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Background A successful transition from the neonatal intensive care unit (NICU) to home is aided by a comprehensive discharge planning program that keeps families involved and engaged with the discharge preparation process. Purpose To compare the assessment of parental NICU discharge preparedness with parental satisfaction with the NICU discharge preparation. Methods Families were surveyed 4 to 6 weeks after NICU discharge, and those selecting "very prepared" were considered "satisfied" with their discharge preparation. On discharge day, families were considered "prepared" for discharge based on their overall level of preparedness and their nurse's rating of them on a discharge readiness assessment tool. Results In total, 1104 families (60%) reported being both "satisfied" and "prepared"; 293 families (16%) were "satisfied" but not "prepared"; 297 families (16%) were not "satisfied" but were "prepared"; and 134 families (7%) were neither "satisfied" nor "prepared." Compared with families that were both "satisfied" and "prepared," families that were neither "satisfied" nor "prepared" were more likely to be raising the infant alone, of Black race, and to have sicker infants. Implications for practice Some families are at a higher risk and merit more consideration during NICU discharge planning. Assess the discharge readiness of all families prior to discharge. Those at an increased risk may benefit from more discharge education and training, specifically for single mothers, those with limited resources, or others considered at high risk.

The health and well-being of childbearing women and children in the US should set a world standard. However, women and children in the US experience higher rates of morbidity and mortality than women and children in almost all other industrialized countries, with marked racial and ethnic disparities. The unfolding effects of the coronavirus disease 2019 (COVID-19) pandemic have highlighted such disparities. In this article, which is part of the National Academy of Medicine's Vital Directions for Health and Health Care: Priorities for 2021 initiative, we draw on a life-course framework to highlight promising interventions and recommend key improvements in programs and policies to optimize health and well-being among women and children in the US. The recommendations address ensuring access, transforming health care, and addressing social and environmental determinants.

To characterize state regulation and behavior of preterm infants after discharge from the neonatal intensive care unit (NICU).We recruited singleton infants born at ≤35 weeks of gestational age (GA) before NICU discharge. Parents completed surveys at discharge and 1, 3, and 6 months after discharge. Infant medical history was gleaned from the medical record. Surveys captured sociodemographic information and measures of infant state regulation (Baby Pediatric Symptom Checklist [BPSC]) and feeding behaviors. We calculated the median BPSC subscale scores at each time point and the proportion of infants with scores in the problem range (≥3/5). We explored longitudinal and cross-sectional correlates of BPSC scores.Fifty families completed the discharge questionnaire, and 42 (84%) completed the 6-month questionnaire. The median GA at birth was 34 weeks (IQR 30.1, 34.4 weeks); the median birth weight was 1930 g (IQR 1460, 2255 g). The median scores were above population norms for irritability and difficulty with routines. Twenty-one infants (40%) had irritability subscale scores in the problem range at 1 month, and 20 (38%) had problem scores on difficulties with routines. Only 9 infants (17%) had problem scores on the inflexibility subscale. Scores in all 3 domains showed different patterns from population norms from 1 to 6 months. BPSC scores were correlated with infant feeding behaviors at 1, 3, and 6 months.Scores for irritability and difficulty with routines among preterm infants were high compared with population norms and differed from normative values through 6 months after discharge. Preterm infants demonstrate problems with state regulation after NICU discharge that may require directed intervention.

INTRODUCTION Shortened sleep duration in adolescence has been found to be associated with adverse health outcomes. While several studies have explored individual predictors, few have examined the role of neighborhood-level factors, family, and peer contexts as predictors of sleep among adolescents. METHOD We examined contextual factors of sleep duration in a sample of 1,614 urban, public high school students from the 2008 Boston Youth Survey. Neighborhood data came from the 2008 Boston Neighborhood Survey of 1,710 adult Boston residents, the 2009 American Community Survey Census (ACS), and Boston Police. RESULTS Using multilevel linear regression, adjusting for neighborhood and school clustering, age, race, and sex, we found concentrated neighborhood poverty to be positively associated with sleep duration (β = 0.09, p = .03). Family context was significantly associated with longer sleep duration: >1-3 hr of homework per night reported longer sleep compared with students reporting ≤1 hr per night (β = 0.20, p = .005). Students reporting lower levels of positive parenting influence had shorter sleep duration (0-25th percentile: β = -0.25, p = .01; 26th-50th β = -0.24, p = .03), compared with students in the highest percentile. Students who never ate dinner with family had shorter sleep duration as compared with those having dinner with family 5 or more times per week (β = -0.22, p = .05). DISCUSSION Our findings focusing on neighborhood and family context represent potentially modifiable practices. These finding are important for public health advocates and health care providers as they seek to curb the epidemic of sleep deprivation in youth. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Supine sleep positioning (SSP) has been shown to reduce the risk of sudden infant death syndrome (SIDS) and preterm infants are at higher risk for SIDS. Population-based estimates of SSP are lacking for the preterm population. The objectives of this study are: (1) compare the prevalence of SSP after hospital discharge for preterm and term infants in the United States; and (2) assess racial/ethnic disparities in SSP for preterm and term infants.We analyzed the 2000 to 2011 data from the Pregnancy Risk Assessment Monitoring System of Centers for Disease Control and Prevention from 35 states. We measured prevalence of SSP by preterm and term gestational age (GA) categories. We calculated adjusted prevalence ratios (APR) to evaluate the likelihood of SSP for each GA category compared with term infants and the likelihood of SSP for non-Hispanic black (NHB) and Hispanic infants compared with non-Hispanic white (NHW) infants.Prevalence of SSP varied by GA: ⩽27, 59.7%; 28 0/7 to 33 6/7, 63.7%; 34 0/7 to 36 6/7 (late preterm), 63.6%; and 37 0/7 to 42 6/7 (term) weeks, 66.8% (P0.001). In the adjusted analyses, late preterm infants were slightly less likely to be placed in SSP compared with term infants (APR: 0.96, confidence interval: 0.95 to 0.98). There were racial/ethnic disparities in SSP for all GA categories when NHB and Hispanic infants were compared with NHW infants.All infants had suboptimal adherence to SSP indicating a continued need to better engage families about SSP. Parents of late preterm infants and families of NHB and Hispanic infants will also require greater attention given their decreased likelihood of SSP.

