Variability in the evaluation and management of opiate-exposed newborns in Maryland.

During 2003 and 2004 an estimated 2000 pregnant women and 31 000 nonpregnant women aged 15 to 44 reported using heroin. The majority of those newborns exposed in utero to opioids will develop symptoms of neonatal abstinence syndrome (NAS). Standardized guidelines for the evaluation and management of opiate-exposed newborns are lacking. The objective of this study was to document variations in the evaluation and management of opiate-exposed newborns among Maryland hospitals using a 13-item phone survey. Twenty-seven (82%) of the hospitals completed the survey. Staff at every hospital reported that they delivered opiate-exposed infants, however only 52% reported using a standardized evaluation and treatment protocol for this population consisting of guidelines for maternal toxicology screening, length-of-stay criteria and a monitoring tool for drug-exposed infants, infant supportive care techniques, and pharmacologic treatment guidelines. Significant variability exists in the evaluation and management of opiate-exposed newborns in Maryland. Validated, evidence-based guidelines are needed to standardize the care of these vulnerable newborns across all hospital settings.

Pediatric observation status beds on an inpatient unit: an integrated care model.

OBJECTIVES: Describe the usage of observation status (OS) beds on a pediatric inpatient unit and identify diagnoses likely to be successfully discharged compared to those requiring formal inpatient admission. METHODS: Retrospective chart review of all patients (0-18 years) transferred to pediatric OS beds from the emergency department (ED) between April 1, 1997 and April 30, 1999. Outcome measures consisted of time interval between ED triage and arrival to an OS bed, total hours in observation, and need for admission or transfer. Using relative risk (RR), we compared admission rates for the 4 most common diagnoses. RESULTS: We studied 800 transfers to pediatric OS beds. Asthma (27%), gastroenteritis/dehydration (16%), infectious disease (12%), and bronchiolitis (9%) were the 4 most common diagnoses. There were 597 patients (75%) successfully discharged from observation and 174 (22%) required inpatient admission. Seventeen patients (2%) were transferred to a psychiatric facility and 12 patients (1%) were transferred to a tertiary care center for further evaluation and treatment. Compared to gastroenteritis/dehydration, patients with asthma were just as likely to be admitted/transferred (RR 1.05, 95% CI, 0.87-1.27), those with an infectious disease were 1.3 times more likely to be admitted/transferred (RR 1.35, 95% CI, 1.0-1.83), and those with bronchiolitis were 2 times more likely to be admitted/transferred (RR 1.92, 95% CI, 1.34-2.74). CONCLUSIONS: We describe the usage of OS beds in a community hospital that we believe can be a successful model for the care of pediatric patients. Future studies are needed to delineate the clinical characteristics of patients that would benefit from this care delivery model.

Assessment of risk of bias among pediatric randomized controlled trials.

OBJECTIVE: The goal was to assess the risk of bias among pediatric, randomized, controlled trials (RCTs) reported in 8 high-impact journals. METHODS: We searched PubMed for all pediatric RCTs reported between July 1, 2007, and June 30, 2008, in 8 journals with high impact factors. Using Cochrane Collaboration methods for risk assessment, we evaluated all reports for risk of bias according to domain (ie, randomized sequence generation, allocation concealment, masking, incomplete outcome data, selective outcome reporting, and other). We used multiple logistic regression to test for associations between the presence of a high risk of bias according to domain and funding source, intervention type, trial registration, and multicenter status. RESULTS: Industry-funded RCTs were more likely to show a high risk of bias for sequence generation, compared with government-funded RCTs (adjusted odds ratio [aOR]: 6.1 [95% confidence interval [CI]: 1.70- 21.89]), and behavioral/educational trials were more likely to show a high risk of bias for sequence generation (aOR: 2.8 [95% CI: 1.06-7.36]) and allocation concealment (aOR: 4.09 [95% CI: 1.69-9.90]), compared with drug trials. Registered trials were less likely to have a high risk of bias for sequence generation, compared with nonregistered trials (aOR: 0.33 [95% CI: 0.15-0.71]). CONCLUSIONS: Overall, we found a large proportion of pediatric RCT reports with a high risk of bias for sequence generation and allocation concealment. Factors associated with a high risk of bias included industry funding and assessment of behavioral/educational interventions, whereas trial registration was associated with a lower risk of bias.

Ethnic differences in parental perceptions and management of childhood fever.

To explore knowledge and management of childhood fever among ethnically diverse parents and identify opportunities for educational intervention, we administered a cross-sectional survey to a convenience sample of 487 parents of children enrolled in 2 urban hospital-based pediatric clinics. Outcomes included parental definition of fever, level of concern, and management of fever. Latino parents were least likely to identify a temperature as nonfebrile from 97-100.3 degrees F (adjusted odds ratios [AOR] 0.06) or identify a fever as a temperature from 100.4-107 degrees F (AOR 0.52). African Americans were least likely to believe that fever can cause death or brain damage (AOR 0.4). African Americans were more likely to dose ibuprofen more frequently than recommended (AOR 1.97). All ethnicities are equally likely to treat normal temperatures and dose acetaminophen too frequently.Therefore continued education of all families about fever is necessary, and there are opportunities to develop ethnically sensitive strategies to target educational interventions.