Search

Estimates the number of infants exposed to legal and illegal substances before birth, drawing on 27 published reports and National Institute on Drug Abuse data. The following are estimated exposure levels: (1) cocaine, 2-3 percent; (2) marijuana, 3-12 percent; (3) cigarettes, 38 percent; and (4) alcohol, 73 percent. (SLD)

Objectives. Medical errors cause significant morbidity and mortality in hospitalized patients. Specialty-based, voluntary reporting of medical errors by health care providers is an important strategy that may enhance patient safety. We developed a voluntary, anonymous, Internet-based reporting system for medical errors in neonatal intensive care, evaluated its feasibility, and identified errors that affect high-risk neonates and their families. Methods. Health professionals (n = 739) from 54 hospitals in the Vermont Oxford Network received access to a secure Internet site for anonymous reporting of errors, near-miss errors, and adverse events. Reports used free-text entry in phase 1 (17 months) and a structured form in phase 2 (10 months). The number and types of reported events and factors that contributed to the events were measured. Results. Of 1230 reports--522 in phase 1 (17 months) and 708 in phase 2 (10 months)--the most frequent event categories were wrong medication, dose, schedule, or infusion rate (including nutritional agents and blood products; 47%); error in administration or method of using a treatment (14%); patient misidentification (11%); other system failure (9%); error or delay in diagnosis (7%); and error in the performance of an operation, procedure, or test (4%). The most frequent contributory factors were failure to follow policy or protocol (47%), inattention (27%), communications problem (22%), error in charting or documentation (13%), distraction (12%), inexperience (10%), labeling error (10%), and poor teamwork (9%). In 24 reports, family members assisted in discovery, contributed to the cause, or themselves were victims of the error. Serious patient harm was reported in 2% and minor harm in 25% of phase 2 events. Conclusions. Specialty-based, voluntary, anonymous Internet reporting by health care professionals identified a broad range of medical errors in neonatal intensive care and promoted multidisciplinary collaborative learning. Similar specialty-based systems have the potential to enhance patient safety in a variety of clinical settings. Pediatrics 2004;113:1609-1618; patient safety, medical error, adverse events, medication error, iatrogenic, error reporting, quality improvement, multidisciplinary teams, neonate neonatal intensive care, Internet., ABBREVIATIONS. JCAHO, Joint Commission for Accreditation of Healthcare Organizations; NICQ, Neonatal Intensive Care Quality; TP, internet protocol; NICU, neonatal intensive care unit; FMEA, failure mode and effects analysis. In its [...]

Objectives. The purpose of this study was to expand the search for risk factors for low birthweight and to find new explanations for the ethnic-group disparities in birth outcomes. Methods. The subjects were 1150 pregnant women from six ethnic groups (African American, Chinese, Dominican, Puerto Rican, Mexican, and White) who received prenatal care at clinics in New York and Chicago between December 1987 and December 1989. Two interviews were conducted during the second and third trimesters of pregnancy. Results. The study, after controlling for poverty and other birthweight correlates, showed that living in public housing and believing that chance plays a major role in determining one's health status were negatively associated with birthweight. Having a stable residence was positively related to birthweight. Material hardship, social adversity, perceived racial discrimination, physical abuse, anxiety, and depression were not associated with birthweight. Conclusions. The negative role of an impoverished living environment and feelings of helplessness, as well as the positive role of having a stable form of social support, suggest new directions for research on the causes of low birthweight and the ethnic disparities in US birth outcomes. (Am J Public Health. 1997;87: 787-793)