Objective To examine general dental and orthodontic utilization and expenditures by health insurance status, public health insurance eligibility, and sociodemographic characteristics among children aged 0 to 17 years using data from 2010–2012. Methods Nationally representative data from the Medical Expenditure Panel Survey (2010–2012) provided data on insurance status, public health insurance eligibility, and visits to dental providers for both general dental care and orthodontic care. Results Overall, 41.9% of US children reported an annual dental office–based visit for general (nonorthodontic) dental care. Fewer Hispanic (34.7%) and non-Latino black children (34.8%) received dental care compared to non-Hispanic whites (47.3%) and Asians (40.3%). Children living in families with the lowest income were also the least likely to have a visit (32.9%) compared to children in the highest-income families (54.7%). Among children eligible for public coverage, Medicaid-eligible children had the lowest percentage of preventive dental visits (29.2%). Socioeconomic and racial/ethnic disparities in use and expenditures for orthodontic care are much greater than those for general and preventive dental care. Average expenditures for orthodontic care were $1,823, of which 56% ($1,023) was paid out of pocket by families. Conclusions Our findings provide a baseline assessment for examining trends in the future, especially as coverage patterns for children may change as the Affordable Care Act is implemented and the future of the State Child Health Insurance Program remains uncertain beyond 2017.

Background Preterm, low-birth-weight (LBW) children are at increased risk for poor academic achievement and special health care needs (SHCN) compared to term-born peers. It is not known how having SHCN during childhood modifies the relationship between LBW and achievement over time. Methods We used data from the Infant Health and Development Program, a multisite randomized trial of an intervention for preterm, LBW infants with longitudinal follow-up. Primary outcome measures were Woodcock-Johnson Tests of Academic Achievement math and reading scores at age 8 and 18 years. Primary predictor was having a SHCN, defined by prescription medication and medical services use, receipt of special therapies, or any functional limitation. We used repeated measures multivariate analysis of covariance to test the effect of SHCN on achievement at 8 and 18 years and effect modification by IQ. Results The 576 participants had a mean body weight of 1798.1 ± 455.0 g and a median gestational age of 33 weeks (range, 26–37 weeks). Mean achievement scores were as follows: math (age 8) 97.5 ± 21.6, math (age 18) 90.1 ± 18.3, reading (age 8) 99.0 ± 20.1, and reading (age 18) 96.8 ± 23.5. Mean full scale IQ at age 8 was 92.3 ± 18.2. Eighty percent had a SHCN. Mean achievement scores were significantly different between those with and without SHCN in both math and reading. There was no evidence of effect modification by IQ. Conclusions SHCNs are associated with poor academic achievement. Targeted interventions for improving performance outcomes by reducing the burden of chronic health problems may be accomplished through prevention strategies or efforts to limit the frequency and severity of symptoms.

Low Apgar score has been associated with higher risk for several neurological and psychiatric disorders, including cerebral palsy and intellectual disability. Studies of the association between Apgar score and autism spectrum disorder (ASD) have been inconsistent. We aimed to investigate (1) the association between low Apgar score at 5 min and risk for ASD, and (2) the modifying effects of gestational age and sex on this association in the largest multinational database of ASD. We included prospective data from 5.5 million individuals and over 33,000 cases of ASD from Norway, Sweden, Denmark and Western Australia who were born between 1984 and 2007. We calculated crude and adjusted risk ratios (RR) with 95% confidence intervals (95% CIs) for the associations between low Apgar score and ASD. All analyses for ASD were repeated for autistic disorder (AD). We used interaction terms and stratified analysis to investigate the effects of sex, gestational age, and birth weight on the association. In fully adjusted models, low Apgar scores (1–3) (RR, 1.42; 95% CI, 1.16–1.74), and intermediate Apgar scores (4–6) (RR, 1.50; 95% CI, 1.36–1.65) were associated with a higher RR of ASD than optimal Apgar score (7–10). The point estimates for low (RR, 1.88; 95% CI, 1.41–2.51) and intermediate Apgar score (RR, 1.54; 95% CI, 1.32–1.81) were larger for AD than for ASD. This study suggests that low Apgar score is associated with higher risk of ASD, and in particular AD. We did not observe any major modifying effects of gestational age and sex, although there seems to be substantial confounding by gestational age and birth weight on the observed association. Electronic supplementary material The online version of this article (10.1007/s10654-018-0445-1) contains supplementary material, which is available to authorized users.

Premature delivery and a potential Neonatal Intensive Care Unit admission may be associated with the risk of poor maternal health. We aimed to examine the mothers’ health-related quality of life (HRQoL) at the time of infant discharge. Fifty mothers completed the Medical Outcomes Study-Short Form 12. It has a Physical Component Score (PCS) and Mental Component Score (MCS), both with a mean of 50 and standard deviation of 10. Analysis included infant, maternal, and pregnancy-related characteristics. In multivariable analyses, a household income of

The family-centered medical home (FCMH) is the recommended healthcare delivery model for children. It is unknown how frequently preterm (PT) children receive care in a FCMH and how this affects health services use. We studied 18,397 children aged 0–3 years in the 2010/2011 National Survey of Children’s Health. We compared PT (

Objective To describe trends in unplanned 30-day all-condition hospital readmissions for children aged 1 to 17 years between 2009 and 2014. Methods Analysis was conducted with the 2009–14 Nationwide Readmissions Database from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project. Annual hospital readmission rates, resource use, and the most common reasons for readmission were calculated for the 2009–14 period. Results The rate of readmission for children aged 1 to 17 years was essentially stable between 2009 and 2014 (5.5% in 2009 and 5.9% in 2014). In 2009, the most common reason (principal diagnosis) for readmission was sickle cell anemia, whereas in 2014 the most common reason was epilepsy. Pneumonia fell from the second to the sixth most common reason for readmission over this period (from 3832 to 2418 stays). Other respiratory infections were among the top 10 principal readmission diagnoses in 2009, but not in 2014. Septicemia was among the 10 most common reasons for readmission in 2014, but not in 2009. Although the average cost of index (ie, initial) stays with a subsequent readmission were similar in 2009 and 2014, the average cost of index stays without a readmission and cost of readmission stays increased by approximately 23%. In both 2009 and 2014, the average cost of the index stays with a subsequent readmission was 73% to 89% higher than that of the index stays of children who were not readmitted within 30 days. The average cost of index stays preceding a readmission was 33% to 45% higher than average costs for readmitted stays. In 2014, the aggregate cost of index stays plus readmissions was $1.58 billion, with 42.9% of the costs attributable to readmissions. Regarding the average costs and lengths of stay for the 10 most common readmission diagnoses, in 2009 the average cost per stay for complications of devices, implants, or grafts was nearly 5 times greater than that of asthma ($21,200 vs $4500, respectively). In 2014, average cost per stay ranged from $5500 for asthma to $39,500 for septicemia. In 2009, the average length of stay (LOS) for complications of devices, implants, or grafts was more than 3 three times higher than that for asthma (7.8 days vs 2.5 days, respectively), and in 2014, the average LOS for septicemia was nearly 4 times higher than that for asthma (10.4 days vs. 2.6 days). Conclusions This study provides a baseline assessment for examining trends in 30-day unplanned pediatric readmissions, an important quality metric as the provisions of the Children's Health Insurance Program Reauthorization Act and the Affordable Care Act are changed and implemented in the future. More than 50,000 pediatric hospital stays in 2014 occurred within 30 days of a previous hospitalization, with an average cost of $13,800. This report is timely, as the health care system works to become more patient-centered and public and private payers grapple with how to pay for quality care for children. The report provides baseline information that can be used to further explore ways to reduce unplanned readmissions.

