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To examine trade-offs between cognitive outcome and overweight/obesity in preterm-born infants at school age and young adulthood in relation to weight gain and linear growth during infancy.We studied 945 participants in the Infant Health and Development Program, an 8-center study of preterm (≤37 weeks gestational age), low birth weight (≤2500 g) infants from birth to age 18 years. Adjusting for maternal and child factors in logistic regression, we estimated the odds of overweight/obesity (body mass index [BMI] ≥85th percentile at age 8 or ≥25 kg/m(2) at age 18) and in separate models, low IQ (85) per z-score changes in infant length and BMI from term to 4 months, from 4 to 12 months, and from 12 to 18 months.More rapid linear growth from term to 4 months was associated with lower odds of IQ85 at age 8 years (OR, 0.82; 95% CI, 0.70-0.96), but higher odds of overweight/obesity (OR, 1.27; 95% CI, 1.05-1.53). More rapid BMI gain in all 3 infant time intervals was also associated with higher odds of overweight/obesity, and BMI gain from 4-12 months was associated with lower odds of IQ85 at age 8. Results at age 18 were similar.In these preterm, low birth weight infants born in the 1980s, faster linear growth soon after term was associated with better cognition, but also with a greater risk of overweight/obesity at age 8 years and 18 years. BMI gain over the entire 18 months after term was associated with later risk of overweight/obesity, with less evidence of a benefit for IQ.

To assess the association between lifetime violence victimization and self-reported symptoms associated with pregnancy complications among women living in refugee camps along the Thai-Burma border. Cross-sectional survey of partnered women aged 15–49 years living in three refugee camps who reported a pregnancy that resulted in a live birth within the past 2 years with complete data (n = 337). Variables included the lifetime prevalence of any violence victimization, conflict victimization, intimate partner violence (IPV) victimization, self-reported symptoms of pregnancy complications, and demographic covariates. Logistic generalized estimating equations, accounting for camp-level clustering, were used to assess the relationships of interest. Approximately one in six women (16.0 %) reported symptoms related to pregnancy complications for their most recent birth within the last 2 years and 15 % experienced violence victimization. In multivariable analyses, any form of lifetime violence victimization was associated with 3.1 times heightened odds of reporting symptoms (95 % CI 1.8–5.2). In the final adjusted model, conflict victimization was associated with a 3.0 increase in odds of symptoms (95 % CI 2.4–3.7). However, lifetime IPV victimization was not associated with symptoms, after accounting for conflict victimization (aOR: 1.8; 95 % CI 0.4–9.0). Conflict victimization was strongly linked with heightened risk of self-reported symptoms associated with pregnancy complications among women in refugee camps along the Thai-Burma border. Future research and programs should consider the long-term impacts of conflict victimization in relation to maternal health to better meet the needs of refugee women.

Follow-up studies as contrasted to follow-up programmes and clinics should be conceptualized and conducted as rigorously as any research effort. This rigour entails careful delineation of the question being addressed with explicit underlying pathogenetic or theoretical frameworks for causality, selection and implementation of valid and reliable data-collection methods, and appropriate analysis and reporting. While follow-up activities may address several objectives, routine clinical follow-up has not produced a rigorous and informative literature on the outcomes of very tiny babies. Future efforts should be directed to improving and broadening the outcomes assessed.

Rationale/Objective. Although the short-and long-term outcome of low birth weight neonatal intensive care unit (NICU) survivors has been extensively studied, much less information is available for normal birth weight (NBW) infants (greater than or equal to 2500 g) who require NICU care. Methods. To address this issue, we retrospectively examined the neonatal hospitalizations and 6-month health status of 521 consecutive NBW admissions to a single NICU. Information on the neonatal hospitalization was obtained from a review of medical records. Postdischarge health status was collected by using telephone survey techniques. Results. NBW infants comprised 88.1% of births in this hospital and 35.4% of NICU admissions during the study period. The in-hospital mortality rate for this group was 2%. The median length of stay was 7.7 days (range 1 to 110 days) with median hospital charges of $5222 (range $565 to $317,820). Only 59% of infants required active intensive care therapy; the remainder received only intensive monitoring. The need for intensive therapy on admission day along with the presence of prematurity and congenital anomalies were significant predictors of hospital charges (R2 = 0.31, P < .01). After initial discharge, 10.1% of these infants required rehospitalization in the first 6 to 8 months of life. The rate of readmission among infants with congenital anomalies was over 30%. In addition to its association with neonatal resource consumption, the presence of congenital anomalies along with low 5-minute Apgar scores was associated with higher postdischarge resource use, as measured by frequency of physician visits, need for special medical items, and rate of rehospitalization (P < .05). Conclusions. NBW infants represent a significant percentage of NICU admissions, but for many of these patients NICU admission could be avoided if alternative care settings that provided intensive monitoring were available. In addition, these infants also incur higher rates of postdischarge use of medical care.

Follow-up of the graduates of neonatal intensive care is an important component of the provision of such care. However, the objectives of these programs and their data-collection strategies vary widely. This report describes the potential objectives and different data-collection strategies. It then reviews briefly what is known about the outcomes of very low birth weight infants to guide the development of assessment packets: Finally, we describe the operation of our program and activities of our team to illustrate the follow-up experience in a large multi-institution program.

Objective. To determine the effect of bronchopulmonary dysplasia (BPD) on growth at school age. Design. A prospective cohort study. Methods. The sample included 406 children selected from a reconstructed cohort of infants of very low birth weight previously enrolled in a multisite, randomized, controlled clinical trial. The children were contacted at 8 to 10 years of age. Height, weight, and head circumference (HC) were measured. Possible confounders including sociodemographic data, and neonatal factors were also recorded. Results. The children in the BPD group were significantly smaller in weight (z score, -0.50 ± 1.19 SD vs -0.06 ± 1.30 SD) and HC (z score, -1.41 ± 1.32 SD vs -0.63 ± 1.62 SD) than those without BPD. However, after controlling for cofounders (using analysis of covariance), no significant differences were demonstrated between the two groups. Power analyses showed that a difference of at least 0.43 z score units could have been detected. The previously documented associations between BPD and suspected confounders were reconfirmed. Conclusions. Significant differences were noted between children with and without BPD for weight and HC but not height. When possible confounders were taken into account, the differences were no longer appreciated. Thus, the previously reported poor growth in children with BPD may have been related to other factors and not necessarily to BPD.

