Journals

Pediatrics

Pediatrics

PEDIATRICS current issue

  • Estimated Nonreimbursed Costs for Care Coordination for Children With Medical Complexity
    BACKGROUND AND OBJECTIVES:
    Multidisciplinary care teams may improve health and control total cost for children with medical complexity (CMC). We aim to quantify the time required to perform nonreimbursed care coordination activities by a multidisciplinary care coordination program for CMC and to estimate the direct salary costs of that time.
    METHODS:
    From April 2013 to October 2015, program staff tracked time spent in practicably measured nonbilled care coordination efforts. Staff documented the discipline involved, the method used, and the target of the activity. Cost was estimated by multiplying the time spent by the typical salary of the type of personnel performing the activity.
    RESULTS:
    Staff logged 53 148 unique nonbilled care coordination activities for 208 CMC. Dietitians accounted for 26% of total time, physicians and nurse practitioners 24%, registered nurses 29%, and social workers 21% (1.8, 2.3, 1.2, and 1.4 hours per CMC per month per full-time provider, respectively). Median time spent in nonreimbursed care coordination was 2.3 hours per child per month (interquartile range 0.8–6.8). Enrollees required substantially greater time in their first program month than thereafter (median 6.7 vs 2.1 hours per CMC per month). Based on 2015 national salary data, the adjusted median estimated cost of documented activities ranged from $145 to $210 per CMC per month.
    CONCLUSIONS:
    In this multidisciplinary model, care coordination for CMC required substantial staff time, even without accounting for all activities, particularly in the first month of program enrollment. Continued advocacy is warranted for the reimbursement of care coordination activities for CMC.


  • A 17-Year-Old Boy With High-Functioning Autism, Gastrointestinal Illness, and Seizures
    A healthy 17-year-old boy with a high-functioning pervasive developmental disorder presented to the emergency department after having a 4-minute episode of seizure-like activity in the setting of presumed viral gastroenteritis. Within an hour of emergency department arrival, he developed a forehead-sparing facial droop, right-sided ptosis, and expressive aphasia, prompting stroke team assessment and urgent neuroimaging. Laboratory results later revealed a serum sodium of 119 mmol/L. Neurologic deficits self-resolved, and a full physical examination revealed diffuse abdominal tenderness in the lower abdomen with rebound tenderness in the right-lower quadrant. The patient was admitted to the PICU for electrolyte management and monitoring. A computed tomography (CT) scan of the abdomen obtained the following morning revealed the patient’s final diagnosis.


  • Use of Social Psychology to Improve Adherence to National Bronchiolitis Guidelines
    OBJECTIVES:
    The American Academy of Pediatrics’ bronchiolitis guidelines recommend against albuterol and corticosteroids for treating and chest radiographs (CRs) for diagnosing infants with bronchiolitis. However, high rates of nonadherence have been documented. Our objective was to improve guideline adherence in infants with bronchiolitis.
    METHODS:
    This quality improvement study was conducted in 1 urban academic pediatric primary care clinic caring for predominately minority and publicly insured children. We tested provider guideline education, display of guidelines in patient care areas, and monthly e-mails to all providers documenting deviation rates, with individual e-mails to providers who deviated. P-charts and interrupted time series analysis were used to estimate the effect of the intervention.
    RESULTS:
    There were 380 children


  • Positive Predictive Value of Administrative Data for Neonatal Abstinence Syndrome
    OBJECTIVES:
    Neonatal abstinence syndrome (NAS) is a postnatal withdrawal syndrome experienced by some infants with opioid exposure. Hospital administrative data are commonly used for research and surveillance but have not been validated for NAS. Our objectives for this study were to validate the diagnostic codes for NAS and to develop an algorithm to optimize identification.
    METHODS:
    Tennessee Medicaid claims from 2009 to 2011 (primary sample) and 2016 (secondary sample; post–International Classification of Diseases, 10th Revision, Clinical Modification [ICD-10-CM]) were obtained. Cases of NAS were identified by using International Classification of Diseases, Ninth Revision, Clinical Modification code (2009–2011) 779.5 and ICD-10-CM code (2016) P96.1. Medical record review cases were then conducted by 2 physicians using a standardized algorithm, and positive predictive value (PPV) was calculated. Algorithms were developed for optimizing the identification of NAS in administrative data.
    RESULTS:
    In our primary sample of 112 029 mother-infant dyads, 950 potential NAS cases were identified from Medicaid claims data and reviewed. Among reviewed records, 863 were confirmed as having NAS (including 628 [66.1%] cases identified as NAS requiring pharmacotherapy, 224 [23.5%] as NAS not requiring pharmacotherapy, and 11 [1.2%] as iatrogenic NAS), and 87 (9.2%) did not meet clinical criteria for NAS. The PPV of the International Classification of Diseases, Ninth Revision, Clinical Modification code for NAS in clinically confirmed NAS was 91% (95% confidence interval: 88.8%–92.5%). Similarly, the PPV for the ICD-10-CM code in the secondary sample was 98.2% (95% confidence interval: 95.4%–99.2%). Algorithms using elements from the Medicaid claims and from length of stay improved PPV.
    CONCLUSIONS:
    In a large population-based cohort of Medicaid participants, hospital administrative data had a high PPV in identifying cases of clinically diagnosed NAS.


