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Background and Objective: Although breastfeeding ensures optimal infant development and maternal health, mothers taking medications may abandon breastfeeding because of uncertainties regarding toxicity to infants. Current methods in predicting infant risk to maternal medication exposure do not account for breastfeeding-related variability or in utero exposure via the umbilical cord (UC). Previously, our workflow integrated variability in infant anatomy and physiology, breast milk intake volume, and drug concentrations in breast milk using physiologically based pharmacokinetic (PBPK) modeling. The upper area under the curve ratio (UAR) was then calculated to assess infant risk from maternal drug. Herein, we enhanced this workflow by coupling pre- and postnatal exposures to predict the overall levetiracetam exposure in breastfeeding infants. Methods: A published pediatric PBPK model of levetiracetam was used to simulate an infant population (n = 100). Daily infant doses were simulated using a weight-normalized milk intake model to calculate volumes ingested across age groups, alongside literature-derived or simulated milk concentrations across maternal doses to predict infant concentrations. Published UC concentrations were used to develop a cord-coupled neonatal model (CCM), which was integrated with the PBPK and milk intake models and evaluated by comparing observed and simulated infant blood concentrations using a 90% prediction interval (PI). Results: UC concentration data from 14 mothers were used to develop the CCM. A total of 16 paired (known milk concentrations) and two unpaired (unknown milk concentrations) individual infant concentrations were identified for evaluating the model along with population values of 64 infants from two age groups (2–4 and 7–31 days). The CCM improved the predictions overall compared with the original workflow, largely due to improvements for the youngest age group evaluated. Overall, 83% (10 of 12) of the individual infant plasma concentrations were successfully captured within the 90% PI for the paired, quantifiable (i.e. above the limit of quantification) evaluation datasets. After administration of a maternal dose of levetiracetam 2000 mg, the calculated UAR ranged from 0.13 to 0.27 for the 95th percentile infants. Conclusions: To our knowledge, this is the first report to combine prenatal levetiracetam exposures from the UC and postnatal exposures from breastfeeding to predict overall infant drug exposure. The results indicate that infant exposure in infants aged 0–7 days may approach therapeutic levels of levetiracetam in the highest-risk infants (i.e. 95th percentile), with a low likelihood of adverse effects based on published clinical studies. This integrated modeling approach provides a more holistic analysis of neonatal exposures. It can be applied in future studies to derive the UAR of drugs administered during breastfeeding to identify infants at risk of potential toxicity. [ABSTRACT FROM AUTHOR]

The article focuses on the use of physiologically based pharmacokinetic (PBPK) modeling to evaluate the effects of pathophysiological changes in neonates. Topics include the strengths and limitations of PBPK models in neonatal drug dosing, challenges in incorporating neonatal-specific physiological data, and future directions for improving model accuracy and applicability in clinical settings.

Competencies in healthcare settings are used to verify that staff have appropriate knowledge and skills to do their job effectively and that they can demonstrate these on an ongoing basis through their bedside behaviors and clinical reasoning. Feeding high-risk infants within a Neonatal Intensive Care Setting (NICU) requires a high level of knowledge and skills, yet many NICUs do not have formal competencies for feeding high-risk infants. Specifically, behavior-based infant-led feedings are often not delineated, leading to inconsistent feeding practices. The Gravens Infant and Family-Centered Developmental Care (IFCDC) Consensus Panel has provided evidence-based recommended standards, competencies, and best IFCDC practices for infant and familycentered developmental care for feeding, eating, and nutrition delivery (FEND). Establishing competencies for standardizing feeding practices within the NICU may lead to safer, more consistent, and pleasurable feeding experiences for infants and their parents. [ABSTRACT FROM AUTHOR]

Optimal performance lies at intermediate autonomic arousal, but no previous research has examined whether the emergence of endogenous control associates with changes in children's up‐regulation from hypo‐arousal, as well as down‐regulation from hyper‐arousal. We used wearables to take day‐long recordings from N = 58, 12‐month‐olds (60% white/58% female); and, in the same infants, we measured self‐regulation in the lab with a still‐face paradigm. Overall, our findings suggest that infants who showed more self‐regulatory behaviors in the lab were more likely to actively change their behaviors in home settings moment‐by‐moment "on the fly" following changes in autonomic arousal, and that these changes result in up‐ as well as down‐regulation. Implications for the role of atypical self‐regulation in later psychopathology are discussed. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the potential of compound‐specific isotope analysis of amino acids (CSIA‐AA) for investigating infant feeding practices, we conducted a long‐term study that compared infant and maternal amino acid (AA) nitrogen isotope ratios. Materials and Methods: Fingernail samples were collected from a single mother–infant dyad over 19 months postpartum. Carbon and nitrogen stable isotope ratios were measured in the bulk keratin of the fingernail samples. Selected samples were then hydrolyzed and derivatized for compound‐specific nitrogen isotope analysis of keratin AAs. Results: As in previous studies, infant bulk keratin nitrogen isotope values increased during exclusive breastfeeding and fell with the introduction of complementary foods and eventual cessation of breastfeeding. Infant trophic AAs had elevated nitrogen isotope values relative to the mother, while the source AAs were similar between the mother and infant. Proline and threonine appeared to track the presence of human milk in the infant's diet as the isotopic composition of these AAs remained offset from maternal isotope values until the cessation of breastfeeding. Discussion: Although CSIA‐AA is costly and labor intensive, it appears to hold potential for estimating the duration of breastfeeding, even after the introduction of complementary foods. Through the analysis of a full suite of AAs, it may also yield insights into infant physiology and AA synthesis. [ABSTRACT FROM AUTHOR]

The effects of preterm birth, neonatal morbidities and environmental influences on infant sleep development is an important yet under-researched topic, with little known about normative sleep for infants born sick or preterm. The aim of this prospective, observational longitudinal study was to evaluate maternal perceptions and degree of bother with infant sleep behaviours and feeding outcomes across the first 9 months after discharge for sick/preterm infants cared for in the neonatal intensive care unit (NICU) and for healthy term-born infants. This paper reports outcomes for the sick/preterm cohort (I = 94) that were recruited from two NICUs in Perth, Western Australia. Total bother scores were on average 20.2% higher at 9 months than at two weeks post-discharge (p < 0.001). Increased night waking frequency, evening settling duration and crying duration were all positively associated with total bother scores. Maternal confidence scores were negatively associated with maternal bother scores; with each unit increase in confidence, maternal bother decreased by 8.5% (p < 0.001). Covariates such as birth gestation, breastfeeding status and multiple births were not associated with maternal bother. Families may benefit from additional support when experiencing increased night waking frequency and crying and settling durations in the first 9 months after discharge from NICU. [ABSTRACT FROM AUTHOR]

