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The effect of comprehensive prenatal care on birth weight was examined using a prospective randomized design. A total of 428 pregnant women were randomly assigned to comprehensive prenatal care (n = 217) or standard prenatal care (n = 211). Comprehensive care was provided by a multidisciplinary team of nurse-midwives, social workers, a nutritionist, paraprofessional home visitors, and a psychologist. Standard prenatal care consisted of medical care provided by obstetric residents. Multiple regression analysis using behavioral, demographic, and medical variables showed a strong relationship between the set of predictors and birth weight. Comprehensive care was related to higher birth weights for primiparous but not multiparous mothers. Separate analyses of variance for primiparas and multiparas similarly showed a favorable effect of comprehensive care on birth weight for primiparous but not multiparous mothers.

Promethazine, available by prescription only since its introduction in 1946, has been widely used for pediatric patients because of its antihistaminic, antiemetic, and sedative properties. Recently, it's makers have sought Federal Drug Administration approval to introduce two liquid over the counter allergy/cold/cough products containing promethazine as an active ingredient. Although millions of doses have been administered, promethazine use has not been free of risk. Promethazine has been reported to cause significant sedation, agitation, hallucinations, seizures, dystonic reactions, and possibly apparent life-threatening events or sudden infant death syndrome. The impact of these relatively uncommon adverse reactions on children would be minimal if parents would use over the counter promethazine only for appropriate indications and only in children greater than 2 years of age. However, according to results of research evaluating the use of various over the counter medications by families for their children, promethazine will be used inappropriately. Both its over the counter status, implying a certain margin of safety, and its formulation as a syrup, providing ease of administration, should increase its use in all age groups including that by children less than 2 years of age who may be most vulnerable to the adverse reactions associated with the drug's use.

Play behaviors and motor imitation skills of 91 children between the ages of 3 and 6 years were investigated to determine their utility in distinguishing autism from mental retardation and other communication disorders. The performance of 22 autistic children was compared with that of 15 mentally retarded, 15 hearing-impaired, 19 language-impaired, and 20 non-handicapped children. Play behaviors were assessed using structured observations of free-play activities, and imitation skills were measured using a set of 12 individually administered tasks. The autistic group spent less total time interacting with toys and using toys appropriately, engaged in fewer functional play acts, and obtained lower imitation scores compared with all other groups. Discriminant function analysis revealed that the latter three variables discriminated the autistic children from the nonautistic handicapped children, with motor imitation emerging as the most important differentiating measure. These results suggest that measuring play and imitation skills may be useful in the clinical diagnosis of autism.

We used a resident continuity clinic to compare prospectively the impact of salary v fee-for-service reimbursement on physician practice behavior. This model allowed randomization of physicians into salary and fee-for-service groups and separation of the effects of reimbursement from patient behavior. Physicians reimbursed by fee-for-services scheduled more visits per patient than did salaried physicians (3.69 visits v 2.83 visits, P less than .01) and saw their patients more often (2.70 visits v 2.21 visits, P less than .05) during the 9-month study. Almost all of this difference was because fee-for-service physicians saw more well patients than salaried physicians (1.42 visits and .99 visits per enrolled patient, respectively, P less than .01). Evaluating visits by American Academy of Pediatrics' guidelines indicated that fee-for-service physicians saw more patients for well-childcare than salaried physicians because they missed fewer recommended visits and scheduled visits in excess of those recommendations. Fee-for-service physicians also provided better continuity of care than salaried physicians by attending a larger percentage of all visits made by their patients (86.6% of visits v 78.3% of visits, P less than .05), and by encouraging fewer emergency visits per enrolled patient (0.12 visits v 0.22 visits, P less than .01). Physicians' interest in private practice, as determined by their career plans, correlated significantly with total number of patients enrolled (r = .48, P less than .05) and total clinic patients seen by each resident during the study (r = .40, P less than .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Low-income mother-infant pairs were randomly assigned to rooming-in (N = 143) or to routine (N = 158) postpartum contact to determine whether rooming-in affects subsequent adequacy in parenting. At mean age 17 months, two rooming-in and ten control children had experienced inadequate parenting. One rooming-in and eight control children were hospitalized for these problems. One rooming-in and five control families were reported to Protective Services for mistreatment of the study child; five control and no rooming-in children were in the care of adults other than their parents at the time of data analysis. In this study, rooming-in correlated with fewer subsequent cases of parenting inadequacy.

