Effect of smoke-free legislation on perinatal and child health: a systematic review and meta-analysis.

BACKGROUND: Smoke-free legislation has the potential to reduce the substantive disease burden associated with second-hand smoke exposure, particularly in children. We investigated the effect of smoke-free legislation on perinatal and child health. METHODS: We searched 14 online databases from January, 1975 to May, 2013, with no language restrictions, for published studies, and the WHO International Clinical Trials Registry Platform for unpublished studies. Citations and reference lists of articles of interest were screened and an international expert panel was contacted to identify additional studies. We included studies undertaken with designs approved by the Cochrane Effective Practice and Organisation of Care that reported associations between smoking bans in workplaces, public places, or both, and one or more predefined early-life health indicator. The primary outcomes were preterm birth, low birthweight, and hospital attendances for asthma. Effect estimates were pooled with random-effects meta-analysis. This study is registered with PROSPERO, number CRD42013003522. FINDINGS: We identified 11 eligible studies (published 2008-13), involving more than 2·5 million births and 247,168 asthma exacerbations. All studies used interrupted time-series designs. Five North American studies described local bans and six European studies described national bans. Risk of bias was high for one study, moderate for six studies, and low for four studies. Smoke-free legislation was associated with reductions in preterm birth (four studies, 1,366,862 individuals; -10·4% [95% CI -18·8 to -2·0]; p=0·016) and hospital attendances for asthma (three studies, 225,753 events: -10·1% [95% CI -15·2 to -5·0]; p=0·0001). No significant effect on low birthweight was identified (six studies, >1·9 million individuals: -1·7% [95% CI -5·1 to 1·6]; p=0·31). INTERPRETATION: Smoke-free legislation is associated with substantial reductions in preterm births and hospital attendance for asthma. Together with the health benefits in adults, this study provides strong support for WHO recommendations to create smoke-free environments. FUNDING: Thrasher Fund, Lung Foundation Netherlands, International Paediatric Research Foundation, Maastricht University, Commonwealth Fund.

When courts intervene: public health, legal and ethical issues surrounding HIV, pregnant women, and newborn infants.

Ninety-three percent of pediatric AIDS cases are the result of perinatal HIV transmission, a disease that is almost entirely preventable with early intervention, which reduces the risk of perinatal HIV infection from 25% to <2%. The American College of Obstetricians and Gynecologists and the American Academy of Pediatrics both recommend routine HIV testing of all pregnant women and at-risk newborn infants. When pregnant women decline HIV testing and/or treatment, public health, legal, and ethical dilemmas can result. Federal courts consistently uphold a woman's right to refuse medical testing and treatment, even though it may benefit her fetus/newborn infant. Federal courts also reliably respect the rights of parents to make health care decisions for their newborn infants, which may include declining medical testing and treatment. Confusing the issue of HIV testing and treatment, however, is the fact that there is no definitive United States Supreme Court ruling on the issue. State laws and standards vary widely and serve as guiding principles for practicing clinicians, who must be vigilant of ongoing legal challenges and changes in the states in which they practice. We present a case of an HIV-positive pregnant woman who declined treatment and then testing or treatment of her newborn infant. Ultimately, the legal system intervened. Given the rarity of such cases, we use this as a primer for the practicing clinician to highlight the public health, legal, and ethical issues surrounding prenatal and newborn infant HIV testing and treatment in the United States, including summarizing key state-to-state regulatory differences.

Estimating the effects of cigarette taxes on birth outcomes.

Employing provincial data from 1979 to 2004 allows us to exploit the significant (45 percent to 60 percent) reduction in excise taxes in Eastern Canada enacted in February 1994 to estimate the impacts of cigarette taxes on birth outcomes. Empirical estimates suggest that an increase in cigarette taxes is significantly associated with lower infant mortalities. However, we also find some evidence of a counter-intuitive positive correlation between taxes and fetal deaths. Overall, conditional on methodology, we find increased lagged per capita health expenditures and the number of physicians to be significantly associated with improvements in birth outcomes.

