Child Abuse, Misdiagnosed by an Expertise Center: Part I-Medico-Social Aspects.

Child abuse is a dangerous situation for an infant. Professionals need to weigh the risk of failing to act when children are seriously harmed against the serious harm done by carrying out safeguarding interventions. In severe cases, foster care might be advisable. The negative effects for the child's psychosocial development requires that such placement must be based on very solid evidence. Our aim is to identify why Dutch parents whose child may have a medical condition that could mimic symptoms of child abuse have a significant chance of being erroneously convicted and losing custody of their child. As a method, we describe and analyze the following case. An Armenian-Dutch newborn (uncomplicated term vaginal delivery), starting at two weeks after birth, developed small bruises on varying body locations. At two months, a Well-Baby Clinic physician referred the girl to a university hospital, mentioning that there were no reasons to suspect child abuse and that her Armenian grandmother easily bruised as well. However, before consultation by a pediatrician of the hospital-located Expertise Center for Child Abuse, the parents were suspected of child abuse. Based on the expertise center's protocols, skeletal X-rays were made, which showed three healed, asymptomatic rib fractures, while invalid statistics suggested, incorrectly, a 10-100 times more likely non-accidental than accidental cause of the symptoms (discussed in Part II of this series). The expertise enter physician ignored any argument that could show parental innocence, including the positive parent-child relationship reported by the Well-Baby Clinic and the general practitioner. The girl and her older brother were placed in a family foster home and then in a secret home. The case radically resolved when a large bruise also developed there, and an independent tissue disease specialist diagnosed a hereditary connective tissue disorder in the mother, implying that the girl's bruises and rib fractures could well be disease-related. In conclusion, if child abuse is suspected, and foster care placement considered, the patient and the parents should be thoroughly investigated by an independent experienced pediatrician together with an experienced pediatric clinical psychologist or psychotherapist to produce an independent opinion. Children deserve this extra safeguard before being separated from their parents.

A risk scoring model to predict progression of retinopathy of prematurity for Indonesia.

INTRODUCTION: Retinopathy of prematurity (ROP) is a serious eye disease in preterm infants. Generally, the progression of this disease can be detected by screening infants regularly. In case of progression, treatment can be instituted to stop the progression. In Indonesia, however, not all infants are screened because the number of pediatric ophthalmologists trained to screen for ROP and provide treatment is limited. Therefore, other methods are required to identify infants at risk of developing severe ROP. OBJECTIVE: To assess a scoring model's internal and external validity to predict ROP progression in Indonesia. METHOD: To develop a scoring model and determine its internal validity, we used data on 98 preterm infants with ROP who had undergone one or more serial eye examinations between 2009 and 2014. For external validation, we analyzed data on 62 infants diagnosed with ROP irrespective of the stage between 2017 and 2020. Patients stemmed from one neonatal unit and three eye clinics in Jakarta, Indonesia. RESULTS: We identified the duration of oxygen supplementation, gestational age, socio-economic status, place of birth, and oxygen saturation monitor setting as risk factors for developing ROP. We developed two models-one based on the duration of supplemental oxygen and one on the setting of the oxygen saturation monitor. The ROP risk and probabilistic models obtained the same sensitivity and specificity for progression to Type 1 ROP. The agreement, determined with the Kappa statistic, between the ROP risk model's suitability and the probabilistic model was excellent. The external validity of the ROP risk model showed 100% sensitivity, 73% specificity, 76% positive predictive value, 100% negative predictive value, positive LR +3.7, negative LR 0, 47% pre-test probability, and 77% post-test probability. CONCLUSION: The ROP risk scoring model can help to predict which infants with first-stage ROP might show progression to severe ROP and may identify infants who require referral to a pediatric ophthalmologist for treatment.

Urinary concentrations of bisphenols and parabens and their association with attention, hyperactivity and impulsivity at adolescence.

