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Objectives: To explore how fat, lean and body mass index (BMI) track in childhood and how this relates to parental obesity., Design and Setting: Prospective population-based cohort study: Avon Longitudinal Study of Parents and Children, UK., Method: Height, weight and leg-to-leg bioelectrical impedance (BIA) were collected at ages 7 and 11 years, as well as pre-pregnancy parental heights and weights. For BMI International Obesity Task Force thresholds of obesity and overweight were used. Impedance data were expressed as separate lean and fat z scores, internally standardised for gender, height and age and a child was defined as over-fat if fat z score was >85th and very over-fat if >95th internal centile., Results: Data were available for 7723 and 7252 children at ages 7 and 11 years, respectively (6066 at both time points). Of those obese at age 7, 75% were still obese at age 11, while of those who had been overweight 16% had become obese and 20% now had normal BMI. Both fat and lean z scores showed moderate levels of tracking (correlation coefficients 0.70 and 0.73, respectively). Children with one or two obese parents had higher fat z scores at age 7 and showed greater increases in fat thereafter. They were more likely to be very over-fat at age 7 and, of these, 69% remained so at age 11 compared to only 45% with non-obese parents (p <0.001)., Conclusions: Children of obese parents already have high fat levels at age 7 and are more likely to remain very over-fat.

Aims: To identify infants with early weight faltering at the 6-8-week check and examine their family circumstances, feeding and behavioural development., Methods: Over a 2-year period, the weight gain of all infants born in an area of North East England was screened. z Scores for weights at birth and at 6-8 weeks were used to calculate a "thrive index" (z score for weight gain). In a nested case-control study within the larger cohort, infants below the fifth centile on the thrive index were identified. 74 cases and 86 controls were followed up. Their development was assessed at 4 and 9 months using the Bayley Scales and their mothers interviewed., Results: Of 1996 infants, weights at birth and at 6-8 weeks were available for 1880 (94%), and 6.1% of term-born infants were identified as weight faltering over the first 6-8 weeks. These infants had more feeding problems and showed some developmental delay as assessed using the Bayley Scales (at 4 months, mean difference and 95% CI -3.5, -0.6 to -6.4 for the Mental Developmental Index (MDI) and -3.6, -0.2 to - 6.9 for the Psychomotor Developmental Index (PDI); at 9 months -2.3, 1.3 to -5.8 for MDI and -2.2, 2.5 to -7.0 for PDI). Their families were not significantly different from those of controls on any economic or educational measure., Conclusion: Infants whose early weight gain is slow show more feeding problems than controls, and some developmental delay. They can be identified using a thrive index at the 6-8-week check.

Background: UK child health promotion guidelines expect health visitors to assess family needs before new babies are aged 4 months and offer targeted care on that basis thereafter. Data from an intensive family support programme were used to assess how accurately family needs can be predicted at this stage., Design: A population based cohort of 1202 families with new babies receiving an intensive health visiting programme. Analysis of routinely recorded data., Setting: Starting Well project, Glasgow, UK., Predictors: Health visitor rating of family needs., Main Outcome Measures: Families receiving high visiting rates or referred to social work services., Results: Of 302 families rated high need, only 143 (47%) were identified by age 4 months. Visiting rates in the first year for those initially rated high need were nearly double those for the remainder, but around two thirds of those with high contact rates/referred to social work were not initially rated high need. Six family characteristics (no income, baby born preterm, multiple pregnancy, South Asian, prior social work/criminal justice involvement, either parent in care as a child) were identified as the commonest/strongest predictors of contact rates; 1003 (83%) families had one such characteristics and/or lived in a highly deprived area, including 228 (93%) of those with high contact rates and 157 (96%) of those referred to social work., Conclusions: Most families at risk will not be identified on an individual basis in the early weeks. Most families in deprived areas need continued input if the most vulnerable families are to be reliably identified.

