Helping first-time mothers establish and maintain breastfeeding: Access to someone who can provide breastfeeding advice is an important factor.

BACKGROUND AND AIMS: First-time mothers often need help with breastfeeding and may feel isolated and uncertain about whom they can turn to for help with breastfeeding challenges. Exploration of whether access to breastfeeding advice helps new mothers initiate and continue breastfeeding is necessary. This study investigated the associations between ease of access to breastfeeding advice for first-time mothers and breastfeeding initiation and duration. METHODS: This was a prospective, longitudinal cohort study of 3,006 women who delivered their first child in Pennsylvania, USA; with prenatal and postpartum interviews. At 1-month postpartum participants reported the extent to which they had access to "Someone to give you advice about breastfeeding if you needed it", via a 5-point scale ranging from "none of the time" to "all of the time". RESULTS: There were 132 women (4.4%) who reported that they had access to someone to give them advice about breastfeeding "none of the time"; 697 (23.3%) reported access "a little of the time" or "some of the time"; and 2,167 (72.3%) reported access "most of the time" or "all of the time". While the majority of the new mothers were breastfeeding at 1-month postpartum (72.5%), less than half were still breastfeeding at 6-months postpartum (44.5%). The higher the level of access to advice about breastfeeding the more likely women were to establish breastfeeding by 1-month postpartum and to still be breastfeeding at 6-months. CONCLUSIONS: For first-time mothers, ease of access to someone who can give them advice about breastfeeding facilitates breastfeeding establishment and continuation.

Cesarean Section and Child Development at 3 Years: A Prospective Cohort Study of First Births in Pennsylvania.

OBJECTIVES: The rising cesarean birth rate globally has led to increasing concern about long-term unintended consequences, with particular focus on child neurodevelopmental outcomes. This study investigated the association between cesarean birth and early child neurodevelopment, measured at 3 years of age. METHODS: This was a large multicenter longitudinal prospective cohort study of first-time mothers and their offspring in Pennsylvania. Mothers completed adapted versions of two measures of child development at 36- months postpartum: the modified Parents' Evaluation of Developmental Status (M-PEDS) and a shortened Ages and Stages Questionnaire (S-ASQ). Logistic regression models were used to assess the association between mode of delivery and delayed child development, controlling for confounding variables. RESULTS: There were 695 (29.3%) children born by cesarean delivery and 1676 (70.7) born vaginally. Children born by cesarean had increased odds of scoring as developmentally delayed on both measures of child development: the M-PEDS (8.9% cesarean and 5.1% vaginal, adjusted odds ratio [aOR] = 1.58, 95% confidence interval [CI] = 1.11-2.24)) and the S-ASQ (6.3% cesarean and 3.3% vaginal, aOR = 1.66, 95% CI = 1.09-2.54). Additional factors associated with developmental delay were male sex, and the maternal factors of high pre-pregnancy body mass index, thyroid disorder, and diabetes. CONCLUSION: In this large prospective cohort study of first-time mothers and their offspring, cesarean delivery was found to be associated with an elevated risk of delayed child development at age 3 years. This analysis highlights the importance of continued research to understand the impact of cesarean delivery on child development.

Paternal Education and Its Impact on Breastfeeding Initiation and Duration: An Understudied and Often Overlooked Factor in U.S. Breastfeeding Practices.

