Adherence to Car Seat Tolerance Screening Differs by Indication and Patient Characteristics.

OBJECTIVES: To assess whether adherence to institutional car seat tolerance screening (CSTS) guidelines differed for infants born preterm (PTM), term low birth weight (T-LBW), or both preterm and low birth weight (P-LBW), and to examine the association between CSTS adherence and patient characteristics. STUDY DESIGN: Within two large academic and community hospitals, we retrospectively reviewed all infants meeting institutional criteria (< 37 weeks' gestation and/or < 2.27 kg) for CSTS from 2014 to 2018. Multivariable logistic regression evaluated the association of patient characteristics with institutional CSTS guideline adherence. RESULTS: 4374 eligible infants were born PTM (50.9%), T-LBW (6.5%), or P-LBW (42.6%). Adherence rates were 92.7% in the neonatal intensive care unit (NICU) and 95.2% in the well-baby nursery with initial CSTS failure rates of 6.1% and 9.9%, respectively. Adherence was lowest among T-LBW (80.7%) compared to PTM (95.1%) or P-LBW (92.2%) infants in the NICU (p < 0.001) and well-baby nursery (81.6%, 96.7% and 97.1%, respectively, p < 0.001). In bivariate analyses, gestational age, birth weight, insurance, race, hospital type, discharge year, and preferred language were associated with adherence. In fully-adjusted models, adherence was positively associated with lower gestational age, higher birth weight, non-Medicaid insurance, and later discharge year (NICU) and lower gestational age and later discharge year (well-baby nursery). CONCLUSIONS: Adherence was lower for T-LBW than PTM or P-LBW infants, despite similar CSTS failure rates. Disparities in adherence among Medicaid-insured patients in the NICU warrant further study. Future studies are needed to clarify the benefit of CSTS and increase adherence in high-risk populations.

Integrated Mental Health Training Relates to Pediatric Residents' Confidence with Child Mental Health Disorders.

OBJECTIVE: The primary aim of this study was to determine the association of an integrated mental health training model on pediatric residents' use of (1) secondary screens, (2) mental health referrals, (3) psychotropic medications, and (4) follow-up appointments for mental health concerns. The secondary aim was to determine resident confidence managing mental health conditions. METHODS: Visits of children ages 6-18 years old with either a positive primary mental health screen or a mental health diagnosis in pre- and post-intervention years (N = 113 and N = 251, respectively) at a single-site continuity clinic were included. Authors also surveyed alumni from pre- and post- intervention years (N = 46) about their confidence with managing mental health disorders. The authors used chi-squared and t-tests to compare visit characteristics between years and multivariable logistic regression to determine correlates of mental health management. RESULTS: Post-intervention residents more often used secondary screening tools (adjusted odds ratio 5.61, 95% confidence interval 2.08-15.17). There were no differences in referrals, prescribing psychotropic medications, or follow-up visits. Post-intervention graduates reported higher confidence with diagnosis, screening, medication management, and follow-up for mental health disorders. CONCLUSIONS: After transitioning to an integrated mental health model, residents were more likely to use secondary screens and post-intervention graduates reported higher confidence with managing mental health disorders.

The Association Between Routine Car Seat Screening and Subsequent Health Care Utilization.

BACKGROUND AND OBJECTIVES: The American Academy of Pediatrics recommends preterm newborns undergo car seat tolerance screening (CSTS) before discharge despite limited evidence supporting the practice. We examined subsequent health care utilization in screened and unscreened late preterm and low birth weight newborns. METHODS: This observational study included late preterm (34-36 weeks) and term low birth weight (<2268 g) newborns born between 2014 and 2018 at 4 hospitals with policies recommending CSTS for these infants. Birth hospitalization length of stay (LOS) in addition to 30-day hospital revisits and brief resolving unexplained events were examined. Unadjusted and adjusted rates were compared among 3 groups: not screened, pass, and fail. RESULTS: Of 5222 newborns, 3163 (61%) were discharged from the nursery and 2059 (39%) from the NICU or floor. Screening adherence was 91%, and 379 of 4728 (8%) screened newborns failed the initial screen. Compared with unscreened newborns, adjusted LOS was similar for newborns who passed the CSTS (+5.1 hours; -2.2-12.3) but significantly longer for those who failed (+16.1; 5.6-26.7). This differed by screening location: nursery = +12.6 (9.1-16.2) versus NICU/floor = +71.2 (28.3-114.1) hours. Hospital revisits did not significantly differ by group: not screened = 7.3% (reference), pass = 5.2% (aOR 0.79; 0.44-1.42), fail = 4.4% (aOR 0.65; 0.28-1.51). CONCLUSIONS: Hospital adherence to CSTS recommendations was high, and failed screens were relatively common. Routine CSTS was not associated with reduced health care utilization and may prolong hospital LOS, particularly in the NICU/floor. Prospective trials are needed to evaluate this routine practice for otherwise low-risk infants.

