Pediatric Program Research Articles

Abstract WP216: Results of a Pediatric Stroke Program Utilizing Stroke Telemedicine Across a Fifteen Hospital Healthcare System in Southern California

Background: The recognition of pediatric stroke symptoms is challenging. A regionwide pediatric stroke program utilizing an educational initiative across 15 emergency departments (ED) coupled with telemedicine was developed to standardize the process for immediate access to stroke experts and decrease door-to-intervention times. This study evaluates the impact of this intervention. Methods: Data from the pre- (1/2020-12/2021) vs post-intervention (1/2022-7/2023) including baseline demographics, volumes, and process measure timeframes: Door-to-Telestroke Page, Door-to-CT Interpretation, Door-to-Telestroke Call Back, and Door-to-Needle Time were abstracted. Chi-Square and Wilcoxon Rank Sum were used for statistical analysis. Results: There were a total of 92 Telestroke consults, with more in the post group: 35(38%) pre vs 57(62%) post (p=0.04). 52% were female with mean age of 12 (±1.2) years. 78(85%) were stroke mimics: 74% had non-cerebrovascular or migrainous neurological disorders as primary diagnoses. 7(7.6%) patients had interventions: 4(4.3%) thrombolytics, 9(9.7%) arterial or venous thrombectomies. 51% were discharged home and 43% were transferred to an acute care facility for higher level of care. There was no difference between pre- and post-implementation median [IQR] Door-to-Telestroke Page (17.5[14-21] vs 15[11-18] mins); Door-to-CT Interpretation (29[25-32] vs 27[23-29] mins) and Door-to-Needle Time. Median Post Door-to-Telestroke Call Back was faster (pre: 20[17-22] vs post: 16.0[13-18] mins [p=0.03]). Conclusion: Systemwide ED education coupled with telemedicine in implementing pediatric stroke systems of care in a large integrated healthcare system improves access to stroke specialists and time-based metrics in this low-volume, high-risk patient population.

European Pediatric Cardiac Anesthesia Fellowship Program: A First Proof of Concept

The Pediatric Cardiac Anesthesia Fellowship is a demanding training program in Europe and the United States. Successful completion of the program requires years of training in anesthesiology, a thorough understanding of cardiovascular anatomy and physiology, and extensive experience in the perioperative management of neonates and children with heart disease. In the context of the first candidate to successfully complete the PCA program in Europe, this article presents excerpts from the design and structure of the European PCA program. The PCA program is critically evaluated by both external and internal reviewers, and points are highlighted that could be included in the next version of the program.

Evaluation of the Diversity, Equity, and Inclusion Curriculum of a Pediatrics Residency Program.

Diversity, equity, and inclusion (DEI) training is essential to graduate medical education, but it lacks standardization. Although the impact of providers' biases and cultural competency on patient outcomes is well documented, the value of and satisfaction with DEI curricula in Pediatrics residency training programs is not well studied. This study aimed to complete a cross-sectional evaluation of the current DEI curriculum at a large Pediatrics-focused academic institution and identify areas of perceived deficiency among Pediatrics trainees. Residents and residency program directors completed surveys in 2020. Respondents evaluated the DEI curriculum of the program and the competency of residents to complete patient care related to specific DEI-oriented actions. Our analysis used descriptive statistics. In total, 48 of 137 resident trainees (35%) and 7 of 9 program leaders (78%) completed the survey. Respondents were most dissatisfied with current education related to implicit bias, refugee/immigrant health, and lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other health topics. Respondents reported low resident competency in DEI-focused patient care tasks and did not view residents as competent to address the healthcare needs of patients and families experiencing racism. Pediatrics residents and program directors consider DEI topics important and express a need for more robust DEI curricula.

Pediatric intensive bowel continence rehabilitation training: a retrospective study to evaluate feasibility, tolerance and effectiveness.

