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.

Using the lens of trauma informed care to inform pediatric obesity management.

PURPOSE OF REVIEW: Summarize the evolution of the trauma-informed care (TIC) approach in pediatrics, highlight the importance of using this lens in pediatric obesity management and treating the whole patient and family, and suggest recommendations for providers to incorporate TIC into their practice. RECENT FINDINGS: Implementing TIC in pediatric obesity management is recommended and offers an approach to address trauma-related symptoms associated with obesity. The TIC framework creates a safe, nurturing space to have open conversations with patients and families to promote resilience and reduce stigma related to obesity without re-traumatization. Screening tools may expose symptoms related to trauma, but are limited. Provider training is available and development of TIC related skills may be improved through using the arts and humanities. Success of TIC requires a tailored, integrated healthcare system approach with commitment from all levels. SUMMARY: The TIC approach offers providers skills to uncover trauma-related symptoms and address obesity-related health disparities while reducing stigma. Collaboration across all levels of the healthcare system and community partners is essential. Further research is warranted on the effectives of this approach in pediatric obesity prevention and management.

Suicide Safety Plan Self-knowledge in Serious Mental Illness: Psychiatric Symptom Correlates and Effects of Brief Intervention.

Psychiatric symptoms experienced by people with serious mental illness (SMI; schizophrenia, bipolar and other psychotic disorders) may impact suicide safety planning. This study examined safety plan self-knowledge, or an individual's own knowledge and awareness of their safety plan, in a sample of people with SMI. Participants (N = 53) with SMI at elevated risk of suicide completed a 4-session intervention that included safety plans, with one intervention group that included mobile augmentation. Self-knowledge was assessed from previous safety plans at 4-, 12- and 24-weeks. Fewer warning signs generated was correlated with greater psychiatric symptoms (r = - .306, p = .026) and suicidal ideation (r = - .298, p = .030). Fewer coping strategies generated was correlated with greater suicidal ideation (r = .- 323, p = .018). Preliminarily, there was greater self-knowledge of warning signs over time among participants in the mobile intervention. These preliminary findings highlight the relationship of safety plan self-knowledge to symptoms and suggest that mobile augmentation of safety planning may be beneficial. Trial Registration: NCT03198364.

Non-Nutritive Suckling System for Real-Time Characterization of Intraoral Vacuum Profile in Full Term Neonates.

Infant breastfeeding diagnostics remain subjective due to the absence of instrumentation to objectively measure and understand infant oral motor skills and suckling characteristics. Qualitative diagnostic exams, such as the digital suck assessment which relies upon a clinician's gloved finger inserted into the infant's mouth, produce a diversity of diagnoses and intervention pathways due to their subjective nature. In this paper, we report on the design of a non-nutritive suckling (NNS) system which quantifies and analyzes quantitative intraoral vacuum and sucking patterns of full-term neonates in real time. In our study, we evaluate thirty neonate suckling profiles to demonstrate the technical and clinical feasibility of the system. We successfully extract the mean suck vacuum, maximum suck vacuum, frequency, burst duration, number of sucks per burst, number of sucks per minute, and number of bursts per minute. In addition, we highlight the discovery of three intraoral vacuum profile shapes that are found to be correlated to different levels of suckling characteristics. These results establish a framework for future studies to evaluate oromotor dysfunction that affect the appearance of these signals based on established normal profiles. Ultimately, with the ability to easily and quickly capture intraoral vacuum data, clinicians can more accurately perform suckling assessments to provide timely intervention and assist mothers and infants towards successful breastfeeding outcomes.

Mobile facial affect recognition and real-time social experiences in serious mental illness.

Background: Emotion recognition deficits are linked with social dysfunction in psychosis, as is inaccurate self-assessment of emotion recognition abilities. However, little is known about the link between ER and real-time social appraisals and behavior. Methods: In 136 people with psychotic disorders or affective disorder with psychosis we administered a novel ecological momentary cognitive test of emotion recognition which both assesses emotion recognition ability and self-assessed performance in conjunction with ecological momentary assessment of social appraisals, motivation, and time spent alone. Hybrid mixed effects models evaluated emotion recognition's associations with social experiences. Results: Better recognition ability was associated with greater pleasure and more positive appraisals of others during interactions, whereas accuracy of self-assessment of emotion recognition ability was associated with more positive appraisals of interactions and social motivation. Overestimation of emotion recognition was linked with concurrent higher social motivation yet greater desire to avoid others. Time alone was unrelated to emotion recognition ability or self-assessment of ability. Discussion: Mobile emotion recognition performance was associated with appraisals of recent interactions but not behavior. Self-assessment of social cognitive performance was associated with more positive appraisals and social motivation, and may be a novel target for interventions aimed at social dysfunction.

