Socio-economic inequality in oral health in childhood to young adulthood, despite full dental coverage.

The aim of this cross-sectional study was to assess differences in caries experience according to socio-economic status (SES) in a health-care system with full coverage of dental costs for children up to the age of 18 yr. In 2011 and 2014, by performing hurdle negative binomial models, we obtained data on 3,022 children and young adults aged 5, 8, 11, 14, 17, 20, and 23 yr, living in four cities in the Netherlands. At all ages between 5 and 23 yr, the percentages of children with caries-free dentitions were lower and mean caries experience were higher in low-SES than in high-SES participants. In 5-yr-old children with dmft > 0, mean caries experience was 3.6 in those with low SES and 2.3 in those with high SES. In 23-yr-old participants, these estimates were 6.8 and 4.4, respectively (P < 0.05). Low-SES children have a greater risk of more caries experience than high-SES children. Thus, in a system with full free paediatric dental coverage, socio-economic inequality in caries experience still exists. Dental health professionals, well-child care doctors and nurses, general practitioners, and elementary school teachers should collaborate to promote oral health at the community level, with specific targeting of low-SES families. We further need policy measures to curtail, at community level, the increasing availability and consumption of highly processed, carbohydrate-rich foods, with particular attention for low-SES families.

Evidence Based Weighing Policy during the First Week to Prevent Neonatal Hypernatremic Dehydration while Breastfeeding.

BACKGROUND: Neonatal hypernatremic dehydration is prevented by daily neonatal weight monitoring. We aim to provide evidence-based support of this universally promoted weighing policy and to establish the most crucial days of weighing. METHODS: Weight measurements of 2,359 healthy newborns and of 271 newborns with clinical hypernatremic dehydration were used within the first seven days of life to simulate various weighting policies to prevent hypernatremic dehydration; its sensitivity, specificity and positive predictive value (PPV) of these policies were calculated. Various referral criteria were also evaluated. RESULTS: A policy of daily weighing with a cut-off value of -2.5 Standard Deviation Score (SDS) on the growth chart for weight loss, had a 97.6% sensitivity, 97.6% specificity and a PPV of 2.80%. Weighing at birth and only at days two, four and seven with the same -2.5 SDS cut-off, resulted in 97.3% sensitivity, 98.5% specificity and a PPV of 4.43%. CONCLUSION: A weighing policy with measurements restricted to birth and day two, four and seven applying the -2.5 SDS cut-off seems an optimal policy to detect hypernatremic dehydration. Therefore we recommend to preferably weigh newborns at least on day two (i.e. ~48h), four and seven, and refer them to clinical pediatric care if their weight loss increases below -2.5 SDS. We also suggest lactation support for the mother, full clinical assessment of the infant and weighing again the following day in all newborns reaching a weight loss below -2.0 SDS.

Prevalence and pattern of alcohol consumption during pregnancy in the Netherlands.

OBJECTIVE: To estimate the prevalence of alcohol consumption during pregnancy in the Netherlands in 2007 and 2010. METHOD: During two identical, nation-wide surveys in 2007 and 2010, questionnaires were handed out to mothers of infants aged ≤6 months who visited a Well-Baby Clinic. By means of the questionnaire mothers were, in addition to questions on infant feeding practices and background variables, asked about their alcohol consumption before, during and after pregnancy. Logistic regression analyses were used to look into relationships of alcohol consumption with maternal and infant characteristics. RESULTS: We obtained 2,715 questionnaires in 2007, and 1,410 in 2010. Within 6 months before pregnancy, 69 % of women consumed alcohol (data from 2010). During pregnancy 22 % consumed alcohol in 2007, 19 % in 2010. During the first three months of pregnancy, 17 % (2007) and 14 % (2010) of mothers consumed alcohol. Alcohol consumption was mainly one glass (~10 g alcohol) on less than one occasion per month. Compared to 2007, in 2010 more women consumed 1-3 or >3 glasses alcohol per occasion (resp. 11 % to 7 % and 1.4 to 0.7 %). Older women and those with a higher education consumed more alcohol, as did smokers. Birth weight, gestational age and weight for gestational age were not associated with alcohol consumption. In 2007 and 2010, 2.5 % resp. 2.4 % of pregnant women both smoked and consumed alcohol; resp. 70 % and 75 % did neither. CONCLUSION: In contrast to Dutch guidelines which advice to completely abstain from alcohol, one in five women in the Netherlands consume alcohol during pregnancy.