Pediatric continence dysfunction is not uncommon. It causes long-term disability, impairing quality of life, activities and relationships with pears and can affect until adulthood. A high-risk population are children with Hirschsprung's disease and congenital anorectal malformation. Conservative medical and surgical management of continence dysfunction in this population is deeply described, while the rehabilitation issues are still unexplored. Aim of this study is to preliminary verify the feasibility, tolerance and effectiveness of an intensive technological aided and individualized pelvic floor rehabilitation program for pediatric patients. This is a single-center, retrospective observational study. The assessment was performed by collecting demographic data, general and local physical examination and scoring assessment tools (Rintala Continence Score and Wexner Score). The study was conducted in the Rehabilitation Unit of the pediatric Giannina Gaslini Institute, a tertiary care pediatric hospital in Genoa (Italy) between September 2015 to August 2019. We enrolled 31 children; 25 male (80.6%) and six females (19%), aged between 5 and 14 years (mean age 9 years) at the beginning of the training. Twenty children (65.5%) had Hirschsprung's disease, and 11 children (34.5%) had a congenital anorectal malformation. The rehabilitation training program was customized on the compromised function, the anatomic characteristics, the child's age and compliance. The training was aimed at improving tone, strength, endurance of the pelvic floor, compliance and rectal sensitivity, and also the frequency of the bowel movements. All patients enrolled in the study underwent an intensive outpatient treatment lasted 5 days for children older than 7 years; 10 days for younger. The intensive rehabilitation treatment was followed by a continuous home training program. Twenty-nine children (96.8%) completed the training. A global improvement is observed in continence functioning in all the cohort at T1 (P<0.0001), maintained at T3 (P<0.0001) at both Rintala Continence Score and Wexner Score. No adverse effects have been referred. Our specific pediatric training program for pelvic floor rehabilitation is effective and safe for children with continence dysfunctions after pelvic surgery due to Hirschsprung's disease and anorectal malformations. The continence rehabilitation multimodal program should be integrated in the care of children with continence dysfunctions. It cooperates in the prevention of the long-term health global impairment and also in the reduction of social economic effort.

The Jerusalem tribune collapse incident: Challenges in the management of a pediatric mass casualty incident.

Children comprise up to 30-50 percent of all disaster victims. Pediatric disaster medicine is a poorly established field, and most protocols are designed without adequate emphasis on the special needs of the pediatric population. During the 2021 Shavuot holiday in Israel, the collapse of temporary steel bleachers in a partially constructed synagogue resulted in a mass casualty incident (MCI) with a majority of pediatric casualties. This study analyzed the differences in post-incident casualty management, treatment, and outcomes in three Jerusalem medical centers. Multicenter retrospective data were collected from two tertiary level 1 trauma centers and one secondary hospital in Jerusalem. The data included demographics, triage scores, injury mechanisms, medical workups, and the management of the pediatric patients. A total of 171 children and adolescents aged 9-18 years presented to three centers. In two institutions, the triage was performed by a senior emergency medicine physician, and in the third institution, by a senior trauma physician. Different protocols were applied, resulting in significant differences in triage, identification and documentation, admission strategies, adherence, and analgesic treatment. Most patients presented with orthopedic injuries (115/171, 67 percent). A small number had head, chest, abdominal, and multisystem injuries (11, 5, 2, and 2 percent, respectively). Pediatric MCI management presents specific challenges. The lack of consistency in triage, registry, and management highlights the need for robust pediatric MCI training programs.

Improving and Sustaining Resident Physician Handover.

Background Handoffs serve a critical patient safety function in the transition between caregivers. In 2006, the Joint Commission on Accreditation of Healthcare Organizations strongly recommended the implementation of "a standardized approach to 'handoff' communications, including an opportunity to ask and respond to questions."Numerous studies have investigated the quality and efficacy of patient handoffs and the utility of structured handoff curriculums, particularly in the context of patient safety and outcomes. Objective The pediatric residents at Penn State Health (PSH) did not utilize a formal written or verbal handoff tool. Our study facilitated the design of a comprehensive handoff curriculum, including verbal and written components, and the implementationof faculty and multidisciplinary care team involvement coupled with resident training and observations.We investigate the impact of this curriculum longitudinally utilizing validated tools completed by external observers as well as the residents themselves. Methods Prior to SAFETIPS being implemented, residents at a mid-sized Pediatric program were observed giving handovers at various intervals to understand baseline habits.Residents were then educated with the SAFETIPS curriculum and again observed.Trained observers of the handover process completed a validated evaluation form concentrating onseven key domains necessary for effective handover and communication; residents involved in the handover also completed a validated evaluation form.Consent for the project was implied with the observer's presence during the process and our study was exempt from full IRB consideration given its quality improvement design.A mix of summary statistics, stacked dot plots, mixed effects regression, and joint F tests were used to analyze data. Results Mean values on all sections of the handover evaluation Likert scale completed by trained observers tended to increase over time; the variance in responses was likewise much smaller at later time periods.Similarly, all sections of the evaluation tools completed by the resident physicians themselves showed significantly increased scores from pre- to post-implementation of our curriculum.Data revealed a plateauing of results towardlater time points suggestive of skills mastery and sustained improvements. Conclusion Our findings suggest that the introduction of a structured handoff curriculum correlated with improved communication among residents, and such improvements were sustained over time.

