Author: Dr. Allen Cherer

Promoting Safe Sleep for Infants

On June 12, 2016

Very few life events result in the anguish that comes with the death of an infant, especially one that is sudden and unexpected. Each year in the United States, approximately 3500 sudden, unexpected infant deaths (SUIDs) occur generally between the ages of 1 month and 1 year at a time when most infants sleep between 12 -18 hours/day.

They consist of three main types with Sudden Infant Death Syndrome (SIDS) being the predominant one, and deaths due to unknown causes and those due to accidental suffocation and strangulation in bed (ASSB) comprising the remainder.

The combined SUID death rate declined markedly following the 1992 American Academy of Pediatrics infant sleep recommendations and the initiation of the Back to Sleep campaign in 1994 with a primary focus on supine positioning during all infant sleep.

The combined SUID death rate decreased again slightly in 2009, and since that time has remained fairly constant. On the other hand, the ASSB, traditionally the least common of the three main causes of SUID, mortality rate remained unchanged until the late 1990s and has started a slow increase with its highest point in 2014.

Due in part to the success of the Back to Sleep campaign and to the increasing incidence of other sleep-related causes of SUID, the American Academy of Pediatrics broadened its focus since 2005 to include other factors resulting in an unsafe sleep environment and contributing to sleep-related infant deaths.

It is important to remember that the recommendations from the Safe to Sleep campaign are wholly derived from case-control studies and are based for the most part on epidemiologic studies including infants up to 1 year of age. The recommendations should therefore be applied to infants up to 1 year of age, except for those individuals in whom medical conditions warrant modification.

When it comes to safe sleep environment, remember the phrases “Back to Sleep”, “Bare is Best”, and “Room-sharing without Bed-sharing”. The basic underlying point to promote a safe sleep environment starts with every caretaker positioning every healthy infant on his or her back for every sleep.

Protective airway mechanisms prevent choking and aspiration. Only those infants with significant upper airway disorders warrant modification. Side sleeping is not recommended, and elevation while supine can be complicated by respiratory compromise if the infant’s position changes.

Preterm infants requiring prolonged hospitalization should also be maintained in the supine position during sleep when they are medically stable and long before they are ready for discharge to home.

Although the general recommendation pertains to infants up to one year of age, once an infant is capable of rolling from supine to prone and vice versa, the infant can remain in the sleep position that he or she assumes.
Since infants spend almost all of their time in a crib, bassinet, or play yard, these environments are especially important. Many infant deaths are associated with broken cribs with loose or missing parts.

Cribs should be no older than ten years and conform to the safety standards of the Consumer Product Safety Commission. Before use, the product should be checked for previous recall. Cribs require narrow slats and stable sides. Since 2011, federal safety standards prohibit the sale of drop side rail cribs. Specific mattresses designed for the crib should be firm and covered with a fitted sheet.

There should be no gaps larger than two finger breadths between the mattress and the crib. Soft materials or objects, such as pillows, comforters, or sheepskins even when covered with a sheet , should not be placed under a sleeping infant. Research shows that babies who sleep on soft surfaces which allow the baby’s head to sink into the surface are at higher risk for SIDS and suffocation.

If an infant falls asleep in a sitting device, such as a car safety seat, stroller, swing, or infant carrier, he or she should be removed from the product and moved to a crib or other appropriate firm flat surface as soon as practical.

When infant slings or cloth carriers are used, the infant’s head should be up and above the fabric, the face visible, and the nose and mouth not obstructed. The crib surface should be free of stuffed animals, pillows, toys, bumper pads, or blankets to reduce the risk of suffocation or entrapment. The crib, bassinet, or play yard should be positioned away from wall hangings, and the area should be free of blind and curtain cords which can result in strangulation.

Room-sharing without bed-sharing is recommended and is most likely to prevent accidental suffocation especially from overlaying, strangulation, and entrapment that might occur when an infant is sleeping in an adult bed. Soft mattresses, pillows, quilts, and loose bed linens provide a high risk environment for infants. Certainly, infants can be brought into the bed for feeding or comforting but should be returned to their own crib or bassinet when the parent is ready to return to sleep.

