ANNOTATIONS

diseases had to wait a long time for a bed. The mental disorders considered included various conditions such as oligophrenia aliae, dyslexia and Down’s syndrome. There were more boys than girls in this group, more of school age (7-15 yrs.) and more eldest children than others. Mental handicaps were also more frequently found in children whose fathers had an academic degree and from families in the upper rather than the lower income bracket. Children with functional symptoms, such as unexplained abdominal pain and headaches, who needed hospital admission also tended to come from the higher income group. The only child was admitted less frequently than the others for functional symptoms. Children with mental and functional disorders tended to occupy beds longer and delays in their discharge from hospital were more frequent-the most important reason cited was because the child was waiting for examinations. With regard to any resistance on the part of the parents to the admission of their child, the Finnish group met opposition in less than 1 per cent of cases.

According to the report from Newcastle,6 one child in every five was admitted to hospital at least once in 5 years. A social admission is not a common diagnostic label, though the social aspects as well as the organic disorder should be incorporated in the complete diagnosis of all children in hospital. The reluctance to recognise the importance of social factors is gradually disappearing. With the challenges that the plans for the future integration and re-organisation of the health and welfare services in the U.K.8 will bring, it is hoped that the opportunities will be seized for further research into the complex and changing socio-economic factors on which these plans depend.

Dept. of Paediatrics, Guy’s Hospital, London, S.E. 1.

W. J. APPLEYARD

REFERENCES 1. Coe, R. M., Wessen, A. F. (1965) ‘Socio-psychological factors influencing the use of community health

2. Crossman, R. (1970) The Future Structure of the National Health Service. H.M.S.O. 3. Eaton. L. (1967) ‘Hosoitalizina emotionallv disturbed children.’ Posrarad. Med.. 41. 399.

resources.’ Amer. J. publ. Hlth., 55, 1024.

4. Mercer, J.’F. (i966) ‘Patterns-of family chsis related to re-acceptan& of the retardate.’ Amer. J. ment.

5 . Miller, F. J. W., Court, S. D. M., Walton, W. S., Knox, E. G. (1960) Growing up in Newcastle upon

6. Rosberg, G. (1969) ‘Social and psychological factors influencing hospital admission of children.’ Actu

7. Spence, J., Walton, W. S., Miller, F. J. W., Court, S. D. M. (1954) A Thousand Families in Newcastle

Defic., 71, 19.

Tyne. London : The Nuffield Foundation. Oxford University Press.

paediuf. scand., Suppl. 196.

upon Tyne. London: Oxford University Press. 8. Straus, P., Coiffard, N., Marzo-Weyl, S., Lenoir, M. (1961) L‘hospitalisation des enfants. Une Btude de

pediatrie sociale dans l’agglomkration parisienne. Monographie de l’Institut National d’Hygikne, Paris, No. 23.

NEUROLOGICAL DEVELOPMENT IN INFANTS OF DIABETIC MOTHERS

DOES maternal diabetes impair the development or functions of the infant’s brain? This problem has recently been approached in two different ways. Three papersl0I lS from Dr. F. J. SCHULTE’S group in Gottingen report studies in infants of diabetic mothers (IDMs) using the combined electrophysiological and polygraphic methods which have been developed and applied so fruitfully by PRECHTL and his colleaguessp and by S c m ~ m l ~ . Peripheral nerve conduction rate in the 14 IDMs studied was similar to that of normal

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DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY. 1970, 12

babies of the same gestational ages, suggesting that myelination of these nerves is not affected by maternal diabetes.ls However, a higher proportion of EEGS taken from IDMs than from a control group showed patterns which were relatively immature.l3 The sleep pattern of the IDMs was also relatively immature, showing a higher proportion of rapid- eye-movement sleep than would be expected for their gestational age." Compared with controls, the IDMs also showed more of the rhythmical tremor characteristic of hyper- excitable babies, occurring spontaneously and on eliciting the Moro reflex.l0 This tremor can be mistaken for convulsions, but it is, in fact, clonus due to an exaggerated and poorly damped stretch reflex.14 None of the IDMs was hypoglycaemic at the time of study, though 3 of the 14 had had blood-glucose concentrations below 20 mg./100 ml. at some time postnatally. Neither the immature EEGS, the immature sleep patterns or the clonic activity seen in the IDMs could be correlated with blood-glucose concentrations obtaining at the time of study or previously.

SCHULTE and his colleagues speculate that these minor abnormalities in the IDMs may indicate retardation of neurological maturation-the immature EEG and sleep patterns being perhaps related to underdevelopment of dendrites and synapses, and the rhythmical tremor to underdevelopment of feedback mechanisms involving inhibitory interneurones in the spinal cord.

CHURCHILL and his colleagues' in Bethesda report a prospective study of neuropsycho- logical development in IDMs, based on 237 such children included in the Collaborative Study of Cerebral Palsy. Their most important findings concern the Binet IQ at 4 years; the mean IQ was significantly lower (96 v. 103) in the IDMs than in the controls matched for hospital of birth, sex, race, social class, maternal age and birth rank. However, further analysis shows a striking difference in outcome for the infant according to whether the mother had acetonuria. This was defined as present if any urine test done during pregnancy, but more than 24 hours before birth, was positive for acetone.* The degree of ketonuria present in the majority of such cases was trivial compared with that seen in clinically evident ketoacidosis. Nevertheless, compared with their controls, infants whose mothers had acetonuria were significantly retarded in Bayley mental and motor scores at 8 months, in postural control at 1 year, and in Binet IQ at 4 years (mean 93 v. 102). Acetonuria was the only factor shown to be correlated with later 1-severity of diabetes (independently of acetonuria), and the need for insulin, had no such effect, nor did the shorter gestation which was usual in the IDMs.

