We sought to implement systematic tobacco dependence interventions for parents and/or caregivers as secondary aims within 2 multisite quality improvement (QI) collaboratives for bronchiolitis. We hypothesized that iterative improvements in tobacco dependence intervention strategies would result in improvement in outcomes between collaboratives.METHODS:
This study involved 2 separate yearlong, multisite QI collaboratives that were focused on care provided to inpatients with a primary diagnosis of bronchiolitis. In each collaborative, we provided tools and training in tobacco dependence treatment and expert coaching on interventions for parents as a secondary aim. Data were collected by chart review and results analyzed by using analysis of means and statistical process control analysis. Outcomes between collaboratives were compared by using relative risks.RESULTS:
Between both collaboratives, 56 hospitals participated and 6258 inpatient charts were reviewed. In the first collaborative, 22% of identified parents who smoke received tobacco dependence interventions at baseline. This rate increased to 51% during the postintervention period, with special cause revealed by analysis of means. In the second collaborative, 31% of parents who smoke received baseline interventions. This rate increased to 53% by the conclusion of the collaborative, with special cause revealed by statistical process control analysis. The relative risk for providing any cessation intervention in 1 collaborative versus the other was 0.9 (confidence interval 0.8–1.1).CONCLUSIONS:
Tobacco dependence treatment of parents and/or caregivers can be integrated into bronchiolitis QI by using relatively low-resource strategies. Using a more intensive QI intervention did not alter the rates of screening or intervention for caregivers who smoke.
World Health Organization guidelines recommend covering the head during kangaroo mother care (KMC), but the effect of a cap on neonatal thermal control during KMC remains to be defined. Our objective was to assess the effectiveness and safety of a woolen cap in maintaining low birth weight infants (LBWIs) in normal thermal range during KMC.METHODS:
Three hundred LBWI candidates for KMC in 3 African hospitals were randomly assigned to KMC with (CAP group) or without (NOCAP group) a woolen cap in a 1:1 ratio during the first week after birth. Axillary temperature was measured every 6 hours. Maternal and room temperature and adherence to skin-to-skin contact were registered at the same time points.RESULTS:
A total number of 5064 measurements were recorded (median 19 measurements per subject; interquartile range: 10–25). Mean time spent in normal temperature range was 55% (SD 24) in CAP and 56% (SD 24) in NOCAP groups. Multivariable analysis estimated a rate ratio of 0.92 (95% confidence interval: 0.84 to 1.00; P = .06) for the effect of the cap versus no cap on time spent in the normal temperature range.CONCLUSIONS:
In these 3 African, low-resource settings and so many days post birth, the use of a woolen cap was safe but provided no advantages in maintaining LBWI in the normal thermal range while being in a KMC ward. LBWIs spent only half of the time in the normal temperature range despite warm rooms and skin-to-skin contact. Maintaining normothermia in LBWIs remains an unfinished challenge in low-resource settings.
To determine if adolescent mothers who were in the care of child protection services (CPS) when they gave birth to their first child are more likely to have that child taken into CPS care before the child’s second birthday than adolescent mothers who were not in the care of CPS.METHODS:
Linkable administrative data were used to create a population-based cohort of adolescent mothers whose first child was born in Manitoba, Canada between April 1, 1998, and March 31, 2013 (n = 5942). Adjusted odds ratios (aOR) of having that first child taken into care before their second birthday were compared between mothers who were in care (n = 576) and mothers who were not in care (n = 5366) at the birth of their child by using logistic regression models.RESULTS:
Adolescent mothers who were in care had greater odds of having their child taken into care before the child’s second birthday (aOR = 7.53; 95% confidence interval [CI] = 6.19–9.14). Specifically, their children had higher odds of being taken into care in their first week of life (aOR = 11.64; 95% CI = 8.83–15.34), between 1 week and their first birthday (aOR = 3.63; 95% CI = 2.79–4.71), and between their first and second birthday (aOR = 2.21; 95% CIl = 1.53–3.19).CONCLUSIONS:
Findings support an intergenerational cycle of involvement with CPS. More and better services are required for adolescent mothers who give birth while in care of CPS.
