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UNLABELLED Body mass index (BMI) has become the measure of choice for determination of nutritional status during the paediatric years, as in adults. Recently, several cross-sectional BMI childhood reference values standards have been published. In order precisely to evaluate childhood nutritional interventions, reference values allowing for the evaluation of changes in BMI values are also needed. For the first time, such reference values can be presented based on 3650 longitudinally followed healthy Swedish children born full term. The reference values for the change in BMI are given as the change in BMI standard deviation scores. The reference values are given as means of mathematical functions adjusting for gender, age of the child and the length of the interval between two measurements for interval lengths of 0.25 to 1.0 y before 2 y of age and of 1 to 5 y between birth and 18 y. The usefulness of the reference values is proved by a graph that forms a part of a clinical computer program; the -2 to +2 standard deviation range of the predicted change in BMI can be computed for an individual child and drawn in the graph as an extended support for clinical decision-making. CONCLUSION For the first time this communication gives access to BMI growth rate values that can be used both in research and in the clinic to evaluate various interventions, be they nutritional, surgical or therapeutic.

Aim: To evaluate the Apgar score predictive power for mortality during different periods in the first year of life in a population with a very low mortality rate. Methods: The records of all singleton live births without severe congenital malformations and length of gestation >25 wk (n= 976635) were collected from the Swedish Medical Birth Registry, 1990 to 1998. Receiver operating characteristic (ROC) analysis was utilized. Results: Both the 1-min and the 5-min Apgar scores were shown to be good discriminators for early mortality, with the area under the ROC curve >0.85. For babies at risk of early death, the selected cut-off values for the 1-min Apgar score was >8 for preterm (true-positive (TP) rate: 83.9%; false-positive (FP) rate: 17.7%) and term babies (TP rate: 69.4%; FP rate: 6.7%). At 5 min, the analysis revealed that newborns with an Apgar score >9 were at risk for early death (preterm babies: TP rate: 79.8%; FP rate: 13.3%; term babies: TP rate: 73.8%; FP rate: 3.4%). Conclusions: Our analysis did not support the common practice in the clinic or in research of grouping infants at risk in Apgar score groups, i.e. a score below 4 or a score below 7. However, the data presented here allow the clinicians and researchers to identify and define a suitable cutoff point in relation to the quality of neonatal care and resources available, rather than adhering to a historical cut-off value that has not been studied in depth.

UNLABELLED Birthweight is a crude indicator of size at birth. Some neonatologists and obstetricians have advocated the use of ponderal index and birthlength to characterize size at birth. This paper examines the associations between various size-at-birth indicators and neonatal and postneonatal mortality, with an emphasis on ponderal index and birthlength. Size at birth, gestational age and mortality data for about one million babies born alive in Sweden between 1987 and 1995 were collected from the Swedish Medical Birth Registry. A multinomial logit regression was used to estimate conditional odds ratios. Birthlength and ponderal index were independently associated with neonatal and postneonatal mortality. In the latter period, ponderal index was only weakly associated with mortality. The associations were not sensitive to exclusion of cases of congenital anomalies and adjustment for gestational age. CONCLUSION Birthlength is strongly associated with both neonatal and postneonatal mortality; ponderal index is strongly associated with neonatal, but weakly with postneonatal mortality. The findings are consistent with previous hypotheses about a transient effect of ponderal index and a persistent effect of birthlength.

UNLABELLED The body mass index or BMI (weight/height2) is a somewhat crude estimate of nutritional status. However, due to its simplicity and high correlation with total body fat, it has been the method of choice in both paediatric clinics and research over the years. Since BMI is not an equivalent measure of the percentage of body fat in different ethnic groups and in the two sexes, population-specific BMI reference data is needed. Several BMI reference values have been published for French, American, British and Hong Kong children in recent years. In Sweden, weight-for-age and height-for-age reference values, which were published in 1976, are still used as the current national growth reference values. Updated growth reference values are needed for assessing nutritional status due to the secular trend toward and increasing prevalence of childhood obesity. The aim of this study was to produce BMI reference values for Swedish children of paediatric age. The series came from a large Swedish population-based longitudinal growth study of 3650 full-term babies followed from birth to 18 y of age. The children in this data set were born in the early 1970s. The pattern and level of 50th centile BMI values presented here are quite similar to those of the Swedish cohort study in the 1950s. In comparison with the US BMI reference values, the Swedish values are much lower, especially for the higher centile values. CONCLUSION The new Swedish BMI chart from our study may provide a useful tool for paediatricians to assess body fat, and consequently nutritional status, in Swedish children.

This study tests the hypothesis that size at birth is associated with diarrhoeal incidence from birth to 24 mo of age and the hypothesis that diarrhoeal incidence from birth to 24 mo is associated with body size at age 24 mo. This is a longitudinal study of 1476 infants born in Lahore Pakistan in 1984-1987. Diarrhoeal incidence was enumerated monthly. A generalized estimating equations approach with Poisson regression showed that birthlength standard deviation score (SDS) and ponderal index at birth (rate ratio = 1.01 and 1.00: each p > 0.05) were not significantly associated with diarrhoeal incidence. Multiple linear regression showed that diarrhoeal incidence was significantly associated with weight SDS and body mass index at 24 mo (regression coefficient or s = 0.58 and -1.02; each p 0.05). The associations were mainly due to a transient effect of diarrhoea in the period 18-24 mo. Conclusion: Prevention of low birthweight is unlikely to have an impact on diarrhoeal incidence in infants. Control of diarrhoeal incidence may not improve the growth of infants in developing countries. (authors)

Exercise and relaxation decrease blood pressure. Qigong is a traditional Chinese exercise consisting of breathing and gentle movements. We conducted a randomised controlled trial to study the effect of Guolin qigong on blood pressure. In all, 88 patients with mild essential hypertension were recruited from the community and randomised to Goulin qigong or conventional exercise for 16 weeks. The main outcome measurements were blood pressure, health status (SF-36 scores), Beck Anxiety and Depression Inventory scores. In the qigong group, blood pressure decreased significantly from 146.3+/-7.8/93.0+/-4.1 mmHg at baseline to 135.5+/-10.0/87.1+/-7.7 mmHg at week 16. In the exercise group, blood pressure also decreased significantly from 140.9+/-10.9/93.1+/-3.5 mmHg to 129.7+/-11.1/86.0+/-7.0 mmHg. Heart rate, weight, BMI, waist circumference, total cholesterol, renin and 24 h urinary albumin excretion significantly decreased in both groups after 16 weeks. General health, bodily pain, social functioning and depression also improved in both groups. No significant differences between qigong and conventional exercise were found. In conclusion, Guolin qigong and conventional exercise have similar effects on blood pressure in patients with mild hypertension. While no additional benefits were identified, it is nevertheless an alternative to conventional exercise in the nondrug treatment of hypertension.

