APPLIED NUTRITIONAL INVESTIGATION

Relation of Cord Serum Levels of Growth Hormone, Insulin-like Growth Factors, Insulin-like Growth Factor Binding Proteins, Leptin, and Interleukin-6 With Birth Weight, Birth Length, and Head Circumference in Term and Preterm Neonates
Hui-Chen Lo, PhD, Lon-Yen Tsao, MS, Wen-Yin Hsu, MS, Hsia-Nan Chen, MD, Wai-Kit Yu, MD, and Chiu-Yen Chi, BS From the Departments of Medical Education and Research, and Pediatrics, and the Team of Clinical Nutrition Support Service, Changhua Christian Hospital, Changhua, Taiwan, Republic of China
OBJECTIVES: Fetal growth process is governed by multiple factors. We investigated the relation of insulin-like growth factors (IGFs), IGF binding proteins (IGFBPs), leptin, and interleukin-6 (IL-6) with intrauterine growth in preterm and term neonates. METHODS: Thirty-eight preterm and 43 term neonates were recruited. Anthropometric measures were recorded and umbilical cord blood samples were collected at birth. RESULTS: Birth weight (BW), birth length (BL), ponderal index, head circumference (HC), and cord serum levels of albumin, prealbumin, retinol-binding protein (RBP), total and free IGF-I, IGF-II, IGFBP-3, acid-labile subunit (ALS), and leptin were signicantly lower, whereas levels of IGFBP-1, IGFBP-2, and IL-6 were signicantly higher in preterm than in term neonates (P 0.05). Total and free IGF-I, ALS, and leptin had signicantly positive correlations, whereas IGFBP-2 had a signicantly negative correlation, with BW and BL in preterm plus term neonates. Forward stepwise multivariate regression analysis showed that gestational age (GA), IGFBP-2, leptin, and free IGF-I are signicant predictors of BW; GA, IGFBP-2, ALS, transferrin, and leptin are signicant predictors of BL; and GA and free IGF-I are signicant predictors of HC in preterm and term neonates. CONCLUSIONS: Our results suggest that IGF-I, IGF-II, IGFBP-2, ALS, and leptin play important roles in intrauterine growth. Nutrition 2002;18:604 608. Elsevier Science Inc. 2002 KEY WORDS: intrauterine growth, insulin-like growth factors, leptin, cytokine

INTRODUCTION
Fetal growth process is governed by interactions between multiple factors, such as the genetic, nutritional, hormonal, and other environmental factors.1 The preterm neonates born with low birth weights are at much greater risk of medical problems requiring intensive medical management, which may be a consequence of disturbances in this interaction. Understanding the relation between hormones and intrauterine growth may help us to predict the mortality and morbidity of preterm and term neonates. Birth weight (BW), birth length (BL), weight:length ratio such as body mass index and ponderal index (PI), and head circumference (HC) have been used as conventional indices for evaluating nutrition status and predicting the metabolic complications of intrauterine growth retardation.2 However, these anthropometric

This work was supported by funds from the GSK Foundation Corporation and grant NSC 89-2320-B-371-002 from the National Science Council of ROC. Correspondence to: Lon-Yen Tsao, MD, Department of Pediatrics, Changhua Christian Hospital, 135 Nanhsia Street, Changhua, 500, Taiwan, ROC Nutrition 18:604 608, 2002 Elsevier Science Inc., 2002. Printed in the United States. All rights reserved.

