Search

Objective To investigate the outcomes after prolonged empirical antibiotic administration to premature infants in the first week of life, and concluding subsequent late onset sepsis (LOS), necrotizing enterocolitis (NEC), and death. Study design Study infants were ≤32 weeks gestational age and ≤1500 g birth weight who survived free of sepsis and NEC for 7 days. Multivariable logistic regression was conducted to determine independent relationships between prolonged initial empirical antibiotic therapy (≥5 days) and study outcomes that control for birth weight, gestational age, race, prolonged premature rupture of membranes, days on high-frequency ventilation in 7 days, and the amount of breast milk received in the first 14 days of life. Results Of the 365 premature infants who survived 7 days free of sepsis or NEC, 36% received prolonged initial empirical antibiotics, which was independently associated with subsequent outcomes: LOS (OR, 2.45 [95% CI, 1.28-4.67]) and the combination of LOS, NEC, or death (OR, 2.66 [95% CI, 1.12-6.3]). Conclusions Prolonged administration of empirical antibiotics to premature infants with sterile cultures in the first week of life is associated with subsequent severe outcomes. Judicious restriction of antibiotic use should be investigated as a strategy to reduce severe outcomes for premature infants.

To compare continuous positive airway pressure (CPAP) vs. traditional mechanical ventilation (MV) at 24 h of age as predictors of neurodevelopmental (ND) outcomes in extremely low birth weight (ELBW) infants at 18–22 months corrected gestational age (CGA). Infants ≤1000 g birth weight born from January 2000 through December 2006 at two hospitals at the Cincinnati site of the National Institute of Child Health and Human Development Neonatal Research Network were evaluated comparing CPAP (n = 198) vs. MV (n = 109). Primary outcomes included the Bayley Score of Infant Development Version II (BSID-II), presence of deafness, blindness, cerebral palsy, bronchopulmonary dysplasia and death. Ventilatory groups were similar in gender, rates of preterm prolonged rupture of membranes, antepartum hemorrhage, use of antenatal antibiotics, steroids, and tocolytics. Infants receiving CPAP weighed more, were older, were more likely to be non-Caucasian and from a singleton pregnancy. Infants receiving CPAP had better BSID-II scores, and lower rates of BPD and death. After adjusting for acuity differences, ventilatory strategy at 24 h of age independently predicts long-term neurodevelopmental outcome in ELBW infants.

Objectives: Cricotracheal resection (CTR) is an effective treatment for moderate-to-severe laryngotracheal stenosis (LTS) in adults. However, one of the potentially significant sequela of this procedure is postoperative dysphonia and permanent voice alteration. The objective of this study is to characterize voice changes in adult patients with subglottic stenosis who have undergone CTR. Study Design: Retrospective case-series. Methods: Acoustic, aerodynamic, and consensus auditory-perceptual evaluation of voice (CAPE-V) data were reviewed for consecutive adult patients undergoing CTR and perioperative voice evaluation from 2000 to 2010. Results: Sixteen patients (median age 44 years, 94% female) underwent CTR and voice evaluation during the study period. Thirteen patients underwent postoperative evaluation and had a mean overall CAPE-V score of 47.5/100, mean fundamental frequency (F0) of 156.7 Hz, average estimated subglottic pressure of 10.0 cm H2O, and an average airflow of 224 mL/sec. Seven patients underwent pre- and postoperative evaluations and had a significant reduction in mean F0 (206.5 vs. 151.1 Hz, P = .002) and mean F0 for connected speech (194.9 vs. 152.7 Hz, P = .047), but not in median intensity, range, estimated subglottic pressure, or airflow. Median overall CAPE-V scores worsened, but did not reach statistical significance (12 vs. 61.5, P = .28). Seventy-one percent of patients underwent an increase in acoustic signal typing postoperatively. Conclusions: Although CTR is an effective treatment for adult LTS, it results in significant alteration of the adult voice. In particular, CTR decreases the fundamental frequency of connected speech and vowel phonation and changes the acoustic signal type. Patients should be counseled about these likely voice alterations prior to undergoing surgery.

To develop a specific, targeted intervention strategy for reducing preterm birth through use of geographic analysis. We utilized Hamilton County, Ohio vital records and Census data from 2003 to 2006. Spatial scanning statistics allowed determination of the prevalence of preterm birth for any geographical point. Attributable risk calculations demonstrated heterogeneity of risk factors within areas of high or low preterm birth prevalence. Three geographically separate areas with high preterm birth proportions (>16%) had differing primary risk factors for preterm birth, including short interpregnancy interval, previous preterm birth, and low prepregnancy weight, despite similarities in demographics and physical location. Primary risk factors also differed when comparing areas with high and low preterm birth proportions, with diabetes and smoking having primary associations in the lower risk areas. Each local region of high preterm birth proportion as well as those with average or low proportion displayed distinct hierarchies of attributable risk. The heterogeneous distribution of preterm birth proportion within an urban county is complex and requires location specific analysis to develop targeted interventions.

The objectives of this review are to provide the reader with a current and concise review of the data and trends in universal newborn hearing screening. Within a relatively short period of time, the concept of screening all infants for hearing loss at the time of birth has evolved from a nascent process to a truly universal system in most developed countries. As a result, the focus and challenges of universal newborn hearing screening have shifted to topics of developing even more efficient and cost-effective approaches, and potentially melding physiologic hearing screenings with ancillary screening techniques.Enhancement of the universal newborn hearing screening process is likely to be accomplished by implementation of novel tools such as wideband reflectance technologies and intelligent incorporation of screening for common genetic and viral causes of congenital hearing loss.With such a rapidly evolving process, it will be critical for clinicians to understand the benefits and limitations of various newborn hearing screening methodologies in order to determine the most appropriate management of children referred from their universal newborn hearing screening. This will entail a working knowledge of emerging audiologic tools as well as infectious and genetic causes of pediatric hearing loss.

Objectives (1) Determine the relationships among a family's specific answers to health history questions and their child's risk for aspiration as determined by a swallow study. (2) Identify key factors which may predict a child's risk for aspiration. Methods Answers to questions and results of Functional Endoscopic Evaluation of Swallow (FEES) and/or Video Swallow Study (VSS) for a sample of 198 children were collected. Subjects were categorized into groups: “aspiration”, “penetration” or “no aspiration or penetration”. Logistic regression modeling was used to determine the contribution of certain characteristics to the odds of aspiration. A model for predicting aspiration or penetration based on those characteristics was assessed. The sensitivity and specificity of the model in predicting aspiration and penetration was determined. Results One hundred ninety eight subjects had a FEES or VSS. Of these, 18% (n = 36) aspirated and 21% (n = 42) were found to have penetration. Many of the factors identified in the health history were found to be significantly associated with aspiration or penetration. The variables “demonstrated aspiration” (this included parent or caregiver seeing food in the tracheotomy tube or aspiration noted on a previous FEES or VSS) (p = 0.02), “hypotonia” (p = 0.02) and “tracheotomy” (p = 0.001) were most predictive of aspiration. History of tracheotomy was found to have an inverse relationship with aspiration. “gastroesophageal reflux” (GER) (p = 0.0007) was most significantly associated with penetration, followed by “prematurity” (p = 0.03) and “developmental delays” (p = 0.04). Based on the prediction model, the probabilities for a child with a history of combinations of the above variables to have aspiration or penetration were calculated. Conclusions Significant relationships exist between aspiration or penetration and the family's answers about their child's medical history. Practitioners should consider a swallow assessment whenever a child has a history which includes variables with a strong association with aspiration or penetration.

