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BACKGROUND: Vitamin D (vitD) plays a major role in maintenance of bone mineral homeostasis. It is unknown if bone mineral content (BMC) and bone mineral density (BMD) differ between infants who receive direct vitD supplementation and those who receive vitD indirectly via their mother's breast milk, while she received a high dose of vitD. It is hypothesized that there would be no differences in BMC or BMD by treatment group. DESIGN/METHODS: Randomized, double-blind trial to compare BMD and BMC of infants who received direct vitD (400 IU vitD(3)/day) in addition to their mother receiving standard dosage (400 IU vitD(3)/day) versus infants whose mothers were their only source of vitD and were given high-dose supplementation (6,400 IU vitD(3)/day). Participants were exclusively breastfeeding mothers and their infant consuming only human milk. Infant BMC and BMD were measured by dual-energy X-ray absorptiometry (DXA) scans of the infant's total body using Hologic Discovery A Densitometer and analyzed using Hologic Infant software at 1, 4, and 7 months of age. RESULTS: Infant BMC and BMD did not differ significantly at 1, 4, or 7 months of age between direct and indirect supplementation arms. The mean difference in BMC from 1 to 7 months was 1.624 and 1.464 g for the 400 and 6,400 IU groups, respectively, (p = 0.5); the mean difference in BMD over this same period was 0.042 and 0.032 g/cm(2) for the 400 and 6,400 IU groups, respectively (p = 0.2). Although some differences among races were observed, this did not reflect changes in bone growth between the treatment arms. CONCLUSION: High-dose vitD supplementation of mothers during lactation provided an efficacious alternative to direct supplementation of infants, as evidenced by noninferior infant BMD and BMC. Clinical Trial Registration number: NCT00412074.

1. John Scheuer, BA* 2. Alice Lehman, MD* 3. Cynthia Howard, MD† 4. Emily Greengard, MD‡ 5. Alexander A. Boucher, MD‡ 1. *Department of Pediatrics, 2. †Department of Pediatrics, Division of Global Pediatrics, and 3. ‡Department of Pediatrics, Division of Pediatric Hematology and Oncology, University of Minnesota Medical School, Minneapolis, MN An 11-year-old boy is transferred from a community emergency department to a university hospital with multifocal bone pain and fevers for 2 weeks. The pain sites include his clavicles, forearms, right leg, and chest, and he has been “crying all night” despite daily use of ice and ibuprofen. He also endorses difficulty walking, fatigue, and anorexia. On physical examination he has a temperature of 100°F (37.8°C) and is tachycardic (heart rate, 118 beats/min) but normotensive. He appears ill and distressed. He has mild scleral icterus and nontender mild hepatomegaly. He has palpable tenderness over his reported pain sites. A 1 × 1-cm warm, soft mass is noted over the mid-shaft of his left clavicle. His laboratory results, shown in Table 1, demonstrate leukocytosis (white blood cell count, 17,700/μL [17.7×109/L]), microcytosis (mean corpuscular volume, 75 µm3 [75 fL]), and reticulocytosis (absolute reticulocyte count, 143×103/µL [143×109/L]), along with an elevated C-reactive protein level (106 mg/dL [1,060 mg/L]) and erythrocyte sedimentation rate (36 mm/h). View this table: Table 1. Laboratory Findings in the Patient and Normal Values The patient is admitted to the hospital for further diagnosis and management with fluids, morphine, and empirical ceftriaxone and vancomycin. Blood cultures from admission are negative, but an interferon-gamma release assay is positive. Point-of-care ultrasonography shows a small area of echogenicity overlying the left clavicle. A chest radiograph demonstrates no nodules or opacities in the lungs and no apparent clavicular abnormality. Magnetic resonance imaging (MRI) of the left clavicle confirms the irregularity detected on ultrasonography, described as a 2.3 × 0.6 × 1.7-cm fluid collection anterior to the …

BACKGROUND: To ensure the safety of higher dose vitamin D supplementation in pregnant and lactating mothers, and urinary calcium/creatinine (UCa/Cr) ratios, serum calcium, and serum 25(OH)D concentrations are closely monitored. To achieve optimal maternal and infant vitamin D status, while avoiding hypercalcemia, safety measures assessing vitD supplementation must be reliable. Whether or not this holds true for infants before 7 months of age, remains unknown. OBJECTIVE: Analyze the association among UCa/Cr ratio, serum calcium, intact serum parathyroid hormone (iPTH), 25(OH)D, and 25(OH)D/iPTH ratio in infants to determine whether evidence supports the use of these parameters as valuable measures of hypervitaminosis D or toxicity in infants. METHODS: A series of analyses were performed on the cohort of infants who participated in the National Institute of Child Health and Human Development lactation vitD supplementation trial to determine the association among UCa/Cr ratio, serum calcium, iPTH, 25(OH)D, and 25(OH)D/iPTH ratio. RESULTS: Upon multivariate analysis, serum calcium was significantly associated with 25(OH)D (p = 0.0441), iPTH (p = 0.0017), and 25(OH)D/iPTH ratio (p = 0.0001). Infant UCa/Cr did not associate with 25(OH)D but did associate with iPTH (p = 0.0008) and 25(OH)D/iPTH ratio (p = 0.0001). The correlation between UCa/Cr and 25(OH)D/iPTH ratios was significantly stronger than the association between UCa/Cr ratio and iPTH. Serum calcium more strongly correlated with 25(OH)D/iPTH ratio versus 25(OH)D and iPTH. CONCLUSION: In this healthy cohort of infants 1 to 7 months old, UCa/Cr and serum calcium are more valid indicators of 25(OH)D/iPTH ratio than either 25(OH)D or iPTH alone. Moreover, serum calcium (and not UCa/Cr) is a valid indicator of infant total circulating 25(OH)D and should be measured if vitamin D toxicity is a concern. Clinical Trial Registration number: FDA IND Number: 66,346; ClinicalTrials.gov Number: NCT00412074.

