The impact of chorioamnionitis on neurodevelopmental outcomes at 3, 8 and 18 years in low-birthweight preterm infants

OBJECTIVE

To assess the long-term cognitive, behavioral and academic status of preterm children exposed to clinical chorioamnionitis.

STUDY DESIGN

In total, 985 infants (<37 weeks and 2500 g at birth) were recruited in a multisite interventional research program. Of these, 43 case-infants were identified based on documented diagnosis of maternal clinical chorioamnionitis. Infants with chorioamnionitis were compared with the remainder of the cohort after controlling for maternal and infant variables. All infants underwent cognitive, behavioral and academic achievement assessments at 3, 8 and 18 years. Standardized cognitive and academic achievement scores were cutoff at 2 s.d.'s below the mean, behavioral scores were cutoff at a T-score >70 and examined with χ(2) statistics. Mean scores were evaluated using preliminary bivariate analysis and were followed by multiple regression models predicting child outcomes.

RESULT

Overall, children with chorioamnionitis did not have lower scores on any assessment at any age. Children without chorioamnionitis performed significantly lower at 8 years on the Woodcock-Johnson reading subscore and the mean score of the Peabody Picture Vocabulary Test (PPVT). No significant difference persisted to 18-year follow-up. In logistic regression, chorioamnionitis independently predicted higher PPVT scores at 8 years, but not lower performance scores on the Woodcock-Johnson reading subscore.

CONCLUSION

Clinical chorioamnionitis was not associated with adverse neurodevelopmental outcomes in this group of preterm infants <37 weeks and 2500 g.

Perceptions of community nutrition and health needs in the Lower Mississippi Delta: a key informant approach

OBJECTIVE

Key informants' perceptions of nutrition and health needs in their southern rural communities were assessed prior to nutrition intervention planning.

DESIGN

This cross-sectional survey used in-person interviews.

SUBJECTS/SETTINGS

A sample of 490 individuals from 12 professional and lay roles in 8 community sectors in 36 counties in Arkansas, Louisiana, and Mississippi was chosen.

STATISTICAL ANALYSES PERFORMED

Factor analysis was carried out on reported food, nutrition, and health problems and contributing factors. The General Linear Models procedure identified within- and between-subject effects for factors. Tukey's post hoc tests identified differences between sectors and states. Frequencies and weighted rankings were computed for health problems.

RESULTS

Key informants rated individual-level factors (food choices, education, willingness to change, health behavior) as more important than community-level factors (food and health care access, resources) with regard to nutrition and health problems and contributors to problems. The number one health problem was hypertension.

IMPLICATIONS

Key informants are knowledgeable about nutrition and health problems, contributing factors, and available resources. Individual factors were perceived as more important contributors to nutrition and health problems providing valuable information for planning nutrition interventions.

An event-related potential study of older children with an early history of failure to thrive

Elementary and junior high school children (n = 13), who were diagnosed with nonorganic failure to thrive (FTT) as infants and toddlers, were compared with a normal control group (n = 14) on visual event-related potentials (ERPs) elicited during a primed lexical decision task. Positive stimuli were real words that were identical to the priming stimuli; negative stimuli were nonpronounceable letter strings. Although the groups did not differ in word-list reading level, the former FTT group had slower reaction (decision) times and did not show ERP evidence of priming in the N400 epoch. Anterior sites yielded better separation of the real words and letter strings than posterior sites. A late anterior component between 500 msec to 650 msec poststimulus onset showed the largest condition effect for both groups. The control group had a larger negative going late anterior component to words than the FTT group. The combined reaction time and ERP findings point to less automatized word recognition in the FTT group.

Children in food-insufficient, low-income families: prevalence, health, and nutrition status

OBJECTIVE

To examine characteristics of US children living in food-insufficient households and to compare food and nutrient intakes, physical inactivity, and overweight and underweight status of children in food-insufficient households with those in food-sufficient households.

DESIGN

Cross-sectional, nationally representative sample of children and households from the Continuing Survey of Food Intakes by Individuals, from 1994 to 1996.

PARTICIPANTS

A group of 3790 households, including 5669 children (ages 0-17 years).

MAIN OUTCOME MEASURE(S)

Estimates of food insufficiency for children were based on the reported adequacy of their households, described as "often don't have enough to eat" or "sometimes don't have enough to eat." Nutrient consumption was based on two 24-hour dietary recalls from in-person interviews.

RESULTS

Three percent of all households with children, and 7.5% of low-income families with children experienced food insufficiency. Several demographic and characteristic differences were observed between the food-sufficient and food-insufficient low-income groups. Children of low-income families, either food-sufficient or food-insufficient, had similar macronutrient and micronutrient intake, reported exercise, television watching, and percentage of overweight and underweight. When compared with the higher-income food-sufficient households, children in the low-income food-insufficient households consumed fewer calories (P =.05) and total carbohydrates (P =.004), but had a higher cholesterol intake (P =.02). The low-income food-insufficient group included more overweight children (P =.04), consumed less fruits (P =.04), and spent more time watching television (P =.02).

CONCLUSIONS

While not different from low-income families who do not report food insufficiency, low-income families with food insufficiency had children who differed from high-income families in several nutrition and anthropometric measures. Clinicians should be aware of the possible effects of poverty and lack of access to food on child health and nutrition status. The long-term effects of these are not yet known.

