[COMMUNITY PEDIATRICS IN ISRAEL DURING THE NEXT DECADE - A NEED FOR A CHANGE].

INTRODUCTION: Community pediatrics in Israel is based on service by pediatricians who have been trained in hospitals in Israel or elsewhere. At the same time, the field of community pediatrics is changing its nature from the management of common acute diseases, to a field dealing with a variety of chronic problems, behavioral issues, family and social issues, developmental delays, problems relating to nutrition and growth' sleep problems, learning disabilities, and of late, excessive exposure to a host of digital media. In addition, lifestyle issues such as adequate physical activity, addictions, accidents and various types of abuse are increasingly part of the pediatric role. The hospital-based residency training of pediatricians does not offer the future pediatrician the opportunity to learn these elements of the "New Morbidity". As a result, many community-based pediatricians choose not to confront these problems, and either ignore them or refer them to various consultants outside of the clinic. The entire health system, including the Ministry of Health, the Israel Medical Association, the medical schools, the health service providers (Kupot Holim) and the hospitals must cooperate in changing the format of residency training, both undergraduate and residency. This is required in order to create a new generation of pediatricians who are better equipped to deal with the increasing number of children needing help with the above-mentioned pathology. Advancing the field of primary care pediatrics by attending to these New Morbidity issues, together with pediatric involvement in community agencies, after appropriate training, will improve the health and development of the child population, together with improvement of their physical, emotional and social welfare.

Delivery room breastfeeding for prevention of hypoglycaemia in infants of diabetic mothers.

OBJECTIVE: To evaluate the effect of duration of early breastfeeding in the delivery room on blood glucose levels among term neonates of diabetic mothers. METHODS: Mothers with gestational diabetes were encouraged to breastfeed their infants immediately after birth in the delivery room. The breastfeeding duration was recorded by the midwife. RESULTS: The longer duration of breastfeeding subgroup (n = 39) demonstrated a lower rate of hypoglycaemia in the first 8 hours of life (< 40 mg/dl) compared to the shorter duration subgroup (n = 40), but this difference did not reach statistical significance (2.6% vs. 17.5% respectively, p = 0.057). Hypoglycaemia was mainly predicted by lower cord glucose for each decrease of 10 mg/dl (OR 2.11 [CI 1.1-4.03] p = 0.024. CONCLUSION: Longer duration of delivery room breastfeeding did not reduce the rate of hypoglycaemia, which was mainly influenced by lower cord blood glucose level.

Excessively high bilirubin and exchange transfusion in very low birth weight infants.

AIM: To evaluate the performance of exchange transfusion in very low birth weight (VLBW) infants with excessively high serum bilirubin levels. METHODS: A population-based observational study using data collected by the Israel National VLBW Infant Database. The study sample comprised 13,499 infants. Two definitions of excessively high-peak bilirubin levels that might be considered as threshold levels for performance of exchange transfusion were used. First, a bilirubin level of ≥15 mg/dL for all infants (PSB-15), and second, incremental bilirubin levels ranging from 12 to 17 mg/dL according to gestational age (PSB-GA). RESULTS: Four hundreds sixty-eight (3.5%) and 1035 infants (7.7%) infants in the PSB-15 and in the PSB-GA groups respectively had peak serum bilirubin levels above thresholds for exchange transfusion. Exchange transfusions were performed in 66 (14.1%) of these infants in the PSB-15 group and 91 (8.8%) in the PSB-GA group. Using logistic regression analysis, peak serum bilirubin was found as an independent factor for performing exchange transfusion. CONCLUSION: Exchange transfusion was performed in only 9-14% of VLBW infants with excessively high bilirubin levels. We speculate that this may be a result of an absence of definitive guidelines or the possible belief that the risks of exchange transfusion outweigh the potential risk of bilirubin-induced neurological injuries.

Community-level evidence for SARS-CoV-2 vaccine protection of unvaccinated individuals.

Mass vaccination has the potential to curb the current COVID-19 pandemic by protecting individuals who have been vaccinated against the disease and possibly lowering the likelihood of transmission to individuals who have not been vaccinated. The high effectiveness of the widely administered BNT162b vaccine from Pfizer-BioNTech in preventing not only the disease but also infection with SARS-CoV-2 suggests a potential for a population-level effect, which is critical for disease eradication. However, this putative effect is difficult to observe, especially in light of highly fluctuating spatiotemporal epidemic dynamics. Here, by analyzing vaccination records and test results collected during the rapid vaccine rollout in a large population from 177 geographically defined communities, we find that the rates of vaccination in each community are associated with a substantial later decline in infections among a cohort of individuals aged under 16 years, who are unvaccinated. On average, for each 20 percentage points of individuals who are vaccinated in a given population, the positive test fraction for the unvaccinated population decreased approximately twofold. These results provide observational evidence that vaccination not only protects individuals who have been vaccinated but also provides cross-protection to unvaccinated individuals in the community.

International workshop on the future of community child healthcare.

Increasing numbers of children with developmental, emotional, and psychosocial issues require adaptation of the services provided by pediatricians in the community. An international workshop that took place in Israel on June 3-4, 2019, addressed this need. Local policy makers and international experts discussed the following topics: (1) the future of training in community pediatrics; (2) enhancing the prestige of the community pediatrician; (3) development of management and research skills; (4) academic advancement within community pediatrics; (5) the future content of community pediatric practice; (6) visit length and community pediatricians' reimbursement; (7) developing the collaborative model of care in community pediatrics and (8) integrating child healthcare. The meeting provided a venue to understand the challenges and to formulate recommendations to policymakers. A key target highlighted was the increased exposure of all pediatric residents to community pediatrics. This gained the support of the Chief Executive Officers of all four Health Funds in Israel. This document provides a synopsis of the topics addressed and suggested recommendations.