Growth in the first year of life: how early can one predict size at twelve months among small-for-dates and large-for-dates babies?

Within groups of small-for-dates (SFD) and large-for-dates (LFD) babies there is great diversity in their postnatal growth patterns. We analysed our data to find out how soon, and for which dimensions, could predictions of size at one year be reasonably made. Among LFD babies a strong correlation (r=0.644) was found between head circumference at birth and 12 months. Comparable values for weight and length were present by 3 months. In the SFD group, correlations of the same order were achieved for all three dimensions at the age of 4 months.

Small-for-dates babies at the age of four years: health, handicap and developmental status.

221 small-for-dates (SFD) and 244 average-for-dates (AFD) children were personally examined at birth, and seen thereafter at regular intervals up to 4 years, when a thorough assessment was made. There was an excess of SFD children with major congenital abnormalities; but no difference between the groups in the number of children who were handicapped without congenital abnormality. Their general health was good, and the prevalence of specific disease or major ill-health did not differ. SFD girls seemed to have less acute hearing than AFD girls; but there was not difference for boys. The prevalence of squint, impaired vision, speech defects, and abnormalities of gross and fine motor movements were equally low in both groups. At 4 years the mean scores for five sectors of development were significantly lower in the SFD than the AFD group. Within group analyses of 16 variables and their effects on developmental scores showed no associations in either group according to maternal height and weight, birthweights of previous siblings, the presence or not of hypertension and pre-eclampsia, bleeding during pregnancy, asphyxia and injury at birth, or birth order. Within each group the net effect of the remaining eight factors was assessed; adjustment being made for the other seven variables. In the SFD group social class and method of delivery made a significant contribution to total scores. In the AFD group significant differences were found according to social class, sex, gestational age at birth and smoking. Method of infant feeding just failed to achieve significance. When all the children were considered together, and birthweight group included as an additional variable, no significant differences remained between the SFD and AFD groups for any sector of development.

Large-for-dates babies at the age of four years: health, handicap and developmental status.

236 Average-for-dates (AFD) and 212 large-for-dates (LFD) children were personally examined at birth, and seen thereafter at regular intervals up to 4 yr, when a thorough assessment was made. No differences were found in the prevalence of handicap, health problems, speech and hearing defects, impaired vision or squint; and abnormalities of gross and fine-motor movements were equally low in both groups. At 4 yr the mean scores for five sectors of development were slightly higher in the LFD group, and the difference in total scores was significant; but when adjustment was made for sex and social class the difference became insignificant. Within group analyses of 16 variables and their effects on developmental scores showed no associations in either group according to maternal weight, height and siblings birthweight; hypertension, pre-eclampsia or bleeding during pregnancy; asphyxia or injury at birth. Within each group the net effect of eight factors was assessed; adjustment being made for the other seven variables. In the AFD group significant differences in total scores were found according to sex, social class, smoking, and method of infant feeding. In the LFD group social class and method of delivery made a significant contribution to total scores.

Children of deviant birthweight at the age of seven years: health, handicap, size and developmental status.

138 small-for-dates (SFD), 138 average-for-dates (AFD) and 136 large-for-dates (LFD) children who had been followed up from birth were examined at the age of 7 years. Nine children had major congenital abnormalities (SFD 5, AFD 2, LFD 2). In addition gross and/or fine motor incoordination was noted in 25 children (SFD 9, AFD 10, LFD 6). There were no differences between the groups in the incidence of chronic or specific ill-health, hearing, sight and speech defects. Highly significant differences were found between the groups for weight, height, head circumference and triceps skinfold thickness; and significant differences were also found between the total developmental scores in the three groups. In every case SFD children had the lowest and LFD children the highest mean values. Within each group analyses were made of 22 parental, pregnancy, perinatal and postnatal factors which might affect growth or development. The net effects of those factors for which significant differences had been found were then assessed, adjustment being made for confounding between variables. In all three groups the children's genetic potential for size was strongly evident by this age, and boys had larger heads than girls. All three groups showed the powerful influence of social class on intellectual ability; and sex on gross and fine-motor function. The other main contributor to developmental differences in the AFD group was gestational age. In the SFD group maternal hypertension was associated with slightly decreased intellectual ability, and in all areas first-born SFD children performed better than subsequent born. Among LFD children instrumental delivery had an adverse effect on all areas of ability, and first-born children had higher intellectual scores. When all the children were considered together and birthweight included as an additional variable the differences in developmental scores between the groups were much reduced. In the SFD and LFD groups some significant correlations were found between size and developmental scores; but none were found among AFD children.

