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Publisher: Elsevier   (Total: 3155 journals)

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Showing 1 - 200 of 3155 Journals sorted alphabetically
A Practical Logic of Cognitive Systems     Full-text available via subscription   (Followers: 9)
AASRI Procedia     Open Access   (Followers: 15)
Academic Pediatrics     Hybrid Journal   (Followers: 34, SJR: 1.655, CiteScore: 2)
Academic Radiology     Hybrid Journal   (Followers: 23, SJR: 1.015, CiteScore: 2)
Accident Analysis & Prevention     Partially Free   (Followers: 96, SJR: 1.462, CiteScore: 3)
Accounting Forum     Hybrid Journal   (Followers: 27, SJR: 0.932, CiteScore: 2)
Accounting, Organizations and Society     Hybrid Journal   (Followers: 38, SJR: 1.771, CiteScore: 3)
Achievements in the Life Sciences     Open Access   (Followers: 5)
Acta Anaesthesiologica Taiwanica     Open Access   (Followers: 7)
Acta Astronautica     Hybrid Journal   (Followers: 412, SJR: 0.758, CiteScore: 2)
Acta Automatica Sinica     Full-text available via subscription   (Followers: 2)
Acta Biomaterialia     Hybrid Journal   (Followers: 27, SJR: 1.967, CiteScore: 7)
Acta Colombiana de Cuidado Intensivo     Full-text available via subscription   (Followers: 2)
Acta de Investigación Psicológica     Open Access   (Followers: 3)
Acta Ecologica Sinica     Open Access   (Followers: 10, SJR: 0.18, CiteScore: 1)
Acta Haematologica Polonica     Free   (Followers: 1, SJR: 0.128, CiteScore: 0)
Acta Histochemica     Hybrid Journal   (Followers: 3, SJR: 0.661, CiteScore: 2)
Acta Materialia     Hybrid Journal   (Followers: 258, SJR: 3.263, CiteScore: 6)
Acta Mathematica Scientia     Full-text available via subscription   (Followers: 5, SJR: 0.504, CiteScore: 1)
Acta Mechanica Solida Sinica     Full-text available via subscription   (Followers: 9, SJR: 0.542, CiteScore: 1)
Acta Oecologica     Hybrid Journal   (Followers: 12, SJR: 0.834, CiteScore: 2)
Acta Otorrinolaringologica (English Edition)     Full-text available via subscription  
Acta Otorrinolaringológica Española     Full-text available via subscription   (Followers: 3, SJR: 0.307, CiteScore: 0)
Acta Pharmaceutica Sinica B     Open Access   (Followers: 1, SJR: 1.793, CiteScore: 6)
Acta Poética     Open Access   (Followers: 4, SJR: 0.101, CiteScore: 0)
Acta Psychologica     Hybrid Journal   (Followers: 28, SJR: 1.331, CiteScore: 2)
Acta Sociológica     Open Access   (Followers: 1)
Acta Tropica     Hybrid Journal   (Followers: 6, SJR: 1.052, CiteScore: 2)
Acta Urológica Portuguesa     Open Access  
Actas Dermo-Sifiliograficas     Full-text available via subscription   (Followers: 3, SJR: 0.374, CiteScore: 1)
Actas Dermo-Sifiliográficas (English Edition)     Full-text available via subscription   (Followers: 2)
Actas Urológicas Españolas     Full-text available via subscription   (Followers: 3, SJR: 0.344, CiteScore: 1)
Actas Urológicas Españolas (English Edition)     Full-text available via subscription   (Followers: 1)
Actualites Pharmaceutiques     Full-text available via subscription   (Followers: 6, SJR: 0.19, CiteScore: 0)
Actualites Pharmaceutiques Hospitalieres     Full-text available via subscription   (Followers: 3)
Acupuncture and Related Therapies     Hybrid Journal   (Followers: 6)
Acute Pain     Full-text available via subscription   (Followers: 14, SJR: 2.671, CiteScore: 5)
Ad Hoc Networks     Hybrid Journal   (Followers: 11, SJR: 0.53, CiteScore: 4)
Addictive Behaviors     Hybrid Journal   (Followers: 17, SJR: 1.29, CiteScore: 3)
Addictive Behaviors Reports     Open Access   (Followers: 8, SJR: 0.755, CiteScore: 2)
Additive Manufacturing     Hybrid Journal   (Followers: 10, SJR: 2.611, CiteScore: 8)
Additives for Polymers     Full-text available via subscription   (Followers: 22)
Advanced Drug Delivery Reviews     Hybrid Journal   (Followers: 154, SJR: 4.09, CiteScore: 13)
Advanced Engineering Informatics     Hybrid Journal   (Followers: 11, SJR: 1.167, CiteScore: 4)
Advanced Powder Technology     Hybrid Journal   (Followers: 17, SJR: 0.694, CiteScore: 3)
Advances in Accounting     Hybrid Journal   (Followers: 8, SJR: 0.277, CiteScore: 1)
Advances in Agronomy     Full-text available via subscription   (Followers: 14, SJR: 2.384, CiteScore: 5)
Advances in Anesthesia     Full-text available via subscription   (Followers: 28, SJR: 0.126, CiteScore: 0)
Advances in Antiviral Drug Design     Full-text available via subscription   (Followers: 2)
Advances in Applied Mathematics     Full-text available via subscription   (Followers: 10, SJR: 0.992, CiteScore: 1)
Advances in Applied Mechanics     Full-text available via subscription   (Followers: 11, SJR: 1.551, CiteScore: 4)
Advances in Applied Microbiology     Full-text available via subscription   (Followers: 24, SJR: 2.089, CiteScore: 5)
Advances In Atomic, Molecular, and Optical Physics     Full-text available via subscription   (Followers: 14, SJR: 0.572, CiteScore: 2)
Advances in Biological Regulation     Hybrid Journal   (Followers: 4, SJR: 2.61, CiteScore: 7)
Advances in Botanical Research     Full-text available via subscription   (Followers: 2, SJR: 0.686, CiteScore: 2)
Advances in Cancer Research     Full-text available via subscription   (Followers: 33, SJR: 3.043, CiteScore: 6)
Advances in Carbohydrate Chemistry and Biochemistry     Full-text available via subscription   (Followers: 9, SJR: 1.453, CiteScore: 2)
Advances in Catalysis     Full-text available via subscription   (Followers: 5, SJR: 1.992, CiteScore: 5)
Advances in Cell Aging and Gerontology     Full-text available via subscription   (Followers: 4)
Advances in Cellular and Molecular Biology of Membranes and Organelles     Full-text available via subscription   (Followers: 12)
Advances in Chemical Engineering     Full-text available via subscription   (Followers: 27, SJR: 0.156, CiteScore: 1)
Advances in Child Development and Behavior     Full-text available via subscription   (Followers: 10, SJR: 0.713, CiteScore: 1)
Advances in Chronic Kidney Disease     Full-text available via subscription   (Followers: 10, SJR: 1.316, CiteScore: 2)
Advances in Clinical Chemistry     Full-text available via subscription   (Followers: 29, SJR: 1.562, CiteScore: 3)
Advances in Colloid and Interface Science     Full-text available via subscription   (Followers: 19, SJR: 1.977, CiteScore: 8)
Advances in Computers     Full-text available via subscription   (Followers: 14, SJR: 0.205, CiteScore: 1)
Advances in Dermatology     Full-text available via subscription   (Followers: 14)
Advances in Developmental Biology     Full-text available via subscription   (Followers: 12)
Advances in Digestive Medicine     Open Access   (Followers: 9)
Advances in DNA Sequence-Specific Agents     Full-text available via subscription   (Followers: 5)
Advances in Drug Research     Full-text available via subscription   (Followers: 25)
Advances in Ecological Research     Full-text available via subscription   (Followers: 44, SJR: 2.524, CiteScore: 4)
Advances in Engineering Software     Hybrid Journal   (Followers: 28, SJR: 1.159, CiteScore: 4)
Advances in Experimental Biology     Full-text available via subscription   (Followers: 8)
Advances in Experimental Social Psychology     Full-text available via subscription   (Followers: 46, SJR: 5.39, CiteScore: 8)
Advances in Exploration Geophysics     Full-text available via subscription   (Followers: 1)
Advances in Fluorine Science     Full-text available via subscription   (Followers: 9)
Advances in Food and Nutrition Research     Full-text available via subscription   (Followers: 58, SJR: 0.591, CiteScore: 2)
Advances in Fuel Cells     Full-text available via subscription   (Followers: 16)
Advances in Genetics     Full-text available via subscription   (Followers: 16, SJR: 1.354, CiteScore: 4)
Advances in Genome Biology     Full-text available via subscription   (Followers: 8, SJR: 12.74, CiteScore: 13)
Advances in Geophysics     Full-text available via subscription   (Followers: 6, SJR: 1.193, CiteScore: 3)
Advances in Heat Transfer     Full-text available via subscription   (Followers: 23, SJR: 0.368, CiteScore: 1)
Advances in Heterocyclic Chemistry     Full-text available via subscription   (Followers: 12, SJR: 0.749, CiteScore: 3)
Advances in Human Factors/Ergonomics     Full-text available via subscription   (Followers: 22)
Advances in Imaging and Electron Physics     Full-text available via subscription   (Followers: 2, SJR: 0.193, CiteScore: 0)
Advances in Immunology     Full-text available via subscription   (Followers: 35, SJR: 4.433, CiteScore: 6)
Advances in Inorganic Chemistry     Full-text available via subscription   (Followers: 8, SJR: 1.163, CiteScore: 2)
Advances in Insect Physiology     Full-text available via subscription   (Followers: 2, SJR: 1.938, CiteScore: 3)
Advances in Integrative Medicine     Hybrid Journal   (Followers: 7, SJR: 0.176, CiteScore: 0)
Advances in Intl. Accounting     Full-text available via subscription   (Followers: 3)
Advances in Life Course Research     Hybrid Journal   (Followers: 8, SJR: 0.682, CiteScore: 2)
Advances in Lipobiology     Full-text available via subscription   (Followers: 1)
Advances in Magnetic and Optical Resonance     Full-text available via subscription   (Followers: 8)
Advances in Marine Biology     Full-text available via subscription   (Followers: 18, SJR: 0.88, CiteScore: 2)
Advances in Mathematics     Full-text available via subscription   (Followers: 11, SJR: 3.027, CiteScore: 2)
Advances in Medical Sciences     Hybrid Journal   (Followers: 6, SJR: 0.694, CiteScore: 2)
Advances in Medicinal Chemistry     Full-text available via subscription   (Followers: 5)
Advances in Microbial Physiology     Full-text available via subscription   (Followers: 4, SJR: 1.158, CiteScore: 3)
Advances in Molecular and Cell Biology     Full-text available via subscription   (Followers: 23)
Advances in Molecular and Cellular Endocrinology     Full-text available via subscription   (Followers: 8)
Advances in Molecular Toxicology     Full-text available via subscription   (Followers: 7, SJR: 0.182, CiteScore: 0)
Advances in Nanoporous Materials     Full-text available via subscription   (Followers: 3)
Advances in Oncobiology     Full-text available via subscription   (Followers: 1)
Advances in Organ Biology     Full-text available via subscription   (Followers: 1)
Advances in Organometallic Chemistry     Full-text available via subscription   (Followers: 17, SJR: 1.875, CiteScore: 4)
Advances in Parallel Computing     Full-text available via subscription   (Followers: 7, SJR: 0.174, CiteScore: 0)
Advances in Parasitology     Full-text available via subscription   (Followers: 5, SJR: 1.579, CiteScore: 4)
Advances in Pediatrics     Full-text available via subscription   (Followers: 24, SJR: 0.461, CiteScore: 1)
Advances in Pharmaceutical Sciences     Full-text available via subscription   (Followers: 12)
Advances in Pharmacology     Full-text available via subscription   (Followers: 16, SJR: 1.536, CiteScore: 3)
Advances in Physical Organic Chemistry     Full-text available via subscription   (Followers: 8, SJR: 0.574, CiteScore: 1)
Advances in Phytomedicine     Full-text available via subscription  
Advances in Planar Lipid Bilayers and Liposomes     Full-text available via subscription   (Followers: 3, SJR: 0.109, CiteScore: 1)
Advances in Plant Biochemistry and Molecular Biology     Full-text available via subscription   (Followers: 10)
Advances in Plant Pathology     Full-text available via subscription   (Followers: 5)
Advances in Porous Media     Full-text available via subscription   (Followers: 5)
Advances in Protein Chemistry     Full-text available via subscription   (Followers: 18)
Advances in Protein Chemistry and Structural Biology     Full-text available via subscription   (Followers: 20, SJR: 0.791, CiteScore: 2)
Advances in Psychology     Full-text available via subscription   (Followers: 64)
Advances in Quantum Chemistry     Full-text available via subscription   (Followers: 6, SJR: 0.371, CiteScore: 1)
Advances in Radiation Oncology     Open Access   (SJR: 0.263, CiteScore: 1)
Advances in Small Animal Medicine and Surgery     Hybrid Journal   (Followers: 3, SJR: 0.101, CiteScore: 0)
Advances in Space Biology and Medicine     Full-text available via subscription   (Followers: 6)
Advances in Space Research     Full-text available via subscription   (Followers: 400, SJR: 0.569, CiteScore: 2)
Advances in Structural Biology     Full-text available via subscription   (Followers: 5)
Advances in Surgery     Full-text available via subscription   (Followers: 11, SJR: 0.555, CiteScore: 2)
Advances in the Study of Behavior     Full-text available via subscription   (Followers: 34, SJR: 2.208, CiteScore: 4)
Advances in Veterinary Medicine     Full-text available via subscription   (Followers: 17)
Advances in Veterinary Science and Comparative Medicine     Full-text available via subscription   (Followers: 13)
Advances in Virus Research     Full-text available via subscription   (Followers: 5, SJR: 2.262, CiteScore: 5)
Advances in Water Resources     Hybrid Journal   (Followers: 46, SJR: 1.551, CiteScore: 3)
Aeolian Research     Hybrid Journal   (Followers: 6, SJR: 1.117, CiteScore: 3)
Aerospace Science and Technology     Hybrid Journal   (Followers: 345, SJR: 0.796, CiteScore: 3)
AEU - Intl. J. of Electronics and Communications     Hybrid Journal   (Followers: 8, SJR: 0.42, CiteScore: 2)
African J. of Emergency Medicine     Open Access   (Followers: 6, SJR: 0.296, CiteScore: 0)
Ageing Research Reviews     Hybrid Journal   (Followers: 11, SJR: 3.671, CiteScore: 9)
Aggression and Violent Behavior     Hybrid Journal   (Followers: 456, SJR: 1.238, CiteScore: 3)
Agri Gene     Hybrid Journal   (Followers: 1, SJR: 0.13, CiteScore: 0)
Agricultural and Forest Meteorology     Hybrid Journal   (Followers: 17, SJR: 1.818, CiteScore: 5)
Agricultural Systems     Hybrid Journal   (Followers: 31, SJR: 1.156, CiteScore: 4)
Agricultural Water Management     Hybrid Journal   (Followers: 41, SJR: 1.272, CiteScore: 3)
Agriculture and Agricultural Science Procedia     Open Access   (Followers: 3)
Agriculture and Natural Resources     Open Access   (Followers: 3)
Agriculture, Ecosystems & Environment     Hybrid Journal   (Followers: 57, SJR: 1.747, CiteScore: 4)
Ain Shams Engineering J.     Open Access   (Followers: 5, SJR: 0.589, CiteScore: 3)
Air Medical J.     Hybrid Journal   (Followers: 6, SJR: 0.26, CiteScore: 0)
AKCE Intl. J. of Graphs and Combinatorics     Open Access   (SJR: 0.19, CiteScore: 0)
Alcohol     Hybrid Journal   (Followers: 11, SJR: 1.153, CiteScore: 3)
Alcoholism and Drug Addiction     Open Access   (Followers: 10)
Alergologia Polska : Polish J. of Allergology     Full-text available via subscription   (Followers: 1)
Alexandria Engineering J.     Open Access   (Followers: 1, SJR: 0.604, CiteScore: 3)
Alexandria J. of Medicine     Open Access   (Followers: 1, SJR: 0.191, CiteScore: 1)
Algal Research     Partially Free   (Followers: 11, SJR: 1.142, CiteScore: 4)
Alkaloids: Chemical and Biological Perspectives     Full-text available via subscription   (Followers: 2)
Allergologia et Immunopathologia     Full-text available via subscription   (Followers: 1, SJR: 0.504, CiteScore: 1)
Allergology Intl.     Open Access   (Followers: 5, SJR: 1.148, CiteScore: 2)
Alpha Omegan     Full-text available via subscription   (SJR: 3.521, CiteScore: 6)
ALTER - European J. of Disability Research / Revue Européenne de Recherche sur le Handicap     Full-text available via subscription   (Followers: 9, SJR: 0.201, CiteScore: 1)
Alzheimer's & Dementia     Hybrid Journal   (Followers: 51, SJR: 4.66, CiteScore: 10)
Alzheimer's & Dementia: Diagnosis, Assessment & Disease Monitoring     Open Access   (Followers: 4, SJR: 1.796, CiteScore: 4)
Alzheimer's & Dementia: Translational Research & Clinical Interventions     Open Access   (Followers: 4, SJR: 1.108, CiteScore: 3)
Ambulatory Pediatrics     Hybrid Journal   (Followers: 6)
American Heart J.     Hybrid Journal   (Followers: 50, SJR: 3.267, CiteScore: 4)
American J. of Cardiology     Hybrid Journal   (Followers: 54, SJR: 1.93, CiteScore: 3)
American J. of Emergency Medicine     Hybrid Journal   (Followers: 45, SJR: 0.604, CiteScore: 1)
American J. of Geriatric Pharmacotherapy     Full-text available via subscription   (Followers: 10)
American J. of Geriatric Psychiatry     Hybrid Journal   (Followers: 14, SJR: 1.524, CiteScore: 3)
American J. of Human Genetics     Hybrid Journal   (Followers: 34, SJR: 7.45, CiteScore: 8)
American J. of Infection Control     Hybrid Journal   (Followers: 28, SJR: 1.062, CiteScore: 2)
American J. of Kidney Diseases     Hybrid Journal   (Followers: 35, SJR: 2.973, CiteScore: 4)
American J. of Medicine     Hybrid Journal   (Followers: 47)
American J. of Medicine Supplements     Full-text available via subscription   (Followers: 3, SJR: 1.967, CiteScore: 2)
American J. of Obstetrics and Gynecology     Hybrid Journal   (Followers: 215, SJR: 2.7, CiteScore: 4)
American J. of Ophthalmology     Hybrid Journal   (Followers: 66, SJR: 3.184, CiteScore: 4)
American J. of Ophthalmology Case Reports     Open Access   (Followers: 5, SJR: 0.265, CiteScore: 0)
American J. of Orthodontics and Dentofacial Orthopedics     Full-text available via subscription   (Followers: 6, SJR: 1.289, CiteScore: 1)
American J. of Otolaryngology     Hybrid Journal   (Followers: 25, SJR: 0.59, CiteScore: 1)
American J. of Pathology     Hybrid Journal   (Followers: 28, SJR: 2.139, CiteScore: 4)
American J. of Preventive Medicine     Hybrid Journal   (Followers: 28, SJR: 2.164, CiteScore: 4)
American J. of Surgery     Hybrid Journal   (Followers: 38, SJR: 1.141, CiteScore: 2)
American J. of the Medical Sciences     Hybrid Journal   (Followers: 12, SJR: 0.767, CiteScore: 1)
Ampersand : An Intl. J. of General and Applied Linguistics     Open Access   (Followers: 7)
Anaerobe     Hybrid Journal   (Followers: 4, SJR: 1.144, CiteScore: 3)
Anaesthesia & Intensive Care Medicine     Full-text available via subscription   (Followers: 62, SJR: 0.138, CiteScore: 0)
Anaesthesia Critical Care & Pain Medicine     Full-text available via subscription   (Followers: 17, SJR: 0.411, CiteScore: 1)
Anales de Cirugia Vascular     Full-text available via subscription  
Anales de Pediatría     Full-text available via subscription   (Followers: 3, SJR: 0.277, CiteScore: 0)
Anales de Pediatría (English Edition)     Full-text available via subscription  
Anales de Pediatría Continuada     Full-text available via subscription  
Analytic Methods in Accident Research     Hybrid Journal   (Followers: 5, SJR: 4.849, CiteScore: 10)
Analytica Chimica Acta     Hybrid Journal   (Followers: 42, SJR: 1.512, CiteScore: 5)
Analytical Biochemistry     Hybrid Journal   (Followers: 180, SJR: 0.633, CiteScore: 2)
Analytical Chemistry Research     Open Access   (Followers: 12, SJR: 0.411, CiteScore: 2)
Analytical Spectroscopy Library     Full-text available via subscription   (Followers: 11)
Anesthésie & Réanimation     Full-text available via subscription   (Followers: 2)
Anesthesiology Clinics     Full-text available via subscription   (Followers: 23, SJR: 0.683, CiteScore: 2)
Angiología     Full-text available via subscription   (SJR: 0.121, CiteScore: 0)
Angiologia e Cirurgia Vascular     Open Access   (Followers: 1, SJR: 0.111, CiteScore: 0)
Animal Behaviour     Hybrid Journal   (Followers: 201, SJR: 1.58, CiteScore: 3)

