Wet Diapers Research Articles

Test-retest Reliability Of Spatial-temporal Characteristics In Novice Walkers

Infant walkers have immature gait patterns. Small perturbations to gait, such as a dry diaper, could impact their already unstable spatial-temporal gait characteristics. However, little is known regarding the test-retest reliability of spatial temporal measurements as measured by the GAITRite of novice walkers in dry diapers. PURPOSE: To determine the reliability of spatial-temporal gait characteristics, such as Velocity, Cadence, Stride length, and Base of Support in 13-16 month old novice walkers wearing a dry diaper. METHODS: The project was approved by local IRB board and participated with written consent from legal guardians. 18 novice walkers, 9 males and 9 females, (14.4±1.0 months of age) participated in a series of 5 walking trials at a self-selected pace in a dry diaper on the GAITRite System (sampling rate 120Hz) on two separate testing sessions one week apart (Day 1 and 2). During each session, participants were fitted with the dry diaper and encouraged to walk 5 or more steps continuously for each trial, five trials total, over the GAITRite. Upon completion of each testing session, the raw data was exported and averaged across five trial for each day. Average gait velocity (cm/s), cadence (step/s), stride length (cm) and base of support (cm) were calculated at each time point. Intraclass Correlations were employed to assess between-day reliability. RESULTS: Gait Velocity, 92.3 ± 25.0 and 93.6 ± 20.0, for Day 1 and 2 respectively, ICC = 0.848 (95% CI = 0.594 to 0.943); Cadence, 208.6 ± 34.7 and 209.9 ± 25.8, for Day 1 and 2 respectively, ICC = 0.836 (95% CI =0.561 to 0.939); Stride Length = 53.0 ± 9.0, and 53.5 ± 7.8, for Day 1 and 2 respectively, ICC = 0.916 (95% CI = 0.777 to 0.969), Base of support, 10.9 ± 2.6, 10.9 ± 1.6, for Day 1 and 2 respectively, ICC = 0.767 (95% CI = 0.376 to 0.913). CONCLUSION: The results of the study demonstrated excellent test-retest reliability for Gait Velocity, Cadence, and Stride Length and good test-retest reliability for Base of support when testing 13-16 month old novice walkers in a dry commercially available diaper on the GAITRite. Future research needs to address the test-retest reliability of infants wearing a wet diaper since wet diapers introduce great perturbation to walking.

Case 4: Fever and Bradycardia in an 8-month-old Girl

1. Duncan Hau, MD* 1. *Department of Pediatrics, Weill Cornell Medical College, New York, NY An 8-month-old previously healthy girl presents to the emergency department with fever (as high as 102.7°F [39.2°C]) for 2 days. She has no cough, vomiting, diarrhea, rash, sick contacts, or recent travel. She is making 4 to 5 wet diapers per day. She normally takes 30 oz of formula daily but has taken 20 oz over the past day. She was seen at her pediatrician’s office the initial day of fever and was diagnosed as having a viral illness. The mother brought her to the emergency department owing to concern about the persistent fever. She was born at term via cesarean delivery. She was noted to have a murmur in the nursery that resolved. Her medical, surgical, and family histories are normal. She was seen 1 time previously in the emergency department at 7 months of age for minor head trauma, and she was discharged after brief observation. On physical examination, her temperature is …

Case 2: The Inconsolable Newborn

A 5-day-old male newborn of 39 weeks’ gestational age was brought to the emergency department (ED) with a complaint of “shaking of upper and lower extremities and fussiness” since birth. After the initial episode at home, he presented to the primary care physician with 2 more shaking episodes that occurred in clusters of 3 minutes described as jerking of both upper and lower extremities with occasional head jerking. The shaking is not associated with eye rolling or with feeds. Concerned about possible seizures, the physician recommended admission to the NICU for further evaluation. The patient did not have a fever, rash, or upper respiratory tract infection symptoms. There was 1 episode of nonbilious, nonbloody vomiting on the day of presentation. He had 10 to 11 wet diapers per day and 8 to 9 stools per day. There was no change in alertness and energy. He is a term infant, born by repeat cesarean delivery to a 32-year-old gravida 5-3-0-2-3 mother, who had received adequate prenatal care. The pregnancy was pertinent for a history of Escherichia coli –positive urinary tract infection at 24 weeks’ gestation and a medical history that included a Chlamydia infection, which had been diagnosed and treated before this pregnancy. Fetal movement and cervical examination findings were normal. She was group B Streptococcus negative, rapid plasma reagin test nonreactive, rubella immune, and hepatitis B surface antigen …

The Effect of Herbal Tea Containing Fenugreek Seed on the Signs of Breast Milk Sufficiency in Iranian Girl Infants.

