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Objective Dermatologic complaints are common in outpatient pediatrics. However, pediatric dermatology specialty care can be difficult to access. We aimed to test the feasibility of co-locating dermatology services within primary care and increase the proportion of patients treated for basic skin complaints within the medical home while decreasing wait times. Methods The Rapid Assessment of Skin Health (RASH) clinic was created within a hospital-based primary care clinic in 11/2013. The clinic was staffed by two pediatricians trained in the dermatology department and supported with specialist advice as needed. Referral volume and wait times to dermatology and RASH clinic were tracked for visits between 11/1/12 and 10/31/18. A chart review was also conducted on a subset of RASH clinic visits. Primary care providers (PCPs) were surveyed about their experiences. Results 58% of patients referred for a dermatologic complaint were scheduled in RASH clinic. Wait times for new patient appointments in RASH clinic were significantly shorter than for new dermatology appointments in the previous 12 months (mean 36 days vs. 65 days, p

Background/objectives Patient education is important to families' ability to manage and cope with pediatric atopic dermatitis (AD). We evaluated whether an educational handbook could improve AD symptoms, caregiver confidence in AD management skills, and AD-related quality of life. Methods Caregivers of children with AD ages 1 month to 16 years were randomly assigned to the intervention arm (handbook in addition to standard AD management) or the control arm (standard management alone). Caregivers completed self-report outcome questionnaires prior to a clinical visit for AD and at 3-month follow-up. Results 175 caregivers completed questionnaires at baseline and follow-up. AD symptoms measured by the Patient-Oriented Eczema Measure (POEM) improved in both the handbook and control arms. However, the decrease in the mean POEM score in the handbook arm (-4.4, 95% CI [-5.8, -3.0]) did not differ from that in the control arm (-3.4, 95% CI [-4.8, -2.03]; P = .343). Change in quality of life did not differ between study arms. Among caregivers attending a new patient visit for AD, mean confidence scores (measured from 0 to 100) increased more in the handbook arm (67 [95% CI {60, 74}] to 83 [95% CI {77, 88}]) relative to the control arm (74 [95% CI {65, 82}] to 75 [95% CI {67, 83}]; P = .012). The majority of caregivers rated the handbook as helpful in managing the child's AD. Conclusions Despite an adequate sample size, the handbook did not improve AD symptoms more than standard management alone. The handbook improved confidence in management skills for families attending new patient visits for AD.

Medication administration errors that take place in the home are common, especially when liquid preparations are used and complex medication schedules with multiple medications are involved; children with chronic conditions are disproportionately affected. Parents and other caregivers with low health literacy and/or limited English proficiency are at higher risk for making errors in administering medications to children in their care. Recommended strategies to reduce home medication errors relate to provider prescribing practices; health literacy–informed verbal counseling strategies (eg, teachback and showback) and written patient education materials (eg, pictographic information) for patients and/or caregivers across settings (inpatient, outpatient, emergency care, pharmacy); dosing-tool provision for liquid medication measurement; review of medication lists with patients and/or caregivers (medication reconciliation) that includes prescription and over-the-counter medications, as well as vitamins and supplements; leveraging the medical home; engaging adolescents and their adult caregivers; training of providers; safe disposal of medications; regulations related to medication dosing tools, labeling, packaging, and informational materials; use of electronic health records and other technologies; and research to identify novel ways to support safe home medication administration.

Background/objective Pediatric hematopoietic stem cell transplantation (HSCT) patients are at an increased risk for skin cancers. Sun exposure is a significant modifiable environmental risk factor. While patient education on sun protection and avoidance behaviors with regular dermatology evaluations are crucial for pediatric HSCT patients, the real-life practice of these sun-protection recommendations in this patient population compared to their peers is unknown. Methods A survey-based cross-sectional cohort study was performed in pediatric HSCT patients seen at the Dana-Farber Cancer Institute and Boston Children's Hospital over a 1.5-year period compared with age/sex/Fitzpatrick skin phototype-matched healthy controls. Study participants were surveyed using the validated Glanz survey for pediatric sun protection behavioral research. Results Eighty-five pediatric HSCT patients and 85 controls completed the study. Pediatric HSCT patients more frequently used sunscreen, hats, umbrellas, and sunglasses and obtained full-body skin exams compared to controls. No difference was observed in sun exposure during hours of peak sun intensity, frequency of purposeful tanning, tanning bed use, and the number of painful sunburns received between pediatric HSCT patients and controls. Conclusions Although pediatric HSCT patients practice more sun protection behaviors, they experienced harmful sunburns and intentional tanning behaviors at the same rate as their peers. Patient-directed counseling and strategies to improve patient adherence to optimal sun protection behaviors could have a significant impact on the dermatology quality of life in pediatric HSCT patients.