Validity of a telephone-administered 24-hour dietary recall in telephone and non-telephone households in the rural Lower Mississippi Delta region

OBJECTIVE

To determine if 24-hour dietary recall data are influenced by whether data are collected by telephone or face-to-face interviews in telephone and non-telephone households.

DESIGN

Dual sampling frame of telephone and non-telephone households. In telephone households, participants completed a 24-hour dietary recall either by face-to-face interview or telephone interview. In non-telephone households, participants completed a 24-hour dietary recall either by face-to-face interview or by using a cellular telephone provided by a field interviewer.

SUBJECTS/SETTING

Four hundred nine participants from the rural Delta region of Arkansas, Louisiana, and Mississippi.

MAIN OUTCOME MEASURES

Mean energy and protein intakes.

STATISTICAL ANALYSES PERFORMED

Comparison of telephone and non-telephone households, controlling for type of interview, and comparison of telephone and face-to-face interviews in each household type using unpaired t tests and linear regression, adjusting for gender, age, and body mass index.

RESULTS

Mean differences between telephone and face-to-face interviews for telephone households were -171 kcal (P = 0.1) and -6.9 g protein (P = 0.2), and for non-telephone households -143 kcal (P = 0.6) and 0.4 g protein (P = 1.0). Mean differences between telephone and non-telephone households for telephone interviews were 0 kcal (P = 1.0) and -0.9 g protein (P = 0.9), and for face-to-face interviews 28 kcal (P = 0.9) and 6.4 g protein (P = 0.5). Findings persisted when adjusted for gender, age, and body mass index. No statistically significant differences were detected for mean energy or protein intake between telephone and face-to-face interviews or between telephone and non-telephone households.

APPLICATIONS/CONCLUSIONS

These data provide support that telephone surveys adequately describe energy and protein intakes for a rural, low-income population.

Behavioral and cognitive status in school-aged children with a history of failure to thrive during early childhood

Twenty-seven school children (aged 8-12 years) earlier diagnosed with nonorganic failure to thrive (FTT) were compared with a normal socioeconomically matched control group (N=17) on current height and weight parameters as well as cognitive, achievement, and behavioral measures from the Child Behavior Checklist (CBCL). The former FTT children were, on average, smaller, less cognitively able, and more behaviorally disturbed than the control children and national normative samples. Sixty percent of former FTT children were below the 20th percentile in height and 48% were below the 20th percentile in weight; 52% had IQs below 80 and 30% had reading standard scores below 80; 48% had clinically adverse attention ratings and 30% had clinically adverse aggression ratings on the CBCL. Within the FTT sample, however, there were no significant associations between current growth measures and cognitive/achievement outcome measures. Mothers' IQs provided the strongest prediction of the FTT children's reading scores. The mothers of the FTT children had not achieved as high levels of education as the mothers of the control children, and more of them were single parents. Early growth problems put children at high risk for multiple adverse sequelae in middle childhood, especially if mothers are poorly educated. Careful ongoing follow-up of such children by pediatricians is encouraged.

An electrophysiological study of school-aged children with a history of failure to thrive during infancy

Sixty-five subjects, ages 8 to 12, participated in a visual electrophysiological study. Twenty-two of the subjects had received a diagnosis of nonorganic failure-to-thrive (FTT) before the age of three. The remaining 43 subjects had no history of FTT and served as Controls. IQs were obtained with the abbreviated WISC-III, and the Controls were split into two groups, LO IQ and HI IQ, to provide a LO IQ Control group with an average IQ equivalent to the FTT group. Event-related brain potentials (ERPs) were recorded from five scalp locations during a cued continuous performance task (CPT). Subjects had to press a button every time they saw the letter "X" following the letter "A" (50 targets out of 400 stimuli). During the CPT, the FTT subjects made marginally more errors of omission to targets than the LO IQ Control group and significantly more errors of omission than the HI IQ Control subjects. The groups did not differ significantly on errors of commission (false alarms) or reaction times to targets. ERP averages revealed a group difference in amplitude in a late slow wave for the 50 non-X stimuli (false targets) that followed the letter A. This difference was greatest over frontal sites, where the FTT group had a more negative going slow wave than each control group. Late frontal negativity to No Go stimuli has been linked with post-decisional processing, notably in young children. Thus, the FTT subjects may have less efficient inhibitory processes, reflected by additional late frontal activation.

The use of telephone interview methodology to obtain 24-hour dietary recalls

OBJECTIVE

To compare 24-hour dietary recalls collected over the telephone to in-person recalls collected in the 1994-1996 Continuing Survey of Food Intakes by Individuals (CSFII).

DESIGN

Trained interviewers collected 24-hour dietary recalls over the telephone using the multiple-pass approach. These results were compared to in-person interviews from a pooled subsample of CSFII respondents.

SUBJECTS/SETTING

List-assisted random-digit dialing was used to identify 700 women between the ages of 20 and 49 years. One eligible woman per household was selected to participate.

STATISTICAL ANALYSES

Approximate t tests to examine differences in average nutrient and energy intakes were conducted on weighted data.