  • Use of a Clinical Care Algorithm to Improve Care for Children With Hematogenous Osteomyelitis
    BACKGROUND AND OBJECTIVES:
    Acute hematogenous osteomyelitis (AHO) causes significant morbidity in children. Quality improvement (QI) methods have been used to successfully improve care and decrease costs through standardization for numerous conditions, including pediatric AHO. We embarked on a QI initiative to standardize our approach to the inpatient management of AHO, with a global aim of reducing inpatient costs.
    METHODS:
    We used existing literature and local consensus to develop a care algorithm for the inpatient management of AHO. We used the Model for Improvement as the framework for the project, which included process mapping, failure mode analysis, and key driver identification. We engaged with institutional providers to achieve at least 80% consensus regarding specific key drivers and tested various interventions to support uptake of the care algorithm.
    RESULTS:
    Fifty-seven patients were included. There were 31 patients in the preintervention cohort and 26 in the postintervention cohort, of whom 19 were managed per the algorithm. Mean inpatient charges decreased from $45 718 in the preintervention cohort to $32 895 in the postintervention cohort; length of stay did not change. Adherence to recommended empirical antimicrobial agents trended upward.
    CONCLUSIONS:
    A simple and low-cost QI project was used to safely decrease the cost of inpatient care for pediatric AHO at a tertiary care children’s hospital. A robust local consensus process proved to be a key component in the uptake of standardization.


  • Neonatal Head Circumference in Newborns With Neonatal Abstinence Syndrome
    OBJECTIVES:
    To compare head circumference (HC) in neonates treated for neonatal abstinence syndrome (NAS) with control neonates without antenatal opioid exposure.
    METHODS:
    Our prospective cohort study ran from April 1, 2014, through December 31, 2016. Newborns treated for NAS delivered from well-dated pregnancies ≥34 weeks’ gestation were compared with newborns who were nonopioid exposed and matched for race, parity, mode of delivery, and gestational age. All mothers underwent serial antenatal urine drug testing. A minimum of 754 study participants were needed (377 in each group) to demonstrate an increase in the proportion of newborns with HCs less than or equal to the 10th percentile from 10% in controls to a minimum of 20% in NAS newborns with 90% power.
    RESULTS:
    A total of 858 neonates were enrolled (429 NAS cases and 429 controls). Mean HC for cases was 33.04 cm (±1.9 cm) compared with 33.99 cm (±2.0 cm) for controls (P < .0001). Among the 429 NAS cases, the mothers of 372 (87%) were on opioid medication-assisted treatment. For NAS cases, 30.1% (95% confidence interval: 25.8%–34.7%) had an HC less than or equal to the 10th percentile (129 of 429 neonates), and 8.2% (95% confidence interval: 5.8%–11.2%) had an HC less than or equal to the third percentile (35 of 429 neonates). Multivariate analysis was used and determined that only chronic opioid use during gestation resulting in a neonate who was NAS treated was a significant risk factor for the observed smaller HC.
    CONCLUSIONS:
    Chronic opioid use during pregnancy sufficient to cause NAS was associated with smaller HCs at birth. Most mothers were on opioid agonist medication-assisted treatment, which is currently the recommended treatment option during pregnancy.


  • Postdischarge Mortality Prediction in Sub-Saharan Africa
    BACKGROUND:
    Although the burden of postdischarge mortality (PDM) in low-income settings appears to be significant, no clear recommendations have been proposed in relation to follow-up care after hospitalization. We aimed to determine the burden of pediatric PDM and develop predictive models to identify children who are at risk for dying after discharge.
    METHODS:
    Deaths after hospital discharge among children aged


  • Insurance Mandates and Out-of-Pocket Spending for Children With Autism Spectrum Disorder
    BACKGROUND:
    The health care costs associated with treating autism spectrum disorder (ASD) in children can be substantial. State-level mandates that require insurers to cover ASD-specific services may lessen the financial burden families face by shifting health care spending to insurers.
    METHODS:
    We estimated the effects of ASD mandates on out-of-pocket spending, insurer spending, and the share of total spending paid out of pocket for ASD-specific services. We used administrative claims data from 2008 to 2012 from 3 commercial insurers, and took a difference-in-differences approach in which children who were subject to mandates were compared with children who were not. Because mandates have heterogeneous effects based on the extent of children’s service use, we performed subsample analyses by calculating quintiles based on average monthly total spending on ASD-specific services. The sample included 106 977 children with ASD across 50 states.
    RESULTS:
    Mandates increased out-of-pocket spending but decreased the share of spending paid out of pocket for ASD-specific services on average. The effects were driven largely by children in the highest-spending quintile, who experienced an average increase of $35 per month in out-of-pocket spending (P < .001) and a 4 percentage point decline in the share of spending paid out of pocket (P < .001).
    CONCLUSIONS:
    ASD mandates shifted health care spending for ASD-specific services from families to insurers. However, families in the highest-spending quintile still spent an average of >$200 per month out of pocket on these services. To help ease their financial burden, policies in which children with higher service use are targeted may be warranted.


  • Neonatal Intubation Practice and Outcomes: An International Registry Study
    BACKGROUND AND OBJECTIVES:
    Neonatal tracheal intubation is a critical but potentially dangerous procedure. We sought to characterize intubation practice and outcomes in the NICU and delivery room (DR) settings and to identify potentially modifiable factors to improve neonatal intubation safety.
    METHODS:
    We developed the National Emergency Airway Registry for Neonates and collected standardized data for patients, providers, practices, and outcomes of neonatal intubation. Safety outcomes included adverse tracheal intubation–associated events (TIAEs) and severe oxygen desaturation (≥20% decline in oxygen saturation). We examined the relationship between intubation characteristics and adverse events with univariable tests and multivariable logistic regression.
    RESULTS:
    We captured 2009 NICU intubations and 598 DR intubations from 10 centers. Pediatric residents attempted 15% of NICU and 2% of DR intubations. In the NICU, the first attempt success rate was 49%, adverse TIAE rate was 18%, and severe desaturation rate was 48%. In the DR, 46% of intubations were successful on the first attempt, with 17% TIAE rate and 31% severe desaturation rate. Site-specific TIAE rates ranged from 9% to 50% (P < .001), and severe desaturation rates ranged from 29% to 69% (P = .001). Practices independently associated with reduced TIAEs in the NICU included video laryngoscope (adjusted odds ratio 0.46, 95% confidence interval 0.28–0.73) and paralytic premedication (adjusted odds ratio 0.38, 95% confidence interval 0.25–0.57).
    CONCLUSIONS:
    We implemented a novel multisite neonatal intubation registry and identified potentially modifiable factors associated with adverse events. Our results will inform future interventional studies to improve neonatal intubation safety.


