Review of Genetic and Artificial Intelligence approaches to improving Gestational Diabetes Mellitus Screening and Diagnosis in sub-Saharan Africa

Background: Adverse outcomes from gestational diabetes mellitus (GDM) in the mother and newborn are well established. Genetic variants may predict GDM and Artificial Intelligence (AI) can potentially assist with improved screening and early identification in lower resource settings. There is limited information on genetic variants associated with GDM in sub-Saharan Africa and the implementation of AI in GDM screening in sub-Saharan Africa is largely unknown. Methods: We reviewed the literature on what is known about genetic predictors of GDM in sub-Saharan African women. We searched PubMed and Google Scholar for single nucleotide polymorphisms (SNPs) involved in GDM predisposition in a sub-Saharan African population. We report on barriers that limit the implementation of AI that could assist with GDM screening and offer possible solutions. Results: In a Black South African cohort, the minor allele of the SNP rs4581569 existing in the PDX1 gene was significantly associated with GDM. We were not able to find any published literature on the implementation of AI to identify women at risk of GDM before second trimester of pregnancy in sub-Saharan Africa. Barriers to successful integration of AI into healthcare systems are broad but solutions exist. Conclusions: More research is needed to identify SNPs associated with GDM in sub-Saharan Africa. The implementation of AI and its applications in the field of healthcare in the sub-Saharan African region is a significant opportunity to positively impact early identification of GDM.

Management of asymptomatic cutaneous lumbosacral findings in newborns: a neurosurgical perspective

OBJECTIVE

The purpose of this study was to find areas of agreement among pediatric neurosurgeons with respect to the clinical management of asymptomatic newborns with a variety of lumbosacral skin findings.

METHODS

An electronic survey containing 18 clinical images and brief vignettes was sent to pediatric neurosurgeons within the American Academy of Pediatrics Section of Neurological Surgery (AAP SONS). In total, 38% (n = 21) of AAP SONS members submitted complete responses to the survey. Respondents were asked if they would advise routine care, watchful waiting, imaging, or subspecialty consultation for each clinical case. Responses were categorized into two groups: 1) watchful waiting and/or routine care, or 2) imaging and/or subspecialty consultation. Consensus was categorized as good (> 90% of responses in the same group), modest (70%-90%), and poor (< 70%). Demographic information, local factors impacting management, and experiences with local referral patterns were also collected.

RESULTS

Among the pediatric neurosurgeons within the AAP SONS network, the authors found high levels (> 90%) of agreement that subcutaneous lipomas, faun tail nevi, large skin tags, and deep/atypical lumbosacral dimples in asymptomatic newborns should prompt an imaging study. Similarly, the authors found high agreement that simple coccygeal dimples do not need imaging. The management of some types of lumbosacral vascular marks and gluteal crease deviations had poor agreement (< 70%). When imaging was recommended, there was preference for spinal MRI in most cases (67%).

CONCLUSIONS

Pediatric neurosurgeons generally agree that imaging of the spine is indicated for asymptomatic newborns with subcutaneous lipomas, faun tail nevi, large skin tags, or deep/atypical lumbar dimples (deep or atypical appearing). They also agree that imaging is unnecessary for infants with simple coccygeal dimples. There was a notable lack of consensus on the appropriate management of certain gluteal cleft deviations and cutaneous vascular marks.

Implementation of Pre-Admission Caregiver Testing for COVID-19

BACKGROUND

Caregivers are often at the bedside of hospitalized children posing an additional risk for coronavirus disease 2019 (COVID-19) transmission. We describe the implementation of caregiver COVID-19 testing before inpatient pediatric admissions and the effect on patient cohorting and bed capacity.

METHODS

We implemented an ordering pathway to facilitate COVID-19 testing of caregivers of patients admitted to the inpatient units from the pediatric emergency department, elective procedural admissions, or direct admissions at a tertiary children's hospital in the Northeastern United States in August 2021. Testing was expedited by the clinical laboratory, and caregiver results were used to inform cohorting, infection prevention, and bed management decisions.

RESULTS

From August 2021 to January 2022, 2558 caregiver tests were ordered through this pathway, and 83 (3.2%) were positive. Of the positive tests, 72 (86.7%) occurred after December 18, 2021, coinciding with the local Omicron variant wave. Among positives, 67 caregiver or child pairs were identified, and 36 positive caregivers had a COVID-19 negative child leading to use of isolation precautions. Reintroduction of patient cohorting increased overall bed capacity from 74% to 100% of available beds.

CONCLUSIONS

The overall incidence of COVID-19 among caregivers before admission correlated well with rates of COVID-19 positivity among asymptomatic adults in the community during the study period. Implementation of caregiver testing increased bed capacity by reintroducing cohorting of patients and identified patients needing isolation that would have been missed by patient testing alone. More research is necessary to determine the extent that routine caregiver testing mitigates the risk of nosocomial severe acute respiratory syndrome coronavirus 2 transmission.

