One-year follow-up of the outcome of a randomized controlled trial of a home-based intervention programme for children with autism and developmental delay and their families.

INTRODUCTION: There is debate about the type and intensity of early childhood intervention that is most helpful for children with developmental problems. The aim of the study was to determine whether a home-based programme provided over 12 months resulted in sustained improvement in development and behaviour 12 months after the intervention ceased. The characteristics of the children and families who benefited most from the intervention were also studied. METHOD: Randomized controlled trial. Participants A total of 59 children, aged 3-5 years, attending two early childhood intervention centres in Melbourne, Australia. Intervention Half of the subjects received an additional home-based programme consisting of 40 weekly visits. MAIN OUTCOME MEASURES: Bayley Scales of Infant Development and Wechsler Preschool and Primary Scale of Intelligence Revised, Preschool Behaviour Checklist, Bayley Behaviour Rating Scale and Behaviour Screening Questionnaire. All tests administered pre-intervention, following the intervention and 12 months later. Secondary outcome measures Family stress, support and empowerment. RESULTS: Fifty-four children completed the assessments 12 months after conclusion of the intervention. Compared with the control group, improvement in aspects of cognitive development in the children who received the extra intervention was sustained 1 year later (P= 0.007) while significant behavioural differences post intervention were not. Analyses of the data by the Reliable Change Index indicated improvement of clinical significance occurred in non-verbal areas. In contrast to the control group who deteriorated, language skills in the intervention group remained stable. Improvements were significantly associated with higher stress in the families. CONCLUSION: Improvements following the provision of a home-based programme to preschool children with developmental disabilities were sustained 1 year later. Children from highly stressed families appeared to benefit most, reinforcing the importance of involving families in early childhood intervention programmes.

Cerebral palsy in Victoria, Australia: mortality and causes of death.

OBJECTIVE: To study the causes of death and the characteristics of children with cerebral palsy that had died over a 25-year period in Victoria, Australia. METHODOLOGY: Names of children that had died were collected from the Victorian Cerebral Palsy Register. Their hospital records were studied and information was gathered about age of death, motor impairment, the presence or absence of associated disabilities and cause of death. RESULTS: One hundred and fifty-five children had died during the period 1970-95. The majority of children had severe spastic quadriplegia, intellectual disability and epilepsy. The predominant cause of death was pneumonia, although for many children who died at home the cause was unknown. CONCLUSIONS: Children with cerebral palsy are a diverse group and those with a severe motor deficit have a reduced life expectancy. Lung disease remains an important cause of morbidity and mortality for this group. Further information about the causes of death is needed, particularly for those children that die at home.

Maternal serum triglyceride, glucose tolerance, and neonatal birth weight ratio in pregnancy.

OBJECTIVE: To determine the value of measuring serum triglyceride (TG) levels early in pregnancy for predicting late-gestation glucose tolerance and neonatal birth weight ratio (BWR) (birth weight corrected for gestational age). RESEARCH DESIGN AND METHODS: The relationships between morning nonfasting TG measured early in pregnancy (gestational age 12 +/- 6 weeks [mean +/- SD]) and glucose tolerance measured by a 3-h 50-g oral glucose tolerance test (OGTT) late in pregnancy (gestational age 30 +/- 3 weeks) and BWR were investigated in 388 women attending routine antenatal care. The data were analyzed for all women in addition to subgroups of Australian/Western European-born (n = 246) and Asian-born (n = 97) women. RESULTS: Morning nonfasting TG positively correlated with the OGTT glucose area under the curve (OGTT-GAUC) (r = 0.23, P < 0.0001) in all subjects. This correlation was stronger in the subset of subjects who had TG measured between 9 and 12 weeks of gestation (r = 0.35, P = 0.0001) and was particularly strong in Asian-born women who had TG measured within this period (r = 0.71, P < 0.0001). Mean TG and the 2- and 3-h OGTT values were higher in Asian-born subjects compared with Australian/Western European-born subjects (P = 0.004, P < 0.0001, and P = 0.02, respectively). TG correlated positively with BWR in all subjects (r = 0.12, P = 0.02), in Asian-born subjects (r = 0.23, P = 0.02), and in subjects with gestational diabetes mellitus (GDM) (r = 0.60, P = < 0.001). CONCLUSIONS: TG, if measured between 9 and 12 weeks of gestation, has moderate predictive value for subsequent glucose tolerance in pregnancy. TG is also predictive of BWR in GDM subjects. Further studies are warranted to investigate the role of early TG measurement in the screening and management of GDM. Metabolic heterogeneity exists between Asian-born and Australian/Western European-born women, the significance of which is still unclear and warrants further study.

