Authors:Catherine D. Shubkin; Jeremy R. Garrett; John D. Lantos Pages: 239 - 242 Abstract: Publication date: April 2018 Source:Academic Pediatrics, Volume 18, Issue 3 Author(s): Catherine D. Shubkin, Jeremy R. Garrett, John D. Lantos Residency is a time of professional identity formation. During this time, residents may first be exposed to conflicts between professional duties and personal beliefs which may lead to a request for a conscience-based exemption. Faculty, whether the supervising attending or the program director, have an important role in the professional and ethical development of residents by acknowledging and supporting residents as they encounter these potential conflicts. In this paper, we highlight three areas of unique issues that arise within the context of residency training programs when a resident makes a request to be excused from clinical duties based on personal conscience: namely, the maintenance of educational standards, the burdens that may be placed on colleagues, and the responsibility for faculty to foster the professional development of ethically sensitive pediatricians.
Authors:Jeanne Van Cleave; Chloe Holifield; James M. Perrin Pages: 266 - 272 Abstract: Publication date: April 2018 Source:Academic Pediatrics, Volume 18, Issue 3 Author(s): Jeanne Van Cleave, Chloe Holifield, James M. Perrin Background The Massachusetts Child Psychiatry Access Project (MCPAP) provides telephone support from mental health specialists to primary care providers (PCPs). Understanding PCPs' use may inform implementation of similar programs. We sought to examine PCPs' decision-making process to use or not use MCPAP when encountering mental health problems. Methods We analyzed data regarding calls from PCPs to MCPAP from October 1, 2010, to July 31, 2011, and interviewed 14 PCPs with frequent use (≥7 calls) and infrequent use (≤4 calls). PCPs were asked about recent patients with mental health problems, and they were asked to describe reasons for calling or not calling MCPAP. Frequent callers were asked what sustained use; infrequent callers were asked about alternative management strategies. Comparisons were made between these groups in qualitative analysis. Results PCPs (n = 993) made 6526 calls (mean = 6.6; median = 3). Factors influencing calling included: MCPAP's guidance is timely and tailored to individual scope of practice; MCPAP's ability to arrange therapy referrals exceeds PCPs' ability; providing a plan at point of care relieves anxious families; and MCPAP's assistance helps accommodate families' preference to keep mental health in primary care. Some infrequent callers had gained skills through MCPAP before 2010 and now called only for complex cases. Other reasons for infrequent calling: PCPs have other consultation sources, have fear of being asked to manage more than they are comfortable, or have misperceptions of MCPAP's offerings. Conclusions MCPAP enhanced PCPs' ability to deliver mental health care consistent with families' preferences. PCPs applied knowledge gained from calls to subsequent patients. Promoting MCPAP components through outreach and tailoring guidance to PCPs' scope of practice may entice greater use.
Authors:William B. Brinkman; John O. Simon; Jeffery N. Epstein Pages: 273 - 280 Abstract: Publication date: April 2018 Source:Academic Pediatrics, Volume 18, Issue 3 Author(s): William B. Brinkman, John O. Simon, Jeffery N. Epstein Objective To describe the prevalence of reasons why children and adolescents stop and restart attention-deficit/hyperactivity disorder (ADHD) medicine and whether functional impairment is present after stopping medicine. Methods We used the prospective longitudinal cohort from the Multimodal Treatment of Study of Children With ADHD. At the 12-year follow-up, when participants were a mean of 21.1 years old, 372 participants (76% male, 64% white) reported ever taking ADHD medicine. Participants reported the age when they last stopped and/or restarted ADHD medicine and also endorsed reasons for stopping and restarting. Results Seventy-seven percent (286 of 372) reported stopping medicine for a month or longer at some time during childhood or adolescence. Participants were a mean of 13.3 years old when they last stopped medicine. The most commonly endorsed reasons for stopping medication related to 1) medicine not needed/helping, 2) adverse effects, 3) logistical barriers of getting or taking medication, and 4) social concerns or stigma. Seventeen percent (64 of 372) reported restarting medicine after stopping for a month or longer. Commonly endorsed reasons for restarting related to medicine being needed or medicine helping; and resolution of logistical barriers to getting or taking medicine. For both stopping and restarting, the proportion endorsing some reasons differed by age range, with the overall pattern suggesting that parental involvement in decisions decreased with age. Nearly all participants had impairment at the assessment after stopping, regardless of whether medication was resumed. Conclusions Different reasons for stopping and/or restarting medicine are relevant at different times for different teens. Tailored strategies may help engage adolescents as full partners in their treatment plan.
Authors:Meghan May; David C. Brousseau; David A. Nelson; Kathryn E. Flynn; Michael S. Wolf; Bryn Lepley; Andrea K. Morrison Pages: 289 - 296 Abstract: Publication date: April 2018 Source:Academic Pediatrics, Volume 18, Issue 3 Author(s): Meghan May, David C. Brousseau, David A. Nelson, Kathryn E. Flynn, Michael S. Wolf, Bryn Lepley, Andrea K. Morrison Objective To explore the decision to seek care and decision-making regarding location of care among parents with low and adequate health literacy. Methods Parents of children 8 years old or younger who presented for ‘sick child’ visits at a clinic or a nonurgent emergency department (ED) visit (triage level 5) were interviewed. The Newest Vital Sign was used to categorize parental health literacy. Interviewers followed a semistructured interview guide to understand: 1) care-seeking for current illness, and 2) choice of clinic or ED. Themes emerged using a grounded theory process, facilitated by NVivo version 10.0 software (QSR International, Melbourne, Australia). Themes included the experiences of low and adequate health literacy in the clinic as well as in the ED. Results Fifty semistructured interviews were completed with parents who brought their child to the ED for a nonurgent visit (n = 30) and clinic parents (n = 20) with 56% possessing low health literacy. Parents with low health literacy were more inclined to overestimate severity of illness and seek care sooner to gain answers about the illness and treatment options, and visit the clinic only when an appointment was available within hours. Parents with adequate health literacy sought reassurance for their ongoing illness management and valued close relationships with their physician, and were willing to wait longer for an appointment. Fever, vomiting, and young child age prompted some parents to seek expedient care regardless of health literacy. Conclusions Caregiving skills (eg, assessing and treating illness, understanding illness severity, and navigating the health care system) in addition to physician-parent relationships and perception of care seem to influence the behavior of parents managing their child's mild acute illness. These factors might be amenable to a future health literacy intervention.
