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Trends and Factors Related to Blunt Use in Middle and High School Students, 2010-2020

Jue, 01/07/2021 - 10:01
BACKGROUND AND OBJECTIVES

Blunt use is a popular mode of marijuana consumption among adolescents in the United States, but little is known about how its prevalence has changed over time or factors associated with its use. With this study, we assessed trends and correlates of past (ever used but not in the past 30 days) and current (used in past 30 days) blunt use among adolescents in Florida.

METHODS

We analyzed data from 2010–2020 cross-sectional, statewide representative Florida Youth Tobacco Surveys that comprised 461 706 middle and high schoolers using Joinpoint to calculate annual percentage change (APC) in the weighted prevalence of past and current blunt use. A weighted multivariable regression model was developed by using 2019–2020 Florida Youth Tobacco Survey data to examine the factors associated with past and current blunt use.

RESULTS

Whereas the prevalence of past (APC = –5.32%) and current (APC = –5.28%) blunt use significantly decreased from 2010 to 2015, an increasing trend in current use prevalence (APC = 14.91%) was observed from 2015 to 2018 and has been approximately constant ever since. Similar increasing trends were observed in current blunt use among female students (APC = 14.92%), middle schoolers (19.57%), and non-Hispanic (NH) white students (APC = 11.12%) from 2016 to 2020. Several factors were consistently associated with greater odds of both past and current blunt use for both middle and high schoolers, including older age, being NH Black (versus NH white), past and current use of cigarettes, electronic cigarettes, hookah, cigars, and ever vaping marijuana.

CONCLUSIONS

Although blunt use among Florida youth decreased from 2010 to 2015, substantial increases were observed since 2015, suggesting that existing tobacco control programs should incorporate marijuana (and blunt) modules into existing tobacco and nicotine prevention programs.

Incidence and Relapse of Idiopathic Nephrotic Syndrome: Meta-analysis

Jue, 01/07/2021 - 10:01
CONTEXT

Idiopathic nephrotic syndrome (INS) in children is a disease with considerable morbidity, yet the incidence and risk for relapse have not been systematically reviewed.

OBJECTIVE

To estimate the overall pooled weighted incidence and risk for relapse of INS in children.

DATA SOURCES

Medline and Embase (until December 2020).

STUDY SELECTION

All studies reporting incidence (per 100 000 children per year) and/or risk for relapse (the proportion of patients who experience ≥1 relapse) of INS in children (age: <18 years) were eligible.

DATA EXTRACTION

After quality assessment, data were extracted: study (design, localization, and sample size) and patient (age, sex, steroid response, and ethnicity) characteristics, incidence, and risk for relapse.

RESULTS

After screening, 73 studies were included for analysis (27 incidence, 54 relapse). The overall pooled weighted estimate and corresponding prediction interval (PI) of the incidence was 2.92 (95% PI: 0.00–6.51) per 100 000 children per year. Higher incidences were found in non-Western countries (P < .001). Incidence tended to be lower in white children, but this was not significant. The overall pooled weighted estimate of the risk for relapse was 71.9% (95% PI: 38.8–95.5). Between 1945 and 2011, incidence did not change (P = .39), yet the risk for relapse decreased significantly (P = .024), from 87.4% to 66.2%.

LIMITATIONS

There was no full-text availability (n = 33), considerable heterogeneity, and limited studies from Africa, Latin America, and Asia.

CONCLUSIONS

INS has a low incidence with ethnic variation but high risk for relapse. Although corticosteroids have significantly reduced the risk for relapse, it remains unacceptably high, underscoring the need for alternative treatment strategies.

Home Visiting for NICU Graduates: Impacts of Following Baby Back Home

Jue, 01/07/2021 - 10:01
BACKGROUND AND OBJECTIVES

The Following Baby Back Home (FBBH) home visiting program supports families of high-risk low birth weight preterm infants after discharge from a hospital NICU. This study compares the health care use, immunization, and infant mortality rate of low birth weight preterm infants enrolled in FBBH with similar infants not in the program.

METHODS

From January 2013 to December 2017, 498 children enrolled in FBBH were identified in Arkansas vital statistics records and the Arkansas All-Payer Claims Database. Infants in FBBH were matched with children in a control group on the basis of demographics and medical conditions of the infant. Generalized linear mixed models with double propensity-score adjustment were used to estimate program effects.

