Pediatrics最新文献

Background and objectives: Health-related social needs (HRSN) affect a wide range of short- and long-term outcomes, health care use, functioning, and quality of life. Although HRSN screening is valuable, it is likely ineffective unless coupled with interventions. This project integrated HRSN screening and intervention(s) across 9 inpatient and outpatient divisions, varied in composition, patient populations, process flows, and resource availability.

Methods: A quality improvement team with a standardized change package facilitated a multimodal initiative for divisions spanning hospital medicine, newborn nurseries, and specialty outpatient clinics at an urban, quaternary pediatric hospital system. We aimed for 80% of patient encounters to be screened for HRSN and that each positive screen receive an agreed upon resource intervention using a centralized resource bank.

Results: From January 2021 to October 2023, 31 834 screenings were conducted across 9 divisions. Performance increased to a mean 92%, with positive screens receiving interventions. The last 7 months of the project were sustained at 92% or higher. Food insecurity was identified in 17.6% of encounters (n = 10 007, 1765 positive), with a 56% decrease in prevalence on repeat screening after identification/intervention.

Conclusions: A centralized quality team and change package can facilitate successful implementation of HRSN screening and connection to resources across multiple disciplines and sites. These interventions may lead to a decrease in subsequent HRSN positivity. Rescreening patients over time is important to capture the full spectrum of HRSN needs of a family.

The effects of armed conflict on children are devastating, with more than 520 million children and adolescents residing in conflict zones worldwide. Armed conflicts not only cause death and destruction but also lead to widespread displacement, exposing children to physical injuries, sexual violence, family separation, food insecurity, and disruption of essential services like education and health care. All pediatricians and health care providers play crucial roles in addressing the complex challenges faced by children in these settings. Pediatric professionals are called to advocate for policy reforms, ensure culturally appropriate, sensitive, and trauma-informed care and community support, and engage in research to mitigate short- and long-term harm and promote resilience. Strategic interventions include ensuring access to health care and mental health services, safeguarding education, and providing bereavement and psychosocial support during and after resettlement. In doing so, pediatricians can help protect children's rights and foster a future where every child, regardless of conflict, has the opportunity to thrive.

Objectives: The objective of this study was to distinguish empirical classes among children with complex chronic conditions (CCCs) and to assess whether such classes can predict future health care use.

Methods: We analyzed claims data from children aged 1 to 18 years with a CCC who were continuously enrolled in a 10-state Medicaid database from 2017 to 2019. We performed a latent class analysis using demographic factors, clinical characteristics, and health care use patterns in 2017 and assessed the ability of the classes to differentiate health care spending and use in 2018 to 2019 using negative binomial and logistic regression.

Results: We included 185 672 children with a CCC (52% male; median [IQR] age: 11 [5, 15] years). Eight indicator variables led to a 3-class solution (entropy = 0.83): Class 1 (9.1% of the cohort) was characterized by high neuro-disability, high technology dependence, and high multimorbidity; Class 2 (14.8%) had high neuro-disability and low technology dependence; and Class 3 (76.0%) had low neuro-disability and low technology dependence. Compared with children in Class 3, total spending in 2017 to 2018 was increased among both Class 1 and Class 2 (total spending rate ratio [RR] 6.9 [95% CI: 6.7-7.0] and RR 2.5 [95% CI: 2.5-2.6], respectively). The largest categories of subsequent spending were for inpatient care and outpatient specialist services among individuals in Class 1 and for outpatient drugs, outpatient specialists, and mental health for those in Class 2.

Conclusions: Children with CCCs can be categorized into meaningful classes based on readily available data with different patterns of future health care use and costs.

Objective: To test the hypothesis that community deprivation, race, and ethnicity lead to decreased likelihood of undergoing hepatoportoenterostomy, older age at surgery, decreased likelihood of achieving successful bile drainage, and lower rates of native liver survival for infants with biliary atresia.

Methods: We analyzed a prospectively enrolled cohort of infants with biliary atresia from the Childhood Liver Disease Research Network (ChiLDReN) that reflects the demographics of the US population. We tested the association between demographic, clinical, and anatomic variables and the probability of undergoing hepatoportoenterostomy, age at surgery, success of surgical intervention, and native liver survival using linear and logistic regression.

Results: Seven hundred nineteen infants with biliary atresia from 15 centers met study inclusion criteria and 672 (93.5%) underwent hepatoportoenterostomy. After adjusting for potential confounders, Asian race (odds ratio [OR] = 0.21, 0.06-0.77), Hispanic ethnicity (OR = 0.33, 0.14-0.76), and community deprivation (0.71 per 0.1 increase, 0.52-0.97) were independently associated with decreased probability of undergoing hepatoportoenterostomy. Each 10% increase in community deprivation increased the age at hepatoportoenterostomy by approximately two-and-one-third days (estimate 2.31; P = .48). Black/African American infants were approximately 9 days older than white infants at the time of operation (estimate 9.19; P = .01), while age at hepatoportoenterostomy (OR = 0.90, P = .01) and successful bile drainage at 3 months (OR = 26.15, P < .01) were independently associated with native liver survival.

