Background: Reducing neonatal mortality rates [NMR] (deaths/1,000 live births within 28 days of delivery) is a key global health goal. Using comparable data from Ghana (West Africa) and Scotland, I investigated NMR, specific causes of death and risk factors in the two countries. By identifying the main causes of excess mortality in Ghana and where they occur, it is hoped more effective strategies can be developed. Methods: This thesis used a multilevel mixed methods study design. Data on live births were obtained from three Health and Demographic Surveillance Systems (HDSS) in the north, middle and south of Ghana respectively: Navrongo (2004-12; 17,016 live births, 320 deaths); Kintampo (2005-10; 11,207 live births, 140 deaths); Dodowa (2006-14; 21,647 live births, 135 deaths). Comparable Scottish data were obtained from the Information Services Division (1992 to 2015; 1,278,846 live births, 2,783 deaths). Each dataset was analysed by neonatal death (dead/alive), using univariate and multivariable logistic regression. The multivariable analyses adjusted for maternal demographic and obstetric characteristics. Missing data were analysed using multiple imputation techniques. Data analyses were complemented by a researcher-developed questionnaire survey of 71 maternity care providers in the three regions of Ghana followed by face-to-face in-depth interviews with 48 maternity care providers who had experience of prematurity, birth asphyxia, neonatal infection and neonatal death. Results: The NMRs in the three HDSS were: Navrongo: 18.8; Kintampo: 12.5; and Dodowa 6.2 and in Scotland it was 2.2; the NMR in both countries is reducing. More than 99% of the neonatal deaths in Scotland occurred in the first week compared to 74% in Ghana. The leading causes of neonatal deaths (NMR) in Ghana were infection (4.3), asphyxia (3.7) and prematurity (2.2). In Scotland, they were congenital malformations (0.6), asphyxia (0.4) and prematurity (0.3). Only 88 deaths (0.07) of neonatal deaths in Scotland were due to infection. Ninety-eight percent of babies born in Scotland were born in a health facility compared to 60% of babies born in Ghana (hospital: 38.1%; clinic: 21.1%). In Ghana, babies born in hospitals had a higher risk of neonatal mortality compared to those born at home (NMR-hospital: 15.6; clinic: 7.1; home: 11.8). Most of the neonatal deaths in Ghana occurred at home (54%); there were more deaths among babies who were born in a hospital but died at home (hosp/home) compared to those born at home but died in a hospital (home/hosp). Asphyxia was the leading cause of death among hosp/hosp, and infection was the leading cause of death among hosp/home, home/home and home/hosp. Neonatal mortality in Ghana was largely influenced by where mothers sought maternity service, or the type of personnel who provided maternity care service. Mothers and babies who were cared for in hospitals by doctors and midwives received relatively better care and proper management of birth complications. Those who were cared for in clinics received basic delivery services and management of uncomplicated asphyxia. Mothers and babies who were cared for at home by traditional birth attendants (TBA) received poor care and poor management of neonatal illnesses based on traditional approaches which increased the risk of death. Women’s maternity choices were influenced by wider societal factors including prominent cultural values, family hierarchical structures and the cost of maternity services, and individual/ family factors including place of residence and availability of transport and beliefs about the cause of disease. Conclusion: There is considerable opportunity for reducing NMR in Ghana, especially deaths due to asphyxia and infections. Most uncomplicated deliveries should be performed by midwives in community clinics. The number of community maternity clinics should gradually be increased to enable home deliveries by TBAs to be phased out. Facilities should be improved for delivery and postnatal care in hospitals and the proportion of sick babies managed by health care workers trained in their care should be increased. Regular postnatal checks in the community by trained staff should be standard.

