Psychiatric outcomes in low-birth-weight children at age 6 years: relation to neonatal cranial ultrasound abnormalities.

BACKGROUND: This study examined the relation of neonatal cranial ultrasound abnormalities to psychiatric disorder at age 6 years in a regional birth cohort of low-birth-weight children. METHODS: Neonatal cranial ultrasound abnormalities were classified as (1) isolated germinal matrix and/or intraventricular hemorrhage (suggestive of injury to glial precursors) or (2) parenchymal lesions and/or ventricular enlargement (suggestive of white matter injury) with or without germinal matrix-intraventricular hemorrhage. Psychiatric disorders by DSM-III-R at age 6 years were assessed by means of a structured parent interview. Children with severe mental retardation were excluded. Analyses were conducted first in the entire sample and then in children with normal intelligence. RESULTS: Twenty-two percent of the cohort had at least 1 psychiatric disorder, the most common being attention deficit hyperactivity disorder (15.6%). In the entire sample, parenchymal lesions and/or ventricular enlargement increased risk relative to no abnormality, independently of other biological and social predictors, for any disorder (odds ratio [OR], 4.4; 95% confidence interval [CI], 1.8-10.3; P < .001), attention deficit hyperactivity disorder (OR, 3.4; CI, 1.3-8.7; P = .02), and tic disorders (OR, 8.7; CI, 1.3-57.7; P = .02). In children of normal intelligence, parenchymal lesions/ventricular enlargement independently increased risk for any disorder (OR, 4.8; CI, 1.6-12.0; P < .01), attention deficit hyperactivity disorder (OR, 4.5; CI, 1.3-16.0; P = .02), and separation anxiety (OR, 5.3; CI, 1.1-24.8; P = .03). These effects were not ameliorated by female sex or social advantage. Isolated germinal matrix/intraventricular hemorrhage was not related to psychiatric disorder at age 6 years. CONCLUSION: Neonatal cranial ultrasound abnormalities suggestive of white matter injury significantly increased risk for some psychiatric disorders at age 6 years in low-birth-weight children.

Mycobacterium avium intracellulare complex infection in HIV-infected children.

OBJECTIVE: To describe the incidence of, and risk factors for, Mycobacterium avium intracellulare complex (MAC) infection in HIV-infected children. SETTING: University-affiliated children's hospital. DESIGN AND METHODS: The medical records of 70 HIV-infected infants and children were reviewed retrospectively. RESULTS: Seven children (10% of the HIV-infected patients; 18% of those with AIDS) developed disseminated MAC (dMAC). An additional seven children had gastrointestinal colonization with MAC. Risk of dMAC was associated with increasing age, decreasing CD4 cell count, and (possibly) long-term steroid therapy. CONCLUSIONS: HIV-infected children are at risk of developing dMAC. Children older than 60 months and those with a CD4 cell count < 100 x 10(6)/l are most at risk.

Practice parameter: neuroimaging of the neonate: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society.

OBJECTIVE: The authors reviewed available evidence on neonatal neuroimaging strategies for evaluating both very low birth weight preterm infants and encephalopathic term neonates. IMAGING FOR THE PRETERM NEONATE: Routine screening cranial ultrasonography (US) should be performed on all infants of <30 weeks' gestation once between 7 and 14 days of age and should be optimally repeated between 36 and 40 weeks' postmenstrual age. This strategy detects lesions such as intraventricular hemorrhage, which influences clinical care, and those such as periventricular leukomalacia and low-pressure ventriculomegaly, which provide information about long-term neurodevelopmental outcome. There is insufficient evidence for routine MRI of all very low birth weight preterm infants with abnormal results of cranial US. IMAGING FOR THE TERM INFANT: Noncontrast CT should be performed to detect hemorrhagic lesions in the encephalopathic term infant with a history of birth trauma, low hematocrit, or coagulopathy. If CT findings are inconclusive, MRI should be performed between days 2 and 8 to assess the location and extent of injury. The pattern of injury identified with conventional MRI may provide diagnostic and prognostic information for term infants with evidence of encephalopathy. In particular, basal ganglia and thalamic lesions detected by conventional MRI are associated with poor neurodevelopmental outcome. Diffusion-weighted imaging may allow earlier detection of these cerebral injuries. RECOMMENDATIONS: US plays an established role in the management of preterm neonates of <30 weeks' gestation. US also provides valuable prognostic information when the infant reaches 40 weeks' postmenstrual age. For encephalopathic term infants, early CT should be used to exclude hemorrhage; MRI should be performed later in the first postnatal week to establish the pattern of injury and predict neurologic outcome.

