Physician personal breastfeeding experience and clinical care of the breastfeeding dyad.

BACKGROUND: Prior research suggests that physicians' personal experience with breastfeeding may influence their attitudes toward breastfeeding. This phenomenon has not been explored in well-newborn care physician leaders, whose administrative responsibilities often include drafting and approval of hospital breastfeeding and formula supplementation policies. METHODS: We conducted a mixed-methods study, surveying physicians in the Better Outcomes through Research for Newborns (BORN) network. We examined physician attitudes toward recommending breastfeeding and their breastfeeding experience. Qualitative analysis was conducted on responses to the question: "How do you think your breastfeeding experience influences your clinical practice?" RESULTS: Of 71 participants, most (92%) had a very positive attitude toward breastfeeding with 75% of respondents reporting personal experience with breastfeeding. Of these, 68% had a very positive experience, 25% had a somewhat positive experience, and 6% had a neutral experience. Four themes emerged with respect to the effect of breastfeeding experience on practice: (1) empathy with breastfeeding struggles, (2) increased knowledge and skills, (3) passion for breastfeeding benefits, and (4) application of personal experience in lieu of evidence-based medicine, particularly among those who struggled with breastfeeding. CONCLUSIONS: Well-newborn care physician leaders reported positive attitudes about breastfeeding, increased support toward breastfeeding persons, and a perception of improved clinical lactation skills. Those who struggled with breastfeeding reported increased comfort with recommending formula supplementation to their own patients. Medical education about evidence-based breastfeeding support practices and provision of lactation support to physicians has the potential to affect public health through improved care for the patients they serve.

Management and Early Outcomes of Neonates Born to Women with SARS-CoV-2 in 16 U.S. Hospitals.

OBJECTIVE: There is a paucity of evidence to guide the clinical care of late preterm and term neonates born to women with perinatal severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The objective of this case series is to describe early neonatal outcomes and inpatient management in U.S. hospitals. STUDY DESIGN: We solicited cases of mother-infant dyads affected by novel coronavirus disease 2019 (COVID-19) from the Better Outcomes through Research for Newborns (BORN) Network members. Using a structured case template, participating sites contributed deidentified, retrospective birth hospitalization data for neonates ≥35 weeks of gestation at birth with mothers who tested positive for SARS-CoV-2 before delivery. We describe demographic and clinical characteristics, clinical management, and neonatal outcomes. RESULTS: Sixteen U.S. hospitals contributed 70 cases. Birth hospitalizations were uncomplicated for 66 (94%) neonates in which 4 (6%) required admission to a neonatal intensive care unit. None required evaluation or treatment for infection, and all who were tested for SARS-CoV-2 were negative (n = 57). Half of the dyads were colocated (n = 34) and 40% directly breastfed (n = 28). Outpatient follow-up data were available for 13 neonates, all of whom remained asymptomatic. CONCLUSION: In this multisite case series of 70 neonates born to women with SARS-CoV-2 infection, clinical outcomes were overall good, and there were no documented neonatal SARS-CoV-2 infections. Clinical management was largely inconsistent with contemporaneous U.S. COVID-19 guidelines for nursery care, suggesting concerns about the acceptability and feasibility of those recommendations. Longitudinal studies are urgently needed to assess the benefits and harms of current practices to inform evidence-based clinical care and aid shared decision-making. KEY POINTS: · Birth hospitalizations were uncomplicated for late preterm and term infants with maternal COVID-19.. · Nursery management of dyads affected by COVID-19 varied between hospitals.. · Adherence to contemporaneous U.S. clinical guidelines for nursery care was low.. · Breastfeeding rates were lower for dyads roomed separately than those who were colocated..

Bisphosphonate therapy for osteogenesis imperfecta.

