Implementing a Hospital-Based Safe Sleep Program for Newborns and Infants.

BACKGROUND: An unsafe sleep environment remains the leading contributor to unexpected infant death. PURPOSE: To determine the effectiveness of a quality improvement initiative developed to create a hospital-based safe sleep environment for all newborns and infants. METHODS: A multidisciplinary team from the well-baby nursery (WBN) and neonatal intensive care unit (NICU) of a 149-bed academic, quaternary care, regional referral center developed and implemented safe sleep environments within the hospital for all prior to discharge. To monitor compliance, the following were tracked monthly: documentation of parent education, caregiver surveys, and hospital crib check audits. On the inpatient general pediatric units, only hospital crib check audits were tracked. Investigators used Plan-Do-Study-Act (PDSA) cycles to evaluate the impact of the initiative from October 2015 through February 2018. RESULTS: Safe sleep education was documented for all randomly checked records (n = 440). A survey (n = 348) revealed that almost all caregivers (95.4%) reported receiving information on safe infant sleep. Initial compliance with all criteria in WBN (n = 281), NICU (n = 285), and general pediatric inpatient units (n = 121) was 0%, 0%, and 8.3%, respectively. At 29 months, WBN and NICU compliance with all criteria was 90% and 100%, respectively. At 7 months, general pediatric inpatient units' compliance with all criteria was 20%. IMPLICATIONS FOR PRACTICE: WBN, NICU and general pediatric inpatient unit collaboration with content experts led to unit-specific strategies that improved safe sleep practices. IMPLICATIONS FOR RESEARCH: Future studies on the impact of such an initiative at other hospitals are needed.

Trends in Pediatric Malpractice Claims 1987-2015: Results From the Periodic Survey of Fellows.

BACKGROUND: Pediatricians are less frequently sued than other physicians. When suits are successful, however, the average payout is higher. Little is known about changes in the risk of litigation over time. We sought to characterize malpractice lawsuit trends for pediatricians over time. METHODS: The Periodic Survey is a national random sample survey of American Academy of Pediatrics members. Seven surveys between 1987 and 2015 asked questions regarding malpractice (n = 5731). Bivariate and multivariable analyses examined trends and factors associated with risk and outcome of malpractice claims and lawsuits. Descriptive analyses examined potential change in indemnity amount over time. RESULTS: In 2015, 21% of pediatricians reported ever having been the subject of any claim or lawsuit, down from a peak of 33% in 1990. Report of successful outcomes in the most-recent suit trended upward between 1987 and 2015, greatest in 2015 at 58%. Median indemnity was unchanged, averaging $128 000 in 2018 dollars. In multivariate analysis, male sex, hospital-based subspecialty (neonatology, pediatric critical care, pediatric emergency medicine, and hospital medicine), longer career, and more work hours were associated with a greater risk of malpractice claim. CONCLUSIONS: From 1987 to 2015, the proportion of pediatricians sued has decreased and median indemnity has remained unchanged. Male pediatricians and hospital-based subspecialists were more likely to have been sued. Greater knowledge of the epidemiology of malpractice claims against pediatricians is valuable because it can impact practice arrangements, advise risk-management decisions, influence quality and safety projects, and provide data to guide advocacy for appropriate tort reform and future research.

Understanding Liability Risks and Protections for Pediatric Providers During Disasters.

Although most health care providers will go through their careers without experiencing a major disaster in their local communities, if one does occur, it can be life and career altering. The American Academy of Pediatrics has been in the forefront of providing education and advocacy on the critical importance of disaster preparedness. From experiences over the past decade, new evidence and analysis have broadened our understanding that the concept of preparedness is also applicable to addressing the unique professional liability risks that can occur when caring for patients and families during a disaster. Concepts explored in this technical report will help to inform pediatric health care providers, advocates, and policy makers about the complexities of how providers are currently protected, with a focus on areas of unappreciated liability. The timeliness of this technical report is emphasized by the fact that during the time of its development (ie, late summer and early fall of 2017), the United States went through an extraordinary period of multiple, successive, and overlapping disasters within a concentrated period of time of both natural and man-made causes. In a companion policy statement (www.pediatrics.org/cgi/doi/10.1542/peds.2018-3892), recommendations are offered on how individuals, institutions, and governments can work together to strengthen the system of liability protections during disasters so that appropriate and timely care can be delivered with minimal fear of legal reprisal or confusion.

Understanding Liability Risks and Protections for Pediatric Providers During Disasters.

