PEDIATRICS recent issues

Creative Approaches for Assessing Long-term Outcomes in Children

Advances in new technologies, when incorporated into routine health screening, have tremendous promise to benefit children. The number of health screening tests, many of which have been developed with machine learning or genomics, has exploded. To assess efficacy of health screening, ideally, randomized trials of screening in youth would be conducted; however, these can take years to conduct and may not be feasible. Thus, innovative methods to evaluate the long-term outcomes of screening are needed to help clinicians and policymakers make informed decisions. These methods include using longitudinal and linked-data systems to evaluate screening in clinical and community settings, school data, simulation modeling approaches, and methods that take advantage of data available in the digital and genomic age. Future research is needed to evaluate how longitudinal and linked-data systems drawing on community and clinical settings can enable robust evaluations of the effects of screening on changes in health status. Additionally, future studies are needed to benchmark participating individuals and communities against similar counterparts and to link big data with natural experiments related to variation in screening policies. These novel approaches have great potential for identifying and addressing differences in access to screening and effectiveness of screening across population groups and communities.

Reducing Unnecessary Treatments for Acute Bronchiolitis Through an Integrated Care Pathway

OBJECTIVES:

To analyze the impact of an integrated care pathway on reducing unnecessary treatments for acute bronchiolitis.

METHODS:

We implemented an evidence-based integrated care pathway in primary care (PC) centers and the referral emergency department (ED). This is the third quality improvement cycle in the management of acute bronchiolitis implemented by our research team. Family and provider experiences were incorporated by using design thinking methodology. A multifaceted plan that included several quality improvement initiatives was adopted to reduce unnecessary treatments. The primary outcome was the percentage of infants prescribed salbutamol. Secondary outcomes were prescribing rates of other medications. The main control measures were hospitalization and unscheduled return rates. Salbutamol prescribing rate data were plotted on run charts.

RESULTS:

We included 1768 ED and 1092 PC visits, of which 913 (51.4%) ED visits and 558 (51.1%) PC visits occurred in the postintervention period. Salbutamol use decreased from 7.7% (interquartile range [IQR] 2.8–21.4) to 0% (IQR 0–1.9) in the ED and from 14.1% (IQR 5.8–21.6) to 5% (IQR 2.7–8) in PC centers. In the ED, the overall epinephrine use rate fell from 9% (95% confidence interval [CI], 7.2–11.1) to 4.6% (95% CI, 3.4–6.1) (P < .001). In PC centers, overall corticosteroid and antibiotic prescribing rates fell from 3.5% (95% CI, 2.2–5.4) to 1.1% (95% CI, 0.4–2.3) (P =.007) and from 9.5% (95% CI; 7.3–12.3) to 1.7% (95% CI, 0.9–7.3) (P <.001), respectively. No significant variations were noted in control measures.

CONCLUSIONS:

An integrated clinical pathway that incorporates the experiences of families and clinicians decreased the use of medications in the management of bronchiolitis.

Extremely Low Birth Weight and Accelerated Biological Aging

BACKGROUND AND OBJECTIVES:

Extremely low birth weight (ELBW) (<1000 g) survivors are exposed to elevated levels of physiologic stress during their lives and may be susceptible to accelerated aging. Using the oldest known longitudinally followed cohort of ELBW survivors, we compared biological aging in this group using an epigenetic clock to a sample of matched normal birth weight (NBW) (>2500 g) control participants.

METHODS:

Buccal cells were collected from 45 ELBW survivors and 49 NBW control participants at 30 to 35 years of age. Epigenetic age was calculated from the weighted average of DNA methylation at 353 cytosine-phosphate-guanine sequence within DNA sites, by using the Illumina Infinium Human Methylation EPIC 850k BeadChip array.

RESULTS:

Before and after statistically adjusting for neurosensory impairment and the presence of chronic health conditions, a significant sex by birth weight group interaction was observed in the 353-site epigenetic-clock assay (P = .03), whereby ELBW men had a significantly older epigenetic age than NBW men (4.6 years; P = .01). Women born at ELBW were not found to be epigenetically older than their NBW peers.

CONCLUSIONS:

The results of this study suggest that prenatal exposures may play an important role in aging, and that men born preterm may experience accelerated aging relative to their peers. We further highlight the need to monitor and promote the health of preterm survivors, with a particular focus on healthy aging across the life span.