Clinical assessment of gestational age at birth: the effects of sex, birthweight, and weight for length of gestation.

During studies on different aspects of fetal growth rate infants who were small-for-dates (SFD) large-for-dates (LFD) or within the normal range of birthweight for length of gestation (AFD) were examined within 48 h of birth. Gestational age was clinically assessed by the Dubowitz method. Among 140 AFD infants boys had higher mean values than girls for total and external scores, but there was no difference in neurological scores. Multiple regression of the score for external criteria on gestation, birthweight and sex, showed a significant contribution for birthweight and sex in addition to gestation; whereas gestation was the only singificant explanatory variable in the regression of the score for neurological criteria. When infants in the three weight groups were matched for length of gestation an sex, the SFD group had significantly lower mean total and external scores than the AFD group. The mean scores for the LFD group were not significantly higher than the AFD group. The neurological scores did not differ in the three groups. Maturation of external characteristics is related to weight as well as gestation. When assessment is made after birth by a clinical examination which includes these characteristics, the length of gestation of some SFD infants will be underestimated. The sex of the infant should also be borne in mind.

Growth and proportionality in early childhood. II. Some population differences.

The postnatal growth patterns of children in four different populations are compared with a sample born and brought up in Oxford. Three indices of proportionality were investigated. Among the three caucasian groups Swedish children had the smallest heads and tallest stature, resulting in particularly low head-chest and head-stature ratios. Denver children had unusually small chest from 2 years onwards; their head-chest ratios were significantly higher than those in Oxford, but head-stature and chest-stature ratios were lower. Japanese children were smaller than Oxford children in all dimensions; but apart from some minor fluctuations they were similar in shape by all three indices used. Guatemalan children of both sexes had extremely high chest-stature ratios from 3 years onwards. Head-stature ratios were also raised, but to a lesser extent. Compared with children in more highly-favoured communities their stature and head circumference were reduced more than weight and chest circumference.

A method of developmental assessment at four years and some associated findings.

A method of assessing the developmental status of 4-year-old children, which can be included in a comprehensive medical examination, is described. It was designed for research purposes, so that a global score, and separate scores for each sector of development, are obtained. Girls, children in the upper social classes, and those who attended nursery school had higher scores, in general, at this age. The importance of assessing and investigating the factors associated with lack of cooperation is stressed.

Hypertension during pregnancy, with and without specific hypotensive treatment. I. Perinatal factors and neonatal morbidity.

In a prospective study, women who were hypertensive before the 28th wk of gestation were randomly allocated into two groups: those who received specific hypotensive therapy (Ht) and those who did not (Hu). The outcome was compared with a random sample of the hospital population (S) ascertained after delivery. In both hypertensive groups there was a higher incidence of clinical signs of possible fetal distress and instrumental delivery. Although there was no difference between the groups in the distribution of birthweight above and below the mean for gestational age, the treated hypertensive group had an excess of infants with relatively smaller head circumferences for their gestational age compared with both the untreated hypertensive group and the hospital sample. Tube-feeding was also more frequent in the treated hypertensive group. In the untreated hypertensive group there were more infants whose neurological status was categorized as questionable or abnormal in the neonatal period, compared with the sample. The different problems encountered by infants in the two hypertensive groups emphasized the need for further study of these babies. Their development during the first year of life will be examined in a subsequent paper.

Hypertension during pregnancy, with and without specific hypotensive treatment. II. The growth and development of the infant in the first year of life.