Although most health care providers will go through their careers without experiencing a major disaster in their local communities, if one does occur, it can be life and career altering. The American Academy of Pediatrics has been at the forefront of providing education and advocacy on the critical importance of disaster preparedness. From experiences over the past decade, new evidence and analysis have broadened our understanding that the concept of preparedness is also applicable to addressing the unique professional liability risks that can occur when caring for patients and families during a disaster. In our recommendations in this policy statement, we target pediatric health care providers, advocates, and policy makers and address how individuals, institutions, and government can work together to strengthen the system of liability protections during disasters so that appropriate and timely care can be delivered with minimal fear of legal reprisal or confusion.

The impact of a hospital-based educational video on maternal perceptions and planned practices of infant safe sleep.

PURPOSE: To evaluate whether an educational video would impact infant sleep practices among new mothers. DESIGN AND METHODS: Survey responses of new mothers who did (n = 43) versus did not (n = 49) watch the educational video were compared to identify differences in observed and planned infant sleep practices. RESULTS: Mothers who watched the video were more likely to observe safe sleep practices while in the hospital (67.4% vs. 46.9%, p < .05). They were also less likely to plan for (unsafe) side positioning (23.9% vs. 7.1%, p < .05). PRACTICE IMPLICATIONS: Given the potentially fatal consequence of unsafe sleep, a brief video provided by nursing staff can be a prudent component of new parent education.

Management of apparent life-threatening events in infants: a systematic review.

OBJECTIVE: To determine in patients who are well-appearing and without a clear etiology after an apparent life-threatening event (ALTE): (1) What historical and physical examination features suggest that a child is at risk for a future adverse event and/or serious underlying diagnosis and would, therefore, benefit from testing or hospitalization? and (2) What testing is indicated on presentation and during hospitalization? STUDY DESIGN: Systematic review of clinical studies, excluding case reports, published from 1970 through 2011 identified using key words for ALTE. RESULTS: The final analysis was based on 37 studies; 18 prospective observational, 19 retrospective observational. None of the studies provided sufficient evidence to fully address the clinical questions. Risk factors identified from historical and physical examination features included a history of prematurity, multiple ALTEs, and suspected child maltreatment. Routine screening tests for gastroesophageal reflux, meningitis, bacteremia, and seizures are low yield in infants without historical risk factors or suggestive physical examination findings. CONCLUSION: Some historical and physical examination features can be used to identify risk in infants who are well-appearing and without a clear etiology at presentation, and testing tailored to these risks may be of value. The true risk of a subsequent event or underlying disorder cannot be ascertained. A more precise definition of an ALTE is needed and further research is warranted.

Parent education by maternity nurses and prevention of abusive head trauma.

OBJECTIVE: A consortium of the 19 community hospitals and 1 tertiary care children's hospital that provide maternity care in the New York State Hudson Valley region implemented a program to teach parents about the dangers of shaking infants and how to cope safely with an infant's crying. This study evaluated the effectiveness of the program in reducing the frequency of shaking injuries. METHODS: The educational program, which was delivered by maternity nurses, included a leaflet explaining abusive head trauma ("shaken baby syndrome") and how to prevent it, an 8-minute video on the subject, and a statement signed by parents acknowledging receipt of the information and agreeing to share it with others who will care for the infant. Poisson regression analysis was used to compare the frequency of shaking injuries during the 3 years after program implementation with the frequency during a 5-year historical control period. RESULTS: Sixteen infants who were born in the region during the 8-year study period were treated at the children's hospital for shaking injuries sustained during their first year of life. Of those infants, 14 were born during the 5-year control period and 2 during the 3-year postimplementation period. The decrease from 2.8 injuries per year (14 cases in 5 years) to 0.7 injuries per year (2 cases in 3 years) represents a 75.0% reduction (P = .03). CONCLUSIONS: Parent education delivered in the hospital by maternity nurses reduces newborns' risks of sustaining an abusive head injury resulting from shaking during the first year of life.

Breastfeeding education and support services offered to pediatric residents in the US.

OBJECTIVE: The American Academy of Pediatrics (AAP) encourages pediatricians to support the practice of breastfeeding and residency educators to develop formal curricula in breastfeeding education. Few studies, however, describe breastfeeding education or support services currently provided to pediatric residents in the United States. The goals of this study were to investigate breastfeeding training offered during 3-year pediatric residency programs and to describe residency programs' policies and services for residents who breastfeed. METHODS: We conducted a cross-sectional study using a Web-based survey of pediatric program directors regarding breastfeeding education and support services for residents. RESULTS: Seventy percent of program directors (132 of 189) completed the survey, with 77.3% of respondents (n = 102) estimating the amount of breastfeeding education offered to their pediatric residents. Residents are provided with a median total of 9.0 hours of breastfeeding training over 3 years, primarily in continuity clinic and in lectures and rounds with attendings. At the programs' primary teaching hospitals, breastfeeding residents are provided breastfeeding rooms (67.0%), breast pumps (75.3%), and breast milk storage facilities (87.6%). Only 10 programs reported having an official policy to accommodate breastfeeding residents. CONCLUSIONS: Pediatric residents receive approximately 3 hours of breastfeeding training per year. In addition, there is less than universal implementation by residency programs of AAP recommendations for supporting breastfeeding in the workplace. Pediatric residency programs should find ways to improve and assess the quality of breastfeeding education and workplace support to better role model this advocacy standard.