Perinatal brain injury in premature infants born to mothers using alcohol in pregnancy. Neonatal Brain Hemorrhage Study Team.

OBJECTIVE: Alcohol has been shown to have teratogenic effects on the fetal central nervous system. However, little research has been done to assess the impact of prenatal alcohol exposure on premature infants, a group particularly vulnerable to perinatal brain injury. METHODS: We examined the relation between maternal alcohol use and the most common forms of brain injury in premature infants--germinal matrix/intraventricular hemorrhage (GM/IVH) and white-matter damage--in a large population-based cohort of infants weighing 2000 g or less. The analyses included 349 infants younger than 31 weeks' gestation who received at least one cranial ultrasound scan and whose mothers were queried about prenatal alcohol use in a postpartum interview. RESULTS: Infants of mothers who reported "moderate" alcohol use (fewer than seven drinks per week and fewer than three drinks per occasion) to "high" use (seven or more drinks per week and/or three or more drinks per occasion) before recognized pregnancy, and moderate alcohol use during pregnancy, were not at increased risk for brain injury. However, after controlling for potentially confounding factors, infants of women reporting high alcohol use during pregnancy were at increased risk of developing isolated brain hemorrhage (odds ratio [OR] = 5.5, 95% confidence interval [CI] = 1.2, 24.7), any brain hemorrhage (OR = 6.7, 95% CI = 1.8, 26.4), and white-matter damage (OR = 9.5, 95% CI = 1.9, 46.4). CONCLUSION: Premature infants of women who report consuming seven or more drinks per week and/or three or more drinks per occasion during pregnancy have substantially elevated risks of both of the most common forms of brain injury in premature infants.

Potential impact of linking an emergency department and hospital-affiliated clinics to immunize pre-school-age children.

OBJECTIVE: To determine whether the use of an urban pediatric emergency department (ED) to immunize pre-school-age children would result in an improvement in the percentage fully vaccinated by the end of the second year of life. DESIGN: A retrospective cohort study of two groups: (1) 100 consecutive children (ED group) enrolled at one of two hospital-affiliated primary care clinics were chosen from the ED patient logs if their second birthday occurred in the 12 months prior to November 1990; and (2) 91 age-matched control children (control group) were chosen at random from the same hospital-affiliated clinics' enrollment logs without regard to ED use. The health care provided during the first 2 years of life for each group was compared. RESULTS: The mean number of visits to the ED in the first 2 years of life by the ED group was significantly greater than that of the control group (2.9 [SD] +/- 2.5 vs 1.1 +/- 1.4; P < .001) during the first 2 years of life. In 67% of ED visits, children would have been well enough to receive a vaccination. Both groups had similar types and numbers of visits to the primary clinics. For example, the ED group had 10 +/- 5 visits by age 2 years compared with the control group, which had 9 +/- 4 visits. There was no significant difference in actual immunization percentages achieved in the clinic, with 62% of the ED group having received four diphtheria, pertussis, and tetanus vaccinations; three oral poliovirus vaccinations; and one measles, mumps, and rubella vaccination by age 2 compared with 69% of control children. There were more missed vaccination opportunities during clinic visits in the ED group (7.4 vs 4.6 per 100 clinic visits; P < .01). If immunizations were offered in the ED to those children who needed them, immunization percentages would have been increased an average of 20% compared with percentages achieved in the clinic alone. CONCLUSION: Routine vaccinations in the ED would significantly increase immunization percentages in children enrolled in two hospital-affiliated clinics. Close linkage and coordination between the ED and hospital-affiliated clinics may improve preventive health care in urban children who use EDs.