Aim: To assess the relation between birthweight and psychological distress as measured by the Malaise Inventory in adult twins. Methods: Data were drawn from the 1958 British birth cohort study, which included twins followed from birth to age 42 y. We examined the relation between birthweight and psychological distress at ages 23, 33 and 42 y measured by the psychological scale of the Malaise Inventory. Analyses were performed both between subjects (n= 282) and within twin pairs (n= 112). The generalized estimating equations approach was used to handle the repeated measurements. Results: Between the 282 twins, the difference in psychological distress score was -0.45 (95% confidence interval -0.74 to -0.15) per Z-score increase in birthweight-for-gestational age. Within twin pairs, the heavier co-twins tended to have a psychological distress score lower than that of their lighter co-twins, the mean difference being -0.35 (-0.78 to 0.09). Conclusion: Results from the between-subject analysis agreed with previous findings from adult singletons that psychological health is related to birthweight. The within-pair analysis suggested a similar relation but did not attain statistical significance.

To identify the risk factors of obesity in preschool children in China.A nationwide case-control study in eight cities in China.A total of 748 boys and 574 girls (age 0.1 - 6.9 y), including the obese and non-obese. One obese child was matched with one non-obese child by sex and age.Weight, height and other measurements were taken for all the subjects. The information on child activity, feeding pattern and family background was collected by our study team from the parents and the kindergarten teacher.Birth weightor =4.0 kg, high eating speed, obesity among the child's relativesor =25%, mother's body mass index (BMI)25 kg/m2 and father's BMI25 kg/m2 were identified as the major significant (P0.05) risk factors of obesity in preschool children in China.Family history of obesity, high birth weight and eating speed were identified as the risk factors of obesity in preschool children in China. Our results show the need for family therapy as part of an intervention program for childhood obesity, which includes behavior modification.

UNLABELLED It is well known that some adult diseases, such as cardiovascular diseases, may be programmed during foetal life. It is not clear, however, whether final height may be predicted from foetal growth. A longitudinal cohort of full-term healthy Swedish babies (n = 3,650) was followed up from birth to maturity in a population-based growth study. Length or height and its changes were analysed from birth to 18 y of age; 2,807 children, with data available on birth length, final height and parental height, were included in this analysis. The result clearly shows that length at birth relates to final height. In terms of standard deviation scores (SDS), the mean difference in length at birth from the mean was greatly decreased in final height, but retained the same order as was seen at birth. In terms of centimeter difference from the reference mean values, the difference in length at birth remained roughly stable into final height. For instance, babies 5 cm above or below the mean birth length will end up approximately 5 cm above or below the mean in final height. Parental height-a surrogate value of the genetic final height potential of an individual-is shown to influence postnatal growth in height strongly. However, the difference from the mean in length at birth remained into adulthood within the same midparental height group. CONCLUSION This study reveals that trends in foetal linear growth continue into maturity. Foetal growth is a significant predictor of postnatal growth. Final height is dependent on both the magnitude of foetal growth and the genetic potential in stature, and appears to some extent to be programmed from foetal growth.

Length/height was studied from birth to 6 years of age in 103 children with congenital hypothyroidism identified by the Norwegian or Swedish screening programs. We used the "infancy-childhood-puberty (ICP) growth model". This model describes normal linear growth during the first 3 years of life by an infancy component with the addition of a childhood component, the latter acting from the second half of the first year. In comparison with reference children, children with hypothyroidism had reduced growth from 6 to 12 months, and increased growth after 12 months of age. Mean onset of the childhood component of growth was delayed from 8.1 months (SD 1.9) to 10.4 months (SD 2.2) in girls, and from 8.9 months (SD 2.0) to 11.0 months (SD 2.1) in boys. Age at onset of the childhood component was correlated with age at start of treatment (r = 0.24), and in children with more severe hypothyroidism (pretreatment serum thyroxine < 40 nmol/l) inversely correlated with the L-thyroxine dose at start of treatment (r = -0.40). Change in height standard deviation score from 1 to 3 years of age was correlated with the serum thyroxine concentration at age 1 year (r = 0.30). The delay in the onset of the childhood component of growth and the association with age at start of treatment and initial L-thyroxine dose indicate that thyroid hormones during the first months of life are essential for normal onset of the childhood component of growth, which otherwise is assumed to be growth hormone-dependent.

To describe the early catch-up growth in length in Chinese low birthweight (2500 g) infants.The infants (n = 181) were delivered between 1988 and 1993 and followed up at Queen Mary and Tsan Yuk Hospitals, Hong Kong. One third had a birthweight below -2SDS, most of whom were term or close-to-term babies small-for-gestational-age (SGA). The remaining babies were appropriate-for-gestational-age (AGA) in birthweight, but frequently born prematurely.The SGA group did not show a catch-up growth in height comparable to that reported on other recent studies, as 33-35% of the patients were still short at 6 and 12 months (7-12% for the AGA group). When comparing the postnatal mean growth curve of the SGA group with the mean curve of the AGA group there was little sign of catch-up growth.The results showed that Hong Kong SGA infants have an incomplete catch-up growth and for successful intervention the causative mechanisms have to be identified.Small-for-gestational-age (SGA) infants have an increased risk of neonatal mortality and morbidity. That SGA infants comprise 20-25% of all short children attests to the fact that reduced fetal growth has a lifelong impact upon both development and survival. 70-90% of SGA infants, however, experience some catch-up growth during the first 6-12 months of life, but those infants who remain short by the end of the first year of life often do not experience later catch-up growth. Catch-up growth in SGA infants refers to a growth rate higher than the average rate of appropriate-for-gestational-age (AGA) infants. The authors describe the early catch-up growth in length among 181 Chinese low-birth-weight (LBW) infants delivered between 1988 and 1993, and followed up at Queen Mary and Tsan Yuk Hospitals, Hong Kong. A LBW baby weighs less than 2500 g at birth. The SGA babies in this study failed to show catch-up growth in height comparable to that reported in other recent studies; 33-35% remained short at ages 6 and 12 months. Comparing the postnatal mean growth curve of the SGA group with the mean curve of the AGA group revealed little indication of catch-up growth. Hong Kong SGA infants have an incomplete catch-up growth and for successful intervention, the causative mechanisms must be identified.

