Authors:Nicole M. Brown; Suzette N. Brown; Rahil D. Briggs; Miguelina Germán; Peter F. Belamarich; Suzette O. Oyeku Pages: 349 - 355 Abstract: Publication date: May–June 2017 Source:Academic Pediatrics, Volume 17, Issue 4 Author(s): Nicole M. Brown, Suzette N. Brown, Rahil D. Briggs, Miguelina Germán, Peter F. Belamarich, Suzette O. Oyeku Objective Although identifying adverse childhood experiences (ACEs) among children with behavioral disorders is an important step in providing targeted therapy and support, little is known about the burden of ACEs among children with attention deficit–hyperactivity disorder (ADHD). We described the prevalence of ACEs in children with and without ADHD, and examined associations between ACE type, ACE score, and ADHD diagnosis and severity. Methods Using the 2011 to 2012 National Survey of Children's Health, we identified children aged 4 to 17 years whose parents indicated presence and severity of ADHD, and their child's exposure to 9 ACEs. Multivariate logistic regression was used to estimate associations between ACEs, ACE score, and parent-reported ADHD and ADHD severity, adjusted for sociodemographic characteristics. Results In our sample (N = 76,227, representing 58,029,495 children), children with ADHD had a higher prevalence of each ACE compared with children without ADHD. Children who experienced socioeconomic hardship (adjusted odds ratio [aOR], 1.39; 95% confidence interval [CI], 1.21–1.59), divorce (aOR, 1.34; 95% CI, 1.16–1.55), familial mental illness (aOR, 1.55; 95% CI, 1.26–1.90), neighborhood violence (aOR, 1.47; 95% CI, 1.23–1.75), and incarceration (aOR, 1.39; 95% CI, 1.12–1.72) were more likely to have ADHD. A graded relationship was observed between ACE score and ADHD. Children with ACE scores of 2, 3, and ≥4 were significantly more likely to have moderate to severe ADHD. Conclusions Children with ADHD have higher ACE exposure compared with children without ADHD. There was a significant association between ACE score, ADHD, and moderate to severe ADHD. Efforts to improve ADHD assessment and management should consider routinely evaluating for ACEs.
Authors:Manuel E. Jimenez; Roy Wade; Ofira Schwartz-Soicher; Yong Lin; Nancy E. Reichman Pages: 356 - 361 Abstract: Publication date: May–June 2017 Source:Academic Pediatrics, Volume 17, Issue 4 Author(s): Manuel E. Jimenez, Roy Wade, Ofira Schwartz-Soicher, Yong Lin, Nancy E. Reichman Objective To examine associations between adverse childhood experiences (ACEs) and attention-deficit/hyperactivity disorder (ADHD) at age 9 years using longitudinal data and assess the extent to which ACEs during middle childhood are independently associated with ADHD at age 9 years. Methods We conducted a secondary analysis of data from the Fragile Families urban birth cohort 5- and 9-year interviews. The sample was limited to children for whom mothers were the primary caregiver and mother-reported information on 8 ACEs and ADHD were available at age 5 and 9 years. We examined associations between ACEs and parent-reported ADHD at age 9 years using logistic regression and controlling for potential confounders. Results We included 1572 children; 48% were African American, 11% had parent-reported ADHD at age 9 years, 41% and 42% experienced ≥1 ACE by age 5 years and between the ages of 5 and 9 years, respectively. ACEs before age 5 years were associated with ADHD at age 9 years. One, 2, and ≥3 ACEs between age 5 and 9 years were associated with ADHD at age 9 years even after controlling for ACEs before age 5 years and ADHD at age 5 years (adjusted odds ratio [AOR], 1.9; 95% confidence interval [CI], 1.2–3; AOR, 2.1; 95% CI, 1.2–3.8; and AOR, 2.2; 95% CI, 1.1–4.3). Conclusions In this study of urban children, ACEs occurring before age 5 years as well as between the ages of 5 and 9 years were associated with ADHD at age 9 years. Even after controlling for early childhood ACEs and ADHD at age 5 years, the association between ADHD and ACEs in middle childhood remained significant, highlighting the importance of screening and intervention throughout childhood.
Authors:Jennifer B. Hansen; Terra Frazier; Mary Moffatt; Timothy Zinkus; James D. Anderst Pages: 362 - 367 Abstract: Publication date: May–June 2017 Source:Academic Pediatrics, Volume 17, Issue 4 Author(s): Jennifer B. Hansen, Terra Frazier, Mary Moffatt, Timothy Zinkus, James D. Anderst Objective Apparent life-threatening events (ALTEs), often accompanied by choking, have been hypothesized to cause subdural hemorrhages (SDH), retinal hemorrhages, and brain injury. If the choking/ALTE hypothesis were true, children who present with ALTE and SDH would have fewer extracranial injuries suspicious for abuse than those with SDH and no ALTE. We aimed to compare the prevalence of suspicious extracranial injuries in children who have ALTE-associated SDH to those with non-ALTE SDH. Methods We performed a 5-year retrospective case–control study of children <2 years of age with SDH evaluated by the Child Abuse Pediatrics program at a children's hospital. Subjects were classified as ALTE-associated SDH and non-ALTE SDH on the basis of ALTE definitions as proposed by the authors of the choking/ALTE hypothesis. The 2 groups were compared for the prevalence of suspicious extracranial injuries. Results Of 170 study subjects, 64 had an ALTE-associated SDH and 106 had non-ALTE SDH. ALTE-associated SDH subjects were nearly 5 times more likely to have at least one suspicious extracranial injury (odds ratio [OR] 4.8, 95% confidence interval [CI] 1.9–12.1) and were more likely to have individual types of suspicious extracranial injuries, including retinoschisis (OR 4.1, 95% CI 1.6–10.2), high-specificity bruising (OR 2.6, 95% CI 1.3–4.9), and internal abdominal injury (3.5, 95% CI 1.2–9.9). Subjects with ALTE-associated SDH were also significantly more likely to die or have persistent neurologic impairment. All 10 subjects with a dysphagic-choking type ALTE had at least 1 suspicious extracranial injury. Conclusions ALTEs are not supported as causative mechanisms for findings concerning abusive head trauma.
Authors:Debra L. Bogen; Bonny L. Whalen; Laura R. Kair; Mark Vining; Beth A. King Pages: 374 - 380 Abstract: Publication date: May–June 2017 Source:Academic Pediatrics, Volume 17, Issue 4 Author(s): Debra L. Bogen, Bonny L. Whalen, Laura R. Kair, Mark Vining, Beth A. King Objective Standardized practices for the management of neonatal abstinence syndrome (NAS) are associated with shorter lengths of stay, but optimal protocols are not established. We sought to identify practice variations for newborns with in utero chronic opioid exposure among hospitals in the Better Outcomes Through Research for Newborns (BORN) network. Methods Nursery site leaders completed a survey about hospitals' policies and practices regarding care for infants with chronic opioid exposure (≥3 weeks). Results The 76 (80%) of 95 respondent hospitals were in 34 states, varied in size (<500 to >8000 births and <10 to >200 opioid-exposed infants per year), with most affiliated with academic centers (89%). Most (80%) had protocols for newborn drug exposure screening; 90% used risk-based approaches. Specimens included urine (85%), meconium (76%), and umbilical cords (10%). Of sites (88%) with NAS management protocols, 77% addressed medical management, 72% nursing care, 72% pharmacologic treatment, and 58% supportive care. Morphine was the most common first-line pharmacotherapy followed by methadone. Observation periods for opioid-exposed newborns varied; 57% observed short-acting opioid exposure for 2 to 3 days, while 30% observed for ≥5 days. For long-acting opioids, 71% observed for 4 to 5 days, 19% for 2 to 3 days, and 8% for ≥7 days. Observation for NAS occurred mostly in level 1 nurseries (86%); however, most (87%) transferred to NICUs when pharmacologic treatment was indicated. Conclusions Most BORN hospitals had protocols for the care of opioid-exposed infants, but policies varied widely and characterized areas of needed research. Identification of variation is the first step toward establishing best practice standards to improve care for this rapidly growing population.
