[Show abstract][Hide abstract] ABSTRACT: Infant colic, or excessive crying of unknown cause in infants less than 3 months old, is common and burdensome. Its aetiology is undetermined, and consensus on its management is still lacking. Recent studies suggest a possible link between infant colic and gut microbiota, indicating probiotics to be a promising treatment. However, only a few strains have been tested, and results from randomised controlled trials are conflicting. It is important to clarify whether probiotics are effective for treating infant colic in general, and to identify whether certain subgroups of infants with colic would benefit from particular strains of probiotics.
Through an individual participant data meta-analysis (IPDMA), we aim to identify whether the probiotic Lactobacillus reuteri DSM 17938 is effective in the management of infant colic, and to clarify whether its effects differ according to feeding method (breast vs formula vs combined), proton pump inhibitor exposure, and antibiotic exposure. The primary outcomes are infant crying duration and treatment success (at least 50% reduction in crying time from baseline) at 21 days postintervention. Individual participant data from all studies will be modelled simultaneously in multilevel generalised linear mixed-effects regression models to account for the nesting of participants within studies. Subgroup analyses of participant-level and intervention-level characteristics will be undertaken on the primary outcomes to assess if the intervention effect differs between certain groups of infants.
Approved by the Royal Children's Hospital Human Research Ethics Committee (HREC 34081). Results will be reported in a peer-reviewed journal in 2015.
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
BMJ Open 12/2014; 4(12):e006475. · 2.06 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: For mothers with breastfeeding difficulties, pumping can be recommended to help establish milk production. However, pumping may present some barriers to successful breastfeeding. Mothers with milk supply concern may be at higher risk of barriers to successful breastfeeding. No previous studies have described experiences of pumping among mothers with milk supply concern. We conducted 10 focus groups of 56 mothers who had milk supply concern in the first month after birth. A paid, trained facilitator led groups in a semi-structured approach. Sessions were audiorecorded and transcribed verbatim. The transcripts were coded independently by two investigators and analysed using grounded theory. We identified five themes related to the experience of pumping among mothers with milk supply concern: (1) additional control over breastfeeding from pumping: ‘I would feed and then give him … whatever I could manage to pump to him’. (2) Painful experience: ‘The first time I pumped my boobs hurt so bad’. (3) Pumped volume affected milk supply concern: ‘Pump and there was hardly anything coming out that's when I started to worry’. (4) Pumping interfered with other nurturing activities: ‘While you're pumping, you can't touch the baby’. (5) Frustration from inconsistent provider advice: ‘They told me to pump … and then said, “That's going to cause your milk to increase too much” ’. Mothers had positive and negative experiences with pumping. Clinicians should assess a mother's experience shortly after she initiates pumping, as further management and counselling may be necessary to avoid barriers to successful breastfeeding.
Maternal and Child Nutrition 09/2014; · 2.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background Various institution-specific guidelines have been developed to prevent ventilator-associated pneumonia. However, the availability of guidelines does not ensure adherence to recommended strategies. Objective To identify factors that influence adherence to guidelines for prevention of ventilator-associated pneumonia, with a focus on oral hygiene, head-of-bed elevation, and spontaneous breathing trials. Methods A cross-sectional descriptive study of critical care nurses at 8 hospitals in Northern California was conducted. A survey was created to gather information on possible facilitators of and barriers to adherence to institution-specific guidelines for preventing ventilator-associated pneumonia. User factors, guideline qualities, and contextual factors were explored and tested for possible relationships. Results A total of 576 critical care nurses participated in the survey. Each hospital had unique guidelines for preventing ventilator-associated pneumonia. In general, nurses had positive attitudes and reported adhering to the guidelines always or most of the time. Factors associated with adherence differed according to the intervention implemented. The score on the user attitude scale was the strongest and most consistent predictor of adherence across interventions (odds ratio, 3.49-4.75). Time availability (odds ratio, 1.54) and the level of prioritization (odds ratio, 1.86) were also significant predictors. Conclusion The most consistent facilitator of adherence to guidelines for prevention of ventilator-associated pneumonia was nurses' positive attitude toward the guidelines.
American Journal of Critical Care 05/2014; 23(3):201-215. · 1.41 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: National guidelines have recommended against codeine use in children, but little is known about prescribing patterns in the United States. Our objectives were to assess changes over time in pediatric codeine prescription rates in emergency departments nationally and to determine factors associated with codeine prescription.
