Two generations--reflections on changes in the treatment of a chronic disease.
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Aftercare↗
Biomedical subjects
L M Osborn
Publications and source records attributed to L M Osborn.
Outcome of pregnancies experienced during residency.
To investigate potential adverse effects of residency training on pregnancy outcome, a cohort study was conducted among 45 university-affiliated residency programs. Outcomes of the first pregnancy experienced during residency were compared between 92 female residents and 144 spouses of male residents. Despite long hours, sleep deprivation, and an increase in perceived stress, the female residents were as likely to give birth to a live, full-term newborn as the spouses of male residents. For white cohort members, an increased risk of premature labor without delivery was identified (RR = 12.3, 95% confidence interval 2.4-61.6). No significant differences were found in prematurity, spontaneous and therapeutic abortions, or presence of congenital abnormalities in the infants. Method of delivery and use of anesthetics and of other medications were similar in both groups. Pregnancy outcomes between the two groups were similar; however, the increased risk for premature labor among female residents is a cause for concern and should be further investigated.
Adult↗
Group well-child care offers unique opportunities for patient education.
By using a group process, health educators can greatly increase the cost effectiveness of well-child care. Benefits of group care, compared with traditional well-child care, include increased time for patient education, prolonged observation of parent-child interactions, the ability to observe children with their peers, and the opportunity to employ a broad variety of teaching techniques, such as role-modeling. This paper describes the author's 15 years of experience using this model, illustrating with examples the advantages of group well-child care.
Child Behavior↗
Preventive health care utilization. Prenatal and the first 3 years in a Utah population.
The utilization of preventive health care services prenatally and for children up to 3 years old was determined by mailed questionnaire. The parents surveyed were randomly chosen from birth records provided by the Utah Bureau of Vital Records. "Adequate use of preventive services" was defined as six prenatal visits for a full-term pregnancy and as seven well-child visits during the first 3 years of life. Responses, received from 219 (36.5%) parents, indicated only 1 percent did not utilize adequate prenatal care. Women made an average of 11.3 visits during their pregnancies; 83 percent saw their prenatal health care provider at least 10 times. Well-child visits were less adequately utilized, an average of 6.3 visits per child. Fifty-six percent made fewer than seven visits; only 23 percent made all of the nine visits recommended by the American Academy of Pediatrics. Patients who made seven or more well-child visits were more likely to have received their fourth diphtheria, pertussis, tetanus (DTP) immunization and to have health insurance policies that paid for preventive health care services. Results indicate that families use preventive services more consistently before the birth of their children than after. Use of preventive services is associated with adequate insurance coverage and results in more thorough immunization.
Adult↗
Influence of parental knowledge and opinions on 12-month diphtheria, tetanus, and pertussis vaccination rates.
To assess the magnitude and cause of decreasing diphtheria, tetanus toxoids, and pertussis (DTP) immunization rates, a retrospective cohort study investigated the immunization status against pertussis among 1-year-old children in Utah. Questionnaires were sent to the parents of 2975 children born in June 1985. Parents were asked about each child's DTP immunization status, including the number, type, and dates of the vaccinations, reasons for or against vaccination, and their knowledge of whooping cough and the vaccine. Children were considered adequately immunized against pertussis when they had received three DTP vaccinations by their first birthday. In Utah, the lack of pertussis immunization among young children is a serious problem: greater than 30% of 1-year-old children were not adequately protected. Accurate parental knowledge about the relative risks of vaccination and illness was associated with a greater likelihood for immunization. Although some parents chose to forego the vaccination because they were concerned about its side effects, the most common reason for incomplete immunization was illness at the time the vaccination was to be given. If immunization rates are to improve, health care professionals must not only make an effort to educate the general population regarding the vaccine, but they must also ensure immediate follow-up for immunization when the procedure is delayed.
Attitude to Health↗
Female residents not at increased risk for adverse pregnancy outcome.
A cohort study was conducted among 45 university-affiliated residency programs to investigate potential adverse effects of residency training on pregnancy outcome. Pregnancy outcomes between female residents and spouses of male residents were similar; however, the increased risk for premature labor among female residents is a cause for concern and should be further investigated.
Adult↗
Management of neonatal jaundice.
Jaundice is the most commonly encountered neonatal clinical problem; 80 percent of neonates become clinically jaundiced, while 5 percent develop serum bilirubin levels above currently recommended treatment standards. This article outlines theories about the pathophysiology of neonatal jaundice and presents a logical approach to its management. First, the health care provider must distinguish between physiologic, exaggerated and pathologic jaundice. The treatment modalities of exchange transfusion, phototherapy and cessation of nursing are discussed.
Bilirubin↗
Temperature and fever in the full-term newborn.
In order to establish temperature norms during the first nine days of life, a retrospective analysis of 501 neonates was completed. After norms were derived, charts of all infants born at the UCLA Medical Center in 1979 were reviewed. Data were analyzed on every infant who had a recorded temperature greater than two standard deviations above the mean high. Sustained fever was unusual but highly predictive of infection. Infants rarely had fever, however, as the only sign of infection. Single elevated temperature readings were not associated with infection.
Bacterial Infections↗
Breast feeding and jaundice in the first week of life.