Authors:Ryan J. Coller; Bergen B. Nelson; Thomas S. Klitzner; Adrianna A. Saenz; Paul G. Shekelle; Carlos F. Lerner; Paul J. Chung Pages: 381 - 388 Abstract: Publication date: May–June 2017 Source:Academic Pediatrics, Volume 17, Issue 4 Author(s): Ryan J. Coller, Bergen B. Nelson, Thomas S. Klitzner, Adrianna A. Saenz, Paul G. Shekelle, Carlos F. Lerner, Paul J. Chung Objective Interventions to reduce disproportionate hospital use among children with medical complexity (CMC) are needed. We conducted a rigorous, structured process to develop intervention strategies aiming to reduce hospitalizations within a complex care program population. Methods A complex care medical home program used 1) semistructured interviews of caregivers of CMC experiencing acute, unscheduled hospitalizations and 2) literature review on preventing hospitalizations among CMC to develop key drivers for lowering hospital utilization and link them with intervention strategies. Using an adapted version of the RAND/UCLA Appropriateness Method, an expert panel rated each model for effectiveness at impacting each key driver and ultimately reducing hospitalizations. The complex care program applied these findings to select a final set of feasible intervention strategies for implementation. Results Intervention strategies focused on expanding access to familiar providers, enhancing general or technical caregiver knowledge and skill, creating specific and proactive crisis or contingency plans, and improving transitions between hospital and home. Activities aimed to facilitate family-centered, flexible implementation and consideration of all of the child's environments, including school and while traveling. Tailored activities and special attention to the highest utilizing subset of CMC were also critical for these interventions. Conclusions A set of intervention strategies to reduce hospitalizations among CMC, informed by key drivers, can be created through a structured, reproducible process. Both this process and the results may be relevant to clinical programs and researchers aiming to reduce hospital utilization through the medical home for CMC.
Authors:Alisa Khan; Jennifer Baird; Jayne E. Rogers; Stephannie L. Furtak; Kathryn A. Williams; Brenda Allair; Katherine P. Litterer; Meesha Sharma; Alla Smith; Mark A. Schuster; Christopher P. Landrigan Pages: 389 - 402 Abstract: Publication date: May–June 2017 Source:Academic Pediatrics, Volume 17, Issue 4 Author(s): Alisa Khan, Jennifer Baird, Jayne E. Rogers, Stephannie L. Furtak, Kathryn A. Williams, Brenda Allair, Katherine P. Litterer, Meesha Sharma, Alla Smith, Mark A. Schuster, Christopher P. Landrigan Objective To assess parent and provider experience and shared understanding after a family-centered, multidisciplinary nighttime communication intervention (nurse–physician brief, family huddle, family update sheet). Methods We performed a prospective intervention study at a children's hospital from May 2013 to October 2013 (preintervention period) and May 2014 to October 2014 (postintervention period). Participants included 464 parents, 176 nurses, and 52 resident physicians of 582 hospitalized 0- to 17-year-old patients. Pre- versus postintervention, we compared parent/provider top-box scores (eg, “excellent”) for experience with communication across several domains; and level of agreement (shared understanding) between parent, nurse, and resident reports of patients' reason for admission, overnight medical plan, and overall medical plan, as rated independently by blinded clinician reviewers (agreement = 74.7%, kappa = .60). Results Top-box parent experience improved for 1 of 4 domains: Experience and Communication With Nighttime Doctors (23.6% to 31.5%). Top-box provider experience improved for all 3 domains, including Communication and Shared Understanding With Families (resident rated, 16.5% to 35.1%; nurse rated, 32.2% to 37.9%) and Experience, Communication, and Shared Understanding With Other Providers (resident rated, 20.3% to 35.0%; nurse rated, 14.7% to 21.5%). Independently rated shared understanding remained unchanged for most domains but improved for parent–nurse composite shared understanding (summed agreement for reason for admission, overall plan, and overnight plan; 36.2% to 48.2%) and nurse–resident shared understanding regarding reason for admission (67.1% to 71.2%) and regarding overall medical plan (45.0% to 58.6%). All P <.05. Conclusions A family-centered, multidisciplinary nighttime communication intervention was associated with improvements in some, but not all, domains of parent/provider experience and shared understanding, particularly provider experience and nurse–family shared understanding. The intervention was promising but requires further refinement.
Authors:Leslie M. Harris; Benard P. Dreyer; Alan L. Mendelsohn; Stacy C. Bailey; Lee M. Sanders; Michael S. Wolf; Ruth M. Parker; Deesha A. Patel; Kwang Youn A. Kim; Jessica J. Jimenez; Kara Jacobson; Michelle Smith; H. Shonna Yin Pages: 403 - 410 Abstract: Publication date: May–June 2017 Source:Academic Pediatrics, Volume 17, Issue 4 Author(s): Leslie M. Harris, Benard P. Dreyer, Alan L. Mendelsohn, Stacy C. Bailey, Lee M. Sanders, Michael S. Wolf, Ruth M. Parker, Deesha A. Patel, Kwang Youn A. Kim, Jessica J. Jimenez, Kara Jacobson, Michelle Smith, H. Shonna Yin Objective Hispanic parents in the United States are disproportionately affected by low health literacy and limited English proficiency (LEP). We examined associations between health literacy, LEP, and liquid medication dosing errors in Hispanic parents. Methods Cross-sectional analysis of data from a multisite randomized controlled experiment to identify best practices for the labeling/dosing of pediatric liquid medications (SAFE Rx for Kids study); 3 urban pediatric clinics. Analyses were limited to Hispanic parents of children aged ≤8 years with health literacy and LEP data (n = 1126). Parents were randomized to 1 of 5 groups that varied by pairing of units of measurement on the label/dosing tool. Each parent measured 9 doses (3 amounts [2.5, 5, 7.5 mL] using 3 tools [2 syringes in 0.2 or 0.5 mL increments, and 1 cup]) in random order. Dependent variable was a dosing error of >20% dose deviation. Predictor variables included health literacy (Newest Vital Sign) (limited = 0–3; adequate = 4–6) and LEP (speaks English less than “very well”). Results A total of 83.1% made dosing errors (mean [SD] errors per parent = 2.2 [1.9]). Parents with limited health literacy and LEP had the greatest odds of making a dosing error compared to parents with adequate health literacy who were English proficient (trials with errors per parent = 28.8 vs 12.9%; adjusted odds ratio = 2.2 [95% confidence interval 1.7–2.8]). Parents with limited health literacy who were English proficient were also more likely to make errors (trials with errors per parent = 18.8%; adjusted odds ratio = 1.4 [95% confidence interval 1.1–1.9]). Conclusions Dosing errors are common among Hispanic parents; those with both LEP and limited health literacy are at particular risk. Further study is needed to examine how the redesign of medication labels and dosing tools could reduce literacy- and language-associated disparities in dosing errors.
Authors:Sarah E. Domoff; Julie C. Lumeng; Niko Kaciroti; Alison L. Miller Pages: 411 - 415 Abstract: Publication date: May–June 2017 Source:Academic Pediatrics, Volume 17, Issue 4 Author(s): Sarah E. Domoff, Julie C. Lumeng, Niko Kaciroti, Alison L. Miller Objective To identify whether child and mother characteristics in early childhood predict TV exposure and engagement during mealtime in middle childhood. Methods A total of 220 low-income mother-child dyads participated. Children were 4.26 years old (SD = 0.51) at baseline and 5.94 years (SD = 0.68) at 2-year follow-up. Mothers completed baseline measures of child negative emotionality and parenting practices. Family mealtimes were video recorded and coded for background TV exposure and child TV engagement. Multinomial logistic regression tested whether child emotionality and parenting practices during early childhood predicted risk of child TV exposure or engagement during mealtime, relative to no TV use, 2 years later. Results Children with greater negative emotionality in early childhood were more likely to engage with TV during mealtime than to have no TV. Similarly, early parenting disciplinary practices characterized by over-reactivity and laxness increased the risk for child TV engagement versus no TV during mealtime approximately 2 years later. Conclusions We identified 2 factors that associated with an increased risk for TV viewing during meals. Helping parents manage child negative emotionality using positive parenting strategies might reduce later child TV engagement and improve the quality of family mealtimes.
Authors:Kori B. Flower; Asheley C. Skinner; H. Shonna Yin; Russell L. Rothman; Lee M. Sanders; Alan Delamater; Eliana M. Perrin Pages: 416 - 423 Abstract: Publication date: May–June 2017 Source:Academic Pediatrics, Volume 17, Issue 4 Author(s): Kori B. Flower, Asheley C. Skinner, H. Shonna Yin, Russell L. Rothman, Lee M. Sanders, Alan Delamater, Eliana M. Perrin Background and Objective Effective communication with primary care physicians is important yet incompletely understood for Spanish-speaking parents. We predicted lower satisfaction among Spanish-speaking compared to English-speaking Latino and non-Latino parents. Methods Cross-sectional analysis at 2-month well visits within the Greenlight study at 4 pediatric resident clinics. Parents reported satisfaction with 14 physician communication items using the validated Communication Assessment Tool (CAT). High satisfaction was defined as “excellent” on each CAT item. Mean estimations compared satisfaction for communication items among Spanish- and English-speaking Latinos and non-Latinos. We used generalized linear regression modeling, adjusted for parent age, education, income, and clinic site. Among Spanish-speaking parents, we compared visits conducted in Spanish with and without an interpreter, and in English. Results Compared to English-speaking Latino (n = 127) and non-Latino parents (n = 432), fewer Spanish-speaking parents (n = 303) reported satisfaction with 14 communication items. No significant differences were found between English-speaking Latinos and non-Latinos. Greatest differences were found in the use of a greeting that made the parent comfortable (59.4% of Spanish-speaking Latinos endorsing “excellent” vs 77.5% English-speaking Latinos, P < .01) and discussing follow-up (62.5% of Spanish-speaking Latinos vs 79.8% English-speaking Latinos, P < .01). After adjusting for parent age, education, income, and study site, Spanish-speaking Latinos were still less likely to report high satisfaction with these communication items. Satisfaction was not different among Spanish-speaking parents when the physician spoke Spanish versus used an interpreter. Conclusions Satisfaction with physician communication was associated with language but not ethnicity. Spanish-speaking parents less frequently report satisfaction with communication, and innovative solutions to enhance communication quality are needed.
