Growth hormone dose-dependent pubertal growth: a randomized trial in short children with low growth hormone secretion

BACKGROUND/AIMS

Growth hormone (GH) treatment regimens do not account for the pubertal increase in endogenous GH secretion. This study assessed whether increasing the GH dose and/or frequency of administration improves pubertal height gain and adult height (AH) in children with low GH secretion during stimulation tests, i.e. idiopathic isolated GH deficiency.

METHODS

A multicenter, randomized, clinical trial (No. 88-177) followed 111 children (96 boys) at study start from onset of puberty to AH who had received GH 33 µg/kg/day for ≥1 year. They were randomized to receive 67 µg/kg/day (GH(67)) given as one (GH(67×1); n = 35) or two daily injections (GH(33×2); n = 36), or to remain on a single 33 µg/kg/day dose (GH(33×1); n = 40). Growth was assessed as heightSDSgain for prepubertal, pubertal and total periods, as well as AHSDS versus the population and the midparental height.

RESULTS

Pubertal heightSDSgain was greater for patients receiving a high dose (GH(67), 0.73) than a low dose (GH(33×1), 0.41, p < 0.05). AHSDS was greater on GH(67) (GH(67×1), -0.84; GH(33×2), -0.83) than GH(33) (-1.25, p < 0.05), and heightSDSgain was greater on GH(67) than GH(33) (2.04 and 1.56, respectively; p < 0.01). All groups reached their target heightSDS.

CONCLUSION

Pubertal heightSDSgain and AHSDS were dose dependent, with greater growth being observed for the GH(67) than the GH(33) randomization group; however, there were no differences between the once- and twice-daily GH(67) regimens. © 2014 S. Karger AG, Basel.

Risks of malignant and non-malignant tumours in tall women treated with high-dose oestrogen during adolescence

BACKGROUND/AIM

High-dose oestrogen treatment has been used to reduce growth in tall adolescent girls. The long-term safety with regard to cancer has not been clarified. Our aim was to study if this growth reduction therapy affects cancer risk later in life.

METHODS

A cohort study of 369 (172 treated, 197 untreated) Swedish women who in 1973-1993 were assessed for tall adolescent stature was designed. Data were collected from university hospital records, patient questionnaires, and the Swedish Cancer Register.

RESULTS

Risks are presented as odds ratios (ORs) with 95% confidence intervals comparing treated to untreated subjects. In treated subjects, the overall OR for having a tumour (malignant or non-malignant) was 1.7 (0.8-3.8). The ORs were 2.3 (0.4-12.8) for breast tumours, 0.8 (0.2-2.6) for gynaecological tumours, and 6.1 (1.04-∞) for melanoma. When limiting to malignant tumours, the crude ORs were of similar magnitude.

CONCLUSION

The OR for any melanoma was higher in treated than in untreated women, suggesting an increased risk of melanoma associated with high-dose oestrogen treatment during adolescence. Although the risk estimates were increased for overall tumours, breast tumours, malignant gynaecological tumours, and malignant melanoma, these associations were not statistically significant. Our results need to be verified in a larger cohort.

Growth Hormone Treatment Improves Cognitive Function in Short Children with Growth Hormone Deficiency

BACKGROUND/AIMS

We investigated the association between cognition and growth hormone (GH) status and GH treatment in short prepubertal children with broadly ranging GH secretion.

METHODS

A total of 99 children (age 3-11 years), 41 with GH deficiency (GHD) and 58 with idiopathic short stature (ISS), were randomized to a fixed dose (43 µg/kg/day) or a prediction model-guided individualized dose (17-100 µg/kg/day) and followed up for 24 months. In a longitudinal and mixed within- and between-subjects study, we examined clinical effect size changes, measured by Cohen's d, in full-scale IQ (FSIQ) and secondary IQ indices.

RESULTS

Significant increases giving medium effect size in FSIQ (p = 0.001, Cohen's d = 0.63), performance IQ (p = 0.001, Cohen's d = 0.65) and processing speed (p = 0.005, Cohen's d = 0.71) were found in the GH-deficient group. In contrast, perceptual organization only increased in the ISS group (p = 0.001, Cohen's d = 0.53). Baseline IQ was normally distributed with small but significant differences between the groups: GH-deficient children had lower FSIQ (p = 0.042) and lower performance IQ (p = 0.021). Using multiple regression analysis, 40% of the variance in delta processing speed scores (0-24 months) was explained by GHmax and IGF-ISDS at baseline.

CONCLUSION

IQ, specifically fluid intelligence, increased in the GH-deficient children. The pretreatment status of the GH/IGF-I axis was significantly predictive for these changes. © 2015 S. Karger AG, Basel.

Silent coeliac disease is over-represented in children with type 1 diabetes and their siblings

AIM

This study measured autoantibodies against tissue transglutaminase (anti-tTG) to detect untreated coeliac disease in children with type 1 diabetes and their siblings.

METHODS

Anti-tTG was measured in prospectively collected sera from 169 children at the onset of diabetes, 88 of their siblings and 96 matched control children. Coeliac disease was confirmed with a small intestinal biopsy.

RESULTS

Coeliac disease was diagnosed in five children before diabetes onset. A further 12 children were diagnosed after diabetes onset, without any gastrointestinal symptoms, and 11 of these had anti-tTG at the onset of diabetes, with the remaining child showing seroconversion within 6 months. Hence, all the children with both diseases had anti-tTG at or before diabetes diagnosis, and the prevalence of coeliac disease was 10.1%. Moreover, 6.8% of the siblings and 3.1% of the control children had elevated levels of anti-tTG. None of the siblings reported any coeliac-related symptoms, despite being positive for anti-tTG, and coeliac disease has so far been biopsy confirmed in 4.5%.

CONCLUSION

Silent coeliac disease is over-represented in children with type 1 diabetes and their siblings. All diabetes children and their siblings should be tested and followed for the presence of anti-tTG and coeliac disease.

Does growth hormone treatment influence pubertal development in short children?

AIM

To study the influence of growth hormone (GH) treatment on the initiation and progression of puberty in short children.

METHODS

This prospective, randomized, controlled study included 124 short children (33 girls) who received GH treatment (Genotropin®; Pfizer Inc.) from a mean age of 11 years until near adult height [intent-to-treat (ITT) population]. Children were randomized into three groups: controls (n = 33), GH 33 μg/kg/day (n = 34) or GH 67 μg/kg/day (n = 57). Prepubertal children at study start constituted the per-protocol (PP) population (n = 101). Auxological measurements were made and puberty was staged every 3 months. Serum sex-steroid concentrations were assessed every 6 months.

RESULTS

No significant differences were found between the groups, of both PP and ITT populations, in time elapsed from start of treatment until either onset of puberty, age at start of puberty or age at final pubertal maturation in either sex. In the ITT population, pubertal duration was significantly longer in GH-treated girls, and maximum mean testicular volume was significantly greater in GH-treated boys than controls, but there were no differences in testosterone levels between the groups.

CONCLUSION

GH treatment did not influence age at onset of puberty and did not accelerate pubertal development. In boys, GH treatment appeared to increase testicular volume.

Increased perinatal intracranial pressure and brainstem dysfunction predict early puberty in boys with myelomeningocele

BACKGROUND

Children with myelomeningocele (MMC) run an increased risk of developing early or precocious puberty (E/PP).

AIM

  To identify risk factors for E/PP in boys with MMC.

METHODS

Boys born between 1970 and 1992, treated for MMC at the University Children's Hospital, Uppsala, were identified. Thirty-eight boys were eligible to be included. Medical records were examined retrospectively. Early puberty was defined as pubertal signs before the age of 10 years and 2 months. Precocious puberty was defined as the appearance of these signs before 9 years of age. Increased intracranial pressure perinatally was defined as wide sutures, bulging fontanelles and increased/increasing head circumference at birth and/or during the first week after birth. Early brainstem dysfunction was defined as severe and persistent feeding and respiratory problems before the age of 3 months despite proper control of the hydrocephalus.

