PEDIATRICS recent issues

A Texting Intervention in Latino Families to Reduce ED Use: A Randomized Trial

BACKGROUND AND OBJECTIVES:

Latino children in immigrant families experience health care disparities. Text messaging interventions for this population may address disparities. The objective of this study was to evaluate the impact of a Spanish-language text messaging intervention on infant emergency department use and well care and vaccine adherence.

METHODS:

The Salud al Día intervention, an educational video and interactive text messages throughout the child’s first year of life, was evaluated via randomized controlled trial conducted in an urban, academic pediatric primary care practice from February 2016 to December 2017. Inclusion criteria were publicly insured singleton infant <2 months of age; parent age >18, with Spanish as the preferred health care language; and at least 1 household cellular phone. Primary outcomes were abstracted from the electronic medical record at age 15 months. Intention-to-treat analyses were used.

RESULTS:

A total of 157 parent-child dyads were randomly assigned to Salud al Día (n = 79) or control groups (n = 78). Among all participants, mean parent age was 29.3 years (SD: 6.2 years), mean years in the United States was 7.3 (SD: 5.3 years), and 87% of parents had limited or marginal health literacy. The incidence rate ratio for emergency department use for the control versus intervention group was 1.48 (95% confidence interval: 1.04–2.12). A greater proportion of intervention infants received 2 flu vaccine doses compared with controls (81% vs 67%; P = .04).

CONCLUSIONS:

This Spanish-language text messaging intervention reduced emergency department use and increased flu vaccine receipt among a population at high risk for health care disparities. Tailored text message interventions are a promising method for addressing disparities.

Behavioral Intervention and Disposal of Leftover Opioids: A Randomized Trial

OBJECTIVES:

Leftover prescription opioids pose risks to children and adolescents, yet many parents keep these medications in the home. Our objective in this study was to determine if providing a behavioral disposal method (ie, Nudge) with or without a Scenario-Tailored Opioid Messaging Program (STOMP) (risk-enhancement education) improves parents’ opioid-disposal behavior after their children’s use.

METHODS:

Parents whose children were prescribed a short course of opioids were recruited and randomly assigned to the Nudge or control groups with or without STOMP. Parents completed surveys at baseline and 7 and 14 days. Main outcomes were (1) prompt disposal (ie, immediate disposal of leftovers after use) and (2) planned retention (intention to keep leftovers).

RESULTS:

There were 517 parents who took part, and 93% had leftovers after use. Prompt disposal behavior was higher for parents who received both the STOMP and Nudge interventions (38.5%), Nudge alone (33.3%), or STOMP alone (31%) compared with controls (19.2%; P ≤ .02). Furthermore, the STOMP intervention independently decreased planned retention rates (5.6% vs 12.5% no STOMP; adjusted odds ratio [aOR] 0.40 [95% confidence interval (CI) 0.19–0.85]). Higher risk perception lowered the odds of planned retention (aOR 0.87 [95% CI 0.79–0.96]), whereas parental past opioid misuse increased those odds (aOR 4.44 [95% CI 1.67–11.79]).

CONCLUSIONS:

Providing a disposal method nudged parents to dispose of their children’s leftover opioids promptly after use, whereas STOMP boosted prompt disposal and reduced planned retention. Such strategies can reduce the presence of risky leftover medications in the home and decrease the risks posed to children and adolescents.

Preventing Self-Harm From Repeat Foreign-Body Ingestion

Mental health disorders in adolescents present some of the most challenging of all ethical dilemmas. This is particularly true when they lead to self-injurious behavior that can only be prevented by either limiting the freedom of the adolescent or forcing treatments on them that they do not want. Intentional and repeated foreign-body ingestion (FBI) in youth is a poorly understood self-injurious behavior that can be life-threatening. It poses unique clinical and ethical challenges. Ingestion of sharp or magnetic objects increases the need for endoscopic retrieval or surgical intervention with associated risks, including perforation and anesthesia-related adverse events. When behavior modification efforts fail to prevent recurrent FBI, the cumulative risk of medical intervention mounts. Sometimes, as a last resort, doctors consider surgical procedures that limit jaw movement and may physically prevent recurrent FBI. In this Ethics Rounds article, we present a case in which doctors consider whether it is in the best interest of a teenager with this behavior to undergo orthodontic jaw wiring as a next step in treatment of repeated FBI. Doctor commentary on the ethical decision-making process is provided.

