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INTRODUCTION: Competence in neonatal care is especially important for military pediatricians because military pediatricians can be asked to serve in remote duty locations with limited resources. We sought to understand how this competence is defined, developed, and assessed by military pediatric training programs. MATERIALS AND METHODS: After Institutional Review Board approval was obtained, we interviewed educators and recent graduates from every pediatric military training program to construct a shared definition of competence. We then used Kern's Six Steps for curriculum development to understand how competence is taught and assessed. RESULTS: Participants felt that competence for military pediatricians in the neonatal setting meant that learners should be able to provide a full spectrum of newborn care in any military setting. Participants confirmed that this competence was particularly important for military pediatricians because of the possibility of remote duty locations. Participants felt that specific knowledge, skills, and attitudes supported competence. Knowledge domains include distinguishing normal newborns from abnormal newborns, managing normal newborn care, managing common newborn abnormalities, and creating a safe escalation plan for complicated or uncommon newborn abnormalities. Specific skills that support competence are newborn resuscitation, delivery of effective ventilation, and neonatal circumcision. Specific attitudes that support competence are, understanding the personal limits of knowledge and understanding the resources for escalation of care. Educators use a variety of modalities to teach toward competence, including the structured curricula, bedside teaching, and simulation. According to participants, the assessment of learners occurs primarily through narrative assessment and feedback but would ideally occur through direct observation. CONCLUSIONS: Competence in the neonatal setting is particularly important for military pediatricians. Essential skills undergo differential assessment and current assessment methods differ from ideal assessment methods. Future work should focus on how these facets can support a unified curriculum in newborn medicine.

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INTRODUCTION: Airway obstruction is a treatable cause of potentially preventable death on the battlefield. Emergency cricothyrotomies are rarely performed in developed countries, but are a common prehospital procedure in recent conflicts in Iraq and Afghanistan. We describe prehospital airway interventions performed on pediatric casualties with a focus on cricothyrotomy during these recent conflicts. MATERIALS AND METHODS: This is a secondary analysis of previously published dataset from the Department of Defense Trauma Registry for pediatric encounters from January 2007 to January 2017. Within our dataset we searched for all instances of airway interventions in the prehospital setting. RESULTS: During this time, there were 3,439 pediatric casualties in the registry with a total of 18 prehospital cricothyrotomies and 211 prehospital intubations. For cricothyrotomies, the median age was 10 years, most (72.2%) were male, median composite injury score was 25, most were injured by explosive (44.4%), more commonly located in Afghanistan (77.8%), and approximately half survived to hospital discharge (44.4%). The head was most frequently injured (44.4%). Of those undergoing endotracheal intubation, the median age was 10 years, most (75.8%) were male, median injury score was 17, most were injured by explosives (53.5%), most were in Afghanistan (85.7%), and most survived to hospital discharge (66.8%). The head/neck most frequently had a serious injury (56.8%). CONCLUSIONS: In this dataset, 6.8% of children underwent prehospital intubation and 0.5% underwent prehospital cricothyrotomy. Airway interventions were frequently associated with head injuries. This highlights the importance of training and equipping prehospital medical personnel for pediatric trauma care in accordance with military clinical practice guidelines.

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OBJECTIVE: Early feeding, skin-to-skin contact, and dextrose gel have been independently shown to promote breastfeeding and decrease NICU admission for neonatal hypoglycemia. We combined these interventions to decrease NICU admissions for asymptomatic hypoglycemia and increase exclusive breastfeeding rates. PROJECT DESIGN: The IHI Model for Improvement was used to design a bundle including feeding within 1 h of birth, 1 h of uninterrupted skin-to-skin within 2 h of birth, and administration of buccal 40% dextrose gel for hypoglycemic infants. RESULTS: Utilization of dextrose gel was 94% following implementation. There were no trends in exclusive breastfeeding at discharge or NICU admissions for asymptomatic hypoglycemia. Post hoc multivariate analysis identified cesarean delivery as an independent risk factor for compliance failure and failure of exclusive breastfeeding but not for NICU admission. CONCLUSIONS: Despite high compliance with dextrose gel utilization, there was no change in exclusive breastfeeding at discharge or NICU admission rates for asymptomatic hypoglycemia.

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