BACKGROUND: Neurobehavioural disorder diagnoses have been increasing over the last decades, leading to heightened interest in the aetiological factors involved. Endocrine disrupting chemicals, such as parabens and bisphenols, have been suggested as one of those factors. It is unknown whether exposure during adolescence may affect neurobehavioural development. OBJECTIVE: To determine whether urinary concentrations of parabens and bisphenols are associated with attention and concentration in adolescents, in general and sex-specific. METHODS: We invited 188 adolescents (13-15 years old) for the follow-up birth cohort-study. Concentrations of five parabens and three bisphenols (BPA; BPF; BPS) were measured in morning urine after overnight fasting, using a validated LC-MS/MS method. Attention and concentration were assessed at the clinic with subtests of the Test of Everyday Attention in Children and the Dutch Attention Deficit Hyperactivity Disorder questionnaire (AVL), the latter being filled in by parents. Linear regression analyses were performed, adjusting for urine creatinine concentrations and potential confounding factors. RESULTS: 101 (54%) adolescents participated (46 girls; 55 boys). Urinary paraben concentrations were higher in girls than in boys. Methylparaben was positively associated with attention in girls (p ≤ .05; B= -2.836; 95%CI= -5.175;-.497), ethylparaben negatively with hyperactivity (p ≤ .05; B= -1.864; 95%CI= -3.587;-.141). Butylparaben was associated with more optimal scores on parent reported attention. Propylparaben was negatively associated with scores on sustained auditory attention in girls (p ≤ .10; B=.444; 95%CI= -.009;.896). Bisphenol concentrations were not associated with scores on attention and concentration after adjusting for confounders. CONCLUSION: In 13-15-year-old Dutch adolescents, urinary concentrations of methylparaben and ethylparaben were associated with better attention and less hyperactivity, whereas a trend toward significance was found between higher urinary propylparaben concentrations and poorer attention. Bisphenol concentrations were not associated with attention and concentration after adjusting for confounders.

Prenatal Environmental Exposure to Persistent Organic Pollutants and Reproductive Hormone Profile and Pubertal Development in Dutch Adolescents.

Persistent organic pollutants (POPs), such as polychlorinated biphenyls (PCBs), may interfere with hormonal processes. Knowledge about the effects of prenatal exposure to PCBs and their hydroxylated metabolites (OH-PCBs) on pubertal development is limited. Therefore, the aim of the current study was to determine whether prenatal environmental PCB and OH-PCB exposure are associated with reproductive hormone levels and pubertal characteristics in 13- to 15-year-old children. In this Dutch observational cohort study, 194 mother-infant pairs were included (1998-2002). Maternal pregnancy serum levels of PCBs, OH-PCBs, and other POPs were measured. At follow-up (2014-2016), we measured serum or plasma levels of reproductive hormones in their children. We assessed Tanner stages and testicular volume (by clinician or standardized self-assessment), and participants completed questionnaires on pubertal onset. In total, 101 adolescents (14.4 ± 0.8 years; 53.7% of invited) participated, and 55 were boys. In boys, higher prenatal PCB levels were associated with higher testosterone levels, higher pubic hair stage, larger testicular volume, and younger age at onset of growth spurt and voice break. In girls, higher prenatal PCB levels were associated with higher stages for breast development. In conclusion, higher prenatal PCB exposure could be associated with more advanced pubertal development in 13- to 15-year-old children.

Evaluation of a mobile application tool (BiliNorm) to improve care for newborns with hyperbilirubinemia in Indonesia.

