Howard Bauchner

Depressive symptoms during pregnancy: Relationship to poor health behaviors

Abstract 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

Association between Vitamin D Deficiency and Primary Cesarean Section

BACKGROUNDnAt the turn of the 20th century, women commonly died in childbirth due to rachitic pelvis. Although rickets virtually disappeared with the discovery of the hormone vitamin D, recent reports suggest vitamin D deficiency is widespread in industrialized nations. Poor muscular performance is an established symptom of vitamin D deficiency. The current U.S. cesarean birth rate is at an all-time high of 30.2%. We analyzed the relationship between maternal serum 25-hydroxyvitamin D [25(OH)D] status, and prevalence of primary cesarean section.nnnMETHODSnBetween 2005 and 2007, we measured maternal and infant serum 25(OH)D at birth and abstracted demographic and medical data from the maternal medical record at an urban teaching hospital (Boston, MA) with 2500 births per year. We enrolled 253 women, of whom 43 (17%) had a primary cesarean.nnnRESULTSnThere was an inverse association with having a cesarean section and serum 25(OH)D levels. We found that 28% of women with serum 25(OH)D less than 37.5 nmol/liter had a cesarean section, compared with only 14% of women with 25(OH)D 37.5nmol/liter or greater (P = 0.012). In multivariable logistic regression analysis controlling for race, age, education level, insurance status, and alcohol use, women with 25(OH)D less than 37.5 nmol/liter were almost 4 times as likely to have a cesarean than women with 25(OH)D 37.5 nmol/liter or greater (adjusted odds ratio 3.84; 95% confidence interval 1.71 to 8.62).nnnCONCLUSIONnVitamin D deficiency was associated with increased odds of primary cesarean section.

The impact of ethnicity, family income, and parental education on children's health and use of health services.

OBJECTIVESnThis study characterized ethnic disparities for children in demographics, health status, and use of services; explored whether ethnic subgroups (Puerto Rican, Cuban, and Mexican) have additional distinctive differences; and determined whether disparities are explained by differences in family income and parental education.nnnMETHODSnBivariate and multivariate analyses of data on 99,268 children from the 1989-91 National Health Interview Surveys were conducted.nnnRESULTSnNative American, Black, and Hispanic children are poorest (35%, 41% below poverty level vs 10% of Whites), least healthy (66%-74% in excellent or very good health vs 85% of Whites), and have the least well educated parents. Compared with Whites, non-White children average fewer doctor visits and are more likely to have excessive intervals between visits. Hispanic subgroup differences in demographics, health, and use of services equal or surpass differences among major ethnic groups. In multivariate analyses, almost all ethnic group disparities persisted after adjustment for family income, parental education, and other relevant covariates.nnnCONCLUSIONSnMajor ethnic groups and subgroups of children differ strikingly in demographics, health, and use of services; subgroup differences are easily overlooked; and most disparities persist even after adjustment for family income and parental education.

A Call for Outcomes Research in Medical Education

The primary goal of medical education is to produce physicians who deliver high-quality health care. Recent calls for greater accountability in medical education and the development of outcomes research methodologies should encourage a new research effort to examine the effects of medical training upon clinical outcomes. The authors offer a research agenda that links medical education and quality of health care and give specific examples of potential research projects that would begin to examine that relationship. A proposed model of patient outcomes research in medical education recognizes the contributory effects of health care system-level factors as well as the continuum of medical education, process measures, and individual training and preparedness to deliver high-quality care. There exists an opportunity to create a research agenda in medical education outcomes research that is multidisciplinary, broad based, and focused on patient-centered outcomes.

Breastfeeding Rates in US Baby-Friendly Hospitals: Results of a National Survey

Objectives. The objectives of this study were to analyze all available breastfeeding data from US Baby-Friendly hospitals in 2001 to determine whether breastfeeding rates at Baby-Friendly designated hospitals differed from average US national, regional, and state rates in the same year and to determine prime barriers to implementation of the Baby-Friendly Hospital Initiative. Methods. In 2001, 32 US hospitals had Baby-Friendly designation. Using a cross-sectional design with focused interviews, this study surveyed all 29 hospitals that retained that designation in 2003. Demographic data, breastfeeding rates, and information on barriers to becoming Baby-Friendly were also collected. Simple linear regression was used to assess factors associated with breastfeeding initiation. Results. Twenty-eight of 29 hospitals provided breastfeeding initiation rates: 2 from birth certificate data and 26 from the medical record. Sixteen provided in-hospital, exclusive breastfeeding rates. The mean breastfeeding initiation rate for the 28 Baby-Friendly hospitals in 2001 was 83.8%, compared with a US breastfeeding initiation rate of 69.5% in 2001. The mean rate of exclusive breastfeeding during the hospital stay (16 of 29 hospitals) was 78.4%, compared with a national mean of 46.3%. In simple linear regression analysis, breastfeeding rates were not associated with number of births per institution or with the proportion of black or low-income patients. Of the Ten Steps to Successful Breastfeeding the 3 described as most difficult to meet were Steps 6, 2, and 7. The reason cited for the problem with meeting Step 6 was the requirement that the hospital pay for infant formula. Conclusion. Baby-Friendly designated hospitals in the United States have elevated rates of breastfeeding initiation and exclusivity. Elevated rates persist regardless of demographic factors that are traditionally linked with low breastfeeding rates.

