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data available on outcomes at different number of outcome variables investi- low birth weight infants in the 2 groups
ages ranged from 100% to 44%. gated and the importance of a conser- compared with controls.10
vative approach to analysis. We took the
Confounders Longitudinal Growth
approach of using available data for
Maternal educational level, housing each outcome because restricting the Early Weight-Faltering Group
tenure, socioeconomic class, and pa- analysis to only those with complete
rental heights were obtained by using Infants with early weight faltering
data for all outcomes would reduce the
postal questionnaires completed dur- showed an increased weight velocity
numbers substantially.
ing the study pregnancy. Mothers and compared with controls between 8
partnerswere asked to self-report their weeks and 2 years, resulting in their
RESULTS weight returning toward the reference
height; data were available for 10 307
mothers and 7165 fathers of the chil- Ascertainment mean for that age (Fig 1). After 2 years,
dren in infancy. Feeding symptoms and From the 11 499 children with complete this group gained weight at a similar
difficulties were captured by parent- growth measurements in infancy, those rate to the controls. From 7 to 13 years,
completed questionnaires. Parents with data available at later ages were both the early group and the controls
were asked to rate on a scale of 1 to 5 more likely to come from families of gained weight faster than the refer-
whether their infant demonstrated higher socioeconomic class, with a ence, but at all points those with pre-
specific feeding behaviors, which were higher maternal educational level, and vious weight faltering remained lighter
named but not described in the ques- secure housing tenure (P #.01 for all), than control children; at 13 years, the
tionnaire, and no definitions were compared with those lost to follow-up. mean weight for the early group was
provided on what constituted a prob- However, there were no differences in 3.3 kg below the mean for controls but
lem. We have used specific questions the proportion of missing data be- was still above the mean of the UK ref-
on feeding from questionnaires com- tween the 2 weight gain groups and the erence. Children from the control group
pleted at 1, 6, and 15 months of age. controls. had mean weights parallel to and above
the reference mean at all age points.
Statistical Analysis Infant Growth The early group was, on average,
The data were analyzed by using Stata The mean 6 SD birth weight of the shorter than controls at all ages, and
(Stata Corp, College Station, TX)21 and whole sample was 3470 6 475 g. there were proportionally more chil-
SPSS (IBM SPSS Statistics, IBM Corpo- Weight z scores (corrected for gender dren below the 10th centile (Supple-
ration, Armonk, NY).22 The effect of and gestational age) at birth, 6 to 8 mental Appendix 1). Between 8 weeks
early growth on anthropometric out- weeks, and 9 months were normally and 9 months, the early group grew in
comes was assessed by running distributed, with a mean just above length at a slower rate than controls;
a general linear model.23 Analysis of 0 and an SD of ∼1. Weight gain z scores after 9 months, the length/height ve-
covariance was used in multivariate were also normally distributed, centiles locity of the early group was not dif-
analysis to investigate interaction were constructed, and infants below ferent from controls (Table 2).
effects. Major confounders included the fifth centile were classified as The height velocity of the early group
maternal anthropometry, socioeco- cases of growth faltering. A total of 507 was slower than their weight velocity up
nomic characteristics, and infant- children showed slow weight gain from to 7 years, resulting in these children
feeding difficulties. Assumption of ho- birth to 8 weeks (early group) and 480 being disproportionately short com-
mogeneity of variances was tested children from 8 weeks to 9 months pared with their weight, but these dif-
by using Levene’s test,24 and the (late group). Thirty children (12 boys, ferences disappeared after this age,
Pearson product moment correlation 18 girls) were common to both slow and there was no difference in mean
coefficient25 was used to assess cor- weight gain groups. The tables show BMI, MAC, or WC between the early
relation among variables. To determine the controls for the early group: the group and controls at 13 years (Table 3).
whether there was a difference between means and confidence interval (CI) for For all these outcome measures, in
the expected frequencies and the ob- the late control group were similar, with multivariate analysis, weight SDS at 8
served frequencies in $1 category, x2 differences ,0.07 SDS. The attained weeks explained the differences be-
tests were conducted. All tests were weights are shown in Table 1, and the tween the early group and the controls.
performed at a significance level of 0.01. conditional weight gains (weight veloc- The models used in the multivariate
A P value of ..01 was used for stepwise ities) are displayed in Table 2. There analyses are presented in Supplemen-
exclusion of covariates in view of the were no differences in the proportion of tal Appendix 2.
