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Contents

The Application of Infant Massage for Mothers of Term
and Near-Term Infants - Bonding with Baby

Obehioge Okojie, MPH, CHES, OMS IV
Kelly Timberlake, LMT
Carl R. Backes, DO, FACOP

_________

Pediatric Obesity with Comorbidities:
Potential Cases of Medical Neglect

Tami Hendriksz, DO, FACOP, FAAP

_________

Outcomes of Various Post-Circumcision Dressings:
An Administrative Project

Joanna Kramer, DO, MPH
Heather Tabor, RN
Carl Backes, DO, FACOP

_________

Prevalence of Bed Sharing and Associated
Factors in an At-Risk Population

S. Humpula-McMahon, DO
C. Petroff, MD
S. Szpunar, PhD

 

_________

 

The Application of Infant Massage
for Mothers of Term and Near-Term
Infants - Bonding with Baby


Obehioge Okojie, MPH, CHES, OMS IV, OUHCOM
Kelly Timberlake, LMT, Certified Newborn Massage
Carl R. Backes, DO, FACOP, Professor of Pediatrics, OUHCOM
Director, Department of Pediatrics
Doctors Hospital/OhioHealth

Introduction
Massage therapy is an ever-increasing modality to treat illness, chronic conditions and maintain wellness in infants and children.(1) Other benefits for the parent and baby as well as mechanisms of action are outlined below. Previously, we published our premature infant massage program in our neonatal intensive care nursery.(2) With excellent results in premature infant massage, we began a well-newborn massage program evaluating the application, feasibility and immediate benefits of massage in term and near-term infants with mothers giving the massage at Doctors Hospital/OhioHealth.

Potential Benefits for the Iinfant and Parent are Outlined Below(3)

   Benefits for the Parent(3)

  • Increases closeness to the infant
  • Eases stress about separation from infant
  • Increases opportunity for eye contact with infant
  • Allows parent alone and quiet time wtih their infant
  • Increases bonding/attachment
  • Decreases maternal depression
  • Increases sense of maternal competence
  • Increases parent self esteem about caregiving
  • Provides parent with opportunity to better understand behaviors and cues of their infant

   Potential Benefits for Infant(3)

  • Provides a special time of communication that provides love, compassion, and respect between the infant and parent
  • Improves functioning of digestion system
  • Enhances control of muscle tone
  • Improves circulation
  • Enahances the immune system
  • Improves sensory awareness
  • Enhances neurological development
  • Enhances deep sleep
  • Increases oxygen and nutrient flow to cells
  • Enhances release of hormones in the body including growth hormone
  • Reduces levels of cortisol in plasma
  • Bonding and attachment – provides all the essential components of intimate infant parent attachment: eye to eye contact, touch, voice, smell, and movement
  • Skin stimulation – all the physiological systems are stimulated

   Mechanisms of Action for Massage and Concept of Massage(4-5)

  • Influence neural activity – modulating subcortical nuclei
  • Improved blood flow and oxygenation of muscle and connective tissue
  • Increase oxytocin
  • Release endorphins and serotonin
  • Increase vagal activity → increase gastric motility → increase insulin and
    insulin-like growth factor-1 (IGF-1)
  • Stimulate large-diameter nerve fibers to inhibit pain receptors
  • Increase weight gain, better sleep/wake pattern
  • Better emotional bonding

Methods
Training materials were developed in the form of a dvd that demonstrated all the massage techniques and a step by step how to pamphlet with pictures that illustrated each massage technique.  Also, there was an intensive training program for all post-partum nursing staff led by a licensed massage therapist certified in neonatal massage.  It included 12 classes over the span of three months, and bedside neonatal massage demonstrations on patients for one month. Once all material and training was completed, we began enrolling infants delivered at Doctors Hospital/OhioHealth. All infants enrolled were well newborns, greater than 35 weeks gestation and medically stable.

Mothers of the newborns were taught how to massage their infant by viewing the dvd, reading the pamphlet and observing a demonstration by a trained nurse.  Mothers then massaged their baby on their own before discharge and subsequently filled out a questionnaire (Appendix 1) about the effectiveness of the teaching modality, their infant’s response as well as their own response to the massage.  Mothers were encouraged to continue massaging their infant at home; and, sent home with a packet containing: grape seed oil, the training dvd and pamphlet. 

Results
Forty infants were involved in the pilot study. There were eight yes or no questions, a comment section, and space for the mothers to note if they wanted to be contacted for follow up with room for contact information. Below is a summary of the questionnaire responses. All the responses are detailed in Table 1, dictating the percentage of each response as well as percentage of people who did not respond. Graph 1 illustrates the percentage of each response for all eight questions. The responses were stratified in Graph 2 and Graph 3 to the benefits of infant massage on both baby and mother, and the feasibility of the teaching material respectively.  Included are pictures for newborn massage including step-by-step strokes and calming techniques.

Summary of Questionnaire Responses
Hard to learn massage – 92.5% NO
Video helpful – 95% YES
Pamphlet easy to follow – 90% YES
Did parent(s) enjoy learning massage – 100% YES
Did massage relax the infant – 82.5% YES
Did massage help the baby cry less – 80% YES
Did you feel closer to your baby during massage – 80% YES


Table 1


Questions

Yes (%)

No (%)

No response (%)

Was infant massage hard to learn?

5

92.5

2.5

Was the instructional video helpful?

95

2.5

2.5

Was the pamphlet easy to follow?

90

0

10

Did you enjoy learning infant massage?

100

0

0

Did massage relax infant?

