Pediatric Primary Care Clinic Research Articles

Social Needs Screening and Uptake Patterns of a Produce Prescription Program in an Urban Pediatric Primary Care Clinic.

Social Needs Screening and Uptake Patterns of a Produce Prescription Program in an Urban Pediatric Primary Care Clinic.

Resource Navigation in Primary CareDuring the First Year of Life: TheStreetCred Economic Bundle.

Public economic resources reduce the impact of poverty on health but are underused and challenging to access, particularly for families from marginalized racial and ethnic groups. We describe the development of a clinically embedded program (the economic bundle) that facilitates enrollment in the Supplemental Nutrition Assistance Program (SNAP), Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), on-site food pantries, free tax preparation, 529 college savings accounts (CSAs), paid family and medical leave (PFML), and the US Department of Housing and Urban Development’s Family Self-Sufficiency (FSS) Program. We designed this economic bundle in response to our pediatric primary care clinic patient population’s needs (85% Medicaid-insured, 30% immigrants, 68% Black/African American or Hispanic/Latinx). We delivered services using navigators embedded into routine well-child visits throughout the first year of life. We performed a retrospective review of the program’s first 14 months (April 2022 to June 2023) to describe the program’s design, implementation, and early outcomes. Among the 311 families who received the service, few eligible families were enrolled in the offered economic resources at the newborn visit (WIC 31%, SNAP 23%, food pantry 17%, PFML 37%, tax preparation 21%, 529 CSA 1%, and FSS 7%). Among families whose infants were aged at least 6 months at the time of follow-up and were eligible but unenrolled at the newborn visit, many subsequently were enrolled in WIC (59%), SNAP (41%), on-site food pantry (39%), PFML (26%), and 529 CSAs (4%); 12% utilized tax preparation services. Our economic bundle is a promising approach to support families’ economic stability throughout the first year of a child’s life.

Trends in Pediatric Clinician Wellbeing During and Immediately After the COVID-19 Pandemic.

Trends in Pediatric Clinician Wellbeing During and Immediately After the COVID-19 Pandemic.

Patterns of Antidepressant and Antianxiety Medication Prescriptions in Pediatric Primary Care in the U.S

Background:Shortages of pediatric mental health (MH) specialty providers have left pediatric primary care providers (PPCP) to care for the influx of youth with MH needs. This study examined trends in prescription of antidepressants and antianxiety medication in pediatric primary care clinics from 2015 to 2023.Methods:Annual rates of prescription of antidepressant and/or antianxiety medication orders were calculated by race/ethnicity, sex, and practice type. Adjusted mean differences (AMD) were calculated and compared for the beginning and end of the study period.Results:Prescription orders for antianxiety and/or antidepressant medications increased between 2015 and 2023 across all patients but was greatest among Hispanic youth (AMD = 50.9, 95% CI = 15.3-86.4) and among females irrespective of race (AMD = 29.3, 95% CI = 16.8-41.7). Despite these increases, non-Hispanic White youth were more likely to receive prescriptions than Hispanic and non-Hispanic Asian or Black youth across time periods. Family practices (treating adults and children) had the highest rates of prescription across time periods.Conclusions:While prescription rates for antidepressant and antianxiety medications have increased overall, treatment gaps between White and ethnoracially minoritized pediatric patients have persisted. Differences in prescribing patterns between practice environments suggest PPCPs may be more comfortable prescribing MH medications in family practices relative to pediatric practices.

Improved pediatric behavioral health appointment scheduling in an integrated primary care program.

To better understand appointment scheduling for pediatric behavioral health (BH) referrals, we examined appointment scheduling behavior among patients with and without access to primary care mental health integration (PCMHI). A prospective cohort study compared PCMHI and non-PCMHI pediatric patients with BH referrals from January 17, 2022, to June 10, 2022. Six pediatric primary care clinics affiliated with a southern California Children's Hospital were studied: two PCMHI and four non-PCMHI clinics with similar patient demographic characteristics. BH referrals at PCMHI clinics are directly referred to the embedded integrated health therapists. Non-PCMHI clinics referred patients to community BH services. Data were collected from electronic health record abstraction and telephone interviews. PCMHI (n = 471) and non-PCMHI (n = 97) groups did not differ significantly in patient characteristics. About 87.3% (n = 172) of PCMHI patients eligible for an integrated health therapist initial BH appointment scheduled their appointment within 14 days compared to 9.2% (n = 7) of the non-PCMHI patients (χ² = 148.2, p < .001). There was no difference in median days to initial BH appointment between the cohorts, PCMHI: 21 (interquartile range = 15, 27.5) and non-PCMHI: 23 (interquartile range = 13, 35), p = .71. Primary reasons for not scheduling initial BH appointments were similar for both groups and included confusion about the referral and patient/parent busy schedules. Patients in the PCMHI cohort were more likely to schedule their initial BH appointment compared to the non-PCMHI cohort. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