Midwives' Perspectives about Vitamin K Prophylaxis Against Vitamin K Deficiency Bleeding of the Newborn

BACKGROUND

The American Academy of Pediatrics recommends one intramuscular (IM) vitamin K injection at birth to prevent Vitamin K Deficiency Bleeding of the Newborn (VKDB). Among factors associated with IM vitamin K refusal, investigators have reported an increased frequency of IM vitamin K refusal among parents who select midwife-assisted deliveries. Reasons behind this association are unclear.

METHODS

To understand the perspectives of midwives on IM vitamin K prophylaxis and approach to counseling parents using qualitative methodology, we conducted in-depth semi-structured interviews of midwives associated with 3 tertiary academic medical centers and surrounding communities in Connecticut, Iowa and Michigan. We used the grounded theory approach and the constant comparative method until saturation was reached.

RESULTS

We interviewed 19 white female midwives from different training pathways. Participants who were Certified Nurse Midwives (CNMs) routinely recommended IM vitamin K prophylaxis and Certified Professional Midwives (CPMs) took a more neutral approach. The following 4 themes emerged: (1) Emphasis on an educational approach to counseling that supports parents' decision-making authority; (2) Low-intervention philosophy in the midwifery model of care attracts certain parents; (3) Need for relationship building between midwives and pediatricians and (4) Opportunities for the future.

CONCLUSIONS

Midwives in our study perceived that the midwifery model of care, the focus on physiologic birth and prioritizing parents' decision-making autonomy appears to attract a sub-set of expectant parents with certain belief systems who question interventions such as IM vitamin K prophylaxis. There are opportunities for better collaboration between midwives and pediatricians.

The Evolving Needs of Children Hospitalized for Eating Disorders During the COVID-19 Pandemic

BACKGROUND AND OBJECTIVES

Throughout the COVID-19 pandemic, there has been an increase in hospital admissions for adolescents with eating disorders (EDs). However, there is a paucity of information on how this increase has affected hospitalization courses and disposition planning. We sought to describe the changes in hospitalizations for EDs at our institution during the pandemic.

METHODS

We reviewed charts of patients admitted to our academic medical center for nutritional restoration from January 1, 2017, to June 30, 2021. We report differences in patient characteristics and hospitalization courses using descriptive statistics and Poisson regression.

RESULTS

We reviewed charts for 85 patients for 108 hospital admissions. Admissions increased from 1.4 per month prepandemic to 3.6 per month during the pandemic (P < .001). Most patients were female (91%), White (79%), had private insurance, (80%) and had restrictive eating behaviors (97%). During the pandemic, we found (1) an increase in the average length of stay (12.6 days vs. 18.0 days) with younger age associated with longer length of stay (P < .001); (2) more patients requiring psychotropic medication management (11% vs 31%, P = .01); and (3) fewer patients discharged from the hospital with outpatient therapy (43% vs 24%, P = .03).

CONCLUSIONS

In addition to an increase in hospital admissions for ED management during the pandemic, our study highlights the evolving needs of ED patients during their hospitalizations. The implications of longer admissions with higher acuity at discharge represent areas where appropriate adaptations in inpatient management and disposition planning may improve the quality of care for ED patients.

Improving Guidance and Maternal Knowledge Retention After Well-Newborn Unit Discharge

BACKGROUND AND OBJECTIVES

In 2015, the American Academy of Pediatrics published a policy statement to provide best practices on mother-infant discharge criteria, including the delivery of anticipatory guidance to mothers of healthy newborns. In our large health system with a mix of hospital types, no standard approach to or measurement of the effectiveness of newborn discharge guidance exists. At one community well-newborn unit, we aimed to increase maternal knowledge retention of newborn guidance from 69% to 90%.

METHODS

Data about newborn guidance effectiveness were collected by assessing maternal knowledge retention through phone follow-up quizzes. By using quality improvement methodology and informed by American Academy of Pediatrics guidelines and curricular and adult learning theory, we standardized a multidisciplinary approach to this education. Interventions included checklist, scripts, temperature-taking demonstration, gift thermometer, staff education, car seat infant mannequin, and car seat training video for staff.

RESULTS

Over a 1-year period, 333 mothers were interviewed after discharge from the well-newborn unit. Baseline data over the first 3 months (n = 93) showed poor maternal knowledge retention (69% correct answers). Common incorrect answers were on newborn urination habits, car seat harness clip positioning, and fever recognition. After restructuring the educational process, special cause was achieved after 3 months, with a shift of the average of correct answers to 83% followed by a second shift to 86%.

CONCLUSIONS

The implementation of interventions to standardize newborn discharge guidance resulted in marked and sustained improvement in maternal knowledge after well-newborn unit discharge. Our next step is to enhance the process by using videos with systemwide implementation.