Authors:Melissa M. Cellini; Janet R. Serwint; Linda H. Chaudron; Constance D. Baldwin; Aaron K. Blumkin; Peter G. Szilagyi Pages: 424 - 430 Abstract: Publication date: May–June 2017 Source:Academic Pediatrics, Volume 17, Issue 4 Author(s): Melissa M. Cellini, Janet R. Serwint, Linda H. Chaudron, Constance D. Baldwin, Aaron K. Blumkin, Peter G. Szilagyi Objective Resident mental health (MH) problems can be associated with reduced empathy and increased medical errors. The Accreditation Council for Graduate Medical Education mandates resident MH support services, but it is unknown if these services are accessible and meet resident needs. We sought to describe the prevalence of anxiety and depression in current pediatric residents in New York State (NYS), and their self-reported use of and barriers to support services. Methods We developed an online survey and distributed it to all categorical pediatric residents in 9 NYS programs. Items addressing self-concern for clinical anxiety and depression and use of MH services were pilot tested for content and construct validity. The validated Patient Health Questionnaire-2 (PHQ-2) measured depressive symptoms. Analyses used descriptive and chi-square tests. Results Respondents included 227 residents (54% response rate) distributed across training levels and programs. Many reported “often” or “almost always” feeling stress (52%), physical exhaustion (41%), and mental exhaustion (35%); 11% had PHQ-2-defined depressive symptoms. Some thought that their stress levels raised concern for clinical depression (25%) or anxiety (28%); among these, only 44% and 39%, respectively, had sought care. More women reported physical exhaustion (P < .05). Only 45% of residents reported educational offerings on resident MH; 66% wanted to know more about available resources. Barriers to receipt of services included inflexible schedules (82%), guilt about burdening colleagues (65%), fear of confidentiality breach (46%), and difficulty identifying services (44%). Conclusions Pediatric residents frequently experience MH symptoms, but many do not know about or use support services. Programs should enhance MH support by overcoming barriers and increasing resident awareness of services.
Authors:Francis J. Real; Dominick DeBlasio; Andrew F. Beck; Nicholas J. Ollberding; David Davis; Bradley Cruse; Zeina Samaan; Daniel McLinden; Melissa D. Klein Pages: 431 - 435 Abstract: Publication date: May–June 2017 Source:Academic Pediatrics, Volume 17, Issue 4 Author(s): Francis J. Real, Dominick DeBlasio, Andrew F. Beck, Nicholas J. Ollberding, David Davis, Bradley Cruse, Zeina Samaan, Daniel McLinden, Melissa D. Klein Objective Influenza vaccine hesitancy is common in the primary care setting. Though physicians can affect caregivers' attitudes toward vaccination, physicians report uneasiness discussing vaccine hesitancy. Few studies have targeted physician–patient communication training as a means to decrease vaccination refusal. Methods An immersive virtual reality (VR) curriculum was created to teach pediatric residents communication skills when discussing influenza vaccine hesitancy. This pilot curriculum consisted of 3 VR simulations during which residents counseled graphical character representatives (avatars) who expressed vaccine hesitancy. Participants were randomized to the intervention (n = 24) or control (n = 21) group. Only residents in the intervention group underwent the VR curriculum. Impact of the curriculum was assessed through difference in influenza vaccine refusal rates between the intervention and control groups in the 3 months after the VR curriculum. Results Participants included postgraduate level (PL) 2 and PL3 pediatric residents. All eligible residents (n = 45) participated; the survey response rate was 100%. In patients aged 6 to 59 months, residents in the intervention group had a decreased rate of influenza vaccination refusal in the postcurriculum period compared to the control group (27.8% vs 37.1%; P = .03). Conclusions Immersive VR may be an effective modality to teach communication skills to medical trainees. Next steps include evaluation of the curriculum in a larger, multisite trial.
Authors:Laura Zastoupil; Amanda McIntosh; Jenna Sopfe; Jason Burrows; Jessica Kraynik; Lindsey Lane; Janice Hanson; L. Barry Seltz Pages: 436 - 442 Abstract: Publication date: May–June 2017 Source:Academic Pediatrics, Volume 17, Issue 4 Author(s): Laura Zastoupil, Amanda McIntosh, Jenna Sopfe, Jason Burrows, Jessica Kraynik, Lindsey Lane, Janice Hanson, L. Barry Seltz Objective To evaluate the impact of transitioning from noon conference (NC) to academic half day (AHD) on conference attendance, interruptions, and perceived protected educational time and to describe pediatric resident experiences with AHD. Methods In this mixed-methods study, data before and after AHD implementation were collected. Quantitative data were analyzed with a 2-variable t test or chi-square test. Five focus groups and 5 individual interviews of pediatric residents were conducted. Data were analyzed using constant comparative methods, and were collected until reaching saturation. In accordance with grounded theory methodology, we developed codes using an iterative approach and identified major themes. Results After AHD implementation, resident attendance increased from 55% (of residents expected at NC) to 94% (of residents scheduled for AHD) (P < .001); interruptions decreased from 0.25 to 0.01 per resident per hour (P < .001). Positive responses regarding perceived protected educational time improved from 50% to 95% (2015 class) and from 19% to 50% (2016 class) (P < .001). Thirty-two residents participated in focus groups and interviews. Analysis yielded 5 themes: aids and barriers to AHD attendance; teaching; curricular content; learning and engagement; and resident well-being. Residents felt aided attending AHD when clinical supervisors supported their educational time. Compared to NC, residents noted better topic selection but fewer covered topics. Residents valued protected educational time without clinical responsibilities and thought that small-group discussions at AHD facilitated learning. Although cross-covering was stressful, AHD positively contributed to resident well-being. Conclusions AHD improves resident attendance, interruptions, and perceived learning, and it contributes to resident wellness. More work is needed to mitigate the workload of cross-covering residents.
Authors:Alyna T. Chien; Karen A. Kuhlthau; Sara L. Toomey; Jessica A. Quinn; Megumi J. Okumura; Dennis Z. Kuo; Amy J. Houtrow; Jeanne Van Cleave; Mary Beth Landrum; Jisun Jang; Isabel Janmey; Michael J. Furdyna; Mark A. Schuster Pages: 443 - 449 Abstract: Publication date: May–June 2017 Source:Academic Pediatrics, Volume 17, Issue 4 Author(s): Alyna T. Chien, Karen A. Kuhlthau, Sara L. Toomey, Jessica A. Quinn, Megumi J. Okumura, Dennis Z. Kuo, Amy J. Houtrow, Jeanne Van Cleave, Mary Beth Landrum, Jisun Jang, Isabel Janmey, Michael J. Furdyna, Mark A. Schuster Objective The quality of primary care delivered to Medicaid-insured children with disabilities (CWD) is unknown. We used the newly validated CWD algorithm (CWDA) to examine CWD prevalence among Medicaid enrollees 1 to 18 years old, primary care quality for CWD, and differences in primary care quality for CWD and non-CWD. Methods Cross-sectional study using 2008 Medicaid Analytic eXtract claims data from 9 states, including children with at least 11 months of enrollment (N = 2,671,922 enrollees). We utilized CWDA to identify CWD and applied 12 validated or endorsed pediatric quality measures to assess preventive/screening, acute, and chronic disease care quality. We compared quality for CWD and non-CWD unmatched and matched on age, sex, and number of nondisabling chronic conditions and outpatient encounters. Results CWDA identified 5.3% (n = 141,384) of our study population as CWD. Care quality levels for CWD were below 50% on 8 of 12 quality measures (eg, adolescent well visits [44.9%], alcohol/drug treatment engagement [24.9%]). CWD care quality was significantly better than the general population of non-CWD by +0.9% to +15.6% on 9 measures, but significantly worse for 2 measures, chlamydia screening (−3.4%) and no emergency department visits for asthma (−5.0%; all P < .01 to .001). Differences in care quality between CWD and non-CWD were generally smaller or changed direction when CWD were compared to a general population or matched group of non-CWD. Conclusions One in 20 Medicaid-insured children is CWD, and the quality of primary care delivered to CWD is suboptimal. Areas needing improvement include preventive/screening, acute care, and chronic disease management.
