Impact of family structure and stability on academic outcome in preterm children at 10 years of age.

OBJECTIVE: To compare school performance at age 10 years in a cohort of extremely preterm children and term control subjects and to examine the impact of family composition and stability on performance. STUDY DESIGN: Prospective, longitudinal follow-up from birth to 10 years of age of a regional cohort of children born at 24 to 31 weeks of gestational age and sociodemographically matched term control subjects. Family composition, extent of parental care giving, and family moves were tracked sequentially. At 10 years, academic achievement and school performance were ascertained for 118 of 125 (94%) preterm survivors and 119 of 125 (95%) term children. RESULTS: Term children were more likely to demonstrate optimal school outcome (appropriate grade level without additional classroom assistance) than were preterm children (odds ratio 3.4, 95% CI 1.9-6.0). Medical complications related to prematurity had little impact on school outcome. Among preterm children, optimal school outcome was significantly associated with increased parental education, child rearing by 2 parents (regardless of marital status), and stability in family composition and geographic residence over 10 years. These environmental influences were less pronounced among term control subjects. CONCLUSION: Although preterm children performed less well in school than term children, family factors were stronger predictors of school performance than were perinatal complications.

Effect of preterm birth on pulmonary function at school age: a prospective controlled study.

OBJECTIVE: To assess long-term pulmonary outcome of a regional cohort of children born at < 32 weeks' gestation compared with a matched term control group. STUDY DESIGN: All 125 surviving children born at 24 to 31 weeks' gestation during a 1-year period and a sociodemographically matched term control group were evaluated at age 7 years. RESULTS: Preterm children with previous bronchopulmonary dysplasia (BPD) were twice as likely to require rehospitalization during the first 2 years of life than were preterm children without BPD (53% vs 26%, P < .01). At 7 years of age the BPD group had more airway obstruction than did both preterm children without BPD and the term control group (significantly reduced mean forced vital capacity, forced expiratory volume in 1 second, and forced expiratory flow, 25% to 75% vital capacity, all, P < .001). Lung function among preterm children without previous BPD was similar to that of the term control group. Bronchodilator responsiveness was observed twice as often in preterm children with previous BPD (20 of 43, 47%) compared with preterm children without BPD (13 of 53, 25%) or the term control group (23 of 108, 21%, P < .001). These differences remained significant after adjustment was done for birth weight and gestational age. CONCLUSION: Preterm children without BPD demonstrate pulmonary function at school age similar to that of children in a healthy term control group, whereas preterm children with previous BPD demonstrate abnormal pulmonary function.

A multi-centre safety and efficacy trial of a preterm infant formula supplemented with long chain polyunsaturated fatty acids (LCP) (48 weeks PCA analysis)

LCP supplementation of premature infant formula has been shown to produce plasma and erythrocyte lipid profiles similar to human milk (HM)-fed preterm infants. Previous studies reported decreased growth with LCP supplemented formula. This prospective, double-blind, randomised, controlled, parallel trial compared safety, growth and phospholipid fatty acid (PFA) levels in preterm infants fed preterms formula with (L+) or without (Lo) LCP. The study consisted of Phase I: enrolment to 40 weeks (wk) postconceptual age (PCA); and Phase II: 40 to 48 wk PCA. Infants (birth weight 750-2000 g, 0-28 days of age) were fed L+ or L preterm formula, 24 Kcal/oz during Phase I, and 20 Kcal/oz during Phase II. A control group was exclusively HM-fed preterms who, if weaned at the end of Phase I, received L. HM and formula intake were unrestricted. Weight (wt), length (Lt), head circumference (OFC) and upper mid-arm circumference (MAC), and phospholipid profiles were measured at 40 and 48 wk PCA. Adverse events were monitored. 183/288 infants completed Phase II. There were no difference in growth rates between formula groups. At 48 wk PCA, mean PFA levels in infants fed L+ were similar to HM-fed and were significantly higher than the L fed group. Adverse events were similar between the 2 formula groups. The number of infants who were discontinued because of an adverse event was similar among all groups. In conclusion the LCP preterm infant formula is safe, support normal growth and maintains phospholipid profiles similar to HM-fed infants.(AU)

Cell-mediated immune status of children with recurrent infection.