Well-Newborn Unit Director Experiences During the COVID-19 Pandemic: A BORN Study

BACKGROUND

As coronavirus disease 2019 (COVID-19) spread across the country, well-newborn unit medical directors developed newborn care plans as guidelines and evidence evolved. We chose to examine approaches to newborn care during these early phases of the COVID-19 pandemic.

METHODS

An electronic survey was administered to well-newborn unit directors in a national network of US well-newborn units in May 2020. Respondents were asked about their approaches to testing, infection prevention, routine newborn care, discharge planning, breastfeeding, rounding, and teaching.

RESULTS

Of 107 sites, 65 (61%) respondents completed the survey. Respondents estimated a 1% positivity rate of 1198 newborns tested for COVID-19. Most sites (86%) performed universal maternal COVID-19 testing, and most (82%) tested newborns of COVID-19-positive mothers at 24 hours of life (75%). Infection prevention and visitation policies varied. Of respondents, in COVID-19-positive mothers, 28% permitted no visitors, 54% recommended rooming-in with the newborn, 55% encouraged breastfeeding at the breast, 38% deferred routine circumcisions of the newborn, 74% initiated immediate bathing of the newborn, 68% continued standard newborn screening, and 55% modified newborn follow-up plans. Medical directors reported adjustments to rounding and teaching workflow. Content analysis of free-text responses revealed themes related to challenges with changing recommendations, discomfort with mother-infant separation recommendations, innovations, and stress management.

CONCLUSIONS

Well-newborn units quickly adopted universal maternal testing and testing of exposed newborns. Despite guidelines, we identified variation in the care of newborns of COVID-19-positive mothers. Further investigation of these differences and newborn outcomes is warranted to develop best practices.

Trends in and Documentation of Refusal of Common Routine Newborn Interventions: 2013-2019

BACKGROUND

Refusals of intramuscular (IM) vitamin K, ocular prophylaxis, and hepatitis B vaccine (HBV) during the birth hospitalization continue to occur. Refusal of IM vitamin K increases the risk of life-threatening vitamin K deficiency bleeding. Trends in refusal rates and how well clinicians document IM vitamin K refusal is unknown.

METHODS

We reviewed charts of livebirths admitted to 5 well newborn units from 2013 to 2019. We report trends in rates of refusal and documentation of no IM vitamin K by clinicians during the birth hospitalization and within the first 6 months of life at emergency department (ED) visits.

RESULTS

Of 67 750 live births, 283 (0.4%) did not receive IM vitamin K, and 1645 (2.4%) did not receive ocular prophylaxis. Rates of IM vitamin K refusal increased slightly over time (P < .05). For HBV, 7551 (11.1%) did not receive the birth dose, but refusal rates decreased from 16.1% to 8.7% (P < .0001). Of 283 newborns who did not receive IM vitamin K, refusal was documented in 49.8% of discharge summaries, 17 (6%) had an invasive procedure without documentation of IM vitamin K administration, and 30 (10.6%) infants <6 months old had ED visits. A total of 4 infants were evaluated for potential bleeding, and there was no documentation about IM vitamin K prophylaxis.

CONCLUSION

Refusal rates of IM vitamin K and ocular prophylaxis remained low, and uptake of HBV increased over time. Documentation of IM vitamin K refusal by clinicians during the birth hospitalization, before invasive procedures, and in ED visits can be improved.

The Term Newborn: Alternative Birth Practices, Refusal, and Therapeutic Hesitancy

The care of late preterm and term newborns delivered in hospital settings in the United States is largely standardized with many routine interventions and screenings that are evidence-based and serve to protect newborn's and the public's health. Refusals of various aspects of routine newborn care are uncommon but can be challenging for clinicians who care for newborns to navigate for many reasons. In this article, we describe the spectrum of refusal. We review suggested approaches that clinicians can take starting with increasing their own awareness of what specific components of newborn care are refused and why.

Parent Perspectives on the Eat, Sleep, Console Approach for the Care of Opioid-Exposed Infants

BACKGROUND

At our institution, the treatment of infants with neonatal abstinence syndrome (NAS) is guided by a function-based assessment called the Eat, Sleep, Console (ESC) approach. Infants room in with their parent(s) on the inpatient units, and most infants are treated exclusively with nonpharmacologic interventions. The experience of parents of infants with NAS treated with the ESC approach is unknown.

METHODS

We chose a deductive, hypothesis-driven approach to perform a content analysis of transcripts from in-depth, semistructured interviews of parents of infants with NAS in our institution. Responses were audiotaped, transcribed, and reviewed by at least 3 members of the research team.

