Vincent C. Smith

Prenatal Substance Abuse: Short- and Long-term Effects on the Exposed Fetus

Prenatal substance abuse continues to be a significant problem in this country and poses important health risks for the developing fetus. The primary care pediatrician’s role in addressing prenatal substance exposure includes prevention, identification of exposure, recognition of medical issues for the exposed newborn infant, protection of the infant, and follow-up of the exposed infant. This report will provide information for the most common drugs involved in prenatal exposure: nicotine, alcohol, marijuana, opiates, cocaine, and methamphetamine.

Prematurity: An Overview and Public Health Implications

The high rate of premature births in the United States remains a public health concern. These infants experience substantial morbidity and mortality in the newborn period, which translate into significant medical costs. In early childhood, survivors are characterized by a variety of health problems, including motor delay and/or cerebral palsy, lower IQs, behavior problems, and respiratory illness, especially asthma. Many experience difficulty with school work, lower health-related quality of life, and family stress. Emerging information in adolescence and young adulthood paints a more optimistic picture, with persistence of many problems but with better adaptation and more positive expectations by the young adults. Few opportunities for prevention have been identified; therefore, public health approaches to prematurity include assurance of delivery in a facility capable of managing neonatal complications, quality improvement to minimize interinstitutional variations, early developmental support for such infants, and attention to related family health issues.

Substance Use Screening, Brief Intervention, and Referral to Treatment for Pediatricians

As a component of comprehensive pediatric care, adolescents should receive appropriate guidance regarding substance use during routine clinical care. This statement addresses practitioner challenges posed by the spectrum of pediatric substance use and presents an algorithm-based approach to augment the pediatricians confidence and abilities related to substance use screening, brief intervention, and referral to treatment in the primary care setting. Adolescents with addictions should be managed collaboratively (or comanaged) with child and adolescent mental health or addiction specialists. This statement reviews recommended referral guidelines that are based on established patient-treatment–matching criteria and the risk level for substance abuse.

Fetal Alcohol Spectrum Disorders

Prenatal exposure to alcohol can damage the developing fetus and is the leading preventable cause of birth defects and intellectual and neurodevelopmental disabilities. In 1973, fetal alcohol syndrome was first described as a specific cluster of birth defects resulting from alcohol exposure in utero. Subsequently, research unequivocally revealed that prenatal alcohol exposure causes a broad range of adverse developmental effects. Fetal alcohol spectrum disorder (FASD) is the general term that encompasses the range of adverse effects associated with prenatal alcohol exposure. The diagnostic criteria for fetal alcohol syndrome are specific, and comprehensive efforts are ongoing to establish definitive criteria for diagnosing the other FASDs. A large and growing body of research has led to evidence-based FASD education of professionals and the public, broader prevention initiatives, and recommended treatment approaches based on the following premises: ▪ Alcohol-related birth defects and developmental disabilities are completely preventable when pregnant women abstain from alcohol use. ▪ Neurocognitive and behavioral problems resulting from prenatal alcohol exposure are lifelong. ▪ Early recognition, diagnosis, and therapy for any condition along the FASD continuum can result in improved outcomes. ▪ During pregnancy: ◦no amount of alcohol intake should be considered safe; ◦there is no safe trimester to drink alcohol; ◦all forms of alcohol, such as beer, wine, and liquor, pose similar risk; and ◦binge drinking poses dose-related risk to the developing fetus.

Discharge Timing, Outpatient Follow-up, and Home Care of Late-Preterm and Early-Term Infants

OBJECTIVE: To compare the timing of hospital discharge, time to outpatient follow-up, and home care practices (breastfeeding initiation and continuation, tobacco smoke exposure, supine sleep position) for late-preterm (LPT; 34 0/7–36 6/7 weeks) and early-term (ET; 37 0/7–38/6/7 weeks) infants with term infants. METHODS: We analyzed 2000–2008 data from the Centers for Disease Control and Prevention’s Pregnancy Risk Assessment Monitoring System. χ2 Analyses were used to measure differences in maternal and infant characteristics, hospital discharge, outpatient care, and home care among LPT, ET, and term infants. We calculated adjusted risk ratios for the risk of adverse care outcomes among LPT and ET infants compared with term infants. RESULTS: In the adjusted analysis, LPT infants were less likely to be discharged early compared with term infants, whereas there was no difference for ET infants (odds ratio [OR; 95% confidence interval (CI)]: 0.65 [0.54–0.79]; 0.95 [0.88–1.02]). LPT and ET infants were more likely to have timely outpatient follow-up (1.07 [1.06–1.08]; 1.02 [1.02–1.03]), more likely to experience maternal tobacco smoke exposure (1.09 [1.05–1.14]; 1.08 [1.06–1.11]), less likely to be initially breastfed (0.95 [0.94–0.97]; 0.98 [0.97–0.98]), less likely to be breastfed for ≥10 weeks (0.88 [0.86–0.90]; 0.94 [0.93–0.96]), and less likely to be placed in a supine sleep position (0.95 [0.93–0.97]; 0.97 [0.96–0.98]). CONCLUSIONS: Given that LPT and ET infants bear an increased risk of morbidity and mortality, greater efforts are needed to ensure safe and healthy posthospitalization and home care practices for these vulnerable infants.

