Mi tl TT Z , ( i I \ Y, : 7) \ ph ( = MCH PROJECTS research to improve . health services on ad for mothers and children 3 U.S, DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE SEP 99 14/5 ; ; fh fg. FES Public Health Service Health Services Administration go aay ''''INTERNATIONAL MCH PROJECTS research to improve health services for mothers and children U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Health Services Administration Bureau of Community Health Services Rockville, Maryland 20852 DHEW Publication No. (HSA) 75-5129 1975 ''(uv Act * @m ''introduction Since 1961 the United States Government has supported research projects on maternal and child health in a number of foreign countries under the Special Foreign Currency Program. These projects complement the domestic maternal and child health re- search program and are also of interest and application in the United States. The Special Foreign Currency Program, which utilizes U.S.- owned foreign currencies derived from the sale of surplus agricul- tural commodities, was authorized by the Agricultural Trade Development and Assistance Act of 1954 (Public Law 83-480). This publication presents summaries of the final reports of some of these research projects, and all are concerned with im- proving the operation, functioning, and effectiveness of maternal and child health and crippled children’s services. This is the sixth in a series of research abstracts. The first five summarized research projects in the United States funded by the Office for Maternal and Child Health of the Bureau of Com- munity Health Services, Health Services Administration. Both the international and domestic research projects were initially administered by the Children’s Bureau and later by the Maternal and Child Health Service. The international research projects have been greatly assisted by U.S. health workers, both governmental and nongovernmental, who volunteered their time to act as project officers and provided technical consultation to the research workers. Much of the credit for this productive international scientific exchange is due to Dr. Katherine Bain, former Chief, Interna- tional Activities for Maternal and Child Health, whose per- sistence and ingenuity overcame many obstacles to bring these and other studies to successful completion. These summaries of research projects were prepared by the Maternal and Child Health Program, School of Public Health, University of California, Berkeley, under MCHS grant MC-R- 060208. Readers interested in more detailed information about the studies should direct their requests to the principal research- ers of the projects. iii OCT 4 1983 '' ''projects THE EFFECT OF INTENSIVE AND EXTENSIVE APPLICATION OF CONTRACEPTION ON THE ABORTION RATE. Angelina Moji¢é, M.D., Federal Institute of Public Health, Belgrade, Yugoslavia ~------ METHODS FOR EARLY DETECTION OF HEARING LOSS IN INFANTS. M. M. Altman, M.D., Rambam Government Hospital, Haifa, Israel _--_-------------- CONGENITAL DYSPLASIA OF THE HIP. Bogdan Brecelj, M.D., Ljubljana Clinical Hospital, Ljubljana, VUGOSICGi ne eo ee eS MENTAL AND MOTOR GROWTH OF INDIAN BABIES. Professor Amita Verma and Dr. Pramila Phatak, The Maharaja Sayajirao University, Baroda, India __-___-__ THE INFLUENCE OF MEDICAL REHABILITATION ON THE GENERAL PERFORMANCE LEVEL OF IN- STITUTIONALIZED MENTALLY RETARDED CHIL- DREN. Danuta Stomma, M.D. and Ignacy Wald, M.D., Psychoneurological Institute, Warsaw, Poland ________- THE HOSPITALIZATION OF YOUNG HAIFA CHIL- DREN. S. T. Winter, M.D., Rothschild Hospital and Aba Khoushy School of Medicine, Haifa, Israel ____--------- '' ''THE EFFECT OF INTENSIVE AND EXTENSIVE APPLICATION OF CONTRACEPTION ON THE ABORTION RATE ANGELINA MOJIC, M.D., Federal Institute of Public Health, Belgrade, Yugoslavia, 1972. Grant No. 02-475-2 (Formerly SRS/CB YUGO-5). The Federal Institute of Public Health of Yugoslavia and the Ma- ternal and Child Health Service, U.S. Department of Health, Education, and Welfare, conducted a study on the effects of a contraception program on the incidence of abortion in Yugoslavia. The purpose of the program was to offer comprehensive contra- ceptive and followup services to women in order to decrease the high rate of abortion. During postwar industrialization, more Yugoslav women en- tered paid employment, and the birth rate declined from 36.7 per 1,000 in 1921 to 18.9 per 1,000 in 1968. The data on pregnancies and abortions in all years studied indicated that one of the most widely used methods of family planning was abortion. Many abortions were performed by unskilled people or the pregnant woman herself. Until 1952, maternal mortality from abortions was 8 times higher than mortality associated with births. In 1952, 1960, and 1969, Yugoslavia passed increasingly more liberal abor- tion laws, providing for abortions in health institutions and em- phasizing the necessity for warning women of the dangers of self-induced abortions. These laws also instituted a system for reporting abortions. Statistics from these reports indicated that after the laws were passed: 1. The rate of abortions increased each year. 2. The number of births decreased. 3. The rate of self-initiated abortions decreased. In 1963, 31.8 percent of the abortions seen at clinics were incomplete or initiated by nonprofessionals. In 1967, this percentage declined to 23.7 per- cent of all abortions. 4. Maternal mortality following abortion decreased. In 1967, there were no maternal deaths following abortions performed in clinics or hospitals. Design of the Siudy This study investigated: 1. Whether women could be influenced to use methods of family planning instead of abortion. ''2. What parts of the intensive contraception program had the widest applicability for women of differing ethnic and social back- grounds. 3. What the outcomes were for each different method of con- traception. Three areas of the country where a high abortion rate existed (3 to 4 abortions to 1 birth) were chosen for the study. These areas differed in religious, cultural, and economic conditions. Bel- grade, the capital of Serbia as well as Yugoslavia, represents a large urban population, mostly Greek Orthodox; Serajevo in Bosnia-Herzegovina, one of the poorer areas, has a large Moslem population; and Subotica, a small city on the border of Hungary which has experienced migrations from other southern European countries, is predominantly Catholic. Within these cities, specific institutions performing a sufficient number of abortions and with clinical facilities for followup, were selected to serve as centers for the “study” group and the “‘con- trol” group. To select the 6,009 women for this study, all women who had an abortion in these institutions between May and October 1967 were routinely cntered in the study until the required number had been reached. The only exclusions were women who started their abor- tions outside the clinic, women who lived outside the three cities, and women with cancer. (A Papanicolaou smear test was given to each woman before her inclusion in the study and at the end of the first and second year.) In the study group of 3,012 women, an effort was made to pre- scribe contraceptives for every woman, and all these women were seen by a physician every 3 months. The 2,997 women in the con- trol group were seen by a physician every 6 months. The ad- vantages of contraception were explained to the control group, but no effort was made to increase their use of contraceptives. The difference between the two groups was therefore only in the amount of outgoing, supportive service provided, since the purpose of the study was to test the acceptance and effectiveness of a comprehensive contraceptive service in a population that had been using abortion as the family planning technique of choice. Characteristics of the Sample Most of the women investigated were between the ages of 20 and 39 (5,481 women or 91.2 percent of the sample). In the study group, 91.1 percent were married, and in the control group, 90.7 percent were married. Among all the women in the sample, 52.9 percent were housewives, 2.7 percent were students, and the re- 2 ''mainder were employed. The study group had a slightly higher percentage of employed women, the control group slightly more housewives. A large proportion (67.8 percent) of the women in the study had elementary school education; 22.0 percent had graduated from secondary school; 6.6 percent had no schooling; and 3.3 percent had education beyond high school. There were more women with higher degrees in the study group (4.7 percent) than in the con- trol group (1.7 percent). The proportion of religious affiliations was similar to that of the total Yugoslav population. Of the 6,009 women under study, 2,485 (41.4 percent) were Greek Orthodox; 1,929 (32.1 percent) were Catholic; and 995 (16.6 percent) were Moslem. Twenty- eight (0.5 percent) belonged to other religions, and 572 (9.5 percent) belonged to no religious group. There were no appreci- able differences in religious affiliations between the two groups. Eighteen percent of the women in the study group and 23 percent of the control group had three or more children. The proportion of women with no children in each group was 8.1 percent and 9.4 percent, respectively. About half of the women in each group had had three or more abortions, including the one that made them eligible for the study. Factors Related to Number of Abortions The histories of the participants provided a number of interesting facts about their reproductive patterns: 1. The average number of births and abortions before joining the study was 1.9 deliveries and 3.3 abortions per woman. 2. In all three religious groups, nearly half the women had had three or more abortions. There was no significant difference in the abortion rate in the three religious groups, an indication that re- ligion was not an obstacle in interrupting pregnancy as a method of family planning. 3. Among the older women, born between 1920-29 and nearing the end of their reproductive period, more than a third had had only two deliveries and about the same proportion had had five or more abortions. 