RESULTS

The reported intakes of most nutrients in the current 24-hour dietary recalls collected over the telephone were significantly higher than those reported in the 1994 and 1995 CSFII, but there were no significant differences between the telephone survey and 1996 CSFII results. The 24-hour dietary recalls collected over the telephone yielded consistently greater mean nutrient intake per respondent compared with a comparable pooled subsample from the 1994, 1995, and 1996 CSFII. Generally, no significant differences were found in the food group data between the telephone survey and the CSFII survey. Mean dietary intakes reported by the comparable CSFII subsample increased from 1994 to 1996.

APPLICATIONS

Collecting 24-hour dietary recalls over the telephone is a practical and valid data collection tool for use in national food consumption surveys.

Operant test battery performance in children: correlation with IQ

The relationship between intelligence and money-(nickel-)reinforced operant behaviors were compared in 115 six year old children. The Operant Test Battery (OTB) consists of tasks thought to engender responses dependent upon specific brain functions that include motivation, color and position discrimination, learning, short-term memory, and time estimation. OTB endpoints were compared with Full Scale, Verbal and Performance IQ scores. Highly significant correlations were noted between several OTB measures (e.g., color and position discrimination accuracy) and IQ scores, but not in others (e.g., motivation task response rate). The results demonstrate the relevance of these measures as metrics of important brain functions. Additionally, since laboratory animals can readily perform these same tasks, these kinds of behaviors in laboratory animals should be useful in studying the effects of neuroactive/neurotoxic compounds on aspects of cognitive function in animals and in predicting adverse effects of such agents on related brain functions in humans.

Growth in weight, recumbent length, and head circumference for preterm low-birthweight infants during the first three years of life using gestation-adjusted ages

Data from 867 preterm low-birthweight participants in the Infant Health and Development Program (IHDP) were used to develop reference data for growth status at an age and for increments from term to 36 month gestation-adjusted age (GAA). Weight, length and head circumference were recorded at 4 month intervals in the first year and at 6 month intervals in the second and third years. Selected percentiles for values at an age (status values) and increments for age intervals are presented in graphs separately for VLBW infants (< or = 1500 g at birth) and for LBW infants (1501-2500 g at birth). Percentiles of weight increments are presented beginning shortly before term for 1 month intervals to 6 month GAA, for 2 month intervals to 12 month GAA, and for 3-month intervals to 36 month GAA. Percentiles for length and head circumference increments are presented from term to 6 months for 2-month intervals, and to 36 month GAA for 3 month intervals. Among LBW infants, boys, had larger status and increment values than girls (P < 0.05), but there were no significant sex-associated differences in VLBW infants for status or increments. The mean status values and increments in weight and head circumference of the LBW infants were larger than those of VLBW infants, but the differences in length were not significant.

Results at age 8 years of early intervention for low-birth-weight premature infants. The Infant Health and Development Program

OBJECTIVE

To reevaluate at age 8 years children who had participated during the first 3 years of life in a randomized clinical trial of special services for low-birthweight (LBW) premature infants.

DESIGN

Follow-up of a randomized controlled trial of premature infants (< or = 37 weeks' gestation), stratified by 2 LBW groups (lighter [< or = 2000 g] and heavier [2001-2500 g]) and divided into intervention (n=377) and follow-up only (n=608) groups.

SETTING

Eight sites serving diverse populations.

PARTICIPANTS

At age 8 years, 874 children were assessed: 336 in the intervention group and 538 in the follow-up only group.

INTERVENTION

The 3-year intervention consisted of home visits (birth to 3 years), child development center services (ages 1 to 3 years), and parent group meetings (ages 1 to 3 years).

PRIMARY OUTCOME MEASURES

Cognitive functioning (Weschler Intelligence Scale for Children-III; Peabody Picture Vocabulary Test-Revised); academic achievement (Woodcock-Johnson Tests of Achievement-Revised); and parental reports of school performance, behavior (Child Behavior Checklist), and health (Child General Health Survey).

RESULTS

At age 8 years, in the entire cohort and in the lighter LBW stratum, the intervention and follow-up only groups were similar on all primary outcome measures. Differences favoring the intervention group were found within the heavier LBW group: full-scale IQ score (4.4 points higher, P=.007), verbal IQ score (4.2 points higher, P=.01), performance IQ score (3.9 points higher, P=.02), mathematics achievement score (4.8 points higher, P=.04), and receptive vocabulary score (6.7 points higher, P=.001). On a physical functioning subscale, the whole intervention group received less favorable ratings, while the lighter LBW intervention group had lower maternal ratings assessing social limitations caused by behavior.

CONCLUSION

Although at age 8 years there were modest intervention-related differences in the cognitive and academic skills of heavier LBW premature children, attenuation of the large favorable effects seen at 3 years was observed in both the heavier and lighter LBW groups. This indicates a need to develop additional intervention strategies for LBW premature children that can provide sustained benefits.

Reference data for head circumference-for-length in preterm low-birth-weight infants

OBJECTIVE

To provide reference data for head circumference-for-length in preterm low-birth-weight infants that are independent of age, but extend for the ranges of head circumference (34-49 cm) and length (52.0-102.9 cm) values found from birth to 36 months of gestation-adjusted age.

