The effects of birth weight and postnatal linear growth retardation on blood pressure at age 11-12 years

STUDY OBJECTIVE: To determine the effects of birth weight and linear growth retardation (stunting) in early childhood on blood pressure at age 11-12 years. DESIGN: Prospective cohort study. SETTING: Kingston, Jamaica. Participants: 112 stunted children (height for age < -2 SD of the NCHS references) and 189 non-stunted children (height for age > -1 SD), identified at age 9-24 months by a survey of poor neighbourhoods in Kingston. MAIN RESULTS: Current weight was the strongest predictor of systolic blood pressure (beta= 4.90 mm Hg/SD weight 95 percent CI 3.97, 5.83). Birth weight predicted systolic blood pressure (beta= -1.28 mm Hg/SD change in birth weight, 95 percent CI -2.17, -0.38) after adjustment for current weight. There was a significant negative interaction between stunting in early childhood and current weight indicating a larger effect of increased current weight in children who experienced linear growth retardation in early childhood. There was no interaction between birth weight and current weight. The increase in blood pressure from age 7 to age 11-12 was greater in children with higher weigth at age 11-12 and less in children with higher birth weight and weight at age 7. CONCLUSIONS: Birth weight predicted systolic blood pressure in Jamaican children aged 11-12. Postnatal growth retardation may potentiate the relation between current weight and blood pressure. Greater weight gain between ages 7 and 11 was associated with a greater increase in systolic blood pressure. The relation between growth and later blood pressure is complex and has prenatal and postnatal components. (AU)

Measurement of lung inflammation in asthmatics - reason for optimism

It is recognized that bronchial asthma is an inflammatory disease. However, aggressive anti-inflammatory therapy is not guided by the degree of lung inflammation. This is of particular concern in children in whom over-aggressive therapy with corticosteroid may lead to growth retardation. Analysis of breath exhaled nitric oxide levels may be an indirect measurement of lung inflammation. Since exhaled nitric oxide levels and inflammation decrease after steroid therapy, measurement of exhaled nitric oxide levels may provide a rationale for optimization of steroid therapy and possible reduction of side effects. Measurement of exhaled nitric oxide levels is not available for routine use but may be so in the near future. This will likely herald a new dawn in the management of asthma, a disease with increasing frequency, mortality and morbidity.(Au)

Two Afro-Trinidadian siblings with end-stage renal disease

The case histories of two Afro-Trinidadian brothers aged 8 and 11 years who developed end-stage renal disease (ESRD) are presented. Neither had had cause in the past to seek medical attention for any renal-related illness. At presentation both had anaemia, growth failure and other clinical and laboratory evidence of ESRD. Kidney histology in one child was consistent with familial juvenile nephronophthisis (NPH). This is common cause of ESRD in children in other countries but it has not been recognized previously in Trinidadian and other West Indian children, and should be considered as a possible aetiology in West Indian children presenting with renal failure.(AU)

Early childhood supplementation does not benefit the long-term growth of stunted children in Jamaica

The long-term benefits of early childhood supplementation and the extents to which catch-up growth occurs following linear growth retardation remain controversial. Stunted children (height-for-age < -2 SD of NCHS reference, n = 122) recruited from a survey of poor neighborhoods in Kingston, Jamaica, participated in a 2-yr randomized, controlled trial of supplementation beginning at ages 9-24 mo. A group of 32 non-stunted children from the same neighborhoods was also followed. Four years after the intervention ended, when children were 7 to 8 y old, there were no effects of supplementation on any anthropometric measure. From the end of the trial until follow-up, the children who had been supplemented gained 1.2 cm less (P < 0.05) than the non-supplemented children, approximately the same amount as they had gained during the trial compard with the non-supplemented children. After adjustment for regression to the mean, the height-for-age of stunted children (supplemented and non-supplemented combined) increase from enrollment to follow-up by 0.31 Z-score (95 percent CI 0.17, 0.46). The height-for-age of the non-stunted children also increase (0.96 Z-score; 95 percent CI 0.70, 1.22). Our results suggest that some catch-up growth is possible even when children remain in poor environments. Long-term benefits of supplementation to growth may not be achieved when intervention begins after age 12 mo in children who have already become undernourished.(AU)

Resting metabolic rate and body composition in stunted and non-stunted children - abstract

