Transitions on and off AFDC: implications for parenting and children's cognitive development.

The goal of current national and state legislation on welfare reform is to decrease the number of people who are dependent on public assistance, most of whom are mothers and their young children. Mothers' patterns of welfare receipt in the 3 years following the birth of a child were examined vis-à-vis their associations with maternal emotional distress (General Health Questionnaire), provision of learning experiences (Home Observation of the Measurement of the Environment), parenting behavior, and the child's cognitive test score (Stanford-Binet) in the third year of life. The data set was the Infant Health and Development Program, an eight-site randomized clinical trial designed to test the efficacy of educational and family support services in reducing developmental delays in low-birthweight, preterm infants (N = 833). Strong negative associations were found between receiving welfare and parenting behavior and child outcomes at age 3 years. Outcomes varied depending on when the mother received public assistance (earlier or later in her child's first 3 years) and family poverty status on leaving welfare. The parenting behavior of mothers who had left welfare by their child's third birthday was more likely to be authoritarian if she had left public assistance without also leaving poverty. Implications of these findings for the well-being of children in low-income families are discussed.

Patterns of service use in preschool children: correlates, consequences, and the role of early intervention.

This article explores service use broadly by examining the mix of educational, health, and psychosocial services that preschool children received in the fifth year of life. The sample included 869 children who participated in the Infant Health and Development Program, an early intervention program designed to evaluate the efficacy of a comprehensive early intervention for low-birth-weight, premature infants during the first 3 years of life and who were followed until age 5. Cluster analyses of services at age 5 yielded 4 service groups--basic health only (doctor visits; n = 114); basic health and educational services (doctor visits and school/preschool; n = 444); basic health, educational, and psychosocial services (or multiple services; doctor visits, school/preschool, and psychosocial services; n = 129); and specialized health and educational services (doctor visits, school/preschool, emergency room visits and special medical visits [ear and/or eye examinations]; n = 182). Results suggest that neonatal health conditions, maternal education at the time of the child's birth, child developmental status at age 3, and maternal health, family income, and insurance status at age 5 were associated with patterns of services at age 5. Patterns of use are consistent over time (the first 3 years of life to the 5th year of life). After covarying the correlates of the service patterns, participation in the early intervention was not associated with patterns of services at age 5, and service patterns were associated with child well-being (health, school readiness, mental health), but results differed by intervention status. Findings are discussed in terms of preventive, responsive, and deficit models of service use.

Evaluation of a long-chain polyunsaturated fatty acid supplemented formula on growth, tolerance, and plasma lipids in preterm infants up to 48 weeks postconceptional age.

BACKGROUND: The last trimester of pregnancy is a period of rapid accretion of long-chain polyunsaturated fatty acids, both in the central nervous system and the body as a whole. Human milk contains these fatty acids, whereas some preterm infant formulas do not. Infants fed formulas without these fatty acids have lower plasma and erythrocyte concentrations than infants fed human milk. Preclinical and clinical studies have demonstrated that single-cell sources (algal and fungal) of long-chain polyunsaturated fatty acids are bioavailable. A balanced addition of fatty acids from these oils to preterm formula results in blood fatty acid concentrations in low birth weight infants comparable to those of infants fed human milk. METHODS: In the present study the growth, acceptance (overall incidence of discontinuation, reasons for discontinuation, overall incidence and type of individual adverse events), and plasma fatty acid concentrations were compared in three groups of infants fed a long-chain polyunsaturated fatty acid-supplemented preterm infant formula, an unsupplemented control formula, or human milk. The study was prospective, double-blind (formula groups only), and randomized (formula groups only). Two hundred eighty-eight infants were enrolled (supplemented formula group, n = 77; control formula group, n = 78; human milk group, n = 133). RESULTS: Anthropometric measurements at enrollment, at first day of full oral feeding, and at both 40 and 48 weeks postconceptional age did not differ between the formula groups, whereas the human milk-fed group initially grew at a lower rate. The incidence of severe adverse events was rare and not significantly different between formula groups. The groups fed either human milk or supplemented formula had long-chain polyunsaturated fatty acid concentrations higher than those in the control formula group. CONCLUSIONS: The results of this study demonstrate the safety and efficacy of a preterm formula supplemented with long-chain polyunsaturated fatty acids from single-cell oils.

The contribution of neighborhood and family income to developmental test scores over the first three years of life.

