Multisystemic inflammatory syndrome in children and the BNT162b2 vaccine: a nationwide cohort study.

Multisystemic inflammatory syndrome in children (MIS-C) is a rare, severe, post-infectious hyperinflammatory condition that occurs after COVID-19 infection. In this study, we aimed to demonstrate the risk reduction of MIS-C and severe MIS-C after Pfizer-BioNTech BNT162b2 mRNA COVID-19 vaccination. This nationwide cohort study included 526,685 PCR-confirmed COVID-19 cases (age < 19 years), of whom 14,118 were fully vaccinated prior to COVID-19 infection. MIS-C cases were collected from all hospitals in Israel from April 2020 through November 2021. The MIS-C rates were calculated among two COVID-19 populations: positive PCR confirmed cases and estimated COVID-19 cases (PCR confirmed and presumed). Vaccination status was determined from Ministry of Health (MoH) records. The MIS-C risk difference (RD) and 95% confidence intervals (95%CI) between vaccinated and unvaccinated patients are presented. Overall, 233 MIS-C cases under the age of 19 years were diagnosed and hospitalized in Israel during the study period. Among the estimated COVID-19 cases, MIS-C RD realistically ranged between 2.1 [95%CI 0.7-3.4] and 1.0 [95%CI 0.4-1.7] per 10,000 COVID-19 cases. For severe MIS-C, RD realistically ranged between 1.6 [95%CI 1.3-1.9] and 0.8 [95%CI 0.7-1.0], per 10,000 COVID-19 cases. Sensitivity analysis was performed on a wide range of presumed COVID-19 rates, demonstrating significant RD for each of these rates. CONCLUSION: This research demonstrates that vaccinating children and adolescents against COVID-19 has reduced the risk of MIS-C during the study period. WHAT IS KNOWN: • Most of the published literature regarding vaccine effectiveness is based on case-control studies, which are limited due to small sample sizes and the inability to fully estimate the risk of MIS-C among vaccinated and unvaccinated children and adolescents. • The known underestimation of COVID-19 diagnosis among children and adolescents is challenging, as they often have few to no symptoms. WHAT IS NEW: • Significant risk difference was found in favor of the vaccinated group, even after including extreme assumptions regarding the underdiagnosed COVID-19 rate. • During this nationwide study period, it was found that vaccinating children and adolescents reduced the risk of MIS-C and its complications.

Improved method for revising the Israel birthweight references.

OBJECTIVES: Birthweight is often used as an indicator of fetal health. Categorization of infants as small or large for gestational age has clinical significance. Due to growth differences between countries, it is important to have local reference data. The aim of the study was to describe an Israel population-based reference of birthweight by gestational age stratified for singletons/multiple births and gender. METHODS: Data on birthweight and gestational age were obtained for the years 2010-2019 from the Ministry of Health Birth Registry. Implausible birthweight and gestational age values were excluded in a two step process. First, overtly implausible values were excluded using visual mapping. Then, infants whose birthweight was below or above the fifth interquartile range for each completed week were excluded. RESULTS: During the 10-year period there were 1,761,884 infants delivered in Israel; 1,689,696 were included in the analysis. 4.4% of the live born infants were from multiple births. The mean birthweight of singletons (3251 g) was 947 ± 4 g higher than that of multiples (2304 g). The birthweight of the male multiple births began to differ from that of the singletons at 30 weeks; female multiple births began to deviate at 31 weeks. The increase in birthweight of singletons leveled after 42 weeks and those born after 43 weeks weighed less than infants born earlier. Comparison of the curves for singletons from the present study to those reported for the years 1993-2001 reveal a similar median but significant differences in the distribution of lower and higher percentiles. CONCLUSIONS: Improved data collection and validation permitted inclusion of 96% of births for analysis. Use of interquartile range distribution to exclude values of birthweight/gestational age that were implausible improved validity. Compared to curves reported previously, changes were found in the distribution of birthweights for the upper and lower percentiles. Periodic updates of growth curve references are important.

[CORONA VIRUS, BREASTFEEDING AND GUIDELINES - A WORLDWIDE REVIEW].

