Pediatric Referrals Research Articles

12 Access to paediatric maltreatment services through a northern community hospital

Abstract Background Few studies have evaluated how paediatric maltreatment services based in community hospitals can provide access to care for populations who live far away from tertiary centres. The Violence Intervention Prevention Program (VIPP) and the Paediatric Abuse and Referral Evaluation (PARE) clinic based in a northern community hospital in Canada offer assessment for sexual and physical maltreatment. Objectives The aim of the study was to describe demographic and clinical characteristics of patients accessing VIPP and PARE services and to characterize the length of time required to access care. Design/Methods We conducted a retrospective chart review of patients, under 16 years of age, who attended PARE clinic for initial consultation between 2017-2019. Analyses were descriptive. This work was approved by the research ethics board at our hospital. There are no funding disclosures. Results Of 164 patients, 62.2% were female; 37.8% male. The mean age was 6.6 years, ranging from 1 month to 15.9 years. 54.3% of referrals were for suspected physical maltreatment, 44.4% for suspected sexual maltreatment and 1.2% for both. 87.5% of patients listed home addresses within the hospital’s city limits. The maximum distance travelled from home to access care was 171 km. 87.2% of patients presented through the emergency department; a minority presented through direct referral to outpatient services (11.5%) or through inpatient (1.2%). When called from the emergency department, on-call VIPP nurses responded within a mean of 32 minutes for initial assessment. These patients received a maltreatment assessment by a paediatrician through the PARE clinic a mean of 14.3 days later. If patients did not present through the emergency department, the mean wait time for a maltreatment assessment by a paediatrician was 16 days. 13.4% (22/164) required referral to other medical or multidisciplinary services. General paediatrics (11/22) was the most frequent referral, followed by community speech programs (5/22). A minority (3.0%) of cases required consultation with external maltreatment teams, where two cases were peer-reviewed with a tertiary care team, one with a paediatric maltreatment physician at another community hospital and two cases were reviewed with a paediatric tertiary care radiologist. Conclusion Our results suggest that community-based paediatric maltreatment services provide care for our regional northern population. There is timely on-call access to allied-health providers through the emergency department. All patients were able to be assessed locally and none were required to travel to a tertiary care hospital. Further study is needed to assess how our data compares to other community maltreatment programs.

85 Improving children and families healthcare experiences through a Community Social Paediatrics model

Abstract Background The clinical presentation of children with referrals related for behavioral and school difficulties is often complex and involves environmental and psychosocial components in addition to medical considerations. Collaborative, team based, holistic and integrated approaches are standard of care for many medically complex conditions but less emphasized for what is considered more general presentations in Paediatrics. Given the complexity of patients presenting with challenging behaviors, an integrated approach should be considered as a patient centered and efficient model of care. Objectives The aim of this study was to determine if using a Community Social Paediatrics (CSP) model with an interdisciplinary team can improve experiences and outcomes for families of children being assessed for challenging behaviors who also have complex psychosocial considerations. Design/Methods This pre-post study recruited families with children who had received behaviour-related Paediatric referrals. Participants received the standard of care and additional resources typical to a CSP model, including support from a social worker, home visits, and referral/funding for clinically indicated therapeutic services such as occupational therapy. Three measures were used to evaluate the experience and outcomes of patients and families prior to intake and after 12 months of care: Paediatric Integrated Care Survey (PICS), Child Behaviour Checklist (CBCL), and Quality of Relationship Inventory (QRI). Descriptive analyses of demographics and subscale scores were conducted. Paired t-tests were conducted to detect significant changes in subscale scores across time points. Results In total, 31 caregivers completed the intake assessment and 26 of these completed the follow-up assessment for their children, who were between the ages of 5 to 14 at the time of intake. The QRI scores, which assessed the child-caregiver relationship, indicated a significant decrease in the conflict subscale between timepoints (M1=2.23, M2=1.87, p<0.005). Similarly, the CBCL scores indicated significant reductions in aggressive behaviour (M1= 68.65, M2= 64.77, p<0.05) and conduct problems (M1= 68.69, M2= 62.31, p<0.05). The PICS scores indicated families reported fewer access problems (M1= 3.35, M2= 1.19, p<0.005), and better communication with health care providers (M1= 14.53, M2= 16.92, p<0.05). Conclusion Findings indicate that aspects of the family experience and child outcomes were significantly improved after receiving care through the CSP model. In particular, the reduction of caregiver-child conflict, aggressive behaviour, and conduct problems may indicate that the child’s needs are being more effectively met, thus reducing conflict at home and school. Paediatricians should strongly consider an interdisciplinary model when seeing children for behavioral referrals. This may be especially true for those with complex psychosocial needs.

