PEDIATRICS recent issues

Recommendations for Prevention and Control of Influenza in Children, 2019-2020

This statement updates the recommendations of the American Academy of Pediatrics for the routine use of influenza vaccines and antiviral medications in the prevention and treatment of influenza in children during the 2019–2020 season. The American Academy of Pediatrics continues to recommend routine influenza immunization of all children without medical contraindications, starting at 6 months of age. Any licensed, recommended, age-appropriate vaccine available can be administered, without preference of one product or formulation over another. Antiviral treatment of influenza with any licensed, recommended, age-appropriate influenza antiviral medication continues to be recommended for children with suspected or confirmed influenza, particularly those who are hospitalized, have severe or progressive disease, or have underlying conditions that increase their risk of complications of influenza.

Pediatric Application of Coding and Valuation Systems

The American Academy of Pediatrics provides this revised policy statement to address health care changes that impact procedural and visit coding and valuation as well as the incorporation of coding principles into innovative, newer payment models. This policy statement focuses solely on recommendations, and an accompanying technical report provides supplemental coding and valuation background.

Pediatric Application of Coding and Valuation Systems

The American Academy of Pediatrics provides this technical report as supplemental background to the accompanying coding and valuation system policy statement. The rapid evolution in health care payment modeling requires that clinicians have a current appreciation of the mechanics of service representation and valuation. The accompanying policy statement provides recommendations relevant to this area, and this technical report provides a format to outline important concepts that allow for effective translation of bedside clinical events into physician payment.

School-aged Children Who Are Not Progressing Academically: Considerations for Pediatricians

Pediatricians and other pediatric primary care providers may be consulted when families have concerns that their child is not making expected progress in school. Pediatricians care not only for an increasingly diverse population of children who may have behavioral, psychological, and learning difficulties but also for increasing numbers of children with complex and chronic medical problems that can affect the development of the central nervous system and can present with learning and academic concerns. In many instances, pediatric providers require additional information about the nature of cognitive, psychosocial, and educational difficulties that affect their school-aged patients. Our purpose for this report is to describe the current state of the science regarding educational achievement to inform pediatricians’ decisions regarding further evaluation of a child’s challenges. In this report, we review commonly available options for psychological evaluation and/or treatment, medical referrals, and/or recommendations for referral for eligibility determinations at school and review strategies for collaborating with families, schools, and specialists to best serve children and families.

Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents

Attention-deficit/hyperactivity disorder (ADHD) is 1 of the most common neurobehavioral disorders of childhood and can profoundly affect children’s academic achievement, well-being, and social interactions. The American Academy of Pediatrics first published clinical recommendations for evaluation and diagnosis of pediatric ADHD in 2000; recommendations for treatment followed in 2001. The guidelines were revised in 2011 and published with an accompanying process of care algorithm (PoCA) providing discrete and manageable steps by which clinicians could fulfill the clinical guideline’s recommendations. Since the release of the 2011 guideline, the Diagnostic and Statistical Manual of Mental Disorders has been revised to the fifth edition, and new ADHD-related research has been published. These publications do not support dramatic changes to the previous recommendations. Therefore, only incremental updates have been made in this guideline revision, including the addition of a key action statement related to diagnosis and treatment of comorbid conditions in children and adolescents with ADHD. The accompanying process of care algorithm has also been updated to assist in implementing the guideline recommendations. Throughout the process of revising the guideline and algorithm, numerous systemic barriers were identified that restrict and/or hamper pediatric clinicians’ ability to adopt their recommendations. Therefore, the subcommittee created a companion article (available in the Supplemental Information) on systemic barriers to the care of children and adolescents with ADHD, which identifies the major systemic-level barriers and presents recommendations to address those barriers; in this article, we support the recommendations of the clinical practice guideline and accompanying process of care algorithm.

Gender Discrepancies Related to Pediatrician Work-Life Balance and Household Responsibilities

BACKGROUND:

Physicians must balance career and home responsibilities, yet previous studies on work-life balance are focused primarily on work-based tasks. We examined gender discrepancies and factors related to household responsibilities and work-life balance among pediatricians.

METHODS:

We used 2015 data from the American Academy of Pediatrics Pediatrician Life and Career Experience Study, a longitudinal study of early-career pediatricians. 2 tests and multivariable logistic regression were used to examine the effects of gender on household responsibilities, satisfaction, and work-life balance attainment. We formally reviewed responses from 2 open-ended questions on work-life balance challenges and strategies for common themes.

