New AHRQ Toolkit Designed to Improve Safety of Fragile Newborms
A new toolkit is available to help improve the safety of infants born preterm or with complex congenital conditions as they transition from the neonatal intensive care unit to their home. Funded by the Agency for Healthcare Research and Quality, the toolkit features information on how to create a Health Coach Program, where the “Health Coach” serves as a teacher and facilitator who encourages open communication with the parents/caregivers to identify their needs and concerns and facilitates follow-up care for the infant by primary care providers. As an online product, the Health Coach Program can customize a broad range of information for each family based on their needs and concerns. Included are approximately 30 fact sheets, directed to either the clinician or the infant’s family, on topics that range from medications to breastfeeding to insurance coverage tips.
The Committee on Fetus and Newborn has released a statement for Pediatricians to help them provide “supportive, informed counsel” to women who choose to deliver their newborns at home. The AAP statement agrees with the ACOG statement but adds that every newborn deserves the same standard of care regardless of the location of birth. This care starts with a designated person at the delivery whose primary responsibility it is to monitor and care for the infant including providing resuscitation if needed. Subsequent care should follow the recommendations as per the Guidelines of Perinatal Care, including newborn screening, eye prophylaxis, Hepatitis B vaccination and screening for hyperbilirubinemia.
The US Secretary of Health and Human Services recently recommended routine oxygen screening of all infants for detection of critical congenital heart disease (heart defects) in the first days after birth. A mother's experience with her newborn's testing is presented in a compelling recent article in The New York Times.
The AAP released a clinical report by the Neuromotor Screening Expert Panel promoting developmental surveillance at preventative care visits. This multidisciplinary group has published an algorithm to assist primary care providers to survey and screen all children at 9, 18, 30 and 48 month visits. During these visits, the Panel recommends that PCPs administer a developmental screening tool, review past medical history for high risk events (such as prematurity or NICU stay) and perform a neurologic exam to evaluate for high, normal or low tone. Any concerning findings should prompt the PCP to refer to Early Childhood intervention, consult/refer to specialists and pursue diagnostic testing.
The AAP has released the 2013 Immunization schedule for children and adolescents. New this year is the recommendation that adolescents and adults receive the Tdap vaccine during each pregnancy to help protect newborns from Pertussis. Pertussis has been implicated in severe illness, hospitalization and even death in newborns.
Recommendations Against Breastfeeding for HIV Infected Mothers
The Committee on Pediatric AIDS has published their recommendations regarding HIV mothers providing their own breastmilk for their infants. Studies have demonstrated that HIV can be transmitted in breastmilk despite maternal antiretroviral treatment and infant prophylaxis. No study has demonstrated the safety of breastfeeding despite an undetectable viral load in the mother. In the United States, where access to clean water and affordable options are available for formula, the AAP recommends that women with HIV should not breastfeed their infants regardless of maternal viral load or antiretroviral therapy.
New Evaluation and Treatment Guidelines for Suspected Neonatal HSV
David W. Kimberlin & the Committee on Infectious Diseases and the Committee on Fetus & Newborn.
Neonatal herpes is a rare but serious illness. Physicians caring for infants often have questions regarding the appropriate evaluation and treatment of a newborn born to a mother with genital herpes but no current symptoms. In a joint policy statement from the Committee on Infectious Diseases and the Committee on Fetus & Newborn, Kimberlin presents an algorithm for the evaluation of asymptomatic neonates after delivery to a mother with active genital herpes lesions.
Julius B. Richmond Center of Excellence provides support to clinicians, educators and families to assist with smoking cessation in the home
Pediatricians who wish to help parents in their practice to quit smoking may benefit from utilizing the many resources available on this website. The mission statement of this AAP affiliated organization is “to improve child health by eliminating children's exposure to tobacco and secondhand smoke. This will be accomplished by changing the clinical practice of pediatrics through the development and dissemination of practice tools; research; and improvement of community health. The Center will work to create a healthy environment for children, adolescents, and families through public education and the promotion of public health policies to eliminate tobacco.”
Meta-analysis on interventions to assist parents
of young children in smoking cessation
According to this recent article in Pediatrics, parents are more likely to succeed in a smoking cessation program when they understand the health benefits for their children. In this study, the authors conducted a meta-analysis of 18 studies that evaluated the effectiveness of smoking cessation or modification programs in parents of young children. They found that 23.1% in the intervention group compared with 18.4% in the control group were successful in quitting smoking. The authors conclude that protecting their children from the harm of 2nd and 3rd hand smoke provide additional motivation for smoking cessation in parents.