Objective. To examine the impact of admission-day illness severity on nosocomial bacteremia risk after consideration of traditional risk determinants such as birth weight and length of stay. Methods. The hospital courses for 302 consecutive very low birth weight (less than 1500 g) infants admitted to two neonatal intensive care units were examined for the occurrence of nosocomial coagulase-negative staphylococcal bacteremia. Using both cumulative incidence and incidence density as measures of bacteremia risk, we explored the relation between illness severity (as measured by the Score for Neonatal Acute Physiology [SNAP]) and bacteremia both before and after birth weight adjustment. In addition, the effect of bacteremia on hospital resource use was estimated. Results. Coagulase-negative staphylococcus was the most common pathogen noted in blood cultures drawn at 48 hours after admission or later. It was isolated on at least one occasion in 53 patients (cumulative incidence of 17.5 first episodes per 100 patients). These episodes occurred during 7652 days at risk, giving an incidence density of 6.9 initial bacteremias per 1000 patient-days at risk. As expected, when compared with the nonbacteremic group, bacteremic patients were of lower birth weight (888 ± 231 vs 1127 ± 258 g; P < .01) and gestational age (26.4 ± 2.1 vs 28.9 ± 2.8 weeks; P < .01). In addition, these patients were more severely ill on admission (SNAP 17.3 ± 6.5 vs 12.2 ± 5.8; P < .01). Even after birth weight stratification, the risk of bacteremia by both measures increased with higher SNAP scores. For example, among infants with birth weights greater than 1 kg, 25% of the most severely ill patients (SNAP 20 and higher) experienced at least one bacteremic episode, whereas the rates seen in infants with intermediate (SNAP 10 to 19) and low illness severity (SNAP 0 to 9) were 8.6% and 3.0%, respectively (χ2 for trend = 7.25; P < .01). Multivariate linear regression showed that bacteremia was associated with a prolongation of neonatal intensive care unit stay of 14.0 ± 4.0 days (P < .01) and an increase in hospital charges of $25 090 ± 12 051 (P < .05), even after adjustment for birth weight and admission-day SNAP. Conclusions. Nosocomial coagulase-negative bacteremia is an important complication among very low birth weight infants. Assessment of illness severity with SNAP provides information regarding nosocomial infection risk beyond that available from birth weight alone.

Evaluated neuropsychological outcomes in 635 children, ages 7 to 10 years, in relation to birth weight group:or = 1,000 g; 1,001-1,500 g; 1,501-2,500 g, and2,500 g. The prevalence of low IQ (85) was related to birth weight. Among children with IQ84 (N = 475): (a) Birth weight was unrelated to Verbal IQ, Performance IQ, Full-scale IQ, or reading achievement; (b) extremely low birth weight (ELBW) children achieved more poorly in mathematics than did other birth weight groups (p.05); (c) ELBW and very low birth weight children performed more poorly on the Rey-Osterrieth Complex Figure, a complex visual processing task, than did heavier birth weight children (p.05), but performance on the Beery Test of Visuomotor Integration was not related to birth weight. Results are consistent with heightened neurobehavioral vulnerability of visual processing to preterm birth.

Preterm infants require close surveillance for gross motor delay after neonatal discharge. The Bayley Scales of Infant Development, 3rdedition (Bayley-III) is used widely in research settings, but is too resource intensive for routine clinical use. The Alberta Infant Motor Scale (AIMS) is an alternative test of motor development that can be administered by a range …

Objective Family practices around weight-related behaviors can shape children's development of disordered weight control behaviors (DWCB), such as vomiting, taking laxatives, or taking diet pills without a prescription. This study examined family meal and physical activity (PA) practices associated with DWCB among a multiethnic sample of youth. Methods We assessed self-report data on frequency of family sit-down dinners, types of parental involvement in their children's PA, and DWCB are from 15,461 6th to 8th grade girls and boys in 47 middle schools participating in the Massachusetts Healthy Choices Study at baseline (2005). Results Youth who had family sit-down dinners every day had lower odds of DWCB (girls: odds ratio [OR] 0.3; 95% confidence interval [CI] 0.2–0.5; boys: OR 0.6; 95% CI 0.4–0.9) than youth who never had family sit-down dinners. Similar effect estimates were found for youth who had family sit-down dinners most days. Parental provision of rides to and from a PA event was also found to be protective against DWCB among girls (OR 0.7; 95% CI 0.5–0.9). In contrast, parental participation in PA with their children was associated with increased risk for DWCB (girls: OR 1.4; 95% CI 1.0–1.8; boys: OR 1.9; 95% CI 1.4–2.4). These associations did not differ by race/ethnicity or weight status. Conclusions Programs emphasizing the importance of family meals may be beneficial in preventing DWCB in youth of all ethnicities. Further research is needed on how various methods of parental involvement in their children's PA are associated with DWCB.

Objective To document the prevalence and characteristics of conflict victimization and its associations with past-year intimate partner violence (IPV) among refugee women affected by the protracted conflict in Burma (Myanmar). Methods A cross-sectional survey was conducted among 861 women living in 3 refugee camps along the Thai–Burma border from February to April 2008. Descriptive statistics were generated regarding experiences of conflict victimization and generalized estimating equations were used to determine the odds of reporting past-year IPV. Results In all, 9.6% of partnered women reported conflict victimization and 7.9% of women reported experiencing past-year IPV. After accounting for demographic variables, women who experienced conflict victimization were 5.9 times more likely to report past-year IPV than women who had not experienced conflict victimization (95% confidence interval, 5.0–6.9). Conclusion Given the strong association uncovered in the present study, interventions to reduce the negative effects of conflict victimization should incorporate other forms of violence prevention, including IPV. Future longitudinal research is needed to discern pathways through which these experiences are related.

Objective To examine trends in children's health access, utilization, and expenditures over time (2002–2009) by race/ethnicity, income, and insurance status/expected payer. Methods Data include a nationally representative random sample of children in the United States in 2002–2009 from the Medical Expenditure Panel Survey (MEPS) and a nationwide sample of pediatric hospitalizations in 2005 and 2009 from the Healthcare Cost and Utilization Project (HCUP). Results The percentage of children with private insurance coverage declined from 65.3% in 2002 to 60.6% in 2009. At the same time, the percentage of publicly insured children increased from 27.0% in 2002 to 33.1% in 2009. Fewer children reported being uninsured in 2009 (6.3%) compared to 2002 (7.7%). The most significant progress was for Hispanic children, for whom the percentage of uninsured dropped from 15.0% in 2002 to 10.3% in 2009. The uninsured were consistently the least likely to have access to a usual source of care, and this disparity remained unchanged in 2009. Non-Hispanic whites were most likely to report a usual source of care in both 2002 and 2009. The percentage of children with a doctor visit improved for whites and Hispanics (2009 vs 2002). In contrast, black children saw no improvement during this time period. Between 2002 and 2009, children's average total health care expenditures increased from $1294 to $1914. Average total expenditures nearly doubled between 2002 and 2009 for white children with private health insurance. Among infants, hospitalizations for pneumonia decreased in absolute number (41,000 to 34,000) and as a share of discharges (0.8% to 0.7%). Fluid and electrolyte disorders also decreased over time. Influenza appeared only in 2009 in the list of top 15 diagnoses with 11,000 hospitalization cases. For children aged 1 to 17, asthma hospitalization increased in absolute number (from 119,000 to 134,000) and share of discharges (6.6% to 7.6%). Skin infections appeared in the top 15 categories in 2009, with 57,000 cases (3.3% of total). Conclusions Despite significant improvement in insurance coverage, disparities by race/ethnicity and income persist in access to and use of care. Hispanic children experienced progress in a number of measures, while black children did not. Because racial/ethnic and socioeconomic disparities are often reported as single cross-sectional studies, our approach is innovative and improves on prior studies by examining population trends during the time period 2002–2009. Our study sheds light on children's disparities during the most recent economic crisis.

