Seasonal variations in weight of children attending an under-fives clinic in Lesotho

The incidence of weight loss between successive visits, prevalence of under centile 3 weight-for-age and over centile 97, showed a marked bimodal annual variation for 1243 children attending an under-fives clinic. 9949 weighings on 661 boys and 682 girls over a five year period, contributed to the database. Season of birth also significantly influenced the centile distributions of weight-attained-for-age. Children over 1 1/2 years old showed considerably higher rates of weight loss (about 1 in 5 children attending in their fifth year of life), than children younger than the mean age of weaning. The rates of weight loss, together with seasonal variation, was considerably higher for a group of 'Regular Attenders' to the clinic, than for a group of 'Low Attenders'. Seasonal influences on growth need to be taken into accounts in evaluating the quality of care and outcome produced by under-fives clinics.     

Effect of deprivation on weight gain in infancy

Weights were retrieved from child health records for an annual cohort of 3418 children, aged 18–30 months, to explore the relationship between deprivation and weight gain. Their level of deprivation was classified, using census data for their area of residence, as affluent (11%), intermediate (69%) or deprived (20%). Children from deprived areas were smaller at all ages with a widening gap: by one year of age, they were three times as likely as affluent children to be below the third centile for weight. The thrive index, a measure of the degree of centile shift, showed a slight gain over the first year in affluent and intermediate children, while in deprived children it decreased ( p = 0.001). Deprived children were 2.2 times more likely than intermediate children to have failure to thrive, as manifest by subnormal thrive index values ( p = 0.00008). Unexpectedly, children from affluent areas also showed slightly increased rates. We suggest that this may be explained by higher rates of breast feeding in affluent areas.     

Is a specialist paediatric diabetic clinic better?

Diabetic control in 88 children attending three general paediatric clinics was compared prospectively over one year with that of 89 children attending a specialist paediatric diabetic clinic. Glycated haemoglobin (HbA1) concentration and days admitted were significantly lower in the group attending the specialist clinic. This has implications for the organisation of paediatric diabetic services.     

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.     

Improving nutritional status of children with cystic fibrosis at Red Cross War Memorial Children's Hospital

Aim: To determine the nutritional status of children attending a cystic fibrosis clinic in a tertiary hospital in South Africa and compare it to previously reported 10‐year rates. Methods: Weights and heights were measured of 69 (37 male and 32 female) children aged between 1 year and 18 years. Expected weight‐for‐age, expected height‐for‐age, expected weight‐for‐height and body mass index (BMI) were compared with international standards for underweight, stunting, wasting and BMI goal. Results: The nutritional status of the patients has improved over the last 10 years, most significantly for wasting, which decreased from 58.3% in 1996 to 15.9% in 2006 (95% confidence interval (CI), 1.315–14.09, P < 0.05). Fifty‐two percent of the children were underweight in 2006, compared with 66.7% in 1996 (95% CI, 0.044–13.96, P < 0.05). Stunting was found in 31.9% of the current sample. Females over 15 years had expected weight‐for‐age 25.9% lower than those between 10 years and 15 years, while no difference was found between the male age groups. Female height‐for‐age was 7.06 percentage points greater than males between 10 years and 15 years (95% CI, 2.16–11.96, P < 0.01). Males between 10 years and 15 years had significantly lower BMIs than the corresponding female group. Coloured patients had significantly lower BMIs than white patients in all age groups. Conclusions: These children demonstrated continuing improvement in nutritional status, although deficits remain. The normalisation of mean weight‐for‐age and weight‐for‐height with far fewer wasted patients is encouraging. Interventions are needed in some areas to ensure that all children show progress.     

