Abstract: Publication date: Available online 14 March 2019Source: Academic PediatricsAuthor(s): Natalie Stavas, Christine Paine, Lihai Song, Justine Shults, Joanne Wood Objectives1) To examine the association between the presence of a child abuse pathway and the odds of skeletal survey performance in infants with injuries associated with high risk of abuse, 2) to determine if pathway presence decreased disparities in skeletal survey performance.MethodsIn this retrospective study of children
Abstract: Publication date: Available online 10 March 2019Source: Academic PediatricsAuthor(s): Megan Quist, Niko Kaciroti, Julie Poehlmann-Tynan, Heidi M. Weeks, Katharine Asta, Priya Singh, Prachi E. ShahABSTRACTObjectiveTo examine the interactive effects of gestational age and infant fussiness on the risk of maternal depressive symptoms in a nationally representative sample.MethodsSample included 8200 children from the Early Childhood Longitudinal Study, Birth Cohort. Gestational age categories were: very preterm (VPT, 24-31 weeks), moderate/late preterm (MLPT, 32-36 weeks) and full-term (FT, 37-41 weeks). Maternal depressive symptoms (categorized as non-depressed/mild/moderate-severe), from the modified Center for Epidemiological Studies Depression Questionnaire, and infant fussiness (categorized as fussy/ not fussy) were assessed at 9 months from parent-report questionnaires. We examined the interactive effects of infant fussiness and gestational age categories, and estimated adjusted odds ratios (aOR) and 95% confidence intervals (CI) of maternal depressive symptoms using multinomial logistic regression.ResultsInfant fussiness interacted with gestational age categories in predicting maternal depressive symptoms (p=.04), with severity varying by gestational age and infant fussiness. Compared with mothers of VPT infants without fussiness, mothers of VPT infants with fussiness had higher odds of mild depressive symptoms (aOR=2.32, 95%CI [1.19, 4.53]). Similarly, compared with mothers of MLPT and FT infants without fussiness, mothers of fussy MLPT and FT infants had higher odds of moderate-severe symptoms (aOR=2.30, 95%CI [1.40, 3.80], and aOR=1.74, 95%CI [1.40, 2.16] respectively).ConclusionsMothers of MLPT and FT infants with fussiness had increased odds of moderate-severe depressive symptoms, and mothers of VPT infants with fussiness had increased risk of mild symptoms. Early screening for infant fussiness in preterm and full-term infants may help identify mothers with depressive symptoms in need of support.
Abstract: Publication date: Available online 10 March 2019Source: Academic PediatricsAuthor(s): Ruth S. Faircloth, Daniel I. Brooks, Karen S. Vogt, Jill E. Emerick ObjectivesTo determine parent preferences when discussing their child's weight regarding weight-based terms, most motivating terms, preferred setting, and if the awareness of their child's weight status impacted these preferences.Study DesignParents of children aged 3-17 years (N=349) presenting for health supervision visits completed a survey to assess the degree of offensiveness and motivation for change of commonly used weight-based terminology, and preferred setting for discussion of weight. Parents were asked to assess their child's weight status using recommended terminology (obese, overweight, healthy weight, underweight) and their response was compared to the child's objective BMI percentile.ResultsChildren were a median age of 10.3 years, 47.3% female, 15.8% with overweight (85th-94th %ile BMI), and 11.5% with obesity (≥95th %ile BMI). Of children with overweight/obesity, 85.2% of parents underestimated their child's weight status. Least offensive terms were “at risk weight”, “BMI is high”, “BMI is above 95%”, and “unhealthy weight”. More offensive terms (p
Abstract: Publication date: Available online 9 March 2019Source: Academic PediatricsAuthor(s): Marcia A. Morgenlander, Hollyce Tyrrell, Lynn C. Garfunkel, Janet R. Serwint, Michael J. Steiner, Samantha SchillingABSTRACTObjectiveDescribe current practices in systematic screening for social determinants of health (SDH) in pediatric resident clinics enrolled in the Continuity Research Network (CORNET).MethodsCORNET clinic directors were surveyed on demographics, barriers to screening, and screening practices for 15 SDH including the screen source, the timing of screening, the process of administering the screen, and the personnel involved in screening. Incidence rate ratios were tabulated to investigate relationships among screening practices and clinic staff composition.ResultsClinic response rate was 41% (65/158). Clinics reported screening for between 0 and 15 SDH (median, 7). Maternal depression (86%), child educational problems (84%), and food insecurity (71%) were the items most commonly screened. Immigration status (17%), parental health literacy (19%), and parental incarceration (21%) were least commonly screened. Within 3 years, clinics plan to screen for 25% of SDH not currently being screened. Lack of time (63%), resources (50%), and training (46%) were barriers to screening.ConclusionsScreening for SDH in our study population of CORNET clinics is common but has not been universally implemented. Screening practices are variable and reflect the complex nature of screening, including the heterogeneity of the patient populations, the clinic staff composition, and the SDH encountered.
