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Asociacin Mdica de Puerto RicoB LETN

CONTENIDO

Mensaje del Presidente de la AMPRRolance G. Chavier Roper

Original Article/Articulos originales

KNOWLEDGE AND MISCONCEPTIONS ABOUT IMMUNIZATIONS AMONG MEDICAL STUDENTS, PEDIATRIC AND FAMILY MEDICI-NE RESIDENTVilmarie Tan MS, Clarimar Borrero MD, Yasmn Pe-drogo MD

EXCLUSIVE BREASTFEEDING REDUCES AS-THMA IN A GROUP OF CHILDREN FROM THE CAGUAS MUNICIPALITY OF PUERTO RICOJessica Gonzlez MD, Mariola Fernndez MD , Lour-des Garca Fragoso MD

EFFICACY, SAFETY AND COST-EFFICIENCY OF USING AN ALTERNATIVE TECHNIQUE FOR AUTOMATED EXCHANGE TRANSFU-SION IN PEDIATRIC PATIENTS WITH SICKLE CELL DISEASEMara B. Villar Prados MD, Ricardo Garca De Jess MD, Alicia Fernndez Sein MD, Manuel Iglesias Gar-ca MD

RESPIRATORY ILLNESS IN LATE PRETERM INFANTS DURING THE FIRST SIX MONTHS OF LIFELeilanie Prez MS, Zahira Corchado , Mariela Rodr-guez , Dora Garca , Lizaida Medina MD, Arian Vicens MD, Nerian Ortiz MD, Lourdes Garca MD, Yasmin Pedrogo MD

PRENATAL BREASTFEEDING INTENTIONS IN A GROUP OF WOMEN WITH HIGH RISK PREGNANCIESHildamary Diaz Rozett MD, Lourdes Garcia Fragoso MD

MINOR HEAD INJURY IN CHILDREN YOUN-GER THAN TWO YEARS OF AGE: DESCRIP-TION, PREVALENCE AND MANAGEMENT IN THE EMERGENCY ROOM OF THE PEDIATRIC UNIVERSITY HOSPITALMara L. Fernndez MS, Linette Mejas MS, Nerian Or-tiz MD, Lourdes Garca-Fragoso MD

ROOMING-IN IMPROVES BREASTFEEDING INITIATION RATES IN A COMMUNITY HOSPI-TAL IN PUERTO RICOCarmen W. Cotto MD, Lourdes Garcia Fragoso MD

Review Articles / Articulos de Resea

ESOPHAGEAL ATRESIA: NEW GUIDELINES IN MANAGEMENT Jessica Gonzlez-Hernndez MS, Humberto Lugo-Vi-cente MD

CLINICAL VERSUS PATHOLOGIC DIAGNOSIS: ACRODERMATITIS ENTEROPATHICAAlicia Fernandez Sein MD

Case Reports / Reporte de Casos

CANDIDA ALBICANS MENINGITIS AND BRAIN ABSCESSES IN A NEONATE: A Case ReportIngrid M. Ancalle MD, Juan A. Rivera MD, Ins Garca MD, Lourdes Garca MD, Marta Valcrcel MD

DENGUE VIRUS ASSOCIATED HEMOPHAGO-CYTIC SYNDROME IN CHILDREN: A Case Re-portYadira Soler Rosario, MD, Ricardo Garcia MD, Alicia Fernandez Sein MD

TRANSANAL CIRCULAR-STAPLED REA-NASTOMOSIS AS A MANAGEMENT ALTERNA-TIVE FOR ANASTOMOTIC COLONIC STRICTU-RES: A NOVEL TECHNIQUE IN THE PEDIATRIC PATIENTHumberto Lugo-Vicente MD, Jorge J. Zequeira MD, Joalex Antongiorgi MD

CME Questions

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Dr. Rolance G. Chavier RoperPresidente

Juan Aranda Ramrez, MD

Francisco J. Muiz Vzquez, MD

Walter Frontera, MD

Mario. R. Garca Palmieri, MD

Natalio Izquierdo Encarnacin, MD

Jos Ginel Rodrguez, MD

Dra. Wanda G. Velez AndujarPresidente Distrito Sur

Presidente Consejo de Educacin Mdica

Dr. Jos C. Romn de JesusPresidente Consejo tico Judicial

Dra. Hilda Rivera TubnsPresidente Consejo Relaciones y Servicios Pblicos

Dr. Salvador Torros RomeuPresidente Consejo Servicios Mdicos

Dr. Jaime M. Diaz HernandezPresidente Consejo Salud Pblica y Bienestar Social

Dr.a. Ilsa FigueroaPresidente Consejo Poltica Pblica y Legislacin

Dr. Eugenio R. Barbosa del VallePresidente Comit de Planes Prepagados y Seguros Mdicos

Dr. Hctor L. Cceres DelgadoPresidente Comit Afiliacin y Credenciales

Dr. Ney Modesti TaonPresidente Comit Ad-hoc de Compaerismo

Dr. Jos A. Rodrguez RuizPresidente Comit de Historia, Cultura y Religin

Dr. Luis A. Romn IrizarryPresidente Comit Mdico Impedido

Dra. Luisa Marrero SantiagoPresidente Comit de Seguros

Dr. Jos I. Gerena DazPresidente Comit Ad-hoc Clnicas Multifsicas

Dr. Flix N. Cotto GonzlezPresidente Comit Ad-hoc de Reclutamiento y

Servicios al Mdico Joven

Humberto Lugo Vicente, MDPresidente

JUNTA EDITORA

JUNTA DE DIRECTORES

Dr. Ral G. Castellanos BranPresidente Electo

Dr. Eduardo Rodrguez VzquezPresidente Saliente

Dr. Pedro Zayas SantosSecretario

Dr. Jos R. Villamil RodrguezTesorero

Dra. Hilda Ocasio MaldonadoVicepresidente

Dr. Natalio Izquierdo EncarnacinVicepresidente

Dr. Ral A. Yordn RiveraVicepresidente

Dr. Arturo Arch MattaPresidente Cmara Delegados

Dr. Juan Rodrguez del ValleVicepresidente Cmara de Delegados

Dr. Gonzalo Gonzlez LiboyDelegado AMA

Dr. Rafael Fernndez FelibertiDelegado Alterno AMAPresidente del Comit Asesor del Presidente

Dr. Benigno Lpez LpezPresidente Distrito Este

Dr. ngel E. Michel TerreroPresidente Distrito Sur

Dra. Mildred R. Arch MattaPresidente Distrito Central

Luis Izquierdo Mora, MD

Melvin Bonilla Flix, MD

Carlos Gonzlez Oppenheimer, MD

Eduardo Santiago Delpin, MD

Francisco Joglar Pesquera, MD

Yocasta Brugal, MD

AMensaje del Presidente - President Message

2010

BOLETIN DE LA ASOCIACION MEDICA DE PUERTO RICO - VOLUMEN 102 NUMERO 1 - ENERO, FEBRERO Y MARZO DE 2010

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Aunque seguramente estaremos de acuer-do en que el valor de la vida humana es incalculable y que la vida de un ser humano vale lo mismo no im-porta en que etapa de su existencia este, no hay duda que, para la gran mayoria de nosotros, la vida y salud de un nino es an ms relevante.

Quizs sea por su inocencia y fragilidad, o por todo lo que sabemos le espera en su desarrollo como persona.

Es por eso que, dentro de la profesin medica, la especialidad de pediatria es tan respetada y queri-da.

La Tranquilidad y felicidad de los padres y de-ms familiares cercanos de un paciente peditrico de-penden de la salud de este y no hay tristeza mayor que la de ver a un nio gravemente enfermo.

Adems de la proficiencia en la profesin, una de las caractersticas mas importantes en un mdico y sobre todo en el pediatra, debe ser la empata. Hay que saber sentir lo mismo que esos padres y tener la paciencia y dedicacion para explicarles en detalle aquella informacin que, aunque simple y rutinaria para nosotros, es complicada e Intimidante para ellos y ms an para los ninos.

En Puerto Rico, nos honramos al tener una ex-celente facultad mdica y entre ellos, magnificos pe-diatras y subespecialistas en este rea.

Para lograr mantener el numero adecuado de profesionales en pediatria, necesitamos promover los

programas de residencias acreditados y crear nuevos que produzcan pediatras que se queden y practiquen en Puerto Rico

La Asociacin Mdica de Puerto Rico se com-place en contribuir con estos propsitos a travs de la publicacin de este nmero de nuestro boletn cientfi-co dedicado a la especialidad de pediatria.

A travs de esta publicacin se abre un impor-tante foro para la difusin de articulos de investigacin realizados por residentes y fellows de pediatria.

Es tambin de nuestro agrado anunciar que hemos reactivado la seccin de pediatria de la Asocia-cin Mdica y agradecemos al Dr. Angel Senquiz y a la Dra. Hilda Rivera Tbens, entre otros, por su colabora-cin en este propsito.

Invitamos a todos aquellos pediatras que an no pertenecen activamente a la Asociacin Mdica a ingresar nuevamente a esta, su casa.

Finalmente y como privilegio personal, deseo reconocer a tres pediatras que fueron Importantes en mi vida personal y profesional. En primer lugar, a la Dra. Rosa Asmar de Deliz (qepd), quien fue mi pediatra y primer contacto con la medicina. En segundo lugar, a la Dra. Ana Navarro y por ltimo, a la Dra. Amalia Mar-tnez Pico, cardiloga pediatrica y figura legendaria de la medicina en Puerto Rico.

Una vez ms, reiteramos el compromiso de la Asociacvin Mdica de Puerto Rico con la educacin medica en nuestro pas.

