Stephen Mark Borowitz

In industrialised areas of Europe, North America, Australia and New Zealand, vitamin B12 deficiency during infancy is thought to be uncommon and the majority of reported cases are in exclusively breastfed infants of mothers consuming vegetarian or vegan diets. We describe a breastfed infant whose mother eats a very diverse diet who developed growth failure, refusal to wean from the breast or eat solid foods and irritability as a result of profound vitamin B12 deficiency caused by unrecognised maternal vitamin B12 deficiency likely secondary to asymptomatic atrophic gastritis and pernicious anaemia. Recent literature suggests vitamin B12 deficiency in breastfed infants is much more common than previously recognised and this case emphasises the importance of considering the possibility of vitamin B12 deficiency in any breastfed infant with poor growth, neurologic symptoms or signs, developmental delay and/or feeding difficulties, particularly difficulty with introduction of complementary foods or weaning from the breast.

Background: Electronic health records (EHRs) play a substantial role in modern health care, especially during prerounding, when residents gather patient information to inform daily care decisions of the care team. The effective use of the EHR system is crucial for efficient and frustration-free prerounding. Ideally, the system should be designed to support efficient user interactions by presenting data effectively and providing easy navigation between different pages. Additionally, training on the system should aim to make user interactions more efficient by familiarizing the users with best practices that minimize interaction time while using the full potential of the system’s capabilities. However, formal training on EHR systems often falls short of providing residents with all the necessary EHR-related skills, leading to the adoption of inefficient practices and the underuse of the system’s full range of capabilities. Objective: This study aims to examine the efficiency of EHR use during prerounding among pediatric residents, assess the effect of experience level on EHR use, and identify areas for improvement in EHR design and training. Methods: A mixed methods approach was used, involving a self-reported survey and video analysis of prerounding practices of the entire population of pediatric residents from a large teaching hospital in the South Atlantic Region. The residents were stratified by experience level by postgraduate year. Data were collected on the number of pages accessed, duration of prerounding, task completion rates, and effective use of data sources. Observational and qualitative data complemented the quantitative analysis. Our study followed the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) reporting guidelines, ensuring completeness and transparency of reporting. Results: Of the 30 pediatric residents, 20 were included in the analyses; of these, 16 (80%) missed at least 1 step during prerounding. Although more experienced residents on average omitted fewer steps, 4 (57%) of the 7 most experienced residents still omitted at least 1 step. On average, residents took 6.5 minutes to round each patient and accessed 21 pages within the EHR during prerounding; no statistically significant differences were observed between experience levels for prerounding times (P=.48) or number of pages accessed (P=.92). The use of aggregated data pages within the EHR system neither seem to improve prerounding times nor decrease the number of pages accessed. Conclusions: The findings suggest that EHR design should be improved to better support user needs, and hospitals should adopt more effective training programs to familiarize residents with the system’s capabilities. We recommend implementing prerounding checklists and providing ongoing EHR training programs for health care practitioners. Despite the generalizability of limitations of our study in terms of sample size and specialization, it offers valuable insights for future research to investigate the impact of EHR use on patient outcomes and satisfaction, as well as identify factors that contribute to efficient and effective EHR usage.

The most common symptom attributed to ankyloglossia is difficulty breast feeding due to poor latch, inefficient milk extraction and/or maternal nipple pain. During the past two decades, despite a declining birth rate, there has been a dramatic increase in the number of infants diagnosed with and treated for ankyloglossia in the United States, Canada and Australia. Despite a dramatic increase in the diagnosis and treatment of ankyloglossia in these countries, there remains no universally agreed upon definition of ankyloglossia and none of the published scoring systems have been rigorously validated. However ankyloglossia is defined, the majority of infants with ankyloglossia are asymptomatic. Perhaps, infants with ankyloglossia have a greater incidence of difficulty breast feeding. Lingual frenulotomy may decrease maternal pain and at least transiently improve the quality of breast feeding in some infants however no published studies take into account the fact that sucking and feeding are soothing to infants and the observed improvements immediately following frenulotomy may be a response to the pain associated with the procedure rather than a result of the procedure itself. While there are almost certainly some infants in whom tongue-tie interferes with breast-feeding, there is currently no good evidence lingual frenulotomy leads to longer duration of breast-feeding. Frenulotomy appears to be a generally safe procedure however there are reports of serious complications. Finally, there are no studies of long-term outcomes following frenulotomy during infancy and given traditional thinking that the lingual frenulum is a cord of connective tissue tethering the tongue to the floor of the mouth may be incorrect and the frenulum contains motor and sensory branches of the lingual nerve, the procedure may be less benign than previously thought.