The abnormal umbilical cord coiling pattern affects the well-being of the newborn in different ways. Moreover the differentiation of mast cell according to these patterns may also varies. The objective: to investigate the detection and enumeration of mast cells in different patterns in human coiling cords in order to explore their effect on the newborn baby health. Materials and methods. Umbilical cord samples were collected from 105 healthy pregnant women. The cords were collected immediately after labor and kept in formalin (10%), according to coil type. Three major categories of umbilical cord coiling (normocoiled, hypercoiled, and hypocoiled) were determined according to the Umbilical Cord Index (UCI). The histological sections of the umbilical cord were collected according to UCI. This step is followed by using different histological stains, including hematoxylin and eosin and toluidine blue stains. The expression of the CD117 mast cell population in the umbilical cord tissue was determined using the immunohistochemical method in the subamniotic, perivascular and central areas. The enumeration of mast cells was done by direct counting and using Image J software. Results. The comparison of mast cell counts using Image J showed statistically significant variations (P<0.05) between normocoiled and hypercoiled cords in mast cell populations. No significant changes (P>0.05) were found in mast cell counts between normocoiled and hypocoiled umbilical cords. Conclusions. The mast cell distribution interpretation suggested that mechanical coiling during embryonic growth affects mast cell dispersal in sectioned umbilical cords. This interpretation’s functional relevance should be applied to coiling events that do not have harmful outcomes on the fetus. Future research could be done on the distribution of mast cells in the abnormally coiled umbilical cords associated with negative perinatal outcomes. [ABSTRACT FROM AUTHOR]

Cochlear implants (CIs) have demonstrated a clear functional benefit in children with severe-to-profound sensorineural hearing loss (SNHL) and thus have gained wide acceptance for treating deafness in the pediatric population. When evaluating young children for cochlear implantation, there are unique considerations beyond the standard issues addressed during surgery in adults. Because of advances in genetic testing, imaging resolution, CI technology, postimplant rehabilitation, and other factors, issues related to CI surgery in children continue to evolve. Such factors have led to changes in candidacy guidelines, vaccine requirements, and lowering of age requirement for surgery. In addition, differences in the anatomy and physiology of infants require special attention to ensure safety when operating on young children. This review summarizes these issues and provides guidance for surgeons treating children with SNHL. [ABSTRACT FROM AUTHOR]

Copyright of Fisioterapia Brasil is the property of Atlantica Editora and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Late preterm infants have lower breastfeeding rates than term infants, yet few published interventions or guidelines exist to guide hospitals in managing them in the non-intensive nursery setting. Here we describe the development and implementation of an interdisciplinary, hospital-based, breastfeeding support program among late preterm infants not requiring intensive care. The Early Bloomer Program includes an order set applied at birth, immediate lactation consultation, availability of donor milk, parent education on late preterm infants, hand expression teaching and kit including spoon and video link, and daily interdisciplinary team huddles. The program was developed with staff input using Diffusion of Innovation Theory, and implemented first among early adopters before expanding to all postpartum nurses. Nursing staff received education on late preterm infant physiology and feeding, and trainings on the Early Bloomers program through various learning modalities during the year leading up to implementation. To further understand the strengths and weakness of the program, we surveyed nurses (n = 43). Nurses reported that they were more attentive to the needs of late preterm infants, more confident in their care, and more aware of possible complications and feeding needs. Areas noted in need of improvement included lack of overnight lactation consults and little involvement of labor and delivery staff in the program. The Early Bloomers program increased confidence in care and was well received by nurses. Well-designed clinical studies are needed to identify effective breastfeeding support practices for late preterm infants. [ABSTRACT FROM AUTHOR]

Purpose: Most infants born preterm will experience some difficulty with sucking and feeding. As clinicians in the neonatal intensive care unit (NICU), it is important to understand the available technologies so that they may be implemented, when appropriate and accessible, to support these infants in their sucking and feeding performance. The purpose of this review is to highlight devices that are available to assist clinicians in the management of pediatric dysphagia in the NICU. We will review the literature surrounding the use of devices in the management of pediatric dysphagia. This is followed by a clinical perspective from a NICU speech-language pathologist (SLP) who shares important considerations, recommendations, and limitations of device use. Conclusions: By reviewing device-facilitated therapies for the management of pediatric dysphagia and discussing their implementation and effectiveness, we hope that SLPs will gain an understanding of the available technologies and insight into their use in the NICU environment. While the research highlighted shows many benefits of the use of device-facilitated therapies in the NICU, this is an emerging area of the field that is continually evolving and more research is needed to establish the pathway to individualized, developmentally supportive, device-facilitated intervention. [ABSTRACT FROM AUTHOR]

Copyright of Ciencia, Cuidado e Saude is the property of Universidade Estadual de Maringa and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The aim of this study was to examine associations between parent reports of bottle-feeding behaviors and infant non-nutritive suck (NNS) on a pacifier as well as oral feeding skills during bottle-feeding. A prospective study was conducted. Full-term infants with no prior diagnosed feeding disorders were recruited at 3-months. Parents reported their infant's bottle-feeding behaviors using the Neonatal Eating Assessment Tool-Bottle-Feeding (NeoEAT-Bottle-Feeding), consisting of five domains: Infant Regulation, Energy and Physiologic Stability, Gastrointestinal Tract Function, Sensory Responsiveness, and Compelling Symptoms of Problematic Feeding. Infant NNS was measured using a custom pacifier, pressure transducer device, which yields the following NNS variables: duration (sec), frequency (Hz), amplitude (cmH20), cycles per burst, cycle amount, and burst amount. The Oral Feeding Skills (OFS) scale was used to measure the initial volume, transfer volume, proficiency, and rate of milk transfer during bottle feeding. Fifty-two infants (58% male) with reported prior bottle experience completed this study. NeoEAT-Bottle-Feeding Total score was significantly positively associated with NNS burst duration and NNS cycles per burst. The NeoEAT-Bottle-Feeding Energy and Physiologic Stability domain was significantly positively correlated with NNS cycles per burst. NeoEAT-Bottle-Feeding Gastrointestinal Tract Function domain score was significantly positively correlated with NNS duration, amplitude, and cycles per burst. There were no significant associations between NeoEAT-Bottle-Feeding domains and the OFS scale. The findings demonstrate that parent reports of problematic feeding at 3 months of age are associated with aspects of infant NNS physiology and not with oral feeding metrics during bottle-feeding. Parent reports of bottle-feeding behaviors, particularly pertaining to gastrointestinal issues, were associated with aspects of infant NNS. These data together will allow for a more nuanced understanding of infant feeding and will be beneficial in determining if infants have a feeding delay. [ABSTRACT FROM AUTHOR]