To assess pediatrician adherence to the 2017 American Academy of Pediatrics' clinical practice guideline for high blood pressure (BP).Pediatric primary care practices (n = 59) participating in a quality improvement collaborative submitted data for patients with high BP measured between November 2018 and January 2019. Baseline data included patient demographics, BP, body mass index (BMI), and actions taken. Logistic regression was used to test associations between patient BP level and BMI with provider adherence to guidelines (BP measurement, counseling, follow-up, evaluation).A total of 2677 patient charts were entered for analysis. Only 2% of patients had all BP measurement steps completed correctly, with fewer undergoing 3-limb and ambulatory BP measurement. Overall, 46% of patients received appropriate weight, nutrition, and lifestyle counseling. Follow-up for high BP was recommended or scheduled in 10% of encounters, and scheduled at the appropriate interval in 5%. For patients presenting with their third high BP measurement, 10% had an appropriate diagnosis documented, 2% had appropriate screening laboratory tests conducted, and none had a renal ultrasound performed. BMI was independently associated with increased odds of counseling, but higher BP was associated with lower odds of counseling. Higher BP was independently associated with an increased likelihood of documentation of hypertension.In this multisite study, adherence to the 2017 American Academy of Pediatrics' guideline for high BP was low. Given the long-term health implications of high BP in childhood, it is important to improve primary care provider recognition and management.ClinicalTrials.gov: NCT03783650.

There is growing emphasis on using patient-reported outcome measures to enhance clinical practice. This study was a retrospective review of scores on the Childhood Asthma Control Test (C-ACT) and the Pediatric Symptom Checklist-17 (PSC-17) at a pediatric primary care center in Boston, Massachusetts. A total of 218 patients were selected at random using billing codes for well-child (WC) care and asthma, excluding complex medical conditions. Cutoff scores were used to identify uncontrolled asthma (C-ACT ⩽19) and clinically significant psychosocial symptoms (+PSC-17). Multiple logistic regression was used to measure associations between C-ACT ⩽19 and +PSC-17, adjusting for covariates. In multivariable analysis, C-ACT ⩽19 at WC visits was associated with +PSC-17 at WC visits (adjusted odds ratio = 3.2 [95% confidence interval = 1.3-8.6]). C-ACT ⩽19 at non-WC visits was also associated with +PSC-17 at WC visits (adjusted odds ratio = 3.1 [95% confidence interval = 1.2-8.9]). Patient-reported outcome measures of asthma control and psychosocial symptoms were positively correlated in this sample.

To test whether an eczema care plan (ECP) would improve provider documentation and management, decrease eczema severity, and increase patient quality of life (QOL) in the pediatric primary care setting.We conducted a randomized controlled trial from June 2015 to September 2016 at a large hospital-based pediatric primary care clinic. Participants included children from 1 month to 16 years of age with a diagnosis of eczema. The intervention group received the ECP and the control group received usual care. Both groups completed a validated eczema severity scale (Patient-Oriented Eczema Measure [POEM]) and a QOL scale (Infant's Dermatitis Quality of Life Index [IDQOL]) or Children's Dermatology Life Quality Index [CDLQI]) before the visit and again ~1 month later.A total of 211 caregivers completed both the pre- and postintervention surveys (100 control group and 111 intervention group [94% completion]). Intervention group providers were more likely to recommend a comprehensive "step-up" plan (88%) vs 28%; P .001, bleach baths (45%) vs 9%; P .001, and wet wraps (50%) vs 7%; P .001. They were also more likely to document providing a written plan to families (80%) vs 2%; P .001. In the intervention and control groups, eczema severity and QOL improved between the pre- and postintervention periods. However, there was not a significant difference between the groups on either measure: POEM difference -0.8, 95% confidence interval (CI) -3.2 to 1.7; IDQOL difference -0.1, 95% CI -1.8 to 1.6; CDLQI difference 0.8, 95% CI -0.9 to 2.6.Intervention group providers documented more comprehensive eczema care than control group providers. Although patients improved on all measures in the postintervention period, the ECP did not augment that improvement.

