Newborn Weight Loss Tool and Readmission for Hyperbilirubinemia.

OBJECTIVE: The aim of this study was to determine if the Newborn Weight Loss Tool (NEWT) can predict hospital readmission due to hyperbilirubinemia. STUDY DESIGN: This is a case-control study of 93 newborns and 186 controls ≥35 weeks' gestation. All were discharged from the Mother-Baby unit of an urban academic center and subsequently readmitted for hyperbilirubinemia. Controls were matched for date of birth, gestational age, and Bhutani risk zone. All infants were screened for hyperbilirubinemia prior to discharge and managed according to American Academy of Pediatrics guidelines in place at the time. Chi-square, Fisher's exact test, and multivariate analysis were utilized as appropriate. RESULTS: There was no significant difference between the groups for a NEWT < 50% at discharge. More cases than controls breastfed. A significantly greater percentage of cases had NEWT > 50% at readmission than discharge. NEWT > 90% was moderately associated with readmission for hyperbilirubinemia (p = 0.081). CONCLUSION: NEWT provides a more nuanced assessment of weight loss following birth and can aid in highlighting newborns at risk for readmission due to hyperbilirubinemia. KEY POINTS: · Weight loss is a risk factor for readmission after birth.. · NEWT is a more nuanced assessment of weight loss.. · NEWT > 90% is associated with readmission for jaundice..

Timeliness of Immunizations in CenteringParenting.

OBJECTIVE: To evaluate the timeliness of immunizations of children in CenteringParenting (Centering), a group well-child model, compared to children in individual well-child care. METHODS: We conducted a retrospective cohort study of infants born October 1, 2014 to February 18, 2019 with a 2-month and subsequent well-child visit, both Centering or individual, at an academic pediatric practice in an urban, low-income community. In Centering, same age infants/mothers and a provider meet for 10, 2-hour group visits, and facilitated discussions. Providers are trained in group facilitation and participate in both Centering and individual visits. Primary outcome was timeliness of immunizations at 7, 13, 19, and 25 months. Analyses were by intention to treat. RESULTS: The study population included 1735 children (Centering n = 342, individual n = 1393). By 25 months, 62% of children in Centering were up to date with all recommended immunizations compared to 44.2% of children in individual care, a 17.8% higher rate (P < .001). By 25 months, children in Centering made 3 additional well-child visits (9.2 vs 6.2, P < .001). Mediation analysis showed 82% of the effect on up to date status was due to increased attendance to well-child visits (P < .001); the remaining 18% was due to a Centering effect beyond the visit increase. CONCLUSIONS: Our study showed a strong association of CenteringParenting with timeliness of immunizations and adherence to well-child visits compared to individual visits in a low income community. These findings warrant further exploration of the impact of Centering in reducing health disparities in communities at risk.

Operationalizing an academic pediatric practice during the COVID-19 crisis.

We report on innovating protocols at an Academic Pediatric practice during the COVID-19 (2019 novel coronavirus) crisis. Facing the challenges of limited personal protective equipment and testing capacity, we rapidly and efficiently changed processes to optimize infection control, providing safe and effective care for our vulnerable population.

Impact of a Baby-Friendly-Aligned Pacifier Policy on Pacifier Use at 1 Month of Age.