Abstract: Publication date: Available online 9 March 2019Source: Academic PediatricsAuthor(s): Nicole Meyers, Alexander F. Glick, Alan L. Mendelsohn, Ruth M. Parker, Lee M. Sanders, Michael S. Wolf, Stacy Bailey, Benard P. Dreyer, Jessica J. Velazquez, H. Shonna YinABSTRACTOBJECTIVEParent use of technology to manage child health issues has the potential to improve access and health outcomes. Few studies have examined how parent health literacy affects usage of Internet and cell phone technologies for health management.METHODSCross-sectional analysis of data collected as part of a randomized controlled experiment in 3 urban pediatric clinics. English- and Spanish-speaking parents (n=858) of children ≤8 years answered questions regarding use of and preferences related to Internet and cell phone technologies. Parent health literacy was measured using the Newest Vital Sign.RESULTSThe majority of parents were high Internet (70.2%) and cell phone (85.1%) utilizers (multiple times a day). 75.1% had limited health literacy (32.1% marginal, 43.0% low). Parents with higher health literacy had greater Internet and cell phone use (adequate vs. low: AOR=1.7[1.2-2.5]) and were more likely to use them for health management (AOR=1.5[1.2-1.8]); those with higher health literacy were more likely to use the Internet for provider communication (adequate vs. marginal vs. low: 25.0 vs. 18.0 vs. 12.0%, p=0.001) and health-related cell phone apps (40.6 vs. 29.7 vs. 16.4%, p
Abstract: Publication date: Available online 9 March 2019Source: Academic PediatricsAuthor(s): Valerie S. Harder, Sara E. Barry, Sarah French, Alyssa B. Consigli, Barbara L. FrankowskiABSTRACTObjectiveDepression among adolescents is a leading public health problem. While screening for adolescent depression in primary care is strongly recommended, screening rates remain low. Effective quality improvement (QI) initiatives can facilitate change. This study aims to assess the impact of a QI learning collaborative on adolescent depression screening and initial plans of care in primary care.MethodsSeventeen pediatric-serving practices in Vermont participated in a QI learning collaborative aimed at improving practitioner knowledge and office systems around adolescent depression screening. Monthly medical record reviews provided monitoring of adolescent depression screening and initial plans of care over seven months for QI. Randomly sampled annual medical record review data allowed comparison of screening and initial plans of care after the QI learning collaborative between participating and 21 control practices.ResultsAs practices improved their office systems around adolescent depression screening and initial plans of care, data showed marked improvement in depression screening at all 17 practices, from 34% to 97% over seven months. Adolescents at participating practices had 3.5 times greater odds (95% CI 1.14-10.98, P=0.03) of being screened for depression and 37.5 times greater odds (95% CI 7.67-183.48, P
Abstract: Publication date: Available online 8 March 2019Source: Academic PediatricsAuthor(s): Jade McNeill, Steven J. Howard, Stewart A. Vella, Dylan P. CliffABSTRACTObjectiveTo investigate associations of traditional (program viewing) and contemporary electronic media use (electronic applications; ‘apps’) with preschoolers’ executive function and psychosocial development 12 months later.MethodsAn analysis of longitudinal data from 185 children (mean age: 4.2 ± 0.6 years). Parents reported children's weekly electronic media use; viewing programs on TV or other devices; and app and game play using tablets, computers, consoles, or other devices. Direct assessments of children's executive functions (working memory, inhibition and shifting) and educator-reported psychosocial difficulties were also collected. Linear regression models assessed associations between baseline predictors and developmental outcomes 12 months later, adjusting for covariates, preschool clustering and baseline levels of predictors.ResultsHigher levels of program viewing at baseline were significantly associated with increases in externalising behaviours (b = 0.008; 95% CI: 0.002, 0.014; p = .010) and total difficulties (b = 0.013; 95% CI: 0.005, 0.022; p = .005) at follow-up. High dose app users (≥30 min/day) had a significantly lower inhibition score (MD = -0.04 CI: -0.09, -0.00, p = 0.044) at follow-up compared to low dose app users (1-29 min/day).ConclusionsLimiting electronic app use to
Abstract: Publication date: Available online 7 March 2019Source: Academic PediatricsAuthor(s): Katherine M Richardson, Sarah D Fouquet, Ellen Kerns, Russell J McCulloh ObjectiveTo evaluate the individual-level impact of an electronic clinical support (ECDS) tool, PedsGuide, on febrile infant clinical decision making and cognitive load.MethodsA counterbalanced, prospective, cross-over simulation study was performed amongst attending and trainee physicians. Participants performed simulated febrile infant cases with use of PedsGuide and with standard reference text. Cognitive load was assessed using the NASA-Task Load Index (NASA-TLX) which determines mental, physical, temporal demand, effort, frustration, and performance. Usability was assessed with the System Usability Scale (SUS). Scores on cases and NASA-TLX scores were compared between condition states.ResultsA total of 32 participants completed the study. Scores on febrile infant cases using PedsGuide were higher compared to standard reference text (89% vs. 72%, p=0.001). NASA-TLX scores were lower (i.e. more optimal) with use of PedsGuide vs. control (mental 6.34 vs. 11.8, p