We performed a serial cross-sectional analysis (2001-2010) of emergency department visits for patients ages 3 to 17 years in the nationally representative National Hospital Ambulatory Medical Care Survey. We determined survey-weighted annual rates of codeine prescriptions and tested for linear trends over time. We used multivariate logistic regression to identify characteristics associated with codeine prescription and interrupted time-series analysis to assess changes in prescriptions for upper respiratory infection (URI) or cough associated with two 2006 national guidelines recommending against its use for these indications.
The proportion of visits (N = 189 million) with codeine prescription decreased from 3.7% to 2.9% during the study period (P = .008). Odds of codeine prescription were higher for children ages 8 to 12 years (odds ratio [OR], 1.42; 95% confidence interval [1.21-1.67]) and among providers outside the northeast. Odds were lower for children who were non-Hispanic black (OR, 0.67 [0.56-0.8]) or with Medicaid (OR, 0.84 [0.71-0.98]). The 2006 guidelines were not associated with a decline in codeine prescriptions for cough or URI visits.
Although there was a small decline in codeine prescription over 10 years, use for cough or URI did not decline after national guidelines recommending against its use. More effective interventions are needed to prevent codeine prescription to children.
[Show abstract][Hide abstract] ABSTRACT: Population-based birth cohorts on asthma and allergies increasingly provide new insights into the development and natural history of the diseases. More than 130 birth cohorts focusing on asthma and allergy have been initiated in the last 30 years. A National Institute of Allergy and Infectious Diseases; National Heart, Lung, and Blood Institute; Mechanisms of the Development of Allergy (MeDALL; Framework Programme 7 of the European Commission) joint workshop was held in Bethesda, Maryland, on September 11-12, 2012, with 3 objectives: (1) documenting the knowledge that asthma/allergy birth cohorts have provided, (2) identifying the knowledge gaps and inconsistencies, and (3) developing strategies for moving forward, including potential new study designs and the harmonization of existing asthma birth cohort data. The meeting was organized around the presentations of 5 distinct workgroups: (1) clinical phenotypes, (2) risk factors, (3) immune development of asthma and allergy, (4) pulmonary development, and (5) harmonization of existing birth cohorts. This article presents the workgroup reports and provides Web links (AsthmaBirthCohorts.niaid.nih.gov or www.medall-fp7.eu), where the reader will find tables describing the characteristics of the birth cohorts included in this report, the type of data collected at differing ages, and a selected bibliography provided by the participating birth cohorts.
The Journal of allergy and clinical immunology 03/2014; · 12.05 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Abstract Objective: One of the most common reasons for medication non-adherence for asthma patients is forgetfulness. Daily medication reminder system interventions in the form of text messages, automated phone calls, and audiovisual reminder devices can potentially address this problem. The aim of this review was to assess the effectiveness of reminder systems on patient daily asthma medication adherence. Methods: We conducted a systematic review of the literature to identify randomized controlled trials which assessed the effect of reminder systems on daily asthma medication adherence. We searched all English-language articles in Pub Med (MEDLINE), CINAHL, EMBASE, PsychINFO, and the Cochrane Library through May, 2013. We abstracted data on the year of study publication, location, inclusion and exclusion criteria, patient characteristics, reminder system characteristics, effect on patient adherence rate and other outcomes measured. Descriptive statistics were used to summarize the characteristics and results of the studies. Results: 5 randomized controlled trials and 1 pragmatic randomized controlled trial were included in the analysis. Median follow-up time was 16 weeks. All of the six studies suggested that the reminder system intervention was associated with greater levels of participant asthma medication adherence compared to those participants in the control group. None of the studies documented a change in asthma-related quality of life or clinical asthma outcomes. Conclusion: All studies in our analysis suggest that reminder systems increase patient medication adherence, but none documented improved clinical outcomes. Further studies with longer intervention durations are needed to assess effects on clinical outcomes, as well as the sustainability of effects on patient adherence.
[Show abstract][Hide abstract] ABSTRACT: Clinical asthma studies across different age groups (ie, cross-age studies) can potentially offer insight into the similarities, differences, and relationships between childhood and adult asthma. The National Institutes of Health's Asthma Research Network (AsthmaNet) is unique and innovative in that it has merged pediatric and adult asthma research into a single clinical research network. This combination enhances scientific exchange between pediatric and adult asthma investigators and encourages the application of cross-age studies that involve participants from multiple age groups who are generally not studied together. The experience from AsthmaNet in the development of cross-age protocols highlights some of the issues in the evaluation of cross-age research in asthma. The aim of this review is to summarize these challenges, including the selection of parallel cross-age clinical interventions, identification of appropriate controls, measurement of meaningful clinical outcomes, and various ethical and logistic issues.
