American Academy Of Pediatrics Guidelines Research Articles

43 The Prevalence of Serious Bacterial Infections in Infants less than 90 Days with and without Features of a Viral Infection: A Retrospective Cohort Study

Abstract Primary Subject area Emergency Medicine - Paediatric Background Prior studies suggest the prevalence of serious bacterial infections (SBI) (i.e., urinary tract infection [UTI], bacteremia, or meningitis) is lower in infants with a viral infection compared to those with fever without a source (FWS) (2-3% vs. 10-15%). Objectives To determine the difference in proportion of SBI in infants with and without clinical features of a viral infection. Design/Methods A retrospective cohort study was done on a consecutive sample of infants ≤ 90 days seen at a pediatric ED over a 5-year period ending August 30, 2019. Eligible subjects had rectal temperatures ≥ 38°C, and had ≥ 1 screening test for SBI (urine, blood and/or cerebrospinal fluid cultures). Excluded were infants who received antibiotics in the past 7 days, had congenital anomalies, required intensive care, or were preterm. We defined a clinical viral infection as > 1 clinical features of a respiratory viral infection (new-onset sneezing, cough, rhinorrhea, or shortness of breath). UTI was defined as per American Academy of Pediatrics guidelines. Results We screened 7021 charts and 885 (12%) were eligible. Of these, 498 (56%) had a clinical viral infection and 387 (44%) did not. Blood and urine cultures were collected from 860 (97%) infants and 308 (35%) had a lumbar puncture. Overall, 84 (10%) infants had an SBI: 76 (9%) UTI, 6 (0.7%) isolated bacteremia, and 2 (0.2%) meningitis. Among those with clinical viral infection, 23 (5%) had SBI, compared to 61 (16%) without viral infection (risk difference [RD] 11%, 95% CI [7%, 15%]). Both cases of meningitis occurred in infants ≤28 days and without any viral symptoms. A logistic regression was done to ascertain the effects of clinical viral infection, known risk factors for sepsis, age ≤ 28 days, or a temperature ≥ 39°C on the likelihood of SBI. Of the 4 predictors, only clinical viral infection and the presence of known risk factors for sepsis were significantly associated with SBI (odds ratio [OR] 0.3, 95% CI [0.17, 0.48] and 2.5, 95% CI [1.4, 4.5], respectively). Proportions of contaminated blood culture and urine culture were 5% (95% CI [4%, 7%]) and 14% (95% CI [12%, 17%]), respectively. Conclusion SBI prevalence in infants without features of a viral infection on assessment is triple that of infants with viral symptoms. Contaminant blood and urine cultures are folds higher than true pathological cultures. Future research is needed to identify infants at low risk of SBI without invasive testing.

Understanding the Obstacles and Influences in Adopting Infant Safe Sleep Practices

Background About 3,500 infants die annually within their first year of life from Sudden Unexplained Infant Death (SUID) and its subset Sudden Infants Death Syndrome (SIDS), making it the single leading cause of infant mortality in the U.S. Evidence indicates adherence to infant Safe Sleep Guidelines developed by the American Academy of Pediatrics (AAP) reduces these mortality rates. Still, since an initial decline following the 1994 guidelines introduction, SIDS rates have leveled, and SUID rates have increased. In addition, SUID rates per 100,000 live births are twice as high among Black and Native American infants than white. The AAP last updated the guidelines in 2016 and is scheduled to issue the next updated guidelines in late 2021. Objective To examine perceptions of the AAP guidelines held by parents and health care providers as they relate to guidelines comprehension and compliance, and to share this information with the AAP 2021 guidelines task force. Methods First Candle commissioned a qualitative research study in 2020, consisting of three online focus groups in three different states to identify perceptions and potential barriers to guidelines adoption by family members and providers, the outcomes of which were shared with the AAP for review as its guidelines task force develops the updated version to be released in 2021. Results Regarding how the AAP guidelines were viewed, there were responses across geographic and sociocultural variation regarding varying levels of general comprehension and trust in them, depending on the resource and acceptance of the language used. Additional factors were the emotional and practical realities of parenting, cultural and family traditions, and the belief that parental volition in decision-making is important. Conclusion Evidence-based protocols regarding infant safe sleep practices and their impact on reducing infant mortality rates may have proven value. Still, professional caregivers and family members feel that more cultural context and personal relevance are needed in presentation and communication if families are to trust and consider them for adoption and compliance.