Diabetes screening outcomes in youth presenting for paediatric weight management: A report of the Paediatric Obesity Weight Evaluation Registry.

Rising prevalence of obesity has led to increased rates of prediabetes and diabetes mellitus (DM) in children. This study compares rates of prediabetes and diabetes using two recommended screening tests (fasting plasma glucose [FPG] and haemoglobin A1c [HbA1c]). Data were collected prospectively from 37 multi-component paediatric weight management programs in POWER (Paediatric Obesity Weight Evaluation Registry). For this study, 3962 children with obesity without a known diagnosis of DM at presentation and for whom concurrent measurement of FPG and HbA1c were available were evaluated (median age 12.0 years [interquartile range, IQR 9.8, 14.6]; 48% males; median body mass index 95th percentile [%BMIp95] 134% [IQR 120, 151]). Notably, 10.7% had prediabetes based on FPG criteria (100-125 mg/dL), 18.6% had prediabetes based on HbA1c criteria (5.7%-6.4%), 0.9% had DM by FPG abnormality (≥126 mg/dL) and 1.1% had DM by HbA1c abnormality (≥6.5%). Discordance between the tests was observed for youth in both age groups (10-18 years [n = 2915] and age 2-9 years [n = 1047]). There is discordance between FPG and HbA1c for the diagnosis of prediabetes and DM in youth with obesity. Further studies are needed to understand the predictive capability of these tests for development of DM (in those diagnosed with prediabetes) and cardiometabolic risk.

Evaluating the Implementation of the Connect for Health Pediatric Weight Management Program

Adoption of primary care interventions to reduce childhood obesity is limited. Progress in reducing obesity prevalence and eliminating disparities can be achieved by implementing effective childhood obesity management interventions in primary care settings. To examine the extent to which implementation strategies supported the uptake of research evidence and implementation of the Connect for Health pediatric weight management program. This quality improvement study took place at 3 geographically and demographically diverse health care organizations with substantially high numbers of children living in low-income communities in Denver, Colorado; Boston, Massachusetts; and Greenville, South Carolina, from November 2019 to April 2022. Participants included pediatric primary care clinicians and staff and families with children aged 2 to 12 years with a body mass index (BMI) in the 85th percentile or higher. Pediatric weight management program with clinician-facing tools (ie, clinical decision support tools) and family-facing tools (ie, educational handouts, text messaging program, community resource guide) along with implementation strategies (ie, training and feedback, technical assistance, virtual learning community, aligning with hospital performance metrics) to support the uptake. Primary outcomes were constructs from the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) Framework examined through parent, clinician, and leadership surveys and electronic health record data to understand the number of children screened and identified, use of the clinical decision support tools, program acceptability, fidelity to the intervention and implementation strategies, and program sustainability. The program screened and identified 18 333 children across 3 organizations (Denver Health, 8480 children [46.3%]; mean [SD] age, 7.97 [3.31] years; 3863 [45.5%] female; Massachusetts General Hospital (MGH), 6190 children [33.8%]; mean [SD] age, 7.49 [3.19] years; 2920 [47.2%] female; Prisma Health, 3663 children [20.0%]; mean [SD] age, 7.33 [3.15] years; 1692 [46.2%] female) as having an elevated BMI. The actionable flagging system was used for 8718 children (48%). The reach was equitable, with 7843 children (92.4%) from Denver Health, 4071 children (65.8%) from MGH, and 1720 children (47%) from Prisma Health being from racially and ethnically minoritized groups. The sites had high fidelity to the program and 6 implementation strategies, with 4 strategies (67%) used consistently at Denver Health, 6 (100%) at MGH, and 5 (83%) at Prisma Health. A high program acceptability was found across the 3 health care organizations; for example, the mean (SD) Acceptability of Intervention Measure score was 3.72 (0.84) at Denver Health, 3.82 (0.86) at MGH, and 4.28 (0.68) at Prisma Health. The implementation strategies were associated with 7091 (39%) uses of the clinical decision support tool. The mean (SD) program sustainability scores were 4.46 (1.61) at Denver Health, 5.63 (1.28) at MGH, and 5.54 (0.92) at Prisma Health. These findings suggest that by understanding what strategies enable the adoption of scalable and implementation-ready programs by other health care organizations, it is feasible to improve the screening, identification, and management of children with overweight or obesity and mitigate existing disparities.