DESIGN

Measurements were made at 9 ages in 867 preterm infants in the Infant Health Development Program, a randomized clinical trial that included various ethnic groups at 8 sites. At birth, two thirds of the infants weighed less than 2000 g, and one third weighed between 2000 and 2500 g. Measurements were taken at birth, at 40 weeks of postconceptional age, and at 4, 8, 12, 18, 24, 30, and 36 months of gestation-adjusted age. A model fitted to the serial data for each infant was used to estimate head circumference and length from 36 weeks after conception to 36 months of gestation-adjusted age.

RESULTS

Tables and charts of means and SDs and selected percentiles for each sex were made. These tables and charts are for very low (< or = 1500 g) and low-birth-weight (1501-2500 g) infants by 3-cm intervals of length.

CONCLUSION

These tables and charts should assist clinicians in evaluating and monitoring head circumference in preterm low-birth-weight infants by taking body length into account.

Weight-for-length reference data for preterm, low-birth-weight infants

OBJECTIVE

To provide weight-for-length reference data for preterm, very-low-birth-weight and low-birth-weight infants.

DESIGN

Data from 867 infants (428 boys and 439 girls) in the Infant Health and Development Program, who each were preterm and who had a low birth weight, were used to develop weight-for-length reference data. The Infant Health and Development Program is a national, randomized, clinical trial that included various ethnic groups at 8 sites. At each site, sampling ensured that two thirds of the infants in the study weighed 2000 g or less and that one third of the infants weighed from 2001 to 2500 g at birth. Infants were examined at birth, at 40 weeks' postconception, and at 4, 8, 12, 18, 24, 30, and 36 months' gestation-adjusted age. Gestation-adjusted age was used instead of chronological age from birth to correct for the degree of prematurity.

RESULTS

Weight-for-length percentiles are given for lengths at 3-cm intervals ranging from 48 to 100 cm. These percentiles are sex specific and are for a very-low-birth-weight group (< or = 1500 g) and a low-birth-weight group (1501-2500 g).

CONCLUSIONS

These data should assist screening for deviations from normal growth and may aid in the early detection of failure to thrive and excessive weight gain in infancy.

Home environment and adaptive social behavior among premature, low birth weight children: alternative models of environmental action

Used data from 465 premature, low birth weight children representing three major sociocultural groups (Caucasian, African American, Hispanic) to examine the relation between children's home environments and their adaptive social behavior. Results showed low to moderate associations between scores on the HOME Inventory at 1 and 3 years and scores on two measures of adaptive social behavior at 30 to 36 months, the Adaptive Social Behavior Inventory, and observations of mother-child interaction in a structured laboratory situation. Results indicated that responsive, nurturant care at both 1 and 3 years are related to child adaptive social behavior, as are cognitively stimulating experiences and materials. However, canonical correlational analysis indicated that only Acceptance and Variety of Experience, measured at age 3, and Variety of Experience measured at age 1 accounted for independent amounts of variance in adaptive social behavior as perceived by mothers. Also, only sociocultural group status and Learning Materials at 36 months contributed to the prediction of persistence and enthusiasm as observed in the laboratory setting.

Early intervention in low-birth-weight premature infants. Results through age 5 years from the Infant Health and Development Program

OBJECTIVE

To evaluate the persistence of effects on health and development at age 5 years of the Infant Health and Development Program, an early childhood intervention that was provided to low-birth-weight (LBW) premature infants from neonatal discharge through age 3 years.

DESIGN

Randomized, controlled, multicenter trial, stratified by two LBW groups: lighter (< or = 2000 g) and heavier (2001 to 2500 g).

SETTING

Eight socioeconomically heterogeneous clinical sites.

PARTICIPANTS

Of 985 eligible infants weighing 2500 g or less and at 37 weeks' or less gestational age, 377 infants were randomly assigned to the intervention group and 608 to the follow-up only group. About two thirds of the infants in each group were in the lighter LBW stratum, and one third were in the heavier LBW stratum.

INTERVENTION

The intervention group received home visits (from neonatal discharge through age 3 years) as well as center-based schooling (from 1 to 3 years of age). Children in both groups received pediatric surveillance.

MAIN OUTCOME MEASURES

Cognitive development, behavioral competence, and health status.

RESULTS

At age 5 years, the intervention group had full-scale IQ scores similar to children in the follow-up only group. However, in the heavier LBW stratum, children in the intervention group had higher full-scale IQ scores (3.7 points higher; P = .03) and higher verbal IQ scores (4.2 points higher; P = .02). No significant differences between intervention and follow-up only groups in cognitive measures at age 5 years were noted in the lighter LBW infants. The intervention and follow-up groups were similar in behavior and health measures regardless of LBW stratum.

CONCLUSION

The early childhood intervention provided in the first 3 years of life had effects on heavier LBW premature infants' IQ and verbal performance at age 5 years that were not observed for lighter LBW premature infants. The intervention did not affect health or behavior at age 5 years in either LBW stratum.

A multifaceted intervention for infants with failure to thrive. A prospective study

OBJECTIVE

To determine whether a multifaceted intervention decreased the incidence of failure to thrive (FTT) in a group of preterm infants with low birth weights and improved the 3-year intelligence, health, growth, and behavior status of the children with FTT.

