American Academy of Pediatrics. Committee on Child Abuse and Neglect and Committee on Community Health Services. Investigation and review of unexpected infant and child deaths.

Although there is a continuing need for timely review of child deaths, no uniform system exists for investigation in the United States. Investigation of a death that is traumatic, unexpected, obscure, suspicious, or otherwise unexplained in a child younger than 18 years requires a scene investigation and an autopsy. Review of these deaths requires the participation of pediatricians and other professionals, usually as a child death review team. An appropriately constituted team should evaluate the death investigation process, review difficult cases, and compile child death statistics.

Challenges in securing access to care for children.

Congressional approval of Title XXI of the Social Security Act, which created the State Children's Health Insurance Program (CHIP), is a significant public effort to expand health insurance to children. Experience with the Medicaid program suggests that eligibility does not guarantee children's enrollment or their access to needed services. This paper develops an analytic framework and presents potential indicators to evaluate CHIP's performance and its impact on access, defined broadly to include access to health insurance and access to health services. It also presents options for moving beyond minimal monitoring to an evaluation strategy that would help to improve program outcomes. The policy considerations associated with such a strategy are also discussed.

Physician response to prenatal substance exposure.

OBJECTIVES: To examine physician responses to suspected prenatal substance exposure and the reasons underlying these responses. METHODS: National mail survey of practicing obstetricians and pediatricians who see neonates. Response rate: 63%. RESULTS: More than 70% of physicians reported having ever suspected prenatal substance exposure. Response rates did not vary by specialty. Twenty-seven percent reported that they had never suspected prenatal substance exposure. The most common lifetime pattern (60%) was some response whenever prenatal substance exposure was suspected; next most common was no suspicion (27%). Just over 10% had a discretionary response: acting in some cases of suspected prenatal substance exposure but ignoring others. Two percent consistently ignored their suspicions. Getting help for the patient and protecting the fetus were the most common reasons to act. Among those who had ignored their suspicions, lack of sufficient evidence of substance use was the most often cited reason. There were some important specialty differences in reasons for response and non-response and in specific responses likely to be taken. Obstetricians are far more likely to provide the patient with information and get a substance use history; pediatricians are more inclined to involve outsiders. CONCLUSIONS: Obstetricians and pediatricians seem quite willing to act on their suspicions of prenatal substance exposure, and generally respond by taking positive actions. Specialty differences are few and reflect practice differences.

Assessing the performance of community systems for children.

OBJECTIVE: To present a framework for measuring the quality of community systems for children, based on key attributes of systems performance for children's services. We present a research agenda for refining the model, evaluating indicators across the performance domains identified, developing normative standards for performance, and assessing the empirical basis for performance criteria. PRINCIPAL FINDINGS: Systems performance can be measured. A systems approach to evaluating community systems for children needs to incorporate the multilevel service delivery networks, programs, and systems of care for children. A model of community systems performance for children includes key dimensions of structure, financing, and accountability. Attributes within these dimensions serve as indicators that communities can use to evaluate systems quality. Performance standards can be based on the evidence from field demonstrations as well as from normative assessments. RECOMMENDATIONS: The model of community systems performance should be refined and developed using empirical findings of analyses of children's systems. A set of indicators that capture vital aspects of performance and that are relevant, scientifically valid, and feasible should be developed and tested in field studies. Once indicators are evaluated for use in performance monitoring, communities will be able to implement performance monitoring.

Adolescent pregnancy: understanding the impact of age and race on outcomes.

PURPOSE: To determine the independent effects of maternal age and race/ethnicity on poor pregnancy outcomes, with and without controlling for other factors. METHODS: Logistic regression analysis of 54,447 linked birth, fetal death, and infant death certificates in California from 1980-87. RESULTS: Women of young maternal age (10-13 years) are approximately 2.5 times more likely to have a low birthweight infant and 3.4 times more likely to have a preterm birth than women of "prime" childbearing age. African-American women are 1.7 times more likely to have a low birthweight infant, and 2 times more likely to have a preterm birth than their white and Hispanic counterparts. The association of infant death with maternal age and race/ethnicity is statistically significant in the unadjusted models, however, those associations disappear completely when birthweight and gestational age are considered. Interactions between maternal age and race/ethnicity explained very little of the variability for any of the outcomes. CONCLUSIONS: Maternal age at delivery and race/ethnicity are independently and significantly associated with poor pregnancy outcomes such as low birthweight and premature births. However, young maternal age and race/ethnicity do not appear to interact in a manner that produces a differential effect on the birth outcomes assessed in this study. The incidence of infant mortality is unrelated to maternal age or race/ethnicity, after controlling for prematurity and low birthweight, underscoring the importance of intervention efforts aimed at their prevention.

PIP: Logistic regression analysis of 54,447 linked birth, fetal death, and infant death certificates in California from 1980-87 revealed that maternal age at delivery and race/ethnicity are independently and significantly associated with poor pregnancy outcomes such as low birth weight (LBW) and premature delivery. Mothers 10-13 years of age were 2.5 times more likely to have a LBW infant and 3.4 times more likely to have a preterm birth than mothers 20-24 years old. Nearly 25% of the youngest mothers received no or late prenatal care compared with only 3-4% of mothers over 25 years of age. The probability of a poor pregnancy outcome declined progressively with age among Blacks, Whites, and Hispanics. However, in each age group, Black mothers faced substantially higher probabilities of poor pregnancy outcomes than White or Hispanic women. Black women were 1.7 times more likely to have a LBW infant and 2 times more likely to have a preterm birth than their White or Hispanic counterparts. Associations of infant mortality with maternal age and race/ethnicity lost significance when birth weight and gestational age were controlled. All age and race/ethnicity main effects were significant at the p 0.001 level. Interactions between maternal age and race/ethnicity explained very little of the variability for any of the outcomes.

