J Karlberg

Reference values for height, height velocity and weight in Turner's Syndrome

As Northern Europeans are currently the tallest people in the world, specific growth charts for girls with Turners Syndrome from this area are needed. Based on height and weight measurements from 598 girls with Turners Syndrome (372 from the Netherlands, 108 from Denmark, 118 from Sweden) not treated with growth‐promoting substances and without signs of spontaneous puberty, we constructed growth charts for height‐for‐age, height‐velocity‐for‐age, weight‐for‐age, weight‐for‐height and Body Mass Index for age. Reference tables and regression equations for mean and standard deviation are provided allowing calculation of Standard Deviation Scores. The height and height velocity curves show a low birth length, gradual deviation from the normal percentile curves without pubertal growth spurt, and a prolonged growth until the early 20s. Mean adult height was 146. 9 ± 7. 8 cm. Mean weight‐for‐age was lower than in normal reference children but height‐adjusted weight was higher, except in infancy and early childhood. Further studies are required on the factors influencing the weight‐height relationship in Turners Syndrome.

Early child health in Lahore, Pakistan: V. Feeding patterns

The feeding practices of children (n=1476) from birth to 24 months, as determined in a longitudinal study, in Lahore, Pakistan, are presented. Four socioeconomic groups at various levels of urbanization were included; a village, periurban slum, urban slum and an upper middle class. Initiation of breastfeeding was delayed in all the neonates. Sixty‐five percent of the periurban slum mothers and 45% of the village mothers had not started breastfeeding at 48 hours after the birth of the infant. Prelacteal feedings, especially of herb water and honey, were the norm. Breastfeeding was highly prevalent. Eighty‐seven to 98% of the infants in all the areas were breastfed at one month of age. Exclusive breastfeeding was rare, with 9% at one month, declining rapidly with age and being highly influenced by season. Partial breastfeeding was the most common mode of feeding. Water in addition to human milk was given by 45–73 % of the mothers living in the urban slum, village and periurban slum at one month of age. Fresh animal milk and/or commercial formula was already being given at 1 month by 22–64% of the mothers in all areas. Commercial formula was the preferred food in the upper middle class, while in the other three areas it was rare and fresh animal milk was mainly used. More than 50% of the mothers in the village and in the periurban slum gave diluted animal milk even beyond the age of 10–15 months. In the upper middle class 50% of the infants were fed semisolids at the age of four months, while in the village, the periurban and the urban slum at 6 months of age only lo%, 12% and 47% of the infants received semisolids. The results of this study indicate that breastfeeding was highly prevalent in the three poorest areas. However, in all the areas initiation of breastfeeding was delayed and prelacteal feeding was the norm. Exclusive breastfeeding was rare, feeding bottles were used by 82–100% of the mothers to feed supplements and human milk substitutes, in the four areas.

Early child health in Lahore, Pakistan: VII. Diarrhoea

Mahmud A, Jalil F, Karlberg J, Lindblad BS. Early child health in Lahore, Pakistan: VII. Diarrhoea. Acta Paediatr 1993;390(suppl):79–85. Stockholm. ISSN 0803–5326

Early child health in Lahore, Pakistan: X. Mortality

Mortality during the first two years of life among 1476 Pakistani infants born between September 1984 and March 1987 is described according to age, causes of death, area of living, season of the year and sex. The mortality rate (deaths under two years/1000 live births) projected over the whole population of Pakistan was 127 and under one year 114. During the first two years of life, the mortality rate was 133/1000 in the village, 159 in the periurban slum, 107 in the urban slum and 17 in the upper middle class group. In the latter group all deaths had occurred within 72 hours after birth. The overall major causes of death were acute and prolonged diarrhoea (36%), asphyxia neonatorurn (13%), respiratory infections (13%), septicaemia (11%) and tetanus (9%). A clear age dependency was noted with 14% of deaths occurring during the first 24 hours of life (asphyxia neonatorum in 86%), and 57% dying within the first 28 days of life. In the later age groups, infections were mainly responsible for 82% of total deaths. Early mortality was therefore extremely high in the poorer areas studied and the cause of death was highly age dependent. Any interventions for reducing mortality must therefore be directed towards better antenatal care and safe delivery and postnatally, towards preventing infections, especially during the first six months of life.

Distinctions between short- and long-term human growth studies.

It is known what the aim is in a complete long‐term growth study; the final height is the outcome measure, although the annual height velocity values provide additional information. Strictly, short‐term growth studies are also defined in terms of minimum length of observation, i.e. one month, as well as the type of measurement errors to be considered. The poor correlation between short‐ and long‐term growth velocity values has led to the conclusion that the short‐term study cannot be interpreted in long‐term perspectives, and vice versa. There is a need to debate the way in which results of short‐term studies should be interpreted. This is especially important when short‐term growth is taken as the outcome measure in a controlled study. Our proposal is that such studies must include information about the growth achieved for a period after the treatment has ended in order to describe possible compensatory growth. Without weighing in some long‐term consequences, we may incorrectly document short‐term growth as a positive or negative effect of a certain treatment.

