American Academy Of Pediatrics Recommendations Research Articles

Stock Photographs Do Not Comply With Infant Safe Sleep Guidelines

We evaluated images in popular stock photography websites for adherence with American Academy of Pediatrics (AAP) guidelines for safe infant sleep practices. Three top stock photo websites were used to collect photographs generated from key phrases. All images depicting an infant sleep environment were analyzed for consistency with AAP guidelines. Descriptive statistics, chi-square and z test of proportions, were conducted. A total of 1233 of 1947 stock photographs showed sleeping infants on a flat surface. In all, 627 (50.8%) photographs showed the infant in the supine position and 79 (5%) of all infant sleep environments were adherent with AAP recommendations. Bedding inconsistent with safe sleep recommendations was identified in 1133 images (71.3%), with blankets noted in 49.5%. Images depicting sleeping infants on stock photography sites do not routinely adhere to AAP recommendations. Media messages inconsistent with health care messages create confusion and misinformation about infant sleep safety and may lead inadvertently to unsafe practices.

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OBJECTIVES/SPECIFIC AIMS: The American Academy of Pediatrics (AAP) recommends that preschool-aged children spend no more than 2 hours/day using digital screens such as TVs. However, there is a proliferation of digital screens in children’s daily lives both at school and at home. The purpose of this study was to examine factors that contribute to children’s screen-time, including their demographic characteristics and whether or not they have screen-time at school. METHODS/STUDY POPULATION: In total, 59 children (3.3±0.4 years of age; 47% female) enrolled in 3 child care centers participated. Center directors reported school screen-time; 1 center was classified as not providing screen-time and 2 centers were classified as providing screen-time. Parents reported child’s age, sex, and maternal education as a proxy for socio-economic status. Parents reported child’s out-of-school screen-time by responding to the question “During the past 30 days, on average how many hours per day did your child sit and watch TV or videos outside of school?” Additional questions queried how many hours per day did the child “use a computer or play computer games,” “play video games,” “use a smartphone,” and “use an iPad or tablet.” Children’s height and weight were collected using standard clinic procedures and body mass index (BMI) was calculated. T tests were used to examine differences in screen-time by age, sex, and school screen-time. General linear models were used to examine the influence of school screen-time (1=no screen-time, 0=between 1 and 60 min/day of screen-time), age, BMI, and maternal education on out-of-school screen-time and time spent with each device. Logistic regression analysis was used to examine likelihood of meeting screen-time recommendations based on the same characteristics. RESULTS/ANTICIPATED RESULTS: Parent-reported total screen-time was 6.3±3.6 hours/day (h/d); specifically, 2.5±1.1 h/d watching TV, 1.5±2.2 h/d using a smartphone, 1.1±0.9 h/d using a tablet, 0.8±1.0 h/d on a computer, and 0.5±0.7 h/d playing video games. Based on total screen-time, 15% of children met AAP recommendations; based on TV viewing only, 52% met AAP recommendations. The 4-year-old children viewed more screen-time overall compared to the 3-year-old children including on TV, computer, and tablet (p<0.05), but there were no sex differences. In fully adjusted linear models, out-of-school screen-time was lower among those who had no screen-time at school (p=0.02) and higher among older children (p<0.01). Computer use was higher among older children (p=0.02). Older children and those with lower maternal education were less likely to meet clinical recommendations based on TV viewing (p<0.05). There were no observed associations with likelihood of meeting clinical recommendations based on total screen-time. BMI was not a significant predictor of screen-time. DISCUSSION/SIGNIFICANCE OF IMPACT: The majority of children exceeded AAP screen-time limits, with screen-time sharply higher among older children, and the associations did not vary by weight status. Children who attended schools that allowed screen-time had higher amounts of out-of-school screen-time. Pediatricians and healthcare providers should query parents on children’s screen-time practices at home and at school and offer strategies to help families meet the clinical recommendations.

Improvements in Infant Sleep Position: We Can Do Better!

