Pediatric Screening Research Articles

The state of the science on trauma inquiry.

Within the context of longitudinal medical care for adults, health care providers have a unique opportunity to inquire and respond to the traumatic life experiences affecting the health of their patients, as well as a responsibility to minimize retraumatizing these patients during medical encounters. While there is literature on screening women for intimate partner violence, and there is emerging data on pediatric screening for adverse life experiences, there is sparse literature on inquiry of broader trauma histories in adult medical settings. This lack of research on trauma inquiry results in an absence of guidelines for best practices, in turn making it challenging for policy makers, health care providers, and researchers to mitigate the adverse health outcomes caused by traumatic experiences and to provide equitable care to populations that experience a disproportionate burden of trauma. This state of the science summarizes current inquiry practices for patients who have experienced trauma, violence, and abuse. It places trauma inquiry within an anchoring framework of trauma-informed care principles, and emphasizes a focus on resilience. It then proposes best practices for trauma inquiry, which include tiered screening starting with broad trauma inquiry, proceeding to risk and safety assessment as indicated, and ending with connection to interventions.

Screening for intellectual disability with the Child and Adolescent Intellectual Screening Questionnaire: a modified Delphi approach.

To develop a consensus framework to evaluate the impact of screening for intellectual disability, using the Child and Adolescent Intellectual Disability Screening Questionnaire (CAIDS-Q) in paediatric neurodevelopment clinics. A modified Delphi survey with four phases (literature review; initial development of framework [participants=11 parents, 8 professionals]; qualitative interviews [participants=4 parents, 15 professionals]; questionnaire development [participants=31 parents, 14 professionals] was used to develop the consensus framework. The framework was used to evaluate the impact of screening on six paediatricians and 31 parents of children who had participated in a previous paediatric screening project. Twelve of the original 20 items were retained based on levels of endorsement of 60 per cent or above. Direct benefits of using the CAIDS-Q were: indicating the child's level of functioning, increasing awareness of intellectual disability, helping to identify children with intellectual disability, and identifying potentially vulnerable children. Benefits related to subsequent diagnostic assessment were: promoting greater understanding of the child, identification of support needs, and receipt of support, particularly for the child at school. The use of the CAIDS-Q had a number of direct and indirect benefits for children, families, and services as reported by parents and paediatricians. A 12-item framework was developed to evaluate the impact of screening for intellectual disability. Direct benefits of the Child and Adolescent Intellectual Disability Screening Questionnaire include increasing awareness and identification of intellectual disability. Indirect benefits included increased identification of support needs and receipt of support.

FMR1 allele size distribution in 35,000 males and females: a comparison of developmental delay and general population cohorts

PurposeDevelopmental delay phenotypes have been associated with FMR1 premutation (PM: 55–200 CGG repeats) and “gray zone” (GZ: 45–54 CGG repeats) alleles. However, these associations have not been confirmed by larger studies to be useful in pediatric diagnostic or screening settings. MethodsThis study determined the prevalence of PM and GZ alleles in two independent cohorts of 19,076 pediatric referrals to developmental delay diagnostic testing through Victorian Clinical Genetics Service (cohort 1: N = 10,235; cohort 2: N = 8841), compared with two independent general population cohorts (newborn screening N = 1997; carrier screening by the Victorian Clinical Genetics Service prepair program N = 14,249). ResultsPM and GZ prevalence rates were not significantly increased (p > 0.05) in either developmental delay cohort (male PM: 0.12–0.22%; female PM: 0.26–0.33%; male GZ: 0.68–0.69%; female GZ: 1.59–2.13-%) compared with general population cohorts (male PM: 0.20%; female PM: 0.27–0.82%; male GZ: 0.79%; female GZ: 1.43–2.51%). Furthermore, CGG size distributions were comparable across datasets, with each having a modal value of 29 or 30 and ~1/3 females and ~1/5 males having at least one allele with ≤26 CGG repeats. ConclusionThese data do not support the causative link between PM and GZ expansions and developmental-delay phenotypes in pediatric settings.

Paediatric periodontal screening methods in undergraduate dental schools.