Characteristics of inflammatory disease structure in the maxillofacial region among children of different age groups in Krasnodar Krai

Relevance. Acute purulent-inflammatory diseases of the maxillofacial region (APID-MFR) are the leading cause of pediatric referrals to the maxillofacial surgery department. The prevalence of APID-MFR requiring hospitalization among children in Krasnodar and Krasnodar Krai averaged 42.9% from 2017 to 2021.Objective. To investigate the nature and structure of odontogenic and non-odontogenic inflammatory processes in patients treated at the maxillofacial surgery department of the State Healthcare Institution "Children’s Regional Clinical Hospital" (CRCH), Krasnodar.Materials and methods. Medical records of patients with inflammatory diseases of the maxillofacial region, treated in the maxillofacial surgery department at CRCH, Krasnodar, from 2017 to 2021, were analyzed. The study focused on examining the structure and characteristics of the pathology in patients receiving inpatient care.Results. The most common pathology identified in children was periostitis (30.9%), which significantly differed (p = 0.007) from the second most prevalent condition, exacerbation of chronic periodontitis (26.1%). The third place was shared by lymphadenitis (13.6%) and inflammatory skin and subcutaneous tissue diseases, including boils and carbuncles (13.5%), both of which significantly differed from the top two conditions (p < 0.001) but not from each other (p > 0.05). In fourth, fifth, and sixth places were other inflammatory skin and subcutaneous tissue diseases: abscess (10.1%), phlegmon (4.8%), and adenophlegmon (1.0%), which also significantly differed from one another.Conclusion. The high prevalence of odontogenic APID-MFR in children highlights the insufficient prevention of caries-related complications and emphasizes the need for enhanced pediatric dental care. Early diagnosis and pre-vention of APID-MFR complications are crucial to improving outcomes in affected children.

The Effects of the COVID-19 Pandemic on Pediatric Orthopedic Injuries: A Single-Center Retrospective Study.

The COVID-19 pandemic has had a profound effect on the pediatric population worldwide. The consequences of the lockdown and the reallocation of hospital resources have caused notable changes in the presentation of pediatric orthopedic injuries. Through our use of patient records, we were able to display the epidemiological trends, as well as analyze the changes in the type and mechanism of various injuries. Our purpose is to further understand the considerable effects of the COVID-19 pandemic on pediatric orthopedic trauma and help guide the allocation of future healthcare resources. We conducted a retrospective cohort study on pediatric patients admitted for any orthopedic injury over a 3-year period (September 2018 to August 2021) at a Midwest level 1 trauma center. Cases were stratified into two groups based on the United States' COVID-19 lockdown (19 March 2020): Pre-COVID-19 cases were any cases prior to the lockdown and Intra-COVID-19 which are cases following the lockdown. Numerical data and categorical variables were summarized and differences between the case groups were examined using either two-Proportion Z-Test, Independent Two-Sample t-test, Pearson's chi-squared, or Fisher's exact tests. A total of 3179 pediatric orthopedic referrals occurred between the Pre-COVID-19 and Intra-COVID-19 study periods. We observed a general decrease in orthopedic injuries following the COVID-19 lockdowns with 1235 injuries compared to 1606 Pre-COVID-19. Patterns in the locations of injuries changed; notably, fractures of the humerus, tibia, and fibula decreased significantly (p < 0.05). Several mechanisms of injuries decreased significantly following the onset of COVID-19 including injuries caused by monkey bars, basketball, and automobiles (p < 0.01). There was a significant increase in the overall injury severity during the Intra-COVID-19 period (p < 0.05). Although there was a reduction in acute orthopedic trauma referrals, many injury mechanisms displayed similar trends regardless of restrictions. We clinically observed an overall increase in the severity of pediatric orthopedic injuries during the COVID-19 pandemic.

Pediatric Dermatology eConsultation in Academic Centers: A Collaborative Model for Optimized Outpatient Care.