RESULTS:

Seventy-two percent of participants completed the survey (1293 of 1801). Women were more likely than men to report having primary responsibility for 13 of 16 household responsibilities, such as cleaning, cooking, and routine care of children (all P < .001). All gender differences except budget management remained significant when controlling for part-time work status and spouse or partner work status (P < .05). Women were less satisfied with their share of responsibilities relative to others (52% vs 62%; P < .001), and few women and men report being very successful at achieving balance between their job and other life areas (15% vs 19%, respectively; P = .05). Open-ended responses (n = 1145) revealed many barriers to achieving work-life balance. Strategies to increase work-life balance included reducing work hours, outsourcing household-related work, and adjustments to personal responsibilities and relationships.

CONCLUSIONS:

Female pediatricians spend more time on household responsibilities than male pediatricians, and gender is a key factor associated with work-life balance satisfaction.

Improving Emergency Department Management of Diabetic Ketoacidosis in Children

BACKGROUND:

Diagnostic delays in the pediatric emergency department (ED) can lead to unnecessary interventions and prolonged ED length of stay (LOS), especially in patients with diabetes mellitus evaluated for diabetic ketoacidosis (DKA). At our institution, baseline DKA determination time (arrival to diagnosis) was 86 minutes, and 61% of patients did not meet DKA criteria. Subsequently, intravenous (IV) placement occurred in 85% of patients without DKA. We aimed to use point-of-care (POC) testing to reduce DKA determination time from 86 to 30 minutes and to reduce IV placements in patients without DKA from 85% to 20% over 18 months.

METHODS:

Four key interventions (POC tests, order panels, provider guidelines, and nursing guidelines) were tested by using plan-do-study-act cycles. DKA determination time was our primary outcome, and secondary outcomes included the percentage of patients receiving IV placement and ED LOS. Process measures included the rate of use of POC testing and order panels. All measures were analyzed on statistical process control charts.

RESULTS:

Between January 2015 and July 2018, 783 patients with diabetes mellitus were evaluated for DKA. After all 4 interventions, DKA determination time decreased from 86 to 26 minutes (P < .001). In patients without DKA, IV placement decreased from 85% to 36% (P < .001). ED LOS decreased from 206 to 186 minutes (P = .009) in patients discharged from the hospital after DKA evaluation. POC testing and order panel use increased from 0% to 98% and 90%, respectively.

CONCLUSIONS:

Using quality-improvement methodology, we achieved a meaningful reduction in DKA determination time, the percentage of IV placements, and ED LOS.

Screening and Referral Practices for Autism Spectrum Disorder in Primary Pediatric Care

OBJECTIVES:

To examine screening practices for autism spectrum disorder (ASD), subsequent referrals, and diagnostic outcomes within a large network of primary pediatric care practices.

METHODS:

Rates of ASD screening with the Modified Checklist for Autism in Toddlers (M-CHAT) at 18- and 24-month well-child visits were examined among 290 primary care providers within 54 pediatric practices between June 2014 and June 2016. Demographic, referral, and diagnostic data were abstracted from the medical records for all children who failed the M-CHAT (ie, score of ≥3) at either or both visits.

RESULTS:

Rates of M-CHAT screening were 93% at 18 months and 82% at 24 months. Among 23 514 screens, scores of 648 (3%) were ≥3 (386 at 18 months, 262 at 24 months) among 530 unique children who failed 1 or both screenings. Among screen-failed cases, 18% received a diagnosis of ASD and 59% received ≥1 non-ASD neurodevelopmental disorder diagnosis within the follow-up period. Only 31% of children were referred to a specialist for additional evaluation.

CONCLUSIONS:

High rates of ASD-specific screening do not necessarily translate to increases in subsequent referrals for ASD evaluation or ASD diagnoses. Low rates of referrals and/or lack of follow-through on referrals appear to contribute to delays in children’s receipt of ASD diagnoses. Additional education of primary care providers regarding the referral process after a failed ASD screening is warranted.

Parenting Behavior and Child Language: A Meta-analysis

CONTEXT:

Early language development supports cognitive, academic, and behavioral success. Identifying modifiable predictors of child language may inform policies and practices aiming to promote language development.

OBJECTIVE:

To synthesize results of observational studies examining parenting behavior and early childhood language in typically developing samples.

DATA SOURCES:

Searches were conducted in Medline, Embase, PsycINFO, Web of Science, and Dissertation Abstracts (1967 to 2017).

