Teller Acuity Cards Research Articles

Relationship between visual acuity, visual evoked patterned potentials done at different spatial frequencies and fundus findings in more than 100 Cerebral Visual Impairment affected subjects

Abstract Purpose: To analyze relationship between visual acuity (VA), visual evoked patterned potentials (VEP) and fundus state of the optic disk in children diagnosed by MR as cerebral visual impaired (CVI). Methods: Full clinical examinations, including Teller Acuity Cards (TAC) and/or optotype for decimal visual acuity, VEP and fundus optic disk findings , were done in 107 CVI affected infants (mean age 7,9±6). TAC were administered at spatial frequencies ranging from 0.23 to 38 cycles/degrees, at a distance varying from 84 to 55 cm. VEPs were recorded at Oz, O1, O2, referenced to Fz. Five black and white checks sizes, 300’,120’,60’,30’,15’, were presented. At least two spatial frequencies were performed depending upon the visual function. Statistical analysis: means and standard deviations were presented, correlation between VA and VEP, and association between optic disk features and VA were made. Results: Mean VA in decimal, was 3.55, ranging from 1.5 (p 25)to 4.8 (p 75). Percent success in TAC responses was 75. Mean VEP latencies in Oz varied from 112 ( 15’) to 105,9 ( 300’). Mean amplitudes varied from 18,8 ( 15’) to 22,3 (300’). VEP percent success was 77.6. A negative correlation coefficient ( r ) was found between VA and larger checks . A weak association was found between VA, VEP and optic disk features. Conclusions: Behavioural and objective tests correlate at different levels with fundus findings in CVI affected children, and are both useful in their follow‐up.

Predicting long-term visual outcome in children with birth weight under 1001 g

To examine the visual acuity development of extremely low birth weight children and to determine factors that are predictive of long-term outcome. This is a prospective observational longitudinal cohort study of children with birth weight less than 1001 g. One hundred thirty-nine children were recruited. Retinopathy of prematurity (ROP) examinations were graded according to the International Classification for ROP. Grating acuity was assessed monocularly with Teller acuity cards. All children were assessed before 24 months corrected age; 123 of the cohort had a grating acuity assessment at over 3 years. For the children who were capable, an assessment of recognition acuity was measured with the Electronic Visual Acuity system. Data are presented for the right eye and the ages reported are adjusted for prematurity to allow comparison with normative data. Initial grating acuity was compared with the late grating and recognition acuity, but in both cases analysis showed no statistically significant association. However, the relative risk analysis showed that, if the slope was abnormal, there was a 5.5 times higher risk of abnormal recognition acuity. Eyes with zone 1 disease were associated with a worse visual acuity outcome, but zone 1 disease also occurred more frequently in children with lower birth weight and gestational age. Early measurements of visual acuity may be misleading in terms of the visual prognosis. The factor that was most predictive of a poor late visual acuity outcome was the rate of development, as calculated by the slope of the early visual acuity measurements.

Reappraisal of Astigmatism Induced by Periocular Capillary Hemangioma and Treatment with Intralesional Corticosteroid Injection

To document refractive status and visual acuity before and after intralesional corticosteroid injection in children with astigmatism induced by periocular capillary hemangioma (PCH). Retrospective, interocular comparison, interventional case series. Thirteen infants with anisometropic astigmatism of at least 1.50 diopters (D) induced by PCH. All infants had one or more intralesional corticosteroid injections of a PCH between 2 and 10 months of age. Injections of 0.3 to 1.0 ml of a 50:50 mixture of triamcinolone (40 mg/ml) and dexamethasone phosphate (4 mg/ml) were given at a single site under deep sedation. Refraction and acuity using Teller acuity cards before and after injection. In affected eyes, mean astigmatisms were 3.75 D (pretreatment) and 1.25 D (posttreatment), and mean spherical errors were 0.75 D (pretreatment) and 1.50 D (posttreatment). Reduction in astigmatism was observed within 1 to 14 months after the injection. Despite reciprocal changes in astigmatism and spherical error, the amount of anisometropia (spherical equivalent) remained constant. Amblyopia was not observed before treatment and was observed in only 2 of 13 children after treatment. Complications were limited to adrenal suppression with transient reductions of linear growth and localized eyelid necrosis. Intralesional corticosteroid injections given in infancy (between 2 and 10 months) resulted in a 63% reduction in the mean amount of astigmatism induced by PCH. The reciprocal changes of astigmatism and spherical error without changes in anisometropia suggest that the treatment effect was due to restoration of the spherical shape of the cornea. Before 3 years of age, visual immaturity exceeded the optical blur related to astigmatism induced by PCH. Therefore, astigmatism, not anisometropia or amblyopia, is the immediate indication for treatment of PCH with intralesional corticosteroids. Injection of corticosteroid at a single site minimizes the potential for severe ocular complications owing to tissue pressure and tumor volume considerations.