Rolance G. Chavier Roper, MD

TOriginal Articles - Artculos Originales

KNOWLEDGE ANDMISCONCEPTIONS ABOUT IMMUNIZATIONS AMONG MEDICAL STUDENTS,PEDIATRIC, AND FAMILY MEDICINE RESIDENTVilmarie Tan MS*Clarimar Borrero MD**Yasmn Pedrogo MD**From the *School of Medicine and**General Pediatric Re-sidency Program, Department of Pediatrics, UPR School of Medicine.Address reprints request to: Yasmn Pedrogo MD, UPR School of Medicine, Department of Pediatrics, PO Box 365067, San Juan, PR 00936-5067. E-mail yasmin.pedro-go@upr.edu.

ABSTRACTBackground: Previous research has indicated that, despite being the most trusted source of health information, medical students, resi-dents and other health related professionals lack accurate and current knowledge regar-ding immunization practices. Objective: To evaluate medical students and primary care resident knowledge about immunizations. Me-thods: Self-administered survey given to stu-dents from four medical schools, Pediatrics residents (2 training programs) and Family Medicine residents (2 programs). Data was analyzed using Statistix 8.0. One-way ANOVA test was used to compare means, and a p-va-lue less than 0.05 was considered statistically significant. Results: Participants (N=376) in-cluded 3rd (64%) and 4th (18%) year medical students and a homogenous distribution of 1st, 2nd and 3rd year residents. The mean percent of correct answers about immunizations was 61%. The participants showed poor knowled-ge about indications (62% correct answers), contraindications (46% correct answers) and myths (71% correct answers). Knowledge about immunizations correlated with higher le-vels of education (p

immunizations (indications, important contraindications and common misconceptions) among third (MSIII) and fourth year (MSIV) medical students, pediatric and fa-mily medicine residents of Puerto Rico medical schools and residency programs. As secondary objectives, we evaluated medical students and residents exposure to vaccines at immunization clinics and identify the pri-mary source of information these health professionals used to learn about immunizations.

MATERIALS AND METHODS This was an observational, cross-sectional stu-dy with 376 subjects that included medical students, pediatric residents and family medicine residents. A self-administered survey was handed to medical stu-dents (MSIII & MSIV) of the four LCME credited me-dical schools in Puerto Rico (University of Puerto Rico School of Medicine, Ponce School of Medicine, Univer-sidad Central del Caribe School of Medicine and San Juan Bautista School of Medicine), Pediatric Residents and Family Medicine Residents at the UPR Medical Science Campus, San Juan Municipal Hospital, Ma-nat Medical Center and Hospital Federico Trilla (UPR Carolina).

The survey consisted of Student/Resident de-mographic data, multiple choice questions based on the 2008 Immunization Schedule, and multiple choice questions about common misconceptions and contrain-dications to immunizations. The surveys were handed out and collected during the months of December 2008 to December 2009. Correct answers to the questions were averaged and a score above 70% of correct an-swers was taken as satisfactory. The survey responses were analyzed using Statistix 8.0. Descriptive statistics (continuous variables and categorical variables) were summarized using frequency, percentages and means. One-way ANOVA test was utilized to compare means, and a p-value less than 0.05 was considered statistica-lly significant. This research project received approval from the University of Puerto Rico Medical Sciences Campus Institutional Review Board.

RESULTS Medical students and residents completed a total of 376 surveys. 52% of participants were fema-le and 48% were male. Mean age for examinees was 26 years old. Most of the surveys were completed by MSIII (64%), followed by MSIV (18%). A similar amount of subjects (6%) of first and second year residents also participated. 5% of participants were PGYIII and 1% was PGYIV-V (Graph 1).

The survey evaluated immunization knowledge in three areas: indications, contraindications and mis-conceptions. Questions tested facts according to the 2008 Immunization Scheme of the Advisory Commit-tee on Immunization Practices ACIP CDC. Correct responses were added for each individual in each of the three areas evaluated and then an average sco-re was assigned for the total obtained. We can then compare the average total score obtained at each level of education (MSIII-PGYIV). This comparison reveals

with a P=0.0000 that a higher level of education pro-vides a greater understanding about immunizations as demonstrated by the increasing trend in average scores at a higher level of education (Graph 2). This was also true when evaluating participant performan-ce exclusively for indications, contraindications and misconceptions regarding immunizations (P < 0.01). Moreover, we compared immunization knowledge between specialties. This comparison revealed with a P=0.0000 that pediatric residents were more familiar with vaccine indications, contraindications and miscon-ceptions (Graph 3).

Graph 1: Distribution of participants per level of education

64%18%

6%6% 5% 1% MSIII

MSIVPGYIPGYIIPGYIIIPGYIV-V

Graph 2: Knowledge about immunizations per level of education

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Graph 3: Knowledge about immunizations according to specialty

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When assessing immunization indications we found that in each of the seven questions we provided, the majority of participants selected the correct answer. Nevertheless, we found that two of the questions in this are where answered correctly by less than the 50% of the participants. These questions required knowledge about immunization schedules and being familiar with the MMR and Varicella vaccines. On the other hand, in the evaluation of immunization contraindications we found that 59% of the subjects knew that fever is not

BOLETIN DE LA ASOCIACION MEDICA DE PUERTO RICO - VOLUMEN 102 NUMERO 1 - ENERO, FEBRERO Y MARZO DE 2010

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a contraindication to immunization except in moderate to severe diseases when vaccination must be postpo-ned. 44% of participants did know that immunizing a woman while breastfeeding is not contraindicated due to risks of infecting the baby. Moreover, only 41% of the subjects were aware that the MMR, MMRV, Measles or Mumps vaccines can be administered to children aller-gic to eggs since there is no risk of anaphylaxis due to egg protein allergy because these vaccines do not contain derivatives of this protein (Graph 4).

Graph 4: Knowledge regarding immunization contraindications

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we observe that 50% of PGYII residents report being rarely being exposed to immunizations, whereas the 33% PGYIII-V residents refer being exposed to vacci-nes a few times a year.

For the evaluation of the participants knowled-ge regarding vaccination misconceptions we included 10 true or false questions. Eight of these questions were answered correctly by at least 70% of the subjects. However, there were erroneous conceptions regarding two of the statements presented in the survey. In the first one only 45% of the participants knew that The Va-ccine Adverse Event Reporting System (VAERS) has not found various dangerous vaccine lots, which have been removed by the FDA. Moreover, just 32% of the subjects knew that the severity of chicken pox has not decreased due to the increase amount of children vac-cinated against it.

In order to assess our secondary objectives for this research we included some questions regarding the sources utilized by the participants to get their immuni-zation knowledge and how often they used them to get vaccination information. Moreover we asked how much they were exposed to immunization at clinics. We found that 72% of the participants use conference and lectu-res as their primary source of immunization knowledge followed by books and journals (Graph 5). In terms of the use of these information resources there was an even distribution in the answers: rarely and a few times a year in which each category received 38%. Only 11% of the participants referred using such resources on a monthly basis, 7% reported using them a few times a week and no more than 6% reported using them on a daily basis. If we assess the use of these learning re-sources in the residents population we can appreciate a tendency to use books and journals gain knowledge about immunizations as the years of training increase (Graph 6). When evaluating immunization exposure at the clinics we found that 40% of the participants refe-rred being rarely exposed to vaccination (Graph 7). If we evaluate that exposure in residents only (Graph 8)

Graph 5: Sources used for immunization knowledge acquisition

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Graph 7: Exposure to immunizations at clinics

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Graph 8: Residents Exposure to Immunizations at Clinics

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BOLETIN DE LA ASOCIACION MEDICA DE PUERTO RICO - VOLUMEN 102 NUMERO 1 - ENERO, FEBRERO Y MARZO DE 2010

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are asked by patients parents on a regular basis. The-refore, we believe they must be well known to medical students and pediatric and family medicine residents.Our results reveal that most medical students and resi-dents reported being rarely exposed or exposed a few times a year to immunizations. This finding could be one of the factors that may have influenced the sur-vey scores of the participants. Finally, our results su-ggest that medical students do not have the expected knowledge about immunizations indications and con-traindications; however, they had an adequate unders-tanding about immunization misconceptions. On the other hand, pediatric and family medicine residents do not have the expected knowledge in immunization con-traindications, but were knowledgeable about immu-nization indications and misconceptions. We believe these results raise a red flag that should make medical school and residencies reevaluate their strategies to improve how they teach about immunizations.

Limitations for this study include the fact that this was a self-administered voluntary survey and we can only assume that those that accepted to participa-te responded to the best of their knowledge. Moreover, due to the voluntary aspect of the survey we could not assess the entire population of Puerto Rico third and fourth year medical students and pediatric and family medicine residents.

REFERENCES1. Szilagyi P. G., Hager J., Roghmann K. J., et. al. Immuniza-tion Practices of Pediatricians and Family Physicians in the United States, Pediatrics 1994; 94: 517-523.2. Ginder J. S., Cutts F. T., Barnett-Antinori M. E., et. al. Suc-cesses and Failures in Vaccine Delivery: Evaluation of the Immu-nization Delivery System in Puerto Rico, Pediatrics 1993; 91: 315-320.3. Askew G. L., Finelli L., Lutz J, et. al., Beliefs and Practices Regarding Childhood Vaccination Among Urban Pediatric Provi-ders I New Jersey, Pediatrics 1995; 96: 889-892.4. Grabowsky M., Marcuse E. K., The Critical Role of Provi-der Practices in Undervaccination, Pediatrics 1996; 97:735-737.5. Levi B. H., Addressing ParentsConcerns About Childho-od Immunizations: A Tutorial for Primary Care Providers, Pedia-trics, 2007; 120: 18-26.6. Garber R. M., Mortimer E. A., Immunizations: Beyond the Basics, Pediatrics in Review, 1992; 13: 98-106.