Maternal cigarette smoking and the development
of necrotizing enterocolitis
Moms who smoke prenatally increase the risk of their preterm infant developing necrotizing enterocolitis (NEC) according to an article this month in Pediatrics. The authors of this study conducted a paired retrospective review of maternal risk factors in 73 infants who developed NEC and 146 matched controls at their institution. Of the factors evaluated, maternal cigarette smoking was the only factor that was significantly correlated with the development of NEC. The authors conclude that pediatricians should take an active role in counseling pregnant mothers in their practice to quit smoking to potentially decrease this disease in preterm neonates.
Prenatal and passive smoke exposure and incidence of asthma and wheeze: systematic review and meta-analysis
Children who are exposed to prenatal and passive smoke have a higher incidence of wheezing and asthmatic episodes according to this study. The authors reviewed 79 prospective studies and analyzed the results. They found a 30-70% increase in wheezing and a 21-85% increase in asthma in children with smoke exposure. The authors conclude that to decrease the incidence of wheezing and asthma, interventions that target smoke exposure prenatally and postnatally are critical.
Neuropathology of the area postrema in sudden intrauterine and infant death syndromes related to tobacco smoke exposure
Researchers in Italy have identified a section of the brain, the area postrema, they believe may have a role in the epidemiologically observed relationship between smoke exposure and SIDS/SUIDS. On autopsy, the authors found a significantly higher incidence of anatomic and chemical changes in this area of the brain in fetuses and infants who died of unexplained causes versus control s who died of known causes. In addition, these changes were significantly more likely to occur with smoke exposure.
BOOK REVIEW - The Importance of Having a Brain:
Tales from the History of Medicine
Tonse N. K. Raju, MD, FAAP
Navigate through the rich and delightful history of one of man's oldest of creeds—the medical profession (not the other, its less illustrious competitor). Told with a perfect blend of historical accuracy, wit, and humor, these assorted stories from the annals of medicine are informative, illuminating, and entertaining. This is a medical history book in small doses. Found at Outskirts Press Inc., Parker, CO.
AAP/CDC Collaboration: Question and Answer (Q & A)
"Prevention and Control of Influenza:
Considerations for Newborns and Very Young Infants
The American Academy of Pediatrics (AAP) in collaboration with the Centers for Disease Control and Prevention (CDC) has developed a Q & A to address 5 common questions regarding prevention and control of influenza in newborns and very young infants.
Since the American Academy of Pediatrics (AAP) recommended all babies should be placed on
their backs to sleep in 1992, deaths from Sudden Infant Death Syndrome (SIDS) have declined dramatically. But sleep related
deaths from other causes, including suffocation, entrapment and asphyxia, have increased.
Breastfeeding is recommended and is associated with a reduced risk of SIDS.
Evidence suggests that immunization reduces the risk of SIDS by 50%.
In September, the Department of Health and Human Services released new recommendations regarding the management of pregnant women infected with HIV and their newborns in the US. Pediatricians and other health care providers who care for these newborns will want to review these updates developed to decrease perinatal transmission.
Language Functions in Preterm-Born Children:
A Systematic Review and Meta-Analysis
Children who were born prematurely (<37 weeks) are at greater risk for language difficulties at school age according to a recent systematic review and meta-analysis published in Pediatrics this month. The authors from the Netherlands pooled analyzed results from 17 studies which assessed simple and complex language skills in children aged 3 to 12 years. The results show that premature infants are significantly more likely to have lower scores on tests for simple and complex skills. In addition, skills related to complex language continue to decrease as they get older in comparison to their term peers. This study highlights the need for continued developmental monitoring of preterm infants through the school years, particularly in the area of complex language skills.
A workgroup comprised of members from the American Academy of Pediatrics, the American College of Cardiology and the American Heart Association has released their recommendations for a standardized approach for screening newborns for cyanotic congenital heart disease with pulse oximetry. The screening protocol recommends that all newborns in low and intermediate care nurseries have their oxygen saturations determined in the right upper and lower extremities at 24-48 hours of age, or prior to discharge home. If the baby has repeated readings less than 95% in both extremities, a difference of at least 3% in both extremities or any reading less than 90%, then further evaluation is required. Unless another explanation for the infant’s hypoxemia can be determined, the workgroup recommends a diagnostic echocardiogram to evaluate for cyanotic congenital heart disease.
Premature Infants are at High Risk for Development of
Myopia in Early Childhood
Premature infants who underwent treatment for Retinopathy of Prematurity (ROP) should undergo repeated assessments by an ophthalmologist during the first three years of life to assess for the development of myopia. The authors of a recent study found that 70% of infants who required treatment for ROP develop myopia during infancy and the early preschool years. In addition, they found that the proportion that develop high myopia (>5 diopers) continues to increase between ages 6 months and 3 years.
