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PURPOSE: Prematurity, prenatal growth restriction, and retinopathy of prematurity (ROP) are associated with altered ocular geometry, such as a steeper corneal shape in childhood, but it is unclear whether perinatal history affects corneal thickness development, so this study investigated whether corneal thickness in adulthood is affected by perinatal history. MARTERIALS AND METHODS: The Gutenberg Prematurity Eye Study (GPES) is a retrospective cohort study with a prospective ophthalmologic examination in Germany. The corneal thickness was measured by Scheimpflug imaging (Pentacam HR, Oculus Optikgeräte GmbH, Wetzlar, Germany), and the relationship between perinatal parameters respective birth weight percentile and corneal thickness at different locations was assessed using uni- and multivariable linear regression models. Covariates included age, sex, mean corneal radius, white-to-white distance, gestational age, birth weight percentile, ROP occurrence, and treatment. The main outcome measures were corneal thickness at the apex, the pupil center, and the corneal periphery. RESULTS: The corneal thickness was measured in 390 participants (754 eyes, mean age 29.7+/-8.7 years, 224 females). In multivariable analyses, a lower birth weight percentile was associated with a lower corneal thickness at the apex (B = 0.20, p = 0.003) and the pupil (B = 0.19, p = 0.007). These effects diminished towards the corneal periphery and were not observed beyond the 4-mm diameter circle around the thinnest corneal position. Neither gestational age, ROP occurrence, or ROP treatment affected the corneal thickness. CONCLUSION: A lower birth weight percentile in subjects born preterm as a proxy for restricted fetal growth is associated with corneal thickness thinning in adults aged 18 to 52 years, indicating that corneal thickness development, particularly in the corneal center, may originate in the fetal stage.

Background/Aims: This study investigated whether there are changes in corneal surface regularity and corneal thickness in adults born small, appropriate, or large for gestational age at term. Methods: This retrospective cohort study involved prospective Scheimpflug imaging of the cornea (Pentacam®) to compare the corneal thickness and aberrations between adults classified as small for gestational age (SGA), normal birth weight (BW), and large for gestational age (LGA). Multivariable linear regression was applied to analyze associations with gestational age, BW percentile, placental insufficiency, preeclampsia, and breastfeeding. Results: In total, 448 eyes of 261 individuals born full term (aged 29.9 ± 9.5 years, 140 females) were examined, including 29 severe SGA (BW < 3rd percentile), 32 moderate SGA (BW between 3rd and 90th and 97th percentile), and 33 severe LGA (BW > 97th percentile). There were no differences between groups in the corneal aberrations of the total cornea as well as of the corneal front surface, except for higher-order aberrations in the front of the cornea (p = 0.032). There was an association between the increased total root mean square of higher-order aberrations and lower birth weight percentile (p = 0.004), with increased higher-order aberrations correlating with lower visual acuity and spherical equivalent. Conclusion: Restricted prenatal growth is associated with increased higher-order aberrations in adulthood.

Objectives This study investigated the effects of prematurity and ROP on visual acuity and VRQoL in adults (18–52 years). Methods The Gutenberg Prematurity Eye Study is a retrospective cohort study with a prospective ophthalmologic examination. Preterm and full-term participants at an age from 18 to 52 years were included. Distant corrected visual acuity (DCVA) and VRQoL were assessed in participants (892 eyes of 450 individuals aged 28.6 ± 8.6 years, 251 females) grouped into full-term controls (gestational age [GA] at birth ≥37 weeks), preterm participants without ROP and GA 33–36 weeks (group 2), GA 29–32 weeks (group 3), GA ≤ 28 weeks (group 4), non-treated ROP (group 5) and treated ROP (group 6). Main outcome measures were distant corrected visual acuity (DCVA), VRQoL and prevalence of amblyopia. Results The DCVA of the better eye correlated (p Conclusion Participants with postnatal ROP and its treatment showed decreased visual acuity and VRQol in adulthood, with amblyopia occurring more frequently in more preterm participants with ROP.

Psychotropic drugs are frequently prescribed ‘off-label’ to children and adolescents and carry the risk of serious adverse drug reactions (sADR). We examined the frequency of sADRs of psychotropic drugs in pediatric inpatients and explored their potential preventability through following the recommendations of a web-based pediatric drug information system (PDIS). The potential socio-economic impacts of using this online system is also addressed. Routine clinical data from all inpatients treated in a child and adolescent psychiatry department between January 2017 and December 2018 were retrospectively examined for the occurrence of sADRs as defined by the European Medicines Agency. The preventability of the sADRs was assessed based on the information of the PDIS. Furthermore, the expected prolongation of the hospital stay due to sADRs was calculated as well as the associated treatment costs. The study was supported by the Innovation Fund of the Joint Federal Committee, grant number 01NVF16021. In total, 1036 patients were screened of whom 658 (63.5%) received psychopharmacological treatment. In 53 (8.1%) of these patients 54 sADRs were documented, of which 37 sADRs were identified as potentially preventable through PDIS. Mitigating sADR through PDIS would likely have prevented prolonged hospital stays and conferred considerable savings for health insurance companies. PDIS provides systematic and evidence-based information about pediatric psychopharmacotherapy and helps to prevent prescribing errors. Therefore, PDIS is a useful tool to increase drug therapy safety in child and adolescent psychiatry. Further prospective studies are needed to confirm the results.

Young age at school entry (ASE) is related to attention-deficit/hyperactivity disorder in higher grades. The reason for this association is unclear, but medical oversupply and stress-related factors are discussed. We aimed to investigate whether ASE is associated with reported symptoms of attention-deficit/hyperactivity (ADH) already in first grade. Data of a population-based prospective cohort study (N = 2003; Mainz-Bingen region; Rhineland-Palatinate; Germany) with baseline assessments prior to school entry and two follow-ups during first grade were analysed. ADH symptoms were assessed by parent and teacher versions of the Strengths and Difficulties Questionnaire. Associations between ASE and scores of the hyperactivity/inattention subscale (range 0–10) were investigated by regression analysis and adjusted for potential confounders and baseline symptoms prior to school entry. In total, 1633 children (52% boys, mean ASE 6.5 years) were included. There were no relationships between ASE and parent-reported scores of the hyperactivity/inattention subscale prior to school entry and 3 months thereafter. However, at the end of first grade, ASE was negatively associated with the hyperactivity/inattention subscale in parent (− 0.7 subscale points per year ASE, standard error = 0.16, p p

