Epilepsy or seizure care is the most common neurologic condition that presents to an emergency department (ED) and accounts for a large number of annual cases. Our aim was to decrease seizure-related ED visits from our baseline of 17 ED visits per month per 1000 patients to 13.6 ED visits per month per 1000 patients (20%) by July 2014.METHODS:
Our strategy was to develop a quality improvement (QI) project utilizing the Institute for Healthcare Improvement model. Our defined outcome was to decrease ED utilization for children with epilepsy. Rate of ED visits as well as unplanned hospitalizations for epilepsy patients and associated health care costs were determined. A QI team was developed for this project. Plan do study act cycles were used with adjustments made when needed.RESULTS:
Nineteen months after implementation of the interventions, ED visits were reduced by 28% (from 17 visits per month per 1000 patients to 12.2 per month per 1000 patients) during the past year. The average number of inpatient hospitalizations per month was reduced by 43% from 7 admissions per month per 1000 patients to 4 admissions per month per 1000 patients. For both outcome measures, a 2-sample Poisson rate exact test yielded a P value < .0001. Health care claims paid were less with $115 200 reduction for ED visits and $1 951 137 reduction for hospitalizations.CONCLUSIONS:
Applying QI methodology was highly effective in reducing ED utilization and unplanned hospitalizations for children with epilepsy at a free-standing children’s hospital.
Patient safety events are underreported by physicians. Baseline data demonstrated that physicians submitted 3% of event reports at Our Lady of the Lake Children’s Hospital. Our aim was to increase the proportion of safety reports filed by residents and faculty to 6% of all reports within a 9-month period.METHODS:
We used the Model for Improvement and serial Plan, Do, Study, Act cycles to test interventions we hypothesized would improve physician recognition and reporting of patient safety events. We tracked the percentage of Our Lady of the Lake Children’s Hospital event reports entered by residents or faculty over time as the primary outcome measure. Changes to teaching team processes included "patient safety rounds" prompted by text messages, an inpatient "superintendent" rotation with core patient safety responsibilities, and a "just-in-time" faculty development program called "QI on the Fly."RESULTS:
Physician-reported events increased to a monthly average of 24% of all events reported, an improvement that has been sustained over 17 months. Resident reporting accounted for most of the increase in physician reports. Increased physician reporting was temporally associated with implementation of the "superintendent" rotation. The total number of events reported increased as a result of increased physician reporting.CONCLUSIONS:
Incorporating patient safety responsibilities into a teaching team’s workflow can increase physician safety event reporting. We plan additional Plan, Do, Study, Act cycles to spread this approach to other clinical settings and investigate the impact increased reporting might have on patient care.
Pediatricians provide a medical home for children with congenital syndromes who often need complex multidisciplinary care. There are some syndromes associated with thrombocytopenia, inherited platelet disorders, factor deficiencies, connective tissue disorders, and vascular abnormalities, which pose a real risk of bleeding in affected children associated with trauma or surgeries. The risk of bleeding is not often an obvious feature of the syndrome and not well documented in the literature. This makes it especially hard for pediatricians who may care for a handful of children with these rare congenital syndromes in their lifetime. This review provides an overview of the etiology of bleeding in the different congenital syndromes along with a concise review of the hematologic and nonhematologic clinical manifestations. It also highlights the need and timing of diagnostic evaluation to uncover the bleeding risk in these syndromes emphasizing a primary care approach.
Ensuring safe human milk in the NICU is a complex process with many potential points for error, of which one of the most serious is administration of the wrong milk to the wrong infant. Our objective was to describe a quality improvement initiative that was associated with a reduction in human milk administration errors identified over a 6-year period in a typical, large NICU setting.METHODS:
We employed a quasi-experimental time series quality improvement initiative by using tools from the model for improvement, Six Sigma methodology, and evidence-based interventions. Scanned errors were identified from the human milk barcode medication administration system. Scanned errors of interest were wrong-milk-to-wrong-infant, expired-milk, or preparation errors. The scanned error rate and the impact of additional improvement interventions from 2009 to 2015 were monitored by using statistical process control charts.RESULTS:
From 2009 to 2015, the total number of errors scanned declined from 97.1 per 1000 bottles to 10.8. Specifically, the number of expired milk error scans declined from 84.0 per 1000 bottles to 8.9. The number of preparation errors (4.8 per 1000 bottles to 2.2) and wrong-milk-to-wrong-infant errors scanned (8.3 per 1000 bottles to 2.0) also declined.CONCLUSIONS:
By reducing the number of errors scanned, the number of opportunities for errors also decreased. Interventions that likely had the greatest impact on reducing the number of scanned errors included installation of bedside (versus centralized) scanners and dedicated staff to handle milk.