Amniotic fluid insulin values in women with gestational diabetes as a predictor of emerging diabetes mellitus.

Amniotic fluid insulin levels were estimated in 30 women with insulin-dependent diabetes, 216 with gestational diabetes and 27 with normal glucose tolerance. Results were correlated with birth-weight, incidences of fetal macrosomia and neonatal hypoglycaemia, and the risk of the mothers with gestational diabetes developing diabetes mellitus on follow-up. The women with prepregnancy diabetes had significantly higher amniotic fluid insulin values and showed a significant correlation between raised liquor insulin values (> 97th percentile) and hypoglycaemia in the infant (p = 0.039). In the gestational diabetic pregnancies there were highly significant associations between elevated liquor insulin values and macrosomia (p < 0.0045) and birth-weight (p < 0.00004), and a weak correlation with neonatal blood glucose levels (p = 0.042). Women with gestational diabetes who later developed permanent diabetes mellitus had higher mean amniotic fluid insulin levels than those whose glucose tolerance remained normal on follow-up (p < or = 0.0072) and more of them had a level greater than the 97th percentile than those whose glucose tolerance remained normal (odds ratio 6.48, 95% confidence interval 1.51-27.8, p = 0.0094). However a high amniotic fluid insulin level was of less clinical value for detection of women destined to develop diabetes (7 of 25, 28%) than was the need for insulin therapy during pregnancy (18 of 39, 46%).

Gestational diabetes and follow-up among immigrant Vietnam-born women.

Gestational diabetes is associated with an increased risk of fetal macrosomia and perinatal death. Immigrant mothers from Vietnam who delivered in the Mercy Hospital for Women between January 1, 1979 and December 31, 1990 were investigated to assess their risk of gestational diabetes, the factors that were associated with gestational diabetes, and the prevalence of diabetes mellitus on follow-up. These mothers were compared with Australian-born mothers attending the same hospital and who delivered in the same period. Using a logistic regression model, gestational diabetes was found to be more common in Vietnam-born mothers who were older, who were primigravidas, or were underweight and the risk of gestational diabetes increased over the time period of the study. The adjusted relative risk of gestational diabetes for Vietnam-born women was 1.43 (95% confidence limits 1.10, 1.86) compared with Australian-born women. The incidence of gestational diabetes was 7.8% (144 of 1,839) in Vietnam-born mothers and 4.3% (1,173 of 27,086) in Australian-born mothers. Vietnam-born mothers also had a greater risk of diabetes mellitus on follow-up; 25% (17 of 68) of those with follow-up testing had developed diabetes mellitus within 9 years of diagnosis of gestational diabetes, in comparison with an incidence of 9% (52 of 581) of Australian-born mothers with follow-up testing. Vietnam-born mothers should have glucose tolerance testing performed during pregnancy to detect gestational diabetes and those diagnosed should have long-term follow-up to detect the development of diabetes mellitus.

Excessive birth weight and maternal glucose tolerance--a 19-year review.

The incidence of birth-weight of 4,540 g (10 lb) or more rose from 0.87% in the years 1971 to 1977 to 1.16% in the 12 years from 1978 to 1989 with a concomitant increase in hyperglycaemia in our antenatal population. The relationship between excessive birth-weight and maternal glucose tolerance was investigated in the light of these observations. The results from glucose tolerance tests performed routinely during the pregnancies of 510 women who delivered infants with a birth-weight of 4,540 g or more were compared with those from a control series of 5,003 women with consecutively tested pregnancies. Glucose tolerance in subsequent pregnancies was also compared with the control series, and in 1991 the study group women were investigated for emergence of permanent diabetes mellitus. Excessive birth-weight was associated with maternal hyperglycaemia (p < 0.05) but not with gestational diabetes; 79% of infants with birth-weight > or = 4,540 g were born to mothers who were not hyperglycaemic. There was no increase in glucose intolerance in subsequent pregnancies in the study group and only 2 of 49 women with follow-up testing had diabetes mellitus. Birth-weight > or = 4,540 g occurred in 1.1% of the total population and 1.1% of women with gestational diabetes, and was related to maternal hyperglycaemia in about 1 in 5 cases. The increased incidence of excessive birth-weight infants was not related to the increased incidence of gestational diabetes in our pregnant population. Birth-weight > or = 4,540 g had a poor association with later development of diabetes.

