Academic Pediatrics最新文献

Background and objectives: Suicide risk identified via universal screening in healthcare settings is associated with subsequent suicidal behavior and is an important prevention strategy. The prevalence of positive suicide risk screening among transgender and gender diverse (TGD) youth in the emergency department (ED) has not been described. The current study examined the association between gender identity and suicide risk screening results, adjusted for other demographic and clinical characteristics.

Methods: Retrospective cross-sectional study of electronic medical record data from ED visits November 2019-August 2022 in an urban academic children's hospital. Participants were youth ages 8-25 who received the Ask Suicide-Screening Questions suicide risk screening tool.

Results: Of 12,112 ED visits with suicide risk screening performed (42% male, median age 14 [12, 16]), 24% had positive screens. Of 565 visits by TGD youth, 78.1% had positive screens and 9.5% had active suicidal ideation. Compared to visits by cisgender females, the adjusted odds of positive screens was 5.35 times higher (95% CI 3.99, 7.18) among visits by TGD youth and 0.45 times lower (95% CI 0.40, 0.52) among visits by cisgender males. Compared to visits by cisgender females, the adjusted odds of active suicidal ideation was higher for cisgender males (aOR 1.34, 95% CI 1.07, 1.68) but did not significantly differ for TGD youth.

Conclusions: TGD youth have high rates of positive suicide risk screening in the ED, demonstrating substantial mental health needs. Opportunities may be available to improve detection, evidence-based brief interventions, and linkage to mental health services for this population.

Objective: Our objectives were to evaluate for any cluster patterns of youth suicide deaths and characterize the level of child opportunity in the communities where suicide deaths occurred.

Methods: Decedents <18 years were identified from San Diego County Medical Examiner death reports from 2000-2020. We mapped decedents' residential ZIP codes and calculated suicide rates per 10,000 youths. ZIP codes identified in overlapping spatial statistical approaches - the spatial scan statistic and Local Moran with EB rates - were considered a cluster for the final analysis. We obtained Child Opportunity Index (COI) scores for each ZIP code to determine if there were differences in: 1) ZIP codes with suicide deaths compared to ZIPs with no deaths 2) differences in distribution of suicide death rates across quintiles of COI.

Results: Scan statistic identified 25 ZIP codes within a cluster (RR 2.6, p = 0.00066). Local Moran with EB rates identified two ZIP codes as a high-high cluster (p < 0.05). The location identified as a cluster in both approaches was in Alpine. The median COI for ZIP codes with suicide deaths was higher at 63.5 (IQR 38-83) compared to 47 (IQR 22.5-75.5) for ZIP codes without suicide deaths. There was a significant difference in suicide rates between Very Low and Moderate levels of Overall opportunity (p =.013).

Conclusion: We identified a cluster of youth suicides in one of the most populous counties in the country. These findings serve to inform policies and prevention programs that aim to mitigate youth suicide mortality.

Objective: To evaluate how social behaviors relate to SARS-CoV-2 test positivity across pediatric age groups.

Methods: Multicenter, cross-sectional study recruiting children <18 years old tested for SARS-CoV-2 infection in emergency departments between 2020 and 2022. We used multivariate logistic regression to assess how self-reported social behaviors affect SARS-CoV-2 test positivity across four age groups. Causal mediation analysis quantified how mask-wearing and presence of an infected close contact mediated the SARS-CoV-2 risk of given behaviors.

Results: 7272 children were enrolled and 1457 (20.0%) tested positive for SARS-CoV-2. Attending a social gathering was associated with increased odds (aOR 1.64, 95%CI: 1.05, 2.57) of SARS-CoV-2 positivity among children aged 5-<12 years. Those attending in-person school/daycare were less likely to test positive for SARS-CoV-2 across all age categories. Attending childcare was associated with 16.3% (95%CI: -21.0%, -11.2%) and 9.0% (95%CI: -11.6%, -6.5%) reductions in the probability of testing positive for SARS-CoV-2 infection, with 53.5% (95%CI: 39.2%, 73.9%) and 22.8% (95%CI: 9.7%, 36.2%) of the effects being mediated by the presence of a close contact among <1 year and 1-<5 year age groups, respectively. Masking in public mediated the association between childcare attendance and SARS-CoV-2 positivity in children aged <1 year.

