How useful is knemometry in measuring neonatal growth?

Background:   Knemometry has been used to accurately measure linear growth in both neonates and children over the last 20 years. It has been used principally as a research tool.
Aim:   To investigate whether serial measurement of lower leg length (LLL) by knemometry is a useful addition to other measures of growth in the neonatal unit.
Methods:   A 1-year prospective hospital-based cohort study from 2004 to 2005. Knemometry was performed every 3–4 days from the time of consent to time of discharge. Infants were grouped by gestation at birth for analysis (<28 weeks, 28–31 weeks, 32–36 weeks and >36 weeks gestation). The main outcome assessed was longitudinal growth. Subgroup analyses were performed on infants <10th percentile for weight, surgical infants and infants who had received antenatal steroids.
Results:   LLL measured by knemometry correlated well with postmenstrual age ( r  = 0.93) and weight ( r  = 0.93). The mean (SD) increase in LLL was 0.45 (0.7) mm/day.
Conclusion:   Change in LLL correlates well with change in weight and postmenstrual age in the neonatal period but adds little extra information to routine practice in the neonatal unit.     

Intermittent growth attenuation: is this a sign of craniopharyngioma?

We present two young children eventually diagnosed with large craniopharyngiomas, who had a normal growth velocity for several years following an initial short period of growth attenuation. These cases suggest the need for a low threshold to undertake hormonal evaluation of patients who present with a past history of growth attenuation.     

Luteinizing hormone (LH) and estradiol suppression and growth in girls with central precocious puberty: is more suppression better? Are pre-injection LH levels useful in monitoring treatment?

CONTEXT: Girls with central precocious puberty (CPP) are treated with gonadotropin releasing hormone (GnRH) analogues to suppress puberty. Gonadotropin levels are used to monitor treatment, since estradiol is difficult to measure at low levels. The optimal degree of hormonal suppression is still unknown. OBJECTIVE: We hypothesized that in girls treated for CPP, estradiol levels (by ultrasensitive bioassay) would correlate with the rate of skeletal maturation and linear growth velocity. We asked whether predicted height would improve with greater luteinizing hormone (LH) and estradiol suppression. We also compared pre- and post-injection LH levels for monitoring treatment. DESIGN: Thirty girls with CPP were followed for up to 2 years during treatment with leuprolide acetate depot at a dose of 0.3 mg/kg/28 days. We measured LH and estradiol levels, bone age, and growth velocity every 6 months. RESULTS: Estradiol levels were suppressed to below the detection limit in three-quarters of the girls and did not correlate with the rate of skeletal maturation or linear growth. Improvement in predicted height correlated significantly with lower pre-injection LH levels. These girls have some of the lowest estradiol and LH levels, best improvement in predicted height, and least amount of bone age advancement published to date. Pre- and post-leuprolide injection LH levels were positively correlated. CONCLUSIONS: Greater LH suppression may improve height outcome in girls treated for CPP with GnRH analogues. The degree of LH suppression achieved is individualized and not necessarily related to absolute dose. Pre-injection LH levels may be useful for monitoring treatment. Ultrasensitive estradiol levels were very low and usually unmeasurable, affirming the increased suppression at the higher doses of GnRH analogue used in these girls. Further investigation is needed, with longer treatment duration, a range of doses, and ultimately final height. Until such studies are completed, clinicians should be cautious when interpreting pubertal suppression.     

Paediatric sudden unexpected death in epilepsy (SUDEP): is it truly unexplained?

Sudden unexpected death in epilepsy (SUDEP) is an increasingly recognized cause of death in children and young people with epilepsy. Although paediatric SUDEP is thought to be a rare event, it may be more common than previously thought, with incidence estimates ranging from 0.22 to 6 per 1000 person years. Limited clinician experience and knowledge about paediatric SUDEP has impaired the ability to inform children and their families about their individual risk and means to reduce it. Although many questions remain, in the past two decades our understanding of paediatric SUDEP has greatly increased. The pathophysiology of paediatric SUDEP remains poorly characterized, with distinct respiratory, cardiac, and central mechanisms all likely to be involved. Recent cohort studies have allowed major risk factors to be identified, including frequent generalized tonic-clonic seizures, nocturnal seizures, and lack of supervision. Optimizing seizure control, alongside the early detection and supervision of seizure activity, are possible risk reduction strategies. Evidenced-based discussions about paediatric SUDEP should form part of routine care for children and young people with epilepsy.     

