Maternal Education and Child Self-Regulation: Do Maternal Self-Regulation and Responsiveness Mediate the Association?

OBJECTIVE

To examine the mediating role of observed maternal responsiveness and maternal self-regulation on the association between maternal education and children's self-regulation.

METHODS

English-speaking mother-child dyads (n = 189) were recruited from a previous study and were eligible if the child was kindergarten eligible at the start of the 2020 to 2021 or 2021 to 2022 school year. Key measures included: Difficulties in Emotion Regulation Scale-Short Form for maternal emotional self-regulation, Culturally Affirming and Responsive Experiences for maternal responsiveness, and the Head-Toes-Knees-Shoulders for child self-regulation. The association between years of maternal education and child self-regulation was examined with linear regression, and the mediation analyses utilized 4 subsequent steps examining their relations. These steps were checked through a series of linear regressions, and beta weights were used to describe associations. Each potential mediator was examined separately.

RESULTS

Children of mothers with higher education had significantly higher self-regulation, slope of 1.3 (95% confidence interval 0.3, 2.4, P = 0.015, beta = 0.18). Further, mothers with higher education had significantly higher observed responsiveness. The beta-weight of 0.34 (P < 0.001) supported maternal responsiveness as a mediator. Finally, in the test for direct and indirect effects, observed maternal responsiveness explained 29% (95% confidence interval 3.3%, 115%) of the association between maternal education and child self-regulation.

CONCLUSIONS

This study highlights a key mechanism related to children's self-regulation skills and the significant role of observed maternal responsiveness in explaining the association between maternal education and child self-regulation.

The importance of community resources for breastfeeding

BACKGROUND

Breastfeeding has long-lasting effects on children's cognition, behavioral, mental and physical health. Previous research shows parental characteristics (e.g., education, race/ethnicity, income level) are associated with breastfeeding initiation and duration. Further, research shows significant variation in access to community resources by race/ethnicity. It is unclear how community resources may impact breastfeeding practices and how this might intersect with maternal race/ethnicity.

METHODS

This study combined nationally-representative data from the Study of Attitudes and Factors Effecting Infant Care (SAFE), which surveyed US mothers immediately after the infant's birth and at two to six months of infant age, with the Child Opportunity Index (COI) 2.0, a census tract measure of community resources associated with child development, to explore the association between community resources and breastfeeding initiation and whether this varies based on maternal race/ethnicity and country of birth. The SAFE Study used a stratified, two-stage, clustered design to obtain a nationally representative sample of mothers of infants, while oversampling Hispanic and non-Hispanic (NH) Black mothers. The SAFE study enrolled mothers who spoke English or Spanish across 32 US birth hospitals between January 2011 and March 2014.

RESULTS

After accounting for individual characteristics, mothers residing in the highest-resourced communities (compared to the lowest) had significantly greater likelihood of breastfeeding. Representation in higher-resourced communities differed by race/ethnicity. Race/ethnicity did not significantly moderate the association between community resources and breastfeeding. In examining within race/ethnic groups, however, community resources were not associated with non-US born Black and Hispanic mothers' rates of breastfeeding, while they were with US born Black and Hispanic mothers.

CONCLUSIONS

Findings suggest that even health behaviors like breastfeeding, which we often associate with individual choice, are connected to the community resources within which they are made. Study implications point to the importance of considering the impact of the contextual factors that shape health and as a potential contributor to understanding the observed race/ethnicity gap.

Breastfeeding Decision-Making Among Mothers with Opioid Use Disorder: A Qualitative Study

Background: Factors that contribute to low initiation and continuation of breastfeeding among mothers with opioid use disorder (OUD) are poorly understood. Objective: To understand barriers and facilitators to breastfeeding initiation and continuation beyond the birth hospitalization for mothers with OUD. Materials and Methods: We conducted 23 in-depth, semistructured interviews with mothers with OUD who cared for their infants at home 1-7 months after birth. Our interview guide was informed by the Theory of Planned Behavior (TPB) framework, which has been used to understand decision-making regarding breastfeeding. An iterative approach was used to develop codes and themes. Results: Among 23 participants, 16 initiated breastfeeding, 10 continued after hospital discharge, and 4 continued beyond 8 weeks. We identified factors influencing breastfeeding decisions in the four TPB domains. Regarding attitudes, feeding intentions were based on beliefs of the healthiness of breastfeeding particularly pertaining to infant withdrawal or exposure to mothers' medications. Regarding social norms, breastfeeding was widely recommended, but mothers had varying levels of trust in medical professional advice. Regarding perceived control, infant withdrawal and maternal pain caused breastfeeding to be difficult, with decisions to continue modulated by level of outside support. Regarding self-efficacy, mothers weighed their own recovery and well-being against the constant demands of breastfeeding, impacting decisions to continue. Conclusion: Mothers with OUD face unique barriers to breastfeeding related to their infants' withdrawal as well as their own health, recovery, and social context. Overcoming these barriers may serve as future intervention targets for breastfeeding promotion among this high-risk population.

