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Improving Discharge Efficiency and Charge Containment on a Pediatric Acute Care Cardiology Unit

Mié, 01/09/2021 - 10:01
BACKGROUND

Hospital discharge delays can negatively affect patient flow and hospital charges. Our primary aim was to increase the percentage of acute care cardiology patients discharged within 2 hours of meeting standardized medically ready (MedR) discharge criteria. Secondary aims were to reduce length of stay (LOS) and lower hospital charges.

METHODS

A multidisciplinary team used quality improvement methods to implement and study MedR discharge criteria in our hospital electronic health record. The criteria were ordered on admission and modified on daily rounds. Bedside nurses documented the time when all MedR discharge criteria were met. A statistical process control chart measured interventions over time. Discharge before noon and 30-day readmissions were also tracked. Average LOS was examined, comparing the first 6 months of the intervention period to the last 6 months. Inpatient charges were reviewed for patients with >2 hours MedR discharge delay.

RESULTS

The mean percentage of patients discharged within 2 hours of meeting MedR discharge criteria increased from 20% to 78% over 22 months, with more patients discharged before noon (19%–32%). Median LOS decreased from 11 days (interquartile range: 6–21) to 10 days (interquartile range: 5–19) (P = .047), whereas 30-day readmission remained stable at 16.3%. A total of 265 delayed MedR discharges beyond 2 hours occurred. The sum of inpatient charges from care provided after meeting MedR criteria was $332 038 (average $1253 per delayed discharge).

CONCLUSIONS

Discharge timeliness in pediatric acute care cardiology patients can be improved by standardizing medical discharge criteria, which may shorten LOS and decrease medical charges.

Empiric Vancomycin Reduction in a Pediatric Intensive Care Unit

Mié, 01/09/2021 - 10:01
BACKGROUND

At our institution, empirical vancomycin is overused in children with suspected bacterial community-acquired infections (CAIs) admitted to the PICU because of high community rates of methicillin-resistant Staphylococcus aureus (MRSA). Our goal was to reduce unnecessary vancomycin use for CAIs in the PICU.

METHODS

Empirical PICU vancomycin indications for suspected CAIs were developed by using epidemiological risk factors for MRSA. We aimed to reduce empirical PICU vancomycin use in CAIs by 30%. After retrospectively testing, the indications were implemented and monthly PICU empirical vancomycin use during baseline (May 2017–April 2018) and postintervention (May 2018–July 2019) periods. Education was provided to PICU providers, vancomycin indications were posted, and the antibiotic order set was revised. Statistical process control methods tracked improvement over time. Proven S aureus infections for which vancomycin was not empirically prescribed and linezolid or clindamycin use were balancing measures.

RESULTS

We identified 1620 PICU patients with suspected bacterial CAIs. Empirical vancomycin decreased from a baseline of 73% to 45%, a 38% relative reduction. No patient not prescribed empirical vancomycin later required the addition of vancomycin or other MRSA-targeted antibiotics. There was no change in nephrotoxicity or in the balancing measures.

CONCLUSIONS

Development of clear and concise recommendations, combined with clinician education and decision support via an order set, was an effective and safe strategy to reduce PICU vancomycin use. Retrospective validation of the recommendations with local data were key to obtaining PICU clinician buy in.

Expediting Treatment of Seizures in the Intensive Care Nursery

Mié, 01/09/2021 - 10:01
OBJECTIVES

Prolonged neonatal seizures are associated with poor neurodevelopmental outcomes. The aim of this quality improvement project was to decrease the time to medical treatment of seizures by 45% within 15 months for neonates admitted to the intensive care nursery (ICN) in an academic children’s hospital.

METHODS

A multidisciplinary team developed key drivers for timely treatment of seizures. Targeted interventions included optimizing a seizure rescue process with a mechanism that brings a pharmacist to the bedside for expedited medication delivery, in addition to interactive educational sessions. The outcome measure was time from the decision to treat seizures to medication administration. The process measure was use of the seizure rescue process with a balancing measure of unnecessary activations of this process. Data were collected from monthly chart review and displayed on statistical process control charts for analysis. The intervention period was from January 2019 to March 2020.

