Complications and misdiagnoses associated with infant frenotomy: results of a healthcare professional survey.

BACKGROUND: In the past 10-15 years, there has been increased concern about ankyloglossia and its effect on infant breastfeeding. This has been associated with increased performance of frenotomy. Physicians and other healthcare professionals with expertise in breastfeeding have voiced concerns about complications related to the performance of infant frenotomy. Reviews of this topic have reported no significant complications after frenotomy. Other data on complications consist of case reports. METHODS: An online survey was developed by physicians with expertise in breastfeeding and e-mailed to physician and dentist members of Academy of Breastfeeding Medicine (ABM) between 11 November and 31 December 2019. It requested information from the respondents who cared for the mother/infant breastfeeding couple about their experiences personally caring for infants with complications or misdiagnoses related to referral for frenotomy or the performance of a frenotomy. Data were analyzed using chi square, Cramer's V correlation, and binomial logistic regression. RESULTS: Of 211 eligible respondents, 129 (61%) had cared for an infant with a complication or misdiagnosis. Two hundred and nine (209) infants were reported to have a complication and 237 had a misdiagnosis. The most common misdiagnoses reported were 101 of 237 infants (43%) with neuromuscular dysfunction and 65 of 237 (27%) with inadequate breastfeeding support. The most common complications reported were a repeat procedure considered/requested/performed 65 of 203 (32%) and oral aversion 57 of 203 (28%). Parental report of infant pain was associated with performance of a posterior frenotomy (Chi Square p < .003). Bleeding was associated with using scissors/scalpel vs laser/bovie/electrosurgery (Chi Square p = .001). Oral aversion was associated with performance of frenotomy by laser/bovie/electrosurgery vs scissors/scalpel (adjusted Odds Ratio of 4.05; 95% CI 2.07, 7.93). CONCLUSIONS: Complications and misdiagnoses are occurring after infant frenotomy. Physicians and dentists should work closely with lactation professionals to provide skilled breastfeeding support and to evaluate for other confounding problems that might impact infant breastfeeding before referral for frenotomy. Randomized controlled trials of optimized lactation support vs. frenotomy and of scissors vs laser in performance of frenotomy are needed.

Continuity of Infant Well Care in a Community Health Center Resident Clinic.

Achieving patient continuity in resident continuity clinic is challenging. Patients, residents and primary care providers (PCP) benefit from this ongoing relationship. We examined rates of continuity of infant well care for first year pediatric residents (PL1) and associated factors in three clinics (W, E and K) in a community health center system. We collected the number of infants who had PL1 PCPs for academic years 2010, 2011 and 2012 and patient demographic data. We measured continuity using the usual provider of care method. We assessed rates of continuity, total numbers of infants and factors associated with continuity and medical home by Chi Square, ANOVA, Student's t test and multivariate linear regression (SPSS version 21). 115 patients had a PL1 PCP and attended 408 visits with 19 residents. The mean number of infants seen per PL1 in each clinic was W 7.8 ± 2.2, E 3.8 ± 1.5 and K 3.7 ± 2.9 (p < .01). PL1 continuity percentage was 66% at W, 47% at E and 54% at K (p < .01). Total continuity of care for all providers at W was 70%, E 65% and K 60% (p < .01 W vs. K only). In multivariate linear regression, only continuity of care for all providers was associated with mean PL1 continuity with ß of 2.24 (95% CI 1.13-3.34), p < .001. PL1 continuity differed significantly between clinic sites. The only predictor of PL1 well care continuity was total clinic continuity of care. Maximizing continuity through the Medical Home practice was significantly associated with increased resident continuity of care.

Marijuana Use During Pregnancy and Breastfeeding: Implications for Neonatal and Childhood Outcomes.

Marijuana is one of the most widely used substances during pregnancy in the United States. Emerging data on the ability of cannabinoids to cross the placenta and affect the development of the fetus raise concerns about both pregnancy outcomes and long-term consequences for the infant or child. Social media is used to tout the use of marijuana for severe nausea associated with pregnancy. Concerns have also been raised about marijuana use by breastfeeding mothers. With this clinical report, we provide data on the current rates of marijuana use among pregnant and lactating women, discuss what is known about the effects of marijuana on fetal development and later neurodevelopmental and behavioral outcomes, and address implications for education and policy.

Interferon-Gamma Release Assay-Based Screening for Pediatric Latent Tuberculosis Infection in an Urban Primary Care Network.