Authors:Nicolas P.N. Goldstein; Sean M. Frey; Maria Fagnano; Sande O. Okelo; Jill S. Halterman Pages: 305 - 309 Abstract: Publication date: April 2018 Source:Academic Pediatrics, Volume 18, Issue 3 Author(s): Nicolas P.N. Goldstein, Sean M. Frey, Maria Fagnano, Sande O. Okelo, Jill S. Halterman Objective Clinician prompts increase the likelihood of guideline-recommended corrective actions (preventive medication prescription, dose change, and/or adherence promotion) for symptomatic children with poorly controlled or persistent asthma in the primary care setting, but it is unclear if all children equally benefit. The objectives of this study were to identify whether asthma severity, visit type, and current preventive medication use were predictive of corrective actions during visits for children with symptomatic asthma, and determine whether these factors modified the effect of a prompting intervention. Methods We conducted prespecified subgroup analyses of a cluster randomized controlled trial of physician prompting that promoted guideline-based asthma management for urban children with symptomatic asthma. We tested predictors of corrective actions with bivariate and multivariate multilevel logistic regressions, compared intervention effects across factor categories via stratified analyses, and characterized effect modification with interaction term analyses. Results Prompting intervention exposure, moderate/severe disease, asthma-focused visits, and current preventive medication use were predictive of corrective actions. The prompting intervention significantly increased the rate of corrective actions for children across categories of disease severity, visit type, and preventive medication use. However, the intervention effect was significantly smaller for children already using a preventive medication (adjusted odds ratio [OR], 2.01; 95% confidence interval [CI], 1.19–3.38) compared with children without preventive medication use (adjusted OR, 6.25; 95% CI, 3.39–11.54). Conclusions Prompting increases the likelihood of corrective actions during clinic encounters; however, children already using preventive medication benefit less. It is critical for providers to recognize the need for corrective actions among these symptomatic children.
Authors:Amy Kornblit; Agnieszka Cain; Laurie J. Bauman; Nicole M. Brown; Marina Reznik Pages: 310 - 316 Abstract: Publication date: April 2018 Source:Academic Pediatrics, Volume 18, Issue 3 Author(s): Amy Kornblit, Agnieszka Cain, Laurie J. Bauman, Nicole M. Brown, Marina Reznik Objective Physical activity (PA) levels are low in today's youth and may even be lower in those with asthma. Barriers to PA have not been well studied in inner-city minority children with asthma. We conducted a qualitative study to characterize parental perceptions of barriers to PA and ways to improve PA levels in children with asthma. Methods We used the socioecologic model to inform development of our interview guide. Questions fell into 2 socioecologic model domains: interpersonal (parent, family) barriers and community (neighborhood, school) barriers. Qualitative semistructured interviews were conducted with 23 parents (21 mothers, 2 fathers) of inner-city children with asthma (aged 8–10 years) from 10 Bronx, New York, elementary schools. Sampling continued until thematic saturation was reached. Interviews were recorded, transcribed, and independently coded for common themes. Emerging themes were discussed and agreed on by investigators. Results Three themes surrounding interpersonal barriers to PA emerged: 1) parental fear of exercise-induced asthma due to lack of child symptom awareness, 2) nonadherence and refusal to take medications, and 3) challenges with asthma management. Four themes around community barriers to PA emerged: 1) lack of trust in school management of asthma, 2) lack of school PA facilities, 3) unsafe neighborhoods, and 4) financial burden of PA. Conclusions A complex, multilevel set of barriers to PA exist in children with asthma. Addressing these barriers by involving stakeholders at the family, school, and community levels may improve PA levels in children with asthma.
Authors:Sean M. Frey; Marybeth R. Jones; Nicolas Goldstein; Kristin Riekert; Maria Fagnano; Jill S. Halterman Pages: 317 - 323 Abstract: Publication date: April 2018 Source:Academic Pediatrics, Volume 18, Issue 3 Author(s): Sean M. Frey, Marybeth R. Jones, Nicolas Goldstein, Kristin Riekert, Maria Fagnano, Jill S. Halterman Objectives To compare the abilities of teens with uncontrolled persistent asthma and their caregivers to identify inhaled medications and state correct indications for use; examine medication responsibility within dyads; and determine whether responsibility is associated with knowledge about inhaled therapies. Methods In the baseline survey for the School-Based Asthma Care for Teens (SB-ACT) trial, we separately asked caregivers and teens to: 1) identify the teen's inhaled asthma therapies by name and from a picture chart (complete matches considered “concordant”); 2) describe indications of use for each medication; and 3) describe the allocation of responsibility for medication use within dyads. We limited analyses to dyads in which either member reported at least one rescue and one inhaled controller medication; we used McNemar and Pearson chi-square tests. Results A total of 136 dyads were analyzed. More caregivers than teens concordantly identified medications (63% vs 31%, P < .001). There was no difference between caregivers and teens in the ability to state correct indications for use (56% vs 54%, P = .79). More teens than caregivers endorsed “full teen responsibility” for rescue medication (65% vs 27%, P < .001) and controller medication use (50% vs 15%, P < .001). Neither concordant identification nor knowing indications for use was associated with reported medication responsibility. Conclusions Medication responsibility within dyads of caregivers and teens with persistent asthma is not associated with knowledge about inhaled therapies. Targeting both members of the dyad with education and self-management strategies before responsibility transitions start may allow providers to avoid a missed opportunity to support these emerging stakeholders to adherence.
