Michael Regalado

Cardiac and respiratory patterns during sleep in cocaine-exposed neonates

Four-hour recordings of heart rate and respiration during spontaneous sleep and wakefulness were obtained from 17 cocaine-exposed and 14 control infants at 2 weeks of age. The median values for heart and respiratory rate and variability were determined for each 1-min epoch of quiet and active sleep. Overall mean rates and variabilities were determined for each state. The cocaine-exposed infants showed significantly greater sleep state effects on heart rate relative to the control infants. Recency of cocaine exposure was not a factor in the differences; even those cocaine-exposed infants who tested negative for the drug perinatally differed significantly from those who had never been exposed. Heart rate variability was increased in cocaine-exposed infants relative to controls in both sleep states. Respiratory rate and variability were not significantly different in the cocaine-exposed and control infants. These results suggest differences in cardiovascular control in infants of cocaine-abusing mothers compared to infants without cocaine exposure. The mechanism responsible for these differences is unclear and may reflect cocaine-induced changes in the autonomic physiology of developing infants or some indirect effect of maternal cocaine use.

Sleep disorganization in cocaine-exposed neonates☆

Abstract The purpose of the study was to examine the effect of prenatal cocaine exposure on infant sleep and wakefulness. Four-hour recordings of sleep and wakefulness were obtained from 17 cocaine-exposed neonates and 14 control infants at 2 weeks of age. Each 1-min epoch was classified as quiet sleep, active sleep, indeterminate sleep, or waking based on eye and body movements and respiratory variability. Analyses of variance were performed on durations of total sleep versus wakefulness, and quiet sleep, active sleep, and indeterminate sleep. The cocaine-exposed infants showed proportions of sleep and wake time similar to those of the control infants. Sleep time was, however, distributed differently among the various sleep states in the cocaine-exposed infants. Infants with prenatal cocaine exposure showed significantly more indeterminate sleep and significantly less active sleep than the control infants, even when confounding variables were controlled statistically. Regression analyses indicated that infrequent cocaine use paradoxically increased indeterminate sleep time to a greater extent than frequent use, possibly due to differences in patterns of cocaine use of recency of exposure. These results suggest that active sleep is less organized at 2 weeks of age in infants of cocaine-abusing mothers than in infants without cocaine exposure.

Preliminary Validation of a Parent-Child Relational Framework for Teaching Developmental Assessment to Pediatric Residents

OBJECTIVE A parent-child relational framework was used as a method to train pediatric residents in basic knowledge and observation skills for the assessment of child development. Components of the training framework and its preliminary validation as an alternative to milestone-based approaches are described. METHODS Pediatric residents were trained during a 4-week clinical rotation to use a semistructured interview and observe parent-child behavior during health visits using clinical criteria for historical information and observed behavior that reflect developmental change in the parent-child relationship. Clinical impressions of concern versus no concern for developmental delay were derived from parent-child relational criteria and the physical examination. A chart review yielded 330 preterm infants evaluated using this methodology at 4 and 15 months corrected age who also had standardized developmental testing at 6 and 18 months corrected age. Sensitivities and specificities were computed to examine the validity of the clinical assessment compared with standardized testing. A subset of residents who completed 50 or more assessments during the rotation was timed at the end of 4 weeks. RESULTS Parent-child behavioral markers elicited from the history and/or observed during the health visit correlated highly with standardized developmental assessment. Sensitivities and specificities were 0.72/0.98 and 0.87/0.96 at 4 to 6 and 15 to 18 months, respectively. Residents completed their assessments <1 minute on average if they had completed at least 50 supervised assessments. CONCLUSIONS A parent-child relational framework is a potentially efficient and effective approach to training residents in the clinical knowledge and skills of child development assessment.

Comment on “Collaborative Training Efforts with Pediatric Providers in Addressing Mental Health Problems in Primary Care”

To the Editor: Incorporating behavioral and mental health into primary care pediatrics has a long history of hope and frustration [1]. As mental health problems in children increase, collaboration between pediatrics and child psychiatry remains a key strategy in promoting optimal mental health. In the article entitled “Collaborative Training Efforts with Pediatric Providers in Addressing Mental Health Problems in Primary Care,” Biel and colleagues present an approach to train pediatricians to deliver mental health interventions in a variety of settings and circumstances [2]. This work shows much promise, but raised two concerns in my mind and two possible approaches to these concerns. The first concern is that the prior educational experience of the pediatric providers in the study was likely to be very limited. Inadequate preparation of primary care pediatricians to deliver developmental, behavioral, or mental health care is a longstanding issue [1]. As the program director at the Los Angeles County-USC Medical Center (LAC/USC) responsible for teaching developmental behavioral pediatrics to residents, I often despair at how little time there is to learn and master this complex arena. With just 1 month of focused training during residency, pediatricians are challenged to develop the knowledge and skills needed to provide a solid foundation for lifelong learning in mental health. My second concern is that interventions like those reported may have short-lived positive results. The interventions of monthly lectures and brief coaching sessions spanning 6–15 months appear to provide a total of 15–30 h of teacher-learner contact at best. There may be a need for periodic reinforcement of learning over time to sustain these kinds of interventions. In part, this is a consequence of the first concern—a weak foundation for learning about mental health. For adult learners, time is a pivotal issue—how to manage and leverage it. Teachers must clearly define the levels of competence one hopes to achieve. Although learning was documented by testing and by noting change in the delivery of screening tests, the level of competence indicated by such documentation is very basic, i.e., remembering information and applying it in a straightforward manner. Moving to higher levels of analysis and evaluation of clinical information is a quantum leap, and in my experience, unlikely to come from interventions like those from this study. The challenges of limited prior knowledge and limited time for teaching work against achieving this level of competence. We want to avoid simply arming pediatricians with screening tests they can administer without providing the quality training experience to build higher levels of competence, the kind of expertise our children and our patients deserve. Biel and colleagues acknowledge the importance of applying principles of adult learning in general terms. Here, I would make two suggestions as a starting point and both pertain to managing and leveraging time. The first suggestion is to begin the collaboration between pediatrics and psychiatry during undergraduate medical education to provide a stronger knowledge base before the clinical years. The second suggestion is to collaborate on the development of an organizational framework to facilitate and expedite the integration of facts and basic skills into meaningful patterns [3]. The leap from simple recall and understanding of information to analysis and evaluation requires the learner to make connections and see relationships between the elements of one’s knowledge and skill * Michael Regalado mregalad@usc.edu