measurements are not sensitive enough to reect mild or moderate growth and metabolic abnormality. Therefore, several serum proteins, e.g., albumin, prealbumin, transferrin, and retinol-binding protein (RBP), have been suggested as sensitive indicators of nutrition status and have been used as clinical indices of intrauterine growth.3 6 However, the clinical experience is controversial with the use of these conventional nutrition-related serum proteins to assess intrauterine growth in preterm neonates. In the past two decades, several serum proteins and hormones have been strongly related to fetal growth. For example, insulinlike growth factors (IGFs), the peptides structurally homologous with proinsulin,710 and leptin, the ob gene product,11,12 have been shown to play important roles in mediating fetal and postnatal growth and development. In addition, IGF binding proteins (IGFBPs), such as IGFBP-1, -2 and -3 that regulate the bioactivity of IGF-I, and acid-labile subunit (ALS), a high-molecular-weight protein bound with IGFBP-3 and IGF-I, are involved in the process of fetal growth.710 Evidence also shows that insulin has a central role in regulating growth in the fetus1 and is related mainly to fetal overgrowth.13 In contrast, fetally derived interleukin-6 (IL-6) plays a role in the pathophysiology of abnormal pregnancy and preterm labor.14 To our knowledge, several studies have focused on the inter0899-9007/02/$22.00 PII S0899-9007(01)00811-5

Nutrition Volume 18, Numbers 7/8, 2002 actions between growth hormone (GH), IGFs, or IGFBPs with gestational age (GA) and BW in neonates. There is growing evidence showing the importance of leptin and cytokines on fetal growth. The interactions between IGFs, IGFBPs, ALS, leptin, cytokine, and intrauterine growth are still unclear. Therefore, we investigated the relation of cord serum levels of these hormones with BW, BL, and HC in term and preterm neonates and sought the dominant proteins regulating intrauterine growth.

IGF, IGFBP, Leptin, and IL-6 in Neonates TABLE I.

SUBJECT CHARACTERISTICS OF PRETERM AND TERM NEONATES* Preterm Male/female Gestational age (wk) Birth weight (g) Birth length (cm) Ponderal index Head circumference (cm) 16/22 29.4 3.2 1165 214 37.7 2.5 5.48 6.98 26.2 2.1 Term 24/19 39.1 1.2 3213 419 50.5 1.9 4.92 4.69 33.6 1.3

605

METHODS AND MATERIALS

Subjects Umbilical cord blood samples were collected from 43 term neonates and 38 preterm neonates admitted to Changhua Christian Hospital with GAs younger than 37 wk and BWs lower than 1250 g and referred to the team of the Clinical Nutrition Support Service. Dating pregnancy from the rst day of the last menstrual period was used to assess GA. All preterm and term neonates had weights appropriate for GA, that is, BWs between the 10th and 90th percentiles of the normal growth chart of infants, and were free of major congenital anomalies, congestive heart failure, renal disease, or major surgical procedures. In addition, the mothers of those neonates were free of cardiovascular disease, renal and liver diseases, hypertension, and diabetes. All umbilical cord blood samples were taken by the nurses at the delivery room and were divided into clinical and laboratory samples. Laboratory samples were centrifuged, divided, and stored at 80C for future assays. Ethical approval from the Institutional Review Board of Changhua Christian Hospital and informed parental consent were obtained. Anthropometric Measurements BW and BL were obtained from each preterm and term neonate immediately after birth. Measurement of HC was done on day 2 to allow for resolution of edema and head molding. Based on BW and BL, PI (BW/BL3; g cm3 100) was calculated and used as an index of nutrition status for neonates.15 Biochemical Analysis Serum concentrations of albumin, prealbumin, and transferrin were measured with an automatic analyzer (Hitachi 747, Tokyo, Japan). Serum concentrations of RBP were determined by a sandwich enzyme-linked immunosorbant assay (ELISA), as described by Topping et al.16 Total and free IGF-I, IGF-II, GH, insulin, IGFBP-1, IGFBP-3, and ALS were measured with commercially available ELISA kits (Diagnostic Systems Laboratories Inc., Webster, TX, USA). IGFBP-2 levels were measured with a commercially available radioimmunoassay kit (Diagnostic Systems Laboratories Inc.). Leptin and IL-6 were analyzed with the DuoSet ELISA Development kit (R & D Systems, Inc., Minneapolis, MN, USA). Samples were analyzed in one assay with duplication. The interassay and intra-assay coefcients of variation were 5% to 10%. Statistical Analysis Values are expressed as mean standard deviation. The signicant difference of each parameter between preterm and term neonates was determined by Students t test. A simple correlation analysis was processed by Pearsons method to assess the relations between GA, sex, and serum substrates in preterm and term neonates. Multiple regression analysis for the effect of serum substrates on BW, BL, PI, and HC was performed in preterm and term neonates after adjustment by sex and GA. Forward stepwise multivariate regression analysis assessed the inuence of multiple