Background:One of the important reasons behind termination of breast-feeding in the first six months after childbirth is insufficient production of breast milk.Objectives:The aim of this study was to determine the effect of herbal tea containing fenugreek seed on the signs of breast milk sufficiency in Iranian girl infants aged 0 - 4 months, at the medical health centers of Tehran university of medical sciences.Patients and Methods:This study was a clinical trial with a control group. Seventy-eight girl infants, 0 - 4 months old that were exclusively breastfed by their mothers, were randomly assigned to the intervention group (received herbal tea containing 7.5 g fenugreek seed powder in addition to 3 g of black tea, three times a day) and the control group (received herbal tea containing 3 g of black tea powder, three times a day). Before and during the four weeks of study, the signs of breast milk sufficiency were evaluated through measurement of growth parameters and use of follow-up forms for measuring the number of wet diapers in one day, frequency of defecation and infant breast-feeding times in a day.Results:Before the intervention there was no significant difference between weight, height, head circumference, the number of wet diapers and frequency of defecation between the two groups (P > 0.05), yet the number of breast feeding times of the control group was more than the Fenugreek group. At the end of the fourth week in proportion to the pre-intervention conditions, the weight of the infants in the fenugreek group increased significantly from 5282.0513 ± 1021.51121 to 6383.0769 ± 952.06190, while head circumference increased from 38.3103 ± 1.62736 to 39.9256 ± 1.50660, number of wet diapers from 5.2821 ± 0.93044 to 8.1648 ± 1.20620, frequency of defecation from 1.8846 ± 1.08495 to 2.7326 ± 0.94771 and the number of breast feeding times from 9.1795 ± 1.39778 to 15.9597 ± 1.45056 (P < 0.001). However, there was no significant effect on height variation (P = 0.078). While in the control group there was no significant difference between the mentioned variables (P > 0.05).Conclusions:Herbal tea of fenugreek seed in comparison to the control group improves the signs of breast milk sufficiency.

Hypoglycemia in an unmonitored full-term newborn

Afull-term male infant was admitted to the neonatal intensive care unit 30 h after birth for hypoglycemia. A review of the history revealed that the mother was a primagravid 30-year-old woman with obesity (body mass index 35 kg/m 2 ) who had a normal glucose tolerance test at 28 weeks’ gestation. The baby was born by spontaneous vaginal delivery after induction of labour at 41 weeks’ gestation. Apgar scores were 8 at 1 min and 9 at 5 min. Cord blood gases were normal. Birth weight was 2900 g. The mother and newborn were transferred to the postnatal ward. Newborn examination was normal. During the first 24 h, the baby had several breastfeeding attempts with good latch and sustained sucking. The baby had two wet diapers, one small meconium stool and weight was 2800 g at 24 h. At 30 h of life, he had a temperature of 36.3°C and was noted to be jittery, with exaggerated startle, and subsequently experienced a cyanotic episode. A bedside glucose measurement was low. A simultaneous serum glucose measurement was 0.9 mmol/L. The baby was admitted to the neonatal intensive care unit and treated with intravenous dextrose 10% 2 mL/kg slow bolus and 6 mg/kg/min glucose maintenance. Infection was ruled out. There were three additional episodes of low glucose (1.8 mmol/L, 1.9 mmol/L and 2.0 mmol/L). A critical sample obtained during the third hypoglycemic event indicated hyperinsulinism. Hypoglycemia and hyperinsulinism resolved four days later, and he was discharged home feeding well with a normal neurological examination. LEARNING PoINTS

The Effect of Herbal Tea Containing Fennel Seed on Breast Milk Sufficiency Signs and Growth Parameters of Iranian Infants