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Journal Cover
Academic Pediatrics
Journal Prestige (SJR): 1.655
Citation Impact (citeScore): 2
Number of Followers: 34  
 
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 1876-2859
Published by Elsevier Homepage  [3155 journals]
  • Community Resource Needs Assessment Among Families Presenting to a
           Pediatric Emergency Department
    • Abstract: Publication date: Available online 22 November 2018Source: Academic PediatricsAuthor(s): Janet E. Semple-Hess, Phung K. Pham, Samuel A. Cohen, Danica B. Liberman ObjectiveTo identify community resource needs among families presenting to a pediatric emergency department (PED).MethodsA convenience sample of English and Spanish-speaking caregivers residing in Los Angeles County who presented to the PED of a large urban children's hospital were surveyed. The needs assessment survey assessed demographics, food insecurity, and previous and anticipated need for 12 common community resources.ResultsOf 768 caregivers who completed the survey, 75% identified as Hispanic/Latinx. Across all survey participants, 83% used at least one resource in the past, and 67% anticipated needing at least one resource in the next 12 months. Low cost/free health clinics were the most common resources used in the past and needed for the future. Caregivers with younger children tended to need baby formula/breastfeeding and women's health resources, while caregivers with older children tended to need safe housing, subsidized utilities, and counseling/therapy. Many families who needed resources in the past and for the future resided south of the children's hospital, where median household income was relatively lower than in other areas of the county. A pattern of heightened use emerged among caregivers who primarily spoke Spanish. On average, caregivers reported feeling comfortable approaching hospital staff about community resources.ConclusionsWe found significant needs for community resources among families who presented to an urban PED. Needs were particularly salient among Spanish-speaking families and families living in close proximity to the children's hospital. Findings from this study help to inform future work connecting families to community resources.
       
  • Development of a brief screening tool for Early Literacy Skills in
           Preschool Children
    • Abstract: Publication date: Available online 16 November 2018Source: Academic PediatricsAuthor(s): Sai Iyer, Diana Do, Natacha Akshoomoff, Vanessa L. Malcarne, Kate Hattrup, Susan P. Berger, Sheila Gahagan, Robert Needlman BackgroundPreschool children develop early literacy skills (ELS) needed for reading acquisition. Screening for delayed ELS could trigger interventions to prevent reading problems.ObjectiveTo develop a brief screening test for ELS delays, the Early Literacy Skills Assessment Tool (ELSAT).MethodsThis study included 4-year-old typically-developing, English language predominant children attending preschool. The ELSAT comprised 63 items relating to three main ELS domains and was piloted with 21 children. After excluding items that were non-discriminatory, 57 items remained and were administered to 96 children. Items were compared with reference measures of ELS (Get Ready to Read – Revised), and language (Peabody Picture Vocabulary Test-4 and Phonological Awareness from the Comprehensive Test of Phonological Processing-2). Within-domain reliability was calculated for each of the three ELS domains and item correlations between all ELSAT items and the reference measures were calculated.ResultsA final set of 10 items was retained that represented all three ELS domains and that maximized correlations with reference measures. Cronbach's alpha for the refined 10-item ELSAT was 0.868; correlations between individual items and a composite of the reference measures ranged from 0.409 to 0.617 (all ps < .01). In a receiver operating characteristic (ROC) curve analysis, a cut-off score of
       
  • Development and pilot testing of a coping kit for parents of hospitalized
           children
    • Abstract: Publication date: Available online 8 November 2018Source: Academic PediatricsAuthor(s): Douglas L. Hill, Karen W. Carroll, KJG Snyder, Maria Mascarenhas, Jessi Erlichman, Chavis A. Patterson, Lamia P. Barakat, Chris Feudtner ObjectiveSerious pediatric illness places great stress on families. Parents who learn coping skills may better manage these stressors. This study sought to develop and refine a stress coping intervention for parents of hospitalized children, assess the intervention acceptability among these parents, and gather preliminary data on stress, negative and positive affect, anxiety, depression, and self-efficacy.MethodsWe conducted an observational study in 2 phases, enrolling parents of children who were inpatients with serious illness, 10 in Phase 1 and 40 in Phase 2. All parents completed at baseline measures of stress and psychological well-being and were introduced to the Coping Kit for Parents. Follow-up interviews were conducted at one week (all parents) and one month (Phase 2 parents only) regarding the acceptability of the intervention.ResultsAt baseline, parents reported that stressful situations were frequent (mean=30.6, SD=6.8) and difficult (mean=26.2, SD=7.1), and revealed elevated levels of negative affect (mean=27.3, SD=7.7), depression (mean=8.5, SD=3.7) and anxiety (mean=11.3, SD=3.1), and moderate levels of self-efficacy related to their child's illness (mean=3.3, SD=0.5). The majority of parents used the kit regularly and on a scale of 1 to 7 agreed that the kit was helpful (mean=6.0, SD=0.9), interesting (mean=5.7, SD=1.3), practical (mean=5.7, SD=1.4), enjoyable (mean=6.0, SD=1.3), and they would recommend it to other parents (mean=6.4, SD=0.9).ConclusionsThe Coping Kit for Parents is an acceptable stress management intervention that could be made available to parents of children with serious illness at pediatric hospitals with minimal staff training or time commitment.
       
  • Presence of small screens in bedrooms is associated with shorter sleep
           duration and later bedtimes in children with obesity
    • Abstract: Publication date: Available online 8 November 2018Source: Academic PediatricsAuthor(s): Michael P. Duggan, Elsie M. Taveras, Monica W. Gerber, Christine M. Horan, Nicolas M. Oreskovic BackgroundThe presence of small screens in the sleep environment has been associated with shorter sleep duration and later bedtimes in children of normal weight, but the role these devices play in the sleep environment of overweight children is unclear.ObjectiveTo examine the association of small screen presence in the sleep environment with sleep behaviors among school-age children with obesity.MethodsWe surveyed 526 parents of children ages 6-12 years old with a body mass index (BMI) ≥ 95th percentile who were participating in a randomized trial to treat childhood obesity. Twelve months after enrollment, parents were asked how frequently their child slept with or near a small screen (defined as a cellphone, smartphone, or texting/chat-capable device). We used multivariable linear regression to examine associations of the presence of small screens with sleep duration, waketime, and bedtime.ResultsCompared to children who rarely/never slept with a small screen in their bedroom, children who did so one day or more per week had shorter sleep durations and later bedtimes. After adjusting for TV presence in the bedroom, small screen presence was still associated with shorter sleep duration (-9.9 minutes; p=0.02) and later weekday (8.8 minutes; p=0.03) and weekend (12.0 minutes; p=0.03) bedtimes.ConclusionChildren with obesity and a small screen present in their sleep environment have shorter sleep durations and later bedtimes than children who rarely/never sleep with a small screen. Pediatricians should consider inquiring about small screens in the bedroom when counseling on healthy sleep and weight management habits.
       