1. Ashley R.B. Bjorklund, MD*,† 2. Tina M. Slusher, MD*,† 3. Abigail Faulman, MD‡ 4. Cynthia R. Howard, MD† 5. Beatrice Odongkara, MBChB§ 1. *Hennepin Healthcare, Minneapolis, MN 2. †University of Minnesota, Minneapolis, MN 3. ‡Children’s Minnesota, Minneapolis, MN 4. §Gulu University/Gulu Regional Referral Hospital, Gulu, Uganda A 12-year-old boy with a history of sickle cell disease (SCD) presents to a government regional referral hospital in Northern Uganda with complaints of feeling ill with fever and a painful lump on his forehead. He also notes pain and swelling of his left upper arm. The fever, forehead lump, and painful swelling of the left arm had been present for at least 2 months. He denies any trauma. On presentation to the hospital he is febrile, tachycardic, and ill appearing. Initial physical examination is remarkable for frontal bossing with multiple tender, fluctuant, round (2- to 3-cm-diameter) lesions over his forehead and scalp; respiratory distress; a prominent systolic murmur; thin limbs; a tender, indurated lesion (approximately 5 × 3 cm) draining purulent fluid on his left upper arm; and no noted focal neurologic deficits. In the emergency department, incision and drainage of the forehead lesion yields scant drainage despite what appears to be a visibly purulent and fluctuant swelling. The fluid obtained is serous and bloody, without overt purulence. There is concern that the lesions may involve more than the subcutaneous tissues, with possible extension to the bone. Laboratory tests show leukocytosis with a neutrophil predominance (white blood cell count, 23,360/μL [23.36×109/L]; neutrophils, 77.5%), thrombocytosis, and anemia (hemoglobin level, 7.7 g/dL [4.78 mmol/L]). Rapid diagnostic testing for malaria is negative. Urine is remarkable for dark coloration without red blood cells on microscopic examination. Cultures from the wound are sent to the laboratory. Radiographs of the cranium (Fig 1) and humerus (Fig 2) are obtained. Figures 1. Radiograph demonstrating lytic lesions of the frontal and parietal bones. Figure 2. Radiograph demonstrating …

Residency programs are increasingly responding to the growing demand for global health (GH) education by forming dedicated GH tracks. These tracks incorporate a targeted curriculum, support best practices surrounding GH electives such as predeparture preparation and post-return debriefing, and encourage meaningful engagement with international and domestic partners. The University of Minnesota’s pediatric residency has had a formal GH track since 2005, and although they have shared several curricular components in the literature, they have yet to provide a comprehensive summary of their GH track. In this article, the authors provide a thorough description of their evolving GH track model, highlighting outcomes and sharing free resources, with the goal of providing a concise, replicable GH track framework for educators seeking to provide more formal GH education within residency programs.

Background While resident participation in global health (GH) rotations has grown, little is known about trainee perceptions of the personal value of these international clinical experiences and their importance to the objectives of GH training. Objective We sought to better understand the clinical scenarios experienced during international rotations that residents perceived as most meaningful and the frequency of these experiences across scenarios and participating residents. Methods Using the conceptual framework of Schön's reflection on action, we asked University of Minnesota GH track pediatric and internal medicine–pediatric residents to describe 10 clinical scenarios they found interesting or impactful during their 2016–2017 GH elective. We conducted a qualitative analysis of the deidentified resident narratives and mapped themes to the Accreditation Council for Graduate Medical Education (ACGME) competencies. Results All eligible residents (n = 13) participated, yielding 129 unique clinical scenarios from 7 countries. We identified 5 thematic groups: (1) addressing challenges in making diagnoses in resource-limited settings; (2) dealing with patient outcomes different from those expected in the United States; (3) encountering and managing diseases in a different clinical context; (4) encountering and managing diseases in a different cultural context; and (5) reflecting on learning and self-growth. Of the 129 unique clinical scenarios, 30% (n = 39) had not been previously experienced by participants. Across the 5 themes, all ACGME core competencies were addressed. Conclusions Residents identified meaningful scenarios of their GH experiences that are relevant to the educational and clinical objectives of GH training.