* Abbreviations: AAP — : American Academy of Pediatrics SIDS — : sudden infant death syndrome SUID — : sudden unexpected infant death On the basis of the New Zealand Cot Study and European data, in 1992 the American Academy of Pediatrics (AAP) recommended that infants no longer sleep in the prone position.1 By 1994, the National Institutes of Health, with other stakeholders, introduced the Back to Sleep campaign. Over the next 10 years, the sudden infant death syndrome (SIDS) rate in the United States fell 53%, correlating with an increase in exclusive supine sleep from <10% to 78%.2 The AAP considers this 1 of the 7 great achievements in pediatric research in the last 40 years.3 But since 2002, the story has become more complicated. The AAP recommendations evolved to back is better than side and then back only in 2005. Other risk factors emerged, such as soft bedding and bed-sharing, and the education campaign became Safe to Sleep in 2012.4 And although the incidence of SIDS continued to decline, other deaths (including accidental suffocation and strangulation in bed and undetermined deaths) began to increase, suggesting a possible “diagnostic coding shift.”5 These sleep-related deaths became … Address correspondence to Michael Goodstein, MD, Office of Newborn Medicine, York Hospital, 1001 S. George St, York, PA 17403. E-mail: mgoodstein{at}wellspan.org

Noise in the Neonatal Intensive Care Unit: What Does the Evidence Tell Us?

In 2014, more than 10% of all births in the United States were preterm (born at <37-weeks' gestation). These high-risk infants will often spend weeks to months within the neonatal intensive care unit (NICU), where noise levels can easily reach 120 decibels adjusted (dBA) on a regular and sometimes consistent basis. The American Academy of Pediatrics recommends that NICU sound levels remain below 45 dBA to promote optimal growth and development. The purpose of this evidence-based brief is to critically appraise the literature concerning preterm infant response to noise within the NICU as well as the use of noise interventions to improve health outcomes for the vulnerable preterm infant population. Systematic searches of databases included the Cochrane Library, CINAHL, PubMed, and Science Direct. Included studies were appraised and then synthesized into a narrative summary. Twenty studies met inclusion criteria for this review. While there are numerous methods that have been shown to reduce noise levels within the NICU, most NICU noise levels remain consistently above the American Academy of Pediatrics recommendations. Studies that assessed interventions found that staff reeducation was critical to sustaining appropriate noise levels. Implementing interventions with rigorous attention to initial and continued staff education with engagement and ownership is recommended. This review identifies gaps in intervention studies targeting vulnerable NICU populations. While noise interventions show promise in the NICU, additional focused research is needed to further strengthen the evidence and inform clinical practice.

What Do Pediatricians Tell Parents About Bed-Sharing?

Background and objectives Despite the risks of bed-sharing, little is known about what pediatricians tell parents about bed-sharing with infants and whether pediatricians provide specific recommendations outlined by the American Academy of Pediatrics (AAP). This study aimed to understand pediatricians' opinions about bed-sharing and the advice pediatricians provide to parents about bed sharing. Methods The study employed a qualitative study design and the conceptual framework of the Theory of Planned Behavior. 24 primary care pediatricians from a variety of practice settings were interviewed about the anticipatory guidance they provide to families whose infants are in the at-risk age group for SIDS. Results Pediatricians' opinions about bed-sharing differed widely both with respect to identifying bed-sharing as a topic they routinely address in anticipatory guidance as well as in what they tell parents about bed sharing. Some strongly and routinely advise against bed-sharing and identify bed-sharing as a clear risk to infants. Others believe bed-sharing to be both safe and useful. A third group allow the content of anticipatory guidance to be driven by parental concerns. Most pediatricians are clearer in their recommendation to place infants supine to sleep than in their recommendation to avoid bed-sharing. Conclusions Overall, there is considerable variation among pediatricians in the advice they provide about bed-sharing, and most advice is not congruent with the AAP recommendations. Additional efforts to educate pediatricians may be necessary to change attitudes and behaviors with respect to anticipatory guidance about safe sleep.

Later School Start Times: What Informs Parent Support or Opposition?

