Adolescent
Gestational
Weight
Gain
and
Birth
Weight
Catherine Stevens-Simon, MDX; Elizabeth R. McAnarney, MD*; and Klaus
J.
Roghmann, PhD*ABSTRACT. Objective. To examine the relationship
among maternal age, prepregnancy weight, gestational weight gain, and birth weight in 141 low-income black adolescents and their infants.
Study sample. One hundred forty-one consecutively
enrolled, low-income, black adolescents who entered
pre-natal care prior to their 23rd week of gestation, were free of chronic diseases, took no regular medications, had no
known uterine anomalies, and gave birth to one live
neonate.
Results. After controlling for prepregnancy weight
and other potentially confounding variables, we found a significant relationship between gestational weight gain and infant birth weight among younger adolescents (<16
years old at conception), but not among older adolescents
(16 through 19 years old at conception); younger adoles-cents contributed more of their gestational weight gain to their fetuses than did older adolescents. Among younger adolescents the rate of maternal weight gain during the
entire gestation was significantly correlated with birth
weight (r = .40; P < .01), whereas for older adolescents only maternal weight gain during the second half of
ges-tation was significantly correlated with birth weight
(r = .25, P < .05).
Conclusions. The data do not support the thesis that
younger adolescents compete with their fetuses for
nu-trients; in fact, younger study adolescents transferred more of their gestational weight gain to their fetuses than
did older adolescents. Pediatrics 199392:805.-809; adoles-cents, gestational weight gain, birth weight, pregnancy.
ABBREVIATION. NCPP, National Collaborative Perinatal Project.
Maternal weight gain during pregnancy
(gesta-tional weight gain) is a particularly important
deter-minant of the birth weight of infants of adolescents. The total amount of gestational weight gain needed to ensure optimal fetal growth during adolescent preg-nancy, however, is disputed?5 Gestational weight gain is especially important for small women, for
whom the optimal weight gain exceeds that for large
women.6 Young pregnant adolescents are usually smaller than are older women; that is, they often have lower prepregnancy weights and are shorter.5 Al-though smaller adults transfer more of their gesta-tional weight gain to their fetuses than do larger women,7 it has been reported that younger adoles-cents (although smaller) transfer less of their
gesta-From the *Divisions of Adolescent Medicine and Ceneral Pediatrics, Uni-versity of Rochester Medical Center, Rochester, NY; and Division of
Ado-lescent Medicine, University of Colorado Health Science Center, Denver. Received for publication Mar 1, 1993; accepted Jun 3, 1993.
Reprints not available.
PEDIATRICS (ISSN 0031 4005). Copyright © 1993 by the American Aced-emy of Pediatrics.
tional weight gain to their fetuses because they are
still growing and compete with their fetuses for
nu-trients.3
The pattern of gestational weight gain is also im-portant. During the first haif of gestation, most ges-tational weight gain goes to the mother; inadequate weight gain during this time may compromise the development of the uteroplacental vascular bed.8
During the second half of gestation, most gestational
weight gain is contributed to the fetus. Among
well-nourished females, weight gain during the second
haif of gestation is the most important determinant of
infant birth weight. Among small or undernourished
women in developing countries, however, the small size of their infants has been associated with
mad-equate weight gain during the first half of gestation.
We question whether young adolescents are similar to
these women in underdeveloped countries as they are small and some may be relatively undernourished.#{176}
This study focuses on the relationship of maternal age, prepregnancy weight, gestational weight gain, and birth weight in an adolescent population.
HYPOTHESES
1. Younger adolescents (<16 years old) transfer less gestational weight gain to their fetuses than do older adolescents (16 through 19 years old) when confounding variables are controlled.
2. The rate of gestational weight gain during the first
half of pregnancy is more predictive of birth weight for the infants of younger adolescents than for the infants of older adolescents.
Subjects
METhODS
The data were collected as part of the Rochester Study of Ado-lescent Pregnancy, a 3-year prospective study conducted between 1986 and I989.h113 jj[ study subjects were consecutively enrolled and entered prenatal care prior to their 23rd week of gestation, were free of chronic diseases, took no regular medications, had no known uterine anomalies, and gave birth to one live newborn. All
study subjects were black and low-income (Hollingshead N or
V)14; the majority (88%) were primiparous. Thus, the relationship of gestational weight gain to neonatal outcome was studied in a healthy, well-cared-for population. Extreme care was directed to-ward standardizing all data collection, particularly the anthropo-metric data.
