Hyperferritinemia and markers of inflammation and oxidative stress in the cord blood of HIV-exposed, uninfected (HEU) infants.

OBJECTIVES: The purpose of this study was to evaluate markers of iron status and inflammation/oxidative stress in maternal and cord blood (CB) of HIV-infected and HIV-uninfected women as potential mechanisms for poor outcomes among HIV-exposed, uninfected (HEU) infants. METHODS: Maternal venous blood and CB specimens were obtained from 87 pregnant women (45 HIV-infected and 42 HIV-uninfected) enrolled at Kalafong Hospital, Pretoria, South Africa. Iron status [serum iron, ferritin and transferrin concentrations, transferrin saturation, soluble transferrin receptor (sTfR) concentration and the sTfR/log ferritin (sTfR/F) index], antenatal exposure to inflammation (CB C-reactive protein and interleukin-6 concentrations and haptoglobin switch-on status) and oxidative stress [total radical trapping ability of CB plasma (TRAP) and chronic oxidative stress (soluble receptor of advanced glycation end-products (sRAGE) concentration] were assessed in laboratory studies. RESULTS: There were no differences between the HIV-infected and HIV-uninfected groups in maternal haematological and iron indices, except that HIV-infected mothers had decreased white blood cell counts (P = 0.048) and increased serum ferritin concentrations (P = 0.032). Ferritin levels were significantly higher in CB than in maternal blood (P < 0.001) in both groups and further elevated in the CB of HEU infants (P = 0.044). There was also an inverse relationship between CB sTfR/F index and sRAGE (r = -0.43; P = 0.003) in the HIV-infected but not in the HIV-uninfected group. CONCLUSIONS: Our study showed for the first time that ferritin was significantly elevated in CB of HEU infants. The inverse relationship between sTfR/F index and sRAGE in CB suggests that chronic oxidative stress or RAGE axis activation in HIV-infected mothers may play a role in modulating ferritin levels.

Support group processes: Perspectives from HIV-infected women in South Africa.

This study examined the experiences and perceived benefits of support group participation among HIV-infected women in South Africa. From a qualitative analysis of responses, key psychological processes through which support groups are potentially beneficial were identified. These processes included: identification; modeling; acceptance; and empowerment. The participants' consequent life changes were explored in order to associate these processes with the positive outcomes of support group participation. Through understanding the relationship between the psychological processes within a support group setting and the potential benefits, and by targeting these processes in the development and implementation of future support group interventions, a framework is provided for achieving positive outcomes associated with support group participation.

Perception of vulnerability among mothers of healthy infants in a middle-income country.

BACKGROUND: Although four decades have passed since the concept of 'vulnerable children' has been introduced into paediatric literature, research on vulnerability is limited to high-income, Western countries. To adapt and adopt practices that have been advised for paediatricians to prevent 'the vulnerable child syndrome', information is needed also on the prevalence and correlates of perceived vulnerability in children in low- and middle-income (LAMI) countries. OBJECTIVE: To determine the rate and correlates of the perception of vulnerability among healthy young children in a healthy population of children in Ankara, Turkey. METHODS: In this cross-sectional observational study, participants comprised of a 'prescriptive sample' of healthy, thriving children with no known health risk for vulnerability. Maternal perception of child vulnerability was assessed using the Child Vulnerability Scale (CVS). Potential risks factors for vulnerability including history of threatened abortion during pregnancy, child gender, birth order, maternal and paternal age and education were collected using a structured questionnaire. RESULTS: A total of 519 children - 264 boys (50.9%) and 255 girls (49.1%) - comprised the sample. The internal consistency of the CVS was 0.71. Item-total scale correlations were 0.30 or above for all of the eight items. The median CVS score of the sample was 2.0 and 30 mothers (5.8%) were found to perceive their children as vulnerable. None of the socio-demographic variables that were investigated were found to be associated with high vulnerability scores. CONCLUSION: This study is the first to examine maternal perceived vulnerability of healthy children in a middle-income country. The findings imply that a high proportion of healthy children are perceived as vulnerable by their mothers and that previously studied socio-demographic factors do not explain perceived vulnerability. The results of this study may provide a comparison point for studies on childhood vulnerability in LAMI countries.

HIV/AIDS stigma in a South African community.