Authors:Laura C. Hart; McLean Pollock; Sherika Hill; Gary Maslow Pages: 450 - 455 Abstract: Publication date: May–June 2017 Source:Academic Pediatrics, Volume 17, Issue 4 Author(s): Laura C. Hart, McLean Pollock, Sherika Hill, Gary Maslow Background Little is known about how transition readiness relates to other developmental skills of adolescence in youth with chronic illness. Better understanding of how transition readiness relates to these other developmental skills could lead to a broader array of tools to improve transition readiness. Intentional self-regulation (ISR) and hopeful future expectations (HFE) are 2 developmental skills of adolescence that improve with participation in developmental programming and thus are modifiable. Methods We explored associations between transition readiness, as measured by the Transition Readiness Assessment Questionnaire 29 (TRAQ-29) and ISR and HFE in youth with chronic illness recruited from a variety of subspecialty clinics from a major southeast medical center. Results A total of 71 adolescents with chronic illness were included in the analysis. The TRAQ-29 Self-Advocacy domain showed positive associations to both ISR (P = .03) and HFE (P = .009). In addition, the TRAQ-29 overall had positive associations to HFE (P = .04). Conclusions The significant associations between TRAQ-29 Self-Advocacy domain scores and ISR and HFE suggest that transition readiness is developing within the context of other developmental areas in adolescence. More work is needed to see if the programming that improves these other developmental skills might also improve transition readiness.
Authors:Meghan May; David C. Brousseau; David A. Nelson; Kathryn E. Flynn; Michael S. Wolf; Bryn Lepley; Andrea K. Morrison Abstract: Publication date: Available online 16 June 2017 Source:Academic Pediatrics 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 presenting for ‘sick child’ visits at a clinic or a non-urgent ED visit (triage level 5) were interviewed. The Newest Vital Sign (NVS) categorized parental health literacy. Interviewers followed a semi-structured 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. Themes included the experiences of low and adequate health literacy in both the clinic and ED. Results Fifty semi-structured interviews were completed with non-urgent ED parents (n=30) and clinic parents (n=20) with 56% possessing low health literacy. Parents with low health literacy are more inclined to overestimate severity of illness and seek care sooner to gain answers about the illness and treatment options, visiting clinic only when an appointment is available within hours. Parents with adequate health literacy seek reassurance of their ongoing illness management and value close relationships with their physician, waiting longer for an appointment. Fever, vomiting, and young child age prompt some parents to seek expedient care regardless of health literacy. Conclusions Caregiving skills (e.g. assessing and treating illness, understanding illness severity, and navigating the healthcare system) in addition to physician-parent relationship and perception of care seem to influence the behavior of parents managing their child’s mild acute illness. These factors may be amenable to a future health literacy intervention.
Authors:Rachel Y. Moon; Fern R. Hauck; Ann L. Kellams; Eve R. Colson; Nicole L. Geller; Timothy C. Heeren; Stephen M. Kerr; Michael J. Corwin Abstract: Publication date: Available online 10 June 2017 Source:Academic Pediatrics Author(s): Rachel Y. Moon, Fern R. Hauck, Ann L. Kellams, Eve R. Colson, Nicole L. Geller, Timothy C. Heeren, Stephen M. Kerr, Michael J. Corwin Objectives To assess how mothers’ choice of email or text messages (SMS) to receive safe sleep communications impacts educational video viewing and responses to care practice queries. Methods 792 new mothers received safe sleep-related communications for 60 days following newborn hospital discharge, as part of a trial of health education interventions on infant care practices. Mothers chose email or SMS for study communications and were sent 22 short safe sleep videos and 41 queries regarding infant care practices. Results 55.7% elected to receive study communications via email. The SMS group had a modestly higher overall view rate of videos (59.1% vs. 54.4%; aOR 1.39, 95% CI 1.07-1.81) and a substantially higher response rate to queries (70.0% vs. 45.2%; aOR 3.48, 95% CI 2.74-4.43). Conclusions Participants more commonly opted to receive infant care practice videos and queries via email. SMS was associated with higher viewing and response rates, especially for query responses. These results highlight the importance of understanding how specific modalities of communication may vary in reach.
Authors:Alan R. Tait; Michael E. Geisser; Lamira Ray; Raymond J. Hutchinson; Terri Voepel-Lewis Abstract: Publication date: Available online 10 June 2017 Source:Academic Pediatrics Author(s): Alan R. Tait, Michael E. Geisser, Lamira Ray, Raymond J. Hutchinson, Terri Voepel-Lewis Objective Despite the importance of child assent, there is little consensus on what information should be disclosed and what information is most important to children for decision-making. This study was designed to compare children’s/adolescents’ priorities for research information with the information parents believe is most important to their children. Methods Child-parent dyads completed separate and independent surveys regarding information (risks, benefits, etc.) that they perceived to be most important to the child in order to make decisions about participating in a hypothetical randomized controlled trial. Parents responded in the context of what information they believed their child (not themselves) would think important. Results 55 parent-child dyads completed surveys. While all information was deemed important, children/adolescents put greater emphasis on privacy and less on knowing the purpose of the study and the benefits compared with what their parents believed was important to their child. Adolescents (13-17yrs) placed greater importance on knowing the procedures, direct benefits, and the voluntary nature of participation compared with younger children (8-12yrs). Parents of older girls in particular placed greater emphasis on their daughter’s need to know the purpose of the study, the procedures, benefits, and voluntary nature, compared to parents of boys. Conclusions Results show that the information priorities of children/adolescents considering participation in a RCT differ from that which their parents think is important to them. Pediatric researchers can use this knowledge to ensure that parents do not conflate their own expectations/priorities with those of their child and that children receive the information they need.
Authors:Dennis Anheyer; Holger Cramer; Romy Lauche; Felix Joyonto Saha; Gustav Dobos Abstract: Publication date: Available online 10 June 2017 Source:Academic Pediatrics Author(s): Dennis Anheyer, Holger Cramer, Romy Lauche, Felix Joyonto Saha, Gustav Dobos Background Herbal medicines are particularly regarded as an alternative or complement to conventional pharmaceuticals in the treatment and prevention of respiratory tract infections (RTI). Objective Therefore the purpose of this review was to identify evidence for herbal therapy in the treatment of RTI concerning effectiveness and safety. Data Sources Medline/PubMed, Scopus and the Cochrane Library were searched through 12 February 2015. Study Eligibility Criteria Randomized controlled trials comparing herbal therapy with no treatment, placebo or any pharmaceutical medication in children and adolescents (age 0 to 18 years) with RTI were eligible. Results Eleven trials with 2,181 participants were included. No clear evidence for Echinacea (4 trials) or an herbal compound preparation (1 trial) in preventing RTI symptoms was found. Meta-analysis revealed evidence for efficacy (responder rates: risk ratio [RR] = 2.56; 95% confidence interval [CI], 1.54 to 4.26; P < 0.01; heterogeneity: I 2 = 38%; χ2 = 9.63; P = 0.14) and safety (patients with adverse events: RR = 1.06; 95% CI, 0.42 to 2.66; P = 0.9; heterogeneity: I 2 = 72%; χ2 = 10.64; P = 0.01) of Pelargonium sidoides in treating respiratory tract infection symptoms compared to placebo (6 trials). Conclusion Due to conflicting evidence in the included studies no concrete conclusion on effects of Echinacea could be drawn so far. In the case of Pelargonium sidoides, performed meta-analysis revealed moderate evidence for efficacy and safety in the treatment of respiratory tract infections in children.