DIN et al
9 mo 2y 4y 7y 10 y 13 y
Early kg 8.51 (8.38 to 8.64) 11.39 (11.20 to 11.58) 15.66 (15.38 to 15.93) 24.61 (23.93 to 25.30) 36.45 (35.12 to 37.78) 52.16 (50.23 to 54.09)
Weight SDS 20.57 (–0.69 to –0.45) 20.21 (–0.34 to –0.08) 20.17 (–0.31 to –0.04) 20.14 (–0.29 to 0.02) 0.12 (–0.04 to 0.29) 0.20 (0.02 to 0.39)
cm 70.86 (70.47 to71.24) 82.66 (82.12 to 83.19) 98.77 (98.20 to 99.34) 123.82 (122.99 to 124.63) 141.69 (140.65 to 142.72) 160.25 (158.93 to 161.58)
Height SDS 20.22 (–0.36 to –0.08) 20.16 (–0.30 to –0.02) 20.33 (–0.46 to –0.19) 20.18 (–0.33 to –0.03) 20.03 (–0.19 to 0.12) 0.04 (–0.13 to 0.21)
w/h2 16.94 (16.87 to 17.02) 16.67 (16.16 to 16.73) 16.07 (15.95 to 16.15) 15.96 (15.65 to 16.27) 17.98 (17.49 to 18.47) 20.19 (19.60 to 20.79)
BMI SDS 20.58 (–0.69 to–0.46) 20.19 (–0.3 to –0.07) 20.99 (–0.01 to –0.21) 20.05 (–0.20 to 0.11) 0.19 (0.008 to 0.37) 0.21 (0.02 to 0.40)
n 451 403 352 284 270 228
Late kg 7.51 (7.38 to 7.64) 10.22 (10.04 to 10.41) 14.44 (14.16 to 14.71) 22.69 (22.03 to 23.37) 33.87 (32.55 to 35.18) 49.18 (47.23 to 51.14)
Weight SDS 21.72 (–1.83 to –1.61) 21.22 (–1.35 to –1.09) 20.85 (–0.98 to –0.72) 20.67 (–0.82 to –0.52) 20.25 (–0.41 to –0.09) 20.10 (–0.29 to 0.09)
cm 69.90 (69.51 to 60.29) 81.02 (80.47 to 81.56) 97.12 (96.53 to 97.70) 121.93 (121.13 to 122.72) 140.03 (139.00 to 141.06) 159.61 (158.27 to 160.96)
Height SDS 20.65 (–0.79 to –0.51) 20.72 (–0.87 to –0.58) 20.74 (–0.88 to –0.60) 20.53 (–0.67 to –0.38) 20.26 (–0.41 to –0.11) 20.06 (–0.23 to 0.11)
w/h2 15.37 (15.27 to15.50) 15.57 (15.50 to 15.64) 15.31 (15.19 to 15.41) 15.19 (14.89 to 15.49) 17.12 (16.63 to 17.60) 19.25 (18.64 to 19.85)
BMI SDS 21.85 (–1.96 to–1.75) 21.05 (–1.17 to –0.93) 20.48 (–0.59 to –0.36) 20.51 (–0.66 to –0.35) 20.20 (–0.38 to –0.02) 20.13 (–0.33 to 0.07)
n 419 385 337 295 275 220
Control kg 9.25 (9.22 to 9.28) 11.94 (11.89 to 11.98) 16.42 (16.37 to 16.48) 25.80 (25.66 to 25.95) 38.16 (37.82 to 38.44) 54.70 (54.29 to 55.12)
Weight SDS 0.19 (0.17 to 0.22) 0.23 (0.20 to 0.26) 0.23 (0.20 to 0.25) 0.20 (0.17 to 0.24) 0.41 (0.37 to 0.45) 0.51 (0.47 to 0.55)
cm 72.50 (72.42 to 72.59) 83.97 (83.85 to 84.08) 100.50 (100.38 to 100.62) 125.74 (125.57 to 125.91) 144.08 (143.86 to 144.30) 163.51 (163.22 to 163.79)
Height SDS 0.48 (0.45 to 0.51) 0.29 (0.26 to 0.32) 0.11 (0.08 to 0.14) 0.19 (0.16 to 0.22) 0.34 (0.31 to 0.37) 0.47 (0.43 to 0.51)
w/h2 17.59 (17.57 to 17.61) 16.96 (16.93 to 16.98) 16.25 (16.23 to 16.28) 16.24 (16.18 to 16.31) 18.25 (18.15 to 18.36) 20.37 (20.24 to 20.50)
BMI SDS 20.09 (–0.12 to –0.07) 0.01 (–0.02 to 0.03) 0.26 (0.24 to 0.28) 0.14 (0.11 to 0.17) 0.33 (0.29 to 0.36) 0.33 (0.29 to 0.38)
n 9773 8675 7799 6474 5925 4887
Control group are the controls for the early growth-faltering group.
