"Good Catch, Kiddo"-Enhancing Patient Safety in the Pediatric Emergency Department Through Simulation.

OBJECTIVES: Adverse events that affect patient safety are a significant concern in pediatrics. Increasing situational awareness, identifying errors and near misses, and reporting them using organizational incident reporting systems enables mitigation of harm. METHODS: We designed and tested a brief, interactive, and easily replicable simulation activity for medical students, and emergency medicine interns and pediatric interns to strengthen their skills and enhance their self-efficacy in identifying and reporting patient safety hazards. Hazards fell into the categories of situational safety, patient identification and privacy, infection prevention, treatment errors, and issues with electronic health records (EHRs). RESULTS: The simulation training significantly increased the self-efficacy of medical students and interns in identifying and reporting patient safety hazards. Learners were very satisfied with the simulation training, successfully recognized key patient safety hazards, provided feedback to improve the training, and improved their ability to report hazards through organizational incident reporting systems. Patient safety hazards associated with patient misidentification were recognized most frequently, whereas safety hazards associated with EHRs were missed with the greatest frequency. CONCLUSIONS: The simulation training enabled learners to identify hazards and near misses and enhanced their ability to report hazards through organizational incident reporting systems. Learners at all levels of training identified safety hazards at comparable rates, which demonstrates the role that trainees play in critically observing clinical settings with fresh eyes and identifying and reporting patient safety hazards. Interventions to promote patient safety need to prioritize building situational awareness of potential hazards associated with EHR use.

The care and keeping of clinicians in quality improvement.

OBJECTIVE: Although frontline clinicians are crucial in implementing and spreading innovations, their engagement in quality improvement remains suboptimal. Our goal was to identify facilitators and barriers to the development and engagement of clinicians in quality improvement. DESIGN: A 25-item questionnaire informed by theoretical frameworks was developed, tested and disseminated by email. SETTINGS: Members and fellows of the International Society for Quality in Healthcare. PARTICIPANTS: 1010 eligible participants (380 fellows and 647 members). INTERVENTIONS: None. MAIN OUTCOME MEASURES: Self-efficacy and effectiveness in conducting and leading quality improvement activities. RESULTS: We received 212 responses from 50 countries, a response rate of 21%. Dedicated time for quality improvement, mentorship and coaching and a professional quality improvement network were significantly related to higher self-efficacy. Factors enhancing effectiveness were dedicated time for quality improvement, multidisciplinary improvement teams, professional development in quality improvement, ability to select areas for improvement and organizational values and culture. Inadequate time, mentorship, organizational support and access to professional development resources were key barriers. Personal strengths contributing to effectiveness were the ability to identify problems that need to be fixed, reflecting on and learning from experiences and facilitating sharing of ideas. Key quality improvement implementation challenges were adopting new payment models, demonstrating the business case for quality and safety and building a culture of accountability and transparency. CONCLUSIONS: Our findings highlight areas that organizations and professional development programs should focus on to promote clinician development and engagement in quality improvement. Barriers related to training, time, mentorship, organizational support and implementation must be concurrently addressed to augment the effectiveness of other approaches.

A three-year multifaceted intervention to prevent obesity in children of Mexican-heritage.

BACKGROUND: Obesity and overweight have increased dramatically in the United States over the last decades. The complexity of interrelated causal factors that result in obesity needs to be addressed within the cultural dynamic of sub-populations. In this study, we sought to estimate the effects of a multifaceted, community-based intervention on body mass index (BMI) among Mexican-heritage children. METHODS: Niños Sanos, Familia Sana (Healthy Children, Healthy Family) was a quasi-experimental intervention study designed to reduce the rate of BMI growth among Mexican-heritage children in California's Central Valley. Two rural communities were matched based on demographic and environmental characteristics and were assigned as the intervention or comparison community. The three-year intervention included parent workshops on nutrition and physical activity; school-based nutrition lessons and enhanced physical education program for children; and a monthly voucher for fruits and vegetables. Eligible children were between 3 and 8 years old at baseline. Intent-to-treat analyses were estimated using linear mixed-effect models with random intercepts. We ran a series of models for each gender where predictors were fixed except interactions between age groups and obesity status at baseline with intervention to determine the magnitude of impact on BMI. RESULTS: At baseline, mean (SD) BMI z-score (zBMI) was 0.97 (0.98) in the intervention group (n = 387) and 0.98 (1.02) in the comparison group (n = 313) (NS). The intervention was significantly associated with log-transformed BMI (ß = 0.04 (0.02), P = 0.03) and zBMI (ß = 0.25 (0.12), P = 0.04) among boys and log-transformed BMI among obese girls (ß = - 0.04 (0.02), P = 0.04). The intervention was significantly and inversely associated with BMI in obese boys and girls across all age groups and normal weight boys in the oldest group (over 6 years) relative to their counterparts in the comparison community. CONCLUSIONS: A community-based, multifaceted intervention was effective at slowing the rate of BMI growth among Mexican-heritage children. Our findings suggest that practitioners should consider strategies that address gender disparities and work with a variety of stakeholders to target childhood obesity. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01900613 . Registered 16th July 2013.

