Pediatric Care Use Research Articles

Service and emotional support animals in pediatrics

There is a growing body of evidence of the positive psychological and social impacts animals can have on individuals with chronic conditions and disabilities. Service animals have been used primarily in the adult population. Recently they have become more prevalent in pediatric care to improve the quality of life and emotional well-being of children with physical and mental health challenges. Studies have shown that both service animals and emotional support animals (ESAs) improve physical, psychological, and social health of children with chronic medical conditions and neurodevelopmental disabilities. Due to the increasing use of service animals and ESAs in pediatrics, providers need to be aware of which children may benefit from having a service animal or ESA, the process to obtain them and recognize the practical, financial, and ethical considerations or challenges children and their families may encounter. This article aims to provide guidance on the differences between service and emotional support animals and considerations for their use in pediatric care.

Attitudes on Artificial Intelligence use in Pediatric Care From Parents of Hospitalized Children

IntroductionArtificial intelligence (AI) may benefit pediatric healthcare, but it also raises ethical and pragmatic questions. Parental support is important for the advancement of AI in pediatric medicine. However, there is little literature describing parental attitudes toward AI in pediatric healthcare, and existing studies do not represent parents of hospitalized children well. MethodsWe administered the Attitudes toward Artificial Intelligence in Pediatric Healthcare, a validated survey, to parents of hospitalized children in a single tertiary children’s hospital. Surveys were administered by trained study personnel (11/2/2021-5/1/2022). Demographic data were collected. An Attitudes toward Artificial Intelligence in Pediatric Healthcare score, assessing openness toward AI-assisted medicine, was calculated for seven areas of concern. Subgroup analyses were conducted using Mann–Whitney U tests to assess the effect of race, gender, education, insurance, length of stay, and intensive care unit (ICU) admission on AI use. ResultsWe approached 90 parents and conducted 76 surveys for a response rate of 84%. Overall, parents were open to the use of AI in pediatric medicine. Social justice, convenience, privacy, and shared decision-making were important concerns. Parents of children admitted to an ICU expressed the most significantly different attitudes compared to parents of children not admitted to an ICU. ConclusionsParents were overall supportive of AI-assisted healthcare decision-making. In particular, parents of children admitted to ICU have significantly different attitudes, and further study is needed to characterize these differences. Parents value transparency and disclosure pathways should be developed to support this expectation.

Telehealth Use in Pediatric Care during the COVID-19 Pandemic: A Qualitative Study on the Perspectives of Caregivers

This qualitative study surveyed caregivers regarding their perspectives on the benefits of, challenges with, and suggestions for improving telehealth during the COVID-19 pandemic. Caregivers who had the responsibility for caring for at least one child aged under 18 years of age in Genesee County, MI, participated. The caregivers were biological parents, stepparents, foster parents, adoptive parents, and guardians. A total of 105 caregivers completed a survey with open-ended questions via Qualtrics. Two independent coders developed themes based on the responses using grounded theory. Participants were primarily biological parents and non-Hispanic White and African Americans. According to the participants, the benefits of telehealth included prevention of exposure to the COVID-19 virus, quality communication with physicians, savings in travel time, and cost-effective methods to receive care. The challenges included a lack of in-person interaction, fear of compromised confidentiality, and the potential for misdiagnosis. Suggestions for improvement by caregivers included increasing access to telehealth for poorer families, offering a media educational campaign to promote telehealth use, and creating a universal platform to share patient information. Future studies may test the effectiveness of interventions such as those suggested by caregivers in this study to improve telehealth.

Assessment of the Plans to Optimize Antimicrobial Use in the Pediatric Population in Catalan Hospitals: The VINCat Pediatric PROA SHARP Survey.

In Spain, many programs have been introduced in recent years to optimize antimicrobial stewardship in pediatric care (known as pediatric PROA). However, information on the current situation of these programs is scarce. The present study assesses current antimicrobial use in pediatric care in the hospitals of Catalonia affiliated with the VINCat pediatric PROA group. Between December 2020 and January 2021, an electronic survey related to the design and use of PROA was administered to members of PROA teams in our hospital network. The survey was conducted at 26 hospitals. Twelve percent of the hospitals had pediatric PROA in operation, 42% were included in adult PROA, and 46% carried out pediatric PROA activities but not as part of an established program. At 81%, the pediatric PROA team included a pediatrician, in 58% a pharmacist, and in 54% a microbiologist. The main activities were monitoring the use of antimicrobials and bacterial resistance. Twenty-seven percent measured indicators regularly. The VINCat Pediatric PROA group's hospitals have implemented measures for optimizing antimicrobial stewardship, but few have a pediatric PROA program in place. Specific measures and indicators must be defined, and the resources available should be increased. The development of pediatric PROA should be monitored in the coming years.