Background Research suggests cardiovascular and metabolic diseases are influenced by psychological distress in adulthood; however, this research is often limited to adult populations and/or a snapshot measure of distress. Given emerging recognition that cardiometabolic diseases have childhood origins, an important question is whether psychological distress earlier in life influences disease development. Objectives This study sought to assess whether life course patterns of psychological distress assessed from childhood through adulthood predict biomarkers of cardiometabolic risk in adulthood and whether effects of sustained distress differ from more limited exposure. Methods The sample (n = 6,714) consists of members of the 1958 British Birth Cohort Study who completed repeated measures of psychological distress and a biomedical survey at age 45 years. Psychological distress profiles over the life course (no distress, childhood only, adulthood only, or persistent distress) were identified from 6 assessments between ages 7 and 42 years. Cardiometabolic risk was assessed by combining information on 9 biomarkers of immune, cardiovascular, and metabolic system function. Covariate adjusted linear regression models were used to assess associations between distress profiles and cardiometabolic risk. Results Compared with those with no distress, cardiometabolic risk was higher among people with psychological distress in childhood only (β = 0.11, SE = 0.03, p = 0.0002), in adulthood only (β = 0.09, SE = 0.03, p = 0.007), and persistent across the life course (β = 0.26, SE = 0.04, p Conclusions Psychological distress at any point in the life course is associated with higher cardiometabolic risk. This is the first study to suggest that even if distress appears to remit by adulthood, heightened risk of cardiometabolic disease remains. Findings suggest early emotional development may be a target for primordial prevention and for promoting lifelong cardiovascular health.

This study investigated the relationship between lifetime DSM-IV posttraumatic stress disorder (PTSD) and intimate partner violence (IPV) perpetration in a representative sample of self-identified heterosexual adult men in the U.S. Analysis was conducted using data from two waves of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) among 11,625 heterosexual men to test the hypothesis that heterosexual men in the general population with lifetime PTSD were more likely to perpetrate IPV than their non-PTSD counterparts. In adjusted models, heterosexual men who reported lifetime PTSD showed significantly higher risk of IPV perpetration (OR = 2.36, 95 % CI = 1.56–3.57, p

The following are the objectives of this study: (1) Assess the feasibility and acceptability of emailing parent-reported measures of infant health and development after NICU discharge. (2) Examine whether post-discharge questionnaire data helps identify infants most likely to benefit from specialized follow-up care. Parents of 51 infants

Objective To evaluate the effect of community-based early intervention (EI) services the on functional outcomes of high-risk infants at school age. Methods This was a retrospective cohort study using data from the US Department of Education's National Early Intervention Longitudinal Study. Participants were enrolled in 1997 to 1998 with follow-up through 5 years and had a neonatal intensive care unit (NICU) admission, birth weight >400 g, and gestational age >23 weeks. Kindergarten outcomes were teacher assessments of academic and physical skills compared with classmates. Because treatment assignment is determined according to level of clinical need, we used repeated measures, marginal structural models with inverse probability of treatment weighting to account for confounding by indication. Results Of 405 participants, 47% had academic ratings average/above average and 71% had physical skills ratings average/above average. Odds of average/above average academic skills were lower for those with delayed EI enrollment (adjusted odds ratio [aOR], 0.65; 95% confidence interval [CI], 0.43–0.99) and trending, although not significantly, higher for those with greater service duration (aOR, 1.47; 95% CI, 0.98–2.22) and breadth (odds ratio, 1.74; 95% CI, 0.95–3.20). Odds of average/above average physical skills were lower for those with delayed EI enrollment (aOR, 0.61; 95% CI, 0.40–0.93) and higher for those with greater intensity (aOR, 1.06; 95% CI, 1.00–1.13) and breadth (aOR, 1.86; 95% CI, 1.03–3.35), approaching significance for those with greater service duration (aOR, 1.41; 95% CI, 0.96–2.09). Conclusions Longer, more intense services were associated with higher kindergarten skills ratings in children at risk for disabilities. Our novel findings support the effectiveness of large-scale EI programs and reinforce the importance of referral after NICU discharge.

Background Little is known about the quality of life of parents and families of preterm infants after discharge from the neonatal intensive care unit (NICU). Our aims were (1) to describe the impact of preterm birth on parents and families and (2) and to identify potentially modifiable determinants of parent and family impact. Methods We surveyed 196 parents of preterm infants

From Agency for Healthcare Research and Quality, Rockville, MD (Dr Dougherty); Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, MA (Dr McCormick); and MGH Center for Child and Adolescent Health Research Policy, Department of Pediatrics, MassGeneral Hospital for Children, Boston, MA (Dr Co) Address correspondence to Denise Dougherty, PhD, Agency for Healthcare Research and Quality, 540 Gaither Rd, Rockville, MD 20850 (e-mail: denise.dougherty@ahrq.hhs.gov).

In this issue of Pediatrics , Spittle et al1 provide an important follow-up report at 8 years to their randomized trial of early intervention for very preterm infants. The intervention was delivered over 9 sessions during the first year of life and was based on a strong theoretical approach. The well-defined set of services aimed to enhance caretakers’ ability to foster the development of their children and to reduce parental stress.2 At planned follow-up assessments at 2 and 4 years of age,3,4 the authors found no difference between the intervention and control groups in the children’s cognitive, language, and motor scores. They did observe a persistent effect of the intervention on decreased mental health symptoms in caretakers at both points. The current follow-up was undertaken based on the relationship between child development and parental mental health, with the expectation that the persistent advantage in the intervention group would result in better child outcomes. The authors employed an expanded test battery to go beyond intelligence to examine specific domains of child cognitive development, attention, … Address correspondence to Marie C. McCormick MD, ScD, Department of Social and Behavioral Sciences, Harvard School of Public Health, 677 Huntington Ave, Boston, MA 02115. E-mail: mmccormi{at}hsph.harvard.edu