OBJECTIVE: Pacifier use decreases the risk of sudden infant death syndrome, but its impact on breastfeeding remains controversial. We evaluated the impact of a pacifier policy aligned with the World Health Organization and United Nations Children's Fund Baby-Friendly Hospital Initiative on subsequent pacifier use and breastfeeding at 1 month of age. METHODS: We conducted a prospective 2-stage (pre- and post-implementation) cohort study of newborns at a birth hospital before and after implementation of a Baby-Friendly-aligned pacifier policy. Consecutive mothers of newborns admitted to the nursery participated in a telephone survey when the infants were 1 month of age. RESULTS: In total, 342 mothers participated (190 before and 152 after implementation of the policy). Pacifier adoption was delayed in the post-implementation group, but pacifier use by 1 month of age was comparable (78.9% pre-implementation vs 77.6% post-implementation; P = .793). In the pre-implementation group, female and male infants used pacifiers at comparable rates; however, in the post-implementation group, females were significantly less likely to use a pacifier compared to males after controlling for insurance, race, parity, and delivery mode (adjusted odds ratio, 0.35; 95% confidence interval, 0.15-0.83; P = .02). In the post-implementation group, exclusive breastfeeding rates at discharge increased significantly (from 40% to 51.3%; P = .04), but rates were not different at 1 month (23.7% pre-implementation vs 24.3% post-implementation; P = .89). CONCLUSION: A Baby-Friendly-aligned pacifier policy delayed pacifier adoption but did not impact overall pacifier use or breastfeeding rates at 1 month of age. The finding of lower pacifier use rates among female infants post-intervention requires verification in other populations before evaluating public heath relevance.

Gestational weight gain among minority adolescents predicts term birth weight.

BACKGROUND: In adolescents, there is limited evidence on the independent and additive effect of prepregnancy body mass index (BMI) and gestational weight gain on infant birth weight. Data also show that this effect may vary by race. We sought to examine the impact of maternal prepregnancy BMI and gestational weight gain on birth weight and risk of large for gestational age (LGA) in term newborns of minority adolescent mothers. METHODS: This was a retrospective cohort study of 411 singleton live term infants born to mothers ≤ 18 years. Data were abstracted from electronic medical records. RESULTS: Gestational weight gain was related to infant birth weight (ρ = 0.36, P < 0.0001), but BMI was not (ρ = 0.025, P = 0.61). On regression analysis, gestational weight gain, gestational age and Hispanic ethnicity were independent predictors of birth weight, controlling for maternal age, BMI, parity, tobacco/drug use and preeclampsia. The probability of having an LGA infant increased with weight gain [adjusted odds ratio (aOR) 1.14, 95% confidence interval (CI) 1.07-1.21] but not with BMI. Mothers who gained weight in excess of 2009 Institute of Medicine (IOM) recommendations had a greater risk of having an LGA infant compared to those who gained within recommendations (aOR 5.7, 95% CI 1.6-19.5). CONCLUSIONS: Minority adolescents with greater gestational weight gain had infants with higher birth weight and greater risk of LGA; BMI was not associated with either outcome. Further studies are needed to examine the applicability of the 2009 BMI-specific IOM gestational weight gain recommendations to adolescents in minority populations.

Qualitative Evaluation of Individual and Group Well-Child Care.

OBJECTIVE: Individual well care (IWC) is the standard delivery model for well-child care in the United States. Alternative models, such as group well care (GWC), may create opportunities to enhance care for babies. The purpose of this study was to evaluate parents' perceptions of social/wellness benefits and system challenges of IWC and GWC. METHODS: Since 2014, we have provided both IWC and GWC at an urban academic practice serving a low-income minority community. We conducted a mixed method study involving surveys and 18 focus groups (11 IWC groups, n = 32 parents; 7 GWC groups, n = 33 parents). Parents completed surveys before convening focus group discussions. Survey results were analyzed using independent t tests; focus groups were digitally recorded, transcribed, and analyzed to identify themes. RESULTS: Both groups had similar demographics: parents were mostly female (91%) and black (>80%); about half had incomes < $20,000. Parents' mean age was 27 years; children's mean age was 11 months. There were no significant differences in overall scores measuring trust in physicians, parent empowerment, or stress. IWC parents' themes highlighted ways to improve care delivery, while GWC parents highlighted both satisfaction with care delivery and social/wellness benefits. GWC parents strongly endorsed this model and reported unique benefits, such as garnering social support and learning from other parents. CONCLUSIONS: Parents receiving both models of care identified ways to improve primary care delivery. Given some of the benefits reported by GWC parents, this model may provide the means to enhance resilience in parents and children in low-income communities.