To investigate parental knowledge about adolescent sleep needs, and other beliefs that may inform their support for or objection to later school start times. In 2014, we conducted a cross-sectional, Internet-based survey of a nationally representative sample of parents as part of the C.S. Mott Children's Hospital National Poll on Children's Health. Parents with teens aged 13-17 years reported their children's sleep patterns and school schedules, and whether the parents supported later school start times (8:30 am or later). Responses associated with parental support of later school start times were examined with logistic regression analysis. Overall, 88% of parents reported school start times before 8:30 am, and served as the analysis sample (n = 554). In this group, 51% expressed support for later school start times. Support was associated with current school start times before 7:30 am (odds ratio [OR] = 3.1 [95% confidence interval (CI) 1.2, 8.4]); parental opinion that their teen's current school start time was "too early" (OR = 3.8 [1.8, 7.8]); and agreement with American Academy of Pediatrics recommendations about school start times (OR = 4.7 [2.2, 10.1]). Support also was associated with anticipation of improved school performance (OR = 3.0 [1.5, 5.9]) or increased sleep duration (OR = 4.0 [1.8, 8.9]) with later school start times. Conversely, parents who anticipated too little time for after-school activities (OR = 0.5 [0.3, 0.9]) and need for different transportation plans (OR = 0.5 [0.2, 0.9]) were often less supportive. Parental education about healthy sleep needs and anticipated health benefits may increase their support for later school start times. Educational efforts should also publicize the positive experiences of communities that have made this transition, with regard to limited adverse effect on after-school activity schedules and transportation.

Nursing Students' Knowledge and Attitudes Toward Infant Sleep Safety

This study evaluated nursing students' knowledge and beliefs of current American Academy of Pediatrics recommendations on Infant Safe Sleep (ISS). A questionnaire was distributed to accredited nursing programs. Responses were compared to evaluate student knowledge of safe sleep recommendations prior to and after pediatric/maternal child education. We reported that nursing students in associate's degree programs have significant gaps in their knowledge regarding ISS even after receiving training. In addition, associate's degree nursing students were less likely to agree with ISS guidelines and felt that their personal experiences as a parent or a caregiver were most helpful in learning about ISS. Curricula need to reflect the most recent evidence-based information on ISS so that students are adequately prepared to enter the workforce.

Prematurity and Sudden Unexpected Infant Deaths in the United States.

Prematurity, a strong risk factor for sudden unexpected infant death (SUID), was addressed in recommendations by the American Academy of Pediatrics in 2011 for safe sleep education in NICUs. We documented associations between gestational age (GA) and SUID subsequent to these guidelines. Using the 2012-2013 US linked infant birth and death certificate period files, we documented rates per live births of sudden infant death syndrome, ill-defined and unspecified causes, accidental suffocation and strangulation in bed, and overall SUID by GA in postneonatal, out-of-hospital, and autopsied cases; compared survivors and cases; and estimated logistic regression models of associations between GA and SUID. SUID cases were more likely than survivors to be <37 weeks' GA (22.61% vs 10.79%; P < .0001). SUID rates were 2.68, 1.94, 1.46, 1.16, 0.73, and 0.51 per 1000 live births for 24 to 27, 28 to 31, 32 to 33, 34 to 36, 37 to 38, and 39 to 42 weeks' GA, respectively. Logistic regression models additionally indicated declines in the risk for SUID as GA increased. Prenatal smoking, inadequate prenatal care, and demographics associated with poverty were strongly associated with SUID. Despite the 2011 American Academy of Pediatrics recommendations for increased safe sleep education in the NICUs, SUID rates were inversely associated with GA in 2012 to 2013, suggesting that risk of SUID associated with prematurity has multiple etiologies requiring continued investigation, including biological vulnerabilities and the efficacy of NICU education programs, and that strategies to reduce SUID should be multifaceted.

Sound levels in a neonatal intensive care unit significantly exceeded recommendations, especially inside incubators.

