Effects of early dietary protein intake on low-birth-weight infants: Evaluation at 3 years of age

12 6

B r i e f clinical a n d l a b o r a t o r y o b s e r v a t i o n s

from the aorta and one from the pulmonary artery. It is suggested that the demonstration of two coronary arteries arising from the aorta does not exclude the presence of a third one arising from the pulmonary artery. REFERENCES

1. Roblcsek, F., Sanger, P. W., Daugherty, tL K., and Gallucci, V.: Origin of the anterior interventricular (descending) coronary artery and vein from the mammary vessels, J, Thorac. Cardiovase. Surg. 53: 602, 1967. 2. Liebman, J., Hellerstein, H. K., Ankeney, J. L., and Tucker, A.: The problem of the anomalous left coronary artery arising from the pulmonary artery in older children: Report of three cases, New Eng. J. Med. 269: 486, 1963. 3. Abrifosoff, A.: Aneurysma des linken Herzventrikels mit abnormer Abgangstelle der linken Karonarterle yon der Pulmonalis bel elnem funfmonathchin Kinde, Virchow. Arch. Path. Anat. 203: 412, 1911.

Effects of early dietary protein intake on low-birth-weight infants: Eraluation at 3 years of age Herbert I. Goldman, M.D., * O. Bernard Liebman, Ph.D., Roslyn Freudenthal, Ph.D., and R i c h a r d Reuben, M.D. N E w HYDE PARK~ N. Y. I N A P R g V I O U S publication, 1 we reported on 304 infants with birth weights beFrom the Premature Unit, Long Island Jewish Medical Center. Supported by United States Public Health Service Research Grant No_ 5R01 HD02081 from the National Institute of Child Health and H u m a n Development, and by a Grant from Mead Johnson & Co. *Address: Lone Island ]ewlsh Medical Center, 270-05 76th Ave., New H*de Park, N. Y. 11040.

The Journal o] Pediatrics January 1971

4. Bland, E. F., White, P. D., and Garland, J.: Congenital anomalies of coronary arteries: Report of an unusual case associated with cardiac hypertrophy, Amer. Heart J. 8: 787, 1933. 5. Edwards, J. E.: Anomalous coronary arteries with special reference to arteriovenous-like communications, Circulation 17: 1001, 1958. 6. Sabiston, D. C., Neill, C. A., and Taussig, H. B.: The direction of blood flow in anomalous left coronary artery arising from the pulmonary artery, Circulation 22: 591, 1960. 7. Nadas, A. S., Gamboa, R., and Hugenholtz, P. G.: Anomalous left coronary artery originating from the pulmonary artery: Report of two surglcatly treated cases with a proposal of hemodynamic and therapeutic classification, Circulation 29: 167, 1964. 8. Nora, J. J., McNamara, D. G., Halhnan, G. L., Sommerville, R. J., and Cooley, D. A.: Medical and surgical management of anomaIous origin of the left coronary artery from the pulmonary artery, Pediatrics 42: 405, 1968.

low 2,000 Gm., who were randomly assigned to either a 2 or 4 per cent protein diet in the premature nursery. More fever and lethargy were observed in infants fed tile 4 per cent diet; more edema and lower plasma protein levels were found with the 2 per cent diet. T h e present study consists of follow-up evaluation at approximately 3 years of age of 234 of 293 surviving children. This was done as a pilot study to explore the possibility of late effects of variation in early dietary protein intake. T w o reasons for considering the possibility of such effects were: the high amino acid levels noted in some infants receiving high protein diets 2-6 and the very wide variation in reported followup assessment of infants of very low birth weight, most particularly the generally favorable results reported by Hess and coworkers 7-s in infants fed h u m a n milk in the premature nursery, contrasted to recent re~oorts of less favorable results in infants who had received high-protein diets2 -11 METHODS

T h e 3 year examination included interval history and physical examination, evaluation by a pediatric neurologist (R. R.) if neuro-

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logic findings were noted, and administration of the Stanford-Binet test, form LM. None of the examiners were made aware of the infants diet group. The Stanford-Binet test was administered in the morning prior to other procedures or examinations. Every attempt was made to enlist the child's cooperation by allowing him sufficient time to adjust to his surrounding and the examiner. One examiner (O. B. L.), with considerable experience in testing young children, carried out 201 of the 234 Stanford-Binet examinations. RESULTS

The incidence of abnormal physical findings was similar in both diet groups (Table I), except for strabismus, which was more Table I. Physical abnormalities detected at 3 year examination No. of children