Growth charts suitable for evaluation of Indian children

OBJECTIVE: To assess the suitability of recently published reference anthropometric data for evaluation of the growth of children in our region. SETTING: Referral Pediatric Endocrinology Clinic in tertiary level care hospital. SUBJECTS: 280 normal school children and 155 children referred for growth retardation to the clinic in 1993 and 1994. METHODS: Heights of school children were plotted on growth charts created from recently published reference growth data of children from high socioeconomic group families. The case records of 155 children referred for growth evaluation were retrospectively analyzed for (i) etiology of short stature, (ii) height percentile based on previously used Indian Council of Medical Research (ICMR) references, and (iii) height percentile and standard deviation scores based on the new references. RESULTS: 93% of school children fell above and 7% below the 5th centile of the new height references. Of the 129 clinic children diagnosed to have growth retardation, 128 fell below the 5th centile of the new references. However, 38 of these (29.5%) fell above the 5th centile of ICMR references. These included patients with pathological causes of short stature. Twenty four of 26 children labelled as having no growth problem fell above the 5th centile of new reference data. CONCLUSIONS: The 5th height centile of new reference data from high socioeconomic group children is an appropriate cut off below which to evaluate children for short stature in our region. It will allow earlier identification and treatment than the hitherto used ICMR percentiles, and yet is not expected to result in over investigation of normal children.     

Clinical implications of growth monitoring: experiences from Sierra Leone.

A 1-month survey of the growth records of children attending Under Fives' Clinics in urban Sierra Leone was performed. Current weight for age of all attendees (n = 877) revealed an overall 17 per cent to be less than 80 per cent reference weight for age (RWA). The 0-5-month-old groups had the lowest incidence (8 per cent) less than 80 per cent RWA and the 12-23-month-old had the highest incidence (31 per cent) less than 80 per cent RWA. Episodes of weight loss greater than 2 per cent of previous recorded weight (n = 299) were analysed retrospectively. The peak incidence (32 per cent) of an episode of weight loss was again in the 12-23-month-olds. Overall respiratory and malarial symptoms were associated with the greatest number of episodes. Dysentery was the most important symptom in the 12-23-month-old (other than multifactorial), was associated with severe degrees of weight loss and had the highest incidence of slow progress following treatment. Episodes of weight loss attributed to helminthic infection became increasingly evident with age. Following treatment, 75 per cent of children had returned to their pre-episodic centile within 6 weeks.     

Audit of diabetes care by caseload

OBJECTIVE: To investigate the relationship between clinic provision, consultant and nursing caseload, and processes and outcomes of diabetes care in children. DESIGN: Retrospective audit in the South Western region of England of 801 children and young people with diabetes; 701 were seen in a designated clinic. Seven of 21 consultants fulfilled the British Paediatric Association (BPA) criteria for a specialist in childhood diabetes. Seventeen nurses provided specialist care. MAIN OUTCOME MEASURES: Glycated haemoglobin, admissions to hospital clinic attendance rates, contacts with a dietitian, measurements of height and weight, and screening rates for hypertension, microalbuminuria, and retinopathy. RESULTS: Children under the care of 'non-specialists' had higher admission rates to hospital with all diabetes related problems and for hypoglycaemia and lower screening rates for microalbuminuria than those under 'specialists'. Children under the care of the two tertiary hospital consultants and lowest glycated haemoglobin results, spent least time in hospital at diagnosis, were most likely to have their heights and weights plotted, and to be screened for microalbuminuria and retinopathy, had higher admission rates, lower clinic attendance rates, and fewer dietitian consultations. Higher nursing caseloads were associated with longer periods of admission at diagnosis, better clinic attendance rates, reduced rates of admission after diagnosis, and less likelihood of having blood pressure measured and being screened for microalbuminuria. Children attending general paediatric clinics were less likely to be seen by a dietitian and to have their height and weight plotted. CONCLUSIONS: The results are consistent with the recommendation of a BPA working party in 1990 that children with diabetes should be cared for by specialist paediatricians with a caseload of more than 40 children, and that children should be seen in a designated diabetic clinic.     

Comparison of the use of Tanner and Whitehouse, NCHS, and Cambridge standards in infancy

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.     