  • Constipation-Related Emergency Department Use, and Associated Office
           Visits and Payments Among Commercially Insured Children
    • Abstract: Publication date: November–December 2018Source: Academic Pediatrics, Volume 18, Issue 8Author(s): Claire A. MacGeorge, Kit N. Simpson, William T. Basco, David G. Bundy ObjectivePediatric constipation is common, costly, and often managed in the Emergency Department (ED). The objectives of this study were to determine the frequency of constipation-related ED visits in a large commercially insured population, the frequency of an office visit in the month before and after these visits, demographic characteristics associated with these office visits, and the ED-associated payments.MethodsData were extracted from the Truven MarketScan database for commercially insured children from 2012 to 2013. Data on the presence and timing of clinic visits within 30 days before and after an ED constipation visit and demographic variables were extracted. Logistic regression was used to predict an outcome of presence of a visit with independent variables of age, sex, and region of the country.ResultsIn a population of 17 million children aged 0 to 17 years, 448,440 (2.6%) were identified with constipation in at least 1 setting, with 65,163 (14.5%) having an ED visit for constipation. Of all children with a constipation-related ED visit, 45% had no office visit in the 30 days before or after the ED visit. Increasing age was associated with absence of an office visit. The median payment by insurance for an ED constipation visit was $523, the median out-of-pocket payment was $100, for a total of $623 per visit.ConclusionOne in 7 children with constipation in this commercially insured population received ED care for constipation, many without an outpatient visit in the month before or after. Efforts to improve primary care utilization for this condition should be encouraged.
       
  • Impact of Presence of Children on Indoor Tobacco Restrictions in
           Households of Urban and Rural Adult Tobacco Users
    • Abstract: Publication date: November–December 2018Source: Academic Pediatrics, Volume 18, Issue 8Author(s): Benjamin T. Kopp, Alice Hinton, Rong Lu, Sarah Cooper, Haikady Nagaraja, Mary Ellen Wewers ObjectivesSecondhand smoke exposure in children is changing as a result of 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 noncombustible product use.MethodsA 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 according to combustible or noncombustible product use and the presence of indoor tobacco use restrictions. Multiple logistic regression determined factors associated with indoor tobacco restrictions.ResultsA total of 1210 tobacco users participated, including 25.7% with children living in the home. Half allowed combustible and two thirds allowed noncombustible tobacco use indoors. Urban location (odds ratio [OR] = 1.58), younger age (OR = 0.88 per 5 year), male sex (OR = 1.40), college education (OR = 1.40), household income of more than $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 years), and nonwhite race (OR = 1.68) were associated with a higher likelihood of banning noncombustible products indoors. Combustible (OR = 4.54) and e-cigarette (OR = 3.04) users were more likely than SLT users to have indoor bans.ConclusionsIndoor restrictions on tobacco use remain infrequent in homes with children and are associated with user type and socioeconomic factors. Public policy should target modifiable risk factors for in-home secondhand smoke exposure.
       
  • Family Caregiver Marginalization is Associated With Decreased Primary and
           Subspecialty Asthma Care in Head Start Children
    • Abstract: Publication date: November–December 2018Source: Academic Pediatrics, Volume 18, Issue 8Author(s): S. Christy Sadreameli, Kristin A. Riekert, Elizabeth C. Matsui, Cynthia S. Rand, Michelle N. Eakin BackgroundUrban minority children are at risk for poor asthma outcomes and might not receive appropriate primary or subspecialty care. We hypothesized that preschool children with asthma whose caregivers reported more barriers to care would be less likely to have seen their primary care provider (PCP) or an asthma subspecialist and more likely to have had a recent emergency department (ED) visit for asthma.MethodsThe Barriers to Care Questionnaire (BCQ) is used to measure expectations, knowledge, marginalization, pragmatics, and skills. We assessed asthma control using the Test for Respiratory and Asthma Control in Kids and these outcomes: PCP visits for asthma in the past 6 months, subspecialty care (allergist or pulmonologist) in the past 2 years, and ED visits in the past 3 months.ResultsThree hundred ninety-five caregivers (96% African-American, 82% low-income, 96% Medicaid) completed the BCQ. Sixty percent (n = 236) of children had uncontrolled asthma, 86% had seen a PCP, 23% had seen a subspecialist, and 29% had an ED visit. Barriers related to marginalization were associated with decreased likelihood of PCP (odds ratio [OR], 0.95; P = .014) and subspecialty visits (OR, 0.92; P = .019). Overall BCQ score was associated with decreased likelihood of subspecialty care (OR, 0.98; P = .027). Barriers related to expectations, knowledge, pragmatics, and skills were not associated with any of the care outcomes.ConclusionsAmong low-income, predominantly African-American preschool children with asthma, primary and subspecialty care were less likely if caregivers reported past negative experiences with the health care system (marginalization). Clinicians who serve at-risk populations should be sensitive to families' past experiences and should consider designing interventions to target the most commonly reported barriers.
       
  • Prenatal Material Hardships and Infant Regulatory Capacity at 10 Months
           Old in Low-Income Hispanic Mother-Infant Pairs
    • Abstract: Publication date: November–December 2018Source: Academic Pediatrics, Volume 18, Issue 8Author(s): Anne Fuller, Mary Jo Messito, Alan L. Mendelsohn, Suzette O. Oyeku, Rachel S. Gross ObjectivePrenatal maternal stresses have been associated with infant temperament patterns linked to later behavioral difficulties. Material hardships, defined as inability to meet basic needs, are important prenatal stressors. Our objective was to determine the associations between prenatal material hardships and infant temperament at 10 months.MethodsThis was a longitudinal study of mother-infant pairs in a randomized controlled trial of a primary care-based early obesity prevention program (Starting Early). Independent variables representing material hardship were: housing disrepair, food insecurity, difficulty paying bills, and neighborhood stress (neighborhood safety). Dependent variables representing infant temperament were assessed using questions from 3 subscales of the Infant Behavior Questionnaire: orienting/regulatory capacity, negative affect, and surgency/extraversion. We used linear regression to investigate associations between individual and cumulative hardships and each temperament domain, adjusting for confounders, and testing for depression as a moderator.ResultsFour hundred twelve mother-infant pairs completed 10-month assessments. Thirty-two percent reported food insecurity, 26% difficulty paying bills, 35% housing disrepair, and 9% neighborhood stress. In adjusted analyses, food insecurity was associated with lower orienting/regulatory capacity scores (β = −0.25; 95% confidence interval [CI], −0.47 to −0.04), as were neighborhood stress (β = −0.50; 95% CI, −0.83 to −0.16) and experiencing 3 to 4 hardships (compared with none; β = −0.54; 95% CI, −0.83 to −0.21). For neighborhood stress, the association was stronger among infants of mothers with prenatal depressive symptoms (interaction term P = .06).ConclusionPrenatal material hardships were associated with lower orienting/regulatory capacity. These findings support the need for further research exploring how temperament relates to child behavior, and for policies to reduce prenatal material hardships.
       
  • ACADEMIC PEDIATRICS: Subject Index to Volume 18
    • Abstract: Publication date: November–December 2018Source: Academic Pediatrics, Volume 18, Issue 8Author(s):
       
  • A Clinical Vignette–Based Study of Physicians’ Adherence to Guidelines
           for Dental Referrals of Young Children
    • Abstract: Publication date: Available online 22 October 2018Source: Academic PediatricsAuthor(s): Ye Zhu, Kelly Close, Leslie Zeldin, Rocio B. Quinonez, B. Alexander White, R. Gary Rozier ObjectivesThe American Academy of Pediatrics (AAP) recommends an oral health risk assessment and referral to a dental home by a child's first birthday. We evaluated the adherence of primary care providers (PCPs) to AAP dental referral guidelines for children age
       
  • Implementing Emotional Debriefing in Pediatric Clinical Education
    • Abstract: Publication date: Available online 18 October 2018Source: Academic PediatricsAuthor(s): Amanda D. Osta, Marta A. King, Janet R. Serwint, Susan B. Bostwick Challenging situations and intense emotions are inherent to clinical practice. Failure to address these emotions has been associated with health care provider burnout. One way to combat this burnout and increase resilience is participation in emotional debriefing. Although there are many models of emotional debriefing, these are not commonly performed in clinical practice. We provide a guide for implementing emotional debriefing training, utilizing the AAP Resilience Curriculum, into clinical training programs with a focus on preparing senior residents and fellows to act as debriefing facilitators. Senior residents and fellows can provide “in the moment” emotional debriefing which allows for more health care provider participation, including medical students and other pediatric trainees. Training of senior residents and fellows may allow more frequent emotional debriefing, and in turn may help to improve the resilience of pediatricians when facing challenging situations in clinical practice.
       
  • Psychometric properties of two developmental screening instruments for
           Hispanic Children in the Philadelphia Region
    • Abstract: Publication date: Available online 10 October 2018Source: Academic PediatricsAuthor(s): Marsha Gerdes, J. Felipe Garcia-Espana, David Webb, Karen Friedman, Sherry Winston, Jennifer Culhane OBJECTIVETo assess the validity of Spanish versions of the Survey of Well-being of Young Children (SWYC) Milestones and the Ages and Stages Questionnaire (ASQ-3) and to document the rates of developmental delays in an urban cohort of children with Hispanic parents.METHODSSpanish speaking families with a child 9 to 60 months of age (n = 991) were initially screened using Spanish translations of the SWYC Milestones and the ASQ-3. A stratified random sample of 494 of these children subsequently received standardized clinical assessment to confirm the presence of developmental delays. Reverse weighting corrected for the selection bias inherent in the stratification scheme.RESULTS55% of toddlers (9 to 41 months of age) and 34.8% of preschoolers (42 to 60 months of age) scored in the moderately to severely delayed range, most frequently in language. Sensitivity and specificity for toddlers with severe delays associated with the SWYC were .69 and .64, respectively, and .55 and .75 for the ASQ-3. Sensitivity and specificity for preschoolers with severe delays associated with the SWYC were .87 and .58, respectively, and .71 and .86 for the ASQ-3.CONCLUSIONSWhile psychometric properties of the Spanish translated versions are not as strong as the English versions, the findings suggest that both the SWYC milestones and ASQ-3 represent promising tools for identifying Hispanic children with developmental delays. The rate of delays were consistent with other studies showing a high percentage of Hispanic children with developmental delays, most frequently in language skills.
       
  • Mental Health Conditions and Healthcare Payments for Children with Chronic
           Medical Conditions
    • Abstract: Publication date: Available online 10 October 2018Source: Academic PediatricsAuthor(s): James M. Perrin, Joan Rosenbaum Asarnow, Terry Stancin, Stephen P. Melek, Gregory K. Fritz ObjectiveTo estimate additional payments associated with co-existing mental health or substance use disorders (MH/SUD) among commercially-insured children and youth with chronic medical conditions (CMC). To determine whether children's MH/SUD have similar associations with parental health care payments.MethodCross-sectional analysis of a national database of paid commercial insurance claims for 2012-13. Participants were children/youth ages 0-26 years covered as dependents on parents’ health insurance and categorized by presence or absence of any of 11 chronic medical conditions and MH/SUD. We determined numbers of children/youth with CMC and paid health care claims categorized as hospital, professional, and pharmacy services, and as medical or behavioral. We compared paid claims for children and youth with CMC with and without co-occurring MH/SUD and for their parents.ResultsThe sample included almost 6.6 million children and youth and 5.8 million parents. Compared to children without CMC, children with CMC had higher costs, even higher when children with CMC had MH/SUDs. Children with CMC and co-occurring MH/SUD had 2.4X the annual payments of those with chronic conditions alone, especially for medical expenses. Estimated additional annual payments associated with MH/SUD in children with CMC were $8.8 billion. Parents of children with CMC and associated MH/SUD had payments 59% higher than payments for parents of children with CMC alone.ConclusionMH/SUD in children/youth with CMC are associated with higher total healthcare payments for both patients and their parents, suggesting potential benefits from preventing or reducing the impact of MH/SUD among children and youth with CMC.
       
  • Applying Self-Determination Theory to Redesign an Inpatient Care Team
    • Abstract: Publication date: Available online 9 October 2018Source: Academic PediatricsAuthor(s): Kelsey A. Miller, Debra Hillier, Christiana Russ, Marcella Luercio, Ariel S. Winn
       
  • Satisfaction, Salaries and Sustainability: Results of a National Survey of
           Pediatric Program Directors
    • Abstract: Publication date: Available online 2 October 2018Source: Academic PediatricsAuthor(s): Adam Pallant, Sharon M. Hudson, Eyal Ben-Isaac ObjectivesDescribe the career and work environment of pediatric program directors (PDs) and associated factors, including salary disparities and long-term career plans.MethodsA national, anonymous, electronic survey was sent to all categorical residency PD members of the Association of Pediatric Program Directors (APPD). Surveys assessed PD demographics, characteristics of the residency program and the PDs’ positions (including salary), and measures of satisfaction. Chi-square and Fisher's exact test were used to analyze results.Results149 PDs (74%) responded. Significantly more men earned $250,000 or more annually (26.9% versus 6.1% of women), and gender remained a significant independent predictor of salary after controlling for age, academic rank and subspecialty. Satisfaction was high for most measures, although 20% or more reported low satisfaction with pay (38.9%), administrative workload (32.1%), managing accreditation and ACGME expectations (31.9%), resources (27.9%), work/life balance (24.1%), and being valued by administration (20.0%). Only 34.3% saw the PD position as an end goal, and 29.5% stated they would be in their current position in 5 years. Satisfaction with the PD career, with faculty relationships, with resident performance, and with administrative workload were associated with plans to remain.ConclusionsMost Pediatric Program Directors did not view the position of PD as their long-term career goal, and many identified administrative duties and work/life balance contributing to significant dissatisfaction. Without changes to address these issues, PD turnover may be high, with potential negative implications for the success of training programs.
       