Many forms of periodontal diseases affect children and adolescents. The simplified basic periodontal examination (BPE) is a screening tool for children aged seven to 17, which enables early recognition of such diseases. This study aims to investigate and compare methods of periodontal health assessments in the 'under-18s' across dental schools in the UK. A web-based questionnaire was issued via email to teaching members of staff in each of the 16 undergraduate dental universities across the UK. Out of the 16 correspondents, ten universities completed the questionnaire, giving a response rate of 63%. All respondents were aware of methods of periodontal screening for children and adolescents such as the simplified BPE. All universities taught and used the 'simplified BPE'. The majority of universities started paediatric clinics in year three and carried out practical periodontal assessments in children aged seven and above, at first visit and at recall. All UK dental schools were aware of, taught and used the simplified BPE as a method of periodontal assessment. Most universities seemed to comply with the guidelines being implemented.

446. Leveraging Partnerships to Care for Babies Born to Mothers after Maternal Zika Infection—US Virgin Islands (USVI)

BackgroundSince February 2016, the US Virgin Islands Department of Health (VIDOH) has been monitoring the Zika outbreak and its effects on maternal and child health. As of March 19, 2018, the territory reported 291 women with confirmed laboratory evidence of Zika virus during pregnancy. Residents had limited access to the recommended pediatric screenings and specialty services related to Zika virus disease. VIDOH requested technical assistance from Centers for Disease Control and Prevention, Health Resources and Services Administration, Family Voices, and American Academy of Pediatrics to provide these services in the USVI in March 2018.MethodsVIDOH staff called 291 mothers, connected with 148, and scheduled 114 appointments. The clinic set-up included: two intake, four neurology, threeophthalmology, one audiology, one developmental, child life team, and two exit stations. Infants received comprehensive neurology, developmental, ophthalmology, and audiology examinations and were connected to resources such as Infant and Toddlers: Early Intervention services, Act Early: Learn the Signs, Disability Rights of the Virgin Islands and local specialized physicians. A data abstraction team of six reviewed charts for accuracy and abstracted data into both the US Zika pregnancy registry forms and the local Zika database.ResultsThe visiting specialists evaluated 88 infants; 65 (73.9%) in St. Thomas and 23 (26.1%) in St. Croix, 84 (73.7%) appointments and four walk-ins. There were 53 (60.2%) males and 35 (39.8%) females. Seven (7.9%) infants were 0–2 months, 18 (20.5%) were 3–6 months, 38 (43.2%) were 7–12 months, 25 (28.4%) were 13–24 months. Fifty-eight (65.9%) infants were referred for further follow-up; 35 (60.3%) to an audiologist, 20 (34.5%) to Infants and Toddlers program, 11 (19%) to a neurologist, 10 (17.2%) to an ophthalmologist, 8 (13.8%) to a developmental pediatrician, 8 (13.8%) for physical therapy, four (6.9%) for speech therapy, three(5.2%) for neuroimaging, three(5.2%) for occupational therapy, and 2 (3.4%) to an otorhinolaryngologists.ConclusionProbable hearing loss was the chief finding in many of the infants screened. Further evaluation on these infants has been recommended based on clinical guidance for infants exposed to Zika virus infection. This can help to identify the types of hearing loss associated with Zika infection in utero.Disclosures All authors: No reported disclosures.

Prevalence of pain reports in pediatric primary care and association with demographics, body mass index, and exam findings: a cross-sectional study

BackgroundPediatric pain is associated to patient weight and demographics in specialized settings, but pain prevalence and its associated patient attributes in general pediatric outpatient care are unknown. Our objective was to determine the rate of positive pain screenings in pediatric primary care and evaluate the relationship between reported pain and obesity, demographics, and exam findings during routine pediatric encounters.MethodsCross-sectional observational study of 26,180 patients ages 2 to 19 seen in five urban pediatric primary care clinics between 2009 and 2016. Data were collected from systematic screening using a computerized clinical decision support system. Multivariable logistic regressions were used to analyze the association between pain reporting and obesity (body mass index), age, sex, race, season, insurance status, clinic site, prior pain reporting, pain reporting method, and exam findings.ResultsPain was reported by the patient or caregiver in 14.9% of visits. In adjusted models, pain reporting was associated with obesity (Odds Ratio (OR) 1.23, 95% Confidence Intervals (CI) 1.11–1.35) and severe obesity (OR 1.32, CI 1.17–1.49); adolescents (OR 1.47, CI 1.33–1.61); and females (OR 1.21, CI 1.12–1.29). Pain reported at the preceding visit increased odds of pain reporting 2.67 times (CI 2.42–2.95). Abnormal abdominal, extremity, ear, nose, throat, and lymph node exams were associated with pain reporting. Pain reporting increased in minority races within clinics that predominantly saw a concordant race.ConclusionsPain is common in general pediatric encounters, and occurs more frequently in obese children and those who previously reported pain. Pain reporting may be influenced by seasonal variation and clinic factors. Future pediatric pain screening may be guided by associated risk factors to improve identification and targeted healthcare interventions.