RESULTS

In the first year after discharge and compared with a propensity-score matched cohort of control infants, those enrolled in FBBH were significantly more likely to have higher numbers of medical appointments and more compliant immunization history. The odds of dying in the first year of life for control infants was 4.4 times (95% confidence interval: 1.2–20.7) higher than those managed in the program.

CONCLUSIONS

A goal of the FBBH home visiting program is to work with parents to educate and support them as they care for their medically fragile infants. We conclude that education and support was instrumental in the infant health care use and outcome differences we observed during the first year of life.

Severity of Bronchopulmonary Dysplasia Among Very Preterm Infants in the United States

Jue, 01/07/2021 - 10:01
BACKGROUND AND OBJECTIVES

The Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network recently proposed new, severity-based diagnostic criteria for bronchopulmonary dysplasia (BPD). This study provides the first benchmark epidemiological data applying this definition.

METHODS

Retrospective cohort study of infants born from 22 to 29 weeks’ gestation in 2018 at 715 US hospitals in the Vermont Oxford Network. Rates of BPD, major neonatal morbidities, and common respiratory therapies, stratified by BPD severity, were determined.

RESULTS

Among 24 896 infants, 2574 (10.3%) died before 36 weeks’ postmenstrual age (PMA), 12 198 (49.0%) did not develop BPD, 9192 (36.9%) developed grade 1 or 2 BPD, and 932 (3.7%) developed grade 3 BPD. Rates of mortality before 36 weeks’ PMA and grade 3 BPD decreased from 52.7% and 9.9%, respectively, among infants born at 22 weeks’ gestation to 17.3% and 0.8% among infants born at 29 weeks’ gestation. Grade 1 or 2 BPD peaked in incidence (51.8%) among infants born at 25 weeks’ gestation. The frequency of severe intraventricular hemorrhage or cystic periventricular leukomalacia increased from 4.8% among survivors without BPD to 23.4% among survivors with grade 3 BPD. Similar ranges were observed for late onset sepsis (4.8%–31.4%), surgically treated necrotizing enterocolitis (1.4%–17.1%), severe retinopathy of prematurity (1.2%–23.0%), and home oxygen therapy (2.0%–67.5%).

CONCLUSIONS

More than one-half of very preterm infants born in the United States died before 36 weeks’ PMA or developed BPD. Greater BPD severity was associated with more frequent development of major neonatal morbidities, in-hospital mortality, and use of supplemental respiratory support at discharge.

Rapid Implementation of Telehealth Services in a Pediatric Pulmonary Clinic During COVID-19

Jue, 01/07/2021 - 10:01
OBJECTIVES

The coronavirus pandemic created significant, abrupt challenges to the delivery of ambulatory health care. Because tertiary medical centers limited elective in-person services, telehealth was rapidly enacted in settings with minimal previous experience to allow continued access to care. With this quality improvement (QI) initiative, we aimed to achieve a virtual visit volume of at least 75% of our prepandemic volume. We also describe patient and provider experience with telehealth services.

METHODS

Our QI team identified the primary drivers contributing to low telehealth volume and developed a telehealth scheduling protocol and data tracking system using QI-based strategies. Patients and providers were surveyed on their telehealth experience.

RESULTS

At the onset of the pandemic, weekly visit volume dropped by 65% (99 weekly visits; historical average of 281). Over the subsequent 3 weeks, using rapid Plan-Do-Study-Act cycles, we achieved our goal volume. In surveys, it was indicated that most participants had never before used telehealth (71% of patients; 82% of providers) yet reported high satisfaction (90% of patients; 81% of providers). Both groups expressed concern over the lack of in-person assessments. Most respondents were interested in future use of telehealth.

CONCLUSIONS

With a QI-based approach, we successfully maintained access to care via telehealth services for pediatric pulmonary patients during the coronavirus pandemic and found high rates of satisfaction among patients and providers. Telehealth will likely continue to be a part of our health care delivery platform, expanding the reach of our services. Further work is needed to understand the effects on clinical outcomes.