Infants who most commonly receive treatment for neonatal hyperbilirubinemia are breast-fed babies in whom no cause for the jaundice can be determined. Hyperbilirubinemia in these newborns may not be caused by the breast feeding as such, but rather by inadequate nursing. This paper reports attempts to decrease readmissions for phototherapy at the UCLA Medical Center by inducing earlier and more functional lactation in the entire nursery population and by formula feeding infants whose bilirubins approached recommended treatment levels. Nursing was interrupted for 24 to 48 hours in 87 newborns; six still required readmission, while 81 were successfully treated at home. At the two-week well-baby visit, no differences in the incidence of breast feeding were found when comparing nonjaundiced breast-fed babies with infants who were taken off the breast or who were readmitted for phototherapy. Differences in the cost of care were significant with an average cost per patient of $126 for those treated at home compared with $1,440 for those readmitted. Policies designed to induce earlier lactation did nothing to decrease the incidence of exaggerated jaundice in the study's breast-fed population. It was concluded that supervised setting with careful counseling and follow-up, can provide an effective alternative to readmission and phototherapy in the treatment of jaundice.
Bilirubin↗
Group well-child care.
Well-child care can be a positive influence on parent-child relationships when social, psychological, and emotional health are stressed. Because of its brevity, the traditional well-child visit does not offer adequate opportunities to address these issues. A group format, in which four to six parent-infant pairs meet, changes the character of the child health maintenance visit. Advantages of group visits include increased time for patient education, more active parental participation, greater time for the physician to observe parents and their children, and more reassurance for parents that they and their children are normal. Problems of group visits are those of space and scheduling. Few pediatric offices have ideal space for group visits, so many visits take place in cramped quarters. Siblings can be disruptive to the group and should be excluded. A dedicated receptionist and an efficient nurse are essential if the groups are to run smoothly. Because the visits last one to one-and-one-half hours, only one group visit can be scheduled during a half day. Although parents of varied socioeconomic and cultural backgrounds benefit from group visits, this format appears to be most acceptable to white, middle-class families. The content of group visits is somewhat dependent upon parental questions and concerns; however, the physician must be careful to include important issues that do not usually arise spontaneously. These topics usually include safety, disease prevention, and anticipatory guidance. Although group visits may not fit every practice, the format does offer to both obstetricians and pediatricians some exciting possibilities. The increased patient-provider contact and the increased patient participation help establish better rapport, better educate families about health, and hopefully, will produce better babies.
Child Health Services↗
Phototherapy in full-term infants with hemolytic disease secondary to ABO incompatibility.
Current guidelines for treatment of hemolytic disease of the newborn make no differentiation between ABO and Rh incompatibility. A protocol that prolonged the observation period in full-term, ABO-incompatible infants with positive Coombs' tests who were otherwise healthy was tested. Postponement of treatment made it possible to determine more accurately which infants needed phototherapy. This dramatically decreased the number of infants treated without increasing their risk of requiring exchange transfusion.
ABO Blood-Group System↗
Jaundice in the full-term neonate.
Hyperbilirubinemia is the most common problem experienced by the full-term infant in the immediate neonatal period. The development of jaundice was prospectively investigated in 866 newborns. Significant correlations were found between the serum bilirubin level and the method of birth, perinatal complications, blood group incompatibilities, birth weight, and method of feeding. Breast-feeding was highly related to the development of exaggerated jaundice. The most common occurrence of jaundice requiring phototherapy was in breast-feeding infants in whom no cause for the jaundice could be determined. Study findings were most compatible with a theory of relative caloric deprivation as an explanation of the increased incidence of hyperbilirubinemia found in breast-fed newborns.
Bilirubin↗
Campylobacter enteritis: prenatal and perinatal implications.
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Adolescent↗
The Winnecott "set situation". A useful tool for the pediatrician.
D.W. Winnecott devised a short, simple test which he used to evaluate normal infants. In this study, we compared 9-month-old infants' behaviors elicited during the Winnecott Test (WSS), both with historical data and with their behavior during a structured separation from their mothers. We found significant correlations between the WSS, the structured separation, and historical data. This simple test can provide the practitioner with invaluable information regarding the infant, his temperamental style, and his relationship with others.
Anxiety, Separation↗
Teaching well child care.
Despite recommendations that the emphasis of the well child visit be on behavior and development, some studies indicate that pediatricians continue to spend a relatively small percentage of each well baby visit on these subjects. One factor contributing to the discrepancy between current recommendations and practice may be the way we teach residents to perform this task. In this study, we investigated and evaluated current methods for teaching well child care. Our data indicate that the content of well child care is being taught, but that problems with teaching setting, methods and frequency of supervision, and lack of formal evaluation may be among the factors which contribute to our continued inability to change the focus of well child visits.
Allied Health Personnel↗
Circumcision. A study of current practices.
The purpose of this study was to investigate the current incidence of circumcision, the reasons governing parental decisions regarding circumcision, the immediate and later complications from the procedure, as well as genital problems occurring in uncircumcised boys. The incidence of circumcision was found not to have changed over the past five years despite the recommendations of the American Academy of Pediatrics Task Force on Circumcision. The reasons given for circumcision reflected mostly the strength of tradition, rather than a medical approach. Four per cent of newborns experienced early complications from the procedure, whereas 13 per cent experienced later, minor complications. Problems reported in uncircumcised infants were probably variants of normal. While the results of this study and evidence for discontinuing neonatal circumcision, we strongly recommend that, if physicians dissuade parents from having their infants circumcised, they must give adequate information concerning hygiene and the slow, natural separation of the foreskin from the glans.
Child↗
Clinical estimation of liver size in newborn infants.
Liver size was measured in 100 healthy newborn infants of gestational ages 35 to 44 weeks. A mean liver span of 5.9 +/- 0.8 cm was determined in these infants by measuring the distance between the percussed upper and palpated lower liver borders along the midclavicular line. This value correlated well with measurements derived from percussing both borders (r = .8) and correlated poorly with measurements of liver projection below the costal margin (r = .55). The practice of reporting liver projection below the costal margin as a single indicator of liver size should be discouraged.
Gestational Age↗
Failure to thrive secondary to upper respiratory tract obstruction and cor pulmonale.
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Cleft Palate↗