PEDIATRICS recent issues

Breastfeeding and Infections in Early Childhood: A Cohort Study

BACKGROUND:

Studies on the association between breastfeeding and infections in children beyond the first year of life reveal conflicting results. In a population-based birth cohort, we investigated whether the duration of breastfeeding was associated with the number of hospitalizations due to infection and symptoms of infection at home.

METHODS:

In the Odense Child Cohort, text message questionnaires were used to register information on breastfeeding (weekly until end of weaning) and symptoms of infection (biweekly; 12–36 months of age). Hospitalization data were obtained from the Danish National Patient Registry.

RESULTS:

Of the 1087 invited, 815 mother-infant pairs were included. The median duration of any breastfeeding was 7.6 (interquartile range: 3.5–10.4) months and of exclusive breastfeeding was 2.1 (interquartile range: 0.7–4.4) months. Hospitalization due to infection was seen in 207 (25.4%) infants during the first 3 years of life. The adjusted incidence rate ratio (IRR) for hospitalization due to any infection decreased with a longer duration of any breastfeeding (adjusted IRR: 0.96; 95% confidence interval 0.93–0.99; P < .001). The strongest associations between the duration of any breastfeeding and hospitalizations due to infection were found within the first year of life, for lower respiratory tract infections, and other infections (P ≤ .05). For infants exclusively breastfed, the adjusted IRR for hospitalization was 0.88 (95% confidence interval: 0.80–0.96; P = .006). No protective associations were present between breastfeeding and infection symptoms registered at home from ages 12 to 36 months.

CONCLUSIONS:

The results suggest that increased duration of breastfeeding, especially exclusive breastfeeding, protects against infections requiring hospitalization in the first year of life but not hospitalizations or symptoms of infection at home beyond the first year.

Road Traffic Accidents and Disparities in Child Mortality

BACKGROUND AND OBJECTIVES:

Road traffic accidents are a leading cause of child deaths in the United States. Although this has been examined at the national and state levels, there is more value in acquiring information at the county level to guide local policies. We aimed to estimate county-specific child mortality from road traffic accidents in the United States.

METHODS:

We queried the Fatality Analysis Reporting System database, 2010–2017, for road traffic accidents that resulted in a death within 30 days of the auto crash. We included all children <15 years old who were fatally injured. We estimated county-specific age- and sex-standardized mortality. We evaluated the impact of the availability of trauma centers and urban-rural classification of counties on mortality.

RESULTS:

We included 9271 child deaths. Among those, 45% died at the scene. The median age was 7 years. The overall mortality was 1.87 deaths per 100 000 children. County-specific mortality ranged between 0.25 and 21.91 deaths per 100 000 children. The availability of a trauma center in a county was associated with decreased mortality (adult trauma center [odds ratio (OR): 0.59; 95% credibility interval (CI), 0.52–0.66]; pediatric trauma center [OR: 0.56; 95% CI, 0.46–0.67]). Less urbanized counties were associated with higher mortality, compared with large central metropolitan counties (noncore counties [OR: 2.33; 95% CI, 1.85–2.91]).

CONCLUSIONS:

There are marked differences in child mortality from road traffic accidents among US counties. Our findings can guide targeted public health interventions in high-risk counties with excessive child mortality and limited access to trauma care.

An Asthma Population Health Improvement Initiative for Children With Frequent Hospitalizations

OBJECTIVES:

A relatively small proportion of children with asthma account for an outsized proportion of health care use. Our goal was to use quality improvement methodology to reduce repeat emergency department (ED) and inpatient care for patients with frequent asthma-related hospitalization.

METHODS:

Children ages 2 to 17 with ≥3 asthma-related hospitalizations in the previous year who received primary care at 3 in-network clinics were eligible to receive a bundle of 4 services including (1) a high-risk asthma screener and tailored education, (2) referral to a clinic-based asthma community health worker program, (3) facilitated discharge medication filling, and (4) expedited follow-up with an allergy or pulmonology specialist. Statistical process control charts were used to estimate the impact of the intervention on monthly 30-day revisits to the ED or hospital. We then conducted a difference-in-differences analysis to compare changes between those receiving the intervention and a contemporaneous comparison group.

