During the first year of life, infants spend most of their time in the sleeping state. Assessment of sleep during infancy presents an opportunity to study the impact of sleep on the maturation of the central nervous system (CNS), overall functioning, and future cognitive, psychomotor, and temperament development. To assess what is currently known regarding sleep during infancy and its effects on cognitive, psychomotor, and temperament development, we assessed the relevant literature published over the last several decades. To provide a foundation for a more in-depth understanding of this literature, we preface this with an overview of brain maturation, sleep development, and various assessment tools of both sleep and development during this unique period. At present, we do not have sufficient data to conclude that a causal relationship exists between infant sleep and cognitive, psychomotor, and temperament development. Caution should be used in predicting outcomes, as the timing and subjectivity of evaluations may obviate accurate assessment. Collectively, studies assess a wide array of sleep measures, and findings from one developmental period cannot be generalized readily to other developmental periods. Future studies should follow patients longitudinally. Additionally, refinements of existing assessment tools would be useful. In view of the relatively high reported pediatric prevalence of cognitive and behavioral deficits that carry significant long-term costs to individuals and society, early screening of sleep-related issues may be a useful tool to guide targeted prevention and early intervention.

Corresponding author's email: Paul.Boesch@cchmc.orgPressure ulcers are commonly acquired in pediatric institutions and are a key indicator of standard and effectiveness of care. Rationale:Pressure ulcers are associated with pain, infection, and length of hospitalization. Tracheostomy tubes cause pressure ulcers by creating a constant pressure interface with further disruption of skin integrity due to wetness from sweat and respiratory secretions. We recognized a high rate of tracheostomy-related pressure ulcers (TRPU) in our ventilator unit and instituted a quality improvement program to develop and test potential interventions for TRPU prevention. We condensed them into a clinical bundle, and then implemented it into standard clinical practice.The setting was an 18-bed multidisciplinary unit within an academic children's hospital, whose primary mission is transition of Methods: children requiring invasive mechanical ventilation to home. All tracheostomy-dependent patients from July 2008-August 2010 were included. TRPU stage, description, number of days each TRPU persisted, and bundle compliance were recorded in real time. All TRPU were staged by a wound-care expert within 24 hours. The intervention model utilized a rapid-cycle, Plan-Do-Study-Act (PDSA), framework for improvement research. The interventions identified for incorporation into the TRPU-prevention bundle included the following: Skin Braden Q risk assessment and full body skin assessments daily, and device assessments every 8 hour shift, assessment:Moisture-free Hydrophilic polyurethane foam under tracheostomy to wick moisture from the skin surface, device interface:Pressure-free device "extended" style tracheostomy tubes in children with anatomy in which the neck was not clearly exposed in the neutral position interface: (figure 1). Figure 1 Fit of standard vs. extended-style tracheostomy tube in ventilated infant. Note the crowding of the ventilator circuit in the neck with focal pressure of the adapter edge against the sternum. This is the site of 72% of the TRPU that developed during the study period.Over the study period there were 717 patients and 8770 trach days evaluated; 22 TRPU were identified. There was a significant Results: decrease in the rate of patients who developed a TRPU from 8.1% during the baseline period, to 2.6% during bundle development, and 0.5% after the bundle was implemented (figure 2). The percentage of trach days affected by a TRPU decreased from 12.5% to 0.4% between baseline and implementation periods. There was a marked difference between standard and extended tracheostomy tubes in TRPU occurrence (3.7% vs 0%, P=0.035) and days affected by a TRPU (6% vs 0.2%, P<0.0001). Figure 2

Education and ongoing assessment of skin integrity and the use of devices that minimize pressure at the tracheostomy-skin interface effectively reduce TRPU even among a population of children at high risk. These interventions can be integrated into daily workflow and result in sustained effect.

To increase clinician adherence to prescribing guidelines for pulmonary medications in children with cystic fibrosis (CF). Design: Quality improvement project with multiple time series design. Setting: The CF center at a tertiary care pediatric hospital in the United States. Patients: Children with CF who were eligible to receive oral azithromycin, nebulized dornase alfa, or inhaled tobramycin sulfate based on prescribing guidelines for CF lung disease. Intervention: Evidence-based prescribing guidelines were designed by a local committee to reflect consensus recommendations from the CF Foundation. Clinicians and families were educated about guidelines. Adherence to prescribing guidelines was tracked using a local CF database and record reviews. Weekly meetings were used to highlight adherence failures and promote clinician accountability. Main Outcome Measure: The rate of clinician adherence to prescribing guidelines. Results: One hundred seventy patients with CF were included. At the start of the project, the rate of clinician adherence to prescribing guidelines was 62%. After 3 months of the project, the rate of clinician adherence to prescribing guidelines was 87% (odds ratio=4.6; 95% confidence interval, 3.0-7.0). The improvements in adherence to prescribing guidelines were sustained for 21 months of follow-up. Conclusions: Educating clinicians about prescribing guidelines, sharing guidelines with families, and monitoring clinician adherence improve prescribing adherence to evidence-based recommendations.

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