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dudas?

DISCUSSION Ever since the inoculation of cowpox lesions from person to person, providing immunization to sma-llpox, vaccination has amazingly reduced the morta-lity from many infectious diseases (6). These outco-mes have promoted the development of immunization campaigns all over the world in an effort to eradicate a variety of diseases. Nevertheless, despite the benefits that immunization may provide to a population and to an individual there are still children that do not receive their vaccines on time or not at all. In some instances this may be due to parental resistance to immuniza-tions (5). In other cases it may be due to healthcare personnel misconceptions about contraindications to vaccinations (2). Whichever the reason that impedes the proper administration of immunization to children, it must be managed. Pediatricians and family medici-ne physicians are accountable for the immunization of most children (1). Therefore, they have the responsi-bility to be knowledgeable about the indications, con-traindications and misconceptions regarding immuni-zations. Moreover, they have to be able to transmit this information to the patients parents in order to gain their authorization instead of their refusal.

It is a requirement by Medical Schools and Licensing Agencies that Medical Students and Pe-diatric and Family Medicine Residents be competent and proficient in their knowledge about indications and contraindications regarding immunizations as part of their Curriculum. Nevertheless, several studies have revealed a lack of up to date immunization knowled-ge in medical students, residents and other healthcare professionals.

The majority of the participants in this study were medical students, specifically MSIII. These sub-jects, although being on their clinical years of medi-cal training, have several occasions in which they take lectures and tests at their medical school campus as compared to the MSIV students that have clerkships in different clinical settings outside of their medical school campus. Moreover, this distribution of partici-pants goes in accordance with the fact that residency programs accept a very limited amount of students per year in comparison to a medical school.

Our results reflect that a higher level of edu-cation correlates with a greater understanding about immunizations as demonstrated by the statistically sig-nificant increasing trend in average scores at a higher level of education in the three areas evaluated. These results may be explained by the acquisition of knowled-ge and experience throughout the years. Moreover, it could be due to the use of books and journals by a high percentage of residents to learn about immunizations.

During the evaluation of the contraindications area it was unexpected to find that more than half of the participants did not know that immunizing a woman while breastfeeding is not contraindicated due to risks of infecting the baby or that the MMR, MMRV, Meas-les or Mumps vaccines can be administered to children allergic to eggs. These facts are relevant, moreover,

RESUMEN Estudios previos revelan que tanto los estudiantes de medicina, residentes y otros profesionales de la salud no poseen un cono-cimiento adecuado sobre vacunacin. Nues-tro objetivo fue evaluar el conocimiento sobre inmunizaciones de los estudiantes de medici-na y residentes de pediatra y medicina de fa-milia. Se administr una encuesta voluntaria a los grupos antes mencionados y la informa-cin se analiz mediante el programa Statistix 8.0. Los participantes (N=376) incluan estu-diantes de medicina de 3ro (64%), 4to (18%) y una distribucin homognea de residentes de 1ro, 2do y 3ro ao. En promedio, los par-ticipantes obtuvieron una calificacin de 61% y se observ que el conocimiento sobre va-cunas aumentaba con el nivel acadmico de los participantes (P

SEXCLUSIVEBREASTFEEDINGREDUCES ASTHMA IN A GROUP OF CHILDREN FROM THE CAGUASMUNICIPALITYOF PUERTO RICOJessica Gonzlez MD *Mariola Fernndez MD *Lourdes Garca Fragoso MD **From the *Department of General Pediatrics and the *Sec-tion of Neonatology, Department of Pediatrics, UPR School of Medicine.Address correspondence and reprints requests to: Lourdes Garca Fragoso MD, UPR School of Medicine, Department of Pediatrics, Neonatology Section, PO Box 365067, San Juan, PR 00936-5067. E-mail: lourdes.garcia1@upr.edu.Poster presentation at the Annual Puerto Rico Pediatrics So-ciety meeting (February 2009), the annual Medical Sciences Campus Research Forum (April 2009), and at the 2009 ALA-PE meeting (November 2009).

ABSTRACT Breast-feeding is the preferred method of infant nutrition. Its role in preventing childho-od asthma is controversial. Objective: Determi-ne whether breastfeeding protects against the development of bronchial asthma in children. Methods: A survey was answered by parents of children less than 18 years of age attending a Pediatric clinic at Cidra, Puerto Rico from July to December 2008. Results: A group of 175 mo-thers were included in the study. The mean age was 28 years (range 14-50). The mean age of the children was 5 years. There was family history of asthma in 64% of the families. The prevalence of asthma in these children was 50%. Sixty-six percent of the mothers breastfed but only 27% did it exclusively. Children who were exclusively breastfed had a lower prevalence of asthma and milk protein allergy. Conclusions: This study co-rrelates with literature reports linking exclusive breastfeeding to a reduction in asthma and other allergic diseases.

Index words: exclusive, breastfeeding, asthma, Caguas, Puerto Rico

The objective of our study was to determine whether breastfeeding or its duration protects against the deve-lopment of bronchial asthma in children.

MATERIAL AND METHODS An anonymous survey, developed and valida-ted for this study, was answered by mothers of children less than eighteen years of age who attended a Pedia-trics clinic in Cidra, Puerto Rico. The survey inquired about breastfeeding duration, use of formula, diagnosis of bronchial asthma, its severity, treatment received, among other questions. The University of Puerto Rico, Medical Sciences Campus, Institutional Review Board approved the study. Statistix 8.0 was used to perform the statistical analysis, which included frequency dis-tribution, means and chi square for differences among groups. A p value < 0.05 was considered statistically significant.

RESULTS A total of 175 mothers participated in the study. The general characteristics of the mothers and children are summarized in Table I. The mothers lived in four municipalities from the Caguas Region in Puerto Rico, most of them in Cidra (86%). These municipalities are located in the central region of the island. There was a positive family history of bronchial asthma in 64% of patients. Fifty percent of the children had bronchial asthma. Most of the children with asthma (68%) had

INTRODUCTION

Studies have shown that Puerto Rican chil-dren have the highest prevalence of lifetime asthma (26%) compared with non-Hispanic black children (16%), non-Hispanic white children (13%), and Mexi-can children (10%). This appreciably higher asthma morbidity rate experienced by Puerto Rican children cannot be explained by socio-demographic and other risk factors measured in the National Health Interview Survey (1). Two separate community-based studies of children in Puerto Rico found the lifetime prevalence of asthma to be higher than 30%. Prez-Perdomo and coworkers (2) found that parents of island Puerto Ri-cans who participated in the 2000 Behavioral Risk Fac-tor Surveillance System reported a lifetime prevalence of asthma in their children of 33.2%. While many stu-dies have shown a high burden of asthma in mainland US cities in which a large proportion of the Hispanic population is of Puerto Rican background, fewer stu-dies have focused on Puerto Ricans specifically (3). A study with the objective to estimate the prevalence of asthma in two municipalities of Northern Puerto Rico showed that among 2,800 students the prevalence of asthma was 46% in elementary schools and 24% in ju-nior-high schools (4). The asthma prevalence in Puerto Rican children being so high should prompt us to find preventive measures. It is known that breastfeeding is the preferred method of infant nutrition for multiple rea-sons. However, its role in the prevention of asthma and other allergic conditions remains controversial. Multiple studies have shown a preventive effect but whether the relation is to exclusive breastfeeding or breastfeeding for a specific amount of time remains to be determined.

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one to 3 bronchial asthma exacerbations in a year; 18% had four to 6, 8% had seven to 10 and only 6% had more than 10. Sixty three percent of children didnt have a bronchial asthma related hospitalization in the past year. Sixty six percent (66%) of children were breastfed. Fifty-four percent (54%) were breastfeed for at least three months, 29% for 6 months, and 20% for more than 6 months. Only 27% of children were exclu-sively breastfeed, the others combined breast milk and formula.

Table I: General characteristics of the participants (N=175)

Characteristics Participants

Age in years, mean 28 (14-50)

Age at child birth, mean 22 (13-43)

Children age, mean 5 (0-18)

Family history of bronchial asthma 64%

Exclusively breastfed children had a lower pre-valence of bronchial asthma (p

exclusively breastfed and only 29% were breastfed for six months. This is far from the goals set by Healthy People for 2010 and shows that there is a long road ahead of us if we want our children to have all the pro-ven benefits that breastfeeding has.

REFERENCES(1) Lara M, Akinbami L, Flores G, Morgenstern H. Heterogeneity of childhood asthma among Hispanic children: Puerto Rican children bear a disproportionate burden. Pediatrics 2006;117(1):43-53.(2)Perez-Perdomo R, Perez-Cardona C, Disdier-Flores O, et al. Prevalence and correlates of asthma in the Puerto Rican popula-tion: Behavioral Risk Factor Surveillance System, 2000. J Asthma 2003; 40:46574(3) Cohen RT, Canino GJ, Bird HR, Shen S, Rosner BA, Celedn JC. Area of residence, birthplace, and asthma in Puerto Rican chil-dren. Chest 2007 ;131(5):1331-8.(4) Loyo-Berros NI, Orengo JC, Serrano-Rodrguez RA. Childhood asthma prevalence in northern Puerto Rico, the Rio Grande, and Loza experience. J Asthma 2006;43(8):619-24.(5) Gdalevich M Mimouni D, Mimouni M. Breast-feeding and the risk of bronchial asthma in childhood: a systematic review with me-ta-analysis of prospective studies. J Pediatr 2001;139(2):261-6. (6) Dell S, To T. Breastfeeding and asthma in young children: fin-dings from a population-based study. Arch Pediatr Adolesc Med 2001;155(11):1261-5. (7) Sears MR, Greene JM, Willan AR, Taylor DR, Flannery EM, et al. Long-term relation between breastfeeding and development of atopy and asthma in children and young adults: a longitudinal stu-dy. Lancet 2002;360(9337):901-7. (8) Kull I, Wickman M, Lilja G, Nordvall SL, Pershagen G. Breast feeding and allergic diseases in infants-a prospective birth cohort study. Arch Dis Child 2002;87(6):478-81. (9) Bener A, Ehlayel MS, Alsowaidi S, Sabbah A. Role of breastfee-ding in primary prevention of asthma and allegrgic diseases in a traditional society. Eur Ann Allergy Clin Immunol 2007;39(10):337-43.(10) Ogbuanu IU, Karmaus W, Arshad SH, Kurukulaaratcgy RJ, Ewart S. Effect of breastfeeding duration on lung function at age 10 years: a prospective birth cohort study. Thorax 2009;64(1):62-6.(11) Scholtens S, Wijga AH, Brunekreef B, Kerkhof M, Hoekstra MO, et al. Breastfeeding, parental allergy and asthma in chil-dren followed for 8 years. The PIAMA birth cohort study. Thorax 2009;64(7):604-9.