RESULTS:

From May 1, 2016, to April 30, 2017, we enrolled 79 patients in the intervention, and 128 patients constituted the control group. Among the eligible population, the average monthly proportion of children experiencing a revisit to the ED and hospital within 30 days declined by 38%, from a historical baseline of 24% to 15%. Difference-in-differences analysis demonstrated 11.0 fewer 30-day revisits per 100 patients per month among intervention recipients relative to controls (95% confidence interval: –20.2 to –1.8; P = .02).

CONCLUSIONS:

A multidisciplinary quality improvement intervention reduced health care use in a high-risk asthma population, which was confirmed by using quasi-experimental methodology. In this study, we provide a framework to analyze broader interventions targeted to frequently hospitalized populations.

XY Gonadal Dysgenesis in a Phenotypic Female Identified by Direct-to-Consumer Genetic Testing

We report a 16-year-old phenotypic female with 46,XY complete gonadal dysgenesis and metastatic dysgerminoma, unexpectedly discovered through direct-to-consumer (DTC) commercial genetic testing. This case underscores the importance of timely interdisciplinary care, including psychosocial intervention and consideration of gonadectomy, to optimize outcomes for individuals with differences of sex development. Her unique presentation highlights the implications of DTC genetic testing in a new diagnostic era and informs general pediatricians as well as specialists of nongenetic services about the value, capabilities, and limitations of DTC testing.

Creatine Transporter Deficiency Presenting as Autism Spectrum Disorder

Autism spectrum disorder (ASD) is the most common disability-causing neurodevelopmental disorder in childhood. Although inborn errors of metabolism (IEM) are rare causes of ASD, they are significant for several reasons, including implications in genetic counseling and determination of prognosis. In this article, we present a 6-year-old boy who presented to us with ASD and was diagnosed with creatine transporter deficiency. Physical and neurologic examination of this patient had not previously raised suspicion of IEM, but twin pregnancy, prematurity, NICU stay due to necrotizing enterocolitis, transient infantile hypotonia, gross-motor delay, breath-holding spells, and a single febrile seizure complicated the history. MRI revealed mild T2-hyperintensity in posterior periventricular white matter. Further evaluation with magnetic resonance spectroscopy, which showed a decreased creatine peak, led to diagnostic investigations for disorders of creatine metabolism, revealing increased urinary creatine:creatinine ratio and a de novo, novel hemizygous frameshift variant in SLC6A8. Clinicians are advised to maintain a high index of suspicion for IEM and to evaluate patients with ASD for syndromic features. Although current guidelines from relevant organizations differ in their recommendations regarding the necessity and the extent of metabolic screening in ASD, there is a growing trend toward screening for treatable IEM. In this case report, we present challenges and pitfalls in the diagnostic journey for creatine transporter deficiency and underline the significance of a thorough history and physical examination in the evaluation of a child with ASD.

Timing of Puberty Suppression and Surgical Options for Transgender Youth

OBJECTIVES:

Puberty suppression (PS) is a cornerstone of treatment in youth experiencing gender dysphoria. In this study, we aim to inform prescribing professionals on the long-term effects of PS treatment on the development of sex characteristics and surgical implications.

METHODS:

Participants received PS according to the Endocrine Society guideline at Tanner 2 or higher. Data were collected from adolescents who received PS between 2006 and 2013 and from untreated transgender controls. Data collection pre- and post-PS and before surgery included physical examination and surgical information.

RESULTS:

In total, 300 individuals (184 transgender men and 116 transgender women) were included. Of these, 43 individuals started PS treatment at Tanner 2/3, 157 at Tanner 4/5, and 100 used no PS (controls). Breast development was significantly less in transgender men who started PS at Tanner 2/3 compared with those who started at Tanner 4/5 and controls. Mastectomy was more frequently omitted or less invasive after PS. In transgender women, the mean penile length was significantly shorter in the PS groups compared with controls (by 4.8 cm [Tanner 2/3] and 2.1 cm [Tanner 4/5]). As a result, the likelihood of undergoing intestinal vaginoplasty was increased (odds ratio = 84 [Tanner 2/3]; odds ratio = 9.8 [Tanner 4/5]).

