Hospital and Home Support during Infancy: Impact on Maternal Attachment, Child Abuse and Neglect, and Health Care Utilization

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Hospital

and

Home

Support

during

Infancy:

Impact

on Maternal

Attachment,

Child

Abuse

and

Neglect,

and

Health

Care

Utilization

Earl Siegel, MD, MPH, Karl E. Bauman, PhD, Earl S. Schaefer, PhD,

Minta M. Saunders, PhD, and Deborah D. Ingram, BA

From the Department of Maternal and Child Health, School of Public Health, University of North Carolina at Chapel Hill

ABSTRACT. Effects of early and extended postpartum

contact and paraprofessional home visits on maternal

attachment, reports ofchild abuse and neglect, and health

care utilization were determined by random assignment

of 321 low-income women to intervention or control

groups immediately after delivery. Observations of

ma-ternal attachment were made at four months and 12

months. Hospital, health and welfare agency records, and

interviews were used to determine reports of child abuse

and neglect and health care utilization. After establishing

a control for maternal background variables, early and

extended contact explained statistically significant but

small amounts of variance in several of the attachment

measures. There were no statistically significant effects

of the home visit interventions on maternal attachment,

and neither intervention was related to reports of child

abuse and neglect and health care utilization. Although

the study supported earlier findings that early and

ex-tended contact has a significant effect, additional

inter-ventions are needed to support mother-infant

attach-ment. Pediatrics 66:183-190, 1980; early and extended

mother-infant contact, home visit program, maternal

attachment, child abuse and neglect, health care utili-zation.

Klaus and associates’ first reported research on

humans suggesting that early and extended contact

between a mother and her newborn infant pro-moted maternal-infant bonding. These findings as

well as later research by Kennell et al2’3 and others4’5 have been widely considered with respect to their implications for child health and development. Our research was stimulated in a large part by the promise shown in these earlier studies.

Received for publication Sept 19, 1979; accepted Nov 12, 1979. Reprint requests to (E.S.) Professor of Maternal and Child

Health, School of Public Health, University of North Carolina,

Chapel Hill, NC 27514.

Our research was also influenced by evidence that a mother’s behavior with her infant may

sta-bilize during the early weeks ofllfe and that home

visit programs for parents with young children had

positive effects for child health and development.”

From this we reasoned that adequately trained and

supervised paraprofessionals visiting with mothers

in their homes to support them and their

relation-ships with their infants might also have positive

impact on mother-infant attachment

From these studies we hypothesized that early

and extended contact between a mother and her newborn infant and frequent paraprofessional home support visits during the first three months

post-partum would influence maternal attachment. We

also hypothesized that the hospital and home inter-ventions would reduce child abuse and neglect since our concept of abuse and neglect is one extreme on

a continuum of maternal attachment. Finally, we

hypothesized that the interventions would affect

health care utilization. Both the hospital and home interventions, through their influence on

attach-ment, could enhance maternal concern for the

health needs of the infant, resulting in increased preventive health care and fewer emergency room

visits and hospitalizations. Health care utilization could also be influenced by the home intervention because a component of that program was the

pro-vision of information about the infant’s health

needs and the services that could directly respond to those needs.

METHODS

Sample

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Jan 1, 1976, and Oct 15, 1977, were eligible for study

if the following criteria were met: they had

uncom-plicated pregnancy and no previous delivery of a

dead baby; they were not expecting twins; they

intended to remain in the area for one year or more;

they were not already in the study; and they did

not have a family member in the study. There were 525 women who met these criteria, and data from 321 of the women were included in the analyses

presented in this paper. The reasons for excluding

women eligible for study were: 79 refused to

partic-ipate; 53 delivered before completing the interview

during pregnancy; 41 did not receive the

interven-tions as described below; 23 could not be located

for interview during pregnancy; and 8 could not participate for a variety of other reasons. For the

analyses involving measures of maternal

attach-ment at 4 and 12 months of age described below, an

additional 84 cases were excluded due to missing

information on these variables. These 84 cases were distributed randomly across experimental and con-trol groups, and the differences on the background variables described below between these cases and

the 237 retained for analyses were negligible. Thus,

data from 237 women were available when viewing

attachment as a dependent variable, whereas for all other dependent variables, information was avail-able from 321 women. Approximately one quarter

of the 321 mothers were white, and about one third

were currently married. They averaged 0.8 babies before the index pregnancy, had attained about 11

years education, and averaged 21 years of age. Of the 321 women, 202 had a normal labor and delivery and a normal infant. They were assigned randomly at the time of delivery to one of four groups: (1) both early and extended hospital contact

and home visits by a paraprofessional infant care

worker; (2) early and extended hospital contact

only; (3) home visits only, and (4) routine hospital

and follow-up care without early and extended

con-tact or home visits. Obstetric and newborn compli-cation criteria employed by the hospital at the time of the study resulted in placement of the remaining

