Cost-benefit analysis of home visiting to reduce infant mortality among preterm infants.

PURPOSE: The Following Baby Back Home (FBBH) visiting program, which is provided by nurse and social worker teams, supports families of low-birthweight preterm infants after discharge from a neonatal intensive care unit. Enrollment in the FBBH program has been documented to reduce the likelihood of infant death. In this study, we conducted a cost-benefit analysis of the FBBH program. DESIGN AND METHODS: Infants enrolled in the FBBH program (N = 416) were identified through administrative records. Infants in the FBBH program were propensity score matched with comparison infants to estimate the difference in healthcare costs in the first year of life. RESULTS: Infants enrolled in the FBBH program incurred similar medical care costs compared to a comparison group. Avoided deaths, program costs, healthcare costs resulted in net economic benefits of the FBBH program to avoid infant death estimate at $83,020, cost per life saved at $3080, and benefit-to-cost ratio at 27.95. CONCLUSIONS: The FBBH program's net economic benefits from avoided deaths suggest a substantial return on investment of resources, yielding benefits in excess of program and healthcare costs. PRACTICE IMPLICATIONS: It is economically beneficial to provide home visiting services to families of low-birthweight babies by a team comprised of a registered nurse and social worker.

Early infant feeding effect on growth and body composition during the first 6 years and neurodevelopment at age 72 months.

BACKGROUND: This study longitudinally characterized the developmental status, growth, and body composition of children who were fed human milk (breastfed, BF), cow's milk-based (MF), or soy protein-based (SF) infant formula from 3 to 12 months. METHODS: Standardized anthropometrics and dual-energy X-ray absorptiometry were used to characterize growth and body composition at 3, 6, 9, 12, 24, 36, 48, 60, and 72 months (NCT00616395). Preschool Language Scale-3, Children's Memory Scale Index (CMS), and Wechsler Preschool and Primary Scale of Intelligence were administered at age 72 months. Mixed-effects models adjusting for gestational age, birth weight, child race and sex, parental education, and maternal IQ were performed. RESULTS: Body Mass index (BMI) was significantly lower between 24 and 72 months in BF children compared to SF children. At 3 and 6 months, BF infants had significantly higher fat mass (FM) than SF infants, whereas BF children had significantly lower FM at 36 and 48 months than SF children. Delayed Recognition Index of the CMS was higher for SF than for MF participants (p = 0.009). There was no other significant difference in developmental outcomes between groups. CONCLUSIONS: In conclusion, BF, MF, and SF support adequate growth and development up to age 6 years. IMPACT: Although soy protein-based infant formula is reported to support normal infant growth and development compared to cow's milk-based formula and human milk, there are limited data on the effect of these feeding methods in school-aged children. This study suggests a significant difference in body composition, specifically BMI, after 24 months between infant feeding methods during the first year of life and in early childhood; however, all diets provide adequate nutrients to maintain normal development up to 72 months.

Long-Term Neurodevelopment of Low-Birthweight, Preterm Infants with Patent Ductus Arteriosus.

OBJECTIVE: To evaluate whether the presence of patent ductus arteriosus (PDA) in preterm infants worsens long-term neurodevelopmental outcomes. STUDY DESIGN: This was a secondary observational analysis of data from 1090 preterm low-birthweight infants in the Infant Health and Development Program (IHDP), a multicenter longitudinal cohort study of outcomes assessed from 3 to 18 years of age. Multivariable analysis was adjusted for IHDP treatment group (intervention or follow-up), birth weight, maternal race, maternal education, infant sex, maternal preconception weight, Home Observation Measurement of the Environment (HOME) total score at 12 months, neonatal health index, and gestational age. RESULTS: Of the 1090 patients (49% male) included in the analysis, 135 had a PDA. Mean birth weight (1322 g vs 1871 g; P < .0001) and gestational age (30.2 weeks vs 33.4 weeks, P < .0001) were lower and mean ventilator days (11.8 vs 1.3; P < .0001), vasopressor use (12.6% vs 1.2%; P < .0001), and congestive heart failure (8.9% vs 0.1%; P < .0001) were higher in the PDA group. There were no differences between the PDA and no-PDA groups in maternal education level and HOME total score at age 12 months. Multivariable analysis demonstrated no between-group differences in cognitive development or behavioral competence at age 3, 8, and 18 years. CONCLUSIONS: The presence of a PDA in moderately preterm, low-birthweight infants does not impact long-term neurodevelopmental outcomes.

