General Pediatric Clinic Research Articles

How does the immunogenicity of hepatitis B vaccine change over the years in childhood?

ABSTRACT Hepatitis B is the leading cause of chronic hepatitis, cirrhosis, and hepatocellular carcinoma worldwide. The incidence of HBV infection has significantly decreased with hepatitis B vaccination. Hepatitis B vaccine is administered to children at 0, 1 and 6 months of age according to the national schedule. There is a high rate of protective antibody (anti-HBs) development after hepatitis B vaccination. We conducted the study to investigate how the hepatitis B surface antibody (anti-HBs) positivity rates and the titers change over time in childhood following vaccination. Patients who presented at the general pediatric outpatient clinic of Yenimahalle Education and Training Hospital and the HBsAg and anti-HBs titers were tested for any reason between July 2011 and May 2018 were retrospectively evaluated. The cutoff level for protection by the anti-HBs titer was accepted as ≥10 mIU/mL with lower levels indicating no protection. Anti-HBs positivity was compared by age group. Anti-HBs levels were studied in 4326 children. The mean age of the included in the study was 127 ± 62 months. A protective anti-HBs level (≥10 mIU/mL) was present in 2292 children (69.2%). The highest anti-HBs antibody positivity rate was in the under 3 years’ age group. The positivity rate significantly decreased after age 7 years. The HBsAg level was determined in all children in the study and five had a positive result. In conclusion, our study found that the anti-HBs positivity rate and the anti-HBs level decreased with age. However, the anti-HBs antibody result remained positive in more than half of the children.

Vaccine hesitancy and reported non-vaccination in an Irish pediatric outpatient population.

Vaccine hesitancy is defined as a delay in acceptance, or refusal, of vaccines, despite availability. It is a complex and context specific phenomenon and identified as a global health priority. The "Parent Attitudes about Childhood Vaccines" (PACV) questionnaire is a validated tool for identifying vaccine hesitancy. Our aim was to use the PACV to assess vaccine hesitancy and its relationship with reported non-vaccination in an Irish population, for the first time. Our participants were parents or caregivers of children attending general pediatric clinics in a tertiary pediatric hospital in Dublin, Ireland, between September and December 2018. In total, 436 participants completed the questionnaire. 5.5% of our population reported non-vaccination. Human papilloma virus and measles, mumps, rubella vaccines were the most commonly cited vaccines of concern (11.5% and 6.7%, respectively), and autism spectrum disorder was the most commonly side effect of concern (4.3%). Mean PACV score was 26.9 (SD 19.1), with a significant difference between non-vaccinators and vaccinators (53.2 vs 25.3, p<0.001). Safety and efficacy concerns were the major contributor to non-vaccination. 14.4% of our population were vaccine-hesitant using the conventional cut-off score, which increased to 22% when using an optimal cut-off which maximized sensitivity and specificity. The accuracy of the PACV score to identify non-vaccination was good (area under the ROC curve = 0.827), and the optimal cut-off had a high negative predictive value (98.5%).Conclusion: PACV identified reported non-vaccination with high accuracy in our population. It may be useful to screen vaccine-hesitant parents who could benefit from interventions to improve uptake. What is Known: • Vaccine hesitancy is a leading threat to global health, with falls in vaccine uptake associated with disease outbreaks worldwide. • The Parent Attitudes about Childhood Vaccines (PACV) questionnaire is a validated measure of vaccine hesitancy and correlates with non-vaccination in many populations. What is New: • This large study in a pediatric outpatient clinic setting represents the first use of the PACV in a Western European population to assess vaccination hesitancy. • The PACV may be an effective way of screening a pediatric clinic population to identify vaccine-hesitant parents or caregivers for targeted vaccine promotion.