Conclusions: Attending social gatherings increased the risk of SARS-CoV-2 test positivity in 5-<12-year-old children, but in-person daycare/school was associated with a reduced odds of testing positive across all ages. Settings with high public health adherence (i.e., schools) reduced the risk of testing positive for SARS-CoV-2, possibly from reduced close contact with SARS-CoV-2 positive individuals.

Objective: To determine the association of patient race, patient-provider racial congruence, patient ethnicity, and family primary language with patient family experience (PFE) survey responses.

Methods: Cross-sectional review of PFE survey responses from all ambulatory medical encounters at a large, urban children's hospital system June 1, 2020-May 31, 2022. Exposures were patient race, patient-provider racial congruence, patient ethnicity, and family primary language. We adjusted analyses for neighborhood-level socioeconomic deprivation, patient sex and age, encounter specialty, and location of care. Outcomes were PFE survey scores for 5 questions focused on overall experience, respect, and safety; categorized using industry standard metric of presence of a "top-box" score, defined as a 9 or 10 for questions on an 11-point scale or as 4 on a 4-point scale.

Results: We included 89,175 surveys (15.6% response rate). The odds of having optimal, "top-box" responses for several assessed questions were lower for patients identified as Asian (e.g., adjusted odds ratio [OR] 0.46; 95% confidence interval [CI] 0.40, 0.52) or Black (e.g., OR 0.65; CI 0.60, 0.70) compared to White, and for Hispanic (e.g., OR 0.84; CI 0.72, 0.97) compared to non-Hispanic. Similarly, the odds of having "top-box" scores were lower for Spanish-primary-language (e.g., OR 0.38; CI 0.30, 0.48) compared to English-primary-language patients. Patient-provider racial congruence had higher odds of "top-box" responses for 2 of 5 assessed questions (e.g., OR 1.18; CI 1.04, 1.35).

Conclusions: We found previously unreported inequities in ambulatory pediatric PFE outcomes, with worse experiences reported by Asian, Black, Hispanic, and Spanish-language patients.

Objective: To describe the use of primary care telehealth following rapid reduction of in-person pediatric primary care availability during the SARS-CoV-2 pandemic and how this varied by community-level social determinants and individual-level social needs.

Methods: We conducted a retrospective cohort study of children 0-17 years across 16 sites within Nationwide Children's Hospital Primary Care Network from March 22^nd-July 31^st, 2020, and a preceding comparator period (2019). The study population includes 107,629 patient encounters. We compared visit type (in-person vs. telehealth), demographics, presence of individual social needs, and community social determinants, using the Child Opportunity Index 2.0 (COI). To assess telehealth utilization, we compared the ratio of 2019 to 2020 primary care visits across levels of COI. We trained a linear regression model predicting the number of telehealth encounters in 2020 using individual patient characteristics and COI.

Results: Patients in census tracts with high and very high levels of opportunity maintained the highest relative encounter volume (2020:2019) at the beginning of the pandemic (0.78 and 0.73, respectively, compared to 65% for children living in very low opportunity neighborhoods; p<0.001). Patients with caregiver-reported social needs (housing, transportation, utilities, food) had relatively greater telehealth use following the start of the public health emergency.

Conclusions: Volume of primary care visits decreased least for high and very high opportunity neighborhoods yet individual social needs were associated with higher relative use of telemedicine. Findings suggest that telehealth was an important modality to deliver care to children with social needs but does not overcome community level barriers.

Objective: To determine whether anxiety and depression symptoms are mechanisms through which adverse childhood experiences (ACEs) contribute toward persistent/recurrent pain (PRP) across early adolescence.