This study measured sound levels in a 2008 built French neonatal intensive care unit (NICU) and compared them to the 2007 American Academy of Pediatrics (AAP) recommendations. The ultimate aim was to identify factors that could influence noise levels. The study measured sound in 17 single or double rooms in the NICU. Two dosimeters were installed in each room, one inside and one outside the incubators, and these conducted measurements over a 24-hour period. The noise metrics measured were the equivalent continuous sound level (Leq ), the maximum noise level (Lmax ) and the noise level exceeded for 10% of the measurement period (L10 ). The mean Leq , L10 and Lmax were 60.4, 62.1 and 89.1 decibels (dBA), which exceeded the recommended levels of 45, 50 and 65 dBA (p<0.001), respectively. The Leq inside the incubator was significantly higher than in the room (+8dBA, p<0.001). None of the newborns' characteristics, the environment or medical care was correlated to an increased noise level, except for a postconceptional age below 32weeks. The sound levels significantly exceeded the AAP recommendations, particularly inside incubators. A multipronged strategy is required to improve the sound environment and protect the neonates' sensory development.

Vertebral fractures in children with Type I Osteogenesis imperfecta

To characterize clinically a cohort of children with OI type I. A cohort of OI type I children younger than 20 year old was evaluated. Demographic, clinical, biochemical and radiological data were registered. Sixty seven patients were included, 55% male, 69% resident in the Metropolitan Region. The mean age of diagnose was 2.9 years, 70% presented vertebral fractures on follow-up, mostly thoracic, and 50% before the age of 5 years. Fifty percentage presented vertebral fractures at diagnose, which was about the age of 5 years. Bone metabolic parameters were in the normal range, without significant change at the moment of vertebral fractures. Calcium intake was found to be below American Academy of Pediatrics recommendations at the time of the first fracture. In this study OI type I has an early diagnose, and vertebral fractures show a high incidence, mostly in toddlers. Calcium intake was found to be below reccomended values, and should be closely supervised in these patients.

Recommendations for Adopting the International Code of Marketing of Breast-milk Substitutes Into U.S. Policy.

In 1981, the World Health Organization adopted the International Code of Marketing of Breast-milk Substitutes ( International Code), with subsequent resolutions adopted since then. The International Code contributes to the safe and adequate provision of nutrition for infants by protecting and promoting breastfeeding and ensuring that human milk substitutes, when necessary, are used properly through adequate information and appropriate marketing and distribution. Despite the World Health Organization recommendations for all member nations to implement the International Code in its entirety, the United States has yet to take action to translate it into any national measures. In 2012, only 22.3% of infants in the United States met the American Academy of Pediatrics recommendation of at least 6 months of exclusive breastfeeding. Countries adopting legislation reflecting the provisions of the International Code have seen increases in breastfeeding rates. This article discusses recommendations for translating the International Code into U.S. policy. Adopting legislation that implements, monitors, and enforces the International Code in its entirety has the potential to contribute to increased rates of breastfeeding in the United States, which can lead to improved health outcomes in both infants and breastfeeding mothers.

Did the 2011 AAP recommendations on youth HIV testing change practice? Trends from a large urban adolescent program.

PurposeThe purpose of this study was to determine whether there is adherence to the October 2011 American Academy of Pediatrics (AAP) recommendations for HIV screening in a large urban adolescent program with availability of a publicly funded program providing free, confidential, sexually transmitted infection (STI) and HIV counseling and testing (then rapid or third generation HIV testing), nested in the same adolescent clinic.MethodsWe conducted a retrospective chart review of HIV screening trends among 13- to 24-year-old patients tested for HIV during periods of January 2010 to June 2011 (18 months pre-AAP recommendations period) and July 2011 to December 2012 (18-month period, which included 15 months after the AAP recommendations).ResultsDuring the period of January 2010 to June 2011, there were 22 tests/1,000 medical visits (N = 824 of 37,520 medical visits), and during the period of July 2011 to December 2012, there were 27 tests/1,000 medical visits (N = 1,068 of 38,763 medical visits) (p < 0.0001, odds ratio [OR] 1.26). The number of 13- to 18-year-old patients screened in the pre-AAP period was 150, compared to 297 in the second 18-month period (X 2 = 43.3, df = 1, p < 0.0001). A summative risk profile score of 0–9 was created in the form of a continuous variable, with a risk score of 0 for those with no risk factor identified and 1 point for each risk behavior identified. The proportion of HIV test clients with zero-specified risk (a risk score of “0”) increased from 2010 to 2012.ConclusionRelease of the 2011 AAP HIV testing guidelines was associated with a modest increase in HIV screening and a shift toward testing younger people and away from risk-based screening.