[Problem of exposure to direct danger of death or grave detriment to health of a child breast-fed by an alcohol-abusing mother in medico-legal opinions]. / Problem narazenia na bezposrednie niebezpieczenstwo utraty zycia lub ciezkiego uszczerbku na zdrowiu dziecka karmionego naturalnie przez matke naduzywajaca alkoholu w opiniowaniu sadowo-lekarskim.

In the last few years, the authors have noted an increasing amount of cases submitted for analysis in the Chair and Department of Forensic Medicine, Poznan University of Medical Sciences, and addressing alcohol abuse by breast-feeding mothers. A question about the exposure to direct danger of death or grave detriment to health of a child by a breast-feeding mother under the influence of alcohol is posed by prosecution or the court, and the expectation is obtaining answers from forensic experts as to whether the situation fulfills the meaning of article 160 of the penal code, which would result in the mother bearing criminal liability. Difficulties that have arisen during the analysis of such cases have prompted the authors to analyze the problem of alcohol abuse by breast-feeding mothers in terms of medico-legal opinions.

Medical futility in children's nursing: making end-of-life decisions.

Caring for infants at end of life is challenging and distressing for parents and healthcare professionals, especially in relation to making decisions regarding withholding or withdrawal of treatment. The concept of medical futility must be considered under these circumstances. Parents and healthcare professionals should be involved together in making these difficult decisions. However, for some parents, emotions and guilt often are unbearable and, understandably, parents can be reluctant to make a decision. Despite the recognition of parental autonomy, if parents disagree with a decision made by medical staff, the case will be referred to and solved by the courts. The courts' decisions are often based on the best interest of the child. In this article, the authors discuss the concepts of 'parental autonomy' and 'the child's best interests' when determining medical futility for infants or neonates. The role of the nurse when caring for the dying child and their family is multifaceted. While nurses do not have a legitimate role in decision making at the end of life, it is often nurses who, through their advocacy role, inform doctors about parents' wishes and it is often nurses who support parents during this difficult time. Furthermore, nurses caring for dying children should be familiar to the family, experienced in end-of-life care and comfortable talking to parents about death and dying and treatment choices. Children's nurses therefore require advanced communication skills and an essential understanding of the ethical and legal knowledge relating to medical futility in end-of-life children's nursing.

Vulnerable infants program of Rhode Island: promoting permanency for substance-exposed infants.

The Vulnerable Infants Program of Rhode Island is a care coordination program to promote permanency for substance-exposed infants by addressing parental needs and increasing collaboration among social service agencies. Over the first four years of the program, there was a decrease in time spent in the newborn nursery beyond medical necessity and identification of permanent placements by 12 months for 84% of infants, with the majority of infants (78%) placed with biological parents or relatives.

Permanency and well-being outcomes for maltreated infants: Pilot results from an infant-toddler court team.

BACKGROUND: Evaluations of infant-toddler court teams suggest improvements related to permanency, service provision, and parenting. However, findings regarding permanency are limited in that they do not capture children who remain in care for long periods. Less is known about how court teams impact child development. OBJECTIVE: The first two objectives are to describe baseline development for a small group of infants and toddlers participating in a pilot court team project and to explore changes in their development and behavior. The third objective is to describe permanency outcomes. PARTICIPANTS AND SETTING: Infants and toddlers (n = 25) under court jurisdiction for substantiated maltreatment and their parents participated in pre-and posttest evaluation of a pilot court team project. All dyads were referred to a parenting intervention, Infant Mental Health Home Visiting. Infant development was assessed using the Bayley-III and behavior was assessed in the Crowell parent-child interaction task. Court records were reviewed for permanency outcomes. RESULTS: Thirty-five percent of children had a developmental delay at program entry and showed significant improvements in expressive language development (p < .01). Increases in prosocial behavior were seen in domains of positive affect (p < .05) and enthusiasm (p < .02) and significant reductions child withdrawal (p < .06). More than two-thirds of children were reunified with their parent(s) and they spent an average of 18.7 months in out-of- home care. CONCLUSIONS: These preliminary findings add to the limited literature on the potential impact that infant-toddler court teams can have on permanency and well-being.

