Reinoud J. B. J. Gemke

Antenatal maternal anxiety is associated with problem behaviour at age five

BACKGROUNDnDevelopmental programming by maternal stress during pregnancy is found to influence behavioural development in the offspring.nnnAIMnTo prospectively investigate the association between antenatal maternal anxiety and childrens behaviour rated by their mothers and teachers.nnnMETHODSnIn a large, community based birth-cohort (the ABCD-study) antenatal maternal state-anxiety (M = 36.7, SD = 9.8) was measured around the 16th week of gestation. Five years later, 3,446 mothers and 3,520 teachers evaluated 3,758 childrens overall problem behaviour, emotional symptoms, conduct problems, hyperactivity/inattention problems, peer relationship problems and pro-social behaviour.nnnRESULTSnHierarchical multiple regression analysis using a large number of potential covariates revealed that children of mothers who reported higher levels of anxiety during their pregnancy showed more overall problem behaviour, hyperactivity/inattention problems, emotional symptoms, peer relationship problems, conduct problems and showed less pro-social behaviour when mothers rated their childs behaviour. When teachers rated child behaviour, children showed more overall problem behaviour and less pro-social behaviour that was related to antenatal anxiety. The childs sex moderated the association between antenatal anxiety with overall problem behaviour and hyperactivity/inattention problems when reported by the mother. In boys, exposure to antenatal anxiety was associated with a stronger increase in overall problem behaviour compared to girls. Furthermore, antenatal anxiety was significantly related to an increase in hyperactivity/inattention problems in boys, while this was not the case in girls.nnnCONCLUSIONSnExposure to antenatal maternal anxiety is associated with childrens problem behaviour, with different outcome patterns for both sexes. Nevertheless, effect sizes in this study were small.

Circumstances of dying in hospitalized children

Abstract Conditions of dying in a tertiary childrens hospital were assessed in a retrospective cohort study. Non-survivors, excluding newborns and emergency room patients, were allocated to four groups: brain death (BD), failed cardiopulmonary resuscitation (failed CPR), death following a do-not-resuscitate (DNR) order and death following withholding or withdrawal of therapy (W/W). In a 4-year period 190 (1.3%) of 14,903 admitted patients died. Of these 134 (71%) died on the paediatric intensive care unit, 42u2009(22%) on the ward and 14 (7%) in the operating room. W/W was found in 75 (39%), failed CPR in 57 (30%), BD in 32 (17%), and death following a DNR order in 26 (14%). Justifications for restrictions of treatment (W/W or DNR) were imminent death in 41u2009(41%), lack of future relational potential in 13 (13%) and excessive burden of disease in 47 (47%). In non-survivors analgesics and sedatives were frequently used to relieve suffering in the terminal phase. General principles for the approach of terminally ill children in whom death may become an option instead of a fate are discussed.nConclusion In the majority of children dying in hospital, death occurred following restrictions of life-sustaining treatment, comprising do-not-resuscitate or other forms of withholding or withdrawal of therapy.

Maternal pre-pregnancy body mass index explains infant’s weight and BMI at 14 months: results from a multi-ethnic birth cohort study

Objective: To investigate the association between (self-reported) maternal pre-pregnancy body mass index (pBMI), and child’s weight, height and BMI at age 14 months. Design: Prospective multi-ethnic community-based cohort study. Setting: Amsterdam, The Netherlands. Participants: 8266 pregnant women from the Amsterdam Born Children and their Development study, filled out a questionnaire covering socio-demographic data, obstetric history, lifestyle, dietary habits and psychosocial factors, 2 weeks after their first antenatal visit. 7730 gave birth to a viable term singleton infant with information on birth weight, gender and pregnancy duration. Growth data were available for 3171 of these children. Main outcome measures: Weight (g), height (cm) and BMI (kg/m2) of the child at age 14 months. Results: pBMI was linearly associated with weight and BMI of the child at age 14 months. One unit increase in pBMI resulted in an increment of 29 g (95% CI 19 to 39) in weight and 0.041 kg/m2 (95% CI 0.030 to 0.053) in BMI. The effect size decreased after adjustment for birth weight (weight: β coefficient 19 g, 95% CI 10 to 28; BMI: β coefficient 0.034 kg/m2, 95% CI 0.023 to 0.046) and hardly changed after adjustment for all other variables (weight: β coefficient 21 g, 95% CI 11 to 30; BMI: β coefficient 0.031 kg/m2, 95% CI 0.019 to 0.043). pBMI was not related to height. Conclusions: pBMI is an independent determinant of weight and BMI of the child at age 14 months. At least one third of this effect is mediated through birth weight.