Purpose Low birth weight (BW) individuals have an increased risk for myopic refractive error. However, it is unclear which ocular geometric alterations lead to an increase in myopic refractive error. This study aims to evaluate the impact of ocular biometry in interaction with BW on refractive error. Methods Participants of the prospective, observational, population-based Gutenberg Health Study (GHS) with self-reported BW aged 40–80 years and objective refraction and optical biometry were included. Linear regression analyses were conducted to evaluate associations between spherical equivalent with corneal power, anterior chamber depth, lens thickness and axial length and its interaction with BW adjusted for age and sex. Low BW was defined as BW

To evaluate the long-term effects of different degrees of prematurity, retinopathy of prematurity (ROP) and associated perinatal factors on refractive error, accommodation and lens opacification development in adults born preterm aged 18-52 years.The Gutenberg Prematurity Eye Study (GPES) investigated adults born preterm and full-term at 18-52 years in Germany to assess refractive error, accommodation amplitude and lens opacification. The participants were grouped into normal gestational age (GA) ≥37 weeks (control group), preterm participants without ROP and GA 33-36 weeks (group 2), GA 29-32 weeks (group 3), GA ≤28 weeks (group 4) and those with ROP without (group 5) or with treatment (group 6). Main outcome measures were refractive error, anisometropia, accommodation amplitude and lens opacification.In total, 856 eyes of 433 preterm and full-term individuals (aged 28.4 +/− 8.6 years, 242 females) were included. A myopic refractive error of6 diopter was observed in 4% (11/278), 2.7% (7/264), 1.2% (2/174), 5.6% (2/36), 10.5% (8/78) and 26.9% (7/26) of eyes and anisometropia ≥2 diopter in 2.9% (4/139), 2.3% (3/132), 3.5% (3/87), 11.1% (2/18), 9.5% (4/44) and 38.5% (5/13) of participants in the respective groups. Spherical equivalent did not differ between participants without postnatal ROP born moderately, very and extremely preterm compared to the full-term control group. ROP treatment was associated with lower accommodation and more lens opacifications.Retinopathy of prematurity treatment using cryocoagulation and laser coagulation increases refractive error associated with increased lens opacifications and reduced accommodation. Preterm delivery has little effect on absolute refractive error but is associated with anisometropia in adulthood.

ObjectiveTo assess incidence and burden of neonatal herpes simplex virus (HSV) infections and to explore possible transmission routes.MethodsA 2-year prospective nationwide surveillance study performed in 2017 and 2018. All German paediatric departments (n=464 in 2017, n=441 in 2018) were contacted on a monthly basis to report potential cases of neonatal HSV infections. Infants with a postnatal age of ≤60 days and a positive HSV PCR or HSV culture from skin, mucous membrane, vesicles or conjunctival smear, blood or cerebrospinal fluid were included in the study.Results37 cases were analysed. 29 patients who exhibited no or only mild clinical symptoms were discharged home without organ damage or neurological abnormalities. Four patients showed significant neurological impairment, one patient required liver transplantation and two patients died during in-patient treatment. The 2-year incidence of neonatal HSV infections was 2.35 per 100 000 live births (95% CI 1.69 to 3.02) and disease-specific mortality was 0.13 per 100 000 live births (95% CI 0.04 to 0.21). Data on possible transmission routes were available in 23 cases. In 20 cases, an orofacial HSV infection was present in one or more family members. An active maternal genital HSV infection was reported in 3 cases.ConclusionNeonatal HSV infections are rare in Germany. Most infants have a benign clinical course, but some infants are severely affected. Postnatal HSV exposure may account for a considerable number of neonatal HSV infections.

Zusammenfassung Hintergrund Frühgeburtlichkeit und das Auftreten der Frühgeborenenretinopathie (ROP) erhöhen das Risiko für das Auftreten von amblyogenen Risikofaktoren in der Kindheit und Jugend. Ziel der Arbeit Das Ziel der vorliegenden Studie war die Beschreibung der augenärztlichen Versorgung und der Augenerkrankungen ehemaliger früh- und reifgeborener Personen im Erwachsenenalter. Material und Methoden Die Gutenberg Prematurity Eye Study (GPES) ist eine retrospektive Kohortenstudie mit einer prospektiven augenärztlichen Untersuchung von ehemaligen früh- und reifgeborenen Personen, geboren zwischen 1969 und 2002 (aktuelles Alter 18 bis 52 Jahre). Alle Teilnehmenden wurden hinsichtlich amblyogener Parameter wie z. B. dem Vorliegen eines Strabismus und von Refraktionsfehlern untersucht. Die Teilnehmenden wurden gruppiert in Personen mit normalem Gestationsalter (GA) ≥ 37 (Kontrollgruppe), Frühgeborene ohne ROP mit GA 33–36 (Gruppe 2), GA 29–32 (Gruppe 3), GA ≤ 28 Wochen (Gruppe 4) und solche mit ROP ohne Behandlung (Gruppe 5) und mit ROP mit Behandlung (Gruppe 6). Es wurde von allen Teilnehmenden erhoben, wie oft sie innerhalb der letzten 12 Monate bei einer augenärztlichen Untersuchung gewesen sind. Ergebnisse Insgesamt wurden die Daten von 140 reifgeborenen und 310 frühgeborenen Erwachsenen in die vorliegende Studie eingeschlossen. Ein Strabismus lag bei 2,1 % (3/140), 6,6 % (9/137), 17,4 % (16/92), 11,1 % (2/18), 27,1 % (13/48) und 60 % (9/15) in den jeweiligen Gruppen 1 bis 6 vor. Der Anteil an Probanden mit augenärztlicher Untersuchung innerhalb der letzten 12 Monate war in den Gruppen der extrem Frühgeborenen mit und ohne ROP im Vergleich zur Kontrollgruppe am höchsten. Insgesamt waren 33,3 % (1/3) der Reifgeborenen und 57,1 % (28/49) der Frühgeborenen mit Strabismus und 0 % (0/3) der Reifgeborenen und 46,9 % (15/32) der Frühgeborenen mit Amblyopie innerhalb der letzten 12 Monate bei einer augenärztlichen Untersuchung. Diskussion Extrem frühgeborene Personen mit und ohne postnatale ROP zeigten die höchste Rate an Augenerkrankungen sowie die höchste Rate an augenärztlichen Kontrolluntersuchungen innerhalb der letzten 12 Monate. Dies deutet darauf hin, dass extrem frühgeborene Personen insbesondere mit postnataler ROP insgesamt lebenslang häufigere augenärztliche Kontrolluntersuchungen wahrnehmen.

