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Background: Weight loss is universal for exclusively breastfed newborns in the first few days after birth. Many newborns exclusively breastfed during birth hospitalization receive formula in the first month after discharge and thus cease exclusive breastfeeding. However, the relationship between early weight loss and subsequent cessation of breastfeeding and exclusive breastfeeding is unknown. Research aim: This study aimed to determine the relationship between newborn weight loss and duration and exclusivity of breastfeeding among newborns breastfed exclusively during the birth hospitalization. Methods: Retrospective cohort study at Kaiser Permanente Northern California hospitals between 2009 and 2013. The main predictor variable was weight loss during birth hospitalization. The main outcomes were cessation of breastfeeding and cessation of exclusive breastfeeding in the first 25 days after discharge. Results: Among our sample, 83,344 were exclusively breastfed during birth hospitalization. At 25 days after discharge, 15.6%, 95% confidence interval (CI) [14.6%, 16.6%], of those delivered vaginally and 17.6%, 95% CI [14.5%, 20.6%], of those delivered by cesarean section were estimated to have completely ceased breastfeeding; 57.0%, 95% CI [55.5%, 58.4%], and 57.9%, 95% CI [53.6%, 61.8%], respectively, had ceased exclusive breastfeeding. Survival curves depicting rates of breastfeeding cessation through 1 month did not differ by degree of weight loss or by weight loss trajectory. However, curves depicting rates of exclusive breastfeeding demonstrated significantly more formula use among those with more weight loss at discharge. Conclusion: Among those exclusively breastfed during birth hospitalization, weight loss nomograms may help identify newborns at higher risk of cessation of exclusive breastfeeding. Lactation support targeted to those with exacerbated weight loss trajectories may improve duration of exclusive breastfeeding.

For mothers with breastfeeding difficulties, pumping can be recommended to help establish milk production. However, pumping may present some barriers to successful breastfeeding. Mothers with milk supply concern may be at higher risk of barriers to successful breastfeeding. No previous studies have described experiences of pumping among mothers with milk supply concern. We conducted 10 focus groups of 56 mothers who had milk supply concern in the first month after birth. A paid, trained facilitator led groups in a semi-structured approach. Sessions were audiorecorded and transcribed verbatim. The transcripts were coded independently by two investigators and analysed using grounded theory. We identified five themes related to the experience of pumping among mothers with milk supply concern: (1) additional control over breastfeeding from pumping: ‘I would feed and then give him … whatever I could manage to pump to him’. (2) Painful experience: ‘The first time I pumped my boobs hurt so bad’. (3) Pumped volume affected milk supply concern: ‘Pump and there was hardly anything coming out that's when I started to worry’. (4) Pumping interfered with other nurturing activities: ‘While you're pumping, you can't touch the baby’. (5) Frustration from inconsistent provider advice: ‘They told me to pump … and then said, “That's going to cause your milk to increase too much” ’. Mothers had positive and negative experiences with pumping. Clinicians should assess a mother's experience shortly after she initiates pumping, as further management and counselling may be necessary to avoid barriers to successful breastfeeding.

Postnatal care has been one of the great public health successes of the past century. In 1910, most infants were born at home, and perinatal mortality was high; 1 in 10 US infants died before their first birthday.1 By 1960, the large majority of US births occurred in a hospital, where infants received multiple effective preventive interventions that led to a steep decrease in mortality rates. At that time, newborn preventive interventions were typically provided in a room called the “nursery,” where infants were lined up in row after row, and nurses moved from infant to infant to deliver care; mothers were housed on the postpartum ward, where they recovered from the birth process by resting quietly in bed. Things have changed for the better in the 21st century: the number, scope, and effectiveness of postnatal preventive interventions has continued to expand, whereas infant mortality has continued to decline. …

Background. Exclusive breastfeeding through 3 months is a Healthy People 2020 goal, yet most US infants who initiate breastfeeding receive formula before 3 months. The effect of birth weight on exclusive breastfeeding has not been previously studied. Methods. We analyzed data from a randomized trial of probiotics for healthy infants to determine the effect of birth weight and other predictors available at birth on any breastfeeding and exclusive breastfeeding through 3 months. We used backward stepwise logistic regression to examine the effect of maternal age, education, feeding plan, delivery method, and parity and infant birth weight and gestational age on the outcomes of any and exclusive breastfeeding through 3 months. Results. Birth weight was strongly associated with exclusive breastfeeding through 3 months (odds ratio = 6.23 [95% confidence interval = 2.27-17.1] per kilogram birth weight), adjusting for maternal college education and maternal plan to breastfeed exclusively. However, birth weight was not associated with any breastfeeding at 3 months when adjusting for the same predictors. Discussion. Smaller newborns were more likely to receive formula before 3 months in this study population. Educating mothers of smaller babies and their physicians about normal newborn growth patterns might reduce unnecessary formula use for smaller newborns.