STUDY SELECTION:

Studies had 1 of 2 observational measures of parenting behavior (i.e., sensitive responsiveness or warmth) and a measure of child language.

DATA EXTRACTION:

Data from 37 studies were extracted by independent coders. Estimates were examined by using random-effects meta-analysis.

RESULTS:

Two meta-analyses were conducted, which examined (1) the association between sensitive-responsive parenting and child language (k = 36; r = 0.27; 95% confidence interval: 0.21 to 0.33); and (2) the association between parental warmth and child language (k = 13; r = 0.16; 95% confidence interval: 0.09 to 21). The pooled effect size for the association between sensitive responsiveness and child language was statistically higher than that of warmth and child language. The association between sensitive responsiveness and child language was moderated by family socioeconomic status (SES): effect sizes were stronger in low and diverse SES groups compared with middle to upper SES groups. Effect sizes were also stronger in longitudinal versus cross-sectional studies.

LIMITATIONS:

Results are limited to typically developing samples and mother-child dyads. Findings cannot speak to causal processes.

CONCLUSIONS:

Findings support theories describing how sensitive parenting may facilitate language and learning.

Celiac Disease Autoimmunity and Emotional and Behavioral Problems in Childhood

BACKGROUND AND OBJECTIVES:

Celiac disease (CeD) is associated with psychopathology in children. It is unknown whether this association is present in children with celiac disease autoimmunity (CDA) identified by screening. We examined the associations between subclinical CDA and emotional and behavioral problems in children without previous CeD diagnosis.

METHODS:

In a population-based cohort study of 3715 children (median age: 6 years), blood titers of tissue transglutaminase autoantibodies were analyzed. CDA was defined as a measurement of tissue transglutaminase autoantibodies ≥7 U/mL (n = 51). Children with previous CeD diagnosis or children on a gluten-free diet, were excluded. The Child Behavior Checklist (CBCL) was filled in by parents and was used to assess behavioral and emotional problems of children at a median age of 5.9 years. Multiple linear regression models were applied to evaluate the cross-sectional associations between CDA and CBCL scores. Sensitivity analyses were done in a subgroup of children who were seropositive carrying the HLA antigen risk alleles for CeD.

RESULTS:

In basic models, CDA was not associated with emotional and behavioral problems on the CBCL scales. After adjustment for confounders, CDA was significantly associated with anxiety problems (β = .29; 95% confidence interval 0.02 to 0.55; P = .02). After exclusion of children who did not carry the HLA-DQ2 and/or HLA-DQ8 risk alleles (n = 4), CDA was additionally associated with oppositional defiant problems (β = .35; 95% confidence interval 0.02 to 0.69). Associations were not explained by gastrointestinal complaints.

CONCLUSIONS:

Our results reveal that CDA, especially combined with the HLA-DQ2 and HLA-DQ8 risk alleles, is associated with anxiety problems and oppositional defiant problems. Further research should be used to establish whether behavioral problems are a reflection of subclinical CeD.

Failure to Provide Adequate Palliative Care May Be Medical Neglect

Doctors are required to notify Child Protective Services (CPS) if parents do not provide appropriate medical care for their children. But criteria for reporting medical neglect are vague. Which treatments properly fall within the realm of shared decision-making in which parents can decide whether to accept doctors’ recommendations? Which treatments are so clearly in the child’s interest that it would be neglectful to refuse them? When to report medical neglect concerns to CPS may be controversial. It would seem inhumane to allow a child to suffer because of parental refusal to administer proper analgesia. In this ethics rounds, we present a case of an adolescent with chronic pain who is terminally ill. Her parents were not adherent to recommended analgesia regimens. Her palliative care team had to decide whether to report the case to CPS.

Gender Differences in Earnings of Early- and Midcareer Pediatricians

BACKGROUND:

The US physician workforce includes an increasing number of women, with pediatrics having the highest percentage. In recent research on physicians, it is indicated that men earn more than women. It is unclear how this finding extends to pediatricians.

METHODS:

We examined cross-sectional 2016 data on earnings from the American Academy of Pediatrics Pediatrician Life and Career Experience Study, a longitudinal study of early- and midcareer pediatricians. To estimate adjusted differences in pediatrician earnings between men and women, we conducted 4 ordinary least squares regression models. Model 1 examined gender, unadjusted; model 2 controlled for labor force characteristics; model 3 controlled for both labor force and physician-specific job characteristics; and model 4 controlled for labor force, physician-specific job, and work-family characteristics.