Fragestellung : Evaluation des Einflusses einer Vitalstoffkombination mit Ginseng-Extrakt G115 auf die LebensqualitAt (LQ) gesunder Probanden. Studiendesign

Measurements of final height were made on more than 4000 children in the final grade of school in Gothenburg in 1992; at the same time, mid-parental heights were recorded. These data were combined with other information (sex, length of gestation, size at birth, estimated age at peak height velocity (PHV) and height measurements made before 8 years of age) and used in a multiple regression analysis to assess the strength of the linear relationship between attained final height and these other potentially predictive measures of adult height. The R2 value increased from 0.16 at birth to 0.64 when the child was 8 years old. The inclusion of mid-parental height in the regression analysis contributed significantly to the explained variation in final height, especially at the earlier ages; the further addition of size at birth and age at PHV provides a small increase in the explained variation. The probability that the final height of a child will be below -2 or above +2 standard deviation scores (SDS) was assessed, based on previous SDS values for height when younger and on mid-parental height SDS. As a result of the large sample size included in the analyses, considerable confidence can be placed on the accurate prediction of final height values in the range -2.5 to +2.5 SDS.

Because child care practices often have an impact on child health important public health information can be gained from an understanding of the relationship between socioeconomic factors and measures of child care in developing countries. Child care practices and hygiene measures were examined in 4 socioeconomically different areas near or in Lahore Pakistan taking into account the sex of the child and the season of the year. 1476 infants born between September 1984 and March 1987 were followed from the fifth month of pregnancy to at least 2 years of age. The infants were from a periurban slum a typical rural village an urban slum and the urban upper-middle class (UMC). Questionnaires soliciting data on child health care practices were administered to the mothers of the 607 boys and 564 girls who remained in the study at 6 months of age. Statistical analysis revealed small differences between the child care measurements for the 2 sexes and the seasons of the year and significant (p < 0.01) differences between the 4 socioeconomic areas. The mothers almost always took care of their infants themselves especially when the babies were sick. 76% of the UMC mothers administered oral rehydration salts (ORS) in cases of diarrheal diseases. In the village 41% used ORS but home remedies were more often used. The UMC mothers fed their babies food which had been cooked less than an hour earlier whereas the duration was longer in the other 3 groups (over 12 hours for a third of the villagers and urban slum dwellers). In all areas doctors were the most popular health care providers but the UMC infants received immediate medical care in 89% of cases vs. 35% in the urban slum 18% in the periurban slum and 12% in the village. UMC mothers provided clean and hygienic environments for their infants whereas the other children lived in dirty surroundings with masses of flies (most mothers covered food to protect it from the flies). Using the hygiene measure of dirty medium or clean surroundings for the children of the urban slum the differences in mean body length at birth 6 12 18 and 24 months of age were analyzed with the UMC class as a reference and length was converted into standard deviation scores. A significant difference was found in the mean standard deviation scores from 6 months of age onwards. The quality of the immediate surroundings of the children was affected by maternal literacy with 78% of those living in dirty conditions being illiterate vs. 10% of those in clean conditions. Even in the presence of poor housing standards child care practices and immediate hygiene status can be improved through the proper communication of health education messages to the mothers.

It is known what the aim is in a complete long-term growth study; the final height is the outcome measure, although the annual height velocity values provide additional information. Strictly, short-term growth studies are also defined in terms of minimum length of observation, i.e. one month, as well as the type of measurement errors to be considered. The poor correlation between short- and long-term growth velocity values has led to the conclusion that the short-term study cannot be interpreted in long-term perspectives, and vice versa. There is a need to debate the way in which results of short-term studies should be interpreted. This is especially important when short-term growth is taken as the outcome measure in a controlled study. Our proposal is that such studies must include information about the growth achieved for a period after the treatment has ended in order to describe possible compensatory growth. Without weighing in some long-term consequences, we may incorrectly document short-term growth as a positive or negative effect of a certain treatment.

Morbidity patterns among 1476 infants born between September 1984 and March 1987 in 4 socioeconomically different areas of Lahore Pakistan (a village a periurban slum an urban slum and the urban upper-middle class [UMC]) were investigated through monthly follow-up from birth to 2 years of age and were described in relation to age sex season of the year and area of habitation. 10.8% of the infants died during this period and 19.5% dropped out of the study. 70% of the remaining infants were successfully examined each month and details of the childs health during the previous month were noted. The research team included trained female community health workers and a pediatrician. Illnesses detected during the home visits were treated and the infants and their families were offered the services of a daily health clinic run by a pediatrician. In 16099 of the 20911 examinations at least one disease was recorded (for a disease load of 77% with a 95% confidence interval). Diarrheal diseases were reported in 30.3% of all monthly intervals acute respiratory tract infections in 22.4% eye and skin infections in 6.7% skin rash in 6.2% anemia in 1.9% and rickets in 0.1%. Vaccine preventable infectious diseases accounted for only 0.5% of the total. Analysis of the monthly incidence rate revealed that diarrheal diseases and respiratory tract infections were the most prevalent at all ages and diarrheal illness peaked at 8-10 months of age while respiratory tract infections peaked at 10-12 months of age. Skin and eye infections peaked at 6-10 months of age. UMC babies had a higher monthly incidence of upper respiratory tract infections as compared to diarrheal episodes a significantly lower incidence of lower respiratory tract illness and significantly more frequent skin rashes than babies from the other 3 areas. Village babies had a significantly lower incidence of upper respiratory tract infection than the UMC. The village and periurban slum babies had more skin and eye infections and anemia and urban slum babies had more scabies and rickets. Diarrheal disease increased as the hot summers approached: skin and eye infections malaria and infectious diseases occurred more often in the hot season; and there was a higher incidence of respiratory tract infection in the cooler months. Disease was evenly distributed between the 2 sexes with the exception of lower respiratory tract infections and scabies which were more common in boys. Patterns of morbidity were influenced by the age of the infants as well as by the area in which they lived. The case fatality rates were 4.8/1000 for acute 14.9 for persistent and 86.6 for chronic diarrheal episodes 0 for upper and 35 for lower respiratory tract infections and 578.9 for septicemia. All of the infants with tetanus neonatorum or meningitis died. The majority of the diseases causing these fatalities could have been prevented through the proper planning and implementation of interventions.