CONCLUSIONS:

PS reduces the development of sex characteristics in transgender adolescents. As a result, transgender men may not need to undergo mastectomy, whereas transgender women may require an alternative to penile inversion vaginoplasty. These surgical implications should inform decision-making when initiating PS.

Preoperative Blood Transfusions and Morbidity in Neonates Undergoing Surgery

BACKGROUND:

Blood transfusions in the neonatal patient population are common, but there are no established guidelines regarding transfusion thresholds. Little is known about postoperative outcomes in neonates who receive preoperative blood transfusions (PBTs).

METHODS:

Using the American College of Surgeons National Surgical Quality Improvement Program–Pediatric Participant Use Data Files from 2012 to 2015, we identified all neonates who underwent surgery. Mortality and composite morbidity (defined as any postoperative complication) in neonates who received a PBT within 48 hours of surgery were compared with that in neonates who did not receive a transfusion.

RESULTS:

A total of 12 184 neonates were identified, of whom 1209 (9.9%) received a PBT. Neonates who received a PBT had higher rates of preoperative comorbidities and worse postoperative outcomes when compared with those who did not receive a transfusion (composite morbidity: 46.2% vs 16.2%; P < .01). On multivariable regression analysis, PBTs were independently associated with increased 30-day morbidity (odds ratio [OR] = 1.90; 95% confidence interval [CI]: 1.63–2.22; P < .01) and mortality (OR = 1.98; 95% CI: 1.55–2.55; P < .01). In a propensity score–matched analysis, PBTs continued to be associated with increased 30-day morbidity (OR = 1.53; 95% CI: 1.29–1.81; P < .01) and mortality (OR = 1.58; 95% CI: 1.24–2.01; P = .01).

CONCLUSIONS:

In a propensity score–matched model, PBTs are independently associated with increased morbidity and mortality in neonates who undergo surgery. Prospective data are needed to better understand the potential effects of a red blood cell transfusion in this patient population.

A Quality Improvement Initiative To Optimize Antibiotic Use in a Level 4 NICU

BACKGROUND:

Given the risks associated with antibiotics, efforts to reduce unnecessary antibiotic use in the NICU have become increasingly urgent. In 2016, a comprehensive 3-year quality improvement (QI) initiative was conducted in a level 4 NICU that sought to decrease the antibiotic use rate (AUR) by 20%.

METHODS:

This local QI initiative was conducted in the context of a multicenter learning collaborative focused on decreasing unnecessary antibiotic use. Improvement strategies focused on addressing gaps in the core elements of antibiotic stewardship programs. Outcome measures included the AUR and the percent of infants discharged without antibiotic exposure. Process measures included the percent of infants evaluated for early-onset sepsis (EOS) and duration of antibiotics used for various infections. Statistical process control charts were used to display and analyze data over time.

RESULTS:

The AUR decreased from 27.6% at baseline to 15.5%, a 43% reduction, and has been sustained for >18 months. Changes most attributable to this decrease include implementation of the sepsis risk calculator, adopting a 36-hour rule-out period for sepsis evaluations, a 36-hour antibiotic hard stop, and novel guideline for EOS evaluation among infants <35 weeks. The percent of infants discharged without antibiotic exposure increased from 15.8% to 35.1%. The percent of infants ≥36 weeks undergoing evaluation for EOS decreased by 42.3% and for those <35 weeks by 26%.

CONCLUSIONS:

Our efforts significantly reduced antibiotic use and exposure in our NICU. Our comprehensive, rigorous approach to QI is applicable to teams focused on improvement.

Aerosolized Calfactant for Newborns With Respiratory Distress: A Randomized Trial

BACKGROUND:

Exogenous surfactants to treat respiratory distress syndrome (RDS) are approved for tracheal instillation only; this requires intubation, often followed by positive pressure ventilation to promote distribution. Aerosol delivery offers a safer alternative, but clinical studies have had mixed results. We hypothesized that efficient aerosolization of a surfactant with low viscosity, early in the course of RDS, could reduce the need for intubation and instillation of liquid surfactant.