Compared with feeding infants breast milk or cow-milk formula, soy formula feeding does not affect subsequent reproductive organ size at 5 years of age.

BACKGROUND: Literature reports suggest that phytochemicals, such as isoflavones found in soybeans, impair reproductive function in animals and raise the possibility that consuming soy infant formula could alter hormonally sensitive organ development in children. OBJECTIVE: This study compared reproductive organs volumes and structural characteristics in children at age 5 y who were enrolled in the Beginnings study long-term cohort. METHODS: Breast bud, uterus, ovaries, prostate, and testes volumes and characteristics were assessed by ultrasonography in 101 children (50 boys and 51 girls) aged 5 y who were breastfed (n = 35) or fed cow-milk formula (n = 32) or soy formula (n = 34) as infants. Analyses were adjusted for race, gestational age, and birth weight. RESULTS: Among girls, no significant differences were found in breast bud, ovarian, or uterine volumes; counts of ovaries with cysts; ovarian cysts numbers; ovarian cyst size; and uterine shape between the diet groups. Among boys, no significant differences were found in breast bud, testes, or prostate volumes or structural characteristics between the diet groups. CONCLUSIONS: In this cohort, no early infant feeding effects were found on reproductive organs volumes and structural characteristics in children age 5 y. The follow-up of these children through puberty is planned and should help delineate potential early infant feeding effect on reproductive function later in life.

Promoting adolescent behavioral adjustment in violent neighborhoods: supportive families can make a difference!

This study examined the moderating effects of family cohesion on the relationship between community violence and child internalizing and externalizing problems at age 18. The study sample consisted of 728 children and families who were part of the Infant Health and Development Program, an intervention study for low-birthweight, preterm infants. Six of eight sites in the Infant Health and Development Program were in large metropolitan areas; two served rural and urban areas. About half of the sample was African American. Research teams collected data from caregivers multiple times in the first 3 years of the target child's life, and at 4, 5, 6½, 8, and 18 years. Caregivers reported on community violence, neighborhood problems with (a) drug users/sellers; (b) delinquent gangs; and (c) crime, assaults, and burglaries reports when children were 4, 5, and 8 years of age. Family cohesion was assessed twice, at ages 6½ and 8 years, using caregiver reports on the Family Environment Scale. Adolescent self-report of Internalizing and Externalizing Behavior Problems at age 18 were assessed using the Behavior Problems Index. In this study, the association between adolescent psychosocial outcomes and community violence were moderated by family cohesion and gender such that being in a highly cohesive family as a child protected male children from the negative effects of community violence. Findings demonstrate the long-term protective effects of family cohesion on child behavioral development for male children but suggest a need to examine additional supports for females exposed to community violence during childhood.

Variation in child health care utilization by medical complexity.

Children with medical complexity (CMC) have multiple specialty need, technology dependence, and high health care utilization. The objective of this study is to profile types of pediatric health care utilization and costs by increasing levels of medical complexity. This is a cross-sectional study of the 2007, 2008 and 2009 Full-Year Data Sets from the Medical Expenditure Panel Survey. Medical complexity was defined by a higher number of positive items from the five question children with special health care needs (CSHCN) Screener. CMC were defined by ≥ 4 positive screener items. Outcomes included the number of inpatient, outpatient, and emergency department visits, associated costs and diagnoses, and reported satisfaction. ICD-9 codes were grouped by Clinical Classifications Software. Of 27,755 total study subjects ≤ 17 years, 4,851 had special needs and 541 were CMC. Older age, male gender, white/non-Hispanic race/ethnicity, and public insurance were all associated with medical complexity (all p < 0.001). CMC had an annual mean of 19 annual outpatient visits ($616) and 0.26 inpatient visits ($3,308), with other significant cost drivers including home health ($2,957) and prescriptions ($2,182). The most common reasons for non-CSHCN and less-complex CSHCN outpatient visits were viral illnesses, while the main reasons for CMC visits were for mental health. Compared to families without CSHCN, those with CMC have, on average, lower satisfaction with health care (8.4 vs. 8.9 out of 10, p < 0.001). Health care models for CMC should account for mental health conditions that may be driving high numbers of outpatient encounters.