Maternal and Child Symptoms Following COVID-19 Vaccination Among Breastfeeding Mothers.

Background: The impact of COVID-19 vaccination on breastfeeding is unknown. The primary aim of this study was to determine whether vaccine-related side effects following COVID-19 vaccination were associated with an adverse impact on breastfeeding. Secondarily, we sought to determine perceived symptoms in breastfed children and maternal opinion about COVID-19 vaccination. Materials and Methods: We conducted a cross-sectional survey of breastfeeding mothers who underwent COVID-19 vaccination >2 days before the survey. Subjects were recruited through social media and websites. Data included sociodemographic information, vaccine history, maternal and child symptoms, and impact on lactation/breastfeeding. Bivariate statistics (chi-square, Wilcoxon rank sum, and t tests) and multivariable logistic regression models examined the association of vaccine side effects with lactation, symptoms in breastfed children, and maternal opinion on vaccination. Results: Analysis included 4,455 breastfeeding mothers. Maternal postvaccination symptoms were more common after the second dose (p < 0.001). Overall, 77 (1.7%) respondents reported a negative impact on breastfeeding postvaccination, and these mothers were more likely to have experienced fatigue, headache, muscle pain, injection site pain, chills, fever, or allergic reactions. After adjusting for confounding variables, higher odds of an adverse impact on lactation were associated with lower breastfeeding intensity, dose of vaccine, and child symptoms. Even among mothers who reported an adverse impact on breastfeeding, maternal opinion about vaccination and confidence in their decision to receive the COVID-19 vaccine were high. Conclusions: COVID-19 vaccination among breastfeeding mothers resulted in minimal disruption of lactation or adverse impact on the breastfed child. These findings may be considered in vaccination decision-making.

Maternal, Fetal, and Child Outcomes of Mental Health Treatments in Women: A Meta-Analysis of Pharmacotherapy.

Objective: The authors systematically reviewed evidence on pharmacotherapy for perinatal mental health disorders. Methods: The authors searched for studies of pregnant, postpartum, or reproductive-age women with mental health disorders treated with pharmacotherapy in MEDLINE, EMBASE, PsycINFO, the Cochrane Library, and trial registries from database inception through June 5, 2020 and surveilled literature through March 2, 2021. Outcomes included symptoms; functional capacity; quality of life; suicidal events; death; and maternal, fetal, infant, or child adverse events. Results: 164 studies were included. Regarding benefits, brexanolone for third-trimester or postpartum depression onset may be associated with improved depressive symptoms at 30 days when compared with placebo. Sertraline for postpartum depression may be associated with improved response, remission, and depressive symptoms when compared with placebo. Discontinuing mood stabilizers during pregnancy may be associated with increased recurrence of mood episodes for bipolar disorder. Regarding adverse events, most studies were observational and unable to fully account for confounding. Evidence on congenital and cardiac anomalies for treatment compared with no treatment was inconclusive. Brexanolone for depression onset in the third trimester or the postpartum period may be associated with risk of sedation or somnolence, leading to dose interruption or reduction when compared with placebo. Conclusions: Evidence from few studies supports the use of pharmacotherapy for perinatal mental health disorders. Although many studies report on adverse events, they could not rule out underlying disease severity as the cause of the association between exposures and adverse events. Patients and clinicians need to make informed, collaborative decisions on treatment choices.

Faculty and Resident Perspectives on Teaching Pediatric Evidence-Based Medicine in the Clinical Setting: A Qualitative Study.

PURPOSE: To describe how pediatric educators effectively teach evidence-based medicine (EBM) in the clinical setting. Secondarily, to identify barriers hindering effective practice and teaching of EBM and strategies to overcome these barriers. METHODS: The authors conducted a cross-sectional multi-institutional qualitative study from July 2016 to December 2017 in which they interviewed pediatric educators across many subspecialties who were identified as exemplary teachers of EBM at 3 academic pediatric residency programs. Pediatric residents who had recently worked with these faculty members were also interviewed to allow triangulation between participants. Qualitative analysis was complete once saturation was achieved. RESULTS: Twenty-six pediatric educators identified as exemplary teachers of EBM and 10 residents who worked with those educators participated in the study. Thirteen explicit teaching strategies and 2 implicit teaching strategies, namely disclosure of uncertainty and role modeling, were identified. Barriers to practicing clinical EBM included balancing patient responsibilities, inadequate time, and personal knowledge. Barriers to teaching clinical EBM were inadequate time and learner engagement. To overcome these barriers, faculty limit and focus teaching points, attempt to make EBM relevant to patient care, and incorporate follow-up strategies. CONCLUSIONS: Numerous teaching strategies are available to faculty to improve the clinical teaching of EBM and to overcome commonly encountered clinical EBM barriers. Familiarity with these clinical EBM teaching strategies can be used for faculty development and to enhance the teaching of EBM to learners.