Maternal Informal Learning Experiences that Shape Parenting Practices

Objective

Current understanding of the linkage between maternal education and parenting practices has largely been informed using a narrow definition of educational attainment-the highest level of education an individual has completed. However, the proximal processes that shape parenting, including informal learning experiences, are also important to understand. Less is known about the informal learning experiences that shape parenting decisions and practices. To this end, we conducted a qualitative inquiry about the informal learning experiences of mothers of children ages 3 to 4 years with the specific goal of understanding how maternal informal learning experiences shape parenting decisions and practices.

Design

We conducted interviews with 53 mothers from across the United States who had previously participated in a randomized controlled trial (RCT) of an intervention targeting infant care practices. We recruited a purposive sample of mothers chosen to maximize diversity across educational attainment and adherence to infant care practices targeted in the RCT. Using a grounded theory approach, data were analyzed using an iterative process for organizing codes and themes that mothers identified as informal learning experiences.

Results

We identified seven themes representing distinct types of maternal informal learning experiences that impact parenting practices, including: (1) experiential learning during childhood; (2) experiential learning during adulthood; (3) interpersonal interactions including via social media; (4) experiences with non-interactive media sources; (5) informal trainings; (6) beliefs; and (7) current circumstances.

Conclusions

Multiple informal learning experiences inform the parenting decisions and practices of mothers with varying levels of formal educational attainment.

Racial and Ethnic Differences in Internal Medicine Residency Assessments

Importance

Previous studies have demonstrated racial and ethnic inequities in medical student assessments, awards, and faculty promotions at academic medical centers. Few data exist about similar racial and ethnic disparities at the level of graduate medical education.

Objective

To examine the association between race and ethnicity and performance assessments among a national cohort of internal medicine residents.

Design, Setting, and Participants

This retrospective cohort study evaluated assessments of performance for 9026 internal medicine residents from the graduating classes of 2016 and 2017 at Accreditation Council of Graduate Medical Education (ACGME)-accredited internal medicine residency programs in the US. Analyses were conducted between July 1, 2020, and June 31, 2022.

Main Outcomes and Measures

The primary outcome was midyear and year-end total ACGME Milestone scores for underrepresented in medicine (URiM [Hispanic only; non-Hispanic American Indian, Alaska Native, or Native Hawaiian/Pacific Islander only; or non-Hispanic Black/African American]) and Asian residents compared with White residents as determined by their Clinical Competency Committees and residency program directors. Differences in scores between Asian and URiM residents compared with White residents were also compared for each of the 6 competency domains as supportive outcomes.

Results

The study cohort included 9026 residents from 305 internal medicine residency programs. Of these residents, 3994 (44.2%) were female, 3258 (36.1%) were Asian, 1216 (13.5%) were URiM, and 4552 (50.4%) were White. In the fully adjusted model, no difference was found in the initial midyear total Milestone scores between URiM and White residents, but there was a difference between Asian and White residents, which favored White residents (mean [SD] difference in scores for Asian residents: -1.27 [0.38]; P < .001). In the second year of training, White residents received increasingly higher scores relative to URiM and Asian residents. These racial disparities peaked in postgraduate year (PGY) 2 (mean [SD] difference in scores for URiM residents, -2.54 [0.38]; P < .001; mean [SD] difference in scores for Asian residents, -1.9 [0.27]; P < .001). By the final year 3 assessment, the gap between White and Asian and URiM residents' scores narrowed, and no racial or ethnic differences were found. Trends in racial and ethnic differences among the 6 competency domains mirrored total Milestone scores, with differences peaking in PGY2 and then decreasing in PGY3 such that parity in assessment was reached in all competency domains by the end of training.