BACKGROUND: Osteogenesis imperfecta is caused by a genetic defect resulting in an abnormal type I collagen bone matrix which typically results in multiple fractures with little or no trauma. Bisphosphonates are used in an attempt to increase bone mineral density and reduce these fractures in people with osteogenesis imperfecta. This is an update of a previously published Cochrane Review. OBJECTIVES: To assess the effectiveness and safety of bisphosphonates in increasing bone mineral density, reducing fractures and improving clinical function in people with osteogenesis imperfecta. SEARCH METHODS: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Inborn Errors of Metabolism Trials Register which comprises references identified from comprehensive electronic database searches, handsearches of journals and conference proceedings. We additionally searched PubMed and major conference proceedings.Date of the most recent search of the Cochrane Cystic Fibrosis and Genetic Disorders Group's Inborn Errors of Metabolism Register: 28 April 2016. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials comparing bisphosphonates to placebo, no treatment, or comparator interventions in all types of osteogenesis imperfecta. DATA COLLECTION AND ANALYSIS: Two authors independently extracted data and assessed the risk of bias of the included trials. MAIN RESULTS: Fourteen trials (819 participants) were included. Overall, the trials were mainly at a low risk of bias, although selective reporting was an issue in several of the trials. Data for oral bisphosphonates versus placebo could not be aggregated; a statistically significant difference favouring oral bisphosphonates in fracture risk reduction and number of fractures was noted in two trials. No differences were reported in the remaining three trials which commented on fracture incidence. Five trials reported data for spine bone mineral density; all found statistically significant increased lumbar spine density z scores for at least one time point studied. For intravenous bisphosphonates versus placebo, aggregated data from two trials showed no statistically significant difference for the number of participants with at least one fracture, risk ratio 0.56 (95% confidence interval 0.30 to 1.06). In the remaining trial no statistically significant difference was noted in fracture incidence. For spine bone mineral density, no statistically significant difference was noted in the aggregated data from two trials, mean difference 9.96 (95% confidence interval -2.51 to 22.43). In the remaining trial a statistically significant difference in mean per cent change in spine bone mineral density z score favoured intravenous bisphosphonates at six and 12 months. Data describing growth, bone pain, and functional outcomes after oral or intravenous bisphosphonate therapy, or both, as compared to placebo were incomplete among all studies, but do not show consistent improvements in these outcomes. Two studies compared different doses of bisphosphonates. No differences were found between doses when bone mineral density, fractures, and height or length z score were assessed. One trial compared oral versus intravenous bisphosphonates and found no differences in primary outcomes. Two studies compared the intravenous bisphosphonates zoledronic acid and pamidronate. There were no significant differences in primary outcome. However, the studies were at odds as to the relative benefit of zoledronic acid over pamidronate for lumbosacral bone mineral density at 12 months. AUTHORS' CONCLUSIONS: Bisphophonates are commonly prescribed to individuals with osteogenesis imperfecta. Current evidence, albeit limited, demonstrates oral or intravenous bisphosphonates increase bone mineral density in children and adults with this condition. These were not shown to be different in their ability to increase bone mineral density. It is unclear whether oral or intravenous bisphosphonate treatment consistently decreases fractures, though multiple studies report this independently and no studies report an increased fracture rate with treatment. The studies included here do not show bisphosphonates conclusively improve clinical status (reduce pain; improve growth and functional mobility) in people with osteogenesis imperfecta. Given their current widespread and expected continued use, the optimal method, duration of therapy and long-term safety of bisphosphonate therapy require further investigation. In addition, attention should be given to long-term fracture reduction and improvement in quality of life indicators.

Bisphosphonate therapy for osteogenesis imperfecta.