4. Complications at delivery, as detailed in the histories, had happened to 272 women (4.3 percent), while 875 women (14.6 per- cent) had had complications with abortions. The age or order of pregnancy did not appear to be related to complications of abortions. ''5. A larger percentage of employed women (14.9 percent) than housewives (3.4 percent) were nulliparous. There was little differ- ence in the abortion rate; 18.3 percent of the employed women and 20.3 percent of the housewives had had five or more abortions. 6. Women with no schooling and those with lower educational levels had had a larger number of both deliveries and abortions than the others. Of the women with no education, 13.4 percent had had five or more deliveries, while only 0.5 percent of uni- versity graduates had had the same number. By groups, the per- centage of women with five or more abortions was: Percent Without education 27.0 With elementary education 20.4 With secondary education 15.3 With a universary degree 12.2 Investigators inferred that the level of education was an im- portant factor in the rate of parity as well as in the use of abor- tion for family planning. Contraceptive Use During the Study 1. The following types of contraceptives were used: Oral (Lindiol and Anovlar) IUD (only Lippes Loop) Emko Foam Vaginal (local products such as jelly, paste, tablets) Diaphragms (only in control group) The various methods of contraception were explained and the women made their own choices. 2. Inthe study group, 78.9 percent used contraceptives through- out the study and 12.2 percent used them intermittently. During the 2-year study period, only 19.8 percent of the control group used a contraceptive continuously; 22.3 percent used a contraceptive intermittently ; and 40.6 percent used no contraceptive. 3. Of the women who had never used contraceptives, 791 who gave consistent answers provided the following reasons: Percent e Never heard of contraception 2.90 e Wanted to have babies 17.83 e Had never gotten pregnant 31.99 e Afraid of contraception 11.88 4 ''¢ Did not believe in the efficiency of contraception 6.45 e Husbands were against it 5.81 ¢ Too busy to see doctor 9.87 e Other reasons 13.27 4. Throughout the study, among 2,994 women in the study group, 71 percent used one type of contraceptive and 21.6 percent used two. Among 1,779 women in the control group, 91.4 percent used one contraceptive method. 5. Among the women using pills, 82.1 percent had no complica- tions, and 17.9 percent had some complications. Most complica- tions consisted of slight disturbances of the menstrual cycle, nausea, and bleeding. There was one case of thrombophlebitis. 6. Among those, using the IUD, 71.0 percent had no complica- tions. Of the 369 women with complications, 54.0 percent had bleeding (this disappeared after the first or second menstrual period) ; 22.8 percent were expulsions or removal of the IUD; 5.1 percent had inflammations; and 8.1 percent had pain. 7. The study data indicated a relationship between the occu- pational level of a woman and the type of contraceptive she chose. Women in occupations requiring a higher degree of education chose oral contraceptives least often. Investigators surmised that the more educated women distrusted oral and intrauterine con- traceptives because alarming news about the effects of these methods appeared in the Yugoslav press in 1968 and 1969. They also observed that housewives and agricultural workers often pre- ferred the pill because they feared that the IUD might drop out or cause bleeding or pain during heavy work. Outcome of the Study Throughout the entire 2-year study period, contact was main- tained with 85.4 percent of the women. Followup procedures showed that contact was usually discontinued because the woman moved to another region or became pregnant. The effects of the contraception program on the study. group were evaluated by comparing the number of unwanted pregnancies in this group with the number in the control group. The investigators in the study determined which pregnancies were wanted through inter- views by the physician. 1. There were 218 pregnancies in the study group and 1,173 pregnancies in the control group, a five-fold difference. No preg- 5 ''nancies were recorded for 93.3 percent of the study women and 67.3 percent of the controls. 2. Of the 6,009 women in both groups, 194 (3.2 percent) had 208 wanted pregnancies, and 988 (16.4 percent) had 1,183 un- wanted pregnancies. No pregnancies were recorded for 4,827 women (80.4 percent) throughout the study period. 3. There were 38 wanted pregnancies (1.3 percent) in the study group and 170 (5.2 percent) in the control group. The study group women had 180 unwanted pregnancies (5.4 percent), compared to 1,003 (27.5 percent) unwanted pregnancies in the control group. These results indicated to the researchers that the intensive contraceptive counseling service changed the attitudes of the study women from acceptance of unwanted pregnancies to rational family planning. The frequent contact with the doctor, whose purpose was to find the most efficient and acceptable contraceptive for each woman, prevented a large number of unwanted preg- nancies. Other data on outcomes from this study include: 1. Of 1,183 unwanted pregnancies, 219 (18.5 percent) occurred while the women were using contraceptives. In the study group, 95 of the 180 unwanted pregnancies occurred among women prac- ticing contraception. In the control group, 124 of the 1,003 un- wanted pregnancies occurred among women using contraceptives. Thus, most unwanted pregnancies in the control group occurred among women not using contraceptives. 2. The 219 pregnancies occurred while the following contracep- tive methods were used: pill, 31.5 percent; Emko foam, 29.7 percent; various vaginal preparations, 25.38 percent; IUD, 13.2 percent. Only 12 women in the study group became pregnant while taking oral contraceptives, compared to 57 women in the control group. The investigators concluded that the high risk of preg- nancy with oral contraceptives was due to irregularity in their use. The least risk occurred with the use of the IUD. 3. The percentage of unwanted pregnancies was smaller for those women who had maintained their contact with the doctors than for those who did not. For those who remained in contact with the study, 5.3 percent of the study women and 8.8 percent of the control women had unwanted pregnancies. Of those who left the study for more than a year, 5.6 percent of the study group and 31.6 of the control group had unwanted pregnancies. 4. Of the 1,391 pregnancies occuring during the study, 198 (14.2 percent) ended in births, and 1,180 (84.9 percent) ended in 6 ''abortions. Investigators noted that although a large number of pregnancies were unwanted, few women in the control group favored rational family planning. 5. Of the 1,180 abortions performed during this study, 84.3 percent were legal, 8.9 percent were induced by unskilled people, and 6.8 percent were spontaneous. There was a greater percentage of self-induced abortions in the study group (13.7 percent of 175 abortions) than in the control group (8.0 percent of 1,005 abortions). 6. The percentage of stillbirths was 0.2 for both groups, less than the national average in Yugoslavia. Similarly, the percent- age of spontaneous abortions was 5.6 percent, while the national average varies between 10 and 15 percent. 7. In the control group, 12.0 percent of the abortions were associated with complications, while in the study group, only 3.4 percent had complications. Conclusions The researchers concluded that abortion can be almost eliminated as a method of family planning in Yugoslavia with the imple- mentation of intensive contraception programs. The need for such programs is shown by the finding that while 32 percent of women not using contraceptives may have been sterile and 18 percent wanted to be pregnant, 50 percent were at risk of preg- nancies they did not want. A further justification for the inten- sive program is that throughout the 2-year period of the study, no death due to birth or abortion occurred, and the percentage of complications following abortion was below the national average. The investigators recommend that the Yugoslav health system in- tensify its efforts to substitute contraception for abortion. They also recommend that the effects of family planning on the birth rate be studied, to prevent depopulation. ''METHODS FOR EARLY DETECTION OF HEARING LOSS IN INFANTS M. M. ALTMAN, M.D., E.N.T. Department, Rambam Government Hospital, Haifa, Israel, August 1969. Grant No. ISRAEL WA/GB-13. The objective of this study was to evaluate methods for early identification of hearing loss in infants under prevailing public health conditions in Israel where the incidence of congenital deaf- ness is 1.2 per 1,000—about the same as in the United States. Its early detection is of paramount importance for the rehabilitation of the affected child. The study evaluated the following screening methods: 1. Selective screening of infants judged to be “at risk” of deafness. 2. Mass screening of all infants between 7 and 10 months old who attended Mother and Child Welfare clinics. 3. Mass screening of neonates. Selective Screening of “At Risk” Infants Data on 10,000 neonates were collected in the maternity wards of three Haifa hospitals. Registration took place between February 1965 and March. 