Breastfeeding and long-chain polyunsaturated fatty acid intake in the first 4 post-natal months and infant cognitive development: an observational study.

The aim of this study was to examine infant feeding and the long-chain polyunsaturated fatty acid (LCPUFA) concentration of breast milk and formulas in relation to infant development. The prospective Pregnancy, Infection and Nutrition Study (n=358) collected data on breastfeeding, breast milk samples and the formulas fed through 4months post-partum. At 12months of age, infants' development was assessed (Mullen Scales of Early Learning). Linear regression was used to examine development in relation to breastfeeding, breast milk docosahexaenoic acid (DHA) and arachidonic acid (AA) concentration, and DHA and AA concentration from the combination of breast milk and formula. The median breast milk DHA concentration was 0.20% of total fatty acids [interquartile range (IQR)=0.14, 0.34]; median AA concentration was 0.52% (IQR=0.44, 0.63). Upon adjustment for preterm birth, sex, smoking, race and ethnicity and education, breastfeeding exclusivity was unrelated to development. Among infants exclusively breastfed, breast milk LCPUFA concentration was not associated with development (Mullen composite, DHA: adjusted ß=-1.3, 95% confidence interval: -10.3, 7.7). Variables combining DHA and AA concentrations from breast milk and formula, weighted by their contribution to diet, were unassociated with development. We found no evidence of enhanced infant development related to the LCPUFA content of breast milk or formula consumed during the first four post-natal months.

Preventing young children's injuries: analysis of data from a population-based surveillance.

The objective of this study is to determine prevention strategies for potentially serious injury events among children younger than 3 years of age based upon circumstances surrounding injury events. Surveillance was conducted on all injuries to District of Columbia (DC) residents less than 3 years old that resulted in an Emergency Department (ED) visit, hospitalization, or death for 1 year. Data were collected through abstraction of medical records and interviews with a subset of parents of injured children. Investigators coded injury-related events for the potential for death or disability. Potential prevention strategies were then determined for all injury events that had at least a moderate potential for death or disability and sufficient detail for coding (n = 425). Injury-related events included 10 deaths, 163 hospitalizations, and 2,868 ED visits (3,041 events in total). Of the hospitalizations, 88% were coded as moderate or high potential for disability or death, versus only 21% of the coded ED visits. For potentially serious events, environmental change strategies were identified for 47%, behavior change strategies for 77%, and policy change strategies for 24%. For 46% of the events more than one type of prevention strategy was identified. Only 8% had no identifiable prevention strategy. Prevention strategies varied by specific cause of injury. Potential prevention strategies were identifiable for nearly all potentially serious injury events, with multiple potential prevention strategies identified for a large fraction of the events. These findings support developing multifaceted prevention approaches informed by community-based injury surveillance.

The National Children's Study of environmental effects on child health and development.

Increasing recognition that children may be more susceptible than adults to environmental exposures and that they experience potentially life-long consequences of such exposures has led to widespread support for a large new cohort study in the United States. In this article, we propose a framework for a new cohort study of children, with follow-up beginning before birth and continuing to age 21 years. We also describe the administrative structure that has been built to develop the proposal further. The structure includes a partnership between federal and nonfederal scientists and relies on a collaborative, interdisciplinary research effort of unprecedented scale in medical research. We discuss briefly how the proposed cohort could be used to examine, among many other things, the effect of chemical contaminants in breast milk on children's health and development.

Relationships between bullying and violence among US youth.

OBJECTIVE: To determine the extent to which bullying and being bullied, both in and away from school, is associated with involvement in violent behavior. DESIGN, SETTING, AND PARTICIPANTS: A US representative cross-sectional sample of 15 686 students in grades 6 through 10 in public and private schools completed the World Health Organization's Health Behaviour in School-aged Children survey in 1998. MAIN OUTCOME MEASURES: Self-report of weapon carrying, weapon carrying in school, physical fighting, and being injured in a physical fight. RESULTS: Involvement in each of the violence-related behaviors ranged from 13% to 23% of boys and 4% to 11% of girls. Bullying others and being bullied were consistently related to each violence-related behavior for both boys and girls. Greater odds of involvement occurred with bullying others than being bullied, and greater odds of involvement occurred with bullying that took place away from school than that occurring in school. For example, the adjusted odds ratio for weapon carrying associated with being bullied in school weekly was 1.5, for bullying others in school 2.6, for being bullied away from school 4.1, and for bullying others away from school 5.9. CONCLUSION: Bullying should not be considered a normative aspect of youth development, but rather a marker for more serious violent behaviors, including weapon carrying, frequent fighting, and fighting-related injury.

Prevalence of and risk factors for depressive symptoms among young adolescents.

