Academic Pediatrics最新文献

Objective: Identify sources of emotional support among caregivers of children with more complex special health care needs (SHCN) and examine their relationships with caregiver emotional well-being.

Methods: Secondary analysis of the 2016-2022 National Survey of Children's Health. We categorized children by degree of medical complexity: no special health care needs (SHCN), less complex SHCN, and more complex SHCN. Our primary outcome was caregivers' self-reported sources of emotional support. Chi-squared testing compared caregivers' sources of emotional support across child medical complexity levels. Adjusted logistic regression analyses then examined the associations between emotional support sources and our secondary outcomes (caregiver-reported mental health, parental coping, and parental aggravation) among caregivers of children with more complex SHCN.

Results: Compared to caregivers of children with no and less complex SHCN, caregivers of more complex SHCN (weighted n=10.1 million) were significantly less likely (p < 0.01) to report receiving emotional support from a spouse/domestic partner (74.9% vs. 78.9-84.5%) and more likely from a healthcare provider (43.3% vs. 27.8-33.1%), mental health professional (30.1% vs. 7.7-10.3%), advocacy group (13.3% vs. 3.0-4.1%), and peer support group (15.4% vs. 12.4-12.7%). Among caregivers of more complex SHCN, emotional support from a family member/close friend, place of worship/religious leader, and peer support group was associated with significantly lower odds of adverse emotional well-being.

Conclusions: Caregivers of children with more complex SHCN report relying on a wide network of emotional support sources. Enhanced care coordination models should include screening for and connecting families to alternative sources of emotional support as central service.

Background: The pediatric workforce has not achieved representation of diversity that reflects the general US population. Data confirm significant underrepresentation of underrepresented in medicine (URIM) trainees in pediatric subspecialty fellowship programs.

Objectives: We aimed to describe: (1) how program directors leverage data regarding applicants' race and ethnicity in the recruitment process; (2) program strategies to recruit a diverse fellowship class; and (3) perceived barriers and facilitators to the recruitment of a diverse fellowship class.

Methods: In collaboration with the Association of Pediatric Program Directors Subspecialty Pediatrics Investigator Network (APPD SPIN), we conducted a national survey of pediatric subspecialty fellowship program directors (FPDs).

Results: With 516 respondents, FPDs overwhelmingly agreed that diversity in subspecialty trainees is important and that it improves patient care. However, race and ethnicity were identified as a top factor influencing the rank list for fewer than 24% of respondents. FPDs employed several strategies to prioritize diversity in recruitment, but none were perceived as effective by more than 40% of respondents. The most prevalent facilitators for recruiting a diverse fellowship class were institutional culture and addressing diversity with applicants. Key barriers included diversity of the applicant pool and institution faculty.

Conclusions: Diversity in pediatric subspecialty fellowship programs is important to FPDs and is thought to improve patient care. Although strategies are being utilized to recruit URIM fellows, FPDs give only modest ratings to their effectiveness.

Introduction: Mistreatment by patients and families is linked to adverse patient outcomes and physician burnout, and particularly affects women and underrepresented in medicine (UIM) physicians. We sought to explore how this source of mistreatment affects trainee professional identity formation (PIF), a key process in the development of altruistic physicians.

Methods: We conducted this multi-institutional qualitative study between May and October 2023 with semi-structured interviews of pediatric residents. We used the constant comparative method consistent with modified grounded theory to analyze data through a lens of Cruess et al's model of PIF in medicine.

Results: We interviewed 32 pediatric residents and identified four primary themes, which we used to develop a conceptual model. 1) Residents identify patient and family-centered care as core to their professional identity, while acknowledging their vulnerability to mistreatment from patients and families. 2) Mistreatment threatens resident PIF through fractured patient-provider relationships, negative impacts on patient care, and decreased psychological safety of the learning environment. 3) Mistreatment that is frequent, unaddressed, and centered around personal traits is particularly damaging to PIF. 4) Residents employ various strategies to mitigate the negative impacts of mistreatment and ultimately deepen their professional identity.