0.0001 0.0001 0.0001 0.0026 0.0001

* Values are means standard deviation.

variables on BW, BL, PI, and HC. Statistical signicance was assumed at P 0.05.

RESULTS
Anthropometric Data Sex, GA, BW, BL, HC, and PI of preterm and term neonates are listed in Table I. There were 16 males and 22 females among preterm neonates and 24 males and 19 females among term neonates. The GA averages were 29.4 3.2 wk and 39.1 1.2 wk for preterm and term neonates, respectively. BW, BL, PI, and HC were 1165 214 g, 37.7 2.5 cm, 2.25 0.44, and 26.2 2.1 cm in preterm neonates and 3213 419 g, 50.5 1.9 cm, 2.50 0.27, and 33.6 1.3 cm in term neonates, respectively. Term neonates had signicantly greater BW, BL, PI, and HC than did preterm neonates (P 0.005). Biochemical Data Cord serum levels of nutrition-related proteins and hormones in preterm and term neonates are shown in Table II. Serum levels of albumin, prealbumin, and RBP were signicantly greater in term neonates than in preterm neonates (P 0.001). There were no signicant differences in cord serum levels of transferrin, insulin, and GH between preterm and term neonates. Cord serum levels of total IGF-I, free IGF-I, IGF-II, IGFBP-3, ALS, and leptin were signicantly greater, whereas those of IGFBP-1, IGFBP-2, and IL-6 were signicantly lower, in term neonates than in preterm neonates. The ratio of free to total IGF-I did not differ signicantly between preterm and term neonates. Correlations There were no signicant correlations between sex and serum substrate levels in preterm, term, and preterm plus term neonates (data not shown). The correlations between GA and serum hormones in preterm, term, and preterm plus term neonates are shown in Table III. Cord serum levels of IGFBP-2 and leptin had significantly positive correlations with GA in preterm neonates. Cord serum levels of IGF-II, IGFBP-2, and IGFBP-3 had signicantly positive correlations, whereas those of insulin and free IGF-I and the ratio of free to total IGF-I had signicantly negative correlations, with GA in term neonates. When combining preterm and term neonates, most of the serum hormones we measured had signicantly positive correlations with GA; IGFBP-1 and IL-6 had signicantly negative correlations with GA and insulin; and GH, IGFBP-2, and the ratio of free to total IGF-I had no signicant correlation with GA. The results of multiple regression analyses between BW, BL,

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Nutrition Volume 18, Numbers 7/8, 2002 TABLE IV.

REGRESSIONS OF BIRTH WEIGHT AND BIRTH LENGTH WITH SERUM HORMONES IN PRETERM PLUS TERM NEONATES* Birth weight P Insulin Growth hormone Total IGF-I Free IGF-I Free/total IGF-I IGF-II IGFBP-1 IGFBP-2 IGFBP-3 ALS Leptin IL-6 NS NS 0.0001 0.0001 0.0422 NS NS 0.0005 0.0395 0.0001 0.0002 NS R2 0.8276 0.8276 0.8641 0.8682 0.8386 0.8298 0.8343 0.8576 0.8389 0.8687 0.8609 0.8082 P NS NS 0.0052 0.0005 0.0310 NS NS 0.0053 NS 0.0003 0.0130 NS Birth length R2 0.8563 0.8547 0.8718 0.8801 0.8651 0.8562 0.8560 0.8717 0.8573 0.8824 0.8683 0.8577