OBJECTIVE: To determine the prevalence, risk factors, and risk behaviors associated with depressive symptoms in a nationally representative, cross-sectional sample of young adolescents. DESIGN: A school-based survey collected through self-administered questionnaires in grades 6, 8, and 10 in 1996. SETTING: Schools in the United States. PARTICIPANTS: 9863 students in grades 6, 8, and 10 (average ages, 11, 13, and 15). MAIN OUTCOME MEASURES: Depressive symptoms, substance use, somatic symptoms, scholastic behaviors, and involvement in bullying. RESULTS: Eighteen percent of youths reported symptoms of depression. A higher proportion of females (25%) reported depressive symptoms than males (10%). Prevalence of depressive symptoms increased by age for both males and females. Among American Indian youths, 29% reported depressive symptoms, as compared with 22% of Hispanic, 18% of white, 17% of Asian American, and 15% of African American youths. Youths who were frequently involved in bullying, either as perpetrators or as victims, were more than twice as likely to report depressive symptoms than those who were not involved in bullying. A significantly higher percentage of youths who reported using substances reported depressive symptoms as compared with other youths. Similarly, youths who reported experiencing somatic symptoms also reported significantly higher proportions of depressive symptoms than other youths. CONCLUSIONS: Depression is a substantial and largely unrecognized problem among young adolescents that warrants an increased need and opportunity for identification and intervention at the middle school level. Understanding differences in prevalence between males and females and among racial/ethnic groups may be important to the recognition and treatment of depression among youths.

Headache, stomachache, backache, and morning fatigue among adolescent girls in the United States: associations with behavioral, sociodemographic, and environmental factors.

BACKGROUND: Data on the prevalence and co-occurrence of multiple somatic symptoms among US adolescent females as they are influenced by sociodemographic, behavioral, and environmental factors is limited. OBJECTIVES: To describe the health status of adolescent US females measured by the prevalence, frequency, and co-occurrence of headache, stomachache, backache, and morning fatigue and to investigate associations between selected risk and protective factors. DESIGN, SETTING, AND PARTICIPANTS: School-based, cross-sectional, nationally representative survey of adolescents in the 6th through 10th grades in the US. Data collected between 1997 and 1998. MAIN OUTCOME MEASURES: Prevalence of headache, stomachache, backache, and morning fatigue. RESULTS: Among US adolescent girls, 29.1% experience headaches, 20.7% report stomachaches, 23.6% experience back pain, and 30.6% report morning fatigue at the rate of more than once a week. Co-occurrence of somatic complaints is common. Among girls who experienced headaches more than once a week, 3.2 million (53.3%) also reported stomach pain more than once a week and 4.1 million (74.3%) reported morning fatigue more than once a week. Heavy alcohol use, high caffeine intake, and smoking cigarettes every day were strongly associated with all symptoms, while parent and teacher support served as protective factors. CONCLUSIONS: Somatic complaints of headache, stomachache, backache, and morning fatigue are common among US adolescent girls and co-occur often. Effective clinical treatment of this population requires comprehensive assessment of all female adolescents presenting with seemingly isolated somatic complaints.

A cross-national study of violence-related behaviors in adolescents.

BACKGROUND: Violent behavior among adolescents is a significant problem worldwide, and a cross-national comparison of adolescent violent behaviors can provide information about the development and pattern of physical violence in young adolescents. OBJECTIVES: To determine and compare frequencies of adolescent violence-related behaviors in 5 countries and to examine associations between violence-related behaviors and potential explanatory characteristics. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional, school-based nationally representative survey at ages 11.5, 13.5, and 15.5 years in 5 countries (Ireland, Israel, Portugal, Sweden, and the United States). MAIN OUTCOME MEASURES: Frequency of physical fighting, bullying, weapon carrying, and fighting injuries in relation to other risk behaviors and characteristics in home and school settings. RESULTS: Fighting frequency among US youth was similar to that of all 5 countries (nonfighters: US, 60.2%; mean frequency of 5 countries, 60.2%), as were the frequencies of weapon carrying (noncarriers: US, 89.6%; mean frequency of 5 countries, 89.6%) and fighting injury (noninjured: US, 84.5%; mean frequency of 5 countries, 84.6%). Bullying frequency varied widely cross-nationally (nonbullies: from 57.0% for Israel to 85.2% for Sweden). Fighting was most highly associated with smoking, drinking, feeling irritable or bad tempered, and having been bullied. CONCLUSIONS: Adolescents in 5 countries behaved similarly in their expression of violence-related behaviors. Occasional fighting and bullying were common, whereas frequent fighting, frequent bullying, any weapon carrying, or any fighting injury were infrequent behaviors. These findings were consistent across countries, with little cross-national variation except for bullying rates. Traditional risk-taking behaviors (smoking and drinking) and being bullied were highly associated with the expression of violence-related behavior.