In Pakistan there are a number of acute problems related to maternal and infant health in the perinatal period. There is also lack of reliable data needed for the formulation of action strategies. To provide a database 1490 women have been followed from the 5th month of pregnancy in four different areas at various levels of urbanization and socio-economic development. After adjusting for gestational age, the proportion of newborns with weight for length < -2SDS in relation to the Swedish National Standard was 12-31% for boys and 12-25% for girls, the figure being highest in the most deprived area. Preterm birth was infrequent compared with IUGR. The overall prevalence rate of birth defects was 21% out of which 8% were severe defects. The overall perinatal mortality rate was 56/1000 births, with rates of 60, 75, 36 and 33/1000 births for the village, periurban slum, urban slum and the upper middle class. Two thirds of the deaths were related to either a continuation of intrauterine disturbances or severe congenital defects incompatible with life. One third of the deaths were due to infection; mostly diarrhoea, clinical sepsis and ARI. Neonatal mortality was significantly related to birth length (< -2SDS, odds ratio 5.5) and length of gestation (< 37 weeks, odds ratio 5.6) and was to a lesser extent related to weight (< -2SDS, odds ratio 2.0) and weight for length (< -2SDS, odds ratio 1.3). Forty percent of the mothers had weight for height below -2SDS, 23-35% had height < -2SDS. Forty percent of mothers from a subset within the cohort had a hemoglobin < 10 gm/dl and 20% showed signs of pre-eclampsia. This presentation raises the issue of expanding the current Child Survival Programs into the perinatal period as well.

This work gives growth reference values at birth to 24 months of age for Pakistan based on upper middle class infants. Growth rate reference values are also included and they are given for various interval lengths. The growth was differently affected in infants living in three poorer areas; the stunting incidence at 24 months of age was 63% in periurban slum, 54% in the village and 26% in the urban slum. Less differences could be seen between the areas in weight for length. There was an age dependency in the incidence of reduced growth; a normal length gain was seen at birth to about six months of age, but they were highly reduced at 6 to 18 months of age. The weight gain was to some degree reduced during the first 12 months of life, followed by a catch-up growth period. The seasonal influence was also age dependent; weight was highly affected during the summer at birth to 24 months of age, but not in the winter. The seasonal effect in length was marginal at birth to 6 months, little at 6 to 12 months (although, constant below the normal) and large at 12 to 24 months of age. We did not see any seasonality of growth in the reference group. The incidence of reduced growth reflects the socio-economic differences in one restricted geographic area, i.e., in the city of Lahore, Pakistan.

A large, population-based representative study (n = 3656) has shown that the vast majority of healthy, full-term, singleton infants born small for gestational age (SGA) achieve catch-up growth during the first 2 years of life. Indeed, most of the increase in height SDS occurs by 2 months of age. Children born SGA who do not show postnatal catch-up growth and so remain short at 2 years of age, have a higher risk of short stature (< −2 SDS) in later life, with a relative risk at 18 years of age of 5.2 if born light and of 7.1 if born short. □ Small for gestational age, postnatal growth, catch-up growth, final height, population study

This short communication discusses the possible influence of final height prediction on the estimation of the growth response to therapy. These influences are illustrated in terms of height at 8 and 18 years of age for 28 prepubertally short boys. On the basis of several treatment simulations and assumptions, we conclude that the mean residual final height; that is, the mean of individual differences between final height and predicted final height, is a robust outcome measure in growth-promoting studies. However, the treatment residual final height (the difference between final height and predicted final height following growth-promoting treatment) was only partially correlated (r2 = 0.27) with the gain due to treatment, but was highly correlated (r2 = 0.75) with the residual final height; thus, growth-response estimations made on the basis of treatment residual final height may be more dependent on the predicted interval, or confidence interval, of final height than on the effect of growth-promoting treatment.

Aim: To assess the change of risk factors that are specific to sudden infant death syndrome (SIDS) after the initialization of a campaign to reduce the risk (RTR) of SIDS compared to non-SIDS postneonatal deaths. Methods: Data were extracted from the Swedish Medical Birth Registry, 1982-1991 and 1993-1998. 1105 infants died from SIDS during the postneonatal period, 2115 postneonatal deaths were from other causes and 11050 live birth controls were selected. Risk factors previously identified to be related to SIDS were defined as high parity, prematurity, young maternal age, low Apgar score, birth during the night, single motherhood, multiple births, maternal smoking, male gender, short length standard deviation score (SDS) and small weight-to-length SDS. Results: Non-SIDS deaths were more significantly related to a low 5-min Apgar score, smaller weight-to-length SDS, and/or short length SDS values; while SIDS deaths were more closely related to mothers with higher parity or multiple births, mothers who smoked during pregnancy and single-parent (mother) families. Maternal smoking was even more prominent among SIDS deaths in the post-campaign period. The adjusted odds ratios, compared with non-SIDS deaths, increased from 1.84 (95% CI: 1.48, 2.28) in the pre-campaign period to 4.11 (95% CI: 2.72, 6.21) in the post-campaign period. Conclusions: Maternal smoking during pregnancy remains the most important modifiable risk factor for SIDS in the post-campaign period in comparison with non-SIDS postneonatal deaths. Other than putting babies in a supine sleeping position, maternal smoking should be the next most important issue to be considered, if there is to be a second campaign.

The prevalence of asthma and eczema in children between 3 and 10 years of age living in Hong Kong was determined by a questionnaire survey administered to the parents of 535 children in 1989. The prevalence of asthma was 6.0% (95% confidence limit (CI) 4.0-8.0%) and the prevalence of eczema 6.8% (95% CI 4.6-9.0%). Age, sex, parental smoking and breast feeding in early life did not show significant associations with asthma. However, four different measures were associated with the prevalence of asthma: the presence of eczema, high serum IgE level, high number of upper respiratory infections and a relatively high family income, with odds ratios of 7.6, 4.9, 4.5 and 2.7, respectively.

