Well-Child Care Disparities in U.S. Military Health System.

OBJECTIVE: To describe adherence rates for well-child visits among military children in the first 15 months of life and identify any disparities in adherence in a universally insured population. METHODS: A retrospective cohort analysis was conducted using the Military Health System data repository which included children who were born between October 2013 and September 2016 and were eligible for TRICARE (the military health insurance program). Children were followed from zero to fifteen months of life to assess adherence with a national Health Effectiveness Data and Information Set (HEDIS) metric of 6 well visits during this period. Differences in adherence rates were evaluated across select demographic characteristics including sponsor rank, race, age, service branch, patient sex, geographic region, number of enrollment sites and provider type. Fitted logistic regression models were used to determine the probability of adherence with the HEDIS metric and identify disparities. RESULTS: The final cohort included 168,830 infants. Across all variables, the mean number of well visits was 6.7 with an overall adherence rate of 86%. Child beneficiaries of junior enlisted, Black, and Air Force military members had lower adherence with the HEDIS metric. Enrollment at a single site and having a pediatrician for a primary care manager was associated with higher rates of adherence. CONCLUSIONS: Sponsor rank, race, and service branch, along with provider type and number of enrollment sites were significantly associated with the probability of adherence. Further research should evaluate barriers to care that affect a universally insured population.

Timing of Circumcision and Breastfeeding Frequency: A Multicenter, Randomized Clinical Trial.

OBJECTIVE: To date, there is little in the literature that describes any relationship between newborn circumcision, its timing, and breastfeeding outcomes. We sought to determine if the timing of circumcision in term, healthy newborns affects exclusive breastfeeding rates during the first 6 months of life. METHODS: One hundred and forty-eight maternal-infant dyads were enrolled in a randomized, multicenter, clinical trial between June 2016 and July 2019. Study participants included parent-infant dyads who desired both circumcision and breastfeeding. Newborns were randomized into 3 groups for circumcision: "early," circumcised within 24 hours of delivery; "intermediate," circumcised between 24 to 72 hours of age; and "late," circumcised between 1 and 3 weeks of age. The primary outcome was exclusive breastfeeding duration, assessed at discharge, 2 weeks, and 2, 4, and 6 months. RESULTS: Baseline characteristics between groups were similar. Exclusive breastfeeding decreased more rapidly over 6 months in the intermediate group (by 74%, 89% to 23%), as compared to the early (by 34%, 81% to 53%) or late (by 50%, 88% to 44%) groups (P = .04). Exclusive breastfeeding was less common in the intermediate group (circumcision between 24 and 72 hours), as compared to the early and late circumcision groups, at each measured time point beyond 2 weeks of age. CONCLUSIONS: Circumcision before 24 hours of age may be advantageous with respect to increased exclusive breastfeeding throughout the first 6 months of life. Deferral of circumcision beyond the immediate newborn period was not superior to performing the procedure within the first 24 hours.

Timing of Circumcision and Breastfeeding Initiation Among Newborn Boys.

BACKGROUND AND OBJECTIVES: Newborn circumcision, particularly in the first 24 hours of life, has been thought to adversely affect breastfeeding initiation. However, no studies specifically support an association between early circumcision and difficulty with breastfeeding initiation or maintenance. This study was designed to determine whether timing of newborn circumcision affects rates of exclusive breastfeeding during the first 2 weeks of life. METHODS: A retrospective study of 797 newborn boys and their mothers was conducted at a large military hospital. Exclusion criteria included gestational age <38 weeks, multiple delivery, NICU admission, and absence of maternal intention to breastfeed. Multivariable logistic regression models examined the relationship between time of elective circumcision and exclusive breastfeeding at 3 time points: hospital discharge and the newborn and 2-week outpatient visits. RESULTS: Mean infant age at circumcision was 29.7 hours. Thirty-one percent were circumcised at <24 hours of age. Rates of exclusive breastfeeding were 66.8%, 64.1%, and 63.7% at hospital discharge and the newborn and 2-week outpatient visits, respectively. In the multivariable model, time of circumcision was not significantly associated with exclusive breastfeeding at hospital discharge (odds ratio [OR], 1.01; 95% confidence interval [CI], 0.99-1.00; P = .54), the newborn outpatient visit (OR, 1.00; 95% CI, 0.99-1.02; P = .84), or the 2-week outpatient visit (OR, 0.99; 95% CI 0.98-1.01; P = .44). CONCLUSIONS: There was no significant association between timing of elective newborn circumcision and exclusive breastfeeding in the first 2 weeks of life. In this setting, early circumcision of otherwise healthy, term boys had no deleterious effects on breastfeeding initiation or maintenance.