Prematurity, chorioamnionitis, and the development of recurrent wheezing: A prospective birth cohort study

BACKGROUNDnPrematurity (< 37 weeks) has been inconsistently associated with asthma and wheezing. Chorioamnionitis may promote both prematurity and inflammatory pathways in infants airways.nnnOBJECTIVEnTo investigate the relationship of prematurity and chorioamnionitis with the development of early childhood recurrent wheezing.nnnMETHODSnThe Boston Birth Cohort (n = 1096) were followed prospectively from birth to a mean age of 2.2 +/- 2 years. Perinatal and postnatal clinical data and placental pathology were collected. The primary outcome was recurrent wheezing (> or =2 physician documented episodes). Secondary outcomes included physician-diagnosed asthma, food allergy, and eczema. Preterm children were grouped by gestational age into moderately (33-36.9 weeks) and very preterm (< 33 weeks) with and without chorioamnionitis, and compared with term children without chorioamnionitis (reference group). Chorioamnionitis was diagnosed either by intrapartum fever or by placental histology findings. Logistic regression models were performed to investigate the independent and joint associations of degree of prematurity and chorioamnionitis.nnnRESULTSnPrematurity was associated with recurrent wheezing (odds ratio [OR], 1.7; 95% CI, 1.2-2.6). However, when subjects were grouped by degree of prematurity with or without chorioamnionitis, the highest risk of wheezing (OR, 4.0; 95% CI, 2.0-8.0) and physician-diagnosed asthma (OR, 4.4; 95% CI, 2.2-8.7) was present in the very preterm children with chorioamnionitis. The effect on both wheezing (OR, 5.4; 95% CI, 2.4-12.0) and asthma (OR, 5.2; 95% CI, 2.3-11.9) was greater in African Americans. Neither prematurity nor chorioamnionitis was associated with food allergy or eczema.nnnCONCLUSIONnWe found a strong joint effect of prematurity and chorioamnionitis on early childhood wheezing. This effect was stronger in African American subjects.

Risk of sudden infant death syndrome among infants with in utero exposure to cocaine

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.

Maternal Birthplace and Breastfeeding Initiation Among Term and Preterm Infants: A Statewide Assessment for Massachusetts

OBJECTIVES. Among premature infants, formula feeding increases the risk for necrotizing enterocolitis, delayed brainstem maturation, decreased scoring on cognitive and developmental tests, and delayed visual development. With this in mind, many interventions are designed to increase breast milk consumption in preterm infants. Breastfeeding initiation rates among US premature infants are not collected nationally, however, and published data on breastfeeding rates in this population are limited. In addition, national surveys calculate breastfeeding rates among term infants according to maternal race/ethnicity, but maternal birthplace is not recorded. This is likely to be important, because breastfeeding is the cultural norm in the countries of origin for many non–US-born US residents. Massachusetts has a diverse racial/ethnic population, including many non–US-born women. The goals of this study were to compare breastfeeding initiation rates among preterm and term infants in Massachusetts in 2002 and to determine the effect of maternal race/ethnicity and birthplace on breastfeeding initiation rates among term and preterm infants. METHODS. Massachusetts Community Health Information Profile, an online public health database that was created by the Massachusetts Department of Public Health, includes breastfeeding initiation data that are obtained from the electronic birth certificate, which we used to compare breastfeeding rates among preterm and term infants. Birth-linked demographics and data that also were accessed were maternal age, race/ethnicity, birthplace, and health insurance (public or private) as an indicator of socioeconomic status and infants gestational age. We assessed the association between breastfeeding initiation and maternal birthplace, as well as race/ethnicity and the other potential confounders, using logistic regression. RESULTS. There were 80624 births in Massachusetts in 2002, and 8.2% (6611) of newborns had a gestational age <37 weeks. The states overall breastfeeding initiation rate was 74.6%. We excluded records of mothers who were younger than 15 years and older than 39 years, nonsingleton births, infants with a gestational age <24 weeks and >42 weeks, and records with missing data. Of the total births in Massachusetts, 67884 (84%) met inclusion criteria for this study. Breastfeeding initiation rates were lowest among preterm infants of the youngest gestational ages. Breastfeeding initiation was 76.8% among term infants born at 37 to 42 weeks, 70.1% among infants born at 32 to 36 weeks, and 62.9% among infants born at 24 to 31 weeks. In univariate analysis, among preterm infants, a lower proportion of US-born black, Asian, and Hispanic mothers initiated breastfeeding than US-born white mothers; non–US-born black and non–US-born Hispanic mothers had the highest breastfeeding initiation rates. Among term infants, US-born black mothers had the lowest initiation rates, and non–US-born black and non–US-born Hispanic mothers had the highest. In multivariate logistic regression, however, after controlling for mothers age, race, birthplace, and insurance, US-born white mothers were least likely to breastfeed either term or preterm infants when compared with any other racial/ethnic group, including US-born black mothers. The likelihood that non–US-born Hispanic mothers would breastfeed was almost 8 times greater than that for US-born white mothers for a preterm infant and almost 10 times greater for a term infant. In multivariate logistic regression analysis stratified by gestational age for both preterm and term infants, older mothers and mothers with private health insurance were most likely to breastfeed. CONCLUSIONS. In Massachusetts, preterm infants were less likely to receive breast milk than term infants, and the likelihood of receiving breast milk was lowest among the youngest preterm infants. In multivariate logistic regression, mothers who were born outside the United States were more likely than US-born mothers to breastfeed either term or preterm infants in all racial and ethnic groups. In an unexpected finding, US-born white mothers were less likely to breastfeed term or preterm infants than US-born black mothers or mothers of any other racial or ethnic group.