OBJECTIVE: To evaluate the cell-mediated immune status of children with recurrent respiratory tract infections. DESIGN: We evaluated the cell-mediated immune status of 76 patients referred because of recurrent infection. Patients were divided into those with serologic abnormalities and those without such findings. Twenty-three healthy children served as control subjects. Studies of lymphocyte phenotype included CD4+ CD29+ cells (an immunologically mature phenotype), lymphocyte proliferation studies, cytokine production including interleukin-2 (IL-2), IL-4, IL-6, and interferon gamma), and measurement of in vitro IgM and IgG synthesis. RESULTS: Lymphocyte proliferation and T-cell phenotype were similar in both patient groups as well as in control subjects. The proportions of CD4+ CD29+ cells at different ages were similar in all groups. Patients with serologic abnormalities (e.g., partial IgA deficiency, partial IgG subclass deficiency) produced more IL-2 and IL-4 than did other patients. The control population had greater spontaneous IgM and IgG synthesis than the patient groups. CONCLUSION: Routine studies of T-cell function of patients with recurrent infection provide little information useful in making clinical decisions.

Healthy municipios in Latin America

The health municipios strategy in Latin America is helping to promote new social pacts in the search for solutions to problems affecting health and well-being; to strengthen the principles of solidarity; and, above all, to find a means of achieving equity. Through this movement, the health sector is bolstering its leadership capability by putting health on the political agenda. In the process, the organization services is being improved and the formulation and implementation of healthy poblic policies is being advanced. The political, financial, and technical challenges are great, but is they can be met, the healthy municipios movement will contribute to building a culture of health through the promotion of healthy lifestyles and to strengthening democratic processes and fostering good citizenship

Paper prepared for the Internatonal Conference on Healthy and Ecological Cities, Madrid, 22-25 March 1995

Efficacy of abamectin injection against Dermatobia hominis in cattle.

The efficacy of abamectin 1%, when injected subcutaneously in cattle at a dose of 200 micrograms/kg body weight, against the larval stages (grubs) of the fly Dermatobia hominis was evaluated in two trials in endemic areas of Brazil and Argentina. Eighteen Holstein x Brahman castrated males and 16 Brahman-cross with natural infestations were used. Larvae were counted by instar in situ on both sides of each animal before treatment, and were expressed, identified as to stage and classified as live or dead 10 days after treatment. Further larval counts were made periodically until day 79 to evaluate the degree of reinfestation and the stage of larval development. Reinfestation was first detected in the abamectin-treated cattle on day 44. Live larvae were found on 6-8 (Argentina) and on all (Brazil) controls at each post-treatment examination. The difference in numbers of live larvae between treatment groups was statistically significant (P < 0.05) at all post-treatment examinations. These data show that abamectin at a dose of 200 micrograms/kg body weight is highly effective in the treatment and control of established parasitic stages of D. hominis in cattle. No adverse reactions were observed in any of the treated animals.

Role of immunoglobulin subclasses and specific antibody determinations in the evaluation of recurrent infection in children.

We studied humoral immune function in 267 children with recurrent respiratory infections referred to our immunology clinic to determine the most appropriate immunologic studies for evaluating recurrent infections in children. Of this highly selected population, 58% had a partial deficiency in one or more of the major immunoglobulin isotypes or IgG subclasses (defined as at least 2 SD below the normal age-adjusted mean). In none of the patients was there a total absence of an immunoglobulin isotype. The most common abnormality was partial IgA deficiency, which was found in one third of the patients. Twenty-six patients had only partial IgG subclass deficiencies, of which 20 were deficiencies of a single subclass. IgG1 was an isolated partial defect in three patients, IgG3 in five patients, and IgG2 and IgG4 were selective partial defects in six patients each. Tetanus toxoid and pneumopolysaccharide type 3 were the most immunogenic of the immunogens tested; hyporesponsiveness to pneumococcal polysaccharide types 7, 9, and 14 was common. Nineteen percent of the patients with normal immunoglobulin concentrations who were tested had lower-than-expected antibody titers; 42% of those tested with partial isotype deficiencies had deficient antibody responses. Of 25 patients with selective partial IgG subclass deficiencies or combined IgG subclass deficiencies, eight had antibody deficiencies. Our findings indicate that a high proportion of children referred to immunology clinics for recurrent infection have a demonstrable immunologic abnormality. Selective IgG subclass deficiency or a combined IgG subclass deficiency without an associated deficiency in a major immunoglobulin isotype is unusual. Identification of such patients is not predictive of the capacity to form antibodies to the antigens tested in this study and, in our opinion, adds little to the initial evaluation of immune function in such children.

Eficácia de soluçäo oral de ivermectin contra larvas de Dermatobia hominis (Linnaeus Jr. 1871) em bovinos / Efficacy of ivermectin oral solution in cattle against larval stages of Dermatobia hominis (Linnaeus Jr. 1781)

Os resultados do presente experimento, realizado em duas fazendas do município de Campinas, SP, demonstram que o ivermectin, quando aplicado por via oral, numa única dose de 200 mcg/kg de peso vivo, é altamente eficaz no tratamento e controle dos estágios parasitários das larvas de D. hominis (bernes) em bovinos

Effect of early low-volume enteral substrate on subsequent feeding tolerance in very low birth weight infants.