1967. Registration charts contained demographic information and medical data on family history, pregnancy and delivery, and the postnatal period. Data on family history or pregnancy were supplemented and verified by direct questioning of mothers. Infants whose medical history indicated they were “at risk” for hearing loss had a first hearing test at age 7-8 months, and their hearing and speech development was followed until the age of 214 years. There were 25 at risk criteria, including family his- tory of hearing loss, family history of nervous system diseases, specific complications of pregnancy and delivery, chronic maternal diseases, maternal drug intake during pregnancy or delivery, various malformations of the newborn, low APGAR scores for the newborn, low birth weight, and diseases and physical compli- cations of the newborn before discharge from the hospital. Using the criteria described above, 3,026 infants were cate- gorized as “at risk.” By the end of the study, 2,860 (94 percent) of these cases had been followed up. 8 ''Among 2,810 “at risk” infants still living at the age of 7-8 months, auditory screening tests showed that 35 had a suspected hearing loss. Further diagnostic procedures revealed that 12 of the 35 children had actual hearing loss. The other 23 children had other organic disorders (Downs syndrome or microcephalus) with normal] hearing. The 12 children with hearing loss included 6 whose hearing loss was profound. Five of these appeared in the register because of family deafness, and the sixth was selected because of consan- guinous parents. Two had malformations of the ears with con- ductive hearing loss. One infant with partial neurosensory hearing loss was born with asphyxia. Multiple risk factors, such as tox- emia, difficult labor and delivery, low birth weight, and neonatal anoxia, were evident in the three cases with both brain damage and hearing loss. Among the 7,000 infants who did not appear in the Risk Regis- ter, 4 children with profound congenital hearing loss were detected 114 to 8 years after birth. There was no evidence that the hearing loss had developed after birth. Hearing loss in the “at risk” group was 2.3 times more common than in the average population. Thirteen children with hearing loss due to congenital causes were discovered among the 10,000 studied infants; 9 of these had appeared in the Risk Register. From the findings of this study, the investigators concluded that the Risk Register is of limited value in identifying early hearing loss in infants. Many causes of hearing loss due to con- genital causes remain unknown, and it is not surprising that even the carefully kept Register of this study led to the detection of only two-thirds of the children with hearing loss in the studied population. The investigators noted that each 5,000 newborns recorded in the Risk Register required the services of 1 full-time nurse, 1 half- time secretary, and the part-time services of a physician and audiometrist. This, they felt, was a high cost for early detection of hearing loss. Mass Screening in Mother and Child Welfare Clinics From April 1, 1965 to April 1, 1968, 10,057 infants aged 7-10 months were tested in 35 of the 40 Mother and Child Welfare clinics of the Haifa District. There were approximately 14,000 children under 1 year within the districts of the 35 clinics during the three years of the study; so that about 71 percent of the in- fant population was screened. ''Test procedures consisted of uncalibrated sounds such as: ¢ Human voice (“pss-pss”—a high frequency sound) ¢ Human voice (“uh-uh”’—a low frequency sound) Tin rattle (peak frequency of 4,000 H) Stirring of spoon in earthenware cup (white noise) ¢ Crumpling of tissue paper (peak frequency of 6,000 H) ¢ Ringing of brass bell (peak frequency of 2,000 H) Tests were performed by the nurses of the clinics after a short training period. Positive responses of the infants were indicated by the turning of the head toward the sound. Those who failed to turn their heads to two or more sounds, or showed doubtful responses, were invited for a second test in the clinic within 2 weeks. Infants failing the second test were sent to the audiological clinic of the Rambam Hospital for full evaluation. After screening, 650 infants (6.5 percent) needed a repeat screening test in the clinic. Of these, 280 (2.9 percent) were sent to the Audiological Center for complete testing. Twenty had hearing loss. The diagnoses were: 6 with temporary hearing loss; 10 with profound deafness; 2 with partial deafness; and 2 with both profound deafness and brain damage. The six children with temporary hearing loss had acute bi- lateral otitis media. The otitis media was asymptomatic—detect- able only by otoscopy— and all the children regained their hearing after treatment. One infant was found to be profoundly deaf 8 months after he had passed the screening test. There was no indication that the hearing loss had been acquired after the hearing test. Investigators noted that the test procedure is inexpensive, since no additional personnel are needed in areas where Mother and Child Welfare clinics are already in operation. The test takes little time, making it useful in mass screening, and it is well- accepted by parents and nurses. The response, full headturn to the sound source, is easy to de- tect. The most suitable age for testing is between 7-10 months, as this is the age when the headturning response should be pres- ent in all normal hearing children. The validity of the test procedure was excellent, as the rates of false positives were low (2.9 percent) and the number of false negatives small (1 child). When most of the screened children were 2 years old, a survey was made in all institutions of Israel that diagnose or rehabilitate children with hearing loss. No ad- ditional cases of hearing loss from this study were located. 10 ''Among the 5,000 infants in Haifa during the study period, but not screened for hearing loss, six other profoundly deaf children were found. Most were diagnosed only at the age of 2 years. The identical rate of hearing loss (1.2 per 1,000) in both groups (screened and unscreened) of the population seemed to support the conclusion that there were no undetected cases. The investigators noted that the use of uncalibrated sounds for testing hearing cannot be used as a final diagnostic test. However, in a mass screening program the procedure was reliable and inexpensive. Mass Screening of Neonates For this part of the study, 6,000 neonates born in Rambam Hos- pital between March 1966 and July 1969 were screened. Using the Vicon Apriton generator, 1,700 infants were tested from May 1966 to March 1967 and 4,300 were tested with the Rudmose “Warblet 3,000” between November 1967 and July 1969. Tests were performed in the nursery and the premature ward of Rambam Hospital. The ages of the infants at time of testing varied from 2 hours to 4 days after birth for normal infants and 75 percent were tested within the first 2 days. Testing of pre- mature infants was delayed when their viability was in doubt. Classifications of responses to the tone signal included: Moro startle reflex Eyeblink Sucking reflex Other responses—movements of limbs, grimacing, head turn, and cessation of activity e Any combination of above Intensity of response was recorded as clear; doubtful; or negative. State of infants at time of testing was classified as awake; crying; restless; or asleep. Among the 1,700 neonates tested with the Apriton, 46 were classified as having doubtful hearing, and 6 did not show any response. Thus, 2.8 percent were suspected of severe hearing loss. Followup of these 52 infants to the age of 214 years did not reveal any with hearing loss. Among the 4,300 neonates tested with the Warblet, 70 were classified as having doubtful hearing, and 91 did not show any response (a rate of 3.7 percent suspected cases). Of the 161 in- fants suspected of hearing loss, 1384 have had their 7-month-old followup. Of these, 3 children with hearing loss have been diag- nosed; all of them were premature infants. 11 ''Clear responses occurred most frequently in infants who were between 48-72 hours old. “Doubtful” or “No Response” reactions occurred most often in crying infants less than 48 hours old. Within the next 2 years of the study (until January 1969), six deaf children were found in the tested population. Only three of them had been suspected of deafness when tested as newborns. The investigators noted that the large number of false positive responses elicited in the neonatal period presents a followup prob- lem. The clearest and most unmistakable response from an infant is the Moro startle reflex, but this occurs in only 50 percent of all newborns. The validity of this procedure in the study, therefore, seemed doubtful, as the rate of negative errors was 50 percent. Conclusions As a result of this study, auditory mass screening of infants has become a permanent and routine procedure in the Mother and Child Welfare clinics in the Haifa District and in northern Israel. It is now routinely performed in many other parts of the country. The Risk Register has also been used as a sample base for other research projects. A partial report on the results of this project was given at the Annual Meeting of the Israel Otolaryngologic Society in Haifa, May 1968, and before the Haifa Medical Society in February 1969. Part of the study was published in Harefuah, the Journal of the Israel Medical Association, March 16, 1969. The study was read before the 1X International Congress of Oto-Rhinolaryngology, Mexico City, August 1969. It was published in full in The Journal of Laryngology and Otology, London, in Vol. 85, No. 1, pp. 85-42, January 1, 1971. 12 ''CONGENITAL DYSPLASIA OF THE HIP BOGDAN BRECELJ, M.D., Orthopaedic Clinic, Ljubljana Clinical Hospitals, Ljubljana, Yugoslavia, May 1973. Grant No. 02-477-2 (formerly SRS- YUGO 28-69). This study investigated the field of congenital malformations of the hip. It established the incidence of congenital dysplasia of the hip in newborns, and investigated the development of hip dysplasia in infants older than 5 months. For the first part of the study, all infants born in Ljubljana, Zagreb, Belgrade, Skopje, and Titograd, Yugoslavia, between June 1, 1969 and May 31, 1970, were examined at birth. The examination consisted of Ortolani’s test for detecting dislocation, and Palmen’s test for discovering instability of the hip joint. All infants with dysplastic hips, all infants suspected of having dysplasia, and 20 percent of the normal infants were scheduled for examination again in 5 months. This examination included X-rays, as well as Palmen’s and Ortolani’s tests. Children examined at 5 months were examined again at 1 year. From June 1, 1969 to May 31, 1970, 60,668 newborns were ex- amined in 29 maternity hospitals. Of these, 2,641 (4.3 percent) had diagnosed or suspected hip anomalies. These children, and 20 percent of the normal infants, were scheduled for another examina- tion at the age of 5 months. Of the 14,245 infants scheduled, 11,100 were brought to the second examination. A third examination was performed when the infants were 13 months old. The same 14,245 children were invited, and 6,846 (48.0 percent) appeared. Of these children, 5,971 had been ex- amined three times, and the others (875) had been observed twice, on the first and third examination. At the third examination, 396 infants (5.8 percent) were found to have a malformation. In this study, the first examination occurred within the first 36 hours of life. The results were used to categorize each infant whatever the outcome of later Palmen and Ortolani tests. For those cases diagnosed as having dysplasia, including those with disloca- tions, unstable hips, and suspected hip anomalies, the study phy- sicians prescribed a flexible aluminum abduction splint. This treatment was continued for 4 months for the infants with dis- locations and unstable hips, and for 6 weeks for those with sus- pected hip anomalies. 