DESIGN

Three-year, prospective, randomized, clinical trial.

SETTING

Eight large university hospital sites throughout the United States.

SAMPLE

Nine hundred fourteen preterm infants with low birth weights who were born at the sites and met study criteria.

INTERVENTION

Home visits weekly during the first year of life and biweekly thereafter until the age of 3 years to provide family support and implement two curricula; and attendance at a child development center from 12 months until 3 years of age, 5 days a week, to deliver an early childhood educational intervention.

RESULTS

The incidence of FTT did not differ between the treatment and control groups (20% vs 22%). Overall, children with FTT in the treatment group were not different from children with FTT in the follow-up group on any of the outcome variables. However, after controlling for other factors, treatment group membership significantly contributed to the prediction model of 36-month IQ (P = .005) for the children with FTT. In addition, children with FTT in the intervention group with higher compliance demonstrated higher 3-year IQ and better behavior scores than the children with FTT in the low-compliance group.

CONCLUSIONS

The intervention did not change the incidence of FTT or the 3-year outcomes in this low-birth-weight, preterm cohort. After controlling for multiple independent variables, marked effects on 3-year IQ were noted. In addition, these beneficial effects were most pronounced in families that were most complaint with the intervention.

A reexamination of the association between HOME scores and income

This study, which represents another look at the relationship between the HOME Inventory and income, uses data from the Infant Health and Development Program (IHDP), a multisite, longitudinal study of low-birth-weight preterm infants. Two versions of the HOME Inventory were used: The Infant/Toddler (IT-HOME), at 12 months of age, and the Early Childhood (EC-HOME), at 36 months of age. Predictor variables were income, ethnicity, maternal education, parity, gestational age, marital status, maternal age, and site. HOME scores were positively correlated with income. However, after controlling for the other variables in the models, the portion of the variance in HOME scores uniquely explained by income was quite low (IT-HOME, 5.1%; EC-HOME, 4.2%). Finally, the relationship between HOME scores and four child characteristics (cognitive development, growth, maladaptive behavior, and social competence) measured when the child was 36 months old were investigated using correlation. The results indicated that the quality of the home environment, as measured by the HOME Inventory, is related to children's development.

A factor analytic study of the infant-toddler and early childhood versions of the HOME Inventory administered to white, black, and Hispanic american parents of children born preterm

Factor analyses were performed on the Infant-Toddler and the Early Childhood versions of the HOME Inventory for 3 groups (blacks, whites, and Hispanics) of premature, low-birthweight children. Participants lived in 8 different U.S. cities. On the IT-HOME, 5 factors were originally retained for each group using the principal factors method of extraction. Factor structures for blacks and whites were similar, accounting for 85% and 75% of the variance, respectively. The structure for Hispanics was somewhat different; a 7-factor solution accounting for 65% of the variance was most interpretable. For the EC-HOME, 6 factors were retained for both black and white groups, accounting for 80% and 73% of the variance, respectively. For Hispanics, an 8-factor solution accounted for 59% of the variance. The factor structures for blacks and whites were largely in agreement with the current organization of items into subscales. The fit for Hispanics was not quite as good, but most factors also corresponded to current subscales.

Early indications of resilience and their relation to experiences in the home environments of low birthweight, premature children living in poverty

The caregiving environment experienced by 243 premature, low birthweight (LBW) children living in poverty was examined to determine whether the quality of care such children receive affords them some measure of protection from the generally deleterious consequences of poverty and prematurity. Only 26 children were identified as functioning in the normal range for cognitive, social/adaptive, health, and growth parameters at age 3. These children, who showed early signs of resiliency, differed from nonresilient children in that they were receiving more responsive, accepting, stimulating, and organized care. They were also living in safer, less crowded homes. 6 "protective" aspects of caregiving were identified and used as part of a cumulative protection index. Children with less than 3 protective aspects of caregiving present at age 1 had only a 2% probability of being resilient, and only a 6% probability if fewer than 3 were present at age 3. Overall, premature LBW children born into conditions of poverty have a very poor prognosis of functioning within normal ranges across all the dimensions of health and development assessed. However, those raised in a setting with 3 or more protective factors were more likely to show early signs of resiliency.

Pediatric clinical assessment of mother-child interaction: concurrent and predictive validity

This study examines whether clinical assessments of mother-infant interactions collected at 8-month health supervision visits are associated with standardized measures of the home environment and mother-child interaction collected at later dates in other settings, and whether these clinical assessments are associated with the child's future developmental and behavioral status. The observation component of the Pediatric Review of Children's Environmental Support and Stimulation (PROCESS) was collected on 46 consecutive mother-infant pairs during an 8-month health supervision visit. The Home Observation Measurement of Environment (HOME) Inventory was collected on these infants' families at 12 and 36 months of age, and mother-child interaction was assessed in a laboratory setting at 30 months. The Bayley Scales of Infant Development were collected at 12 and 24 months, and the Stanford Binet Intelligence Test and the Achenbach Child Behavior Checklist were collected at 36 months of age. The 8-month clinical ratings were strongly associated with the measures of the home environment and mother-child interaction and with child developmental and behavioral problem status at 36 months. These findings attest to the power and usefulness of systematic observations of maternal behavior by the clinician during health supervision visits.