Factors associated with COVID-19 vaccine intent among Latino SNAP participants in Southern California.

BACKGROUND: COVID-19 is significantly impacting the health and well-being of the country, particularly for ethnic minority populations and low-income groups. Our goal was to determine COVID-19 vaccination intent in a low-income, Latino population receiving aid from the Supplemental Nutrition Assistance Program (SNAP) in Southern California, and identify contributing factors and concerns. METHODS: A cross-sectional, mixed-methods survey was conducted among participants in the Southern California Nutrition Incentives Program (¡Más Fresco! More Fresh). Only Latino respondents were included in this analysis. Primary outcome was vaccine intent trichotomized into: "definitely/likely yes", "not sure/don't know", and "definitely/likely not." RESULTS: The majority of participants (n = 486) were female (93%), Spanish speaking (74%), with a median age of 40 years (IQR = 13). Approximately half (48%) reported they would get a COVID-19 vaccine, 39% were unsure, and 13% reported "definitely/likely not". In the multivariable multinomial logistic regression model, participants with a household member with a COVID-19 health risk factor were more likely to be unsure about getting the vaccine. Participants who were primarily English speaking, did not receive the influenza vaccine last season, and reported not reading or talking about COVID-19 were more likely to report not intending to receive the vaccine. Many respondents were concerned about "side effects and ingredients", and did not trust the vaccine development process, particularly with how fast it happened. CONCLUSION: Low-income Latinos in Southern California were generally hesitant to get a COVID-19 vaccine. Culturally sensitive vaccine promotion campaigns need to address the concerns of minority populations who experience increased morbidity and mortality from COVID-19.

A Contactless Method for Measuring Full-Day, Naturalistic Motor Behavior Using Wearable Inertial Sensors.

How can researchers best measure infants' motor experiences in the home? Body position-whether infants are held, supine, prone, sitting, or upright-is an important developmental experience. However, the standard way of measuring infant body position, video recording by an experimenter in the home, can only capture short instances, may bias measurements, and conflicts with physical distancing guidelines resulting from the COVID-19 pandemic. Here, we introduce and validate an alternative method that uses machine learning algorithms to classify infants' body position from a set of wearable inertial sensors. A laboratory study of 15 infants demonstrated that the method was sufficiently accurate to measure individual differences in the time that infants spent in each body position. Two case studies showed the feasibility of applying this method to testing infants in the home using a contactless equipment drop-off procedure.

Office-Based Educational Handout for Influenza Vaccination: A Randomized Controlled Trial.

OBJECTIVES: To assess the impact of a parent educational intervention about influenza disease on child vaccine receipt. METHODS: A convenience sample of parents of children ≥6 months old with a visit at 2 New York City pediatric clinics between August 2016 and March 2017 were randomly assigned (1:1:1) to receive either usual care, an educational handout about influenza disease that was based on local data, or an educational handout about influenza disease that was based on national data. Parents received the handout in the waiting room before their visit. Primary outcomes were child influenza vaccine receipt on the day of the clinic visit and by the end of the season. A multivariable logistic regression was used to assess associations between intervention and vaccination, with adjustment for variables that were significantly different between arms. RESULTS: Parents who received an intervention (versus usual care) had greater odds of child influenza vaccine receipt by the end of the season (74.9% vs 65.4%; adjusted odds ratio 1.68; 95% confidence interval: 1.06-2.67) but not on the day of the clinic visit. Parents who received the national data handout (versus usual care) had greater odds of child influenza vaccine receipt on the day of the clinic visit (59.0% vs 52.6%; adjusted odds ratio 1.79; 95% confidence interval: 1.04-3.08) but not by the end of the season. CONCLUSIONS: Providing an educational intervention in the waiting room before a pediatric provider visit may help increase child influenza vaccine receipt.

The use of technology to promote vaccination: A social ecological model based framework.

Vaccinations are an important and effective cornerstone of preventive medical care. Growing technologic capabilities and use by both patients and providers present critical opportunities to leverage these tools to improve vaccination rates and public health. We propose the Social Ecological Model as a useful theoretical framework to identify areas in which technology has been or may be leveraged to target undervaccination across the individual, interpersonal, organizational, community, and society levels and the ways in which these levels interact.

Influenza Vaccination Beliefs and Practices in Elderly Primary Care Patients.