METHODS:

A prospective, multicenter, randomized, unblinded comparison trial of aerosolized calfactant (Infasurf) in newborns with signs of RDS that required noninvasive respiratory support. Calfactant was aerosolized by using a Solarys nebulizer modified with a pacifier adapter; 6 mL/kg (210 mg phospholipid/kg body weight) were delivered directly into the mouth. Infants in the aerosol group received up to 3 treatments, at least 4 hours apart. Infants in the control group received usual care, determined by providers. Infants were intubated and given instilled surfactant for persistent or worsening respiratory distress, at their providers’ discretion.

RESULTS:

Among 22 NICUs, 457 infants were enrolled; gestation 23 to 41 (median 33) weeks and birth weight 595 to 4802 (median 1960) grams. In total, 230 infants were randomly assigned to aerosol; 225 received 334 treatments, starting at a median of 5 hours. The rates of intubation for surfactant instillation were 26% in the aerosol group and 50% in the usual care group (P < .0001). Respiratory outcomes up to 28 days of age were no different.

CONCLUSIONS:

In newborns with early, mild to moderate respiratory distress, aerosolized calfactant at a dose of 210 mg phospholipid/kg body weight reduced intubation and surfactant instillation by nearly one-half.

Parental Awareness of Youth Tobacco Use and the Role of Household Tobacco Rules in Use Prevention

BACKGROUND AND OBJECTIVES:

Noncigarette tobacco use is increasing. In this study, we reexamined (1) parental knowledge or suspicion of their children’s tobacco use and (2) associations of household tobacco-free rules with youth initiation.

METHODS:

Participants were youth (aged 12–17) in waves 1 to 4 (2013–2018) of the Population Assessment of Tobacco and Health Study. A pseudo cross-sectional time-series analysis (N = 23 170) was used to examine parent or guardian knowledge or suspicion of their child’s tobacco use according to youth-reported use categories: cigarette only, electronic cigarette only, smokeless tobacco only, noncigarette combustible only, and poly use. A longitudinal analysis among wave 1 never users (n = 8994) was used to examine rules barring tobacco inside the home and whether parents talked with youth about not using tobacco as predictors of youth tobacco initiation after 1 to 3 years. Survey-weighted multivariable models were adjusted for tobacco use risk factors.

RESULTS:

In all waves, parents or guardians much less often knew or suspected that their children used tobacco if youth only reported use of electronic cigarettes, noncigarette combustible products, or smokeless tobacco compared with cigarettes. Youth tobacco initiation was lower when youth and parents agreed that rules prohibited all tobacco use throughout the home (1-year adjusted odds ratio: 0.74; 95% confidence interval: 0.59–0.94) but not when parents talked with youth about tobacco (adjusted odds ratio: 1.08; 95% confidence interval: 0.94–1.23).

CONCLUSIONS:

Many parents are unaware of their children’s noncigarette tobacco use. Setting expectations for tobacco-free environments appears more effective at preventing youth tobacco initiation than parents advising children not to use tobacco.

Child Social Media Influencers and Unhealthy Food Product Placement

OBJECTIVES:

We aimed to determine the frequency with which kid influencers promote branded and unbranded food and drinks during their YouTube videos and assess the nutritional quality of food and drinks shown.

METHODS:

Researchers used Socialbakers data to identify the 5 most-watched kid influencers (ages 3 to 14 years) on YouTube in 2019. We searched for 50 of their most-watched videos and 50 of their videos that featured food and/or drinks on the thumbnail image of the video. We coded whether kid influencers consumed or played with food or toys, quantified the number of minutes food and/or drinks appeared, and recorded names of branded food and/or drinks. We assessed the nutritional quality of foods using the Nutrient Profile Model and identified the number of drinks with added sugar.

RESULTS:

A sample of 418 YouTube videos met the search criteria, and 179 of those videos featured food and/or drinks. Food and/or drinks were featured in those videos 291 times. Kid influencers’ YouTube videos were collectively viewed >48 billion times, and videos featuring food and/or drinks were viewed 1 billion times. Most food and/or drinks were unhealthy branded items (n = 263; 90.34%; eg, McDonald’s), followed by unhealthy unbranded items (n = 12; 4.1%; eg, hot dogs), healthy unbranded items (n = 9; 3.1%; eg, fruit), and healthy branded items (n = 7; 2.4%; eg, Yoplait yogurt).