Preterm Birth and Attention-Deficit/Hyperactivity Distorder
Karolina Lindstrom, Frank Lindblad and Anders Hjern
In a population-based cohort of Swedish children, decreasing gestational age was correlated with increasing risk of ADHD. Using national registries, the authors were able to collect genetic, environmental and perinatal risk factors associated with each birth.
The highest risk was noted in infants born between 22-28 weeks gestation age, however, increased risk was also noted for infants born moderately and late preterm. Of the genetic, environmental and perinatal risks analyzed, only maternal education modified the risk of ADHD in the late preterm infant. This study provides additional support for the need for developmental follow up of both preterm and late preterm infants through the school years.
Recent research has pointed to previously unrecognized and important health issues faced by preterm infants. In response, the NICHD National Child and Maternal Health Education Program (NCMHEP) Coordinating Committee has been formed to provide a forum for reviewing, translating, and disseminating new research in the field of maternal and child health through a coalition of the nation's most prominent health care provider associations, federal agencies, nonprofit maternal and child health organizations, and other partners. This group has launched a website and educational materials raise awareness of the implications of late preterm birth and non-medically indicated deliveries prior to 39 weeks of gestation.
The American Heart Association and the International Consensus on Cardiopulmonary Resuscitation recently published new neonatal resuscitation guidelines. Included in the new guidelines are recommendations and updated algorithms with emphasis on CPAP and positive pressure ventilation.
Deletion of meconium from initial assessment
Changes in recommendation for 100% oxygen
Stronger indications of when to intubate
Stronger recommendations of two-thumb chest compressions
Use of pulse oximetry when using oxygen in resuscitation
U.S. Court Rules Again Against
Vaccines that contain a mercury-based preservative called thimerosal cannot cause autism on their own, a special U.S. court ruled, dealing one more blow to parents seeking to blame vaccines for their children's illness.
Standing orders for healthy newborns are valid,
say CMS, Joint Commission
A new letter from the Centers for Medicare & Medicaid Services (CMS) confirms that hospital standing orders for healthy newborns — including the administration of hepatitis vaccine, vitamin K and prophylactic ophthalmic antibiotics — are indeed valid, and that physicians no longer will need to provide round-the-clock approval to initiate such care.
From the Association of Maternal and Child Health Programs, Implementing Health Reform: Key Provisions and Opportunities to Improve Infant Health reviews the key provisions for Title V MCH Programs and how best to get involved.
2010 Guidelines for Prevention of Perinatal
Group B Streptococcal (GBS) Disease
In November 2010, the CDC published revised guildelines for the prevention of GBS infection in neonates, which are supported by ACOG, AAP, ACNM, AAFP, and ASM. The new guidelines have a revised neonatal management algorithm which can be applied to all newborns and is based on the clinical status of the infant, presence of infective risk factors and the adequacy of maternal intrapartum antibiotic prophylaxis (IAP). Adequate IAP is clarified as > or = 4 hours of IV penicillin, ampicillin or cefazolin before delivery. Other agents or durations of antibiotics are considered inadequate coverage, as there is no data to support that they can prevent early onset spesis with GBS in the neonate.
Study Links Preterm Birth to Diet Soda Consumption
Danish researchers examined the diets of almost 60,000 pregnant women and found that the risk of premature births is 38% higher in those who drank at least one serving of diet soda a day compared with those who did not drink any soda. The researchers said the data "warrants further attention."
According to data in the 21st annual KIDS COUNT Data Book, released July 23rd, overall improvements in child well-being that began in the late 1990s stalled in the years just before the current economic downturn. This book profiles the status of children on a national and state-by-state basis and ranks states on 10 measures of well-being. On their web site, you can download the 56-page report or select a specific state's information as well as find out more about the 10 indicators.
Report on the Overall Findings from the 2007 National Survey of Children's Health
The Health Resources and Services Administration's Maternal and Child Health Bureau is pleased to announce that The Health and Well-Being of Children: A Portrait of States and the Nation 2007 is now available online. This chartbook provides both national and state-level data on U.S. children based on the 2007 National Survey of Children's Health.
Among the findings are:
In 2007, 88.5% of children reported receiving a preventive health care visit, up from 77% in 2003. Among children who had no health insurance, however, the rate was far lower: only 72.6% of those children had a preventive health care visit.
More than 15% of U.S. children had no health insurance for all or part of 2007.
