Characteristics and Geographic Variation in Sudden Unexpected Infant Deaths in the District of Columbia.

ABSTRACT: Sleep-related infant death is a major cause of infant mortality in the United States. In the District of Columbia, infant mortality varies widely among regions (2 to 14 per 1000 live births). The study objectives were to analyze the patient characteristics and related variables to sudden unexpected infant deaths at 2 pediatric emergency department (ED) sites and the geographic patterns of infant deaths and their relationship to social vulnerability. This retrospective cohort study examined infants under 1 year of age presenting with cardiac arrest at 2 ED sites from 2010 to 2020. Analysis showed 81 deaths with a median population age of 75 days (SD, 46 days). The most frequent demographics of deceased patients were African American Black (89%) with Medicaid insurance (63%), born at term gestation (66%), and without comorbidity (60%). The cause of death was most frequently undetermined (32%) and asphyxia (31%). Most cases involved bed-sharing (63%), despite more than half of those cases having a known safe sleep surface available. Infant death location showed that most deaths occurred in areas with the highest social vulnerability index, including near a community ED location. Understanding the etiologies of this geographic variability may enhance sleep-related infant death prevention strategies.

Liquid Nicotine, E-Cigarettes, and Vaping: Information for the Pediatric Emergency Medicine Provider.

ABSTRACT: E-cigarettes, or electronic cigarettes, are electronic nicotine delivery systems that are marketed as a healthier alternative to tobacco cigarettes. There has been an exponential increase in their use among youth since their introduction to the United States market in 2007. With increased use and popularity, there has been an increase in calls to poison control centers regarding liquid nicotine toxicity in children and adolescents. Recent US Food and Drug Administration and other federal regulations of e-cigarettes have attempted to limit availability to youth. This article reviews trends in e-cigarette use among youth, the background and mechanism of action of e-cigarettes, liquid nicotine toxicity, management of liquid nicotine toxicity, and recent policy updates regarding e-cigarettes.

Variations in Safe Sleep Practices and Beliefs: Knowledge is not Enough.

OBJECTIVES: Sleep-related infant deaths in the District of Columbia (DC) varies, with rates in certain geographical areas three times higher than DC and seven times higher than the national average. We sought to understand differences in infant sleep knowledge, beliefs, and practices between families in high-risk infant mortality and low-risk infant mortality areas in DC. METHODS: Caregivers of infants presenting to the emergency department were surveyed. The associations between location and safe sleep knowledge, beliefs, and practices were analyzed. RESULTS: Two hundred and eighty-four caregivers were surveyed; 105 (37%) were from the high-risk infant mortality area. The majority (68%) of caregivers reported placing their infant to sleep on their backs, sleeping in a crib, bassinet, or pack and play (72%), and were familiar with the phrase "safe sleep" (72%). Caregivers from the high-risk infant mortality area were more likely to report that their infants sleep in homes other than their own (aOR 1.53; 95% CI 1.23, 2.81) and other people took care of their infants while sleeping (aOR 1.76; 95% CI 1.17, 3.19), adjusting for race/ethnicity, education, marital status, and help with childcare. No differences in safe sleep knowledge, beliefs, and practices were present. CONCLUSIONS FOR PRACTICE: Infants from the high-risk infant mortality area were more likely to sleep in homes other than their own and have other caretakers while sleeping. Lack of differences in caregiver awareness of safe sleep recommendation or practices suggests effective safe sleep messaging. Outreach to other caregivers and study of unmet barriers is needed.

Association of Ventilation during Initial Trauma Resuscitation for Traumatic Brain Injury and Post-Traumatic Outcomes: A Systematic Review.

OBJECTIVES: In the absence of evidence of acute cerebral herniation, normal ventilation is recommended for patients with traumatic brain injury (TBI). Despite this recommendation, ventilation strategies vary during the initial management of patients with TBI and may impact outcome. The goal of this systematic review was to define the best evidence-based practice of ventilation management during the initial resuscitation period. METHODS: A literature search of PubMed, CINAHL, and SCOPUS identified studies from 2009 through 2019 addressing the effects of ventilation during the initial post-trauma resuscitation on patient outcomes. RESULTS: The initial search yielded 899 articles, from which 13 were relevant and selected for full-text review. Six of the 13 articles met the inclusion criteria, all of which reported on patients with TBI. Either end-tidal carbon dioxide (ETCO2) or partial pressure carbon dioxide (PCO2) were the independent variables associated with mortality. Decreased rates of mortality were reported in patients with normal PCO2 or ETCO2. CONCLUSIONS: Normoventilation, as measured by ETCO2 or PCO2, is associated with decreased mortality in patients with TBI. Preventing hyperventilation or hypoventilation in patients with TBI during the early resuscitation phase could improve outcome after TBI.

Triple threat: New presentation with diabetic ketoacidosis, COVID-19, and cardiac arrhythmias.