BACKGROUND: Severe hyperbilirubinemia is more frequent in low- and middle-income countries such as Indonesia than in high-income countries. One of the contributing factors might be the lack of adherence to existing guidelines on the diagnosis and treatment of hyperbilirubinemia. We developed a new national guideline for hyperbilirubinemia management in Indonesia. To help healthcare workers use this guideline, a web-based decision support tool application may improve both the adherence to the guideline and the care for infants with hyperbilirubinemia. METHODS: We developed a web-based application (BiliNorm) to be used on a smartphone that displays the bilirubin level of the patient on the nomogram and advises about the treatment that should be started. Healthcare workers of two teaching hospitals in East Java, Indonesia, were trained on the use of BiliNorm. At 6 months after the introduction, a questionnaire was sent to those who worked with the application enquiring about their experiences. An observational study was conducted in two time epochs. A chart review of infants with hyperbilirubinemia in the two hospitals was sent. The appropriateness of hyperbilirubinemia management during a 6-month period before BiliNorm introduction was compared to that during a 7-month period after its introduction. RESULTS: A total of 43 participants filled in the questionnaire, the majority (72%) of them indicated that BiliNorm was well received and easy to use. Moreover, 84% indicated that BiliNorm was helpful for the decision to start phototherapy. Chart review of 255 infants before BiliNorm introduction and that of 181 infants after its introduction indicated that significantly more infants had received treatment according to the guideline (38% vs 51%, p = 0.006). Few infants received phototherapy, but bilirubin level was not measured (14% vs 7%, p = 0.024). There was no difference in the proportion of infants who were over- and under-treated (34% vs 32% and 14% vs 10%, respectively). CONCLUSIONS: The web-based decision tool BiliNorm appears to be a valuable application. It is easy to use for healthcare workers and helps them adhere to the guideline. It improves the care for infants with hyperbilirubinemia and may help reduce the incidence of severe hyperbilirubinemia in Indonesia.

Prenatal Environmental Exposure to Persistent Organic Pollutants and Indices of Overweight and Cardiovascular Risk in Dutch Adolescents.

Persistent organic pollutants (POPs) may have obesogenic effects. Knowledge about the effects of prenatal exposure to POPs on anthropometric measurements and metabolic parameters into adolescence is limited. Therefore, the aim of the current study was to determine whether prenatal environmental exposure to several POPs is associated with indices of overweight and cardiovascular risk in 13-15-year-old children. In this Dutch observational cohort study, 194 mother-infant pairs were included (1998-2002). Maternal pregnancy serum levels of PCBs, OH-PCBs, PBDEs, and other POPs were measured. At follow-up (2014-2016), levels of cholesterol, HDL-C, LDL-C, triglycerides, fasting insulin, fasting glucose, leptin, and adiponectin were measured in their children. The children's height, weight, waist circumference, hip circumference, and blood pressure were measured. In total, 101 adolescents (14.4 ± 0.8 years; 53.7% of invited) participated of which 55 were boys. Mean BMI was 19.1 ± 3.6 kg/m2 and mean BMI z-score 0.13 ± 1.14. Higher prenatal levels of PCBs were associated with lower levels of HDL-C and adiponectin in boys and higher levels of PBDEs with higher triglycerides in girls. We found significant differences by sex in the associations with OH-PCBs, with lower HDL-C and adiponectin, higher LDL-C/HDL-C ratio, fasting glucose, HOMA2-IR, height, and weight for boys. Our study indicates that higher prenatal exposure to PCBs, OH-PCBs, and PBDEs was associated with adolescent levels of some metabolic cardiovascular risk markers and hormones associated with the development of obesity and cardiovascular disease.

Diagnostic Properties of a Portable Point-of-Care Method to Measure Bilirubin and a Transcutaneous Bilirubinometer.

BACKGROUND: Recently, the Bilistick®, a point-of-care instrument to measure bilirubin levels, has been developed. It is fast and cheaper than transcutaneous bilirubin (TCB)-measuring devices, but data on diagnostic properties are scarce. OBJECTIVE: This study aimed to compare the performance of the Bilistick® (BM-BS 1.0 - FW version 2.0.1) and the JM-105 bilirubinometer for measuring bilirubin. METHOD: This is a prospective study in infants born after ≥32 weeks' gestation, and/or a birth weight of ≥1,500 g, and a postnatal age ≤14 days in Surabaya, Indonesia. Bilirubin was measured with the Bilistick® System (BM-BS 1.0 - FW version 2.0.1), transcutaneously (TCB) with the JM-105 bilirubinometer, and in serum (TSB) with a routine laboratory technique. Mean differences and 95% limits of agreement (LOA) and correlations were calculated. RESULT: We enrolled 149 neonates and 126 had paired measurements of Bilistick® bilirubin, TCB, and TSB. Bilistick® failed in 16 (10.7%) infants. Mean Bilistick® bilirubin-TSB difference was -11 µmol/L (95% LOA: -101 to 79 µmol/L) and r = 0.738 (p < 0.001). Mean TCB-TSB difference was 26 µmol/L (95% LOA: -33 to 88) and r = 0.785 (p < 0.001). The sensitivity, specificity, PPV, and NPV for Bilistick® bilirubin for a TSB above treatment thresholds were 0.74, 0.84, 0.67, and 0.88, respectively, and for TCB 0.92, 0.64, 0.54, and 0.95, respectively. CONCLUSION: The Bilistick® System (BM-BS 1.0 - FW version 2.0.1) underestimates TSB, whereas TCB overestimates TSB in jaundiced Indonesian infants. Further improvement of Bilistick®'s diagnostic accuracy with less false-negative readings is essential to increase its use.