Conclusions and Relevance

In this cohort study, URiM and Asian internal medicine residents received lower ratings on performance assessments than their White peers during the first and second years of training, which may reflect racial bias in assessment. This disparity in assessment may limit opportunities for physicians from minoritized racial and ethnic groups and hinder physician workforce diversity.

The Impact of Maternal Worry on Infant Care Practices

OBJECTIVES

Examine the 1) prevalence of worries among US mothers of infants; 2) association between worries and American Academy of Pediatrics recommended infant care practices (breastfeeding, supine sleep, roomsharing without bedsharing); 3) association of maternal and household characteristics with worries.

METHODS

We analyzed a nationally representative sample of 3165 mothers who were surveyed regarding safe sleep and breastfeeding when infants were 2 to 6 months of age in 2011-2014. We examined the prevalence of 8 maternal worries (housing, job, income, neighborhood, family relationships, health, baby's health, family member health). We used multivariable logistic regression to examine associations of A) both overall number of worries and individual worries with each infant care practice; and B) maternal and household characteristics with worries.

RESULTS

Twenty-six percent of mothers reported 0 worries, 26% reported 1-2 worries, 23% reported 3-4 worries, and 25% reported 5-8 worries. Compared to those with 0 worries, mothers with 5-8 worries had increased odds of bedsharing (adjusted odds ratio = 1.60 [1.19-2.14]) and non-supine sleep (aOR = 1.37 [1.07-1.74]). Specific worries associated with increased odds of bedsharing included: housing (aOR = 1.39 [1.09-1.78]), income (aOR = 1.35 [1.09-1.67]), neighborhood (aOR = 1.37 [1.05-1.78]), family relationships (aOR = 1.43 [1.10-1.86]), and health of a family member (aOR = 1.24 [1.06-1.46]). Maternal worries were not associated with infant feeding practices.

CONCLUSIONS

We found a high prevalence of worries regarding basic needs, family relationships, and health among US mothers. Greater total worries and several individual worries were associated with higher odds of bedsharing. The "cognitive load" of maternal worries may impact adherence to safe sleep practices and requires further investigation.

Investigating Mechanisms for Maternal Education Disparities in Enacting Health-Promoting Infant Care Practices

BACKGROUND

Although higher education and healthier practices are positively associated, the explanatory mechanisms for this association remain unclear. The purpose of this study was to better understand mechanisms underlying this association by examining maternal adherence to 2 health-promoting infant care practices: supine placement and breastfeeding.

METHODS

We analyzed nationally representative data from the Study of Attitudes and Factors Effecting Infant Care, which surveyed US mothers after infant birth and 2 months thereafter. Using the Theory of Planned Behavior as a framework, we used structural equation models to elucidate mediational pathways from maternal education to supine infant placement or any breastfeeding.

RESULTS

Data from 3297 mothers demonstrated 77.0% of infants usually were placed supine, and 57.8% received any breastfeeding. The overall direct effect of maternal educational level on supine placement and any breastfeeding was odds ratio (OR) 1.31 (95% confidence interval [CI] 1.11-1.54) and OR 2.82 (95% CI 2.35-3.37), respectively. In pathway analyses, the strongest associations with both supine position and breastfeeding were seen with positive attitudes (supine: aOR 18.96, 95% CI 9.00-39.92; breastfeeding: aOR 3.86, 95% CI 2.19-6.82) and positive social norms (supine: aOR 6.69, 95% CI 4.52-9.89; breastfeeding: aOR 5.17, 95% CI 4.28-6.23). Mothers with more education had higher odds of both positive attitudes and positive norms for the 2 practices.

CONCLUSIONS

The associations linking educational attainment with health practices are intricate, with multiple mediating pathways. Attitudes and social norms are powerful forces that mediate the association between maternal educational attainment and both infant supine positioning and breastfeeding, and may be important mediators for other health behaviors.