Prematurity and retinopathy of prematurity (ROP) are associated with altered corneal shape and reduced visual acuity in childhood, but their long-term effects on corneal shape in later life are still unclear. This study evaluated whether prematurity and related perinatal factors are associated with corneal aberrations in adulthood.The Gutenberg Prematurity Eye Study (GPES) is a cohort study using Scheimpflug imaging of the cornea. Associations were assessed between corneal Zernike aberrations and gestational age (GA), birth weight (BW), BW percentile, ROP occurrence, ROP treatment and other perinatal factors using univariate and multivariable linear regression analyses.This study involved 444 eyes of 256 individuals born preterm (aged 28.1 ± 8.4 years, 146 females) and 231 eyes of 132 individuals born full-term (aged 29.8 ± 8.9 years, 77 females). Multivariable analyses revealed an association between corneal higher-order aberrations and lower birth weight percentile (B = -0.001, p 0.001) as well as ROP treatment (B = 0.120, p = 0.03). Corneal lower-order aberrations were also associated with lower birth weight percentile (B = -0.004; p = 0.001) and ROP treatment (B = 0.838, p = 0.01) but not with ROP occurrence. Increased corneal aberrations were correlated with lower visual acuity and the spherical equivalent refractive error.Perinatal factors, particularly low birth weight percentile and ROP treatment lead to a more irregular corneal shape in adulthood, thereby reducing optical image quality and potentially contributing to reduced visual acuity and altered refractive error.

Background/Aims: This study aimed to analyze the effects of perinatal history on tear film properties and lid geometry in adults born preterm. Methods: The Gutenberg Prematurity Eye Study (GPES) is a German prospective examination of adults born preterm and term aged 18 to 52 years with Keratograph® 5M and Schirmer test I. Main outcome measures were first non-invasive tear film break-up time (F-NITBUT), bulbar redness (BR), Schirmer test, and nasal palpebral angle measurement. The associations with gestational age (GA), birth weight (BW), and BW percentile, retinopathy of prematurity (ROP), ROP treatment, and other perinatal factors were evaluated using regression analyses. Results: 489 eyes of 255 preterm and 277 eyes of 139 full-term individuals (aged 28.6 +/− 8.8 years, 220 females) were included. Of these, 33 participants (56 eyes) had a history of spontaneously regressed ROP and 9 participants (16 eyes) had a history of ROP treatment. After adjustment for age and sex, lower F-NITBUT (

Introduction: Participation is an important dimension of healthy child development and is associated with higher self-rated health, educational attainment and civic engagement. Many children with special healthcare needs (SHCN) experience limited participation and are thus at risk for adverse health and developmental outcomes. Despite this, interventions that promote participation in healthcare are scarce. We therefore evaluate the effectiveness of a complex age- and condition-generic intervention that strengthens participation-centred care involving parents and their children with SHCN by, inter alia, assessing preferences, specifying participation goals and facilitating shared decision-making in care. Methods and analysis: In this study protocol we describe the design and procedures for an unblinded, stepped wedge, cluster randomised trial conducted in 15 German interdisciplinary healthcare facilities providing services for children aged 0–18 years with SHCN. Sites are randomised to five periods in which they switch from control to intervention condition in blocks of three. The intervention includes: (1) team training focused on participation-centred care, (2) introduction of a new software facilitating participation-focused documentation and (3) implementation support promoting the transfer of training content into routine care. Study sites deliver routine care while in the control condition. As primary outcome, the degree of perceived shared decision-making with parents (CollaboRATEpediatric parent scale), a potential antecedent of achieving participation goals in everyday life, is assessed on one randomly selected day per week during the entire study period, directly following care appointments. We aim to sample 70 parents per study site and period. Additionally, participation of children is assessed within a closed embedded cohort with three parent and patient surveys. Intervention effectiveness will be modelled with a marginal model for correlated binary outcomes using generalised estimation equations and complete cases. A comprehensive mixed-methods process evaluation complements the effectiveness analyses.

Low birth weight (BW) is associated with altered ocular geometry such as a steeper corneal shape in adulthood. However, it is unclear whether low birth weight affects corneal thickness development in the center or periphery in adulthood which may contribute to ocular disease. The purpose of this study was to investigate corneal thickness in former low birth weight individuals in adulthood. Methods: The German Gutenberg Health Study is a prospective, population-based study in which every participant (age range 40–80 years) was measured with Scheimpflug imaging (Pentacam HR, Oculus Optikgeräte GmbH, Wetzlar, Germany). BW was collected by self-reports. The relationship between birth weight and corneal thickness at different locations were assessed. Linear regression models were carried out including uni- and multivariable analyses with adjustment for age, sex, mean corneal radius, and white-to-white distance. Main outcome measures were corneal thickness at the apex, at the pupil center, and at the corneal periphery. Results: Overall, 5657 participants were successfully measured (3019 females, aged 56.0 ± 10.3 years). In multivariable analyses a lower BW was associated with a thinner corneal thickness at the apex (B = 1.71 µm/500 g, p &lt, 0.001) and at the pupil (B = 1.69 µm/500 g, p &lt, 0.001). These effects diminished towards the corneal periphery resulting in no differences in the perilimbal regions. Conclusion: The present study provides evidence that lower birth weight goes along with corneal thickness alterations even into adult ages of 40 to 80 years. Thinner measurements of the cornea were particularly found in the corneal center and diminished in the periphery. This indicates that there may be fetal origins affecting corneal thickness development particularly in the corneal center.

The present study investigated the long-lasting effect of prematurity, prenatal growth restriction, and associated factors on foveal and peripapillary choroidal thickness in adulthood.The Gutenberg Prematurity Eye Study (GPES) is a retrospective cohort study with a prospective ophthalmologic examination in Germany. Foveal and peripapillary choroidal thicknesses were measured at different sectors using spectral-domain optical coherence tomography. Multivariable linear regression analyses were performed to determine associations among gestational age, birth weight percentile, retinopathy of prematurity (ROP) occurrence and treatment, and other perinatal factors, such as maternal smoking and others with foveal and global peripapillary choroidal thickness.A total of 735 eyes of 408 study participants were included (age = 28.4 ± 8.6 years, 229 women). Multivariable regression analyses revealed that foveal choroidal thinning was associated with maternal smoking during pregnancy (B = -38.1, 95% confidence interval [CI] = -65.5 to -10.7, P = 0.006), whereas other perinatal factors revealed no association. Global peripapillary choroidal thinning showed a trend to a lower birth weight percentile (B = 0.22, 95% CI = -0.01 to 0.45, P = 0.057). No correlation was observed between foveal and peripapillary choroidal thicknesses with visual acuity.This study indicates that maternal cigarette smoking during pregnancy has adverse long-lasting effects on choroidal development in the fovea and low birth weight percentile as a surrogate marker for adverse perinatal growth might be linked with peripapillary choroidal thinning whereas prematurity showed no long-term effects.Altered choroidal layer development caused by perinatal influence factors might be a risk factor for reduced visual function and predispose affected individuals to eye diseases in later life.