Because of the opioid epidemic, hepatitis C virus (HCV) infection is increasing among pregnant women, resulting in an increased risk of perinatal transmission and HCV infection among children. Our primary objectives in this study were to determine the prevalence of HCV among pregnant women and the frequency of pediatric HCV screening.METHODS:
A population-based, retrospective cohort of pregnant women who delivered between 2006 and 2014 was identified and classified as HCV infected or HCV uninfected by billing codes. Infant records linked to the HCV-infected pregnant women were identified and queried for HCV tests and the receipt of well-child services, which were defined as the presence of hemoglobin and/or lead testing at or after 9 months of age.RESULTS:
Between 2006 and 2014, 1043 (1.2%) HCV-infected pregnant women delivered, and the HCV prevalence increased by 60%. HCV-infected women were more likely to be <30 years of age (67% vs 53%; P < .001), white (93% vs 72%; P < .001), insured by Medicaid (77% vs 29%; P < .001), and have opiate use disorder (68% vs 1%; P < .001) than HCV-uninfected women. Infants born to HCV-infected women were more likely to be preterm (<37 weeks’ gestation; 22% vs 10%; P < .001) and of low birth weight (<2500 g; 23% vs 8%; P < .001). Among 1025 HCV-exposed infants with available pediatric records, 323 (31%) received well-child services, and among these, only 96 (30%) were screened for HCV.CONCLUSIONS:
Despite the increased HCV prevalence among pregnant women and the risk of perinatal HCV transmission, HCV-exposed infants are not adequately screened, and many pediatric HCV infections remain undetected.
To evaluate glycemic control among children and adults with type 1 diabetes mellitus (T1DM) who consume a very low–carbohydrate diet (VLCD).METHODS:
We conducted an online survey of an international social media group for people with T1DM who follow a VLCD. Respondents included adults and parents of children with T1DM. We assessed current hemoglobin A1c (HbA1c) (primary measure), change in HbA1c after the self-reported beginning of the VLCD, total daily insulin dose, and adverse events. We obtained confirmatory data from diabetes care providers and medical records.RESULTS:
Of 316 respondents, 131 (42%) were parents of children with T1DM, and 57% were of female sex. Suggestive evidence of T1DM (based on a 3-tier scoring system in which researchers took into consideration age and weight at diagnosis, pancreatic autoimmunity, insulin requirement, and clinical presentation) was obtained for 273 (86%) respondents. The mean age at diagnosis was 16 ± 14 years, the duration of diabetes was 11 ± 13 years, and the time following a VLCD was 2.2 ± 3.9 years. Participants had a mean daily carbohydrate intake of 36 ± 15 g. Reported mean HbA1c was 5.67% ± 0.66%. Only 7 (2%) respondents reported diabetes-related hospitalizations in the past year, including 4 (1%) for ketoacidosis and 2 (1%) for hypoglycemia.CONCLUSIONS:
Exceptional glycemic control of T1DM with low rates of adverse events was reported by a community of children and adults who consume a VLCD. The generalizability of these findings requires further studies, including high-quality randomized controlled trials.
To assess effects of justified versus unjustified screen violence on parents’ willingness to allow children to view films that contain extensive gun violence.METHODS:
A national US sample of 610 parents with at least 1 child between ages 6 and 17 was randomly assigned to view a series of four 90-second video clips from popular films depicting violent gun use under either justified or unjustified conditions. Graphic consequences were removed to mimic the violence common in PG-13 movies. Parents reported their perceived justification for the violence, their emotional reaction while viewing it, the minimum age they would consider appropriate for viewing the film, and whether they would allow their own child to view it. Predictors included experimental condition, viewing order, child age, and recent moviegoing. Growth curve modeling determined the effects of the predictors on both intercepts and slopes of viewing order.RESULTS:
Parents were less emotionally upset and more accepting of child viewing for justified than unjustified gun violence, with perceptions of justification better predictors of parental restriction than emotion. Nevertheless, with the exception of parents with extensive moviegoing habits, parents viewed justified violence as appropriate for adolescents starting at age 15, older than the PG-13 rating suggests.CONCLUSIONS:
Parents are less restrictive of child viewing of gun violence in PG-13 movies when it features characters whose weapon use is seen as justified. The apparent acceptance of rising gun violence in PG-13 movies may be partly attributable to the perception that the violence in those films is justified.