RESUMEN La lactancia es el mtodo preferido de nutri-cin para infantes. Sin embargo, su rol en la preven-cin del asma en nios es controversial. Objetivo: Determinar si la lactancia es un factor protector para el asma en nios. Mtodos: Una encuesta fue con-testada por madres de nios menores de 18 aos que visitaron una clnica peditrica en Cidra, Puerto Rico de Julio a Diciembre de 2008. Resultados: Un grupo de 175 madres fueron incluidas en el estudio. La edad promedio fue 28 aos (14-50). La edad pro-medio de los nios fue 5 aos. Haba historial fami-liar de asma en 64% de las familias. La prevalencia de asma en los nios fue 50%. Sesenta y seis por ciento de las madres lactaron pero solo 27% lo hizo exclusivamente. Los nios lactados exclusivamente tuvieron una menor prevalencia de asma y de aler-gia a la protena de la leche. Conclusin: Este es-tudio correlaciona con reportes en la literatura que asocian la lactancia exclusiva con una reduccin en el asma y otras enfermedades alrgicas.

(12) Burgess SW, Dakin CJ, O'Callaghan MJ. Breastfeeding does not increase the risk of asthma at 14 years. Pediatrics 2006;117(4):e787-92. (13) Matheson MC, Erbas B, Balasuriya A, Jenkins MA, Wharton CL, et al. Breast-feeding and atopic disease: a cohort study from childhood to middle age. J Allergy Clin Immunol 2007;120(5):1051-7.

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SEFFICACY, SAFETY AND COST-EFFICIENCY OF USING AN ALTERNATIVE TECHNIQUE FORAUTOMATED EXCHANGE TRANSFUSIONIN PEDIATRIC PATIENTS WITH SICKLE CELLDISEASEMara B. Villar Prados MD*Ricardo Garca De Jess MD*Alicia Fernndez Sein MD*Manuel Iglesias Garca MD**From the *Pediatric Critical Care Section and **Pediatric Re-sidency Program, Department of Pediatric, UPR School of Medicine.Address reprints request to: Maria Villar Prados, MD, UPR School of Medicine, Department of Pediatrics, PO Box 365067, San Juan, PR 00936-5067. E-mail mvillarprados@hotmail.com.

ABSTRACTBackground: Sickle cell disease (SCD) patients su-ffer complications requiring simple and/or exchan-ge transfusion. In 1999 we developed an automa-ted exchange technique using infusion pumps and vascular catheters (IV Pump Method). Objective: To prove that IV Pump Method is cost-efficient, and as safe and effective as automated cell separa-tors. Methods: Retrospective chart review of SCD patients requiring exchange transfusion admitted to PICU from 2003-2009. Evaluated method used, complications, costs, and Hemoglobin S% (HgS%) change, excluding patients not requiring exchange transfusion. Results: Cost-reduction with IV Pump Method is around $1000. Average HgS% reduction using IV Pump Method was 30.3 vs. 28.8 in Blood Cell Separator group (p = 0.84). We had no compli-cations or mortalities, with the majority of patients being male (p = 0.03) and on the oldest age group (11-19 y/o) for both methods. Conclusion: The IV Pump Method is a safe, effective, and cost-efficient alternative to perform exchange transfusion.

Index words: automated, exchange, transfusion, sickle, cell, disease

INTRODUCTION

Sickle cell disease (SCD) is the most com-mon congenital hemoglobinopathy, affecting 1 in 4000 Puerto Rican births (1, 2). Patients suffer from serious complications, such as chronic anemia, infection, sple-nic sequestration, pain crisis, cholecystitis, mesente-ric ischemia, cerebrovascular accidents, and acute chest syndrome, among others (1). Treatment usually includes simple and/or exchange transfusion, with the goal of reducing hemoglobin S (HgS%) to less than 30%, particularly in critically ill patients (3). Exchange transfusion quickly reduces HgS% without the risks of iron overload or hyperviscosity, and the same rate for alloimmunization, infection, hypocalcemia, and neuro-logical deterioration as simple transfusions (4, 5).

Exchange transfusion can be performed using automated blood cells separators (6, 7) but this tech-nology is not available at all institutions. In 1999 we developed an automated red cell exchange technique using infusion pumps connected to vascular catheters (IV Pump Method) (8), providing an effective procedure for reducing HgS%. Vascular access is obtained by cannulation of a central vein with a dual lumen catheter (Quinton Permacath), or alternatively, using a cen-tral vein and an arterial catheter. The setup is prepared as follows (See Fig.1):

Connect arterial port to a three-way, to allow for heparin flushing if needed, then to an IV pump (e.g. Abbott Plum A+) in the secondary line site, using IV tubing and a male-male connection. A heparinized

Heparinizedsolution

Sickle cell free PRBCs

Secondary site

Primary site

IV Pump

IV Pump

Secondary site

Primary site

Venous side

Arterial side

Male-Male connection

IntraViaContainer

Saline solution

Bag Access Device

Three-way

Quinton Catheter

Figure 1: Setup for performing exchange transfusion using IV Pump Method.

solution with a final concentration of 2 units/ml will be connected to the primary site. This pump empties to an empty container (e.g. Baxter IntraVia Container) via a Bag Access Device (ICU Medical, Inc.) to dis-card the extracted blood. Another IV pump is con-nected to the venous port through the secondary line to transfuse the sickle cell free blood. A normal sali-ne solution will be connected to the primary site. To-tal rate of infusion will be the same for both pumps.

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Patient must be heparinized, with an initial bolus of 50 units/kg, followed by a continuous infusion at 15 units/kg/hr for the length of the procedure. Total vo-lume exchanged, as per Hematology Service recom-mendations, should be completed in no more than four hours.

Our objective was to prove that the use of the IV Pump Method is more cost-efficient, and as safe and effective as automated blood cell separators per-forming exchange transfusion in SCD patients in order to reduce HgS%.

MATERIALS AND METHODS We conducted a retrospective chart review of all SCD patients requiring exchange transfusion admit-ted to the PICU of a public, government subsidized, tertiary Childrens Hospital in San Juan, Puerto Rico from July 2003 to June 2009. Inclusion criteria were all patients with SCD, males and females, ages 1 to 19 years of age, admitted to PICU for exchange trans-fusion per Hematology service recommendation. We further divided patients by sex and age groups (1-4 years, 5-10 years, 11-19 years). We evaluated the me-thod used for exchange transfusion, complications from the procedure, and Pre- and Post- exchange transfu-sion Hg S%, obtained by hemoglobin electrophoresis performed at our center. We also compared the costs of performing the exchange transfusion using the IV pump method vs. the automated blood cell separator, a service provided by the local Red Cross Chapter. Ex-clusion criteria were patients admitted to the PICU with SCD not requiring exchange transfusion. IRB approval was obtained. Data was analyzed using InStat 3, Gra-ph Pad Software. Statistical analysis was performed using unpaired t-test. The significance level was p = 0.05. We made no assumptions about missing data.

RESULTS We identified 39 admissions of SCD patients admitted to PICU, for a total of 19 admissions and 20 exchange transfusions performed during the stu-dy period, since one patient received two exchan-ge transfusions during her PICU stay (See Fig. 2). SCD PICU

Admissions: 39 admissions

Exchange transfusion: 20 admissions

n = 14 admissions

Other treatments:

19 admissions

Incomplete data: 6 admissions

We excluded 6 patients due to incomplete data, and used a total of 14 admissions for our study. We analy-zed the sex and age of the patients, complications from the procedure, and change in HgS% after the procedu-re (See Table I).

DISCUSSION The cost of performing Therapeutic Hemaphe-resis Treatment provided by the American Red Cross Blood Services of P.R. using the COBE Spectra Aphere-sis System (CaridianBCT) ranges from around $1000 to $1800, depending on procedure delays, procedures performed on weekends and holidays, and extra pro-cedures, to name a few examples. To this we must add the cost of the catheter ($443), transfusion charges ($293), plus the cost of each unit of packed red blood cells (PRBCs) ($142/unit) used for the procedure. The cost for the IV Pump Method is around $43, plus the cost of the catheter, transfusion charges, and each unit of packed red blood cells and fresh frozen plasma (FFP) ($113/unit). This represents a significant cost re-duction of at least $1000 when compared to the cost of the service provided by the American Red Cross. This is particularly important in centers with scarce econo-mic resources.

The average reduction in HgS% using the IV Pump Method was 30.3, compared to 28.8 in the Blood Cell Separator group, with a p = 0.84 ( 95% CI = -14.80 to 17.80 ). These results show that there is no statis-tically significant difference between the groups, and that the IV Pump Method for exchange transfusion is as effective as the Red Blood Cell Separator Method in reducing HgS% (See Fig. 3). This provides a strong ar-gument for the use of the IV Pump Method, particularly in centers with limited resources that dont have ac-cess to an automated red cell separator and specially trained personnel to operate the machine. Also, when compared to manual techniques for exchange transfu-sion, the IV Pump Method requires less medical and nursing interventions, decreasing the contamination risk and medical and nursing care hours.