Phenylketonuria screening: effect of early newborn discharge.

OBJECTIVE: To determine the percentage of term newborns discharged by 24 hours of life and the actions taken by physicians and institutions to avoid false-negative phenylketonuria (PKU) screens in these infants. DESIGN: Descriptive cross-sectional survey. PARTICIPANTS: One hundred forty term nurseries and 157 pediatricians. SELECTION PROCEDURE: Stratified sampling techniques were used to sample nurseries from the 1992 American Hospital Association guide to provide equal representation of each region of the country. Pediatricians were systematically sampled from a national list of practicing pediatricians supplied by Ross Laboratories to provide equal sampling from each state. RESULTS: The response rates were 95% (n = 133) for term nurseries and 83% (n = 131) for pediatricians. Twenty-four percent of healthy newborns are discharged by 24 hours of life. Ninety-three percent of nurseries screen all infants for PKU before discharge. In states without laws mandating rescreening, only 48% of institutions that discharge the majority of their infants (> 50%) by 24 hours of life rescreen. Also, in states without rescreening laws, 64% of pediatricians rescreen. The timing of this repeat screen ranges from less than 72 hours of life to 4 weeks. Determining which infants to rescreen varies by practitioner; some rescreen all infants, whereas others rescreen those discharged early. Just more than half of all pediatricians, whether practicing in a state requiring repeat PKU screening, claim to be familiar with the American Academy of Pediatrics recommendations regarding repeated PKU screening of infants discharged by 24 hours of life. CONCLUSION: Twenty-four percent of term newborns in the United States are discharged by 24 hours of life. Most hospitals screen all infants for PKU before discharge regardless of age. The majority of states do not mandate rescreening; rescreening policies among pediatricians and institutions in those states vary widely. A significant number of infants do not receive repeated screening and are therefore at risk for delayed or missed diagnosis of PKU because of insensitive initial screens. Pediatrician awareness of the need to perform repeated PKU screens on infants discharged by 24 hours is poor.

Cranial ultrasound prediction of disabling and nondisabling cerebral palsy at age two in a low birth weight population.

OBJECTIVE: To employ multivariate analytic techniques to assess the association between neonatal cranial ultrasound (US) abnormalities and subsequent cerebral palsy (CP), defined as disabling CP (DCP) or nondisabling CP (NDCP) depending on the level of motor dysfunction. DESIGN: Prospective cohort study. SUBJECTS AND METHODS: The Neonatal Brain Hemorrhage Study enrolled a geographically representative sample of 1105 newborns 501 to 2000 g and obtained follow-up data on 777 (86%) of the 901 survivors at age two. One hundred thirteen children (14.6%) had motor findings severe enough to classify them as having CP. The 61 (7.9%) of these children who were disabled by their motor impairment we classified as having DCP. The remaining 52 (6.7%) who had definite neurologic findings (usually mild spastic diplegia) but without evidence of interference with daily living, we classified as having NDCP. RESULTS: In a multivariate logistic regression model of perinatal and postnatal variables, the following factors were found to be significant risk factors for DCP: parenchymal echodensities/lucencies or ventricular enlargement (PEL/VE) on cranial US (OR = 15.4; 7.6, 31.1), germinal matrix/intraventricular hemorrhage (GM/IVH) (OR = 3.5; 1.7, 6.9) and mechanical ventilation (OR = 2.9; 1.2, 7.1). Fully 93.4% of infants were correctly classified as to presence or absence of DCP on the basis of this model. Birth weight, gestational age, length of hospital stay, gender, race, plurality, presence of labor and Apgar score were not significant independent predictors of DCP. For NDCP, the only risk factor significant in the multivariate model was PEL/VE (OR = 5.3; 2.2, 12.6). CONCLUSIONS: Among perinatal and postnatal factors, cranial US abnormalities are by far the most powerful predictors of disabling CP in low birth weight infants. Although PEL/VE was the strongest predictor, GM/IVH also appeared to independently contribute to the risk of DCP. NDCP in low birth weight infants appears to have a different risk profile than DCP. In particular, it is less closely related to US evidence of perinatal brain injury.

