[SOCIAL-ECONOMIC-DEMOGRAPHIC DIFFERENCES IN REASONS NOT TO COMPLY IN TIME WITH ROUTINE CHILDHOOD VACCINATIONS].

BACKGROUND: In recent years, there has been an increase in parents who do not comply with recommended routine vaccines. The vaccination coverage rates in Israel are known, but the reasons for not completing immunizations are unknown. The aim of this study was to assess the extent of failure to complete the routine vaccinations in time and the reasons among different population groups. METHODS: This is a retrospective case-control cohort study, among children born in 2009. A total of 14,232 medical records of children who received services at Mother-Child Health Clinics were checked. The children who received all three core vaccines (3th Hepatitis B, 4th DTaP and MMR vaccines) were considered fully compliant and those missing at least one vaccination were considered non-compliant. Six reasons for not complying were identified: medical reasons, parental refusal to vaccinate, requests for a deferred schedule of vaccinations, parental behavior, organizational reasons and others. The differences between groups were analyzed by univariate analysis and logistic regression. RESULTS: In this study, 7.4% of children, were not fully compliant with all three core vaccines within two years. The main reasons in the Jewish population were: refusal and requests for variation in scheduling (44.3%) and in the Arabic population: parental behavior (40.8%). The risk for not completing the vaccinations was higher in children of Jewish mothers, residence in the Hadera sub-district, parents who had an academic education and older parents. CONCLUSIONS: There are differences between Arab and Jewish populations in the reasons for not complying in time with childhood vaccinations. In order to obtain herd immunity in the Israeli population, we need to tailor interventions suitable for each population group according to their characteristics.

Association of Socioeconomic Factors and Infant Nutrition Decisions: Breastfeeding and Type of Formula.

Objective: Breastfeeding is considered the gold standard of infant feeding during the first year of life. However, many women experience difficulty breastfeeding and do not breastfeed to the extent that they initially planned. Our aims were to present factors influencing parents' choices of infant nutrition and to examine whether these choices are influenced by socioeconomic status (SES). Materials and Methods: We conducted a cross-sectional survey by interviewing mothers attending family health centers in various areas of Tel Aviv, Israel. Results: A total of 239 mothers participated in the survey. The choice of source of their infants' nutrition up to the age of 6 months was divided between exclusive breastfeeding, a combination of infant formula (IF) and breastfeeding, and exclusive IF (36%, 34%, and 30%, respectively). Exclusive breastfeeding was related to a higher SES (p = 0.02). The leading cause for combining IF in the infant's diet was maternal difficulty in breastfeeding (60%). The leading factors that influenced the choice of a specific IF product were continuation from the IF given in the hospital nursery (20%), advice from friends or family (20%) and cost (10%). There was a significant difference based on SES. A greater proportion of responders in a higher SES continued the IF that was supplied in the hospital, whereas lower SES parents tended to choose a formula according to its price (p < 0.05 for both). Conclusion: There is an overall lower prevalence of exclusive breastfeeding among low-income families. The maternal choice of the type of IF is associated with parental SES, with the choice of high SES mothers what was fed in the hospital and the choice of low SES related to price.

Different Reasons for Not Completing Routine Vaccinations Among Jewish and Arab Children in Israel.

Minority communities are at high risk for low childhood vaccination coverage rates. This paper compared the rate of children not fully vaccinated and the reasons for that between Jewish (majority) and Arab (minority) children in Israel. This cross-sectional study screened the medical files of 14,232 children (12,360 Jewish and 1872 Arab), registered at Mother-Child Health Clinics in two large geographical area, to identify children who did not complete the last dose of hepatitis B and DTaP or first dose of MMR vaccines. We compared the reasons for not completing the vaccine schedule registered by the nurses between Jewish and Arab children. We identified 1052 children who did not complete at least one of the vaccines: 975 Jewish children and 77 Arab children. Four causal categories were identified: medical reasons, parental decision, parental behaviour, and organizational reasons. Multinomial logistic regression analysis was performed to analyze the reasons for not completing the vaccination protocol. Arab children compared to Jewish children were more likely not to complete the vaccination protocol due to medical reasons (OR 3.81, CI 1.53-9.49) and less likely due to the reason parental decision (OR 0.35, CI 0.13-0.96). Therefore, patterns of reasons for not completing vaccinations vary, depending on population. Interventions to reduce the number of children not fully vaccinated should be tailored to the specific population.

Nutrition and the Use of Supplements in Women During Pregnancy: A Cross-Sectional Survey.