Studies have often compared the postnatal motor development of 'small' versus 'normal' newborns. Not much is known about the associations between a broad spectrum of size at birth and motor development. The effect of early postnatal growth on motor development is little researched. Growth failure in terms of shortness and thinness should be differentiated, but not many studies have the data for this analysis.This is a longitudinal study of infants born in Lahore, Pakistan, between 1984 and 1987. Age at commencement of independent walking and age at 'building a 3-cube tower' were taken as indicators of gross and fine motor development, respectively. Size at birth was captured by length and thinness as continuous variables; postnatal growth from birth to 6 months of age was measured by changes in length and thinness. Adjustment for covariates and handling of censored cases were performed by generalized log gamma regression.Thinness at birth and postnatal stunting and wasting had a linear, inverse association with gross motor development (each P0.05). Birth length had a non-linear, inverse association with this outcome (P0.05). Birth length, thinness at birth and postnatal wasting had a linear, inverse association with fine motor development (each P0.05).Both fetal and early postnatal growth over a broad spectrum may affect infants' motor development. It is not just the babies who were very small at birth that suffered. Birth length appeared to be more influential than other anthropometric indicators.

Objective: To assess the impact of time of birth on infant mortality and early neonatal mortality in full term and preterm births. Design: Analysis of data from the Swedish birth register, 1973-95. Participants: 2 102 324 spontaneous live births of infants without congenital malformation. Outcome measurements: Absolute and relative risk of infant mortality, early neonatal mortality, and early neonatal mortality related to asphyxia. Results: Infant mortality, early neonatal mortality, and early neonatal mortality related to asphyxia were higher in infants who were born during the night (9 pm to 9 am) compared with those born during the day for 1973-9, 1980-9, and 1990-5. The difference was more dramatic for preterm infants. The largest difference was observed during 1990-5, when there was a 30% increase in early neonatal mortality (relative risk 1.31,95% confidence interval 1.10 to 1.57) and a 70% increase in early neonatal mortality related to asphyxia (1.70, 1.22 to 2.38) in preterm infants born during the night compared with rates for preterm infants born during the day. A detailed analysis over 24 hours revealed two "high risk" periods: between 5 pm and 1 am and around 9 am. Conclusions: Infants born during the night have a greater risk of infant and early neonatal mortality and early neonatal mortality related to asphyxia than those born during the day. There has been no improvement over the past two decades. The problem is more serious for preterm births and was even worse in the 1990s. Shift changes and the hours immediately after such changes are high risk periods for neonatal care., published_or_final_version

OBJECTIVES It has been known that size at birth is important for postnatal growth and final height. However, there are few data in the literature on the difference in height growth patterns from fetal size to final height between less privileged and more privileged populations. The aim of this study was to describe the important features in height growth from birth to maturity in an underprivileged Hong Kong Chinese cohort in comparison to a more privileged Swedish cohort. METHODS The longitudinal height growth data from birth to maturity in full-term healthy Hong Kong Chinese children (n=132) who were born in 1967 were analyzed, and compared with those for Swedish children who were born in 1973-75 (n=3650). RESULTS Children with longer birth length achieved taller adult stature with respect to their target height. The mean final height retained the same order as that of the mean length at birth for various birth length groups. All children in the Hong Kong Chinese series showed catch-down height growth during the first 2 years of life, in contrast to the catch-up in smaller babies and catch-down in larger babies for the Swedish series. The growth deficit for the Hong Kong Chinese was -0.9 SDS at birth, -1.8 SDS at 2.0 years of age, -2.1 SDS at 8 years of age, and -1.7 SDS at final height. CONCLUSIONS Fetal size is important for postnatal growth and attained final height with respect to a child's familial genetic potential in stature, not only for privileged populations, but also for underprivileged populations. However, children in underprivileged populations experience a persistent increasing growth deficit during infancy and childhood. Special attention should be given to monitor their growth status in early years and to institute appropriate intervention programs.

Body mass index (BMI) is one of the anthropometric measurements for assessing nutritional status, body composition and adiposity in children. Racial differences in BMI between black and white children and adolescents have been shown in several studies. The aim of this study was to determine whether an ethnic difference in BMI exists between Chinese and Caucasian children in the first two years of life. The BMI of Chinese and Caucasian infants was compared so as to assess the usefulness of the National Center for Health Statistics (NCHS) growth reference data in the assessment of nutritional status of Chinese children. Mean weight, length and BMI were compared between six cohorts of Chinese children and five cohorts of Caucasian children together with the NCHS growth reference data. The changes in the mean BMI curves during the first two years of life in the two ethnic groups were entirely different but the different cohorts in the same ethnic groups displayed a similar pattern of change with age. The difference in change in BMI in the Chinese cohorts was related to the difference in change in their mean weight as compared to the NCHS weight-for-age reference data. In contrast, the change in mean length of the well-nourished Hong Kong Chinese children in the present study followed the mean NCHS height-for-age values. The results of this study suggest that linear growth would be better for the assessment of health and nutrition in infancy and early childhood. If BMI and weight-for-height standards were to be used then an ethnic group-specific and population based reference data set should be used.

Objectives: The objectives of this study were to investigate early linear growth retardation and to identify potential risk factors for it. Methodology: A community-based prospective study was performed in Chongqing, China, with infants being examined at 12 and 15 months of age. A total of 101 infants were examined twice. Supine length, bodyweight, lower leg length, head circumference, middle upper arm circumference and biceps skinfold thickness were measured. Results: The prevalence of short stature (length-for-age standard deviation score, < – 2) was 22% and 23% at 12 and 15 months of age, respectively, while the incidence of growth stunting (low growth velocity) between 12 and 15 months of age was 24%, using the stunting screening method. A mother having a history of abortion and infants having current episodes of diarrhoea were identified as risk factors for growth stunting. Conclusions: We conclude that both short stature and growth stunting are common in the population studied. The stunting screening method used is applicable in developing communities.

Objective: To assess the prevalence and risk factors of childhood asthma and allergies in Hong Kong and compare with that in Singapore and Great Britain. Methodology: Parents of 3618 randomly selected 6- to 7-year-old children responded to a questionnaire prepared by the International Study of Asthma and Allergies in Childhood (ISAAC) together with supplementary questions on risk factors. Results: The 12-month prevalences of wheezing, rhinitis symptoms and itchy rash were 9.2%, 35.1% and 4.2%, respectively. Wheezing in the past year was significantly associated with rhinitis symptoms in the past year, itchy rash in the past year, rhinitis interfering with daily activities moderately or severely, kept awake by itchy rash in the past year, parental wheezing (one or both parents), frequent upper respiratory tract infections (URTI), born in Hong Kong and male sex. For girls, the prevalence of wheezing in the past year was lowest when they were born in July/August and highest when born in January/February. Conclusions: The prevalence of allergic disorders in Hong Kong was comparable to that in Singapore and Great Britain. Several potential risk factors such as parental wheezing, frequent URTI, born in Hong Kong, male sex and month of birth in girls were identified.

