Special management considerations for propranolol use in breastfed infants of mothers taking antihypertensives.

Propranolol is approved for treatment of infantile hemangiomas (IH). IH proliferation coincides with the time when most women are breastfeeding, yet there are no reports describing the clinical effects on infants treated with propranolol while being nursed by mothers on oral antihypertensive medications. We describe two cases of breastfed infants, with mothers taking multiple antihypertensives of different drug classes, who were initiated on propranolol for IH treatment and discuss the theoretical risk of propranolol use in this setting.

Cerebro-facio-thoracic dysplasia (Pascual-Castroviejo syndrome): Identification of a novel mutation, use of facial recognition analysis, and review of the literature.

BACKGROUND: Cerebro-facio-thoracic dysplasia (CFTD) is a rare, autosomal recessive disorder characterized by facial dysmorphism, cognitive impairment and distinct skeletal anomalies and has been linked to the TMCO1 defect syndrome. OBJECTIVE: To describe two siblings with features consistent with CFTD with a novel homozygous p.Arg114* pathogenic variant in the TMCO1 gene. METHODS: We conducted a literature review and summarized the clinical features and laboratory results of two siblings with a novel pathogenic variant in the TMCO1 gene. Facial recognition analysis was utilized to assess the specificity of facial traits. CONCLUSION: The novel homozygous p.Arg114* pathogenic variant in the TMCO1 gene is responsible for the clinical features of CFTD in two siblings. Facial recognition analysis allows unambiguous distinction of this syndrome against controls.

Reasons for Infant Feeding Decisions in Low-Income Families in Washington, DC.

BACKGROUND: Breastfeeding rates for low-income, African American infants remain low. OBJECTIVE: This study aimed to determine the barriers, support, and influences for infant feeding decisions among women enrolled in the Washington, DC, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) after revisions in the WIC package to include more food vouchers for breastfeeding mothers and their infants and improvement of in-hospital breastfeeding support. METHODS: We surveyed 100 women, using a 42-item verbally administered survey that asked about demographics, infant feeding method, and influences and support for feeding decisions. RESULTS: The majority of participants (76%) initiated breastfeeding; 31% exclusively breastfed in the hospital. Participants were more likely to breastfeed if they had some college education, were unemployed or employed full-time, had only one child, and had been breastfed themselves as infants. Barriers to prolonged breastfeeding included limited support after hospital discharge, pain, and perceived insufficient milk supply. Participants in this study had higher breastfeeding initiation and in-hospital exclusivity rates after improvement of in-hospital breastfeeding support. CONCLUSION: Clients of WIC initiated breastfeeding at a high rate but either supplemented with formula or stopped breastfeeding for reasons that could be remedied by improved prenatal education, encouragement of exclusive breastfeeding in the hospital, and more outpatient support.

Breastfeeding in African Americans may not depend on sleep arrangement: a mixed-methods study.

BACKGROUND: Despite high bedsharing rates, breastfeeding rates are low among African Americans. OBJECTIVE: Describe the association between breastfeeding and bedsharing; elucidate barriers to breastfeeding in African Americans. METHODS: African American mothers with infants <6 months were recruited for this cross-sectional, mixed-methods study and completed an infant care practices survey. A subgroup participated in focus groups or individual interviews. RESULTS: A total of 412 completed the survey; 83 participated in a focus group or interview. Lower socioeconomic status mothers were more likely to breastfeed exclusively or at all if they bedshared (P = .02 and P = .01, respectively). Bedsharing was not associated with breastfeeding among higher socioeconomic status mothers. Breast pain, lack of support, and maternal skepticism about breastfeeding benefits were barriers; the latter was a recurrent theme among nonbreastfeeding mothers. CONCLUSIONS: While bedsharing is associated with breastfeeding in lower socioeconomic groups, it is not in higher socioeconomic African American groups. Skepticism about breastfeeding benefits may contribute to low breastfeeding rates in African Americans.

Surveying the knowledge, attitudes, and practices of District of Columbia ACOG members related to breastfeeding.

Although the American Academy of Pediatrics and the American Congress of Obstetricians and Gynecologists (ACOG) recommend exclusive breastfeeding for the first 6 months, only 14.6% of babies born in the District of Columbia (DC) reached this goal. Breastfeeding support from providers has been shown to increase exclusive breastfeeding. We aim (1) to describe breastfeeding knowledge and attitudes, (2) to determine the presence of breastfeeding in routine prenatal discussions, and (3) to determine the knowledge of facility adoption of the Perinatal Care (PC) Core Measure Set among DC ACOG members. A survey sent to DC ACOG members assessed knowledge, attitudes, and practices related to breastfeeding and evaluated participants' barriers to breastfeeding counseling, management of breastfeeding challenges, and awareness of facility adoption of the PC Core Measure Set. All 29 respondents reported breastfeeding as the best infant nutrition and that physicians should encourage breastfeeding. However, despite 75% reporting counseling most of their patients regarding breastfeeding, only 27% reported that most of their patients were breastfeeding at the postpartum visit. Participants scored 83% correct on knowledge-based questions. Perceived barriers to breastfeeding counseling included lack of time (66%), reimbursement (10%), and competence in managing breastfeeding problems (7%). Most respondents were unsure of both adoption of, and breastfeeding data collection for, the PC Core Measure Set (52% and 55%, respectively). Participants had knowledge gaps and identified barriers to discussing breastfeeding. There was limited awareness of hospital data collection about breastfeeding. These results indicate a need for more breastfeeding education among DC obstetricians-gynecologists and better outreach about the PC Core Measure Set.