BACKGROUND: Osteogenesis imperfecta is caused by a genetic defect resulting in an abnormal type I collagen bone matrix which typically results in multiple fractures with little or no trauma. Bisphosphonates are used in an attempt to increase bone mineral density and reduce these fractures in people with osteogenesis imperfecta. OBJECTIVES: To assess the effectiveness and safety of bisphosphonates in increasing bone mineral density, reducing fractures and improving clinical function in people with osteogenesis imperfecta. SEARCH METHODS: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Inborn Errors of Metabolism Trials Register which comprises references identified from comprehensive electronic database searches, handsearches of journals and conference proceedings. We additionally searched PubMed and major conference proceedings.Date of the most recent search: 07 April 2014. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials comparing bisphosphonates to placebo, no treatment, or comparator interventions in all types of osteogenesis imperfecta. DATA COLLECTION AND ANALYSIS: Two authors independently extracted data and assessed the risk of bias of the included trials. MAIN RESULTS: Fourteen trials (819 participants) were included. Overall, the trials were mainly at a low risk of bias, although selective reporting was an issue in several of the trials. Data for oral bisphosphonates versus placebo could not be aggregated; a statistically significant difference favouring oral bisphosphonates in fracture risk reduction and number of fractures was noted in two trials. No differences were reported in the remaining three trials which commented on fracture incidence. Five trials reported data for spine bone mineral density; all found statistically significant increased lumbar spine density z scores for at least one time point studied. For intravenous bisphosphonates versus placebo, aggregated data from two trials showed no statistically significant difference for the number of participants with at least one fracture, risk ratio 0.56 (95% confidence interval 0.30 to 1.06). In the remaining trial no statistically significant difference was noted in fracture incidence. For spine bone mineral density, no statistically significant difference was noted in the aggregated data from two trials, mean difference 9.96 (95% confidence interval -2.51 to 22.43). In the remaining trial a statistically significant difference in mean per cent change in spine bone mineral density z score favoured intravenous bisphosphonates at six and 12 months. Data describing growth, bone pain, and functional outcomes after oral or intravenous bisphosphonate therapy, or both, as compared to placebo were incomplete among all studies, but do not show consistent improvements in these outcomes. Two studies compared different doses of bisphosphonates. No differences were found between doses when bone mineral density, fractures, and height or length z score were assessed. One study compared oral versus intravenous bisphosphonates and found no differences in primary outcomes. Two studies compared the intravenous bisphosphonates zoledronic acid and pamidronate. There were no significant differences in primary outcome. However, the studies were at odds as to the relative benefit of zoledronic acid over pamidronate for lumbosacral bone mineral density at 12 months. AUTHORS' CONCLUSIONS: Bisphophonates are commonly prescribed to individuals with osteogenesis imperfecta. Current evidence, albeit limited, demonstrates oral or intravenous bisphosphonates increase bone mineral density in children and adults with this condition. These were not shown to be different in their ability to increase bone mineral density. It is unclear whether oral or intravenous bisphosphonate treatment consistently decreases fractures, though multiple studies report this independently and no studies report an increased fracture rate with treatment. The studies included here do not show bisphosphonates conclusively improve clinical status (reduce pain; improve growth and functional mobility) in people with osteogenesis imperfecta. Given their current widespread and expected continued use, the optimal method, duration of therapy and long-term safety of bisphosphonate therapy require further investigation. In addition, attention should be given to long-term fracture reduction and improvement in quality of life indicators.

An Analysis of Workplace-Based Assessments for Core Entrustable Professional Activities for Entering Residency: Does Type of Clinical Assessor Influence Level of Supervision Ratings?

PURPOSE: The authors describe use of the workplace-based assessment (WBA) coactivity scale according to entrustable professional activities (EPAs) and assessor type to examine how diverse assessors rate medical students using WBAs. METHOD: A WBA data collection system was launched at Oregon Health and Science University to visualize learner competency in various clinical settings to foster EPA assessment. WBA data from January 14 to June 18, 2021, for medical students (all years) were analyzed. The outcome variable was level of supervisor involvement in each EPA, and the independent variable was assessor type. RESULTS: A total of 7,809 WBAs were included. Most fourth-, third-, and second-year students were assessed by residents or fellows (755 [49.5%], 1,686 [48.5%], and 918 [49.9%], respectively) and first-year students by attending physicians (803 [83.0%]; P < .001). Attendings were least likely to use the highest rating of 4 (1 was available just in case; 2,148 [56.7%] vs 2,368 [67.7%] for residents; P < .001). Learners more commonly sought WBAs from attendings for EPA 2 (prioritize differential diagnosis), EPA 5 (document clinical encounter), EPA 6 (provide oral presentation), EPA 7 (form clinical questions and retrieve evidence-based medicine), and EPA 12 (perform general procedures of a physician). Residents and fellows were more likely to assess students on EPA 3 (recommend and interpret diagnostic and screening tests), EPA 4 (enter and discuss orders and prescriptions), EPA 8 (give and receive patient handover for transitions in care), EPA 9 (collaborate as member of interprofessional team), EPA 10 (recognize and manage patient in need of urgent care), and EPA 11 (obtain informed consent). CONCLUSIONS: Learners preferentially sought resident vs attending supervisors for different EPA assessments. Future research should investigate why learners seek different assessors more frequently for various EPAs and if assessor type variability in WBA levels holds true across institutions.

