Promoting education, mentorship, and support for pediatric research.

Pediatricians have an important role to play in the advancement of child health research and should be encouraged and supported to pursue research activities. Education and training in child health research should be part of every level of pediatric training. Continuing education and access to research advisors should be available to practitioners and academic faculty. Recommendations to promote additional research education and support at all levels of pediatric training, from premedical to continuing medical education, as well as suggestions for means to increase support and mentorship for research activities, are outlined in this statement.

Hospital infant formula discharge packages. Do they affect the duration of breast-feeding?

OBJECTIVE: To determine whether the duration of breast-feeding is affected by the contents of the hospital discharge package. DESIGN: A randomized clinical trial with 2 experimental interventions (a discharge package containing a manual breast pump only and a discharge package containing a commercially prepared infant formula and a manual breast pump) and a control group who received a commercially prepared infant formula discharge package only. Sociodemographic characteristics and information concerning prior births (including feeding methods) were obtained from each mother within 48 hours of her infant's birth. Sources of influence on the mother's feeding decision, maternal attitudes concerning breast-feeding, and maternal feeding preferences were also assessed. PARTICIPANTS: The sample consisted of 763 women who had given birth who were admitted to the maternal-fetal unit of a midwestern community hospital. MAIN OUTCOME MEASURES: Information concerning current method of infant feeding was obtained from telephone interviews conducted at 2-week intervals until the infant was 16 weeks old. The data were analyzed using descriptive statistics, multivariate analysis of variance, logistic regression analysis, and survival analysis. RESULTS: The content of the hospital discharge package did not affect whether the mother engaged in exclusive or partial breast-feeding during the 16-week follow-up interval. However, there was some evidence that providing formula samples at discharge from the hospital increased the duration of exclusive breast-feeding compared with providing a manual breast pump. CONCLUSION: This study does not support the assumption that inclusion of infant formula in hospital discharge packages decreases the duration of breast-feeding.

Does increased nitrate ingestion elevate nitrate levels in human milk?

OBJECTIVE: To determine whether the nitrate content of human milk is influenced by maternal ingestion of water containing elevated nitrate levels. DESIGN: Prospective, nonrandomized, volunteer study. SETTING: Clinical Research Center at the University of Iowa Hospitals and Clinics, Iowa City. PATIENTS: Twenty healthy lactating women with infants older than 6 months. INTERVENTIONS: The mothers were asked to consume a minimum of 1500 mL of water containing 0 mg of nitrate per liter on day 1, 45 mg on day 2, and 100 mg on day 3 in addition to consuming and recording their dietary intake. Breast-feeding was permitted during days 1 and 2, but milk was expressed on day 3 and the infants were given alternate food sources. After each 24-hour study day, maternal urine and milk samples were collected and frozen. A modified cadmium column reduction method was used to determine spot urinary and milk nitrate content. RESULTS: The meant total nitrate intake from diet and water on days 1,2, and 3, respectively, was 46.6, 168.1, and 272.0 mg. Spot urine nitrate content on days 1, 2, and 3, respectively, was 36.0, 66.0, and 84.0 mg. Nitrate concentration of human milk on days 1,2, and 3, respectively, was 4.4, 5.1 and 5.2 mg/L. CONCLUSION: Women who consume water with a nitrate concentration of 100 mg/L or less do not produce milk with elevated nitrate levels.

Elevated environmental lead levels in a day care setting.

OBJECTIVE: To determine the risk of lead poisoning among children enrolled in day care centers with elevated environmental lead burdens. DESIGN: Survey. SETTING: Six day care centers on properties owned by a major state-supported university. PATIENTS AND OTHER PARTICIPANTS: One hundred fifty-five of 234 eligible children (mean age, 4.8 years) enrolled in these centers were screened by questionnaire for risk factors of lead exposures. Blood samples for lead levels were also obtained. Observations of day care activities relative to lead exposure risks were recorded. Analyses of lead levels in paint, dust, and/or soil samples at the six centers were obtained. MAIN OUTCOME MEASURES: Prevalence of elevated blood lead levels and associated behavioral risk factors for lead exposure in children attending day care centers. RESULTS: Elevated levels of lead in paint (2.4% to 40% lead) were present in all day care facilities. Three day care centers had elevated lead levels in windowsill dust (62,000 to 180,000 micrograms [corrected] of lead per square meter) or soil (530 to 1100 mg of lead per kilogram): Questionnaires documented low risk for lead exposure to children in the home environments. Direct observations in the day care setting revealed optimal supervision and hygiene of the children. Blood lead levels were less than 0.5 mumol/L (10 micrograms/dL) in all but one of the 155 children screened. CONCLUSIONS: Children attending day care centers with high environmental lead burdens need further documentation of blood lead levels, at-risk behaviors, and lead exposure risks in the home environments as an adjunct to the instigation of lead abatement procedures at the day care centers.