Fiscal analysis of the pediatric immunization program in Belgium applying a lifetime government perspective framework

ABSTRACT Objectives A public economic framework was used to explore lifetime government costs and benefits in relation to the Pediatric Immunization Program (PIP) in Belgium based on cases and deaths averted. Methods To estimate changes in net government revenue, we developed a decision-analytic model that quantifies lifetime tax revenues and transfers based on changes in morbidity and mortality arising from Belgium’s Pediatric Immunization Program (PIP). The model considered differences in incidence rates with vaccines included in Belgium’s PIP: compared with the pre-vaccine era. Changes in deaths and comorbid conditions attributed to PIP on the Belgium 2020 birth cohort were used to estimate gross lifetime earnings changes, tax revenue gains attributed to averted morbidity and mortality avoidance, disability transfer cost savings, and averted special education costs associated with each vaccine. Results Vaccinating a single birth cohort according to the PIP gives rise to fiscal gains of €56 million in averted tax revenue loss, €8 million disability savings, and €6 million special education cost-savings. Based on the costs of implementing the PIP, we estimate the fiscal benefit–cost ratio (fBCR) of €2.2 investment return for the government from every €1 invested excluding longevity costs. Conclusions Reducing vaccine-preventable conditions generates tax revenue for the government, providing fiscal justification for sustained immunization investments.

Combining living and deceased donation for pediatric first isolated liver transplantation: A win-win even in countries with high deceased donor donation rates.

Split and living donor liver transplantations are both key surgical strategies for development of pediatric liver transplant programs. Often, however, teams tend to prioritize only one preferentially. In the context of a very active national split liver graft allocation program (Italy), retrospective study of 226 consecutive pediatric first isolated liver transplants performed by a single team using organs from both deceased and living donors. Clinical characterisitics and outcome were compared. In the context of a steadily slowly decreasing split graft offer, living donation activity steadily increased. Deceased and living donation accounted for 52.6% and 47.4% of transplantations, respectively. Both strategies were equally used for transplanting patients up to 30 kg of weight, while deceased donors were predominantly used for older recipients. Technical variants represented 86% of all transplants, with 183 conisting of left lateral segment grafts (76 split liver grafts and 107 left grafts from living donors). Outcome of both surgical strategies was similar, with excellent outcomes at early, mid-, and long-term. Splitting livers of deceased donors and using living donation were complementary and non-competitive strategies for developping pediatric liver transplant activity. Implementing both activities in parallell allowed to maintain stable the number of annual transplant in Italy and allowed to reach superior outcomes. This analysis provides evidence that living donation plays a role in Italy despite an existing very active "mandatory-split" national policy.

Implementation and assessment of a structured curriculum for a 4-week pediatric rheumatology rotation for pediatric residents