Early diagnosis of autism in the community is associated with marked improvement in social symptoms within 1-2 years.

It is widely believed that early diagnosis and treatment of autism spectrum disorder is essential for better outcome. This is demonstrated by the American Academy of Pediatrics recommendation to screen all 1.5–2.5-year-old toddlers for autism spectrum disorder. However, multiple longitudinal studies of children diagnosed with autism spectrum disorder at 1.5–6 years of age and treated in community settings have not reported any associations between earlier diagnosis and improved outcome in core symptoms. Here, we quantified Longitudinal changes in core autism spectrum disorder symptoms of 131 children diagnosed at 1.2–5 years of age using the Autism Diagnostic Observation Schedule–Second Edition Calibrated Severity Scores over a 1-2 year period. We examined the prevalence and magnitude of Calibrated Severity Scores changes across children who were diagnosed at different ages. The results revealed that age of diagnosis was significantly correlated with poorer outcome (r(129) = 0.41, p < 0.001). Approximately 65% of the children diagnosed before 2.5 years of age exhibited improvements in Autism Diagnostic Observation Schedule–Second Edition Calibrated Severity Scores (⩾2 points) in contrast to only 23% of the children diagnosed after this age. Changes in younger children were driven by improvements in social symptoms despite deterioration in restricted and repetitive behaviors. These findings reveal that autism spectrum disorder diagnosis before the age of 2.5 is associated with considerable improvement in social symptoms. We suggest that greater brain plasticity and behavioral flexibility enable younger children to benefit more from autism spectrum disorder interventions even in community settings with heterogeneous services. This motivates further prioritization of early autism spectrum disorder screening as recommended by American Academy of Pediatrics guidelines.Lay abstractIt is widely believed that early diagnosis and treatment of autism spectrum disorder is essential for better outcome. This is demonstrated by the American Academy of Pediatrics recommendation to screen all 1.5–2.5-year-old toddlers for autism spectrum disorder. However, multiple longitudinal studies of children diagnosed with autism spectrum disorder at 1.5–6 years of age and treated in community settings have not reported any associations between earlier diagnosis and improved outcome in core autism spectrum disorder symptoms. In this study, we measured changes in core autism spectrum disorder symptoms over a 1–2-year period in 131 children diagnosed with autism spectrum disorder at 1.2–5 years of age, and treated in the community. The results revealed that children who were diagnosed before 2.5 years of age were three times more likely to exhibit considerable improvements in social autism spectrum disorder symptoms in comparison to children diagnosed at later ages. These results highlight the importance of early diagnosis and treatment of autism spectrum disorder even in community settings with heterogeneous services. In addition, these results motivate further prioritization of universal screening for autism spectrum disorder before 2.5 years of age.

Differences in Blood Pressure Levels Among Children by Sociodemographic Status.

IntroductionThe American Academy of Pediatrics (AAP) updated its blood pressure (BP) screening guidelines in 2017 to emphasize body weight as a risk factor. We provide contemporary, nationally representative estimates of prevalence of elevated and hypertensive BP among US children and examine sociodemographic prevalence differences, accounting for the influence of weight.MethodsWe used cross-sectional data from children aged 8 to 17 years (N = 5,971; weighted N = 36,612,323) collected from 2011 through 2018 in 4 biennial cycles of the National Health and Nutrition Examination Survey (NHANES). Children’s BP was categorized as normal, elevated, or hypertensive. Sociodemographic characteristics included were sex, age, race/ethnicity, family income, and education. Log binomial regression, with and without adjustment for weight (dichotomized at the 85th body mass index percentile), determined prevalence estimates and differences for elevated and hypertensive BPs with 95% CIs.ResultsIn NHANES data collected from 2011 through 2018, 7.2% (95% CI, 6.3%–8.3%) of US children had elevated BP, and 3.8% (95% CI, 3.3%–4.5%) had hypertensive BP according to 2017 AAP guidelines. Differences in prevalence of weight-adjusted elevated BP indicated higher prevalence among children aged 16 to 17 years compared with children aged 8 to 9 years (prevalence difference, +6.3%; 95% CI, 3.2%–9.4%), among males compared with females (+4.6%; 95% CI, 2.7%–6.4%), and among non-Latino Black children compared with non-Latino White children (+4.0%; 95% CI, 2.2%–5.8%). Crude hypertensive BP prevalence was highest among children aged 8 to 9 years, male children, and Mexican American children. The only difference remaining after weight adjustment was among children aged 8 to 9 years and 13 to 15 years.ConclusionElevated BP was most prevalent among US children who were older, male, or non-Latino Black. Factors beyond inequalities in body weight may contribute to disparities in elevated BP.

