Pediatricians' views of postpartum depression: a self-administered survey.

OBJECTIVE: To assess pediatricians' knowledge and views about postpartum depression (PPD). METHOD: Self-administered survey of a nationwide random sample of general pediatricians. RESULTS: Of 1200 eligible pediatricians sampled, 389 responded (32%). Half of pediatricians (49%) reported little or no education about PPD. Many respondents (51%) underestimated the overall incidence of PPD. Most pediatricians (80%) estimated the incidence in their practice as less than the published incidence. Few pediatricians felt confident they would recognize PPD (31%). Pediatricians were rarely familiar with available screening tools (7%). Many pediatricians (51%) felt screening was feasible in their practices. In logistic regression analysis, intent to begin screening was independently associated with <6 years in practice, positive view of feasibility and greater awareness of PPD. CONCLUSIONS: Pediatricians sampled have limited awareness of PPD and are unfamiliar with screening tools. Efforts to involve pediatricians in screening should address these knowledge barriers.

A comparison of the safety of cupfeedings and bottlefeedings in premature infants whose mothers intend to breastfeed.

OBJECTIVE: To compare the safety of cupfeeding, an alternative feeding method, to bottlefeeding, the current standard of artificial feeding in the United States, in preterm infants whose mothers intend to breastfeed. STUDY DESIGN: In a prospective, randomized crossover study, 56 infants or=34 weeks' corrected gestational age, the order of the first two non-breast oral feedings was randomized by coin toss to one cupfeeding and one bottlefeeding. Trained Neonatal Intensive Care Unit nurses provided the feedings. Heart rate, respiratory rate, and oxygen saturation were recorded at 1-minute intervals for 10 minutes before and during the feeding. Volume taken, time required to complete the feed, and any apnea, bradycardia, choking, or spitting episodes were recorded. RESULTS: Heart rate (p<0.0001) and respiratory rate (p<0.0001) increased and oxygen saturation decreased (p=0.0002) during both cup and bottlefeedings compared to pre-feeding baselines. The amount of change in these three parameters from baseline to feeding period was similar for both feeding methods. The fraction of O(2) saturation <90% during baseline compared to the study period was different between these two feeding methods (p=0.02). There was a 10-fold increase in desaturations <90% during bottlefeeds compared to no change during cupfeeds. When comparing cupfeeding periods to bottlefeeding periods, heart rates were higher (p=0.009) and oxygen saturations lower (p=0.02) during bottlefeeds. There were no differences between methods in respiratory rate, choking, spitting or apnea, and bradycardia. Volumes taken were lower (p=0.001) and duration of feeds longer (p=0.002) during cupfeedings. CONCLUSION: During cupfeedings, premature infants are more physiologically stable, with lower heart rates, higher oxygen saturations, and less desaturations, than during bottlefeedings. However, cupfed infants took less volume, over more time, than bottlefed for these initial feedings. Based on better physiologic stability and no difference in untoward effects, cupfeeding is at least as safe, if not safer, than bottlefeeding in this population. This study supports the use of cupfeeding as a safe alternative feeding method for premature infants learning to breastfeed.

Fitness, fatness, and the effect of training assessed by magnetic resonance imaging and skinfold-thickness measurements in healthy adolescent females.

The relation between fitness and adiposity is particularly relevant to adolescent females in whom fitness is known to decrease and fatness to increase. However, little is known about the interaction of these variables in normally active, nonobese subjects. Our major hypotheses were that adiposity would be inversely correlated with physical fitness and that even a relatively brief intervention would lead to measurable, site-specific changes in body fat. We used a cross-sectional protocol to correlate body adiposity with indexes of fitness and a prospective study design to examine body adiposity before and after a 5-wk period of endurance training in 44 nonobese females aged 15-17 y (control group, n = 22; training group, n = 22). Adiposity was assessed by magnetic resonance imaging of the abdomen and thigh as well as by standard skinfold-thickness measuring techniques. Fitness was assessed by using cycle ergometer measurements of maximal oxygen uptake (VO2max). There were significant negative correlations between VO2max normalized to body weight and subcutaneous abdominal, thigh, and skinfold estimates of fat. However, when VO2 max was normalized to muscle volume these correlations were not significant. Abdominal fat increased in direct proportion to body weight (scaling factor = 1.14 +/- 0.16) but thigh fat increased proportionately less (scaling factor = 0.38 +/- 0.12, P < 0.05). Training increased thigh muscle mass significantly only in the midmuscle region and prevented the observed fat increase in the distal thigh of the control subjects. Body fat distribution in adolescent females appeared to be affected by many factors, including overall body weight and the level of physical activity.