Identifying at-risk children for early intervention services: lessons from the Infant Health and Development Program

A U.S. law mandates early intervention services for infants and young children who have, or are at risk for, developmental problems. Participating states must develop definitions for identifying infants and young children at risk for developmental problems. To assess the sensitivity, specificity, and positive predictive value of some commonly identified risk factors, we examined the definitions proposed by five states. Data on risk factors and 36-month developmental outcomes were obtained from follow-up participants in the Infant Health and Development Program, a multisite, collaborative prospective intervention program involving 985 low birth weight preterm infants. Few individual risk factors proposed by these states were associated with poor developmental outcomes. Characteristics with positive predictive values greater than 30% were highly specific but tended to involve few cases. Risk factors with positive predictive values greater than 50%, such as hypothyroidism, occurred infrequently (< 6%) in this sample. When state definitions for at-risk children were examined in composite, each definition yielded a positive predictive value of 25% to 35%, with poor specificities ranging from 12% to 40%. These data on low birth weight infants have implications for the design and funding of population-based early intervention programs, and suggest that more careful clinical and longitudinal research is necessary before appropriate definitions can be promulgated for identifying children in need of early intervention services.

Risk factors and outcomes for failure to thrive in low birth weight preterm infants

OBJECTIVE

To determine the epidemiology, clinical characteristics, and outcomes for low birth weight (LBW) infants with growth deficiency, or failure to thrive (FTT, the term commonly used by pediatric providers to describe growth deficiency or faltering in early childhood).

DESIGN

Three-year prospective cohort study with matched case-control study of outcomes.

SETTING

Eight large university hospital sites throughout the United States.

SAMPLE

914 LBW infants inborn at the sites and meeting study criteria.

RESULTS

FTT was a common condition in this cohort, with 180 (19.7%) of 914 LBW infants meeting case criteria by 30 months. New cases of FTT peaked at 8 months gestation-corrected age. In addition to expected differences in growth between infants with and without FTT, infants with FTT had lower developmental indices and less stimulating home environments. At 36 months, FTT infants had lower IQ scores and were much smaller than infants without FTT.

CONCLUSIONS

Growth deficiency, or FTT, is a common clinical condition for those involved in the follow-up care of LBW infants. Worse cognitive and growth outcomes were observed for those meeting the restrictive case criteria employed in this study. More than 80% of the cases in this LBW cohort did not involve any chronic medical disorders, but several biological and environmental differences were found between those who developed FTT and those who did not.

Low-birth-weight infants born to adolescent mothers. Effects of coresidency with grandmother on child development

OBJECTIVE

To explore the impact of young maternal age, coresidency with infant's grandmother, and other familial and environmental factors on development of low-birth-weight (LBW) infants.

DESIGN

Prospective cohort analyses.

SETTING

Eight medical institutions in different geographical locations participating in the Infant Health and Development Program.

PARTICIPANTS

Control population of 272 LBW, preterm infants enrolled in the Infant Health and Development Program born to mothers aged 15 to 24 years.

MAIN OUTCOME MEASURE

Child cognitive, behavioral, and health outcomes at 36 months' gestation-corrected age.

RESULTS

Maternal age was not significantly related to child development. Coresidence with infant's grandmother was associated with improved cognitive and health outcomes. Maternal ethnicity, maternal verbal ability, and other environmental factors were also associated with child outcomes.

CONCLUSIONS

Findings of this study support the need for programs that include the extended family of at-risk infants, providing education and literacy skills to the mothers and encouraging participation of all care givers of the child.

Growth status and growth rates of a varied sample of low birth weight, preterm infants: a longitudinal cohort from birth to three years of age

To obtain follow-up growth data on a large sample of low birth weight, preterm infants, 985 infants were monitored longitudinally in an eight-site collaborative program until 3 years of age, corrected for prematurity. The growth of 608 of these infants was described previously through 1 year of age. In the full sample, 149 infants weighed less than or equal to 1250 gm at birth, 474 between 1250 and 2000 gm, and 362 between 2000 and 2500 gm. Thirty-three percent were white, 53% were black, and 11% were Hispanic. Weight, length, and head circumference were measured at birth and at 40 weeks and 4, 8, 12, 18, 24, 30, and 36 months gestation-corrected age in at least 862 infants each time. Descriptive statistics and estimated growth rates for all growth variables and a body mass index (height in kilograms per square meter), plotted by sex and birth weight group, demonstrated growth patterns lower than published standards for term infants of the same age and sex. These patterns of growth differed by birth weight group. Little catch-up was noted by the 36-month examination for gestation-corrected age for any birth weight group. We conclude that low birth weight, preterm infants have different patterns of growth than term infants during the first 3 years of life, even with plotting corrected for gestational age.