Objectives Prior research on the relationship between early adversity and adult chronic disease has often relied on retrospective reports of a limited range of exposures and has not considered childhood psychological distress as a mediator. We investigate whether distress in childhood is one pathway by which early social disadvantage leads to greater cardiometabolic risk in middle adulthood. Methods Data are from the 1958 British Birth Cohort study (sample n = 6027). We created an early social disadvantage index based on 16 exposures related to family and socioeconomic hardship from birth to age 7. Childhood psychological distress was ascertained from internalizing and externalizing symptoms at ages 7, 11, and 16 years. Cardiometabolic risk was assessed with a Z-standardized score derived from 9 immune, cardiovascular, and metabolic biomarkers measured at age 45. We used linear regression models and formal tests of mediation to assess relationships between disadvantage, distress, and subsequent cardiometabolic risk. Results Higher social disadvantage predicted increased adult cardiometabolic risk (β = 0.05; 95% CI = 0.03-0.07). Mediation analyses revealed a significant direct (path c'; β = 0.03; 95% CI = 0.01-0.05) and indirect (path ab; β = 0.02; 95% CI = 0.01-0.02) effect of social disadvantage on cardiometabolic risk, adjusting for potential confounders. Child psychological distress accounted for 37% (95% CI = 34-46%) of the observed association. Conclusions Results suggest childhood distress may be one factor on the pathway linking early disadvantage to higher risk of developing cardiometabolic diseases. Such results may point to the importance of blocking the translation of psychosocial to biological risk during a potentially sensitive developmental window.

Objective Identification and refinement of psychometric properties of the Reproductive Coercion Scale (RCS) for use in survey research and clinical practice. Study design Young women aged 16–29 years seeking services in 24 Pennsylvania and 5 California family planning clinics completed questionnaires. Data were pooled for analysis (n=4674), and underlying domains were assessed using Horn's Parallel Analysis and Exploratory Factor Analysis. Multidimensional Item Response Theory was used to refine the scale and assess reliability and validity of a short-form RCS. Results The full, nine-item RCS had two underlying domains: pregnancy coercion and condom manipulation. Five items were retained in the short form: three about pregnancy coercion (e.g., “told you not to use birth control…”) and two for condom manipulation (e.g., “taken off the condom while you were having sex…”; one of these items is the combination of two original items on damaging the condom that were combined because of similar statistical properties and face validity and a third item on removing the condom was retained on its own). Recent reproductive coercion was reported by 6.7% and 6.3% of the sample with the full and short-form RCS, respectively. Characteristics of women reporting reproductive coercion were similar with both forms. Conclusion Findings indicate that reproductive coercion includes pregnancy coercion and deliberate manipulation of condoms to promote pregnancy. Moreover, women experience reproductive coercion across a continuum of severity. We selected items that varied in RC severity and discrimination to generate a five-item short-form RCS for survey research and clinical practice. Implications This study assesses the psychometric properties of the RCS, identifying pregnancy coercion and condom manipulation as underlying domains of reproductive coercion. Recommendations for using the RCS in research and clinical practice are discussed.

Access to good intensive care blunts the effects of deprivation In the linked prospective cohort study (doi:10.1136/bmj.b4702), Smith and colleagues assessed socioeconomic inequalities in survival and neonatal care provision among very preterm infants.1 A cohort of 7449 infants born during a 10 year period (1998-2007) at between 22+0 and 32+6 weeks’ gestation were followed up until discharge from neonatal care. What do the findings suggest about equity of neonatal care provision? Preterm birth is a leading cause of infant mortality worldwide and a substantial cause of childhood disability in survivors. The risks of death are highest in babies born before 33 weeks’ gestation—the very preterm group. Furthermore, both preterm birth and infant mortality are associated with socioeconomic position, with the risks being highest in those from the most deprived socioeconomic groups.2 3 As might be expected, the most striking socioeconomic inequalities in neonatal survival are seen from a global perspective, with 98% of neonatal deaths occurring in less developed countries.4 However, even in high income …

Dietary and physical activity (PA) behaviors can predict disordered weight control behaviors (DWCB) among youth. This study examines dietary and PA correlates of DWCB and differences by race/ethnicity and weight status in a diverse sample of youth.Self-reported data on dietary weight management behaviors, strengthening/toning exercises, moderate-to-vigorous physical activity, and DWCB (vomiting, taking laxatives, and/or taking diet pills without a prescription) were obtained from 15,260 sixth to eighth graders in 47 middle schools participating in the Massachusetts Healthy Choices Study at baseline (2005). Generalized estimating equations were used to estimate odds of DWCB associated with dietary and PA behaviors and to examine for differences by race/ethnicity and weight status, adjusting for covariates and clustering of individuals within schools.Disordered weight control behaviors were reported by 3.6% of girls and 3.1% of boys. Youth who engaged in strengthening/toning exercises 7 days per week versus 0-3 days per week had increased odds of DWCB (girls odds ratio [OR] = 1.9; 95% confidence interval [CI] = 1.3 - 3.0; boys OR = 1.5; 95% CI = 1.0 - 2.2). Dietary weight management behaviors were associated with increased odds of DWCB (girls OR = 1.2; 95% CI = 1.1 - 1.3; boys OR = 1.3; 95% CI = 1.2 - 1.4) for each additional behavior. These associations did not differ by race/ethnicity or weight status.Persons promoting healthy dietary and PA behaviors among youth should consider the co-occurrence of strengthening/toning and dietary weight management behaviors with DWCB and the consistency in these associations across racial/ethnic and weight status groups.

Background Former preterm and very low birth weight (VLBW) infants require close neurodevelopmental surveillance after hospital discharge, but in-person professional testing is resource-intensive and inconvenient for families. A standardised developmental questionnaire completed by parents offers an alternative to in-person testing, but few such questionnaires have been validated. Our aim was to validate the Motor and Social Development (MSD) scale in a sample of former preterm infants.