Currently, the prevention, assessment, and management of procedural pain in neonates continues to challenge clinicians and researchers. Objective. To investigate the analgesic effect of low-level laser therapy (LLLT) during heel lance compared to breast milk (BM) feeding in healthy term neonates. In this randomized controlled trial, healthy term neonates who underwent heel lance were randomly assigned to an LLLT or a BM group. The LLLT group received laser therapy to the heel lance site for 20 s before heel lance. The BM group received 5 mL expressed BM via a syringe before heel lance. The primary outcomes were behavioral responses. The secondary outcomes were physiological responses and levels of salivary cortisol and α-amylase. A total of 125 neonates were included, of whom 55 in the LLLT group and 59 in the BM group completed the study. There were no significant differences in latency to first cry and cry duration between the two groups. The squeeze time was significantly shorter in the LLLT group than in the BM group (p = 0.047). There were no significant differences in pain scores, heart rate, respiratory rate, oxygen saturation, and blood pressure before and after heel lance between the two groups. There were no significant differences in salivary cortisol and α-amylase levels in the LLLT group before and after heel lance; however, the differences were significant in the BM group. These findings suggest that the analgesic effect of LLLT is similar to that of BM during heel lance in healthy term neonates. LLLT has potential as an analgesic treatment. [ABSTRACT FROM AUTHOR]

Background: Infants with single‐ventricle (SV) physiology undergo the 3‐stage Fontan surgery. Norwood patients, who have completed the first stage, face the highest interstage mortality. The Berlin Heart EXCOR (BH), a pediatric pulsatile ventricular assist device, has shown promise in supporting these patients. However, clinical questions regarding device configurations prevent optimal support. Methods: We developed a combined idealized mechanics‐lumped parameter model of a Norwood patient and simulated two additional patient‐specific cases: pulmonary hypertension (PH) and post‐operative treatment with milrinone. We quantified the effects of BH support across different device volumes, rates, and inflow connections on patient hemodynamics and BH performance. Results: Increasing device volume and rate increased cardiac output, but with unsubstantial changes in specific arterial oxygen content. We identified distinct SV–BH interactions that may impact patient myocardial health and contribute to poor clinical outcomes. Our results suggested BH settings for patients with PH and for patients treated post‐operatively with milrinone. Conclusions: We present a computational model to characterize and quantify patient hemodynamics and BH support for infants with Norwood physiology. Our results emphasized that oxygen delivery does not increase with BH rate or volume, which may not meet patient needs and contribute to suboptimal clinical outcomes. Our findings demonstrated that an atrial BH may provide optimal cardiac loading for patients with diastolic dysfunction. Meanwhile, a ventricular BH decreased active stress in the myocardium and countered the effects of milrinone. Patients with PH showed greater sensitivity to device volume. In this work, we demonstrate the adaptability of our model to analyze BH support across varied clinical situations. [ABSTRACT FROM AUTHOR]

Background: Childbirth has become increasingly medicalised, which may impact on the mother's birth experience and her newborn infant's physiology and behaviour. Although associations have been found between a mother's subjective birth experience and her baby's temperament, there is limited qualitative evidence around how and why this may occur. Objectives: This qualitative study aimed to explore mothers' childbirth and postnatal experiences, perceptions of their baby's early behavioural style, and whether they saw these as related. Methods: A qualitative semi-structured interview schedule collected rich in-depth data. Twenty-two healthy mothers over 18 years of age and with healthy infants aged 0–12 months born at term, were recruited from Southwest regions of England and Wales. Thematic analysis was performed on the data. Results: Mothers experienced childbirth as a momentous physical and psychological process. However, they did not necessarily perceive the birth as affecting their baby's early behaviour or temperament. While some mothers drew a direct relationship, such as linking a straightforward birth to a calm infant, others did not make an explicit connection, especially those who experienced a challenging birth and postnatal period. Nevertheless, mothers who had a difficult or medicalised birth sometimes reported unsettled infant behaviour. It is possible that mothers who feel anxious or depressed after a challenging birth, or those without a good support network, may simply perceive their infant as more unsettled. Equally, mothers who have been well-supported and experienced an easier birth could be more likely to perceive their baby as easier to care for. Conclusions: Childbirth is a physical and psychological event that may affect mother-infant wellbeing and influence maternal perceptions of early infant temperament. The present findings add to prior evidence, reinforcing the importance of providing good physical and emotional support during and after childbirth to encourage positive mother-infant outcomes. [ABSTRACT FROM AUTHOR]

An increase in the birth rate of premature and low birth weight children at the current level of medical development requires the development of fundamental ideas about the physiology of the cardiovascular system in a history of preterm birth from the point of view of pre- and postnatal ontogenesis. For practicing neonatologists, pediatricians, therapists, cardiologists, reproductologists, etc., it is necessary to improve the traditional ideas about the mechanisms of damage to the cardiovascular system in this category of patients. Because it is established that this clinical subgroup is characterized by increased risks of early onset of pathology of the heart and blood vessels, as well as a high mortality rate in adulthood. Pathological changes of the cardiovascular system in conditions of prematurity can occur at various levels of integration of the body (molecular, subcellular, cellular, organ, functional systems, organismal). The use of modern noninvasive technology of "spot tracing" makes it possible to study the features of segmental deformation and the variety of forms of left ventricle (LV) torsion mechanics during postnatal growth and development in prematurely born children. Optimization of research and diagnostic processes in the field of mechanics of the infant heart in the prenatal and postnatal periods from the point of view of progressive data on anatomy, histology, and clinical biochemistry allows us to study the nature of various contractile–rotational models, as well as reasonably assume the contribution of the fibrous skeleton of the infant heart to the formation of "childhood types" of left ventricular twisting. The search and development of informative criteria for the early diagnosis of latent subclinical heart dysfunction in childhood, taking into account the possibilities of non-invasive ultrasound technology of spot tracing (analysis of types of rotational movement, determination of areas of reduced longitudinal deformation of the LV), based on the current provisions of evidence-based medicine, have become quite possible in modern conditions and are demonstrated by the authors in this review. The information offered to the readers will allow them to expand the understanding of the physiology and pathophysiology of the infant heart with a history of premature birth, bearing in mind the fact that prematurity is considered a chronic condition. [ABSTRACT FROM AUTHOR]