Growth patterns of low birth weight preterm infants: a longitudinal analysis of a large, varied sample

To obtain growth data on a large sample of low birth weight preterm infants, we monitored 608 infants longitudinally in an eight-site collaborative program. Ninety-nine infants weighed less than or equal to 1250 gm at birth, 289 between 1250 and 2000 gm, and 220 infants between 2000 and 2500 gm. Thirty-four percent were white, 52% black, and 14% Hispanic. Weight, height, and head circumference were measured at birth and at 40 weeks and 4, 8, and 12 months of gestation-corrected age on at least 553 infants each time. Descriptive statistics for all growth variables and a body mass index (kilograms per square meter), plotted by sex and birth weight group, demonstrated growth patterns lower than published standards for term infants of the same age and sex. These patterns of growth differed by birth weight group. No catch-up growth was noted by the 12-month examination (gestation-corrected age) for any birth weight group. We conclude that low birth weight preterm infants have different patterns of growth than term infants during the first year of life, even with plotting corrected for gestational age.

The clinical assessment of a child's social and physical environment during health visits

The quality of a child's home environment plays a critical role in long-term developmental status. The Pediatric Review and Observation of Children's Environmental Support and Stimulation (PROCESS) Inventory was developed to clinically assess aspects of the child's physical environment and the parent-child interaction during a health supervision visit. The final version was used with 76 mother-child pairs by two pediatricians. The Home Observation for Measurement of the Environment (HOME) Inventory was performed within 3 weeks on all pairs, and a laboratory observation of parent-child interaction was completed with 30 of the pairs. Correlations of the PROCESS with the HOME Inventory and parent-child interaction were 0.84 and 0.86 (less than 0.001), respectively. These significant correlations persisted while controlling for family income and education. When high and low scores of the HOME Inventory known to correlate with positive and negative developmental outcomes were cross-tabulated with PROCESS scores, low scores on the PROCESS identified 77% of low HOME Inventory scores and high scores on the PROCESS identified 95% of the high HOME Inventory scores. The PROCESS provides pediatricians a brief, easy-to-score, clinically useful, reliable, and valid method to measure children's home environments.

Developmental intervention: a pediatric clinical review

We have attempted to review developmental intervention for pediatricians in a way that is of clinical relevance to primary care pediatricians. In so doing, we chose not to evaluate certain topics such as therapeutic intervention for handicapped children or center-based educational programs because these have been adequately addressed elsewhere. It is clear that pediatricians have a unique and important role to play in developmental intervention for the following reasons: pediatricians have easy and routinely accepted access to infants and families in the prenatal, perinatal, and preschool periods: pediatricians possess a socially accepted role of authority; and pediatricians can integrate understanding of the child's health and developmental status within the context of the family and social environment to make clinical interpretation regarding the child's developmental status and prognosis. Pediatricians are thus in the best position to convince parents of their impact on their child's development. The following general roles have been identified for pediatricians. First, pediatricians should be aware of the child's biologic status and family environmental situation and the relative degree of risk for developmental problems. This clinical awareness, in combination with the use of appropriate screening instruments of the child's development and family environment, will allow clinical judgment regarding the frequency and type of child health supervision, the need for further diagnostic evaluation, and the need for referral to intervention programs and other resources. Second, the pediatrician should develop an approach for developmental intervention for all children, whatever their degree of biological risk. This review of medical, educational, and psychological literature demonstrate the following recurring important themes as goals for primary intervention: Improve parental understanding of normal child development and developmental expectations. Assist parent's understanding of the individual developmental characteristics and temperamental style of their child. Promote parental sensitivity to the social nature of infant behaviors. Encourage parent responsiveness to the social behaviors. Improve parental feelings of confidence and competence to affect their child's development. Pediatricians can be influential in supporting structural changes that can have beneficial effects on children's development. Support of humanization of obstetric and nursery practices, and the increased use of child health supervision to parents in groups are examples of such efforts.(ABSTRACT TRUNCATED AT 400 WORDS)

Compensatory growth in infants with severe failure to thrive

We studied compensatory growth and caloric intake during an accelerated growth period of ten infants with severe failure to thrive (FTT). The mean age at diagnosis was 7.1 months (range 1.5 to 16.0 months). The average percentage of normal weight for age in this group was 54.9%, mean length was 58 cm (86% normal for age), and the mean head circumference was 39.7 cm (92% normal for age). Compensatory growth rebound was completed after 6.2 months (range 3.5 to 9.0 months). Minimal calorie counts during peak rate of growth averaged 187 kcal/kg/day (range 147 to 213). The final group average percentage of normal weight for age was 95.5%, an increase of 40%. The group of rebounding infants gained 31 gm/day. The group's length increased to 94% of that expected for age and head circumference to 98% of that expected for age. Like malnourished infants, these with FTT had compensatory growth when managed with ad libitum caloric intake equal to twice the expected intake.

Management of children with failure to thrive in a rural ambulatory setting. Epidemiology and growth outcomes

To evaluate the growth course of children with failure to thrive (FTT) who receive aggressive management, we reviewed the 2-year experience of a secondary level ambulatory diagnostic and management clinic for children with FTT in a mostly rural state. We examined the children managed in this setting for cause of FTT, for growth outcomes after 1 year according to FTT clinical type, and for differentiating predisposing sociodemographic information Of 154 children referred to this clinic, 131 were diagnosed as suffering from FTT. Eighteen were admitted to the hospital after initial outpatient evaluation, and 93 were followed for at least 1 year. Twenty-two (17%) suffered from organic, 59 (45%) non-organic, and 46 (35%) mixed etiology FTT. After 1 year, 48 (52%) of the FTT children were improved, 37 (40%) were stable, and 8 (9%) were worse. Children placed in foster care were more likely to be improved (78%). FTT children considered improved after 1 year demonstrated the following at the time of initial diagnosis: lower maternal income, lower maternal education, and lower family socioeconomic status; higher birth order; more often black; and less likely for the father to be present in the home (all p less than or equal to .05). This experience offers several insights into the growth course and team management of FTT children.