Abstract: Publication date: March 2019Source: Academic Pediatrics, Volume 19, Issue 2Author(s): Rebecca N. Dudovitz, Mitchell D. Wong, Giselle Perez-Aguilar, Grace Kim, Paul J. Chung
Abstract: Publication date: March 2019Source: Academic Pediatrics, Volume 19, Issue 2Author(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
Abstract: Publication date: March 2019Source: Academic Pediatrics, Volume 19, Issue 2Author(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 been made 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 (NGTs), one with residents and one with faculty and fellow supervisors, were used to generate RSQMs for 3 specific illnesses (asthma, bronchiolitis, and closed head injury) as well as general care for the pediatric emergency department. 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 3 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.ConclusionsThis study continues to pave the path forward in developing future RSQMs by exploring specific settings, measures, and stakeholders to consider when undertaking this work.
Abstract: Publication date: March 2019Source: Academic Pediatrics, Volume 19, Issue 2Author(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 home visit experiences with families of children with special needs demonstrate evidence of exposure to 9 selected competencies for pediatric clerkships designated by the Council on Medical Student Education in Pediatrics.MethodsWe reviewed written reflections from 152 third-year medical students. For each competency (2 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 1 of the 8 expected competencies. Each reflection exhibited an average of 3 (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 nonverbal communication skills (a combination of 2 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.
Abstract: Publication date: March 2019Source: Academic Pediatrics, Volume 19, Issue 2Author(s): Lindsay Johnston, Taylor Sawyer, Akira Nishisaki, Travis Whitfill, Anne Ades, Heather French, Kristen Glass, Rita Dadiz, Christie Bruno, Orly Levit, Sandeep Gangadharan, Daniel Scherzer, Ahmed Moussa, Marc Auerbach, INSPIRE Research Network BackgroundNeonatal 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 an NTI competency assessment tool with multisource validity evidence could be developed and be used for formative and summative assessment during simulation-based training.MethodsAn NTI assessment tool was developed based on a literature review. The tool was refined through 2 rounds of a modified Delphi process involving 12 subject-matter experts. The final tool included a 22-item checklist, a global skills assessment, and an entrustable professional activity (EPA) level. The validity of the checklist was assessed by having 4 blinded reviewers score 23 videos of health care providers intubating a neonatal simulator.ResultsThe checklist items had good internal consistency (overall α = 0.79). Checklist scores were greater for providers at greater training levels and with more NTI experience. Checklist scores correlated with global skills assessment (ρ = 0.85; P < .05), EPA levels (ρ = 0.87; P < .05), percent glottic exposure (r = 0.59; P < .05), and Cormack-Lehane scores (ρ = 0.95; P < .05). Checklist scores reliably predicted EPA levels.ConclusionsWe developed an NTI competency assessment tool with multisource 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.
Abstract: Publication date: March 2019Source: Academic Pediatrics, Volume 19, Issue 2Author(s): Dominick DeBlasio, Francis J. Real, Nicholas J. Ollberding, Melissa D. Klein ObjectiveTo determine the impact of a curriculum that included parent feedback, via the Communication Assessment Tool (CAT), 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 CAT, a validated survey to assess physician communication. Intervention residents participated in learning conferences that reviewed communication best practices and received parental feedback via individual and group CAT scores. Scores were dichotomized as 5 (excellent) versus 1 to 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 the beginning of the year to the 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%–73.8% vs 61.1%–69.8; P = .38). When scores of residents in both arms were combined, improvement was found from the beginning to the end of the year for all CAT items (P < .001).ConclusionsA curriculum including parent feedback from CATs did not significantly impact communication skills. However, communication skills improved over the year in intervention and control groups, suggesting that communication training occurs in multiple settings.