Background: Breastfeeding is an economic and valuable method to protect infant's health during the life and provides unique biological and emotional effects for mothers and infants. Objectives: This study aimed to determine the effect of herbal tea containing Fennel seed on breast milk sufficiency signs and growth parameters of Iranian infants in medical health centers of Tehran University of Medical Sciences, Tehran, Iran. Patients and Methods: This study was a randomized clinical trial performed on 78 girl infants aged 0-4 months who were exclusively breastfed. After getting informed consent infants were randomly assigned into the intervention group (received herbal tea containing 7.5 g Fennel seed powder in addition to 3 grams black tea three times a day) and the control group (received herbal tea containing 3 grams black tea powder three times a day). Before and during four weeks of study, signs of breast milk sufficiency were evaluated through measuring the growth parameters and the number of wet diapers in a day, frequency of defecation and infant breastfeeding times. Results: Before intervention, there was no significant difference between weight, height, head circumference, the number of wet diapers and frequency of defecation times between the two groups (P > 0.05), but the number of breastfeeding times of control group was more than the Fennel group. After fourth weeks, Fennel significantly increased weight from (5261.0256 ± 1167.65801) to (6393.3333 ± 1083.42132), head circumference from (38.6103 ± 2.20033) to (40.1538 ± 2.00510), the number of wet diapers from (5.5000 ± 1.05131) to (8.5421 ± 1.21182), the frequency of defecation times from (1.7692 ± 1.03139) to (2.6410 ± 1.14655) and the number of breastfeeding times from (9.9359 ± 1.85380) to (16.7399 ± 1.63766) (P < 0.001), but it had no effect on height (P = 0.066). Conclusions: Herbal tea containing fennel seed improved breast milk sufficiency signs.

Index of Suspicion in the Nursery

An 8-day-old, formula-feeding male infant was admitted to the neonatal intensive care unit (NICU) for failure to thrive (down ∼12% from birthweight). Birth history was remarkable for birth at 37 1/7 weeks’ gestation (according to last menstrual period) via vaginal delivery with a birthweight of 2,900 g. Apgar scores were 9 and 9 at 1 minute and 5 minutes, respectively. Maternal laboratory test results were unremarkable, and the mother was negative for group B streptococcus with rupture of membranes ∼2 hours before delivery. Initial hospital course was unremarkable. At the time of discharge, the infant was formula-feeding well, with a discharge weight of 2,745 g (down 5.5% from his birthweight). At the 2-day follow-up visit, the infant demonstrated continued weight loss despite taking appropriate volumes of formula. After multiple outpatient visits and close monitoring of weight trajectory, the infant was admitted for further evaluation of failure to thrive. Upon admission, the infant was 12% down from birthweight, but he was taking 30 mL of 22 kcal/oz formula every 2 hours with only occasional emesis (according to maternal report). The infant was having wet diapers and stools with almost every feeding. On examination, the infant was a nondysmorphic-appearing male with normal results on physical examination and vital signs; he had normal-appearing circumcised male genitalia, with testes descended bilaterally, and normal pigmentation. The infant was initially admitted to the pediatrics ward and then subsequently transferred to the NICU for further evaluation and management. ### Progression Initial laboratory test results on admission demonstrated hyponatremia (sodium, 129 mmol/L) and hyperkalemia (potassium, 8.3 mmol/L). The electrocardiography (ECG) was unremarkable. Blood pressures via a peripheral arterial line …

Mother’s knowledge over child-toilet training in Sebardan village in Erbil

Background and objectives: Child toilet training is a paramount skill to learn, it virtually involves many steps for parents to endorse should the child success. The aim of the study was to assess mother’s knowledge about child-toilet training in Sebardan Village in Erbil. Methods: A cross-sectional descriptive study was carried out in Sebardan Village in Erbil Governorate from the 1st / March / 2010 to the 30th / May / 2010. A convenience sample of 300 mothers with their children under the age of five years old was selected. Results: Less than half (31.4%) of the mothers age were between 21-25 years old, (85.4%) of them were housewives, (34%) completed a primary school and all of them were from the rural areas. Less than half (40.4%) of mothers whom their male children exhibited physical readiness to reduce their number of wet diapers. Conclusion: Our survey concluded that mother’s knowledge had an effect on the child’s readiness for toilet training, and highly significant relationship between mother's level of education and their knowledge of their child’s readiness (physical, mental and psychological ) toward toilet training at p ≤ 0.05. The study has been recommended to provide guidance through the media and different community health centers to promote parental awareness toward developmental milestones and child-toilet training.

