Autism spectrum disorder (ASD) is a common neurodevelopmental disorder with reported prevalence in the United States of 1 in 59 children (approximately 1.7%). Core deficits are identified in 2 domains: social communication/interaction and restrictive, repetitive patterns of behavior. Children and youth with ASD have service needs in behavioral, educational, health, leisure, family support, and other areas. Standardized screening for ASD at 18 and 24 months of age with ongoing developmental surveillance continues to be recommended in primary care (although it may be performed in other settings), because ASD is common, can be diagnosed as young as 18 months of age, and has evidenced-based interventions that may improve function. More accurate and culturally sensitive screening approaches are needed. Primary care providers should be familiar with the diagnostic criteria for ASD, appropriate etiologic evaluation, and co-occurring medical and behavioral conditions (such as disorders of sleep and feeding, gastrointestinal tract symptoms, obesity, seizures, attention-deficit/hyperactivity disorder, anxiety, and wandering) that affect the child’s function and quality of life. There is an increasing evidence base to support behavioral and other interventions to address specific skills and symptoms. Shared decision making calls for collaboration with families in evaluation and choice of interventions. This single clinical report updates the 2007 American Academy of Pediatrics clinical reports on the evaluation and treatment of ASD in one publication with an online table of contents and section view available through the American Academy of Pediatrics Gateway to help the reader identify topic areas within the report.
Promoting Optimal Development: Identifying Infants and Young Children With Developmental Disorders Through Developmental Surveillance and Screening
Early identification and intervention for developmental disorders are critical to the well-being of children and are the responsibility of pediatric professionals as an integral function of the medical home. This report models a universal system of developmental surveillance and screening for the early identification of conditions that affect children’s early and long-term development and achievement, followed by ongoing care. These conditions include autism, deafness/hard-of-hearing, intellectual and motor disabilities, behavioral conditions, and those seen in other medical conditions. Developmental surveillance is supported at every health supervision visit, as is as the administration of standardized screening tests at the 9-, 18-, and 30-month visits. Developmental concerns elicited on surveillance at any visit should be followed by standardized developmental screening testing or direct referral to intervention and specialty medical care. Special attention to surveillance is recommended at the 4- to 5-year well-child visit, prior to entry into elementary education, with screening completed if there are any concerns. Developmental surveillance includes bidirectional communication with early childhood professionals in child care, preschools, Head Start, and other programs, including home visitation and parenting, particularly around developmental screening. The identification of problems should lead to developmental and medical evaluations, diagnosis, counseling, and treatment, in addition to early developmental intervention. Children with diagnosed developmental disorders are identified as having special health care needs, with initiation of chronic condition management in the pediatric medical home.
This clinical report is a revision of "Preparing for Pediatric Emergencies: Drugs to Consider." It updates the list, indications, and dosages of medications used to treat pediatric emergencies in the prehospital, pediatric clinic, and emergency department settings. Although it is not an all-inclusive list of medications that may be used in all emergencies, this resource will be helpful when treating a vast majority of pediatric medical emergencies. Dosage recommendations are consistent with current emergency references such as the Advanced Pediatric Life Support and Pediatric Advanced Life Support textbooks and American Heart Association resuscitation guidelines.
A well-implemented and adequately funded medical home not only is the best approach to optimize the health of the individual patient but also can function as an effective instrument for improving population health. Key financing elements to providing quality, effective, comprehensive care in the pediatric medical home include the following: (1) first dollar coverage without deductibles, copays, or other cost-sharing for necessary preventive care services as recommended by Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents; (2) adoption of a uniform definition of medical necessity across payers that embraces services that promote optimal growth and development and prevent, diagnose, and treat the full range of pediatric physical, mental, behavioral, and developmental conditions, in accord with evidence-based science or evidence-informed expert opinion; (3) payment models that promote appropriate use of pediatric primary care and pediatric specialty services and discourage inappropriate, inefficient, or excessive use of medical services; and (4) payment models that strengthen the patient- and family-physician relationship and do not impose additional administrative burdens that will only erode the effectiveness of the medical home. These goals can be met by designing payment models that provide adequate funding of the cost of medical encounters, care coordination, population health services, and quality improvement activities; provide incentives for quality and effectiveness of care; and ease administrative burdens.
