Scott D. Krugman

Update on child abuse prevention

Purpose of review Child abuse remains a significant problem in the United States with 2.9 million reports and 825 000 indicated cases in 2005. This report will highlight recent efforts toward child abuse prevention, focusing on home visiting programs, abusive head trauma primary prevention, parent training programs, sexual abuse prevention, and the effectiveness of laws banning corporal punishment. Recent findings Most home visitation programs have demonstrated a lack of effectiveness in recent randomized trials. One exception is the Nurse Family Partnership, which remains the most effective and longest enduring intervention for high-risk families. Child sexual abuse prevention programs and parent training programs need further evaluation with more rigorous methodology and outcome measures. Providing universal parent education about coping with crying infants appears to be effective in lowering the incidence of abusive head trauma. Although advocated for, further study will determine the effectiveness of laws banning corporal punishment or mandating abusive head trauma education to parents of newborns. Summary Pediatricians play an important role in the prevention of child maltreatment. Their knowledge of the effectiveness of different programs can help guide parents toward appropriate services.

Improving Infant Sleep Safety Through a Comprehensive Hospital-Based Program

We evaluated a comprehensive hospital-based infant safe sleep education program on parental education and safe sleep behaviors in the home using a cross-sectional survey of new parents at hospital discharge (HD) and 4-month follow-up (F/U). Knowledge and practices of infant safe sleep were compared to the National Infant Sleep Position Study benchmark. There were 1092 HD and 490 F/U surveys. Supine sleep knowledge was 99.8% at HD; 94.8% of families planned to always use this position. At F/U, 97.3% retained supine knowledge, and 84.9% maintained this position exclusively (P < .01). Knowledge of crib as safest surface was 99.8% at HD and 99.5% F/U. Use in the parents’ room fell to 91.9% (HD) and 68.2% (F/U). Compared to the National Infant Sleep Position Study, the F/U group was more likely to use supine positioning and a bassinette or crib. Reinforcing the infant sleep safety message through intensive hospital-based education improves parental compliance with sudden infant death syndrome risk reduction guidelines.

Newborn Adiposity by Body Mass Index Predicts Childhood Overweight

Objective: To evaluate the association between adiposity at birth and in infancy with overweight at age 5 years. This study hypothesizes that adiposity at birth as approximated by body mass index (BMI) predicts childhood fatness. Methods: Anthropomorphic data from birth to 5 years were used to calculate BMI percentiles. Multiple logistic regression assessed the association between BMI percentile ≥85% at 2 weeks and BMI percentile ≥85% at 6, 12, 36, and 60 months. Results: Elevated BMI at age 2 weeks ≥85th percentile was associated with significant increases in risk of overweight at 6, 12, 36, and 60 months of age. Infants with a BMI at age 2 weeks ≥85th percentile had an adjusted odds ratio of 3.42 (95% confidence interval [CI] = 1.79, 6.50) and an adjusted risk ratio of 2.12 (95% CI = 1.71, 2.61) of being overweight at 60 months of age. Conclusions: Adiposity at birth as approximated by BMI is a significant predictor of overweight at 5 years.

Variability of the Institutional Review Board Process Within a National Research Network

Objective. To determine the variability of the institutional review board (IRB) process for a minimal risk multicenter study. Methods. Participants included 24 Continuity Research Network (CORNET) sites of the Academic Pediatric Association that participated in a cross-sectional study. Each site obtained individual institutional IRB approval. An anonymous questionnaire went to site investigators about the IRB process at their institution. Results Twenty-two of 24 sites (92%) responded. Preparation time ranged from 1 to 20 hours, mean of 7.1 hours. Individuals submitting ≤3 IRB applications/year required more time for completion than those submitting >3/year (P < .05). Thirteen of 22 (59%) study sites received approval with “exempt” status, and 6 (27%) approved as “expedited” studies. Conclusions. IRB experiences were highly variable across study sites. These findings indicate that multicenter research projects should anticipate barriers to timely study implementation. Improved IRB standardization or centralization for multicenter clinical studies would facilitate this type of practice-based clinical research.

Parental Advice: Given Perhaps, but Not Received

* Abbreviation: SIDS — : sudden infant death syndrome We all think we give good advice, and we think we do it well. We’ve mastered the anticipatory guidance section of the well-child or nursery visit. We have our formula: we cover the salient topics, throw in some personal experience, and assume our parental advice on child rearing has been received and understood. Unfortunately, as shown by Eisenberg et al1 in this issue of Pediatrics , we appear to be failing miserably. Mothers received correct advice from doctors about sleep position only 54% of the time and about sleep location only 19% of the time. Even if doctors gave correct advice more frequently than reported, information cannot protect infants if mothers do not hear, believe, and act on it. Why does this matter? Is our advice really that important? In the case of sleep position and location, it can be a matter of life or death. Every day in the United States, healthy … Address correspondence to Scott D. Krugman, MD, MS, Chairman, Department of Pediatrics, MedStar Franklin Square Medical Center, 9000 Franklin Square Dr, Baltimore, MD 21237. E-mail: scott.krugman{at}medstar.net

Parent-Infant Bedsharing Is Not Recommended

tional Academies, nonemergency medical transportation services were found to be cost-effective especially for patients with chronic conditions.6 While health reform can be predicted to improve access to child health care for millions of currently uninsured children, geospatial barriers will persist. Only by resolving these barriers with new transportation resources will children reliably benefit from health reform.