Historically, inflammatory bowel disease (IBD) was most common in North America and Europe and more common with a north-south gradient. Over the past century, there has been a marked increase in IBD in general and in childhood IBD in particular and over the past 50 years IBD has spread into the developing world. The greatest risk factor of developing IBD is an affected family member. Concordance rates between dizygotic twins is ∼4% and ∼50% in monozygotic twins, and more than half of pairs are diagnosed within 2 years of each other. Nevertheless, most patients with IBD do not have an affected family member. More than 200 genes are associated with an increased risk for IBD, but most associations are weak with odds ratios between 1.2 and 2.0 suggesting the environment plays a role. IBD is more common in urban than rural regions and is associated with “good standards” of domestic hygiene during childhood. People who migrate from areas with a low incidence to areas with a high incidence of IBD have an increased risk of developing IBD and the younger they are when they migrate, the greater their risk of developing IBD. Moreover, people who migrate from regions with a high incidence to areas with a low incidence of IBD have a decreased risk of developing IBD. Together, these findings strongly suggest particular environmental exposures occurring early in life may trigger inflammatory bowel disease in genetically susceptible individuals. The key is figuring out what those exposures might be.

BACKGROUND Electronic health records (EHRs) play a substantial role in modern health care, especially during prerounding, when residents gather patient information to inform daily care decisions of the care team. The effective use of the EHR system is crucial for efficient and frustration-free prerounding. Ideally, the system should be designed to support efficient user interactions by presenting data effectively and providing easy navigation between different pages. Additionally, training on the system should aim to make user interactions more efficient by familiarizing the users with best practices that minimize interaction time while using the full potential of the system’s capabilities. However, formal training on EHR systems often falls short of providing residents with all the necessary EHR-related skills, leading to the adoption of inefficient practices and the underuse of the system’s full range of capabilities. OBJECTIVE This study aims to examine the efficiency of EHR use during prerounding among pediatric residents, assess the effect of experience level on EHR use, and identify areas for improvement in EHR design and training. METHODS A mixed methods approach was used, involving a self-reported survey and video analysis of prerounding practices of the entire population of pediatric residents from a large teaching hospital in the South Atlantic Region. The residents were stratified by experience level by postgraduate year. Data were collected on the number of pages accessed, duration of prerounding, task completion rates, and effective use of data sources. Observational and qualitative data complemented the quantitative analysis. Our study followed the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) reporting guidelines, ensuring completeness and transparency of reporting. RESULTS Of the 30 pediatric residents, 20 were included in the analyses; of these, 16 (80%) missed at least 1 step during prerounding. Although more experienced residents on average omitted fewer steps, 4 (57%) of the 7 most experienced residents still omitted at least 1 step. On average, residents took 6.5 minutes to round each patient and accessed 21 pages within the EHR during prerounding; no statistically significant differences were observed between experience levels for prerounding times (P=.48) or number of pages accessed (P=.92). The use of aggregated data pages within the EHR system neither seem to improve prerounding times nor decrease the number of pages accessed. CONCLUSIONS The findings suggest that EHR design should be improved to better support user needs, and hospitals should adopt more effective training programs to familiarize residents with the system’s capabilities. We recommend implementing prerounding checklists and providing ongoing EHR training programs for health care practitioners. Despite the generalizability of limitations of our study in terms of sample size and specialization, it offers valuable insights for future research to investigate the impact of EHR use on patient outcomes and satisfaction, as well as identify factors that contribute to efficient and effective EHR usage.