OBJECTIVE: A healthy diet during pregnancy is essential to ensure optimal fetal growth and development. Women's awareness of dietary guidelines may assist them in following a healthy diet for themselves and their unborn babies. The Institute of Medicine and the American College of Obstetrics and Gynecology have published recommendations concerning the nutrition of pregnant/nursing women. The Israeli Ministry of Health has adopted these recommendations in revised guidelines published in 2015. The aim of this study was to describe the dietary habits among pregnant/nursing women in Israel and to assess the correlation between socioeconomic parameters and adherence to those guidelines. METHODS: We performed a cross-sectional survey by interviewing pregnant/lactating women attending family health centers (FHC) in different areas of Tel Aviv, Israel. RESULTS: One-half of the 239 recruited women reported having been informed of the guidelines for dietary changes during and after pregnancy, 30% by a professional source. Women in a lower socioeconomic status (SES) consumed more undercooked (rare) beef, raw fish, and caffeine compared to women in a higher SES (P = 0.03 and P = 0.003, respectively). The former was less compliant with the recommendation for folic acid supplementation (155 [(88.1]) vs 47 [(77]), P = 0.05) and less likely to use other dietary supplements during pregnancy, e.g., multivitamins and omega 3, than the latter (P = 0.01 and P < 0.001, respectively). CONCLUSION: This survey revealed deficiencies in adherence to the implementation of medical guidelines to nutrition during and after pregnancy, as well as gaps between women of different SESs, mostly in the use of dietary supplements.

Growth, developmental achievements and vaccines timeliness of undocumented migrant children from Eritrea compared with Israelis.

INTRODUCTION: Israel has absorbed >40,000 Eritrean undocumented migrants since 2007, while the majority live in the southern neighborhoods of Tel-Aviv. As non-citizens and citizens infants in Israel receive free preventive treatment at the mother and child health clinics (MCHC), this study aimed to compare development and growth achievements between children of Eritrean mothers (CE) to children of Israeli mothers (CI), and assess their compliance to routine follow-up and vaccination-timeliness. METHODS: This cohort study included all Israeli-born CE between 2009 and 2011, compared with a random sample of CI and treated at the same MCHC and followed-up to the age of 30-months. Dependent outcomes included anthropometric measurements, developmental achievements and adherence to immunization schedule. RESULTS: Of all 271 CE who were compared with 293 CI, no statistically significant differences were found in birth anthropometric measurements. Yet, CE had increased weight and length than CI after reaching one year of age (p<0.05). CE were more likely to fail in tests assessing fine-motor skills, linguistic and socio-emotional domains than CI, while no statistical difference was found in gross-motor achievements. At the end of follow-up, 203 (74.9%) of the CE and 271 (74.1%) of the CI completed the vaccination schedule, p = 0.9. CONCLUSION: CE had greater anthropometric measurements than CI after one year of age, and showed higher impairments in fine motor, linguistic and socio-emotional domains. Adherence to vaccination was similar. The inequalities in child health should be responded in the MCTC, and Eritrean mothers should be trained with the current recommendations for child well-being.

A path analysis model suggesting the association between health locus of control and compliance with childhood vaccinations.

Despite vaccines benefits, parent's vaccine hesitancy is growing. Health locus of control (HLOC) may affect decision making regarding child vaccinations. The aim of this study was to investigate the relationship between parents' HLOC and compliance with routine childhood immunization programs. A cross-sectional survey was conducted among 731 parents of children aged 3-4 years. Internal HLOC, powerful others and chance HLOC (dimensions of external HLOC), reliability of information sources, and attitudes towards vaccines were measured. Path analysis was conducted to explore direct and indirect associations between HLOC and vaccination's compliance. The results show that High powerful others HLOC has a direct association with vaccination compliance (ß = 0.23, p < 0.001). High internal and chance HLOC have indirect associations through parents' attitudes regarding vaccines. Perceived reliability of information sources was associated with not complying with vaccines (ß = -0.07, p < 0.05). For conclusions, Interaction between internal and external HLOC may explain vaccination compliance. Decreasing levels of chance HLOC and increasing powerful others HLOC may increase levels of compliance with childhood vaccinations.

Parents with high levels of communicative and critical health literacy are less likely to vaccinate their children.

