To assess the prevalence of and factors associated with actual recent practice and near-future intention for infant sleep location in a national sample.METHODS:
There were 3260 mothers from 32 US hospitals who responded to a survey at infant age 2 to 6 months regarding care practices, including usual and all infant sleep locations in the previous 2 weeks and intended location for the next 2 weeks. Mothers were categorized as (1) having practiced and/or intending to practice exclusive room-sharing without bed-sharing, (2) having practiced anything other than exclusive room-sharing but intending to practice exclusive room-sharing, (3) intending to have the infant sleep in another room; and (4) intending to practice bed-sharing all night or part of the night. Multivariable multinomial logistic regression examined associations between sleep-location category, demographics, feeding method, doctor advice, and theory of planned behavior domains (attitudes, social norms, and perceived control).RESULTS:
Fewer than half (45.4%) of the mothers practiced and also intended to practice room-sharing without bed-sharing, and 24.2% intended to practice some bed-sharing. Factors associated with intended bed-sharing included African American race and exclusive breastfeeding; however, the highest likelihood of bed-sharing intent was associated with perceived social norms favoring bed-sharing (adjusted odds ratio [aOR] 5.84; 95% confidence interval [CI] 4.14–8.22) and positive attitudes toward bed-sharing (aOR 190.1; 95% CI 62.4–579.0). Women with a doctor’s advice to room-share without bed-sharing intended to practice bed-sharing less (aOR 0.56; 95% CI 0.36–0.85).CONCLUSIONS:
Sleep-location practices do not always align with the recommendation to room-share without bed-sharing, and intention does not always correspond with previous practice. Attitudes, perceived social norms, and doctor advice are factors that are amenable to change and should be considered in educational interventions.
Investigate the relationship between maternal alcohol-use disorder and multiple biological and social child outcomes, including birth outcomes, child protection, justice contact, and academic outcomes for both Indigenous and non-Indigenous children.METHODS:
Women with a birth recorded on the Western Australian Midwives Notification System (1983–2007) and their offspring were in scope. The exposed cohort were mothers with an alcohol-related diagnosis (International Classification of Diseases, Ninth Revision and International Classification of Diseases, 10th Revision) recorded in an administrative data set and their offspring (non-Indigenous: n = 13 969; Indigenous: n = 9635). The exposed cohort was frequency matched with mothers with no record of an alcohol-related diagnosis and their offspring (comparison cohort; non-Indigenous: n = 40 302; Indigenous: n = 20 533).RESULTS:
Over half of exposed non-Indigenous children (55%) and 84% of exposed Indigenous children experienced ≥1 negative outcome. The likelihood of any negative outcome was significantly higher for the exposed than the comparison cohort (non-Indigenous: odds ratio [OR] = 2.67 [95% confidence interval (CI) = 2.56–2.78]; Indigenous: OR = 2.67 [95% CI = 2.50–2.85]). The odds were greatest for children whose mothers received a diagnosis during pregnancy (non-Indigenous: OR = 4.65 [95% CI = 3.87–5.59]; Indigenous: OR = 5.18 [95% CI = 4.10–6.55]); however, numbers were small.CONCLUSIONS:
The effects of maternal alcohol-use disorder are experienced by the majority of exposed children rather than a vulnerable subgroup of this population. These findings highlight the need for universal prevention strategies to reduce harmful alcohol use and targeted interventions to support at-risk women and children.
Eosinophilic gastrointestinal diseases (EGIDs) are a diverse group of intestinal diseases involving the infiltration of eosinophils into the bowel wall. EGID can present with a variety of clinical conditions, which are largely dependent on the location of eosinophils in the intestinal wall. We describe the first reported pediatric cases of EGID presenting with symptomatic partial bowel obstruction from intestinal masses due to isolated focal mural involvement. Both patients subsequently responded favorably to therapy with exclusive elemental nutrition in the first case and exclusive elemental nutrition with steroids in the second case. These cases reveal the wide-ranging clinical manifestations of EGID, expand on the differential diagnosis of focal intestinal masses, and provide guidance on the evaluation of ambiguous cases.