Multiple risk behavior and injury: an international analysis of young people.

BACKGROUND: Multiple risk behavior plays an important role in the social etiology of youth injury, yet the consistency of this observation has not been examined multinationally. OBJECTIVE: To examine reports from young people in 12 countries, by country, age group, sex, and injury type, to quantify the strength and consistency of this association. SETTING: World Health Organization collaborative cross-national survey of health behavior in school-aged children. PARTICIPANTS: A multinational representative sample of 49 461 students aged 11, 13, and 15 years. MAIN EXPOSURE MEASURES: Additive score consisting of counts of self-reported health risk behaviors: smoking, drinking, nonuse of seat belts, bullying, excess time with friends, alienation at school and from parents, truancy, and an unusually poor diet. MAIN OUTCOME MEASURE: Self-report of a medically treated injury. RESULTS: Strong gradients in risk for injury were observed according to the numbers of risk behaviors reported. Overall, youth reporting the largest number (> or =5 health risk behaviors) experienced injury rates that were 2.46 times higher (95% confidence interval, 2.27-2.67) than those reporting no risk behaviors (adjusted odds ratios for 0 to > or =5 reported behaviors: 1.00, 1.22, 1.48, 1.73, 1.98, and 2.46, respectively; P<.001 for trend). Similar gradients in risk for injury were observed among youth in all 12 countries and within all demographic subgroups. Risk gradients were especially pronounced for nonsports, fighting-related, and severe injuries. CONCLUSIONS: Gradients in risk for youth injury increased in association with numbers of risk behaviors reported in every country examined. This cross-cultural finding indicates that the issue of multiple risk behavior, as assessed via an additive score, merits attention as an etiological construct. This concept may be useful in future injury control research and prevention efforts conducted among populations of young people.

Depressive symptoms during pregnancy and the concentration of fatty acids in breast milk.

The aim of the present study was to examine the association between depressive symptoms in pregnancy and the concentration of long-chain polyunsaturated fatty acids (LCPUFAs) in breast milk. Women (n = 287) enrolled in the Pregnancy, Infection, and Nutrition Study completed the Center for Epidemiologic Studies Depression Scale in pregnancy (< 20 and 24-29 weeks) and had LCPUFAs measured in breast milk (4 months postpartum). Multiple linear regression was used to examine associations between depressive symptoms and breast milk LCPUFAs. Increasing depressive symptoms at < 20 weeks were associated with lower docosahexaenoic acid concentrations (adjusted ß = -1.15, 95% confidence interval = -2.12, -0.19). No similar associations were observed with other fatty acids nor between symptoms at 24-29 weeks and LCPUFAs. Depressive symptoms, even in the subclinical range, early in pregnancy are inversely associated with breast milk docosahexaenoic acid. This may have implications for the timing of screening and interventions for perinatal depression and the nutritional value of breast milk.

A prospective study of maternal anxiety, perceived stress, and depressive symptoms in relation to infant cognitive development.

AIM: Our objective was to examine the associations between maternal psychological health (trait anxiety, perceived stress, and depressive symptoms) during pregnancy or postpartum and infant visual, language, motor, and overall cognitive development. STUDY DESIGN AND METHODS: In the prospective Pregnancy, Infection, and Nutrition Study (2001-2006), central North Carolina women completed self-administered questionnaires during pregnancy to assess trait anxiety and depressive symptoms. An in-person interview assessed maternal perceived stress and depressive symptoms in the 4th postpartum month. Infant development was assessed at 12 months using the Mullen Scales of Early Learning (n=358). Multiple linear regression with restricted cubic splines was used to examine potential non-linear associations between trait anxiety, perceived stress, and depressive symptoms in relation to Mullen sub-scales and Composite scores. RESULTS: Increasing maternal anxiety was associated with poorer overall cognition (adjusted ß for Composite=-0.2, 95% CI: -0.4, 0.0). Postpartum stress was positively associated with language development and general cognition (adjusted ß for Expressive Language=0.2, 95% CI: 0.0, 0.4; adjusted ß for Composite=0.3, 95% CI: 0.0, 0.6). Elevated depressive symptoms throughout pregnancy and postpartum were associated with better fine motor skills (adjusted ß=9.7, 95% CI: 3.9, 15.5). Anxiety, postpartum depressive symptoms and stress were associated with gross motor skills in a non-linear fashion, as were postpartum depressive symptoms and stress with expressive language. CONCLUSIONS: Maternal trait anxiety, depressive symptoms and stress had little negative influence on infant cognitive development. In fact, moderate psychosocial distress may slightly accelerate motor development in particular, and some aspects of language.

Assault-injured adolescents presenting to the emergency department: causes and circumstances.