BACKGROUND AND OBJECTIVES:Recent public health efforts focus on reducing formula use for breastfed infants during the birth hospitalization. No previous randomized trials report the effects of brief early formula use. The objective of the study was to determine if small formula volumes before the onset of mature milk production might reduce formula use at 1 week and improve breastfeeding at 3 months for newborns at risk for breastfeeding problems.METHODS:We randomly assigned 40 exclusively breastfeeding term infants, 24 to 48 hours old, who had lost ≥5% birth weight to early limited formula (ELF) intervention (10 mL formula by syringe after each breastfeeding and discontinued when mature milk production began) or control (continued exclusive breastfeeding). Our outcomes were breastfeeding and formula use at 1 week and 1, 2, and 3 months.RESULTS:Among infants randomly assigned to ELF during the birth hospitalization, 2 (10%) of 20 used formula at 1 week of age, compared with 9 (47%) of 19 control infants assigned during the birth hospitalization to continue exclusive breastfeeding (P = .01). At 3 months, 15 (79%) of 19 infants assigned to ELF during the birth hospitalization were breastfeeding exclusively, compared with 8 (42%) of 19 controls (P = .02).CONCLUSIONS:Early limited formula may reduce longer-term formula use at 1 week and increase breastfeeding at 3 months for some infants. ELF may be a successful temporary coping strategy for mothers to support breastfeeding newborns with early weight loss. ELF has the potential for increasing rates of longer-term breastfeeding without supplementation based on findings from this RCT.

This article provides the pediatric community with a practical overview of milk expression and an update on the recent literature. Approaches for working mothers, preterm infants, critically ill infants, and mothers before lactogenesis II are presented separately, as these groups may benefit from practices tailored to individual needs.

OBJECTIVE: Clinicians expect newborns to surpass birth weight by age 10 to 14 days, yet few studies have examined the natural history of weight change in the weeks after birth. We sought to determine the distribution of weight loss and subsequent regain during the first month, the proportion not surpassing birth weight by 14 and 21 days, and whether findings differed by delivery mode. METHODS: For 161 471 singleton neonates delivered at ≥36 weeks’ gestation at Kaiser Permanente Northern California Medical Centers between 2009 and 2013 and weighing 2000 to 5000 g at birth, we extracted daily weights from inpatient electronic records and weights from outpatient visits in the first month. Quantile regression appropriate for repeated measures was used to estimate percentiles of weight change as a function of time after birth, stratified by delivery mode. RESULTS: After exclusions, weight data were analyzed from 143 889 newborns (76% born vaginally). Based on percentile estimates, 50% of newborns were at or above birth weight at 9 and 10 days after vaginal and cesarean delivery, respectively. Among those delivered vaginally, 14% and 5% were not back to birth weight by 14 and 21 days, respectively. For those delivered by cesarean, 24% and 8% were not back to birth weight by 14 and 21 days, respectively. CONCLUSIONS: It is not uncommon for newborns to be below birth weight 10 to 14 days after delivery. A larger percentage of newborns delivered by cesarean had yet to regain birth weight at every time point through 1 month.

To determine whether higher reimbursement for children's preventive dentistry correlates with greater utilization of preventive dental care.A cross-sectional analysis of National Survey of Children's Health 2011/2012 was conducted, combined with state Medicaid reimbursement rates for preventive dentistry. Analyses included prevalence, unadjusted odds ratios, and multivariable logistic regression for receipt of preventive dental services.Of all surveyed American children 1-17 years, almost 20 percent had not received preventive dental care in prior year; this percentage is even higher in those with public insurance. Each $10 increase in state reimbursement was associated with a 17 percent decrease in odds of children not receiving preventive services.Higher state reimbursement for preventive services may increase children's receipt of preventive dental care.

BACKGROUND: Transcutaneous bilirubin (TcB) meters are widely used for screening newborns for jaundice, with a total serum bilirubin (TSB) measurement indicated when the TcB value is classified as “positive” by using a decision rule. The goal of our study was to assess the clinical utility of 3 recommended TcB screening decision rules. METHODS: Paired TcB/TSB measurements were collected at 34 newborn nursery sites. At 27 sites (sample 1), newborns were routinely screened with a TcB measurement. For sample 2, sites that typically screen with TSB levels also obtained a TcB measurement for the study. Three decision rules to define a positive TcB measurement were evaluated: ≥75th percentile on the Bhutani nomogram, 70% of the phototherapy level, and within 3 mg/dL of the phototherapy threshold. The primary outcome was a TSB level at/above the phototherapy threshold. The rate of false-negative TcB screens and percentage of blood draws avoided were calculated for each decision rule. RESULTS: For sample 1, data were analyzed on 911 paired TcB-TSB measurements from a total of 8316 TcB measurements. False-negative rates were CONCLUSIONS: Although all of the decision rules can be used effectively to screen newborns for jaundice, each will “miss” some infants with a TSB level at/above the phototherapy threshold.