Weight fluctuation during childhood and cardiometabolic risk at young adulthood.

OBJECTIVES: To test the hypothesis that greater weight fluctuation between 2 and 6 years is associated with an increase in weight measures (such as body mass index [BMI]) and cardiometabolic risk in young adulthood. STUDY DESIGN: Weight fluctuation (determined by BMI SD scores) was measured at least 3 times between the ages of 2 and 6 years in 166 girls and 116 boys from the Terneuzen Birth Cohort. Cardiometabolic risk factors in young adulthood include components of the metabolic syndrome and weight. The extent of weight fluctuation was determined by assessing each individual's SE (or variation) around each individual's linear regression slope (or weight slope). The obtained variation scores were subsequently related to adult BMI, other weight measures, and cardiometabolic risk factors. RESULTS: In girls, greater weight fluctuation between 2 and 6 years was statistically significantly related to greater adult weight measures (1.08; 95% CI 1.01-1.15) and nonsignificantly with the metabolic syndrome. For boys weight fluctuation was not associated with adult weight (1.04; 95% CI 0.97-1.11), but weight slope was statistically significantly associated with adult overweight. CONCLUSIONS: The results suggest that weight fluctuations during early childhood are predictive for adult overweight in girls. For boys weight slope instead of weight fluctuation is predictive for adult overweight.

[Young people with Down syndrome: independence and social functioning]. / Zelfredzaamheid van jongeren met Down-syndroom.

OBJECTIVE: To determine the level of independence and social functioning in young people with Down syndrome. DESIGN: Cross-sectional study. METHOD: Via the Dutch Down Syndrome Foundation (Stichting Downsyndroom), we asked parents of children with Down syndrome born in 1992, 1993 or 1994 to complete a written questionnaire about their child. This questionnaire contained the following standardised lists: the 'Dutch social competence rating scale for people with a learning disability', the 'Child behaviour checklist' and the 'Children's social behaviour questionnaire', and additional questions on background characteristics. The results of this Dutch cohort were compared with available data on peers without Down syndrome. RESULTS: Data from 322 young people with Down syndrome, mean age 18.4 years (range 16.8-19.9 years), were collected (response 63%). Almost 60% of participants mastered basic skills of independent functioning, such as maintaining adequate standards of personal hygiene, preparing breakfast and being able to spend at least 30 minutes at home alone. About 10% of the participants had basic skills such as cooking and paying in a shop. Nine out of ten participants had more problems with social functioning than peers without Down syndrome, mainly with social interaction, processing information and regulating their emotions. Half of the participants had clinically relevant behavioural problems. CONCLUSION: The results of this study show that young people with Down syndrome have limited practical and social skills, and more behavioural problems than their peers without Down syndrome. In daily life they are to a greater or lesser extent dependent on others, and need lifelong support.

Charts for weight loss to detect hypernatremic dehydration and prevent formula supplementing.

BACKGROUND: Most breast-fed newborns get the milk they need. However, very rarely milk intake is insufficient mostly as a result of poor breastfeeding techniques. Dramatic weight loss and hypernatremic dehydration may occur. Our aim was to construct charts for weight loss. METHODS: A case-control study was performed. Charts with standard deviation score (SDS) lines for weight loss in the first month were constructed for 2,359 healthy breast-fed term newborns and 271 cases with breastfeeding-associated hypernatremic dehydration with serum sodium level > 149 mEq/L. Day 0 was defined as the day of birth. RESULTS: Many cases with (or who will develop) hypernatremic dehydration (84%; +1 SDS line) fell below the -1 SDS line at day 3, the -2 SDS line at day 4, and the -2.5 SDS line at day 5 in the chart of the healthy breast-fed newborns. Weight loss of cases with permanent residual symptoms was far below the -2.5 SDS. CONCLUSIONS: Already at an early age, weight loss differs between healthy breast-fed newborns and those with hypernatremic dehydration. Charts for weight loss are, therefore, useful tools to detect early, or prevent newborns from developing, breastfeeding-associated hypernatremic dehydration, and also to prevent unnecessary formula supplementing.