13 ''Postnatal Development of Infants with a Dislocated Hip at Birth e Among the 5,971 newborns in this study, 272 (4.7 percent) had Ortolani’s phenomenon, indicating a dislocated hip. e¢ When the infants were 5 months old, 203 (74.63 percent) of those with a dislocated hip had recovered. Of the remaining 69 children, 17 (6.25 percent) still had a dislocation; 27 (9.93 per- cent) were suspected of having a dislocation; 14 (5.15 percent) had dysplasia; and 11 (4.04 percent) had subluxations. Recoveries occurred in some infants who had not had splints; in others dis- location persisted despite the prescribed therapy. ¢ When the infants were examined at the age of 13 months, the following results were obtained: of 203 babies who were normal at the second examination, 196 (96.55 percent) were still normal. Of 27 with a suspected dislocation at 5 months, recovery was ob- served in 26 (96.30 percent) ; of 14 dysplasias, 11 (78.57 percent) became normal; 7 (68.64 percent) of 11 subluxations recovered; and 4 (23.53 percent) of 17 cases with previous dislocations recovered. ¢ In this group of infants born with a dislocated hip, 244 of 272 cases recovered by 1 year of age; a rate of 89.70 percent. The remaining infants had 12 cases of dysplasia, 6 subluxations, 6 dis- locations, 3 suspicions of osteochondritis, and 1 “other.” Postnatal Development of Infants with Unstable Hips at Birth ¢ Of 561 infants with unstable hips at birth (positive Palmen test), 427 (76.11 percent) had recovered at 5 months. The remain- ing incidence of anomalies was: 68 (11.23 percent) suspected hip malformations; 31 (5.53 percent) dysplasias; 26 (4.63 percent) subluxations; and 14 (2.50 percent) dislocations. ¢ At 13 months, 417 out of 427 infants (97.66 percent) who were normal at 5 months were still normal. Of 63 children with suspected anomalies at 5 months, recovery was established in 60 babies (95.23 percent) at 1 year; of 31 cases of dysplasia, 24 (77.42 percent) manifested recovery at 1 year; of 26 subluxations, 19 (73.07 percent) were established as “normal”; and 4 (28.57 per- cent) of the 14 dislocations demonstrated a state of reduction at 1 year. ¢ Thus, of 561 infants with unstable hips at birth, 524 (93.40 percent) recovered by 1 year. There remained 8 dysplasias, 11 subluxations, 6 dislocations, 1 osteochondritis, 2 suspected cases of osteochondritis, and 7 suspected cases of dysplasia. 14 ''Postnatal Development of Infants with Suspected Hip Anomalies at Birth ¢ Of the 5,971 infants selected for the study, 175 had suspected hip joint instability at birth (results of both the Ortolani and Palmen tests were not conclusive). These infants were treated with splints, but the splints were left on only 6 weeks. At the age of 5 months, 143 (81.71 percent) had recovered. Remaining were 11 (6.29 percent) suspected malformations, 9 (5.14 percent) dysplasias, 6 (3.43 percent) subluxations, and 6 (3.48 percent) dislocations. e At 13 months, 142 of the 143 normal infants remained normal and 166 (94.86 percent) of the 175 babies suspected in hip anom- alies at birth had recovered. The malformations that still per- sisted were: 3 dysplasias, 4 subluxations, and 2 suspected dysplasias ; an incidence of 5.14 percent still needed further treat- ment. Postnatal Development of Infants with Normal Hips at Birth e Of the 5,971 infants who had all three examinations, 4,963 had normal hips at birth. ¢ At the age of 5 months, 4,444 (89.54 percent) babies normal at birth had remained normal, while 519 (10.46 percent) were be- lieved to have late identified dysplasia. Of the 519 infants with new malformations, 242 (4.88 percent) had suspected hip dys- plasia; 126 (2.54 percent) had diagnosed hip dysplasia; 87 (1.75 percent) had a subluxation; and 64 (1.29 percent) had a dislocated hip. e At the age of 13 months, many infants had recovered from the abnormalities they had developed at 5 months. Of 242 suspected abnormalities, 227 had reverted to normal (93.80 percent) ; of 126 dysplasias at 5 months, 107 (84.92 percent) were not detectable at 1 year; of 87 subluxations, 69 (79.31 percent) became normal; and of 64 infants with dislocated hips at 5 months, 30 (46.88 per- cent) recovered. In these cases, the least severe malformations had the greatest recovery rate. e At 13 months, the proportion of newly-apparent abnormalities decreased. On the third examination (13 months), 4,417 infants had normal hips, which is 99.39 percent of the infants normal at 5 months. By comparison, only 89.54 percent of those normal at birth were normal at 5 months. 15 ''Followup Examination of Children with Abnormal Hips An analysis of results from the third examination when the infants were 13 months old showed that neither a final evaluation of the hips nor a diagnosis of their further development could be made for several infants. The study was therefore extended for another year to allow for examination of 2-year old children. In the last phase of the research, 396 babies who had had abnormal hips at the 13-month examination were asked to come for another ex- amination at the end of their second year. Of these, 316 (81.86 percent) were brought in for examination. Of the 316 children abnormal at 13 months, 232 (73.4 percent) had recovered by age 2, while pathologic change persisted in 84 (26.6 percent). By category, the anomalies were: 28 dysplasias, 5 subluxations, 2 dislocations, 9 suspected cases of osteochondritis, 32 cases with osteochondritis, and 8 “other.” The lowest percent- age of normalization was evident in the group with the most severe pathology: of 12 dislocations, reduction was established in 7 infants (58 percent). Of the 316 babies, 100 (31.8 percent) had had hip abnormalities at birth, while 216 (68.2 percent) were infants who had been nor- mal at birth and had developed hip abnormalities in their first year, At the third examination, there had been 52 children who had had small centers of ossification in the femoral head, and no other malformation. Normalization occurred in 87 children, but the remaining 15 showed signs of abnormal development of the femoral head. Ten of these children had been observed only, but not treated, so that vascular damage of the femoral head could not be attributed to fixation in abduction. The investigators reached the following conclusions from the second part of the study: 1. Among children with abnormalities examined in the second year of life, 32 percent had shown abnormalities at birth, and 68 percent had been normal. The discovery of the late occurrence of dislocation of the hip was the most important finding of the study. 2. The presumption that the infant’s hips continued to develop after the first year of life was confirmed by the study data. 3. Of 316 cases that were pathologic by the end of 1-year, 73 percent recovered. 4. During the second year of life, X-rays detected abnormalities of the hips more frequently than clinical examinations. X-rays were particularly useful in detecting osteochondritic and/or vas- 16 ''cular disorders in the structure of the femoral head, and residual dysplasias of the acetabulum. 5. A tendency for hip abnormalities to normalize, confirmed in this study, does not refer to congenital dislocation of the hip. This remained unchanged in cases where treatment had been refused. 6. The percentage of suspected and diagnosed hip abnormali- ties among newborns was 4.3 percent. Of a total of 58,027 infants with stable hips at birth, 20 percent had been scheduled for fur- ther observation. However, only 4,963 (8.55 percent) were ex- amined at 5 months of age. For this reason the investigators concluded that they could not establish the exact incidence of late- identified pathology in the project as a whole. There were 519: (10.46 percent) late-identified cases among the 4,963 children with stable hips. Since 246 cases were “suspected” cases, and recovery was established in 227 infants on the third examination, there remained only 292 (5.88 percent) pathological cases, including dysplasias, subluxations, and dislocations. 7. The investigators made a study of joint laxity in children and families of children with hip dysplasia. They concluded that joint laxity plays an important role in the etiology of congenital dysplasia of the hip. They found that 38 of 51 girls with con- genital dysplasia of the hip also had joint laxity. Five out of nine boys with hip dysplasia also had joint laxity. The investigators observed that problems of diagnosis and treat- ment of dislocation of the hip had not been completely solved. Further and more detailed studies are required. Experiences of this and other studies have demonstrated that early detection and immediate fixation in abduction considerably diminished postnatal evolution of dysplastic processes in the hip, and usually resulted in normalization of the joint structures. The study presented radiographs and descriptions of 17 chil- dren followed from birth to age 2, including some with abnormali- ties manifested at the second, rather than the first, examination. Further information about this study can be obtained from Dr. Frederic N. Silverman, consultant and reviewer for this project, at Children’s Hospital, Cincinnati, Ohio 45229. 