Object To assess whether younger siblings of participants in an early (preschool) educational program would benefit in terms of developmental and educational outcomes. Design Assessment of a cohort of siblings of intervention participants at a mean age of 13.5 years. Setting The Infant Health and Development Program (IHDP), an 8-site randomized trial of 3 years of early education for premature low-birth-weight infants who were followed up through 18 years of age. Participants Siblings born within 5 years of the IHDP study participants. Main Exposure A sibling born no more than 5 years earlier who participated in the IHDP. Main Outcome Measures Observed IQ; youth report of behavioral problems, their expectations of future success, and their relationship with their parents; and the caregiver's report on the youth's school progress and their expectations of the youth's educational attainment. Results Of 878 IHDP participants who were followed up, 466 (53.1%) had an eligible younger sibling, and 229 of those siblings (49.1%) agreed to participate. No differences were seen between the siblings of those who did and did not receive the IHDP intervention on any of the outcome measures. Adjusting for maternal race/ethnicity, age, and educational attainment at the birth of the study participant; study site; sex of the sibling; and losses to the cohort did not alter the results. Conclusion Participation in an early educational program confers no apparent benefit on younger siblings in their early adolescent years.

We examined whether differences across states in race/ethnicity-specific breastfeeding rates are due solely to state differences in individual factors associated with breastfeeding or additionally, certain state "contextual" factors. Using data from the 2007 National Survey of Children's Health, multilevel models examined whether state variability in race/ethnicity specific breastfeeding initiation and duration to 6 months were explained by (1) individual sociodemographic characteristics of women in states, and (2) an aggregate state measure of the availability of evidence-based maternity care services related to breastfeeding. Observed variability of race/ethnicity-specific breastfeeding rates was only minimally reduced after adjusting for sociodemographic characteristics (Median Odds Ratios (MOR), breastfeeding initiation: non-Hispanic White = 1.46, non-Hispanic Black = 2.26; Hispanic = 1.89. MOR, breastfeeding for 6 months: non-Hispanic White = 1.36, non-Hispanic Black = 1.84; Hispanic = 1.56). Overall variability in the degree of state gaps changed little in adjusted models (breastfeeding initiation: non-Hispanic Black σ(2) = 0.74, se 0.28, Hispanic σ(2) = 0.45, se 0.11; breastfeeding to 6-months: non-Hispanic Black σ(2) = 0.41, se 0.10, Hispanic σ(2) = 0.22, se 0.05). The measure of maternity care services was positively associated with breastfeeding overall but generally did not explain a substantial portion of between-state variability nor the overall variability in racial/ethnic gaps. Contextual sources of variation in state breastfeeding practices and disparities remain poorly understood. Differences in the socioeconomic makeup of states do not fully explain variability. The association of state breastfeeding rates and disparities with relevant policy and practice factors should be further investigated.

OBJECTIVE Identifying interrelationships among childhood social disadvantage, emotional functioning and adult health may help illustrate how health disparities may become embedded early in life, yet few have considered how these factors are associated. We examined whether the association of child emotional functioning and adult health risk was modified by child socioeconomic status (CSES), or whether child emotional functioning mediated the association of CSES and adult health risk. METHOD We studied 430 adult offspring (mean age 42 years) of Collaborative Perinatal Project participants, a cohort of pregnant women enrolled in 1959-1966 (Broman, Nichols, & Kennedy, 1975; Niswander & Gordon, 1972). Child emotional functioning was assessed by psychologist ratings at age 7 and included inappropriate self regulation (ISR) and distress proneness. CSES measures included parental education, household income, and parental occupation. Adult health risk was measured by the inflammatory marker C-reactive protein (CRP). Hypotheses were tested with multiple linear regression. Effect modification was evaluated via interaction terms and stratification of fully adjusted models by CSES. Mediation by child emotional functioning was evaluated via coefficient changes. RESULTS There was no evidence that child emotional functioning mediated the association of CSES and CRP. Significant interactions were observed for ISR and low income (b = 1.67, SE = 0.70, p < .05), and distress proneness and low (b = 3.14, SE = 1.47, p < .05) and middle (b = 3.52, SE = 1.46, p < .05) income. Stratified models indicated that associations of child emotion with CRP varied significantly by level of parental education, household income and occupation. CONCLUSION The highest levels of adult inflammation were observed among those with childhood emotional problems who were also exposed to low socioeconomic status as children. This study suggests adulthood disparities in CRP may have developmental origins in childhood adversity.

Objective. To examine the effect of birth weight on the classroom behavior of children during elementary school (N = 1120; mean age = 9.16 years). Design. The study used an inception cohort. Setting/Participants. Participants were from two previously studied multi-site cohorts: very low birth weight (VLBW) children referred to participating intensive care units and heavier low birth weight (HLBW) children from a stratified random sample of births in geographically defined regions. Teacher reports of children's behavior were obtained for 80% of those eligible. Information was obtained for 137 children who were extremely low birth weight (ELBW, ≤1000 g at birth), 223 who were other very low birth weight (OVLBW, 1001 to 1500 g), 434 who were HLBW (1501 to 2500 g), and 326 who were normal birth weight (NBW, > 2500 g). Main Outcome Measures. The child's teacher provided reports of language and attention in the classroom, behavior problems, and social competence. Results. Comparisons were made among the four birth weight groups: ELBW, OVLBW, HLBW, and NBW. The ELBW children had lower attention and language skills, overall social competence, scholastic competence, and athletic ability than all other birth weight groups as measured by classroom teachers, even when controlling for neonatal stay, child's gender and ethnicity, and maternal education. All low birth weight (LBW) children had lower attention and language skills and scholastic competence and higher daydreaming and hyperactivity scores than NBW children. White children and children with more educated mothers generally had greater language and attention and social competence scores and fewer behavior problems; girls had fewer behavior problems than boys. Neonatal health was generally not associated with outcomes, except that healthier children had lower anxiety scores. The classroom behavior of LBW (< 2500 g) children was rated by teachers as poor, even for children who had not failed a grade; LBW children who are on grade level still may be at risk for school problems. Differences between ELBW and NBW children persisted for overall language and attention and social competence scores even when additional controls were added for sociodemographic and familial variables. Of these variables, maternal depression and home environment were significantly associated with social competence scores.

Background. Clinicians' estimates of mortality risk in the neonatal intensive care unit (NICU) have implications for patient triage, transfer, initiation and termination of life support, and allocation of medical resources. The accuracy of these judgments has not been studied, nor the differences between nurses and attending physicians. Objectives. 1) evaluate the accuracy of subjective judgments of NICU unit mortality risk, 2) identify the key components of clinician judgments, 3) compare accuracy between attending physicians and nurses, and 4) examine the utility of combining an objectively computed risk and clinician judgments to improve predictions. Methods. We obtained estimates of mortality risk on 544 admissions to two NICUs on the day of admission from the attending physician and primary nurse. These were compared with an objective computed mortality risk based on birth weight and the Score for Neonatal Acute Physiology (SNAP) using a linear judgment analysis model, as well as with actual outcomes. Results. Physicians and nurses had good discriminating power with actual mortality rates ranging from 0% among low risk patients to 67% among those with the highest mortality estimates. Physicians had a tendency to overestimate mortality risk. Clinicians base their estimates on the same factors and similar judgment weights as the empiric mortality risk model (22% birth weight, 62% illness severity (SNAP), 13% low Apgar, and 3% for intrauterine growth restriction). Clinicians place additional emphasis on therapeutic as well as physiologic factors. When the computed risk and physician judgment were combined, both made significant contributions in a logistic mortality risk model. Conclusions. Clinician judgments of mortality risk are fairly accurate and similar to an objective illness severity index. This simple method provides insight into clinical decision making and has important applications in improving direct patient care, appropriate allocation of medical resources, and medical training.

