Patrick H. Casey

Early Intervention in Low Birth Weight Premature Infants: Results at 18 Years of Age for the Infant Health and Development Program

OBJECTIVE. To assess whether improvements in cognitive and behavioral development seen in preschool educational programs persist, we compared those in a multisite randomized trial of such a program over the first 3 years of life (INT) to those with follow-up only (FUO) at 18 months of age. METHODS. This was a prospective follow-up of the Infant Health and Development Program at 8 sites heterogeneous for sociodemographic characteristics. Originally 985 children were randomized to the INT (n = 377) or FUO (n = 608) groups within 2 birth weight strata: heavier low birth weight (HLBW; 2001–2499 g) and lighter low birth weight (LLBW; ≤2000 g). Primary outcome measures were the Peabody Picture Vocabulary Test (PPVT-III), reading and mathematics subscales of the Woodcock-Johnson Tests of Achievement, youth self-report on the Total Behavior Problem Index, and high-risk behaviors on the Youth Risk Behavior Surveillance System (YRBSS). Secondary outcomes included Weschler full-scale IQ, caregiver report on the Total Behavior Problem Index, and caregiver and youth self-reported physical health using the Medical Outcome Study measure. Assessors were masked as to study status. RESULTS. We assessed 636 youths at 18 years (64.6% of the 985, 72% of whom had not died or refused at prior assessments). After adjusting for cohort attrition, differences favoring the INT group were seen on the Woodcock-Johnson Tests of Achievement in math (5.1 points), YRBSS (−0.7 points), and the PPVT-III (3.8 points) in the HLBW youth. In the LLBW youth, the Woodcock-Johnson Tests of Achievement in reading was higher in the FUO than INT group (4.2). CONCLUSIONS. The findings in the HLBW INT group provide support for preschool education to make long-term changes in a diverse group of children who are at developmental risk. The lack of observable benefit in the LLBW group raises questions about the biological and educational factors that foster or inhibit sustained effects of early educational intervention.

The Association of Child and Household Food Insecurity With Childhood Overweight Status

CONTEXT. The prevalence of childhood overweight status is increasing. Some have suggested that childhood overweight is associated with food insecurity, defined as limited or uncertain access to enough nutritious food. OBJECTIVES. The purpose of this work was to assess the association of household and child food insecurity with childhood overweight status. METHODS. The National Health and Nutrition Examination Survey 1999–2002 uses a stratified multistaged probability sample and collects a broad array of data from a nationally representative sample of US citizens. All children 3 to 17 years old in this sample are included in these analyses. We measured BMI categorized as at risk for overweight or greater (≥85%) or overweight (≥95%) and household and child food security/insecurity using the US Food Security Scale. RESULTS. When compared with children from food-secure households, children from food-insecure households were more likely to demonstrate significant associations with being at risk for overweight or greater in the following demographic categories: 12 to 17 years, girls, white, and in households with income <100% and >4 times the federal poverty level. Household food insecurity is associated with child overweight status in children aged 12 to 17, girls, and children who live in households with incomes >4 times the federal poverty level. Child food insecurity demonstrated the same associations with being at risk for overweight or greater, as did household food insecurity, but associations were also seen in 3- to 5-year-old children, boys, and Mexican American children. Child food insecurity is significantly associated with child overweight status for children aged 12 to 17, girls, white children, and children in families with income ≤100% poverty level. Controlling for ethnicity, gender, age, and family poverty index level, childhood food insecurity is associated with a child being at risk for overweight status or greater, but not overweight status. CONCLUSIONS. Household and child food insecurity are associated with being at risk for overweight and overweight status among many demographic categories of children. Child food insecurity is independently associated with being at risk for overweight status or greater while controlling for important demographic variables. Future longitudinal research is required to determine whether food insecurity is causally related to child overweight status.

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.

