Long-term effects of nurse home visitation on children's criminal and antisocial behavior: 15-year follow-up of a randomized controlled trial

CONTEXT

A program of home visitation by nurses has been shown to affect the rates of maternal welfare dependence, criminality, problems due to use of substances, and child abuse and neglect. However, the long-term effects of this program on children's antisocial behavior have not been examined.

OBJECTIVE

To examine the long-term effects of a program of prenatal and early childhood home visitation by nurses on children's antisocial behavior.

DESIGN

Fifteen-year follow-up of a randomized trial. Interviews were conducted with the adolescents and their biological mothers or custodial parents.

SETTING

Semirural community in New York.

PARTICIPANTS

Between April 1978 and September 1980, 500 consecutive pregnant women with no previous live births were recruited, and 400 were enrolled. A total of 315 adolescent offspring participated in a follow-up study when they were 15 years old; 280 (89%) were born to white mothers, 195 (62%) to unmarried mothers, 151 (48%) to mothers younger than 19 years, and 186 (59%) to mothers from households of low socioeconomic status at the time of registration during pregnancy.

INTERVENTION

Families in the groups that received home visits had an average of 9 (range, 0-16) home visits during pregnancy and 23 (range, 0-59) home visits from birth through the child's second birthday. The control groups received standard prenatal and well-child care in a clinic.

MAIN OUTCOME MEASURES

Children's self-reports of running away, arrests, convictions, being sentenced to youth corrections, initiation of sexual intercourse, number of sex partners, and use of illegal substances; school records of suspensions; teachers' reports of children's disruptive behavior in school; and parents' reports of the children's arrests and behavioral problems related to the children's use of alcohol and other drugs.

RESULTS

Adolescents born to women who received nurse visits during pregnancy and postnatally and who were unmarried and from households of low socioeconomic status (risk factors for antisocial behavior), in contrast with those in the comparison groups, reported fewer instances (incidence) of running away (0.24 vs 0.60; P = .003), fewer arrests (0.20 vs 0.45; P = .03), fewer convictions and violations of probation (0.09 vs 0.47; P<.001), fewer lifetime sex partners (0.92 vs 2.48; P= .003), fewer cigarettes smoked per day (1.50 vs 2.50; P= .10), and fewer days having consumed alcohol in the last 6 months (1.09 vs 2.49; P = .03). Parents of nurse-visited children reported that their children had fewer behavioral problems related to use of alcohol and other drugs (0.15 vs 0.34; P = .08). There were no program effects on other behavioral problems.

CONCLUSIONS

This program of prenatal and early childhood home visitation by nurses can reduce reported serious antisocial behavior and emergent use of substances on the part of adolescents born into high-risk families.

High frequency of Gag- and envelope-specific cytotoxic T lymphocyte precursors in children with vertically acquired human immunodeficiency virus type 1 infection

Circulating human immunodeficiency virus type 1 (HIV-1)-specific cytotoxic T lymphocytes (CTL) are seen less frequently in unstimulated peripheral blood mononuclear cells (PBMC) from children with vertically acquired HIV infection than in PBMC from HIV-infected adults. HIV-1 Gag-, reverse transcriptase (RT)-, and envelope (Env)-specific cytotoxic activity was studied in PBMC from HIV-infected children. Only 9% of subjects had Gag- or RT-specific CTL in unstimulated PBMC. However, in PBMC studied after CD3 stimulation, Gag- and Env-specific CTL were found in PBMC from 91% and 78% of HIV-infected children, respectively. Limiting dilution analysis of precursor CTL (pCTL) frequencies in PBMC from children > 12 months old demonstrated Gag- and Env-specific pCTL frequencies from 0.5 to 6.3/10,000 PBMC and from 0.66 to 33.0/10,000 PBMC, respectively. Thus, children with vertically acquired HIV infection have high frequencies of HIV-specific pCTL.

Theoretical cost effectiveness of management options for children with persisting middle ear effusions

OBJECTIVE

The purpose of this theoretical study is to assess the cost effectiveness of options involving observation, antibiotics alone, corticosteroids alone, corticosteroids plus antibiotics, and surgery to clear persisting middle ear effusions during three visits.

METHODOLOGY

In a hypothetical case the expected average per patient expenditures are calculated using the efficacy rates determined by the meta-analysis of randomized controlled clinical trials involving corticosteroids plus an antibiotic (six trials), corticosteroids alone (three trials), and antibiotic alone (four trials). In this analysis, all children whose bilateral middle ear effusions persist for 12 weeks despite medical management are referred for ventilating tubes.