INTRODUCTION: The COVID-19 pandemic has forced countries worldwide to face major issues and challenges. Among those challenges is breastfeeding from the first hours after birth until late infancy, in hospitals and communities. There is a consensus throughout the world and among leading international professional medical associations that breastfeeding is of significant importance for short- and long-term health outcomes in mothers and infants, as well as for its public health impact and reduction of national health expenditures. Moreover, breastfeeding or human milk feeding have been shown to reduce morbidity, specifically respiratory infections, among infants and children. This is not the first time health systems are dealing with coronavirus outbreaks, although currently, in the COVID-19 pandemic, there is still much that is unknown. Dealing with the unknown can lead to guidelines that may not fully take into consideration relevant risk benefit ratios for individuals and groups. In this review, we aim to summarize the guidelines of different leading professional groups around the world dealing with the COVID-19 pandemic. Evidence-based medicine rests on relevant scientific evidence, patients' values and preferences and clinical judgment. We wish to propose guidelines based on available evidence concerning breastfeeding, the current pandemic and weighing in potential risks and benefits while highlighting the need for ongoing breastfeeding research.

Post-discharge neonatal hyperbilirubinemia surveillance.

AIM: To assess implementation of the Israel Neonatal Society's 2008 guidelines for universal community assessment of jaundice within 72 hours of discharge from birth hospitalisation. METHODS: Mothers of newborns were interviewed at Maternal Child Health Clinics in the Jerusalem District, Israel, and asked whether their newborn had been evaluated for jaundice within the recommended time frame. Newborn discharge letters from Israeli hospitals were assessed for appropriate inclusion of instructions for early follow-up for jaundice. RESULTS: Out of 659, 217 (32.9%) mothers whose newborns were at low risk for neonatal hyperbilirubinemia reported an examination within 72 hours of discharge. Eighteen (8.3%) were referred for a bilirubin test. In contrast, 99.1% (109/110) of high-risk newborns who were specifically invited for a bilirubin test the day following discharge complied. Out of 26, 12 (46.2%) hospital discharge letters specified both a time limit of 72 hours post-discharge and jaundice as a reason for early follow-up. CONCLUSION: The early community surveillance rate for jaundice was low, contrasting with near universal compliance in those who received a specific instruction for a post-discharge bilirubin blood test. Inclusion of specific written instructions in hospital discharge summaries was also low and may contribute to poor implementation of guidelines.

Community-Oriented Epidemic Preparedness and Response to the Jerusalem 2018-2019 Measles Epidemic.

Measles epidemics are still a public health challenge worldwide, necessitating a rapid response. The Jerusalem District Health Office applied a community-oriented intervention during the 2018-2019 epidemic (2150 notified cases). Program development targeted the socioeconomic and cultural characteristics of high-incidence Jewish ultraorthodox communities. Health care and community collaboration led to coverage rates of measles vaccination increasing from 80% to 95% within three months and a significant decline in incidence. Epidemic preparedness calls for maintaining the infrastructure of countermeasures combined with sustaining immunization coverage.

Corneal and conjunctival injury seen in urgent care centres in Israel.

PURPOSE: Corneal and conjunctival injuries (CCI) comprise a large portion of the cases presenting to hospital-based emergency departments (ED) with ocular involvement. Urgent Care Centres (UCC) offer community based emergency care at lower cost than hospital-based emergency departments (ED) and with greater temporal convenience than primary care office settings. While CCI prevalence and treatment at hospital-based EDs has been well studied, this is the first report, to our knowledge, on CCI demographics and aetiology presenting to UCCs. METHODS: This retrospective study was approved by the institutional ethics committee. The setting is a UCC system in Israel, modelled on USA urgent care facilities, consisting of 17 branches at the time of the study. Electronic medical record data (between November 1, 2015 and October 31, 2016) of patients diagnosed with corneal disorder, foreign body or eye disorder were retrieved and reviewed for inclusion/exclusion criteria. Data collected included gender, age, chief complaint, diagnosis, treatment and discharge status (sent home or referred to ED). International Classification of Diseases, Ninth Revision (ICD-9) codes were assigned to each record based on a review of all fields. UCC results were compared to all ED patients in Israel using data from a public report. Data were analysed by descriptive statistics and logistic regression analysis. RESULTS: Of the 602 074 charts screened, 4797 patients presented with CCI (0.8%). The average age was 32.6 ± 18.2 years and 71.3% were male. Among these, 26.4% were referred to the ED compared to 6.8% from the entire UCC cohort. ICD-9 code Foreign body (FB) of the eye was the most common cause of CCI (56.5%) followed by the following ICD-9 codes: trauma (18.1%), chemical in the eye (11.1%) and corneal disorder due to a contact lens (5.1%). Logistic regression analyses showed the following risk factors for ED referral: age (22-64), male gender, ICD-9 code FB, work-related injury and the presence of a clinical abrasion in the eye. CONCLUSIONS: The aetiology of ocular injury at UCC is similar to previous studies of ED. Most CCI can be treated at UCC saving ED resources and underscores the importance of this mode of health care delivery in the overall health system.