Mainstream and special school attendance among a Dutch cohort of children with Down Syndrome.

OBJECT: To determine the level of mainstream education in a nationwide cohort of adolescents with Down Syndrome (DS), and to find characteristics related to mainstream or special school attendance. METHOD: Dutch children with DS born in 1992, 1993 or 1994, were assessed when 16-19 years old. Parents scored school enrolment between the age of 4-18 years, general characteristics and the levels of intellectual disability using the Dutch Social Competence Rating Scale. Associations between disability and years in mainstream school were assessed by ordinal logistic regression, adjusting for sex and parental education. RESULTS: We collected data from 170 boys and 152 girls (response 63%); mean age 18.3 years (ranges 16.8-19.9). Intellectual disability was mostly moderate (43%). Most children (74%) entered mainstream education between 4 and 6 years of age. At 13 years 17% was in mainstream school and 7% stayed in up to 16 years. From the age of 8 years onwards the majority was in special education, while 6% never attended school. Girls were more often in mainstream school and stayed in longer. Level of disability was significantly associated with number of years in mainstream education. CONCLUSION: Three out of four Dutch children with DS entered mainstream primary education, however late entry and high dropout are common.

The attitudes and intention to participate in hemoglobinopathy carrier screening in The Netherlands among individuals from Turkish, Moroccan, and Surinamese descent.

OBJECTIVE: To explore factors that influence intention to participate in hemoglobinopathy (HbP) carrier screening under Dutch subjects at risk, since HbP became more common in The Netherlands. METHOD: Structured interviews with 301 subjects from Turkish, Moroccan, or Surinamese ethnicity. RESULTS: Half of the participants were familiar with HbP, 27% with carrier screening. Only 55% correctly answered basic knowledge items. After balanced information, 83% percent of subjects express intention to participate in HbP carrier screening. Intention to participate was correlated with (1) anticipated negative feelings, (2) valuing a physician's advice, and (3) beliefs on significance of carrier screening. Risk perception was a significant determinant, while respondents were unaware of HbP as endemic in their country of birth. Respondents preferred screening before pregnancy and at cost < 50€. CONCLUSION: These findings show the importance of informing those at risk by tailored health education. We propose easy access at no costs for those willing to participate in HbP carrier screening.

Practical and social skills of 16-19-year-olds with Down syndrome: independence still far away.

Survival of children with Down syndrome (DS) has improved considerably, but insight into their level of daily functioning upon entering adulthood is lacking. We collected cross-sectional data from a Dutch nationwide cohort of 322 DS adolescents aged 16-19 (response 62.8%) to assess the degree to which they master various practical and social skills, using the Dutch Social competence rating scale and the Children's Social Behavior Questionnaire. Up to 60% mastered some of the skills required for independent functioning, such as maintaining adequate standards of personal hygiene and preparing breakfast. Less than 10% had achieved basic skills such as basic cooking and paying in a shop. It is difficult for DS people to master all the skills necessary to live independently. Ninety percent of adolescents with DS experience significant problems in social functioning.

Problem behavior of individuals with Down syndrome in a nationwide cohort assessed in late adolescence.