Care of the well newborn.

The birth of an infant is one of the most memorable experiences a family shares. Pediatric health care professionals are privileged to participate in this experience and recognize it as a time to promote the health of the newborn and family. Ideally, a well-designed care system would be replete with comprehensive supports during the prenatal period, birth, and transition to home. Opportunities exist to improve the care we deliver with universal screening of all pregnant women; coordinated assessments of family health, including mental health; and access to coordinated supports and services for mother and infant. If 90% of US families could comply with medical recommendations to breastfeed exclusively for 6 months, it is estimated the United States would save billions of dollars per year and prevent more than 900 deaths, nearly all of which would be in infants. All infants, whether breastfed or formula fed, should receive 400 IU supplemental vitamin D. Influenza and TdaP vaccination of postpartum mothers and other caregivers helps cocoon the vulnerable infant from influenza and pertussis until he or she can be fully vaccinated. When children reach the highest weight or length allowed by the manufacturer of their infant-only seat, they should continue to ride rear-facing in a convertible seat. It is best for children to ride rear-facing as long as possible to the highest weight and height allowed by the manufacturer of their convertible seat.

Timing of Vaccine Decision-Making Among First-Time Parents.

OBJECTIVE: Decreased childhood vaccination can lead to local outbreaks of vaccine-preventable disease. In a pilot study from our group, 72% of parents of newborns reported initiating their vaccine decision-making for that child prior to conception. Since a sound understanding of the timing of parental vaccine decision-making is needed to direct educational efforts, we surveyed a national cohort of first-time parents to extend our preliminary findings. METHODS: From March 2019 to March 2020, first-time parents of newborns in mother-baby units of the Better Outcomes through Research for Newborns (BORN) network completed the Vaccine Preference Development Survey (VPDS). The VPDS measures intent to vaccinate, timing of vaccine decision-making, and sources of influence. Univariate and multivariate analyses explored associations between intent to vaccinate and timing of vaccine decision-making with demographic variables. RESULTS: Twenty-three sites provided surveys through site-specific nonrandom systemic sampling; 91% (1393/1524) of surveys were used in the analysis. Most parents planned to fully vaccinate (1191/1380, 86.3%) and started vaccine decision-making prior to conception (850/1378, 61.7%). Maternal age, race and ethnicity, relationship status, and education were all significantly associated with planning to fully vaccinate and preconception decision-making (P < .001). Preconception decision-making correlated strongly with intent to fully vaccinate (P < .001). Parents influenced by personal education, medical professionals, and family/friends were more likely to endorse preconception decision-making; those strongly influenced by internet/social media were less likely to allow all vaccines or start decision-making prior to conception. CONCLUSIONS: Vaccine decision-making occurs preconception for most new parents. Initiating vaccine discussions during the birth hospitalization may be too late.

Workplace-Based Entrustment Scales for the Core EPAs: A Multisite Comparison of Validity Evidence for Two Proposed Instruments Using Structured Vignettes and Trained Raters.

PURPOSE: In undergraduate medical education (UME), competency-based medical education has been operationalized through the 13 Core Entrustable Professional Activities for Entering Residency (Core EPAs). Direct observation in the workplace using rigorous, valid, reliable measures is required to inform summative decisions about graduates' readiness for residency. The purpose of this study is to investigate the validity evidence of 2 proposed workplace-based entrustment scales. METHOD: The authors of this multisite, randomized, experimental study used structured vignettes and experienced raters to examine validity evidence of the Ottawa scale and the UME supervisory tool (Chen scale) in 2019. The authors used a series of 8 cases (6 developed de novo) depicting learners at preentrustable (less-developed) and entrustable (more-developed) skill levels across 5 Core EPAs. Participants from Core EPA pilot institutions rated learner performance using either the Ottawa or Chen scale. The authors used descriptive statistics and analysis of variance to examine data trends and compare ratings, conducted interrater reliability and generalizability studies to evaluate consistency among participants, and performed a content analysis of narrative comments. RESULTS: Fifty clinician-educators from 10 institutions participated, yielding 579 discrete EPA assessments. Both Ottawa and Chen scales differentiated between less- and more-developed skill levels (P < .001). The interclass correlation was good to excellent for all EPAs using Ottawa (range, 0.68-0.91) and fair to excellent using Chen (range, 0.54-0.83). Generalizability analysis revealed substantial variance in ratings attributable to the learner-EPA interaction (59.6% for Ottawa; 48.9% for Chen) suggesting variability for ratings was appropriately associated with performance on individual EPAs. CONCLUSIONS: In a structured setting, both the Ottawa and Chen scales distinguished between preentrustable and entrustable learners; however, the Ottawa scale demonstrated more desirable characteristics. These findings represent a critical step forward in developing valid, reliable instruments to measure learner progression toward entrustment for the Core EPAs.