Medical decision-making in children is not a static process. In pediatrics, parents and health professionals actively participate in clinical decision-making. They always consider what is in the child’s best interest and sometimes weigh that against other considerations. As children get older, the level of participation in this process may change according to their own cognitive development and maturity level. In this article, we present a case of an adolescent with a life-limiting condition at the end of life. He wants to participate in his health management and speak for himself. He does not always prefer interventions that his parents think are best. Health care practitioners must include mature minors in the decision-making process and be willing to listen to their voices.
Sexual minority adolescents face mental health disparities relative to heterosexual adolescents. We evaluated temporal changes in US adolescent reported sexual orientation and suicide attempts by sexual orientation.METHODS:
We used Youth Risk Behavioral Surveillance data from 6 states that collected data on sexual orientation identity and 4 states that collected data on sex of sexual contacts continuously between 2009 and 2017. We estimated odds ratios using logistic regression models to evaluate changes in reported sexual orientation identity, sex of consensual sexual contacts, and suicide attempts over time and calculated marginal effects (MEs).RESULTS:
The proportion of adolescents reporting minority sexual orientation identity nearly doubled, from 7.3% in 2009 to 14.3% in 2017 (ME: 0.8 percentage points [pp] per year; 95% confidence interval [CI]: 0.6 to 0.9 pp). The proportion of adolescents reporting any same-sex sexual contact increased by 70%, from 7.7% in 2009 to 13.1% in 2017 (ME: 0.6 pp per year; 95% CI: 0.4 to 0.8 pp). Although suicide attempts declined among students identifying as sexual minorities (ME: –0.8 pp per year; 95% CI: –1.4 to –0.2 pp), these students remained >3 times more likely to attempt suicide relative to heterosexual students in 2017. Sexual minority adolescents accounted for an increasing proportion of all adolescent suicide attempts.CONCLUSIONS:
The proportion of adolescents reporting sexual minority identity and same-sex sexual contacts increased between 2009 and 2017. Disparities in suicide attempts persist. Developing and implementing approaches to reducing sexual minority youth suicide is critically important.
Children with asthma are at increased risk of complications from influenza; hospitalization represents an important opportunity for vaccination. We aimed to increase the influenza vaccination rate among eligible hospitalized patients with asthma on the pediatric hospital medicine (PHM) service from 13% to 80% over a 4-year period.METHODS:
Serial Plan-Do-Study-Act cycles were implemented to improve influenza vaccination rates among children admitted with status asthmaticus and included modifications to the electronic health record (EHR) and provider and family education. Success of the initial PHM pilot led to the development of a hospital-wide vaccination tracking tool and an institutional, nurse-driven vaccine protocol by a multidisciplinary team. Our primary outcome metric was the inpatient influenza vaccination rate among PHM patients admitted with status asthmaticus. Process measures included documentation of influenza vaccination status and use of the EHR asthma order set and a history and physical template. The balance measure was adverse vaccine reaction within 24 hours. Data analysis was performed by using statistical process control charts.RESULTS:
The inpatient influenza vaccination rate increased from 13% to 57% over 4 years; special cause variation was achieved. Overall, 50% of eligible patients were vaccinated during asthma hospitalization in the postintervention period. Documentation of influenza vaccination status significantly increased from 51% to 96%, and asthma history and physical and order set use also improved. No adverse vaccine reactions were documented.CONCLUSIONS:
A bundle of interventions, including EHR modifications, provider and family education, hospital-wide tracking, and a nurse-driven vaccine protocol, increased influenza vaccination rates among eligible children hospitalized with status asthmaticus.