In this study, we investigated trends in cannabis use among parents with children at home in the United States and estimated changes in prevalence of any cannabis use and daily cannabis use among parents who identified as cigarette smokers and nonsmokers with children in the home from 2002 to 2015.METHODS:
The National Survey on Drug Use and Health is an annual, nationally representative, cross-sectional study conducted in the United States. Using logistic regression models, associations between cigarette smoking and any past-month and daily past-month cannabis use among parents with children in the home from 2002 to 2015 were estimated. Moderation of these associations by demographics and trends over time was examined.RESULTS:
Past-month cannabis use among parents with children in the home increased from 4.9% in 2002 to 6.8% in 2015, whereas cigarette smoking declined from 27.6% to 20.2%. Cannabis use increased from 11.0% in 2002 to 17.4% in 2015 among cigarette-smoking parents and from 2.4% to 4.0% among non–cigarette-smoking parents (P value for trends <.0001). Cannabis use was nearly 4 times more common among cigarette smokers versus nonsmokers (17.4% vs 4.0%; adjusted odds ratio = 3.88 [3.16–4.75]), as was daily cannabis use (4.6% vs 0.8%; adjusted odds ratio = 3.70 [2.46–5.55]). The overall percentage of parents who used either cigarettes and/or cannabis decreased from 29.7% in 2002 to 23.5% in 2015.CONCLUSIONS:
Efforts to decrease secondhand smoke exposure via cigarette smoking cessation may be complicated by increases in cannabis use. Educating parents about secondhand cannabis smoke exposure should be integrated into public education programs on secondhand tobacco smoke exposure.
Influenza-associated encephalitis and encephalopathy (IAE) is a severe complication of influenza infection with high morbidity and mortality. We present the case of a patient with IL-10RA mutation who developed encephalopathy after influenza infection. A 10-day-old boy developed recurrent fever and anal fistula. Growth failure gradually became apparent. He had been treated with antibiotics and elemental nutrition. However, the patient did not respond to the treatments. At 11 months, he suddenly developed shock with encephalopathy and multiple organ failures. He was then diagnosed with IAE. A cytokine study revealed elevated levels of IL-1 receptor antagonist, IL-2, IL-6, IL-8, IP-10, eotaxin, G-CSF, MCP-1, and IL-10. These cytokines are normally downregulated by IL-10. Genetic testing revealed a IL-10RA mutation at the 3' end of exon 4 (c.537G->A). These findings might reflect an increased risk of severe IAE in patients with IL-10RA mutation.
Patients with a primary mental health condition account for nearly 10% of pediatric hospitalizations nationally, but little is known about the quality of care provided for them in hospital settings. Our objective was to develop and test medical record–based measures used to assess quality of pediatric mental health care in the emergency department (ED) and inpatient settings.METHODS:
We drafted an evidence-based set of pediatric mental health care quality measures for the ED and inpatient settings. We used the modified Delphi method to prioritize measures; 2 ED and 6 inpatient measures were operationalized and field-tested in 2 community and 3 children’s hospitals. Eligible patients were 5 to 19 years old and diagnosed with psychosis, suicidality, or substance use from January 2012 to December 2013. We used bivariate and multivariate models to examine measure performance by patient characteristics and by hospital.RESULTS:
Eight hundred and seventeen records were abstracted with primary diagnoses of suicidality (n = 446), psychosis (n = 321), and substance use (n = 50). Performance varied across measures. Among patients with suicidality, male patients (adjusted odds ratio: 0.27, P < .001) and African American patients (adjusted odds ratio: 0.31, P = .02) were less likely to have documentation of caregiver counseling on lethal means restriction. Among admitted suicidal patients, 27% had documentation of communication with an outside provider, with variation across hospitals (0%–38%; P < .001). There was low overall performance on screening for comorbid substance abuse in ED patients with psychosis (mean: 30.3).CONCLUSIONS:
These new pediatric mental health care quality measures were used to identify sex and race disparities and substantial hospital variation. These measures may be useful for assessing and improving hospital-based pediatric mental health care quality.