Universal hepatitis B immunization.

OBJECTIVE: To determine the practices of US nurseries, neonatal intensive care units (NICUs), and pediatricians regarding universal hepatitis B vaccination. DESIGN: Descriptive cross-sectional survey. PARTICIPANTS: One hundred forty term nurseries, 152 NICUs, and 157 pediatricians. Selection procedure. Nurseries and NICUs were systematically sampled from the 1992 American Hospital Association Guide to provide equal sampling from each region of the country. Pediatricians were systematically sampled from a national list of practicing pediatricians supplied by Ross Laboratories to provide equal sampling from each state. RESULTS: The response rates were 95% (n = 133) for term nurseries, 95% (n = 144) for NICUs, and 83% (n = 131) for pediatricians. Sixty-two nurseries (47%) provide routine hepatitis B vaccine (HBV) to their infants. Eighty-five NICUs (59%) routinely vaccinate their preterm infants; 62 (73%) initiate the series just before discharge; and 11 (13%) do so at birth. Principal reasons for not vaccinating include cost and a preference to allow the primary-care physician to initiate the series. One hundred ten (85%) pediatricians provide universal hepatitis B vaccination. Principal reasons for not vaccinating include cost and parents opting against vaccination. CONCLUSIONS: More than half of NICUs provide HBV routinely to their preterm infants, predominantly just before hospital discharge. A minority of NICUs are initiating vaccination at birth, which may provide suboptimal seroconversion. Although less than half of participating term nurseries are routinely vaccinating before discharge, 85% of pediatricians do initiate HBV by two months of age. The principal reasons for not providing vaccine are financial.

The apgar score and its components in the preterm infant.

OBJECTIVE: The Apgar score is well-characterized in full-term infants but not in premature infants. The objective of this study was to assess the Apgar score in preterm infants with respect to the relationships between the 1- and 5-minute scores, the correlation of the Apgar score with pH and with other variables, and the relationship among the individual Apgar components. METHODOLOGY: We recorded Apgar scores at 1 and 5 minutes in a population-based cohort of preterm infants (n = 1105) with birth weight <2000 g, from three intensive care nurseries in central New Jersey. Linear correlation analysis was used to examine the relationship between 1- and 5-minute Apgar scores and between the individual components of the Apgar score. Multiple regression analysis was used to explore the relationship between various perinatal characteristics and the Apgar score, and between pH and Apgar score. Stepwise logistic regression analysis was used to assess the determinants of mortality. RESULTS: The 1-minute Apgar score median (25%, 75%) was 6(4,8) and correlated with the 5-minute score of 8(7,9) at r = .78. Slight but significant differences were seen between male (n = 557) and female (n = 508) infants in the 1-minute (6[4,8] and 7[4,8]) Apgar scores. One- and 5-minute scores of white infants (7[4,8] and 8[7,9]; n = 713) were significantly higher than those of black infants (5[3,7] and 8[6,9]; n = 280). Birth weight and gestational age were both linearly related to both Apgar scores. Low Apgar score (<3 at 1 minute and <6 at 5 minutes) was significantly associated with birth weight, gestational age and mode of delivery. Low arterial blood pH (<7.01) at birth was significantly related to low Apgar score. One hundred fifty-nine infants died; these infants were significantly smaller (983 +/- 382 vs 1462 +/- 369 g), less mature (27 vs 31 weeks), had lower arterial blood pH (7.20 +/- 0.18 vs 7.31 +/- 0.11), had lower 1- (3[2,6] vs 7[4,8]) and 5-minute Apgar scores (6[4,8] vs 8[7,9]), and a greater incidence of low Apgar score (32% vs 6%) than did survivors. CONCLUSIONS: Among the components of the Apgar score, respiratory effort, muscle tone, and reflex activity correlated well with one another; heart rate correlated less well; and color the least. Our data confirms the limited use of the Apgar score in preterm infants and demonstrates the different responses of the Apgar score's components.