BackgroundGeneral pediatricians often initially address children’s musculoskeletal (MSK) issues and play a crucial role in triaging and managing patients’ rheumatologic conditions. This study assessed the effectiveness of a structured curriculum in enhancing pediatric residents’ knowledge, MSK examination skills, and confidence during a 4-week pediatric rheumatology rotation.MethodsPediatric residents in their either second or third year who participated in the 4-week rheumatology rotation once across three academic years (July 2020–June 2023) were enrolled. Residents’ knowledge, MSK examination skills, and confidence were assessed at pre- and post-rotation by using 25 multiple-choice questions, the Thai pediatric Gait Arms Legs Spine examination, and a questionnaire, respectively. The curriculum comprised instruction on MSK examinations, interactive lectures, case-based discussion, topic reviews, MSK radiology conference, clinical experience in rheumatology clinic and consultations, with self-guided learning with educational resources.ResultsFifty-eight pediatric residents (48 females, 10 males) with a mean age of 28.9 ± 0.8 years participated. Significant improvements were noted postrotation. Knowledge scores rose from 63.0 ± 12.2 to 79.7 ± 9.1 (mean difference 16.7 ± 10.3, p < 0.001). Similarly, MSK examination scores increased from 67.5 ± 14.4 to 93.6 ± 8.7 (mean difference 26.1 ± 14.6, p < 0.001). Residents also reported a marked increase in confidence across all evaluated areas, including history taking, MSK examination, arthrocentesis, and diagnosing and treating rheumatologic conditions (p < 0.001).ConclusionsThe 4-week structured curriculum in the pediatric rheumatology rotation significantly enhanced pediatric residents’ knowledge, MSK examination skills, and confidence. These findings support the integration of pediatric rheumatology rotations into pediatric residency training programs.

Long-term outcomes of an educational paediatric antimicrobial stewardship programme: a quality improvement study

Background and objectivesAntimicrobial stewardship programmes (ASPs) have resulted in antimicrobial consumption (AMC) reduction and quality of prescription (QOP) improvement. However, evidence of ASP impact in paediatrics is still limited. This...

Challenges faced in establishing a pediatric liver transplant program in a lower-middle-income country with free healthcare service.

Liver transplant is the cure for children with liver failure. Sri Lanka is a lower-middle-income country with a predominant free, state health system. Pediatric liver transplant program in Sri Lanka is still in the budding state where the initial experience of the program is yet to be documented. A retrospective review was performed including the clinical characteristics of all pediatric liver transplant recipients of Colombo North Centre for Liver Diseases since the inception of the program from June 2020 to May 2023. There were 14 PLT performed in 3 years. The median recipient age and weight were 8 years (6 months-15 years) and 23.3 kg (6.4-49.2), respectively. The majority were boys (64%). All were from low-income backgrounds. Indications for LT were acute liver failure (5/14), decompensated chronic liver disease (5/14), and acute on chronic liver failure (4/14). Underlying liver diseases were Wilson disease (6/14), autoimmune liver disease (3/14), biliary atresia (2/14) and progressive familial intrahepatic cholestasis type 3 (1/14), and unknown etiology (2/14). The majority were living donor liver transplants (86%). Of the living donors, 42% (5/12) were Buddhist priests. There were three immediate deaths and two late deaths. The 3-month survival was 78%, and overall survival was 64%. Living donor transplants carried a higher success rate (92%) compared to diseased donor transplants (0%; 2/2). Initial experience of pediatric liver transplant program of Sri Lanka is promising despite being established in a free healthcare system amidst the crisis circumstances.

Establishing a High-Quality Pediatric Cardiac Surgery Program in Post-Conflict Regions: A Model for Limited Resource Countries.

Congenital Heart Disease stands as a prominent cause of infant mortality, with notable disparities in surgical outcomes evident between high-income and low- to middle-income countries. This study presents a collaborative partnership between a local governmental entity and an international private organization to establish a high-quality Pediatric Cardiac Surgery Program in a post-conflict limited resource country, Iraq. A descriptive retrospective study analyzed pediatric cardiac surgery procedures performed by a visiting pediatric heart surgery team from October 2021 to October 2022, funded by the Ministry of Health (MOH). We used the STS-EACTS complexity scoring model (STAT) to assess mortality risks associated with surgical procedures. A total of 144 patients underwent 148 procedures. Infants comprised 58.3% of the patients. The most common anomalies included tetralogy of Fallot, ventricular septal defect, and various single ventricle categories, constituting 76% of the patient cohort. The overall surgical mortality rate was 4.1%, with an observed/expected surgical mortality rate of 1.1 (95% CI 0.5, 2.3). There was no significant difference between our observed surgical mortality in Category 2, 3, and 4 and those expected/reported by the STS-EACTS Database (p = 0.07, p = 0.72, and p = 0.12, respectively). The expenses incurred by the MOH for conducting surgeries in Iraq were lower than the alternative of sending patients abroad for the same procedures. The partnership model between a local public entity committed to infrastructure development and funding and an international private organization delivering clinical and training services can provide the foundation for building sustainable, high-quality in situ programs in upper-middle-income countries.

