Application of Statistical Analysis and Machine Learning to Identify Infants' Abnormal Suckling Behavior.

OBJECTIVE: Identify infants with abnormal suckling behavior from simple non-nutritive suckling devices. BACKGROUND: While it is well known breastfeeding is beneficial to the health of both mothers and infants, breastfeeding ceases in 75 percent of mother-child dyads by 6 months. The current standard of care lacks objective measurements to screen infant suckling abnormalities within the first few days of life, a critical time to establish milk supply and successful breastfeeding practices. MATERIALS AND METHODS: A non-nutritive suckling vacuum measurement system, previously developed by the authors, is used to gather data from 91 healthy full-term infants under thirty days old. Non-nutritive suckling was recorded for a duration of sixty seconds. We establish normative data for the mean suck vacuum, maximum suck vacuum, suckling frequency, burst duration, sucks per burst, and vacuum signal shape. We then apply computational methods (Mahalanobis distance, KNN) to detect anomalies in the data to identify infants with abnormal suckling. We finally provide case studies of healthy newborn infants and infants diagnosed with ankyloglossia. RESULTS: In a series of case evaluations, we demonstrate the ability to detect abnormal suckling behavior using statistical analysis and machine learning. We evaluate cases of ankyloglossia to determine how oral dysfunction and surgical interventions affect non-nutritive suckling measurements. CONCLUSIONS: Statistical analysis (Mahalanobis Distance) and machine learning [K nearest neighbor (KNN)] can be viable approaches to rapidly interpret infant suckling measurements. Particularly in practices using the digital suck assessment with a gloved finger, it can provide a more objective, early stage screening method to identify abnormal infant suckling vacuum. This approach for identifying those at risk for breastfeeding complications is crucial to complement complex emerging clinical evaluation technology. CLINICAL IMPACT: By analyzing non-nutritive suckling using computational methods, we demonstrate the ability to detect abnormal and normal behavior in infant suckling that can inform breastfeeding intervention pathways in clinic.Clinical and Translational Impact Statement: The work serves to shed light on the lack of consensus for determining appropriate intervention pathways for infant oral dysfunction. We demonstrate using statistical analysis and machine learning that normal and abnormal infant suckling can be identified and used in determining if surgical intervention is a necessary solution to resolve infant feeding difficulties.

The Term Newborn: Alternative Birth Practices, Refusal, and Therapeutic Hesitancy.

The care of late preterm and term newborns delivered in hospital settings in the United States is largely standardized with many routine interventions and screenings that are evidence-based and serve to protect newborn's and the public's health. Refusals of various aspects of routine newborn care are uncommon but can be challenging for clinicians who care for newborns to navigate for many reasons. In this article, we describe the spectrum of refusal. We review suggested approaches that clinicians can take starting with increasing their own awareness of what specific components of newborn care are refused and why.

Repetitive Transcranial Magnetic Stimulation Delivered With an H-Coil to the Right Insula Reduces Functional Connectivity Between Insula and Medial Prefrontal Cortex.

OBJECTIVE: Insula neurocircuitry alterations are reported in a range of neuropsychiatric disorders holding promise for clinical interventions. We measured, in a pilot study, acute neuroplastic modulations resulting from high- and low-frequency stimulation with repetitive transcranial magnetic stimulation (rTMS) delivered via an H-coil that targeted the right insula and overlying prefrontal cortex. METHODS: Healthy, nonsmoking, adult participants (N = 28), in a within-participant, sham-controlled experiment, received a single rTMS session on four separate days. Participants received one session each of low- (1 Hz) and high (10 Hz)-frequency stimulation and two sessions of sham stimulation matched to each rTMS frequency. After each rTMS session, participants completed a functional magnetic resonance imaging (fMRI) scan while performing two cognitive tasks and a resting-state scan. The effect of rTMS was examined on task behavior as well as blood oxygenated level-dependent (BOLD) response during task performance and resting state. We expected low- and high-frequency stimulation to decrease and increase, respectively, insula and overlying cortical BOLD signal and network connectivity. RESULTS/CONCLUSIONS: There was no effect of rTMS, regardless of frequency, on task behavior or task-based BOLD response. There was an effect of rTMS compared to sham on rsFC between insula and medial prefrontal cortex, with connectivity reduced after rTMS compared to sham, regardless of frequency. Implications for using rTMS to the insula as a treatment for neuropsychiatric disorders are discussed in light of insula-medial prefrontal cortex connectivity.