There were 169 consecutive adolescent subjects (<20 years of age at conception) who entered the study. Of the 169, 141 (83.4%) completed the entire study protocol. There were no significant differences in mean maternal age, socioeconomic status, school completion, and parity between the study subjects (n = 141) and those who left the study prior to delivery (n = 28). The study protocol was approved by the Committee on Investigations In-volving Human Subjects at the University of Rochester Medical Center.
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Data Collection
Details of the procedures for data collection have been pub-lished previously.’3
Maternal Age. Maternal chronologic age at conception defined as the difference in years between the date of the last menstrual period and the mother’s date of birth.
Prepregnancy Weight. Prepregnancy weight was determined by mothers’ report of prepregnancy weight corroborated by school and/or medical records.’2
Gestational Weight Gain. Maternal weight was measured to the nearest 10th of a kilogram on a balance-beam scale at each prenatal visit.’2 The first weight was determined at enrollment into prenatal care and the last, at approximately I week prior to delivery.
Neonatal Outcome. Birth weight was measured within I hour of delivery; the neonates were weighed naked to the nearest 10th of a gram on a balance scale. Gestational age was calculated from the date of the mother’s last menstrual period by use of Naegele’s rule’5 and was verified by ultrasound and Dubowitz examina-tions.’6 A preterm infant was defined as an infant born prior to the 37th week of gestation.’7
Potentially Confounding Variables. Psychosocial, dietary, and health habits were elicited from interviews and standardized methods.
1. Psychosocial data: Data on socioeconomic status; living ar-rangements; family and peer relationships; personal, behav-ioral, school, and legal problems; stress (Newton’s 24-item ver-sion of the Cochrane and Robertson Life Events Scale); and a constructed variable of total number of environmental
stress-ors’8 and depression (Center for Epidemiologic Studies-Depres-sion Scale, the CES-D Scale)’9 were obtained both early and late in pregnancy.
2. Dietary habits: A dietitian inquired about cooking facilities, food availability, eating habits, and intake of specific nutrients twice during pregnancy.2#{176}
3. Health habits: Adequacy of prenatal care,2’ level of daily
activ-ity and exercise pattern, and substance use (seff-reported ciga-rette smoking, alcohol, and illicit drug use verified by urine testing for nicotine and commonly abused illicit drugs) were examined.
The occurrence of obstetric complications (such as pregnancy-induced hypertension, vaginal bleeding, and premature rupture of membranes) and medical problems (such as sexually transmitted diseases, anemia, and viral syndromes) was recorded throughout gestation.
Data Analysis
Total gestational weight gain was defined as the difference between the last weight of pregnancy and the prepregnancy weight. Because the duration of gestation affects both birth weight and gestational weight gain, total weight gain was “adjusted”
(standardized) to a 40-week gestational period by use of the
fol-lowing formula: actual weight gain plus (the average weekly weight gain after 26 weeks’ gestation times the difference in weeks between 40 weeks and weeks of gestation at delivery). The rate of “actual” weight gain per week of gestation was also calculated.
Both measures, the “adjusted” total gestational weight gain and the “actual” rate of gestational weight gain per week, were used in the analyses.
Individual patterns of weight gain were determined from
graphs on which individual maternal weight determinants were
plotted against gestational age. Weights extrapolated from these
graphs were used to calculate gestational weight gain during the
first and second halves of gestation.
Summary statistics were calculated for the range, distributions, means, and variances of all variables. Age was used primarily as a categorical variable, contrasting data of younger adolescents (<16 years old) and older adolescents (16 through 19 years old).
Independent t test and tests were used to test for differences
between these two age groups. Within each of these two age groups, and within the combined total sample, hierarchical regres-sions were used to estimate effect sizes of maternal variables on infant variables (birth weight and gestational age) and test them for significance. Maternal prepregnancy weight and age were in-troduced as the first step. All potentially confounding variables, that is, factors that were significantly correlated with birth weight, were introduced in step 2 (these included stress, urinary tract infections, toxemia, and premature rupture of membranes). Maternal weight gain was introduced in step 3.
