Showing papers in "Pediatrics in 2001"

A New and Improved Population-Based Canadian Reference for Birth Weight for Gestational Age

Abstract: Background. Existing fetal growth references all suffer from 1 or more major methodologic problems, including errors in reported gestational age, biologically implausible birth weight for gestational age, insufficient sample sizes at low gestational age, single-hospital or other non-population–based samples, and inadequate statistical modeling techniques. Methods. We used the newly developed Canadian national linked file of singleton births and infant deaths for births between 1994 and 1996, for which gestational age is largely based on early ultrasound estimates. Assuming a normal distribution for birth weight at each gestational age, we used the expectation-maximization algorithm to exclude infants with gestational ages that were more consistent with 40-week births than with the observed gestational age. Distributions of birth weight at the corrected gestational ages were then statistically smoothed. Results. The resulting male and female curves provide smooth and biologically plausible means, standard deviations, and percentile cutoffs for defining small- and large-for-gestational-age births. Large-for-gestational age cutoffs (90th percentile) at low gestational ages are considerably lower than those of existing references, whereas small-for-gestational-age cutoffs (10th percentile) postterm are higher. For example, compared with the current World Health Organization reference from California (Williams et al, 1982) and a recently proposed US national reference (Alexander et al, 1996), the 90th percentiles for singleton males at 30 weeks are 1837 versus 2159 and 2710 g. The corresponding 10th percentiles at 42 weeks are 3233 versus 3086 and 2998 g. Conclusions. This new sex-specific, population-based reference should improve clinical assessment of growth in individual newborns, population-based surveillance of geographic and temporal trends in birth weight for gestational age, and evaluation of clinical or public health interventions to enhance fetal growth. fetal growth, birth weight, gestational age, preterm birth, postterm birth.

Children, Adolescents, and Television

Abstract: .This statement describes the possible negative health effects of television viewing on children and adolescents, such as violent or aggressive behavior, substance use, sexual activity, obesity, poor body image, and decreased school performance. In addition to the television ratings system a

Relationship of Childhood Obesity to Coronary Heart Disease Risk Factors in Adulthood: The Bogalusa Heart Study

Abstract: Background. Childhood obesity is related to adult levels of lipids, lipoproteins, blood pressure, and insulin and to morbidity from coronary heart disease (CHD). However, the importance of the age at which obesity develops in these associations remains uncertain. Objective and Design. We assessed the longitudinal relationship of childhood body mass index (BMI, kg/m2) to adult levels of lipids, insulin, and blood pressure among 2617 participants. All participants were initially examined at ages 2 to 17 years and were reexamined at ages 18 to 37 years; the mean follow-up was 17 years. Results. Of the overweight children (BMI ≥95th percentile), 77% remained obese (≥30 kg/m2) as adults. Childhood overweight was related to adverse risk factor levels among adults, but associations were weak (r ∼ 0.1–0.3) and were attributable to the strong persistence of weight status between childhood and adulthood. Although obese adults had adverse levels of lipids, insulin, and blood pressure, levels of these risk factors did not vary with childhood weight status or with the age (≤8 years, 12–17 years, or ≥18 years) of obesity onset. Conclusions. Additional data are needed to assess the independent relationship of childhood weight status to CHD morbidity. Because normal-weight children who become obese adults have adverse risk factor levels and probably will be at increased risk for adult morbidity, our results emphasize the need for both primary and secondary prevention.

Very low birth weight outcomes of the National Institute of Child health and human development neonatal research network, January 1995 through December 1996. NICHD Neonatal Research Network.

Abstract: Objectives. To determine the mortality and morbidity for infants weighing 401 to 1500 g (very low birth weight [VLBW]) at birth by gestational age, birth weight, and gender. Study Design. Perinatal data were collected prospectively on an inborn cohort from January 1995 through December 1996 by 14 participating centers of the National Institute of Child Health and Human Development Neonatal Research Network and were compared with the corresponding data from previous reports. Sociodemographic factors, perinatal events, and the neonatal course to 120 days of life, discharge, or death were evaluated. Results. Eighty four percent of 4438 infants weighing 501 to 1500 g at birth survived until discharge to home or to a long-term care facility (compared with 80% in 1991 and 74% in 1988). Survival to discharge was 54% for infants 501 to 750 g at birth, 86% for those 751 to 1000 g, 94% for those 1001 to 1250 g, and 97% for those 1251 to 1500g. The incidence of chronic lung disease (CLD; defined as receiving supplemental oxygen at 36 weeks9 postmenstrual age; 23%), proven necrotizing enterocolitis (NEC; 7%), and severe intracranial hemorrhage (ICH; grade III or IV; 11%) remained unchanged between 1991 and 1996. Furthermore, 97% of all VLBW infants and 99% of infants weighing Mortality for 195 infants weighing 401 to 500 g was 89%, with nearly all survivors developing CLD. Mortality in infants weighing 501 to 600 g was 71%; among survivors, 62% had CLD, 35% had severe ICH, and 15% had proven NEC. Conclusions. Survival for infants between 501 and 1500 g at birth continued to improve, particularly for infants weighing

Health Supervision for Children With Down Syndrome

Abstract: These guidelines are designed to assist the pediatrician in caring for the child in whom a diagnosis of Down syndrome has been confirmed by chromosome analysis. Although a pediatrician's initial contact with the child is usually during infancy, occasionally the pregnant woman who has been given a prenatal diagnosis of Down syndrome will be referred for review of the condition and the genetic counseling provided. Therefore, this report offers guidance for this situation as well.

Prenatal and postnatal flavor learning by human infants.