The effects of neighborhood and family income and family risk factors on developmental test scores at ages 1 through 3 are examined using a subsample (N = 347) from the Infant Health and Development Program. Beneficial effects of low numbers of risks were found for scores at ages 1 through 3. Family poverty was associated with lower scores at ages 2 and 3. Neighborhood affluence was associated with higher scores at age 3. The family risks-test score association at ages 1 through 3 and family income-test score association at ages 2 and 3 were mediated by home environment. Mediated effects were stronger for family income-test score associations at age 3 than for neighborhood income. Moderating effects of family risk on family and neighborhood income effects revealed an interaction between family poverty and risks for scores at age 3. Explanations for the early links between family risks and test scores and the later links between income and test scores are discussed.

Behavioral outcomes in low birth weight infants.

Low birth weight infants are at increased risk for behavioral and emotional problems. The Infant Health and Development Program was designed to evaluate the efficacy of intense pediatric and family support on reducing developmental and behavioral problems in low birth weight, premature infants. The major findings of this and other studies are presented in this article.

A multi-centre safety and efficacy trial of a preterm infant formula supplemented with long chain polyunsaturated fatty acids (LCP) (48 weeks PCA analysis)

LCP supplementation of premature infant formula has been shown to produce plasma and erythrocyte lipid profiles similar to human milk (HM)-fed preterm infants. Previous studies reported decreased growth with LCP supplemented formula. This prospective, double-blind, randomised, controlled, parallel trial compared safety, growth and phospholipid fatty acid (PFA) levels in preterm infants fed preterms formula with (L+) or without (Lo) LCP. The study consisted of Phase I: enrolment to 40 weeks (wk) postconceptual age (PCA); and Phase II: 40 to 48 wk PCA. Infants (birth weight 750-2000 g, 0-28 days of age) were fed L+ or L preterm formula, 24 Kcal/oz during Phase I, and 20 Kcal/oz during Phase II. A control group was exclusively HM-fed preterms who, if weaned at the end of Phase I, received L. HM and formula intake were unrestricted. Weight (wt), length (Lt), head circumference (OFC) and upper mid-arm circumference (MAC), and phospholipid profiles were measured at 40 and 48 wk PCA. Adverse events were monitored. 183/288 infants completed Phase II. There were no difference in growth rates between formula groups. At 48 wk PCA, mean PFA levels in infants fed L+ were similar to HM-fed and were significantly higher than the L fed group. Adverse events were similar between the 2 formula groups. The number of infants who were discontinued because of an adverse event was similar among all groups. In conclusion the LCP preterm infant formula is safe, support normal growth and maintains phospholipid profiles similar to HM-fed infants.(AU)

Health care use of 3-year-old low birth weight premature children: effects of family and neighborhood poverty.

OBJECTIVE: The objective of this study was to examine the effect of family and neighborhood income on health care use of young children born prematurely and of low birth weight (N = 619). DESIGN: A birth cohort was enrolled in a clinical randomized trial of early childhood educational and family services. SETTINGS/PARTICIPANTS: Infant Health and Development Program provided a sample of low birth weight premature infants stratified by clinical site, birth weight, and treatment group. Maternal reports of health care use, family income, and heath insurance were obtained at 12, 24, and 36 months of corrected age. Neighborhood income was based on census tract residence at birth. MAIN OUTCOME MEASURES: Maternal reports of hospitalizations, doctor visits, and emergency department visits were used; data were averaged over the child's first 3 years of life. RESULTS: Children from poorer families were more likely to be hospitalized and to have more emergency department visits than were children from more affluent families. Residence in poor and middle-income neighborhoods was associated with more emergency department visits than residence in affluent neighborhoods. Families in middle-income neighborhoods reported more doctor visits than families in poor or affluent neighborhoods. CONCLUSION: Neighborhood residence influences health care use by poor and nonpoor families and by insured and uninsured families. The use of the emergency department for low birth weight premature children in middle-income and poor neighborhoods is discussed.

The effectiveness of early intervention: examining risk factors and pathways to enhanced development.