SERUM BIOCHEMICAL CHARACTERISTICS OF PRETERM AND TERM NEONATES* Preterm Albumin (g/L) Prealbumin (mg/L) Transferrin (g/L) RBP (g/L) Insulin (mU/L) Growth hormone (g/L) Total IGF-I (g/L) Free IGF-I (g/L) Free/total IGF-I IGF-II (g/L) IGFBP-1 (g/L) IGFBP-2 (g/L) IGFBP-3 (g/L) ALS (mg/L) Leptin (g/L) IL-6 (ng/L) 46.4 11.4 81.8 24.8 1.26 0.53 10.5 3.8 5.48 6.98 22.6 13.5 29.5 14.8 1.29 1.33 0.055 0.090 302 62 282 241 31.3 20.7 744 315 1.97 0.97 0.58 0.89 66.6 84.2 Term 58.5 5.7 100.5 21.4 1.42 0.32 13.7 4.3 4.92 4.69 26.6 14.9 66.5 26.7 3.22 1.61 0.048 0.021 332 47 82 80 23.4 7.33 1549 686 3.43 1.47 5.94 3.38 12.4 33.4 P 0.0001 0.0006 NS 0.0008 NS NS 0.0001 0.0001 NS 0.0169 0.0001 0.0226 0.0001 0.0001 0.0001 0.0004

* Values are means standard deviation. ALS, acid-labile subunit; IGF, insulin-like growth factor; IGFBP, insulin-like growth factor binding protein; IL-6, interleukin-6; NS, not signicant; RBP, retinol-binding protein.

* Values are the corresponding P and adjusted R2 values after adjustment by gestational age and sex. ALS, acid-labile subunit; IGF, insulin-like growth factor; IGFBP, insulin-like growth factor binding protein; IL-6, interleukin-6; NS, not signicant.

and serum hormone levels in preterm plus term neonates, adjusted by GA and sex, are shown in Table IV. Cord serum levels of total and free IGF-I, IGFBP-3, ALS, leptin, and the ratio of free to total IGF-I had signicantly positive correlations with BW. However, cord serum levels of IGFBP-2 had a signicantly negative correlation with BW. There was no signicant correlation between BW and serum concentrations of insulin, GH, IGF-II, IGFBP-1, or IL-6 in preterm plus term neonates. Cord serum levels of total and free IGF-I, ALS, leptin, and the ratio of free to total IGF-I had signicantly positive correlations, whereas that of IGFBP-2 had a signicantly negative correlation,

with BL (Table IV). There was no signicant correlation between BL and cord serum levels of insulin, GH, IGF-II, IGFBP-1, IGFBP-3, or IL-6 in preterm plus term neonates. Most serum hormones we measured had no signicant correlation with HC; free IGF-I had a signicantly positive correlation with HC (P 0.0103, R2 0.8389). In addition, cord serum levels of IGF-II had signicantly positive correlations with PI in preterm plus term neonates (P 0.0134, R2 0.1117). Multiple regression analysis between total IGF-I and other serum hormones in preterm plus term neonates was performed after adjusting for GA and sex. Serum levels of total IGF-I had signicantly positive correlations with free IGF-I (P 0.0001,

TABLE III.
CORRELATION COEFFICIENTS BETWEEN GESTATIONAL AGE AND SERUM HORMONES IN PRETERM, TERM, AND PRETERM PLUS TERM NEONATES* Preterm r Insulin Growth hormone Total IGF-I Free IGF-I Free/Total IGF-I IGF-II IGFBP-1 IGFBP-2 IGFBP-3 ALS Leptin IL-6 0.1193 0.3132 0.0765 0.2634 0.2405 0.0469 0.0566 0.4806 0.1496 0.1135 0.5619 0.3729 P NS NS NS NS NS NS NS 0.0026 NS NS 0.0004 NS r 0.3410 0.0502 0.1244 0.3248 0.3112 0.4697 0.1754 0.4554 0.3490 0.0152 0.2876 0.1497 Term P 0.0252 NS NS 0.0336 0.0422 0.0015 NS 0.0022 0.0218 NS NS NS r 0.1143 0.1995 0.5819 0.4054 0.1501 0.2670 0.4225 0.0307 0.5611 0.4349 0.7193 0.4805 Preterm plus term P NS NS 0.0001 0.0002 NS 0.0149 0.0001 NS 0.0001 0.0001 0.0001 0.0001