Objectives/Hypothesis: Quantify post-cochlear implant (CI) language among children with disabilities and determine the role of nonverbal cognitive quotients (NVCQ) in predicting language. Study Design: Small cohort study in pediatric tertiary care center. Methods: Children (n = 20) with CIs and developmental disabilities were enrolled. Receptive and expressive language was reported as language quotients (LQs). Pre- and post-CI LQs were compared using the signed-rank test. Multiple regression models analyzed language while controlling for possible confounders. Results: Five subjects had symptomatic cytomegalovirus, and four subjects had CHARGE syndrome with hearing loss etiology. Seventy-five percent had cognitive deficits, and 55% had motor delays. Median age of CI was 24 months; median CI duration was 27.7 months. The range of NVCQs for the study cohort was 27 to 115. Fifteen subjects had NVCQs

Objectives/Hypothesis: Our objectives were to determine genotype-phenotype correlations in patients with sensorineural hearing loss (SNHL) who undergo testing for GJB2 mutations and to examine the relationship of temporal bone anomalies seen on computed tomography (CT) and GJB2 mutations. Study design: We conducted a retrospective review of all children diagnosed with SNHL and who underwent GJB2 testing from 1997 to 2006. Results: Of 840 patients, 146 (17.4%) had mutations. Seventy-six (9.1%) had biallelic GJB2 mutations and 70 (8.3%) had heterozygous mutations. When biallelic mutations were categorized as missense or nonsense mutations, the presence of at least one missense mutation was associated with mild or moderate SNHL. Biallelic nonsense mutations were associated with severe to profound SNHL. Among patients with GJB2 mutations, those with heterozygous mutations (n = 14 [20%]) had a higher rate of asymmetric SNHL loss than those with biallelic mutations (n = 6 [7.9%], P = .03). Those with heterozygous mutations were more likely to experience progression than were those with biallelic mutations, though this difference was only marginally significant (26.5% vs. 12.3%, respectively; P = .06). Patients who were wild type for GJB2 were more likely to have an enlarged vestibular aqueduct (EVA) than were those with biallelic and heterozygous mutations (29% vs. 11.9%, respectively; P = .004). Compared to patients who were wild type, those with biallelic mutations had a significantly lower rate of EVA. Conclusions: This is the largest single-institution study of pediatric patients with GJB2 mutations and SNHL. The functional consequences of GJB2 mutations correlated with the degree of hearing loss. Patients with M34T mutations and/or mild SNHL had a low risk of progression. Temporal bone anomalies were uncommon in patients with GJB2 mutations. Laryngoscope, 119:554–558, 2009

The objective of this study was to investigate trends in the referral process among pediatric cochlear implant candidates. Medical and audiologic charts between 2003 and 2005 were reviewed, and children five years and younger with moderately-severe or worse sensorineural hearing loss were included. Of the 105 audiograms meeting the inclusion criteria, 69% were referred for a cochlear implant, and 52% were considered as definite candidates for an implant by audiologists with expertise in cochlear implant technology. Children referred for an implant, compared to children who were not referred, were more likely to have married parents (91% vs. 70%, p=0.02) and more likely to have private insurance (56% vs. 29%, p=0.02). Multivariable regression results were consistent with the unadjusted findings regarding marital status, but not insurance status. Children with sensorineural hearing loss are inconsistently referred to cochlear implant teams despite similar audiologic findings. To reach the Healthy People 2010 goals, this disparity should be addressed. A further understanding of the population of children not referred is important in diminishing inconsistencies and understanding barriers to care.

Objectives: We sought to understand auditory skills outcomes in young children with cochlear implants and developmental delay. Methods: Children who received cochlear implants at less than 36 months of age were identified via chart review. Their postimplant auditory skills outcomes were measured with the Auditory Skills Checklist. Results: Of 35 children who received cochlear implants before the age of 36 months, 14 children (40%) had additional disabilities or some form of developmental delay. The 12-month postimplant data indicated progress in all groups of children. Children with additional disabilities had the same rate of auditory skills progress as children with no additional disabilities (β = 9.3 versus 9.3; p = 0.5). However, the children with additional disabilities tended to start at a lower baseline skills set (approximately 6 points lower) on the Auditory Skills Checklist. For children with average developmental quotients (at least 80), the rate of progress was twice that of children with a developmental quotient of less than 80, irrespective of a developmental disability (β = 9.9 versus 4.8; p = 0.03). Children with a developmental quotient of less than 80 were less likely to gain skills in discrimination and identification after the first postimplant year. Conclusions: Children with additional disabilities make progress in auditory skills, but may not develop higher auditory skills of identification and comprehension within the first 6 months after implantation. Categorizing children according to a cognitive developmental quotient may provide more predictive ability than does categorizing them by disability type.

OBJECTIVE. Because most internationally adopted children come from areas of high tuberculosis prevalence, an initial tuberculin skin test is recommended after arrival to the United States. We evaluated whether repeat testing of children ≥3 months after arrival to the United States would identify additional children with latent tuberculosis infection.METHODS. Internationally adopted children who were seen at our International Adoption Center and had a tuberculin skin test within 2 months of arrival to the United States were eligible for the study. Children not diagnosed with tuberculosis with initial testing were retested at least 3 months later. The prevalence of tuberculosis on arrival and after repeat testing was determined, and potential risk factors for infection were examined.RESULTS. Of the 527 internationally adopted children with an initial tuberculin skin test completed, 111 (21%) had evidence of latent tuberculosis infection. Repeat tuberculosis testing was complete for 191 internationally adopted children (46.9% of those who had an initially negative tuberculin skin test). Latent tuberculosis infection was found in 20% of those who were retested. No children were found to have active tuberculosis disease. Children with an initially positive tuberculin skin test result had slightly higher weight-for-age z scores at their initial clinic visit, whereas those whose tuberculin skin test result was positive after repeat testing had slightly lower weight-for-age z scores. A strong correlation between BCG immunization and tuberculin skin test result was observed.CONCLUSIONS. Latent tuberculosis infection is common in internationally adopted children. A high proportion of internationally adopted children had an initially false-negative tuberculin skin test. Repeat tuberculosis testing of all internationally adopted children with an initially negative tuberculin skin test should be the standard of care for identifying tuberculosis infection and preventing tuberculosis disease in this high-risk population.

Objectives: To evaluate rates of long-term survival in a prospective, longitudinal, closed HIV cohort in Africa between 1986 and 2006. Methods: A total of 548 HIV-infected Rwandan women were recruited from prenatal clinics in Kigali and followed at 3-6 month intervals to February 2006. Overall, 401 women (73%) were HIV positive at initial cross-sectional testing in 1986 (seroprevalent cohort) and 147 women (27%) were initially HIV negative but seroconverted during follow-up from 1986 to 1993 (seroincident cohort). Kaplan-Meier survival methods were used to calculate survival times censored in mid-2003. Results: In February 2006, 109 women (20%) remained alive in the cohort. Time to 50% non-genocide mortality was 11.9 years among seroincident women and 8.9 years among seroprevalent women. Smoothed mortality rates increased with duration of follow-up to a peak of 0.12 deaths per person-year at 9.5 years of follow-up but subsequently declined. After 15 years of follow-up (pre-HAART introduction), the survival probability was 36% for seroincident women and 26% for seroprevalent women. Most survivors had virological and immunological evidence of disease progression. The median CD4 cell count of survivors declined from 447 cells/μl in 1998 to 268 cells/μl in 2003. Among survivors, 57 women (52%) met treatment criteria and initiated antiretroviral treatment by 2006. Conclusion: Although median survival times in this cohort were similar to those observed in high-income countries, the rates of long-term survival after 15 years of follow-up were higher than expected. A levelling off of mortality rates during the late stages of follow-up may explain this high rate of long-term survival.