  • Mowat-Wilson Syndrome Presenting With Purpura Fulminans
    Purpura fulminans is a rapidly progressive syndrome of intravascular thrombosis and hemorrhagic infarction of the skin. The most common infectious etiology is Neisseria meningitidis sepsis, and less commonly it has been documented as a complication of invasive Streptococcus pneumoniae. In children who are otherwise healthy, splenic dysfunction is a significant predisposing factor for invasive pneumococcal infection. We present the case of a 10-month-old girl with a history of developmental delay, who developed an overwhelming infection complicated by purpura fulminans and was found to have previously undiagnosed Mowat-Wilson syndrome with anatomic asplenia. We propose screening patients with clinical features suggestive of Mowat-Wilson syndrome for asplenia to evaluate the need for additional preventive care.


  • Physical Activity and Sedentary Behavior From 6 to 11 Years
    OBJECTIVES:
    Physical activity (PA) is presumed to decline during childhood and adolescence, but only few long-term studies about PA development during this period of life exist. We assessed PA and sedentary behavior (SB) over a 5-year period to gain a better understanding of the extent of change in activity and potential influencing factors.
    METHODS:
    PA and SB of 600 children from the Childhood Obesity Project were objectively measured with the SenseWear Armband 2 at the ages of 6, 8, and 11 years, resulting in 1254 observations. Longitudinal changes of total PA, moderate-to-vigorous physical activity (MVPA), light physical activity (LPA), and SB were modeled with mixed-effects models.
    RESULTS:
    Total PA revealed a significant quadratic decline with age (P < .001), resulting in a change of total PA by –75.3 minutes per day from 6 to 11 years. LPA linearly declined (P < .001) by 44.6 minutes per day, MVPA quadratically declined (P < .001) by an overall 30.7 minutes, whereas SB increased significantly (+107 minutes; P = .001). Boys showed a steeper decline in LPA (P = .003) and MVPA (P < .001) than did girls. Higher fat mass index and BMI z scores were associated with lower levels of total PA and MVPA and higher levels of SB (all P < .001).
    CONCLUSIONS:
    We showed that PA decreased, and SB increased in earlier years than previously thought. MVPA remained relatively stable until 8 years, but revealed a drop-off at 11 years, identifying this period as a crucial time for intervention.


  • Developmental Dysplasia of the Hip
    Pediatricians are often the first to identify developmental dysplasia of the hip (DDH) and direct subsequent appropriate treatment. The general treatment principle of DDH is to obtain and maintain a concentric reduction of the femoral head in the acetabulum. Achieving this goal can range from less-invasive bracing treatments to more-invasive surgical treatment depending on the age and complexity of the dysplasia. In this review, we summarize the current trends and treatment principles in the diagnosis and treatment of DDH.



  • Nurse Home Visiting for Families Experiencing Adversity: A Randomized Trial
    OBJECTIVES:
    Nurse home visiting (NHV) may redress inequities in children’s health and development evident by school entry. We tested the effectiveness of an Australian NHV program (right@home), offered to pregnant women experiencing adversity, hypothesizing improvements in (1) parent care, (2) responsivity, and (3) the home learning environment at child age 2 years.
    METHODS:
    A randomized controlled trial of NHV delivered via universal child and family health services was conducted. Pregnant women experiencing adversity (≥2 of 10 risk factors) with sufficient English proficiency were recruited from antenatal clinics at 10 hospitals across 2 states. The intervention comprised 25 nurse visits to child age 2 years. Researchers blinded to randomization assessed 13 primary outcomes, including Home Observation of the Environment (HOME) Inventory (6 subscales) and 25 secondary outcomes.
    REULTS
    Of 1427 eligible women, 722 (50.6%) were randomly assigned; 306 of 363 (84%) women in the intervention and 290 of 359 (81%) women in the control group provided 2-year data. Compared with women in the control group, those in the intervention reported more regular child bedtimes (adjusted odds ratio 1.76; 95% confidence interval [CI] 1.25 to 2.48), increased safety (adjusted mean difference [AMD] 0.22; 95% CI 0.07 to 0.37), increased warm parenting (AMD 0.09; 95% CI 0.02 to 0.16), less hostile parenting (reverse scored; AMD 0.29; 95% CI 0.16 to 0.41), increased HOME parental involvement (AMD 0.26; 95% CI 0.14 to 0.38), and increased HOME variety in experience (AMD 0.20; 95% CI 0.07 to 0.34).
    CONCLUSIONS:
    The right@home program improved parenting and home environment determinants of children’s health and development. With replicability possible at scale, it could be integrated into Australian child and family health services or trialed in countries with similar child health services.