Under the Rainbow: Characterizing Integrated Behavioral Health Services with Gender Diverse Youth in a Pediatric Primary Care (PPC) Setting

Objective: Research indicates the importance of providing gender-affirming care in pediatric primary care (PPC) settings, where transgender and gender diverse (TGD) youth may initially disclose gender and mental health concerns ( Guss et al., 2019 ). This study aimed to characterize gender-affirming care in primary care by qualitatively coding actions of behavioral health clinicians (BHCs) and primary care providers (PCPs). Methods: Participants from a large, residency training, PPC clinic seen between January 2019 and February 2023 were selected by purposive sampling from BHCs clinical cases and clinical informatics in electronic medical record (EMR) software using gender markers as selection criteria. Participants were ages 3–19 years old ( N = 56, M age = 12.41 years, SD = 3.16), and most identified as transgender female (23%) or transgender male (23%). A preliminary chart review was used to develop a codebook for thematic content analysis, which was conducted on electronic health records from primary care visits. Results: Of the 70% of participants who received depression screening, 39% endorsed clinically elevated depression symptoms. Findings suggested that PCPs most often document referring to a gender specialty clinic, while BHCs are typically involved for mood or risk concerns, and provide general rather than gender specific resources. Conclusions: Results suggest that PCPs and BHCs address gender identity in a non-standardized fashion and inform effective practice transformation to enhance gender-affirming care within PPC settings.

Material Goods Provided in Pediatric Primary Care Clinics: A Landscape Analysis.

Material Goods Provided in Pediatric Primary Care Clinics: A Landscape Analysis.

Tiered Clinician Vaccine Communication Strategy to Improve Childhood Vaccine Uptake

No experimental studies to date have tested the effectiveness of clinician communication strategies to improve vaccine uptake among children of parents with negative vaccine attitudes. To evaluate the effect of a tiered vaccine communication strategy on children of parents with negative vaccine attitudes. This cluster randomized clinical trial was conducted from September 1, 2019, to March 31, 2023, at primary care pediatric clinics in Colorado (n = 12) and Washington State (n = 12). Parents with negative vaccine attitudes who had infants 2 months or younger and were receiving health supervision at a participating clinic during the intervention period were eligible for the study. Tiered strategy in which clinicians initiated vaccine discussions with all parents using a presumptive format and then used motivational interviewing with parents who verbally resisted recommended vaccines. Clinicians at intervention clinics received training on the tiered vaccination strategy, whereas clinicians at control clinics practiced usual care. Child vaccination status at 19 months of age characterized as percentage of days underimmunized (DU) in receiving recommended doses of 8 routinely recommended vaccines, with 0% DU described as up to date (UTD) on time. A total of 937 parent-child dyads (intervention: n = 586; control: n = 351) were included in analysis; 434 (46.3%) had an annual household income greater than $75 000 and 682 (72.8%) had some college, a 2-year degree, or more education. In bivariable analyses, more intervention (vs control) participants were UTD on time (130 [22.2%] vs 64 [18.2%]), but intervention (vs control) participants had higher mean (SD) percentage of DU (32.1% [37.9%] vs 23.7% [32.4%]). Variation was observed across states, with intervention participants in Washington (vs Colorado) having a lower mean (SD) percentage of DU (22.4% [31.8%] vs 39.6% [40.1%]) and more infants who were UTD on time (77 [30.0%] vs 53 [16.1%]). In multivariable regression models, there was no difference between intervention and control arms in mean (SD) percentage of DU (adjusted incidence rate ratio, 1.06; 95% CI, 0.69-1.63) or UTD on time (adjusted odds ratio, 1.45; 95% CI, 0.69-3.04), although there were increased odds of being UTD on time among Washington intervention (vs control) participants (adjusted odds ratio, 2.47; 95% CI, 1.09-5.59). In this cluster randomized clinical trial of a tiered vaccine communication strategy, vaccine uptake of children of parents with negative vaccine attitudes did not improve, although state-specific effects were observed. ClinicalTrials.gov ID: NCT03885232.