Objectives:The Auditory Skills Checklist© (ASC) was developed to address the need for tools to evaluate functional auditory skill progress in very young children with sensorineural hearing loss. We describe the development, validation, and utility of the ASC for use in young children with cochlear implants.Methods:Using the ASC, we measured auditory skills in 37 subjects who received cochlear implants at no more than 36 months of age. Repeated measures analysis was conducted to determine expected auditory skill development after implantation. Interrater reliability was tested on a small subset. The ASC was compared to the Infant-Toddler Meaningful Auditory Integration Scale (IT-MAIS) to determine its validity in measuring functional auditory skills.Results:The ASC had excellent internal consistency (Cronbach's alpha, 0.98) and interrater reliability (intraclass correlation coefficient, 0.99), and was highly correlated with the IT-MAIS (r = 0.90). According to the repeated measures analysis, children who received a cochlear implant at 36 months of age or earlier were expected to increase their ASC score by 8 points every 3 months (beta coefficient, 8.3; p < .001).Conclusions:The ASC is a clinically relevant and easily administered tool for assessing the functional auditory skills of young children with a cochlear implant. By assessing auditory skill development over time with the ASC, we can better realize expectations for a particular child based on his or her age, hearing loss level, and management strategies in place.

Objective Inner ear inflammation triggered by CMV infection may play a role in CMV-related auditory pathogenesis. The purpose of the study was to determine if a virally encoded macrophage inflammatory protein played a role in CMV-related hearing loss. Design Mutagenesis was performed with deletion of a guinea pig CMV macrophage inflammatory protein. Intracochlear inoculations were performed on three groups of animals (n = 18). Group 1 received sterile viral media, Group 2 received wild-type CMV virus, and Group 3 received “knockout” (KO) virus with a deleted immunomodulation gene. Baseline and postinoculation ABRs were obtained. ELISA and PCR were performed and temporal bones examined. Subjects Eighteen guinea pigs. Results The KO group had significantly better hearing than the WT group. There were no significant differences between the KO and sham groups. The WT group had significant hearing loss at all frequencies. Inflammation and fibrosis were noted in the WT temporal bones only. Conclusions Virally encoded macrophage inflammatory proteins appear to play a significant role in CMV-related hearing loss.

Hypoxic ischemic encephalopathy is a common cause of neurological complications resulting in chronic handicapping conditions, such as cerebral palsy. Amplitude-integrated electroencephalography (EEG) has been used in many European countries for more than a decade in the evaluation of infants with hypoxic ischemic encephalopathy but has not been widely used in the United States. The objective of this study was to evaluate the evidence supporting use of amplitude-integrated EEG as a quantitative predictor of neurodevelopmental outcome in full-term infants with hypoxic ischemic encephalopathy. To assess efficacy, the authors performed a meta-analysis of the literature evaluating the use of the amplitude-integrated EEG or cerebral function monitor in full-term infants with hypoxic ischemic encephalopathy and their neurodevelopmental outcome. A total of 8 studies were eligible for the primary meta-analysis. There was an overall sensitivity of 91% (95% CI 87-95) and a negative likelihood ratio of 0.09 (95% CI .06-.15) for amplitude-integrated EEG tracings to accurately predict poor outcome. Amplitude-integrated EEG is a valuable bedside tool for predicting long-term neurodevelopmental outcome in term infants with hypoxic ischemic encephalopathy. This information is useful in structuring communication and care plans for physicians and parents. Early assessment techniques such as amplitude-integrated EEG provide objective means for determining inclusion in clinical studies evaluating therapies for hypoxic ischemic encephalopathy and for predicting which patients are most likely to respond to treatment.

BACKGROUND AND PURPOSE: The size of vestibular aqueducts (VAs) seen on CT studies varies. The current practice of calling a VA enlarged when it exceeds a certain threshold (eg, 1.5 mm at the midpoint) is arbitrary. Our hypothesis was that statistical analysis of the range of VA widths in a normal-hearing population would lead to a mathematic definition of the upper-limit-of-normal VA width. Materials and METHODS: The VA midpoint and opercular widths were measured in 73 children with normal hearing. Statistical analysis yielded values of the 99th, 97.5th, 95th, 90th, 75th, and 50th percentiles for this normal distribution. RESULTS: The upper-limit-of-normal (95th percentile) values for the VA midpoint and opercular widths were 0.9 and 1.9 mm, respectively. The VAs with greater widths may reasonably be considered enlarged. CONCLUSION: The VAs with midpoint or opercular widths of 1.0 and 2.0 mm or greater, respectively, are enlarged.

To compare the duration of opioid treatment and length of stay among infants treated for neonatal abstinence syndrome (NAS) by using a pilot buprenorphine vs conventional methadone treatment protocol.This retrospective cohort analysis evaluated infants who received pharmacotherapy for NAS at 6 hospitals in Southwest Ohio from January 2012 through August 2014. A single neonatology provider group used a standardized methadone protocol across all 6 hospitals. However, at one of the sites, infants were managed with a buprenorphine protocol unless they had experienced chronic in utero exposure to methadone. Linear mixed models were used to calculate adjusted mean duration of opioid treatment and length of inpatient hospitalization with 95% CIs in infants treated with oral methadone compared with sublingual buprenorphine. The use of adjunct therapy was examined as a secondary outcome.A total of 201 infants with NAS were treated with either buprenorphine (n = 38) or methadone (n = 163) after intrauterine exposure to short-acting opioids or buprenorphine. Buprenorphine therapy was associated with a shorter course of opioid treatment of 9.4 (CI 7.1-11.7) vs 14.0 (12.6-15.4) days (P.001) and decreased hospital stay of 16.3 (13.7-18.9) vs 20.7 (19.1-22.2) days (P.001) compared with methadone therapy. No difference was detected in the use of adjunct therapy (23.7% vs 25.8%, P = .79) between treatment groups.The choice of pharmacotherapeutic agent is an important determinant of hospital outcomes in infants with NAS. Sublingual buprenorphine may be superior to methadone for management of NAS in infants with select intrauterine opioid exposures.

OBJECTIVES: To evaluate the generalizability of stringent protocol-driven weaning in improving total duration of opioid treatment and length of inpatient hospital stay after treatment of neonatal abstinence syndrome (NAS). METHODS: We conducted a retrospective cohort analysis of 981 infants who completed pharmacologic treatment of NAS with methadone or morphine from January 2012 through August 2014. Before July 2013, 3 of 6 neonatology provider groups (representing Ohio’s 6 children’s hospitals) directed NAS nursery care by using group-specific treatment protocols containing explicit weaning guidelines. In July 2013, a standardized weaning protocol was adopted by all 6 groups. Statistical analysis was performed to identify effects of adoption of the multicenter weaning protocol on total duration of opioid treatment and length of hospital stay at the protocol-adopting sites and at the sites with preexisting protocol-driven weaning. RESULTS: After adoption of the multicenter protocol, infants treated by the 3 groups previously without stringent weaning guidelines experienced shorter duration of opioid treatment (23.0 vs 34.0 days, P < .001) and length of inpatient hospital stay (23.7 vs 31.6 days, P < .001). Protocol-adopting sites also experienced a lower rate of adjunctive drug therapy (5% vs 21%, P = .004). Outcomes were sustained by the 3 groups who initially had specific weaning guidelines after multicenter adoption (duration of treatment = 17.0 days and length of hospital stay = 23.3 days). CONCLUSIONS: Adoption of a stringent weaning protocol resulted in improved NAS outcomes, demonstrating generalizability of the protocol-driven weaning approach. Opportunity remains for additional protocol refinement.

