'Humility, Concern, Respect': A Qualitative Study Exploring Parent Perspectives on a Pediatrician's Role in Addressing Racism.

OBJECTIVE: To explore racially minoritized families' perceptions on how, and if, physicians should address children's racial identity and concepts of racism within clinical settings. STUDY DESIGN: Parents of racially minoritized children, ages 5 through 18, were interviewed to explore experiences with racial identity formation, discrimination, and the extent to which they wanted pediatricians to address these topics. Children were included at the discretion of their parents. Interviews were transcribed, coded, and analyzed through a critical race theory lens based in constructivist grounded theory. RESULTS: Parents encouraged their children to embrace their racial identities but also wanted to shield them from negative experiences of racism to preserve identity safety. Parents felt pediatricians should address racial issues in a manner specific to their child's situation. Thoughtful inclusion of race-related questions, whether in discussion or on questionnaires, is essential to prevent tension in a therapeutic relationship. There was no consensus on the use of preclinical screening. Instead, families highlighted the importance of embracing humility, trust, and respect. CONCLUSIONS: Participant families have preferences for approaches to address the effects of racism on their children's health. Pediatricians should understand the importance of identity safety and approach their discussions with cultural humility, which includes self-reflection, empathy, active listening, and flexible negotiation. Above all, pediatricians need to create a safe environment for appropriate discussion of these issues.

Conceptualizing and Developing Competence in Newborn Medicine Among Military Pediatricians.

INTRODUCTION: Competence in neonatal care is especially important for military pediatricians because military pediatricians can be asked to serve in remote duty locations with limited resources. We sought to understand how this competence is defined, developed, and assessed by military pediatric training programs. MATERIALS AND METHODS: After Institutional Review Board approval was obtained, we interviewed educators and recent graduates from every pediatric military training program to construct a shared definition of competence. We then used Kern's Six Steps for curriculum development to understand how competence is taught and assessed. RESULTS: Participants felt that competence for military pediatricians in the neonatal setting meant that learners should be able to provide a full spectrum of newborn care in any military setting. Participants confirmed that this competence was particularly important for military pediatricians because of the possibility of remote duty locations. Participants felt that specific knowledge, skills, and attitudes supported competence. Knowledge domains include distinguishing normal newborns from abnormal newborns, managing normal newborn care, managing common newborn abnormalities, and creating a safe escalation plan for complicated or uncommon newborn abnormalities. Specific skills that support competence are newborn resuscitation, delivery of effective ventilation, and neonatal circumcision. Specific attitudes that support competence are, understanding the personal limits of knowledge and understanding the resources for escalation of care. Educators use a variety of modalities to teach toward competence, including the structured curricula, bedside teaching, and simulation. According to participants, the assessment of learners occurs primarily through narrative assessment and feedback but would ideally occur through direct observation. CONCLUSIONS: Competence in the neonatal setting is particularly important for military pediatricians. Essential skills undergo differential assessment and current assessment methods differ from ideal assessment methods. Future work should focus on how these facets can support a unified curriculum in newborn medicine.

High Uptake of Respiratory Syncitial Virus Prevention for Neonates in a Military Treatment Facility.

We investigated the uptake of nirsevimab for infants and the bivalent respiratory syncytial virus prefusion F (RSVPreF) vaccine for pregnant persons as measures for RSV prevention during an infant's birth hospitalization in a military treatment facility. We found >85% uptake between October 2023 to February 2024. These data may aid health systems plan for future RSV seasons.

Readmission Reduction for Hyperbilirubinemia in Infants ≥ 35 Weeks Estimated Gestational Age Using a Standardized Protocol.

BACKGROUND: Most newborns experience hyperbilirubinemia. Monitoring and treatment must be balanced with the risk of unintended harm, including readmission to the birth hospital. From January 2019 to April 2021, the average rate of inborn readmission for all causes was 2.09% at the study hospital; hyperbilirubinemia accounted for 91% of these readmissions. The aim of this project was to decrease readmission rate for hyperbilirubinemia by 60% within eight months of protocol implementation. METHODS: The Lean system of quality improvement was used to assess root causes and implement countermeasures. A hyperbilirubinemia protocol was developed, and phototherapy equipment was upgraded. Monthly readmission rates were the main outcome measure. Process measures included hour of life for initial transcutaneous bilirubin measurement. Balance measures included number of serum bilirubin labs obtained per 100 infants, percentage treated with phototherapy, mean length of phototherapy treatment, and length of hospital stay. Statistical process control charts were used to measure changes in quality over time. RESULTS: Baseline data showed a monthly readmission rate for hyperbilirubinemia of 1.9%. Following countermeasure implementation, there was a clinically significant downward shift in the monthly readmission rate to 0.64%, representing a 66% decrease from baseline. CONCLUSION: Implementation of the project protocol was associated with a clinically significant decrease in readmissions for hyperbilirubinemia with no concurrent clinically significant changes in the number of labs drawn, number of infants started on phototherapy, or average length of hospital stay. For military treatment facilities or institutions with similar staffing models, this protocol may offer a model for improvement.