RESULTS
Summary data on the background variables,
con-founding variables, gestational weight gain variables,
and infant outcome variables are presented in Table I. There were significant differences in the maternal age and prepregnancy weight of the younger and older adolescents. There were no significant differ-ences in confounding variables between younger and older adolescents. The mean “adjusted” total gesta-tional weight gain did not differ for the younger and older adolescents. The mean birth weight and mean
gestational age of the infants of younger adolescents
and older adolescents did not differ.
As shown in Table 2, a hierarchical regression
model was computed separately for the data of the 52 younger and the 89 older adolescents and their in-fants. When entered in step 1, prepregnancy weight was not a significant predictor of the birth weight of the infants of younger adolescents, but it was for the
TABLE 1. Summary Statistics for Key Variables*
Variables Younger
Adolescents (n =52)
Older Adolescents
(n= 89)
Total Sample (n = 141)
P
Background
Maternal age, y 14.6 (0.9) 17.6 (1.1) 16.5 (1.8) t
Prepregnancy wt, kg 59.4 (10.6) 62.8 (14.1) 61.5 (13.0) t
Confounding
Stress, % 31.7 27.3 29.0 NS
UTIs, % 1.9 4.5 3.5 N5
Toxemia, % 1.9 3.4 2.8 NS
PROM, % 9.6 13.5 12.1 NS
Cestational wt gain
“Adjusted” total gain, kg 14.9 (5.9) 13.9 (6.0) 14.3 (6.0) NS
Weekly rate, g 362 (150) 341 (152) 349 (151) NS
Infant outcome
Birth wt, g 3110 (595) 3116 (538) 3114 (558) NS
Gestation, wk 38.6 (2.8) 38.7 (2.2) 38.7 (2.4) NS
*Values represent mean (SD) or percent. Abbreviations: UTI, urinary tract infection; PROM, premature rupture of membranes; NS, not significant.
t P < .05, difference between younger adolescents and older adolescents.
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TABLE 2. Regression of Birth Weight and Maternal Variables* Birth We B ight, g SE P
Younger adolescents (n = 52)
Step I
Maternal age, y 25.8 10.3 NS
Prepregnancy wt, kg 11.4 8.0 NS
Step 2
Stress -545.7 279.9 .06
UTIs -233.0 609.8 NS
Toxemia 55.4 585.1 NS
PROM -184.2 266.5 NS
Step 3: “Adjusted” total wt gain, 38.2 14.1 .009
g/kg
Older adolescents (n = 89) Step 1
Age, y 54.0 43.1 NS
Prepregnancy wt, kg 9.9 3.5 .05
Step 2
Stress -120.6 179.7 NS
UTIs -773.0 253.7 .003
Toxemia -984.1 256.4 .000
PROM -344.5 140.7 .02
Step 3: “Adjusted” total wt gain, 5.6 7.9 NS
g/kg Total sample
Step I
Age, y 16.2 24.4 NS
Prepregnancy wt, kg 10.4 3.3 .002
Step 2
Stress -317.3 151.0 .04
UTIs -561.3 236.5 .02
Toxemia -736.1 252.1 .004
PROM -303.2 129.5 .02
Step 3: “Adjusted” total wt gain, 18.1 7.0 .01
g/kg
*U-fl, urinary tract infection; PROM, premature rupture of mem-branes; NS, not significant.
infants of older adolescents. In step 2, most of the
confounding medical variables did not have strong
effects on the birth weight of the infants of younger
adolescents, but had strong effects on the birth weight
of the infants of older adolescents. The confounding psychosocial variable “stress” had a nearly significant impact on the birth weight of the infants of younger adolescents, but not on that of the infants of older
adolescents. In step 3, there was a significant and
strong effect of “adjusted” total weight gain on birth weight for younger adolescents (38.2 g/kg weight
gain; SE = 14.1, P < .009), but not for older adolescents
(5.6 g/kg weight gain; SE = 7.9, not significant). The
first hypothesis that younger adolescents transfer less
gestational weight gain to their infants than do older
adolescents, therefore, was refuted. A hierarchical
re-gression model was also computed substituting
ges-TABLE 3. Correlations Between Rate of W per Week) and Birth Weight
eight Gain (Grams
Birth Weight Younger adolescents (n = 52)
Rate of total weight gain Weight gain (1st half of pregnancy) Weight gain (2nd half of pregnancy) Older adolescents (n = 89)
Rate of total weight gain Weight gain (1st half of pregnancy) Weight gain (2nd half of pregnancy)
.40k .24 .22 .20 .03 .25t
*Significant at P < .01 (two-tailed).t Significant at P < .05
(two-tailed).
tational age for birth weight. There was no significant
relationship among prepregnancy weight, gestational weight gain, and gestational age.