17 ''MENTAL AND MOTOR GROWTH OF INDIAN BABIES PROFESSOR AMITA VERMA and DR. PRAMILA PHATAK, Department of Child Development, Faculty of Home Science, The Maharaja Sayajirao University, Baroda, India, 1970. Supported in part by Grant No. HSMHA 01-476-2. This extensive study of the mental and motor development of Indian infants was conducted from 1967 to 1970, using the Bayley Scales of Infant Development. The study included three samples: 1. Longitudinal records of 4,141 upper-class urban babies in Baroda, with subsamples ranging in size from 60 to 178 and ages of children ranging from 1-30 months. 2. Cross-sectional records of 1,090 lower-class babies, with sub- samples ranging in size from 59 to 78 and babies aged 1-15 months. 3. Cross-sectional records of 656 rural infants from surround- ing villages in the state of Gujarat, with subsamples ranging from 25 to 52, and babies aged 1-15 months. Social status of the urban samples was determined by occupa- tion, education, and income of the family. In the rural population it was determined by the occupation, education, and social partici- pation of the head of the family, and the caste, land ownership, kind of housing, type of farm, and material possessions of the family. Findings 1. The more traditionally-reared rural infants showed the great- est acceleration of psychomotor growth, followed closely by the poorer urban infants. The motor development of the more West- ernized upper-class infants (whose parents enroll their preschool children in the university nursery school) was slower than that of the poor urban and rural infants, although superior to U.S. in- fants in the first half of the first year of life. However, there was a gradual slowing down of the motor com- petence of the Indian babies around 1 year of age, with the rural and lower-class urban infants falling behind the upper-class urban infants in the second year of life. In the latter part of the second year, even the more privileged urban infants in Baroda had psy- chomotor scores that were lower than those of U.S. infants of comparable age. 2. The upper-class urban babies tended to score consistently higher on the mental scale than the lower-class urban and rural 18 ''children at all age levels studied, with mean scores comparable to or slightly above those of U.S. infants. The mean mental scores of the urban poor and rural infants declined steadily from a normal level at 2 months to a below average level at 15 months. By the time they had passed their first birthday, their mean scores were 5 points lower than those of the upper-class urban infants. 3. All three groups of Indian babies tended to score higher than United Kingdom and Israeli babies on the motor scale. How- ever, the comparative findings on the mental tests indicated that wherever comparative data were noted for Israeli babies they tended to score highest. The scores of United Kingdom babies often were between those of Indian and U.S. infants. 4. The differences between the mean scores of males and females tended to be significant during the ages of 3 to 10 months. The mean scores of females were consistently higher than those of males. 5. The validity and reliability of the Bayley tests as applied to Indian babies were considered satisfactory. Dr. Emmy Werner, a consultant on this study, made the follow- ing observations about the study data in her article, “Infants Around the World: Cross Cultural Studies of Psychomotor De- velopment from Birth to Two Years” (Journal of Cross Cultural Psychology 3:111-134) : It is interesting to note the difference in the type of motor items on which Indian babies were advanced in comparison with U.S. infants. They include items that deal with fine motor skills, eye-hand coordination, anti-gravity and locomotion—all finished products of maturation, in- volving independent control of head, hand, wrist, upper and lower ex- tremities. Items on the mental scale which showed Indian babies ahead of U.S. infants also involved eye-hand coordination, manipulation of objects and spatial relationships, reflecting well-developed fine motor skills. In con- trast, motor items on which even the upper-class urban infants lagged behind U.S. infants required a certain amount of risk-taking, self- reliance and independence as well as getting used to unfamiliar equip- ment (walking-board, tape measure). The acceleration of the Indian infants in the first part of the first year, followed by a drop in performance in the latter part of the year 1 and in year 2, may be explained with reference to several factors: (1) birthweight: Indian babies have the lowest birthweight of all samples studied (mean 2.74 kg) and the next to the lowest mean weight at year 1 (8.00 kg); (2) a warm, tropical climate that requires little or no restriction by clothing; (3) a permissive child-rearing philosophy in an extended family of several care-takers that results in a combination of great freedom to explore, but also great dependency on adults for the immediate satisfaction of the infant’s needs. LO ''The investigators observed that comparisons among this study sample and samples from other studies must allow for differences in sample sizes, differences in the testing situation, and in the training of testers. For comparisons between Indian and Ameri- can babies, the samples were sufficiently large, and both study groups consulted Dr. Bayley for their test design and in the training of their testers. The superiority of Indian babies over U.S. babies, especially during their first 15 months, has been observed by almost all In- dian authors. The investigators in this study suggested that child rearing practices, especially in relation to freedom of movement and social communication, may account for the differences. In a further study, they found that parental education, differ- ence in parents’ ages, diet during pregnancy, birth weight, and birth order were some of the parameters correlated with different motor scores. Trends for mental scores were difficult to distin- guish before the age of 1 year. However, parents’ education, in- come, diet during pregnancy, and birth order appeared to be possibly related to mental development. The investigators suggested a need for further research on the following questions: e What will be the trend of differences in urban socioeconomic classes and rural areas in the motor and mental performances of babies beyond the age of 15 months? ¢ What are the differentiating variables for varying outcomes? ¢ Are biological differences in the sexes evidenced in early motor and mental growth? A product of this study was the pamphlet, “Abridged Mental and Motor Scales of Bayley Scales of Infant Development, Re- search Report No. 5’”* available from the Maharaja Sayajirao Uni- versity of Baroda. The abridged scales were compiled from the full-length Bayley scales and were tested in this study. The investigators found the abridged scales useful for practical diagnos- tic use, although they recommended the full scales for critical re- search into child growth and development. The mental tests are reduced to one-fourth their original number (42 items) and the motor scales to one-half their original number (34 items). For this abridged test, highly specialized testing materials were avoided. Other publications related to this research include: Derasari, A.J., “Pattern of Primary Dentition,” Indian Pediatrics, 7:113-23, 1970 (February). * Mimeographed report. A few copies are available on payment of postage. 20 ''Phatak P., V. Gopalan, and Nareshkumar, “Application of Abridged Bayley Scales of Infant Development (B.S.I.D.) I. Compilation and Elevation of the Scales,” Indian Pediatrics, 11:545-549, 1974, Phatak, P., Arun T. Phatak, “Application of Abridged Bayley Scales of In- fant Development (B.S.I.D.) II. Application to Neurologic Cases,” Indian Pediatrics, 11:551-555, 1974. Phatak, Pramila and Arun T. Phatak, “Application of Bayley Scales of In- fant Development (B.S.I.D.) to Neurological Cases,’ Indian Pediatrics, X (March 1978), 147-154. Phatak, P., “Behavior Patterns of Infants Under Testing,” Psychological Studies, X (1966), 115-123. Phatak, P., “Mental Development Patterns During Infancy and Some Related Factors,” Psychological Studies, 19:1-7, 1974. Phatak, P., “Mental Growth of Normal Indian Children,” Archives of Child Health, 10:41-47, 1968. Phatak, P., “Motor Growth Patterns of Indian Babies and Some Related Factors,” Indian Pediatrics, 7:619-624, 1970. Phatak, P., “Motor and Mental Development of Indian Babies from One Month to 30 Months,” Indian Pediatrics, 6:18-23, 1969 (January). Phatak, P., “Motor and Mental Development of Indian Infants from 1 Month to 25 Months,” J. of Guj. Res. Soc., Ahmedabed, 1964. Phatak, P., A. Khatri, A. Jashi, B. Gandhi, T. Saraswathi, and M. Desai, “Research in Child Development, Marriage and Family Relations Done in Indian Institutions of Teaching and Research,” Department of Child De- velopment, Faculty of Home Science, The Maharaja Sayajirao University, Baroda, India, 1966. Research Unit: “Heights and Weights of Babies in Baroda from One Month to Thirty Months,” Pediatric Clinics of India, 3:137-142, 1968. Verma, Amita and Pramila Phatak, “Manual for Using Bayley Scales of Infant Development (Research Form 1961) Based on Baroda Studies and Baroda Norms,” Research Report No. 6, Department of Child Develop- ment, Faculty of Home Science, The Maharaja Sayajirao University, Baroda, India, 1978. Verma, Anita, Pramila Phatak, V. Gopalan, and Nareshkumar, “Mental and Motor Growth Patterns and Growth Velocity of Indian Babies,’ Research Report No. 4, Department of Child Development, Faculty of Home Science, The Maharaja Sayajirao University, Baroda, India, 1973. 