Conclusions: Community deprivation, race, and ethnicity are associated with both lower hepatoportoenterostomy rates and older age at the time of operation, whereas clinical and anatomic variables are associated with successful biliary drainage and native liver survival.

Pediatricians play a key role in preparing patients and families for anesthesia and surgery by primarily addressing 2 major areas of concern. The first involves preparation and ensures that the patient is in optimal medical condition for surgery and that the patient and family are emotionally and cognitively ready for surgery. The second category concerns logistics and addresses the necessary communication and prerequisites to enable safe passage through the perioperative process. This revised report updates the recommendations for the pediatrician's role in the perioperative preparation of patients.

Background and objectives: Gaps exist in pediatric primary care office preparedness to care for medical emergencies, and providers often express discomfort in caring for these patients. Collaboration with local academic medical centers (AMCs) improved pediatric preparedness in community emergency departments. Our aims were to improve pediatric emergency preparedness and quality of care in a cohort of pediatric primary care offices using a model of in situ simulation and collaboration with local AMCs.

Methods: This was a multicenter, prospective study that measured emergency preparedness and quality of care in a cohort of pediatric primary care offices partnered with multiple AMCs. The study consisted of 3 phases: baseline assessment, an intervention phase, and follow-up assessment. Emergency preparedness was measured using a checklist derived from existing American Academy of Pediatrics guidelines, and quality of care was measured using in situ simulations of common pediatric outpatient emergencies. After baseline assessment, offices were shown their performance and worked with their local AMC on improvement strategies. Repeat assessment was conducted 6 to 10 months later to measure change.

Results: Twenty-one offices were recruited, with 18 completing both preparedness assessments and 12 completing both in situ simulations. Median preparedness scores improved from 68% to 82% (P = .02). Median performance scores for the respiratory distress and seizure simulations improved from 50% to 82% (P < .001) and 42% to 85% (P < .001), respectively.

Conclusions: Our collaborative approach improved both emergency preparedness and quality of care in a simulated setting in pediatric primary care offices across multiple AMCs. Future work will focus on expansion and long-term effects of this project.

Citrobacter koseri, a facultative gram-negative bacillus, colonizes the intestine and environmental reservoirs. In neonates, especially preterm infants, it can cause severe central nervous system infections (eg, meningitis, encephalitis, abscesses), often with fatal outcomes. Pneumocephalus, an accumulation of intracranial gas, is a rare but deadly complication. We report a preterm female infant admitted to the neonatal intensive care unit (NICU) for respiratory distress who developed high fever and sepsis; blood culture results were positive for C. koseri. Rapid neurological deterioration with seizures occurred, and a cranial computed tomography scan showed extensive pneumocephalus. Despite intensive care, the infant died at 17 days. Autopsy and histology revealed widespread purulent meningitis and meningoencephalitis, pneumocephalus, cerebral hemorrhages, acute edema, and ventricular dilation. An environmental investigation traced the origin of the infection to the bathroom sinks, confirming the nosocomial nature of the pathogen. This case highlights the high virulence of C. koseri in neonates, the catastrophic potential of pneumocephalus, and the crucial importance of strict infection control in NICUs.

Objective: Compared with first-generation antihistamines (FGAs), second-generation antihistamines (SGAs) are equally effective, longer acting, and better tolerated. We aimed to reduce the proportion of patients receiving FGAs among all receiving antihistamines from baselines of 74% in the pediatric emergency department (PED) and 54% in inpatient units by 50% within 6 months and sustain this change for 6 months.

Methods: This multidisciplinary quality improvement initiative was conducted between 2022-2024. Implemented interventions were clinician education, flyers, ensuring cetirizine availability, and clinical pathways updates. The outcome measures were the proportion of patients receiving FGAs (diphenhydramine or hydroxyzine) or SGAs (cetirizine) among all receiving antihistamines. The process measures were educational sessions, knowledge assessments, and clinical pathways usage. The balancing measures were emergency department revisit within 48 hours, median inpatient length of stay, and antihistamine cost. We assessed improvement using statistical process control charts.

Results: The proportion of patients receiving FGAs decreased from 74% to 28% in the PED and from 54% to 36% in inpatient units. Reductions were sustained for 8.5 and 9 months, respectively. Cetirizine use increased from 31% to 75% in the PED and from 54% to 74% in inpatient units. Knowledge scores doubled posteducation. Clinical pathways usage increased from 36 to 44 clinicians monthly. Emergency department revisits and length of stay remained stable. Monthly median antihistamine costs increased in the PED from $53 to $177 and inpatient from $57 to $104.

Conclusions: Using the Model for Improvement, we reduced FGA use and increased cetirizine use in the PED and inpatient setting.