OBJECTIVE: To assess problem behavior in adolescents with Down syndrome and examine the association with sex and severity of intellectual disability. STUDY DESIGN: Cross-sectional data of a Dutch nationwide cohort of Down syndrome children aged 16-19 years were collected using a written parental questionnaire. Problem behavior was measured using the Child Behavior Checklist and compared with normative data. The degree of intellectual disability was determined using the Dutch Social competence rating scale. RESULTS: The response rate was 62.8% (322/513), and the mean age 18.3 years (SD ± 0.8). The total score for problem behavior was higher in adolescents with Down syndrome than in adolescents without Down syndrome (26.8 vs 16.5; P < .001). Overall, 51% of adolescents with Down syndrome had problem scores in the clinical or borderline range on 1 or more Child Behavior Checklist subscales; this is more than twice as high as adolescents without Down syndrome. Adolescents with Down syndrome had more internalizing problems than their counterparts without Down syndrome (14% and 9%, respectively, in the clinical range); the percentages for externalizing problems were almost equal (7% and 9%, respectively, in the clinical range). The highest problem scores in adolescents with Down syndrome were observed on the social problems and thought problems subscales (large to very large standardized differences). Male sex and/or more severe mental disabilities were associated with more behavioral problems. CONCLUSIONS: Serious problem behavior is more prevalent in adolescents with Down syndrome. This demonstrates the need for a focus on general behavior improvement and on the detection and treatment of specific psychopathology in individuals with Down syndrome.

Prevalence of overweight in Dutch children with Down syndrome.

OBJECTIVE: Prevalence of overweight in children is increasing, causing various health problems. This study aims to establish growth references for weight and to assess the prevalence rates of overweight and obesity in a nationwide sample of Dutch children with Down syndrome (DS), taking into account the influence of comorbidity. METHODS: In 2009, longitudinal growth data from Dutch children with trisomy 21 who were born after 1982 were retrospectively collected from medical records of 25 Dutch regional specialized DS centers. "Healthy" was defined as not having concomitant disorders or having only a mild congenital heart defect. Weight and BMI references were calculated by using the LMS method, and prevalence rates of overweight and obesity by using cutoff values for BMI as defined by the International Obesity Task Force. Differences in prevalence rates were tested by multilevel logistic regression analyses to adjust for gender and age. RESULTS: Growth data of 1596 children with DS were analyzed. Compared with the general Dutch population, healthy children with DS were more often overweight (25.5% vs 13.3% in boys, and 32.0% vs 14.9% in girls) and obese (4.2% vs 1.8%, and 5.1% vs 2.2%, respectively). Prevalence rates of overweight between DS children with or without concomitant disorders did not vary significantly. CONCLUSIONS: Dutch children with DS have alarmingly high prevalence rates of overweight and obesity during childhood and adolescence. Health care professionals should be aware of the risk of overweight and obesity in children with DS to prevent complications.

Healthy growth in children with Down syndrome.

OBJECTIVE: To provide cross-sectional height and head circumference (HC) references for healthy Dutch children with Down syndrome (DS), while considering the influence of concomitant disorders on their growth, and to compare growth between children with DS and children from the general population. STUDY DESIGN: Longitudinal growth and medical data were retrospectively collected from medical records in 25 of the 30 regional hospital-based outpatient clinics for children with DS in The Netherlands. Children with Trisomy 21 karyotype of Dutch descent born after 1982 were included. The LMS method was applied to fit growth references. RESULTS: We enrolled 1,596 children, and collected 10,558 measurements for height and 1,778 for HC. Children with DS without concomitant disorders (otherwise healthy children) and those suffering only from mild congenital heart defects showed similar growth patterns. The established growth charts, based on all measurements of these two groups, demonstrate the three age periods when height differences between children with and without DS increase: during pregnancy, during the first three years of life, and during puberty. This growth pattern results in a mean final height of 163.4 cm in boys and 151.8 cm in girls (-2.9 standard deviation (SD) and -3.0 SD on general Dutch charts, respectively). Mean HC (0 to 15 months) was 2 SD less than in the general Dutch population. The charts are available at www.tno.nl/growth. CONCLUSIONS: Height and HC references showed that growth retardation in otherwise healthy children with DS meanly occurs in three critical periods of growth, resulting in shorter final stature and smaller HC than the general Dutch population shows. With these references, health care professionals can optimize their preventive care: monitoring growth of individual children with DS optimal, so that growth retarding comorbidities can be identified early, and focusing on the critical age periods to establish ways to optimize growth.

Development, problem behavior, and quality of life in a population based sample of eight-year-old children with Down syndrome.