21 ''THE INFLUENCE OF MEDICAL REHABILITATION ON THE GENERAL PERFORMANCE LEVEL OF INSTITUTIONALIZED MENTALLY RETARDED CHILDREN DANUTA STOMMA, M.D., and IGNACY WALD, M.D., Psychoneurological Institute, Warsaw, Poland, 1972. Grant No. 05-476-2. The purpose of this project was to establish if and to what degree multidisciplinary medical and rehabilitative measures would in- fluence the physical condition, mental abilities, general perform- ance, and social adjustment of institutionalized mentally retarded children (IQ below 50). The ultimate objective was to find those factors that appeared to have had an influence on improving the general status of the children and increased their self-care abili- ties, and to analyze the results as a basis for designing a better system of delivery of care to this group. The project was carried out in four stages: 1. Screening examinations to select and match study partici- pants (1968) 2. Comprehensive baseline studies of children selected for the project (1968) 3. Application of multidisciplinary and rehabilitation effort (1969-71) 4, Final evaluation of all children in the study and analysis of data (1972) Four institutions for the profoundly and severely retarded ad- ministered by social welfare agencies in the Warsaw district, which appeared to have approximately the same staff—patient ratio and seemed to be providing the same level of care, were selected. Sixty girls between the ages of 5 and 15 who were to be given special rehabilitative services and medical treatment by the multidisciplinary team were selected (Group R). All were in one institution. They were matched with 60 girls, the control group from the other institutions (Group C). Baseline Studies Comprehensive family and medical histories were compiled on all children selected for both the control and rehabilitation groups. Extensive biochemical and laboratory workups were performed. Teams of specialists from the special project staff representing pediatrics, neurology, psychiatry, orthopedics, dentistry, psy- chology, ophthalmology, physical medicine, and speech and hear- 22 ''ing, researched each child in the study, developing a profile of specific areas of disability, problems, and needs. A prescriptive plan of management was developed for each child. The team evaluations by the same specialists for each child were repeated annually, documenting which recommendations had been carried out, what growth had or had not taken place, and what progress had been made. Rehabilitation Efforts During the third phase of the project, the 60 children in the con- trol group were cared for by the staff in the institutions in which they were housed, utilizing whatever resources:and services were available to these institutions to meet their needs. For the 60 children in the rehabilitation group, all at the same institution, an intensive program supervised by the special multidisciplinary project team was set up to carry out the prescriptive manage- ment plan initially devised by this same group. Special consult- ants in areas such as cardiology and endocrinology were made available, and some staff necessary to carry out prescribed man- agement regimes were added (motor therapy, physical therapy, and speech therapy). Team members reviewed the rehabilitation group at least twice a month during the third phase of the project to evaluate or modify the course of treatment. Results At the end of the 3-year period, 105 children remained in the pro- gram, 54 in Group R and 51 in Group C. Morbidity was high in the 1969 examination; among 105 chil- dren, 910 medical problems were diagnosed. In the pediatric examination, 54.8 percent of the children had at least 1 diagnosed problem. For the other specialties, the percentage of children with diagnosed problems was: Orthopaedics 93.1% Neurology 80.8 Ophthalmology 86.5 Speech 98.0 Dentistry 98.1 At the end of the 3-year treatment period, the number of pedi- atric problem diagnoses decreased almost threefold (from 29 to 10) in Group R, whereas in Group C the decrease in the number of pediatric problem diagnoses was not significant (49 to 42). 23 ''The percentages of children needing treatment from each kind of specialist were as follows: Group R (N-54) Group C (N-51) 1969 1971 1969 1971 Pediatrics 47.2% 17.0% 62.7% 62.7% Orthopaedics 87.0 79.6 100.0 100.0 Neurology 17.4 75.5 84.3 84.3 Ophthalmology 81.1 85.0 92.2 91.8 Speech 98.0 88.5 98.0 96.0 Dentistry 100.0 94.4 96.1 96.1 The number of children in Group R with at least 1 problem de- creased in all specialties except ophthalmology. In Group C, the number of medical problem diagnoses remained the same or de- creased by 2 percentage points. The investigators suggest that the increased number of ophthalmological diagnoses in Group R and Group C in 1971 appeared to result from the fact that in 1971 some children were more accessible for examination, and morbidity was therefore more readily apparent. The number of children with chronic and recurring illnesses of the internal organs decreased in Group R. They had 878 days of acute illness in 1969 and 222 days in 1971. Group C children were acutely ill for 441 days in 1969 and 778 days in 1971. In the neurological examination, Group R and Group C were compared on 10 variables: paresis of limbs (upper and lower and right and left sides), muscular tonus, physiological and spas- tic reflexes, and muscular atrophy of upper and lower limbs, right and left sides. Statistically significant differences between Group R and Group C emerged on 3 variables: paresis of upper and lower limbs on the right side, and muscular atrophy. The chil- dren in the control group showed marked muscle deterioration and paresis after 3 years, while Group R children showed no change. The rehabilitated group showed statistically significant im- provement in muscle strength and decreases in contractures. There was no statistically significant differences between the two groups for sitting, standing, and walking, although more children in the rehabilitated group performed these functions adequately. In 1969 there were 123 grand mal epileptic seizures in 4 chil- dren of Group R. In 1971, 5 children had only 73 seizures. In 1969, 10 children in Group C had 257 seizures, and in 1971, 9 children had 270 seizures. Thus, in Group R, in the third year of rehabili- tation, the number of seizures had decreased by almost half, whereas Group C had a slight increase. 24 ''Group R children showed significantly greater improvement in spontaneous speech, articulation in mimicking, and repetition than Group C children. No significant differences were found for the variable “speech and voice” (including intonation, rate of speech, singing, and manner of breathing). In the 1969 speech examination, 1 child in each group was considered normal. In 1971, there were 6 normal speakers in Group R and 2 in Group C. In both groups, the percentage of children for whom it was impossible to determine visual acuity was very high. In 1969 the percentage was 76 percent in Group R and 86 percent in Group C. In 1971, this percentage decreased to 66 percent in Group R and to 84 percent in Group C. The percentage of children with normal visual acuity in Group R was 17 percent (right and left eyes) in 1969, and 21 percent (right and left eyes) in 1971. In Group C the percentages were 8 percent (right eye) and 10 percent (left eye) in 1969; 10 percent (right eye) and 12 percent (left eye) in 1971. The investigators noted that the acceptance of corrective lenses by these severely retarded children was surprisingly good. The dental examination of 1971 showed that the number of chil- dren with caries and gum pathology, including necrosis, decreased in Group R and increased in Group C. In 1969 the average IQ for Group R was 18.16, for Group C, it was 12.59.* This difference between the two groups was statis- tically significant. During the 3-year period, the average IQ did not show a statistically significant change for either group. Using the Doll-Vineland Scale for measuring social maturity, in 1969 the average Social Maturity Quotient was 24.03 for Group R and 17.81 for Group C. This difference was not statis- tically significant. In 1971 the SMQ increased significantly for Group R but remained unchanged for Group C. The greatest changes were observed in the children whose mental development was between 20 and 50 IQ points. In Group C there were no changes in SMQ for any level of mental retardation. The study utilized a test of motor ability developed by Dr. Kostrzewski, for children from birth to 5 years old. Average motor ability for both groups increased to a statistically sig- nificant degree over the 3-year period. The improvement in Group R, however, was much greater than for Group C. Psychiatric examination revealed that of 18 variables, statis- tically significant differences were found on 11. On the variables of psychomotor activity and mood disturbance, Group R improved and Group C deteriorated. Group R improved its orientation, * The level of mental development (IQ) was assessed either with use of Psyche-Cattel or Terman-Merrill Scales. £ 25 ''understanding and carrying out of orders, motor excitation, affect disturbances, autoaggression, nightmares, and sleep, while Group C remained the same on these variables. For motor-stereotyped movements and masturbation, Group R remained the same and Group C deteriorated. No statistically significant changes were noted for spontaneous speech, negativism, aggression, disturbances of appetite, dis- turbed eating behavior, micturition and defecation, or night bed wetting. Observations The investigators believed their most important observation from this research was that severely retarded children could make bet- ter social adjustments when they were medically rehabilitated. They discovered that in many cases the morbidity in these chil- dren had existed for a long time and its intensity depended at least to some extent on its duration. This was particularly true in neurological and/or orthopedic findings such as paresis, contrac- ture, and other defects, and in psychiatric, opthalmological and dental morbidity. The researchers also believed that severe and frequent seizures were one of the major roadblocks to rehabilitation. They felt that more speech and physical therapy than was provided for the rehabilitation group would have been useful. They found that hospitals, orthopedic surgeons, and anesthetists were usually un- willing to deal with severely retarded children, and therefore some of the operations recommended were not performed. During the study, the project staff learned much about the extensive medical needs of severely retarded children and how these needs could be met. The attitude of the staff in the institu- tion where the project was carried out also changed in a positive direction. Prejudices toward the children decreased and job- related morale improved. Parental visits increased, and the in- vestigators attributed this to the more dynamic atmosphere. Classes and lectures designed to facilitate the research project also improved the medical practice of institution and research personnel. The investigators observed that although they were chiefly concerned with the many medical needs of the retarded children in the project, their efforts resulted in a greater apprecia- tion of the nonmedical needs of the children. Conclusions The project staff concluded that the incidence of morbidity and mental disturbance in severely retarded children is high, and that 26 ''the existing system of medical care does not guarantee the provi- sion of services to meet all their needs. These needs cannot be met by a single physician or specialist, but require the services of a team of specialists (pediatrician, neurologist, psy- chiatrist, orthopedist, speech therapist, opthalmologist, dentist, and psychologist). Specific Recommendations 1. All children should be examined by a team of specialists be- fore institutionalization, and recommendations for medical and rehabilitative treatment made at that time. 2. To meet the needs of these children, more specialists will be required, and the existing services of a number of clinics, hospitals, and regional and specialized health service units must be made available to the institutions. 