Authors:Elizabeth Reifsnider; David P. McCormick; Karen W. Cullen; Michael Todd; Michael W. Moramarco; Martina R. Gallagher; Lucia Reyna Pages: 324 - 333 Abstract: Publication date: April 2018 Source:Academic Pediatrics, Volume 18, Issue 3 Author(s): Elizabeth Reifsnider, David P. McCormick, Karen W. Cullen, Michael Todd, Michael W. Moramarco, Martina R. Gallagher, Lucia Reyna Objectives Infants are at risk of overweight. Infant overweight predisposes child, adolescent, and adult to obesity. We hypothesized that parent education, initiated prenatally and provided in the home, would reduce the incidence of infant overweight at age 12 months. Methods Pregnant obese Latina women were recruited at Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and randomized to intervention versus control. Intervention subjects received home visits by trained Spanish-fluent community health workers who provided counseling on infant growth, breastfeeding, nutrition, child development, sleep, physical activity, and safety. Promotoras did not visit the control subjects. A research assistant collected outcome data on all subjects. Results Compared to controls, parent education did not reduce infant overweight. Infant overweight developed rapidly and was present in 46% of infants by age 6 months. Infants overweight at 6 months were likely to be overweight at age 12 months (r = 0.60, P < .0001). Overweight was more common in formula-fed infants at ages 6 months (P < .06) and 12 months (P = .005). Breastfeeding was less common in families with employed mothers (P = .02) and unemployed fathers (P < .01), but the father living with the mother at the time of the prenatal visit predicted successful breastfeeding at infant age 2 months (P < .003). Compared to formula feeding, overweight at age 12 months was 2.7 times less likely for infants breastfed for ≥2 months (P = .01). Conclusions The lack of success of the intervention may be explained in part by a high cesarean section rate in the intervention group, food and employment insecurity, and confounding by WIC breastfeeding promotion, which was available to all mothers. Breastfeeding was the most important mediator of infant overweight. The study supports efforts by WIC to vigorously promote breastfeeding.
Authors:Callie L. Brown; Eliana M. Perrin; Karen E. Peterson; Holly E. Brophy Herb; Mildred A. Horodynski; Dawn Contreras; Alison L. Miller; Danielle P. Appugliese; Sarah C. Ball; Julie C. Lumeng Pages: 334 - 341 Abstract: Publication date: April 2018 Source:Academic Pediatrics, Volume 18, Issue 3 Author(s): Callie L. Brown, Eliana M. Perrin, Karen E. Peterson, Holly E. Brophy Herb, Mildred A. Horodynski, Dawn Contreras, Alison L. Miller, Danielle P. Appugliese, Sarah C. Ball, Julie C. Lumeng Background Picky eating is common in children. Few studies have examined predictors of picky eating, and the association of picky eating with weight status and dietary quality is inconsistent in the literature. We aimed to identify predictors of picky eating and to test the association of picky eating with child body mass index z-score (BMIz), dietary quality, and micronutrient intake. Methods This was a cross-sectional analysis of baseline data from a randomized controlled trial to prevent obesity among 506 preschoolers attending Head Start. Parents completed questionnaires to assess picky eating and child temperament. Three 24-hour dietary recalls were collected to assess dietary intake. Multivariate regression models assessed child, parent, and family predictors of picky eating; additional models tested adjusted associations of picky eating with child BMIz, dietary quality (measured using the Healthy Eating Index-2010), and micronutrient intake. Results Picky eating was predicted by male sex, older child age, and more difficult temperament but not race/ethnicity, maternal body mass index, maternal depressive symptoms, household food insecurity, or single parent home. Picky eating was not associated with child BMIz or micronutrient deficiencies; it was inversely associated with total Healthy Eating Index-2010 score and servings of whole fruit, total vegetables, greens and beans, and total protein foods. Conclusions Pediatric providers should support parents in expanding the number of healthy foods the child eats to improve dietary quality, but reassure parents that picky eating is not associated with children's weight status or micronutrient deficiencies.
Authors:Shanna Doucette Knierim; Sophia Newcomer; Alyssa Castillo; Alanna Kulchak Rahm; Silvia Raghunath; Christina Clarke; Leslie Wright; Matthew Haemer; Simon J. Hambidge Pages: 342 - 353 Abstract: Publication date: April 2018 Source:Academic Pediatrics, Volume 18, Issue 3 Author(s): Shanna Doucette Knierim, Sophia Newcomer, Alyssa Castillo, Alanna Kulchak Rahm, Silvia Raghunath, Christina Clarke, Leslie Wright, Matthew Haemer, Simon J. Hambidge Objective Little is known about Latino parents' perceptions of weight-related language in English or Spanish, particularly for counseling obese youth. We sought to identify English and Spanish weight counseling terms perceived by Latino parents across demographic groups as desirable for providers to use, motivating, and inoffensive. Methods Latino parents of children treated at urban safety-net clinics completed surveys in English or Spanish. Parents rated the desirable, motivating, or offensive properties of terms for excess weight using a 5-point scale. We compared parental ratings of terms and investigated the association of parent and child characteristics with parent perceptions of terms. Results A total of 525 surveys met inclusion criteria (255 English, 270 Spanish). English survey respondents rated “unhealthy weight” and “too much weight for his/her health” the most motivating and among the most desirable and least offensive terms. Spanish survey respondents found “demasiado peso para su salud” highly desirable, highly motivating, and inoffensive, and respondents valued its connection to the child's health. Commonly used clinical terms “overweight”/“sobrepeso” and “high BMI [body mass index]”/“índice de masa corporal alta” were not as desirable or as motivating. “Chubby,” “fat,” “gordo,” and “muy gordo” were the least motivating and most offensive terms. Parents' ratings of commonly used clinical terms varied widely across demographic groups, but more desirable terms had less variability. Conclusions “Unhealthy weight,” “too much weight for his/her health,” and its Spanish equivalent, “demasiado peso para su salud,” were the most desirable and motivating, and the least offensive terms. Latino parents' positive perceptions of these terms occurred across parent and child characteristics, supporting their use in weight counseling.