Core Entrustable Professional Activities (EPAs) and the Transition from Medical School to Residency: the Postgraduate Year One Resident Perspective.

INTRODUCTION: The Association of American Medical Colleges (AAMC) proposed thirteen core Entrustable Professional Activities (EPAs) that all graduates should be able to perform under indirect supervision upon entering residency. As an underlying premise is that graduates ready to do so will be better prepared to transition to the responsibilities of residency, we explored the relationship between postgraduate year (PGY)-1 residents' self-assessed preparedness to perform core EPAs under indirect supervision at the start of residency with their ease of transition to residency. METHODS: Using response data to a questionnaire administered in September 2019 to PGY-1 residents who graduated from AAMC core EPA pilot schools, we examined between-group differences and independent associations for each of PGY-1 position type, specialty, and "EPA-preparedness" score (proportion of EPAs the resident reported as prepared to perform under indirect supervision at the start of residency) and ease of transition to residency (from 1 = much harder to 5 = much easier than expected). RESULTS: Of 274 questionnaire respondents (19% of 1438 graduates), 241 (88% of 274) had entered PGY-1 training and completed all questionnaire items of interest. EPA-preparedness score (mean 0.71 [standard deviation 0.26]) correlated with ease of transition (3.1 [0.9]; correlation = .291, p < .001). In linear regression controlling for specialty (among other variables), EPA-preparedness score (ß-coefficient 1.08; 95% confidence interval .64-1.52; p < .001) predicted ease of transition to residency. CONCLUSION: Graduates who felt prepared to perform many of the core EPAs under indirect supervision at the start of PGY-1 training reported an easier-than-expected transition to residency. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s40670-021-01370-3.

Implementing a Real-time Workplace-based Assessment Data Collection System Across an Entire Medical School's Clinical Learning Environment.

This article was migrated. The article was marked as recommended. Background & Objectives: Workplace-based assessments (WBAs) are a vital aspect of medical student competency assessment for the core Entrustable Professional Activities (EPAs), but pose significant challenges since assessment must occur in real-time during the routine care of patients. We developed an online WBA system designed to overcome these challenges, and implemented it across an entire undergraduate medical education program to address the need for EPA competency assessment. We describe the development and implementation process, and present initial results from our inaugural medical student cohort. Methods: The WBA tool was designed to be student-driven, easy to use, and minimally disruptive to clinical care. Students trigger assessments by choosing the desired EPA to be assessed within a custom-built Qualtrics XM survey application. Their clinical assessor is prompted to select their level of involvement in the activity using the modified Ottawa co-activity scale and provide brief written feedback. Direct verbal feedback at time of discussion is encouraged. Results: 3,568 WBAs were completed. The mean number of assessments per student for all EPAs combined was 24.27 with a range of 1-103. All students completed at least one WBA. Over the course of 12 months, the mean number of EPAs recorded per student in this cohort was lowest for EPA 10 (Recognizing a Patient Requiring Urgent or Emergent Care and Initiate Evaluation and Management) (mean=0.36; range 0-4; n=53) and was highest for EPA 6 (Provide an Oral Presentation for a Clinical Encounter) (mean=5.46; range 1-17; n=803). The mean number of minutes it took to complete the assessments was 2.7 minutes with a standard deviation of 1.2 minutes (n=2,803). Conclusion: An electronic application-based survey collecting real-time WBAs to assess progress toward attaining competence in EPA performance resulted in increased assessment data within a medical school cohort.