HIV/AIDS-related stigma threatens to undermine interventions to prevent and treat HIV/AIDS. To address stigma in a South African community, a thorough understanding of the nature of stigma in the specific cultural context is needed. The goals of this research were to assess the level of stigmatising attitudes among members of a community, compare this to the level of stigma that is perceived to exist within the community and determine to what extent stigmatising attitudes are affected by socio-demographic characteristics, HIV-related experience and cultural beliefs. A questionnaire was completed by 1077 respondents in key areas in two communities in Tshwane, South Africa. The questionnaire included an assessment of HIV-related experience, HIV-knowledge, personal stigma and perceptions of stigma within the community. The findings indicate that the level of personal stigma was significantly lower than that perceived to be present in the community. Respondents who were more stigmatising were older, male, less educated and less knowledgeable about HIV. They were less likely to know someone with HIV and had more traditional cultural viewpoints. While socio-demographic and cultural factors are difficult to change, efforts aimed at increasing people's knowledge and experience of the epidemic occurring in their community could change the level of stigmatising attitudes within their community. Such efforts could have potential benefits in addressing the epidemic and providing greater support for those with HIV.

The AIDS epidemic. Past and future.

As we near the end of the second decade of AIDS, this global epidemic is characterized by a widening gap between wealthier nations in North America and Europe and the poorer nations of the world. In developed countries the epidemic has stabilized and there are dramatic decreases in morbidity and mortality resulting from the use of intensive but expensive therapies. This contrasts with the experience of poorer nations, where the epidemic's spread is often unabated and has devastating effects on communities, families, and individuals. A decrease in transmission from mothers to their children is a possibility that still needs to be realized in developing countries, although the potential now exists. Adolescents and young adults are most at risk for contracting the infection, and, recognizing that an effective vaccine is unlikely to be a reality for many years, there is great need for culturally appropriate and innovative means of affecting behavior to decrease the risk of transmission. Although the extent of children's suffering through the loss of their parents has already been felt worldwide, the extreme magnitude of this is still to come, particularly in those countries and communities that have the least resources. The epidemic is a global problem, and addressing the disease and its consequences on children and youth worldwide requires an international response. The potential for complacency in developed countries needs to be replaced by a determination to bridge existing gaps. This requires the focus and support of governments, international agencies such as UNAIDS, nongovernmental organizations, corporations (particularly those that produce antiretroviral medications and artificial milk formulas), researchers from many disciplines, and other individuals.

HIV infection in children. A new hope.

A new understanding of the pathophysiology of HIV infection and recent advances in the development of antiretroviral medications have led to dramatic changes in the ways that children and adolescents are affected by their disease and has provided new hope that did not exist in earlier years of the epidemic. These advances and the changes they have produced, however, have posed new difficulties and challenges to ensuring that each infected child and adolescent benefits maximally. Although there will likely continue to be pauses in the pace of progress, the future holds real promise, and the third decade of the AIDS epidemic should see new developments that will continue to improve the lives of those infected with the virus.

Health care and hospitalizations of young children born to cocaine-using women.

OBJECTIVES: To examine the health care and hospitalizations of young children (birth to age 2 years) born to cocaine-using women and to assess the extent to which premature births account for differences between these children and comparison children. DESIGN: A retrospective cohort design using a repeat-matching method: comparison children were matched to subjects with exposure to cocaine on 6 sociodemographic variables, first, without attention to gestational age and then using the gestational age as additional matching variable. SETTING: City hospitals and primary care clinics. SUBJECTS: Children of women giving birth at a single hospital. MAIN OUTCOME MEASURES: Hospital admission and indexes of health care use for children from birth to age 2 years. RESULTS: Of the 139 subjects with exposure to cocaine, 23% were born prematurely compared with only 6% in the first comparison ( P < .001). At birth, children with exposure to cocaine remained in the hospital longer (P < .01), but this difference was explained by the increased prevalence of prematurity. By age 2 years, these children had significantly fewer visits for health care maintenance (P < .001), were less likely to have completed immunizations (P < .05), and spend more days in the hospital than comparison children. These differences were not related to prematurity, but were explained by differences in sociodemographic characteristics. CONCLUSION: Although prematurity is the major reason for lengthier hospital stays at birth of children with exposure to cocaine, adverse social factors contribute most to inadequate preventive health care and increased stays in the hospital in subsequent years.