Kramer Score, an Evidence of Its Use in Accordance with Indonesian Hyperbilirubinemia Published Guideline.

Background: In some hospitals in low/middle-income countries, methods to determine the bilirubin level in newborn infants are unavailable and based on a clinical evaluation, namely a clinical score designed by Kramer. In this study, we evaluated if this score can be used to identify those infants that need phototherapy. Method: Infants admitted between November 2018 and June 2019 to three hospitals in Surabaya, Indonesia were included. The jaundice intensity was scored using the Kramer score. Blood was sampled for total serum bilirubin (TSB) measurement. The infants were categorized into Treatment Needed (TN) group when treatment with phototherapy was indicated and the No Treatment Needed (NTN) group when phototherapy was not indicated, based on the Indonesian Guideline for hyperbilirubinemia. Result: A total of 280 infants with a mean birth weight of 2744.6 ± 685.8 g and a gestational age of 37.3 ± 2.3 weeks were included. Twenty-seven of 113 (24%) infants with Kramer score 2 needed phototherapy, compared with 41 of 90 (46%) infants with score 3 and 20 of 28 (71%) of infants with score 4. The percentage of infants that needed phototherapy was higher with decreasing gestational age. Conclusion: The Kramer score is an invalid method to distinguish between those infants needing phototherapy and those infants where this treatment is not indicated.

Corrigendum to "The knowledge of Indonesian pediatric residents on hyperbilirubinemia management" [Heliyon 7 (4) (2021) e06661].

[This corrects the article DOI: 10.1016/j.heliyon.2021.e06661.].

The incidence of osteopenia of prematurity in preterm infants without phosphate supplementation: A prospective, observational study.

ABSTRACT: To meet their requirements for bone mineralization, it is recommended that preterm infants receive nutritional support containing calcium and phosphate. There are no clear data on the incidence of osteopenia of prematurity (OFP) in preterm infants without phosphate supplementation.This study aimed to investigate the incidence of OFP in preterm infants without phosphate supplementation and its relationship with the duration of parenteral nutrition (PN).This was a prospective and observational study.This study included 30 infants aged <32 gestational weeks and weighed <1500 g at birth. All infants received PN according to a standard protocol, beginning on day 1 with calcium, without phosphate. Starting from the first day of life, all infants received human milk without fortifiers. Oral vitamin D (400 IU/d) was administered when enteral nutrition reached 100 mL/kg/d.The diagnosis of OFP was based on radiographs that were taken of both wrists. Serum alkaline phosphatase (ALP) was measured 3 times: at the start of PN (ALP 1), at the end of PN (ALP 2), and at discharge or the expected due date (ALP 3). Radiographs were obtained on the same day as ALP 3. The duration of PN was analyzed in the presence of OFP using receiver operating characteristic curve analysis.Among the 30 infants, 13 (43%) were diagnosed with OFP. The duration of PN was significantly longer in the OFP group than in the group without OFP (16 vs 12 days; P < .05). The provision of PN for >15 days significantly increased the risk of OFP (odds ratio, 5.40; 95% confidence interval, 1.12-26.04; P = .035).We found a high incidence of OFP in preterm infants without phosphate supplementation. An association was found between the duration of PN and the incidence of OFP. Further research is needed to prevent the development of osteopenia in preterm infants.

