Birth weight and adolescent blood pressure measured at age 12 years in the Gateshead Millennium Study.

Birth weight and early growth have been associated with later blood pressure. However, not all studies consistently find a significant reduction in blood pressure with an increase in birth weight. In addition, the relative importance of birth weight and of other lifestyle and environmental factors is often overlooked and the association is rarely studied in adolescents. We investigated early life predictors, including birth weight, of adolescent blood pressure in the Gateshead Millennium Study (GMS). The GMS is a cohort of 1029 individuals born in 1999-2000 in Gateshead in Northern England. Throughout infancy and early childhood, detailed information were collected, including birth weight and measures of height and weight. Assessments of 491 returning participants at age 12 years included measures of body mass and blood pressure. Linear regression and path analysis were used to determine predictors and their relative importance on blood pressure. Birth weight was not directly associated with blood pressure at the age of 12. However, after adjustment for contemporaneous body mass index (BMI), an inverse association of standardized birth weight on systolic blood pressure was significant. The relative importance of birth weight on later systolic blood pressure was smaller than other contemporaneous body measures (height and BMI). There was no independent association of birth weight on blood pressure seen in this adolescent population. Contemporaneous body measures have an important role to play. Lifestyle factors that influence body mass or size, such as diet and physical activity, where interventions are directed at early prevention of hypertension should be targeted.

Improving screening and brief intervention activities in primary health care: Secondary analysis of professional accuracy based on the AUDIT-C.

INTRODUCTION AND OBJECTIVE: The ODHIN trial found that training and support and financial reimbursement increased the proportion of patients that were screened and given advice for their heavy drinking in primary health care. However, the impact of these strategies on professional accuracy in delivering screening and brief advice is underresearched and is the focus of this paper. METHOD: From 120 primary health care units (24 in each jurisdiction: Catalonia, England, the Netherlands, Poland, and Sweden), 746 providers participated in the baseline and the 12-week implementation periods. Accuracy was measured in 2 ways: correctness in completing and scoring the screening instrument, AUDIT-C; the proportion of screen-negative patients given advice, and the proportion of screen-positive patients not given advice. Odds ratios of accuracy were calculated for type of profession and for intervention group: training and support, financial reimbursement, and internet-based counselling. RESULTS: Thirty-two of 36 711 questionnaires were incorrectly completed, and 65 of 29 641 screen-negative patients were falsely classified. At baseline, 27% of screen-negative patients were given advice, and 22.5% screen-positive patients were not given advice. These proportions halved during the 12-week implementation period, unaffected by training. Financial reimbursement reduced the proportion of screen-positive patients not given advice (OR = 0.56; 95% CI, 0.31-0.99; P < .05). CONCLUSION: Although the use of AUDIT-C as a screening tool was accurate, a considerable proportion of risky drinkers did not receive advice, which was reduced with financial incentives.

Development of the MapMe intervention body image scales of known weight status for 4-5 and 10-11 year old children.

Background: Parents tend to visually assess children to determine their weight status and typically underestimate child body size. A visual tool may aid parents to more accurately assess child weight status and so support strategies to reduce childhood overweight. Body image scales (BIS) are visual images of people ranging from underweight to overweight but none exist for children based on UK criteria. Our aim was to develop sex- and age-specific BIS for children, based on British growth reference (UK90) criteria. Methods: BIS were developed using 3D surface body scans of children, their associated weight status using UK90 criteria from height and weight measurements, and qualitative work with parents and health professionals. Results: Height, weight and 3D body scans were collected (211: 4-5 years; 177: 10-11 years). Overall, 12 qualitative sessions were held with 37 participants. Four BIS (4-5-year-old girls and boys, 10-11-year-old girls and boys) were developed. Conclusions: This study has created the first sex- and age-specific BIS, based on UK90 criteria. The BIS have potential for use in child overweight prevention and management strategies, and in future research. This study also provides a protocol for the development of further BIS appropriate to other age groups and ethnicities.

Longitudinal study of the associations between change in sedentary behavior and change in adiposity during childhood and adolescence: Gateshead Millennium Study.