Variation in Newborn Skincare Policies Across United States Maternity Hospitals.

OBJECTIVE: Newborn skincare influences levels of beneficial factors from vernix and vaginal secretions but also the emergence of potential skin pathogens. However, evidence-based national guidelines for newborn skincare do not exist, and actual hospital practices for newborn skincare have not been described. In this study, we test the hypothesis that US maternity hospitals follow differing policies with regard to newborn skincare. METHODS: A 16-question survey querying skin care practices was distributed to nursery medical directors at the 109 US hospital members of the Better Outcomes through Research for Newborns network. Data from free text responses were coded by 2 study personnel. Survey responses were analyzed by using descriptive statistics and compared by region of the United States. RESULTS: Delaying the first newborn bath by at least 6 hours is a practice followed by 87% of US hospitals surveyed. Discharging newborns without a bath was reported in 10% of hospitals and was more common for newborns born in nonacademic centers and on the West Coast. Procedures and products used for newborn skincare varied significantly. Parental education on tub immersion and soap use was also inconsistent and potentially contradictory between providers. Evidence cited by hospitals in forming their policies is scant. CONCLUSION: In this study, we identify similar and strikingly different newborn skincare policies across a national network of US maternity hospitals. Research is needed to identify effects of differing skincare routines on skin integrity, infection rates, and childhood health outcomes to improve the evidence base for the care of newborn skin.

Quality Improvement Analyses Revealed a Hidden Shift Following a Retrospective Study on Breastfeeding Rates.

Factors affecting exclusive breastfeeding rates are complex. Evaluations for early-onset sepsis can negatively impact breastfeeding success. We sought to determine whether implementing an algorithm utilizing the sepsis risk score (SRS) in chorioamnionitis-exposed newborns would increase exclusive breastfeeding rates. We collaborated with healthcare systems experts to analyze and understand our outcomes. METHODS: We describe a retrospective cohort study of chorioamnionitis-exposed newborns 35 weeks and older gestation in the Mother-Baby Unit at our institution following a quality improvement project that implemented an SRS algorithm. We compared exclusive breastfeeding rates over 2 time periods, 33 months before and 15 months after SRS algorithm implementation. We completed bivariate comparisons using chi-square and Mann-Whitney U tests to understand the factors contributing to exclusive breastfeeding rates. In a secondary analysis, breastfeeding rates and demographic patterns were examined using p-charts. RESULTS: Following algorithm implementation, exclusive breastfeeding rates increased from 49% to 58% (P = 0.10) in chorioamnionitis-exposed newborns. Factors associated with increased exclusive breastfeeding included Caucasian race, English as the primary language, private insurance, vaginal delivery, and positive group B Streptococcus status. In the secondary analysis, the proportion of non-Hispanic mothers increased from 63% to 80% during the study. CONCLUSIONS: Despite SRS implementation, exclusive breastfeeding rates increased but not significantly, and certain sociodemographic factors remain associated with exclusive breastfeeding. Secondary analysis revealed an overall demographic shift affecting the dataset, highlighting the importance of thorough data analysis when evaluating a quality improvement project.

Pacifier Use and Breastfeeding: A Qualitative Study of Postpartum Mothers.

Objective: Due to the inconclusive evidence supporting the traditional recommendation to avoid early pacifier use among breastfeeding newborns, this study aims to understand what information mothers are receiving from hospital based care providers and their perspectives about pacifier use in the newborn period. Methods: Interviews with mothers of healthy, term newborns during the postpartum hospitalization were conducted in this qualitative study. Results: Qualitative data analysis yielded several major themes that included the following: (1) pacifiers are beneficial for the maternal/infant experience, (2) concerns that pacifiers may interfere with breastfeeding, and (3) concerns about long-term use (including reliance and effect on teeth). Conclusion: Given the maternal perception of benefit and the paucity of high-quality evidence showing harm, further research on the effects of early pacifier use is needed.

Supplementation Practices and Donor Milk Use in US Well-Newborn Nurseries.