1. Jessica Hane, MD* 2. Cynthia Howard, MD, MPHTM* 3. Kelly Dietz, MD† 4. Stacene R. Maroushek, MD, PhD, MPH‡ 1. *Division of Pediatric Hospital Medicine and 2. †Department of Radiology, Pediatrics Division, and 3. ‡Division of Pediatric Infectious Disease, Hennepin Healthcare and University of Minnesota School of Medicine, Minneapolis, MN An 8-year-old boy presents to the adoption clinic for behavioral concerns and poor growth. The patient was adopted from Ethiopia 2 years before presentation. His medical history is significant for physical abuse and multiple housing transitions, including time spent in an orphanage. The patient does not have any immunization records but was noted to have a borderline Mantoux tuberculin skin test (TST) on arrival in the United States at an outside clinic. His parents are concerned that he has not grown taller since arriving in the United States. The patient has a good appetite and denies any fever, cough, or weight loss. He enjoys competitive running and has won multiple 5-km races. In the clinic, the patient’s weight is 48.7 lb (22.1 kg) (8th percentile on the Centers for Disease Control and Prevention [CDC] growth chart), height is 47.2 in (119.8 cm) (third percentile on the CDC growth chart), BMI is 15.4 (37th percentile on the CDC growth chart), and occipital frontal circumference is 21.3 in (54 cm) (75th percentile on the CDC growth chart). The physical examination reveals a small-for-age but otherwise well-appearing child. His lung fields are clear bilaterally, and no lymphadenopathy is appreciated. His complete blood cell count is normal except for a mildly elevated absolute eosinophil count of 600/μL (0.6 × 109/L). His thyrotropin level is normal (1.61 mIU/L), free thyroxine level is normal (1.23 ng/dL \[15.83 pmol/L]), insulinlike growth factor binding protein 3 level is normal (2,100 ng/mL [275 nmol/L]), insulinlike growth factor 1 level is low normal (63 ng/mL [8.25 nmol/L\] (reference range, 62–349 ng/mL [8.12–45.72 nmol/L]), and 25-hydroxyvitamin D level is low normal (23 ng/mL [57.41 nmol/L]). Results of human immunodeficiency virus 1 and 2 antibody, hepatitis B surface antibody and antigen, hepatitis C antibody, and Treponema pallidum antibody tests are all negative. …

1. Judith Kim Eckerle, MD*,† 2. Megan Marie Bresnahan, OTR/L† 3. Maria Kroupina, PhD, LP*,† 4. Dana Ernest Johnson, MD, PhD*,† 5. Cynthia Ruth Howard, MD, MPHTM*,† 1. *Department of Pediatrics, University of Minnesota, Minneapolis, MN 2. †MHealth Fairview University of Minnesota Masonic Children’s Hospital, Minneapolis, MN * Abbreviations: Ab : : antibody ACE : : adverse childhood experience CDC : : Centers for Disease Control and Prevention CXR : : chest radiography IA : : international adoptee TB : : tuberculosis 1. Key information for accurate assessment of the preadoption referral. 2. Determining immunization status and planning catch-up strategy. 3. Updated screening protocol for and treatment of latent tuberculosis infection. 4. Evaluation of developmental delays in the context of international adoption. 5. Screening for risk factors indicating the need for referral to child mental health and developmental specialists. After completing this article, readers should be able to: 1. Review the basic components of an adoption referral file and know when to consult an international adoption medicine expert. 2. Perform the initial medical assessment of a newly arrived international adoptee, including evaluation of the efficacy of previous immunizations and planning of catch-up immunization based on new recommendations. 3. Screen for tuberculosis and treat latent tuberculosis infection based on recent Centers for Disease Control and Prevention (CDC) guidelines. 4. Understand the multiple areas of a developmental baseline of adopted children and assess for catch-up needs. 5. Identify the child with multiple risk factors and/or parental or family stressors who needs a referral to an adoption-competent mental health specialist. Although interest in intercountry adoption continues to be high, the numbers of international adoptions have changed dramatically since the peak in 2004 when 45,483 international adoptees (IAs) were placed in families worldwide. By 2017, the number dropped 79% to 9,387. In the United …

Background: The safety of higher dose vitamin D (vitD) supplementation in women who change from exclusive or full breastfeeding to combination feeding or who continue supplementation after cessation of breastfeeding is unknown. Objective: Compare vitD supplementation safety of 6,400 to 400 IU/day and 2,400 IU/day using specific laboratory parameters in postpartum women and their infants through 7 months postpartum by feeding type. Design: In this randomized controlled trial, mothers (exclusively breastfeeding or formula-feeding) were randomized at 4–6 weeks' postpartum to 400, 2,400, or 6,400 IU vitD(3) (cholecalciferol)/day for 6 months. Breastfeeding infants in 400 IU group received oral 400 IU vitD(3)/day; infants in 2,400 and 6,400 IU groups received placebo. Maternal safety parameters (serum vitD, 25-hydroxy-vitamin D [25(OH)D; calcidiol], calcium, phosphorus, intact PTH; urinary calcium/creatinine ratios; and feeding type/changes) were measured monthly; infant parameters were measured at months 1, 4, and 7. Sufficiency was defined as 25(OH)D >50 nmol/L. Feeding type was defined as exclusive/full, combination, or formula-feeding. Data were analyzed using SAS 9.4. Results: Four hundred nineteen mother-infant pairs were randomized into the three treatment groups and followed: 346 breastfeeding and 73 formula-feeding pairs. A dose of 6400 IU/day safely and significantly increased maternal vitD and 25(OH)D from baseline in all mothers regardless of feeding type (p