Background Neurobehavioral disabilities occur in 5–15 % of preterm infants with an estimated 50–70 % of very low birth weight preterm infants experiencing later dysfunction, including cognitive, behavioral, and social delays that often persist into adulthood. Factors implicated in poor neurobehavioral and developmental outcomes are hospitalization in the neonatal intensive care unit (NICU) and inconsistent caregiving patterns. Although much underlying brain damage occurs in utero or shortly after birth, neuroprotective strategies can stop lesions from progressing, particularly when these strategies are used during the most sensitive periods of neural plasticity occurring months before term age. The purpose of this randomized trial is to test the effect of a patterned feeding experience on preterm infants’ neurobehavioral organization and development, cognitive function, and clinical outcomes. Methods This trial uses an experimental, longitudinal, 2-group design with 120 preterm infants. Infants are enrolled within the first week of life and randomized to an experimental group receiving a patterned feeding experience from the first gavage feeding through discharge or to a control group receiving usual feeding care experience. The intervention involves a continuity of tactile experiences associated with feeding to train and build neuronal networks supportive of normal infant feeding experience. Primary outcomes are neurobehavioral organization as measured by Neurobehavioral Assessment of the Preterm Infant at 3 time points: the transition to oral feedings, NICU discharge, and 2 months corrected age. Secondary aims are cognitive function measured using the Bayley Scales of Infant and Toddler Development, Third Edition at 6 months corrected age, neurobehavioral development (sucking organization, feeding performance, and heart rate variability), and clinical outcomes (length of NICU stay and time to full oral feeding). The potential effects of demographic and biobehavioral factors (perinatal events and conditions of maternal or fetal/newborn origin and immunologic and genetic biomarkers) on the outcome variables will also be considered. Discussion Theoretically, the intervention provided at a critical time in neurologic system development and associated with a recurring event (feeding) should enhance neural connections that may be important for later development, particularly language and other cognitive and neurobehavioral organization skills. Trial registration NCT01577615 11 April 2012. Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-0781-3) contains supplementary material, which is available to authorized users.

To estimate the rate of psychotropic medication use in children and adolescents with Down syndrome (DS) and to describe age-related trends.Data were obtained from electronic health records from 2010 to 2013 for a retrospective cohort of 832 children with DS, aged 5 to 21 years, including 5324 visits. The following medication classes: central nervous system (CNS) stimulants, selective serotonin reuptake inhibitors, atypical antipsychotics, and alpha adrenergic agonists were examined. The distribution of rates of medication use across ages was assessed graphically and with the Cochran-Armitage trend test. Between-group comparisons of medication classes were conducted using χ. Repeated measures models with generalized estimating equations were used to assess changes in rates of medication use over time.Children aged 12 to 21 years were more likely to be on any medication at some point compared with children aged 5 to 11 years (25% vs 17%, respectively, p = .003). For 5 to 11 year olds, the odds of being on a psychotropic medication increased with age for all medication classes studied. For 12 to 18 year olds, the odds of being on a CNS stimulant significantly decreased with increasing age (odds ratio: 0.73, 95% confidence intervals, 0.58-0.91), whereas the odds of being on a medication from one of the other classes was stable.Changes in psychotropic medication use across the age span in children with DS suggest that the type and severity of neurobehavioral problems in this population likely also change over time. These findings will inform future research on the common mental health conditions and treatments for children with DS.

Objective To determine whether exposure to acute chorioamnionitis and fetal inflammation caused short-term adverse outcomes. Design This is a prospective observational study: subjects were mothers delivering at 32–36 weeks gestation and their preterm infants at a large urban tertiary level III perinatal unit (N=477 infants). Placentae and fetal membranes were scored for acute histological chorioamnionitis based on the Redline criteria. Fetal inflammation was characterised by histological diagnosis of funisitis (umbilical cord inflammation), increased cord blood cytokines measured by ELISA, and activation of the inflammatory cells infiltrating the placenta and fetal membranes measured by immunohistology. Maternal and infant data were collected. Results Twenty-four per cent of 32–36-week infants were exposed to histological chorioamnionitis and 6.9% had funisitis. Immunostaining for leucocyte subsets showed selective infiltration of the placenta and fetal membranes with activated neutrophils and macrophages with chorioamnionitis. Interleukin (IL) 6, IL-8 and granulocyte colony-stimulating factor were selectively increased in the cord blood of preterm infants with funisitis. Compared with infants without chorioamnionitis, funisitis was associated with increased ventilation support during resuscitation (43.8% vs 15.4%) and more respiratory distress syndrome postnatally (27.3% vs 10.2%) in univariate analysis. However, these associations disappeared after adjusting for prematurity. Conclusions Despite fetal exposure to funisitis, increased cord blood cytokines and activated placental inflammatory cells, we could not demonstrate neonatal morbidity specifically attributable to fetal inflammation after adjusting for gestational age in moderate and late preterm infants.

Summary Rationale To examine the management and outcomes of choanal atresia in children with CHARGE association compared with non-CHARGE children. Methods This is a retrospective chart review at a tertiary care children's hospital examining the management and outcomes of choanal atresia repair in children with CHARGE from 1990–2005. At least two CHARGE features were used to define these children. Children with CHARGE association were compared with non-CHARGE children regarding type of atresia, method of repair, post-operative management, re-stenosis rate and revision surgery. Results Fifty-seven children (36 female, 21 male) with complete records were identified with 24% diagnosed with CHARGE association. The median age of primary repair was 0.75 months for CHARGE and 15 months for non-CHARGE children ( p = 0.047). Unilateral atresia was diagnosed in 36% of CHARGE children and 81% of non-CHARGE children. Bilateral atresia was diagnosed in 64% of CHARGE and 19% of non-CHARGE children ( p = 0.006). The median duration of stent placement was slightly longer in the CHARGE group with no difference in the median number of post-operative dilations. Of those with CHARGE, 36% required revision surgery compared to 44% of the non-CHARGE subjects ( p = 0.58). Of those undergoing primary transnasal repairs, 40% of the CHARGE and 37% of the non-CHARGE patients failed. 50% of CHARGE patients with primary transnasal repair for bilateral atresia failed. Only 25% of transpalatal CHARGE repairs failed, while 75% of transpalatal repairs failed in the non-CHARGE group. The median follow-up was 24.6 months for CHARGE and 24.9 months for non-CHARGE patients. Conclusions Children with CHARGE and unilateral choanal atresia can be managed successfully with a transnasal approach. However, our data, as well as prior published reports, suggests that CHARGE patients with bilateral atresia should have primary transpalatal repairs due to the high failure rate with the transnasal approach in this population.