RESULTS

Of the 38 boys, 8 (21%) had E/PP, which was strongly associated with increased intracranial pressure perinatally and also with early brainstem dysfunction. Multivariate regression analysis showed early brainstem dysfunction to have the highest explanatory value regarding the occurrence of early puberty.

CONCLUSION

Increased intracranial pressure perinatally and brainstem dysfunction early in life are strong predictors of E/PP in boys with MMC.

Improvements in behaviour and self-esteem following growth hormone treatment in short prepubertal children

BACKGROUND/AIMS

To evaluate effects of growth hormone (GH) treatment on behaviour and psychosocial characteristics in short-stature children.

METHODS

99 referred prepubertal non-familiar short-stature children (32 GH deficiency; 67 idiopathic short stature) aged 3-11 years, randomized to fixed or individual GH doses and their parents completed questionnaires (Child Behaviour Checklist, Birleson Depression Self-Report Scale, Abbreviated Parent-Teacher Questionnaire, I Think I Am, Well-Being Visual-Analogue Scales for Short-Stature Children) at baseline (BL) and after 3, 12, and 24 months.

RESULTS

At BL, children showed higher levels of internalizing behaviour (p < 0.001), lower levels of externalizing behaviour (p < 0.006) and self-esteem (p < 0.001) compared to reference values. During GH treatment, behavioural measures (p < 0.001) and depression (p < 0.01) changed towards the mean of the population within the first 3 months and remained improved to 24 months. Self-esteem improved at all time points (p < 0.001), and in all subgroups, as did well-being dimensions stability and mood (p < 0.05). Multiple regression analysis showed that greater improvements were related to lower BL value, height gain, higher maximal GH value, being older, and being male.

CONCLUSION

On GH treatment, prepubertal short children significantly improved on behavioural, depression, and psychosocial evaluations over a 2-year period of GH treatment. Most change occurred within the first 3 months, which highlights this short period as important not only for growth and metabolic changes but also for behaviour and psychosocial improvements following GH treatment.

Fetal, developmental, and parental influences on cystatin C in childhood: the Uppsala Family Study

BACKGROUND

The aim was to identify determinants (biomedical and social characteristics of children and their parents) of cystatin C levels in healthy children drawn from a population sample.

STUDY DESIGN

Cross-sectional study.

SETTING & PARTICIPANTS

425 pairs of consecutive full siblings born 1987-1995 in Uppsala were identified using the Swedish Medical Birth Registry and invited with their parents for examination in 2000-2001.

OUTCOME

Serum cystatin C level was log-transformed and analyzed using random-effects models.

MEASUREMENTS

The examination in parents and children consisted of a nonfasting blood sample, anthropometry, and questionnaires about lifestyle and socioeconomic position. Tanner stage was used for assessment of pubertal status.

RESULTS

In age-, height-, and body mass index-adjusted analyses, cystatin C level increased by 2.6% (95% CI, 0.3%-4.8%) higher in Tanner stage 2 vs 1 girls, and 1.6% (95%CI, 0.2%-3.1%) lower in boys than girls. For every 10% increase in maternal cystatin C level, offspring cystatin C level increased by 3.0% (95% CI, 2.2%-3.8%); the equivalent effect for paternal cystatin C level was 2.1% (95% CI, 1.3%-2.9%). Lower maternal education was associated with a 2.4% (95% CI, 0.3%-4.6%) higher cystatin C level in their offspring.

LIMITATIONS

Cross-sectional study design, missing cystatin C values for subset of parents, lack of urinary measurements, no gold-standard measurement of glomerular filtration rate.

CONCLUSIONS

There are intergenerational associations of cystatin C level in families in line with previous reports of heritability of kidney disease. Lower maternal education is associated with higher cystatin C levels in their children. Further studies of healthy children are needed to explore the biological mechanisms for these findings. If cystatin C is measured, these studies will need to record pubertal stages.

Short adult stature and overweight are associated with poor intellectual performance in subjects born preterm

BACKGROUND/AIMS

To study the association between preterm birth and adult intellectual performance, with special emphasis on the influence of postnatal growth.

METHODS

A population-based cohort study was performed on 272,046 males, born between 1973 and 1978, of whom 248,447 were conscripted for military service between 1991 and 1997. Birth characteristics were obtained from the Swedish Medical Birth Register and information on intellectual performance, final height and BMI were taken from the Swedish Conscript Register. Multiple logistic regression analysis was performed.

RESULTS

At conscription, males born preterm had lower results at tests of intellectual performance compared to those born at term. Short adult stature among these males enhanced the risk of low intellectual performance, as compared to those with normal adult stature. Moreover, a high adult BMI in the males born preterm was associated with an increased risk of subnormal performance as compared to those with normal BMI.

CONCLUSIONS

Subjects born preterm had poorer intellectual performance than those born at term. Short adult stature or a high BMI was associated with an even higher risk for poor intellectual performance in the subjects born preterm. This indicates the occurrence of common mechanisms underlying growth and cognitive development.

Preterm appropriate for gestational age infants: size at birth explains subsequent growth

AIM

 The aim was to evaluate growth and breastfeeding up to 18 months corrected age (CA) among preterm appropriate for gestational age (AGA) infants whose mothers initiated breastfeeding during the infants' hospital stay.

METHODS

 One hundred and twenty-seven preterm AGA infants with a median birth weight of 2320 (769-3250) g and gestational age 34.29 (25.00-35.86) weeks were evaluated up to a CA of 18 months. A retrospective, descriptive and comparative design was used. Data were obtained by chart review of hospital medical records and a questionnaire completed by the mothers.

RESULTS

The changes in standard deviation scores (SDS) during the infants' hospital stay were -0.9 for weight, -0.3 for length and -0.5 for head circumference (HC). Infants with higher SDS at birth showed more negative changes from birth to discharge. Median increments in SDS from discharge to a CA of 2 months were as high as, or higher than, the loss from birth to discharge.

CONCLUSION

 Preterm AGA infants with higher SDS for weight, length and HC at birth are at higher risk of inadequate growth during their hospital stay.

Enterovirus markers and serum CXCL10 in children with type 1 diabetes

Most patients with type 1 diabetes are considered to have a T-cell mediated autoimmune disease. The chemokine CXCL10 promotes the migration of activated T-cells. Virus infections might contribute to the pathogenesis of type 1 diabetes and enterovirus protein and/or genome have been detected in beta-cells from a majority of tested newly diagnosed children with type 1 diabetes. The chemokine CXCL10 is induced in human islet cells by enterovirus infections in vivo and in vitro, but is not expressed in islets from normal organ donors. Since CXCL10 is a chemokine known to be induced by virus infections and/or cellular damage, our aim was to study if levels of CXCL10 are elevated in serum from children with type 1 diabetes and whether it correlates to the presence of enterovirus markers. CXCL10, neutralizing antibody titer rises against certain enterovirus, and antibodies against GAD65 were measured in serum, and enterovirus PCR was performed on whole blood from 83 type 1 diabetes patients at onset, 48 siblings and 69 controls. CXCL10 was also measured in serum from 46 patients with proven enterovirus infection and in serum from 46 patients with other proven virus infections. The CXCL10 serum levels were not elevated in children at onset of type 1 diabetes and there was a considerable overlap between the groups with 99 (8-498) pg/ml in serum from children with type 1 diabetes, 120 (17-538) pg/ml in serum from controls, and 117 (7-448) pg/ml in siblings of the children with type 1 diabetes. The CXCL10 serum levels in patients with proven enterovirus infection were slightly increased compared to the levels in the other groups, 172 (0-585) pg/ml but there was no statistically significant difference. In contrast, CXCL10 serum levels in patients with other proven virus infections were clearly elevated 418 (34-611) pg/ml. Despite that elevated CXCL10 levels have been demonstrated in some groups of patients with type 1 diabetes, in this study the mean CXCL10 serum levels were not elevated in patients with type 1 diabetes neither in patients with proven enterovirus infection. In contrast, in patients with other virus infections the CXCL10 levels were elevated, presumably reflecting the severity or the site of infection. This suggests that local production of CXCL10 in the affected organ cannot be measured reproducible in serum and that its potential use in clinical practice is limited.