1. Rachel Cafferty, MD† 2. Cynthia Howard, MD, MPHTM† 3. Rahul Kaila, MD‡ 1. †Department of Pediatrics, and 2. ‡Department of Pediatric Emergency Medicine, University of Minnesota Masonic Children’s Hospital, Minneapolis, MN After Match Day this month, some senior medical students will be heading off for global health rotations. Some residents and practicing physicians are finalizing plans for summer service-learning trips in countries far from home. Meanwhile, pediatric offices in North America are increasingly seeing recent immigrants who might carry conditions that seem uncommon. To help prepare all readers in all parts of the world, Index of Suspicion highlights cases this month that are particularly relevant to readers interested in global health. Philip R. Fischer, MD Associate Editor, Index of Suspicion A 16-year-old previously healthy girl with recent international emigration with refugee status from Tanzania presents via emergency medical services (EMS) with new-onset seizurelike activity. She had spent the 48 hours immediately before presentation traveling from Tanzania to the United States via Switzerland, with minimal sleep. The EMS was called to the home after the family found the girl lying on the floor covered in vomit with shaking movements of her extremities and eyes rolled back. She is without seizure activity and is not postictal in appearance when EMS arrives. She is noted to have a history of malaria several years earlier (treated and without recurrence), but no other medical problems. She has no personal or family history of seizure disorders, she is not taking medications, and there is no concern for illicit substance abuse, medication ingestion, or precipitating trauma. She has had no recent fever, headache, abdominal pain, vomiting, diarrhea, or other concerns. During transport to the emergency department (ED) she receives a dose of ondansetron. On arrival, her temperature is 98.4°F (36.9°C), respirations are 16 breaths/min, heart rate is …

Introduction Maternal exposure to tobacco smoke is associated with shortened breastfeeding duration, but few studies have examined the effects on breastfeeding outcomes of low level exposures to other toxic chemicals. Moreover, it is unclear if passive smoking is associated with duration of breastfeeding. Our objective was therefore to examine the effect of low-level prenatal exposures to common environmental toxins (tobacco smoke, lead, and phthalates) on breastfeeding exclusivity and duration. Methods We conducted an analysis of data from the Health Outcomes and Measures of the Environment (HOME) Study. Serum and urine samples were collected at approximately 16 and 26 weeks gestation and at delivery from 373 women; 302 breastfed their infants. Maternal infant feeding interviews were conducted a maximum of eight times through 30 months postpartum. The main predictor variables for this study were gestational exposures to tobacco smoke (measured by serum cotinine), lead, and phthalates. Passive smoke exposure was defined as cotinine levels of 0.015-3.0 μg/mL. Primary outcomes were duration of any and exclusive breastfeeding. Results Serum cotinine concentrations were negatively associated with the duration of any breastfeeding (29.9 weeks unexposed vs. 24.9 weeks with passive exposure, p = 0.04; and 22.4 weeks with active exposure, p = 0.12; p = 0.03 for linear trend), but not duration of exclusive breastfeeding. Prenatal levels of blood lead and urinary phthalate metabolites were not significantly associated with duration of any or exclusive breastfeeding. Conclusions Passive exposure to tobacco smoke during pregnancy was associated with shortened duration of any breastfeeding.

Background Perfluoroalkyl substances (PFAS) may affect breast development and decrease duration of breastfeeding, thus interfering with the health benefits of breastfeeding. We investigated the association between maternal PFAS exposure and breastfeeding duration. Methods We measured PFAS concentrations in maternal serum collected during pregnancy in 2003–2006. After delivery, women (n=336) completed standardized breastfeeding surveys every 3 months until ending breastfeeding or 36 months postpartum. We estimated relative risks (RRs) for ending any breastfeeding within 3–6 months postpartum by Poisson regression, adjusted for relevant confounding factors. Results Women in the 4th quartile of perfluorooctanoic acid (PFOA) serum concentration had 1.77 times the risk of ending any breastfeeding by 3 months (95% confidence interval (CI): 1.23, 2.54; p-trend=0.003) and 1.41 times the risk of ending any breastfeeding by 6 months (95%CI: 1.06, 1.87; p-trend=0.038), compared with women in the first quartile. Women in the 4th quartile of perfluorooctane sulfonic acid serum concentration had a marginally increased risk of discontinuing any breastfeeding by 3 months (RR=1.32; 95%CI: 0.97, 1.79; p-trend=0.065). Conclusions Maternal serum PFOA concentrations were inversely related to duration of any breastfeeding in this cohort, even after controlling for prior breastfeeding. These findings suggest that PFOA exposure may adversely affect breastfeeding duration and highlight the need to consider the potential adverse effects of maternal environmental chemical exposure on breastfeeding.

Ninety percent of the world’s children live in low- and middle-income countries, where barriers to health contribute to significant child morbidity and mortality. The American Academy of Pediatrics is dedicated to the health and well-being of all children. To fulfill this promise, this policy statement defines the role of the pediatrician in global health and provides a specific set of recommendations directed to all pediatricians, emphasizing the importance of global health as an integral function of the profession of pediatrics.

BACKGROUND AND OBJECTIVES: Knowledge and skills related to global child health are increasingly recognized as important to the practice of pediatrics. However, little is known about the status and trends in global health (GH) education in US pediatric residency programs. Our aim was to measure trends in residents’ exposure to GH training, their GH education assessments, and GH career plans. METHODS: We analyzed GH-focused questions from national American Academy of Pediatrics surveys of graduating residents in 2008 and 2016. Logistic regression was used to estimate changes over time by using derived predicted values. RESULTS: A total of 1100 graduating pediatric residents participated; response rates were 58.8% for 2008 and 56.0% for 2016. The percentage of residents reporting that their programs offered GH training grew from 59.1% in 2008 to 73.1% in 2016 (P < .001). The majority were somewhat likely, very likely, or definitely planning to work or volunteer in a low- or middle-income country after their residency (predicted value of 70.3% in 2008 and 69.4% in 2016; P = .76). Fourteen percent of respondents reported having completed an international elective in 2016; of those, 36.5% did not receive formal preparation before the experience, and 24.3% did not participate in debriefing sessions on return. Overall, 27.3% of respondents in 2016 reported excellent (8.8%) or very good (18.5%) GH training. CONCLUSIONS: Although a substantial percentage of pediatric residents participate in international electives and plan to include GH activities in their careers, gaps remain, including suboptimal preparation and debriefing for GH electives.