Conclusions: Mistreatment from patients and families negatively affects pediatric resident well-being, learning, and professional identity, with particular impacts on women and UIM residents. Our study informs ways that institutions can best structure support to navigate mistreatment while optimizing trainee learning and PIF, along with patient care.

Objective: We examined the association between in utero cannabis exposure and well child care (WCC) attendance, emergency department (ED) visits, and developmental delay (DD) diagnosis during the first two years of life.

Methods: Infants with a meconium drug screen conducted between April 1, 2014 and April 30, 2022 were identified from Carolina Data Warehouse and linked with NC Medicaid claims to create a merged dataset. Infants were categorized as cannabis-exposed (meconium positive for cannabis only) or substance-unexposed (meconium negative and urine absent/negative for all substances). The primary outcome was WCC attendance; secondary outcomes were ED encounters and DD in the first two years. Negative binomial and logistic regression were used to examine the association between cannabis exposure and outcomes. DD sub-analysis was conducted over three years.

Results: Among 7,240 infants with a meconium screen, 5,448 infants (75%) were linked to Medicaid. There were 1,671 infants with a meconium screen positive for cannabis only and 2,599 infants negative for all substances. No difference in WCC or ED visits was observed between cannabis-exposed and substance-unexposed infants. There was a decrease in the odds of DD in the first 2 years among cannabis exposed infants and no difference at 3 years.

Conclusions: Compared to those unexposed, Medicaid-insured children who were exposed to cannabis in utero have similar WCC attendance and ED use over the first 2 years and similar developmental outcomes at 3 years.

Background: Prior research on confessions of physical abuse (PA) has explored mechanisms of injury. Little is known about conditions supporting a confession of abuse or how confessions may influence case outcomes.

Methods: This cross-sectional study of suspected PA in children age <10 years at 10 centers participating in CAPNET, a multicenter child PA research network, included children with in-person Child Abuse Pediatrics (CAP) consultations between Feb 2021-Dec 2022 and excluded children without injury. Our focus was a confession of inflicted injury known to the CAP during clinical involvement. We compared child and clinical characteristics, out-of-home (OOH) placements, and arrests between cases with and without confessions. Multivariable models using generalized estimating equations (GEE) produced adjusted predicted probabilities (APP) clustering by CAPNET site.

Results: Confessions were known to CAPs in 115/4297 (2.7%) cases, with significant site variability. In a multivariable GEE model, confessions were more likely in cases with injuries with high-specificity for abuse (APP 6.0% vs 1.5%, p<0.001), near-fatality (APP 5.5% vs 2.3%, p<0.001), and older children (APP 4.8% vs 2.5%, p = 0.025). OOH placements and arrests were more common in cases with confessions. CAP awareness of confessions, OOH placements, and arrests did not follow racial or ethnic patterns seen in the US child welfare system. Lower socioeconomic status was associated with OOH placements and arrests but not CAP awareness of confessions.

Conclusions: Our findings highlight differences in case characteristics and outcomes where a confession is known to the CAP and raise questions about agency response based on child characteristics.

Unambiguous federal policy support of accessible public spaces and communications for individuals with disabilities has been in place for 35 years. Rigorous models of accessibility best practices, such as Universal Design (UD) and Human Centered Design, have existed for nearly as long. Despite the Americans with Disabilities Act's clear requirements, health care equity for disabled individuals - a large minority of the population - is still out of reach. Research shows that increasing health care professionals' broader understanding of accessibility best practices for adults is an important step toward creating more welcoming health care settings, yet medical schools continue to exclude disability education from their curriculum, and physicians continue to report discomfort with providing care for all ages of this population. Thoughtful, dignifying best practices in creating and evaluating supportive health care environments for children with disabilities are well documented, but there is little in the literature on tactical steps toward implementation or impact of these adapted environments. This article shows child health care professionals how to apply Universal Design theory to one's everyday practice, beginning with a single patient and her care team.

Objective: Well-child care visits are critical, but time is limited so we sought to better understand preventive care topic coverage and communication dynamics between parents and clinicians during early childhood well-child care visits.