Exclusive breastfeeding provides optimal nutrition through 6 months. Recent research has shown that milk expression may affect breastfeeding duration. A woman's experience with milk expression might mediate the effect of milk expression on breastfeeding duration. The objective of this study was to develop a measure to evaluate women's experiences of expressing milk. Based on the available literature, we developed a brief measure of the Breast Milk Expression Experience (BMEE) assessing three dimensions: (1) social support for milk expression; (2) ease of learning how to express milk; and (3) personal experiences of milk expression. All items used 1-5 Likert scales, with higher scores indicating better experiences. We administered the items immediately after expression to 68 mothers who expressed milk post-partum. We evaluated this measure for reliability using Cronbach's alpha. Mothers completing the BMEE were 57% primiparous with 75% vaginal births. The BMEE demonstrated appropriate reliability with a Cronbach's alpha of 0.703 for the summary index and 0.719-0.763 for social support, learning experience and personal experience subscales. The BMEE also indicated good predictive validity; of the six mothers who had a mean score

Accurate measurements of prevalence of "any" breastfeeding and "exclusive" breastfeeding help assess progress toward public health goals. We compared two commonly used data sources for measuring breastfeeding rates to assess agreement.The National Immunization Survey (NIS) is used by the Centers for Disease Control and Prevention to measure progress toward national breastfeeding goals and obtains breastfeeding outcomes retrospectively at 19-35 months. The California Newborn Screen (CNS) is a contemporaneous measure of breastfeeding during birth hospitalization and measures progress toward public health goals in California. We compared results for "any breastfeeding" and "exclusive breastfeeding" for California infants in the NIS to those in the CNS using descriptive statistics.Our results show that the two methods produce similar results for "any" breastfeeding at4 days: 82.7%, 95% confidence interval (79.6%, 85.8%) in the NIS and 86.1% (86.0%, 86.2%) in the CNS. However, the two methods produce very different results for "exclusive" breastfeeding at4 days: 60.4% (56.6%, 64.1%) in the NIS and 41.6% (41.5%, 41.7%) in the CNS. Rates of "exclusive" breastfeeding varied more for some subgroups; for Hispanics, estimates were 61.1% (56.1%, 66.1%) in the NIS and 29.7% (29.5%, 29.9%) in the CNS.There is good agreement between two disparate methods for assessing "any" breastfeeding rates. However, our findings suggest that the NIS, the CNS, or both are flawed measures of "exclusive" breastfeeding. Validated methods for measuring "exclusive" breastfeeding would allow improved monitoring of breastfeeding prevalence.

Exclusive breastfeeding reduces infant infectious disease. Losingor =10% birth weight may lead to formula use. The predictive value of first-day weight loss for subsequent weight loss has not been studied. The objective of the present study was to evaluate the relationship between weight loss at24 hours and subsequent in-hospital weight lossor =10%.For 1,049 infants, we extracted gestational age, gender, delivery method, feeding type, and weights from medical records. Weight nadir was defined as the lowest weight recorded during birth hospitalization. We used multivariate logistic regression to assess the effect of first-day weight loss on subsequent in-hospital weight loss.Mean in-hospital weight nadir was 6.0 +/- 2.6%, and mean age at in-hospital weight nadir was 38.7 +/- 18.5 hours. While in the hospital 6.4% of infants lostor =10% of birth weight. Infants losingor =4.5% birth weight at24 hours had greater risk of eventual in-hospital weight lossor =10% (adjusted odds ratio 3.57 [1.75, 7.28]). In this cohort, 798 (76.1%) infants did not have documented weight gain while in the hospital.Early weight loss predicts higher risk ofor =10% in-hospital weight loss. Infants with high first-day weight loss could be targeted for further research into improved interventions to promote breastfeeding.

OBJECTIVE. We undertook a decision analysis to evaluate the economic and health effects and incremental cost-effectiveness of using targeted tuberculin skin testing, compared with universal screening or no screening, before kindergarten.METHODS. We constructed a decision tree to determine the costs and clinical outcomes of using targeted testing compared with universal screening or no screening. Baseline estimates for input parameters were taken from the medical literature and from California health jurisdiction data. Sensitivity analyses were performed to determine plausible ranges of associated outcomes and costs. We surveyed California health jurisdictions to determine the prevalence of mandatory universal tuberculin skin testing.RESULTS. In our base-case scenario, the cost to prevent an additional case of tuberculosis by using targeted testing, compared with no screening, was $524897. The cost to prevent an additional case by using universal screening, compared with targeted testing, was $671398. The incremental cost of preventing a case through screening remained above $100000 unless the prevalence of tuberculin skin testing positivity increased to >10%. More than 51% of children entering kindergarten in California live where tuberculin skin testing is mandatory.CONCLUSIONS. The cost to prevent a case of tuberculosis by using either universal screening or targeted testing of kindergarteners is high. If targeted testing replaced universal tuberculin skin testing in California, then $1.27 million savings per year would be generated for more cost-effective strategies to prevent tuberculosis. Improving the positive predictive value of the risk factor tool or applying it to groups with higher prevalence of latent tuberculosis would make its use more cost-effective. Universal tuberculin skin testing should be discontinued, and targeted testing should be considered only when the prevalence of risk factor positivity and the prevalence of tuberculin skin testing positivity among risk factor–positive individuals are high enough to meet acceptable thresholds for cost-effectiveness.