Delayed-Onset ADA1 (ADA) Deficiency Not Detected by TREC Screen

A 9-month-old boy presented to a community pediatrician with a recent history of failure to thrive. Workup revealed neutropenia and lymphopenia. Subsequent admission for fever and pneumonia revealed an absolute neutrophil count of 860 and absolute lymphocyte count of 214. Lymphopenia affected all lymphocyte subsets and his naïve and memory CD4+ T-cell ratio was inverted for age. Immunoglobulin levels were normal for age, and tetanus and diphtheria antibody titers were protective. The profound lymphopenia raised suspicion for severe combined immunodeficiency (SCID), despite a normal newborn screening by T-cell receptor excision circle analysis. He did not have a previous history of recurrent fevers or infections, had attended day care, and had received all age-appropriate vaccines. He subsequently was diagnosed with Pneumocystis jirovecii pneumonia, adenovirus upper respiratory infection, and rotaviral diarrhea. An enzyme assay revealed absent adenosine deaminase (ADA) activity and elevated erythrocyte deoxyadenosine nucleotides. With genetic sequencing, 2 pathogenic variants in the ADA gene were confirmed. Acute management of ADA-SCID is aimed at restoration of enzyme activity, followed by curative therapy. The patient is currently on immunoglobulin therapy and recombinant ADA (Revcovi), with an excellent immune response, while awaiting sibling hematopoietic cell transplant from a matched sibling. Hypomorphic ADA variants can present with delayed-onset SCID, and some of these patients are missed by SCID newborn screening. A careful review of a complete blood cell count might offer clues and promote confirmatory diagnostic investigation.

Quality Improvement for Rapid Development and Scale-Up of COVID-19-Related Screening Processes

BACKGROUND:

In March 2020, Ohio strongly recommended temperature and health screening for coronavirus disease 2019 symptoms in all businesses to reduce the spread of infection.

METHODS:

We used multiple plan-do-study-act cycles and workplace efficiency techniques iteratively to develop 12 intervention components required to effectively screen employees and visitors across all locations. We used run and control charts to summarize our performance over time.

RESULTS:

Over the course of 20 days of rapid testing, we increased from 0% to 100% of locations successfully screening. The volume of people undergoing screening peaked during employee shift change. Employee positive screen results decreased by >50% after the first 7 days of screening, whereas family positive screen results remained stable throughout the study period.

CONCLUSIONS:

An empowered, multidepartmental steering team, disciplined use of rapid cycle quality improvement processes, and explicit, standardized training processes enabled rapid successful scale-up of standard screening and masking process for employees and patients during the coronavirus disease 2019 pandemic. This approach can assist hospitals in adapting screening processes to evolving evidence.

Predictors of Deceased Organ Donation in the Pediatric Population

BACKGROUND:

A shortage of donor organs represents the major barrier to the success of solid organ transplantation. This is especially true in the pediatric population for which the number of organ donors has decreased over time. With this study, we aimed to assess the factors associated with deceased organ donor consent in the pediatric population and determine the variability in consent rates across organ procurement organizations (OPOs).

METHODS:

All eligible pediatric deaths were identified from the Scientific Registry of Transplant Recipients (2008–2019). The rate of organ donor consent was determined, and multivariable logistic regression was used to assess the factors independently associated with successful donor recruitment. The probability of donor consent was determined for each OPO after adjusting for patient demographics.

RESULTS:

A total of 11 829 eligible pediatric deaths were approached to request consent for organ donation. Consent was successful in 8816 (74.5%) subjects. Consent rates are lower in the pediatric population compared with young adults and are directly related to patient age such that eligible infant deaths have the lowest rate of successful donor consent. There is significant variability in donor consent rates across OPOs, independent of population demographic differences.

CONCLUSIONS:

OPO is predictive of pediatric deceased organ donor consent independent of demographic differences, with some regions having consistently higher consent rates than others. Sharing best practices for pediatric deceased donor recruitment may be a strategy to increase organ availability in the pediatric population.

Longitudinal Associations Between Screen Use and Reading in Preschool-Aged Children

BACKGROUND AND OBJECTIVES:

The home literacy environment has been identified as a key predictor of children’s language, school readiness, academic achievement, and behavioral outcomes. With the increased accessibility and consumption of digital media, it is important to understand whether screen use impacts off-line enrichment activities such as reading or whether reading activities offset screen use. Using a prospective birth cohort, we examined reading and screen use at 24, 36, and 60 months to elucidate the directional association between screen use and reading over time.

METHODS:

This study included data from 2440 mothers and children in Calgary, Alberta, drawn from the All Our Families cohort. Children’s screen use and reading activities were assessed via maternal report at age 24, 36, and 60 months. Sociodemographic covariates were also collected.

RESULTS:

Using a random-intercepts cross-lagged panel model, which statistically controls for individual-level confounds, this study revealed that greater screen use at 24 months was associated with lower reading at 36 months (β = –.08; 95% confidence interval: –0.13 to –0.02). In turn, lower reading at 36 months was associated with greater screen use at 60 months (β = –.11; 95% confidence interval: –0.19 to –0.02). Covariates did not modify the associations.

