Birgitte Weile

Failure to thrive: the prevalence and concurrence of anthropometric criteria in a general infant population

Background: Failure to thrive (FTT) in early childhood is associated with subsequent developmental delay and is recognised to reflect relative undernutrition. Although the concept of FTT is widely used, no consensus exists regarding a specific definition, and it is unclear to what extent different anthropometric definitions concur. Objective: To compare the prevalence and concurrence of different anthropometric criteria for FTT and test the sensitivity and positive predictive values of these in detecting children with “significant undernutrition”, defined as the combination of slow conditional weight gain and low body mass index (BMI). Methods: Seven criteria of FTT, including low weight for age, low BMI, low conditional weight gain and Waterlow’s criterion for wasting, were applied to a birth cohort of 6090 Danish infants. The criteria were compared in two age groups: 2–6 and 6–11 months of life. Results: 27% of infants met one or more criteria in at least one of the two age groups. The concurrence among the criteria was generally poor, with most children identified by only one criterion. Positive predictive values of different criteria ranged from 1% to 58%. Most single criteria identified either less than half the cases of significant undernutrition (found in 3%) or included far too many, thus having a low positive predictive value. Children with low weight for height tended to be relatively tall. Conclusions: No single measurement on its own seems to be adequate for identifying nutritional growth delay. Further longitudinal population studies are needed to investigate the discriminating power of different criteria in detecting significant undernutrition and subsequent outcomes.

Striking differences in the incidence of childhood celiac disease between Denmark and Sweden : a plausible explanation

Summary Among 771 children (381 Swedish and 390 Danish) investigated between 1972 and 1989 because of suspected celiac disease (CD), 179 proved to have the disease. Surprisingly only 24 CD patients were found among the Danish children, compared with 155 in the Swedish group, despite the close ethnic, geographical, and cultural background of the two populations. The Swedish CD children were diagnosed at an earlier age than the Danish children (mean, 1.5 vs. 5.5 years). The symptoms of the Swedish patients were dominated by failure to thrive (93 vs. 71%), whereas a higher proportion of the Danish CD patients suffered from stomach pain (21 vs. 5%). Breast-feeding habits were comparable. The estimated content of gliadin in the officially recommended diets of the two countries in 1987 differed substantially, the Swedish diet containing more than 40 times more gliadin than the Danish (4,400 vs. 100 mg) at the age of 8 months, and 4 times more (3,600 vs. 900 mg) at the age of 12 months. The Danish infant diet differed significantly from the Swedish in containing a larger amount of the lower gluten-containing rye flour. The earlier introduction of food items with a high gluten content in the Swedish compared with the Danish diet seems to be an obvious explanation for the great difference in incidence and symptomatology of CD between the two populations.

High prevalence rates of adult silent coeliac disease, as seen in Sweden, must be expected in Denmark.

Aim: To disclose the prevalence of adult “silent” coeliac disease in Denmark and Sweden. Experimental design: 1573 Danish and 1866 Swedish healthy blood donors were screened for the presence of serum anti‐gliadin antibodies (AGA) by enzyme‐linked immunosorbent assay. AGA‐positive serum samples were further analysed for IgA anti‐endomysium antibodies (EmA) by indirect immunofluorescence microscopy. Main results: The Danish donor population had a higher mean age than the Swedish (41.4 years versus 37.6 years) and a higher proportion of females (41% versus 32%), and had a lower mean level of AGA (17.3 units versus 20.6 units). Sixty‐one (3.9%) Danish donors had AGA above the cut‐off limit, and four of these also had positive EmA tests. Sixty (3.2%) Swedish donors had AGA above the cut‐off limit, and five of these also had positive EmA. Coeliac pathology was proven by biopsy in all five coeliac disease‐suspected Swedish donors. No small intestinal biopsy was performed in the coeliac disease‐suspected Danish donors. Conclusions: Based upon the finding of EmA in AGA‐positive serum samples, silent coeliac disease may be suspected in 1 per 394 Danish blood donors (2.5 per 1,000). A similar rate was proven in 1 per 373 Swedish blood donors (2.7 per 1,000), indicating no major differences in the prevalence of adult silent coeliac disease between the two neighbouring countries.

Interobserver variation in diagnosing coeliac disease. a joint study by Danish and Swedish pathologists

There is an almost 40‐fold difference in incidence rates of symptomatic coeliac disease between Denmark and Sweden. In an attempt to explain this difference, the present study focused on the interobserver agreement when pathologists were assessing small intestinal biopsy specimens from children suspected of suffering from coeliac disease. The study was performed on 90 biopsy specimens from 73 children. Most of the biopsies came from children who turned out not to suffer from coeliac disease after a clinical evaluation including small intestinal biopsy. Using the kappa methodology, the interobserver agreement between two Danish pathologists and one Swedish pathologist, all of whom were experienced, was “moderate” to “substantial” or 0.57–0.75. Kappa indices when the pathologists evaluated selected histological elements were in the interval from 0.24 to 0.67. A comparison of a previous routine diagnostic assessment of the 90 biopsies (14 pathologists) with the results of the experienced pathologists in the present study gave kappa indices of from 0.53 to 0.57. The study could prove no major differences in the histopathological assessment of small intestinal biopsy specimens made by Danish and Swedish pathologists. The difference in clinical presentation of coeliac disease in Denmark and Sweden does not relate to differences in the histopathological assessment of small intestinal biopsies.

