Burden of Early Life Obesity and Its Relationship with Protein Intake in Infancy: The Middle East Expert Consensus.

Adequate nutrition in early life is proposed to shape a child's future health by launching the growth trajectory in the proper direction, which helps to avoid negative metabolic programming effects. Protein intake during infancy and early childhood is of great importance, as it plays a key role in infant metabolic programming and the future risk of obesity. Breastfeeding provides the best nutrition in early life, with many benefits tailored for the baby, including the appropriate quantity and quality of proteins. Considering the high prevalence of childhood, and subsequent adult, obesity in the region, a virtual Middle East expert consensus meeting was held to discuss an effective approach for managing childhood obesity. Leading pediatric experts from Bahrain, Egypt, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates participated in the meeting. The experts discussed, debated, and agreed on certain directions, including the importance of educating parents, endorsing breastfeeding, and ensuring optimum quantity and quality intake of proteins in early life. This expert consensus may serve as the starting point for healthcare professionals in the region who are interested in shaping a healthy future for the generations to come.

Growth and Growth hormone - Insulin Like Growth Factor -I (GH-IGF-I) Axis in Chronic Anemias.

Anaemia is a global public health problem affecting both developing and developed countries with major consequences for human health as well as social and economic development. It occurs at all stages of the life cycle, but is more prevalent in pregnant women and young children. Iron deficiency anaemia (IDA) was considered to be among the most important contributing factors to the global burden of disease. Prolonged and/or chronic anemia has a negative effect on linear growth especially during the rapid phases (infancy and puberty). Additionally infants with chronic IDA have delayed cognitive, motor, and affective development that may be long-lasting. In view of the significant impact of chronic anemias on growth, pediatricians endocrinologists and hematologists should advocate primary prevention and screening for growth disturbance in these forms of anemias. The extent of the negative effect of different forms of chronic anemias on linear growth and its possible reversibilty is addressed in this review. The possible mechanisms that may impair growth in the different forms of anemias are addressed with special attention to their effect on the growth hormone (GH) - insulin like growth factor -I (IGF-I).

A Cross-Cultural Study of the Cognitive Model of Depression: Cognitive Experiences Converge between Egypt and Canada.

INTRODUCTION: Models of depression that arise in the West need to be examined in other regions of the world. This study examined a set of foundational hypotheses generated by Beck's cognitive model of depression among depressed individuals in Egypt and Canada. METHOD: We recruited 29 depressed and 29 non-depressed Egyptians and compared their results with those of 35 depressed and 38 non-depressed Canadians. Depression status was ascertained using a structured interview, scores on the Beck Depression Inventory, and scores on the Psychiatric Diagnostic Screening Questionnaire. Participants completed questionnaires designed to measure the frequency of negative and positive automatic thoughts (ATQ-N, BHS, and ATQ-P), and dysfunctional attitudes (DAS). RESULTS: Depressed individuals in both countries had significantly more negative thoughts about self and future, greater frequency of dysfunctional attitudes, and diminished positive self-thoughts in comparison to non-depressed individuals. Egyptians generally showed significantly more dysfunctional attitudes than their Canadian counterparts. DISCUSSION: The four hypotheses that were tested were supported among the depressed Egyptian sample, which is consistent with the cognitive model. Implications for the cognitive-behavioral model and treatment for this group of sufferers are discussed.

Does priming with sex steroids improve the diagnosis of normal growth hormone secretion in short children?

INTRODUCTION: There is still controversy for priming with sex steroid before growth hormone (GH) testing. OBJECTIVE: We studied GH response to stimulation in 92 children >9 years with idiopathic short stature (height standard deviation score [HtSDS]-2). They were divided randomly into two groups. Children in Group 1 (n = 50) were primed with premarin in girls and testosterone in boys and those in Group 2 were not primed (n = 42). All children were tested using standard clonidine test and their serum insulin-like growth factor-I concentration (IGF-I). Additionally the growth and GH-IGF-I data of the two groups of children were compared with those for 32 short children (HtSDS <-2) below the age 9 years who were non-primed before GH testing (Group 3). RESULTS: Neither GH peak response to provocation nor IGF-I concentrations differed between the two groups with and without priming. DISCUSSION: Taking a cut-level of 7 ng/ml for normal GH response to clonidine, priming with sex steroids did not significantly increase the percentage of patients with normal GH response (52%) versus nonpriming (47%). IGF-I level did not show any significant difference among the two studied groups >9 years. The peak GH response to clonidine provocation test did not differ before (n = 42) versus after 9 years (n = 32) of age. CONCLUSIONS: In this randomized study priming with sex steroids before GH testing did not significantly increase the yield of diagnosing short patients with normal GH secretion. In addition, GH response to provocation did not vary significantly between young (<9 years) and old (>9 years) short children.