CONCLUSIONS:

A reciprocal relationship between screen use and reading was identified. Early screen use was associated with lower reading activities, resulting in greater screen use at later ages. Findings emphasize the need for practitioners and educators to discuss screen use guidelines and encourage families to engage in device-free activities to foster early literacy exposure.

Trends in HPV Vaccination Initiation and Completion Within Ages 9-12 Years: 2008-2018

BACKGROUND AND OBJECTIVES:

Routine human papillomavirus (HPV) vaccination is recommended at ages 11 to 12 years and may be initiated as early as 9 years of age.

METHODS:

Data were derived from the National Immunization Survey-Teen, spanning 2008–2018. Using health care provider–verified vaccination histories, we examined trends in human papillomavirus vaccination up-to-date (HPV-UTD) rates within ages 9 to 12 years. Furthermore, we assessed vaccination status by sociodemographic factors and US state of residence.

RESULTS:

Overall, amid evidence of recent stagnation, HPV vaccination between ages 9 to 12 increased over the years. Initiation rates rose from 17.3% in 2008 to 62.8% in 2018, and HPV-UTD rates rose from 13.5% in 2011 to 32.8% in 2018. After the inception of gender-neutral HPV vaccination, HPV-UTD rates between 2011 and 2018 rose by 31.9% among boys and only 6.6% among girls. For most of the study period, non-Hispanic Black and Hispanic individuals had higher rates of initiation and HPV-UTD than non-Hispanic white individuals. In 2018, vaccination initiation rates exceeded 70% in several states; however, HPV-UTD rates in most US states were <50%, excluding Rhode Island (61.6%), Colorado (58.7%), Hawaii (53.5%), District of Columbia (53.2%), and Ohio (50%).

CONCLUSIONS:

HPV vaccination within ages 9 to 12 years is suboptimal. To leverage the substantial benefits of HPV vaccination within this age range, it is imperative that conscious efforts are taken at the national and state levels to promote HPV vaccination for this age group.

The Pediatric Workforce: Recent Data Trends, Questions, and Challenges for the Future

The future of the pediatric workforce has been the subject of significant dialogue in the pediatric community and generated much discussion in the academic literature. There are significant concerns regarding the ability of pediatricians to meet the growing demands of our pediatric population. Over the past 5 years, there has been a decline in the percentage of doctor of osteopathic medicine students who pursue a career in pediatrics but an equally important increase in the number of pediatric positions that are filled by doctor of osteopathic medicine students and international medical graduates. Although there has been an increase in the number of pediatric positions offered in the National Resident Matching Program, the last 4 years have seen a significant increase in the number of unfilled pediatric positions. A number of pediatric subspecialties struggle to fill their training positions, and those with low match rates may have 20% to 40% fewer applicants than positions. The pediatric vision for the future must include a commitment to a comprehensive strategic planning process with the many organizations involved across the multiple stages of the educational continuum. It is time to elucidate and address the questions raised by the workforce data. Developing solutions to these questions will require a careful planning process and a thoughtful analysis of the pediatric workforce data. Establishing this as an important priority will require a major collaborative effort between pediatric academic and professional organizations, but the future benefit to the nation’s children will be significant.

Smoking Susceptibility and Tobacco Media Engagement Among Youth Never Smokers

BACKGROUND:

Susceptibility to future smoking among youth never smokers has not changed in the past 20 years, although experimental cigarette smoking has decreased. We assessed how smoking susceptibility and tobacco industry–related marketing influenced smoking initiation.

METHODS:

Four waves (2013–2018) of the Population Assessment of Tobacco and Health Study data were analyzed among youth aged 12 to 17 years at wave 1 who completed wave 4. Susceptibility was assessed by 4 items (openness to curiosity, try soon, try in the next year, and if your best friend offered) and categorized into 4 levels (0 = definitely no to all; 1 = yes to 1; 2 = yes to 2; and 3 + 4 = yes to 3 or 4 susceptibility items). Multivariable logistic regression evaluated how susceptibility levels, electronic cigarette use, and tobacco-related media activity predicted future experimental (≥1 puff), current (past 30 days), or established (≥100 cigarettes) smoking.

RESULTS:

Among 8899 never smokers at wave 1, 16.4% became experimental smokers, 7.6% current smokers, and 1.8% established smokers at wave 4. Black and Latino/a youth were less likely to experiment. Youth who endorsed 3 or 4 susceptibility items at wave 1 were more likely to be experimental (adjusted odds ratio [aOR] = 6.0; confidence interval [CI] = 4.8–7.4), current (aOR = 4.2; CI = 3.2–5.4), or established (aOR = 4.4; CI = 2.4–7.9) smokers at wave 4. Exposure to tobacco marketing, using tobacco-related apps, seeing social media content posted about tobacco, and ever use of electronic cigarettes also predicted experimental smoking.