RESULTS:

Sixty-seven percent of Pediatrician Life and Career Experience Study participants completed the 2016 surveys (1213 out of 1801). The analytic sample was restricted to participants who completed training and worked in general pediatrics, hospitalist care, or subspecialty care (n = 998). Overall pediatrician-reported mean annual income was $189 804. Before any adjustment, women earned ~76% of what men earned, or ~$51 000 less. Adjusting for common labor force characteristics such as demographics, work hours, and specialty, women earned ~87% of what men earned, or ~$26 000 less. Adjusting for a comprehensive set of labor force, physician-specific job, and work-family characteristics, women earned ~94% of what men earned, or ~$8000 less.

CONCLUSIONS:

Early- to midcareer female pediatricians earned less than male pediatricians. This difference persisted after adjustment for important labor force, physician-specific job, and work-family characteristics. In future work, researchers should use longitudinal analyses and further explore family obligations and choices.

Accuracy of Autism Screening in a Large Pediatric Network

BACKGROUND:

Universal screening is recommended to reduce the age of diagnosis for autism spectrum disorder (ASD). However, there are insufficient data on children who screen negative and no study of outcomes from truly universal screening. With this study, we filled these gaps by examining the accuracy of universal screening with systematic follow-up through 4 to 8 years.

METHODS:

Universal, primary care-based screening was conducted using the Modified Checklist for Autism in Toddlers with Follow-Up (M-CHAT/F) and supported by electronic administration and integration into electronic health records. All children with a well-child visit (1) between 16 and 26 months, (2) at a Children’s Hospital of Philadelphia site after universal electronic screening was initiated, and (3) between January 2011 and July 2015 were included (N = 25 999).

RESULTS:

Nearly universal screening was achieved (91%), and ASD prevalence was 2.2%. Overall, the M-CHAT/F’s sensitivity was 38.8%, and its positive predictive value (PPV) was 14.6%. Sensitivity was higher in older toddlers and with repeated screenings, whereas PPV was lower in girls. Finally, the M-CHAT/F's specificity and PPV were lower in children of color and those from lower-income households.

CONCLUSIONS:

Universal screening in primary care is possible when supported by electronic administration. In this "real-world" cohort that was systematically followed, the M-CHAT/F was less accurate in detecting ASD than in previous studies. Disparities in screening rates and accuracy were evident in traditionally underrepresented groups. Future research should focus on the development of new methods that detect a greater proportion of children with ASD and reduce disparities in the screening process.

A Multistate Outbreak of E Coli O157:H7 Infections Linked to Soy Nut Butter

BACKGROUND:

In 2017, we conducted a multistate investigation to determine the source of an outbreak of Shiga toxin-producing Escherichia coli (STEC) O157:H7 infections, which occurred primarily in children.

METHODS:

We defined a case as infection with an outbreak strain of STEC O157:H7 with illness onset between January 1, 2017, and April 30, 2017. Case patients were interviewed to identify common exposures. Traceback and facility investigations were conducted; food samples were tested for STEC.

RESULTS:

We identified 32 cases from 12 states. Twenty-six (81%) cases occurred in children <18 years old; 8 children developed hemolytic uremic syndrome. Twenty-five (78%) case patients ate the same brand of soy nut butter or attended facilities that served it. We identified 3 illness subclusters, including a child care center where person-to-person transmission may have occurred. Testing isolated an outbreak strain from 11 soy nut butter samples. Investigations identified violations of good manufacturing practices at the soy nut butter manufacturing facility with opportunities for product contamination, although the specific route of contamination was undetermined.

CONCLUSIONS:

This investigation identified soy nut butter as the source of a multistate outbreak of STEC infections affecting mainly children. The ensuing recall of all soy nut butter products the facility manufactured, totaling >1.2 million lb, likely prevented additional illnesses. Prompt diagnosis of STEC infections and appropriate specimen collection aids in outbreak detection. Child care providers should follow appropriate hygiene practices to prevent secondary spread of enteric illness in child care settings. Firms should manufacture ready-to-eat foods in a manner that minimizes the risk of contamination.

The Impact of Physical Activity on Brain Structure and Function in Youth: A Systematic Review

CONTEXT:

Advances in neuroimaging techniques have resulted in an exponential increase in the number of studies investigating the effects of physical activity on brain structure and function. Authors of studies have linked physical activity and fitness with brain regions and networks integral to cognitive function and scholastic performance in children and adolescents but findings have not been synthesized.

OBJECTIVE:

To conduct a systematic review of studies in which the impact of physical activity on brain structure and function in children and adolescents is examined.