Early child health in Lahore, Pakistan: I. Study Design

In this paper, details are given of a community based follow up study of four areas: a village, a periurban slum, an urban slum and an upper middle class control group living in and around Lahore, Pakistan. The aim was to characterize the determinants of child health in a rapidly urbanizing community. The study was undertaken in two steps. An initial cross‐sectional survey collecting socio‐economic and demographic background information was carried out between March to August 1984. This was followed by a longitudinal study of 1476 infants representing the outcome of the pregnancies registered continuously between September 1984 to March 1987 among the 3242 families in the study. These infants were followed monthly from birth to 3 years of age and thereafter less frequently. In this communication we describe the study design, the study population, the organization and the research methodology used, including the reasons for drop outs from birth to 24 months of age. The internal consistency of the data is also presented. After the initial examination of the newborns within between 0–7 days of birth, the infants were visited monthly for 24 months making a total of 20911 examinations. At 24 months of age 70% of the infants were still in the study, 11% had died before reaching this age, 13% had moved from the area and 6% had refused to participate in the study. The economic, conditions, social structure, and the quality of life were found, not surprisingly, to vary significantly among the four areas. This community‐based project provides new, critical and reliable information for local health planners. The study highlights the importance of the development of a useful model for research collaboration between institutions in developed and developing countries.

Early child health in Lahore, Pakistan: IX. Perinatal events

In Pakistan there are a number of acute problems related to maternal and infant health in the perinatal period. There is also lack of reliable data needed for the formulation of action strategies. To provide a database 1490 women have been followed from the 5th month of pregnancy in four different areas at various levels of urbanization and socio‐economic development. After adjusting for gestational age, the proportion of newborns with weight for length < ‐2SDS in relation to the Swedish National Standard was 12–31% for boys and 12–25% for girls, the figure being highest in the most deprived area. Preterm birth was infrequent compared with IUGR. The overall prevalence rate of birth defects was 21% out of which 8% were severe defects. The overall perinatal mortality rate was 56/1000 births, with rates of 60, 75, 36 and 33/1000 births for the village, periurban slum, urban slum and the upper middle class. Two thirds of the deaths were related to either a continuation of intrauterine disturbances or severe congenital defects incompatible with life. One third of the deaths were due to infection; mostly diarrhoea, clinical sepsis and ARI. Neonatal mortality was significantly related to birth length (<‐2SDS, odds ratio 5.5) and length of gestation (<37 weeks, odds ratio 5.6) and was to a lesser extent related to weight (<‐2SDS, odds ratio 2.0) and weight for length (<‐2SDS, odds ratio 1.3). Forty percent of the mothers had weight for height below ‐2SDS, 23–35% had height <‐2SDS. Forty percent of mothers from a subset within the cohort had a hemoglobin < 10 gm/dl and 20% showed signs of pre‐eclampsia. This presentation raises the issue of expanding the current Child Survival Programs into the perinatal period as well.

Early child health in Lahore, Pakistan: VI. Morbidity

Morbidity patterns were studied according to the age, area of living, sex and season among 1476 monthly followed infants born during 1984–1987 in four socio‐economically different areas in Lahore, Pakistan. Infections were responsible for 87.0% of the morbidity during the first two years of life. The overall monthly based morbidity was 77.0% between birth and 24 months of age; diarrhoeal diseases 30.3%, upper and lower acute respiratory tract infections (ARI) 22.4%, skin and eye infections 6.7% and skin rash 6.2%. The vaccine‐preventable diseases were only 0.5% of the total. Anaemia and rickets were rare (2.0%), but commonly seen among the nutritional deficiencies. Diarrhoea, tetanus, septicaemia, AN and infections of the skin and eyes were reported more during earlier ages and from the three poorer areas of living. Diarrhoeal diseases, respiratory tract, skin and eye infections, in particular, followed clear seasonal patterns, while scabies prevailed throughout the year. The presence of these many preventable infections and illnesses implies that proper planning of interventions must be forthcoming.

Early child health in Lahore, Pakistan: II. Inbreeding

The prevalence of consanguineous marriages was studied in 940 families belonging to four different socio‐economic groups in and around Lahore, Pakistan. The births occurring in these families from September 1984 to March 1987 were also investigated for birth defects. The overall prevalence of consanguineous marriages was 46%. The first cousin marriages were most common (67%), followed by the marriages between second cousins, 19%. The prevalence of consanguineous marriages was clearly associated with the socio‐economic status of the study groups; 50% of the marriages was related in the periurban slum, 49% in the village, 44% in the urban slum and 31% in the upper middle class. The birth defects were also more prevalent in the poorer areas, being highest in the periurban slum (17.7%) followed by the urban slum (15.6%) and then the village (14.8%) and lowest in the upper middle class (12.3%). Although, the frequency of both consanguinity and birth defects were related with the socio‐economic levels of the study groups, there was no association between inbreeding and birth defects. Perhaps, deleterious recessive genes for birth defects have been “bred out”, because of continuous inbreeding over generations in this population. There was a significant predilection of major birth defects in boys without clear sex linkage. The conclusion is that the rate of consanguineous marriages was high, especially in the poorer areas, but the relationship between consanguineous marriages and birth defects was little or none. However, other child health indicators may be affected by consanguineous marriages.

Early child health in Lahore, Pakistan: XII. Milestones

Psychomotor development was assessed in 1476 infants from four different levels of urbanization in and around Lahore, Pakistan. Development was assessed monthly at birth to 24 months of age by using a set of 10 milestones selected from the Denver Developmental Screening Test and the Developmental Screening Inventory. The psychomotor development of children in the upper middle (Um) class was consistent with reference population groups in Europe and North America, hence this group was used as control. There was significant delay in the psychomotor development of infants belonging to the poorer areas compared to the Um class. There was no sex difference in the development of the milestones in any study area, except for girls in the Um class who were earlier for about one month than boys in talking. Infants in the poorer areas were, on average about 3 months, delayed in their walking and fine motor activity (building a tower of 3 cubes) in comparison with the Um class. Observed disturbance in psychomotor development at an early age may affect the abilities and achievements in later life.