82.5

5

12.5

Did infant massage help baby cry less?

80

5

15

Did infant massage make you feel closer to your baby?

80

7.5

12.5

Were you aware of the multiple benefits of infant massage?

37.5

62.5

0

Graph 1

Graph 1

Graph 2

Graph 2

Graph 3

Graph 3

Conclusion
As noted, the results were overwhelmingly positive.  The findings suggest massage is a technique that is enjoyable and can easily be taught successfully to nursing staff and mothers, who can subsequently perform it independently.  In addition, massage relaxes the baby, and strengthens the bond between mother and infant.  

Appendix I

Bonding with Baby

We hope that you have enjoyed your educational and bonding experience on touching and massaging your newborn. To allow us this continued service for our families, we are requesting you complete this questionnaire.

Please circle the correct answer with written comments below.

Were you aware of the multiple benefits of infant massage? YES or NO

Did you enjoy learning to do infant massage? YES or NO

Was infant massage hard to learn? YES or NO

Did infant massage relax your baby? YES or NO

Did infant massage help the baby cry less? YES or NO

Did infant massage make you feel closer to your baby? YES or NO

Was the instructional video helpful? YES or NO

Was the informational pamphlet easy to follow, including the pictures in the back? YES or NO

Any comments?

May we contact you in 6 months with follow-up questions to see if you have continued to use Bonding with Baby massage?

If so, contact information:
Name _____________________________________________ Number _____________

References:

  1. Shipwright S, Dryden T. (2012). Paediatric massage: an overview of the evidence. Focus on Alternative and Complementary Therapies. 17(2), 103-110.
  2. Beachy JM. (2003). Premature infant massage in the NICU. Neonatal Network. 22(3), 39-45.
  3. McGrath JM, Thillet M, Van Cleave L. (2007). Parent delivered infant massage: are we truly ready for implementation? Newborn and Infant Nursing Reviews. 7(1), 39-46.
  4. Gonzalez AP, Vasquez-Mendoza G, García-Vela A, Guzmán-Ramirez A, Salazar-Torres M, Romero-Gutierrez G. (2009). Weight gain in preterm infants following parent-administered Vimala Massage: a randomized controlled trial. American Journal of Perinatology. 26(4), 247-252.
  5. Kulkarni A, Kaushik JS, Gupta P, Sharma H, Argrawal RK. (2010). Massage and touch therapy in neonates: The current evidence. Indian Pediatrics. 47(9), 771-776.

_____________________

Pediatric Obesity with Comorbidities:
Potential Cases of Medical Neglect

Tami Hendriksz, DO, FACOP, FAAP
Touro University California College of Osteopathic Medicine
Vallejo, CA

Introduction
When confronted with the idea of childhood neglect, people often picture cachectic and malnourished children. As the rates of childhood obesity continue to soar to epidemic proportions, a new image of the neglected child emerges. Instead of being thin and frail, the child in this image is severely obese.  Obese children can be considered cases of medical neglect when their obesity is accompanied by serious comorbid conditions that their caregivers are failing to adequately address.  If caregivers are not willing or able to help their child decrease their obesity and treat their comorbid conditions, then such noncompliance can constitute reportable childhood neglect.(1) This article will review the current accepted definitions of obesity and neglect, discuss the challenges associated with predicting and assessing imminent harm in obese pediatric patients, briefly address mandated reporting and the importance of documentation, and finally highlight the additional community resources and support that are needed for such interventions.

Definitions
Childhood Obesity: Childhood obesity is not measured by a simple number on the Body Mass Index (BMI) scale, but is instead plotted, like all other growth parameters in pediatrics, on a chart to identify patients who fall outside of the expected range of normal.  Pediatric obesity is defined as a BMI greater than the ninety-fifth percentile, and severe obesity is greater than the ninety-ninth percentile.(2)

Obesity with Comorbid Conditions: This refers to children that have diseases that are secondary to obesity.  The comorbidities that are seen with childhood obesity include (but are not limited to): insulin resistance, type 2 diabetes mellitus, hypertension, dyslipidemia, nonalcoholic steatosis of the liver, obstructive sleep apnea, school absenteeism, and poor psychosocial functioning.(3,4)

Neglect: Neglect is typically defined as the failure of the parent or guardian to provide (i.e., supervision, shelter, food, medical care) for the child to the degree that the child’s health and well-being are threatened with harm.(5)   The threshold for state intervention in cases of medical neglect remains very high due largely to the psychological stress of removing a child from their home as well as for respect for family autonomy. This calls for the need of strong evidence that the comorbidities of obese children can cause significant harm if they aren’t treated in an appropriate and timely manner.

Challenges of Assessing and Predicting Imminent Harm
Since obesity comorbidities lie on a spectrum of severity, it makes assessing the imminent harm of any individual challenging. For example, sleep apnea ranges from very low risk of harm with mild snoring, all the way through to cor pulmonale, pulmonary hypertension, and premature death (ii).  Similarly, fatty liver disease can range from low risk elevated transaminases to cirrhosis and premature death (ii).  It can be difficult to decide which points on all of these spectrums represent potential irreversible damage. Studies have shown that obese children are at risk of having cardiovascular disease as adults.(6)   This further highlights the challenges of knowing when to initiate state intervention.

Varness, et al describe the situation where they feel that removal from the child’s home is justified (all three conditions must be met in each individual case): “1. a high likelihood that serious imminent harm will occur; 2. a reasonable likelihood that coercive state intervention will result in effective treatment; and 3. the absence of alternative options for addressing the problem.” This highlights the significance of the presence of comorbidity with obesity, as obesity alone is unlikely to result in “serious imminent harm.”