We compared sex-stratified developmental and temperamental profiles at 18 months in children screening negative for autism spectrum disorder (ASD) on the Modified Checklist for Autism in Toddlers (M-CHAT) but later receiving diagnoses of ASD (false-negative group) versus those without later ASD diagnoses (true-negative group).METHODS:
We included 68 197 screen-negative cases from the Norwegian Mother and Child Cohort Study (49.1% girls). Children were screened by using the 6 critical items of the M-CHAT at 18 months. Groups were compared on domains of the Ages and Stages Questionnaire and the Emotionality Activity Sociability Temperament Survey.RESULTS:
Despite passing M-CHAT screening at 18 months, children in the false-negative group exhibited delays in social, communication, and motor skills compared with the true-negative group. Differences were more pronounced in girls. However, with regard to shyness, boys in the false-negative group were rated as more shy than their true-negative counterparts, but girls in the false-negative group were rated as less shy than their counterparts in the true-negative group.CONCLUSIONS:
This is the first study to reveal that children who pass M-CHAT screening at 18 months and are later diagnosed with ASD exhibit delays in core social and communication areas as well as fine motor skills at 18 months. Differences appeared to be more pronounced in girls. With these findings, we underscore the need to enhance the understanding of early markers of ASD in boys and girls, as well as factors affecting parental report on early delays and abnormalities, to improve the sensitivity of screening instruments.
The earned income tax credit (EITC), refundable monies for America’s working poor, is associated with improved child health. Yet, 20% of eligible families do not receive it. We provided free tax preparation services in clinics serving low-income families and assessed use, financial impact, and accuracy.METHODS:
Free tax preparation services ("StreetCred") were available at 4 clinics in Boston in 2016 and 2017. We surveyed a convenience sample of clients (n = 244) about experiences with StreetCred and previous tax services and of nonparticipants (n = 100; 69% response rate) and clinic staff (n = 41; 48% response rate) about acceptability and feasibility.RESULTS:
A total of 753 clients received $1 619 650 in federal tax refunds. StreetCred was associated with significant improvement in tax filing rates. Of surveyed clients, 21% were new filers, 47% were new users of free tax preparation, 14% reported new receipt of the EITC, and 21% reported new knowledge of the EITC. StreetCred had high client acceptability; 96% would use StreetCred again. Families with children were significantly more likely to report StreetCred made them feel more connected to their doctor (P = .02). Clinic staff viewed the program favorably (97% approval).CONCLUSIONS:
Free tax services in urban clinics are a promising, feasible financial intervention to increase tax filing and refunds, save fees, and link clients to the EITC. With future studies, we will assess scalability and measure impact on health. StreetCred offers an innovative approach to improving child health in primary care settings through a financial intervention.
