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Over the past 20 years, hospitalists have emerged as a distinct group of pediatric practitioners. In August of 2014, the American Board of Pediatrics (ABP) received a petition to consider recommending that pediatric hospital medicine (PHM) be recognized as a distinct new subspecialty. PHM as a formal subspecialty raises important considerations related to: (1) quality, cost, and access to pediatric health care; (2) current pediatric residency training; (3) the evolving body of knowledge in pediatrics; and (4) the impact on both primary care generalists and existing subspecialists. After a comprehensive and iterative review process, the ABP recommended that the American Board of Medical Specialties approve PHM as a new subspecialty. This article describes the broad array of challenges and certain unique opportunities that were considered by the ABP in supporting PHM as a new pediatric subspecialty.

OBJECTIVE: In response to limitations in access to subspecialty care, I present personal observations and suggestions related to education of future pediatricians regarding development of critical thinking skills, care of complex and chronically ill patients, development of empathy, and restoration of responsibility that may help ameliorate this serious problem. Toward this end, I also offer 1 approach, a 24/7 telephone consultation network, for enriching interaction of primary care providers (PCPs) and subspecialists who can potentially provide rapid access to needed advice, reduce demand for subspecialty appointments, bolster decision-making and expertise, and realign resources with need. METHODS: Data were obtained from 579 requests by PCPs for telephone consultation by subspecialists in 8 areas (including child psychiatry). RESULTS: Of calls, 27% took CONCLUSIONS: Development of rapid telephone consultation networks could provide increased access to care for those children in greatest need, use limited resources more efficiently, foster collegial and productive relationships between medical providers, and increase expertise of PCPs and subspecialists.

* Abbreviation: EPA — : entrustable professional activity Within this compendium of perspectives and expert consensus about the education of subspecialty fellows, we are told that “ Recent advances in medical education allow the question of required duration of training to be examined using the metric of the pediatrics milestones.…” The consensus also reinforces that “Training should remain at three years for now, but over time the Board could allow a shorter or longer period to demonstrate expertise in a particular subspecialty. ” 1 Here we have the setting for 2 fundamental, but potentially conflicting, metrics, time versus maturation, that can collide and put substantial strain on resources intended to educate and certify fellows. If time is used as the gating mechanism for the advancement of fellows, it stands to reason that there will be heterogeneity of skills, knowledge, and maturity upon completion of the requisite time. Alternatively, if maturation is used as the gating mechanism, then there will likely be heterogeneity in the time to completion. It is worth exploring some of the consequences of these options. To the extent that the milestones (such as the Denver Developmental Screening Test) and entrustable professional activities (EPAs; such as the driver’s road test) will provide a blueprint for assessing the maturation of a fellow, the potential benefit is a rigorous, reproducible, and logical method to recognize what competencies have been achieved throughout the course of education and clinical practice. In addition, this method should provide a means to track a fellow’s progress in real time, which would permit formative feedback and potential for midcourse adjustments and, even more importantly, for self-directed learning and development. This approach requires validation of the evaluation, establishment of confidence intervals, measurement of interrater agreement, certainty that the maturational schema is properly ordered, and assessment of ease of application. It is essential to recognize that … Address correspondence to George Lister, MD, Department of Pediatrics, Yale School of Medicine, PO Box 208064, New Haven, CT 06520-8064. E-mail: george.lister{at}yale.edu

Participants of the first colloquium of the Residency Review and Redesign in Pediatrics (R3P) Project considered possible scenarios affecting pediatric practice over the next 15 to 20 years and speculated about the knowledge and skills that pediatricians would need to care for children, adolescents, and young adults in the future. They concluded that the imponderables and complexity of that undertaking fell into the category of a “wicked problem” with no unique solutions. The specifics of the future cannot be predicted, but the themes important to thinking about the future are clear and must be incorporated into thinking about pediatric residency education.

OBJECTIVES. The risk for sudden infant death syndrome in black infants is twice that of white infants, and their parents are less likely to place them in the supine position for sleep. We previously identified barriers for parents to follow recommendations for sleep position. Our objective with this study was to quantify these barriers, particularly among low-income, primarily black mothers. DESIGN/METHODS. We conducted face-to-face interviews with 671 mothers, 64% of whom were black, who attended Women, Infants, and Children Program centers in Boston, Massachusetts, Dallas, Texas, Los Angeles, California, and New Haven, Connecticut. We used univariate analyses to quantify factors that were associated with choice of sleeping position and multivariate logistic regression to calculate adjusted odds ratios for the 2 outcome variables: “ever” (meaning usually, sometimes, or last night) put infant in the prone position for sleep and “usually” put infant in the supine position to sleep. RESULTS. Fifty-nine percent of mothers reported supine, 25% side, 15% prone, and 1% other as the usual position. Thirty-four percent reported that they ever placed infants in the prone position. Seventy-two percent said that a nurse, 53% a doctor, and 38% a female friend or relative provided source of advice. Only 42% reported that a nurse, only 36% a doctor, and only 15% a female friend or relative recommended the supine position for sleep. When a female friend or relative recommended the prone position, mothers were more likely ever to place their infants in the prone position and less likely usually to choose supine compared with those who received no advice from friends or relatives. When a doctor or a nurse recommended a nonsupine position, the mothers were less likely to choose supine compared with those who received no advice from a doctor or a nurse. Mothers who trusted the opinion of a doctor or a nurse about infant sleeping position were more likely to place their infants in the supine position. Half of the mothers believed that infants were more likely to choke when supine, and they were less likely to place their infants supine. Mothers who believed that infants are more comfortable in the prone position (36%) were more likely to place their infants prone. Twenty-nine percent believed that having their infants sleep with an adult helps prevent sudden infant death syndrome, and only 43% believed that sudden infant death syndrome is related to sleeping position. CONCLUSIONS. We identified specific barriers to placing infants in the supine position for sleep (lack of or wrong advice, lack of trust in providers, knowledge and concerns about safety and comfort) in low-income, primarily black mothers that should be considered when designing interventions to get more infants onto their back for sleep.