Figure 2: PICU admissions of patients with SCD that re-quired exchange transfusion.

30.3

28.8

28

28.5

29

29.5

30

30.5

Reduction in HgS%

IV Pump Method

Blood CellSeparator Method

Figure 3: Average reduction in Hemoglobin S% after Exchange Transfusion

One of the limitations of the IV Pump Method is that on patients over 35 kg of weight, due to the lar-ge volume required to perform the exchange transfu-sion, including both sickle cell free PRBCs and FFP, the length of the procedure extends to over four hours.

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Table I: Sex, age, method, complications, and Pre and Post Exchange Transfusion Hg S% of patients admitted to PICU.

Sex Age Method Complications Pre HgS% Post HgS% Change M 4 y/o IV Pump None 20.9 8.1 12.8 M 6 y/o IV Pump None *** 31.2 *** M 12 y/o IV Pump None *** 24.6 *** M 4 y/o IV Pump None 60.9 24.8 36.1 M 8 y/o IV Pump None 67.8 34.5 33.3 F 13 y/o IV Pump None 44.1 25.4 18.7 M 9 y/o IV Pump None 66.4 28.5 37.9 M 14 y/o IV Pump None 59.6 19.5 40.1 M 10 y/o IV Pump None 69.7 28.7 41 F 12 y/o IV Pump None 73.7 51.0 22.7 F 12 y/o Blood cell separator None 51.0 25.3 25.7 M 14 y/o Blood cell separator None 48.9 24.85 24.1 M 19 y/o Blood cell separator None 71.5 22.1 49.4 M 7 y/o Blood cell separator None 64.2 48.1 16.1

*** Data not availableM = Male; F = Female; HgS = Hemoglobin S

This is due to the rate limit on the IV pumps (999 ml/hr). For this reason, when available, we use the Red Cell Separator Method in most of our teenage patients. It is important to mention that with the IV Pump Method the patient will be exposed to both PRBCs and FFP, in order to keep a physiologic blood composition, putting the patient at risk of developing transfusion reactions to both of these blood products. Another disadvantage of the IV Pump Method is that it would not be practical in an outpatient setting for chronic exchange transfu-sion therapy.

We had no complications with any of our ad-missions in either group, including problems with clot-ting within the catheter. We had experienced complica-tions in that regard in the past while using the IV Pump Method, but we havent had any more cases since we started systemic heparinization of all our patients. We havent encountered any bleeding complications, he-modynamic instability, transfusion reactions, or acute clinical deterioration. This demonstrates that the IV Pump Method is as safe and as well tolerated as the Red Cell Separator Method.

No mortality in either group was found for the studied period, compared to an average mortality of 6.8% for all PICU admissions (p = 0.0001). All cause mortality for pediatric SCD patients has been descri-bed in the literature ranging from as high as 12.5% in some African countries (9, 10), to survival rates of 85% at 18 years of age in the United States (11, 12), and as high as 99% survival rate in London (13). Mortality from exchange transfusion in neonates for hyperbiliru-binemia has been reported as 0.3%. To our knowled-

ge, there are no recent studies looking at mortality from exchange transfusion in SCD patients in the literature. We would need to further investigate other markers for disease severity (e.g. PRISM scores, length of stay, oxygen requirements, baseline Hct, home medica-tions, previous events), and time-lines from hospital admission to PICU admission to reach more concrete conclusions about the low mortality in our study popu-lation. We also need to consider the socio-economic background and access to specialized care of our po-pulation compared to patients in other countries.

We had some unexpected findings. We had three females and 11 males that underwent exchange transfusion (p = 0.03) (See Fig. 4).

0

2

4

6

8

10

12

14

Exchangetransfusion

IV Pump Method Blood Cell Separator

FemaleMale

Figure 4: Sex Distribution of Patients Undergoing Ex-change Transfusion

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The fact that more males than females in our popula-tion ended up requiring exchange transfusion may be due to males engaging in more extraneous physical activity in our hot climate, becoming dehydrated and more at risk of developing SCD complications treated with exchange transfusion. This trend has been repor-ted in some African countries (9, 10). We also noticed that our patients ages ranged from 4 to 19 years of age, with a mean age of 10.3 years. If we further di-vided patients by age groups (1-4 y/o, 5-10 y/o, and 11-19 y/o), we find that the majority of patients who underwent exchange transfusion were on the oldest age group for both methods (p < 0.05) (See Fig. 5). This finding could be explained by the fact that SCD patients suffer chronic pulmonary and vascular dama-ge throughout the years, making older patients more at risk of developing these complications.

We are the only center in the country that ser-ves the SCD population and the only center where exchange transfusion is performed as a treatment for SCD complications. Our data spans through six years, and is our plan to continue collecting and analyzing fu-ture data in hopes of using this information to better guide patient care. The IV Pump Method represents a realistic, safe, and effective alternative to perform exchange transfusion. This is particularly important in centers where due to geographic, socio-political, or economic limitations it is not feasible to perform this procedure using automated blood cell separators.

This study has several limitations. This is after all, a retrospective study, in only one center in Puerto Rico, looking at a procedure performed selectively in a small patient population. Our hospital runs on a paper-based system, making it at times impossible to retrieve all the necessary data for each admission. This fact fur-ther limited our n to 14 admissions, limiting as well our statistical analysis. A prospective study design would help us overcome this obstacle. It was also difficult to pair patients in both method groups by age or sex, sin-ce we had a significant male predominance and older patients using the Blood Cell Separator method.

CONCLUSION The data suggests that the IV Pump Method is a safe, effective, readily available, and cost-efficient alternative to perform exchange transfusion in patients suffering SCD related complications. Further data co-llection is warranted to increase our study population. Further research is required for better understanding of the disease process. The development of evidence ba-sed treatment guidelines will also result in the improve-ment of patient care and further reduction of morbidity.

0

1

2

3

4

5

6

7

Exchange transfusion IV Pump Method Blood Cell Separator

1-4 y/o

5-10 y/o

11-15 y/o

Figure 5: Age Distribution of Patients Undergoing Ex-change Transfusion

REFERENCES1. Vichinsky F, Neumavr L, Earles A, et al. Causes and Outcomes of the Acute Chest Syndrome in Sickle Cell Disease: National Acute Chest Syndrome Group. N Engl J Med. 200 Jun 22;342(25):1855-65. 2. Informe Annual 2009 Vigilancia de Defectos Congenitos en Puerto Rico. Departamento de Salud de Puerto Rico. August 2009. http://www.salud.gov.pr/Programas/CampanaAcidoFolico/Estadis-ticas/InformeAnual2009.pdf

3. Boga C, Kozanoglu I, Ozdogu H, et al. Plasma exchange in criti-cally ill children with Sickle Cell Disease. Transfus Apher Sci. 2007 Aug;37(1):17-22. Epub 2007 Aug 17.

4. Melton C, Haynes J. Sickle Acute Lung Injury: Role of preven-tion and early aggressive intervention strategies on outcome. Clin Chest Med 27 (2006) 487-502.

5. Swerdlow P. Red cell exchange in sickle cell disease. Hematolo-gy Am Soc Hematol Educ Program. Jan 2006: 48-53.

6. Lawson S, Oakley S, Smith N, et al. Red cell exchange in sickle cell disease. Clin Lab Haematol. Apr 1999; 21(2): 99-102.

7. Janes S, Pocock M, Bishop E, et al. Automated Red Cell Ex-change in Sickle Cell Disease. British Journal of Haematology. 97(2):256-258, May 1997.

8. Sotomayor F, Fernandez-Sein A, Gotay F. Technique for auto-mated exchange transfusion in pediatric patients with Sickle Cell Disease. Boletin Asoc. Med. de P.R. Vol.95:1.

9. Ye D, Kouta F, Dao L, et al. Pediatric Management of Sickle Cell Disease: Experience at the Charles de Gaulle Childrens Hospital in Ouagadougou. Sante. 2008 Apr-Jun;18(2):71-5.

10. Ikefuna A, Emodi I. Hospital admission of Patients with Sickle Cell Anemia Pattern and outcome in Enugu area of Nigeria. Niger J Clin Pract. 2007 Mar;10(1): 24-9.

11. Quinn C, Rogers Z, Buchanan G. Survival of Children with Sic-kle Cell Disease. Blood. 2004 Jun 1;103(11):4023-7.

12. Yanni E, Grosse S, Yang Q, et al. Trends in Pediatric Sickle Cell Disease-Related Mortality in the United States, 1983-2002. J Pediatr. 2009 Apr;154(4): 541-5.

13. Telfer P, Coen P, Chakravorty S, et al. Clinical Outcomes in Children with Sickle Cell Disease living in England: A Neonatal Co-hort in East London. Haematologica. 2007 Jul;92(7):905-12.

14. Hulbert ML. Exchange transfusion compared with single trans-fusion for first overt stroke is associated with a lower risk of subse-quent stroke. J Pediatr. 2006 Jul; 149(5): 710-2.

15. Gladwin M, Vichinsky E. Pulmonary Complications of Sickle Cell Disease. New Engl J Med. 2008 Nov 20; 359(21): 2254-65.

16. Arnaez-Solis J, Ortega-Molina M, Cervera-Bravo A, et al. Evaluation of twenty-three episodes of acute thoracic syndro-

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me in Patients with Sickle Cell Anemia. An Pediatr (Barc.). 2005 Mar;62(3):221-8.