Homelessness during pregnancy: a unique, time-dependent risk factor of birth outcomes.

Evaluate homelessness during pregnancy as a unique, time-dependent risk factor for adverse birth outcomes. 9,995 mothers of children <48 months old surveyed at emergency departments and primary care clinics in five US cities. Mothers were classified as either homeless during pregnancy with the index child, homeless only after the index child's birth, or consistently housed. Outcomes included birth weight as a continuous variable, as well as categorical outcomes of low birth weight (LBW; <2,500 g) and preterm delivery (<37 weeks). Multiple logistic regression and adjusted linear regression analyses were performed, comparing prenatal and postnatal homelessness with the referent group of consistently housed mothers, controlling for maternal demographic characteristics, smoking, and child age at interview. Prenatal homelessness was associated with higher adjusted odds of LBW (AOR 1.43, 95 % CI 1.14, 1.80, p < 0.01) and preterm delivery (AOR 1.24, 95 % CI 0.98, 1.56, p = 0.08), and a 53 g lower adjusted mean birth weight (p = 0.08). Postnatal homelessness was not associated with these outcomes. Prenatal homelessness is an independent risk factor for LBW, rather than merely a marker of adverse maternal and social characteristics associated with homelessness. Targeted interventions to provide housing and health care to homeless women during pregnancy may result in improved birth outcomes.

Body fat and bone mineral content of infants fed breast milk, cow's milk formula, or soy formula during the first year of life.

OBJECTIVE: To characterize growth, fat mass (FM), fat-free mass (FFM), and bone mineral content (BMC) longitudinally in healthy infants fed breast milk (BM), cow's milk formula (CMF), or soy formula (SF) during the first year of life. STUDY DESIGN: Infants were assessed at age 3, 6, 9, and 12 months. Growth was evaluated using standard anthropometric techniques, and body composition was assessed by dual-energy X-ray absorptiometry. Mixed-effects models with repeated measures were used, adjusting for race, socioeconomic status, gestational age, birth weight, birth length, sex, age, and diet history. RESULTS: Compared with infants fed formulas, infants fed BM had higher FM at age 3 months, and lower FFM at age 6-12 months (P < .001). Infants fed SF had greater FFM at age 6 months and 9 months compared with infants fed CMF (P < .001). BMC was higher in infants fed BM and lower in infants fed SF at age 3 months (P < .001), but by age 12 months, BMC was significantly higher in infants fed SF. CONCLUSION: Infants fed CMF and SF had significantly different fat and bone accretion trajectories, and all infants fed formula were significantly different from infants fed BM. Infants fed SF had a leaner body phenotype throughout the first year of life, lower bone mineralization by age 3 months, and greater bone mineral accretion during the first year of life compared with infants fed BM or CMF. Although the body composition profiles are strikingly different in these 3 diet groups, the implications for long-term health outcomes and bone health remain unclear.

Preterm infant linear growth and adiposity gain: trade-offs for later weight status and intelligence quotient.

OBJECTIVE: 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. STUDY DESIGN: 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. RESULTS: More rapid linear growth from term to 4 months was associated with lower odds of IQ <85 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 IQ <85 at age 8. Results at age 18 were similar. CONCLUSION: 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.

US Housing insecurity and the health of very young children.

