My Magic Wand Publication date: Available online 3 September 2019 Source: Academic Pediatrics Author(s): Moira Szilagyi

Grace amid turmoil: Death in the delivery room Publication date: Available online 3 September 2019 Source: Academic Pediatrics Author(s): Sarah Mongiello Bernstein

Parental Dual Use of e-Cigarettes and Traditional Cigarettes Publication date: September–October 2019 Source: Academic Pediatrics, Volume 19, Issue 7 Author(s): Emara Nabi-Burza, Susan Regan, Bethany Hipple Walters, Jeremy E. Drehmer, Nancy A. Rigotti, Deborah J. Ossip, Julie A. Gorzkowski, Douglas E. Levy, Jonathan P. Winickoff Abstract Background E-cigarettes are growing in popularity. Dual use of e-cigarettes and cigarettes is an increasingly common practice, but little is known about patterns of dual use in parents. We sought to describe smoking-related behaviors among dual-users. Methods Parent exit surveys were conducted following their child's visit in 5 control pediatric practices in 5 states participating in the Clinical Effort Against Secondhand Smoke Exposure trial. We examined factors associated with dual use of e-cigarettes and cigarettes versus cigarette-only smokers, assessed by self-report. Results Of 1382 smokers or recent quitters screened after their child's visit between April and October 2017, 943 (68%) completed the survey. Of these, 727 parents reported current use of cigarettes; of those, 81 (11.1%) also reported e-cigarette use, meeting the definition of dual use. Compared with cigarette-only smokers, dual users were more likely to have a child younger than 1 year old, planned to quit in the next 6 months, and had tried to quit in the past (had a quit attempt in the past 3 months, called the quitline, or used medicine to quit in the past 2 years; P < .05 for each). Conclusions Parents who use both e-cigarettes and cigarettes may have greater rates of contemplating smoking cessation than parents who only smoke cigarettes. These parents may be using e-cigarettes for harm reduction or as a step toward cessation. Identification of these parents may provide an opportunity to deliver effective treatment, including nicotine-replacement therapies that do not expose infants and children to e-cigarette aerosol.

Self-Confidence in Endotracheal Intubation Among Pediatric Interns: Associations With Gender, Experience, and Performance Publication date: September–October 2019 Source: Academic Pediatrics, Volume 19, Issue 7 Author(s): Kelsey A. Miller, Michael C. Monuteaux, Christopher Roussin, Joshua Nagler Abstract Background and Objective Supervisors’ decisions regarding procedural readiness are influenced by resident confidence. Confidence is a valuable metric if we understand how it correlates with trainee characteristics and procedural competence. Our objective was to evaluate the relationship between self-reported confidence in endotracheal intubation (ETI) and pediatric interns’ characteristics (gender, prior intubation experience) and performance (airway management knowledge, demonstrated skills on airway trainers). Methods This was a secondary analysis of a randomized, controlled trial of an airway management curriculum. Gender and prior intubation experience were reported on a preparticipation questionnaire. Interns’ performance was measured 1) using a 14-item knowledge-based assessment of airway management and 2) as time to successful intubation across 4 simulated intubation scenarios. After completing the curriculum and assessment, interns reported retrospective precurriculum and current postcurriculum confidence with ETI using a 10-point Likert scale. Results Forty-nine interns participated, of whom 16 (33%) were male. Eleven (22%) had ≥1 previous successful intubation. Median [interquartile range] pre- and postcurriculum confidence scores were 3 [2, 5] and 6 [5, 8], respectively. Male interns reported higher precurriculum confidence than females (median difference: 2.0; 95% confidence interval: 0.1, 3.9); postcurriculum confidence among males was also higher but not statistically significant. There was no correlation between self-reported precurriculum confidence and prior experience. There was no correlation between pre- or postcurriculum self-reported confidence and performance on the knowledge-based assessment or time to successful intubation on airway trainers. Conclusions Male pediatric interns self-report higher initial confidence in ETI compared to females. Self-reported confidence did not correlate with prior experience, airway management knowledge, or intubation performance on airway trainers.