The WHO recommends exclusive breast-feeding (EBF) for the first 6 mo of life to decrease the burden of infectious disease. However, some are concerned about the effect of EBF6 mo on iron status of children in developing countries in which anemia is prevalent. This study examines the risk of anemia in relation to the duration of EBF and maternal anemia in a birth cohort studied between March 1998 and April 2003. All infant birth weights wereor=2.2 kg. All mothers received home-based peer counseling to promote EBF. Infant feeding data were collected weekly. Nurses measured hemoglobin (Hb) values every 3 mo. Hb was measured in 183 infants at 9 mo of age. Anemia at 9 mo was defined as a Hb value100 g/L. EBF was defined by WHO criteria and ranged in duration from 0 to 31 wk. At 9 mo, Hb (mean +/- SEM) was 114 +/- 0.9 g/L; 23 children (12.5%) had Hb levels100 g/L. EBF6 mo, but not EBF 4-6 mo, was associated with increased risk of infant anemia compared with EBF4 mo (odds ratio=18.4, 95% CI=1.9, 174.0). Maternal anemia was independently (P=0.03) associated with a 3-fold increased risk of infant anemia. These associations were not explained by confounding with other maternal or infant factors. By linear regression, a lower infant Hb at 9 mo was associated with increased EBF duration among mothers who had a history of anemia (beta=-0.07, P=0.003), but not among mothers with no history of anemia. Infants who are exclusively breast-fed for6 mo in developing countries may be at increased risk of anemia, especially among mothers with a poor iron status; greater attention to this issue is warranted.

The objective of this study was to compare 2 interventions promoting condoms and vaginal microbicides to prevent sexually transmitted disease (STD). Women (N = 427) attending an STD clinic were randomly assigned to 2 clinician-delivered interventions and followed up monthly to assess condom/microbicide use and incidence of gonorrhea chlamydia and syphilis. During follow up condom use rates were 69% (enhanced) and 49% (basic) and microbicide use rates were 44% and 29% respectively. STD rates did not significantly differ between intervention groups. Perfect condom use (regardless of intervention arm) was associated with a 3-fold decrease in STD rates (relative risk [RR] 0.3; 95% confidence interval [CI] 0.1–0.8). Using a vaginal microbicide during > 50% of the acts of intercourse was associated with reduced STD rates (RR 0.5; 95% CI 0.3–1.0) across intervention groups and condom use categories. The enhanced intervention increased use of condoms and vaginal microbicide; however STD rates did not decrease because a protective effect was seen only among perfect barrier users and the enhanced intervention only modestly increased perfect use. (authors)

Summary Objective: To correlate audiometric findings and outcomes with the clinical, radiological and educational findings in a symptomatic congenital cytomegalovirus (CMV) population with sensorineural hearing loss. Methods: A retrospective review of data from 21 symptomatic congenital CMV patients identified in a pediatric hearing impaired database of 1500 patients. Clinical data, audiometric thresholds and outcomes, radiographic abnormalities, communication and educational achievements were used as outcome measures. Results: Twenty-one patients were identified with symptomatic congenital CMV infection at birth; 5 with unilateral hearing loss and 16 with bilateral hearing loss. The median initial pure-tone average (PTA) for the 21 subjects was 86 dB and the median final PTA was 100 dB. Progression of hearing loss was seen in 9 patients (43%). Neurological and radiological sequelae of symptomatic CMV infection were seen in 81% of affected patients. Children with neurological dysfunction were significantly more likely to rely on special education (p = 0.045). There was a significant correlation between the severity of the initial PTA and the development of a progressive hearing loss (p = 0.0058). Initial hearing thresholds were significantly better in those children with a history of jaundice (p = 0.002), hepatosplenomegaly (HSM) (p = 0.022) and cerebral palsy (CP) (p = 0.013). There was a significant correlation between a less severe final PTA and the presence of CP (p = 0.005). A history of mental retardation in children was significantly associated with poorer communication skills (p = 0.043). Conclusions: The severity of neurological manifestations in congenital symptomatic CMV infection was positively correlated with the need for total and manual communication and the reliance on special education. Statistical associations between clinical findings such as hepatic dysfunction, CP and hearing level were identified however plausible mechanisms explaining these associations remain ambiguous and are discussed in the context of this complex population of children with congenital symptomatic CMV.

To characterize vernix caseosa in newborn infants with respect to factors that influence vernix distribution on the skin surface, vernix effects on thermal stability, skin hydration, acid mantle development, and vernix antioxidant properties. Vernix distribution was determined for 430 infants. Thermal stability was assessed in parallel groups following vernix retention (n=66) and removal (n=64). The effects of vernix retention on skin hydration, pH, erythema, and dryness/scaling were determined. Samples were analyzed for vitamin E before and after UV exposure. Vernix distribution depended upon gestational age, delivery mode, gender, race, and meconium exposure. Retention had no effect on axillary temperatures. Skin hydration was significantly higher for vernix-retained skin. Skin pH and erythema were significantly lower with retention. Vitamin E levels were decreased by ultraviolet radiation. Vernix is a naturally occurring barrier cream with multiple salubrious effects, which support its retention on the skin surface at birth.

The objective of this abstract is to identify the prevalence of additional disabilities among children with cochlear implants and assess their communication strategies.

To test the hypothesis that human milk fucosyloligosaccharides are part of an innate immune system, we addressed whether their expression (1) depends on maternal genotype and (2) protects breastfed infants from pathogens. Thus the relationship between maternal Lewis blood group type and milk oligosaccharide expression and between variable oligosaccharide expression and risk of diarrhea in their infants was studied in a cohort of 93 Mexican breastfeeding mother-infant pairs. Milk of the 67 Le(a-b+) mothers contained more LNF-II (Le(a)) and 3-FL (Le(x)) (oligosaccharides whose fucose is exclusively alpha 1,3- or alpha 1,4-linked) than milk from the 24 Le(a-b-) mothers; milk from Le(a-b-) mothers contained more LNF-I (H-1) and 2'-FL (H-2), whose fucose is exclusively alpha 1,2-linked. The pattern of oligosaccharides varied among milk samples; in each milk sample, the pattern was summarized as a ratio of 2-linked to non-2-linked fucosyloligosaccharides. Milks with the highest ratios were produced primarily by Le(a-b-) mothers; those with the lowest ratios were produced exclusively by Le(a-b+) mothers (p

Breastfeeding hospitalized infants can be difficult. The authors assessed the effectiveness of an International Board Certified Lactation Consultants (IBCLC) service to increase the proportion of infants given their own mother's milk (OMM) in a children's hospital neonatal intensive care unit (NICU). The charts of 350 randomly selected patients admitted the year before and after implementation of the service in July 1997 were abstracted. Factors significantly associated with infants being given OMM included infant sex, ethnicity, length of NICU stay, and 5-minute Apgar score. After comparison of the periods before and after pro-gram implementation, the proportion of NICU infants ever given their OMM was found to have increased from 31% to 47% ( P = .002). This increase differed significantly in relation to infants' clinical status and/or management (5-minute Apgar score, length of NICU stay, and age at NICU admission) but not in relation to maternal factors. Mothers with infants in the NICU should have access to lactation counseling. J Hum Lact. 19(3):286-292.

Objective: The goal of this study was to evaluate risk factors for readmission among late-preterm (34–36 weeks’ gestation) infants in clinical practice. Methods: This was a retrospective, matched case-control study of late-preterm infants receiving care across 8 regional hospitals in 2009 in the United States. Those readmitted within 28 days of birth were matched to non-readmitted infants at a ratio of 1:3 according to birth hospital, birth month, and gestational age. Step-wise modeling with likelihood ratio tests were used to develop a multivariable logistic regression model. A subgroup analysis of hyperbilirubinemia readmissions was also performed. Results: Of 1861 late-preterm infants delivered during the study period, 67 (3.6%) were readmitted within 28 days of birth. These were matched to 201 control infants, for a final sample of 268 infants. In multivariable regression, each additional day in length of stay was associated with a significantly reduced odds ratio (OR) for readmission (0.57, P = .004); however, for those infants delivered vaginally, there was no significant association between length of stay and readmission (adjusted OR: 1.08, P = .16). A stronger inverse relationship was observed in subgroup analysis for hyperbilirubinemia readmissions, with the adjusted OR associated with increased length of stay 0.40 (P = .002) for infants born by cesarean delivery but 1.14 (P = .27) for those delivered vaginally. Conclusions: Infants born via cesarean delivery with longer length of hospital stay have a decreased risk for readmission. As hospitals implement protocols to standardize length of stay, mode of delivery may be a useful factor to identify late-preterm infants at higher risk for readmission.

