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A System-Wide Hospital Child Maltreatment Patient Safety Program

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

Hospital-wide patient safety programs have been used to ensure appropriate provision of care. Similar approaches have not been widely applied to child maltreatment. In this study, we describe a hospital-system child maltreatment safety program by characterizing the frequency of patients needing further intervention, associations between the age of patient and location of care and need for further intervention, and patients who require immediate intervention.

METHODS

For all staff concerns for child maltreatment, a social worker completed a patient at risk (PAR) form. All PAR forms were reviewed within 24 hours by the child abuse team and categorized on the basis of 6 types of interventions, most significantly an "immediate callback." Wilcoxon rank and 2 tests were used for group comparisons.

RESULTS

Over a 30-month period, program interventions occurred in 2061 of 7698 PARs (26.8%). The most common reason for a PAR form was physical abuse (32.5%). Subjects requiring an intervention were no different in age than those who did not (median age: 5.6 vs 5.2 years). PAR forms performed in the emergency departments or urgent care were more likely to require an intervention than inpatient (odds ratio: 4.4; 95% confidence interval 3.6–5.3) or clinic (odds ratio: 2.0; 95% confidence interval 1.7–2.3) PAR forms. Of the 53 immediate callbacks, potential diagnostic errors and safe discharge concerns occurred in nearly one-half, and >40% involved subjects with bruising. Immediate follow-up in the child abuse pediatrician clinic occurred in 87% (46 of 53) of cases, resulting in a new or changed diagnosis in 57% of such cases.

CONCLUSIONS

A child maltreatment safety program encompassing a health system can identify and address medical errors.

The Evolution of Quality Benchmarks for Bronchiolitis

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

Evidence suggests that average performance on quality measures for bronchiolitis has been improving over time, but it is unknown whether optimal performance, as defined by Achievable Benchmarks of Care (ABCs), has also changed. Thus, we aimed to compare ABCs for established bronchiolitis quality measures between 2 consecutive time periods. As a secondary aim, we evaluated performance gaps, defined as the difference between median performance and ABCs, to identify measures that may benefit most from targeted quality initiatives.

METHODS

We used hospital administrative data from the Pediatric Health Information System database to calculate ABCs and performance gaps for nonrecommended bronchiolitis tests and treatments in 2 groups (patients discharged from the emergency department [ED] and those hospitalized) over 2 time periods (2006–2014 and 2014–2019) corresponding to publication of national bronchiolitis guidelines.

RESULTS

Substantial improvements were identified in ABCs for chest radiography (ED –8.8% [confidence interval (CI) –8.3% to –9.4%]; hospitalized –17.5% [CI –16.3% to –18.7%]), viral testing (hospitalized –14.6% [CI –13.5% to –15.7%]), antibiotic use (hospitalized –10.4% [CI –8.9% to –11.1%]), and bronchodilator use (ED –9.0% [CI –8.4% to –9.6%]). Viral testing (ED 11.5% [CI 10.9% to 12.1%]; hospitalized 21.5% [CI 19.6% to 23.4%]) and bronchodilator use (ED 13.8% [CI 12.8% to 14.8%]; hospitalized 22.8% [CI 20.6% to 25.1%]) demonstrated the largest performance gaps.

CONCLUSIONS

Marked changes in ABCs over time for some bronchiolitis quality measures highlight the need to reevaluate improvement targets as practice patterns evolve. Measures with large performance gaps, such as bronchodilator use and viral testing, are recommended as targets for ongoing quality improvement initiatives.

Incidence of COVID-19 and Risk of Diabetic Ketoacidosis in New-Onset Type 1 Diabetes

Mié, 01/09/2021 - 10:01
OBJECTIVES

With this study, our aim was to quantify the relative risk (RR) of diabetic ketoacidosis at diagnosis of type 1 diabetes during the year 2020 and to assess whether it was associated with the regional incidence of coronavirus disease 2019 (COVID-19) cases and deaths.

METHODS

Multicenter cohort study based on data from the German Diabetes Prospective Follow-up Registry. The monthly RR for ketoacidosis in 2020 was estimated from observed and expected rates in 3238 children with new-onset type 1 diabetes. Expected rates were derived from data from 2000 to 2019 by using a multivariable logistic trend regression model. The association between the regional incidence of COVID-19 and the rate of ketoacidosis was investigated by applying a log-binomial mixed-effects model to weekly data with Germany divided into 5 regions.

RESULTS

The observed versus expected frequency of diabetic ketoacidosis was significantly higher from April to September and in December (mean adjusted RRs, 1.48–1.96). During the first half of 2020, each increase in the regional weekly incidence of COVID-19 by 50 cases or 1 death per 100 000 population was associated with an increase in the RR of diabetic ketoacidosis of 1.40 (95% confidence interval, 1.10–1.77; P = .006) and 1.23 (1.14–1.32; P < .001), respectively. This association was no longer evident during the second half of 2020.