Early Prediction of Autistic Spectrum Disorder Using Developmental Surveillance Data.

Importance: With the continuous increase in the prevalence of autistic spectrum disorder (ASD), effective early screening is crucial for initiating timely interventions and improving outcomes. Objective: To develop predictive models for ASD using routinely collected developmental surveillance data and to assess their performance in predicting ASD at different ages and in different clinical scenarios. Design, Setting, and Participants: This retrospective cohort study used nationwide data of developmental assessments conducted between January 1, 2014, and January 17, 2023, with minimal follow-up of 4 years and outcome collection in March 2023. Data were from a national program of approximately 1000 maternal child health clinics that perform routine developmental surveillance of children from birth to 6 years of age, serving 70% of children in Israel. The study included all children who were assessed at the maternal child health clinics (N = 1 187 397). Children were excluded if they were born at a gestational age of 33 weeks or earlier, had no record of gestational age, or were followed up for less than 4 years without an ASD outcome. The data set was partitioned at random into a development set (80% of the children) and a holdout evaluation set (20% of the children), both with the same prevalence of ASD outcome. Exposures: For each child, demographic and birth-related covariates were extracted, as were per-visit growth measurements, quantified developmental milestone assessments, and referral summary covariates. Only information that was available before the prediction age was used for training and evaluating the models. Main Outcome and Measure: The main outcome was eligibility for a governmental disabled child allowance due to ASD, according to administrative data of the National Insurance Institute of Israel. The performance of the models that predict the outcome was evaluated and compared with previous work on the Modified Checklist for Autism in Toddlers (M-CHAT). Results: The study included 1 187 397 children (610 588 [51.4%] male). The performance of the ASD prediction models improved with prediction age, with fair accuracy already at 12 months of age. A model that combined longitudinal measures of developmental milestone assessments with a minimal set of demographic variables, which was applied at 18 to 24 months of age, achieved an area under the receiver operating characteristic curve of 0.83, with a sensitivity of 45.1% at a specificity of 95.0%. A model using single-visit assessments achieved an area under the receiver operating characteristic curve of 0.81 and a sensitivity of 41.2% at a specificity of 95.0%. The best performing prediction models surpassed the pooled performance of M-CHAT (sensitivity, 40%; specificity, 95%) reported in studies with a similar design. Conclusions and Relevance: This cohort study found that ASD can be predicted from routine developmental surveillance data at an accuracy surpassing M-CHAT screening. This tool may be seamlessly integrated in the clinical workflow to improve early identification of children who may benefit from timely interventions.

Sex-Specific Developmental Scales for Surveillance.

BACKGROUND: Developmental surveillance, conducted routinely worldwide, is fundamental for early detection of children at risk for developmental delay. We aimed to explore sex-related difference in attainment rates of developmental milestones and to evaluate the clinical need for separate sex-specific scales. METHODS: This is a cross-sectional, natiowide retrospective study, utilizing data from a national child surveillance program of ∼1000 maternal child health clinics. The main cohort, used for constructing sex-specific developmental scales, included all children born between January 2014 to September 2020, who visited maternal child health clinics from birth to 6 years of age (n = 839 574). Children with abnormal developmental potential were excluded (n = 195 616). A validation cohort included all visits between 2020 and 2021 (n = 309 181). The sex-differences in normative attainment age of 59 developmental milestones from 4 domains were evaluated. The milestones with a significant gap between males and females were identified, and the projected error rates when conducting unified versus sex-specific surveillance were calculated. RESULTS: A new sex-specific developmental scale was constructed. In total, females preceded males in most milestones of all developmental domains, mainly at older ages. Conducting routine developmental surveillance using a unified scale, compared with sex-specific scales, resulted in potential missing of females at risk for developmental delay (19.3% of failed assessments) and over-diagnosis of males not requiring further evaluation (5.9% of failed assessments). CONCLUSIONS: There are sex-related differences in the normative attainment rates of developmental milestones, indicating possible distortion of the currently used unified scales. These findings suggest that using sex-specific scales may improve the accuracy of early childhood developmental surveillance.