Methods: This study described the direct and indirect (i.e. mediated) effects of ACEs on PRP across early adolescence, using four years of Adolescent Brain Cognitive Development Study® data. Annual pain frequency, anxiety, and depression symptoms were measured using the Child Behavior Checklist, and youth with pain for ≥3 of the 4-year study period were classified with PRP. Early (up to age 9-10 years; reported at baseline) and recent (at age 10-11 years; reported at year 1) ACE exposures were derived from parent and youth completed surveys. Structural equation modeling estimated the direct and indirect associations among early and recent ACEs, pain outcomes, and anxiety/depression symptoms reported in the year(s) in between.

Results: Among 7,951 youth, 2,540 (31.9%) were classified with PRP. Higher levels of early ACE exposure were associated with an increased probability of having PRP (adj.β 0.65 (95% Confidence Interval [CI] 0.07, 1.22). Early ACEs also had indirect effects on PRP via higher interim anxiety (adj. β 5.36 [95% CI 3.45, 7.26]) and depression symptoms (adj. β 4.57 [95% CI 3.01, 6.13]). Early and recent ACE exposures predicted higher pain frequency scores in subsequent years, with mixed results regarding the role of anxiety and depression in the relationships between ACEs and pain frequency scores.

Conclusion: Anxiety and depression symptoms are potentially important interventional targets to lower the risk for PRP among youth exposed to ACEs.

Objective: To qualitatively understand and characterize the experience of racism in outpatient pediatric healthcare settings from the perspectives of Black families.

Methods: We conducted focus groups with parents or guardians of Black children, recruited from academic primary care offices at a single pediatric institution. Focus groups were facilitated virtually by Black team members using an open-ended, semi-structured focus group guide. We analyzed focus group transcripts using iterative, thematic, inductive open coding performed independently by trained coders, with final codes reached by group consensus.

Results: We conducted 6 focus groups of 3 to 5 participants each and 1 individual interview, with 24 total parents. We identified the following themes: 1)"I just felt like we was a number": Black families perceived experiences which felt impersonal and lacked empathy; 2)"Why is the doctor treating me like I don't matter?": Black families perceived experiences with poor care, worse treatment; 3)Black families experience racism across socioecological levels when interacting with pediatric health systems; 4)Positive perceived experiences can guide improvement; and 5)Improvement will require antiracist efforts across the levels of racism.

Conclusions: In this qualitative study, we found that Black families have had many poor pediatric experiences, perceive racism as affecting child health broadly across socioecological levels, and recommend a multidimensional antiracist approach to improvement. Our findings underscore the importance of elevating Black family voices in developing policies that prioritize antiracism and work to eliminate the harmful impacts of racism on child health.

Objective: To assess whether child food allergy is associated with family food insecurity, overall, and across different income levels.

Methods: We used the 2011-2018 National Health Interview Survey, a nationally representative cross-sectional survey. The exposure was child food allergy, and our main outcome was odds of family food insecurity, which was calculated using multivariable logistic regression models adjusted for child demographics, family characteristics and survey year. We examined for effect modification by the ratio of family income to the poverty threshold using stratification and tests for statistical interaction.

Results: Among 83,287 children 6% had food allergy and 22% experienced family food insecurity. Child food allergy was associated with a 1.39-fold (95% confidence interval [CI]: 1.26, 1.53) increased odds of family food insecurity overall. Child food allergy was associated with a 1.46-fold (95% CI: 1.29, 1.66) increased odds of family food insecurity among children whose families lived below 200% of the federal poverty level, and a 1.26-fold (95% CI: 1.05, 1.51) increased odds of family food insecurity among children whose families lived at 200 to 399% of the federal poverty level, with no association among children whose families lived at or above 400% of the federal poverty level (P =.04 for interaction).

Conclusion: There is an association between child food allergy and family food insecurity, and this association is modified by the ratio of family income to the poverty threshold. Improved availability and subsidy of allergen-free foods in nutrition assistance programs and food pantries are urgently needed.