To determine the effect of small enteral feedings on small bowel function, 46 infants with birth weight less than 1500 g, selected on the basis of risk factors for feeding intolerance, were assigned randomly to one of two feeding groups. Group 1 received low-volume enteral feeds (12 ml/kg/day) in addition to parenteral alimentation for 10 days beginning on day 8 of life; group 2 received parenteral alimentation alone until day 18 of life. After this trial period feedings were increased by 15 ml/kg/day in all infants. Four infants (9%) developed necrotizing enterocolitis (one prior to any feeds, two in group 1, and one in group 2); two others were dropped from the study for reasons unrelated to feeding. The remaining 18 infants in group 1 had improved feeding tolerance compared with the 22 in group 2, as manifested by fewer days that gastric residuum totalled more than 10% of feedings (1.3 +/- 0.5 days vs 3.2 +/- 0.6 days, respectively, p less than 0.05) and fewer days that feedings were discontinued because of feeding intolerance (2.7 +/- 0.8 days vs 5.5 +/- 0.9 days, respectively, p less than 0.05). Consequently, 17 of 18 (94%) infants who had received the early low-volume enteral feedings achieved an enteral intake of 120 kcal/kg/day by 6 weeks of life, whereas only 14 of 22 (64%) infants in the delayed feeding group reached this intake (p less than 0.05). Peak total serum bilirubin concentrations were comparable in the two groups. The initiation of hypocaloric enteral substrate as an adjunct to parenteral nutrition improved subsequent feeding tolerance in sick infants with very low birth weight.

Bone mineralization in preterm infants fed human milk with and without mineral supplementation.

The bone mineral status of healthy preterm infants fed maternal milk was compared with that of similar infants fed maternal milk with mineral supplementation. Fifty infants with birth weight less than 1600 g were fed human milk for 1 week until reaching an intake of 120 kcal/kg/d. Thereafter, infants were assigned randomly to one of three diets: (1) continued unsupplemented human milk, providing an intake of 40 to 50 mg/kg/d calcium and 23 to 30 mg/kg/d phosphorus; (2) human milk mixed with a high mineral containing formula, providing total intakes of 130 mg/kg/d calcium and 68 mg/kg/d phosphorus; or (3) human milk alone for 1 additional week, followed by human milk mixed with a powdered fortifier, providing total intakes of 160 mg/kg/d calcium and 90 mg/kg/d phosphorus. Infants fed human milk with formula supplementation, but not those fed human milk with fortifier, had significantly higher serum phosphorus concentrations and significantly lower serum alkaline phosphatase concentrations than did those fed unsupplemented human milk (P less than 0.01). Bone mineral content of the humerus, determined by photon absorptiometry, however, was similar in all three groups; values averaged 0.104 g/cm at the beginning of the study, and remained unchanged irrespective of mineral supplementation. Shortly before hospital discharge, study diets were discontinued and infants were fed standard proprietary formula or were nursed by their mothers. At 44 weeks postconceptional age (7 to 10 weeks after change in diet), infants were reexamined. Serum phosphorus concentrations increased, serum alkaline phosphatase concentrations decreased, and bone mineral content more than doubled to values comparable with those in term infants. Results at follow-up were comparable for all three initial diet groups and for infants who were formula-fed or breast-fed after hospital discharge. The lack of any significant effect of early maternal milk supplementation on bone mineralization by 44 weeks postconceptional age suggests that these methods of supplementation of maternal milk may not be warranted for healthy preterm infants.

Vitamin E status in preterm infants fed human milk or infant formula.

Vitamin E status was assessed in 36 infants with birth weights less than 1500 gm who were assigned randomly to receive one of three sources of nutrition: milk obtained from mothers of preterm infants (preterm milk), mature human milk, or infant formula. Infants in each dietary group were further assigned randomly to receive iron supplementation (2 mg/kg/day) beginning at 2 weeks or to receive no iron supplementation. All infants received a standard multivitamin, providing 4.1 mg alpha-tocopherol daily. Serum vitamin E concentrations at 6 weeks were significantly related both to type of milk (P less than 0.0001) and to iron supplementation (P less than 0.05). Infants fed preterm milk had significantly higher serum vitamin E levels than did infants fed mature human milk, and both groups had significantly higher levels than did those fed formula. Ratios of serum vitamin E/total lipid were also significantly greater for infants fed human milks than for those fed formula. The addition of iron to all three diets resulted in significantly lower serum vitamin E levels at 6 weeks (P less than 0.05); however, only in the group fed formula was there evidence of vitamin E deficiency. Preterm milk with routine multivitamin supplementation uniformly resulted in vitamin E sufficiency in VLBW infants whether or not iron was administered.