The majority of influenza related deaths and hospitalizations occur among individuals ≥65 years, yet the national influenza vaccination rate for this group is 63% and is lower in the Hispanic population. Previous studies have described negative predictors of vaccination; however, there is a knowledge gap of how influenza vaccine-specific beliefs affect vaccination rates. We examined the relationship between influenza vaccine health beliefs and vaccination behaviors in a cross sectional sample of 200 primarily Hispanic patients aged ≥65 years in an academic general internal medicine clinic. Participants were asked about perceptions of influenza vaccine effectiveness and safety. Interview responses regarding influenza vaccine concerns were evaluated qualitatively with conventional content analysis. Logistic regression evaluated associations between beliefs and self-reported vaccination the previous year, adjusted for age, gender, and language. Of those approached to complete the questionnaire, 88% participated. Self-reported influenza vaccination rate during the study year was 75%. Only 46.5% endorsed the belief that influenza vaccine is very effective and 47% that it is very safe. Many stated specific concerns about flu vaccine including that it causes side effects/adverse outcomes, is not effective, vaccine components are harmful, and vaccination is not necessary. Belief that the flu shot causes the flu and concern for variability of the flu shot were associated with reduced odds of vaccination (aOR 0.19, 95% CI [0.05, 0.83] and 0.06 [0.006, 0.63] respectively). The patient-perceived distinction between cold, flu, and other symptoms warrants further exploration. This information can be used to develop targeted communication to promote vaccination.

Early experience with medial femoral tension band plating in idiopathic genu valgum.

PURPOSE: For correction of angular deformity, tension band plating has been proposed as a safe and minimally invasive technique. The purpose of this study was to assess the experiences and report the rate of correction obtained with this procedure in patients with idiopathic genu valgum. METHODS: This study was a retrospective review of 47 valgus deformities of the knee treated with medial hemiepiphysiodesis using a tension band plate. The tibiofemoral angle (TFA) and the anatomic lateral distal femoral angle (aLDFA) were assessed on anteroposterior (AP) radiographs of the lower extremity taken at multiple time intervals. The values were charted to determine the change in orientation of the joint surface over time. Pearson's correlation was used to analyze the correction over time. A subanalysis was performed evaluating the effect of age and the number of plates utilized. RESULTS: A total of 47 deformities in 25 patients were reviewed. The average time of follow-up from index surgery was 12.7 months, with an average correction of 0.96° every 3 months or 3.8° per year. The aLDFA corrected at a faster rate in knees with two plates per hemiepiphysiodesis than those with one plate, 4.2° and 3.3° per year, respectively (P = 0.035). Girls <11 years of age and boys <13 years of age corrected at a rate of 4.5°, while older children corrected at a rate of 3.4° per year (P = 0.39). There were no complications or instrumentation breakages. CONCLUSION: Hemiepiphysiodesis with tension band plating provides an effective and predictable correction of idiopathic genu valgum. Two plates appear to provide a greater rate of correction. There is also a trend toward faster correction in younger patients as well.

Is ultrasound screening for DDH in babies born breech sufficient?

PURPOSE: To review our incidence of developmental dysplasia of the hip (DDH) in breech infants referred for ultrasound screening and to determine if subsequent follow-up radiographs are necessary in these patients with normal clinical and ultrasound examinations. METHODS: A review of the clinical data and imaging studies of all children with the risk factor of breech presentation that were referred for orthopedic evaluation over a 5-year period was conducted. All patients were examined by a fellowship-trained pediatric orthopedic surgeon and all ultrasounds were done at approximately 6 weeks of age by an experienced ultrasonographer. Ultrasounds were evaluated using the dynamic method as described by Harcke. As per our protocol, all patients with normal screening ultrasounds were brought back for a final clinical examination and radiographic check at 4-6 months. Acetabular dysplasia was indicated by radiographic parameters-if there was severe blunting of the sourcil, abnormal acetabular index for age, or if there was significant asymmetry of acetabular indices side-to-side-in the setting of clinical parameters-if there was greater than 10° difference in side-to-side abduction or symmetric abduction of less than 60°. RESULTS: Three hundred patients with the risk factor of breech presentation were included. Thirty-four patients had clinically unstable hips; 266 had clinically stable hips and were screened by ultrasound. Sixty-four percent were female and 36% were male. Twenty-seven percent of these breech patients had abnormal screening ultrasounds and were subsequently treated. Of the remaining 73% with normal ultrasounds, who were returned per protocol at a mean of 5 months, 29% had evidence of dysplasia and underwent treatment. The diagnosis of dysplasia following a normal ultrasound was based on both radiographic and clinical parameters. Of the hips treated with a Pavlik harness, 62% had acetabular indices at least two standard deviations from the age-corrected average versus 26% of patients not treated. The average length of follow-up was 10 months. CONCLUSIONS: Retrospectively, we found that, at approximately 6 weeks of age, ultrasound screening of breech patients with clinically stable hips produces an incidence of DDH of 27%. In those patients with a normal ultrasound, 29%, at 4-6 months radiographic follow-up, were found to have dysplasia requiring treatment. This data supports breech as the most important risk factor for hip dysplasia and we, therefore, recommend careful and longitudinal evaluation of these patients with: a careful newborn physical examination, an ultrasound at age 6 weeks, and an anteroposterior (AP) pelvis and frog lateral radiograph at 6 months, as the risk of subsequent dysplasia is too high to discharge patients after a normal ultrasound.