Development of a supplement to the HOME Scale for children living in impoverished urban environments.

A Supplement to the HOME (Home Observation for Measurement of the Environment Scale) for impoverished Families (SHIF) was developed for use with young children living in impoverished urban environments. After interviews with clinicians and pilot studies with families, we developed 20 items and added them to the HOME. The supplement was field tested in a sample of 73 high-risk families to evaluate its psychometric properties and ease of use. During the home visit, the Nursing Child Assessment Feeding Scale and the Nursing Child Assessment Teaching Scale were also administered to examine construct validity. Results indicated that the SHIF provided new clinical data, was easy to administer, and, when added to the HOME, had good psychometric properties, e.g., high inter-rater reliability, internal consistency, item-total reliability, and intact construct validity. The SHIF offers a reliable and valid addition to the HOME for use with young children living in impoverished urban environments.

Maltreatment of children born to women who used cocaine during pregnancy: a population-based study.

BACKGROUND: Previous studies of maltreatment of children born to women who used cocaine during pregnancy have relied on either selected samples of infants identified at birth or biased, high-risk samples referred to protective services. OBJECTIVE: To determine the relative risk of either maltreatment or placement outside the home during the first 2 years of life in children born to women who used cocaine during pregnancy compared with a sociodemographically similar comparison group. PATIENTS: We reviewed the medical records of consecutive deliveries at Yale-New Haven Hospital from August 1, 1989 through September 30, 1990. Of the 1140 women who were eligible for the study, 173 had a positive history and/or a positive urine test for cocaine; 139 of the infants were included in the study. A comparison group of infants was chosen from 526 women whose obstetric records indicated that they had not used cocaine during pregnancy based on at least two separate notations in the record. For each of the 139 cocaine-exposed infants, an infant was chosen from the comparison group based on seven matching characteristics: date of birth, race, method of payment for the hospitalization, gestational age, mother's parity, mother's age at delivery, and timing of the first prenatal visit. MAIN OUTCOME MEASURES: Children's medical records at the only two hospitals in the region, the two neighborhood health centers, and the only health maintenance organization were reviewed from birth to 2 years of age. Each injury was classified by two independent reviewers who used predefined criteria to distinguish maltreatment (physical abuse, neglect, or abandonment) from unintentional injuries. Placements outside the home were categorized according to whether the placement was in foster care or with a relative. MAIN RESULTS: The children were mainly African-Americans (80%), and most were enrolled in Medicaid (96.5%). By 2 years of age, 9.3% of the infants in the cocaine-exposed group versus 1.4% in the comparison group had been maltreated [matched relative risk = 6.5; 95% confidence interval (CI) = 1.47, 28.80], and 25.9% vs 8.6% had spent some time in placement (matched relative risk = 5.0; 95% CI = 2.08, 12.01). After controlling for differences between the groups in baseline clinical and social variables, the adjusted odds ratios for both maltreatment (3.98; 95% CI = .81, 22.80) and placement (1.66; 95% CI = .74, 17. 83) decreased and were no longer statistically significant. CONCLUSION: In this population-based study, children born to women who used cocaine during pregnancy were at a substantially increased risk of maltreatment or placement outside the home compared with a sociodemographically similar comparison group. Differences in baseline variables between the two groups, however, partially accounted for this increased risk. Therefore, a mother's use of cocaine is more likely a marker of increased risk rather than a single explanatory variable.

Development of a prognosis-based clinical staging system for infants infected with human immunodeficiency virus.

PURPOSE: To develop a prognosis-based clinical staging system for infants infected with human immunodeficiency virus. METHODS: Abstraction of data from medical records of 75 infected children. For each clinical finding present in infancy, the magnitude of the relative risk (RR) for early death was used to assign subjects to different clinical stages. RESULTS: Stage IV (RR > 3) included subjects with Pneumocystis carinii pneumonia, other opportunistic infections, or encephalopathy. Stage III (RR, 2 to 3) included those with anemia, thrombocytopenia, hepatitis, fever, oral candidiasis, or one or more serious bacterial infections. Stage II included those with hepatomegaly, splenomegaly, failure to thrive, or persistent diarrhea, and stage I included those who had lymphadenopathy or were free of symptoms. When clinical staging was applied to the study population at ages as early as 6 months, survival curves were significantly different (IV vs III: p < 0.0005; III vs II + I: p < 0.005). CONCLUSIONS: Clinical staging should be beneficial in advising parents about an infant's prognosis, therapeutic decision making, and stratification for clinical trials.