In this paper we examine the effectiveness of early intervention, especially vis-à-vis (a) child and family risk factors and (b) the pathways to enhanced child and family development. To address these issues we draw on findings from the Infant Health and Development Program (IHDP) for low-birth-weight premature infants. The data we present reveal the considerable effectiveness of the IHDP intervention in enhancing several aspects of early and later child and family development. The findings also illustrate the importance of looking beyond intervention group differences to examine the extent to which early intervention effects are more pronounced for some children and families than others and to examine the processes underlying intervention effects (e.g., exactly how do early interventions change children and families?). For example, both initial and longer-term IHDP intervention effects varied by both characteristics of the children and characteristics of their families. Our data also provide some insight into the processes by which intervention effects may have occurred. We conclude our consideration of these many complexities with suggestions for practice, social policy, and future research.

Patterns of cognitive development in very low birth weight children during the first six years of life.

BACKGROUND: Cognitive development in very low birth weight (VLBW, < or = 1500 g) infants typically has been reported based on mean endpoints in cross-sectional studies. These overall group means mask individual patterns of cognitive development. Given the heterogeneity of VLBW infants, it is important to identify individual patterns of development and the factors associated with the different patterns. OBJECTIVE: We sought to determine individual patterns of cognitive development over the first 6 years in VLBW children and to examine the relative influence of selected biomedical and sociodemographic factors on these patterns. METHOD: VLBW infants (N = 203) were followed from birth to six years. Cognitive scores were obtained at four yearly intervals, and biomedical and social data were obtained beginning with the neonatal period. Cluster analysis was used to identify individual patterns of cognitive development. RESULTS: Five developmental patterns were identified: average-stable (13% of the sample); average-declined to low average (24% of the sample); average-declined to below average (43% of the sample); very low-increased to low average (8% of the sample); and very low-stable (12% of the sample). The patterns could be differentiated by several biomedical factors, including birth weight, gestational age, neonatal health, and 1-year assessments of neurological status and head circumference, as well as by level of maternal education. In particular, abnormal neurological status at 1 year was associated with a pattern of very low stable scores, and a suspicious status was associated with a pattern of improving cognitive development. Maternal education was influential among children born at the upper end of the VLBW range, who had a more favorable set of biomedical factors. CONCLUSIONS: Biomedical factors are of major importance for the cognitive development of VLBW infants, and their influence increases as birth weight declines. Differences in neurological integrity at 1 year were an important indicator of different patterns of cognitive development, especially for infants at the lower end of the VLBW range.

Results at age 8 years of early intervention for low-birth-weight premature infants. The Infant Health and Development Program.

OBJECTIVE: To reevaluate at age 8 years children who had participated during the first 3 years of life in a randomized clinical trial of special services for low-birthweight (LBW) premature infants. DESIGN: Follow-up of a randomized controlled trial of premature infants (< or = 37 weeks' gestation), stratified by 2 LBW groups (lighter [< or = 2000 g] and heavier [2001-2500 g]) and divided into intervention (n=377) and follow-up only (n=608) groups. SETTING: Eight sites serving diverse populations. PARTICIPANTS: At age 8 years, 874 children were assessed: 336 in the intervention group and 538 in the follow-up only group. INTERVENTION: The 3-year intervention consisted of home visits (birth to 3 years), child development center services (ages 1 to 3 years), and parent group meetings (ages 1 to 3 years). PRIMARY OUTCOME MEASURES: Cognitive functioning (Weschler Intelligence Scale for Children-III; Peabody Picture Vocabulary Test-Revised); academic achievement (Woodcock-Johnson Tests of Achievement-Revised); and parental reports of school performance, behavior (Child Behavior Checklist), and health (Child General Health Survey). RESULTS: At age 8 years, in the entire cohort and in the lighter LBW stratum, the intervention and follow-up only groups were similar on all primary outcome measures. Differences favoring the intervention group were found within the heavier LBW group: full-scale IQ score (4.4 points higher, P=.007), verbal IQ score (4.2 points higher, P=.01), performance IQ score (3.9 points higher, P=.02), mathematics achievement score (4.8 points higher, P=.04), and receptive vocabulary score (6.7 points higher, P=.001). On a physical functioning subscale, the whole intervention group received less favorable ratings, while the lighter LBW intervention group had lower maternal ratings assessing social limitations caused by behavior. CONCLUSION: Although at age 8 years there were modest intervention-related differences in the cognitive and academic skills of heavier LBW premature children, attenuation of the large favorable effects seen at 3 years was observed in both the heavier and lighter LBW groups. This indicates a need to develop additional intervention strategies for LBW premature children that can provide sustained benefits.