  • Trends in Outpatient Antibiotic Use in 3 Health Plans
    OBJECTIVES:
    Previous analyses of data from 3 large health plans suggested that the substantial downward trend in antibiotic use among children appeared to have attenuated by 2010. Now, data through 2014 from these same plans allow us to assess whether antibiotic use has declined further or remained stable.
    METHODS:
    Population-based antibiotic-dispensing rates were calculated from the same health plans for each study year between 2000 and 2014. For each health plan and age group, we fit Poisson regression models allowing 2 inflection points. We calculated the change in dispensing rates (and 95% confidence intervals) in the periods before the first inflection point, between the first and second inflection points, and after the second inflection point. We also examined whether the relative contribution to overall dispensing rates of common diagnoses for which antibiotics were prescribed changed over the study period.
    RESULTS:
    We observed dramatic decreases in antibiotic dispensing over the 14 study years. Despite previous evidence of a plateau in rates, there were substantial additional decreases between 2010 and 2014. Whereas antibiotic use rates decreased overall, the fraction of prescribing associated with individual diagnoses was relatively stable. Prescribing for diagnoses for which antibiotics are clearly not indicated appears to have decreased.
    CONCLUSIONS:
    These data revealed another period of marked decline from 2010 to 2014 after a relative plateau for several years for most age groups. Efforts to decrease unnecessary prescribing continue to have an impact on antibiotic use in ambulatory practice.


  • Early Caffeine Administration and Neurodevelopmental Outcomes in Preterm Infants
    BACKGROUND:
    Although caffeine use for apnea of prematurity is well studied, the long-term safety and benefit of routine early caffeine administration has not been explored. Our objective was to determine the association between early (within 2 days of birth) versus late caffeine exposure and neurodevelopmental outcomes in preterm infants.
    METHODS:
    Infants of


  • An Educational Intervention to Improve HPV Vaccination: A Cluster Randomized Trial
    BACKGROUND:
    Human papillomavirus (HPV) infection can lead to serious health issues and remains the most common sexually transmitted infection. Despite availability of effective vaccines, HPV vaccination rates are suboptimal.
    METHODS:
    In a cluster randomized trial, an intervention used to target parents of adolescents (11–17 years) eligible for a dose of HPV vaccine, was tested in pediatric clinics part of an urban health system. Parents watched a digital video outlining the risks and benefits of vaccine using a tablet in the examination room. The primary outcome was change in HPV vaccine status 2 weeks after the clinic visit. An intention-to-treat analysis for the primary outcome used generalized estimating equations to accommodate the potential cluster effect of clinics.
    RESULTS:
    A total of 1596 eligible adolescents were observed during the 7-month trial. One-third of adolescents visited an intervention clinic. Adolescents who attended an intervention clinic were more likely to be younger (11–12 years) than those who attended a control clinic (72.4% vs 49.8%; P < .001). No differences in race or sex were observed. The proportion of adolescents with an observed change in vaccine status was higher for those attending an intervention clinic (64.8%) versus control clinic (50.1%; odds ratio, 1.82; 95% confidence interval, 1.47–2.25; P < .001). Adolescents whose parents watched the video had a 3-times greater odds of receiving a dose of the HPV vaccine (78.0%; odds ratio, 3.07; 95% confidence interval, 1.47–6.42; P = .003).
    CONCLUSIONS:
    Educational interventions delivered within a clinical setting hold promise to improve vaccination behaviors.


  • When a Child Needs a Transplant but Lacks Familial Social Support
    We present the case of a 19-month-old boy with complex congenital heart disease. His single father is skeptical of traditional medicine and does not offer the social support needed to make heart transplantation successful for his son. After the father demonstrates commitment to transplant success and provides enhanced social support, doctors place the child on a Berlin Heart (a biventricular assist device) as a bridge to transplantation and list him for transplant. When the child is matched to a donor heart, the father refuses transplantation, despite that it is the child’s only chance for survival. His doctors report the case to child protective services, but they decline to take protective custody. The father then changes his mind and asks that the child be put back on the waiting list for transplant. By this time, the social supports the father implemented are no longer in place. This case raises a number of issues. First, should courts order heart transplantation when doctors believe that it is in the child’s best interest and parents do not consent? Second, once parents refuse a transplant, can they change their minds? Third, if there are uncertainties regarding whether the child has the social support to make transplantation successful, should the child be relisted? Finally, should a child who is not currently a transplant candidate but who may become one in the future be supported with ventricular assist devices?


  • Global Health Education for Pediatric Residents: Trends, Training Experiences, and Career Choices
    BACKGROUND AND OBJECTIVES:
    Knowledge and skills related to global child health are increasingly recognized as important to the practice of pediatrics. However, little is known about the status and trends in global health (GH) education in US pediatric residency programs. Our aim was to measure trends in residents’ exposure to GH training, their GH education assessments, and GH career plans.
    METHODS:
    We analyzed GH-focused questions from national American Academy of Pediatrics surveys of graduating residents in 2008 and 2016. Logistic regression was used to estimate changes over time by using derived predicted values.
    RESULTS:
    A total of 1100 graduating pediatric residents participated; response rates were 58.8% for 2008 and 56.0% for 2016. The percentage of residents reporting that their programs offered GH training grew from 59.1% in 2008 to 73.1% in 2016 (P < .001). The majority were somewhat likely, very likely, or definitely planning to work or volunteer in a low- or middle-income country after their residency (predicted value of 70.3% in 2008 and 69.4% in 2016; P = .76). Fourteen percent of respondents reported having completed an international elective in 2016; of those, 36.5% did not receive formal preparation before the experience, and 24.3% did not participate in debriefing sessions on return. Overall, 27.3% of respondents in 2016 reported excellent (8.8%) or very good (18.5%) GH training.
    CONCLUSIONS:
    Although a substantial percentage of pediatric residents participate in international electives and plan to include GH activities in their careers, gaps remain, including suboptimal preparation and debriefing for GH electives.