Acute hemorrhagic edema of infancy: a worrisome presentation, but benign course.

Acute hemorrhagic edema of infancy (AHEI) is a benign type of leukocytoclastic vasculitis. It is a benign phenomenon although it manifests with fever, large palpable purpuric skin lesions, and edema. The presentation of AHEI can often resemble that of Henoch-Schönlein purpura. Since AHEI is a self-limited disease, conservative management is the most commonly followed approach. Our patient had complete resolution of AHIE without medical treatment.

Placental weight: relation to maternal weight and growth parameters of full-term babies at birth and during childhood.

OBJECTIVE: Human growth is a continuous process. Studies defining placental effect on prenatal and postnatal human growth are few. We studied the anthropometric data of hundred mothers who gave birth at term after an uncomplicated singleton pregnancy, and their infants in relation to their placental weight using linear regression analysis. Mother weight, placental weight, and infant length (BL), weight (BW), and head circumference (HC) were obtained at birth and during childhood period (4.5 ± 2 years) of age. At birth, placental weights were correlated significantly with maternal weights (r = 0.21, P = 0.031). Placental weights were significantly correlated with growth parameters of the child at birth and during childhood. Infant BW (r = 0.71, r < 0.001), body mass index SDS (BMI SDS) (r = 0.589, P < 0.001), length SDS (LSDS) (0.567, P < 0.001) and HC (r = 0.699, P < 0.001). During childhood, placental weights were correlated with BMI SDS (r = 0.296, P = 0.002) and HtSDS = (r = 0.254, P = 0.009). LSDS at birth was correlated significantly with HtSDS during childhood (r = 0.445, P < 0.001). Placental weight represents a good marker of fetal growth (at birth) and significantly correlates with early childhood growth in full-term infants.

Age related IGF-I changes and IGF-I generation in thalassemia major.

We measured serum concentrations of insulin like growth factor-I (IGF-I) in 20 thalassemic males with short stature (height SDS <-2) and/or slow growth velocity (GV <-1 SD) throughout their childhood and adolescence, compared these data with normal reference data validated in our lab, and evaluated their growth hormone secretion in response to clonidine and glucagon stimulation. We also performed IGF-I generation test on 26 patients with beta thalassemia major (BTM) before and after blood transfusion to evaluate the effect of increased hemoglobin (Hb) on IGF-I and its response to GH. We obtained the following results. 1) No statistical difference in age, HSDS, target height SDS or bone age was observed between BTM patients with growth hormone deficiency (GHD) compared to those with normal GH secretion (GHS). 2) The age-related levels in serum total IGF-I in thalassemic males were significantly decreased from early childhood to 18 years of age compared to normal subjects. Thalassemic males with GHD did not show any significant peak of IGF-I levels until 18 years of age, whereas thalassemic males with normal GH response to provocation (GHS) achieved a significant peak level of IGF-I that was attenuated and late compared to normal males. The basal serum IGF-I concentrations at different ages did not differ between the GHD and GHS groups until the age of 12 years. After 12 years of age, IGF-I levels were significantly higher in thalassemic children with GHS. A significant increase in the circulating basal IGF-I concentrations from 53 +/-35 ug/l to 82.6 +/- 39 ug/L was achieved with increasing Hb concentration after blood transfusion. The serum total IGF-I levels increased significantly with the administration of human growth hormone (hGH) for 4 days, both before and after blood transfusion. The peak IGF-I response to GH injections did not differ before compared to after blood transfusion. The percent increment of IGF-I levels generated after GH injections was higher in thalassemic children with GHD as compared to those with GHS both before and after blood transfusion. In conclusion, our results showed that agerelated serum IGF-I concentrations were significantly lower in short thalassemic patients, with and without GHD, during childhood and adolescence, compared to normal standards. Correction of anemia significantly increased serum concentration of IGF-I but does not affect the increase of IGF-I in response to GH stimulation.