Factors Associated with Outpatient Therapy Utilization in Extremely Preterm Infants.

OBJECTIVE: Factors influencing utilization of outpatient interventional therapies for extremely low gestational age newborns (ELGANs) after discharge remain poorly characterized, despite a significant risk of neurodevelopmental impairment. We sought to assess the effects of maternal, infant, and environmental characteristics on outpatient therapy utilization in the first 2 years after discharge using data from the Preterm Erythropoietin Neuroprotection (PENUT) Trial. STUDY DESIGN: This is a secondary analysis of 818, 24 to 27 weeks gestation infants enrolled in the PENUT trial who survived through discharge and completed at least one follow-up call or in-person visit between 4 and 24 months of age. Utilization of a state early intervention (EI) program, physical therapy (PT), occupational therapy (OT), and speech therapy (ST) was recorded. Odds ratios and cumulative frequency curves for resource utilization were calculated for patient characteristics adjusting for gestational age, treatment group, and birth weight. RESULTS: EI was not accessed by 37% of infants, and 18% did not use any service (PT/OT/ST/EI). Infants diagnosed with severe morbidities (intraventricular hemorrhage, retinopathy of prematurity, bronchopulmonary dysplasia, necrotizing enterocolitis), discharged with home oxygen, or with gastrostomy placement experienced increased utilization of PT, OT, and ST compared with peers. However, substantial variation in service utilization occurred by the state of enrollment and selected maternal characteristics. CONCLUSIONS: ELGANs with severe medical comorbidities are more likely to utilize services after discharge. Therapy utilization may be impacted by maternal characteristics and state of enrollment. Outpatient therapy services remain significantly underutilized in this high-risk cohort. Further research is required to characterize and optimize the utilization of therapy services following NICU discharge of ELGANs. KEY POINTS: · Outpatient therapy is underutilized in ELGANs.. · Medical comorbidities may impact therapy use.. · Maternal characteristics may impact therapy use.. · State of enrollment may impact therapy use..

Supplementation-based hypoglycemia guidelines including donor breast milk reduce NICU admission.

OBJECTIVE: To study the effects of a supplementation-based hypoglycemia guideline including donor (DM) on NICU admission, exclusive breastfeeding, and blood glucose concentrations in infants at-risk for neonatal hypoglycemia (NH). PROJECT DESIGN: We integrated DM, feeding supplementation, and reduced frequency of blood glucose testing into an NH bundle for term and late-preterm newborns. We then examined NICU admission rates and rates of exclusive breastfeeding at discharge. RESULTS: NICU admission rates were reduced to 6% (-10%). Exclusive breastfeeding rates increased to 55% (+22%). Median cost of DM utilization was $13.73 per patient with an average volume of 50.8 ml/infant. DM supplementation resulted in similar times to last hypoglycemic episode and greater increases in blood glucose compared to expressed breast milk or breastfeeding alone (+9.6 mg/dL, p < 0.05). CONCLUSIONS: A supplementation-based hypoglycemia guideline including donor milk may be an effective way to reduce NICU admissions for asymptomatic hypoglycemia and support mothers in achieving breastfeeding goals.

Evaluating the effects of a neonatal hypoglycemia bundle on NICU admission and exclusive breastfeeding.

OBJECTIVE: Early feeding, skin-to-skin contact, and dextrose gel have been independently shown to promote breastfeeding and decrease NICU admission for neonatal hypoglycemia. We combined these interventions to decrease NICU admissions for asymptomatic hypoglycemia and increase exclusive breastfeeding rates. PROJECT DESIGN: The IHI Model for Improvement was used to design a bundle including feeding within 1 h of birth, 1 h of uninterrupted skin-to-skin within 2 h of birth, and administration of buccal 40% dextrose gel for hypoglycemic infants. RESULTS: Utilization of dextrose gel was 94% following implementation. There were no trends in exclusive breastfeeding at discharge or NICU admissions for asymptomatic hypoglycemia. Post hoc multivariate analysis identified cesarean delivery as an independent risk factor for compliance failure and failure of exclusive breastfeeding but not for NICU admission. CONCLUSIONS: Despite high compliance with dextrose gel utilization, there was no change in exclusive breastfeeding at discharge or NICU admission rates for asymptomatic hypoglycemia.

Novel anti-viability ceramide analogs: design, synthesis, and structure-activity relationship studies of substituted (S)-2-(benzylideneamino)-3-hydroxy-N-tetradecylpropanamides.

A group of novel L-serinamides, substituted (S)-2-(benzylideneamino)-3-hydroxy-N-tetradecylpropanamides (3a-o) and substituted (S)-2-(benzylamino)-3-hydroxy-N-tetradecyl propanamides (4c, 4i, 4l, and 4o), were synthesized as potential anti-tumor lead compounds. In vitro cell viability assay results indicate treatment with 3a-o compounds resulted in significant inhibition of cell viability in the chemoresistant breast cancer cell line, MCF-7TN-R. Compounds 3i and 3l, both ortho-substituted analogs, show the greatest efficacy with IC50 values of 10.3 microM and 12.5 microM, respectively. The SAR analysis indicate that the imine functional group of 3a-o is critical for the cellular anti-viability effect, and the partial atomic charge (PAC) value of imine C atom is a valuable structural parameter for predicting the activity of these ceramide analogs.