OBJECTIVE: To investigate the relationship between parents' health literacy and decision-making regarding child vaccinations. METHODS: A cross-sectional survey was conducted among 731 parents of children aged 3-4 years. Functional, communicative, and critical health literacy (HL), knowledge, beliefs, reliability of the vaccine's information resources, and vaccine's attitudes were measured. Attitudes included three types: pro-vaccine attitudes, anti-vaccine attitudes, and attitudes regarding mandatory vaccination. Path analysis was conducted to explore direct and indirect associations of compliance with childhood vaccinations and HL. RESULTS: Communicative HL has a significant negative direct association with compliance with vaccinations (ß=-0.06, p<0.05). High functional and critical HL have significant negative indirect associations with vaccinations through parents' attitudes regarding vaccines. Higher levels of perception of reliability of informal information resources are associated with non-compliance. CONCLUSIONS: The results indicate that parents with high functional, communicative, and critical HL are more at risk of not vaccinating their children. The results are contrary to expectations in which people with high HL adopt more positive health behaviors. PRACTICAL IMPLICATIONS: Public health professionals may need more sophisticated communication methods to transfer messages regarding vaccines to parents in order to prevent decline in vaccine coverage rates, taking into account levels of trust and health literacy.

Melatonin production in infants.

This study investigated the relationships of the excretion of the melatonin metabolite, 6-sulfatoxymelatonin, to prenatal, natal, and postnatal variables and its possible relation to psychomotor development. nocturnal urinary excretion of 6-sulfatoxymelatonin was studied over a 13-hour period in 355 term infants at 8 weeks of age (n = 320) and 16 weeks of age (n = 96). data on a variety of perinatal factors including pregnancy course, delivery, early postnatal course, birth weight, medical problems, growth (length, weight, and head circumference), and psychomotor development were collected at 1, 3, 6, 9, 12, and 18 months. the relationship between nocturnal 6-sulfatoxymelatonin excretion at 8 and 16 weeks of age and these factors was investigated and analyzed. 6-sulfatoxymelatonin levels at 16 weeks of age were significantly lower in infants with abnormal vs normal development at 3 months of age (7.27 + 1.44 vs 7.97 + 1.06, p = 0.05) as well as at 6 months of age (7.15 + 1.29 vs 7.95 + 1.10, p = 0.04). no other significant relation was evident among growth, perinatal complications, medical problems, and 6-sulfatoxymelatonin excretion at 8 weeks of age and at 16 weeks of age. low melatonin excretion in the first weeks of life correlates with delayed psychomotor achievements at 3 and 6 months of age. this association suggests a causal or predictive link between melatonin and neurodevelopment in infants.

Sleep position in Israeli Jewish infants following the "back to sleep" campaign.

BACKGROUND: Prone sleeping has been recognized as a risk factor for sudden infant death syndrome. Ten years ago, non-prone sleeping was recommended in many countries around the world including Israel. The rate of infants sleeping prone and the rate of parents' adherence with the recommendations have not been studied. OBJECTIVES: To study infants' sleep position and parents' adherence to recommendations, and to identify risk factors for prone sleeping following the campaign to prevent prone sleeping in the Israeli population. METHODS: We conducted a longitudinal telephone survey with the parents of 608 randomly selected 2 month old infants, repeated at 4 and 6 months. RESULTS: Non-prone sleeping decreased from 75% to 67% and 63% at 2, 4 and 6 months respectively. There was a significant relationship between prone positioning and the use of a home apnea monitor at 2 months (P = 0.038, odds ratio 1.37, 95% confidence interval 0.94-2.15). Other risk factors for prone sleeping were the level of religious practice, with ultra-Orthodox Jews having the highest prevalence (2 months: OR 2.78, 95% CI 1.75-4.55) and higher parity - especially in families with more than five children (P = 0.041). CONCLUSIONS: The prone sleeping position is relatively high in Israel. Groups at high risk were closely associated with the level of religiousness and parity. Efforts to promote supine sleeping should be directed towards identifiable groups.

Maternal cognitions and depression in childhood behavioral insomnia and feeding disturbances.