As robotic‐assisted (RAL) surgery expanded to treat pediatric congenital disease, infant anatomy and physiology posed unique challenges that prompted adaptations to the technology and surgical technique, which are compiled and reviewed in this manuscript. From the beginning, collaboration with anesthesia is critical for a safe, efficient case including placement of an endotracheal tube rather than a laryngeal mask (LMA) and placement of a nasogastric tube and/or rectal tube to relieve distended stomach or bowel, respectively. Furthermore, end‐tidal CO2 (EtCO2) is important for monitoring and predicting the effects of pneumoperitoneum on caridiovascular physiology, incranial pressure, and risk of acidosis and hypercarbia. Positioning can further exacerbate these effects and affect intra‐abdominal working space. For infant robotic pyeloplasty and heminephrectomy, a "beanbag" is commonly used for stabilization in the lateral decubitus position. We advise against the use of a "baby bump" because it brings the bowels and vasculature more anterior than expected. Pnuemoperitoneum pressure of 8–10 mmHg during port placement maximizes safety, but thereafter, the pneumoperitoneum pressure can be minimized to 6–8 mmHg during the procedure without compromising the visual field. Port sites should be marked after insufflation, followed by the open Hasson technique for peritoneal access and port placement under direct vision with intussusception of the trocars to avoid vascular or bowel injury. Additional tips can be obtained through this manuscript, immersive fellowships, and mini‐fellowships. Ulitmately, infant robotic surgery has the potential to benefit many children but is presently limited by the lack of pediatric‐specific robotic technology and its associated costs. [ABSTRACT FROM AUTHOR]

Improved offspring emotion regulation (ER) has been associated with maternal intake of single nutrients or exercise during pregnancy but has not been examined in randomized trials. We investigated the impact of a maternal nutrition + exercise intervention during pregnancy on offspring ER at 12 months of age. Mothers in the Be Healthy In Pregnancy randomized controlled trial were randomly assigned to an individualized nutrition + exercise intervention plus usual care (UC) or UC alone (control group). A multimethod assessment of infant ER using parasympathetic nervous system function (high frequency heart rate variability [HF‐HRV] and root mean square of successive differences [RMSSD]) as well as maternal reports of infant temperament (Infant Behavior Questionnaire‐ Revised short form) was completed with a subsample of infants of enrolled mothers (intervention = 9, control = 8). The trial was registered at www.clinicaltrials.gov (NCT01689961). We observed greater HF‐HRV (M = 4.63, SD = 0.50, p =.04, ƞ2p =.25) and RMSSD (M = 24.25, SD = 6.15, p =.04, ƞ2p =.25) in infants of mothers in the intervention versus control group. Intervention group infants also had higher maternally rated surgency/extraversion (M = 5.54, SD = 0.38, p =.00, ƞ2p =.65) and regulation/orienting (M = 5.46, SD = 0.52, p =.02, ƞ2p =.81), and lower negative affectivity (M = 2.70, SD = 0.91, p =.03, ƞ2p =.52). These preliminary results suggest that pregnancy nutrition + exercise interventions could improve infant ER but these findings require replication in larger, more diverse samples. [ABSTRACT FROM AUTHOR]

[Display omitted] • Whey protein and casein in IFs have synergistic action on colonic physiology and microbiota. • Serum metabolites related to microbiota (polyamines) and tryptophan metabolism were changed. • Ideal whey and non-micellar caseins would improve health benefits of IFs. Despite the WHO recommendations in favor of breastfeeding, most infants receive infant formulas (IFs), which are complex matrices involving numerous ingredients and processing steps. Our aim was to understand the impact of the quality of the protein ingredient in IFs on gut microbiota and physiology, blood metabolites and brain gene expression. Three IFs were produced using whey proteins (WPs) from cheese whey (IF-A) or ideal whey (IFs-C and -D) and caseins, either in a micellar form (IFs-A and -C) or partly in a non-micellar form (IF-D). Twenty-four Yucatan minipiglets received one of the IFs from 2- to 21-days of age. The piglets were then euthanized 84 min postprandially. Blood, ileal and colonic digesta and tissues, the liver and the hypothalamus were sampled. Gut microbiota composition and activity, the expression of intestinal and brain genes involved in barrier, immune, endocrine, nutrient carrier and neuronal functions and serum metabolite levels were determined. Intestinal paracellular permeability was assessed with an ex vivo Ussing chamber. The data were analyzed using multifactorial and univariate analyses. The colon was the main site to be physiologically affected by the quality of the dairy protein ingredients used in IFs. Colonic paracellular permeability was significantly higher in IF-D-fed piglets than in those receiving IFs-A and -C, in line with the expression of genes encoding tight junction proteins (OCLN, CLDN3 and CLDN4). IF-D up-regulated the colonic expression of genes involved in the immune function (SOCS3, PIGR and TNFα) when compared to IF-A. Although intestinal α- and β-diversities did not significantly differ among IFs, some specific differences were observed, such as the abundances of Campylobacterota phylum and Bacteroides genera and fecal butyrate production, which were increased with IFs-C and -D versus IF-A. The kynurenine pathway was favored in piglets fed IF-D compared to IF-A, based on colonic gene expression and serum metabolites. In addition, levels of some serum metabolites, particularly putrescine, spermidine and spermine, were higher in piglets fed IF-D than IFs-A and -C. Overall, IF-D, which combined ideal WPs and some non-micellar caseins, appeared to differ most from IF-A in terms of its physiological consequences, suggesting that both WP and casein ingredient quality may mediate the physiological properties of IFs, probably through changes to the colonic microbiota composition and activity. [ABSTRACT FROM AUTHOR]