Manifestations of severe vitamin D deficiency in adolescents: effects of intramuscular injection of a megadose of cholecalciferol.

We recorded the manifestations of severe vitamin D deficiency (VDD) in 40 adolescents before and 3 and 6 months after treatment with a mega dose of cholecalciferol (10 000 IU kg(-1), max 600 000 IU). Significant improvement of symptoms related to VDD was reported in 34/40. Three months after the injection, serus calcium, phosphate, alkaline phosphatase and parathormone were normal in all adolescents with VDD with 25-hydroxyvitamin D (25OHD) level = or >20 ng ml(-1). After 6 months, the majority had 25OHD level <20 ng ml(-1). Two patterns of radiological changes have been recorded with complete healing achieved in all patients after a year of therapy. A mega dose of cholecalciferol is an effective therapy for treatment of VDD in adolescents for 3 months but not for 6 months. Radiographs of the ends of long bones are still valuable tool for diagnosis and follow-up of these patients.

Clinical responses to a mega-dose of vitamin D3 in infants and toddlers with vitamin D deficiency rickets.

OBJECTIVES: Was to investigate the effect of treatment with an IM injection, a mega dose of vitamin D3 (10,000 IU/kg) on the clinical, biochemical and radiological parameters of 40 rachitic children with vitamin D deficiency (VDD) over a period of 3 months. DESIGN: In this prospective study we evaluated the clinical, biochemical and radiological responses of an IM injection of cholecalciferol (10,000 IU/kg) for 3 months. RESULTS: At presentation, the most frequent manifestations were enlarged wrist joints, hypotonia, irritability, cranial bossing, wide anterior fontanel, bow legs, delayed teething and walking and Harrison's sulcus with chest rosaries. Short stature (length SDS < -2) was recorded in 30% of patients. Craniotabes and hypocalcemic tetany were the least common presentations. In VDD children the most frequent biochemical abnormality was high alkaline phosphatase (ALP) (100%), followed by low phosphate (PO(4)) (75%) and low calcium (Ca) (12.5%). One month after treatment, serum Ca, PO(4) and 25(OH)D concentrations were normal. Three months after the injection, serum level of ALP and parathormone (PTH) decreased to normal. The majority of patients (87.5%) had serum 25(OH)D level >or= 20 ng/ml, but some (12.5%) had level <20 ng/ml. Hypercalcemia was not recorded in any patient during the 3-month-period. Significant cure of all symptoms and signs related to vitamin D deficiency had been achieved in all children. Leg bowing showed significant improvement in all patients but was still evident in one third. Complete healing of the radiological evidence of rickets was achieved in 95% of all children. CONCLUSION: An IM injection of a mega dose of cholecalciferol is a safe and effective therapy for treatment of VDD rickets in infants and toddlers with normalization of all the biochemical parameters and healing of radiological manifestations. Measurement of serum 25(OH)D level is highly recommended in all short children with a clear need for a general vitamin D supplementation for all infants and young children in Qatar.

Linear growth in children with iron deficiency anemia before and after treatment.

We measured growth [length (L) standard deviation score (SDS), growth velocity (GV) SDS and body mass index (BMI)] and hematological (hemoglobin, hematocrit, MCV and MCH) parameters in 40 children (aged 17.2 +/- 12.4 months) with iron deficiency anemia (IDA) before and after iron therapy. Before treatment children with IDA had LSDS = -1.2 +/- 1, GV = 7.5 +/- 2.2, GVSDS = -1.42 +/- 0.6 and BMI = 13.5 +/- 1.2. They were significantly shorter and had reduced growth as compared with age-matched controls. After treatment, their growth parameters significantly increased with LSDS = -0.6 +/- -0.9, GV = 13.2 +/- 4.4 cm year(-1), GVSDS = 1.7 +/- 0.5 and BMI = 14.2 +/- 1.1. Their GV correlated significantly with serum ferritin concentration (r = 0.48, p < 0.001) and BMI (r = 0.32, p < 0.1). In summary, IDA during the first 2 years of life significantly impairs growth.

Calcium homeostasis in 40 adolescents with beta-thalassemia major: a case-control study of the effects of intramuscular injection of a megadose of cholecalciferol.

