Adolescents as victims of familial violence: a hospital based surveillance.

Adolescent abuse is an important and understudied issue in society. The objective of this study was to examine the epidemiology of physical injuries due to maltreatment among adolescents aged 10-19 years. Subjects came from seven hospitals/trauma centres in Washington DC that were involved in the Washington DC Initiative to Reduce Infant Mortality and Prevention of Childhood Injuries Study. From 1996-1998, information was gathered about all injuries to adolescents aged 10-19 years that resulted in a visit to a participating emergency department. This paper focuses on the subset 178 adolescents aged 10-19 years who presented with physical injuries due to maltreatment. It was found that 55% of victims of abuse were female. Abuse victims were more likely to be female than those with unintentional injury. The most common injuries were contusions to the extremities (29%). Mothers were the most common perpetrators (48%). A total of 64% of victims were assaulted with an object/weapon and the most common object used was a belt. There are some similarities and some important differences between patterns of maltreatment in adolescents vs. younger children. Increased awareness of maltreatment among older children is a critical step in increasing and improving screening and prevention practices among health-care professionals.

The spectrum of intoxication and poisonings among adolescents: surveillance in an urban population.

AIM: Among adolescents, poisoning is a leading cause of injury mortality in the United States. This study describes the epidemiology of poisonings, intoxication, and maladaptive effects of drugs among adolescents age 10-19 years in a large city. METHODS: An injury surveillance system used records at seven hospitals, medical examiner records, and vital records over a two year period. RESULTS: Of 633 cases (618 injuries/100 000/year), 6% were unintentional, 36% self-inflicted, 41% alcohol intoxication, and 15% maladaptive effects of drugs. Alcohol was involved in 45% of cases, 23% illegal drugs, 23% non-prescription drugs, 19% prescription drugs; 19% involved more than one substance. Hospitalization was required in 20%; 8% transferred to another hospital; one died from intoxication. The authors found high rates of self-inflicted poisoning, intoxication, and maladaptive effects of drugs among this urban population. CONCLUSION: The study highlights the need to broadly define poisonings among adolescents and the challenge of assessing intent in some cases.

Long term cognitive development in children with prolonged crying.

BACKGROUND: Long term studies of cognitive development and colic have not differentiated between typical colic and prolonged crying. OBJECTIVE: To evaluate whether colic and excessive crying that persists beyond 3 months is associated with adverse cognitive development. DESIGN: Prospective cohort study. A sample of 561 women was enrolled in the second trimester of pregnancy. Colic and prolonged crying were based on crying behaviour assessed at 6 and 13 weeks. Children's intelligence, motor abilities, and behaviour were measured at 5 years (n = 327). Known risk factors for cognitive impairment were ascertained prenatally, after birth, at 6 and 13 weeks, at 6, 9, and 13 months, and at 5 years of age. RESULTS: Children with prolonged crying (but not those with colic only) had an adjusted mean IQ that was 9 points lower than the control group. Their performance and verbal IQ scores were 9.2 and 6.7 points lower than the control group, respectively. The prolonged crying group also had significantly poorer fine motor abilities compared with the control group. Colic had no effect on cognitive development. CONCLUSIONS: Excessive, uncontrolled crying that persists beyond 3 months of age in infants without other signs of neurological damage may be a marker for cognitive deficits during childhood. Such infants need to be examined and followed up more intensively.

Level of maternal antibody required to protect neonates against early-onset disease caused by group B Streptococcus type Ia: a multicenter, seroepidemiology study.

Because of the difficulty of conducting efficacy trials of vaccines against group B streptococcus (GBS), the licensure of these vaccines may have to rely on studies that measure vaccine-induced antibody levels that correlate with protection. This study estimates the level of maternal antibody required to protect neonates against early-onset disease (EOD) caused by GBS type Ia. Levels of maternal serum IgG GBS Ia antibodies, measured by ELISAs in 45 case patients (neonates with EOD caused by GBS Ia) and in 319 control subjects (neonates colonized by GBS Ia but without EOD) born at > or =34 weeks gestation were compared. The probability of developing EOD declined with increasing maternal levels of IgG GBS Ia antibody (P = .03). Neonates whose mothers had levels of IgG GBS Ia antibody > or =5 microg/mL had an 88% lower risk (95% confidence interval, 7%-98%) of developing type-specific EOD, compared with those whose mothers had levels < 0.5 microg/mL. A vaccine that induces IgG GBS Ia antibody levels > or =5 microg/mL in mothers can be predicted to confer a high degree of type-specific immunity to EOD to their infants.