Screening for Food Insecurity in a Pediatric Diabetes Program: Provider and Parent/Guardian Perspectives.

Food insecurity (FI) is associated with poor health outcomes in children, and studies have shown higher FI among children with diabetes mellitus. This study assessed provider (N = 22, 35.5% response rate) and parent/guardian (N = 207, 14.6% response rate) perspectives toward FI screening in a pediatric diabetes program. Among 22 providers, most "rarely" (54.5%) or "never" (27.3%) screened for FI although all felt that screening was at least "slightly important." Barriers included lack of time (63.6%), not remembering to screen (59.1%), lack of knowledge about how to address positive screens (45.5%), and being unsure how to screen (40.9%). Among 186 parent/guardians, only 24.1% had been asked about FI at a pediatric medical appointment, but only 8.6% disliked the idea of being asked by a medical provider at endocrinology visits. To be effective and sustainable, FI screening must fit within the visit flow, and providers need education on how to address positive screens.

Attrition from Face-to-Face Pediatric Outpatient Chronic Pain Interventions: A Narrative Review and Theoretical Model.

There is limited understanding of attrition (premature treatment withdrawal and non-completion) from pediatric chronic pain services. This narrative review aimed to summarize attrition prevalence from face-to-face pediatric outpatient chronic pain interventions, identify associated factors and develop a theoretical model to account for attrition in this setting. A comprehensive search of the published literature revealed massive variability (0-100%) in the reported attrition rates from pediatric chronic pain interventions that varied in type and format (individual vs. group, single discipline vs. interdisciplinary, psychological only vs. multiple combined interventions, of different durations). The factors associated with attrition from pediatric chronic pain programs varied between the studies: some have assessed patient sex, psychological and other comorbidities, avoidance strategies, missed schooling, family composition/tensions, caregiver catastrophizing, scheduling, caregiver leave and clinic access. A theoretical model is presented depicting youth, caregiver and service factors that may impact attrition from pediatric chronic pain interventions. Where available, literature is drawn from the pediatric chronic pain context, but also from adult chronic pain and pediatric weight management fields. The implications for research and clinical practice are discussed, including improved reporting, patient screening and targeted supports to promote intervention completion. This review contributes to a better understanding of attrition, which is crucial for optimizing pediatric chronic pain service outcomes.

Assessing Pediatric Rheumatology Fellow Competence in the Milestone Era: Past, Present, and Future.

Starting in 2015, pediatric rheumatology fellowship training programs were required by the Accreditation Council for Graduate Medical Education to assess fellows' academic performance within 21 subcompetencies falling under six competency domains. Each subcompetency had four or five milestone levels describing developmental progression of knowledge and skill acquisition. Milestones were standardized across all pediatric subspecialties. As part of the Milestones 2.0 revision project, the Accreditation Council for Graduate Medical Education convened a workgroup in 2022 to write pediatric rheumatology-specific milestones. Using adult rheumatology's Milestones 2.0 as a starting point, the workgroup revised the patient care and medical knowledge subcompetencies and milestones to reflect requirements and nuances of pediatric rheumatology care. Milestones within four remaining competency domains (professionalism, interpersonal and communication skills, practice-based learning and improvement, and systems-based practice) were standardized across all pediatric subspecialties, and therefore not revised. The workgroup created a supplemental guide with explanations of the intent of each subcompetency, 25 in total, and examples for each milestone level. The new milestones are an important step forward for competency-based medical education in pediatric rheumatology. However, challenges remain. Milestone level assignment is meant to be informed by results of multiple assessment methods. The lack of pediatric rheumatology-specific assessment tools typically result in clinical competency committees determining trainee milestone levels without such collated results as the foundation of their assessments. Although further advances in pediatric rheumatology fellowship competency-based medical education are needed, Milestones 2.0 importantly establishes the first pediatric-specific rheumatology Milestones to assess fellow performance during training and help measure readiness for independent practice.

A guide on transnasal endoscopy: setting up a pediatric unsedated endoscopy program.

