Pediatric Office Setting Research Articles

Impact of Interleukin-37 and Vitamin D on children with Streptococcus pyogenes sore throat in Salah al-Din Governorate, Iraq

Sore throat is a common presentation in pediatric office settings and emergency departments. Bacterial infection due to Streptococcus pyogenes represented about 25% of sore throat in children. The study aimed to find a relationship between interleukin-37 and vitamin D levels in children with sore throat infection by S. pyogenes bacteria from Salah Al-din General Hospital and Samarra General Hospital in Salah al-Din Governorate, Iraq. The number of sore throat patients in the present study was 317, aged between 5 and 17 years old. The control group included 80 healthy individuals. Throat swabs from children were collected and aseptically inoculated on Petri plate media. Blood samples were collected from patients and control children for determination of Vitamin D and IL-37 by ELISA. The study showed that 30.28% (96 of 317) of the children studied were infected with S. pyogenes bacteria. The results revealed a significant elevation in the mean IL-37 level among children with S. pyogenes infection (96.9±12.2 pg/ml) compared to the control group (62.5±11.3 pg/ml) (p-value = 0.0001). Furthermore, children with S. pyogenes infection had a significantly lower mean vitamin D level (22.3±6.1 pg/ml) compared to the control group (52.8±3.08 pg/ml) (p-value = 0.0001). In conclusion, this study provides evidence of significant alterations in immune markers, including IL-37, and vitamin D levels, in children with S. pyogenes infection compared to the control group. These findings suggest the involvement of these immune markers in the pathogenesis of S. pyogenes infection.

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.

Statewide Asthma Learning Collaborative Participation and Asthma-Related Emergency Department Use.

Quality improvement (QI) efforts can improve guideline-recommended asthma care processes in the pediatric office setting. We sought to assess whether practice participation in an asthma QI collaborative was associated with decreased asthma-related emergency department (ED) visits. A statewide network of practices participated in a pediatric asthma QI collaborative from 2015 to 2016. We evaluated asthma-related ED visit rates per 100 child-years for children ages 3 to 21 years with asthma, using the state's all-payer claims database. We used a difference-in-differences approach, with mixed-effects negative binomial regression models to control for practice and patient covariates. Our main analysis measured the outcome before (2014) and after (2017) the QI collaborative at fully participating and control practices. Additional analyses assessed (1) associations during the intervention period (2016) and (2) associations including practices partially participating in QI collaborative activities. In the postintervention year (2017), participating practices' (n = 20) asthma-related ED visit rate decreased by 5.8 per 100 child-years, compared to an increase of 1.8 per 100 child-years for control practices (n = 15; difference in differences = -7.3; P = .002). Within the intervention year (2016), we found no statistically significant differences in asthma-related ED visit rates compared to controls (difference in differences = -4.3; P = .17). The analysis including partially participating practices yielded similar results and inferences to our main analysis. Participation in an asthma-focused QI collaborative was associated with decreased asthma-related ED visit rates. For those considering implementing this type of QI collaborative, our findings indicate that it takes time to see measurable improvements in ED visit rates. Further study is warranted regarding QI elements contributing to success for partial participants.

Marijuana Legalization and Youth.

Various states have legalized marijuana for medical purposes and/or decriminalized recreational marijuana use. These changes coincide with a decrease in perceived harmfulness of the drug and an increase in its use among youth. This change is of critical concern because of the potential harmful impact of marijuana exposure on adolescents. Marijuana use has been associated with several adverse mental health outcomes, including increased incidence of addiction and comorbid substance use, suicidality, and new-onset psychosis. Negative impacts on cognition and academic performance have also been observed. As the trend toward legalization continues, the pediatric community will be called on to navigate the subsequent challenges that arise with changing policies. Pediatricians are uniquely positioned to provide innovative care and educate youth and families on the ever-evolving issues pertaining to the impact of marijuana legalization on communities. In this article, we present and analyze the most up-to-date data on the effects of legalization on adolescent marijuana use, the effects of adolescent use on mental health and cognitive outcomes, and the current interventions being recommended for use in pediatric office settings.