BACKGROUND: Sedentary time (ST) has been reported to have a range of negative health effects in adults, however, the evidence for such effects among children and adolescents is sparse. The primary aim of the study was to examine associations between changes in sedentary behavior (time and fragmentation) and changes in adiposity across childhood and adolescence. METHODS: Participants were recruited as part of the Gateshead Millennium Study. Measures were taken at age 7 (n=502), 9 (n=506), 12 (n=420) and 15 years (n=306). Participants wore an ActiGraph GT1M and accelerometer epochs were 'sedentary' when recorded counts were ⩽25 counts per 15 s. ST was calculated and fragmentation (SF) was assessed by calculating the number of sedentary bouts per sedentary hour. Associations of changes in ST and SF with changes in adiposity (body mass index (BMI), and fat mass index (FMI)) were examined using bivariate linear spline models. RESULTS: Increasing ST by 1% per year was associated with an increase in BMI of 0.08 kg m-2 per year (95% CI: 0.06-0.10; P<0.001) and FMI of 0.15 kg m-2 per year (0.11-0.19; P<0.001). Change in SF was associated with BMI and FMI (P<0.001). An increase of 1 bout per sedentary hour per year (that is, sedentary time becoming more fragmented) was associated with an increase in BMI of 0.07 kg m-2 per year (0.06-0.09; P<0.001) and an increase in FMI of 0.14 kg m-2 per year (0.10-0.18; P<0.001) over the 8 years period. However, an increase in SF between 9-12 years was associated with a 0.09 kg m-2 per year decrease in BMI (-0.18-0.00; P=0.046) and 0.11 kg m-2 per year decrease in FMI (-0.22-0.00; P=0.049). CONCLUSIONS: Increased ST and increased SF from 7-15 years were associated with increased adiposity. This is the first study to show age-specific associations between change in objectively measured sedentary behavior and adiposity after adjustment of moderate-to-vigorous-intensity physical activity in children and adolescents. The study suggests that, targeting sedentary behavior for obesity prevention may be most effective during periods in which we see large increases in ST.

Mothers' perceptions of child weight status and the subsequent weight gain of their children: a population-based longitudinal study.

BACKGROUND: There is a plethora of cross-sectional work on maternal perceptions of child weight status showing that mothers typically do not classify their overweight child as being overweight according to commonly used clinical criteria. Awareness of overweight in their child is regarded as an important prerequisite for mothers to initiate appropriate action. The gap in the literature is determining whether, if mothers do classify their overweight child's weight status correctly, this is associated with a positive outcome for the child's body mass index (BMI) at a later stage. OBJECTIVE: To explore longitudinal perceptions of child weight status from mothers of a contemporary population-based birth cohort (Gateshead Millennium Study) and relationships of these perceptions with future child weight gain. METHODS: Data collected in the same cohort at 7, 12 and 15 years of age: mothers' responses to two items concerning their child's body size; child's and mother's BMI; pubertal maturation; demographic information. RESULTS: Mothers' perceptions of whether their child was overweight did not change markedly over time. Child BMI was the only significant predictor of mothers' classification of overweight status, and it was only at the extreme end of the overweight range and in the obese range that mothers reliably described their child as overweight. Even when mothers did appropriately classify their child as overweight at an earlier stage, this was not related to relatively lower child BMI a few years later. CONCLUSIONS: Mothers tend to classify their child as overweight in only more extreme cases. It is an important finding that no beneficial impact was shown on later child BMI in overweight children whose mothers classified their child's weight status as overweight at an earlier stage.

Rapid growth and short life spans characterize pipefish populations in vulnerable seagrass beds.

The life-history traits of two species of pipefish (Syngnathidae) from seagrass meadows in New South Wales, Australia, were examined to understand whether they enhance resilience to habitat degradation. The spotted pipefish Stigmatopora argus and wide-bodied pipefish Stigmatopora nigra exhibit some of the shortest life spans known for vertebrates (longevity up to 150 days) and rapid maturity (male S. argus 35 days after hatching (DAH) and male S. nigra at 16-19 DAH), key characteristics of opportunistic species. Growth rates of both species were extremely rapid (up to 2 mm day(-1) ), with seasonal and sex differences in growth rate. It is argued that short life spans and high growth rates may be advantageous for these species, which inhabit one of the most threatened marine ecosystems on earth.

Determinants of changes in sedentary time and breaks in sedentary time among 9 and 12 year old children.