The demand for pediatric dermatology services in the U.S. is high, especially at large academic healthcare centers. eConsultation programs provide a solution to poor in-person access by offering diagnostic and management support to primary care providers (PCPs). To determine the real-world utility of eConsultation in pediatric dermatology within a closed system at a major academic center, we assessed the outcomes, diagnostic and management concordance, and predictors of eConsult completion of an asynchronous provider-to-provider pediatric dermatology eConsult program. Retrospective cohort study of 900 consecutive outpatient pediatric dermatology eConsult referrals from PCPs at a tertiary academic center from 2017 to 2021. Of 900 eConsult referrals, 621 (69%) were completed without the need for in-person dermatology follow-up. 46 (5%) were completed but required follow-up. 233 eConsult referrals (26%) were declined, primarily due to medical complexity. Thirty referrals (3%) were declined because of inadequate clinical photos. The PCP communicated eConsult recommendations to the patient/family on an average of 1.6 days (SD 3) after receiving the completed eConsult. eConsults for adolescents were less likely to be completed compared to infants (p = 0.03). Diagnostic and management concordance between PCP and dermatologist was 78% and 67%, respectively. Provider-to-provider eConsultation provides rapid speciality guidance to PCPs managing low-complexity skin conditions in pediatric outpatients. The lower rate of management plan concordance compared to diagnostic concordance suggests that eConsultation improves outpatient skin management by PCPs.

Development and Evaluation of Pediatric Acute Care Hospital Referral Regions in Eight States

To develop a set of pediatric acute care hospital referral regions for use in studying pediatric acute care delivery, and test their utility relative to other regional systems. We used state-level administrative databases capturing all pediatric acute care in eight states to construct novel referral regions. We first constructed pediatric hospital service areas (PHSAs) based on 5,837,464 pediatric emergency department encounters. We then aggregated these PHSAs to pediatric hospital referral regions (PHRRs) based on 344,440 pediatric hospitalizations. Finally, we used three measures of spatial accuracy (localization index, market share index, and net patient flow) to compare this novel region system with the Dartmouth Atlas, designed originally to study adult specialty care, and the Pittsburgh Atlas, designed originally to study adult acute care. The development procedure resulted in 717 novel PHSAs, which were then aggregated to 55 PHRRs across the included states. Relative to HRRs in the Dartmouth and Pittsburgh Atlases, PHRRs were fewer in number and larger in area and population. PHRRs more accurately captured patterns of pediatric hospitalizations, (eg, mean localization index: 69.1 out of 100, compared with a mean of 58.1 for the Dartmouth Atlas and 62.4 for the Pittsburgh Atlas). The use of regional definitions designed specifically to study pediatric acute care better captures contemporary pediatric acute care delivery than the use of existing regional definitions. Future work should extend these definitions to all US states to enable national analyses of pediatric acute care delivery.

Analysis of interhospital emergency referrals despite safety concerns on the roads: Emergency referrals in Northwest Syria intraregional borders

Objectives This study aims to assess emergency patient referrals between hospitals in the northwestern region of Syria. In this way, determining the patient profiles referred in the region can help shed light on the reasons for avoidable referrals, reduce referrals, and reduce the risks associated with referrals. Methods This retrospective study investigated the patients who were referred to AAA Hospital, BBB Hospital, and CCC Hospital and from these facilities within the borders of the northwestern region of Syria between 01/01/2020-01/01/2021. Referral records of patients transferred between hospitals and ambulance stations were searched in files and computer records. Because there was no automation system in the healthcare facilities involved in the study, data were recorded manually on the data collection form and processed for statistical analysis. Statistical analyzes of the study were performed as descriptive statistics of variables are reported as mean∓standard deviation, median (min-max), and n(%). Statistical analyzes of categorical variables were performed using the chi-square test and Fisher Freeman Halton Exact test. Results The mean age of the patients of 899 patients included in the study was 33.68∓26.80 years, 530(59.0%) were male and 369(41.0%) were female. 27.3% of patients were trauma patients and of both sexes. Male trauma patients were approximately 2.5 times more common than female trauma patients. Among pediatric referrals, trauma was present in one out of every three patients. Patients were most frequently referred in February, March, and June and least frequently in January (p &lt; 0.05). It was found that the need for adult, newborn, and pediatric intensive care, the need for medical material and equipment, the need for further examination/treatment, followed by the need for treatment under the supervision neurosurgeon, obstetric and gynecologist, cardiology specialist, or pediatrician. It was also noted that referrals for COVID -19 (SARS-CoV-2 Coronavirus Disease 2019) service needs due to the impact of the COVID -19 outbreak during the study period were among the most common reasons. COVID -19, falls, respiratory distress, traffic accidents, and acute MI were the most common diagnoses in all referred age groups. Conclusion In northwestern Syria, emergency patients are most often referred from one hospital to another because they require all types of intensive care units, medical materials and equipment, advanced diagnostic treatment, and specialists in neurosurgery, obstetrics and gynecology, cardiology, and pediatrics. Increasing hospital capacity and qualifications of hospitals within the humanitarian response and increasing the number of specialists, may be considered to reduce inter-hospital referrals of emergency patients.

