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BACKGROUND:Prenatal and infancy home-visiting by nurses is promoted as a means of improving maternal life-course, but evidence of long-term effects is limited. We hypothesized that nurse-visitation would lead to long-term reductions in public-benefit costs, maternal substance abuse and depression, and that cost-savings would be greater for mothers with initially higher psychological resources.METHODS:We conducted an 18-year follow-up of 618 out of 742 low-income, primarily African-American mothers with no previous live births enrolled in an randomized clinical trial of prenatal and infancy home visiting by nurses. We compared nurse-visited and control-group women for public-benefit costs, rates of substance abuse and depression, and examined possible mediators of intervention effects.RESULTS:Nurse-visited women, compared with controls, incurred $17 310 less in public benefit costs (P = .03), an effect more pronounced for women with higher psychological resources ($28 847, P = .01). These savings compare with program costs of $12 578. There were no program effects on substance abuseor depression. Nurse-visited women were more likely to be married from child age 2 through 18 (19.2% vs 14.8%, P = .04), and those with higher psychological resources had 4.64 fewer cumulative years rearing subsequent children after the birth of the first child (P = .03). Pregnancy planning was a significant mediator of program effects on public benefit costs.CONCLUSIONS:Through child age 18, the program reduced public-benefit costs, an effect more pronounced for mothers with higher psychological resources and mediated by subsequent pregnancy planning. There were no effects on maternal substance abuse and depression.

OBJECTIVES: Given earlier effects found in randomized clinical trials of the Nurse-Family Partnership, we examined whether this program would improve 18-year-old first-born youths' cognition, academic achievement, and behavior and whether effects on cognitive-related outcomes would be greater for youth born to mothers with limited psychological resources (LPR) and on arrests and convictions among females. METHODS: We enrolled 742 pregnant, low-income women with no previous live births and randomly assigned them to receive either free transportation for prenatal care plus child development screening and referral (control; n = 514) or prenatal and infant home nurse visit (NV) plus transportation and screening (n = 228). Assessments were completed on 629 18-year-old first-born offspring to evaluate these primary outcomes: (1) cognitive-related abilities (nonverbal intelligence, receptive language, and math achievement) and (2) behavioral health (internalizing behavioral problems, substance use and abuse, sexually transmitted infections, HIV risk, arrests, convictions, and gang membership). RESULTS: Compared with control-group counterparts, NV youth born to mothers with LPR had better receptive language (effect size = 0.24; 95% confidence interval [CI]: 0.00 to 0.47; P = .05), math achievement (effect size = 0.38; 95% CI: 0.14 to 0.61; P = .002), and a number of secondary cognitive-related outcomes. NV females, as a trend, had fewer convictions (incidence ratio = 0.47; 95% CI: 0.20 to 1.11; P = .08). There were no intervention effects on other behaviors. CONCLUSIONS: The program improved the cognitive-related skills of 18-year-olds born to mothers with LPR and, as a trend, reduced female convictions but produced no other effects on youth behavioral health.

Introduction The objective of this study was to examine the experiences of pediatric nurse practitioners (PNPs) in the identification and management of child abuse, determine the frequency of their reporting, and describe the effects, attitudes, and confidence in reporting child abuse. Methods A survey based on the 2006 CARES survey was disseminated via e-mail through use of Survey Monkey to 5,764 PNP members of the National Association of Pediatric Nurse Practitioners. The data from this survey were then subjected to statistical analysis, and the resultant findings were compared and contrasted with other similar studies. Results Data analysis revealed that smaller numbers of PNPs in the sample group failed to report suspected child abuse than did their physician colleagues. PNPs and physicians encountered similar perceived barriers to reporting and used similar processes in dealing with them. Both physicians and PNPs with recent child abuse continuing education hours expressed greater confidence in child abuse management skills and were more likely to report suspected cases of abuse. Discussion Much information was learned about PNP reporting practices regarding child abuse. The most significant facts that emerged from this study were that all health care providers require further child abuse education, both in their curriculum preparation and continuing education, to effectively diagnose and manage child abuse.

Introduction Parent–health care provider (HCP) communication is an important component of pediatric asthma management. Given the high prevalence of complementary and alternative medicine (CAM) and over-the-counter (OTC) medication use among this population, it is important to examine parental nondisclosure of these asthma management strategies. Method One-time interview and 1-year retrospective medical record review with 228 parents of 5- to 12-year-old children with asthma enrolled from six pediatric primary care practices examining parental nondisclosure of CAM and OTC medication use, reasons for nondisclosure, medical record documentation of CAM usage, and association between parent-HCP relationship and nondisclosure. Results Seventy-one percent of parents reported using CAM and/or OTC medication for children's asthma management, and 54% of those parents did not disclose usage. Seventy-five percent “did not think” to discuss it. Better parent-HCP relationship led to decreased nondisclosure. Discussion HCPs can play an important role in creating an environment where parents feel comfortable sharing information about their children's asthma management strategies in order to arrive at a shared asthma management plan for the child, leading to improved asthma health outcomes.