Funding Sources and Perceived Financial Insecurity in Pediatric Subspecialty Fellowship Programs Publication date: September–October 2019 Source: Academic Pediatrics, Volume 19, Issue 7 Author(s): Pnina Weiss, Angela L. Myers, Kathleen A. McGann, Katherine E. Mason, Jennifer C. Kesselheim, Geoffrey Fleming, Christine Barron, Ann Klasner, Melvin B. Heyman, Doria L. Weiss, Elizabeth Mauer, Linda M. Gerber, Erika L. Abramson Abstract Objective Shortages of pediatric subspecialists exist in many fields with insufficient recruitment of new fellows. The current system of funding graduate medical education is inadequate. We examined funding sources for trainee salary and educational expenses in pediatric fellowship programs, effects of funding constraints, and program characteristics associated with financial insecurity as reported by fellowship program directors (FPD). Methods We conducted a national survey of FPD between November 1, 2016 and February 9, 2017. We used multivariable logistic regression to examine the association between perceived financial insecurity, program characteristics, and funding sources for fellow salary. Results We obtained data from 519 FPD, representing 14 different pediatric subspecialties. FPD reported that funding limitations restricted program size and educational resources in 22% and 36% of programs, respectively. Nineteen percent of FPD perceived funding of their program to be insecure. Programs with 7 or more fellows (OR .50 [95% CI .27–.90], P = .03) or hospital or graduate medical education/Children's Hospital graduate medical education funding (OR .58 [95% CI .35–.96], P = .04) were less likely to be perceived as insecure. Conversely, programs with extramural (OR 1.74 [95% CI 1.07–2.81], P = .03) or division funding (OR 1.70 [95% CI 1.02–2.82], P = .04) or in subspecialties with more than 25% unfilled positions or programs (OR 1.86 [95% CI 1.11–3.09], P = .02) were more likely to be perceived as insecure. Conclusions Perceived financial insecurity of fellowship programs was strongly associated with program size, funding source, and unfilled positions, limiting recruitment and resources. Stable funding of fellowship programs is critical to maintain an adequate pediatric subspecialty workforce.

Impact of a Baby-Friendly–Aligned Pacifier Policy on Pacifier Use at 1 Month of Age Publication date: September–October 2019 Source: Academic Pediatrics, Volume 19, Issue 7 Author(s): Maheswari Ekambaram, Matilde M. Irigoyen, Andrew Paoletti, Iqra Siddiqui Abstract Objective Pacifier use decreases the risk of sudden infant death syndrome, but its impact on breastfeeding remains controversial. We evaluated the impact of a pacifier policy aligned with the World Health Organization and United Nations Children's Fund Baby-Friendly Hospital Initiative on subsequent pacifier use and breastfeeding at 1 month of age. Methods We conducted a prospective 2-stage (pre- and post-implementation) cohort study of newborns at a birth hospital before and after implementation of a Baby-Friendly–aligned pacifier policy. Consecutive mothers of newborns admitted to the nursery participated in a telephone survey when the infants were 1 month of age. Results In total, 342 mothers participated (190 before and 152 after implementation of the policy). Pacifier adoption was delayed in the post-implementation group, but pacifier use by 1 month of age was comparable (78.9% pre-implementation vs 77.6% post-implementation; P = .793). In the pre-implementation group, female and male infants used pacifiers at comparable rates; however, in the post-implementation group, females were significantly less likely to use a pacifier compared to males after controlling for insurance, race, parity, and delivery mode (adjusted odds ratio, 0.35; 95% confidence interval, 0.15–0.83; P = .02). In the post-implementation group, exclusive breastfeeding rates at discharge increased significantly (from 40% to 51.3%; P = .04), but rates were not different at 1 month (23.7% pre-implementation vs 24.3% post-implementation; P = .89). Conclusion A Baby-Friendly–aligned pacifier policy delayed pacifier adoption but did not impact overall pacifier use or breastfeeding rates at 1 month of age. The finding of lower pacifier use rates among female infants post-intervention requires verification in other populations before evaluating public heath relevance.

Content of Infant Safe Sleep Counseling and Maternal Reported Practices in an Urban Clinic Publication date: September–October 2019 Source: Academic Pediatrics, Volume 19, Issue 7 Author(s): Tierra D. Burrell, Eileen M. McDonald, Patricia Mahoney, Rashelle J. Musci, Wendy Shields, Andrea Gielen, Barry S. Solomon Abstract Objective Sudden Infant Death Syndrome is a leading cause of mortality in infants, and pediatric providers can influence caregiver infant safe sleep practices. We described the content of safe sleep counseling by pediatric providers and examined pediatric provider and caregiver factors that may be related to the delivery of safe sleep counseling. Methods A sample of mothers and providers enrolled in the Safe Start Study, a randomized controlled trial assessing a safe sleep intervention, were audio-recorded during the 2-week well child visits (WCV) at a large urban pediatric practice in Baltimore, Maryland from October 2015 to April 2017. Provider counseling content related to infant sleep was transcribed and coded based on American Academy of Pediatrics (AAP) policy statement Grade A recommendations. Maternal reported infant sleep practices were defined by items on an interviewer administered survey. Multivariate logistic regression analyses were used to examine the relation between maternal reported infant sleep practices and provider counseling. Results Most, 92%, of WCVs included at least 1 safe sleep topic, but there was inconsistency in content delivered based on AAP recommendations. Yet, only 12% of WCVs included all 4 components of ABC counseling. Maternal report of infant sleeping with a person or an object in sleep space was associated with decreased odds of receiving counseling on alone no person, no objects (adjusted odds ratio: 0.34, 95% confidence interval: 0.13, 0.90). Conclusions Pediatric provider counseling on safe sleep is inconsistent across AAP recommendations demonstrating a need for enhanced provider education and a more standardized approach to assess infant sleep practices.