The growth and development of three groups of infants were prospectively assessed from birth to 12 mth. In two groups the mothers had been hypertensive before the 28th wk of gestation; one group was randomly allocated to specific hypotensive therapy, the other group was allocated to no specific treatment. The third group was a sample of the hospital population. General health, and the incidence of sight and hearing problems did not differ. Infants in the treated hypertensive group had had more perinatal problems, and there was an excess of infants with relatively small heads for their gestational age at birth. At 6 mth their heads were still smaller than the hospital sample, but by the age of 1 yr the difference was no longer present. The neurological status of infants in the untreated hypertensive group was less favourable in the neonatal period, and there was still an excess of infants in this group rated questionable on neurological assessment at the age of 12 mth. In both hypertensive groups there was an excess of infants with delayed fine-motor function at 6 mth, and in the untreated group there was an excess with delayed gross-motor function at 12 mth compared with the hospital sample. Our varied findings draw attention to the dangers of assessing the effects of different pregnancy conditions in terms of neonatal mortality and morbidity alone. Our date indicate that follow-up should extend for longer than 12 mth when the effects of adverse pregnancy factors and their management are under consideration. Further evaluation will be made when these children are 4 yr old.

Induction of labour by different methods in primiparous women. I Some perinatal and postnatal problems.

A personal prospective study was made of some perinatal and postnatal problems associated with induction of labour by three different methods in primiparous women with unripe cervices. The methods of induction were: (A) amniotomy followed by intravenous oxytocin [49], (B) amniotomy followed by intravenous prostaglandin E2 [39], (C) prostaglandin E2 by the extra-amniotic route [42]. A spontaneous group (D) comprising 54 mother--infant pairs was also studied. Length of gestation was between 37 and 42 wk in all but 2 cases. There was no perinatal mortality, and no infant had hyaline membrane disease. A close association was found between method of delivery and method (or absence) or induction. The caesarean section rate was highest in group C and lowest in group D. The spontaneous vaginal delivery rate was lowest in group C and highest in group D. More infants in the three induction groups were admitted to the Special Care Baby Unit (SCBU) than in the spontaneous group. No significant associations were found between the severity of the conditions leading to induction and caesarean section rates, low Apgar scores, admissions to SCBU, or the favourability of the cervix before induction. Among those who intended to breast feed fewer infants in the spontaneous group changed from breast to bottle while in hospital and after discharge from hospital than in the combined induction groups. Success in breast-feeding was not significantly associated with method of delivery or whether the infant was admitted to SCBU or not.

Induction of labour by different methods in primiparous women. II. Neuro-behavioural status of the infants.

The infants of primiparous women in whom labour had been induced by three different methods were studied, together with a fourth group (D) who had laboured spontaneously. The methods of induction were: amniotomy followed by intravenous oxytocin (A), amniotomy followed by intravenous prostaglandin E2 (B), and prostaglandin E2 by the extra-amniotic route (C). Neurological assessments were made on the first day after birth, 4 days later, and at the age of 2 mth. No significant associations were found between method of delivery and neurological scores at any age. On day 1 infants with a lower Apgar score at 1 min had a lower neurological score than those with a high Apgar score (P < 0.05). On day 5 infants with a high serum bilirubin level (> 207 mumol/l) had a lower mean neurological score than those with a lower recorded serum bilirubin level (P < 0.05). By the age of 2 mth this difference had increased still further (P > 0.001). No differences were found in the mean neurological scores of infants in the four groups during the neonatal period, but at the age of 2 mth the mean score for infants in group A was significantly lower than that for infants in group C (P > 0.05) and D (P > 0.01). Among those children seen again at the age of 18 mth fine-motor adaptive performance was poorer for infants in group A than in groups B (P > 0.05), C (P > 0.005) and D (P > 0.01).

The first-born child: patterns of development.

209 first-born infants and their mothers were studied at birth and again two months later in order to learn how they had adapted to post-natal life. Only a small minority had escaped ill-health and also achieved the ideal of a contented breast-fed baby with an established routine. At two months 33-5 per cent were still breast feeding. Difficulties with feeding were reported by 55 per cent of mothers. 24-4 per cent of the babies were having a night feed at two months and 24-8 per cent had not yet established a daytime routine. The daily number of feeds ranged from three to seven, with a median of five. Medical problems had occurred in 46-5 per cent of the babies. Bottle-fed babies had more infections, and were more likely to use a dummy than breast-fed babies. Wakefulness during the daytime ranged from less than four hours to more than 10 hours. Many of these women were over-anxious. The primary care teams and paediatric services face a major task in helping today's primiparous mothers and their infants make a good start in life together.