Use of Electronic Health Records in Pediatric Office Settings

Use of Electronic Health Records in Pediatric Office Settings

Use of Electronic Health Records in Pediatric Office Settings

Background and Objectives: The American Recovery and Reinvestment Act of 2009 accelerated the implementation of electronic health records (EHRs) in pediatric offices. We determined the prevalence and functionalities of EHRs, as well as pediatricians' perceptions of EHRs. Methods: An 8-page self-administered questionnaire was sent to 1,619 randomly selected non-retired US …

Trends in Use of Electronic Health Records in Pediatric Office Settings

To determine the prevalence and functionalities of electronic health records (EHRs) and pediatricians' perceptions of EHRs. An 8-page self-administered questionnaire sent to 1619 randomly selected nonretired US American Academy of Pediatrics members in 2016 was completed by 709 (43.8%). Responses were compared with surveys in 2009 and 2012. The percent of pediatricians who were using EHRs increased from 58% in 2009 and 79% in 2012 to 94% in 2016. Those with fully functional EHRs, including pediatric functionality, more than doubled from 8.2% in 2012 to 16.9% in 2016 (P = .01). Fully functional EHRs lacking pediatric functionality increased slightly from 7.8% to 11.1% (P = .3), and the percentage of pediatricians with basic EHRs remained stable (30.4% to 31.0%; P < .3). The percentage of pediatricians who lacked basic EHR functionality or who reported no EHR decreased (from 53.6% to 41.0%; P < .001). On average, pediatricians spent 3.4 hours per day documenting care. Although the adoption of EHRs has increased, >80% of pediatricians are working with EHRs that lack optimal functionality and 41% of pediatricians are not using EHRs with even basic functionality. EHRs lacking pediatric functionality impact the health of children through increased medical errors, missed diagnoses, lack of adherence to guidelines, and reduced availability of child-specific information. The pediatric certification outlined in the 21st Century Cures Act may result in improved EHR products for pediatricians.

No Matter Where, Adolescent Sexual Health Is Everyone's Job.

The United States should be proud of its declining teenaged pregnancy rates over the past several years, with data from 2016 revealing a continued and significant decrease in birth rates in adolescents aged 15 to 19 years from 2007 to 2016.1 However, we still lag far behind other developed nations.2 Moreover, adolescents and young adults still share a disproportionate burden of sexually transmitted infections (STIs) compared with other age groups.3–5 The Centers for Disease Control and Prevention estimate that individuals aged 15 to 24 years account for one-half of all new STIs in the United States and one-quarter of new HIV diagnoses but account for only one-quarter of the population that is sexually active.6,7 Despite this, one-third of adolescents have health maintenance examinations without any mention of sexual health. If sexual health is discussed at all, it is for an average of merely 36 seconds.8 The American Academy of Pediatrics emphasizes the significant role that pediatricians can play in preventing these avoidable health outcomes, primarily by focusing on the pediatric office setting.9 However, it is time for pediatric hospitalists to embrace sexual and reproductive health, including STI and HIV testing, as routine inpatient care regardless of the chief complaint or reason for admission. Currently, there is limited research in this area. In this issue of Hospital Pediatrics , 3 important articles related to sexual and reproductive health for adolescents are presented in which researchers look beyond the classic office scenario to the hospital setting. Studies have already revealed that adolescents are open to receiving contraceptive counseling in a variety of settings, such as school-based health centers,10 …

Breastfeeding among Latino Families in an Urban Pediatric Office Setting.

Objective. To determine the breastfeeding rate of Latino infants at an urban pediatric clinic in the first six months of life and to identify factors associated with breastfeeding. Methods. Investigators conducted a retrospective chart review of infants seen at the clinic in 2014 as part of a mixed methods study. Topics reviewed included demographics, infant health data, and feeding methods at 5 points in time. Bivariate correlations and cross-tabulations explored associations between variables. Results. Most of the mothers (75%) fed their newborns with both breastfeeding and formula (las dos). At 6 months, a majority were formula-fed only (55.9%). Approximately 10% of mothers exclusively breastfed their newborns, and the trend of exclusive breastfeeding remained steady through the 6-month visit. Over time, the number of mothers who exclusively bottle-feed their infants steadily rises. There were no statistical differences among the feeding method groups with regard to birth order of child, number of adults or children in the household, vaccination rate, number of sick visits, or infants' growth. Conclusions. More targeted attention to this population and other immigrant populations with culturally tailored interventions spanning the prenatal to early infancy periods could increase exclusive breastfeeding and ultimately improve child health.