Differences in death rates in neonatal intensive care units (NICUs) may be due to differences in effectiveness of care. Researchers compared outcomes among 62 NICUs for 7,672 infants weighing 501 to 1,500 grams at birth. Death rates within 28 days ranged from 10% to 18% and averaged 15% overall. After making statistical adjustments for variations in the admission characteristics of the infants, neither the volume of very-low-birth-weight patients per year nor the presence of a residency program explained the differences between NICUs., Background. The outcomes for very low birth weight infants vary among neonatal intensive care units (NICUs), but the reasons for this variation are not well understood. We used the database of a large neonatology research network to determine whether either admission characteristics of the infants or specific characteristics of the units such as annual patient volume and the presence of a pediatric residency program could account for observed differences in neonatal mortality rates among units. Methods. We studied 7672 infants with birth weights from 501 to 1500 g treated during 1991 and 1992 at 62 NlCUs participating in the Vermont Oxford Network Database. Results. Overall, 14.7% of the study infants died within 28 days of birth (interquartile range 9.9% to 18.1%). The ratio of the number of observed deaths at an NICU to the number of deaths predicted based on the characteristics of infants treated at the NICU (standardized neonatal mortality ratio, [SNMR]) varied significantly among units (range 0 to 1.69, z = 4.24). There was no association between annual patient volume and either mortality rate (r = .17) or SNMR (r = .22). Observed mortality rates (17% vs 13%) and SNMR (1.04 vs .87) were both higher at the 24 hospitals with pediatric residency training programs than at the 38 hospitals without such programs. Hospitals with residency programs had higher average annual patient volumes (104 vs 66). In an analysis simultaneously adjusting for patient characteristics, volume, and presence of a residency program, neither volume (odds ratio IOR] per 10 additional cases treated 1.01, 95% confidence interval [CI], .98 to 1.04) nor presence of a pediatric residency program (OR 1.18, 95% CI, .94 to 1.47) was significantly associated with neonatal mortality risk. Conclusion. There are differences in neonatal mortality rates among NICUs that cannot be explained by differences in the measured admission characteristics of the infants, suggesting that the effectiveness of medical care varies among units. Neither the annual volume of very low birth weight infants treated in a unit nor the presence of a pediatric residency training program was independently associated with neonatal mortality rates for very low birth weight infants. Pediatrics 1997;99:149-156; neonate, very low birth weight, mortality, variation, volume, residency training., ABBREVIATIONS. NICU, neonatal intensive care unit; OR, odds ratio; CI, confidence interval; ROC, receiver operating characteristic; SNMR, standardized neonatal mortality ratio; CRIB, clinical risk index for babies; SNAP, score for [...]

It may be advisable for pediatricians and newborn specialists to be vigilant in examining the effectiveness of treatment guidelines presented by hospital administrations and third party payers in the name of cost containment. The process involved in developing, implementing, and regulating current practice guidelines affecting pediatricians and newborn specialists has been presented. Researchers have also evaluated the effectiveness and legal implications of some of these guidelines and have presented strategies for doctors to further evaluate current guidelines., Clinical practice guidelines are becoming pervasive in pediatrics and newborn medicine. They have spanned a wide range of primary care practice parameters from treating otitis media with effusion, to performing complex surgery for congenital heart disease, and management of respiratory distress syndrome and coordinating discharge from the neonatal intensive care unit. Administrators believe that using clinical practice parameters reduces health care costs, improves quality of care, and limits malpractice liability. Practice parameters and guidelines have grown in use because powerful interests--third-party payers, insurers, and health maintenance organizations, as well as hospital administrators bent on reducing variable costs of care and contracting for capitated care--champion their development, implementation, and monitoring. Economic credentialing of physicians with excessive variances without risk-adjusting for other than average patients is problematic and remains unchecked partly because of the fundamental characteristics of the evolving health care industry in which costs are more easily measured than quality. For highly autonomous physicians this standardization of medical decision making may represent a difficult transition into corporate practice by realigning traditional values of the doctor-patient relationship. However because guidelines are almost certainly here to stay, pediatricians and neonatologists need to think critically about how their content and method of implementation, monitoring, and modification may influence medical teaching and decision making in the future. If guidelines are introduced primarily as a cost savings or containment tool that ignores the impact on the quality of care and restricts necessary care for infants and children, especially those with chronic illness or who are developmentally at risk, then neonatologists and pediatricians must be quick and determined to challenge the potentially damaging use of practice parameters or guidelines. Furthermore, there are many medicolegal implications of guideline implementation that may not favor physicians and leave to hospitals, insurers, and ultimately the courts decisions regarding evidence-based practice. In this review article, we pay special attention to the guidelines developed in newborn medicine. We discuss why and how guidelines are developed and critically evaluate the available evidence describing potential benefits and drawbacks of guidelines in general. There are legal implications to the implementation of guidelines, and guidelines may increase provider susceptibility to malpractice allegations. Neonatologists and pediatricians should critically analyze the following questions when guidelines are being developed: Are clinical practice parameters the most effective means to reduce the costs of health care, or improve the quality of health care services while reducing the need for and protecting physicians from malpractice suits? Or do clinical practice guidelines more closely resemble an audit system developed by health care organizations, insurers, and others including government-sponsored health care to appease powerful interests-with limited evidence for promise and perhaps potential negative cost, quality, and malpractice liability implications? In pediatric and newborn medicine there is limited evidence that guidelines have achieved the desired goals and further analysis of their process of care and the costs of implementation is warranted. Pediatrics 1997;99:100-114; practice guidelines., ABBREVIATIONS. TQM, total quality management; CQI, continuous quality improvement; CPM, critical pathway methodologies; NICU, neonatal intensive care unit; ALOS-hospital, average length of stay for hospital days; ALOS-ICU, average length of [...]