17. Mallhou AA, Asha M. Beneficial effect of blood transfusion in children with sickle cell chest syndrome. Am J Dis Child. 1988 Feb;142(2):178-82.

18. Van-Dumen JC, Alves JG, Bernardino L, et al. Factors as-sociated with sickle cell disease mortality among hospitalized Angolan children and adolescents. West Afr J Med. 2007 Oct-Dec;26(4):269-73.

19. Loureiro MM, Rozenfeld S. Epidemiology of Sickle Cell Di-sease hospital admission in Brazil. Rev Saude Publica. 2005 Dec;39(6):943-9. Epub 2005 Dec 7.

20. Manci EA, Culberson DE, Yang YM, et al. Causes of dea-th in sickle cell disease: an autopsy study. Br J Haematol. 2003 Oct;123(2):359-65.

21. Adams D, et al. Erythropheresis can reduce iron overload and prevent the need for chelation therapy in chronically transfused pe-diatric patients. J Pediatr Hemat/Onco. 18(1) Feb 1996:46-50

22. Masera N, Tavecchia L. Periodic erythroexchange is an effecti-ve strategy for high risk paediatric patients with sickle-cell disease. Transf Apher Sci. Dec 2007, 37(3):241-7.

23. Graham JK, Mosunjac M, Hanzlick RL, et al. Sickle Cell Disea-se and sudden death: retrospective/prospective study of 21 autop-sy cases and literature review. Am J Forensic Med Pathol. 2007 Jun;28(2):168-72.

RESUMENTrasfondo: Pacientes con Anemia Falciforme (AF) sufren de complicaciones que requieren transfu-sin simple y/o de intercambio. En 1999 desarro-llamos una tcnica de intercambio automatizado usando bombas de infusin y catteres vascula-res (Mtodo IV Pump). Objetivo: Probar que el Mtodo IV Pump es costo-efectivo, y tan seguro y eficiente como los separadores automatizados. Mtodos: Estudio retrospectivo de expedientes de pacientes de AF que requirieron transfusin de in-tercambio, admitidos a UCI entre 2003-2009. Eva-luamos mtodo utilizado, complicaciones, costos y cambio en Hemoglobina S% (HgS%), excluyendo pacientes que no requirieron transfusin de inter-cambio. Resultados: La reduccin en costo con el Mtodo IV Pump es de alrededor $1000. Re-duccin de HgS% promedio con Mtodo IV Pump fue 30.3 vs. 28.8 en el grupo de Separador Auto-matizado (p = 0.84). No tuvimos complicaciones o mortalidad, con la mayora de los pacientes siendo masculinos (p = 0.03) y en el grupo de mayor edad (11-19 aos) para ambos mtodos. Conclusin: El Mtodo IV Pump es una alternativa segura, costo-efectiva y eficiente para realizar transfusiones de intercambio.

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SRESPIRATORY ILLNESS IN LATE PRETERM INFANTS DURING THE FIRST SIX MONTHS OF LIFELeilanie Prez MS1Zahira Corchado 1Mariela Rodrguez 1Dora Garca 1Lizaida Medina MD2Arian Vicens MD2Nerian Ortiz MD2Lourdes Garca MD3Yasmin Pedrogo MD2

From the UPR Rio Piedras and Medical Science Campus1, Department of General Pediatrics2 and Section of Neona-tology3 of the UPR School of Medicine, Puerto Rico Health Science Center.Address reprints requests to: Yasmin Pedrogo MD, UPR School of Medicine, Department of Pediatrics, PO Box 365067, San Juan, PR 00936-5067, e-mail address yasmin.pedrogo@upr.edu.

ABSTRACTLate preterm infants are physiologically immature and at risk for respiratory complications. The studys objective was to determine the incidence of respi-ratory illnesses in a group of preterm infants (33-35 weeks) during the first six months of life. Methods: Parents were contacted by phone in the six months period after participating in an educational program and a short survey was performed. Results: None of the infants required admission to the intensi-ve care unit in the newborn period. According to parents, 71% of the babies had a common cold, 9% bronchiolitis, and 3% pneumonia. Fifty four percent of the babies visited the emergency room due to respiratory illnesses and (12%) required ad-mission. Conclusion: Late preterm infants present respiratory illnesses during the first months of life which result in medical expenditures, emergency room visits, and hospital admissions. Educational interventions about preventive measures are nee-ded to decrease the morbidity associated to these illnesses.

Index words: prematurity, low birth weight, respira-tory syncitial virus

childhood bronchiolitis and 50% of childhood pneumo-nia. It has been also found as a risk factor for wheezing later in childhood.

There are several preventive strategies for RSV, which involve palivizumab prophylaxis, limiting contact with infected individuals, good hand washing and avoidance of second hand smoking. Not every preterm infant receives palivizumab prophylaxis, only high risk ones are considered for it. According to the AAP, infants born between 33-35 weeks GA can recei-ve prophylaxis if they are less than 3 months of age at the start of RSV season and if they have at least one of the following risk factors: attending to child care or a sibling younger than 5 years of age. In addition they can receive it if they have cyanotic or complicated con-genital heart disease, chronic lung disease, congenital abnormalities of the airway or neuromuscular disease (8). In Puerto Rico, RSV infection is frequent, but there is no surveillance system to determine the incidence or its epidemic levels. It is estimated that 20% of bron-chiolitis cases seen on a monthly basis are caused by RSV in Puerto Rico (9).

Despite preventive measures, respiratory in-fections continue to be one of the leading causes of infant hospitalizations. In Puerto Rico there is no data about respiratory associated morbidity in late preterm infants. Therefore, the purpose of this study is to deter-mine the incidence of respiratory illnesses in a group of late preterm infant, born at the University District Hos-pital (UDH) of Puerto Rico, during the first six months of life. This data will provide background information for further studies about the impact that this population has on public health and health costs.

INTRODUCTION

Since 1990 late preterm births has climbed more than 25% (1). The term late preterm was adop-ted for infants born between 34 and 36 6/7 weeks ges-tations (GA) by the National Institute of Child Health and Human Development (2). This group of infants is vulnerable to a variety of illnesses and developmental risk, primarily because they are deprived of the last few weeks of development in the uterus. Compared to term infants, they have higher rates of morbidity and mortality at birth and are more frequently readmitted to the hos-pital during the neonatal period (3). Late preterm infants have higher frequencies of hypoglycemia, kernicterus, respiratory disease and seizures (4).

In the United States late preterm infants (34- 36 weeks gestation) account for nearly three quarters of all preterm births, yet little is known about their morbi-dity risk (5). In Puerto Rico the preterm deliveries rate increased 29.3% (11.6 % to 15.0 %) from 1990 to 2000. That increase is mainly attributable to an increase in the rate of preterm births between 32-36 weeks gestation (6).

In addition, those infants are physiologically im-mature and at risk for respiratory complications. The increased risk of respiratory disease can be mainly attributed to three factors: (a) underdeveloped lungs, (b) an immature immune system, and (c) incomplete transfer of maternal antibodies (7). In late preterm in-fants immunity is further compromise posing them at an increased risk for infections, including Respiratory Syncitial Virus (RSV) (7). RSV accounts for 80% of

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MATERIALS AND METHODS A pilot, observational longitudinal study of preterm infants (33-35 weeks gestation) born in the University District Hospital (UDH) from October 2007 through October 2008 was performed. Parents of tho-se infants were contacted by phone in a six months period after participating in an educational program about prevention of second hand smoking. A telepho-ne survey was performed, which included incidence of infants respiratory illnesses, emergency room visits, hospital admissions and RSV bronchiolitis. The study was approved by the University of Puerto Rico, Medi-cal Sciences Campus, Institutional Review Board. Per-centiles and proportions were used to interpret data.

RESULTS Subjects included 32 parents. The mean gesta-tional age of the newborns was 34 weeks (33-35 wee-ks gestation). None of the infants required admission to the intensive care unit in the newborn period. Parents reported that after being home: 71% of the babies had a common cold, 9% bronchiolitis and 3% pneumonia (Table I). Forty one percent (41%) of the babies visited the emergency room and twenty-one (21) proportion of that percent were due to respiratory illnesses. Fif-ty four percent (54%) of the total ER visits were due to respiratory illnesses compare to 46% that were re-lated to other illnesses other than respiratory. Thirty one percent of infants (31%) required admission to the hospital and forty (40%) of those admissions were due to respiratory illnesses. Seventy four percent (74%) of the parents considered themselves to have lack of knowledge about bronchiolitis due to RSV.

Table I: Incidence of Respiratory Illnesses of Preterm Infants Less than Six Month of Age

Development of Disease No Development of DiseaseUpper Respiratory Infection 71% 29%Bronchiolitis 9% 91%Pneumonia 3% 97%

DISCUSSION Late preterm infants present respiratory asso-ciated illnesses during the first months of life, which result in medical expenditures, emergency room visits, and hospital admissions. The main target group of this study was the infants between 33 to 35 weeks of ges-tation due to the overlapping of late preterm (34- 36 weeks gestation) infants and those considered for the administration palivizumab prophylaxis (33-35 weeks gestation). Those infants of 33 to 35 weeks of gestation are at increased risk of developing respiratory illnesses and hospital admissions after being discharge home at birth. Other study also reports that the late preterm group is at a higher risk for re-hospitalization (15.2%) compare to term infants (7.9%) (10).

In our study, the most common respiratory ill-nesses were: common cold illness, bronchiolitis, as-thma and pneumonia. Hospital admissions and emer-gency room visits were mostly associated to respiratory illnesses. Other research studies have demonstrated that respiratory and gastrointestinal disorders are the most common diagnoses for readmission during the first year of life of late preterm infants (10). Another study done in California showed that respiratory disor-ders are the most common cause of readmission for infants born at 35 weeks gestation (11).