Estimation of strabismic amblyopia by small-sized concentric gratings in preverbal children

Evaluate the ability to assess strabismic amblyopia of small-sized Concentric Gratings in comparison with classic linear gratings preferential looking test. Thirty-three preverbal children (age 6-30 months) with esotropia were tested for monocular visual acuity, using small-sized Concentric Gratings (target size 1.6, in 1/3 octave steps) and the Teller Acuity Cards. A fixation preference testing score was also obtained. In 17 of these children, 1-3 years later, after treatment of amblyopia and strabismus, fixation preference testing score, and visual acuity with Teller Acuity Cards, Concentric Gratings, and Glasgow Acuity Cards were measured. In 24 additional verbal untreated strabismic children (age 39-48 months), the same procedures were used. Correlations between interocular acuity difference of each preferential looking test and the Glasgow Acuity Cards were compared. Correlations between interocular acuity difference of each preferential looking procedure and fixation preference testing score were also compared. Concentric Gratings procedure was correlated significantly better than Teller Acuity Cards with fixation preference testing score (0.7 and 0.49, respectively), in the preverbal group (P=0.04). In treated verbal children, correlation of Concentric Gratings and Glasgow Acuity Cards (0.90) was stronger (P=0.06) than correlation of Teller Acuity Cards and Glasgow Acuity Cards (0.64). In untreated verbal children, correlation of Concentric Gratings and Glasgow Acuity Cards (0.89) was stronger (P=0.045) than correlation of Teller Acuity Cards and Glasgow Acuity Cards (0.67). The small-sized Concentric Gratings procedure improves detection and estimation of amblyopia depth in strabismus when compared with classic linear gratings.

Visual dysfunctions and ocular disorders in children with developmental delay. I. prevalence, diagnoses and aetiology of visual impairment

To describe the prevalence, diagnoses and aetiologies of visual impairment in children with developmental delay (DD) in a Danish county with a population of 618 000 citizens. We carried out a cross-sectional study in Copenhagen County of children aged 4-15 years with profound to borderline DD (IQ <or= 80). Children were located through school psychologists or paediatric clinics. The number of children with DD was estimated using the capture-recapture method. A total of 1126 children fulfilled the inclusion criteria, corresponding to 97.7% of the estimated number of children with DD in the county. Ophthalmological examinations were performed in 923 children. The prevalence of visual impairment was 10.5% in the study group and 22.4% in those with an IQ <or= 50. The diagnoses were predominantly cerebral visual impairment, optic atrophy, retinal dystrophies and congenital nystagmus. The aetiology of visual impairment was prenatal in 54 children, perinatal in 29 children and postnatal in seven children. Visual impairment is highly increased in children with DD and is correlated to low IQ.

Teller Acuity Card norms with and without use of a testing stage

To determine whether norms obtained using the Teller Acuity Card stage are appropriate for comparison with results obtained when the stage is not used. Eighty children were tested, 20 each at 3.5, 11, 17, and 30 months of age. Binocular grating acuity was measured once with Teller Acuity Cards presented with the stage and once without the stage. Test order was counterbalanced across subjects. Testers were aware that gratings progressed from lower to higher spatial frequencies, but were masked to the absolute spatial frequency of the grating on each card. Testers were masked to acuity results until the child completed testing. Repeated measures ANOVA with age as a between-subjects variable and test setting as a within-subjects variable showed a significant effect of age (p < 0.001) and test setting (p < 0.001), and a significant interaction between age and test setting (p < 0.01). Post-hoc comparisons (with Bonferroni correction) showed that the difference in acuity results obtained with the stage versus without the stage was significant at 17 months (p < 0.05), but not at 3.5, 11, or 30 months. Grating acuity norms obtained with the Teller Acuity Card stage are appropriate for comparison with data obtained without the stage in children 3.5, 11, and 30 months of age. However, when 17-month-old children are tested without the stage, comparison of results with norms obtained with the stage is problematic, because testing without the stage results in reduced acuity scores in this age group.