Dr. Jennifer Cheng discusses her experience with filing a report with the Child Protective Services (CPS) for two of her obese patients in her New England Journal of Medicine Perspective.(7)  She describes the 10-year-old and 13-year-old siblings as having a long history of medical non-adherence and progressive morbid obesity. The girls also had a significant number of comorbidities, including “poorly controlled type 2 diabetes, hypertension, dyslipidemia, hepatic abnormalities, severe obstructive sleep apnea, poor psychosocial functioning, and chronic school absenteeism. ”The events that led up to Dr. Cheng’s CPS report involved multiple missed appointments, failure to bring the children in for an agreed upon in-clinic monitoring regimen, and ultimately the inability to contact the family.  After the CPS report was filed, Dr. Cheng explains that she was able to check in with the family more frequently (the children remained in their home). She also describes the limited help that agencies like CPS were able to offer her patients, and the desperate need of improved resources to promote good health at all socio-economic levels.

Mandated Reporting and Documentation
Pediatricians remain mandated reporters, regardless of the fear that involvement of agencies like CPS may not result in successful treatment of their obese patients. This means that they are required to report suspected or known cases of child abuse and neglect. The specific State.(8) A report typically must be made when the reporter suspects or has reason to believe that a child has been abused or neglected. Another standard that is most commonly used is situations in which the reporter has knowledge of conditions that would reasonably result in harm to the child, or observes a child being subjected to such conditions.  The cases involving childhood obesity with imminent harm could fall into either category (suspected neglect or awareness of conditions that may be harmful to the child.)

Most States maintain toll-free telephone numbers for receiving reports of abuse or neglect. Reports may be made anonymously to most of these reporting numbers, but it is much more useful to the investigations to know the identity of the reporters.  As with all reports of abuse or neglect, accurate and detailed documentation of the case is very important.  For these particular cases, appropriate documentation includes clinic notes, consultation reports, laboratory results, study results, documented attempts to contact the family members, their responses to recommendations, and their adherence to follow-up visits and consultations.  In addition, clear documentation should demonstrate the interventions that have been attempted, guardian understanding of the repercussions of failure to lose weight, and the physician’s concern that the caregivers have not been able to comply with needed medical care.

Future Directions
Just as obesity is a multifactorial disease (most commonly involving genetic as well as environmental factors), the approach to its resolution would best involve multiple systems. Increasing the number of resources for nutritional, exercise, and obesity risks and prevention education may help families realize the importance of heeding the medical advice and treatment plans of their pediatricians. Increasing access to playgrounds, safe gyms for kids, and healthy low cost foods could also have great potential impact. Putting emphasis and focus into measures like these will hopefully decrease the need for the controversial discussion of removing obese children from their families.  Increasing community resources, support systems and education may help to improve the lives and livelihoods of many children, instead of focusing on problematic individuals.  In the meantime the guidelines for when to intervene on individual patients that are at great risk of damage to their health are becoming more clearly established.

Conclusions
As childhood obesity rates increase, so do the incidences of the associated life-threatening comorbidities. When parents and caregivers are unwilling or unable to step in and address the life-threatening conditions of their children, then pediatricians are mandated to report such comorbidities. The challenges of assessing and predicting imminent harm in cases of childhood obesity have been discussed, and mandated reporting and the importance of accurate and complete documentation have been reviewed. The hope is that through an increase in education and support services, physicians will be able to work within their communities and healthcare teams to protect children and provide the best possible future outcomes for all.

References:

  1. Varness T, Allen DB, Carrel AL, Fost N. Childhood obesity and medical neglect. Pediatrics. 2009;14(1):399–406.
  2. Freedman DS, Mei Z, Srinivasan SR, Berenson GS, Dietz WH. Cardiovascular risk factors and excess adiposity among overweight children and adolescents: the Bogalusa Heart Study. J Pediatr.2007;150(1):12– 17.
  3. WHO. Obesity and Overweight. Geneva: World Health Organization; 2003.
  4. Orsi C, Hale D, Lynch J. Pediatric obesity epidemiology. Curr Opin Endocrinol Diabetes Obes. 2011;14(1):14–22.
  5. U.S. Department of Health and Human Services. Child Welfare Information Gateway. Definitions of Child Abuse and Neglect. State Statutes. https://www.childwelfare.gov/systemwide/laws_policies/statutes/
    define.pdf#Page=2&view=Fit
  6. hitlock EP, Williams SB, Gold R, Smith PR, Shipman SA. Screening and interventions for childhood overweight: a summary of evidence for the US Preventive Services Task Force. Pediatrics.2005;116 (1).
  7. Cheng, J. Confronting the Social Determinants of Health — Obesity, Neglect, and Inequity. N Engl J Med 2012; 367:1976-1977.
  8. Child Welfare Information Gateway: Mandatory Reporters of Child Abuse and Neglect. State Statutes.