119 infants in the observation nursery for 24 hours

of close survefflance. Thus, it was not possible to implement early contact between these mothers and infants. When these infants were discharged

from the nursery within 24 hours, they were

ran-domly assigned to receive either a combination of

extended contact and home visits or no interven-tion. The research design is shown by diagram in

the Figure.

Hospital and Home Support Interventions

The early and extended contact intervention comprised at least 45 minutes of mother-infant

contact during the first three hours after delivery

(“early contact”) and at least five additional hours

each day during the hospital stay (“extended

con-tact”). Most mothers in our control groups had the

traditional, brief contact with their infants following

delivery and approximately 2#{189}hours of routine

contact each day while in the hospital.

The major functions of the home intervention were to promote the mother’s involvement with

their infants and to support mothers in coping with

the range of situational stresses that might be

con-fronting them. The workers first visited with the

mother in the hospital and then made nine home

visits during the first three months of the infant’s

life. The home visit intervention was carried out by

paraprofessionals who were carefully recruited and

given 200 hours of preservice training as well as

continuous supervision. Preservice training and

su-pervision were provided by the project field director who had an advanced degree in child development and considerable experience in training and

super-vising paraprofessional infant care workers in the

study community. Public health nurses participated

in the preservice training and served as continuing

resources to the infant care workers. The project

office was located in the health department which

facilitated close relationships between the infant

care workers and the nurses. The preservice

train-ing program included three months of multi-method

classroom learning experiences plus field work

dur-ing the last month of training. The training began

with an orientation to the research project and then covered the following topics: mother-infant

attach-ment; child care and development; importance of

play and stimulation for infant learning and

lan-guage development; special needs of mothers and

infants during the early months; use of community

resources appropriate to meeting these needs; skills

in relating to mothers; other family members and

community resources; and infant care workers as a

mutually supporting team. (A description of the

training program may be obtained from Minta

Saunders, PhD, Assistant Secretary, Department

of Human Resources, 325 N Salisbury St, Raleigh,

NC 27611.) During the first six months of visits to

the homes of subjects, infant care workers met as a

group with the field director for three hours twice a week and thereafter once a week for three hours.

The field director also was available to the workers

for advice and support as needed.

Data Collection

Data were collected by interview during the last

trimester of pregnancy, by interviews and

observa-tions in the home when the infant was 4 months

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I

N = 202

With Uncomplicated Labor and Delivery

and Normal Infants

N =47

N = 119

N =52

With Complicated Labor and/or

Delivery: Infants in

Observation Nursery for 24 hours

N =59

N=50 N=53

[lYandnJ

I

Contact

N=60

[Txtended Contact +

Home Visit

No Extended Contact

No Home Visit

Low-Income Pregnant Women

with Uncomplicated Pregnancies

N = 321

[arly and Extended

Contact

+ Home Visit

No Early

and Extended

Contact

No Home

________

______

Visit

Figure. Experimental and control group samples for hospital and home support study.

and welfare agency records. The investigators with-held information regarding intervention group membership from all data collectors.

The observations in the home included

approxi-mately 30 items of specific mother and infant

at-tachment behavior that were recorded by two

ob-servers immediately after each of the mother-infant

interaction situations of bathing, dressing, feeding, and play at 4 months and bathing, dressing, and play at 12 months of age. Ratings on a 92-item Attachment Inventory that was designed to de-scribe maternal acceptance vs rejection and in-volvement vs detachment were also completed after the home interviews and observations. Factor

anal-yses of the 4-month observations and Attachment

Inventory items yielded three factors: mother’s

ac-ceptance of the infant (“Acceptance”), mother’s

interaction/stimulation of the infant (“Interaction/

Stimulation”), and mother’s consoling ofthe crying

infant (“Consoling of Crying Infant”). The

accept-ance and interaction/stimulation factors emerged

again in the factor analyses of the 12 months

obser-vation and Attachment Inventory items, while the consoling factor was replaced by a factor infant’s

positive vs negative behavior (“Infant’s Positive/

Negative Behavior”). It should be noted that

4-month factors and 12-month factors, even when

assigned the same label, were not composed of

identical items since the observation and

Attach-ment Inventory items used at four and 12 months were not identical. Thus differences in the 4- and