Neonatal cranial ultrasound abnormalities in low birth weight infants: relation to cognitive outcomes at six years of age.

OBJECTIVE: To assess the independent relation of neonatal cranial ultrasound (US) abnormalities in low birth weight (LBW) infants to cognitive outcomes at 6 years of age. DESIGN: Prospective cohort study. SAMPLE AND METHODS: Six-year follow-up data were obtained on a regional birth cohort of LBW infants (< 2 kg) systematically screened as neonates with serial US. US abnormalities were dichotomized into isolated germinal matrix/intraventricular hemorrhage (GM/IVH) and parenchymal lesions/ventricular enlargement (PL/VE). Global cognitive outcomes (mental retardation, borderline intelligence, and normal intelligence) and selected specific cognitive abilities were assessed at 6 years of age with standardized instruments. Multivariate techniques were used to assess the effects of US independent of maternal social disadvantage at birth and other perinatal and neonatal risk factors. RESULTS: The sample as a whole had a significantly elevated rate of mental retardation (MR; 5%), almost all moderate to profound in severity. PL/VE was independently related to MR (odds ratio [OR], 65.8; confidence interval [CI], 19.1 to 22.4) and borderline intelligence (OR, 3.7; CI, 1.3 to 10.8); isolated GM/IVH was more modestly related to MR (OR, 4.6; CI, 1.2 to 18.6) but not related to borderline intelligence. Approximately half of the cases of MR were attributable to PL/VE independent of other factors. Of non-US factors, the number of days receiving mechanical ventilation increased the risk for MR. Maternal social disadvantage increased the risk for borderline intelligence but not MR. Among children of normal intelligence, those with PL/VE, but not isolated GM/IVH, performed more poorly than those without US abnormalities on tests of visual perceptual organization but not on tests of language, memory, or quantitative skills. CONCLUSION: Prevention of white matter injury would substantially improve cognitive outcomes for LBW infants.

Blood pressure ranges in premature infants: II. The first week of life.

OBJECTIVE: To examine the arterial blood pressure in the first week of life in a healthy premature population. DESIGN: Population-based cohort study. SETTING: Three intensive care nurseries in central New Jersey. PATIENTS: Premature infants with birth weights less than 2000 g. MAIN OUTCOME MEASURES: We documented daily maximum and minimum systolic and maximum and minimun diastolic blood pressures during the first 7 days of life. To examine the effects on the ranges of blood pressure, we identified four groups of infants: (1) healthy infants without any of the major risk factors (n = 193); (2) infants who were mechanically ventilated but free of any of the other conditions (n = 225); (3) infants with histories of maternal hypertension or preeclampsia (n = 38) and (4) infants with low Apgar scores (less than 3 at 1 minute and less than 6 at 5 minutes) regardless of the presence of other conditions (n = 86). RESULTS: Blood pressure increased steadily in the first week of life in all four groups. There was no relationship between any of the four blood pressure variables, or trends in blood pressure over time, with birth weight, gender, or race. Regression equations (based on all infants with available data) for blood pressure ranges by day of life revealed that the maximum systolic blood pressure increased by 2.6 mm Hg/d, the minimum systolic blood pressure increased by 1.8 mm Hg/d,the maximum diastolic blood pressure increased by 2.0 mm HHg/d, and the minimum diastolic blood pressure increased by 1.3 Hg/d. CONCLUSIONS: Infants with birth asphyxia and ventilated infants had significantly lower systolic and diastolic blood pressures than healthy infants.