Abstract: Background. Flavors from the mother9s diet during pregnancy are transmitted to amniotic fluid and swallowed by the fetus. Consequently, the types of food eaten by women during pregnancy and, hence, the flavor principles of their culture may be experienced by the infants before their first exposure to solid foods. Some of these same flavors will later be experienced by infants in breast milk, a liquid that, like amniotic fluid, comprises flavors that directly reflect the foods, spices, and beverages eaten by the mother. The present study tested the hypothesis that experience with a flavor in amniotic fluid or breast milk modifies the infants9 acceptance and enjoyment of similarly flavored foods at weaning. Methods. Pregnant women who planned on breastfeeding their infants were randomly assigned to 1 of 3 groups. The women consumed either 300 mL of carrot juice or water for 4 days per week for 3 consecutive weeks during the last trimester of pregnancy and then again during the first 2 months of lactation. The mothers in 1 group drank carrot juice during pregnancy and water during lactation; mothers in a second group drank water during pregnancy and carrot juice during lactation, whereas those in the control group drank water during both pregnancy and lactation. Approximately 4 weeks after the mothers began complementing their infants9 diet with cereal and before the infants had ever been fed foods or juices containing the flavor of carrots, the infants were videotaped as they fed, in counterbalanced order, cereal prepared with water during 1 test session and cereal prepared with carrot juice during another. Immediately after each session, the mothers rated their infants9 enjoyment of the food on a 9-point scale. Results. The results demonstrated that the infants who had exposure to the flavor of carrots in either amniotic fluid or breast milk behaved differently in response to that flavor in a food base than did nonexposed control infants. Specifically, previously exposed infants exhibited fewer negative facial expressions while feeding the carrot-flavored cereal compared with the plain cereal, whereas control infants whose mothers drank water during pregnancy and lactation exhibited no such difference. Moreover, those infants who were exposed to carrots prenatally were perceived by their mothers as enjoying the carrot-flavored cereal more compared with the plain cereal. Although these same tendencies were observed for the amount of cereal consumed and the length of the feeds, these findings were not statistically significant. Conclusions. Prenatal and early postnatal exposure to a flavor enhanced the infants9 enjoyment of that flavor in solid foods during weaning. These very early flavor experiences may provide the foundation for cultural and ethnic differences in cuisine.

Food insufficiency and American school-aged children's cognitive, academic, and psychosocial development.

Abstract: Objective. This study investigates associations between food insufficiency and cognitive, academic, and psychosocial outcomes for US children and teenagers ages 6 to 11 and 12 to 16 years. Methods. Data from the Third National Health and Nutrition Examination Survey (NHANES III) were analyzed. Children were classified as food-insufficient if the family respondent reported that his or her family sometimes or often did not get enough food to eat. Regression analyses were conducted to test for associations between food insufficiency and cognitive, academic, and psychosocial measures in general and then within lower-risk and higher-risk groups. Regression coefficients and odds ratios for food insufficiency are reported, adjusted for poverty status and other potential confounding factors. Results. After adjusting for confounding variables, 6- to 11-year-old food-insufficient children had significantly lower arithmetic scores and were more likely to have repeated a grade, have seen a psychologist, and have had difficulty getting along with other children. Food-insufficient teenagers were more likely to have seen a psychologist, have been suspended from school, and have had difficulty getting along with other children. Further analyses divided children into lower-risk and higher-risk groups. The associations between food insufficiency and children9s outcomes varied by level of risk. Conclusions. The results demonstrate that negative academic and psychosocial outcomes are associated with family-level food insufficiency and provide support for public health efforts to increase the food security of American families.

Clinical Practice Guideline: Treatment of the School-Aged Child With Attention-Deficit/Hyperactivity Disorder

Abstract: This clinical practice guideline provides evidence-based recommendations for the treatment of children diagnosed with attention-deficit/hyperactivity disorder (ADHD). This guideline, the second in a set of policies on this condition, is intended for use by clinicians working in primary care settings. The initiation of treatment requires the accurate establishment of a diagnosis of ADHD; the American Academy of Pediatrics (AAP) clinical practice guideline on diagnosis of children with ADHD(1) provides direction in appropriately diagnosing this disorder. The AAP Committee on Quality Improvement selected a subcommittee composed of primary care and developmental-behavioral pediatricians and other experts in the fields of neurology, psychology, child psychiatry, education, family practice, and epidemiology. The subcommittee partnered with the Agency for Healthcare Research and Quality and the Evidence-based Practice Center at McMaster University, Ontario, Canada, to develop the evidence base of literature on this topic.(2) The resulting systematic review, along with other major studies in this area, was used to formulate recommendations for treatment of children with ADHD. The subcommittee also reviewed the multimodal treatment study of children with ADHD(3) and the Canadian Coordinating Office for Health Technology Assessment report (CCOHTA).(4) Subcommittee decisions were made by consensus where definitive evidence was not available. The subcommittee report underwent extensive review by sections and committees of the AAP as well as by numerous external organizations before approval from the AAP Board of Directors. The guideline contains the following recommendations for the treatment of a child diagnosed with ADHD:

Adolescents' Perceptions of Social Status: Development and Evaluation of a New Indicator

Abstract: Objective. Eliminating health disparities, including those that are a result of socioeconomic status (SES), is one of the overarching goals of Healthy People 2010. This article reports on the development of a new, adolescent-specific measure of subjective social status (SSS) and on initial exploratory analyses of the relationship of SSS to adolescents9 physical and psychological health. Methods. A cross-sectional study of 10 843 adolescents and a subsample of 166 paired adolescent/mother dyads who participated in the Growing Up Today Study was conducted. The newly developed MacArthur Scale of Subjective Social Status (10-point scale) was used to measure SSS. Paternal education was the measure of SES. Indicators of psychological and physical health included depressive symptoms and obesity, respectively. Linear regression analyses determined the association of SSS to depressive symptoms, and logistic regression determined the association of SSS to overweight and obesity, controlling for sociodemographic factors and SES. Results. Mean society ladder ranking, a subjective measure of SES, was 7.2 ± 1.3. Mean community ladder ranking, a measure of perceived placement in the school community, was 7.6 ± 1.7. Reliability of the instrument was excellent: the intraclass correlation coefficient was 0.73 for the society ladder and 0.79 for the community ladder. Adolescents had higher society ladder rankings than their mothers (μ teen = 7.2 ± 1.3 vs μ mom = 6.8 ± 1.2; P = .002). Older adolescents9 perceptions of familial placement in society were more closely correlated with maternal subjective perceptions of placement than those of younger adolescents (Spearman9s rho teens = 0.31 vs Spearman9s rho teens ≥15 years = 0.45; P society = 0.89, 95% confidence interval = 0.83, 0.95; odds ratio community = 0.91, 95% confidence interval = 0.87, 0.97). For both depressive symptoms and obesity, community ladder rankings were more strongly associated with health than were society ladder rankings in models that controlled for both domains of SSS. Conclusions. This new instrument can reliably measure SSS among adolescents. Social stratification as reflected by SSS is associated with adolescents9 health. The findings suggest that as adolescents mature, SSS may undergo a developmental shift. Determining how these changes in SSS relate to health and how SSS functions prospectively with regard to health outcomes requires additional research.