Background Recognition of high blood pressure (BP) in children is poor, partly due to the need to compute age-sex-height referenced percentiles. This study examined the change in abnormal BP recognition before versus after the introduction of an electronic health record (EHR) app designed to calculate BP percentiles with a training lecture. Methods and results Clinical data were extracted on all ambulatory, non-urgent encounters for children 3–18 years old seen in primary care, endocrinology, cardiology, or nephrology clinics at an urban, academic hospital in the year before and the year after app introduction. Outpatients with at least 1 BP above the age-gender-height referenced 90th percentile were included. Abnormal BP recognition was defined as a BP related ICD-9 code, referral to nephrology or cardiology, an echocardiogram or renal ultrasound to evaluate BP concern, or a follow-up primary care visit for BP monitoring. Multivariable adjusted logistic regression compared odds of recognition before and after app introduction. Of 78 768 clinical encounters, 3521 had abnormal BP in the pre- and 3358 in the post-app period. App use occurred in 13% of elevated BP visits. Overall, abnormal BP was recognized in 4.9% pre-app period visits and 7.1% of visits post-app (P < .0001). Recognition was significantly higher when the app was actually used (adjusted OR 3.17 95% CI 2.29–4.41, P < .001). Without app use recognition was not different. Conclusions BP app advent modestly increased abnormal BP recognition in the entire cohort, but actual app use was associated with significantly higher recognition. Predictors of abnormal BP recognition deserve further scrutiny.

The national shortage of pediatric neurologists is worsening, yet referral rates by pediatricians are high. Suboptimal training of pediatric residents in care of patients with neurologic disease may be a contributing factor. We formed a partnership between the Boston Children’s Primary Care at Longwood clinic and Child Neurology Residency Training Program. The educational intervention included lectures, observed neurologic examinations, in-person and virtual triage, and an electronic medical record–based consult system. Residents in other primary care clinics served as the comparison group. Intervention-group residents reported significantly improved confidence in diagnosis of chronic/recurrent headache, attention deficit hyperactivity disorder (ADHD), and developmental delay; initial management of ADHD and developmental delay; and secondary management of ADHD, developmental delay, and concussion/traumatic brain injury. Comparison-group residents reported significantly improved confidence only in diagnosis of developmental delay. Our multipronged intervention is a promising approach to improving pediatric resident training in pediatric neurology and may be generalizable to subspecialty collaborations for other residency programs.

11-year old twin boy found to have idiopathic precocious puberty after routine well-child examination revealed discordant pubertal growth between the two brothers.

Atopic dermatitis (AD) is the most common pediatric skin disease. AD has a significant effect on patient and family quality of life caused by intense pruritus, sleep disruption, dietary and nutritional concerns, and psychological stress associated with the disease and its management. Multidisciplinary approaches to AD care have been developed in appreciation of the complex interplay among biological, psychological, behavioral, and dietary factors that affect disease control and the wide range of knowledge, skills, and support that patients and families require to effectively manage and cope with this condition. Common components of multidisciplinary treatment approaches include medical evaluation and management by an AD specialist, education and nursing care, psychological and behavioral support, and nutritional assessment and guidance. Models of care include both clinical programs and structured educational groups provided as adjuncts to standard clinical care. Available evidence suggests beneficial effects of multidisciplinary interventions in improving disease severity and quality of life, particularly for patients with moderate-to-severe disease. Additional research is needed to identify the best candidates for the various multidisciplinary approaches and evaluate the cost-effectiveness of these programs.