Risk severity moderated effectiveness of pain treatment in adolescents

Background and aims A targeted pain program may prevent the progression and subsequent occurrence of chronic pain in adolescents. This study tested the effectiveness of a new acceptance and commitment therapy -based pain management intervention, using physical and psychological functions as the outcomes. The objective was also to determine whether Pediatric Pain Screening Tool risk profiles function as outcome moderator in the current sample. A valid screening tool would enable the program development. Methods Thirty-two consecutive adolescent patients (13-17 years old) with idiopathic recurrent musculoskeletal pain completed the study. The intervention comprised acceptance and commitment therapy-oriented multidisciplinary treatment. Pediatric Pain Screening Tool, pain frequency, functional disability, school attendance, physical endurance, depressive symptoms, and catastrophizing coping style were measured before treatment (baseline) and again at 6 and 12 months after the initiation of treatment. To test the effectiveness of the new program, we also determined whether the original risk classification of each patient remained constant during the intervention. Results The intervention was effective for high-risk patients. In particular, the pain frequency decreased, and psychosocial measures improved. In post-intervention, the original risk classification of seven patients in the high-risk category changed to medium-risk. PPST classification acted as a moderator of the outcome of the current program. Conclusions The categorization highlighted the need to modify the program content for the medium-risk patients. The categorization is a good tool to screen adolescent patients with pain. Implications The results support using the Pediatric Pain Screening Tool in developing rehabilitation program for pediatric musculoskeletal pain patients. According to the result, for adolescent prolonged musculoskeletal pain patients the use of ACT-based intervention program is warranted.

Pediatric pain screening identifies youth at risk of chronic pain in sickle cell disease.

This study aimed to evaluate the preliminary validation and application of a pain screening tool to identify biopsychosocial risk factors for chronic pain in pediatric sickle cell disease (SCD) and classify youth with SCD into prognostic risk groups. Youth presenting to a pediatric SCD clinic completed the Pediatric Pain Screening Tool (PPST), a brief 9-item self-report questionnaire developed for rapid identification of risk in youth with pain complaints. Youth also completed a battery of standardized patient-reported outcomes, including pain characteristics, pain burden, functional disability, pain interference, depressive symptoms, pain catastrophizing, and fear of pain. Healthcare utilization was extracted from medical chart review. Seventy-three 8- to 18-year-olds (94% Black, 57% female) with SCD participated. The PPST demonstrated discriminant validity that ranged from fair to excellent (area under the curves (AUC)=0.74-0.93, P values<0.001) for identifying significant pain frequency, disability, pain interference, and psychosocial distress. Receiver operating characteristic curve analyses indicated that previously established cutoff scores were appropriate for the SCD sample. Participants were classified into low-risk (28.8%), medium-risk (38.4%), and high-risk (32.9%) groups, with significant group differences across measures, F(18, 116)=6.67, P<0.001. The high-risk group reported significantly higher pain intensity, pain frequency, pain burden, functional disability, pain interference, and depressive symptoms relative to both low-risk and medium-risk groups (P values<0.005). The high-risk group demonstrated a pain and psychosocial profile consistent with chronic SCD pain. The PPST may be useful for efficiently identifying youth with chronic SCD pain or those at risk of poor outcomes.

Evaluation of the intensified tuberculosis case finding guidelines for children living with HIV.

Out-patient paediatric human immunodeficiency virus (HIV) clinic in Soweto, South Africa. To evaluate the yield of symptom screening for intensified tuberculosis (TB) case finding (ICF) and potential eligibility for isoniazid preventive therapy (IPT) in children living with HIV on antiretroviral treatment (ART). A cohort of 247 children (age 0-8 years) was systematically screened for TB symptoms during the first 2 years of ART. Children with symptoms were assessed using chest X-ray, smear microscopy and culture. Over 2 years, 1346 TB symptom screens were performed in 220 children not on anti-tuberculosis treatment. Only 48 (3.6%) screens in 39 children were positive for current cough, current fever, weight loss (>5%) or contact with a TB patient. The positive predictive value of symptom screening was 8.9% (95%CI 2.5-21.2); the sensitivity was 57.1% (95%CI 18.4-90.1). Most children (85.8%) were IPT-eligible according to World Health Organization guidelines; however, few (1.2%) were eligible according to South African guidelines. The yield of TB symptom screening was relatively poor in children on ART, highlighting the need for future research on paediatric TB symptom screening approaches in this population. The vastly different criteria for IPT eligibility between guidelines suggest that research is also needed to define the optimal use of IPT in children on ART.