To document the association between a lack of readiness, termed "unreadiness," for postpartum discharge and the health of mothers and their term newborns.Prospective observational cohort study of 4300 mother-infant dyads in a national, pediatric, practice-based research network. The association between unreadiness for discharge and health care use, health-related behaviors, and health outcomes was analyzed by the use of bivariate, multivariate linear, and logistic models.Sixteen percent of mother-infant dyads were unready for discharge. Unreadiness was significantly associated with maternal and infant health care use and health outcomes but not independently associated with health-related behaviors. In multivariable analyses, after we controlled for important covariates and confounders, unready dyads had more calls to health care providers than ready dyads (13.3% increase for mothers, P = .01; 18.7% increase for infants, P .01) during the first 2 weeks after discharge. In this same time frame, unready dyads also had more symptom days (8.5% increase for mothers, P .01; 8.7% increase for infants, P .01). Unready mothers had lower mean physical (5.0% decrease, P .01) and mental (4.4% decrease, P .01) health status scores at 4 weeks after discharge.Unreadiness at postpartum discharge was associated with increased health care use and poorer health outcomes in the first 2 to 4 weeks after discharge. Discharge plans should be individualized and jointly tailored to a family's needs rather than to a set timescale.

The aim of this study is to investigate the association between oral health experiences of women in the peripartum period and the risk of preterm delivery (

SummarySon preference has been considered as a determinant of women's risk of intimate partner violence (IPV) experience in India, although quantitative evidence from large nationally representative studies testing this relationship is limited. This study examines the association between husband's son preference, sex composition of children and risk of physical and sexual IPV victimization among wives. Information was collected for 26,284 couples in the nationally representative 2005–2006 National Family Health Survey of India. The exposures were husband's son preference measured as husband's desire for one or more sons greater than the number of daughters and sex composition of the household: only sons, only daughters and mixed. Outcome included past year physical and/or sexual IPV. The results showed that husband's reported son preference (RR: 1.05; 95% CI: 0.98–1.13) and sex composition of children were not associated with risk for IPV victimization in the models adjusted for socio-demographic factors. The findings from this first population-based study of socio-cultural norms around son preference and married Indian women's risk for IPV victimization indicate that cultural preference for sons does not influence women's risk for IPV victimization.

Empirical evidence regarding the relationship between use of child health services and maternal intimate partner violence (IPV) exposure is sparse. The present study examined the relationship between maternal IPV and childhood immunization status in India using the nationally representative NFHS-3 (n = 6947). Exposure was past year IPV and the outcome was full immunization. IPV victimization was associated with decreased likelihood of being fully immunized after controlling for a range of socio-demographic variables. We also found that differences in measurement of the immunization status (self-report vs. health card) had different implications for the observed association; women reporting IPV and not having the vaccination card were most vulnerable to lack of immunization of their children. Findings suggest the need for increased programmatic efforts to prevent both the prevalence of IPV as well as the multiple MCH consequences of such violence.

Few have considered whether and how child emotional functioning is associated with inflammation later in life. Therefore, we evaluated whether child emotional functioning at age 7 years is associated with C-reactive protein (CRP), an indicator of systemic inflammation, in middle adulthood.We studied adult offspring (mean age 42.2 years) of participants in the National Collaborative Perinatal Project, a national cohort of pregnant women enrolled between 1959 and 1966. Three measures of child emotional functioning were derived from psychologist ratings of child behavior at age 7 years: inappropriate self-regulation (ISR), distress proneness, and behavioral inhibition. Multiple linear regression models were fit to investigate the association between childhood emotional functioning and adulthood CRP and also to evaluate potential mediators of this association. Model n's were from 400 for Model 1 to 379 for Model 4 depending on covariates included and missing data on those covariates.Children with high ISR and distress proneness at age 7 years had significantly higher CRP as adults (ISR: β = 0.86; standard error [SE] = 0.28; p = .002; distress proneness: β = 1.23; SE = 0.57; p = .03). In contrast, children with high levels of behavioral inhibition had lower CRP as adults (β = -0.58; SE = 0.38; p = .04). Furthermore, there was evidence that associations of ISR and distress proneness with CRP may be mediated in part by adulthood body mass index (Sobel significance tests of mediation: ISR: p = .003; distress proneness: p = .07).Findings suggest that poor childhood emotional functioning is associated with inflammation in adulthood. These results suggest a potential childhood origin of adult inflammatory risk.

health is critical to assuring national well-being, now and in the future. However, monitoring the status of the health of children and adolescents and understanding the role of various factors in fostering optimal health have proven difficult. Of particular importance is the influence of the availability, use, and quality of health care services, especially for those with life-threatening conditions or special health care needs. Despite the presence of multiple data sets and measures, the United States currently has no national information system that can provide timely, comprehensive, and valid and reliable indicators of health and health care quality for children and adolescents. Although progress has been made in selected areas, the country lacks a comprehensive strategy to make better use of existing resources and identify the need for new indicators and methods.

Autistic traits—social impairment, communication impairment, and restricted and repetitive behaviors and interests—are heritable in the general population. Previous analyses have consistently reported limited genetic and environmental overlap between autistic trait domains in samples assessed in middle childhood. Here we extend this research to parent-report data for 12-year-olds. Data from 5,944 pairs in the Twins Early Development Study were analyzed to explore the domain-specific heritability and degree of shared genetic and environmental influences across different autistic traits in the general population and among individuals scoring in the top 5% of each domain. Sex differences in the etiological estimates were also tested in these analyses. Autistic traits were moderately to highly heritable (0.58–0.88) at age 12. Bivariate genetic correlations in the full sample (0.18–0.40) and the extremes (0.24–0.67), as well as even lower unique environmental correlations, all suggested considerable fractionation of genetic and environmental influences across autistic trait domains, in line with previous findings.

This study investigated the developmental course of autistic traits in a nationally representative sample of subjects 7 to 13 years of age.The parents of 6,539 children in the Avon Longitudinal Study of Parents and Children completed the Social and Communication Disorders Checklist at ages 7, 10, and 13. The phenotypic progression of autistic traits was assessed in the full sample and in high-scoring individuals (e.g., top 10%, 5%). Gender, IQ, and overall behavior difficulties were examined as potentially relevant influences on autistic trait trajectories.Autistic traits were highly stable in the general population overall and in the high-scoring groups. In the full sample, there was no change in mean Social and Communication Disorders Checklist scores for female subjects ages 7 to 13 (p = .43). Scores for male subjects decreased slightly, but significantly, on the order of 0.1 standard deviations (p.001). There was no mean change in parent-rated autistic traits within any of the high-scoring groups. IQ was not related to phenotypic progression; high parent-rated behavior problems predicted slight improvement in Social and Communication Disorders Checklist scores over the course of the study period in high-scoring individuals (p.01).These findings suggest that autistic traits are highly stable in the general population, even in individuals with the highest concentrations of autism-like behaviors. Phenotypic stability is consistent with expectations for individuals with autism spectrum disorders, providing further support for a phenomenologic continuum across the clinical threshold. Moreover, the gap between female and male risk for autistic symptomology is consistent over time.