[New guidelines to decrease x-ray use may increase unnecessary antibiotic use].

BACKGROUND: The newly reLeased guidelines of infectious disease societies suggest abstaining from performing routine chest radiographs in the diagnosis of community acquired pneumonia in clinically stable children, based upon studies where the measured outcome is time to resolution of the disease not antibiotic use. However, the impact of possible over-treatment with antibiotics that might result from this clinical approach is not discussed. OBJECTIVES: The goal of this study was to quantify how many children with clinicaL signs suggestive of pneumonia would have been given unnecessary antibiotic treatment had the chest radiograph not been performed. METHODS: In a system of urgent care centers, we reviewed the medical records of patients > 2 months and <10 years with the chief complaint of fever, cough or dyspnea who had a chest X-ray performed upon their evaluation. Demographic and cLinical data were obtained with the final reports of X-rays interpreted by senior radiologists. An X-ray was considered positive if an infiltrate or pneumonia was noted in the report. RESULTS: There were 3343 children over a one year period who met the inclusion criteria. A total of 877 had findings suggestive of pneumonia on the basis of physical examination. Of these, 433 (48.6%) had normal chest radiographs. Among those with negative X-rays, 305 (68.8%) had rates or crepitus on auscultation. CONCLUSIONS: Reliance on physical examination alone in the diagnosis of community-acquired pneumonia (CAP) in children may over-diagnose cases of pneumonia in a clinically significant manner. Further consideration of this possibility is needed before widely disseminating guidelines that advocate antibiotic treatment based on clinical diagnosis alone.

Functional tests as predictors of ankle instability six months after an acute lateral ankle sprain.

BACKGROUND: This study investigated whether functional tests performed in the acute-subacute phase after a lateral ankle sprain and demographic data are predictive of ongoing ankle instability. METHODS: Thirty-three subjects (mean age 23.6±3.6 years, 63.6% males) were tested within three weeks of injury using the Balance Error Scoring System (BESS) modified with a dual cognitive task, the single-leg drop landing task (SLDL) and the drop vertical jump task (DVJ). The Cumberland Ankle Instability Tool (CAIT) at six months and the occurrence of a new sprain during follow-up were used to define potential ankle instability. Associations between functional tests and demographic variables to ankle instability outcomes were measured with χ2, Mann-Whitney U Test, and logistic regressions. RESULTS: Twenty-one participants (63.6%) met the ankle instability criteria at six months from injury. Each extra point in the Modified-BESS Foam-Tandem sub-task increased the likelihood of ankle instability (OR=1.55, P=0.037). Unwillingness to perform SLDL increased the likelihood of ankle instability (OR=10.0, 95% CI: 1.1-91.9, RR=1.8, 95% CI: 1.1-2.8), as did non-dominant ankle sprain (OR=6.0, 95% CI: 1.2-29.4, RR=1.88, 95% CI: 1.03-3.4). These three outcomes explained between 33.6% to 45.9% of the variance and correctly classified 75.8% of cases (sensitivity, 85.7%; specificity, 58.3%; P=0.004). CONCLUSIONS: The variables studied may help identify individuals who have an increased potential to develop ankle instability and may be used in decision-making. Further studies should validate these findings with a larger and broader sample.

ABM Clinical Protocol #37: Physiological Infant Care-Managing Nighttime Breastfeeding in Young Infants.