Can the TW3 bone age determination method provide additional criteria for growth hormone treatment in adopted girls with early puberty? A comparison of the Tanner-Whitehouse 3 method with the Greulich-Pyle and the Tanner-Whitehouse 2 methods

BACKGROUND/AIMS

Gonadotropin-releasing hormone analogues (GnRHa) are the accepted treatment of idiopathic central precocious puberty. As it has been found that growth velocity may be decreased with GnRHa treatment, clinical trials with GnRHa combined with growth hormone (GH) have been carried out. In a recent study 46 adopted girls with early or precocious puberty were randomly assigned to treatment with either GnRHa or GnRHa combined with GH, and followed to final height (FH). It was found that FH was significantly higher in the combined treatment group, 158.9 compared with 155.8 cm in the GnRHa treated group. In order to select the patients who could benefit from added GH, predictions of FH at the start of treatment according to the methods of bone age determination of Greulich-Pyle (GP) and Tanner-Whitehouse 2 (TW2) were compared. It was found that the GP method was the most useful method for patient selection. Recently, a revision of the Tanner-Whitehouse method, named Tanner-Whitehouse 3 (TW3), has been developed. The present study examined the usefulness of the TW3 method in selecting suitable patients for combined treatment.

METHOD

The TW3 method bone age determinations of the 46 girls were compared to the GP and TW2 method determinations, using the differences between actual FH and predicted adult height (PAH). Beside accuracy of prediction of FH, the criteria of efficiency of selection and replicability were applied in the comparison.

RESULTS

We found that the GP method, also when compared to the TW3 method, gave the most accurate prediction of the FH on only GnRHa treatment. This gives the best ground for selection of patients who can benefit from combined treatment. The GP method was also the most efficient in selecting patients, i.e., it could select the least number of patients that needed the combined treatment. The only drawback of the GP method was that it requires an experienced pediatric radiologist. Automated methods are being developed and may soon facilitate the use of the GP method for those less experienced. The FH after combined treatment could be predicted with an equation including PAH GP as well as PAH TW3 as variables.

CONCLUSION

The GP method remains the most useful method for selection of those patients who will benefit most from the addition of GH to GnRHa in the treatment of idiopathic central precocious or early puberty. FH prediction after combined treatment requires PAH GP as well as PAH TW3.

Relationships between ophthalmological and neuropaediatric findings in children adopted from Eastern Europe

PURPOSE

This study aimed to evaluate and relate visual function, ocular dimensions and neuropaediatric findings in adoptees from Eastern Europe.

METHODS

We studied 72 of 99 children, born during 1990-95 and adopted from Eastern Europe to western Sweden during 1993-97. The children (mean age 7.5 years, range 4.8-10.5 years; 41 boys, 31 girls) were examined after a mean period of 5 years post-adoption by a multidisciplinary team. Correlations between ophthalmological findings and neuropaediatric data were analysed.

RESULTS

Bivariate and regression analyses indicate a significant positive correlation between visual acuity (VA) and perceptual organization (p < 0.001), as well as between strabismus and verbal comprehension (p < 0.02). Fetal alcohol syndrome (FAS) was correlated with low VA (p < 0.02), subnormal stereovision (p < 0.009) and small optic discs (p < 0.02). Small head circumference was related to low VA (p < 0.015) and small optic discs (p < 0.03). Furthermore, small optic discs were related to low birthweight (p < 0.005) and preterm birth (p < 0.01). Large optic cups were correlated with poorer perceptual organization (p < 0.02).

CONCLUSIONS

In this group of adoptees from Eastern Europe, ophthalmological findings were correlated to neuropaediatric findings, especially those arising from prenatal adverse events resulting in growth deficiency and central nervous system damage. Therefore, it is important and valuable with an ophthalmological examination in children adopted from Eastern Europe.

Gestational diabetes and offspring body disproportion

AIM

It has been demonstrated that females born large for gestational age (LGA) in weight but not length are at increased risk of being obese at childbearing age. We addressed the question whether women with gestational diabetes mellitus (GDM) are at increased risk of giving birth to such infants.

METHODS

Birth characteristics of 884,267 infants of non-diabetic mothers and 7817 of mothers with GDM were analysed. LGA was defined as birth weight or birth length >2 standard deviation scores for gestational age. Multiple logistic regression analysis was performed.

RESULTS

The odds ratio (OR) for a woman with GDM to give birth to an LGA infant that was heavy alone was four times increased (OR: 3.71, 95% CI: 3.41-4.04). Furthermore, in the population of mothers giving birth to LGA infants, the proportion heavy alone was 68% in the group of women with GDM compared with 64.4% in the group of non-diabetic women. The risks were independent of gender of the foetus.

CONCLUSION

Women with GDM have an almost four times higher risk of delivering an LGA infant that is heavy alone. The noted disproportion between weight and length in infants of such mothers may have an impact on the risk of later obesity.

Concern for privacy in relation to age during physical examination of children: an exploratory study

OBJECTIVES

To explore whether physicians behave differently regarding ethics and respect for privacy depending on children's age. We explored whether physician behaviours contributed to child uneasiness.

STUDY DESIGN

Observational study of 21 children (0-12 years; 18 boys; mean age 3.2) undergoing evaluation for inguinal hernia. Specific physician-initiated verbal and nonverbal behaviours were coded from digital video discs of the consultations.

RESULTS

Physician intrusiveness (i.e. approaching the child suddenly or in an uninvited way) during the physical examination was related to concurrent child uneasiness (r = 0.42, p < 0.06) and lasted through the postexamination phase of the consultation (r = 0.52, p < 0.01). Child mood during the examination strongly predicted postexamination mood (r = 0.69, p < 0.0001). Neither the total number of physician-initiated positive behaviours or privacy-related behaviours was associated with child age. Negative physician behaviours were strongly related to negative mood in the child (r = 0.72, p < 0.0001) at the close of the consultation.

CONCLUSION

Although physicians were more likely to provide information to older than younger children, their behaviours regarding privacy did not differ by child age. We found that intrusiveness was rather common and related to child uneasiness that has implications for the ethical practice and a child's willingness to be examined.

Growth hormone (GH) dosing during catch-up growth guided by individual responsiveness decreases growth response variability in prepubertal children with GH deficiency or idiopathic short stature

CONTEXT

Weight-based GH dosing results in a wide variation in growth response in children with GH deficiency (GHD) or idiopathic short stature (ISS).

OBJECTIVE

The hypothesis tested was whether individualized GH doses, based on variation in GH responsiveness estimated by a prediction model, reduced variability in growth response around a set height target compared with a standardized weight-based dose.

SETTING

A total of 153 short prepubertal children diagnosed with isolated GHD or ISS (n = 43) and at least 1 SD score (SDS) below midparental height SDS (MPH(SDS)) were included in this 2-yr multicenter study.

INTERVENTION

The children were randomized to either a standard (43 microg/kg.d) or individualized (17-100 microg/kg.d) GH dose.