High specificity of the Pediatric Vision Scanner in a private pediatric primary care setting

To determine the specificity of the Pediatric Vision Scanner, a binocular retinal birefringence scanner, in its intended setting, a pediatric primary care office. A total of 102 preschool children (age 2-6 years) were screened during a well-child pediatric visit using the Pediatric Vision Scanner and the SureSight Autorefractor and completed a masked comprehensive pediatric ophthalmic examination (gold standard examination). Based on the gold standard examination, one child had anisometropic amblyopia, and the remaining 101 had no amblyopia or strabismus. Specificity of the Pediatric Vision Scanner was 90% (95% CI, 82%-95%) while specificity of the SureSight was 87% (95%CI, 79-93%). Combining these results with the sensitivity of the devices determined in our previous study conducted in a pediatric ophthalmology office setting, the positive likelihood ratio for the Pediatric Vision Scanner was 10.2; for the SureSight, 5.0. The negative likelihood ratio for the Pediatric Vision Scanner was 0.03; for the SureSight, 0.42, a significant difference. The Pediatric Vision Scanner had high specificity (90%) in screening for amblyopia and strabismus as part of a pediatric well-child visit. Likelihood ratio analysis suggests that affected children have a high probability of being correctly identified by the Pediatric Vision Scanner. The high level of confidence conferred by Pediatric Vision Scanner screening may remove an important barrier to vision screening in pediatric primary care.

Binge Drinking.

Alcohol is the substance most frequently abused by children and adolescents in the United States, and its use is associated with the leading causes of death and serious injury at this age (ie, motor vehicle accidents, homicides, and suicides). Among youth who drink, the proportion who drink heavily is higher than among adult drinkers, increasing from approximately 50% in those 12 to 14 years of age to 72% among those 18 to 20 years of age. In this clinical report, the definition, epidemiology, and risk factors for binge drinking; the neurobiology of intoxication, blackouts, and hangovers; genetic considerations;and adverse outcomes are discussed. The report offers guidance for the pediatrician. As with any high-risk behavior, prevention plays a more important role than later intervention and has been shown to be more effective. In the pediatric office setting, it is important to ask every adolescent about alcohol use.

High specificity of the pediatric vision scanner in a private pediatric primary care setting

The Pediatric Vision Scanner (PVS) directly detects strabismus and amblyopia by analyzing binocular scans for birefringence that, due to the organization of the radially arranged Henle fibers, is characteristic of steady, bifoveal fixation. In a pediatric ophthalmology office setting,1 we found that the PVS had 97% sensitivity and 87% specificity for detection of strabismus and amblyopia. However, this study did not directly assess performance of the PVS in a primary care screening setting, where it is designed to be used. Here we report PVS specificity and positive likelihood ratio for a cohort of children screened in a pediatric primary care setting.

Impact of a Nutrition and Health Education Program on Obese Children

The purpose of this study was to evaluate the impact of the Health Matters for Families Program, which is a nutrition and health education intervention on the dietary and general lifestyle habits of obese children and their families. This was a prospective cohort study that enrolled clinically diagnosed obese children between 4 and 17 years of age. The intervention was individualized, conducted within a local pediatric office setting, and consisted of 6 face‐to‐face sessions of nutrition and health education for obese children and their caregivers. The intervention utilized culturally tailored materials, behavioral goal setting, and a multi‐component focus, which cumulatively targeted child‐centered goals. Our preliminary results show that participation in physical activity (蠅 30 minutes per day) improved from baseline measures. Fruit and vegetable consumption also improved; consumption of 2‐3 servings of fruit daily increased by 47.6%, while a similar trend was observed for vegetable consumption. The proportion of children drinking at least 4 cups of water daily increased by approximately 10%, while consumption of sugar‐sweetened beverages declined. No significant change was observed in BMI‐for‐age during the follow‐up. Findings from this study may have a significant public health impact by informing the development of effective interventions to address the current obesity epidemic and poor dietary habits of children from minority and low‐income households. Additionally, this project provides foundational knowledge for clinical and community health researchers to develop and implement obesity interventions targeting medical outcomes and lifestyle changes in children.