Objectives To predict the duration of any breastfeeding using the duration of exclusive breastfeeding in a socioeconomically heterogeneous sample of mothers using receiver operator characteristic (ROC) analysis. Study design The Mother Baby Health Survey, a birth certificate-linked cross-sectional survey was sent at 4-5 months postpartum to a stratified random sample of socioeconomically and racially diverse women in upstate New York; 797 mothers who initiated exclusive breastfeeding were included in this study. Split-sample validation was employed; eligible subjects were divided into training or test samples at random (80% and 20%, respectively). ROC curves were constructed using the training sample and optimal exclusive breastfeeding duration thresholds were tested using the remaining test sample. Logistic regression using the training sample provided estimates of the predictive ability (sensitivity, specificity, positive predictive value) of thresholds in both unadjusted and adjusted analyses (covariates: age, education, parity, marital status, and race). Results The ROC analysis in this sample demonstrated that 9 weeks of exclusivity was required for maintenance of breastfeeding at 3 months, and 14.9 weeks of exclusivity was required for maintenance at 20 weeks. Unadjusted and adjusted models yielded similar results; women who exclusively breastfed for at least 9 weeks had 2.2 times the risk (95% CI 1.7-2.8) of maintaining any breastfeeding at 3 months. Conclusions These results are similar to our previous results, from a less diverse cohort, and support that these thresholds may be useful in clinical settings for helping mothers achieve breastfeeding duration goals.

Appeals for health equity call for departments of pediatrics to improve the health of all children including those from underserved communities in North America and around the world. Consequently, North American (NA) departments of pediatrics have a role in global child health (GCH) which focuses on providing health care to underserved children worldwide. In this review, we describe how NA departments of pediatrics can collaboratively engage in GCH education, clinical practice, research, and advocacy and summarize best practices, challenges, and next steps for engaging in GCH in each of these areas. For GCH in low- and middle-income countries (LMICs), best practices start with the establishment of ethical, equitable, and collaborative partnerships with LMIC communities, organizations, and institutions engaged in GCH who are responsible for the vast majority of work done in GCH. Other best practices include adequate preparation of trainees and clinicians for GCH experiences; alignment with local clinical and research priorities; contributions to local professional development and ongoing monitoring and evaluation. Challenges for departments include generating funding for GCH activities; recruitment and retention of GCH-focused faculty members; and challenges meeting best practices, particularly adequate preparation of trainees and clinicians and ensuring mutual benefit and reciprocity in NA–LMIC collaborations. We provide examples of how departments have overcome these challenges and suggest next steps for development of the role of NA departments of pediatrics in GCH. Collaborative implementation of best practices in GCH by LMIC–NA partnerships can contribute to reductions of child mortality and morbidity globally.

Breastfeeding rates in the United States are suboptimal. Health professionals (HPs) have a unique opportunity to support breastfeeding because of the frequency and timing of their visits with mothers and infants as well as their call by professional organizations to do so. The objective of this study was to understand HPs' perceived roles and experiences with providing breastfeeding-related care.In-depth qualitative interviews were conducted with 34 HPs (obstetricians, midwives, pediatricians, nurses, and lactation consultants) who care for pregnant or lactating women. Interviews were audio-recorded, transcribed, and verified for accuracy; content analysis was used to identify themes using a grounded theory approach.The overarching theme was discontinuity in breastfeeding care across the continuum. Most HPs relied on other HPs to provide breastfeeding care, which resulted from and contributed to problematic gaps in care that were reported. A minority of HPs attempted to bridge gaps in breastfeeding care or improve continuity. Contributing to the discontinuity were a lack of time, lack of skills, inconsistent messages, and low communication across stages of care. HPs were unsure whether their help was effective and whether required follow-up was completed.Despite HPs' recognition of breastfeeding as the best choice for infant feeding, breastfeeding care may be disjointed and a barrier to achieving breastfeeding recommendations. These problems should be investigated and systemically addressed in future research so that maternal-infant dyad breastfeeding care can be improved.

OBJECTIVE: Compare effectiveness of maternal vitamin D3 supplementation with 6400 IU per day alone to maternal and infant supplementation with 400 IU per day. METHODS: Exclusively lactating women living in Charleston, SC, or Rochester, NY, at 4 to 6 weeks postpartum were randomized to either 400, 2400, or 6400 IU vitamin D3/day for 6 months. Breastfeeding infants in 400 IU group received oral 400 IU vitamin D3/day; infants in 2400 and 6400 IU groups received 0 IU/day (placebo). Vitamin D deficiency was defined as 25-hydroxy-vitamin D (25(OH)D) RESULTS: Of the 334 mother-infant pairs in 400 IU and 6400 IU groups at enrollment, 216 (64.7%) were still breastfeeding at visit 1; 148 (44.3%) continued full breastfeeding to 4 months and 95 (28.4%) to 7 months. Vitamin D deficiency in breastfeeding infants was greatly affected by race. Compared with 400 IU vitamin D3 per day, 6400 IU/day safely and significantly increased maternal vitamin D and 25(OH)D from baseline (P < .0001). Compared with breastfeeding infant 25(OH)D in the 400 IU group receiving supplement, infants in the 6400 IU group whose mothers only received supplement did not differ. CONCLUSIONS: Maternal vitamin D supplementation with 6400 IU/day safely supplies breast milk with adequate vitamin D to satisfy her nursing infant’s requirement and offers an alternate strategy to direct infant supplementation.