Assisted Reproductive Techniques, ADHD, and School Performance

Jue, 01/07/2021 - 10:01
OBJECTIVES

To examine the long-term impact of assisted reproductive techniques (ART) on offspring neurodevelopment, accounting for parental factors and the role of infertility.

METHODS

Linkage of national registers allowed follow-up of >2.4 million children born in Sweden 1986–2012. Information on ART was retrieved from fertility clinics, medical records, and maternal self-report. Attention-deficit/hyperactivity disorder (ADHD) was identified from specialist diagnosis and/or use of medication through 2018. School performance was assessed from records of ninth year final grade averages (0–20) and eligibility for upper secondary school through 2017.

RESULTS

Children conceived with ART had lower risk of ADHD (hazard ratio 0.83; 95% confidence interval [CI]: 0.80 to 0.87) and did better in school (grade mean difference 1.15; 95% CI: 1.09 to 1.21 and eligibility odds ratio 1.53; 95% CI: 1.45 to 1.63) compared with all other children. Differences in parental characteristics explained and even reversed associations, whereas no disadvantage was seen when the comparison was restricted to children of couples with known infertility (adjusted hazard ratio 0.95; 95% CI: 0.90 to 1.00, adjusted mean difference 0.05; 95% CI: –0.01 to 0.11, and adjusted odds ratio 1.03; 95% CI: 0.96 to 1.10). Among children conceived with ART, there was furthermore no indication that intracytoplasmic sperm injection (compared with standard in vitro fertilization) or frozen (compared with fresh) embryo transfer had any adverse influence.

CONCLUSIONS

With this nationwide, long-term follow-up, we provide additional reassurance concerning offspring neurodevelopment after use of ART, finding no indication for concern about risk of ADHD or school performance in adolescence.

Risk Factors and Outcomes After a Brief Resolved Unexplained Event: A Multicenter Study

Jue, 01/07/2021 - 10:01
BACKGROUND

The accuracy of the risk criteria for brief resolved unexplained events (BRUEs) from the American Academy of Pediatrics (AAP) is unknown. We sought to evaluate if AAP risk criteria and event characteristics predict BRUE outcomes.

METHODS

This retrospective cohort included infants <1 year of age evaluated in the emergency departments (EDs) of 15 pediatric and community hospitals for a BRUE between October 1, 2015, and September 30, 2018. A multivariable regression model was used to evaluate the association of AAP risk factors and event characteristics with risk for event recurrence, revisits, and serious diagnoses explaining the BRUE.

RESULTS

Of 2036 patients presenting with a BRUE, 87% had at least 1 AAP higher-risk factor. Revisits occurred in 6.9% of ED and 10.7% of hospital discharges. A serious diagnosis was made in 4.0% (82) of cases; 45% (37) of these diagnoses were identified after the index visit. The most common serious diagnoses included seizures (1.1% [23]) and airway abnormalities (0.64% [13]). Risk is increased for a serious underlying diagnosis for patients discharged from the ED with a history of a similar event, an event duration >1 minute, an abnormal medical history, and an altered responsiveness (P < .05). AAP risk criteria for all outcomes had a negative predictive value of 90% and a positive predictive value of 23%.

CONCLUSIONS

AAP BRUE risk criteria are used to accurately identify patients at low risk for event recurrence, readmission, and a serious underlying diagnosis; however, their use results in the inaccurate identification of many patients as higher risk. This is likely because many AAP risk factors, such as age, are not associated with these outcomes.

Intubation Competence During Neonatal Fellowship Training

Jue, 01/07/2021 - 10:01
OBJECTIVES

To characterize neonatal-perinatal medicine fellows’ progression toward neonatal intubation procedural competence during fellowship training.

METHODS

Multi-center cohort study of neonatal intubation encounters performed by neonatal-perinatal medicine fellows between 2014 through 2018 at North American academic centers in the National Emergency Airway Registry for Neonates. Cumulative sum analysis was used to characterize progression of individual fellows’ intubation competence, defined by an 80% overall success rate within 2 intubation attempts. We employed multivariable analysis to assess the independent impact of advancing quarter of fellowship training on intubation success.