102: Validation of a Vitamin D Dietary Intake Screening Questionnaire in Young Children

Vitamin D dietary intake is an important predictor of vitamin D status in young children; however, measuring vitamin D intake in early childhood is challenging in the pediatric office setting. To determine how well a simple, 1 min parent completed, dietary screening questionnaire (DSQ) completed in the pediatric office setting correlates with a detailed prospective three-day estimated food record (EFR) in measuring daily dietary vitamin D intake in children one to five years of age and to examine the correlation between the DSQ and EFR for assessing milk and vitamin D supplement intake. The mean vitamin D dietary intake values derived from the DSQ and EFR were compared using a paired two-tailed Student's t test and Spearman correlation coefficient. Seventy-four children consented to participate in this study and were included in the analysis. Mean age was 34 months, 60% were male, 55% were European, and median zBMI was 0.12. The mean calorie intake according to the EFR was 1257 calories. The mean vitamin D dietary intake according to the DSQ was 493 (SD 399) IU and EFR was 443 (SD 389) IU. Paired student t-test revealed a P value of 0.37. The Spearman correlation was 0.47 for total vitamin D intake, 0.56 for vitamin D supplement intake and 0.69 for cow's milk intake. A 1 min DSQ completed in the pediatric office setting, including cow's milk and supplement use correlates well with a detailed EFR. Future studies include determining whether the DSQ predicts 25-hydroxyvitmain D.

Improving Parenting Skills for Families of Young Children in Pediatric Settings

Disruptive behavior disorders, such as attention-deficient/hyperactivity disorder and oppositional defiant disorder, are common and stable throughout childhood. These disorders cause long-term morbidity but benefit from early intervention. While symptoms are often evident before preschool, few children receive appropriate treatment during this period. Group parent training, such as the Incredible Years program, has been shown to be effective in improving parenting strategies and reducing children's disruptive behaviors. Because they already monitor young children's behavior and development, primary care pediatricians are in a good position to intervene early when indicated. To investigate the feasibility and effectiveness of parent-training groups delivered to parents of toddlers in pediatric primary care settings. This randomized clinical trial was conducted at 11 diverse pediatric practices in the Greater Boston area. A total of 273 parents of children between 2 and 4 years old who acknowledged disruptive behaviors on a 20-item checklist were included. A 10-week Incredible Years parent-training group co-led by a research clinician and a pediatric staff member. Self-reports and structured videotaped observations of parent and child behaviors conducted prior to, immediately after, and 12 months after the intervention. A total of 150 parents were randomly assigned to the intervention or the waiting-list group. An additional 123 parents were assigned to receive intervention without a randomly selected comparison group. Compared with the waiting-list group, greater improvement was observed in both intervention groups (P < .05). No differences were observed between the randomized and the nonrandomized intervention groups. Self-reports and structured observations provided evidence of improvements in parenting practices and child disruptive behaviors that were attributable to participation in the Incredible Years groups. This study demonstrated the feasibility and effectiveness of parent-training groups conducted in pediatric office settings to reduce disruptive behavior in toddlers. clinicaltrials.gov Identifier: NCT00402857.

Distance-based training in two community health centers to address tobacco smoke exposure of children

BackgroundThe CEASE (Clinical Effort Against Secondhand Smoke Exposure) intervention was developed to help pediatricians routinely and effectively address the harms of family smoking behaviors. Based on paper versions of CEASE, we partnered with the American Academy of Pediatrics’ online education department and developed a completely distance-based training, including an online CME training, handouts and education materials for families, and phone and email support.MethodsThe pediatric offices of two low income health clinics with primarily Medicaid populations were selected for the study. Pre and post intervention data by survey of the parents was collected in both practices (Practice 1 n = 470; Practice 2 n = 177). The primary outcome for this study was a comparison of rates of clinician’s asking and advising parents about smoking and smoke-free home and cars.ResultsExit surveys of parents revealed statistically significant increases in rates of clinicians asking about parental smoking (22% vs. 41%), smoke-free rules (25% vs. 44%), and asking about other smoking household members (26% vs. 48%).ConclusionsThrough a completely distance based intervention, we were able to train pediatricians who see low income children to ask parents about smoking, smoke-free home and car rules, and whether other household members smoke. Implementing a system to routinely ask about family tobacco use and smoke-free home and car rules is a first step to effectively addressing tobacco in a pediatric office setting. By knowing which family members use tobacco, pediatricians can take the next steps to help families become completely tobacco-free.Trial registrationClinical trials number: NCT01087177