OBJECTIVE: To assess outcomes from a QuantiFERON-tuberculosis (TB) Gold (QFT)-based screening for pediatric latent TB infection (LTBI) in the Denver Health Community Health System (CHS), an urban primary-care network in the US. STUDY DESIGN: We retrospectively analyzed all QFTs (n = 6685) performed on children aged 2-18 years between January 5, 2011, and August 18, 2014. Risk factors for positive testing in the CHS population were identified by logistic regression, and further assessed using a case-control comparison. Results from CHS were compared with higher-TB-risk populations (refugee and TB clinics) in our health system. RESULTS: Positive QFT occurred in 79 of 3745 (2.1%) CHS patients. Positive rates increased with age (0.3% in age 2-5 years to 4.9% in age 13-18 years). Indeterminate results were uncommon (0.8%) including in children <5 (1.3%). Risk factors for positive tests in the CHS population included non-Medicaid insured/uninsured and non-English/Spanish preferred language. In the case-control analysis, birth/travel to/residence in a TB-endemic country was the only identified risk factor for positive testing (OR 5.2 [95% CI 1.04-25.5]). Rates of positive testing were lower in the CHS population than the refugee/TB clinic populations, including among children age 2-5. DISCUSSION: QFT-based LTBI screening was successfully introduced in our pediatric primary-care health system, and supported our programmatic goals of identifying LTBI cases while limiting unnecessary LTBI treatment courses. Increasing positive rates with age, and higher rates in the refugee/TB populations compared with CHS, add indirect evidence of adequate test sensitivity, even among young children, for whom data on interferon-gamma release assay performance are limited.

"BreastfeedingBasics": web-based education that meets current knowledge competencies.

BACKGROUND: The United States has not met the majority of the Centers for Disease Control and Prevention goals for breastfeeding duration. Studies have shown a lack of knowledge about breastfeeding by health care professionals and students (HCP/S). Web-based education can be a cost-effective manner of education for HCP/S. "BreastfeedingBasics" is an online free educational program available for use. AIMS: This study compares information in "BreastfeedingBasics" to the breastfeeding knowledge competencies recommended by the US Breastfeeding Committee (USBC). It also evaluates usage of "BreastfeedingBasics" by users and health care professional faculty. METHODS: Using anonymous information from Web site users, the authors compared mean pre-test and post-test scores of the modules as a measure of the knowledge gained by HCP/S users. They evaluated usage by demographic information and used a Web-based survey to assess benefits of usage of "BreastfeedingBasics" to faculty. RESULTS: Overall, 15 020 HCP/S used the Web site between April 1999 and December 2009. "BreastfeedingBasics" meets 8 of the 11 USBC knowledge competencies. Mean post-test scores increased (P < .001) for all modules. Faculty reported its benefits to be free, broad scope, and the ability to be completed on the students' own time; 84% of the faculty combined the use of "BreastfeedingBasics" with clinical work. CONCLUSIONS: Use of "BreastfeedingBasics" can help HCP/S meet the USBC core breastfeeding knowledge competencies and gain knowledge. Faculty are satisfied with its use. Wider use of "BreastfeedingBasics" to help improve the knowledge of HCP/S may help in improving breastfeeding outcomes.

Pediatric influenza immunization in an integrated safety net health care system.

OBJECTIVE: In 2008 the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) recommended that all children aged 6 months to 18 years receive annual influenza vaccine. Full pediatric influenza administration has proven difficult. We compared rates of full influenza immunization between a safety net health care system and CDC sentinel sites and evaluated sociodemographic factors associated with full influenza immunization. PATIENTS AND METHODS: We matched influenza immunization data for 2008-2009 from a health care system immunization registry with patient demographic/billing data and compared rates to CDC sentinel sites using bivariate analysis. We evaluted immunization rates by patient characteristics using multivariate analysis. RESULTS: Full influenza immunization was achieved in 32% of Denver Health (DH) children compared to 12% at the CDC sites (p<0.001). The largest differences occurred in children aged 11-12 and 13-18 years, 47% DH vs 12% CDC sites, and 33% DH vs 9% CDC sites respectively, (p<0.001 for both). In multivariate analysis, DH children were more likely to be immunized if they were Asian, Odds Ratio (OR) 1.59 95%CI (CI) 1.32-1.91, or Hispanic OR 1.18 CI 1.07-1.30, compared to white, spoke Spanish OR 1.19 CI 1.13-1.26, or other non-English language OR 2.05 CI 1.80-2.34, and had a greater number of visits for well care OR 2.86 CI 2.74-2.98 and sick/follow-up care OR 1.59 CI 1.56-1.62, during the influenza season. They were less likely to be immunized if they had commercial insurance OR 0.68 CI 0.62-0.75 or were uninsured OR 0.77 CI 0.72-0.80, compared to Medicaid/SCHIP. CONCLUSIONS: Using immunization registry prompts, standing orders, multiple sites and visit types for immunization, an integrated safety net health care system had higher full influenza immunization rates than the CDC sentinel sites singularly or collectively. These procedures can be applied elsewhere to improve influenza immunization rates.

