Carol D. Berkowitz

Maternal Depression, Changing Public Assistance, Food Security, and Child Health Status

OBJECTIVE To examine the association of positive report on a maternal depression screen (PDS) with loss or reduction of welfare support and foods stamps, household food insecurity, and child health measures among children aged < or =36 months at 6 urban hospitals and clinics. METHODS A convenience sample of 5306 mothers, whose children <36 months old were being seen in hospital general clinics or emergency departments (EDs) at medical centers in 5 states and Washington, District of Columbia, were interviewed from January 1, 2000 until December 31, 2001. Questions included items on sociodemographic characteristics, federal program participation and changes in federal benefits, child health status rating, childs history of hospitalizations since birth, household food security status, and a 3-question PDS. For a subsample interviewed in the ED, whether the child was admitted to the hospital that day was recorded. RESULTS PDS status was associated with loss or reduction of welfare support and food stamps, household food insecurity, fair/poor child health rating, and history of child hospitalization since birth but not low child growth status measures or admission to the hospital at the time of ED visit. After controlling for study site, maternal race, education, and insurance type as well as child low birth weight status, mothers with PDS were more likely to report fair/poor child health (adjusted odds ratio [AOR]: 1.58; 95% confidence interval [CI]: 1.33-1.88) and hospitalizations during the childs lifetime (AOR: 1.20; 95% CI: 1.03-1.39), compared with mothers without PDS. Controlling for the same variables, mothers with PDS were more likely to report decreased welfare support (AOR: 1.52; 95% CI: 1.03-2.25), to have lost food stamps (AOR: 1.56; 95% CI: 1.06-2.30), and reported more household food insecurity (AOR: 2.69; 95% CI: 2.33-3.11) than mothers without PDS. CONCLUSION Positive maternal depression screen status noted in pediatric clinical samples of infants and toddlers is associated with poorer reported child health status, household food insecurity, and loss of federal financial support and food stamps. Although the direction of effects cannot be determined in this cross-sectional survey, child health providers and policy makers should be aware of the potential impact of maternal depression on child health in the context of welfare reform.

Effects of prenatal methamphetamine exposure on fetal growth and drug withdrawal symptoms in infants born at term.

ABSTRACT. To determine fetal growth and the incidence of withdrawal symptoms in term infants exposed to methamphetamine in utero, we retrospectively identified neonates whose mothers used methamphetamine during pregnancy and matched them to unexposed newborns. Exclusion criteria included multiple and preterm gestations. Although there were no differences in infant growth parameters between the methamphetamine-exposed and methamphetamine-unexposed neonates, methamphetamine exposure throughout gestation was associated with decreased growth relative to infants exposed only for the first two trimesters. In addition, there were significantly more small for gestational age infants in the methamphetamine group compared with the unexposed group. Methamphetamine-exposed infants whose mothers smoked had significantly decreased growth relative to infants exposed to methamphetamine alone. Withdrawal symptoms (as determined by a previously reported scoring system) requiring pharmacologic intervention were observed in 4% of methamphetamine-exposed infants. These preliminary findings indicate that methamphetamine use is associated with growth restriction in infants born at term.

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 Childrens 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.

A Brief Indicator of Household Energy Security: Associations With Food Security, Child Health, and Child Development in US Infants and Toddlers