RESULTS

Between January 2016 and March 2020, there were 203 seizure treatment events (160 preintervention and 43 postintervention) in the ICN. Time to treatment of neonatal seizures decreased by 48%, from a baseline of 27 minutes (January 2016 to December 2018) to 14 minutes by March 2020, which reflected significant and sustained improvement. This was associated with improvement in the process metric during the same time periods. Unnecessary seizure rescue process activations were stable postintervention.

CONCLUSIONS

Implementation of an innovative seizure rescue process, in conjunction with staff and provider education, expedited antiseizure therapy in the ICN without requiring code resources.

Reducing Chest Radiographs in Bronchiolitis Through High-Reliability Interventions

Mié, 01/09/2021 - 10:01
BACKGROUND AND OBJECTIVES

Bronchiolitis is a leading cause of pediatric hospitalization in the United States, resulting in significant morbidity and health care resource use. Despite American Academy of Pediatrics recommendations against obtaining chest radiographs (CXRs) for bronchiolitis, variation in care continues. Historically, clinical practice guidelines and educational campaigns have had mixed success in reducing unnecessary CXR use. Our aim was to reduce CXR use for children <2 years with a primary diagnosis of bronchiolitis, regardless of emergency department (ED) disposition or preexisting conditions, from 42.1% to <15% of encounters by March 2020.

METHODS

A multidisciplinary team was created at our institution in 2012 to standardize bronchiolitis care. Given success with higher reliability interventions in asthma, similar interventions affecting workflow were subsequently pursued with bronchiolitis, starting in 2017, by using quality improvement science methods. The primary outcome was the percent of bronchiolitis encounters with a CXR. The balancing measure was return visits within 72 hours to the ED. Statistical process control charts were used to monitor and analyze data obtained from an internally created dashboard.

RESULTS

From 2012 to 2020, our hospital had 12 120 bronchiolitis encounters. Preimplementation baseline revealed a mean of 42.1% for CXR use. Low reliability interventions, like educational campaigns, resulted in unsustained effects on CXR use. Higher reliability interventions were associated with sustained reductions to 23.3% and 18.9% over the last 4 years. There was no change in ED return visits.

CONCLUSIONS

High-reliability workflow redesign was more effective in translating American Academy of Pediatrics recommendations into sustained practice than educational campaigns.

Use of Complete Blood Cell Count Components to Screen for Hereditary Spherocytosis in Neonates

Mié, 01/09/2021 - 10:01
BACKGROUND AND OBJECTIVES

The neonatal hereditary spherocytosis (HS) index, defined as the mean corpuscular hemoglobin concentration divided by the mean corpuscular volume, has been proposed as a screening tool for HS in neonates. In a population of mostly white infants, an HS Index >0.36 was 97% sensitive and >99% specific. We evaluated the utility of the HS Index among a more racially and ethnically diverse population and determined if its discrimination varies with total serum bilirubin (TSB) levels.

METHODS

Infants born at ≥35 weeks’ gestation at 15 Kaiser Permanente Northern California hospitals from 1995 to 2015 were eligible (N = 670 272). Erythrocyte indices from the first complete blood count drawn at ≤7 days and TSB levels drawn at ≤30 days were obtained. Diagnoses of HS were confirmed via chart review.

RESULTS

HS was confirmed in 79 infants, 1.2 per 10 000. HS was more common among infants of white and "other" race or ethnicity and among those with higher peak TSB levels. The area under the receiver operating characteristic curve for the HS Index was 0.84 (95% confidence interval 0.78–0.90). Likelihood ratios ranged from 10.1 for an HS Index ≥0.380 to 0.1 for an HS Index <0.310. Dichotomized at 0.36, the HS Index was 56% sensitive and 93% specific. Discrimination of the HS Index appeared best among infants with TSB levels <10 mg/dL.

