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This study analyses whether prematurity, retinopathy of prematurity (ROP), and associated factors lead to altered foveal shape in adulthood and whether these alterations are associated with visual acuity.The Gutenberg Prematurity Eye Study is a German cohort study with a prospective ophthalmologic examination (participants aged 18-52 years) of individuals born preterm and full-term that were examined with spectral domain optical coherence tomography. Participants were grouped according to gestational age (GA) and postnatal ROP status. Multivariable linear regression analyses for foveolar retinal thickness, foveal hypoplasia, and posterior vitreous status were performed.A total of 755 eyes of 414 preterm and full-term individuals were included (aged 28.6 ± 8.6 years, 233 female individuals). Central foveal retinal thickness increased as GA decreased. The prevalence of foveal hypoplasia was 2% (control group), 9% (GA 33-36), 18% (GA 29-32), 48% (GA ≤28), 50% (ROP without treatment), and 82% of eyes (with ROP requiring treatment). In multivariable analyses, central foveal thickness was independently associated with GA and advanced stages of ROP requiring treatment while foveal hypoplasia was only associated with GA. Posterior vitreous was more frequently visible as partially detached in full-term than in preterm individuals. Lower distant-corrected visual acuity correlated with increased foveolar thickness (rho = 0.08; P = 0.03) and with foveal hypoplasia (rho = 0.15, P0.001).Our findings indicate that there are fetal origins affecting foveal shape, resulting in foveal hypoplasia potentially affecting the visual acuity in adulthood.

Objectives: To report validation data for the Pupillographic Sleepiness Test (PST) in children and adolescents, evaluate its applicability for diagnosing excessive daytime sleepiness and its relationship to sleepiness-associated outcomes. Methods: A cross-sectional diagnostic test accuracy study was performed. Patients underwent three PST at 9 a.m. (T1), 11 a.m. (T2) and 1 p.m. (T3) plus the Multiple Sleep Latency Test (MSLT) on a single day. Additionally, two neurocognitive tests were performed and three questionnaires about quality of life, sleep-related self-efficacy and behavioural aspects completed. Gender-stratified z-values of the natural logarithm of the Pupillary Unrest Index (z-lnPUI) were correlated to Sleep Latency (SL) and Mean Sleep Latency (MSL) and to variables of neurocognitive tests and questionnaires using Spearman's rank correlation. Cut-off values were determined by receiver operating characteristic (ROC) analysis. Results: 47 patients were recruited (median 10.6 years, range 6e18). Correlation between z-lnPUI and SL was r(T1) = -0.373 (p = 0.011); r(T2) = -0.320 (p = 0.028) and r(T3) = -0.336 (p = 0.022). Correlation between z-lnPUI and MSL was r(T1) = -0.338 (p = 0.020); r(T2) = -0.202 (p = 0.173); r(T3) = -0.117 (p = 0.433). ROC analysis showed an area under the curve of 90.7% and PUI cut-off values of 12.6 mm/min (boys) and 11.6 mm/min (girls). There were moderate correlations between z-lnPUI(T1) and reaction time and omission errors in neurocognitive tests (r = 0.394, p = 0.007 and 0.391, p = 0.008). Conclusions: We found satisfactory correlations between PST and MSLT results. The z-lnPUI(T1) was related to MSL and objective measures of attention ability. Given this accuracy, the PST may be used as a screening tool for evaluating daytime sleepiness in children and adolescents. Corresponding gender-related reference values are now available. (C) 2021 Elsevier B.V. All rights reserved.

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.

This study investigated whether prematurity and associated factors or prenatal growth restriction have long-term effects on the peripapillary retinal nerve fiber layer (pRNFL) in adulthood.Retrospective cohort study.The Gutenberg Prematurity Eye Study (GPES) is a retrospective cohort study with a prospective ophthalmologic examination in Germany. Selected individuals born term and preterm (age 18-52 years) were examined with spectral-domain optical coherence tomography (SD-OCT) in adulthood, and perinatal medical charts were reviewed. The pRNFL thickness was measured using SD-OCT. Univariate and multivariable linear regression analyses were conducted to investigate associations between pRNFL and gestational age (GA; categorical), birth weight percentile (categorical), retinopathy of prematurity (ROP) occurrence, and treatment and other perinatal parameters with adjustment for age, sex, and spherical equivalent.In total, 766 eyes of 406 preterm and full-term individuals were included (mean age 28.4 ± 8.6 years, 228 females). After adjustment for age, sex, and spherical equivalent, global pRNFL thinning was associated with moderate (GA = 33-36 wk, β = -4.68, P.001), very (GA = 29-32 wk, β = -5.72, P.001), and extreme (GA ≤ 28 wk, β = -8.69, P.001) prematurity but not with low birth weight percentile (25th percentile, P = .9) and ROP occurrence (P = .9) in multivariable analysis. ROP treatment was associated with increased pRNFL in the temporal sector (P = .002). Maternal smoking during pregnancy showed an association with pRNFL thinning (P = .07).Our data indicate that the more preterm individuals are born the more pRNFL thinning occurs, whereas prenatal growth restriction and postnatal occurrence of ROP show less effects on pRNFL thickness. Furthermore, individuals with severe ROP with treatment but not lower ROP stages without treatment showed an increased temporal pRNFL thickness.