Regulating the System: Development and Early Implementation of a Behavioral Escalation Response Team in Pediatric Primary Care

Objective: Behavioral escalation in pediatric primary care destabilizes the healthcare system and ultimately impedes medical care. There is currently no standard to address behavioral escalation in this primary care setting. This gap in care disproportionately impacts patients who are most at risk. This article describes the implementation of a novel Behavioral Escalation Response Team (BERT) in a pediatric primary care setting and illustrates how a quality improvement approach can be used to develop a trauma-informed response to behavioral escalations. Method: BERT was developed in a pediatric primary care clinic serving patients with complex needs. A conceptual model for BERT was developed through the engagement of stakeholders and the completion of needs assessments. A quality improvement approach was used to iteratively construct and refine the BERT protocol. The BERT protocol was created to improve identification, assessment, and implementation of evidence-based de-escalation and intervention strategies in primary care. Behavioral escalation was categorized based on the severity of risk, and relevant interventions were implemented to de-escalate patients and families. Results: The BERT protocol was activated for 48 individual patient encounters throughout the first year of trial and implementation. Most BERT encounters engaged patients and families who were at risk due to developmental delay and/or history of trauma. BERT was most often implemented during well-child visits and in conjunction with in-office procedures. Conclusions: This study provides preliminary evidence of BERT’s value as a safe and effective strategy to identify and de-escalate patients and families through the implementation of a structured and predictable therapeutic response.

Primary Care Clinician Perspectives on Medication Prescribing for Child Mental Health Concerns.

This study describes the frequency and comfort of pediatric primary care clinicians (PCCs) as it relates to initiating, continuing, and stopping medications for attention-deficit/hyperactivity disorder (ADHD), anxiety/depression, and sleep problems across age groups (≤5 years, 6-12, and 13+). Primary care clinicians (N = 148) within an integrated primary care national research consortium participated in an anonymous online survey including questions examining practice settings, provider characteristics, prescribing frequency, and prescribing comfort. Results indicate that comfort and prescribing practices vary by patient age, practice setting, provider experience, and presenting diagnoses. Primary care clinicians generally felt more comfortable prescribing for school-age children and older and prescribing for ADHD-related concerns. Primary care clinicians appeared similarly comfortable starting, maintaining, and stopping medications. Rural PCCs reported greater comfort initiating and managing medication. Results highlight the need for ongoing training and support for PCCs in managing common childhood mental health conditions. Implications for establishing collaborative infrastructure support and team-based care are discussed.

Impact of a Brief Educational Intervention on Breastfeeding Knowledge and Intention for Pediatric Primary Care Clinicians.

Impact of a Brief Educational Intervention on Breastfeeding Knowledge and Intention for Pediatric Primary Care Clinicians.

Pediatricians' Attitudes Toward and Use of Terminology About Mothers With Opioid Use Disorder.

Stigmatizing experiences for mothers with opioid use disorder (OUD) may impede health care engagement. We sought to characterize attitudes and terminology use among pediatric primary care clinicians as a potential target for improvement. We conducted a cross-sectional survey of 1004 clinicians at 28 clinics affiliated with 7 US residency programs (April to June 2022). Survey questions focused on trust, blame, and support for mothers with OUD were adapted from prior studies of self-reported attitudes, and terminology was categorized as preferred versus nonpreferred based on national recommendations. Frequencies were tabulated, and a 2-stage process of factor analysis and k-means clustering was used to group respondents by attitudinal responses. Multivariable logistic regression evaluated the association between participant characteristics and attitudinal groups. Of 272 respondents (response rate 27.1%), most were female, non-Hispanic White residents; the distribution of clinical roles was similar among nonrespondents. Use of nonpreferred terminology was infrequent, although over 69% reported usual or occasional use of "substance abuse." Analyses supported clustering respondents across 3 main constructs of trust, blame, and support. About 27% were categorized as having a low level of blame, and about 38% had a high level of trust. Adjusting for covariates, high trust was associated with confidence in training to provide care for opioid-exposed children (adjusted odds ratio [AOR] 1.84, P=0.04), and low blame was associated with education on OUD stigma (AOR 3.43, P=0.001). Pediatrician attitudes reflecting mistrust and blame toward mothers with OUD are not uncommon but may be addressed through training and education.

