Implementing a Hospital-Based Safe Sleep Program for Newborns and Infants.

BACKGROUND: An unsafe sleep environment remains the leading contributor to unexpected infant death. PURPOSE: To determine the effectiveness of a quality improvement initiative developed to create a hospital-based safe sleep environment for all newborns and infants. METHODS: A multidisciplinary team from the well-baby nursery (WBN) and neonatal intensive care unit (NICU) of a 149-bed academic, quaternary care, regional referral center developed and implemented safe sleep environments within the hospital for all prior to discharge. To monitor compliance, the following were tracked monthly: documentation of parent education, caregiver surveys, and hospital crib check audits. On the inpatient general pediatric units, only hospital crib check audits were tracked. Investigators used Plan-Do-Study-Act (PDSA) cycles to evaluate the impact of the initiative from October 2015 through February 2018. RESULTS: Safe sleep education was documented for all randomly checked records (n = 440). A survey (n = 348) revealed that almost all caregivers (95.4%) reported receiving information on safe infant sleep. Initial compliance with all criteria in WBN (n = 281), NICU (n = 285), and general pediatric inpatient units (n = 121) was 0%, 0%, and 8.3%, respectively. At 29 months, WBN and NICU compliance with all criteria was 90% and 100%, respectively. At 7 months, general pediatric inpatient units' compliance with all criteria was 20%. IMPLICATIONS FOR PRACTICE: WBN, NICU and general pediatric inpatient unit collaboration with content experts led to unit-specific strategies that improved safe sleep practices. IMPLICATIONS FOR RESEARCH: Future studies on the impact of such an initiative at other hospitals are needed.

Interpreting Osteogenesis Imperfecta Variants of Uncertain Significance in the Context of Physical Abuse: A Case Series.

Unexplained childhood fracture(s) warrant consideration of physical abuse and osteogenesis imperfecta (OI). Genetic OI testing may identify "variants of unknown significance (VUS)." Interpretation of VUS in context of potential abuse may have protective, criminal, and medical impacts. This case series explores practices regarding clinicians' interpretation of VUS during child abuse evaluations. Variability was noted regarding factors considered for interpreting clinical significance. Based on these cases, recommendations for careful and thorough evaluation are detailed, including proposed use of a limited follow-up skeletal survey in 3 months, as a consideration to assess healing of prior fractures and to look for any additional injuries.

The Interpretation of Repeat Positive Results for Gonorrhea and Chlamydia in Children.

BACKGROUND: The diagnosis of gonorrhea and/or chlamydia in a prepubertal child beyond the neonatal period is confirmatory of mucosal contact with infective bodily secretions and therefore highly concerning for sexual abuse. When such a diagnosis is made, a report to protective authorities is warranted so that safety and potential criminal activity may be evaluated concurrent with the medical management. Occasionally, despite perceived adequate medical management and protective safety plans, a child may present with a repeat positive result for sexually transmitted infections. In this scenario, it is important for medical providers to carefully consider and be aware of the possible reasons for the repeat positive result: (1) treatment failure, (2) a new infection from repeated abuse, or (3) a false-positive result due to the limitations of nonculture testing. CASE: Prepubertal sisters were diagnosed with gonorrhea and Chlamydia and treated with antibiotics, and the individual identified as having sexually abused them was removed from the home. SUMMARY AND CONCLUSION: Over a 4-month period, both children continued to have positive testing for chlamydia via the nucleic acid amplification test and/or culture. Concurrent with using alternate antibiotic treatment options, protective authorities were alerted to the fact that this was likely a reinfection. The investigative team later determined that a second adult, who tested positive for gonorrhea and chlamydia, was also sexually abusing both girls. Disclosures of abuse regarding both adult individuals were deemed credible by authorities and supported with collateral information.

The impact of a hospital-based educational video on maternal perceptions and planned practices of infant safe sleep.

PURPOSE: To evaluate whether an educational video would impact infant sleep practices among new mothers. DESIGN AND METHODS: Survey responses of new mothers who did (n = 43) versus did not (n = 49) watch the educational video were compared to identify differences in observed and planned infant sleep practices. RESULTS: Mothers who watched the video were more likely to observe safe sleep practices while in the hospital (67.4% vs. 46.9%, p < .05). They were also less likely to plan for (unsafe) side positioning (23.9% vs. 7.1%, p < .05). PRACTICE IMPLICATIONS: Given the potentially fatal consequence of unsafe sleep, a brief video provided by nursing staff can be a prudent component of new parent education.

Is fluorescence under an alternate light source sufficient to accurately diagnose subclinical bruising?

This single-blinded, randomized validation study was conducted to evaluate whether fluorescence under alternate light sources (ALS) is sufficient to diagnose subclinical bruising (bruising not visible under white light). Standardized trauma was induced on randomly selected ventral forearms. On days 1, 7, and 14 investigators independently examined case forearms under white light for perceived bruising and under ALS for fluorescence and compared body maps. 56 case and 62 control forearms (n = 118) were examined. Sensitivity of ALS on days 1, 7, and 14 was 76.8%, 69.6%, and 60.7%, respectively, compared to 69.6%, 60.0%, and 32.1% for white light. The specificity of ALS on days 1, 7, and 14 was 51.6%, 59.7%, and 53.2%, respectively, compared to 71.0%, 81.4%, and 86.9% for white light. ALS has increased sensitivity yet low specificity compared to white light in accurately detecting bruises. Fluorescence under ALS is not sufficient to accurately or responsibly diagnose subclinical bruising.

Parent education by maternity nurses and prevention of abusive head trauma.

OBJECTIVE: A consortium of the 19 community hospitals and 1 tertiary care children's hospital that provide maternity care in the New York State Hudson Valley region implemented a program to teach parents about the dangers of shaking infants and how to cope safely with an infant's crying. This study evaluated the effectiveness of the program in reducing the frequency of shaking injuries. METHODS: The educational program, which was delivered by maternity nurses, included a leaflet explaining abusive head trauma ("shaken baby syndrome") and how to prevent it, an 8-minute video on the subject, and a statement signed by parents acknowledging receipt of the information and agreeing to share it with others who will care for the infant. Poisson regression analysis was used to compare the frequency of shaking injuries during the 3 years after program implementation with the frequency during a 5-year historical control period. RESULTS: Sixteen infants who were born in the region during the 8-year study period were treated at the children's hospital for shaking injuries sustained during their first year of life. Of those infants, 14 were born during the 5-year control period and 2 during the 3-year postimplementation period. The decrease from 2.8 injuries per year (14 cases in 5 years) to 0.7 injuries per year (2 cases in 3 years) represents a 75.0% reduction (P = .03). CONCLUSIONS: Parent education delivered in the hospital by maternity nurses reduces newborns' risks of sustaining an abusive head injury resulting from shaking during the first year of life.