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.

The association between health status in childhood and later educational achievement is unknown. We describe the association between a chronic health condition (CHC) and school performance at the end of first grade.As part of the child health survey ikidS, 2,003 preschoolers from the Mainz-Bingen area (Rhineland-Palatinate; Germany) were recruited.In a prospective cohort study, children with CHC were identified by the children with special health care needs screener. At the end of first grade, classroom teachers evaluated the child's school performance on a rating scale ranging from - 2 through+2 in 5 domains: numeracy, science, reading, writing, and social competencies. Associations between special health care needs (SHCN) and each domain were assessed by linear mixed regression models adjusted for potential confounders.1,463 children (51% males) were analyzed. Of these, 15% had SHCN. Compared to their classmates, children with SHCN performed poorer in numeracy (adjusted mean difference: - 0.40; 95% CI[- 0.57; - 0.23]) and writing (- 0.22; 95% CI[- 0.39; - 0.05]).For the first time in a German sample, we found an indication which educational competencies might be negatively impacted by SHCN early in school. This could have long-lasting effects on educational attainment and later socio-economic status.Our results question the uptake and/or effectiveness of existing medical care as well as educational support concepts for children with a CHC.Die Zusammenhänge zwischen kindlichem Gesundheitsstatus und weiterem Bildungsweg sind unklar. Wir beschreiben die Assoziation zwischen einer chronischen Erkrankung (CE) und schulischen Fähigkeiten am Ende der ersten Klasse.Im Rahmen der Kindergesundheitsstudie ikidS wurden insgesamt 2003 Schulanfänger der Region Mainz-Bingen rekrutiert.In einer prospektiven Kohortenstudie wurden Kinder mit CE mittels Elternfragebögen über ihren speziellen medizinischen Versorgungsbedarf aufgrund einer CE identifiziert. Am Ende der ersten Klasse schätzten Lehrkräfte die schulischen Fähigkeiten auf einer 5-stufigen Skala von − 2 bis+2 in 5 Bereichen ein: Mathematik, Naturwissenschaften, Sprache, Schriftsprache und soziale Fähigkeiten. Der Zusammenhang zwischen dem speziellen Versorgungsbedarf und den schulischen Fähigkeiten erfolgte jeweils mit linearen gemischten Regressionsmodellen unter Berücksichtigung potentieller Confounder.In die Analysen wurden 1463 Kinder (51% männlich) eingeschlossen. 15% der Kinder hatten einen speziellen Versorgungsbedarf. Diese Kinder zeigten in den Bereichen Mathematik (adjustierte Mittelwertsdifferenz: − 0,40; 95% KI[− 0,57; − 0,23]) und Schriftsprache (− 0,22; 95% KI[− 0,39; − 0,05]) niedrigere schulische Fähigkeiten als Kinder ohne Versorgungsbedarf.Wir haben erstmals für Deutschland Hinweise darauf gefunden, in welchen schulischen Fähigkeiten Kinder mit speziellem Versorgungsbedarf bereits früh in der Bildungslaufbahn Defizite aufweisen könnten. Dies könnte sich langfristig auf Bildungsabschlüsse und den späteren sozioökonomischen Status auswirken.Die vorliegenden Ergebnisse hinterfragen die Inanspruchnahme und/oder Wirksamkeit bestehender Versorgungs- und Fördermaßnahmen für Kinder mit CE.

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.

This study aimed to investigate associations of prematurity and associated factors with optic disc morphology in adulthood as long-term effects.Retrospective cohort study.The Gutenberg Prematurity Eye Study (GPES) is a retrospective cohort study with a prospective ophthalmologic examination of adults (age 18-52 years) in Germany. In every participant, photography of optic discs was performed with a nonmydriatic fundus camera, and optic disc measurements were done manually. The vertical cup-to-disc ratio (VCDR), optic disc area, and torted and tilted discs were assessed and exploratively compared between individuals with retinopathy of prematurity (ROP) with treatment, an ROP group without treatment and groups of individuals of different gestational ages (GAs) without ROP (GA ≤ 28 weeks, GA 29-32 weeks, GA 33-36 weeks, and GA ≥ 37 weeks [control group]).The present analysis included 743 eyes of 393 individuals born preterm and full-term (aged 28.4 ± 8.6 years, 223 females). The VCDR was significantly larger in subjects with a GA ≤28 weeks without ROP compared to the full-term control group (GA ≥37 weeks) (P = .002). Subjects with ROP without treatment also had a larger VCDR (P = .001), whereas those with ROP treatment showed a smaller VCDR than the full-term control group (P = .02). In addition, individuals with ROP treatment were more likely to have a torted disc than the full-term control group (P = .006).The present study provides evidence that individuals born extremely preterm have increased VCDR in adulthood. Furthermore, these results indicate that fetal origins affect optic disc morphology until adulthood, which might predispose the affected individual to degenerative optic nerve head diseases or being incorrectly diagnosed to glaucoma.