The knowledge of Indonesian pediatric residents on hyperbilirubinemia management.

Hyperbilirubinemia in the newborn occurs more frequently in Indonesia. Therefore, it is important that pediatric residents in Indonesia acquire adequate knowledge of hyperbilirubinemia management. This study aims to determine the pediatric residents' knowledge on hyperbilirubinemia management, whether they follow recommended guidelines, and whether differences exist between five large Indonesian teaching hospitals. We handed out a 25-question questionnaire on hyperbilirubinemia management to pediatric residents at five teaching hospitals. A total of 250 questionnaires were filled in completely, ranging from 14 to 113 respondents per hospital. Approximately 76% of the respondents used the Kramer score to recognize neonatal jaundice. Twenty-four percent correctly plotted the total serum bilirubin levels (TSB) on the phototherapy (PT) nomograms provided by the American Academy of Pediatrics (AAP) and the National Institute for Health and Care Excellence (NICE) for full-term and nearly full-term infants. Regarding preterm infants <35 weeks' gestational age, 66% of the respondents plotted TSB levels on the AAP nomogram, although this nomogram doesn't apply to this category of infants. Seventy percent of residents knew when to perform an exchange transfusion whereas 27% used a fixed bilirubin cut-off value of 20 mg/dL. Besides PT, 25% reported using additional pharmaceutical treatments, included albumin, phenobarbitone, ursodeoxycholic acid and immunoglobulins, while 47% of the respondents used sunlight therapy, as alternative treatment. The limited knowledge of the pediatric residents could be one factor for the higher incidence of severe hyperbilirubinemia and its sequelae. The limited knowledge of the residents raises doubts about the knowledge of the supervisors and the training of the residents since pediatric residents receive training from their supervisors.

Pesticide Exposure of Residents Living Close to Agricultural Fields in the Netherlands: Protocol for an Observational Study.

BACKGROUND: Application of pesticides in the vicinity of homes has caused concern regarding possible health effects in residents living nearby. However, the high spatiotemporal variation of pesticide levels and lack of knowledge regarding the contribution of exposure routes greatly complicates exposure assessment approaches. OBJECTIVE: The objective of this paper was to describe the study protocol of a large exposure survey in the Netherlands assessing pesticide exposure of residents living close (<250 m) to agricultural fields; to better understand possible routes of exposure; to develop an integrative exposure model for residential exposure; and to describe lessons learned. METHODS: We performed an observational study involving residents living in the vicinity of agricultural fields and residents living more than 500 m away from any agricultural fields (control subjects). Residential exposures were measured both during a pesticide use period after a specific application and during the nonuse period for 7 and 2 days, respectively. We collected environmental samples (outdoor and indoor air, dust, and garden and field soils) and personal samples (urine and hand wipes). We also collected data on spraying applications as well as on home characteristics, participants' demographics, and food habits via questionnaires and diaries. Environmental samples were analyzed for 46 prioritized pesticides. Urine samples were analyzed for biomarkers of a subset of 5 pesticides. Alongside the field study, and by taking spray events and environmental data into account, we developed a modeling framework to estimate environmental exposure of residents to pesticides. RESULTS: Our study was conducted between 2016 and 2019. We assessed 96 homes and 192 participants, including 7 growers and 28 control subjects. We followed 14 pesticide applications, applying 20 active ingredients. We collected 4416 samples: 1018 air, 445 dust (224 vacuumed floor, 221 doormat), 265 soil (238 garden, 27 fields), 2485 urine, 112 hand wipes, and 91 tank mixtures. CONCLUSIONS: To our knowledge, this is the first study on residents' exposure to pesticides addressing all major nondietary exposure sources and routes (air, soil, dust). Our protocol provides insights on used sampling techniques, the wealth of data collected, developed methods, modeling framework, and lessons learned. Resources and data are open for future collaborations on this important topic. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/27883.

Multicentre survey of retinopathy of prematurity in Indonesia.

