Superior Labial Frenulum Attachment Site and Correlation with Breastfeeding Outcomes.

OBJECTIVES: Current literature suggests that infant oral anatomy may impact breastfeeding outcomes. Our research seeks to evaluate superior labial frenulum (SLF) attachment site grade utilizing a modified existing system and investigate the correlation with breastfeeding outcomes. METHODS: Two hundred and eight dyads were recruited from the nursery at Brooke Army Medical Center. The neonate's SLF and lingual frenulum were evaluated and photo-documented. Photos were assessed by blinded reviewers utilizing a modified Stanford SLF grade. Breastfeeding mothers completed surveys on attitudes and associated pain with feedings 24 h postdelivery, at 2 weeks and at 2 months. Categorical data were analyzed using chi-squared tests or Fisher's exact tests. Means and standard deviations were analyzed using analysis of variance or Wilcoxon's test. RESULTS: At 2 weeks and 2 months, 86.8% and 72.8% were breastfeeding, respectively. At 2 months, SLF grade 1 newborn dyads had a significantly lower breastfeeding rate (50.0%) compared to SLF grade 2 (75.3%) and SLF grade 3 (85.7%) subjects (p = 0.0384). At 2 weeks and 2 months, there was no difference between SLF groups with regard to maternal breastfeeding attitudes or pain scores. There was no significant difference in terms of weight, referrals, or lingual-labial frenulectomy between SLF groups. CONCLUSIONS: Our study shows no correlation between SLF attachment grade and breastfeeding outcomes to include length of breastfeeding, maternally reported confidence, maternal pain, or infant weight. Our findings do not support labial frenulectomy based on SLF grade alone and highlight the need for a more robust functional grading system. LEVEL OF EVIDENCE: 2 Oxford Center for Evidence-Based Medicine. http://www.cebm.net/index.aspx?o=5653 Laryngoscope, 132:2498-2504, 2022.

Supplementation-based hypoglycemia guidelines including donor breast milk reduce NICU admission.

OBJECTIVE: To study the effects of a supplementation-based hypoglycemia guideline including donor (DM) on NICU admission, exclusive breastfeeding, and blood glucose concentrations in infants at-risk for neonatal hypoglycemia (NH). PROJECT DESIGN: We integrated DM, feeding supplementation, and reduced frequency of blood glucose testing into an NH bundle for term and late-preterm newborns. We then examined NICU admission rates and rates of exclusive breastfeeding at discharge. RESULTS: NICU admission rates were reduced to 6% (-10%). Exclusive breastfeeding rates increased to 55% (+22%). Median cost of DM utilization was $13.73 per patient with an average volume of 50.8 ml/infant. DM supplementation resulted in similar times to last hypoglycemic episode and greater increases in blood glucose compared to expressed breast milk or breastfeeding alone (+9.6 mg/dL, p < 0.05). CONCLUSIONS: A supplementation-based hypoglycemia guideline including donor milk may be an effective way to reduce NICU admissions for asymptomatic hypoglycemia and support mothers in achieving breastfeeding goals.

A different kind of battle: the effects of NICU admission on military parent mental health.

OBJECTIVE: To determine the incidence of mental health symptoms in military families after prolonged NICU admission. STUDY DESIGN: Prospective cohort study of military-affiliated NICU parents participating in serial electronic surveys, which included validated screening tools for acute stress (ASD), post-traumatic stress (PTSD), and depression disorders. RESULTS: Among 106 military parents surveyed after NICU admission, 24.5% screened positive for ASD and 28.3% for depression. 77 (72.6%) parents continued participation beyond discharge, with 7.8% screening positive for PTSD and 15.6% for late depression. Positive ASD correlated with later symptoms of PTSD (OR 8.4 [2.4-30]) and early depression with both PTSD symptoms (OR 5.7 [1.7-18.8]) and late depression (OR 8.4 [2.4-30]) after discharge. Secondary analysis determined these findings were independent of deployment and other military related factors. CONCLUSION: This study highlights the potential mental health burden experienced by military-affiliated NICU parents. Early ASD and depression screening may identify parents at risk for mental health symptoms after discharge.

A Descriptive Analysis of Pediatric Transports Throughout the U.S. Indo-Pacific Command.