Diaper Need Is Associated with Pediatric Care Use: An Analysis of a Nationally Representative Sample of Parents of Young Children

To examine the possible association between diaper need, difficulty affording an adequate amount of diapers, and pediatric care visits for urinary tract infections and diaper dermatitis. This cross-sectional analysis using nationally representative survey data collected July-August 2017 using a web-based panel examined 981 parents of children between 0 and 3years of age in the US (response rate, 94%). Survey weighting for differential probabilities of selection and nonresponse was used to estimate the prevalence of diaper need and to perform multivariable logistic regression of the association between parent reported diaper need and visits to the pediatrician for diaper rash or urinary tract infections within the past 12months. An estimated 36% of parents endorsed diaper need. Both diaper need (aOR 2.37; 95% CI 1.69-3.31) and visiting organizations to receive diapers (aOR 2.14; 95% CI 1.43-3.21) were associated with diaper dermatitis visits. Similar associations were found for diaper need (aOR 2.63; 95% CI 1.54-4.49) and visiting organizations to receive diapers (aOR 4.50; 95% CI 2.63-7.70) for urinary tract infection visits. Diaper need is common and associated with increased pediatric care visits. These findings suggest pediatric provider and policy interventions decreasing diaper need could improve child health and reduce associated healthcare use.

Prevalence of Social Risks on Inpatient Screening and Their Impact on Pediatric Care Use.

Screening for social determinants of health in the inpatient setting is uncommon. However, social risk factors documented in billing and electronic medical record data are associated with increased pediatric care use. We sought to describe (1) the epidemiology of social risks and referral acceptance and (2) association between social risks identified through routine inpatient screening and care use. Parents of children ages 0 to 18 admitted to a general pediatric floor at an academic children's hospital completed a psychosocial screening survey from October 2017 to June 2019. The survey covered the following domains: finances, housing, food security, medications, and benefits. Patient characteristics and care use outcomes were abstracted from the electronic medical record and compared by using Pearson's χ2 or the Wilcoxon rank test and logistic regression analyses. Of 374 screened families, 141 (38%) had a positive screen result, of whom 78 (55%) reported >1 need and 64 (45%) accepted a community resource. In bivariate analyses, patients with a positive screen result had higher 30-day readmission (10% vs 5%; P = .05), lower median household income ($62 321 vs $71 460; P < .01), lower parental education (P < .01), public insurance (57% vs 43%; P < .01), lived in a 1-parent household (30 vs 12%; P < .01), and had a complex chronic condition (35% vs 23%; P = .01) compared with those with a negative screen result. There was no difference in care reuse by screening status in adjusted analyses. Social risks are common in the pediatric inpatient setting. Children with medical complexity offer a good target for initial screening efforts.

2622. Multiplex Polymerase Chain Reaction (PCR) Panels in Pediatric Hospital Care: New Insights into Factors Driving Antimicrobial Use

BackgroundMultiplex PCR panels are diagnostic tools that first became available in 2011. They have rapid turnaround time and excellent sensitivity and specificity for a wide spectrum of microbial targets. However, it remains controversial whether its widespread use leads to optimal use of antimicrobials. We aimed to determine whether use of these tests was associated with appropriate antimicrobial therapy (AAT).MethodsWe conducted a single-center, retrospective study of hospitalized pediatric patients from 2015 to 2018 looking at 4 different respiratory panels and 1 meningoencephalitis panel (MEP). We analyzed test results and compared them to antimicrobial treatment. Using logistic regression, we analyzed the clinical and laboratory factors associated with AAT (defined as directed antimicrobial therapy based on clinical assessment and tests results).ResultsThere were 1,002 encounters in 951 patients. Mean length of stay was 7 days. 53.2% encounters had intensive care unit (ICU) admission. 77.1% of respiratory panels and 17.3% of MEP were positive. Co-detection in respiratory samples was 44.2%. Enterovirus was the most common virus detected while H. influenza was the most frequent bacteria. Respiratory Syncytial Virus was commonly detected with bacteria when compared with other common viruses. 13.4% patients were intubated, concordance with sputum culture was 63%. Patients admitted to the floor were more likely to have AAT than ICU patients (82.5% vs. 71.7%). ICU admission increased the odds of unnecessary antimicrobials (OR 1.6; 95% CI 1.1–2.5). Positive result from a comprehensive respiratory panel (bacteria + virus) decreased the odds of AAT (odds ratio: 0.4, 95% CI 0.3–0.8). Age, season, comorbidity, and intubation were not significantly associated with AAT. Only 0.5% of blood cultures in patients tested for respiratory infection were positive (3/579).ConclusionWe present new insights into factors driving antimicrobial use in pediatric hospital care. ICU admission was significantly associated with unnecessary antimicrobial use after adjusting for clinical findings and diagnostics. Frequently PCR results were not acted upon or caused additional use of antimicrobials. Further investigation is warranted to understand factors influencing antimicrobial use in pediatric care. Disclosures All authors: No reported disclosures.