OBJECTIVE. Household energy security has not been measured empirically or related to child health and development but is an emerging concern for clinicians and researchers as energy costs increase. The objectives of this study were to develop a clinical indicator of household energy security and assess associations with food security, health, and developmental risk in children <36 months of age. METHODS. A cross-sectional study that used household survey and surveillance data was conducted. Caregivers were interviewed in emergency departments and primary care clinics form January 2001 through December 2006 on demographics, public assistance, food security, experience with heating/cooling and utilities, Parents Evaluation of Developmental Status, and child health. The household energy security indicator includes energy-secure, no energy problems; moderate energy insecurity, utility shutoff threatened in past year; and severe energy insecurity, heated with cooking stove, utility shutoff, or ≥1 day without heat/cooling in past year. The main outcome measures were household and child food security, child reported health status, Parents Evaluation of Developmental Status concerns, and hospitalizations. RESULTS. Of 9721 children, 11% (n = 1043) and 23% (n = 2293) experienced moderate and severe energy insecurity, respectively. Versus children with energy security, children with moderate energy insecurity had greater odds of household food insecurity, child food insecurity, hospitalization since birth, and caregiver report of child fair/poor health, adjusted for research site and mother, child, and household characteristics. Children with severe energy insecurity had greater adjusted odds of household food insecurity, child food insecurity, caregivers reporting significant developmental concerns on the Parents Evaluation of Developmental Status scale, and report of child fair/poor health. No significant association was found between energy security and child weight for age or weight for length. CONCLUSIONS. As household energy insecurity increases, infants and toddlers experienced increased odds of household and child food insecurity and of reported poor health, hospitalizations, and developmental risks.

Parental recall after a visit to the emergency department.

Using exit interviews, we determined parental recall of their childs diagnosis, treatment, and follow-up instructions after a visit to the emergency department (ED). Over 2 weeks, 159 parents were interviewed. Exclusion criteria were: parental language other than Spanish or English, admission, trauma, child abuse, or a primary psychiatric diagnosis. Neither language nor parental satisfaction with communication (reported in 93%) was associated with ability to state the diagnosis correctly (P = NS). Seventy-five percent (88 of 117) of parents of children given a single diagnosis stated it correctly; 55% (23 of 42) of parents of children given multiple diagnoses were able to correctly state them all (P = 0.013). If a single medication was prescribed, 30% (20 of 67) of parents knew its name, while only 13% (four of 31) knew all names of multiple medications (P= 0.070). Of those parents given a single medication, 51% (34 of 67) knew how to administer it, while only 10% (three of 31) knew how to administer multiple medications (P <0.001). Similarly, 58% (46 of 79) of parents given a single appointment knew the date and place of their childs follow-up, while only 16% (three of 19) given multiple appointments knew all dates and locations (P = 0.001). These data suggest that despite high parental satisfaction with communication, many parents cannot fully recall their childs diagnosis, treatment, and follow-up — especially when multiple diagnoses, medications, or appointments are given.

Bloody nipple discharge in infancy

7. Howley PM, Israel MA, Law MF, Martin M: A rapid method for detecting and mapping homology between heterologous DNAs. J Bio Chem 254:4876, 1979. 8. Andiman WA: The Epstein-Barr virus and EB virus infections in childhood. J PEDIATR 95:171, 1979. 9. Goldberg GN, Fulginiti VA, Ray G, Ferry P, Jones JF, Cross H, Minnich L: In utero Epstein-Barr virus (infectious mononucleosis) infection. JAMA 246:1579, 1981. 10. Hewetson J, Rocchi G, Henle W, Henle G: Neutralizing antibodies to Epstein-Barr virus in healthy populations and patients with infectious mononucleosis. J Infect Dis 128:283, 1973.

Documentation of Child Physical Abuse: How Far Have We Come?

Objectives. To determine the effects of increased physician training and a structured clinical form on physician documentation of child physical abuse. Design. Retrospective chart review. Participants. Children evaluated in the pediatric emergency department in 1980 and 1995 who were given the diagnosis of physical abuse. Measurements. The unstructured pediatric emergency department form and the structured child abuse reporting form were reviewed for documentation of 20 items including history, physical examination, diagnostic procedures, and disposition. Data documented in 1980 were compared with that in 1995. Results. The only significant differences between 1980 and 1995 concerning documentation on the unstructured pediatric emergency department form were better recording in the latter year of Child Protective Services involvement and case disposition. Half or more of the records omitted documentation of at least one of the following: witnesses to injury, past injuries, description of size and/or color of injuries, illustration, and a genital exam. None of the records contained a developmental history. Significantly fewer skeletal surveys were obtained in 1995, although notation of the results was similar to 1980. For both years, the structured child abuse reporting form improved documentation of only two items: time of arrival to the pediatric emergency department and illustrations of injuries. Conclusions. Little improvement in physician documentation of child physical abuse was noted between 1980 and 1995 despite increased efforts to educate housestaff in the evaluation of child abuse during this time period. Although a structured form prompted physicians to document dates and times and to illustrate physical injuries on the diagram provided, it did not significantly improve documentation of other items.