  • Update on how School Environments, Social Networks, and Self-Concept
           impact Risky Health Behaviors
    • Abstract: Publication date: Available online 2 October 2018Source: Academic PediatricsAuthor(s): Rebecca N. Dudovitz, Mitchell D. Wong, Giselle Perez-Aguilar, Grace Kim, Paul J. Chung
       
  • Child Abuse and Neglect Risk Assessment: Quality Improvement in a Primary
           Care Setting
    • Abstract: Publication date: Available online 29 September 2018Source: Academic PediatricsAuthor(s): Esther K. Chung, Ruth S. Gubernick, Marianna LaNoue, Diane J. Abatemarco ObjectivesPracticing Safety™ (PS) is an AAP toolkit to help practices address child abuse and neglect (CAN) risk by increasing screening and providing resources. The objectives, in an urban practice serving low-income children, were to 1) standardize CAN risk assessment and developmental screening and 2) improve resource provision.MethodsA quality improvement (QI) initiative to standardize CAN risk assessment, using materials adapted from PS (aPS) was conducted through the use of “SmartTools” in an electronic health record (EHR). The Edinburgh Postnatal Depression Scale and Parents Evaluation of Developmental Status were used to assess maternal depression and child development, respectively. Charts were reviewed in waves: pre-, immediate post-, and early post-implementation (waves 1-3), monthly for six months (waves 4-9), then quarterly for 12 months (waves 10-13) to assess screening and resource provision for six domains: infant crying, maternal depression, development, discipline, temper tantrums, and toilet training.ResultsA total of 581 charts were reviewed (waves 1-3: 92, 95, 94, respectively; waves 4-13: 30 each). Screening for infant crying, maternal depression, development, and discipline rose from 0% pre- to over 50% post-implementation. Screening for temper tantrums and toilet training rose from 6% to 72% and 36% to 82%, respectively. For all measures, resource provision improved over time, and all improvements were maintained for 1.5 years post-implementation.ConclusionsIncorporating aPS into an EHR is a practical and effective approach to improving CAN risk assessment and resource provision. This QI initiative is an example of a practice-wide improvement that resulted in clinical practice change.
       
  • Creation and validation of tool to assess resident competence in neonatal
           resuscitation
    • Abstract: Publication date: Available online 28 September 2018Source: Academic PediatricsAuthor(s): Sara K. Kane, Diane E. LorantABSTRACTBackgroundThe American Board of Pediatrics requires that pediatricians be able to initiate stabilization of a newborn. After residency, 45% of general pediatricians routinely attend deliveries. However, there is no standard approach or tool to measure resident proficiency in newborn resuscitation across training programs. In a national survey, we found a large variability in faculty assessment of the amount of supervision trainees need for various resuscitation scenarios. Objective documentation of trainee performance would permit competency-based decisions on the level of supervision required and facilitate feedback on trainee performance.MethodsA simplified tool was created following the Neonatal Resuscitation Program (NRP) algorithm, with emphasis on communication, leadership, knowledge of equipment, and initial stabilization. To achieve content validity, the tool was evaluated by the NRP steering committee. To assess internal structure of the tool, we filmed 10 simulated resuscitation scenarios 9 of which contained errors. Experienced resuscitation team members used the tool to assess performance of the team leader in the videos. To evaluate the response process, the tool was used to assess experienced resuscitators in real time at academic and non-academic sites.ResultsThe NRP steering committee approved the tool, providing evidence of content validity. Performance of the team leader in the simulated videos was assessed by 16 evaluators using the tool. There was an intra-class coefficient of 0.86 showing excellent agreement. There was no statistical difference in scores between 102 resuscitations led by experienced resuscitators at academic and non-academic hospitals (p=0.98), which demonstrates generalizability.ConclusionsThe tool we have developed to assess performance in initiating newborn resuscitation shows evidence of construct validity based on assessment of content and internal structure (inter-observer agreement, response processes, and generalizability).
       
  • Developing Resident Sensitive Quality Measures: Engaging Stakeholders to
           Inform Next Steps
    • Abstract: Publication date: Available online 27 September 2018Source: Academic PediatricsAuthor(s): Daniel J. Schumacher, Abigail Martini, Eric Holmboe, Kartik Varadarajan, Jamiu Busari, Cees van der Vleuten, Carol Carraccio ObjectiveDespite the need for quality measures relevant to the work residents complete, few attempts have sought to address this gap. Resident sensitive quality measures (RSQMs) can help fill this void. This study engaged resident and supervisor stakeholders to develop and inform next steps in creating such measures.MethodsTwo separate nominal group techniques (NGT), one with residents and one with faculty and fellow supervisors, were used to generate RSQMs for three specific illnesses (asthma, bronchiolitis, closed head injury) as well as general care for the pediatric emergency department (PED). Two separate Delphi processes were then used to prioritize identified RSQMs. The measures produced by each group were compared side-by-side, illuminating similarities and differences that were explored through focus groups with residents and supervisors. These focus groups also probed future settings in which to develop RSQMs.ResultsIn the NGT and Delphi groups, residents and supervisors placed considerable focus on measures in three areas across the illnesses of interest: 1) appropriate medication dosing, 2) documentation, and 3) information provided at patient discharge. Focus groups highlighted hospital medicine and general pediatrics as priority areas for developing future RSQMs but also noted contextual variables that influence the application of similar measures in different settings. Residents and supervisors had both similar as well as unique insights into developing RSQMs.DiscussionThis study continues to pave the path forward in developing future RSQMs by exploring specific settings, measures, and stakeholders to consider when undertaking this work.
       
  • Differences in febrile and respiratory illnesses in minority children: The
           sociodemographic context of restrictive parenting
    • Abstract: Publication date: Available online 27 September 2018Source: Academic PediatricsAuthor(s): Danielle S. Roubinov, Nicole R. Bush, Nancy Adler, W. Thomas Boyce ObjectiveTo examine the moderating role of restrictive parenting on the relation of socioeconomic status (SES) to febrile illnesses (FI) and upper respiratory illnesses (URI) among ethnic minority and non-minority children.MethodsChildren from diverse ethnic backgrounds (Caucasian, African American, Asian, Latino, Other, or Multiethnic) were followed across the course of the kindergarten year. Parents reported on SES and parenting. A nurse completed 13 physical exams per child over the year to assess FIs and URIs.ResultsDuring the school year, 28% of children (n = 199, 56% ethnic minority) exhibited one or more FIs (Range 0-6) and 90% exhibited one or more URIs (Range 0-10). No main or moderating effects of SES or restrictive parenting on FIs or URIs were found among Caucasian children. However, among ethnic minority children, the relation of SES to FIs was conditional upon restrictive parenting (b = .66, p = .02): the fewest FIs were found for lower SES, minority children whose parents reported more restrictive practices. Additionally, in minority children, more restrictive parenting was marginally associated with fewer URIs (b = -.21, p = .05).ConclusionsUnexpectedly among minority children, the fewest illnesses occurred among lower SES children whose parents endorsed more restrictive parenting. This may be due to unique appraisals of this rearing style among minority children in lower SES environments and its potential to influence immune functioning. Results suggest variability in the effects of parenting on offspring health and support context-specific evaluations of parenting in efforts to ameliorate early health disparities.
       
  • A Hand to Hold
    • Abstract: Publication date: Available online 25 September 2018Source: Academic PediatricsAuthor(s): Sumeet L. Banker
       
  • Parental Feeding Beliefs and Practices and Household Food Insecurity in
           Infancy
    • Abstract: Publication date: Available online 21 September 2018Source: Academic PediatricsAuthor(s): Colin J Orr, Maureen Ben-Davies, Sophie N. Ravanbakht, H. Shonna Yin, Lee M Sanders, Russell L. Rothman, Alan M. Delamater, Charles T. Wood, Eliana M Perrin ObjectiveFood insecurity is associated with childhood obesity possibly mediated through caregiver feeding practices and beliefs. We examined if caregiver feeding practices differed by household food security status in a diverse sample of infants. We hypothesize feeding practices differ based on food security status.Patients and MethodsBaseline cross-sectional analysis of data from a randomized controlled trial to prevent obesity. Included in the analysis was 842 caregivers of 2-month-old infants presenting for well-child care at 4 academic institutions. Food insecurity exposure was based on an affirmative answer to one of two items in a 2-item validated questionnaire. Chi-square tests examined the association between parent feeding practices and food security status. Logistic regression adjusted for covariates. Differences in caregiver feeding practices by food security status and race/ethnicity were explored with an interaction term (food security status x race/ethnicity).Results43% of families screened as food insecure. In adjusted logistic regression, parents from food-insecure households were more likely to endorse that “the best way to make an infant stop crying is to feed him/her” (aOR: 1.72, 95% CI: 1.28-2.29); and “When my baby cries, I immediately feed him/her” (aOR: 1.40, 95%CI: 1.06-1.83). Food insecure caregivers less frequently endorsed paying attention to their baby when s/he is full or hungry (OR 0.57 95%CI: 0.34-0.96). Racial/ethnic differences in beliefs and behaviors were observed by food security status.ConclusionsDuring early infancy, feeding practices differed among caregivers by household food security status. Further research is needed to examine whether these practices are associated with increased risk of obesity and obesity-related morbidity.
       
  • Parental optimism about children's risk of future tobacco use and
           excessive weight gain
    • Abstract: Publication date: Available online 21 September 2018Source: Academic PediatricsAuthor(s): Olivier Drouin, Jonathan P. Winickoff, Anne N. Thorndike BackgroundAdults tend to underestimate their personal risk of disease, but little is known about parents’ perceptions of children's risk.Methods648 parents of children 0-18 years old attending two pediatric practices were surveyed about their children's exposure to smoking; 344 parents with children ≥ 2 years old were also asked about their children's sugar-sweetened beverage (SSB) consumption and physical activity. Children were categorized as “at risk” or “not at risk” for each factor. Parents estimated the risk of their child becoming a smoker or gaining excessive weight, and were categorized as “optimistic” if they believed their children were less likely than others to use tobacco or gain weight.ResultsOverall, 92% of parents thought their children were at lower risk than average for tobacco use, and 86% believed their children were at lower risk for excessive weight gain. A high frequency of optimistic bias occurred even among parents with “at risk” children, including parents with children exposed to tobacco use (70.4%), SSB consumption (77.6%),>2 hours of screen time (82.1%), and low physical activity (84.1%). In multivariable analyses, parents with children exposed to tobacco smoke (OR 0.51, 95% C.I.: 0.09-0.49); or who consumed SSBs daily (OR 0.44, 95% C.I.:0.20-0.97) were less likely to be optimistic about their child's future tobacco use and excessive weight gain respectively.ConclusionsMost parents believed their children were at lower risk than average for tobacco use or excessive weight gain. Eliciting parents’ optimistic biases might facilitate behavior change counseling in pediatric settings.
       
  • Intimate Partner Relationships, Work-Life Factors, and their Associations
           With Burnout Among Partnered Pediatric Residents
    • Abstract: Publication date: Available online 13 September 2018Source: Academic PediatricsAuthor(s): Selin Tuysuzoglu Sagalowsky, Angela M. Feraco, Tamara E. Baer, Heather J. Litman, David N Williams, Robert J. Vinci BackgroundBurnout is prevalent among pediatric residents, and reducing burnout is a priority for pediatric residency programs. Understanding residents’ personal circumstances, including relationship satisfaction and perceived work-life conflict, may identify novel determinants of burnout.ObjectivesTo describe intimate partner relationships among pediatric residents and examine associations among relationship satisfaction, work-life factors, and burnout.MethodsWe identified 203 partnered residents (married or in a self-identified committed, ongoing relationship) from a cross-sectional survey of 258 residents in 11 New England pediatric programs (response rate 54% of 486 surveys distributed), conducted from April through June of 2013. We analyzed associations among relationship satisfaction, work-life factors, and burnout using multivariable regression. Burnout was measured with the brief Maslach Burnout Inventory, and relationship satisfaction with the validated Relationship Assessment Scale.Results40.9% of partnered respondents endorsed burnout. The vast majority of partnered residents (n=167; 85.2%) reported high relationship satisfaction. Lower relationship satisfaction was not associated with burnout. Approximately half of respondents (n=102; 51.5 %) reported being satisfied with life as a resident. When controlling for common stressors, such as sleep deprivation, work-life measures associated with burnout included frequent perceived conflicts between personal and professional life (aOR 4.35; 95% CI 1.91, 9.88) and dissatisfaction with life as a resident (aOR 11.74; 95% CI 4.23, 32.57).ConclusionLow relationship satisfaction and common work-life stressors were not associated with burnout among partnered pediatric residents. However, perceived work-life conflict and dissatisfaction with resident life were strongly associated with burnout, and are targets for residency programs seeking to ameliorate burnout.
       
  • Operation Homefront: Meeting Clerkship Competencies with Home Visits to
           Families of Children with Special Needs
    • Abstract: Publication date: Available online 7 September 2018Source: Academic PediatricsAuthor(s): Emily E. Anderson, Bridget Boyd, Nadia K. Qureshi, Jerold M. Stirling, Virginia McCarthy, Mark G. Kuczewski ObjectiveWe assessed how third-year medical students’ written reflections on a home visit experience with families of children with special needs demonstrate evidence of exposure to nine selected competencies for pediatric clerkships designated by the Council on Medical Student Education in Pediatrics (COMSEP).MethodsWe reviewed written reflections from 152 third-year medical students. For each competency (two related to communication were combined), we tabulated the number of reflections in which a given competency was demonstrated. Within each competency, themes are described and presented with exemplary quotes to provide a more robust picture of students’ exposure and experience.ResultsOf 152 reflections, 100% demonstrated at least one of the eight expected competencies. Each reflection exhibited an average of three (3.1) competencies (range: 1-7). The competencies most frequently mentioned were demonstration of respect for patient, parent, and family attitudes, behaviors, and lifestyles (90%) and demonstration of positive attitude toward education (76%). Less frequently mentioned competencies included demonstration of behaviors and attitudes that promote patients’ and families’ best interests (41%); demonstration of effective verbal and non-verbal communication skills (a combination of two communication-related competencies) (33%); and description of barriers that prevent children from accessing health care (37%). The following competencies were least often mentioned: description of a pediatrician's role and responsibility in advocating for patients’ needs (10%), description of the important role of patient education (8%), or description of the types of problems that benefit from a community approach (17%).ConclusionsOur analysis demonstrates that community-based home visits can provide medical students with opportunities to meet required pediatric clerkship competencies.
       