_________________________

Outcomes of Various Post-Circumcision Dressings: An Administrative Project

Joanna Kramer, DO MPH
Heather Tabor, RN
Carl R. Backes, DO, FACOP

Doctor’s Hospital Columbus
Department of Pediatrics
Columbus, OH

Abstract
Newborn circumcision is a common practice in the United States. There is a great deal of literature describing the risks, benefits, anesthesia, varying techniques, and counseling about the procedure but no official recommendations exist for post-operative dressing of the circumcised penis. A commonly used dressing is the petroleum jelly impregnated gauze dressing left in place for varying amounts of time. Removal of this dressing has been associated with pain, bleeding, anxiety, and rare reports of more serious complications. An IRB exempt administrative project was completed at Doctor’s Hospital in Columbus, Ohio to study outcomes of petroleum jelly gauze dressings removed at various time intervals compared to the use of petroleum jelly alone. Neonates  (N=132) were circumcised using the Gomco clamp method and divided into groups of petroleum jelly alone and petroleum jelly gauze dressing removed at 6, 12, and 24 hours. Each group was observed post operatively for bleeding, pain, and infection. No significant difference was found in bleeding or pain between the petroleum jelly alone, 12 hour removal and 24 hour removal groups. The 6 hour removal group experienced significantly more pain compared to all other groups but no difference in bleeding was observed. No signs of infection were observed in any of the groups. These results have led to a change in practice at our institution. Petroleum jelly alone is now used in place of petroleum jelly gauze with favorable clinical outcomes.

Introduction
Neonatal male circumcision is a common practice in the United States with approximately 58% of infants circumcised in the hospital prior to discharge  (CDC 2011). There is an extensive body of literature that reviews varying techniques of circumcision, the risks and benefits of the procedure, methods of pain management, and complications. Despite the popularity of the procedure, there are few peer-reviewed studies examining post-operative wound care. Authors have reported the use of sterile gauze with petroleum jelly, petroleum jelly/paraffin-impregnated gauze, antibiotic-impregnated gauze, petroleum jelly alone, nonstick bandages, and nanometer silver dressings with dressings left in place ranging from 12-48 hours (Abdulwahab-Ahmed and Mungadi 2013, Chen, Zhang et al. 2011, Holman et al 1995, Lukong 2012, Molokwa 2104, Weismiller 2014). The most recent technical report on male circumcision by the American Academy of Pediatrics Task Force on Circumcision includes recommendations for counseling, anesthesia, and procedural techniques, but makes no mention of which post-operative dressing is preferred (AAP, 2007).

Doctor’s Hospital in Columbus, Ohio is a medium-sized community hospital where approximately 400 neonatal circumcisions are performed each year. Prior to this study, circumcisions were dressed with petroleum gauze for 24 hours and subsequently removed. The medical staff observed several pitfalls with this practice including pain and/or bleeding with dressing removal, dressing adhering to the skin, and accidental premature removal.  When discharge occurs prior to the 24 hour removal point, dressing removal at home can be a source of anxiety for parents who are unsure of the normal appearance and amount of bleeding or pain to expect. Worse than this, parents may fail to remove the dressing as instructed at 24 hours leaving the gauze to harden and adhere until the initial newborn visit. This can lead to a difficult removal causing much distress to the child and parents and may lead to increased risk of infection at the site (Freeland 1996). Based on these observations, we decided to conduct an administrative project to examine possible ways to reduce patient distress, morbidity and parental anxiety.   

The aim of this study was to determine whether there is a difference in pain and/or bleeding after circumcision when petroleum gauze dressings are removed at varying time intervals or not used at all. We predicted that an increased amount of pain and bleeding would be observed with the use of petroleum jelly gauze compared to petroleum jelly alone.

Methods
An IRB exempt administrative project took place at Doctor’s Hospital between June 2009-January 2010.  All newborn males whose parents requested a circumcision and for whom circumcision was medically appropriate were included in the study. One pediatrician performed all circumcisions using the Gomco Clamp Method. Patients were separated by month for ease of data collection into one of four groups: infants circumcised in June and October 2009 had a petroleum impregnated gauze dressing applied to the circumcision site and removed after 24 hours. Infants circumcised in July and November 2009 had the dressing removed after 12 hours, infants circumcised in August and December 2009 had the dressing removed after 6 hours, infants circumcised in September 2009 and January 2010 had petroleum jelly alone applied to the circumcision site with no gauze dressing.  For all groups, petroleum jelly was applied to the site at each diaper change either on top of the gauze or onto the glans itself. At the specified removal time, additional petroleum jelly was applied to the gauze and then carefully removed.

Infants were evaluated for pain, bleeding, and infection at the time of removal. Pain was evaluated by nursing staff using the Neonatal Infant Pain Scale (NIPS) scoring system (Lawrence, 1993) with scores ≥ 3 considered to be significant pain. Any active bleeding at time of removal was noted, as were signs of infection including fever, discharge, excessive erythema and foul odor. Infants with petroleum jelly only were scored at time intervals of 6, 12, and 24 hours for pain, active bleeding, or signs of infection. Patients were excluded from the study if they were discharged prior to their scheduled gauze removal, the gauze fell off prior to scheduled removal, or if there was incomplete data recorded. Two-sample z tests were performed to compare outcomes between each group. All tests were two-tailed with a level of p <0.05 considered to be significant.

Results
A total of 151 circumcisions were performed during the study period. Nineteen patients were excluded due to discharge prior to removal, gauze falling off early, or incomplete data. Out of the 132 remaining, 26 patients had petroleum gauze removed at 24 hours, 27 had gauze removed at 12 hours, 52 had gauze removed at 6 hours, and 27 were dressed with petroleum jelly alone. See Table 1 for frequencies of pain and bleeding. All bleeding observed was classified as mild and hemostasis was achieved either with the application of local pressure or without intervention. There were no symptoms of infection in any of the groups.