Using an online quiz-based reinforcement system to teach healthcare quality and patient safety and care transitions at the University of California.

QUALITY ISSUE: Implementing quality improvement (QI) education during clinical training is challenging due to time constraints and inadequate faculty development in these areas. INITIAL ASSESSMENT: Quiz-based reinforcement systems show promise in fostering active engagement, collaboration, healthy competition and real-time formative feedback, although further research on their effectiveness is required. CHOICE OF SOLUTION: An online quiz-based reinforcement system to increase resident and faculty knowledge in QI, patient safety and care transitions. IMPLEMENTATION: Experts in QI and educational assessment at the 5 University of California medical campuses developed a course comprised of 3 quizzes on Introduction to QI, Patient Safety and Care Transitions. Each quiz contained 20 questions and utilized an online educational quiz-based reinforcement system that leveraged spaced learning. EVALUATION: Approximately 500 learners completed the course (completion rate 66-86%). Knowledge acquisition scores for all quizzes increased after completion: Introduction to QI (35-73%), Patient Safety (58-95%), and Care Transitions (66-90%). Learners reported that the quiz-based system was an effective teaching modality and preferred this type of education to classroom-based lectures. Suggestions for improvement included reducing frequency of presentation of questions and utilizing more questions that test learners on application of knowledge instead of knowledge acquisition. LESSONS LEARNED: A multi-campus online quiz-based reinforcement system to train residents in QI, patient safety and care transitions was feasible, acceptable, and increased knowledge. The course may be best utilized to supplement classroom-based and experiential curricula, along with increased attention to optimizing frequency of presentation of questions and enhancing application skills.

Prevalence and Perception of Childhood Obesity in California's Farmworker Communities.

In California's central valley, childhood obesity rates are above the national average. The majority of families living in the rural, agricultural communities of this region are immigrant of Mexican heritage, and face numerous social and environmental challenges. Demographic and anthropometric data were collected from a population of Mexican-heritage children 3-8 years (N = 609) and families (N = 466) living in two central valley communities. Overall, 45 % of children and 82 % of mothers were classified as overweight or obese. Multivariable analyses indicated that mother's BMI and acculturation level were positively associated with child BMI z-score. Most children classified as overweight or obese (92 % and 53 %, respectively) were perceived as having 'normal' weight by their mothers. Childhood obesity remains a major public health issue in Mexican-heritage, central valley communities. Our model indicates that mother's BMI is predictor of child obesity, and parents tend to underestimate their child's weight status. These findings highlight a need for family-targeted and culturally-tailored approaches to address relevant perceptions of obesity and risk factors in these communities.

Addressing health disparities in rural communities using telehealth.

The regionalization of pediatric services has resulted in differential access to care, sometimes creating barriers to those living in underserved, rural communities. These disparities in access contribute to inferior healthcare outcomes among infants and children. We review the medical literature on telemedicine and its use to improve access and the quality of care provided to pediatric patients with otherwise limited access to pediatric subspecialty care. We review the use of telemedicine for the provision of pediatric subspecialty consultations in the settings of ambulatory care, acute and inpatient care, and perinatal and newborn care. Studies demonstrate the feasibility and efficiencies gained with models of care that use telemedicine. By providing pediatric subspecialty care in more convenient settings such as local primary care offices and community hospitals, pediatric patients are more likely to receive care that adheres to evidence-based guidelines. In many cases, telemedicine can significantly improve provider, patient, and family satisfaction, increase measures of quality of care and patient safety, and reduce overall costs of care. Models of care that use telemedicine have the potential to address pediatric specialists' geographic misdistribution and address disparities in the quality of care delivered to children in underserved communities.