It is evident that infants born between 33-35 weeks GA require greater attention in their manage-ment. Physically they look as term infants, but actua-lly they are physiologically immature posing them to an increase morbidity and mortality rate. This study showed that most of the parents have lack knowled-ge about bronchiolitis due to RSV and its prevention. Educational interventions for parents about preventive measures, including proper hand washing, palivizumab prophylaxis, and second hand smoke avoidance are needed in order to decrease the morbidity associated to these illnesses. Physicians and nurses also need to be educated about careful evaluation, monitoring and follow up of late preterm infants. In addition, further stu-dies are required as the data group in this research was too small to obtain epidemiologic values.

In summary, infants between 33- 35 weeks of gestational age in Puerto Rico are at increased risk of developing respiratory diseases, hospital readmis-sions, and emergency room visits during their first six months of life. In consequence, parents and health care workers should be educated about the management,

evaluation, and monitoring of those infants. In Puerto Rico further studies are required in order for therapies, prophylaxis, and monitoring strategies to be formally evaluated and modified in the required cases.

REFERENCES1. Hamilton B, Martin J, & Ventura S. Births: Preliminary data for 2007. National Vital Statistics Reports. 2009. 57: 123.2. Engle A, Tomashek K, & Wallman C. "Late-preterm" in-fants: A population at risk. Pediatrics. 2007. 120: 13901401. 3. Shapiro-Mendoza C, Tomashek K, Kotelchuck M, & et al. Risk factors for neonatal morbidity and mortality among healthy late preterm newborns. Seminars in Perinatology. 2006. 30: 5460.

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4. Raju A. et al. Optimizing care and outcome for late pre-term (near term) infants: a summary or the workshop sponsored by the National Institute of Child and Human Development. Pediatrics. 2006. 118: 1207-1214.5. Shapiro-Mendoza C, Tomashek KM, Kotelchuck M, & et al. Effect of late preterm birth and maternal medical condition on newborn morbidity risk. . Declerq E SO Pediatrics. 2008. 121: 223-32.6. Varela R. Perez R. Duerr A. et al. Infant Heath Among Puerto Ricans- Puerto Rico and U.S. Mainland, 1998-2000. CDC MMWR. 2003. 52: 1012-10167. Coffman S. et al. Late Preterm infants and risk for RSV. The American Journal of Maternal/ Child Nursing. 2009. 34: 378-384.8. Pickering L, Baker C, Kimberlin D, et al. Red Book: 2009 Report of the Comitee on Infectious Disease. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics. 2009: 560-5699. Molinari M, Garcia I, Garcia L, et al. Respiratory Syncitial Virus- related bronchiolitis in Puerto Rico.10. Mclaurin K. Hall C. Jackson Ea. Et al. Persistence of mor-bidity and cost difference between late preterm and term infants during the first year of life. Pediatrics 2009. 123: 65311. Underwood M. Danielsen B. Gilbert M. Cost, causes and rates of rehospitalization of preterm infants. J Perinatol. 2007. 27: 614

RESUMENLos infantes pre-termino tardos son inmaduros fi-siolgicamente y estn a riesgo de complicaciones respiratorias. El objetivo del estudio fue determinar la incidencia de enfermedad respiratoria en infantes pre-termino (33-35 semanas) durante los primeros seis meses de vida. Mtodos: Los padres fueron contactados va telefnica en un periodo de seis meses, y se hizo un cuestionario. Resultados: Al nacer, ninguno de los recin nacidos fue admitido a la unidad de cuidado intensivo. De acuerdo a los padres, 71% de los bebs tuvo catarro, 9% bron-quiolitis y 3% pulmona. Veinte y uno por ciento de los bebes visit la sala de emergencia debido a enfermedades respiratorias y 12 % requiri admi-sin. Conclusin: Los infantes pre-trmino tardos presentan enfermedades respiratorias durante los primeros meses de vida, lo cual resulta en gastos mdicos, visitas a salas de emergencia y admi-siones a hospitales. Se necesitan intervenciones educativas acerca de las medidas preventivas para poder disminuir la morbilidad asociada a estas en-fermedades.

AGREGUE LA INFORMACION DE SU OFICINA A UN WEBSITE VISITADO POR LOS PACIENTES QUE NECESITAN DE SUS SERVICIOS

TPRENATALBREASTFEEDING

INTENTIONS INA GROUP OF WOMEN

WITH HIGH RISKPREGNANCIES

Hildamary Diaz Rozett MD*Lourdes Garcia Fragoso MD**

From the * Department of Pediatrics and ** Neonataology Section Department of Pediatrics, UPR School of Medicine.Address reprints requests to: Lourdes Garca MD, UPR School of Medicine, Department of Pediatrics, Neonatolo-gy Section, PO Box 365067, San Juan, PR 00936-5067. E-mail: lourdes.garcia1@upr.edu.Poster presentation at the Annual Puerto Rico Pediatrics So-ciety meeting (February 2009), the annual Medical Sciences Campus Research Forum (April 2009), and at the 2009 ALA-PE meeting (November 2009).

ABSTRACTThe American Academy of Pediatrics recom-mends exclusive breastfeeding for the first 6 mon-ths of life. In spite of a limited number of contra-indications, there are mothers who decide not to breastfeed their infants. Objective: To determine intention to breastfeed in women with high-risk pregnancies. Methods: Pregnant women who attended the Obstetrics high-risk clinics at the University District Hospital answered a survey. Results: Participants included 186 women. Mean maternal age was 27 years (15-47) and mean gestational age 27 weeks (9-41). Ninety-four per-cent intended to breastfeed. The most common reason for not planning to was the use of medica-tions. Breastfeeding intentions were associated to higher education (p

Breastfeeding intentions were associated to higher education (p

breastmilk, the virtues of formula, and the practical and sociocultural challenges of breastfeeding. Womens ambivalence resulted in widespread complementary feeding pattern that included breastmilk and formula, and resulted in short breastfeeding durations.

This group of women with high-risk pregnan-cies showed high interest in breastfeeding their babies but also showed misconceptions about the effects of medications and lack of confidence in being able to breastfeed their babies. These women were followed up at a high risk clinic seen frequently by an obstetri-cian. Nevertheless, obstetricians were not identified as sources of information about breastfeeding. Physicians taking care of women with medical conditions affecting the pregnancy or fetus should reinforce the desire to breastfeed among their patients and identify miscon-ceptions that may deter women from giving their new-borns the best available nutrition.

Table I: Factors associated to the intention to breastfeed (N=186)

Characteristic Breastfeeding No Breastfeeding p-value (N=175) (N=11)

Maternal age (years) 26 26 NSSGestational age (weeks) 29 24 NSSMaternal educationHigh school or beyond 87% 45% p

IMINOR HEAD INJURY IN CHILDREN YOUNGER THAN TWO YEARS OF AGE: DESCRIPTION,PREVALENCE ANDMANAGEMENT IN THE EMERGENCY ROOM OF THE PEDIATRICUNIVERSITY HOSPITALMara L. Fernndez MS*Linette Mejas MS*Nerian Ortiz MD**Lourdes Garca-Fragoso MD**

From the *School of Medicine, **Department of General Pe-diatrics, UPR School of Medicine. Address reprints request to: Nerian Ortiz MD, UPR School of Medicine, Department of Pediatrics, PO Box 365067, San Juan, PR 00936-5067. E-mail nerian.ortiz@upr.edu.

ABSTRACTBackground: In children less than two years old, minor head trauma can result in intracranial in-jury. No known studies exist that determine the number of children younger than two years old who visit the emergency room (ER) due to minor head injury in Puerto Rico. Objective: To deter-mine the prevalence of children with minor head trauma and describe related issues. Methods: Information was gathered from the medical re-cords of children 0 to 2 years old who visited the University Pediatric Hospital ER from 2004-2006. Several factors were analyzed. Results: From our 136 subjects, there was a male preva-lence of 59%. The predominant reason for head injury was a fall (86%). There was abuse in 7% of the subjects. Eighty-five percent (85%) of in-juries occurred at home. Conclusions: The most common etiology of head trauma was a fall at home. The prevalence of abuse in 7% of these children should alert physicians.

Index words: head trauma, infants, injury, falls

INTRODUCTION

In children less than two years old, minor head trauma is a common injury that can result in skull fractu-re and intracranial injury (1). Head trauma is one of the most common childhood injuries, annually accounting for approximately 600,000 emergency department vi-sits, 95,000 hospital admissions, and 550,000 hospital days; hospital care costs alone exceed 1 billion dollars per year (2-5). Most children receive a head injury as a result of a fall (6). Mild head injury is usually considered an insignificant event as any alteration of conscious-ness is transient and medical intervention is rare. Most patients with mild head injury are currently discharged from the emergency department without sequelae after a brief observation period. Although the great majority recovers, apparently uneventfully, the risk of life-threa-tening intracranial complication dominates attitudes to management and requires a structured, logical appro-ach. Despite the frequent occurrence of head injury in children, diagnostic strategies differ among individuals and institutions. To our knowledge, there are no pre-vious studies that determine the mechanism of injury or the number of children younger than two years old who visit the emergency rooms due to minor head injury in Puerto Rico. Also, no established protocol exists con-cerning the adequate management of these patients in the hospitals in Puerto Rico. The purpose of this study was to determine the prevalence of children with minor head trauma who visit the emergency room of the Uni-versity Pediatric Hospital and describe related issues concerning minor head injury.

MATERIALS AND METHODS Information was gathered from the medical re-cords of children 0-2 years old who visited the emer-gency room of the University Pediatric Hospital in San Juan, Puerto Rico with a chief complaint of head trau-ma from January 2004 through December 2006.