ObjectiveClosed-loop automatic control (CLAC) of the fractional inspired oxygen (FiO2) improved oxygen administration to preterm infants on respiratory support. We investigated whether a revised CLAC algorithm (CLACfast, ≤2 FiO2 adjustments/min), compared with routine manual control (RMConly), increased the proportion of time with arterial haemoglobin oxygen saturation measured by pulse oximetry within prespecified target ranges (Target%) while not being inferior to the original algorithm (CLACslow: ≤0.3 FiO2 adjustments/min).DesignUnblinded randomised controlled crossover study comparing three modes of FiO2 control in random order for 8 hours each: RMC supported by CLACfast was compared with RMConly and RMC supported by CLACslow. A computer-generated list of random numbers using a block size of six was used for the allocation sequence.SettingTwo German tertiary university neonatal intensive care units.PatientsOf 23 randomised patients, 19 were analysed (mean±SD gestational age 27±2 weeks; age at randomisation 24±10 days) on non-invasive (n=18) or invasive (n=1) respiratory support at FiO2 >0.21.Main outcome measureTarget%.ResultsMean±SD [95% CI] Target% was 68%±11% [65% to 71%] for CLACfast versus 65%±11% [61% to 68%] for CLACslow versus 58%±11% [55% to 62%] for RMConly. Prespecified hypothesis tests of: (A) superiority of CLACfast versus RMConly and (B) non-inferiority of CLACfast versus CLACslow with margin of 5% yielded one-sided p values of ConclusionsThis revised and faster CLAC algorithm was still superior to routine care in infants on respiratory support and not inferior to a previously tested slower algorithm.Trial registration numberNCT03163108.

To conduct a preliminary evaluation of psychometric properties of CollaboRATEPatients aged ≥ 7 years and parents were recruited in two outpatient facilities providing healthcare services for children with neurological and behavioral health conditions. We collected 46, 169 and 227 pediatric patient, parent-proxy and parent reports, respectively. Convergent, divergent and discriminative validity were investigated. Acceptability of the scales and agreement between patient and parent-proxy reports were explored by assessing item nonresponse and Bland-Altman plots.While convergent and divergent validity were established for the parent scale, discriminative validity was not demonstrated for any of the scales. The scales showed good to excellent acceptability. Parent-proxy reports agreed to a moderate extent with patients' self-reports of SDM.CollaboRATEGiven limited psychometric support for the pediatric patient scale, we recommend using both the pediatric patient and parent-proxy report scales to assess SDM in pediatric patients until further psychometric testing is concluded.

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.

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.

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.

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.

Objective Acoustic analyses of snoring sounds have been used to objectively assess snoring and applied in various clinical problems for adult patients. Such studies require highly automatized tools to analyze the sound recordings of the whole night's sleep, in order to extract clinically relevant snore- related statistics. The existing techniques and software used for adults are not efficiently applicable to snoring sounds in children, basically because of different acoustic signal properties. In this paper, we present a broad range of acoustic characteristics of snoring sounds in children (N = 38) in comparison to adult (N = 30) patients. Approach Acoustic characteristics of the signals were calculated, including frequency domain representations, spectrogram-based characteristics, spectral envelope analysis, formant structures and loudness of the snoring sounds. Main results We observed significant differences in spectral features, formant structures and loudness of the snoring signals of children compared to adults that may arise from the diversity of the upper airway anatomy as the principal determinant of the snore sound generation mechanism. Furthermore, based on the specific audio features of snoring children, we proposed a novel algorithm for the automatic detection of snoring sounds from ambient acoustic data specifically in a pediatric population. The respiratory sounds were recorded using a pair of microphones and a multi-channel data acquisition system simultaneously with full-night polysomnography during sleep. Brief sound chunks of 0.5 s were classified as either belonging to a snoring event or not with a multi-layer perceptron, which was trained in a supervised fashion using stochastic gradient descent on a large hand-labeled dataset using frequency domain features. Significance The method proposed here has been used to extract snore-related statistics that can be calculated from the detected snore episodes for the whole night's sleep, including number of snore episodes (total snoring time), ratio of snore to whole sleep time, variation of snoring rate, regularity of snoring episodes in time and amplitude and snore loudness. These statistics will ultimately serve as a clinical tool providing information for the objective evaluation of snoring for several clinical applications.

Objective There is growing interest in the link between sleep habits and child health but reference values specific to toddlers as well as longitudinal data on sleep are scarce. We aimed to describe parent-reported child sleep habits and their intra-individual changes in 2- to 3-year-olds using data from a regional birth cohort study. Methods In the Ulm SPATZ Health Study, a birth cohort study conducted at Ulm, Southern Germany, with baseline examination from April 2012 to May 2013, the German version of the Children's Sleep Habits Questionnaire (CSHQ-DE) was used longitudinally at follow-ups at 2 and 3 years ( N = 615 children). Descriptive statistics including intra-individual differences between 3- and 2-year scores were reported, the latter using the sign test. Results The sample-averaged total and subscale CSHQ scores differed only slightly between 2 and 3 years (max. Cohen's d = 0.39). Intra-individual comparisons of the CSHQ subscales or single items revealed congruent but also opposing changes in items belonging to the same subscale. Whereas items on bedtime resistance generally improved, sleep duration shortened with older age. With regard to sleep anxiety, we found worsening in the item ‘Afraid of sleeping in the dark' in about one-fifth of our children whereas other items on this CSHQ subscale showed an opposing trend with age. A similar opposing trend was detected within the subscale on night wakings. Conclusion Our data provide initial descriptive information on sleep habits in toddlers. The high intra-individual changes, partly in opposing directions which may be masked by aggregation, indicate a need for age- and item-specific analyses.