Methods: We audio-recorded 104 well-visits in English and Spanish for children ages 2-24 months. Recordings were coded for content (e.g., feeding, sleep) and communication dynamics (e.g., provider question- asking). Following qualitative analysis, the number of codes for visit content and communication dynamics were calculated for further quantitative analysis. To assess general communication patterns between parents and clinicians, Mann-Whitney U tests were used to determine if the number of communication dynamic episodes differed significantly by parent language, visit length, and content discussed during the visit (e.g., development and behavior).

Results: 39% of visits were conducted in Spanish. Topics most often discussed related to physical health, nutrition, and growth. Instances of clinician and parent information giving happened significantly (p<0.001) more often in English compared to Spanish visits. Longer WCC visits have significantly (p<0.01) more instances of positive report building; visits with positive rapport building are more likely to include discussions related to developmental milestones (p<0.04), as well as parenting experience (p<0.03).

Conclusion: Parent-provider communication dynamics were enhanced when visits lasted over 15 minutes, and when positive rapport building was more frequent. Our findings highlight the importance of adequate time and rapport building during visits to facilitate engagement of parents in meaningful discussions.

Objective: Adverse childhood experiences (ACEs) are associated with poor health and educational outcomes on a population level. School-based health centers (SBHCs) may be uniquely positioned to support youth with ACEs, but little is known about ACEs screening and response in that setting. In this qualitative study, we characterized barriers and facilitators to addressing ACEs in SBHCs from the perspectives of SBHC clinicians.

Methods: We conducted semi-structured interviews with clinicians affiliated with a large public school district in Southern California that had implemented ACEs screening in its SBHCs. Interviews explored attitudes toward and experiences with ACEs screening in SBHCs, as well as differences between screening in SBHCs and other settings. We used a thematic analysis approach, continuing until thematic saturation was reached.

Results: The sample included 10 SBHC clinicians. Six major themes emerged. Three themes were considered opportunities: 1) SBHCs serve as a bridge to care and resources for youth with ACEs, 2) SBHC clinicians are versatile in their approach to addressing ACEs, and 3) structural elements of SBHCs facilitate ACEs screening and response. The remaining three were considered challenges: 1) SBHCs have limited capacity for follow-up for youth with ACEs, 2) providers experience challenges with obtaining accurate ACEs screening results, and 3) responding to ACEs screening is complex.

Conclusions: SBHCs have the potential to support identification and response among youth with ACEs, though challenges remain. Policy and practice recommendations may consider how SBHCs can be leveraged as a unique context to support vulnerable populations at risk of toxic stress.

Objective: Trainee assessments have demonstrated gender and race or ethnicity biases across specialties. Assessment based on the Entrustable Professional Activity(EPA) framework involves assigning a supervision level for the professional activities included in the EPA. We analyzed Clinical Competency Committee (CCC) assigned EPA supervision levels for differences by gender and race or ethnicity among pediatric subspecialty fellows.

Methods: This is a secondary analysis of two de-identified datasets. CCCs provided supervision levels for each fellow for the Pediatric Subspecialty EPAs from fall 2018 through spring 2022. These data were linked to fellows who participated in a well-being study during residency that included their gender, race, and ethnicity. Based on race or ethnicity, fellows were categorized as underrepresented in medicine, Asian, or White. For each EPA, we fitted an ordinal mixed effects model to supervision ratings, with training year, gender, and race category as covariates, adjusting for clustering of ratings within fellow and institution, and multiple comparisons.

Results: Demographic data were linked for 561 fellows. Asian fellows were more likely to receive a lower supervision level for the Consultation EPA compared with White fellows (adjusted odds-ratio 0.48, 95% CI:0.31-0.77). No other significant differences were found among the common Subspecialty EPAs.

Conclusion: EPA-based assessments of pediatric subspecialty fellows demonstrated no differences by gender and a single difference based on race or ethnicity. Given the national trend toward using EPA-based assessments in medical education for health professions, it's reassuring that this first study in pediatric subspecialty fellows demonstrated almost no bias in these assessments.