RESULTS

We interviewed 18 parents of infants with NAS. Most participants were ≥30 years, were white, and had a high school or equivalent level of education. Four major themes emerged: (1) parents were supportive of fewer interventions and normalizing of newborn care in the ESC approach; (2) parents felt encouraged to lead their infant's NAS care; (3) parents perceived gaps in communication about what to expect in the hospital immediately after delivery and during their infant's hospital stay; and (4) parents experienced feelings of guilt, fear, and stress and expressed the need for increased support.

CONCLUSIONS

Parents in our study had an overall positive experience with the ESC approach. This engagement probably contributes to the success of the ESC approach in our institution. Future opportunities include better preparation of expectant mothers and continued emotional support after delivery.

More Than Meets the Eye: Idiopathic Orbital Inflammation Mimicking Orbital Cellulitis

An 18-year-old female presented with left eye periorbital swelling, erythema, and pain for three days. Computed tomographic images showed swelling of the medial rectus muscle, and she was diagnosed with orbital cellulitis and initiated on empiric antibiotics. Over the next 48 hours, she did not clinically improve, resulting in an MRI and further workup of infectious, oncologic, endocrinologic, and rheumatologic etiologies was unrevealing and ruled-out malignancy, sarcoidosis, Wegner’s, and thyroid eye disease.

Given the negative workup, the presentation was determined to be consistent with idiopathic orbital inflammation (orbital myositis variant) via a diagnosis of exclusion. Therefore, the patient was empirically treated with intravenous steroids that produced pronounced improvement within 24 hours. The patient was discharged in improved condition with a prednisone taper and rheumatology follow-up. Idiopathic orbital inflammation is a rare diagnosis of exclusion in pediatrics that merits prompt consideration and work-up if treatment for orbital cellulitis does not progress as expected.

Ethical and Public Health Implications of Targeted Screening for Congenital Cytomegalovirus

Congenital cytomegalovirus (cCMV) is the most common congenital infection and is associated with sensorineural hearing loss, developmental delays, and visual impairment. The clinical presentation of cCMV is variable, and the majority (80%-90%) of newborns will never manifest any clinical symptoms. Given the clinical heterogeneity of cCMV infection, it is challenging to identify which newborns may benefit from testing. Recently, certain states have implemented a targeted screening program in which newborns who fail the newborn hearing screen are tested for cCMV. Clinicians and legislative bodies have been propelled into debates about the ethical and moral permissibility of a targeted cCMV screening approach. Those who oppose this screening approach describe undue burden on patients, families, and the health care system because the majority of newborns who fail the newborn hearing screen and have cCMV will not go on to have any sequelae related to cCMV, including hearing loss. However, those who support this screening approach cite the importance of early detection and ongoing surveillance for hearing loss and developmental delays in this high-risk group of newborns. This debate will be considered by experts in the field.

Variation in Management of Cutaneous Lumbosacral Findings in Newborns

BACKGROUND

Cutaneous lumbosacral findings in neonates are common in the newborn nursery but may also be associated with occult spinal dysraphism. Variation in management of lumbosacral findings by neonatal clinicians has not been previously described.

METHODS

Clinicians in the Better Outcomes through Research for Newborns (BORN) Network were invited to participate in an electronic survey. Participants reviewed 18 photographs of lumbosacral findings in asymptomatic neonates and selected 1 or more initial management step(s): routine care, watchful waiting, imaging, and/or subspecialty consultation. Additional data collected include ease of access to imaging and subspecialty consultants and characteristics of respondents.

RESULTS

Of 407 BORN Network clinicians, 206 (51%) completed the survey. Respondents were in >90% agreement in initial management approach of 8 of 18 cases. The most common initial actions were spinal ultrasound (53%), neurosurgery evaluation (18%), and MRI (13%). Anomalies of the gluteal crease had the lowest proportion of agreement. In 2 cases, there were differences in respondents' choice to image or consult a subspecialist depending on their percent clinical full time equivalent spent taking care of neonates <1 month of age: (1) coccygeal hair (P = .02) and (2) deviated gluteal crease (P = .02).

CONCLUSIONS

Variation in initial management of neonatal lumbosacral findings by clinicians in the BORN Network was seen most often for deviations of the gluteal crease, flat vascular macules, and coccygeal hair.

Refusal of Intramuscular Vitamin K by Parents of Newborns: A Review

In 2019, the American Academy of Pediatrics made public education about intramuscular vitamin K administration at birth a public health priority, partly in response to reports of refusal of intramuscular vitamin K by parents of newborns that led to vitamin K deficiency bleeding (VKDB). We reviewed the literature on the frequency of, reported reasons for, and factors associated with refusal of intramuscular vitamin K, incidence of VKDB in newborns who did not receive intramuscular vitamin K, and use of oral vitamin K to prevent VKDB. Without prophylaxis, estimates of the incidence per 100 000 births of VKDB range from 250 to 1700 for early VKDB and from 10.5 to 80 for late VKDB. The frequency of refusal of intramuscular vitamin K by parents ranged from 0% to 3.2% in US hospitals, up to 14.5% in home births, and up to 31.0% in birthing centers. Reported reasons for refusal were concern of harm from the injection, a desire to be natural, and a belief in alternative methods of prophylaxis. Parents who refused intramuscular vitamin K were more likely to refuse immunizations. Many different regimens were used for orally administered vitamin K; it is not clear which is best, but all are less effective than intramuscular vitamin K. VKDB is rare but can result in either neurologic sequelae or death. In addition to continued surveillance of the frequency of both refusal of intramuscular vitamin K and VKDB, a renewed focus on education of and collaboration with parents is needed to address this major public health threat.