CONCLUSIONS

The HS Index, when obtained from a CBC drawn within the first week after birth, had only modest ability to alter the probability of HS.

Hospital Quality of Care and Racial and Ethnic Disparities in Unexpected Newborn Complications

Mié, 01/09/2021 - 10:01
OBJECTIVES

To investigate racial and ethnic differences in unexpected, term newborn morbidity and the influence of hospital quality on disparities.

METHODS

We used 2010–2014 birth certificate and discharge abstract data from 40 New York City hospitals in a retrospective cohort study of 483 834 low-risk (term, singleton, birth weight ≥2500 g, without preexisting fetal conditions) neonates. We classified morbidity according to The Joint Commission’s unexpected newborn complications metric and used multivariable logistic regression to compare morbidity risk among racial and ethnic groups. We generated risk-standardized complication rates for each hospital using mixed-effects logistic regression to evaluate quality, ranked hospitals on this measure, and assessed differences in the racial and ethnic distribution of births across facilities.

RESULTS

The unexpected complications rate was 48.0 per 1000 births. Adjusted for patient characteristics, morbidity risk was higher among Black and Hispanic infants compared with white infants (odds ratio: 1.5 [95% confidence interval 1.3–1.9]; odds ratio: 1.2 [95% confidence interval 1.1–1.4], respectively). Among the 40 hospitals, risk-standardized complications ranged from 25.3 to 162.8 per 1000 births. One-third of Black and Hispanic women gave birth in hospitals ranking in the highest-morbidity tertile, compared with 10% of white and Asian American women (P < .001).

CONCLUSIONS

Black and Hispanic women were more likely to deliver in hospitals with high complication rates than were white or Asian American women. Findings implicate hospital quality in contributing to preventable newborn health disparities among low-risk, term births. Quality improvement targeting routine obstetric and neonatal care is critical for equity in perinatal outcomes.

Factors Related to Serious Safety Events in a Childrens Hospital Patient Safety Collaborative

Mié, 01/09/2021 - 10:01
BACKGROUND AND OBJECTIVES

Serious safety events (SSEs) occur infrequently at individual hospitals, making it difficult to establish trends to improve patient care. Patient safety organizations, such as the Child Health Patient Safety Organization (CHILDPSO), can identify trends and support learning across children’s hospitals. We aim to describe longitudinal trends in SSE rates among CHILDPSO member hospitals and describe their sources of harm.

METHODS

SSEs from 44 children’s hospitals were assigned severity and reported to CHILDPSO from January 1, 2015, to December 31, 2018. SSEs were classified into groups and subgroups based on analysis. Events were then tagged with up to 3 contributing factors. Subgroups with <5 events were excluded.

RESULTS

There were 22.5 million adjusted patient days included. The 12-month rolling average SSE rate per 10 000 adjusted patient days decreased from 0.71 to 0.41 (P < .001). There were 830 SSEs reported to CHILDPSO. The median hospital volume of SSEs was 12 events (interquartile range: 6–23), or ~3 SSEs per year. Of the 830 events, 21.0% were high severity (SSE 1–3) and approximately two-thirds (67.0%, n = 610) were patient care management events, including subgroups of missed, delayed, or wrong diagnosis or treatment; medication errors; and suboptimal care coordination. The most common contributing factor was lack of situational awareness (17.9%, n = 382), which contributed to 1 in 5 (20%) high-severity SSEs.

CONCLUSIONS

Hospitals sharing SSE data through CHILDPSO have seen a decrease in SSEs. Patient care management was the most frequently seen. Future work should focus on investigation of contributing factors and risk mitigation strategies.