Swaddling and Infant Sleeping Practices.

Swaddling promotes quiet sleep and may be a useful strategy to encourage infant safe sleep practices. We explored the effect of a swaddling education intervention on infant sleep practices in an urban minority community. We compared a cohort of postpartum mothers who were given education about swaddling to a historical group. Breastfeeding and pacifier use were similar in both groups. Compared to the historical group (n = 121), mothers in the swaddling group (n = 40) were more likely to swaddle infants to sleep (52.5 vs. 23.1 %, p = .001) and less likely to bedshare (15.4 vs. 33.1 %, p = .042). No significant effect was reported on infant supine sleep (81.6 vs. 69.4 %, p = .212). A postpartum swaddling education intervention had a limited impact on infant safe sleeping practices in an urban minority community. A recent metaanalysis demonstrated an increased risk of sudden infant death in infants swaddled for sleep and recommended the need to avoid the prone and side sleep position, especially for swaddled infants, and to set an age and developmentally appropriate limit for the use of swaddling. Ongoing studies are needed to monitor the safety and effectiveness of swaddling as a tool to promote safe sleeping in infants.

Exposure and Use of Mobile Media Devices by Young Children.

BACKGROUND AND OBJECTIVES: Research on children's use of mobile media devices lags behind its adoption. The objective of this study was to examine young children's exposure to and use of mobile media devices. METHODS: Cross-sectional study of 350 children aged 6 months to 4 years seen October to November 2014 at a pediatric clinic in an urban, low-income, minority community. The survey was adapted from Common Sense Media's 2013 nationwide survey. RESULTS: Most households had television (97%), tablets (83%), and smartphones (77%). At age 4, half the children had their own television and three-fourths their own mobile device. Almost all children (96.6%) used mobile devices, and most started using before age 1. Parents gave children devices when doing house chores (70%), to keep them calm (65%), and at bedtime (29%). At age 2, most children used a device daily and spent comparable screen time on television and mobile devices. Most 3- and 4-year-olds used devices without help, and one-third engaged in media multitasking. Content delivery applications such as YouTube and Netflix were popular. Child ownership of device, age at first use, and daily use were not associated with ethnicity or parent education. CONCLUSIONS: Young children in an urban, low-income, minority community had almost universal exposure to mobile devices, and most had their own device by age 4. The patterns of use suggest early adoption, frequent and independent use, and media multitasking. Studies are urgently needed to update recommendations for families and providers on the use of mobile media by young children.

Change in childhood lead exposure prevalence with new reference level.

In 2012, the Centers for Disease Control and Prevention changed the "actionable" reference blood lead level from 10 µg/dL to 5 µg/dL, representing the highest 2.5 percentile of lead levels nationwide. In a high-risk urban community, the prevalence of children classified as lead exposed increased ninefold, from 1% to 9.1% (p < .0001) with the new reference level. This dramatic increase in the prevalence of children newly classified as lead exposed will require additional health care and public health resources for tracking, surveillance, and home lead abatement.

Failure to return: parental, practice, and social factors affecting missed immunization visits for urban children.

OBJECTIVE: To assess parental, practice, and social factors associated with missed immunization visits by young, urban children. STUDY DESIGN: Parents of children ≤ 36 months(n = 705) were surveyed. The primary outcome was missed immunization visit, by parental report. Key parent, practice, and social factors were assessed using hierarchical logistical regression. Results. Families were predominantly Latino and publicly insured. Parents who rescheduled (adjusted odds ratio [AOR] = 3.27; 95% confidence interval [95% CI] = 1.76-6.09) or had problems scheduling appointments (AOR = 4.00; 95% CI = 1.49-10.75) were more likely to miss an immunization visit, as were those with vaccine safety fears (AOR = 3.76; 95% CI = 1.23-11.5) or more limited communication with their provider (AOR = 2.38; 95% CI = 1.05-5.36). Having friends and families with positive immunization views was protective (AOR = 0.030; 95% CI = 0.002-0.41). CONCLUSION: This study highlights factors that may help urban families keep immunization visits: open communication with providers, flexibility in scheduling appointments, and individual and community education.