Peritonitis with continuous ambulatory peritoneal dialysis and continuous cycling peritoneal dialysis.

The frequency and cause of peritonitis in 18 children receiving continuous ambulatory peritoneal dialysis (CAPD) and nine children receiving continuous cycling peritoneal dialysis (CCPD) are described. Cumulative CAPD and CCPD experience demonstrated 58 episodes of peritonitis in 294 patient treatment months (one case per 5.1 patient treatment months). Total hospitalization for the treatment of peritonitis was 0.18 days per patient treatment month. Life table analysis revealed no significant difference in the peritonitis-free "survival" between the two modalities. Gram-negative organisms accounted for a significantly increased percentage of the peritonitis in CAPD compared with CCPD (65% vs 17%) (P less than 0.001). Thirty-seven percent of the gram-negative infections in the CAPD population were in children with nephrostomies. Factors predisposing to peritonitis were identified in 76% of cases occurring with CAPD. Peritonitis remains the major contributor to the morbidity associated with peritoneal dialysis, regardless of the technique. The resultant frequency of hospitalization is not prohibitive. Attention to the "high-risk" pediatric patient and education directed at several well-recognized predisposing factors may yield improved results.

Normative early head growth in very-low-birth-weight infants.

Normative head growth curves were developed from serial weekly measurements of head circumference in 50 infants with birth weights less than 1500 gm who had good neurodevelopmental outcome at 2 years of age (assessed by neurologic examination and by the Bayley Mental Developmental Scale). Forty-one of the infants with good outcome were normocephalic at birth; after head shrinkage during the first week of life, increments in head circumference averaged 0.49 cm during the second week, 0.79 cm during the third week, and 0.95 cm per week thereafter. Nine infants with good outcome were microcephalic at birth; these infants had no head shrinkage during the first week of life and had a significantly greater mean weekly increment in head circumference of 0.98 cm (P less than 0.008). In contrast, 10 normocephalic and seven microcephalic infants with poor outcome had significantly less postnatal head growth (P less than 0.02 and p less than 0.001, respectively). Head growth curves developed from measurements in infants with documented good short-term developmental outcome are the most appropriate standards for head growth for very-low-birth-weight infants.

Controlled study of treatment for disseminated intravascular coagulation in the neonate.

Thirty-three neonates with disseminated intravascular coagulation were assigned randomly to one of three treatment groups: (1) exchange transfusion, (2) administration of fresh-frozen plasma and platelets, and (3) control (no therapy directed specifically at the coagulopathy). The three groups were comparable for degree of abnormality in initial coagulation studies and underlying pathologic processes. Shock was a common accompaniment of DIC and occurred in 85% of all infants. In all cases, underlying disease states and shock were treated aggressively. Resolution of DIC and survival were not different in the three treatment groups. Outcome of DIC was dependent on the success of treatment of the underlying pathologic process and aggressive supportive care, including restoration of blood pressure, but was not altered by therapy specifically directed at the coagulopathy.

Elevated IgA concentration in milk produced by mothers delivered of preterm infants.

Concentrations of immunoglobulins G, M, and A were measured by double-antibody radioimmunoassay in morning milk samples collected during the first month postpartum from 35 mothers delivered of preterm infants and 14 mothers delivered of term infants. Mean concentrations of IgG (1.8, to 2.8 mg/gm protein) and IgM (2.8 to 11.7 mg/gm protein) were similar in milk from both groups of mothers. In contrast, IgA was present in significantly higher concentrations throughout the first month postpartum in milk from mothers delivered of preterm infants than in milk from those giving birth at term (P less than 0.01). To determine the effect of milk flow on IgA concentration, IgA was also measured in complete 24-hour milk collections; milk from mothers with preterm deliveries again contained significantly higher concentrations of IgA than milk from mothers with term deliveries (P less than 0.01). This higher IgA concentration was not secondary to method of milk expression. The concentration of IgA was found, however, to vary inversely with milk volume (P less than 0.01). Although mean values of milk volumes for the groups were not statistically different, the overall lower volumes of milk produced by mothers giving birth preterm resulted in comparable total IgA production per 24 hours. There were no differences in serum IgA concentrations of preterm infants fed their own mother's milk and comparable infants fed a cow milk formula, suggesting that IgA in milk is not absorbed from the intestine in significant amounts.

Folate compartments during gestational maturation.

Studies on 41 healthy preterm infants and 53 term infants revealed that almost 70% of the total folate is present in the bound form. Beyond the enonatal period the increase in bound folate with increasing gestational maturity reflects fetal demands placed on folate transport and affords an explanation for the loss of folate and corresponding increase in unsaturated binder during pregnancy. With the knowledge of folate biology gained from radioligand data, it is reasonable to postulate that effective folate metabolism depends upon a metabolically active transport mechanism.