Using a population-based sample of youth, we examined rates of cigarette use and trends in cigarette use disparities between heterosexual youth and 3 subgroups of sexual minority youth (SMY) (ie, lesbian or gay, bisexual, and unsure) from 2005 to 2015.METHODS:
Data are from 6 cohorts of the Youth Risk Behavior Survey, a national, biennial, school-based survey of ninth- to 12th-grade students in the United States (n = 404 583). Sex-stratified analyses conducted in 2017 examined trends in 2 cigarette-related behaviors: lifetime cigarette use and heavy cigarette use (20+ days in the past 30).RESULTS:
Disparities in lifetime cigarette use between lesbian and heterosexual girls were statistically smaller in 2015 relative to 2005 (adjusted odds ratio [aOR] 0.29; 95% confidence interval [CI] 0.12–0.75; P = .011). Sexual orientation disparities in heavy use were narrower for bisexual boys in 2015 compared with 2005 (aOR 0.39; 95% CI 0.17–0.90; P = .028). Girls and boys unsure of their sexual identity had wider disparities in heavy use in 2015 (aOR 3.85; 95% CI 1.39–11.10; P = .009) relative to 2005 (aOR 2.44; 95% CI 1.22–5.00; P = .012).CONCLUSIONS:
SMY remain at greater risk for cigarette-related behaviors despite greater acceptance of lesbian, gay, and bisexual people in the United States. Focused policies and programs aimed at reducing rates of SMY cigarette use are warranted, particularly for youth questioning their sexual identity.
Clinicians prescribe antihypertensive medication to children with primary hypertension, but without data to define a particular choice as first-line therapy. A one-size-fits-all approach may not be appropriate for these patients. Our aim was to develop a personalized approach to hypertension treatment, using repeated ambulatory blood pressure monitoring (ABPM) in n-of-1 trials (single-patient randomized crossover trials).METHODS:
Children undergoing hypertension management at a single pediatric referral center were offered participation in an n-of-1 trial with repeated ABPM to compare 3 commonly used medications. The medication producing the greatest blood pressure reduction, and without unacceptable side effects, was selected as the preferred therapy for the individual.RESULTS:
Forty-two children agreed to participate; 7 were normotensive without medication; and 3 failed to complete one treatment cycle. Of the remaining 32 patients, lisinopril was preferred for 16, amlodipine for 8, hydrochlorothiazide for 4, and 4 had uncontrolled blood pressure on maximum doses of monotherapy. In conservative Bayesian analyses, the proportion of patients who preferred lisinopril was 49% (95% credible interval [CrI]: 32% to 69%), 24% (95% CrI: 12% to 41%) preferred amlodipine, and 12% (95% CrI: 4% to 26%) preferred hydrochlorothiazide. The preferred therapy for the majority (67%) of African American participants was lisinopril. Unacceptable side effects were reported in 24% of assessments for hydrochlorothiazide, 16% for lisinopril, and 13% for amlodipine.CONCLUSIONS:
No single medication was preferred for more than half of hypertensive children. n of-1 trials with repeated ABPM may promote better informed and individualized decisions in pediatric hypertension management.
Previous research has documented less dialogic interaction between parents and preschoolers during electronic-book reading versus print. Parent-toddler interactions around commercially available tablet-based books have not been described. We examined parent-toddler verbal and nonverbal interactions when reading electronic versus print books.METHODS:
We conducted a videotaped, laboratory-based, counterbalanced study of 37 parent-toddler dyads reading on 3 book formats (enhanced electronic [sound effects and/or animation], basic electronic, and print). We coded verbalizations in 10-second intervals for parents (dialogic, nondialogic, text reading, format related, negative format-related directives, and off task) and children (book related, negative, and off task). Shared positive affect and collaborative book reading were coded on a scale of 1 to 5 (5 = high). Proc Genmod and Proc Mixed analyzed within-subjects variance by book format.RESULTS:
Parents showed significantly more dialogic (print 11.9; enhanced 6.2 [P < .001]; basic 8.3 [P < .001]), text-reading (print 14.3; enhanced 10.6 [P = .003]; basic 14.4 [P < .001]), off-task (print 2.3; enhanced 1.3 [P = .007]), and total (29.5; enhanced 28.1 [P = .003]; basic 29.3 [P = .005]) verbalizations with print books and fewer format-related verbalizations (print 1.9; enhanced 10.0 [P < .001]; basic 8.3 [P < .001]). Toddlers showed more book-related verbalizations (print 15.0; enhanced 11.5 [P < .001]; basic 12.5 [P = .005]), total verbalizations (print 18.8; enhanced 13.8 [P < .001]; basic 15.3 [P < .001]), and higher collaboration scores (print 3.1; enhanced 2.7 [P = .004]; basic 2.8 [P = .02]) with print-book reading.CONCLUSIONS:
Parents and toddlers verbalized less with electronic books, and collaboration was lower. Future studies should examine specific aspects of tablet-book design that support parent-child interaction. Pediatricians may wish to continue promoting shared reading of print books, particularly for toddlers and younger children.