Large families and inadequate spacing of children increase the risk of abuse. Twin births incorporate both of these factors, yet the association of twinning with subsequent abuse has not been explored. Forty-eight families with twins from St Vincent Hospital and Medical Center and Nashville General Hospital were compared with 124 single-birth families, matched for hospital of delivery, birth date, maternal age, race, and socioeconomic status. Three control (2.4%) and nine twin (18.7%) families were reported for maltreatment (P less than .001). Mothers of twins experienced greater previous parity than did control subjects (P less than .001). Twins also had significantly longer nursery stays (P less than .001), lower birth weights (P less than .001), and lower Apgar scores at one (P less than .01) and five (P less than .05) minutes. A regression analysis incorporating all of these variables, however, showed that twin status was most predictive of subsequent abuse.

A surplus of general pediatricians has been predicted for 1990. This surplus could provide both opportunity and need for practitioners to identify areas of maternal concern that might guide expansion of marketable physician services. For this purpose, maternal concerns were assessed by interviewing 207 mothers seeking care in private pediatric offices. Only 30% of mothers were most worried about their child's physical health. The remaining 70% were most concerned about problems falling into six categories of parenting, behavior, and development (psychosocial concerns): personality/social development, discipline, mental development, mother-child interaction time, adjustment to divorce and other life changes, and adolescent transition. Although the majority of these concerns conceivably could be handled in private offices, only 28% of these mothers had discussed their greater psychosocial concern with their pediatrician. A search for explanations of this failure to communicate indicated mothers often were not aware that their pediatrician could help, or they questioned his ability or interest in assisting them. Characteristics that correlated significantly with communication were higher family socioeconomic levels, and greater physician self-perceived ability and interest in these psychosocial problems. Parenting, behavior, and development concerns represent an opportunity for expanding services if some of these obstacles can be overcome.

Nine infants with apparent life-threatening events that occurred as a result of poisoning by a caretaker are described. These episodes were characterized by apnea plus some combination of color change, choking or gagging, and abnormal muscle tone. Five of the infants responded to vigorous stimulation, and four required cardiopulmonary resuscitation. Most poisonings (seven infants) were detected by a urine drug screen. Medications detected included acetaminophen, amphetamine, benzodiazepines (two infants), cocaine, codeine, meperidine (two infants), Methadone, phenobarbital, and phenothiazines (three infants). Four infants received two or more drugs. Most perpetrators of the poisonings were mothers (seven) and five of the parents admitted administering the various agents. Reasons for the poisonings included an apparent attempt to harm an infant, the need to sedate a fussy infant, or a gross misunderstanding of the potential risk of various agents to infants. Because no history of drug administration was elicited at the time of hospital admission, six infants might have been discharged with a diagnosis of apnea of infancy had not an attempt been made to investigate the possibility of poisoning. These cases suggest that poisoning by a caretaker should be added to the differential diagnosis of any infant brought to medical attention because of an apparent life-threatening event and that urine drug screening should be considered in the evaluation.

To investigate the process by which families identified and selected their children's current physicians, a close-ended questionnaire was administered to 750 families in a mail panel. Of 630 responses (84.0%), 244 had children in the home; 229 (93.9%) identified a regular and current physician for their youngest child. However, parents did not spend much time or energy selecting a physician and rarely explored medical expertise in their decisions. Families averaged 1.2 sources of information consulted per decision; few considered more than two physician choices and infrequently considered alternative types of doctors (pediatricians v family or general practitioners). Selection priorities ranked in order of importance concerned parents' perceptions of their doctors' communication skills, accessibility, and quality as determined by recommendations of friends or physicians. Parents appeared less concerned with issues of cost and convenience. Families selecting pediatricians differed from those selecting family and general practitioners in sources of information used and selection priorities. The survey also identified 84 families who had changed or seriously considered changing the physician who was caring for their youngest child. The most frequent dissatisfaction was the perception that an illness was not being managed adequately, followed by believing that the doctor or staff were rude or unconcerned. Families unhappy with pediatricians expressed different reasons from those unhappy with family or general practitioners. The study results provide insight about the first step in obtaining child health care services, a relatively unexplored area of patient decision making.