Safety and immunogenicity of Haemophilus influenzae type b polysaccharide and polysaccharide diphtheria toxoid conjugate vaccines in children 15 to 24 months of age.

To evaluate the safety and immunogenicity of the Haemophilus influenzae type b polysaccharide vaccine, PRP, and a new polysaccharide-diphtheria toxoid conjugate vaccine, PRP-D, a collaborative study was carried out in six centers in five states. Subjects were 585 infants 15 to 24 months of age. They were randomly assigned to receive a single dose of PRP or PRP-D vaccine. There were no significant differences in the rate of adverse reactions between the two vaccine groups. Minor local reactions occurred in 10.3% of PRP and 12.5% of PRP-D recipients, and fever in 27.4% of PRP and 23.8% of PRP-D recipients. All reactions resolved within 48 hours. Serum samples were obtained just before vaccination and after 1 month. Prevaccination antibody levels were similar for the PRP (0.035 micrograms/mL) and PRP-D (0.027 micrograms/mL) groups, with no differences in levels by age, sex, race, vaccine lot, or study site. Both groups had significant rises in geometric mean levels, but this difference was significantly greater for PRP-D (2.166 micrograms/mL) than for PRP (0.154 micrograms/mL). In addition, the percentage of responders as determined by three definitions (twofold titer rise, greater than 0.15 micrograms/mL, and greater than 1.0 micrograms/mL) was also significantly greater for PRP-D than PRP. In contrast to a marked age-related immunogenicity to PRP (P less than 0.001), there was no significant variation in immune response to PRP-D by age. PRP-D conjugate vaccine appears to be as safe and significantly more immunogenic than PRP vaccine for children vaccinated at 15 to 24 months of age.

Sexual Abuse in the Developmentally Disabled: Dilemmas of Diagnosis.

Evaluation of developmentally disabled persons for physical signs of sexual abuse presents many challenges to the practitioner. This group is especially vulnerable to all types of abuse. A group of 35 mentally retarded females from a residential treatment facility was examined by the child abuse medical team at Harbor/UCLA Medical Center after one inpatient was found to be pregnant. Patients ranged in age from 13 to 55 years (median, 26 years; mean, 31.3 +/- 13.6 years). All of the women had some degree of disability, with 24 (69%) being categorized as profoundly retarded. No patient was able to provide a history. There were 13 (37%) patients who had genital findings we believe are consistent with prior vaginal penetration. Dilemmas which arose during evaluation included the significance of healed genital lesions in this population and the implications of the findings for the residential facility. While developmentally disabled persons need an advocate in the medical and legal systems, these patients can overwhelm the practitioner. Whenever possible, a team approach is recommended to decrease the work load and frustration and provide collegial support and affirmation of findings.

A hair tourniquet resulting in strangulation and amputation of the clitoris.

BACKGROUND Hair tourniquet syndrome involves fibers of hair or thread wrapped around an appendage producing tissue necrosis. Appendages commonly involved include the toe, finger, and penis. We report a hair tourniquet resulting in amputation of the clitoris. CASE An adolescent presented with a 4-year history of intermittent genital pain that increased in severity over the preceding 5 days. Physical examination revealed a necrotic clitoris surrounded by a black hair. During the examination, the tissue fell off resulting in immediate improvement in the patients pain. CONCLUSION We report a case of a clitoral hair tourniquet syndrome leading to autoamputation of the clitoris. A high index of suspicion for this condition is important because of the potential consequences of delayed treatment.