Can hospitalists improve COVID-19 vaccination rates?

Three years after the start of the SARS-CoV-2 virus (COVID-19) pandemic, its effects continue to affect society and COVID-19 vaccination campaigns continue to be a topic of controversy and inconsistent practice. After experiencing spikes in COVID-19 cases, our University of California Davis Health Division of Hospital Medicine sought to understand the reasons underlying the low COVID-19 vaccination rates in our county and find approaches to improve the number of vaccinations among adults admitted to the inpatient setting. This quality improvement project aimed to increase COVID-19 primary and booster vaccine efforts through a multi-pronged approach of increased collaboration with specialised staff and optimisation of use of our electronic health record system.Our key interventions focused on developing a visual reminder of COVID-19 vaccine status using the functionality of our electronic medical record (EMR), standardising documentation of COVID-19 vaccine status and enhancing team-based vaccination discussions through team huddles and partnering with inpatient care coordinators. While our grassroots approach enhanced COVID-19 vaccination rates in the inpatient setting and had additional benefits such as increased collaboration among teams, system-level efforts often made a greater impact at our healthcare centre. For other institutions interested in increasing COVID-19 vaccination rates, our top three recommendations include integrating vaccination into pre-existing workflows, optimising EMR functionality and increasing vaccine accessibility in the inpatient setting.

Niños Sanos, Familia Sana: Mexican immigrant study protocol for a multifaceted CBPR intervention to combat childhood obesity in two rural California towns.

BACKGROUND: Overweight and obese children are likely to develop serious health problems. Among children in the U.S., Latino children are affected disproportionally by the obesity epidemic. Niños Sanos, Familia Sana (Healthy Children, Healthy Family) is a five-year, multi-faceted intervention study to decrease the rate of BMI growth in Mexican origin children in California's Central Valley. This paper describes the methodology applied to develop and launch the study. METHODS/DESIGN: Investigators use a community-based participatory research approach to develop a quasi-experimental intervention consisting of four main components including nutrition, physical activity, economic and art-community engagement. Each component's definition, method of delivery, data collection and evaluation are described. Strategies to maintain engagement of the comparison community are reported as well. DISCUSSION: We present a study methodology for an obesity prevention intervention in communities with unique environmental conditions due to rural and isolated location, limited infrastructure capacity and limited resources. This combined with numerous cultural considerations and an unstable population with limited exposure to researcher expectations necessitates reassessment and adaptation of recruitment strategies, intervention delivery and data collection methods. Trial registration # NCT01900613. TRIAL REGISTRATION: NCT01900613.

Telemedicine and face-to-face care for pediatric obesity.

The University of California Davis Medical Center (Sacramento, CA) has pioneered the use of telemedicine in its approach to childhood obesity to cover more than 20 rural clinics in California. In our study, we compared the outcomes of the Telemedicine Weight Management Clinic (TM) with those of its face-to-face (FTF) Weight Management Clinic counterpart over the last 5 years, predicting the results to be equivalent or in favor of TM. All children seen in the TM from June 2006 to June 2011 were included (n=121), and encounter notes in medical records were reviewed. For comparison, an equivalent sample of FTF patients was selected from that time frame (n=122). Data that were also abstracted from the medical record included age at first visit, gender, race, referral site, and comorbid diagnoses. Forty-two percent of TM patients compared with 52% of FTF patients received a change in diagnosis. Thirty-nine percent of TM patients received a change in diagnostic evaluation compared with 67% of patients in FTF. When comparing patients who received more than one visit with either form of consultation, the TM group demonstrated substantially more improvement than the FTF group in improving nutrition (88% versus 65%), increasing activity (76% versus 49%), and decreasing screen time (33% versus 8%). Substantially more TM patients were successful with a combined outcome of any one of the weight parameters that included weight loss, weight maintenance, or slowing of weight gain (69% TM versus 44% FTF). Our study suggests that telemedicine can serve as a feasible strategy to increase access to medical care for childhood obesity in rural communities and promote changes in lifestyle with the goal of maintaining a healthy weight.

Understanding adolescent stress during the COVID-19 pandemic.