Statistical analyses were performed using EpiTools© 2014. There was no significant difference in pain (p =0.96) or bleeding (p =0.96) between the patients who had petroleum jelly only (no gauze) and those who had gauze removed at 24h. Between the 24h and 12h groups, there was also no significant difference in pain (p =0.28) or bleeding (p =0.07).  Patients who had gauze removed at 6h were more likely to have pain than those removed at 24h (p <0.01), 12h (p <0.01), and those without gauze (p <0.01). However, there were no significant differences in bleeding between those who had gauze removed at 6h when compared to those removed at 24h (p =0.42), 12h (p =0.22) or without gauze (p =0.42). There was no significant difference in pain (p =0.27) or bleeding (p =0.07) between the 12h group or the no gauze group.

Discussion
Post operative dressing removal after circumcision can be a source of pain and bleeding for the infant, anxiety for the parent, and difficulty and frustration for medical staff. Though rare, there have been case reports of more serious complications attributed to post-operative dressings. Craig et al. (1994) reported a case of obstructive uropathy and subsequent bladder dysfunction secondary to compression and edema caused by the post-circumcision dressing. Shulman et al. (1964) reported a similar case of obstructive uropathy attributed to a constricting dressing as well as a case of pressure necrosis and urethral fistula developing when a dressing was left in place for several months following circumcision. These complications, while infrequent, can lead to serious morbidity.

There are varying practices in post-circumcision wound care but no published national standards or guidelines. A literature review revealed that little attention is paid to the topic despite the common nature of this procedure. Petroleum gauze is a common dressing used by pediatricians following circumcision and is thought to aid in hemostasis and prevent irritation from the diaper in the immediate post-circumcision period. To the best of our knowledge there is no published literature to support this.

A 1996 study of 50 subjects in Glasgow showed increased psychological distress, bleeding, and infection in boys aged <1 year to 13 who had petroleum gauze dressings placed following circumcision when compared to no dressing (Freeland 1996). This study did not specify the method(s) used to perform the procedure, nor did it mention how long the dressing was left in place. Gough and Lawton  (1990) compared paraffin tulle to antibiotic-impregnated tulle and benzoin soaked tulle in 159 children who had undergone circumcision. They found delayed healing in the benzoin group and no benefit from using an antibiotic dressing compared to paraffin alone. They raised the question of whether any dressing at all was necessary. Numerous other reviews and technical papers have described the application of petroleum, paraffin, iodine, or antibiotic impregnated gauze to the glans after circumcision for a period ranging from 12-48 hours (Elder 2007, Lukong et al. 2012, Holman et al. 1995, Molokwa 2104) but did not comment on the utility or efficacy of these dressings.

The results of our study show no difference in bleeding, pain, or infection in patients who had petroleum gauze dressings removed at 12 or 24 hours compared to those who had petroleum jelly alone. There was significantly more pain noted for boys who had dressings removed at 6 hours compared to all other patients. This finding may be due to the fresh nature of the wound and/or the half life of the anesthetic used.

Given that there was no significant difference in bleeding, pain, or infection observed among the 12 hour, 24 hour, and petroleum jelly alone group, we propose that forgoing a dressing in favor of petroleum jelly alone is a favorable option after neonatal circumcision. In our institution, there was a great deal of satisfaction from parents, nursing staff, and physicians when using petroleum jelly alone. Practical drawbacks observed with using a gauze dressing were avoided and there was no increase in pain, bleeding, or infection. A larger study group with longer follow up and greater subjectivity would be beneficial in promoting this practice in other institutions, however, the results of our study were sufficient to alter the practice at our institution with excellent clinical results in the years following.

This study has several limitations. Our design was neither randomized nor blinded due to the nature of the study question and the data collection. The data collection was subjective to the nurse completing the evaluation. While NIPS is the most standardized tool available for evaluating neonatal pain, it is not possible to differentiate distress caused from circumcision pain from agitation caused by diaper changing or another source. Infant temperaments are highly variable which may have led to collection bias. Our sample size was relatively small although comparable to the only other study completed on this topic. Finally, the study had limited follow up as patients were discharged from the newborn nursery soon after the dressing was removed, limiting our knowledge of complications that may have arisen after discharge.  

Table 1.
Frequency of pain, bleeding, and infection among patients with dressing removed
at 6, 12, 24 hours and those without a dressing


Time Dressing Removed

n

Pain (%)

Bleeding (%)

Symptoms of Infection

24 hours

26

3   (11)

2  (7)

0

12 hours

27

6   (22)

7 (25)

0

6 hours

52

28 (53)

7 (13)

0

No dressing

27

3   (11)

2  (7)

0

Total

132

40

18

0

Conclusion
In the present administrative study, no statistically significant difference was found in pain, bleeding, or infection between patients who had petroleum jelly alone applied following circumcision and those who had petroleum gauze applied and removed at 12 hours and 24 hours. These findings combined with the clinical drawbacks observed with using petroleum gauze have led to a change in practice at our institution. The use of petroleum jelly alone without a gauze dressing has been met with great satisfaction on the part of nursing, parents, and physicians at Doctor’s Hospital. Further research with a larger sample size, longer follow-up, and randomization is needed to fully compare outcomes and complication rates between these methods.

References:

American Academy of Pediatrics Task Force on Circumcision. (2102). Male Circumcision. Pediatrics, 130, e756-e784.

Abdoulwahab-Ahmed A and Mungadi I. (2013).Techniques of Male Circumcision. Surg Tech Case Rep,  5(1), 1-7.

Centers for Disease Control and Prevention. (2011). Trends in in-hospital newborn male circumcision- United States. MMWR Morb Mortal Wkly Rep, 60(34), 1167-1168.

