has potential in clinical practice.

STUDY DESIGN

116 Dutch school-age BM survivors were included in the validation cohort and screened for sensorineural hearing loss (>25 dB). Risk factors were obtained from medical records. The model was applied to the validation cohort and its performance was compared with the development cohort. Validation was performed by application of the model on the validation cohort and by assessment of discrimination and goodness of fit. Calibration was evaluated by testing deviations in intercept and slope. Multiple imputation techniques were used to deal with missing values.

RESULTS

Risk factors were distributed equally between both cohorts. Discriminative ability (Area Under the Curve, AUC) of the model was 0.84 in the development and 0.78 in the validation cohort. Hosmer-Lemeshow test for goodness of fit was not significant in the validation cohort, implying good fit concerning the similarity of expected and observed cases. There were no significant differences in calibration slope and intercept. Sensitivity and negative predicted value were high, while specificity and positive predicted value were low which is comparable with findings in the development cohort.

CONCLUSIONS

Performance of the model remained good in the validation cohort. This prediction model might be used as a screening tool and can help to identify those children that need special attention and a long follow-up period or more frequent auditory testing.

The association between interpregnancy interval and birth weight: what is the role of maternal polyunsaturated fatty acid status?

Background

The objective of this study was to evaluate the mediating role of maternal early pregnancy plasma levels of long chain polyunsaturated fatty acids (LCPUFAs) in the association of interpregnancy interval (IPI) with birth weight and smallness for gestational age (SGA) at birth.

Methods

We analysed a subsample of the Amsterdam Born Children and their Development (ABCD) cohort, comprising 1,659 parous pregnant women recruited between January 2003 and March 2004. We used linear and logistic regression to evaluate the associations between fatty acid status, interpregnancy interval and pregnancy outcome.

Results

Low plasma phospholipids concentrations of eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA) and dihomo-gamma-linolenic acid (DGLA), and high concentrations of arachidonic acid (AA) during early pregnancy were associated with reduced birth weight and/or an increased risk of SGA. Short IPIs (< 6 months, with 18–23 months as a reference) were associated with a mean decrease of 207.6 g (SE: ± 73.1) in birth weight (p = 0.005) and a twofold increased risk of SGA (OR: 2.05; CI: 0.93–4.51; p = 0.074). Adjustment for maternal fatty acid concentrations did not affect these results to any meaningful extent.

Conclusions

Despite the observed association of maternal early pregnancy LCPUFA status with birth weight and SGA, our study provides no evidence for the existence of an important role of maternal EPA, DHA, DGLA or AA in the association of short interpregnancy intervals with birth weight and SGA.

Explaining socioeconomic inequalities in childhood blood pressure and prehypertension: the ABCD study

Much remains to be understood about the socioeconomic inequalities in hypertension that continue to exist. We investigated the association of socioeconomic status with blood pressure and prehypertension in childhood. In a prospective cohort, 3024 five- to six-year-old children had blood pressure measurements and available information on potential explanatory factors, namely birth weight, gestational age, smoking during pregnancy, pregnancy-induced hypertension, familial hypertension, maternal body mass index, breastfeeding duration, domestic tobacco exposure, and body mass index. The systolic and diastolic blood pressures of children from mid-educated women were 1.0-mm Hg higher (95% CI, 0.4-1.7) and 0.9-mm Hg higher (95% CI, 0.3-1.4), and the blood pressures of children with low-educated women were 2.2-mm Hg higher (95% CI, 1.4-3.0) and 1.7-mm Hg higher (95% CI, 1.1-2.4) compared with children with high-educated women. Children with mid- (odds ratio, 1.50; 95% CI, 1.18-1.92) or low-educated mothers (odds ratio, 1.80; 95% CI, 1.35-2.42) were more likely to have prehypertension compared with children with high-educated mothers. Using path analyses, birth weight, breastfeeding duration, and body mass index were determined as having a role in the association of maternal education with offspring blood pressure and prehypertension. The socioeconomic gradient in hypertension appears to emerge from childhood as the results show a higher blood pressure and more prehypertension in children from lower socioeconomic status families. Socioeconomic disparities could be reduced by improving 3 factors in particular, namely birth weight, breastfeeding duration, and body mass index, but other factors might also play a role.