To compare an indigenous sleep device (wahakura) for infants at high risk for sudden unexpected death with a bassinet, for measures of infant sleep position, head covering, breastfeeding, bed-sharing, and maternal sleep and fatigue.METHODS:
A total of 200 mainly Māori pregnant women were recruited from deprived areas of New Zealand. They were randomized to receive a bassinet or wahakura and asked to sleep the infant in this device from birth. Questionnaires at 1, 3, and 6 months and an overnight infrared video in the home at 1 month were completed.RESULTS:
An intention-to-treat and an "as-used" analysis of questionnaires showed no group differences at 1, 3, and 6 months in infant-adult direct bed-sharing (7% vs 12%, P = .24 at 1 month), and at the 6-month interview, the wahakura group reported twice the level of full breastfeeding (22.5% vs 10.7%, P = .04). Maternal sleep and fatigue were not significantly different between groups. Video identified no increase in head covering, prone/side sleep position, or bed-sharing in the wahakura group, either from intention-to-treat analysis, or when analyzed for actual sleep location.CONCLUSION
There were no significant differences in infant risk behaviors in wahakura compared with bassinets and there were other advantages, including an increase in sustained breastfeeding. This suggests wahakura are relatively safe and can be promoted as an alternative to infant-adult bed-sharing. Policies that encourage utilization are likely to be helpful in high-risk populations.
Breastfeeding has many well-established health benefits for infants and mothers. There is greater risk reduction in health outcomes with exclusive breastfeeding (EBF). Our urban academic facility has had long-standing low EBF rates, serving a population with breastfeeding disparities. We sought to improve EBF rates through a Learning Collaborative model by participating in the Best Fed Beginnings project.METHODS:
Formal improvement science methods were used, including the development of a key driver diagram and plan–do–study–act cycles. Improvement activities followed the Ten Steps to Successful Breastfeeding.RESULTS:
We demonstrated significant improvement in the median adherence to 2 process measures, rooming in and skin-to-skin after delivery. Subsequently, the proportion of infants exclusively breastfed at hospital discharge in our facility increased from 37% to 59%. We demonstrated an increase in sustained breastfeeding in a subset of patients at a postpartum follow-up visit. These improvements led to Baby-Friendly designation at our facility.CONCLUSIONS:
This quality improvement initiative resulted in a higher number of infants exclusively breastfed in our patient population at "high risk not to breastfeed." Other hospitals can use these described methods and techniques to improve their EBF rates.
To examine changes in the prevalence of 15 HIV/AIDS sex and drug risk behaviors in delinquent youth during the 14 years after they leave detention, focusing on sex and racial/ethnic differences.METHODS:
The Northwestern Juvenile Project, a prospective longitudinal study of 1829 youth randomly sampled from detention in Chicago, Illinois, recruited between 1995 and 1998 and reinterviewed up to 11 times. Independent interviewers assessed HIV/AIDS risk behaviors using the National Institutes on Drug Abuse Risk Behavior Assessment.RESULTS:
Fourteen years after detention (median age, 30 years), one-quarter of males and one-tenth of females had >1 sexual partner in the past 3 months. One-tenth of participants reported recent unprotected vaginal sex with a high-risk partner. There were many sex and racial/ethnic differences. For example, African American males had 4.67 times the odds of having >1 partner than African American females (95% confidence interval [CI], 3.22–6.76). Over time, compared with non-Hispanic white males, African American males had 2.56 times the odds (95% CI, 1.97–3.33) and Hispanic males had 1.63 times the odds (95% CI, 1.24–2.12) of having multiple partners, even after adjusting for incarceration and age. Non-Hispanic white females were more likely to have multiple partners than racial/ethnic minority females.CONCLUSIONS:
Although rates decrease over time, prevalence of sex risk behaviors are much higher than the general population. Among males, racial/ethnic minorities were at particular risk. The challenge for pediatric health is to address how disproportionate confinement of racial/ethnic minority youth contributes to disparities in the HIV/AIDS epidemic.
