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manifestations similar to NIDDM. The actual function of this gene has yet to be determined, however, and awaits further

investigation. Additionally, researchers have identified several mutations in the gene for insulin receptors in patients with rare but severe forms of NIDDM. Finally, a variety of other genes may be related to the long-term complications suffered by those with all forms of diabetes. In these areas, we do not yet know which genes are involved. Thus, the diversity of genes that may be involved in diabetes is presently an extremely active area of research.

Understanding the genetics of diabetes will provide at least two valuable results. Since each individual has his/her genes from birth, those genes that put them at risk for diabetes could be identified early in life. This would allow those individuals to undertake potentially preventive interventions which are now being developed before the disease occurs. Second, identification of relevant genes will help us understand what goes wrong to cause diabetes and, thereby, suggest promising new ways to treat and prevent this disease.



Question. Dr. Gordon, last year this Committee requested that ̧ the Institute consider establishing research centers to study Kidney and Urological Diseases in children. What action has the Institute undertaken regarding this initiative? In your professional judgment, is there a need for additional centers?

Answer. I am pleased to report that the NIDDK issued a Request for Applications for a Research Center of Excellence in Pediatric Nephrology and Urology in January 1991. The receipt date for the applications is April 2, 1991. We anticipate funding one center in 1991. The National Kidney and Urologic Diseases Advisory Board recommended that the number of research centers directed toward adult urologic and nephrologic diseases be increased from 6 to 18. I agree with this estimate. Many urologic and nephrologic diseases begin in the pediatric age group. Therefore, there is a definite need for research in the pediatric population, if we are to prevent or treat kidney and urologic diseases of young adults.



Senator HARKIN. Dr. Alexander, welcome back to the subcommittee. I look forward to hearing your plans for the Institute because the research programs are targeted on some of the most urgent public health issues in the United States today. I believe the work done by your Institute is critical to improving the health and well-being of our children in the future. And when we talk about prevention and early intervention, that is your backyard.

Doctor, we have your request for $520.6 million, an increase of about 8.7 percent from last year. Would you begin by highlighting the major programs included in your budget request?

Dr. ALEXANDER. Thank you, Mr. Chairman.

In 1989, more than 4 million babies were born in the United States, but of these almost 39,000 died before their first birthday. Although our infant mortality rate is at an all-time low, the pace of our progress in reducing it has slowed. Our scientists are trying to determine why the Nation's rate of low birthweight has remained constant and why low birthweight is twice as prevalent among black women as compared to white women.

An important advance was made this year in the treatment of children infected with the AIDS virus. NICHD-supported investigators found that monthly administration of intravenous immunoglobulin, a solution that contains concentrated antibodies, significantly reduces the number of serious bacterial infections, reduces the number of hospitalizations required, and prolongs by as much as 1 year the time free from serious bacterial infections in children who are afflicted with symptoms of HIV infection.

In other research related to pediatric AIDS, the NICHD, in a joint effort with the National Institute of Allergy and Infectious Diseases, is beginning clinical trials in pregnant women to attempt to reduce transmission of the virus from mother to fetus.

Sudden Infant Death Syndrome continues to resist revealing its causes. Now, new technologies are allowing us to investigate factors that may hold the key to our being able to predict or prevent apnea or SIDS.

The Food and Drug Administration recently licensed the first vaccine effective in infants against Haemophilus influenzae type b. As Dr. Fauci indicated, this conjugate vaccine is based on the work of Dr. John Robbins in the NICHD intramural research program and was further developed with both NIAID and NICHD support. This vaccine, once it is widely used, should nearly eliminate H. flu meningitis as a cause of mental retardation and deafness.

Assuring that research advances are transferred from the laboratory bench to the health-care system is an Institute priority.

Evidence of this commitment is NICHD's recent establishment of a national program of child health research centers. We also plan to fund several new centers over the next year related to women's health issues. At least one center will focus on infertility research and as many as three will concentrate on contraceptive development. These centers will become part of the Institute's historically strong research centers program.