MAIN OUTCOME MEASURE

We measured the deviation of height(SDS) from individual MPH(SDS) (diffMPH(SDS)). The primary endpoint was the difference in the range of diffMPH(SDS) between the two groups.

RESULTS

The diffMPH(SDS) range was reduced by 32% in the individualized-dose group relative to the standard-dose group (P < 0.003), whereas the mean diffMPH(SDS) was equal: -0.42 +/- 0.46 and -0.48 +/- 0.67, respectively. Gain in height(SDS) 0-2 yr was equal for the GH-deficient and ISS groups: 1.31 +/- 0.47 and 1.36 +/- 0.47, respectively, when ISS was classified on the basis of maximum GH peak on the arginine-insulin tolerance test or 24-h profile.

CONCLUSION

Individualized GH doses during catch-up growth significantly reduce the proportion of unexpectedly good and poor responders around a predefined individual growth target and result in equal growth responses in children with GHD and ISS.

Temporal trends of HLA genotype frequencies of type 1 diabetes patients in Sweden from 1986 to 2005 suggest altered risk

The aim of this study was to compare the frequency of human leukocyte antigen (HLA) genotypes in 1-18-year-old patients with type 1 diabetes newly diagnosed in 1986-1987 (n = 430), 1996-2000 (n = 342) and in 2003-2005 (n = 171). We tested the hypothesis that the HLA DQ genotype distribution changes over time. Swedish type 1 diabetes patients and controls were typed for HLA using polymerase chain reaction amplification and allele specific probes for DQ A1* and B1* alleles. The most common type 1 diabetes HLA DQA1*-B1*genotype 0501-0201/0301-0302 was 36% (153/430) in 1986-1987 and 37% (127/342) in 1996-2000, but decreased to 19% (33/171) in 2003-2005 (P \ 0.0001). The 0501-0201/0501-0201 genotype increased from 1% in 1986-1987 to 7% in 1996-2000 (P = 0.0047) and to 5% in 2003-2005 (P > 0.05). This study in 1-18-year-old Swedish type 1 diabetes patients supports the notion that there is a temporal change in HLA risk.

Dose-dependent effect of growth hormone on final height in children with short stature without growth hormone deficiency

CONTEXT

The effect of GH therapy in short non-GH-deficient children, especially those with idiopathic short stature (ISS), has not been clearly established owing to the lack of controlled trials continuing until final height (FH).

OBJECTIVE

The aim of the study was to investigate the effect on growth to FH of two GH doses given to short children, mainly with ISS, compared with untreated controls.

DESIGN AND SETTING

A randomized, controlled, long-term multicenter trial was conducted in Sweden.

INTERVENTION

Two doses of GH (Genotropin) were administered, 33 or 67 microg/kg.d; control subjects were untreated.

SUBJECTS

A total of 177 subjects with short stature were enrolled. Of these, 151 were included in the intent to treat (AllITT) population, and 108 in the per protocol (AllPP) population. Analysis of ISS subjects included 126 children in the ITT (ISSITT) population and 68 subjects in the PP (ISSPP) population.

MAIN OUTCOME MEASURES

We measured FH sd score (SDS), difference in SDS to midparenteral height (diff MPHSDS), and gain in heightSDS.

RESULTS

After 5.9+/-1.1 yr on GH therapy, the FHSDS in the AllPP population treated with GH vs. controls was -1.5+/-0.81 (33 microg/kg.d, -1.7+/-0.70; and 67 microg/kg.d, -1.4+/-0.86; P<0.032), vs. -2.4+/-0.85 (P<0.001); the diff MPHSDS was -0.2+/-1.0 vs. -1.0+/-0.74 (P<0.001); and the gain in heightSDS was 1.3+/-0.78 vs. 0.2+/-0.69 (P<0.001). GH therapy was safe and had no impact on time to onset of puberty. A dose-response relationship identified after 1 yr remained to FH for all growth outcome variables in all four populations.

CONCLUSION

GH treatment significantly increased FH in ISS children in a dose-dependent manner, with a mean gain of 1.3 SDS (8 cm) and a broad range of response from no gain to 3 SDS compared to a mean gain of 0.2 SDS in the untreated controls.

Effects of being born small for gestational age on long-term intellectual performance

Size at birth has been associated repeatedly with increased risk of cardiovascular morbidity and mortality later in life. However, there is accumulating evidence to suggest an association between being born small for gestational age (SGA) and increased risk of lower intelligence, poor academic performance, low social competence and behavioural problems, compared with individuals born appropriate for gestational age. Crude neurological handicaps, such as cerebral palsy, are extremely rare in children born SGA at term. Such handicaps are more common in very premature children. However, there does appear to be an increase in the risk for non-severe neurological dysfunction in individuals born SGA. Intellectual performance is evaluated in young children in several different ways, including standardized tests such as Weschler's Intelligence Scale - Revised, and teachers and parents' reports. In adulthood, indirect variables such as education and occupation are used in addition to standardized tests. It may be possible to modify the effects of SGA on intellectual development by breast feeding the baby for more than 6 months. Nutrient-enriched formula does not have any advantages when it comes to intellectual development, and induces a risk of rapid weight gain and eventually overweight. Growth hormone treatment may also have some effect on intelligence quotient.

A unifying hypothesis on the development of type 1 diabetes and celiac disease: gluten consumption may be a shared causative factor

This paper presents a hypothesis of the aetiology of the increasing incidence of type 1 diabetes (T1D). This together with the global increased incidence of celiac disease (CD) and that these increases cannot be explained by genetic factors suggest a common environmental factor for these two diseases. Even though enterovirus (EV) infections are believed to trigger T1D and gluten is the trigger of CD, the increasing intake of gluten containing products all over the world could be the trigger for both diseases directly and indirectly. It has been shown that the duration of exposure to gluten is related to the prevalence of T1D. It has also been shown that T1D patients at onset have an inflammatory reaction in the gut. Hence, early diagnose of CD followed by elimination of dietary gluten will lead to a decreased incidence of T1D.

Recent enterovirus infection in type 1 diabetes: evidence with a novel IgM method

Enterovirus (EV) infection has been associated with Type 1 (T1D) diabetes and on a few occasions virus could be isolated at onset of the disease. Using two such isolates as antigens in a quantitative PCR enhanced immunoassay (T1D-EV-QPIA) we have measured IgM antibodies against such potentially diabetogenic viruses in serum from 33 newly diagnosed T1D children, 24 siblings, and 27 healthy children. Sera were also analysed with regard to autoantibodies against GAD65, the cytokine TNF-alpha and the chemokine IP-10. EV-RNA detection was performed on peripheral blood mononuclear cells (PBMC). IgM antibodies against this "new" EV antigen were more frequent in serum from T1D children than in serum from siblings and/or controls (P < 0.001). EV-RNA was detected more frequently in PBMC from T1D children than in healthy control children (P < 0.001) and also compared to the siblings (P < 0.003). The cytokine TNF-alpha was less frequently detected in serum from the T1D children compared with serum from siblings and/controls (P < 0.001). A positive correlation was found between the results obtained with the T1D-EV-QPIA and the EV-PCR (P < 0.001). These findings are in line with earlier findings of an increased frequency of enteroviral infections in newly diagnosed T1D patients. In addition, we found that T1D children at onset of the disease had lower frequencies of the chemokine TNF-alpha in their serum than age- and sex-matched controls had, suggesting an impaired immune response.