Factors Influencing Adolescent COVID-19 Vaccination During the Omicron Surge.

While most adolescents experience mild-COVID-19 infection, those with underlying medical conditions have an increased risk of severe health outcomes. Furthermore, compared with other pediatric populations, adolescents have experienced higher rates of COVID-19-associated hospitalization. COVID-19 vaccine decision-making in adolescents during COVID-19 surges is not well understood. Our objective was to explore factors influencing parental and adolescents' COVID-19 vaccine decision-making during the Omicron winter 2021/2022 surge. Participants were recruited from an academic pediatric primary care clinic. Eligible adolescents (aged 12-17 years) who received their first dose of the COVID-19 vaccine between December 2021 and February 2022 were recruited to participate in a semistructured interview with their parent. Perspectives were illuminated through thematic analysis of the data that included coding and pattern identification. Ten parent-adolescent dyads' interview data were analyzed and classified into three principal themes influencing vaccine acceptance during the Omicron surge: perceived risk of COVID-19 infection, family member influence, and clear, two-way communication with a clinician. Despite widespread COVID-19 vaccine availability for adolescents, vaccination rates remain suboptimal even during times of increased disease prevalence. Using health promotion practices to emphasize perceived risk of infection while navigating family dynamics through two-way communication during COVID-19 surges may support vaccine uptake.

A Brief Online Intervention to Increase Use of Nonphysical Discipline Approaches: A Randomized Controlled Trial.

Moderate levels of child disruptive behavior are common and developmentally appropriate during toddlerhood. Caregiver discipline methods influence the development of regulatory strategies in children and the trajectory of behavior problems as children develop. Spanking is a commonly used discipline method in the United States that has been found to result in negative outcomes in childhood and adulthood. Given the high prevalence of child disruptive behaviors and frequency of caregivers' reliance on spanking to manage child behavior, it is important to disseminate information about safe and effective alternatives, including timeout. Previous research has shown that Play Nicely, a brief online program, may be an efficacious approach to reduce caregivers' positive attitudes toward spanking. However, investigators have yet to investigate whether Play Nicely may also influence caregivers' use of alternative nonphysical discipline methods. This study is a follow-up of a randomized controlled trial that examined Play Nicely's impact on attitudes toward and use of spanking. This study investigated whether Play Nicely increased reported use of nonphysical discipline methods among caregivers following intervention. Participants were 107 caregivers of 1- to 5-year-old children recruited from a pediatric primary care clinic and randomly assigned to participate in the Play Nicely program (n = 49) or a control condition (n = 58). Data on caregivers' use of effective nonphysical discipline methods were collected using a self-report measure administered in a primary care clinic at baseline and at one month following intervention. Participants in the treatment group were significantly more likely than those in the control group to report using timeout following the intervention (p < .05). Findings indicate that participation in Play Nicely may increase caregivers' self-reported use of timeout, suggesting that further dissemination of this program may be an effective means of increasing caregivers' use of alternatives to spanking.

Improving Adherence to the Lead Exposure Protocol at Boston Medical Center's Pediatric Clinic.

Using plan-do-study-act cycles, our team aimed to increase mean provider adherence to the Lead Exposure Protocol at the Boston Medical Center Pediatric Primary Care Clinic from 16% (baseline global mean provider adherence) to 80% from April 1, 2021, to February 1, 2023, thereby curbing the secondary effects of lead exposure. Our team performed a chart review of patients 6 months to 5 years of age with blood lead levels (BLLs) ≥2 µg/dL (n = 853) to track provider adherence to Boston Medical Center's Lead Exposure Protocol. We created p charts to track the efficacy of interventions to improve adherence. Interventions included (1) electronic medical record SmartPhrases, (2) provider education, (3) provider feedback, (4) implementation of a follow-up nursing workflow, and (5) simplification of nursing workflow. For BLL 2-4 µg/dL (n = 783), a centerline shift in provider adherence was observed, with >8 points above the preintervention mean after intervention (2) and an increase in mean adherence from 14.1% to 50%. For BLL 5-9 µg/dL (n = 58), no centerline shift was observed, with only 6 points above the upper control limit after intervention (4). The 2-4 µg/dL range changes indicate special cause variance and system change. Global mean provider adherence increased by 3.3 times to 53%. Simple, low-cost process changes improved adherence to complex guidelines for managing lead-exposed children in the primary care setting. Similar interventions could be implemented on a broader scale to standardize the management of other routine pediatric screens.

