Poorer behavioral and developmental outcome more than 10 years after treatment for iron deficiency in infancy.

OBJECTIVE: To determine the long-term effects of iron deficiency in infancy. DESIGN: Longitudinal follow-up study of children who had been tested and treated for iron deficiency as infants. SETTING: Periurban community near San Jose, Costa Rica. PARTICIPANTS: Of the original 191 participants, 87% were reevaluated at 11 to 14 years old (average age: 12.3 years). The children were free of iron deficiency and growing normally by US standards. Those who had chronic, severe iron deficiency in infancy (n = 48) were compared with those who had good iron status before and/or after iron therapy in infancy (n = 114). OUTCOME MEASURES: Comprehensive set of cognitive, socioemotional, and motor tests and measures of school functioning. RESULTS: Children who had severe, chronic iron deficiency in infancy scored lower on measures of mental and motor functioning. After control for background factors, differences remained statistically significant in arithmetic achievement and written expression, motor functioning, and some specific cognitive processes (spatial memory, selective recall, and tachistoscopic threshold). More of the formerly iron-deficient children had repeated a grade and/or been referred for special services or tutoring. Their parents and teachers rated their behavior as more problematic in several areas, agreeing in increased concerns about anxiety/depression, social problems, and attention problems. CONCLUSIONS: Severe, chronic iron deficiency in infancy identifies children who continue at developmental and behavioral risk >10 years after iron treatment.

Cosleeping in context: sleep practices and problems in young children in Japan and the United States.

OBJECTIVE: To determine the relationship between cosleeping and sleep problems in cultures with very different sleep practices. DESIGN: Interview study. SETTING: Families in urban Japan and the United States identified through pediatric and other professional contacts. PARTICIPANTS: Parents of healthy 6- to 48-month-old children (56 Japanese parents and 61 white US parents). All children had been breast-fed and lived in 2-parent, middleclass households. INTERVENTION: None. MAIN OUTCOME MEASURE: Sleep practices and sleep problems. RESULTS: More Japanese than US children coslept 3 or more times per week (59% vs. 15%, P<.001). All cosleeping Japanese children regularly slept all night with their parents (vs. 11% of US cosleepers, P<.001). Japanese and US children did not differ in part-night cosleeping (7% vs. 13%, P = .37). Most Japanese children had adult company and body contact as they fell asleep, and fathers slept separately in 23% of families. A greater proportion of US children had regular bedtime struggles and night waking. Within the US sample, cosleeping was associated with more bedtime struggles (P<.001), night waking (P<.01), and overall stressful sleep problems (P<.01). In the Japanese sample, cosleeping was associated only with night waking (P<.05); however, the proportion of cosleeping Japanese children with frequent night waking was at the level reported for US children who slept alone (30% vs 23%, P = .47). CONCLUSIONS: Cultural differences seem to influence the relationship between sleep practices and sleep problems. The experience of the Japanese families indicates that cosleeping per se is not associated with increased sleep problems in early childhood.

Iron-deficiency anemia and infant development: effects of extended oral iron therapy.

OBJECTIVE: To determine whether extended oral iron therapy corrects lower developmental test scores in infants with iron-deficiency anemia. STUDY DESIGN: Double-blind, controlled trial in Costa Rica involving 32 12- to 23-month-old infants with iron-deficiency anemia and 54 nonanemic control subjects. Anemic infants were treated with orally administered iron for 6 months; half the nonanemic children were treated with iron and half with placebo. Developmental test scores and hematologic status were evaluated before treatment, after 3 months, and after 6 months. RESULTS: Iron-deficient anemic infants received lower mental test scores than nonanemic infants at all three time points (p < 0.05 pretreatment and at 3 months, p = 0.07 at 6 months). There were no significant differences in motor test scores. More of the anemic infants were rated as unusually tearful and unhappy. Anemic infants came from families with lower maternal education and less support for child development and were less likely to be breast fed, were weaned earlier, and consumed more cow milk. CONCLUSIONS: Lower mental test scores persisted in infants with iron-deficiency anemia despite extended oral iron therapy and an excellent hematologic response. Iron-deficiency anemia may serve as a marker for a variety of nutritional and family disadvantages that may adversely affect infant development.

Cosleeping and early childhood sleep problems: effects of ethnicity and socioeconomic status.

This study examined ethnic differences in the relationship between cosleeping and sleep problems in the United States, taking socioeconomic status (SES) into consideration. The sample consisted of 186 urban families with a healthy 6- to- 48-month-old child and was grouped as follows: white lower SES (n = 40), white higher SES (n = 54), black lower SES (n = 43), and black higher SES (n = 47). Regular cosleeping was associated with increased night waking and/or bedtime protests among lower SES white children and higher SES black children. Among families who coslept, white parents were more likely than black parents to consider their child's sleep behavior to be a problem, i.e., stressful, conflictual, or upsetting as well as regularly occurring. One explanation is that differing childrearing attitudes and expectations influenced how parents interpreted their children's sleep behavior.