The current study aimed to identify the determinants of objectively measured changes in sedentary time and sedentary fragmentation from age 9- to age 12 years. Data were collected as part of the Gateshead Millennium Birth Cohort study from September 2008 to August 2009 and from January 2012 to November 2012. Participants were 9.3 (± 0.4) years at baseline (n = 508) and 12.5 (± 0.3) years at follow-up (n = 427). Sedentary behaviour was measured using an ActiGraph GT1M accelerometer. Twenty potential determinants were measured, within a socio-ecological model, and tested for their association with changes in sedentary time and the extent to which sedentary behaviour is prolonged or interrupted (fragmentation index). Univariate and multivariate linear regression analyses were conducted. Measurements taken during winter and a greater decrease in moderate-to-vigorous intensity physical activity (MVPA) over time were associated with larger increases in sedentary time (seasonality ß: - 3.03; 95% CI: - 4.52, - 1.54; and change in MVPA ß: - 1.68; 95% CI: - 1.94, - 1.41). Attendance at sport clubs was associated with smaller increases in sedentary time (- 1.99; - 3.44, - 0.54). Girls showed larger decreases in fragmentation index (- 0.52; - 1.01, - 0.02). Interventions aimed at decreasing the decline in MVPA and increasing/maintaining sport club attendance may prevent the rise in sedentary time as children grow older. In addition, winter could be targeted to prevent an increase in sedentary time and reduction in sedentary fragmentation during this season.

Mothers' judgements about their child's weight: distinguishing facts from values.

BACKGROUND: Mothers' responses to questionnaire items assessing their child's weight status typically do not correspond to conventional clinical classifications based on body mass index (BMI). From this observation health professionals infer that mothers do not recognize overweight in their child. But the questions used have generally confounded factual judgements with values, so it is not clear whether the mothers are making factual errors, or differ from professionals in their values. METHODS: Cross-sectional study of population-based birth cohort at 6-8 years and their mothers (n = 540). An objective BMI matching task was used to determine the accuracy of mothers' recognition of their child's weight. Mothers matched their child to sex- and age-specific images of children of known BMI ranging from very thin to obese, and chose a descriptor of their child's weight of the kind used in previous research. RESULTS: Mothers tended to underestimate their child's BMI on the matching task. Matching errors significantly predicted mothers' description of their child's weight; those who overestimated their child's BMI on the matching task were more likely to say their child was overweight, while those who underestimated it were less likely to, independently of their child's actual BMI. CONCLUSIONS: Educational programmes aimed at parents of young primary school children need to address separately the factual and the evaluative components of their assessment of child weight.

Validation of otolith daily increment formation for two temperate syngnathid fishes: the pipefishes Stigmatopora argus and Stigmatopora nigra.

Otoliths were used for the first time to successfully validate the age of members of the family Syngnathidae: the spotted pipefish Stigmatopora argus and the wide-bodied pipefish Stigmatopora nigra. Otolith increments were deposited daily in (1) known-age juveniles ranging in age from 0 to 31 days and (2) adults that had been stained with alizarin complexone, and a hatch mark was found on all otoliths which represented day 0. Otolith increment validation will allow development of growth models for S. argus and S. nigra, essential to understanding and managing these exclusive seagrass species.

Parental perceptions of weight status in children: the Gateshead Millennium Study.

OBJECTIVES: To investigate parents' perceptions of weight status in children and to explore parental understanding of and attitudes to childhood overweight. DESIGN: Questionnaires and focus groups within a longitudinal study. SUBJECTS: 536 parents of Gateshead Millennium Study children, of which 27 attended six focus groups. MAIN OUTCOME MEASURES: Parents' perception of their child's weight status according to actual weight status as defined by International Obesity Taskforce (IOTF) cutoffs. Focus group outcomes included parental awareness of childhood overweight nationally and parental approaches to identifying overweight children. RESULTS: The sensitivity of parents recognising if their child was overweight was 0.31. Prevalence of child overweight was underestimated: 7.3% of children were perceived as 'overweight' or 'very overweight' by their parents, 23.7% were identified as overweight or obese using IOTF criteria. 69.3% of parents of overweight or obese children identified their child as being of 'normal' weight. During focus groups parents demonstrated an awareness of childhood overweight being a problem nationally but their understanding of how it is defined was limited. Parents used alternative approaches to objective measures when identifying overweight in children such as visual assessments and comparisons with other children. Such approaches relied heavily on extreme and exceptional cases as a reference point. The apparent lack of relevance of childhood overweight to their child's school or own community along with scepticism towards both media messages and clinical measures commonly emerged as grounds for failing to engage with the issue at a personal level. CONCLUSION: Parents' ability to identify when their child was overweight according to standard criteria was limited. Parents did not understand, use or trust clinical measures and used alternative approaches primarily reliant on extreme cases. Such approaches underpinned their reasoning for remaining detached from the issue. This study highlights the need to identify methods of improving parental recognition of and engagement with the problem of childhood overweight.