Preterm or Early Term Birth and Risk of Autism

Mié, 01/09/2021 - 10:01
OBJECTIVES

Preterm birth has been linked with increased risk of autism spectrum disorder (ASD); however, potential causality, sex-specific differences, and association with early term birth are unclear. We examined whether preterm and early term birth are associated with ASD in a large population-based cohort.

METHODS

A national cohort study was conducted of all 4 061 795 singleton infants born in Sweden during 1973–2013 who survived to age 1 year, who were followed-up for ASD identified from nationwide outpatient and inpatient diagnoses through 2015. Poisson regression was used to determine prevalence ratios for ASD associated with gestational age at birth, adjusting for confounders. Cosibling analyses were used to assess the influence of unmeasured shared familial (genetic and/or environmental) factors.

RESULTS

ASD prevalences by gestational age at birth were 6.1% for extremely preterm (22–27 weeks), 2.6% for very to moderate preterm (28–33 weeks), 1.9% for late preterm (34–36 weeks), 2.1% for all preterm (<37 weeks), 1.6% for early term (37–38 weeks), and 1.4% for term (39–41 weeks). The adjusted prevalence ratios comparing extremely preterm, all preterm, or early term versus term, respectively, were 3.72 (95% confidence interval, 3.27–4.23), 1.35 (1.30–1.40), and 1.11 (1.08–1.13) among boys and 4.19 (3.45–5.09), 1.53 (1.45–1.62), and 1.16 (1.12–1.20) among girls (P < .001 for each). These associations were only slightly attenuated after controlling for shared familial factors.

CONCLUSIONS

In this national cohort, preterm and early term birth were associated with increased risk of ASD in boys and girls. These associations were largely independent of covariates and shared familial factors, consistent with a potential causal relationship.

Children With Special Health Care Needs and Forgone Family Employment

Mié, 01/09/2021 - 10:01
BACKGROUND

Family income is known to affect child health, but this relationship can be bidirectional. We sought to characterize this relationship by quantifying forgone family employment (FFE) due to a child’s health condition in families of children with special health care needs (CSHCN) with updated figures.

METHODS

We conducted a secondary data analysis from the 2016–2017 National Survey of Children’s Health. CSHCN with previously employed caregivers were included (N = 14 050). FFE was defined as any family member having stopped work and/or reduced hours because of their child’s health or health condition. Child, caregiver, and household characteristics were compared by FFE status. Logistic regression analysis was conducted to evaluate the association between hours of medical care provide by a family member and FFE. US Bureau of Labor Statistics reports were used to estimate lost earnings from FFE.

RESULTS

FFE occurred in 14.5% (95% confidence interval [CI] 12.9%–16.1%) of previously employed families with CSHCN and was 40.9% (95% CI 27.1%–54.7%) for children with an intellectual disability. We observed disproportionately high FFE among CSHCN who were 0 to 5 years old and of Hispanic ethnicity. We found a strong association between FFE and increasing hours of family-provided medical care, with an adjusted odds ratio (aOR) of 1.72 (95% CI 1.25–2.36) for <1 hour per week (compared with 0 hours), an aOR of 5.96 (95% CI 4.30–8.27) for 1 to 4 hours per week, an aOR of 11.89 (95% CI 6.19–22.81) for 5 to 10 hours per week, and an aOR of 8.89 (95% CI 5.26–15.01) for >10 hours per week. Lost earnings for each household with FFE were estimated at ~$18 000 per year.

CONCLUSIONS

With our findings, we highlight the need to implement programs and policies that address forgone income experienced by families of CSHCN.

An Integrated Primary Care Initiative for Child Health in Northern Togo

Mié, 01/09/2021 - 10:01
OBJECTIVES

To determine if the Integrated Community-Based Health Systems-Strengthening (ICBHSS) initiative was effective in expanding health coverage, improving care quality, and reducing child mortality in Togo.