When administered intramuscularly, vitamin K has been found to be associated with a twofold increase in cancer risk during childhood. Nearly all newborns in the US, Canada and much of Europe receive this drug. The public implications would be dire if this association were causal. In this study, no evidence was found that perinatal exposure to vitamin K is associated with a greater risk of leukemia or of cancer in general during childhood. The benefits of neonatal Vitamin K prophylaxis in fighting hemorrhagic disease are well documented. However, because the number of cases studied was small, slight increases in the overall risk of specific types of cancer cannot be ruled out on the basis of this data. In the absence of more compelling data, the recommendation of the American Academy of Pediatrics that newborns receive intramuscular vitamin K remains intact.

Studies show that when breast-feeding is supplemented with formula, the duration of breast-feeding is shortened. The role of the hospital staff in promoting breast-feeding and hospital routines which control the duration of contact between a mother and newborn affect breast-feeding practice and early use of formula. The maternal and hospital factors that may influence the use of supplementary formula were assessed by survey of 726 breast-feeding mothers. Breast-feeding was supplemented by use of formula during the hospital stay in 37 percent of cases. Mothers who delivered in a university hospital tended to breast-feed exclusively. Furthermore, the likelihood of using formula was increased with longer duration between birth and introduction of breast-feeding. The factors associated with exclusive breast-feeding included on-demand feeding schedules and college education and marital status of the mother. Hospital factors such as routines that promote the early use of formula tend to delay the initiation of breast-feeding. (Consumer Summary produced by Reliance Medical Information, Inc.)

It has been reported that female resident physicians are at an increased risk of adverse pregnancy outcomes, such as preterm delivery, retardation of fetal growth, low birth weight, and pregnancy-induced hypertension, especially during the period of residency training. Studies published to date show that first trimester spontaneous abortions (miscarriages) are actually less prevalent in female residents than in the general population, but low response rates to the survey questionnaires limit the reliability of that data. To further investigate the outcome of pregnancy in female residents compared with nonphysicians, a questionnaire was sent to the 5,096 females who graduated from medical school in 1985. To obtain comparison data, the same questionnaire was sent to a random sample of 5,000 (of 12,306 total) male medical school graduates for the same year, to be filled out by their spouse or sexual partner (nonphysician). Data were discarded for those cases where the spouse was also a physician. Approximately 85 percent of the subjects responded from both the male and female physician groups. Female residents reported undergoing spontaneous abortion in 14.8 percent of 1,284 pregnancies; nonphysicians reported this occurrence in 12.6 percent of 1,481 pregnancies. Female residents were much more likely than nonphysicians to voluntarily terminate a pregnancy (8.2 percent versus 2.7 percent). However, this was true only for unmarried women; in the case of married female residents, the rates were roughly equal to those of the nonphysicians. The rate of voluntary pregnancy termination among female residents was about half that of the general United States population between the ages of 25 and 34 years. (Consumer Summary produced by Reliance Medical Information, Inc.)

Medical residency is a difficult, strenuous period of training that often demands night work, long shifts and prolonged periods of standing. All of these factors have been associated with an increased risk of preterm delivery (before the 37th week of gestation). Female physicians generally pass through residency training during a period of life when many women wish to have children, and some studies have indicated that pregnant residents suffer an increased rate of adverse outcomes. The present study examines the risks of preterm delivery and other complications of pregnancy in a group of 4,412 medical residents, and a group of 4,235 wives of male residents (a control group). Despite the arduous work of the residents, there were no significant differences in the numbers of miscarriages, ectopic pregnancies (outside of the uterus), and stillbirths between the two groups of pregnant women. A similar number of babies with birth weights less than the 10th percentile for their gestational age were born to mothers in both groups. Although the female residents reported a greater incidence of preterm labor (11 percent) than the control group (6.5 percent), they did not deliver more preterm babies (6.5 percent versus 6.0 percent). Preeclampsia (toxicity of pregnancy) was more frequent among residents (8.8 percent) than controls (3.5 percent). The authors conclude that the effects of long working hours in a very stressful role generally had little effect on the outcome of pregnancy in female medical residents. (Consumer Summary produced by Reliance Medical Information, Inc.)