Background: One barrier to receiving adequate asthma care is inaccurate estimations of symptom severity. Aims: To interview parents of children with asthma in order to: (1) describe the range of reported illness severity using three unstructured methods of assessment; (2) determine which assessment method is least likely to result in a “critical error” that could adversely influence the child’s care; and (3) determine whether the likelihood of making a “critical error” varies by sociodemographic characteristics. Methods: A total of 228 parents of children with asthma participated. Clinical status was evaluated using structured questions reflecting National Asthma Education and Prevention Panel (NAEPP) criteria. Unstructured assessments of severity were determined using a visual analogue scale (VAS), a categorical assessment of severity, and a Likert scale assessment of asthma control. A “critical error” was defined as a parent report of symptoms in the lower 50th centile for each method of assessment for children with moderate–severe persistent symptoms by NAEPP criteria. Results: Children with higher severity according to NAEPP criteria were rated on each unstructured assessment as more symptomatic compared to those with less severe symptoms. However, among the children with moderate–severe persistent symptoms, many parents made a critical error and rated children in the lower 50th centile using the VAS (41%), the categorical assessment (45%), and the control assessment (67%). The likelihood of parents making a critical error did not vary by sociodemographic characteristics. Conclusions: All of the unstructured assessment methods tested yielded underestimations of severity that could adversely influence treatment decisions. Specific symptom questions are needed for accurate severity assessments.

Introduction Effective communication about symptoms is a critical prerequisite to appropriate treatment. Study aims were to: (a) document the symptoms that children with asthma and their parents associate with asthma, (b) identify differences between the "professional model "of asthma symptoms and the "lay model," (c) describe the family's proposed action in response to symptoms, and (d) investigate the congruence between parental assessment of "good control" and severity obtained using National Asthma Education and Prevention Program criteria. Method Children with asthma and their parents (N = 228) were recruited from diverse clinical practice sites. Parents and children described symptoms they associated with an asthma exacerbation and their proposed action. Perceived asthma control was compared with a structured assessment of severity. Results One hundred and thirty-six unique symptoms were reported. While 78% of parents reported at least one standard asthma symptom, 48% also reported nonstandard asthma symptoms. Sixty-five percent of parents whose children's symptoms were consistent with severe asthma reported "good control." Discussion Improved communication about symptoms would improve asthma care. Proposed strategies include standardized screening questionnaires to assess symptoms, more frequent routine visits for children with persistent asthma, and wide dissemination of realistic goals for symptom control.

Objective To test, among an urban primarily African American sample, the effects of prenatal and infancy home visiting by nurses on mothers' fertility, partner relationships, and economic self-sufficiency and on government spending through age 12 years of their firstborn child. Design Randomized controlled trial. Setting Public system of obstetric and pediatric care in Memphis, Tennessee. Participants A total of 594 urban primarily African American economically disadvantaged mothers (among 743 who registered during pregnancy). Intervention Prenatal and infancy home visiting by nurses. Main Outcome Measures Mothers' cohabitation with and marriage to the child's biological father, intimate partner violence, duration (stability) of partner relationships, role impairment due to alcohol and other drug use, use and cost of welfare benefits, arrests, mastery, child foster care placements, and cumulative subsequent births. Results By the time the firstborn child was 12 years old, nurse-visited mothers compared with control subjects reported less role impairment owing to alcohol and other drug use (0.0% vs 2.5%, P = .04), longer partner relationships (59.58 vs 52.67 months, P = .02), and greater sense of mastery (101.04 vs 99.60, P = .005). During this 12-year period, government spent less per year on food stamps, Medicaid, and Aid to Families with Dependent Children and Temporary Assistance for Needy Families for nurse-visited than control families ($8772 vs $9797, P = .02); this represents $12 300 in discounted savings compared with a program cost of $11 511, both expressed in 2006 US dollars. No statistically significant program effects were noted on mothers' marriage, partnership with the child's biological father, intimate partner violence, alcohol and other drug use, arrests, incarceration, psychological distress, or reports of child foster care placements. Conclusion The program improved maternal life course and reduced government spending among children through age 12 years. Trial Registration clinicaltrials.gov Identifier:NCT00438165