Developmental delays at school enrollment can affect early educational achievement. Thus, diagnosis and treatment prior to school entry are important. In Germany, SOPESS - a pediatric developmental screening instrument for preschool health examinations (PHE) - was introduced in several federal states. We investigated the relationships between the results of the language-related domain of the SOPESS and later academic language competencies at the end of first grade.Data of the population-based cohort study ikidS (Rhineland Palatinate; Germany) and the PHE provided by public health authorities were linked at individual level. The relationship between the SOPESS-language risk score (range: 0 to 6, higher values indicate more developmental delay) and class teacher-based ratings of academic language competencies (range: -4 to+4, higher values indicate better competencies) was investigated with linear regression models and adjusted for several socio-economic and medical language predictors (e. g. age at school entry, gender, parental education, migration background, hearing disorder). The additional benefits of the SOPESS-language risk score was analyzed using analysis of variance.In total, 1357 children (48% girls, age at PHE 4.9-7.2 years) were included. A clear negative relationship between the SOPESS-language risk score and competencies in spoken and written language was found. Mean academic language competencies decreased with increasing SOPESS-language risk level from 0.8 (SD=1.7) at a risk score of 0 to-3.2 (SD=0.9) at a risk score of 6. The relationship persisted after adjusting for other language predictors. Analysis of variance showed significant benefits of the SOPESS-language risk score, even when further language predictors were considered.There was a clear relationship between results of the SOPESS-language screening and later academic language competencies. Hence, the language-related domain of the SOPESS may be useful for further recommendations of tailored special educational and medical support services, especially if additional socio-economic and medical factors are considered.Eine frühe Diagnostik und Behandlung von Entwicklungsstörungen vor der Einschulung ist für den weiteren Bildungserfolg maßgeblich. Deshalb wurde das Sozialpädiatrische Entwicklungsscreening für Schuleingangsuntersuchungen (SOPESS) konzipiert und in mehreren Bundesländern flächendeckend eingeführt.Wir untersuchten die Zusammenhänge zwischen den Screening-Ergebnissen der SOPESS-Sprachaufgaben vor der Einschulung und den schulischen Sprachkompetenzen am Ende der ersten Klasse als Teil einer umfassenden Evaluation des SOPESS.Daten der rheinland-pfälzischen Schuleingangsuntersuchung und der prospektiven Kindergesundheitsstudie ikidS wurden zusammengeführt und ausgewertet. Zusammenhänge zwischen dem Gesamtrisikowert Sprache des SOPESS vor Einschulung (ordinal-skaliertes Merkmal, 6 Risikostufen) und dem Gesamtfähigkeitswert Sprache am Ende der ersten Klasse (subjektive Lehrkrafteinschätzung, intervall-skaliertes Merkmal, Range −4 bis+4) wurden mittels linearer Regressionsmodelle ohne und mit Berücksichtigung von weiteren sozio-demografischen und medizinischen Sprachprädiktoren untersucht (z. B. Alter bei Einschulung, Geschlecht, Schulbildung der Eltern, Migrationshintergrund, Hörstörung). Der zusätzliche Nutzen des Gesamtrisikowertes Sprache des SOPESS wurde durch Varianzanalysen geprüft.In die Auswertung konnten 1357 Kinder einbezogen werden (48% Mädchen, Alter bei Schuleingangsuntersuchung 4,9–7,2 Jahre). Es zeigte sich ein klarer negativer Zusammenhang zwischen den Stufen des Gesamtrisikowertes Sprache des SOPESS und den schulischen Sprachkompetenzen. In der Risikostufe 0 (kein Risiko) lag der Mittelwert der Sprachkompetenzen bei 0,8 (SD=1,7); in der Stufe 6 (hohes Risiko für Entwicklungsstörung) sank der Wert auf −3,2 Punkte ab (SD=0,9). Varianzanalysen zeigten zudem, dass der Gesamtrisikowert Sprache des SOPESS einen signifikanten Zusatznutzen gegenüber weiteren Sprachprädiktoren hat.Es zeigte sich ein klarer Zusammenhang zwischen den vorschulischen SOPESS-Sprachaufgaben und den schulischen Sprachkompetenzen am Ende der ersten Klasse. Dieses Sprachscreening könnte daher – unter Einbezug von weiteren soziodemografischen und medizinischen Prädiktoren – die Basis für eine passgenaue Auswahl von weiteren Versorgungs- und/oder Fördermaßnahmen sein.

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.

