Alternative Birth Plans and Unintended Maternal and Neonatal Consequences: A Review of the Literature.

IMPORTANCE: Birth plans are an important part of childbirth preparation for many women. OBJECTIVE: The aim of this review was to discuss some common requests, specifically home birth, water birth, placentophagy, lotus birth, vaccination refusal, and vaginal seeding, including evidence-based recommendations, perceived benefits, and potential maternal and neonatal consequences. EVIDENCE ACQUISITION: A literature search for each topic was undertaken using PubMed and Web of Science. For the home birth section, the MeSH terms home AND birth OR childbirth AND outcomes OR complications OR recommendations OR guidelines were used. For the vaccination section, birth OR childbirth OR maternal AND vaccination refusal were searched. For the remainder of the sections, umbilical cord AND nonseverance OR placentophagy OR vaginal seeding OR lotus birth were searched. A total of 523 articles were identified. The abstracts were reviewed by 2 authors (J.R.W. and J.A.R.); 60 of these articles were selected and used for this review. RESULTS: Home birth is currently not recommended in the United States. Immersion in water for labor is acceptable, but delivery should not occur in water. Placentophagy and lotus birth should be discouraged because of risk of neonatal infection. Vaccines should be administered in accordance with national guidelines. Vaginal seeding should be discouraged until more is known about the practice. CONCLUSIONS AND RELEVANCE: These evidence-based recommendations provide clear guidance for physicians so that the birthing experience can be enhanced for both mother and neonate without compromising safety. RELEVANCE STATEMENT: This is an evidence-based literature review of alternative birth plans and recommendations for directive counseling.

Peds PLACE: quality continuing medical education in Arkansas.

The University of Arkansas for Medical Sciences (UAMS) and Arkansas Children's Hospital (ACH) sponsor Peds PLACE (Pediatric Physician Learning and Collaborative Education), a telemedicine continuing education program. This study assessed to what extent participants were satisfied with Peds PLACE and how to improve it. It was found that 95% of the participants agreed that the presentations related to their professional needs and 98% that it increased their knowledge. In addition, 81% evaluated the presentations as some of the best they have attended and 93% agreed that the information would translate into professional practice and enhance patient care. Comments were positive and correlated with the survey data. Participants recommended several ways to improve Peds PLACE.

Telemedicine: Pediatric Applications.

Telemedicine is a technological tool that is improving the health of children around the world. This report chronicles the use of telemedicine by pediatricians and pediatric medical and surgical specialists to deliver inpatient and outpatient care, educate physicians and patients, and conduct medical research. It also describes the importance of telemedicine in responding to emergencies and disasters and providing access to pediatric care to remote and underserved populations. Barriers to telemedicine expansion are explained, such as legal issues, inadequate payment for services, technology costs and sustainability, and the lack of technology infrastructure on a national scale. Although certain challenges have constrained more widespread implementation, telemedicine's current use bears testimony to its effectiveness and potential. Telemedicine's widespread adoption will be influenced by the implementation of key provisions of the Patient Protection and Affordable Care Act, technological advances, and growing patient demand for virtual visits.

Through with the flu: how free family and caregiver immunization protects sick neonates.

Newborns represent the pediatric population most at risk for influenza-related morbidity and mortality, especially premature newborns and those with chronic disease. Compounding this problem is the fact that influenza immunizations are ineffective until 6 months of age. This article describes a successful program that follows the "cocoon" theory of immunization. Free influenza vaccines were given in the nursery to all family members, caregivers, and others living in the homes of discharged infants. Planning and implementation steps are described, along with lessons learned during implementation. The response to the program exceeded expectations, with 185 contacts immunized. Future plans include the expansion of the current program to include the H1N1 influenza vaccine and the Tdap vaccine. The described vaccination effort encourages and substantiates the benefits of cocoon immunization in other nurseries across the nation.

Achieving success connecting academic and practicing clinicians through telemedicine.