Use of Parent Navigators in a General Pediatrics Clinic to Facilitate Connection to Early Intervention

Use of Parent Navigators in a General Pediatrics Clinic to Facilitate Connection to Early Intervention

Comparison of laboratory parameters between children with and without febrile convulsion

Background/Aim: Febrile convulsion is the most common central nervous system disease of childhood. The etiology of febrile convulsion is not fully brightened. In this study, we aimed to evaluate the relationship between hemogram, biochemical and hormonal parameters and febrile convulsion, and the roles of laboratory parameters in its etiopathogenesis. Methods: A total of fifty-four patients diagnosed with febrile convulsion in the pediatric neurology outpatient clinic of a tertiary hospital from October 2017 to December 2018 were included in this retrospective cohort study. Age, sex, age of first convulsion, type of convulsion and laboratory parameters of the patients were recorded. ILAE classification system was used for the diagnosis of febrile convulsion. Febrile convulsion patients were included in the study group, while the control group was randomly selected from patients between 6 months and 6 years of age who visited general pediatric outpatient clinic. Results: A total of 54 patients (30 males, 24 females) in the study group and 82 patients (53 males, 29 females) in the control group were included in the study (P=0.288). The mean ages of the patients in the study and control groups were 30.31 (14.64) months and 32.32 (19.70) months, respectively (P=0.524). Mean platelet volume (MPV), platelet count, 25-OH D3, vitamin B12 and phosphorus values were significantly lower in the study group (P<0.001, P=0.013, P=0.017, P=0.020). Conclusion: MPV, platelet count, 25 OH D3, vitamin B12 lower levels may be risk factors for febrile convulsion. Studies related to the etiopathogenesis of febrile convulsion are necessary to enlighten the subject and laboratory results will be the guide in this sense.

Reducing Waiting Time in the General Pediatric Clinic at Al Wakra Hospital, Qatar

Waiting times for clinic appointments constitute a key indicator of an outpatient department performance for access to care and patient satisfaction. This is particularly relevant for pediatric population. The Ministry of Public Health in Qatar set a waiting time of 28 days for patients to get new appointment in General Outpatient Department (GOPD). The current average waiting time to get a new appointment in the general pediatric clinic (GPC) at AWH is 57 days. As the aim is to decrease the average waiting time to get a new clinic appointment from 57 days to 28 days by the end of December 2018, and to meet the national targets set by the Ministry of Public Health. Using the Model for Improvement (MFI) will make it a Quality Improvement (QI) project. The MFI framework is designed to support organizations answering fundamental questions before agreeing on drivers for change. The implementation of change was be facilitated by the Plan-Do-Study-Act (PDSA) cycles methodology. The QI project team performed a root cause analysis using the Ishikawa diagram and identified the key contributing factors to the long waiting times to get a new appointment. Twenty-seven PDSA cycle ramps were designed with support of predictive tool to test innovative changes in current operational processes in an attempt to improve waiting time in the general pediatric clinic at Al Wakra Hospital. As a result, the monthly average number of referrals for GPC increased by 200% between the pre and post implementation periods. The average triage waiting time improved from 6 to 2.6 days in 2018 and the average become 1 day in 2019. Post-implementation the average waiting time for patients to get new appointment improved from 57 days to 28 days in 2018 and the average waiting time improved to 16 days in 2019. In conclusion The quality improvement project for the AWH general pediatric clinic demonstrates significant improvement in waiting times for new appointments, the recommendation for the hospital leadership would be to rollout the improvement methodology to other clinics that suffer from similar challenges.