Effects of dexamethasone on blood pressure in premature infants with bronchopulmonary dysplasia.

OBJECTIVE: To determine the incidence and time course of blood pressure elevation in dexamethasone-treated premature infants with bronchopulmonary dysplasia. METHODS: In a prospective, self-controlled, consecutive case study, 16 ventilator-dependent very low birth weight neonates treated with dexamethasone were studied. Systolic, diastolic, and mean arterial pressure and heart rate were recorded at three specific times daily. Data were recorded from day 1 of dexamethasone treatment through the duration of therapy and up to 2 weeks after its completion. Retrospective daily data were collected for up to 14 days before therapy. RESULTS: The 788 daily observations (a systolic and diastolic average of the three blood pressure recordings per day) were recorded for 16 infants, a mean of 49 +/- 11 daily observations each (range, 24 to 67). Systolic and diastolic blood pressures before dexamethasone therapy were correlated to corrected gestational age. At initiation of dexamethasone, blood pressures increased significantly from days 1 to 2. For all observations, mean systolic pressure was 51 +/- 9.5 mm Hg before dexamethasone therapy, compared with 64 +/- 10.2 mm Hg during therapy (p < 0.01); diastolic pressure was 29 +/- 6.7 mm Hg before therapy compared with 41 +/- 8.2 mm Hg during therapy (p < 0.01). After completion of dexamethasone therapy, pressures continued to increase: systolic, 67 +/- 8.8 mm Hg (p < 0.01); diastolic, 42 +/- 6.2 mm Hg (not significant). Both systolic and diastolic pressures increased as a function of weight and age; when we controlled for these covariates, an independent effect of dexamethasone itself on the group was shown. Of the 2182 individual systolic pressure readings, 9.4% were considered in the hypertensive range. The six infants treated with hydralazine had higher mean systolic pressures before dexamethasone therapy than did infants without hydralazine (56 +/- 9.4 mm Hg vs 46 +/- 6.4 mm Hg; p < 0.001) and were 2 weeks older at initiation of therapy. CONCLUSIONS: Blood pressure significantly increases during dexamethasone therapy, particularly within the first 48 hours, and does not return to baseline levels after therapy. Those infants most likely to be labeled hypertensive tend to be older at initiation of therapy but do not appear to have any other significant risk factors.

Inability of community-based laboratories to identify pathological casts in urine samples.

OBJECTIVE: To determine the accuracy of microscopic examination of urine from patients with known renal disease, performed by community-based laboratories. DESIGN: Twenty-six urine specimens from 7 children with Alport syndrome, lupus nephritis, and IgA nephropathy were simultaneously submitted to 4 investigative sites: 2 community-based medical laboratories (laboratories A and B), and the offices of 2 nephrologists (nephrologists C and D). Participants A, B, and C were unaware of the nature of this investigation and blinded to the diagnosis associated with each specimen. RESULTS: Twenty-six specimens from 7 children were analyzed. Pathological casts were identified in the 26 submitted specimens in the following order: 1 (4%) by laboratory A, 2 (8%) by laboratory B, 20 (77%) by nephrologist C, and 26 (100%) by nephrologist D. Four-way and 3-way (A, B, C) comparisons using the chi 2 test are significant at the P < .001 level. CONCLUSIONS: The 2 community-based medical laboratories participating in this study did not accurately identify pathological casts in urine specimens routinely submitted to them. In addition to raising quality assurance issues, these misleading reports may result in inaccurate diagnosis and unnecessary laboratory and diagnostic investigations.

Lyme disease in children in southeastern Connecticut. Pediatric Lyme Disease Study Group.