  • Assessing Potential Confounding and Misclassification Bias When Studying
           the Safety of the Childhood Immunization Schedule
    • Abstract: Publication date: September–October 2018Source: Academic Pediatrics, Volume 18, Issue 7Author(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 ObjectivesSome 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 examine the risk of misclassification of vaccination status in electronic health record data, and to assess the potential for confounding if asthma risk factors varied by vaccination status.MethodsA survey was conducted among parents of children 19 to 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 undervaccinated 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.ResultsAmong a survey sample of 2043 parents, 1209 responded (59.2%). For receiving no vaccines, the observed agreement between parent report and electronic health record data was 94.0% (κ = 0.79); for receiving all vaccines with no delays, the observed agreement was 87.3% (κ = 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.ConclusionsMeasurement and control of disease risk factors should be carefully considered in observational studies of the safety of the immunization schedule.
       
  • Financial Analysis of Pediatric Resident Physician Primary Care
           Longitudinal Outpatient Experience
    • Abstract: Publication date: September–October 2018Source: Academic Pediatrics, Volume 18, Issue 7Author(s): Carole H. Stipelman, Brad Poss, Laura Anne Stetson, Luca Boi, Michael Rogers, Caleb Puzey, Sri Koduri, Robert Kaplan, Vivian S. Lee, Edward B. Clark ObjectiveTo determine whether residency training represents a net positive or negative cost to academic medical centers, we analyzed the cost of a residency program and clinical productivity of residents and faculty in an outpatient primary care practice with or without residents.MethodsPatient volume and revenue data (Current Procedural Terminology codes) from an academic primary care general pediatric clinic were evaluated for faculty clinics (faculty only) and resident teaching clinics (longitudinal outpatient experience [LOE]) with 1 to 4 residents per faculty. A detailed cost per resident was determined using a departmental financial model that included salary, benefits, faculty and administrative staff effort, nonpersonnel costs, and institutional graduate medical education support.ResultsThe LOE clinics had a greater mean number of patient visits (11.6 vs 6.8) than faculty clinics per faculty member. In the LOE clinic, the number of patient visits per clinic was directly proportional to the number of residents per faculty. The cost for each resident was $250 per clinic ($112 per resident, $88 per medical assistant per resident, and $50 per room per resident). When factoring in clinic costs and faculty supervision time, the LOE clinics (average 3.5 residents with 1 supervising faculty) had greater average cost (+$687.00) and revenue (+$319.45) and lower operating margin (revenue minus cost, −$367.55) than the faculty clinics (1 faculty member).ConclusionsPediatric resident LOE clinics had a greater average number of patient visits and revenue per faculty member but higher costs and lower operating margins than faculty clinics.
       
  • Early Childhood Media Exposure and Self-Regulation: Bidirectional
           Longitudinal Associations
    • Abstract: Publication date: September–October 2018Source: Academic Pediatrics, Volume 18, Issue 7Author(s): Dylan P. Cliff, Steven J. Howard, Jenny S. Radesky, Jade McNeill, Stewart A. Vella ObjectiveTo investigate: 1) prospective associations between media exposure (television viewing, computers, and electronic games) at 2 years and self-regulation at 4 and 6 years, and 2) bidirectional associations between media exposure and self-regulation at 4 and 6 years. We hypothesized that media exposure and self-regulation would show a negative prospective association and subsequent bidirectional inverse associations.MethodsData from the nationally-representative Longitudinal Study of Australian Children when children were aged 2 years (n = 2786) and 4/6 years (n = 3527) were used. Primary caregivers reported children's weekly electronic media exposure. A composite measure of self-regulation was computed from caregiver-, teacher-, and observer-report data. Associations were examined using linear regression and cross-lagged panel models, accounting for covariates.ResultsLower television viewing and total media exposure at 2 years were associated with higher self-regulation at 4 years (both β = −0.02; 95% confidence interval [CI], −0.03 to −0.01). Lower self-regulation at 4 years was also significantly associated with higher television viewing (β = −0.15; 95% CI, −0.21 to −0.08), electronic game use (β = −0.05; 95% CI, −0.09 to −0.01), and total media exposure (β = −0.19; 95% CI, −0.29 to −0.09) at 6 years. However, media exposure at 4 years was not associated with self-regulation at 6 years.ConclusionsAlthough media exposure duration at 2 years was associated with later self-regulation, and self-regulation at 4 years was associated with later media exposure, associations were of small magnitude. More research is needed to examine content quality, social context, and mobile media use and child self-regulation.
       
  • Workforce Trends and Analysis of Selected Pediatric Subspecialties in the
           United States
    • Abstract: Publication date: September–October 2018Source: Academic Pediatrics, Volume 18, Issue 7Author(s): Mary E. Rimsza, Holly S. Ruch-Ross, Conrad J. Clemens, William B. Moskowitz, Holly J. Mulvey ObjectiveTo update pediatric subspecialty workforce data to support evidence-based legislation and public policy decisions by replicating the American Academy of Pediatrics' 1998 Future of Pediatric Education (FOPE II) workforce survey.MethodsA descriptive and comparative analysis of survey responses from 9950 US pediatric subspecialists who completed an electronic survey.ResultsPediatric subspecialists are working fewer hours and spending less of their time in direct patient care than they did in 1998 but the mean hours worked differs significantly according to subspecialty. Most subspecialists continue to be board-certified, white, non-Hispanic men, although the percentage who are women and from minority groups has increased. The proportion of subspecialists practicing in an academic medical center has increased since 1998. Thirty percent of pediatric subspecialists reported appointment wait times of>2 weeks and pediatric subspecialists in developmental pediatrics, endocrinology, and neurology identified much longer wait times than other subspecialists.ConclusionThe demographic and practice characteristics of pediatric subspecialists have changed since the FOPE II survey and access to subspecialty care in a family's community remains a challenge. However, pediatric subspecialties are not monolithic and solutions to workforce shortages will need to take into account these differences to improve access to subspecialty care.
       
  • Provider and Parent Perspectives on Enhanced Communication Tools for Human
           Papillomavirus Vaccine–Hesitant Parents
    • Abstract: Publication date: September–October 2018Source: Academic Pediatrics, Volume 18, Issue 7Author(s): Steven Lockhart, Amanda F. Dempsey, Jennifer Pyrzanowski, Sean T. O'Leary, Juliana G. Barnard ObjectiveHuman papillomavirus (HPV) vaccine initiation and completion rates remain far below the Healthy People 2020 goal, suggesting that additional tools and training may be needed to help medical staff provide a quality recommendation. As part of a larger pragmatic trial, we conducted a qualitative study to understand how a multifaceted communication intervention used by medical staff with HPV vaccine–hesitant parents can improve HPV vaccination rates in the primary care setting.MethodsAt 8 primary care intervention clinics in the Denver metro area, medical staff and parents of adolescent boys and girls ages 11 to 17 years eligible to start the HPV vaccine series at a recent well care visit were recruited for study participation. Focus groups with medical staff and in-depth interviews with hesitant parents were conducted during the post-intervention period. All data were recorded, transcribed, and analyzed using established qualitative methods.ResultsTwenty parents and 46 medical staff participated. All parents and medical staff felt that the overall intervention was beneficial and should continue to be used and preferred the HPV vaccine fact sheet component. Medical staff reported that communication trainings (intervention component) that taught a presumptive approach and motivational interviewing were the most beneficial for introducing the HPV vaccine and for countering HPV vaccine hesitancy, respectively. Least favorable components were the decision aid, disease images, and parent website.ConclusionsSelect components of a multifaceted communication intervention were seen as beneficial to HPV vaccine-hesitant parents and medical staff. Future studies should look at how to implement these intervention components in a greater number of primary care settings.
       
  • Quality Improvement Initiative to Improve Human Papillomavirus Vaccine
           Initiation at 9 Years of Age
    • Abstract: Publication date: September–October 2018Source: Academic Pediatrics, Volume 18, Issue 7Author(s): Martha J. Goleman, Millie Dolce, Jennifer Morack ObjectiveAdolescent human papillomavirus (HPV) vaccine rates remain low. Early vaccination may improve the efficacy of the vaccine and immunization rates; however, clinicians have not routinely made a strong recommendation for younger adolescents. This study assessed the feasibility of routine vaccination at 9 years of age.MethodsThree sequential quality improvement (QI) interventions were implemented to shift the initiation of the HPV vaccine to 9 years of age in a primary care network in low-income neighborhoods in Columbus, Ohio. The first intervention changed the electronic medical record alert for the HPV vaccine from 11 to 9 years of age and focused on cancer prevention when discussing the vaccine with families. The second intervention was formation of an HPV QI team. The third intervention was a clinic incentive for HPV captured opportunity rates. Immunization rates were monitored using statistical process control charts to compare the HPV immunization rate in a sample of 9- and 10-year-old children with a sample of 11- and 12-year-old children.ResultsThe percentage of patients receiving an HPV vaccine before 11 years increased from 4.6% to 35.7% during the 6 months after the QI initiative began and to 60.8% 18 months after the project began. In comparison, the HPV vaccination rate in the sample of 11- and 12-year-olds increased from 78.7% to 82.8% 18 months later.ConclusionsThis QI project used multiple interventions to increase HPV vaccination at 9 years of age in a large primary care network serving a diverse low-income population.
       
  • Screen-Related Parenting Practices in Low-Income Mexican American Families
    • Abstract: Publication date: September–October 2018Source: Academic Pediatrics, Volume 18, Issue 7Author(s): Darcy A. Thompson, Sarah J. Schmiege, Susan L. Johnson, Elizabeth A. Vandewater, Richard E. Boles, Ruth E. Zambrana, Jerusha Lev, Jeanne M. Tschann ObjectivesTo (1) examine whether the Information–Motivation–Behavioral Skills Model predicts maternal screen-related parenting practices and (2) evaluate the relationship of American Academy of Pediatrics (AAP)–recommended parenting practices with child television (TV) use behaviors.MethodsIn this cross-sectional study, 312 Spanish-speaking and/or English-speaking female primary caregivers of Mexican descent with a child 3 to 5 years of age were recruited from safety-net pediatric clinics. Participants completed a phone interview and screen media diary. Measures included maternal screen-related beliefs, self-efficacy, parenting practices (time restriction, TV in the child's bedroom, allowing viewing while eating meals and while eating snacks), and child viewing behaviors (amount of TV viewing, frequency of eating while viewing). Two path analytic models were estimated.ResultsPositive general beliefs about TV viewing and positive functional beliefs were negatively associated with maternal self-efficacy to restrict TV time (β = –0.14, P < .05; β = –0.27, P < .001). Greater self-efficacy to restrict time was associated with more maternal restriction of time (β = 0.29, P < .001). Greater positive functional beliefs were associated with less self-efficacy to restrict TV viewing with snacks (odds ratio = 0.56; 95% confidence interval, 0.38–0.81). High self-efficacy to restrict viewing with snacks was associated with less allowing of viewing while snacking (β = –0.16, P < .01). Time restriction, TV in the child's bedroom, and allowing viewing while snacking were associated with child TV viewing behaviors.ConclusionsProviders should consider maternal beliefs, including beliefs regarding the functional use of screens, and self-efficacy to engage in AAP-recommended parenting practices, when counseling on screen use in this population.
       
  • Promoting Father Involvement for Child and Family Health
    • Abstract: Publication date: September–October 2018Source: Academic Pediatrics, Volume 18, Issue 7Author(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, including improved cognition, improved mental health, reduced obesity rates, and asthma exacerbation. 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, rather than the mother–father–child triad, remains a frequent focus of care. 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 affect the health of both father and child. 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 that 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.
       
  • Obesity Prevention and Treatment in Primary Care
    • Abstract: Publication date: September–October 2018Source: Academic Pediatrics, Volume 18, Issue 7Author(s): Callie L. Brown, Eliana M. Perrin Despite extensive public health and clinical interventions, obesity rates remain high, and evidence-based preventive strategies are elusive. Many consensus guidelines suggest that providers should screen all children after age 2 years for obesity by measuring height and weight, calculating body mass index (BMI), and sensitively communicating weight status in the context of health to the family at each visit. However, preventive counseling should begin in infancy and focus on healthy feeding, activity, and family lifestyle behaviors. For children with overweight or obesity, the American Academy of Pediatrics outlines 4 stages of treatment: 1) Primary care providers should offer “prevention plus,” the use of motivational interviewing to achieve healthy lifestyle modifications in family behaviors or environments; 2) children requiring the next level of obesity treatment, structured weight management, need additional support beyond the primary care provider (such as a dietitian, physical therapist, or mental health counselor) and more structured goal setting with the team, including providers adept at weight management counseling; 3) children with severe obesity and motivated families may benefit from referral to a comprehensive multidisciplinary intervention, such as an obesity treatment clinic; and 4) tertiary care interventions are provided in a multidisciplinary pediatric obesity treatment clinic with standard clinical protocols for evaluation of interventions, including medications and surgery. Although it is certainly a challenge for providers to fit in all the desired prevention and treatment counseling during preventive health visits, by beginning to provide anticipatory guidance at birth, providers can respond to parents’ questions, add to parents’ knowledge base, and partner with parents and children and adolescents to help them grow up healthy. This is especially important in an increasingly toxic food environment with numerous incentives and messages to eat unhealthfully, barriers to appropriate physical activity, and concomitant stigma about obesity. Focusing on key nutrition and physical activity habits and establishing these healthy behaviors at an early age will allow children to develop a healthy growth trajectory. However, much more work is needed to determine the best evidence-based practices for providers to counsel families on improving target behaviors, environmental modifications, and parenting skills and to decrease abundant disparities in obesity prevalence and treatment.
       