The relationship between the employment of the mother and the initiation and duration of breast feeding was studied among 668 black and 510 white women. Ninety-one percent of the white women and 80 percent of the black women continued to work during pregnancy. Black women who planned to return to work part time were twice as likely to breast feed than formula feed. In addition, Black women who returned to work breast fed for a shorter period than those who did not return to work. Women returning to professional occupations breast fed for longer periods than women returning to sales or technical positions. White women in professional occupations nursed for longer periods than white women in clerical occupations. Until U.S. employers develop maternity policies that do not discourage breast feeding, it will remain hard for most employed women to achieve the six months of recommended breast feeding.

The effect of anemia in the mother on subsequent preterm births was studied in 35,000 pregnancies. There was no significant relationship between anemia and preterm birth except for a slight tendency for women with anemia early in the last trimester of pregnancy to give birth before term. Anemia during the last trimester could not account for the substantially higher rate of preterm birth among black women. Anemia after 30 weeks of pregnancy was not associated with premature birth. In women delivering infants weighing over 2,500 grams, the percentage of red cells in the maternal blood increased by 3 percent among black women and 2 percent among white women from the 25th week of pregnancy to term. Anemia was most likely during the 28th week of pregnancy, and became less likely as delivery approached. Anemia is not a major cause of preterm birth; comparison of women in preterm and term labor produces biased results., ABSTRACT: The effect of anemia (hematocrit

Abstract: Ethnic differences in preterm (<37 weeks) and very preterm (<33 weeks) delivery were evaluated in a prospective cohort of 28,330 women. Blacks had the highest rate of preterm and very preterm delivery, followed by Mexican-Americans, Asians, and Whites. Adjustment for maternal age, education, marital status, employment, parity, number of previous spontaneous or induced abortions, smoking and drinking during pregnancy, infant sex, and gestational age at initiation of prenatal care resulted in the following odds ratios for preterm delivery: 1.79 (1.55-2.08) for Blacks, 1.40 (1.19-1.63) for Mexican-Americans, 1.40 (1.16-1.69) for Asians, and 1.00 for Whites. The corresponding odds ratios for very preterm delivery were 2.35 (1.72-3.22) for Blacks, 1.31 (0.88-1.94) for Mexican-Americans, 1.10 (0.67-1.83) for Asians, and 1.00 for Whites. Exclusion of cases of premature rupture of membranes, placenta previa, and abruptio placenta did not explain the large ethnic differences. Although Whites and Mexican-Americans had similar birthweight distributions, Mexican-Americans had an increased risk for preterm delivery. Fifty-five per ¢ of low birthweight babies in Kaiser were preterm and this fraction did not vary substantially by ethnic group. [ABSTRACT FROM AUTHOR]

The influence of sociodemographic factors on the incidence and duration of breast-feeding was evaluated in 668 black and 511 white women delivering their first child in the metropolitan Washington, DC, area. Breast-feeding rates were 84% among white and 49% among black women. Maternal educational level was strongly associated with breast-feeding, whereas the effect of ethnicity was moderate. Women with some college or some graduate school education had adjusted odds of breast-feeding that were 2.6 (95% confidence limit 1.9 to 3.7) and 5.2 (95% confidence limit 2.7 to 10.2) times higher than women with a high school education or less. In contrast, the adjusted odds of breast-feeding were 2.0 (95% confidence limit 1.4 to 3.1) times higher for white women compared with black women. The odds of breast-feeding increased among black women if they attended childbirth classes, were married, or were older. Among black women, the frequency of breast-feeding decreased sharply by I month postpartum. Breast-feeding duration for black v white women was 74% v 90% at 1 month, 44% v 72% at 4 months, and 26% v 50% at 7 months postpartum. The majority of black women (53%) used formula supplements in the hospital, which was the only factor significantly related to a shortened duration in this group (P < .01). The high rate of formula supplementation among black women and its strong association with shortened duration of breast-feeding point to a need for more advice and support and less reliance on formula during the hospital stay. [ABSTRACT FROM AUTHOR]

Examines the effects of maternal anemia on the pathogenesis of preterm birth. Incidence of preterm birth among women with and without anemia; Dose-response effect for anemia; Comparison of hematocrits from women who are in preterm and term labor.

In a population of about 300,000 Northern California women aged 15-44, the age-adjusted incidence of ectopic pregnancy rose from 55.5 to 84.2/100,000 women. 1972-1978. The ratio of ectopics to 1,000 deliveries-plus spontaneous abortions rose from 9.4 to 14.8. The change occurred mainly in women under age 30, and was observed in seven of the eight hospitals in the area. There was no alteration in the frequency of hospitalized pelvic inflammatory disease (PID): salpingitis decreased over the years studied; and tubal sterilization events remained constant at around 0.9 per cent per year of women aged 15-44. [ABSTRACT FROM AUTHOR]