The article in Pediatric Anesthesia discusses the impact of positive end-expiratory pressure (PEEP) on atelectasis and apnea time in infants during anesthesia induction. While the study has limitations such as potential bias from an open-label design and sample size calculations based on adult studies, it provides valuable insights into age-specific effects of PEEP on infants. The research highlights the importance of tailoring anesthesia protocols to specific pediatric populations and suggests future studies should address limitations by employing blinding techniques, using pediatric-specific data for sample size calculations, and exploring underlying mechanisms of age-related responses to PEEP. Overall, the study contributes significantly to pediatric anesthesiology and offers guidance for improving anesthesia practices in infants. [Extracted from the article]

One criterion for infant NICU discharge is the ability to meet all nutritional needs by mouth, therefore, it is important to understand interventions that can improve the trajectory to full oral feeding. While many oral motor and feeding interventions are used in clinical practice, it remains unclear which are supported by the literature. The aim of this integrative review was to identify and understand what oral motor interventions are defined in the literature to support positive outcomes for preterm infants and their parents. An integrative review of studies published from 2002 to 2022 focusing on applied oral motor interventions and their impact on feeding-related outcomes was completed. The systematic search used databases including PubMed, Cochrane, CINAHL, Scopus, and Google Scholar. Studies were included if they used a study population of preterm infants born

Excessive accumulation of fluid may result in interstitial edema and multiorgan dysfunction. Over the past few decades, the detrimental impact of fluid overload has been further defined in adult and pediatric populations. Growing evidence highlights the importance of monitoring, preventing, managing, and treating fluid overload appropriately. Translating this knowledge to neonates is difficult as they have different disease pathophysiologies, and because neonatal physiology changes rapidly postnatally in many of the organ systems (i.e., skin, kidneys, and cardiovascular, pulmonary, and gastrointestinal). Thus, evaluations of the optimal targets for fluid balance need to consider the disease state as well as the gestational and postmenstrual age of the infant. Integration of what is known about neonatal fluid overload with individual alterations in physiology is imperative in clinical management. This comprehensive review will address what is known about the epidemiology and pathophysiology of neonatal fluid overload and highlight the known knowledge gaps. Finally, we provide clinical recommendations for monitoring, prevention, and treatment of fluid overload. [ABSTRACT FROM AUTHOR]

The objective of this study was to verify the effects on 4- to 18-month-old babies' NPMD after the family-centered Kids Intervention Therapy – Aquatic Environment (KITE) programme. This quasi-experimental study involved 61 families. The NPMD was assessed with Alberta Infant Motor Scale (AIMS), Denver II Developmental Screening Test, context assessment with questionnaire and Affordance in the Home Environment for Motor Development – Infant Scale (AHEMD-IS), and quality of life (QOL) assessment with Pediatric Quality of Life Inventory™ Infant Scales (PedsQL™). 24 babies in the intervention group (IG) participated in the KITE session twice a week for 4 weeks. 37 children participated in the control group. The IG sample had improved NPMD in post-intervention (p = 0.001) and retention (p = 0.002), with a large intervention effect (η = 0.178/0.156). The IG improved in the QOL physical capacity domain (p = 0.023), with a medium effect (d = 0.573). There were no differences between the groups regarding the stimulation received at home, which reinforces the effects of the KITE. It is concluded that the KITE had positive effects on the NPMD and QOL physical capacity domain in the participating. [ABSTRACT FROM AUTHOR]

Acute kidney injury (AKI) in children with Transposition of Great arteries (TGA) undergoing Arterial Switch operation (ASO) is an important complication in the post-operative period associated with worse outcomes. AKI in children post open cardiac surgery has been well studied, with lesser data in literature pertaining to TGA and its sub-types specifically. This was a prospective, observational study enrolling infants with TGA undergoing ASO at a single center over a span of a decade from January 2010 to December 2020. The infants were followed during the duration of ICU and hospital stay, with documentation of baseline and intraoperative parameters as well as post-operative course. Out of 145 infants enrolled in the study, 83.1% developed AKI with majority (83.9%) having stage 1 AKI. Higher odds of AKI were seen in infants requiring Norepinephrine [odds ratio − 16.76 (95% CI 2.19–128.2), p < 0.001] and those who developed gram-negative infections [2.81 (1.04–7.56), p − 0.036]. Infants with AKI had significantly higher vasoactive-inotropic support at day 1 than those without AKI [16 (12.5–21.50 vs 13 (10.25–15.75), p − 0.014]. Seventeen infants in the AKI group (14%) died as opposed to none in the non-AKI group (p = 0.076). Median hours of ventilator support required were significantly higher in those with AKI than those who did not develop AKI (48 vs 45.5 p = 0.015). The infants with ASO + ASD + PDA (53% of neonates who died) were younger, had less weight at admission, more gram-negative sepsis and need for dopamine, as compared to ASO + VSD + ASD (23.5% of mortality) and ASO + ASD + VSD + aortic arch repair (23.5% of mortality). AKI in infants with TGA undergoing ASO is common and associated with poorer outcomes. In this subpopulation, AKI development is associated most commonly with hemodynamic instability and infections. This is the first study, looking at outcomes of TGA depending on the sub-types of ASO surgeries done in the infants [ASO with ASD + PDA or ASD + VSD or ASD + VSD + Arch Repair]. [ABSTRACT FROM AUTHOR]

This study tested whether newborn attention and arousal provide a foundation for the dynamics of respiratory sinus arrhythmia (RSA) in mother–infant dyads. Participants were 106 mothers (Mage = 29.54) and their 7‐month‐old infants (55 males and 58 White and non‐Hispanic). Newborn attention and arousal were measured shortly after birth using the NICU Network Neurobehavioral Scale. Higher newborn arousal predicted a slower return of infant RSA to baseline. Additionally, greater newborn attention predicted mothers' slower return to baseline RSA following the still‐face paradigm, and this effect only held for mothers whose infants had lower newborn arousal. These findings suggest that newborn neurobehavior, measured within days of birth, may contribute to later mother–infant physiological processes while recovering from stress. [ABSTRACT FROM AUTHOR]

