Pediatric Primary Care Research Articles

Nutritional counselling and risk factors for obesity: an observational study in toddlers

BackgroundNutrition exerts a fundamental role in the prevention of obesity (OB). The aim of this study was to assess the extent to which well recognized risk factors for early OB can be associated to overweight (OW) or OB under a standardized nutritional approach and surveillance in toddlers.MethodsThe eligible population was represented by 676 toddlers aged 24–36 months, assigned to 18 primary care pediatricians trained on nutritional issues who shared a standardized nutritional approach. Six-hundred-twenty-nine children (333 boys), mean age 27.8 ± 4.2 months were effectively included in this observational study. Parents received nutritional advice with particular emphasis to proteins and sugar composition supported by leaflets and reinforced at each visit. Body mass index was assessed at the age of 24–36 months. The following individual and family risk factors were considered: gestational age, birth weight, eutocic/caesarean delivery, milk feeding history, household smoking or antibiotics exposure, parents’ weight, height and educational level. Prevalence of OW/OB was compared to a group of 742 toddlers (373 boys) under usual care.ResultsUnder a standardized nutritional counselling, 28.1% toddlers were classified as OW/OB compared to 36.9% toddlers under usual care (p = 0.005). In unadjusted models, parental OW/OB was significantly associated to OW/OB in toddlers (p < 0.01), while high birth weight did not reach statistical significance (p = 0.07). In adjusted models, including all the explanatory variables studied, only paternal OW/OB vs. normal weight was significantly associated to OW/OB in toddlers (OR 2.035, 95% confidence interval 1.206–3.436). No protective effect of exclusive breast feeding during the first 6 months of age was demonstrated.ConclusionsToddlers under a standardized nutrition counselling focused to limit protein and simple sugars, showed lower prevalence of OW/OB compared to usual care. Healthy promotion activities should take into account the influence of paternal BMI on the offspring adiposity.

A systematic review and meta-analysis of pediatric integrated primary care for the prevention and treatment of physical and behavioral health conditions.

To evaluate the effects of behavioral health interventions delivered within pediatric integrated primary care models on clinical outcomes. We searched Medline, EMBASE, CENTRAL, PsycINFO, and SCOPUS for studies published from January 1, 1998, to September 20, 2023. We included studies that evaluated onsite behavioral health integration in pediatric primary care using a comparator condition (usual, enhanced usual care, or waitlist). Outcome data on symptom change, impairment/quality of life, health indicator, and behavior change were extracted using Covidence software. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline was followed Risk of bias analysis was conducted using the Cochrane Risk of Bias tool. We used multilevel meta-analysis to synthesize multiple outcomes nested within studies. Open Science Foundation pre-registration: #10.17605/OSF.IO/WV7XP. In total, 33 papers representing 27 studies involving 6,879 children and caregivers were included. Twenty-four studies were randomized controlled trials and three were quasi-experimental designs. Seventeen papers reported on treatment trials and 16 reported on prevention trials. We found a small overall effect size (SMD = 0.19, 95% confidence interval [0.11, 0.27]) supporting the superiority of integrated primary care to usual or enhanced usual care. Moderator analyses suggested similar effectiveness between co-located and integrated models and no statistically significant differences were found between treatment and prevention trials. Results suggest that integrated primary care is superior to usual and enhanced usual care at improving behavior, quality of life, and symptoms. Integrated primary care research needs improved standards for reporting to promote better synthesis and understanding of the literature.

Pediatric Primary Care Billing Trends After the 2021 Evaluation and Management Coding Changes

This cross-sectional study examines the differences in billing trends for pediatric patient care compared with adult care after the 2021 evaluation and management (E/M) policy changes.

Pediatric Pharmacology for the Primary Care Provider: Advances and Limitations.