  • Mupirocin for Staphylococcus aureus Decolonization of Infants in Neonatal Intensive Care Units
    BACKGROUND AND OBJECTIVES:
    Staphylococcus aureus (SA) is the second leading cause of late-onset sepsis among infants in the NICU. Because colonization of nasal mucosa and/or skin frequently precedes invasive infection, decolonization strategies, such as mupirocin application, have been attempted to prevent clinical infection, but data supporting this approach in infants are limited. We conducted a phase 2 multicenter, open-label, randomized trial to assess the safety and efficacy of intranasal plus topical mupirocin in eradicating SA colonization in critically ill infants.
    METHODS:
    Between April 2014 and May 2016, infants


  • Father-Son Communication About Consistent and Correct Condom Use
    OBJECTIVES:
    With this study, we explore communication about consistent and correct condom use among African American and Latino male adolescents ages 15 to 19 and their fathers.
    METHODS:
    Twenty-five father-son dyads completed semistructured interviews designed to elicit specific preferences for teaching and learning about consistent and correct condom use and strategies for addressing common condom use errors and problems. For analysis, we used in vivo coding and vertical and horizontal analysis techniques.
    RESULTS:
    Fathers and sons agreed that communication about condom use is feasible and acceptable. However, fathers tended to convey vague messages regarding protecting oneself from the negative consequences of sexual activity. Furthermore, both fathers and sons reported barriers hindering conversations. Secondly, the style and frequency of condom use conversations can help overcome barriers and support father-son relationship management. Talking frequently in 1-on-1 settings and using strategies to reduce discomfort made communication easier. Lastly, fathers and sons reported distinct preferences for teaching and learning about condom use. Sons wanted fathers to give specific guidance on the use and management of condoms. Fathers expressed interest in opportunities for improving their own condom knowledge and skills. Fathers identified gaps in their own condom use knowledge as a limitation to effective instruction of their sons.
    CONCLUSIONS:
    A father-focused communication intervention about condom use is feasible and acceptable. Enhancing the intergenerational benefits of father-son communication by addressing specific father-son preferences and learning needs for condom use instruction, as well as communication barriers, represents a novel mechanism for reducing male sexual reproductive health disparities.



  • Room Air for Initiating Term Newborn Resuscitation: A Systematic Review With Meta-analysis
    CONTEXT:
    The International Liaison Committee on Resuscitation prioritized to rigorously review the initial fraction of inspired oxygen (Fio2) during resuscitation of newborns.
    OBJECTIVE:
    This systematic review and meta-analysis provides the scientific summary of initial Fio2 in term and late preterm newborns (≥35 weeks’ gestation) who receive respiratory support at birth.
    DATA SOURCES:
    Medline, Embase, Evidence Based Medicine Reviews, and Cumulative Index to Nursing and Allied Health Literature were searched between January 1, 1980 and August 10, 2018.
    STUDY SELECTION:
    Studies were selected by pairs of independent reviewers in 2 stages, with a Cohen’s of 0.8 and 1.0.
    DATA EXTRACTION:
    Pairs of independent reviewers extracted data, appraised risk of bias, and assessed Grading of Recommendations Assessment, Development and Evaluation certainty of evidence.
    RESULTS:
    Five randomized controlled trials (RCTs) and 5 quasi RCTs included 2164 patients. Room air (Fio2 0.21) was associated with a statistically significant benefit in short-term mortality compared with 100% oxygen (Fio2 1.0) (7 RCTs; n = 1469; risk ratio [RR] = 0.73; 95% confidence interval [CI]: 0.57 to 0.94). No significant differences were observed in neurodevelopmental impairment (2 RCTs; n = 360; RR = 1.41; 95% CI: 0.77 to 2.60) or hypoxic-ischemic encephalopathy (5 RCTs; n = 1315; RR = 0.89; 95% CI: 0.68 to 1.18).
    LIMITATIONS:
    The Grading of Recommendations Assessment, Development and Evaluation certainty of evidence was low for short-term mortality and hypoxic-ischemic encephalopathy and very low for neurodevelopmental impairment.
    CONCLUSIONS:
    Room air has a 27% relative reduction in short-term mortality compared with Fio2 1.0 for initiating neonatal resuscitation ≥35 weeks’ gestation.



  • A 6-Year-Old Child With Citrin Deficiency and Advanced Hepatocellular Carcinoma
    We report the case of a 6-year-old boy with citrin deficiency and advanced hepatocellular carcinoma diagnosed by using imaging. He exhibited intrahepatic cholestasis 2 days after his birth and was misdiagnosed with inspissated bile syndrome at that time. The symptoms of jaundice spontaneously resolved when he was 5 months old. However, his transaminase levels remained elevated for ~6 years, for which he received no treatment. He preferred a high-protein, high-fat, low-carbohydrate diet, which has been observed in many patients with citrin deficiency, but no clinical features of adult-onset type II citrullinemia were observed. At the age of 6 years, he was admitted to our hospital with a nonviral infection and high α-fetoprotein level; results from an abdominal MRI and computed tomography revealed multiple tumors in the liver. Because of his history of intrahepatic cholestasis in the neonatal period, he was suspected to have citrin deficiency. A genetic analysis of solute carrier family 25, member 13 revealed the presence of a homozygous 851del4 mutation, and a diagnosis of citrin deficiency was made. The patient did not qualify for liver transplantation and died 2 months later, after discharge from our hospital. Thus, this case reveals that not all patients with neonatal intrahepatic cholestasis spontaneously and totally improve, and this case is used to emphasize that patients with neonatal intrahepatic cholestasis should be managed carefully, especially in the stage of failure to thrive and dyslipidemia caused by citrin deficiency, which may lead to advanced hepatocellular carcinoma.