Association between body size and blood pressure in children from different ethnic origins

Objective

To assess associations between body size and blood pressure in children (5-6 years) from different ethnic origins.

Method

Five ethnic groups of the ABCD cohort were examined: Dutch (n=1 923), Turkish (n=99), Moroccan (n=187), Black-African (n=67) and Black-Caribbean (n=121). Data on body-mass-index (BMI), waist-to-height ratio (WHtR), fat-mass-index (FMI), and systolic blood pressure (SBP) and diastolic blood pressure (DBP), were collected. Linear regression analysis with restricted cubic splines was used to examine non-linear associations between body size and blood pressure, adjusted for age, sex, height and birth weight.

Results

Ethnic differences were found in associations of BMI with SBP and DBP (SBP: p=0.001 and DBP: p=0.01) and FMI with SBP (p=0.03). BMI and FMI had a relatively large positive association with SBP in Turkish children (BMI: β=2.46mmHg; 95%CI:1.20-3.72; FMI: β=2.41mmHg; 95%CI:1.09-3.73) compared to Dutch (BMI: β=1.31mmHg; 95%CI:0.71-1.92; FMI: β=0.84mmHg; 95%CI:0.23-1.45). Black-Caribbean and Moroccan children showed high blood pressure with low BMI and FMI. Moroccan children showed higher SBP with high BMI and FMI. WHtR was positively associated with SBP and DBP, similar in all ethnic groups. Generally, strongest associations with blood pressure were found for BMI in all ethnic groups.

Conclusion

Ethnic-specific associations between BMI, and FMI and blood pressure are present at young age, with Turkish children showing the highest increase in blood pressure with increasing body size. The higher blood pressure in the Black-Caribbean and Moroccan children with low BMI needs further research. WHtR or FMI do not seem to be associated more strongly to blood pressure than BMI in any ethnic group.

Hypothalamic-pituitary-adrenal axis function in survivors of childhood acute lymphoblastic leukemia and healthy controls

Of all malignancies in children, acute lymphoblastic leukemia (ALL) is the most common type. Since survival significantly improves over time, treatment-related side effects become increasingly important. Glucocorticoids play an important role in the treatment of ALL, but they may suppress the hypothalamic-pituitary-adrenal (HPA) axis. The duration of HPA axis suppression is not yet well defined. The present study aimed at assessing the function of the HPA axis by determining the cortisol awakening response (CAR) and the dexamethasone (DEX) suppression test in children that were treated for childhood ALL, compared to a healthy age and sex matched reference group. In addition, questionnaires regarding sleep, fatigue, depression and quality of life were completed by the children and their parents. Fourty-three survivors who finished their treatment for childhood ALL 37 (interquartile range 22-75) months before and 57 healthy controls were included. No differences in CAR were observed between ALL survivors and the reference group, but survivors of ALL had higher morning cortisol levels and an increased cortisol suppression in response to oral dexamethasone. Higher cortisol levels in childhood ALL survivors were associated with more fatigue and poorer quality of life. We conclude that the experience of a stressful life event in the past may have caused a long-term dysregulation of the HPA axis in childhood ALL survivors, as reflected in an increased cortisol production and an enhanced negative feedback mechanism.

The association between prenatal psychosocial stress and blood pressure in the child at age 5-7 years

Objective

Prenatal maternal stress could have permanent effects on the offspring’s tissue structure and function, which may predispose to cardiovascular diseases. We investigated whether maternal psychosocial stress is a prenatal factor affecting the blood pressure (BP) of offspring.

Study Design

In the Amsterdam Born Children and their Development (ABCD) study, around gestational week 16, depressive symptoms, state-anxiety, pregnancy-related anxiety, parenting daily hassles and job strain were recorded by questionnaire. A cumulative stress score was also calculated (based on 80^th percentiles). Systolic and diastolic BP and mean arterial pressure (MAP) were measured in the offspring at age 5–7 years. Inclusion criteria were: no use of antihypertensive medication during pregnancy; singleton birth; no reported cardiovascular problems in the child (N = 2968 included).