Impact of attitudes on maternal decisions regarding infant feeding.

It is essential that physicians and other health care professionals seeking to increase the rate of initiation and duration of breast-feeding build on the body of information concerning factors that influence a woman's attitudes about breast-feeding. The relation between positive attitudes concerning breast-feeding and its initiation is important to the development of programs targeting women before they become pregnant, and to the provision of active support for breast-feeding throughout the pregnancy, perinatal, and postnatal period. However, it is not sufficient for these programs to target only the mother or potential mother; members of a woman's social network must be considered as information targets. Educational programs must also be directed to the appropriate racial or ethnic group to develop programs that reach the individuals (father, female relative, or friend) most likely to influence the mother's breast-feeding decision. Physicians may be very knowledgeable about the nutritional and immune properties of human milk and yet not be supportive of the act of breast-feeding. This lack of support may be manifested by the lack of verbal support for women who intend to or are in the process of breast-feeding, the provision of infant formula before or at the time of birth of the baby, or encouragement to terminate breast-feeding should the mother encounter any difficulties with lactation. To increase physician awareness of the process of breast-feeding and the properties of human milk, information about the benefits should be integrated in both the basic science and the clinical curricula of medical schools. Primary care training programs, including obstetrics, should actively involve trainees in the management of breast-feeding women so that trainees become aware of the spectrum of circumstances that confront women seeking to establish and maintain successful breast-feeding. This type of involvement would provide a contextual base for physicians' understanding the attitudes and behaviors supportive of breast-feeding. Attitudes and behavior of women, although more complex then demographic factors, provide a powerful tool for meeting the Healthy People 2000 goals for the initiation and duration of breast-feeding. It is important to build on the base of research reviewed here to develop new and and more powerful interventions. Thus the emphasis on the known health advantages of human milk or the discovery of additional health benefits of breast-feeding should continue to be discussed because they may tip the balance in favor of breast-feeding for some women. Nevertheless, it may ultimately be more important to increase the amount of information provided to women (and girls and boys) about the practical aspects of the breast feeding process (e.g., ease of night feeding, fathers ability to feed mother's milk by bottle, lower cost, strategies to control leaking) then to rely solely on the positive health outcomes related to breast-feeding.

Nitrate in baby foods. Adding to the nitrate mosaic.

OBJECTIVE: To identify commercial baby food varieties high in nitrate content using ion chromatography and compare the health risk associated with the consumption of high-nitrate water and high-nitrate commercial baby food. DESIGN: Ion chromatographic determination of nitrate concentration in a variety of commercial baby foods. SETTING: University Hygienic Laboratory, University of Iowa College of Medicine, Iowa City. PATIENTS: None. RESULTS: Commercial baby foods with nitrate levels higher than 45 ppm include mixed vegetables, bananas, carrots, garden vegetables, spinach, green beans, and beets. The amount of nitrate in one 113-g (4 oz) jar of beets, for example, is equivalent to the amount of nitrate in nearly 5.5 L of water at 45 ppm nitrate. CONCLUSIONS: A controlled clinical trial is needed to clarify how consuming high-nitrate foods correlates with methemoglobin levels in infants younger than 6 months.

Maternal attitudes as predictors of infant feeding decisions.

To achieve the goal of Healthy People 2000 of increasing the rate and duration of breast-feeding in the United States, it is important to determine how maternal attitudes influence choice of infant feeding method. This study of postpartum women explores the extent to which maternal attitudes concerning process (how the baby is fed) and product (what the baby is fed) can predict the method of infant feeding during the hospital stay. A cross-sectional analysis of mothers' attitudes and infant feeding behavior was conducted. The participants included 216 mothers of infants less than 48 hours of age. Sociodemographic characteristics and maternal attitudes were analyzed to determine their ability to predict choice of feeding method. The results of the study indicate that maternal attitudes are better predictors of feeding method than are sociodemographic factors. These attitudinal variables, reflecting concerns over food intake, infant nutrition, and parental role, were most strongly related to choice of infant feeding method. The study indicates that maternal attitudes concerning the process and product dimensions of infant feeding provide valuable information regarding the women most likely to select either breast-feeding or formula-feeding. To increase the rate of breast-feeding, interventions should be developed that are consonant with positive maternal attitudes concerning the process and product dimensions of breast-feeding.