Cut points for pediatric lipid screening

The current recommendations from the American Academy of Pediatrics support universal lipid screening for children age 9-11 years. Historically, the cut points used for screening identified children with abnormal lipid values. In this volume of The Journal, Peterson et al evaluated potential higher thresholds that would indicate the need for pharmacologic treatment. They evaluated such thresholds for non-HDL-cholesterol and for HDL-C. They did not find useful thresholds for HDL-C. However, they identified potential new cut points for non-HLD-C, which can be measured without fasting and represents the circulating atherogenic lipid-containing particles. The cut point of 156 mg/dL for children with one or more cardiovascular risk factors and 199 mg/dL for children with no cardiovascular risk factors had 95% or greater sensitivity in predicting the recommendation for pharmacotherapy all had good specificity. These cut points may be useful in the creation of future guidelines for pediatric lipid screening. Article page 220 ▶ Novel Lipid Thresholds for Screening Predict the Need for PharmacotherapyThe Journal of PediatricsVol. 202PreviewTo identify non-high-density lipoprotein cholesterol (HDL-C) and HDL-C thresholds for pediatric nonfasting lipid screens that are more predictive of the need for lipid-lowering pharmacotherapy and estimate numbers of potentially avoidable fasting lipid panels. Full-Text PDF

Nutritional assessment of resettled paediatric refugees in Western Australia.

Nutritional deprivation, inadequate diet and food insecurity are common refugee experiences. The growth and nutritional status of paediatric refugees following resettlement in developed countries and the related interplay with socio-economic factors remain less defined; this study aims to describe these features. Standardised dietary, medical and socio-demographic health assessments of new refugee patients attending a multidisciplinary paediatric Refugee Health Service (RHS) in Western Australia between 2010 and 2015 were analysed. Demographic data from 1131 paediatric refugees are described (age 2 months to 17.8 years). The majority experienced socio-economic disadvantage, had limited parental education and required interpreters. Nutritional deficiencies were common but varied across ethnicities: iron deficiency (ID) (12.3%), anaemia (7.3%) and inadequate dairy intake (41.0%). A third of children (32.6%) did not consume meat. Infant breastfeeding was sustained (77.8%) in infants <12 months. Prolonged breastfeeding (44.9% aged 12-24 months) was associated with an increased risk of ID (odds ratio 4.0, 95% confidence interval 1.4-11.6). Median body mass index increased significantly for those >24 months between referral and RHS assessment (median period 1.8 months). Overall, 27.1% required additional formal dietetic follow-up, with higher nutritional concerns in refugee children <24 months compared to older patients. Identification of frequent post-settlement nutritional concerns has been captured through structured multidisciplinary paediatric health screening. Specific screening for socio-economic influencing factors, including education, poverty and food insecurity, during refugee clinical assessments is recommended. Development of targeted, culturally appropriate parental education resources and interventions may improve management following resettlement. Longitudinal research assessing resettlement growth trajectories is required.

Implementation of an Automated Pediatric Malnutrition Screen Using Anthropometric Measurements in the Electronic Health Record