Background: The incidence of retinopathy of prematurity (ROP) is higher in Indonesia than in high-income countries. In order to reduce the incidence of the disease, a protocol on preventing, screening and treating ROP was published in Indonesia in 2010. To assist the practical implementation of the protocol, meetings were held in all Indonesia regions, calling attention to the high incidence of ROP and the methods to reduce it. In addition, national health insurance was introduced in 2014, making ROP screening and treatment accessible to more infants. Objective: To evaluate whether the introduction of both the guideline drawing attention to the high incidence of ROP and national health insurance may have influenced the incidence of the disease in Indonesia. Setting: Data were collected from 34 hospitals with different levels of care: national referral centres, university-based hospitals, and public and private hospitals. Methods: A survey was administered with questions on admission numbers, mortality rates, ROP incidence, and its stages for 2016-2017 in relation to gestational age and birth weight. Results: We identified 12 115 eligible infants with a gestational age of less than 34 weeks. Mortality was 24% and any stage ROP 6.7%. The mortality in infants aged less than 28 weeks was 67%, the incidence of all-stage ROP 18% and severe ROP 4%. In the group aged 28-32 weeks, the mortality was 24%, all-stage ROP 7% and severe ROP 4%-5%. Both mortality and the incidence of ROP were highest in university-based hospitals. Conclusions: In the 2016-2017 period, the infant mortality rate before 32 weeks of age was higher in Indonesia than in high-income countries, but the incidence of ROP was comparable. This incidence is likely an underestimation due to the high mortality rate. The ROP incidence in 2016-2017 is lower than in surveys conducted before 2015. This decline is likely due to a higher practitioner awareness about ROP and national health insurance implementation in Indonesia.

How to prevent ROP in preterm infants in Indonesia?

BACKGROUND AND AIMS: Retinopathy of prematurity (ROP) is a severe disease in preterm infants. It is seen more frequently in Low-Middle Income Countries (LMIC) like Indonesia compared to High-Income Countries (HIC). Risk factors for ROP development are -extreme- preterm birth, use of oxygen, neonatal infections, respiratory problems, inadequate nutrition, and blood and exchange transfusions. In this paper, we give an overview of steps that can be taken in LMIC to prevent ROP and provide guidelines for screening and treating ROP. METHODS: Based on the literature search and data obtained by us in Indonesia's studies, we propose guidelines for the prevention, screening, and treatment of ROP in preterm infants in LMIC. RESULTS: Prevention of ROP starts before birth with preventing preterm labor, transferring a mother who might deliver <32 weeks to a perinatal center and giving corticosteroids to mothers that might deliver <34 weeks. Newborn resuscitation must be done using room air or, in the case of very preterm infants (<29-32 weeks) by using 30% oxygen. Respiratory problems must be prevented by starting continuous positive airway pressure (CPAP) in all preterm infants <32 weeks and in case of respiratory problems in more mature infants. If needed, the surfactant should be given in a minimally invasive manner, as ROP's lower incidence was found using this technique. The use of oxygen must be strictly regulated with a saturation monitor of 91-95%. Infections must be prevented as much as possible. Both oral and parenteral nutrition should be started in all preterm infants on day one of life with preferably mothers' milk. Blood transfusions can be prevented by reducing the amount of blood needed for laboratory analysis. DISCUSSION: Preterm babies should be born in facilities able to care for them optimally. The use of oxygen must be strictly regulated. ROP screening is mandatory in infants born <34 weeks, and infants who received supplemental oxygen for a prolonged period. In case of progression of ROP, immediate mandatory treatment is required. CONCLUSION: Concerted action is needed to reduce the incidence of ROP in LMIC. "STOP - R1O2P3" is an acronym that can help implement standard practices in all neonatal intensive care units in LMIC to prevent development and progression.

Duration of Breastfeeding in Late Preterm Infants: Maternal and Infant Factors.