IA-2 autoantibodies in incident type I diabetes patients are associated with a polyadenylation signal polymorphism in GIMAP5

In a large case-control study of Swedish incident type I diabetes patients and controls, 0-34 years of age, we tested the hypothesis that the GIMAP5 gene, a key genetic factor for lymphopenia in spontaneous BioBreeding rat diabetes, is associated with type I diabetes; with islet autoantibodies in incident type I diabetes patients or with age at clinical onset in incident type I diabetes patients. Initial scans of allelic association were followed by more detailed logistic regression modeling that adjusted for known type I diabetes risk factors and potential confounding variables. The single nucleotide polymorphism (SNP) rs6598, located in a polyadenylation signal of GIMAP5, was associated with the presence of significant levels of IA-2 autoantibodies in the type I diabetes patients. Patients with the minor allele A of rs6598 had an increased prevalence of IA-2 autoantibody levels compared to patients without the minor allele (OR=2.2; Bonferroni-corrected P=0.003), after adjusting for age at clinical onset (P=8.0 x 10(-13)) and the numbers of HLA-DQ A1*0501-B1*0201 haplotypes (P=2.4 x 10(-5)) and DQ A1*0301-B1*0302 haplotypes (P=0.002). GIMAP5 polymorphism was not associated with type I diabetes or with GAD65 or insulin autoantibodies, ICA, or age at clinical onset in patients. These data suggest that the GIMAP5 gene is associated with islet autoimmunity in type I diabetes and add to recent findings implicating the same SNP in another autoimmune disease.

SUMO4 M55V polymorphism affects susceptibility to type I diabetes in HLA DR3- and DR4-positive Swedish patients

SUMO4 M55V, located in IDDM5, has been a focus for debate because of its association to type I diabetes (TIDM) in Asians but not in Caucasians. The current study aims to test the significance of M55V association to TIDM in a large cohort of Swedish Caucasians, and to test whether M55V is associated in those carrying human leukocyte antigen (HLA) class II molecules. A total of 673 TIDM patients and 535 age- and sex-matched healthy controls were included in the study. PCR-RFLP was performed to identify the genotype and allele variations. Our data suggest that SUMO4 M55V is not associated with susceptibility to TIDM by itself. When we stratified our patients and controls based on heterozygosity for HLA-DR3/DR4 and SUMO4 genotypes, we found that presence of SUMO4 GG increased further the relative risk conferred by HLA-DR3/DR4 to TIDM, whereas SUMO4 AA decreased the risk. From the current study, we conclude that SUMO4 M55V is associated with TIDM in association with high-risk HLA-DR3 and DR4, but not by itself.

Ethics takes time, but not that long

Background

Time and communication are important aspects of the medical consultation. Physician behavior in real-life pediatric consultations in relation to ethical practice, such as informed consent (provision of information, understanding), respect for integrity and patient autonomy (decision-making), has not been subjected to thorough empirical investigation. Such investigations are important tools in developing sound ethical praxis.

Methods

21 consultations for inguinal hernia were video recorded and observers independently assessed global impressions of provision of information, understanding, respect for integrity, and participation in decision making. The consultations were analyzed for the occurrence of specific physician verbal and nonverbal behaviors and length of time in minutes.

Results

All of the consultations took less than 20 minutes, the majority consisting of 10 minutes or less. Despite this narrow time frame, we found strong and consistent association between increasing time and higher ratings on all components of ethical practice: information, (β = .43), understanding (β = .52), respect for integrity (β = .60), and decision making (β = .43). Positive nonverbal behaviors by physicians during the consultation were associated particularly with respect for integrity (β =.36). Positive behaviors by physicians during the physical examination were related to respect for children's integrity.

Conclusion

Time was of essence for the ethical encounter. Further, verbal and nonverbal positive behaviors by the physicians also contributed to higher ratings of ethical aspects. These results can help to improve quality of ethical practice in pediatric settings and are of relevance for teaching and policy makers.

Milk for small infants

This study investigated weight patterns of infants born SGA, in relation to two different feeding regimens during hospital stay. We compared 21 SGA infants prescribed 200 mL/kg milk on day 2, with 21 infants, prescribed 170 mL/kg on day 9. The infants fed according to the proactive nutrition policy tolerated large volumes of milk and showed lower weight loss.

CONCLUSION

A proactive nutrition policy demonstrably reduces weight loss in SGA infants.

Females born large for gestational age have a doubled risk of giving birth to large for gestational age infants

AIM

To analyse if females born large for gestational age (LGA) have an increased risk to give birth to LGA infants and to study anthropometric characteristics in macrosomic infants of females born LGA.

METHODS

The investigation was performed as an intergenerational retrospective study of women born between 1973 and 1983, who delivered their first infant between 1989 and 1999. Birth characteristics of 47,783 females, included in the Swedish Birth Register both as newborns and mothers were analysed. LGA was defined as >2 SD in either birth weight or length for gestational age. The infants were divided into three subgroups: born tall only, born heavy only and born both tall and heavy for gestational age. Multiple logistic and linear regression analyses were performed.

RESULTS

Females, born LGA with regard to length or weight, had a two-fold (adjusted OR 1.96, 95% Cl 1.54-2.48) increased risk to give birth to an LGA infant. Females, born LGA concerning weight only, had a 2.6 (adjusted OR 2.63, 95%, 1.85-3.75) fold increased risk of having an LGA offspring heavy only and no elevated risk of giving birth to an offspring that was tall only, compared to females born not LGA. In addition, maternal obesity was associated with a 2.5 (adjusted OR 2.56, 95%, 2.20-2.98) fold increased risk of having an LGA newborn, compared to mothers with normal weight.

CONCLUSION

Females, born LGA, have an increased risk to give birth to LGA infants, compared to mothers born not LGA. Maternal overweight increases this risk even further.

Relation problems in internationally adopted juvenile delinquents

OBJECTIVE

Internationally adopted delinquents are overrepresented in juvenile Swedish institutions. With the purpose of investigating possible reasons for this overrepresentation, this study compared adopted delinquent adolescents and internationally adopted controls in the structure and functioning of their current relations, especially with their parents.

METHODS

Internationally adopted adolescents admitted to institutional care (N=20) and non-delinquent internationally adopted controls (N=21) were compared through: a questionnaire; "family relations", a subscale in I think I am; "Family climate" (from Karolinska Scale of Personality); Individual Schedule of Social Interaction; and an Attachment Test.

RESULTS

Bad relations with adoptive parents were more prevalent in internationally adopted delinquents compared to internationally adopted controls. Furthermore, the adopted delinquents and their parents blamed each other for the problems and the adopted delinquents reported physical and emotional abuse.

CONCLUSIONS

Internationally adopted delinquents reported more problems in their relationships to their parents than adopted controls did.

Effects on isolated human pancreatic islet cells after infection with strains of enterovirus isolated at clinical presentation of type 1 diabetes

Enterovirus (EV) infections have been associated with the pathogenesis of type 1 diabetes (T1D). They may cause beta-cell destruction either by cytolytic infection of the cells or indirectly by triggering the autoimmune response. Evidence for EV involvement have been presented in several studies, EV-IgM antibodies have been reported in T1D patients, EV-RNA has been found in the blood from T1D patients at onset, and EV have been isolated from newly diagnosed T1D. Our aim was to study infections with EV isolates from newly diagnosed T1D patients in human pancreatic islets in vitro. Two of them (T1 and T2) originated from a mother and her son diagnosed with T1D on the same day, the other two (A and E) were isolated from a pair of twins at the time of diagnosis of T1D in one of them. Isolated human pancreatic islets were infected and viral replication, viability and degree of cytolysis as well as insulin release in response to high glucose were measured. All four EV isolates replicated in the islet cells and virus particles and virus-induced vesicles were seen in the cytoplasm of the beta-cells. The isolates varied in their ability to induce cytolysis and to cause destruction of the islets and infection with two of the isolates (T1 and A) caused more pronounced destruction of the islets. Infection with the isolate from the healthy twin boy (E) was the least cytolytic. The ability to secrete insulin in response to high glucose was reduced in all infected islets as early as 3 days post infection, before any difference in viability was observed. To conclude, strains of EV isolated from T1D patients at clinical presentation of T1D revealed beta-cell tropism, and clearly affected the function of the beta-cell. In addition, the infection caused a clear increase in the number of dead cells.