Abstract: Publication date: March 2019Source: Academic Pediatrics, Volume 19, Issue 2Author(s): Matthew W. Zackoff, Francis J. Real, Erika L. Abramson, Su-Ting T. Li, Melissa D. Klein, Maryellen E. Gusic Historically, health sciences education has been guided by tradition and teacher preferences rather than by the application of practices supported by rigorous evidence of effectiveness. Although 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 by employing 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.
Abstract: Publication date: March 2019Source: Academic Pediatrics, Volume 19, Issue 2Author(s): Su-Ting T. Li, Melissa Klein, Katherine A. Poehling, Robert M. Jacobson
Abstract: Publication date: March 2019Source: Academic Pediatrics, Volume 19, Issue 2Author(s): Esther K. Chung, Ruth S. Gubernick, Marianna LaNoue, Diane J. Abatemarco ObjectivesPracticing Safety is an American Academy of Pediatrics 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 initiative to standardize CAN risk assessment, using materials adapted from Practicing Safety, was conducted through the use of SmartTools in an electronic health record. 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 to 3); monthly for 6 months (waves 4 to 9); and quarterly for 12 months (waves 10 to 13)—to assess screening and resource provision for 6 domains: infant crying, maternal depression, development, discipline, temper tantrums, and toilet training.ResultsA total of 581 charts were reviewed (92, 95, and 94 for waves 1 to 3, respectively; 30 each for waves 4 to 13). Screening for infant crying, maternal depression, development, and discipline rose from 0% pre-implementation to over 50% post-implementation. Screening for temper tantrums and toilet training rose from 6% to 72% and from 36% to 82%, respectively. For all measures, resource provision improved over time, and all improvements were maintained for 1.5 years post-implementation.ConclusionsIncorporating an adapted version of Practicing Safety into an electronic health record is a practical and effective approach to improving CAN risk assessment and resource provision. This quality improvement initiative is an example of a practice-wide improvement that resulted in clinical practice change.
Abstract: Publication date: Available online 1 March 2019Source: Academic PediatricsAuthor(s): Peter D. Wong, Patricia C. Parkin, Rosemary G. Moodie, David W.H. Dai, Jonathan L. Maguire, Catherine S. Birken, Cornelia M. Borkhoff, TARGet Kids! CollaborationABSTRACTBackground and ObjectiveHealth care policy positions breastfeeding as an important part of the solution to household food insecurity. The relationship between breastfeeding duration (exposure variable) and household food insecurity (outcome variable) has critical gaps in knowledge to support this hypothesis. Our objective was to examine this relationship.MethodsA cross-sectional study was conducted of healthy urban children (n=3838), aged 0-3 years recruited from the TARGet Kids! practice-based research network, Toronto, Canada (2008-16). Total breastfeeding duration was collected from parent-reported questionnaires. Household food insecurity was measured using 1-item and 2-item food insecurity screens. Multivariable regression analysis was performed adjusting for pre-specified covariates.ResultsThe median total breastfeeding duration was 10.5 months (Interquartile Range 6.0, 14.0) and 14.7% of households were food insecure. After adjusting for child characteristics (age and sex), maternal characteristics (age, ethnicity, education, employment) and family characteristics (number of children, single parent family, neighborhood equity score) there was no significant association between total breastfeeding duration and household food insecurity (OR 0.99; 95% CI 0.98-1.01). While low-income families had an increased odds of being household food insecure (P≤0.001), we found no significant association between total breastfeeding duration and household food insecurity at varying income levels.ConclusionsWe found no association between breastfeeding duration and household food insecurity, regardless of family income. Although breastfeeding is associated with improved child health outcomes and considered to be part of the solution to household food insecurity, interventions focused on social determinants may provide more promising targets for the prevention of household food insecurity.