The Effect of Hypothyroidism on Pulmonary Function in School-age Children

<i>Background</i>: Hypothyroidism is a relative public health problem in pediatric, associated with increased morbidity due to multisystemic impairment including deleterious changes in lung function.<i> Objective</i>: The aim of this study is to assess lung function in children affected by hypothyroidism. In addition to, comparison lung function between clinical and subclinical hypothyroidism. <i>Materials and Methods</i>: An Observational Comparative Cross-Sectional study was conducted in 40 patients with newly diagnosed hypothyroidism and 40 healthy children aged 6-14 years. They are selected from Endocrinology and General Pediatric Clinic, Tishreen University Hospital between August 2020 and August 2021. Weight and height were measured and body mass index BMI was calculated. Blood samples were taken and TSH, FT4 were measured.<i> Results</i>: A total of 80 children, 30 males (37.5%) and 50 females (62.5%) with mean age 10.4±2.1 years were included in the study. Out of the 80 children, 40 (50%) were euthyroidism, 20 (25%) were with subclinical hypothyroidism, and 20 (25%) were with clinical hypothyroidism. BMI was higher in patients with clinical hypothyroidism compared to other groups with significant difference (p: 0.04). A statistically significant decrease in FEV1, FVC, and increase in FEV1/FVC were seen in children with clinical hypothyroidism compared to other children (p: 0.0001). Significant negative correlation was seen between TSH and FEV1 (r:-0.36, p: 0.02), FVC (r:-0.64, p: 0.0001), and positive correlation with FEV1/FVC (r: 0.44, p: 0.004). Positive correlation was found between FT4 and FEV1 (r: 0.88, p: 0.04), FVC (r: 0.49, p: 0.001) and negative correlation with FEV1/FVC (r: -0.43, p: 0.006).

The relationship between body weight and dietary habits with respect to the timing of puberty among saudi children and adolescents.

Objective:The objective is to investigate the timing of pubertal onset as determined by the development of secondary sexual characteristics in relation to body weight and dietary patterns among Saudi females.Methods:Children/adolescents visiting general and endocrinology pediatric clinics in King AbdulAziz University Hospital were invited to participate in this study. Female subjects between the ages of 5 and 20 years were included in this study, and those with syndromic disease, chronic comorbidities, endocrinopathies, organic causes of precocious puberty, positive family history of early pubertal onset, and under chronic medication were excluded from the study. Data were collected through clinical interviews with the consent of the legal guardians, and physical examinations were conducted.Results:A total of 164 females were investigated. The mean age of thelarche, adrenarche, and menarche was 10, 11.3, and 12.2 years, respectively. We found a significant correlation between higher weight standard deviation and an earlier age of both thelarche and adrenarche. In addition, daily consumption of fast foods was significantly associated with an earlier menarchal age. Consumption of nonorganic poultry was linked to early thelarche.Conclusion:Efforts should be directed to increase public and community awareness that fast food consumption, inorganic poultry, and higher body weight are important modifiable factors that lead to an earlier onset of female puberty across different parameters: breast development, adrenarche, and menstruation.

The Effect of The Height of a Second-Degree Relative on Children with Short Stature

Objective: This study aimed to investigate the effect of the heights of second-degree relatives on adult height. Methods: This was a cross-sectional study. Healthy children who applied to the general pediatric outpatient clinic to monitor the development of growth were considered as control group. Case group consisted of patients over 3 years of age with genetic, idiopathic short stature or without short stature but below the target height. All participants had either an uncle and an aunt with a short stature. Two groups were compared for their demographic characteristics and family information. Results: The control group consisted of 43 children who were older than 3 years. A total of 101 cases of short stature were included in the study. Prevalence rates of idiopathic (39.6%: n=40), familial (36.6%: n=37), and constitutional (23.7%: n=24) short stature were as indicated. When the males included in the study were examined from different perspectives (case, control, presence of consanguineous marriage), the height of the uncle was predicted to be closer to or equal to the target height. Conclusion: In case of short stature, the ‘target height’ criterion alone is shown to be not reliable in the assessment of genetic compatibility as well as the deviation from the predicted final height. Predicted final height was demonstrated to be similar to aunt height for girls and uncle height for boys. Therefore, the height of a second-degree relative can be used as an aid in the estimation.