Epidemiologic studies have demonstrated increased risks for SIDS and suffocation when bed-sharing involves infants less than three months of age, other children or multiple persons, and caretakers who are excessively tired, current smokers, or are using medications or substances that impair alertness or ability to arouse. It is best to provide separate sleep areas and avoid co-bedding for twins and higher multiples in the hospital and at home.

Certain sudden, unexpected infant deaths are not preventable. Continuing research particularly related to SIDS will provide new insights into the mechanisms resulting in this tragedy. Nevertheless, vigilance in attending to those modifiable environmental risk factors is highly desirable.

Newborn Screening and Severe Combined Immune Deficiency

By Dr. Allen Cherer

On May 15, 2016

In Child Health Care, Neonatal Care

April (April 22-29) has been designated as National Primary Immunodeficiency Awareness Month and provides an opportunity to better understand the more than 250 rare, genetic disorders in which the body’s normal immune system is absent or functions improperly. Since an important function of the immune system is to protect against infection, patients with primary immune deficiency have an increased susceptibility to infection.

Severe Combined Immune Deficiency (SCID), popularized in the 1976 movie “The Boy in the Plastic Bubble”, is generally considered to be the most serious of the primary immunodeficiencies. There are at least 13 different genetic defects that can cause the disease; all of which are present at birth, involve missing T lymphocytes which are important in identifying and attacking perceived “invaders”, and affect the function of B lymphocytes which produce antibodies against infection.

The absence of T lymphocytes and antibody immunity results in severe infections, diarrhea, and failure to thrive. Regardless of the genetics, patients invariably succumb to an early death due to overwhelming infection. New approaches to diagnosis and management have changed what at one time was a dismal prognosis.

Treatment options have come a long way over the past 4 decades and include enzyme replacement, bone marrow transplant, and gene therapy. Paramount to this change is early diagnosis before the infant has had a chance to develop any serious infections.

The most effective therapy to date is immune reconstitution via stem cell transplant which has been shown to be highly successful (94%) if performed by 3.5 months of age. Hence, timing is crucial in terms of diagnosis and treatment.

Typically, infants with SCID appear totally normal at birth and have no family history of immunodeficiency. In the past, patients were primarily identified either by previous family history, physical manifestations, or after onset of life-threatening infection. Early identification of SCID has been achieved through the use of the 7-cell receptor excision circle (TREC) assay as part of the routine newborn screening program.

Absent or low TREC levels can indicate insufficient T lymphocyte production characteristic of SCID, as well as low T lymphocyte, non-SCID conditions as seen in DiGeorge Syndrome, Trisomy 21, CHARGE Syndrome, and ataxia telangiectasia. On May 21, 2010, The U.S. Department of Health and Human Services (HHS) recommended that every state include the assay as part of the newborn screen.

In the landmark study based on retrospective data on more than 3 million infants from 11 newborn screening programs using the TREC methodology conducted by Jennifer Puck, MD and colleagues and published August 20, 2014 in The Journal of the American Medical Association, the value of early detection and treatment of SCID was confirmed.

In addition, the study found an incidence rate almost twice as great (1 in 58,000 births) as had been previously estimated. Since the point of newborn screening is to identify conditions for which early treatment is life-saving, the study was a crucial step in the adoption of universal screening.

As of April 1, 2016, all, except for 11, states have adopted routine newborn screening programs for SCID. A 2016 study published in the Journal of Pediatrics by Ding and others provided an eloquent cost-benefit analysis of newborn screening in the treatment of Severe Combined Immune Deficiency.

Based on data obtained from 86,000 infants in Washington state, the study showed that newborn screening for SCID is clearly cost-effective. Hopefully, the study provides additional support in economic terms for the adoption of universal screening programs in all 50 states.

Reflections on Cesarean Section Rates

By Dr. Allen Cherer

On May 9, 2016

In Child Health Care, Neonatal Care

Cesarean section delivery is among the most common surgical procedures. It is estimated that in 2012 alone, over 22 million cesarean deliveries were performed worldwide. Data from the National Vital Statistics show that the total cesarean section rate in the U.S. in 1996 was approximately 21%.