Patients with diabetes have increased susceptibility to infection with Severe acute respiratory syndrome-coronavirus 2 and increased morbidity and mortality from Coronavirus disease 2019 (COVID-19) infection. Mortality from COVID-19 is sometimes caused by cardiac arrhythmias. Electrolyte disturbances in patients with diabetic ketoacidosis (DKA) can increase the risk of cardiac arrhythmias. Despite these correlations, little has been reported about the co-incidence of these three conditions: COVID-19, DKA and cardiac arrhythmias. In this case report we describe two children with COVID-19, new-onset DKA and cardiac arrhythmias. These cases emphasize the importance of close cardiac and electrolyte monitoring in patients with COVID-19 infection.

So much nuance: A qualitative analysis of parental perspectives on child passenger safety.

OBJECTIVE: To explore barriers and facilitators to optimal child restraint system (CRS) use for diverse parents of newborn infants and to obtain input from parents on the use of technology-assisted remote car seat checks as tools for promoting optimal CRS use. METHODS: Parents were recruited using purposive sampling. Interviews were conducted with English- or Spanish-speaking parents with a full term newborn and regular access to a car. Interviews were conducted by phone, and recorded and transcribed verbatim. Interviews were conducted until thematic saturation was reached. Data were organized for analysis using Atlas.ti, and codes grouped by theme using constant comparison. RESULTS: 30 parents were enrolled. Barriers and facilitators to optimal CRS use were classified into three themes, as were thoughts on the pros and cons regarding remote car seat checks. Themes on barriers and facilitators included motor vehicle and CRS features (such as age and size of the motor vehicle and presence of the Lower Anchors and Tethers for Children LATCH system), resources (availability, accessibility, and accuracy of resources), and parental factors (parental emotions and characteristics). Themes related to pros and cons of remote car seat checks included the ability (and challenge) of remote car seat checks to identify and correct errors, the potential use of remote car seat checks in certain situations (such as CRS transitions and periods of growth), and convenience of remote car seat checks (including increased availability and ease of access). Subthemes with further detail were arranged within each theme identified. CONCLUSION: From a parent perspective, there are several identified barriers and facilitators of optimal CRS use. Although car seat checks were identified as a resource, in-person accessibility was an issue, and there were mixed opinions on technology-assisted remote car seat checks. These results provide a foundation for additional study on targeted interventions, including remote interventions for which there is an increased need due to the COVID-19 pandemic.

The Joys and Frustrations of Breastfeeding and Rooming-In Among Mothers With Opioid Use Disorder: A Qualitative Study.

OBJECTIVES: To investigate perspectives of mothers with opioid use disorder regarding breastfeeding and rooming-in during the birth hospitalization and identify facilitators and barriers. METHODS: We conducted in-depth qualitative interviews with 25 mothers with opioid use disorder 1-12 weeks after delivery. Grounded theory analysis was used until thematic saturation was reached. Findings were triangulated, with experts in the field and a subset of informants themselves, to ensure data reliability. RESULTS: Among 25 infant-mother dyads, 36% of infants required pharmacologic treatment, 72% of mothers initiated breastfeeding, and 40% continued until discharge. We identified the following themes: (1) information drives maternal feeding choice; (2) the hospital environment is both a source of support and tension for mothers exerting autonomy in the care of their infants; (3) opioid withdrawal symptoms negatively impact breastfeeding; (4) internal and external stigma negatively impact mothers' self-efficacy; (5) mothers' histories of abuse and trauma affect their feeding choice and bonding; (6) mothers' recovery makes caring for their infants emotionally and logistically challenging; and (7) having an infant is a source of resilience and provides a sense of purpose for mothers on their path of recovery. CONCLUSIONS: Future interventions aimed at increasing breastfeeding and rooming-in during the birth hospitalization should focus on education regarding the benefits of breastfeeding and rooming-in, supporting mothers' autonomy in caring for their infants, minimizing stigma, and maximizing resilience.

Impact of Parental Presence at Infants' Bedside on Neonatal Abstinence Syndrome.

BACKGROUND: Despite increased incidence of neonatal abstinence syndrome (NAS) over the past decade, minimal data exist on benefits of parental presence at the bedside on NAS outcomes. OBJECTIVE: To examine the association between rates of parental presence and NAS outcomes. METHODS: This was a retrospective, single-center cohort study of infants treated pharmacologically for NAS using a rooming-in model of care. Parental presence was documented every 4 hours with nursing cares. We obtained demographic data for mothers and infants and assessed covariates confounding NAS severity and time spent at the bedside. Outcomes included length of stay (LOS) at the hospital, extent of pharmacotherapy, and mean Finnegan withdrawal score. Multiple linear regression modeling assessed the association of parental presence with outcomes. RESULTS: For the 86 mother-infant dyads, the mean parental presence during scoring was on average 54.4% (95% confidence interval [CI], 48.8%-60.7%) of the infant's hospitalization. Maximum (100%) parental presence was associated with a 9 day shorter LOS (r = -0.31; 95% CI, -0.48 to -0.10; P < .01), 8 fewer days of infant opioid therapy (r = -0.34; 95% CI, -0.52 to -0.15; P < .001), and 1 point lower mean Finnegan score (r = -0.35; 95% CI, -0.52 to -0.15; P < .01). After adjusting for breastfeeding, parental presence remained significantly associated with reduced NAS score and opioid treatment days. CONCLUSIONS: More parental time spent at the infant's bedside was associated with decreased NAS severity. This has important implications for clinical practice guidelines for NAS.