BACKGROUND: Late preterm infants (34–37 weeks' gestation) are often perceived at similar risks for morbidity and mortality as term infants. OBJECTIVE: To compare the neurodevelopmental outcomes of late preterm to term infants. METHODS: Our study sample of 6300 term and 1200 late preterm infants came from the Early Childhood Longitudinal Study-Birth Cohort. We used general estimating equations to get weighted odds of having developmental delay, mental index scores (MDI) or psychomotor index scores (PDI) < 70, at 24 months of age. RESULTS: Late preterm infants compared with term infants had lower MDI (85 vs 89) and PDI (88 vs 92), both P < .0001, respectively. A higher proportion of late preterm infants compared with term infants had an MDI CONCLUSIONS: Late preterm infants have poorer neurodevelopmental outcomes than term infants and have increased odds to have a mental and/or physical developmental delay.

Objective The aim of this study was to describe selected trends in hospital inpatient care for children between 2000 and 2007. Study Design Analysis was conducted of administrative data from annual nationwide databases of hospital discharges from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project, along with survey data from a nationally representative random sample of children from the Medical Expenditure Panel Survey. Hospital utilization rates and expenses, risk-adjusted rates of potentially avoidable hospitalization, and safety indicators in the hospital are calculated and tracked with established and downloadable software. Results The rate of hospital discharges for children aged 15 to 17 years declined significantly, mainly due to fewer maternity-related discharges. The leading principal conditions by age group were similar to the report for 1995 to 2000; however, the rate of admissions for skin infections doubled to 9 per 10 000. Hospital cost per discharge increased by an annual average of 4.5% per year compared with 2.6% annual growth in the gross domestic product deflator. Medicaid is increasingly important relative to private insurance as a payer for hospital care for children. The rate of potentially preventable hospitalizations for both acute and chronic conditions declined substantially (18%, adjusted for age and gender). Several measures of patient safety improved—the rates of postoperative sepsis, iatrogenic pneumothorax, and selected infections due to medical care declined by 14.2%, 17.8%, and 23.5%, respectively. However, the rate of accidental punctures and lacerations and the rate of decubitus ulcer increased by 25.6% and 34.5%, respectively. The trends in safety indicators varied somewhat by age group, income quartile of zip codes, insurance, region, and type of location without a consistent pattern. Conclusions/Implications Although teenage pregnancy rates were declining, there was a worsening trend in skin infections. The latter may eventually be impacted by recent publication of new guidelines for treatment by office-based physicians. A gradually increasing role of Medicaid as a payer for hospital care for children will likely put an increasing strain on public resources in advance of the full implementation of the health insurance reforms recently enacted. The decline in potentially avoidable admissions reduces the use of the most expensive resources. For asthma and diabetes, children in the lowest income zip codes had persistently higher rates of admission, but the rate fell by one third during the period. Children in the South and West regions had substantial and significant declines in preventable admissions. Particular indicators of safety were improving, whereas others were worsening. Trends were not the same in all types of hospitals, all regions, and income categories. This is already a rich area for further research on the impact of quality improvement strategies; however, attention is needed to developing more tools to more thoroughly track quality of care for children.

The high rate of premature births in the United States remains a public health concern. These infants experience substantial morbidity and mortality in the newborn period, which translate into significant medical costs. In early childhood, survivors are characterized by a variety of health problems, including motor delay and/or cerebral palsy, lower IQs, behavior problems, and respiratory illness, especially asthma. Many experience difficulty with school work, lower health-related quality of life, and family stress. Emerging information in adolescence and young adulthood paints a more optimistic picture, with persistence of many problems but with better adaptation and more positive expectations by the young adults. Few opportunities for prevention have been identified; therefore, public health approaches to prematurity include assurance of delivery in a facility capable of managing neonatal complications, quality improvement to minimize interinstitutional variations, early developmental support for such infants, and attention to related family health issues.

To examine the effect of early educational intervention after discharge from the hospital on the health and developmental status of very low birth weight (or = 1500 gm) infants.Randomized, controlled trial, with post hoc analysis.Eight sites, heterogeneous for sociodemographic and health care use.Infants (N = 280) born weighingor = 1500 gm and selected for the Infant Health and Development Program. Eligibility was limited primarily by geographic distance from the day care center. One third were randomly assigned to the intervention (INT) group and two thirds to follow-up only.All children received intensive pediatric and developmental surveillance. The INT group received home visits and center-based educational interventions until 36 months of age (corrected for gestational age when final assessments were completed).Cognitive development (Stanford-Binet Intelligence Scale), behavioral competence (Achebach Child Behavior Checklist), and health status (indexes summarizing reported morbidity, the Functional Status II (R) Scale, and General Health Ratings Index).Cognitive development scores were 7.2 points higher (p = 0.002) in the INT group, after adjustment for baseline differences in site, sociodemographic characteristics, and neonatal morbidity, and were 9.4 points higher (p0.0003) when the 29 children with significant cerebral palsy were removed. No differences in behavior, serious morbidity, functional status, or health rating were found overall. The infants in the INT group who weightedor = 1000 gm at birth had significantly lower behavior problem scores but no differences on other outcomes. All children in the INT group had slightly higher rates of less serious morbidity.The advantage conferred by being in the INT group, as previously reported for heavier infants, extends to very low birth weight children, supporting the use of early intervention in this group.

Objective : To assess whether very low birth weight (VLBW) increases the risk of hospitalization at school age. Design : Prospective, multisite cohort study. Participants : Selected from a previous multisite, hospital-based trial, 611 VLBW children, and, from a prior representative sample, 724 children who weighed 1501 to 2500 gm and 533 who welghed >2500 gm. All the children were recontacted at 8 to 10 years of age for this study. Methods : Maternal interview with the use of standardized questions. Main outcome : Hospitalization in year before interview. Results : The VLBW children were three or four times more likely to be rehospitalized than children of normal birth weight, both in the year before the interview (7% vs 2%) and since birth (50% to 60% vs 22%). Morbidity and Medicald coverage increased the risk of hospitalization in the year before the interview; non-white race decreased it. After control for other factors, however, lower birth weight remained a significant risk factor for hospitalization. Conclusions : The VLBW children continue to have an increased risk of hospitalization; the risk is similar in magnitude to that seen in infancy.

Several methodologic issues affect the literature on the outcomes of very low birth weight children, making assessing trends difficult. A conservative estimate is that the proportion of handicapped survivors has remained stable, and with increasing survival, the absolute numbers will increase, but many studies suggest decreasing proportions with handicap. Suggestions for improving responses to the questions are proposed.

The substantial variation in birth weight-adjusted mortality among neonatal intensive care units (NICUs) may reflect differences in population illness severity. Development of an illness severity measure is essential for comparisons of outcomes. The Score for Neonatal Acute Physiology (SNAP) was developed and validated prospectively on 1643 admissions (114 deaths) in three NICUs. SNAP scores the worst physiologic derangements in each organ system in the first 24 hours. SNAP showed little correlation with birth weight and was highly predictive of neonatal mortality even within narrow birth weight strata. It was capable of separating patients into groups with 2 to 20 times higher mortality risk. It also correlated highly with other indicators of severity including nursing workload (r = .59), therapeutic intensity (r = .78), physician estimates of mortality risk (r = .65), and length of stay (R2 = .59). SNAP is an important new tool for NICU research.