Index of Suspicion * Case 1: Irritability and Signs of Peritonitis in a Neonate * Case 2: Red Eye, Excessive Tearing, Photophobia, Irritability, and Splenomegaly in an Infant * Case 3: 2-year-old Girl Who Has Cough, Right Pulmonary Abnormalities

* ALL: : acute lymphoblastic leukemia CT: : computed tomography IVC: : inferior vena cava NA: : neonatal appendicitis NEC: : necrotizing enterocolitis WBC: : white blood cell A 7-day-old boy born at term is brought to the emergency department by his foster mother for refusal to feed for ∼20 hours and increased crying, although he is intermittently consolable. When given his bottle, the infant starts to suck but then cries as though in pain. He has not vomited, and his last bowel movement was yesterday. The stool has been moderately well formed without blood or mucus, and wet diapers have continued. There is no history of respiratory symptoms, lethargy, rashes, or jaundice. The biological mother is a 27-year-old woman with a known history of previous drug abuse; she had received some prenatal care. This infant was born by scheduled cesarean delivery. Initial physical examination reveals a crying but consolable neonate. His temperature is 37.7°C, heart rate is 170 beats/minute, and respiratory rate is 56 breaths/minute; the remainder of his findings are normal. His complete blood count (white blood cell [WBC] 11.7 × 109/L, 78.5% neutrophils, 11.4% monocytes, 9.8% lymphocytes), serum concentrations of electrolytes and glucose, urinalysis, and cerebrospinal fluid studies are normal. Cultures are obtained. An abdominal radiograph is normal and abdominal ultrasonography reveals trace pelvic fluid. He is given a bolus of normal saline and is started on antibiotics to treat possible sepsis. A few hours after admission, repeat examination is concerning for inconsolability, poor suck reflex, and lethargy. His abdomen is distended, firm, and tender to palpation. Bowel sounds are normal. Further studies are performed that reveal the diagnosis. A previously healthy 10-month-old boy is seen for a 2-week history of an erythematous left eye with tearing. Earlier, he was diagnosed as having conjunctivitis at an urgent care clinic and was treated with a 10-day course of polymyxin B/trimethoprim eye drops without improvement. He has felt warm intermittently but has not had a …

Competence to Provide Urinary Incontinence Care in Taiwan's Nursing Homes

Nursing staff play an essential role in ensuring the quality of continence care in nursing homes. The purpose of this study was to describe the level of competence (knowledge, attitudes, and practice behaviors) of urinary incontinence (UI) care in nursing home staff in Taiwan. A cross-sectional postal survey was used to gather self-reported data from an island-wide sample of 195 nurses and 99 nurse assistants (NAs) in Taiwan. Participants completed the UI knowledge, the UI attitude, and the practice behaviors of UI care scales. The level of UI knowledge in nurses was higher than that of NAs, although nurses had less-positive attitudes than NAs. Reported practice behaviors of UI care did not differ between nurses and NAs. Changes of wet clothes, linens, and diapers were the most commonly reported practice behaviors. Information-gathering, physical examination, and pelvic floor muscle exercises were performed less commonly in nursing homes. Knowledge and positive attitudes regarding UI need to be improved in both nurses and NAs in nursing homes. Several deficits were found in practice behaviors of UI care. A competency-based education approach is suggested to enable awareness of UI and cultural changes on individual and institutional levels.