Metabolic Syndrome in Obese Children over Five Years Old

Background: Obesity is an important pediatric public health problem associated with increased risk of many complications in childhood and increased morbidity and mortality throughout adult life. Objectives: To assess the prevalence of Metabolic Syndrome in obese children and the relationship between Metabolic Syndrome and Body mass index (BMI), sex, age and family risk factors like obesity, hypertension, diabetes mellitus and cardiovascular disease. Materials and Methods: An analytic cross-sectional study was conducted in 178 overweight and obese children and adolescents aged 5-16 years old seen at the General Pediatric Clinic of the Tishreen University Hospital between March 2020 and February 2021. Weight, high, waist Circumference and blood pressure were measured. Blood samples were taken after 12 hours fasting and fasting blood glucose (FBG), total cholesterol (T Cho), high- density lipoprotein cholesterol (HDL) and low- density lipoprotein cholesterol (LDL) were measured. The Metabolic Syndrome MS was diagnosed based on pediatric and adolescent criteria adapted from the National Cholesterol Education Program Third Adult Treatment Panel (NCEP-ATP III) definition. Results: A total of 178 children, 82 males (46.1%) and 96 females (53.9%) with mean age 9.9±2.5 SD were in our study. Out of the 178 children, 62 (34.8%) were overweight, 101 (56.7%) obese and 15 (8.4%) were severe obese. According to the NCEP ATP III, (32.6%) out of (178) children were diagnosed with MS. Among children with MS, most components of MS were increased waist circumference WC (93.1%), increased TG (86.2%), reduced HDL (51.7%), increased BP (50%) and increased FBS (25.9%). MS prevalence was 12.9%, 36.6%, 86.7% in overweight, obese and severe obese children respectively

Perceived Versus Actual Aeroallergen Sensitization in Urban Children

MN Pham, JT Andrade, M Mishoe, Y Chun, S Bunyavnich. J Allergy Clin Immunol Pract . 2019;7(5):1591–1598.e4 This study analyzed the correlations between perceived and actual sensitization to indoor and outdoor allergens. Participants included 253 children in an urban general and subspecialty pediatric clinic setting. They were 13.5 years old on average and identified as White (43.99%), Black (15.4%), 24.1% Latino (24.1%), Asian (7.5%), or Multiracial (8.3%). Most children had a family history of atopy (75.7%), and about half had a history of allergic rhinitis (50.2%) and asthma (46.6%). Participants completed a questionnaire along …

Fifteen-minute consultation: Vulval soreness in the prepubertal girl

A general practitioner (GP) refers to your general paediatric outpatient clinic a 6-year old girl with an intermittently sore vulva with occasional discharge. Her mother noticed her ‘vagina’/genitalia has been...

The Impact of Hydroxyurea Use on Cognitive Functioning of Children with Sickle Cell Disease in Ghana