Despite >1 in 5 children taking prescription drugs in the United States, off-label drug use is common. To increase the study of drugs in children, regulatory bodies have enacted legislation to incentivize and require pediatric drug studies. As a result of this legislation, novel trial approaches, and an increase in personnel with pediatric expertise, there have been numerous advancements in pediatric drug development. With this review, we aim to highlight developments in pediatric pharmacology over the past 6 years for the most common disease processes that may be treated pharmacologically by the pediatric primary care provider. Using information extracted from label changes between 2018 and 2023, the published literature, and Clinicaltrials.gov, we discuss advances across multiple therapeutic areas relevant to the pediatric primary care provider, including asthma, obesity and related disorders, mental health disorders, infections, and dermatologic conditions. We highlight instances in which new drugs have been developed on the basis of a deeper mechanistic understanding of illness and instances in which labels have been expanded in older drugs on the basis of newly available data. We then consider additional factors that affect pediatric drug use, including cost and nonpharmacologic therapies. Although there is work to be done, efforts focused on pediatric-specific drug development will increase the availability of evidence-based, labeled guidance for commonly prescribed drugs and improve outcomes through the safe and effective use of drugs in children.

Accelerating Innovation in Primary Care to Support Adolescent Health Discussions.

Adolescent strengths and risks are not routinely captured in systematized and actionable ways in pediatric primary care. To address this problem, we developed a comprehensive adolescent health questionnaire (AHQ) integrated within the electronic health record and evaluated the AHQ's impact on collection of information on prioritized health-related domains. We developed and pilot tested the AHQ. We then scaled and assessed the AHQ's impact on data collection. AHQ development used innovation methods and measured feasibility and acceptability outcomes. Scaling and postscaling outcomes included Reach, Effectiveness, Adoption, Implementation, Maintenance and Sustainability measures: Reach (total questionnaires completed), Effectiveness (capture of key information across health domains pre- vs post-AHQ scaling), Adoption (proportion of practices that adopted the AHQ), Implementation (proportion of eligible adolescents who completed the AHQ), and Maintenance (monthly completion rates). AHQ development led to a tool that was feasible and acceptable for use. During scaling (October 2020-December 2021), 22 147 questionnaires were completed by 20 749 unique adolescents aged 13 to 21 years at their preventive visit. Comparing pre- versus post-AHQ scaling data, use of the AHQ increased collection of information across domains, especially for strengths, gun safety, substance use, sexual activity, sexual orientation, and gender identity, from ranges of 0%-25% to 92%-95%. All 31 practices adopted the AHQ with completion at 88.7% of visits (n = 24 968). Two years postscaling, completion rates were >91% per month. We successfully developed, scaled, and maintained an AHQ in a widely-used electronic health record system, a model for improving adolescent care and foundation for developing future interventions.

Understanding barriers to well-child visit attendance among racial and ethnic minority parents

ObjectivesTo assess racial and ethnic minority parents’ perceptions about barriers to well-child visit attendance.MethodsFor this cross-sectional qualitative study, we recruited parents of pediatric primary care patients who were overdue for a well-child visit from the largest safety net healthcare organization in central Massachusetts to participate in semi-structured interviews. The interviews focused on understanding potential knowledge, structural, and experiential barriers for well-child visit attendance. Interview content was inductively coded and directed content analysis was performed to identify themes.ResultsTwenty-five racial and ethnic minority parents participated; 17 (68%) of whom identified Spanish as a primary language spoken at home. Nearly all participants identified the purpose, significance, and value of well-child visits. Structural barriers were most cited as challenges to attending well-child visits, including parking, transportation, language, appointment availability, and work/other competing priorities. While language emerged as a distinct barrier, it also exacerbated some of the structural barriers identified. Experiential barriers were cited less commonly than structural barriers and included interactions with office staff, racial/ethnic discrimination, appointment reminders, methods of communication, wait time, and interactions with providers.ConclusionsRacial and ethnic minority parents recognize the value of well-child visits; however, they commonly encounter structural barriers that limit access to care. Furthermore, a non-English primary language compounds the impact of these structural barriers. Understanding these barriers is important to inform health system policies to enhance access and delivery of pediatric care with a lens toward reducing racial and ethnic-based inequities.

Supporting School Readiness in Pediatric Primary Care: The Importance of Both Screening and Developmental Promotion

Supporting School Readiness in Pediatric Primary Care: The Importance of Both Screening and Developmental Promotion

Quand mettre en route un traitement systémique dans la dermatite atopique ?