This study investigates the prevalence of manifest strabismus and its subtypes in adulthood and analyzes the risk factors and its impact on vision-related quality of life (VRQoL).The Gutenberg Health Study (GHS) is a population-based, observational cohort study. A cross-sectional analysis of the baseline examination was conducted.Participants aged 35 to 74 years were included (n = 15 010).All participants were examined with a comprehensive ophthalmologic and general examination including the Hirschberg corneal reflex test to detect manifest strabismus. The following risk factors were analyzed: age, sex, socioeconomic status, birth weight, maternal age at birth, anisometropia, astigmatism, spherical equivalent, low visual acuity in the worse seeing eye (≥1.3 logMAR), and cardiovascular factors, and included in multivariable logistic regression analysis. Lifetime period prevalence and point prevalence of manifest strabismus were computed, and VRQoL was compared between participants with and without strabismus.Strabismus prevalence.A total of 14 700 participants (age, 55.0±11.1 years; 49.5% were female) were included in this analysis. The weighted prevalence of ever having strabismus was 2.9% (2.6%-3.2%), and the point prevalence for concomitant strabismus was 2.5% (2.3%-2.8%). Esotropia was twice as frequent as exotropia, and 2 participants had paralytic strabismus. Concomitant strabismus was associated with age 65 to 69 years (odds ratio [OR], 0.13 [0.05-0.39], P0.001); age 70 to 74 years (OR, 0.14 [0.05-0.4], P0.001); anisometropia (1.0 diopters [D]: OR, 3.61 [2.32-5.62], P0.001;2.0 D: OR, 6.93 [4.23-11.35], P0.001); astigmatism (≥1.0 D: OR, 2.09 [1.42-3.08], P0.001; ≥2.0 D: OR, 3.74 [2.35-5.97], P0.001); spherical equivalent (per diopter: OR, 1.43 [1.33-1.53], P0.001); and low visual acuity in the worse seeing eye (≥1.3 logMAR: OR, 21.7 [11.2-42.0], P 0.001). VRQoL was lower in participants with strabismus compared with participants without strabismus in adjusted analysis (B = -5.96, P0.001).Strabismus is a frequent chronic eye condition that is associated with a lower VRQoL. Individuals with anisometropia, astigmatism, and hyperopia are more likely to have strabismus. In addition, low visual acuity in the worse eye was linked to strabismus prevalence.

Strabismus is a common cause for amblyopia and affected children need regular ophthalmic care. This study evaluated the frequency of ophthalmic care in children suffering from strabismus and analyzed associated factors.The data of the German Health Interview and Examination Survey for Children and Adolescents from the Robert Koch Institute (KiGGS, baseline survey 2003-2006, N = 17,640) were analyzed. Details on the presence of strabismus and the frequency of ophthalmic care were documented from information provided by the parents. Children aged 1-6 years were included. The relationship between strabismus and ophthalmic care in the previous 12 months was analyzed using multivariable logistic regression analysis and adjusted for age, sex, socioeconomic status, migration background, region and participation in regular pediatric check-ups.A total of 5247 children were included in this study of which 3.0% (N = 175) were reported by the parents as suffering from strabismus. Ophthalmic care within the last 12 months was reported by 66.9% of the parents (95% confidence interval [CI] 54.7-77.2%) of children with strabismus and was more frequent compared to those without strabismus (19.7%, 95% CI 18.2-21.3%). Of the children with strabismus 33.8% had visited an ophthalmologist in the last 12 months once, 33.1% twice, 12.6% three times, 13.3% four times and 7.2% more than four times. There was a relationship between strabismus (odds ratio [OR] = 9.21, 95% CI 5.44-15.6) and ophthalmic care during the preceding year.In Germany approximately one third of children with strabismus did not receive ophthalmic care within the previous year. This underlines the need for improvements in ophthalmic care in children with strabismus.

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

Vision-relevant refractive errors in children require regular ophthalmological control examinations. In this study we estimated the prevalence of wearing glasses for children and adolescents in Germany and the frequency of ophthalmological care.We analyzed data of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS, baseline survey 2003-2006, N = 17,640). Wearing glasses was documented from the age of 3 years in the examination part. We estimated the prevalence of wearing glasses and investigated the relationship with ophthalmological care during the preceding 12 months. Multivariable logistic regression analysis was used to calculate adjusted odds ratios (OR) and 95% confidence intervals (95%CI). Associations were adjusted for age, gender, socioeconomic status, migration background, residence (East/West Germany), participation in regular pediatric check-ups, and presence of strabismus.The prevalence of wearing glasses was 19.7% (95% CI: 18.8-20.5%) in the age range of 3-17 years. The prevalence was higher in girls (22.1%; 21.0-23.3%) compared to boys (17.3%; 16.3-18.3%) and increased with age up to 29.2% (27.6-30.9%) in the age group 14-17 years. The frequency of ophthalmological care within the last 12 months was 61.6% (59.4-63.8%) for those wearing glasses and 15.2% (14.3-6.2%) for those without glasses. Regression analysis revealed an association between ophthalmological care and wearing glasses (OR = 11.4; 10.1-13.0).In Germany, wearing glasses depends on gender and age and almost one third of adolescents already wear glasses. The majority of children and adolescents wearing glasses visit an ophthalmologist once a year.