Administering inactivated influenza vaccine (IIV), 13-valent pneumococcal conjugate vaccine (PCV13), and diphtheria-tetanus-acellular pertussis (DTaP) vaccine together has been associated with increased risk for febrile seizure after vaccination. We assessed the effect of administering IIV at a separate visit from PCV13 and DTaP on postvaccination fever.METHODS:
In 2017–2018, children aged 12 to 16 months were randomly assigned to receive study vaccines simultaneously or sequentially. They had 2 study visits 2 weeks apart; nonstudy vaccines were permitted at visit 1. The simultaneous group received PCV13, DTaP, and quadrivalent IIV (IIV4) at visit 1 and no vaccines at visit 2. The sequential group received PCV13 and DTaP at visit 1 and IIV4 at visit 2. Participants were monitored for fever (≥38°C) and antipyretic use during the 8 days after visits.RESULTS:
There were 110 children randomly assigned to the simultaneous group and 111 children to the sequential group; 90% received ≥1 nonstudy vaccine at visit 1. Similar proportions of children experienced fever on days 1 to 2 after visits 1 and 2 combined (simultaneous [8.1%] versus sequential [9.3%]; adjusted relative risk = 0.87 [95% confidence interval 0.36–2.10]). During days 1 to 2 after visit 1, more children in the simultaneous group received antipyretics (37.4% vs 22.4%; P = .020).CONCLUSIONS:
In our study, delaying IIV4 administration by 2 weeks in children receiving DTaP and PCV13 did not reduce fever occurrence after vaccination. Reevaluating this strategy to prevent fever using an IIV4 with a different composition in a future influenza season may be considered.
Since the discovery of propranolol in the treatment of infantile hemangioma (IH), there has been emergent investigation of β-adrenergic receptor (β-AR) signaling in IH and the mechanisms of action for which β-AR blockers regulate hemangioma cell proliferation. However, β-AR agonists and antagonists are known to act antithetically via the same intracellular β-AR–driven proangiogenic pathways. We present the case of a patient with involuted IH treated with propranolol that showed a full and rapid regrowth during the intravenous administration of salbutamol, a selective β2-adrenergic agonist, for an episode of severe obstructive bronchitis. This observation brings forward the clinical implication of β-signaling effects in IH and raises awareness of the potential proliferative response of IH to β-AR agonists such as salbutamol.
Maternal drinking is associated with child emotional and behavior problems. There is, however, a lack of studies that properly account for confounding. Our objective was to estimate the association between at-risk drinking in mothers of young children and child emotional and behavior problems, taking into account the passive transmission of familial risk.METHODS:
This population-based sample consists of 34 039 children nested within 21 911 nuclear families and 18 158 extended families from the Norwegian Mother, Father, and Child Cohort Study. Participants were recruited between 1999 and 2009 during routine ultrasound examinations. Data were collected during the 17th and 30th gestational week and when the children were 1.5, 3, and 5 years old. We applied a multilevel structural equation model that accounted for unobserved familial risks.RESULTS:
Children of mothers with at-risk drinking had a higher likelihood of behavior problems (β = 3.53; 95% confidence interval [CI] 3.01 to 4.05) than children of mothers with low alcohol consumption. This association was reduced after adjusting for factors in the extended family (β = 1.93; 95% CI 1.16 to 2.71) and the nuclear family (β = 1.20; 95% CI 0.39 to 2.01). Maternal at-risk drinking had a smaller association with child emotional problems (β = 1.80; 95% CI 1.26 to 2.34). This association was reduced after adjusting for factors in the extended family (β = 0.67; 95% CI –0.12 to 1.46) and the nuclear family (β = 0.58; 95% CI –0.31 to 1.48).CONCLUSIONS:
The results suggest an association between maternal at-risk drinking and child behavior problems. A reduction in maternal drinking may improve outcomes for children with such symptoms.