* Values are means standard deviation. ALS, acid-labile subunit; IGF, insulin-like growth factor; IGFBP, insulin-like growth factor binding protein; IL-6, interleukin-6; NS, not signicant.

Nutrition Volume 18, Numbers 7/8, 2002 TABLE V.

FORWARD STEPWISE MULTIVARIATE REGRESSION ANALYSIS OF PREDICTORS OF BIRTH WEIGHT, BIRTH HEIGHT, AND HEAD CIRCUMFERENCE IN PRETERM PLUS TERM NEONATES* Estimate Birth weight Intercept GA IGFBP-2 Leptin Free IGF-I Birth length Intercept GA IGFBP-2 ALS Transferrin Leptin Ponderal index Intercept Transferrin IGFBP-2 IGF-II Head circumference Intercept GA Free IGF-I Standard error P

IGF, IGFBP, Leptin, and IL-6 in Neonates

607

2621.39 139.22 11.19 63.32 64.61 10.1689 1.0484 0.0589 0.4767 0.0199 0.2391 1.5711 0.0044 0.0155 0.0019 7.1869 0.6426 0.3401

338.07 10.91 3.10 15.99 30.97 2.2393 0.0688 0.0185 0.2281 0.0666 0.1103 0.2305 0.0010 0.0047 0.0008 1.3911 0.0416 0.1259

0.0001 0.0001 0.0006 0.0002 0.0405 0.0001 0.0001 0.0021 0.0402 0.0038 0.0335 0.0001 0.0001 0.0017 0.0203 0.0001 0.0001 0.0088

* All variables signicantly correlated with birth weight, birth length, ponderal index, or head circumference were included in the initial model. The R2 values were 0.9007 for the model of birth weight, 0.9035 for the model of birth length, 0.3657 for the model of ponderal index, and 0.8372 for the model of head circumference. ALS, acid-labile subunit; IGF, insulin-like growth factor; IGFBP, insulin-like growth factor binding protein; IL-6, interleukin-6.

R2 0.6009), IGFBP-3 (P 0.0001, R2 0.4556), ALS (P 0.0001, R2 0.5707), and leptin (P 0.0137, R2 0.3469) but signicantly negative correlations with IGFBP-1 (P 0.0068, R2 0.3776) and IGFBP-2 (P 0.0001, R2 0.4880). There were no signicant correlations between total IGF-I and IGF-II, GH, insulin, or IL-6 (data not shown). Serum levels of IGF-II had signicantly positive correlations with IGFBP-2 (P 0.0008, R2 0.1614), IGFBP-3 (P 0.0001, R2 0.2235), ALS (P 0.0069, R2 0.1074) and leptin (P 0.0031, R2 0.1275). There were no signicant correlations between IGF-II and free IGF-I, IGFBP-1, GH, insulin, or IL-6 (data not shown). Predictors of BW, BL, PI, and HC The results of forward stepwise multivariate regression analysis are shown in Table V. After including all the serum substrates, our data showed that GA and cord serum levels of IGFBP-2, leptin, and free IGF-I are the signicant predictors of BW in preterm plus term neonates. In addition, GA and cord serum levels of IGFBP-2, ALS, transferrin, and leptin are the signicant predictors of BL; GA and cord serum level of free IGF-I are the signicant predictors of HC; and serum levels of transferrin, IGFBP-2, and IGF-II are the signicant predictors of PI.