Despite the advent of numerous new treatments for atopic dermatitis, many patients, both adults and children, are still on treatment errands and are not receiving sufficient treatment to control their disease in the long term. It is therefore important to identify patients who need systemic treatment when topical treatments are no longer suitable. The decision to initiate a systemic treatment must be based on several factors that go well beyond the marketing authorisation and reimbursement of a drug. This approach involves a multidimensional assessment of the disease’s severity, in which scores have a place if they are feasible in practice and if they take into account the patient’s perception of their symptoms and the impact of the disease on their quality of life. Shared decision-making means that the expectations of the doctor and the patient (or the patient’s family in the case of children) can be harmonised, and a suitable and realistic therapeutic objective can be defined in a collaborative manner. Identifying a patient eligible for systemic treatment at an early stage requires appropriate training in primary care (general practitioner or paediatrician) and a good city-hospital cooperation for the dermatologist or allergist in order to facilitate the patient pathway and guarantee access to «the right treatment at the right time».

Pediatric Skills Lab: Strengthening Communication Skills for the Conversations with Psychologically burdened Families.

Pediatric Skills Lab: Strengthening Communication Skills for the Conversations with Psychologically burdened Families To identify psychosocially burdened families early and motivate them to seek further assistance is a central aspect of pediatric preventivemedicine.The aim of the feasibility study was to develop the Pediatric Skills Lab to promote methods for identifying and addressing psychosocially burdened families, and to evaluate it. Thirteen primary care pediatricians participated in two trials of the Pediatric Skills Lab, an interdisciplinary developed two-part digital training.They answered questions regarding their work with psychosocially burdened families and their satisfaction with the Pediatric Skills Lab. Overall, there was a high level of satisfaction reported with the Pediatric Skills Lab. Specifically, the presentation of results on the effects of psychosocial stressors, the practical exercises, and the exchange with colleagues during the interactive webinar were highly praised. Criticisms included, for example, the short duration of practical exercises and the lack of sufficient examples and live demonstrations. The Pediatric Skills Lab is a training concept tailored to meet the existing needs. With widespread implementation, it could enhance psychosocial care provision. Consideration should be given to extending the duration of the training to allow formore practical exercises. Future studies building upon this feasibility study should examine the effects of the training. Additionally, ways to integrate the Pediatric Skills Lab into existing curricula formedical education should be explored.

Pediatric Primary Care of Children With Intrauterine Opioid Exposure: Survey of Academic Teaching Practices

ObjectiveIntrauterine opioid exposure (IOE) has increased over the last 2 decades and is associated with additional needs after birth. To date, no clinical guidelines address the primary care of children with IOE. We aimed to characterize clinician-reported screening and referral practices, barriers to effective primary care for children with IOE, and clinician- and practice-level characteristics associated with perceived barriers. MethodsWe conducted a cross-sectional survey of pediatric residents, pediatricians, and advanced practitioners at 28 primary care clinics affiliated with 7 pediatric residency programs (April–June 2022). We assessed screening and other clinical practices related to IOE and perceived barriers to addressing parental opioid use disorder (OUD). We used descriptive statistics to analyze survey responses, assessed the distribution of reported barriers, and applied a 2-stage cluster analysis to assess response patterns. ResultsOf 1004 invited clinicians, 329 (32.8%) responses were returned, and 325 pediatric residents and pediatricians were included in the final analytic sample. Almost all (99.3%) reported parental substance use screening as important, but only 11.6% screened routinely. Half of the respondents routinely refer children with IOE to early intervention services and social work. Lack of standard screening for substance use was the most frequently selected barrier to addressing parental OUD. Participants reporting fewer barriers to addressing parental OUD identified having greater access to OUD treatment programs and home visiting programs. ConclusionsPediatricians report variations in primary care screenings and referrals for children with IOE. Access to parental OUD treatment programs may mitigate perceived barriers to addressing parental OUD in the pediatric office.