Prevalência de astigmatismo refracional e sua relação com a acuidade visual de resolução em crianças de 2 a 36 meses

To evaluate refractional astigmatism prevalence and its relationship with grating acuity in a cohort of non-verbal children. 482 normal children, aged from 2 to 36 months, were submitted to ophthalmological examination. Fourteen subjects were excluded due to ocular disease and the sample remained with 468 subjects (936 eyes); 230 (49%) males e 238 (51%) females. Grating acuity was assessed binocularly and monocularly with Teller acuity cards. All children underwent eye examination including cycloplegic retinoscopy and fundus by indirect ophthalmoscopy. Astigmatism was found in 222 (47.43%) of the children, with the hyperopic and with the rule types most frequently found in all ages. Concerning magnitude, this condition was equal or greater than 1.00 cylindric diopter in 24.35% of the children; equal or greater than 2.00 cylindric diopter in 5.55%; lower than 1.00 in 26.92% and between 1.00 and 2.00 in 18.73%. Grating acuity was normal in 219 of the subjects, despite magnitude, type and orientation of astigmatism. Visual acuity assessed by the acuity card procedure was not influenced by astigmatism.

Accuracy of the Contrast Sensitivity Card Test for Infants: Retest Variability and Prediction of Spatial Resolution

We assessed the retest variability of a new contrast sensitivity (CS) card procedure and its ability to predict spatial resolution. Twenty-four 3-month-olds were tested twice with the CS cards and once with the Teller acuity cards (TAC) within a single session. Coefficient of repeatability (COR) analysis revealed that retest variability of the new cards is superior to that of an earlier prototype at low to mid spatial frequencies. Furthermore, retest variability is comparable to that of infant visual evoked potential studies and the Vistech 6500, a chart commonly used to measure CS in adults. Finally, estimates of visual acuity based on the CS cards were consistent with those provided by the TAC (although CS-based estimates were generally lower overall). Given its reliability and accuracy, the new CS card procedure has good potential as a clinical tool for assessing spatial vision in infants and toddlers.

Visual Acuity Development After the Implantation of Unilateral Intraocular Lenses in Infants and Young Children

Intraocular lenses (IOLs) are now being implanted in infants and children with unilateral cataracts. However, there are no prospective data on the development of visual acuity after implantation. The aim of the present study was to prospectively assess the development of acuity in infants and preschool children who received IOLs or aphakic contacts lenses (CLs) after the extraction of a unilateral cataract. Visual acuity was assessed using Teller Acuity Cards and/or crowded HOTV tests at target ages of 6 months, 1, 2, 3, and 4 years. Infants who received a primary IOL after extraction of dense congenital unilateral cataract (n = 5) showed improvement from an initially low mean visual acuity of 20/170 at 6 months to 20/85 at 12 months and 20/54 at 4 years. Visual acuity in the IOL group was similar to that of children who had good-to-excellent compliance with CL wear (n = 36; 4-year visual acuity 20/50) and better than that of children who had moderate-to-poor compliance (n = 11; 4-year visual acuity 20/135). Children who received IOLs after extraction of developmental unilateral cataracts by 6 months (n = 4; 4-year visual acuity 20/55) had visual acuity development similar to those treated with CLs (n = 5; 4-year visual acuity 20/55). Children who received IOLs after extraction of developmental unilateral cataracts after 1 year of age (n = 18) had better visual acuity than children those treated with CLs (n = 4) at 4 years of age (20/40 vs. 20/135). IOLs and aphakic CLs support similar visual acuity development after surgery for a unilateral cataract. IOLs may support better visual acuity development when compliance with CL wear is moderate to poor or when a cataract is extracted after 1 year of age.