Are families prepared for discharge from the NICU

Objective:(1) Quantify and compare the familys and the nurses perception regarding the familys discharge preparedness. (2) Determine which elements contribute to a familys discharge preparedness.Study Design:We studied the families of all the infants discharged from a neonatal intensive care unit after a minimum of a 2-week admission. The families rated their overall discharge preparedness with a 9-point Likert scale on the day of discharge. Independently, the discharging nurse evaluated the familys discharge preparedness. Families were considered discharge ‘prepared’ if they rated themselves and the nurse rated their technical and emotional preparedness as ⩾7 on the Likert scale.Result:We had 867 (58%) family–nurse pairs who completed the survey. Most families (87%) were prepared for discharge as assessed by the concordant questionnaire (Likert scores of ⩾7 by the parent and the nurse). In multivariate analysis, confidence in their childs health and maturity (odds ratios, OR=2.5 95% confidence interval, CI (1.2, 5.3)), their readiness for their infants to come home (OR=2.9 95% CI (1.0, 8.3)), and selecting a pediatrician (OR=4.2 95% CI (1.6, 11.0)) were statistically significant.Conclusion:Assistance with pediatrician selection and home preparation may improve the percentage of families prepared for discharge.

Neonatal intensive care unit discharge preparation, family readiness and infant outcomes: connecting the dots

Neonatal intensive care unit (NICU) discharge readiness is defined as the masterful attainment of technical skills and knowledge, emotional comfort, and confidence with infant care by the primary caregivers at the time of discharge. NICU discharge preparation is the process of facilitating comfort and confidence as well as the acquisition of knowledge and skills to successfully make the transition from the NICU to home. In this paper, we first review the literature about discharge readiness as it relates to the NICU population. Understanding that discharge readiness is achieved, in part, through successful discharge preparation, we then outline an approach to NICU discharge preparation.

Neonatal Intensive Care Unit Discharge Preparedness: Primary Care Implications

Objective. To investigate specific post–neonatal intensive care unit (NICU) discharge outcomes and issues for families. Study design. The authors prospectively surveyed family’s discharge preparedness at the infant’s NICU discharge. In the weeks after the infant was discharged, families were interviewed by telephone for self-reported utilization of health services as well as any infant-associated problems or issues. Results. At discharge, 35 of 287 (12%) families were “unprepared” as defined by a Likert response of less than 7 by either the family member or nursing assessment. Unprepared families were more likely to report that their pediatrician could not access the infant’s NICU hospital discharge summary, problems with the infant’s milk/formula, and an inability to obtain needed feeding supplies. Conclusions. Although most of the families are “prepared” for discharge at the time of discharge, this study highlights several issues that primary care providers accepting care and NICU staff discharging infants/families should be aware.

Late Preterm Infants and Neurodevelopmental Outcomes at Kindergarten

BACKGROUND AND OBJECTIVE: Late preterm infants (LPIs) (gestation 34 weeks and 0 days to 36 weeks and 6 days) compared with full-term infants (FTIs) are at increased risk for mortality and short- and long-term morbidity. The objective of this study was to assess the neurodevelopmental outcomes in a longitudinal cohort study of LPIs from infancy to school age and determine predictive values of earlier developmental testing compared with school-age testing. METHODS: We used general estimating equations to calculate the odds of school readiness in a nationally representative cohort of 4900 full-term and 950 late preterm infants. We generated positive and negative predictive values of the ability of the 24-month Mental Developmental Index (MDI) scores of the Bayley Short Form, Research Edition, to predict Total School Readiness Score (TSRS) at kindergarten age. RESULTS: In multivariable analysis, late preterm infants had higher odds of worse TSRSs (adjusted odds ratio 1.52 [95% confidence interval 1.06–2.18], P = .0215). The positive predictive value of a child having an MDI of <70 at 24 months and a TSRS <5% at kindergarten was 10.4%. The negative predictive value of having an MDI of >70 at 24 months and a TSRS >5% was 96.8%. Most infants improved score ranking over the study interval. CONCLUSIONS: LPIs continue to be delayed at kindergarten compared with FTIs. The predictive validity of having a TSRS in the bottom 5% given a MDI <70 at 24 months was poor. A child who tested within the normal range (>85) at 24 months had an excellent chance of testing in the normal range at kindergarten.

Racial/Ethnic Disparities in Maternal Oral Health Experiences in 10 States, Pregnancy Risk Assessment Monitoring System, 2004-2006

To describe and assess racial/ethnic differences in maternal oral health experiences during their most recent pregnancy. We analyzed 2004–06 data from the CDC Pregnancy Risk Assessment Monitoring System (PRAMS), a population-based surveillance system that collects data on pregnancy and postpartum experiences of mothers who have recently delivered a live infant. Ten states included in the analysis had a ≥70% weighted response rate and three standard questions pertaining to oral health. A total of 35,267 white non-Hispanic (WNH), black non-Hispanic (BNH) and Hispanic women were included in the analysis. We used weighted percentages/standard errors and multivariate logistic regression, controlling for selected descriptive characteristics. Only 41% of all women received oral health counseling during pregnancy. In the multivariate analyses, compared to WNH women, BNH women were more likely to have a dental problem (OR 1.19, CI 1.05–1.35). BNH and Hispanic women were less likely to obtain dental care during pregnancy (OR 0.87, CI 0.77–0.98; OR 0.77, CI 0.64–0.91 respectively) and were less likely to ever have had a teeth cleaning (OR 0.64, CI 0.52–0.78; 0.36, OR CI 0.29–0.46 respectively) when compared to WNH women. In addition, BNH and Hispanic women were less likely to have a teeth cleaning before (OR 0.82, CI 0.72–0.94; OR 0.60, CI 0.50–0.72 respectively) as well as during pregnancy (OR 0.68, CI 0.59–0.78; OR 0.74, CI 0.61–0.90) when compared to WNH women. Significant racial/ethnic disparities in maternal oral health experiences exist. Most women are not offered dental counseling during pregnancy.