Introduction: Sickle cell disease (SCD) is a genetic blood disorder characterized by a mutated hemoglobin that polymerizes when deoxygenated leading to sickle-shaped red blood cells. Tissue hypoxia and organ damage are downstream effects of red blood cell sickling. A manifestation of end organ damage that is of increasing concern, given its devastating functional effects, is cognitive impairment. Sub-Saharan Africa accounts for the highest annual SCD burden in the world, yet little is known about cognitive impairment in children from Africa with SCD. This knowledge gap inhibits the development of targeted interventions to prevent or mitigate cognitive deficits in children with SCD. In particular, it is unknown if hydroxyurea, the oldest FDA-approved drug for SCD, preserves cognitive functioning. The primary objective of this study was to assess the potential cognitive benefits of hydroxyurea administered over at least one year in children with SCD from Ghana. Methods: We conducted a cross-sectional study funded by an ASH Minority Resident Hematology Award at both the general pediatric sickle cell clinic and the hydroxyurea clinic at Korle Bu Teaching Hospital in Ghana. Children with a diagnosis of SCD (HbSS, HbSC and HbS/β-thalassemia) between the ages of 5 and 13 were approached and enrolled in two arms of the study - non-hydroxyurea and hydroxyurea groups - under an IRB-approved protocol. Children without any exposure to hydroxyurea were included in the non-hydroxyurea group while children who had been taking hydroxyurea for at least one year were included in the hydroxyurea group. Children's demographic data were obtained via an ad-hoc questionnaire. Anthropomorphic and laboratory data were obtained from the patients' charts. Cognitive function was assessed using Cogstate, a computer-based neurocognitive testing tool. A brief battery of tests was administered consisting of Detection, Identification, One Back and Groton Maze Learning tests, which assess psychomotor function, attention, working memory and executive functioning, respectively. We used multiple linear regression analysis and inverse proportional to weight propensity score analysis to test the association between hydroxyurea treatment and cognitive test scores. Results: We enrolled 58 children with SCD in the study, including 28 in the non-hydroxyurea group (mean age 9.2 ± 2.40, 54% girls), and 30 in the hydroxyurea group (mean age 9.2 ± 2.17, 57% girls). Children taking hydroxyurea had higher hemoglobin (9.34 vs 8.32 g/dL, P=0.02) and mean corpuscular volume values (94 ± 9.2 vs 77 ± 9.1 fL, P=&amp;lt;0.01) when compared to the non-hydroxyurea group. Children in the hydroxyurea group performed significantly better in the area of working memory (adjusted difference 0.19, p=0.02, Table 1), while there was no significant difference in the other domains. Other confounders including age, nutritional status, gender and subject education level did not impact the findings.Within the hydroxyurea group, increased transcranial doppler velocity in the left internal carotid and left anterior cerebral arteries (a stroke risk factor) was associated with worse psychomotor function (correlation coefficient 0.41, p=0.047). Conclusion:To our knowledge, this is the first study conducted in Africa to explore the impact of hydroxyurea on cognitive functioning. While causality cannot be inferred in this observational study, our results support the findings of a study conducted in the United States showing that children withSCD on hydroxyurea had improved cognitive functioning as compared to those not on the drug (Puffer et al.Child Neuropsychology. 2007). It is possible that hydroxyurea may result in improved cerebral oxygenation, potentially by ameliorating anemia. In a prior study we found that higher cognitive functioning in children with SCD is associated with higher maternal education (Oluwole et al.Pediatr Blood Cancer. 2016), however, the difference in working memory remained significant after adjusting for this variable. Future longitudinal and interventional studies are needed to further assess the potential benefits of hydroxyurea on cognitive functioning, particularly in sub-Saharan Africa, where other interventions aimed at reducing neurological complications of SCD, such as blood transfusions, remain limited. Disclosures No relevant conflicts of interest to declare.

Implementing Routine HIV Screening in an Urban Adolescent Population at a General Pediatric Clinic

PurposeTo increase the rate of routine HIV screening during preventative visits for adolescent patients aged 15 to 21 in a pediatric and adolescent clinic in accordance with national recommendations, which are poorly implemented nationwide. MethodsThis was a quality improvement initiative. Four plan-do-study-act (PDSA) cycles were conducted from May 2016 to February 2020. Interventions included education of and reminders for the multidisciplinary team on guidelines and testing, creation of a standardized workflow, introduction of a rapid point-of-care HIV antibody test (POCT), and implementation of an opt-out, medical assistant/nursing-driven protocol for HIV rapid point-of-care testing. The primary outcome measure was the monthly percentage of adolescents screened for HIV during preventative visits. Data is presented in a p-control chart and means were adjusted for special cause variation according to the Institute for Healthcare Improvement guidelines. ResultsRates of routine HIV screening at preventative visits for youth ages 15 to 21 increased from the pre-intervention rate of 5.16% to a final rate of 41.5% over four PDSA cycles. Mean screening rates were adjusted after introducing the HIV POCT (+18.5%) and after implementing the medical assistant/nursing-driven protocol (+17.9%). ConclusionsWe successfully increased routine HIV screening rates at preventative visits for adolescents at an urban pediatric and adolescent clinic. This was in large part due to testing with a rapid HIV POCT and a clinic protocol allowing medical assistants and nurses to order the test under a physician’s name as part of the intake process. Ours can be a model for other clinics.

Association between cumulative exposure to adverse childhood experiences and childhood obesity.