BACKGROUND AND OBJECTIVES: Guidelines encourage exclusive breastfeeding for healthy newborns but lack specificity regarding criteria for medically indicated supplementation, including type, timing, and best practices. We set out to describe practice patterns and provider perspectives regarding medically indicated supplementation of breastfeeding newborns across the United States. METHODS: From 2017 to 2018, we surveyed the Better Outcomes through Research for Newborns representative from each Better Outcomes through Research for Newborns hospital regarding practices related to medically indicated supplementation. We used descriptive statistics to compare practices between subgroups defined by breastfeeding prevalence and used qualitative methods and an inductive approach to describe provider opinions. RESULTS: Of 96 providers representing discrete hospitals eligible for the study, 71 participated (74% response rate). Practices related to criteria for supplementation and pumping and to type and caloric density of supplements varied widely between hospitals, especially for late preterm infants, whereas practices related to lactation consultant availability and hand expression education were more consistent. The most commonly reported criterion for initiating supplementation was weight loss of ≥10% from birth weight, and bottle-feeding was the most commonly reported method; however, practices varied widely. Donor milk use was reported at 20 (44%) hospitals with ≥81% breastfeeding initiation and 1 (4%) hospital with <80% breastfeeding initiation (P = .001). CONCLUSIONS: Strategies related to supplementation vary among US hospitals. Donor milk availability is concentrated in hospitals with the highest prevalence of breastfeeding. Implementation of evidence-based management of supplementation among US hospitals has the potential to improve the care of term and late preterm newborns.

Exposure to Hospital Breastfeeding Support by Maternal Race and Ethnicity: A Pilot Study.

INTRODUCTION: The Ten Steps to Successful Breastfeeding are evidence-based practices used to improve breastfeeding outcomes, and most are to be implemented shortly after birth. Although breastfeeding is increasing in the United States, racial disparities persist. Available national samples used to examine trends in maternity care rely on maternal recall, which may be subject to error and bias. Thus, we conducted a pilot study to determine the feasibility of a large-scale study conducted during the birth hospitalization to explore patterns in practices supporting breastfeeding across maternal racial and ethnic groups. METHODS: A convenience sample of 37 women with healthy, term singletons who intended to breastfeed were recruited from 2 academic medical centers (one in the Midwest and the other in the Pacific Northeast) and surveyed during their birth hospitalizations between July and November 2016. Women were asked whether they received the 7 steps that are recommended to be implemented shortly after birth (eg, encourage breastfeeding on demand). We generated descriptive statistics and conducted independent chi-square tests to determine associations between self-reported exposure to these 7 practices and race and ethnicity. RESULTS: In this sample, 23 women (62.2%) were non-Hispanic white, 5 (13.5%) were non-Hispanic black, and 6 (16.2%) were Hispanic. Approximately 26 (70.3%) reported experiencing at least 6 of the 7 practices. Non-Hispanic white women were significantly more likely to room-in with their newborns, were less likely to receive formula, and were less likely to receive pacifiers than women of other races and ethnicities (P < .05). Furthermore, differences in exposure to practices by maternal race/ethnicity appeared more pronounced at one center than the other. DISCUSSION: Preliminary findings suggest that some practices used to improve breastfeeding may be provided inconsistently across maternal racial and ethnic groups. Additional investigation is needed to further explore these patterns and to identify reasons for any inconsistencies in order to reduce health disparities in the United States.

Bisphosphonate therapy for osteogenesis imperfecta.