Beyond ‘‘Screen & Refer’’: Understanding Families’ Use of Resources for Health-Related Social Needs Identified via Primary Care

ObjectiveAs health-related social needs (HRSN) screening increases, attention to families’ resource preferences lags. This study of a pediatric primary care intervention (DULCE) with reliable HRSN screening and resource connection explored whether resources adequately addressed families’ needs and, when HRSN persisted, families' reasons for declining resources. MethodsThis retrospective cohort, mixed-methods study analyzed data from 989 families that received care at seven pediatric clinics implementing DULCE in three states. DULCE screens for seven HRSN around the 1-month and 4-month well-child visits; we calculated the percent of initial and ongoing positive screens. For positive rescreens, we calculated the percent that had all eligible or wanted resources and that were interested in further resources. We also analyzed case notes, which elicited families’ resource preferences, and explored demographic characteristics associated with ongoing HRSN. ResultsHalf of enrolled families (508 of 989) initially screened positive for HRSN; 124 families had positive rescreens; 26 expressed interest in further assistance. Most families with ongoing concrete supports needs accessed all eligible resources (60–100%); 20–58% had everything they wanted. Fewer families with ongoing maternal depression and intimate partner violence accessed all eligible resources (48% and 18%, respectively); most reported having all wanted resources (76% and 90%, respectively). Families declined resources due to lack of perceived need, the HRSN resolving, or families addressed HRSN themselves. White families were more likely to rescreen positive. ConclusionsPediatric medical homes must honor family-centered decision-making while empowering families to accept beneficial resources. Health care systems should advocate for resources that families need and want.

The Impact of Structural Racism on Continuity of Care at Pediatric Academic Primary Care Clinics

ObjectiveUsing a structural racism framework, we assessed racial inequities in continuity of care, using the Usual Provider Continuity Index (UPC – the proportion of visits with the provider the patient saw most frequently out of all visits), in a set of large pediatric academic clinics. MethodsWe conducted a retrospective cohort study. Patients 12–24 months seen at three pediatric academic primary care clinics for any visit during October 1–31, 2021 were included. We then reviewed continuity for these patients in the preceding 12 months. Outcomes included each patient’s UPC for all visits, and a modified UPC for well child checks only (UPC Well). Covariates included race, ethnicity, insurance, clinic site, age, sex, care management, or seeing a social worker. We evaluated for differences in outcomes using bivariate analyses and multivariable regression models. ResultsOur cohort included 356 patients (74% Black, 5% Hispanic, 85% Medicaid, 52% female, median age 15.8 months). The median UPC was 0.33 and median UPC Well was 0.40. Black patients had significantly lower median values for UPC (0.33 Black vs 0.40 non-Black, P < .01) and UPC Well (0.33 Black vs 0.50 non-Black, P < .01). There were similar inequities in continuity rates by insurance and clinic site. In multivariable models, clinic site was the only variable significantly associated with continuity. ConclusionsClinic sites serving higher percentages of Black patients had lower rates of continuity. The main driver of racial inequities in continuity rates was at the institutional level.

The Feasibility and Acceptability of Delivering Brief Telehealth Behavioral Parent Training in Pediatric Primary Care

The Feasibility and Acceptability of Delivering Brief Telehealth Behavioral Parent Training in Pediatric Primary Care

Childhood dyslipidemia: Clinician management practices in the primary care setting

Abstract Objectives To describe clinician management practices for childhood dyslipidemia in the community setting. Methods A descriptive study was conducted for children aged 2 to 10 years with dyslipidemia as defined by the National Cholesterol Education Program Expert Panel on Cholesterol in Children criteria. A convenience sample of participants from the TARGet Kids! cohort study (Toronto, Canada) was used. Trained research assistants reviewed participant medical records to document clinician management practices of abnormal lipid levels. The study outcome was the proportion of clinicians engaging in each management practice. Descriptive statistics were completed, reporting the proportion of clinician engagement in management practices. Results All 768 children were seen by primary paediatric care providers after lipid levels identified dyslipidemia. Medical history regarding lifestyle behaviours and cardiovascular risk factors were frequently obtained (n = 565, 73.6%). Physicians rarely informed families about abnormal lipid levels (n = 11, 1.43%). Management plans for abnormal lipid levels were rarely documented (n = 4, 0.5%). Clinicians did not refer to paediatric lipid specialists or initiate statin therapy. Conclusions Paediatric care providers rarely identified and initiated early management for abnormal lipid levels. Our results may inform the need for improved knowledge translation of the recently published Canadian clinical practice update for the detection and management of childhood dyslipidemia.

A Pilot Randomized Controlled Trial of the Family Assessment and Feedback Intervention(FAFI): Effects on Mental Health Literacy and Attitudinal Engagement with Health Supports and Services.