BACKGROUND: The U.S. Indo-Pacific Command (INDOPACOM) has over 375,000 military personnel, civilian employees, and their dependents. Routine pediatric care is available in theater, but pediatric subspecialty, surgical, and intensive care often require patient movement. Transfer is frequently performed by military air evacuation teams and intermittently augmented by civilian services. Pediatric care requires special training and equipment, yet most transports are staffed by non-pediatric specialists. We seek to describe the epidemiology of pediatric transport missions in INDOPACOM. METHODS: A retrospective review of all patients less than 18 years old transported within INDOPACOM and logged into the Transportation Command Regulating and Command and Control Evacuation System (TRAC2ES) database from June 2008 through June 2018 was conducted. Data are reported using descriptive statistics. Patients were categorized into four age groups: neonatal (<31 days), infant (31-364 days), young children (1 to <8 years), and older children (8-17 years). RESULTS: During the study period, 687 out of 4,217 (16.3%) transports were children. Median age was 4 years (interquartile range 6 months to 8 years) and 654 patients (95.2%) were transported via military fixed-wing aircraft. There were 219 (31.9%) neonates, 162 (23.6%) infants, 133 (19.4%) young children, and 173 (25.2%) older children. Most common diagnoses encountered were respiratory, cardiac, or abdominal, although older children had a higher percentage of psychiatric diagnoses (28%). Mechanical ventilation was used in 118 (17.2%) patients, and 75 (63.6%) of these patients were neonates. CONCLUSIONS: Within TRAC2ES, nearly one in six encounters were patients aged <18 years, with neonates or infants representing nearly one of three pediatric encounters. Slightly more than one in six pediatric patients required intubation for transport. The data suggest the need for appropriately trained transport teams and equipment be provided to support these missions.

Congenital Diaphragmatic Hernia Presenting in a 7-Day-Old Infant.

A 7-day-old male infant presented to the emergency room after respiratory distress was noted at an outpatient well child check. On exam, he was observed to have tachypnea, increased work of breathing, and decreased breath sounds on the left side of the chest. On chest X-ray, he was found to have a left-sided congenital diaphragmatic hernia. The infant was transported to a tertiary care facility where the defect was repaired without complication. Interestingly, the mother had a history of a normal antenatal ultrasound, completed at 19 + 2 weeks of gestational age. This case report summarizes the challenges of diagnosing late-presenting congenital diaphragmatic hernia, associated malformations, possible etiologies, and prognosis.

Sodium-coupled neutral amino acid transporter 1 (SNAT1) modulates L-citrulline transport and nitric oxide (NO) signaling in piglet pulmonary arterial endothelial cells.

RATIONALE: There is evidence that impairments in nitric oxide (NO) signaling contribute to chronic hypoxia-induced pulmonary hypertension. The L-arginine-NO precursor, L-citrulline, has been shown to ameliorate pulmonary hypertension. Sodium-coupled neutral amino acid transporters (SNATs) are involved in the transport of L-citrulline into pulmonary arterial endothelial cells (PAECs). The functional link between the SNATs, L-citrulline, and NO signaling has not yet been explored. OBJECTIVE: We tested the hypothesis that changes in SNAT1 expression and transport function regulate NO production by modulating eNOS coupling in newborn piglet PAECs. METHODS AND RESULTS: A silencing RNA (siRNA) technique was used to assess the contribution of SNAT1 to NO production and eNOS coupling (eNOS dimer-to-monomer ratios) in PAECs from newborn piglets cultured under normoxic and hypoxic conditions in the presence and absence of L-citrulline. SNAT1 siRNA reduced basal NO production in normoxic PAECs and prevented L-citrulline-induced elevations in NO production in both normoxic and hypoxic PAECs. SNAT1 siRNA reduced basal eNOS dimer-to-monomer ratios in normoxic PAECs and prevented L-citrulline-induced increases in eNOS dimer-to-monomer ratios in hypoxic PAECs. CONCLUSIONS: SNAT1 mediated L-citrulline transport modulates eNOS coupling and thus regulates NO production in hypoxic PAECs from newborn piglets. Strategies that increase SNAT1-mediated transport and supply of L-citrulline may serve as novel therapeutic approaches to enhance NO production in patients with pulmonary vascular disease.

Management of a fetal intrapericardial teratoma: a case report and review of the literature.

Intrapericardial teratomas are rare but potentially fatal. With prenatal ultrasound, early diagnosis and decision for treatment can be accomplished. However, the decision becomes to treat prenatally vs. waiting until the neonatal period for definitive surgical management. The most common sequelae of intrapericardial teratomas are pericardial effusion and often progression to hydrops. It is these sequelae that tend to guide management. Presented here is a case report of the diagnosis and management of a twin fetus with an intrapericardial teratoma, as well as a review of the literature.