BACKGROUND: Although the incidence of Lyme disease is highest in children, there are few prospective data on the clinical manifestations and outcomes in children. METHODS: We conducted a prospective, longitudinal, community-based cohort study of children with newly diagnosed Lyme disease in an area of Connecticut in which the disease is highly endemic. We obtained clinical and demographic information and performed serial antibody tests and follow-up evaluations. RESULTS: Over a period of 20 months, 201 consecutive patients were enrolled; their median age was 7 years (range, 1 to 21). The initial clinical manifestations of Lyme disease were a single erythema migrans lesion in 66 percent, multiple erythema migrans lesions in 23 percent, arthritis in 6 percent, facial-nerve palsy in 3 percent, aseptic meningitis in 2 percent, and carditis in 0.5 percent. At presentation, 37 percent of the patients with a single erythema migrans lesion and 89 percent of those with multiple erythema migrans lesions had antibodies against Borrelia burgdorferi. All but 3 of the 201 patients were treated for two to four weeks with conventional antimicrobial therapy, which was administered orally in 96 percent. All had prompt clinical responses. After four weeks, 94 percent were completely asymptomatic (including the two patients whose parents had refused to allow antimicrobial treatment). At follow-up a mean of 25.4 months later, none of the patients had evidence of either chronic or recurrent Lyme disease. Six patients subsequently had a new episode of erythema migrans. CONCLUSIONS: About 90 percent of children with Lyme disease present with erythema migrans, which is an early stage of the disease. The prognosis is excellent for those with early Lyme disease who are treated promptly with conventional courses of antimicrobial agents.

Injury prevention training in pediatric residency programs.

OBJECTIVES: To quantify the content and setting of injury prevention training provided to pediatric residents and to identify aspects of residency programs associated with this training. DESIGN: Mail survey. SETTING: US pediatric residency programs. PARTICIPANTS: Residency program directors. MAIN OUTCOME MEASURES: Number of programs stating that they train residents in various injury prevention topics, and the setting of this training. RESULTS: More than 80% of programs addressed 92% of topics surveyed dealing with disease prevention, but only 59% of topics dealing with injury prevention. Injury prevention topics covered less frequently included smoke detector use and swimming pool, sports, and firearm safety. Programs used continuity clinics most often to teach injury prevention. No specific program characteristic was associated with the content or setting of injury prevention training. Residency programs located in states in which house fires, drowning, or firearm injuries are the leading causes of death were not more likely to offer prevention training on these topics. CONCLUSIONS: Injury prevention is less frequently taught than disease prevention in pediatric residency training. Injury prevention is most often taught in continuity clinics, the setting most consistent with ongoing primary patient care. A gap exists between the leading causes of injury death and injury prevention topics taught to pediatric residents. Residency programs must better recognize and adapt to the epidemiology of trauma in their communities, better enabling new pediatricians to meet their patient's needs.

Evaluation of the effectiveness of a pavement stencil in promoting safe behavior among elementary school children boarding school buses.

OBJECTIVE: The majority of school bus-related fatalities among children attending elementary school in the United States occur as children board or alight from buses. Injuries occur during boarding when children enter the street and are struck by buses or other vehicles. This study evaluated the effectiveness of a stencil in the shape of a school bus applied to the pavement at a bus stop in improving safe behaviors at bus stops. Specifically, we assessed the frequency of children running toward the bus as it approached or entered the street. METHODS: Elementary school bus stops with similar roadways, traffic profiles, and numbers of children boarding participated in the study. Stops were randomly assigned to an intervention group, in which children were instructed to remain within a safe area during boarding that was demarcated by a pavement stencil, or an education-only group, in which the safe area was demarcated by some existing environmental feature. Both groups received education about safe boarding procedures. Observers rated behavior at each stop daily for 5 consecutive weeks. Data were analyzed as bivariate odds of any unsafe behavior in the education-only group. RESULTS: One hundred forty-five observations from seven bus stops with stencils and 174 daily observations from six education-only stops were completed. Observations of children in the education-only group were twice as likely to show unsafe behavior while waiting (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.3-3.6) and during boarding (OR, 2.1; 95% CI, 1.2-3.9). ORs were significantly higher in the education-only group for boys, girls, and children in grades 4 through 6. When no adult was present, there was a greater likelihood of unsafe behavior among all children in the education-only group while waiting (OR, 16.1; 95% CI, 3.9-72.4) and during boarding (OR, 15.0; 95% CI, 3.2-81.4). The presence of an adult at the stop did not have an independent effect on behavior. Children at education-only stops located on roadways with high traffic volume were more likely to engage in unsafe behavior while waiting (OR, 8.0; 95% CI, 3.8-17.3) and during boarding (OR, 4.9; 95% CI, 2.2-11.0). No differences were observed during boarding between stencil and education-only groups when 10 or more children were at the stops. CONCLUSION: The pavement stencil, when accompanied by education about safe boarding, may represent a cost-effective approach to reducing unsafe behavior at bus stops by children of elementary school age.