Using the HOME inventory with infants in Costa Rica.

PIP: It has been established through several decades of research that children's home environments significantly influence their development. Many researchers have also been interested in expanding research beyond indirect measures of the home environment, such as socioeconomic status, to help understand the nature of specific environmental mechanisms which influence early behavior and cognitive development. The Home Observation for Measurement of the Environment (HOME) Inventory was developed to meet these needs. Specifically, HOME measures the quality of stimulation in a child's early family environment. Almost all studies of the approach's reliability and validity have been conducted with US samples. HOME is, however, being used in other countries. The authors report their findings from a study of whether the psychometric properties of HOME based upon US samples parallel those found in Costa Rica, and whether HOME discriminates between Costa Rican environments with different associations to child health and development. Focus centers upon the infant/toddler version of the HOME Inventory. HOME data for 183 healthy Costa Rican infants were compared to the original HOME standardization sample from Little Rock, Arkansas. The study found the HOME Inventory to be helpful in identifying children at risk for delayed development in this Latin American sample. Lower HOME scores related to a shorter duration of breastfeeding and differentiated children with iron deficiency anemia in infancy, a condition associated with long-lasting developmental disadvantage.^ieng

Serum prolactin levels and behavior in infants.

This study examined the relationship between serum prolactin levels and behavior in infants and toddlers who experienced two potentially stressful experiences (developmental testing and venipuncture). Serum prolactin levels showed considerable consistency over a 3-month period (r = 0.64 between study entry and three months, p < 0.001, n = 50). There was also stability in having either a normal or a high value (> or = 25 ng/ml). Among children who had a normal value on initial testing, 97% also has a normal value after 3 months; 55% of those with initial high values continued to have high values (chi 2 = 19.26, p < 0.001). Children with high serum prolactin levels were more likely to be rated as unusually hesitant and unhappy during developmental testing. Overall, 53% of the children with serum prolactin levels > or = 25 ng/ml were considered abnormal in affect, compared to 20% of those with lower serum prolactin values (total n = 138, chi 2 = 13.56, p < 0.001). These results suggest that, even in early life, serum prolactin levels may reflect characteristic individual behavioral and neuroendocrine responses to stress.

No evidence of developmental III effects of low-level lead exposure in a developing country.

Despite substantial controversy regarding the blood levels at which lead adversely affects neurobehavioral development, public health policy in some industrialized countries is prescribing ever more stringent screening criteria for all ages. This study addressed the question of ill effects of lead exposure at the new lower levels, specifically during the late infancy period, which has been targeted for maximum surveillance in pediatric practice. The sample of 184 participants consisted of 12- to 23-month-old healthy infants and toddlers who participated in a community-based study in a developing Central American country (Costa Rica) where extensive family and developmental information was collected. The mean infant blood lead level was 11.0 micrograms/dL, ranging from 5.4 to 37.0 micrograms/dL. Lead levels were not related to the Mental or Psychomotor Developmental Index of the Bayley Scales of Infant Development. When the children were 5 years old, they were reevaluated with complete physical and psychological testing. Blood lead levels in infancy did not predict any of the developmental outcome measures. Thus, among a group of healthy toddlers in a developing country, no ill effects on development of low blood lead levels were observed.

Transligamentous motor branch of the median nerve discovered during endoscopically assisted carpal tunnel release.

The endoscopically assisted carpal tunnel release is an alternative to open procedures. A case is presented in which a transligamentous motor branch of the median nerve exits from the main trunk in a proximal and ulnar location. It is discovered from within the carpal canal during an endoscopically assisted procedure. The authors suggest adherence to strict principles to minimize potential complications in the rare event of an anatomic anomaly.

Early genital naming.

To evaluate the clinical impression that young girls are given little or confusing information about their genitals, a sample of 117 mothers with 1- to 4-year-old children were asked which words for genitals, if any, they used with their children. The ethnically and socioeconomically heterogeneous sample was composed of 63 girls and 54 boys, with the average ages of 26 and 29 months, respectively. Neither boys nor girls were likely to be given a standard anatomical genital term, although many children received colorful colloquial expressions. However, girls were less likely than boys to receive a term for their genitals. Receiving names for genitals was related to certain family circumstances, such as higher parental education, exposure to adult male nudity, having a sibling of the opposite sex, and cosleeping. Pediatric health professionals have the opportunity to contribute to early sex education by conveying accurate information regarding genital terms in the course of routine physical examinations.

Long-term developmental outcome of infants with iron deficiency.