The effect of imaging on the clinical management of breast pain.

BACKGROUND: Breast pain is a common complaint to primary care and breast specialists. Literature recommends imaging to provide reassurance of benign etiology. The effect of imaging on reassurance and subsequent healthcare utilization has not been described. OBJECTIVE: To determine if initial imaging for breast pain reduces subsequent utilization. DESIGN: Retrospective cohort study at a hospital-based breast health practice. PATIENTS: Women referred for breast pain from 2006-2009. MAIN MEASURES: Imaging ordered at initial provider visit; clinical utilization, defined as the number of follow-up visits, diagnostic imaging studies, and biopsies completed within 12 months following initial visit. KEY RESULTS: Sixty-percent of women were age 40 or younger, 87% were from racial/ethnic minority groups. Twenty-five percent had imaging ordered at initial visit. Of those who received initial imaging, 75% had normal radiographic findings, yet 98% returned for additional evaluation. In adjusted analyses, women with initial imaging had increased clinical services utilization (OR 25.4, 95% CI: 16.7, 38.6). Women with normal clinical breast exams who received initial imaging exhibited increased odds for subsequent clinical services utilization (OR 23.8, 95% CI: 12.9, 44.0). Six cancers were diagnosed; imaging in the absence of clinical breast exam abnormalities did not result in any cancer identification. CONCLUSIONS: Initial imaging for women with breast pain increased the odds of subsequent clinical utilization and did not increase reassurance in ruling out malignancy.

The addition of internists to a breast health program.

With the increases in complexity of care for breast health concerns, there is a growing need for efficient and effective clinical evaluation, especially for vulnerable populations at risk for poor outcomes. The Breast Health Center at Boston Medical Center is a multidisciplinary program, with internists providing care alongside breast surgeons, radiologists, and patient navigators. Using a triage system previously shown to have high provider and patient satisfaction, and the ability to provide timely care, patients are assigned to either a breast surgeon or internist. From 2007 to 2009, internists cared for 2,408 women, representing half of all referrals. Women served were diverse in terms of race (33% black, 30% Hispanic, 5% Asian), language (34% require language interpreter), and insurance status (51% had no insurance or public insurance). Most presented with an abnormal screen (breast examination 54% or imaging 4%) while the remainder were seen for symptoms such as pain (26%), non-bloody nipple discharge (4%), or risk assessment (7%). A majority of final diagnoses were made through clinical evaluation alone (n = 1,760, 73%), without the need for additional diagnostic imaging or tissue sampling; 9% (n = 214) received a benign diagnosis with the aid of breast imaging; 19% (n = 463) required tissue sampling. Only 4% went on to see a breast surgeon. Internists diagnosed 15 incident cancers with a median time to diagnosis of 19 days. Patient and provider satisfaction was high. These data suggest that a group of appropriately trained internists can provide quality breast care to a vulnerable population in a multidisciplinary setting. Replication of this model requires the availability of more clinical training programs for non-surgical providers.

Assessing youth risk behavior in a clinical trial setting: lessons from the infant health and development program.

PURPOSE: The purpose of this article was to describe the use of the Youth Risk Behavior Surveillance System (YRBSS) with known 17-18-year-old patients in follow-up of a multisite randomized clinical trial, and to develop a new scoring algorithm indicating the degree of risk-taking behavior for between-group analyses. METHODS: Seventy-five questions from the YRBSS were incorporated into the study questionnaire, with the development of safety plans to guide the disposition of participants. The YRBSS questions were grouped into two categories (with three subdomains each) named problem behaviors (conduct problems, sexual behavior, and suicide/hopelessness) and substance use (cigarettes, alcohol, and marijuana use), with scores for each subdomain indicating high, moderate, and low risk. RESULTS: Of the 677 participants, the safety plan was activated 215 times for 199 (29.4%) of participants. Risk behaviors included binge drinking (149), alcohol/substance use and driving (41), depression (22), hopelessness (37), and suicidal ideation (13; all in the past). No emergency room evaluations were required. The subdomain scaling was analyzed by demographic characteristics, and findings were consistent with the literature; for example, higher rates of conduct problems in males, more suicidal ideation in females, greater sexual risk in African Americans, more substance use in males and whites, and more alcohol use in youth with mothers with higher levels of education. CONCLUSIONS: YRBSS can be administered in a research setting with appropriate safety precautions. These results should provide a useful guide to the application of the YRBSS to other adolescent populations in the future.