Objective: The primary objective was to determine the role that paternal education level plays in the initiation and duration of breastfeeding for their infants. Materials and Methods: As part of a prospective cohort study, primiparous women, aged 18-35 years, living in Pennsylvania, were enrolled and interviewed during pregnancy (N = 3,006) and at 1 and 6 months postpartum. Logistic regression models were used to evaluate the associations between paternal education level and breastfeeding initiation and duration, controlling for maternal education level and other covariates-including marital/relationship status, household poverty level, maternal age, race/ethnicity, smoking, attending breastfeeding class during pregnancy, mode of delivery, gestational age, and plans to return to work ≤2 months after delivery. Results: Information on both paternal and maternal education levels and breastfeeding outcomes was available for 2,839 couples. Most of the women reported that they planned to breastfeed (92.5%); 92.0% initiated breastfeeding; and 49.5% of those who initiated breastfeeding were still breastfeeding by 6 months postpartum. Paternal education level was independently associated with breastfeeding initiation and duration in both regression models-the higher the level of education of the father, the more likely breastfeeding was initiated and the mother was still breastfeeding at 6 months postpartum, even after controlling for maternal education level and other relevant covariates. Conclusions: In this large prospective cohort study of first-time mothers and their newborns, paternal education level was independently associated with breastfeeding initiation and duration. These findings highlight the importance of including the father in prenatal breastfeeding education initiatives.

Improving Hospital Infant Safe Sleep Compliance by Using Safety Prevention Bundle Methodology.

BACKGROUND AND OBJECTIVES: Sudden unexpected infant death often results from unsafe sleep environments and is the leading cause of postneonatal mortality in the United States. Standardization of infant sleep environment education has been revealed to impact such deaths. This standardized approach is similar to safety prevention bundles typically used to monitor and improve health outcomes, such as those related to hospital-acquired conditions (HACs). We sought to use the HAC model to measure and improve adherence to safe sleep guidelines in an entire children's hospital. METHODS: A hospital-wide safe sleep bundle was implemented on September 15, 2017. A safe sleep performance improvement team met monthly to review data and discuss ideas for improvement through the use of iterative plan-do-study-act cycles. Audits were performed monthly from March 2017 to October 2019 and monitored safe sleep parameters. Adherence was measured and reviewed through the use of statistical process control charts (p-charts). RESULTS: Overall compliance improved from 9% to 72%. Head of bed flat increased from 62% to 93%, sleep space free of extra items increased from 52% to 81%, and caregiver education completed increased from 10% to 84%. The centerline for infant in supine position remained stable at 81%. CONCLUSIONS: Using an HAC bundle safety prevention model to improve adherence to infant safe sleep guidelines is a feasible and effective method to improve the sleep environment for infants in all areas of a children's hospital.

A crawling case of benign acute childhood myositis.

Benign acute childhood myositis is a relatively uncommon complication of viral illness, particularly influenza A and B infections. In this abstract, we present a case report of benign acute childhood myositis secondary to influenza. On presentation, he was ill-appearing, febrile and had significant calf pain that limited mobility. Examination revealed mildly erythematous throat and bilateral calf tenderness with pain on dorsiflexion bilaterally. A respiratory virus panel was positive for influenza A subtype H3 and he was found to have an elevated creatine phosphokinase. He was diagnosed with benign acute childhood myositis secondary to influenza type A infection and symptoms gradually resolved following supportive management. Management involves oral hydration, pain management, and follow-up to ensure resolution. Extensive laboratory evaluation and hospitalization are often unnecessary. Benign acute childhood myositis is self-limiting with an excellent prognosis and should be included in the differential for a child who develops difficulty walking, particularly when presentation follows a respiratory infection.

Validity of the Autism Mental Status Exam in Developmental Pediatrics and Primary Care Settings.

The Autism Mental Status Exam (AMSE) is a brief clinician-completed observational instrument that has shown promise in identifying autism spectrum disorder (ASD) in a referred sample. Our study explores the feasibility of the AMSE in both developmental pediatric and primary care samples. Fifty-three toddlers with ASD and other disabilities were scored using the AMSE and compared with 55 typically developing toddlers. AMSE scores differed significantly between ASD, non-ASD developmental disability, and neurotypical groups. A cutoff score on the AMSE of ≥5 for ASD maximized sensitivity (81.2%) and specificity (90.5%). Score differences between groups suggest that the AMSE may be useful in a clinical setting to help identify children with possible ASD.

Diagnostic Accuracy, Prescription Behavior, and Watchful Waiting Efficacy for Pediatric Acute Otitis Media.