Burnout Among Beginning First-Year Students from Three Health Professional Training Programs

The study objective was to learn about burnout prevalence among beginning first-year students from three health professional programs-Advance Practice Registered Nursing (APRN), Medicine, and Physician Associate (PA) training. All first-year students were invited to anonymously complete a survey measuring burnout. Subscales for exhaustion and disengagement together accounted for burnout. Means and frequencies were derived for categorical variables (gender, program, and direct entry from college). Subscales were summarized with means and standard deviations. Analysis of variance and post hoc t-tests compared unadjusted differences in means. Based on results, multivariable linear regressions for total burnout and exhaustion examined associations for the independent variables. With a 97% response rate, 70% were female (the APRN program is predominantly female), and 32% began training directly after college. Female students had significantly higher average total burnout and exhaustion than males. APRN and PA students had significantly higher total burnout and exhaustion than MD students. There were no other significant associations. In multivariable linear regressions, APRN students had significantly higher, and PA students had not quite significantly higher, burnout and exhaustion compared with medical students, with no moderation by any other variables. Burnout among first-year students in all three programs was more prevalent than anticipated. Consistent with previous literature, the programs with students who experienced higher burnout used more competitive, multi-tiered grading systems and introduced clinical expectations earlier in training. The implication is that educational leaders should consider effects of competitive grading and early clinical exposure on burnout among beginning health professional students.

Factors Associated With Choice of Infant Sleep Location

OBJECTIVE

To assess the prevalence of and factors associated with actual recent practice and near-future intention for infant sleep location in a national sample.

METHODS

There were 3260 mothers from 32 US hospitals who responded to a survey at infant age 2 to 6 months regarding care practices, including usual and all infant sleep locations in the previous 2 weeks and intended location for the next 2 weeks. Mothers were categorized as (1) having practiced and/or intending to practice exclusive room-sharing without bed-sharing, (2) having practiced anything other than exclusive room-sharing but intending to practice exclusive room-sharing, (3) intending to have the infant sleep in another room; and (4) intending to practice bed-sharing all night or part of the night. Multivariable multinomial logistic regression examined associations between sleep-location category, demographics, feeding method, doctor advice, and theory of planned behavior domains (attitudes, social norms, and perceived control).

RESULTS

Fewer than half (45.4%) of the mothers practiced and also intended to practice room-sharing without bed-sharing, and 24.2% intended to practice some bed-sharing. Factors associated with intended bed-sharing included African American race and exclusive breastfeeding; however, the highest likelihood of bed-sharing intent was associated with perceived social norms favoring bed-sharing (adjusted odds ratio [aOR] 5.84; 95% confidence interval [CI] 4.14-8.22) and positive attitudes toward bed-sharing (aOR 190.1; 95% CI 62.4-579.0). Women with a doctor's advice to room-share without bed-sharing intended to practice bed-sharing less (aOR 0.56; 95% CI 0.36-0.85).

CONCLUSIONS

Sleep-location practices do not always align with the recommendation to room-share without bed-sharing, and intention does not always correspond with previous practice. Attitudes, perceived social norms, and doctor advice are factors that are amenable to change and should be considered in educational interventions.

Mothers' Perceptions of the Cardboard Box as a Potential Sleep Space

OBJECTIVE

Due to increasing popularity, our hospital began considering distributing cardboard boxes combined with safe sleep education to new mothers. As a first step in studying the impact of this intervention on bedsharing in our community, we sought to understand mothers' perceptions of the cardboard box.

METHODS

We recruited primarily low-income, English- or Spanish-speaking mothers of infants aged 2 to 16 weeks during routine primary care visits. Participants responding to a cross-sectional survey about infant sleep practices were invited to participate in in-depth interviews about the cardboard box. We used a grounded theory approach and the constant comparative method until saturation was reached.

RESULTS

Of 120 participants in the survey, 50 (42%) participated in the qualitative study. Participants were mothers of infants aged ≤4 weeks (46%), 4 to 8 weeks (32%), and 16 weeks (22%). Of 50 participants, 52% said they would use the cardboard box for their infant to sleep in, if provided, compared with 42% who said they would not and 6% were unsure. Three themes emerged from the data: (1) safety of the cardboard box; (2) appearance, and (3) variation in planned use. Some participants planned to place the cardboard box in their bed.

CONCLUSIONS

Participants in our study were divided about whether they would use the cardboard box for their infant to sleep in. If distributed, hospital staff should advise families to not place the cardboard box in their bed. Next steps include determining bedsharing frequency among parents who choose to use the cardboard box for their infant.

Postpartum Nurses' Experience Caring for Infants With Neonatal Abstinence Syndrome

OBJECTIVES

In previous years, otherwise healthy infants with neonatal abstinence syndrome (NAS) in our hospital were transferred to the NICU and frequently treated with medication. Currently, infants with NAS room-in with their mothers and rarely require medication. We sought to understand the lived experience of nurses on maternity and well-newborn units caring for infants with NAS.