Projecting postoperative recovery in pediatric surgical patients is challenging. We assessed how the patients’ number of complex chronic conditions (CCCs) and chronic medications interacted with active health issues to influence the likelihood of postoperative physiologic decline (PoPD).METHODS:
A prospective study of 3295 patients undergoing elective surgery at a freestanding children’s hospital. During preoperative clinical evaluation, active health problems, CCCs, and medications were documented. PoPD (compromise of cardiovascular, respiratory, and/or neurologic systems) was measured prospectively every 4 hours by inpatient nurses. PoPD odds were estimated with multivariable logistic regression. Classification and regression tree analysis distinguished children with the highest and lowest likelihood of PoPD.RESULTS:
Median age at surgery was 8 years (interquartile range: 2–15); 2336 (70.9%) patients had a CCC; and 241 (7.3%) used ≥11 home medications. During preoperative evaluation, 1556 (47.2%) patients had ≥1 active health problem. After surgery, 882 (26.8%) experienced PoPD. The adjusted odds of PoPD were 1.2 (95% confidence interval [CI]: 1.0–1.4) for presence versus absence of an active health problem; 1.4 (95% CI: 1.0–1.9) for ≥11 vs 0 home medications; and 2.2 (95% CI: 1.7–2.9) for ≥3 vs 0 CCCs. In classification and regression tree analysis, the lowest rate of PoPD (8.6%) occurred in children without an active health problem at the preoperative evaluation; the highest rate (57.2%) occurred in children with a CCC who used ≥11 home medications.CONCLUSIONS:
Greater than 1 in 4 pediatric patients undergoing elective surgery experienced PoPD. Combinations of active health problems at preoperative evaluation, polypharmacy, and multimorbidity distinguished patients with a low versus high risk of PoPD.
Exposure to negative social interactions (such as rudeness) has robust adverse implications on medical team performance. However, little is known regarding the effects of positive social interactions. We hypothesized that expressions of gratitude, a prototype of positive social interaction, would enhance medical teams’ effectiveness. Our objective was to study the performance of NICU teams after exposure to expressions of gratitude from alternative sources.METHODS:
Forty-three NICU teams (comprising 2 physicians and 2 nurses) participated in training workshops of acute care simulations. Teams were randomly assigned to 1 of 4 conditions: (1) maternal gratitude (in which the mother of a preterm infant expressed gratitude to NICU teams, such as the one that treated her child), (2) expert gratitude (in which a physician expert expressed gratitude to teams for participating in the training), (3) combined maternal and expert gratitude, or (4) control (same agents communicated neutral statements). The simulations were evaluated (5-point Likert scale: 1 = failed and 5 = excellent) by independent judges (blind to team exposure) using structured questionnaires.RESULTS:
Maternal gratitude positively affected teams’ performances (3.9 ± 0.9 vs 3.6 ± 1.0; P = .04), with most of this effect explained by the positive impact of gratitude on team information sharing (4.3 ± 0.8 vs 4.0 ± 0.8; P = .03). Forty percent of the variance in team information sharing was explained by maternal gratitude. Information sharing predicted team performance outcomes, explaining 33% of the variance in diagnostic performance and 41% of the variance in therapeutic performance.CONCLUSIONS:
Patient-expressed gratitude significantly enhances medical team performance, with much of this effect explained by enhanced information sharing.