Nearly 1/3 of U.S. children, ages 10 to 17, were overweight or obese. Most significantly, the incidence of obesity continued to rise from 14.8% of U.S. children in 2003 to 16.4% by 2007.
About 4 out of 10 children in need of mental health services for emotional development or behavioral problems did not receive them. Among uninsured children, more than half did not.
Over 25% of American children under age 5 were at risk for developmental and behavioral problems or social delays, but fewer than one in five received recommended screening.
More than 4 in 10 children were not receiving care within a "medical home."
Exploring & Evaluating Practices in Neonatal-Perinatal Medicine
New from the Committee on Practice
Making the transition from residency and fellowship training into practice is difficult and challenging, whether the move is to the familiar realm of academia or to a world of private practice, professional corporate, or hospital-employed neonatology. The Perinatal Section's Committee on Practice has developed these materials to assist fellows in their career planning, and interviewing with, and evaluation of, practices.
Pediatricians considering the role of neonatology in their community setting may also find these discussions enlightening as they negotiate a mutually-supportive relationship. Neonatal divisions and practice groups evaluating the scope of their practices and the duties assumed by practice associates will likewise find these materials helpful, especially if expanding their scope of practice responsibilities, enlarging their patient base, or adding/replacing an associate.
AAP Modifies Indications for Use of Palivizumab in High-risk Infants and Young Children
Respiratory syncytial virus (RSV) is the most common cause of bronchiolitis and pneumonia in young infants. Based on additional data regarding the seasonality of RSV disease and the risk factors for disease severity in 32 through 35 weeks gestation preterm infants, AAP guidelines for immunoprophylaxis have been modified to ensure optimal balance of benefit and cost. The updated recommendations are in the 2009 Red Book (published in June 2009).
The updated recommendations and major policy changes include:
Modification of recommendations for initiation and termination of RSV prophylasix based on current CDC descriptions of seasonality in different areas of the United States.
Emphasis on need for no more than a maximum of 5 doses in all geographic areas.
Modification of risk factors for severe disease in infants born between 32 and 35 weeks of gestation.
For infants 32 through 35 weeks of gestation who qualify for prophylaxis based on presence of risk factors, prophylaxis is recommended until 90 days of age (maximum of 3 doses).
For further details, please see the article in AAP News Online that summarizes the recommendations and major changes present in the 2009 Red Book (pages 562-568) and in the AAP Policy Statement soon to be published in Pediatrics.
Guideline on Management of Jaundice in the Newborn at 35 or More Weeks of Gestation
In July 2004, the Subcommittee on Hyperbilirubinemia of the American Academy of Pediatrics (AAP) published its clinical practice guideline on the management of hyperbilirubinemia in the newborn infant at 35 or more weeks of gestation. Experience with its implementation suggests that some areas of the guideline require clarification. In addition, new information is available that affects how we manage the jaundiced newborn. An addendum currently is under development that will address these issues and provide clarification and a modified management strategy. The addendum will be available on the Website as soon as it is complete.
University of Louisville neonatologist, David Adamkin, has dedicated his career to sick babies, particularly to low and very low birthweight babies, their nutritional needs, and strategies to help them grow and thrive. The smaller a baby is, the greater his risk of neurodevelopmental problems.
An expert in infant nutrition, Adamkin has found, through clinical experience and research, that aggressive feeding makes a difference for these babies, especially in the first 2 to 3 weeks after birth. He has outlined his feeding guidelines and strategies in the new book "Nutritional Strategies for the Very Low Birthweight Infant."
Chemical Found in Baby Bottles Might Cause Health Problems
In August, an expert panel reported on the safety of Bisphenol A (BPA), a chemical used to make some plastics such as baby bottles, sport bottles, water jugs and children's dental sealants; it's also found in other plastics. The National Institutes of Health panel ruled that BPA is unlikely to cause prostate cancer, reproductive problems, or birth defects, but it might affect nerve or nervous system development and behavior.
National Association of Neonatal Nurses Issues Statement on Human Milk and Breastfeeding
Mother's milk and breastfeeding are important aspects of optimal care of newborns, especially those who are born preterm or with other serious conditions. The unique nutritional and immunological benefits of human milk make it an integral component of care of infants in the newborn intensive care unit. NANN has issued a statement strongly supporting human milk and breastfeeding.
(09/21/09) A national coalition of health care and information providers for pregnant women and children have an urgent message for pregnant women concerning influenza. The normal changes of pregnancy place pregnant women at increased risk of the harmful effects of flu infection, and as such, they should take increased precautions.