Increasing Prevalence of Medically Complex Children in US Hospitals

OBJECTIVE: In this study we used national data to determine changes in the prevalence of hospital admissions for medically complex children over a 15-year period. PATIENTS AND METHODS: Data from the Nationwide Inpatient Sample, a component of the Healthcare Cost and Utilization Project, was analyzed in 3-year increments from 1991 to 2005 to determine national trends in rates of hospitalization of children aged 8 days to 4 years with chronic conditions. Discharge diagnoses from the Nationwide Inpatient Sample were grouped into 9 categories of complex chronic conditions (CCCs). Hospitalization rates for each of the 9 CCC categories were studied both individually and in combination. Trends of children hospitalized with 2 specific disorders, cerebral palsy (CP) and bronchopulmonary dysplasia, with additional diagnoses in more than 1 CCC category were also examined. RESULTS: Hospitalization rates of children with diagnoses in more than 1 CCC category increased from 83.7 per 100 000 (1991–1993) to 166 per 100 000 (2003–2005) (P[r] < .001). The hospitalization rate of children with CP plus more than 1 CCC diagnosis increased from 7.1 to 10.4 per 100 000 (P = .002), whereas the hospitalization rates of children with bronchopulmonary dysplasia plus more than 1 CCC diagnosis increased from 9.8 to 23.9 per 100 000 (P < .001). CONCLUSIONS: Consistent increases in hospitalization rates were noted among children with diagnoses in multiple CCC categories, whereas hospitalization rates of children with CP alone have remained stable. The relative medical complexity of hospitalized pediatric patients has increased over the past 15 years.

A National Profile of Caregiver Challenges Among More Medically Complex Children With Special Health Care Needs

OBJECTIVES To profile the national prevalence of more medically complex children with special health care needs (CSHCN) and the diversity of caregiver challenges that their families confront. DESIGN Secondary analysis of the 2005-2006 National Survey of Children With Special Health Care Needs (unweighted n = 40 723). SETTING United States-based population. PARTICIPANTS National sample of CSHCN. MAIN EXPOSURE More complex CSHCN were defined by incorporating components of child health and family need, including medical technology dependence and care by 2 or more subspecialists. MAIN OUTCOME MEASURES Caregiver challenges were defined by family-reported care burden (including hours providing care coordination and home care), medical care use (on the basis of health care encounters in the last 12 months), and unmet needs (defined by 15 individual medical care needs and a single nonmedical service need). RESULTS Among CSHCN, 3.2% (weighted n = 324 323) met criteria for more complex children, representing 0.4% of all children in the United States. Caregivers of more complex CSHCN reported a median of 2 (interquartile range, 1-6) hours per week on care coordination and 11 to 20 (interquartile range, 3->21) hours per week on direct home care. More than half (56.8%) reported financial problems, 54.1% reported that a family member stopped working because of the childs health, 48.8% reported at least 1 unmet medical service need, and 33.1% reported difficulty in accessing nonmedical services. CONCLUSIONS Extraordinary and diverse needs are common among family caregivers of more complex CSHCN. Enhanced care coordination support, respite care, and direct home care may begin to address the substantial economic burden and the multiple unmet needs that many of these families face.

Growth status and growth rates of a varied sample of low birth weight, preterm infants: A longitudinal cohort from birth to three years of age

To obtain follow-up growth data on a large sample of low birth weight, preterm infants, 985 infants were monitored longitudinally in an eight-site collaborative program until 3 years of age, corrected for prematurity. The growth of 608 of these infants was described previously through 1 year of age. In the full sample, 149 infants weighed less than or equal to 1250 gm at birth, 474 between 1250 and 2000 gm, and 362 between 2000 and 2500 gm. Thirty-three percent were white, 53% were black, and 11% were Hispanic. Weight, length, and head circumference were measured at birth and at 40 weeks and 4, 8, 12, 18, 24, 30, and 36 months gestation-corrected age in at least 862 infants each time. Descriptive statistics and estimated growth rates for all growth variables and a body mass index (height in kilograms per square meter), plotted by sex and birth weight group, demonstrated growth patterns lower than published standards for term infants of the same age and sex. These patterns of growth differed by birth weight group. Little catch-up was noted by the 36-month examination for gestation-corrected age for any birth weight group. We conclude that low birth weight, preterm infants have different patterns of growth than term infants during the first 3 years of life, even with plotting corrected for gestational age.