Authors:J. Lindsey Lane; Jennifer B. Soep; Janice L. Hanson Pages: 354 - 356 Abstract: Publication date: April 2018 Source:Academic Pediatrics, Volume 18, Issue 3 Author(s): J. Lindsey Lane, Jennifer B. Soep, Janice L. Hanson A process and tool that prompts learners to think about and reflect on their clinical performance was implemented. Learner narrative reflections about their work and faculty feedback, both captured in the moment, provided data for decisions about level of performance in a competency-based assessment system.
Authors:Sarah Muradian; Alicia Widge; Janice L. Hanson; J. Lindsey Lane; Claire Boogaard; Dewesh Agrawal; Mary Ottolini; Ellen K. Hamburger Pages: 357 - 359 Abstract: Publication date: April 2018 Source:Academic Pediatrics, Volume 18, Issue 3 Author(s): Sarah Muradian, Alicia Widge, Janice L. Hanson, J. Lindsey Lane, Claire Boogaard, Dewesh Agrawal, Mary Ottolini, Ellen K. Hamburger Management of referral and consultation is an entrustable professional activity for pediatric residents; however, few tools exist to teach these skills. We designed and implemented tools to prompt discussion, feedback, and reflection about the process of referral, notably including the family's perspective.
Authors:Shannon Stokley; Peter G. Szilagyi Abstract: Publication date: March 2018 Source:Academic Pediatrics, Volume 18, Issue 2, Supplement Author(s): Shannon Stokley, Peter G. Szilagyi
Authors:Lauri E. Markowitz; Julianne Gee; Harrell Chesson; Shannon Stokley Abstract: Publication date: March 2018 Source:Academic Pediatrics, Volume 18, Issue 2, Supplement Author(s): Lauri E. Markowitz, Julianne Gee, Harrell Chesson, Shannon Stokley Since human papillomavirus (HPV) vaccine was first introduced for females in the United States in 2006, vaccination policy has evolved as additional HPV vaccines were licensed and new data became available. The United States adopted a gender neutral routine HPV immunization policy in 2011, the first country to do so. Vaccination coverage is increasing, although it remains lower than for other vaccines recommended for adolescents. There are various reasons for low coverage, and efforts are ongoing to increase vaccine uptake. The safety profile of HPV vaccine has been well established from 10 years of postlicensure monitoring. Despite low coverage, the early effects of the HPV vaccination program have exceeded expectations.
Authors:Debbie Saslow; Jennifer Sienko; Jennifer L.Z. Nkonga; Noel T. Brewer Abstract: Publication date: March 2018 Source:Academic Pediatrics, Volume 18, Issue 2, Supplement Author(s): Debbie Saslow, Jennifer Sienko, Jennifer L.Z. Nkonga, Noel T. Brewer
Authors:Gerry Fairbrother; Jean L. Raphael; Paul J. Chung; Peter G. Szilagyi Pages: 125 - 128 Abstract: Publication date: March 2018 Source:Academic Pediatrics, Volume 18, Issue 2 Author(s): Gerry Fairbrother, Jean L. Raphael, Paul J. Chung, Peter G. Szilagyi
Authors:Erika L. Abramson; Caroline R. Paul; Jean Petershack; Janet Serwint; Janet E. Fischel; Mary Rocha; Meghan Treitz; Heather McPhillips; Tai Lockspeiser; Patricia Hicks; Linda Tewksbury; Margarita Vasquez; Daniel J. Tancredi; Su-Ting T. Li Pages: 129 - 139 Abstract: Publication date: March 2018 Source:Academic Pediatrics, Volume 18, Issue 2 Author(s): Erika L. Abramson, Caroline R. Paul, Jean Petershack, Janet Serwint, Janet E. Fischel, Mary Rocha, Meghan Treitz, Heather McPhillips, Tai Lockspeiser, Patricia Hicks, Linda Tewksbury, Margarita Vasquez, Daniel J. Tancredi, Su-Ting T. Li Rigorous medical education research is critical to effectively develop and evaluate the training we provide our learners. Yet many clinical medical educators lack the training and skills needed to conduct high-quality medical education research. We offer guidance on conducting sound quantitative medical education research. Our aim is to equip readers with the key skills and strategies necessary to conduct successful research projects, highlighting new concepts and controversies in the field. We utilize Glassick's criteria for scholarship as a framework to discuss strategies to ensure that the research question of interest is worthy of further study and how to use existing literature and conceptual frameworks to strengthen a research study. Through discussions of the strengths and limitations of commonly used study designs, we expose the reader to particular nuances of these decisions in medical education research and discuss outcomes generally focused on, as well as strategies for determining the significance of consequent findings. We conclude with information on critiquing research findings and preparing results for dissemination to a broad audience. Practical planning worksheets and comprehensive tables illustrating key concepts are provided in order to guide researchers through each step of the process. Medical education research provides wonderful opportunities to improve how we teach our learners, to satisfy our own intellectual curiosity, and ultimately to enhance the care provided to patients.