Oral Vitamin K Prophylaxis in Newborns: A Survey of Clinician Opinions and Practices

OBJECTIVES

The majority of newborns in the United States receive intramuscular (IM) vitamin K for prophylaxis against vitamin K deficiency bleeding (VKDB). Oral vitamin K is less effective than IM vitamin K in preventing VKDB but is widely used in Europe and by some in the United States when parents refuse IM vitamin K for their newborn. Our aim was to assess the practices, opinions, and knowledge of newborn clinicians regarding oral vitamin K prophylaxis when parents refuse IM vitamin K.

METHODS

We conducted an electronic survey of newborn clinicians from 3 academic medical centers in California, Iowa, and Connecticut. Descriptive statistics and χ² tests were performed.

RESULTS

Of 160 newborn clinicians at 3 sites, 110 (69%) completed the survey. Of respondents, 58 (53%) believed the incidence of IM vitamin K refusal is increasing and had prescribed or recommended oral vitamin K at least once. Regarding knowledge, 32 (28%) and 23 (20%) respondents did not know whether oral vitamin K decreases the risk of early- and late-onset VKDB, respectively. There were no significant differences in opinions, knowledge, or practices across institutions or practice settings (NICU, well-newborn nursery, or both) (P > .05).

CONCLUSIONS

Our study findings suggest that newborn clinicians may lack knowledge about the effectiveness of oral vitamin K in preventing VKDB. More information is needed about oral vitamin K regimens and outcomes of newborns who receive oral vitamin K.

Mothers' Perceptions of the Cardboard Box as a Potential Sleep Space

OBJECTIVE

Due to increasing popularity, our hospital began considering distributing cardboard boxes combined with safe sleep education to new mothers. As a first step in studying the impact of this intervention on bedsharing in our community, we sought to understand mothers' perceptions of the cardboard box.

METHODS

We recruited primarily low-income, English- or Spanish-speaking mothers of infants aged 2 to 16 weeks during routine primary care visits. Participants responding to a cross-sectional survey about infant sleep practices were invited to participate in in-depth interviews about the cardboard box. We used a grounded theory approach and the constant comparative method until saturation was reached.

RESULTS

Of 120 participants in the survey, 50 (42%) participated in the qualitative study. Participants were mothers of infants aged ≤4 weeks (46%), 4 to 8 weeks (32%), and 16 weeks (22%). Of 50 participants, 52% said they would use the cardboard box for their infant to sleep in, if provided, compared with 42% who said they would not and 6% were unsure. Three themes emerged from the data: (1) safety of the cardboard box; (2) appearance, and (3) variation in planned use. Some participants planned to place the cardboard box in their bed.

CONCLUSIONS

Participants in our study were divided about whether they would use the cardboard box for their infant to sleep in. If distributed, hospital staff should advise families to not place the cardboard box in their bed. Next steps include determining bedsharing frequency among parents who choose to use the cardboard box for their infant.

Postpartum Nurses' Experience Caring for Infants With Neonatal Abstinence Syndrome

OBJECTIVES

In previous years, otherwise healthy infants with neonatal abstinence syndrome (NAS) in our hospital were transferred to the NICU and frequently treated with medication. Currently, infants with NAS room-in with their mothers and rarely require medication. We sought to understand the lived experience of nurses on maternity and well-newborn units caring for infants with NAS.

METHODS

We conducted focus groups of registered nurses on postpartum units at 2 hospitals using qualitative methodology. Themes were identified through consensus, and the focus groups were stopped when no new themes were identified.

RESULTS

Seventeen postpartum nurses participated in 5 focus groups. The following major themes emerged: (1) managing the expectations of parents of newborns with NAS, (2) current NAS protocol (positive aspects of rooming-in and challenges with withdrawal scoring tool), (3) inconsistencies in care and communication, (4) perceived increase in nursing workload on the postpartum unit, and (5) nurses' emotional response to the care of infants with NAS.

CONCLUSIONS

We highlight the perspectives of nursing staff on the well-newborn unit who were previously unaccustomed to caring for infants with NAS. With increasing numbers of infants with NAS and longer stays on the well-newborn unit, hospitals must prepare to better support staff and implement protocols that offer consistency in practice.