Growth, puberty, and final height in children with Type 1 diabetes

OBJECTIVE

The aims of this study were to assess the physical growth and pubertal development in a group of diabetic children and to evaluate the effect of height at diagnosis, duration of illness, and degree of glycemic control on final height and sexual maturation.

RESEARCH DESIGN

A cohort of 72 Sudanese diabetic children, 7-13 years of age at diagnosis, was followed longitudinally from the onset of diabetes until the attainment of final height.

RESULTS

The mean height standard deviation scores (SDS) at diagnosis were 0.04 in boys and -0.15 in girls, which was greater than their genetic target height (GTH). The growth velocity between diagnosis and final height was slow, with significant reduction in pubertal growth spurt. The mean final height attained by these children was lower than their GTH, a finding that contradicts most of the recently published reports. The average age at menarche in girls (15.1 years) and the mean age of full sexual maturation in boys (17.2 years) were significantly delayed in this group of diabetic patients. This retardation in physical growth and pubertal development was positively correlated with the duration of diabetes before the onset of puberty and glycated haemoglobin (HbA1c) concentration. The majority of these patients were thin at diagnosis of diabetes, with median body mass index (BMI) <22, but showed a remarkable, progressive weight gain during puberty, which was more evident in girls. The weight gain was independent of weight at diagnosis and duration of diabetes, but was positively correlated with the daily dose of insulin and HbA1c concentration.

CONCLUSION

Conventional therapy of diabetic children is associated with impairment of physical growth and delayed sexual maturation.

Treatment of central precocious puberty

The problems of central precocious puberty (CPP) are serious enough to the patient to deserve treatment. There is a general consensus among paediatric endocrinologists that the treatment of true CPP (i.e., in children young enough to have a formal diagnosis) is indicated in many cases. In children with modestly early puberty who are not fulfilling the diagnostic criteria, this is not the case. The treatment of choice is a gonadotropin-releasing hormone (GnRH) analogue. Prolonged analogues are more effective than short-acting ones and, most importantly, independent of patient compliance. Data on agonists have accumulated over two decades and evidence of effects is rich in girls but sparse in boys. GnRH agonists are generally effective and safe drugs; the suppression of puberty is reversible and there is much information on GnRH agonists for the treatment of CPP showing very few adverse effects and the effects on final height are well documented in girls < 6 years of age. There is some (but not highly convincing) evidence for their effect on final height for those of 6 - 8 years of age and there is no evidence for an increase in final height after the age of 8 years in girls. If a decision to have treatment is taken, treatment should start immediately as a possible benefit is less probable if the start of treatment is delayed. When treatment should be stopped is a matter of controversy. Combination with growth hormone increases final height, but the clinical relevance can be discussed as well as the health economy aspects. The limits of indications are still to be defined.

Birth characteristics and risk of low intellectual performance in early adulthood: are the associations confounded by socioeconomic factors in adolescence or familial effects?

OBJECTIVE

In this study we investigated whether the association between measures of fetal growth restriction and intellectual performance was mediated by socioeconomic or familial factors.

METHODS

This was a population-based cohort study of 357,768 Swedish males born as singletons without congenital malformations between 1973 and 1981. The main outcome measure was intellectual performance at military conscription.

RESULTS

Compared with men born with appropriate birth weight for gestational age, men born light for gestational age suffered an increased risk of low intellectual performance after adjustment for maternal and socioeconomic factors. The increase in risk of low intellectual performance related to a decrease in birth weight for gestational age was similar between families and within families. Men born short or with a small head circumference for gestational age were also at increased risk of low intellectual performance, both when adjusting for maternal and socioeconomic factors and within families.

CONCLUSIONS

We found that all of the studied dimensions of restricted fetal growth are independently associated with increased risks of low intellectual performance and that these associations are only partly mediated by socioeconomic or familial factors.

Risks for low intellectual performance related to being born small for gestational age are modified by gestational age

OBJECTIVE

We sought to study whether the association between being born small for gestational age and risk for low intellectual performance was modified by gestational age.

METHODS

A population-based cohort study was conducted of 352,125 boys who were born between 28 and 43 completed weeks of gestation from 1973 to 1981 in Sweden. Risk for low intellectual performance at military conscription, estimated as odds ratios with 95% confidence intervals was measured.

RESULTS

Compared with men who were born preterm (28-36 weeks) and had normal birth weight for gestational age, men who were born preterm and had a very low birth weight for gestational age were not at increased risk for low intellectual performance. In contrast, men who were born preterm with a very short birth length or a very small head circumference for gestational age faced a near doubled risk for low intellectual performance compared with their appropriate peers. Among men who were born at term (37-41 weeks), risk for low intellectual performance was increased among those with very or moderately small birth weight, birth length, or head circumference for gestational age.

CONCLUSIONS

During early stages of gestation, growth in length and head circumference may be more important for intellectual development than weight increase. Future studies on size at birth and intellectual performance should consider also including anthropometric measurements other than birth weight.

Parents' perspectives on research involving children

Children's participation in research is essential for the development of safe and age-appropriate treatments. However, children's participation is limited. The aim of this study was to determine (1) mothers' and fathers' views on which agencies/persons should evaluate the level of acceptable risk for children and (2) parents' willingness to allow children to participate in research. Medical factors, sociodemographics, and research attitudes were related to willingness. The study used a cross-sectional and longitudinal design with 863 expectant parents (435 women; 428 men) consecutively recruited at gestational week 19 during routine ultrasound examination at 2 hospitals in Uppsala County, Sweden. 123 women at gestational week 34 were followed-up. Parental ratings of agencies/persons' degree of involvement in risk-evaluation for. child research participants and parents' willingness to allow children to participate in research were the main outcome measures. Most parents believed that more pediatric research was needed. Attitudes played a major role in willingness, indicating a potential for information that could modify willingness. Over 80% of mothers and fathers rated the attending physician as needing to be "fully involved" in risk evaluation for research participants. Parents' views contradict current trends in research ethics which place evaluation of risk in the hands of regional agencies. Instead, the majority of parents would like the decision to be individually based on the attending physicians advise. We conclude that children's participation in research could be improved by actively incorporating the attending physician and by educating the public so that research attitudes can be based on accurate information.

Can bone age determination provide criteria for growth hormone treatment in adopted girls with early puberty?

In treatment of idiopathic central precocious puberty, GnRH analogues (GnRHa) have been accepted as the treatment of choice. Since growth velocity may be impaired with GnRHa treatment growth hormone (GH) treatment has been added in clinical trials. Recently, a study followed adopted girls with early or precocious puberty on GnRHa or combined GnRHa and GH treatment to final height. It was found that final height was significantly higher in the combined treatment group, although the difference was small. It was seen that patients that were extremely short at arrival and short at start of treatment seemed to be candidates for combined treatment. We have now analysed the data in order to define criteria for the sub-group in need of combined GnRHa-GH treatment in order to achieve normal final height, i.e. above -2 SDS. Bone ages of 46 patients at start of treatment, randomized to either GnRHa treatment or GnRHa treatment combined with GH, were examined blindly by the same radiologist and the PAH calculated. The methods according to Greulich-Pyle / Bayley-Pinneau (GP/BP) and Tanner-Whitehouse (TW2) were used. Predictions versus final height data were analysed. The accuracy of FH prediction was greatest for GnRHa treated group using the GP/BP method. The GP/BP method gave useful cut off limits for when combined treatment was necessary to possibly achieve normal height. If pre-treatment GP/PAH was > 157cm, the patients attained normal height with GnRHa treatment only. Ten out of 13 (77%) such girls could be correctly identified. Using TW2 with a cut off of 164 cm, 9 out of 13 could be selected. Using a multi regression equation of best fit the number of correctly selected cases for GnRHa treatment only, could not be further increased in this group. We conclude that bone age determination and adult height prediction with the Greulich-Pyle/Bayley-Pinneau method, provides useful criteria for selecting the subgroup of adopted girls with early puberty where combined treatment with GnRHa and GH is not necessary to reach normal final height.