Severe vitamin D deficiency among heart and liver transplant recipients.

INTRODUCTION: Although patients with end-stage organ failure are at high risk for vitamin D deficiency because of limited sunlight exposure and hepatic dysfunction, few studies have measured 25-hydroxy vitamin D (25OHD) at the time of transplantation. METHODS: We measured serum 25OHD immediately after transplantation in 69 heart and liver transplant recipients. RESULTS: Forty-six heart and 23 liver transplant recipients were evaluated (mean age 53 yr). Mean 25OHD was well below the lower limit of the normal range (43.2 +/- 21.2 nmol/L). Ninety-one percent had levels below 75 nmol/L, the threshold commonly used to denote sufficiency, and 71% had levels below 50 nmol/L. Severe deficiency (25OHD <25 nmol/L) was found in 16%. Vitamin D levels did not differ by race, age, gender, or season. Mean 25OHD was lower among liver than heart transplant recipients (34.4 +/- 17.5 vs. 47.7 +/- 20.7 nmol/L; p < 0.03). Among liver transplant recipients, 22% had undetectable levels (<17 nmol/L). CONCLUSIONS: Vitamin D deficiency is highly prevalent among heart and liver transplant recipients; those with liver failure are at greatest risk. As vitamin D deficiency has many serious skeletal and extra-skeletal sequelae, physicians who treat transplant patients should maintain a high degree of vigilance for this problem.

Retrospective comparison of nebulized levalbuterol and albuterol for adverse events in patients with acute airflow obstruction.

The objective of this study was to retrospectively compare the mean change in heart rate (HR) of patients with acute airflow obstruction treated with nebulized levalbuterol vs. albuterol. The study was conducted at the Akron General Medical Center, a 537-bed adult tertiary care teaching and research medical center. The participants were patients (> or = 18 years old) presenting to the emergency department with acute airflow obstruction. This was a retrospective chart review. Treatment groups received either levalbuterol (0.63 mg) or albuterol (2.5 mg). Respiratory care notes record HRs before and after nebulization of levalbuterol or albuterol. Primary analysis was conducted on days 1 and 3 of therapy to determine whether there is a difference between levalbuterol and albuterol with regard to mean change in HR with each treatment. In the primary analysis data, 35 subjects in each treatment group were compared. The mean age (+/- SD) was 65 +/- 16.4 and 68 +/- 16.5 for levalbuterol and albuterol, respectively. On day 1 of therapy, the difference in the mean change in HR with albuterol compared with levalbuterol was 1.0 bpm (95% CI, -1.6 to 3.7). On day 3, a statistically significant difference occurred in mean change in HR between treatment groups at 2.7 bpm (95% CI, 0.02 to 5.4). An increase in HR of 2.7 bpm by albuterol compared with levalbuterol on day 3 of therapy was the only significant finding among the analyses. However, this finding did not demonstrate dangerous elevations in HR following treatment with albuterol. Even the upper end of the confidence interval range at 5.4 bpm does not support a clinically significant difference in tachycardia with the pure isomer compared with the racemic mixture during acute airway obstruction.

Leptin gene expression in human preadipocytes is switched on by maturation-induced demethylation of distinct CpGs in its proximal promoter.

The peptide hormone leptin plays a major role in the regulation of energy intake and expenditure and is predominantly expressed in mature adipocytes but not in preadipocytes. Using bisulfite genomic sequencing, we found that 32 CpGs, distributed within a 317-bp sequence of the proximal leptin promoter, were highly methylated in human preadipocytes (73.4% +/- 9.0%). During maturation toward terminally differentiated adipocytes, this promoter region was extremely demethylated (9.4% +/- 4.4%). CpG methylation-dependent transcriptional activity of the promoter fragment was determined in transfection experiments using a set of 5'-truncated mock-, HhaI-, and SssI-methylated promoter-reporter constructs. Whereas the methylated CpG within the CCAAT/enhancer-binding protein alpha recognition site down-regulated reporter expression, methylated CpGs proximal to the TATA motif and/or in a further upstream region abrogated promoter activity completely. These distinct promoter CpG sequences were found unmethylated in leptin-expressing mature adipocytes. As evidenced by electrophoretic mobility shift assays, nuclear protein complexes were specifically formed on methylated oligonucleotide probes corresponding to the dedicated promoter sequences, indicating that methyl-CpG binding proteins participate in transcriptional repression and regulation of the human leptin gene.