Educating pediatric residents about breastfeeding: evaluation of 3 time-efficient teaching strategies.

BACKGROUND: Previously reported breastfeeding curricula for residents have combined different teaching methods, have focused on knowledge and attitudes, and have been time-intensive. OBJECTIVE: This study aimed to evaluate 3 time-efficient breastfeeding curricula for effectiveness in regard to pediatric residents' knowledge, confidence, and skills in managing a simulated breastfeeding scenario. METHODS: First-year pediatric residents during their 4-week community hospital newborn nursery rotation were consecutively assigned to 1 of 3 groups. Group 1 shadowed an International Board Certified Lactation Consultant (IBCLC) for 1 hour; group 2 watched a 25-minute case-based breastfeeding DVD; and group 3 observed a 3-hour prenatal parent breastfeeding class (CLS). Residents were assessed by (1) a pretest and posttest evaluating their breastfeeding knowledge and confidence, and (2) a clinical skills scenario managing a breastfeeding standardized patient (SP). RESULTS: Thirty-nine pediatric residents participated in the study (11 in IBCLC, 16 DVD, 12 CLS) over a 1-year period. All groups significantly improved their knowledge scores and confidence in managing breastfeeding problems, with the IBCLC group showing more improvement in knowledge than the other groups (P = .02) and a higher rating of their teaching method (P = .01). All groups performed well on the SP clinical skills scenario, with no significant difference between groups. CONCLUSION: All 3 teaching methods were time-efficient and produced important gains in knowledge and confidence, with residents in the IBCLC group demonstrating greatest improvement in knowledge and a higher rating of their teaching method. Our study provides support for 3 methods of teaching residents breastfeeding management and demonstrates that IBCLCs are well-received as interprofessional educators.

The DC breastfeeding-friendly hospital initiative: an evaluation of hospitals' support for breastfeeding in the capital of the United States.

Maternity facilities that follow the 10 steps of the Baby-Friendly Hospital Initiative have improved breastfeeding outcomes. Prior to the DC Breastfeeding-Friendly Hospital Initiative, no maternity facilities in Washington, DC, were recognized as Baby-Friendly. Each facility's journey toward improved breastfeeding support is unique. The purpose of this project was to help facilities identify areas to focus on in pursuit of this goal. All 8 birthing facilities in Washington, DC, participated in the baseline assessment in September 2008. The 10 steps were used as a framework for developing the assessment tools. Data were collected from each facility regarding (1) accessibility of breastfeeding information and resources on its website, (2) content of written breastfeeding policies, and (3) practices that support breastfeeding. The DC Breastfeeding Coalition shared the outcomes of the assessment with each facility and offered an educational session addressing each facility's specific needs. The coalition also conducted postintervention evaluations between July and August 2009 to assess changes in each facility's score. Most facilities were receptive to the intervention, resulting in modest improvements in all areas reviewed. This project provides a model for state and local breastfeeding coalitions to evaluate and recognize incremental improvements in breastfeeding-related maternity care practices.

Reasons for in-hospital formula supplementation of breastfed infants from low-income families.

In-hospital formula supplementation of breastfed infants negatively impacts breastfeeding duration. Infants from low-income families have some of the lowest exclusive breastfeeding rates in the United States. The objectives of this study were to identify (1) reasons low-income breastfeeding mothers begin in-hospital formula supplementation and (2) risk factors for in-hospital formula supplementation. We surveyed 150 low-income mothers in a Washington, DC, clinic. Sixty percent had initiated breastfeeding, and 78% of these breastfed infants received formula supplementation in the hospital. There was no clear medical need for supplementation for 87% of the breastfed infants receiving supplementation. Infants of mothers who did not attend a prenatal breastfeeding class were almost 5 times more likely to receive in-hospital formula supplementation than those infants whose mothers had attended a class (OR, 4.7; 95% CI, 1.05-21.14). Improved knowledge about breastfeeding among nursing and medical providers is important to minimize unnecessary formula supplementation for breastfed infants.

Decreasing variability in faculty ratings of student case presentations: a faculty development intervention focusing on reflective practice.

BACKGROUND: Faculty perceptions of medical student knowledge are often based on case presentations, but their assessment of student performance can vary significantly based on content, presentation skill, and interpersonal characteristics. PURPOSE: To determine if a brief faculty development intervention could significantly decrease (>or= 20%) faculty members' variability in rating student case presentations in the ambulatory setting. METHODS: During the 1998-99 academic year, we videotaped 10 third-year medical students during one well-child presentation. Seven general pediatric faculty rated the videotapes using a validated scoring instrument measuring content: History of Present Illness (HPI), Past Medical History, and Physical Exam (PE); and communication skill: Precision of Language, Fluency, and Economy. Baseline ratings were from June to September 1999 and then repeated in October to November 2000 following a workshop where faculty reflected on the rating process and decreasing rating variance. The change in mean faculty ratings of the student's overall performance and for each item and the change in the mean difference in standard deviation before and after the workshop were analyzed. RESULTS: Internal consistency of the scoring instrument using Cronbach's alpha was 0.88. The mean faculty rating for overall presentation performance and the PE did not significantly change after the workshop, whereas for all other items it did. The mean standard deviation of faculty ratings decreased significantly for the overall performance and all other items except HPI. CONCLUSION: Despite using a validated scoring instrument to rate student case presentations significant variability exists among faculty, with rating inflation likely. A brief faculty development intervention using "reflection-on-action" was associated with more congruent ratings in the short term.