A central goal of the Academy of Breastfeeding Medicine (ABM) is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient. The ABM empowers health professionals to provide safe, inclusive, patient-centered, and evidence-based care. Pregnant and lactating people identify with a broad spectrum of genders, pronouns, and terms for feeding and parenting. There are two reasons ABM's use of gender-inclusive language may be transitional or inconsistent across protocols. First, gender-inclusive language is nuanced and evolving across languages, cultures, and countries. Second, foundational research has not adequately described the experiences of gender-diverse individuals. Therefore, ABM advocates for, and will strive to use language that is as inclusive and accurate as possible within this framework. For more explanation, please read ABM Position Statements on Infant Feeding and Lactation-Related Language and Gender (https://doi.org/10.1089/bfm.2021.29188.abm) and Breastfeeding As a Basic Human Right (https://doi.org/10.1089/bfm.2022.29216.abm).

Morbidity of Returning Travelers Seen in Community Urgent Care Centers throughout Israel.

Information regarding post-travel morbidity is usually reported via dedicated post-travel clinics and mainly relates to travelers returning from low-middle-income countries (LMIC), however, the spectrum of morbidity seen within the community setting is scarcely reported. This prospective observational study among visitors to 17 community Urgent Care Centers (UCC) was designed to evaluate the reasons for post-travel community clinic visits and to compare travelers returning from LMIC to high-income countries (HIC). All visitors within one-month post-travel to all destinations were included. A total of 1580 post-travel visits were analyzed during 25 months. Travelers to LMICs were younger (mean 36.8 years old vs. 41.4 in the HIC group) and stayed longer periods abroad (30.1 ± 41.2 vs. 10.0 ± 10.6 in the HIC group) but more of them had pre-travel vaccines (35.5% vs. 6.6%). Travel-related morbidity was significantly more common in the LMIC group 58.3% (253/434) vs. 34.1% (391/1146) in the HIC group, (p < 0.001). Acute diarrhea was the leading cause of morbidity after visiting LMIC (28.8%) and was significantly more common than in the HIC (6.6%, p < 0.001). Other common morbidities in the LMIC cohort were respiratory (23.3%), cutaneous (15.8%), and injuries (9.9%). In the HIC group, the common morbidities were respiratory (37.3%), and diarrhea composed only 6.6% of the complaints. Our study group represents a less biased sample of travelers to LMIC as well as HIC, therefore, data from the UCC setting and at the specialized travel clinics complete each other in understanding the true extent of morbidity in travelers.

Trends in Atrial Fibrillation Management-Results from a National Multi-Center Urgent Care Network Registry.

BACKGROUND: Atrial fibrillation (AF) is a common diagnosis in patients presenting to urgent care centers (UCCs), yet there is scant research regarding treatment in these centers. While some of these patients are managed within UCCs, some are referred for further care in an emergency department (ED). OBJECTIVES: We aimed to identify the rate of patients referred to an ED and define predictors for this outcome. We analyzed the rates of AF diagnosis and hospital referral over the years. Finally, we described trends in patient anticoagulation (AC) medication use. METHODS: This retrospective study included 5873 visits of patients over age 18 visiting the TEREM UCC network with a diagnosis of AF over 11 years. Multivariate analysis was used to identify predictors for ED referral. RESULTS: In a multivariate model, predictors of referral to an ED included vascular disease (OR 1.88 (95% CI 1.43-2.45), p < 0.001), evening or night shifts (OR 1.31 (95% CI 1.11-1.55), p < 0.001; OR 1.68 (95% CI 1.32-2.15), p < 0.001; respectively), previously diagnosed AF (OR 0.31 (95% CI 0.26-0.37), p < 0.001), prior treatment with AC (OR 0.56 (95% CI 0.46-0.67), p < 0.001), beta blockers (OR 0.63 (95% CI 0.52-0.76), p < 0.001), and antiarrhythmic medication (OR 0.58 (95% CI 0.48-0.69), p < 0.001). Visits diagnosed with AF increased over the years (p = 0.030), while referrals to an ED decreased over the years (p = 0.050). The rate of novel oral anticoagulant prescriptions increased over the years. CONCLUSIONS: The rate of referral to an ED from a UCC over the years is declining but remains high. Referrals may be predicted using simple clinical variables. This knowledge may help to reduce the burden of hospitalizations.

A Developmental Surveillance Score for Quantitative Monitoring of Early Childhood Milestone Attainment: Algorithm Development and Validation.