Minor head injury has been described befo-re by several authors (5) as patients with a Glasgow Coma Scale score of > 13 and a history of loss of cons-ciousness or amnesia for the event; loss of conscious-ness if evident of less than 20 minutes, hospitalization of equal or less than 2 days, if this occurred and no evidence of skull fracture; based on a Glasgow Coma Scale score on arrival at the hospital of 15. For the purpose of this study, minor head injury was defined as a Glasgow score >13, loss of consciousness of less than 1 minute, negative neurological examination, nor-mal mental status, no skull fracture, vomiting less than 5 times without worsening, and normal head computed tomography (CT) scan. Data gathered included gen-der and age group distribution, mechanism of injury, anatomical location of the injury, location of the subject at the time of injury, neurological findings on physical examination, radiological tests performed, where the patient was sent for observation, and consultations to other specialists.

Statistical analysis of collected data was done by using frequency, mean and range. Differences among groups were evaluated using Chi-square and Pearson t-test. A p-value less than 0.05 was considered

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statistically significant. The study was approved by the Medical Sciences Campus Institutional Review Board.

RESULTS The study included 136 subjects between the ages 0 to 2 years old. Table I shows the demographic characteristics of the subjects. The predominant rea-sons for head injury were falls (86%) followed by suspi-cion of abuse (7%), and motor vehicle accidents (4%). Eighty-five percent (85%) of these injuries occurred at home and in all the cases there was an adult present at the moment of the injury. The most common anatomi-cal location for the lesion was the parietal region of the skull (52%). Specific neurological findings analyzed included crying (84%); hematoma (40%); scalp swe-lling (19%); vomiting (18%); and loss of consciousness (2%). The mean Glasgow Coma Scale was 14 (range 13-15).

The radiological tests performed were CT (58%); skull radiographs (34%); and C-spine (16%). Thirty percent of the infants who had a skull radiograph performed had a fracture. A CT scan was performed more commonly in infants with a skull x-ray showing a fracture (86% of patients with fracture vs. 27% of pa-tients without fracture [OR 16, 95% CI 2.98-86, p

A comprehensive approach to the head injured child begins in the pre-hospital area and continues through acute hospital management and ultimate rehabilita-tion. Predetermined protocols facilitate accurate as-sessment and treatment during the initial moments of care (6). It is important for every institution evaluating young children with minor head trauma to develop pro-tocols for the uniform evaluation of these children.

3. Homer CJ, Lawrence K. Technical report: head injury in children. Pediatrics 1999;104:78-84.4. Roddy SP, Cohn SM, Moller BA, Duncan CC, Gosche JR, Seashore JH, Touloukian RJ. Minimal head trauma in children revi-sited: is routine hospitalization required? Pediatrics 1998;101:575-577.5. Quayle KS, Jaffe DM, Kuppermann N, Kaufman BA, Lee BCP, Park TS, McAlister WH. Diagnostic testing for acute head injury in children: when are head computed tomography and skull radiographs indicated? Pediatrics 1997;99:11-18.6. McKinlay A, Dalrymple-Alford JC, Horwood LJ, Fergus-son DM. Long term psychosocial outcomes after mild head injury in early childhood. J Neurol Neurosurg Psychiatry 2002;73:281-288.

RESUMENIntroduccin: En nios menores de dos aos, trau-ma menor a la cabeza puede resultar en dao in-tracraneal. No se conocen estudios que determi-nen la prevalencia de nios menores de dos aos que visitan la sala de emergencia debido a trauma menor de cabeza. Objetivo: Determinar la preva-lencia de nios menores de dos aos que visitan la Sala de Emergencia del Hospital Peditrico Uni-versitario debido a trauma menor de cabeza. M-todos: Se obtuvo informacin de los expedientes mdicos de pacientes de 0-2 aos que visitaron la sala de emergencia del Hospital Peditrico Uni-versitario en los aos 2004-2006. Se analizaron varios factores. Resultados: De una muestra de 136, se observ una prevalencia masculina de 59%. La razn principal del trauma fue una cada (86%). Se observ abuso en 7% de los sujetos. Conclusiones: La etiologa ms comn fue una cada en la casa. La prevalencia de abuso debe alertar a los mdicos.

Table I: General characteristics of the participants (N=136)

Characteristics ParticipantsAge 0 3 months old 21% 4 6 months old 14% 7 9 months old 13% 10 12 months old 5% 1 - 2 years old 47%Gender Males 59% Females 41%

Cada da es ms importante la utilizacin de la tecnologa informtica en todas las profesiones.

La Asociacin Mdica de Puerto Rico est colaborando con la clase mdica para que se incorpore adecuadamente a la misma.

Mantngase informado envindonos su direccion email a travs de nuestro regis-tro en www.asociacionmedicapr.org

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REFERENCES1. Schutzman SA, Barnes P, Duhaime AC, Greenes D, Ho-mer C, Jaffe D, Lewis RJ, Luerssen TG, Schunk J. Evaluation and management of children younger than two years old with apparently minor head trauma: proposed guidelines. Pediatrics 2001;107:983-993.2. Committee on Quality Improvement, American Academy of Pediatrics and Commission on Clinical Policies and Research, American Academy of Family Physicians. The management of minor closed head injury in children. Pediatrics. 1999;104:1407-1415.

Deber incluirse lo siguiente: ttulo, nombre de autor(es) y su grado (ej.: MD, FACP), ciudad donde se hizo el trabajo, el hospital o institucin acadmica, patrocinadores del estudio, y si un artculo ha sido ledo en alguna reunin o congreso, as debe hacerse constar como una nota al calce.

El articulo debe comenzar con una breve introduccin en la cual se especifique el propsito del mismo. Las secciones principales (como por ejemplo: materiales y mtodos) deben identificarse con un encabezamiento en letras mayuscula negritas (bold).

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ResumenUn abstracto no mayor de 250 palabras en estudios clnicos y no mayor de 150 palabras en reporte de casos o resea. Debe incluir los puntos principales que ilustren la substancia del artculo y la exposicin del problema, mtodos, resultados y conclusiones. El resumen debe estar escrito en ingls y en espaol.

ReferenciasLas referencias deben ir numeradas sucesivamente de acuerdo a su aparicin en el texto. Los nmeros deben aparecer en parntesis al nivel de la lnea u oracin y no como subindices ni ninguna otra forma de referencia. Al final de cada artculo las referencias deben aparecer en el orden numrico en que se citan en el texto. Deben utilizarse solamente las abreviaturas para ttulos de revistas cientficas segn indicadas en el Cumulative Index Medicus" que publica la Asociacin Mdica Americana.Las referencias deben seguir el patrn que se describe a continuacin.1. Para artculos de revistas: Apellido(s) e iniciales del nombre del autor(es), ttulo del artculo, nombre de la revista, ao, volumen, pginas. Por ejemplo: Villavicencio R: Soplos inocentes en pediatra, Bol Asoc Md P Rico 198 1; 73: 479-87. Si hay ms de 7 autores, incluir los primeros 3 y aadir et al.2. Para citacin de libros donde el autor(es) del captulo citado es a su vez el (los) editor(es): Apellido(s) e iniciales del autor(es), ttulo del libro, nmero de edicin, ciudad, casa editora, ao y pgina. Por ejemplo: Keith JD, Rowe RD, Vlad P: Heart disease in infancy and childhood, 3d. Ed., New York, MacMillan, 1978: 7893. Para citacin de libros donde el editor(es) no es el autor(es) del captulo citado se aade el autor(es) del captulo y el ttulo del mismo. Por ejemplo: Olley PM: Cardiac arrythmias; In: Keith ID, Rowe RD, Vlad P Eds. Heart disease in infancy and childhood, 3d Ed., New York, MacMillan, 1978: 275-301

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Should include the following: title, authors and their degrees (e.g. MD, FACP), city where the work was done, hospital or academic institutions, acknowledgments of financial sponsors, and if the paper has been at a meeting the place and date should be given.

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ReferencesThese should be numbered serially as they appear in the text. The number should be enclosed in parentheses on the line or writing and not as superscript or subscripts, numbers. At the end of the article references should be listed in the numerical order in which they are first cited in the text.The titles of journals should be abbreviated according to the style used in the "Cumulative Index Medicus" published by the American Medical Association. The correct forms of references are as given below:1. For periodicals: Surname and initials of author(s), title of article, name of journal, year, volume, pages. For example: Villavicencio R.: Soplos inocentes en pediatra. Bol Asoc Med P Rico 198 1; 73: 479 87. If there are more than 7 authors list only 3 and add et al.2. For books when the authors of the cited chapter is at the same time the editor: Surname and initials of author(s), title, edition, city, publishing house, ~ear and page. For example: Keith JD, Rowe RD, Vlad P: Heart disease in infancy and childhood, 3d Ed., New York, MacMillan, 1978: 7893. For chapter in book when the author of the chapter is not one of the Olley PM: Cardiac arrythmias: In: Keith JD, Rowe RD, Vlad P. Eds. Heart disease in infancy and childhood, 3d Ed. New York, MacMillan, 1978, 275-301

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RROOMING-IN IMPROVES BREASTFEEDINGINITIATION RATES IN A COMMUNITY HOSPITALIN PUERTO RICO

Carmen W. Cotto MD*Lourdes Garcia Fragoso MD

From the *Department of General Pediatrics and the **Sec-tion of Neonatology, UPR School of Medicine.Address reprints requests to: Lourdes Garca MD, UPR School of Medicine, Department of Pediatrics, Neonatology Section, PO Box 365067, San Juan, PR 00936-5067Email: lourdes.garcia1@upr.edu.

ABSTRACTSeveral studies have shown that rooming-in can have a positive impact on lactation success. The objective of this study was to assess if the establis-hment of rooming-in in a community hospi