Longitudinal studies across the globe documented significant increases in psychological stress and mental health problems among adolescents during the COVID-19 pandemic. Health concerns, school disruptions, and social disconnection were major sources of stress. High levels of perceived stress predicted worse mental health outcomes, with girls, older adolescents, and socio-economically marginalized youth experiencing more pronounced mental health deteriorations. However, social support from family and peers was a protective factor against increased stress and accompanying mental health problems. We urge policymakers and other key decision-makers to improve the availability and financing of mental health services and support programs for adolescents to address the wave of mental health challenges following the pandemic.

Impacts of a Multicenter Medical Education Curriculum for Training Pediatric Residents on Tobacco Cessation for Adult Caregivers of Pediatric Patients.

The Clinical Effort Against Secondhand Smoke Exposure (CEASE) is an evidence-based framework that increases pediatric providers' ability to address secondhand smoke exposure of minors. Physician champions at 4 University of California sites conducted regular 1-hour didactic trainings on CEASE principles to pediatric residents as part of a longitudinal curriculum. At the conclusion of the academic year, 111 of 284 residents (39%) completed an anonymous survey. CEASE-trained residents reported significantly higher rates than untrained residents of counseling on smoking cessation (adjusted odds ratio [OR] = 4.50, P = .009), and referring to the smokers' quitline (adjusted OR 3.6, P = .007) to 50% or more of their patients' caregivers who smoked. In addition, among CEASE-trained residents, there were significant increases in multiple post-training knowledge and self-efficacy items. Our results show that a brief educational curriculum can be helpful in changing pediatric residents' attitudes and behavior toward assisting adult caregivers to pediatric patients in smoking cessation.

Clinical practice and variation in care for childhood obesity at seven clinics in California.

BACKGROUND: The Healthy Eating Active Living TeleHealth Community of Practice is a virtual quality-improvement learning network of seven rural clinics in California. The goal of this network is to improve childhood obesity prevention and management practices at participating clinics. AIM: Our objective is to describe clinical practices regarding weight assessment and nutrition and physical activity counselling at participating clinics before implementation of the quality improvement intervention. METHODS: Participants were 2-11 year old children seen for well-child care in 2010. Telephone surveys of English and Spanish-speaking parents were conducted within three days of their child's well-child visit to determine the content of counselling during the visit regarding nutrition and physical activity. Medical record reviews were conducted to determine clinicians' assessment of weight status. FINDINGS: Twenty-seven clinicians conducted 144 well-child visits included in the study. Body mass index (BMI) was documented in 71% of medical records. Fewer than 10% of medical records had documentation of weight category. Sixty-nine percent of parents received counselling on physical activity and 62% reported receiving counselling on fruit and vegetable intake. Parents were counselled less frequently on breakfast intake, sweetened beverages, television and family meals. Parents of overweight/obese children did not receive more counselling than parents of children with a healthy BMI. Clinician-level effects accounted for moderately large amount of variation in counselling, but accounted for smaller variation in documentation of BMI and weight category. There was high between-clinic variation in documentation practices, with 54% of the total variance for documentation attributable to clinic-level effects. CONCLUSIONS: Rural clinicians, like those elsewhere, do not uniformly assess BMI percentile or counsel families on behavioural risk factors for paediatric obesity. There exists considerable clinician-level variation in counselling practices and clinic-site level correlation in documentation practices related to BMI percentile and weight category.

Comparison of parent satisfaction with care for childhood obesity delivered face-to-face and by telemedicine.

OBJECTIVE: Childhood obesity is a serious health concern, especially in rural areas. Its management involves in-depth lifestyle and psychosocial assessment as well as patient-centered counseling. Telemedicine has increased the ability of patients in rural areas to obtain subspecialty consultations. Our objective was to determine whether a significant difference in quality of care, as measured by parent satisfaction, existed between consultations for childhood obesity delivered face to face and by telemedicine. MATERIALS AND METHODS: We performed a pilot study in which questionnaires were distributed to parents of children under 12 years of age who had received consultations for childhood obesity at a university-affiliated pediatric weight management clinic, either face to face or by telemedicine. The questionnaires assessed various aspects of quality of care and patient-centered care including consulting providers' listening skills, ease of understanding instructions delivered to patients and their families, and the comfort level of parents in discussing health concerns. RESULTS: A total of 54 surveys were collected (22 telemedicine, 32 face-to-face). Of those, 25 (10 telemedicine, 15 face-to-face) met inclusion criteria. There was no difference in overall parent satisfaction with consultations between the two groups. However, parents rated telemedicine visits slightly lower than face-to-face visits when asked whether the provider explained things about the child's health in a way that was easy to understand (p=0.01). All parents of children who had received care via telemedicine said that they would participate in telemedicine consultations again. CONCLUSIONS: In our pilot, there was no significant difference in parent satisfaction between consultations for childhood obesity delivered face to face and by telemedicine. Therefore, preliminary evidence suggests that childhood obesity care delivered by telemedicine can improve access to quality patient-centered care in underserved rural areas. An important limitation is our sample size, which was not large enough to determine whether satisfaction in the telemedicine group was greater than in the face-to-face group.