* Abbreviations: SIDS = : sudden infant death syndrome • ECG = : electrocardiogram • LQTS = : long QT syndrome We read with interest the article on the proposed association of prolonged QT interval and the sudden infant death syndrome (SIDS) by Schwartz et al.1 Recognizing the previous failures to determine cause(s) for SIDS and the risks of changing practice in response to one study, we wish to take this opportunity to place the findings of the study in perspective and reflect on directions that might be pursued. Although the mechanism for SIDS (the most common cause of death from 1 month to 1 year of age) remains unknown, certain factors, such as smoking during pregnancy and sleep position of the infant lter the risk of SIDS.2–7 The hypothesis that there is a relationship between SIDS and prolonged QT has been previously raised by Schwartz8 and other authors,9–12 and disputed by some,13–15 but the recent data by Schwartz et al1 are the most compelling to date. Schwartz et al obtained electrocardiogram (ECG) recordings 3 to 4 days after birth in 34 443 newborn infants, 24 of whom died within the first year after birth with a diagnosis of SIDS. The authors found that these 24 infants had an average QT interval (corrected for heart rate) that was longer than in 9725 randomly selected living infants and longer than in 10 infants who died of other causes. Accordingly, this report raises several important questions. What is the cause of the long QT interval in the infants? Schwartz et al1 suggest that the prolonged QT might be caused by: a) different rates of development of the right and left sympathetic nerves rendering the infant susceptible to an arrhythmia during sudden increases in sympathetic activity8 ,16 ,17; or b) mutation in one of the genes encoding sodium or potassium channels, as has been identified … Address correspondence to George Lister, MD, Department of Pediatrics, Yale University School of Medicine, 333 Cedar St, PO Box 208064, New Haven, CT 06520-8064.

The recent study by Shipman et al1 is noteworthy, particularly given their focused examination of pediatric workforce data at the level of primary care service areas (PCSAs). As Shipman noted, although concerns regarding the number of primary care physicians have led to efforts to increase the number of trainees who elect careers in primary care, little has been done regarding the inequitable geographic distribution of the pediatric workforce. Although we agree that primary care for children across the United States may not be distributed equitably and support the need for further research in this area, some limitations can potentially threaten the interpretability of the results. The workforce numbers that are reported annually by the American Board of Pediatrics (ABP) differ from those presented in the article. The main reason for the difference is the database used …

A wide variety of artifacts may be found when monitoring the ECG in a neonatal intensive care unit. Many of the artifacts resemble arrhythmias, and unless they are recognized as artifacts they may lead to serious errors of diagnosis and therapy. Many of the artifacts are caused by patient movement such as seizures, tremulousness, or hiccups. Others may be introduced by the monitor itself or be caused by electrical equipment in the vicinity. A group of ECC tracings is presented to illustrate the various artifacts encountered. Features that distinguish the artifacts from the arrhythmias they mimic are described, as are suggestions for elimination of the artifacts.

The effect of physical training on the exercise performance of 26 patients following surgical repair of tetralogy of Fallot (16 patients) and ventricular septal defect (ten patients) was evaluated. Base line exercise testing was performed on a bicycle ergometer using the technique of Godfrey. Patients were placed on a six-week alternate day submaximal interval home exercise program of varying duration and intensity. Work loads at 50%, 60%, and 70% maximum oxygen consumption were selected to maintain heart rates between 130 and 160 beats per minute. Subjects completed an average of 18 of the possible 21 training sessions (range 11 to 21). A 25% improvement (P < .001) was noted in maximum work capacity (747 to 935 km). Sixty-five percent of the patients performed at less than expected maximum work capacity prior to training, but only 31% performed at less than expected maximum work capacity after training. Repeat testing at work loads of one-third, one-half, and two-thirds the original maximum work capacity revealed improved aerobic efficiency as manifested by significantly decreased oxygen consumption and heart rate at each level of work. No significant difference was noted in maximum oxygen consumption. It is concluded that physical training can improve the exercise performance of patients after surgical repair, permitting the individuals to function at levels of activity at, or closely approaching, normal.

The examination of multiple bones from a child who died of complications of septicemia and osteomyelitis elucidated the pathologic processes of infantile osteomyelitis. From a metaphyseal focus, there is spread in several directions. Most important, the infection can spread across the growth plate, along transphyseal vessels, to penetrate the epiphysis. Areas of direct destruction of growth plate were frequent findings, and allowed another route into the epiphysis.