An Internet-based education program improves breastfeeding knowledge of maternal-child healthcare providers.

BACKGROUND AND OBJECTIVES: Breastfeeding rates in the United States remain below the Surgeon General's Healthy People 2010 goals. Encouragement of breastfeeding and education by maternal-child healthcare (MCH) providers (physicians, residents, and midlevel providers) improves breastfeeding initiation and duration. Surveys of MCH providers show lack of knowledge about breastfeeding. This study evaluated the effect of usage of "BreastfeedingBasics," a free Internet-based educational course, on the knowledge of MCH providers and evaluation of the baseline knowledge of course users. METHODS: A before and after intervention study was done of MCH providers using the "BreastfeedingBasics" website between 1999 and 2008. Baseline knowledge and change in knowledge were assessed by computer-scored pretests and posttests. RESULTS: Of 3,456 MCH providers enrolled, 2,237 (65%) completed one or more pretest. Total mean pretest/posttest scores were as follows: midlevel providers, 81%/89%; residents, 84%/93%; and physicians, 85%/92% (p < 0.001 among groups and between pretests and posttests). Mean pretest/posttest scores of the modules were as follows: Anatomy/Physiology, 79%/93%; Growth/Development, 72%/91%; Mother-Infant Couple (normal newborn), 82%/92%; and Breastfed Infant with Problems, 77%/91% (p < 0.001 for all). Specific topics with the lowest pretest scores and subsequent posttest scores were as follows (pretest/posttest): supplementation with vitamin D, 61%/93%; breastfeeding physiology, 38%/65%; growth of breastfed infants at 10 days, 80%/95%, 14 days, 72%/91%, and 3-4 months, 39%/84%; and stopping breastfeeding for maternal problems when not indicated, 69%/93% (p < 0.001 for all). CONCLUSIONS: Use of an Internet-based educational program improved knowledge of MCH providers as measured by pretest and posttest scores. Knowledge of the growth of breastfed infants is particularly poor. Increasing knowledge is the first step in improving clinical practice that is necessary for increasing breastfeeding rates and duration.

"Dyading" in the pediatric clinic improves access to care.

OBJECTIVE: This project evaluates the effect of "dyading" on pediatric outpatient care. METHODS: In "dyading," the medical assistant (MA) works with the provider in the exam room during the chart review, history taking, and patient education. In sequential care, the patient interacts with the MA, then the provider, then the MA again, with waiting in between. The authors measured visit time (from the MA starting with patient to the end of visit), the mean number of patients seen in a clinic session per provider, and patient satisfaction. RESULTS: After implementation of "dyading," mean visit time decreased from 37 + or - 14 to 25 + or - 11 minutes, the mean number of visits/session increased from 8.24 to 9.25, and waiting in the exam room reported by families decreased from 77% to 46%. CONCLUSIONS: "Dyading" decreased visit time, which increased the number of patients seen, thereby improving access to care. Patient time in the exam room decreased, which freed up exam rooms.

Are 2 weeks of daily breastfeeding support insufficient to overcome the influences of formula?