Results

After adjustment for confounders, the single stress scales were not associated with systolic and diastolic BP, MAP and hypertension (p>0.05). The presence of 3–4 psychosocial stressors prenatally (4%) was associated with 1.5 mmHg higher systolic and diastolic BP (p = 0.046; p = 0.04) and 1.5 mmHg higher MAP in the offspring (p = 0.02) compared to no stressors (46%). The presence of 3–4 stressors did not significantly increase the risk for hypertension (OR 1.8; 95% CI 0.93.4). Associations did not differ between sexes. Bonferroni correction for multiple testing rendered all associations non-significant.

Conclusions

The presence of multiple psychosocial stressors during pregnancy was associated with higher systolic and diastolic BP and MAP in the child at age 5–7. Further investigation of maternal prenatal stress may be valuable for later life cardiovascular health.

Ethnic differences in cardiometabolic risk profile at age 5-6 years: the ABCD study

BACKGROUND

To examine ethnic differences in cardiometabolic risk profile in early age, and explore whether such differences can be explained by differences in body mass index (BMI) or waist circumference (WC).

METHOD

Anthropometric measurements, blood pressure and (in a subsample) fasting blood were collected during a health check of 2,509 children aged 5-6 years. Four ethnic groups were distinguished: Dutch (n=2,008; blood n=1,300), African descent (n=199; blood n=105), Turkish (n=108; blood n=57) and Moroccan (n=194; blood n=94). Ethnic differences in diastolic and systolic blood pressure (DBP/SBP), fasting glucose, low-density lipoprotein (LDL), high-density lipoprotein (HDL) and triglyceride levels were determined and the explanatory role of BMI and WC was examined with regression analysis.

RESULTS

After adjustment for confounders, African descent children showed higher DBP (β2.22 mmHg; 95%CI:1.09-3.36) and HDL levels (β:0.09 mmol/l; 95%CI:0.03-0.16) compared to Dutch children (reference group). Turkish children showed higher SBP (β:1.89 mmHg; 95%CI:0.25-3.54), DBP (β:2.62 mmHg; 95%CI:1.11-4.13), glucose (β:0.12 mmol/L; 95%CI:0.00-0.25) and triglyceride levels (β:0.13 mmol/L; 95%CI:0.02-0.25). Higher BMI values were found in all non-Dutch groups (differences ranged from 0.53-1.03 kg/m(2)) and higher WC in Turkish (β:1.68 cm; 95%CI:0.99-2.38) and Moroccan (β:1.65 cm; 95%CI:1.11-2.19) children. BMI and WC partly explained the higher SBP/DBP and triglyceride levels in Turkish children.

CONCLUSION

Ethnic differences in cardiometabolic profile exist early in life and are partly explained by differences in BMI and WC. African children showed favourable HDL levels and Turkish children the most unfavourable overall profile, whereas their Moroccan peers have less increased cardiometabolic risk in spite of their high BMI and WC.

Socioeconomic inequalities in lipid and glucose metabolism in early childhood in a population-based cohort: the ABCD-Study

Background

Socioeconomic inequalities in cardiovascular disease are pervasive, yet much remains to be understood about how they originate. The objective of this study was to explore the relations of socioeconomic status to lipid and glucose metabolism as indicators of cardiovascular health in 5–6 year olds. Additionally to explore the explanatory role of maternal factors, birth outcome, and child factors.

Methods

In 1308 5–6 year old ethnic Dutch children from the ABCD cohort study, lipids (cholesterol, LDL, HDL, triglycerides), glucose and C-peptide were measured after an overnight-fast.