Nutrition evaluation and intervention in hospitalized pediatric patients is critical, because undernutrition negatively impacts physical and cognitive development, wound healing, immune function, mortality, and quality of life. 1 Brinksma A. Sanderman R. Roodbol P.F. et al. Malnutrition is associated with worse health-related quality of life in children with cancer. Support Care Cancer. 2015; 23: 3043-3052 Crossref PubMed Scopus (56) Google Scholar , 2 Co-Reyes E. Li R. Huh W. Chandra J. Malnutrition and obesity in pediatric oncology patients: Causes, consequences, and interventions. Pediatr Blood Cancer. 2012; 59: 1160-1167 Crossref PubMed Scopus (59) Google Scholar , 3 Lange B.J. Gerbing R.B. Feusner J. et al. Mortality in overweight and underweight children with acute myeloid leukemia. JAMA. 2005; 293: 203-211 Crossref PubMed Scopus (216) Google Scholar , 4 Mehta N.M. Corkins M.R. Lyman B. et al. Defining pediatric malnutrition: A paradigm shift toward etiology-related definitions. JPEN J Parenter Enteral Nutr. 2013; 37: 460-481 Crossref PubMed Scopus (378) Google Scholar Multiple, validated pediatric nutrition screening tools are available, yet no consensus on the ideal tool exists. 5 Chourdakis M. Hecht C. Gerasimidis K. et al. Malnutrition risk in hospitalized children: Use of 3 screening tools in a large European population. Am J Clin Nutr. 2016; 103: 1301-1310 Crossref PubMed Scopus (86) Google Scholar , 6 Elia M. Stratton R.J. Considerations for screening tool selection and role of predictive and concurrent validity. Curr Opin Clin Nutr Metabol Care. 2011; 14: 425-433 Crossref PubMed Scopus (56) Google Scholar , 7 Gerasimidis K. Keane O. Macleod I. Flynn D.M. Wright C.M. A four-stage evaluation of the Paediatric Yorkhill Malnutrition Score in a tertiary paediatric hospital and a district general hospital. Br J Nutr. 2010; 104: 751-756 Crossref PubMed Scopus (133) Google Scholar , 8 Joosten K.F. Hulst J.M. Nutritional screening tools for hospitalized children: Methodological considerations. Clin Nutr. 2014; 33: 1-5 Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar , 9 McCarthy H. Dixon M. Crabtree I. Eaton-Evans M.J. McNulty H. The development and evaluation of the Screening Tool for the Assessment of Malnutrition in Paediatrics (STAMP(c)) for use by healthcare staff. J Hum Nutr Dietetics. 2012; 25: 311-318 Crossref Scopus (113) Google Scholar Generally, the aims of the nutrition screening process are identification of current nutrition status and determination of a need for further nutrition assessment and intervention. 8 Joosten K.F. Hulst J.M. Nutritional screening tools for hospitalized children: Methodological considerations. Clin Nutr. 2014; 33: 1-5 Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar , 10 Hartman C. Shamir R. Hecht C. Koletzko B. Malnutrition screening tools for hospitalized children. Curr Opin Clin Nutr Metabol Care. 2012; 15: 303-309 Crossref PubMed Scopus (70) Google Scholar Nutrition screening tools include, but are not limited to, dietary intake, anthropometrics, comorbid disease state, and subjective assessment of body habitus. 8 Joosten K.F. Hulst J.M. Nutritional screening tools for hospitalized children: Methodological considerations. Clin Nutr. 2014; 33: 1-5 Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar , 10 Hartman C. Shamir R. Hecht C. Koletzko B. Malnutrition screening tools for hospitalized children. Curr Opin Clin Nutr Metabol Care. 2012; 15: 303-309 Crossref PubMed Scopus (70) Google Scholar These manual screening tools require variable time commitments for completion by nurses, physicians, or dietitians. 8 Joosten K.F. Hulst J.M. Nutritional screening tools for hospitalized children: Methodological considerations. Clin Nutr. 2014; 33: 1-5 Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar , 10 Hartman C. Shamir R. Hecht C. Koletzko B. Malnutrition screening tools for hospitalized children. Curr Opin Clin Nutr Metabol Care. 2012; 15: 303-309 Crossref PubMed Scopus (70) Google Scholar In addition, nutrition screens are typically completed once on admission and do not continue repeatedly throughout an admission. Likewise, most traditional screens are not applicable when patients cross care environments such as transitioning from the inpatient to an outpatient setting. Although the general consensus is that nutrition screening is important, no universal, standardized approach exists for pediatric inpatients. 10 Hartman C. Shamir R. Hecht C. Koletzko B. Malnutrition screening tools for hospitalized children. Curr Opin Clin Nutr Metabol Care. 2012; 15: 303-309 Crossref PubMed Scopus (70) Google Scholar