Millions of Americans are encumbered by physical disability resulting from birth defects, injuries, or diseases. Helping these individuals regain their physical or functional ability to the fullest extent possible is the objective of a new National Center for Medical Rehabilitation Research established within NICHD. The new center will conduct and coordinate research and research training related to rehabilitation of individuals with physical disabilities.

Mr. Chairman, our fiscal year 1992 budget request is $520,584,000.

I will be pleased to answer any questions.

[The statement follows:]


The United States is a nation that holds its children in high esteem. A child who dies prematurely or who fails to develop to its full human potential represents a societal as well as a personal tragedy.

The research programs of the National Institute of Child Health and Human Development (NICHD) are designed to ensure the health and well-being of American children and their families. That goal is pursued through the support and conduct of research addressing some of the urgent public health problems facing our nation. These problems include a high national infant mortality rate; maternal, pediatric and adolescent AIDS; unintended pregnancy, a large portion of which is teenage childbearing; Sudden Infant Death Syndrome; factors that inhibit the physical or behavioral development of children; and the physical disabilities that result from impaired development, accidents or disease.

The NICHD supports a broad range of biomedical and behavioral research on such challenges as birth defects, mental retardation or other developmental disabilities, learning disabilities, medical rehabilitation and the development of better, more effective fertility regulation, including contraceptive choices.

Improving the health status of mothers and infants remains a national challenge. In 1989, more than 4,000,000 babies were born in the United States. Of these, almost 39,000 died before their first birthday, with black babies dying at twice the rate of white babies. Although the nation's infant mortality rate is at an all-time low, the pace of progress has slowed. Important determinants of infant mortality such as the incidence of low birth weight and early prenatal care show no recent improvements.

NICHD scientists are trying to determine why the nation's rate of low birth weight has remained constant and why low birth weight is twice as prevalent among black women as compared to white women.

Socioeconomic factors

alone do not explain the disparity, and researchers are currently investigating the effect of social support, level of work and other physical activity, nutrition, stress, health behaviors and other factors on the

occurrence of low birth weight among various ethnic groups including blacks

and Hispanics.

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Sudden Infant Death Syndrome (SIDS), which claims the lives of 6,000 to 7,000 infants each year, continues to resist revealing its causes. However,

research is making some inroads.

Differences in the number of short pauses in

breathing during sleep may be a clue as to why apparently healthy infants die. During the second month of life, babies who die of SIDS appear to have a decrease in the number of normal pauses in breathing. This decrease occurs just prior to the age at which most SIDS deaths occur, leading investigators to conclude that this change may be related to factors in the infant's respiratory control system. A prospective study being developed by NICHD will use the new technology of event recorders with apnea monitors to determine whether this decrease in breathing pauses or other factors may be able to predict, detect, or prevent apnea and SIDS.

The improvement in infant mortality that has been noted is largely attributable to advances in the technology of caring for ill or premature newborns. Assuring that these advances are transferred from the laboratory bench to the health care system is an Institute priority. Evidence of this commitment is the NICHD's' recent establishment of a national program of Child Health Research Centers. Seven Centers were funded last year in response to Congressional interest. This program is designed to foster the development of improved treatment techniques, expedite the transfer of these findings from basic research to the care of sick children, and encourage the development of a new generation of highly trained research clinicians specializing in pediatric research.

Survival of premature or low birth weight infants is not the only issue. The future intellectual and behavioral functioning of these children is also at stake. Low birth weight or premature infants often suffer developmental disabilities ranging from mild learning problems to severe mental retardation. The results from a large-scale study jointly supported by the Robert Wood Johnson Foundation and the NICHD demonstrated that early intervention can prevent many behavioral problems and raise I.Q. scores in at-risk children. The low birth weight children in the study began receiving weekly visits soon after birth from health care professionals who taught parents not only how to take care of their children's physical needs but also how to play with their children in ways that would stimulate their minds. At one year of age, the

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