Abstract: Publication date: Available online 23 February 2019Source: Academic PediatricsAuthor(s): Nisha Dalvie, Victoria Nguyen, Eve Colson, Jaspreet Loyal ObjectiveDue to increasing popularity, our hospital began considering distributing cardboard boxes combined with safe sleep education to new mothers. As a first step in studying the impact of this intervention on bedsharing in our community, we sought to understand mothers’ perceptions of the cardboard box.MethodsWe recruited primarily low-income, English or Spanish speaking mothers of infants aged 2-16 weeks during routine primary care visits. Participants responding to a cross-sectional survey about infant sleep practices were invited to participate in in-depth interviews about the cardboard box. We used a grounded theory approach and the constant comparative method until saturation was reached.ResultsOf 120 participants in the survey, 50 (42%) participated in the qualitative study. Participants were mothers of infants aged ≤ 4 weeks (46%), 4-8 weeks (32%) and 16 weeks (22%). Of 50 participants, 52% said they would use the cardboard box for their infant to sleep in, if provided, compared with 42% who said they would not and 6% were unsure. Three themes emerged from the data: (1) safety of the cardboard box; (2) appearance and (3) variation in planned use. Some participants planned to place the cardboard box in their bed.ConclusionsParticipants in our study were divided about whether they would use the cardboard box for their infant to sleep in. If distributed, hospital staff should advise families to not place the cardboard box in their bed. Next steps include determining bedsharing frequency amongst parents who choose to use the cardboard box for their infant.
Abstract: Publication date: Available online 21 February 2019Source: Academic PediatricsAuthor(s): Elizabeth E Halvorson, Thomas Curley, Mariah Wright, Joseph A Skelton ObjectiveWeight bias can influence medical care but has not been studied in the pediatric inpatient setting. We will quantify implicit and explicit weight bias of pediatric inpatient providers and qualitatively explore providers’ attitudes toward children with obesity and patient/family perceptions of weight bias in the hospital.MethodsWe performed a mixed-methods study including semi-structured key informant interviews and validated tests for implicit (Implicit Association Test, IAT) and explicit (Crandall's Anti-Fat Attitudes Questionnaire, AFAQ) bias with pediatric hospitalists, residents, and acute care nurses. We performed semi-structured key informant interviews with pediatric inpatients aged 7-17 years and the patient's parent(s) or guardian(s). Interviews were coded using an inductive approach to identify recurrent themes.ResultsWe enrolled 28 pediatric providers, 12 patients, and 12 parents/guardians. 71% of providers exhibited moderate or significant implicit weight bias, with generally lower scores for explicit bias. Qualitative analysis identified seven themes: the existence of weight bias, shared responsibility for a child's obesity, a potential for provider bias towards the parents of pediatric patients with obesity, possible effects of patient weight on inpatient care, importance of terminology in addressing obesity, and the possibility of addressing obesity inpatient but a preference for obesity to be addressed in the outpatient setting.ConclusionsHealth care providers, patients, and families in the pediatric inpatient setting identified multiple ways that obesity could impact care, including provider weight bias.
Abstract: Publication date: Available online 14 February 2019Source: Academic PediatricsAuthor(s): Maheswari Ekambaram, Matilde M. Irigoyen, Andrew Paoletti, Iqra SiddiquiABSTRACTObjectivePacifier use decreases the risk of Sudden Infant Death Syndrome (SIDS) but its impact on breastfeeding remains controversial. We evaluated the impact of a Baby Friendly-aligned pacifier policy on subsequent pacifier use and breastfeeding at one month of age.MethodsWe conducted a prospective two stage (pre- and post-) cohort study of newborns at a birth hospital before and after implementation of a Baby Friendly-aligned pacifier policy. Consecutive mothers of newborns admitted to the nursery participated in a telephone survey at one month of age.Results342 mothers participated (190 pre-, 152 post-). Pacifier adoption was delayed in the post-group, but pacifier use by one month of age was comparable (78.9% pre-, 77.6% post-, p 0.793). In the pre-group, female and male infants used pacifier at comparable rates, but in the post-group females were significantly less likely to use a pacifier compared to males after controlling for insurance, race, parity and delivery mode (aOR 0.35, 95% CI – 0.15-0.83; p=0.02). In the post-group, exclusive breastfeeding rates at discharge increased significantly (from 40% to 51.3%, p=0.04) but rates were not different at one month (23.7% pre-, 24.3% post-, p=0.89).ConclusionA Baby Friendly-aligned pacifier policy delayed pacifier adoption but did not impact overall pacifier use or breastfeeding rates at one month of age. The finding of lower pacifier use rates among female infants post- intervention needs verification in other populations before evaluating public heath relevance.