BackgroundExposure to adverse childhood experiences (ACEs) is associated with many childhood diseases and poor health outcomes in adulthood. However, the association with childhood obesity is inconsistent. We investigated the association between reported cumulative ACE score and body mass index (BMI) in a large sample of patients at a single institution.MethodsThis cross-sectional study included children aged 2–20 years that were screened in a general pediatrics clinic for ACEs utilizing the Center for Youth Wellness ACEs questionnaire between July 2017 and July 2018. Overall ACE score was categorized as ‘no exposure’ (score = 0), ‘low exposure’ (score = 1), and ‘high exposure’ (score≥ 2). BMI was categorized as overweight/obese (BMI percentile ≥ 85) or non-obese (BMI percentile < 85). The association between ACEs score and obesity was determined using univariate and multivariable logistic regression.ResultsOf the 948 patients included in the study, 30% (n = 314) were overweight/obese and 53% (n = 504) had no ACE exposure, 19% (n = 179) had low ACE exposure, and 28% (n = 265) had high ACE exposure. High ACE exposure was associated with increased odds of obesity (OR = 1.47, 95%CI = 1.07–2.03, p = 0.026). However, after adjusting for age, race/ethnicity, insurance type, and birth weight, the association attenuated and was null (OR = 1.01, 95%CI = 0.70–1.46, p = 0.97).ConclusionThe study findings may suggest an association between ACE and childhood obesity. However, the association attenuated after adjusting for age, race/ethnicity, insurance type, and birth weight. Larger prospective studies are warranted to better understand the association.

Vitamin B12 and folic acid levels in pediatric migraine patients.

Migraine is a recurrent, primary cause of headache. Although prophylactic vitamin B12 therapy is used on migraine patients, there is a limited number of studies examining the levels of B12 vitamin and folic acid in pediatric patients diagnosed with migraine. The study group (Group 1) included 65 pediatric patients diagnosed with migraine in the Pediatric neurology outpatient clinic, and 87 healthy cases admitted to the general pediatric clinic were included in the control group (Group 2). Complete blood count parameters, vitamin B12, folic acid, ferritin, and 25 OH D vitamin levels of the study and control groups were compared. The mean vitamin B12 level was 196.42 ± 95.54pg/mL (59-499) in Group 1 and 240 ± 105.24pg/mL (74-619) in Group 2. The mean folic acid level was 8.85 ± 3.49pg/mL (3.68-23.70) in Group 1 and 7.24 ± 7.17pg/mL (1.11-35.50) in Group 2. There was a statistically significant difference between Group 1 and 2 in terms of vitamin B12 and folic acid levels (p = 0.008, p = 0.00). The results of this study indicate the requirement for routine evaluation of vitamin B12 and folic acid levels in pediatric patients diagnosed with migraine.

42. HEALTHY SMILE HAPPY START

Background Dental caries is the most common chronic disease in childhood in the US and they are the single greatest risk factor for caries in permanent dentition. Caries and cavities are largely preventable and fluoride varnish has been proven effective for combating the disease. Only 1.5% of one-year-olds have been to a dentist in comparison to 89% who have been seen by a pediatrician. Given the low prevalence of children with a dental medical home, AAP, Bright Futures and USPSTF released a statement in 2014 addressing oral healthcare, recommending fluoride varnish in the primary care setting beginning at first tooth emergence. Aim Statement Increase the percentage of at least one fluoride varnish application in 9 to 36-month old children to 50% and oral health documentation in the electronic health record (EHR) by 80% by June 2020. Interventions Population and setting included patients presenting to our general pediatrics clinics (ACC and Kendall UHealth) for their 9, 18, 24, 30, 36-month well child visits, after their first tooth eruption. The first cycle took place from Sept-Dec 2019 and involved applying fluoride varnish to eligible patients. The second cycle is planned for Jan-Mar 2020 and includes distributing a FAQ sheet about fluoride and using a trackable smart phrase for oral health documentation. The final cycle will include another change to increase application and documentation from Mar-June 2020. Measures A questionnaire was used to collect baseline and post-intervention data to determine the % of eligible patients who received fluoride varnish application. Chart review was done for the eligible patients to determine % of dental assessments documented in the EHR. Results After the first cycle, fluoride varnish application increased from 17.2% to 79.5% at ACC and from 9.1% to 38.8% at Kendall; dental assessment documentation increased from 40.3% to 50.6% at ACC and from 62.5% to 98.6% at Kendall. Conclusions and Next Steps Our clinics did not previously apply fluoride varnish at routine well child visits, which created a gap in preventative medicine. Knowing that dental caries account for the most common chronic disease in childhood, we have made strides to prevent this disease by increasing application significantly, which we will continue to do through added changes. While dental assessment documentation increased as well, there is still room to improve to ensure it is as compressive as possible, which will be closely tracked in coming months.