OBJECTIVES: We investigated the association between housing insecurity and the health of very young children. METHODS: Between 1998 and 2007, we interviewed 22,069 low-income caregivers with children younger than 3 years who were seen in 7 US urban medical centers. We assessed food insecurity, child health status, developmental risk, weight, and housing insecurity for each child's household. Our indicators for housing insecurity were crowding (> 2 people/bedroom or>1 family/residence) and multiple moves (≥ 2 moves within the previous year). RESULTS: After adjusting for covariates, crowding was associated with household food insecurity compared with the securely housed (adjusted odds ratio [AOR] = 1.30; 95% confidence interval [CI] = 1.18, 1.43), as were multiple moves (AOR = 1.91; 95% CI = 1.59, 2.28). Crowding was also associated with child food insecurity (AOR = 1.47; 95% CI = 1.34, 1.63), and so were multiple moves (AOR = 2.56; 95% CI = 2.13, 3.08). Multiple moves were associated with fair or poor child health (AOR = 1.48; 95% CI =1.25, 1.76), developmental risk (AOR 1.71; 95% CI = 1.33, 2.21), and lower weight-for-age z scores (-0.082 vs -0.013; P= .02). CONCLUSIONS: Housing insecurity is associated with poor health, lower weight, and developmental risk among young children. Policies that decrease housing insecurity can promote the health of young children and should be a priority.

Association between Home Environment in Infancy and Child Movement Behaviors.

Introduction: An adequate balance of movement behaviors, including physical activity (PA), sleep, and screen time, is important for preventing excess weight gain in children. This study examined the relationship between the infant home environment and movement behaviors later in life. Methods: Pregnant women were recruited for a cohort study related to maternal and child development. The home environment was assessed for developmental stimulation, organization, and toys by the Pediatric Review of Children's Environmental Support and Stimulation (PROCESS) questionnaire when the child was 6 months of age. At 2 years of age, mother-reported child screen time, and child PA and sleep duration were estimated by accelerometry. Child behaviors were compared with the 24-hour Movement Guidelines (≥180 minutes/day of total PA, 11-14 hours/day of sleep, and ≤1 hour/day of screen time). Logistic regression was used to assess the relationship between the home environment and movement behaviors, adjusting for maternal and child covariates. Results: Mother/child dyads (n = 141) were mainly white (84.4%), and middle (32.8%) or low income (48.9%). All children (100%) met the PA guideline, some met the sleep guideline (71.6%), fewer met the screen-time guideline (44.7%), and only one-third (34.0%) met all three guidelines. Children who met the screen-time guideline lived in homes with more developmental stimulation and toys (p < 0.05). Children who met all 3 guidelines lived in homes with more organization and toys (p < 0.05). Conclusion: The infant home environment was associated with appropriate amounts of movement behaviors at 2 years. Promoting organization (i.e., routines) and toys in infancy may help facilitate nonscreen-based habits and healthy development. The clinical trial registration number is NCT01131117.

Home Visiting for NICU Graduates: Impacts of Following Baby Back Home.

BACKGROUND AND OBJECTIVES: The Following Baby Back Home (FBBH) home visiting program supports families of high-risk low birth weight preterm infants after discharge from a hospital NICU. This study compares the health care use, immunization, and infant mortality rate of low birth weight preterm infants enrolled in FBBH with similar infants not in the program. METHODS: From January 2013 to December 2017, 498 children enrolled in FBBH were identified in Arkansas vital statistics records and the Arkansas All-Payer Claims Database. Infants in FBBH were matched with children in a control group on the basis of demographics and medical conditions of the infant. Generalized linear mixed models with double propensity-score adjustment were used to estimate program effects. RESULTS: In the first year after discharge and compared with a propensity-score matched cohort of control infants, those enrolled in FBBH were significantly more likely to have higher numbers of medical appointments and more compliant immunization history. The odds of dying in the first year of life for control infants was 4.4 times (95% confidence interval: 1.2-20.7) higher than those managed in the program. CONCLUSIONS: A goal of the FBBH home visiting program is to work with parents to educate and support them as they care for their medically fragile infants. We conclude that education and support was instrumental in the infant health care use and outcome differences we observed during the first year of life.

Developmental assessments during the first 5 years of life in infants fed breast milk, cow's milk formula, or soy formula.