Comparison of the use of Tanner and Whitehouse, NCHS, and Cambridge standards in infancy.

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.     

Recognising failure to thrive in early childhood.

The maximum weight centile achieved by a child between 4 and 8 weeks of age was found to be a better predictor of the centile at 12 months than the birth weight centile. Children whose weight deviated two or more major centiles below this maximum weight centile for a month or more showed significant anthropometric differences during the second year of life from those who showed no such deviation. It is suggested that this leads to a logical and practical definition of failure to thrive.     

The developmental sequelae of nonorganic failure to thrive

The developmental sequelae of infant failure to thrive (FTT) were examined in an unreferred group of 6-year-olds with a history of severe nonorganic growth retardation, sampled from a 1-year birth cohort in an inner-city area of South London. Children who failed to thrive in infancy (weight below the third centile for at least 3 months) and their pairwise matched comparisons were originally studied at 15 months, and 42 cases and 42 controls (89.5% of the sample) were followed up. At 6 years, previously growth-retarded children were considerably smaller than matched comparisons, in terms of body mass index (BMI), and height and weight for age Z scores. History of FTT explained substantial variance in weight and BMI at 6 years, with maternal height also contributing to variation in height for age. Child cognitive functioning at 6 years was examined using the McCarthy Scales: cases had more limited quantitative and memory skills than comparisons, but there was no intergroup variation in general cognitive performance. In contrast to analyses of physical development, failure to thrive did not account for cognitive functioning; maternal IQ was the sole significant predictor of performance on all indices of child cognitive abilities. At 15 months, earlier growth faltering was linked to limitations in mental development, but these findings were not confirmed by the follow-up data: the timing of FTT was not related to cognitive abilities at 6 years. Results correspond to past research indicating that nonorganic failure to thrive is associated with persistent limitations in physical stature. There was little evidence of cognitive disadvantage for case group children at school age, suggesting that the adverse effects of early malnutrition on cognitive functioning appear to diminish over time.     

INCIDENCE, AGE AT ONSET AND SEASONAL VARIATION OF DIABETES MELLITUS IN NORWEGIAN CHILDREN, 1973–1977

ABSTRACT. Joner, G. and Søvik, O. (Department of Paediatrics, University of Bergen, Norway). Incidence, age at onset and seasonal variation of diabetes mellitus in Norwegian children, 1973–1977. Acta Paediatr Scand, 70:329, 1980.–A retrospective study was undertaken to estimate the incidence of diabetes mellitus in Norwegian children. Data were collected from all hospitals in the country and from a central insurance register. Eight hundred and forty-five new cases in the age group 0–14 years and with onset in the five-year study period 1973–1977 were detected. The calculated mean annual incidence was 17.6 per 100000 children, with a year-to-year variation of IS.4–19.3 per 100 000. The geographic variation in incidence was considerable with the lowest rate in the North (6.8/100 000/year) and the highest rates in the South-Eastern part of the country (approx. 20/100000/year). There was a significantly higher incidence for boys (18.8/100 000/year) than for girls (16.4/100 000/year). The age variation in the incidence rates showed rising values towards a peak at 12 years for girls and a plateau at 12–14 years for boys, with an abrupt decline after 12 and 14 years, respectively. There were more cases with onset in the winter and autumn, with significant peaks in February and October. From these data the prevalence of diabetes mellitus in the age group 0–14 years can be calculated to 1.2 per 1 000 children. In the whole of Norway, about 170 new cases of diabetes mellitus below the age of 15 years can be expected every year. Compared with previous studies, the present data suggest an increasing incidence of childhood diabetes in Norway.     

Clinical measures of adiposity and percentage fat loss: which measure most accurately reflects fat loss and what should we aim for?