Addressing Environmental Smoke Exposure During Pediatric Hospitalization: Attitudes and Practices of Pediatric Nurses Versus Respiratory Therapists.

BACKGROUND: Tobacco smoke exposure leads to numerous adverse health effects in children. Providing cessation interventions to caregivers who smoke during pediatric hospitalizations can help protect children from such exposure. Both pediatric registered nurses (RNs) and pediatric respiratory therapists (RTs) are well positioned to provide these interventions. Little is known about their rates of participation in cessation efforts. Our objective was to compare the attitudes and practice of pediatric RNs versus pediatric RTs to evaluate their relative cessation-intervention practices in the in-patient pediatric setting. METHODS: An online survey was sent to pediatric RNs and RTs at 4 tertiary pediatric hospitals in California. The survey assessed individual demographics, work environment, experience, beliefs, and practices related to smoking cessation activities. Questions used 3-point and 5-point Likert scales and were compared with the chi-square test. Institutions with a response rate < 20% were excluded. RESULTS: A total of 401 respondents were included in the final analysis (292 RNs, 109 RTs). RTs versus RNs were older (42.0 y vs 35.4 y, respectively, P < .001) and more likely to be former smokers (29.9% vs 13.3%, respectively, P < .001). RNs reported lower levels of confidence in discussing smoking cessation with parents, with 11.7% saying they felt "very confident" compared to 29.0% of RTs (P < .001). RNs also reported screening for smoke exposure less frequently than RTs, with 18.8% responding "often" or "always" compared to 28.9% of RTs (P = .033). RNs had lower rates of advising parents "to make a smoke-free home policy" compared to RTs (ie, 13.4% vs 26.9%, respectively, P = .002). CONCLUSIONS: Compared to in-patient pediatric RNs, RTs reported higher rates of confidence in providing cessation interventions, screening for smoke exposure, and counseling on reducing smoke exposure, suggesting that they may be better positioned for intervening. These results can inform the design of an in-patient cessation intervention for caregivers of hospitalized children.

Preventing Home Medication Administration Errors.

Medication administration errors that take place in the home are common, especially when liquid preparations are used and complex medication schedules with multiple medications are involved; children with chronic conditions are disproportionately affected. Parents and other caregivers with low health literacy and/or limited English proficiency are at higher risk for making errors in administering medications to children in their care. Recommended strategies to reduce home medication errors relate to provider prescribing practices; health literacy-informed verbal counseling strategies (eg, teachback and showback) and written patient education materials (eg, pictographic information) for patients and/or caregivers across settings (inpatient, outpatient, emergency care, pharmacy); dosing-tool provision for liquid medication measurement; review of medication lists with patients and/or caregivers (medication reconciliation) that includes prescription and over-the-counter medications, as well as vitamins and supplements; leveraging the medical home; engaging adolescents and their adult caregivers; training of providers; safe disposal of medications; regulations related to medication dosing tools, labeling, packaging, and informational materials; use of electronic health records and other technologies; and research to identify novel ways to support safe home medication administration.

Presentation of body mass index within an electronic health record to improve weight assessment and counselling in children and adolescents.