There is little information supporting the common assumption that stunted children have reduced energy requirements. Previously we found that stunted Jamaican children, aged 9-24 months, have higher energy intakes per kilogram body weight than non-stunted children. We hypothesized that this may be related to differences in basal metabolism and body composition, particularly in lean body mass (LBM) which is the major determinant of resting energy expenditure (RMR). We therefore compared the RMR (using indirect calorimetry) and body composition (using anthropometry amd impedance) in 34 stunted children (S) aged 7-8 years, with two groups of non-stunted controls matched for either age and sex (A), or height and sex (H). The RMR per kilogram body weight of S (58.9ñ6.9 kcal/kg) was significantly higher than A (52.5ñ6.0 kcal/kg; p <0.001), yet lower than the height controls (64.1ñ8.kcal/kg; p <0.01). However, after controlling for sex and weight or LBM in a multiple regression analysis, the RMRs of S and A were no longer significantly different, while the younger H continued to have significantly higher RMRs (p <0.001). No significant group differences were found in the proportions of body fat and LBM to total body weight. In conclusion, the LBM of stunted and non-stunted children of the same age and sex is proportionately and functionally the same, differences in their RMRs being accounted for by size. The lower RMR of stunted children compared to younger non-stunted children of the same size and body composition may be due to age-related changes in the composition of the LBM (AU)

Testosterone deficiency and extreme retardation of puberty in homozygous sickle-cell disease

Homozygous sickle-cell (SS) disease is associated with retardation of physical and sexual development but most Jamaican children commence their adolescent growth spurt before 16 years of age. Analysis of growth from children in the Jamaican Cohort Study noted extreme growth retardation , defined as an absence of the adolescent growth spurt and pre-pubertal sexual development (Tanner stage 1 or 2) at age 16 years, in 8/52 (15 percent) SS boys. These and two boys from the general sickle-cell clinic with a similar growth pattern provided a study group of 10 boys who were investigated for a possible endocrine explanation for their extreme retardation of physical maturation. A sub-optimal testosterone response (<10 nmol/l) to human chorionic gonadotrophin and an exaggerated gonadotrophin hormone releasing hormone was consistent with poor testicular function in 5 boys. Retardation of adolescent growth and development is common in boys wit SS disease but, when extreme, requires early investigation to identify potentially correctable mechanisms (AU)

Relationships between physical growth, mental development and nutritional supplementation in stunted children: the Jamaican study

The relationship between physical growth and change in mental development on the Griffiths mental development scales was investigated in 127 stunted Jamaican children over a 2-year period. The role of nutritional supplementation in this relationship was examined. There were no consistent associations between changes in weight-for-height or head circumference and developmental change. Height gain over 2 years was significantly associated with change in mental age, and locomotor and hearing and speech subscale scores. Height gain in the first year predicted change in mental age, and hearing and speech in the second year. Some of the effect of supplementation on development was shared with linear growth. Therefore, nutrition probably explains part of the relationship between growth and development. However, supplementation also had effects on development independent of growth. The benefits of supplementation on development and the extent to which they were shared with growth varied among the subscales (AU)

Growth monitoring: the role of community health volunteers

A community volunteer programme was initiated in rural Jamaica in May 1990. The main aim of the programme was to monitor the growth of children less than 36 months of age through community health volunteers (CHVs) and improve their nutritional status. At the end of the second year the programme was evaluated to determine effectiveness. The results of the evaluation indicated that almost all (95.6 percent) of the children were covered by the CHVs. In addition the participation rate was high (78.5 percent). However, only 50 percent of the children were adequately covered. Nonetheless, 81 percent of them gained adequate weight. Indeed, malnutrition levels declined by 34.5 percent. The annual cost per child per year for the total programme was fairly moderate (US$14.5) with growth monitoring accounting for nearly half (42.7). The results suggest that CHVs can play an important role in primary health care programmes in developing countries(AU)

Delayed adolescent growth in homozygous sickle cell disease

Analysis of the growth abnormalities in sickle cell disease has been limited by the lack of longitudinal observations in individuals, and by an inability to quantitate the observed patterns. To investigate the timing and pattern of the adolescent growth spurt, longitudinal observations of height from the Jamaican cohort study were fitted to a mathematical model of growth (Preece-Baines model 1). The study included 44 children with homozygous sickle cell (SS) disease, 44 age and sex matched subjects with sickle cell haemoglobin C (SC) disease, and 44 age and sex matched controls with normal (AA) haemoglobin. Compared with AA controls, the onset of the adolescent growth spurt was delayed in SS disease by 1.4 years (95 percent confidence interval 0.8 to 2.0) with no significant sex difference. The age at peak height velocity was delayed by 1.6 years (0.9 to 2.3) in SS compared with AA subjects but the adolescent growth of SS children was otherwise normal and there was no difference in the attained height by age 17.9 years. The growth spurt was not delayed in SC disease. The age at menarche in girls with SS disease (mean (SD) 15.4 (1.3) years) was significantly later than girls with SC disease (13.7 (1.7) years) and those with AA haemoglobin (13.1 (1.3) years) but these genotype differences were no longer significant after controlling for the delay in the adolescent growth spurt. The normally coordinated but slightly delayed pattern of growth and normal adult heights suggests a good prognosis for adolescent growth delay in SS disease. Most children with SS disease can therefore be reassured on the outcome of retarded adolescent growth (AU)