Prevalence and predictors of immunization among inner-city infants: a birth cohort study.

CONTEXT: Although the proportion of US children who are appropriately immunized increased dramatically in the past decade, rates remain suboptimal among low-income, inner-city youth. Timely initiation of immunization is an important predictor of immunization status later in childhood; however, prospective studies identifying predictors of initiation are lacking. OBJECTIVES: The objectives of this study were to: 1) describe immunization patterns in a cohort of infants born to predominantly low-income, inner-city mothers; 2) identify determinants, as measured at birth, of immunization status at 3 and 7 months of age; and 3) identify determinants of continuation of immunization among those who initiate immunization by 3 months of age. DESIGN: Prospective, birth cohort study. METHODS: Maternal/infant dyads were systematically selected from 3 District of Columbia hospitals between August 1995 and September 1996. Three hundred sixty-nine mothers were interviewed shortly after delivery, at 3 to 7 months postpartum, and at 7 to 12 months postpartum. Medical records were reviewed at all reported sites of care for 324 (88%) infants. Vaccinations assessed included diphtheria, tetanus, and pertussis; polio; and Haemophilus influenzae type B. Multivariate logistic regression analyses were used to determine factors associated with immunization status of infants at 3 and 7 months of age. RESULTS: At 3 months of age, 75% of infants were up-to-date (UTD) versus only 41% at 7 months. In adjusted analyses, baseline factors associated with being UTD at 3 months included enrollment in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) during pregnancy, intention to breastfeed, and presence of the infant's grandmother in the household. Infants were less likely to be UTD if their mothers perceived higher barriers to immunization. Baseline factors associated with being UTD at 7 months included lower birth order and maternal employment. Among the subset of infants who were UTD at 3 months, only 53% remained UTD at 7 months. Factors measured at the first follow-up interview that were associated with continuation of immunization at 7 months included maternal employment and lower perceived barriers. CONCLUSIONS: Immunization rates during the first 7 months of life were low in this inner-city population. Factors associated with immunization status that are potentially amenable to change included perceived barriers to immunization and enrollment in WIC during pregnancy.

Where children drown, United States, 1995.

CONTEXT: Drowning is the second leading cause of unintentional injury death among children ages 1 to 19 years. Details about the specific site of submersion are important for implementation of primary prevention efforts, but are not routinely available from national data. OBJECTIVES: To provide national data about the specific sites of drowning among US children and to examine site-specific drowning rates by age, race, and gender. SETTING: United States, 1995. DESIGN: Information was abstracted from death certificates for unintentional drownings among children <20 years of age. The site of drowning was coded from free text on death certificates. Proportional distributions of the site of drowning by age, region, gender, and race were examined. Site-specific drowning rates were calculated by age, race, and gender. Denominators were based on US Census Bureau, June 1995 estimates of the US population. RESULTS: For 1995, death certificates were obtained for 1420 unintentional drownings among children <20 years of age, 98% of the number of drowning deaths reported by the National Center for Health Statistics for the same year. Site of drowning was specified on 1308 (92%) death certificates. Fifty-five percent of infant drownings were in bathtubs. Among children between the ages of 1 to 4 years, 56% of drownings were in artificial pools and 26% were in other bodies of freshwater. Among older children, 63% of drownings were in natural bodies of freshwater. Site-specific drowning rates varied by race. Importantly, after the age of 5 years, the risk of drowning in a swimming pool was greater among black males compared with white males with rate ratios of 15.1 (95% confidence interval: 6.7-38.5) among 10- to 14-year-olds and 12.8 (95% confidence interval: 6.5-26.9) among 15- to 19-year-olds. CONCLUSION: The variety of sites in which children drown, even within specific age groups, emphasizes the need for a multifaceted approach to prevention. Reductions in the relatively high rates of drowning among black adolescent males will require targeted interventions to prevent swimming pool drownings among this group.

Lawn mower-related injuries to children.

Lawn mower-related injuries to children are relatively common and can result in severe injury or death. Many amputations during childhood are caused by power mowers. Pediatricians have an important role as advocates and educators to promote the prevention of these injuries.

The effectiveness of risk-based intrapartum chemoprophylaxis for the prevention of early-onset neonatal group B streptococcal disease.