Growth and breastfeeding among low birth weight infants fed with or without protein enrichment of human milk

The effect of protein enrichment of mother's milk on growth of low birthweight infants needs further exploration in order to optimize feeding strategies. The aim of this study was to describe feeding and growth of infants weighing <1,900 g at birth, up to a corrected age of 18 months, with or without protein-enriched breastmilk. A retrospective, descriptive, non-experimental design was used to describe the growth of 52 low birthweight infants. Data on their growth and feeding were collected from medical records at hospitals and child health care clinics. Despite more severe morbidity, the infants given protein-enriched milk showed similar growth as the other study infants. Standard deviation score for length at birth correlated positively with delta standard deviation score for length, from discharge to 12 and from discharge to 18 months corrected age. Duration of 'full' breastfeeding had a significant impact on subsequent improvement in SDS for weight. At discharge a smaller proportion of singletons fed with protein enriched milk were breastfed 'fully'. Infants who established breastfeeding at an early post-menstrual age were born with more optimal weight standard deviation score and had a better weight gain after discharge. We conclude that protein-enriched breast milk enables low birthweight infants requiring especially intensive care to attain growth at discharge comparable to that of healthier infants not given enriched milk. Low standard deviation score for length at birth may predict poor growth after discharge. However duration of 'full' breastfeeding had a significant impact on subsequent improvement in SDS for weight. Therefore it is important that mothers of LBW infants are given sufficient support of lactation and breastfeeding.

Fetal, Developmental, and Parental Influences on Childhood Systolic Blood Pressure in 600 Sib Pairs

BACKGROUND

Little is known about the contribution of maternal and paternal factors to the inverse association between birth weight and later blood pressure in human offspring. A study of within- and between-family associations of birth weight with blood pressure, which collected data on both parents, would address this gap in our knowledge.

METHODS AND RESULTS

The study examined families composed of mother, father, and 2 full sibs delivered between 38 and 41 weeks' gestation within 36 months of each other. A total of 1967 families meeting our inclusion criteria were contacted and 602 were examined (children 5 to 14 years old, 1998 to 2000). Birth weight and gestational age were available from obstetric records. Systolic blood pressure in childhood was inversely associated with birth weight within families (-2.3 mm Hg/kg, 95% CI -4.4 to -0.3) after adjustment for gestational age, sex, height, and weight at examination. The between-family effect (-1.5 mm Hg/kg, -3.1 to 0.0) was strengthened on adjustment for maternal and paternal height and weight, whereas adjustment for paternal and maternal systolic blood pressure at examination independently attenuated the effect.

CONCLUSIONS

The existence of an inverse association of birth weight with systolic blood pressure within families (adjusted for height and weight at examination) demonstrates that factors that vary between pregnancies in the same woman (including fetal genotype) can influence the later blood pressure of offspring. We conclude that this apparent fetal programming effect on blood pressure will not be eliminated solely by interventions aimed at modifying growth and cumulative nutritional status from conception through childhood or other fixed characteristics of future mothers.

Risk of high blood pressure among young men increases with the degree of immaturity at birth

BACKGROUND

Survivors of preterm birth constitute a new generation of young adults, but little is known about their long-term health. We investigated the association between gestational age (GA) and risk of high blood pressure (HBP) in young Swedish men and whether GA modified the risk of HBP; ie, whether HBP was related to being born small for gestational age (SGA).

METHODS AND RESULTS

This population-based cohort study included 329 495 Swedish men born in 1973 to 1981 who were conscripted for military service in 1993 to 2001. Multivariate linear- and logistic-regression analyses were performed. Main outcome measures were systolic and diastolic BPs at conscription. Linear-regression analyses showed that systolic BP increased with decreasing GA (regression coefficient -0.31 mm Hg/wk, P<0.001). Systolic and diastolic BPs both increased with decreasing birth weight for GA, but the association with systolic BP was most evident (regression coefficient -0.67 mm Hg per SD score in birth weight for GA, P<0.001). Compared with men born at term (GA, 37 to 41 weeks), the adjusted odd ratios (95% confidence intervals [CIs]) for high systolic BP (> or =140 mm Hg) were as follows: moderately preterm (33 to 36 weeks), 1.25 (1.19 to 1.30); very preterm (29 to 32 weeks), 1.48 (1.30 to 1.68); and extremely preterm (24 to 28 weeks), 1.93 (1.34 to 2.76). Being SGA was associated only with an increased risk of high systolic BP among men born at 33 weeks or later. The risk estimates for high diastolic BP (> or =90 mm Hg) increased with decreasing GA, but the risk reached significance only among men born moderately preterm.

CONCLUSIONS

Preterm birth, a common pregnancy complication, is a risk factor for HBP in young men. The risk of high systolic BP associated with birth weight for GA is modified by GA, suggesting that perinatal contributions to BP elevation later in life may be induced by different biological pathways.

Growth and growth hormone in children born small for gestational age

Although most children born small for gestational age catch up in growth by age 2 y, up to 14% remain more than 2 standard deviations below the mean for height. Recombinant growth hormone is approved by the US Food and Drug Administration and by the European Agency for Evaluation of Medicinal Products for the treatment of children born small for gestational age who fail to manifest catch-up growth by 2 y or 4 y, respectively.

CONCLUSION

We conclude from clinical studies that growth hormone therapy can induce catch-up growth in these children.

Birth Characteristics and Risk of High Systolic Blood Pressure in Early Adulthood

BACKGROUND

Although an inverse association between size at birth and blood pressure has been found in several studies, few studies have adjusted for the influence of socioeconomic and familial effects.

METHODS

We investigated whether the association between birth weight and systolic blood pressure in young men is confounded by socioeconomic factors in adolescence or familial factors (ie, common genes and shared environment). Our population-based cohort study comprised 330,768 Swedish men born between 1973 and 1981, and conscripted for military service between 1991 and 2000. The analyses of family effects were restricted to 89,856 siblings from the initial cohort. A high systolic blood pressure at conscription was defined as a systolic blood pressure >/=140 mm Hg. Birth weight for gestational age <-2 standard deviation scores was considered "light for gestational age."

RESULTS

Compared with men who had normal birth weight for gestational age, men who had been born light for gestational age were at increased risk of high systolic blood pressure (odds ratio = 1.14; 95% confidence interval = 1.07-1.22), even after adjustment for important confounders such as socioeconomic status. The increase in risk of high systolic blood pressure related to 1 standard deviation score decrease in birth weight for gestational age was similar within families (1.08; 1.04-1.12) and between families (1.05; 1.03-1.08).

CONCLUSIONS

This study suggests that low birth weight for gestational age slightly increases the risk of high systolic blood pressure, and that the association appears not to be confounded by socioeconomic or familial effects.

High risk of sensorineural hearing loss in men born small for gestational age with and without obesity or height catch-up growth: a prospective longitudinal register study on birth size in 245,000 Swedish conscripts

BACKGROUND

Several components of the metabolic syndrome coincide with those risk factors linked to sensorineural hearing loss (SNHL). According to the thrifty phenotype hypothesis, the metabolic syndrome can be caused by events during the fetal period. This study tests the thrifty phenotype hypothesis on hearing, using body size at birth and conscription as indirect markers for fetal programming and body mass index as an indicator for the metabolic syndrome.