Background Moderately premature infants, defined here as those born between 30 0/7 and 34 6/7 weeks gestation, comprise 3.9% of all births in the United States and 32% of all preterm births. While long-term outcomes for these infants are better than for less mature infants, morbidity and mortality are still substantially increased in comparison to infants born at term. There is an added survival benefit resulting from birth at a tertiary neonatal care center, and although many of these infants require tertiary level care, delivery at lower level hospitals and subsequent neonatal transfer are still common. Objective Our primary aim was to determine the impact of maternal characteristics and antenatal medical management on the early neonatal course of the moderately premature infant. The secondary aim was to create a clinical prediction rule to determine which infants require intubation and mechanical ventilation in the first 24 hours of life. Such a prediction rule could inform the decision to transfer maternal-fetal patients prior to delivery to a facility with a Level III Neonatal Intensive Care Unit (NICU), where optimal care could be provided without the requirement for a neonatal transfer. Methods Data for this analysis came from the cohort of infants in the Moderately Premature Infant Project (MPIP) database, a multi-center cohort study of 850 infants born at gestational age 30 0/7 to 34 6/7 weeks, who were discharged home alive. We built a logistic regression model to identify maternal characteristics associated with need for tertiary care, as measured by administration of surfactant. Using statistically significant covariates from this model, we then created a numerical decision rule to predict need for tertiary care. Results In multivariate modeling, 4 factors were associated with reduction in the need for tertiary care, including, surfactant administration, including non-White race (OR=0.5, [0.3, 0.7], older gestational age, female gender (OR=0.6 [0.4, 0.8]) and use of antenatal corticosteroids (OR=0.5, [0.3, 0.8]). The clinical prediction rule to discriminate between infants who received surfactant, versus those who did not, had an area under the curve of 0.77 [0.73, 0.8]. Conclusions Four antenatal risk factors are associated with a requirement for Level III NICU care as defined by the need for surfactant administration. Future analyses will examine a broader spectrum of antenatal characteristics and revalidate the prediction rule in an independent cohort.

This study examines the relationship between the husband's preference for a son, sex composition of children and risk of anaemia and underweight among married Indian women. Information was collected regarding 29,517 couples having at least one child in the nationally representative 2005-06 National Family Health Survey of India. The exposures were husband's preference for a son and sex composition of children: sons only, daughters only and mixed. Outcome included maternal underweight and moderate/severe anaemia. Husband's preference for a son was not found to be associated with his wife's risk of anaemia or underweight. Sex composition of the children was modestly associated with increased odds of anaemia among women from households with daughters only as compared with those with sons only [AOR: 1.19; 95% CI 1.04, 1.35]. The findings from this population-based study of socio-cultural norms around preference for a son and married Indian women's nutritional status do not support the hypothesis that husband's preference for sons influences the nutritional status of their wives. However, having daughters only is associated with maternal anaemia for reasons that remain to be established.

Purpose The objectives of this study were (1) to examine whether the association between childhood family conflict and the risk of substance use disorders (SUDs) in adolescence differs by gender, and (2) to determine whether anxious/depressive symptoms and conduct problems explain this association among adolescent males and females. Methods Data were obtained from 1,421 children aged 10–16 years at the time of enrollment in the Project on Human Development in Chicago Neighborhoods. We assessed gender differences in the association between childhood family conflict and adolescent SUDs by fitting a logistic regression model that included the interaction of gender and family conflict. We also investigated whether conduct problems and anxious/depressive symptoms explained the association between family conflict and SUDs differently for males and females through gender-specific mediation analyses. Results The association between childhood family conflict and SUDs in adolescence differed by gender ( p = .04). Family conflict was significantly associated with SUDs among females (OR: 1.61; CI: 1.20–2.15), but not among males (OR: 1.00; CI: .76–1.32). The elevated risk of SUDs among females exposed to family conflict was partly explained by girls' conduct problems, but not by anxious/depressive symptoms. Conclusions Females living in families with elevated levels of conflict were more likely to engage in acting out behaviors, which was associated with the development of SUDs. Future epidemiologic research is needed to help determine when this exposure is most problematic with respect to subsequent mental health outcomes and the most crucial time to intervene.

The objective of this study is to investigate prenatal and perinatal determinants of school age blood pressure (BP) in former preterm, low birth weight infants.We studied 694 participants in the Infant Health and Development Program, an eight-center longitudinal study of children born ≤ 37 weeks and ≤ 2500 g. We obtained information about prenatal and perinatal factors by interview and medical record review, and measured BP three times at age 6.5 years.Adjusting for sex, age, sociodemographic variables and height Z-score; for each Z-score birth weight for gestational age-which represents fetal growth-systolic BP at 6.5 years was 0.7 mm Hg higher (95% confidence interval -0.1, 1.6). Maternal age, pre-pregnancy weight, gestational weight gain, smoking, preeclampsia, gestational diabetes, and child gestational age and neonatal complications were also not associated with BP.In contrast to full-term infants, slower fetal growth was not associated with higher BP in former preterm, low birth weight infants.

This study described predictors of caregiver burden among parents of children with developmental disabilities. The sample, obtained from the 2005–2006 National Survey of Children With Special Health Care Needs, included 12,225 children, aged 5 to 17 years, with a developmental disability. Structural equation modeling assessed the relationships between the factors of Caregiver Burden, Ease of Accessing and Navigating the Health Care System, and Unmet Health Care Needs. Caregiver burden was inversely associated with ease of accessing and navigating the health care system (β = −0.094, SE (β) = 0.045) and positively associated with unmet health care needs (β = 0.428, SE (β) = 0.036). Parents of poor, minority, and uninsured children experienced significantly greater caregiver burden. Bolstering services, particularly for vulnerable families, may ameliorate caregiver burden.

This is the first investigation of the relationship between parental age and extreme social-communicative autistic traits in the general population. The parents of 5,246 children in the Avon Longitudinal Study of Parents and Children (ALSPAC) completed the Social and Communication Disorders Checklist (SCDC). The association between parental age and SCDC scores was assessed in the full sample and among high scoring individuals (e.g. top 5%, 1%). There was no association between parental age and social-communicative autistic traits in the general population. Neither maternal nor paternal age was associated with extreme scores. These findings suggest that advanced parental age does not confer increased risk for extreme social and communication impairment assessed quantitatively.

OBJECTIVE: Apnea of prematurity is one of the most common diagnoses in the NICU. Because resolution of apnea is a usual precondition for discharge from the hospital, different monitoring practices might affect length of stay for premature infants. Our objective was to compare the proportion of 33 to 34 weeks' gestational age infants diagnosed with apnea in different NICUs and to assess whether variability in length of stay would be affected by the rate of documented apnea. METHODS: This was a prospective cohort study of moderately preterm infants who survived to discharge in 10 NICUs in Massachusetts and California. RESULTS: The study population comprised 536 infants born between 33 and 3467 weeks of which 264 (49%) were diagnosed with apnea. The mean postmenstrual age at discharge was higher in infants diagnosed with apnea compared with those without apnea (36.4 ± 1.3 vs 35.7 ± 0.8; P < .001, analysis of variance). Significant inter-NICU variation existed in the proportion of infants diagnosed with apnea (range: 24%–76%; P < .001). Postmenstrual age at discharge also varied between NICUs (range: 35.5 ± 0.6 to 36.7 ± 1.5 weeks; P < .001). As much as 28% of the variability in postmenstrual age at discharge between NICUs could be explained by the variability in the proportion of infants diagnosed with apnea. CONCLUSIONS: NICUs vary in the proportion of moderately preterm infants diagnosed with apnea, which significantly affects length of stay. Standardization of monitoring practices and definition of clinically significant cardiorespiratory events could have a significant impact on reducing the length of stay in moderately preterm infants.