Behavioral problems among twins.

Despite the frequency of multiple births, little information is available to assist parents and health professionals in the identification and management of behavior problems in multiple-birth siblings. Three case reports are presented that describe quarreling, aggression, and feeding problems among twins. To develop intervention strategies most appropriate for the problem behavior, it is important to determine whether (1) parents are able to effectively implement the intervention strategy, (2) behavior is isolated to one sibling, and (3) different reasons are responsible for similar behavior in siblings. Structured observations were used to determine whether the undesired behavior occurred to escape nonpreferred activities, gain access to preferred activities, or obtain parental attention. The cases provide a framework to facilitate the identification and management of common behavior problems occurring among multiple-birth siblings.

Physicians treating their own children.

OBJECTIVES: To determine the types of health care interventions physicians provided to their own children, identify those conditions most often treated by physician-parents, compare the differences in treatment practices among physician groups, and explore the reasons physicians give for treating their own children. DESIGN: Questionnaire. SETTING: University-affiliated teaching hospital in Iowa City, Iowa. PARTICIPANTS: Three hundred fifty-three physicians in residency and fellowship training and faculty who were parents of children aged 18 years or younger. INTERVENTIONS: None. MEASUREMENTS/MAIN RESULTS: The majority of physicians reported treating their afebrile child for acute illness. Fifty-five percent of physicians reported that they rarely or never treated their febrile child (temperature > 38.3 degrees C) without consultation with the child's physician. Only 47% of physicians reported that they always performed a physical examination on their child before treating. Physician-parents were more likely to auscultate the child's chest or perform otoscopy and less likely to obtain urine samples or throat swabs for culture before treating. Sixty-two percent of physicians reported that they have never performed routine health maintenance examinations on their own children, but 29% referred their children to a specialist. Medications were prescribed for their children by 65% of physicians. Neither gender nor level of training influenced the treatment practices of physician-parents. Primary care physicians were less likely to contact the child's physician for advice in treating their febrile child than were subspecialists. Pediatricians more often treated their afebrile and febrile children, performed physical examinations and laboratory studies, and prescribed medications than did other primary care physicians. Convenience was the most important reason physicians gave for treating their own children. CONCLUSIONS: Physicians frequently treat their own ill children, prescribe medications for them, and self-refer them to specialists largely for the sake of convenience.

Effect of discharge samples on duration of breast-feeding.

The breast-feeding patterns of 146 women who initiated breast-feeding during their hospital stay were evaluated to determine whether those women who received a hospital discharge package containing a manual breast pump breast-fed their infants for a longer period of time than did women who received a discharge package containing an infant formula. Women were randomly assigned to receive either a specially prepared pack containing a manual breast pump but no infant formula or a commercially available infant formula package. The women were interviewed in the hospital and by computer-assisted telephone interviews at 2, 4, 6, and 8 weeks postdischarge. Information obtained included infant-feeding practices, sociodemographic characteristics, and attitudinal data. Follow-up interviews were completed for nearly 85% of eligible women at each time period. Women who received a discharge pack containing a breast pump but no infant formula continued exclusive breast-feeding for a greater number of weeks (mean = 4.18 weeks) than did women receiving infant formula in their discharge package (mean = 2.78 weeks) (P less than .05). Also, women who indicated that ease of nighttime feeding was an important consideration were more likely to breast-feed over the entire 8-week period if they received the breast pump rather than infant formula (P less than .05). The conclusion is that an easily implemented, low-cost intervention, the inclusion of a breast pump in discharge packages, may increase the duration of breast-feeding.

Growth and the nutritional status of nonsteroid-dependent asthmatic children.

Nonsteroid dependent children were evaluated to determine the effect of asthma on growth and nutritional status. No significant differences were observed for the growth of asthmatics and control groups. In addition, dietary records indicated asthmatics met or exceeded the recommended daily allowance for total calories and nutrients.

Breast feeding preference of Hispanic and Anglo women. 1978-1985.

Hispanic women of Mexican origin are one of the fastest growing minority groups in the United States, but little information is available regarding the rate of breast feeding among this group of women. The breast feeding preferences of Hispanic women delivering at a southern California university hospital were determined by retrospective analysis of birth log records from 1978 to 1985. Approximately 95 percent of the Hispanic women delivering at this institution were of Mexican origin. Hispanic women had a preference for breast feeding similar to the national average for the same time period. The rate of breast feeding among Hispanic women of Mexican descent was consistently higher than previous reports from other regions of the United States.