BACKGROUND: In osteogenesis imperfecta (OI) a genetic defect in type I collagen results in multiple fractures with little or no trauma. Bisphosphonates are used to attempt to reduce these fractures. OBJECTIVES: To assess the effectiveness and safety of bisphosphonates in increasing bone mineral density (BMD), reducing fractures and improving clinical function in people with OI. SEARCH STRATEGY: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearches of journals and conference proceedings. We searched PubMed and major conference proceedings.Register last searched: August 2008. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials comparing bisphosphonates to placebo, no treatment, or comparator interventions in all types of OI. DATA COLLECTION AND ANALYSIS: Two authors independently extracted data and assessed trial quality. MAIN RESULTS: Eight studies (403 participants) were included. Data for oral bisphosphonates versus placebo could not be aggregated. A significant difference favouring bisphosphonates in fracture risk reduction and number of fractures was noted in one trial. No differences were reported in the remaining three trials. Two trials reported data for spine BMD; one found significantly increased lumbar spine density z scores at 12 months and one reported a significant increase in lumbar spine BMD at 12, 24 and 36 months; both favouring bisphosphonates. For intravenous bisphosphonates versus placebo, aggregated data from two trials showed no significant difference for the number of participants with at least one fracture, RR 0.56 (95% CI 0.30 to 1.06). In the remaining trial no significant difference was noted in fracture incidence. For spine BMD, no significant difference was noted in the aggregated data from two trials, MD 9.96 (95%CI -2.51 to 22.43). In the remaining trial a significant difference in mean per cent change in spine BMD z score favoured intravenous bisphosphonates at 6 and 12 months. One trial compared oral versus intravenous bisphosphonates and found no differences in primary outcomes. Data describing growth, bone pain, and functional outcomes after bisphosphonate therapy were incomplete. AUTHORS' CONCLUSIONS: Evidence suggests oral or intravenous bisphosphonates increase BMD in children and adults with OI. These were not shown to be different in their ability to increase BMD; it is unclear whether either treatment decreases fractures. Additional studies may determine whether bisphosphonates improve clinical status (reduce fractures and pain; improve growth and functional mobility) in this population. Optimal method, duration of therapy and long-term safety of bisphosphonate therapy requires further investigation.

Human Donor Milk or Formula: A Qualitative Study of Maternal Perspectives on Supplementation.

BACKGROUND: Breastfeeding is fundamental to maternal and child health and is the most cost-effective intervention to reduce child mortality. Pasteurized human donor milk (HDM) is increasingly provided for term newborns requiring temporary supplementation. Few studies examine maternal perspectives on supplementation of term newborns. MATERIALS AND METHODS: We conducted semistructured in-person interviews with mothers of term newborns (n = 24) during postpartum hospitalization. Mothers were asked whether they had chosen or would choose to supplement with HDM versus infant formula, if medically indicated, and why. Data were gathered to saturation and analyzed inductively by consensus. Emerging semantic themes were compared between mothers who chose or would choose HDM and those who chose or would choose infant formula. RESULTS: Most mothers had concerns about HDM, including uncertainty regarding screening and substances passed through HDM. Experiences with prior children influenced decision-making. Mothers who chose or would choose HDM (56%, n = 14) praised it as "natural," and some felt suspicious of infant formula as "synthetic." Mothers who chose or would choose infant formula (44%, n = 10) did not know enough about HDM to choose it, and many viewed infant formula as a short-term solution to supply concerns. Mothers unanimously mistrusted online milk purchasing sources, although the majority felt positively about using a friend or family member's milk. CONCLUSIONS: Counseling regarding term newborn supplementation should focus on HDM education, specifically on areas of greatest concern and uncertainty such as donor selection, screening, transmission of substances, and mother's milk supply. Research is needed to assess the long-term impact of attitudes and choices on breastfeeding.

Implementation of the sepsis risk score for chorioamnionitis-exposed newborns.

BACKGROUND: To prevent early onset sepsis (EOS), ~10% of neonates receive antibiotics based on CDC recommendations regarding chorioamnionitis exposure. A sepsis risk score (SRS) predicts EOS and spares unnecessary evaluation and treatment. LOCAL PROBLEM: Chorioamnionitis-exposed neonates utilize significant resources. METHODS: An SRS algorithm was implemented to decrease resource utilization in chorioamnionitis-exposed neonates ≥35 weeks'. Outcome measures included antibiotic exposure, time in NICU, laboratory evaluations, and length of stay (LOS). Balancing measures were missed cases of EOS and readmissions. Data were assessed using run charts. INTERVENTIONS: Plan-Do-Study-Act cycles were utilized to process map, implement and reinforce the algorithm. RESULTS: A number of 356 patients met inclusion criteria. After algorithm implementation, antibiotic exposure reduced from 95 to 9%, laboratory evaluation from 96 to 22%, NICU observation from 73 to 10%. LOS remained unchanged. No missed cases of EOS, nor sepsis readmissions. CONCLUSIONS: Algorithm implementation decreased antibiotic and resource utilization without missing cases of EOS.