Background: One of the numerous challenges preterm birth poses for parents and physicians is prognostic disclosure. Prognoses are based on scientific evidence and medical experience. They are subject to individual assessment and, hence, will generally remain uncertain with regard to the individual. This can result in differences in prognostic framing and thus affect the recipients’ perception. In neonatology, data on the effects of prognostic framing are scarce. In particular, it is unclear whether parents prefer a more optimistic or a more pessimistic prognostic framing.Objective: To explore parents’ preferences concerning prognostic framing and its effects on parent reported outcomes and experiences. To identify predictors (demographic, psychological) of parents’ communication preferences.Design, setting, participants: Unblinded, randomized-controlled cross-over trial (RCT) at the Division of Neonatology of the University Medical Center Mainz, Germany, including German-speaking parents or guardians of infants born preterm between 2009 and 2019 with a birth weight Intervention: Embedded in an online-survey and in pre-specified order, participants will watch two video-vignettes depicting a more optimistic vs. a more pessimistic framing in prognostic disclosure to parents of a preterm infant. Apart from prognostic framing, all other aspects of physician-parent communication are standardized in both videos.Main outcomes and measures: At baseline and after each video, participants complete a two-part online-questionnaire (baseline and post-intervention). Primary outcome is the preference for either a more optimistic or a more pessimistic prognostic framing. Secondary outcomes include changes in state-anxiety (STAI-SKD), satisfaction with framing, evaluation of prognosis, future optimism and hope, preparedness for shared decision-making (each assessed using customized questions), and general impression (customized question), professionalism (adapted from GMC Patient Questionnaire) and compassion (Physician Compassion Questionnaire) of the consulting physician.Discussion: This RCT will explore parents’ preferences concerning prognostic framing and its effects on physician-parent communication. Results may contribute to a better understanding of parental needs in prognostic disclosure and will be instrumental for a broad audience of clinicians, scientists and ethicists.Trial registration: drks.de DRKS00024466. Registered on April 16, 2021

Objectives Long-term survivors of childhood cancer are at increased risk for sequelae such as poor mental health (MH) or impaired health-related quality of life (HrQoL). We aimed to evaluate early adverse effects on MH and HrQoL in young childhood cancer survivors (YCCS) before school entry. Methods In a nationwide prospective cohort study, children with cancer other than brain tumors diagnosed at preschool age and completed cancer treatments were identified from the German Childhood Cancer Registry. The comparison group was children of the same age without a cancer diagnosis who participated in the prospective population-based health survey ikidS. MH problems and HrQoL were assessed by parental versions of the Strengths and Difficulties Questionnaire (SDQ) and the questionnaire for health-related quality of life in children (KINDL), respectively. Associations between cancer and MH as well as HrQoL were analyzed by multivariable linear regression. Results Of 382 YCCS contacted, 145 were enrolled (mean age 6.6 years) and 124 analyzed. Compared to children without a cancer diagnosis (3683 contacted, 2003 enrolled, 1422 analyzed), YCCS had more MH problems (13% vs. 3%) and slightly worse HrQoL (median 78.7 vs. 80.2 points). In the adjusted analysis, YCCS had higher SDQ scores (2.2 points, 95% confidence interval [CI] 1.3, 3.0) and lower KINDL scores (-2.4 points, 95% CI -3.7, -1.1) compared to children without cancer diagnosis. Conclusion Already at preschool age, YCCS may be at increased risk of MH problems and impaired HrQoL. This could have impacts on subsequent school performance and educational attainment. Follow-up health care for YCCS may include early screening for MH problems and reasons for HrQoL deficits.

Low birth weight (BW) is associated with increased corneal aberrations in childhood and alterations of corneal geometry in adulthood. Increased corneal aberrations may be a factor contributing to decreased visual function in former low BW newborns in later life. Hence, the aim of this study was to analyze the long-term effect of low BW on corneal aberrations in adulthood.In the German population-based Gutenberg Health Study (GHS) participants (age: 40-80 years) were examined with Scheimpflug imaging (Pentacam HR, Oculus Optikgeräte GmbH, Wetzlar, Germany). The relationship between self-reported BW and the different types of corneal aberrations was analyzed using linear regression analysis as uni- and multivariable analysis with adjustment for potential confounders. The main outcome measures were corneal aberrations defined as astigmatism (ZOverall, 5,628 participants were included in this analysis (3,004 women, aged 56.0 +/- 10.3 years). In a multivariable analysis lower BW was associated with decreased horizontal trefoil (B = 0.004 [0.001; 0.006] µm/500 g; p=.008); higher spherical aberrations (B=-0.006 [-0.008;-0.003] µm/500 g; p.001), higher RMS (B=-0.028 [-0.042;-0.014] µm/500 g; p.001), increased HOA (B=-0.007 [-0.010;-0.003] µm/500 g; p.001) and increased LOA (B=-0.027 [-0.041;-0.013] µm/500 g; p.001). No association was observed between birth weight and the other types of corneal aberrations in multivariable model.Our results indicate an association between BW and spherical aberration in adults aged 40 to 80 years. This indicates that low BW may have an association with an altered corneal shape development which may affect optical image quality and, hence, visual function.

