Joel L. Bass

The Effect of Chronic or Intermittent Hypoxia on Cognition in Childhood: A Review of the Evidence

Objective. A review of the evidence concerning the effect of chronic or intermittent hypoxia on cognition in childhood was performed by using both a systematic review of the literature and critical appraisal criteria of causality. Because of the significant impact of behavioral disorders such as attention-deficit/hyperactivity disorder on certain cognitive functions as well as academic achievement, the review also included articles that addressed behavioral outcomes. Methods. Both direct and indirect evidence were collected. A structured Medline search was conducted from the years 1966-2000 by using the OVID interface. Both English- and non–English-language citations were included. Significant articles identified by the reviewers up to 2003 were also included. To be included as direct evidence, an article needed to be an original report in a peer-reviewed journal with data on cognitive, behavioral, or academic outcomes in children up to 14 years old, with clinical conditions likely to be associated with exposure to chronic or intermittent hypoxia. Indirect evidence from other reviews and publications in closely related fields, including experimental studies in adults, was used to help formulate conclusions. Two reviewers screened abstracts and titles. Each article included as direct evidence received a structured evaluation by 2 reviewers. Adjudication of differences was performed by a group of 2 reviewers and a research consultant. After this review, tables of evidence were constructed that were used as the basis for group discussion and consensus development. Indirect evidence assigned by topic to specific reviewers was also presented as part of this process. A formal procedure was used to rank the studies by design strength. The critical appraisal criteria for causation described in Evidence Based Pediatrics and Child Health (Moyer V, Elliott E, Davis R, et al, eds. London, United Kingdom: BMJ Books; 2000:46–55) were used to develop consensus on causality. Results. A total of 788 literature citations were screened. For the final analysis, 55 articles met the criteria for inclusion in the direct evidence. Of these, 43 (78.2%) reported an adverse effect. Of the 37 controlled studies, 31 (83.8%) reported an adverse effect. Adverse effects were noted at every level of arterial oxygen saturation and for exposure at every age level except for premature newborns. The studies were classified into 5 clinical categories: congenital heart disease (CHD), sleep-disordered breathing (SDB), asthma, chronic ventilatory impairment, and respiratory instability in infants. Two of these categories, CHD and SDB, which accounted for 42 (76.4%) of the included articles, fulfilled the Evidence Based Pediatrics and Child Health criteria for causation. The indirect evidence included 8 reviews, 1 meta-analysis, and 10 original reports covering the fields of adult anoxia, animal research, SDB in adults, natural and experimental high-altitude studies, perinatal hypoxic-ischemic encephalopathy, anemia, and carbon-monoxide poisoning. The studies of high-altitude and carbon-monoxide poisoning provided evidence for causality. Conclusions. Adverse impacts of chronic or intermittent hypoxia on development, behavior, and academic achievement have been reported in many well-designed and controlled studies in children with CHD and SDB as well as in a variety of experimental studies in adults. This should be taken into account in any situation that may expose children to hypoxia. Because adverse effects have been noted at even mild levels of oxygen desaturation, future research should include precisely defined data on exposure to all levels of desaturation.

Comparison of Respiratory Physiologic Features When Infants Are Placed in Car Safety Seats or Car Beds

OBJECTIVE. The objective of this study was to compare the respiratory physiologic features of healthy term infants placed in either a car bed or a car safety seat. METHODS. Within the first 1 week of life, 67 healthy term infants were recruited and assigned randomly to be monitored in either a car bed (33 infants) or a car safety seat (34 infants). Physiologic data, including oxygen saturation and frequency and type of apnea, were obtained and analyzed in a blinded manner. RESULTS. The groups spent similar amounts of time in the devices (car bed: 71.6 minutes; car seat: 74.2 minutes). The mean oxygen saturation values were not different between the groups (car bed: 97.1%; car seat: 97.3%). The percentages of time with oxygen saturation of <95% were also similar for the 2 groups (car bed: 18.3%; car seat: 11.8%). In both groups, a number of infants spent high percentages of study time with oxygen saturation of <95%. The 6 infants with the most time at this level were all in the car safety seat group (54%–63% of study time). Values for the 6 infants in the car bed group with the most time at this level were lower (20%–42%). This difference in the duration of oxygen saturation of <95% was not statistically significant. The mean end-tidal carbon dioxide levels and the numbers of episodes of apnea were similar for the 2 groups. CONCLUSIONS. The respiratory physiologic features of infants in the 2 car safety devices were observed to be similar. Of note, substantial periods of time with oxygen saturation of <95% were surprisingly common in both groups.

The Infant Car Seat Challenge: Determining and Managing an “Abnormal” Result

In this issue of Pediatrics , DeGrazia et al1 provide important information on whether weight and age are predictors for passing the Infant Car Seat Challenge (ICSC). Because they found they were not, the authors recommend repeat testing if the test is initially failed. They also point out the need for standardization of the ICSC. This is an issue of great importance, because meaningful clinical decisions and research on testing cannot go forward without standardization. The most recent American Academy of Pediatrics (AAP) clinical report on the subject2 provided some advice regarding the duration of the test (90–120 minutes or duration of travel if longer). Identification of oxygen desaturation, episodes of apnea, and bradycardia were mentioned as the outcomes to denote failure. Although there are standard and widely accepted definitions of apnea (20 seconds) and bradycardia (<80 beats per minute [bpm]), the lower-limit-of-normal pulse oximeter saturation (Spo2) has not been universally recognized. Authors of the first … Address correspondence to Joel L. Bass, MD, Department of Pediatrics, Newton-Wellesley Hospital, 2014 Washington St, Newton, MA 02462. E-mail: jbass{at}partners.org

Newborn car bed testing in a community hospital: implementing the American Academy of Pediatrics recommendations.