A pediatric residency experience with surgical co-management.

BACKGROUND AND OBJECTIVE: Acquisition of knowledge and skills in the care of surgical patients is defined as an essential element of training by the Pediatric Residency Review Committee. The pediatric-surgical comanagement model of care is increasingly utilized, yet its impact on residency training has not been described. The goal of this study was to describe a 5-year experience with a co-management model in a pediatric residency program. METHODS: We describe the planning and implementation of a surgical co-management model in a pediatric residency program and report on case volume and diversity from 2005 to 2010. We assessed the experience of pediatric residents and faculty through rotation evaluations, program leadership meetings, and an anonymous online survey. In the survey, residents rated the value of their exposure on knowledge and skills in selected perioperative domains and their experience with interprofessional teamwork. RESULTS: The volume of co-managed patients increased threefold from 2005 to 2010; most (79%) had concurrent medical conditions, and one-third (36%) were children with special health care needs (CYSHCN). Residents reported that co-management helped them gain knowledge and skills in pain management, fluid and electrolytes, respiratory, and nutritional support, as well as in interprofessional teamwork. Other strengths included greater exposure to CYSHCN and subspecialty faculty, and preparedness for critical care rotations. Challenges included clarity of roles and responsibilities between pediatric and surgery residents and interservice communication. CONCLUSIONS: A surgical co-management model in pediatric residency training presented important opportunities for development of residents' knowledge and skills in perioperative care and interprofessional teamwork.

Breastfeeding among inner-city women: from intention before delivery to breastfeeding at hospital discharge.

OBJECTIVE: This study assessed the degree to which women's intention to breastfeed prior to delivery translates to actual breastfeeding at hospital discharge and to investigate predictors of breastfeeding in a minority inner-city population. STUDY DESIGN AND METHODS: We conducted a retrospective cohort study of consecutive mother-infant dyads born July-September 2010 and discharged from the nursery at an academic community hospital in Philadelphia. RESULTS: The demographics of the 578 women who participated included a mean age of 25.3 years (SD 6.1), 61% African American and 18% Latina, 85% covered by Medicaid, and a mean postpartum hospital stay of 2.3 days. Overall, 60% expressed an intention to breastfeed prior to delivery (exclusively or with formula), but only 50% were breastfeeding at discharge. Of those who intended to breastfeed (exclusively or with formula), 75% were breastfeeding at discharge. Of those who intended to breastfeed exclusively, 40% were doing so at discharge. Of those who intended to bottle feed, 11% were breastfeeding at discharge. In multivariable analysis, older mothers and those with lower parity were more likely to breastfeed at discharge and also to breastfeed exclusively, controlling for ethnicity, parity, insurance, pregravida body mass index, score on the Edinburgh Postpartum Depression Scale, type of delivery, infant birth weight and gestational age. CONCLUSIONS: In a minority inner-city population, only three in four women who intended to breastfeed prior to delivery were breastfeeding at hospital discharge. However, one in 10 women previously not intending to breastfeed did so. Strategies are needed to promote and strengthen women's intention to breastfeed and to help women's breastfeeding outcomes meet their intentions.

Determinants of influenza vaccination among young children in an inner-city community.