When Too Much Is Not Enough: Obsessive-Compulsive Disorder as a Pathology of Stopping, Rather than Starting

BackgroundIn obsessive-compulsive disorder (OCD), individuals feel compelled to repeatedly perform security-related behaviors, even though these behaviours seem excessive and unwarranted to them. The present research investigated two alternative ways of explaining such behavior: (1) a dysfunction of activation—a starting problem—in which the level of excitation in response to stimuli suggesting potential danger is abnormally strong; versus (2) a dysfunction of termination—a stopping problem—in which the satiety-like process for shutting down security-related thoughts and actions is abnormally weak.MethodIn two experiments, 70 patients with OCD (57 with washing compulsions, 13 with checking compulsions) and 72 controls were exposed to contamination cues—immersing a hand in wet diapers —and later allowed to wash their hands, first limited to 30 s and then for as long as desired. The intensity of activation of security motivation was measured objectively by change in respiratory sinus arrythmia. Subjective ratings (e.g., contamination) and behavioral measures (e.g., duration of hand washing) were also collected.ResultsCompared to controls, OCD patients with washing compulsions did not differ significantly in their levels of initial activation to the threat of contamination; however, they were significantly less able to reduce this activation by engaging in the corrective behavior of hand-washing. Further, the deactivating effect of hand-washing in OCD patients with checking compulsions was similar to that for controls, indicating that the dysfunction of termination in OCD is specific to the patient's symptom profile.ConclusionsThese results are the first to show that OCD is characterized by a reduced ability of security-related behavior to terminate motivation evoked by potential danger, rather than a heightened initial sensitivity to potential threat. They lend support to the security-motivation theory of OCD (Szechtman & Woody, 2004) and have important implications both for research into the biological mechanisms underlying OCD and for the development of new treatment approaches.

Adapting to Change

It has been said that the only people who like change are babies with wet diapers. This statement rings true whether it involves designing and building a new hospital, an additional tower, or even renovating an existing unit. It seems that we have great difficulty letting go of what is familiar even when the familiar does not work well. In a recent article, one chief nursing officer expressed surprise that physicians and staff who were heavily involved the design of a new children's hospital were voicing discontent about the design once the building was open and functional (Stichler, 2008). How could this be? Some were the very same people who met with the design teams, participated the design decisions, and even signed off on documents indicating their approval of the design.Unfortunately, this is not an isolated incident. Even with the excitement of opening a new building, people resist change. It is likely that there are few organizational initiatives that can compare to the change process that occurs with the design and opening of a new hospital, yet few organizational leaders provide the same due diligence to the change process as they do to structural change. The change associated with individual and organizational adaptation to moving into a new environment is complex and convoluted, and the change process must be as carefully orchestrated as the design process as a whole. Organizational leaders must guide physicians and staff through the process of discarding their current realities, introduce new practice patterns, and encourage the adoption of new behavioral paradigms. Moving into a new facility forces organizational culture change even when such change is not anticipated.Leading Change Using Classic Change TheoriesLeading change is one of a leader's most important and difficult roles. Although there are many excellent change theories that can be used to guide the change process, not all change is alike, nor can all organizational changes be approached the same way to yield expected results. Perhaps the greatest failure is not addressing the change process at all and expecting everyone to be excited about a new facility. Using change theories as a framework for developing the structure and process of organizational change can enhance positive adaptation to a new patient care environment.Lewin's Change TheoryLewin was the first to develop the notion that change should be planned rather than allowing unintentional or accidental processes to occur, and he first described three levels of change: unfreezing, changing, and refreezing (Lewin, 1951). This classic theory still guides many planned organizational processes with great success. Using this theory, an organization's leaders would first demonstrate the need to change and explain why maintaining the status quo would be detrimental to patients, employees, the organization, and even the community. Kotter (1995) would describe this as creating a of urgency. At the same time, leaders must assess an organization's readiness for change and identify those who may be resistant to the vision and trench in to the current status, situation, or even care delivery models.Applying the unfreezing stage of Lewin's theory, physicians and staff must be motivated to change by means of exposure to new ideas and creating a sense of urgency around the shared vision of how patient care outcomes and the work environment could be enhanced by the proposed change. The critical step of developing a shared vision is not only important the design process, but it is also a critical part of the change process that must be orchestrated concurrently with the design and construction phases of a new facility. In the unfreezing stage, leaders at the departmental level must begin to examine existing work flow processes and design new processes the context of the new building, equipment, or departmental relationships. Some healthcare professionals might need orientation to new equipment or have to be certified to perform new procedures or patient care activities that result from the changes facility design or processes. …