Are Norms Based on the Original Teller Acuity Cards Appropriate for Use with the New Teller Acuity Cards II?

We sought to compare visual acuity results obtained with the original Teller Acuity Cards (TAC), which are no longer commercially available, and the modified, laminated Teller Acuity Cards II (TAC II), which recently became commercially available. Sixty children were tested, 20 at each of 3 ages: 3.5 months, 11 months, and 30 months. Each subject's binocular grating acuity was measured once with the TAC and once with the TAC II, with the order of testing counterbalanced across subjects. Testers were aware that acuity cards were arranged in ascending order of spatial frequency, but they were masked to the absolute spatial frequencies of the gratings in the subset of cards used. Testers were also masked to acuity results until testing of the child was completed. Repeated-measures analysis of variance with age as a between-subjects variable and card type as a within-subjects variable showed a significant effect of age (P < 0.001) and a significant effect of card type (P < 0.001), but no interaction between age and card type. Post hoc comparisons (with Bonferroni correction) showed that mean acuity score was significantly better with TAC than with TAC II at 3.5 months (0.2 octave, P < 0.05), 11 months (0.4 octave, P < 0.01), and 30 months (0.7 octave, P < 0.001). These results suggest that normative grating acuity data obtained with the original Teller Acuity Cards need to be adjusted toward lower acuity values by approximately 0.5 octave to be appropriate for use with the new Teller Acuity Cards II.

Effects of Prenatal Alcohol Exposure on Infant Visual Acuity

To examine the effects of prenatal alcohol exposure ascertained prospectively on infant visual acuity across a range of exposures and factors that mediate or moderate these effects. Infant visual acuity was examined in 131 Cape Coloured (mixed ancestry) maternal-infant pairs in Cape Town, South Africa. Drinking patterns were documented by maternal reporting during pregnancy. Grating acuity was assessed with Teller Acuity Cards (TAC) at 6.5 months after term. Data were analyzed by correlation, multiple regression, and analysis of variance. Greater average daily prenatal alcohol exposure was related to poorer acuity, as indicated by lower TAC scores. The effect of alcohol on acuity was significant primarily for infants born to mothers > or =30 years of age at delivery, in comparison to infants born to younger mothers. This effect was not mediated by gestational age or birth size or attributable to alcohol-related neurocognitive deficits. This study linked prenatal alcohol exposure ascertained prospectively to poorer visual acuity in infancy. The results are consistent with clinical and animal evidence of alcohol-related disruption of the visual system.

Visual acuity and behavior in people with severe motor and intellectual disabilities

The authors examined the relationship between visual acuity and daily behavior in people with severe motor and intellectual disabilities (SMIDs). The visual acuity of 15 subjects was assessed using two methods: Teller Acuity Cards and the STYCAR balls vision test. The subjects' caregivers evaluated the subjects' daily behavior and completed a questionnaire. Results implied that visual acuity and behavior were correlated.

Intraobserver Reliability of the Teller Acuity Card Procedure in Infants With Perinatal Complications

Intraobserver test-retest reliability of the Teller Acuity Card (TAC) procedure for estimating grating acuity was assessed in 79 infants who had been treated in a neonatal intensive care unit for preterm birth and/or other perinatal complications. Subjects were tested monocularly at one or more of four different age intervals that ranged between 2.5 and 18.5 mo corrected age. Testers were masked to the location and spatial frequency of the grating on each card. Of the intraobserver test-retest scores, 91% differed by no more than one octave and 68% differed by no more than 0.5 octave. Intraobserver agreement was similar to that reported previously for healthy, preterm infants. Reliability was uniform between infants of differing levels of risk for abnormal visual development but bore effects of low tester ratings of confidence. The results demonstrate the reliability of the TAC procedure but suggest that test sessions should be repeated when tester confidence in validity of results is low.