Background: Failure to thrive (FTT) in early childhood is associated with subsequent developmental delay and is recognised to reflect relative undernutrition. Although the concept of FTT is widely used, no consensus exists regarding a specific definition, and it is unclear to what extent different anthropometric definitions concur., Objective: To compare the prevalence and concurrence of different anthropometric criteria for FTT and test the sensitivity and positive predictive values of these in detecting children with "significant undernutrition", defined as the combination of slow conditional weight gain and low body mass index (BMI)., Methods: Seven criteria of FTT, including low weight for age, low BMI, low conditional weight gain and Waterlow's criterion for wasting, were applied to a birth cohort of 6090 Danish infants. The criteria were compared in two age groups: 2-6 and 6-11 months of life., Results: 27% of infants met one or more criteria in at least one of the two age groups. The concurrence among the criteria was generally poor, with most children identified by only one criterion. Positive predictive values of different criteria ranged from 1% to 58%. Most single criteria identified either less than half the cases of significant undernutrition (found in 3%) or included far too many, thus having a low positive predictive value. Children with low weight for height tended to be relatively tall., Conclusions: No single measurement on its own seems to be adequate for identifying nutritional growth delay. Further longitudinal population studies are needed to investigate the discriminating power of different criteria in detecting significant undernutrition and subsequent outcomes.

Aims: To study the influence of maternal socioeconomic and emotional factors on infant weight gain and weight faltering (failure to thrive) in the first year of life., Methods: The Gateshead Millennium Baby Study is a population birth cohort in northeast England studied prospectively from birth, via parental questionnaires and a health check aged 13 months. Data were collected on maternal education, deprivation, eating attitudes, and depression, using the Edinburgh Post Natal Depression Scale (EPDS) at 3 months. Weight gain was assessed using change in weight SD score, conditional on birth weight (Thrive Index); weight faltering was defined as conditional weight gain below the 5th centile., Results: Of 923 eligible infants born at term, 774 (84%) had both weight and questionnaire data. Replicating a previous finding, both the highest and the lowest levels of deprivation were associated with weight faltering; this was independent of the type of milk feeding. No relation was found with maternal educational status. Maternal eating restraint was unrelated to weight gain. Infants of mothers with high depression symptom scores (EPDS >12) had significantly slower weight gain and increased rates of weight faltering up to 4 months (relative risk 2.5), especially if they came from deprived families, but by 12 months they were no different from the remainder of the cohort., Conclusions: In this setting, social and maternal characteristics had little influence on infants' weight gain, apart from a strong, but transient effect of postnatal depression.

Background: Iron deficiency is common in early childhood and has been associated with developmental delay. It is not known how reliably markers of iron deficiency identify true iron deficiency, defined as a therapeutic response to oral iron., Methods: The subjects were members of the Millennium Baby Study cohort. At age 13 months a venous blood sample was taken for mean cell volume (MCV), haemoglobin, mean cell haemoglobin (MCH), ferritin, and zinc protoporphyrin (ZPP). Children with abnormal values were offered treatment with oral iron and dietary modification, and re-sampled after 3 months., Results: Samples were obtained for 462 children. All markers were moderately correlated with each other except ferritin. Treatment was offered to 147 (32%) children with at least one abnormal value, of whom 126 (86%) were re-sampled. Children with a haemoglobin or an MCH below the screening cut off, or with abnormal values for two or more of the remaining three measures, showed a large therapeutic response to iron, but isolated abnormalities of MCV, ZPP, or ferritin were not consistently associated with a response. Of the screened population 13% could be defined as iron deficient (abnormal haemoglobin or MCH, or abnormal levels of two or more of the remaining three markers), but this was not strongly associated with any dietary, demographic, or anthropometric characteristic., Conclusions: Low total or mean cell haemoglobin in isolation is a specific marker of iron deficiency, but other markers are only predictive when found in combination with other abnormal values.