DISCUSSION
The control of growth in the fetus and neonate is complex. Several hormones, such as insulin, IGFs, IGFBPs, leptin, and cytokines,

have been individually shown to play important roles in regulating the fetal growth and nutrition status. The relations between these hormones and intrauterine growth are still under investigation. We investigated the relation of cord serum levels of GH, IGFs, IGFBPs, ALS, insulin, leptin, and IL-6 with BW, BL, and HC in preterm and term neonates. Our results suggested that cord serum levels of IGF-I, IGF-II, IGFBP-2, ALS, and leptin are important mediators in regulating the intrauterine growth. Many fetal tissues, other than the liver, produce abundant amounts of IGF-I and IGF-II.8,17 Therefore, serum levels of IGF-I and IGF-II should be less affected by the maturation of liver function than the conventional nutrition-related serum proteins. It has been demonstrated that IGF-I and IGF-II play important roles in the regulation of fetal growth710 and IGF-II stimulates in utero somatic overgrowth.14 Several studies have shown that fetal plasma IGF-I and IGF-II levels are lower in the preterm than in the term neonates15,18 and had positive correlations with BW and GA.9,13,18 In this study, we found differences in cord serum levels of IGF-I and IGF-II between preterm and term neonates. We also found that IGF-I correlates positively with BW and BL and that IGF-II correlates positively with BW and PI but not with BL in preterm plus term neonates. Together these ndings suggest that IGF-I and IGF-II are the useful markers in reecting weight gain and that IGF-I may be a useful marker in reecting fetal length gain. Most IGFs in the circulation and tissues are bound to specic carrier proteins that extend their half-lives and inhibit or enhance IGF bioavailability and action. In the fetal period, circulating IGF-I binds mainly with IGFBP-1 and IGFBP-2,19 whereas IGFBP-3 is the main IGF carrier during postnatal life.20 The accumulation of IGFBP-1 and IGFBP-2 in fetal serum may inhibit fetal growth,7,9,10,13,15 whereas that of IGFBP-3 may stimulate fetal growth.20,21 Few studies have investigated the role of ALS, a high-molecular-weight protein bound with IGFBP-3 and IGF-I, in fetal growth. In this study, we found that preterm and term neonates have signicantly different levels of these IGF carrier proteins. In addition, IGFBP-1 is negatively correlated, whereas IGFBP-3 and ALS are positively correlated, with GA, suggesting a transition in the expression of binding proteins in the late gestational period. After adjustment with GA and sex, IGFBP-2 and ALS correlated signicantly with IGF-I, BW, and BL in preterm plus term neonates. Based on these results, we suggest that IGFBP-2 and ALS are better serum markers than the other IGF carrier proteins for evaluating the intrauterine growth. Free IGF-I, the active form of IGF-I, plays an essential role in accelerating growth.9,22 There is a linear correlation between free and total IGF-I. Therefore, we measured the level of free IGF-I and calculated the ratio of free to total IGF-I to compare the bioavailability of IGF-I in preterm and term neonates. Our results showed that free and total IGF-I paralleled advancing GA. After adjusting for GA and sex, the ratio of free to total IGF-I correlated positively with BW, BL, and HC, which shows that free IGF-I is the major portion of IGF-I in affecting fetal growth. In this study, free IGF-I was about 5% of the total IGF-I in preterm and term neonates, which is higher than the level Kawai et al. reported in infants, children, and adults.22 However, the levels of free and total IGF-I and the ratio of free to total IGF-I in our term neonates were similar to those reported by Klauwer et al. in healthy newborns.23 Therefore, we believe that the high ratio of free to total IGF-I might be due to the greater requirement of IGF-I for accelerated fetal development. Our ndings support the concepts that neither IGF-I nor IGFBP-3 synthesis is under GH control in fetal growth14,21; the GHIGF axis may be immature in the fetus and at birth; and the signicant impact of insulin on fetal growth may not be found in preterm and term neonates with weights appropriate for GA. It has been reported that leptin derived from placenta or fetal adipose tissue correlates positively with fetal growth11,12 with or without sex differences.12,24 We observed no sex difference in leptin, but