The safety of oral propranolol for infantile hemangioma has not yet been studied at population level since the pediatric use marketing authorization was obtained in Europe.METHODS:
A survey of a nationwide, claim-based observational cohort of children <3 years old, with at least 1 delivery of oral propranolol between July 2014 and June 2016, was performed by using the database of the French National Health Insurance system. Standardized morbidity ratios (SMRs) were calculated by using, from the same database, a representative random sample of nonexposed subjects. The main outcomes were hospitalizations for cardiovascular (conduction disorders, bradycardia, and hypotension), respiratory (bronchial hyperactivity and bronchospasm), or metabolic events (hypoglycemia and hyperkalaemia), identified through the hospitalization diagnostic codes of the International Classification of Diseases, 10th Revision. The main analysis was conducted separately on "healthy" children (N = 1484), that is, free from of any prespecified underlying disease and on children with 1 of these underlying diseases (N = 269).RESULTS:
In all, 1753 patients <3 years of age had at least 2 deliveries of oral propranolol. In the healthy population, we observed 2 cardiovascular events (SMR = 2.8 [0–6.7]), 51 respiratory events (SMR = 1.7 [1.2–2.1]), and 3 metabolic events (SMR = 5.1 [0–10.9]). In the population with an underlying disease (mainly congenital heart disease), we observed 11 cardiovascular events leading to an SMR of 6.0 (2.5–9.6). SMRs were not significantly raised for respiratory or metabolic events in this "nonhealthy" population.CONCLUSIONS:
In this study on a large continuous nationwide claims database, we confirm the safety profile of oral propranolol in healthy children to be good.
To describe the characteristics and trends of exposures to attention-deficit/hyperactivity disorder (ADHD) medications among individuals 0 to 19 years old reported to US poison control centers.METHODS:
National Poison Data System data from 2000 through 2014 were retrospectively analyzed to examine pediatric ADHD medication exposures.RESULTS:
From 2000 through 2014, there were 156 365 exposures reported to US poison control centers related to ADHD medications. The overall rate of reported exposures increased 71.2% from 2000 to 2011, followed by a 6.2% decrease from 2011 to 2014. Three-fourths (76.0%) of exposures involved children ≤12 years old. Methylphenidate and amphetamine medications accounted for 46.2% and 44.5% of exposures, respectively. The most common reason for exposure was therapeutic error (41.6%). Intentional medication exposures (including suspected suicide and medication abuse and/or misuse) were reported most often among adolescents (13–19 years old), accounting for 50.2% of exposures in this age group. Overall, the majority of exposed individuals (60.4%) did not receive health care facility treatment; however, 6.2% were admitted to a hospital for medical treatment, and there were 3 deaths. The increasing number and rate of reported ADHD medication exposures during the study period is consistent with increasing trends in ADHD diagnosis and medication prescribing. Exposures associated with suspected suicide or medication abuse and/or misuse among adolescents are of particular concern.CONCLUSIONS:
Unintentional and intentional pediatric exposures to ADHD medications are an increasing problem in the United States, affecting children of all ages.
Interferon- release assays (IGRAs) are important adjunctive tests for diagnosing tuberculosis (TB) disease in children.METHODS:
We analyzed California TB registry data for patients ≤18 years with laboratory-confirmed TB disease during 2010–2015 to identify case characteristics associated with test selection and performance and measure IGRA sensitivity.RESULTS:
In total, 778 cases of TB were reported; 360 were laboratory confirmed. Indeterminate IGRAs were associated with being <1 year old (prevalence rate ratio 9.23; 95% confidence interval 2.87 to 29.8) and having central nervous system disease (prevalence rate ratio 2.69; 95% confidence interval 1.06 to 6.86) on multivariable analysis. Ninety-five children had both an IGRA and tuberculin skin test (TST) performed. Among those, the sensitivity of IGRA in 5- to 18-year-olds was 96% (66 out of 69) vs 83% (57 out of 69) for TST (P = .01); IGRA sensitivity compared with TST in children ages 2 to 4 was 91% (10 out of 11) vs 91% (10 out of 11) (P > .99), and the sensitivity compared with TST in children aged <2 years was 80% (12 out of 15) vs 87% (13 out of 15) (P > .99).CONCLUSIONS:
This is the largest North American analysis of IGRA use and performance among children with TB disease. In children <5 years old, IGRA sensitivity is similar to TST, but sensitivity of both tests are reduced in children <2 years old. Indeterminate results are higher in children <1 year old and in central nervous system disease. In children ≥5 years old with laboratory-confirmed TB, IGRA has greater sensitivity than TST and should be considered the preferred immunodiagnostic test..