Comparison of the 2017 American Academy of Pediatrics with the fourth report and the 2016 European Society of Hypertension guidelines for the diagnosis of hypertension and the detection of left ventricular hypertrophy in children and adolescents: a systematic review and meta-analysis.

In 2017, the American Academy of Pediatrics (AAP) recommended new blood pressure (BP) thresholds for the diagnosis of hypertension in children and adolescents. We assessed the impact of the AAP guideline, as compared to the Fourth Report and the 2016 European Society of Hypertension guidelines (ESH), on the prevalence of hypertension and the detection of left ventricular hypertrophy (LVH). We systematically searched for studies evaluating the impact of the 2017 AAP guidelines on the prevalence of hypertension and LVH compared with the Fourth Report or the 2016 ESH guidelines. Meta-analysis was performed to compare the overall risk of LVH between the guidelines. We used a random-effects model to synthesize quantitative data. We included 18 observational studies in the systematic review with an overall moderate to high risk of bias. The AAP guideline identified more children with hypertension than the Fourth Report and the ESH guidelines. In the meta-analysis of three observational studies, the guidelines revealed similar associations with LVH [odds ratio (OR) = 3.89, 95% confidence interval (95% CI) 1.68-8.99 for AAP and OR = 3.19, 95% CI 1.14-8.88 for Fourth Report/ESH guidelines]. Qualitative analysis of two observational studies revealed similar predictive value of the guidelines for LVH in adult life. Despite the higher prevalence of hypertension frequently reported by the adoption of AAP guideline BP thresholds compared with Fourth Report and the ESH guidelines, the new thresholds have not been proved to advance assessment of cardiovascular risk in terms of LVH currently the most accepted subclinical marker in youth.

Initiative to Reduce Antibiotic Exposure of Asymptomatic Infants Born to Mothers with Intraamniotic Infection.

Introduction:Infants born to mothers with intraamniotic infection (IAI) received antibiotic treatment per the Centers for Disease Control and Prevention and American Academy of Pediatrics guidelines in our neonatal intensive care unit (NICU) for early-onset bacterial sepsis evaluation. We conducted a quality improvement project to decrease antibiotic use and NICU admission in infants born to mothers with IAI.Methods:We aimed to decrease the antibiotic exposure for asymptomatic infants born to mothers with IAI from 100% to 20% in 6 months. We obtained baseline data on these infants from January 2018 to January 2019, with the intervention starting in February 2019. A new standardized guideline to clinically monitor and follow laboratories on asymptomatic infants in couplet care was created with a multidisciplinary team’s help and implemented after provider education. The team reviewed data monthly and used PDSA cycles to make necessary changes, including updating order sets, more educational handouts, and real-time coaching to both nurses and physicians.Results:There was a dramatic decline (93%–0%) in antibiotic exposure and NICU admission after implementing this guideline. There was also a decrease in IAI diagnosis. There were no readmissions of infants for infection within 30 days of discharge, and there were no positive blood cultures.Conclusions:Implementing best antibiotic stewardship practices through a standardized guideline, testing, implementation of processes, and education by a multidisciplinary team limited the antibiotic exposure and NICU admissions for infants born to mothers with IAI with no known increase in readmissions.

Preparedness for Pediatric Office Emergencies: A Multicenter, Simulation-Based Study.