OBJECTIVE: To investigate the effects of infant feeding mode on childhood cognition and language as the differential effects of infant feeding on development remain understudied. METHODS: Breastfed [BF, 174], cow's milk-based formula-fed [MF, 169], or soy protein-based formula-fed [SF, 161] children were longitudinally tested from age 3 to 60 months for neurodevelopment. Data were analyzed using mixed models while adjusting for multiple covariates. Sex differences were also assessed. RESULTS: Standard scores were within established norms for all groups. There were no differences in mental development to age 24 months, yet BF children had significantly higher motor development scores at age 3 months than SF children (99.1 versus. 97.2). BF children had significantly higher composite intelligence scores at 48 months than MF and SF children (113.4 versus. 109.6 and 108.4, respectively) and higher verbal intelligence scores than SF children at 48 (105.6 versus. 100.7) and 60 months (109.8 versus. 105.9). Greater total language scores at ages 36 and 48 months were found in BF children compared with children fed MF or SF (p < .001), with differences between sexes for auditory comprehension. Higher total language scores at age 60 months were found between BF and SF (105.0 versus. 100.1). CONCLUSION: Breastfeeding was associated with small, statistically significant, differences between children ages 3 and 5 years in verbal intelligence, expressive communication, and auditory comprehension with the latter having potential sexual dimorphic effects. Yet, these differences remain small and may not be of clinical relevance. Overall, MF and SF did not significantly differ.

Food insecurity and risk of poor health among US-born children of immigrants.

OBJECTIVES: We investigated the risk of household food insecurity and reported fair or poor health among very young children who were US citizens and whose mothers were immigrants compared with those whose mothers had been born in the United States. METHODS: Data were obtained from 19,275 mothers (7216 of whom were immigrants) who were interviewed in hospital-based settings between 1998 and 2005 as part of the Children's Sentinel Nutrition Assessment Program. We examined whether food insecurity mediated the association between immigrant status and child health in relation to length of stay in the United States. RESULTS: The risk of fair or poor health was higher among children of recent immigrants than among children of US-born mothers (odds ratio [OR] = 1.26; 95% confidence interval [CI] = 1.02, 1.55; P < .03). Immigrant households were at higher risk of food insecurity than were households with US-born mothers. Newly arrived immigrants were at the highest risk of food insecurity (OR = 2.45; 95% CI = 2.16, 2.77; P < .001). Overall, household food insecurity increased the risk of fair or poor child health (OR = 1.74; 95% CI = 1.57, 1.93; P < .001) and mediated the association between immigrant status and poor child health. CONCLUSIONS: Children of immigrant mothers are at increased risk of fair or poor health and household food insecurity. Policy interventions addressing food insecurity in immigrant households may promote child health.

Triple risk: do difficult temperament and family conflict increase the likelihood of behavioral maladjustment in children born low birth weight and preterm?

OBJECTIVE: This study examined the impact of family conflict on internalizing and externalizing behavior at age 8 for children born low birth weight (LBW) and preterm (PT), with specific attention to the moderating role of early temperament. METHODS: The sample included 728 families enrolled in the longitudinal study of the Infant Health and Development Program. The study relied on maternal reports of child temperament at age 1, family conflict at age 6(1/2) years and 8 years, and child behavior at age 8 years. RESULTS: Children exposed to high levels of family conflict had more internalizing problems. Child temperament assessed in infancy moderated the impact of family conflict on externalizing but not internalizing problem behavior. DISCUSSION: LBW/PT children with a difficult temperament are more at risk for poor developmental outcomes, such as externalizing behavior problems, when exposed to family conflict than children with a less difficult temperament.

CH medical home program for special needs children. A new medical era...

The ACH Medical Home Program serves as a comprehensive, multi-discipline clinic and program designed to facilitate comprehensive, coordinated care to the most medically complex and fragile children in Arkansas. In partnership with the family, the PCP and the subspecialty physicians, the program strives to ensure that the ideals of providing the "medical home" are accomplished, both in the community and at Arkansas Children's Hospital. An ongoing evaluation process has been implemented and it is the hope and mission of this program to evolve to provide the highest quality of care and highest quality of life for these children with complex medical conditions and for their families. Referrals and inquiries are welcomed and encouraged and can be made at (501) 364-3030.