Novel D: -erythro N-octanoyl sphingosine analogs as chemo- and endocrine-resistant breast cancer therapeutics.

PURPOSE: Resistance to endocrine and chemotherapies remains the primary cause of breast cancer treatment failure. We have synthesized four novel D: -erythro N-octanoyl sphingosine analogs and catalogued their activity in drug-sensitive (MCF-7), endocrine-resistant (MDA-MB-231) and chemoresistant (MCF-7TN-R) breast cancer cells. METHODS: 3-(4,5-Dimethylthiazol-2-Yl)-2,5-diphenyltetrazolium bromide (MTT) assay was used to determine cell viability; colony assay was performed to determine effects on clonogenic survival and (1)H NMR, (13)C NMR, HPLC spectra and elemental analytical data analyses were used to determine analog identity and purity. RESULTS: All four analogs inhibited both viability and clonogenic survival, with analog C exhibiting a log-fold improvement in anti-survival activity compared to the parent compound. CONCLUSION: With resistance to current breast cancer chemotherapies on the rise, the development of novel therapeutic targets is of growing importance. Our results show that lipid analogs have therapeutic potential in treating chemo- and endocrine-resistant breast cancer.

A new technique for precisely and accurately measuring lumbar spine bone mineral density in mice using clinical dual energy X-ray absorptiometry (DXA).

Dual Energy X-ray Absorptiometry (DXA) is effective in measuring bone mineral density (BMD) in mice for early detection of osteoporosis. However, scanners designed for use with small animals (i.e. PIXImus) are very expensive. Used human DXA machines are cheaper to obtain, but analysis of scans from these instruments is operator-dependent. Obtaining reliable data depends on having a single operator analyze the scans in a blinded fashion. Scan quality is improved by excising the bone prior to scanning, which does not allow serial measurements. This study describes a novel method of analyzing lumbar spine BMD in mice using whole body DXA. This non-invasive technique has a high degree of precision and reproducibility, with good correlation between multiple observers. Inter-observer variability (0.063 +/- 0.00317 g/cm(2) [mean +/- SD], 5.05 [% coefficient of variation (CV)], repeat scan variability (0.063 +/- 0.00364 g/cm(2) [mean +/- SD], 5.94 [%CV]) were very low compared to variability between different animals (0.063 +/- 0.00588 g/cm(2) [mean +/- SD], 9.64 [%CV]) and variability seen in same animal over time (0.011 +/- 0.00885 g/cm(2) [mean +/- SD], 80.68 [%CV]). The measurement error is thus smaller than the biological variation. Accuracy was determined by comparing average peak BMD from two scans per mouse in-vivo (0.066 g/cm(2)) versus excised spine (0.065 g/cm(2)). Furthermore, correlation between bone ash weights and whole body lumbar spine BMD measurements (p < 0.0001) was highly significant. This technique thus shows a high degree of precision and accuracy, even with multiple observers, for measuring BMD in mice using a DXA machine designed for clinical use.

Breastfeeding does not protect against urinary tract infection in the first 3 months of life, but vitamin D supplementation increases the risk by 76%.

Our goal was to determine if breastfeeding provides any protection against urinary tract infection (UTI) and if vitamin D supplementation imposes any additional risks for UTI in infants < 3 months of age. In this study, 40% of the children who had urine cultures were breastfed, and 18.7% of the children were exclusively breastfed. Twenty percent of all of the urine cultures tested positive, and this number was greater in females (22.5%) than in males (18.1%, P < .05). There was no significant difference between the rates of positive urine cultures in exclusively breastfed (22% vs 21%, nonsignificant [NS]) formula-fed infants. The relative risk of UTI with breastfeeding versus formula feeding was 1.03 (0.58-1.82), and any breastfeeding versus no breastfeeding was 0.92 (0.58-1.45). Vitamin D supplementation increased the UTI risk, with a relative risk of 1.76 (1.07-2.91, P < .05). However, only formula-fed infants showed an increased risk of UTI after vitamin D supplementation.

Effects of stress after hurricanes katrina and rita on pubertal disorders in children.

Hurricanes Katrina and Rita caused widespread damage that resulted in increased stress levels for families living in the New Orleans area. This study examined the relationship between this stress and the onset of puberty in children by conducting a retrospective chart review of patients referred before and after the storm to a pediatric endocrine practice in New Orleans. The total number of new patients referred and the incidence of diagnoses that are unlikely to be affected by stress (ie, thyroid disease and premature adrenarche) were essentially unchanged. On the other hand, the incidence of central precocious puberty decreased by 52% after the storm, while the incidence of pubertal delay increased by 9% in the post storm period. This study thus provides evidence that stress delays the onset of puberty in children.