This randomized controlled trial tested the Family Assessment and Feedback Intervention (FAFI), a new intervention to enhance family engagement with emotional and behavioral health services. The FAFI is a guided conversation with families about results of their multidimensional assessment that is set in the context of motivational enhancement. It differs from other assessment-with-feedback interventions by extending the focus of assessment beyond the target child to parents and the family environment, addressing parental emotional and behavioral problems and competencies, spanning a broad range of children's and parents' strengths and difficulties, and being generalizable to many settings and practitioners. Participants were 81 families in primary care pediatrics. The FAFI was associated with a significant increase in parental mental health literacy and with an increase in parental attitudinal engagement with health supports and services that closely approached statistical significance (p = .052), while controlling for children's age and gender and family socioeconomic status.

Specialist nurse's health promotion work with the national childhood immunization programme: A qualitative study.

Childhood immunizations have proven to be one of the most beneficial interventions to promote public health and prevent childhood deaths due to disease. However, global coverage of childhood immunization has decreased throughout the world due to guardians' growing hesitancy towards immunizations. This study aims to describe how specialist nurses promote legal guardians to adhere to national childhood immunization programmes. This study had a qualitative design. Semistructured interviews with 11 specialist nurses, who were paediatric primary care nurses or nurse practitioners, were conducted. Data were analysed using qualitative content analysis. The findings, with four main categories including four subcategories, showed nurses using both local guidelines and national guidelines to promote guardians to adhere to the childhood immunization programme. The main intervention the nurses did to promote childhood immunization coverage was giving legal guardians general information about the programme. With hesitant guardians, adopting a person-centred approach towards the legal guardian improved adherence. Further research should focus on how specialist nurses can respond to guardians who decline immunization for their children, as this study identified difficulties in this area. Furthermore, research on guardians' perspectives towards childhood immunization may also help generate further effective guidance on how to promote immunization coverage among children.

User-Centered Framework for Implementation of Technology (UFIT): Development of an Integrated Framework for Designing Clinical Decision Support Tools Packaged With Tailored Implementation Strategies.

Electronic health record-based clinical decision support (CDS) tools can facilitate the adoption of evidence into practice. Yet, the impact of CDS beyond single-site implementation is often limited by dissemination and implementation barriers related to site- and user-specific variation in workflows and behaviors. The translation of evidence-based CDS from initial development to implementation in heterogeneous environments requires a framework that assures careful balancing of fidelity to core functional elements with adaptations to ensure compatibility with new contexts. This study aims to develop and apply a framework to guide tailoring and implementing CDS across diverse clinical settings. In preparation for a multisite trial implementing CDS for pediatric overweight or obesity in primary care, we developed the User-Centered Framework for Implementation of Technology (UFIT), a framework that integrates principles from user-centered design (UCD), human factors/ergonomics theories, and implementation science to guide both CDS adaptation and tailoring of related implementation strategies. Our transdisciplinary study team conducted semistructured interviews with pediatric primary care clinicians and a diverse group of stakeholders from 3 health systems in the northeastern, midwestern, and southeastern United States to inform and apply the framework for our formative evaluation. We conducted 41 qualitative interviews with primary care clinicians (n=21) and other stakeholders (n=20). Our workflow analysis found 3 primary ways in which clinicians interact with the electronic health record during primary care well-child visits identifying opportunities for decision support. Additionally, we identified differences in practice patterns across contexts necessitating a multiprong design approach to support a variety of workflows, user needs, preferences, and implementation strategies. UFIT integrates theories and guidance from UCD, human factors/ergonomics, and implementation science to promote fit with local contexts for optimal outcomes. The components of UFIT were used to guide the development of Improving Pediatric Obesity Practice Using Prompts, an integrated package comprising CDS for obesity or overweight treatment with tailored implementation strategies. ClinicalTrials.gov NCT05627011; https://clinicaltrials.gov/study/NCT05627011.

Enhancing Early Identification of Speech-Language-Hearing Delays Through Interprofessional Peer Teaching in a Communication Sciences and Disorders Graduate Training Program.