OBJECTIVE: To determine which clinical measure of childhood obesity should be monitored to best reflect change in adiposity in a weight management programme and estimate the degree of change needed to be relatively certain of fat reduction. SUBJECTS: 92 obese children with a mean (range) age of 12.8 (6.9-18.9) years and a mean body mass index standard deviation score (BMI SDS) of +3.38 (+2.27 to +4.47) attending a hospital-based clinic on a regular, 3 monthly basis. Measurements: Pairs of weight and height measured up to 2.41 years apart used to derive BMI as kg/m2, and adjusted for age and gender to give weight and BMI SDS (BMI-z score) using British 1990 Growth Reference Data. Contemporaneous adiposity estimated by fatness measured by a bioimpedance segmental body composition analyser. RESULTS: Changes in BMI-z scores, compared to BMI, weight and weight SDS, most accurately reflected loss of fat. Reductions of 0.25, 0.5, 0.75, and 1 BMI SDS equate to expected mean falls in total body fat percentage of 2.9%, 5.8%, 8.7% and 11.6%. Approximate 95% prediction intervals indicated that a fall in BMI SDS of at least 0.6 over 6-12 months (or 0.5 over 0-6 months) is consistent with actual fat loss. CONCLUSION: Change in BMI-z score best reflects percentage fat loss compared to BMI, weight and weight SDS. The wide variation in likely percentage fat loss for a given BMI SDS reduction means a loss of 0.5-0.6 is required to be relatively certain of definite percentage fat reduction.     

Insulin dependent diabetes in under 5 year olds.

Insulin dependent diabetes mellitus presenting in children under five years old exhibits several clinical and management features that differ from diabetes presenting in older children. In this review of the current population of the Oxford children''s diabetes clinic, children with diabetes diagnosed aged 0- less than 5 years are compared with those diagnosed aged 5- less than 10 years to illustrate these differences. The mean annual age specific incidence of diabetes for children aged 0- less than 5 is 9.9/100 000 compared with 13.8/100 000 for the children diagnosed aged 5- less than 10. Although children with diabetes currently aged less than 5 comprise only 8% of the clinic population, such children ultimately make up 41% of the total number of children with diabetes aged under 15 attending the clinic. Diabetes diagnosed in children under the age of 5 seems to have increased in incidence over the past 10 years, exhibits a male preponderence (1.5:1), and shows an unusual seasonal variation in incidence with an autumn/early winter trough, late winter/early spring peak, and the absence of mid-summer trough seen in other age groups. First degree family history was positive in 16% of children diagnosed under the age of 5 compared with 10% of the group diagnosed aged 5- less than 10. In none of these children was the mother the affected relative.     

Combination chemotherapy in histiocytosis X.

Twenty-five children with generalized histiocytosis X were treated with a combination of cyclophosphamide, vinblastine, and prednisone: 8 patients experienced complete response, 8 partial response, 2 imporvement, and 7 no response. Response rates for children over 1 year of age were higher than those reported for single agents. Twelve children are now off therapy with no evidence of disease for 10--50 months. Very poor response rates and high toxicity were seen in children less than 1 year of age. The two infants who eventually achieved CR did so by other therapies. Further trials in combination chemotherapy must weight possible long-term effects of such therapy against the prospect of more rapid disease control.     

Normal growth in cystic fibrosis associated with a specialised centre.

OBJECTIVE: To assess the impact of lifetime continuous care within the John Hunter Hospital cystic fibrosis (CF) clinics on growth and lung function. DESIGN: A cross sectional survey of variables affecting nutritional status in CF was undertaken for 1993 and 1997. Data were retrieved from medical records and grouped into 5 year age bands. MAIN OUTCOME MEASURES: Change in height z-score, weight centile, and forced expiratory volume in one second (FEV(1)) between patient cohorts receiving specialised care for different lengths of time. RESULTS: Improved mean height z-score (-0.880 v -0.047) and weight centile (28.3% v 48.1%) for the 10-15 year age group in 1997, who had received continuous lifetime care within the clinic, compared with the same age group in 1993, for whom continuous medical care started at an older age. There was no corresponding improvement in FEV(1), as an indicator of lung function, in this group (81.6% predicted v 89.5% predicted). CONCLUSIONS: This study suggests that lifetime continuous care within a specialised CF centre is associated with improved growth but not improved lung function.     