3. Institutionalized children should be re-examined at least once a year to reevaluate their course of treatment and management. 4, Physicians and staff of institutions should be systematically trained in the rehabilitation of the mentally retarded. Training efforts can be enhanced by encouraging special research programs and by developing channels of communication and cooperation between institutions and special education programs. 5. Recommendations for the child’s emotional development must accompany any medical rehabilitation effort and should in- clude a wide range of social activities and experiences. 6. Further studies should be conducted to assess the value and effectiveness of multidisciplinary rehabilitation. The impact of such factors as time of intervention, age of child, level of child’s development, clinical state of child, and duration of treatment need to be explored. 7. Special attention must be directed to very young retarded children to prevent intensification and consolidation of their physi- cal disabilities. 27 ''THE HOSPITALIZATION OF YOUNG HAIFA CHILDREN S. T. WINTER, M.D., Pediatric Department, Rothschild Hospital and Aba Khoushy School of Medicine, Haifa, Israel, 1971. Grant No. CB-Isr-19. The purpose of this study was to seek parameters of the family and neonate in order to identify those newborns who had an above average risk of being hospitalized during infancy. The investi- gators postulated that defining those groups with a high risk of later hospitalization would allow agencies to allocate child health services more productively. Haifa, the district from which the study sample was drawn, is the main port of Israel on the Mediterranean Sea. A network of 36 neighborhood centers in Haifa offer prenatal care to pregnant women and regular health supervision of infants during the first 2 years of life. Maternity hospitalization costs are borne by the State. Each employed mother has 12 weeks’ paid leave after child- birth, and all mothers receive a maternity stipend. Mother and child health centers are staffed by public health nurses and periodic examinations by physicians are available. There is no fee, and the clinics are attended by more than 90 percent of the families in the area. Young children, when ill, are admitted only to the Rothschild and Rambam Hospitals. The Rothschild Hospital has a general pediatric ward of 50 beds, and the Rambam Hospital has 2 general pediatric wards and a surgical ward for children, with a total of 96 beds. Haifa thus has 146 hospital beds for children. For this study, a cohort of 5,243 newborn infants was selected from Rothschild, Rambam, and Elisha Hospitals. The cohort was selected between January 1, 1965 and November 4, 1966, when 11,310 infants were born at the three participating hospitals. Newborns with poor prospects of survival (because of birth in- jury, very low birth weight, or malformations), those being con- sidered for adoption, and those from families living in outlying areas were excluded. Information collected at birth included demographic and social data on both parents, and the sex and birth weight of the infant. Records of all children admitted to Haifa hospitals were reviewed weekly to determine if any cohort children had been hospitalized. Experience at Haifa hospitals over the last 16 years led investi- gators to assume that very few cohort infants left Haifa or were admitted to pediatric wards in other towns. 28 ''Characteristics of Hospitalized Children In the first 2 years of life, 767 study infants had 1,078 admissions to a hospital. Of these, 585 had a single admission to a hospital, and 182 (23.7 percent) had from 2 to 20 admissions. The number of hospitalizations decreased as the infants in the cohort grew older. There was a sharp drop in the number of hos- * pitalizations among infants older than 9 months and another sharp drop after 18 months. Factors Associated with Hospitalization of Haifa Children Factors significantly associated with hospitalization of the Haifa cohort included: male sex of infant; mothers older than 39 years; fathers younger than 20 years; mothers who immigrated to Israel between 1952-57; longer marriages; birth weight below 2,250 grams; limited education of parents; children of second or later marriages; increasing birth order; number of stillbirths and neonatal deaths mother had experienced; consanguinous mar- riages; non-Jewish mothers; children whose parents were not born in Israel; children whose parents were born in Asia or Africa (rather than Europe or America) ; Jews from rural areas; non- Jewish residents in Haifa; and children born during November through February. Several variables associated with hospitalization were also as- sociated with each other. Parents with many children were also older and had been married longer—factors contributing to in- creased risk of the child’s hospitalization. To study the effect of each factor separately, multivariate analysis was used. It was found that the most important single factor associated with the hospitalization of a child was increasing birth order. Other fac- tors, in order of decreasing significance, were: male sex; limited education of the mother (less than 4 years of education) ; birth weight less than 2,250 grams; Jewish mothers born in Asia or Africa; and mothers younger than 24 years. On the basis of these risk factors, investigators could predict approximately 43.3 per- cent of the initial hospitalizations. Most of the diagnoses associated with hospitalization were en- vironmental in origin and potentially preventable. There were 1,977 clinical diagnoses for 1,078 episodes of hospitalization. In- fections (1,174), external causes and accidents (67), and nutri- tional deficiencies (273) made up 1,514 of the clinical diagnoses. The most frequent infections were respiratory infections and otitis media (648) and diarrhea (345). From birth to 13 months of age, 234 (33.8 percent) of hospitalized children had diarrhea 29 ''as a primary or associated diagnosis. After 18 months of age, only 74 (6.8 percent) of hospitalized children had diarrhea. AlI- though 273 children had nutritional deficiencies, in only 0.4 per- cent was this the primary cause of admission. The mean body weight of infants at initial admission was above the 90th percentile of modified Harvard standards. The mean hemoglobin value for all age groups from 2 to 23 months was be- ° low 11 grams and thus “anemic” according to the World Health Organization definition. Of the 693 children hospitalized before they were 18 months old, 160 (23.1 percent) had hemoglobin values of 9 grams or less. During 81 (7.5 percent) of the 1,073 hospitalizations, 1 or more hospital infections appeared. Fifty-six children were readmitted 77 times because of infections which were apparently acquired during previous hospitalizations, but that appeared within 10 days after discharge from the initial hospitalization. Twenty-six of the hospitalized cohort children died in the hos- pital. A review of all death certificates in the Haifa region re- vealed four additional cohort deaths at home. Nine deaths were due directly to congenital conditions, and six other deaths were due to infections possibly acquired in the hospital. Only one death was categorized as a “crib death,” confirming the theory that this is uncommon in Israel. The mortality rate for the cohort was 5.7 deaths per 1,000 births; 3.4 deaths per 1,000 hospitalized children ; and 2.4 deaths per 1,000 episodes of hospitalization. Rehospitalization of Children Of the 767 hospitalized cohort children, 182 were admitted to the hospital a total of 493 times. Thus 311 of the total 1,078 admis- sions were second or subsequent hospitalizations. Conditions directly related to a previous hospitalization leading to rehospitalization include: 1. A congenital, chronic, or recurrent condition; conditions re- quiring repeated surgical procedures; sequelae and complications of conditions present during the previous hospitalization. 2. An apparently direct continuation of an illness present dur- ing a previous hospitalization. This occurred in 27 hospitaliza- tions. 3. A hospital infection manifesting itself after return to the home. Of the 311 rehospitalizations, 174 (55.9 percent) were con- sidered to be related to previous hospitalizations. 