Revisiting the low birthweight paradox using sibling data with implications for the classification of low birthweight.

Background: We examined the birthweight threshold for increased odds of neonatal death among second births based on their elder sibling's birthweight category. Methods: This population-based cohort study included 190 575 women who delivered their first two non-anomalous singleton live births in Missouri (1989-2005). We examined the birthweight distribution and neonatal mortality curves of second births whose elder sibling had low versus adequate/high birthweight. We determined the optimal cut-off point for the classification of low birthweight among infants in each group based on the Youden index. Results: Infants whose elder sibling had low birthweight had a lower mean birthweight and a higher percentage of low birthweight infants versus those whose elder sibling had adequate/high birthweight, but low birthweight infants in the former group had a lower rate of neonatal mortality. Upon standardizing the birthweight distribution to a Z-scale, neonatal mortality rates became comparable between the two groups at every rescaled birthweight for Z-scores ≥-3.7. The optimal cut-off point for low birthweight was 2500 and 3000 g among infants whose elder sibling had low and adequate/high birthweight, respectively. Conclusions: Using sibling data for the classification of LBW may enable the identification of average-sized infants who may be at increased risk of neonatal mortality.

Racial/Ethnic Differences in Correlates of Spontaneous and Medically-Indicated Late Preterm Births among Adolescents.

STUDY OBJECTIVE: To investigate the racial/ethnic differences in the correlates of spontaneous and medically-indicated late preterm birth (LPTB), defined as deliveries between 34 0/7 and 36 6/7 weeks gestation, among US adolescents. DESIGN: Population-based, retrospective cohort study. SETTING: Births in the United States to adolescents in 2012. PARTICIPANTS: Adolescents (younger than 20 years; n = 171,573) who delivered nonanomalous singleton first births between 34 and 44 weeks of gestation. INTERVENTIONS AND MAIN OUTCOME MEASURES: Bivariate and multivariable logistic regression were used to evaluate the associations between maternal risk factors and spontaneous and medically-indicated LPTB, stratified according to maternal race/ethnicity. RESULTS: Risk factors for spontaneous LPTB included single marital status among Asian adolescents; no insurance coverage among whites, Asian, and Hispanic adolescents; inadequate prenatal care among all racial/ethnic groups except American Indian, and adequate plus prenatal care among all races/ethnicities; prenatal smoking among whites and black adolescents; insufficient gestational weight gain among all racial/ethnic groups except American Indian; and prepregnancy underweight among white, black, and Hispanic adolescents. Risk factors for medically-indicated LPTB included inadequate prenatal care among white, black, and Hispanic adolescents, and adequate plus prenatal care among all racial/ethnic groups except Asian; insufficient gestational weight gain among white, black, and Hispanic adolescents; and prepregnancy overweight and obesity among white, black, and Hispanic adolescents. CONCLUSION: Our results show racial/ethnic differences in the correlates of spontaneous and medically-indicated LPTB among US adolescents and support the need for risk-specific interventions among different racial/ethnic groups.

Gestational weight gain and preterm birth: disparities in adolescent pregnancies.

OBJECTIVE: To examine racial differences in the association between gestational weight gain and preterm birth subtypes among adolescents. STUDY DESIGN: We conducted a retrospective cohort study of 211 403 adolescents using 2012 United States natality data. The outcome was preterm birth and the primary exposure was gestational weight gain. Multinomial logistic regression analyses were used to estimate adjusted odds ratios, stratified by race and body mass index (BMI). RESULTS: Black and White mothers who gained below the recommendations had increased risks for spontaneous preterm birth in all BMI categories, except obese. All Hispanic mothers who gained below the recommendations had increased risks of spontaneous preterm birth. White normal and overweight mothers and Black, Hispanic and Other normal weight mothers who exceeded the recommendations had decreased risks of spontaneous preterm birth. CONCLUSION: The effect of gestational weight gain on spontaneous and medically indicated preterm birth is modified by race and BMI.