Given that diet, physical activity, and social support are associated with depression, we examined whether a health promotion intervention designed to modify these factors in low-income, postpartum women would reduce depressive symptoms. This study used a randomized, controlled design to examine the effect of the Just for You (JFY) Program, an educational intervention promoting healthy lifestyles through home visits by nutrition paraprofessionals and motivational telephone counseling, on postpartum depressive symptoms. A total of 679 women income-eligible for the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) were recruited at 6-20 weeks post delivery and randomized to Usual WIC Care or JFY. Using an intention-to-treat analysis, the authors modeled depressive symptoms on the Center for Epidemiologic Studies Depression Scale (CES-D) among 403 women (59%) completing follow-up at a mean of 15 months infant age, adjusting for baseline CES-D, age, household income and randomization strata (body mass index (BMI), race/region). As a secondary analysis, the authors evaluated potential mediators related to social support and self-efficacy to change one or more health behaviors targeted by the intervention. Women randomized to JFY reported 2.5 units lower CES-D score (P = 0.046) compared with those receiving Usual WIC Care alone. This relationship was attenuated by change in self-efficacy (β = -2.3; P = 0.065), suggesting this construct may partially have mediated the effect of JFY on maternal depressive symptoms. A health promotion intervention delivered through home visits and telephone calls can reduce depressive symptoms at 15 months postpartum among low-income, ethnically diverse women.

Objective The aim of this study was to explore the joint effect of race/ethnicity and insurance status/expected payer or income on children's health care quality. Methods The analyses are based on data from a nationally representative random sample of children in the United States in 2004 and 2005 from the Medical Expenditure Panel Survey (MEPS) and pediatric hospitalizations from a nationwide sample of hospitals in 2005 from the State Inpatient Databases disparities analysis file from the Healthcare Cost and Utilization Project (HCUP). We provide estimates of differences in race/ethnicity within income and insurance/expected payer categories on key pediatric quality indicators to provide a more nuanced understanding of disparities in care for children. Our indicators of quality cover several domains from the Institute of Medicine report, including effectiveness, patient centeredness, timeliness, and patient safety. Results Across a broad set of 23 quality indicators, findings indicate that racial/ethnic disparities vary by income levels and types of insurance. Key highlights include the finding that racial/ethnic differences within income or insurance/payer groups are more pronounced for some racial/ethnic groups than others. Hispanic children followed by Asian children had worse quality than whites as measured by the majority of quality indicators. Exceptions included rates of admissions for diabetes, admissions for gastroenteritis, accidental puncture during procedures, and decubitus ulcers. Many indicators showed less than ideal quality for all subgroups of children, even whites with private insurance. Conclusions The extensive findings in this report make clear that patterns of racial/ethnic disparity vary by income and insurance/expected payer subgroup. However, disparities in quality are not similar across all measures of quality, and strategies to address these disparities need to be designed with these nuances in mind.

OBJECTIVE: Moderately preterm infants (30–3467 weeks' gestational age) represent the largest population of NICU residents. Whether their clinical outcomes are associated with differences in NICU nurse-staffing arrangements has not been assessed. The objective of this study was to test the influence of patient-to-nurse ratios (PNRs) on outcomes of care provided to moderately preterm infants. PATIENTS AND METHODS: Using data from a prospective, multicenter, observational cohort study of 850 moderately preterm infants from 10 NICUs in California and Massachusetts, we tested for associations between PNR and several important clinical outcomes by using multivariate random-effects models. To correct for the influence of NICU size, we dichotomized the sample into those with an average daily census of RESULTS: Overall, we found few clinically significant associations between PNR and clinical outcomes of care. Mean PNRs were higher in large compared with small NICUs (2.7 vs 2.1; P < .001). In bivariate analyses, an increase in PNR was associated with a slightly higher daily weight gain (5 g/day), greater gestational age at discharge, any intraventricular hemorrhage, and severe retinopathy of prematurity. After controlling for case mix, NICU size, and site of care, an additional patient per nurse was associated with a decrease in daily weight gain by 24%. Other variables were no longer independently associated with PNR. CONCLUSIONS: In this population of moderately preterm infants, the PNR was associated with a decrease in daily weight gain, but was not associated with other measures of quality. In contrast with findings in the adult intensive care literature, measured clinical outcomes were similar across the range of nurse-staffing arrangements among participating NICUs. We conclude that the PNR is not useful for profiling hospitals' quality of care delivery to moderately preterm infants.

(1) Quantify and compare the family's and the nurse's perception regarding the family's discharge preparedness. (2) Determine which elements contribute to a family's discharge preparedness.We studied the families of all the infants discharged from a neonatal intensive care unit after a minimum of a 2-week admission. The families rated their overall discharge preparedness with a 9-point Likert scale on the day of discharge. Independently, the discharging nurse evaluated the family's discharge preparedness. Families were considered discharge 'prepared' if they rated themselves and the nurse rated their technical and emotional preparedness asor=7 on the Likert scale.We had 867 (58%) family-nurse pairs who completed the survey. Most families (87%) were prepared for discharge as assessed by the concordant questionnaire (Likert scores ofor=7 by the parent and the nurse). In multivariate analysis, confidence in their child's health and maturity (odds ratios, OR=2.5 95% confidence interval, CI (1.2, 5.3)), their readiness for their infants to come home (OR=2.9 95% CI (1.0, 8.3)), and selecting a pediatrician (OR=4.2 95% CI (1.6, 11.0)) were statistically significant.Assistance with pediatrician selection and home preparation may improve the percentage of families prepared for discharge.

This study examined the characteristics of families which may be more vulnerable than others to the impact of caring for a child with spina bifida. Morbidity and the use of health services were unexpectedly high. The impact on the family was related less to clinical diagnoses than to the characteristics of the child's functioning in the home and of the family. Major predictors of greater impact on the family were the number of the child's activities of daily living, parental perceptions of the child's health, low maternal educational attainment, low family income, the number of adults in the family, insurance status, the number of visits to a doctor in the month before the interview, and whether the adults in the family were employed. These results reinforce the need for assessments to include the child's function in the home, and for additional resources to help some families care for their child.