Integrated behavioral health as a vehicle for improved mental health care

Integrated behavioral health care is an umbrella term that describes methods of delivering behavioral health services in a familiar medical setting to facilitate patient access to care and increase utilization by improving convenience, reducing weight times, and reducing the stigma of seeking mental health care. There are a number of models of integrated care, with the collaborative care and primary care behavioral health models being the most well‐known and evidence‐supported (Kallenberg &amp; Sieber, 2024; Reiter et al., 2018; Yonek et al., 2020). Currently, integrated behavioral health exists in multiple forms in Rhode Island. In this article we will describe the current landscape and future directions of integrated behavioral health (IBH) at Hasbro Children's Pediatric Primary Care Clinic, including the team makeup, goals, and common reasons for consultation. Our aim is to help community providers, both pediatric and behavioral health providers better understand the IBH team and describe the types of services provided.

Default Antibiotic Order Durations for Skin and Soft Tissue Infections in Outpatient Pediatrics: A Cluster Randomized Trial.

Antibiotic durations for uncomplicated skin/soft tissue infections (SSTI) often exceed the guideline-recommended 5-7 days. We assessed the effectiveness of a default duration order panel in the Electronic Health Record to reduce long prescriptions. Cluster randomized trial of an SSTI order panel with default antibiotic durations (implemented 12/2021), compared to a control panel (no decision support) in 14 pediatric primary care clinics. We assessed long prescription rates from 23 months before to 12 months after order panel implementation (1/2020-12/2022). Antibiotic duration was considered long if >5 days for cellulitis or drained abscess, or >7 days for undrained abscess, impetigo, or other SSTI. We included 1123 and 511 encounters in intervention and control clinics, respectively. In a piecewise generalized linear model, the long prescription rate decreased from 63.8% to 54.6% (absolute difference, -9.2%) in the intervention group and from 70.0% to 54.9% (absolute difference, -15.1%) in the control group. The relative change in trajectories from pre-panel to post-panel periods did not differ significantly between intervention and control groups (P = .488). Although used in only 29.4% of eligible encounters, intervention panel use had lower odds of long prescription compared to all other prescriptions (odds ratio 0.18). We did not detect an overall impact of an order panel with default durations in reducing long antibiotic prescriptions for SSTIs. When ordered from the intervention panel, prescriptions were usually guideline-concordant. Effective strategies to make choosing a default duration more automatic are necessary to further reduce long prescriptions.

Multi-Prong Formative Evaluation of a Pediatric Clinical-Community Food Access and Nutrition Education Intervention.

To understand pediatricians', community partners', and food insecure parent/caregivers' perspectives on addressing food access and nutrition education in clinical settings, and to conduct a formative evaluation of a clinical-community food access and nutrition education intervention. A mixed-methods evaluation. Data was collected from pediatricians and parents/caregivers recruited from one urban pediatric primary care clinic, and from community partners involved in food access. Pediatricians (n = 14), parents at risk of food insecurity (n = 7), and community partner staff (n = 8) participated in qualitative interviews. A cross-sectional survey among pediatricians assessing demographics, nutrition training, and knowledge of food access programs was administered. Semi-structured virtual interviews were conducted to understand experiences with food insecurity and food access programs, and to identify content and delivery preferences for a clinical-community intervention. Descriptive statistics were used to characterize the pediatrician and parent demographics and pediatrician nutrition knowledge. A hybrid deductive-inductive thematic analysis was used to identify emerging themes from qualitative interviews. Few pediatricians (n = 3, 11%) reported receiving previous nutrition training, and knowledge-based food access program questions revealed significant gaps in pediatricians' understanding of program eligibility. Thematic analyses underscore challenges in addressing food insecurity in the clinical setting, gaps in clinical-community partnerships, and barriers to participating in food access programs. Findings provide recommendations for the development of clinical-community food access and nutrition education interventions.