Visual Acuity in Premature Infants

Purpose: To measure grating visual acuity in premature infants and compare it with that in full-term infants. Methods: The visual acuity of 73 premature and 73 full-term infants was tested at 6 months of age by the Teller Acuity Card procedure. All premature infants had undergone indirect funduscopy for the detection of retinopathy of prematurity (ROP). Seven infants had developed ROP. The mean gestational age of the premature infants was 33 ± 1.4 weeks as compared with 39.9 ± 0.9 weeks in the full-term infants. The mean birth weights of the 2 groups were 1,906 ± 412 and 3,244 ± 420 g, respectively. Results: Impaired binocular visual acuity was found in 53.4% of the premature infants, but in only 11% of the full-term infants (p < 0.0001). Impaired monocular visual acuity was found in 13.7% of the premature infants as compared with 2.7% of the full-term infants. Within the premature infant group, monocular visual acuity was impaired in 42.9% of those with ROP and in 10.6% of those without ROP (p = 0.0497). Pathological refraction was found in 33.3% of the prematures without ROP and in 14.3% of the prematures with ROP. This difference was not statistically significant. Visual acuity of preterm infants was not different from full-term infants when examined at 6 months of postconceptual age. Conclusions: Both monocular and binocular visual acuities as measured by the Teller Acuity Cards are worse in premature infants than in full-term infants at the same chronological age. Poor visual acuity in premature infants can be attributed mainly to immaturity of the visual system.

Is exposure to cocaine or cigarette smoke during pregnancy associated with infant visual abnormalities?

The aim of this study was to assess the association between cocaine or cigarette smoke exposure in utero and visual outcome. A total of 153 healthy infants (89 males, 64 females; gestational age range 34 to 42 weeks) were prospectively enrolled in a masked, race‐matched study. Quantitative analyses of urine and meconium were used to document exposure to cigarette smoke and cocaine. Infants with exposure to other illicit drugs, excepting marijuana, were excluded. At 6 weeks of age, grating acuity and visual system abnormalities (VSA; eyelid oedema, gaze abnormalities, and visual inattention) of 96 infants from the original study sample were assessed with the Teller acuity card procedure and a detailed neurological examination. Neither cocaine nor cigarette smoke exposure was associated with acuity or VSA. However, VSAs were associated with abnormal neurological examination, independent of drug exposure and other risk factors (odds ratio 7.9; 95% confidence interval 2.0 to 31.5; p=0.004). This unexpected finding could prove a helpful clinical marker for the infant at risk for neurological abnormalities.

Is exposure to cocaine or cigarette smoke during pregnancy associated with infant visual abnormalities?

The aim of this study was to assess the association between cocaine or cigarette smoke exposure in utero and visual outcome. A total of 153 healthy infants (89 males, 64 females; gestational age range 34 to 42 weeks) were prospectively enrolled in a masked, race-matched study. Quantitative analyses of urine and meconium were used to document exposure to cigarette smoke and cocaine. Infants with exposure to other illicit drugs, excepting marijuana, were excluded. At 6 weeks of age, grating acuity and visual system abnormalities (VSA; eyelid oedema, gaze abnormalities, and visual inattention) of 96 infants from the original study sample were assessed with the Teller acuity card procedure and a detailed neurological examination. Neither cocaine nor cigarette smoke exposure was associated with acuity or VSA. However, VSAs were associated with abnormal neurological examination, independent of drug exposure and other risk factors (odds ratio 7.9; 95% confidence interval 2.0 to 31.5;p=0.004). This unexpected finding could prove a helpful clinical marker for the infant at risk for neurological abnormalities.

Multicenter trial of early treatment for retinopathy of prematurity: study design

The Early Treatment for Retinopathy of Prematurity (ETROP) study was a randomized, prospective multicenter trial comparing the safety and efficacy of earlier vs. conventionally timed ablation of the peripheral retina for the management of moderate to severe retinopathy of prematurity (ROP). Approximately 7000 infants with birth weights <1251 g were screened at 26 centers over a 2-year period to achieve the sample size of 401 consented infants for the randomized trial. In order to minimize treatment of eyes with ROP that were likely to undergo spontaneous regression of the disease, a risk analysis model, RM-ROP2, was used to select for inclusion in the randomized trial only prethreshold eyes that had a high risk of an adverse outcome. The primary outcome measure was grating visual acuity measured by Teller acuity card testing conducted by masked testers in eyes randomized to earlier treatment vs. eyes randomized to conventional management when infants were 9 months post-term. Results were categorized into favorable (≥1.85 cycles/degree) vs. unfavorable (<1.85 cycles/degree). The secondary outcome measure was retinal structure, assessed by ophthalmological examinations conducted at 6 and 9 months post-term. Here we describe a unique approach used in the ETROP study to select high-risk prethreshold ROP eyes for randomization and details about design of the study. Study results indicated that earlier intervention in selected high-risk prethreshold eyes results in improved vision in premature infants with ROP.