Authors:Keeley J. Pratt; Joseph A. Skelton Abstract: Publication date: Available online 11 April 2018 Source:Academic Pediatrics Author(s): Keeley J. Pratt, Joseph A. Skelton Childhood obesity recommendations advise providers to utilize family-based care for the treatment of youth and adolescent obesity. Family-based care, defined as the inclusion of a caregiver and a youth, is commonly conducted through behavioral interventions that target the dietary and physical activity behaviors of the attending parent-youth dyads. However, focusing on behaviors isolated to the parent and youth neglects the rest of the family members, and the larger rules, routines, communication, and dynamics in the family. Family-based interventions grounded in Family Systems Theory (FST) target family dynamics to influence weight-related behaviors through higher-level changes in the family. The utility of using FST in childhood obesity treatment has not been extensively conceptualized or applied. Few outcome studies have reported on variables representative of FST, and even fewer FST interventions have been conducted. Given the lack of detail on the application of FST to childhood obesity treatment, providers are left with little clarity on how to utilize FST in clinical encounters. We provide the background and evidence for use of FST, detail how families organize around weight-related behaviors that contribute to obesity, and based on their organization what type of treatment may be beneficial, FST-informed or family-based behavioral interventions. Finally, a suggested family-based clinical algorithm is provided detailing the use of FST through assessment, intervention, and follow-up that can be refined over time by providers and researchers committed to viewing obesity in the context of the family and family dynamics.
Authors:Benjamin T. Kopp; Alice Hinton; Rong Lu; Sarah Cooper; Haikady Nagaraja; Mary Ellen Wewers Abstract: Publication date: Available online 10 April 2018 Source:Academic Pediatrics Author(s): Benjamin T. Kopp, Alice Hinton, Rong Lu, Sarah Cooper, Haikady Nagaraja, Mary Ellen Wewers Objectives Secondhand smoke exposure (SHSe) in children is changing due to new public policy and electronic nicotine products (e-cigarettes). We examined factors related to self-imposed indoor household tobacco restrictions, with emphasis on children in the household and associations with combustible and non-combustible product use. Methods A cross-sectional survey of urban and rural Ohio adult tobacco users classified participants as exclusive combustible users, smokeless tobacco (SLT) users, e-cigarette users, or dual users. They were further stratified based upon combustible or non-combustible product use and the presence of indoor tobacco use restrictions. Multiple logistic regression determined factors associated with indoor tobacco restrictions. Results 1210 tobacco users participated including 25.7% with children living in the home. One-half allowed combustible and two-thirds allowed non-combustible tobacco use indoors. Urban location (OR=1.58), younger age (OR=0.88 per 5 year), male sex (OR=1.40), college education (OR=1.40), household income > $15,000 (OR=1.78), and being married (OR=2.43) were associated with a higher likelihood of banning combustible products indoors. SLT (OR=8.12) and e-cigarette (OR=5.85) users were more likely to have indoor bans compared to combustible users. Children in the household (OR=1.89), older age (OR=1.12 per 5 year) and non-white race (OR=1.68) were associated with a higher likelihood of banning non-combustible products indoors. Combustible (OR=4.54) and e-cigarette (OR=3.04) users were more likely than SLT users to have indoor bans. Conclusions Indoor restrictions on tobacco use remain infrequent in homes with children and are associated with user types and socioeconomic factors. Further public policy should target modifiable risk factors for in-home SHSe.
Authors:Brandon S. Allport; Sara Johnson; Anushka Aqil; Alain B. Labrique; Timothy Nelson; Angela KC; Yorghos Carabas; Arik V. Marcell Abstract: Publication date: Available online 10 April 2018 Source:Academic Pediatrics Author(s): Brandon S. Allport, Sara Johnson, Anushka Aqil, Alain B. Labrique, Timothy Nelson, Angela KC, Yorghos Carabas, Arik V. Marcell Paternal involvement in children's lives is associated with a variety of child outcomes, from improved cognition and mental health to reduced obesity rates and asthma exacerbations. Given this evidence, the American Academy of Pediatrics has promoted actions by pediatricians to engage fathers in pediatric care. Despite these recommendations, the mother-child dyad remains a frequent focus of care, rather than the mother-father-child triad. Furthermore, pediatric care is often leveraged to improve maternal health, such as screening for maternal depression, but paternal health is infrequently addressed even as men tend to exhibit riskier behaviors, poorer primary care utilization, and lower life expectancy. Therefore, increasing efforts by pediatric clinicians to engage fathers may have impacts on both father and child health. These efforts to engage fathers are informed by currently used definitions and measures of father involvement, which are discussed here. Factors described in the literature which affect father involvement are also summarized, including: culture and context; interpersonal factors; logistics; knowledge and self-efficacy; and attitudes, beliefs, and incentives. Innovative ways to reach fathers both in the clinic and in other settings are currently under investigation, including use of behavior change models, motivational interviewing, mobile technologies, peer support groups, and policy advocacy efforts. These modalities show promise in effectively engaging fathers and improving family health.
Authors:Corinna J. Rea; Larissa M. Wenren; Katherine D. Tran; Eric Zwemer; Daniel Mallon; Miya Bernson-Leung; Ronald C. Samuels; Sara L. Toomey Abstract: Publication date: Available online 3 April 2018 Source:Academic Pediatrics Author(s): Corinna J. Rea, Larissa M. Wenren, Katherine D. Tran, Eric Zwemer, Daniel Mallon, Miya Bernson-Leung, Ronald C. Samuels, Sara L. Toomey Objective The quality of children's health is compromised by poor care coordination between primary care providers (PCPs) and specialists. Our objective was to determine how an electronic consultation and referral system impacts referral patterns and PCP-specialist communication. Methods The primary care clinic at Boston Children's Hospital piloted an electronic referral and consultation system with the Neurology and Gastroenterology departments from 4/1/14-10/31/16. PCPs completed an electronic consult form and, if needed, specialists replied with advice or facilitated expedited appointments. Specialist response times, referral rates, wait times and completion rates for specialty visits were tracked. PCPs and specialists also completed a survey to evaluate feasibility and satisfaction. Results 82 PCPs placed 510 consults during the pilot period. Specialists responded to 88% of requests within three business days. Eighteen percent of specialty visits were deferred, and 21% were expedited. Wait times for specialty appointments to both departments significantly decreased, from 48 to 34 days (p<.001), and completion rates improved from 58% to 70% (p<.01), but referral volumes remained stable (25/month to 23/month; p=0.29). Most PCPs said the Shared Care system facilitated better communication with specialists (89%) and enabled them to provide superior patient care (92%). Specialists reported that the system required a minimal amount of time and enabled them to educate PCPs and triage referrals. Conclusions Implementation of an electronic referral and consultation system was feasible and provided timely access to specialty care, but did not impact referral volume. This system could serve as a model for other healthcare organizations and specialties.