OBJECTIVE: Children with Down syndrome (DS) have delayed psychomotor development. We investigated levels of development, problem behavior, and Health-Related Quality of Life (HRQoL) in a population sample of Dutch eight-year-old children with DS. Developmental outcomes were compared with normative data of eight-year-old children from the general population. METHOD: Over a three-year-period all parents with an eight-year-old child with DS were approached by the national parent organization. Developmental skills were assessed by means of the McCarthy Scales of Children's Ability. To measure emotional and behavioral problems we used the Child Behavior Checklist. HRQoL was assessed with the TNO-AZL Children's Quality of Life questionnaire. Analyses of variance were applied to compare groups. RESULTS: A total of 337 children participated. Mean developmental age was substantially lower than mean calendar age (3.9 years, SD 0.87 and 8.1 years, SD 0.15 respectively). Mean developmental age was significantly lower among boys than girls (3.6 (SD 0.85) and 4.2 years (SD 0.82) respectively; p<0.001). Compared with the general population, children with DS had more emotional and behavioral problems (p<0.001). However on the anxious/depressed scale, they scored significantly more favorably (p<0.001). Significantly lower HRQoL scores for the scales gross motor skills, autonomy, social functioning and cognitive functioning were found (p-values<0.001). Hardly any differences were observed for the scales physical complaints, positive and negative emotions. CONCLUSION: Eight-year-old children with DS have an average developmental delay of four years, more often have emotional and behavioral problems, and have a less favorable HRQoL compared with children from the general population.

The Terneuzen Birth Cohort. Longer exclusive breastfeeding duration is associated with leaner body mass and a healthier diet in young adulthood.

BACKGROUND: Breastfeeding (BF) is protective against overweight and is associated with dietary behaviour. The aims of our study were to assess the relationship between exclusive BF duration and BMI, waist circumference (WC) and waist-hip ratio (WHR) at adulthood, and to study whether dietary behaviour could explain the relationship between BF duration and the proxies of fat mass. METHODS: In 2004-2005, 822 subjects from the Terneuzen Birth Cohort (n = 2,604), aged 18-28 years, filled in postal questionnaires including sociodemographic factors and aspects of dietary behaviour (dietary pattern, and consumption of fruit and vegetables, snacks, sweetened beverages and alcohol); 737 subjects also underwent anthropometric measurements of weight, height, and waist and hip circumference. The relationship between exclusive BF duration and dietary outcomes was investigated by logistic regression analysis. The relationships of BF duration with the anthropometric measures were investigated by linear regression analyses. All results were corrected for age, gender and possible confounders. Finally, regression analyses were performed to investigate if diet factors had a mediating effect on the relationship between BF duration and fat mass. RESULTS: A significant inverse dose-response relationship of BF duration was found for BMI (ß-0.13, SE 0.06), WC (ß-0.39, SE 0.18) and WHR (ß-0.003, SE 0.001), after correction for age, gender and confounders. The odds ratio (OR) of exclusive BF duration in months for a breakfast frequency of at least 5 times a week was 1.16 (95%CI 1.06-1.27), and for snack consumption of less than twice a week was 1.15 (95%CI 1.06-1.25). Both ORs were corrected for age, gender and confounders. For other dietary outcomes, the results point in the same direction, i.e. a positive relationship with BF duration, but these were not statistically significant. A mediating effect of the diet factors on the association between BF and anthropometric outcomes was not shown. CONCLUSIONS: Exclusive BF duration had a significant inverse dose-response relationship with BMI, WC and WHR at young adulthood. BF duration was positively related to a healthier diet at adulthood, but this did not explain the protective effect of BF against body fat. Our results underline the recommendation of the WHO to exclusively breastfeed for 6 months or longer.

Identifying young children without overweight at high risk for adult overweight: the Terneuzen Birth Cohort.