Growth Hormone With Aromatase Inhibitor May Improve Height in CYP11B1 Congenital Adrenal Hyperplasia
With an estimated prevalence of 1 in 100 000 births, 11β-hydroxylase deficiency is the second most common form of congenital adrenal hyperplasia (CAH) and is caused by mutations in CYP11B1. Clinical features include virilization, early gonadotropin-independent precocious puberty, hypertension, and reduced stature. The current mainstay of management is with glucocorticoids to replace deficient steroids and to minimize adrenal sex hormone overproduction, thus preventing virilization and optimizing growth. We report a patient with CAH who had been suboptimally treated and presented to us at 6 years of age with precocious puberty, hypertension, tall stature, advanced bone age, and a predicted final height of 150 cm. Hormonal profiles and genetic analysis confirmed a diagnosis of 11β-hydroxylase deficiency. In addition to glucocorticoid replacement, the patient was commenced on growth hormone and a third-generation aromatase inhibitor, anastrozole, in an attempt to optimize his growth. After the initiation of this treatment, the patient’s growth rate improved significantly and bone age advancement slowed. The patient reached a final height of 177.5 cm (0.81 SD score), 11.5 cm above his mid-parental height. This patient is only the second reported case of the use of an aromatase inhibitor in combination with growth hormone to optimize height in 11β-hydroxylase-deficient CAH. This novel treatment proved to be highly efficacious, with no adverse effects. It may therefore provide a promising option to promote growth in exceptional circumstances in individuals with 11β-hydroxylase deficiency presenting late with advanced skeletal maturation and consequent short stature.
Cytomegalovirus (CMV) is the most common congenital infection and nongenetic cause of congenital sensorineural hearing loss in the United States. Utah was the first state to pass legislation mandating CMV screening for newborns who fail newborn hearing screening (NBHS). The study objective was to present outcomes of hearing-targeted CMV screening and determine factors predicting CMV screening.METHODS:
We used Utah Department of Health HiTrack and Vital Records databases to examine CMV screening from 509 infants who failed NBHS in the 24 months after implementation of the Utah legislation. Multivariate logistic regression analyses were conducted to identify predictors of compliance with CMV screening and diagnostic hearing evaluation.RESULTS:
Sixty-two percent of infants who never passed hearing screening underwent CMV screening. Fourteen of 234 infants tested within 21 days were CMV positive; 6 (42.9%) had hearing loss. Seventy-seven percent of eligible infants completed a diagnostic hearing evaluation within 90 days of birth. Compliance with CMV screening was associated with sociodemographic factors, time since the law was enacted, and NBHS protocol. Infants born after the legislation showed greater odds of achieving timely diagnostic hearing evaluation than infants born before the law.CONCLUSIONS:
Incorporating CMV screening into an established NBHS program is a viable option for the identification of CMV in infants failing NBHS. The addition of CMV testing can help a NBHS program attain timely audiological diagnostics within 90 days, an important early hearing detection and intervention milestone.
To describe the strategies families report using to address the needs and concerns of siblings of children, adolescents, and young adults undergoing hematopoietic stem cell transplant (HSCT).METHODS:
A secondary semantic analysis was conducted of 86 qualitative interviews with family members of children, adolescents, and young adults undergoing HSCT at 4 HSCT centers and supplemented with a primary analysis of 38 additional targeted qualitative interviews (23 family members, 15 health care professionals) conducted at the primary center. Analyses focused on sibling issues and the strategies families use to address these issues.RESULTS:
The sibling issues identified included: (1) feeling negative effects of separation from the patient and caregiver(s); (2) experiencing difficult emotions; (3) being faced with additional responsibilities or burdens; (4) lacking information; and (5) feeling excluded. Families and health care providers reported the following strategies to support siblings: (1) sharing information; (2) using social support and help offered by family or friends; (3) taking siblings to the hospital; (4) communicating virtually; (5) providing special events or gifts or quality time for siblings; (6) offering siblings a defined role to help the family during the transplant process; (7) switching between parents at the hospital; (8) keeping the sibling’s life constant; and, (9) arranging sibling meetings with a certified child life specialist or school counselor.CONCLUSIONS:
Understanding the above strategies and sharing them with other families in similar situations can begin to address sibling issues during HSCT and can improve hospital-based, family-centered care efforts.