METHODS

Population-representative cross-sectional household surveys adapted from the Demographic Household Survey and Multiple Indicator Cluster Surveys were conducted at baseline (2015) and then annually (2016–2020) in 4 ICBHSS catchment sites in Kara, Togo. The primary outcome was under-5 mortality, with health service coverage and health-seeking behavior as secondary outcomes. Costing analyses were calculated by using "top-down" methodology with audited financial statements and programmatic data.

RESULTS

There were 10 022 household surveys completed from 2015 to 2020. At baseline (2015), under-5 mortality was 51.1 per 1000 live births (95% confidence interval [CI]: 35.5–66.8), and at the study end period (2020), under-5 mortality was 35.8 (95% CI: 23.4–48.2). From 2015 to 2020, home-based treatment by a community health worker increased from 24.1% (95% CI: 21.9%–26.4%) to 45.7% (95% CI: 43.3%–48.2%), and respondents reporting prenatal care in the first trimester likewise increased (37.5% to 50.1%). Among respondents who sought care for a child with fever, presenting for care within 1 day increased from 51.9% (95% CI: 47.1%–56.6%) in 2015 to 80.3% (95% CI: 74.6%–85.0%) in 2020. The estimated annual additional intervention cost was $8.84 per person.

CONCLUSIONS

Our findings suggest that the ICBHSS initiative, a bundle of evidence-based interventions implemented with a community-based strategy, improves care access and quality and was associated with reduction in child mortality.

Anti-NMDAR Encephalitis After Neonatal HSV-1 Infection in a Child With Low TLR-3 Function

Mié, 01/09/2021 - 10:01

Neonatal herpes simplex virus encephalitis (HSVE) often results in long-lasting neuro-disability in affected children. In addition to primary HSVE and HSVE relapses, children with herpes simplex virus are at increased risk of developing anti–N-methyl-d-aspartate receptor encephalitis (NMDARe), an autoimmune encephalitis. In this study, we describe a patient with neonatal disseminated herpes infection, who developed HSVE after discontinuation of 2 years of acyclovir suppressive therapy. After resolution of HSVE, the patient rapidly deteriorated with significant behavioral and neurologic changes including emotional outbursts, fearfulness, involuntary movements, and focal seizures. The patient was diagnosed with anti-NMDARe and was later found to have low toll-like receptor-3 function. In this study, we review published pediatric cases of anti-NMDARe after HSVE as well as previous literature and primary data examining the presentation, predisposing risk factors, predictive outcomes, future directions, and the role of immunodeficiency in HSVE-mediated anti-NMDARe. The neonatal immune system and developing brain are disproportionately vulnerable to early viral exposure; therefore, it is important to recognize the value of early immunodeficiency screening in patients with neonatal herpes simplex virus. By understanding the immune landscape within this patient population, we can mitigate long-term neurologic disability and improve the quality of life of affected children.

The Case of Billy Best: 25 Years Later

Mié, 01/09/2021 - 10:01

Billy Best was diagnosed with Hodgkin lymphoma in 1994 at age 16 and became well-known when he ran away from home to avoid receiving further chemotherapy. His story became national news when, with the support of his adopted parents, he returned home and opted to use complementary and alternative medicine (CAM) instead of standard chemotherapy and radiation for his cancer treatment. Now 25 years since Billy Best entered the public eye, his story is one that is frequently referenced in pediatrics, bioethics, and other related fields. Here, the authors examine the evolution of various features of this case, including treatment of Hodgkin lymphoma, the interplay between medicine and the media, the role of CAM in pediatric care, navigating entrenched disagreements and how best to integrate adolescents into health care decision-making, and the role of narrative in medical practice. The authors explore the unique role of each of these facets of Billy Best’s case, describing how each has or has not changed in the quarter century since that time amid the changing landscape of pediatric health care. Ultimately, although many advances have occurred since Billy Best’s time, significant work remains. Additional effort will be required in the future to optimize communication, improve treatment toxicities from Hodgkin lymphoma without decreasing survival, integrate the voice and perspective of adolescents into their treatment decisions, and navigate the roles of CAM and the media in pediatric health care.