When do mothers think their child is overweight?

OBJECTIVE: To quantify how overweight children have to be for their mothers to classify them as overweight and to express concern about future overweight, and to investigate the adiposity cues in children that mothers respond to. DESIGN: Cross-sectional. SUBJECTS: A total of 531 children from the Gateshead Millennium Study cohort at 6-8 years and their mothers. MEASUREMENTS: In the mother: responses to two questions concerning the child's adiposity; height; weight; educational qualifications; and economic status. In the child: height; weight; waist circumference; skinfold thicknesses; bioelectrical impedance; and bone frame measurements. RESULTS: The body mass index (BMI) at which half the mothers classify their child as overweight was 21.3 (in the obese range for children of this age). The BMI at which half the mothers were concerned about their child becoming overweight in the future was 17.1 (below the overweight range). Waist circumference and skinfolds contributed most to mothers' responses. Although BMI and fat scores were important predictors individually, they did not contribute independently once waist circumference and skinfolds (their most visible manifestations) were included in the regression equations. Mothers were less likely to classify girls as overweight. Mothers with higher BMIs were less likely to classify their child as overweight, but were more likely to be concerned about future overweight. CONCLUSION: Health promotion efforts directed at parents of young primary school children might better capitalise on their concern about future overweight in their child than on current weight status, and focus on mothers' response to more visible characteristics than the BMI.

Diabetes and genital warts: an unhappy coalition.

Through clinical practice, it is often perceived that patients with diabetes are more likely to suffer from severe and recalcitrant warts. This study was set up to investigate if genital warts were more common in patients with diabetes and to determine if patients with diabetes and genital warts required more treatment than those without diabetes. Only female patients with diabetes and genital warts were investigated and were compared to the non-diabetic population. Results suggested that patients with diabetes had more extensive warts and recurrences. This study will hopefully further inform the debate surrounding preferential use of quadrivalent human papilloma virus (HPV) vaccine as opposed to bivalent HPV vaccine especially in the setting of a Diabetes Young Person's clinic.

Pain in children with cerebral palsy: a cross-sectional multicentre European study.

AIM: To determine the prevalence and associations of self-reported and parent-reported pain in children with cerebral palsy (CP) of all severities. METHOD: Cross-sectional design using a questionnaire; analysis using ordinal regression. Children aged 8-12 years were randomly selected from population-based registers of children with CP in eight European regions; a further region recruited 75 children from multiple sources. Outcome measures were pain in the previous week among children who could self-report and parents' perception of their child's pain in the previous 4 weeks. RESULTS: Data on pain were available from 490 children who could self-report and parents of 806 children (those who could and could not self-report). The estimated population prevalence of self-reported pain in the previous week was 60% (95% CI: 54-65%) and that of parent-reported pain in the previous 4 weeks was 73% (95% CI: 69-76%). In self-reporting children, older children reported more pain but pain was not significantly associated with severity of impairment. In parent reports, severity of child impairment, seizures and parental unemployment were associated with more frequent and severe pain. CONCLUSION: Pain in children with CP is common. Clinicians should enquire about pain and consider appropriate physical, therapeutic or psychological management.

Health status of children with cerebral palsy living in Europe: a multi-centre study.