Effect of Exclusive Breastfeeding Among Overweight and Obese Mothers on Infant Weight-for-Length Percentile at 1 Year.

BACKGROUND: Breastfeeding is associated with decreased risk of childhood obesity. However, there is a strong correlation between maternal weight status and childhood obesity, and it is unclear whether or not breastfeeding among overweight mothers could mitigate this risk. Our goal was to examine whether or not exclusive breastfeeding (compared to formula feeding) among overweight and obese mothers is associated with lower weight-for-length (W/L) percentile at 1 year. MATERIALS AND METHODS: Data from the Infant Feeding Practices II study were used. Infants who were preterm or underweight at 1 year, and mothers who were underweight before pregnancy, were excluded from analysis. There was a significant interaction between exclusive breastfeeding for 4 months and maternal prepregnancy weight status (normal weight, overweight, obese) on infant W/L percentile at 1 year. Stratified linear mixed-effects growth modeling controlling for covariates was created to test the relationship between exclusive breastfeeding and infant W/L percentile within each maternal weight category. RESULTS: A total of 915 subjects met inclusion criteria. Normal weight and obese mothers who exclusively breastfed for 4 months had infants with a smaller rate of increase in W/L percentile during the first year compared with those who used formula. Infants of overweight and obese mothers who exclusively breastfed for 4 months had lower W/L percentile at 1 year than those who used formula. CONCLUSIONS: Exclusive breastfeeding for 4 months among normal weight and obese mothers resulted in less increase in W/L percentiles in the first year. Obese mothers often have a difficult time initiating and maintaining breastfeeding. Concerted efforts are needed to support this population with breastfeeding.

Interest in marijuana treatment programs among teenage smokers and nonsmokers.

Little is known about adolescents' interest in marijuana treatment programs. This question was evaluated by telephone interview in a convenience sample of 575 adolescents responding to advertisements for tobacco research studies. Eighty-one percent of respondents endorsed the need for marijuana treatment programs for adolescents. These adolescents were younger and less likely to smoke tobacco, smoke marijuana, or use alcohol than those not endorsing such a need. Among the 192 marijuana smokers, the 58.8% who endorsed the need for marijuana treatment programs took their first puff of marijuana at a younger age than those who did not endorse the need. Those who were willing to participate in a marijuana treatment program were more likely African American and took their first marijuana puff at a younger age than those not interested in treatment. These findings suggest that most adolescent marijuana smokers endorse the need for and are willing to attend marijuana treatment programs.

A link between adolescent nicotine metabolism and smoking topography.

Adult slow nicotine metabolizers have lower smoke exposure, carbon monoxide levels, and plasma nicotine levels than normal and fast metabolizers. Emerging evidence suggests nicotine metabolism influences smoking topography. This study investigated the association of nicotine metabolism (the ratio of plasma 3-hydroxycotinine to cotinine; 3OHCOT/COT) with smoking topography in adolescent smokers (n = 85; 65% female, 68% European American; mean age, 15.3 +/- 1.2 years; mean cigarettes per day, 18.5 +/- 8.5; mean Fagerström Test for Nicotine Dependence, 7.0 +/- 1.2) presenting for a nicotine replacement therapy trial. Measures obtained included puff volume, interpuff interval, number of puffs, puff duration, and puff velocity. Linear regression analysis controlling for hormonal contraception use showed that 3OHCOT/COT ratios predicted mean puff volume in the overall sample (t = 2.126; P = 0.037; adjusted R(2) = 0.067). After gender stratification, faster metabolism predicted higher mean puff volume (t = 2.81; P = 0.009; adjusted R(2) = 0.192) but fewer puffs (t = -3.160; P = 0.004; adjusted R(2) = 0.237) and lower mean puff duration (t = -2.06; P = 0.048; adjusted R(2) = 0.101) among boys only, suggesting that as nicotine metabolism increases, puff volume increases but puffing frequency decreases. No significant relationships were found between nicotine metabolism and total puff volume, mean puff duration, interpuff interval, or puff velocity. If confirmed in a broader sample of adolescent smokers, these findings suggest that as among dependent adult smokers, rate of metabolism among adolescent boys is linked to select parameters of puffing behavior that may affect cessation ability.

Pharmacy informatics in controlled substances research.