Pediatric emergencies can occur in pediatric primary care offices. However, few studies have measured emergency preparedness, or the processes of emergency care, provided in the pediatric office setting. In this study, we aimed to measure emergency preparedness and care in a national cohort of pediatric offices. This was a multicenter study conducted over 15 months. Emergency preparedness scores were calculated as a percentage adherence to 2 checklists on the basis of the American Academy of Pediatrics guidelines (essential equipment and supplies and policies and protocols checklists). To measure the quality of emergency care, we recruited office teams for simulation sessions consisting of 2 patients: a child with respiratory distress and a child with a seizure. An unweighted percentage of adherence to checklists for each case was calculated. Forty-eight teams from 42 offices across 9 states participated. The mean emergency preparedness score was 74.7% (SD: 12.9). The mean essential equipment and supplies subscore was 82.2% (SD: 15.1), and the mean policies and protocols subscore was 57.1% (SD: 25.6). Multivariable analyses revealed that independent practices and smaller total staff size were associated with lower preparedness. The median asthma case performance score was 63.6% (interquartile range: 43.2-81.2), whereas the median seizure case score was 69.2% (interquartile range: 46.2-80.8). Offices that had a standardized process of contacting emergency medical services (EMS) had a higher rate of activating EMS during the simulations. Pediatric office preparedness remains suboptimal in a multicenter cohort, especially in smaller, independent practices. Academic and community partnerships using simulation can help address gaps and implement important processes like contacting EMS.

CHARACTERIZING PRIMARY AMENORRHEA IN A LARGE DIVERSE COHORT

To our knowledge, no recent large studies in the US have reexamined the etiologies of primary amenorrhea; particularly, in the context of increasing obesity rates and diverse ethnic backgrounds. The purpose of this study is to identify and characterize underlying causes of primary amenorrhea amongst a large, diverse cohort. We performed a retrospective chart review of the Kaiser Permanente Southern California database for patients with primary amenorrhea using ICD9 and ICD10 diagnosis codes 626.0 and N91.0, selecting for females ages 0-21 years old at first diagnosis from 2008-2019. Charts were then reviewed to determine which patients met diagnostic criteria for primary amenorrhea, as defined by the American Academy of Pediatrics (AAP): lack of menarche by age 15 years old or by >3 years after onset of secondary sexual characteristics. BMI-for-age percentile (BMIPCT) was used per CDC and AAP guidelines for patients ages 2-19 to account for differences in body composition with sex and age. Medical records were reviewed for demographics and clinical characteristics. Data were analyzed using ANOVA and Tukey analysis; p<0.05. Out of 936 patients from initial search, 748 were diagnosed with primary amenorrhea by chart review. Of those diagnosed, 45% identified as Hispanic (n=340), 32% as White (n=238), 10% as Black (n=73), and 7% as Asian (n=51). The remaining 6% (n=46) identified as Native American/Alaskan, Pacific Islander, Multiple, Other, or Unknown were excluded from final statistical analyses due to small sample size. Within ethnicity groups, patients were normally distributed by age. There was no significant difference in age of presentation between ethnicity groups. BMIPCT ranged from <1 to >99 with a median percentile of 69. The mean BMIPCT was 71 for Hispanic, 46 for White, 63 for Black, and 45 for Asian patients. There was a significant difference for both BMI and BMIPCT when comparing Hispanic vs. White (P<.001) and Hispanic vs. Asian patients (P<.001). A similar trend was seen comparing Black vs. Asian (P<.001) and Black vs. White patients (P<.001). There was no significant difference comparing Hispanic vs. Black, nor White vs. Asian patients. Hispanic and Black populations have significantly higher BMI and BMI-for-age percentiles at time of primary amenorrhea diagnosis when compared to White and Asian populations. However, there is no difference in age of presentation between ethnicity groups. Traditionally, the most common diagnosis underlying primary amenorrhea is hypogonadotropic hypogonadism or gonadal dysgenesis, followed by Mullerian anomaly, physiologic delay, and polycystic ovarian syndrome. Over the past 10 years, limited research in Europe and Asia evaluating differing ethnicities suggest alternative etiologies for primary amenorrhea.

Brief resolved unexplained events: a new diagnosis, with implications for evaluation and management.