We used hospital discharge data to estimate incidence and distribution of coccidioidomycosis-associated hospitalizations in California. For 1997-2002, the average annual rate of hospitalization was 3.67 per 100,000 population. County of residence, older age, black race, male sex, HIV infection, and pregnancy were strongly associated with increased risk for hospitalization.

Nomograms that show hour-by-hour percentiles of weight loss during the birth hospitalization were recently developed to aid clinical care of breastfeeding newborns. The nomograms for breastfed neonates were based on a sample of 108,907 newborns delivered at 14 Kaiser Permanente medical centers in Northern California (United States). The objective of this study was to externally validate the published nomograms for newborn weight loss using data from a geographically distinct population.Data were compiled from the Penn State Milton S. Hershey Medical Center located in Hershey, PA. For singleton neonates delivered at ≥36 weeks of gestation between January 2013 and September 2014, weights were obtained between 6 hours and 48 hours (vaginal delivery) or 60 hours (cesarean delivery) for neonates who were exclusively breastfeeding. Quantile regression methods appropriate for repeated measures were used to estimate 50th, 75th, 90th, and 95th percentiles of weight loss as a function of time after birth. These percentile estimates were compared with the published nomograms.Of the 1,587 newborns who met inclusion criteria, 1,148 were delivered vaginally, and 439 were delivered via cesarean section. These newborns contributed 1,815 weights for vaginal deliveries (1.6 per newborn) and 893 weights for cesarean deliveries (2.0 per newborn). Percentile estimates from this Penn State sample were similar to the published nomograms. Deviations in percentile estimates for the Penn State sample were similar to deviations observed after fitting the same model separately to each medical center that made up the Kaiser Permanente sample.The published newborn weight loss nomograms for breastfed neonates were externally validated in a geographically distinct population.

Objectives: To develop nomograms depicting percentiles of weight loss by hour of age for both vaginal and cesarean-delivered newborns who are exclusively formula fed. Methods: Data regarding delivery mode, race/ethnicity, feeding type, and weights were extracted from electronic medical records of the birth hospitalization at 14 Kaiser Permanente Northern California hospitals between 2009 and 2013. Newborns whose first feeding was formula from a cohort of 161 471 healthy, term, singleton neonates born at ≥36 weeks’ gestation between 2009 and 2013 were identified. Quantile regression was used to create nomograms stratified according to delivery mode; percentiles of weight loss were estimated as a function of time among formula-fed neonates. Weights measured subsequent to any breast milk feeding were excluded. Percentiles were determined through 48 and 72 hours of age for those born vaginally and via cesarean delivery, respectively. Results: A total of 7075 formula-fed newborns had weights recorded; 4525 were delivered vaginally, and 2550 were born via cesarean delivery. The median weight loss was 2.9% at 48 hours after vaginal delivery; weight loss >7% was rare. For cesarean-delivered neonates, median weight losses at 48 and 72 hours were 3.7% and 3.5%, respectively; weight loss >8% was rare. Conclusions: For newborns who are formula fed, these results provide nomograms depicting percentiles of weight loss according to mode of delivery. These plots can be used to classify early weight loss according to percentile and may enable early identification of feeding difficulties or other neonatal morbidities.

Breastfeeding confers several health advantages to both infants and mothers. For reasons that are multifactorial, infants born even a few weeks prematurely are less likely to initiate breastfeeding, and those who breastfeed do so for a shorter duration than term infants.Qualitative analysis of structured telephone interviews was used to examine the breastfeeding experience of mothers of late preterm infants.Our study found that, among mothers of late preterm infants, breastfeeding is both a positive bonding experience and a challenging experience, fraught with physical and medical struggles and feelings of guilt and failure. When looking back at the breastfeeding experience, many mothers recount negative experiences of milk supply concerns and breast pumping and report aspiring to be able to feed at breast more and pump less with their next child.Mothers of late preterm infants reported that breastfeeding was a bonding experience for themselves and their infants, and many plan to do it again if they have future children. However, these mothers also reported that their breastfeeding experience included challenges with latching and milk supply, inadequate lactation support from providers after hospital discharge, and feelings of failure. Interventions with the potential to improve the breastfeeding experience of mothers of late preterm infants include (1) nipple shields and other devices to assist with latching, (2) hand expression or supplementation with small volumes of donor milk or formula to help limit the burden of pumping, (3) provider education to improve lactation support after hospital discharge, and (4) peer support groups.