Food Insecurity, Health, and Development in Children Under Age Four Years.

BACKGROUND AND OBJECTIVES: Food insecurity and pediatric obesity affect young children. We examine how food insecurity relates to obesity, underweight, stunting, health, and development among children <4 years of age. METHODS: Caregivers of young children participated in a cross-sectional survey at medical centers in 5 US cities. Inclusion criteria were age of <48 months. Exclusion criteria were severely ill or injured and private health insurance. The Household Food Security Survey Module defined 3 exposure groups: food secure, household food insecure and child food secure, and household food insecure and child food insecure. Dependent measures were obesity (weight-age >90th percentile), underweight (weight-age <5th percentile), stunting (height/length-age <5th percentile), and caregiver-reported child health and developmental risk. Multivariable logistic regression analyses, adjusted for demographic confounders, maternal BMI, and food assistance program participation examined relations between exposure groups and dependent variables, with age-stratification: 0 to 12, 13 to 24, 25 to 36, and 37 to 48 months of age. RESULTS: Within this multiethnic sample (N = 28 184 children, 50% non-Hispanic African American, 34% Hispanic, 14% non-Hispanic white), 27% were household food insecure. With 1 exception at 25 to 36 months, neither household nor child food insecurity were associated with obesity, underweight, or stunting, but both were associated with increased odds of fair or poor health and developmental risk at multiple ages. CONCLUSIONS: Among children <4 years of age, food insecurity is associated with fair or poor health and developmental risk, not with anthropometry. Findings support American Academy of Pediatrics recommendations for food insecurity screening and referrals to help families cope with economic hardships and associated stressors.

SNAP, Young Children's Health, and Family Food Security and Healthcare Access.

INTRODUCTION: The Supplemental Nutrition Assistance Program (SNAP) is the largest nutrition assistance program in the U.S. This study's objective was to examine the associations between SNAP participation and young children's health and development, caregiver health, and family economic hardships. METHODS: Cross-sectional data from 2006 to 2016 were analyzed in 2017 for families with children aged <3 years in 5 cities. Generalized estimating equations and logistic regression were used to evaluate the associations of SNAP participation with child and caregiver health outcomes and food insecurity, forgone health care, and health cost sacrifices. Nonparticipants that were likely to be eligible for SNAP were compared with SNAP participants and analyses adjusted for covariates including Consumer Price Index for food to control for site-specific food prices. RESULTS: The adjusted odds of fair or poor child health status (AOR=0.92, 95% CI=0.86, 0.98), developmental risk (AOR=0.82, 95% CI=0.69, 0.96), underweight, and obesity in children were lower among SNAP participants than among nonparticipants. In addition, food insecurity in households and among children, and health cost sacrifices were lower among SNAP participants than among nonparticipants. CONCLUSIONS: Participation in SNAP is associated with reduced household and child food insecurity, lower odds of poor health and growth and developmental risk among infants and toddlers, and reduced hardships because of healthcare costs for their families. Improved SNAP participation and increased SNAP benefits that match the regional cost of food may be effective preventive health strategies for promoting the well-being of families with young children.

Loss Of SNAP Is Associated With Food Insecurity And Poor Health In Working Families With Young Children.

The Supplemental Nutrition Assistance Program (SNAP) helps working families meet their nutritional needs. Families whose earned income increases in a given month may have their SNAP benefits abruptly reduced or cut off in the following month. Using sentinel sample data from 2007-15 for families with children younger than age four, we investigated how SNAP benefit reductions or cutoffs resulting from increased income were related to economic hardships (food and energy insecurity, unstable housing, forgone health and/or dental care, and health cost sacrifices) and to caregiver and child health. After we controlled for covariates, we found that the groups whose SNAP benefits were reduced or cut off had significantly increased odds of household and child food insecurity, compared to a group with consistent participation in SNAP. Reduced benefits were associated with 1.43 and 1.22 times greater odds of fair or poor caregiver and child health, respectively. Policy modifications to smooth changes in benefit levels as work incomes improve may protect working families with young children from increased food insecurity, poor health, and forgone care.