In this study, we determined trends in prevalence of suicidal thoughts and behaviors among lesbian, gay, bisexual, and heterosexual youth from 1995 to 2017 using population-based surveillance data.METHODS:
Data were drawn from the Massachusetts Youth Risk Behavior Survey from 1995 to 2017 (unweighted N = 41 636). The annual percent change (APC) in prevalence of suicidal ideation, plans, and attempts was stratified by sexual orientation as indexed by sexual identity and sexual behavior.RESULTS:
Among sexual minority youth, prevalence rates declined over the entire study period for suicidal ideation (APCsexual identity = –1.25; APCsexual behavior = –1.83), plans (APCsexual identity = –1.88; APCsexual behavior = –1.95), and attempts (APCsexual identity = –2.64; APCsexual behavior = –2.47). Among heterosexual youth, prevalence rates declined from 1995 to 2007 for suicidal ideation (APCsexual identity = –6.67; APCsexual behavior = –6.77) and plans (APCsexual identity = –5.73; APCsexual behavior = –6.25). These declines in ideation and plans were steeper than those for sexual minority youth. Prevalence of suicide attempts declined across the entire study period among heterosexual youth (APCsexual identity = –3.66; APCsexual behavior = –4.01). Prevalence of all 3 outcomes remained markedly high among sexual minority youth across the 23-year study period.CONCLUSIONS:
Although suicidal thoughts and behavior have generally declined among sexual minority and heterosexual youth, disparities in these outcomes persist, and their prevalence among sexual minority youth has remained consistently elevated. Prioritized screening for risk for suicidal thoughts and behaviors in this vulnerable population is imperative to reduce disparities and prevalence of these outcomes.
Children with medical complexity (CMC) often have multiple life-limiting conditions with no unifying diagnosis and an unclear prognosis and are at high risk for morbidity and mortality. Advance care planning (ACP) conversations need to be uniquely tailored to this population. Our primary objective for this study was to develop an in-depth understanding of the ACP experiences from the perspectives of both parents and health care providers (HCPs) of CMC.METHODS:
We conducted 25 semistructured interviews with parents of CMC and HCPs of various disciplines from a tertiary pediatric hospital. Interview guide questions were focused on ACP, including understanding of the definition, positive and negative experiences, and suggestions for improvement. Interviews were conducted until thematic saturation was reached. Interviews were audio recorded, transcribed verbatim, coded, and analyzed using content analysis.RESULTS:
Fourteen mothers and 11 HCPs participated in individual interviews. Interviews revealed 4 major themes and several associated subthemes (in parentheses): (1) holistic mind-set, (2) discussion content (beliefs and values, hopes and goals, and quality of life), (3) communication enhancers (partnerships in shared decision-making, supportive setting, early and ongoing conversations, consistent language and practice, family readiness, provider expertise in ACP discussions, and provider comfort in ACP discussions), and (4) the ACP definition.CONCLUSIONS:
Family and HCP perspectives revealed a need for family-centered ACP for CMC and their families. Our results aided the development of a family-centered framework to enhance the delivery of ACP through a holistic mind-set, thoughtful discussion content, and promoting of conversation enhancers.
Successful intervention for inborn errors of metabolism (IEMs) is a triumph of modern medicine. For many of these conditions, medical foods are the cornerstone of therapy and the only effective interventions preventing disability or death. Medical foods are designed for patients with limited or impaired capacity to ingest, digest, absorb, or metabolize ordinary foods or nutrients, whereby dietary management cannot be achieved by modification of the normal diet alone. In the United States today, access to medical foods is not ensured for many individuals who are affected despite their proven efficacy in the treatment of IEMs, their universal use as the mainstay of IEM management, the endorsement of their use by professional medical organizations, and the obvious desire of families for effective care. Medical foods are not sufficiently covered by many health insurance plans in the United States and, without insurance coverage, many families cannot afford their high cost. In this review, we outline the history of medical foods, define their medical necessity, discuss the barriers to access and reimbursement resulting from the regulatory status of medical foods, and summarize previous efforts to improve access. The Advisory Committee on Heritable Disorders in Newborns and Children asserts that it is time to provide stable and affordable access to the effective management required for optimal outcomes through the life span of patients affected with IEMs. Medical foods as defined by the US Food and Drug Administration should be covered as required medical benefits for persons of all ages diagnosed with an IEM.