  • Advanced Cervical Spine Imaging in Abusive Head Trauma: An Update on
           Recent Literature and Future Directions
    • Abstract: Publication date: September–October 2018Source: Academic Pediatrics, Volume 18, Issue 7Author(s): M. Katherine Henry, Joanne N. Wood
       
  • A Forbidden Island
    • Abstract: Publication date: September–October 2018Source: Academic Pediatrics, Volume 18, Issue 7Author(s): Adam D. Wolfe
       
  • Immigration Policy: Valuing Children
    • Abstract: Publication date: September–October 2018Source: Academic Pediatrics, Volume 18, Issue 7Author(s): Fernando S. Mendoza, Victor Cueto, Duncan Lawrence, Lee Sanders, Dana Weintraub
       
  • Pediatric Program Director Minimum Milestone Expectations Before Allowing
           Supervision of Others and Unsupervised Practice
    • Abstract: Publication date: September–October 2018Source: Academic Pediatrics, Volume 18, Issue 7Author(s): Su-Ting T. Li, Daniel J. Tancredi, Alan Schwartz, Ann Guillot, Ann E. Burke, R. Franklin Trimm, Susan Guralnick, John D. Mahan, Kimberly Gifford BackgroundThe Accreditation Council for Graduate Medical Education requires semiannual Milestone reporting on all residents. Milestone expectations of performance are unknown.ObjectiveTo determine pediatric program director (PD) minimum Milestone expectations for residents before being ready to supervise and before being ready to graduate.MethodsMixed methods survey of pediatric PDs on their programs' Milestone expectations before residents are ready to supervise and before they are ready to graduate, and in what ways PDs use Milestones to make supervision and graduation decisions. If programs had no established Milestone expectations, PDs indicated expectations they considered for use in their program. Mean minimum Milestone level expectations were adjusted for program size, region, and clustering of Milestone expectations by program were calculated for before supervise and before graduate. Free-text questions were analyzed using thematic analysis.ResultsThe response rate was 56.8% (113 of 199). Most programs had no required minimum Milestone level before residents are ready to supervise (80%; 76 of 95) or ready to graduate (84%; 80 of 95). For readiness to supervise, minimum Milestone expectations PDs considered establishing for their program were highest for humanism (2.46; 95% confidence interval [CI], 2.21–2.71) and professionalization (2.37; 95% CI, 2.15–2.60). Minimum Milestone expectations for graduates were highest for help-seeking (3.14; 95% CI, 2.83–3.46). Main themes included the use of Milestones in combination with other information to assess learner performance and Milestones are not equally weighted when making advancement decisions.ConclusionsMost PDs have not established program minimum Milestones, but would vary such expectations according to competency.
       
  • SEXUAL AND REPRODUCTIVE HEALTH OF YOUNG WOMEN WITH CYSTIC FIBROSIS: A
           CONCEPT MAPPING STUDY
    • Abstract: Publication date: Available online 31 August 2018Source: Academic PediatricsAuthor(s): Traci M Kazmerski, Olga V Prushinskaya, Kelsey Hill, Eliza Nelson, Jessica Leonard, Kelly Mogren, Sarah AB Pitts, Julia Roboff, Ahmet Uluer, S. Jean Emans, Elizabeth Miller, Gregory S Sawicki ObjectiveAdolescent and young adult (AYA) women with pediatric-onset chronic diseases, such as cystic fibrosis (CF), face disease-specific sexual and reproductive health (SRH) concerns. Using concept mapping (CM), this study aimed to identify the SRH topics and outcomes valued by AYA women with CF and parents.MethodsWomen with CF aged 13-30 years and parents of 13-30-year-old daughters with CF participated in an online CM study. Participants individually brainstormed, rated, and sorted SRH topics important for AYA women with CF. Using multidimensional scaling, hierarchical cluster analyses, and T-tests to assess rating differences, multidisciplinary stakeholders interpreted results during an in-person meeting.ResultsTwenty-four participants (13 AYAs and 11 parents) generated 109 statements around SRH in CF; 88% completed rating and sorting. Sixteen stakeholders named six main clusters of concepts: Fertility and Pregnancy, Deciding to Have Children, Birth Control, Navigating Life, Sex, and Gynecologic Concerns. Participants rated Birth Control as highest in importance for adolescent women (mean=3.9± 0.1 out of 5-point scale) and Fertility and Pregnancy highest for young adult women (mean=4.2±0.04). Parents provided higher importance ratings for all clusters compared to patient participants. Stakeholders identified patient-centered outcomes for each cluster and focused on how to improve SRH knowledge, decision-making, and patient-provider communication in the subspecialty setting.ConclusionsEliciting patient-centered outcomes using CM can inform improvements in the care of AYAs with pediatric-onset chronic diseases. The SRH topics and patient-centered outcomes identified in this study should inform enhancements to comprehensive clinical care delivery for these populations.
       
  • Using Behavioral Economics to Encourage Parent Behavior Change:
           Opportunities to Improve Clinical Effectiveness
    • Abstract: Publication date: Available online 30 August 2018Source: Academic PediatricsAuthor(s): Brian P Jenssen, Alison M Buttenheim, Alexander G Fiks Pediatric clinical practice often involves improving child health by changing parents' behavior. Strategies from behavioral economics - a field that leverages predictable patterns in human decision-making to overcome barriers to behavior change - can improve health outcomes in adults. Though more research is needed, the application of these approaches to parent behavior change in pediatric settings has the potential to improve the clinical effectiveness of child healthcare. We review the foundational concepts of behavioral economics and identify the unique role of pediatricians in motivating parent behavior change. We then discuss how to apply four key strategies in practice - message framing, use of defaults, enhanced active choice, and harnessing social forces - to support parent decision-making to improve child health. Leveraging behavioral economic principles around parental decision-making has the potential to supercharge program effectiveness and improve patient and family health.
       
  • Lessons Learned from My Mentors: the 2018 Miller Sarkin Award Recipient
           speech
    • Abstract: Publication date: Available online 30 June 2018Source: Academic PediatricsAuthor(s): Janet R. Serwint
       
  • “In the Clinic They Know Us”: Preferences for Clinic-Based Financial
           and Employment Services in Urban Pediatric Primary Care
    • Abstract: Publication date: Available online 27 June 2018Source: Academic PediatricsAuthor(s): Caitlin Quinn, Karl Johnson, Catherine Raney, Jacqueline Baker, Kristin Topel, Megan M. Tschudy, Devan Jaganath, Barry S. Solomon ObjectiveTo understand views of adolescent and adult caregivers on integrating employment and financial services into a pediatric primary care clinic serving low-income families.MethodsEighteen in-depth qualitative interviews were conducted among caregivers of pediatric patients. Participants were recruited from those who completed a survey assessing financial and employment needs. Audio-recorded transcripts were analyzed using line-by-line coding of emerging themes.ResultsAdolescent and adult caregivers expressed difficulty managing financial stress. They cited having a criminal history, limited financial literacy, and lack of available quality jobs as barriers to achieving financial stability. A clinic-based employment and financial program was highly acceptable among potential users for the convenience it offers and the established trust and understanding between patients and clinical providers. Participants preferred one-on-one counseling for sensitive employment and financial issues, although they did believe that some topics, such as building a resume, could be accomplished in group workshops.ConclusionsCaregivers attending a pediatric clinic expressed interest in and anticipated value from clinic-based employment and financial services if implemented services are relevant, accessible, and provide options for group and individualized approaches.
       
  • What Is the Relationship Between Incarceration of Children and Adult
           Health Outcomes'
    • Abstract: Publication date: Available online 21 June 2018Source: Academic PediatricsAuthor(s): Elizabeth S. Barnert, Laura S. Abrams, Rebecca Dudovitz, Tumaini R. Coker, Eraka Bath, Lello Tesema, Bergen B. Nelson, Christopher Biely, Paul J. ChungAbstractObjectiveWe sought to quantify the association between child incarceration in the United States and subsequent adult health outcomes.MethodsWe analyzed National Longitudinal Study of Adolescent to Adult Health data from 1727 adult (Wave IV) participants first incarcerated at age
       
  • Care Quality and Spending Among Commercially Insured Children With
           Disabilities
    • Abstract: Publication date: Available online 19 June 2018Source: Academic PediatricsAuthor(s): Alyna T. Chien, Sara L. Toomey, Dennis Z. Kuo, Jeanne Van Cleave, Amy J. Houtrow, Megumi J. Okumura, Matthew Y. Westfall, Carter R. Petty, Jessica A. Quinn, Karen A. Kuhlthau, Mark A. Schuster ObjectiveTo identify opportunities to improve care value for children with disabilities (CWD), we examined CWD prevalence within a commercially insured population and compared outpatient care quality and annual health plan spending levels for CWD relative to children with complex medical conditions without disabilities; children with chronic conditions that are not complex; and children without disabling, complex, or chronic conditions.MethodsThis cross-sectional study comprised 1,118,081 person-years of Blue Cross Blue Shield Massachusetts data for beneficiaries aged 1 to 19 years old during 2008 to 2012. We combined the newly developed and validated Children with Disabilities Algorithm with the Pediatric Medical Complexity Algorithm to identify CWD and non-CWD subgroups. We used 14 validated or National Quality Forum–endorsed measures to assess outpatient care quality and paid claims to examine annual plan spending levels and components.ResultsCWD constituted 4.5% of all enrollees. Care quality for CWD was between 11% and 59% for 8 of 14 quality measures and>80% for the 6 remaining measures and was generally comparable to that for non-CWD subgroups. Annual plan spending among CWD was a median and mean 23% and 53% higher than that for children with complex medical conditions without disabilities, respectively; CWD mean and median values were higher than for all other groups as well.ConclusionsCWD were prevalent in our commercially insured population. CWD experienced suboptimal levels of care, but those levels were comparable to non-CWD groups. Improving the care value for CWD involves a deeper understanding of what higher spending delivers and additional aspects of care quality.
       
  • Lower Body Mass Index Z-Score Trajectory During Early Childhood After the
           Birth of a Younger Sibling
    • Abstract: Publication date: Available online 18 June 2018Source: Academic PediatricsAuthor(s): Dina H. Griauzde, Julie C. Lumeng, Prachi E. Shah, Niko Kaciroti ObjectiveThe objectives of this study were to examine differences in body mass index z-score (BMIZ) trajectory during early childhood among children with a younger sibling compared with those without and to test potential mediators.MethodsThis longitudinal cohort study included 6050 participants of the Early Childhood Longitudinal Study, Birth Cohort (ECLS-B). Focal children's weight, height, sibship status, screen time, active play time, family dinner frequency, and diet quality were assessed at 9 months, 24 months, preschool, and kindergarten when available. A piecewise linear regression model was used to examine the association between sibling birth and focal child's subsequent BMIZ trajectory to kindergarten. Mediation by screen time, active play time, family dinner frequency, and diet quality was tested.ResultsBMIZ trajectory was lower among children who had a new sibling join the family before kindergarten compared to children who did not have a new sibling join the family by kindergarten. The association was strongest when new sibship occurred when the focal child was 48 to 66 months (b = –0.026, P = .044). The association was not mediated by screen time, active play time, family dinner frequency, or diet quality.ConclusionAmong a nationally representative cohort of US children, new sibship before kindergarten was associated with a lower BMIZ trajectory. Several common obesogenic risk factors did not explain the association.
       
  • Post-training Shared Decision Making Barriers and Facilitators for
           Pediatric Healthcare Providers: A Mixed-Methods Study
    • Abstract: Publication date: Available online 1 June 2018Source: Academic PediatricsAuthor(s): Laura Boland, Margaret L. Lawson, Ian D. Graham, France Légaré, Kristin Dorrance, Allyson Shephard, Dawn Stacey ObjectiveTo assess barriers to and facilitators of shared decision making (SDM) for pediatric healthcare providers (HCPs) after they have been trained in SDM.MethodsA mixed methods study using triangulation of data sources. Pediatric HCPs with SDM training who worked at a Canadian tertiary care pediatric hospital were eligible. Participants completed a validated SDM barriers survey (n = 60) and a semi-structured interview (n = 11). We calculated descriptive statistics. Univariate and multivariable ordinary least squares linear regression models determined predictors of HCPs’ intention to use SDM. Interviews were audiotaped and transcribed verbatim. We analyzed qualitative data using deductive and inductive content analyses and organized categories according to the Ottawa Model of Research Use.ResultsIntention to use SDM was high (mean score = 5.6/7, SD = 0.78) and positively correlated with SDM use (RR = 1.46, 95% CI 1.18-1.81). However, 52% of survey respondents reported not using SDM after training. HCPs identified factors influencing SDM at the levels of innovation, adopter, environment, and training. Insufficient time (barrier) and buy-in and agreement with SDM (facilitators) were most commonly cited. To improve SDM use, HCPs want a more team-based approach to SDM training, continuing education, and implementation.ConclusionsDespite training and positive intentions, many HCPs report not subsequently using SDM and identified numerous post-training barriers to its use. To overcome SDM barriers and improve uptake, HCPs recommend creating a socially supportive environment through a team-based approach to SDM training and implementation. These findings can inform SDM training and implementation interventions at pediatric health care centers.
       
  • The Benefits and Challenges of Involving Adolescents in Medical Education:
           A Qualitative Study
    • Abstract: Publication date: Available online 30 May 2018Source: Academic PediatricsAuthor(s): Katherine A. Moreau, Kaylee Eady ObjectiveTo explore the potential benefits and challenges of involving adolescents in the education of medical students and residents from the perspectives of adolescents who are hospitalized with chronic health conditions.MethodsWe conducted qualitative interviews with adolescents at a Canadian pediatric hospital. Eligible participants were those between 13 and 18 years of age who had chronic health conditions lasting more than 3 months and were feeling well enough to participate in an interview. We used conventional content analysis to analyze the data.ResultsSixteen adolescents participated in the study. In terms of benefits, the participants described how involving adolescents in the education of medical students and residents would improve patient–physician interactions, increase patients’ confidence and self-worth, encourage patients to self-reflect and gain knowledge about their health conditions and themselves, and enable patients to socialize with other patients. When asked about the challenges, the participants discussed how it might be difficult to include diverse patient perspectives, manage adolescents’ negativity, and ensure that learners are nonjudgmental toward adolescents and take them seriously.ConclusionsAlthough many of the reported benefits and challenges correspond with those featured in the literature on adult patient involvement in medical education, our findings underscore the distinctive benefits and challenges that medical educators may experience in designing and implementing educational initiatives that involve adolescents. Future design and implementation of educational initiatives should further explore the benefits and challenges of such adolescent involvement, because we know that adolescents can be valuable contributors to medical education.
       