OBJECTIVES: To describe the causes and circumstances of conflict leading to assault injury among urban youth seeking care in the emergency department. METHODS: The authors conducted in-person and telephone interviews with a convenience sample of 143 youth aged 12-19 years presenting to two urban emergency departments with an interpersonal assault injury. Patients were interviewed about the nature and circumstances of their injury. Descriptive analysis was performed, including stratified analysis by gender, age (12-15 vs. 16-19 years), and weapon use. RESULTS: Seventy percent of patients knew or knew of the person(s) who injured them; most were friends, classmates, or acquaintances. More than half of the injuries (56%) were related to a past disagreement. Among assaults related to a past disagreement, 33% of patients had previous arguments with their assailant, 16% had previous fights, and 14% had previous weapons threats. Twenty-nine percent had been previously threatened, and 11% had previously threatened their assailant. Twenty-eight percent of patients believed they helped to cause the injury by provoking a fight or letting down their guard. Nearly two thirds (64%) believed there were things they could change to prevent future injury, including staying away from dangerous situations and bad influences or controlling their tempers. CONCLUSIONS: Most assault injuries among adolescents involved past disagreements with people they knew. Many injured youth were mutually involved in conflict before their injury. Over time, many victims and perpetrators may be interchangeable. These data may help inform emergency department-based interventions to prevent assault injury.

Adolescent assault injury: risk and protective factors and locations of contact for intervention.

BACKGROUND: Violence is a large contributor to morbidity and mortality among adolescents. Most studies assessing markers for violent injury are cross-sectional. To guide intervention, we conducted a case-control study to explore factors associated with assault injury and locations to reach at-risk adolescents. OBJECTIVE: 1) To assess risk and protective factors for adolescent assault injury compared with 2 control groups of youth with unintentional injuries and noninjury complaints presenting to the emergency department and 2) to assess locations of contact with assault-injured youth for prevention programs. METHODS: Face-to-face and phone interviews were conducted with systematic samples of youth aged 12 to 19 years presenting to the emergency department with assault injury, unintentional injury, and noninjury complaints. Youth with intentional injuries were matched to youth in the 2 control groups on age +/-1 year, gender, race, and residency. RESULTS: One hundred forty-seven 147 assault-injured youth completed interviews. One hundred thirty-three assault-injured youth were matched to 133 unintentionally injured and 133 noninjured youth presenting to the emergency department. Compared with the 2 control groups, assault-injured youth were more likely to have had more fights in the past year (odds ratio [OR]: 3.91; 95% confidence interval [CI]: 2.02, 7.58; OR: 4.00; 95% CI: 2.23, 7.18) and fights requiring medical treatment (OR: 35.49; 95% CI: 8.71, 144.68; OR: 80.00; 95% CI: 11.13, 574.80). Eighty percent of assault-injured youth had been in 1 or more fights in the last 12 months compared with 55% and 46% in unintentional and noninjured controls, respectively. Assault-injured youth were more likely to have had previous weapon injuries (OR: 9.50; 95% CI: 3.39, 26.6; OR: 8.50; 95% CI: 3.02, 23.95) and have seen someone shot (OR: 2.00; 95% CI 1.12, 3.58; OR: 2.00; 95% CI: 1.12, 3.58). Eighty-six percent of assault-injured youth had a regular health care provider with 82% reporting a visit within the last year. There were no differences between cases and controls with regard to physician contact, extracurricular activity involvement, school or church attendance, police contact, weapon access or weapon-carrying, or witnessing nonweapon-related violence. CONCLUSIONS: Fighting was common among all groups. Assault-injured youth were more likely to have had previous weapon injuries and were high-risk for future injury. Past fights, past fight injuries, and seeing someone else shot were markers associated with assault injury. Health providers do have access to at-risk teens for clinical risk assessment and intervention.

Injury surveillance in the ED: design, implementation, and analysis.

Comprehensive, population-based surveillance for nonfatal injuries requires uniform methods for data collection from multiple hospitals. To show issues related to design and implementation of multihospital, emergency department (ED), injury surveillance, a city-wide system in the United States is discussed. From October 1, 1995 to September 30, 1996 all injury-related ED visits among District of Columbia residents <3 years of age were ascertained at the 10 hospitals where city children routinely sought care. Information was abstracted from 2,938 injury-related, ED visits (132.7 visits/1,000 person-years). Based on this experience, suggestions to facilitate design of multihospital, injury surveillance in other locations are offered. Importantly, injury-related visits were reliably ascertained from ED logs, and for most variables, a systematic sample of injury-related visits was representative of the total injured population. However, there is a need for more complete documentation of circumstances surrounding injuries and for standardization of data elements on ED logs and treatment records.