OBJECTIVE. The goal was to examine the factors influencing parental satisfaction with neonatal intensive care for moderately premature infants in 10 hospitals in Massachusetts and California.METHODS. A total of 677 infants without major anomalies or chromosomal disorders who were born between 30 and 34 weeks of gestation in the participating hospitals and discharged alive were included. Parental satisfaction with neonatal intensive care was ascertained 3 months after discharge by using a previously developed scale of 12 Likert items (scored 1–5), addressing such issues as perceptions regarding the staff providing emotional support, information, or education. The questionnaire, which was administered by telephone, also included parental ratings of child health and reports of subsequent health care use, sociodemographic characteristics, and history of infertility treatment. Data on the prenatal, perinatal, and neonatal course were abstracted from the medical charts, and the factors associated with parental satisfaction were analyzed.RESULTS. Parental satisfaction with neonatal intensive care varied significantly across the 10 hospitals. The major predictors of satisfaction were sociodemographic characteristics, history of infertility treatment, and especially parental ratings of child health 3 months after discharge, rather than aspects of the perinatal or neonatal course. Controlling for these factors, differences across hospitals were not statistically significant. However, the variance explained by all of the measured factors, including child health rating, was modest (19%).CONCLUSIONS. Although we included variables across the full spectrum of neonatal intensive care, we found that the major predictor of parental satisfaction with neonatal intensive care was child health at the time of the interview, followed by sociodemographic factors and previous infertility treatment. However, the variance explained was limited, which suggests that research is needed on the factors influencing satisfaction.

The Infant Health and Development Program (IHDP) was a randomized clinical trial of early intervention services for low birth weight, premature infants. Mothers and infants received services for 3 years beginning at neonatal discharge. At the intervention's conclusion, mothers in the intervention group who had lighter (< 2001 g) birth weight infants had been employed longer than mothers in the comparison group. Intervention group mothers also reported less emotional distress, scored higher on the home environment measure and used harsh discipline less frequently with sons. Among measures of mothers' employment, mental health and home environment at 2-, 5-and 15-years post-intervention, employment was the only domain showing a treatment effect over time; this effect depended on child birth weight. Results suggest that early intervention services may have more success altering a mother's life course than her mental health or parenting style. Further research is needed to investigate the factors influencing the decisions made by low birth weight infants' mothers regarding whether and when to work outside the home.

Summary Correspondence: Henry H. Bernstein, D.O.,Chief, General AcademicPediatrics, DartmouthHitchcock Medical Center,One Medical Center Drive,Lebanon, NH 03756, USA.E-mail:henry.bernstein@hitchcock.org Finch SA, Lalama C, Spino C, Schwartz HC, Wasserman RC, McCormick MC, Bern-stein HH. Practice-based research network solutions to methodological challengesencountered in a national, prospective cohort study of mothers and newborns. Paedi-atric and Perinatal Epidemiology 2008; 22 : 87–98.The emergence of practice-based research networks (PBRN) has facilitated the execu-tion of multifaceted community-based studies.As study complexity increases, so doesthe number of methodological barriers encountered. This paper’s goal was to delineatemethodological barriers and to evaluate the effectiveness of selected strategies andapproaches developed and implemented in allowing a prospective, national PBRNcohort study to succeed in enrolling geographically dispersed mother/healthy terminfant dyads ( n

OBJECTIVES. Postpartum discharge of mothers and infants who are not medically or psychosocially ready may place the family at risk. Most studies of postpartum length of stay, however, do not reflect the necessary complexity of decision-making. With this study we aimed to characterize decision-making on the day of postpartum discharge from the perspective of multiple key informants and identify correlates of maternal and newborn unreadiness for discharge.PATIENTS AND METHODS. This was a prospective observational cohort study of healthy term infants with mothers, pediatric providers, and obstetricians as key informants to assess the decision-making process regarding mother-infant dyad unreadiness for discharge. A mother-infant dyad was defined as unready for postpartum hospital discharge if ≥1 of 3 informants perceived that either the mother or infant should stay longer at time of nursery discharge. Data were collected through self-administered questionnaires on the day of discharge.RESULTS. Of 4300 mother-infant dyads, unreadiness was identified in 17% as determined by the mother (11%), pediatrician (5%), obstetrician (1%), and ≥2 informants (CONCLUSIONS. Mothers, pediatricians, and obstetricians must make decisions about postpartum discharge jointly, because perceptions of unreadiness often differ. Sensitivity toward specific maternal vulnerabilities and an emphasis on perinatal education to insure individualized discharge plans may increase readiness and determine optimal timing for discharge and follow-up care.

OBJECTIVE. The timely discharge of moderately premature infants has important economic implications. The decision to discharge should occur independent of unit census. We evaluated the impact of unit census on the decision to discharge moderately preterm infants. DESIGN/METHODS. In a prospective multicenter cohort study, we enrolled 850 infants born between 30 and 34 weeks' gestation at 10 NICUs in Massachusetts and California. We divided the daily census from each hospital into quintiles and tested whether discharges were evenly distributed among them. Using logistic regression, we analyzed predictors of discharge within census quintiles associated with a greater- or less-than-expected likelihood of discharge. We then explored parental satisfaction and postdischarge resource consumption in relation to discharge during census periods that were associated with high proportions of discharge. RESULTS. There was a significant correlation between unit census and likelihood of discharge. When unit census was in the lowest quintile, patients were 20% less likely to be discharged when compared with all of the other quintiles of unit census. In the lowest quintile of unit census, patient/nurse ratio was the only variable associated with discharge. When census was in the highest quintile, patients were 32% more likely to be discharged when compared with all of the other quintiles of unit census. For patients in this quintile, a higher patient/nurse ratio increased the likelihood of discharge. Conversely, infants with prolonged lengths of stay, an increasing Score for Neonatal Acute Physiology II, and minor congenital anomalies were less likely to be discharged. Infants discharged at high unit census did not differ from their peers in terms of parental satisfaction, emergency department visits, home nurse visits, or rehospitalization rates. CONCLUSIONS. Discharges are closely correlated with unit census. Providers incorporate demand and case mix into their discharge decisions.

BACKGROUND AND OBJECTIVE: Late preterm infants (LPIs) (gestation 34 weeks and 0 days to 36 weeks and 6 days) compared with full-term infants (FTIs) are at increased risk for mortality and short- and long-term morbidity. The objective of this study was to assess the neurodevelopmental outcomes in a longitudinal cohort study of LPIs from infancy to school age and determine predictive values of earlier developmental testing compared with school-age testing. METHODS: We used general estimating equations to calculate the odds of school readiness in a nationally representative cohort of 4900 full-term and 950 late preterm infants. We generated positive and negative predictive values of the ability of the 24-month Mental Developmental Index (MDI) scores of the Bayley Short Form, Research Edition, to predict Total School Readiness Score (TSRS) at kindergarten age. RESULTS: In multivariable analysis, late preterm infants had higher odds of worse TSRSs (adjusted odds ratio 1.52 [95% confidence interval 1.06–2.18], P = .0215). The positive predictive value of a child having an MDI of 70 at 24 months and a TSRS >5% was 96.8%. Most infants improved score ranking over the study interval. CONCLUSIONS: LPIs continue to be delayed at kindergarten compared with FTIs. The predictive validity of having a TSRS in the bottom 5% given a MDI 85) at 24 months had an excellent chance of testing in the normal range at kindergarten.