Paediatric patient referrals from Greenland to the National University Hospital, Rigshospitalet, Denmark.

Greenlandic patients may be referred to Denmark for specialised diagnostics and treatment. The main collaborator for these activities is the National University Hospital, Rigshospitalet, Copenhagen. We aimed to investigate the referral pattern of Greenlandic paediatric patients to Rigshospitalet. This was an observational quality assurance project comprising all Greenlandic patients below 18 years who received healthcare services at Rigshospitalet in the 2017-2021 period. This period was chosen to obtain the most updated, available and coherent data possible. Unique patients and disease courses were stratified by paediatric subspecialities and procedures. During the five-year period, a total of 310 unique patients were referred to Rigshospitalet, resulting in a total of 676 disease courses and yielding an average 62 annual referrals of paediatric Greenlandic patients. This represents around 0.5% of all Greenlandic children. Age groups were distributed as 28% aged 0-1 years, 23% 2-4 years, 13% 5-9 years, 21% 10-14 years and 16% 15-17 years. During the study period, the number of disease courses increased by 89% with most patients being managed as outpatients. The subspecialities with most referrals were ophthalmology (17%), oto-rhino-laryngology (16%) and cardiovascular diseases (10%). Approximately 0.5% of Greenlandic children were referred annually to Rigshospitalet with a marked increase being observed during the five-year study period. We observed a shift towards an increasing proportion of outpatient treatments at Rigshospitalet. None. Not relevant.

Optimizing paediatric specialist referrals for short stature in an era of multiple growth hormone indications.

The assessment of growth during infancy and childhood is an essential component of paediatric medicine, as atypical growth may point to the existence of an underlying health condition. To reduce morbidity, it is vital that treatment for growth disorders is provided in a timely fashion. However, although there are guidelines regarding referral criteria for short stature in Europe and the USA, there are no such guidelines in Canada. To address this, a series of consultations and workshops with paediatricians, paediatric endocrinologists, family physicians and nurses were held, with the aim of developing a consensus-based set of recommendations for children in Canada showing atypical growth and to identify red flags for children who might benefit from early referral. To achieve this, a referral algorithm and referral form for primary care providers were developed to ensure timely and appropriate referrals, and transmission of the most relevant details to the secondary care consultant.

Outcomes of paediatric and adolescent referrals into a specialist breast unit

Outcomes of paediatric and adolescent referrals into a specialist breast unit

Evaluating Chat Generative Pre-trained Transformer Responses to Common Pediatric In-toeing Questions.

Chat generative pre-trained transformer (ChatGPT) has garnered attention in health care for its potential to reshape patient interactions. As patients increasingly rely on artificial intelligence platforms, concerns about information accuracy arise. In-toeing, a common lower extremity variation, often leads to pediatric orthopaedic referrals despite observation being the primary treatment. Our study aims to assess ChatGPT's responses to pediatric in-toeing questions, contributing to discussions on health care innovation and technology in patient education. We compiled a list of 34 common in-toeing questions from the "Frequently Asked Questions" sections of 9 health care-affiliated websites, identifying 25 as the most encountered. On January 17, 2024, we queried ChatGPT 3.5 in separate sessions and recorded the responses. These 25 questions were posed again on January 21, 2024, to assess its reproducibility. Two pediatric orthopaedic surgeons evaluated responses using a scale of "excellent (no clarification)" to "unsatisfactory (substantial clarification)." Average ratings were used when evaluators' grades were within one level of each other. In discordant cases, the senior author provided a decisive rating. We found 46% of ChatGPT responses were "excellent" and 44% "satisfactory (minimal clarification)." In addition, 8% of cases were "satisfactory (moderate clarification)" and 2% were "unsatisfactory." Questions had appropriate readability, with an average Flesch-Kincaid Grade Level of 4.9 (±2.1). However, ChatGPT's responses were at a collegiate level, averaging 12.7 (±1.4). No significant differences in ratings were observed between question topics. Furthermore, ChatGPT exhibited moderate consistency after repeated queries, evidenced by a Spearman rho coefficient of 0.55 ( P = 0.005). The chatbot appropriately described in-toeing as normal or spontaneously resolving in 62% of responses and consistently recommended evaluation by a health care provider in 100%. The chatbot presented a serviceable, though not perfect, representation of the diagnosis and management of pediatric in-toeing while demonstrating a moderate level of reproducibility in its responses. ChatGPT's utility could be enhanced by improving readability and consistency and incorporating evidence-based guidelines. Level IV-diagnostic.