OBJECTIVE: Our purpose was to evaluate the effectiveness of a risk-based intrapartum antibiotic prophylaxis strategy for the prevention of early-onset neonatal group B streptococcal disease. STUDY DESIGN: Cases and controls were selected from infants born to women with one or more risk factors: preterm labor or rupture of membranes, prolonged rupture of membranes (>18 hours), fever during labor, or previous child with group B streptococcal disease. Cases were matched with controls by birth hospital and gestational age. Data abstracted from medical records were analyzed to estimate the effectiveness of intrapartum antibiotic prophylaxis. RESULTS: We analyzed data from 109 cases and 207 controls. Nineteen (17%) case versus 69 (33%) control mothers received an acceptable regimen of intrapartum antibiotic prophylaxis. In adjusted analyses, the effectiveness of intrapartum antibiotic prophylaxis was 86% (95% confidence interval, 66%-94%). When the first dose of antibiotics was given > or =2 hours before delivery, the effectiveness increased to 89% (95% confidence interval, 70%-96%); when it was given within 2 hours of delivery, the effectiveness was 71% (95% confidence interval, -8%-92%). Effectiveness was lowest in mothers with intrapartum fever (72%, 95% confidence interval, -9%-93%). On the basis of a 70% prevalence of maternal risk factors expected among cases in the absence of intrapartum antibiotic prophylaxis, we estimate that the risk-based strategy could reduce early-onset group B streptococcal disease by 60%. CONCLUSIONS: The risk-based approach to intrapartum antibiotic prophylaxis is effective in preventing early-onset group B streptococcal disease. To achieve the maximum preventive effect, the first dose of antibiotics should be administered at least 2 hours before delivery.

Differences in birth weight and blood pressure at age 7 years among twins.

Blood pressure later in life has been inversely associated with birth weight. However, concerns have been raised about whether this association merely reflects common environmental risk factors for both fetal growth restriction and high blood pressure or whether there is a genetic tendency to give birth to small babies and have high blood pressure. This study examined whether difference in birth weight of twins is associated with difference in blood pressure at age 7 years. The authors used data from the Collaborative Perinatal Project, United States, 1959-1966, which included 119 pairs of monozygotic and 86 pairs of same-sex dizygotic twins. The smaller twin in each pair had an average 300-g lower birth weight and was substantially thinner than the larger twin (p < 0.001). At age 7 years, body size and blood pressure were similar. Multiple linear regression was used to examine the association between difference in birth size and difference in blood pressure, adjusting for difference in body weight at age 7 years. None of the associations was statistically significant, and the direction of the associations was inconsistent. Further analyses stratified by birth weight, race, and sex revealed a similar, inconsistent pattern. The authors' findings fail to support the hypothesis that an unfavorable intrauterine environment adversely affects blood pressure in children.

Violent injuries among adolescents: declining morbidity and mortality in an urban population.

STUDY OBJECTIVE: Adolescent homicide rates are decreasing nationally for unclear reasons. We explore changes in intentional injury morbidity and mortality within the context of other injuries and specific causes. METHODS: We performed surveillance of hospital, medical examiner, and vital records for nonfatal injury among adolescents age 10 to 19 years living in the District of Columbia from June 15, 1996, to June 15, 1998, and fatal injury from 1989 to 1998. RESULTS: Over the 2-year study period, 15,190 adolescents were seen for injury, resulting in an event-based rate of 148 injuries per 1,000 adolescents per year; 7% required hospitalization, and 0.8% died. Interpersonal intentional injuries accounted for 25% of all injuries, 45% of hospitalizations, and 85% of injury deaths. Assault morbidity decreased with no change noted for unintentional and self-inflicted injury. Firearm injuries, stabs, and assaults with other objects showed the largest decrease, with no decrease in unarmed assaults. Injury mortality peaked in 1993 and has declined since. Firearms caused 72% to 90% of all injury deaths from 1989 to 1998, most the result of homicide. CONCLUSION: There has been a decline in intentional injury rates over the study periods related to decreased weapon injury; data suggest a change in the lethality of fighting methods but no change in unarmed fighting behavior.

Antibiotic susceptibility profiles for group B streptococci isolated from neonates, 1995-1998.