Brief resolved unexplained events (BRUE) are concerning episodes of short duration (typically < 1min) characterized by a change in breathing, consciousness, muscle tone (hyper- or hypotonia), and/or skin color (cyanosis or pallor). The episodes occur in a normal-appearing infant in the first year of life, self-resolve, and have no readily identifiable explanation for the cause of the event. Previously called apparent life-threatening events (ALTE), the term BRUE was first defined by the American Academy of Pediatrics (AAP) in 2016. The criteria for BRUE carry greater specificity compared to that of ALTE and additionally are indicative of a diagnosis of exclusion. While most patients with BRUE will have a benign clinical course, important etiologies, including airway, cardiac, gastrointestinal, genetic, infectious, neurologic, and traumatic conditions (including nonaccidental), must be carefully considered. A BRUE is classified as either lower- or higher-risk based on patient age, corrected gestational age, event duration, number of events, and performance of cardiopulmonary resuscitation at the scene. The AAP clinical practice guideline provides recommendations for the management of lower-risk BRUEs, advocating against routine admission, blood testing, and imaging for infants with these events, though a short period of observation and/or an electrocardiogram may be advisable. While guidance exists for higher-risk BRUE, more data are required to better identify proportions and risk factors for serious outcomes among these patients. Conclusion: BRUE is a diagnosis with greaterspecificity relative to prior definitions and is now a diagnosis of exclusion. Additional research is needed, particularly in theevaluation of higher-risk events. Recent data suggest that the AAP guidelines for the management of lower-risk infants can besafely implemented.This review article summarizes the history, definitional changes, current guideline recommendations, and future research needs for BRUE. What is Known: • BRUE, first described in 2016, is a diagnosis used to describe a well-appearing infant who presents with change in breathing, consciousness, muscle tone (hyper- or hypotonia), and/or skin color (cyanosis or pallor). • BRUE can be divided into higher- and lower-risk events. Guidelines have been published for lower-risk events, with expert recommendations for higher-risk BRUE. What is New: • BRUE carries a low rate of serious diagnoses(< 5%), with the most common representing seizures and airway abnormalities. • Prior BRUE events are associated with serious diagnoses and episode recurrence.

Comparison of ESHG2016 and AAP2017 hypertension guidelines in adolescents between the ages of 13 and 16: effect of body mass index on guidelines.

The diagnosis of hypertension in adolescents aged ≥13 and <16 years is based on the percentile according to age, gender, and height in the European Society of Hypertension guidelines guideline; whereas, the American Academy of Pediatrics guideline uses blood pressure above 130/80 mmHg as a single criterion. Therefore, this study aimed to evaluate the compatibility of these two guidelines in adolescents aged ≥13 and <16 years. This study was designed by retrospectively screening the records of 395 adolescents with both office and 24-hour ambulatory blood pressure measurements. Each blood pressure measurement was classified according to both the ESGH2016 and AAP2017 guidelines. Patients were divided into three subgroups according to body mass index. Cohen's kappa analysis was used to evaluate the agreement between the two guidelines. The majority of adolescents were normotensive according to both guidelines, 55.9% by ESHG2016 and 43.1% by AAP2017. For the whole group, the frequency of hypertension was 32.4% with ESHG2016 and 34.4% with AAP2017; while, in obese patients, hypertension frequencies were 38.8% and 43.3%, respectively. The diagnosis of hypertension was demonstrated with the two guidelines, and there was significant agreement at a substantial level, both for the obese subgroup and the whole study group (kappa value = 0.738 and 0.785, respectively). The frequency of white-coat hypertension was higher with the AAP2017 guideline (28.1% versus 16.2%, p < 0.001). With our experience in this single-centre study, it seems that both the AAP2017 and the ESHG2016 guidelines can be used in the diagnosis of hypertension in adolescents.

Utilization of chronic lung disease treatment before the respiratory syncytial virus season as palivizumab prophylaxis qualifier in the American Academy of Pediatrics Guidelines.

Guidelines from the American Academy of Pediatrics recommend palivizumab immunoprophylaxis for children with CLD in their second year of life if they continue to need treatment within 6 months before the RSV season. The utilization patterns of treatment (chronic corticosteroid therapy, diuretic therapy, or supplemental oxygen) are not well understood. We examined variations in CLD treatment for ten consecutive 20-day segments preceding RSV season onset. Among infants and children with CLD (n = 19,026), 35.2% received one or more medical treatments for CLD any time within 200 days before entering the second RSV season: 8.6%, 3.2%, and 29.7% received supplemental oxygen, diuretics, and corticosteroids, respectively. Utilization decreased as infants’ age increased with corticosteroids surpassing oxygen and diuretics. To avoid the capture of intermittent use of corticosteroids for acute infections, we found requiring a minimum of 45 days cumulative exposure was reasonable to determine chronic use. What is Known:• Guidelines from the American Academy of Pediatrics recommend palivizumab immunoprophylaxis for children with CLD in their second year of life if they continue to need treatment within 6 months before the RSV season.• The utilization patterns of treatment (chronic corticosteroid therapy, diuretic therapy, or supplemental oxygen) are not well understood. A definition of chronic corticosteroid therapy in this setting is not available.What is New:• Among infants and children with CLD of prematurity, 35.2% received one or more medical treatments for CLD any time within 200 days before entering the second RSV season: 8.6%, 3.2%, and 29.7% received oxygen, diuretics, and corticosteroids, respectively. Utilization decreased as infants’ age increased with corticosteroids surpassing oxygen and diuretics.• A minimum of 45 days cumulative corticosteroid use within the past 90 days would accurately capture chronic use to fulfill criteria for immunoprophylaxis while limiting the inclusion of intermittent use of corticosteroids for acute infections.