Authors:Jennifer Watts; Christiana Russ; Nicole E. St Clair; Omolara Thomas Uwemedimo Abstract: Publication date: Available online 28 March 2018 Source:Academic Pediatrics Author(s): Jennifer Watts, Christiana Russ, Nicole E. St Clair, Omolara Thomas Uwemedimo Objective The number of pediatric Global Health (GH) Tracks has more than doubled in less than ten years. The goal of this study was to describe the characteristics of the pediatric GH Tracks to identify commonalities and differences in track structure, funding and education. In addition, we also identified demographic, institutional or residency-related factors that were significantly associated with educational offerings and logistical challenges. Methods A cross-sectional survey was electronically administered to pediatric residency programs with GH Tracks. Statistical analyses included frequencies to describe GH Track characteristics. Fisher's exact tests were used to identify bivariate associations between track structure and funding with educational offerings and logistical challenges. Results Leaders of thirty-two pediatric GH Tracks (67%) completed the survey. The majority of GH Tracks were completed within the three years of residency (94%), and identified a GH Track director (100%); however, tracks varied in size, enrollment methods, domestic and international partnerships, funding, and evaluations. Dedicated faculty time and GH Track budget amounts were associated with more robust infrastructure pertaining to resident international electives, including funding and mentorship. Many tracks did not meet American Academy of Pediatrics recommended standards for clinical international rotations. Conclusions Despite the presence of multiple similarities among pediatric GH Tracks, there are large variations in regards to Track structure, education and funding. The results from this study support the proposal of a formal definition and minimum standards for a GH Track, which may provide a framework for quality, consistency and comparison of GH Tracks.
Authors:Matthew F. Daley; Jo Ann Shoup; Sophia R. Newcomer; Michael L. Jackson; Holly C. Groom; Steven J. Jacobsen; Huong Q. McLean; Nicola P. Klein; Eric S. Weintraub; Michael M. McNeil; Jason M. Glanz Abstract: Publication date: Available online 28 March 2018 Source:Academic Pediatrics Author(s): Matthew F. Daley, Jo Ann Shoup, Sophia R. Newcomer, Michael L. Jackson, Holly C. Groom, Steven J. Jacobsen, Huong Q. McLean, Nicola P. Klein, Eric S. Weintraub, Michael M. McNeil, Jason M. Glanz Objectives Some parents are concerned the childhood immunization schedule could increase risk for allergic disorders, including asthma. To inform future safety studies of this speculated association, a parent survey was conducted to: 1) examine risk of misclassification of vaccination status in electronic health record (EHR) data; and 2) assess potential for confounding if asthma risk factors varied by vaccination status. Methods A survey was conducted among parents of children 19-35 months old at 6 medical organizations within the Vaccine Safety Datalink. Parents of children in 4 vaccination groups were surveyed: 1) no vaccines by 12 months of age and a diagnosis of parental vaccine refusal; 2) consistent vaccine-limiting (≤2 vaccines per visit); 3) not consistently vaccine-limiting, but otherwise under-vaccinated with a vaccine refusal diagnosis; and 4) fully vaccinated with no delays and no vaccine refusal. Parents were surveyed about their child's vaccination status and whether asthma risk factors existed. Results Among a survey sample of 2043 parents, 1209 (59.2%) responded. For receiving no vaccines, the observed agreement between parent report and EHR data was 94.0% (kappa 0.79); for receiving all vaccines with no delays, the observed agreement was 87.3% (kappa 0.73). Although most asthma risk factors (allergic rhinitis; eczema; food allergies; family asthma history) reported by parents did not differ significantly between children in the vaccination groups studied, several factors (aeroallergen sensitivity; breastfeeding) differed significantly between groups. Conclusions Measurement and control of disease risk factors should be carefully considered in observational studies of the safety of the immunization schedule.
Authors:Jeffrey H. Silber; Ashley E. Zeigler; Joseph G. Reiter; Lauren L. Hochman; Justin Ludwig; Wei Wang; Shawna Calhoun; Susmita Pati Abstract: Publication date: Available online 23 March 2018 Source:Academic Pediatrics Author(s): Jeffrey H. Silber, Ashley E. Zeigler, Joseph G. Reiter, Lauren L. Hochman, Justin Ludwig, Wei Wang, Shawna Calhoun, Susmita Pati Objective Administrative data are often used to estimate state Medicaid/CHIP duration of enrollment and insurance continuity, but generally not used to estimate participation (the fraction of eligible children enrolled) because administrative data do not include reasons for disenrollment and cannot observe eligible never-enrolled children, causing estimates of eligible unenrolled to be inaccurate. Analysts are therefore forced to either utilize survey information that is not generally linkable to administrative claims, or rely on duration and continuity measures derived from administrative data and forgo estimating claims–based participation. We introduce “Appendectomy Based Participation” (ABP) to estimate statewide participation rates using claims, by taking advantage of a natural experiment around statewide appendicitis admissions to improve the accuracy of participation rate estimates. Methods Medicaid Analytic eXtract (MAX) from 2008-2010; American Community Survey from 2008-2010, from 43 states to calculate: Appendectomy Based Participation (ABP), the Continuity Ratio (CR), Duration, and participation based on the American Community Survey (ACS). Results In the validation study, median participation rates using ABP was 86% versus 87% for ACS-based participation estimates using logical edits, and 84% without logical edits. Correlations between ABP and ACS with or without logical edits was 0.86, P < 0.0001. Using regression, ABP alone was a significant predictor of ACS (P < 0.0001) with or without logical edits, and adding Duration and/or CR did not significantly improve the model. Conclusion Using the Appendectomy Based Participation Rate derived from administrative claims (MAX) is a valid method to estimate statewide public insurance participation rates in children.