Validation of dynamic random dot stereotests in pediatric vision screening

PurposeStereo vision tests are widely used in the clinical practice for screening amblyopia and amblyogenic conditions. According to literature, none of these tests seems to be suitable to be used alone as a simple and reliable tool. There has been a growing interest in developing new types of stereo vision tests, with sufficient sensitivity to detect amblyopia. This new generation of assessment tools should be computer based, and their reliability must be statistically warranted. The present study reports the clinical evaluation of a screening system based on random dot stereograms using a tablet as display. Specifically, a dynamic random dot stereotest with binocularly detectable Snellen-E optotype (DRDSE) was used and compared with the Lang II stereotest.MethodsA total of 141 children (aged 4–14, mean age 8.9) were examined in a field study at the Department of Ophthalmology, Pécs, Hungary. Inclusion criteria consisted of diagnoses of amblyopia, anisometropia, convergent strabismus, and hyperopia. Children with no ophthalmic pathologies were also enrolled as controls. All subjects went through a regular pediatric ophthalmological examination before proceeding to the DRDSE and Lang II tests.ResultsDRDSE and Lang II tests were compared in terms of sensitivity and specificity for different conditions. DRDSE had a 100% sensitivity both for amblyopia (n = 11) and convergent strabismus (n = 21), as well as a 75% sensitivity for hyperopia (n = 36). However, the performance of DRDSE was not statistically significant when screening for anisometropia. On the other hand, Lang II proved to have 81.8% sensitivity for amblyopia, 80.9% for strabismus, and only 52.8% for hyperopia. The specificity of DRDSE was 61.2% for amblyopia, 67.3% for strabismus, and 68.6% for hyperopia, respectively. Conversely, Lang II showed about 10% better specificity, 73.8% for amblyopia, 79.2% for strabismus, and 77.9% for hyperopia.ConclusionsThe DRDSE test has a better sensitivity for the detection of conditions such as amblyopia or convergent strabismus compared with Lang II, although with slightly lower specificity. If the specificity could be further improved by optimization of the stimulus parameters, while keeping the sensitivity high, DRDSE would be a promising stereo vision test for screening of amblyopia.

Automating a Manual Sepsis Screening Tool in a Pediatric Emergency Department.

This article describes the method of integrating a manual pediatric emergency department sepsis screening process into the electronic health record that leverages existing clinical documentation and keeps providers in their current, routine clinical workflows. Criteria in the manual pediatric emergency department sepsis screening tool were mapped to standard documentation routinely entered in the electronic health record. Data elements were extracted and scored from the medical history, medication record, vital signs, and physical assessments. Scores that met a predefined sepsis risk threshold triggered interruptive system alerts which notified emergency department staff to perform sepsis huddles and consider appropriate interventions. Statistical comparison of the new electronic tool to the manual process was completed by a two-tail paired t-test. The performance of the pediatric electronic sepsis screening tool was evaluated by comparing flowsheet row documentation of the manual, sepsis alert process against the interruptive system alert instance of the electronic sepsis screening tool. In an 8-week testing period, the automated pediatric electronic sepsis screening tool identified 100% of patients flagged by the manual process (n = 29), on average, 68 minutes earlier. Integrating a manual sepsis screening tool into the electronic health record automated identification of pediatric sepsis screening in a busy emergency department. The electronic sepsis screening tool is as accurate as a manual process and would alert bedside clinicians significantly earlier in the emergency department course. Deployment of this electronic tool has the capability to improve timely sepsis detection and management of patients at risk for sepsis without requiring additional documentation by providers.

Pilot of a Pediatric Palliative Care Early Intervention Instrument.

Current research demonstrates that pediatric symptom management care is often initiated in the late stages of disease once clinicians are no longer able to meaningfully impact symptom burden. Given that physicians or nurse practitioners are responsible for initiating palliative care referrals, it is incumbent upon registered nurses to advocate when improved symptom management care is needed. The pediatric palliative care screening instrument pilot provides a centralized instrument to document and quantify a patient's symptom profile, giving registered nurses the opportunity to objectively communicate and track a patient's need for improved symptom management care within the areas of pain, secretions, dyspnea, intractable seizures, nausea, vomiting, constipation, diarrhea, anorexia, cachexia, sleep disturbance, lethargy, anxiety, depression, and/or agitation. The 4-week quality improvement project at an academic teaching hospital formally incorporated the bedside registered nurses' symptom assessment into a centralized document. Fifty-three patients were identified as having an uncontrolled symptom burden in at least one of the symptom domains, indicating that excessive and untreated symptom burden was present on the acute care floor. The pediatric palliative care screening instrument could act as a conduit between bedside registered nurses and the palliative care team, serving to reduce the time between onset of excessive symptom burden and initiation of symptom management services.