Few studies have examined potential factors that contribute to low influenza vaccination rates among minority children. This study aimed to assess the prevalence of early childhood influenza vaccination among young black and Latino children, living in inner-city neighborhoods, and examine the effects of child, caregiver and health system factors. Secondary data analysis was performed using a survey about medical home experiences conducted from May 2007-June 2008. The study sample was limited to children ≥6 months in any influenza season prior to the 2006-2007 influenza season. Bivariate analyses and multivariable logistic regression tested associations between influenza vaccination receipt and socio-demographic and health system characteristics. One-third of children received an influenza vaccination by the end of 2006-2007 season, while only 11% received a vaccination within their first season of eligibility. Black children were more likely than Latino children to have been vaccinated (50% vs. 31%, P<0.01) during their first few eligible seasons. Children whose mothers were older, proficient in English, and frequent users of healthcare were more likely to obtain vaccination. Child attendance at healthcare settings with immunization reminder systems was also positively correlated with influenza vaccination. Our findings suggest that initial vaccination receipt among minority children from inner-city communities might be improved by expanded influenza promotion activities targeting younger mothers or those with limited English proficiency. Strategies to increase the frequency of child's actual contact with the medical home, such as reminder systems, may be useful in improving uptake of influenza vaccination among inner-city, minority children.

Tap or bottled water: drinking preferences among urban minority children and adolescents.

The last decade has seen an increasing trend in consumer preference of bottled water over tap water. Little is known what type of water children and adolescents prefer for drinking and what their parents think of their community tap water. The study objective was to assess drinking water preferences, perceptions of the qualities of tap water and bottled water, and fluoride knowledge in an urban pediatric population. We conducted an anonymous survey of a convenience sample of caretakers of children and adolescents at an urban clinic regarding their preferences for tap or bottled water, their perceptions of the quality of tap and bottled water and their knowledge of fluoride. Of the 208 participants (79% African American, 9% Latino), 59% drank tap water, 80% bottled water. Only 17% drank tap water exclusively, 38% drank bottled water exclusively, 42% drank both. We found no significant differences in water preferences across age groups, from infancy to adulthood, or among ethnic groups. Ratings for taste, clarity, purity and safety were significantly higher for bottled water than tap water (P < 0.001). Only 24% were aware of fluoride in drinking water. We conclude bottled water was preferred over tap water in an urban minority pediatric population. Perceptions of the qualities of water seemed to drive drinking preferences. Public health strategies are needed to increase public awareness of the impact of bottled water consumption on oral health, household budgets and the environment.

How parents' negative experiences at immunization visits affect child immunization status in a community in New York City.

OBJECTIVE: Little is known about how families' experiences with immunization visits within the medical home may affect children's immunization status. We assessed the association between families' negative immunization experiences within the medical home and underimmunization. METHODS: We surveyed parents (n = 392) of children aged 2-36 months about immunization experiences at community health centers, hospital-based clinics, private practices, and community-based organizations in New York City. We used Chi-square tests and odds ratios (ORs) to assess the relationship between medical home elements and parental immunization experience ratings. We used multivariable analysis to determine the association between negative experiences during immunization visits and underimmunization, controlling for insurance, maternal education, and receipt of benefits from the Special Supplemental Nutrition Program for Women, Infants, and Children. RESULTS: The majority of children were of Latino race/ethnicity and had Medicaid and a medical home. One-sixth (16.9%) of families reported a previous negative immunization experience, primarily related to the child's reaction, waiting time, and attitudes of medical and office staff. Parents' negative immunization experiences were associated with the absence of four components of the medical home: continuity of care, family-centered care, compassionate care, and comprehensive care. In addition, children in families who reported a negative experience were more likely to have been underimmunized (adjusted OR = 2.00; 95% confidence interval 1.12, 3.58). CONCLUSIONS: In a community in New York City, underimmunization of young children was associated with negative immunization experiences. Strategies to improve family experiences with immunization visits within the medical home (particularly around support for the family), medical and ancillary staff attitudes, and reduced waiting time may lead to improved immunization delivery.

A collaborative model for inpatient training in a small pediatric residency program.