The Journal of allergy and clinical immunology 01/2014; 133(1):27-33. · 12.05 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE:To assess variation among hospitals on pediatric readmission and revisit rates and to determine the number of high- and low-performing hospitals.METHODS:In a retrospective analysis using the State Inpatient and Emergency Department Databases from the Healthcare Cost and Utilization Project with revisit linkages available, we identified pediatric (ages 1-20 years) visits with 1 of 7 common inpatient pediatric conditions (asthma, dehydration, pneumonia, appendicitis, skin infections, mood disorders, and epilepsy). For each condition, we calculated rates of all-cause readmissions and rates of revisits (readmission or presentation to the emergency department) within 30 and 60 days of discharge. We used mixed logistic models to estimate hospital-level risk-standardized 30-day revisit rates and to identify hospitals that had performance statistically different from the group mean.RESULTS:Thirty-day readmission rates were low (<10.0%) for all conditions. Thirty-day rates of revisit to the inpatient or emergency department setting ranged from 6.2% (appendicitis) to 11.0% (mood disorders). Study hospitals (n = 958) had low condition-specific visit volumes (37.0%-82.8% of hospitals had <25 visits). The only condition with >1% of hospitals labeled as different from the mean on 30-day risk-standardized revisit rates was mood disorders (4.2% of hospitals [n = 15], range of hospital performance 6.3%-15.9%).CONCLUSIONS:We found that when comparing hospitals' performances to the average, few hospitals that care for children are identified as high- or low-performers for revisits, even for common pediatric diagnoses, likely due to low hospital volumes. This limits the usefulness of condition-specific readmission or revisit measures in pediatric quality measurement.
[Show abstract][Hide abstract] ABSTRACT: Background. Exclusive breastfeeding through 3 months is a Healthy People 2020 goal, yet most US infants who initiate breastfeeding receive formula before 3 months. The effect of birth weight on exclusive breastfeeding has not been previously studied. Methods. We analyzed data from a randomized trial of probiotics for healthy infants to determine the effect of birth weight and other predictors available at birth on any breastfeeding and exclusive breastfeeding through 3 months. We used backward stepwise logistic regression to examine the effect of maternal age, education, feeding plan, delivery method, and parity and infant birth weight and gestational age on the outcomes of any and exclusive breastfeeding through 3 months. Results. Birth weight was strongly associated with exclusive breastfeeding through 3 months (odds ratio = 6.23 [95% confidence interval = 2.27-17.1] per kilogram birth weight), adjusting for maternal college education and maternal plan to breastfeed exclusively. However, birth weight was not associated with any breastfeeding at 3 months when adjusting for the same predictors. Discussion. Smaller newborns were more likely to receive formula before 3 months in this study population. Educating mothers of smaller babies and their physicians about normal newborn growth patterns might reduce unnecessary formula use for smaller newborns.
[Show abstract][Hide abstract] ABSTRACT: Tap water provides a calorie-free, no-cost, environmentally friendly beverage option, yet only some youth drink it.
To examine sociodemographic characteristics, weight status, and beverage intake of those aged 1-19 years who drink tap water.
National Health and Nutrition Examination Survey data (2005-2010) were used to examine factors associated with tap water consumption. A comparison was made of beverage intake among tap water consumers and nonconsumers, by age, race/ethnicity, and income.
Tap water consumption was more prevalent among school-aged children (OR=1.85, 95% CI=1.47, 2.33, for those aged 6-11 years; OR=1.85, 95% CI=1.32, 2.59, for those aged 12-19 years) as compared to those aged 1-2 years. Tap water intake was less prevalent among girls/women (OR=0.76, 95% CI=0.64, 0.89); Mexican Americans (OR=0.32, 95% CI=0.23, 0.45); non-Hispanic blacks (OR=0.48, 95% CI=0.34, 0.67); and others (OR=0.50, 95% CI=0.36, 0.68) as compared to whites; Spanish speakers (OR=0.72, 95% CI=0.55, 0.95); and among referents with a lower than Grade-9 education (OR=0.52, 95% CI=0.31, 0.88); Grade 9-11 education (OR=0.50, 95% CI=0.32, 0.77); and high school/General Educational Development test completion (OR=0.50, 95% CI=0.33, 0.76), as compared to college graduates. Tap water consumers drank more fluid (52.5 vs 48.0 ounces, p<0.01); more plain water (20.1 vs 15.2 ounces, p<0.01); and less juice (3.6 vs 5.2 ounces, p<0.01) than nonconsumers.