  • Home Health Care Availability and Discharge Delays in Children With Medical Complexity
    BACKGROUND:
    An increasing proportion of pediatric hospital days are attributed to technology-dependent children. The impact that a pediatric home care nursing (HCN) shortage has on increasing length of hospital stay and readmissions in this population is not well documented.
    METHODS:
    We conducted a 12-month multisite prospective study of children with medical complexity discharging with home health. We studied the following 2 cohorts: new patients discharging for the first time to home nursing and existing patients discharging from the hospital to previously established home nursing. A modified delay tool was used to categorize causes, delayed discharge (DD) days, and unplanned 90-day readmissions.
    RESULTS:
    DD occurred in 68.5% of 54 new patients and 9.2% of 131 existing patients. Lack of HCN was the most frequent cause of DD, increasing costs and directly accounting for an average length of stay increase of 53.9 days (range: 4–204) and 35.7 days (3–63) for new and existing patients, respectively. Of 1582 DDs, 1454 (91.9%) were directly attributed to lack of HCN availability. DD was associated with younger age and tracheostomy. Unplanned 90-day readmissions were due to medical setbacks (96.7% of cases) and occurred in 53.7% and 45.0% of new and existing patients, respectively.
    CONCLUSIONS:
    DD and related costs are primarily associated with shortage of HCN and predominantly affect patients new to HCN. Medical setbacks are the most common causes of unplanned 90-day readmissions. Increasing the availability of home care nurses or postacute care facilities could reduce costly hospital length of stay.


  • Work Experiences and Satisfaction of International Medical School Graduates
    OBJECTIVES:
    We compared demographics and work, financial, and satisfaction experiences of early-career and midcareer pediatricians categorized by their childhood and medical school locations.
    METHODS:
    Data from the Pediatrician Life and Career Experience Study were used to examine the characteristics and experiences of 3 groups, which were categorized as (1) international childhood and medical school graduate (international-IMG), (2) United States childhood and international medical school graduate (US-IMG), and (3) United States or international childhood and United States medical school graduate (USMG). With multivariable logistic regression, we examined the experiences of the groups, controlling for participant characteristics.
    RESULTS:
    Data from 1467 of 1804 participants were analyzed; 13% were categorized as international-IMGs, 6% were categorized as US-IMGs, and 81% were categorized as USMGs. International-IMGs and US-IMGs were less likely than USMGs to report their race and ethnicity as white and non-Hispanic (26%, 32%, and 71%, respectively; P < .05) and more likely to report caring for patients with public insurance (adjusted odds ratio [aOR] 1.80 [95% confidence interval (CI) 1.27–2.56] and aOR 2.12 [95% CI 1.31–3.42], respectively). International-IMGs were less likely than USMGs to agree that physician colleagues value their work (aOR 0.35; 95% CI 0.21–0.56). Overall, 8 in 10 reported that their work was personally rewarding; international-IMGs were less likely than USMGs to report such satisfaction (P < .05).
    CONCLUSIONS:
    Among a national sample of pediatricians, international-IMGs and US-IMGs play important roles in workforce diversity. They also report unique challenges. Most are satisfied with their work, but international-IMGs are the least satisfied.


  • Meningococcal Disease Among College-Aged Young Adults: 2014-2016
    BACKGROUND:
    Freshman college students living in residence halls have previously been identified as being at an increased risk for meningococcal disease. In this evaluation, we assess the incidence and characteristics of meningococcal disease in college-aged young adults in the United States.
    METHODS:
    The incidence and relative risk (RR) of meningococcal disease among college students compared with noncollege students aged 18 to 24 years during 2014–2016 were calculated by using data from the National Notifiable Diseases Surveillance System and enhanced meningococcal disease surveillance. Differences in demographic characteristics and clinical features of meningococcal disease cases were assessed. Available meningococcal isolates were characterized by using slide agglutination, polymerase chain reaction, and whole genome sequencing.
    RESULTS:
    From 2014 to 2016, 166 cases of meningococcal disease occurred in persons aged 18 to 24 years, with an average annual incidence of 0.17 cases per 100 000 population. Six serogroup B outbreaks were identified on college campuses, accounting for 31.7% of serogroup B cases in college students during this period. The RR of serogroup B meningococcal (MenB) disease in college students versus noncollege students was 3.54 (95% confidence interval: 2.21–5.41), and the RR of serogroups C, W, and Y combined was 0.56 (95% confidence interval: 0.27–1.14). The most common serogroup B clonal complexes identified were CC32/ET-5 and CC41/44 lineage 3.
    CONCLUSIONS:
    Although the incidence is low, among 18- to 24-year-olds, college students are at an increased risk for sporadic and outbreak-associated MenB disease. Providers, college students, and parents should be aware of the availability of MenB vaccines.