Within the framework of the German pediatric screening examinations, the checks include visual functions. There is no ophthalmological screening examination in childhood in Germany. This study investigated whether participation in the pediatric screening examinations U8 (at the end of the fourth year of life) and U9 (at the beginning of the sixth year of life) is associated with the results of visual acuity, which are compiled at the school entry examinations (SEU).This study evaluated data of the SEU for school the enrollment years 2009/2010-2014/2015 of the State of Rhineland-Palatinate. In these years visual acuity was assessed using the Rodenstock visual testing device (E-hooks; Rodenstock intruments GmbH, Ottobrunn, Deutschland) wearing glasses if present. The association between participation in the U8 and U9 screening examinations and the presence of unilateral and bilateral visual acuity0.7 was investigated using multiple logistic regression adjusted for important disturbance variables.Data from 189,704 children (91,041 girls, 98,663 boys) from 35 out of 36 districts were included. A visual acuity0.7 was measured in 8416 (4.4%) children and in both eyes in 4345 (2.3%) children. The participation rates in the U8 and U9 were 93.9% and 93.3%, respectively. There was a negative association between participation in the U8 and U9 and a unilateral or bilateral SEU visual acuity0.7 (adjusted odds ratio, OR 0.68, 95% confidence interval, CI 0.61-0.75; p 0.01, N = 124,467/adjusted OR 0.57, 95% CI 0.51-0.65; p 0.01, N = 121,496).The proportion of children with visual acuity0.7 at the SEU was high. Children who were examined in the U8 and U9 had a better chance for a good visual acuity in the school entry examination.HINTERGRUND: Im Rahmen der kinderärztlichen Vorsorgeuntersuchungen U1 bis U9 von der Geburt bis zum Beginn des sechsten Lebensjahres wird unter anderem das Sehvermögen getestet – eine augenärztliche Vorsorgeuntersuchung im Kindesalter gibt es in Deutschland nicht. Diese Studie untersucht, ob eine Teilnahme an der U8 (am Ende des vierten Lebensjahres) und der U9 (zu Beginn des sechsten Lebensjahres) mit Sehschärfeergebnissen assoziiert ist, die im Rahmen der Schuleingangsuntersuchungen (SEU) erhoben werden.Ausgewertet wurden Daten der SEU des Landes Rheinland-Pfalz der Einschulungsjahrgänge 2009/2010 bis 2014/2015. In diesen Jahrgängen wurde die Sehschärfe mittels Rodenstock-Sehtestgerät (E-Haken; Rodenstock Instrumente GmbH, Ottobrunn, Deutschland) und eigener Korrektur geprüft. Festgehalten wurden reduzierte Sehschärfen von0,7. Der Zusammenhang zwischen der Teilnahme an den Vorsorgeuntersuchungen U8 bzw. U9 und dem Vorliegen einer ein- und beidseitigen Sehschärfe0,7 bei SEU wurde mithilfe von multipler logistischer Regressionsanalyse untersucht und für wichtige Störgrößen adjustiert.Daten von 189.704 Kindern (91.041 Mädchen und 98.663 Jungen) aus 35 von 36 Landkreisen konnten eingeschlossen werden. Eine Sehschärfe0,7 wurde bei 8416 Kindern (4,4 %) ermittelt, in beiden Augen bei 4345 (2,3 %) Kindern. Die Teilnahmequote an der U8 bzw. U9 betrug 93,9 % bzw. 93,3 %. Es bestand eine negative Assoziation zwischen der Teilnahme an der U8 bzw. U9 und einem ein- oder beidseitigen SEU-Visus0,7 (adjustierte OR: 0,68; 95 %-KI: 0,61–0,75; p 0,01; N = 124.467/adjustierte OR: 0,57; 95 %-KI: 0,51–0,65; p 0,01; N = 121.496).Es zeigt sich ein hoher Anteil an Kindern mit verminderter Sehschärfe bei der Schuleingangsuntersuchung. Kinder, die in der U8 und U9 untersucht worden waren, hatten eine bessere Chance für eine gute Sehschärfe bei der Schuleingangsuntersuchung.

Purpose: This study investigates the relationship between diabetic retinopathy (DR) and birth weight (BW) in diabetic subjects sampled from the general population. Methods: The Gutenberg Health Study (GHS) is a population-based, observational cohort study in participants aged from 35 to 74 years. Criteria for diabetes diagnosis were HbA1c ≥6.5% at study entry, a doctor-diagnosis of diabetes, or diabetes medication. The presence of DR was determined by evaluating fundus photographs. BW was assessed by self-reports. GHS participants were divided into three different BW groups (low: 4000 g). Logistic regression analysis was conducted as uni- and multivariable analysis with adjustment for age and sex. Effect mediators were separately investigated. Results: A total of 1,124 GHS participants (7.5% of the cohort) had diabetes at study entry. Of these, 402 subjects (35.8%) had gradable fundus photographs, reported BW data and were included into this study. Overall, 91/402 subjects (23%) had DR. With regard to BW groups, DR was descriptively more frequent in subjects with low (28.1% [95%-CI: 14.4–47.0%; n = 32]) and high BW (30.8% [95%- CI: 19.1–45.3%; n = 52]) compared to normal BW (20.8% [95%-CI: 16.5–25.7%; n = 318]). Both high and low BW were associated with DR in multivariable analysis (high: OR = 1.68, p = .037; low: OR = 1.81, p = .05). The BW effect was mediated by duration of diabetes in both BW groups and by arterial hypertension in the low BW group. Conclusion: Low and high BW in persons with diabetes is related to higher risk of diabetic retinopathy. Longer duration of diabetes and higher prevalence of arterial hypertension are factors in these subjects explaining the elevated risk.

Background: Nasal continuous positive airway pressure (NCPAP) devices using variable (vf-) and continuous (cf-) flow or synchronized nasal intermittent positive pressure ventilation (s-NIPPV) are used to prevent or treat intermittent hypoxia (IH) in preterm infants. Results on which is most effective vary. We aimed to investigate the effect of s-NIPPV and vf-NCPAP compared to cf-NCPAP on the rate of IH episodes.Methods: Preterm infants with a gestational age of 24.9-29.7 weeks presenting with IH while being treated with cf-NCPAP were monitored for 8 hours, then randomized to 8 h of treatment with vf-NCPAP or s-NIPPV. Data from 16 infants were analyzed. Due to an unexpectedly low sample size, results are only reported descriptively.Results: No relevant changes in the rate of IH events were detected between cf- vs. vf-NCPAP or between cf-NCPAP vs. s-NIPPV.Conclusion: Although limited by its small sample size, s-NIPPV, vf- and cf-NCPAP seemed to be similarly effective in the treatment of IH in these infants.Trial registration: This study was registered with the German Clinical Trials register - DRKS00005387. Registered 12 November 2013, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00005387

Objective: In children with congenital heart defects (CHD), a sedentary lifestyle should be avoided and usually WHO recommendations on physical activity (PA) are supposed to be followed. In order to obtain representative data of the actual amount of PA (and potential influencing factors) in children with CHD we performed a nationwide online survey.Methods: All patients aged 6–17 years registered in the German National Register for CHD were contacted by email and asked to participate in the survey using the comprehensive questionnaire of the “Motorik-Modul” from the German Health Interview and Examination Survey for Children and Adolescents (KiGGS), thus allowing the comparison with a representative age-matched subset of 3.385 participants of the KiGGS study. The questionnaire for CHD-patients was amended by specific questions regarding medical care, sports recommendations and PA restrictions.Results: Complete datasets of 1.198 patients (mean age of 11.6 ± 3.1 years) were available for evaluation. Compared to the reference group, CHD patients significantly less frequently reached the WHO recommended level of 60 min of daily PA (8.8 vs. 12%; p < 0.001). Enjoyment in sports was almost equally distributed across CHD and reference groups, and strongly correlated with the level of PA (r = 0.41; p < 0.001). Remarkably, 49.2% of children with complex CHD, 31.7% with moderate, and even 13.1% with simple CHD were advised by their physician to restrict PA.Conclusions: According to this nationwide survey, PA is markedly reduced in children with CHD. An important reason for this might be an unexpected high rate of physician-recommended restrictions on levels of PA.

