Wednesday, July 1, 2015

Umbilical Cord Milking or Delayed Cord Clamping in Preterm Infants: Which Results in Better Systemic Blood Flow in Newborns?

By: Lewis First, MD, MS; Editor-in-Chief  

          When it comes to improving systemic blood flow in preterm infants, recent recommendations (doi: 10.1542/peds.2013-0191) point to delayed cord clamping as a preferred method of placental transfusion.  Yet other studies suggest that if a preterm infant is delivered by caesarean section rather than vaginal delivery, the amount of blood transfused via delayed cord clamping is less than desired, prompting a resurgence of interest in umbilical cord milking.   
      Anup et al. (doi:10.1542/peds.2015-0368) report this week on a two-center trial to see if preterm infants randomized to get one technique or the other show better systemic blood flow with one of these two methods used for both vaginal and caesarean section deliveries.   While no differences were noted regardless of method used for vaginal deliveries, umbilical cord milking appears to be statistically better for improving systemic blood flow in the setting of a caesarean section. So is this study enough to change current recommendations for delayed cord clamping?   
      You will want to also read the commentary by Drs. Tarnow-Mordi and Soll (doi: 10.1542/peds.2015-1545) that accompanies this study to determine whether this study resolves the best method for placental transfusion or not.  Which method do you prefer and why?  Will this study convince your local obstetrician to milk the cord rather than delay in clamping it?   
     Share with us your thoughts and practices with a response to this blog, an e-letter or a posting on our Facebook or Twitter sites.

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Monday, June 29, 2015

National Guidelines for Pediatric Illness Management: They May Exist But Do We Ever Read Them, Let Alone Use Them?

By: Lewis First, MD, MS; Editor-in-Chief  

COD Newsroom
          In almost every issue of Pediatrics, we seem to be publishing a set of guidelines for diagnosing, treating, or preventing one pediatric illness or another—all of them as evidence-based as possible in the recommendations they make. Yet despite their import, creation or endorsement by a Section or Committee of the American Academy of Pediatrics (AAP), and despite the publicity they may get in AAP’s Pediatric News and often by the mass media itself, awareness of these guidelines remains less than optimal.  This week we share two studies reinforcing the benefits of using the guidelines as well as the variability and increased cost of care when such guidelines are not used.  The first of these studies by Williams et al. (doi: 10.1542/peds.2014-3047) focuses on 2011 national guidelines for narrow-spectrum antibiotic use in children hospitalized with community acquired pneumonia (CAP) at three children’s hospitals.  To no surprise, when a hospital aggressively promoted and targeted the evidence-based guidelines throughout the institution, the use of penicillin/ampicillin increased significantly and the use of a third generation cephalosporin declined.
Similarly a second study by Mahant et al. (doi: 10.1542/peds.2015-0127) looked at the 2011 guidelines for tonsillectomy perioperative care and then using a retrospective cohort of children in a national database, analyzed perioperative care processes and outcomes pre and post-publication of these guidelines (e.g. use of perioperative dexamethasone, non-use of antibiotics).  While the results suggest more dexamethasone use post guidelines and lower antibiotic usage, the changes are only a few percentage points despite their significance and there was no change in overall outcomes and complications except some increased revisits due to pain issues.  Both studies suggest guidelines will work to improve quality and reduce cost but only if you use them.   
Are you using guidelines to share your clinical management?  If so, which ones?  If not, why not?  Are you guidelined out? Does your EHR system trigger a guideline when you enter a diagnostic code to help direct your management?  We are eager to hear how important clinical guidelines are to you so hopefully these two articles and blog will guide you to a response either below this blog, with an e-letter on with a posting on our Facebook or Twitter websites.

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Friday, June 26, 2015

Yet Another Reason (and a New One to Us) As to Why Exclusive Breastfeeding for the First 6 Months of Life Is Recommended

          We certainly don’t have to reiterate what the AAP recommends on the basis of strong evidence gathered in the peer-reviewed literature to date—i.e. exclusive breastfeeding for the first six months of life carries more benefits than we would ever have time to list or mention in this blog!  Yet Peres et al. (doi: 10.1542/peds.2014-3276) this month add to that list of benefits by hypothesizing that breastfeeding has a protective effect in regard to primary dental malocclusions.   
     The investigators followed a birth cohort of more than 1300 infants and monitored them for their feeding preferences at birth, 3, 12, and 24 months of age and then examined them for malocclusions such as open bite, cross bite, and other types and variants of this problem while controlling for a variety of potential confounders in their analysis.  
       The results are mouth-opening and easy to bite into and include a 72% reduced rate of moderate and severe malocclusion if an infant had been exclusively breastfed for at least 6 months. If you are looking for that one additional reason to breastfeed, this study may have just the jaw-dropping results you were looking for to share with families who are less eager to breastfeed.

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Wednesday, June 24, 2015

Emergency Department Visits for Teen Self-Inflicted Injuries

By: Lewis First, MD, MS; Editor-in-Chief  
Dana Beveridge

          One of the most concerning situations we face is when one of our teen patients tries to hurt himself or herself in a serious manner, resulting in serious self-injury and sometimes even death.   
     To get a better sense of just how prevalent self-inflicted injuries in teens can be, Cutler et al. (doi: 10.1542/peds.2014-3573) share the results of their analysis of more than 286,000 teens in the National Trauma Data Bank from 2009-2012 and identified more than 3600 teens with a self-inflicted injury with numbers increasing upward by year. What kinds of self-inflicted injuries were most common?   
     Interestingly enough, for males, it was firearm injuries and for women, cuttings and piercings.  Sadly those teens who did experience an episode of self-injury also had increased odds of subsequent death when compared to teens with other non-self-inflicted traumatic injuries.  So what can we do about this? 
      If we knew, we would be doing it—although if you aren’t assessing adolescents for access to firearms or evaluating their mental health and wellbeing, you may want to do so after reading this troubling study.  Are there things you feel are working to reduce the risk of self-inflicted injury in your teen patients?   
     Do you discuss this topic with your adolescent patients?  Share your thoughts with us by responding to this blog, sending us an e-letter, or posting your comments on our Facebook or Twitter sites.

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Monday, June 22, 2015

Lend Me Your Ears: Binaural Hearing In Developing Children

By: Joann Schulte  DO, MPH; Editorial Board Member 

      Listen up, if you only have one functioning ear you can’t localize sounds like an ambulance wailing behind you or follow the conversation in noisy restaurants.
      For children, it’s harder because the sounds they have to hear and understand are in an environment where sounds are always booming, fading and coming from different directions. That’s the reality of a complex learning environment that includes playgrounds, busy school hallways and crowded classrooms.  Children have a more dynamic environment because there are more motions and changes in people’s locations.
      Gordon et al (doi: 10.1542/peds.2014-3520) explore the issues of asymmetric hearing in a state of the art review published in Pediatrics this month. You already know that a child who doesn’t hear stops babbling and doesn't develop language unless appropriate early intervention is required.  That’s the whole point of newborn hearing screening programs that now are mandated in 43 states and the District of Columbia.  Children whose hearing loss is recognized by six months of age and enrolled in a treatment program are more likely to experience emotional and social development that are in synch with their physical development.
Gordon et al. explore what can be done to help children who don’t have binaural hearing.   
      They explore devices, including cochlear implants and hearing aids, which can be used to help children.  Such efforts are important because a recent cohort study indicated that children with unilateral hearing loss had mean lower vocabulary and IQ scores compared to their counter parts who could hear with both ears.
Clearly it is not just a matter of listening up.  It’s a matter of doing what is state of the art to create  two good ears even if only one is initially functioning well.

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