Childhood-onset systemic lupus erythematosus (c-SLE) is a complex autoimmune disease that requires systemic immunosuppressive therapy. Infections are the second leading cause of death in these patients, with invasive pneumococcal infections being a major preventable cause of morbidity and mortality. Pneumococcal vaccination is recommended in this population; however, vaccination rates remain low.METHODS:
The plan-do-study-act method of quality improvement was applied. We calculated baseline vaccination rates for pneumococcal conjugate and pneumococcal polysaccharide vaccines in patients with c-SLE in the rheumatology clinic from January 2015 to August 2016. We developed an age-based algorithm to simplify the vaccination guidelines. The clinical pharmacist and nurses performed weekly previsit planning to update vaccine records, make targeted recommendations, and ensure vaccine availability. The primary outcome measure was the percentage patients with of c-SLE seen per month who had received age-appropriate pneumococcal vaccination.RESULTS:
The percentage of children receiving at least 1 pneumococcal vaccine increased from 24.9% to 92.7% by 12 months. By 18 months, the compliance rate with both pneumococcal vaccines increased from 2.5% to 87.3%, with sustained results. No serious adverse events or disease flares were reported.CONCLUSIONS:
By identifying the major barriers to pneumococcal vaccination in our population with c-SLE, we significantly improved vaccination rates while decreasing time burden on providers. We attribute our success to a team-based quality improvement approach and plan to implement alerts in the electronic health record to streamline the process.
A 9-year-old African American boy was admitted to hospital with a 12-day history of fevers, diarrhea, abdominal pain and a 1-day history of joint pain. His abdominal pain and diarrhea resolved within the first few days of admission, but he continued with high-grade fevers and intermittent joint pain. The joints affected included the right first interphalangeal joint, right wrist, right elbow, and left knee joint. His initial laboratory tests revealed normal complete blood count, comprehensive metabolic panel, and C-reactive protein. Consequently, he developed fatigue, lower back pain, and bicytopenias. After 19 days of fevers, a multispecialty collaborative evaluation arrived at a final diagnosis and treatment plan. In this article, we discuss the child’s hospital course and our clinical thought process. Written consent was obtained from the family.
Integrated care models may improve health care for children and young people (CYP) with ongoing conditions.OBJECTIVE:
To assess the effects of integrated care on child health, health service use, health care quality, school absenteeism, and costs for CYP with ongoing conditions.DATA SOURCES:
Medline, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library databases (1996–2018).STUDY SELECTION:
Inclusion criteria consisted of (1) randomized controlled trials, (2) evaluating an integrated care intervention, (3) for CYP (0–18 years) with an ongoing health condition, and (4) including at least 1 health-related outcome.DATA EXTRACTION:
Descriptive data were synthesized. Data for quality of life (QoL) and emergency department (ED) visits allowed meta-analyses to explore the effects of integrated care compared to usual care.RESULTS:
Twenty-three trials were identified, describing 18 interventions. Compared with usual care, integrated care reported greater cost savings (3/4 studies). Meta-analyses found that integrated care improved QoL over usual care (standard mean difference = 0.24; 95% confidence interval = 0.03–0.44; P = .02), but no significant difference was found between groups for ED visits (odds ratio = 0.88; 95% confidence interval = 0.57–1.37; P = .57).LIMITATIONS:
Included studies had variable quality of intervention, trial design, and reporting. Randomized controlled trials only were included, but valuable data from other study designs may exist.CONCLUSIONS:
Integrated care for CYP with ongoing conditions may deliver improved QoL and cost savings. The effects of integrated care on outcomes including ED visits is unclear.
The increasing prevalence of behavioral and/or mental health (B/MH) problems among children, adolescents, and young adults is rapidly forcing the pediatric community to examine its professional responsibility in response to this epidemic. Stakeholders involved in pediatric workforce training were brought together in April 2018, invited by the American Board of Pediatrics and the National Academies of Sciences, Engineering, and Medicine, to consider facilitators and barriers for pediatrician training to enhance care for B/MH problems and to catalyze commitment to improvement efforts. During the interactive meeting, parents, young adult patients, and trainees, together with leaders of pediatric training programs and health care organizations, acknowledged the growing B/MH epidemic and discussed past and current efforts to improve training and care, including integrated delivery models. Attendees committed in writing to making a change within their department or organization to improve training. There also was agreement that organizations that set the standards for training and certification bear some responsibility to ensure that future pediatricians are prepared to meet the needs of children and adolescents. Reports on commitments to change 12 months after the meeting indicated that although attendees had encountered a variety of barriers, many had creatively moved forward to improve training at the program or organizational level. This article describes the context for the April 2018 meeting, themes arising from the meeting, results from the commitments to change, and 3 case studies. Taken together, they suggest we, as a pediatric community, can and must collaborate to improve training and, by extension, care.