RESULTS

There were 2297 intubation encounters performed by 92 fellows in 8 hospitals. Of these, 1766 (77%) were successful within 2 attempts. Of the 40 fellows assessed from the start of training, 18 (45%) achieved procedural competence, and 12 (30%) exceeded the deficiency threshold. Among fellows who achieved competence, the number of intubations to meet this threshold was variable, with an absolute range of 8 to 46 procedures. After adjusting for patient and practice characteristics, advancing quarter of training was independently associated with an increased odds of successful intubation (adjusted odds ratio: 1.10; 95% confidence interval 1.07–1.14).

CONCLUSIONS

The number of neonatal intubations required to achieve procedural competence is variable, and overall intubation competence rates are modest. Although repetition leads to skill acquisition for many trainees, some learners may require adjunctive educational strategies. An individualized approach to assess trainees’ progression toward intubation competence is warranted.

Complete Absence of the Extrahepatic Biliary Tree in a Newborn With Pigmented Stools

Jue, 01/07/2021 - 10:01

"Yellow stools in neonatal cholestasis exclude biliary atresia." This conventional wisdom led to the development of the infant stool color card, which alerts parents to seek medical referral when pale stools are observed, a strategy that has been shown to improve survival in infants with biliary atresia (BA). Here, we present a case of a newborn with significant direct hyperbilirubinemia (direct bilirubin level of up to 9.2 mg/dL on day of life 10) who continued to produce colored stools. Whole-genome sequencing results were negative for genetic causes of cholestasis. Hepatobiliary scintigraphy findings were nonexcretory. A liver biopsy specimen revealed cholestasis, ductular hyperplasia, giant cell formation, minimal inflammation, minimal portal or periportal fibrosis, and no evidence of viral changes. On day of life 38, during the exploratory laparotomy, the patient was found to have complete absence of the extrahepatic biliary tree, or biliary aplasia, possibly a rare, severe form of BA. This report aims to increase our vigilance and help prevent diagnostic error in patients with signs and symptoms of BA who may produce pigmented stools. Primary care physicians should hence refer an infant (early and urgently) to a pediatric gastroenterologist for further workup for a direct bilirubin level >1.0 mg/dL with any total bilirubin level, irrespective of the color of the infant’s stools.

Availability of Pediatric Inpatient Services in the United States

Jue, 01/07/2021 - 10:01
OBJECTIVES

We sought to evaluate trends in pediatric inpatient unit capacity and access and to measure pediatric inpatient unit closures across the United States.

METHODS

We performed a retrospective study of 4720 US hospitals using the 2008–2018 American Hospital Association survey. We used linear regression to describe trends in pediatric inpatient unit and PICU capacity. We compared trends in pediatric inpatient days and bed counts by state. We examined changes in access to care by calculating distance to the nearest pediatric inpatient services by census block group. We analyzed hospital characteristics associated with pediatric inpatient unit closure in a survival model.

RESULTS

Pediatric inpatient units decreased by 19.1% (34 units per year; 95% confidence interval [CI] 31 to 37), and pediatric inpatient unit beds decreased by 11.8% (407 beds per year; 95% CI 347 to 468). PICU beds increased by 16.0% (66.9 beds per year; 95% CI 53 to 81), primarily at children’s hospitals. Rural areas experienced steeper proportional declines in pediatric inpatient unit beds (–26.1% vs –10.0%). Most states experienced decreases in both pediatric inpatient unit beds (median state –18.5%) and pediatric inpatient days (median state –10.0%). Nearly one-quarter of US children experienced an increase in distance to their nearest pediatric inpatient unit. Low-volume pediatric units and those without an associated PICU were at highest risk of closing.

CONCLUSIONS

Pediatric inpatient unit capacity is decreasing in the United States. Access to inpatient care is declining for many children, particularly those in rural areas. PICU beds are increasing, primarily at large children’s hospitals. Policy and surge planning improvements may be needed to mitigate the effects of these changes.