2% Protein 4% Protein AbnormaIity Pneumonia, bronchitis, or asthma Herniorrhaphy Yellow teeth Congenital heart disease Hearing loss Undescended testicle Congenital dislocation of hip Urinary tract obstruction Spasmus mutans Diabetes mellitus Spastic diplegia Convulsive disorder Questionable neurological abnormality Strabismus Cataract

diet

diet

36 14 4 4 2 1

31 16 2 1 0 I

1

1

1 1 1 3 5

0 0 0 3 6

5 5 1

6 17 1

I 27

frequent in the 4 per cent diet group (p < 0.02--all statistical evaluations were made by calculating chi-square with Yates correction). The excess strabismus in the 4 per cent diet group was present only in infants of birth weights below 1,700 Gin. (Table II). Table III presents I.Q. scores for both diet groups based on chronologic age (I.Q.) and on chronologic age corrected for weeks of prematurity (C.I.Q.). There are fewer C.I.Q. scores as the gestations of 18 infants were unknown. The incidence of scores below 70 were similar for both diet groups. There were more I.Q. and C.I.Q. scores between 70 and 89 in the 4 per cent diet group and more C.I.Q. scores above 110 in the 2 per cent diet group, but these differences were not statistically significant (p > 0.05). Analysis was made in various subgroups of weight, maturity, race, and sex (Table IV). Significant differences between the incidence of low I.Q. scores in the two diet groups were noted in children whose birth weight was below 1,300 Gin. and in children who were undergrown at birth. These children are currently being reexamined at 5 ~ years of age. Data are also being collected on maternal I.Q. scores and family socioeconomic status for the purpose of comparing the two diet groups with regard to these parameters. The results, to date, of this study are sufficiently suggestive to provide support for the recent recommendation of Drillien ~2 that long-term clinical trials of the late effects of variation in the early nutritional intake of low-birth-weight infants are needed.

Table II. Occurrence of strabismus according to weight group No. of children

2% Birth weight <( 1,300 Gm.

I

4%

No. with strabismus

2%

4%

Percentage with strabismus

2%

4%

Protein diet[Protein diet Protein diet Protein diet Protein diet Protein diet 26

21

1,300-1,700 Gm.

1

4

41

1,701-2,000 Gin.

51

4

19

51

2

44

2

I1

5

22

2

4

5

!28

Brie[ clinical and laboratory observations

Table III. Stanford-Binet

The Journal o[ Pediatrics ]anuary 1971

scores a t 3 y e a r s of a g e

No. o[ children Scores

.

2% Protein diet I 4% Protein diet

;}

I.Q. ~ Scores

<70 70-79

80-89 90-110 > I10 Untestable

19 1 60 18 4

Total

118

36

1 24J 50 17

Percentage o[ children 2% Protein diet I 4% Protein diet

48

10 15 51 15

31

15 20 43 15

1

3

i

116

100

100

41

C.I.Q.t Scores 70-79 80-89 90-110 > 110 Untestable

26

i}

35

1 49 32 4

Total 111 abased on chronologic age. }Based on chronologic age corrected for weeks of prematurity.

Table IV. Stanford-Binet maturity,

scores ( I . Q . )

23

11 16 44

46 23

1 44 29

1

4

1

105

100

100

33

22

b e l o w 90 a c c o r d i n g to w e i g h t g r o u p ,

r a c e , a n d sex

No. with I.Q. < 90

Percentage with 1.(2. < 90

4% Protein diet

2% Protein diet

4% Prorein diet

2% Protein diet

4% Prorein diet

p Value IF P< 0.05

26 41 51 39 72 7 72

21 51 44 45 59 12 73

6 14 I6 9 23 4 19

16 20 12 21 20 7 24

23 34 31 23 32 57 26

76 39 27 47 34 58 33

0.0I --0.05 ----

46 59 59

43 57 59

17 24 12

24 26 22

37 41 20

56 46 37

----

No. o[ children Weight group, maturity, I-2% Prorace, and sex I rein diet Birth weight < 1,300 Gin. 1,300-1,700 Gm. 1,701-2,000 Gm. Undergrown ~ Adequately grownt Gestation unknown Caucasian Other (Negro, Puerto Rican, Oriental) Male Female

Total study 118 116 36 48 31 41 -~Less than or at the tenth percentile of weight for gestation age, according to data of Lubchenko and associates.~a ?More than tenth percentile.

REFERENCES

1. Goldman, H. I., Freudenthal, R., Holland, B., and Karelitz, S.: Clinical effects of two different levels of protein intake on lowbirth-weight infants, J. PEDIAT. 74: 881, 1969. 2. Avery, lVf. E., Clow, R. T., Menkes, J. I-I., Ramos, A., Striver, C. R., Stern, L., and Wasserman, B. P.: Transient tyrosinemla of the newborn: Dietary and clinical aspects, Pediatrics 39: 378, 1967.