CONCLUSIONS:

Kid influencers generate millions of impressions for unhealthy food and drink brands through product placement. The Federal Trade Commission should strengthen regulations regarding product placement on YouTube videos featuring young children.

High-Flow Nasal Cannula Use Outside of the ICU Setting

OBJECTIVES:

To describe the practice of high-flow nasal cannula (HFNC) use in the pediatric ward setting across North America.

METHODS:

A survey was distributed through the Pediatric Research in Inpatient Settings Network, which represents 114 hospital sites. Questions included indication for HFNC use, flow and oxygen parameters, guideline availability, and use of outcomes measures.

RESULTS:

There was a response rate of 68% to the survey from sites representing all regions from the United States. Thirty-seven sites (48%) used HFNC in the pediatric ward setting. All 37 sites used HFNC for patients with bronchiolitis. All children’s hospital sites providing HFNC on the wards had an on-site ICU, compared with only 60% of non–children’s hospital sites (P = .003). Seventy-six percent of sites used local protocols, including parameters for patient assessment, initiation, weaning, and feeding practices.

CONCLUSIONS:

HFNC is used outside the ICU in nearly 50% of responding hospitals, with variation related to flow rate, feeding, and protocol use. HFNC is used for management of acute respiratory distress due to bronchiolitis, asthma, and pneumonia. Study findings suggest that HFNC is often used by pediatric hospitalists, but its use across North American hospitals remains variable and based on local consensus.

Observation Encounters and Length of Stay Benchmarking in Childrens Hospitals

BACKGROUND AND OBJECTIVES:

Length of stay (LOS) is a common benchmarking measure for hospital resource use and quality. Observation status (OBS) is considered an outpatient service despite the use of the same facilities as inpatient status (IP) in most children’s hospitals, and LOS calculations often exclude OBS stays. Variability in the use of OBS by hospitals may significantly impact calculated LOS. We sought to determine the impact of including OBS in calculating LOS across children’s hospitals.

METHODS:

Retrospective cohort study of hospitalized children (age <19 years) in 2017 from the Pediatric Health Information System (Children’s Hospital Association, Lenexa, KS). Normal newborns, transfers, deaths, and hospitals not reporting LOS in hours were excluded. Risk-adjusted geometric mean length of stay (RA-LOS) for IP-only and IP plus OBS was calculated and each hospital was ranked by quintile.

RESULTS:

In 2017, 45 hospitals and 625 032 hospitalizations met inclusion criteria (IP = 410 731 [65.7%], OBS = 214 301 [34.3%]). Across hospitals, OBS represented 0.0% to 60.3% of total discharges. The RA-LOS (SD) in hours for IP and IP plus OBS was 75.2 (2.6) and 54.3 (2.7), respectively (P < .001). For hospitals reporting OBS, the addition of OBS to IP RA-LOS calculations resulted in a decrease in RA-LOS compared with IP encounters alone. Three-fourths of hospitals changed ≥1 quintile in LOS ranking with the inclusion of OBS.

CONCLUSIONS:

Children’s hospitals exhibit significant variability in the assignment of OBS to hospitalized patients and inclusion of OBS significantly impacts RA-LOS calculations. Careful consideration should be given to the inclusion of OBS when determining RA-LOS for benchmarking, quality and resource use measurements.

Emicizumab-Induced Seronegative Full-House Lupus Nephritis in a Child

Hemophilia A (HA) is a serious inherited bleeding disorder resulting from a deficiency of coagulation factor VIII (FVIII). Replacement therapy with intravenous infusion of FVIII can be associated with treatment failure in approximately one-third of patients secondary to the development of neutralizing alloantibodies (inhibitor). Emicizumab is a recombinant, humanized, bispecific monoclonal antibody that binds factor IXa and factor X and mimics FVIII. It has been licensed in many countries for the treatment of patients with HA with and without inhibitors with a favorable efficacy and safety profile. A 7-year-old child with severe HA and FVIII inhibitors, refractory to immune tolerance therapy, developed hematuria with nephrotic-range proteinuria after the first dose of emicizumab and subsequently also after a second dose 6 weeks later, which was associated with mild and transient leukopenia. Renal biopsy revealed a pattern of a full-house lupus nephritis. The patient fully and spontaneously recovered between 2 weeks after symptoms onset. In this report, we provide insights on a new and so far unreported renal complication associated to emicizumab treatment. Although emicizumab offers significant benefits for patient with HA, clinicians should be aware of this rare and potential serious renal adverse effect.