There is a paucity of literature on the topic of banked donor breastmilk use for healthy newborns. Herein, we describe two cases demonstrating the day-to-day medically indicated use of pasteurized, banked donor breastmilk in the University of Iowa Children's Hospital newborn nursery. These cases may inform scientific opinion about the role of banked donor milk for healthy newborns and may also facilitate research on the use of banked donor milk for this population.

For mothers with breastfeeding difficulties, pumping can be recommended to help establish milk production. However, pumping may present some barriers to successful breastfeeding. Mothers with milk supply concern may be at higher risk of barriers to successful breastfeeding. No previous studies have described experiences of pumping among mothers with milk supply concern. We conducted 10 focus groups of 56 mothers who had milk supply concern in the first month after birth. A paid, trained facilitator led groups in a semi‐structured approach. Sessions were audiorecorded and transcribed verbatim. The transcripts were coded independently by two investigators and analysed using grounded theory. We identified five themes related to the experience of pumping among mothers with milk supply concern: (1) additional control over breastfeeding from pumping: ‘I would feed and then give him … whatever I could manage to pump to him’. (2) Painful experience: ‘The first time I pumped my boobs hurt so bad’. (3) Pumped volume affected milk supply concern: ‘Pump and there was hardly anything coming out that's when I started to worry’. (4) Pumping interfered with other nurturing activities: ‘While you're pumping, you can't touch the baby’. (5) Frustration from inconsistent provider advice: ‘They told me to pump … and then said, “That's going to cause your milk to increase too much” ’. Mothers had positive and negative experiences with pumping. Clinicians should assess a mother's experience shortly after she initiates pumping, as further management and counselling may be necessary to avoid barriers to successful breastfeeding.

Background: There is a paucity of evidence to guide clinical management for term and late preterm newborns. The Better Outcomes through Research for Newborns (BORN) network is a national collaborative of clinicians formed to increase the evidence-base for well newborn care. Objective: To develop a consensus-based, prioritized research agenda for well newborn care. Design: A two-round modified Delphi survey of BORN members was conducted. Round 1 was an open-ended survey soliciting 5 clinical questions identified as important and under-researched. Using qualitative methods, 20 most common themes were extracted and transformed into research questions. Round 2 survey respondents ranked the top 20 questions using a 5- point Likert scale and a quantitative analysis was conducted. Results: Round 1 survey generated 439 unique research questions that fell into 57 themes. In the Round 2 survey, the highest rated questions were: 1) At what weight-loss percentage is it medically necessary to formula supplement a breastfeeding infant? 2) What is the optimal management of infants with neonatal abstinence syndrome? 3) How and when should we initiate a workup for sepsis, and how should these newborns be managed? Conclusions: Research priorities of clinicians include criteria for medically indicated formula supplementation of the breastfed newborn, management of neonatal abstinence syndrome and management of newborns at-risk for sepsis.

Background: A recent study proposed a risk factor scoring system for prediction of hyperbilirubinaemia that assigned increased risk to infants of higher birth weight. Objective: To investigate this novel finding in a large, retrospective cohort analysis. Methods: 105 384 newborns (⩾2000 g and ⩾36 weeks) were analysed, and the effect of higher birth weight on total serum bilirubin (TSB) ⩾342 μmol/l was reported using logistic regression to control for gestational age, scalp injury diagnosis, maternal diabetes, method of delivery and other confounders. Results: The odds ratio for the effect of an additional 500 g of birth weight on TSB ⩾342 μmol/l declined with increasing gestational age from 1.55 (95% CI 1.28 to 1.87) at 36 weeks to 1.30 (95% CI 1.12 to 1.50) at 37 weeks and 1.14 (95% CI 1.01 to 1.29) at 38 weeks. There was no association for infants ⩾39 weeks. Conclusion: Higher birth weight predicts TSB ⩾342 μmol/l in 36–38 week infants, but not in infants ⩾39 weeks. Further research should explore the causal mechanism for the association in less-mature infants.

To examine the relationship between high (≥5%) weight loss during the first 24 h after birth and eventual excess weight loss (EWL) of ≥10% of birth weight.Retrospective cohort study.Kaiser Permanente Northern California hospitals.63 096 infants born at ≥36 weeks in 2009-2010, of whom 59 761 (94.5%) had a weight subsequent to birth weight measured at24 h.Per cent of birth weight lost by 24 h of age.Weight nadir, defined as the lowest recorded inpatient or outpatient weight in the first 30 days after birth, expressed as a percentage of birth weight.Among infants who breastfed at least once, mean (±SD) weight nadir was 6.3±3.5% below birth weight, and 9.6% of the newborns lost ≥10% of birth weight. Among 2670 infants who lost ≥5% of their birth weight in the first 24 h, 782 (29%) eventually developed EWL, compared with 4840 (8%) of 57 109 infants who lost5% (p0.0005). In multivariate analysis, ≥5% first-day weight loss predicted eventual EWL (≥10%) with an OR of 4.06 (95% CI 3.69 to 4.46) after adjusting for gestational age, method of delivery, maternal race/ethnicity and hospital of birth.High first-day weight loss predicts eventual weight nadir and can be used to identify infants who might benefit from targeted interventions to support breastfeeding and prevent EWL.