Sa2062 - The Use of a Computerized Provider Order Entry Alert to Decrease Rates of Clostridium Difficile Testing in Young Pediatric Patients

BACKGROUND Infants and young children are frequently colonized with C. difficile but rarely have symptomatic disease. However, C. difficile testing remains prevalent in this age group. OBJECTIVE To design a computerized provider order entry (CPOE) alert to decrease testing for C. difficile in young children and infants. DESIGN An interventional age-targeted before-after trial with comparison group SETTING Monroe Carell Jr. Children's Hospital at Vanderbilt University, Nashville, Tennessee. PATIENTS All children seen in the inpatient or emergency room settings from July 2012 through July 2013 (pre-CPOE alert) and September 2013 through September 2014 (post-CPOE alert) INTERVENTION In August of 2013, we implemented a CPOE alert advising against testing in infants and young children based on the American Academy of Pediatrics recommendations with an optional override. We further offered healthcare providers educational seminars regarding recommended C. difficile testing. RESULTS The average monthly testing rate significantly decreased after the CPOE alert for children 0-11 months old (11.5 pre-alert vs 0 post-alert per 10,000 patient days; P<.001) and 12-35 months old (61.6 pre-alert vs 30.1 post-alert per 10,000 patients days; P<.001), but not for those children ≥36 months old (50.9 pre-alert vs 46.4 post-alert per 10,000 patient days; P=.3) who were not targeted with a CPOE alert. There were no complications in those children who testing positive for C. difficile. CONCLUSIONS The average monthly testing rate for C. difficile for children <35 months old decreased without complication after the use of a CPOE alert in those who tested positive for C. difficile. Infect Control Hosp Epidemiol 2017;38:542-546.

The role of serial measurements of serum insulin-like growth factor 1 levels in the development of retinopathy of prematurity.

To determine the role of serum insulin-like growth factor-1 levels in the development of retinopathy of prematurity, which is a major cause of childhood blindness worldwide. We prospectively studied newborn infants born at a postmenstrual age of <32 weeks and birth weights <1 500 gr, between January 1st, 2015, and December 31st, 2015. A total of 40 infants were enrolled in the study. The retinal examination time was determined in accordance with the American Academy of Pediatrics recommendations for retinopathy of prematurity screening and follow-up. Retinopathy of prematurity was classified according to the international classification of retinopathy of prematurity. Serum Insulin like growth factor 1 levels were measured serially in blood samples on the 1st, 3rd, 7th, 21st, and 28th day. Among the 40 infants, 11 (27.5%) constituted the retinopathy of prematurity group and 29 comprised the non-retinopathy of prematurity group. In the retinopathy of prematurity group, the mean gestational age and birth weight was significantly lower. The demographic features of the study cohort were similar. The duration of mechanical ventilation was significantly greater in the retinopathy of prematurity group compared with the non-retinopathy of prematurity group (p=0.036). In terms of neonatal morbidities such as respiratory distress syndrome, intraventricular hemorrhage, bronchopulmonary dysplasia, patent ductus arteriosus, and necrotizing enterocolitis, no differences were detected between the groups. The mean serum insulin-like growth factor-1 levels in retinopathy of prematurity group were significantly lower than those in the non-retinopathy of prematurity group at each time point (1st, 3rd, 7th, 21st, and 28th day of postnatal life) (p=0.001). This study demonstrated the low serum insulin-like growth factor-1 levels was associated with retinopathy of prematurity development.