Still Lost in Translation

?Habla espanol? Bạn co noi tiếng việt? If you don’t, then make sure you bring the interpreter into that patient’s room. Not only is it likely your hospital’s policy and a Joint Commission requirement,1 but it’s also good medical care. The pediatric literature over the past few decades has highlighted the importance of quality interpretation for Limited English Proficient (LEP) patients to provide quality care. For a decade, Glen Flores has pointed out the health risks associated with not speaking English.2 Poor outcomes such as disparities in care, adverse events, readmissions and medical errors all can complicate a hospitalization of a patient with LEP. In this month’s Hospital Pediatrics, researchers from Seattle Children’s add to the growing literature of challenges faced …

Breastfeeding and IQ.

To the Editor. We are writing to express concern about the article “Breastfeeding and Later Cognitive and Academic Outcomes” recently published in Pediatrics electronic pages. 1 This article has led to a fervent and dangerous response from the lay and medical press, which is based on a biased presentation and incorrect interpretation of the results. Not only did the study fail to clarify the relationship between breastfeeding and IQ, but it also made a leap of reason by identifying specific components of breast milk that may be related to increases in IQ. Because of the nature of the study design (ie, observational, nonblinded, nonrandomized), it is impossible to prove causality. The determinants of breastfeeding and IQ are multiple, involving socioeconomic, cultural, religious beliefs and so on, a list of confounding variables that is lengthy and probably impossible to complete. In Table 2 of this paper the authors demonstrate the significance of each confounding variable. It is rare that a list of evaluated cofounders in such a paper all turn out to be significant. This result begs the question, “Could there have been more or other as yet unidentified factors?” There could have been; and given the fact that almost every variable had an impact on the intelligence and outcome scores as demonstrated in Table 3, if more had been considered, the effect of breastfeeding on IQ may have been smaller. The most concerning conclusion …

A Hospital-Based Initiative to Reduce Postdischarge Sudden Unexpected Infant Deaths

BACKGROUND AND OBJECTIVES Sudden unexpected infant deaths (SUID) most often occur because infants are placed in unsafe sleep environments. Although authors of previous literature have demonstrated that parents who receive comprehensive safe sleep education increase knowledge and intention to place children in safe sleep environments, no studies have demonstrated improved outcomes. We describe the development of a hospital-based newborn SUID risk reduction quality improvement project and its effectiveness in reducing subsequent SUIDs in a community using linked outcome data from local Child Fatality Review Teams. METHODS Qualitative and quantitative evaluation of a long-term iterative performance improvement intervention for a nursery-based comprehensive safe sleep program in a community teaching hospital. Key themes and exemplary comments were noted. The rate of infant deaths per 1000 births was the primary quantitative outcome. The rate is calculated quarterly and monitored with control charts by using Child Fatality Review data about infant sleep deaths. RESULTS The average death rate fell from 1.08 infants per 1000 births preintervention to 0.48 infants per 1000 births after complete intervention, and the average number of deaths between deliveries increased from 1 in every 584 deliveries (upper control limit: 3371) to 1 in every 1420 deliveries (upper control limit: 8198). Qualitative observation of nursery providers revealed 3 themes, including routine inclusion of sleep safety information, dissemination of safety information by all staff, and personal commitment to success. CONCLUSIONS A comprehensive sleep safety culture change can be effectively integrated into a nursery setting over time by using feedback from Child Fatality Review and performance improvement methodology. Repeated messaging and education by the entire nursery staff has the potential to play a role in reducing sleep-related deaths in infants born at their hospital.

Fatal Child Abuse

According to official statistics, more than 1,500 children each year die from child abuse and neglect. However, due to inadequate death investigations and inconsistent child fatality review processes, the actual number is likely higher. Infants under 1 year old account for 47 % of child abuse fatalities, most often as a result of abusive head trauma (AHT). Other causes of fatal child abuse include suffocation, Munchausen Syndrome by Proxy, fatal poisoning, and neglect. While not often discussed, child neglect plays a role in two thirds of all child maltreatment fatalities and can occur as a result of failure to provide medical treatment, starvation, drowning, fires, and heat induced from automobiles. No single effective strategy exists to prevent child abuse fatalities. Global home visiting strategies as well as AHT counseling efforts in nurseries and communities are often employed but clear evidence to support a single intervention is lacking.