Working Towards an Appropriate Use of Ibuprofen in Children: An Evidence-Based Appraisal.

Ibuprofen is the most widely used non-steroidal anti-inflammatory drug (NSAID) for the treatment of inflammation, mild-to-moderate pain and fever in children, and is the only NSAID approved for use in children aged ≥3 months. Its efficacy and safety profile have led to its increasing use in paediatric care, even without medical prescription. However, an increase of suspected adverse reactions to ibuprofen has been noted in concomitance with the raised, often medically unsupervised, consumption of the drug. The purpose of this work was a critical review of the paediatric literature over the last 15 years on side effects and adverse events associated with ibuprofen, in order to highlight circumstances associated with higher risks and to promote safe and appropriate use of this drug. The literature from 2000 to date demonstrates that gastrointestinal events are rare, but (when they occur) include both upper and lower digestive tract lesions. Dehydration plays an important role in triggering renal damage, so ibuprofen should not be given to patients with diarrhoea and vomiting, with or without fever. Likewise, ibuprofen should never be administered to patients who are sensitive to it or to other NSAIDs. It is contraindicated in neonates and in children with wheezing and persistent asthma and/or during varicella. Most of the analysed studies reported adverse events when ibuprofen was being used for fever symptoms or flu-like syndrome. Ibuprofen should not be used as an antipyretic, except in rare cases. Ibuprofen remains the drug of first choice in the treatment of inflammatory pain in children.

Pharmacovigilance for Children’s Sake

Child age-specific information on efficacy and risk of medicines can be limited for healthcare professionals and patients. It is therefore very important to make the best use of a risk planned approach to the pharmacological treatment of children. This means pharmacovigilance in the broadest sense of gaining the best data from the use of medicines in clinical practice. We consider issues that complicate safe medication use in paediatric care, as well as current progress and provide suggestions for building knowledge within paediatric pharmacovigilance to be used to minimise patient harm. The continuous development in children constitutes a challenge to prescribing and administering age-suitable doses for individual children. Children are not only different from adults but differ vastly within their own age group. Physical growth during childhood is apparent to the eye, but less obvious is the ongoing maturation of organ function important for drug disposition and action. Systematic issues such as medication errors, off-label use and the lack of age-suitable formulations are considerable obstacles for safe medication use in paediatrics. The recognition of emerging adverse drug reactions could be more challenging in developing children. Initiatives to improve the situation have been made by the WHO and regulators in the USA and EU. Age-specific changes in physiology, pharmacology and psychology, as well as systematic issues specific for children need to be considered in the work of assessing spontaneous reports in children. Pharmacovigilance needs to broaden its aims considerably beyond merely capturing new associations between drugs and events, and encompass careful collection on patient characteristics and circumstances around the reported adverse drug reaction to provide essential information that will give clues on how to prevent harm to children.

Passive and iontophoretic transdermal delivery of phenobarbital: Implications in paediatric therapy

The objective of this investigation was to evaluate phenobarbital transdermal delivery for possible use in paediatric care. In vitro experiments were performed using intact pig skin and barriers from which the stratum corneum had been stripped to different extents to model the less resistant skin of premature babies. Cathodal iontophoretic delivery of phenobarbital was superior to anodal transport and optimised delivery conditions were achieved by reduction of competing co-ion presence in the drug formulation. Phenobarbital transport across intact or partially compromised skin was controlled by iontophoresis which was more efficient than passive diffusion. Across highly compromised skin, however, passive diffusion increased drastically and iontophoretic control was lost. Overall, this study demonstrates the feasibility of phenobarbital transdermal delivery for paediatric patients.