RESULTS

The most cost-effective intervention combination is corticosteroid plus an antibiotic at visit 1 (6 weeks after diagnosis of acute otitis media) followed by a second antibiotic in nonresponders at visit 2 (9 weeks after diagnosis of acute otitis media) and referral for ventilating tubes in nonresponders at visit 3 (12 weeks after diagnosis of acute otitis media). The expected average expenditures per case to clear the bilateral middle ear effusions is $600.91 based on reimbursement of private practice charges and $350.27 based on Medicaid reimbursement (all payments to providers are based on 1992 data from Colorado). The difference in the expected average total expenditures per case between this most cost-effective approach versus the use of sequential courses of antibiotics followed by surgery is $372.81 ($973.72-$600.91) with full reimbursement of private practice charges and $202.57 ($552.84-$350.27) with Medicaid reimbursement. In clearing the middle ear effusion, the average estimated travel expenses per case is $21.46, and lost parental wages per case are $45.12. When the expenditures associated with an additional 6-month follow-up period are included, the expected average per case expenditures is $1088.54 with reimbursement of private practice charges and @659.00 with Medicaid reimbursement. The difference in the expected average per case expenditures to clear the effusions and follow-up for 6 months between the most cost-effective approach using corticosteroids plus antibiotics at the 6- and 9-week visits followed by surgery in nonresponders at 12 weeks versus sequential courses of antibiotics is $405.30 ($1493.84-$1088.54) with reimbursement of private practice charges and $217.32 ($876.32-$659.00) with Medicaid reimbursement.

RECOMMENDATIONS

Although the analysis does not consider risks, side effects, and parental or provider preferences, the findings suggest that the implementation of cost-effective clinical guidelines can potentially reduce national expenditures for managing persistent middle ear effusions.

Saturation by pulse oximetry: comparison of the results obtained by instruments of different brands

We noticed that arterial oxygen saturation by pulse oximetry (SpO2) was generally lower when determined by the Ohmeda Biox 3700 pulse oximeter than when determined by the Nellcor N-100 pulse oximeter, and we investigated whether this finding was consistent and the reason for the discrepancy. We placed both oximeters simultaneously on 30 infants with indwelling arterial catheters and measured arterial partial pressure of oxygen (PaO2), percentage of fetal hemoglobin, and complete cooximetry, including arterial oxygen saturation (SaO2) with a Radiometer OSM-3 cooximeter, with and without correction for fetal hemoglobin levels, in four samples of blood from each infant during a 12-hour period for a total of 120 samples. The Nellcor SpO2 was consistently higher than the Ohmeda SpO2 by a mean (+/- SD) of 1.61% +/- 2.69% (p < 0.001). The Nellcor SpO2 correlated best with functional SaO2 (oxyhemoglobin (HbO2)/(HbO2 + reduced hemoglobin)) x 100); Ohmeda SpO2 correlated best with fractional SaO2 (HbO2/(HbO2 + reduced hemoglobin + carboxyhemoglobin + methemoglobin)) x 100), reflecting a fundamental difference in the calibration algorithms used in the two instruments. A desired PaO2 of 50 to 100 mm Hg, is maintained when the range of SpO2 is 90% to 96% for Ohmeda SpO2 and 92% to 98% for Nellcor SpO2 in the neonate, giving a positive predictive value in this study of 94% to 95%. We conclude that SpO2 determined by pulse oximeters of different brands is not interchangeable, and this may be of clinical importance in predicting PaO2 on the basis of SpO2.

Hip flexion contracture in cerebral palsy. The association between clinical and radiologic measurement methods

Hip flexion contracture was examined in 51 spastic cerebral palsy patients by three clinical methods and two radiologic methods. An extremely low association was found between the clinical and radiologic methods with no particular method, clinical or radiologic, showing a higher association. The method of clinical examination should be chosen by convenience. Radiologic measurements by the methods used did not add useful information.

Prediction of the need for transfusion during anemia of prematurity

We reviewed erythrocyte transfusions, given after 2 weeks of age to premature infants, to derive patient selection criteria for trials of administration of recombinant human erythropoietin to maintain hematocrit during the anemia of prematurity. We first studied 122 infants, less than 36 weeks of gestational age, who remained in a level 3 nursery longer than 4 weeks. Multiple logistic regression analysis was used to select those variables associated with more than two transfusions after the second week; these included gestational age, 5-minute Apgar score, transfusion during the first week, and patent ductus ligation. The best predictor, alone or combined, was gestational age less than 30 weeks. This predictor was applied to a second population of 44 premature infants from a level 2 nursery, and we found a 94% probability of excluding those infants who did not receive a transfusion. This information will allow selection of premature infants who are candidates for administration of recombinant human erythropoietin.

Intrauterine resuscitation with tocolysis. An alternate month clinical trial

Fifty patients were compared for the purpose of investigating the usefulness of intrauterine resuscitation with tocolysis (IURT). Terbutaline was given, as an intravenous bolus, to 31 women in labor in whom fetal distress was diagnosed and urgent delivery by cesarean section was indicated. In alternate months, a control group of 19 women with similar diagnoses was urgently delivered after standard interventions such as maternal positioning, oxygen administration, hydration, and discontinuation of oxytocin. Improvement in perinatal outcome was shown in infants after IURT. Apgar scores were less than 7 in 42% of the study group and in 71% of the control group at 1 minute (P = .04). Five-minute Apgar scores less than 7 occurred in 7% of the study group and 24% of the control group. A low venous pH was seen in 55% of the control group compared with 29% of the infants resuscitated with terbutaline. Estimated maternal blood loss and hematocrit change was not different in the two groups. Maternal blood pressure and pulse changes following IURT were modest and of doubtful significance. We conclude that intravenous terbutaline administered as a bolus injection at the time of fetal distress in labor improves infant outcome as evidenced by more vigorous Apgar scores and less acidemia without significant adverse physiologic effects on the mother.