Antibiotic susceptibility profiles were analyzed for 119 invasive and 227 colonizing strains of group B streptococci isolated from neonates at 6 US academic centers. All strains were susceptible to penicillin, vancomycin, chloramphenicol, and cefotaxime. The rate of resistance to erythromycin was 20.2% and to clindamycin was 6.9%. Resistance to erythromycin increased in 1997. Type V strains were more resistant to erythromycin than were type Ia (P=.003) and type Ib (P=.004) strains and were more resistant to clindamycin than were type Ia (P<.001), type Ib (P=.01), and type III (P=.001) strains. Resistance rates varied with geographic region: in California, there were high rates of resistance to erythromycin and clindamycin (32% and 12%, respectively), and low rates in Florida (8.5% and 2.1%, respectively). Penicillin continues to be the drug of choice for treatment of group B streptococcus infection. For women who are penicillin intolerant, however, the selection of an alternative antibiotic should be guided by contemporary resistance patterns observed in that region.

Parental attitudes regarding interviews about injuries to their children.

BACKGROUND: Questions about the circumstances of injuries, especially to infants and young children, might be perceived by parents as threatening or intrusive. Some institutional research review committees express concerns that interviews about childhood injuries may be offensive to parents. The perceived value and potential risk of questions about a young child's injury could affect the quality of responses. OBJECTIVES: To assess parents' perceptions of threat and value of interviews about injury to their young children. SETTING: District of Columbia, 1 October 1995 to 30 September 1996. METHODS: Trained research assistants telephoned the parents of children seen in an emergency department or admitted to the hospital after an injury. To be eligible for inclusion the child must have been <3 years of age and a resident of the District of Columbia at the time of the event. After collection of sociodemographic information and circumstances of injury, the respondents were asked if the interview caused them to feel angry, offended or threatened, and if participation in the study was considered worthwhile. RESULTS: Seventy eight per cent of eligible families were contacted. Among those contacted, 93% completed the interview. Eighty two per cent of respondents were mothers and 11% fathers. Ninety per cent (95% confidence interval (CI) 88.4 to 91.6) of the respondents reported that the interview did not make them feel angry, offended, or threatened. Only 13 (1%; 95% CI 0.5 to 1.5) reported being very angry and 7.1% (95% CI 5.8 to 8.5) reported being a little angry. The majority of participants (61.2%, 95% CI 58.6 to 63.8) felt that participation in the study was definitely worthwhile and only 5.5% (95% CI 4.3 to 6.7) felt that it was not at all worthwhile. Parents of children with intentional injuries were more likely to report feelings of anger than parents of children with unintentional injuries (24% v 8%; p=0.02). The per cent of respondents reporting any anger was greater when the interview was conducted within 14 days of the hospital visit compared with later interviews (11% v 7%; p=0.02). CONCLUSIONS: In similar populations most parents of young, injured children are neither upset nor threatened by interviews that probe for details about how their children become injured. In general, collecting data aimed to prevent injuries is perceived as worthwhile, and parents readily cooperate with providing this information. Investigators and review committees should consider that interviews about infant and young child injuries are of no or minimal risk.

Sports injuries: An important cause of morbidity in urban youth. District of Columbia Child/Adolescent Injury Research Network.

INTRODUCTION: Sports injuries account for substantial morbidity and medical cost. To direct intervention, a population-based study of the causes and types of sports injuries was undertaken. METHOD: An injury surveillance system was established at all trauma center hospitals that treat residents 10 to 19 years old in the District of Columbia and the Chief Medical Examiner's Office. Medical record abstractions were completed for those seen in an emergency department, admitted to the hospital, or who died from injury June 1996 through June 1998. FINDINGS: Seventeen percent (n = 2563) of all injuries occurred while participating in 1 of 6 sports (baseball/softball, basketball, biking, football, skating, and soccer) resulting in an event-based injury rate of 25.0 per 1000 adolescents or 25.0/1000 population year. Rates were higher in males for all sports. The most common mechanisms were falls (E880-888) and being struck by or against objects (E916-918). Hospitalization was required in 2% of visits and there were no deaths. Of those requiring hospitalization, 51% involved other persons, 12% were equipment-related, and 8% involved poor field/surface conditions. Of all baseball injuries, 55% involved ball or bat impact often of the head. Basketball injuries included several injuries from striking against the basketball pole or rim or being struck by a falling pole or backboard. Biking injuries requiring admission included 2 straddle injuries onto the bike center bar and collision with motor vehicles. Of all football injuries, 48 (7%) involved being struck by an opponent's helmet and 63 (9%) involved inappropriate field conditions including falls on or against concrete, glass, or fixed objects. In soccer there were 4 goal post injuries and a large proportion of intracranial injuries. There were 51 probable or clear assaults during sports and an additional 30 to 41 injuries from baseball bat assaults. CONCLUSIONS: Many sports including noncontact sports involved injuries of the head suggesting the need for improved head protection. Injuries involving collisions with others and assaults point to the need for supervision and enforcement of safety rules. The 16% of sports injury visits and 20% of hospitalizations related to equipment and environmental factors suggest that at least this proportion of injury may be amenable to preventive strategies. Design change may be warranted for prevention of equipment-related injuries. The many injuries involving inappropriate sports settings suggest the need for and use of available and safe locations for sports.