Objective To test the effect of prenatal and infancy home visits by nurses on 12-year-old, firstborn children's use of substances, behavioral adjustment, and academic achievement. Design Randomized controlled trial. Setting Public system of obstetric and pediatric care in Memphis, Tennessee. Participants We studied 12-year-old, firstborn children (n = 613) of primarily African American, economically disadvantaged women (743 randomized during pregnancy). Intervention Program of prenatal and infancy home visits by nurses. Outcome Measures Use of cigarettes, alcohol, and marijuana; internalizing, externalizing, and total behavioral problems; and academic achievement. Results By the time the firstborn child was 12 years of age, those visited by nurses, compared with those in the control group, reported fewer days of having used cigarettes, alcohol, and marijuana during the 30-day period before the 12-year interview (0.03 vs 0.18, P = .02) and were less likely to report having internalizing disorders that met the borderline or clinical threshold (22.1% vs 30.9%, P = .04). Nurse-visited children born to mothers with low psychological resources, compared with their control group counterparts, scored higher on the Peabody Individual Achievement Tests in reading and math (88.78 vs 85.70, P = .009) and, during their first 6 years of education, scored higher on group-administered standardized tests of math and reading achievement (40.52 vs 34.85, P = .02). No statistically significant program effects were found on children's externalizing or total behavioral problems. Conclusions Through age 12, the program reduced children's use of substances and internalizing mental health problems and improved the academic achievement of children born to mothers with low psychological resources. Trial Registration clinicaltrials.gov Identifier:NCT00438165

OBJECTIVE:The goal was to describe the accuracy of the Edinburgh Postnatal Depression Scale (EPDS), Beck Depression Inventory II (BDI-II), and Postpartum Depression Screening Scale (PDSS) in identifying major depressive disorder (MDD) or minor depressive disorder (MnDD) among low-income, urban mothers attending well-child care (WCC) visits during the postpartum year.METHODS:Mothers (N = 198) attending WCC visits with their infants 0 to 14 months of age completed a psychiatric diagnostic interview (standard method) and 3 screening tools. The sensitivities and specificities of each screening tool were calculated in comparison with diagnoses of MDD or MDD/MnDD. Receiver operating characteristic curves were calculated and the areas under the curves for each tool were compared to assess accuracy for the entire sample (representing the postpartum year) and subsamples (representing early, middle, and late postpartum time frames). Optimal cutoff scores were calculated.RESULTS:At some point between 2 weeks and 14 months after delivery, 56% of mothers met criteria for either MDD (37%) or MnDD (19%). When used as continuous measures, all scales performed equally well (areas under the curves of ≥0.8). With traditional cutoff scores, the measures did not perform at the expected levels of sensitivity and specificity. Optimal cutoff scores for the BDI-II (≥14 for MDD and ≥11 for MDD/MnDD) and EPDS (≥9 for MDD and ≥7 for MDD/MnDD) were lower than currently recommended. For the PDSS, the optimal cutoff score was consistent with current guidelines for MDD (≥80) but higher than recommended for MDD/MnDD (≥77).CONCLUSIONS:Large proportions of low-income, urban mothers attending WCC visits experience MDD or MnDD during the postpartum year. The EPDS, BDI-II, and PDSS have high accuracy in identifying depression, but cutoff scores may need to be altered to identify depression more accurately among urban, low-income mothers.

Objective To examine the effect of prenatal and infancy nurse home visitation on the life course development of 19-year-old youths whose mothers participated in the program. Design Randomized trial. Setting Semirural community in New York. Participants Three hundred ten youths from the 400 families enrolled in the Elmira Nurse-Family Partnership program. Intervention Families received a mean of 9 home visits (range, 0-16) during pregnancy and 23 (range, 0-59) from birth through the child's second birthday. Main Outcome Measures Youth self-reports of educational achievement, reproductive behaviors, welfare use, and criminal involvement. Results Relative to the comparison group, girls in the pregnancy and infancy nurse-visited group were less likely to have been arrested (10% vs 30%; relative risk [RR], 0.33; 95% confidence interval [CI], 0.13-0.82) and convicted (4% vs 20%; 0.20; 0.05-0.85) and had fewer lifetime arrests (mean: 0.10 vs 0.54; incidence RR [IRR], 0.18; 95% CI, 0.06-0.54) and convictions (0.04 vs 0.37; 0.11; 0.02-0.51). Nurse-visited girls born to unmarried and low-income mothers had fewer children (11% vs 30%; RR, 0.35; 95% CI, 0.12-1.02) and less Medicaid use (18% vs 45%; 0.40; 0.18-0.87) than their comparison group counterparts. Conclusions Prenatal and infancy home visitation reduced the proportion of girls entering the criminal justice system. For girls born to high-risk mothers, there were additional positive program effects consistent with results from earlier phases of this trial. There were few program effects for boys. Trial Registration clinicaltrials.gov Identifier:NCT00443638