Chen C, Zhang Q, Xi  ZJ, et al. (2011). Nanometer silver dressing alleviates pain after circumcision. Zhongua Nan Ke Xue ,17(3), 261-263.

Craig JC, Grigor WG, Kinght JF. (1994). Acute obstructive uropathy- a rare complication of circumcision. Eur J Pediatr 153, 369-371.

Elder J. (2007). Circumcision. BJU International, 99 (6).

Freeland, A. (1996). Vaseline gauze dressings after circumcision. Paediatric Nursing, 8(3), 23-26.

Gough DC and Lawton N. (1990). Circumcision-which dressing? British Journal of Urology, 65(4), 418-419.

Holman JR, Lewis EL, Ringler RL. (1995). Neonatal circumcision techniques. American Family Physician, 52(2), 511-520.

Lawrence j, Alcock D, McGrath P, et al. (1993). The development of a tool to assess neonatal pain. Neonatal Network, 12(6) 59-66.

Lukong CS. (2012). Dorsal slit-sleeve technique for male circumcision. J Surg Tech Case Rep, 4(2), 94-97.

Molokwu CN, and Peracha AM. (2104) Securing the dressing after circumcision in adults. Annals of the Royal College of Surgeons of England, 92(2), 170.

Shulman J, Ben-Hur N, Neumar Z. (1964). Complications of circumcision. American Journal of Diseases of Children, 170(2), 149-154.

Weismiller D. (2014). Techniques for neonatal circumcision. Up To Date Retrieved from http://www.uptodate.com/contents/techniques-for-neonatal-circumcision?source=search_result&search=circumcision
&selectedTitle=1%7E69

_______________________

Prevalence of Bed Sharing and Associated
Factors in an At-Risk Population

S. Humpula-McMahon, DO*
C. Petroff, MD*
S. Szpunar, PhD**

*Department of Pediatrics
**Department of Medical Education
St. John Providence Children’s Hospital
Detroit, MI

Abstract:
Background:  Sleep-related deaths are the leading cause of post-neonatal mortality in infants 28 days to one year of age. In 1992, the American Academy of Pediatrics (AAP) initiated the Back to Sleep campaign, which reduced the rate of Sudden Infant Death Syndrome (SIDS).  Sleep-related deaths from other causes, however, have increased.  Because bed-sharing plays a major role in sleep related death, in 2011, the AAP expanded their Safe Sleep guidelines, to include recommendations for the use of a firm sleep surface, room-sharing without bed sharing, and avoidance of infant overheating. So far, there have been no studies evaluating the impact of these guidelines.

Objectives:  1) To determine the prevalence of bed sharing in a high risk population; 2) to identify demographic, personal, and environmental factors associated with bed-sharing; and 3) to determine the impact of education on bed sharing.

Methods: From 1/14/2014 to 3/3/2014 at the St. John Children’s Center Resident Clinic, parents were asked to complete an anonymous survey during regularly scheduled newborn, 2-, 4- and 6-month well visits. We collected demographics for the parent and child, type and timing of Safe Sleep education, and sleep practices (including infant sleep site, bed type, presence of and reasons for bed-sharing). Data were analyzed using the Chi-squared test and Student’s t-test.

Results:  167 parents completed the survey. Mean parental age was 25.8 ± 6.5 years; mean infant age was 3.0 ± 2.2 months; 51.8% of the infants were female and 81.8% were Black.  The prevalence of bed sharing was 19% (32/163).  There were no significant associations between bed sharing and any demographic or personal characteristics assessed. When evaluating education received,  24% of parents who remembered getting information from the resident or pediatrician in the hospital practiced bed sharing compared to 11.5% who did not recall such education (p=0.05). Reasons for bed sharing included better sleep (40.6%), monitoring (25.0%), and other factors, such as environmental reasons (e.g. a broken window).

Conclusions:  The 19% bed sharing rate in our study was lower than that reported in national studies carried out prior to 2011. The low recall rate of bed sharing education and the higher rate of bed sharing reported among parents who did remember suggests that new parents may not be absorbing the negative aspects of bed sharing during the information overload occurring at initial newborn discharge. Information about bed sharing should be reinforced at all infant clinic visits.

Introduction: Sudden infant death syndrome (SIDS) is a cause which is assigned to infant deaths that are unexplainable even after a thorough case investigation, including scene investigation, autopsy, and review of the clinical history.(1,2,3)  In contrast, the terms “sudden unexplained infant death” (SUID), or “sudden unexpected death in infancy” (SUDI), can be used to describe any sudden, unexpected infant death which may be explained or unexplained.  Common causes of SUID may include asphyxia, suffocation, entrapment, infection, metabolic diseases, ingestions, and accidental or non-accidental trauma.(1)

The pathogenesis of SIDS has been proposed to be a combination of three factors. The first is exogenous “stressors” including prone sleep position, over bundling, and airway obstruction. The second factor in SIDS, which is most common before six months of age, is that it occurs during a critical period of development. The third factor is the infant’s dysfunctional or immature cardiorespiratory and arousal systems which lead to a failure of protective responses in the infant. The convergence of these factors results in progressive asphyxia, bradycardia, hypotension, metabolic acidosis, and ineffectual gasping, all of which lead to death.(1)