Vitamin D and pediatric bone health: Important information and considerations for the pediatric orthopaedic surgeon

Vitamin D is an essential fat-soluble vitamin produced in the skin during sun exposure. It plays a considerable role in musculoskeletal health and is largely responsible for the regulation of calcium and phosphate metabolism to maintain a healthy, mineralized skeleton. Optimizing bone mineral density in childhood and adolescence is essential to the foundation of skeletal health; however, the literature lacks consensus on values for normal, deficient, and insufficient serum 25-hydroxyvitamin D levels making supplementation and treatment somewhat challenging.The pediatric orthopaedic surgeon is important to optimizing bone health, particularly in the context of bony pathology/injury. Up to 60% of boys and 40% of girls sustain a fracture in childhood. On top of this baseline incidence, children with low vitamin D levels have been noted to be subject to a higher incidence of fractures from normal activities. While the prevalence of vitamin D deficiency in children in the general population has been determined to be 9%, the prevalence of vitamin D deficiency in the pediatric fracture population can be as high as 75% and 61% of the pediatric population has been determined to have vitamin D insufficiency. The pediatric orthopedist also often is the first to diagnose nutritional rickets as these patients can present solely for complaints of limb deformity. Knowledge of appropriate evaluation, vitamin D supplementation, and indications for pediatric endocrinology referral is vital for the treatment of these patients.In the pediatric population, there is a lack of consensus regarding risk factors that warrant screening for vitamin D deficiency, determining insufficient thresholds, and identifying optimal supplementation recommendations and treatment dosages. More research is needed to clarify the ideal amounts of vitamin D necessary through critical growth periods to prevent rickets and to mitigate fracture risk. Regardless, pediatric Orthopaedic surgeons should promote supplementation to all children and treat diagnosed vitamin D deficiency. Key Concepts(1)Vitamin D plays a vital role in musculoskeletal health and optimizing vitamin D levels in childhood and adolescence is crucial to proper bone development.(2)Vitamin D deficiency and insufficiency in the general population is common; 9% of the pediatric population, representing 7.6 million US children and adolescents, are vitamin D deficient and 61%, representing 50.8 million US children and adolescents, are vitamin D insufficient. The prevalence of vitamin D deficiency in the pediatric fracture population can be as high as 75%.(3)Vitamin D deficiency can lead to nutritional rickets which is the most frequent cause of pediatric bone disease in the world, is entirely preventable, and is characterized by deficient mineralization and subsequent architectural disruption of the physis.(4)Vitamin D supplementation is widely recommended and believed to be beneficial, but there are inconsistent guidelines regarding target levels for optimal vitamin D status.

What's age got to do with it? A study of the implementation of the discharge medicines service for paediatric patients.

The discharge medicines service (DMS) was introduced as an essential service for all community pharmacies in England through the Community Pharmacy Contractual Framework (CPCF) in February 2021. This study aimed to describe the implementation of this service for paediatric patients and to identify any barriers to referrals. The study was undertaken in a 24-bed paediatric ward in a District General Hospital from September 2022 to February 2023. All paediatric inpatients on long-term medications were eligible for inclusion. Out of 169 eligible participants, 149 were referred. Community pharmacists accessed referrals through PharmOutcomes® and could accept, complete, or reject referrals on this platform. Of the 149 referred patients, 24 (16.1%) were accepted but not yet actioned; 63 (42.3%) were fully or partially completed; 19 (12.8%) were rejected, and 43 (28.9%) there was no response (remained as referred). Younger children (<2 years) were more likely to have their referral rejected than older children (6 years and older). The feedback from parents was overwhelmingly positive (93.5%) and two families reported that they believed the DMS service prevented readmission to the hospital for their children. No children were involved in the community pharmacist consultation. Barriers to referrals included patients not having a nominated pharmacy and a lack of confidence in completing paediatric referrals. This study demonstrates the value of completing referrals for paediatric patients. More research is required to explore how community pharmacists can be supported to complete paediatric DMS referrals.