The influence of grandmothers and other senior caregivers on sleep position used by African American infants.

OBJECTIVES: To describe beliefs about infant sleep position among African American grandmothers and other older caregivers (senior caregivers [SCGs]) and to measure the incremental effect on the rates of prone sleep after educating a group of African American SCGs. DESIGN: Survey of sleep practices and beliefs. Randomized, controlled trial of a teaching intervention. SETTING: Managed care prenatal clinic for normal risk obstetrics patients. PARTICIPANTS: Low-income pregnant women, self-identified as African American. An SCG is an older family member or friend to whom they would go for advice about routine child care. Pregnant women randomly assigned to the control group (educated about safe sleep practices) or the experimental group (education for both pregnant women and their SCG). INTERVENTION: During the third trimester, 2 teaching sessions for pregnant women (both control and experimental groups) and for the experimental group's SCGs. One-on-one teaching emphasizing that infants should sleep supine. MAIN OUTCOME MEASURES: During the third trimester, description of rate of preference for prone sleep for infants among pregnant women and SCGs. Effects of teaching SCGs on (1) SCGs' postnatal beliefs about sleep position as a means to reduce the risk of sudden infant death syndrome, and (2) the eventual rate of prone sleeping among study infants. RESULTS: One hundred twenty-five women were in the control group; 98 pregnant women and SCG pairs were in the experimental group. Senior caregivers were 47.1 +/- 12.4 years old (mean +/- SD). Most were grandmothers (either maternal, 72.5%, or paternal, 14.3%) or aunts or sisters (10.2%). No differences were noted in the prenatal rates of the prone preference (controls, 36.3%; experimental group, 35.7%; and SCGs, 34.7%). Teaching SCGs did not increase the rate of the usual prone sleep in the experimental vs the control group (13.3% vs 17.3%, chi(2) = 0.59, P =.44, 95% confidence interval for difference from -5.8% to +13.8%). After the teaching and during the pregnancy, the SCGs became less worried that the infant was susceptible to sudden infant death syndrome (chi(2) = 16.6, P =.003) or likely to die of sudden infant death syndrome (chi(2) = 24.7, P<.001). Their concerns about sudden infant death syndrome were significantly less postnatally, in particular when the infant was placed supine (chi(2) = 19.4, P<.001). CONCLUSIONS: Most African American women and SCGs endorsed the supine sleeping position for infants. Among a group of African American infants, prenatal teaching of their grandmothers and other SCGs did not have a statistically significant incremental effect on the rates of the usual prone sleeping position. Contrary to our starting hypothesis, the SCGs of pregnant women who receive prenatal care seemed responsive to messages about supine sleeping. The Back-to-Sleep message should be delivered prenatally, but special prenatal interventions should attempt to reach women who do not receive prenatal care and SCGs who persist in their opposition to the supine sleeping position.

Sleep position and the use of soft bedding during bed sharing among African American infants at increased risk for sudden infant death syndrome.

UNLABELLED: Soft bedding increases the risk for death among prone infants. We compared the softness of beds and bedding and infant sleep position for infants sleeping alone and for those bed sharing. STUDY DESIGN: Questionnaires were used to record the bedding and sleep practices of 218 consecutive African American infants. Enrollment was prospective. Mechanical models were used in the homes of a subgroup to measure the softness of bedding and its propensity to cause rebreathing. Results were compared by using the Student t test, Mann-Whitney U test, and chi(2) analysis. RESULTS: In a cross-sectional sample of infants, at 8.2 +/- 3.3 weeks of age, 61% (133 of 218) had bed shared > or =1 of the previous 14 nights and 48.6% (106 of 218) had bed shared the night before. Breast-feeding rates were not different for bed sharers and those sleeping alone. The rates of maternal smoking for both groups were low (13.6% vs 11.8%). Comforters, pillows, and waterbeds were more commonly used beneath bed-sharing infants. Bed sharers were twice as likely to habitually be placed prone for sleep (18% vs 9%). In the subgroup studied in their homes (13 bed sharing, 19 alone), the shared beds were softer (P <.0001) and could cause more rebreathing (P =.007). CONCLUSIONS: Infants at increased risk for sudden infant death syndrome, by sociodemographic criteria, who also bed share are more likely to sleep prone and to use softer beds. These findings may explain part of the risk associated with bed sharing among US infants, a risk that appears to be independent of the effects of maternal smoking.