UNLABELLED: The prevalence of disturbed calcium homeostasis in adolescents with beta thalassemia major (T) varies among different populations. Moreover, the cholecalciferol uptake required to achieve or maintain any given serum 25-hydroxycholecalciferol level is not well known, particularly within ranges of the probable physiologic supply of the vitamin. OBJECTIVES: The objectives of the study were to estimate the prevalence of abnormal calcium homeostasis in 40 adolescent thalassemic patients, and to investigate the effect of an IM injection of a mega dose of vitamin D3 on serum 25-hydroxycholecalciferol (25-OH D) concentration and other calcium homeostasis parameters in vitamin D deficient (VDD) thalassemic adolescents, and to compare these results with those for non-thalassemic adolescents with VDD. DESIGN: In this prospective study we measured parameters of calcium homeostasis in 40 adolescents with T and 40 matched non-thalassemic (NT) controls. An IM dose (10,000 IU/kg, max 600,000 IU) of cholecalciferol was injected in those with VDD (38 adolescents with thalassemia and 26 non-thalassemic adolescents). Parameters of calcium homeostasis were measured at intervals of 3 months during the course of the study. RESULTS: Of the 40 adolescents with T, 2 had hypoparathyroidism and low 25-OH D, and 2 had hypocalcemia with hypophosphatemia, high alkaline phosphatase (ALP), high PTH and serum 25-OH D below ng/ml. The rest of the patients (n=36) had low circulating 25-OH D concentrations with normal serum Ca and PO4 concentrations. Of the 40 non-thalassemic adolescents, 26 had 25-OH D levels below 20 ng/ml (65%). Patients with T and VDD had lower circulating PTH and ALP concentrations compared to non-thalassemic patients with VDD. Significant improvement of symptoms related to vitamin D deficiency was reported in 18 out of 26 of symptomatic T and 12 out of 16 of NT adolescents at 1 to 3 months after the injection. Three months after injecting vitamin D the mean serum 25-OH D concentration was lower in the T group as compared to the NT group but the majority of patients had 25-OH D levels equal to or greater than 20 ng/ml. CONCLUSION: Vitamin D deficiency was detected in 100 % of our thalassemic adolescents. An IM injection of a mega dose of cholecalciferol is an effective therapy for treatment of hypovitaminosis D in thalassemic and non-thalassemic adolescents for 3 months but its effects do not persist for 6 months.

An adolescent boy with thalassemia major presenting with bone pain, numbness, tetanic contractions and growth and pubertal delay: panhypopituitarism and combined vitamin D and parathyroid defects.

A 16-year-old boy with transfusion-dependent thalassemia major presented with tetany, numbness, bone pain, short stature and pubertal delay. His height SDS score=-2.6, BMI=22.4, spleen was palpable 5 cm and liver 7 cm below the costal margins. The cardio-vascular examination was normal. Laboratory investigations showed a hemoglobin level (8 g/dL), hypocalcemia, hyperphosphatemia and elevated alkaline phosphatase (ALP) with serum 25-OH D below 3 ng/ml and a normal magnesium level. Serum parathyroid hormone (PTH) level was lower (21 pg/mL; normal 16-70 pg/mL) than expected for the degree of hypocalcemia. Serum ferritin concentration was 4442 ug/L, insulin-like growth factor I (IGF-I) was 31 microg/L (normal 122- 286 microg/L), free T4 was 13.1 microg/dL, TSH 1.2 mIU/ml. These results revealed a combined vitamin D-parathyroid defect. Peak growth hormone (GH) responses to clonidine and glucagon tests were 7.6 ng/ml and 6.2 ng/ml, respectively. Serum LH and FSH concentrations were below 0.5 U/L and testosterone was below 10 ng/dl. Radiographs revealed osteopenia of the phalanges and long bones and DXA scanning revealed low BMD Z-score of the femoral neck and 4th and 5th lumbar spines. MRI showed evidence of hemosiderin deposition in the pituitary. The patient was started on oral daily calcium carbonate (1500 mg elemental calcium) and vitamin D2 (calciferol) 25,000 IU/day and intensive iron chelation therapy. A low dose of IM testosterone enanthate (1 mg/kg/month) was injected for 6 months. Follow-up after 4, 8 and 12 months revealed normal Ca, PO4, ALP, and 25-OH D concentrations and disappearance of spasms and numbness and increased growth velocity. In conclusion, investigating calcium homeostasis at regular intervals and early management of any abnormality can preclude the occurrence of complications.