30 ''Known attributes of the study infants which were significantly associated with rehospitalization included: low birth weight; mothers with less than 4 years of education; increasing birth order; number of stillbirths and neonatal deaths the mother had experienced ; consanguinity between parents; Jewish mothers born in Africa; non-Jewish mothers; mothers not born in Israel; and non-Jewish mothers who reside in Haifa. Conditions that were significantly related to rehospitalization were: crowding at home (room density of 2.5 persons or more per room); family size larger than 5 persons; 3 or more children under 10 years of age in the home; younger age of rehospitalized infant; children with body weight under the 80th percentile; and children who were first admitted to the Rambam Hospital. Factors that did not affect the likelihood of a child’s re- admission to the hospital were: hemoglobin level; a diagnosis of malnutrition, rickets, or anemia; breast feeding; type of diag- nosis at initial admission; length of time in initial hospitaliza- tion; whether or not an accident or hospital infection occurred; and month of initial admission. The utilization of available health services by families was studied by obtaining information on immunization status and hospitalization during the first 2 years of life of the older siblings of cohort children. The investigators found that immunization was so common that immunization status was of no value as an indicator of health service utilization. The hospitalization rates of the older siblings was also not a good indicator because of the small sample size (194). Conclusions and Recommendations From the multivariate analysis of factors in this study, the in- vestigators concluded that the following factors, in order of decreasing significance, were highly significant in determining the infant’s risk of admission to the hospital: increasing birth order, male sex, birth weight less than 2,250 grams, low maternal educa- tion, mother born in Asia or Africa, and maternal age of less than 25 years. The number of stillbirths and neonatal deaths the the mother had had, consanguinous marriage, place of residence, and the month and year of birth were not shown to be significant factors after multivariate analysis. The investigators concluded that “risk coefficients of hospitali- zation” could be useful to the health planner. The use of a risk coefficient of 0.20 and over on this population would have en- compassed only 23.3 percent of the population, but would include 31 ''43.3 percent of those initially hospitalized. Allocation of health services to this high risk group would represent a significant gain in efficient use of health care resources. The following publications resulted from this study: S. T. Winter, ‘The Male Disadvantage in Disease Acquired in Childhood,” Develop. Med. Child Neurol., 14:517, 1972. S. T. Winter, W. Mainzer, D. Muogbdo, A. Friedman, A. Bender- ley, and M. Zeltzer, “The Incidence of Cross-Infection Among Hospitalized Children,” Public Health, 16:7, 1973. (Hebrew) S. T. Winter and N. E. Emetarom, “Sudden Infant Death: An Enquiry Into Its Frequency in Israel,” Isr. J. Med. Sci., 9:447, 1973. S. T. Winter and A. Bloch, “Sudden Infant Deaths in Israel,” Forensic Science, 2:384, 1973. A. M. Davies and S. T. Winter, “Admission of Infants to Hos- pital: Some Recent Prospective Studies,” Child Health in Israel, 9:24, 1973. 8. T. Winter, “The Age Factor in Acute Diarrhea During Child- hood,” Clinical Pediatrics, 18:17, 1974. S. T. Winter, W. Mainzer, A. Friedman, D. Muogbdo, A. Bender- ley, and M. Zeltzer, “Patterns of Disease in Hospitalized Infants: Changes Over a Decade,” Harefuah, 86:242, 1974. (Hebrew) S. T. Winter and P. Lilos, “Prediction of Hospitalization During Infancy: Scoring the Risk of Admission,” Pediatrics, 53:716, 1974. 32 ''* we m7 FF ss rr 3 previous publications The Maternal and Child Health Service Reports on Research To Improve Health Services for Mothers and Children. DHEW Pub- lication No. (HSM) 73-5116 The Care-By-Parent Unit for Hospitalization of Children Vernon L. James and Melvin J. Lerner, University of Kentucky Predicting and Enhancing Compliance in aC & Y Project Marshall H. Becker, Johns Hopkins University Adolescent Health in Harlem Ann F. Brunswick and Eric Josephson, Columbia University The Atlanta Adolescent Pregnancy Program John D. Thompson and James L. Waters, Jr., Emory University Analysis of Programs for Pregnant Adolescents John J. Dempsey, Johns Hopkins University The Health and Medical Care of Children under Title 19 (Medicaid) Helen M. Wallace, Hyman Goldstein, and Allan C. Oglesby, University of California, Berkeley Validity of 5-Year Prophylaxis in Noncardiac Rheumatics John C. MacQueen, Iowa State Services for Crippled Children Radiographic Study of Hip Dysplasia in Cerebral Palsy J. V. Basmajian, Emory University Analysis and Classification of Infant Food Composition Samuel J. Fomon and Thomas A. Anderson, University of Iowa Effectiveness of Counseling at the Time of Pregnancy Tests Marvin L. Dietrich, University of Nebraska MCH Research Series No. 2: Research To Improve Health Services for Mothers and Children. DHEW Publication No. (HSA) 74-5120 Family Health Care: A Study of its Meaning in Practice William Schmidt and Helen D. Cohn, Harvard School of Public Health Automated Screening Technique for Vitamin C Assay Requiring Small Quantities of Blood Philip J. Garry and George M. Owen, Ohio State University Galactosemia Screening of the Newborn in the Community Morris London, North Shore Hospital, Manhasset, New York Congenital Anomalies of the Hand Adrian E. Flatt and John C. MacQueen, University of Iowa Pregnant Adolescents 33 ''Michael Baizerman, Cynthia Sheehan, David L. Ellison, and Edward R. Schlesinger, University of Pittsburgh A National Study of Comprehensive Programs for Pregnant Ado- lescents Michael Baizerman, Cynthia Sheehan, David L. Ellison, Haumei Ko, and Edward R. Schlesinger, University of Pittsburgh Operational Research in Maternity Care of Adolescents, Part I David L. Ellison, Joyce M. Fuchs, Dolores B. Glaser, Josephine Hatley, Haumei Ko, and Edward R. Schlesinger, University of Pittsburgh Operational Research in Maternity Care of Adolescents, Part IT Operational Research in Maternity Care of Adolescents, Part III Operational Research in Maternity Care of Adolescents, Part IV Enhancement of Recreation Service to Disabled Children Doris L. Berryman, Annette Logan, Dorothy Lander, and Bernard Braginsky, New York University MCH Research Series No. 3: Research To Improve Health Services for Mothers and Children. DHEW Publication No. (HSA) 74-5121 The Kauai Pregnancy and Child Study Jessie M. Bierman, Emmy E. Werner, and Fern E. French, University of California, Berkeley and Davis Child Amputees: Disability Outcomes and Antecedents, Part I G. E. Ned Sharples, University of Michigan Child Amputees: Disability Outcomes and Antecedents, Part II G. E. Ned Sharples and R. L. Crawford, University of Michigan Marital Patterns and Fertility Among New Orleans Negroes Ann Fischer and Virginia Ktsanes, Tulane University Nutritional Resources of Young, Pregnant, Negro and Puerto Rican Women Living in New York Hughes Bryan, Rebecca Broach Bryan, Barbara Lahab, and Nexy A. Quinones-Toyos, University of North Carolina Programmed Instruction in Prenatal and Infant Care Dale A. Cruise, University of Nebraska Barriers to Maternal and Child Health in New Haven Yale University MCH Research Series No. 4: Research To Improve Health Services for Mothers and Children. DHEW Publication No. (HSA) 74-5122 Repeat Abortions in New York City: 1970-72 Edwin F. Daily, Nick Nicholas, Freda Nelson, and Jean Pakter, New York City Department of Health 34 ay wl ''eee “= Perinatal Casualty Report: Kansas 1964-65 Irvin G. Franzen, Kansas State Department of Health Maternity Care and Perinatal Mortality: The Southeast J. Richard Udry, University of North Carolina A Study of Preparation of Infant Formulas: A Medical and So- ciocultural Appraisal Norman Kendall, Victor C. Vaughn, III, and Aysun Kusakcioglu, Temple University Family Risk Indices and Child Care Services Ruth M. Butler, Massachusetts Department of Public Health Psychological Assessment of the Preschool Child Leon A. Rosenberg, Johns Hopkins Hospital A Multidimensional Study of Handicapped Children Aubrey L. Ruess and Edward F. Lis, University of Illinois Study of a Legged Walker for Limb-Handicapped Children Charles O. Bechtol and Mary L. Brenneman, University of California, Los Angeles Analysis of Effectiveness of Treatment for Orthopedic Conditions of Infancy and Childhood as Commonly Seen in an Orthopedic Clinic Robert C. Dickerson, University of Rochester Social and Economic Aspects of Handicapping Conditions of Fetal and Perinatal Origin Helen M. Wallace, University of California, Berkeley MCH Research Series No. 5: Research to Improve Health Services for Mother and Children. DHEW Publication No. (HSA) 74-5123 Assessment of Family Planning for High-Risk Patients David L. Barclay, Tulane University Family Planning Services and AFDC Families Joseph Goldman, U.S. Department of Health, Education, and Welfare, and Leonard S. Kogan, City University of New York The Planned Family: Goal of Family Planning Mayhew Derryberry, Dorothy Belcher, and Mary Lee Austin, University of California Prenatal Care Personnel Utilization Project Edward R. Schlesinger, Willa Dean Lowery, Dolores B. Glaser, Margaret D. Milliover, and Sati Mayundar, University of Pitts- burgh Diagnostic-Therapeutic Studies of High Risk Pregnancy Martin L. Stone, New York Medical College Infant and Perinatal Mortality Rates by Age and Color, United States, Each State and County, 1951-55, 1956-60, 1961-65 35 ''Maternal and Child Health Project, the George Washington University, and the Children’s Bureau, U.S. Department of Health, Education, and Welfare Health and Medical Care of Mothers and Children in an Urban Community Elinor F. Downs, Columbia University Effects of Clinic Structure on Pediatrician’s Role Constance A. Nathanson and Marshall H. Becker, Johns Hop- kins University Nutritional Studies of Preschool Children C. M. Owen, P. J. Garry, K. M. Hedges, J. E. Lowe, and W. A. Zacherl, Ohio State University Children’s Lower-Extremity Orthotics Problems V. T. Inman and W. H. Henderson, University of California ee ee yy U.S. GOVERNMENT PRINTING OFFICE: 1975 O—575—936 36 '' '' '' PUBLIC HEALTH LIBRARY OCT 4 1983 €029174228 '' U.S. DEPARTMENT OF _ HEALTH, EDUCATION, AND WELFARE Public Health Service _ Health Services Administration - Bureau of Community Health Services - Rockville, Maryland 20852 OFFICIAL BUSINESS Penalty for Private Use $300 DHEW Publication No. (HSA) 75-5129 eet Postage and Fees Pai U.S. Department of HEW - HEW 396 ''