Chinese guideline for the diagnosis and treatment of childhood obstructive sleep apnea (2020).

Chinese guideline for the diagnosis and treatment of childhood obstructive sleep apnea (2020).

Obesity-Related Hypertension in Pediatrics, the Impact of American Academy of Pediatrics Guidelines

The prevalence of primary hypertension in pediatric patients is increasing, especially as a result of the increased prevalence of obesity in children. New diagnostic guidelines for blood pressure were published by the American Academy of Pediatrics (AAP) in 2017 to better define classes of hypertension in children. The aim of our study is to evaluate the impact of new guidelines on diagnosis of hypertension in pediatrics and their capacity to identify the presence of cardiovascular and metabolic risk. Methods: Retrospective clinical and laboratory data from 489 overweight and obese children and adolescents were reviewed. Children were classified according to the 2004 and 2017 AAP guidelines for systolic and diastolic blood pressure. Lipid profile and glucose metabolism data were recorded; triglyceride/HDL ratio (TG/HDL) was calculated as an index of endothelial dysfunction. Hepatic steatosis was detected using the ultrasonographic steatosis score. Results: Children with elevated blood pressure increased from 12.5% with the 2004 AAP to 23.1% with the 2017 AAP criteria (p < 0.001). There was a statistically significant increase in children with high blood pressure in all age groups according to the new cut-off values. Notably, the diagnosis of hypertension according to 2017 AAP criteria had a greater positive association with Hepatic Steatosis (rho 0.2, p < 0.001) and TG/HDL ratio (rho 0.125, p = 0.025). Conclusions: The 2017 AAP tables offer the opportunity to better identify overweight and obese children at risk for organ damage, allowing an earlier and more impactful prevention strategy to be designed.

Infant media use: A harm reduction approach

There are a myriad of potentially harmful developmental outcomes associated with infant digital media use. Studies revealing risk associated with early media use have informed the current American Academy of Pediatrics (AAP) recommendations that discourage most digital media use among children under 18 months of age. Recent research advances, however, suggest potential benefits of technology engagement in this age group. Additionally, surveys of parents reveal that most infants engage with digital media for at least 30 min a day, exceeding the AAP recommendations. In response to these discoveries and cultural trends, some scholars have made compelling cases to adapt the AAP guidelines for infants. A helpful model for developing infant digital media use guidelines for families may be the harm reduction approach. The intent of this review is to suggest adaptations to the AAP guidelines for infant media engagement using a harm reduction framework. This review describes the challenge of restrictive guidelines, briefly summarizes the harm reduction approach, provides a review of risks and benefits associated with infant media use in each developmental domain (physical, cognitive, and socioemotional), summarizes correlates of infant screen media use, and examines intervention strategies for reducing screen time. The paper concludes with examples of possible adaptations to current AAP infant media use recommendations using harm reduction and bioecological frameworks.

Defining Risk Factors for Children Following a BRUE: The Need to Revisit the AAP BRUE Guideline.

Defining Risk Factors for Children Following a BRUE: The Need to Revisit the AAP BRUE Guideline.

Improving Isotonic Maintenance Intravenous Fluid Use in the Emergency Department.