AIM: The aim of this report is to describe the health status of 8-12-year-old children with cerebral palsy (CP) of all severities in Europe using the Child Health Questionnaire (CHQ). METHOD: A total of 818 children with CP from nine centres in defined geographical areas participated. CP type, gross and fine motor function, additional impairments were classified and family data were obtained. The CHQ was used to measure the parent's perception of their child's physical (PHY) and psychosocial (PSY) health. RESULTS: PHY scores were lower than the reference samples with a median of 46. The severity of gross motor function influenced the CHQ scores significantly in the PHY scale with the lowest scores for children with least gross motor function. There were significant differences between the CP types in PHY with the higher scores for children with unilateral spastic and the lowest scores for children with bilateral spastic and dyskinetic CP type. Fine motor function severity significantly affected both the PHY and PSY scales. The severity of intellectual impairment was significantly associated with CHQ scores in most dimensions with higher scores for higher IQ level in PHY and PSY. Children with seizures during the last year had a significantly lower health compared with children without seizures. The results of the multivariate regression analyses (forward stepwise regression) of CHQ scores on CP subtype, gross and fine motor function, cognitive function, additional impairments, seizures, parental education and employment revealed gross motor function, cognitive level and type of school attended were significant prognostic factors. CONCLUSION: This report is based on the largest sample to date of children with CP. Health status as measured using the CHQ was affected in all children and was highly variable. Gross motor function level correlates with health from the PHY well-being perspective but the PSY and emotional aspects do not appear to follow the same pattern.

Surveillance of physical activity in the UK is flawed: validation of the Health Survey for England Physical Activity Questionnaire.

OBJECTIVE: Public health surveillance of physical activity in children in the UK depends on a parent-reported physical activity questionnaire which has not been validated. We aimed to validate this questionnaire against measurement of physical activity using accelerometry in 6-7-year-old children. METHODS: In 130 children aged 6-7 years (64 boys, 66 girls) we estimated habitual moderate-vigorous intensity physical activity (MVPA) using the Health Survey for England parent-report questionnaire for physical activity. For the same time period and the same children, we measured MVPA objectively using 7-day accelerometry with the Actigraph accelerometer. RESULTS: The questionnaire over-estimated MVPA significantly (paired t test, p<0.01). Mean error (bias) when using the questionnaire was 122 min/day (95% CI 124 to 169). Mean time spent in MVPA was 146 min/day (95% CI 124 to 169) using the questionnaire and 24 min/day (95% CI 22 to 26) using the accelerometer. Rank order correlations between MVPA measured by accelerometer and estimated by the questionnaire were not statistically significant. CONCLUSIONS: Public health surveillance of physical activity should not rely on this questionnaire. Levels of habitual physical activity in children are likely to be substantially lower than those reported in UK health surveys.

Participation of disabled children: how should it be characterised and measured?

PURPOSE: The aim of the paper is to explore the issues involved in measuring children's participation. METHOD: The concept of participation as encapsulated in the International Classification of Functioning, Disability and Health (ICF) is discussed as it applies to children. The essential components of any measure of children's participation are outlined, including participation essential for normal development and survival, leisure activities, and educational participation. Some existing instruments are briefly reviewed in terms of their coverage of the essential components and the adequacy of their approach to measurement. RESULTS: Key issues regarding the content of an adequate measure of participation include the need to consider the child's dependency on the family, and their changing abilities and autonomy as they grow older. Instruments may be most appropriate where they ask the child directly, implying use of visual as well as verbal presentation. Their focus should be on 'performance' such as whether and how often an activity is taken part in, and not incorporate degree of assistance within the measurement scaling. CONCLUSIONS: Currently available measures of children's participation all have some limitations in terms of their applicability across impairment groupings, whether the child can directly respond, and in the ICF components covered. The feasibility of developing measurement instruments of children's participation at different ages is discussed.

The influence of maternal socioeconomic and emotional factors on infant weight gain and weight faltering (failure to thrive): data from a prospective birth cohort.

AIMS: To study the influence of maternal socioeconomic and emotional factors on infant weight gain and weight faltering (failure to thrive) in the first year of life. METHODS: The Gateshead Millennium Baby Study is a population birth cohort in northeast England studied prospectively from birth, via parental questionnaires and a health check aged 13 months. Data were collected on maternal education, deprivation, eating attitudes, and depression, using the Edinburgh Post Natal Depression Scale (EPDS) at 3 months. Weight gain was assessed using change in weight SD score, conditional on birth weight (Thrive Index); weight faltering was defined as conditional weight gain below the 5th centile. RESULTS: Of 923 eligible infants born at term, 774 (84%) had both weight and questionnaire data. Replicating a previous finding, both the highest and the lowest levels of deprivation were associated with weight faltering; this was independent of the type of milk feeding. No relation was found with maternal educational status. Maternal eating restraint was unrelated to weight gain. Infants of mothers with high depression symptom scores (EPDS >12) had significantly slower weight gain and increased rates of weight faltering up to 4 months (relative risk 2.5), especially if they came from deprived families, but by 12 months they were no different from the remainder of the cohort. CONCLUSIONS: In this setting, social and maternal characteristics had little influence on infants' weight gain, apart from a strong, but transient effect of postnatal depression.