Since that time, there has been a rapid increase in the rate, such that in 2011, close to 1 in 3 mothers delivered by cesarean. Although the rate has leveled since then, there remains no evidence that such a significant increase has been accompanied by a concomitant decrease in maternal or neonatal mortality.

Although cesarean delivery can be life-saving for the fetus, the mother, or both in certain cases, the concern exists that cesarean delivery is overused. Hence, the matter is a global health issue. Since one of the main driving forces for the increased total cesarean rate has been a marked shift to repeat cesarean delivery following a previous primary cesarean section, a concerted effort over the past several years has been to examine closely the factors related to the safe management of the nulliparous pregnancy.

As early as 1985, the World Health Organization (WHO) stated there was no justification for any region to have a cesarean delivery rate greater than 10-15 /100 live births. Nevertheless, the rates continued to increase worldwide with no scientific evidence indicative of substantial maternal or perinatal benefit.

In fact, a number of studies have associated higher rates of cesarean deliveries with negative consequences, including increased maternal and neonatal morbidity and mortality as well as increased consumption of limited health resources by procedures without medical indications.

In March 2014, a consensus report was issued by the American College of Obstetrics and Gynecology and the Society for Maternal-Fetal Medicine on the safe prevention of the primary cesarean section. Among other points, it addressed management guidelines for the most frequent indications for primary cesarean deliveries, namely, labor dystocia, abnormal or indeterminate fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected macrosomia.

The report encouraged obstetricians to allow more time to progress through a vaginal delivery without intervention, recommended improved and standardized fetal heart rate interpretation and management, and advocated access to non-medical interventionsduring labor, such as continuous labor and delivery support.

A study by researchers at Harvard Medical School and the Stanford University School of Medicine published December 2015 in The Journal of the American Medical Association suggested that based on analyses of cesarean section rates and maternal and neonatal outcomes among 194 WHO member countries the ideal rate of childbirth by cesarean section approximates 19% of all births as opposed tothe previously considered optimal rate of 10-15%. Although the finding is higher than the former target, it remains significantly lower than the current rate in U.S. hospitals.

In its April 2015 position statement on cesarean delivery, the WHO moved away from any target rate. Rather, it emphasized that every effort should be made to ensure cesarean sections are provided to the women in need and only be performed when medically necessary.

It is gratifying that the concept of “target rate” is no longer tied to the delivery of quality medical care. Primarily due to the lack of a consistent classification system to monitor and compare different obstetric profiles, meaningful data relative to cesarean section rates is missing.

It is only when such systems as the Robson Ten Group Classification System are widely adopted by institutions that valid “risk-adjusted”cesarean section rates can potentially be developed and comparisons be made between institutions, regions, and countries.

IVF and Childhood Cancer Risk

By Dr. Allen Cherer

On March 2, 2016

In Child Health Care

Assisted Reproductive Technology (ART) has been successfully employed to treat infertility. In vitro fertilization (IVF) is one form of ART, and it is unclear whether it increases the risks of birth defects . Since childhood cancers, such as leukemia, occur earlier in life, it is reasonable to question if factors related to early embryonic development and intrauterine environment may play a role in their occurrence.

A recent study from Norway suggests a slightly increased risk of childhood leukemia and Hodgkin’s lymphoma among children born through the use of ART. The findings were based on a review of children born between the years 1984 and 2011 and the use of ART. The data were then paired with cancer registry data. Out of 4500 cancer patients identified, 51 were conceived via ART. Although overall cancer risk was not found to be increased among ART children, the odds of leukemia and Hodgkin’s lymphoma were.

As pointed out by Dr. Susan Amirian, assistant professor with the Baylor College of Medicine’s Duncan Cancer Center in an accompanying editorial, although the findings suggest a possible association, the very small numbers of actual cases (17 cases of leukemia and 3 cases of Hodgkin’s lymphoma) call for caution in interpretation of the results. It would require more studies to establish a true association. Certainly other health factors that result in infertility may play a role in the apparent association.