Visits to the emergency department (ED) for psychiatric purposes are an indicator of chronic and acute unmet mental health needs. In the current study, we examined if psychiatric ED visits among individuals 6 to 24 years of age are increasing nationwide.METHODS:
ED data came from the 2011–2015 National Hospital Ambulatory Medical Care Survey, a national survey of ED visits across the United States. Psychiatric ED visits were identified by using the International Classification of Diseases, Ninth Revision and reason-for-visit codes. Survey-weighted logistic regression analyses were employed to examine trends in as well as correlates of psychiatric ED visits. Data from the US Census Bureau were used to examine population rates.RESULTS:
Between 2011 and 2015, there was a 28% overall increase (from 31.3 to 40.2) in psychiatric ED visits per 1000 youth in the United States. The largest increases in psychiatric ED visits per 1000 US youth were observed among adolescents (54%) and African American (53%) and Hispanic patients (91%). A large increase in suicide-related visits (by 2.5-fold) was observed among adolescents (4.6–11.7 visits per 1000 US youth). Although psychiatric ED visits were long (51% were ≥3 hours in length), few (16%) patients were seen by a mental health professional during their visit.CONCLUSIONS:
Visits to the ED for psychiatric purposes among youth are rising across the United States. Psychiatric expertise and effective mental health treatment options, particular those used to address the rising suicide epidemic among adolescents, are needed in the ED.
Antimicrobial stewardship programs (ASPs) are targeted to optimize antimicrobial use. However, pediatric metrics used to measure outcomes of ASPs are not well established. Our aim for this project was to identify, refine, and develop consensus on standard metrics for pediatric ASPs.METHODS:
By using a modified Delphi process, 2 surveys were sent to experts and stakeholders to establish consensus on the utility of metrics. These were subdivided into 4 ASP domains: (1) antimicrobial consumption, (2) microbiologic outcomes, (3) clinical outcomes, and (4) process measures. Respondents were asked to rank the scientific merit, impact, feasibility, and accountability of each metric. Metrics with ≥75% agreement for scientific merit were included and metrics with ≤25% agreement were discarded. Consensus was finalized with a face-to-face meeting and final survey.RESULTS:
Thirty-eight participants from 15 pediatric hospitals across Canada completed all 3 rounds of the Delphi survey. In the domain of antimicrobial consumption, the 2 selected metrics were (1) days of therapy per 1000 patient-days and (2) total antimicrobial days. The clinical and process outcomes chosen were (1) 30-day readmission rate and (2) adherence to ASP recommendations, respectively. A microbiologic outcome was felt to be important and feasible, but consensus could not be obtained on a measure. Several barriers to implementation of the metrics were identified, including information technology limitations at various centers.CONCLUSIONS:
We obtained consensus on 4 metrics to evaluate pediatric antimicrobial stewardship activities in Canada. Adoption of these metrics by pediatric ASPs will facilitate measurement of outcomes nationally and internationally.
Heterotopic gastric mucosa (HGM) is defined as the presence of gastric mucosa outside of the stomach, which is documented by histologic finding. HGM is typically a solitary lesion; however, in our Case Report, the patient presented with multilocus HGM, an uncommon form in which the small bowel is extensively involved. We report a unique case of multilocus HGM mimicking very early–onset inflammatory bowel disease with recurrent gastrointestinal bleeding, chronic inflammation, and stricturing in a newborn patient. Histologic findings from the ileocecal specimen revealed multiple ulcers surrounded by chronic inflammation. Subsequently, a Technetium-99m pertechnetate scan demonstrated an increased tracer uptake in the remaining ileum. This radiologic finding, in combination with the discovery of gastric mucosa within the remainder of resected ileal specimen, led to the diagnosis of HGM. Omeprazole was initiated, and the patient is now asymptomatic without further gastrointestinal bleeding. Increased awareness of this rare disease and performing a Technetium-99m pertechnetate early can correctly diagnose HGM and prevent disease complication.