Authors:Mandy A. Allison; Sean T. O’Leary; Megan C. Lindley; Lori A. Crane; Laura P. Hurley; Brenda L. Beaty; Michaela Brtnikova; Andrea Jimenez-Zambrano; Christine Babbel; Stephen Berman; Allison Kempe Abstract: Publication date: Available online 7 June 2017 Source:Academic Pediatrics Author(s): Mandy A. Allison, Sean T. O’Leary, Megan C. Lindley, Lori A. Crane, Laura P. Hurley, Brenda L. Beaty, Michaela Brtnikova, Andrea Jimenez-Zambrano, Christine Babbel, Stephen Berman, Allison Kempe Objectives Vaccines represent a significant portion of primary care practices’ expenses. Our objectives were to determine among Pediatric (Ped) and Family Medicine (FM): 1) relative payment for vaccine purchase and administration and estimated profit margin by payer type, 2) strategies used to reduce vaccine purchase costs and increase payment, and 3) whether practices have stopped providing vaccines due to finances. Methods A national survey conducted April—September 2011 among Ped and FM in private, single-specialty practices. Results The response rate was 51% (221/430). Depending on payer type, 61%--79% of practices reported that payment for vaccine purchase was at least 100% of purchase price and 34%--74% reported that payment for vaccine administration was at least $11. Reported strategies to reduce vaccine purchase cost were online purchasing (81% Ped, 36% FM), prompt pay (78% Ped, 49% FM) and bulk order (65% Ped, 49% FM) discounts. Fewer than half of practices used strategies to increase payment; in a multivariable analysis, practices with > 5 providers were more likely to use strategies compared to practices with fewer providers (adjusted odds ratio 2.65, 95% confidence interval 1.51-4.62). When asked if they had stopped purchasing vaccines due to financial concerns, 12% of Ped and 23% of FM responded ‘yes’, and 24% of Ped and 26% of FM responded ‘no, but have seriously considered’. Conclusions Practices report variable payment for vaccination services from different payer types. Practices may benefit from increased use of strategies to reduce vaccine purchase costs and increase payment for vaccine delivery.
Authors:Maureen Cunningham; Vickie Thomson; Erica McKiever; L. Miriam Dickinson; Anna Furniss; Mandy A. Allison Abstract: Publication date: Available online 23 May 2017 Source:Academic Pediatrics Author(s): Maureen Cunningham, Vickie Thomson, Erica McKiever, L. Miriam Dickinson, Anna Furniss, Mandy A. Allison Background and Objectives Completion of newborn hearing screening (NBHS) is recommended by 1 month old. Delays and loss to follow-up and documentation (LTF/LTD) after failed NBHS are common. Committees of experts have established hospital guidelines to reduce LTF/LTD. We aimed to identify maternal and infant factors associated with LTF/LTD and determine if adherence to hospital guidelines is associated with timely completion of follow-up screening. Methods We conducted a retrospective study of all infants born in Colorado hospitals who failed the newborn admission hearing screen from 2007-2012 and a cross-sectional survey of NBHS coordinators at Colorado birthing hospitals. NICU infants were excluded. Outcomes: documented completion of the follow-up NBHS and completion by 1 month. Data sources: Electronic Birth Record, Infant Hearing Integrated Data System, NBHS coordinator survey. Data were analyzed using logistic regression. Results 13,904 newborns did not pass the newborn admission hearing screen from 2007-2012 and11,422 (82%) had documentation of a completed follow-up screen. 10,558 (76%) completed follow-up screening by 1 month. 100% of NBHS coordinators (n=53) completed the survey. Maternal age, education, smoking, and birth country; and payer, race, birth order, and population density were associated with completion of follow-up hearing screening. Maternal education, payer, population density, birth weight and cleft lip were associated with completion by 1 month of age. Only birth in a facility that charges a re-screening fee was associated with completion of follow-up screening. Conclusions Low income, rural, and minority infants are at risk for LTF. Further studies are needed to determine if adherence to guidelines can overcome barriers to follow-up.
Authors:Raquel G. Hernandez; Akshata Hopkins; Kimberly R. Collins Abstract: Publication date: Available online 20 May 2017 Source:Academic Pediatrics Author(s): Raquel G. Hernandez, Akshata Hopkins, Kimberly R. Collins
Authors:James M. Perrin; Ellen C. Perrin Abstract: Publication date: Available online 17 May 2017 Source:Academic Pediatrics Author(s): James M. Perrin, Ellen C. Perrin
Authors:JoAnna K. Leyenaar; Mary Pat Frintner Abstract: Publication date: Available online 11 May 2017 Source:Academic Pediatrics Author(s): JoAnna K. Leyenaar, Mary Pat Frintner Objective In October 2016, the American Board of Medical Specialties approved the petition for pediatric hospital medicine (PHM) to become the newest pediatric subspecialty. Knowledge about residents entering the PHM workforce is needed to inform certification and fellowship accreditation. This study describes the characteristics of graduating pediatric residents with PHM positions and identifies factors associated with post-residency position choices. Methods We analyzed data from the American Academy of Pediatrics Annual Survey of Graduating Residents, 2006-2015. Chi-square tests were used to compare responses between residents entering PHM to those entering subspecialty fellowships, and to compare residents entering PHM at community and tertiary hospitals. We used multivariable logistic regression to identify associations between resident and training characteristics and position choices. Results 5969 respondents completed the survey (60.6% response rate); 593 (10.3%) reported that they were entering PHM and 1954 (33.9%) reported subspecialty fellowships. Of residents entering PHM, 345 (60.7%) reported positions at tertiary care hospitals and 194 (34.2%) reported positions at community hospitals. 70% of residents entering PHM envisioned long-term PHM careers, with PHM career goals more frequently reported among residents entering community hospitalist positions (p<0.01). In multivariable analysis, residents entering PHM were significantly more likely to be female, to have children, to report that family factors limited their job selection, and to have higher levels of educational debt than residents entering fellowships. Conclusions Factors associated with post-residency PHM positions, including substantial educational debt and sociodemographic characteristics, may influence development of the field as the specialty pursues fellowship accreditation. Teaser What’s new: From 2006-2015, one-in-ten graduating pediatric residents entered hospital medicine; 70% of these envisioned hospital medicine careers. Factors associated with position choices, including substantial educational debt and sociodemographic characteristics, may negatively impact growth of the field as the specialty pursues fellowship accreditation.
Authors:Peter G. Szilagyi; Benard P. Dreyer; Elena Fuentes-Afflick; Tamera Coyne-Beasley; Lewis First Abstract: Publication date: Available online 3 May 2017 Source:Academic Pediatrics Author(s): Peter G. Szilagyi, Benard P. Dreyer, Elena Fuentes-Afflick, Tamera Coyne-Beasley, Lewis First
Authors:Robert S. Kahn; Srikant B. Iyer; Uma R. Kotagal Abstract: Publication date: Available online 3 May 2017 Source:Academic Pediatrics Author(s): Robert S. Kahn, Srikant B. Iyer, Uma R. Kotagal
Authors:Gerry Fairbrother; Denise Dougherty; Rosina Pradhananga; Lisa A. Simpson Abstract: Publication date: Available online 28 April 2017 Source:Academic Pediatrics Author(s): Gerry Fairbrother, Denise Dougherty, Rosina Pradhananga, Lisa A. Simpson Background Prior health services research (HSR) agendas for children have been published, but major ones are now over 15 years old and do not reflect augmented understanding of the drivers and determinants of children’s health; recent changes in the organization, financing, and delivery of health care; a growing emphasis on population health; and major demographic shifts in the population. A policy-relevant research agenda that integrates knowledge gained over the past two decades is essential to guide future child HSR (CHSR). Objective To develop and disseminate a robust, domestically focused, policy-oriented CHSR agenda. Methods The new CHSR agenda was developed through a series of consultations with leaders in CHSR and related fields. After each round of consultation, the authors synthesized the previous experts’ guidance to help inform subsequent discussions. The multi-step process in generation of the agenda included identification of major policy-relevant research domains and specification of high-value research questions for each domain. Stakeholders represented in the discussions included those with expertise in child and family advocacy, adult health, population health, community development, racial and ethnic disparities, women’s health, health economics, and government research funders and programs. Results In total, 180 individuals were consulted in developing the research agenda. Six priority domains were identified for future research, including both enduring and emerging emphases: 1) framing children’s health issues so that they are compelling to policy-makers; 2) addressing poverty and other social determinants of child health and wellbeing; 3) promoting equity in population health and health care; 4) preventing, diagnosing, and treating high priority health conditions in children; 5) strengthening performance of the health care system; and 6) enhancing the CHSR enterprise. Within these six domains, forty specific topics were identified as the most pertinent for future research. Three overarching and crosscutting themes that affect research across the domains were also noted: the need for syntheses to build on the current, and sometimes extensive, evidence base to avoid duplication; the interrelated nature of the domains, which could lead to synergies in research; and the need for multidisciplinary collaborations in conducting research, since research studies will look beyond the health sector. Conclusions The priorities presented in the agenda are policy-oriented and include a greater emphasis on how findings are framed and communicated to support action. We expect that the agenda will be useful for immediate uptake by investigators and research funders.