Objectives. This study assessed the effect of the national Healthy Start Program on its clients. Methods. We used a cross-sectional survey of a sample from Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) rosters of women less than 6 months postpartum who were residents of Healthy Start Program areas. Results. Healthy Start clients revealed higher sociodemographic risk, but not behavioral risk, for adverse pregnancy outcome than other area residents. They did not differ from other residents in receipt of services except for a greater likelihood of receiving case management, using birth control at the time of the interview, and rating their prenatal care more highly. Conclusions. The Healthy Start Program succeeded in enrolling women at high risk. It had little effect on the immediately concluded pregnancy, but it might influence future outcomes.

To describe and assess racial/ethnic differences in maternal oral health experiences during their most recent pregnancy. We analyzed 2004–06 data from the CDC Pregnancy Risk Assessment Monitoring System (PRAMS), a population-based surveillance system that collects data on pregnancy and postpartum experiences of mothers who have recently delivered a live infant. Ten states included in the analysis had a ≥70% weighted response rate and three standard questions pertaining to oral health. A total of 35,267 white non-Hispanic (WNH), black non-Hispanic (BNH) and Hispanic women were included in the analysis. We used weighted percentages/standard errors and multivariate logistic regression, controlling for selected descriptive characteristics. Only 41% of all women received oral health counseling during pregnancy. In the multivariate analyses, compared to WNH women, BNH women were more likely to have a dental problem (OR 1.19, CI 1.05–1.35). BNH and Hispanic women were less likely to obtain dental care during pregnancy (OR 0.87, CI 0.77–0.98; OR 0.77, CI 0.64–0.91 respectively) and were less likely to ever have had a teeth cleaning (OR 0.64, CI 0.52–0.78; 0.36, OR CI 0.29–0.46 respectively) when compared to WNH women. In addition, BNH and Hispanic women were less likely to have a teeth cleaning before (OR 0.82, CI 0.72–0.94; OR 0.60, CI 0.50–0.72 respectively) as well as during pregnancy (OR 0.68, CI 0.59–0.78; OR 0.74, CI 0.61–0.90) when compared to WNH women. Significant racial/ethnic disparities in maternal oral health experiences exist. Most women are not offered dental counseling during pregnancy.

OBJECTIVES: More rapid infant weight gain may be associated with better neurodevelopment but also with higher blood pressure (BP). The objective of this study was to determine the extent to which infant weight gain is associated with systolic BP (SBP) and IQ at school age in former preterm, low birth weight infants. METHODS: We studied 911 participants in the Infant Health and Development Program, an 8-center longitudinal study of children born at ≤37 weeks' gestation and ≤2500 g. Study staff weighed participants at term and at 4 and 12 months' corrected ages; measured BP 3 times at 6.5 years; and administered the Wechsler Intelligence Scale for Children, Third Edition (WISC-III), an IQ test, at 8 years. In linear regression, we modeled our exposure “infant weight gain” as the 12-month weight z score adjusted for the term weight z score. RESULTS: Median (interquartile range) weight z score was −0.7 (−1.5 to −0.0) at 12 months. Mean ± SD SBP at 6.5 years was 104.2 ± 8.4 mmHg, and mean ± SD WISC-III total score at 8 years was 91 ± 18. Adjusting for child gender, age, and race and maternal education, income, age, IQ, and smoking, for each z score additional weight gain from term to 12 months, SBP was 0.7 mmHg higher and WISC-III total score was 1.9 points higher. CONCLUSIONS: In preterm infants, there seem to be modest neurodevelopmental advantages of more rapid weight gain in the first year of life and only small BP-related effects.

Severity-of-illness scales have proven valuable able in assessing clinical outcomes and resource consumption in adult and pediatric intensive care, but they have been less extensively developed for neonatal care. The National Therapeutic Intervention Scoring System (NTISS) was created by modifying the Therapeutic Intervention Scoring System (TISS). From the 76 original TISS items, 42 were deleted and 28 added to form the NTISS. Like TISS, NTISS assigns score points from 1 to 4 for various intensive care therapies. Admission-day NTISS scores were calculated for 1643 newborns admitted to three neonatal intensive care units (NICUs) between November 1, 1989, and September 30, 1990. NTISS scores ranged from 0 to 47 with a mean of 12.3 ± 8.7 (SD). There was little correlation with birth weight (r = -.11) or gestational age (r = -.17), but NTISS scores were highly correlated with expected markers of illness severity, including mortality risk estimates by neonatal attending physicians (r = .70, P < .0001), in-hospital mortality rates (P < .05), and a measure of nursing acuity (Medicus) (r = .05), and a measure of nursing acuity (Medicus) (r = .69, P < .0001). In addition, admission-day NTISS scores were found to be predictive of both NICU length of stay (r = .37, P < .0001) and total hospital charges for survivors (r = .65, P < .0001). It is concluded that NTISS is a valid measure of therapeutic intensity that is independent of birth weight and can be used as an indicator of neonatal illness severity and resource utilization. Further validation in other NICUs is required.

Objective: To describe the health status and factors influencing health status of mothers following delivery in low-income, minority women; and to delineate opportunities for interpregnanc...

OBJECTIVE: This purpose of this study was to describe differences in early intervention (EI) participation according to state among a cohort of young children with parent-reported developmental delays and disabilities.METHODS: Data were obtained from the 2005–2006 National Survey of Children With Special Health Care Needs to describe state differences in EI participation. Multilevel modeling was used to estimate the relative contributions of child sociodemographic and developmental characteristics, and state EI eligibility policy on EI participation.RESULTS: The overall rate of EI participation was 45.7% (23.1%–83.3% across the states). EI participants were less likely to be Hispanic, live in a multiracial family, be poor, have a developmental delay, or have a less severe condition/delay. The predicted probability of receiving EI was lower for children who lived in states with more strict EI eligibility criteria than those with liberal criteria (.43 vs .52). Poverty influenced this association, with the adjusted probabilities of receiving EI for poor (185% federal poverty level) children being .18 and .36, respectively (P < .05). Among nonpoor children, those who lived in states with strict eligibility criteria were nearly as likely as poor children who lived in states with liberal eligibility criteria to receive EI (.33 vs .36; P < .05).CONCLUSIONS: The results of this study reveal marked disparities and unmet needs in EI participation as a function of both characteristics of the child and the state program. Improving developmental services for vulnerable populations requires addressing these sources of disparity.

OBJECTIVES: The goals of this study were to describe nutritional practices in the first month of life for a large cohort of extremely low gestational age newborns and to determine the impact of these nutritional practices on growth velocity (GV) over the same period. METHODS: The sample included 1187 infants born at 23 to 27 weeks of gestation, at 14 institutions, between 2002 and 2004. Inclusion criteria included survival until day 28 and weight information for days 7 and 28. GV, expressed as grams per kilogram per day, was calculated for the interval between days 7 and 28. Nutritional practices during the first week and on days 14, 21, and 28 were compared with current nutritional guidelines in the literature. Multivariable logistic regression models estimated the contribution of limited nutrition to limited GV. RESULTS: Protein and fat delivery approximated current nutritional recommendations, whereas carbohydrate and total energy intake delivery did not. Despite this, GV of our study infants exceeded the current guideline of 15 g/kg per day. Nevertheless, we found extrauterine growth restriction (ie, weight for gestational age below the 10th centile) in 75% of the infants at 28 days, compared with only 18% at birth. A GV of 20 to 30 g/kg per day was associated with infants' maintaining or exceeding their birth weight z score, with rates in the upper range for the gestationally youngest infants. Early (day 7) nutritional practices were positively associated with GV measured between days 7 and 28. CONCLUSION: The early provision of nutrients is an important determinant of postnatal growth. Extrauterine growth restriction remains high in extremely premature infants even when they achieve a GV rate within current guidelines.