Obstetric and birthweight differences between Vietnam-born and Australian-born women.

OBJECTIVES: To measure the frequency of obstetrical complications and assess the outcome of pregnancies in Vietnam-born mothers; to compute birthweight percentile charts for their infants; and to compare these parameters in Vietnam-born women with those of a control group of Australian-born women. DESIGN: A retrospective study of all pregnancies in Vietnam-born and Australian-born mothers managed in the Mercy Hospital for Women over a 10-year period, 1979-1988 inclusive. SETTING: The Mercy Hospital for Women provides primary and secondary obstetric care to public and private patients. PATIENTS: All women born in Australia or Vietnam who delivered in the Mercy Hospital for Women, Melbourne, over the 10-year period and their infants. Twins, stillborn babies and infants with congenital malformations were not included in the calculation of birthweight percentiles. RESULTS: Gestational diabetes (7.3% v. 4.3%, P less than 0.0001) and low oestriol excretion (14.4% v. 10.8%, P less than 0.0001) were more common whereas essential hypertension (0.3% v. 1.2%, P less than 0.001) and pre eclampsia (3.7% v. 8.6%, P less than 0.0001) were less common among Vietnam-born mothers. Intervention for labour and delivery was less common among Vietnam-born mothers: induction of labour (7.1% v. 24.7%, P less than 0.0001) and forceps delivery (17.8% v. 21.9%, P less than 0.001); caesarean section rates were similar. Infants of Vietnam-born mothers were significantly lighter than those of Australian-born; percentile charts for birthweight and gestational age are presented. CONCLUSIONS: Pregnancies among Vietnam-born women migrants in Australia were associated with few complications in spite of a higher incidence of gestational diabetes and a low oestriol excretion. The infants were lighter than those born to Australian-born mothers. Our percentile charts for birthweight relative to gestational age will provide a more accurate assessment of intrauterine growth for these infants.

Incidence and severity of gestational diabetes mellitus according to country of birth in women living in Australia.

Gestational diabetes mellitus (GDM) was diagnosed in 1928 of 35,253 (5.5%) tested pregnancies at the Mercy Maternity Hospital in Melbourne between 1979 and the end of 1988. Compared with women born in Australia and New Zealand, the incidence of GDM was significantly greater in women born on the Indian subcontinent (15%); in women born in Africa (9.4%), Vietnam (7.3%), Mediterranean countries (7.3%), and Egypt and Arabic countries (7.2%); and in Chinese (13.9%) and other Asian (10.9%) women. There was no significant difference for women born in the United Kingdom and northern Europe (5.2%), Oceania (5.7%), North America (4.0%), or South America (2.2%). With the World Health Organization criteria as a guide to the severity of hyperglycemia, compared with mothers born in Australia and New Zealand, there were significant increases in the incidences of the more severe grades of GDM in parturients born in the Mediterranean region, Asia, the Indian subcontinent, Egypt, and Arabic countries. The incidence of GDM increased significantly in all racial groups, rising from 3.3% during 1979-1983 to 7.5% during 1984-1988.

Incidence and severity of gestational diabetes in Bahrain and Australia.