BACKGROUND: More than 550,000 late preterm infants are born each year in Indonesia. These infants, born between 340/7-366/7 weeks, have more complications than term infants. Breastfeeding is considered the most optimal nutrition for newborn infants. Two groups of factors are important for successful breastfeeding: infant and maternal factors. The infant factors can be evaluated using the Infant Breastfeeding Assessment Tool and the maternal aspects with the Breastfeeding Self-Efficacy Scale-Short Form. AIM: To determine whether the Infant Breastfeeding Assessment Tool or the Breastfeeding Self-Efficacy Scale-Short Form was more predictive of successful breastfeeding among late preterm infants. METHODS: This study was conducted in the Academic Teaching Hospital in Surabaya, Indonesia in March-July 2017. Mothers who delivered their infant between a gestational age of 340/7 and 366/7 weeks were included. RESULTS: Fifty-four single born participant mother-infant pairs were included. The mean total Breastfeeding Self-Efficacy Scale-Short Form score was 57.8 (SD = 8.9). The mean Infant Breastfeeding Assessment Tool score was 8.3 (SD = 1.8). There was a significant correlation between the total Breastfeeding Self-Efficacy Scale-Short Form score and the Infant Breastfeeding Assessment Tool score (p = .020, r = 0.316). The Breastfeeding Self-Efficacy Scale-Short Form was significantly higher in the participant (mothers) of the infants breastfed ≥ 4 months, compared to < 4 months, 61.59 (SD = 5.78) versus 51.78 (SD = 11.64; p = .001). No correlation was found between the duration of breastfeeding and Infant Breastfeeding Assessment Tool score (p = .087). CONCLUSION: Maternal factors were more important for successful breastfeeding in these late preterm infants than infant factors in our sample.

Limitations of Dutch Growth Research Foundation Commercial Software Weight Velocity for Age Standard Deviation Score.

BACKGROUND The commercial software for hospitals, Weight Velocity for Age Standard Deviation Score (SDSWVA), claims to document the growth and development of children, although published details are unavailable. The statistics-derived parameter SDSWVA includes the weight velocity at age t, WV(t) (weight gained between t and (t-1.23) years, divided by 1.23), and 3 standard weight velocity curves at average age AA, defined as AA=t-1.23/2 years. SDSWVA denotes the number of standard deviations that WV(t) deviates from the 0 SD weight velocity at AA. WV(t) yielded erroneous outcomes when applied to weights of a seriously underweight boy with an allergy to cows' milk who showed strong weight growth after being fed on food free of cows' milk. The SDSWVA software tacitly suggests that it is more accurate than WV(t). CASE REPORT The case of this boy was previously described in this Journal. Using SDSWVA(t,AA) software, his weight growth was analyzed by his third pediatrician, beginning at age 1.5 years. The diagnosis of the mother with Pediatric Condition Falsification was confirmed, adding 6 months to foster care, which totalled 8.5 months. Testing of the SDSWVA software on the boy's weight curve yielded results that were complex, nontransparent, and as erroneous as WV(t), explaining the misdiagnosis by the third pediatrician. CONCLUSIONS SDSWVA software should not be used for children under 3 years and during variable weight behavior. Erroneous performance, unpublished details, and an error identified in their new but untested software make the Dutch Growth Research Foundation unlikely to meet the 2020 European Union regulations for in vitro medical devices.

Motor development in children 0-2 years pre- and post-LTX, a prospective study.

To determine prospectively gross and fine motor development of children <2 years of age, who undergo LTX. In this prospective study, children aged <2 years who undergo LTX were tested using the motor scale of the Bayley Scales of infant and toddler development, 3rd edition Dutch version. Testing was done during screening pre- and post-LTX: at the time of hospital discharge (2-6 weeks), at 3 months, 6 months, and 1 year. Z-scores were calculated. Twenty-nine children participated in this study, 14 boys, median age 6 months, at screening for LTX. Gross motor skills were delayed pre-LTX (Z-score -1.3). Fine motor skills were normal (Z-score 0.3). Immediately post-LTX, both skills reduced, and at 1 year post-LTX, gross motor skills Z-score was -1.0 and fine motor skills Z-score 0.0. Both gross and fine motor skills Z-scores decline post-LTX and tend to recover after 1 year, gross motor skills to low normal and fine motor skills to normal levels. Monitoring of gross motor development and attention on stimulating gross motor development post-LTX remains important, to enable participation in physical activity and sport for health benefits later in life.