OBJECTIVE: To evaluate the effectiveness of proactive telephone breastfeeding support in low-income, primiparous, primarily Latina women on 1) duration and exclusivity of breastfeeding, 2) satisfaction with feeding, 3) rationale for discontinuing breastfeeding and 4) health care utilization. METHODS: Randomized controlled trial comparing usual care to 2 weeks of daily telephone calls by nurses by using culturally informed scripted protocols; and qualitative study of focused interviews on a sample of women in the intervention group (n = 40). RESULTS: Breastfeeding duration and exclusivity rates, feeding method satisfaction, and reasons for stopping breastfeeding did not differ significantly between intervention (n = 161) and control (n = 180) groups, with 74% of both breastfeeding at 1 month and 28% and 37%, respectively, at 6 months. Insufficient milk supply was the main reason for stopping in both groups. Intervention infants were less likely to have a sick visit by 1 month (25%) than controls (35%, P = .05). Qualitative interviews revealed that the intervention was informative and helpful, with breastfeeding reported as healthier but harder; formula was a good alternative. Intervention mothers reporting < or =2 supplemental formula feedings on day 4 were more likely than mothers reporting > or =3 supplemental feedings to breastfeed at 1 month (odds ratio 7.7; 95% confidence interval 2.4-24.3). CONCLUSIONS: Two weeks of daily telephone support did not increase breastfeeding duration but was associated with a decrease in sick visits in the first month. Early supplementation and the perception of formula as a good alternative to dealing with the breastfeeding difficulties appeared to be factors in failure of the intervention.

Effect of open access scheduling on missed appointments, immunizations, and continuity of care for infant well-child care visits.

OBJECTIVE: To examine the effect of open access scheduling (OA) on infant well-child care (WCC). DESIGN: Cluster randomization of 2 methods of OA compared with a baseline group (prior to OA). SETTING: Community health center pediatric clinic, August 1, 2003, to January 31, 2004. PARTICIPANTS: Ten providers (pediatricians and physician assistants) and 878 infants; 2-, 4-, and 6-month WCC visits were scheduled. INTERVENTIONS: Two scheduling methods were compared under the OA model: the OA future visit group scheduled their infant's next WCC visit when leaving the visit, and the OA same day group called for a same-day appointment. MAIN OUTCOME MEASURES: Missed appointment rates, on-time immunization rates, and continuity of care. RESULTS: Missed appointment rates decreased from 21% in the baseline group to 14% and 9% in the OA future visit and OA same day groups, respectively (P<.02). For 630 infants older than 5 months at study end, on-time immunization rates were 59% in the baseline group and 74% in both OA groups (P<.006). Of 412 infants with 2 or more WCC visits, 75% in the OA future visit group and 60% in the OA same day group saw the same provider for all visits (P = .001). This difference was due to differences among providers, not to the different scheduling methods. CONCLUSION: Open access scheduling decreases missed appointments for infant WCC visits and appears to increase on-time immunizations.

Early infant feeding decisions in low-income Latinas.

Breastfeeding rates remain low, especially among low-income minority women. The objective of this qualitative study was to assess barriers to breastfeeding and reasons for combination feeding among low-income Latina women and their families. Meetings were held with key informants to inform the sampling plan and develop questions for focus groups. Data were collected from eight qualitative focus groups with primiparous mothers postpartum, mothers breastfeeding at 4 to 6 months, mothers formula feeding at 4 to 6 months, grandmothers and fathers, and 29 individual interviews with formula- and combination-feeding mothers. Transcripts of focus groups and interviews were content coded and analyzed for thematic domains and then compared for concurrence and differences. Four main domains with 15 categories were identified: (a) Best of both: Mothers desire to ensure their babies get both the healthy aspects of breast milk and "vitamins" in formula. (b) Breastfeeding can be a struggle: Breastfeeding is natural but can be painful, embarrassing, and associated with breast changes and diet restrictions. (c) Not in Mother's Control: Mothers want to breastfeed, but things happen that cause them to discontinue breastfeeding. (d) Family and cultural beliefs: Relatives give messages about supplementation for babies who are crying or not chubby. Negative emotions are to be avoided so as to not affect mother's milk. Those counseling Latina mothers about infant feeding should discourage and/or limit early supplementation with formula, discuss the myth of "best of both," understand the fatalism involved in problem-solving breastfeeding issues, and enlist the altruism embedded in the family unit for support of the mother-infant pair.

Risk factors associated with latent tuberculosis infection in Mexican American children.