Early Diagnosis of Cystic Fibrosis Through Neonatal Screening Prevents Severe Malnutrition and Improves Long-Term Growth

Abstract: Objective. Despite its relative frequency among autosomal recessive diseases and the availability of the sweat test, cystic fibrosis (CF) has been difficult to diagnose in early childhood, and delays can lead to severe malnutrition, lung disease, or even death. The Wisconsin CF Neonatal Screening Project was designed as a randomized clinical trial to assess the benefits and risks of early diagnosis through screening. In addition, the incidence of CF was determined, and the validity of our randomization method assessed by comparing 16 demographic variables. Methodology. Immunoreactive trypsinogen analysis was applied to dried newborn blood specimens for recognition of CF risk from 1985 to 1991 and was coupled to DNA-based detection of the ΔF508 mutation from 1991 to 1994. Randomization of 650 341 newborns occurred when their blood specimens reached the Wisconsin screening laboratory. This created 2 groups—an early diagnosis, screened cohort and a standard diagnosis or control group. To avoid selection bias, we devised a unique unblinding method with a surveillance program to completely identify the control subjects. Because sequential analysis of nutritional outcome measures revealed significantly better growth in screened patients during 1996, we accelerated the unblinding and completely identified the control group by April 1998. Having each member of this cohort enrolled and evaluated for at least 1 year and having completed a comprehensive surveillance program, we performed another statistical analysis of anthropometric evaluated indices that includes all CF patients without meconium ileus. Results. The incidence of classical CF, ie, patients diagnosed in this trial with a sweat chloride of 60 mEq/L greater, was 1:4189. By incorporating other CF patients born during the randomization period, including 2 autopsy diagnosed patients and 8 probable patients, we calculate a maximum incidence of 1:3938 (95% confidence interval: 3402–4611). Although there were group differences in the proportion of patients with ΔF508 genotypes and with pancreatic insufficiency, validity of the randomization plan was demonstrated by analyzing 16 demographic variables and finding no significant difference after adjustment for multiple comparisons. Focusing on patients without meconium ileus, we found a marked difference in the mean ± standard deviation age of diagnosis for screened patients (13 ± 37 weeks), compared with the standard diagnosis group (100 ± 117). Anthropometric indices of nutritional status were significantly higher at diagnosis in the screened group, including length/height, weight, and head circumference. During 13 years of study, despite similar nutritional therapy and the inherently better pancreatic status of the control group, analysis of nutritional outcomes revealed significantly greater growth associated with early diagnosis. Most impressively, the screened group had a much lower proportion of patients with weight and height data below the 10th percentile throughout childhood. Conclusions. Although the screened group had a higher proportion of patients with pancreatic insufficiency, their growth indices were significantly better than those of the control group during the 13-year follow-up evaluation and, therefore, this randomized clinical trial of early CF diagnosis must be interpreted as unequivocally positive. Our conclusions did not change when the height and weight data before 4 years of age for the controls detected by unblinding were included in the analysis. Also, comparison of growth outcomes after 4 years of age in all subjects showed persistence of the significant differences. Therefore, selection bias has been eliminated as a potential explanation. In addition, the results show that severe malnutrition persists after delayed diagnosis of CF and that catch-up may not be possible. We conclude that early diagnosis of CF through neonatal screening combined with aggressive nutritional therapy can result in significantly enhanced long-term nutritional status.

Adolescent Suicide Attempts: Risks and Protectors

Abstract: Objective. In 1997, suicide was the third leading cause of death among 10- to 19-year-olds in the United States, with the greatest increases in suicide rates in the previous decade experienced by black and other minority youth. The purpose of this study was to identify risk and protective factors for suicide attempts among black, Hispanic, and white male and female adolescents. Methods. We used data from the National Longitudinal Study of Adolescent Health, conducted in 1995 and 1996. A nationally representative sample of 13 110 students in grades 7 through 12 completed 2 in-home interviews, an average of 11 months apart. We examined Time 1 factors at the individual, family, and community level that predicted or protected against Time 2 suicide attempts. Results. Perceived parent and family connectedness was protective against suicide attempts for black, Hispanic, and white girls and boys, with odds ratios ranging from 0.06 to 0.32. For girls, emotional well-being was also protective for all of the racial/ethnic groups studied, while a high grade point average was an additional protective factor for all of the boys. Cross-cutting risk factors included previous suicide attempt, violence victimization, violence perpetration, alcohol use, marijuana use, and school problems. Additionally, somatic symptoms, friend suicide attempt or completion, other illicit drug use, and a history of mental health treatment predicted suicide attempts among black, Hispanic, and white females. Weapon-carrying at school and same-sex romantic attraction were predictive for all groups of boys. Calculating the estimated probabilities of attempting suicide for adolescents with increasing numbers of risk and protective factors revealed that the presence of 3 protective factors reduced the risk of a suicide attempt by 70% to 85% for each of the gender and racial/ethnic groups, including those with and without identified risk factors. Conclusions. In these national samples of black, Hispanic, and white youth, unique and cross-cutting factors derived from a resiliency framework predicted or protected against attempting suicide. In addition to risk reduction, promotion of protective factors may offer an effective approach to primary as well as secondary prevention of adolescent suicidal behavior.

Postnatal malnutrition and growth retardation: an inevitable consequence of current recommendations in preterm infants?

Abstract: Background. Nutrient intakes meeting recommended dietary intakes (RDIs) take time to establish and once established are rarely maintained throughout hospital stay in preterm infants. A nutrient deficit, therefore, accrues. RDI are based on needs for maintenance and growth, with no provision to replace this deficit. We, therefore, hypothesized that postnatal malnutrition and growth retardation were inevitable in infants fed current RDI. Methodology. Dietary intakes were prospectively collected, by a single observer (N.P.), on a daily basis in a group of preterm infants (n = 105; birth weight ≤1750 g; gestational age ≤34 weeks) admitted to neonatal intensive care unit over a 6-month period. Actual was subtracted from recommended energy (120 kcal/kg/day) and protein (3 g/kg/day) intakes and nutritional deficits calculated. Infants were weighed on admission and throughout hospital stay. The data were analyzed using a combination of repeated measures analysis of variance and stepwise regression analysis. Results. Nutrient intakes meeting current RDIs were rarely achieved during early life. By the end of the first week, cumulative energy and protein deficits were 406 ± 92 and 335 ± 86 kcal/kg and 14 ± 3 and 12 ± 4 g/kg in infants ≤30 and those at ≥31 weeks. By the end of the fifth week, cumulative energy and protein deficits were 813 ± 542 and 382 ± 263 kcal/kg and 23 ± 12 and 13 ± 15 g/kg and the zscores were −1.14 ± .6 and −.82 ± .5 for infants at ≤30 and ≥31 weeks. Stepwise regression analysis indicated that variation in dietary intake accounted for 45% of the variation in changes inz score. Conclusions. Preterm infants inevitably accumulate a significant nutrient deficit in the first few weeks of life that will not be replaced when current RDIs are fed. This deficit can be directly related to subsequent postnatal growth retardation. postnatal growth retardation, preterm infants.