Widespread Vitamin D Deficiency in Urban Massachusetts Newborns and Their Mothers

OBJECTIVE: To determine vitamin D status and associated factors in a cohort of newly delivered infants and their mothers in Boston, Massachusetts. PATIENTS AND METHODS: Enrollment in this cross-sectional study took place from 2005 to 2007 in an urban Boston teaching hospital with 2500 births per year. A questionnaire and medical-record data were used to identify variables that are potentially associated with vitamin D deficiency (25-hydroxyvitamin D [25(OH)D] < 20 ng/mL). Infant and maternal blood was obtained by venipuncture within 72 hours of birth. The main outcome measure was infant and maternal 25(OH)D status, assessed by competitive protein binding. RESULTS: We enrolled 459 healthy mother/infant pairs. After subsequent exclusions, analyses were performed on 376 newborns and 433 women. The median infant 25(OH)D level was 17.2 ng/mL (95% confidence interval [CI]: 16.0–18.8; range: <5.0 to 60.8 ng/mL). The median maternal 25(OH)D level was 24.8 ng/mL (95% CI: 23.2–25.8; range: <5.0 to 79.2 ng/mL). Overall, 58.0% of the infants and 35.8% of the mothers were vitamin D deficient (25[OH]D < 20 ng/mL); 38.0% of the infants and 23.1% of the mothers were severely deficient (25[OH]D < 15 ng/mL). Risk factors for infant vitamin D deficiency included maternal deficiency (adjusted odds ratio [aOR]: 5.28 [95% CI: 2.90–9.62]), winter birth (aOR: 3.86 [95% CI: 1.74–8.55]), black race (aOR: 3.36 [95% CI: 1.37–8.25]), and a maternal BMI of ≥35 (aOR: 2.78 [95% CI: 1.18–6.55]). Maternal prenatal-vitamin use throughout the second and third trimesters was protective against infant deficiency (aOR: 0.30 [95% CI: 0.16–0.56]). Similarly, prenatal-vitamin use of ≥5 times per week in the third trimester was protective for mothers (aOR: 0.37 [95% CI: 0.20–0.69]). Despite this, >30% of the women who took prenatal vitamins were still vitamin D deficient at the time of birth. CONCLUSIONS: A high proportion of infants and their mothers in New England were vitamin D deficient. Prenatal vitamins may not contain enough vitamin D to ensure replete status at the time of birth.

Sleep Problems in Childhood

Sleep, like eating and toileting, is an individual physical requirement that changes with time as the child matures. Although much about a childs sleep is biologically determined, extrinsic factors, usually through the parents, also mold the childs sleep behavior. Normal sleep for a child is restful to the child and not excessively disruptive to others. Sleep problems interfere with the quality of the childs sleep and frustrate or frighten caretakers. Several sleep problems have their origins in normal sleep behavior from an earlier age. Some, the parasomnias, are caused by self-limited biologic diatheses. Many sleep problems have psychosocial triggers. Sleep disorders only rarely are a primary medical problem that is adequately treated with medication (e.g., narcolepsy). Good history-taking, often accompanied by diary-keeping, will usually identify the problem--the first step in effective treatment. Treatment of a sleep disorder in the pediatricians office can start with educating caretakers about normative sleep for the age of the child and providing information regarding the cause and natural course of the problem. Treatment also may involve behavioral or psychological intervention or both, but medication is generally not indicated. When needed for short-term treatment, mild sedatives such as antihistamines are used most often. More serious sleep or behavioral problems should be acknowledged by the primary care pediatrician, followed by referral to an appropriate specialist. Inquiry into a childs sleep habits at each well-child visit, coupled with appropriate anticipatory guidance, could make an important contribution to the child and family by preventing problems with sleep and identifying sleep problems early in their evolution. Pediatricians and parents can work together to help children develop good sleep habits that fulfill the childs evolving sleep requirements within the context of the familys needs and expectations.