BACKGROUND: Iron-deficiency anemia has been associated with lowered scores on tests of mental and motor development in infancy. However, the long-term developmental outcome of infants with iron deficiency is unknown, because developmental tests in infancy do not predict later intellectual functioning. METHODS: This study is a follow-up evaluation of a group of Costa Rican children whose iron status and treatment were documented in infancy. Eighty-five percent (163) of the 191 children in the original group underwent comprehensive clinical, nutritional, and psychoeducational assessments at five years of age. The developmental test battery consisted of the Wechsler Preschool and Primary Scale of Intelligence, the Spanish version of the Woodcock-Johnson Psycho-Educational Battery, the Beery Developmental Test of Visual-Motor Integration, the Goodenough-Harris Draw-a-Man Test, and the Bruininks-Oseretsky Test of Motor Proficiency. RESULTS: All the children had excellent hematologic status and growth at five years of age. However, children who had moderately severe iron-deficiency anemia as infants, with hemoglobin levels less than or equal to 100 g per liter, had lower scores on tests of mental and motor functioning at school entry than the rest of the children. Although these children also came from less socioeconomically advantaged homes, their test scores remained significantly lower than those of the other children after we controlled for a comprehensive set of background factors. For example, the mean (+/- SD) adjusted Woodcock-Johnson preschool cluster score for the children who had moderate anemia in infancy (n = 30) was 448.6 +/- 9.7, as compared with 452.9 +/- 9.2 for the rest of the children (n = 133) (P less than 0.01); the adjusted visual-motor integration score was 5.9 +/- 2.1, as compared with 6.7 +/- 2.3 (P less than 0.05). CONCLUSIONS: Children who have iron-deficiency anemia in infancy are at risk for long-lasting developmental disadvantage as compared with their peers with better iron status.

The use of the MacAndrew Alcoholism Scale in detecting substance abuse and antisocial personality.

We evaluated the hypothesis that characterological factors, particularly antisocial personality, influence scores on the MacAndrew Alcoholism Scale (MAC). Using the Washington University research criteria to establish diagnoses, the following subgroups were defined: subjects who received no psychiatric diagnoses; subjects who received diagnoses other than alcoholism, drug dependence, or antisocial personality; and subjects who received a diagnosis of alcoholism, drug dependence, and/or antisocial personality, alone or in combination with other psychiatric diagnoses. The highest MAC scores were obtained by subjects diagnosed as having antisocial personality without alcoholism or drug dependence and subjects diagnosed with antisocial personality, drug dependence, and alcoholism. Alcoholics without antisocial personality or drug dependence, and subjects with other psychiatric diagnoses scored lowest. Although higher MAC scores were obtained by males, MAC scores greater than 24 correctly classified the greatest number of males and females as alcoholic, drug dependent and/or antisocial. These findings are interpreted as consistent with MacAndrew's reinterpretation of the scale as assessing a dimension of personality, rather than solely a tendency to addiction.

Apparent phase advance in diurnal MHPG rhythm in depression.

Several investigators have proposed that diurnal rhythms, particularly that of the norepinephrine metabolite 3-methoxy-4-hydroxyphenylglycol (MHPG), show abnormalities in affective disorders. The present study compared diurnal MHPG rhythms in the plasma of 18 male depressed patients and 12 healthy male volunteers. A diurnal rhythm of MHPG closely fit to a cosine model was observed in volunteers and, to a lesser extent, in depressed patients. Patients, especially those with endogenous depression (N = 11), demonstrated an earlier acrophase (mean +/- SD = 12.53 +/- 3.38 hours), and treatment with desipramine was associated with a significant (3-hour) phase delay. This study confirms and extends previous reports of apparent phase advances in circadian noradrenergic rhythms in depressed patients.

Low level lead exposure in the prenatal and early preschool periods: intelligence prior to school entry.

The hypothesis that low level lead exposure in the fetal and early preschool years is related to neuropsychological deficit is being examined in a prospective study of development through the preschool years. Clear and consistent support for the hypothesis was not obtained in previously reported findings relating maternal and cord blood lead level (PbB) and PbB from venous samples through age three years to a series of developmental tests. It was concluded the relationship of lead level and cognitive development was primarily a function of the dependence of each on the quality of the caretaking environment. The cohort has now been examined at age four years, ten months, an age selected to assess development just prior to school age. The test used was the Wechsler Preschool and Primary Scale of Intelligence. We found statistically significant correlations between most of the PbB measures and the intelligence test scores, but these were attenuated, not statistically significant and not consistent in direction when relevant confounding variables were considered. Possible biases or threats to validity were reviewed. Effect sizes relating both prenatal and preschool lead exposure to intellectual development were small, not statistically significant, and not consistent in direction.

Object attachment, thumbsucking, and the passage to sleep.

