Biomedical subjects
Publications and source records attributed to H Bauchner.
A patient with posterior urethral valves presented with unilateral lower leg ecchymosis and edema. He initially had significant renal function impairment. The ecchymosis and edema resolved after appropriate therapy, and his renal function returned to normal.
The purpose of this study was to investigate to what extent selected adverse demographic, clinical, and psychosocial data measured at the 2-week well child visit could predict poorer reliability of mothers' judgments during acute illness episodes over the next 32 months. The study was a randomized trial of the Acute Illness Observation Scales (AIOS); 369 mothers participated, 183 in the intervention group using the Acute Illness Observation Scales and 186 in the control group using a three-point global assessment scale. There were 704 acute illnesses judged simultaneously and independently by mothers and pediatricians. Standard Pearson r correlations were performed between the independent variables, taken singly and in all possible combinations, and the dependent variable, reliability of mothers' judgments as measured by weighted kappa (kappa W). Group assignment was entered as an independent variable. Analyses were performed separately for all first, second, and third acute illness visits to control for any "practice effect" (analysis 1). To control for consistency of observers, the first, second, and third visits of mothers with three visits were also analyzed (analysis 2). Depending on the visit number, adverse demographic, clinical, and psychosocial characteristics did correlate with poorer reliability independent of group assignment. The correlations ranged from small (analysis 1, first visit, multiple variable r2 = 4%) to large (analysis 2, second visit, multiple variable r2 = 29%). Controlling for both visit number and consistency of observers vs visit number alone (analysis 2 vs analysis 1) increased multivariate correlations to kappa W. The results support the untoward impact that adverse demographic, clinical, and psychosocial factors have on mothers' clinical judgment. These data may assist pediatricians in identifying parents who might benefit from more intensive teaching and support about acute illness episodes in their children.
Night waking occurs commonly in infants and young children. The goal of this study is to determine whether parents who report being present when their infant falls asleep at bedtime are more likely to report increased frequency of night waking by the infant. Mothers were consecutively recruited when they brought their infants to the clinic for their 9-month well-child visit. A total of 122 mothers agreed to participate and completed a questionnaire consisting of closed-ended, forced choice questions about their infant's feeding and sleeping behavior, and demographic and psychosocial characteristics. For 33% of the mothers, a parent was routinely present when the infant went to sleep. The entire sample of infants averaged 4.1 night wakings during the week prior to questionnaire completion. Infants whose parents were present at bedtime were significantly more likely to wake at night than infants whose parents were not present (6.2 vs 3.1, P = .01). Frequent night waking (seven or more wakings in the prior week) occurred in 28% of the sample. More of the infants whose parents were present experienced frequent night waking compared with infants whose parents were not present (40% vs 22%, P less than .04). When potential confounding variables were controlled by multivariate analysis, parents being present when the child went to sleep was independently associated with night waking (P less than .03). The association of parental presence at bedtime and night waking has implications for preventing and managing disruptive night waking in infancy.
This report describes the physician-parent-child encounter during an invasive medical procedure in a pediatric emergency department. Fifty children underwent venipuncture or intravenous cannulation performed by 22 physicians and 6 nurses. The median age of the children was 12 months. Parents remained with their children during 31 (62%) of the 50 procedures. Parents were more likely to stay if they had previously stayed when this child (P = .05) or another (P = .02) had undergone a procedure. Parental decision to stay was not related to parental age, gender, race, marital status, or level of education, nor to the residents' age, gender, or level of training. Only 43% of the parents who did stay were given that option by the residents, and of those who did not stay 37% reported that physicians asked them to leave. Nonverbal cues by the residents, such as pulling the curtain closed or turning their back toward parents, were noted in 58% of the encounters in which parents did not stay. The residents and nurses indicated that parents should stay with their child for the following procedures: laceration repair, 66%; venipuncture, 58%; intravenous cannulation, 48%; arterial blood sampling, 32%; suprapubic aspiration, 20%; and lumbar puncture, 14%. In the emergency room studied, it appears that for venipuncture and intravenous cannulation, the majority of parents stay with their children. Parental decision to stay or leave is frequently made without discussion with the physician.