Behavioral economics applies key principles from psychology and economics to address obstacles to behavior change. The important topic of pediatric firearm injuries has not yet been explored through a behavioral economic lens. Pediatric firearm-related injuries are a significant public health problem in the United States. Despite American Academy of Pediatrics guidelines advising that firearms be stored unloaded, in a locked box or with a locking device, and separate from ammunition, estimates suggest that ~4.6 million children live in homes with at least 1 loaded and unlocked firearm. In this article, we use behavioral economic theory to identify specific cognitive biases (ie, present bias; in-group, out-group bias; and the availability heuristic) that may influence parental decision-making around firearm storage. We illustrate situations in which these biases may occur and highlight implementation prompts, in-group messengers, and increased salience as behaviorally informed strategies that may counter these biases and subsequently enhance safe firearm storage. We also describe other opportunities to leverage the behavioral economic tool kit. By better understanding the individual behavioral levers that may impact decision-making around firearm storage, behavioral scientists, pediatric providers, and public health practitioners can partner to design and test tailored interventions aimed at decreasing pediatric firearm injuries. Further empirical study is warranted to identify the presence of specific biases and heuristics and determine the most effective behavior change strategies for different subpopulations.
Vitamin B12 and folate are important for normal brain development. Our objective for this study was to measure the effects of 6-month supplementation of vitamin B12 and/or folic acid in early childhood on cognition when the children were 6 to 9 years old.METHODS:
The study is a follow-up of a factorial randomized, double-blind, placebo-controlled trial in 1000 North Indian children. Children 6 to 30 months of age were randomly assigned to receive a placebo or 1.8 µg of vitamin B12, 150 mg of folic acid, or both daily for 6 months. After 6 years, we re-enrolled 791 of these children for cognitive assessments. We compared the scores of the main outcomes (the Wechsler Intelligence Scale for Children, Fourth Edition [India], the Crichton Verbal Scale, and subtests of the NEPSY-II) between the study groups. We also measured the associations between markers of the B vitamins (plasma cobalamin, folate, and total homocysteine concentrations) in early childhood and the cognitive outcomes.RESULTS:
There were no differences between the intervention groups and the placebo group on the cognitive outcomes. Plasma cobalamin, folate, and total homocysteine concentrations in early childhood were associated with the cognitive outcomes at follow-up in the unadjusted models. These associations disappeared in models adjusted for relevant confounders.CONCLUSIONS:
Our findings, from both an observational and a randomized design suggest that vitamin B12 and folate in children 6 to 36 months have limited public health relevance for long-term cognition.
When parents or guardians hope for a miracle for their child who is critically ill, ethical and professional challenges can arise. Often, although not always, the parent or guardian’s hope for a miracle entails a request for continued life-sustaining interventions. Striking a balance between the pediatrician’s conception of good medicine and the parent or guardian’s authority requires a response that is sensitive, practical, and ethically sound. In this article, we recommend 3 cumulative steps that promote such a response. First, we recommend ways of exploring essential issues through open inquiry, interdisciplinary dialogue, and self-reflection. As part of this exploration, pediatricians will discover that parents or guardians often have unique ideas about what a miracle might be for their child. The second step includes analyzing this diversity and seeking understanding. We classify the hope for a miracle into 3 distinct categories: integrated, seeking, and adaptive. After the pediatrician has categorized the parent or guardian’s hope, they can consider specific recommendations. We detail context-specific responses for each kind of hope. By attending to these nuances, not only will the parent or guardian’s perspective be heard but also the pediatrician’s recommendation can strike a balance between advocating for their conception of good medicine and respecting the parent or guardian’s beliefs.
Adolescent men who have sex with men (AMSM) have a high rate of HIV diagnoses. An estimated 14.5% of HIV infections in the United States are undiagnosed; but among 13- to 24-year-olds, the rate is 51.4%. We describe HIV testing rates and identifies salient individual, family, school, and health care influences among AMSM.METHODS:
Data were collected as part of SMART, an ongoing pragmatic trial of an online HIV prevention intervention for AMSM (N = 699). Measures included lifetime HIV testing, demographics, sexual behaviors, condom use, HIV education from school and family, sexual health communication with doctors, HIV knowledge, and risk attitudes.RESULTS:
Only 23.2% of participants had ever had an HIV test. Rates of testing increased with age (5.6% in 13- to 14-year-olds; 15.8% in 15- to 16-year-olds; 37.8% in 17- to 18-year-olds), and sexual experience was a strong predictor of testing (odds ratio: 6.54; 95% confidence interval: 3.95–11.49; P < .001). Most participants had a regular doctor (67.5%), but few had conversations about same-sex sexual behaviors (21.3%), HIV testing (19.2%), or sexual orientation (29.2%). Speaking to a doctor about HIV testing had a large effect (odds ratio: 25.29; confidence interval: 15.91–41.16; P < .001), with 75.4% who had such conversations having been tested, compared to only 10.8% of those who had not had such conversations.CONCLUSIONS:
Despite higher risk, few participants reported ever having received an HIV test. Data indicate pediatricians are an important, but largely untapped, source of testing and could be integral to achieving testing rates needed to end the epidemic.