Preparedness for Pediatric Office Emergencies: A Multicenter, Simulation-Based Study

Mié, 01/09/2021 - 10:01
OBJECTIVES

Pediatric emergencies can occur in pediatric primary care offices. However, few studies have measured emergency preparedness, or the processes of emergency care, provided in the pediatric office setting. In this study, we aimed to measure emergency preparedness and care in a national cohort of pediatric offices.

METHODS

This was a multicenter study conducted over 15 months. Emergency preparedness scores were calculated as a percentage adherence to 2 checklists on the basis of the American Academy of Pediatrics guidelines (essential equipment and supplies and policies and protocols checklists). To measure the quality of emergency care, we recruited office teams for simulation sessions consisting of 2 patients: a child with respiratory distress and a child with a seizure. An unweighted percentage of adherence to checklists for each case was calculated.

RESULTS

Forty-eight teams from 42 offices across 9 states participated. The mean emergency preparedness score was 74.7% (SD: 12.9). The mean essential equipment and supplies subscore was 82.2% (SD: 15.1), and the mean policies and protocols subscore was 57.1% (SD: 25.6). Multivariable analyses revealed that independent practices and smaller total staff size were associated with lower preparedness. The median asthma case performance score was 63.6% (interquartile range: 43.2–81.2), whereas the median seizure case score was 69.2% (interquartile range: 46.2–80.8). Offices that had a standardized process of contacting emergency medical services (EMS) had a higher rate of activating EMS during the simulations.

CONCLUSIONS

Pediatric office preparedness remains suboptimal in a multicenter cohort, especially in smaller, independent practices. Academic and community partnerships using simulation can help address gaps and implement important processes like contacting EMS.

Thirty-Day Outcomes of Children and Adolescents With COVID-19: An International Experience

Mié, 01/09/2021 - 10:01
OBJECTIVES

To characterize the demographics, comorbidities, symptoms, in-hospital treatments, and health outcomes among children and adolescents diagnosed or hospitalized with coronavirus disease 2019 (COVID-19) and to compare them in secondary analyses with patients diagnosed with previous seasonal influenza in 2017–2018.

METHODS

International network cohort using real-world data from European primary care records (France, Germany, and Spain), South Korean claims and US claims, and hospital databases. We included children and adolescents diagnosed and/or hospitalized with COVID-19 at age <18 between January and June 2020. We described baseline demographics, comorbidities, symptoms, 30-day in-hospital treatments, and outcomes including hospitalization, pneumonia, acute respiratory distress syndrome, multisystem inflammatory syndrome in children, and death.

RESULTS

A total of 242 158 children and adolescents diagnosed and 9769 hospitalized with COVID-19 and 2 084 180 diagnosed with influenza were studied. Comorbidities including neurodevelopmental disorders, heart disease, and cancer were more common among those hospitalized with versus diagnosed with COVID-19. Dyspnea, bronchiolitis, anosmia, and gastrointestinal symptoms were more common in COVID-19 than influenza. In-hospital prevalent treatments for COVID-19 included repurposed medications (<10%) and adjunctive therapies: systemic corticosteroids (6.8%–7.6%), famotidine (9.0%–28.1%), and antithrombotics such as aspirin (2.0%–21.4%), heparin (2.2%–18.1%), and enoxaparin (2.8%–14.8%). Hospitalization was observed in 0.3% to 1.3% of the cohort diagnosed with COVID-19, with undetectable (n < 5 per database) 30-day fatality. Thirty-day outcomes including pneumonia and hypoxemia were more frequent in COVID-19 than influenza.

CONCLUSIONS

Despite negligible fatality, complications including hospitalization, hypoxemia, and pneumonia were more frequent in children and adolescents with COVID-19 than with influenza. Dyspnea, anosmia, and gastrointestinal symptoms could help differentiate diagnoses. A wide range of medications was used for the inpatient management of pediatric COVID-19.