The Assessment and Management of Acute Pain in Infants, Children, and Adolescents

Abstract: Acute pain is one of the most common adverse stimuli experienced by children, occurring as a result of injury, illness, and necessary medical procedures. It is associated with increased anxiety, avoidance, somatic symptoms, and increased parent distress. Despite the magnitude of effects that acute pain can have on a child, it is often inadequately assessed and treated. Numerous myths, insufficient knowledge among caregivers, and inadequate application of knowledge contribute to the lack of effective management. The pediatric acute pain experience involves the interaction of physiologic, psychologic, behavioral, developmental, and situational factors. Pain is an inherently subjective multifactorial experience and should be assessed and treated as such. Pediatricians are responsible for eliminating or assuaging pain and suffering in children when possible. To accomplish this, pediatricians need to expand their knowledge, use appropriate assessment tools and techniques, anticipate painful experiences and intervene accordingly, use a multimodal approach to pain management, use a multidisciplinary approach when possible, involve families, and advocate for the use of effective pain management in children.

Earlier onset of puberty in girls: relation to increased body mass index and race.

Abstract: Objective. A recent study conducted by the Pediatric Research in Office Settings network provided evidence that girls in the United States, especially black girls, are starting puberty at a younger age than earlier studies had found, but the reasons for this are not known. Because nutritional status is known to affect timing of puberty and there is a clear trend for increasing obesity in US children during the past 25 years, it was hypothesized that the earlier onset of puberty could be attributable to the increasing prevalence of obesity in young girls. Therefore, the objective of this study was to reexamine the Pediatric Research in Office Settings puberty data by comparing the age-normalized body mass index (BMI-ZS; a crude estimate of fatness) of girls who had breast or pubic hair development versus those who were still prepubertal, looking at the effects of age and race. Results. For white girls, the BMI-ZS were markedly higher in pubertal versus prepubertal 6- to 9-year-olds; for black girls, a smaller difference was seen, which was significant only for 9-year-olds. Higher BMI-ZS also were found in girls who had pubic hair but no breast development versus girls who had neither pubic hair nor breast development. A multivariate analysis confirms that obesity (as measured by BMI) is significantly associated with early puberty in white girls and is associated with early puberty in black girls as well, but to a lesser extent. Conclusions. The results are consistent with obesity9s being an important contributing factor to the earlier onset of puberty in girls. Factors other than obesity, however, perhaps genetic and/or environmental ones, are needed to explain the higher prevalence of early puberty in black versus white girls.

Worldwide timing of growth faltering: implications for nutritional interventions

Abstract: Objective. It is widely assumed that growth faltering starts at around 3 months of age, but there has been no systematic assessment of its timing using representative national datasets from a variety of countries. Methodology. The World Health Organization Global Database on Child Growth and Malnutrition includes the results of 39 nationally representative datasets from re- cent surveys in developing countries. Based on these data, mean z scores of weight for age, length/height for age, and weight for length/height were compared with the National Center for Health Statistics and Cambridge growth references, for children younger than 60 months. Results. Mean weights start to falter at about 3 months of age and decline rapidly until about 12 months, with a markedly slower decline until about 18 to 19 months and a catch-up pattern after that. Growth falter- ing in weight for length/height is restricted to the first 15 months of life, followed by rapid improvement. For length/height for age, the global mean is surprisingly close to National Center for Health Statistics and Cam- bridge references at birth, but faltering starts immedi- ately afterward, lasting well into the third year. Conclusions. These findings highlight the need for prenatal and early life interventions to prevent growth failure. Pediatrics 2001;107(5). URL: http://www. pediatrics.org/cgi/content/full/107/5/e75; growth, body height, body weight, infant nutrition disorders, child nu- trition disorders.

Reducing antibiotic use in children: a randomized trial in 12 practices.

Abstract: Objective. To test whether an educational outreach intervention for families and physicians, based on the Centers for Disease Control and Prevention (CDC) principles of judicious antibiotic use, decreases antimicrobial drug prescribing for children younger than 6 years old. Setting. Twelve practices affiliated with 2 managed care organizations (MCOs) in eastern Massachusetts and northwest Washington State. Patients. All enrolled children younger than 6 years old. Methods. Practices stratified by MCO and size were randomized to intervention or control groups. The intervention included 2 meetings of the practice with a physician peer leader, using CDC-endorsed summaries of judicious prescribing recommendations; feedback on previous prescribing rates were also provided. Parents were mailed a CDC brochure on antibiotic use, and supporting materials were displayed in waiting rooms. Automated enrollment, ambulatory visit, and pharmacy claims were used to determine rates of antibiotic courses dispensed (antibiotics/person-year) during baseline (1996–1997) and intervention (1997–1998) years. The primary analysis (for children 3 to Results. The practices cared for 14 468 and 13 460 children in the 2 study years, respectively; 8815 children contributed data in both years. Sixty-two percent of antibiotic courses were dispensed for otitis media, 6.5% for pharyngitis, 6.3% for sinusitis, and 9.2% for colds and bronchitis. Antibiotic dispensing for children 3 to Conclusions. A limited simultaneous educational outreach intervention for parents and providers reduced antibiotic use among children in primary care practices, even in the setting of substantial secular trends toward decreased prescribing. Future efforts to promote judicious prescribing should continue to build on growing public awareness of antibiotic overuse.

Atomoxetine in the treatment of children and adolescents with attention-deficit/hyperactivity disorder: a randomized, placebo-controlled, dose-response study.