Modulation of the nuclear factor kappa B pathway by Shp-2 tyrosine phosphatase in mediating the induction of interleukin (IL)-6 by IL-1 or tumor necrosis factor.

Shp-2, a src homology (SH)2-containing phosphotyrosine phosphatase, appears to be involved in cytoplasmic signaling downstream of a variety of cell surface receptors, although the mechanism is unclear. Here, we have determined a role of Shp-2 in the cytokine circuit for inflammatory and immune responses. Production of interleukin (IL)-6 in response to IL-1 alpha or tumor necrosis factor (TNF)-alpha was nearly abolished in homozygous mutant (Shp-2(-/)-) fibroblast cells. The targeted Shp-2 mutation has no significant effect on the activation of the three types of mitogen-activated protein (MAP) kinases, extracellular signal-regulated kinase (Erk), c-Jun NH(2)-terminal kinase (Jnk), and p38, by IL-1/TNF, indicating that Shp-2 does not work through MAP kinase pathways in mediating IL-1/TNF-induced IL-6 synthesis. In contrast, IL-1/TNF-stimulated nuclear factor (NF)-kappa B DNA binding activity and inhibitor of kappa B (I kappa B) phosphorylation was dramatically decreased in Shp-2(-/)- cells, while the expression and activity of NF-kappa B-inducing kinase (NIK), Akt, and I kappa B kinase (IKK) were not changed. Reintroduction of a wild-type Shp-2 protein into Shp-2(-/)- cells rescued NF-kappa B activation and IL-6 production in response to IL-1/TNF stimulation. Furthermore, Shp-2 tyrosine phosphatase was detected in complexes with IKK as well as with IL-1 receptor. Thus, this SH2-containing enzyme is an important cytoplasmic factor required for efficient NF-kappa B activation. These results elucidate a novel mechanism of Shp-2 in cytokine signaling by specifically modulating the NF-kappa B pathway in a MAP kinase-independent fashion.

Missouri rural adolescent pregnancy project (MORAPP).

The purpose of this study was to investigate the pregnancy outcomes and services available to adolescent women in Missouri, comparing rural and urban residents. A secondary analysis of a large public use data set obtained from the Missouri Department of Health was done for the 5-year period 1992 to 1996. Data were collected by county, with each of the 114 counties of the state classified as rural or urban. The SAS program was used for analysis. Results demonstrated definite patterns of similarity and dissimilarity among the teen mothers based on residence, when age and race were controlled. There were over 54,000 births to adolescent mothers in the 5-year study period. Among the outcomes of pregnancy studied were: abortion rates, inadequate weight gain, intrauterine growth retardation, and low-birthweight (LBW) infants. Among the services available to the young mothers that were studied were fertility services, WIC (women, infants, and children supplemental nutrition) program, food stamps, and Medicaid coverage for pregnancy and infant care. The outcomes are probably generalizable to Midwestern, rural/urban states similar to Missouri.

Functional characterization of domains contained in hepatocyte growth factor-like protein.