Objectives:Over the past decade, thoracic slide tracheoplasty (TST) has become the principal operation in the management of congenital tracheal stenosis. The purpose of this report is to (1) describe our experience with revision TST following unsuccessful prior tracheal reconstruction and (2) compare our outcomes with primary TST.Methods:Patients undergoing TST on cardiopulmonary bypass between January 2005 and 2014 were reviewed. Patients with a history of prior airway surgery were extracted for further analysis. Preoperative patient variables and postoperative outcomes were evaluated.Results:A total of 108 patients were reviewed over the study period. Twenty-two revision patients (20 referrals, 2 primary patients) met inclusion criteria. Eighteen patients had a history of complete tracheal rings and 4 patients had cartilaginous deficiency. A total of 35 tracheoplasties (rib graft = 6; slide tracheoplasty = 5; pericardial patch = 4; homograft = 3;resection = 1; cricoid split = 1; combined tracheal recons...

OBJECTIVES:To compare pharmacologic treatment strategies for neonatal abstinence syndrome (NAS) with respect to total duration of opioid treatment and length of inpatient hospital stay.METHODS:We conducted a cohort analysis of late preterm and term neonates who received inpatient pharmacologic treatment of NAS at one of 20 hospitals throughout 6 Ohio regions from January 2012 through July 2013. Physicians managed NAS using 1 of 6 regionally based strategies.RESULTS:Among 547 pharmacologically treated infants, we documented 417 infants managed using an established NAS weaning protocol and 130 patients managed without protocol-driven weaning. Regardless of the treatment opioid chosen, when we accounted for hospital variation, infants receiving protocol-based weans experienced a significantly shorter duration of opioid treatment (17.7 vs 32.1 days, P < .0001) and shorter hospital stay (22.7 vs 32.1 days, P = .004). Among infants receiving protocol-based weaning, there was no difference in the duration of opioid treatment or length of stay when we compared those treated with morphine with those treated with methadone. Additionally, infants treated with phenobarbital were treated with the drug for a longer duration among those following a morphine-based compared with methadone-based weaning protocol. (P ≤ .002).CONCLUSIONS:Use of a stringent protocol to treat NAS, regardless of the initial opioid chosen, reduces the duration of opioid exposure and length of hospital stay. Because the major driver of cost is length of hospitalization, the implications for a reduction in cost of care for NAS management could be substantial.

To evaluate costs associated with surgical treatment for neonates with Pierre Robin sequence (PRS).Retrospective cohort study.Cincinnati Children's Hospital Medical Center.With Institutional Review Board approval, we retrospectively studied neonates with PRS treated from 2001 to 2009 with either tracheostomy (Trach), mandibular distraction (MD), or Trach with subsequent MD (Trach+MD). Actual charges over a 3-year period associated with operative costs, hospital stay, imaging and sleep studies, clinic visits, and related emergency room visits were collected. Home tracheostomy care charges were estimated individually for each patient. Charges were compared using regression and appropriate statistical analyses.Forty-seven neonates were included in the study (MD, n = 26; Trach, n = 12; Trach+MD, n = 9). Trach group patients had 2.6-fold higher charges than the MD group despite no difference in length of hospital stay. This difference increased to 7.3-fold when including home trach care-related costs. Trach+MD group patients had longer hospital lengths of stay and higher operation room (OR) fees, but no increased total charges compared with the Trach only group.For patients with severe PRS, mandibular distraction provides significant cost savings over tracheostomy ($300,000 per patient over 3 years). Increased costs with tracheostomy come from greater hospital-related charges, more frequent airway procedures, a higher incidence of gastrostomy tube feeds, and home trach care costs. A careful examination of long-term outcomes will be critical as mandibular distraction continues to gain acceptance for treatment of PRS.

OBJECTIVES We report our institution's 5-year experience with upper gastrointestinal study with small bowel follow-through (UGI-SBFT) and contrast enema (CE) for the diagnosis of a post-necrotizing enterocolitis (NEC) stricture. We hypothesized that sensitivity and specificity of UGI-SBFT and CE were

Objective To evaluate the efficacy of a universal maternal drug testing protocol for all mothers in a community hospital setting that experienced a 3-fold increase in neonatal abstinence syndrome (NAS) over the previous 5 years. Study design We conducted a retrospective cohort study between May 2012 and November 2013 after the implementation of universal maternal urine drug testing. All subjects with positive urine tests were reviewed to identify a history or suspicion of drug use, insufficient prenatal care, placental abruption, sexually transmitted disease, or admission from a justice center, which would have prompted urine testing using our previous risk-based screening guidelines. We also reviewed the records of infants born to mothers with a positive toxicology for opioids to determine whether admission to the special care nursery was required. Results Out of the 2956 maternal specimens, 159 (5.4%) positive results were recorded. Of these, 96 were positive for opioids, representing 3.2% of all maternity admissions. Nineteen of the 96 (20%) opioid-positive urine tests were recorded in mothers without screening risk factors. Seven of these 19 infants (37%) required admission to the special care nursery for worsening signs of NAS, and 1 of these 7 required pharmacologic treatment. Conclusion Universal maternal drug testing improves the identification of infants at risk for the development of NAS. Traditional screening methods underestimate in utero opioid exposure.

The primary aim of this study was to investigate the relationship between language levels and communication and social function skills in young children who are deaf/hard-of-hearing.A cross-sectional design was used with participants sampled predominately from a single clinic setting. Children between 3 and 6 years of age with permanent bilateral hearing loss were enrolled in the study. All children received the Preschool Language Scales-Fifth Edition language assessment and a neurocognitive assessment using the Leiter International Performance Scale-Revised at the study visit. Communication and social function skills were measured using the Vineland Adaptive Behavior Scales-Second Edition (VABS-II; mean 100 ± 15) and the Pediatric Evaluation of Disability Inventory (PEDI; mean 50 ± 10).Analysis included 65 children with mild to profound bilateral hearing loss (mean age 56.8 months, SD ± 14.1); 52% had hearing loss in the mild to moderate range. The mean nonverbal intelligence quotient (IQ) was 95.7 (±18.8), the mean receptive language standard score was 83.7 (±18.6), and mean expressive language standard score was 83.0 (±18.5). The mean VABS-II communication standard score was 89.1 (±17.5), and the mean PEDI social function score was 39.6 (±15.3). Both nonverbal IQ and receptive language relative to nonverbal IQ (the ratio of language to IQ) were significantly associated with communication and social functioning, explaining more than 50% of the variance in communication function scores. Children with language commensurate with their IQ had significantly higher communication and social function scores than children with language significantly lower than IQ. This finding was consistent across different levels of IQ and independent of degree of hearing loss.Even with early identification and intervention, hearing loss continues to have a life-long impact on functioning. It is important to identify when language levels are not meeting a child's capabilities in order to intervene most effectively.