Cognitive and neurologic development of the premature, small for gestational age infant through age 6: comparison by birth weight and gestational age.

OBJECTIVE: To compare the neurologic and cognitive outcomes of 129 premature small for gestational age (SGA) infants with 300 premature appropriate for gestational age (AGA) infants through 6 years of age. DESIGN: Infants born at < or = 37 weeks gestational age and < or = 2500 g with birth weight 2 standard deviations or more below the mean birth weight for gestational age were categorized as SGA. Cognitive and neurologic outcomes of SGA and AGA prematures at 1, 2, 3, and 5 and/or 6 years of age were compared when the infants were stratified by gestational age in 2-week intervals or by birth weight in 500-g intervals. The association between SGA/AGA and neurologic status on cognitive outcomes at each age was also examined. RESULTS: SGA infants had significantly poorer cognitive scores at each age when compared with AGA infants of similar gestational ages. Normal neurologic status was more likely at all assessments for the AGA than for SGA infants of comparable gestational age. There were no differences between SGA and AGA children in cognitive or neurologic outcomes at any age when grouped by birth weight. Cognitive impairment was closely associated with neurologic abnormality in both SGA and AGA groups. There was, nevertheless, a significant effect of SGA on cognitive outcome independent of neurologic status at all ages except 3 years. CONCLUSIONS: Irrespective of degree of prematurity, SGA infants are at greater risk for neurodevelopmental impairment than are equally premature AGA infants. The cognitive impairment can be largely, but not entirely, attributed to a higher incidence of neurologic abnormalities in the SGA infants at each gestational age.

Early intervention for low-birth-weight premature infants: what can we achieve?

Low-birth-weight (LBW) premature infants are at increased risk for abnormal development. It is unclear whether intervention programs designed to prevent the disabilities in preterm children are efficacious. This paper reviews the settings in which interventions take place (e.g. nursery, home) and to whom they are directed (e.g. infant, parent). One intervention program, the Infant Health and Development Program (IHDP) is reviewed in detail. The IHDP was a multisite randomized clinical trial to evaluate the efficacy of combining developmental and support services along with paediatric follow-up to reduce the developmental problems seen among LBW preterm infants. Results from all studies suggest that preventive developmental interventions for LBW, premature infants have thus far demonstrated only modest success. Future research endeavours should investigate the type, duration, critical age onset, and intensity of the intervention as well as which subgroups of LBW infants most benefit from such programs.

Relations between infant neurobehavioral performance and cognitive outcome in very low birth weight preterm infants.

The predictive utility of three aspects of neonatal neurobehavioral performance was examined in 144 very low birth weight (< 1500 g) preterms who were followed until 6 years of age. Visual-following and auditory-orienting composites derived from the Einstein Neonatal Neurobehavioral Assessment Scale were modestly related to the Mental Developmental Index (MDI) and IQ scores at several ages, whereas the active motility composite was only related to MDI scores at 1 year of age (corrected). Infants who showed deviant performance on both visual following and auditory orienting composites had significantly lower cognitive test scores at 1 and 6 years of age and were more likely to be classified as subaverage at 6 years of age (IQ < 85). Group differences were independent of both neonatal health status and motor scores and were not due to the performance of children with severe sensory impairments. These findings suggest that visual following and auditory orienting measured in the neonatal period can offer a useful way of indexing initial capacities.

Preventive interventions with low birth weight premature infants: an evaluation of their success.

The outcome literature on low birthweight (LBW) premature children indicates that they are at risk for a variety of neurodevelopmental impairments throughout childhood. To prevent such disabilities, numerous interventions have been initiated with LBW children. Nineteen intervention programs designed for LBW preterms that have published study results dating from 1971 are reviewed. Included are interventions in the neonatal nursery, at home, and at centers as well as interventions that are both child-focused and parent-focused. One randomized clinical trial evaluating comprehensive intervention services, the Infant Health and Development Program, is described in detail. Conclusions from the studies reviewed indicate that intervention programs have had only modest success in altering neurodevelopmental outcomes, although parent-child interaction has often been facilitated. Future research on the effects of preventive intervention needs to examine long-term developmental competencies and to replicate positive findings in multiple settings.

Early intervention in low-birth-weight premature infants. Results through age 5 years from the Infant Health and Development Program.