The reliability of height and height velocity in the assessment of growth (the Wessex Growth Study)

Both biochemical and auxological measurements can be used to assess growth. Quality control in routinely reported in laboratory studies, but the reproducibility of height measurements, and the height velocity data derived from them, is seldom considered. We have previously established our error and in this report we examine its implications for the screening of short children and subsequent monitoring of their growth. The 95% confidence interval for height for a 5 year old observed to be on the 3rd centile for height, spanned the 2nd-4th centile. However, the confidence interval for a 12 month height velocity appropriate to such a child spanned the 8th-52nd centiles, the lower limit pathological and the upper more than satisfactory. A single height velocity even over 12 months therefore lacks the precision to provide a reliable index of current growth in short children. Furthermore, serial height velocity calculations on a cohort of 78 short normal children showed no significant correlation from year to year, suggesting that velocity is also unable to predict future growth. Although the proportion of this cohort of short children lying beneath the 25th centile for velocity remained constant from year to year, the identity of the individuals comprising that proportion changed, a phenomenon which could be largely accounted for by the random error associated with height velocity. Our data suggest that, by the time a trend in abnormal velocity is reliably established, a deviation from the height centiles is clearly evident. Although velocity charts are attractive in concept, they seem to be no more discriminating than height charts in practice, and may be clinically deceptive unless interpreted with great care.     

Neonatal weight loss in breast and formula fed infants

OBJECTIVE: To define the range of neonatal weight loss in a population relative to feeding method. DESIGN: Prospective observational cohort study. SETTING: Maternity service providing geographically defined, community based newborn follow up. PARTICIPANTS: 971 consecutive term newborns of birth weight > or = 2500 g during the first 2-3 weeks of life; 34 excluded (inadequate data). 937 included: 45% breast fed, 42% formula fed, 13% breast and formula fed. OUTCOME MEASURES: Maximum weight loss and timing, age on regaining birth weight. RESULTS: Median weight loss: formula fed 3.5%, breast fed 6.6%. Upper centiles for maximum weight loss differ considerably (95th centiles: breast fed = 11.8%, formula fed = 8.4%; 97.5th centiles: breast fed = 12.8%, formula fed = 9.5%). Median time of maximum weight loss: 2.7 days for breast fed and formula fed. Recovery of birth weight: breast fed median 8.3 days, 95th centile 18.7 days, 97.5th centile 21.0 days; formula fed median 6.5 days, 95th centile 14.5 days, 97.5th centile 16.7 days. The time taken to regain birth weight correlates with both the degree and timing of initial weight loss for all groups. CONCLUSIONS: Early neonatal weight loss is defined allowing identification of infants who merit closer assessment and support.     

A clinical study of Noonan syndrome.

Clinical details are presented on 151 individuals with Noonan syndrome (83 males and 68 females, mean age 12.6 years). Polyhydramnios complicated 33% of affected pregnancies. The commonest cardiac lesions were pulmonary stenosis (62%), and hypertrophic cardiomyopathy (20%), with a normal echocardiogram present in only 12.5% of all cases. Significant feeding difficulties during infancy were present in 76% of the group. Although the children were short (50% with a height less than 3rd centile), and underweight (43% with a weight less than 3rd centile), the mean head circumference of the group was on the 50th centile. Motor milestone delay was usual, the cohort having a mean age of sitting unsupported of 10 months and walking of 21 months. Abnormal vision (94%) and hearing (40%) were frequent findings, but 89% of the group were attending normal primary or secondary schools. Other associations included undescended testicles (77%), hepatosplenomegaly (50%), and evidence of abnormal bleeding (56%). The mean age at diagnosis of Noonan syndrome in this group was 9.0 years. Earlier diagnosis of this common condition would aid both clinical management and genetic counselling.