DATA SOURCES:

Six electronic databases (PubMed, PsychINFO, Scopus, Ovid Medline, SportDiscus, and Embase) were systematically searched for experimental studies published between 2002 and March 1, 2019.

STUDY SELECTION:

Two reviewers independently screened studies for inclusion according to predetermined criteria.

DATA EXTRACTION:

Two reviewers independently extracted data for key variables and synthesized findings qualitatively.

RESULTS:

Nine studies were included (task-based functional MRI [n = 4], diffusion tensor imaging [n = 3], arterial spin labeling [n = 1], and resting-state functional MRI [n = 1]) in which results for 5 distinct and 4 similar study samples aged 8.7 ± 0.6 to 10.2 ± 1.0 years and typically of relatively low socioeconomic status were reported. Effects were reported for 12 regions, including frontal lobe (n = 3), parietal lobe (n = 3), anterior cingulate cortex (n = 2), hippocampus (n = 1), and several white matter tracts and functional networks.

LIMITATIONS:

Findings need to be interpreted with caution as quantitative syntheses were not possible because of study heterogeneity.

CONCLUSIONS:

There is evidence from randomized controlled trials that participation in physical activity may modify white matter integrity and activation of regions key to cognitive processes. Additional larger hypothesis-driven studies are needed to replicate findings.

Newborn Screening for Sickle Cell Disease Using Point-of-Care Testing in Low-Income Setting

BACKGROUND:

Newborn screening provides early diagnosis for children with sickle cell disease (SCD), reducing disease-related mortality. We hypothesized that rapid point-of-care (POC) Sickle SCAN would be reliable in Haiti and would assist newborn screening.

METHODS:

Dried blood specimens were obtained from infant heel sticks and analyzed by isoelectric focusing (IEF) at a public hospital in Cap-Haïtien during a 1-year period. A total of 360 Guthrie cards were also analyzed for quality assurance by high-performance liquid chromatography at the Florida Newborn Screening Laboratory. In addition, two-thirds of the infants were also screened by the POC to assess differences with the IEF. The hemoglobinopathy incidence and the specificity and sensitivity of the POC scan were assessed.

RESULTS:

Overall, 1.48% of the children screened positive for SCD. The specificity and the sensitivity of POC Sickle SCAN were 0.97 (confidence interval 0.95–0.99) and 0.90 (confidence interval 0.55–1.00), respectively, relative to high-performance liquid chromatography gold standard. The confirmatory testing rate was 75% before POC and improved to 87% after POC was added for dual screening. Confirmatory testing revealed that 0.83% of children screened had SCD. Children who screened positive for SCD by POC started penicillin earlier, had their first pediatric follow-up a median of 38 days earlier, and received antipneumococcal vaccination on time when compared with those who screened positive for SCD by IEF alone.

CONCLUSIONS:

The observational study revealed a high incidence of SCD among Haitian newborns. Sickle SCAN had excellent specificity and sensitivity to detect SCD during newborn screening and shortened health care access for children positive for SCD.

Reducing Streptococcal Testing in Patients <3 Years Old in an Emergency Department

BACKGROUND:

Although pharyngitis is common, group A Streptococcus is an uncommon etiology, and sequelae are rare in patients <3 years old. Inappropriate testing leads to increased cost of health care and unnecessary exposure to antibiotics. Rapid streptococcal tests (RSTs) for group A Streptococcus pharyngitis are not routinely indicated in this age group. At our urban, tertiary pediatric emergency department (ED), on average, 20 RSTs were performed each month for patients <3 years of age. Our objective was to reduce RSTs in the ED in patients aged <3 years by 50% in 18 months.

METHODS:

We initiated this project in October 2016 at an urban, tertiary pediatric ED. We surveyed pertinent multidisciplinary stakeholders to identify factors leading to RSTs in children <3 years of age. We conducted multiple interventions and collected weekly data on the number of RSTs in children aged <3 years (outcome measure) and the number of family complaints and return visits for complications of pharyngitis (balancing measure). We used statistical process control for analysis.

RESULTS:

The mean number of RSTs ordered per month in patients aged <3 years declined by 52% in 10 months. The majority of tests during the study phase were ordered by nurse practitioners (62%) for patients aged 25 to 36 months (66%). There has been 1 family grievance and no patient complications attributable to the project.

CONCLUSIONS:

Our interventions led to a successful and sustained reduction of RSTs in patients aged <3 years. A local clinical practice guideline was developed, and the project was expanded to other acute care settings.

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