Infant brain responses to social sounds: A longitudinal functional near-infrared spectroscopy study

Infants are responsive to and show a preference for human vocalizations from very early in development. While previous studies have provided a strong foundation of understanding regarding areas of the infant brain that respond preferentially to social vs. non-social sounds, how the infant brain responds to sounds of varying social significance over time, and how this relates to behavior, is less well understood. The current study uniquely examined longitudinal brain responses to social sounds of differing social-communicative value in infants at 3 and 6 months of age using functional near-infrared spectroscopy (fNIRS). At 3 months, infants showed similar patterns of widespread activation in bilateral temporal cortices to communicative and non-communicative human non-speech vocalizations, while by 6 months infants showed more similar, and focal, responses to social sounds that carried increased social value (infant-directed speech and human non-speech communicative sounds). In addition, we found that brain activity at 3 months of age related to later brain activity and receptive language abilities as measured at 6 months. These findings suggest areas of consistency and change in auditory social perception between 3 and 6 months of age.

Refusal of Vitamin K by Parents of Newborns: A Qualitative Study

OBJECTIVE

Despite American Academy of Pediatrics recommendations, some parents refuse intramuscular (IM) vitamin K as prophylaxis against vitamin K deficiency bleeding for their newborns. The purpose of our study was to describe attitudes and perceptions of parents who choose to defer IM vitamin K for their newborns.

METHODS

Using qualitative methodology, we conducted in-depth semi-structured interviews with parents of newborns in 3 hospitals in Connecticut and California. We used the grounded theory approach and the constant comparative method until saturation was reached.

RESULTS

Nineteen participants (17 mothers and 2 fathers) of 17 newborns were interviewed; 14 newborns did not receive IM vitamin K due to refusal by the parents, and for 3 newborns IM vitamin K administration was delayed due to initial hesitation by the parents. Four major themes emerged: 1) risk-to-benefit ratio, where parents refused IM vitamin K due to a perceived risk to their newborn from preservatives, for example; 2) "natural" approaches, which led to seeking oral vitamin K or increasing the mother's own prenatal dietary vitamin K intake; 3) placement of trust and mistrust, which involved mistrust of the medical and pharmaceutical community with overlapping concerns about vaccines and trust of self, like-minded allopathic and non-allopathic health care providers, the social circle, the internet, and social media; and 4) informed by experiences, reflecting hospital experiences with prior pregnancies and communication with health care providers.

CONCLUSIONS

Parents' perception of risk, preference for alternative options, trust, and communication with health care providers were pivotal factors when making decisions about IM vitamin K.

Newborn Falls in a Large Tertiary Academic Center Over 13 Years

OBJECTIVES

We sought to report the frequency of, circumstances surrounding, and outcomes of newborn falls in our hospital. We evaluated the impact of specific interventions on the frequency of newborn falls and the time between falls.

METHODS

We performed a retrospective study of newborn falls reported on our postpartum unit over a 13-year period. Demographic information and circumstances of falls were collected via an electronic event reporting system and medical record review.

RESULTS

There were 63 633 births and 29 newborn falls, yielding an average of 4.6 falls per 10 000 live births (median: 2 per year; range 0-5 per year). Newborns who sustained a fall were exclusively breastfeeding (75.9%), 24 to 48 hours of age at the time of the fall (58.6%), and had first-time parents (62.1%). At the time of the fall, most newborns were with the mother compared with being with the father or both parents (65.5% vs 34.5%); in the mother's bed compared with being elsewhere, such as on a couch or chair, with a parent, or in the parent's arms (62.1% vs 37.9%); and feeding at the time of the fall versus not (79.3% vs 20.7%). All newborns were monitored after the fall, with no adverse outcomes. Despite interventions, we continued to see cases of newborn falls, although the overall trend revealed decreasing falls per 10 000 patient-days and longer time between falls over the study period.

CONCLUSIONS

Newborn falls in our hospital are infrequent but continue to occur despite preventive efforts, highlighting the importance of continuous awareness and education.

Factors Associated With Refusal of Intramuscular Vitamin K in Normal Newborns

BACKGROUND AND OBJECTIVE

Refusal of intramuscular (IM) vitamin K administration by parents is an emerging problem. Our objective was to assess the frequency of and factors associated with refusal of IM vitamin K administration in well newborns in the United States.

METHODS

We determined the number of newborns admitted to well newborn units whose parents refused IM vitamin K administration in the Better Outcomes through Research for Newborns network and, in a nested patient-control study, identified factors associated with refusal of IM vitamin K administration by using a multiple logistic regression model.