Seizure freedom is the optimal response to antiepileptic treatment. In previous studies, it has been shown that between 61% and 71% of children with epilepsy achieve seizure freedom, whereas 7% to 20% have drug-resistant epilepsy. The definition of drug resistance has not been consistent across studies, and there is a lack of contemporary population-based data. We used data from a large nationwide child cohort to provide such information, implementing the current standard definition of drug resistance.METHODS:
The study was based on the Norwegian Mother and Child Cohort Study. Potential epilepsy cases were identified through registry linkages and parental questionnaires. Medical record reviews and parental interviews were used to collect clinical information and to classify seizures, epilepsies, and etiologies.RESULTS:
The cohort included 112 745 eligible children aged 3 to 13 years (median age 7 years) at end of follow-up. Of these, 600 were epilepsy cases with at least 1 year of follow-up since epilepsy onset (median follow-up time: 5.8 years). There were 178 (30%) who had developed drug-resistant epilepsy, 353 (59%) who had been seizure free for ≥1 year, and 69 (12%) with intermediate seizure outcomes. Having an identified cause of epilepsy (genetic, structural, metabolic, or infectious) was associated with unsatisfactory seizure outcome (48% drug resistance) and influenced the relative risk associated with other prognostic factors. Sociodemographic characteristics were not associated with short-term seizure outcomes.CONCLUSIONS:
Drug resistance occurs in 3 out of 10 children with epilepsy, whereas 6 out of 10 become seizure free. Having an identified cause of epilepsy is associated with poor response to treatment.
Retinal vessel imaging is a noninvasive diagnostic tool used to evaluate cardiovascular risk. Childhood obesity and elevated blood pressure (BP) are associated with retinal microvascular alterations.OBJECTIVE:
To systematically review and meta-analyze associations between obesity, BP, and physical activity with retinal vessel diameters in children.DATA SOURCES:
We conducted a literature search through the databases of PubMed, Embase, Ovid, Web of Science, and the Cochrane Register of Controlled Trials.STUDY SELECTION:
School- and population-based cross-sectional data.DATA EXTRACTION:
General information, study design, participants, exposure, and outcomes.RESULTS:
A total of 1751 studies were found, and 30 full-text articles were analyzed for eligibility. Twenty-two articles (18 865 children and adolescents) were used for further assessment and reflection. Eleven articles were finally included in the meta-analysis. We found that a higher BMI is associated with narrower retinal arteriolar (pooled estimate effect size –0.37 [95% confidence interval (CI): –0.50 to –0.24]) and wider venular diameters (0.35 [95% CI: 0.07 to 0.63]). Systolic and diastolic BP are associated with retinal arteriolar narrowing (systolic BP: –0.63 [95% CI: –0.92 to –0.34]; diastolic BP: –0.60 [95% CI –0.95 to –0.25]). Increased physical activity and fitness are associated with favorable retinal vessel diameters.LIMITATIONS:
Long-term studies are needed to substantiate the prognostic relevance of retinal vessel diameters for cardiovascular risk in children.CONCLUSIONS:
Our results indicate that childhood obesity, BP, and physical inactivity are associated with retinal microvascular abnormalities. Retinal vessel diameters seem to be sensitive microvascular biomarkers for cardiovascular risk stratification in children.
Antibiotic-resistant infections pose a growing threat to public health. Antibiotic use, regardless of whether it is warranted, is a primary factor in the development of resistance. In the United States, the majority of antibiotic health care expenditures are due to prescribing in outpatient settings. Much of this prescribing is inappropriate, with research showing that at least 30% of antibiotic use in outpatient settings is unnecessary. In this State of the Art Review article, we provide an overview of the latest research on outpatient antibiotic prescribing practices in the United States. Although many of the researchers in these studies describe antibiotic prescribing across all patient age groups, we highlight prescribing in pediatric populations when data are available. We then describe the various factors that can influence a physician’s prescribing decisions and drive inappropriate antibiotic use and the potential role of behavioral science in enhancing stewardship interventions to address these drivers. Finally, we highlight the role that a wide range of health care stakeholders can play in aiding the expansion of outpatient stewardship efforts that are needed to fully address the threat of antibiotic resistance.