  • Instruments to Measure Outcomes in Pediatric Palliative Care: A Systematic Review
    CONTEXT:
    Pediatric palliative care (PPC) is intended to promote children’s quality of life by using a family-centered approach. However, the measurement of this multidimensional outcome remains challenging.
    OBJECTIVE:
    To review the instruments used to assess the impact of PPC interventions.
    DATA SOURCES:
    Five databases (Embase, Scopus, The Cochrane Library, PsychInfo, Medline) were searched.
    STUDY SELECTION:
    Inclusion criteria were as follows: definition of PPC used; patients aged 0 to 18 years; diseases listed in the directory of life-limiting diseases; results based on empirical data; and combined descriptions of a PPC intervention, its outcomes, and a measurement instrument.
    DATA EXTRACTION:
    Full-text articles were assessed and data were extracted by 2 independent researchers, and each discrepancy was resolved through consensus. The quality of the studies was assessed by using the Standard Quality Assessment Criteria for Evaluating Primary Research Papers From a Variety of Fields checklist.
    RESULTS:
    Nineteen of 2150 articles met the eligibility criteria. Researchers in 15 used quantitative methods, and 9 were of moderate quality. Multidimensional outcomes included health-related quality of life, spiritual well-being, satisfaction with care and/or communication, perceived social support, and family involvement in treatment or place-of-care preferences. PPC interventions ranged from home-based to hospital and respite care. Only 15 instruments (of 23 reported) revealed some psychometric properties, and only 5 included patient-reported (child) outcome measures.
    LIMITATIONS:
    We had no access to the developmental process of the instruments used to present the underlying concepts that were underpinning the constructs.
    CONCLUSIONS:
    Data on the psychometric properties of instruments used to assess the impact of PPC interventions were scarce. Children are not systematically involved in reporting outcomes.


  • In-hospital Neonatal Falls: An Unintended Consequence of Efforts to Improve Breastfeeding
    In-hospital neonatal falls are increasingly recognized as a postpartum safety risk, with maternal fatigue contributing to these events. Recommendations to support rooming-in may increase success with breastfeeding; however, this practice may also be associated with maternal fatigue. We report a cluster of in-hospital neonatal falls associated with a hospital program to improve breastfeeding, which included rooming-in practices. Metrics related to breastfeeding were prospectively collected by chart audit or patient survey while ongoing efforts to improve breastfeeding occurred (September 2015–August 2017). Falls were identified through the hospital adverse event reporting system from January 2011 to February 2018. Medical records were reviewed to determine factors associated with the falls, including time of event, pain medication administration, hours of life at fall, method of delivery, or other notable factors that may have contributed to the fall event. Three fall events occurred within 1 year of commencing improvement efforts as process and outcome metrics associated with breastfeeding improved. All events were associated with mothers falling asleep while feeding their infant, and all occurred between midnight and 6 am. Falls occurred from 38.0 to 75.7 hours after birth. No sedating pain medications were administered within 4 hours of any event. In 2 of 3 cases, mothers experienced notable ongoing social stressors. Rooming-in was the most significant change involved in our health care delivery during the programmatic effort to improve breastfeeding. Monitoring for in-hospital neonatal falls may be needed during projects aimed at improving breastfeeding, particularly if rooming-in practices are involved.



  • Developmental Outcomes in Duarte Galactosemia
    OBJECTIVES:
    For decades, infants with Duarte galactosemia (DG) have been identified by newborn screening (NBS), but whether they should be treated with dietary restrictions of galactose has remained unknown. To clarify, we conducted a study of dietary and developmental outcomes in 206 children with DG (case patients) and 144 controls, all of whom were 6 to 12 years old.
    METHODS:
    We recruited case patients from states where they were identified by NBS; unaffected siblings served as controls. Diet in infancy was ascertained by retrospective parent surveys; developmental outcomes were assessed in 5 domains, yielding 73 outcome measures for each child. We divided subjects randomly into independent discovery (n = 87) and validation (n = 263) sets. We tested the discovery set to order the 73 outcome measures by ascending P values and tested the 10 outcomes with the lowest P values for possible association with DG in the validation set. We also tested these same 10 outcomes for possible association with milk exposure in infancy among case patients in the validation set.
    RESULTS:
    None of the 73 outcomes tested in the discovery set revealed significant association with DG, and none of the 10 outcomes tested in the validation set revealed either significant association with DG or significant association with milk exposure among children with DG.
    CONCLUSIONS:
    Through our results, we demonstrated that there were no significant differences in outcomes tested between case patients and controls or among case patients as a function of milk exposure in infancy. In this study, we provide a long-needed foundation of knowledge for health care providers, families, and NBS professionals seeking to make evidence-based decisions about DG.








  • Psychosocial Factors in Children and Youth With Special Health Care Needs and Their Families
    Children and youth with special health care needs (CYSHCN) and their families may experience a variety of internal (ie, emotional and behavioral) and external (ie, interpersonal, financial, housing, and educational) psychosocial factors that can influence their health and wellness. Many CYSHCN and their families are resilient and thrive. Medical home teams can partner with CYSHCN and their families to screen for, evaluate, and promote psychosocial health to increase protective factors and ameliorate risk factors. Medical home teams can promote protective psychosocial factors as part of coordinated, comprehensive chronic care for CYSHCN and their families. A team-based care approach may entail collaboration across the care spectrum, including youth, families, behavioral health providers, specialists, child care providers, schools, social services, and other community agencies. The purpose of this clinical report is to raise awareness of the impact of psychosocial factors on the health and wellness of CYSHCN and their families. This clinical report provides guidance for pediatric providers to facilitate and coordinate care that can have a positive influence on the overall health, wellness, and quality of life of CYSHCN and their families.


  • Health and Mental Health Needs of Children in US Military Families
    Children in US military families share common experiences and unique challenges, including parental deployment and frequent relocation. Although some of the stressors of military life have been associated with higher rates of mental health disorders and increased health care use among family members, there are various factors and interventions that have been found to promote resilience. Military children often live on or near military installations, where they may attend Department of Defense–sponsored child care programs and schools and receive medical care through military treatment facilities. However, many families live in remote communities without access to these services. Because of this wide geographic distribution, military children are cared for in both military and civilian medical practices. This clinical report provides a background to military culture and offers practical guidance to assist civilian and military pediatricians caring for military children.