To provide an example of a successful, novel statewide effort to increase early identification of young children at risk for autism spectrum disorder (ASD) using a 2-tiered screening process with enhanced quality assessment, interagency policy collaboration and coordination.METHODS:
The South Carolina Act Early Team (SCAET) provided focused collaboration among leaders representing state agencies, universities, health care systems, private organizations, and families to improve quality of life for children with ASD. Specific focus was on implementing policy changes and training to result in earlier identification and home-based behavioral intervention for young children at risk for ASD.RESULTS:
Policy changes, training, and modified state agency practices were accomplished. Presumptive eligibility, on the basis of a 2-tiered screening process was implemented by BabyNet (South Carolina’s Early Intervention Program) in collaboration with the lead agency for developmental disability services. There was a fivefold increase in children eligible for early intensive behavioral intervention without waiting for a diagnosis of ASD, avoiding long waits for diagnostic evaluations. Only 16 children (2.5%) were later found not to have ASD from a comprehensive evaluation.CONCLUSIONS:
Improvements in early identification and intervention are feasible through collaborative policy change. The South Carolina Act Early Team and its key stakeholders committed to improving outcomes for this population used existing tools and methods in new ways to improve early identification of children with ASD and to make available evidence-based intervention services. This example should be replicable in other states with key stakeholders working collaboratively for the benefit of young children with ASD.
Extrapyramidal symptoms are an uncommon but well-recognized side effect after the administration of general anesthesia in patients without a significant neurologic history. Several case reports implicate propofol as the likely causative agent producing these symptoms, which include ballismus, dystonia, choreoathetosis, and opisthotonus. Currently, there is no clear consensus on first-line treatment of these symptoms. In each of the published cases, anticholinergic medications and benzodiazepines were central to initial management, although the speed and extent of symptom resolution were variable. Here we present a case of a 17-year-old boy with ulcerative colitis who presented with ballismus, torticollis, tongue thrusting, and oculogyric movements after colonoscopy under general anesthesia with propofol. The patient responded promptly to treatment with diphenhydramine. This is the first reported case in which diphenhydramine was successfully used as the primary treatment of severe extrapyramidal symptoms in a pediatric patient after propofol administration.
Iatrogenic Cushing’s syndrome (CS) is a severe adverse effect of systemic glucocorticoid (GC) therapy in children, but is extremely rare in the setting of topical ocular GC therapy. In this article, we report the case of a 9-year-old girl suffering from idiopathic uveitis who developed CS due to topical ocular GC treatment. She was referred to the ophthalmology department with a complaint of painful eyes, at which time she was diagnosed with bilateral iridocyclitis and started on a treatment of betamethasone sodium phosphate eye drops. Six months after the initiation of topical ocular GC treatment, she was referred to our pediatric department with stunted growth, truncal obesity, purple skin striate, buffalo hump, and moon face. Because her serum cortisol and plasma adrenocorticotropic hormone levels were undetectable, she was diagnosed with iatrogenic CS. After the doses of topical ocular GC were reduced, the clinical symptoms of CS were improved. The fact that the amount of topical ocular GC with our patient was apparently less than that of similar previous cases tempted us to perform genetic analysis of her NR3C1 gene. We found that our patient had a single heterozygous nucleotide substitution in the 3' untranslated region of the NR3C1 gene, which may explain why she developed CS. However, additional investigations are required to determine if our findings can be extrapolated to other patients. In conclusion, clinicians should be aware that even extremely low doses of topical ocular steroid therapy can cause iatrogenic CS.
