Mary Lu Angelilli

From suspicion of physical child abuse to reporting: Primary care clinician decision-making

OBJECTIVES. The goals were to determine how frequently primary care clinicians reported suspected physical child abuse, the levels of suspicion associated with reporting, and what factors influenced reporting to child protective services. METHODS. In this prospective observational study, 434 clinicians collected data on 15003 child injury visits, including information about the injury, child, family, likelihood that the injury was caused by child abuse (5-point scale), and whether the injury was reported to child protective services. Data on 327 clinicians indicating some suspicion of child abuse for 1683 injuries were analyzed. RESULTS. Clinicians reported 95 (6%) of the 1683 patients to child protective services. Clinicians did not report 27% of injuries considered likely or very likely caused by child abuse and 76% of injuries considered possibly caused by child abuse. Reporting rates were increased if the clinician perceived the injury to be inconsistent with the history and if the patient was referred to the clinician for suspected child abuse. Patients who had an injury that was not a laceration, who had >1 family risk factor, who had a serious injury, who had a child risk factor other than an inconsistent injury, who were black, or who were unfamiliar to the clinician were more likely to be reported. Clinicians who had not reported all suspicious injuries during their career or who had lost families as patients because of previous reports were more likely to report suspicious injuries. CONCLUSIONS. Clinicians had some degree of suspicion that ∼10% of the injuries they evaluated were caused by child abuse. Clinicians did not report all suspicious injuries to child protective services, even if the level of suspicion was high (likely or very likely caused by child abuse). Child, family, and injury characteristics and clinician previous experiences influenced decisions to report.

Dose-response relationships between iron deficiency with or without anemia and infant social-emotional behavior.

OBJECTIVE To assess dose-response relationships between severity of iron deficiency (ID) and infant social-emotional behavior. STUDY DESIGN The study group was a cohort of 9- to 10-month-old African-American infants (n = 77 with final iron status classification). The infants were given oral iron for 3 months. Social-emotional outcomes included mother and examiner ratings at 9 and 12 months and quantitative behavioral coding from videotape at 12 months. General linear model analyses tested for linear effects of iron status group (ordered from worst to best: iron-deficient anemia [IDA], nonanemic iron-deficient [NA ID], iron-sufficient [IS]) and determined thresholds for effects. RESULTS There were significant (P <.05) linear effects of poorer iron status for shyness (increasing, maternal rating), orientation-engagement, and soothability (decreasing, examiner ratings), and the following quantitatively coded behaviors: positive affect (decreasing) and latencies to engage with the examiner (increasing) and move away from the examiner (decreasing). The threshold for all but 1 effect was ID with or without anemia versus IS. CONCLUSIONS Infant social-emotional behavior appears to be adversely affected by ID with or without anemia. ID without anemia is not detected by common screening procedures and is more widespread than IDA. Infant social-emotional behavior can profoundly influence the care-giving environment, with repercussions for overall development.

Iron deficiency anemia and cognitive function in infancy.

OBJECTIVES: This study examined effects of iron deficiency anemia (IDA) on specific domains of infant cognitive function and the role of IDA-related socioemotional deficits in mediating and/or moderating these effects. METHODS: Infants were recruited during routine 9-month visits to an inner-city clinic. IDA was defined as hemoglobin level <110 g/L with ≥2 abnormal iron deficiency indicators (mean corpuscular volume, red cell distribution width, zinc protoporphyrin, transferrin saturation, and ferritin). At 9 and 12 months, the Fagan Test of Infant Intelligence (FTII); A-not-B task; Emotionality, Activity, and Sociability Temperament Survey; and Behavior Rating Scale were administered. Analyses were adjusted for potential confounders, including age and sociodemographic variables. RESULTS: Twenty-eight infants met criteria for IDA, 28 had nonanemic iron deficiency (NA ID) and 21 had iron sufficiency (IS). There was a linear effect for object permanence at 9 months: infants with IDA were least likely to exhibit object permanence, IS most likely, and NA ID intermediate. Infants with IDA and those with hemoglobin level ≤105 g/L showed poorer recognition memory on the FTII than infants without IDA. The Behavior Rating Scale orientation/engagement measure partially mediated these effects. Stronger effects of IDA on these outcomes were seen in infants who scored more poorly on the socioemotional measures. CONCLUSIONS: These data indicate poorer object permanence and short-term memory encoding and/or retrieval in infants with IDA at 9 months. These cognitive effects were attributable, in part, to IDA-related deficits in socioemotional function. Children with poor socioemotional performance seem to be more vulnerable to the effects of IDA on cognitive function.

An Event-Related Potential Study of Attention and Recognition Memory in Infants With Iron-Deficiency Anemia

OBJECTIVES. The purpose of this work was to determine whether iron-deficiency anemia in infancy represents a risk factor for deficits in attention and memory development using event-related potentials. METHODS. Artifact-free event-related potential data were obtained at 9 and/or 12 months from 15 infants with iron-deficiency anemia and 19 who were iron sufficient during a test of the infants ability to discriminate a highly familiar stimulus, the mothers face, from a strangers face. RESULTS. A midlatency negative component associated with attention and a late-occurring positive slow wave associated with memory updating were identified at both ages in the iron-deficiency anemia and iron-sufficient groups. Consistent with the age-appropriate pattern of development at 9 months, the iron-sufficient group showed a greater attentional response (negative component) to the mother and a greater updating of memory for the stranger (positive slow wave). This pattern of responses was not evident in the iron-deficiency anemia group until 12 months, suggesting a delay in cognitive development. CONCLUSIONS. These data suggest that iron-deficiency anemia adversely affects the allocation of neurophysiologic resources to attention and recognition memory during the processing of information about familiar and unfamiliar stimuli. This delay in cognitive development may reflect alterations in efficiency of central nervous system functions that seem related to early iron deficiency.