At this point, the study results should not deter parents from using assisted reproductive technology and only careful monitoring of children born using the techniques is warranted. Take a look at this link for more information about this study.

Physical Trauma and Pregnancy

By Dr. Allen Cherer

On February 20, 2016

In Neonatal Care

Trauma is an important cause of maternal and fetal morbidity and mortality, and blunt abdominal trauma is a particular concern. Approximately 8% of pregnant women sustain some form of traumatic injury. Automobile accidents and falls account for most of the injuries.

Studies of pregnant women involved in automobile accidents have demonstrated increased rates of premature rupture of membranes, placental abruption, preterm birth, and stillbirth. A recent study examines pregnancies complicated by traumatic injuries and outcomes in relation to place of triage.

According to the retrospective study published in the Journal of the American College of Surgeons, pregnant women who sustained traumatic injuries and were triaged to trauma centers experienced improved pregnancy outcomes compared to women cared for in non-trauma hospitals. For the study, the researchers linked two databases, the Washington State Birth Events Records Database and the Comprehensive Hospital Abstract Recording System.

The method allowed them to assess the maternal and neonatal outcomes of all injured, pregnant women (3429 patients) who were hospitalized in Washington State between the years 1995 and 2012. The findings showed that after adjusting for a number of confounding factors, including injury severity score, pregnant women who were cared for in trauma facilities had better outcomes with significantly decreased odds of preterm labor, preterm birth, and low birth weight infants.

Since trauma centers are specialized medical facilities which have optimal processes and resources in place to monitor and treat injured patients, the study suggests that many injured, pregnant women may in fact be under-triaged and treated in non-trauma hospitals where their care may not be optimal.

According to the coauthors, John Distelhorst, DO, MPH and Vijay Krishnamoorthy, MD, the findings may lead to further analyses of state trauma systems and the triage of specific patient populations to improve quality of care and patient outcomes. To read more about this, please visit this site.

Proton Radiotherapy: A Gentler Form of Radiation Treatment

By Dr. Allen Cherer

On February 18, 2016

In Child Health Care

Recent studies in Pediatric patients with brain tumors point to the efficacy of a new way of delivering radiation treatment which may result in improved long term outcomes for children. Although not widely available, the new treatment, proton radiotherapy, focuses the radiation dose on the target area alone. Standard photon (X-ray) radiation has the troublesome effect of exposing surrounding healthy tissues and organs to the radiation as well. The new treatment has the distinct advantage of getting to “hard to get to” tumors.

A new study completed at the Massachusetts General Hospital describes the results in a Pediatric patient population with medulloblastoma treated with the usual combination of surgery, radiation, and chemotherapy. Medulloblastoma is a fast-growing, high grade tumor always located in the cerebellum of the brain. It is a relatively rare tumor with more than 70% being diagnosed in children under 10 years of age. Like many tumors, its exact cause is unknown. In the study, the newer form of targeted radiation therapy was used and compared with the more conventional (photon) radiation. The results, as pointed out by Dr. Torunn Yock, Associate Professor of Radiation Oncology at Harvard Medical School, showed comparable survival and tumor recurrence risks as well as long term hormone deficits between the two groups but far fewer side effects related to hearing, cognition, and other organ systems.

The results are exciting in that they demonstrate the efficacy and safety of proton radiotherapy with decreased long term side effects, thus improving the quality of life in these young survivors.

Approaching a Birth Plan

By Dr. Allen Cherer

On February 14, 2016

In Neonatal Care

Pregnancy is an exciting time for expectant parents, and childbirth is a miraculous event. Nevertheless,due to the innate unknowns, it can result in considerable anxiety and sense of loss of control. One means of combating these feelings is through thoughtful preparation of a birth plan based on realistic and trustful communication among all the parties who will be involved.

Since the early Roman period, pregnant women in labor had been attended by friends, relatives, or others experienced in aiding with childbirth. As time progressed, the management of the laboring woman became more involved and the advancement of technologies to better monitor the unborn child and the mother required a change in the birth place and the sophistication of the caregivers.