One question which should always be asked when statistical comparisons of two groups show a slightly but significantly lower mean IQ in one of them is whether the difference is due to a general lowering Of IQ in the group as a whole, or to the presence of a small number of severely retarded children in a population, the rest of whom have intelligence not differing significantly from the controls. CHURCHILL and his colleagues have set out their findings particularly fully and clearly, and though among the 62 children of acetone- positive diabetics who were tested at 4 years there was one child of very low IQ (who had infantile spasms), it is clear that the distribution of I Q ~ in this group was otherwise consistent with a Gaussian curve shifted downwards compared with the controls.

Thus, these two very different studies suggest that, in at least some infants of diabetic mothers, the development of the fetal brain is somewhat retarded, and that this retardation results in minor neuropsychological deficits which are still detectable at 4 years. Information

* This definition differs slightly from that given on p. 258 of the paper cited' but Dr. Churchill kindly informs me that the definition given here was the one actually used in the study. R.R.

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ANNOTATIONS

on acetonuria is not given in SCHULTE’S series, which is, in any case, probably too small to allow comparison of babies with and without it. CHURCHILL et a/. suggest that the loss of amino acids used for ketoacid production may diminish the supply available to the fetus for cerebral development-a conclusion similar in principle to that of SCHULTE and his colleagues. Such a conclusion is also congruous with the observation by DRISCOLL et FEE and WEIL~ and GRUENWALD~ (though not by NAEYE’) that the brains of IDMs weigh less than expected for their gestational age.

These observations seem disquieting, but the lowering of IQ in the acetone-positive group of CHURCHILL et a/. was comparatively small, and 1QS measured at 4 years have to be viewed with caution. In FARQUHAR’S very long follow-up of babies born to diabetic mothers in Ed inb~rgh ,~ 6 out of 251 survivors are educationally subnormal, and 3 others are dull but manage in ordinary schools. This certainly does not represent more than a small excess over the usual incidence of educational subnormality.

These papers will stimulate further interest in the outlook for babies of diabetic mothers. Meanwhile one practical conclusion can certainly be drawn from the study of CHURCHILL et al. : it provides a further argument for good control of diabetes in pregnancy and for the prevention of acetonuria-a policy which is already widely accepted as lowering perinatal mortality.B*

Institute of Child Health, Hammersmith Hospital, Du Cane Road, London, W.12.

ROGER ROBINSON

REFERENCES 1. Churchill, J. A., Berendes, H. W., Nemore, J. (1969) ‘Neuropsychological deficits in children of diabetic

mothers.’ Amer. J. Obstet. Gynec., 105, 257. 2. Driscoll, S. G., Benirschke, K., Curtis, G. W. (1960) ‘Neonatal deaths ammg infants of diabetic mothers.’

Amer. J . Dis. Child., 100, 8 I 8. 3. Farquhar, J. W. (1969) ‘Prognosis for babies born to diabetic mothers in Edinburgh.’ Arch. Dis. Childh.,

44, 36. 4. Fee, B. A., Weil, W. B. (1963) ‘Body composition of infants of diabetic mothers by direct analysis.’

Ann. N . Y. Acad. Sci., 110, 869. 5 . Gruenwald, P. (1965) ‘Quantitative data on infants of diabetics.’ Pediatrics, 36,804. 6. Harley, J. M. G., Montgomery, D. A. D. (1965) ‘Management of pregnancy complicated by diabetes.’

Brit. med. J., I, 14. 7. Naeye, R. L. (1965) ‘Infants of diabetic mothers: a quantitative, morphological study.’Pediatrics, 35,980. 8. Prechtl, H. F. R. (1968) ‘Polygraphic studies of the full-term newborn: II. Computer analysis of recorded

data.’ In R. MacKeith and M. Bax (Eds.) Studies in Infancy. London: Spastics Soc./Heinemann, p. 22. 9. - Akiyama, Y., Zinkin, P., Kerr Grant, D. (1968) ‘Polygraphic studies of the full-term newborn: I.

Technical aspects and qualitative analysis.’ In R. MacKeith and M. Bax (Eds.) Studies in Infancy. London: Spastics SocJHeinemann, p. 1.

10. Schulte, F. J., Albert, G., Michaelis, R. (1969) ‘Brain and behavioural maturation in newborn infants of diabetic mothers. Part IU: Motor behaviour.’ Neuropadiatrie, 1,M.

11. - Lasson, U., Parl, U., Nolte, R.. Jurgens, U. (1969). ‘Brain and behavioural maturation in newborn infants of diabetic mothers. Part 11: Sleep cycles.’ Neuropadiatrie, 1, 36.

12. - Linke, I., Michaelis, R., Nolte, R. (1969) ‘Excitation, inhibition and impulse conduction in spinal motoneurones of preterm, term and small-for-dates newborn infants.’ In R. J. Robinson (Ed.) Brain and Early Behaviour: Development in the Fetus and Infant. London and New York: Academic Press, p. 87.

13, - Michaelis, R., Nolte, R., Albert, G., Parl, U., Lasson, U. (1969) ‘Brain and behavioural maturation in newborn infants of diabetic mothers. Part I : Nerve conduction and EEG patterns.’ Neuropadiatrie, 1,24.

14. - Schwenzel, W. (1965) ‘Motor control and muscle tone in the newborn period. Electromyographic studies.’ Biol. Neonat. (Basel), 8, 198.

IS. Wright, A. D., Dixon, H. G., Joplin, G. F. (1968) Diabetes and latent diabetes in pregnancy.’ Brit. med. Bull., 24, 25.

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