High prevalence of carbapenem resistance and clonal expansion of blaNDM gene in Klebsiella pneumoniae isolates in an Iranian referral pediatric hospital

BackgroundThe increasing global concern regarding antibiotic resistance necessitates in-depth studies to comprehend the phenotypic and genotypic characteristics of resistant bacterial strains. This study aimed to investigate the prevalence, antibiotic resistance profiles, and molecular characteristics of carbapenem-resistant Klebsiella pneumoniae (CRKP) isolates in an Iranian referral pediatrics hospital. Methods: In this study, we examined CRKP isolates collected from hospitalized pediatric patients across various wards. The isolates underwent antimicrobial susceptibility testing, the polymerase chain reaction (PCR) analysis for carbapenemase genes (blaNDM, blaVIM and blaIMP), and genetic relatedness assessment using pulsed-field gel electrophoresis (PFGE).ResultsAmong 166 K. pneumoniae isolates, 54 (32.5%) exhibited resistance to carbapenems. Notably, all these resistant isolates were resistant to imipenem, with 35 (65%) displaying resistance to both imipenem and meropenem. Of the 54 CRKP isolates, 24 (44%) were metallo-β-lactamases (MBL)-producing. The prevalence of the blaNDM gene among CKCP and MBL-producing isolates was 20% (n = 11) and 44% (n = 24), respectively. The blaVIM and blaIMP genes were not detected in any of the isolates. Twenty-six CRKP isolates (48%) were recovered from ICUs. PFGE analysis of CRKP isolates revealed 20 clusters, with cluster S being the most prevalent, comprising 24% of the total (n = 13).ConclusionOur study reveals a concerning prevalence of carbapenem resistance in K. pneumoniae isolates. Specifically, the detection of the blaNDM gene in 20% of CRKP isolates, with a significant proportion (82%) observed in isolated CRKP from the ICUs and emergency departments, underscores the potential clonal expansion of these resistant strains within these critical hospital wards.

Pediatric ACEs Screening and Referral: Facilitators, Barriers, and Opportunities for Improvement.

Despite well-documented associations between adverse childhood experiences (ACEs) and lifelong impairments in health and well-being, few studies have examined how to facilitate implementation of ACEs screening and referral programs in pediatric settings. We sought to identify facilitators and barriers related to screening for and addressing ACEs in a large integrated healthcare delivery system in Southern California. Using a developmental evaluation approach, we conducted twenty semi-structured interviews with pediatricians, nurses, social workers, and community referral organization staff. Interviews took place across six pediatric clinic pilot sites in Kaiser Permanente Southern California, where more than 7,000 pediatric patients were screened for ACEs between July 2018 and December 2019. Thematic analysis was conducted to identify themes. Key facilitators for screening and referrals for pediatric ACEs screening included providing clinician education to normalize conversations about ACEs, using screening data to provide more holistic and compassionate care, and collaborating across different types of clinicians. Key barriers included screening tool challenges related to patient confusion and cultural differences, capacity limitations, training issues, and care team silos. When used in the context of a trauma- and resilience-informed workforce, ACEs screening may be a powerful tool to support more collaborative and impactful care decisions that move away from symptom management to address root causes and promote prevention.

Impact of Cytomegalovirus (CMV) on an Academic Pediatric Infectious Diseases Outpatient Clinic Referral Population, 2005-2020: Will the Advent of Universal Congenital CMV (cCMV) Screening Change Clinical Practice Referral Patterns?