Abstract: Objective. Atomoxetine is an investigational, nonstimulant pharmacotherapy being studied as potential treatment for attention-deficit/hyperactivity disorder (ADHD). It is thought to act via blockade of the presynaptic norepinephrine transporter in the brain. We assessed the efficacy of 3 doses of atomoxetine compared with placebo in children and adolescents with ADHD. Methods. A total of 297 children and adolescents who were 8 to 18 years of age and had ADHD as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition , were randomized to placebo or atomoxetine dosed on a weight-adjusted basis at 0.5 mg/kg/day, 1.2 mg/kg/day, or 1.8 mg/kg/day for an 8-week period. ADHD symptoms, affective symptoms, and social and family functioning were assessed using parent and investigator rating scales. Results. Approximately 71% of children enrolled were male, approximately 67% met criteria for mixed subtype (both inattentive and hyperactive/impulsive symptoms), and the only common psychiatric comorbidity was oppositional defiant disorder (approximately 38% of the sample). At baseline, symptom severity was rated as moderate to severe for most children. At endpoint, atomoxetine 1.2 mg/kg/day and 1.8 mg/kg/day were consistently associated with superior outcomes in ADHD symptoms compared with placebo and were not different from each other. The dose of 0.5 mg/kg/day was associated with intermediate efficacy between placebo and the 2 higher doses, suggesting a graded dose-response. Social and family functioning also were improved in the atomoxetine groups compared with placebo with statistically significant improvements in measures of children9s ability to meet psychosocial role expectations and parental impact. Discontinuations as a result of adverse events were Conclusion. Among children and adolescents aged 8 to 18, atomoxetine was superior to placebo in reducing ADHD symptoms and in improving social and family functioning symptoms. Atomoxetine was associated with a graded dose-response, and 1.2 mg/kg/day seems to be as effective as 1.8 mg/kg/day and is likely to be the appropriate initial target dose for most patients. Treatment with atomoxetine was safe and well tolerated.

Parental Monitoring: Association With Adolescents' Risk Behaviors

Abstract: Context. Contemporary threats to adolescents9 health are primarily the consequence of risk behaviors and their related adverse outcomes. Identifying factors associated with adolescents9 risk behaviors is critical for developing effective prevention strategies. A number of risk factors have been identified, including familial environment; however, few studies have examined the impact of parental monitoring. Objective. To examine the influence of less perceived parental monitoring on a spectrum of adolescent health-compromising behaviors and outcomes. Design. Survey. Setting. A family medicine clinic. Participants. To assess eligibility, recruiters screened a sample of 1130 teens residing in low-income neighborhoods. Adolescents were eligible if they were black females, between the ages of 14 and 18 years, sexually active in the previous 6 months, and provided written informed consent. Most teens (n = 609) were eligible, with 522 (85.7%) agreeing to participate. Main Outcome Measures. Variables in 6 domains were assessed, including: sexually transmitted diseases, sexual behaviors, marijuana use, alcohol use, antisocial behavior, and violence. Results. In logistic regression analyses, controlling for observed covariates, adolescents perceiving less parental monitoring were more likely to test positive for a sexually transmitted disease (odds ratio [OR]: 1.7), report not using a condom at last sexual intercourse (OR: 1.7), have multiple sexual partners in the past 6 months (OR: 2.0), have risky sex partners (OR: 1.5), have a new sex partner in the past 30 days (OR: 3.0), and not use any contraception during the last sexual intercourse episode (OR: 1.9). Furthermore, adolescents perceiving less parental monitoring were more likely to have a history of marijuana use and use marijuana more often in the past 30 days (OR: 2.3 and OR: 2.5, respectively); a history of alcohol use and greater alcohol consumption in the past 30 days (OR: 1.4 and OR: 1.9, respectively); have a history of arrest (OR: 2.1); and there was a trend toward having engaged in fights in the past 6 months (OR: 1.4). Conclusions. The findings demonstrate a consistent pattern of health risk behaviors and adverse biological outcomes associated with less perceived parental monitoring. Additional research needs to focus on developing theoretical models that help explain the influence of familial environment on adolescent health and develop and evaluate interventions to promote the health of adolescents.

Iron deficiency and cognitive achievement among school-aged children and adolescents in the United States.

Abstract: Context. Iron deficiency anemia in in- fants can cause developmental problems. However, the relationship between iron status and cognitive achieve- ment in older children is less clear. Objective. To investigate the relationship between iron deficiency and cognitive test scores among a nation- ally representative sample of school-aged children and adolescents. Design. The National Health and Nutrition Examina- tion Survey III 1988 -1994 provides cross-sectional data for children 6 to 16 years old and contains measures of iron status including transferrin saturation, free erythro- cyte protoporphyrin, and serum ferritin. Children were considered iron-deficient if any 2 of these values were abnormal for age and gender, and standard hemoglobin values were used to detect anemia. Scores from standard- ized tests were compared for children with normal iron status, iron deficiency without anemia, and iron defi- ciency with anemia. Logistic regression was used to es- timate the association of iron status and below average test scores, controlling for confounding factors. Results. Among the 5398 children in the sample, 3% were iron-deficient. The prevalence of iron deficiency was highest among adolescent girls (8.7%). Average math scores were lower for children with iron deficiency with and without anemia, compared with children with nor- mal iron status (86.4 and 87.4 vs 93.7). By logistic regres- sion, children with iron deficiency had greater than twice the risk of scoring below average in math than did chil- dren with normal iron status (odds ratio: 2.3; 95% confi- dence interval: 1.1- 4.4). This elevated risk was present even for iron-deficient children without anemia (odds ratio: 2.4; 95% confidence interval: 1.1-5.2). Conclusions. We demonstrated lower standardized math scores among iron-deficient school-aged children and adolescents, including those with iron deficiency without anemia. Screening for iron deficiency without anemia may be warranted for children at risk. Pediatrics 2001;107:1381-1386; iron deficiency, anemia, cognition, math, children, adolescence.

Prevalence of autism in a United States population: the Brick Township, New Jersey, investigation

Abstract: Objective. This study determined the prevalence of autism for a defined community, Brick Township, New Jersey, using current diagnostic and epidemiologic methods. Methods. The target population was children who were 3 to 10 years of age in 1998, who were residents of Brick Township at any point during that year, and who had an autism spectrum disorder. Autism spectrum disorder was defined as autistic disorder, pervasive developmental disorder-not otherwise specified (PDD-NOS), and Asperger disorder. The study used 4 sources for active case finding: special education records, records from local clinicians providing diagnosis or treatment for developmental or behavioral disabilities, lists of children from community parent groups, and families who volunteered for participation in the study in response to media attention. The autism diagnosis was verified (or ruled out) for 71% of the children through clinical assessment. The assessment included medical and developmental history, physical and neurologic evaluation, assessment of intellectual and behavioral functioning, and administration of the Autism Diagnostic Observation Schedule—Generic. Results. The prevalence of all autism spectrum disorders combined was 6.7 cases per 1000 children. The prevalence for children whose condition met full diagnostic criteria for autistic disorder was 4.0 cases per 1000 children, and the prevalence for PDD-NOS and Asperger disorder was 2.7 cases per 1000 children. Characteristics of children with autism in this study were similar to those in previous studies of autism. Conclusions. The prevalence of autism in Brick Township seems to be higher than that in other studies, particularly studies conducted in the United States, but within the range of a few recent studies in smaller populations that used more thorough case-finding methods.