Zero-order correlations between the rate of
gesta-tional weight gain and birth weight are presented in
Table 3. Gestational weight gain during the entire
pregnancy (rate of total weight gain) was significantly
correlated with the birth weight of the infants of younger adolescents, but not with the birth weight of
the infants of older adolescents. Only the rate of
ges-tational weight gain in the second half of pregnancy
was significantly correlated with the birth weight of
the infants of older adolescents. Thus, hypothesis 2 is partially supported; the rate of gestational weight gain during the entire pregnancy was the best
pre-dictor of the birth weight of infants of younger
ado-lescents. The rate of gestational weight gain did not correlate significantly with gestational age among
ei-ther younger or older adolescents.
DISCUSSION
Both younger and older black adolescents in this
study had adequate prepregnancy weights, had
ad-equate gestational weight gains, and had average-size
infants (Table 4). As a group, the adolescent mothers’
mean prepregnancy weight was 61.5 kg, their mean
gestational weight gain was 14.3 kg, and the mean
birth weight of their infants was 3114 g. All study
adolescents received adequate and sustained prenatal
care.
There was an increase of 38.2 g of birth weight for each kilogram of “adjusted” total weight gained by younger adolescents compared with an increase of 5.6 g for each kilogram gained by older adolescents when we controlled for significant confounding variables.
This was a surprising finding, as on the basis of
pre-vious studies in the literature, we hypothesized that younger adolescents would contribute less of their gestational weight gain (rather than more of their
ges-TABLE 4. Maternal Size, Gestational Weight Gain, and Birth Weight: Rochester and NCPP Studies*
Rochester (1986-1989) NCPP (1959-1965)
<16y I6Throughl9 y <16y l6Throughl9y
Prepregnancy wt, kg 59.4 ± 10.6 62.8 ± 14.1
Height, cm 160.1 ± 6.3 162.8 ± 6.8
Gestational wt gain, kg 14.9 ± 5.9 13.9 ± 6.Ot
Birth wt, g 3110 ± 595 3116 ± 538
54.3 57.4
159.3 160.9
10.3 9.8
2954.2 2982.8
*Data are from black adolescents only and represent mean ± Perinatal Project.t Adjusted for length of gestation.
SD. NCPP, National Collaborative
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1. Stevens-Simon C, McAnarney ER. Adolescent maternal weight gain and low birthweight: a multifactorial modeL Am JClin Nutr. 1988;47:948-953
2. Horon IL, Strobino DM, MacDonald HM. Birth weights among infants
born to adolescent and young adult women. Am IObstet Gynecol. 1983; 146:444-449
3. Naeye RL. Teenaged and pre-teenaged pregnancies: consequences of the fetal-maternal competition for nutrients. Pediatrics. 198L67:146-150
4. Frisancho AR, Mates J, Flegel P. Maternal nutritional status and ado-lescent pregnancy outcome. Am IClin Nutr. 198330:739-746
5. Cam SM, Petzold AS. Characteristics of the mother and child in teenage pregnancy. AJDC. 1983;137:365-368
6. Food and Nutrition Board, Institute of Medicine, National Academy of
Sciences. Nutrition During Pregnancy. Washington, DC: National Acad-emy Press; 1990
7. Winikoff B, Debrouner CH. Anthropometric determinants of birth weight. Obstet Gynecol. 198158:678-.684
8. Rosso P. Nutrition and maternal fetal exchange. Am IClin Nutr. 1981;
34:744-755
9. Susser M. Prenatal nutrition, birthweight, and psychological
development: an overview of experiments, quasi-experiments, and
tational weight gain) to their infants than did older adolescents.3’4 It has been hypothesized by others that
younger adolescents compete with their fetuses for
nutrients because the younger adolescents are smaller
and may still be growing. We found no evidence of
this “competition for nutrients” premise from our
data.