Despite the American Academy of Pediatrics’ recommendations against pediatric use of creatine and testosterone boosters, research suggests that many young teenagers take these dietary supplements. Our objective was to determine to what extent health food stores would recommend and/or sell creatine and testosterone boosters to a 15-year-old boy customer.METHODS:
Research personnel posing as 15-year-old high school athletes seeking to increase muscle strength contacted 244 health food stores in the United States via telephone. Researchers asked the sales attendant what supplements he/she would recommend. If a sales attendant did not mention creatine or testosterone boosters initially, each of these supplements was then specifically asked about. Supplement recommendations were recorded. Sales attendants were also asked if a 15-year-old could purchase these products on his own in the store.RESULTS:
A total of 67.2% (164/244) of sales attendants recommended creatine: 38.5% (94/244) recommended creatine without prompting, and an additional 28.7% (70/244) recommended creatine after being asked specifically about it. A total of 9.8% (24/244) of sales attendants recommended a testosterone booster. Regarding availability for sale, 74.2% (181/244) of sales attendants stated a 15-year-old was allowed to purchase creatine, whereas 41.4% (101/244) stated one could purchase a testosterone booster.CONCLUSIONS:
Health food store employees frequently recommend creatine and testosterone boosters for boy high school athletes. In response to these findings, pediatricians should inform their teenage patients, especially athletes, about safe, healthy methods to improve athletic performance and discourage them from using creatine or testosterone boosters. Retailers and state legislatures should also consider banning the sale of these products to minors.
We report, to the best of our knowledge, the first case of a child with typical ataxia telangiectasia (A-T) who developed juvenile idiopathic arthritis (JIA). The patient was a 15-year-old boy with A-T who presented with noninfectious polyarthritis. A-T is a rare, autosomal recessive disorder characterized by cerebellar atrophy, oculocutaneous telangiectasia, immunodeficiency, radiosensitivity, and predisposition to cancer. The gene responsible for A-T is the A-T mutated (ATM) gene. Clinical manifestations of the disorder are the result of lacking ATM protein, which is involved in DNA repair, apoptosis, various checkpoints in the cell cycle, gene regulation, translation, initiation, and telomere maintenance. There are a few articles that describe deficiency of the DNA repair enzyme, ATM, in rheumatoid arthritis, but the connection between the absence of ATM protein and JIA has not been presented or studied yet. JIA is a heterogeneous group of diseases characterized by arthritis of unknown origin with onset before the age of 16 years. It is the most common childhood chronic rheumatic disease and causes significant disability. Because immunodeficiency can be part of A-T, infectious arthritis can occur, but chronic autoimmune arthritis in these patients is rare. We report a rare case of a 15-year-old boy with A-T and JIA. This case shows a possible relationship between altered function of ATM protein and the pathogenesis of JIA.
Previous studies identified associations between maternal obesity and childhood neurodevelopment, but few examined paternal obesity despite potentially distinct genetic/epigenetic effects related to developmental programming.METHODS:
Upstate KIDS (2008–2010) recruited mothers from New York State (excluding New York City) at ~4 months postpartum. Parents completed the Ages and Stages Questionnaire (ASQ) when their children were 4, 8, 12, 18, 24, 30, and 36 months of age corrected for gestation. The ASQ is validated to screen for delays in 5 developmental domains (ie, fine motor, gross motor, communication, personal-social functioning, and problem-solving ability). Analyses included 3759 singletons and 1062 nonrelated twins with ≥1 ASQs returned. Adjusted odds ratios (aORs) and 95% confidence intervals were estimated by using generalized linear mixed models accounting for maternal covariates (ie, age, race, education, insurance, marital status, parity, and pregnancy smoking).RESULTS:
Compared with normal/underweight mothers (BMI <25), children of obese mothers (26% with BMI ≥30) had increased odds of failing the fine motor domain (aOR 1.67; confidence interval 1.12–2.47). The association remained after additional adjustment for paternal BMI (1.67; 1.11–2.52). Paternal obesity (29%) was associated with increased risk of failing the personal-social domain (1.75; 1.13–2.71), albeit attenuated after adjustment for maternal obesity (aOR 1.71; 1.08–2.70). Children whose parents both had BMI ≥35 were likely to additionally fail the problem-solving domain (2.93; 1.09–7.85).CONCLUSIONS:
Findings suggest that maternal and paternal obesity are each associated with specific delays in early childhood development, emphasizing the importance of family information when screening child development.