Authors:Carlos F. Lerner; Thomas S. Klitzner Abstract: Publication date: Available online 27 April 2017 Source:Academic Pediatrics Author(s): Carlos F. Lerner, Thomas S. Klitzner The medical home has been widely promoted as a model of primary care with the potential to transform the healthcare delivery system. Although this model was initially focused on children with chronic conditions, the American Academy of Pediatrics has endorsed a generalization of the model, promoting the statement “Every child deserves a medical home.” Recently, other major professional and governmental organizations have embraced this more inclusive vision, and the medical home concept has been promoted in provisions of the Affordable Care Act. Yet, rigorous evaluation of the value of the medical home, within pediatrics and beyond, has been limited, and the results have been mixed. Early results from large demonstration projects in adults have generally noted modest improvements in quality without accompanying reductions in cost. At this critical period in healthcare, with widespread interest in healthcare delivery and payment reform, these results present a potential threat to the medical home. Understanding possible reasons for these early findings is crucial to sustaining the spread of the medical home beyond its first fifty years. With this aim, we review the history of the medical home and trends in child health, and we explore the concepts of value and complexity as they pertain to pediatric health care delivery. We propose that, given the demographics and economics of child health and current policy imperatives with regard to health care, a strong value proposition for the medical home in pediatrics should focus on children with medical complexity.
Authors:Ross Mangum; John Lazar; Melissa J. Rose; John D. Mahan; Suzanne Reed Abstract: Publication date: Available online 27 April 2017 Source:Academic Pediatrics Author(s): Ross Mangum, John Lazar, Melissa J. Rose, John D. Mahan, Suzanne Reed
Authors:Wanda M. Tempelaar; Nelleke de Vos; Carolien M. Plevier; Willemijn A. van Gastel; Fabian Termorshuizen; James H. MacCabe; Marco P.M. Boks Abstract: Publication date: Available online 26 April 2017 Source:Academic Pediatrics Author(s): Wanda M. Tempelaar, Nelleke de Vos, Carolien M. Plevier, Willemijn A. van Gastel, Fabian Termorshuizen, James H. MacCabe, Marco P.M. Boks Objective Previous research suggests that cognitive functioning is associated with the risk of several adult psychiatric disorders. This study investigates whether adolescents who perform worse than expected at secondary school are at a higher risk for general mental health problems. Methods In a cross-sectional survey comprising 10 866 Dutch adolescents aged 13-16 years, underachievement at secondary school was defined as the discrepancy between predicted school grade and actual grade one or three years later. Mental health problems were assessed with the Strengths and Difficulties Questionnaire (SDQ). We investigated the association of underachievement with mental health problems using logistic regression, adjusting for potential confounders. Results Underachievement was associated with general psychopathology in pupils aged 13-14 (OR: 1.86, 95% CI 1.47-2.37) and in pupils aged 15-16 (OR: 2.05, 95% CI 1.67-2.52) in a multivariate analysis including sociodemographic factors. The association between underachievement and mental health problems was attenuated when school factors such as teacher advice and interaction between underachievement and teacher advice were added, but underachievement remained significantly associated with mental health problems in adolescents in the higher educational tracks (pupils aged 13-14 OR: 2.22, 95% CI 1.07-4.60 and OR: 2.41, 95% CI 1.10-5.30, age 15-16 OR 2.63, 95% CI 1.38-5.03). This association was most pronounced for the hyperactivity subscale of the SDQ. Conclusions Underachievement at secondary school is associated with general mental health problems, especially with hyperactivity symptoms, in pupils who started at high educational tracks. Teaser Whereas a higher risk for mental disorders in adolescents with poor educational performance is well established, we focus on the reciprocal relationship by showing that underachievement acts as an indicator of common mental health problems, and does so more strongly for adolescents initially placed into higher education tracks than for those placed into lower or medium level educational tracks.a
Authors:Jason H. Choi; Alan L. Mendelsohn; Adriana Weisleder; Carolyn Cates; Caitlin Canfield; Anne Seery; Benard P. Dreyer; Suzy Tomopoulos Abstract: Publication date: Available online 25 April 2017 Source:Academic Pediatrics Author(s): Jason H. Choi, Alan L. Mendelsohn, Adriana Weisleder, Carolyn Cates, Caitlin Canfield, Anne Seery, Benard P. Dreyer, Suzy Tomopoulos Objective To determine whether educational media as actually used by low-income families promotes parent-child cognitive stimulation activities. Methods Secondary analysis of the control group of a longitudinal cohort of mother-infant dyads enrolled post-partum in urban public hospital. Educational media exposure (via a 24-hour recall diary) and parent-child activities that may promote cognitive stimulation in the home (using StimQ) were assessed at 6, 14, 24, and 36 months. Results 149 mother-child dyads; 93.3% Latino. Mean (standard deviation) educational media exposure at 6, 14, 24, and 36 months was: 25 (40), 42 (58), 39 (49), and 39 (50) mins/day. In multilevel model analyses, prior educational media exposure had small positive relationship with subsequent total StimQ (β=0.11, P=.03), but was non-significant (β = 0.08, P = .09) after adjusting for confounders (child: age, gender, birth order, non-educational media exposure, language; mother: age, ethnicity, marital status, country of origin, language, depressive symptoms)Educational media did predict small increases in verbal interactions and toy provision (adjusted models, respectively: β = 0.13, P = .02; β = 0.11; P = .03). In contrast, more consistent relationships were seen for models of the relationship between prior StimQ (total, verbal interactions and teaching; adjusted models, respectively: β = 0.20, P = .002; β = 0.15, P = .006; β = 0.20, P = .001) and predicted subsequent educational media. Conclusions Educational media as used by this sample of low-income families does not promote cognitive stimulation activities important for early child development or activities such as reading and teaching.
Authors:Tristram Smith; Suzannah Iadarola; David S. Mandell; Robin Harwood; Connie Kasari Abstract: Publication date: Available online 25 April 2017 Source:Academic Pediatrics Author(s): Tristram Smith, Suzannah Iadarola, David S. Mandell, Robin Harwood, Connie Kasari Objective To illustrate the process of community-partnered participatory research (CPPR) to develop and evaluate interventions for children with autism in urban school districts Methods We formed partnerships of school personnel, parents, and researchers to guide the project. We then conducted focus groups, key informant interviews, and town halls to explore how public schools currently serve students with autism. We used findings from these activities to adapt interventions for public schools. We then tested interventions in randomized clinical trials (RCTs). Results Community input indicated a particular need for interventions to improve children’s social interaction and instructional supports to promote their success throughout the day. Based on this input, we adapted two interventions: Remaking Recess for improving peer engagement during social times; and Schedules, Tools, and Activities for Transition (STAT) for facilitating successful transitions between activities throughout the daily routine. Results of the RCT of Remaking Recess are not yet available. The RCT of STAT involved 150 children and 56 teachers. Teachers reported high buy-in and increased their proficiency at implementing STAT; children with ASD reduced their disruptive behavior and made progress toward teacher-nominated goals. However, teachers’ implementation remained inconsistent, and children did not reliably improve in academic engagement or independence. Conclusions The findings suggest that, although CPPR has limitations, it can assist in selecting interventions to address community priorities and produce some favorable outcomes for children with autism in public schools. An important next step is to evaluate the sustainability of the interventions introduced in this project.
Authors:Savithri Nageswaran; Shannon L. Golden Abstract: Publication date: Available online 24 April 2017 Source:Academic Pediatrics Author(s): Savithri Nageswaran, Shannon L. Golden Objectives The objectives of this study are to (1) describe the quality of home healthcare services for children with medical complexity, (2) identify barriers to delivering optimal home healthcare, and (3) discuss potential solutions to improve home healthcare delivery. Methods In this qualitative study, we conducted 20 semi-structured in-depth interviews with primary caregivers of children with medical complexity, and 4 focus groups with 18 home health nurses. During an iterative analysis process, we identified themes related to quality of home healthcare. Results There is substantial variability between home health nurses in the delivery of home healthcare to children. Lack of skills in nurses is common and has serious negative health consequences for children with medical complexity including hospitalizations, emergency room visits and need for medical procedures. Inadequate home healthcare also contributes to caregiver burden. A major barrier to delivering optimal home healthcare is the lack of training of home health nurses in pediatric care and technology use. Potential solutions for improving care include home health agencies training nurses in the care of children with medical complexity, support for nurses in clinical problem-solving and reimbursement for training nurses in pediatric home care. Caregiver-level interventions includes preparation of caregivers about: providing medical care for their children at home and addressing problems with home healthcare services. Conclusions There are problems in the quality of home healthcare delivered to children with medical complexity. Training nurses in the care of children with medical complexity and preparing caregivers about home care could improve home healthcare quality.