OBJECTIVE: To develop a tool to identify children with high risk of adult overweight (AO), especially before developing overweight, based on body mass index (BMI) standard deviation score(s) (SDS) changes between 2-6 years (y) of age. METHODS: We fitted a linear spline model to BMI SDS of 762 young Caucasian adults from the Terneuzen Birth Cohort at fixed ages between birth and 18 y. By linear regression analysis, we assessed the increase in explained variance of the adult BMI SDS by adding the BMI SDS at 2 y to the models including the BMI SDS at 4 y, 6 y and both 4 y and 6 y. AO risk was modelled by logistic regression. The internal validity was estimated using bootstrap techniques. Risk models were represented as risk score diagrams by gender for the age intervals 2-4 y and 2-6 y. RESULTS: In addition to the BMI SDS at certain ages, the previous BMI SDS during childhood is positively related to adult weight. Receiver Operating Curves analysis provides insight into sensible cut-offs (AUC varied from 0.76 to 0.83). The sensitivity and specificity for 2-6 y at the cut-off of 0.25 and 0.5 are respectively, 0.76 and 0.74, and 0.36 and 0.93, whereas the PPV is 0.52 and 0.67, respectively. CONCLUSIONS: The risk score diagrams can serve as a tool for young children for primary prevention of adult overweight. To avoid wrongly designating children at risk for AO, we propose a cut-off with a high specificity at the risk of approximately 0.5. After external validation, wider adoption of this tool might enhance primary AO prevention.

The Terneuzen Birth Cohort: BMI change between 2 and 6 years is most predictive of adult cardiometabolic risk.

BACKGROUND: We recently reported the age interval 2-6y being the earliest and most critical for adult overweight. We now aim to determine which age intervals are predictive of cardiometabolic risk at young adulthood. METHODS AND FINDINGS: We analyzed data from 642 18-28 years olds from the Terneuzen Birth Cohort. Individual BMI SDS trajectories were fitted by a piecewise linear model. By multiple regression analyses relationships were assessed between subsequent conditional BMI SDS changes and components of the metabolic syndrome (MetS), skinfold thickness and hsCRP at young adulthood. Results were adjusted for gender and age, and other confounders. Gender was studied as an effect modifier. All BMI SDS changes throughout childhood were related to waist circumference and skinfold thickness. No other significant relationship was found before the age of 2 years, except between the BMI SDS change 0-1y and hsCRP. Fasting blood glucose was not predicted by any BMI SDS change. BMI SDS change 2-6y was strongly related to most outcome variables, especially to waist circumference (ß 0.47, SE 0.02), systolic and diastolic blood pressure (ß 0.20 SE 0.04 and ß 0.19 SE 0.03), and hsCRP (ß 0.16 SE 0.04). The BMI SDS change 10-18y was most strongly related to HDL cholesterol (ß -0.10, SE 0.03), and triglycerides (ß 0.21, SE 0.03). To a lesser degree, the BMI SDS change 6-10y was related to most outcome variables. BMI SDS changes 2-6y and 10-18y were significantly related to MetS: the OR was respectively 3.39 (95%CI 2.33-4.94) and 2.84 (95%CI 1.94-4.15). CONCLUSION: BMI SDS changes from 2y onwards were related to cardiometabolic risk at young adulthood, the age interval 2-6y being the most predictive. Monitoring and stabilizing the BMI SDS of children as young as 2-6y may not only reverse the progression towards adult overweight, but it may also safeguard cardiometabolic status.

The Terneuzen birth cohort: BMI changes between 2 and 6 years correlate strongest with adult overweight.

BACKGROUND: Complications of overweight amplify with age, and irreversible damage already exists in young persons. Identifying the most sensitive age interval(s) for adult overweight is relevant for primary prevention. The aim of the study was to assess the relative contribution of body mass index (BMI) changes between 0 and 18 years to adult overweight, and to identify the earliest critical growth period. METHODS AND FINDINGS: Data from 762 subjects in the Terneuzen Birth Cohort with an average of 21 growth measurements per subject from birth until 18 years were used. The main outcome measure was the BMI standard deviation score (SDS) at young adulthood. For each subject BMI SDS was fitted by a piecewise linear model at eight different ages and correlated to adult BMI SDS. The age intervals in between are considered critical according to three criteria, tested by respectively Students' t-tests, multiple linear regression analyses and Pearson's correlation tests. In the age intervals 4 months(m) -1 year(y), 2-6 y, 6-10 y and 10-18 y the BMI SDS change differs between adults with and without overweight (P