Authors:Laura J. Chavez; Connor Grannis; Millie Dolce; Deena J. Chisolm Abstract: Publication date: Available online 15 March 2018 Source:Academic Pediatrics Author(s): Laura J. Chavez, Connor Grannis, Millie Dolce, Deena J. Chisolm Background Caring for teens with special health care needs places physical and mental health burdens on parents, which can be exacerbated by the stresses of transitions to independence. Medical homes can improve teen transitions to greater self-management and reduce health care-related time and financial burdens for families. This analysis examines the association between parent-reported teen medical home status and caregiver health-related quality of life (HRQOL). Methods The study sample included parents/caregivers of teens with special health care needs, ages 15-18, recruited from a pediatric Medicaid accountable care organization who participated in a survey (response rate=40.5%). The primary outcome was parent HRQOL scores (0-100 points) measured using the PedsQL Family Impact Module. Medical home status was based on parent report of teen's health care meeting medical home criteria. Linear regression models were used to estimate HRQOL scores, adjusted for demographic characteristics, health literacy, and teen functional limitation Results Among 488 parents, 27% reported their teen received care consistent with a medical home. Adjusted parent HRQOL scores were significantly higher among those whose teens had a medical home (74.40; 95% CI 71.31-77.48), relative to those whose teens did not (65.78; 95% CI 63.92-67.65). Medical home subscale analyses showed HRQOL scores had significant positive associations with family-centered care and coordinated care, but not other subscales. Conclusions Teen medical home status was positively associated with caregiver HRQOL, suggesting that the medical home may benefit overall caregiver well-being. In particular, receiving care that was family centered and coordinated appeared to be the most beneficial.
Authors:Jason P. Block; L. Charles Bailey; Matthew W. Gillman; Douglas Lunsford; Janne Boone-Heinonen; Lauren P. Cleveland; Jonathan Finkelstein; Casie Horgan; Melanie Jay; Juliane S. Reynolds; Jessica Sturtevant; Christopher B. Forrest; William Adams; Brad Appelhans; Andrew Brickman; Jiang Bian; Matthew F. Daley; Arthur Davidson; Amanda Dempsey; Lara R. Dugas; Ihuoma Eneli; Stephanie L. Fitzpatrick; William Heerman; Michael Horberg; Daniel S. Hsia; Jenny Ingber; Carmen R. Isasi; David M. Janicke; Doug Kane; Elyse Kharbanda; David Meltzer; Mary Jo Messito; Prakash Nadkarni; Kevin O'Bryan; Holly Peay; Jon Puro; Daksha Ranade; Goutham Rao; Alfredo Tirado-Ramos; Maria Rayas; Hanieh Razzaghi; Iben M. Ricket; Marc Rosenman; Robert M. Siegel; Tony Solomonides; Elsie M. Taveras; Bradley Taylor; Veeral Tolia; Zachary Willis; Jeffrey VanWormer; Tim Wysocki; Xiaobo Zhou Abstract: Publication date: Available online 15 March 2018 Source:Academic Pediatrics Author(s): Jason P. Block, L. Charles Bailey, Matthew W. Gillman, Douglas Lunsford, Janne Boone-Heinonen, Lauren P. Cleveland, Jonathan Finkelstein, Casie Horgan, Melanie Jay, Juliane S. Reynolds, Jessica Sturtevant, Christopher B. Forrest Objectives The National Patient-Centered Clinical Research Network (PCORnet) supports observational and clinical research using health care data. The PCORnet Antibiotics and Childhood Growth Study is one of PCORnet's inaugural observational studies. We sought to describe the processes used to integrate and analyze data from children across 36 participating institutions, and the cohort characteristics and prevalence of antibiotic use. Methods We included children in the cohort if they had at least one same-day height and weight measured in each of 3 age periods: 1) before 12 months, 2) 12 to 30 months, and 3) after 24 months. We distributed statistical queries that each institution ran on its local version of the PCORnet common data model, with aggregate data returned for analysis. We defined overweight or obesity as age- and sex-specific body mass index ≥85th, obesity ≥95th percentile, and severe obesity ≥120% of 95th percentile. Results A total of 681,739 children met the cohort inclusion criteria and were racially/ethnically diverse (24.9% black, 17.5% Hispanic). Before 24 months, 55.2% of children received at least one antibiotic prescription; 21.3% received a single antibiotic prescription, 14.3% received 4 or more, and 33.3% received a broad-spectrum antibiotic. Overweight and obesity prevalence was 27.6% at age 4 to <6 years (n = 362,044) and 36.2% at 9 to <11 years (n = 58,344). Conclusions The PCORnet antibiotics study is a large national longitudinal observational study in a diverse population that will examine the relationship between early antibiotic use and subsequent growth patterns in children.