Background Myopia (near-sightedness) is increasing worldwide, especially in Asia. The aim of this study was to describe trends in the prevalence of myopia in Germany. Methods We analyzed data from the German Health Interview and Examination Survey for Children and Adolescents (KiGGS; baseline survey 2003-2006, N = 17 640; wave 2, 2014-2017, N = 15 023). The presence of myopia was determined from a parent questionnaire and validated by the use of a visual aid. The population prevalence of myopia was calculated. Based on the KiGGS wave 2 data, potential risk factors for myopia were identified by means of logistic regression. Results The prevalence of myopia at the age of 0-17 years in Germany was 11.6% (95% confidence interval [11.0; 12.2]) in the period 2003-2006 and 11.4% [10.7; 12.2] in 2014-2017. No age group of either sex exhibited a relevant, statistically significant change in the prevalence of myopia. In the adjusted model (adjusted for age, sex, family socioeconomic status, family history of migration), no association was found between myopia and use of digital media. More time spent reading books was associated with myopia: reading for more than 2 h/day showed an odds ratio of 1.69 [1.3; 2.2]. Conclusion The prevalence of myopia in children and adolescents in Germany has remained virtually unchanged over a period of approximately 10 years. Changes in media consumption, such as the increased use of smartphones in this age group, have therefore had no detectable impact on the development of myopia, at least not so far. Future studies should investigate the influences of further increases in media use and examine the long-term effects.

Purpose Low birth weight (BW) is associated with alterations of foveal shape development in childhood—leading to an increased retinal thickness of the fovea. The aim of the present study was to assess whether BW has a long-term effect on foveal retinal thickness (RT) and is still present in adulthood. Methods In the German population-based Gutenberg Health Study (GHS), participants were examined with spectral-domain optical coherence tomography. The association between self-reported BW and RT in the foveolar and perifoveal locations was assessed. Multivariable linear regression analyses with adjustment for potential confounders and grading of foveal hypoplasia were performed. Results Overall, RT measurements and self-reported BW were available for 2,539 participants (1300 female, mean age 54.5 ± 9.7 years). The absolute foveolar RT was 239.6 ± 25.8 µm, 232.2 ± 20.1 µm and 234.8 ± 21.0 µm, respectively, in the low (4000 g) BW groups (P < 0.001). After adjustment for confounders, an association was observed between lower BW and increased foveolar thickness (B = –0.35 [95% confidence interval {CI}: –0.49; –0.20] µm/100 g; P < 0.001), whereas only a weak association with RT was observed with the nasal (P = 0.010), temporal (P = 0.011), and inferior (P = 0.021) quadrants in the 1 mm distance, with no association in the 2 mm distance to the fovea. Foveal hypoplasia grade 1 was more frequent in the low BW group (6.8%) compared to the normal (0.9%) and high BW group (1.2%). Conclusions This study provides evidence of an association between lower BW and increased foveolar thickness and foveal hypoplasia, indicating that prenatal growth may affect macular morphology, which in turn may persist until adulthood and predispose to retinal disease later in life.

Background Organizational readiness for implementing change (ORIC) is presumed key for successful change in healthcare settings. At the same time, ORIC is theorized to depend on cultural and other factors of the organizational context. Within the process evaluation of the PART-CHILD intervention in interdisciplinary pediatric outpatient centres (IPOC) for children with chronic health conditions in Germany, we assessed to what extent ORIC is associated with organizational culture and further contextual factors. Methods In 2019 data was collected from health care professionals in 12 IPOC, using a questionnaire comprising subjectively perceived ORIC (measure: ORIC, 5-point Likert scale), the organization’s culture (measure: Competing Values Framework, four domains: Group, Developmental, Rational, and Hierarchical Culture) and further contextual factors (e.g., size of the facility, number of patients per year). Results In all, responses from 206 health care professionals were included in the analyses (response rate: 47%; preliminary results). Analyses show a moderate ORIC (3,4; SD = 0,6), positively associated with Group Culture (r2=0,178, p = 0,01) and negatively associated with Rational Culture (r2=-0,273, p < 0,001). We found no correlations between ORIC and Developmental or Hierarchical Culture. In congress presentation we report to what extent ORIC depends on further contextual factors (e.g., size of the facility, patients’ demographic characteristics). Discussion IPOC with a strong Group Culture show a higher ORIC than those with prevailing Rational Culture. To potentially increase effective implementation of interventions in healthcare facilities in future, a preceding evaluation of the organizational culture might be valuable. Thereby, settings with prevailing Rational Culture could be identified at an early stage and receive additional implementation support, e.g. through enhancing the Group Culture among the health care professionals on-site (e.g, executive coaching). Key messages Both organizational readiness for implementing change and organizational culture are presumed to be important for implementing change in healthcare facilities‘ routine care. Assessing both constructs prior to implementing a costly intervention with demanding change processes within healthcare settings could be valuable.

IMPORTANCE: Low birth weight is associated with altered ocular organ development in childhood, including the morphology of the eye. However, no population-based data exist about this association in adulthood. OBJECTIVE: To evaluate whether low birth weight has a long-term association with anterior segment anatomy and axial length in adulthood. DESIGN, SETTING, AND PARTICIPANTS: The Gutenberg Health Study is a population-based, observational cohort study in Germany. All participants underwent ocular biometry. Among the participants with follow-up and self-reported birth weight available, associations were assessed between low birth weight and anterior segment anatomy and axial length using multivariable linear regression analysis with adjustment for age and sex. In patients with phakia, anterior chamber depth and lens thickness were also examined. Data for this study were collected from April 27, 2012, through April 28, 2017, and analyzed from January through April 2018. EXPOSURES: Low birth weight. MAIN OUTCOMES AND MEASURES: Corneal curvature, central corneal thickness, white-to-white distance, anterior chamber depth, lens thickness, and axial length. RESULTS: Overall, 11 294 eyes of 7120 participants were included (52.4% female; mean [SD] age, 56.2 [10.3] years). Most of the participants were white (98.6%). After adjustment for age and sex, an association was found between a lower birth weight and steeper corneal curvature (β = 0.005 mm/100 g; 95% CI, 0.005-0.006 mm/100 g; P

Children with chronic health conditions may perform poorer at school. Associations may be confounded by numerous social factors. We aimed to estimate the effects of a chronic health condition on overall school performance in first graders with an emphasis on rigorous adjustment for potential confounders.A population-based cohort study was performed in the area of Mainz-Bingen (Germany). In 2015 all preschoolers were approached and the presence of a chronic health condition was assessed by parental questionnaires and preschool health examination data. The identification of a chronic health condition was based on special health care needs and presence of a doctor's diagnosis out of 24 school-relevant diseases. At the end of the first school year, overall school performance was assessed by teachers and rated on a 5-item scale ranging from -10 to +10.Of 3683 children approached, 2003 were enrolled. Overall school performance was available for 1462 children (51% boys). Of these, 52% suffered from a chronic health condition. Compared to children without a chronic health condition, children with special health care needs (15%) performed worse at school (adjusted mean difference: -0.95, 95% CI: [-1.55; -0.35], P = 0.002). Children with a doctor's diagnosis but without special health care needs (37%) did not perform worse at school. The effect was further analysed considering the extent of special health care needed.Chronic health conditions affect overall school performance early in primary school. To identify academically at-risk children, a chronic health condition identification based on special health care needs may be used.