Early engagement in mental health intervention is critical, yet the vast majority of children who are experiencing mental health concerns are not receiving needed services. Pediatric primary care clinics have been recognized as an ideal setting in which to identify and address mental health problems early, although engagement in mental health services within primary care and in community-based settings remains low. Navigators, or individuals with experience in navigating the mental health system, have been highlighted as promising partners in efforts to improve engagement in mental health services. Navigation has a growing body of research support among adults and in targeting medical concerns, but there has been limited research on integrating family navigators into pediatric primary care settings to address mental health concerns. Despite this gap in the evidence base, we believe there is significant promise for the use of this model in addressing children’s mental health needs. In this report, we discuss factors contributing to high levels of unmet mental health needs and low levels of engagement in mental health services, the role that navigators can play in increasing engagement in mental health care, and implications and recommendations related to integrating mental health–focused family navigators into pediatric primary care settings.
Our purpose in this study was to adapt and validate the Traumatic Events Screening Inventory (TESI) as a primary-care childhood adversity screening tool for children living in vulnerable neighborhoods using a community-partnered approach.METHODS:
In this cross-sectional, descriptive study, we used a sample of 261 children (3–16 years old) who were seeking services at a Federally Qualified Health Center with colocated behavioral health services in Chicago and had a positive Pediatric Symptom Checklist screen result or received a referral for behavioral health evaluation. The TESI was adapted as a screening tool to be sensitive to adverse childhood experiences (ACEs) unique to the clinic communities. ACEs were mapped by zip code with objective neighborhood crime data, and latent class analysis was performed to identify ACE subgroups.RESULTS:
The mapping validation suggested face validity for geographic overlap between participant ACEs and objective violent-crime occurrence. With latent class analysis, we identified 3 ACE subgroups: (1) high ACE (18.0% of the sample; polyvictimization and/or maltreatment), (2) moderate ACE (52.1%; violent environments), and (3) low ACE (29.9%; few adverse experiences). Membership in the high-ACE subgroup was associated with higher odds of a clinically significant Pediatric Symptom Checklist score (odds ratio = 3.83) and clinical-level attention problems (odds ratio = 3.58) even after accounting for child resilience and parent depression.CONCLUSIONS:
ACEs play a significant role in predicting a need for behavioral health services among children seeking primary-care services. The community-adapted TESI is a valid ACE screening tool.
To examine the impact of social media influencer marketing of foods (healthy and unhealthy) on children’s food intake.METHODS:
In a between-subjects design, 176 children (9–11 years, mean 10.5 ± 0.7 years) were randomly assigned to view mock Instagram profiles of 2 popular YouTube video bloggers (influencers). Profiles featured images of the influencers with unhealthy snacks (participants: n = 58), healthy snacks (n = 59), or nonfood products (n = 59). Subsequently, participants’ ad libitum intake of unhealthy snacks, healthy snacks, and overall intake (combined intake of healthy and unhealthy snacks) were measured.RESULTS:
Children who viewed influencers with unhealthy snacks had significantly increased overall intake (448.3 kilocalories [kcals]; P = .001), and significantly increased intake of unhealthy snacks specifically (388.8 kcals; P = .001), compared with children who viewed influencers with nonfood products (357.1 and 292.2 kcals, respectively). Viewing influencers with healthy snacks did not significantly affect intake.CONCLUSIONS:
Popular social media influencer promotion of food affects children’s food intake. Influencer marketing of unhealthy foods increased children’s immediate food intake, whereas the equivalent marketing of healthy foods had no effect. Increasing the promotion of healthy foods on social media may not be an effective strategy to encourage healthy dietary behaviors in children. More research is needed to understand the impact of digital food marketing and inform appropriate policy action.
Exercise-induced purpura, which has also been called "golfer’s purpura," is a phenomenon that has been rarely reported in the pediatric literature. This is the first case series in which this benign vasculopathy, which is most often associated with warm weather and high-impact activity, is described. In this series, we describe 5 patients, most of whom had an erythematous purpuric rash above the sock line that extended to the knees and was associated with warm weather and prolonged activity. Exercise-induced purpura may be mistaken for Henoch-Schönlein purpura or as a manifestation of a possible systemic vasculitis. Recognition of this benign condition is vital to avoid an unnecessary workup and a costly evaluation with accompanying anxiety.