12-month factor structures may reflect, in part, differences in factor definitions and not changes in

attachment over time. A more detailed discussion

of the concepts, methods, and factor structures has

been reported.’2

Ofthe 237 subjects included in the factor analyses

that produced the attachment factors described above, 47 lacked data for either the 4-month data collection point or for the 12-month data collection point. Two analyses of these factors, one including the 47 subjects and one excluding them, produced

virtually the same results. Hence, the analyses

which included the 47 subjects are reported here.

Reports of child abuse and neglect through 1 year of age were obtained from the county unit for protective services and the state central registry. These agencies were provided with the names of subjects in the study and each searched their files for reported cases. Data regarding health care

uti-lization by the infant were abstracted from clinic,

emergency room, and hospital records, and these variables were also measured by interviews with

the mothers at 4 and 12 months. An infant was considered to have received services if so indicated in any of these data sources.

Statistical Procedures

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.5 CI) 0 S i0 0 z -V S .5 o. .5 Cl) 0 S

I

a w o ©

_C, used were: race, marital status, parity, education,

age, and a score derived from a shortened version of the Peabody Picture Vocabulary Test.13 Data in Table 1 show that the differences between compar-ison groups on these background variables were not statistically significant at P < .05, thereby increas-ing our confidence that the random allocation pro-cedure produced comparable experimental and con-trol groups with respect to most variables other than the interventions. However, for some multiple

regression analyses we further increased control of

these background variables by entering them in the

analyses first and then adding the intervention var-iables. This analysis strategy had the advantages of reducing error variability in the dependent vari-ables, and it allowed assessment of the relative contribution of the interventions after the

back-ground variables had explained variance in the

de-pendent variables.

RESULTS

The results of the multiple regressions on the

three attachment factors at 4 months and at 12

months of age for the mothers whose infants were not placed in the observation nursery for 24 hours are shown in Table 2. At 4 months, 22% of the

variance in Acceptance was accounted for by the

background variables (P < .0001), and early and

extended contact added 2.5% to the amount of

variance explained (P < .04), but neither the home

visit nor home visit interaction with early and

ex-tended contact increased the amount of variance explained. Although the background variables were related to Interaction/Stimulation (P < .0001),

none of the interventions improved the prediction of this attachment factor. Slightly more than 10% of the variance in Consoling of Crying Infant was explained by the background variables (P <

.03),

early and extended contact added 2.5% (P < .05), but again neither home visit nor home visit inter-action with early and extended contact increased the amount of variance explained. At 12 months of age, the set of background and intervention van-ables were not significantly related to Acceptance. The background variables were related to Interac-tion/Stimulation (P < .0001), but none of the inter-ventions explained additional amounts of variance in that factor. Early and extended contact was the only variable significantly related to the Infant’s Positive/Negative Behavior (P < .04), explaining

3.2% of the variance.

The analogous analyses for the mothers whose

infants were placed in the observation nursery dur-ing the first 24 hours of life are shown in Table 3. The background variables explained a significant

17.2% of the variance in Acceptance at 4 months (P

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TABLE 2. Regression Analysis of Selected Variables on

Nursery during First 24 Hours of Life (N = 149)

Attachment Factors of Infants Not Placed in Observation

Attachment Factors

Backgroundt Home Visit

Variables

Early and Extended Contact

Home Visit Plus Early

and Extended Contact

Total Model

Acceptance

4 mo 0.217, P < .0001 0.221, NS 0.245, P < .04 0.258, NS P < .0001

12 mo 0.084, NS 0.085, NS 0.085, NS 0.091, NS NS

Interaction/stimulation

4 mo 0.198, P < .0001 0.198, NS 0.203, NS 0.209, NS P < .0002

12 mo 0.190, P < .0001 0.193, NS 0.201, NS 0.203, NS P < .004

Consoling of crying infant

4 mo 0.102, P < .03 0.110, NS 0.135, P < .05 0.136, NS P < .02

Infant’s positive/negative

behavior

12 mo 0.046, NS 0.046, NS 0.078, P < .04 0.078, NS NS

SCumulative variance and significance levels (significance level of the increase in predicted variance).

t

Race, marital status, parity, education, age, and Peabody Picture Vocabulary Test.