Ventilator-associated pneumonia and upper airway colonisation with Gram negative bacilli: the role of stress ulcer prophylaxis in children

AbstractObjective. To assess the risk of ventilator-associated pneumonia (VAP) and the incidence of upper airway colonisation related to the use of stress ulcer prophylaxis in critically ill children.n Design. Retrospective study.n Setting. Paediatric intensive care unit (PICU) of a tertiary care centre.n Patients. All children who were mechanically ventilated for more than 48xa0h.n Interventions. None.n Results. A total of 54 patients were given ranitidine, 53 patients were given sucralfate and 48 patients were given no stress ulcer prophylaxis. Thirteen (8.4%) patients developed VAP: 6 (11.1%) patients in the ranitidine group, 4 (7.5%) in the sucralfate group and 3 (6.2%) in the group without prophylaxis. The rate of upper airway colonisation with Gram negative bacilli was 25.9% (14/54) in the ranitidine group, 22.6% (12/53) in the sucralfate group and 37.5% (18/48) in the group without prophylaxis. The differences among the groups were not significant.n Conclusions. In contrast to findings in adults, we found that, in children, sucralfate does not decrease the incidence of VAP or the incidence of upper airway colonisation with Gram negative bacilli as compared to ranitidine or no stress ulcer prophylaxis. However, the small sample size and study design substantially limit our conclusions.

Psychological outcome and quality of life in children born with congenital diaphragmatic hernia

Objective: To assess psychological and social functioning and health related quality of life and its early determinants in children born with congenital diaphragmatic hernia (CDH). Design: Cross-sectional follow-up study. Setting: Outpatient clinic of a tertiary care hospital. Participants: 33 CDH survivors aged 6–16 years. Main exposure: Patients who developed CDH associated respiratory distress within 24 h after birth. Main outcome measure: Psychological and social functioning assessed with the Wechsler Intelligence Scale for Children (WISC-R), Bourdon-Vos test, Beery Developmental Test of Visual Motor Integration, Child Behavior Checklist (CBCL) and Teacher Report Form (TRF), and health related quality of life assessed with the Child Health Questionnaire (CHQ) and Health Utilities Index (HUI). Results: Normal mean (SD) total IQ (100.0 (13.2)) and normal visual-motor integration, but significantly lower results for sustained attention (Bourdon-Vos test, 38.8 (11.2) points) were found. Learning difficulties were reported by 30% of parents. Eight children had scores in the clinical range on the CBCL and/or TRF, indicating clinically significant behavioural problems. Except for the CHQ scale General Health, health status was not different from the reference population. No significant correlations between test results and severity of CDH were found, except for an association of general health and physical functioning with length of hospital stay. Conclusion: CDH patients are at risk for subtle cognitive and behavioural problems, probably not related to CDH severity. Perception of general health is reduced compared to the reference population, indicating that CDH survivors and their parents believe their health is poor and likely to get worse.