Objective The goal of this study was to examine the relationship between quality of life (QOL) and symptoms of obstructive sleep apnea (OSA) as well as objectively measured severity of OSA using polysomnography (PSG) in a cohort of overweight and at risk for overweight children and adolescents. Methods One hundred and fifty-one overweight subjects [90 males, average ages of 12.52, mean body mass index (BMI) Z-score of 2.27) and their parent/guardian completed surveys assessing QOL and symptoms of OSA syndrome. The subjects also underwent overnight PSG. Results Overweight patients reported poor QOL. Polysomnographic variables did not correlate with QOL. However, symptoms of OSA as reported on the Pediatric Sleep Questionnaire significantly correlated with QOL from both the parent and the subject. Conclusions Overweight youth with symptoms of OSA have a lower QOL both by their report and parental report. Interestingly, objective measures of OSA did not correlate with QOL.

OBJECTIVE. Our goal was to test the effect of prenatal and infancy home visits by nurses on mothers' fertility and children's functioning 7 years after the program ended at child age 2. METHODS. We conducted a randomized, controlled trial in a public system of obstetric and pediatric care. A total of 743 primarily black women RESULTS. Nurse-visited women had longer intervals between births of first and second children, fewer cumulative subsequent births per year, and longer relationships with current partners. From birth through child age 9, nurse-visited women used welfare and food stamps for fewer months. Nurse-visited children born to mothers with low psychological resources, compared with control-group counterparts, had better grade-point averages and achievement test scores in math and reading in grades 1 through 3. Nurse-visited children, as a trend, were less likely to die from birth through age 9, an effect accounted for by deaths that were attributable to potentially preventable causes. CONCLUSIONS. By child age 9, the program reduced women's rates of subsequent births, increased the intervals between the births of first and second children, increased the stability of their relationships with partners, facilitated children's academic adjustment to elementary school, and seems to have reduced childhood mortality from preventable causes.

Mothers and children living in adverse contexts are at risk of premature death.To determine the effect of prenatal and infant/toddler nurse home visiting on maternal and child mortality during a 2-decade period (1990-2011).A randomized clinical trial was designed originally to assess the home visiting program's effect on pregnancy outcomes and maternal and child health through child age 2 years. The study was conducted in a public system of obstetric and pediatric care in Memphis, Tennessee. Participants included primarily African American women and their first live-born children living in highly disadvantaged urban neighborhoods, who were assigned to 1 of 4 treatment groups: treatment 1 (transportation for prenatal care [n = 166]), treatment 2 (transportation plus developmental screening for infants and toddlers [n = 514]), treatment 3 (transportation plus prenatal/postpartum home visiting [n = 230]), and treatment 4 (transportation, screening, and prenatal, postpartum, and infant/toddler home visiting [n = 228]). Treatments 1 and 3 were included originally to increase statistical power for testing pregnancy outcomes. For determining mortality, background information was available for all 1138 mothers assigned to all 4 treatments and all but 2 live-born children in treatments 2 and 4 (n = 704). Inclusion of children in treatments 1 and 3 was not possible because background information was missing on too many children.Nurses sought to improve the outcomes of pregnancy, children's health and development, and mothers' health and life-course with home visits beginning during pregnancy and continuing through child age 2 years.All-cause mortality in mothers and preventable-cause mortality in children (sudden infant death syndrome, unintentional injury, and homicide) derived from the National Death Index.The mean (SE) 21-year maternal all-cause mortality rate was 3.7% (0.74%) in the combined control group (treatments 1 and 2), 0.4% (0.43%) in treatment 3, and 2.2% (0.97%) in treatment 4. The survival contrast of treatments 1 and 2 combined with treatment 3 was significant (P = .007); the contrast of treatments 1 and 2 combined with treatment 4 was not significant (P = .19), and the contrast of treatments 1 and 2 combined with treatments 3 and 4 combined was significant (post hoc P = .008). At child age 20 years, the preventable-cause child mortality rate was 1.6% (0.57%) in treatment 2 and 0.0% (SE not calculable) in treatment 4; the survival contrast was significant (P = .04).Prenatal and infant/toddler home visitation by nurses is a promising means of reducing all-cause mortality among mothers and preventable-cause mortality in their first-born children living in highly disadvantaged settings.clinicaltrials.gov Identifier: NCT00708695.