Judicial failure to thrive

The case of a toddler who developed nonorganic failure to thrive during the course of a custody determination is reported. The child demonstrated physical, emotional, and developmental aspects of failure to thrive. These signs correlated with custody ordered by the judge, during which time the child's care was alternated between parents. The symptoms resolved when the child was in the hospital and when provided stable care by his grandmother. With the increasing frequency of divorce, failure to thrive resulting from judicial decisions will probably increase. Physicians should monitor these children carefully in order to prevent serious psychosocial complications. The judicial system should expedite custody decisions, availing itself of information in child development.

Social and nonsocial home environments of infants with nonorganic failure-to-thrive

Nonorganic failure-to-thrive (NOFT) is a clinical syndrome that is poorly understood and inadequately studied. Because empirical data are lacking, an attempt was made to identify differentiating aspects of the mother-infant interaction and environment of infants with NOFT compared with those of matched infants who grew normally. Prospectively, 23 infants who were suffering from NOFT were chosen in a referral clinic. Each infant was matched with a control subject with normal growth by age, sex, and race of the infant and family income, maternal education, and number of people living in the household. An assistant who was unaware of infant growth status visited the homes of these infants within 3 weeks of diagnosis and gathered: the Home Observation for Measurement of the Environment (HOME); the Coddington Life Events Record; and the Index of Parent Attitude Scales. The total HOME Inventory and the subscales entitled Maternal Acceptance of the Child, Organization of the Physical Environment, and Emotional Responsivity were significantly less favorable (P less than .05) in the NOFT group. There were no group differences in the Life Events Record and the Parent Attitudes Scales. A discriminant function analysis correctly placed 32 of the 46 infants into failure-to-thrive and control groups. It is concluded that certain aspects of the home environments of infants with NOFT differ from those of infants of similar socioeconomic status who grow normally.

The impact of the home environment on children's development: clinical relevance for the pediatrician

Pediatricians utilize standardized screening techniques to monitor children's development. Typically, however, pediatricians fail to assess the quality of the child's home environment. This paper selectively reviews the literature which demonstrates the major impact of the environment on children's development in the three developmental high-risk categories. Specific aspects of the home environment which optimize or impede developmental progression are discussed. Finally, the various instruments which are available to screen the home environment are presented. Information regarding the environment increases accuracy of developmental predictions, facilitates more appropriate treatment plans, and serves as a basis for specific counseling. The optimal clinical instrument for screening the child's social and inanimate environment has not yet been developed.

The mother-infant relationship and infant development: the effect of pediatric intervention

This study examined the impact of intervention provided in the context of pediatric health supervision visits on the mother-infant relationship during the first 6 months of life. 32 mother-infant dyads were randomly assigned at birth to either an intervention or attention control group, each of which received routine well-child care plus discussions regarding infant social development or accident prevention and nutrition, respectively. Blind assessment of infant and mother behavior frequencies, responsive behavior sequences, and affective relationship characteristics during a 21-min play observation revealed more sensitivity, cooperativeness, appropriateness of interaction, and appropriateness of play by the intervention group pairs, although differences in Bayley Mental Scales and the Uzgiris and Hunt subscales did not attain significance. Post hoc inspection of the behavioral correlates of the affective relationship characteristics provided support for molar assessment of mother-infant interaction as an adjunct to contemporary methods of behavioral microanalytic study.

A special education course with pediatric components

Handicapped children are often plagued by multiple problems. However, training in most of the helping professions tends to be focused on a single orientation, with little attention given to the thinking and techniques used in the other professions. This article reports on a model of personnel preparation in which university special education and pediatrics faculty members work together to train teachers about the medical aspects of educational disabilities.

Effect of the pediatrician on the mother-infant relationship

Child development literature suggests a relationship between mother-child interaction and enhanced infant development. We conducted a randomized clinical trial to determine if a pediatrician's guidance improves the mother-infant relationship and the infant's development. Thirty-two normal mothers and their healthy first-born infants were followed by one pediatrician at 2, 4, 8, 15, and 21 weeks of age. These dyads were randomly assigned to a control group, who received customary care, or to an intervention group, who also received guidance based on the infant's developmental status at each age. Just prior to a 27-week visit, the mother-infant relationship was assessed by a person blind to group assignment. Infant development was assessed with the Bayley Mental Scales of Infant Development and two of the Uzguris-Hunt Ordinal Scales. Intervention group mothers were rated significantly higher on sensitivity, cooperation, appropriateness of interaction, and appropriateness of play (P less than .05). Experimental infants were advanced on the Vocal Imitation ordinal scale. This study shows the effectiveness of this intervention on both the mother-infant relationship and infant development and supports pediatric involvement in this biosocial approach to well child care.