TABLE 3. Regression Analysis of Selected Variables on Attachment Fa

Placed in Observation Nursery during First 24 Hours of Life (N = 88)

ctors of Infants

Attachment Factors Variable

Backgroundt Extended Contact and Total Model

Home Visit

Acceptance

4 mo 0.172, P < .03 0.172,

NS

P < .05

12 mo 0.061, NS 0.086, NS NS

Interaction/stimulation

4 mo 0.129, NS 0.131, NS NS

12 mo 0.209, P < .007 0.213, NS P < .0119

Consoling of crying infant

4 mo 0.082, NS 0.124, NS NS

Infant’s positive/negative behavior

12 mo 0.135, NS 0.137, NS NS

SCumulative variances and significance levels (significance level ofthe increase in predicted variance).

1Race, marital status, parity, education, age, and Peabody Picture Vocabulary Test.

< .03), but the program of combined extended con-tact and home visits did not add to the amount of

variance explained in Acceptance. At 4 months,

none of the variables entering the regression

ex-plained Interaction/Stimulation or Consoling of the

Crying Infant. At 12 months, the background van-ables explained a significant 20.9% of the variance in Interaction/Stimulation (P < .007). However, the background variables were not significantly re-lated to the other two attachment factors. Finally, the extended contact and home visit intervention was not related to any of the three attachment measures.

The distribution of reports of abuse and neglect is shown in Table 4 for both groups of study moth-ers. Whether infants were or were not placed in the observation nursery provided no data to suggest a relationship between type of intervention and re-ports of abuse and neglect to the county unit for

protective services or to the state central registry.

In Table 5 we show the number of

hospitaliza-tions, number of emergency room visits, mean num-ber of preventive care visits, and the mean number of immunizations for infants who were and infants who were not placed in the observation nursery. There was no indication in these data that a rela-tionship exists between type of intervention and health care utilization.

DISCUSSION

Although the major hypotheses of our research focused on the effects of the hospital and home support interventions, the background variables ex-plained substantially more variance in maternal behavior than did these interventions. Specifically the background variables played a substantial role in explaining, at age 4 months, the mother’s accept-ance of the infant, positive interaction and stimu-lation of the infant, and consoling of crying infant and in explaining, at age 12 months, the mother’s

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Observation Nursery Total No Observation Nursery Total

Reported Not Reported Reported Not Reported

Early and extended 3 56 59 4 43 47

contact plus home

visit

Early and extended 3 47 5J

contact

Home visit 7 46 53

No extended contact 3 57 60 3 49 52

and no home visit

Total 6 113 119 17 185 202

TABLE 4. Reports of Child Abuse and Neglect by Hospital and Home Visit Intervention

Child Abuse and Neglect

Type of Intervention

TABLE 5. Hospitalizations, Emergency Room Visits, Preve

Home Visit Intervention at Age 12 Months5

ntive Care Visits, and Immunizatio us by Hospital and

Type of Intervention Hospitalizations Emergency Room Visits

Preventive Care Visits

Immunizations

Observation nursery

Extended contact plus home visit (N 4 25 3.9 4.8

=60) .

No extended contact and no home 7 17 4.2 4.8

visit (N = 59)

No observation nursery

Early and extended contact plus 4 9 3.8 4.7

home visit (N

=

47)

Early and extended contact (N = 50)

Homevisit(N=53)

1 4

13 11

3.8 4.1

4.4 5.1

No early and extended contact and 3 13 4.1 4.5

. no home visit (N = 52)

4)No statistically significant differences were observed between groups for these variables.

economic, and other stresses associated with the background variables are burdens often intergen-erational in nature that are not easily altered. Our

background variable data provide support for

rec-ommendations for a comprehensive national policy for families and children.

A number of studies have reported favorable effects of early and extended contact on maternal behavior during the first postpartum days.”3’4”’6 Other studies, with follow-up periods of several months, suggest that the length of breast-feeding,’7 the amount of affectional behaviors,”2’#{176} and eye-to-eye contact”7’#{176} also are enhanced. But only a few studies have demonstrated effects be-yond the first year of life. Ringler et al5 from a two-year follow-up of a sub-sample of the original sam-ple of full-term infants by Klaus et al’ reported that mothers who experienced early and extended con-tact provided more language stimulation to their children. O’Connor et al21 randomly assigned 301

infants to rooming-in (extended contact) or to

rou-tine care (control). After an interval of 12 to 24 months, one rooming-in infant and nine of the control infants experienced parenting disorders.