Even though its development starts early in utero, neonatal skin is still immature at birth relative to adult and undergoes a maturation process extending to the first years of life. It is now established that the stratum corneum is thinner and dryer and that skin contains less natural moisturizing factors and lipids in newborns compared to children and adults. Moreover, it has been shown that skin surface area expansion is not linear throughout life and is peaking perinatally, suggesting that baby skin has a higher epidermal cellular turnover. Despite growing resources showing differences between adult and infant skin physiology, molecular and metabolic specificities of baby skin are still poorly understood. To address this critical knowledge gap, we performed an integrative transcriptomic and metabolomic study comparing human primary foreskin and abdominal keratinocytes from male babies and female adults, respectively. Based on state‐of‐the‐art integrative frameworks, our analyses revealed a major shift in the global energetic metabolism in baby foreskin keratinocytes compared to adult abdominal keratinocytes, highlighting increased amino acid metabolism and mitochondrial oxidative phosphorylation in baby cells to fuel the citric acid cycle, while showing glycolysis as the major cell energy source in adult cells. [ABSTRACT FROM AUTHOR]

The resurgence of interest in the interrelationship and interdependence between the physiological and psychological aspects of being human (i.e. in wholistic health) and concern regarding attachment issues and dynamics also questions and bespeaks both of the quality of care given to newborns and the impact this care has on their ability to develop healthy attachments and personalities. This article addresses these issues in relation to how newborns are physically handled at birth and the impact that this has on their physical and psychological wellbeing--most specifically, how the obstetrical and postpartum procedures affect the connective tissues which have been found through research to be not only physiological in substance but also psychological in nature. [ABSTRACT FROM AUTHOR]

Various developmental aspects of respiratory physiology put infants and young children at an increased risk of respiratory failure, which is associated with a higher rate of critical incidents during anesthesia. The immaturity of control of breathing in infants is reflected by prolonged central apneas and periodic breathing, and an increased risk of apneas after anesthesia. The physiology of the pediatric upper and lower airways is characterized by a higher flow resistance and airway collapsibility. The increased chest wall compliance and reduced gas exchange surface of the lungs reduce the pulmonary oxygen reserve vis‐à‐vis a higher metabolic oxygen demand, which causes more rapid oxygen desaturation when ventilation is compromised. This review describes the various developmental aspects of respiratory physiology and summarizes anesthetic implications. [ABSTRACT FROM AUTHOR]

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Background: The choice of the perioperative crystalloid is a key component of the fluid management and must take into account the liver function and the appearing metabolic disorders to avoid increase the liver extra metabolism. The aim of this study is to analyze the effect of acetate Ringer's solution or lactate Ringer's solution in biliary atresia patients.Methods: We included 68 infant patients aged between 21 ~ 65 d, ASA physical status II or III, who underwent elective Kasai hepatoportoenterostomy, received either AR and LR for intravenous fluid resuscitation according to their group allocation. Lactate concentration, serum electrolytes and pH were noteded before skin incision (T1), end of surgery (T2) and postoperative 12 h. We also recorded the time of operation, stay of hospital, loss of blood and urinary, total volume of infusion of crystalloid.Results: Lactate level was significantly higher in Group LR than in Group AR patients at T2 (0.76 ± 0.13 versus 0.57 ± 0.22, P = 0.03). Compared with T3, sodium and chlorine were significantly higher in two groups at T2 (145.2 ± 3.1 versus 143.4 ± 3.4 and 104.6 ± 3.7 versus 105.2 ± 2.1). No significant differences were noted in potassium, HCO3- and calcium. There was no statistically significant difference in pH. No glycopenia was recorded in two groups. No significant difference was noted in administration of vasoactive drug (0.7% versus 1%).Conclusions: Resuscitation with AR and LR was associated with similar clinical improvement in infants with biliary atresia. Use of AR reduced the level of lactate comparison with LR. [ABSTRACT FROM AUTHOR]

Objective: Adopted children tend to show an increased risk for a variety of psychopathological outcomes, even when adoption occurs at birth, which some suggest is a result of nonrandom assignment of adoptees and parents. This study uses a nonhuman primate model, in which adoptions were randomly assigned, to investigate the behavioral and physiological outcomes associated with at-birth adoption.Method: Immediately following birth, rhesus monkey infants were randomly assigned to be reared by either their biological mother (n = 113) or by an unrelated, lactating, adoptive mother (n = 34). At 6 months of age, infant behavior and physiology were assessed during a stressful series of mother-infant separations. Four years later, stress-related behaviors were measured following confrontation by an unfamiliar intruder, an ecologically meaningful stressor.Results: When compared to infants reared by their biological mothers, adopted infants exhibited more behavioral withdrawal and higher plasma adrenocorticotropic hormone (ACTH) concentrations in response to separation. These behavioral differences persisted 4 years later during a stressful intruder challenge, with adoptees exhibiting more behavioral withdrawal, stereotypies, and impulsive approaches of the potentially aggressive intruder.Conclusion: Compared to infants reared by their biological mothers, adopted infants exhibited more behavioral inhibition, impulsivity, and higher ACTH concentrations, even when subjects were randomly assigned to be adopted or to remain with their biological mother. To the extent that these findings generalize to humans, they suggest that the overall risk for psychopathology in adopted individuals persists even after random assignment to adoption conditions. [ABSTRACT FROM AUTHOR]

Background: The first 2 years of life are the window of opportunity to promote healthy feeding practices. Thus, the present study aimed to assess the impact of a health workers training in infant dietary guidelines on energy intake and anthropometric measurement into childhood. Methods: Cluster randomised field trial (NCT00635453) was conducted in Porto Alegre, Brazil. Healthcare centres were randomised into intervention (n = 9) and control (n = 11) groups. In intervention sites, health workers were trained to promote healthy feeding practices based on the Brazilian guideline for children's nutrition. Pregnant women who were in the last trimester of pregnancy were registered as potential mothers who would receive dietary counselling from the health workers. Energy and macronutrient intake and anthropometric measurements were obtained from children at ages 6 months, 12 months, 3 years and 6 years from low‐income families. Results: At age 3 years, intervention group had lower consumption of energy [−92.5 kcal; 95% confidence interval (CI) = −153.5 to −31.5], carbohydrates (−11.9 g; 95% CI = −19.9 to −2.3), and total fat (−3.9 g; 95% CI = −6.2 to −1.2), compared to the control group. At 6 years of age, children in the intervention group had lower waist circumference (−1.3 cm; 95% CI = −2.7 to −0.0), triceps (−1.3 mm; 95% CI = −2.5 to −0.0) and subscapular skinfolds (−1.3 mm; 16 95% CI = −2.6 to −0.0) thickness measurements compared to those in the control group. Conclusions: The health workers training to promote infant healthy feeding practices resulted in lower energy, carbohydrates and fat intake at 3 years and lower waist circumference, triceps and subscapular skinfolds measurements at 6 years. [ABSTRACT FROM AUTHOR]