Unsedated transnasal endoscopy is becoming an increasingly popular option for the evaluation of upper gastrointestinal tract disorders in adults and children worldwide. This innovative technology has transformative potential as it provides for a more efficient, safe, and cost-effective method for endoscopy and reduces the risks associated with anesthesia, which is particularly relevant in pediatrics as endoscopy is commonly done under general anesthesia or conscious sedation. The aim is to address knowledge gaps amongst pediatric gastroenterologists who may be considering the development of a TNE program, detailing how to implement sedation-free TNE into practice for pediatric patients and current and forthcoming technologies. We conducted a comprehensive review of current literature and collection of data from experts and clinicians in the field on how sedation-free programs were started and being conducted. We aimed to collate the data to provide a guide to address knowledge gaps with a focus on setting up and starting a sedation-free endoscopy program. Here in, we provide a detailed guide for implementing a sedation-free endoscopy program in pediatrics including design and layout of a TNE unit, special staffing needs, equipment, current and forthcoming technologies, financial considerations and training considerations. We highlight special considerations that are relevant in pediatrics incorporating distraction or dissociation techniques such as Virtual Reality Systems, developmentally appropriate preparation for children, and topical analgesia. Sedation-free endoscopy is a rapidly growing option for pediatric patients. Development of an unsedated pediatric endoscopy program will improve patient care, decrease the need for anesthesia, provide a lower cost and safe alternative to traditional sedated endoscopy, and is a viable component to a pediatric gastroenterology practice.

Parenting Styles and Psychosocial Factors of Mother-Child Dyads Participating in the ENDORSE Digital Weight Management Program for Children and Adolescents during the COVID-19 Pandemic.

Semi-structured clinical interviews were conducted with all participating mothers pre-and post-intervention. The Parenting Styles and Dimensions Questionnaire (PSDQ) evaluated the mothers' parenting styles. The psychosocial functioning of the participating children was assessed with the parental version of the Strengths and Difficulties Questionnaire (SDQ). The relationship between parenting styles, psychosocial parameters, and weight outcomes was investigated using a linear regression analysis. Weight-related stigma at school (56%), body image concerns (66%), and difficulties in family relationships (48%) were the main concerns documented during the initial psychological interviews. According to the SDQ, there was a significant decrease in children's conduct problems during the study's initial phase (pre-pilot group). A decrease in maternal demandingness (i.e., strict parenting style) was associated with a decrease in BMI z-score (beta coefficient = 0.314, p-value = 0.003). Decreasing parental demandingness was associated with better weight outcomes, highlighting the importance of assessing parenting factors in pediatric weight management programs.

Pathways to paediatric urology subspecialisation: a study of casemix, incumbent attitudes and opinions

ObjectiveTo identify any self-reported differences or attitudes towards certification, publication, or practice patterns between adult urology and paediatric general surgery-trained paediatric urology providers. There are no known published differences in clinical/operative/research outcomes in either group.MethodsAn 18-item cross-sectional survey was compiled through the EAU Young Academic Urologists (YAU) office and disseminated to a trans-Atlantic convenience sample of current practising paediatric urologists. This was created using a mini-Delphi method to provide current semi-quantitative data relating to current opinions and attitudes of this cohort.ResultsA total of 228 respondents completed the survey, with female respondents representing 37% and 34% for urology and paediatric general surgery, respectively. Nearly 90% overall respondents felt that a full 2-year paediatric fellowship program was very important and 94% endorsed a collaborative dedicated paediatric urology on call service, with 92% supporting the joint development of transitional care. Urology managed higher numbers of bedwetting (p = 0.04), bladder bowel dysfunction (p = 0.02), endourological procedures (p = 0.04), and robotics (p = 0.04). Paediatric general surgery managed higher numbers of laparoscopic reconstruction (p = 0.03), and posterior urethral valve ablation (p = 0.002).ConclusionThis study represents the first time that a cross-sectional cohort of paediatric urologists from different training backgrounds were compared to assess their productivity, practice patterns and attitudes. Paediatric urology is in a unique position to have two contributing specialities, with the ability to provide optimal transitional and lifelong care. We believe that there should be a strong emphasis on collaboration and to remove any historically-created barriers under policies of equity, diversity and inclusivity.