Purpose The purpose of this article was to describe the use of the Youth Risk Behavior Surveillance System (YRBSS) with known 17–18-year-old patients in follow-up of a multisite randomized clinical trial, and to develop a new scoring algorithm indicating the degree of risk-taking behavior for between-group analyses. Methods Seventy-five questions from the YRBSS were incorporated into the study questionnaire, with the development of safety plans to guide the disposition of participants. The YRBSS questions were grouped into two categories (with three subdomains each) named problem behaviors (conduct problems, sexual behavior, and suicide/hopelessness) and substance use (cigarettes, alcohol, and marijuana use), with scores for each subdomain indicating high, moderate, and low risk. Results Of the 677 participants, the safety plan was activated 215 times for 199 (29.4%) of participants. Risk behaviors included binge drinking (149), alcohol/substance use and driving (41), depression (22), hopelessness (37), and suicidal ideation (13; all in the past). No emergency room evaluations were required. The subdomain scaling was analyzed by demographic characteristics, and findings were consistent with the literature; for example, higher rates of conduct problems in males, more suicidal ideation in females, greater sexual risk in African Americans, more substance use in males and whites, and more alcohol use in youth with mothers with higher levels of education. Conclusions YRBSS can be administered in a research setting with appropriate safety precautions. These results should provide a useful guide to the application of the YRBSS to other adolescent populations in the future.

Summary. Longer-term follow-up of infants with specific health concerns, such as low birthweight, is critical to assessing the effect of medical interventions. This report examines the approach of reconstructing previously studied cohorts in terms of the factors discriminating between respondents and non-respondents. Follow-up was attempted during 1987-1988 for 1875 children born during a 6-month period in 1978 in three geographically defined regions in the United States, for whom 1-year assessments of health and developmental status were obtained at 1 year of age as part of a previous study. For a 25% sample, participation involved a clinic visit for developmental assessments; for the remainder an interview by telephone or home visit. Follow-up was obtained for 72.5% of the cohort. Refusal rates were low (7%); most non-response was due to an inability to locate the families. Predictors of non-response reflected primarily low socio-economic status; completion rates were not influenced by mode of assessment. The role of a tracing agency is discussed. We conclude that cohort reconstruction is feasible with response rates comparable to some prospective studies with ongoing cohort maintenance.

Exposure to adverse family environments in childhood can influence the risk trajectory for developing substance use disorders in adolescence. Evidence for this is largely based on cross-sectional studies which have been unable to establish the temporality of this association and investigate underlying pathways.The sample consisted of 1421 adolescents from the Project on Human Development in Chicago Neighborhoods, a three wave longitudinal study conducted between 1994 and 2001 that followed children from ages 10 to 22. Logistic regression analyses with multiple imputation were conducted to examine the relation between familial conflict in childhood and substance use disorders in late adolescence and emerging adulthood. We conducted mediational analyses to determine if internalizing and externalizing problems explain this relationship, and we investigated whether external social support mitigates the adverse effects of familial conflict on the development of substance use disorders.Familial conflict was significantly associated with the risk of substance use disorders during adolescence (odds ratio: 1.23; 95% CI: 1.02-1.47), and 30% of this effect was due to higher levels of externalizing problems (but not internalizing problems). External social support in childhood did not buffer the effects of familial conflict on substance use disorders during adolescence.Exposure to familial conflict early in life increases the risk of substance use disorders during late adolescence and emerging adulthood, due partly to higher levels of externalizing problems, but not internalizing problems. Future research is needed to identify additional pathways underlying this association, and the extent to which these pathways are modifiable.

In this paper we examine the effectiveness of early intervention, especially vis-a-vis (a) child and family risk factors and (b) the pathways to enhanced child and family development. To address these issues we draw on findings from the Infant Health and Development Program (IHDP) for low-birth-weight premature infants. The data we present reveal the considerable effectiveness of the IHDP intervention in enhancing several aspects of early and later child and family development. The findings also illustrate the importance of looking beyond intervention group differences to examine the extent to which early intervention effects are more pronounced for some children and families than others and to examine the processes underlying intervention effects (e.g., exactly how do early interventions change children and families?). For example, both initial and longer-term IHDP intervention effects varied by both characteristics of the children and characteristics of their families. Our data also provide some insight into the processes by which intervention effects may have occurred. We conclude our consideration of these many complexities with suggestions for practice, social policy, and future research.

The emergence of practice-based research networks (PBRN) has facilitated the execution of multifaceted community-based studies. As study complexity increases, so does the number of methodological barriers encountered. This paper's goal was to delineate methodological barriers and to evaluate the effectiveness of selected strategies and approaches developed and implemented in allowing a prospective, national PBRN cohort study to succeed in enrolling geographically dispersed mother/healthy term infant dyads (n = 4300) on the day of post-partum discharge. Specific methodological barriers included: (1) obtaining multiple Institutional Review Board (IRB) approvals; (2) gathering longitudinal data from multiple individuals; (3) soliciting multiple perspectives on discharge decision making; and (4) bolstering minority enrolment. The most effective strategies and approaches we employed to address these methodological challenges were: (1) preparing and distributing the 'IRB Packet'; (2) recruiting multiple practices covered by the same IRB; and (3) obtaining supplemental funding for increasing minority enrolment. We expect that other PBRN investigators can benefit from our experience and solutions in the successful conduct of this multifaceted community-based study.

Several randomized clinical trials have shown that surfactant therapy improves the pulmonary status of infants with respiratory distress syndrome and has the potential to reduce morbidity and mortality in these infants. Relatively little is known, however, about the long-term consequences of surfactant treatment. In this report, the results of health and developmental assessment are described at 1 and 2 years of age of 32 survivors of an initial group of 41 infants enrolled in a randomized clinical trial of bovine surfactant therapy. The frequencies of abnormal findings were comparable in the two groups although there was a trend toward a greater frequency of allergic manifestations in the control group (6 of 16 (38%) vs 1 of 15 (7%), P = .08). Similarly, no differences were seen in the mental and motor scores of the Bayley Scales of Infant Development at either 1 or 2 years of age. This study and other recently published reports of follow-up studies of infants treated with surfactant provide encouraging evidence that major long-term side effects do not result from surfactant therapy.

There is an error in the third-to-last sentence of the “Design, Setting, and Participants” subsection in the Methods. The correct sentence is: We further excluded infants who died before discharge (n = 39), infants discharged after 48 weeks corrected age (n = 348); infants who developed NEC (n = 13) or underwent surgery (n = 385); and infants missing growth data (n = 178). In Fig 1, the second box of the flow chart contains incorrect information. “600” should be “3279.” Please see the corrected Fig 1 here. Fig 1 Population Flow Chart In Fig 2, the axis labels are missing from both panels. Please see the corrected Fig 2 here. Fig 2 Comparison of nutritional practices in 75 institutions in Japan. In Fig 4, there are errors in the axis labels for all three panels. “n = 2677 non-SGA infants” should be “n = 2662 non-SGA infants” and “n = 4006 All infants” should be “n = 4005 All infants.” Fig 4 Estimated effect of administering parenteral nutrition. There are a number of errors in Table 1. Please see the complete, correct Table 1 here. Table 1 Maternal and infant characteristics of 4,005 very low birth weight infants of 24–32 weeks’ of gestation who reached full enteral feeding within 2 weeks.