BACKGROUND: Developmental surveillance, conducted routinely worldwide, is fundamental for timely identification of children at risk of developmental delays. It is typically executed by assessing age-appropriate milestone attainment and applying clinical judgment during health supervision visits. Unlike developmental screening and evaluation tools, surveillance typically lacks standardized quantitative measures, and consequently, its interpretation is often qualitative and subjective. OBJECTIVE: Herein, we suggested a novel method for aggregating developmental surveillance assessments into a single score that coherently depicts and monitors child development. We described the procedure for calculating the score and demonstrated its ability to effectively capture known population-level associations. Additionally, we showed that the score can be used to describe longitudinal patterns of development that may facilitate tracking and classifying developmental trajectories of children. METHODS: We described the Developmental Surveillance Score (DSS), a simple-to-use tool that quantifies the age-dependent severity level of a failure at attaining developmental milestones based on the recently introduced Israeli developmental surveillance program. We evaluated the DSS using a nationwide cohort of >1 million Israeli children from birth to 36 months of age, assessed between July 1, 2014, and September 1, 2021. We measured the score's ability to capture known associations between developmental delays and characteristics of the mother and child. Additionally, we computed series of the DSS in consecutive visits to describe a child's longitudinal development and applied cluster analysis to identify distinct patterns of these developmental trajectories. RESULTS: The analyzed cohort included 1,130,005 children. The evaluation of the DSS on subpopulations of the cohort, stratified by known risk factors of developmental delays, revealed expected relations between developmental delay and characteristics of the child and mother, including demographics and obstetrics-related variables. On average, the score was worse for preterm children compared to full-term children and for male children compared to female children, and it was correspondingly worse for lower levels of maternal education. The trajectories of scores in 6 consecutive visits were available for 294,000 children. The clustering of these trajectories revealed 3 main types of developmental patterns that are consistent with clinical experience: children who successfully attain milestones, children who initially tend to fail but improve over time, and children whose failures tend to increase over time. CONCLUSIONS: The suggested score is straightforward to compute in its basic form and can be easily implemented as a web-based tool in its more elaborate form. It highlights known and novel relations between developmental delay and characteristics of the mother and child, demonstrating its potential usefulness for surveillance and research. Additionally, it can monitor the developmental trajectory of a child and characterize it. Future work is needed to calibrate the score vis-a-vis other screening tools, validate it worldwide, and integrate it into the clinical workflow of developmental surveillance.

Increased rates of unattained developmental milestones among Israeli children between 2016 and 2020: a national report.

BACKGROUND: The early years of children's lives are critical for their healthy development. Although children's growth and development rates may vary, a significant delay during early childhood could indicate a medical or a developmental disorder. Developmental surveillance is used worldwide by healthcare providers in routine encounters, as well as by educators and parents, to elicit concerns about child development. In this work, we used a national dataset of developmental assessments to describe temporal trends of milestone attainment rates and associations between milestone attainment and various sociodemographic factors. METHODS: The study included 1,002,700 children ages birth until 6 years with 4,441,689 developmental visits between the years 2016 and 2020. We used the Israeli developmental scale to assess the annual rates of failure to attain language, social and motoric milestones by the entire population, as well as by subgroups stratified by sociodemographic factors. In addition, we evaluated the rates of parental concern for child development and of the nurse's report of development inadequate for age. We used multivariable logistic regression to analyze the impact of different sociodemographic factors on the odds of failure to attain milestones, while controlling for confounding. RESULTS: Milestone failure rates progressively increased over the examined years in all developmental domains, and most prominently in the language domain. Conversely, the rates of parental concern for developmental delay remained constant. In multivariable analysis, higher risk of milestone attainment failure was observed in children whose mothers were divorced, unemployed, immigrant, had lower education, of Bedouin origin or were over 40 years old when giving birth. CONCLUSIONS: This report describes national trends of child development in the gross motor, fine motor, language, and social domains. A periodic report of these trends should be published to objectively evaluate subgroups in need for intervention, and to assess the effectiveness of intervention programs in attempt to maximize the developmental potential of children in Israel.

Diagnosis of childhood pneumonia: clinical assessment without radiological confirmation may lead to overtreatment.