Experiences and reflections of former pediatric chief residents.

OBJECTIVE: To compare actual and ideal time commitments of pediatric chief residents between 1972 and 1992 and to determine if actual time commitments have changed. DESIGN: Descriptive, cross-sectional survey. PARTICIPANTS: One thousand two hundred eighty-four former pediatric chief residents. RESULTS: Chief residents between 1972 and 1982 spent a greater percentage of time teaching and providing patient care than chief residents between 1983 and 1992. Chief residents between 1983 and 1992 spent a greater percentage of time scheduling and performing other administrative tasks. In general, chief residents desired more time to teach, to conduct research, and to provide outpatient care and desired less time for scheduling and for performing other administrative duties. CONCLUSIONS: Although chief residents desire to spend more time teaching and less time performing administrative tasks, administrative duties have increased at the expense of teaching and patient care responsibilities over the past 20 years.

Vision outcome at age 2 years in a low birth weight population.

We assess the prevalence of vision problems in a cohort of low birth weight infants at age 2 years and the relationship of these problems to neonatal brain injury. Data on prenatal and neonatal history and brain injury status were prospectively collected on 721 children weighing 500-2,000 gm at birth enrolled in a multi-center, population-based longitudinal study. Visual acuity was evaluated using the Teller Acuity Card Procedure. Abnormalities of the eye were assessed by a specially trained pediatric nurse practitioner. Failure of the acuity screen occurred in 62 of 699 tested (8.9%). Multiple logistic regression analysis revealed that the only significant independent predictors of failure included presence of disabling cerebral palsy (DCP) (odds ratio [OR] = 14.8) or nondisabling cerebral palsy (NDCP) (OR = 4.0) and Apgar score of less than 5 at 5 minutes (OR = 2.4). Parenchymal brain injury (PEL) was of borderline significance. Strabismus was present in 123 of 702 children (17.5%). Multiple logistic regression analysis disclosed that the joint predictors of strabismus were presence of DCP (OR = 7.2) and length of hospital stay (OR = 1.6). We conclude that low birth weight infants with parenchymal brain lesions leading to cerebral palsy are at particular risk for vision problems early in life and should be carefully evaluated.

MRI, MRA, and neurodevelopmental outcome following neonatal ECMO.

Cranial magnetic resonance imaging (MRI) of 31 newborn infants treated with venoarterial cardiopulmonary bypass for severe but reversible respiratory failure, revealed major focal parenchymal lesions in 7 of 31 infants (23%) and demonstrated abnormal enlargement of extra-axial and ventricular cerebrospinal fluid spaces in 16 of 31 (51%). No preferential left versus right lateralization of focal injury was observed in conjunction with right common carotid artery and jugular vein ligation. No statistically significant relationships were found between major brain lesions on MRI scans and the clinical characteristics of the pre-extracorporeal membrane oxygenation (ECMO), ECMO, and post-ECMO course. Major focal brain lesions were significantly associated with an asymmetric cerebrovascular response to carotid ligation of the right versus left middle cerebral arteries as detected by magnetic resonance angiography (P < .05). Enlarged cerebrospinal fluid spaces were not significantly related to the presence of parenchymal MRI lesions, but were associated with lower Bayley neurodevelopmental scores for mental (MDI) and psychomotor evaluations (PDI) at 6 and 12 months (P < .05). It is concluded that asymmetries of cerebral vascular adaptation detected by magnetic resonance angiography after ECMO may be associated with major brain lesions revealed by MRI. Thereafter, the presence of enlarged cerebrospinal fluid spaces on MRI is associated with a poor shortterm developmental outcome.

Teen father participation in child rearing: family perspectives.