Results

There were no differences in cholesterol, HDL, LDL, and triglycerides between socioeconomic groups, as indicated by maternal education and income adequacy. However, children of low educated mothers had on average a higher glucose (β = 0.15; 95% confidence interval (CI) 0.03 – 0.27), logC-peptide (β = 0.07; 95% CI 0.04 – 0.09), and calculated insulin resistance (HOMA-IR) (β = 0.15; 95% CI 0.08 – 0.22) compared to children of high educated mothers. Only childhood BMI partly explained these differences (models controlled for age, height, and sex).

Conclusions

The socioeconomic gradient in cardiovascular risk factors seems to emerge in early childhood. In absence of underlying mechanisms these empirical findings are relevant for public health care and further explanatory research.

Frequency of lower respiratory tract infections in relation to adaptive immunity in children with Down syndrome compared to their healthy siblings

AIM

Children with Down syndrome (DS) experience respiratory tract infections (RTIs) more frequently than healthy children. We investigated whether this is related to different immunological characteristics associated with DS.

METHODS

The study group consisted of 22 children with DS and 22 of their healthy, age-range matched siblings. Data were collected on infections and hospitalizations because of lower RTIs. Immunoglobulin and IgG subclass levels in blood, as well as lymphocyte and T cell (subset) counts, were determined.

RESULTS

The children with DS had a significantly higher frequency of lower RTIs and related hospitalization than their siblings. We also found significantly reduced IgG2 levels as well as significantly lower counts of total lymphocytes, CD4(+) T lymphocytes, CD4(+) invariant natural killer (iNKT) cells and regulatory T cells in the DS group.

CONCLUSION

In children with DS, reduced levels of IgG2, total lymphocytes, T lymphocytes, iNKT cells and regulatory T cells might contribute to their higher susceptibility to lower RTIs.

Psychosocial stress during pregnancy is related to adverse birth outcomes: results from a large multi-ethnic community-based birth cohort

BACKGROUND

Prevalence rates of psychosocial stress during pregnancy are substantial. Evidence for associations between psychosocial stress and birth outcomes is inconsistent. This study aims to identify and characterize different clusters of pregnant women, each with a distinct pattern of psychosocial stress, and investigate whether birth outcomes differ between these clusters.

METHODS

Latent class analysis was performed on data of 7740 pregnant women (Amsterdam Born Children and their Development study). Included constructs were depressive symptoms, state anxiety, job strain, pregnancy-related anxiety and parenting stress.

RESULTS

Five clusters of women with distinct patterns of psychosocial stress were objectively identified. Babies born from women in the cluster characterized as 'high depression and high anxiety, moderate job strain' (12%) had a lower birth weight, and those in the 'high depression and high anxiety, not employed' cluster (15%) had an increased risk of pre-term birth.

CONCLUSIONS

Babies from pregnant women reporting both high levels of anxiety and depressive symptoms are at highest risk for adverse birth outcomes.

The relation of maternal job strain and cortisol levels during early pregnancy with body composition later in the 5-year-old child: the ABCD study

BACKGROUND

Prenatal exposure to maternal stress may program the fetal HPA axis, potentially leading to altered metabolism in later life, associated with adiposity and diabetes.

AIMS

This association is little studied in humans, and thus we explore whether high maternal job strain during early pregnancy, as well as maternal cortisol levels are associated with increased body mass index (BMI), central adiposity or body fat mass in the offspring at age five. Additionally, we explore whether these associations are modified by gender or mediated by gestational age and fetal growth restriction.

STUDY DESIGN

2939 pregnant women (ABCD cohort study) completed a questionnaire around gestational week 16 including the Job Content Questionnaire, assessing job strain. Serum total cortisol was assessed in a subsample (n=1320). Gestational age (≥37 weeks), standardized birth weight and information on many covariates were available. At the age five health check, height, weight (BMI, kg/m(2)), waist circumference (waist-to-height ratio, WHtR) and Fat Mass Index (FMI, kg/m(2)) were assessed.

RESULTS

Job strain was not associated with higher BMI, WHtR or FMI. Higher maternal cortisol was independently associated with marginally higher FMI in girls, but marginally lower FMI in boys (β 0.09 and β -0.10 per 100 unit increase in serum cortisol, respectively. p<0.01). This association was not mediated by gestational age or fetal growth restriction.