Neonatal lupus erythematosus is a rare autoimmune disease caused by passive transplacental acquisition of maternal autoantibodies manifesting in cutaneous, cardiac, haematological and hepatobiliary abnormalities. The hallmark dermatological finding is erythematous annular lesions with a predilection for photo-exposed areas of the skin. We present a case of a female infant born to a mother with Sjogren’s syndrome, who initially presented to an ambulatory care setting with non-specific erythematous papules involving the face and scalp. Within 6 days the rash changed in appearance, consisting of widespread erythematous annular and polycyclic lesions with central violaceous clearing and atrophy. Serological tests revealed asymptomatic anemia and leukopenia, elevated liver enzymes, and positive antinuclear antibodies (ANA) and anti-SSb/La antibodies. Further cardiac evaluation was normal. She was managed conservatively in the outpatient setting with topical steroids, avoidance of sunlight and fluorescent light exposure, and primary care, rheumatological and dermatological follow-up.

BackgroundIron deficiency anaemia (IDA) in infancy is prevalent and associated with impaired neurodevelopment; however, studies suggest that treatment and follow-up rates are poor.ObjectivesTo improve the rate of ferrous sulfate prescription for suspected IDA among infants aged 8–13 months to 75% or greater within 24 months.MethodsWe implemented a multidisciplinary process improvement effort aimed at standardising treatment for suspected IDA at two academic paediatric primary care clinics. We developed a clinical pathway with screening and treatment recommendations, followed by multiple plan-do-study-act cycles including provider education, targeted reminders when ferrous sulfate was not prescribed and development of standardised procedures for responding to abnormal lab values. We tracked prescription and screening rates using statistical process control charts. In post hoc analyses, we examined rates of haemoglobin (Hgb) recheck and normalisation for the preintervention versus postintervention groups.ResultsThe prescription rate for suspected IDA increased from 41% to 78% following implementation of the intervention. Common reasons for treatment failure included prescription of a multivitamin instead of ferrous sulfate, and Hgb not flagged as low by the electronic medical record. Screening rates remained stable at 89%. Forty-one per cent of patients with anaemia in the preintervention group had their Hgb rechecked within 6 months, compared with 56% in the postintervention group (pConclusionsA multipronged interdisciplinary quality improvement intervention enabled: (1) development of standardised practices for treating suspected IDA among infants aged 8–13 months, (2) improvement of prescription rates and (3) maintenance of high screening rates. Rates of Hgb recheck and normalisation also increased in the intervention period.​

Systemic hypertension is a major cause of morbidity and mortality in adulthood. High blood pressure (HBP) and repeated measures of HBP, hypertension (HTN), begin in youth. Knowledge of how best to diagnose, manage, and treat systemic HTN in children and adolescents is important for primary and subspecialty care providers. OBJECTIVES: To provide a technical summary of the methodology used to generate the 2017 “Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents,” an update to the 2004 “Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents.” DATA SOURCES: Medline, Cochrane Central Register of Controlled Trials, and Excerpta Medica Database references published between January 2003 and July 2015 followed by an additional search between August 2015 and July 2016. STUDY SELECTION: English-language observational studies and randomized trials. METHODS: Key action statements (KASs) and additional recommendations regarding the diagnosis, management, and treatment of HBP in youth were the product of a detailed systematic review of the literature. A content outline establishing the breadth and depth was followed by the generation of 4 patient, intervention, comparison, outcome, time questions. Key questions addressed: (1) diagnosis of systemic HTN, (2) recommended work-up of systemic HTN, (3) optimal blood pressure (BP) goals, and (4) impact of high BP on indirect markers of cardiovascular disease in youth. Once selected, references were subjected to a 2-person review of the abstract and title followed by a separate 2-person full-text review. Full citation information, population data, findings, benefits and harms of the findings, as well as other key reference information were archived. Selected primary references were then used for KAS generation. Level of evidence (LOE) scoring was assigned for each reference and then in aggregate. Appropriate language was used to generate each KAS based on the LOE and the balance of benefit versus harm of the findings. Topics that could not be researched via the stated approach were (1) definition of HTN in youth, and (2) definition of left ventricular hypertrophy. KASs related to these stated topics were generated via expert opinion. RESULTS: Nearly 15 000 references were identified during an initial literature search. After a deduplication process, 14 382 references were available for title and abstract review, and 1379 underwent full text review. One hundred twenty-four experimental and observational studies published between 2003 and 2016 were selected as primary references for KAS generation, followed by an additional 269 primary references selected between August 2015 and July 2016. The LOE for the majority of references was C. In total, 30 KASs and 27 additional recommendations were generated; 12 were related to the diagnosis of HTN, 13 were related to management and additional diagnostic testing, 3 to treatment goals, and 2 to treatment options. Finally, special additions to the clinical practice guideline included creation of new BP tables based on BP values obtained solely from children with normal weight, creation of a simplified table to enhance screening and recognition of abnormal BP, and a revision of the criteria for diagnosing left ventricular hypertrophy. CONCLUSIONS: An extensive and detailed systematic approach was used to generate evidence-based guidelines for the diagnosis, management, and treatment of youth with systemic HTN.