Why Don't Low-Income Mothers Worry About Their Preschoolers Being Overweight?

Abstract: Context. Mothers are in an important position to prevent obesity in their children by shaping early diet and activity patterns. However, many mothers of overweight preschool children are not worried about their child's weight. Objective. To explore mothers' perceptions about how they determine when a child is overweight, why children become overweight, and what barriers exist to preventing or managing childhood obesity. Design. Three focus groups with 6 participants in each. Participant comments were transcribed and ana- lyzed. Themes were coded independently by the 6 au- thors who then agreed on common themes. Setting. A clinic of the Special Supplemental Nutri- tion Program for Women, Infants, and Children in Cin- cinnati, Ohio. Participants. Eighteen low-income mothers (13 black, 5 white) of preschool children (mean age of 44 months) who were at-risk for later obesity. All but 1 mother had a body mass index (BMI) >25 kg/m 2 , and 12 mothers had a BMI >30 kg/m 2 . All but 1 child had a BMI >85th per- centile for age and sex, and 7 had a BMI >95th percentile. Results. Mothers did not define overweight or obese in their children according to how height and weight measurements were plotted on the standard growth charts used by health professionals. Instead, mothers were more likely to consider being teased about weight or developing limitations in physical activity as indica- tors of their child being overweight. Children were not believed to be overweight if they were active and had a healthy diet and/or a good appetite. Mothers described overweight children as thick or solid. Mothers believed that an inherited tendency to be overweight was likely to be expressed in the child regardless of environmental factors. In trying to shape their children's eating, mothers believed that their control over the child's diet was chal- lenged by other family members. If a child was hungry, despite having just eaten, it was emotionally difficult for mothers to deny additional food. Conclusions. Health professionals should not assume that defining overweight according to the growth charts has meaning for all mothers. Despite differing percep- tions between mothers and health professionals about the definition of overweight, both groups agree that chil- dren should be physically active and have healthy diets. Health professionals may be more effective in prevent- ing childhood obesity by focusing on these goals that they share with mothers, rather than on labeling children as overweight. Pediatrics 2001;107:1138 -1146; obesity, body weight, mothers, child, preschool, mother-child rela- tions.

Exclusive breastfeeding reduces acute respiratory infection and diarrhea deaths among infants in Dhaka slums.

Abstract: Objectives. To describe breastfeeding practices and investigate the influence of exclusive breastfeeding in early infancy on the risk of infant deaths, especially those attributable to respiratory infections (ARI) and diarrhea. Methods. A prospective observational study was conducted on a birth cohort of 1677 infants who were born in slum areas of Dhaka in Bangladesh and followed from birth to 12 months of age. After enrollment at birth, the infants were visited 5 more times by 12 months of age. Verbal autopsy, based on a structured questionnaire, was used to assign a cause to the 180 reported deaths. Proportional hazards regression models were used to estimate the effect of breastfeeding practices, introduced as a time-varying variable, after accounting for other variables, including birth weight. Overall neonatal, postneonatal and infant mortality, and mortality attributable to ARI and diarrhea were measured. Results. The proportion of infants who were breastfed exclusively was only 6% at enrollment, increasing to 53% at 1 month and then gradually declining to 5% at 6 months of age. Predominant breastfeeding declined from 66% at enrollment to 4% at 12 months of age. Very few infants were not breastfed, whereas the proportion of partially breastfed infants increased with age. Breastfeeding practices did not differ between low and normal birth weight infants at any age. The overall infant mortality rate was 114 deaths per 1000 live births. Compared with exclusive breastfeeding in the first few months of life, partial or no breastfeeding was associated with a 2.23-fold higher risk of infant deaths resulting from all causes and 2.40- and 3.94-fold higher risk of deaths attributable to ARI and diarrhea, respectively. Conclusion. The important role of appropriate breastfeeding practices in the survival of infants is clear from this analysis. The reduction of ARI deaths underscores the broad-based beneficial effect of exclusive breastfeeding in prevention of infectious diseases beyond its role in reducing exposure to contaminated food, which may have contributed to the strong protection against diarrhea deaths.

Peer, parent, and media influences on the development of weight concerns and frequent dieting among preadolescent and adolescent girls and boys.

Abstract: Objective. To assess prospectively the influence of peers, parents, and the media on the development of weight concerns and frequent dieting. Design. Prospective cohort study. Setting. Questionnaires mailed annually to participants throughout the United States. Participants. One-year follow-up of 6770 girls and 5287 boys who completed questionnaires in 1996 and 1997 and were between 9 and 14 years of age in 1996. Main Outcome Measure. Onset of high levels of concern with weight and dieting frequently to control weight. Results. During 1 year of follow-up, 6% of girls and 2% of boys became highly concerned with weight and 2% of girls and 1% of boys became constant dieters. Peer influence was negligible. Independent of age and body mass index, both girls (odds ratio [OR]): 1.9; 95% confidence interval [CI]: 1.1–3.1) and boys (OR: 2.7; 95% CI: 1.1–6.4) who were making a lot of effort to look like same-sex figures in the media were more likely than their peers to become very concerned with their weight. Moreover, both girls (OR: 2.3; 95% CI: 1.1–5.0) and boys (OR: 2.6; 95% CI: 1.1–6.0) who reported that their thinness/lack of fat was important to their father were more likely than their peers to become constant dieters. Conclusions. Our results suggest that parents and the media influence the development of weight concerns and weight control practices among preadolescents and adolescents. However, there are gender differences in the relative importance of these influences.