Indications for Early Treatment of Retinopathy of Prematurity

Source: Early Treatment for Retinopathy of Prematurity Cooperative Group. Revised indications for the treatment of retinopathy of prematurity. Arch Ophthalmol.2003;121:1684–1694.Retinal detachment and reduced visual acuity from retinopathy of prematurity (ROP) continue to be major disabilities afflicting preterm infants.1 Investigators from 26 clinical sites collaborated to determine whether earlier treatment of infants at high risk for severe ROP resulted in improved visual acuity and retinal structural outcomes as compared with conventional treatment. Infants with birth weights less than 1,251g born from 2000 to 2002 were screened for ROP at 26 participating centers. If an infant developed ROP, parents were asked to consent to data collection and increased examination frequency. The threshold for treatment of ROP was defined as a risk of approximately 50% for retinal detachment. Infants with ROP were eligible for this randomized trial if the risk of progression to an unfavorable outcome in the absence of treatment was calculated to be 15% or higher and a second examination by a masked, study-certified ophthalmologist confirmed findings consistent with this risk. Of 828 infants whose parents had given consent for systematic follow-up of ROP, 499 were classified as high-risk for progression to an unfavorable outcome and 401 were ultimately enrolled. If both eyes were eligible for randomization, 1 eye was randomly assigned to earlier treatment with ablative therapy within 48 hours of the first diagnosis of high-risk ROR Treatment generally consisted of laser therapy, but cryotherapy was also allowed. The other eye served as the control and was managed conventionally (observed until it either reached threshold for treatment and was treated or the ROP regressed without progressing to threshold). In cases where only 1 eye reached high-risk prethreshold ROP, that eye was randomized either to treatment within 48 hours or to conventional management.The functional outcome of each randomized eye at a corrected age of 9 months was evaluated using Teller Acuity Cards to assess monocular acuity. Structural outcome was documented with a dilated fundus examination at corrected ages of 6 and 9 months by study-certified examiners. Based on the acuity outcomes at 9 months, there was a significant benefit from early treatment of eyes with high-risk ROP: 14.5% with unfavorable visual acuity outcome compared to 19.5% with conventional treatment. At 9 months, unfavorable structural outcomes were lower among patients in the early treatment group than among those receiving conventional treatment (9.1% versus 15.6%, P<.001). The authors conclude that early treatment of high-risk, prethreshold ROP significantly reduced unfavorable outcomes to a clinically important degree. Long-term follow-up is being conducted to learn whether the benefits noted in the first year after birth will persist into childhood.Despite major advances in the management of severe ROP, retinal detachment and reduced visual acuity from ROP continue to be one of the most common causes of severe visual impairment in childhood. During the past several years, the timing and indications for treatment of ROP have been questioned, with some physicians advocating earlier treatment and others recommending a more conventional wait-and-see approach. The primary concern about earlier treatment is the expected increase in surgical intervention in eyes with ROP that would otherwise regress without any treatment. This concern has led to efforts to identify treatment selection criteria that will result in earlier treatment only in those eyes at highest risk for an unfavorable visual or structural outcome in the absence of treatment.This study documents a significant improvement of structural and functional outcome in early treatment of eyes showing findings of aggressive proliferative ROP These criteria will lead to an increased number of surgeries in the high-risk group, since some of them may have had spontaneous resolution of their ROP if not treated. However, the outcome, on average, of each surgical procedure will likely be much improved. Whether a surgery in a particular case might not have been necessary can never be determined by the data presented here since this, like most studies, deals with statistical probability, not individual cases. My impression is that the results will be significantly better, both structurally and functionally, and I have adopted the authors’ recommendations in my own clinical ROP practice.