Maternal Adverse Childhood Experiences and Child Behavior Problems: A Systematic Review

Mié, 01/09/2021 - 10:01
CONTEXT

A growing body of research has examined the role of maternal adverse childhood experiences (ACEs) on child behavior problems.

OBJECTIVE

To summarize the literature examining the association between maternal ACEs and child behavior problems via a systematic review.

DATA SOURCES

Electronic searches were conducted in Medline, PsycINFO, and Embase (1998–June 2020). Reference lists were reviewed. In total, 3048 records were screened.

STUDY SELECTION

Studies were included if an association between maternal ACEs and child externalizing (eg, aggression) and/or internalizing (eg, anxiety) problems was reported. In total, 139 full-text articles were reviewed for inclusion.

DATA EXTRACTION

Data from 16 studies met full inclusion criteria. Studies were synthesized by child externalizing and internalizing outcomes.

RESULTS

Maternal ACEs were significantly associated with child externalizing problems across all studies (number of studies synthesized per outcome [k] = 11). Significant associations were also found for inattention, hyperactivity, and impulsivity (k = 4), and aggression (k = 2). For internalizing problems (k = 11), significant associations were identified across 8 studies and nonsignificant associations were reported for 3 studies. Maternal ACEs were consistently associated with child anxiety and depression (k = 5). However, inconsistent findings were reported for somatization (k = 2).

LIMITATIONS

Results are limited to mother-child dyads and questionnaire measures of behavior problems in primarily North American countries.

CONCLUSIONS

Mothers’ ACEs demonstrated largely consistent associations with children’s behavior problems. Future research is needed to determine if specific types of maternal ACEs (eg, household dysfunction) are more strongly associated with child behavior problems.

Pediatric Telehealth in the COVID-19 Pandemic Era and Beyond

Mié, 01/09/2021 - 10:01

The coronavirus disease 2019 (COVID-19) pandemic led to an unprecedented demand for health care at a distance, and telehealth (the delivery of patient care using telecommunications technology) became more widespread. Since our 2018 state-of-the-art review assessing the pediatric telehealth landscape, there have been many changes in technology, policy, payment, and physician and patient acceptance of this care model. Clinical best practices in telehealth, on the other hand, have remained unchanged during this time, with the primary difference being the need to implement them at scale.

Because of the pandemic, underlying health system weaknesses that have previously challenged telehealth adoption (including inequitable access to care, unsustainable costs in a fee-for-service system, and a lack of quality metrics for novel care delivery modalities) were simultaneously exacerbated. Higher volume use has provided a new appreciation of how patients from underrepresented backgrounds can benefit from or be disadvantaged by the shift toward virtual care. Moving forward, it will be critical to assess which COVID-19 telehealth changes should remain in place or be developed further to ensure children have equitable access to high-quality care.

With this review, we aim to (1) depict today’s pediatric telehealth practice in an era of digital disruption; (2) describe the people, training, processes, and tools needed for its successful implementation and sustainability; (3) examine health equity implications; and (4) critically review current telehealth policy as well as future policy needs. The American Academy of Pediatrics (AAP) is continuing to develop policy, specific practice tips, training modules, checklists, and other detailed resources, which will be available later in 2021.

Infant Deaths From Medical Causes After a Maltreatment Report

Mié, 01/09/2021 - 10:01
OBJECTIVES

To examine whether postneonatal infants reported for maltreatment face a heightened risk of deaths attributable to medical causes.

METHODS

Birth and death records for all children born in California between 2010 and 2016 (N = 3 455 985) were linked to administrative child protection system records. Infants were prospectively followed from birth through death or age 1 year. Reports of maltreatment and foster care placement episodes were modeled as time-varying covariates; sociodemographic characteristics at birth were modeled as baseline covariates. Stratified, multivariable competing risk models were used to estimate the adjusted relative hazard of postneonatal infant death attributed to a medical cause (n = 1051).

