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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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)

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.

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.

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.

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.

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.

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.