Is insulin-like growth factor-1 monitoring useful in assessing the response to growth hormone of growth hormone-deficient children?

OBJECTIVE: To assess the relationship between insulin-like growth factor-1 (IGF-1), the growth hormone (GH) dose utilized to treat GH-deficient children and the changes noticed in height-standard deviation score (H-SDS) and height velocity (HV). STUDY DESIGN: We studied 24 prepubertal GH-deficient patients with a mean age of 10.5 +/- 1.8 years and a mean bone age (BA) of 8.4 +/- 2.1 years. H-SDS for chronologic age (CA) and BA before therapy were -2.6 +/- 0.8 and -1.2 +/- 0.8, whereas height velocity (HV)-SDS was -1.1 +/- 1.5. Serum IGF-1 and insulin-like growth factor binding protein-3 (IGFBP-3) levels were measured before, after 6 and 12 months of GH, and correlated with the GH dose used. Based on the increment of IGF-1 used during treatment, patients were divided into 2 groups: G1 (>1 SDS) and G2 (<1 SDS). HV-SDS and interval height increases were analyzed. RESULTS: HV-SDS, as well as H-SDS for CA and BA during the first year of treatment, were significantly greater than before therapy. IGF-1 SDS increased significantly during the first 6 months of therapy (P <.0003), but increased no further at 12 months despite the use of a higher GH dose (0.1 vs 0.14 IU/kg/day), whereas IGFBP-3 SDS increased at both 6 and 12 months. There was no correlation between the GH dose used and IGF-1 and IGFBP-3 levels. When patients were divided according to their IGF-1 increment during therapy, a significant increase in H-SDS for BA and in HV-SDS was noted only in group 2. CONCLUSIONS: The increment in IGF-1 SDS during therapy did not correlate with the interval height increase. IGF-1 measurement may be helpful in monitoring compliance and safety, but seems to be less useful in adjusting the GH dose needed to treat prepubertal GH-deficient children.     

Epidermal growth factor in maternal urine--a predictor of intrauterine growth restriction?

Epidermal growth factor (EGF), an angiogenic and mitogenic peptide, is known to be essential for normal fetal development in mice. Hypothetically, low maternal urine EGF levels might be associated with intrauterine growth restriction (IUGR) or pre-eclampsia (PE). We carried out a prospective study of 1009 consecutive women whose urine was sampled in early pregnancy (at a median of 13 weeks of gestation) between January and November 1993. Thirty women gave birth to IUGR babies and 24 developed PE. The study was designed as a nested case-control study with two matched controls for each case. EGF and human chorionic gonadotrophin (HCG) levels were measured and expressed in ng EGF/mg creatinine and IU HCG/mg creatinine. Logistic regression analysis was made with EGF or HCG levels as explanatory variables. Urinary EGF levels were significantly lower in the IUGR subgroup than in their controls, but no such difference was found between the PE subgroup and their controls. In the series as a whole, smokers were found to have lower EGF and HCG levels than non-smokers. In addition, correlation was found to exist between EGF and HCG levels (Spearman's rho 0.35; P<0.001). We conclude that a relative deficiency of EGF in early pregnancy might be one of the pathophysiological mechanisms of IUGR. However, the EGF level was an insufficiently discriminative variable to be of use for screening purposes.     

Are twins growth restricted?

It is now well established that IUGR is associated with an increased risk of a range of adult onset diseases, including cardiovascular disease, obesity, and type 2 diabetes. Infants from twin pregnancies are generally born smaller than singletons; therefore, it has been suggested that twins represent a naturally occurring model of IUGR. Although twin gestations contribute significantly to the population burden of preterm birth and small size at birth, whether twins have the same long-term health consequences as IUGR singletons remains unclear. The purpose of this review is to consider what is currently known about the clinical implications of twinning, the differences that exist between the growth and developmental profiles of singleton and twin fetuses, and to use this as a basis for exploring the question of whether fetuses conceived as twins are analogous to IUGR singletons of similar birthweight and gestation. This question is increasingly important in both the clinical and research settings, because the incidence of twinning is increasing and the long-term implications of reduced size at birth are mostly investigated in species which bear multiple offspring.     

Postnatal weight loss in term infants: what is "normal" and do growth charts allow for it?