OBJECTIVES: To determine risk factors that are associated with the presence of latent tuberculosis infection (LTBI) in Mexican American children. METHODS: In this prospective cohort study, we administered tuberculin skin tests (TSTs) and a tuberculosis (TB) risk factor questionnaire to children who were aged 1 to 18 years in immigrant families at a Denver inner-city community health center and elementary school-based health center. Information requested on the questionnaire included child demographics, child and parent birth location, Bacille Calmette-Guérin (BCG) vaccination, and a history and the duration of child and family travel to and visitors from countries where TB is endemic. TST results were read at 48 to 72 hours and were interpreted as positive at 5- and 10-mm induration, depending on risk factor history. All participants received $5 coupons on return for TST reading. RESULTS: Of 584 children enrolled, 96% returned for TST evaluation, median age was 4 years, 48.6% were male, 98.5% were Latino, 66.3% were born in the United States, and 33% were born in Mexico. Overall, 12.4% of children had positive TSTs. For all children in the study, a positive TST was associated with birth in Mexico and no BCG received (adjusted odds ratio [OR]: 15.7; 95% confidence interval [CI]: 1.5-165.2), birth in Mexico and received BCG (adjusted OR: 29; 95% CI: 12.7-66.1), birth in the United States and received BCG (adjusted OR: 9.1; 95% CI: 2.4-34.1), and child travel to Mexico (adjusted OR: 2.8;95% CI: 1.5-5.4). Risk factors for having a positive TST in the 387 children who were born in the United States were travel to Mexico (unable to calculate the OR because all had traveled to Mexico), older age (median: 6 years; adjusted OR: 1.2/year; 95% CI: 1.02-1.40), and a history of BCG vaccination (adjusted OR: 8.2; 95% CI: 2.0-34.0). For the 195 children who were born in Mexico, logistic regression of the following variables showed that none of the variables remained in the model: child age, gender, BCG status, family travel to Mexico, visitors to the United States, child travel to Mexico, years lived in Mexico, and years since BCG. CONCLUSIONS: In a population of primarily Mexican American children, those who were born in the United States had an increased risk for developing LTBI when they had a history of BCG vaccination or had traveled to Mexico. For children who were born in Mexico, we were unable to identify additional risk factors for the presence of LTBI, besides their birth in Mexico. Incentives for return for TST reading, such as grocery coupons, are highly effective.

Use of the child development review increases residents' discussion of behavioral problems.

OBJECTIVE: To assess whether use of a parent questionnaire, the Child Development Review (CDR), before health maintenance examinations (HMEs) increases parent identification and increases resident discussion and documentation of behavioral issues for toddler and preschool-aged children. STUDY DESIGN: Quasi-experimental design using convenience samples with comparisons before and after questionnaire implementation. SAMPLE: Children 15 to 47 months of age and their parents attending a hospital-based, primary care clinic serving a low-income population, and the residents caring for them. METHODS: Participants were enrolled into early control, concurrent control, and intervention groups. All parents completed an exit interview about 9 behavioral issues and were asked if they had discussed these issues with the doctor. Before the visit, the intervention group parents completed the CDR, which was available for the residents to review. Information from the CDR and exit interview, and resident documentation were compared for control and intervention groups. RESULTS: There were 122 intervention and 135 control group HMEs. Parents using the CDR identified more behavioral issues for their children at the exit interview (median, 2.0 vs 1.0, P =.01). The 6 issues on both the CDR and the exit interview accounted for this increase. Intervention group parents reported discussion of more behavioral issues (median, 2.0 vs 0.0, P <.001). Discussion increased for all issues. Documentation was not increased for the intervention group. CONCLUSION: Use of the CDR before HMEs increased parent identification and reported discussion of behavioral topics for toddler and preschool children.

Medical staff appointment and delineation of pediatric privileges in hospitals.

The review and verification of credentials and the granting of clinical privileges are required of every hospital to ensure that members of the medical staff are competent and qualified to provide specified levels of patient care. The credentialing process involves the following: 1) assessment of the professional and personal background of each practitioner seeking privileges; 2) assignment of privileges appropriate for the clinician's training and experience; 3) ongoing monitoring of the professional activities of each staff member; and 4) periodic reappointment to the medical staff on the basis of objectively measured performance. This statement examines the essential elements of a credentials review for initial and renewed medical staff appointments along with suggested criteria for the delineation of clinical privileges. Sample forms for the delineation of privileges can be found on the American Academy of Pediatrics Web site (http://www.aap.org/visit/cmte19.htm). Because of the differences in individual hospitals, no one method for credentialing is universally applicable. The medical staff of each hospital must, therefore, establish its own process based on the general principles reviewed in this statement. The issues of medical staff membership and credentialing have become very complex, and institutions and medical staffs are vulnerable to legal action. Consequently, it is advisable for hospitals and medical staffs to obtain expert legal advice when medical staff bylaws are constructed or revised.