Congenital Diaphragmatic Hernia: Long-term Risk of Gastroesophageal Reflux Disease

Objectives: Gastroesophageal reflux disease (GERD) is a well-recognized consequence of congenital diaphragmatic hernia (CDH). Results of studies examining predictive factors for early and late GERD are inconclusive. The aim of this study was to assess the incidence of early (<2 years) and late GERD (≥6 years) following CDH repair and to identify predictive variables. Patients and Methods: Of 183 patients born with high-risk CDH, 107 survived and 38 were excluded. Perinatal and postnatal data of 69 eligible patients were analysed to identify variables predictive for early GERD. For the follow-up study, 58 patients (84%) (ages 12.1 ± 3.4 years; range 6–17) completed a standardised questionnaire. Results were compared with those from a healthy control group (n = 83). Patients who had a score indicating increased risk of GERD underwent further diagnostic assessment. Predictive factors for early and late GERD were identified using multivariate regression analysis. Results: Early GERD was demonstrated in 27 patients (39%). Patch closure and intrathoracic position of the stomach were independent predictive variables for early GERD. At the time of follow-up, 9 of 58 patients (16%) had symptoms suggestive of GERD. In 7 patients (12%), late GERD was confirmed. For late GERD, however, no perinatal or postnatal risk factors were identified. Conclusions: Early GERD is more common in CDH patients with patch closure or intrathoracic position of the stomach. Predictive factors for late GERD could not be identified and screening for early GERD does not protect for future GERD; therefore, long-term follow-up for GERD in CDH survivors is mandatory.

Pediatric intensive care: result of a European survey

AbstractnObjective. To assess and compare the structure, organisation, management, and staffing in different paediatric intensive care units (PICUs) in Europe.nDesign. Descriptive study.nSetting. A questionnaire was sent to physicians in PICUs. Physicians names were obtained from the membership list of the European Society of Paediatric and Neonatal Intensive Care.nInterventions. None.nParticipants. Physicians from 92 European PICUs.nMeasurements and main results. Responses were obtained from 92 PICUs (60% of those surveyed, 64% of hospitals with PICUs). A blank response was obtained in <2% of the questions. Considerable diversity in structure, organisation, staffing, and management in European PICUs was found. Significant differences were observed in unit size, which ranged from 2–56 (average: 8–10) beds/unit. In several – predominantly German-speaking – countries paediatric and neonatal intensive care beds are frequently combined in single units. Most European PICUs (98%) had at least part-time coverage by a paediatric intensivist; 78% had 24-h intensivist coverage. Specialized PICU nurses were present in 98% of European PICUs, and most (75%) had 24-h physician coverage by a physician with no responsibilities outside the PICU.nConclusions. Data obtained in our survey demonstrate the substantial structural, organisational management, and staff diversity of paediatric ICUs. Most European PICUs employ specialized PICU nurses and have at least part time coverage by paediatric intensivists.

Overweight at age two years in a multi-ethnic cohort (ABCD study): the role of prenatal factors, birth outcomes and postnatal factors

BackgroundChildhood overweight/obesity is a major public health problem worldwide which disproportionally affects specific ethnic groups. Little is known about whether such differences already exist at an early age and which factors contribute to these ethnic differences. Therefore, the present study assessed possible ethnic differences in overweight at age 2 years, and the potential explanatory role of prenatal factors, birth outcomes and postnatal factors.MethodsData were derived from a multi-ethnic cohort in the Netherlands (the ABCD study). Weight and height data of 3,156 singleton infants at age 2 years were used. Five ethnic populations were distinguished: Dutch native (n = 1,718), African descent (n = 238), Turkish (n = 162), Moroccan (n = 245) and other non-Dutch (n = 793). Overweight status was defined by the International Obesity Task Force guidelines. The explanatory role of prenatal factors, birth outcomes and postnatal factors in ethnic disparities in overweight (including obesity) was assessed by logistic regression analysis.ResultsCompared to the native Dutch (7.1%), prevalence of overweight was higher in the Turkish (19.8%) and Moroccan (16.7%) group, whereas the prevalence was not increased in the African descent (9.2%) and other non-Dutch (8.8%) group. Although maternal pre-pregnancy body mass index partly explained the ethnic differences, the odds ratio (OR) of being overweight remained higher in the Turkish (OR: 2.66; 95%CI: 1.56-4.53) and Moroccan (OR: 2.11; 95%CI: 1.31-3.38) groups after adjusting for prenatal factors. The remaining differences were largely accounted for by weight gain during the first 6 months of life (postnatal factor). Maternal height, birth weight and gender were independent predictors for overweight at age 2 years, but did not explain the ethnic differences.ConclusionTurkish and Moroccan children in the Netherlands have 2- to 3-fold higher odds for being overweight at age 2 years, which is largely attributed to maternal pre-pregnancy BMI and weight gain during the first 6 months of life. Further study on the underlying factors of this early weight gain is required to tackle ethnic differences in overweight among these children.

