The impact of malaria in pregnancy on changes in blood pressure in children during their first year of life.

We established a maternal birth cohort in Ibadan, Nigeria, where malaria is hyperendemic, to assess how intrauterine exposure to malaria affected infant blood pressure (BP) development. In a local maternity hospital, healthy pregnant women had regular blood films for malaria parasites from booking to delivery. Growth and BP were measured on 318 babies, all followed from birth to 3 and 12 months. Main outcomes were standardized measures of anthropometry and change in BP to 1 year. Babies exposed to maternal malaria were globally smaller at birth, and boys remained smaller at 3 months and 1 year. Change in systolic BP (SBP) during the year was greater in boys than in girls (20.9 versus 15.7 mm Hg; P=0.002) but greater in girls exposed to maternal malaria (18.7 versus 12.7 mm Hg; 95% confidence interval, 1-11 mm Hg; P=0.02). Eleven percent of boys (greater than twice than expected) had a SBP ≥95th percentile (hypertensive, US criteria), of whom 68% had maternal malaria exposure. On regression analysis (ß coefficients, mm Hg), sex (boys>girls; ß=4.4; 95% confidence interval, 1.1-7.7; P=0.01), maternal malaria exposure (3.64; 0.3-6.9; P=0.03), and weight change (2.4; 0.98-3.8/1 standard deviation score; P=0.001) all independently increased SBP change to 1 year, whereas increase in length decreased SBP (-1.98; -3.6 to -0.40). In conclusion, malaria-exposed boys had excess hypertension, whereas malaria-exposed girls a greater increase in SBP. Intrauterine exposure to malaria had sex-dependent effects on BP, independent of infant growth. Because infant-child-adult BP tracking is powerful, a malarial effect may contribute to the African burden of hypertension.

Maternal malaria status and metabolic profiles in pregnancy and in cord blood: relationships with birth size in Nigerian infants.

BACKGROUND: Malaria is more common in pregnant than in non-pregnant Nigerian women, and is associated with small birth size and the attendant short- and long-term health risks. The influence of malaria on maternal metabolic status in pregnancy and in cord blood and how this relates to birth size has not been studied. The study objective was to define relationships between maternal and cord serum metabolic markers, maternal malaria status and birth size. METHODS: During pregnancy, anthropometric measurements, blood film for malaria parasites and assays for lipids, glucose, insulin and TNF were obtained from 467 mothers and these analytes and insulin-like growth factor-I (IGF-I) were obtained from cord blood of 187 babies. RESULTS: Overall prevalence of maternal malaria was 52%, associated with younger age, anaemia and smaller infant birth size. Mothers with malaria had significantly lower cholesterol (total, HDL and LDL) and higher TNF, but no difference in triglyceride. In contrast, there was no effect of maternal malaria on cord blood lipids, but the median (range) cord IGF-I was significantly lower in babies whose mothers had malaria: 60.4 (24, 145) µg/L, versus no malaria: 76.5 (24, 150) µg/L, p = 0.03. On regression analysis, the key determinants of birth weight included maternal total cholesterol, malarial status and cord insulin and IGF-I. CONCLUSIONS: Malaria in pregnancy was common and associated with reduced birth size, lower maternal lipids and higher TNF. In the setting of endemic malaria, maternal total cholesterol during pregnancy and cord blood insulin and IGF-I levels are potential biomarkers of foetal growth and birth size.

Maternal malaria, birth size and blood pressure in Nigerian newborns: insights into the developmental origins of hypertension from the Ibadan growth cohort.

BACKGROUND: Hypertension is an increasing health issue in sub-Saharan Africa where malaria remains common in pregnancy. We established a birth cohort in Nigeria to evaluate the early impact of maternal malaria on newborn blood pressure (BP). METHODS: Anthropometric measurements, BP, blood films for malaria parasites and haematocrit were obtained in 436 mother-baby pairs. Women were grouped to distinguish between the timing of malaria parasitaemia as 'No Malaria', 'Malaria during pregnancy only' or 'Malaria at delivery', and parasite density as low (<1000 parasites/µl of blood) and high (≥ 1000/µl). RESULTS: Prevalence of maternal malaria parasitaemia was 48%, associated with younger maternal age (p<0.001), being primigravid (p = 0.022), lower haematocrit (p = 0.028). High parasite density through pregnancy had the largest effect on mean birth indices so that weight, length, head and mid-upper arm circumferences were smaller by 300 g, 1.1 cm, 0.7 cm and 0.4 cm respectively compared with 'No malaria' (all p ≤ 0.005). In babies of mothers who had 'malaria at delivery', their SBPs adjusted for other confounders were lower respectively by 4.3 and 5.7 mmHg/kg compared with 'malaria during pregnancy only' or 'none'. In contrast the mean newborn systolic (SBP) and diastolic BPs (DBP) adjusted for birth weight were higher by 1.7 and 1.4 mmHg/kg respectively in babies whose mothers had high compared with low parasitaemia. CONCLUSIONS: As expected, prenatal malarial exposure had a significant impact on fetal growth rates. Malaria at delivery was associated with the lowest newborn BPs while malaria through pregnancy, which may attenuate growth of the vascular network, generated higher newborn BPs adjusted for size. These neonatal findings have potential implications for cardiovascular health in sub-Saharan Africa.