In this study, we benchmark outcomes and identify factors associated with tracheostomy placement in infants of very low birth weight (VLBW).METHODS:
Data were prospectively collected on infants of VLBW (401–1500 g or gestational age of 22–29 weeks) born between 2006 and 2016 and admitted to 796 North American centers. Length of stay (LOS), mortality, associated surgical procedures, and comorbidities were assessed, and infants who received tracheostomy were compared with those who did not. Multivariable logistic regressions were performed to identify risk factors for tracheostomy placement and for mortality in those receiving tracheostomy.RESULTS:
Of 458 624 infants of VLBW studied, 3442 (0.75%) received tracheostomy. Infants with tracheostomy had a median (interquartile range) LOS of 226 (168–304) days and a mortality rate of 18.8%, compared with 58 (39–86) days and 8.3% for infants without tracheostomy. Independent risk factors associated with tracheostomy placement included male sex, birth weight <1001 g, African American non-Hispanic maternal race, chronic lung disease (CLD), intraventricular hemorrhage, patent ductus arteriosus ligation, and congenital neurologic, cardiac, and chromosomal anomalies. Among infants who received tracheostomy, male sex, birth weight <751 g, CLD, and congenital anomalies were independent predictors of mortality.CONCLUSIONS:
Infants of VLBW receiving tracheostomy had twice the risk of mortality and nearly 4 times the initial LOS of those without tracheostomy. CLD and congenital anomalies were the strongest predictors of tracheostomy placement and mortality. These benchmark data on tracheostomy in infants of VLBW should guide discussions with patient families and inform future studies and interventions.
An adolescent female patient presenting with subacute onset of dysphagia and hoarseness underwent a direct laryngoscopy, which revealed epiglottitis. After 2 hospitalizations and multiple consultations and biopsies, all infectious testing results for viral, bacterial, fungal, and acid-fast bacilli etiologies were negative. The patient’s use of electronic cigarettes was the only exposure elicited with a likely role in her presentation. This case, combined with the growing body of evidence revealing the toxic effects of vaping and the increasing use of electronic cigarettes among adolescent patients, highlights the many unknowns and risks regarding the biological effects of this practice.
Opioid overprescription has the potential to lead to harmful medications remaining in homes and to a rise in accidental or deliberate ingestion by children and adolescents. Although methods for opioid disposal are available, many are costly or require greater than minimal effort for the patient. In this study, we used a mail-back return envelope to retrieve unused opioids after ambulatory pediatric surgery.METHODS:
This feasibility study was performed to assess the rate of opioid return by using a mail-back envelope for children ages 0 to 18 prescribed opioids after outpatient surgery. Participants were provided a return envelope as well as instruction on the dangers of opioids in the home. Our primary outcome was to assess the absolute percent return rate through the use of a mail-back envelope.RESULTS:
Between November 2017 and October 2018, we identified 355 patients, of whom 331 were included in the analysis. In total, 64 (19.3%) returned opioids. In total, >2000 mL of liquid opioids and >250 tablets or nearly 3000 mg of oral morphine equivalents were removed from the homes of the 64 participants. Of those patients returning unused medications, the median rate of return was 58% (interquartile range = 34.7%–86.1%) of the written prescription.CONCLUSIONS:
The findings suggest that providing a free mail-back return envelope is a suitable way to remove unused opioids from the home after pediatric surgery. Additional research is needed to identify barriers to return of unused medications.