In 2014, the American Academy of Pediatrics published bronchiolitis guidelines recommending against the use of bronchodilators. For the winter of 2015 to 2016, we aimed to reduce the proportion of emergency department patients with bronchiolitis receiving albuterol from 43% (previous winter rate) to <35% and from 18% (previous winter rate) to <10% in the inpatient setting.METHODS:
A team identified key drivers of albuterol use and potential interventions. We implemented changes to our pathway and the associated order set recommending against routine albuterol use and designed education to accompany the pathway changes. We monitored albuterol use through weekly automated data extraction and reported results back to clinicians. We measured admission rate, length of stay, and revisit rate as balancing measures for the intervention.RESULTS:
The study period included 3834 emergency department visits and 1119 inpatient hospitalizations. In the emergency department, albuterol use in children with bronchiolitis declined from 43% to 20% and was <3 SD control limits established in the previous year, meeting statistical thresholds for special cause variation. Inpatient albuterol use decreased from 18% to 11% of patients, also achieving special cause variation and approaching our goal. The changes in both departments were sustained through the entire bronchiolitis season, and admission rate, length of stay, and revisit rates remained unchanged.CONCLUSIONS:
Using a multidisciplinary group that redesigned a clinical pathway and order sets for bronchiolitis, we substantially reduced albuterol use at a large children’s hospital without impacting other outcome measures.
In Lyme disease endemic areas, initial management of children with arthritis can be challenging because diagnostic tests take several days to return results, leading to potentially unnecessary invasive procedures. Our objective was to examine the role of the C6 peptide enzyme immunoassay (EIA) test to guide initial management.METHODS:
We enrolled children with acute arthritis undergoing evaluation for Lyme disease presenting to a participating Pedi Lyme Net emergency department (2015–2019) and performed a C6 EIA test. We defined Lyme arthritis with a positive or equivocal C6 EIA test result followed by a positive supplemental immunoblot result and defined septic arthritis as a positive synovial fluid culture result or a positive blood culture result with synovial fluid pleocytosis. Otherwise, children were considered to have inflammatory arthritis. We report the sensitivity and specificity of the C6 EIA for the diagnosis of Lyme arthritis.RESULTS:
Of the 911 study patients, 211 children (23.2%) had Lyme arthritis, 11 (1.2%) had septic arthritis, and 689 (75.6%) had other inflammatory arthritis. A positive or equivocal C6 EIA result had a sensitivity of 100% (211 out of 211; 95% confidence interval [CI]: 98.2%–100%) and specificity of 94.2% (661 out of 700; 95% CI: 92.5%–95.9%) for Lyme arthritis. None of the 250 children with a positive or equivocal C6 EIA result had septic arthritis (0%; 95% CI: 0%–1.5%), although 75 children underwent diagnostic arthrocentesis and 27 underwent operative joint washout.CONCLUSIONS:
In Lyme disease endemic areas, a C6 EIA result could be used to guide initial clinical decision-making, without misclassifying children with septic arthritis.
In this study, we aim to evaluate the current trends in pediatric fractures related to trampolines.METHODS:
The National Electronic Injury Surveillance System was queried for fractures occurring between 2008 and 2017 in individuals aged 0 to 17 years. Sex, anatomic region, locale of injury, admission status, and year of injury were recorded. Incidence rates were calculated by using national census data. Poisson regression analysis was used to test for changes in fracture incidence across the time period. Logistic regression analyses were used to test temporal trends in the odds of a fracture occurring at a place of recreation or sport and a patient with a fracture being admitted.RESULTS:
Between 2008 and 2017, there was a 3.85% (95% confidence interval [CI]: 0.51–7.30) increase in the incidence of trampoline-related pediatric fractures per person-year. The incidence of pediatric trampoline-related fractures increased from 35.3 per 100 000 person-years in 2008 to 53.0 per 100 000 person-years in 2017. There was no change in the odds of a trampoline fracture requiring hospitalization (odds ratio per 1 year: 1.02; 95% CI: 0 6–1.07; P = .5431). There was a significant increase in the odds of a fracture occurring at a place of recreation or sport (odds ratio per year: 1.32; 95% CI: 1.21–1.43; P < .0001).CONCLUSIONS:
Between 2008 and 2017, there was a significant increase in the national incidence of trampoline-related fractures. We identified a significant increase in the proportion of trampoline fractures that occurred at a place of recreation or sport. Advocacy campaigns should consider these sites in their prevention efforts.