First Time Wheezing in a 2-Year-Old

Jue, 01/07/2021 - 10:01

Pediatric patients with respiratory signs and symptoms who are found to be wheezing present a diagnostic dilemma to pediatricians. The majority of these cases are diagnosed as some degree of reactive airway disease, either as viral bronchiolitis or asthma. In this scenario, a patient with wheezing was initially given 2 courses of appropriate antibiotics on the basis of the duration and concurrence of other symptoms. However, he was subsequently referred to a pediatric pulmonologist for further workup after failure to improve and persistent oxygen saturations in the low-to-mid 90s. More extensive testing was completed by the pediatric pulmonologist, in addition to a short hospital admission. A rigid bronchoscopy was eventually completed, which revealed small pieces of partially digested material. Although his persistent cough resolved, his saturations continued to be suboptimal. A chest computed tomography scan with contrast was then completed, which eventually led to his diagnosis and appropriate treatment and resolution of his symptoms.

Firearms Injuries Involving Young Children in the United States During the COVID-19 Pandemic

Jue, 01/07/2021 - 10:01
OBJECTIVES

Increased rates of firearm ownership, school closures, and a suspected decrease in supervision during the coronavirus disease 2019 (COVID-19) pandemic place young children at increased risk of firearm injuries. We measured trends in firearm injuries in children and inflicted by children discharging a firearm during the pandemic and correlated these changes with a rise in firearm acquisition.

METHODS

In this cross-sectional study with an interrupted time series analysis, we used multiyear data from the Gun Violence Archive. We compared trends in (1) firearm injuries in children younger than 12 years old and (2) firearm injuries inflicted by children younger than 12 years old during the pre-COVID-19 period (March to August in the years 2016–2019) and during the first 6 months of the COVID-19 pandemic (March 2020 to August 2020). Linear regression models were developed to evaluate the relationship between firearm injuries and new firearm acquisitions.

RESULTS

There was an increased risk of (1) firearm injuries in young children (relative risk = 1.90; 95% confidence interval 1.58 to 2.29) and (2) firearm injuries inflicted by young children (relative risk = 1.43; 95% confidence interval 1.14 to 1.80) during the first 6 months of the COVID-19 pandemic as compared to the pre-COVID-19 study period. These increased incidents correlate with an increase in new firearm ownership (P < .03).

CONCLUSIONS

There has been a surge in firearm injuries in young children and inflicted by young children during the first 6 months of the COVID-19 pandemic. There is an urgent and critical need for enactment of interventions aimed at preventing firearm injuries and deaths involving children.

Pediatric Vaccination During the COVID-19 Pandemic

Jue, 01/07/2021 - 10:01
OBJECTIVES

The impact of the coronavirus disease 2019 pandemic on vaccination coverage, critical to preventing vaccine-preventable diseases, has not been assessed during the reopening period.

METHODS

Vaccine uptake and vaccination coverage for recommended vaccines and for measles-containing vaccines at milestone ages were assessed in a large cohort of children aged 0 to 18 years in Southern California during January to August 2020 and were compared with those in the same period in 2019. Differences in vaccine uptake and vaccination coverage (recommended vaccines and measles-containing vaccines) in prepandemic (January to March), stay-at-home (April to May), and reopening (June to August) periods in 2020 and 2019 were compared.

RESULTS

Total and measles-containing vaccine uptake declined markedly in all children during the pandemic period in 2020 compared with 2019, but recovered in children aged 0 to 23 months. Among children aged 2 to 18 years, measles-containing vaccine uptake recovered, but total vaccine uptake remained lower. Vaccination coverage (recommended and measles-containing vaccines) declined and remained reduced among most milestone age cohorts ≤24 months during the pandemic period, whereas recommended vaccination coverage in older children decreased during the reopening period in 2020 compared with 2019.

CONCLUSIONS

Pediatric vaccine uptake decreased dramatically during the pandemic, resulting in decreased vaccination coverage that persisted or worsened among several age cohorts during the reopening period. Additional strategies, including immunization tracking, reminders, and recall for needed vaccinations, particularly during virtual visits, will be required to increase vaccine uptake and vaccination coverage and reduce the risk of outbreaks of vaccine-preventable diseases.

Childrens Drawings of Coronavirus

Jue, 01/07/2021 - 10:01
OBJECTIVES

To understand how children perceive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in relation to public representations and to evaluate their interpretations.

METHODS

Children’s perceptions of SARS-CoV-2 were evaluated by asking 103 French children, aged 5 to 17 years old, first to draw a coronavirus and then to identify SARS-CoV-2 in a series of 16 images during summer 2020.