Humans are the only mammals who feed our young special complementary foods before weaning and we are the only primates that wean our young before they can forage independently. There appears to be a sensitive period in the first several months of life when infants readily accept a wide variety of tastes and this period overlaps with a critical window for oral tolerance. As a result, infants should be exposed to a wide variety of flavors while mother is pregnant, while mother is nursing and beginning at an early age. There also appears to be a sensitive period between 4 and 9 months when infants are most receptive to different food textures. There remains debate about when it is best to begin introducing solid foods into an infant's diet however, the available evidence suggests that provided the water and food supply are free of contamination, and the infant is provided adequate nutrition, there are no clear contraindications to feeding infants complementary foods at any age. There is emerging evidence that introduction of solid foods into an infant's diet by 4 months may increase their willingness to eat a variety of fruits and vegetables later in life, decrease their risk of having feeding problems later in life, and decrease their risk of developing food allergies, and the early introduction of solid foods into an infant's diet does not appear to increase their risk of obesity later in childhood.

Sodium is an essential nutrient and inadequate sodium intake and/or excessive sodium losses can result in suboptimal growth. Infants with ileostomies are at significant risk of developing growth failure as a result of excessive sodium loss in their ileostomy effluent. Chronic sodium depletion can also limit the kidney’s ability to excrete hydrogen and potassium ions, mimicking electrolyte abnormalities found in type 4 renal tubular acidosis. This report describes an infant with an ileostomy with severe growth failure, hyperkalaemia and metabolic acidosis—all of which promptly resolved with sodium supplementation.

Article Citation: Stephen M. Borowitz, Linda A. Waggoner-Fountain, and Ellen J. Bass (2013) Impact of a Computerized System on Resident Sign-Out. Biomedical Instrumentation & Technology: Human Factors & IT, Vol. 47, No. s2, pp. 68-72.

We report an ongoing outbreak of ulcerative colitis and Crohn's disease in Forest, Virginia involving 15 unrelated children and teenagers who resided in close proximity to dairy farms. Some of our cases demonstrated serologic evidence of Mycobacterium avium subspecies paratuberculosis infection, suggesting its potential role as an etiologic agent.

Background: During sign-out (handover of care), information and responsibility about patients is transferred from one set of caregivers to another. Few residency training programmes formally teach resident physicians how to sign out or assess their ability to sign out, and little research has examined the sign-out process. Objective: To characterise the effectiveness of the sign-out process between resident physicians on an acute care ward. Design/methods: Resident physicians rotating on a paediatric acute care ward participated in a prospective study. Immediately after an on-call night, they completed a confidential survey characterising their night on call, the adequacy of the sign-out they received, and where they went to get information they had not received during sign-out. Results: 158 of 196 (81%) potential surveys were collected. On 49/158 surveys (31%), residents indicated something happened while on call they were not adequately prepared for. In 40/49 instances residents did not receive information during sign-out that would have been helpful, and in 33/40 the situation could have been anticipated and discussed during sign-out. The quality of sign-out (assessed using a five-point Likert scale from 1 = inadequate to answer call questions to 5 = adequate to answer call questions) on the nights when something happened the resident was not adequately prepared for were significantly different than the nights they felt adequately prepared (mean (SD) score 3.58 (0.92) and 4.48 (0.70); p = 0.001). There were no significant differences in: how busy the nights were; numbers of patients on service at the beginning of the call shift; numbers of admissions during a call shift; numbers of transfers to an intensive care unit; whether residents were “cross-covering” or were members of the general ward team; or whether the resident had cared for the patient previously. Conclusion: Although sign-out between resident physicians is a frequent activity, there are many times when important information is not transmitted. Analysis of these “missed opportunities” can be used to help develop an educational programme for resident physicians on how to sign out more effectively.