We investigated factors associated with quality of life (QOL) in children with eczema. We conducted a cross-sectional analysis of survey data from 224 parents of children with eczema attending a large, hospital-based pediatric clinic. Parents completed a validated eczema severity scale (Patient-Oriented Eczema Measure), a QOL scale (Infants’ Dermatitis QOL Index or Children’s Dermatology Life Quality Index), and a knowledge and understanding questionnaire. In adjusted multivariate analyses, worse eczema severity was associated with worse overall QOL (β = 0.5; 95% confidence interval [CI] = [0.5, 0.6]), while a higher knowledge score was associated with better QOL (β = −3.4; 95% CI = [−6.6, −0.2]). Similarly, even after adjustment for eczema severity, greater understanding of a child’s individual treatment plan was associated with better QOL (β = −0.7; 95% CI = [−1.4, −0.08]), while increased frequency of worrying about a child’s eczema was associated with worse QOL (β = 0.7; 95% CI = [0.03, 1.1]). These results suggest primary care providers may be able to influence QOL through optimal eczema management and family education.

BACKGROUND AND OBJECTIVES:Timely provision of developmental services can improve outcomes for children 0 to 3 years old with developmental delays. Early Intervention (EI) provides free developmental services to children under age 3 years; however, data suggests that many children referred to EI never connect to the program. We sought to ensure that 70% of patients referred to EI from an academic primary care clinic serving a low-income population were evaluated within 120 days of referral.METHODS:Recognizing that our baseline system of EI referrals had multiple routes to referral without an ability to track referral outcome, we implemented a multifaceted referral process with (1) a centralized electronic referral system used by providers, (2) patient navigators responsible for processing all EI referrals submitted by providers, and (3) a tracking system postreferral to facilitate identification of patients failing to connect with EI.RESULTS:The percentage of patients evaluated by EI within 120 days increased from a baseline median of 50% to a median of 72% after implementation of the systems (N = 309). After implementation, the centralized referral system was used a median of 90% of the time. Tracking of referral outcomes revealed decreases in families refusing evaluations and improvements in exchange of information with EI.CONCLUSIONS:Rates of connection to EI improved substantially when referrals were centralized in the clinic and patient navigators were responsible for tracking referral outcomes. Knowledge of EI intake processes and relationships between the practice and the EI site are essential to ensure successful connections.

The quality of children's health is compromised by poor care coordination between primary care providers (PCPs) and specialists. Our objective was to determine how an electronic consultation and referral system impacts referral patterns and PCP-specialist communication.The primary care clinic at Boston Children's Hospital piloted an electronic referral and consultation system with the neurology and gastroenterology departments from April 1, 2014, to October 31, 2016. PCPs completed an electronic consult form, and if needed, specialists replied with advice or facilitated expedited appointments. Specialist response times, referral rates, wait times, and completion rates for specialty visits were tracked. PCPs and specialists also completed a survey to evaluate feasibility and satisfaction.A total of 82 PCPs placed 510 consults during the pilot period. Specialists responded to 88% of requests within 3 business days. Eighteen percent of specialty visits were deferred and 21% were expedited. Wait times for specialty appointments to both departments significantly decreased, from 48 to 34 days (P .001), and completion rates improved from 58% to 70% (P .01), but referral volumes remained stable (25 per month to 23 per month; P = .29). Most PCPs said the Shared Care system facilitated better communication with specialists (89%) and enabled them to provide superior patient care (92%). Specialists reported that the system required a minimal amount of time and enabled them to educate PCPs and triage referrals.Implementation of an electronic referral and consultation system was feasible and provided timely access to specialty care, but did not affect referral volume. This system could serve as a model for other health care organizations and specialties.