Abstract: Publication date: Available online 29 January 2019Source: Academic PediatricsAuthor(s): Gunjan Tiyyagura, Paula Schaeffer, Marcie Gawel, John M. Leventhal, Marc Auerbach, Andrea G. Asnes ObjectivesEmergency Department (ED) providers may fail to recognize or report child abuse and/or neglect (CAN). To improve recognition and reporting, we designed the Community ED CAN Program in which teams of local clinicians (nurses, physicians, physician assistants) received training in CAN and 1) disseminated evidence-based education, 2) provided consultation, case follow-up and access to specialists, and 3) facilitated multi-disciplinary case review. The aims of this study were to understand the Program's strengths and challenges and to explore factors that influenced implementation.MethodsWe used a qualitative research design with semi-structured, oneon-one interviews to understand key stakeholders' perspectives of the Community ED CAN Program. We interviewed twenty-seven stakeholders at 3 community hospitals and 1 academic medical center. Researchers analyzed transcribed data using constant comparative method of grounded theory and developed themes.ResultsProgram strengths included: 1) Comfort in seeking help from local champions, 2) access to CAN experts, 3) increased CAN education/awareness and 4) improved networks and communication. Facilitators of implementation included: 1) leadership support, 2) engaged local champions and external change agents (eg, CAN experts), 3) positive attributes of the champions and 4) implementation flexibility. Program Challenges/Barriers to implementation included: 1) variability of institutional support for the champions and 2) variability in awareness about the program.ConclusionsA Community ED CAN Program has the potential to improve recognition and reporting of CAN. Key steps to facilitate implementation include the identification of committed local champions, strong leadership support, connections to experts, program publicity and support of the champions' time.
Abstract: Publication date: Available online 28 January 2019Source: Academic PediatricsAuthor(s): David Vyles, Rakesh Mistry, Viday Heffner, Patrick Drayna, Asriani Chiu, Alexis Visotcky, Raphael Fraser, David C. Brousseau BackgroundPEM and PCP providers are the most likely physicians to initially label a child as penicillin allergic. Differences in knowledge and management of reported penicillin allergy between these two groups has not been well characterized.MethodsA cross-sectional 20-question survey was administered to PEM and PCP's to ascertain differential knowledge and management of penicillin allergy. Knowledge regarding high and low-risk symptoms for true allergy and extent of history taking regarding allergy were compared between the two groups using t-tests, Chi-square and Wilcoxon tests.Results182 PEM and 54 PCP's completed the survey. PEM and PCP's reported that 74.1% ± 19.5 and 69.0% ± 23.8 of patients with remote low-risk symptoms of allergy could tolerate penicillin without an allergic reaction. PEM and PCP's incorrectly identified low-risk symptoms of allergy, as high-risk, including vomiting with medication administration and delayed skin rash. PCP's took more detailed allergy histories when compared to PEM providers. 143 (78.5%) of PEM providers and 51 (94.4%) PCP's were interested in utilizing a penicillin allergy questionnaire to segregate children into high or low-risk categories.ConclusionMost pediatric providers believe that children with a remote history of low-risk allergy symptoms could tolerate penicillin without an allergic reaction, however this is infrequently acted upon. Both PEM and PCP providers were likely to classify low-risk symptoms as high-risk and infrequently referred children for further detailed allergy assessment. Both groups were receptive to decision support measures to facilitate improved penicillin allergy classification and labeling and support antibiotic appropriateness in their patients.
Abstract: Publication date: Available online 21 January 2019Source: Academic PediatricsAuthor(s): Kayla Morel, Kelsey Nichols, Yvonne Nong, Nalini Charles, Sarah Price, Elsie Taveras, Roberta Goldman, Jennifer A. Woo BaidalABSTRACTBackgroundNovel approaches to reduce sugar-sweetened beverage (SSB) consumption during the first 1,000 days – pregnancy through age 2 years - are urgently needed.ObjectiveTo examine perceptions of SSB consumption and acceptability of potential intervention strategies to promote SSB avoidance in low income families in the first 1,000 days.MethodsIn this qualitative research, we performed semi-structured in-depth interviews of 25 women and 7 nutrition/health care providers. Eligible women were WIC-enrolled and pregnant or had an infant under age 2 years. Eligible providers cared for families during the first 1,000 days. Using immersion-crystallization techniques we examined perceptions, barriers, and facilitators related to avoidance of SSB consumption; acceptability of messages framed as positive gains or negative losses; and perceived influence on SSB consumption of various intervention modalities.ResultsThemes related to SSB consumption included parental confusion about healthy beverage recommendations, and maternal feelings of lack of control over beverage choices due to pregnancy cravings and infant tastes. Themes surrounding message frames included: negative health consequences of sugary drink consumption are strong motivators for behavior change; and savings and cost count, but are not top priority. Highly acceptable intervention strategies included use of images showing health consequences of SSB consumption, illustrations of sugar content at the point of purchase, and multi-modal delivery of messages.ConclusionsMessages focused on infant health consequences and parental empowerment to evaluate and select healthier beverages based on sugar content should be tested in interventions to reduce SSB consumption in the first 1,000 days.