Effects of early growth on blood pressure of infants of British European and South Asian origin at one year of age: the Manchester children's growth and vascular health study.

OBJECTIVE: The objective of this study was to investigate early influences of postnatal growth on blood pressure (BP) in healthy, British-born South Asian and European origin infants. We tested the hypotheses that South Asian infants would be smaller in all body dimensions (length and weight) with higher relative truncal skinfold thickness at birth, and that increased (central) adiposity and accelerated growth up to 1 year would be associated with higher BP in both ethnic groups. PATIENTS AND METHODS: Five hundred and sixty infants were followed prospectively from birth to 3 and/or 12 months with measures of anthropometry and resting BP, compared against a UK 1990 growth reference, and analysed using regression methods. RESULTS: Marked differences in birth size persisted, as expected, between European and South Asian babies, but with a sexual dichotomy: South Asian boys were smaller in all anthropometric parameters (P < 0.001), including skinfolds (P < 0.05), than European boys, but South Asian girls, although smaller in length and weight, had similar skinfolds to European girls and thus a slightly larger subscapular skinfold thickness relative to birth weight [1.3 versus 1.2, mean difference 0.07, 95% confidence interval (CI) 0.0009-0.14, P = 0.047]. The dichotomy persisted postnatally; South Asian boys showed a striking early increase in weight and length compared with European boys, associated with significant accrual of subscapular fat (6.1 versus 5.3 mm, mean difference 0.8, 95% CI 0.3-1.3, P = 0.003). In gender and ethnicity adjusted regression models, infants with the largest weight standard deviation score (SDS) increases in the first 3 months had the highest 12-month systolic BP (beta = 2.4, 95% CI 0.5-4.2, P = 0.01), while those with the greatest birth length (beta = 0.7, 95% CI 0.05-1.4, P = 0.04) but the smallest changes in length over 3-12 months (beta = -0.57, 95% CI -0.95 to -0.19, P = 0.004) had the highest diastolic BP. CONCLUSIONS: Ethnic and gender differences in growth and adiposity present in early infancy include truncal fat preservation in South Asian girls from birth, which in boys is related to rapid early weight gain. Weight gain during the first 3 months appears to drive the rise in systolic BP to 1 year, itself a likely driver of later BP.

Concurrent bacteraemia and malaria in febrile Nigerian infants.

In the tropics, febrile illnesses are often presumed to be due to malaria, because of its endemicity, and treatment can lead to delay in diagnosis or failure to detect severe infections such as bacteraemia. This study sought to determine the prevalence of bacteraemia and malaria parasitaemia in febrile post-neonatal infants (age 1-12 months) at the University College Hospital, Ibadan, Nigeria, and the bacterial aetiological agents of bacteraemia in the infants. Therefore, 102 infants aged 1-12 months who presented with fever with a negative history of antimicrobial use in the week prior to presentation were evaluated and had blood cultures done for the detection of aerobic organisms by standard methods and blood films for malaria parasites. Bacteraemia was found in 38.2% of the infants, malaria parasitaemia was found in 46.1%. The most common organisms isolated were Escherichia coli (35.9%), Staphylococcus aureus (33.3%) and Klebsiella spp. (10.3%). Febrile children should be investigated for the presence of bacterial infection even if the blood film for malaria parasites is positive. Where laboratory facilities are not available, consideration should be given to the use of both anti-malarial therapy and empiric antibiotic therapy in the management of febrile infants, depending on the clinician's judgement.

Predictors of bacteraemia among febrile infants in Ibadan, Nigeria.

Fever is a common complaint in infancy, and bacteraemia is one of the more serious causes of such fever. However, there exists scanty data on risk of bacteraemia among febrile infants of developing countries and what clinical predictors, if any, could identify those febrile infants with bacteraemia. To address this issue, 102 infants aged 1-12 month(s) attending the Children's Emergency Ward of University College Hospital, Ibadan, Nigeria, with rectal temperatures of > or = 38 degrees C and with a negative history of antimicrobial use for at least one week prior to presentation, were studied to identify clinical predictors of bacteraemia. Infants, meeting the eligibility criteria of the study, underwent a full clinical evaluation and had blood cultures done for aerobic organisms by standard methods. Over 38% of the infants had bacteraemia. Escherichia coli (35.9%), Staphylococcus aureus (33.3%), and Klebsiella spp. (10.3%) of positive cultures were commonly isolated. Three variables, age of < or = 6 months, restlessness, and a white cell count of >15,000/mm3, were significant independent predictors of bacteraemia. Each of these variables was associated with a 3-6-fold increase in risk of bacteraemia (age of < or = 6 months: odds ratio 3.2, p = 0.017; restlessness: odds ratio 6.3, p = 0.019; and white cell count of >15,000/mm3: odds ratio 5.4, p = 0.024). The variables, in combination, correctly classified 70% of the infants into 'bacteraemia' or 'no bacteraemia'. It is concluded that; in the setting of the study, about 4 in 10 febrile infants would have a positive blood culture for aerobic organisms and that age of < or = 6 months, restlessness, and a white cell count of > or = 15,000/mm3 are associated with a significantly increased risk of bacteraemia. Clinicians practising in such a setting need to be aware of the increased risk of bacteraemia in infants with these clinical features.