These pediatric hypertension guidelines are an update to the 2004 “Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents.” Significant changes in these guidelines include (1) the replacement of the term “prehypertension” with the term “elevated blood pressure,” (2) new normative pediatric blood pressure (BP) tables based on normal-weight children, (3) a simplified screening table for identifying BPs needing further evaluation, (4) a simplified BP classification in adolescents ≥13 years of age that aligns with the forthcoming American Heart Association and American College of Cardiology adult BP guidelines, (5) a more limited recommendation to perform screening BP measurements only at preventive care visits, (6) streamlined recommendations on the initial evaluation and management of abnormal BPs, (7) an expanded role for ambulatory BP monitoring in the diagnosis and management of pediatric hypertension, and (8) revised recommendations on when to perform echocardiography in the evaluation of newly diagnosed hypertensive pediatric patients (generally only before medication initiation), along with a revised definition of left ventricular hypertrophy. These guidelines include 30 Key Action Statements and 27 additional recommendations derived from a comprehensive review of almost 15 000 published articles between January 2004 and July 2016. Each Key Action Statement includes level of evidence, benefit-harm relationship, and strength of recommendation. This clinical practice guideline, endorsed by the American Heart Association, is intended to foster a patient- and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient diagnoses and outcomes, support implementation, and provide direction for future research.

To examine the extent to which parent health behaviors and parenting practices are associated with school-age children's sleep duration.We surveyed 790 parents of children, aged 6 to 12 y, who had a body mass index (BMI) ≥ 90th percentile and were participating in a randomized controlled obesity trial. The main exposures were parent sleep duration, screen time and physical activity, parental limits placed on child TV viewing time and TV content, and parents' confidence regarding their ability to help their child get enough sleep. The primary outcome was child sleep duration. We used linear regression models to examine associations of parent behaviors and parenting practices with child sleep duration.On average, children slept 9.2 h per night, whereas parents slept 6.9 h. Parents reported having an average of 1.9 h of screen time per day and 0.6 h of physical activity. There were 57.3% of parents who reported feeling very/extremely confident that they could help their child get enough sleep. In adjusted multivariate analyses, child sleep duration was 0.09 h/day (95% confidence interval: 0.03, 0.15) longer for each 1-h increment in parent sleep duration. Additionally, children whose parents reported being very/extremely confident they could help their child get age-appropriate sleep duration slept 0.67 h/day longer (95% confidence interval: 0.54, 0.81) than those whose parents were not/somewhat confident.Educating parents about their own sleep health and enhancing parent confidence to help their children get enough sleep are potential areas of intervention to increase child sleep duration.

Objective To measure public library use in a sample of families with young children and examine associations with reading aloud. Study design We interviewed 200 parents of 6- to 18-month-old children visiting a hospital-based pediatric clinic. We assessed public library card ownership, public library visitation, and awareness of public library programming. We assessed reading aloud using the StimQ READ questionnaire. We used multivariable logistic and linear regression to examine associations while adjusting for sociodemographic characteristics. Results In multivariable analysis, parents who owned a public library card had greater odds of reading aloud daily to their 6- to 18-month-old child (aOR, 2.0; 95% CI, 1.0-3.8) and higher StimQ READ scores (β = 0.9; 95% CI, 0.2-1.6). Parents who visited a public library once a month or more often had greater odds of reading aloud daily (aOR, 3.4; 95% CI, 1.8-6.7) and higher StimQ READ scores (β = 1.3; 95% CI, 0.6-2.0). Parents whose 6- to 18-month-old child had ever visited a public library did not have greater odds of reading aloud daily (aOR, 1.4; 95% CI, 0.7-2.9), but did have higher StimQ read scores (β = 1.2; 95% CI, 0.4-2.0). Parents who felt informed about available public library programs for children had greater odds of reading aloud daily (aOR, 2.5; 95% CI, 1.3-5.1) and higher StimQ READ scores (β = 1.1; 95% CI, 0.4-1.9). Conclusion In this sample of families with young children, we found positive associations between public library use and reading aloud.