RESULTS

Of 102 878 newborns from 35 Better Outcomes through Research for Newborns sites, parents of 638 (0.6%) refused IM vitamin K administration. Frequency of refusal at individual sites varied from 0% to 2.3%. Exclusive breastfeeding (adjusted odds ratio [aOR] = 3.4; 95% confidence interval [CI]: 2.1-5.5), non-Hispanic white race and/or ethnicity (aOR = 1.7; 95% CI: 1.2-2.4), female sex (aOR = 1.6; 95% CI: 1.2-2.3), gestational age (aOR = 1.2; 95% CI: 1.1-1.4), and mother's age (aOR = 1.05; 95% CI: 1.02-1.08) were significantly associated with refusal of IM vitamin K administration. Refusal of the administration of both ocular prophylaxis and hepatitis B vaccine was also strongly associated with refusal of IM vitamin K administration (aOR = 88.7; 95% CI: 50.4-151.9).

CONCLUSIONS

Refusal of IM vitamin K by parents of newborns is a significant problem. Interventions to minimize risks to these newborns are needed.

Creating a Program for Junior Faculty Professional Development: A Tool Kit

INTRODUCTION

Junior academic faculty must balance increasing clinical responsibilities whilst maintaining academic portfolios aimed at promotion. Our goal was to design, implement, and evaluate a curriculum for career development amongst junior faculty in pediatrics.

METHODS

Following the Kern method of curriculum development, we performed a needs assessment of junior faculty via an electronic survey to identify areas for career development. We created objectives based on the themes identified and developed associated learning activities, including (1) a monthly seminar series, (2) an orientation day for new hires, and (3) a formal mentoring program for junior faculty. At the end of each academic year, we sent electronic surveys to junior faculty participants for program evaluation.

RESULTS

Of 50 junior faculty, 60% completed the initial needs assessment and identified a need for a forum for junior faculty orientation, career development, and formal mentoring. Local experts were solicited to create and lead a 10-part seminar series to cover topics such as CV review, promotions, and mentoring. Twenty-one junior faculty (42%) who did not already have established mentors joined the formal mentoring program. All incoming new junior faculty attended a formal orientation day held annually. At the end of the first year, a follow-up survey for program evaluation was completed by 17 (27%) junior faculty, and 98% reported satisfaction with the learning activities.

DISCUSSION

We successfully developed and implemented a junior faculty career development program at our institution that can be replicated at other institutions.

Results of a Targeted Screening Program for Congenital Cytomegalovirus Infection in Infants Who Fail Newborn Hearing Screening

BACKGROUND

Congenital cytomegalovirus (CMV) infection is a major cause of sensorineural hearing loss. By law, newborns in Connecticut who fail newborn hearing screening are tested for infection with CMV. This targeted screening is controversial, because most children with congenital CMV infection are asymptomatic, and CMV-related hearing loss can have a delayed onset. Our hospital uses a saliva polymerase chain reaction (PCR) assay (confirmed by a urine PCR assay) to detect CMV. Here, we report the results of the first year of our screening program.

METHODS

We reviewed the medical records of newborns in the Yale New Haven Health System who failed the newborn hearing screening test between January 1 and December 31, 2016.

RESULTS

Of 10964 newborns, 171 failed newborn hearing screening, and 3 of these newborns had positive saliva CMV PCR test results. Of these 3 newborns, 2 had positive results on the confirmatory test (for 1 of them the confirmatory test was not performed until the infant was 10 weeks old), and 1 had a negative result on the confirmatory test. Three additional newborns with congenital CMV infection were tested because of clinical indications (1 for ventriculomegaly on prenatal ultrasound and 2 for CMV infection of the mother). Results of audiology follow-up were available for 149 (87.1%) of the 171 newborns who failed newborn hearing screening; 127 (85.2%) had normal results.

CONCLUSION

Our targeted screening program for congenital CMV infection had a low yield. Consideration should be given to other strategies for identifying children at risk of hearing loss as a result of congenital CMV infection.

Vulvar lichen planus pemphigoides

Lichen planus pemphigoides (LPP) is a rare blistering disease with features of both lichen planus and bullous pemphigoid. LPP typically appears on the extremities and occasionally involves the oral mucosa. Herein, we describe a case of LPP of the vulva of an 80-year-old woman, an uncommon location for this disease process. This clinical scenario can be confused with a number of similarly appearing entities such as erosive vulvar lichen planus, mucous membrane pemphigoid, and erosive lichen sclerosus et atrophicus. In fact, our patient carried a diagnosis of lichen sclerosus by an outside physician for 2 years prior to being properly diagnosed and treated. A detailed discussion of the epidemiology, clinical, and pathogenesis as well as the histologic and immunofluorescence characteristics of this uncommon diagnosis is presented. Our case emphasizes the necessity of microscopic analysis to differentiate lookalike disease states when making a diagnosis and choosing the correct therapeutics.

Refusal of Vitamin K by Parents of Newborns: A Survey of the Better Outcomes Through Research for Newborns Network

OBJECTIVE

To survey newborn clinicians in the United States regarding the frequency of intramuscular (IM) vitamin K refusal by a parent, reasons for refusal, and approaches of clinicians to refusals.