Background: The recommended age of introduction of solids food to the diet of infants (weaning) has recently been increased in the UK to 6 months, but most babies are still weaned before the age of 4 months., Aims: To examine what predicts the age of weaning and how this relates to weight gain and morbidity using data from a population based cohort., Methods: Parents of 923 term infants born in a defined geographical area and recruited shortly after birth were studied prospectively using postal questionnaires, weaning diaries, and routinely collected weights, of whom 707 (77%) returned data on weaning., Results: The median age of first weaning solids was 3.5 months, with 21% commencing before 3 months and only 6% after 4 months of age. Infants progressed quickly to regular solids with few reported difficulties, even when weaned early. Most parents did not perceive professional advice or written materials to be a major influence. The strongest independent predictors of earlier age at weaning were rapid weight gain to age 6 weeks, lower socioeconomic status, the parents' perception that their baby was hungry, and feeding mode. Weight gain after 6 weeks was unrelated to age of weaning. Babies weaned before 3 months, compared to after 4 months, had an increased risk of diarrhoea., Conclusions: Social factors had some influence on when weaning solids were introduced, but the great majority of all infants were established on solids before the previously recommended age of 4 months, without difficulty. Earlier weaning was associated with an increased rate of minor morbidity.

Since the introduction of new growth charts in the mid 1990s, there has been confusion about which charts should be used, with many districts using more than one version. Because of this uncertainty, an expert working party, the Growth Reference Review Group, was convened by the Royal College of Paediatrics and Child Health to provide guidance on the validity and comparability of the different charts currently in use. This paper describes the technical background to the construction and evaluation of growth charts and outlines the group's findings on the validity of each growth reference in relation to contemporary British children. The group concluded that for most clinical purposes the UK90 reference is superior and for many measures is the only usable reference that can be recommended, while the original Tanner-Whitehouse and the Gairdner-Pearson charts are no longer reliable for use at any age. After the age of 2 the revised Buckler-Tanner references are still suitable for assessing height. There are presently no reliable head circumference reference charts for use beyond infancy. The group propose that apart from refinements of chart design and layout, the new UK90 reference should now be "frozen", with any future revisions only undertaken after careful planning and widespread consultation.

Background and Aims: Little is known about injuries resulting from accidents in premobile infants. We aimed to describe the pattern of minor accidents in infants and their resulting injuries., Methods: The ALSPAC study collected data in successive postal questionnaires. At 6 months of age, parents were asked to describe any accident since birth. The type of fall, distance fallen, resulting injury, and help sought were independently coded. Burns were similarly coded., Results: A total of 11 466 responses were available. In 2554 children, 3357 falls were reported; 53% fell from beds or settees and 12% fell from arms or while being carried. Only 14% reported visible injury, of which 56% were bruises; 97% of injuries specified involved the head. Only 21 falls (<1%) resulted in concussion or fracture. A burn or scald occurred in 172 cases (1.5%). The main causes of scalds were hot drinks and water, with contact burns caused by radiators, cookers, and hot food., Conclusions: Falls in young infants are common while burns are rare. Injuries from falls are infrequent, predominantly trivial, and almost entirely confined to the head. Falls from beds and settees did not result in skull fractures. Serious injury was the result of complex accidents.

Mid-parental heights are widely used to help assess an individual child's growth. However, the methods in use vary, and most make no allowance for extremes of parental height. This study aimed to examine the actual distribution of parental heights in a survey population and the relation with their children's heights. The heights of 419 representatively sampled children aged 8-9 years were compared with their reported mid-parental heights, all expressed as standard deviation scores (SDS). These confirmed previous predictions that 90% of the children's heights would fall within 1.5 SDS (approximately two centile spaces) of their mid-parental heights. However, where parents were unusually tall or short, their children were relatively less tall or short, respectively, and the mid-parental height was a poor predictor of attained height. A simple calculator for expected height centile is described that automatically adjusts for this regression to the mean. Of 13 children below the second centile for height, eight were within two centile spaces (90% range) of their mid-parental height SDS. However, when allowance was made for regression to the mean, only three of 13 were within the 90% range. Although mid-parental height provides a useful guide to expected height centile for children and parents of average stature, it can be misleading when used to assess short children.