Abstract: Publication date: Available online 16 January 2019Source: Academic PediatricsAuthor(s): Richard G. Bachur, Kenneth A. Michelson, Mark I. Neuman, Michael C. MonuteauxABSTRACTObjectivesAs both fever and pneumonia can be are associated with tachypnea, we investigated the relationship between body temperature and respiratory rate (RR) in young children and whether temperature-adjusted RR enhances the prediction of pneumonia.MethodsIn this retrospective cross-sectional analysis of 91,429 children
Abstract: Publication date: Available online 11 January 2019Source: Academic PediatricsAuthor(s): Ariel S. Winn, Lise E. Nigrovic, Frederick H. Lovejoy, Thomas J. Sandora
Abstract: Publication date: Available online 11 January 2019Source: Academic PediatricsAuthor(s): Danielle Cullen, Ashley Woodford, Joel Fein Background/ObjectiveAlthough there is growing interest in screening for food insecurity in the clinical setting, little evidence exists regarding screening formats that maximize disclosure and caregiver comfort.MethodsIn this randomized trial, we asked English-speaking adult caregivers of pediatric patients in the ED at an urban, freestanding children's hospital to complete a validated, two-question screen for FI. Respondents were assigned via block randomization to complete the survey by either verbal interview or electronic tablet. Caregivers reported perceived importance of the screening questions, comfort level with screening in the ED or in their child's primary care site, and their preference of screening modality.Results20.6% of the 1818 participants screened positive for FI. There was a significantly higher rate of reported FI for those screened by tablet (23.6%) compared to those screened verbally (17.7%) (p=0.002). Of those who had a preference of screening modality, 83.2% of all participants, and 84.5% of patients reporting FI, preferred tablet-based screen over verbal interview. Overall, more participants reported comfort completing the screen in the ED compared to their child's doctor's office however comfort in both of these setting were rated highly (86.1% vs. 80.2%, p
Abstract: Publication date: Available online 10 January 2019Source: Academic PediatricsAuthor(s): Meinou H.C. Theunissen, Marianne S. de Wolff, Sijmen A. Reijneveld PurposeValidated questionnaires help community pediatric services to identify emotional and behavioral problems (EBP). This study assesses the psychometric properties of the self-report version of the Strengths and Difficulties Questionnaire for the identification of EBP in adolescents (13-14 years) and the added value of the SDQ parent-form.MethodsWe obtained data on 500 adolescents (mean age 13.5 years) from community well-child services and schools. Adolescents completed the SDQ self-report, and the Youth Self-Report (YSR). Parents completed the SDQ parent-form and the Child Behavior Checklist (CBCL) for their child. We assessed the internal consistency and validity using the YSR and CBCL as the criteria, and the degree to which the SDQ parent-form provides additional information by comparison with the self-report.ResultsThe internal consistency of the SDQ Total Score was good (Cronbach's alpha 0.75). Sensitivity and specificity using the YSR as the criterion were 0.75 and 0.91 respectively. When the CBCL was adopted as the criterion, these validity indices were lower. The SDQ parent-form does not provide additional information by comparison with self-reporting only when the YSR score is used as the criterion (odds ratio 0.48, 95%, CI 0.14-1.65) but it does do so when the CBCL is the criterion (odds ratio 10.9, 95%-CI 4.23-27.9).ConclusionsThe SDQ self-report is valid for the detection of EBP in adolescents and the SDQ parent-form provides additional information by comparison with the self-report. This indicates that it is useful to involve adolescents and their parents as informants for the identification of EBP in adolescents.
Abstract: Publication date: January–February 2019Source: Academic Pediatrics, Volume 19, Issue 1Author(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.
Abstract: Publication date: January–February 2019Source: Academic Pediatrics, Volume 19, Issue 1Author(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.
Abstract: Publication date: January–February 2019Source: Academic Pediatrics, Volume 19, Issue 1Author(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.