Habitually snoring children are at a greater risk of poor school performance (PSP). We investigated the ability of conventional sleep-disordered breathing (SDB) measures for predicting PSP in habitually snoring children.The dataset of Hannover Study on Sleep Apnea in Childhood (HASSAC), a large community-based study in primary school children, was retrospectively analyzed. All habitual snorers were included. Based on their grades, children were grouped into good and poor school performers. SDB measures obtained by a parental questionnaire, a home pulse oximetry, and a home polysomnography were evaluated for their accuracy in predicting poor school performance by calculating receiver operating characteristic curves and area under this curve (AUC). The most predictive single factors were identified and entered into a prediction model.Of 114 habitual snorers (mean age 9.6 years, 51 boys), 59 had PSP. All investigated SDB measures showed low accuracy (ie, AUC0.8). The highest AUC observed was 0.686 for a questionnaire score, 0.565 for an oximetry factor, and 0.624 for a polysomnography factor. Of 20 single significant predictors for PSP, five were selected for inclusion into a prediction model. The model reached an unadjusted AUC of 0.826 and an adjusted AUC of 0.851.Conventional SDB measures obtained with questionnaire, oximetry, or polysomnography may not be sufficiently predictive of PSP in children suspected for SDB. However, combining factors in a clinical prediction model may improve prediction. Results of such a model may be used to assess the risk of developing neurocognitive impairment and to decide whether a child suspected for SDB might benefit from treatment.

We aimed to estimate unbiased effects of mental health problems (MHPs) on school performance in first graders, with an emphasis on rigorous adjustment for potential confounders. A population-based prospective cohort study was performed in the area of Mainz-Bingen (Germany). In 2015, all preschoolers were approached, and the presence and type of MHP (externalising/internalising) and other physical chronic health conditions were identified by the preschool health examination and study-specific questionnaires. At the end of the first grade, school performance (reading, writing, numeracy, and science) was assessed by the class teacher and rated on a four-item scale ranging from − 8 to + 8. Of 3683 children approached, 2003 (54%) were enrolled. School performance was available for 1462 children (51% boys, mean age 7.3 years). Of these, 41% had signs of at least one MHP. Compared to children without indications of mental and physical chronic health conditions, children with MHPs had lower school performance scores [adjusted mean difference − 0.98, 95% CI (− 1.35; − 0.61); P

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.

Objectives Sleep problems are often assessed using questionnaires, but it is unclear whether the responses given are influenced by age and gender. We addressed this question in several widely used pediatric sleep questionnaires and provide age-dependent percentile curves. Methods Data of a community-based study in schoolchildren were reanalyzed (N = 163, 50% males, age 6–17 years). Children and their parents completed the Sleep-Related Breathing Disorder Scale (SRBDS) of the Pediatric Sleep Questionnaire, the Sleep Disturbance Scale for Children (SDSC), the Sleep Self Report (SSR) of the Children's Sleep Habits Questionnaire in a long and short version, the Epworth Sleepiness Scale in a parent- (ESSp) and self-report version for children (ESSc), and the Pediatric Daytime Sleepiness Scale (PDSS). Linear and quantile regression analysis was used to i) assess the influence of age and gender on scores of questionnaire scales/subscales, ii) to calculate age- and gender-appropriate reference values and iii) to provide age-depending percentile curves. Results Only the PDSS showed relevant gender differences (β [95th confidence interval] = 0.155 [0.000; 0.270], p-value = 0.04, reference category: male), while the following subscales were all age dependent: SRBDS-somnolence and behavioral subscales, SDSC-somnolence subscale, SSR-long and short version; ESSp and ESSc, as well as the PDSS. Conclusions Age and gender should be taken into account for research purposes and individual patient assessments regarding sleep problems. Preliminary age- and gender-appropriate reference values and percentile curves are now available and may be used by researchers and clinicians.

To estimate the prevalence of strabismus in children and adolescents in Germany and to determine the associated risk factors, particularly those related to early childhood development.In the German Health Interview and Examination Survey for Children and Adolescents (KiGGS, baseline survey 2003 to 2006, N = 17,640, 49.1% girls), the presence of strabismus and potential risk factors were derived using parental questionnaires. The analyses were performed using the KIGGS public use file. The following relevant factors were analyzed: smoking during pregnancy, gestational age at birth, birth weight, medical problems within the first four weeks of life, and officially confirmed disability. Associations with strabismus were evaluated using multivariable logistic regression analysis. Odds ratios and 95% confidence intervals [95%-CI] were calculated and adjusted for age, sex, socio-economic status, migrational background, and participation in regular pediatric checkups.The prevalence of strabismus was estimated to be 4.1% [3.7-4.5]. Boys had a slightly lower prevalence (3.7%; [3.3-4.2%]) compared to girls (4.4%; [3.9-5.0%]; p value 0.05). After adjusting for confounders, strabismus was found to be significantly associated with smoking during pregnancy (OR = 1.38; [1.08-1.78]), gestational age (OR = 0.91 per week; [0.86-0.96]), medical problems within the first four weeks of life (OR = 1.29; [1.01-1.65]) and disability (OR = 4.33; [2.81-6.67]), but not with other risk factors under study.In Germany, strabismus is among the most prevalent chronic eye conditions. Former preterm infants and disabled children and adolescents are at greater risk.

Objective To report preliminary validation data for the pupillographic sleepiness test (PST) in children and adolescents. Methods Twelve patients (13.1±4.4years of age) underwent the multiple sleep latency test (MLST) and three PSTs at 09:00, 11:00, and 13:00 on one single day. Correlations were tested between mean sleep latency and gender-adjusted z -values of the natural logarithm of the pupillary unrest index (zlnPUI). Results Spearman's correlation ( P -value) between the zlnPUI values obtained at 09:00 and 11:00 with the MSL was r S =−0.641 (0.025) and r =−0.553 (0.062). Conclusion There was satisfactory agreement between PST and the MLST, which is similar to what is found in adults. The PST may be promising for the evaluation of daytime sleepiness in children and adolescents, and should be further evaluated in future studies.