Authors:Emily F. Rothman; Jennifer Paruk; Ashlee Espensen; Jeff R. Temple; Kelley Adams Abstract: Publication date: Available online 24 April 2017 Source:Academic Pediatrics Author(s): Emily F. Rothman, Jennifer Paruk, Ashlee Espensen, Jeff R. Temple, Kelley Adams Objective There is no empirical information about how parents react when they discover that their young children have seen pornography. To address this gap in the literature, the current study sought to improve our understanding of parental reactions to discovering that their children ages <12 years old have seen pornography using a mixed-methods approach. Methods A convenience sample of participants (N=279) were recruited from the online survey service mTurk. Eligible participants completed an online survey comprising close-ended and open-ended questions about their reactions when their young children saw pornography. Qualitative data were analyzed using a content analysis approach. Results Parents had five main reactions when realizing that their children had viewed pornography: (a) angry, shaming, or punitive; (b) calm and factual; (c) ignoring, minimizing or denying that it happened; (d) panic or fear; and (e) lying to the child about what the child viewed. Most parents reacted calmly while a small percentage reported that they hit, scolded, or shamed their young children for seeing the pornography. Many reported not knowing what to say or do. Conclusions Development and evaluation of parental scripts for developmentally-appropriate parent-child communication, or pediatrician-child communication, about pornography could benefit the field. Teaser Many parents are not sure what to say or do when their young children see pornography. Pediatricians could offer guidance to parents about what to do when children see pornography.
Authors:John S. Hutton; Resmi Gupta; Rachel Gruber; Jennifer Berndsen; Thomas DeWitt; Nicholas J. Ollberding; Judith B. Van Ginkel; Robert T. Ammerman Abstract: Publication date: Available online 24 April 2017 Source:Academic Pediatrics Author(s): John S. Hutton, Resmi Gupta, Rachel Gruber, Jennifer Berndsen, Thomas DeWitt, Nicholas J. Ollberding, Judith B. Van Ginkel, Robert T. Ammerman Background Sleep-related infant deaths have plateaued in the past decade, disproportionately affecting low-socio-economic-status (SES) families. Printed materials are widely used for anticipatory guidance, yet none for safe sleep have been studied. Objectives To test the efficacy of a specially designed children’s book compared to brochures for safe sleep knowledge and adherence, which we hypothesized would be greater due to superior readability and engagement. Methods This randomized controlled trial involved low-SES mothers (n=282) enrolled in a home visiting program. Home visitors (n=56) were randomly assigned to perform safe sleep teaching and assessments during three visits: 3rd trimester, 1 week, and 2-months old, exclusively utilizing a specially-designed children’s book or brochures, and surveys incorporating AAP safe sleep recommendations. Outcomes were safe sleep knowledge, adherence, and usefulness of materials, controlling for maternal health literacy. Results Safe sleep knowledge increased across all time points with no overall group difference, though gains for sleep-evocative and general health items varied. Odds of bed-sharing were higher, and exclusive crib use lower, for the brochure group (p < 0.05). Mothers and home visitors reported similar usefulness, though home visitors reported greater dialogue via the book and mothers in the book group reported more book sharing with their baby. Conclusions While a specially-designed children’s book and brochures were equally effective conveying aggregate safe sleep knowledge in low-SES mothers, adherence to exclusive crib use and avoiding bed-sharing were greater in the book group, attributable to enhanced dialogue, readability and emotional engagement. Children’s books are a promising mode of anticipatory guidance, warranting further investigation. Teaser Compared to standard brochures, high-risk mothers presented with safe sleep information by home visitors using a specially designed children’s book showed greater adherence to exclusive crib use and avoiding bed-sharing, attributable to enhanced dialogue, readability and emotional engagement.
Authors:Mitchell D. Wong; Danielle Strom; Lourdes R. Guerrero; Paul J. Chung; Desiree Lopez; Katherine Arellano; Rebecca Dudovitz Abstract: Publication date: Available online 18 April 2017 Source:Academic Pediatrics Author(s): Mitchell D. Wong, Danielle Strom, Lourdes R. Guerrero, Paul J. Chung, Desiree Lopez, Katherine Arellano, Rebecca Dudovitz Purpose We examined whether standardized test scores and grades are related to risky behaviors among low-income minority adolescents and whether social networks and social-emotional factors explained those relationships. Methods We analyzed data from 929 high school students exposed by natural experiment to high- or low-performing academic environments in Los Angeles. We collected information on grade point average (GPA), substance use, sexual behaviors, participation in fights and carrying a weapon from face-to-face interviews and obtained California math and English standardized test (CST) results. Logistic regression and mediation analyses were used to examine the relationship between achievement and risky behaviors. Results Better GPA and CST scores were strongly associated with lower rates of substance use, high risk sexual behaviors and fighting. The unadjusted relative odds of monthly binge drinking was 0.72 (95%CI: 0.56-0.93) for 1 standard deviation increase in standardized test scores and 0.46 (0.29-0.74) for GPA of B minus or higher compared to C plus or lower. Most associations disappeared after controlling for social-emotional and social network factors. Averaged across the risky behaviors, mediation analysis revealed social-emotional factors accounted for 33% of the relationship between test scores and risky behaviors and 43% of the relationship between GPA with risky behaviors. Social network characteristics accounted for 31% and 38% of the relationship between behaviors with test scores and GPA, respectively. Demographic factors, parenting and school characteristics were less important explanatory factors. Conclusions Social-emotional factors and social network characteristics were the strongest explanatory factors of the achievement-risky behavior relationship and may be important to understanding the relationship between academic achievement and risky behaviors.
Authors:Carolyn S. Avery; Jimmy Beck; Ryan Padrez; Lauren LaRue Walker; Lisa E. Herrmann; Suzanne Woods; Alan R. Schroeder; Adam Schickedanz Abstract: Publication date: Available online 18 April 2017 Source:Academic Pediatrics Author(s): Carolyn S. Avery, Jimmy Beck, Ryan Padrez, Lauren LaRue Walker, Lisa E. Herrmann, Suzanne Woods, Alan R. Schroeder, Adam Schickedanz
Authors:Niraj Sharma; Kitty O’Hare; Karen G. O’Connor; Umbereen Nehal; Megumi J. Okumura Abstract: Publication date: Available online 18 April 2017 Source:Academic Pediatrics Author(s): Niraj Sharma, Kitty O’Hare, Karen G. O’Connor, Umbereen Nehal, Megumi J. Okumura Objective Youth with Special Health Care Needs (YSHCN) require assistance from their pediatricians to transition to adult care. There is little data on what transition resources pediatricians have. This paper studies if care coordination and/or comprehensive electronic health record (CEHR) implementation are associated with improved transition processes. Methods Using AAP Periodic Survey #79, we report whether practices generated written transition plans, assisted in finding adult providers, and discussed confidentiality issues. Descriptive statistics and a logistic regression model were done to evaluate whether CEHR, care coordination, or practice and physician characteristics improve transition planning. Results Transition planning support in practices is low. Pediatricians with any care coordinator report more written transition plans for YSHCN (23% vs. 6%, p<0.001), assistance identifying adult providers (59% vs. 39%, p<0.001), and discussing confidentiality issues (50% vs. 33%, p<0.001). Pediatricians with a CEHR compared to those without are more likely to report written transition plans for YSHCN (24% vs. 12 % p<0.05) and discussing confidentiality issues (51% vs. 39%, p<0.05). In the logistic regression model, having care coordination (AOR 11.1, 95% CI 5.9-21.3) and CEHR (AOR 2.6, 95% CI 1.5-5.0) are independently associated with higher odds of having a written transition plan. Conclusions Only 1 in 5 pediatricians have a transition coordinator in their practice and just 15% have a CEHR, even as these resources are associated with improved transition processes for YSHCN. Policy decisions should be made to help practices with supports, such as care coordination and EHR implementation, in order to improve transitions to adulthood.
Authors:Jill S. Halterman; Reynaldo Tajon; Paul Tremblay; Maria Fagnano; Arlene Butz; Tamara Perry; Ken McConnochie Abstract: Publication date: Available online 18 April 2017 Source:Academic Pediatrics Author(s): Jill S. Halterman, Reynaldo Tajon, Paul Tremblay, Maria Fagnano, Arlene Butz, Tamara Perry, Ken McConnochie Overview:In the spirit of Dr. Haggerty’s teachings, we present an overview of our work to improve care for children with asthma in the context of 3 lessons learned:1 1) The importance of providing integrated services across disciplinary boundaries for children with chronic illness, 2) The need to move from a care model focused only on the individual child to a model focused on the child, family, and community, and 3) The need to expand beyond the local community and take a broad perspective on improving health on a national level. The goal of our program is to develop sustainable models to overcome the multiple obstacles to effective preventive care for urban children with asthma. The primary intervention for our original School Based Asthma Therapy (SBAT) program was directly observed administration of preventive asthma medications in school (with dose adjustments based on NHLBI guidelines).2 We found that children who received preventive medications in school through directly observed therapy had improved outcomes across multiple outcome measures.3 Our subsequent asthma programs have focused on dissemination and sustainability, with the incorporation of communication technology to enhance the system of care. We are currently testing the ‘School-Based Telemedicine Enhanced Asthma Management’ (SB-TEAM) program, including 400 children with persistent asthma from the Rochester City School District. This program includes directly observed administration of preventive asthma medication at school, and school-based telemedicine to assure appropriate evaluation, preventive medication prescription, and follow-up care. It is designed to implement and sustain guideline-based asthma care through existing community infrastructure, and could serve as a model for the integration of services in both rural and urban communities.