Assessment of Safe Sleep: Validation of the Parent Newborn Sleep Safety Survey

PurposeSudden Infant Death Syndrome (SIDS) and suffocation account for more than half of all Sudden Unexpected Infant Deaths (SUID). The American Academy of Pediatrics (AAP) recommendations describe the safest environments to protect infants. This study compared parent responses on the Newborn Sleep Safety Survey and observational assessments (N=72) of infant sleep environments in families thought to be at high-risk for non-compliance with AAP recommendations. Design and MethodsA naturalistic study of participants enrolled in two home visitation support programs was used. Observed risks ranged from 36.6% (never use pacifier) to 4.3% (never use firm mattress). ResultsResults comparing report to observation demonstrated acceptable concordance. Five items had fair concordance (Kappa>.4), four showed moderate concordance (Kappa>.6), and one excellent concordance (Kappa>.8). Although direct observation of safety behaviors is the gold standard in the injury prevention field, direct observation is logistically difficult, time consuming, and costly. ConclusionsResearch and interventions aimed at a reduction of Sudden Infant Death Syndrome (SIDS) and suffocation require accurate assessment of the infant sleep environment. This study provides acceptable evidence for the use of the Newborn Sleep Safety Survey as an alternative to direct observation to assess parent adherence to recommendations. Limitations are discussed. Practical ImplicationsThis study provided evidence of the usefulness of the Newborn Sleep Safety Survey, a parent survey of infant sleep environments. This tool will provide medical and research professionals a reliable, inexpensive tool to evaluation of the quality of sleep environments using a standard definition.

The association between pregnancy intendedness and experiencing symptoms of postpartum depression among new mothers in the United States, 2009 to 2011: A secondary analysis of PRAMS data.

Postpartum depression (PPD) is a form of major depressive disorder affecting approximately 13% of women worldwide. Unintended pregnancies, reaching close to 50% of the pregnancies in the United States, have become a major health concern. While many physiologic and psychosocial causes have been analyzed, few studies have examined the relationship between unintended pregnancy and symptoms of PPD.A cross-sectional study was conducted using surveillance data from the Centers for Disease Control and Prevention's Pregnancy Risk Assessment Monitoring System (PRAMS) from 2009 to 2011. The PRAMS population-based random sample included women who have had recent live births and is representative of 78% of the United States population. The chi-squared test was used to examine bivariate associations. Binary logistic regression was utilized to study unadjusted and adjusted associations between PPD and pregnancy intendedness, as well as other demographic and clinical characteristics of mothers in the sample. Multicollinearity in the adjusted model was evaluated using variance inflation factors. Sampling weights were used to account for PRAMS’ complex sampling design.Of the 110,231 mothers included in the sample, only 32.3% reported desiring the pregnancy at the time of conception. Women with pregnancies categorized as mistimed: desired sooner, mistimed: desired later, or unwanted were 20% (adjusted odds ratio [AOR] = 1.2; 95% confidence interval [CI]: 1.1–1.3), 30% (AOR = 1.3; 95% CI: 1.2–1.4), and 50% (AOR = 1.5; 95% CI: 1.3–1.7) more likely to experience symptoms of PPD, respectively, compared to women with desired pregnancies. Other factors found to be associated with experiencing symptoms of PPD were a gestational age of <27 weeks (AOR = 3.1; 95% CI: 2.5–4.0), having a previous history of depression (AOR = 1.8; 95% CI: 1.6–2.0), and being abused during or before pregnancy (AOR = 1.6; 95% CI: 1.4–2.0).We found that women with mistimed or unwanted pregnancies were more likely to experience symptoms of PPD. Our findings support the current US Preventive Services Task Force and American Academy of Pediatrics recommendations for an integrated approach to screening for depression, aiding in the maximization of intervention and early referral for women at risk for PPD.

Respiratory Support for Very Low Birth Weight Infants Receiving Dexamethasone

To assess how neonatal intensive care units followed the American Academy of Pediatrics guidelines for use of dexamethasone in preterm infants by evaluating respiratory support at the time of dexamethasone administration. This is an observational study of infants discharged from one of 290 neonatal intensive care units from 2003 to 2010. The cohort included very low birth weight (<1500 g birth weight) infants born at ≤32 weeks gestational age. The main outcome was respiratory support at time of exposure to dexamethasone. Significant respiratory support was defined as invasive respiratory support (conventional or high-frequency ventilation) with a fraction of inspired oxygen (FiO2) > 0.3. Of 81 292 infants; 7093 (9%) received dexamethasone. At the time that dexamethasone was initiated, 4604 (65%) of infants were on significant respiratory support. In accordance with the American Academy of Pediatrics recommendations, a majority of infants were on significant respiratory support when receiving dexamethasone, yet a substantial number of infants still received dexamethasone on less than significant respiratory support. Further research on reducing dexamethasone use in premature infants is required to decrease the risk of neurodevelopmental impairment.