BACKGROUND AND OBJECTIVE: In preterm infants receiving supplemental oxygen, routine manual control (RMC) of the fraction of inspired oxygen (FIO2) is often difficult and time consuming. We developed a system for closed-loop automatic control (CLAC) of the FIO2 and demonstrated its short-term safety and efficacy in a single-center study. The objective of this study was to test the hypothesis that this system is more effective than RMC alone in maintaining arterial oxygen saturation within target levels when evaluated over 24 hours under routine conditions and with different target levels. METHODS: We performed a multicenter, randomized controlled, crossover clinical trial in 34 preterm infants receiving mechanical ventilation or nasal continuous positive airway pressure and supplemental oxygen. Twenty-four–hour periods with RMC were compared with 24-hour periods of RMC supported by CLAC. RESULTS: The median (range) percentage of time with arterial oxygen saturation levels within target range was 61.4 (31.5–99.5) for RMC and 71.2 (44.0–95.4) for CLAC (P < .001). The median (range) number of manual FIO2 adjustments was reduced from 77.0 (0.0–224.0) for RMC to 52.0 (10.0–317.0) for CLAC (P = .007). CONCLUSIONS: CLAC may improve oxygen administration to preterm infants receiving mechanical ventilation or nasal continuous positive airway pressure while reducing workload related to RMC.

Objective A new oral appliance to treat obstructive sleep apnea in infants with Pierre Robin sequence has recently been shown to be superior to a sham procedure. We now investigate safety and long-term effects of this appliance on obstructive sleep apnea in infants with Pierre Robin sequence. Design Case series with repetitive follow-up examinations. Setting Tertiary neonatal intensive care unit at the University Children's Hospital Tuebingen, Germany. Patients Fifteen infants (11 girls and four boys; median age, 5 days) with Pierre Robin sequence and obstructive sleep apnea (i.e., mixed-obstructive-apnea index > 3). Intervention A custom-made intraoral appliance with velar extension was used continuously in situ from admission until 3 months after hospital discharge. Main Outcome Measure The mixed-obstructive-apnea index was determined prior to the intervention at admission, at discharge, and 3 months later using polygraphic sleep studies. The geometric mean of the mixed-obstructive-apnea index and its 95% confidence interval were calculated. Results Compared with admission (mean, 17.2; 95% confidence interval, 11.1–26.7), there was a significant decrease in the mixed-obstructive-apnea index to discharge (mean, 3.8; 95% confidence interval, 2.2–6.6) and 3 months later (mean, 1.2; 95% confidence interval, 0.7–2.2; p value < .001). No severe adverse events occurred. Conclusions This oral appliance was safe and appears to treat obstructive sleep apnea effectively in infants with Pierre Robin sequence.

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.

Summary Background Obstructive sleep apnea (OSA) is characterized by habitual snoring, heavy breathing, sleep-related hypoxia and arousals from sleep, and is found in approximately 3% of children. Objective To review the efficacy of medical, behavioral, mechanical and surgical interventions in improving OSA in children. Methods Bibliographic databases, relevant conference proceedings and trial registers were searched. Randomized controlled trials assessing interventions in children with objectively diagnosed OSA (as per polysomnography; apnea/hypopnea index (AHI) or respiratory disturbance index (RDI)≥1/h) were considered. Results The search identified 1690 potentially relevant studies. The five trials that met the inclusion criteria investigated seven different interventions (intranasal steroids, adenotonsillectomy, maxillary distraction, temperature-controlled radiofrequency ablation, oral appliances, continuous and bilevel positive airway pressure therapy). Intranasal steroids had a significant advantage over placebo in decreasing the AHI (one study). Temperature-controlled radiofrequency ablation and adenotonsillectomy were equally effective in reducing the RDI (one study). Continuous and bilevel positive airway pressure therapy was equally effective in reducing the AHI (one study). There was insufficient evidence to support the use of oral appliances. Conclusions Despite a broad array of treatment options for OSA, there is limited evidence to support their use. More research is needed before general recommendations can be made.

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.

Objective. Hypoxemia, often assessed via pulse oximetry, is associated with neurocognitive deficits in children. The best way to qualify hypoxemia, or which level of hypoxemia already affects cognition, is unknown.Methods. We assessed the association of pulse oximetry-derived variables that qualify hypoxemia with impaired academic performance in mathematics in a population-based cross-section of 995 primary school children who underwent overnight home recordings of motion-resistant new-generation pulse oximeter saturation (Spo2). Impaired academic performance in mathematics was based on the last school report and defined as grade 4 to 6 on a 6-point scale (ie, approximately the lowest quintile grades).Results. Of 10 variables under study, only the nadir of the Spo2 values was significantly associated with impaired performance. Categories of this variable representing mild (ie, 91%–93% Spo2; odds ratio: 1.65; 95% confidence interval: 1.06–2.56) and moderate hypoxemia (ie, ≤90% Spo2; odds ratio: 2.28; 95% confidence interval: 1.30–4.01) both were associated with impaired performance in mathematics.Conclusions. We suggest using the nadir of the Spo2 values in an overnight study to qualify hypoxemia in future studies. This variable may predict neurocognitive deficits in school children. Mild hypoxemia, as yet widely considered benign, may already affect cognition in childhood.