Background. Milk supply concern is the most common reason given by mothers for discontinuing breastfeeding. Objectives. To describe maternal experiences of interactions with health care providers related to milk supply. Patients and methods. Ten focus groups (N = 56 participants) were conducted among mothers who had had milk supply concern in the first month after birth. Group sessions were audio-recorded, transcribed, coded, and analyzed to identify themes. Results. Interactions regarding milk supply concern evoked strong emotions, including gratitude, guilt, disappointment, and fear, and measurement of infant weight was frequently reported as a trigger for these emotions. Some mothers reported that experiencing “pressure” and “guilt” when providers emphasized exclusive breastfeeding led to suboptimal breastfeeding choices. Conclusions. Interactions with providers about milk supply concern evoke strong emotions among mothers. Providers should be aware that how they communicate routine advice regarding infant weight and formula may have unintended consequences, including discontinuation of breastfeeding.

Background Bronchiolitis is common in the first two years of life and is the most frequent cause of hospitalization in this age group. No previous studies have used an episode-of-care analysis to describe the frequency, duration, and predictors of bronchiolitis episodes of care during the first two years. Methods We conducted a retrospective cohort study of 123,264 infants ≥32 weeks gestation born at 6 Northern California Kaiser Permanente hospitals between 1996 and 2002. We used electronic medical records to concatenate hospital, emergency department and outpatient health care encounters for bronchiolitis into discrete episodes of care. We used descriptive statistics to report frequency and duration of bronchiolitis episodes and used logistic regression to assess the effect of gestational age and other clinical and demographic predictors on the outcome of bronchiolitis episodes. Results Among all infants, the rate of bronchiolitis episodes was 162 per 1000 children during the first 2 years of life; approximately 40% required >1 day of medical attention with a mean duration of 7.0 ± 5.9 days. Prematurity was associated with increased risk of bronchiolitis episodes and longer duration. Bronchiolitis episodes rates per 1000 infants were 246 for 32–33 weeks gestational age, 204 for 34–36 weeks, and 148–178 for >36 weeks. Male gender, African-American and Hispanic race/ethnicity, and parental history of asthma were associated with an increased risk of having a bronchiolitis episode and/or longer duration. Conclusions Bronchiolitis episodes of care are frequent during the first two years of life and the duration ranges from 1 to 27 days. Prematurity was associated with more frequent and longer duration of bronchiolitis episodes of care, which may reflect illness severity and/or perceived vulnerability.

Exclusive breastfeeding provides optimal nutrition through 6 months. Recent research has shown that milk expression may affect breastfeeding duration. A woman's experience with milk expression might mediate the effect of milk expression on breastfeeding duration. The objective of this study was to develop a measure to evaluate women's experiences of expressing milk. Based on the available literature, we developed a brief measure of the Breast Milk Expression Experience (BMEE) assessing three dimensions: (1) social support for milk expression; (2) ease of learning how to express milk; and (3) personal experiences of milk expression. All items used 1-5 Likert scales, with higher scores indicating better experiences. We administered the items immediately after expression to 68 mothers who expressed milk post-partum. We evaluated this measure for reliability using Cronbach's alpha. Mothers completing the BMEE were 57% primiparous with 75% vaginal births. The BMEE demonstrated appropriate reliability with a Cronbach's alpha of 0.703 for the summary index and 0.719-0.763 for social support, learning experience and personal experience subscales. The BMEE also indicated good predictive validity; of the six mothers who had a mean score3 on the 11-item scale post-partum, two (33.3%) were expressing breast milk at 1 month, compared with 37 (80.4%) of the 46 mothers who had a mean score ≥3 on the 11-item scale post-partum (P = 0.012). The BMEE is a promising measure of milk expression experience in this population. Use of this measure may allow improved understanding of women's experiences expressing milk.