Index Of Suspicion In The Nursery

An 11-day-old female infant presents to the hospital because of “projectile vomiting.” According to her mother, the infant vomits after every feeding and subsequently appears hungry. She has three wet diapers and one bowel movement per day. Her emesis is reported to be bright yellow but does not appear to be the color of her formula. The patient was born at term via normal spontaneous vaginal delivery. She weighed 3.7 kg and there were no complications or infection. She was sent home on cow milk formula, feeding 2 oz every 3 hours. Today, she is acting appropriately and has no fever, cough, congestion, or sick contacts. On physical examination, her temperature is 36.4°C, heart rate is 160 beats/min, respiratory rate is 44 breaths/min, blood pressure is 87/40 mm Hg, weight is 3.065 kg (10th percentile), length is 50 cm (50th percentile), and head circumference is 33.5 cm (5th percentile). The infant is awake, alert, active, and in no acute distress. She has a normocephalic head with an open and soft anterior fontanelle and no evidence of trauma. The eye examination reveals bilaterally symmetric red reflexes and anicteric sclera. Findings on the oropharyngeal examination are normal, with no exudates, an intact palate, and moist mucous membranes. Cardiovascular examination demonstrates no murmurs, a regular rate and rhythm, good femoral pulses, and a capillary refill of less than 2 seconds. Lungs are clear to auscultation bilaterally. Abdominal examination documents active bowel sounds over a soft, nontender, and nondistended abdomen, with no masses or notable hepatosplenomegaly. Genitourinary examination notes normal female genitalia with a patent anus. Extremity examination shows no clubbing, cyanosis, or edema. The laboratory results on admission are:

Relationships Among Intrapartum Maternal Fluid Intake, Birth Type, Neonatal Output, and Neonatal Weight Loss During the First 48 Hours After Birth

To examine predictive relationships among intrapartum maternal fluid intake, birth type, neonatal output, and neonatal weight loss during the first 48 hours after birth. Prospective descriptive design. Women's center of a 900-bed regional acute care facility with 6,700 births per year. A convenience sample of 200 mother/neonate dyads. The Optimality Index of Murphy and Fullerton guided the inclusion and exclusion criteria to ensure healthy dyads. Data collection began in the intrapartum period and concluded with maternal/neonatal discharge. Measures included maternal intrapartum fluid intake from admission to birth, daily neonatal weight, output, and feedings. Data were analyzed via descriptive statistics, tests of significance and multiple regression. Neonatal weight loss was not significantly related to intrapartum maternal fluid intake. Strong predictors of neonatal weight loss and significant weight loss within the first 48 hours were type of feeding (p=.000) and average number of wet diapers (p=.003). Variables predictive of neonatal weight loss can facilitate identification of at-risk neonates to prevent significant weight loss. Close monitoring of the number of wet diapers in the first 48 hours and accurate daily weights at birth time can lead to early detection and preventive interventions.

Index of Suspicion in the Nursery

A 5-week-old previously well female born at 41 weeks gestational age presents to the pediatric emergency department in the winter with a 2-day history of poor feeding. Her mother is concerned that the baby is more tired than usual, “is not getting enough to eat,” and is having difficulty latching on to the breast. The mother explains that 2 weeks ago, the infant developed a dry cough and began having emesis after each feeding. She describes the emesis as nonbilious and nonbloody and approximately 1 ounce. An outside pediatrician prescribed a cough and cold medication and told the mother that the emesis was “normal baby spit-up.” Three days ago, the infant developed projectile vomiting immediately following each feeding. Today, the mother reports that the infant is breathing much harder and deeper than usual, with continued and more frequent coughs. She describes the cough as paroxysmal, although she experiences no color changes. The mother is concerned that her baby does not look like herself and is difficult to arouse. A review of systems reveals that the baby has not taken any human milk today, although her urine output has remained the same, with heavy, wet diapers. Her 2-year-old sister, who attends child care, has a cough and upper respiratory tract infection. The infant has no diarrhea, and her bowel movements are normal. There were no complications during the pregnancy. Her birthweight was 2,722 g, and she has been gaining weight appropriately, although the mother describes her as “scrawny” at birth. Physical examination of the infant in the emergency department shows a temperature …