METHODS

An electronic survey was administered to the clinician site representative (nursery director or designee knowledgeable about site-specific nursery policies) at all newborn nurseries in the Better Outcomes through Research for Newborns (BORN) network of newborn nurseries.

RESULTS

Of 92 BORN sites, 85 (92%) respondents completed the survey. Frequency of IM vitamin K refusal during the past 5 years was reported as increased by 52% of respondents, unchanged by 42%, and 6% did not know. Reported frequencies of refusal of IM vitamin K was weekly (9%), a few times a month (31%), once a month (13%), once every 3 to 4 months (20%), once or twice a year (26%), or never (1%). The overall distribution of the reported frequencies of refusal differed among regions in the United States (higher in the West and the South; P < .05). Reported reasons for refusal by parents included perceptions of parents that the injection was unnecessary, lack of knowledge about vitamin K deficiency bleeding, and concern about preservatives. Approaches to refusal included attempts to educate parents, enlisting support from community clinicians, a state mandate, and prescription of oral vitamin K.

CONCLUSIONS

Respondents from a national sample of newborn nursery clinicians reported an increase in refusal of IM vitamin K in the past 5 years with regional variation. Approaches to refusals need further investigation to determine effectiveness.

Evaluation of a Screening Program to Detect Critical Congenital Heart Defects in Newborns

OBJECTIVES

To report the results of and to identify problems with implementing a screening program to detect critical congenital heart defects (CCHDs) in newborns by using differential pulse oximetry (POx).

METHODS

Charts of all live-born infants from 4 Yale-New Haven health system hospitals in Connecticut between January 1 and December 31, 2014, were reviewed.

RESULTS

Of 10 589 newborns, 171 (1.6%) underwent an echocardiogram before screening, 10 320 (97.5%) were screened by POx, and 98 (0.9%) were not screened. Thirteen newborns (0.1%) were diagnosed with a CCHD. No infants with CCHDs were identified through POx screening (POxS) alone. Eleven (85%) were already suspected of having a CCHD lesion on the basis of prenatal ultrasound, 1 (8%) was diagnosed because of clinical concern before undergoing screening, and 1 (8%) had a false-negative screening result, but a CCHD was identified after an echocardiogram was performed because a murmur was heard. Four infants with a positive POx screen showed noncritical cardiac lesions by echocardiogram. The majority of infants were screened within the recommended 24 to 72 hours of age interval and had POx screens that were interpreted and documented correctly. Of 10 316 infants with negative POx screens, 52.1% were still in the Yale-New Haven Hospital health system at 1 year of age and no CCHD lesions were listed in their charts.

CONCLUSIONS

Although a CCHD screening program was effectively implemented, perhaps because most children with a CCHD (85%) were detected antenatally by ultrasound, in our hospital system POxS did not lead to a substantial increase in the early identification of CCHDs.

Simulated colonoscopy training using a low-cost physical model improves responsiveness of surgery interns

AIM

Surgery residents are required to become proficient in colonoscopy before completing training. The aim of this study was to evaluate the responsiveness of surgery interns to simulated colonoscopy training.

METHOD

Interns, defined as postgraduate year 1 residents without exposure to endoscopy, underwent training in a physical model including colonoscopy, synthetic anatomy trays with luminal tattoos and a hybrid simulator. After baseline testing and mentored training, final testing was performed using five predetermined proficiency criteria. Content-valid metrics defined by the extent of departure from clinical reality were evaluated by two blinded assessors. Responsiveness was defined as change in performance over time and assessed comparing baseline testing with nonmentored final testing.

RESULTS

Twelve interns (eight male, mean age 26, 80% right-handed) performed 48 colonoscopies each over 1 year. Improvement was seen in the overall procedure time (24 min 46 s vs 20 min 54 s; P = 0.03), passing the splenic flexure (20 min 33 s vs 10 min 45 s; P = 0.007), passing the hepatic flexure (23 min 31 s vs 12 min 45 s; P = 0.003), caecal intubation time (23 min 38 s vs 13 min 26 s; P = 0.008), the duration of loss of view of the lumen (75% vs 8.3%; P = 0.023), incomplete colonoscopy (100% vs 33.3%; P = 0.042), colonoscope withdrawal < 6 min (16.7% vs 8.3%; P = 0.052). Tattoo identification time (9 min 16 s vs 12 min 25 s; P = 0.50), colon looped time (2 min 12 s vs 1 min 45 s; P = 0.50) and rate of colon perforation (8.3% vs 8.3%; P = 1) remained unchanged. Interrater reliability was 1.0 for all measures.

CONCLUSION

Simulated colonoscopy training in a low-cost physical model improved the performance of surgery interns with decreased procedure time, increased rates of complete colonoscopy and appropriate scope withdrawal.