METHODS

We conducted focus groups of registered nurses on postpartum units at 2 hospitals using qualitative methodology. Themes were identified through consensus, and the focus groups were stopped when no new themes were identified.

RESULTS

Seventeen postpartum nurses participated in 5 focus groups. The following major themes emerged: (1) managing the expectations of parents of newborns with NAS, (2) current NAS protocol (positive aspects of rooming-in and challenges with withdrawal scoring tool), (3) inconsistencies in care and communication, (4) perceived increase in nursing workload on the postpartum unit, and (5) nurses' emotional response to the care of infants with NAS.

CONCLUSIONS

We highlight the perspectives of nursing staff on the well-newborn unit who were previously unaccustomed to caring for infants with NAS. With increasing numbers of infants with NAS and longer stays on the well-newborn unit, hospitals must prepare to better support staff and implement protocols that offer consistency in practice.

Mediators of Improved Adherence to Infant Safe Sleep Using a Mobile Health Intervention

OBJECTIVES

To determine mediators of improvements in infant safe-sleep (SS) practices in a mobile health intervention.

METHODS

In a cluster-randomized controlled trial, mothers received SS intervention or breastfeeding control videos for 60 days. Maternal responses about infant sleep position and location (outcomes) and mediators (attitudes, perceived social norms, and perceived control) from the theory of planned behavior were assessed. Intervention effects on mediators and association between mediators and outcomes were examined.

RESULTS

Of 1600 recruited, 1263 mothers participated. Mothers receiving SS videos were more likely to have positive attitudes and norms for supine sleep (attitudes: adjusted odds ratio [aOR] = 2.35 [95% confidence interval (CI) 1.72 to 3.20]; norms: aOR = 1.75 [95% CI 1.27 to 2.42]) and recommended sleep location (attitudes: aOR = 1.91 [95% CI 1.54 to 2.36]; norms: aOR = 1.37 [95% CI 1.13 to 1.66]). Positive attitudes and norms toward supine sleep and room-sharing without bed-sharing were associated with higher odds of both practices (supine: aOR = 8.25 [95% CI 4.72 to 14.43] for positive attitudes and aOR = 6.67 [95% CI 4.25 to 10.46] for norms; room-sharing: aOR = 7.14 [95% CI 5.35 to 9.53] for positive attitudes and aOR = 4.44 [95% CI 3.03 to 6.51] for norms). Both positive attitudes and positive norms mediated the effect of the intervention.

CONCLUSIONS

The intervention achieved success in improving adherence to SS recommendations by changing maternal attitudes and norms about supine sleeping and room-sharing without bed-sharing. Recognition that these attitudes and norms appear to be the main drivers of mothers' choices regarding infant-sleep practices should inform health messaging strategies to promote SS.

Refusal of Vitamin K by Parents of Newborns: A Qualitative Study

OBJECTIVE

Despite American Academy of Pediatrics recommendations, some parents refuse intramuscular (IM) vitamin K as prophylaxis against vitamin K deficiency bleeding for their newborns. The purpose of our study was to describe attitudes and perceptions of parents who choose to defer IM vitamin K for their newborns.

METHODS

Using qualitative methodology, we conducted in-depth semi-structured interviews with parents of newborns in 3 hospitals in Connecticut and California. We used the grounded theory approach and the constant comparative method until saturation was reached.

RESULTS

Nineteen participants (17 mothers and 2 fathers) of 17 newborns were interviewed; 14 newborns did not receive IM vitamin K due to refusal by the parents, and for 3 newborns IM vitamin K administration was delayed due to initial hesitation by the parents. Four major themes emerged: 1) risk-to-benefit ratio, where parents refused IM vitamin K due to a perceived risk to their newborn from preservatives, for example; 2) "natural" approaches, which led to seeking oral vitamin K or increasing the mother's own prenatal dietary vitamin K intake; 3) placement of trust and mistrust, which involved mistrust of the medical and pharmaceutical community with overlapping concerns about vaccines and trust of self, like-minded allopathic and non-allopathic health care providers, the social circle, the internet, and social media; and 4) informed by experiences, reflecting hospital experiences with prior pregnancies and communication with health care providers.

CONCLUSIONS

Parents' perception of risk, preference for alternative options, trust, and communication with health care providers were pivotal factors when making decisions about IM vitamin K.