School performance, nutritional status and trichuriasis in Jamaican schoolchildren

Severe infections by the geohelminth Trichuris trichiura detrimentally affect young children's growth and development. There is concern that mild to moderate infections may affect older children's school performance and nutritional status. We therefore examined the relationship between varying intensities of infection and school achievement, attendance and nutritional status in 616 schoolchildren. A total of 409 children with Trichuris infection of intensities greater than 1200 eggs per gram of stool (epg) were first identified, then for every 2 infected children in a class, an uninfected child was selected. After controlling for socioeconomic status, gender, age, school and the presence of Ascaris infections, the uninfected children had higher reading and arithmetic scores than children with infections of more than 4000 epg and were taller than those with intensities greater than 2000 epg. However, there were no significant differences in spelling, school attendance and body mass index. Although a treatment trial is needed to determine causation, these results indicate that moderate levels of infection are associated with poor school achievement and growth (AU)

Treatment effects in trichuris dysentery syndrome

Heavy infection with the geohelminth Trichuris trichiura causes the Trichuris dysentery syndrome (TDS). Growth retardation and anaemia are characteristic of TDS and both are associated with poor development. We have examined the growth and developmental responses to treatment in 19 children aged 27-84 months with TDS. Development levels (DQ) were measured with the Griffiths mental development scales. Compared with a control group matched for age, gender and neighbourhood, the TDS children initially had serious deficits in DQ (24 points, p<0.001). After a year of anthelmintic treatment, the TDS children showed improvement in locomotor development (0.001) compared with the controls. The TDS children also had initial deficits in height-for-age, weight-for-height, mid upper arm circumference and haemoglobin levels. They caught up rapidly in indices of wasting (weight-for-height and mid-upper arm circumference) and showed steady improvement in height-for-age and haemoglobin levels. Catch-up in height was comparable to that of children recovering from coeliac disease. The importance of continuing prevention after initial treatment is highlighted (AU)

Effects of a hurricane on growth and morbidity in children from low-income families in Kingston, Jamaica

This is the first report of the effects of a hurricane on children's health and nutritional status in which data were available preceeding and following the event. When Hurricane Gilbert struck Jamaica in 1988, a longitudinal study was in progress in which children's weights and heights were recorded every 2 months and their morbidity histories taken every week. The investigation included 127 stunted (low height-for-age) and 32 non-stunted children aged 23-44 months, living in poor areas of Kingston. The data from the 4 months before and after the hurricane were compared. There was an increase in the occurrence of respiratory symptoms including rapid or difficult breathing (P < 0.04), coughs (P < 0.001) and nasal discharges (P < 0.001) during the first 2-month period after the hurricane. Howerver there was no significant effect on the occurrence of diarrhoea and injuries. Deficits were also found in height gain (P < 0.0001) during the same period. These adverse effects were found in spite of the large amount of food aid received and the aggressive health education programme implemented after the hurricane (AU)

Management of sickle cell disease; lessons from the Jamaican Cohort Study

Sickle cell disease is enormously variable in its expression and outcome. In addition to this intrinsic variablity are the problems of symptomatic selection biasing observations towards the sever end of a wide clinical spectrum and a truly changing natural history as a result of better management. Against this background, there was a need for a description of the disease in a truly representative sample of patients and this objective has been approached in the Jamaican Cohort Study of Sickle Cell Disease. Initiated in 1973, this study is based on all cases of sickle cell disease detected among 100,000 consecutive normal deliveries in Kingston, Jamaica. All affected children as well as age matched normal controls have been followed prospectively and are currently ages 11 to 19 years. The following review is based on lessons learnt from this cohort study. It is not intended to be a comprehensive survey of knowledge of sickle cell disease and does not address major contributions from studies elsewhere. In some ways, therefore, the review may appear unbalanced because of this specific objective. However, a great deal has been learnt about the evolution of the abnormal haematology of sickle cell disease and its relationship to clinical features. The causes of early mortality in sickle cell disease in Jamaica are described and the major complications such as acute splenic sequestration, pneumococcal septicaemia, aplastic crisis, hypersplenism, and acute chest syndrome have been addressed with varying success. Overall survival to the age of 19 years has been 75 percent and it is planned that the study should continue to define the problems of late adolescence and early adult life (AU)