In the current health care landscape, a paradigm shift toward team-based care is underway. Integrating interprofessional education experiences into graduate communication sciences and disorders (CSD) programs is essential to cultivate collaborative skills and prepare future professionals for the interprofessional demands of the field. Within this context, peer teaching has emerged as a noteworthy strategy to promote learning. This study aims to contribute to this evolving field by reporting the impact of an interprofessional (speech-language pathology and audiology) peer teaching educational intervention on physician assistant (PA) students' knowledge of speech-language-hearing developmental milestones and developmental screening. A quantitative, descriptive methodology with a pretest, posttest interventional design was utilized to assess the impact of a CSD peer-led educational intervention on the knowledge of 35 PA students. The perceived satisfaction of the PA students with the peer-led educational experience was also evaluated. Data analysis revealed a significant increase on knowledge posttest scores compared to pretest scores. PA students also reported an overall positive peer learning experience. The collaboration between speech-language pathology, audiology, and PA students through peer teaching holds significant importance in the context of pediatric primary care, and for CSD graduate trainings programs interested in improving educational experiences that tailor to interprofessional learning and practice.

Disparities in accessing specialty behavioral health services during the COVID-19 pandemic and why we need pediatric integrated primary care.

Youth unmet behavioral health needs are at public health crisis status and have worsened since the onset of the coronavirus disease 2019 pandemic (Covid-19). Integrating behavioral health services into pediatric primary care has shown efficacy in addressing youth behavioral health needs. However, there is limited guidance on facilitating equitable access to care in this setting, including in triaging access to co-located services (i.e., onsite outpatient behavioral health services with only the behavioral health provider) or to specialty behavioral health services in other clinics within larger health systems. A retrospective, comparative study was conducted to examine variability in access to co-located and specialty behavioral health (SBH) services for a pre-Covid-19 cohort (April 2019 to March 2020; n = 367) and a mid-Covid-19 cohort (April 2020 to March 2021; n = 328), while accounting for integrated primary care consultation services. The sample included children 1-18 years old served through a large, inner-city primary care clinic. Logistic regression models were used to examine the association between scheduled and attended co-located and SBH visits, pre- and mid-Covid-19 effects, and sociodemographic factors of race and ethnicity, language, health insurance (SES proxy), age, and sex. The majority of youth were not directly scheduled for a co-located or SBH visit but the majority of those scheduled attended their visit(s). The odds of not being directly scheduled for a co-located or SBH visit were greater for the mid-Covid-19 cohort, Black youth, and older youth. Accounting for integrated primary care consultation visits addressed these disparities, with the exception of persisting significant differences in scheduled and attended co-located and SBH visits for Black youth even while accounting for IPC consultation. Findings from the current study highlight the effective role of integrated primary care consultation services as facilitating access to initial behavioral health services, especially given that referrals to integrated primary care co-located and SBH services within the larger health system often involve barriers to care such as longer wait-times and increased lack of referral follow through. Ongoing research and equitable program development are needed to further this work.

Moving Beyond Hemangioma: Interactive, Multidisciplinary, Case-Based Teaching in Vascular Anomalies for Pediatric Residents.

Vascular anomalies are a spectrum of disorders, including vascular tumors and malformations, that often require multispecialty care. The rarity and variety of these lesions make diagnosis, treatment, and management challenging. Despite the recognition of the medical complexity and morbidity associated with vascular anomalies, there is a general lack of education on the subject for pediatric primary care and subspecialty providers. A needs assessment and the lack of an available standardized teaching tool presented an opportunity to create an educational workshop for pediatric trainees using the POGIL (process-oriented guided inquiry learning) framework. We developed a 2-hour workshop consisting of an introductory didactic followed by small- and large-group collaboration and case-based discussion. The resource included customizable content for learning assessment and evaluation. Residents completed pre- and posttest assessments of content and provided written evaluations of the teaching session. Thirty-four learners in pediatrics participated in the workshop. Session evaluations were positive, with Likert responses of 4.6-4.8 out of 5 on all items. Pre- and posttest comparisons of four content questions showed no overall statistically significant changes in correct response rates. Learners indicated plans to use the clinical content in their practice and particularly appreciated the interactive teaching forum and the comprehensive overview of vascular anomalies. Vascular anomalies are complex, potentially morbid, and often lifelong conditions; multispecialty collaboration is key to providing comprehensive care for affected patients. This customizable resource offers a framework for trainees in pediatrics to appropriately recognize, evaluate, and refer patients with vascular anomalies.