To delineate the functional protein domains necessary for the biological activity of hepatocyte growth factor-like protein (HGFL), we created various site-directed and deletion mutated cDNAs coding for this protein. Wild-type and mutated versions of HGFL were produced after transfection of the corresponding cDNAs into tissue culture cells. The biological importance of the domains within HGFL was then examined by addition of recombinant wild-type or mutant forms of HGFL to assays aimed at elucidating regions involved in the stimulation of DNA synthesis, the induction of shape changes in macrophages, and the ability to stimulate cell scattering. Mutant proteins lacking the serine protease-like domain (light chain) were not biologically active in any of the assays tested and could not compete with wild-type HGFL in cell scattering experiments. These data, in addition to direct enzyme-linked immunosorbent assay analyses, suggest that the light chain may play an important role in the interaction of HGFL with its receptor, Ron. Elimination of the proposed protease cleavage site between the heavy and light chains (by mutation of Arg-483 to Glu) produced a protein with activity comparable to wild-type HGFL. Further studies with this mutated protein uncovered an additional proteolytic cleavage site that produces biologically active protein. Deletion of the various kringle domains or the amino-terminal hairpin loop had various effects in the multiple assays. These data suggest that the heavy chain may play a pivotal role in determining the functional aspects of HGFL.

Vaginal gonococcal cultures in sexual abuse evaluations: evaluation of selective criteria for preteenaged girls.

OBJECTIVE: Accurate selective criteria could limit the number of vaginal cultures for Neisseria gonorrhoeae performed on preteenaged girls as part of their sexual abuse evaluations. This study was performed to determine whether the published selective criteria by the American Academy of Pediatrics (AAP) Committee on Child Abuse and Neglect and by Siegel et al would have accurately detected all cases of vaginal gonococcal infections in our large study population. METHODS: We prospectively studied girls, ages 1 to 12 years, who were referred to our Child Sexual Abuse Team (CSAT) at Wake Medical Center in Raleigh, NC, between July 1, 1976 to July 1, 1996, for sexual abuse evaluations which were performed using a protocol that included collecting historical information, a sexual abuse interview, and a detailed genital examination which included a vaginal culture for N gonorrhoeae. RESULTS: Our study population consisted of 2898 girls of whom 2731 (94%) had vaginal cultures successfully performed for N gonorrhoeae. There were 84 girls with vaginal gonococcal infections, 80 of whom had a vaginal discharge. The four girls without a vaginal discharge included two with a history of having vaginal intercourse with an alleged perpetrator with gonorrhea, one with N gonorrhoeae isolated from a urine culture, and one whose preteenaged sister had gonorrhea. All of the 84 girls would have been identified using the selective culturing criteria of the AAP Committee on Child Abuse and Neglect: culturing when epidemiologically indicated (interpreted as the girl having another sexually transmitted disease [STD], a child sibling, child household member, a close child associate or a perpetrator with a known STD) or when the history and/or physical findings suggest the possibility of oral, genital, or rectal contact, or Siegel et al's more selective criteria: only culturing prepubertal girls for N gonorrhoeae if there is a vaginal discharge at the time of presentation or if there is a high risk for STD acquisition, defined as having a STD diagnosed, a sibling with a STD, contact with a perpetrator known to have a STD, contact with multiple perpetrators, or Tanner stage III or above. CONCLUSION: Both the selective criteria of the AAP Committee on Child Abuse and Neglect and the more selective criteria of Siegel et al as we interpreted them were accurate when applied to identifying girls with vaginal gonococcal infections in our study population.

Genetic and environmental contributions to healthcare need and utilization: a twin analysis.

OBJECTIVE: An exploratory study to examine the genetic and environmental influences on healthcare-seeking behavior for four health conditions (high blood pressure, mental health problems, joint disorders, and hearing problems). DATA SOURCES: Data collected from 3,602 male-male twin pair members of the Vietnam Era Twin (VET) Registry. STUDY DESIGN: Varying models for the relationship between genetic and environmental influences on health condition liability and on treatment use were tested in an attempt to explain the relative contributions of additive genetic, common, and unique environmental effects to health condition and treatment use. DATA COLLECTION: A mail and telephone survey of general health status was administered in 1987 to VET Registry twins. PRINCIPAL FINDINGS: Variance component estimates under the best-fitting model for the genetic component ranged from 24 percent to 52 percent for the condition status and from 42 percent to 56 percent for treatment-seeking behavior. CONCLUSIONS: Utilization models that consider only environmental parameters will leave a large percentage of variability unexplained. Familial patterns have an impact not only on disease susceptibility but also on healthcare utilization, thereby having lifelong implications for social and fiscal constraints placed on the healthcare system. Thus, explanatory models for healthcare utilization behavior should consider the contribution of genetic factors in the decision to seek and use health services.