The pretreatment mixed cross-sectional and longitudinal height measurements of 203 patients with Turner's syndrome (TS) were analysed. Only one observation was included per year per child and a total of 858 observations formed the basis of the growth study. The mean and SD values were fitted separately by a second-degree polynomial function, giving smoothed growth curves. The spontaneous growth pattern of Chinese girls with TS runs parallel to published Caucasian TS growth curves. The mean final height of Chinese patients with TS was 142 cm compared to 147 cm and 139 cm observed in Northern European and Japanese patients, respectively. Patients with the 46, X, i(Xq) karyotype were found to be significantly shorter, whereas children with the 45, X/46, XY and 46, X, del(Xq) karyotypes were significantly taller among this group of patients. Patients with TS who were disomic for Xp are significantly taller than patients who were monosomic for Xp. Our results suggest that karyotype can have a significant effect on the growth of children with TS.

A large number of studies have documented a strong correlation between size at birth and subsequent height, although the reported incidence of catch-up growth and consequently the impact on final height has varied with time and between countries. These variations may be real, but could also be related to a number of methodological problems. The aim of this study was to explore two important aspects related to postnatal growth after disturbed fetal growth: first, the definition of small for gestational age (SGA), including the selection of cut-off points in defining shortness; and, secondly, the importance of the general socio-economic status of the population with regard to the incidence of growth faltering in early life. Data were analysed from two longitudinal population-based studies, one from Sweden and one from Hong Kong. Of the Swedish cohort, 3.8% had a birth length below -2 SD scores; in the Hong Kong population the corresponding value was 11.9% (Swedish reference values were used in both studies). The following conclusions were made. Size at birth is important for postnatal growth, and the difference in length at birth of 9-10 cm between the two extreme birth length subgroups remains, on average, until maturity. This seems to be true for the two study populations with different degrees of socio-economic development. However, the rate of catch-up growth is highly dependent on the definition of SGA, on the rate of catch-up growth in early life and on the incidence of growth faltering between 6 and 18 months of age.

Postnatal linear growth can be described in terms of three distinct phases: the nutrition-dependent infancy phase, the growth-hormone-dependent childhood phase and puberty, with the additional growth during adolescence which is driven by sex steroids (1). The main objective of this work was to evaluate the importance of nutrition in the linear growth seen during childhood, i.e. from 2 years of age to the onset of puberty.

The aim of this study was to determine the developmental profile of mannose-binding protein (MBP) in preterm infants. MBP was measured in 885 longitudinally collected serum samples from 168 preterm infants, and 63 were genotyped with respect to the codon 54 mutation in the MBP gene. MBP level/codon 54 genotyping were also determined on the cord blood of 146/123 term infants and 138/123 adults, respectively. The best cut-off values of MBP for dividing preterm, term infants and adults into 'low' and 'high' MBP groups were 400 ng/ml (55 low, 113 high), 700 ng/ml (35 low, 111 high) and 750 ng/ml (33 low, 105 high), respectively, by achieving the least number of misclassifications according to the codon 54 mutation. The relative risk of the 'low' groups for presence of the codon 54 mutation compared with 'high' groups were 42.4, 67.9 and 22.9 for preterm, term infants and adults, respectively (P < 0.00001). The gestational age and birth weight of the 'low' (n = 55) and 'high' (n = 113) MBP groups of the 168 preterm infants were 29.5 ± 2.8 weeks, 30.5 ± 2.8 weeks (P = 0.03) and 1230 ± 317 g, 1277 ± 289 g (P = 0.35), respectively. The mean MBP levels of these two groups of preterm infants were different (P < 0.001) at all ages measured. As a whole group, the MBP level rose from a mean of 500 ng/ml at 25 weeks gestation to 1700 ng/ml at 20 weeks post full-term. The mortality rates of 'low' and 'high' MBP groups of preterm infants were 22% and 12%, respectively (P = 0.113). This difference in mortality was due to gestational age and birth weight standard deviation score (SDS) after adjusting for length of gestation and gender (P = 0.0001) rather than to low MBP levels (P = 0.65). MBP levels were not related to birthweight SDS score (P = 0.26). The mean ± s.d. MBP levels for preterm, term infants and adults without the codon 54 mutation were 1225 ± 701 ng/ml (n = 45), 2064 ± 829 ng/ml (n = 88) and 2473 ± 1395 ng/ml (n = 95), respectively; the corresponding values for those with the codon 54 mutation were 130 ± 275 ng/ml (n = 18), 533 ± 665 ng/ml (n = 35) and 330 ± 225 ng/ ml (n = 28), respectively. Intra-uterine growth retardation in preterm infants does not influence MBP levels. For those without the codon 54 mutation, there is a significant difference in MBP level between the three age groups. For those with the codon 54 mutation, there is a significant difference between preterm and term infants, but not between term infants and adults. We conclude that there is a maturation in MBP levels for preterm infants. and that a moderately low MBP phenotype does not affect survival. We cannot exclude an effect of profoundly reduced MBP levels (characteristic of homozygous for the codon 54 mutation). Since no such preterm infant was identified in this study., published_or_final_version

This study reports the growth of 11 short non-GH deficient children before, during short-term GH therapy for 1 year and for 2 years after the cessation of treatment. The mean growth velocity increased significantly (p < 0.0001) from the pretreatment mean of 4.6 (SD = 0.95) cm/year to 8.4 (SD = 1.1) cm/year after 1 year of GH treatment without accelerated advancement of skeletal maturation. The serum IGF-1 levels also increased significantly with treatment. In nine children who remained prepubertal followed for one year after GH treatment, the mean growth velocity increased from 4.5 (SD = 0.69) cm/year before treatment to 8.7 (SD = 1.28) cm/year after 1 year of GH treatment (p < 0.0001). After stopping GH treatment, the growth velocity decreased significantly (p < 0.001) to 2.4 (SD = 0.68) cm/year during the first year of follow-up. In the six prepubertal children followed up for 2 years after treatment, the mean growth velocity was 4.1 (SD = 1.04) cm/year which was not significantly different from the pretreatment growth velocity. The significant decrease in growth velocity during the first post-treatment year could not be explained by the usual fall of growth velocity with increasing age in prepubertal children. Our results indicate that the effect of one year of GH treatment on height gain is partly transient and cast doubt on the efficacy of short-term GH therapy in short non-GH deficient patients.