Ordering rates for imaging studies and procedures may change if clinicians are shown the prices of those tests while they are ordering. We studied the effect of 2 forms of paid price information, single median price and paired internal/external median prices, on how often pediatric-focused and adult-oriented clinicians (most frequently general pediatricians and adult specialists caring for pediatric-aged patients, respectively) order imaging studies and procedures for 0- to 21-year-olds.METHODS:
In January 2014, we randomized 227 pediatric-focused and 279 adult-oriented clinicians to 1 of 3 study arms: Control (no price display), Single Median Price, or Paired Internal/External Median Prices (both with price display in the ordering screen of electronic health record). We used 1-way analysis of variance and paired t tests to examine how frequently clinicians (1) placed orders and (2) designated tests to be completed internally within an accountable care organization.RESULTS:
For pediatric-focused clinicians, there was no significant difference in the rates at which orders were placed or designated to be completed internally across the study arms. For adult-oriented clinicians caring for children and adolescents, however, those in the Single Price and Paired Price arms placed orders at significantly higher rates than those in the Control group (Control 3.2 [SD 4.8], Single Price 6.2 [SD 6.8], P < .001 and Paired Prices 5.2 [SD 7.9], P = .04). The rate at which adult-oriented clinicians designated tests to be completed internally was not significantly different across arms.CONCLUSIONS:
The effect of price information on ordering rates appears to depend on whether the clinician is pediatric-focused or adult-oriented.
The prospective relation between physical activity and Diagnostic and Statistical Manual of Mental Disorders-defined major depression in middle childhood is unknown, as is the stability of depression. We therefore aimed to (1) determine whether there are reciprocal relations between moderate-to-vigorous physical activity (MVPA) and sedentary behavior, on one hand, and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition defined symptoms of major depressive disorder, on the other and (2) assess the extent of stability in depressive symptoms from age 6 to 10 years.METHODS:
A community sample of children living in Trondheim, Norway, comprising a total of 795 6-year-old children was followed up at 8 (n = 699) and 10 (n = 702) years of age. Physical activity was recorded by accelerometry and symptoms of major depression were measured through semistructured clinical interviews of parents and children. Bidirectional relationships between MVPA, sedentary activity, and symptoms of depression were analyzed through autoregressive cross-lagged models, and adjusted for symptoms of comorbid psychiatric disorders and BMI.RESULTS:
At both age 6 and 8 years, higher MVPA predicted fewer symptoms of major depressive disorders 2 years later. Sedentary behavior did not predict depression, and depression predicted neither MVPA nor sedentary activity. The number of symptoms of major depression declined from ages 6 to 8 years and evidenced modest continuity.CONCLUSIONS:
MVPA predicts fewer symptoms of major depression in middle childhood, and increasing MVPA may serve as a complementary method to prevent and treat childhood depression.
Like their adult counterparts, pediatric hospitals are increasingly at risk for financial penalties based on readmissions. Limited information is available on how the composition of a hospital’s patient population affects performance on this metric and hence affects reimbursement for hospitals providing pediatric care. We sought to determine whether applying different readmission metrics differentially affects hospital performance based on the characteristics of patients a hospital serves.METHODS:
We performed a cross-sectional analysis of 64 children’s hospitals from the Children’s Hospital Association Case Mix Comparative Database 2012 and 2013. We calculated 30-day observed-to-expected readmission ratios by using both all-cause (AC) and Potentially Preventable Readmissions (PPR) metrics. We examined the association between observed-to-expected rates and hospital characteristics by using multivariable linear regression.RESULTS:
We examined a total of 1 416 716 hospitalizations. The mean AC 30-day readmission rate was 11.3% (range 4.3%–19.6%); the mean PPR rate was 4.9% (range 2.9%–6.9%). The average 30-day AC observed-to-expected ratio was 0.96 (range 0.63–1.23), compared with 0.95 (range 0.65–1.23) for PPR; 59% of hospitals performed better than expected on both measures. Hospitals with higher volumes, lower percentages of infants, and higher percentage of patients with low income performed worse than expected on PPR.CONCLUSIONS:
High-volume hospitals, those that serve fewer infants, and those with a high percentage of patients from low-income neighborhoods have higher than expected PPR rates and are at higher risk of reimbursement penalties.