Normal hematologic values and prevalence of anemia in children living on selected Pacific atolls.

The hematologic status of infants and children living on the small islands of the Pacific basin has been poorly documented. This report determines the normal ranges for hemoglobin (Hb) and mean corpuscular volume (MCV) for children residing on four of the small atolls of the Republic of the Marshall Islands in the archipelago of Micronesia. The difficulty in establishing normal hematologic values in pediatric populations is discussed and a methodology suggested that does not exclude any Hb value above the mean in determining the normal range for Hb. The study population was comprised of 563 Marshallese children representing approximately 3.4% of all children less than 16 years of age living in the Marshall Islands. The local prevalence of anemia and iron deficiency was also established.

Aeroallergen exposure in the elementary school setting.

Ten elementary schools in southern California were surveyed to identify and quantitate allergens present in the school environment. The Anderson sampler was used to quantitate viable molds. Pollens and non-viable molds were determined by roto rod techniques. Statistically significant differences existed between indoor and outdoor mean counts for molds and pollens identified by roto rod techniques. Viable mean mold spore counts inside schools compared favorably to local homes. House dust mites were found in considerably lower concentrations in the schools than in homes in the same area. Results indicate that the school interior is a protective environment for individuals sensitive to mold, pollens, and house dust mites.

Personal preferences and ethnic variations among Anglo and Hispanic breast and bottle feeders.

The preferences of Spanish-speaking Hispanics and English-speaking Anglos for breast and bottle feeding were evaluated using marketing research techniques. Preliminary interviews with 55 mothers conducted within the first 48 hr post-partum elicited a list of verbatim responses regarding the positive and negative aspects of both feeding methods. An additional 195 women rank-ordered the most frequently mentioned statements in terms of their preference for each. Socio-demographic data on the mothers were analyzed with chi-square analysis and discriminant analysis. Multidimensional scaling was used to assess the preferred characteristics of breast and bottle feeding. Results indicated that most mothers prefer a method of infant feeding that allows the mother to be 'closer to her baby' and allows the baby to 'grow up healthier.' Bottle feeders perceived bottle feeding to be superior because it insured that baby would be 'full and satisfied' and would 'get all the vitamins and nutrients it needed,' especially when 'mother was not eating right" or was 'on medications.' Analysis of cultural preference patterns revealed that there exists a strong culture pattern or preference for breast feeding and its characteristics among Anglos. In contrast, the Hispanics show no clear preference for either breast or bottle feeding.

Congenital hyperextension of the knees in twins.

Bilateral congenital hyperextension of the knees occurring in dizygotic twins is reported. Twin A had the mild form of the disease, genu recurvatum, while twin B had a more severe form of the disease, congenital subluxation. Hyperextension of the knee may occur as a sporadic abnormality, in conjunction with multiple dislocations or as a feature of a syndrome. Early detection and diagnosis are important, especially in the more severe forms of the condition, subluxation and dislocation, which require aggressive immediate intervention to prevent long-term sequelae. Conservative treatment consisting of manipulations and immobilization usually will correct the mild forms of the condition if instituted soon after birth. Prognosis is less favorable with delayed treatment, in the presence of other congenital anomalies, and with genetic syndromes.

Pediatrics in the Marshall Islands.

The delivery of health care to children living on isolated island communities presents unique challenges to health professionals. An evolved method of providing longitudinal services to infants and children residing on islands of the Marshall Island chain--a central Pacific portion of the Micronesian archipelago--is presented. The difficulties associated with provision of comprehensive health care in a vast ocean area are discussed.

Nafcillin extravasation injury. Use of hyaluronidase as an antidote.

Subcutaneous extravasation of parenteral nafcillin sodium can cause deep-tissue necrosis, sometimes necessitating multiple debridements and skin grafting. We report two cases in which nafcillin-induced tissue injury was successfully prevented by prompt clysis of hyaluronidase to the site of infiltration; these patients are compared with an infant in whom hyaluronidase was not used and in whom full-thickness skin loss resulted. Hyaluronidase is an enzyme that reduces or prevents tissue injury by causing the rapid diffusion of extravasated fluids through tissues by temporarily destroying tissue cement, thus increasing absorptive surface and the resultant rate of absorption. We have found that hyaluronidase, when used promptly after an extravasation has occurred, is effective in markedly reducing the amount of local tissue damage and destruction caused by the infiltration of nafcillin.