Congenital malformations and transplacental cancers.

The development of the mammalian embryo can be impaired by physical and chemical exogenous agents, leading to congenital malformations or tumours. These accidents represent at present the main cause of perinatal mortality and postnatal morbidity. The principles of teratogenicity and of transplacental cancers are analysed and the therapeutical implications of the prenatal pathology are examined.

Identification and assessment of the effects of chemicals on reproduction and development (reproductive toxicology).

Most studies for determining the reproductive toxicity of a chemical have to be conducted with whole animals. Test procedures used to investigate parts or the whole of the reproductive cycle are described in current guidelines. Other techniques, such as in vitro methods, and those for investigating specific events in the cycle, are under development. Epidemiological studies can give valuable information, although they are difficult to perform and interpret in practice. There is a need for more epidemiological studies of exposed populations and for recording and quantifying the concentrations of chemicals to which such populations are exposed. It is suggested that animal experiments should be programmed in a stepwise manner, and should take into account effects seen in previous toxicity studies. The programme of tests for determining reproductive toxic potential should be established on a case-by-case basis, since many factors will influence the choice of studies and the sequence in which they should be performed.

Oxetorone-induced hyperprogesteronemia and the development of uterine decidual lesions in rats.

Application of the deciduoma formation test showed that 3-benzofurol[3,2-c][1] benzoxepin-6(12H)-ylidene-N,N-dimethyl-l-propanamin-(E )-2-butenedioate (1:1) (oxetorone, L-6257, Nocertone) stimulated secretion of progesterone by the ovaries in rats and that this hyperprogesteronemia resulted from an increased secretion of prolactin. The studies carried out also showed that the apparition of uterine decidual lesions observed in certain animals undergoing chronic oxetorone treatment was linked to this hyperprogesteronemia. In view of the specific physiology of prolactin in rodents, such uterine lesions can only develop in these animals and cannot occur in man.

The teratogenic risk.

Reproduction can be impaired in animals and man by drugs and various environmental agents. Depending on the time of exposure--from fertilization through the fetal period and eventually during lactation--the consequences can range from embryotoxicity, gross malformations and a large variety of more subtle morphological, biochemical, and functional abnormalities. The high susceptibility of the embryo to exogenous agents is due to cellular multiplication and differentiation and to the lack of development of the enzyme systems necessary for the detoxification of chemicals. At present, developmental impairments represent the main cause of perinatal mortality and postnatal morbidity. After a review of prenatal physiology and teratogenic principles, the action of selected drugs and environmental agents is analyzed. The potential danger of environmental factors during intrauterine development is of particular concern because of its irreversible nature.

[Effect of veralipride on the estral cycle, genital tract, mammary gland and pituitary gland in female rats (author's transl)]. / Etude de l'action du véralipride sur le cycle oestral, le tractus génital, la glande mammaire et l'hypophyse de la ratte.

A study of the potential biological effects of veralipride was conducted in female rats. A definite stimulating action on the mammary gland was noted, but doses of 5 to 20 mg/kg/day are required to produce secretion, which is varying from one animal to another. Follicular maturation is preserved, though there is an increase in the number of corpora lutea with more marked development in some of them. Progesterone impregnation of the uterus occurs in a variable way and then only at doses of 5 + 0 20 mg/kg/day. Vaginal mucification, from a reduction in estrogen in relation to progesterone impregnation, is noted after 1 mg/kg/day (though 25 p. cent of the animals still demonstrate vaginal keratinization after 20 mg/kg/day). Finally, degranulation of the carminophile cells of the anterior pituitary gland, occurs after 5 mg/kg/day.

[Pseudotumoral uterine reaction in the rat treated with a benzofuro-benzoxepin]. / Réaction utérine pseudo-tumorale chez le rat soumis à l'action d'une benzofuro-benzoxepine.

When orally administered, 5-(3-diméthylamino propyliden)-benzofuro [2,3-c] benzoxepin-1, which antagonizes several biogenic amines, is slightly sedative and has also endocrinological properties in the Rat, induces the appearance of localized lesions of uterine stroma in 2 to 16% of the animals. The cytological picture could suggest a tumorogenesis. In fact, these lesions represent a non-tumoral reactional hyperplasia with nuclear abnormalities due to a hormonal stimulation.

Post natal side effects in rats induced by hypolipidaemic treatment during pregnancy.

Maternal, foetal and peri- and post-natal toxicity studies of a hypolipidaemic agent, 2-[p-(2,2-dichlorocyclopropyl)phenoxy]-2-methyl propionic acid (WIN 35833), were performed on different animal species during animal evaluation of this new drug. In teratology studies in rats, mice and rabbits, no adverse effects were detected following drug exposure during the organogenesis period. In peri-natal studies, a neonatal abnormality related to treatment just before term was shown in rats. This modification, previously observed with other hypolipidaemic drugs, seems to be species specific and characteristic of compounds in the aryloxyalkanoic acid series.