RESULTS

After adjusting for baseline risk factors, and compared with infants never reported for maltreatment, the medical-related mortality risk was almost twice as great among infants reported once for maltreatment (hazard ratio: 1.77; 95% confidence interval: 1.36–2.30) and 3 times greater if there was >1 maltreatment report (hazard ratio: 3.27; 95% confidence interval: 2.48, 4.30). Among infants reported for maltreatment, periods of foster care placement reduced the risk of death by roughly half.

CONCLUSION

Infants reported for alleged maltreatment had a higher risk of death from medical causes, with foster care emerging as protective. Targeted support services for parents and improved communication between the child protection system and the pediatric health care community is needed, especially when infants who may be medically fragile remain at home after an allegation of abuse or neglect.

Congenital Syphilis Diagnosed Beyond the Neonatal Period in the United States: 2014-2018

Mié, 01/09/2021 - 10:01
BACKGROUND AND OBJECTIVES

During 2014–2018, reported congenital syphilis (CS) cases in the United States increased 183%, from 462 to 1306 cases. We reviewed infants diagnosed with CS beyond the neonatal period (>28 days) during this time.

METHODS

We reviewed surveillance case report data for infants with CS delivered during 2014–2018 and identified those diagnosed beyond the neonatal period with reported signs or symptoms. We describe these infants and identify possible missed opportunities for earlier diagnoses.

RESULTS

Of the 3834 reported cases of CS delivered during 2014–2018, we identified 67 symptomatic infants diagnosed beyond the neonatal period. Among those with reported findings, 67% had physical examination findings of CS, 69% had abnormal long-bone radiographs consistent with CS, and 36% had reactive syphilis testing in the cerebrospinal fluid. The median serum nontreponemal titer was 1:256 (range: 1:1–1:2048). The median age at diagnosis was 67 days (range: 29–249 days). Among the 66 mothers included, 83% had prenatal care, 26% had a syphilis diagnosis during pregnancy or at delivery, and 42% were not diagnosed with syphilis until after delivery. Additionally, 24% had an initial negative test result and seroconverted during pregnancy.

CONCLUSIONS

Infants with CS continue to be undiagnosed at birth and present with symptoms after age 1 month. Pediatric providers can diagnose and treat infants with CS early by following guidelines, reviewing maternal records and confirming maternal syphilis status, advocating for maternal testing at delivery, and considering the diagnosis of CS, regardless of maternal history.

Breastfeeding and Risk of Late-Onset Group B Streptococcal Disease

Mié, 01/09/2021 - 10:01
BACKGROUND

Group B Streptococcus (GBS) is a major contributor to neonatal sepsis worldwide. Late-onset group B Streptococcus disease (LOGBS) and its risk factors remain poorly understood. The isolation of GBS from breast milk has been described in cases of LOGBS. This potential association has raised concerns for mothers and clinicians regarding the safety of ongoing breastfeeding. In this study, we aimed to investigate whether exposure to breast milk is associated with increased risk of LOGBS.

METHODS

A case-control study of LOGBS was conducted across 4 hospital networks in Victoria, Australia, including the 2 major tertiary pediatric centers in the state, to evaluate 11 years of data (2007–2017). Cases were captured initially from microbiology databases and recaptured with International Classification of Diseases discharge coding. Each case patient was matched with 4 controls to assess feeding status. Patients were matched for chronological age, gestation, discharge status, recruitment site, and calendar year.

RESULTS

We identified 92 cases of LOGBS: 73 cases on initial capture and 76 cases on the recapture analysis. Case patients were matched with 368 controls: 4 controls to each patient. Seventy-two patients were exposed to breast milk at the time of LOGBS (78.3%), compared with 274 controls (74.5%; odds ratio 1.2 [95% confidence interval 0.7–2.3]).

CONCLUSIONS

Breastfeeding was not associated with increased risk of LOGBS. Breast milk should not be tested for GBS during a first episode of LOGBS.

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