Sleep and Behavior Problems in School-Aged Children

Abstract: Objectives. The primary purposes of the present study were to survey the prevalence of sleep problems in school-aged children and to examine these associations with parental perception of sleep problems, medical history, and childhood psychopathology. Methods. Sleep and medical history questionnaires and the Child Behavior Checklist were administered to the parents of 472 children between ages 4 and 12 years receiving routine pediatric care from urban, rural, and suburban pediatric practices. Results. Although sleep problems were reported for 10.8% of the sample during the past 6 months, less than one half of the parents who identified sleep problems reported that they had discussed sleep with their child9s pediatrician. The best predictor of current sleep problems was a history of sleep problems before age 2 years. Sleep problems such as snoring, tiredness during the day, and taking excessive time to fall asleep were very common, occurring at least 1 night per week in over 20% of the total sample. Factor analysis of the sleep problems questionnaire resulted in 5 sleep problem factors that accounted for 58.7% of the variance. Specific sleep problem factors include: parasomnias, enuresis/gags, tiredness, noisy sleep, and insomnia. Sleep problem factor scores were differentially associated with medical history variables and measures of childhood psychopathology. Children rated highly on parasomnias were more likely to have frequent falls and to display pica. Parasomnias and noisy sleep were inversely associated with socioeconomic status (SES). Children from lower SES families were rated higher on these factors than children from higher SES families. Enuresis/gags was the only sleep problem factor associated with age. Younger children scored higher on this factor. Duration of naps was highly correlated with age and with bed times during the week and weekends. As expected, younger children were more likely to nap for longer periods and to have earlier bed times. In addition, higher tiredness factor scores were associated with napping and with later bed times during the week and weekend. Boys were much more likely than were girls to have higher scores on enuresis/gags, and higher enuresis/gags scores were associated with an increased prevalence of trauma and falls. Bed times were not associated with any other sleep problem factor score. Children rated highly on tiredness were more likely to have a history of hospitalizations. Tiredness factor scores were strongly associated with the sleep practice of sharing a bed but not with sharing a room. Sharing a room was not associated with any sleep problem factor score. High scores on noisy sleep were associated with allergies, falls frequently, and with sharing a bed. Children with high scores on the insomnias were also more likely to display an increased prevalence of allergies. Conclusions. Parental perception of global sleep problems was surprisingly common in school-aged children receiving routine pediatric care. Parental reports of their children9s sleep problems may be a red flag for specific sleep problems and psychiatric, social, or medical problems. Sleep problems should be queried about during pediatric visits for school-aged children.

Deaths attributed to pediatric complex chronic conditions: national trends and implications for supportive care services.

Abstract: Background. Children with complex chronic conditions (CCCs) might benefit from pediatric supportive care services, such as home nursing, palliative care, or hospice, especially those children whose conditions are severe enough to cause death. We do not know, however, the extent of this population or how it is changing over time. Objectives. To identify trends over the past 2 decades in the pattern of deaths attributable to pediatric CCCs, examining counts and rates of CCC-attributed deaths by cause and age (infancy: <1 year old, childhood: 1–9 years old, adolescence or young adulthood: 10–24 years old) at the time of death, and to determine the average number of children living within the last 6 months of their lives. Design/Methods. We conducted a retrospective cohort study using national death certificate data and census estimates from the National Center for Health Statistics. Participants included all people 0 to 24 years old in the United States from 1979 to 1997. CCCs comprised a broad array of International Classification of Diseases, Ninth Revision codes for cardiac, malignancy, neuromuscular, respiratory, renal, gastrointestinal, immunodeficiency, metabolic, genetic, and other congenital anomalies. Trends of counts and rates were tested using negative binomial regression. Results. Of the 1.75 million deaths that occurred in 0- to 24-year-olds from 1979 to 1997, 5% were attributed to cancer CCCs, 16% to noncancer CCCs, 43% to injuries, and 37% to all other causes of death. Overall, both counts and rates of CCC-attributed deaths have trended downward, with declines more pronounced and statistically significant for noncancer CCCs among infants and children, and for cancer CCCs among children, adolescents, and young adults. In 1997, deaths attributed to all CCCs accounted for 7242 infant deaths, 2835 childhood deaths, and 5109 adolescent deaths. Again, in 1997, the average numbers of children alive who would die because of a CCC within the ensuing 6-month period were 1097 infants, 1414 children, and 2548 adolescents or young adults. Conclusions. Population-based planning of pediatric supportive care services should use measures that best inform our need to provide care for time-limited events (perideath or bereavement care) versus care for ongoing needs (home nursing or hospice). Pediatric supportive care services will need to serve patients with a broad range of CCCs from infancy into adulthood.

Relationships between use of television during meals and children's food consumption patterns.

Abstract: Objective. We examined relationships between the presence of television during meals and children9s food consumption patterns to test whether children9s overall food consumption patterns, including foods not normally advertised, vary systematically with the extent to which television is part of normal mealtime routines. Methods. Ninety-one parent–child pairs from suburbs adjacent to Washington, DC, recruited via advertisements and word of mouth, participated. Children were in the fourth, fifth, or sixth grades. Socioeconomic data and information on television use were collected during survey interviews. Three nonconsecutive 24-hour dietary recalls, conducted with each child, were used to construct nutrient and food intake outcome variables. Independent sample t tests were used to compare mean food and nutrient intakes of children from families in which the television was usually on during 2 or more meals ( n = 41) to those of children from families in which the television was either never on or only on during one meal ( n = 50). Multiple linear regression models, controlling for socioeconomic factors and other covariates, were used to test strength of associations between television and children9s consumption of food groups and nutrients. Results. Children from families with high television use derived, on average, 6% more of their total daily energy intake from meats; 5% more from pizza, salty snacks, and soda; and nearly 5% less of their energy intake from fruits, vegetables, and juices than did children from families with low television use. Associations between television and children9s consumption of food groups remained statistically significant in multiple linear regression models that controlled for socioeconomic factors and other covariates. Children from high television families derived less of their total energy from carbohydrate and consumed twice as much caffeine as children from low television families. There continued to be a significant association between television and children9s consumption of caffeine when these relationships were tested in multiple linear regression models. Conclusion. The dietary patterns of children from families in which television viewing is a normal part of meal routines may include fewer fruits and vegetables and more pizzas, snack foods, and sodas than the dietary patterns of children from families in which television viewing and eating are separate activities.