The incidence and severity of gestational diabetes in a series of 5,199 predominantly Arab patients in Bahrain, and 2,643 of mixed racial origin in Australia were studied. The incidence of gestational diabetes in Bahrain (5.4%) was less than in Australia (7.2%) but the more severe degrees were 3 times more common in Bahrain (p less than 0.001). The incidence of gestational diabetes was significantly increased with increasing maternal age and parity. A notable difference between the 2 populations occurred in the groups weighing less than 70 kg. Although Bahrain had a higher proportion of patients weighing less than 70 kg (64.7% versus 55.9%; p less than 0.001) there was a significantly higher incidence of gestational diabetes in this group in the Australian series (13.9% versus 3.7%, p less than 0.001). Postnatal testing of 165 gestational diabetics in Bahrain and 194 in Australia indicated that although the severe degrees of glucose intolerance were more likely to persist postnatally, it was impossible to predict in the individual patient the change in glucose tolerance that would occur after delivery. All gestational diabetics should therefore have a postnatal glucose tolerance test.

Contribution of prematurity and low birth-weight to neonatal death in Chinese and Western populations.

This paper analyses the contribution of low birth-weight (birth-weight between 500 and 2,500 g) and prematurity (gestation less than 37 weeks) to neonatal death in Chinese and Western populations. The incidences of low birth-weight in the Tsan Yuk Hospital, Hong Kong, the State of Victoria, and the Mercy Maternity Hospital, Melbourne, were 4.63%, 4.29% and 5.66% respectively and the incidences of prematurity were 2.08%, 4.89% and 7.42% respectively. The neonatal mortality rate (per 1,000 livebirths) for premature infants born in Victoria was 64, 89 for those born at the Mercy Maternity Hospital and 119 for the Tsan Yuk Hospital. This paper has demonstrated that a striking differences exists in prematurity rates between Chinese and Western populations, and also that the mortality rate of premature infants is lower in Western populations. If the reason for the lower incidence of prematurity in the Chinese population could be determined and the mortality of premature infants maintained in the Western population, a significant lowering of perinatal mortality would result. Studies to determine causes for premature births in Chinese and Western populations should therefore be undertaken.

Survey of hand symptoms in pregnancy.

In a study of 1216 pregnancies, 427 (35%) patients reported hand symptoms. Symptoms of the same quality and distribution were reported by 40 (30%) of 132 control subjects within the previous year, and although invariably mild, these symptoms suggest that pregnancy may aggravate a pre-existing condition. Fewer than 20% of the 427 affected patients described a classic median-nerve symptom distribution (carpal tunnel syndrome), while 12% of patients described an ulnar-nerve distribution, which is thought to represent a genuine and previously underestimated occurrence of ulnar-nerve neuropathy in pregnancy. In 69% of patients, hand symptoms were generalized. Most symptoms were bilateral, commenced in the third trimester and resolved soon after delivery. There was a significant correlation of hand symptoms in pregnancy with the presence of preeclampsia, tight rings, the weight at confinement, the birth weight and a history of premenstrual bloating. Operative intervention was not required for any patient.

Rubella screening and vaccination programme at a Melbourne maternity hospital. A five-year review.

Antibody to rubella virus titres were measured in 7133 serum samples collected from pregnant women and nurses between 1976 and 1980. A significant decline in susceptibility to rubella was found in women under 25 years of age, but not in those over 25 years of age. Most of the former would have been vaccinated at school. One hundred and sixty of 325 women vaccinated with Cendehill vaccine (Cendevax) were subsequently retested. Two failed to develop antibodies and 19 initially "seronegative" women responded poorly. Ten of 38 women with low prevaccination titres had a significant boost in titre, and the remaining 28 showed little or no change. All 13 women who were revaccinated with RA 27/3 vaccine (Almevax) after responding poorly to Cendevax vaccination had a boost in titre; in 10, the rise was four-fold or greater. it is disappointing that Almevax is no longer available in Australia.

Incidences and types of malformations in newborn infants.

The incidence of fetal malformations in a teaching hospital was determined by prospective study of 10,454 consecutively born infants. One or more major malformation was detected in 424 (4-1%) and one or more minor malformation was detected in 680 (6-5%). Major malformations were more common in stillborn infants (14-1%), in those who died in the neonatal period (36-7%) and in those who were small for dates (8-6%). Small for dates infants were the only group with a significant increase in the incidence of minor malformations (9-7%). The most common major malformations involved the genital organs (17-8%), limbs (14-2%), heart (11-4%) and central nervous system (10-6%). The most common minor malformations involved the skin, hair and nails (67-3%), limbs (7-7%) and genital organs (5-5%). Small for dates infants should be carefully examined to exclude major and minor malformations.