Since the data supporting the “competition for
nu-trients” theory was from a substudy of the National
Collaborative Perinatal Project (NCPP), we compared
the anthropometric data of the mothers and their in-fants from that study with data from our study.5 We found differences in the mean prepregnancy weight,
gestational weight gain, and mean birth weight when we compared the data of the youngest adolescents
and their infants from each study. As noted in Table 4, younger Rochester adolescents were
approxi-mately 5.1 kg heavier when they became pregnant
and gained approximately 4.6 kg more during
ges-tation than did the younger adolescents in the NCPP
group. The infants of the younger Rochester adoles-cents were approximately 156 g heavier than were the
infants of the younger NCPP mothers.
Younger Rochester adolescents, because of their relatively greater prepregnancy weight in contrast to the younger NCPP adolescents, may function more
like “small” adults than as undergrown adolescents. That is, the Rochester and the NCPP populations were
anthropometrically different when they entered their
pregnancies. Nearly 30 years have intervened,
how-ever, between the performance of these two studies
and we know adolescents in general are larger today than they were in past decades. Thirty years ago, younger, smaller adolescents may have indeed
com-peted with their fetuses for nutrients.3’4
The anthropometric determinants of birth weight
for both Rochester younger and older adolescents
were nearly identical with those reported for a group
of healthy, middle-upper socioeconomic status adults
bearing infants of greater than 38 weeks’ gestation.7
The younger, smaller Rochester adolescents
de-pended on their gestational weight gain to nourish
their fetuses, much as did the adults who were “low weight-for-height” for whom gestationalweight gain,
and not prepregnancy weight, was significantly
cor-related with birth weight (partial correlation = .291,
P < .01). In contrast, the older, heavier Rochester
ado-lescents depended on their prepregnancy weight to
nourish their fetuses much as did the adults who were
“medium weight-for-height,” for whom
prepreg-nancy weight, and not gestational weight gain, was
significantly correlated with birth weight (partial
cor-relation = .313, P < .01). Thus, both the younger Roch-ester adolescents and the low weight-for-height adults who start pregnancy smaller are more likely to rely on their gestational weight gain to nourish their
infants rather than on their pregnancy weight; in
con-trast, both the older Rochester adolescents and the
medium weight-for-height adults who start
preg-nancy larger are more likely to rely on their
prepreg-nancy weight to nourish their infants.
The younger Rochester adolescents also depended on their weight gain throughout pregnancy and not
just during the second half of pregnancy. In part, this
may be in an effort in the first half of gestation to make
up for their smaller prepregnancy size as weight gain early in pregnancy is more likely to go to the mother. The importance of nutrition throughout pregnancy for the fetus of the younger adolescent also suggests the need for nutritional intervention early in
preg-nancy and for close attention to the nutritional status
of younger adolescents throughout the gestation. Even though adolescents today begin their
pregnan-des better nourished than they did in the 1960s, they
still may not reap the maximal benefit from
nutri-tional programs initiated late in gestation.
The Rochester study adolescents were
well-nourished and entered prenatal care early and
at-tended consistently. We were most likely studying a group of healthy adolescents who start pregnancy
small, but well-nourished. Conditions were ideal to
investigate the ultimate ability of even the youngest adolescents to provide their fetuses nutrients and to
protect their fetuses against possible biologic and/or
psychosocial stressors. There were stringent medical exclusion criteria so we were able to investigate the
pure relationship between gestational weight gain
and neonatal outcome independent of issues relating to access to care and major prenatal complications. Even the youngest adolescents who received ad-equate prenatal care were able to nourish their fetuses efficiently and effectively.
It is known that the greatest effect of prenatal care on birth weight occurs in the youngest
adoles-cents.24’ Perhaps the effects of prenatal care are
me-diated through better nutrition and better gestational
weight gain for the youngest adolescents that is then
contributed to the fetus, resulting in improved birth
weight. Since all our study subjects were low-income
black adolescents, the data cannot be generalized to other groups.
CONCLUSION
There was no evidence to support the thesis that
well-nourished, younger black adolescents competed
with their fetuses for nutrients. Weight gain through-out gestation was important for the outcome of these
infants of these younger mothers.