High levels of antenatal maternal anxiety are associated with altered cognitive control in five-year-old children

This longitudinal prospective study examined the relation between maternal anxiety during pregnancy and specific aspects of childrens cognitive functioning at age five. Antenatal maternal state-anxiety was measured around the 16th week of pregnancy. Childrens neurocognitive functioning was examined using a simple reaction time (RT) task, and a choice RT task. Multiple regression analyses in the total sample (Nu2009=u2009922) showed that antenatal anxiety was positively related to childrens intra-individual variability in RT in the simple task. In a subsample (nu2009=u2009100) of women with state-anxiety scores above the 90th percentile, antenatal anxiety was positively associated with mean RT and intra-individual variability in RT in the incompatible trials of the choice RT task. In addition, in this subsample of highly anxious mothers we found a significant positive association in boys but not in girls, between prenatal maternal anxiety and intra-individual variability in RT in the simple task.

Ethnic differences in maternal underestimation of offspring's weight: the ABCD study

OBJECTIVE:To determine the ethnic variation in maternal underestimation of their childs weight status and the explanatory role of socio-economic status (SES), acculturation and parental body mass index (BMI).METHOD:A multi-ethnic sample of 2769 normal or overweight/obese children (underweight children excluded) aged 5–7 years was examined (The Amsterdam Born Child and their Development study), comprising five ethnic subgroups: Dutch (n=1744), African descent (n=184), Turkish (n=86), Moroccan (n=161) and other non-Dutch (n=592). Data on mothers’ perception of their childs weight status (5-point scale from ‘too low’ to ‘too high’), SES, acculturation, parental BMI and the childrens height and weight were collected. Underestimation was defined by comparing maternal perception with the actual weight status of her child (International Obesity Task Force guidelines). Ethnic differences in underestimation were calculated in the normal weight and overweight/obese categories.RESULTS:Underestimation ranged from 3.6 (Dutch) to 15.7% (Moroccan) in normal-weight children, and from 73.0 (Dutch) to 92.3% (Turkish) in overweight/obese children. After correction for ethnic differences in childs BMI, higher odds ratios (ORs) for underestimation were found in the Turkish (normal weight: OR 6.83; 95% confidence interval (CI) 2.33–20.05 and overweight: OR 2.80; 95% CI 1.12–6.98) and Moroccan (normal weight: OR 11.55; 95% CI 5.28–25.26) groups (reference is the Dutch group). Maternal educational level and immigrant generation largely explained the ethnic differences, with a minor contribution of maternal age. After correction, ORs remained higher in the Moroccan group (OR 4.37; 95% CI 1.79–10.62) among the normal-weight children.CONCLUSION:Mothers frequently underestimate the actual weight status of their child, especially mothers from Turkish or Moroccan origin. Having a lower SES, being first-generation immigrant and a young mother are important determinants in explaining these differences. As weight perceptions may affect weight gain and almost all mothers of overweight/obese children underestimate their childs weight, health professionals should help mothers (particularly those from ethnic minority groups) to acquire a realistic perception of their childrens weight status.