Current guidelines recommend "watchful waiting" (WW) as an alternative to immediate antibiotic treatment. Continued high rates of antibiotic use suggest that WW may be underutilized. We conducted a retrospective chart review of 474 pediatric acute otitis media (AOM) cases at a clinic in central Pennsylvania. We assessed physical examination findings, diagnostic behavior, WW utilization, prescription writing, and filling in cases of pediatric AOM to evaluate the underutilization of WW. We evaluate diagnostic consistency with published guidelines and rates of antibiotic prescription resulting from misdiagnosis. We report WW instructions and compliance, and prescription filling behaviors. Fifty percent of AOM diagnoses in this sample were not supported by physical examination findings. The majority of these AOM diagnoses received antibiotic prescriptions, suggesting that unsupported diagnoses translated to injudicious prescribing. WW instructions corresponded to 57% fewer filled prescriptions and longer fill delay. We discuss the implications and recommendations to improve antibiotic stewardship.

Use of an annual art competition to promote Web site traffic and engage children in antimicrobial stewardship in Pennsylvania.

We used Google Analytics to assess whether annual kids' art competitions changed traffic to a Web site on appropriate antibiotic use. We found that announcements about kids' art competitions correlated with increased traffic to the Web site, suggesting that this innovation has promise in promoting antimicrobial stewardship efforts.

Campaign Preparation for Complex Initiatives: A Person-Centered Approach to Audience Segmentation of Parents' Antibiotic Stewardship.

The evolution of antibiotic resistance is outpacing the speed at which new antibiotics will reach the marketplace. To slow the rate of resistance, people need to engage in antibiotic stewardship, which includes acts to prevent the spread of bacteria and judicious use of antibiotics to treat infections. This study identified the patterns and predictors of antibiotic stewardship behaviors of parents (N = 516) related to their children. The latent class analysis revealed three profiles of parental stewardship, labeled Stewards, Requesters, and Non-Stewards. The findings implied different campaign goals: to encourage Stewards to follow through on their intentions, to encourage Requesters to stop asking providers for antibiotics when their children have ear infections, and to influence Non-Stewards to accept medical advice when an antibiotic is not indicated and to dispose of leftover antibiotics. The covariate analysis provided theoretical insight into the strategies to pursue in campaigns targeting these three groups. For example, parents who perceived antibiotic-resistant infections as less serious health conditions, felt less worry when thinking about their child getting an antibiotic-resistant infection, and had stronger misattributions of antibiotics' efficacy to treat multiple symptoms were more likely to be Requesters and Non-Stewards, instead of Stewards.

Toward Reduction in Antibiotic Use for Pediatric Otitis Media: Predicting Parental Compliance with "Watchful Waiting" Advice.

"Watchful waiting" (WW) can reduce unnecessary antibiotic use in the treatment of pediatric otitis media (ear infection), but the utility of the strategy is impaired by underutilization and noncompliance. Guided by advice response theory (ART), the current study examines how parental compliance with WW and trust in the prescribing physician is predicted by evaluative and affective responses to the advice. Parents (N = 134) of at least one child aged 5 years or younger completed questionnaires that assessed responses to WW advice they received for their youngest child. Perceptions of the advantage from and capacity to undertake WW, the child's level of pain, and the tact (autonomy-granting politeness) of the health care provider predicted compliance and provider trust both directly and indirectly, through advice quality and negative affect. The study suggests modifications to ART that will extend its scope and provides practical guidance for health care providers seeking to improve parent compliance with WW advice.

BRCA locus-specific loss of heterozygosity in germline BRCA1 and BRCA2 carriers.