Our findings indicated that, after control for

background and other variables, early and extended contact explained variance in several but not all

dimensions of maternal attachment when the infant

was 4 and 12 months of age. In contrast to the above reports, we analyzed the amount of variance in maternal attachment explained by early and extended contact in addition to level of statistical

significance. We found at 4 months that the size of

the contributed variance is only 2.4% for acceptance and 2.5% for consoling the crying infant. At 12 months only 3.5% of the variance was contributed for infant’s positive vs negative behavior. Each of these relationships are statistically significant, but

the amount of contributed variance is small and the

relatively limited impacts at 4 months were even less noteworthy at 12 months. For mothers whose

infants were placed in the observation

nursery-potentially vulnerable child syndrome infants-the

interventions did not explain a statistically

signifi-cant amount of the variance in any of the attach-ment factors at either 4 or 12 months. The absence of differences between early and extended contact and control groups in reports of child abuse and neglect and in health care utilization were

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for maternal attachment. Thus the effects of early and extended contact at 4 months appear to be shortlived, tending to deteriorate as life stresses outweigh them.

Although home visit programs directed at older

children have been effective, particularly in relation

to cognitive development,#{176}’1 we found few home

visit intervention studies with the objectives of

enhancing maternal attachment, reducing abuse

and neglect, or improving health care utilization among infants. Gray et al carried out a controlled investigation of the effects of a health visitor and a single, permanent pediatrician on infants at high

risk of abuse and neglect. They demonstrated an impact of this intervention on the incidence of child abuse but none on neglect. We found no evidence in our study to support the hypothesis that the

home visit intervention program influenced

mater-nal attachment. Our findings also failed to indicate

that the home visit intervention was related to

reports of abuse and neglect or to health care

utili-zation.

Although it might be questioned whether our

infant care workers had the required level of skills

that could impact on maternal stresses, promote

attachment, and improve maternal care, we can only reiterate that the workers were carefully re-cruited, were given 200 hours of preservice training and had continuous, high quality supervision. It

also may be suggested that the three-month home

visit intervention was too brief, or that our

mea-sures were taken too long after the interventions,

but it should be noted that maternal attachment

measures were obtained within one month of the

end of home visiting before the effects of the inter-vention should have dissipated. A reasonable hy-pothesis is that the home visit intervention started

too late, a comment the infant care workers fre-quently made. They reported that, after delivery, the mother was so busy trying to cope with the new baby and with often overwhelming personal prob-lems, crises, and stresses that she had little time to spare for the unknown infant care worker. The

infant care workers felt that if they had visited with

the mother during her pregnancy, they could have

established the rapport with her that they needed

in order to be effective in their roles. They also could have helped the mother prepare more ade-quately for the baby and address some of her

per-sonal problems so that she would have less stress

after the baby’s birth. However, these are

hy-potheses rather than conclusions from our study.

CONCLUSIONS

What are the implications for child health care in

this large scale, controlled research of two specific,

short-term interventions intended to influence

ma-ternal behavior, child abuse and neglect, and health

care utilization? Despite the small variances ex-plained in attachment by early and extended

con-tact, the findings were statistically significant and

concordant with other studies, therefore supporting action by health professionals and hospitals.

But, based on our research on a low-income sam-ple of women and infants who entered the study and for whom data were collected at 4 and 12 months of age, a compelling conclusion emerges. Even though we found some enhancement of

ma-ternal attachment during the first year of life by

early and extended contact, it appears that

pro-grams other than early and extended contact and

home visitation must be developed to produce

sub-stantial influences on attachment, reports of abuse

and neglect, and health care utilization among mothers comparable to those in our study. A corn-bination of actions including recommendations of

the major health professional organizations,’ for

changes in prenatal, labor and delivery, and

post-partum practices, may be needed to promote the

positive outcome hypothesized in this research.

ACKNOWLEDGMENTS

This investigation was supported by grant

5-ROl-HD09003 from the National Institute of Child Health and

Human Development, Bethesda, MD and by a grant from

the William T. Grant Foundation, New York.

A number of agencies and persons in Greensboro, NC,

provided advice and support to the research project:

RObert Difiard, MD, Martha Sharpless, MD, and Wilma

K. Deal, RN of Moses H. Cone Hospital; Sarah T.

Mor-row, MD, MPH, and Lois Isler, BSN, MPH, of the

Department of Social Services deserve special recogni-tion. Jean Wall, PhD, served as field project director

during the later phases of infant care worker supervision

and data collection.