Adolescent growth in homozygous sickle-cell disease is delayed but follows a normal pattern - abstract

Analysis of the growth abnormalities in homozygous sickle-cell (SS) disease has been limited by the lack of longitudinal observations in individuals, and by an inability to quantitate the observed patterns. In the Jamaican cohort study, longitudinal observations of height and other anthropometric indicies have been made since birth. These data have been fitted to a mathematical model of growth allowing investigation of the timing and pattern of the adolescent growth spurt of children with homozygous sickle-cell (SS) disease and sickle-cell-haemoglobin C (SC) disease. The study included all live, post-pubertal children with SS disease aged over 16 years at the study date. There were 44 SS subjects (21 male, 23 female) matched by age and sex with 44 patients with SC disease and 44 children with a normal haemoglobin (AA) genotype, giving a study group of 132 subjects. Compared to normal AA controls, the onset of the adolescent growth spurt was delayed in SS disease by 1.4 years (p<0.001) with no significant sex difference. The growth spurt occurred normally in SC disease. The age at peak height was normal and there was no difference in the predicted adult height. The normally co-ordinated but slightly delayed pattern of adolescent growth in SS patients argues against an endocrine abnormality. Most children with SS disease can therefore be reassured on the outcome of the retarded growth and delayed skeletal maturation (AU)

The effect of nutritional supplementation and stunting on morbidity in young children: the Jamaican study

Infection and undernutrition in young children are thought to act synergistically. However, studies of the relationship between low height-for age (stunting) and morbidity in young children have had inconsistent findings and there are few adequate data on the effects of nutritional supplimentation on morbidity. 129 stunted and 21 non-stunted children aged between 9 and 24 months, from poor Kingston neighbourhoods, identified from a house to house survey, were studied. The stunted children were randomly assigned to supplementation or no supplementation. Every week for 24 months the mothers were asked about the occurrence of any symptoms of illness. Supplementation had no consistent effect on the incidence or duration of symptoms. The stunted children had significantly more attacks of diarrhoea, fever, anorexia and apathy than the non-stunted children. The difference remained after controlling for social background and previous attacks of diarrhoea. There was also some indication of more severe illness in the stunted than the non-stunted children (AU)

Morbidity and the growth of stunted and nonstunted children, and the effect of supplementation

Children aged 9-24 months were recruited by a survey of poor areas of Kinston, Jamaica. Stunted children were randomly assigned to supplementation or not. Weekly morbidity histories were taken for 2 y. Separate multiple regressions on each symptom for weight or length gain in 2-mo intervals showed significant reductions in weight gain with coughing, apathy, anorexia, diarrhea, and fever, ranging from -2.1 to -16.8g/d ill. Apathy and diarrhea reduced gins in length (-0.26 and -0.20 mm/d ill). Significant reductions in linear growth with lower respiratory-tract infections (-0.16 mm/d ill) occurred only in nonsupplemented children. Growth over 4-mo intervals was reduced if diarrhea occurred in the first 2 mo of the interval but there were no long-term effects of apathy, fever, or anorexia. Some of the effects of morbidity on growth were therefore transient and morbidity on growth were therefore transient and morbidity is unlikely to be a major cause of growth retardation in this population.(AU)

Nutritional supplementation, psychosocial stimulation, and growth of stunted children: the Jamaican study

The benefits of nutritional supplementation, with or without psychosocial stimulation, on the growth of stunted children were evaluated. Children aged 9-24 mo with lengths < -2 SD of the National Center of Health Statistics references (n = 129) were randomly assigned to four groups: control, nutritional supplementation, stimulation, and both interventions. A fifth group with lengths > -1 SD was also enrolled. Length, weight, head and arm circumferences, and triceps and subscapular skinfold thicknesses were measured on enrollment and 6 and 12 mo later. Multiple-regression analysis was used to determine the effects of the interventions in which age, sex, initial status, initial dietary intake, and several socioeconomic variables were controlled for. Stimulation had no effect on growth and there was no interaction between the interventions. After 12 mo supplemented children had significantly increased length, weight, and head circumference (all P < 0.01). The effects of supplementation were not cumulative but occurred in the first 6 mo.(AU)