3. Mathews, J., and Partington, M. W.: T h e plasma tyrosine levels of premature babies, Arch. Dis. Child. 39: 371, 1964. 4. Snyderman, S. E., Holt, L. E., Jr., Norton, P. M., Roitman, E., and Pansalkar, S. V.: The plasma aminogram. I. Influence of the level of protein intake and comparison of whole protein and amino acid diets, Pediat. Res. 2: 131, 1968. 5. Light, I. J., Berry, H. K., and Sutherland, J. M.: Aminoaeidemia of prematurity: Its

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6.

7.

8. 9.

response to ascorbic acid, Amer. J. Dis. Child. 112: 229, 1966. Levy, H. L., Shlh, V. E., Madlgan, P. M., KaroIkewicz, J., Carr, J. R., Lum, A., Richards, A. A., Crawford, J. D., and MacCready, R. A.: Hypermethioninemia with other hyperaminoacldemias, Amer. J. Dis. Child. 117: 96, 1969. Hess, J. H., Mohr, G. J., and Bartelme, P. F.: The physical and mental growth of prematurely born children, Chicago, 1934, University of Chicago Press. Hess, J. H.: Experiences gained in a thirty year study of prematurely born infants, Pediatrics 11: 425, 1953. Lubchenco, L. O., Homer, F. A., Reed, L. H., Hix, I. E., Jr., Metcalf, D., Cohig, R., Eliott, H. C., and Bourg, M.: Sequelae of

Treatment of parasitic infestation in children n:itb malignant neoplasms R. J. A. Aur, M.D. MEMPHIS~ TENN.

A L T H O U G I-I infection has become the single most important complication of malignant disease, there are few reports on the occurrence of parasitic infestation. StrongyIoides stercoralis infestation has been reported in 3 adults, 2 with leukemia 1, 2 and 1 with Hodgkin's disease? A survey of the English literature failed to uncover similar associations in children. T h e purpose of this p a p e r is to report the occurrence and response to therapy of parasitic infestations in 9 children with malignant neoplasms. From the Department o[ Pediatrics, St. Jude Children's Research Hospital, and University of Tennessee Medical Units. Supported by Public Health Service Research Grants CA-08480 and CA-07594, and Training Grant CA-05176 [rom the National Cancer Institute and by ALSAC. RelJrlnt adrress: P.O. Box 318 Memphis, Tenn. 39101.

Brie[ clinical and laboratory observations

10. 11.

12. 13.

129

premature birth. Evaluation of premature infants of low birth weight at 10 years of age, Amer. J. Dis. Child. 106: I01, 1963. Dann, M., Levine, S. Z., and New, E. V.: A long term follow-up study of small premature infants, Pediatrics 33: 945, 1964. Harper, P. A., Fischer, L. K., and Rider, R. V.: Neurological and intellectual status of prematures at three to five years of age, J. Pm)IAT. 55: 679, 1959. Drillien, C. M.: Fresh approach to prospective studies of high risk infants, Pediatrics 45: 7, 1970. Lubchenko, L. I., Hansman, C., Dressler, M., and Boyd, E.: Intrauterine growth as estimated from liveborn birth-weight data at 24 to 42 weeks of gestation, Pediatrics 32: 793, 1963.

SUBJECTS AND METHODS All patients were in various stages of therapy for malignant neoplasms at St. Jude Children's Research Hospital. T h e y were studied if their personal, familial, or environmental history suggested parasitic disease (e.g., excretion of worms, affected siblings or pets, or pica) or if they h a d persistent eosinophilia regardless of clinical manifestation. Fresh stool samples were collected and examined by the formalin-ether concentration method of RitchieY Cellulose tape preparations were utilized for Enterobius vermieularis identification. T h e n u m b e r of stool samples examined from each patient was 1 to 10. Most patients lived in the southwestern United States. T r e a t m e n t for ~ardiasis was furazolidone, 8 mg. per kilogram per day by m o u t h for 7 days. Ascariasis was treated with piperazine hexahydrate, 60 mg. per kilogram per day by m o u t h for 3 days. Trichiuriasis and strongyloidiasis were treated with thiabendazole, 50 mg. per kilogram per day by m o u t h for 10 days. Enterobiasis was treated with pyrvinium pamoate, 5 mg. per kilogram per single dose by mouth.

RESULTS Of 32 patients investigated for parasitic infestation between M a y and October, 1967.