OBJECTIVES: Consensus guidelines discourage the use of routine radiologic confirmation of clinically diagnosed pneumonia in children. The goal of the present study was to assess the degree of antibiotic overtreatment resulting from this approach. DESIGN: This was a prospective data collection. SETTING: This was performed in 5 urgent care clinics in Jerusalem, Israel. PARTICIPANTS: This study was composed of previously healthy children between 2 months and 18 years of age who presented with a chief complaint of fever, cough, or dyspnea between August 1, 2007, and March 15, 2008, by for whom chest x-rays were obtained because of clinical suspicion of pneumonia. OUTCOME MEASURES: Outcome measure was percentage of children with clinical findings associated with pneumonia (hypoxia, tachypnea, rales, dyspnea) who did not have radiological findings of pneumonia. RESULTS: With the exception of wheezing, 55% to 65% of children with specific signs and symptoms did not have radiologic pneumonia. A similar range of children with a combination of the signs did not have radiologic pneumonia. For wheezing, alone or in combination, the percentages were higher. On multivariate analysis, only fever was found to be predictive of pneumonia. Wheezing was found to be negatively predictive. CONCLUSIONS: Treatment of childhood pneumonia on the basis of clinical parameters alone with no chest x-ray confirmation may lead to a large portion of children receiving unnecessary antibiotic therapy. In an era when the emphasis is to decrease antibiotic resistance, radiological confirmation of pneumonia should be obtained when possible.

[Fever phobia in the ultra-religious community in Israel].

INTRODUCTION: Fever phobia has been described for over 30 years without significant prevalence change. NevertheLess, there is only minimal data about this phenomenon in IsraeL and within its varied sub-populations. The study goal was to examine the prevalence of this phobia among parents seeking care for their febrile child in an urgent care center (UCC), especialLy Charedi (ultra-religious) parents. The working hypothesis was that as the Charedi parents tended to be younger, and have Less formal education, they would be more LikeLy to have greater rates of fever phobia. METHODS: Site: Two UCCs in Jerusalem and Modiin. INSTRUMENT: A structured 38-item interview was conducted encompassing the original fever phobia questionnaire, demographic information, and knowledge and beliefs regarding fever. PARTICIPANTS: Parents of children who visited a UCC with a febrile child aged between 2 months and 10 years. RESULTS: A total of 349 interviews were conducted; 90% of the parents felt that fever could cause damage; 33% were very worried when their child has fever; 55% worried and 12% were not worried. It was found that there was lack of knowledge and false assumptions existed. For example, 1/3 of the parents defined fever < 37.7 degrees C as fever and 1/2 of the parents start treatment for fever < 38 degrees C. n contrast to the working hypothesis, the Charedi parents were less worried. The larger the family, the less likely the parents were to be worried. CONCLUSIONS: There continues to be both lack of knowledge and incorrect assumptions regarding fever in parents using UCC. Charedi parents are less worried, perhaps secondary to larger family size.

Nationwide community based emergency centers reveal scale of hand trauma.

INTRODUCTION: This study describes the characteristics of hand trauma treated in community-based emergency centers (CBECs) in Israel. It was hypothesized that the rate of hand trauma, as well as patient and injury characteristics, would differ from a recent study of patients treated in hospital emergency departments (EDs) in Jerusalem. METHODS: Data on all hand injury patients treated at any of the CBECs belonging to a large nationwide chain in 2017 were retrieved from the electronic medical records of the treatment centers, including demographic and clinical characteristics. RESULTS: Over the course of 2017, 53,574 individuals were treated for forearm, wrist and hand injuries (35% of all trauma patients treated during this period). The majority of the patients were male (62%). Contusions and fractures were common (80%) with a minority of lacerations (10%). Crush injuries and amputations were rare. Dog bites accounted for 1.5% of the injuries under the age of 10. Females were treated more with painkillers and opioids, especially over the age of 65, with variability between centers. Although the rate of fractures was similar between teens and the elderly, the elderly were treated with immobilization less frequently, and were referred to EDs for further care. Hospital referral rates differed significantly between centers. DISCUSSION: A higher rate of hand trauma was found in the CBECs in comparison to the hospital ED report (35% vs. 20% of all trauma patients, respectively). Patients treated at the CBECs, in comparison to the ED, were less often male, less often young adults, and differed in terms of type of injury. In the CBECs there were more contusions, as well as fewer lacerations and open wound injuries. In contrast, dog bites in children were found to be much more prevalent than previously reported. Hospital referral indications, the use of immobilization and pain management were found to vary according to age, gender and treatment center. Due to the high rate of hand trauma in CBECs, specific protocols are needed for these patients. The use of opioids should be specifically addressed, considering recent changes in treatment protocols. Thus, the prevalence and characteristics of hand trauma may be biased in studies based on hospital records.