Aggregate/community-centered undergraduate community health nursing clinical experience.

Debate continues about the appropriateness of clinical experiences targeting aggregates in undergraduate community health nursing education. This paper describes a practical model to teach, through experience, the concepts of aggregate/community-centered practice at the baccalaureate level. As a voluntary alternative to the usual community assessment paper, groups of students worked in partnership with community groups to define health needs and to address one need. Sequential student groups focused the assessment and implemented a plan. The required time for each project varied. One project is described to illustrate the model. While independent community-centered practice is not expected of the B.S.N. graduate, the model described here develops comprehension of the concepts and process of such practice.

Building community for health: lessons from a seven-year-old neighborhood/university partnership.

This article presents two case studies highlighting the role of community conflict in the process of community empowerment. A graduate program for community health nurses (CHNs) in a large Midwestern city formed a partnership with a diverse, integrated neighborhood for the dual purposes of enhancing the community's capacity to improve its own health and teaching CHNs community organizing as a means to improve health. Central to the partnership are a broad definition of health, trust developed through long-term involvement, a commitment to reciprocity, social justice, and Freire's model of adult learning. Two initiatives that gave rise to major conflicts between community groups are analyzed. Conflicts, external and internal to the community, proved to be both powerful catalysts and potential barriers to the use of Freirian themes in community organization. Both university and community participants report needing better skills in the early recognition and management of conflict. We conclude that conflict management theory must be integrated with empowerment education theory, particularly when empowerment education is applied in a diverse community.

Measures of mother-child interaction: a comparison of three methods.

Three methods of recording mother-child interaction were compared in a sample of 136 adolescent mothers with children ranging in age from 8 to 27 months. Mother-child interaction was rated during in-home observations using Barnard's Teaching Scale, Schaefer's Attachment Inventory, and Clarke-Stewart's Rating Scales. The results indicate that each measure complements the other two, and that their interrelationships support the validity of the dimensions each describes. Yet, analyses indicate that they do not share common underlying factors. The findings suggest that each measure contributes to a more complete description of mother-child interaction.

Paths to adolescent parenthood: implications for prevention.

Adolescent pregnancy and parenthood are increasingly common today and pose many problems for both the individual persons involved and society as a whole. For programs to address these issues successfully, factors associated with unintended pregnancy and resulting parenthood must first be identified and understood. This paper is a review of current research on the factors associated with the four steps leading to an adolescent becoming a parent. Being an adolescent parent requires taking a particular path at four crossroads: becoming sexually active, not using or incorrectly using contraceptives, carrying rather than aborting a pregnancy, and parenting rather than placing a child for adoption. Much research in the last 15 years has explored adolescent childbearing, but many studies only compared adolescent parents to nonparents to reach conclusions about differences in these groups. This review focuses on recent studies that explore the four processes, or crossroads, separately and it excludes studies that generalize and overlap these processes. Factors that influence adolescent behavior at multiple points on the path to parenthood indicate areas particularly relevant for preventive intervention. For instance, boyfriends exert influence at all four crossroads. Sexual activity and contraceptive use increase with longevity of relationships, yet closer relationships are less often associated with raising a child. Better general communication skills, and particularly an increased ability to discuss sexuality, increases use of contraceptives, and low educational and occupational aspirations appear to influence each successive turn toward parenthood. This summary of current research serves to highlight those individual, family, dyadic, and social factors that exert great impact on adolescent parenthood by influencing young people at each of the four crossroads. These factors suggest potentially effective points for intervention to reduce the incidence of adolescent parenthood. However, poverty, unemployment, and racism also play central roles in early intercourse and childbearing, and any attempt at fundamental change must take these forces into account.