Transitional Care Interventions for Youth With Disabilities: A Systematic Review

CONTEXT:

Transition from the pediatric to the adult health care system is a complex process that should include medical, psychosocial, educational, recreational, and vocational considerations.

OBJECTIVE:

In this systematic review, we aim to synthesize the evidence on transitional care interventions (TCIs) to improve the quality of life (QoL) for adolescents and young adults with childhood-onset disabilities, including neurodevelopmental disorders.

DATA SOURCES:

Four electronic databases (Medline, Embase, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature) were searched.

STUDY SELECTION:

In the included studies, researchers examined TCIs for adolescents and young adults (12–24 years of age) with childhood-onset disabilities. Studies were experimental, quasi-experimental, and observational studies published in the last 26 years.

DATA EXTRACTION:

Two reviewers independently completed study screening, data extraction, and risk-of-bias assessment.

RESULTS:

Fifty-two studies were included. Five studies reported on QoL, but statistically significant improvements were noted in only 1 of these studies. Significant improvements were also found in secondary outcomes including disability-related knowledge and transitional readiness. TCIs targeted patients, families and/or caregivers, and health care providers and exhibited great heterogeneity in their characteristics and components.

LIMITATIONS:

Inconsistent reporting on interventions between studies hindered synthesis of the relationships between specific intervention characteristics and outcomes.

CONCLUSIONS:

Although there is limited evidence on the impact of TCIs on the QoL for youth with childhood-onset disabilities, there is indication that they can be effective in improving patient and provider outcomes. The initiation of transition-focused care at an early age may contribute to improved long-term health outcomes in this population.

Motivational Interviewing for Overweight Children: A Systematic Review

CONTEXT:

Motivational interviewing (MI) is a communication method to help facilitate adherence to health behaviors through a series of person-centered strategies. MI’s evidence base supports its use as a potential intervention strategy at the parental decision-maker level to impact young children’s lifestyle behaviors to address childhood obesity; however, clarity is needed on the literature.

OBJECTIVE:

The purpose of this systematic review is to synthesize the literature examining the use of MI at the parental level to impact young children’s weight status.

DATA SOURCES:

A modified Cochrane method of systematic search and review was conducted in several databases (eg, PsycINFO, Academic Search Premier, Medline, Cumulative Index to Nursing and Allied Health Literature, Health Source: Nursing/Academic Edition, and SPORTDiscus).

STUDY SELECTION:

Criteria for retention included randomized controlled trials and studies using varied settings, methods, interventionists, target behaviors, and outcomes.

DATA EXTRACTION:

Extraction domains included study characteristics and risk of bias.

RESULTS:

Of the 352 references initially identified, 7 studies were included in the review. In most studies, authors reported significant anthropometric changes as well as significant changes in nonanthropometric outcomes related to weight management compared to usual care.

LIMITATIONS:

The heterogeneity of the included studies and lack of comparison with attention control groups may cloud generalizations. Studies not written in English were excluded, possibly biasing the results.

CONCLUSIONS:

MI, compared to usual care, revealed positive effects for parent influence on young child anthropometric measures when applied. Future research should be focused on sample diversity, using attention control groups, using exercise physiologists for MI delivery, and reporting sex-specific results.

Long-term Outcomes of Individuals With Metabolic Diseases Identified Through Newborn Screening

BACKGROUND:

Although extended newborn screening (NBS) programs have been introduced more than 20 years ago, their impact on the long-term clinical outcome of individuals with inherited metabolic diseases (IMDs) is still rarely investigated.

METHODS:

We studied the clinical outcomes of individuals with IMDs identified by NBS between 1999 and 2016 in a prospective multicenter observational study.