Factors Associated With Refusal of Intramuscular Vitamin K in Normal Newborns

BACKGROUND AND OBJECTIVE

Refusal of intramuscular (IM) vitamin K administration by parents is an emerging problem. Our objective was to assess the frequency of and factors associated with refusal of IM vitamin K administration in well newborns in the United States.

METHODS

We determined the number of newborns admitted to well newborn units whose parents refused IM vitamin K administration in the Better Outcomes through Research for Newborns network and, in a nested patient-control study, identified factors associated with refusal of IM vitamin K administration by using a multiple logistic regression model.

RESULTS

Of 102 878 newborns from 35 Better Outcomes through Research for Newborns sites, parents of 638 (0.6%) refused IM vitamin K administration. Frequency of refusal at individual sites varied from 0% to 2.3%. Exclusive breastfeeding (adjusted odds ratio [aOR] = 3.4; 95% confidence interval [CI]: 2.1-5.5), non-Hispanic white race and/or ethnicity (aOR = 1.7; 95% CI: 1.2-2.4), female sex (aOR = 1.6; 95% CI: 1.2-2.3), gestational age (aOR = 1.2; 95% CI: 1.1-1.4), and mother's age (aOR = 1.05; 95% CI: 1.02-1.08) were significantly associated with refusal of IM vitamin K administration. Refusal of the administration of both ocular prophylaxis and hepatitis B vaccine was also strongly associated with refusal of IM vitamin K administration (aOR = 88.7; 95% CI: 50.4-151.9).

CONCLUSIONS

Refusal of IM vitamin K by parents of newborns is a significant problem. Interventions to minimize risks to these newborns are needed.

Refusal of Vitamin K by Parents of Newborns: A Survey of the Better Outcomes Through Research for Newborns Network

OBJECTIVE

To survey newborn clinicians in the United States regarding the frequency of intramuscular (IM) vitamin K refusal by a parent, reasons for refusal, and approaches of clinicians to refusals.

METHODS

An electronic survey was administered to the clinician site representative (nursery director or designee knowledgeable about site-specific nursery policies) at all newborn nurseries in the Better Outcomes through Research for Newborns (BORN) network of newborn nurseries.

RESULTS

Of 92 BORN sites, 85 (92%) respondents completed the survey. Frequency of IM vitamin K refusal during the past 5 years was reported as increased by 52% of respondents, unchanged by 42%, and 6% did not know. Reported frequencies of refusal of IM vitamin K was weekly (9%), a few times a month (31%), once a month (13%), once every 3 to 4 months (20%), once or twice a year (26%), or never (1%). The overall distribution of the reported frequencies of refusal differed among regions in the United States (higher in the West and the South; P < .05). Reported reasons for refusal by parents included perceptions of parents that the injection was unnecessary, lack of knowledge about vitamin K deficiency bleeding, and concern about preservatives. Approaches to refusal included attempts to educate parents, enlisting support from community clinicians, a state mandate, and prescription of oral vitamin K.

CONCLUSIONS

Respondents from a national sample of newborn nursery clinicians reported an increase in refusal of IM vitamin K in the past 5 years with regional variation. Approaches to refusals need further investigation to determine effectiveness.

Evaluation of a Screening Program to Detect Critical Congenital Heart Defects in Newborns

OBJECTIVES

To report the results of and to identify problems with implementing a screening program to detect critical congenital heart defects (CCHDs) in newborns by using differential pulse oximetry (POx).

METHODS

Charts of all live-born infants from 4 Yale-New Haven health system hospitals in Connecticut between January 1 and December 31, 2014, were reviewed.

RESULTS

Of 10 589 newborns, 171 (1.6%) underwent an echocardiogram before screening, 10 320 (97.5%) were screened by POx, and 98 (0.9%) were not screened. Thirteen newborns (0.1%) were diagnosed with a CCHD. No infants with CCHDs were identified through POx screening (POxS) alone. Eleven (85%) were already suspected of having a CCHD lesion on the basis of prenatal ultrasound, 1 (8%) was diagnosed because of clinical concern before undergoing screening, and 1 (8%) had a false-negative screening result, but a CCHD was identified after an echocardiogram was performed because a murmur was heard. Four infants with a positive POx screen showed noncritical cardiac lesions by echocardiogram. The majority of infants were screened within the recommended 24 to 72 hours of age interval and had POx screens that were interpreted and documented correctly. Of 10 316 infants with negative POx screens, 52.1% were still in the Yale-New Haven Hospital health system at 1 year of age and no CCHD lesions were listed in their charts.