US Housing insecurity and the health of very young children.

OBJECTIVES We investigated the association between housing insecurity and the health of very young children. METHODS Between 1998 and 2007, we interviewed 22,069 low-income caregivers with children younger than 3 years who were seen in 7 US urban medical centers. We assessed food insecurity, child health status, developmental risk, weight, and housing insecurity for each childs household. Our indicators for housing insecurity were crowding (> 2 people/bedroom or>1 family/residence) and multiple moves (≥ 2 moves within the previous year). RESULTS After adjusting for covariates, crowding was associated with household food insecurity compared with the securely housed (adjusted odds ratio [AOR] = 1.30; 95% confidence interval [CI] = 1.18, 1.43), as were multiple moves (AOR = 1.91; 95% CI = 1.59, 2.28). Crowding was also associated with child food insecurity (AOR = 1.47; 95% CI = 1.34, 1.63), and so were multiple moves (AOR = 2.56; 95% CI = 2.13, 3.08). Multiple moves were associated with fair or poor child health (AOR = 1.48; 95% CI =1.25, 1.76), developmental risk (AOR 1.71; 95% CI = 1.33, 2.21), and lower weight-for-age z scores (-0.082 vs -0.013; P= .02). CONCLUSIONS Housing insecurity is associated with poor health, lower weight, and developmental risk among young children. Policies that decrease housing insecurity can promote the health of young children and should be a priority.

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.

The Use of Telephone Interview Methodology to Obtain 24-hour Dietary Recalls

OBJECTIVE To compare 24-hour dietary recalls collected over the telephone to in-person recalls collected in the 1994-1996 Continuing Survey of Food Intakes by Individuals (CSFII). DESIGN Trained interviewers collected 24-hour dietary recalls over the telephone using the multiple-pass approach. These results were compared to in-person interviews from a pooled subsample of CSFII respondents. SUBJECTS/SETTING List-assisted random-digit dialing was used to identify 700 women between the ages of 20 and 49 years. One eligible woman per household was selected to participate. STATISTICAL ANALYSES Approximate t tests to examine differences in average nutrient and energy intakes were conducted on weighted data. RESULTS The reported intakes of most nutrients in the current 24-hour dietary recalls collected over the telephone were significantly higher than those reported in the 1994 and 1995 CSFII, but there were no significant differences between the telephone survey and 1996 CSFII results. The 24-hour dietary recalls collected over the telephone yielded consistently greater mean nutrient intake per respondent compared with a comparable pooled subsample from the 1994, 1995, and 1996 CSFII. Generally, no significant differences were found in the food group data between the telephone survey and the CSFII survey. Mean dietary intakes reported by the comparable CSFII subsample increased from 1994 to 1996. APPLICATIONS Collecting 24-hour dietary recalls over the telephone is a practical and valid data collection tool for use in national food consumption surveys.

Growth in weight, recumbent length, and head circumference for preterm low-birthweight infants during the first three years of life using gestation- adjusted ages

Data from 867 preterm low-birthweight participants in the Infant Health and Development Program (IHDP) were used to develop reference data for growth status at an age and for increments from term to 36 month gestation-adjusted age (GAA). Weight, length and head circumference were recorded at 4 month intervals in the first year and at 6 month intervals in the second and third years. Selected percentiles for values at an age (status values) and increments for age intervals are presented in graphs separately for VLBW infants (< or = 1500 g at birth) and for LBW infants (1501-2500 g at birth). Percentiles of weight increments are presented beginning shortly before term for 1 month intervals to 6 month GAA, for 2 month intervals to 12 month GAA, and for 3-month intervals to 36 month GAA. Percentiles for length and head circumference increments are presented from term to 6 months for 2-month intervals, and to 36 month GAA for 3 month intervals. Among LBW infants, boys, had larger status and increment values than girls (P < 0.05), but there were no significant sex-associated differences in VLBW infants for status or increments. The mean status values and increments in weight and head circumference of the LBW infants were larger than those of VLBW infants, but the differences in length were not significant.