OBJECTIVE: Practicing clinicians, especially in rural areas, are often isolated from learning opportunities and interactions with subspecialty providers. Pediatric Physician Learning and Collaborative Education, an interactive, educational, telemedicine program, was developed to address this need. We evaluated the success of this program through surveys with practicing and academic physicians. METHODS: Pediatric Physician Learning and Collaborative Education was assessed by using 2 evaluation forms collected from October 2007 to May 2008. One of the forms was completed by 197 attendees from the University of Arkansas for Medical Sciences and 172 attendees from remote sites. Another form was completed by 131 participants from Arkansas Children's Hospital, an academic, freestanding, children's hospital. Both evaluation forms asked participants to use a 5-point Likert scale to rank a number of criteria and included a section for participants to write comments and recommendations. Additional data were collected through an open-response e-mail survey of participants. RESULTS: Ninety-five percent of the participants agreed that the presentations related to their professional needs, 98% agreed that the presentations increased their subject-matter knowledge, 81% evaluated the presentations as some of the best they had attended, and 93% agreed that the information would translate into professional practice, enhancing patient care. Health care personnel from the University of Arkansas for Medical Sciences evaluated the presentations significantly higher than did remote participants. Nursing staff members evaluated the presentations significantly higher than did medical staff members. Comments were generally positive and correlated with the Likert-scale data. CONCLUSION: Participants reported being highly satisfied with Pediatric Physician Learning and Collaborative Education and considered it an effective way to address the continuing education needs of practitioners throughout Arkansas, especially in rural and underserved areas.

Trends in hospitalizations for neonatal jaundice and kernicterus in the United States, 1988-2005.

CONTEXT AND OBJECTIVE: Recent reports have raised global concerns about a reemergence of kernicterus. Accurate information on the incidence of kernicterus is unavailable because of the rarity of the condition and the lack of a systematic surveillance strategy. We used nationally representative hospital discharge data to evaluate trends in the diagnosis and management of neonatal jaundice and the incidence of kernicterus in relation to the American Academy of Pediatrics hyperbilirubinemia clinical practice guideline. PATIENTS AND METHODS: The data came from the Healthcare Cost and Utilization Project family of databases. The Nationwide Inpatient Sample and the Kids' Inpatient Database were combined to generate trend data for the years 1988-2005. All neonatal discharges with primary or secondary International Classification of Diseases, Ninth Revision, Clinical Modification diagnoses codes for jaundice or kernicterus occurring within the first 30 days of life were selected with population incidence rates calculated from estimates of term and preterm newborn hospitalizations derived from the Healthcare Cost and Utilization Project data. To increase the reliability of identified kernicterus hospitalizations, newborns with a diagnosis of kernicterus and a procedure code for phototherapy or exchange transfusion were included as cases. RESULTS: Hospital diagnosis codes for kernicterus likely included a substantial number of rule-out cases, because approximately 70% did not include a procedure code for phototherapy or exchange transfusion. Including only cases with a procedure code for phototherapy or exchange transfusion resulted in 2.7 per 100000 diagnosed with kernicterus over the entire study period. A diagnosis code for jaundice was recorded for 15.6% of newborns. The diagnosis of jaundice and kernicterus differed according to race and gender. Rates also were elevated in preterm relative to term infants for both jaundice and kernicterus. Trends in diagnosis for newborn jaundice were u-shaped, with rates falling in the years before the initial American Academy of Pediatrics guideline (1988-1993) and increasing in the years after publication of the guideline (1997-2005). In contrast, the number of newborn hospitalizations with a diagnosis of kernicterus generally declined throughout the study period. Most of the decline in hospitalizations for term infants with a diagnosis of kernicterus occurred before and immediately after publication of the 1994 guideline, going from 5.1 per 100000 in 1988 to 1.5 per 100000 in the years from 1994 to 1996 and has since remained constant. CONCLUSIONS: Nationally representative hospital data indicate a declining incidence of hospitalizations with a diagnosis of kernicterus in newborn infants over the period 1988-2005. The decline occurred before and immediately after publication of the 1994 American Academy of Pediatrics guideline on hyperbilirubinemia. Epidemiologic findings were mostly consistent with other studies. Healthcare Cost and Utilization Project data provide an important system for monitoring hospitalizations of uncommon newborn conditions such as kernicterus.