CONCLUSIONS:

Smoking susceptibility and exposure to tobacco industry–related marketing were predictive of cigarette smoking. Clinicians should consider screening adolescents for smoking susceptibility and tobacco-related media exposure.

Antibody Response and Protection After Receipt of Inactivated Influenza Vaccine: A Systematic Review

CONTEXT:

Children are at increased risk of influenza-related complications. Public health agencies recommend 2 doses of influenza vaccine for children 6 months through 8 years of age receiving the vaccine for the first time.

OBJECTIVE:

To systematically review studies comparing vaccine effectiveness (VE) and immunogenicity after 1 or 2 doses of inactivated influenza vaccine (IIV) in children.

DATA SOURCES:

Data sources included Medline, Embase, and Cochrane Library databases.

STUDY SELECTION:

We included studies published in a peer reviewed journal up to April 2, 2019, with available abstracts, written in English, and with children aged 6 months through 8 years.

DATA EXTRACTION:

VE among fully and partially vaccinated children was compared with that of unvaccinated children. We extracted geometric mean titers of serum hemagglutination inhibition (HAI) antibodies against influenza A(H1N1), A(H3N2), and B-lineage vaccine antigens after 1 and 2 IIV doses. Outcomes were evaluated by age, timing of doses, vaccine composition, and prevaccination titers.

RESULTS:

A total of 10 VE and 16 immunogenicity studies were included. VE was higher for fully vaccinated groups than partially vaccinated groups, especially for children aged 6–23 months. Our findings show increased HAI titers after 2 doses, compared with 1. Older children and groups with prevaccination antibodies have robust HAI titers after 1 dose. Similar vaccine strains across doses, not the timing of doses, positively affects immune response.

LIMITATIONS:

Few studies focused on older children. Researchers typically administered one-half the standard dose of IIV. HAI antibodies are an imperfect correlate of protection.

CONCLUSIONS:

Findings support policies recommending 2 IIV doses in children to provide optimal protection against influenza.

The Heart of the Matter: Secondary Hypogammaglobulinemia and Constrictive Pericarditis

Constrictive pericarditis is the final common result of a number of processes that affect the pericardium. Establishing the diagnosis and determining the underlying etiology of constrictive pericarditis are often a diagnostic rendezvous. Here, we describe a patient who presented to the general practitioner with edema, ascites, and weight gain and was found to have constrictive pericarditis secondary to an inflammatory myofibroblastic tumor of the mediastinum. Interestingly, she had a relative lack of cardiorespiratory complaints, and, aside from the edema and mildly elevated jugular venous pressure, she had an unremarkable cardiac and pulmonary examination. During the diagnostic evaluation for constrictive pericarditis, she was found to have hypogammaglobulinemia and profound lymphocytopenia. A stool α-1-antitrypsin level was sent and was elevated, which confirmed the diagnosis of protein-losing enteropathy, a rare but important complication of constrictive pericarditis. This case highlights important diagnostic considerations and management of these complications for the general practitioner.

Electronic Vapor Product Use and Sexual Risk Behaviors in US Adolescents

BACKGROUND AND OBJECTIVES:

Adolescent electronic vapor product (EVP) usage continues to increase and is associated with heightened engagement in other risk behaviors. However, there is limited research on associations between youth EVP use and sexual risk behaviors (SRBs). In this study, we examined how current youth EVP and/or cigarette usage, as well as EVP usage frequency, is related to several SRBs.

METHODS:

Respondents (N = 12 667) of the 2017 National Youth Risk Behavior Survey were categorized by previous 30-day EVP and/or cigarette usage: nonuse, EVP use only, cigarette use only, or dual use. Separately, respondents were categorized by previous 30-day EVP usage frequency: 0, 1 to 9, 10 to 29, or 30 days. Ten SRBs were identified as dependent variables. Adjusted prevalence ratios were calculated by using modified Poisson regression to determine associations between SRBs and both current EVP and/or cigarette usage and EVP usage frequency. Linear contrasts compared adjusted prevalence ratios across usage and frequency categories.

RESULTS:

Youth EVP-only users and dual users were more likely than nonusers to engage in 9 of 10 SRBs. Prevalence proportions did not differ between EVP-only users and dual users for 7 of 10 behaviors. Occasional EVP users were more likely than nonusers to engage in 9 of 10 SRBs and were similarly as likely as frequent and daily users to engage in all 10 SRBs.

CONCLUSIONS:

EVP usage among US high school students, with or without concurrent cigarette use, was associated with heightened engagement in several SRBs. Prevalence of engagement in most SRBs did not differ among occasional, frequent, and daily EVP users.

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