Maintenance intravenous fluids (IVFs) are commonly used in the hospital setting. Hypotonic IVFs are commonly used in pediatrics despite concerns about high incidence of hyponatremia. We aimed to increase isotonic maintenance IVF use in children admitted from the emergency department (ED) from a baseline of 20% in 2018 to >80% by December 2019. We included patients aged 28 days to 18 years receiving maintenance IVFs (rate >10 mL/hour) at the time of admission. Patients with active chronic medical problems were excluded. Interventions included institutional discussions on isotonic IVF based on literature review, education on isotonic IVF use per the American Academy of Pediatrics guideline (isotonic IVF use with appropriate potassium chloride and dextrose), electronic medical record changes to encourage isotonic IVF use, and group practice review with individual physician audit and feedback. Balancing measures were the frequency of serum electrolyte checks within 24 hours of ED admission and occurrence of hypernatremia. Data were analyzed by using statistical process control charts. Isotonic maintenance IVF use improved, with special cause observed twice; the 80% goal was met and sustained. No difference was noted in serum electrolyte checks within 24 hours of admission (P > .05). There was no increase in occurrence of hypernatremia among patients who received isotonic IVF compared with those who received hypotonic IVF (P > .05). The application of improvement methods resulted in improved isotonic IVF use in ED patients admitted to the inpatient setting. Institutional readiness for change at the time of the American Academy of Pediatrics guideline release and hardwiring of preferred fluids via electronic medical record changes were critical to success.

Meeting Nutrition and Physical Activity Guidelines at 24-Months-of-Age Is Associated With Executive Function

ObjectivesExecutive function (EF) and its constructs, cognitive flexibility (F), inhibitory self-control (ISC), emergent metacognition (EM), have been linked to overweight in older children. However, few studies have investigated toddler-aged children, when rapid neurophysiological development occurs. We hypothesized that the American Academy of Pediatrics (AAP) obesity prevention guidelines for toddlers would provide a useful framework for optimizing EF. Herein, the relationships between weight status, adherence to AAP guidelines and EF at 24 mo was examined. MethodsParents and 24-mo-old children (N = 246) were recruited from the STRONG Kids 2 cohort study. Weight-for-length z-scores (WFLz) were computed and weight status classified per WHO standards. Parents completed the Behavioral Rating Inventory of Executive Function for Preschoolers (BRIEF-P) to assess EF and reported physical activities per week (Sports, Play, and Active Recretion for Kids Survey), dietary intake (Block Food Frequency Questionnaires), and screen timeCommon Sense Media Survey). Toddlers met AAP recommendations if they consumed at least 5 servings of fruits and vegetables (FV), were physically active (PA), refrained from sugar-sweetened beverages (SSB) and limited screen time (ST) to less than 60 min per day. ResultsUsing age- and sex-standardized scores, toddlers ranged between the 43rd and 46th percentile of EF, ISC, F and EM. 43% of toddlers were at risk of overweight or overweight/obese. Most toddlers met recommendations for PA (66%), ST (50%) and SSB(62%), but only 4% met FV recommendations. There was no significant difference in BRIEF-P based on weight status or FV recommendation adherence. Toddlers that met guidelines for limiting SSB had higher EF (mean difference = –0.329, p = 0.013), ISC (–0.206, p = 0.015) and EM (–0.406, p = 0.018) than those not meeting the guidelines. Toddlers who were physically active had higher EM (–0.235, p = 0.027) than those who were not physically active every day of the week. ConclusionsBeing physically active every day and abstaining from SSB may be of significance for improving EF in toddlers. Funding SourcesSupported by the NIH, the National Dairy Council and a USDA National Needs fellowship (AM).

Abstract 077: In Utero Exposure To Metal Mixtures And Offspring Blood Pressure: An Analysis Of The Boston Birth Cohort Using Bayesian Kernel Machine Regression