Quality Health Care for Homeless Children: Achieving the AAP Recommendations for Care of Homeless Children and Youth.

We assessed whether and how health care organizations serving homeless pediatric patients meet recommendations issued by the American Academy of Pediatrics (AAP). We conducted a web-based survey of Health Care for the Homeless (HCH) Program grantees serving children. Of 169 grantees, 77 (46%) responded. All organizations reported connecting patients to specialty services. Nearly all reported screening for homelessness (90%), facilitating Medicaid enrollment (90%), connecting patients to benefits (94%), addressing underlying causes of homelessness (83%), assisting with transportation (83%), and knowing about the causes of homelessness (76%). Fewer reported integrating comprehensive care into acute visits (61%) or having medical-legal partnerships (57%). Federally qualified health center status was associated with meeting more recommendations. We described barriers and facilitators to meeting recommendations. Health care organizations serving homeless children largely meet AAP recommendations, but integrating comprehensive care into acute visits remains an area for improvement. Disseminating best practices may support guideline adherence.

Pharmacist-driven respiratory syncytial virus prophylaxis stewardship service in a neonatal intensive care unit.

The development and implementation of a pharmacist-driven respiratory syncytial virus (RSV) prophylaxis stewardship program in a neonatal intensive care unit (NICU) are described. An RSV prophylaxis stewardship service was created in the NICU at Brigham and Women's Hospital to align with the newly updated 2014 American Academy of Pediatrics (AAP) recommendations for palivizumab. The service comprised two NICU clinical pharmacists with oversight from the NICU medical director and the chair of the NICU infection control committee. Supervising physicians provided oversight for the identification of qualified patients on a weekly basis and assisted in the evaluation of controversial cases. The goals of the RSV prophylaxis stewardship service were to identify qualifying infants, improve adherence to the current AAP recommendations, educate staff and families on the recently updated AAP recommendations, streamline communication between providers regarding qualifying infants, and prepare and deliver palivizumab for administration in an organized and cost-effective manner. Twice-weekly "RSV prophylaxis days" were designated, with a set administration time on each day. Workflow was successfully streamlined between members of the healthcare team, including NICU pharmacists, prescribers, off-shift pharmacists, and nurses. Pharmacists involved in a multidisciplinary RSV prophylaxis stewardship service successfully identified qualifying patients for RSV prophylaxis while adhering to the latest AAP recommendations, educated staff and families regarding RSV, streamlined communication among healthcare providers, and ensured preparation of palivizumab in an organized and cost-effective manner.

Safe Sleep Infant Care Practices Reported by Mothers of Twins.

The high prevalence of prematurity and low birth-weight places twin infants at increased risk for sudden unexpected infant death (SUID) and/or sudden infant death syndrome (SIDS). Risk for these SUID and SIDS is affected by a combination of nonmodifiable intrinsic risk factors and modifiable extrinsic stressors including infant care practices related to sleep. Although adherence to the full scope of American Academy of Pediatrics (AAP) 2011 recommendations is intended to decrease risk, these recommendations are aimed at singleton infants and may require tailoring for families with multiple infants. The study describes infant care practices reported by mothers of twins in the first 6 months postpartum. Mothers caring for twin infants (N = 35) were surveyed online both longitudinally (at 2, 8, 16, and 24 weeks after infant hospital discharge) and cross-sectionally. AAP recommendations (2011) guided survey content. The degree of adherence to AAP recommendations varied over time. For example, mothers of twins reported 100% adherence to placing twins supine for sleep initially, but many reported putting babies on their stomachs for naps as twins became older. Sharing a parent's bedroom decreased over time as did frequency of crib sharing. Fewer than half of mothers offered a pacifier most or all of the time for sleep. Opportunities exist for development of an educational program geared specifically for postpartum parents of twins. Barriers affecting adherence to AAP recommendations and effectiveness of educational programs addressing needs of this unique population need further exploration.