Esta dissertação é fruto de profundas inquietações a respeito da origem e da importância das primeiras relações entre mãe e bebê, bem como das forças atuantes na constituição do psiquismo infantil. Ao longo do estudo, surgiu a necessidade de pesquisar a depressão pós-parto como conseqüência do retorno a si mesma, fruto da regressão da mãe e do contato facilitado que toda mãe é levada a fazer ao dar à luz um bebê com conteúdos e conflitos inconscientes relativos a experiências e fantasias infantis e suas reverberações no desencontro da dupla. O estudo inicia-se pela visão de Freud, Klein e alguns de seus discípulos atuais sobre como a menina se torna mulher e qual o impacto da maternidade para o psiquismo feminino; discute a importância da complexa trama envolvida no cenário das primeiras relações; demonstra as competências do recém-nascido, seu uso dos cinco sentidos, e a noção de estados de consciência; trata das confirmações encontradas pela neurociência às questões da importância das relações iniciais que a psicanálise discute; aborda aspectos da interação mãe e bebê, inclusive a psicopatologia do bebê decorrente do desencontro entre a dupla e seus efeitos, com atenção especial à compreensão da depressão materna no período puerperal. Num segundo momento, discutem-se entrevistas que realizamos com pediatras profissionais que atendem no início a dupla mãe-bebê possuidores de experiência diversificada em clínica médica. Aborda-se o universo que apresentam, bem como se registram as reflexões advindas desses contatos produtivos, articulando-os com os conhecimentos teóricos oferecidos pela psicanálise. Assim, propõe-se verificar e observar a capacitação dos pediatras no diagnóstico da depressão puerperal; investigar a atenção que os pediatras dedicam aos aspectos da relação entre mãe e filho e seu impacto no desenvolvimento do bebê; e apontar de que forma a psicologia e a psicanálise podem fornecer subsídios à pediatria. / This essay is a result of profound concerns about the origins and the importance of the early relationship between mother and baby and of the active crosscurrents in the constitution of child psyche. Throughout the work, there came the necessity of researching the postpartum depression as a consequence of the return to the self, a product of mother regression and of the facilitated contact which every mother is supposed to undergo after child bearing with unconscious themes and conflicts related to child experiences and fantasies and their reverberations in the lack of mother-baby approximation. This study begins with the perspectives of Freud, Klein and some of their contemporary followers about how the girl becomes a woman and the impact of motherhood in women psyche; then, it discusses the importance of the complex web involved in the early relationships; it shows the skills of the newborn baby, its use of the five senses, and the concept of states of conscience; it addresses how neuroscience has confirmed the issues related to the centrality of the early relationships discussed by psychoanalysis; it approaches the aspects relating to the interactions between mother and baby and their effects, focusing specially in the understanding of motherhood depression in the puerperal period. In a second stance, our work discusses the interviews we have made with pediatricians professionals giving an early medical care to mother and baby who have a diverse experience in medical practice. Our work addresses the universe they present, and observes the reflections that come from these productive contacts, articulating them with the theoretical knowledge offered by psychoanalysis. By this light, we intend to examine and observe the ability pediatricians have in the diagnosis of puerperal depression; to investigate the attention they give to the aspects of mother-baby relationship and their impact on child development; and to show how psychology and psychoanalysis are able to furnish useful tools to pediatrics.

BACKGROUND: Parent medication errors are exceedingly common, with one child experiencing an outpatient medication error every 8 minutes. In a previous randomized controlled trial where the intervention was carried out under ideal conditions, we examined the efficacy of a pictographic, health literacy-informed medication instruction sheet-based intervention (HELPix) in reducing parent dosing errors. While our intervention was efficacious in reducing errors, reproducing these results in a real world setting, is necessary to examine the true effectiveness of HELPix. OBJECTIVES: 1) To examine the impact of HELPix implementation on parent medication dosing errors. 2) To assess the effect of HELPix implementation on provider use of medication counseling strategies. DESIGN/METHODS: A pre-implementation/post-implementation study design was used in 2 pediatric Emergency Departments (EDs) in New York City, one with planned implementation of the HELPix intervention (HELPix site) and the other a control site within the same hospital network. Subject inclusion criteria included: 1) English or Spanish-speaking parent, 2) child <9 years old, child prescribed a short course (≤14 days) daily liquid medicine, and 3) parent present with the child in the emergency department and received medication counseling. Parents were recruited over the phone; those who enrolled completed a phone interview along with a follow-up in-person assessment (median time to follow-up=15 days). ED providers (residents, fellows, attendings) were also recruited. The HELPix intervention consists of: 1) provider provision of patient- and medicine-specific pictographic instruction sheets, 2) provider use of pictures/drawings as part of counseling to reinforce dosing information, 3) provider demonstration of the dose using an oral syringe, 3) teachback of dose information, 4) parent showback of the dose they plan to give, and 5) provider provision of an oral syringe. At the HELPix site, ED providers were trained in the use of HELPix counseling strategies as well as how to use the electronic medical record (EMR) system to generate the instruction sheets while ordering a prescription. Outcomes assessed were: 1) provider provision of HELPix instruction sheets via web tracking, 2) dosing errors ≥ 20% deviation from prescribed dose, assessed from observation at follow-up visit, 3) provider counseling practices (i.e. use of pictures/drawings, demonstration, teachback, showback, provision of dosing tool) obtained by parent report. RESULTS: A total of 1493 parents were assessed by telephone for eligibility in the pre-/post-implementation phases. 561 parent-child dyads were recruited by phone (284 at HELPix site; 277 at control site). A total of 92% were mothers, 52% were Spanish speakers, 78% were Latino, 16% were Black, and 85% were of low socioeconomic status. Web tracking at the HELPix intervention site indicated that for 58% of the enrolled families in the post-implementation period, providers generated HELPix medication instruction sheets. Compared to the pre-implementation period at the intervention site, parent dosing errors rates were significantly reduced during the post-implementation period (37% versus 16%; AOR=0.3, p<0.001); with an overall Relative Risk Reduction (RRR)=57%, with greatest reductions in errors among those that received HELPix sheets (12% error rate, RRR=68%). Providers at the HELPix implementation site were significantly more likely to use recommended provider counseling strategies post-implementation compared to pre-implementation (pictures/drawings: 37% versus 1%; dosing demonstration: 59% versus 33%; teachback: 24% versus 8%; showback: 33% vs. 13%, and provision of oral syringe 79% versus 25%; p<0.0001 for all strategies). In the non-intervention site, there were no differences in parent dosing error rates, or in provider use of counseling strategies between the pre- and post-implementation periods. CONCLUSION: Implementation of the HELPix intervention resulted in increased provider use of recommended counseling strategies as well as decreased parent medication dosing errors in an urban public hospital setting serving low socioeconomic status families. Use of HELPix supports high quality provider medication counseling and appears to be feasible to incorporate as part of routine Emergency Department discharge practices.