Complete loss of BRCA1 or BRCA2 function is associated with sensitivity to DNA damaging agents. However, not all BRCA1 and BRCA2 germline mutation-associated tumors respond. Herein we report analyses of 160 BRCA1 and BRCA2 germline mutation-associated breast and ovarian tumors. Retention of the normal BRCA1 or BRCA2 allele (absence of locus-specific loss of heterozygosity (LOH)) is observed in 7% of BRCA1 ovarian, 16% of BRCA2 ovarian, 10% of BRCA1 breast, and 46% of BRCA2 breast tumors. These tumors have equivalent homologous recombination deficiency scores to sporadic tumors, significantly lower than scores in tumors with locus-specific LOH (ovarian, P = 0.0004; breast P < 0.0001, two-tailed Student's t-test). Absence of locus-specific LOH is associated with decreased overall survival in ovarian cancer patients treated with platinum chemotherapy (P = 0.01, log-rank test). Locus-specific LOH may be a clinically useful biomarker to predict primary resistance to DNA damaging agents in patients with germline BRCA1 and BRCA2 mutations.Most tumours associated with germline BRCA1/BRCA2 loss of function mutations respond to DNA damaging agents, however, some do not. Herein, the authors identify that a subset of breast/ovarian tumors retain a normal allele, which is associated with decreased overall survival after DNA damage-inducing platinum chemotherapy.

Watchful Waiting for Cases of Pediatric Otitis Media: Modeling Parental Response to Physician Advice.

Watchful waiting (WW) can reduce unnecessary antibiotic use in the treatment of pediatric otitis media (ear infection), but its utility is impaired by underutilization and noncompliance. Guided by advice response theory, the current study proposes advantage and capacity as factors that predict how caregivers evaluate and respond affectively to WW. Parents (N = 373) of at least 1 child age 5 years or younger completed questionnaires that assessed responses to hypothetical WW advice for their youngest child. Perceptions of advantage from WW and the capacity to monitor and manage symptoms predicted advice quality, physician trust, and future compliance both directly and indirectly through negative affect. The findings suggest the elaboration of advice response theory to include more aspects of advice content evaluation (e.g., advantage) and the influence of negative affect. The study also provides practical guidance for physicians seeking to improve caregiver reception of WW advice.

Reduced Breastfeeding Rates in Firstborn Late Preterm and Early Term Infants.

OBJECTIVES: The primary objective was to determine the rate of breastfeeding by gestational age reported by new mothers 1 month postpartum, with particular focus on early term newborns (37-38(6)/7 weeks). MATERIALS AND METHODS: Three thousand six primiparous women aged 18-36 years were interviewed during their third trimester and again 1 month postpartum. Logistic regression analysis was used to model the association between gestational age and breastfeeding 1 month postpartum among those who reported that they planned to breastfeed, controlling for potentially confounding variables. RESULTS: Two thousand seven hundred seventy-two women planned to breastfeed (92.2%), among whom 116 (4.2%) delivered late preterm (34-36(6)/7 weeks), 519 (18.7%) early term (37-38(6)/7 weeks), and 2,137 (77.1%) term or postterm (39+ weeks). Among those who delivered late preterm, 63.8% were breastfeeding 1 month postpartum, early term 72.6%, and term or postterm 76.5%. This relationship was verified by a multivariate logistic regression analysis; late preterm newborns were significantly less likely to be breastfeeding 1 month postpartum than the term or postterm newborns (odds ratio [OR] 0.44; 95% confidence interval [CI] 0.28-0.69; p ≤ 0.0001), as were early term newborns (OR 0.77; 95% CI 0.60-0.99; p = 0.038). CONCLUSIONS: In this large prospective study of first-time mothers and newborns, gestational age was significantly associated with breastfeeding 1 month postpartum; highlighting late preterm and early term infants as populations at risk for shortened breastfeeding duration and the need to create specific breastfeeding support and education.

Preparing for Antibiotic Resistance Campaigns: A Person-Centered Approach to Audience Segmentation.