Introduction: Long-chain polyunsaturated fatty acids (LC-PUFAs) are critical for infant growth and development, particularly arachidonic acid (ARA, C20:4n-6) and docosahexaenoic acid (DHA, C22:6n-3). ARA and DHA are components of cell membrane phospholipids and play an important role in cell division, differentiation, and signaling; and DHA is the n-3 fatty acid predominant in the developing brain and retina. During the third trimester of pregnancy, LC-PUFAs increase substantially in fetal circulation, and a "biomagnification" process in the fetal brain is observed. Moreover, LC-PUFAs are precursors of eicosanoids and metabolites, which modulate the intensity and duration of the immune response. LC-PUFA synthesis implies complex desaturation and elongation processes on their principal precursors, linoleic acid (LA) (18:3 n-6) (series n-6) and α-linolenic acid (LNA) (20:3 n-3) (series n-3), where fatty acid desaturases (FADS) and elongases (ELOVL) are competing. It is important to notice that during the first months of life, as a consequence of low enzymatic activity, LC-PUFA synthesis from LA and LNA is reduced, especially in those infants carrying variations in the FADS and ELOVL genes, which are involved in LC-PUFA synthesis, and so they are unable to supply their own DHA and ARA needs. Homozygote infants for FADS haplotype A (97 % of the Latinoamerican population) show low levels of ARA (only 43 %) and DHA (only 24 %) when compared to those carrying haplotype D (more prevalent in Europe, Africa and Asia). Human milk is the only source of LA, LNA, ARA, and DHA for the neonate and infant till complementary feeding (CF) is introduced. Infants fed with infant formulas must receive enough amounts of LA, LNA, ARA, and DHA to cover their nutritional requirements. The new guidelines by the European Food Safety Authority (EFSA) (2016) recommend that infant formulas and follow-on formulas must contain 20-50 mg of DHA/100 kcal (0.5-1 % of total fatty acids, which is higher than in human milk and the majority of infant formulas in the market), and it is not necessary to add ARA. This new regulation, which is already applicable since February 2020, has resulted in profound controversy because there is no scientific evidence about its appropriateness and safety for healthy children. Then, different international expert groups have revised the research already published about the effects of ARA and DHA addition to infant formulas, and discussed different emerging questions from this European directive. The expert group led from the University of Granada (Spain) recommends the addition of ARA in similar or higher concentrations than those of DHA, at least equal to those present in human milk (0.3 % of total fatty acids), although preferably 0.5 % and up to around 0.64 % of total fatty acids, since new studies confirm the optimal intake of ARA and DHA during the different developmental stages. This recommendation could be of particular importance for infants carrying the haplotype A of FADS. [ABSTRACT FROM AUTHOR]

The maternal deprivation hypothesis was arguably the most discussed debate in midcentury psychiatry. Combined with the gender ideology prevalent in America and Britain, it solidified the idea that the mother-child relationship had formative influence on personality development. This essay explores the formation of this hypothesis by situating its knowledge claims against an institutional innovation set to prevent juvenile delinquency and promote mental hygiene, the establishment of child guidance clinics on both sides of the Atlantic in the late 1920s. It then tracks the development of investigative agendas by child guidance practitioners, examining the practices they adopted to construct psychological knowledge claims in conformity with preventive objectives and positivist standards. Shifting the historiographical focus toward the clinical scenes in which psychological assertions were made, the essay examines how investigators sought to determine the "pathogenic" influence of early parental environment by way of estimating its emotional qualities. It argues that it was this positivist-determinist effort to achieve preventive goals that foregrounded the role of the mother in the etiology of personality disturbance and marked the knowledge field that came to be called the maternal deprivation debate. [ABSTRACT FROM AUTHOR]

The current study is the first to examine the role of exploration in play milestones development using a multi–measure micro–analytic approach. Fifteen infants, between the ages of 8 and 17 months, were observed in their natural home environment once a month for a one–hour session; their spontaneous mouthing and fingering and their play level with objects were recorded. Four types of play acts were coded: single–object play, single–object sequences, multi–object play, and multi–object sequences. The relative degree of usage of each type of behaviour at each month was examined. The results show that a combination of mouthing and fingering supported most play acts. Mouthing alone supports the simplest type of play act while fingering supports an advanced type that involves a single or several objects combined in sequences of actions. The benefits of exploring the object orally and manually in the development of play behaviour are discussed. [ABSTRACT FROM AUTHOR]

Although recent behavioral and neural research indicates that infants represent the body's structure, how they engage self-representations for action is little understood. This study addressed how the human face becomes a reaching space. Infants (N = 24; 2-11 months) were tested longitudinally approximately every 3 weeks on their ability to reach to a vibrating target placed at different locations on the face. Successful reaches required coordinating skin- and body-based codes for location, a problem known as tactile remapping. Findings suggest that a functional representation of the face is initially fragmented. Infants localized targets in the perioral region before other areas (ears/temples). Additionally, infants predominantly reached ipsilaterally to targets. Collectively, the findings illuminate how the face becomes an integrated sensorimotor space for self-reaching. [ABSTRACT FROM AUTHOR]

Objectives: Some hospitals have instituted separation of mothers and their newborn(s) when SARS-CoV-2 is suspected or confirmed in the mother. Limited data are available for SARS-CoV-2 vertical transmission, including studies on breast milk. This article looks at SARS CoV-2 case studies and data to date as well as prior pertinent research. Methods: Informal searches of PUBMED, CINAHL and Ovid Emcare were used to identify early reports of vertical transmissions of the novel Coronavirus, case reports, and population based reports of early evolving protocols and their outcomes. As this is a novel virus the authors used previously identified anti-infectivity and antiviral mechanisms of human milk on other similar viruses to guide analysis. Further this article reviewed the well established literature regarding the risks of undue infant separation which negatively affect nearly every aspect of infant and maternal health. Results: Informal searches conducted in the spring and early summer of 2020 identified 14 early reports attempting to analyze the initial and evolving global response to SARS-CoV-2 and the effects of the virus on the maternal-infant dyad. Conclusion: The feasibility of single-family rooms and support for breastfeeding as an alternative approach that addresses many of the risks favorably and reduces economic cost, both in lifetime disease burden and direct care are discussed. Initial reports seem to indicate that immediate separation of the mother from her newborn is likely to increase the risk to both mother and infant. [ABSTRACT FROM AUTHOR]