Malnutrition is concerning in children because it effects proper growth and development. Handgrip Strength (HGS) has been identified as a diagnostic indicator for identifying pediatric malnutrition but normal reference ranges have not yet been established; therefore, HGS can be used to identify malnutrition but not quantify the degree of malnutrition: mild, moderate, or severe. The aim of this study was to determine if HGS differed between hospitalized and non-hospitalized children and to describe the association between HGS and several parameters including height, weight, body mass index (BMI), and mid-upper arm circumference (MUAC). One hundred nine hospitalized and 110 non-hospitalized pediatric patients ages 6-14 years participated in this cross sectional, nonequivalent control group design study. Nutrition status was evaluated using BMI z scores and MUAC z scores, and HGS was evaluated within 48 hours of hospital admission or at a well-child appointment. According to BMI z scores, 24.8% of hospitalized and 18.3% of non-hospitalized participants were malnourished. Mean HGS of hospitalized participants was not significantly different from non-hospitalized participants (p=.2053). HGS was found to be associated with age, height, dominant hand, and MUAC z scores in all participants. The difference in HGS measurements was not statistically significant between hospitalized and non-hospitalized children using a one-time HGS measurement. Further research examining HGS measurements over time as well as comparing HGS measurements to the degree of malnutrition deficit in pediatrics is needed.

Nationally, it has been estimated that 10 to 21% of children with psychosocial concerns are seen in primary care settings (Jellinek et al., 1999; McInerny, Szilagyi, Childs, Wasserman & Kelleher, 2000; Palermo et al., 2002). Often, however, children go undiagnosed with/treated for psychosocial concerns in pediatric primary care due to lack of physician time and poor referral rates to mental health providers. Evaluations of integrated care models, in which a behavioral health consultant is present in primary care practices, has shown to increase the availability of mental health services (Stancin, Perrin, & Ramirez, 2009). Using extant data from patient records extracted by a trained nurse, this study aims to assess practice scheduling habits and seasonal variation in behavioral health consultant (BHC) usage on days when a BHC is present versus non-BHC days in one rural pediatric office over the course of four years. This study aims to evaluate economic efficiency based on the number of patients scheduled per day. It is hypothesized that the presence of an onsite BHC will increase patient volume and, thus, economic efficiency. Information gathered from the clinic’s electronic scheduling system included: 1) the number of patients scheduled on a BHC day and 2) the number of patients scheduled on a non-BHC day for each week of the BHC’s employment. These data—both overall and by year and season—were analyzed using one-way ANOVA and post hoc Tukey testing. There were no significant differences in scheduled patient volume found between the day types overall. However, yearly analysis revealed significant differences between 2010 and 2012, 2013, and 2014 on BHC days and between 2010 and 2014 on non-BHC days. When examined by season, significant differences were found between Fall/Winter and Spring/Summer on both day types in post hoc Tukey testing. These findings have important implications for the trajectory of benefits provided by a BHC in a rural integrated care model.

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This review of scientific literature was performed in Brazillan and North American studies about the prevalence and assessment procedures of Infant Hearing Loss. Fourteen Brazilian articles and 12 American publications of prevalence between 2000 and 2012 were reviewed. The prvalence of infant hearing loss in Brazilian papers was between 0.2% and 10.2% and American papers from 0.22% to 3.61%. As or the procedures used for diagnosis there was a high similarity in the choice of methods.