A Framework to Measure and Improve Well-Being in Primary Care

Pediatricians aspire to optimize overall health and development, but there are no comprehensive measures of well-being to guide pediatric primary care redesign. The objective of this article is to describe the Cincinnati Kids Thrive at 5 outcome measure, along with a set of more proximal outcome and process measures, designed to drive system improvement over several years. In this article, we describe a composite measure of "thriving" at age 66 months, using primary care data from the electronic health record. Thriving is defined as immunizations up-to-date, healthy BMI, free of dental pain, normal or corrected vision, normal or corrected hearing, and on track for communication, literacy, and social-emotional milestones. We discuss key considerations and tradeoffs in developing the measure. We then summarize insights from applying this measure to 9544 patients over 3 years. Baseline rates of thriving were 13% when including all patients and 31% when including only patients with complete data available. Interpretation of results was complicated by missing data in 50% of patients and nonindependent success rates among bundle components. There was considerable enthusiasm among other practices and sectors to learn with us and to measure system performance using time-linked trajectories. We learned to present our data in ways that balanced aspirational long-term or multidisciplinary goal-setting with more easily attainable short-term aims. On the basis of our experience with the Thrive at 5 measure, we discuss future directions and place a broader call to action for pediatricians, researchers, policy makers, and communities.

Apps As Learning Tools: A Systematic Review

CONTEXT:

Young children have increasing access to interactive applications (apps) at home and at school. Existing research is clear on the potential dangers of overuse of screens, but there is less clarity around the extent to which interactive apps may be helpful in supporting early learning.

OBJECTIVE:

In this systematic review, we present a narrative synthesis of studies examining whether children <6 years can learn from interactive apps.

DATA SOURCES:

The PsycInfo, PubMed, ACM Digital Library, and ERIC databases were searched.

STUDY SELECTION:

Studies were included if the study design was randomized or nonrandomized controlled (quasi-experimental), the sample mean age was <6 years, the intervention involved children playing with an interactive app, and academic, cognitive, or social-emotional skill outcomes were measured.

DATA EXTRACTION:

Of 1447 studies, 35 were included.

RESULTS:

Evidence of a learning benefit of interactive app use for early academic skills was found across multiple studies, particularly for early mathematics learning in typically developing children. Researchers did not find evidence of an intervention effect for apps aiming to improve social communication skills in children with autism spectrum disorder.

LIMITATIONS:

Risk of bias was unclear for many studies because of inadequate reporting. Studies were highly heterogenous in interventions, outcomes, and study design, making comparisons of results across studies difficult.

CONCLUSIONS:

There is emerging evidence to suggest that interactive apps may be useful and accessible tools for supporting early academic development. More research is needed to evaluate both the potential of educational apps to support early learning, and their limitations.

Intranasal Dexmedetomidine for Procedural Distress in Children: A Systematic Review

CONTEXT:

Intranasal dexmedetomidine (IND) is an emerging agent for procedural distress in children.

OBJECTIVE:

To explore the effectiveness of IND for procedural distress in children.

DATA SOURCES:

We performed electronic searches of Medline (1946–2019), Embase (1980–2019), Google Scholar (2019), Cumulative Index to Nursing and Allied Health Literature (1981–2019), and Cochrane Central Register.

STUDY SELECTION:

We included randomized trials of IND for procedures in children.

DATA EXTRACTION:

Methodologic quality of evidence was evaluated by using the Cochrane Collaboration’s risk of bias tool and the Grading of Recommendations Assessment, Development, and Evaluation system, respectively. The primary outcome was the proportion of participants with adequate sedation.

RESULTS:

Among 19 trials (N = 2137), IND was superior to oral chloral hydrate (3 trials), oral midazolam (1 trial), intranasal midazolam (1 trial), and oral dexmedetomidine (1 trial). IND was equivalent to oral chloral hydrate (2 trials), intranasal midazolam (2 trials), and intranasal ketamine (3 trials). IND was inferior to oral ketamine and a combination of IND plus oral ketamine (1 trial). Higher doses of IND were superior to lower doses (4 trials). Adverse effects were reported in 67 of 727 (9.2%) participants in the IND versus 98 of 591 (16.6%) in the comparator group. There were no reports of adverse events requiring resuscitative measures.

LIMITATIONS:

The adequacy of sedation was subjective, which possibly led to biased outcome reporting.

CONCLUSIONS:

Given the methodologic limitations of included trials, IND is likely more effective at sedating children compared to oral chloral hydrate and oral midazolam. However, this must be weighed against the potential for adverse cardiovascular effects.