CONCLUSIONS

These findings suggest that the local severity of the pandemic rather than health policy measures appear to be the main reason for the increase in diabetic ketoacidosis and thus the delayed use of health care during the pandemic.

Recipe for Disaster: Homemade Formula Leading to Severe Complications in 2 Infants

Mié, 01/09/2021 - 10:01

Families and physicians alike benefit from the advances and ease of the Internet. Similarly, both can be unaware of harmful misinformation circulating the Web. In this article, we describe the presentation of 2 unrelated infants, within 1 week of each other, with vitamin D deficiency rickets and severe extraskeletal manifestations of hypocalcemia, including seizures and cardiac arrest, from homemade, vegan formula found through Pinterest (San Francisco, CA). Despite good parental intentions this formula did not meet macronutrient and micronutrient standards, particularly regarding vitamin D, phosphorus, and calcium content, and led to rare, life-threatening complications in both cases. Before presentation, both patients followed appropriately with their pediatrician and discussed feeding in detail, although neither family disclosed the use of homemade formula. Pediatricians must be aware of these dangerous homemade alternative formulas, consider the manner and depth of their feeding history questioning, and continue to counsel against homemade formula to prevent further harm to children.

A 13-Year-Old With Fever and Chest Pain

Mié, 01/09/2021 - 10:01

Maternal Vaccination and Infant Influenza and Pertussis

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

Infant influenza and pertussis disease causes considerable morbidity and mortality worldwide. We examined the effectiveness of maternal influenza and pertussis vaccines in preventing these diseases in infants.

METHODS

This inception cohort study comprised women whose pregnancies ended between September 1, 2015, and December 31, 2017, in Victoria, Australia. Maternal vaccination status was sourced from the Victorian Perinatal Data Collection and linked to 5 data sets to ascertain infant outcomes and vaccination. The primary outcome of interest was laboratory-confirmed influenza or pertussis disease in infants aged <2 months, 2 to <6 months, and <6 months combined. Secondary outcomes included infant hospitalization (emergency presentation or admission) and death. Risk ratios and 95% confidence intervals (CIs) were estimated by Poisson regression. Vaccine effectiveness (VE) was estimated as (1 minus the risk ratio) x 100%.

RESULTS

Among 186 962 pregnant women, 85 830 (45.9%) and 128 060 (68.5%) were vaccinated against influenza and pertussis, respectively. There were 175 and 51 infants with laboratory-confirmed influenza and pertussis disease, respectively. Influenza VE was 56.1% (95% CI, 23.3% to 74.9%) for infants aged <2 months and 35.7% (2.2% to 57.7%) for infants aged 2 to <6 months. Pertussis VE was 80.1% (95% CI, 37.1% to 93.7%) for infants aged <2 months and 31.8% (95% CI, –39.1% to 66.6%) for infants aged 2 to <6 months.

CONCLUSIONS

Our study provides evidence of the direct effectiveness of maternal influenza and pertussis vaccination in preventing these diseases in infants aged <2 months. The findings strengthen the importance of maternal vaccination to prevent these diseases in infants.

Restricting the Sale of Electronic Nicotine Delivery System Flavors

Mié, 01/09/2021 - 10:01

Electronic nicotine delivery system use contributes to the epidemic of youth vaping. Regulations to curtail or prohibit the sale of flavored nicotine products aim to disrupt initiation of child nicotine use by reducing access to enticing nicotine flavorings. A total of 6 states and >300 localities have restricted or banned flavored nicotine product sales. In this case study, we outline the use of a localized town-based strategy, which offered 2 potential bills to incrementally restrict or prohibit sale of flavored vape products when county or state legislation was not politically feasible. Over the course of 18 months, these bills reduced the number of municipalities where these products could be sold or advertised until county, city, and statewide bans were effectively in place, ultimately making the passage of a bill in the statehouse palatable. Strong partnerships with officials who had expertise in local town government, local American Academy of Pediatrics chapter physician champions, and a diverse coalition were instrumental in motivating smaller governments, which often pass legislation faster than larger legislatures, to create child-protective tobacco policies.