This first report from a population-based postnatal growth study of 3650 healthy Swedish subjects born at full term provides new reference values for height and weight and shows that over the last 20 years there has been a small secular trend in height (0.2-0.4 SDS over the whole age range) in Sweden in both boys and girls. Within this cohort, 111 (3.1%) were of low birth weight (below -2 SDS) and 141 (3.5%) were of low birth length (below -2 SDS); 54 (1.5%) were both light and short at birth. Of the children born small for gestational age, 87% showed full catch-up growth within 2 years of life. They attained puberty at a normal or early age and reached a mean final height of -0.7 SDS. The remaining subgroup of 13% born small for gestational age remained below -2 SDS throughout childhood and reached puberty somewhat early. Their mean final height was -1.7 SDS. The current data set is too small to identify possible background factors, but it is being expanded with this objective in mind.

The feeding practices of children (n = 1476) from birth to 24 months, as determined in a longitudinal study, in Lahore, Pakistan, are presented. Four socioeconomic groups at various levels of urbanization were included; a village, periurban slum, urban slum and an upper middle class. Initiation of breastfeeding was delayed in all the neonates. Sixty-five percent of the periurban slum mothers and 45% of the village mothers had not started breastfeeding at 48 hours after the birth of the infant. Prelacteal feedings, especially of herb water and honey, were the norm. Breastfeeding was highly prevalent. Eighty-seven to 98% of the infants in all the areas were breastfed at one month of age. Exclusive breastfeeding was rare, with 9% at one month, declining rapidly with age and being highly influenced by season. Partial breastfeeding was the most common mode of feeding. Water in addition to human milk was given by 45-73% of the mothers living in the urban slum, village and periurban slum at one month of age. Fresh animal milk and/or commercial formula was already being given at 1 month by 22-64% of the mothers in all areas. Commercial formula was the preferred food in the upper middle class, while in the other three areas it was rare and fresh animal milk was mainly used. More than 50% of the mothers in the village and in the periurban slum gave diluted animal milk even beyond the age of 10-15 months. In the upper middle class 50% of the infants were fed semisolids at the age of four months, while in the village, the periurban and the urban slum at 6 months of age only 10%, 12% and 47% of the infants received semisolids. The results of this study indicate that breastfeeding was highly prevalent in the three poorest areas. However, in all the areas initiation of breastfeeding was delayed and prelacteal feeding was the norm. Exclusive breastfeeding was rare, feeding bottles were used by 82-100% of the mothers to feed supplements and human milk substitutes, in the four areas.

Mortality rates causes and age at death were examined in relation to place of residence sex and season of the year in a cohort of 1476 infants born between September 1984 and March 1987 in one of 4 areas around and in Lahore Pakistan. The infants were from a village a periurban slum an urban slum and the urban upper middle class (UMC). During the first 2 years of life 6.4% of the mothers refused to participate in the study 13.1% moved from the study area and 10.8% of the infants died. 68% of the live newborns were examined within 72 hours and 17% more were seen within the first week of life. The babies were examined monthly thereafter during home visits. Verbal autopsy and a careful recording of histories confirmed causes of death along with available hospital records. Statistical analyses used life-table and life-table survival rates with 2-tailed chi-square tests used to test the difference between proportions. The number of deaths/1000 live births from birth to 24 months was 159 in the periurban slum 133 for the village 107 in the urban slum and 17 among the urban UMC for an overall rate of 114. Weighing the mortality rates with the projected representation of the total Pakistani population resulted in an overall rate of 127/1000 and a rate of 114/1000 for those under a year old. More than half of the deaths occurred in the first 28 days of life (all 17 deaths among the UMC occurred in the first 3 days). Birth asphyxia accounted for 13% of the total deaths and was evenly divided among the 4 groups. The other causes of death were divided evenly among the 3 poorer areas and included diarrhea (35%) respiratory infections (13%) septicemia (11%) and tetanus neonatorum (9%). Birth asphyxia was associated with prematurity and congenital malformations and postdiarrheal paralytic ileus and malnutrition were commonly associated with diarrheal deaths. In 5 cases septicemia and meningitis were associated with neural tube defects. Death occurred from asphyxia and birth trauma within 72 hours tetanus within 7-28 days and septicemia between 7 and 28 days. 8 of the 21 deaths from respiratory infection occurred between 7 and 28 days. Acute diarrhea deaths started at 3 days and peaked at a month. Chronic diarrhea deaths began after a month and peaked at 1-3 months. Half of the diarrhea deaths occurred within 3 months of age and 80% by 6 months. Diarrhea was the major cause of death after 6 months. The only seasonal relationship to causes of death was an increase in respiratory deaths during the winter with a corresponding decrease in prolonged diarrheal deaths. Acute diarrheal deaths showed an opposite seasonal trend. The number of deaths among boys and girls showed no significant difference. Since this study has shown that 80% of the deaths occurred from essentially preventable diseases in infants under 6 months of age who belonged to an underprivileged segment of society maximum effort and resources should be expended on this group.

The family situation for mothers in 3 areas differing in degree of urbanization and an upper middle class control group in Lahore Pakistan was described. Area differences in socio-economic family composition and housing and sanitary conditions were investigated. Data from a longitudinal sample (n = 1476 newborns) were compared with data from a cross-sectional population survey (n = 2998 families). Risk factors for child mortality and morbidity were common in the village and periurban slum area; conditions were somewhat better in the urban slum community. The sample was concluded to be representative of the population in the 3 areas and also for Pakistan in general. Two indices for cross-study comparisons were proposed one for socio-economic background and the other for housing standard. The 2 indices were shown to be related to maternal weight-for-height at 9 months of pregnancy in the urban slum area; the socio-economic level was also functionally related to the weight-for-height measure in the village. The lower the socio-economic and housing standard level the lower was the mothers relative weight just before childbirth. The findings were discussed in terms of risk factors for infant mortality morbidity and psychological development. (authors)

