of P e d i a t r i c s , Camden, New J e r s e y Over t h e p a s t decade, o b s t e t r i c i a n s have begun t o u t i l i z e maternal perception of f e t a l movements i n utero as a measurement of f e t a l well-being.Some have speculated t h a t f e t a l movements may be a q u a l i t a t i v e measure of p l a c e n t a l perfusion. Recent f i n d i n g s of brainstem g l i o s i s i n victims of Sudden I n f a n t Death Syndrome ( s I D s ) '~~~ other i n d i c a t o r s of d e f i c i e n t brainstem funct i o n have l e d Naeye and others t o p o s t u l a t e t h a t i n t r a u t e r i n e hypoxemia may be an important p r e n a t a l f a c t o r i n such children. The possible c o r r e l a t i o n &tween decreased f e t a l movements and i n t r a u t e r i n e hypoxemia l e d us t o question mothers of i n f a n t s who d i e d of SIDS, a s well a s mothers of i n f a n t s with observed apnea and cyanosis, about the movements of t h e i r children p r i o r t o delivery. A s i g n i f i c a n t decrease i n f e t a l a c t i v i t y was recorded only i f t h e r e was a t o t a l absence of a c t i v i t y f o r 24 consecutive hours o r longer during t h e pregnancy. Forty percent (8/20) of SIDS victims were r e t r o s p e c t i v e l y r e c a l l e d by t h e i r mothers t o have decreased i n t r a u t e r i n e a c t i v i t y . Similar questioning of mothers of "near m i s s " i n f a n t s l e d t o a 43% (59/137) response i n d i c a t i v e of an absence of f e t a l a c t i v i t y f o r a t l e a s t 24 hours. Clearly t h i s represents a very s i g n i f i c a n t minority of t h e SIDS population. A prospective study of i n f a n t s e x h i b i t i n g decreased f e t a l a c t i v i t y is being designed t o t e s t t h i s hypothesis.I d e n t i f i c a t i o n of such previously unrecognized "at r i s k " i n f a n t s may be e f f e c t i v e i n helping t o prevent SIDS deaths. DISCORDANCE BETWEEN MALE/FEMALE DEATHS DUE TO THE578 RESPIRATORY DISTRESS SYNDROME (RDS) : IS IT REAL?Robert Perelman. Mari P a l t a . Russell Kirby. P h i l i~ F a r r e l l . Univ. of Wisc. and Wisc. Div of Health, Madison. Wisc.Despite a marked diminution i n n a t i o n a l and Wisconsin (WISC) neonatal m o r t a l i t y r a t e s (NNMR). RDS has remained t h e leading cause of death i n 9 of 11 years previously analyzed. accounting f o r 19.5% of f a t a l i t i e s . Male/female (M/P) r a t i o s of 1.35 f o r NNMR and 1 . 6 f o r RDS deaths support t h e contention t h a t t h e r e is a d i s t i n c t male disadvantage t o premature b i r t h . To b e t t e r e l u c i d a t e t h i s a s s e r t i o n , we examined a l l relevant b i r t hweight-linked mortality s t a t i s t i c s f o r t h e S t a t e of Wisc. 1.14 1.93 i n d i c a t e t h a t neonatal deaths secondary t o RDS a r e c o n s i s t e n t l y g r e a t e r i n males and t h a t t h e discordance between males and females occurrs most predominantly between 1-1.5 kg birthweight. These s i g n i f i c a n t d i f f e r e n c e ...

Although the outcome of pregnancy for women with diabetes meilitus has improved in recent years, the infant of the diabetic mother has an increased risk of major clinical problems, particularly in the early neonatal period. These include birth injury due to macrosomia, neonatal hypoglycemia, respiratory distress syndrome, and serious congenital anomalies. Because of the great difficulties encountered during attempts to investigate these problems in clinical research protocols, there is a continuing need to establish appropriate animal models of the diabetic pregnancy. Studies carried out over the past decade, primarily with chemically-induced diabetes have suggested techniques which might be useful. In general, the choice of the animal to be studied will depend on the hypotheses being addressed. For instance, small animals such as rabbits and rats made diabetic with streptozotocin have been successfully used for investigation of fetal lung development. Furthermore, the rat model has been helpful for evaluation of fetal anomalies associated with maldevelopment of the spine and central nervous system. Larger animals, such as the nonhuman primate, are more appropriate for studying placental function and amniotic fluid composition in diabetic pregnancies. The task group on pregnancy and fetal development recommends that animal models of diabetes meilitus be used for a more extensive hormonal and metabolic characterization of diabetic mothers during pregnancy, for investigation of placental physiology with respect to the transfer of substrates from mother to fetus, for systematic and comprehensive study of mechanisms controlling fetal lung development, and for delineation of the pathophysiology of neonatal hypoglycemia. it is further recommended that animal models of spontaneous diabetes such as the BB/W rat be used in future studies dealing with pregnancy and fetal development. Because females with spontaneous diabetes show reduced conception rates, there is a pressing need to enhance the fertility of these animals in order to intensify studies on fetal development.

Food intake of control and streptozotocin-diabetic rhesus monkeys was measured during menstrual cycles and pregnancy. Intake of control monkeys was lower at the time of ovulation than during other phases of the menstrual cycle. Intake of control monkeys was also low during most of pregnancy, but this was accompanied by normal fetal growth and net maternal weight gain. Diabetic monkeys ate more than controls in all conditions and their intake did not vary reliably according to reproductive status. It is suggested that (1) oestrogen normally inhibits food intake during menstrual cycles and pregnancy, (2) food energy is utilized more efficiently during pregnancy than during non-pregnant states, and (3) the influence of oestrogen on food intake is either attenuated by insulinopenia or is obscured by the hyperphagia typically exhibited by the diabetic monkeys.

Reduction of unexplained variation in medical practice and health outcomes is of paramount importance, which indicates a need for a continuum of medical learning that begins in medical school and continues until the end of a professional career. That, in turn, indicates need for continuing assessment of professional competence. The American Board of Pediatrics, the American Academy of Pediatrics, and the Accreditation Council for Graduate Medical Education are working together to develop a common approach to documenting acquisition of competence during residency and maintenance of competence thereafter. A common approach will eliminate redundancy and make it possible to follow the evolution of professional competence over time. Pediatrics 2009;123:S56-S58

Improving Performance in Practice (IPIP) is a large system intervention designed to align efforts and motivate the creation of a tiered system of improvement at the national, state, practice, and patient levels, assisting primary-care physicians and their practice teams to assess and measurably improve the quality of care for chronic illness and preventive services using a common approach across specialties. The long-term goal of IPIP is to create an ongoing, sustained system across multiple levels of the health care system to accelerate improvement. IPIP core program components include alignment of leadership and leadership accountability, promotion of partnerships to promote health care quality, development of attractive incentives and motivators, regular measurement and transparent sharing of performance data, participation in organized quality improvement efforts using a standardized model, development of enduring collaborative improvement networks, and practice-level support. A prototype of the program was tested in 2 states from March 2006 to February 2008. In 2008, IPIP began to spread to 5 additional states. IPIP uses the leadership of the medical profession to align efforts to achieve large-scale change and to catalyze the development of an infrastructure capable of testing, evaluating, and disseminating effective approaches directly into practice.