IRON DEFICIENCY AND INFANT MOTOR DEVELOPMENT

BACKGROUND Iron deficiency (ID) during early development impairs myelination and basal ganglia function in animal models. AIMS To examine the effects of iron deficiency anemia (IDA) and iron deficiency (ID) without anemia on infant motor skills that are likely related to myelination and basal ganglia function. STUDY DESIGN Observational study. SUBJECTS Full-term inner-city African-American 9- to 10-month-old infants who were free of acute or chronic health problems with iron status indicators ranging from IDA to iron sufficiency (n=106). Criteria for final iron status classification were met by 77 of these infants: 28 IDA, 28 non-anemic iron-deficient (NA ID), and 21 iron-sufficient (IS). OUTCOME MEASURES Gross motor developmental milestones, Peabody Developmental Motor Scale, Infant Neurological International Battery (INFANIB), motor quality factor of the Bayley Behavioral Rating Scale, and a sequential/bi-manual coordination toy retrieval task. General linear model analyses tested for linear effects of iron status group and thresholds for effects. RESULTS There were linear effects of iron status on developmental milestones, Peabody gross motor (suggestive trend), INFANIB standing item, motor quality, and toy retrieval. The threshold for effects was ID with or without anemia for developmental milestones, INFANIB standing item, and motor quality and IDA for toy retrieval. CONCLUSIONS Using a comprehensive and sensitive assessment of motor development, this study found poorer motor function in ID infants with and without anemia. Poorer motor function among non-anemic ID infants is particularly concerning, since ID without anemia is not detected by common screening procedures and is more widespread than IDA.

History of In Utero Cocaine Exposure in Language-Delayed Children

To determine whether children with language delays are more likely to have been exposed to cocaine in utero than children with normal language development, a case-control study was undertaken. Based on routine office screening in our primary-care clinic over a 1-year period, we identified 29 consecutive children, aged 24 to 48 months, as language-delayed. They were compared with an approximate 2:1 match of children without language delay who had been seen in the clinic on the same days and who were of similar age. There was more reported cocaine use during pregnancy (six of 29, 21%) among the language-delayed children than among the controls (five of 71, 7%). This difference is statistically significant (P < 0.05, χ2 = 3.92; odds ratio = 3.4 ± 2.2). Discriminant analysis revealed that both cocaine and nicotine exposure were associated with delayed language development — with an unexpected negative, i.e., an antagonistic, protective, interactive effect (F[3,96] = 4.66, R2 = 12.7%, P<.005); neither gender nor caretaker contributed to language development in this sample. These results suggest that children with language delay detected in a clinical setting are more likely to have been exposed in utero to cocaine than children with normal language development. Prenatal cocaine exposure should be a risk factor in monitoring development in children.

Inter-rater evaluation of a clinical scoring system in children with asthma

BACKGROUND Many clinical scores that measure the degree of asthma are used without adequate evaluation of inter-rater reliability. When reliability is tested, most often the Cohen K statistic is used, which limits the comparative results of only two raters at a time. OBJECTIVE To evaluate inter-rater agreement of a clinical asthma score using a multi-rater K statistic. METHODS Four raters administered a clinical asthma score to 17 children with clinical asthma. Five items were evaluated: O2 requirement, inspiratory breath sounds, accessory muscle use, expiratory wheeze, and cerebral function. For each, a score of zero indicated a normal state; one, moderate impairment; two, severe impairment. A multi-rater kappa statistic was used as a measure of agreement among all four raters simultaneously. This was applied using hand calculations then cross-checked by using a standard statistical syntax, a component of the Statistical Package for Social Sciences (SPSS 9.0). RESULTS Application of the multi-rater K statistic revealed strong agreement among raters on oxygenation (K = 0.759), moderate agreement for expiratory wheeze and cerebral function (K = 0.698), and poor agreement for accessory muscle use (K = 0.528) and inspiratory breath sounds (K = 0.316). CONCLUSIONS The level of agreement varied by item with the least subjective item, O2 requirement, demonstrating the highest inter-rater correlation. A multi-rater kappa statistic can be applied to data obtained from a clinical scoring instrument either manually or by using statistical syntax provided by SPSS.

Higher Infant Blood Lead Levels with Longer Duration of Breastfeeding

OBJECTIVE To determine whether longer breastfeeding is associated with higher infant lead concentrations. STUDY DESIGN Data were analyzed from 3 studies of developmental effects of iron deficiency in infancy: Costa Rica (1981-1984), Chile (1991-1996), and Detroit (2002-2003). The relation between duration of breastfeeding and lead levels was assessed with Pearson product-moment or partial correlation coefficients. RESULTS More than 93% of the Costa Rica and Chile samples was breastfed (179 and 323 breastfed infants, respectively; mean weaning age, 8-10 months), as was 35.6% of the Detroit sample (53 breastfed infants; mean weaning age, 4.5 months). Lead concentrations averaged 10.8 microg/dL (Costa Rica, 12-23 months), 7.8 microg/dL (Chile, 12 months), and 2.5 microg/dL (Detroit, 9-10 months). Duration of breastfeeding as sole milk source and total breastfeeding correlated with lead concentration in all samples (r values = 0.14-0.57; P values = .06-<.0001). CONCLUSIONS Longer breastfeeding was associated with higher infant lead concentration in 3 countries, in 3 different decades, in settings differing in breastfeeding patterns, environmental lead sources, and infant lead levels. The results suggest that monitoring lead concentrations in breastfed infants be considered.