Authors:Beno Ackery; Colaco Boutis Abstract: Publication date: Available online 14 April 2017 Source:Academic Pediatrics Author(s): S. Beno, A. Ackery, K. Colaco, K. Boutis Objectives Recreational trampoline use is increasing in popularity, with a resulting increase in significant trampoline-related injuries in children. Parents are the best advocates for the safety of their children during recreational trampoline use. Our primary objective was to determine the proportion of parents who were aware of five key recommendations for safer recreational trampoline use in children. Methods This was a cross-sectional survey of parents whose children presented to a tertiary care pediatric emergency department (ED) with an extremity injury. Survey questions were derived and validated using expert opinion, available literature, and pre and pilot testing of questions on the target audience. Results Of the 1415 enrolled parents, 654 (46.2%) had regular access to a trampoline and 125 (8.8%) of their children had a history of trampoline injury. A total of 116 (8.2%; 95% CI 6.8 to 9.6) parents were aware of all five key safety recommendations for home trampoline use. Specifically, the proportion of parents who reported knowledge of the requirement for active supervision, regularly inspected safety equipment, avoiding stunts, multiple jumpers and use by children 6 years of age and older was 89.0%, 77.2%, 44.3%, 41.6%, and 18.3%, respectively. Conclusions Trampoline safety knowledge of the five key recommendations amongst parents was low, specifically with respect to recommended age, number of jumpers, and stunts. Since it is unlikely that use of recreational trampolines will decrease, a harm reduction approach that includes a public knowledge translation strategy of recommendations for safer home use of trampolines is necessary.
Authors:Alejandro Torres; Ruth M. Parker; Lee M. Sanders; Michael S. Wolf; Stacy Bailey; Deesha A. Patel; Jessica J. Jimenez; Kwang-Youn A. Kim; Benard P. Dreyer; Alan Mendelsohn; H. Shonna Yin Abstract: Publication date: Available online 8 April 2017 Source:Academic Pediatrics Author(s): Alejandro Torres, Ruth M. Parker, Lee M. Sanders, Michael S. Wolf, Stacy Bailey, Deesha A. Patel, Jessica J. Jimenez, Kwang-Youn A. Kim, Benard P. Dreyer, Alan Mendelsohn, H. Shonna Yin Background and Objectives A recent AAP policy statement recommends mL-exclusive dosing for pediatric liquid medications. Little is known about parent preferences regarding units, perceptions about moving to mL-only, and the role of health literacy and prior mL-dosing experience. Methods Cross-sectional analysis of data collected as part of a randomized controlled study in 3 urban pediatric clinics (SAFE-Rx for Kids study). English/Spanish-speaking parents (n=493) of children <8 years were randomized to 1 of 4 study arms and given labels/dosing tools which varied in label instruction format (text+pictogram, text-only) and units (mL-only, mL/tsp). Outcomes: teaspoon preference in dosing instructions, perceived difficulty with mL-only dosing. Predictor variable: health literacy (Newest Vital Sign; low[0-1], marginal[2-3], adequate[4-6]). Mediating variable: prior mL-dosing experience. Results Over two-thirds of parents had low or marginal health literacy. The majority (>70%) preferred to use mL, perceived mL-only dosing to be easy, and had prior mL-dosing experience; 11.5% had a teaspoon preference, 18.1% perceived mL-only dosing will be difficult, and 17.7% had no prior mL-dosing experience. Parents with lower health literacy had a higher odds of having a teaspoon preference (low vs. adequate: AOR=2.9[1.3-6.2]), and greater odds of perceiving difficulty with mL-only dosing (low vs. adequate: AOR=13.9[4.8-40.6]), marginal vs. adequate: AOR=7.1[2.5-20.4]). Lack of experience with mL-dosing partially mediated the impact of health literacy. Conclusions Most parents were comfortable with mL-only dosing. Parents with low health literacy were more likely to perceive mL-only dosing to be difficult; educational efforts will need to target this group to ensure safe medication use.
Authors:Marina Arvanitis; Neal A. deJong; Laurel K. Leslie; Darren A. DeWalt; Gregory D. Randolph; Kori B. Flower Abstract: Publication date: Available online 2 April 2017 Source:Academic Pediatrics Author(s): Marina Arvanitis, Neal A. deJong, Laurel K. Leslie, Darren A. DeWalt, Gregory D. Randolph, Kori B. Flower Background From 2010-2014, pediatricians completed Part 4 Maintenance of Certification (MOC) through practice- or organization-developed quality improvement (QI) activities approved by the American Board of Pediatrics (ABP). Organization-developed activities were online modules, such as the ABP’s Performance Improvement Modules (PIMs), through which pediatricians implemented QI strategies in practice, and reported quality measures. Objectives Aim 1) Assess the proportion of pediatricians who completed practice- vs organization-developed QI activities for Part 4 MOC, and test the relationship between activities and pediatrician demographics. Aim 2) Assess the relationship between PIM completion and improvement in care processes and outcomes as determined by PIM quality measures. Methods Aim 1) Using de-identified demographic data from the ABP, we summarized QI activity completion and performed bivariate testing by pediatrician demographics; Aim 2) Using de-identified parent and pediatrician-reported quality measures from the ADHD, Asthma, Hand Hygiene, and Influenza PIMs, we used two-sample tests of proportions to calculate pre-post changes in quality measures. Results Aim 1) Of 50,433 pediatricians who completed Part 4 MOC from 2010-2014, 22% completed practice-, and 78% organization-developed activities. More pediatricians completed organization-developed activities, regardless of age, gender, or subspecialty status. The majority (73%) of pediatricians who completed organization-developed activities completed ABP PIMs. Aim 2) PIM completion was associated with improvement on nearly all pediatrician and parent-reported quality measures. Conclusions At the outset of the Part 4 MOC system, pediatricians most commonly completed online, organization-developed activities. Pediatricians and parents reported improvements in care processes and outcomes associated with PIMs, suggesting PIMs can be an effective means of facilitating practice improvement. Teaser At the outset of Part 4 MOC, board-certified pediatricians completed organization-developed, online modules in higher frequencies than practice-developed QI activities. The most frequently completed online modules – ABP PIMs – were associated with improvements in nearly all parent- and pediatrician-reported quality measures.
Authors:Jaspreet Loyal; James A. Taylor; Carrie A. Phillipi; Neera K. Goyal; Niramol Dhepyasuwan; Eugene D. Shapiro; Eve Colson Abstract: Publication date: Available online 9 March 2017 Source:Academic Pediatrics Author(s): Jaspreet Loyal, James A. Taylor, Carrie A. Phillipi, Neera K. Goyal, Niramol Dhepyasuwan, Eugene D. Shapiro, Eve Colson Objective To survey newborn clinicians in the United States regarding the frequency of intramuscular (IM) vitamin K refusal by a parent, reasons for refusal, and approaches of clinicians to refusals. Methods An electronic survey was administered to the clinician site representative (nursery director or designee knowledgeable about site-specific nursery policies) at all newborn nurseries in the Better Outcomes through Research for Newborns (BORN) network of newborn nurseries. Results Of 92 BORN sites, 85 (92%) respondents completed the survey. Frequency of IM vitamin K refusal during the past 5 years was reported as increased by 52% of respondents, unchanged by 42%, and 6% did not know. Reported frequencies of refusal of IM vitamin K was weekly (9%), a few times a month (31%), once a month (13%), once every 3 to 4 months (20%), once or twice a year (26%), or never (1%). The overall distribution of the reported frequencies of refusal differed among regions in the United States (higher in the West and the South; P < .05). Reported reasons for refusal by parents included perceptions of parents that the injection was unnecessary, lack of knowledge about vitamin K deficiency bleeding, and concern about preservatives. Approaches to refusal included attempts to educate parents, enlisting support from community clinicians, a state mandate, and prescription of oral vitamin K. Conclusions Respondents from a national sample of newborn nursery clinicians reported an increase in refusal of IM vitamin K in the past 5 years with regional variation. Approaches to refusals need further investigation to determine effectiveness.
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