ObjectiveBreast pumping or hand expression may be recommended when newborns latch or suck poorly. A recent trial found worse outcomes among mothers who used a breast pump in the early postpartum period. The objective of this study was to compare bilateral electric breast pumping to hand expression among mothers of healthy term infants feeding poorly at 12–36 h after birth.DesignRandomised controlled trial.SettingWell-baby nursery and postpartum unit.Patients68 mothers of newborns 12–36 h old who were latching or sucking poorly were randomly assigned to either 15 min of bilateral electric pumping or 15 min of hand expression.Mainoutcome measuresMilk transfer, maternal pain, breastfeeding confidence and breast milk expression experience (BMEE) immediately after the intervention, and breastfeeding rates at 2 months after birth.ResultsThe median volume of expressed milk (range) was 0.5 (0–5) ml for hand expressing mothers and 1 (0–40) ml for pumping mothers (p=0.07). Maternal pain, breastfeeding confidence and BMEE did not differ by intervention. At 2 months, mothers assigned to hand expression were more likely to be breastfeeding (96.1%) than mothers assigned to breast pumping (72.7%) (p=0.02).ConclusionsHand expression in the early postpartum period appears to improve eventual breastfeeding rates at 2 months after birth compared with breast pumping, but further research is needed to confirm this. However, in circumstances where either pumping or hand expression would be appropriate for healthy term infants 12–36 h old feeding poorly, providers should consider recommending hand expression.

Breastfeeding improves infant health by reducing the risk of gastroenteritis, lower respiratory tract infection, sudden infant death syndrome, and many other diseases of infancy.1 Increased awareness of the many benefits of breastfeeding has led public health organizations, including the Centers for Disease Control and Prevention,2 the World Health Organization,3 and the American Academy of Pediatrics,4 to issue guidelines that support exclusive breastfeeding through 6 months of age. Over the past 2 decades, US rates of any breastfeeding have risen substantially, but rates of exclusive breastfeeding have risen much less.5 “Common-sense” approaches to increasing rates of exclusive breastfeeding are sometimes not effective; 2 recent well-designed randomized trials of intensive breastfeeding support revealed no sustained effect on rates of exclusive breastfeeding.6,7 A recent national policy change regarding breastfeeding was designed to promote exclusive breastfeeding but could possibly have unintended negative consequences on breastfeeding rates and infant health. In April 2010, the Joint Commission added measurement of exclusive breastfeeding during the birth hospitalization to their list … Address correspondence to Valerie J. Flaherman, MD, MPH, Department of Pediatrics, University of California, 3333 California St, Box 0503, San Francisco, CA 94143-0503. E-mail: flahermanv{at}peds.ucsf.edu

To describe the incidence and predictors of total serum bilirubin (TSB) levels that meet or exceed American Academy of Pediatrics (AAP) exchange transfusion (ET) thresholds in the setting of universal screening.We conducted a retrospective cohort analysis of electronic data on 18 089 newborns ≥35 weeks gestation born at Northern California Kaiser Permanente Medical Care Program hospitals implementing universal TSB screening in 2005 to 2007, with chart review for subjects with TSB levels reaching the AAP threshold for ET.The outcome developed in 22 infants (0.12%); 14 (63.6%) were38 weeks gestation. Only one infant received an ET; none of the infants had documented sequelae. The first TSB was at least high-intermediate risk on the AAP risk-nomogram for all 22 infants and high-risk for those ≥38 weeks, but was less than the phototherapy level in 15 infants (68%). Of these 15 infants, 2 failed phototherapy and 13 did not have a TSB repeated in24 hours. However, re-testing all infants at high-intermediate risk or greater would have required 2166 additional bilirubin tests.Screening was sensitive but not specific for predicting exchange threshold.

Bronchiolitis has the highest incidence rate of any lower respiratory infection among infants and children2 years of age. Respiratory syncytial virus (RSV) is the most common etiology of bronchiolitis. The American Academy of Pediatrics does not recommend routine RSV testing for infants and children with bronchiolitis. The clinical predictors of RSV testing are unknown.The aims of this study were to identify the rates and predictors of RSV testing during bronchiolitis and to explore the relationship between RSV test results and antibiotic treatment among infants and children aged2 years.A retrospective study was conducted of 123,264 infants ≥32 weeks' gestational age (GA) who were born at 1 of 6 Northern California Kaiser Permanente Medical Center Program hospitals between 1996 and 2004. A bronchiolitis episode of care (EOC) was defined as ≥1 medical encounters with a bronchiolitis diagnosis code followed by 14 clear days without a bronchiolitis-related medical encounter. Descriptive statistics were used to report the frequency of tests, and logistic regression was used to assess the effect of hospitalization, chronologic age, gestational age, and season on the frequency of testing for RSV. Rapid direct fluorescent antibody testing was performed during the study.The birth cohort was 51.2% male and 42.7% white, 20.8% Hispanic, 20.3% Asian, 8.4% African American, and 7.9% other. Of 23,748 bronchiolitis EOCs, 4969 (20.9%) had ≥1 test for RSV. Overall, 44.2% of all tests were positive for RSV. Physicians ordered RSV tests in 30.4% and 26.7% of bronchiolitis EOCs for infants born at 32 to 33 and 34 to 36 weeks' GA, respectively, compared with 17.9% of bronchiolitis EOCs for infants born at ≥41 weeks' GA. Bronchiolitis hospitalization, younger chronologic age, prematurity, and RSV season were associated with RSV testing in a multivariate model controlling for other variables, with an adjusted odds ratio (AOR) of 28.55 (95% CI, 24.99-36.62) for hospitalization status; AOR of 6.89 (95% CI, 5.19-9.15) for chronologic age1 month; AOR of 0.85 (95% CI, 0.76-0.95) for GA41 weeks; and AOR of 2.48 (95% CI, 2.24-2.74) for RSV season (December-March). Among hospitalized infants who were tested and had a diagnostic code suggesting treatment with antibiotics, use of antibiotics was significantly lower among those with a positive RSV test (63.4%) than those with a negative RSV test (75.5%) (χ(2) test; P0.001).Approximately 20% of these children with bronchiolitis EOCs were tested for RSV; of those tested, about half were positive. In this integrated health care system, hospitalization with bronchiolitis, chronologic age, gestational age37 weeks, neonatal oxygen exposure, and bronchiolitis EOC during the RSV season were the factors associated with testing for RSV.