Prompts, Feedback, Positive Reinforcement, and Potty Training

Two parents were concerned because their two young girls were delayed in learning to use the potty. In this study we obtained data on the frequency of wet diapers and use of the potty at home. Following baseline, an intervention was implemented that involved increased intake of liquids and salty foods, prompting, and positive reinforcement. Once a substantial decrease in wet diapers was achieved, together with an increase in use of the potty, the girls were offered the opportunity to wear “Princess Underwear!” as an even more powerful prompt and reinforcer. An ABC design was used with each girl. The results showed significant increases in their use of the potty and decreased incidents of wet diapers when the intervention was in effect. Although this design does not rule out possible effects of coincidences, the data are consistent with the hypothesis that the intervention produced improvements in potty training.

What causes the “wet diaper” artifact? computed tomography and magnetic resonance observations

Disposable diapers contain super absorbent polymers that absorb liquid. A radio-dense artifact, seen when the diaper is wet, obscures radiographic information but is frequently misinterpreted. Our purpose was to examine this artifact on CT and MR to further clarify and explain its origin. Dry and wet diapers were imaged. Fluid within the wet diaper appeared as small nodules with characteristics of bound water. No free water was detected. Dry diapers produced no artifact. The artifact is most undesirable on radiographs, but does not obscure diagnostic information on cross-sectional imaging. It should not be misinterpreted as contrast.

Increased Work of Breathing in a 16-day-old Newborn

A 16-day-old term Caucasian boy presents with increased work of breathing and “head-bobbing” since birth.He was born full term via induced vaginal delivery with Oxytocin to a 28-year-old G2P2002 mother without any complications. He weighed 8lbs at birth. He has since had no other medical problems, and has received the first dose of hepatitis B vaccine.The pertinent family history includes asthma in the father, and obstructive sleep apnea in the mother. His sibling is healthy. There is no substance (tobacco, alcohol, illicit drugs) abuse in the family. He currently takes no medications.His parents took him to his primary care physician who after a brief examination stated that “everything was okay” and that the infant was doing well. His parents deny any episodes of cyanosis, apnea or breath holding. According to the mother, the patient moves his entire body when breathing, along with “head-bobbing.” She also states that his breathing sounds exactly like a suction-bulb syringe. He has decreased oral intake for one day and is experiencing “constipation” for two days. There are no sick contacts, no URI symptoms, no emesis and no change in number of wet diapers. Usually he drinks cow’s milk formula (4 ounces every 3 hours).Physical examination revealed heart rate of 138 beats/min and respiratory rate of 38 breaths/min. All other Vital Signs were within normal limits. Significant examination findings include subcostal retractions and decreased breath sounds in all fields of the right lung. The rest of the examination was unremarkable.Laboratory results are as follows: WBC count 10,900/mcL (30% Neutrophils, 3% Bands, 58% Lymphocytes, 6% Monocytes, 2% Eosinophils), Hgb 11.9 gm/dL, Hct 33.8%, and Platelets 500,000/mcL. Capillary Blood Gas showed pH 7.39, PCO2 57, PO2 58, HCO3 31, SPO2 98%.The infant underwent surgery (Figure 2) and was discharged in healthy condition (Figure 3) The infant was seen in follow-up a month later (Figure 4) and was doing well.The incidence of congenital lobar emphysema (CLE) is approximately 1/ 20,000 – 30,000 live births, predominantly affecting males. It most commonly affects the left upper lobe or right middle lobe for unknown reasons. However, in some infants both lungs may be affected. The age of presentation can be from the newborn period to one year of age. Young infants usually present with severe disease. Most (95%) of patients are symptomatic before the age of 5 months.The pathogenesis of CLE is currently unknown. Some of the theories which explain the pathogenesis of CLE are: inadequate cartilaginous support of the bronchus; poly-alveolar lobe leading to a drastic increase in the number alveoli present in a single lobe of the lung and external compression of the bronchus by aberrant vessels.Common presenting symptoms of CLE are generally non-specific respiratory findings such as difficulty breathing, increased work of breathing, feeding difficulty, and fatigue. Signs that may be associated with CLE include wheezing, stridor, cyanosis and asymmetric breath sounds. The physical examination of the infant with CLE may or may not include all of these signs and symptoms. Thus the symptoms and signs are non-specific and suggestive of CLE but not diagnostic for it. The next step in diagnosing CLE would be chest radiographs.Chest Radiographs in CLE show a hyperlucent area surrounded by minimal bronchovascular markings. Possible mediastinal shift may occur depending on the severity and progression of the disorder.Initial management of the disease depends on the severity of symptoms. These patients may need to have CT of chest, bronchoscopy and V/Q scan performed to evaluate the extent and severity of the disease. Patients with mild to moderate symptoms may be treated conservatively with close follow-up. Patients with severe symptoms require immediate surgery. The definitive treatment of the lesions is lobectomy.JoDee M. Anderson, MD, Division of Neonatal Medicine, Oregon Health & Science University, Portland, OR.Dr. Deepak Kamat MD, PhD†‡