RESULTS:

In total, 306 screened individuals with IMDs (115 with phenylketonuria and 191 with other IMDs with a lifelong risk for metabolic decompensation) were followed for a median time of 6.2 years. Although the risk for metabolic decompensation was disease-specific and NBS could not prevent decompensations in every individual at risk (n = 49), the majority did not develop permanent disease-specific signs (75.9%), showed normal development (95.6%) and normal cognitive outcome (87.7%; mean IQ: 100.4), and mostly attended regular kindergarten (95.2%) and primary school (95.2%). This demonstrates that not only individuals with phenylketonuria, serving as a benchmark, but also those with lifelong risk for metabolic decompensation had a favorable long-term outcome. High NBS process quality is the prerequisite of this favorable outcome. This is supported by 28 individuals presenting with first symptoms at a median age of 3.5 days before NBS results were available, by the absence of neonatal decompensations after the report of NBS results, and by the challenge of keeping relevant process parameters at a constantly high level.

CONCLUSIONS:

NBS for IMDs, although not completely preventing clinical presentations in all individuals, can be considered a highly successful program of secondary prevention.

Infant Mortality in Rural and Nonrural Counties in the United States

BACKGROUND AND OBJECTIVES:

Rural counties have the highest infant mortality rates across the United States when compared with rates in more urban counties. We use a social-ecological framework to explain infant mortality disparities across the rural-urban continuum.

METHODS:

We created a cohort of all births in the United States linked to infant death records for 2014 to 2016. Records were linked to county-level data from the Area Health Resources File and the American Community Survey and classified using the National Center for Health Statistics Urban-Rural Classification Scheme. Using multilevel generalized linear models, we investigated the association of infant mortality with county urban-rural classification, considering county health system resources and measures of socioeconomic advantage, net of individual-level characteristics, and controlling for US region and county centroid.

RESULTS:

Infant mortality rates were highest in noncore (odds ratio [OR] = 1.32, 95% confidence interval [CI]: 1.26–1.39) and micropolitan counties (OR = 1.26, 95% CI: 1.20–1.32) when compared with large metropolitan fringe counties, controlling for geospatial measures. Inclusion of county health system characteristics did little to attenuate the greater odds of infant mortality in rural counties. Instead, a composite measure of county-level socioeconomic advantage was highly protective (adjusted OR = 0.84; 95% CI: 0.82–0.86) and eliminated any difference between the micropolitan and noncore counties and the large metropolitan fringe counties.

CONCLUSIONS:

Higher infant mortality rates in rural counties are best explained by their greater socioeconomic disadvantage than more-limited access to health care or the greater prevalence of mothers’ individual health risks.

Web-Based Tailored Messaging to Increase Vaccination: A Randomized Clinical Trial

BACKGROUND:

To increase vaccine acceptance, we created a Web-based the "Vaccines and Your Baby" intervention (VAYB) that provided new parents with vaccine information messages tailored to vaccine beliefs and values. We evaluated the effectiveness of the VAYB by comparing timely uptake of infant vaccines to an untailored version of the intervention (UT) or usual care intervention (UC) only.

METHODS:

Between April 2016 and June 2019, we conducted a randomized clinical trial. Pregnant women and new parents were randomly assigned to the VAYB, UT, or UC arms. In the VAYB and UT arms, participants were exposed to interventions at 4 time points from pregnancy until their child was 15 months of age. The primary outcome was up-to-date status for recommended vaccines from birth to 200 days of age. A modified intent-to-treat analysis was conducted. Data were analyzed with logistic regression to generate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS:

We enrolled 824 participants (276 VAYB, 274 UT, 274 UC), 143 (17.4%) of whom were lost to follow-up. The up-to-date rates in the VAYB, UT, and UC arms were 91.44%, 92.86%, and 92.31%, respectively. Infants in the VAYB arm were not more likely to be up to date than infants in the UC arm (OR = 0.89; 95% CI, 0.45–1.76) or in the UT arm (OR = 0.82; 95% CI, 0.42–1.63). The odds of being up to date did not differ between UT and UC arms (OR = 1.08; 95% CI, 0.54–2.18).

CONCLUSIONS:

Delivering Web-based vaccine messages tailored to parents’ vaccine attitudes and values did not positively impact the timely uptake of infant vaccines.

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