Child mortality remains a global health challenge and has resulted in demand for expanding the global child health (GCH) workforce over the last 3 decades. Institutional partnerships are the cornerstone of sustainable education, research, clinical service, and advocacy for GCH. When successful, partnerships can become self-sustaining and support development of much-needed training programs in resource-constrained settings. Conversely, poorly conceptualized, constructed, or maintained partnerships may inadvertently contribute to the deterioration of health systems. In this comprehensive, literature-based, expert consensus review we present a definition of partnerships for GCH, review their genesis, evolution, and scope, describe participating organizations, and highlight benefits and challenges associated with GCH partnerships. Additionally, we suggest a framework for applying sound ethical and public health principles for GCH that includes 7 guiding principles and 4 core practices along with a structure for evaluating GCH partnerships. Finally, we highlight current knowledge gaps to stimulate further work in these areas. With awareness of the potential benefits and challenges of GCH partnerships, as well as shared dedication to guiding principles and core practices, GCH partnerships hold vast potential to positively impact child health.

This study describes the patterns of planned use and actual receipt of immediate postpartum depot medroxyprogesterone (DMPA) prior to hospital discharge among low-income breastfeeding initiators.Bivariate analyses among DMPA recipients by prenatal planned/unplanned use and the sensitivity of DMPA self-report relative to pharmacologic record were calculated.Among immediate postpartum DMPA recipients (n=58), 72.4% (n=42) did not plan to use DMPA. The sensitivity of self-reported DMPA use was 89.7% (95% confidence interval, 85.2, 94.2).Clinically, it is unclear if the immediate postpartum period is the appropriate time to obtain consent and administer a long-acting contraceptive method. In our sample, women accurately recalled receiving DMPA in the immediate postpartum period. However, the majority did not plan to use this contraceptive method. Further high-quality qualitative and quantitative research regarding women's contraceptive plans and perception of the postpartum DMPA consent process and the healthcare provider's attitudes regarding consent and prescription of immediate postpartum DMPA are warranted.

Depot medroxyprogesterone acetate (DMPA) is often administered immediately postpartum to reduce the risk of short-interval repeat or unintended pregnancies, but little is known about the actual patterns of postpartum DMPA use. This article examines the patterns of DMPA administered among low-income new mothers in an upstate New York State community.Mothers attending urban pediatric practices (births 2009-2011) completed a mailed survey approximately 5 months after delivery. Among 83 survey items were questions about breastfeeding and timing of DMPA receipt.Unintended pregnancy was reported by 48.8% of the subjects. Their deliveries occurred across four local hospitals. Among the 31.3% of subjects who received postpartum DMPA, 62.6% received it prior to hospital discharge. Those receiving in-hospital DMPA (n=127) were significantly more likely than other mothers to be black, older, urban dwelling, non-high school graduates, multiparous, and planning to formula feed. Administration patterns differed by hospital.This study of postpartum DMPA administration among a convenience sample of low-income mothers demonstrated rates of 26% overall, but there was between-hospital variability. Additional study may identify approaches to ensure timely administration to appropriate candidates.

Background: The effect of latitude on maternal and infant vitamin D status during lactation is presumed to be strongly associated with higher rates of deficiency in those living at higher latitudes, yet with lifestyle changes, this conclusion may no longer be correct. Objective: To ascertain if higher latitude adversely affects the vitamin D status of lactating women and their fully breastfeeding infants. Study Design/Methods: Fully breastfeeding women and their infants were eligible for participation in this study as part of a larger prospective vitamin D supplementation trial. Women were recruited from two sites of differing latitude: Charleston, SC at 32˚N and Rochester, NY at latitude 43˚N. Maternal and infant baseline vitamin D status, intact parathyroid hormone (IPTH), serum calcium and phosphorus as a function of site/latitude were measured. The primary outcome was maternal and infant total circulating 25(OH)D at baseline by center/latitude, and the secondary outcome was the percent of women and infants who had achieved a baseline concentration of at least 20 ng/mL, meeting the Institute of Medicine’s definition of sufficiency at 4 to 6 weeks postpartum. Statistical analysis was performed using SAS version 9.3. Results: Higher latitude adversely affected vitamin D status only in lactating Caucasian women. African American and Hispanic women and infants living in Rochester compared to Charleston had improved vitamin D status, an effect that was no longer significant when controlling for socioeconomic factors and season. Overall, there was a significant vitamin D deficiency at baseline in lactating mothers, and a far greater deficiency in their infants. Maternal baseline 25(OH)D concentration remained positively associated with being Caucasian, BMI and summer months. Breastfeeding infant vitamin D status mirrored maternal status and remained positively associated with being Caucasian and summer months. Those infants who had been on a vitamin D supplement at the time of enrollment in the study had markedly improved vitamin D status compared to those infants not on supplement, but represented a significant minority of the cohort. Conclusions: There was a significant vitamin D deficiency among a cohort of women and their infants living at two diverse latitudes—Charleston, SC and Rochester, NY. Given the higher rate of vitamin D deficiency among African American and Hispanic women and their infants living at a lower latitude, conclusions about vitamin D status based on latitude alone may be faulty.