Currently,the vast majority (>98%) of deliveries in the U.S. occur in the hospital setting and are attended by midwives or physicians. In association with these changes came the option of operative delivery (cesarean section) which in 2012 accounted for close to 30% of all births in the United States, according to the Centers for Disease Control and Prevention (CDC). Cesarean sections are known to be medically indicated for a number of reasons to safeguard the well being of baby and/or mother.

At the same time, for most pregnancies that are low risk, cesarean section may pose greater risks than vaginal delivery, especially risks related to future pregnancies. Due to the recent rapid increase in the cesarean section rate and concerns that operative delivery is overused without clear evidence of improved maternal or newborn outcomes, the American College of Obstetricians and Gynecologists (ACOG) issued in 2014 new recommendations targeted at preventing women from having cesarean sections with their first birth and at decreasing the national cesarean rate.

Pain management is a significant component of the birth plan. Although most mothers report only mild discomfort during early labor, as contractions become stronger, longer, and more frequent, pain intensifies and may require relief with either spinal or epidural anesthesia.

Although the medications are generally considered safe, very rare complications can occur. For those women opting for a more natural childbirth, the participation in a yoga program during pregnancy or the use of hypnosis have been described.

Whatever birth plan is developed for an individual pregnancy, it should always be tempered based onthe saying “the best laid plans of mice and men often go awry”. The overriding goal should always be a safe birth for both mother and baby. If communication and trust exist among all parties, childbirth can be a magnificent process.

Eating Tips for Your Pregnancy

By Dr. Allen Cherer

On February 7, 2016

In Neonatal Care

The nutritional status of women when becoming pregnant and during pregnancy can have significant influence on infant and maternal health problems. Numerous studies of nutritional education and counseling before and during pregnancy have demonstrated beneficial effects in terms of improved gestational weight, increased head circumference, reduced risk of preterm birth, and reduced risk at birth of maternal anemia.

A pregnant woman needs to ensure that her diet provides enough nutrients and energy for her baby to grow and develop properly and also to make sure her body is capable of sustaining the multiple demands that come with pregnancy. Caloric intake grows with pregnancy and weight gain varies considerably. For the average healthy woman, ideal weight gain is 25-35 lbs during the nine month pregnancy.

Either excessive or insufficient weight gain can be deleterious to the health of both the baby and the mother. In general, mother’s diet needs to be balanced and nutritious, involving right proportions of protein, carbohydrate, and fat while consuming a wide variety of fruits and vegetables.

Specifically, fat should provide no more than 30% of daily calories with monosaturated fats being preferable. Examples are foods such as olive oil, peanut oil, sesame oil, canola oil, avocado, and many nuts and seeds. Excellent sources of carbohydrates are potatoes, rice, pasta, and bread.

Animal-sourced protein includes lean meat and fish, as well as eggs. Beans, lentils, and legumes are good sources of protein as well as being rich in iron. Quinoa is notable as a source of all the essential amino acids. As far as fruits and vegetables, fresh and frozen produce usually have higher vitamin and nutrient content as well as being excellent sources of fiber.

Micronutrient deficiencies can be addressed through diet as well as supplements. The value of prenatal vitamins cannot be overemphasized. Folic acid, iron, vitamin D, calcium, iodine, and zinc are especially important during pregnancy. Adequate folic acid before and during pregnancy is critical in preventing neural tube defects which affect the brain and spinal cord. Recommended daily intake is 400-600 mcg.

During pregnancy, maternal blood volume increases significantly and adequate iron supplementation is required to prevent anemia and promote adequate oxygen carrying capacity. Vitamin D deficiency is common even in the non-pregnant state. Adequate Vitamin D during pregnancy is critical for normal fetal skeletal development and may be beneficial in mother to prevent preeclampsia.

Recommended dose is controversial and ranges from 600-4000 IU/day. Iodine is important for normal fetal thyroid development and function.

Clearly, pregnancy places impressive metabolic demands on the mother’s body. Only through nutritional education and counseling can the best outcomes for both mother and baby be achieved.