American Academy of Pediatrics. Committee on Injury and Poison Prevention. Safe transportation of newborns at hospital discharge.

All hospitals should set policies that require the discharge of every newborn in a car safety seat that is appropriate for the infant's maturity and medical condition. Discharge policies for newborns should include a parent education component, regular review of educational materials, and periodic in-service education for responsible staff. Appropriate child restraint systems should become a benefit of coverage by Medicaid, managed care organizations, and other third-party insurers.

American Academy of Pediatrics. Committee on Injury and Poison Prevention. Transporting children with special health care needs.

Children with special health care needs should have access to proper resources for safe transportation. This statement reviews important considerations for transporting children with special health care needs and provides current guidelines for the protection of children with specific health care needs, including those with a tracheostomy, a spica cast, challenging behaviors, or muscle tone abnormalities as well as those transported in wheelchairs.

Deaths attributable to injuries in infants, United States, 1983-1991.

OBJECTIVE: To describe risk factors for injury death among infants in the United States by the specific external cause of death. METHODS: Data were analyzed from the US-linked birth/infant death files for the years 1983-1991. Potential risk factors for injury death were identified from birth certificate data and included both maternal and infant factors. Injury rates were calculated by external cause of death. Characteristics of infants who died from an injury were compared with those of the entire birth cohort. The independent effect of potential risk factors was assessed in multivariate analyses using a case-control study design. RESULTS: A total of 10 370 injury deaths were identified over the 9-year study period (29. 72/100 000 live births). The leading causes of death were homicide, suffocation, motor vehicle crashes, and choking (inhalation of food or objects). There was no significant temporal trend in the overall rate of injury death; however, this was because significant increases in the rates of death from homicide (6.4%/year) and mechanical suffocation (3.7%/year) were offset by decreases in rates of death from fires (-4.7%/year) and choking (-4.6%/year). In adjusted analyses, infants born to mothers with no prenatal care, <12 years of education, two or more previous live births, Native American race, or <20 years of age were at twice the risk of injury death compared with the lowest risk groups (initiation of prenatal care in the first trimester, >/=16 years of education, no previous live births, white, or >/=25 years of age). When analyzed by the specific cause of death, the factors that were associated most strongly with death varied. For example, Native Americans were at greatest risk of a motor vehicle related death (compared with whites: OR: 3.6; 95% CI: 1.8-7.1), and infants with birth weights of <1500 g were at greatest risk of death attributable to inhalation of food (compared with >/=2500 g: OR: 9.6; 95% CI: 3.3-28.0) or objects (OR: 11.8; 95% CI: 4.5-30.5). CONCLUSION: A number of sociodemographic characteristics are associated with an increased risk of injury-related death in infants. The strength of associations between specific risk factors and death varies with the external cause of death, thus identifying high-risk subgroups for targeting of cause-specific interventions and simultaneously increasing our understanding of the individual and societal mechanisms underlying these tragedies.

A new paradigm of injury intentionality.

OBJECTIVE: To improve understanding of processes leading to injury and assess more specifically the degree of intentionality. METHODS: A new paradigm was developed that characterizes the act of inflicting injury (self, other, not inflicted) and the motive. Motives are determined for the act of injury and for the outcome. To test this, 986 cases of adolescent injuries in seven hospitals were reviewed. Three investigators independently classified all cases using the new paradigm and three used standard definitions of intent. Inter-rater reliability was measured. RESULTS: Of injuries inflicted by others, 61% were intentional using the standard classification. In the new paradigm 67% were intended acts and 59% involved intentional motive for outcome. Altogether 87% of sports injuries were coded as unintentional acts compared with 96% using standard methods. Using standard classification there was 93% agreement between paired raters, with an average kappa of 0.86. In the new paradigm questions on intentionality of act, outcome, and infliction of act, the agreement was 89%, 91%, 88%, with a kappa of 0.79, 0.80, 0.76, respectively. CONCLUSIONS: This paradigm defines a spectrum of injury intent, enhances understanding of the causal sequence of injury, and has important implications for research and prevention.