The objectives of this study were to verify the influence of a short-duration training session on proximal and distal adjustments at the onset of goal-directed reaching and to verify whether these adjustments change in specificity with the body position trained. Twenty-four infants aged 3-4 months were assessed in supine and reclined during pre and posttraining conditions. During the interval (4 min), 8 infants received reaching training in supine, 8 infants received reaching training in reclined, and 8 infants received no training. The frequencies of reaches, unimanual reaches and reaches with semiopen and oblique hand increased in the posttraining condition for all infants except control infants. Infants trained in the reclined position increased the frequencies of variables in the reclined position. Infants trained in the supine position increased the frequencies of variables in both positions. Few minutes of reaching training are effective to facilitate reaching behavior in infants at the onset of reaching. The effects are specific to the body position trained. As the training in supine requires higher torque to initiate reaching movements, it is more effective to facilitate reaches in both supine and reclined positions. [ABSTRACT FROM AUTHOR]

Infants with hypoplastic left heart are at increased risk of adverse events including mortality when they undergo procedures with general anesthesia in the inter-stage period after stage I Norwood. This is primarily caused by an imbalance between pulmonary and systemic blood flows augmented by decreased function of the single ventricle. These factors can be aggravated by general anesthesia, hence the increased risk. Many of these infants experience feeding dysfunction and require a gastrostomy to optimize nutrition. We report a case of open gastrostomy in an infant with Norwood physiology under spinal anesthesia with an excellent outcome. [ABSTRACT FROM AUTHOR]

The early onset of weaning in modern humans has been linked to the high nutritional demand of brain development that is intimately connected with infant physiology and growth rate. In Neanderthals, ontogenetic patterns in early life are still debated, with some studies suggesting an accelerated development and others indicating only subtle differences vs. modern humans. Here we report the onset of weaning and rates of enamel growth using an unprecedented sample set of three late (~70 to 50 ka) Neanderthals and one Upper Paleolithic modern human from northeastern Italy via spatially resolved chemical/isotopic analyses and histomorphometry of deciduous teeth. Our results reveal that the modern human nursing strategy, with onset of weaning at 5 to 6 mo, was present among these Neanderthals. This evidence, combined with dental development akin to modern humans, highlights their similar metabolic constraints during early life and excludes late weaning as a factor contributing to Neanderthals' demise. [ABSTRACT FROM AUTHOR]

Incorporating systematic evidence with clinical expertise is a key element in the quest to improve quality of care and patient outcomes. The evidence supporting skin‐to‐skin contact in the first hour after birth is robust and includes significantly improved outcomes for both mother and infant. This paper compares available iterative data about newborn behaviour in the first hour after birth to further describe the observable behaviour pattern and to provide clinical insight for further research. Although the evidence for positive outcomes through skin‐to‐skin contact are robust, there is a dearth of research specifically focused on clinical practice. The methodology considers the four available data sets that used Widström's 9 stages, which consists of studies from Japan, Sweden, Italy and the United States, examining the parameters of each stage across settings from around the world. This research provides an expanded understanding of the timing of the newborn's progression through Widström's 9 observable stages. We found that newborns in all four data sets began with a birth cry and continued through the remaining stages of relaxation, awakening, activity, rest, crawling, familiarization, suckling and sleeping during the first hours after birth and consolidated the data into a Sign of the Stages chart to assist in further research. The evidence supports making a safe space and time for this important newborn behaviour. Clinical practices should encourage and protect this sensitive period. [ABSTRACT FROM AUTHOR]

BACKGROUND: There is limited evidence supporting an optimum method for removing mucus from the airways of hospitalized infants with bronchiolitis. This study was designed to evaluate short-term physiologic effects between nasal aspiration and nasopharyngeal suctioning in infants. METHODS: Sixteen infants requiring hospitalization for supportive management of bronchiolitis were instrumented with transcutaneously measured partial pressure of carbon dioxide (PtcCO2) and SpO2 monitoring. Electrical impedance tomography (EIT) was used to estimate changes in inspiratory and end-expiratory lung volume loss and recovery. Subjects were suctioned with both nasal aspiration and nasopharyngeal suctioning methods in a randomized order (8 received nasal aspiration followed by nasopharyngeal suctioning, and 8 received nasophayrgeal suctioning followed by nasal aspiration). Noninvasive gas exchange and EIT measurements were obtained at baseline (pre-suction) and at 10, 20, and 30 min following each suctioning intervention. Sputum mass was obtained following suctioning, and clinical respiratory severity scores, before and after suctioning, were computed. RESULTS: There were no differences in inspiratory EIT (P = .93), change in end-expiratory lung impedance (ΔEELI; P = .53), PtcCO2 (P = .41), SpO2 (P = .88), heart rate (P = .31), or breathing frequency (P = .15) over the course of suctioning between nasal aspiration and nasopharyngeal suctioning. Sputum mass (P = .14) and clinical respiratory score differences before and after suctioning (P = .59) were not different between the 2 suctioning interventions. Sputum mass was not associated with ΔEELI at 30 min for nasal aspiration (p = 0.11, P = .69), but there was a moderate positive association for nasopharyngeal suctioning (p = 0.50, P = .048). CONCLUSIONS: Infants with viral bronchiolitis appeared to tolerate both suctioning techniques without adverse short-term physiologic effects, as indicated by the unchanged gas exchange and estimated lung volumes (EIT). Nasopharyngeal suctioning recovered 36% more sputum than did nasal aspiration and there was moderate correlation between sputum mass and end-expiratory lung impedance change at 30 minutes post-suction with nasopharyngeal that was not present with nasal aspiration. It is possible that a subset of patients may benefit from one type of suctioning over another. Future research focusing on important outcomes for suctioning patients with bronchiolitis with varying degrees of lung disease severity is needed. [ABSTRACT FROM AUTHOR]