ABO blood group incompatibility between mother and fetus can lead to hemolytic disease of the fetus and newborn (HDFN). We present the first case of severe O/A HDFN associated with extremely high-titer (1:32 000) immunoglobulin G anti-A antibodies in a Cameroon mother. Cord blood analysis revealed severe fetal hemolytic anemia and conjugated hyperbilirubinemia. After exclusion of an underlying disease and other risk factors, cholestasis resolved after treatment with ursodeoxycholic acid, a red blood cell transfusion, and intravenous immunoglobulins. This case is presented to create awareness for a more severe course of ABO HDFN in nonwhite and non-European mother-child pairs.
To examine the incidence, mortality, and health care use related to neonatal herpes simplex virus (HSV) infection.METHODS:
A retrospective longitudinal cohort study using a multistate Medicaid claims database. We identified neonates hospitalized with HSV infection from 2009 to 2015 by using discharge diagnosis codes and managed them for 6 months after discharge. Incidence rates were corrected for the imperfect sensitivity and specificity of thediagnosis codes for identifying HSV infection.RESULTS:
Of 2 107 124 births from 2009 to 2015, 900 neonates were identified with HSV infection, with a corrected incidence rate of 4.5 (95% confidence interval [CI]: 4.2–4.8) per 10 000 births. The yearly disease incidence increased by 56%, from 3.4 (95% CI: 2.8–4.2) per 10 000 births (or 1 in 2941 births) in 2009 to 5.3 (95% CI: 4.6–6.1) per 10 000 births (or 1 in 1886 births) in 2015 (P < .001). Of the 900 neonates with HSV infection, 54 (6.0% [95% CI: 4.4%–7.6%]) died during the index hospitalization; there was no increase in the yearly mortality rate. Of the 692 (81.2%) infants with follow-up data, 316 (45.7%) had an emergency department visit, and 112 (16.2%) had a hospital readmission. Total payments at 6 months amounted to $60 620 431, a median of $87 602 per case of neonatal HSV infection.CONCLUSIONS:
We observed an increase in neonatal HSV infection incidence over a recent 7-year period in a Medicaid population. Associated health care use and payments were substantial. Public health interventions targeting disease prevention and early diagnosis are needed.
To determine how smoke-free and vape-free home and car policies differ for parents who are dual users of cigarettes and electronic cigarettes (e-cigarettes), who only smoke cigarettes, or who only use e-cigarettes. To identify factors associated with not having smoke-free or vape-free policies and how often smoke-free advice is offered at pediatric offices.METHODS:
Secondary analysis of 2017 parental interview data collected after their children’s visit in 5 control practices participating in the Clinical Effort Against Secondhand Smoke Exposure trial.RESULTS:
Most dual users had smoke-free home policies, yet fewer had a vape-free home policies (63.8% vs 26.3%; P < .01). Dual users were less likely than cigarette users to have smoke-free car (P < .01), vape-free home (P < .001), or vape-free car (P < .001) policies. Inside cars, dual users were more likely than cigarette users to report smoking (P < .001), e-cigarette use (P < .001), and e-cigarette use with children present (P < .001). Parental characteristics associated with not having smoke-free or vape-free home and car policies include smoking ≥10 cigarettes per day, using e-cigarettes, and having a youngest child >10 years old. Smoke-free home and car advice was infrequently delivered.CONCLUSIONS:
Parents may perceive e-cigarette aerosol as safe for children. Dual users more often had smoke-free policies than vape-free policies for the home. Dual users were less likely than cigarette-only smokers to report various child-protective measures inside homes and cars. These findings reveal important opportunities for intervention with parents about smoking and vaping in homes and cars.