Addressing Tobacco Screening and Treatment Among Racially and Ethnically Minoritized Parents in Pediatric Clinics: Barriers and Facilitators.

Household secondhand smoke (SHS) exposure remains a significant health issue for racially and ethnically minoritized children in the United States. Delivering parental tobacco treatment during pediatric primary care visits can reduce children's SHS exposure. This study examined current tobacco screening practices and health system stakeholder perceptions of facilitators and barriers to addressing tobacco use during pediatric visits among racially and ethnically minoritized parents. We conducted 25 semistructured interviews with clinicians, staff, and health system leaders from five pediatric primary care clinics in Minneapolis-St. Paul, Minnesota. The study was informed by the Health Equity Implementation Framework. Interviews were analyzed using both directed content and thematic analysis. Participants identified multilevel facilitators and barriers to addressing parental tobacco use in minoritized families. Within the clinical encounter, barriers included linguistic and cultural barriers, health system navigational challenges, medical mistrust, low levels of clinician and staff knowledge, skills, and confidence, time constraints, and lack of alignment with external metrics. Facilitators centered on leveraging interpreters' cultural knowledge and the presence of culturally congruent clinicians and staff to reduce medical mistrust and stigma, developing linguistically and culturally relevant resources, and integrating prompts and resources into the electronic health record. Participants described how lessons from previous system change mechanisms would facilitate this work. Addressing health system, training and resources, and linguistic and cultural barriers among clinicians and staff is essential to strengthen their capacity to address household SHS exposure among racially and ethnically minoritized populations as a component of pediatric preventive care. Clinicians and health system staff perceive unique barriers to identifying and addressing parental tobacco use among racially and ethnically minoritized parents during pediatric primary care visits. Solutions to expand tobacco treatment access to minoritized parents in pediatric settings must attend to clinician training needs on tobacco treatment, embedding clinical encounter resources and reminders that match the linguistic and cultural needs and preferences of their patient populations, and increasing access to high-quality interpreting services and culturally congruent staff.

Culturally Tailored Messages and Trial Registry Enrollment

Marginalized populations have lower levels of clinical trial representation than other populations. Tailoring recruitment materials and providing incentives may improve representation. To determine whether culturally tailored video improves parents' decision to enroll (DTE) Black children in a research registry. A randomized clinical trial, using mixed methods and consecutive sampling, was conducted in an urban primary care pediatric clinic. A post hoc study assessed the association of a monetary incentive with DTE. Ninety-three parents were recruited before their child's scheduled clinic visit. Participants completed a survey during which they were randomly assigned to review a paragraph (control group), generic video, or tailored video and received a gift card. Video watchers completed questions about its effectiveness. All participants were invited to join the registry. In the post hoc study, consenting participants followed the control group protocol and the coordinator promised them an ink pen for participating. The study was conducted between November 15, 2022, and August 29, 2023. A survey regarding the importance of being included in research studies was administered after participants watched a culturally tailored video. The primary outcome was DTE. Covariates were message effectiveness, clinical trial knowledge, and trust. Intention-to-treat analysis was performed. A total of 125 individuals were included. All groups had similar mean (SD) parent age (overall, 32.6 [7.35] years), gender (110 [88.0%] women), and race (116 [92.8%] Black or African American). There was no significant difference in the odds of DTE between the appeal video and control (odds ratio [OR], 1.19; 95% CI, 0.38-3.72) or between the generic video and control (OR, 1.91; 95% CI, 0.54-6.71). However, DTE was higher for all 3 gift card groups vs the ink pen incentive group (eg, control vs ink pen incentive: OR, 5.01; 95% CI, 1.68-14.95). After adjusting for trust, monetary incentives were associated with higher odds of DTE (adjusted OR, 5.92; 95% CI, 2.44-14.39). In this randomized clinical trial, targeted messaging was not associated with a higher decision to enroll in a pediatric clinical trial registry. There may be a role for combining holistic messaging with monetary incentives to improve enrollment. ClinicalTrials.gov Identifier: NCT06138145.