OBJECTIVES: To investigate (1) maternal cognitions regarding infant's sleep and feeding and maternal depression among mothers of children with behavioral insomnia, feeding disturbances and healthy controls, and (2) the association between maternal cognitions about sleep and those about feeding. METHODS: Children 6-36 months of age with either behavioral insomnia or feeding disorders were recruited. Children 6-36 months of age who attended the well-baby clinics were recruited and served as controls. The participants' mothers completed three questionnaires on their cognitions/perceptions of their child's sleep and feeding habits and about their own feelings of depression. RESULTS: A total of 230 children (31 with behavioral insomnia, 29 with feeding disorders, 170 controls) were enrolled. Their mean age was 16.1 ± 7.6 months. Maternal cognitions/perceptions about sleep (maternal cognition infant sleep questionnaire, MCISQ) did not differ significantly between the behavioral insomnia group and the feeding disorders group. The MCISQ score was significantly higher in the behavioral insomnia group compared with controls (P < .02). Mothers of children with feeding disorders reported being significantly more frustrated or anxious when they fed their child (P < .0005), less confident about their child getting enough food (P < .0005), and less confident in their ability to manage their child's behavior at mealtime (P < .02) compared to the controls. Significant positive correlations were found between the MCISQ scores and the Beck Depression Inventory scores (r = 0.29, P < .0002), and between the MCISQ scores and the maternal cognitions of their child's feeding scores (r = 0.26, P < .0002). The latter remained significant after controlling for maternal depression (r = 0.25, P < .002). CONCLUSIONS: Mothers of children with either behavioral insomnia or feeding disorders differ significantly from mothers of controls regarding their cognitions about sleep and feeding. Maternal cognitions about infant sleep behavior correlated with their cognitions about infant feeding. Maternal cognitions are a modifiable factor that may serve as a target for intervention in both sleep and feeding disorders in children.

Risk factors of underutilization of childhood immunizations in ultraorthodox Jewish communities in Israel despite high access to health care services.

BACKGROUND: The risk factors of underutilization of childhood vaccines in populations with high access to health services are not fully understood. OBJECTIVES: To determine vaccination coverage and factors associated with underutilization of childhood vaccines in a population with sub-optimal vaccination compliance, despite a high health care access. METHODS: The study was conducted among 430 children from ultraorthodox Jewish communities in the Bnei Brak city and Jerusalem district. Data on immunization status, socio-demographic factors and on parents' attitudes regarding vaccines were obtained from medical records and through parents' interviews. RESULTS: The proportion of fully vaccinated children was 65% in 2- to 5-year-old ultraorthodox children from Jerusalem district, and 86% in 2.5-year-old children from Bnei Brak city. The factors that were significantly associated with vaccines underutilization in Bnei Brak were having >6 siblings, maternal academic education, parental religious beliefs against vaccination, perceived risk of vaccine preventable diseases as low, and mistrust in the Ministry of Health (MOH). Similarly, in Jerusalem, religious beliefs against vaccination, and the perceived low risk of vaccine preventable diseases significantly increased the likelihood of under-immunization, while having a complementary health insurance was inversely related with vaccines underutilization. CONCLUSIONS: The risk factors of under-immunization are in part modifiable, by means of health education on the risks of vaccine preventable diseases and by improving the trust in the MOH. The leaders of the ultraorthodox communities could play an important role in such interventions.

Coexistence of sleep and feeding disturbances in young children.

OBJECTIVE: Behavioral insomnia and feeding difficulties are 2 prevalent conditions in healthy young children. Despite similarities in nature, etiology, prevalence, and age distribution, the association between these 2 common disorders in young children has not been examined thus far. PATIENTS AND METHODS: Children aged 6 to 36 months with either behavioral insomnia or feeding disorders were recruited. Children aged 6 to 36 months who attended the well-care clinics were recruited and served as controls. Sleep and feeding were evaluated by using a parental questionnaire. RESULTS: Six hundred eighty-one children were recruited. Fifty-eight had behavioral insomnia, 76 had feeding disorders, and 547 were controls. The mean age was 17.0 ± 7.6 months. Parents of children with feeding disorders considered their child's sleep problematic significantly more frequently compared with controls (37% vs 16%, P = .0001 [effect size (ES): 0.66]). They reported shorter nocturnal sleep duration and delayed sleep time compared with controls (536 ± 87 vs 578 ± 88 minutes, P = .0001) and 9:13 ± 0.55 PM vs 8:26 ± 1.31 PM, P = .003). Parents of children with behavioral insomnia described their child's feeding as "a problem" more frequently compared with controls (26% vs 9%, P = .001 [ES: 0.69]). They reported being more concerned about their child's growth (2.85 ± 1.1 vs 2.5 ± 1.0, P = .03) and reported higher scores of food refusal compared with controls (3.38 ± 0.54 vs 3.23 ± 0.44, P = .04). CONCLUSIONS: Problematic sleep and feeding behaviors tend to coexist in early childhood. Increased awareness of clinicians to this coexistence may allow early intervention and improve outcome.