  • INSIGHT Study Maternal Return to Work and Infant Weight Outcomes
    • Abstract: Publication date: Available online 23 August 2018Source: Academic PediatricsAuthor(s): Sally G. Eagleton, Emily E. Hohman, Nicole Verdiglione, Leann L. Birch, Ian M. Paul, Jennifer S. Savage ObjectiveMaternal return to work within 12 weeks of delivery is associated with poor child health and development. However, little is known about the impact of return to work on child obesity risk. We examined whether timing of maternal return to work is associated with rapid infant weight gain from 0-6 months and weight-for-length at 1 year.MethodsSecondary data analysis of 279 mother-newborn dyads from the INSIGHT Study, a randomized controlled trial evaluating a responsive parenting (RP) intervention. Rapid infant weight gain from 0-6 months was assessed using conditional weight gain scores. Infant weight-for-length was calculated using World Health Organization reference values. Analysis of variance (ANOVA) examined whether infant weight outcomes differed by timing of maternal return to work (≤12 weeks vs.>12 weeks after delivery). Moderation by study group (RP intervention vs. safety control) and mediation by breastmilk feeding were examined in ANOVA models.ResultsAmong 261 mothers approximately half (n=130) returned to work within 12 weeks. Compared to infants of mothers who returned to work after 12 weeks, infants of mothers who returned to work within 12 weeks had higher conditional weight gain scores from 0-6 months (p = 0.006) and were heavier at 1 year (p = 0.05). These associations were not moderated by study group or mediated by breastmilk feeding.ConclusionMaternal return to work within 12 weeks was associated with rapid infant weight gain in the first 6 months and higher weight-for-length at 1 year, though the mechanisms to explain our findings are unclear.
       
  • Enhancing Educational Scholarship through Conceptual Frameworks: A
           Challenge and Roadmap for Medical Educators
    • Abstract: Publication date: Available online 20 August 2018Source: Academic PediatricsAuthor(s): Matthew W. Zackoff, Francis J. Real, Erika L. Abramson, Su-Ting T. Li, Melissa Klein, Maryellen E. Gusic Historically, health sciences education has been guided by tradition and teacher preference rather than by application of practices supported by rigorous evidence of effectiveness. Though often underutilized, conceptual frameworks, theories that describe the complexities of educational and social phenomenon, are essential foundations for scholarly work in education. Conceptual frameworks provide a lens through which educators can develop research questions, design research studies and educational interventions, assess outcomes and evaluate the impact of their work. Given this vital role, conceptual frameworks should be considered at the onset of an educational initiative. Use of different conceptual frameworks to address the same topic in medical education may provide distinctive approaches. Exploration of educational issues through the employment of differing, theory-based approaches advances the field through the identification of the most effective educational methods. Dissemination of sound educational research based on theory is similarly essential to spark future innovation. Ultimately, this rigorous approach to medical education scholarship is necessary to allow us to establish how our educational interventions impact the health and well-being of our patients.
       
  • Use and Utility of Skeletal Surveys to Evaluate for Occult Fractures in
           Young Injured Children
    • Abstract: Publication date: Available online 16 August 2018Source: Academic PediatricsAuthor(s): Joanne N Wood, M. Katherine Henry, Rachel P. Berger, Daniel M. Lindberg, James D. Anderst, Lihai Song, Russell Localio, Chris Feudtner ObjectivesTo describe the percentage and characteristics of children
       
  • Evaluation of the Implementation of a Multi-Component Intervention to
           Improve Healthcare Provider Communication about HPV Vaccination
    • Abstract: Publication date: Available online 11 August 2018Source: Academic PediatricsAuthor(s): Jenna E. Reno, Sean T. O'Leary, Jennifer Pyrzanowski, Steven Lockhart, Jacob Thomas, Amanda F. Dempsey ObjectiveTo evaluate the relative use, usefulness, and facilitators and barriers to use, as perceived by providers, of five different components in an HPV vaccine communication intervention—which was found to be effective at improving HPV vaccination rates.MethodsFour serial surveys of 108 providers (MD, NP, or PA) from intervention clinics involved in the study assessed use and usefulness of the 5 communication intervention components over a 12-month period.ResultsResponse rates were 79%-86%. The fact sheet (64%-77%) and motivational interviewing techniques (MI; 86%) were the most used components—use was sustained over the 12-month period. These components were also perceived as somewhat or very useful by most providers, and this perceived usefulness increased over time (very or somewhat useful at end of study, 97% fact sheet, 98% MI, respectively). Although fewer providers reported using the website (15%-42%), or disease images (6%-17%%), when these were used, most providers (67%-87%) felt they were somewhat or very useful. The decision aid was not used frequently (17%-41% of providers) and 43% of providers felt it was not very or not at all useful. Facilitators and barriers were identified for each component. The fact sheet and MI were perceived as the easiest to integrate into the clinic workflow.Conclusion(s)the fact sheet and MI were the most used and most useful intervention components, both were easy to integrate into clinic workflow, and their use was sustained over time. Dissemination of similar interventions in the future should focus on these two specific components.
       
  • The Sounds of Grief
    • Abstract: Publication date: Available online 11 August 2018Source: Academic PediatricsAuthor(s): Selin Tuysuzoglu Sagalowsky
       
  • Neonatal Intubation Competency Assessment Tool: Development and Validation
    • Abstract: Publication date: Available online 11 August 2018Source: Academic PediatricsAuthor(s): Lindsay Johnston, Taylor Sawyer, Akira Nishisaki, Travis Whtifill, Anne Ades, Heather French, Kristen Glass, Rita Dadiz, Christie Bruno, Orly Levit, Sandeep Gangadharan, Daniel Scherzer, Ahmed Moussa, Marc Auerbach, INSPIRE Research NetworkABSTRACTBackground: Neonatal tracheal intubation (NTI) is an important clinical skill. Suboptimal performance is associated with patient harm. Simulation training can improve NTI performance. Improving performance requires an objective assessment of competency. Competency assessment tools need strong evidence of validity. We hypothesized that a NTI competency assessment tool with multi-source validity evidence could be developed, and could be used for formative and summative assessment during simulation-based training.Methods: A NTI assessment tool was developed based on a literature review. The tool was refined through two rounds of a modified Delphi process involving 12 subject matter experts. The final tool had a 22 item checklist, a global skills assessment (GSA), and an entrustable professional activity (EPA) level. The validity of the checklist was assessed by having four blinded reviewers score 23 videos of healthcare providers intubating a neonatal simulator.Results: The checklist items had good internal consistency (overall α 0.79). Checklist scores were higher for providers at higher training levels and more NTI experience. Checklist scores correlated with GSA (ρ=0.85; P < 0.05), EPA levels (ρ=0.87; P < 0.05), percent glottic exposure (r=0.59; P < 0.05), and Cormack-Lehane scores (ρ=0.95; P < 0.05). Checklist scores reliably predicted EPA levels.Conclusion: We developed a NTI competency assessment tool with multi-source validity evidence. The tool was able to discriminate NTI performance based on experience. The tool can be used during simulation-based NTI training to provide formative and summative assessment and can aid with entrustment decisions.
       
  • Sleep, Physical Activity, and General Health Status: US Pediatricians and
           the General US Adult Population
    • Abstract: Publication date: Available online 10 August 2018Source: Academic PediatricsAuthor(s): Elizabeth A. Gottschlich, Kandyce Larson, BlakeSisk, Mary Pat Frintner ObjectiveTo examine US pediatricians and US adults on three self-reported health measures (sleep, physical activity, and general health status), and to assess factors related to these measures for each group.MethodsPediatrician data were collected through a 2012 AAP Periodic Survey (response rate=64.0%). US population data originated from the 2012 National Health Interview Survey (response rate=61.2%). Analytic samples included those currently working and ≥30 years old; restricted to post-trainees (pediatricians; n=854) and those with at least a Bachelor's degree (US population; n=5,447). Accounting for sample demographic differences, predicted probabilities compared the proportions reporting ≥7 hours of sleep, meeting physical activity recommendations, and reporting very good/excellent health. Multivariable logistic regression examined characteristics associated with health measures for pediatricians and US adults separately.ResultsWhen the US population demographic profile was adjusted to resemble the pediatrician sample, 7 in 10 pediatricians (71.2%, CI=68.0%-74.5%) and US adults (69.9%, CI=67.8%-72.0%) reported ≥7 hours of sleep. Pediatricians were more likely than US adults to meet physical activity recommendations (71.4%, CI=68.0%-74.8% vs. 62.9%, CI=60.6%-65.2%), and less likely to report very good/excellent health (74.3%, CI=71.2%-77.3% vs. 80.2%, CI=78.3%-82.1%). In pediatrician and US population multivariable models, self-identified Asians and those working ≥50 hours were less likely to get ≥7 hours of sleep (p
       
  • Trends in prevalence and management of childhood anxiety by Australian
           pediatricians
    • Abstract: Publication date: Available online 9 August 2018Source: Academic PediatricsAuthor(s): Margie Danchin, Alisha Gulenc, Daryl Efron, Emma Sciberras, Christos Symeonides, Harriet HiscockABSTRACTObjective:Rising anxiety rates and equity of care are ongoing concerns. Through two pediatric practice audits conducted five years apart, we aimed to determine the change in (1) anxiety diagnoses; (2) associated comorbid diagnoses; (3) variance in management by location and (4) child, family and pediatrician predictors of management.Methods:Members of the Australian Paediatric Research Network (APRN) were invited to participate in patient-level prospective national pediatric practice audits in 2008 and 2013. Pediatricians were asked to complete standardized forms for 100 consecutive patients or all patients seen over two weeks, whichever was completed first. Demographic data, diagnoses, medications and referrals were collected. Logistic regressions were conducted, clustered at the pediatrician level.Results:Of eligible APRN pediatricians in 2013 and 2008, 48% and 66% participated and contributed 7102 and 8345 consultations, respectively. Anxiety diagnoses increased over the five-year period (4.4% to 7.6%; p
       
  • Development and Assessment of an Online Training for the Medical Response
           to Sex Trafficking of Minors
    • Abstract: Publication date: Available online 8 August 2018Source: Academic PediatricsAuthor(s): Sydney Hansen, Marlene Melzer-Lange, Melodee Nugent, Ke Yan, Angela Rabbitt
       
  • Using Mobile Health to Promote Early Language Development: A Narrative
           Review
    • Abstract: Publication date: Available online 8 August 2018Source: Academic PediatricsAuthor(s): Catherine McClure, Maureen Cunningham, Sheana Bull, Stephen Berman, Mandy A. Allison : In this narrative review, we will present a brief overview of known disparities in children's language development based on socioeconomic status (SES) and efforts in the primary care setting to promote children's language development. Next, we will define mobile-health (m-health) and review the limited, published literature regarding the effectiveness of m-health interventions in promoting children's health, in general, and language development, in particular. Finally, we will discuss the potential role of smart phone applications to increase parental behaviors that promote their children's language development as well as challenges that should be addressed as the field of m-health continues to grow.
       
  • Best Practices for Labeling and Dosing Liquid MedicationsIdentifying and
           Advancing Best Practices for the Labeling and Dosing of Pediatric Liquid
           Medications: Progress and Challenges
    • Abstract: Publication date: Available online 7 August 2018Source: Academic PediatricsAuthor(s): H. Shonna Yin, Carrie Vuong, Ruth M. Parker, Lee M. Sanders, Alan L. Mendelsohn, Benard P. Dreyer, Jessica J. Velazquez, Michael S. WolfWhat's NewThe NIH-funded SAFE Rx for Kids study has identified best practices for the labeling/dosing of pediatric liquid medications. Findings support use of pictographic instructions and optimized provision of dosing tools, along with careful selection of the unit of measurement used.
       