CONCLUSIONS

Results show that prenatal maternal job strain and cortisol may not program obesity and adiposity in the next generation in humans, but gender differences should always be considered.

Educational inequalities in perinatal outcomes: the mediating effect of smoking and environmental tobacco exposure

OBJECTIVE

Socioeconomic status (SES) is adversely associated with perinatal outcomes. This association is likely to be mediated by tobacco exposure. However, previous studies were limited to single perinatal outcomes and devoted no attention to environmental tobacco exposure. Therefore, this study aimed firstly to explain the role of maternal smoking in the association between maternal education and preterm birth (PTB), low birth weight (LBW) and small for gestational age (SGA), and secondly to explain whether environmental tobacco smoke mediates these associations further.

STUDY DESIGN

This study was nested in a population-based cohort study in the Netherlands, the Amsterdam Born Children and their Development (ABCD) study. Analyses were done in a sample of 3821 pregnant women of Dutch origin, using logistic regression analysis.

RESULTS

Least educated women, who were more often smoking and exposed to environmental tobacco smoke, had a significantly higher risk of PTB (OR 1.95 [95% CI: 1.19-3.20]), LBW (OR 2.41 [95% CI: 1.36-4.27]) and SGA (OR 1.90 [95% CI 1.32-2.74]) than highly educated women. The mediating effect of smoking in the least educated women was 43% for PTB, 55% for LBW and 66% for SGA. Environmental tobacco smoke did not explain these associations further. After adjustment for maternal smoking, the association between lower maternal education and pregnancy outcomes was no longer significant.

CONCLUSIONS

Smoking explains to a considerable extent the association between lower maternal education and adverse perinatal outcomes. Therefore, tobacco-interventions in lower educated women should be primarily focussed on maternal smoking to reduce PTB, LBW, and SGA. Additional attention to environmental tobacco exposure does not seem to reduce educational inequalities in perinatal outcomes.

Health-related quality of life and utility scores in short-term survivors of pediatric acute lymphoblastic leukemia

Purpose

Increase of survival in pediatric acute lymphoblastic leukemia (ALL) has made outcomes such as health-related quality of life (HRQL) and economic burden more important. To make informed decisions on the use of healthcare resources, costs as well as utilities need to be taken into account. Among the preference-based HRQL instruments, the Health Utilities Index (HUI) is the most employed in pediatric cancer. Information on utility scores during ALL treatment and in long-term survivors is available, but utility scores in short-term survivors are lacking. This study assesses utility scores, health state, and HRQL in short-term (6 months to 4 years) ALL survivors.

Methods

Cross-sectional single-center cohort study of short-term ALL survivors using HUI3 proxy assessments.

Results

Thirty-three survivors (median 1.5 years off treatment) reported 14 unique health states. The majority of survivors (61 %) enjoyed a perfect health, but 21 % had three affected attributes. Overall, HRQL was nonsignificantly lower compared to the norm, although the difference was large and may be clinically relevant. Cognition was significantly impaired (p = 0.03).

Conclusion

Although 61 % of short-term survivors of ALL report no impairment, the health status of the other patients lead to a clinically important impaired HRQL compared to norms. Prospective studies assessing utility scores associated with pediatric ALL should be performed, enabling valid and reliable cost-utility analyses for policy makers to make informed decisions.

Prenatal stress and balance of the child's cardiac autonomic nervous system at age 5-6 years

OBJECTIVE

Autonomic nervous system (ANS) misbalance is a potential causal factor in the development of cardiovascular disease. The ANS may be programmed during pregnancy due to various maternal factors. Our aim is to study maternal prenatal psychosocial stress as a potential disruptor of cardiac ANS balance in the child.

METHODS

Mothers from a prospective birth cohort (ABCD study) filled out a questionnaire at gestational week 16 [IQR 12-20], that included validated instruments for state anxiety, depressive symptoms, pregnancy-related anxiety, parenting daily hassles and job strain. A cumulative stress score was also calculated (based on 80(th) percentiles). Indicators of cardiac ANS in the offspring at age 5-6 years are: pre-ejection period (PEP), heart rate (HR), respiratory sinus arrhythmia (RSA) and cardiac autonomic balance (CAB), measured with electrocardiography and impedance cardiography in resting supine and sitting positions.