Discussion groups with parents of children with cerebral palsy in Europe designed to assist development of a relevant measure of environment.

BACKGROUND: An instrument to measure environmental factors relevant to physically impaired children is being developed in a European context. Preliminary work in England had identified some potentially important themes. Further inquiry was needed to identify issues important in other European countries. OBJECTIVE: To inform the content of a questionnaire relevant to the environment of children with cerebral palsy (CP) living in Europe. DESIGN: A qualitative study using discussion groups. PARTICIPANTS: Parents of 28 children with CP from five countries; Denmark, France, Italy, Ireland and Sweden. One discussion group was held in each country with an average of seven parents per group. RESULTS: The four themes identified in the preliminary work done in England were strongly confirmed across Europe - namely: Mobility, Transport, Support by and to parents, and Attitudes of individuals and institutions towards children. Two new themes identified in the discussion groups were Bureaucracy and Access to information about rights and entitlements. CONCLUSIONS: The environmental factors that cause concern to parents of children with CP are similar across Europe. A prototype environmental questionnaire has been developed based on these findings. The environmental questionnaire is in use in a study in nine European centres.

The diagnosis of borderline iron deficiency: results of a therapeutic trial.

BACKGROUND: Iron deficiency is common in early childhood and has been associated with developmental delay. It is not known how reliably markers of iron deficiency identify true iron deficiency, defined as a therapeutic response to oral iron. METHODS: The subjects were members of the Millennium Baby Study cohort. At age 13 months a venous blood sample was taken for mean cell volume (MCV), haemoglobin, mean cell haemoglobin (MCH), ferritin, and zinc protoporphyrin (ZPP). Children with abnormal values were offered treatment with oral iron and dietary modification, and re-sampled after 3 months. RESULTS: Samples were obtained for 462 children. All markers were moderately correlated with each other except ferritin. Treatment was offered to 147 (32%) children with at least one abnormal value, of whom 126 (86%) were re-sampled. Children with a haemoglobin or an MCH below the screening cut off, or with abnormal values for two or more of the remaining three measures, showed a large therapeutic response to iron, but isolated abnormalities of MCV, ZPP, or ferritin were not consistently associated with a response. Of the screened population 13% could be defined as iron deficient (abnormal haemoglobin or MCH, or abnormal levels of two or more of the remaining three markers), but this was not strongly associated with any dietary, demographic, or anthropometric characteristic. CONCLUSIONS: Low total or mean cell haemoglobin in isolation is a specific marker of iron deficiency, but other markers are only predictive when found in combination with other abnormal values.

Why are babies weaned early? Data from a prospective population based cohort study.

BACKGROUND: The recommended age of introduction of solids food to the diet of infants (weaning) has recently been increased in the UK to 6 months, but most babies are still weaned before the age of 4 months. AIMS: To examine what predicts the age of weaning and how this relates to weight gain and morbidity using data from a population based cohort. METHODS: Parents of 923 term infants born in a defined geographical area and recruited shortly after birth were studied prospectively using postal questionnaires, weaning diaries, and routinely collected weights, of whom 707 (77%) returned data on weaning. RESULTS: The median age of first weaning solids was 3.5 months, with 21% commencing before 3 months and only 6% after 4 months of age. Infants progressed quickly to regular solids with few reported difficulties, even when weaned early. Most parents did not perceive professional advice or written materials to be a major influence. The strongest independent predictors of earlier age at weaning were rapid weight gain to age 6 weeks, lower socioeconomic status, the parents' perception that their baby was hungry, and feeding mode. Weight gain after 6 weeks was unrelated to age of weaning. Babies weaned before 3 months, compared to after 4 months, had an increased risk of diarrhoea. CONCLUSIONS: Social factors had some influence on when weaning solids were introduced, but the great majority of all infants were established on solids before the previously recommended age of 4 months, without difficulty. Earlier weaning was associated with an increased rate of minor morbidity.