Pharmacies have become essential components in support of clinical research. Their operations become highly complex when preponderance of prescriptions is composed of controlled substances. Application of informatics will result in more efficient operations. We present the Pharmacy Information Management System (PIMS) that includes a set of decision support systems to address the pharmacy challenges and is integrated into our electronic health record system.

Does allowing adolescents to smoke at home affect their consumption and dependence?

Negative parental attitudes towards smoking decrease adolescent smoking initiation but limited research explores the relationship between parental attitudes and degree of adolescent smoking among established smokers. The aim of this study was to examine the relationship between parental allowance of smoking in the home and adolescent smoking behavior and level of dependence. Interviews from 408 youths seeking assistance to quit smoking showed that adolescents who were allowed to smoke at home smoked more cigarettes per day and had higher scores on the Fagerström Test of Nicotine Dependence than those not allowed to smoke at home. Studies that additionally evaluate parental smoking status and the temporal relationship of parental allowance of smoking with changes in adolescent smoking behavior are warranted to clarify public health implications of parental smoking interdictions.

A clinical recruiting management system for complex multi-site clinical trials using qualification decision support systems.

A clinical recruiting management system with qualification decision support systems was developed to increase the efficiency of screening and evaluation of participants during a recruiting process whereby recruiting for various protocols are conducted at multiple sites by different groups with process interdependencies. This system is seamlessly integrated into our enterprise-scale Human Research Information System (HuRIS), encompassing research participants' electronic health records (EHR), with real-time access to the clinical trial data.

Behavioral predictors of substance-use initiation in adolescents with and without attention-deficit/hyperactivity disorder.

OBJECTIVE: Our goal was to examine substance-use initiation in healthy adolescents and in adolescents who have been diagnosed with attention-deficit/hyperactivity disorder. METHODS: Seventy-eight adolescents (28 healthy and 50 with attention-deficit/hyperactivity disorder) participated in an ongoing longitudinal study of predictors of substance use. The substances most commonly reported were tobacco, alcohol, and marijuana. Aggression, conduct problems, hyperactivity, impulsivity, inattention, anxiety/depression, social difficulties, and somatic complaints were assessed at study entry and tested as predictors for later substance use. RESULTS: With an average of 4 years into the study, 37 adolescents had not used any substances, 41 had experimented with at least 1 substance, and 29 experimented with >1 substance. Psychiatric diagnoses (attention-deficit/hyperactivity disorder, attention-deficit/hyperactivity disorder and conduct disorder, and attention-deficit/hyperactivity disorder and depression/anxiety) did not influence reports of substance use. Distinct behavioral measures collected at study entry predicted use of different substances. In a multivariate analysis, aggression had the greatest association with tobacco smoking and marijuana use. Impulsivity was associated with alcohol use. Severity of drug exposure, indexed by the number of substances used, was predicted by aggression. CONCLUSIONS: This 4-year longitudinal study captured the onset of substance use, not abuse. Behavioral predictors differed with the type of substance used. These behavioral characteristics may raise suspicion among pediatricians for enhanced risk for substance-use initiation.

Neural substrates of decision making in adults with attention deficit hyperactivity disorder.

OBJECTIVE: The characteristics of attention deficit hyperactivity disorder (ADHD) include abnormalities in reward responsivity that may interfere with decision making. The study examined reward responsivity in ADHD by comparing the neural correlates of decision making in adults with childhood-onset ADHD and in healthy adults. METHOD: The neural correlates of performance on a decision-making task and a control task were compared in 10 adults with ADHD and 12 age-matched healthy volunteers by using [(15)O]H(2)O positron emission tomography. The decision-making task tested the ability to weigh short-term rewards against long-term losses. The control task matched all components of the decision-making task except for the decision-making process and related contingency. RESULTS: The ventral and dorsolateral prefrontal cortex and the insula were activated during performance of the decision-making task in both the ADHD and healthy groups; however, activation in the ADHD group was less extended and did not involve other regions, such as anterior cingulate and hippocampus, that subserve emotion/memory processes. Direct comparison of data from the ADHD subjects and the healthy volunteers suggested that the healthy subjects engaged the hippocampal and insular regions more than did the ADHD subjects and that the ADHD subjects recruited the caudal part of the right anterior cingulate more than did the healthy subjects. CONCLUSIONS: The findings suggest that the neural circuits engaged during decision making differ in subjects with ADHD and healthy comparison subjects. This difference may explain observed deficits in motivated behaviors in ADHD. A better understanding of the nature of these deficits could ultimately be applied to refine treatment strategies for ADHD.