Children’s Depression Screener (ChilD-S): Development and Validation of a Depression Screening Instrument for Children in Pediatric Care

The aim of the present study was to develop and validate the Children's Depression Screener (ChilD-S) for use in pediatric care. In two pediatric samples, children aged 9-12 (N(I)=200; N(II)=246) completed an explorative item pool (subsample I) and a revised item pool (subsample II). Diagnostic accuracy of each of the 22 items from the revised pool was evaluated in order to select the best items for the brief instrument ChilD-S. Areas under the curve (AUCs) of the revised item pool and the ChilD-S were compared. A diagnostic interview, the Kinder-DIPS, served as gold standard. For the purpose of screening for depressive disorders in children, the eight-item ChilD-S (AUC=0.97) performed just as well as the revised 22-item pool (AUC=0.94). For the ChilD-S the optimal cut-off point of ≥11 yielded a sensitivity of 0.91 and a specificity of 0.89. The ChilD-S shows high potential for depression screening of children in pediatric care.

Off-label Paediatric Drug Use for Juvenile Depression and the Clinical Trial Regulations 2004: The Impact of Available Protective Mechanisms

Across Europe, around one in four adults experience a mental health problem in any 1 year. It is estimated that 2–6% of children and adolescents suffer from depression and suicide is now the third leading cause of death in 10–19 year olds. Despite traditional Freudian teachings that children rarely suffer from clinically diagnosed depression, treatment figures for juvenile depression have soared in recent years. For adults, the current treatment trend, as advocated by the National Institute for Health and Clinical Excellence (NICE), is the use of Selective Serotonin Reuptake Inhibitors (SSRIs), such as Prozac. For children, efficacy of such treatment remains difficult to judge as all SSRI use in paediatric care remains ‘off-label’ or unlicensed. Notwithstanding this, in 2006 the European Medicines Agency (EMEA) advocated the use of Prozac within the EU for children from the age of eight, a position that reinforced the stance adopted by NICE in 2005. These recommendations have been made despite growing concern that many SSRIs have some serious side effects. In new legislation for paediatric medicines, that came into effect on 26th January 2007, the European Union (EU) has attempted to address several unresolved issues relating to children’s needs for medicines in Europe. This paper considers the position of off-label drug-therapy for juvenile depression, and assesses the effectiveness of available legal mechanisms that can protect juveniles from harm when involved in clinical drug trials, most notably the Clinical Trial Regulations 2004. It further reviews the new EU legislation and evaluates its likely impact.

Treatment of Childhood Disease and Prevention of Childhood and Adult Disease.

There are many examples of safe and efficacious supplement use in pediatric care, mostly the use of vitamins, minerals, protein, carbohydrate, and fat in specific clinical and diagnostic settings. The available scientific literature does not support the use of herbal and botanical compounds for common acute or chronic pediatric conditions. In health promotion and disease prevention, with few exceptions, there are no data to evaluate the safety and efficacy of supplements in preventing childhood disease. There is no literature to support supplement use in childhood to prevent adult disease, and this would require very long observation periods to establish efficacy.

Quality of Mother-Infant Attachment and Pediatric Health Care Use

The relationship between infant pediatric care use in the first year of life and the quality of mother-infant attachment at 1-year of age was examined. Fifty-six mother and infant pairs were classified by the Ainsworth Strange Situation procedure as securely (n = 17) or anxiously attached (n = 39). Pediatric records for the first 12 months of life were reviewed for frequency and type of visit, diagnoses, treatment, and symptoms prompting the care visit. Anxiously attached infants used acute care services (walk-in and emergency room) significantly earlier and more often than infants with a secure attachment. Use of acute care services began at a mean age of 3.8 months for the anxiously attached infants compared with 6.5 months for the securely attached. Differences in utilization persisted through the year. Mean acute care use in the anxiously attached infants was 3.6 visits compared with 1.9 visits for the securely attached. Acute care use was associated with a variety of common infant illnesses in both groups. In contrast, there was no difference in the use of well-baby care (mean 6 visits). Utilization and attachment status were independent of birth or prenatal difficulties. High cumulative use of pediatric care during the first year of life may identify infant and mother pairs who are experiencing strain in their interactions and relationship. Early recognition would provide an opportunity for comprehensive assessment and preventive intervention in the pediatric setting.