The psychological effects of parental human immunodeficiency virus infection on uninfected children.

OBJECTIVES: To assess the mental health of children of mothers infected with the human immunodeficiency virus. DESIGNS: Matched comparison of 26 children of mothers infected with the human immunodeficiency virus and 26 children with no experience of human immunodeficiency virus infection within their families. SETTINGS: Subject children were identified through hospital acquired immunodeficiency syndrome clinics and comparison children were identified through the primary care center of the same hospital. PARTICIPANTS: Subjects and controls were aged 6 to 16 years and matched by age, sex, race, and maternal marital and employment status. MAIN OUTCOME MEASURES: Parents completed the Child Behavior Checklist and the children completed the Revised Children's Manifest Anxiety Scale and the Children's Depression Inventory. RESULTS: Controlling for confounding variables, subjects were found by the Child Behavior Checklist to be significantly more withdrawn (P < .05) and to have more problems with attention (P < .005) than controls, although total Child Behavior Checklist scores were not significantly different. Compared with control children, the subject children reported more depression on the Children's Depression Inventory (P < .05) but were not more anxious. However, compared with children of asymptomatic mothers, the children of symptomatic mothers were reported to be significantly more anxious and/or depressed on the Child Behavior Checklist (P < .01) and the children reported more anxiety on the Revised Children's Manifest Anxiety Scale (P < .05). CONCLUSIONS: This study focusing specifically on uninfected children in families affected by the human immunodeficiency virus demonstrates some of the psychological ramifications of this disease. Larger studies are required to identify factors that contribute to the vulnerabilities and resilience of such children. Attention needs to focus on ameliorating these adverse effects on the children of the acquired immunodeficiency syndrome epidemic.

The child vulnerability scale: an instrument to measure parental perceptions of child vulnerability.

Developed and validated an instrument for identifying children perceived as vulnerable. Mothers of 1,095 children, aged 4-8 years, completed interviews that included the original 12-item Child Vulnerability Scale. Eight items that correlated best with each of two major variables that contribute to vulnerability were retained in the revised scale and a cutoff score was identified for children perceived as vulnerable. The internal consistency of the revised scale was good. Using the revised scale, 10.1% of children were identified as perceived vulnerable. Children categorized as perceived vulnerable had a significant increase in behavior problems and acute medical visits. The revised Child Vulnerability Scale should be useful in providing a better understanding of the causes and effects of an important factor in child development.

Primary care of children with HIV infection.

As the number of children affected by the HIV epidemic increases, the primary care physician can have an important role in ensuring that these children receive comprehensive health care. Clinical aspects of pediatric HIV disease are reviewed, including the recently revised Centers for Disease Control and Prevention classification system. Important advances include the development and application of techniques for establishing in early infancy whether or not a child is infected. The implications for the use of these techniques are discussed, and recommendations are made for a system of coordinated care between the primary care physician and specialty clinic. Specific treatment approaches, such as the early introduction of Pneumocystis carinii pneumonia prophylaxis, antiretroviral medications, and the use of intravenous immunoglobulin, are discussed.

Psychological sequelae of medical complications during pregnancy.

To determine whether mothers with complicated pregnancies are at increased risk of postpartum depression and whether their children are at increased risk of being perceived as vulnerable, the investigators conducted an interview survey of mothers of 1095 children aged 4 to 8 in a community-based sample of primary care pediatric practices. The offspring were viewed as vulnerable by 17% of the women with severe pregnancy complications and 9% of the women without pregnancy complications (relative risk = 1.88; 95% confidence interval = 1.11, 2.63). Women with a severe complication of pregnancy were significantly more likely to report postpartum depression than those without a complication (27% vs 11%; relative risk = 2.45; 95% confidence interval = 1.55, 3.01). These relationships persisted after adjustment for prematurity, neonatal hospitalization, and demographic factors. It is concluded that pregnancy complications may place a woman at increased risk of postpartum depression and may have important effects on a mother's long-term perceptions of her child's vulnerability to illness.