ACKNOWLEDGMENTS
This work was supported by the Bureau of Maternal and Child
Health (Resources and Development grant MCJ-360534).
natural experiments in the past decade. AmJ Clin Nutr. 198134:784-803 10. Lederman SA. Physiological changes of pregnancy and their relation to
nutrient needs. In: Winick M, ed. Feeding the Mother and Infant. New
York, NY: John Wiley and Sons; 1985:13-43
11. Stevens-Simon C, McAnarney ER. Subfecundity: a prenatal risk factor
for adults but not for adolescents. JAdolesc Health Care. 1990;11:432-436 12. Stevens-Simon C, Roghmann KJ, McAnarney ER. Relationship of
self-reported prepregnant weight and weight gain during pregnancy and
relationship to body habitus and maternal age. JAm Diet Assoc. 1992;
92:85-87
13. Stevens-Simon C, Roghxnann KJ, McAnarney ER. Early vaginal
bleed-ing, late prenatal care, and misdating in adolescent pregnancy. Ped
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14. Hollingshead AB. Four factor index of social dass. New Haven, CT: Yale University; 1976. Unpublished manuscript
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16. Dubowitz LMS, DUbOWitZ V, Goldberg C. Clinical assessment of
ges-tational age in the newborn infant. I Pediatr. 1970;77:1-10
17. Committee to Study the Prevention of Low Birthweight, Division of
Health Promotion and Disease Prevention, Institute of Medicine.
Pre-venting Low Birthweight. Washington, DC: National Academy Press; 1985
18. Newton RW, Webster PAC, Binu PS, Maskrey N, Phillips AB.
Psycho-social stress in pregnancy and its relation to the onset of premature labour. Br Med J.1979;2:411-413
19. Radloff L The CES-D scale: a self-report depression scale forresearch in the general population. I Appl Psychol Meas. 1977;1:385-401
20. Block C. A review of validations of dietary assessment methods. Am I Epidemol. 1982;115:492-505
21. Kessner DM, Singer J, Kalk CE. Infant death: an analysis by maternal
risk and health care. In: Contrasts in Health Status. Washington, DC:
National Academy of Sciences; 1973:59
22. Hingson R, Zuckerman B, Amaro H, et al. Maternal marijuana use and neonatal outcome: uncertainty posed by self-report. Am IPublic Health.
1986;76:667-669
23. Hoff C, Wertelecki W, Zansky 5, Reyes E, Dutt J, Stumpe A. Earlier maturation of pregnant black and white adolescents. AJDC. 1985;139: 981-986
24. Felice ME, Granados JL, Ances IC, et al. The young pregnant teenager: impact of comprehensive prenatal care. I Adolesc Health Care. 1981;1:
193-197
25. Olds DL, Henderson CR, Tatelbaum R, et aL Improving the delivery of
prenatal care and outcomes of pregnancy: a randomized trial of nurse
home visitation. Pediatrics. 1986;77:16-28
INFANT BONDING: A BOGUS NOTION?
The saga of bonding begins in 1972. . . with a study in the New England Journal of Medicine. The study looked at 14 mothers who were given 16 extra hours of
contact with their infants right after birth. The scientists argued that these mothers
later showed better mothering skills than mothers who had not had the contact. The study also asserted that the “bonded” infants did better than their baby peers on some developmental tests...
In addition, the original study-on which dozens were modeled-was poorly
constructed. There was no attempt to measure hormones or any other biological
phenomena, both factors that were central to the scientists’ theory. Then there was
the matter of measuring better mothering. There were only a few measures (four
out of 75) in which the bonded group of 14 mothers got better scores. And the higher scores for certain behaviors were quite subjective: they included standing close to the child in a pediatric exam, or a mother’s not enjoying leaving the house
without her baby during the first month...
By the early 1980s, studies of the bonding of mothers and their newborns had
been dismissed by much of the scientific community. Bonding nevertheless
re-mained a tenet of our society. It is, for example, officially recognized by most
hospitals, which routinely place the baby in the mother’s arms for a few minutes
after birth.
Ms. Eyer, a professor of psychology at the University of Pennsylvania, is author of “Mother-Infant Bonding: A scientific Fiction,” to be published by Yale University Press in January [19931.
Eyer D. Infant bonding: a bogus notion. The Wall Street Journal. November 24, 1992.
Noted by J.F.L., MD
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1993;92;805
Pediatrics
Catherine Stevens-Simon, Elizabeth R. MCAnarney and Klaus J. Roghmann
Adolescent Gestational Weight Gain and Birth Weight
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1993;92;805
Pediatrics
Catherine Stevens-Simon, Elizabeth R. MCAnarney and Klaus J. Roghmann
Adolescent Gestational Weight Gain and Birth Weight
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