In 1992, the American Academy of Pediatrics (AAP) recommended that all infants be placed in a non-prone position to sleep in an attempt to reduce the incidence of SIDS; a number of epidemiologic studies identified prone sleep position as a major risk factor.  In 1994, the “Back to Sleep” campaign was initiated.(1,2)  Between 1992 and 2001, following the initiation of these recommendations, the incidence of SIDS declined with the most rapid rate of decline occurring in the first years following the initial non-prone sleeping recommendation.(1)  In the US alone, the rate of SIDS decreased from approximately 120 deaths per 100,000 live births in 1992 to 56 deaths per 100,000 live births in 2001. Since 2001, the incidence of SIDS has remained constant, and SIDS still remains the third-leading cause of infant mortality and the leading cause of postneonatal mortality in children age 28 days to one year.(1,2,5)  While the incidence of SIDS has plateaued, the rate of other causes of SUID occurring during sleep has increased. Most notably, the incidence of accidental suffocation and strangulation in bed quadrupled between 1984 and 2004.(1,4) This increase in SUIDs has provoked researchers to further investigate additional factors which increase infants’ risk for sleep related infant death.(1)

One factor, in particular, that has been found to play a significant role in sleep related infant death is parent-infant bed-sharing, especially in the presence of parental smoking.(5,6)  Bed-sharing is a specific type of co-sleeping in which the infant shares the same sleep surface with another person. The AAP reported an increasing prevalence of bed-sharing rates in 2005 and increasing death rates in 2011, “particularly while bed-sharing and/or sleeping on a couch or armchair”.(7)  It is estimated that approximately half of all sudden and unexpected infant deaths in the United States occur when an infant is sharing a sleep surface with someone else.(4) Currently, the AAP recommends room-sharing without bed-sharing for all infants until 6 months of age. Evidence has shown room-sharing to decrease the incidence of SIDS by an estimated 50% by facilitating closer monitoring of the infant by the parents. In contrast, bed-sharing increases the infant’s risk of suffocation, strangulation, and entrapment.(1,3)  Epidemiologic studies have also shown bed-sharing to increase an infant’s risk of over-heating, rebreathing or airway obstruction, head covering, and exposure to tobacco smoke. Additionally, bed-sharing in an adult bed can be hazardous in that adult beds generally do not meet the same safety standards as those designed for infants. Adult beds also pose an increased risk of accidental injuries, such as falls, to the infant.(1)  In 2011, the AAP expanded its Safe-Sleep guidelines to include not only supine sleep positioning and room-sharing without bed-sharing, but also the use of a firm sleep surface, breastfeeding, routine immunization, consideration of a pacifier, avoidance of soft bedding and overheating, and avoidance of exposure to tobacco smoke, alcohol, and illicit drugs. 

Despite the known risks of bed-sharing, a national survey found parent-infant bed-sharing to be a relatively common practice with 45% of parents stating that they had shared a bed with their infant who was eight months of age or younger at least once in the two weeks prior to the survey being conducted.(1)  It has been suggested that this rate may be even higher in some racial/ethnic groups. Some studies have shown that the incidence of bed-sharing in non-Hispanic black infants is nearly double that of non-Hispanic white infants.  While the reasons behind bed-sharing are personal and may have a significant cultural influence, it has been suggested that they probably include convenience for feeding, which results in maximizing sleep for both the mother and infant, as well as the perception of facilitation of bonding with the baby. Some parents may even believe that they can be more vigilant of their infant by bed-sharing.(1) Our study sought to evaluate the prevalence of bed-sharing in an urban pediatric residency clinic with a primarily African American population, which is known to be at higher risk, as well as identify any demographic, personal, or environmental factors associated with the practice of bed-sharing. The impact of safe-sleep anticipatory guidance education received, with specific focus on the type and timing of education received, was also evaluated.

Methods & Materials: 
This was a single site descriptive survey conducted at St. John Children’s Center resident clinic in Detroit, Michigan from January 14, 2014 through March 3, 2014. Surveys were given to the parents/guardians of all infants seen for regularly scheduled newborn, two-month, four-month, and six-month-old well visits irrespective of the infant’s age. Infants in the previously described age group who were seen for visits other than well visits (e.g. sick visits or follow-up visits) were excluded from the study. 

Data collected in the survey included demographic data such as the age of the infant and parent/guardian, race, ethnicity, birth history, gender of each patient, socioeconomic status, as well as inquiries regarding each family’s current sleep practices and preferences for means of education about sleep safety. This included previous and current sleep location of the infant, bedding items present in each infant’s sleep space, bedding type, presence of bed-sharing, primary parental reasoning for choosing to bed-share if bed-sharing is a current practice, and the type and timing of Safe Sleep education received by the family if any.

Eligible survey participants were provided with an envelope at the beginning of their well visit appointment containing the blank survey as well as an informational letter describing the study. Participants were asked to complete the survey prior the end of their visit, and, after completion, seal it in the envelope provided and return it to the clinic staff at check out. Survey completion was entirely voluntary, and survey answers/participation did not affect the quality of care provided. No personal identifying data in the form of patient names, dates of birth, or patient identification numbers were collected as a part of the survey. By standard well visit prompts, parents/guardians were asked about sleep practices during the anticipatory guidance portion of their visit. By this means, bed-sharing families were identified and appropriately counseled without compromising the anonymity of the collected surveys. IRB approval was obtained prior to initiation of the study.

Data collected from the surveys was compiled into an Excel document and then processed using descriptive statistics to characterize the study population. Survey responses were summarized using frequency distributions, means, and medians. Associations between survey responses and ages of the infants were assessed using the chi-squared test, and all data was analyzed using SPSS v. 2.0.  A p-value of 0.05 or less was considered to be statistically significant. 