The perinatal patient safety nurse: a new role to promote safe care for mothers and babies.

Medical malpractice premiums and costs of obstetric claims, settlements, and jury awards are at an all-time high. This article describes one professional liability company's initiative to promote safer perinatal care and decrease costs of claims, including the development of the perinatal patient safety nurse role. The primary responsibility of the perinatal patient safety nurse is to promote safe care for mothers and babies by keeping patient safety as a focus of all unit operations and clinical practices.

Newborn screening policy in the United Kingdom & the United States: two different communities of practice.

Newborn screening is a rapidly developing area driven by both technological advances and public pressure. If they are not yet, all nurses working with mothers and children will soon be involved with implementing newborn-screening programs, and it is therefore important that they appreciate both the benefits and potential harms of such programs. In the United Kingdom, policy regarding the implementation of newborn-screening programs is developed at national level, and consideration of the introduction of new tests is subject to a formalized evaluation framework. In the United States, by contrast, each state develops its own screening program. Knowledge of developments in newborn screening in different countries that have diverse types of healthcare systems helps to inform nurses about the totality of healthcare for newborns, and assists them in becoming more knowledgeable about how international standards differ from those in the United States.

The medical and economic impact of the Newborns' and Mothers' Health Protection Act.

OBJECTIVE: We evaluated the effect of the Newborns' and Mothers' Health Protection Act on clinical and cost outcomes. METHODS: We conducted an observational study of 18,023 healthy, mother-infant dyads before (n = 8670) and after (n = 9353) implementation of the Newborns' and Mothers' Health Protection Act legislation. Logistic regression was used to calculate adjusted odds ratios (ORs) for the following outcome measures: length of stay at least 48 hours, satisfaction with maternal length of stay, 7- and 30-day hospital readmission utilization, and 7- and 30-day emergency room utilization. Analysis of covariance was used to evaluate adjusted mean hospitalization costs per delivery. RESULTS: Mothers in the postlegislation period were more likely to have hospital stays at least 48 hours (OR 3.99; 95% confidence interval [CI] 3.57, 4.44) and rate their length of stay as "about right" (OR 5.54; 95% CI 4.76, 6.46) compared with mothers in the prelegislation period. Neonates in the postlegislation period were more likely to have hospital stays of at least 48 hours (OR 3.96; 95% CI 3.54, 4.43) and less likely to be rehospitalized within 7 days after hospitalization (OR 0.61; 95% CI 0.40, 0.95) compared with neonates in the prelegislation period. Adjusted mean hospitalization costs increased $116 per delivery in the postlegislation period. CONCLUSIONS: After implementation of the Newborns' and Mothers' Health Protection Act legislation, maternal and newborn length of stay and maternal satisfaction with length of stay increased substantially, and hospitalization costs increased significantly. The strongest clinical benefit was observed among neonates who were at a lower risk for hospitalization within 1 week of discharge. With the exception of 30-day emergency room utilization, there was insufficient statistical power to test for differences among other maternal clinical outcomes.

Case study. Erythropoietin for anaemia in a preterm Jehovah's Witness baby.

An infant born at 24 weeks gestation to Jehovah's Witness parents was made a Ward of Court and treated against their wishes with blood products. Erythropoietin was used without obvious benefit, but the child did well. The parents did not reject the child and maintained a good relationship with medical and nursing staff. We present this case in the light of current discussions on child welfare and recent reform of the law relating to child protection and highlight the many difficult dilemmas faced by the medical team.