Abstract: Publication date: January–February 2019Source: Academic Pediatrics, Volume 19, Issue 1Author(s): Anna D. Johnson, Christina M. Padilla ObjectiveWe investigated links between childcare experiences—specifically, care instability and mothers' perceptions of care access—and maternal depressive symptoms in an effort to illuminate policy-amenable mechanisms through which childcare experiences can support maternal mental health.MethodsData were taken from the nationally representative Early Childhood Longitudinal Study–Birth Cohort. We used regression models with lagged dependent variables to estimate associations between aspects of childcare instability and perceptions of care availability and maternal depressive symptoms. We did so on the full sample and then on subgroups of mothers for whom childcare instability may be especially distressing: mothers who are low income, working, single, or non-native speakers of English.ResultsChildcare instability—length in months in the longest arrangement and number of arrangements—was not associated with maternal depressive symptoms. However, mothers’ perceptions of having good choices for care were associated with a reduced likelihood of clinical depressive symptoms, even after controlling for prior depressive symptoms and concurrent parenting stress; this latter association was observed both in the full sample (adjusted odds ratio [AOR] = 0.77; 95% confidence interval [CI] = 0.63–0.96) and among subgroups of employed mothers (AOR = 0.71; CI = 0.57–0.87) and single mothers (AOR = 0.72; CI = 0.52–0.99).ConclusionsAlthough dimensions of care instability did not associate with maternal depressive symptoms, mothers’ perceptions of available care options did. If replicated, findings would highlight a previously unconsidered avenue—increasing care accessibility and awareness of available options—for promoting maternal mental health in a population likely to experience depression but unlikely to be treated.
Abstract: Publication date: Available online 20 December 2018Source: Academic PediatricsAuthor(s): Michelle Shankar, Maria Fagnano, Susan W. Blaakman, Hyekyun Rhee, Jill S. HaltermanABSTRACTObjectivesAsthma is the most common chronic disease of childhood in the U.S., disproportionately affecting urban, poor, and minority children. Adolescents are at high risk for poor asthma outcomes and for depressive symptoms. The purpose of this study is to investigate associations between depressive symptoms and asthma-related clinical and functional outcomes among urban teens.MethodsWe used baseline data from a 3-arm randomized trial, School-Based Asthma Care for Teens (SB-ACT), in Rochester, NY. We used the Center for Epidemiological Studies -Depression scale with a standard cutoff score of 16 to identify subjects at risk for clinical depression. We used structured in-home surveys and validated scales to assess clinical and functional outcomes and conducted bivariate and multivariate analyses to evaluate differences between groups.ResultsWe identified 277 eligible teens (ages 12-16, participation 80%, 54% Black, 34% Hispanic, 45% Female, 84% Medicaid). Overall, 28% reported depressive symptoms. Teens with depressive symptoms experienced greater asthma symptom severity and more acute healthcare utilization for asthma (all p
Abstract: Publication date: Available online 11 December 2018Source: Academic PediatricsAuthor(s): Alexander F. Glick, Suzy Tomopoulos, Arthur H. Fierman, Anne Elixhauser, Leonardo Trasande ObjectivePneumonia is a leading cause of pediatric admissions. While air pollutants are associated with poor outcomes, few national studies have examined associations between pollutant levels and inpatient pediatric pneumonia outcomes. We examined the relationship between ozone (O3) and fine particulate matter with a diameter ≤2.5µm (PM2.5) and outcomes related to disease severity.MethodsIn this cross-sectional study, we obtained discharge data from the 2007-2008 Nationwide Inpatient Sample and pollution data from the Air Quality System. Patients ≤18 years with a principal diagnosis of pneumonia were included. Discharge data were linked to O3 and PM2.5 levels (predictors) from the patient's ZIP Code (not publicly available) from day of admission. Outcomes were mortality, intubation, length of stay (LOS), and total costs. We calculated weighted national estimates and performed multivariable analyses adjusting for sociodemographic and hospital factors.ResultsThere were a total of 57,972 (278,871 weighted) subjects. Median PM2.5 level was 9.5 (interquartile range [IQR] 6.8 to 13.4) µg/m3. Median O3 level was 35.6 (IQR 28.2 to 45.2) parts per billion. Mortality was 0.1%; 0.75% of patients were intubated. Median LOS was 2 (IQR 2 to 4) days. Median costs were $3,089 (IQR $2,023 to $5,177). Higher levels of PM2.5 and O3 were associated with mortality, longer LOS, and higher costs. Higher O3 levels were associated with increased odds of intubation.ConclusionsHigher levels of O3 and PM2.5 were associated with more severe presentations of pneumonia. Future work should examine these relationships in more recent years and over a longer time period.
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.
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
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.
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.
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.
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.
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.
Abstract: Publication date: Available online 9 October 2018Source: Academic PediatricsAuthor(s): Kelsey A. Miller, Debra Hillier, Christiana Russ, Marcella Luercio, Ariel S. Winn
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.
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).
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.
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.
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.
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.
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.
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.
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
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.
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.
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.
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