Successful Use of Cidofovir in an Immunocompetent Child With Severe Adenoviral Sepsis

Adenovirus infection is common in childhood and is generally associated with self-limited disease. Cidofovir, a viral DNA polymerase inhibitor, is used to treat adenovirus infection in select populations but is not often recommended for immunocompetent patients because of limited antiviral activity and nephrotoxicity. Here, we report a case of fulminant adenovirus infection associated with lymphopenia and multiple organ failure requiring extracorporeal membrane oxygenation support in a previously healthy child. After 1 week of supportive therapy, the patient had persistent organ failure and continued to have adenoviremia of >560 000 copies per mL. Weekly doses of cidofovir with concurrent probenecid for renal protection was initiated. Adenovirus blood load declined after the first cidofovir dose, becoming undetectable after 3 doses. The patient was successfully decannulated from extracorporeal membrane oxygenation, extubated, and eventually discharged at his functional baseline without need for ongoing respiratory support. Lymphopenia improved after viremia resolved, and a subsequent immunologic workup revealed no evidence of primary immunodeficiency. The viral isolate was genotyped as adenovirus type 7. This case reveals the successful use of cidofovir for management of severe adenovirus infection in a previously healthy child. To date, there are no universally accepted recommendations for the use of cidofovir in this population. Further study is warranted to determine the potential role of cidofovir in treating severe adenovirus infections in immunocompetent children.

Distinct Populations of Sudden Unexpected Infant Death Based on Age

OBJECTIVES:

In most recent studies, authors combine all cases of sudden infant death syndrome, other deaths from ill-defined or unknown causes, and accidental suffocation and strangulation in bed as a single population to analyze sudden unexpected infant death (SUID). Our aim with this study is to determine if there are statistically different subcategories of SUID that are based on the age of death of an infant.

METHODS:

In this retrospective, cross-sectional analysis, we analyzed the Centers for Disease Control and Prevention Birth Cohort Linked Birth/Infant Death Data Set (2003–2013: 41 125 233 births and 37 624 SUIDs). Logistic regression models were developed to identify subpopulations of SUID cases by age of death, and we subsequently analyzed the effects of a set of covariates on each group.

RESULTS:

Two groups were identified: sudden unexpected early neonatal deaths (SUENDs; days 0–6) and postperinatal SUIDs (days 7–364). These groups significantly differed in the distributions of assigned International Classification of Diseases, 10th Revision code, live birth order, marital status, age of mother, birth weight, and gestational length compared to postperinatal SUIDs (days 7–364). Maternal smoking during pregnancy was not a significant risk factor for deaths that occurred in the first 48 hours.

CONCLUSIONS:

SUEND should be considered as a discrete entity from postperinatal SUID in future studies. These data could help improve the epidemiological understanding of SUEND and SUID and provide clues to a mechanistic understanding underlying the causes of death.

Global Health Experience and Interest: Results From the AAP Periodic Survey

BACKGROUND:

Interest and participation in global health (GH) experiences have increased over the past 30 years in both medical schools and residencies, but little is known at the level of practicing pediatricians.

METHODS:

Data were compared from the American Academy of Pediatrics Periodic Surveys conducted in 1989 and 2017. The surveys had a response rate of 70.8% in 1989 and 46.7% in 2017. There were 638 and 668 postresidency pediatricians in the 1989 and 2017 surveys, respectively. Descriptive analyses were performed to look at changes in experience and interest in GH. A multivariable logistic regression was conducted specifically looking at characteristics associated with interest in participating in GH experiences in the next 3 years.

RESULTS:

Pediatrician participation in GH experiences increased from 2.2% in 1989 to 5.1% in 2017, with statistically significant increases in pediatricians ≥50 years of age. Interest in participating in future GH experiences increased from 25.2% in 1989 to 31.7% in 2017, with a particular preference for short-term clinical opportunities. In the multivariable logistic regression model, the year 2017 was associated with an increased interest in future GH experience, especially in medical school, hospital or clinic practice settings, as well as among subspecialists.

CONCLUSIONS:

Over the past 28 years, practicing pediatricians have increased their involvement in GH, and they are more interested in future GH experiences. The focus is on short-term opportunities. Our study reveals that practicing pediatricians mirror medical trainees in their growing interest and participation in GH.

Car Seat Tolerance Screening for Late-Preterm Infants

BACKGROUND:

The belief that late-preterm infants have similar cardiorespiratory maturity to term infants has led many institutions to limit car seat tolerance screens (CSTSs) to those born early preterm. The objective of this study was to evaluate the incidence and predictors of CSTS failure, focusing on late-preterm infants.

METHODS:

We performed a retrospective review of late-preterm infants born from 2013 to 2017 to identify the incidence and predictors of CSTS failure, focusing on location of admission. We performed multivariable linear regression to assess the effect of CSTS results on length of stay (LOS).