Maternal smoking during pregnancy is an established risk factor for sudden unexpected infant death (SUID). Here, we aim to investigate the effects of maternal prepregnancy smoking, reduction during pregnancy, and smoking during pregnancy on SUID rates.METHODS:
We analyzed the Centers for Disease Control and Prevention Birth Cohort Linked Birth/Infant Death Data Set (2007–2011: 20 685 463 births and 19 127 SUIDs). SUID was defined as deaths at <1 year of age with International Classification of Diseases, 10th Revision codes R95 (sudden infant death syndrome), R99 (ill-defined or unknown cause), or W75 (accidental suffocation or strangulation in bed).RESULTS:
SUID risk more than doubled (adjusted odds ratio [aOR] = 2.44; 95% confidence interval [CI] 2.31–2.57) with any maternal smoking during pregnancy and increased twofold between no smoking and smoking 1 cigarette daily throughout pregnancy. For 1 to 20 cigarettes per day, the probability of SUID increased linearly, with each additional cigarette smoked per day increasing the odds by 0.07 from 1 to 20 cigarettes; beyond 20 cigarettes, the relationship plateaued. Mothers who quit or reduced their smoking decreased their odds compared with those who continued smoking (reduced: aOR = 0.88, 95% CI 0.79–0.98; quit: aOR = 0.77, 95% CI 0.67–0.87). If we assume causality, 22% of SUIDs in the United States can be directly attributed to maternal smoking during pregnancy.CONCLUSIONS:
These data support the need for smoking cessation before pregnancy. If no women smoked in pregnancy, SUID rates in the United States could be reduced substantially.
Multilevel surgery (MLS) is standard care for reducing musculoskeletal disorders among children with spastic cerebral palsy (CP).OBJECTIVE:
To summarize the literature examining effects of MLS and satisfaction with MLS for children with CP.DATA SOURCES:
Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials were searched.STUDY SELECTION:
Studies in which authors reported effects of or satisfaction with MLS in children with CP were selected.DATA EXTRACTION:
Two authors screened and extracted data on gross motor function, gait speed, gait (eg, Gait Profile Score), range of motion, strength, spasticity, participation, quality of life, satisfaction, and adverse events.RESULTS:
Seventy-four studies (3551 participants) were identified. One was a randomized controlled trial (RCT) (n = 19); the remainder were cohort studies. Pooled analysis of cohort studies revealed that MLS did not have a long-term effect on gross motor function (standardized mean difference [SMD]: 0.38; 95% confidence interval [CI]: –0.25 to 1.01) or gait speed (SMD: 0.12; 95% CI: –0.01 to 0.25) but did improve gait (SMD: –0.80; 95% CI: –0.95 to –0.65). The RCT also revealed no effect of MLS on gross motor function but improvements in the Gait Profile Score at 1 year. Participation and quality of life were reported in only 5 studies, and adverse events were adequately reported in 17 studies.LIMITATIONS:
Data were largely from cohort studies.CONCLUSIONS:
Findings reveal that gait, but not gross motor function, improves after MLS. RCTs and improved reporting of studies of MLS are required.
Little is known about the use of chronic medications (CMs) in children. We assessed the prevalence of CM use in children and the association of clinical characteristics and health care resource use with the number of CMs used.METHODS:
This is a retrospective study of children ages 1 to 18 years using Medicaid from 10 states in 2014 grouped by the annual number of CMs (0, 1, 2–4, 5–9, and ≥10 medications), which are defined as a dispensed ≥30-day prescription with ≥2 dispensed refills. Trends in clinical characteristics and health care use by number of CMs were evaluated with the Cochran-Armitage trend test.RESULTS:
Of 4 594 061 subjects, 18.8% used CMs. CM use was 44.4% in children with a complex chronic condition. Across all children, the most common CM therapeutic class was neurologic (28.9%). Among CM users, 48.8% used multiple CMs (40.3% used 2–4, 7.0% used 5–9, and 0.5% used ≥10). The diversity of medications increased with increasing number of CMs: for 1 CM, amphetamine stimulants were most common (29.0%), and for ≥10 CMs, antiepileptics were most common (7.1%). Of $2.3 billion total pharmacy spending, 59.3% was attributable to children dispensed multiple CMs. Increased CM use (0 to ≥10 medications) was associated with increased emergency department use (32.1% to 56.2%) and hospitalization (2.3% to 36.7%).CONCLUSIONS:
Nearly 1 in 5 children with Medicaid used CMs. Use of multiple CMs was common and correlated with increased health care use. Understanding CM use in children should be fundamentally important to health care systems when strategizing how to provide safe, evidence-based, and cost-effective pharmaceutical care to children.