Factors associated with the blood pressures of children born to women who were hypertensive during pregnancy.

At age 7.5 years the supine blood pressures of 216 children born to women who had been hypertensive during pregnancy were recorded. No associations were found between the blood pressures of the children and their mothers. The blood pressures of children whose mothers received methyldopa during pregnancy did not differ from those of children whose mothers had no specific treatment. Four boys whose mothers had taken methyldopa for more than 150 days had significantly lower systolic and diastolic pressures than those in whom the treatment had been of shorter duration. Significant findings from multiple regression analyses were: positive associations between boys' systolic and diastolic pressures and current weight, and diastolic pressure and maternal weight; negative associations between boys' systolic and diastolic pressures and birthweight; and a positive association between girls' systolic pressure and current weight.

Increased bilirubin levels in neonates after induction of labour by intravenous prostaglandin E2 or oxytocin.

PIP: 4 groups of 30 primigravidas and their infants were studied prospectively. No patient with rhesus incompatibility was included in the study. The 4 groups went into labor in the following ways: 1) induced by intravenous oxytocin; 2) induced by intravenous prostagladin (PG)E2; 3) induced by extraamniotic PGE2; and 4) spontaneous labor. Mean infant bilirubin levels on day 5 were significantly higher (p.005 and p.025 respectively) for the 1st 2 groups than for the spontaneous group. Levels for the group whose labor was induced with extraamniotic PGE2 infusion were not significantly different from those in the 1st 2 groups or the spontaneous group. The mean serum-bilirubin level was significantly lower (p.025) after caesarean section than after assisted vaginal delivery. Serum-bilirubin levels were not affected by previous maternal use of oral contraceptives, maternal smoking, or methods of infant feeding. Serum bilirubin levels below 10 mg/100 ml. are considered within the normal phsyiological limits during the neonatal period. Measured by this criteria, 14, 10, 9, and 6 babies in groups 1-4 respectively had abnormally high levels. The difference between groups 1 and 4 was significant at the p.05 level. Mean Apgar scores were significantly lower for the babies whose mothers had induced delivery with extraamniotic PGE2 infusion. These results suggest that the observed hyperbilirubinemia may be due to interruption of pregnancy rather than to any direct drug effect. There is no evidence to suggest that such high bilirubin levels are harmful to the child in the long run.^ieng

Hypertension during pregnancy with and without specific treatment; the development of the children at the age of four years.

In a controlled trial pregnant women who were hypertensive before the 28th week of gestation were randomly allocated to treatment with methyldopa or no anti-hypertensive treatment. The children from these pregnancies have been re-examined at four years of age and their development compared with a random sample from the same maternity hospital population. Their health, height, weight, and the incidence of sight, hearing and speech problems did not differ. None had gross neurological abnormalities. Boys in the treated hypertensive group had significantly smaller heads than in the other two groups, but there was no correlation between head circumference and developmental score in this group (r = 0.020). On average the children in the random sample were the most advanced when assessed by a global score of development. In each developmental sector the mean score for the treated hypertensive group was consistently higher than the untreated hypertensive group. We conclude that maternal hypertension is associated with slight developmental delay in early childhood. There are some indications that treatment with methyldopa may reduce this effect.

Neonatal head circumference and the treatment of maternal hypertension.

In a random controlled trial of methyldopa for the treatment of hypertension in pregnancy presenting before 28 weeks gestation, the newborn in the treated group had relatively smaller head circumferences. This difference persisted at two months of age when correction had been made for birth weight, gestation and sex, but was no longeer detectable at six or twelve months. Within the treated group no relationship was found between neonatal head circumference and the total amount or duration of methyldopa received during pregnancy. Comparison of treated and untreated groups according to the time of entry to the study showed that significant differences in neonatal head circumference were only present in patients who entered between 16 and 20 weeks gestation. It is possible that this could be a sensitive period for the interaction of fetal head growth and the onset of specific treatment in hypertensive pregnancy.