BACKGROUND: Assessment of weight and counselling on nutrition and physical activity is infrequently conducted during well child visits, despite recent expert recommendations. OBJECTIVE: We investigated whether automatic calculation of body mass index (BMI) in an electronic health record improved assessment of weight and counselling on nutrition and physical activity. METHODS: Retrospective review of well child visit records of children between two and 18 years of age (n =550) before and after implementation of an electronic health record system at an academic medical centre's paediatric clinic. Body mass index was automatically calculated and presented within the electronic health record. We measured clinicians' documentation of assessment of weight status, and assessment of and counselling for nutrition and physical activity risk factors. RESULTS: Documentation of assessment of BMI and weight status did not increase. There were no consistent increases in assessment for or counselling on specific nutrition and physical activity behaviours, except with respect to high calorie food intake. Although overall assessment of physical activity decreased, physical activity counselling significantly increased. Documentation of the presence of high-risk family history increased significantly; the provision of counselling for high-risk family history did not show any corresponding increase. Patients with higher BMI percentile scores were more completely assessed for weight status. Completeness of weight status assessment was associated with increased counselling for nutrition and physical activity. CONCLUSIONS: Passive changes, such as automatic calculation of BMI, are insufficient to result in systematic improvements in assessment of weight and counselling for nutrition and physical activity.

Improving blood pressure screening and control at an academic health system.

The goal of the University of California Davis Health Blood Pressure (BP) Quality Improvement Initiative was to improve the diagnosis, management and control of high BP. Patients aged 18-85 years were included in the initiative. Lean A3 problem solving was used to implement the following evidence-based interventions based on stakeholder interviews, value stream mapping and the Centers for Disease Control and Prevention's Million Hearts Initiative: staff training on accurate BP measurement, visual cues and reminders for BP screening, virtual case-based videoconferences, standardised clinical management algorithm, academic detailing visits, clinical decision support tools, access to pharmacists for medication comanagement, clinician workflow modification, patient education and access to home BP monitors. Following implementation of interventions, accurate screening of BP increased from 14% to 87% and BP control increased from 62% to 75%. Strategies that contributed the most to improvements were using a team-based approach, adjusting clinic workflow and frequent communication of results to staff.

Weight status of children and adolescents in a telepsychiatry clinic.

The prevalence of overweight and obesity is approximately 32% among children and adolescents in the United States. Comorbid conditions associated with pediatric overweight and obesity include psychiatric conditions. The purpose of this study was to determine the prevalence of overweight and obesity among children and adolescents presenting for consultation from rural communities to the UC Davis Telemedicine Program (UCDTP), as well as to collect preliminary data to design an integrated disease management program for children and adolescents with obesity and mental illness. Patients aged 21 and under seen for psychiatric consultation at the UCDTP between 2004 and 2006 were included. Retrospective medical record review was conducted to determine the major psychiatric diagnoses, height, weight, body-mass index, and weight status (underweight/at risk for underweight, normal weight, overweight, or obese) for each patient. Of the 230 patients referred, a total of 121 patients had both height and weight values documented. Three patients were underweight; 51 were normal weight; 28 were overweight; 39 were obese. The most common psychiatric diagnoses in the 121 patients were attention deficit/hyperactivity disorder (ADHD; n = 40), bipolar disorder (n = 36), and depression (n = 31). The most common psychiatric diagnoses in patients with available weight and height data who were overweight and obese were bipolar disorder (n = 20), depression (n = 18), and ADHD (n = 17). Approximately 55% of child and adolescent patients seen for telepsychiatry consultation whose charts documented height and weight measurements were overweight or obese. Psychiatric diagnoses in overweight youngsters need to be researched further to determine whether the weight change is primary or secondary to mood and/or to treatments, such as medication. At such a high rate of comorbidity, monitoring the weight status of young psychiatric patients in this population is indicated.

For debate: childhood obesity - is there hope for therapy and prevention?

The diagnosis and treatment of co-morbidities of obesity that were once the province of clinicians who treated adult patients, are now among the daily activities of pediatricians. The approach to therapy usually involves changes in diet and activity, or medical or surgical therapies. However, limited proven effect of most efforts at treatment and limited personnel to handle the overwhelming needs make it clear that overweight and obesity in youth must be addressed by significant public health measures rather than primarily by a medical model of disease. This editorial argues that given the limited proven long-term efficacy of most treatment programs once obesity develops, the prevention of obesity should be at the forefront of our efforts to address this epidemic of chronic disease.

The breastfeeding mother and the pediatrician.

An estimated 70% of mothers in the United States initiate breastfeeding annually. Mothers often discuss breastfeeding problems with their infant's pediatrician. Pediatricians may feel unsure about their role when assisting the nonpatient, breastfeeding mother. By having practical solutions and support systems in place to anticipate and tend to breastfeeding mothers' needs, pediatricians can be instrumental in preventing early weaning. The purpose of this article is to provide practical suggestions to outpatient-based pediatric health care providers when assisting the breastfeeding dyad.