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1. Klaus MH, Jerauld R, Kreger NC, et al: Maternal

attach-ment: Importance of the first postpartum days. N Engi J

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2. Kennell JH, Jerauld R, Wolfe H, et al: Maternal behavior

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4. Lozoff B, Brittenham GM, Trause MA, et al: The

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6. Moss HA: Sex, age and state as determinants of

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8. Schaefer ES: Development of hierarchial configurational models for parent behavior and child behavior, in Hill JE

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10. Barbrack C, Horton D: Educational intervention in the home

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11. Lazar JB, Chapman J: A review of present status and future

research needs of programs to develop parenting skills.

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12. Schaefer ES, Bauman KB, Siegel E, et al: Measurement,

stability, and predictability of maternal attachment to the

infant. Presented at the annual meeting of the American

Public Health Association, Los Angeles, 1978

13. Dunn LM: Peabody Picture Vocabulary Test Manual.

Min-neapolis, American Guidance Service, mc, 1965

14. Klaus MH, Kennell JH: Human maternal and paternal

behavior, in Klaus MH, Kennell JH (ed): Maternal-Infant

Bonding. St. Louis, CV Mosby Co., 1976, pp 38-98 15. de Chateau P, Wiberg B: Long term effect on mother-infant

behavior of extra contact during the first hour postpartum.

I. First observations at 36 hours. Acta Paediatr Scand 66:

137, 1977

16. Carlsson 5G. Fagerberg H, Horneman G: Effects of amount of contact between mother and child on the mother’s nursing

behavior. Dcv Psychobiol 11:143, 1978

17. de Chateau P, Wiberg B: Long term effect on mother-infant behavior of extra contact during the first hour postpartum.

II. Follow up at three months. Acta Paediatr Scand 66:145,

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18. Hales DJ, Lozoff B, Sosa R, et al: Defining the limits of the maternal sensitive perod. Dev Med Child Neurol 19:454, 1977

19. Sosa R, Kennell JH, Klaus M, et al: Breastfeeding and the

mother: The effect of early mother-infant contact on breast-feeding, infection and growth. Ciba FoundSymp 45:179, 1976 20. Kontos D: A study of the effects of extended mother-infant

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21. O’Connor S, Sherrod KB, Sandier HM, et al: The effect of extended postpartum contact on problems with parenting: A controlled study of 301 families. Birth Family J 5:231, 1978

22. Gray J, Cutler C, Dean J, et al: Prediction and prevention of

child abuse and neglect. ChildAbuse and Neglect 1:45, 1977

23. American Medical Association: Statement on parent-infant

bonding. Washington DC, House of Delegates, 1977 24. Interprofessional Task Force on Health Care of Women and

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FETAL HYDANTOIN SYNDROME

At the annual meeting of the Teratology Society (Pocono Manor, PA,

May 12, 1975) J. W. Hanson and D. W. Smith ofSeattle expanded the description

of the fetal hydantoin syndrome. They observed five unrelated affected children,

whose mothers were given hydantoin anticonvulsant therapy (100 to 400 mg

daily) for idiopathic epilepsy throughout pregnancy. The children had

charac-teristic craniofacial abnormalities, defects of the fingers and toes (including

hypoplasia of the nails), and deficiencies in growth and performance. (Persons

with epilepsy treated with diphenythydantoin have developed lymphoma or

pseudolymphoma. Hence, there is a possibility of transplacental induction of

these neoplasms in the offspring of women treated during pregnancy. In this

connection, physicians who see young children with lymphoma or

pseudolym-phoma might especially examine their fingernails and toenails for hypoplasia.)

Hanson and Smith examined 36 other children because their mothers had been

on hydantoin anticonvulsant therapy during pregnancy. Four of the 36 had the

syndrome and eight others had minor manifestations of it. The frequency of

milder effects has been confirmed by the authors in a study of 103 children of

treated mothers as compared with matched controls in the Collaborative

Peri-natal Study conducted by the National Institute of Neurologic Diseases and

Stroke (NIH).

Robert W. Miller, MD

National Cancer Institute-National Institutes of Health

(9)

1980;66;183

Pediatrics

Earl Siegel, Karl E. Bauman, Earl S. Schaefer, Minta M. Saunders and Deborah D. Ingram

Abuse and Neglect, and Health Care Utilization