The British (Tanner and Whitehouse) and American (National Center for Health Statistics, NCHS) growth standards are widely used internationally, although the data are now over 30 years old. Routine weight data was retrieved from the child health records of a complete annual cohort of 3418 children aged 18-30 months to test the validity of these standards for modern infants. Compared with the Tanner and Whitehouse standards, Newcastle children rose initially and then fell a mean of 0.7 SDs between 6 weeks and 18 months, resulting in a threefold difference in the proportion of children below the 3rd centile at different ages. NCHS standards showed a similar pattern. When compared with modern standards from the Cambridge growth study, there was a much closer match, although Newcastle children showed a slight gain by the age of 1 year. Existing standards for weight introduce inaccuracy into the estimation of centile position in the early months of life. As both standards show similar problems this probably represents a real secular change due to changes in infant nutrition. These findings support the need to develop new national growth reference standards.

The role of medical treatment of patients who had resting nocturnal angina as well as exertional angina was investigate. The effects of atenolol 100 mg a day, nifedipine 20 mg three times a day, and isosorbide mononitrate 40 mg twice a day were investigated in a double blind, triple dummy randomised study. Nine patients with coronary artery disease, early positive exercise tests, and transient daytime and nocturnal ambulatory ST segment changes were initially assessed off all antianginal medication. They were then treated with each drug for three five day periods. Angina diaries were reviewed and maximal treadmill exercise tests and 48 hour ambulatory ST segment monitoring were performed at the end of each treatment period. Resting and exercise heart rate and blood pressure were significantly lower on atenolol than on either isosorbide mononitrate or nifedipine. The duration of exercise to 1 mm ST segment depression was significantly greater on atenolol than on isosorbide mononitrate. Only one patient had an improvement in exercise tolerance on nifedipine that was greater than the improvement on atenolol; this patient had single vessel disease. The total number and duration of episodes of ST segment change during ambulatory monitoring were significantly lower with atenolol than on either isosorbide mononitrate or nifedipine. Nocturnal ST segment changes were abolished in six patients on atenolol, in six patients on nifedipine, and in five patients on isosorbide mononitrate. When nocturnal ST segment changes occurred, their frequency was reduced with all three drugs. Pain was abolished in four patients on atenolol and pain relief was significantly better on atenolol than on isosorbide mononitrate. There was no significant difference in pain relief between isosorbide mononitrate and nifedipine. Thus beta receptor blockade with atenolol was the most effective means of reducing myocardial ischaemia both during exercise and at rest at night without causing deterioration in any patient. Nocturnal myocardial ischaemia in patients with severe coronary artery disease can be effectively treated with beta receptor antagonists and vasodilators.

Although left ventricular outflow tract obstruction is commonly associated with congenitally corrected transposition of the great vessels, this obstruction is seldom caused by accessory mitral valve tissue. Three cases in which accessory mitral valve tissue caused left ventricular outflow tract obstruction in children are described. Two had congenitally corrected transposition and one had normally connected great vessels. The accessory leaflet tissue, which was identified by echocardiography and angiography, was attached by chordae tendineae to normally sited papillary muscles and herniated into the left ventricular outflow tract during systole. Operation was successful in these patients. The accessory valve tissue was excised via an arteriotomy in the great vessel that arose from the left ventricle. The obstructive tissue was excised close to its peripheral attachments in the outflow tract and its chordae tendineae were divided. Resection was performed without injury to the abnormally placed conduction system or to the normal valve structures.

Since therapeutic decisions in patients with angina pectoris are usually based on the reported frequency of exertional and rest pain the relations between the historical frequency of chest pain and objective evidence of myocardial ischaemia during normal daily activity were investigated in 100 patients by 48 hour ambulatory ST segment monitoring. Of these 100 consecutive patients with chest pain, 91 had typical pain and nine some atypical features. Twenty six patients had normal coronary arteries and 52 of the 74 with significant coronary disease had ambulatory ST segment changes. There was no relation between the frequency of reported exertional or rest pain and (a) the severity of coronary artery disease or (b) the frequency of daytime or nocturnal ST segment changes. Twelve patients had nocturnal ST segment changes but only four complained of nocturnal angina. Most patients had both painful and painless episodes of ST segment changes, but a substantial number had either painless or painful episodes only. These differences were not related to the severity of coronary artery disease. Chest pain after the onset of ST segment change was perceived with wide interpatient and intrapatient variability. Thus the frequency of pain is a poor indicator of the frequency of significant cardiac ischaemia. Individual differences in the perception of pain may be more important.