Perceptions of vulnerability 3 1/2 years after problems of feeding and crying behavior in early infancy.

The long-term consequences for infants with problems of feeding and crying behavior remain unknown. The purpose of this research was to determine whether such children are later perceived by their parents as vulnerable and more often have behavior problems and have different personalities than children without problems in infancy. The implications of managing such problems by changing milk formulas is explored. Mothers of 379 infants were enrolled in the postpartum period. Information about problems of feeding and crying behavior was obtained at 4 months. Thirty-six percent of the infants had problems and the formula had been changed for 17%. At 3 1/2 years, 320 (84%) mothers completed a questionnaire. Children who had had problems were more often perceived as vulnerable (relative risk [RR] 1.86; 95% confidence interval [CI] 1.09, 3.19) and more often had behavior problems (RR 1.78; 95% CI 1.03, 3.07). There were no differences in personality. Children whose problems had been managed by changing milk formulas were more often perceived as vulnerable (RR 2.18; 95% CI 1.05, 4.53). Although allergies were reported significantly more often for those children who had had problems, there were no differences in the prevalence of asthma or eczema. Problems of feeding and crying behavior in early infancy and the way they are managed may have long-term implications for the child.

A novel approach to training pediatrics primary care residents.

From 1984 through 1987, 12 pediatrics residents from the Yale University School of Medicine took part in a three-year program that emphasized four areas in primary care: well-child care, developmental-behavioral pediatrics, chronic illness, and adolescent medicine. Program evaluation included a videotaped interview, an assessment of the residents' skill in the management of patients' behavioral problems, and multiple-choice examinations. The program residents improved their interviewing skills more than did the comparison residents, particularly in the process and psychosocial content areas, and also did better in the management of patients' behavioral problems. There was no difference in factual knowledge of behavioral and developmental pediatrics and adolescent medicine. While traditional residency training in primary care may provide the resident with comparable cognitive knowledge, such training may not always improve the resident's ability to apply the knowledge in the primary care setting.

Persistent perceptions of vulnerability following neonatal jaundice.

Treatments for neonatal jaundice are generally considered both safe and effective. We hypothesized that such treatments would be associated with symptoms of the vulnerable child syndrome, persisting up to 6 months. Mothers of otherwise healthy infants who had jaundice and demographically similar infants without jaundice born at Yale-New Haven (Conn) Hospital were surveyed and compared 6 months after discharge from the hospital. By 6 months, the infants with jaundice had significantly more feeding difficulties, eg, they were less likely to be breast-feeding. Unexpectedly, the mothers of infants with jaundice switched from being less likely to leave their infants with someone else at 1 month to leaving the infants significantly more than mothers of infants in the comparison group. Although the mothers of infants in the comparison group reported a similar number of infant health problems, the mothers of infants with jaundice were more likely to judge the problems as serious and to have taken the infant to an emergency department. The benefits of treating jaundice in otherwise healthy infants should be weighted against the risks of developing the vulnerable child syndrome.

Colic and the effect of changing formulas: a double-blind, multiple-crossover study.

This study investigated the effect of changing the formulas of colicky infants and addressed the methodologic flaws of earlier studies. Attention was paid to issues of designing a blind study, providing a washout period, and measuring and reproducing the effect. In this randomized, double-blind trial, three changes of formula were made: for each of four 4-day periods, colicky infants alternately received a casein hydrolysate formula (Nutramigen) and a formula containing cow milk. Mothers recorded crying in diaries and indicated which crying episodes they considered to have been caused by colic. Nine infants were started on Nutramigen and eight on the cow milk formula. With the first formula change there was significantly less crying and colic in infants when they were fed Nutramigen than when they were fed cow milk (p less than 0.01); with the second change there was less colic when infants were fed Nutramigen (p less than 0.05) but not significantly less crying. By the third change there were no significant differences between formulas. Further analyses demonstrated that there were more clinically meaningful positive responses (a change in crying by at least one third) to Nutramigen than to cow milk (p less than 0.05). However, only one subject had a clinically meaningful response in colic to all three formula changes. These results demonstrate that in some instances, colic improves with elimination of cow milk formula. However, the effect diminishes with time, and only infrequently is the effect reproducible.