Continuity Clinic Case of the Week New parents bring their 2 week old John into your clinic

for a routine visit. In your normal questioning, you ask about sleep position and learn that they are placing him in a lateral position to sleep. You also learn that he is breastfeeding well and that they have begun to supplement him with a few ounces of formula a day, so that mom can return to work in a few weeks. She works part-time at a department store and wont have time given to her to pump, but she will breastfeed him when she is with him. R1: What are the priorities that you should discuss at the 1-2 week visit? Why is it important to have an early visit? R2: 1. What are the recommendations for a safe sleep environment and the prevention of SIDS? a. Infant should be placed in a supine position b. Infant should be placed in a prone position c. Infant should be placed in a lateral position d. No loose bedding should be near the infant e. A, C and D f. A and D 2. True or False: A lateral sleeping position is almost as safe as a supine sleeping position. R3: What are the most recent recommendations for the use of Vitamin D supplementation in infants? a. All infants should receive vitamin D supplementation b. Infants who are exclusively breastfed should receive 200 IU vitamin D supplementation c. Infants who are exclusively breastfed should receive 400 IU vitamin D supplementation d. Infants who breastfeed and consume 500 cc of formula a day, do not need vitamin D supplementation e. No infants need vitamin D supplementation

R1: What are the priorities that you should discuss at the 1-2 week visit? Why is it important to have an early visit? Bright Futures Guidelines for Health Supervision recommends that after addressing parent concerns, the physician addresses the following:

This visit is critical for assessing the newborn infant for physiologic changes, for murmurs, for jaundice, nutritional adequacy, to address concerns or problems with breastfeeding and to discuss anticipatory guidance. R2: 1. What are the latest recommendations for a safe sleep environment and the prevention of SIDS? a. Infant should be placed in a supine position b. Infant should be placed in a prone position c. Infant should be placed in a lateral position d. No loose bedding should be near the infant e. A, C and D f. A and D 2. True or False: A lateral sleeping position is almost as safe as a supine sleeping position. Safe Sleep Environment and Sudden Infant Death Syndrome (SIDS) 1. The correct answer is f (A and D). Infants should be placed in the supine position and no loose bedding should be near them. 2. The correct answer is false: A lateral sleeping position is NOT almost as safe as a supine sleeping position.

The American Academy of Pediatrics published guidelines for the prevention of SIDS in 1992 and 1996. The first guidelines in 1992 (recommending supine positioning) were largely responsible for a 40% reduction in the SIDS national incidence. The evidence had suggested that lateral (side) position was associated with an increased risk of SIDS compared to a supine (back) position and the guidelines were updated to reflect these changes. In addition to prone positioning, the following factors are associated with an increased incidence of SIDS: overheating, a soft sleep surface, and soft bedding. Evidence has demonstrated that SIDS may decrease if infants use pacifiers or if a fan1 is placed in the room where they sleep. An update was released in 2011 that focused on a safe sleep environment in general, to prevent other causes of newborn deaths associated with sleep (suffocation and asphyxia). The policy recommends against bed sharing and soft items in the bed (including bumper pads). A study in Washington State, evaluated the results from a large survey and found that: Most respondents placed their children in a supine position (7,029), followed by lateral (3,123) then prone (1,188). 65% typically placed their infants to sleep in the supine position, 10.6% in the prone position, and 24.1% in the lateral position. Maternal African-American race, being born in the United States, primiparity, and earlier infant birth year were most predictive of prone sleep positioning. Maternal residence outside the Seattle area and infant male sex were also positively associated with prone sleep positioning. The factors most highly predictive of lateral sleep positioning were maternal nonwhite and non-Native American race, Medicaid payment for delivery, infant's earlier birth year, and mother's county or residence being other than the Seattle area. Other independent, positive predictors included primiparity, mother's receipt of government benefits during pregnancy, prematurity, and infant of normal birthweight (vs. low birthweight).

The authors conclude that "SIDS prevention efforts may benefit from consideration of factors predicting either lateral or prone infant sleep positioning."2 Targeted questioning of higher risk families is important. And if a routine screening question demonstrates that a family places their infant in the lateral position, they should be instructed to place them in a supine position. R3: What are the most recent recommendations for the use of Vitamin D supplementation in infants? a. All infants should receive vitamin D supplementation b. Infants who are exclusively breastfed should receive 200 IU vitamin D supplementation c. Infants who are exclusively breastfed should receive 400 IU vitamin D supplementation d. Infants who breastfeed and consume 500 cc of formula a day, do not need vitamin D supplementation

e. No infants need vitamin D supplementation Vitamin D Supplementation The correct answer is c. The American Academy of Pediatrics came out with 2008 guidelines for vitamin D supplementation for breastfeeding infants, children and adolescents. These guidelines are in light of mounting evidence that many children are vitamin D deficient and that it may be reaching epidemic proportions in the United States. This deficiency may not result in clinical rickets (as it is not as severe), but as children spend more time indoors and drink less milk, there are more children who are deficient in vitamin D. The implications of vitamin D deficiency are also better understood, it impacts not only bone health but also immune function and for the prevention of long-latency diseases. Recommendation: All infants and children, including adolescents, have a minimum daily intake of 400 IU of vitamin D beginning soon after birth. Breastfed and partially breastfed infants should be supplemented with 400 IU/day of vitamin D beginning in the first few days of life. Supplementation should be continued unless the infant is weaned to at least 1 L/day or 1 qt/day of vitamin D fortified formula or whole milk. All non-breastfed infants, as well as older children who are ingesting <1000 mL/day of vitamin Dfortified formula or milk, should receive a vitamin D supplement of 400 IU/day. Adolescents who do not obtain 400 IU of vitamin D per day through vitamin D fortified milk (100 IU per 8-oz serving) and vitamin Dfortified foods (such as fortified cereals and eggs [yolks]) should receive a vitamin D supplement of 400 IU/day.

Coleman-Phox K, Odouli R, De-Kun L. 2008. Use of a fan during sleep and the risk of sudden infant death syndrome. Archives of Pediatrics and Adolescent Medicine 162(10):963-968. Abstract available at http://archpedi.ama-assn.org/cgi/content/short/162/10/963.
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McKinney CM, Holt VL, Cunningham ML, et al. 2008. Maternal and infant characteristics associated with prone and lateral infant sleep positioning in Washington State, 1996-2002. Journal of Pediatrics 153(2):194-198. Abstract available at http://www.jpeds.com/article/S0022-3476(08)00099-1/abstract. Task Force on Sudden Infant Death Syndrome. 2011. SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment. Pediatrics 2011;128;e1341; originally published online October 17, 2011. http://pediatrics.aappublications.org/content/128/5/e1341.full.pdf+html?sid=23245a9c-cfd9-4539-b0e1-37eac68e82b9 Carol L. Wagner and Frank R. Greer. 2008. Prevention of Rickets and Vitamin D Deficiency in Infants, Children, and Adolescents. Pediatrics 2008;122;1142. http://pediatrics.aappublications.org/content/122/5/1142.full.pdf+html?sid=dffda2ca-94f2-4763-a078ae93e1e21791