Background: Prevalence rates for both overweight and asthma have been increasing among children in developed countries over the past two decades. Some recent studies have postulated a causal relation between these but have lacked power to form a definitive conclusion. Aim: To estimate the effect of high body weight in childhood on the future risk of asthma. Methods: Medline search (1966 to October 2004), supplemented by manual search of reference lists and grey literature. Cohort studies that examined high body weight at birth or during childhood and future outcome of asthma were included. Data from each study were extracted on exposure status, clinical outcome, and study characteristics. Results: A total of 402 studies were initially identified, of which 12 met the inclusion criteria. The combined results from four studies that examined the effect of high body weight during middle childhood on the outcome of subsequent asthma showed a 50% increase in relative risk (RR 1.5, 95% CI 1.2 to 1.8). The combined results from nine studies that examined the effect of high birth weight on subsequent asthma had a pooled RR of 1.2 (95% CI 1.1 to 1.3). There was consistency among the results in sensitivity analyses examining studies containing only estimates of odds ratios, studies containing only the outcome of physician diagnosis of asthma, and studies including all definitions of high body weight. Conclusions: Children with high body weight, either at birth or later in childhood, are at increased risk for future asthma. Potential biological mechanisms include diet, gastro-oesophageal reflux, mechanical effects of obesity, atopy, and hormonal influences. Further research might elucidate the causal pathway, which could improve our understanding of the pathophysiology of asthma and perhaps lead to knowledge of potential preventive interventions.

Background: A prospective study estimated that 64% of children with bronchiolitis tested positive for respiratory syncytial virus (RSV), however, no studies have examined frequency or predictors of RSV testing. Objective: To determine rates and predictors of RSV testing during bronchiolitis care episodes. Design/methods: Retrospective cohort study involving 125,031 infants ≥32 weeks gestation born at 6 Kaiser Permanente hospitals 1996-2002. We defined an episode as a time period that: Results: Of 21,789 bronchiolitis episodes of care in our cohort, 4275 (19.6%) had at least one test for RSV. In multivariate analyses, gestational age 34-36 weeks, hospitalization status, and length of episode between 2-13 days predicted testing status, with adjusted odds ratios of 1.23 (95%CI, 1.07, 1.41), 17.6 (15.3, 20.1) and 3.49 (3.20, 3.80), respectively. Overall, 45.5% of RSV tests were positive. Conclusions: Only a small portion of infants with bronchiolitis are tested for RSV, leading to an underdiagnosis of RSV by approximately 80%. The strongest predictors of testing status are episode length and whether the episode includes a hospitalization. The study was sponsored by MedImmune.

Background: Bronchiolitis is common in children < 2 years. No previous studies have combined electronic outpatient, emergency department (ED), and inpatient data to define a care episode and measure total utilization during the course of illness. Objective: We describe bronchiolitis episodes by chronological and gestational age (GA) in a large multi-ethnic cohort. Design/Methods: Retrospective study involving 125,031 infants ≥32 weeks GA We defined an episode as a time period that: 1) included ICD-9 codes for bronchiolitis, 2) a bronchiolitis-related code 2 days prior and 3) ended with a bronchiolitis code followed by 14 clear days. Results: We identified 18,401 infants who had a care episode of bronchiolitis in the first two years (14.7%). These 18,401 infants had 21,789 episodes. Most (59.6%) episodes involved only a single outpatient or ED encounter. Approximately 8,663 care episodes were longer than 1 day with a mean duration of 7.05.8(SD) days and a median of 5.0 days. Rate and mean duration of episodes varied by GA from 23% and 4.5±5.5 days for babies born at 32- 33 weeks to 13.6% and 3.2±4.5 days for babies born at 40 weeks. For infants < 6 months the proportion of episodes including a hospitalization was 11.7%; this proportion was 6% for infants aged 6 to 24 months. Conclusions: The rate of bronchiolitis is high during the first two years, but most care episodes involve a single encounter. Younger GA is associated with increasing frequency and duration of bronchiolitis episodes suggesting more severe disease. The study was sponsored by MedImmune.