Antibiotic resistance is a growing threat to public health that calls for urgent attention. However, creating campaigns to slow the emergence and spread of drug-resistant pathogens is challenging because the goal-antibiotic stewardship-encompasses multiple behaviors. This study provided a novel approach to audience segmentation for a multifaceted goal, by using a person-centered approach to identify profiles of U.S. adults based on shared stewardship intentions. The latent class analysis identified three groups: stewards, stockers, and demanders. The findings suggest campaigns with goals aimed at encouraging stewards to follow through on their intentions, encouraging stockers to dispose of their leftover antibiotics, and convincing demanders to accept providers' evidence-based judgment when a prescription for antibiotics is not indicated. Covariate analysis showed that people who held more inaccurate beliefs about what antibiotics can treat had higher odds of being demanders and stockers instead of stewards. People with stronger health mavenism also had higher odds of being stockers instead of stewards. The covariate analysis provided theoretical insight into the strategies to pursue in campaigns targeting these 3 groups.

Breastfeeding outcome comparison by parity.

OBJECTIVE: Anecdotally, breastfeeding experiences differ between those who have previously nursed an infant and those who are primiparous. This analysis contrasted breastfeeding outcomes between primiparous women and those with previous experience spanning from maternity stay through 6 months postpartum. STUDY DESIGN: A secondary analysis was conducted of data collected in a randomized, controlled trial with mothers and "well" newborns ≥34 weeks of gestation comparing two post-hospital discharge care models. Mothers completed an in-person interview during the postpartum stay and phone surveys at 2 weeks, 2 months, and 6 months where questionnaires related to breastfeeding were completed. All participants intended to breastfeed. Chi-squared and Wilcoxon rank sum tests were used to test for differences between parity groups. Breastfeeding duration by parity group was compared using a Kaplan-Meier plot and a logrank test. A Cox proportional hazards model was used to evaluate the relationship between breastfeeding duration and parity after adjusting for covariates. RESULTS: Among 1,099 mothers available for analysis, 542 (49%) were primiparous. Multiparous mothers had a longer intended breastfeeding duration (median, 9 vs. 6 months; p<0.001). Following delivery, primiparous mothers had a longer median time to first breastfeeding attempt (119 vs. 96 minutes; p<0.001) and were more likely to have eight or fewer feeding attempts in the first 24 hours (33% vs. 44%; p<0.001)). More primiparous women reported early breastfeeding problems (35% vs. 20%; p<0.001) and mixed feeding at hospital discharge (39% vs. 23%; p<0.001) despite reporting less breastfeeding-associated pain during the first week (p=0.04). Multiparous women were more likely to breastfeed through 6 months (p<0.001). In a multivariable Cox model for breastfeeding duration, an interaction existed between intended breastfeeding duration and parity (p=0.006); among those intending to breastfeed for 12 months, multiparous mothers had a significantly lower hazard of stopping breastfeeding (hazard ratio=0.66; p=0.03) than primiparous mothers. CONCLUSIONS: Women who have breastfed previously have significantly different breastfeeding experiences than primiparous women. Pre- and postdelivery breastfeeding support should differentially target primiparous women to improve breastfeeding outcomes.

Compliance of middle school-aged babysitters in central Pennsylvania with national recommendations for emergency preparedness and safety practices.

OBJECTIVE: To determine the compliance of middle school-aged babysitters with national recommendations for emergency preparedness and safety practices. PATIENTS AND METHODS: A prospective, self-administered questionnaire-based study was conducted at 3 middle schools in central Pennsylvania. RESULTS: A total of 1364 questionnaires were available for analysis. Responding babysitters (n = 890) reported previous training that included babysitter (21%), first aid (64%), and cardiopulmonary resuscitation (59%) training. Reported unsafe babysitter practices were leaving a child unattended (36%) and opening the door to a stranger (24%). The most common emergency experience encountered by responding babysitters included cut or scrape (83%), burns (28%), and choking (14%). Ten percent of responding babysitters have activated the 911 system. CONCLUSIONS: Middle school-aged babysitters will likely encounter common household emergencies and therefore benefit from first aid training; however, very little difference in safety knowledge was found between trained and untrained babysitters, suggesting modifications in babysitter training programs may be required.