BACKGROUND: The nationwide decline in pediatric admissions to community hospitals threatens the sustainability of small pediatric residency programs. Little is known about the response of small programs to this challenge. OBJECTIVES: We report on the design and evaluation of an innovative, collaborative model for pediatric inpatient training between an academic community medical center and a children's hospital. METHODS: We describe the operational, academic, and financial features of the model. Outcome measures include patient volume and subspecialty mix, resident and faculty perceptions as reported in an anonymous survey, and Accreditation Council for Graduate Medical Education Residency Review Committee (RRC) review. RESULTS: In 2003, Albert Einstein Medical Center (Einstein) closed its pediatric inpatient unit and established an independent teaching service at St Christopher's Hospital for Children (St Christopher's) in Philadelphia, Pennsylvania. Under the new model, patient volume and subspecialty mix more than tripled. Einstein residents and faculty identified 5 major strengths: level of responsibility and decision making, caring for medically complex children, quality of teaching, teamwork, and opportunity to participate in academic activities at a children's hospital. St Christopher's leadership reported increased volume, no disruption of their residency program, and no dilution of clinical teaching material. The Einstein program was reaccredited by the RRC in 2006 for 2 years and in 2009 for 4 years. CONCLUSION: A collaborative model for inpatient training was successful in maintaining a community hospital-based pediatric residency program. Positive outcomes were documented for the residency program, the parent community hospital, and the collaborating children's hospital.

Latino parents' perceptions of their ability to prevent obesity in their children.

The obesity epidemic in Latino children has reached staggering proportions. This study explored Latino parents' perceptions of their ability to prevent obesity in children. Three focus groups were conducted with 26 Latino parents of preschoolers at a New York City Head Start program. Parents perceived high levels of ability to prevent obesity primarily via dietary influence. Four factors negatively impacted parents' ability: family history, intergenerational and interparental issues, adolescence, and societal pressures. Culturally effective, family-based obesity interventions among Latinos should build upon parental perceptions of ability to prevent obesity, while simultaneously helping parents address the factors they perceive challenge this ability.

Change in parental reasons for use of an urban pediatric emergency department in the past decade.

OBJECTIVE: To assess changes over the past decade in parental reasons associated with nonurgent visits to pediatric emergency departments (PEDs) during regular primary care office hours. METHODS: Secondary analysis of cross-sectional surveys of families of children younger than 3 years visiting a PED in a low-socioeconomic area in New York City conducted in 1997 and 2006. We performed multivariable analyses to assess differences in parental reported reasons for PED use over the period, controlling for sociodemographic factors. RESULTS: Most children (95.6%) had a usual source of care across both periods. Compared with those seen in 1997, children seen in 2006 were far less likely to be brought to the PED during regular primary care office hours for parental perceived urgency (adjusted odds ratio [AOR], 0.076; 95% confidence interval [CI], 0.024-0.24; P < 0.001). At the same time, these children were more likely to be brought to the PED for limited access to their usual source of care (AOR, 3.35; 95% CI, 1.24-9.02; P < 0.05) and greater trust in the medical expertise of the PED (AOR, 5.95 95% CI, 1.20-29.45; P < 0.05). CONCLUSIONS: Over the last decade, despite the presence of a usual source of care, a greater number of parents report visiting this urban PED during regular office hours for reasons unrelated to parental perceived urgency. Limited access to care and greater trust in the medical expertise available in PEDs have played important roles. Approaches to decreasing nonurgent visits must take into account all of these factors.

Effective strategies for integrating immunization promotion into community programs.

Most immunization coalitions have originated with health care providers, potentially excluding families without medical homes. This study focused on a community-based approach to providing timely vaccinations. A coalition of 23 organizations developed an immunization program in a low-income community in New York City. Nearly 1,000 community health workers incorporated immunization promotion into social service and educational programs. Outcomes were coverage rates for the 4:3:1:3:3 series at 19 to 35 months, which were compared with national data by ethnicity, as reported in the National Immunization Survey 2002-2006. Parents (n = 10,251) of children <5 years received immunization education and reminders. The 2003-2007 rates of 80% equaled or exceeded the national rates for 19- to 35-month-olds, and the 2007 rate of 96.8% far surpassed the national average. Coalitions can effectively integrate immunization promotion activities into community programs. Immunization rate improvements maintained for a 5-year period, suggesting this approach to be sustainable.