Breastfeeding the very preterm hospitalized infant: An ethnographic study

Purpose. To develop a greater understanding of the experience—including the thoughts, feelings, and actions—of mothers' initiation and maintenance of lactation within the context of the NICU following the birth of a very preterm infant. ^ Design. Mixed method with dominant focused ethnographic approach. Setting: A 76-bed neonatal intensive care unit in the largest children's hospital located in a large metropolitan city in southeast Texas. ^ Sample. Purposeful sampling resulted in 23 interviews with 14 subjects. ^ Methods. Mixed method design with a dominant qualitative approach combined with a quantitative component to further identify and expand upon the investigation of the population in question. Open-ended semi-structured interviews and fieldwork were used to explore the experience of breastfeeding in the context of the NICU for mothers of very preterm infants. Longitudinal data obtained from each subject included in-depth interviews, demographic and clinical information, milk expression patterns (including pumping frequency, duration, and milk volumes obtained), and scores obtained from the Edinburgh Postpartum Depression Scale (EPDS). ^ Findings. Thematic analysis revealed that mothers of very preterm infants experienced an interruption in the process of becoming a mother, a paradoxical experience related to aspects of their milk expression routines and patterns, and negotiating the NICU environment. Sub-themes of becoming a mother-interrupted included: attribution, separation, connection, and navigation. Additional sub-themes related to the paradoxical experience included: the pump sometimes acting as a wedge or link to the infant; diversionary thoughts/activities during pumping; and perceptions of milk flow/volume. The process of negotiation included the environment, adaptive/maladaptive strategies related to milk expression, motivating factors related to the provision of breast milk, and learning their infant's feeding cues/abilities. EPDS scores did not reveal congruent differences in those mothers scoring high compared to those scoring low. ^ Conclusions. Understanding the experiences of the mothers in this study allows for a better perspective of breastfeeding the very preterm infant in the context of the NICU. Findings from this study validate the difficult and incremental process of attaining maternal identity and the significant burden placed on these women with regards to the provision of breast milk and breastfeeding during their infant's hospitalization. ^

Defining barriers in caring for seriously-ill children in a resource-limited setting: An observational study of 2 children's hospitals in Haiti

Background. According to the WHO 2007 country report, Haiti lags behind the Millennium Development Goal of reducing child mortality and maintains the highest under-5 mortality rate in the Western hemisphere. 3 Overall, few studies exist that seek to better grasp barriers in caring for a seriously ill child in a resource-limited setting and only a handful propose sustainable, effective interventions. ^ Objectives. The objectives of this study are to describe the prevalence of serious illnesses among children hospitalized at 2 children's hospitals in Port au Prince, to determine the barriers faced when caring for seriously ill children, and to report hospital outcomes of children admitted with serious illnesses. ^ Methods. Data were gathered from 2 major children's hospitals in Port au Prince, Haiti (Grace Children's Hospital [GCH] and Hopital d l'Universite d'Etat d'Haiti [HUEH]) using a triangulated approach of focus group discussions, physician questionnaires, and retrospective chart review. 23 pediatric physicians participated in focus group discussions and completed a self-administered questionnaire evaluating healthcare provider knowledge, self-efficacy, and perceived barriers relating to the care of seriously ill children in a resource-limited setting. A sample of 240 patient charts meeting eligibility criteria was abstracted for pertinent elements including sociodemographics, documentation, treatment strategies, and outcomes. Factors associated with mortality were analyzed using χ2 test and Fisher exact test [Minitab v.15]. ^ Results. The most common primary diagnoses at admission were gastroenteritis with moderate dehydration (35.5%), severe malnutrition (25.8%), and pneumonia (19.3%) for GCH, and severe malnutrition (32.6%), sepsis (24.7%), and severe respiratory distress (18%) for HUEH. Overall, 12.9% and 27% of seriously ill patients presented with shock to GCH and HUEH, respectively. ^ Shortage of necessary materials and equipment represented the most commonly reported limitation (18/23 respondents). According to chart data, 9.4% of children presenting with shock did not receive a fluid bolus, and only 8% of patients presenting with altered mental status or seizures received a glucose check. 65% of patients with meningitis did not receive a lumbar puncture due to lack of materials. ^ Hospital mortality rates did not differ by gender or by institution. Children who died were more likely to have a history of prematurity (OR 4.97 [95% CI 1.32-18.80]), an incomplete vaccination record (OR 4.05 [95% CI 1.68-9.74]), or a weight for age ≤3rd percentile (OR 6.1 [95% CI 2.49-14.93]. Case-fatality rates were significantly higher among those who presented with signs of shock compared with those who did not (23.1% vs. 10.7%, RR=2.16, p=0.03). Caregivers did not achieve shock reversal in 21% of patients and did not document shock reversal in 50% of patients. ^ Conclusions. Many challenges face those who seek to optimize care for seriously ill children in resource-limited settings. Specifically, in Haiti, qualitative and quantitative data suggest major issues with lack of supplies, pre-hospital factors, including malnutrition as a comorbidity, and early recognition and management of shock. A tailored intervention designed to address these issues is needed in order to prospectively evaluate improvements in child mortality in a high-risk population.^

A case-control study of medication-associated acute kidney injuries in hospitalized pediatric patients

Acute kidney Injury (AKI) in hospitalized pediatric patients can be a significant event that can result in increased patient morbidity and mortality. The incidence of medication associated AKI is increasing in the pediatric population. Currently, there are no data to quantify the risks of developing AKI for various potentially nephrotoxic medications. The primary objective of this study was to determine the odds of nephrotoxic medication exposure in hospitalized pediatric patients with AKI as defined by the pediatric modified pRIFLE criteria. A retrospective case-control study was performed with patients that developed AKI, as defined by the pediatric pRIFLE criteria, as cases, and patients without AKI as controls that were matched by age category, gender, and disease state. Patients between 1 day and 18 years of age, admitted to a non-intensive care unit at Texas Children's Hospital for at least 3 days, and had at least 2 serum creatinine values drawn were included. Patient data was analyzed with Student's t test, Mann-Whitney U test, Chi square analysis, ANOVA, and conditional logistic regression. ^ Out of 1,660 patients identified for inclusion, 561 (33.8%) patients had AKI, and 357 cases were matched with 357 controls to become pairs. Of the cases, 441 were category 'R', 117 category 'I', 3 patients were category 'F', and no patient died. Cases with AKI were significantly younger than controls (p < 0.05). Significantly longer hospital length of stays, increased hospital costs, and exposure to more nephrotoxic medications for a longer period of time were characteristics of patients with AKI compared to patient without AKI. Patients with AKI had greater odds of exposure to one or more nephrotoxic medication than patients without AKI (OR 1.3, 95% CI 1.1–1.4, p < 0.05). Percent changes in estimated creatinine clearance (eCCl) from baseline were greatest with increased number of nephrotoxic medication exposures. ^ Exposure to potentially nephrotoxic medications may place pediatric patients at greater risk of acute kidney injury. Multiple nephrotoxic medication exposure may confer a greater risk of development of acute kidney injury, and result in increased hospital costs and patient morbidity. Due to the high percentage of patients that were exposed to potentially nephrotoxic medications, monitoring and medication selection strategies may need to be altered to prevent or minimize risk.^