Breastfeeding challenges and support in a high initiation population.

BACKGROUND: The breastfeeding initiation rate in Israel is approximately 90%, yet exclusive breastfeeding drops sharply in the early postnatal period. The study objective was to assess early postpartum professional breastfeeding support, its association with breastfeeding success and identification of risk factors for early breastfeeding discontinuation. METHODS: As part of a post-discharge newborn follow-up study, a convenience sample of 868 mothers attending Maternal and Child Health Centers (MCHCs) up to three months post-partum were interviewed using a 26-item questionnaire. Breastfeeding-related questions covered demographic variables, pregnancy and birth details; breastfeeding duration, lactation support in hospital and post-discharge; and problems experienced. RESULTS: Most mothers, 797 (91.8%), initiated breastfeeding in hospital. All women who initiated breastfeeding in the hospital reported exclusive breastfeeding; by two weeks postpartum, 70 women (13.2%) were supplementing with formula (partial breastfeeding). Kaplan-Meier Survival Analysis revealed an estimated mean duration of exclusive breastfeeding in the sample population of 66.8 ± 1.5 days. This duration was shorter for women with preterm births, low birthweight infants (LBW), cesarean births, and hospitalizations in neonatal intensive care units (NICU). A total of 472 (59.3%) breastfeeding mothers reported receiving in-hospital guidance. Of these, 290 (61.3%) were observed breastfeeding. Of all women who initiated breastfeeding, 280 (35.1%) attended MCHC follow-up within 72 h of hospital discharge. A higher proportion of women experiencing breastfeeding difficulties attended an MCHC within 72 h (131/297, 44.1%) compared to women not experiencing difficulties (148/499, 29.7%). The most frequently reported problems were mechanical (55.2%) or milk supply concerns (18.5%). First-time mothers were more likely to report problems, as were Jewish (vs Arab) mothers. CONCLUSIONS: Even in a population with high initiation rates of breastfeeding, breastfeeding duration, both exclusive and partial, is less than recommended. As much of this drop-off occurs during maternity leave, it is likely related to breastfeeding challenges other than employment. Breastfeeding support needs of women are currently not adequately met; staffing and time for both in-hospital and community-based counseling needs to be funded as well as mandated. Counseling hours should be tailored to assure adequate coverage of high-risk groups such as women after cesarean delivery and newborns requiring intensive care.

Assessing the Attainment Rates of Updated CDC Milestones Using a New Israeli Developmental Scale.

OBJECTIVES: Developmental milestones norms are widely used worldwide and are fundamental for early childhood developmental surveillance. We compared a new Israeli evidence-based national developmental scale with the recently updated Centers for Disease Control and Prevention (CDC) checklists. METHODS: We used a cohort of nearly 4.5 million developmental assessments of 758 300 full-term born children aged 0 to 6 years (ALL-FT cohort), who visited maternal child health clinics in Israel for routine developmental surveillance. Among the assessed milestones of 4 developmental domains (gross motor, fine motor, language, and personal-social) we identified milestones that had equivalents on the CDC checklists and assessed the attainment rates of the Israeli children at the ages recommended by the CDC, at which ≥75% of the children would be expected to achieve the milestone. The analysis was repeated on a subgroup of 658 958 children who were considered healthy, typically developing by their birth and growth characteristics (NORMAL-FT cohort). RESULTS: There were 29 milestones, across all developmental domains and assessment ages, whose definitions by both tools were compatible, and could be compared. The attainment rate at the CDC-recommended age was >90% for 22 (76%) and 23 (79%) milestones, and the median attainment rates were 95.2% and 96.3% in the ALL-FT and NORMAL-FT cohorts, respectively. CONCLUSIONS: For almost all comparable milestones of all domains and all ages, children of the Israeli cohorts achieved the milestones earlier than expected by the CDC-defined threshold age. Evidence-based analysis of milestone norms among different populations may enable adjustments of developmental scales and facilitate more personalized developmental surveillance.