OBJECTIVE: To evaluate the persistence of effects on health and development at age 5 years of the Infant Health and Development Program, an early childhood intervention that was provided to low-birth-weight (LBW) premature infants from neonatal discharge through age 3 years. DESIGN: Randomized, controlled, multicenter trial, stratified by two LBW groups: lighter (< or = 2000 g) and heavier (2001 to 2500 g). SETTING: Eight socioeconomically heterogeneous clinical sites. PARTICIPANTS: Of 985 eligible infants weighing 2500 g or less and at 37 weeks' or less gestational age, 377 infants were randomly assigned to the intervention group and 608 to the follow-up only group. About two thirds of the infants in each group were in the lighter LBW stratum, and one third were in the heavier LBW stratum. INTERVENTION: The intervention group received home visits (from neonatal discharge through age 3 years) as well as center-based schooling (from 1 to 3 years of age). Children in both groups received pediatric surveillance. MAIN OUTCOME MEASURES: Cognitive development, behavioral competence, and health status. RESULTS: At age 5 years, the intervention group had full-scale IQ scores similar to children in the follow-up only group. However, in the heavier LBW stratum, children in the intervention group had higher full-scale IQ scores (3.7 points higher; P = .03) and higher verbal IQ scores (4.2 points higher; P = .02). No significant differences between intervention and follow-up only groups in cognitive measures at age 5 years were noted in the lighter LBW infants. The intervention and follow-up groups were similar in behavior and health measures regardless of LBW stratum. CONCLUSION: The early childhood intervention provided in the first 3 years of life had effects on heavier LBW premature infants' IQ and verbal performance at age 5 years that were not observed for lighter LBW premature infants. The intervention did not affect health or behavior at age 5 years in either LBW stratum.

Effects of in utero drug exposure on children's development. Review and recommendations.

Effects of in utero drug exposure on pregnancy outcome, infant development, and preschool functioning are reviewed. Six possible mechanisms underlying possible negative outcomes seen in children exposed to drugs in utero are considered. Recommendations and opportunities for future research focus on process-oriented assessments, methodological and procedural issues, research design, and interventions.

Early educational intervention for very low birth weight infants: results from the Infant Health and Development Program.

OBJECTIVE: To examine the effect of early educational intervention after discharge from the hospital on the health and developmental status of very low birth weight (< or = 1500 gm) infants. DESIGN: Randomized, controlled trial, with post hoc analysis. SETTING: Eight sites, heterogeneous for sociodemographic and health care use. PARTICIPANTS: Infants (N = 280) born weighing < or = 1500 gm and selected for the Infant Health and Development Program. Eligibility was limited primarily by geographic distance from the day care center. One third were randomly assigned to the intervention (INT) group and two thirds to follow-up only. INTERVENTIONS: All children received intensive pediatric and developmental surveillance. The INT group received home visits and center-based educational interventions until 36 months of age (corrected for gestational age when final assessments were completed). OUTCOMES: Cognitive development (Stanford-Binet Intelligence Scale), behavioral competence (Achebach Child Behavior Checklist), and health status (indexes summarizing reported morbidity, the Functional Status II (R) Scale, and General Health Ratings Index). RESULTS: Cognitive development scores were 7.2 points higher (p = 0.002) in the INT group, after adjustment for baseline differences in site, sociodemographic characteristics, and neonatal morbidity, and were 9.4 points higher (p < 0.0003) when the 29 children with significant cerebral palsy were removed. No differences in behavior, serious morbidity, functional status, or health rating were found overall. The infants in the INT group who weighted < or = 1000 gm at birth had significantly lower behavior problem scores but no differences on other outcomes. All children in the INT group had slightly higher rates of less serious morbidity. CONCLUSION: The advantage conferred by being in the INT group, as previously reported for heavier infants, extends to very low birth weight children, supporting the use of early intervention in this group.

A neonatal preventive intervention study: Issues of recruitment and retention.

Intervention to prevent negative mental health outcomes in families of ill and premature newborns is an important part of neonatal care. This study addresses the factors which influence participation in a parent support group for parents of ill and premature newborns. Demographic, social support, and infant health data were examined to determine how support group participants and nonparticipants differed. In addition, efforts at enhancing recruitment and retention into support groups were examined. Results showed participants in the support group to have less healthy infants with longer hospital stays than nonparticipants. Participants reported more favorable financial situations, slightly higher incomes and less social support as measured by fewer contacts with family and friends than nonparticipants. Recommendations for future intervention research are discussed.