Cross-cultural studies suggest that children who sleep in the same room as their parents and who are breast-fed are less likely to use an attachment object. The present study examined childrearing practices that emphasize physical proximity of parent and child and use of an attachment object and thumbsucking at bedtime with 126 healthy U.S. infants. Four child-rearing practices were focused on: presence or absence of a caregiver when the child actually fell asleep; mode of feeding; location of the child's bed or sleeping place; whether or not the child slept with the parents during the night. Children who had an adult present as they fell asleep were less likely to use an attachment object or suck their thumbs. In contrast to cross-cultural research, the results of the present study suggest that where a child sleeps during the night or how the child is fed is not as important an influence on the bedtime use of an attachment object or thumbsucking as whether an adult is present as the child actually falls asleep.

A statistical evaluation of the literature regarding the associations among alcoholism, drug abuse, and antisocial personality disorder.

Prior literature suggested an association among alcoholism, drug abuse, and antisocial personality disorder. A meta-analysis of inferential studies bearing on these associations was performed on 40 studies. Results demonstrated that each diagnosis in the triad had a significant positive association with each of the other two. Possible common etiologies of the diagnoses were discussed. Presence of one of the three diagnoses suggests that consideration of the other two is advisable. Finally, interrelationships among the diagnoses may explain treatment results common to several of the diagnoses.

Low level lead exposure and intelligence in the preschool years.

Definitive evidence of neuropsychological effects of low level Pb exposure continues to be sought in prospective studies of child development. The period from mid-infancy to age three years is important because behavioral and physiological characteristics of that age are associated with the intake and retention of environmental Pb. In the Cleveland study, we measured blood Pb (PbB) at ages six months, two years, and three years. At ages six months, one year and two year, the Mental Development Index (MDI) of the Bayley Scales of Infant Development was administered. The Stanford Binet Intelligence Scale IQ was obtained at age three years. Eight multiple regression analyses tested the relationship of each of the three PbB measures with the respective current and each ensuring developmental assessment. Demographic data and measures of the caretaking environment were selected as covariates for the control of confounding factors. Six months PbB was not related significantly to any of five assessments with or without control of confounding variables. The remaining three analyses were significant in the initial analyses, but the effect was completely attenuated with statistical control of confounding variables. These results suggest that obtained correlations between lead exposure and preschool intelligence depend on the caretaking environment.

Iron deficiency anemia and iron therapy effects on infant developmental test performance.

The behavioral effects of iron deficiency and its treatment were evaluated in a double-blind randomized controlled community-based study of 191 Costa Rican infants, 12 to 23 months of age, with various degrees of iron deficiency. The Bayley Scales of Infant Development were administered before and both 1 week and 3 months after IM or oral administration of iron. Appropriate placebo-treated control infants were also tested. Infants with iron deficiency anemia showed significantly lower mental and motor test scores, even after considering factors relating to birth, nutrition, family background, parental IQ, and the home environment. After 1 week, neither IM nor oral iron treatments differed from placebo treatment in effects on scores. After 3 months, lower mental and motor test scores were no longer observed among iron-deficient anemic infants whose anemia and iron deficiency were both corrected (36%). However, significantly lower mental and motor test scores persisted among the majority of initially anemic infants (64%) who had more severe or chronic iron deficiency. Although no longer anemic, they still showed biochemical evidence of iron deficiency after 3 months of treatment. These persistent lower scores suggest either that iron therapy adequate for correcting anemia is insufficient to reverse behavioral and developmental disturbances in many infants or that certain ill effects are long-lasting, depending on the timing, severity, or chronicity of iron deficiency anemia in infancy.

Low level lead exposure in the prenatal and early preschool periods: early preschool development.

The hypothesis that low level lead exposure in the fetal and early preschool years is related to neuropsychological deficit was examined in a prospective study of child development. We also tested the hypothesis of reverse causality, i.e., that lead level is a function of prior developmental status. Fetal lead exposure was measured in maternal and cord blood while preschool lead level was measured in venous blood samples at ages six months, two years and three years. These blood lead measures (PbB) were related to concurrent and ensuing scores on developmental measures at six months, one year, two years, and three years. With statistical control of covariate measures (age, sex, race, birth weight, birth order, gestational exposure to other toxic substances, maternal intelligence, and several indicators of the quality of the caretaking environment) as well as potentially confounding risk factors (gestational exposure to alcohol and other toxic substances), most statistically significant associations of PbB with concurrent and later development were completely attenuated. Effects of lead exposure, significant or not, were not consistent in direction. In reverse-causality analyses, PbB was not related significantly to prior measures of developmental retardation or acceleration. It was concluded that the relationship of lead level and measures of development in these early years was primarily a function of the dependence of each on the quality of the caretaking environment.