Objectives: Premature and low birth weight children have a high prevalence of academic difficulties. This study examines a model comprised of cumulative risk factors that allows early identification of these difficulties. Methods: This is a secondary analysis of data from a large cohort of premature (

Objective: To compare gestational age at discharge between infants born at 30–34 +6 weeks gestational age who were admitted to neonatal intensive care units (NICUs) in California, Massachusetts, and the United Kingdom. Design: Prospective observational cohort study. Setting: Fifty four United Kingdom, five California, and five Massachusetts NICUs. Subjects: A total of 4359 infants who survived to discharge home after admission to an NICU. Main outcome measures: Gestational age at discharge home. Results: The mean (SD) postmenstrual age at discharge of the infants in California, Massachusetts, and the United Kingdom were 35.9 (1.3), 36.3 (1.3), and 36.3 (1.9) weeks respectively (p = 0.001). Compared with the United Kingdom, adjusted discharge of infants occurred 3.9 (95% confidence interval (CI) 1.4 to 6.5) days earlier in California, and 0.9 (95% CI −1.2 to 3.0) days earlier in Massachusetts. Conclusions: Infants of 30–34 +6 weeks gestation at birth admitted and cared for in hospitals in California have a shorter length of stay than those in the United Kingdom. Certain characteristics of the integrated healthcare approach pursued by the health maintenance organisation of the NICUs in California may foster earlier discharge. The California system may provide opportunities for identifying practices for reducing the length of stay of moderately premature infants.

Background: Newborns of 30–34 weeks gestation comprise 3.9% of all live births in the United States and 32% of all premature infants. They have been studied much less than very low birthweight infants. Objective: To measure in-hospital outcomes and readmission within three months of discharge of moderately premature infants. Design: Prospective cohort study including retrospective chart review and telephone interviews after discharge. Setting: Ten birth hospitals in California and Massachusetts. Patients: Surviving moderately premature infants born between October 2001 and February 2003. Main outcome measures: ( a ) Occurrence of assisted ventilation during the hospital stay after birth; ( b ) adverse in-hospital outcomes—for example, necrotising enterocolitis; ( c ) readmission within three months of discharge. Results: With the use of prospective cluster sampling, 850 eligible infants and their families were identified, randomly selected, and enrolled. A total of 677 families completed a telephone interview three months after hospital discharge. During the birth stay, these babies experienced substantial morbidity: 45.7% experienced assisted ventilation, and 3.2% still required supplemental oxygen at 36 weeks. Readmission within three months occurred in 11.2% of the cohort and was higher among male infants and those with chronic lung disease. Conclusions: Moderately premature infants experience significant morbidity, as evidenced by high rates of assisted ventilation, use of oxygen at 36 weeks, and readmission. Such morbidity deserves more research.

This paper assesses whether chemically dependent adolescents with comorbid learning disorders (LDs) derived less effective treatment results when compared to chemically dependent adolescents without LD and examines the moderating effects of prior treatments, treatment length, and treatment completion. Two hundred one adolescents were recruited between 1992 and 1993 from Massachusetts residential treatment centers and subsequently followed up 6 months after enrollment. Compared to chemically dependent teenagers without LD, those with LD were twice as likely to re-use substances at least once by follow-up. LD teenagers were more likely to attend Alcoholics/Narcotics Anonymous if they had prior admissions to treatment programs and longer treatment length. LD teenagers who completed treatment also experienced a greater decrease in current depression compared to LD teenagers not completing the treatment. This study is the first to consider outcomes of substance abuse treatment for adolescents with LD and contributes to the growing literature on comorbidity and substance abuse treatment.

Variation in care and outcomes of very low birth weight infants (VLBW) in neonatal intensive care units (NICU) has been widely reported in the past decade. Less is known about care provided to healthy premature infants born between 30 and 35 weeks gestational age (GA). We have previously reported inter-NICU variation in discharge (D/C) timing and achievement of maturational milestones in this population. To compare inter-NICU growth outcomes and feeding practices in healthy, moderately premature infants. Records of 450 infants, 30 to 35 weeks gestation, without medical or surgical complications, and consecutively discharged from 15 Massachusetts NICUs (nine Level II and six Level III) were reviewed. Final analyses included 382 infants with hospital length of stay >6 days (d). GA at birth and birth weight (BW) were 33.2 weeks (SD 1.2) and 2024?g (389). Mean Z-score decreased 0.67z (0.37) from birth to D/C. Weight loss from birth to 7?d averaged 4.0%. Mean growth velocity from 7?d to D/C was 13.3?g/k/d (5.2) with net growth velocity of 5.5?g/k/d (5.6). Mean net growth velocity ranged from 0.1 to 8.4?g/k/d (p

Objective.—To examine changes in insurance coverage, health care utilization, perceived quality of care, and expenditures for children and youth in the United States using data from 1987–2001. Methods.—Three national health care databases serve as the sources of data for this report. The Medical Expenditure Panel Survey (1996–2001) provides data on insurance coverage, utilization, expenditures, and perceived quality of care. The National Medical Expenditure Survey (1987) provides additional data on utilization and expenditures. The Nationwide Inpatient Sample (1995–2000) from the Healthcare Cost and Utilization Project provides information on hospitalizations. Results.—The percent of children uninsured for an entire year declined from 10.4% in 1996 to 7.7% in 1999. Most changes in children's health care occurred between 1987 and the late 1990s. Overall utilization of hospital-based services has declined significantly since 1987, especially for inpatient hospitalization. Several of the observed changes from 1987 varied significantly by type of health insurance coverage, poverty status, and geographic region. Quality of care data indicate some improvement between 2000 and 2001, which varies by insurance coverage. Overall, mean length of stay of hospitalizations did not change significantly from 1995 to 2000, but changes in the prevalence of hospitalizations and the length of stay associated with age-specific diagnoses were evident during this time period. Conclusions.—Health care for children and youth has changed significantly since 1987, with most of the changes occurring between 1987 and 1996. Insurance coverage has improved, the site of care has shifted toward ambulatory sites, hospital utilization has declined, and expenditures on children as a proportion of total expenditures have decreased. Variation in these changes is evident by insurance status, poverty, and region.