Evaluating a No Hit Zone program and provider interventions at an urban academic pediatric practice

BackgroundVery few analyses of the effectiveness of No Hit Zone (NHZ) programs have been done to date. Prior research has demonstrated the negative impacts of corporal punishment (CP) as well as the positive role healthcare providers can play in providing information on disciplinary techniques. The Children’s Hospital of The King’s Daughters (CHKD) set up a NHZ program to address these needs. ObjectivesTo determine the effect of a fully-implemented No Hit Zone program and provider intervention on caregiver beliefs around discipline.To determine how effectively the program was implemented. Participants and settingThose surveyed were 244 parents or guardians of children between the ages of 18 months and 5 years at the General Academic Pediatrics (GAP) clinic at CHKD. MethodsParticipants were approached in their individual exam rooms. Once consent was obtained, participants were given a survey with questions investigating demographics, discipline use, NHZ awareness, and intervention effectiveness. ResultsAnalyses revealed about half of all participants reported having previously used corporal punishment to discipline their child at least once. Only 30% of participants reported having heard about the NHZ. Among those who had, self-reported viewpoint change about discipline style use had been significantly affected by the NHZ education and discussion with their pediatrician (p < 0.001). ConclusionsProvider interventions and establishment of a NHZ was found to be significantly associated with self-reported changes in attitudes about the use of discipline by caregivers. Areas of improvement include the dissemination of NHZ materials and applying the education interventions with more families.

A Text Messaging Initiative to Improve the Well Child HEDIS Metric in a General Pediatrics Clinic

Background: In 2016, the Naval Medical Center San Diego General Pediatrics Clinic was not compliant ( < 75th percentile benchmark) with national a HEDIS goal for well child visits, which specifies a minimum of 6 well child encounters in the first 15 months of life. Goal: Our specific process improvement aim was to improve patient compliance with scheduled well child visits such that we would achieve the HEDIS 90th percentile benchmark …

A Text Messaging Initiative to Improve the Well Child HEDIS Metric in a General Pediatrics Clinic

A Text Messaging Initiative to Improve the Well Child HEDIS Metric in a General Pediatrics Clinic

COVID-19 and Telehealth: Prevention of Exposure in a Medically Complex Patient With a Mild Presentation

The novel coronavirus disease-2019 (COVID-19) was declared a pandemic by the World Health Organization on March 11, 2020. We discuss a less common presentation of COVID-19 in a patient where the use of telemedicine technology prevented the exposure of the healthcare team in an academic general pediatrics clinic. A medically complex 20-year-old male presented via virtual visit for unilateral eye redness and discharge. He received topical ophthalmic antibiotics for presumed acute bacterial conjunctivitis and was counseled on return precautions. Three days later, the patient developed shortness of breath, fever to 102.6°F, and chest pain. COVID-19 testing returned positive. Conjunctivitis is a presenting symptom in 32% of COVID-19 cases. Current evidence suggests that these patients may transmit their illness at the time of presentation. Using telehealth, we avoided exposure to a COVID-19–positive patient who would not have met criteria for testing or droplet precautions. Telehealth allows providers to triage patients, identifying those who need to be seen in person, thereby minimizing exposure. Transitioning toward virtual practice, particularly during a pandemic, prepares for the possibility of healthcare workers being quarantined but still able to provide care and minimizes exposure to asymptomatic patients or those with atypical symptoms.