Does birth weight predict adult serum cortisol concentrations? Twenty-four-hour profiles in the United kingdom 1920-1930 Hertfordshire Birth Cohort.

Low birth weight and weight in infancy are associated with adult insulin resistance and type 2 diabetes. A proposed mechanism is programming of the hypothalamic-pituitary-adrenal axis by intrauterine undernutrition, leading to persistently elevated cortisol concentrations. We examined 24-h serum cortisol profiles (samples every 20 min) in 83 healthy elderly men and women whose birth weight and infant weight were recorded. Variables derived from these profiles included trough, peak, and area under the curve concentrations; the time of onset, rate of rise, duration, and peak of the early morning cortisol rise; postprandial secretion; and regularity of secretion (approximate entropy). None of these parameters was related to birth weight, weight at 1 yr, or change in weight SD score between birth and 1 yr. Consistent with other studies, 0730-0900 h cortisol concentrations were higher in men and women of lower birth weight, although this was not statistically significant (P = 0.08). Our findings do not support the hypothesis that reduced intrauterine and infant growth are associated with continuously raised cortisol concentrations in old age. Programmed effects on the hypothalamic-pituitary-adrenal axis may influence reactivity rather than resting secretion.

Insulin resistance syndrome in 8-year-old Indian children: small at birth, big at 8 years, or both?

We have studied 477 8-year-old Indian children to define the relationship between birth weight and cardiovascular risk factors, including insulin resistance syndrome (IRS) variables and plasma total and LDL cholesterol concentrations. All risk factors were strongly related to current weight. After adjustment for current weight, age, and sex, lower birth weight was associated with higher systolic blood pressure (P = 0.008), fasting plasma insulin and 32-33 split proinsulin concentrations (P = 0.08 and 0.02), glucose and insulin concentrations 30 min postglucose (P = 0.06 and 0.04), subscapular/triceps skinfold ratio (P = 0.003), and plasma total and LDL cholesterol concentrations (P = 0.002 and 0.001). Lower birth weight was associated with increased calculated insulin resistance (homeostasis model assessment [HOMA], P = 0.03), but was not related to the HOMA index of beta-cell function. The highest levels of IRS variables and total and LDL cholesterol were in children of low birth weight but high fat mass at 8 years. Taller height at 8 years predicted higher fasting plasma insulin concentrations, insulin resistance, and plasma total and LDL cholesterol concentrations. The most insulin-resistant children were those who had short parents but had themselves grown tall. Although the implications of our findings in relation to height are unclear, interventions to improve fetal growth and to control obesity in childhood are likely to be important factors in the prevention of cardiovascular disease and IRS in India.

Pallor as a clinical sign of severe anaemia in children: an investigation in the Gambia.

Anaemia associated with malaria is a major public health problem in African countries. Since most primary health facilities have to rely on physical signs and not laboratory tests to detect anaemic patients who need referral for blood transfusion, we have assessed the reliability of simple clinical signs to predict severe anaemia. A trained field assistant examined 368 children admitted to a tertiary care hospital, assessing the pallor of their eyelids (conjunctiva), palms and nailbeds, counting the respiratory rate, and looking for signs of respiratory distress. After the children's admission, their packed cell volume (PCV) was measured, and the need for transfusion and the outcomes were noted. A second observer examined 173 of these children so that interobserver variability in the detection of clinical signs could be assessed. A total of 27% of the 368 children had a PCV of < 15%. In a multiple regression analysis, definite pallor of the conjunctiva, definite pallor of the palms, and a "sick" appearance of the child were identified as independent significant predictors of a PCV of < 15%. The best predictor was a combination of definite pallor of the conjunctiva and pallor of the palms, with a sensitivity of 80% and a specificity of 85%. Inclusion of signs of respiratory distress did not improve the prediction. Pallor was a reproducible sign (weighted kappa statistic for the comparison between two observers: kappa = 0.6 for conjunctival pallor). We conclude that pallor can be used as a sign for referring children who may require blood transfusion.

PIP: Most primary health care facilities in Africa, must rely on physical signs, rather than expensive laboratory tests, to detect anemic patients in need of referral for blood transfusion. This study assessed the reliability of simple clinical signs to predict severe anemia in 368 children, admitted to a tertiary care hospital (Royal Victoria) in the Gambia, primarily with malaria. A trained field assistant examined each child, assessing pallor of the conjunctiva, palms, and nailbeds, on a scale of 0 (no pallor) to 3 (definite severe pallor), and looked for signs of respiratory distress. Examination of 173 of these children by a second observer confirmed inter-observer consistency in the detection of pallor. After the children's admission, their packed cell volume (PCV) was measured. 27% of the children had a PCV under 15%, indicative of severe anemia. Multiple regression analysis identified definite pallor of the conjunctiva, definite pallor of the palms, and a "sick" appearance as significant independent predictors of a PCV under 15%. The best predictor, a combination of definite pallor of the conjunctiva and definite pallor of the palms, had a positive predictive value of 67%, a sensitivity of 80%, and a specificity of 85%. Inclusion of signs of respiratory distress did not improve the prediction. These findings indicate that definite pallor of the conjunctiva, alone or in combination with definite pallor of the palms, can be used in primary health care centers to predict severe anemia with high precision.