RESULTS:

We identified 918 subjects who underwent CSTSs, of whom 4.6% failed. Those infants who were admitted to both the NICU and nursery before discharge had the highest failure rate (8.5%). Of those who failed, 24% failed ≥2 CSTSs. Of these, 20% (all from the nursery) were found to have obstructive apnea and desaturations, and a total of 40% required supplemental oxygen for safe discharge from the hospital. Although crude LOS was longer for those who failed an initial CSTS, when accounting for location of admission, level of prematurity, and respiratory support requirements, the CSTS result was not a significant predictor of longer LOS.

CONCLUSIONS:

A concerning number of late-preterm infants demonstrated unstable respiratory status when placed in their car seat. Those who failed repeat CSTSs frequently had underlying respiratory morbidities that required escalation of care. Although further study is warranted, LOS was not associated with CSTS results but rather with the cardiorespiratory immaturity noted or discovered by performing a CSTS.

Cardiopulmonary Bypass and Infant Vaccination Titers

BACKGROUND:

Infants with congenital heart disease remain vulnerable to potentially preventable pathogens. Although immunization can significantly reduce this risk, it is unknown how immunization status can be affected by cardiac surgery with cardiopulmonary bypass (CPB). The objective was to evaluate the effect of CPB on infant vaccination status after cardiac surgery.

METHODS:

We conducted a prospective observational study of patients between 2 and 14 months of age who had received at least their first round of infant vaccinations and who required cardiac surgery with CPB. Antibody titers were measured before CPB and again the following morning. Demographic and surgical variables were assessed via regression methods for their effects on the change in titers.

RESULTS:

Among the 98 patients followed, there was no demonstrated difference between the pre- and postoperative values in regard to diphtheria, tetanus, polio 1, polio 3, or Haemophilus influenzae titers. Bordetella (1.03 vs 0.84, P < .001), and hepatitis B (log 2.10 vs 1.89, P = .001) titers did reduce after CPB but did not fall below the immunized threshold. Changes in antibody titers were not associated with time between immunization and surgery, age or weight at surgery, blood products administered, number of previous doses, time on CPB, or heterotaxy diagnosis for most of the vaccines.

CONCLUSIONS:

Infant vaccine antibody titers were minimally affected by CPB and not associated with any easily modifiable surgical variables. Although antibody titers are only 1 marker of immunity, deviation from the recommended vaccination schedule may be unnecessary for children requiring congenital heart surgery.

Response to Suffering of the Seriously Ill Child: A History of Palliative Care for Children

Most pediatric clinicians aspire to promote the physical, emotional, and developmental well-being of children, hoping to bestow a long and healthy life. Yet, some infants, children, and adolescents confront life-threatening illnesses and life-shortening conditions. Over the past 70 years, the clinician’s response to the suffering of these children has evolved from veritable neglect to the development of pediatric palliative care as a subspecialty devoted to their care. In this article, we review the history of how clinicians have understood and responded to the suffering of children with serious illnesses, highlighting how an initially narrow focus on anxiety eventually transformed into a holistic, multidimensional awareness of suffering. Through this transition, and influenced by the adult hospice movement, pediatric palliative care emerged as a new discipline. Becoming a discipline, however, has not been a panacea. We conclude by highlighting challenges remaining for the next generation of pediatric palliative care professionals to address.

PrEP and Adolescents: The Role of Providers in Ending the AIDS Epidemic

Surveillance data on high school adolescent sexual activity, including teenaged pregnancy rates and incidence of sexually transmitted infections (STIs), require pediatricians and other youth providers to be competent and confident in addressing sexual and reproductive health care needs in adolescent and/or young adult populations. The American Academy of Pediatrics has published guidelines, recommendations, clinical reports, and resources on the promotion of healthy sexual development in clinical settings, encouraging sexual health assessments that are inclusive of HIV and STI testing as an integral component of comprehensive health visits. The need for a more determined effort to address sexual health as it relates to HIV specifically is evidenced by a decrease in the number of in-school youth reporting ever being tested, 15- to 24-year-olds representing 21% of new infections, and estimates that >40% of youth with HIV are undiagnosed. Ending the HIV epidemic requires adherence to published HIV testing recommendations, sexual health assessments, screening for STIs, and appropriate primary and secondary prevention education. Preexposure prophylaxis, an efficacious biomedical prevention intervention for reducing HIV acquisition, was approved in July 2012 and in May 2018 was authorized for use in minors. This state-of-the-art review article provides background information on preexposure prophylaxis, current guidelines and recommendations for use, and strategies to introduce and implement this valuable HIV prevention method in clinical practice with adolescents and young adults.

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