iciHHV-6 in a Patient With Multisystem Inflammatory Syndrome in Children

Mié, 01/09/2021 - 10:01

Multisystem inflammatory syndrome in children (MIS-C) is a serious, sometimes life-threatening late complication of coronavirus disease 2019 (COVID-19) with multiorgan involvement and evidence of immune activation. The pathogenesis of MIS-C is not known, nor is the pathogenesis of the severe organ damage that is the hallmark of MIS-C. Human herpesvirus 6 (HHV-6), the virus responsible for roseola, is a ubiquitous herpesvirus that causes close to universal infection by the age of 3 years. HHV-6 remains latent for life and can be activated during inflammatory states, by other viruses, and by host cell apoptosis. HHV-6 has been associated with end-organ diseases, including hepatitis, carditis, and encephalitis. In addition, ~1% of people have inherited chromosomally integrated human herpesvirus 6 (iciHHV-6), which is HHV-6 that has been integrated into chromosomal telomeric regions and is transmitted through the germ line. iciHHV-6 can be reactivated and has been associated with altered immune responses. We report here a case of MIS-C in which an initial high HHV-6 DNA polymerase chain reaction viral load assay prompted testing for iciHHV-6, which yielded a positive result. Additional research may be warranted to determine if iciHHV-6 is commonly observed in patients with MIS-C and, if so, whether it may play a part in MIS-C pathogenesis.

Preventing COVID-19 Transmission in Education Settings

Mié, 01/09/2021 - 10:01
OBJECTIVES

In fall 2020, community hubs opened in San Francisco, California, to support vulnerable groups of students in remote learning. Our objectives were to (1) describe adherence to coronavirus disease 2019 (COVID-19) mitigation policies in these urban, low-income educational settings; (2) assess associations between policy adherence and in-hub COVID-19 transmission; and (3) identify barriers to and facilitators of adherence.

METHODS

We conducted a mixed-methods study from November 2020 to February 2021. We obtained COVID-19 case data from the San Francisco Department of Public Health, conducted field observations to observe adherence to COVID-19 mitigation policies, and surveyed hub leaders about barriers to and facilitators of adherence. We summarized quantitative data using descriptive statistics and qualitative data using thematic content analysis.

RESULTS

A total of 1738 children were enrolled in 85 hubs (39% Hispanic, 29% Black). We observed 54 hubs (n = 1175 observations of children and 295 observations of adults). There was high community-based COVID-19 incidence (2.9–41.2 cases per 100 000 residents per day), with 36 cases in hubs and only 1 case of hub-based transmission (adult to adult). Sixty-seven percent of children and 99% of adults were masked. Fifty-five percent of children and 48% of adults were distanced ≥6 ft. Facilitators of mitigation policies included the following: for masking, reminders, adequate supplies, and "unmasking zones"; for distancing, reminders and distanced seating.

CONCLUSIONS

We directly observed COVID-19 mitigation in educational settings, and we found variable adherence. However, with promotion of multiple policies, there was minimal COVID-19 transmission (despite high community incidence). We detail potential strategies for increasing adherence to COVID-19 mitigation.

Behavioral Health Risk Factors for Nonmedical Prescription Opioid Use in Adolescence

Mié, 01/09/2021 - 10:01
BACKGROUND

Adolescent nonmedical prescription opioid use is associated with overdose and other adverse outcomes, but its risk factors are poorly understood.

METHODS

Data were drawn from a prospective cohort study of Los Angeles, California, high school students. At baseline (mean age = 14.6 years), students completed self-report screening measures of problem alcohol, cannabis, and drug use and 6 mental health problems (major depression, generalized anxiety, panic disorder, social phobia, obsessive-compulsive disorder, and hypomania or mania). Past 6-month nonmedical prescription opioid use (yes or no) was assessed across 7 semiannual follow-ups.

RESULTS

Among baseline never users of nonmedical prescription opioids (N = 3204), average past 6-month prevalence of new nonmedical prescription opioid use across the 42-month follow-up was 4.4% (range 3.5%–6.1%). In a multivariable model co-adjusting for 9 baseline behavioral problems and other factors, major depression, hypomania or mania, cannabis, alcohol, and other drug use problems were associated with increased odds of nonmedical prescription opioid use over follow-ups. Cumulative indices of behavioral health comorbidity showed successively greater odds of subsequent nonmedical prescription opioid use for students with 1 (odds ratio [OR]: 3.74; 95% confidence interval [CI]: 2.79–5.01), 2 (OR: 8.79; 95% CI: 5.95–12.99), or 3 (OR: 9.69; 95% CI: 5.63–16.68) vs 0 baseline substance use problems, and similar increases were associated with increasing number of mental health problems (1 [OR: 1.60; 95% CI: 1.03–2.88] to all 6 [OR: 3.98; 95% CI: 1.09–14.82] vs 0).

CONCLUSIONS

Behavioral health problems may be associated with increased risk of subsequent nonmedical prescription opioid use during mid to late adolescence, with successively greater risk for those with greater behavioral health comorbidity. In pediatric clinical practice or school-based prevention, behavioral health screeners may be useful for identifying youth at high risk for nonmedical prescription opioid use.

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