METHODS

Odds ratios were used to analyze birth data regarding body size from birth to conscription as risk factors for hearing loss in 245,092 conscripted Swedish men.

FINDINGS

Compared with conscripts born short for gestational age with catch-up growth, those born short with absence of catch-up growth exhibited 134% higher risk of SNHL. Adult short stature was associated with a 50% increased risk. Compared with conscripts with average body mass index, overweight was associated with 30%, obesity with 99%, and overweight if born light for gestational age with 118% higher risk of SNHL. Conscripts born light for gestational age had a 41% increased risk, independent of the later growth pattern.

CONCLUSION

The thrifty phenotype hypothesis also seems to be valid for SNHL, meaning that SNHL in adulthood may originate from events during fetal life. SNHL might be a new clinical feature of the metabolic syndrome.

Growth retardation in Down syndrome in relation to insulin-like growth factors and growth hormone

Growth retardation is a cardinal characteristic of Down syndrome (DS). It is most pronounced from the age of 6 months, when growth starts to become growth hormone (GH) regulated. DS children have normal serum levels of GH. GH regulates the production of insulin-like growth factors (IGFs), which act as growth hormones. Therefore, the serum IGF pattern and the levels of their receptors were studied in fetuses with trisomy 21 and in patients with DS throughout life. Serum levels of IGF were determined by radioimmunoassays for insulin-like growth factors 1 and 2 (RIA-IGF-1 and RIA-IGF-2) showing normal serum RIA-IGF-2 levels throughout life. However, serum RIA-IGF-1 did not rise during childhood and remained at a low level throughout life. Determination of serum IGF by a radioreceptor assay (RRA-IGF), which detects both IGF-1 and IGF-2 as well as enhanced activity in the fetal circulation, showed a deficit in serum RRA-IGF in fetuses with trisomy 21, but at birth and throughout life elevated serum RRA-IGF levels. In spite of this, no differences were observed in fetal brain or liver binding sites for IGF-1, IGF-2, or insulin. Since in the RRA-IGF method IGF-1, IGF-2, and a fetal form of IGF-1 cross-react, it is possible that there is a delayed maturation with incomplete switching from production of the fetal form of IGF to production of the GH-regulated IGF-1 in DS. The deficit in IGF-1-like peptides might account for the growth retardation in DS. In order to study the effect of human growth hormone (hGH) therapy in DS, 5 growth-retarded children with DS were treated with hGH for 6 months. During this period the growth velocity doubled and the serum IGF-1 levels were restored to normal. Thus, DS children respond to hGH treatment.

Simultaneous type 1 diabetes onset in mother and son coincident with an enteroviral infection

Enterovirus (EV) infections have been implicated in the development of type 1 diabetes. (T1D). They may cause beta-cell destruction either by cytolytic infection of the cells or indirectly by triggering the autoimmune response. Virus was isolated from a woman at diagnosis of T1D (Tuvemo 1) and in addition, virus was isolated from her son at diagnosis of T1D at the same day (Tuvemo 2). None of the isolates could initially be serotyped by conventional methods. The Tuvemo 1 virus was genotyped and after sub-cultivation it was also serotyped as Coxsackievirus B5. The mother revealed antibodies against GAD65. The boy and the father both revealed a significant increase in neutralization antibody titre against two strains of CBV-4, clearly indicating a recent or ongoing EV infection. In addition, the brother showed such a titre rise against another CBV-4 strain (E2) and against a CBV-5 strain (4429). These results show that the whole family had a proven EV infection at the time of T1D diagnosis of the mother and the 10-years-old boy, indicating that the infection might cause or accelerate the T1D.

Final height after combined growth hormone and GnRH analogue treatment in adopted girls with early puberty

BACKGROUND

Girls adopted from developing countries often have early or precocious puberty, requiring treatment with gonadotrophin-releasing hormone (GnRH) analogues. During such treatment, decreased growth velocity is frequent.

AIM

To study whether the addition of growth hormone (GH) to GnRH analogue treatment improves final height in girls with early or precocious puberty.

METHODS

Forty-six girls with early or precocious puberty (age < or =9.5 y) adopted from developing countries were randomized for treatment for 2-4 y with GnRH analogue, or with a combination of GH and GnRH analogue.

RESULTS

During treatment, the mean growth velocity in the GH/GnRH analogue group was significantly higher compared to the control group. Combined GH/GnRH analogue treatment resulted in a higher final height: 158.9 cm compared to 155.8 cm in the GnRH analogue-treated group. Three out of 24 girls (13%) in the combined group and nine of the 22 girls (41%) treated with GnRH analogue alone attained a final height below -2 standard deviation scores (SDS).

CONCLUSION

The difference between the two groups is statistically significant, and possibly of clinical importance. A future challenge is to identify a subgroup with clinically significant advantage of GH addition to GnRH analogue treatment. Being very short on arrival in Sweden and being short and young at start of treatment are possible indicators.

Enterovirus infections with beta-cell tropic strains are frequent in siblings of children diagnosed with type 1 diabetes children and in association with elevated levels of GAD65 antibodies

Enterovirus infections have been associated with type 1 diabetes in a number of reports. Recent prospective studies have suggested that enterovirus infections initiate the autoimmune process. Variation in virulence and replication pattern between strains of a serotype has also been shown. The aim was to study if there were specific Coxsackievirus strains that were associated more often with the type 1 diabetes children than with controls and/or siblings and to analyse if there was any time-relationship between such infections and the appearance of antibodies against glutamic acid decarboxylase 65 (GAD65). In the present study, serum was tested from newly diagnosed type 1 diabetes children, their siblings and matched controls for neutralising antibodies against different strains of Coxsackievirus B (CBV). Tests for the presence of antibodies against GAD65 in the same groups were also carried out. Newly diagnosed type 1 diabetes children revealed higher titres of neutralising antibodies against a strain of Coxsackievirus B4 (CBV-4, VD2921) that has been shown to cause persistent infection in human pancreatic islet cells. The type 1 diabetes child and its sibling often encountered the same infection. Among the former, 16 of 27 (59%) had a significant rise in neutralising antibodies. Eight of the type 1 diabetes children had such a rise against a recombinant strain, V89 4557. Among the siblings 10 of 13 (77%) had significant titre increases. Among the type 1 diabetes children, increasing neutralising titres was associated positively with increasing antibody levels against GAD65. All siblings with antibodies against GAD 65 had significant titre increase against any of the CBV strains.

Cognitive and neuropsychological functioning in transnationally adopted juvenile delinquents

AIM

To evaluate cognitive and neuropsychological abilities of adopted delinquent adolescents in institutional care.

METHODS

Transnationally adopted adolescents admitted to institutional care (n = 20) and non-delinquent controls who were also transnationally adopted (n = 21) were compared concerning the Wechsler Intelligence Scale for Children and Adults (WISC and WAIS), the Wisconsin Card Sorting Test (WCST) and the Tower of London test (TOL). The adoptive parents answered questions about the adoption, early childhood and family circumstances by a questionnaire sent by mail.

RESULTS

The adopted delinquents had a significantly lower IQ and significantly lower results on several other measurements in the WISC/WAIS compared to the controls even after adjustment for age of arrival in the adoptive home. Both groups of adoptees scored low in the WISC/WAIS subscale of arithmetics when compared to the population mean. The TOL test showed that the delinquents were slower and made more errors than the controls.

CONCLUSION

The delinquent adoptees scored significantly lower on many variables in the WISC/WAIS. Both delinquent and non-delinquent adoptees had some difficulties with arithmetic. The weak performances in arithmetics might point to some weaknesses in the neuropsychological domain. These results probably have complex explanatory causes and need to be further evaluated.