Infant injury deaths with unknown intent: what else do we know?

OBJECTIVES: Strong evidence based on case record reviews indicates that the incidence of child homicide reported from death certificates is under ascertained. The characteristics of infant injury fatalities with undetermined, but suspicious, intent were compared for the probability that they should be considered homicides. METHODS: Using linked birth and death certificates for all birth cohorts in the US from 1983-91, 2345 injury fatalities reported as intentional, 7594 as unintentional, and 431 as undetermined intent were identified. Maternal and infant variables potentially predictive of injury fatalities were selected based on increased bivariate associations. Relative risks of injury death by intentional, unintentional, and undetermined intent were assessed for maternal and infant characteristics. RESULTS: Relative risks were consistently higher across all intent categories for infants of mothers with the least education, no prenatal care, young maternal age, and single marital status, as well as for infants who are second or later born, preterm, black, or American Indian. Fatalities with undetermined intent have larger relative risks in the highest risk categories than either intentional or unintentional injuries. Deaths with undetermined intent have risk profiles that more closely resemble profiles for intentional deaths than unintentional. CONCLUSIONS: Injury homicide rates would be almost 20% greater than official classifications indicate if deaths with undetermined intent were included. In analyses of infant homicide, excluding deaths of undetermined intent may lead to an underestimation of the magnitude of the public health problem of intentional injuries among infants. Other studies based on record reviews from multiple sources indicate that misclassification and under ascertainment of homicides may be even greater.

Risk factors for infant homicide in the United States.

BACKGROUND: Homicide is the leading cause of infant deaths due to injury. More than 80 percent of infant homicides are considered to be fatal child abuse. This study assessed the timing of deaths and risk factors for infant homicide. METHODS: Using linked birth and death certificates for all births in the U.S. between 1983 and 1991, we identified 2776 homicides occurring during the first year of life. Birth-certificate variables were reviewed in both bivariate and multivariate stratified analyses. Variables potentially predictive of homicide were selected on the basis of increased relative risks among subcategories with adequate numbers for stable estimates. RESULTS: Half the homicides occurred by the fourth month of life. The most important risk factors were a second or subsequent infant born to a mother less than 17 years old (relative risk, 10.9) or 17 to 19 years old (relative risk, 9.3), as compared with a first infant born to a mother 25 years old or older; a maternal age of less than 15 years, as compared with an age of at least 25 years (relative risk, 6.8); no prenatal care as compared with early prenatal care (relative risk, 10.4); and less than 12 years of education among mothers who were at least 17 years old (relative risk, 8.0), as compared with 16 or more years of education. CONCLUSIONS: Childbearing at an early age was strongly associated with infant homicide, particularly if the mother had given birth previously. Our findings may have implications for prevention.

Prevalence and predictors of the prone sleep position among inner-city infants.

CONTEXT: The prone sleep position is associated with an increased risk of sudden infant death syndrome (SIDS), but few studies have assessed factors associated with the choice of infant sleep position. OBJECTIVES: To describe infant sleep position in a cohort of infants born to predominantly low-income, inner-city mothers and to identify predictors of the prone sleep position in this population. DESIGN: Prospective birth cohort study. PATIENTS AND SETTING: Three hundred ninety-four mother-infant dyads, systematically selected from 3 District of Columbia hospitals between August 1995 and September 1996. Mothers were interviewed shortly after delivery and again at 3 to 7 months postpartum. MAIN OUTCOME MEASURES: Position in which infants were placed for sleep on the night prior to the 3- to 7-month interview. RESULTS: At 3 to 7 months of age, 157 infants (40%) were placed for sleep in the prone position. Independent predictors of prone sleep position included poverty (odds ratio [OR], 1.81; 95% confidence interval [CI], 1.10-2.99), black race (OR, 2.06; 95% CI, 1.05-4.04), presence of infant's grandmother in the home (OR, 1.83; 95% CI, 1.11-3.00), and intent, as measured shortly after delivery, to place the infant in the prone position (OR, 2.28; 95% CI, 1.44-3.60). Importantly, of the 43 mothers who observed their infants in the prone sleep position while in the hospital, 40 (93%) intended to place their infants prone at home. CONCLUSIONS: A substantial proportion of infants in this predominantly low-income population were placed in the prone sleep position. Educational efforts should address both initial intentions and reinforcement of the correct sleep position, once initiated. Hospitals should ensure that healthy newborn infants are placed in the supine sleep position during the postpartum hospital stay.