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7. Giudice LC, Zegher F, Gargosky SE, et al. Insulin-like growth factors and their binding proteins in the term and preterm human fetus and neonate with normal and extremes of intrauterine growth. J Clin Endocrinol Metab 1995;80:1548 8. Holmes R, Montermagno R, Jones J, et al. Fetal and maternal plasma insulin-like growth factors and binding proteins in pregnancies with appropriate or retarded fetal growth. Early Hum Dev 1997;49:7 9. Klauwer D, Blum WF, Hanitsch S, et al. IGF-I, IGF-II, free IGF-I and IGFBP-I, -2 and -3 levels in venous cord blood: relationship to birth weight, length and gestational age in healthy newborns. Acta Paediatr 1997;86:826 10. Smith WJ, Underwood LE, Keyes L, Clemmons DR. Use of insulin-like growth factor-I (IGF-I) and IGF-binding protein measurements to monitor feeding of premature infants. J Clin Endocrinol Metab 1997;82:3982 11. Harigaya A, Nagashima K, Nako Y, Morikawa A. Relationship between concentration of serum leptin and fetal growth. J Clin Endocrinol Metab 1997;82:3281 12. Ertl T, Funke S, Sarkany I, et al. Postnatal changes of leptin levels in full-term and preterm neonates: their relation to intrauterine growth, gender and testosterone. Biol Neonate 1999;75:167 13. Verhaeghe H, Bree RV, Herck EV, et al. C-peptide, insulin-like growth factors I and II, and insulin-like growth factor binding protein-1 in umbilical cord serum: correlations with birth weight. Am J Obstet Gynecol 1993;169:89 14. DErcole AJ. Mechanisms of in utero overgrowth. Act Paediatr 1999; 428(suppl):31 15. Barrios V, Argente J, Pazo J, et al. Insulin-like growth factor-I, insulin-like growth factor binding proteins, and growth hormone binding protein in Spanish premature and full-term newborns. Horm Res 1996;46:130 16. Topping MD, Forster HW, Dolman C, Luczynska CM, Bernard AM. Measurement of urinary retinol-binding protein by enzyme-linked immunosorbent assay, and its application to detection of tubular proteinuria. Clin Chem 1986;32:1863 17. Han VKM, Lund PK, Lee DC, DErcole AJ. Expression of somatomedin/insulinlike growth factor messenger ribonucleic acids in the human fetus: identication, characterization, and distribution. J Clin Endocrinol Metab 1988;66:422 18. Bennett A, Wilson DM, Liu F, et al. Levels of insulin-like growth factor I and II in human cord blood. J Clin Endocrinol Metab 1983;57:609 19. Wang HS, Lim H, English J, Irvine L, Chard T. The concentrations of insulin-like growth factor-I and insulin-like growth factor-binding protein-1 in human umbilical cord serum at delivery: relation to fetal weight. J Endocrinol 1991;129:459 20. Colonna F, Pahor T, de Vonderweid U, Tonini G, Radillo L. Serum insulin-like growth factor-I (IGF-I) and IGF binding protein-3 (IGFBP-3) in growing preterm infants on enteral nutrition. J Pediatr Endocrinol Metab 1996;9:483 21. Diaz-Gomez NM, Domenech E, Barroso F. Breast-feeding and growth factors in preterm newborn infants. J Pediatr Gastroenterol Nutr 1997;24:322 22. Kawai N, Kanzaki S, Takano-Watou S, et al. Serum free insulin-like growth factor-I (IGF-I), total IGF-I, and IGF-binding protien-3 concentrations in normal children and children with growth hormone deciency. J Clin Endocrinol Metab 1999;84:82 23. Klauwer D, Blum WF, Hanitsch S, et al. IGF-I, IGF-II, free IGF-I, and IGFBP-1, -2, and -3 levels in venous cord blood: relationship to birth weight, length and gestational age in healthy newborns. Acta Paediatr 1997;86:826 24. Maffeis C, Moghetti P, Vettor R, et al. Leptin concentrations in newborns cord blood: relationship to gender and growth-regulating hormones. Int J Obes Relat Metab Disord 1999;23:943 25. De Benedetti F, Alonzi T, Moretta A, et al. Interleukin-6 causes growth impairment in transgenic mice through a decrease in insulin-like growth factor-I. A model for stunted growth in children with chronic inammation. J Clin Invest 1997;99:643 26. Dudley DH, Trautman MS, Edwin SS, Lundin-Schiller S, Mitchell MD. Biosynthesis of interleukin-6 by cultured human chorion leave cells: regulation by cytokines. J Clin Endocrinol Metab 1992;75:1081