Infections and apparent life-threatening events.

The need for routine sepsis evaluation in patients who have experienced an apparent life-threatening event but lack signs of infection remains controversial. To assess their risk of a serious occult bacterial infection, records were reviewed of 95 infants in whom infections were discovered during their inpatient evaluation after an apparent life-threatening event. Noted for each patient was the presence of any suggestive findings that would have prompted a physician to consider the given type of infection in the differential diagnosis. Thirty patients had bacterial infections; all but 5 had suggestive findings. The exceptions included 1 patient with pneumonia and 4 with urinary tract infections. None of the remaining 25 patients had occult bacterial infections. In patients with an apparent life-threatening event who appear well and lack signs suggestive of a serious bacterial infection, it may be possible to forego routine sepsis evaluation beyond a chest radiograph and urine culture without risking a serious missed diagnosis.

Yield of diagnostic testing in infants who have had an apparent life-threatening event.

OBJECTIVE: Many infants who have experienced an apparent life-threatening event (ALTE) seem normal by the time they reach the hospital. Nevertheless, they typically undergo an extensive evaluation to rule out serious underlying conditions. The purpose of the present investigation was to determine the yield of different diagnostic tests in helping to identify the cause of the ALTE. METHODS: We reviewed test results from a consecutive series of infants who were younger than 12 months and admitted to a tertiary care academic medical center between November 1996 and June 1999 after having experienced a sudden breathing irregularity, color change, or alteration in mental status or muscle tone. For each patient, we noted whether a given test was performed, whether the result was positive, and, if so, whether the test contributed to the diagnosis, that is, suggested or helped establish the cause. We also noted whether the initial history and physical examination contributed information that eventually led to the final diagnosis. RESULTS: A total of 243 patients met the enrollment criteria. Of the 3776 tests ordered, 669 (17.7%) were positive and 224 (5.9%) contributed to the diagnosis. Prompted by findings from the initial clinical assessment, the following tests proved useful in patients who had a contributory history and physical examination: blood counts, chemistries, and cultures; cerebrospinal fluid analysis and cultures; metabolic screening; screening for respiratory pathogens; screening for gastroesophageal reflux; chest radiograph; brain neuroimaging; skeletal survey; electroencephalogram; echocardiogram; and pneumogram. In the remaining patients, who had a noncontributory history and physical examination, only the following tests proved useful: screening for gastroesophageal reflux, urine analysis and culture, brain neuroimaging, chest radiograph, pneumogram, and white blood cell count. Broad evaluations for systemic infections, metabolic diseases, and blood chemistry abnormalities were not productive in these patients. CONCLUSIONS: For many tests used in the evaluation of an ALTE, the likelihood of a positive result is low and the likelihood of a contributory result is even lower. Estimates of diagnostic yield derived from the present investigation can help clinicians maximize the productivity and efficiency of their evaluation.

Abusive head injury as a cause of apparent life-threatening events in infancy.

BACKGROUND: An apparent life-threatening event (ALTE) refers to the sudden occurrence of a breathing abnormality, color change, or alteration in muscle tone or mental status in an infant. Several patients with ALTEs admitted to our institution were found to have sustained abusive head injuries. OBJECTIVE: To systematically examine the possible causes of ALTEs and their relative frequencies. STUDY DESIGN: Prospective consecutive case series of 243 infants younger than 12 months admitted to a tertiary care academic medical center for evaluation of an ALTE during a 32-month interval. RESULTS: Thirty-five different causes of ALTEs were identified. Six subjects (2.5%) were diagnosed as having abusive head injuries, or 1 admission every 5 months. Three patients died in the hospital, 2 of whom were diagnosed as having abusive head injuries. CONCLUSIONS: A wide spectrum of diseases and disorders can precipitate an ALTE. Among them, abusive head injury, a recently recognized cause, occurs frequently enough to obligate its inclusion in the differential diagnosis. An ophthalmologic evaluation with dilated fundus examination and cranial imaging should therefore be considered early in the investigation unless another cause becomes apparent soon after admission.