Determine the prevalence of high-frequency sensorineural hearing loss (HFSNHL) in our hearing loss population and a diagnostic algorithm for these patients.Retrospective case series.We identified patients diagnosed with sensorineural hearing loss (SNHL) at our pediatric tertiary care institution from 1981 to 2010. Based on audiometric profiles, these patients were subdivided into those with a flat SNHL configuration and those with HFSNHL. Imaging and genetic testing data and data regarding age at diagnosis, laterality, and risk factors were obtained for both groups. Comparisons were then made between the two groups.Of 2,867 patients included in the study, 7.6% had HFSNHL. Age at diagnosis was significantly higher in HFSNHL patients (8.3 years vs. 6.1 years; P .0001). These patients also had a significantly higher proportion of unilateral versus bilateral loss (49.1% vs. 26.1%; P .0001); unilateral losses were also less severe. Genetic testing showed no significant difference between groups in the proportion of patients tested or in those who tested positive. Similarly, imaging data revealed no difference in the proportion of patients tested in the two groups; however, overall diagnostic yield was significantly higher in flat SNHL patients (29.5% vs.17.3; P = .02).The positive predictive value of simple genetic testing is similar to that of imaging studies. However, given cost differences between genetic testing and imaging, it is prudent to perform genetic testing as the initial diagnostic test. Determination of whether high-throughput, multigene diagnostic platforms offer an added benefit in the evaluation of children requires further study.4. Laryngoscope, 126:1236-1240, 2016.

Patients with severe micrognathia are predisposed to airway obstruction. Mandibular distraction osteogenesis (MDO) is an alternative to tracheotomy that lengthens the mandible in order to improve the retrolingual airway. This study presents outcomes from one of the largest cohorts reported.To assess the rate and predictors of surgical success and complications among (1) patients who underwent MDO prior to other airway procedures (MDO first), and (2) patients who required an initial tracheotomy and were subsequently treated with MDO (tracheotomy first).Retrospective cohort study at a tertiary care pediatric medical center of patients diagnosed as having micrognathia resulting in symptomatic airway obstruction (Pierre Robin sequence) and who underwent MDO from September 1995 to December 2009.Electronic medical records were reviewed. Multivariable regression analysis was used to assess for predictors of outcome.Rates of surgical success (defined as either tracheotomy avoidance or decannulation) and complications. Potential predictors included demographics, syndrome presence, follow-up time, and surgical history.A total of 123 patients (61 in MDO-first subgroup, 62 in tracheotomy-first subgroup) underwent MDO during the study period. Median age at time of distraction was 21 months (range, 7 days-24 years). Surgical success and complication rates were 83.6% and 14.8% in the MDO-first subgroup and 67.7% and 38.7% in the tracheotomy-first subgroup. Tracheotomy-first patients were more likely to have a syndromic diagnosis (66.0% vs 43.0%; P = .009) and were older at the time of MDO (median age, 30 months vs 5.1 months; P .001). Poorer odds of success were associated with the need for 2 or more other airway procedures (odds ratio [OR], 0.14 [95% CI, 0.02-0.82]) in the MDO-first subgroup and craniofacial microsomia or Goldenhar syndrome (OR, 0.07 [95% CI, 0.009-0.52]) in the tracheotomy-first subgroup.Mandibular distraction osteogenesis has a high rate of success in avoiding tracheotomy. Patients who required a tracheotomy before MDO had a lower success rate in achieving decannulation and a higher rate of complications. However, these patients also had a higher rate of syndromic diagnoses and associated comorbidities. Patients with Goldenhar syndrome have a decreased likelihood of surgical success.

Post-operative management of children undergoing airway reconstruction has been well-described. However, many of these patients develop post-operative fevers. We conducted a retrospective review in an attempt to define the significance of post-operative fever following pediatric airway reconstruction.Retrospective analysis of 78 pediatric laryngotracheoplasties (LTPs) from May 1, 2006 - April 30, 2007 at a tertiary care pediatric hospital. Fever was defined as temperatureor=38.5. A fever was "significant" if accompanied by a positive sputum, blood or urine culture, or an elevated WBC. Chest radiograph (CXR) results and co-morbidities were examined.Forty-five percent of cases (35/78) had fever. Of those febrile, 46% (n=16) had significant fever. Overall, 20.5% had significant fevers. Fifty-two cases were single-stage LTP (SSLTP) with 31 febrile and 26 cases were double-stage LTP (DSLTP) with 4 febrile. SSLTP cases were at a significantly greater risk for post-operative fever compared with DSLTP, 59% vs 15% respectively (p=0.0002). 42% of febrile SSLTPs (n=13) had significant fevers compared to 50% (n=2) of febrile DSLTPs (Fisher's Exact p=1.0). 81.5% of cases with CXR findings had fevers, but only 50% of these fevers were significant. Subjects with post-operative atelectasis were more likely to have a fever compared to subjects with no post-operative atelactasis (93% vs. 33% respectively, p0001). 30.8% of those with atelectasis had significant fever, compared to 52% of those without atelectasis (p=0.2) and 25 of SSLTPs vs. 3.9% of DSLTPs had atelactasis (p=0.027). No comorbidities were shown to be significant risk factors for post-operative fever.Based on our review, most children undergoing LTPs will have insignificant fevers. Those children undergoing SSTLP and/or having post-operative atelectasis are at higher risk for post-operative fever. Fevers in children with double-stage procedures or all reconstruction cases with CXR findings other than atelectasis should have a thorough fever work-up.

BACKGROUND AND OBJECTIVE:Home visiting programs seek to improve care management for women at high risk for preterm birth (METHODS:Retrospective cohort study of women in southwest Ohio with a singleton pregnancy enrolled in home visiting before 26 weeks’ gestation. Vital statistics and hospital discharge data were linked with home visiting data from 2007 to 2010 to ascertain birth outcomes. Eligibility for home visiting required ≥1 of 4 risk factors: unmarried, low income, RESULTS:Among 441 participants enrolled by 26 weeks, 10.9% delivered preterm; 17.9% of infants were born SGA. Mean gestational age at enrollment was 18.9 weeks; mean number of prenatal home visits was 8.2. In multivariable regression, ≥8 completed visits by 26 weeks compared with ≤3 visits was associated with an odds ratio 0.38 for preterm birth (95% confidence interval: 0.16–0.87), while having ≥12 total home visits compared with ≤3 visits was significantly associated with a hazards ratio 0.32 for SGA (95% confidence interval: 0.15–0.68).CONCLUSIONS:Among at-risk, first time mothers enrolled prenatally in home visiting, higher dosage of intervention is associated with reduced likelihood of adverse pregnancy outcomes.

A total of 104 couples participated in a randomized crossover trial to compare a new baggy condom with a straight-shaft condom produced by the same manufacturer. Participants completed a coital log after using each condom. All couples used five condoms of each type. Among 102 couples who did not report major deviations from the protocol, the breakage rate was eight of 510 (1.6%) for the baggy condom, and six of 510 (1.2%) for the standard condom (rate difference, RD = 0. 4%, 95% confidence interval of the RD, CI = -1.0%; +1.8%). Slippage was reported in 50 baggy condom logs and in 58 standard condom logs; the slippage rate was 50 of 510 (9.8%) for the baggy condom, and 58 of 510 (11.4%) for the standard condom (RD = -1.6%, 95% CI = -5.4%; +2.2%). Slippage was most often partial (1 inch) and may not indicate condom failure. Severe slippage rates were 11 of 510 (2.2%) for the baggy condom, and 18 of 510 (3.5%) for the standard condom (RD = -1.4%, 95% CI = -3.4%; +0.7%). The findings support the conclusion that the two condoms are equivalent with respect to breakage and slippage. The participants appeared to prefer the baggy condom, suggesting that the new product may be more acceptable to the public than the traditional straight-shaft condoms, and may be easier to use consistently over long time periods.

