No abstract

Objective: To study whether a cue-based clinical pathway for oral feeding initiation and advancement of premature infants would result in earlier achievement of full oral feeding.Study Design: Age of achievement of full oral intake was compared for two groups of preterm infants; a prospective study group vs historic cohort controls. Study infants had oral feedings managed by nurses using a clinical pathway that relied on infant behavioral readiness signs to initiate and advance oral feedings. Controls had oral feedings managed by physician orders.Result: Fifty-one infants (n ¼ 28 study and n ¼ 23 control) were studied. Gender distribution, gestational age, birth weight and ventilator days were not different between groups. Study infants reached full oral feedings 6 days earlier than controls (36±1 3/7 weeks of postmenstrual age (PMA) vs 36 6/7±1 4/7 weeks of PMA, P ¼ 0.02). Conclusion:The cue-based clinical pathway for oral feeding initiation and advancement of premature infants resulted in earlier achievement of full oral feeding.

NTIMICROBIAL RESISTANCE IS A serious public threat that is exacerbated by the gradual withdrawal of the pharmaceutical industry from new antimicrobial agent development. 1 Overuse of antimicrobial agents fosters the spread of antimicrobial-resistant organisms. 2,3 Despite recent trends that demonstrate reduced outpatient use of antimicrobial agents, prescribing continues to significantly exceed prudent levels. 4-8 Approximately 50% of courses of ambulatory antimicrobial drugs are prescribed for patients with viral respiratory infections and therefore are not clinically indicated. 9-12 Behavioral facilitators of antimicrobial overuse and barriers to prudent use operate on both clinicians and patients. 13-16 Patient demand, perceived or actual, creates chal-See also pp 2315 and 2354.

Undernutrition is associated with poor cognitive development, late entry into school, decreased years of schooling, reduced productivity and smaller adult stature. We use longitudinal data from 1674 Peruvian children participating in the Young Lives study to assess the relative impact of early stunting (stunted at 6-18 months of age) and concurrent stunting (stunted at 4.5-6 years of age) on cognitive ability. Anthropometric data were longitudinally collected for children at 6-18 months of age and 4.5-6 years of age at which time verbal and quantitative ability were also assessed. We estimate that an increase in concurrent height-for-age z-scores (HAZ) by one standard deviation was associated with an increase in a child's score on the Peabody Picture Vocabulary Test (PPVT) by 2.35 points [confidence interval (CI): 1.55-3.15] and a 0.16 point increase on the cognitive development assessment (CDA) (CI: 0.05-0.27). Furthermore, we report that the estimate for concurrent HAZ and PPVT is significantly higher than the estimate for early stunting and PPVT. We found no significant difference between early and concurrent estimates for HAZ and CDA. Children from older mothers, children whose mothers had higher education levels, children living in urban areas, children who attended pre-school, children with fewer siblings and children from wealthier backgrounds scored higher on both assessments. Cognitive skills of children entering school were associated with early stunting but the strongest association was found with concurrent stunting suggesting that interventions preventing linear growth faltering should not only focus on the under 2s but include children up to 5 years of age.

Stunting is associated with adverse cognitive development in childhood and adolescence, fewer years of schooling, decreased productivity, and reduced adult stature. Recovery from early stunting is possible; however, few studies explore whether those who demonstrate linear catch-up growth experience long-term cognitive deficits. Using longitudinal data on 1674 Peruvian children from the Young Lives study, we identified factors associated with catch-up growth and assessed whether children who displayed catch-up growth have significantly lower cognition than children who were not stunted during infancy and childhood. Based on anthropometric data for children 6-18 mo of age and again for the same children when they were 4.5-6 y of age, we categorized participants as not stunted, stunted in infancy but not childhood (catch-up), stunted in childhood, and stunted in infancy and childhood. Children who had grandparents in the home, had less severe stunting in infancy, and had taller mothers were more likely to demonstrate catch-up growth by round 2. Children who experienced catch-up growth had verbal vocabulary and quantitative test scores that did not differ from children who were not stunted (P = 0.6 and P = 0.7, respectively). Those stunted in childhood as well as those stunted in infancy and childhood scored significantly lower on both assessments than children who were not stunted. Based on findings from this study, policy makers and program planners should consider redoubling efforts to prevent stunting and promote catch-up growth over the first few years of life as a way of improving children's physical and intellectual development.