Refusal of Vitamin K by Parents of Newborns: A Qualitative Study Publication date: September–October 2019 Source: Academic Pediatrics, Volume 19, Issue 7 Author(s): Jaspreet Loyal, Theresa R. Weiss, Jessica H. Cheng, Laura R. Kair, Eve Colson Abstract Objective Despite American Academy of Pediatrics recommendations, some parents refuse intramuscular (IM) vitamin K as prophylaxis against vitamin K deficiency bleeding for their newborns. The purpose of our study was to describe attitudes and perceptions of parents who choose to defer IM vitamin K for their newborns. Methods Using qualitative methodology, we conducted in-depth semi-structured interviews with parents of newborns in 3 hospitals in Connecticut and California. We used the grounded theory approach and the constant comparative method until saturation was reached. Results Nineteen participants (17 mothers and 2 fathers) of 17 newborns were interviewed; 14 newborns did not receive IM vitamin K due to refusal by the parents, and for 3 newborns IM vitamin K administration was delayed due to initial hesitation by the parents. Four major themes emerged: 1) risk-to-benefit ratio, where parents refused IM vitamin K due to a perceived risk to their newborn from preservatives, for example; 2) “natural” approaches, which led to seeking oral vitamin K or increasing the mother's own prenatal dietary vitamin K intake; 3) placement of trust and mistrust, which involved mistrust of the medical and pharmaceutical community with overlapping concerns about vaccines and trust of self, like-minded allopathic and non-allopathic health care providers, the social circle, the internet, and social media; and 4) informed by experiences, reflecting hospital experiences with prior pregnancies and communication with health care providers. Conclusions Parents’ perception of risk, preference for alternative options, trust, and communication with health care providers were pivotal factors when making decisions about IM vitamin K.

Mothers’ Perceptions of the Cardboard Box as a Potential Sleep Space Publication date: September–October 2019 Source: Academic Pediatrics, Volume 19, Issue 7 Author(s): Nisha Dalvie, Victoria Nguyen, Eve Colson, Jaspreet Loyal Abstract Objective Due to increasing popularity, our hospital began considering distributing cardboard boxes combined with safe sleep education to new mothers. As a first step in studying the impact of this intervention on bedsharing in our community, we sought to understand mothers’ perceptions of the cardboard box. Methods We recruited primarily low-income, English- or Spanish-speaking mothers of infants aged 2 to 16 weeks during routine primary care visits. Participants responding to a cross-sectional survey about infant sleep practices were invited to participate in in-depth interviews about the cardboard box. We used a grounded theory approach and the constant comparative method until saturation was reached. Results Of 120 participants in the survey, 50 (42%) participated in the qualitative study. Participants were mothers of infants aged ≤4 weeks (46%), 4 to 8 weeks (32%), and 16 weeks (22%). Of 50 participants, 52% said they would use the cardboard box for their infant to sleep in, if provided, compared with 42% who said they would not and 6% were unsure. Three themes emerged from the data: (1) safety of the cardboard box; (2) appearance, and (3) variation in planned use. Some participants planned to place the cardboard box in their bed. Conclusions Participants in our study were divided about whether they would use the cardboard box for their infant to sleep in. If distributed, hospital staff should advise families to not place the cardboard box in their bed. Next steps include determining bedsharing frequency among parents who choose to use the cardboard box for their infant.

Weight Bias in Pediatric Inpatient Care Publication date: September–October 2019 Source: Academic Pediatrics, Volume 19, Issue 7 Author(s): Elizabeth E. Halvorson, Thomas Curley, Mariah Wright, Joseph A. Skelton Abstract Objective Weight bias can influence medical care but has not been studied in the pediatric inpatient setting. We will quantify implicit and explicit weight bias of pediatric inpatient providers and qualitatively explore providers’ attitudes toward children with obesity and patient/family perceptions of weight bias in the hospital. Methods We performed a mixed-methods study including semistructured key informant interviews and validated tests for implicit (Implicit Association Test) and explicit (Crandall's Anti-Fat Attitudes Questionnaire) bias with pediatric hospitalists, residents, and acute care nurses. We performed semistructured key informant interviews with pediatric inpatients aged 7 to 17 years and the patient's parent(s) or guardian(s). Interviews were coded using an inductive approach to identify recurrent themes. Results We enrolled 28 pediatric providers, 12 patients, and 12 parents/guardians. In total, 71% of providers exhibited moderate or strong implicit weight bias, with generally lower scores for explicit bias. Qualitative analysis identified seven themes: the existence of weight bias, shared responsibility for a child's obesity, a potential for provider bias toward the parents of pediatric patients with obesity, possible effects of patient weight on inpatient care, importance of terminology in addressing obesity, and the possibility of addressing obesity inpatient but a preference for obesity to be addressed in the outpatient setting. Conclusions Health care providers, patients, and families in the pediatric inpatient setting identified multiple ways that obesity could impact care, including provider weight bias.