RESULTS

One hundred three children were included in the study, either during outpatient visits at the hospital (in Marseille and Paris) or through the authors’ social network, and were grouped in terms of age, parents’ occupation, mode of recruitment, and recollection of having previously seen a representation of a coronavirus. Half of the children drew the coronavirus as circular in shape, and almost all included a crownlike feature. One-third of the drawings had anthropomorphic features. Although the pictorial representations of the virus were fairly accurate overall, the children’s interpretations of the crownlike structure were imaginative. The explanations the children gave for their drawings were in some cases surprising. Among the 16 pictures they were shown, the children correctly identified those of SARS-CoV-2, other than the electron micrograph, in more than two-thirds of cases.

CONCLUSIONS

Children of all ages, even the youngest, and both sexes had a relatively accurate perception of SARS-CoV-2, as evaluated through their drawings and their ability to recognize it among other pictures. The children’s drawings of the coronavirus were colorful and had a less frightening tone than expected in the light of media coverage, suggesting that they had developed coping mechanisms.

Ethics of Implementing US Preventive Services Task Force Recommendations for Childhood Obesity

Jue, 01/07/2021 - 10:01

Childhood obesity represents a serious and growing concern for the United States. Its negative consequences for health and well-being can be far-reaching, devastating, and intergenerational. In 2017, the US Preventive Services Task Force (USPSTF) issued a grade B recommendation for screening children and adolescents for obesity and offering or referring to comprehensive, intensive behavioral interventions as indicated. However, many communities in the United States have limited access to such interventions. The USPSTF’s mission is to review and grade research evidence for clinical preventive services and does not include cost or population-based operationalization and implementation logistics considerations for its recommendations. Yet implementing recommendations without considering cost and operationalization may lead to equity and access challenges. These are essential considerations, but oversight of the implementation of these recommendations is not standardized or assigned to any one agency or organization. As such, a central ethical feature inherent to the implementation of USPSTF recommendations calls for stakeholder collaborations to take on the next step beyond the establishment of evidence-based recommendations: to ensure the ethical application of such guidelines across diverse populations. Furthermore, the screening-intervention relationship inherent to this USPSTF recommendation raises ethical concerns regarding US societal norms surrounding obesity, particularly when contrasted against other screening-intervention modalities. More efforts, such as increased incentives or expansion of clinical services in low-resource areas, should be taken to facilitate this recommended intervention by expanding access to childhood obesity interventions to fulfill ethical responsibilities to equity and to ensure the right to open futures for children.

Weapon Carrying Among Boys in US Schools by Race and/or Ethnicity: 1993-2019

Jue, 01/07/2021 - 10:01
BACKGROUND

High adolescent gun-related mortality, gun violence, pro-gun policies, white supremacy, and the long-term socioeconomic and other effects of racial oppression are intricately linked in the United States. Racist prejudice depicts male individuals of color as more prone to criminality than white male individuals. We described long-term patterns of weapon carrying in US schools among non-Hispanic (NH) white, NH Black/African American, and Hispanic boys, hypothesizing that in contrast to racist stereotypes, boys of color did not bring weapons into schools more often than NH white boys in recent years.

METHODS

We conducted a time series analysis using 1993–2019 Youth Risk Behavior Surveillance System data comparing boys’ self-reported weapon carrying in a nationally representative sample of US high schools by race and/or ethnicity, age, and self-reported experience of safety and violence at school.

RESULTS

Weapon carrying in schools has declined among all boys. Comparing all schools, we found no significant differences in weapon carrying (4%–5%) by race and/or ethnicity in 2017 and 2019. Boys who reported experiencing violence or feeling unsafe at school were at least twice as likely to bring a weapon into school, and such negative experiences were more common among boys of color (8%–12%) than among NH white boys (4%–5%). In schools perceived as safer, NH white boys have been more likely to bring weapons into schools than NH Black/African American or Hispanic boys in the past 20 years.

CONCLUSIONS

Our findings contradict racist prejudice with regard to weapon carrying in schools, particularly in more favorable school environments. Making schools safer may reduce weapon carrying in schools where weapon carrying is most common.

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