Pediatric pulse oximetry-based OSA screening at different thresholds of the apnea-hypopnea index with an expression of uncertainty for inconclusive classifications

BackgroundAssessments of pediatric obstructive sleep apnea (OSA) are underutilized across Canada due to a lack of resources. Polysomnography (PSG) measures OSA severity through the average number of apnea/hypopnea events per hour (AHI), but is resource intensive and requires a specialized sleep laboratory, which results in long waitlists and delays in OSA detection. Prompt diagnosis and treatment of OSA are crucial for children, as untreated OSA is linked to behavioral deficits, growth failure, and negative cardiovascular consequences. We aim to assess the performance of a portable pediatric OSA screening tool at different AHI cut-offs using overnight smartphone-based pulse oximetry. Material and methodsFollowing ethics approval and informed consent, children referred to British Columbia Children's Hospital for overnight PSG were recruited for two studies including 160 and 75 children, respectively. An additional smartphone-based pulse oximeter sensor was used in both studies to record overnight pulse oximetry [SpO2 and photoplethysmogram (PPG)] alongside the PSG.Features characterizing SpO2 dynamics and heart rate variability from pulse peak intervals of the PPG signal were derived from pulse oximetry recordings. Three multivariate logistic regression screening models, targeted at three different levels of OSA severity (AHI ≥ 1, 5, and 10), were developed using stepwise-selection of features using the Bayesian information criterion (BIC). The “Gray Zone” approach was also implemented for different tolerance values to allow for more precise detection of children with inconclusive classification results. ResultsThe optimal diagnostic tolerance values defining the “Gray Zone” borders (15, 10, and 5, respectively) were selected to develop the final models to screen for children at AHI cut-offs of 1, 5, and 10. The final models evaluated through cross-validation showed good accuracy (75%, 82% and 89%), sensitivity (80%, 85% and 82%) and specificity (65%, 79% and 91%) values for detecting children with AHI ≥ 1, AHI ≥ 5 and AHI ≥ 10. The percentage of children classified as inconclusive was 28%, 38% and 16% for models detecting AHI ≥ 1, AHI ≥ 5, and AHI ≥ 10, respectively. ConclusionsThe proposed pulse oximetry-based OSA screening tool at different AHI cut-offs may assist clinicians in identifying children at different OSA severity levels. Using this tool at home prior to PSG can help with optimizing the limited resources for PSG screening. Further validation with larger and more heterogeneous datasets is required before introducing in clinical practice.

A Retrospective Comparison between the PNST and other Paediatric Nutritional Screening Tools

Background: Although it is widely acknowledged that hospitalized children are at greater risk of malnutrition, the available paediatric Nutritional Risk Screening (NRS) tools have not yet become universally used to identify those children at greater risk. Furthermore, the utility of one NRS tool over another remains unclear. Materials and Methods: The utility of a recently developed tool, the Paediatric Nutritional Screening Tool (PNST), was evaluated using data previously collected in the assessment of three other NRS tools in 281 children from Iran and New Zealand. The sensitivity and specificity of each tool was then assessed based on the WHO criteria for malnutrition. Results: The PNST recognized about half of the malnourished patients while the other three tools identified at least 85% of these children. The sensitivity of PNST for moderate (BMI-z &lt; 2) and severe malnutrition (BMI-z &lt;-3) was 37% and 46% respectively, while the sensitivity for other three NRS tools ranged from 82-100%. Conclusion: In this data set, the PNST tool did not perform as well as the three more established NRS tools. Further work is required to provide optimal tools for the identification of hospitalized children at risk of malnutrition

Novel Lipid Thresholds for Screening Predict the Need for Pharmacotherapy

To identify non-high-density lipoprotein cholesterol (HDL-C) and HDL-C thresholds for pediatric nonfasting lipid screens that are more predictive of the need for lipid-lowering pharmacotherapy and estimate numbers of potentially avoidable fasting lipid panels. In this retrospective review of children and youths aged 8-21 years presenting for preventive cardiology care, initial lipid results, recommendations for pharmacotherapy, and presence of additional cardiovascular risk factors were noted. Receiver operating characteristic curve analysis calculated threshold lipid values predicting the need for pharmacotherapy and were applied to 2 screening populations. Rates of potentially unnecessary fasting lipid panels were calculated. A non-HDL-C value >156 mg/dL for children with ≥1 cardiovascular risk factors and >199 mg/dL for children without risk factors conferred 95% or greater sensitivity in predicting a recommendation for pharmacotherapy with higher specificity, positive predictive value, and negative predictive value compared with current guidelines. HDL-C was a poor predictor of pharmacotherapy. Application of the current thresholds to screening populations indicated that 38.5%-92.3% of follow-up fasting lipid panels would not result in pharmacotherapy. Using higher non-HDL-C and lower HDL-C thresholds could prevent unnecessary follow-up lipid panels and reduce patient anxiety, cost, and time. This could improve compliance with universal pediatric lipid screening for both health care providers and families.