BackgroundEach child in Germany undergoes a preschool health examination including vision screening and recommendations for further ophthalmic care. This study investigated the frequency of and adherence to these recommendations.MethodsA population-based prospective cohort study was performed in the area of Mainz-Bingen (Rhineland-Palatinate, Germany). All preschoolers were examined at the statutory preschool health examination, which includes vision testing (Rodenstock vision screener) with available correction in the last preschool year. Based on the results, recommendations for further ophthalmic care were given to the parents. Six weeks prior to school entry, parents were surveyed concerning ophthalmic health care visits, diagnoses, and treatments. Ophthalmic care recommendation frequency and its adherence were investigated using logistic regression analysis adjusted for potential confounders.Results1226 children were included in this study, and 109 children received a recommendation for ophthalmic care based on the preschool health examination. At the follow-up, 84% of children who had received a recommendation had visited an ophthalmologist within the preceding year compared to 47% of children who had not received a recommendation. The recommendation for ophthalmic care was clearly associated with a higher number of ophthalmological visits (odds ratio = 7.63; 95% confidence interval: 3.96-14.7). In a subgroup analysis, adherence to a recommendation was lower in children with migrant background (OR = 2.26; 95%-CI: 0.64-7.90, compared to: OR = 11.6; 95%-CI: 4.95-27.4) and in those with low socio-economic status.ConclusionsAdherence to preschool recommendations for ophthalmic care is high in German preschoolers. However, a migrant background and low socio-economic status may reduce this adherence.

Objective Children with chronic health conditions may perform poorer at school. Associations may be confounded by numerous social factors. We aimed to estimate the effects of a chronic health condition on overall school performance in first graders with an emphasis on rigorous adjustment for potential confounders. Methods A population-based cohort study was performed in the area of Mainz-Bingen (Germany). In 2015 all preschoolers were approached and the presence of a chronic health condition was assessed by parental questionnaires and preschool health examination data. The identification of a chronic health condition was based on special health care needs and presence of a doctor’s diagnosis out of 24 school-relevant diseases. At the end of the first school year, overall school performance was assessed by teachers and rated on a 5-item scale ranging from -10 to +10. Results Of 3683 children approached, 2003 were enrolled. Overall school performance was available for 1462 children (51% boys). Of these, 52% suffered from a chronic health condition. Compared to children without a chronic health condition, children with special health care needs (15%) performed worse at school (adjusted mean difference: -0.95, 95% CI: [-1.55; -0.35], P = 0.002). Children with a doctor’s diagnosis but without special health care needs (37%) did not perform worse at school. The effect was further analysed considering the extent of special health care needed. Conclusions Chronic health conditions affect overall school performance early in primary school. To identify academically at-risk children, a chronic health condition identification based on special health care needs may be used.

We aimed to investigate the prevalence of primary snoring (PS) and its association with neurocognitive impairments.Data from a community-based study in 1,114 primary school children were used to identify children who never (N = 410) or habitually snored (N = 114). In order to separate children with PS from those with upper airway resistance syndrome (UARS) or obstructive sleep apnoea (OSA), home polysomnography was conducted in all habitually snoring children. Neurocognitive impairments and poor school performance were compared between children who never snored, PS, and UARS/OSA.Polysomnography was successfully conducted in 92 habitual snorers. Of these, 69 and 23 had PS and UARS/OSA, respectively. Prevalence [95% confidence interval (95% CI)] of PS was 6.1% (4.5-7.7). Compared to children who had never snored, children with PS had more hyperactive (39% vs. 20%) and inattentive behaviour (33% vs. 11%), as well as poor school performance in mathematics (29% vs. 16%), science (23% vs. 12%), and spelling (33% vs. 20%; all P values0.05). PS was a significant risk factor (odds ratio; 95% CI) for hyperactive behaviour (2.8; 1.6-4.8), inattentive behaviour (4.4; 2.4-8.1), as well as daytime sleepiness (10.7; 4.0-28.4). PS was also an independent risk factor for poor school performance in mathematics (2.6; 1.2-5.8), science (3.3; 1.2-8.8), and spelling (2.5; 1.1-5.5). Odds ratios throughout were similar to the UARS/OSA group.Children with non-hypoxic, non-apnoeic PS may exhibit significant neurocognitive impairments. Consequences may be similar to those associated with UARS or OSA. If confirmed, PS is not "benign" and may require treatment.

Purpose: To compare left ventricular (LV) volume and mass assessment using two-dimensional (2D) cine steady-state free precession (SSFP) and k-t space broad-use linear acquisition speed-up technique (k-t BLAST) accelerated 3D magnetic resonance imaging (MRI). Materials and Methods: On a commercially available 1.5T MR scanner, 2D cine SSFP, six- and eight-fold accelerated 3D k-t BLAST were performed to evaluate LV volumes and mass in 17 volunteers. After semiautomatic segmentation of the different MR data sets, the resulting volumes and mass were compared according to the mean difference, 95% confidence interval, standard deviation (SD), Pearson's correlation coefficient, Bland-Altman analysis, and the Pitman-Morgan test. Results: Data acquisition was successful in all subjects. The number of required breathholds was reduced from a maximal of five for the 2D cine SSFP sequence to two for 3D k-t BLAST sequences. Comparing LV volumes, there was excellent agreement between 2D and 3D cine 8× k-t BLAST SSFP volumes (mean difference ± 2SD end-diastolic volume [EDV] = 5 ± 8 mL, end-systolic volume [ESV] = 1 ±12 mL, and stroke volume [SV] = 3 ± 8 mL), and mass (-1.8 ± 9 g). Conclusion: k-t BLAST-accelerated 3D sequences allow accurate assessment of LV volumes and mass compared to 2D cine SSFP. This method may reduce costs and increase patient comfort due to shortened data acquisition time and reduced number of breathholds.