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.

Objectives. Sleep-disordered breathing is associated with impaired behavior and poor academic performance in children. We aimed to determine the extent of behavioral problems in snoring children, clarify the role of intermittent hypoxia, and test the reversibility of impaired behavior and poor academic performance. Methods. In 1144 children, habitual snoring (HS; snoring frequently or always) and impaired behavior were assessed using parental questionnaires. Intermittent hypoxia (ie, presence of ≥5 arterial oxygen desaturations by ≥4% or ≥1 desaturation to ≤90%) was investigated with pulse oximetry. Poor academic performance (grade 4–6 on a 6-point scale in mathematics, science, or spelling) was based on the last school report. HS, impaired behavior, and academic performance were reevaluated after 1 year. Adjusted odds ratios (ORs) were calculated using unconditional logistic regression. Results. HS was significantly associated with hyperactive (OR: 2.4) and inattentive behavior (OR: 4.0), daytime tiredness (OR: 7.1), and sleepiness (OR: 2.6–4.8). These associations were independent of intermittent hypoxia. HS was also significantly associated with bad conduct (OR: 2.8), emotional symptoms (OR: 5.5), and peer problems (OR: 9.7). At follow-up, hyperactive and inattentive behavior but not academic success had significantly improved in children in whom HS had ceased. Conclusions. We suggest that impaired behavior is a key feature of HS independent of intermittent hypoxia and improves when HS ceases.

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.

To provide reference values for pulse oximeter saturation (SpO(2)) in primary school children, measured at home during sleep.Recordings of SpO(2) and signal quality from 100 children were randomly selected from a larger population-based sample intended to study the prevalence of sleep-disordered breathing. Recordings were analyzed for the duration of artifact-free recording time (AFRT), minimum SpO(2) (SATmin) and median SpO(2) (SAT(50)), the SpO(2) below which the child spent 5% of AFRT (SAT(5)), and the SpO(2) below which the child spent 10% of AFRT (SAT(10)). In addition, the time in seconds with SpO(2)or= 90% per hour of AFRT (TI(90)) was calculated, as were the number of falls in SpO(2) byor= 4% per hour of AFRT (DI(4)), the number of falls in SpO(2) toor= 90% per hour of AFRT (DI(90)), and the number of falls in SpO(2) toor= 92% per hour of AFRT (DI(92)).Ten recordings had to be excluded because of insufficient AFRT (5 h). Mean age of the remaining 90 children (54 girls) was 9.3 years (SD, 0.6). Median (range; fifth centile) values for SATmin, SAT(5), SAT(10), and SAT(50) were 93% (76 to 97; 87.5), 97% (88 to 99; 95), 97% (89 to 99; 96), and 98% (94 to 100; 97). Median values (range; 95th centile) for TI(90), DI(4), DI(90), and DI(92) were 0.0 s (0.0 to 5.8; 1.6), 0.8 (0.0 to 6.1; 3.9), 0.0 (0.0 to 1.2; 0.2), and 0.0 (0.0 to 2.0; 0.6).Baseline SpO(2) values97% were uncommon in these children, as were intermittent desaturations toor= 90%. These data may serve as a basis for the interpretation of clinical recordings of SpO(2) in children referred for sleep-related breathing disorders.

The supine or prone positioning of infants has been a cause of much controversy. Recently it has been postulated that the position dependent hypoperfusion of the brainstem represents a possible cause of sudden infant death. To demonstrate position dependency and maturational changes of cerebral perfusion in premature newborn infants we investigated cerebral blood flow velocities (CBFV) in the main supratentorial and brainstem cerebral arteries. Measurements of CBFV were done with transfontanellar colour-coded Doppler sonography in the internal carotid artery (ICA), basilar artery (BA), and vertebral artery (VA) in the prone (head centered-baseline) and supine positions (maximal rotation to both sides) in 23 premature infants aged between 3–5 days of life. We performed follow-up measurements in 17 infants 7–10 days later and in 16 infants at the corrected age of 1 month. There was no difference in mean CBFVs between the prone and supine position at the first investigation. At the third investigation, CBFVs were significantly higher in the supine compared to the prone position. The CBFVs of the ICA were higher than in the BA and VA. This difference was not influenced by the body position but increased with post-natal age more in the VA (159%) than in the BA (129%) and ICA (128%). Position dependency was not seen in the ICA perfusion. In the prone position, five infants showed an incomplete steal effect in the contralateral VA. There was no significant side difference in the CBFVs of the ICA and VA, but in the resistance indices in the VA (left >right). Conclusion: in premature newborns, position dependent changes of cerebral blood flow velocity develop with maturation and are most pronounced in the vertebrobasilar system. These changes are possibly due to compression of the vertebral artery by neck movement and suggest an individual risk of brainstem perfusion deficits that may be aggravated with age and head rotation in a prone position.