Validation of Peek Acuity application in pediatric screening programs in Paraguay.

To validate the Peek Acuity mobile phone application in pediatric populations and compare its utility, both economic and diagnostic, against conventional screening methods using a pediatric ophthalmologist examination as the gold standard. A cohort of 393 subjects from Fernando de la Mora, Paraguay (ages 6-16y) were enrolled in the study. Subjects were randomly assigned a starting screening modality among: Peek Acuity, a single line of tumbling E optotypes set at 20/40, and Spot Vision Screener. Once completing the first screening modality, the subjects completed the two remaining techniques. Referral criteria were established based on the most current American Association of Pediatric Ophthalmology and Strabismus (AAPOS) recommendations: 20/40 for Peek Acuity and the tumbling E, and refractive error detection for the Spot Vision Screener. Subjects that failed to achieve the cut-off for any of the three screening techniques or subjects that passed the screening but were randomly selected to perform a comprehensive eye exam to determine the false negative rate, were evaluated by a pediatric ophthalmologist. This evaluation was considered the gold standard, and included vision assessment by a Snellen chart, strabismus evaluation, and cycloplegic refraction with dilated fundoscopy. We obtained 48% sensitivity, 83% specificity, 43% positive predictive value, and 86% negative predictive value for Peek Acuity's ability to refer compared to evaluation by a pediatric ophthalmologist, failing to achieve a desired sensitivity for implementation. Peek Acuity trended to overestimate the subject's visual acuity, providing a higher visual acuity that would not indicate referral for a comprehensive eye examination. However, its high specificity accurately predicted a significant number of children who did not need further evaluation. When comparing the three screening methods, no single screening modality outperformed the others. Peek Acuity represented a technology that was economically feasible compared to other screening modalities in low income settings, due to the prevalence of cell phone use. Peek Acuity represents an efficient tool that has potential for implementation in school screenings with different strategies aimed at pediatric populations due to its low cost and high specificity. An increase in sensitivity would improve detection of children with refractive errors.

Evaluation of a Pediatric Resident Skills-Based Screening, Brief Intervention and Referral to Treatment (SBIRT) Curriculum for Substance Use

PurposeTo evaluate a screening, brief intervention and referral to treatment curriculum for alcohol and other substance use developed, implemented and integrated into a pediatric residency program. MethodsDuring a 1-month adolescent medicine rotation, pediatric, and medicine/pediatric residents in an urban teaching hospital completed a 2 1/2-hour formal curriculum including a didactic lecture, a 40-minute video describing the Brief Negotiation Interview (BNI), and a skill-based session practicing the BNI and receiving individualized feedback. Access to a website with didactic material was provided. Outcome measures were pre- and post-training knowledge, BNI performance measured with a standardized patient using a validated BNI adherence scale, satisfaction with training, and adoption of BNI into clinical practice. ResultsOf the 106 residents trained, 92(87%) completed both pre- and post-test evaluations. Significant improvements were found in pre- versus post-test scores of knowledge, (20.0 [2.4 SD] vs. 24.1 [3.5 SD], p <.001) and BNI performance comparing pre- and post BNI adherence scale total scores, (5.14 [1.8 S.D.] vs. 11.5 [.96], p<.001). Residents reported high satisfaction with training, [1.4, SD .5, immediately and 1.6, SD .6, 30-days post training)with scores ranging from 1 to 5 with lower score=greater satisfaction. During the 12-month follow-up period, we received 83 responses from residents reporting a total of 129 BNIs in actual clinical settings. ConclusionsA screening, brief intervention and referral to treatment curriculum was successfully integrated into an adolescent medicine elective in a pediatric residency program. Residents demonstrated significant improvements in knowledge and skills performing the BNI, with high satisfaction and adoption of the BNI into clinical practice.