Habitual snoring is associated with daytime symptoms like tiredness and behavioral problems. Its association with sleep problems is unclear. We aimed to assess associations between habitual snoring and sleep problems in primary school children. The design was a population-based cross-sectional study with a nested cohort study. The setting was twenty-seven primary schools in the city of Hannover, Germany. Habitual snoring and sleep problems were assessed in primary school children using an extended version of Gozal's sleep-disordered breathing questionnaire (n = 1144). Approximately 1 year later, parents of children reported to snore habitually (n = 114) and an equal number of children who snored never or occasionally were given the Sleep Disturbance Scale for Children, a validated questionnaire for the assessment of pediatric sleep problems. Snoring status was re-assessed using the initial questionnaire and children were then classified as long-term habitual snorers or ex-habitual snorers. An increasing prevalence of sleep problems was found with increasing snoring frequency for sleep-onset delay, night awakenings, and nightmares. Long-term habitual snorers were at significantly increased risk for sleep-wake transition disorders (e.g. rhythmic movements, hypnic jerks, sleeptalking, bruxism; odds ratio, 95% confidence interval: 12.0, 3.8-37.3), sleep hyperhidrosis (3.6, 1.2-10.8), disorders of arousal/nightmares (e.g. sleepwalking, sleep terrors, nightmares; 4.6, 1.3-15.6), and excessive somnolence (i.e. difficulty waking up, morning tiredness, daytime somnolence; 6.3, 2.2-17.8). Ex-habitual snorers were at increased risk for sleep-wake transition disorders (4.4, 1.4-14.2). Habitual snoring was associated with several sleep problems in our study. Long-term habitual snorers were more likely to have sleep problems than children who had stopped snoring spontaneously.

Abbreviated home polysomnography may be an alternative to laboratory polysomnography in children but is not yet generally accepted, partly due to a lack of reference values. Also, there are no normative data on respiratory events obtained using nasal prongs. We determined the prevalence and frequency of central, obstructive, and mixed apneas and hypopneas in a population-based sample of 50 children (mean age 10.1 years) using abbreviated home polysomnography and nasal prongs. We also determined the frequency of movements/arousals and body position changes. All children had central apneas. Obstructive apneas, mixed apneas, and hypopneas were found in 36%, 6%, and 14% of children, respectively. Average number of central, obstructive, and mixed apneas; hypopneas; movement/arousals; and body position changes per hour of sleep was 1.5, 0.1, 0.01, 0.02, 8.2, and 3.7, respectively. The corresponding cutoff values (mean plus 2 standard deviations or 95th centile) were 3.7, 0.7, 0.1, 0.2, 13.4, and 9.1, respectively. We did not find significant gender differences regarding any sleep variable under study. The presented reference values may help clinicians and researchers to improve the interpretation of abbreviated home polysomnography in school-age children.

In preterm infants receiving supplemental oxygen, manual control of the inspired oxygen fraction is often time-consuming and inappropriate. We developed a system for automatic oxygen control and hypothesized that this system is more effective than routine manual oxygen control in maintaining target arterial oxygen saturation levels. We performed a randomized controlled crossover clinical trial in 12 preterm infants receiving nasal continuous positive airway pressure and supplemental oxygen. Periods with automatic and routine manual oxygen control were compared with periods of optimal control by a fully dedicated person. The median (range) percentage of time with arterial oxygen saturation levels within target range (87-96%) was 81.7% (39.0-99.8) for routine manual oxygen control, 91.0% (41.4-99.3) for optimal control, and 90.5% (59.0-99.4) for automatic control (ANOVA: p = 0.01). Pairwise post hoc comparisons revealed a statistically significant difference between automatic and routine manual oxygen control (Dunnett's test: p = 0.02). The frequency of manual oxygen adjustments was lowest in automatic control (Friedman's test: p < 0.001). Automatic oxygen control may optimize oxygen administration to preterm infants receiving nasal continuous positive airway pressure and reduce nursing time spent with oxygen control.

Sleep-disordered breathing is associated with impaired attention and neurocognitive deficits. We assessed the association of snoring and intermittent hypoxia with poor academic performance in third grade school children (1,144 children). Snoring frequency and intermittent hypoxia were investigated using parental questionnaire and nocturnal home pulse oximetry. Intermittent hypoxia was specified as desaturation events of 90% or less pulse oximeter saturation. Poor academic performance was defined as grade 4-6 on a six-point scale (i.e., approximately the lowest quintile grades) in mathematics, science, reading, spelling, and/or handwriting in the most recent school report. Snoring "always" was significantly associated with poor academic performance in mathematics (odds ratio; 95% confidence interval: 3.6; 1.3-10.1), science (4.3; 1.3-14.6), and spelling (3.5; 1.2-10.3). Snoring "frequently" was also significantly associated with poor academic performance in mathematics (2.4; 1.3-4.7) and spelling (2.0; 1.04-3.8). A significant relationship between snoring and poor academic performance was also found in children without intermittent hypoxia, whereas intermittent hypoxia did not show an independent association with poor academic performance. Thus, habitual snoring (i.e., snoring frequently or always) was associated with poor academic performance in these primary school children.

Objective To identify potential risk factors for unexpected sudden infant deaths (SID) and severe apparent life-threatening events (S-ALTE) within 24 h of birth. Design Case-control study embedded in an epidemiological survey over a 2-year period. Patients and methods Throughout 2009, every paediatric department in Germany was asked to report cases of unexplained SID or S-ALTE in term infants with a 10-min Apgar score ≥8 to the Surveillance Unit for Rare Pediatric Conditions. Throughout 2010, the inclusion criteria were extended to infants ≥35 week gestational age and those where an explanation for the deterioration had been found. For each unexplained case, hospitals were asked to fill in a questionnaire for 3 (near-)term controls with good postnatal adaptation at the age (in minutes) when the event had occurred in the case under study. Results Of the 85 cases reported, 34 fulfilled the entry criteria; of these, two were near-term newborns and, in three cases, a cause had been identified for the event. For the 31 cases with unknown cause for the event (13 males; mean (SD) gestational age 38.9 (1.7) week), the authors gathered 93 controls (51 male infants; 38.9 (1.4) week). As significant risk factors for S-ALTE and SID, the authors could identify primipara (OR 6.22; 95% CI 2.11 to 18.32) and potentially asphyxiating position (OR 6.45; 95% CI 1.22 to 34.10). Conclusions Close observation of newborns seems necessary, particularly in primipara; a potentially asphyxiating position should be avoided.