Cytomegalovirus (CMV) infections exert a substantial impact on the practice of pediatric infectious diseases. Although most infections in children are minimally symptomatic, several populations are at risk for CMV-associated disease, including immunosuppressed children, children with HIV infection, and, most significantly, children with congenital CMV (cCMV) infection. In spite of the ubiquitous nature of CMV infection, few studies have quantified the impact of CMV-associated care in a pediatric outpatient clinic setting. We evaluated the impact of CMV on clinical care in an outpatient clinic setting over a fifteen-year period at the University of Minnesota (UMN) Masonic Children's Hospital Pediatric Infectious Diseases (PID) Clinic. A retrospective review of clinic appointments identified 253 unique patients specifically evaluated over this time period for consideration of CMV infection. Of these, 242 were pediatric patients. The majority of the pediatric patients evaluated in the PID clinic were referred for either confirmed or suspected cCMV infection, including children referred for consideration of CMV as a potential reason for a failed newborn hearing screen (NHS) and/or for evaluation of CMV as a possible etiology for documented hearing loss. In total, 116 of the children evaluated during this time period (48%) were unequivocally confirmed as having cCMV infection, with an additional 37 (15%) presenting with presumed, probable, or possible cCMV infection. A total of 16 (7%) of the pediatric CMV cases were confirmed to be post-natally acquired infections. Of the 253 total patients, 11 (4%) of the referrals were for pregnant patients seeking advice about potential therapies in the setting of a known or suspected primary maternal infection during their pregnancies, with an attendant risk of fetal CMV infection. This overview of the demographics and referral patterns for patients evaluated for known or suspected CMV infections in a tertiary care center outpatient PID clinic will serve as a useful baseline assessment, even as future patterns of outpatient care are highly likely to evolve. We predict that PID clinic referrals for newborns identified by universal cCMV screening programs will result in a shift of the CMV outpatient population to healthier infants with clinically inapparent infections, and care will need to be taken by practitioners not to over-medicalize management for these asymptomatic newborns.

Protocol-Based Standardized Endocrinological Evaluation of Children With Traumatic Brain Injury: A Quality Improvement Initiative.

Traumatic brain injury (TBI) can disrupt the hypothalamo-pituitary axis, causing neuroendocrine dysfunction. As a third of children can develop post-traumatic hypothalamo-pituitary axis dysfunction (HPAD), a longitudinal follow-up is required in children with TBI. The study comprised a pre-quality improvement (QI) phase (baseline phase) and a QI phase (post-intervention phase). Retrospective data were collected on children with TBI at our hospital during the pre-QI phase of the study to estimate the baseline data on HPAD prevalence and pediatric endocrine referral rate. Guidance protocol for standardizing the pediatric endocrine referral, evaluation, and follow-up of children with TBI was implemented. Prospective data were collected to estimate outcome measures (prevalence of HPAD, rate of initial endocrine consultation and outpatient follow-up) and process measures (protocol adherence rate). Twenty-seven children, aged ≤19 years, were admitted with TBI in the pre-QI phase. The median age was 9 years. Motor vehicle accidents predominated. Thirty percent had limited endocrine evaluation, and 4% had transient cranial diabetes insipidus (DI). The QI phase included 8 children. Demographic data were similar to those in the pre-QI phase. Both outcome and process measures increased to 75% from the pre-QI phase following the protocol implementation. A lower prevalence rate of HPAD in the current cohort may be owing to underevaluation and a smaller sample size. The QI initiative incorporating a guidance protocol-based endocrinological approach to children with TBI improved the pediatric endocrinology referral and follow-up rates.

Safety beyond Sight: Handheld Metal Detectors as Diagnostic Allies in the Management of Children Suspected to have Ingested Foreign Bodies.

Foreign body (FB) ingestion remains a common cause of pediatric emergency department referrals, and the gold standard for detection is whole-digestive-tract radiographic examination. Our study explores whether handheld metal detectors (HHMD) can effectively identify the presence and location of ingested metal objects, potentially reducing the need for additional radiographic examination. We collected medical data from children with suspected metal FB ingestion who were referred to our emergency department (October 2017-March 2023), focusing on object type and correlating metal detector findings with radiographic images. Data from 43 children (39.5% female; mean age: 4 y) referred to our emergency department were analyzed. Coins (32.6%), button batteries (18.6%), and hairpins (11.6%) were the most common ingested objects. Metal detectors detected the presence of FBs in 81.4% of cases (sensitivity: 89.7%; specificity: 100%). Radiographs, taken for 40 children, showed that the most common locations were the stomach (37%) and intestine (33%). The metal detector signals matched the radiography results in 69.8% of cases. According to HHMD, 34.9% of objects were accessible via endoscopy, contrasting with 51.2% via radiography (p < 0.05). While the findings obtained using handheld metal detectors often correlate well with radiograph findings in detecting metal FBs, for an important number of children, this confirmation is lacking, especially when determining the exact location of an object.