OBJECTIVES: To explore adolescent fatherhood from the perspectives of teen fathers, teen mothers, paternal grandmothers (PGMs), and maternal grandmothers (MGMs). To identify perceived barriers to and recommendations for the enhancement of teen father participation in child rearing. METHODS: A total of 61 teen parents participated in the design of a structured interview. A community-based sample of 173 teen fathers, 167 teen mothers, 76 PGMs, and 79 MGMs were interviewed by teenage assistants. Multiple logistic regression analysis using maximum likelihood estimation and the best subset algorithm identified barriers most predictive of paternal uninvolvement in child rearing. RESULTS: Fifty-four percent of teen fathers and 70% of partners of teen mothers' met the definition of involvement in child rearing. Disinterest in child rearing most consistently predicted uninvolvement. Fathers were less likely than mothers to report paternal disinterest as a barrier and more likely to attribute their lack of involvement to resistance from mothers and MGMs (p < 0.05). The best model predicting paternal involvement from the fathers' perspective included paternal disinterest [odds ration (OR) = 0.42, confidence interval (CI) = 0.19-0.92] and age (OR = 0.74, CI = 0.56-0.97). The best model from the mothers' perspective included paternal disinterest (OR = 0.16, CI = 0.07-0.36) and lack of time (OR = 0.31, CI = 0.15-0.91). Of those fathers who cited disinterest, there was an association with lack of money (p = 0.002) and lack of knowledge of child care (p = 0.069. While fathers and mothers disagreed on several interventions, they agreed (82% and 95%, respectively) that availability of jobs would promote paternal involvement. CONCLUSIONS: Most teen fathers in this study were involved and interested in child rearing. A young father's financial insecurity or confusion about child care was most likely to lead to a stated disinterest, and that disinterest predicted uninvolvement.

PIP: A community-based sample of 173 teen fathers, 167 teen mothers, 76 paternal grandmothers, and 79 maternal grandmothers was interviewed by teenage assistants to explore adolescent fatherhood from a range of differing perspectives. 54% of teen fathers and 70% of partners of teen mothers met the definition of involvement in child rearing. Disinterest in child rearing most consistently predicted uninvolvement. Fathers were less likely than mothers to report paternal disinterest as a barrier and more likely to attribute their lack of involvement to resistance from mothers and maternal grandmothers. The best model predicting paternal involvement from the fathers' perspective included paternal disinterest and age, while the best model from the mothers' perspective included paternal disinterest and lack of time. Of those fathers who cited disinterest, there was an association with lack of money and lack of knowledge of child care. While fathers and mothers disagreed upon several interventions, they agreed that an availability of jobs would promote paternal involvement.

Association of reported infant crying and maternal parenting stress.

Infant crying is a well-recognized source of parental concern and anxiety, but little is known about other possible effects of excessive crying on parents or caretakers. The objective of this descriptive study was to investigate the relationship between reported infant crying and parenting stress. Mothers, who were consecutively enrolled at the time of their infants' well-child checkups, reported the number of minutes their infant generally cried in a 24-hour day. Excessive crying was defined as more than three hours per 24-hour day. Seventy-five of 94 mothers subsequently completed the Parenting Stress Index (PSI) at their infant's 4- or 6-month checkup. Mothers who reported excessive crying were 5.7 times more likely to score high on the reinforcement subscale of the PSI. Although the direction of this association is not known, it indicates that mothers who report excessive crying are more likely than other mothers to perceive a lack of positive reinforcement from their infants.

Obstetric and perinatal events: the accuracy of maternal report.

Physicians commonly rely on maternal recall of events during pregnancy, delivery, and the perinatal period. Investigators who are doing research in the reproductive and perinatal areas also rely on maternal recall. However, there is little information regarding its accuracy. This study evaluates the accuracy of maternal knowledge of events during pregnancy, delivery, and the perinatal period by comparing maternal report with information recorded on the medical records of the mother-infant pair. Results are presented as sensitivity, specificity, and chance-corrected agreement. Mothers demonstrated poor knowledge of pregnancy and delivery-room events. Agreement between maternal reports and hospital records was excellent for infant birth weight and type of delivery, and good for infant jaundice. However, other important areas of the infant's history, such as an evaluation for sepsis, were poorly recalled. The implications of these results are both medical- and research-specific. Physicians must be aware of possible inaccuracies in the mother's history and make every attempt to obtain the nursery discharge summary. In addition, researchers must verify the results of their data when relying on maternal recall, with the exception of infant birth weight and method of delivery.