Opinion VIEWPOINT Greg J. Duncan, PhD School of Education, University of California, Irvine. Marie C. McCormick, MD, ScD Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, Massachusetts. Constance F. Citro, PhD National Research Council, National Academy of Sciences, Washington, DC. Corresponding Author: Greg J. Duncan, PhD, School of Education, University of California, Irvine, 2001 Education, Irvine, CA 92697-5500 (gduncan@uci.edu). jamapediatrics.com The Future of the National Children’s Study On December 12, 2014, National Institutes of Health Director Francis Collins, MD, PhD, announced his inten- tion to discontinue the National Children’s Study (NCS), ending nearly 15 years of planning and pilot testing at a cost of $1.3 billion. As 3 of the authors and editors of the report by the National Research Council and Institute of Medicine The National Children’s Study 2014: An Assessment, 1 we welcome the opportunity to provide our perspectives on future directions for the study. The NCS was authorized by the Children’s Health Act of 2000 (Pub L No. 106-310) to accord priority to (1) gathering data from birth to adulthood to evaluate en- vironmental influences on diverse populations of chil- dren; (2) considering health disparities among chil- dren; and (3) incorporating behavioral, emotional, educational, and contextual consequences to enable complete assessment of the physical, chemical, biologi- cal, and psychosocial environmental influences on chil- dren’s well-being. The Program Office in the Eunice Kennedy Shriver National Institute of Child Health and Human Development designed the study as the first in the world to collect a broad range of environmental ex- posure measures for a national probability sample of about 100 000 children followed up from birth, or even before birth, to age 21 years. Our panel’s review of the study design concluded that the NCS had the potential to add substantially to sci- entific knowledge about the impact of environmental ex- posures, broadly defined, on children’s health and de- velopment in the United States. The panel supported almost all of the basic elements of the proposed design for the NCS Main Study, including the use of a national equal probability sample for a large cohort of births (the panel recommended that almost all of the sample be re- cruited prenatally), its concept of the study as a data col- lection platform with a focus on health and develop- ment guided by exemplar scientific hypotheses, its concentration of measurement on the prenatal and early childhood periods, and the collection and storage of bio- logical and environmental samples to permit subse- quent analysis of archived specimens. For many important issues regarding the NCS’s pro- posed design, the panel did not receive sufficiently de- tailed information from the Program Office to provide an informed assessment. Because of this lack of infor- mation and related reasons, the panel concluded that achieving a scientifically grounded and cost-effective de- sign and implementation would require expansion of the scientific expertise in the Program Office, establish- ment of an authoritative multidisciplinary oversight structure to review the Program Office’s decisions, and regular independent outside review. Collins’s December 12, 2014, statement about the NCS concluded that while research addressing the links between the environment and child health and devel- opment is important, the NCS is not feasible. He called for alternative designs to be initiated within the scien- tific community that would employ the use of the grow- ing number of clinical research networks. Neither Collins’s statement nor the report of the Working Group he commissioned explains why the basic NCS design is infeasible, which handicaps our efforts to point to prom- ising new directions. Our panel judged that the basic ele- ments of the data collection plan were indeed feasible and noted that most had been incorporated into suc- cessful national longitudinal birth cohort studies in other counties or proved their worth in the Vanguard testing sites. Although we judged that the study’s manage- ment structure and system of oversight needed to be re- formed, we also pointed to a number of successful man- agement models that could help to guide these efforts. Perhaps the key to the Working Group’s and Collins’s “infeasibility” judgment was the cost of the study de- sign. Our panel estimated that the data collection por- tion of study costs alone would range between $200 mil- lion and $300 million annually by the third year of data collection—amounts well above the past Congressional appropriations for the total costs of running the study. These high costs had little to do with the NCS Program Office’s decision to adopt probability methods for draw- ing the study’s sample, but instead were driven by the total sample size, the frequency of interviewing, and the need for periodic in-home visits to collect data on envi- ronmental exposures that could not be measured in blood or placentas. Any replacement collection of NCS-related studies—including those initiated in clini- cal research networks—involving similar total numbers of subjects and periodic in-home interviews would likely cost as much or more. As a final prefatory note, the importance of under- standing health disparities figured prominently in our pan- el’s deliberation. Ensuring adequate representation of our nation’s most disadvantaged children in studies such as the NCS is a formidable task. These children are unlikely to be well represented in studies that draw their samples from administrative records or patient pools. And the resi- dential mobility of disadvantaged children makes them exceedingly difficult to follow up in studies operating in limited geographic areas. These concerns contributed to our panel’s endorsement of a national scope and prob- ability sampling methods for the study. How best to address the priorities dictated by the Children’s Health Act of 2000 at considerably lower cost? Although it may be sensible to mount a number of valuable low-cost specialized studies, we see no substi- tute for a national study that follows up diverse groups of children through adolescence and engages in inten- sive assessments of a variety of environmental expo- sures through periodic home visits. And we reiterate the endorsements of our panel and the Working Group for (Reprinted) JAMA Pediatrics June 2015 Volume 169, Number 6 Copyright 2015 American Medical Association. All rights reserved. Downloaded From: http://archpedi.jamanetwork.com/ by a University of California - Irvine User on 06/28/2015

Objectives: Few studies have examined factors associated with compliance with a postpartum visit (PPV). The identification of such factors is of particular importance in populations with high rates of unintended pregnancies and medical complications of pregnancy. This study seeks to determine factors associated with compliance with a PPV among low-income women in the population served by fourteen Healthy Start sites. Methods: Data from the Healthy Start Survey of Postpartum Women were reviewed to identify variables associated with compliance with a PPV at or beyond 6 weeks. Multiple logistic regression models were created, based on a sociobehavioral model of health services use, to examine which types of factors (demographic, social, enabling or need) are most strongly associated with the use of a PPV. Results: The study population consisted of survey respondents interviewed six weeks or more following delivery. Eighty-five percent of respondents had had a PPV at time of interview. In a multiple regression analysis, enabling factors such as multiple moves (OR (95% CI) = 0.34 (0.18, 0.67)), trouble understanding the provider (OR (95 % CI) = 0.65 (0.43, 0.99)) and appointment reminders (OR (95% CI) = 2.37 (1.40, 4.02)) were most strongly associated with a PPV. Conclusions: This work finds that women with unstable housing, transportation barriers, and difficulties communicating with providers are at risk for not receiving a PPV. This suggests that access to postpartum health services in the Healthy Start communities studied may not be entirely equitable. Policies aimed at improving interconception care will need to address these barriers to accessing health services.

Improvements in immunizations have been perceived as one of the greatest medical advances. However, recently, there has been increasing mistrust of the effects of vaccines on children. This chapter delineates how this decline in trust occurred, including sections on changes in policy, adverse events, myths, misinformation, and incomplete science. It describes ways that physicians can enhance the patient-physician relationship by increasing patient trust in vaccines and immunizations, through better communication and flexibility.