BACKGROUND: Although it is a well known phenomenon, limited normative data on neonatal weight loss and subsequent gain are available, making it hard to assess individual children with prolonged weight loss. OBJECTIVE: To establish, using data from a large prospective population based cohort study, norms and limits for postnatal weight loss and its impact on current growth reference charts. METHOD: A cohort of 961 term infants were recruited at birth and followed using parental questionnaires and community nursing returns. Routine weights were collected for half the cohort at 5 days and for all at 12 days and 6 weeks. RESULTS: Less weight loss was seen than the 3-6% suggested by previous studies, but one in five infants had not regained their birth weight by 12 days. Those lightest at birth showed least weight loss. Twenty six (3%) children had more than 10% weight loss, but none showed evidence of major organic disease. Actual weights in the first fortnight are half to one centile space lower than growth charts suggest, while birthweight centiles for children born at 37 weeks were two centile spaces lower. CONCLUSIONS: Neonatal weight loss is brief, with few children remaining more than 10% below birth weight after 5 days. Growth charts are misleading in the first 2 weeks, because they make no allowance for neonatal weight loss.     

Children conceived after intracytoplasmic sperm injection (ICSI): is there a role for the paediatrician?

AIM: The aim of the study was to evaluate current medical knowledge about children born after intracytoplasmic sperm injection (ICSI) with respect to congenital malformations, chromosome abnormalities and postnatal growth. RESULTS: The total malformation rate in children conceived after ICSI was comparable to the background population in nine of the 11 articles studied. In two of the studies, a significant increase in congenital malformations was found. More specifically, children born after ICSI appear to have a higher risk of urogenital malformations, especially hypospadias, which may be related to paternal subfertility. There is insufficient knowledge about chromosomal or genetic anomalies and auxological data in children born after ICSI. The methodological approach to follow-up the children was inconsistent, as the clinical examinations were not done with standardized ascertainment. CONCLUSION: Paediatricians and obstetricians should collaborate with fertility clinics to obtain valid longitudinal observations with respect to congenital malformations, neurological development, growth, pubertal maturation, fertility and morbidity in children conceived by ICSI.     

CSF生理特点及在细菌性脑膜炎时的改变

了解脑脊液(CSF)流体动力学非常之重要。CSF的改变可揭示中枢神经系统(CNS)的许多致病过程。要根据CSF状况做出准确判断,就需要了解CSF生理和特殊致病过程中的特征性改变。快速、及时地作出判断,并最大限度争取良好的预后。     

When does growth faltering start?

Three indicators were used to assess the onset of growth faltering: (a) average weight - and length - for - age as percentage of the NCHS references or (b) the Cambridge references based on breastfed infants and (c) incremental growth over 4 weeks in which "faltering" was defined as a weight increment less than minus 2 standard deviations, calculated by Waterlow from USA and British data or no gain in length. The population covered were singleton infants born in two villages in Madura in September 1982 through December 1984 (N = 391). Weight and length were measured at 4 week intervals. The first two indicators did not properly identify the age period at which growth became unacceptable according to weight or length increments. This was mainly due to the large variation and the skewed distribution of weight and length of Madurese infants. Arbitrarily a magnitude of 20% weight falterers was used as a cut-off point for the onset of growth faltering. Among Madurese infants it would be at or before 3-4 months. It is recommended to analyse weight increments from data, generated by growth monitoring at POSYANDUS for mapping of the age period at risk throughout Indonesia.     

Intrauterine growth correlation to postnatal growth — influence of risk factors and complications in pregnancy

In a population of 616 pregnant women with increased risk of intrauterine growth retardation, we examined the relationship of third trimester fetal growth to maternal and pregnancy risk factors, the infants condition at birth, and postnatal growth. Intrauterine growth velocity was calculated from repeated estimations of fetal weight using ultrasound. Postnatal growth up to 3 months was measured in 313 of the infants. Intrauterine growth velocity was directly correlated to birth weight deviation (R = 0.35, P < 0.0001) and inversely correlated to postnatal growth (R = 0.21, P = 0.0001). Heavy smoking throughout pregnancy was the most pronounced factor associated with loss of fetal growth percentiles (P = 0.006), and it was also associated with postnatal catchup (P = 0.01). Infants who needed neonatal care had significantly lower intrauterine growth velocities compared to the rest of the study group; no correlation was found between intrauterine growth velocity and Apgar scores or umbilical pH. It is concluded that growth retardation in the third trimester can be identified by ultrasound fetometry, and is associated with maladaptation at birth and postnatal catchup. However, the correlations were weak suggesting that deviation at birth reflects, only to a limited degree, acceleration or deceleration of growth in the third trimester.