The management of prepubertal children with gonorrhea.

To determine whether test-of-cure cultures are necessary for prepubertal children diagnosed with Neisseria gonorrhoeae, we examined the records of all 66 patients < 10 years old seen at Children's Hospital of Philadelphia over a 7.5-year period (1987-1994) diagnosed with gonorrhea. Ninety-eight percent had genital discharge on examination. All children with genital gonorrhea were symptomatic, but only 10% of children with rectal gonorrhea and 20% with pharyngeal infection were symptomatic. Seventy-seven percent of children were treated with ceftriaxone. Of these, 72% returned for test-of-cure cultures. Ninety-three percent of children had complete resolution of physical symptoms at test-of-cure, and all follow-up cultures were negative for N. gonorrhoeae. Our data suggest that most prepubertal children with gonorrhea are symptomatic at initial presentation and are cured after recommended treatment with ceftriaxone. The Centers for Disease Control and Prevention recommendations for obtaining test-of-cure cultures in young children with gonorrhea are unnecessary, potentially harmful, and should be revised.

Longitudinal assessment for lead poisoning.

In a previous study, we showed that in our region the prevalence of lead poisoning (Pb > or = 10 micrograms/dL [0.483 mumol/L]) was high (29%) among urban infants. The objectives of this study were to assess the prevalence of lead poisoning over time in this cohort to determine the best screening strategy. Eighty-nine percent (115/129) of infants who were initially screened for lead poisoning between 6 and 12 months of age had a repeat venous lead level by age 3 years (mean = 19.8 months). The majority (70%) lived in a major city and had private medical insurance (80%). The initial and repeat mean venous lead levels were similar for the overall population (lead1 = 8.7 micrograms/dL +/- 6.2 [0.420 +/- 0.299 mumol/L] and lead2 = 7.7 micrograms/dL +/- 6.8 [0.371 +/- 0.328 mumol/L]). However, the percentage of lead-poisoned (Pb > or = 10 micrograms/dL or 0.483 mumol/L) children whose levels were > or = 15 micrograms/dL (0.724 mumol/L) increased from 28% to 48% on repeat. The utility of the initial screen in predicting a second elevated lead level > or = 20 micrograms/dL (0.966 mumol/L) was as follows: sensitivity = 33%, specificity = 97%, positive predictive value = 40%, negative predictive value = 96%. We conclude that in this population, a single screen at 18-24 months of age would reduce the need for multiple venipunctures and would detect those children in need of an intervention.

Prevalence of lead poisoning in an urban cohort of infants with high socioeconomic status.

The purpose of this study was to assess the prevalence of lead poisoning in an urban cohort of infants with high socioeconomic status and to determine the usefulness of the Centers for Disease Control (CDC) questionnaire in predicting lead poisoning. The CDC questionnaire was administered to consecutive parents of infants, beginning with their 6-month well-child visit. All infants had a venous lead level by 12 months of age. The 165 infants were between 5.9 and 12 months (mean = 9.4 months). The majority (67%) lived in a major city, had parents who were college graduates (67%), and had private medical insurance (85%). The overall prevalence of lead poisoning (Pb > or = 10 micrograms/dL [0.483 mumol/L]) was 29%. The relative risk of lead poisoning, given exposure as defined by the CDC instrument, was 0.99 (95% CI = .81 to 1.21). The sensitivity and specificity of the questionnaire were 40% and 60%, respectively. We conclude that the prevalence of lead toxicity and the poor sensitivity of the CDC questionnaire in this cohort of urban infants with high socioeconomic status support the 1991 CDC recommendation for universal lead screening in this region.