Amblyopia Care Trends Following Widespread Photoscreener Adoption

Amblyopia can result in permanent vision loss if not properly treated before age 7 years. In 2017, the US Preventive Services Task Force recommended that vision screening should occur at least once in all children aged 3 to 5 years to detect amblyopia. To understand trends and factors associated with screening, referral, or diagnosis of amblyopia before and after photoscreening expansion across a relatively large health care system in late 2017. This is a retrospective cohort study of electronic health record data from patients with a well child care visit at approximately age 3 years (ages 2.75-3.25 years) in a relatively large, multispecialty group practice in Northern California and linked census data between 2015 and 2022. Data were extracted and analyzed from October 2022 through August 2023. Patient sex, race and ethnicity, immunization records, previous well child care visits, and census-level median household income. Vision screening, pediatric ophthalmology referral, or amblyopia diagnosis, compared using adjusted odds ratios (AORs). The study included 2015-2017 data from 23 246 patients aged 3 years with at least 1 well child care visit (11 206 [48.2%] female) compared with 2018-2022 postexpansion data from 34 281 patients (16 517 [48.2%] female). The screening rate increased from 5.7% (424 of 7505) in 2015 to 72.1% (4578 of 6354) in 2022. The referral rate increased from 17.0% (1279 of 7505) in 2015 to 23.6% (1836 of 7792) in 2018. The diagnosis rate was 2.7% (200 of 7505) in 2015, peaked at 3.4% (263 of 7792) in 2018, and decreased to 1.4% (88 of 6354) in 2022. Compared with White patients, patients who were Asian, Black, or Hispanic were less likely to be screened (Asian: AOR, 0.80; 95% CI, 0.72-0.88; Black: AOR, 0.71; 95% CI, 0.53-0.96; Hispanic: AOR, 0.88; 95% CI, 0.80-0.97). Compared with White patients, patients who were Asian or Hispanic were more likely to be referred (Asian: AOR, 1.49; 95% CI, 1.36-1.62; Hispanic: AOR, 1.32; 95% CI, 1.18-1.48) and were more likely to be diagnosed (Asian: AOR, 1.29; 95% CI, 1.07-1.56; Hispanic: AOR, 1.67; 95% CI, 1.33-2.11). In this study, increased availability of photoscreeners was associated with an increase in overall rates of vision screening for children aged 3 years in a relatively large health care system. Given that US rates of visual impairment are predicted to increase, additional targeted interventions would be needed to address remaining disparities in amblyopia care along patient- and clinician-level factors.

Racial Inequities in Palliative Referral for Children with High-Intensity Neurologic Impairment

ObjectiveTo evaluate whether racial and socioeconomic inequities in pediatric palliative care utilization extend to children with high-intensity neurologic impairment (HI-NI), which is a chronic neurological diagnosis resulting in substantial functional morbidity and mortality. Study designWe conducted a retrospective study of patients with HI-NI who received primary care services at a tertiary care center from 2014 through 2019. HI-NI diagnoses that warranted a palliative care referral were identified by consensus of a multidisciplinary team. The outcome was referral to palliative care. The primary exposure was race, categorized as Black or non-Black to represent the impact of anti-Black racism. Additional exposures included ethnicity (Hispanic/non-Hispanic) and insurance status (Medicaid/non-Medicaid). Descriptive statistics, bivariate analyses, and multivariable logistic regression models were performed to assess associations between exposures and palliative care referral. ResultsA total of 801 patients with HI-NI were included; 7.5% received a palliative referral. There were no differences in gestational age, sex, or ethnicity between patients who received a referral and those who did not. In multivariable analysis, adjusting for ethnicity, sex, gestational age, and presence of complex chronic conditions, Black children (aOR 0.47, 95% CI 0.26, 0.84) and children with Medicaid insurance (aOR 0.40, 95% CI 0.23, 0.70) each had significantly lower odds of palliative referral compared with their non-Black and non-Medicaid-insured peers, respectively. ConclusionsWe identified inequities in pediatric palliative care referral among children with HI-NI by race and insurance status. Future work is needed to develop interventions, with families, aimed at promoting more equitable, antiracist systems of palliative care.