One in six children/adolescents does not drink tap water, and this finding is more pronounced among minorities. Sociodemographic disparities in tap water consumption may contribute to disparities in health outcomes. Improvements in drinking water infrastructure and culturally relevant promotion may help to address these issues.
American journal of preventive medicine 07/2013; 45(1):75-82. · 4.24 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND AND OBJECTIVES:Recent public health efforts focus on reducing formula use for breastfed infants during the birth hospitalization. No previous randomized trials report the effects of brief early formula use. The objective of the study was to determine if small formula volumes before the onset of mature milk production might reduce formula use at 1 week and improve breastfeeding at 3 months for newborns at risk for breastfeeding problems.METHODS:We randomly assigned 40 exclusively breastfeeding term infants, 24 to 48 hours old, who had lost ≥5% birth weight to early limited formula (ELF) intervention (10 mL formula by syringe after each breastfeeding and discontinued when mature milk production began) or control (continued exclusive breastfeeding). Our outcomes were breastfeeding and formula use at 1 week and 1, 2, and 3 months.RESULTS:Among infants randomly assigned to ELF during the birth hospitalization, 2 (10%) of 20 used formula at 1 week of age, compared with 9 (47%) of 19 control infants assigned during the birth hospitalization to continue exclusive breastfeeding (P = .01). At 3 months, 15 (79%) of 19 infants assigned to ELF during the birth hospitalization were breastfeeding exclusively, compared with 8 (42%) of 19 controls (P = .02).CONCLUSIONS:Early limited formula may reduce longer-term formula use at 1 week and increase breastfeeding at 3 months for some infants. ELF may be a successful temporary coping strategy for mothers to support breastfeeding newborns with early weight loss. ELF has the potential for increasing rates of longer-term breastfeeding without supplementation based on findings from this RCT.
[Show abstract][Hide abstract] ABSTRACT: Much has been written regarding poor physician adherence to the National Asthma Education, Prevention Program (NAEPP) guidelines, but no data are available regarding nurse practitioners (NP) adherence. This descriptive study compared NP adherence to figures reported for medical doctors (MDs) in the 2001 and 2007 analyses by Cabana and colleagues.
A national, cross-sectional survey approach was used to assess NP knowledge, attitudes, and behaviors regarding the NAEPP guidelines. The survey was adapted from Cabana's 48-item questionnaire.
NPs provided more prescriptions of inhaled corticosteroids (ICSs) to patients with daily symptoms than did physicians (NPs, 79%; MDs, 54%). Overall, compared with MDs, NPs reported higher adherence on three of the four NAEPP guideline components surveyed, two of which were statistically significant.
This survey suggests that NPs have greater adherence to prescribing ICSs than do MDs. However, improved adherence still needs to be a goal for all providers because prescription of ICSs is the cornerstone of management of persistent asthma.
Journal of Pediatric Health Care 03/2013; 27(2):e17-24. · 1.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Physician Asthma Care Education (PACE) is a programme developed in the USA to improve paediatric asthma outcomes. AIMS: To examine translation of PACE to Australia. METHODS: The RE-AIM framework was used to assess translation. Demographic characteristics and findings regarding clinical asthma outcomes from PACE randomised clinical trials in both countries were examined. Qualitative content analysis was used to examine fidelity to intervention components. RESULTS: Both iterations of PACE reached similar target audiences (general practice physicians and paediatric patients with asthma); however, in the USA, more children with persistent disease were enrolled. In both countries, participation comprised approximately 10% of eligible physicians and 25% of patients. In both countries, PACE deployed well-known local physicians and behavioural scientists as facilitators. Sponsorship of the programme was provided by professional associations and government agencies. Fidelity to essential programme elements was observed, but PACE Australia workshops included additional components. Similar outcomes included improvements in clinician confidence in developing short-term and long-term care plans, prescribing inhaled corticosteroids, and providing written management instructions to patients. No additional time was spent in the patient visit compared with controls. US PACE realised reductions in symptoms and healthcare use, results that could not be confirmed in Australia because of limitations in follow-up time and sample sizes. US PACE is maintained through a National Heart, Lung, and Blood Institute website. Development of maintenance strategies for PACE Australia is underway. CONCLUSIONS: Based on criteria of the RE-AIM framework, the US version of PACE has been successfully translated for use in Australia.