Weight velocity equations with 14-448 days time separated weights should not be used for infants under 3 years of age.

Abnormal growth of infants may indicate disease of the children, thus methods to identify growth disorders are wanted in medicine. We previously showed that two-time-points weight growth velocities at age t, calculated by a commercial software product as [Weight(t) - Weight(t - X)]/X, with X = 448 days, were erroneous due to the long separation of 448 days. We were convinced that shorter X-values would solve this accuracy problem. However, our hypothesis is that: "shorter time separations than 448 days cause a decreased accuracy of numerical weight velocity equations in realistic infant weights until an age of about three years". Supporting evidence comes from analyzing how shorter X-values will affect the accuracy of two-time-points weight velocity calculations. We systematically varied X between 1 and 448 days of various P50/0SD-related standard weight curves: (a) P50/0SD with the weights separated by 1 day and X = 1,28,224,448 days; (b) P50/0SD with the weights at variable ages and X = 14-448 days; and (c) case (b) and incorporating weight fluctuations typically occurring in infants. Cases (b) and (c) include details observed in a clinical case. Our results show that the combination of weight fluctuations and varying time intervals between consecutive weights make weight velocity predictions worse for shorter X values in children younger than three years. Because these two causes of failure occur naturally in infants whose weight is regularly measured, other weight velocity equations face the same causes for inaccuracy. In conclusion, our hypothesis suggests that any software that predicts weight velocities should be abandoned in infants < 3 years. Practically, it should require that when (commercial) software weight velocity prediction suggests a medical problem, careful clinical checking should be mandatory, e.g. by linking predicted and exact weight velocities at age t (the latter from the mathematical first derivative at age t of standard weight curves).

[Rubber granules on synthetic turf pitches: safe or not safe for children?] / Rubbergranulaat op kunstgrasvelden.

Rubber granules from old car tyres used in synthetic turf pitches contain a significant number of carcinogenic and endocrine-disrupting chemicals. In 2017 the Dutch National Institute for Public Health and the Environment (RIVM) and the European Chemical Agency (ECHA) concluded that the risks for children are negligible. However, their reports contain some scientific inaccuracies and omissions which may have led them to underestimate the risks for children. It is therefore premature to conclude that it is safe for children to play on synthetic turf pitches with rubber granules. It is now primarily up to the parents to decide whether or not playing sports is acceptable in these circumstances. The Dutch government should, in accordance with ECHA recommendations, advise parents that their children ought to avoid hand-and-mouth contact with these granules as much as possible.

Current phototherapy practice on Java, Indonesia.

BACKGROUND: In Indonesia, the burden of severe hyperbilirubinemia is higher compared to other countries. Whether this is related to ineffective phototherapy (PT) is unknown. The aim of this study is to investigate the performance of phototherapy devices in hospitals on Java, Indonesia. METHODS: In 17 hospitals we measured 77 combinations of 20 different phototherapy devices, with and without curtains drawn around the incubator/crib. With a model to mimic the silhouette of an infant, we measured the irradiance levels with an Ohmeda BiliBlanket Meter II, recorded the distance between device and model, and compared these to manufacturers' specifications. RESULTS: In nine hospitals the irradiance levels were less than required for standard PT: < 10 µW/cm2/nm and in eight hospitals irradiance failed to reach the levels for intensive phototherapy: 30 µW/cm2/nm. Three hospitals provided very high irradiance levels: > 50 µW/cm2/nm. Half of the distances between device and model were greater than recommended. Distance was inversely correlated with irradiance levels (R2 = 0.1838; P < 0.05). The effect of curtains on irradiance levels was highly variable, ranging from - 6.15 to + 15.4 µW/cm2/nm, with a mean difference (SD) of 1.82 (3.81) µW/cm2/nm (P = 0.486). CONCLUSIONS: In half of the hospitals that we studied on Java the levels of irradiance are too low and, in some cases, too high. Given the risks of insufficient phototherapy or adverse effects, we recommend that manufacturers provide radiometers so hospitals can optimize the performance of their phototherapy devices.