Problems with alcohol are common in the United States but are too frequently ignored by physicians, particularly those working with children. We explored pediatricians' knowledge and practices regarding parental use of alcohol and compared these attributes with those of family practitioners. Child health care providers attending three continuing medical education courses in general pediatrics were surveyed using a closed-item questionnaire. One hundred ninety (69%) of the participants responded, including 90 pediatricians and 39 family practitioners. Forty-six percent of responding pediatricians, compared with 90% of family practitioners, stated that they ask about problems with alcohol in taking a routine family history. Thirty-eight percent of pediatricians who knew the frequency of alcoholism, compared with 47% of those who did not, indicated that they include it in taking a routine family history. Forty-six percent of pediatricians who have experienced a problem with alcohol in their own family, compared with 20% of pediatricians without such personal experience, routinely address the issue of alcohol use with parents and children. Similar analyses among the family practitioners revealed no significant differences. We conclude that fewer than half of pediatricians ask about problems with alcohol in taking a family history. The likelihood of asking about such problems was not influenced by the health care provider's knowledge of alcoholism, but it was influenced by the provider's personal family history of problems with alcohol. Because of the important morbidity associated with alcohol use in families, and because intervention can improve functioning and adaptation of the child, training and Continuing Medical Education courses should address this issue.
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The relationship of maternal use of marijuana and cocaine during pregnancy to measures of neonatal body proportionality and body composition was assessed in a multiethnic sample of 1082 newborn infants. Maternal use of marijuana and cocaine during pregnancy was ascertained by self-report and by an enzyme-multiplied immunoassay technique for screening of urine samples obtained prenatally and again post partum. After each substance was analytically controlled for use of the other and for other potentially confounding variables, detection of marijuana metabolites in maternal urine was associated (p less than 0.05) with depressed mean arm muscle circumference and nonfat area of the arm but not with any measure of neonatal fatness. In contrast, detection of cocaine in maternal urine was associated (p less than 0.05) with decrements of subscapular fat folds and of the fat and nonfat areas of the arm. Although both substances were associated with depressed birth weight, there was no decrement of neonatal ponderal index or of the arm circumference/head circumference ratio in association with exposure to either substance. We conclude that both marijuana exposure and cocaine exposure during pregnancy are associated with symmetric intrauterine growth retardation, but that deficits are in differing compartments of intrauterine growth. These findings suggest that marijuana may retard fetal growth through maternal-fetal hypoxia, whereas cocaine may alter nutrient transfer to the fetus and fetal metabolism.
The purpose of this study was to investigate whether the reliability, sensitivity, and specificity of mothers' judgments about acute illnesses in their children could be improved by using the Acute Illness Observation Scales (AIOS). At the 2-week well child care visit in a primary care center and a private practice, 369 mothers were divided at random into an intervention group (n = 183) and a control group (n = 186). A teaching film and booklet were used to educate mothers in the intervention group about the AIOS; control group mothers were taught a 3-point global scoring system for evaluating the chance of serious illness. In the 32 months of follow-up, 704 acute illnesses were evaluated in tandem and independently by mothers and pediatricians before the history and physical examination; 20 of these illnesses were serious. The judgments of the intervention group were more reliable than those of the control group (weighted kappa = 0.50 vs 0.26, respectively), as was the specificity of their judgments (85% vs 52%, respectively; p less than 0.0001). No difference was noted in the sensitivity of intervention group and control group mothers' judgments (80% vs 90%, respectively). Teaching parents to assess specific clinical information, as represented in the AIOS, has its greatest effect on the reliability and specificity, not the sensitivity, of their judgments. Such teaching could lead to fewer unnecessary office visits during acute illnesses.
Maternal depression is associated with a wide range of adverse outcomes for children, including poor mother-infant interactions at 3 months post-partum. The aim of this study is to determine whether maternal depressive symptoms during pregnancy are associated with neonatal neurobehavioral functioning, as measured by the Neurologic and Adaptive Capacity Scale. The study population consists of 1,123 mothers and their term infants who were participants in a larger study of maternal health and infant outcomes. Women were administered the Center for Epidemiologic Studies-Depression (CES-D) questionnaire for depressive symptoms during their pregnancy. Their infants were subsequently assessed by a pediatrician blind to their CES-D scores. The CES-D score was associated with unconsolability and excessive crying (p less than 0.01). The higher the mother's CES-D score, the more likely it was that the infant would be unconsolable or cry excessively. Mothers with CES-D scores at the 90th percentile were 2.6 times more likely to have unconsolable newborns, compared with women with CES-D scores at the 10th percentile (95% C.I. = 1.54, 4.23). When potentially confounding variables, such as cigarette smoking, alcohol, marijuana, and cocaine use, poor weight gain, income, birth weight, and other drug use, were controlled, the relationship between CES-D score and newborn unconsolability and excessive crying remain unchanged. The results of this study suggest that the relationship between early childhood problems and maternal depressive symptoms may be part of a sequence that starts with depressive symptoms during pregnancy.