CONCLUSIONS

Although a CCHD screening program was effectively implemented, perhaps because most children with a CCHD (85%) were detected antenatally by ultrasound, in our hospital system POxS did not lead to a substantial increase in the early identification of CCHDs.

Qualitative analysis of mothers' decision-making about vaccines for infants: the importance of trust

BACKGROUND

The high visibility of controversies regarding vaccination makes it increasingly important to understand how parents decide whether to vaccinate their infants.

OBJECTIVE

The purpose of this research was to investigate decision-making about vaccinations for infants.

DESIGN

We conducted qualitative, open-ended interviews.

PARTICIPANTS

Subjects included mothers 1 to 3 days postpartum and again at 3 to 6 months.

RESULTS

We addressed 3 topics: attitudes to vaccination, knowledge about vaccination, and decision-making. Mothers who intended to have their infants vaccinated ("vaccinators," n = 25) either agreed with or did not question vaccination or they accepted vaccination but had significant concerns. Mothers who did not intend to vaccinate ("nonvaccinators," n = 8) either completely rejected vaccination or they purposely delayed vaccinating/chose only some vaccines. Knowledge about which vaccines are recommended for children was poor among both vaccinators and nonvaccinators. The theme of trust in the medical profession was the central concept that underpinned all of the themes about decision-making. Promoters of vaccination included trusting the pediatrician, feeling satisfied by the pediatrician's discussion about vaccines, not wanting to diverge from the cultural norm, and wanting to adhere to the social contact. Inhibitors included feeling alienated by or unable to trust the pediatrician, having a trusting relationship with an influential homeopath/naturopath or other person who did not believe in vaccinating, worry about permanent side effects, beliefs that vaccine-preventable diseases are not serious, and feeling that since other children are vaccinated their child is not at risk.

CONCLUSION

Trust or lack of trust and a relationship with a pediatrician or another influential person were pivotal for decision-making of new mothers about vaccinating their children. Attempts to work with mothers who are concerned about vaccinating their infants should focus not only on providing facts about vaccines but also on developing trusting and positive relationships.

Differential diagnosis and management of anemia in the newborn

Neonatal anemia is a condition with a diverse etiologic spectrum.Therefore, in order to form a focused differential diagnosis, it is important for the caregiver to have some knowledge of the more common causes of low hemoglobin and hematocrit concentrations in the neonate. Proper history taking, physical examination, and interpretation of diagnostic tests can narrow this focus and aid in establishing an accurate diagnosis and in directing the appropriate therapeutic interventions.

Regional brain volumes and their later neurodevelopmental correlates in term and preterm infants

OBJECTIVE

To compare regional brain volumes measured in term and preterm infants, and to correlate regional volumes with measures of neurodevelopmental outcome.

METHODS

High-contrast, high-resolution magnetic resonance imaging scans were acquired in 10 preterm and 14 term infants who were scanned near term. The cerebrum was segmented into cortical gray matter, white matter, cerebral ventricles, subcortical gray matter, cerebellum, and brainstem. The cortical gray matter, white matter, and ventricles were further divided into specific anatomic subregions, and the volumes were compared across groups. Measures of cognitive and motor development were acquired between 18 and 20 months of corrected age. Correlations of regional brain volumes with developmental outcome were assessed in the preterm group.

RESULTS

Volumes in preterm infants were reduced in parieto-occipital gray matter and increased in the midbody, occipital horn, and temporal horns of the lateral ventricles. Gray matter volumes were also less prominently reduced in the sensorimotor and inferior occipital cortices. Normal lateralization of white matter volumes were altered in the parieto-occipital region in the preterm infants, who had significantly larger left-sided and smaller right-sided structures. White matter volumes in the sensorimotor and midtemporal regions correlated strongly with measures of neurodevelopmental outcome.

CONCLUSIONS

These findings of reduced volumes in sensorimotor and parieto-occipital regions in preterm infants, and the prospective correlations of regional volumes with cognitive outcome, confirm and extend findings previously reported in a cross-sectional study of 8-year-old prematurely born children. The data suggest that regional brain volumes near term are a promising marker for predicting disturbances of cognitive outcome in preterm infants. Further prospective, longitudinal studies of neonatal brain volumes and developmental indices into later childhood are required to confirm the utility of regional brain volumes as predictors of longer term outcome.