Objective To evaluate the association between delayed lactogenesis II (>3 days postpartum; delayed onset lactogenesis II [DLII]) and the cessation of any and exclusive breastfeeding at 4-weeks postpartum. Study design We constructed multivariable logistic regression models using data from 2491 mothers enrolled in the prospective Infant Feeding Practice Study II cohort. Models included DLII, known risk factors for breastfeeding cessation (age, education, race, parity/previous breastfeeding, and exclusive breastfeeding plan), and potential confounders identified in bivariate analyses ( P ≤ .1). Backward selection processes ( P ≤ .1) determined risk factor retention in the final model. Results DLII was associated with cessation of any and exclusive breastfeeding at 4-weeks postpartum (OR 1.62; CI 1.14-2.31; OR 1.62; CI 1.18-2.22, respectively); numerous independent risk factors qualified for inclusion in the multivariable model(s) and were associated with the outcome(s) of interest (eg, supplemental nutrition program for women, infants, and children enrollment, onset of prenatal care, feeding on-demand, time initiated first breastfeed, hospital rooming-in, obstetric provider preference for exclusive breastfeeding, and maternal tobacco use). Conclusions Women experiencing DLII may be less able to sustain any and/or exclusive breastfeeding in the early postpartum period. Routine assessment of DLII in postpartum breastfeeding follow-up is warranted. Women with DLII may benefit from additional early postpartum interventions to support favorable breastfeeding outcomes.

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient. These guidelines are not intended to be all-inclusive, but to provide a basic framework for physician education regarding breastfeeding.

In the first 2 weeks of life, most breastfeeding mother-infant dyads in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) receive infant formula from WIC, instead of a larger food package designed for exclusively breastfeeding mothers. This study was designed to explore reasons for high rates of formula supplementation of breastfeeding newborns enrolled in WIC and the limited use of the WIC expanded food package.We conducted in-depth interviews with 29 mothers who either partially or exclusively breastfed for at least 2 months. Interviews were transcribed verbatim, analyzed, coded, and organized into 10 themes.Participants view the WIC program in a contradictory manner. They see it as highly supportive of breastfeeding, but also as a promoter of infant formula. The expanded food package for mothers is not valued, but free supplemental formula is highly valued. Misinformation about breastfeeding pervades the healthcare system, and exclusive breastfeeding is not promoted as an important health goal. Lack of access to breast pumps, the unacceptability of pumping in the workplace, and difficulties with nursing in public all contribute to formula supplementation.The healthcare system, the WIC program, and demands of daily life all contribute to low rates of exclusive breastfeeding in the WIC program. The available expanded food package for mothers who are exclusively breastfeeding is both disliked and underutilized, while free supplemental formula is rarely discouraged.

Recent outbreaks of diseases erroneously thought by many to be contained by borders or eliminated by vaccines have highlighted the need for proper training of all residents in global health. Beyond infectious diseases, all pediatricians should know how to care for other conditions in global child health, ranging from malnutrition to the nuances of care for immigrant and refugee children. The call for broader education for pediatric residents in global health has been increasing over the last decade, with all major pediatric organizations underscoring its importance in statement and action. Herein, the current status of global child health education in pediatric residency training in the United States is summarized, highlighting where it has been, where it is now, and where it should go next.

We screened 52 children adopted from Ethiopia for malaria because they had previously lived in a disease-endemic region or had past or current hepatomegaly or splenomegaly. Seven (13.5%) children had asymptomatic malaria parasitemia by microscopy (n = 2) or PCR (n = 5). Our findings suggest that adoptees at risk for asymptomatic malaria should be screened, preferably by PCR.

Infant crying can cause parental distress, and colic is associated with low maternal self-efficacy and heightened risk for depression. Breastfeeding is recognized as an effective method of calming infants, but the relationship of colic and the use of breastfeeding to remedy infant crying have not been tested for any effects on breastfeeding duration.To evaluate the effects of infant colic (colic analysis) and breastfeeding as a method of infant calming (calming analysis) on breastfeeding duration.The authors followed 700 healthy breastfeeding mother-baby dyads from birth to 1 year. Maternal interviews were conducted postpartum, and at 2, 5, 10, 16, 24, 38, and 52 weeks to ascertain demographic factors, infant crying patterns, comforting practices, physician-diagnosed colic, and breastfeeding behaviors. Cox survival analyses were used to evaluate the independent effects of: (a) physician diagnosed colic; and (b) breastfeeding as a comforting practice on breastfeeding duration. Data from all 700 breastfeeding dyads were used in the colic analyses. In the calming analyses, to assure that breastfeeding was appropriately established, data were used from the 617 couplets that had breastfed for at least 2 weeks. Using a stepwise process, models, adjusted for typical predictors of breastfeeding duration, were developed for exclusive, full and partial breastfeeding duration. Variables of interest (i.e., colic diagnosis, breastfeeding for comfort) were then forced into the baseline models to determine any independent effects.In the first 16 weeks, parents found that holding (87%), breastfeeding (82%), walking (67%), and rocking (63%) were highly effective calming practices. Mothers who rated breastfeeding as highly effective had a higher frequency of breastfeeding at all contacts (p0.05). In adjusted analyses the use of breastfeeding to comfort infants was a significant predictor of longer partial (overall) ([hazard ratio] HR = 0.6, 95% CI 0.4 to 0.9; p = 0.02) but not exclusive or full breastfeeding duration. By 6 months, 44 mothers (6.3%) reported a diagnosis of colic. Mothers of infants with a diagnosis of colic were less likely to report breastfeeding as effective method of infant comforting (p = 0.03). In adjusted analyses the authors found that a diagnosis of colic predicted shorter full breastfeeding duration (HR = 2.4, 95% CI 1.4 to 4.2; p = 0.001) but not exclusive or partial duration.Breastfeeding to comfort a crying infant is a strong predictor of partial (overall) duration and is rated as a highly effective calming method by parents. These data suggest that parents may benefit from education about normal infant crying patterns and effective methods of infant comforting, including breastfeeding. However, mothers of infants diagnosed with colic are at risk for shortened duration of full breastfeeding. Although the reasons for this are unclear, it may be helpful to specifically address the subject of colic and infant feeding and encourage mothers to fully breastfeed for the recommended 6 months.