The prevalence and correlates of jitteriness were evaluated in a sample of 936 healthy full-term infants. Jitteriness was seen in 44% of this sample: 23% were classified as mildly jittery, 8% as moderately jittery, and 13% as extremely jittery. Jitteriness was seen most commonly in infants who were sleepy or active and least commonly in infants who were quietly wakeful during the neonatal examination. Jittery infants were more likely to be difficult to console when crying (P less than .01) and less visually alert (P less than .001) than were nonjittery infants. Jitteriness was seen more commonly in slightly smaller (P less than .05) and shorter (P less than .001) infants, in those more than 12 hours old (P less than .01), and in those not exposed to general anesthesia (P less than .05). In an expanded sample of 1054 healthy and sick full-term infants, jitteriness was observed more commonly in neonates who had been exposed prenatally to maternal marijuana use (P less than .01), but not to cocaine use (P = .1), and whose mothers had a positive postpartum urine assay for marijuana (P less than .05) or cocaine (P = .06). The magnitude of these drug effects, however, was small. These findings have important implications for the early parent-infant relationship, pediatric practice, and future research.
Although depression is well studied in women, little information is available regarding depression during pregnancy. The purpose of this study was to determine the correlates of depressive symptoms as measured by the Center for Epidemiological Studies-Depression Scale during pregnancy. Between 1984 and 1987, 1014 women, primarily poor and of minority status, who attended the prenatal clinic at Boston City Hospital were interviewed and were asked to furnish urine samples that were then assayed for marijuana and cocaine metabolites. Scores on the Center for Epidemiological Studies-Depression Scale ranged from 0 to 57, with a median score of 16. Depressive symptoms during pregnancy were associated with increased life stress (p less than 0.001), decreased social support (p less than 0.001), poor weight gain (p less than 0.01), and the use of cigarettes (p less than 0.001), alcohol (p less than 0.001), and cocaine (p less than 0.05). These findings are important because these health behaviors have been demonstrated to have an an adverse effect on infant outcome. Interventions to change health behaviors during pregnancy should consider a woman's affective state, social context, and mental health.
Five studies assessing the predictive validity of the Denver Developmental Screening Test (DDST) were evaluated and the results were pooled. Only one study demonstrated good compliance with the authors' methodological standards, but the results were similar to the over-all pooled results. The pooled data indicated that for children over three years of age: (1) the DDST is specific (94 per cent of the children with a good outcome were categorized as normal); (2) the DDST is not sensitive (it did not identify 80 per cent of the children who later had a poor outcome); and (3) a child with a poor outcome was 14 times more likely to have an abnormal or questionable DDST result than a normal one. These data suggest that a child with an abnormal DDST is likely to have a poor school outcome and that many children with school-related problems who might benefit from early intervention are not identified by the DDST.
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To determine whether the risk of sudden infant death syndrome (SIDS) among infants exposed to cocaine in utero may be elevated, we assessed the risk for SIDS in a large, well-described, prospective cohort of infants whose mothers had or had not used cocaine during pregnancy. Of 996 women consecutively enrolled while registering for prenatal care, 175 used cocaine during pregnancy. Only one infant of the mothers who used cocaine died of SIDS, a risk of 5.6 in 1000, compared with four infants among the 821 nonexposed infants, a risk of 4.9 in 1000. The relative risk for SIDS among infants whose mothers used cocaine during pregnancy compared with those whose mothers did not use cocaine was 1.17 (95% confidence interval 0.13, 10.43), suggesting that there is no increased risk of SIDS among infants exposed in utero to cocaine.
Approximately 40,000 infants weighing less than 1500 grams are born in the United States each year. Caring for these infants after their discharge from the newborn intensive care unit is complex and difficult. The survival, growth, routine health care maintenance, neurologic and developmental outcome and assessment, and long-term medical complications are reviewed.