Background: In utero exposure to metals lead (Pb), cadmium (Cd), and mercury (Hg) may be associated with higher childhood systolic blood pressure (SBP), while trace elements manganese (Mn) and selenium (Se) may have protective, antioxidant effects that modify metal-SBP associations. No study has examined how in utero co-exposure to these metals affect offspring SBP. Objectives: To examine the individual and joint effects of in utero exposure to Cd, Pb, Hg, Mn, and Se on offspring SBP. Methods: We used data from the Boston Birth Cohort (enrolled 2002-2013). We measured metals in maternal red blood cells collected 24-72 hours after delivery. We calculated child age-, sex-, and height-specific SBP percentile per 2017 American Academy of Pediatrics guidelines. We used linear regression models to estimate associations of each metal, and Bayesian kernel machine regression (BKMR) to examine metal co-exposures, with child SBP between 3 to 15 years of age. Results: Our analytic sample comprised 1194 mother-child pairs (61% Black, 20% Hispanic). Hg and Pb were not associated with child SBP. Se and Mn were inversely associated with child SBP: each log2(Se) and log2(Mn) increment was associated with a 6.23 (95% CI: 0.96-11.51) and a 2.62 (95% CI: 0.04-5.20) percentile lower child SBP, respectively. BKMR models showed similar results ( Panel A ). While Cd was not overall associated with child SBP, there was an antagonistic interaction between Cd and Mn (P-interaction = 0.036): the association of Mn and lower child SBP was stronger with higher levels of Cd ( Panel B ). Consistent with this finding, in utero exposure to cigarette smoke (a major source of Cd) modified the association of Mn and child SBP: among children born mothers who smoked cigarette in pregnancy, each log2(Mn) increment was associated with a 10.09 (95% CI: 2.15-18.03) percentile lower SBP ( Panel C ). Conclusion: Optimizing in utero Se levels, as well as Mn levels in pregnant women who had high Cd or smoked during pregnancy, may protect offspring from developing high BP during childhood.

Assessment and optimization of respiratory syncytial virus prophylaxis in Connecticut, 1996\u20132013

Respiratory syncytial virus (RSV) causes seasonal respiratory infection, with hospitalization rates of up to 50% in high-risk infants. Palivizumab provides safe and effective, yet costly, immunoprophylaxis. The American Academy of Pediatrics (AAP) recommends palivizumab only for high-risk infants and only during the RSV season. Outside of Florida, the current guidelines do not recommend regional adjustments to the timing of the immunoprophylaxis regimen. Our hypothesis is that adjusting the RSV prophylaxis regimen in Connecticut based on spatial variation in the timing of RSV incidence can reduce the disease burden compared to the current AAP-recommended prophylaxis regimen. We obtained weekly RSV-associated hospital admissions by ZIP-code in Connecticut between July 1996 and June 2013. We estimated the fraction of all Connecticut RSV cases occurring during the period of protection offered by immunoprophylaxis (“preventable fraction”) under the AAP guidelines. We then used the same model to estimate protection conferred by immunoprophylaxis regimens with alternate start dates, but unchanged duration. The fraction of RSV hospitalizations preventable by the AAP guidelines varies by county because of variations in epidemic timing. Prophylaxis regimens adjusted for state- or county-level variation in the timing of RSV seasons are superior to the AAP-recommended regimen. The best alternative strategy yielded a preventable fraction of 95.1% (95% CI 94.7–95.4%), compared to 94.1% (95% CI 93.7–94.5%) for the AAP recommendation. In Connecticut, county-level recommendations would provide only a minimal additional benefit while adding complexity. Initiating RSV prophylaxis based on state-level data may improve protection compared with the AAP recommendations.

Randomized Trial of a Mobile App Introduced During Well-Visits to Enhance Guidance for Reading With Young Children.

To estimate feasibility, usability and efficacy of a mobile parenting app (Rx for Success; RxS) to enhance reading guidance provided to parents of young children during well-visits. This trial was conducted at a clinic serving primarily families of Hispanic ethnicity and low-socioeconomic status (SES) where Reach Out and Read (ROR) is standard practice. It involved 252 parent-child dyads in 2 age groups (~6-months old, ~18-months old) randomized during well-visits to receive RxS or a children's book modeling alternatives to screen time (Control) by research coordinators. RxS involves videos, activities and "push" messages. Follow-up assessments were conducted approximately 6 months later, including impression and use, shared reading behaviors, child language and screen time. A total of 217 dyads completed both visits (110 RxS, 107 Control). Time to introduce RxS was under 3 minutes and 32% of parents experienced largely minor performance issues. Parent impression of RxS was favorable for both age groups at baseline and follow-up, though use was infrequent, attributable to a desire for more relevant and updated content. Significant findings favoring RxS included shared reading as a favorite activity, more frequent shared reading reported at 12 months and higher language scores at 24 months. Screen time was equivalent between cohorts, exceeding American Academy of Pediatrics guidelines. A mobile app introduced to parents of young children from low-SES backgrounds was feasible during well-visits, rated as helpful, and effective to enhance shared reading at younger and language at older ages. While a potentially impactful enhancement to ROR, features needing improvement were identified.