  • Utilizing Family-Centered Process and Outcome Measures to Assess
           Hospital-to-Home Transition Quality
    • Abstract: Publication date: Available online 2 August 2018Source: Academic PediatricsAuthor(s): Arti D. Desai, Tamara D. Simon, JoAnna K. Leyenaar, Maria T. Britto, Rita Mangione-Smith
       
  • Implementing a standardized constipation management pathway to reduce
           resource utilization
    • Abstract: Publication date: Available online 2 August 2018Source: Academic PediatricsAuthor(s): David R. Sandweiss, Lauren Allen, Mark Deneau, Janet Harnsberger, Amy Pasmann, Randall Smout, Michael Mundorff, Nanette Dudley Background and ObjectiveConstipation is commonly diagnosed in our pediatric ED. Care has varied significantly, with a heavy reliance on abdominal radiography (AR) for diagnosis and inpatient management for bowel cleanout. We implemented a standardized approach to caring for patients presenting to a pediatric ED with symptoms consistent with constipation, emphasizing clinical history, physical exam, less reliance on AR, and standardized home management.MethodsUsing QI methodology, a multidisciplinary group developed an ED constipation management pathway, encouraging less reliance on AR for diagnosis and promoting home management over inpatient bowel cleanout. The pathway included a home management “gift-basket” containing over-the-counter medications and educational materials to promote successful bowel cleanout. Outcome measures included pathway utilization, AR rate, ED cost and LOS, and ED admission rate for constipation.ResultsWithin 3 months, over 90% of patients discharge home with an ED disposition diagnosis of constipation left with standardized educational materials and home medications. Staff education and feedback, pathway and “gift-basket” changes, and a higher threshold for inpatient management led to significant drops in AR rate (73.3% to 24.6%, p
       
  • Improving Response Rates and Representation of Hard-to-Reach Groups in
           Family Experience Surveys
    • Abstract: Publication date: Available online 26 July 2018Source: Academic PediatricsAuthor(s): Sara L. Toomey, Marc N. Elliott, Alan M. Zaslavsky, Jessica Quinn, David J. Klein, Stephanie Wagner, Cassandra Thomson, Melody Wu, Sarah Onorato, Mark A. SchusterABSTRACTBackgroundMost US hospitals conduct patient experience surveys by mail or telephone after discharge to assess patient/family-centeredness of care. Pediatric response rates are usually very low, especially for black, Latino, and low-income respondents. We investigated whether day of discharge surveying using tablets improves response rates and respondent representativeness.MethodsQuasi-experimental study of parents of patients discharged from four units of a children's hospital. Parents were assigned to receive Child HCAHPS via an audio-enabled tablet before discharge or via mail ∼1 week post-discharge. Intervention and control conditions alternated by week. We compared response rates, child/respondent characteristics, and mean top-box scores between Tablet and Mail Only arms.ResultsAdministering Child HCAHPS on a tablet was administratively feasible and did not interfere with the discharge process (median completion time 12.4 minutes). Tablet response rate was 71.1% (424/596), vs. 16.3% (96/588) for Mail Only. Although Tablet response rates were higher in every subgroup, Tablet respondents were more likely to be fathers (20.4% vs. 6.4%, p=.006) and have ≤high school education (17.5% vs. 8.4%, p=.002); patients were were less likely to be white (56.8% vs. 71.9%, p=.006) and more likely to be publicly-insured (31.4% vs. 19.8%, p=.02). Tablet scores were significantly higher than Mail Only scores for 3 of 17 measures.ConclusionsThe response rate for day-of-discharge tablet survey administration was>four times higher than with single-wave mail-only administration, with greater participation of hard-to-reach groups. These findings suggest tablet administration before discharge shows great promise for real-time feedback and QI and may transform the field of inpatient survey administration.
       
  • Performance of International Medical Graduates in Pediatric Residency: A
           Study of Peer and Faculty Perceptions
    • Abstract: Publication date: Available online 26 July 2018Source: Academic PediatricsAuthor(s): Andres Jimenez-Gomez, Michael R. FitzGerald, Carmen Leon-Astudillo, Javier Gonzalez-del-Rey, Charles J. Schubert PurposeInternational Medical Graduates (IMGs) constitute around 25% of the US pediatric workforce. Their recruitment into US residency training yields concerns regarding their competence, though this has not been formally studied. Cincinnati Children's Hospital has systematically recruited IMGs over 16 years. This study evaluates perceptions of IMG performance by faculty and US-graduate (USG) peers.Methods
      Authors surveyed IMG, USG and faculty groups including current and former trainees, assessing perceived IMG performance compared to USGs in clinical knowledge/skills, resource utilization, communication, public health knowledge and efficiency, and overall impact on the program.ResultsOverall perceived performance was within one standard deviation of expected USG performance. IMGs outperformed USGs in clinical knowledge/skills and resource utilization, underperforming in communication, public health knowledge and efficiency. Significant differences were noted in communication with patients and public health knowledge (IMGs ranked their performance significantly lower than USGs/Faculty ranked their performance). Overall impact was perceived positively, including an increased interest in global health in among USGs.ConclusionCarefully recruited IMGs are perceived to perform near equally to USG peers and their presence is perceived as positive to a major pediatric residency program. Specific domains for educational interventions are identified for programs wishing to expand IMG recruitment.
       
  • Identifying Associations among Co-occurring Medical Conditions in Children
           with Autism Spectrum Disorders
    • Abstract: Publication date: Available online 24 July 2018Source: Academic PediatricsAuthor(s): Ann M Neumeyer, Julia Anixt, James Chan, James Perrin, Donna Murray, Daniel L Coury, Amanda Bennett, Justin Farmer, Robert A Parker BackgroundChildren with autism spectrum disorders (ASD) have high prevalence of co-occurring medical conditions including speech, sleep, and gastrointestinal disorders (constipation and feeding difficulties), developmental delay, attention deficit/hyperactivity disorder, hypotonia, epilepsy, anxiety, disruptive behavior, pica, and eczema. Less is known about whether these commonly co-exist in the same children. We sought to determine clinically meaningful, statistically significant associations among co-occurring medical conditions in children with ASD that could lead to better identification, treatment or understanding of the disease process.MethodsWe studied 2114 children with ASD ages 17 months to 5 years and 1221 children 6-17 years at 15 Autism Speaks-Autism Treatment Network Registry sites. Clinician-reported diagnoses and problems were grouped into 12 core conditions. We determined observed prevalence (O) of co-occurring conditions and estimated expected prevalence (E) across the network, adjusting for site variability in the prevalence of individual conditions. P-values were calculated using a Cochran-Mantel-Haenszel test stratified by site. We identified pairs of conditions co-occurring more frequently than expected (O/E> 1) and less frequently than expected (O/E < 1) and highlighted statistically significant differences.ResultsAmong the 66 condition pairs for each age group, we confirmed previously identified associations such as sleep disorders and anxiety symptoms in older children. We found associations not previously described: feeding with sleep disorders (younger children only), constipation with sleep disorders, feeding with speech disorders, and constipation with speech disorders.ConclusionsWe identified new associations among co-occurring medical conditions in children with ASD, offering the potential to examine common pathways.
       
  • Professional Interpreter Use and Discharge Communication in the Pediatric
           Emergency Department
    • Abstract: Publication date: Available online 23 July 2018Source: Academic PediatricsAuthor(s): Colleen K. Gutman, Liliana Cousins, Jesse Gritton, Eileen J. Klein, Julie C. Brown, Jack Scannell, K. Casey Lion ObjectiveFamilies with limited English proficiency (LEP) experience communication barriers and are at risk for adverse events after discharge from the pediatric emergency department (ED). We sought to describe the characteristics of ED discharge communication for LEP families and to assess whether professional interpreter use was associated with provider communication quality during ED discharge.MethodsTranscripts of video-recorded ED visits for Spanish-speaking LEP families were obtained from a larger study comparing professional interpretation modalities in a freestanding children's hospital. Caregiver-provider communication interactions that included discharge education were analyzed for content and for the techniques providers used to assess caregiver comprehension. Regression analysis was used to assess for an association between professional interpreter use and discharge education content or assessment of caregiver comprehension.ResultsWe analyzed 101 discharge communication interactions from 47 LEP patient visits; 31% of communications did not use professional interpretation. Although most patients (70%) received complete discharge education content, only 65% received instructions on medication dosing and only 55% were given return precautions. Thirteen percent of patient visits included an open-ended question to assess caregiver comprehension and none included teach-back. Professional interpreter use was associated with greater odds of complete discharge education content (OR 7.1, 95% CI 1.4-37.0) and high-quality provider assessment of caregiver comprehension (OR 6.1, 95% CI 2.3-15.9).ConclusionsProfessional interpreter use is associated with superior provider discharge communication behaviors. This study identifies clear areas for improving discharge communication, which may improve safety and outcomes for LEP children discharged from the ED.
       
  • Neighborhood Commute to Work Times and Self-Reported Caregiver Health
           Behaviors and Food Access
    • Abstract: Publication date: Available online 21 July 2018Source: Academic PediatricsAuthor(s): Michelle J. White, H. Shonna Yin, Russell L. Rothman, Lee M. Sanders, Alan Delamater, Kori Flower, Eliana M. Perrin ObjectivesTime spent commuting is associated with obesity. The objective of this study was to assess the relationship between neighborhood-level commute to work (CTW) times and self-reported health behaviors and food access.MethodsWe conducted a cross-sectional analysis of caregivers with infants as part of the Greenlight study, a multisite obesity trial in Chapel Hill, NC; New York, New York; Nashville, TN and Miami, FL. Zip-code based commute estimates were determined using the U.S. Census’ American Community Survey. Self-reported health behavior and food access data were collected via directed interview. Logistic and linear regression models determined associations between neighborhood CTW times and health behaviors and food access.ResultsThe average neighborhood CTW time for all zip codes was 29 mins (N=846). Caregivers in longer CTW time neighborhoods were more likely to endorse fewer food choices (AOR=1.39; 95% CI 1.15,1.69; p=0.001) and difficulty accessing markets with fresh produce (AOR=1.51; 95% CI 1.02, 2.25; p=0.04). Neighborhood CTW time>30 mins were associated with less caregiver physical activity (AOR=0.58; 95% CI 0.34, 0.98; p=0.044). Neighborhood CTW time was inversely related to infant television time (adjusted mean 399 min/day for ≤30min; 256min/day for>30 minutes; p=0.025). New York families in longer CTW neighborhoods were more likely to report difficulty accessing markets with fresh produce (AOR= 1.80, 95% CI 1.03, 3.14; p=0.039).ConclusionsNeighborhood CTW times are associated with several self-reported health behaviors and perceived food access among caregivers with children. Neighborhood CTW times may represent city-specific features including transportation infrastructure which may impact the health of families.
       
  • Dual Food and Energy Hardship and Associated Child Behavior Problems
    • Abstract: Publication date: Available online 11 July 2018Source: Academic PediatricsAuthor(s): Cristina R. Fernández, Maiko Yomogida, Yumiko Aratani, Diana HernándezABSTRACTObjectiveTo examine dual food and energy hardship and internalizing and externalizing behavior problems in 9 year-old children.MethodsWe conducted a cross-sectional analysis of the Fragile Families and Child Wellbeing Study, a prospective national urban birth cohort, when the children were 9 years-old. Maternal reported “food hardship” (ever hungry and/or ever received free food) and “energy hardship” (ever unable to pay utility bill and/or utility shut-off) within the past year, and child behavior using the Child Behavior Checklist/6-18 years were assessed. Multiple logistic regression analyses estimated associations between individual and dual food and energy hardship and child behavior problems, adjusting for a priori covariates (child sex, health insurance, maternal sociodemographic characteristics, poverty, reported health, attention deficit hyperactivity disorder, depressive symptoms, smoking, and substance and alcohol abuse).ResultsApproximately 10% of households reported dual food and energy hardship. Children experiencing dual food and energy hardship had 3 times greater odds of withdrawn/depressed behaviors (adjusted odds ratio [AOR]=2.8, 95% CI:1.4-5.5), 3 times greater odds of somatic complaints (AOR=3.2, 95% CI:1.5-6.9), and 4 times greater odds of rule breaking behavior (AOR=3.7, 95% CI:1.5-9.2) in the borderline/clinical range compared to children with no hardship, and had 4 times greater odds of borderline/clinical range somatic complaints (AOR=4.2, 95% CI: 1.7-10.3) compared to children with only energy hardship.ConclusionsChildren experiencing dual food and energy hardship have greater odds of coexisting internalizing and externalizing behaviors after controlling for possible confounders. Providers can consider screening and resource referrals for these addressable hardships alongside behavior assessments in the clinical setting.
       
  • Opioids in Adolescents’ Homes: Prevalence, Caregiver Attitudes and Risk
           Reduction Opportunities
    • Abstract: Publication date: Available online 6 July 2018Source: Academic PediatricsAuthor(s): Jane M. Garbutt, Katharine Kulka, Sherry Dodd, Randall Sterkel, Kathryn PlaxABSTRACTObjectiveThe most common source for misused opioids is pain relievers prescribed for family and friends. Our objective was to assess knowledge, attitudes and behaviors of adolescents’ caregivers regarding prescribed opioids in the home.MethodsThe self-administered survey was completed by caregivers in the waiting rooms of 12 pediatric practices in the mid-west. Eligibility required living in a home where youth ≥10 years old were frequently present. 700 of 793 (88.3%) eligible caregivers completed the survey, and 76.8% were the parent.ResultsOf 700 caregivers, 34.6% reported opioids in their home (13.6% active prescription, 12.7% leftover medications, 8.3% both). Of those with an active prescription, 66.0% intended to keep any leftover medications for future need (for the patient 60.1%, someone else 5.9 %). Of those with leftover medications, 60.5% retained them for the same reason (for the patient 51.0%, someone else, 9.5%). Others kept medications unintentionally: they never got around to disposing of them (30.6%), did not know how (15.7%), or it never occurred to them (7.5%). Many caregivers were unaware that adolescents commonly misuse opioids (30.0%), use them to attempt suicide (52.3%), and that opioid use can lead to heroin addiction (38.6%). 7.1% would give leftover opioid medications to an adolescent to manage pain and 5.9% may do so.ConclusionOpioids are prevalent in homes in our community and many parents are unaware of the risks they pose. Study findings can inform strategies to educate parents about opioid risk and encourage and facilitate timely, safe disposal of unused medications.
       
  • Provision of Parent Feedback via the Communication Assessment Tool: Does
           It Improve Resident Communication Skills'
    • Abstract: Publication date: Available online 5 July 2018Source: Academic PediatricsAuthor(s): Dominick DeBlasio, Francis J. Real, Nicholas J. Ollberding, Melissa D. Klein ObjectiveTo determine the impact of a curriculum which included parent feedback on resident communication skills.MethodsIn a prospective, controlled study, categorical pediatric residents in continuity clinic were divided into control and intervention groups based on clinic day. Parent feedback was obtained for all residents at the beginning and end of the year using the Communication Assessment Tool (CAT), a validated survey to assess physician communication. Intervention residents participated in learning conferences which reviewed communication best practices and received parental feedback via individual and group CAT scores. Scores were dichotomized as 5 (excellent) versus 1-4 (less than excellent) and reported as percentage of items rated excellent. Curriculum impact was assessed by comparing score changes between groups. Residents’ scores in both arms were combined to assess changes from year beginning to end. Statistical testing was performed using generalized linear mixed effects models.ResultsAll residents (n=68) participated. Intervention (n=38) and control (n=30) residents received at least 10 CATs at the beginning and end of the year. The percentage of parents rating all items as excellent increased by similar percentages in intervention and control groups (60.9% to 73.8% vs. 61.1% to 69.8; p=0.38). When scores of residents in both arms were combined, improvement was found from the beginning to end of the year for all CAT items (p
       
 
 
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