Index of Suspicion in the Nursery

A 4-day-old term female infant is being evaluated for fever, with a rectal temperature of 100.9°F (38.2°C), and an episode of oxygen desaturation to 70% while breathing room air. The mother reports that the infant had increasing fussiness. Prenatal care and delivery were within normal parameters. She denies use of illicit drugs and is unsure of her group B Streptococcus status. The infant has eight to nine wet diapers and about 10 bowel movements per day. She consumes 1 to 2 oz of regular infant formula every 3 hours. The only finding of note on physical examination is the fever. Her neck is supple and has no abnormalities. A full sepsis evaluation is performed, including a complete blood count and blood, urine, and cerebrospinal fluid cultures. Respiratory syncytial virus antigen and influenza test results are negative. Radiographs of the chest and lungs appear normal. The infant is admitted and treatment with ampicillin and cefotaxime is begun. Thirteen hours later, the infant develops respiratory distress manifesting with stridor and desaturation while breathing room air. Physical examination at this time reveals a new cystic, moveable mass on the anterior triangle of her neck. Follow-up radiograph of the neck shows displacement of the trachea to the right. An 80% helium/20% oxygen mixture is started in the pediatric intensive care unit. Computed tomography (CT) scan of the neck and chest shows a 4.0×2.5-cm cystic lesion with an air-fluid level located in the anterior triangle of her neck slightly to the left of midline (Fig. 1). Thyroid study results are normal. Surgical removal of the cyst and histologic evaluation lead to the diagnosis. Figure 1. Computed tomography scan showing a cystic lesion with an air-fluid level in the anterior triangle of the neck. ### Hospital Course The patient was taken to the operating room the next day for neck exploration. …

Can an individualized and comprehensive care strategy improve urinary incontinence (UI) among nursing home residents?

Urinary incontinence (UI) is one of the most common and distressing conditions among nursing home residents. Although scheduled care is usually provided for them, incontinence care should be individualized regarding going to the toilet, changing diapers, and taking food and water. We have developed an individualized and comprehensive care strategy to address the problem. We conducted an intervention study that involved training chiefs of staffs, who in turn trained other staffs, and encouraging residents. A total of 153 elderly subjects selected from 1290 residents in 17 nursing homes were eligible to receive our individualized and comprehensive care. The goals of the care strategy were (i) to complete meal intake; (ii) to take fluids up to 1500ml/day; (iii) to urinate in a toilet; (iv) to spend over 6h out of bed; and (v) to reduce time spent in wet diapers. We explained the aims of our strategy to the chiefs of staff of each nursing home and instructed them to encourage residents to take an active part in our individualized and comprehensive care strategy for 12 weeks. For 3 days before and after that period, we assessed the changes in fluid volume intake, time spent in wet diapers, size of diaper pads, and urination habits. The result was that fluid volume intake significantly increased (p<0.001) while time spent in wet diapers decreased (p<0.001). The number of residents wearing diapers decreased as did the size of pads during the day (p=0.0017). The proportion of residents using diapers at night was reduced and those using toilets at night increased (p=0.007). This study suggests that such an individualized and comprehensive care strategy can offer a measurable improvement in UI care.