Low incidence rates by birth of symptomatic coeliac disease in a Danish population of children

Using the original diagnostic criteria of the European Society for Paediatric Gastroenterology and Nutrition for symptomatic coeliac disease in children, we found an average incidence rate by birth of 0.10 per 1000 live births in a demographically homogeneous Danish population over a 15‐year period. This incidence rate by birth is the lowest described in an epidemiological study in contrast with rates of 0.33 to 8 per 1000 live births found in other western countries. This difference may be explained by the different diagnostic criteria used for coeliac disease. Another contributing factor may be a late and gradual introduction of gluten‐containing cereals into the diet of Danish infants.

Extremely low incidence rates of celiac disease in the danish population of children

Incidence rates by birth of celiac disease of 0.09 per 1000 live births were described for the period 1960-88 in the entire Danish population. Broad diagnostic criteria were used in order to prevent the risk of under-diagnosing the disease. The observations support previous local reports from Copenhagen County of low incidence rates by birth of celiac disease. The study presents the lowest incidence rate by birth of celiac disease yet described.

Insulin-like growth factor-I in celiac disease.

To contribute to the description of the physiopathological mechanisms of celiac disease, changes in insulin-like growth factor I (IGF-I) were folio wed-up in 21 children suspected of suffering from celiac disease. Thirteen children were suffering from celiac disease according to the original criteria of the European Society of Paediatric Gastroenterology and Nutrition. Ten celiac children changing from a gluten-containing to a gluten-free diet presented a significant rise in IGF-I (+1.54 mM per month). In a group of eight celiac children challenged with gluten, seven had a significant decrease in IGF-I (-1.11 mM per month), and five celiac children returning to the gluten-free diet after challenge with gluten had a marked but not significant increase in IGF-I (+1.7 mM per month). Eight children not suffering from celiac disease, but challenged with gluten, had a significant increase in IGF-I (+ 0.29 mM per month), corresponding to the expected age-dependent increase. The significant changes in IGF-I described under the diagnostic dietetic phases of celiac disease reflect the extent of growth retardation caused by the disease. IGF-I may be a supplementary aid in the diagnosis of celiac disease in describing individual changes under the dietetic phases.

Infant feeding patterns during the first year of life in Denmark: Factors associated with the discontinuation of breast-feeding

We prospectively studied 500 infants born consecutively in a university-affiliated community hospital in Copenhagen, Denmark, over the first 12 months of life using a detailed monthly mailed questionnaire (overall response rate = 73%) which focused on feeding practices and illnesses. Seventy-seven percent of respondents breast-fed their infants at 1 month of life compared to 19% at 12 months of life. Analysis of breast-feeding behavior using survival analysis showed that 50% of the mothers who breast-fed since the first month of their infants life were still breast-feeding at 7 months of life. Also, there was a greater than two-fold increase in the rate of discontinuation of breast-feeding for infants in daycare compared to infants not attending daycare (RR = 2.08, 95% CI = 1.43, 3.01). Discontinuation of breast-feeding was not significantly associated with the number of children in the family or with social class. These results give insight into infant feeding patterns in a developed country and suggest that: (1) breast-feeding is the dominant method of feeding during the infants first year of life, and (2) the rate of discontinuation of breast-feeding is increased by the entry of these infants into daycare.

Does the low intake of wheat in Danish infants cause the low incidence rate of coeliac disease

Does the low intake of wheat in Danish infants cause the low incidence rate of coeliac disease?

The relationship between Apgar score, umbilical artery pH and operative delivery for fetal distress in 2778 infants born at term

A total of 2778 infants born at term were studied to determine the relationship between Apgar scores after 1 min, umbilical artery pH values, mode of delivery, a diagnosis of fetal distress leading to operative delivery, and sex. Eighty-three percent of the population had normal Apgar scores (greater than or equal to 8) and normal pH values (greater than 7.15) in which 10% were operatively delivered for fetal distress (ODFD). Sixty-one percent of the children with low Apgar scores (less than or equal to 7) had normal pH values, and 74% of the infants with acidosis (pH less than or equal to 7.15) had normal Apgar score. Twenty-four percent of the infants with a low Apgar score and/or acidosis were ODFD (sensitivity). Ninety percent of the infants who had Apgar scores and pH values were not ODFD (specificity). The predictive value (a low Apgar score and/or acidosis) of ODFD was 33%, and the negative predictive value (normal Apgar score and a normal pH) of ODFD was 85%. A significantly higher incidence of ODFD and acidosis was found in boys.