  • Incorporating Recognition and Management of Perinatal Depression Into Pediatric Practice
    Perinatal depression (PND) is the most common obstetric complication in the United States. Even when screening results are positive, mothers often do not receive further evaluation, and even when PND is diagnosed, mothers do not receive evidence-based treatments. Studies reveal that postpartum depression (PPD), a subset of PND, leads to increased costs of medical care, inappropriate medical treatment of the infant, discontinuation of breastfeeding, family dysfunction, and an increased risk of abuse and neglect. PPD, specifically, adversely affects this critical early period of infant brain development. PND is an example of an adverse childhood experience that has potential long-term adverse health complications for the mother, her partner, the infant, and the mother-infant dyad. However, PND can be treated effectively, and the stress on the infant can be buffered. Pediatric medical homes should coordinate care more effectively with prenatal providers for women with prenatally diagnosed maternal depression; establish a system to implement PPD screening at the 1-, 2-, 4-, and 6-month well-child visits; use community resources for the treatment and referral of the mother with depression; and provide support for the maternal-child (dyad) relationship, including breastfeeding support. State chapters of the American Academy of Pediatrics, working with state departments of public health, public and private payers, and maternal and child health programs, should advocate for payment and for increased training for PND screening and treatment. American Academy of Pediatrics recommends advocacy for workforce development for mental health professionals who care for young children and mother-infant dyads, and for promotion of evidence-based interventions focused on healthy attachment and parent-child relationships.


  • Incorporating Recognition and Management of Perinatal Depression Into Pediatric Practice
    Perinatal depression is the most common obstetric complication in the United States, with prevalence rates of 15% to 20% among new mothers. Untreated, it can adversly affect the well-being of children and families throught increasing the risk for costly complications during birth and lead to deterioration of core supports, including partner relationships and social networks. Perinatal depression contributes to long-lasting, and even permanent, consequences for the physical and mental health of parents and children, including poor family functioning, increased risk of child abuse and neglect, delayed infant development, perinatal obstetric complications, challenges with breastfeeding, and costly increases in health care use. Perinatal depression can interfere with early parent-infant interaction and attachment, leading to potentially long-term disturbances in the child’s physical, emotional, cognitive, and social development. Fortunately, perinatal depression is identifiable and treatable. The US Preventive Services Task Force, Centers for Medicare and Medicaid Services, and many professional organizations recommend routine universal screening for perinatal depression in women to facilitate early evidence-based treatment and referrals, if necessary. Despite significant gains in screening rates from 2004 to 2013, a minority of pediatricians routinely screen for postpartum depression, and many mothers are still not identified or treated. Pediatric primary care clinicians, with a core mission of promoting child and family health, are in an ideal position to implement routine postpartum depression screens at several well-child visits throughout infancy and to provide mental health support through referrals and/or the interdisciplinary services of a pediatric patient-centered medical home model.








  • Selecting Appropriate Toys for Young Children in the Digital Era
    Play is essential to optimal child development because it contributes to the cognitive, physical, social, and emotional well-being of children and youth. It also offers an ideal and significant opportunity for parents and other caregivers to engage fully with children using toys as an instrument of play and interaction. The evolution of societal perceptions of toys from children’s playthings to critical facilitators of early brain and child development has challenged caregivers in deciding which toys are most appropriate for their children. This clinical report strives to provide pediatric health care providers with evidence-based information that can be used to support caregivers as they choose toys for their children. The report highlights the broad definition of a toy; consideration of potential benefits and possible harmful effects of toy choices on child development; and the promotion of positive caregiving and development when toys are used to engage caregivers in play-based interactions with their children that are rich in language, pretending, problem-solving, and creativity. The report aims to address the evolving replacement of more traditional toys with digital media–based virtual “toys” and the lack of evidence for similar benefits in child development. Furthermore, this report briefly addresses the role of toys in advertising and/or incentive programs and aims to bring awareness regarding safety and health hazards associated with toy availability and accessibility in public settings, including some health care settings.






  • Clinical Practice Guideline for the Management of Infantile Hemangiomas
    Infantile hemangiomas (IHs) occur in as many as 5% of infants, making them the most common benign tumor of infancy. Most IHs are small, innocuous, self-resolving, and require no treatment. However, because of their size or location, a significant minority of IHs are potentially problematic. These include IHs that may cause permanent scarring and disfigurement (eg, facial IHs), hepatic or airway IHs, and IHs with the potential for functional impairment (eg, periorbital IHs), ulceration (that may cause pain or scarring), and associated underlying abnormalities (eg, intracranial and aortic arch vascular abnormalities accompanying a large facial IH). This clinical practice guideline for the management of IHs emphasizes several key concepts. It defines those IHs that are potentially higher risk and should prompt concern, and emphasizes increased vigilance, consideration of active treatment and, when appropriate, specialty consultation. It discusses the specific growth characteristics of IHs, that is, that the most rapid and significant growth occurs between 1 and 3 months of age and that growth is completed by 5 months of age in most cases. Because many IHs leave behind permanent skin changes, there is a window of opportunity to treat higher-risk IHs and optimize outcomes. Early intervention and/or referral (ideally by 1 month of age) is recommended for infants who have potentially problematic IHs. When systemic treatment is indicated, propranolol is the drug of choice at a dose of 2 to 3 mg/kg per day. Treatment typically is continued for at least 6 months and often is maintained until 12 months of age (occasionally longer). Topical timolol may be used to treat select small, thin, superficial IHs. Surgery and/or laser treatment are most useful for the treatment of residual skin changes after involution and, less commonly, may be considered earlier to treat some IHs.