Background The purpose of our study was to measure the sound level generated by selected commercially available cast saws. These levels were then compared with the level of everyday sounds and to accepted intensities by Safety Administrations to see whether the mandatory use of hearing protection should be recommended to prevent noise-induced hearing loss. Methods We assessed the sound levels generated by the Quiet Cast Removal System (QCR; OrthoPediatrics Corp., Warsaw, IN), Stryker 986 Cast Vac (Stryker Corp.), and the Stryker 840 Cast Cutter (Stryker Corp.). The sound generated by these saws was measured with a sound level meter at the source and at 6, 12, and 36 inches. The sound level from each device was assessed both while operating alone and while cutting casts for a total of 3 repetitions at each of the distances tested and analyzed statistically. Results The maximal mean sound intensity of the Stryker 986 and Stryker 840 saws was 90.7 and 88.6 dBA at 36 inches, respectively while cutting a cast, whereas the QCR System produced 50.1 dBA at this distance. At 6 inches, the mean sound intensity was 99.4, 96.4, and 64.5 dBA for the Stryker 840, 986, and QCR, respectively. Statistically significant differences in sound intensity between Stryker and QCR saws were noted under all testing scenarios (P Conclusions None of the cast saws produced intensities exceeding recommended standards for a single exposure or intensities reaching occupational hazard levels. The QCR saw was significantly quieter than both the Stryker 840 and 986 under all scenarios. The need for a recommendation of mandatory usage of hearing protection for patients and office personal could not be demonstrated. Clinical relevance Cast saw noise is common in orthopaedic clinics. Our study demonstrates sound levels from commercially available saws do not reach occupational hazards but are sufficiently high that practical methods to reduce intensity may be warranted.

Using vital records and census data representing 165,136 singleton births from 2003–2006, geospatial filtering and density estimates enabled the calculation of preterm birth rates at each geographical point within three urban Ohio counties. Adjusted attributable risk calculations were used to identify risk factors associated with regions of high and low rates of preterm birth. Among the three counties, affected populations varied in size as well as in demographic composition. Variation in the risk factors from one region to another suggests that a single one size fits all intervention strategy would be unlikely to efficiently or effectively impact the complex preterm birth problem. Although more useful in areas with a heterogeneous distribution of preterm birth, application of the presented approach supports the development of efficient community-level health intervention strategies by identifying communities with the highest potential impact and allowing for the prioritization of efforts on specific risk factors within those communities.

The first trimester fetal foregut generates organs from larynx to ligament of Treitz. The incidence and clinical impact of many of the 29 congenital malformations arising from the foregut organs remain under characterized. We performed a retrospective chart review on patients from a geographically defined area born between 2006 and 2008 admitted to Cincinnati Children’s Hospital Neonatal Intensive Care Unit with diagnoses consistent with one or more congenital foregut malformations. We found foregut malformations occurred in 1 in 801 births and determined the incidence for each individual foregut malformation, including some that have not previously been reported. We report a high rate of multiple congenital foregut malformations within an individual with coincidence of foregut malformations of 51.5%, and a high association with cardiovascular malformations (40%). Hospital stay was prolonged (32 days versus 5days). Need for assisted feeding (51%) and respiratory support (27%) at discharge were higher when compared to control patients (12 and 6%, respectively). Mortality was 7% in patients with foregut malformations. These data provide needed quantitation of the incidence, morbidity, and mortality related to congenital foregut defects present in inpatient neonates. The coincidence of foregut malformations with cardiovascular malformations underscores the need for further research into their coordinated embryologic formation to aid their prevention and treatment.

Objective To implement a novel system of care for pediatric critical airway obstruction. Design Retrospective, observational study of data gathered prospectively during high-fidelity simulations. Setting Emergency department (ED) and operating rooms (ORs) of a pediatric referral center. Subjects Health care provider simulation participants. Main Outcome Measures Time from ED attending physician request to arrival of an otolaryngologist, participant survey responses, identified latent safety threats, and simulated patient outcomes. Methods Twelve high-fidelity simulations were conducted: 6 to identify problems with an existing system of care, and 6 to implement a novel system. The simulation scenarios involved a 4-year-old patient with severe respiratory distress after foreign-body aspiration managed solely in the ED or in the ED and OR, depending on stability. Results There were 196 participants in 12 simulations. The mean (SD) time from ED attending physician request to otolaryngologist arrival was 7.8 (1.6) minutes for the existing system simulations and 5.0 (1.1) minutes for the novel system (P = .001). Latent safety threats identified in the simulations included a lack of specialized airway equipment in the ED. Death of the simulated patient occurred in the ED in 2 of 6 existing system simulations; specialized airway equipment was available for neither. For the novel system simulations, specialized airway equipment was available for all 6, no simulated patient deaths occurred. Conclusions High-fidelity simulation was an effective method to design and implement a novel system of care for pediatric critical airway obstruction. The novel system was associated with more rapid response times and elimination of simulated patient deaths.

Objectives/Hypothesis To describe the clinical phenotype of pediatric patients with unilateral enlarged vestibular aqueduct (EVA) and then to compare the findings to two clinically related phenotypes: bilateral EVA and unilateral hearing loss without EVA. In view of clinical observations and previously published data, we hypothesized that patients with unilateral EVA would have a much higher rate of contralateral hearing loss than patients with unilateral hearing loss without EVA. Study Design Retrospective cohort study. Methods Patients with unilateral or bilateral EVA were identified from a database of children with sensorineural hearing loss who were seen at a tertiary care institution between 1998 and 2010. Those with imaging findings consistent with well-established EVA criteria were identified. A comparative group of patients with unilateral hearing loss without EVA was also identified. The following specific outcome measurements were analyzed: 1) hearing loss phenotype, 2) laterality of EVA and hearing loss, 3) midpoint and operculum vestibular aqueduct measurements, and 4) genetic test results. Results Of the 144 patients who met our inclusion criteria, 74 (51.4%) had unilateral EVA. There was a strong correlation between the presence of hearing loss and ears with EVA. Fifty-five percent of patients with unilateral EVA had hearing loss in the contralateral ear; in most of these patients, the hearing loss was bilateral. Contralateral hearing loss occurred in only 6% of patients with unilateral hearing loss without EVA. No significant differences were found in temporal bone measurements between the ears of patients with unilateral EVA and ipsilateral hearing loss and all ears with EVA and normal hearing (P = .4). There was no difference in the rate of hearing loss progression in patients with unilateral EVA between ears with or without EVA (16 of 48 [33.3%] vs. 9 of 27 [33.3%], respectively; P = 1.0). There was no difference in the rate of hearing loss progression in patients with bilateral and unilateral EVA (41 of 89 ears [46.1%] vs. 25 of 75 ears [33.3%], respectively; P = .1); however, both EVA groups had higher rates of progression compared to patients with unilateral hearing loss without EVA. There was a strong correlation between the presence of hearing loss at 250 Hz and the risk of more severe hearing loss and progressive hearing loss. Patients with bilateral EVA and SLC26A4 mutations had a higher rate of progression than patients who had no mutations (P = .02). No patients with unilateral EVA had Pendred syndrome. Conclusions Children with unilateral EVA have a significant risk of hearing loss progression. Hearing loss in the ear contralateral to the EVA is common, suggesting that unilateral EVA is a bilateral process despite an initial unilateral imaging finding. In contrast to bilateral EVA, unilateral EVA is not associated with Pendred syndrome and may have a different etiology. Temporal bone measurements, hearing loss severity, and hearing loss at 250 Hz were all correlated with the risk of progressive hearing loss. Clinicians should become knowledgeable regarding the implications of this disease process so that families can be counseled appropriately. Level of Evidence 2b.