TABLE 2 Conditional Weight and Length/Height Gain SDS (Velocity) in Weight-Faltering and Control Groups
Weight Gain Groups Subject Age
10 y 13 y
weeks showed early recovery with en- in referred samples of children with self-reported and not based on clini-
hanced weight gain and had almost failure to thrive. The use of conditional cal measurements. Father’s heights
“caught up” by 2 years, whereas those weight gain, both to identify children were only available in 56% of the late
with later weight faltering between 8 with slow weight gain in the 2 time weight-faltering group, and we there-
weeks and 9 months gained weight periods and to measure their sub- fore used maternal height rather than
slowly until 7 years, then had a spurt sequent growth trajectories, adjusted mid-parental height in the final models.
between 7 and 10 years, but remained for the regression to the mean; this Because ALSPAC is an observational
considerably shorter and lighter than finding would be expected for small study, with limited information on use of
both the normally growing controls infants at the extreme of the distribu- health services, we cannot ascertain
and the early weight-faltering group. tion. However, the study has some im- which infants showing weight faltering
The differences in anthropometric portant limitations, especially missing received nutritional or medical inter-
outcomes between the growth- data: although all subjects selected for ventions. It is likely that many of the
faltering groups and controls at 13 this project had complete weight data infants putting on weight slowly in the
years was largely explained by their up to 9 months, loss of follow-up took first 2 months would have received
weight gain in infancy, re-enforcing the place from 9 months onward, which interventions in primary care, such as
importance of the first year of life in increased as children got older, so that management of feeding problems and
determining subsequent growth. some of the variables at 13 years were increasing energy intake by switching
Although the infants who faltered in only available for 44% of the original to formula and providing supplemen-
weight gain did eventually recover their cohort. However, it is reassuring that tary feeds. We have already reported15
weight, their linear growth remained there were no differences in the pro- that early slow weight gain in ALSPAC
relatively restricted, with ∼20% below portion of missing data between the infants was associated with feeding
the 10th centile at 13 years, showing weight gain groups and the controls. We symptoms, and we speculate that the
that slow weight gain in infancy was used the 1990 UK growth reference infants in the early-faltering group
associated with subsequent shortness because it has data from birth to 18 would have been more readily identified
consistent with previous studies.5,9,26 years derived from British population at the 8-week check, resulting in early
As both parents of the late weight- surveys, whereas the World Health Or- treatment and therefore a more rapid
faltering infants were shorter than the ganization growth standards are only recovery of weight gain. However, it is
parents of control children, it is likely published up to 5 years of age. It must be also possible that the differences in
that a proportion of these children were acknowledged that much of the data recovery of weight between early and
showing growth patterns normal for that contributed to the 1990 UK refer- late weight falterers may reflect differ-
their genetic potential. The Millennium ence were collected in the 1970s and ent underlying causes and mechanisms.
Cohort Study in the United Kingdom has 1980s from a British population that The term catch-up growth can be
concluded that both maternal and pa- was mainly bottle-fed. However, be- defined as increased growth velocity
ternal height and weight exert in- cause we are comparing slow-growing (rapid gain in weight or height) during
dependent and significant influences on groups with controls assessed against a defined period of time, after a tran-
a child’s birth weight and weight gain the same standards, the conclusions sient period of growth restriction.
between birth and 9 months.27 would not be changed if we had used However, catch-up weight gain is not
This study used a large representative a different standard. A final limita- always beneficial; for example, children
cohort and avoided the biases inherent tion is that parental heights were who show pronounced catch-up growth
e848 DIN et al
Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on January 11, 2015
ARTICLE
in the first 2 years can develop central follow-up of both groups in ALSPAC will between groups at this age can be
obesity.28 The early-faltering group, be undertaken to trace their growth explained by weight in infancy rather
who showed catch-up by age 2 years, outcomes during adolescence. than by other environmental factors.
did demonstrate this tendency with
weight disproportionate to height ACKNOWLEDGMENTS
during childhood, but by 13 years, CONCLUSIONS We are extremely grateful to all the
their mean BMI was not different from Overall, clinicians and parents alike will families who took part in this study,
controls. In comparison, the catch-up find the growth outcomes at 13 years the midwives for their help in recruiting
growth in the late-faltering group was reassuring, in that both early- and late them, and the whole ALSPAC team,
much later in childhood, and these growth-faltering groups recovered to which includes interviewers, computer
children remained shorter and lighter be within normal ranges by this age. The and laboratory technicians, clerical
with a lower mean BMI than their peers, children whose weight faltered in in- workers, research scientists, volun-
although the findings were within the fancy had BMIs within the normal teers, managers, receptionists, and
reference norms at 13 years. Further range at 13 years, and any differences nurses.
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