Authors:Cara Lichtenstein; Desiree de la Torre; Olanrewaju Falusi; Alexandra Sims; Yael Smiley; Melissa Baiyewu Abstract: Publication date: Available online 9 March 2018 Source:Academic Pediatrics Author(s): Cara Lichtenstein, Desiree de la Torre, Olanrewaju Falusi, Alexandra Sims, Yael Smiley, Melissa Baiyewu
Authors:Sanne Verkooijen; Nelleke de Vos; Betty J.W. Bakker-Camu; Susan J.T. Branje; René S. Kahn; Roel A. Ophoff; Carolien M. Plevier; Marco P.M. Boks Abstract: Publication date: Available online 9 March 2018 Source:Academic Pediatrics Author(s): Sanne Verkooijen, Nelleke de Vos, Betty J.W. Bakker-Camu, Susan J.T. Branje, René S. Kahn, Roel A. Ophoff, Carolien M. Plevier, Marco P.M. Boks Objective To investigate the prevalence of adolescent sleep disturbances and their relation with psychosocial difficulties and health risk behaviours we analysed data of a province-wide health survey (n=16,781). Methods Psychosocial difficulties were measured with the Strength and Difficulties Questionnaire. Additional assessments included self-reported sleep disturbances, suicidality and health risk behaviours including current use of tobacco, alcohol and drugs, physical inactivity and compulsive use of multimedia. We used multi-level analyses to investigate the relations including differences between boys and girls, as well as the mediating role of emotional problems. Results Just under 20 % of adolescents reported sleep disturbances in the previous month. These sleep disturbances were associated with psychosocial problems (OR: 6.42, p<0.001), suicidality (OR: 3.90 - 4.14, p<0.001) and all health risk behaviours (OR: 1.62-2.66, p<0.001) but not with physical inactivity. We found moderation by gender for the relations between sleep and suicide attempts (OR: 0.38, p<0.002) and sleep and cannabis use (OR: 0.52, p=0.002), indicating attenuated relations in girls compared to boys. Emotional problems partially mediated the relations between sleep disturbances and multimedia use. Conclusions The current study reiterates the high prevalence of sleep disturbances during adolescence. These sleep disturbances were strongly related to psychosocial problems and a wide range of health risk behaviours. Although the direction of causality cannot be inferred, the current study emphasizes the need for awareness of impaired sleep in adolescents. Moreover, the gender differences in associated suicide attempts and cannabis use call for further research into tailored intervention strategies.
Authors:Jennifer Benjamin; Judith Groner; Jennifer Walton; Garey Noritz; Gregg M. Gascon; John D. Mahan Abstract: Publication date: Available online 5 March 2018 Source:Academic Pediatrics Author(s): Jennifer Benjamin, Judith Groner, Jennifer Walton, Garey Noritz, Gregg M. Gascon, John D. Mahan
Authors:Corinna J. Rea; Katherine D. Tran; Maria Jorina; Larissa M. Wenren; Elena B. Hawryluk; Sara L. Toomey Abstract: Publication date: Available online 2 March 2018 Source:Academic Pediatrics Author(s): Corinna J. Rea, Katherine D. Tran, Maria Jorina, Larissa M. Wenren, Elena B. Hawryluk, Sara L. Toomey Objectives We hypothesized that use of an Eczema Care Plan (ECP) would improve provider documentation and management, decrease eczema severity, and increase patient quality of life (QOL) in the pediatric primary care setting. Methods We conducted a randomized controlled trial between 6/15 and 9/16 at a large, hospital-based pediatric primary care clinic. Participants included children between 1 month and 16 years of age with a diagnosis of eczema. The intervention group received the ECP and the control group received usual care. Both groups completed a validated eczema severity scale (POEM) and a QOL scale (IDQOL or CDLQI) before the visit and again approximately one month later. Results 211 caregivers completed both the pre- and post- survey (100 control group and 111 intervention group [94% completion]). Intervention group providers were more likely to recommend a comprehensive “step-up” plan (88% vs. 28%, p<0.001), bleach baths (45% vs. 9%, p<0.001) and wet wraps (50% vs. 7%, p<0.001). They were also more likely to document providing a written plan to families (80% vs. 2%, p<0.001). In the intervention and control groups, eczema severity and QOL improved between the pre- and post- period. However, there was not a significant difference between the groups on either measure ([POEM difference, -0.8; 95%CI: -3.2, 1.7], [IDQOL difference, -0.1, 95%CI: -1.8, 1.6], [CDLQI difference, 0.8; 95%CI: -0.9, 2.6]). Conclusions Intervention group providers documented more comprehensive eczema care than control group providers. Although patients improved on all measures in the post-intervention period, the ECP did not augment that improvement.
Authors:Megan L. Ranney; Julie Bromberg; Alyssa Hozey; T. Charles Casper; Michael J. Mello; Anthony Spirito; Thomas H. Chun; James G. Linakis Abstract: Publication date: Available online 2 March 2018 Source:Academic Pediatrics Author(s): Megan L. Ranney, Julie Bromberg, Alyssa Hozey, T. Charles Casper, Michael J. Mello, Anthony Spirito, Thomas H. Chun, James G. Linakis Objective Problem behaviors such as substance use and peer aggression frequently co-exist, and are common among youth seen in emergency departments (EDs). EDs are increasingly urged to screen for both psychological distress and problem behaviors. To inform screening and intervention efforts, we aimed to identify classes of problematic substance use and peer aggression in a sample of adolescents from 16 pediatric EDs, and to examine the relative prevalence of psychological distress in identified classes. Methods We completed a cross-sectional survey of youth (n = 5001) presenting for any reason to 16 pediatric EDs across the United States, using validated measures of demographics, alcohol and substance use, and peer aggression. We used standard latent class analysis (LCA) techniques to create behavioral risk classes of adolescents, based on violence and substance use variables; then conducted logistic regression to examine the relationship between psychological distress and latent classes. Results Three classes of problem behaviors were identified: low-risk (few problem behaviors, 91.2% of sample), medium risk (high cigarette smoking; moderate violence, alcohol, substance use, 5.2%), and high risk (high levels of all problem behaviors, 3.5%). A significant directional association (p < .001) between worse psychological distress and higher risk behavior classes was noted, even after adjusting for demographics. Conclusions Youth seen in the ED for any reason, who report higher levels of past-year substance use and peer aggression, are significantly more likely to report negative mood symptoms. Targeted screening and interventions for this population may be indicated.
Authors:Arvin Garg; Radley Christopher Sheldrick; Paul H. Dworkin Abstract: Publication date: Available online 20 December 2017 Source:Academic Pediatrics Author(s): Arvin Garg, Radley Christopher Sheldrick, Paul H. Dworkin
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