leptin correlated positively with GA, BW, BL, and total IGF-I. These observations may be explained by the increased expression of leptin during the late gestational period; the increased leptin levels may reect more body fat in term neonates; and leptin plays an important role in regulating intrauterine growth in a sexindependent manner. Fetally derived IL-6 was shown to play a role in the physiology of normal pregnancy and the pathophysiology of abnormal pregnancy.14 Moreover, IL-6 mediated decrease in IGF-I production is the major mechanism affecting growth in mice.25,26 For preterm and term neonates with BW appropriate for GA, we found no inverse relation between IL-6 and total IGF-I. However, preterm neonates had higher levels of IL-6 than did term neonates, which implicates IL-6 as a useful marker for predicting preterm labor, as reported by Dudley et al.26 The role of IL-6 in regulating intrauterine growth needs further investigation. To our knowledge, no study has compared the relation of the GHIGF axis, IGFBPs, insulin, leptin, and IL-6 with GA, BW, BL, HC, and PI in preterm and term neonates in one study. With the forward stepwise multivariate regression analysis, we sought the most powerful serum markers reecting intrauterine growth. There is no doubt that GA is the strongest factor affecting BW, BL, PI, and HC. Among all of the serum hormones we measured, IGFBP-2, leptin, free IGF-I, IGF-II, and ALS were the best candidates for predicting fetal growth. In summary, our results suggest that IGF-I, IGF-II, IGFBP-2, ALS, and leptin play important roles in regulating intrauterine growth.

SUMMARY
The concentrations of IGFs, IGFBPs, leptin, and IL-6 in umbilical cord blood samples were measured and their relation with BW was investigated in preterm and term neonates. The data suggested that IGF-I, IGF-II, IGFBP-2, ALS, and leptin are the most important factors in intrauterine growth.

REFERENCES
1. Ogilvy-Stuart AL, Hands SJ, Adcock CJ, et al. Insulin, insulin-like growth factor I (IGF-I), IGF-binding protein-1, growth hormone, and feeding in the newborn. J Clin Endocrinol Metab 1998;83:3550 2. Yau KT, Chang MH. Weight to length ratioa good parameter for determining nutritional status in preterm and full-term newborns. Acta Padiatr 1992;82:427 3. Nieto-Diaz A, Villar J, Matorras-Weinig R, Valenzuela-Ruiz P. Intrauterine growth retardation at term: association between anthropometric and endocrine parameters. Acta Obstet Gynecol Scand 1996;75:127 4. Warner A, Jang R. Biochemical measurement in cord blood as an indicator of neonatal maturity. Ann Clin Lab Sci 1990;20:398 5. Misake M, Kumazawa M, Sugita M, Shima T, Okazaki T. A possible relationship between cord blood transferrin and birth length in infants. Horm Res 1987;25:228 6. Sasanow SR, Spitzer AR, Pereira GR, Heaf L, Watkins JB. Effect of gestational age upon prealbumin and retinol binding protein in preterm and term infants. J Pediatr Gastroenterol Nutr 1986;5:111