Racial and Temporal Variations in the Prevalence of Heart Defects

Abstract: Background. Documenting the preva- lence and trends of congenital heart defects provides useful data for pediatric practice, health-care planning, and causal research. Yet, most population-based studies use data from the 1970s and 1980s. We sought to extend into more recent years the study of temporal and racial variations of heart defects occurrence in a well-defined population. Methods. We used data from the Metropolitan At- lanta Congenital Defects Program, a population-based registry with active case ascertainment from multiple sources. Heart defects were identified among liveborn infants up to 1 year old, among stillborn infants, and among pregnancy terminations to mothers residing in metropolitan Atlanta. Results. From 1968 through 1997, the registry ascer- tained 5813 major congenital heart defects among 937 195 infants, for a prevalence of 6.2 per 1000. The prevalence increased to 9.0 per 1000 births in 1995 through 1997. The prevalence of ventricular septal defects, tetralogy of Fal- lot, atrioventricular septal defects, and pulmonary steno- sis increased, whereas that of transposition of the great arteries decreased. For some defects, prevalence and trends varied by race. Conclusions. The prevalence of congenital heart de- fects is increasing. Whereas most findings likely result from improved case ascertainment and reporting, others might be because of changes in the distribution of risk factors in the population. The basis of the racial varia- tions is incompletely understood. Pediatrics 2001;107(3). URL: http://www.pediatrics.org/cgi/content/full/107/3/ e32; heart defects, whites, blacks, epidemiology, preva- lence.

Prenatal Alcohol Exposure and Childhood Behavior at Age 6 to 7 Years: I. Dose-Response Effect

Abstract: Objective. Moderate to heavy levels of prenatal alcohol exposure have been associated with alterations in child behavior, but limited data are available on adverse effects after low levels of exposure. The objective of this study was to evaluate the dose-response effect of prenatal alcohol exposure for adverse child behavior outcomes at 6 to 7 years of age. Methods. Beginning in 1986, women attending the urban university-based maternity clinic were routinely screened at their first prenatal visit for alcohol and drug use by trained research assistants from the Fetal Alcohol Research Center. All women reporting alcohol consumption at conception of at least 0.5 oz absolute alcohol/day and a 5% random sample of lower level drinkers and abstainers were invited to participate to be able to identify the associations between alcohol intake and child development. Maternal alcohol, cigarette, and illicit drug use were prospectively assessed during pregnancy and postnatally. The independent variable in this study, prenatal alcohol exposure, was computed as the average absolute alcohol intake (oz) per day across pregnancy. At each prenatal visit, mothers were interviewed about alcohol use during the previous 2 weeks. Quantities and types of alcohol consumed were converted to fluid ounces of absolute alcohol and averaged across visits to generate a summary measure of alcohol exposure throughout pregnancy. Alcohol was initially used as a dichotomous variable comparing children with no prenatal alcohol exposure to children with any exposure. To evaluate the effects of different levels of exposure, the average absolute alcohol intake was relatively arbitrarily categorized into no, low (>0 but 2 standard deviations from the sample mean, or had incomplete data. The Achenbach Child Behavior Checklist (CBCL) was used to assess child behavior. The CBCL is a parent questionnaire applicable to children ages 4 to 16 years. It is widely used in the clinical assessment of children9s behavior problems and has been extensively used in research. Eight syndrome scales are further grouped into Externalizing or undercontrolled (Aggressive and Delinquent) behavior and Internalizing or overcontrolled (Anxious/Depressed, Somatic Complaints, and Withdrawn) behaviors. Three syndromes (Social, Thought, and Attention Problems) fit neither group. Higher scores are associated with more problem behaviors. Research assistants who were trained and blinded to exposure status independently interviewed the child and caretaker. Data were collected on a broad range of control variables known to influence childhood behavior and/or to be associated with prenatal alcohol exposure. These included perinatal factors of maternal age, education, cigarette, cocaine, and other substances of abuse and the gestational age of the baby. Postnatal factors studied included maternal psychopathology, continuing alcohol and drug use, family structure, socioeconomic status, children9s whole blood lead level, and exposure to violence. Data were collected only from black women as there was inadequate representation of other racial groups. Statistical Analyses. Statistical analyses were performed using the SPSS statistical package. Frequency distribution, cross-tabulation, odds ratio, and χ 2 tests were used for analyzing categorical data. Continuous data were analyzed using t tests, analyses of variance (ANOVAs) with posthoc tests, and regression analysis. Results. Testing was available for 501 parent–children dyads. Almost one fourth of the women denied alcohol use during pregnancy. Low levels of alcohol use were reported in 63.8% and moderate/heavy use in 13% of pregnancies. Increasing prenatal alcohol exposure was associated with lower birth weight and gestational age, higher lead levels, higher maternal age, and lower education level, prenatal exposure to cocaine and smoking, custody changes, lower socioeconomic status, and paternal drinking and drug use at the time of pregnancy. Children with any prenatal alcohol exposure were more likely to have higher CBCL scores on Externalizing (Aggressive and Delinquent) and Internalizing (Anxious/Depressed and Withdrawn) syndrome scales and the Total Problem Score. The odds ratio of scoring in the clinical range for Delinquent behavior was 3.2 (1.3–7.6) in children with any prenatal exposure to alcohol compared with nonexposed controls. The threshold dose was evaluated with the 3 prenatal alcohol exposure groups. One-way ANOVA revealed a significant between group difference for Externalizing (Aggressive and Delinquent) and the Total Problem Score. Posthoc tests revealed the between group differences to be significant (no and low-exposure group) for Aggressive and Externalizing behavior suggesting that the adverse effects of prenatal alcohol exposure on child behavior at age 6 to 7 years are evident even at low levels of exposure. For Delinquent and Total Problem behavior, the difference was significant between the no and moderate-heavy exposure group, suggesting a higher threshold for these behaviors. Prenatal alcohol exposure remained a significant predictor of behavior after adjusting for covariates. Although maternal psychopathology was the most important predictor of behavior, gender was also a significant predictor, with boys having higher scores on Externalizing (Delinquent) and Attention Problems. The amount of variance uniquely accounted for by prenatal alcohol exposure ranged between 0.6% to 1.7%. Conclusions. Maternal alcohol consumption even at low levels was adversely related to child behavior; a dose-response relationship was also identified. The effect was observed at average levels of exposure of as low as 1 drink per week. Although effects on mean scores for Externalizing and Aggressive behaviors were observed at low levels of prenatal alcohol exposure, effects on Delinquent behavior and Total Problem Scores were observed at moderate/heavy levels of exposure. Children with any prenatal alcohol exposure were 3.2 times as likely to have Delinquent behavior scores in the clinical range compared with nonexposed children. The relationship between prenatal alcohol exposure and adverse childhood behavior outcome persisted after controlling for other factors associated with adverse behavioral outcomes. Clinicians are often asked by pregnant women if small amounts of alcohol intake are acceptable during pregnancy. These data suggest that no alcohol during pregnancy remains the best medical advice.