OBJECTIVE This study was designed to describe our experience in implementing the American Academy of Pediatrics (AAP) recommendation to test infants in a car bed if they fail a car seat challenge test. STUDY DESIGN Car seat challenge testing was performed for 90 minutes or the anticipated duration of the trip home, whichever was longer. Based on the pulse oximetry saturation values (90-92% or < 90%) two categories of test failure were used. Infants who failed in the car seat were tested in the car bed. Testing took place in both the normal newborn nursery (NBN) and special care nursery (SCN). NBN babies who failed in the car bed were transferred to our SCN for additional assessment and management. RESULTS A total of 197 infants were tested in car seats out of which 177 (89.8%) passed the test. Of the 20 infants who failed, 16 passed the car bed challenge test on the first attempt and were discharged in those devices. All infants who failed the car bed challenge were NBN patients. CONCLUSIONS Using 93% as the acceptable lower limit of oxygenation we successfully implemented the AAP recommendations for car bed challenge testing in our nursery.

Trends in the Incidence of Sudden Unexpected Infant Death in the Newborn: 1995-2014

Objective To evaluate the epidemiology of sudden unexpected infant death (SUID) over a 20‐year period in the US, to assess the potential frequency of sudden unexpected postnatal collapse in the early days of life, and to determine if SUID rates in the neonatal period (0‐27 days) have changed in parallel with rates in the postneonatal periods, including the percentages attributed to codes that include accidental suffocation. Study design Data from the US Centers for Disease Control and Prevention Linked Birth/Infant Death Records for 1995‐2014 were analyzed for the first hour, day, week, and month of life. A comparison of neonatal and postneonatal data related to SUID, including accidental suffocation, was carried out. Results Death records for 1995‐2014 indicate that, although SUID rates in the postneonatal period have declined subsequent to the 1992 American Academy of Pediatrics sleep position policy change, newborn SUIDs have failed to decrease, and the percentage of SUIDs attributed to unsafe sleep conditions has increased significantly in both periods; 29.2% of the neonatal cases occurred within the first 6 days of life. Conclusions The frequency of SUIDs during the neonatal period warrants ongoing attention to all circumstances contributing to this category of deaths. The development of a standardized definition of sudden unexpected postnatal collapse and a national registry of these events is recommended. Ongoing research on the effects of early neonatal practices on postneonatal SUID should also be encouraged.

Re: Best Fed Beginnings: Long-term Breastfeeding Outcomes and Safety Concerns

The July 2017 report on BFB by Feldman-Winter et al is based on the premise that BF designation and breastfeeding exclusivity on the day of discharge from the birth hospital are appropriate criteria to ascertain the success of hospital support for breastfeeding. Neither breastfeeding rates after discharge nor adverse outcomes are included in the report. The World Health Organization evidence for the Ten Steps, the basis of BF designation, does not provide evidence that all of the 79 specific BF requirements (including 48 arbitrary numerical targets) are necessary or that strict breastfeeding exclusivity in the first days of life is an absolute precondition … E-mail: jbass{at}partners.org

Car Seat–Associated Hypoxia: Low Birth Weight Term Newborns, Another Group at Risk

* Abbreviation: AAP — : American Academy of Pediatrics Oxygen desaturation of premature newborns in car seats was first reported by Willet1 in 1986. In response to that study, the American Academy of Pediatrics (AAP) recommended in 1991 that infants <37 weeks’ gestation be monitored for oxygen desaturation and bradycardia in their car seat before discharge.2 The most recent AAP statement on this issue identifies other infants who are ≥37 weeks and who may be at risk for this problem as potential candidates for car seat testing.3 Although term low birth weight newborns are not specifically mentioned in that statement, they would be logical candidates for inclusion given the presumed mechanism of desaturation in these devices (physical-mechanical mismatch) as well as case reports of desaturation in some low birth weight newborns.4 The current report by Davis5 provides the results of the first large-scale study of car seat testing in term low birth weight newborns. Unfortunately, although the AAP advice on the need to test certain high-risk infants is quite clear, the current statement does not provide exact thresholds for … Address correspondence to Joel L. Bass MD, Department of Pediatrics, Newton-Wellesley Hospital, 2014 Washington St, Newton, MA 02462. E-mail: jbass{at}partners.org

The educational value of a single injury prevention counseling encounter.

* Abbreviations: TIPP = : The Injury Prevention Program • AAP = : American Academy of Pediatrics • PAG = : pictorial anticipatory guidance In this months Pediatrics electronic pages , Powell et al1 compare the efficacy of verbal versus pictorial materials used to implement a single injury prevention teaching episode directed to a group of clinic parents. The patient population in the study was drawn from low-income urban families. Based on other studies, the parents were presumed to have less than 9th-grade reading levels and were therefore possibly less likely to benefit from The Injury Prevention Program (TIPP) sheets of the American Academy of Pediatrics (AAP) as opposed to pictorial anticipatory guidance (PAG) sheets that the authors designed. The authors do not reference their method of determining the reading level of the TIPP materials (stated to be 9th grade), but the AAP-assessed grade level is 6.3 using … Address correspondence to Joel L. Bass, MD, Director of Ambulatory and Community Pediatrics, MetroWest Medical Center, 115 Lincoln St, Framingham, MA 01702-9167.