RESULTS

2,624 mother-child pairs, only single births, were available for analysis. The stress scales were not significantly associated with HR, PEP, RSA and CAB (p≥0.17). Accumulation of maternal stress was also not associated with HR, PEP, RSA and CAB (p≥0.07).

CONCLUSION

Results did not support the hypothesis that prenatal maternal psychosocial stress deregulates cardiac ANS balance in the offspring, at least in rest, and at the age of five-six years.

[Living with a short bowel: longer and better?]

Congenital malformations or complications of premature birth may require extensive intestinal resection which could result in short bowel syndrome. Prolonged parenteral nutrition and its complications (e.g. cholestasis, venous catheter-associated infections, thrombosis and limited vascular access) have a major impact on the quality of life of infants and comprise a great burden for parents. The merits of extensive intestinal resection are discussed from the perspective of a Dutch intestinal rehabilitation programme that provides multidisciplinary medical care and advanced surgical options, including liver and intestinal transplantation.

Increased pro-inflammatory cytokine production in Down Syndrome children upon stimulation with live influenza A virus

PURPOSE

Children with down syndrome (DS) have an increased susceptibility to infections, due to altered humoral and/or cellular immunity. The aim of this study was to determine the cytokine production in whole blood of children with DS upon stimulation with live influenza A virus.

METHODS

Whole blood of 61 children with DS and 57 of their healthy siblings was stimulated with 2.5 × 10(4) TCID50/ml influenza A virus during 6, 24, and 48 h. TNF-α, IL-1β, IL-6, IL-8, IL-10, IL-12p70, IFN-α, IFN-γ concentrations, and viral load were measured at all time points.

RESULTS

At most of the time points, TNF-α, IL-1β, IL-6, and IL-8 concentrations were significantly higher in children with DS following stimulation with live influenza A virus. IFN-α and IFN-γ levels were also significantly higher in the DS group. Viral clearance, however, was equal in both groups.

CONCLUSIONS

Children with DS have an altered immune response to influenza A virus. The production of higher levels of pro-inflammatory cytokines may be responsible for a more severe clinical course of viral disease in these children.

Cost-effectiveness of treatment of childhood acute lymphoblastic leukemia with chemotherapy only: the influence of new medication and diagnostic technology

BACKGROUND

Survival for childhood acute lymphoblastic leukemia (ALL) has reached 80-90%. Future improvement in treatment success will involve new technologies and medication, adding to the pressure on limited financial resources. Therefore a retrospective cost-effectiveness analysis of ALL treatment with chemotherapy only according to the two most recent Dutch Childhood Oncology Group treatment protocols was performed. The most recent protocol ALL10 included more expensive medication (pegasparaginase) and implemented a new diagnostic technique (minimal residual disease levels) compared to the previous ALL9 protocol.

PROCEDURE

Fifty children from a single center cohort were included. All direct medical costs made during treatment, including those in satellite hospitals, were determined. Costs per life year saved (LYS) were calculated. The cost-effectiveness ratio of the most recent treatment protocol was determined. LYS were calculated based on national 5-year event-free survival.

RESULTS

Mean total costs were between $115,858 (ALL9) and $163,350 (ALL10) per patient. Hospital admissions (57%) and medication (11-17%) were important drivers of overall costs, and were higher in the most recent protocol ALL10. Costs per LYS were $1,962 (ALL9) and $2,655 (ALL10) and the cost-effectiveness ratio was $8,215.

CONCLUSION

Treatment of childhood ALL with chemotherapy only is well within accepted ranges of cost-effectiveness. The use of new technology and more expensive medication in the most recent protocol ALL10 lead to higher costs but more LYS. In future (ALL) treatment protocols, costs in relation to effects should be taken into account in order to establish more cost-effective disease management without jeopardizing survival and quality of life.