The prevalence of consanguineous marriages was studied in 940 families belonging to four different socio-economic groups in and around Lahore, Pakistan. The births occurring in these families from September 1984 to March 1987 were also investigated for birth defects. The overall prevalence of consanguineous marriages was 46%. The first cousin marriages were most common (67%), followed by the marriages between second cousins, 19%. The prevalence of consanguineous marriages was clearly associated with the socio-economic status of the study groups; 50% of the marriages was related in the periurban slum, 49% in the village, 44% in the urban slum and 31% in the upper middle class. The birth defects were also more prevalent in the poorer areas, being highest in the periurban slum (17.7%) followed by the urban slum (15.6%) and then the village (14.8%) and lowest in the upper middle class (12.3%). Although, the frequency of both consanguinity and birth defects were related with the socio-economic levels of the study groups, there was no association between inbreeding and birth defects. Perhaps, deleterious recessive genes for birth defects have been "bred out", because of continuous inbreeding over generations in this population. There was a significant predilection of major birth defects in boys without clear sex linkage. The conclusion is that the rate of consanguineous marriages was high, especially in the poorer areas, but the relationship between consanguineous marriages and birth defects was little or none. However, other child health indicators may be affected by consanguineous marriages.

In Lahore Pakistan researchers from institutions in Pakistan and Sweden conducted a community-based follow up study of 1476 infants whose mothers registered pregnancies between September 1984 and March 1987 in Halloki and Sadoki villages about 40 km from Lahore; a periurban slum near the old city; an urban slum within the old walled city; and upper middle class suburbs. They wanted to identify determinants of child health in typical Pakistani communities that reflect the urbanization process. In 1984 they conducted a cross-sectional survey of all families in the 4 areas to gather socioeconomic and demographic data. They then followed 1476 infants monthly from birth to 24 months of age (20911 examinations). The study design included 2 project leaders a research team (6 physicians) a data group (3 people) a laboratory group (7 people) and a management group (1.5 persons). The researcher team headed up 4 field work teams 1 for each community type. Each field work team consisted of a physician psychologist midlevel worker laboratory technician and sometimes a vaccinator a driver and traditional birth attendants. Most group members were research students. All health team members had undergone research training in early 1984. 70% of the infants were still part of the study at the end of 24 months. 11% had died before reaching their 2nd birthday. 13% left the area. The parents of 6% had refused to participate. A higher proportion of infants from the periurban slum belonged to families with a low income per month (< Rs 1000) than the other areas (92% vs. 88% for village and 52% for urban slum). Child mortality was highest in the village and periurban slum (20% vs. 11% for urban slum). Villages and the urban slum were well organized communities while the periurban slum and the upper middle class group were not. Local health planners can learn new important and reliable information from this project. This study shows the importance of developing a practical model for research collaboration between institutions in developed and developing countries.

Psychomotor development was assessed in 1476 infants from four different levels of urbanization in and around Lahore, Pakistan. Development was assessed monthly at birth to 24 months of age by using a set of 10 milestones selected from the Denver Developmental Screening Test and the Developmental Screening Inventory. The psychomotor development of children in the upper middle (Um) class was consistent with reference population groups in Europe and North America, hence this group was used as control. There was significant delay in the psychomotor development of infants belonging to the poorer areas compared to the Um class. There was no sex difference in the development of the milestones in any study area, except for girls in the Um class who were earlier for about one month than boys in talking. Infants in the poorer areas were, on average about 3 months, delayed in their walking and fine motor activity (building a tower of 3 cubes) in comparison with the Um class. Observed disturbance in psychomotor development at an early age may affect the abilities and achievements in later life.

This study was carried out to obtain reliable prospective data on the incidence, home management and duration of infantile diarrhoeal disease in a developing and rapidly urbanizing community. Fourteen hundred and seventy six infants from 4 different communities of Lahore, representing different stages of urbanization, were followed prospectively from birth to 2 years of age. Each child had an average of 3.6 episodes of diarrhoea during one year; 4.3 episodes per child per year in the village, 4.4 in the periurban slum, 3.4 in the urban slum and 1.4 in the upper middle (Um) class control group. The maximum incidence of diarrhoeal episodes occurred in children between 9-10 months of age. No sex difference was found. The seasonal variation showed a peak incidence during April-June. Bloody diarrhoea, in 3-5% of the episodes, was predominantly seen in winter months and in older infants. The maximum use of ORS was seen in the Um class (53%). Antibiotics were used in 75% of all diarrhoeal episodes maximally in the Um class, and morphine derivatives in 1% of all cases. The overall incidence of persistent diarrhoea was 14% of all acute cases, being highest in the village (18%), followed by the periurban slum (14%), Um class (10%) and urban slum (8%) with peak incidence occurring in June and July. Our results confirm the magnitude of the problem of diarrhoea.(ABSTRACT TRUNCATED AT 250 WORDS)

Publisher Summary This chapter discusses the role of breast milk in neonatal host defense. Human milk is rich in host defense factors, although so far only SIgA antibodies have been shown to be protective per se. Defense via human milk may largely be anti-inflammatory. Thus, milk lactoferrin seems to be able to prevent IL-6 release after exposure of human macrophages and gut epithelial cells to lipopolysaccharides (LPS). The start of breast-feeding is traditionally delayed during the first days of life in some, possible many, societies in the developing world, for example, in Pakistan. Thereafter partial breast-feeding is most common with the addition of animal milk and extra water using a bottle, especially during the hot season when there is increased incidence of diarrhea. Such partial breast-feeding protects strongly against neonatal sepsis and early diarrheal diseases. Breast-feeding also protects against necrotizing enterocolitis. Mortality in lower respiratory tract infections is decreased as well by breast-feeding.

Protection against neonatal sepsis by breast feeding was investigated in a developing community. A case-control study was carried out with 42 cases from a hospital and 270 controls, matched for age and socioeconomic conditions from the community. Exclusive breast feeding was extremely rare, most babies being partially breast fed and a few being given formula feed or animal milk. A highly significant odds ratio of 18 was obtained, showing that even partial breast feeding protects against neonatal sepsis in such a population.

Recent publications have provided evidence that the short-term growth process may be regarded as pulsatile rather than constant over time. The possible influence of changes in soft tissue thickness is one reason why it is not possible to draw any final conclusion about the existence or not of such a pulsatile short-term growth pattern. An answer can probably not be reached until a method has been developed that measures longitudinal bone growth without any soft tissue involvement, especially since such a method has recently been used in the rabbit showing that the day-to-day growth rate was linear or continuous.