OBJECTIVE. The American Academy of Pediatrics recommends exclusive breastfeeding for an infant's first 6 months of life. When compared with exclusive breastfeeding for 4 months, greater protection against gastrointestinal infection, but not respiratory tract infection, has been demonstrated for the 6-month duration. The objective of this study was to ascertain if full breastfeeding of ≥6 months compared with 4 to METHODS. Secondary analysis of data from the National Health and Nutrition Examination Survey III, a nationally representative cross-sectional home survey conducted from 1988 to 1994, was performed. Data from 2277 children aged 6 to RESULTS. In unadjusted analyses, infants who were fully breastfed for 4 to CONCLUSIONS. This nationally representative study documents increased risk of respiratory tract infection including pneumonia and recurrent OM in children who were fully breastfed for 4 vs 6 months. These findings support current recommendations that infants receive only breast milk for the first 6 months of life.

Objective: To determine the relative contribution of residential lead hazards to children's blood lead concentrations during early childhood. Methods: We enrolled children 6 months of age and followed them until 24 months of age. Blood and samples of dust, soil, water and paint were analyzed for lead at 6-month intervals, and interviews were conducted to estimate nutritional, behavioral, and demographic factors linked with lead exposure. Results: Of the 276 children enrolled, 249 (90%) were followed until 24 months of age. The geometric mean blood lead concentration of children at 6 months of age was 2.9 μg/dL (95% CI, 2.7-3.1). At 24 months of age, children's mean blood lead was 7.5 μg/dL; 82 (33%) had a blood lead level of ≥10 μg/dL. In adjusted analyses, lead-contaminated floor dust, soil, and water contributed to children's lead intake throughout the first 2 years of life (P < .05). Lead-contaminated dust from window troughs was a source of lead exposure, especially in the second year of life. Dietary iron intake, but not calcium intake, was inversely associated with blood lead levels (P < .05). Blood lead concentration was over 50% higher in black than in white children (P = .0001). Conclusion: Lead-contaminated house dust is the major source of lead intake during early childhood. Black children remain at increased risk for higher blood lead concentration after adjusting for environmental lead exposures and dietary intake. (J Pediatr 2002;140:40-7)

Breastfeeding support is a team event. The physician works with many health care professionals to provide complete care to the perinatal patient, including working with nurses trained in prenatal care, labor, delivery, and postpartum and newborn care, and working with midwives who provide prenatal care, labor, and delivery for the normal, uncomplicated patient. The pediatrician is part of this team and interacts with all of these players and with the office or clinic staff who provide follow-up, newborn, and child care.

Background. To prevent breastfeeding problems, cup-feeding has been recommended as a method of providing medically necessary supplemental feedings to breastfed infants. Objectives. To compare amounts ingested, administration time, and infant physiologic stability during cup-, bottle-, and breastfeeding. Design/Methods. A total of 98 term, healthy newborns were randomized to either cup-feeding (n = 51) or bottle-feeding (n = 47). The heart (HR), respiratory (RR), and oxygen (O2) saturation rates were monitored on these infants and 25 breastfed newborns during 1 feeding. Differences in amounts ingested and administration times were evaluated with t tests and physiologic data with repeat measures analysis of variance. Results. There were no significant differences in administration time, amounts ingested or overall HR, RR, and (O2) saturation rates, between cup and bottle groups. Breastfed infants had longer administration times and lower overall HR, RR, and higher O2 saturation as compared with cup- and bottle-fed infants. Conclusions. Administration times, amounts ingested, and infant physiologic stability do not differ with cup- and bottle-feeding. Breastfeeding takes longer than cup- or bottle-feeding, but infants experience less physiologic variability. These data support cup-feeding as an alternative to bottle-feeding for supplying supplements to breastfed infants.

There are many benefits to the infant to be breastfed and to the mother to breastfeed. There are, however, a few conditions where the tremendous benefit may be outweighed by maternal infection, disease, drugs, or contaminants as these are rare. HIV is the only infection that is an absolute contraindication in developed countries. Galactosemia is the only infant disease and there are a few medications that are contraindicated.