Population-based growth stunting.

Growth stunting, defined as height for age below the fifth percentile on a reference growth curve, is traditionally used as an indicator of nutritional status in children. Growth stunting is a population-based indicator and can indicate the prevalence of malnutrition or nutrition-related disorders among an identified population of children. Among certain segments of the U.S. child population, most notably poor children, growth stunting occurs more often than expected, suggesting that inadequate nutrition may be a problem for these children. Available general population data are not recent enough to allow for an assessment of the impact of several major public programs designed to address the risk of inadequate nutrition among children. Analysis of data from these programs does show, however, a higher-than-expected-albeit-declining level of stunting among program participants. The serious consequences of growth stunting and malnutrition-particularly impaired cognitive development-suggest that careful consideration of the growth stunting indicator should remain an important part of policy discussions on public nutrition programs.

Hospital and patient characteristics associated with variation in 28-day mortality rates for very low birth weight infants. Vermont Oxford Network.

BACKGROUND: The outcomes for very low birth weight infants vary among neonatal intensive care units (NICUs), but the reasons for this variation are not well understood. We used the database of a large neonatology research network to determine whether either admission characteristics of the infants or specific characteristics of the units such as annual patient volume and the presence of a pediatric residency program could account for observed differences in neonatal mortality rates among units. METHODS: We studied 7672 infants with birth weights from 501 to 1500 g treated during 1991 and 1992 at 62 NICUs participating in the Vermont Oxford Network Database. RESULTS: Overall, 14.7% of the study infants died within 28 days of birth (interquartile range 9.9% to 18.1%). The ratio of the number of observed deaths at an NICU to the number of deaths predicted based on the characteristics of infants treated at the NICU (standardized neonatal mortality ratio, [SNMR]) varied significantly among units (range 0 to 1.69, z = 4.24). There was no association between annual patient volume and either mortality rate (r = .17) or SNMR (r = .22). Observed mortality rates (17% vs 13%) and SNMR (1.04 vs .87) were both higher at the 24 hospitals with pediatric residency training programs than at the 38 hospitals without such programs. Hospitals with residency programs had higher average annual patient volumes (104 vs 66). In an analysis simultaneously adjusting for patient characteristics, volume, and presence of a residency program, neither volume (odds ratio [OR] per 10 additional cases treated 1.01, 95% confidence interval [CI], .98 to 1.04) nor presence of a pediatric residency program (OR 1.18, 95% CI, .94 to 1.47) was significantly associated with neonatal mortality risk. CONCLUSION: There are differences in neonatal mortality rates among NICUs that cannot be explained by differences in the measured admission characteristics of the infants, suggesting that the effectiveness of medical care varies among units. Neither the annual volume of very low birth weight infants treated in a unit nor the presence of a pediatric residency training program was independently associated with neonatal mortality rates for very low birth weight infants.

Price, public policy, and smoking in young people.

OBJECTIVE: To examine the effect of cigarette taxes, limits on public smoking, laws regulating access to tobacco by young people, and exposure to pro-tobacco and anti-tobacco messages on smoking participation and the intention to smoke among ninth-grade students (aged 13-16). DATA SOURCES: Two cross-sectional, school-based surveys (total of 15432 responses) of ninth-grade students conducted in 21 North American communities in 1990 and 1992 in conjunction with the Community Intervention Trial for Smoking Cessation. OUTCOME MEASURES: A ninth-grader was classified as a smoker if he or she reported smoking a whole cigarette on at least one of the 30 days preceding the survey. Among non-smokers, a positive intention to smoke was attributed to those who claimed they probably or definitely would be smoking within a year. RESULTS: Both smoking participation and the intent to smoke were related to differences in cigarette prices, with estimated price elasticities of -0.87 and -0.95, respectively. Boys were far more sensitive to price than girls with respect to smoking participation (elasticities of -1.51 and -0.32, respectively); however, the effect of price on the intent to smoke was similar for boys and girls. Policies limiting minors' access to tobacco (a minimum purchase age of 18 years, a ban on cigarette vending machines, and a ban on giving away free samples of tobacco products) were associated with reductions in participation and intention to smoke. Exposure to tobacco education in school was associated with decreased participation and intention to smoke. Policies that prohibited smoking in public places and in schools were not significantly related to the smoking patterns of ninth-graders. Frequency of exposure to pro-tobacco advertisements was marginally associated with increased participation and intention to smoke; paradoxically, frequency of exposure to anti-tobacco advertisements was correlated with an increased likelihood of smoking. CONCLUSIONS: Policies limiting access to tobacco by young people, increasing education about the effects of tobacco use, and a sharp and sustained increase in real cigarette excise taxes are likely to be most successful in accomplishing the US Food and Drug Administration's goal of cutting the smoking prevalence of adolescents in half over the next seven years.

The direct cost of low birth weight.

Medical and technological advances in the care of infants with low birth weight (less than 2,500 grams, or 5 pounds, 8 ounces) and very low birth weight (less than 1,500 grams, or 3 pounds, 5 ounces) have substantially increased the survival rate for these infants and have led to concerns about the demands their care places upon their families and society. The dollar cost of the resources used disproportionately to care for low birth weight children is one measure of the burden of low birth weight. Using analyses of national survey data for 1988 for children ages 0 to 15, this article presents estimates of the direct incremental costs of low birth weight--costs of the resources used to care for low birth weight infants above and beyond those used for infants of normal birth weight. In 1988, health care, education, and child care for the 3.5 to 4 million children ages 0 to 15 born low birth weight between $5.5 and $6 billion more than they would have if those children had been born normal birth weight. Low birth weight accounts for 10% of all health care costs for children, and the incremental direct costs of low birth cost weight are of similar magnitude to those of unintentional injuries among children and in 1988 were substantially greater than the direct costs of AIDS among Americans of all ages in that year.