We aimed to describe the national epidemiology of burnout in pediatric residents.METHODS:
We conducted surveys of residents at 34 programs in 2016, 43 programs in 2017, and 49 programs in 2018. Survey items included the Maslach Burnout Inventory, demographics, program characteristics, personal qualities, experiences, and satisfaction with support, work-life balance, and learning environment. Analyses included cross-sectional comparisons and cross-sectional and longitudinal regression.RESULTS:
More than 60% of eligible residents participated; burnout rates were >50% in all years and not consistently associated with any demographic or residency characteristics. Cross-sectional associations were significant between burnout and stress, sleepiness, quality of life, mindfulness, self-compassion, empathy, confidence in providing compassionate care (CCC), being on a high-acuity rotation, recent major medical error, recent time off, satisfaction with support and career choice, and attitudes about residency. In cross-sectional logistic regression analyses, 4 factors were associated with an increased risk of burnout: stress, sleepiness, dissatisfaction with work-life balance, and recent medical error; 4 factors were associated with lower risk: empathy, self-compassion, quality of life, and CCC. Longitudinally, after controlling for 2017 burnout and 2018 risk factors (eg, recent error, sleepiness, rotation, and time off), 2017 quality of life was associated with 2018 burnout; 2017 self-compassion was associated with lower 2018 stress; and 2017 mindfulness, empathy, and satisfaction with learning environment and career choice were associated with 2018 CCC.CONCLUSIONS:
A majority of residents met burnout criteria. Several identified factors (eg, stress, sleepiness, medical errors, empathy, CCC, and self-compassion) suggest targets for interventions to reduce burnout in future studies.
Nadolol is a β-adrenergic antagonist that has been shown to be efficacious in the treatment of infantile hemangioma. It has been suggested that this drug may have fewer side effects compared with the gold standard therapy, propranolol, because it does not exhibit membrane-stabilizing effects and has little ability to cross the blood-brain barrier. However, the pharmacokinetics and safety of nadolol in infants are not well understood, potentially making this therapy dangerous. β-adrenergic antagonist toxicity causes bradycardia, hypotension, hypoglycemia, and even death. We report a case of a 10-week-old girl who was started on nadolol for infantile hemangioma, died 7 weeks later, and was found to have an elevated postmortem cardiac blood nadolol level of 0.94 mg/L. The infant had no bowel movements for 10 days before her death, which we hypothesize contributed to nadolol toxicity. Pharmacokinetics studies show a large fraction of oral nadolol either remains in the feces unchanged or is excreted into feces via the biliary system, allowing continued absorption over time in infants who stool infrequently. Propranolol may be a safer therapy overall. Not only does it have a shorter half-life, but propranolol is hepatically metabolized and renally eliminated, allowing for less drug accumulation in healthy infants with variable stooling patterns. We suggest that if nadolol is selected for therapy, pediatricians should instruct parents to monitor their infants’ bowel movements closely and encourage early intervention in the event of decreased stooling. This intervention may greatly improve the safety of nadolol in this vulnerable patient population.
Despite being unable to purchase firearms directly, many adolescents have access to guns, leading to increased risk of injury and death. We sought to determine if the National Instant Criminal Background Check System (NICS) changed adolescents’ gun-carrying behavior.METHODS:
We performed a repeated cross-sectional study using National Youth Risk Behavior Survey data from years 1993 to 2017. We used a survey-weighted multivariable logistic regression model to determine if the NICS had an effect on adolescent gun carrying, controlling for state respondent characteristics, state laws, state characteristics, the interaction between the NICS and state gun laws, and time.RESULTS:
On average, 5.8% of the cohort reported carrying a gun. Approximately 17% of respondents who carried guns were from states with a universal background check (U/BC) provision at the point of sale, whereas 83% were from states that did not have such laws (P < .001). The model indicated that the NICS together with U/BCs significantly reduced gun carrying by 25% (adjusted relative risk = 0.75 [95% confidence interval: 0.566–0.995]; P = .046), whereas the NICS independently did not (P = .516).CONCLUSIONS:
Adolescents in states that require U/BCs on all prospective gun buyers are less likely to carry guns compared with those in states that only require background checks on sales through federally licensed firearms dealers. The NICS was only effective in reducing adolescent gun carrying in the presence of state laws requiring U/BCs on all prospective gun buyers. However, state U/BC laws had no effect on adolescent gun carrying until after the NICS was implemented.