Longchain polyunsaturated fatty acid supplementation in preterm infants.

The n-3 and n-6 essential fatty acids alpha linolenic acid (ALA) and linoleic acid (LA) are the precursors of the n-3 and n-6 longchain polyunsaturated fatty acids (LCPUFA). Controversy exists over whether LCPUFA are essential nutrients for preterm infants who may not be able to synthesise sufficient amounts of LCPUFA to satisfy the needs of the developing brain and retina. The aim of this review is to assess whether supplementation of formula with LCPUFA is safe and of benefit to preterm infants. Trials were identified by MEDLINE (October 2003), Oxford Database of Perinatal Trials, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2003) and by checking reference lists of relevant articles and conference proceedings. All randomised trials of formula supplemented with LCPUFA and with clinical endpoints were reviewed. Eleven randomised trials assessing the clinical effects of feeding formula supplemented with LCPUFA were included in the review. Of the eleven randomised trials included in the review, two of these were not classified as of high quality despite blinded assessment and complete follow-up, due to problems with assessment methodology. VISUAL ACUITY: Visual acuity over the first year was measured by Teller acuity cards in six studies, by VEP in four studies and by ERG in two studies. Most studies found no significant differences in any visual assessment between supplemented and control infants. Most of the trials have used Bayley Scales of Infant Development (BSID) at 12 to 24 months postterm and shown no significant effect following supplementation. Meta-analysis of BSID of three studies (Fewtrell 2002, O'Connor 2001, van Wezel 2002) shows no significant effect of supplementation on development. Carlson 1993 and Carlson 1996 demonstrated lower novelty preferences (possibly predictive of lower intelligence) in the supplemented compared with the control group. The investigators however concluded that supplemented infants may have more rapid visual information processing given that they had more looks and each look was of shorter duration. Most trials have reported no significant effect of LCPUFA supplementation on growth of preterm infants. Two trials (Carlson 1993, Carlson 1996) suggest that LCPUFA supplemented infants grow less well than controls, possibly due to a reduction in AA levels which occurs when n-3 supplements are used without n-6 supplements. Recent trials with addition of AA to the supplement have reported no significant effect on growth. Fewtrell 2002 reported mild reductions in length and weight z scores at 18 months. Contrary to these results, the meta-analysis of five studies (Uauy 1992, Carlson 1996, Hansen 1997, Vanderhoof 1999, Innis 2002) showed increased weight and length at two months post-term in supplemented infants. Uauy 1992 reported no significant effect of LCPUFA supplementation on bleeding time and red cell membrane fragility. Infants enrolled in the trials were relatively mature and healthy preterm infants. Assessment schedule and methodology, dose and source of supplementation and fatty acid composition of the control formula varied between trials. No long-term benefits were demonstrated for infants receiving formula supplemented with LCPUFA. There was no evidence that supplementation of formula with n-3 and n-6 LCPUFA impaired the growth of preterm infants.

A double-masked, randomized control trial of iron supplementation in early infancy in healthy term breast-fed infants

ObjectivesTo test whether iron supplementation affects hematologic, biochemical, and developmental status in term breast-fed infants. Study designTerm breast-fed infants (n=77) were randomly selected to receive either 7.5 mg per day of elemental iron as ferrous sulfate or placebo from 1 to 6 months of age. Investigators and families were unaware of group assignment. Complete blood count and ferritin, red cell superoxide dismutase, catalase, plasma ferric reducing antioxidant power, and zinc and copper levels were analyzed at 1, 3.5, 6, and 12 months of age. Bayley mental and psychomotor developmental indexes (MDI and PDI) and visual acuity (with the use of Teller acuity cards) were assessed from 12 to 18 months of age. Analysis performed by analysis of variance and t tests was by intention to treat. ResultsIron supplementation resulted in higher hemoglobin and mean corpuscular volume at 6 months of age and significantly higher visual acuity and PDI at 13 months of age (100±12 vs 93±9 [±SD]). Treatment and placebo groups did not differ in anthropometric indexes, compliance, biochemical status, or demographic characteristics. ConclusionsIron supplementation of breast-fed infants appears safe and might have beneficial hematologic and developmental effects for some infants.