Objective detection of amblyopia and strabismus . . . not just screening for risk factors

To date, preschool vision screening for strabismus and/or amblyopia involves assessment of risk factors, including refractive error and stereoacuity. Most children who are positive for risk factors never develop strabismus or amblyopia. The Pediatric Vision Scanner (PVS) is the first objective, automated screening device that directly assesses bifoveal fixation. This study was undertaken to assess the ability of the PVS to identify patients with strabismus and/or amblyopia in a pediatric ophthalmology office setting.

Immunizing Parents and Other Close Family Contacts in the Pediatric Office Setting

Additional strategies are needed to protect children from vaccine-preventable diseases. In particular, very young infants, as well as children who are immunocompromised, are at especially high risk for developing the serious consequences of vaccine-preventable diseases and cannot be immunized completely. There is some evidence that children who become infected with these diseases are exposed to pathogens through household contacts, particularly from parents or other close family contacts. Such infections likely are attributable to adults who are not fully protected from these diseases, either because their immunity to vaccine-preventable diseases has waned over time or because they have not received a vaccine. There are many challenges that have added to low adult immunization rates in the United States. One option to increase immunization coverage for parents and close family contacts of infants and vulnerable children is to provide alternative locations for these adults to be immunized, such as the pediatric office setting. Ideally, adults should receive immunizations in their medical homes; however, to provide greater protection to these adults and reduce the exposure of children to pathogens, immunizing parents or other adult family contacts in the pediatric office setting could increase immunization coverage for this population to protect themselves as well as children to whom they provide care.

The Time and Practice Challenges of Developmental-Behavioral Pediatrics: An Australian National Study

: Developmental/behavioral diagnoses are common in pediatric practice but, until the impact on pediatricians of caring for these children is quantified, training and remuneration barriers are unlikely to be addressed. In a prospective audit of Australian office-based pediatricians, developmental-behavioral and medical consultations were examined regarding (1) consultation characteristics, (2) child and parent health, and (3) referrals and investigations ordered. : In 2008, all 300 eligible members of the nationwide Australian Paediatric Research Network were invited to prospectively record standardized information for every consultation over 2 weeks or 100 consecutive patients, whichever came first. After coding all diagnoses, consultations were classified as developmental/behavioral, medical, or "mixed." These groups were compared using simple 3-group comparisons (Aims 1 and 2) and logistic regression (Aim 3). : One hundred ninety-nine (66%) pediatricians recorded 15,360 diagnoses for 8,335 consultations (34% developmental/behavioral, 48% medical, and 18% mixed). Compared with medical patients, developmental/behavioral patients were older, more likely to be male, and required on average ∼9 minutes more time per consultation; self-reported parent health was worse; and referrals were more common (odds ratio 2.2, 95% confidence interval 1.9 to 2.5; p < .0001), but investigations less common (odds ratio 0.4, 95% confidence interval 0.3 to 0.4; p < .0001). Child health was worst in the "mixed" group. : Developmental/behavioral consultations are common in pediatric office settings. They are time-consuming, often lead to referrals, and the worse health reported by their parents may pose additional challenges. Pediatric training and funding models must address these barriers if adequate and comprehensive care is to be accorded to these complex patients.

Comparison of the Inverness Medical Acceava Strep A Test With the Genzyme OSOM and Quidel QuickVue Strep A Tests

Previous studies of the accuracy of rapid in-office tests for group A Streptococcus had disparate results, ranging from a sensitivity of 70% to more than 90%. The sensitivity and specificity of 3 commercially available Strep A tests were determined in 2 private pediatric office settings. Acceava Strep A, Genzyme OSOM Strep A, and the Quidel QuickVue Strep A tests were the representative rapid tests for detection of Streptococcus pyogenes. Overnight culture on standard 5% sheep blood agar was the reference standard for this study. All 3 Clinical Laboratory Improvement Amendments-waived tests had sensitivities and specificities that exceeded 95%.