Results: As shown in Table 1, a total of 167 surveys were collected during the study period. The mean parental age was 25.8±6.5 years, and the mean infant age was 2.97±2.2 months. Female infants comprised 51.8% of the study population, and 81.8% identified themselves as Black.

Study Population  (N=167)

Characteristic

Mean or %

Parental age (yrs)

 25.8±6.5

Infant age (mos)

2.97±2.2

Visit type

     Newborn

28.5%

     2 Months

30.9%

     4 Months

23.0%

     6 Months

17.6%

Infant gender

     Male

48.2%

     Female

51.8%

Race

     Black

81.8%

     White

13.9%

     Other

4.2%

Table 1. Study population demographics

            A total of 165 survey participants completed the question assessing the practice of bed-sharing, and the prevalence of bed-sharing was reported to be 19% as is demonstrated in Figure 1 below.

Figure 1 

Figure 1. Prevalence of Bed-Sharing
The prevalence of bed-sharing was compared to various demographic factors including parental age, infant age, visit type, infant birth weight, gestational age, and race (Table 2).  We also compared with the highest level of education achieved by the parent/guardian completing the survey, as well as the birth order of the infant (Table 3).  None of these comparisons showed a statistically significant difference between those families who reported bed-sharing and those who did not.

Table

Table 2.  Prevalence of bed-sharing compared with parental age, infant age, visit type, birth weight, gestational age, and race

Table

Table 3.  Prevalence of bed-sharing compared with educational level of parent/guardian and birth order of the infant
When evaluating the type and timing of safe sleep education received by each family (Table 4), we found that 24% of parents who remembered getting information from the resident or attending pediatrician in the hospital after delivery practiced bed-sharing compared to 11.5% who did not recall such education.  This was statistically significant with p=0.049.

Table

Table 4.  Prevalence of bed-sharing compared with type and timing of safe sleep education received
Parents were also asked about the primary reasons they choose to bed-share.  Here we found the most commonly reported reason to be better sleep for either the infant or parent (40.6%) followed by a perceived ability of the parent to better monitor the infant by bed-sharing (25.0%) (Graph 1).  Additional reasons included increased ease of feeding and environmental reasons.  One family reported not having a crib for their infant, and another stated that there was a broken window in the infant’s room leading them to bed-share.

Graph

Graph 1.  Primary reasons reported for bed-sharing

Discussion:
The 19% bed-sharing rate in our study was lower than the rate of 45% reported in national studies carried out prior to 2011, despite our patient population being predominantly black, a population known to be at higher risk. The vast majority of families surveyed were able to recall receiving education regarding safe sleep at some point during the newborn period.  Therefore, the lower rate of bed-sharing in our study may possibly be attributed to the high rates of education provided to our patient families.
 
With regard to the statistically significant higher rate of bed-sharing in families who recalled receiving safe sleep education from either the resident or attending pediatrician during the post-partum period in the hospital as compared to those who did not, we postulate a couple of reasons.  These families may have been found to already be bed-sharing while still in the hospital, prompting the physician to discuss safe sleep recommendations with them more so than families who were not found to be bed-sharing.  Also, if these families were already bed-sharing early on in the post-partum period, they may have been more inclined to continue to do so later on in the newborn/infancy period.

Ultimately, provision of safe sleep education to families at multiple points during the post-partum/newborn period was observed to be successful at decreasing the prevalence of bed-sharing and should be reinforced at all infant clinic visits.  In the future, we recommend further studies with a larger population base be conducted to confirm the validity of our findings.  It would also be beneficial to assess in those families found to be bed-sharing whether there would be any different interventions that could be taken by the pediatrician to assist in changing this behavior.  However, this might better be assess during a face-to-face interview with families as opposed to survey format as not enough families were willing to complete this portion of our survey to make any kind of accurate assessment. 

Acknowledgements:
We would like to thank all of the staff and patients of the St. John Children’s Center Resident Clinic for their help in distributing and completing the surveys. 

References

  1. SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment (2011). Pediatrics 128(5):e1341-e1367
  2. Lisa B.E. Shields, Donna M. Hunsaker, Susan Muldoon, Tracey S. Corey, & Betty S. Spivack (2005) Risk Factors Associated With Sudden Unexplained Infant Death: A Prospective Study of Infant Care Practices in Kentucky.  Pediatrics 116(1):e13-e20
  3. Christine A. Ateah & Kathy J. Hamelin (2008) Maternal Bedsharing Practices, Experiences, and Awareness of Risks. JOGNN 37(3):274-281
  4. Rachel Y. Moon, Rosalind P. Oden, Brandi L. Joyner, & Taiwo I. Ajao (2010) Qualitative Analysis of Beliefs and Perceptions about Sudden Infant Death Syndrome in African-American Mothers: Implications for Safe Sleep Recommendations. The Journal of Pediatrics 157(1):93-97
  5. Linda Y. Fu, Eve R. Colson, Michael J. Corwin, & Rachel Y. Moon (2008) Infant Sleep Location: Associated Maternal and Infant Characteristics with Sudden Infant Death Syndrome Prevention Recommedations. The Journal of Pediatrics, October 2008:503-508
  6. Mechtild M. Vennemann, Hans-Werner Hense, Thomas Bajanowski, et al (2012) Bed Sharing and the Risk of Sudden Infant Death Syndrome: Can We Resolve the Debate?. The Journal of Pediatrics 160(1):44-48
  7. Sharon Hitchcock (2012) Endorsing Safe Infant Sleep A Call to Action. Nursing for Women’s Health 16(5):388-396

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