Introducing the Concepts of Advocacy and Social Determinants of Health Within the Pediatric Clerkship.

Introduction: Although advocacy and social determinants of health (SDH) are fundamental components of pediatrics and other areas of health care, medical education often lacks formal training about these topics and the role of health care professionals as advocates. SDH are common targets of advocacy initiatives; however, little is known about optimal ways to incorporate this content into medical education curricula. Methods: We developed a lecture and assessment for third-year medical students that included interactive discussion of advocacy, SDH issues specific to children, and opportunities for learners to engage in advocacy. Learners attended the lecture during the pediatric clerkship. Over the course of a year, questionnaires assessing knowledge of advocacy, SDH, and incorporation of advocacy into practice were administered to 75 students before the lecture and as the clerkship ended. We used chi-square and Fisher's exact tests to compare knowledge before and after the lecture. Results: Students showed significant improvement on most individual questions and overall passing rates. Learners provided positive feedback on the quality of the lecture material and demonstrated interest in engaging in current advocacy projects to address SDH. Discussion: As recognition of the importance of advocacy and SDH increases, the development of educational tools for teaching this information is critical. Our lecture produced significant improvement in knowledge of these topics and was well received by students. Early introduction to advocacy and SDH during relevant clinical rotations emphasizes the importance of these topics and may establish a foundation of advocacy as fundamental to health care.

Recent Trends in Infant Car Seat Tolerance Screening Failure Within a Large Health Care System, 2014-2018.

OBJECTIVES: To describe temporal trends in car seat tolerance screening (CSTS) failure within a large hospital system (2014-2018). METHODS: We conducted a retrospective cohort study using electronic medical record data for infants who underwent a CSTS. Our primary outcome measure was the CSTS failure rate. Covariates included year, CSTS location (well nursery or NICU), gestational age (GA), race, sex, birth weight, CSTS date, and age at CSTS. Associations of covariates with CSTS failure were examined by using χ2 tests, t tests, analysis of variance, and Wilcoxon rank tests. Multivariable logistic regression was used to determine the adjusted odds of CSTS failure. RESULTS: Of 4849 infants tested, the failure rate was 8.1% (n = 394). Most CSTS occurred in the well nursery (79.5%) and involved late preterm (55.2%) or term infants (23.7%). In bivariate analyses, year, unit location, higher birth weight, younger chronological age at testing, and higher GA were positively associated with CSTS failure (P < .05). After stratification by CSTS location, the CSTS failure rate rose in the well nursery but remained stable in the NICU, and use of screening rose among term infants. In the adjusted model, year, GA, and corrected gestational age at CSTS were associated with failure. Each subsequent year was associated with a 19% increase in odds of CSTS failure (P < .001). CONCLUSIONS: We found a higher rate of CSTS failure in the well nursery compared with the NICU, and the difference in failure rates increased over time. Improved understanding of infants at the highest risk of CSTS failure could impact routine screening guidelines.

Septooptic Dysplasia with an Associated Arachnoid Cyst.

A 4-week-old male infant presented with hypothermia, hypoglycemia, and hyperbilirubinemia. His medical history was remarkable for hydrocephalus secondary to an arachnoid cyst, intermittent hypoglycemia, hypothermia, and poor feeding requiring nasogastric tube for nutrition. Physical exam revealed retrognathia, mild hypotonia, micropenis, and clinodactyly. Ophthalmologic exam demonstrated bilateral optic nerve hypoplasia (ONH). Laboratory data confirmed inadequate cortisol and growth hormone response to hypoglycemia, a low thyroxine level, and direct hyperbilirubinemia. Magnetic resonance imaging of the brain confirmed the known history of arachnoid cyst with hydrocephalus but also revealed anterior pituitary hypoplasia, absence of the posterior pituitary bright spot, a thin pituitary stalk, and bilateral optic nerve hypoplasia. A diagnosis of septooptic dysplasia (SOD) was made. Hormone replacement with hydrocortisone and levothyroxine was started with improvement in the infant's glycemic control, thermoregulation, feeding, and cholestasis. This case reinforces the importance of careful physical examination and laboratory review in a patient with known history of arachnoid cyst which has been previously described as an associated feature of optic nerve hypoplasia and hypopituitarism.