Primary care respiratory journal: journal of the General Practice Airways Group 11/2012; · 2.91 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: PURPOSE OF REVIEW: Although current asthma guidelines stress the importance of assessing and enhancing adherence to asthma treatment, medication adherence rates in asthma patients are consistently low in practice. In this review, we summarize current literature on method of measurement, prevalence, outcome and intervention of medication adherence in asthma patients. RECENT FINDINGS: Nonadherence to prescribed treatment continues to be a frequent problem in patients with asthma even in recent years. Objective measurement of adherence should be implemented whenever possible. Review of pharmacy refill data or electronic monitoring of inhaler actuation may be a preferred method to assess adherence. Educational programmes should be specifically designed to address the unmet need and specific reasons for nonadherence for the target population. Large, well designed clinical trials to assess the efficacy of remote electronic monitoring and reminder systems to improve adherence are needed. SUMMARY: There is an urgent clinical need for systematic, proven methods to assess and address medication nonadherence in asthma patients.
Current opinion in pulmonary medicine 11/2012; · 2.96 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Hypertension occurs in 2% to 5% of children in the United States, and its prevalence has increased during the obesity epidemic. There is no consensus among professional organizations about how frequently blood pressure should be measured in children >3 years old. The purpose of this study was to estimate the frequency of hypertension screening during ambulatory pediatric visits in the United States and to determine patient- and provider-level factors associated with screening during visits specifically for preventive care.
We analyzed data from a nationally representative sample of ambulatory visits by using the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey from 2000 through 2009. In the subset of visits involving patients aged 3 to 18 years, we estimated the frequency of screening during all visits, preventive visits, and preventive visits in which overweight/obesity was diagnosed. We used multivariable logistic regression to identify patient- and provider-level factors associated with screening.
Hypertension screening occurred during 35% of ambulatory pediatric visits, 67% of preventive visits, and 84% of preventive visits in which overweight/obesity was diagnosed. Between 2000 and 2009, the frequency of screening increased in all visits and in preventive visits. Factors independently associated with screening included older age and overweight/obesity diagnosis.
Providers do not measure blood pressure in two-thirds of pediatric visits and one-third of pediatric preventive visits. Providers may understand the importance of screening among overweight/obese children; however, efforts to encourage routine screening, particularly in young children, may be needed.
[Show abstract][Hide abstract] ABSTRACT: RationaleVitamin D insufficiency (a serum 25(OH)D <30 ng/ml) has been associated with severe asthma exacerbations, but this could be explained by underlying racial ancestry or disease severity. Little is known about vitamin D and asthma in Puerto Ricans.ObjectiveTo examine whether vitamin D insufficiency is associated with severe asthma exacerbations in Puerto Rican children, independently of racial ancestry, atopy and time outdoors.MethodsCase-control study of 560 children ages 6 to 14 years with (n=287) and without (n=273) asthma in San Juan (PR). We measured plasma vitamin D and estimated the percentage of African racial ancestry among participants using genome-wide genotypic data. We tested whether vitamin D insufficiency is associated with severe asthma exacerbations, lung function atopy (≥1 positive IgE to allergens) using logistic or linear regression. Multivariate models were adjusted for African ancestry, time outdoors, atopy and other covariates.ResultsVitamin D insufficiency was common in children with (44%) and without (47%) asthma. In multivariate analyses, vitamin D insufficiency was associated with higher odds of ≥1 severe asthma exacerbation in the prior year (odds ratio [OR]=2.6, 95% confidence interval [CI]=1.5-4.9, P=0.001) and atopy, and a lower FEV1/FVC in cases. After stratification by atopy, the magnitude of the association between vitamin D insufficiency and severe exacerbations was greater in non-atopic (OR=6.2, 95% CI=2-21.6, P=0.002) than in atopic (OR=2.0, 95% CI=1.0-4.1, P=0.04) cases. ConclusionsVitamin D insufficiency is associated with severe asthma exacerbations in Puerto Rican children, independently of racial ancestry, atopy or markers of disease severity or control.
American Journal of Respiratory and Critical Care Medicine 07/2012; · 11.04 Impact Factor