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Background: Acute respiratory infections (ARIs), especially pneumonia, remain a major cause of infant mortality worldwide. In Indonesia, pneumonia is the second most common cause of infant and toddler deaths. Exclusive breastfeeding and basic immunization can protect infants and children from contracting pneumonia.Purpose: Our goal was to assess the risk factors for childhood pneumonia in regions with a high prevalence of pneumonia in Indonesia.Methods: This case-control study was conducted between March and April 2019. A total of 176 infants and toddlers aged 10–59 months were enrolled and selected from among patients who visited the community health center. Cases of pneumonia were diagnosed clinically based on the World Health Organization guidelines, and the control was nonpneumonia.Results: The risk factors for the diagnosis of pneumonia included no or nonexclusive breastfeeding (odds ratio [OR], 7.95; 95% confidence interval [CI], 3.52–17.94), incomplete basic immunizations (OR, 4.47; 95% CI, 2.22–8.99), indoor air pollution (OR, 7.12; 95% CI, 3.03–16.70), low birth weight (OR, 3.27; 95% CI, 1.19–8.92), and a high degree of wasting (OR, 2.77; 95% CI, 1.06–7.17). Other variables such as nutritional status (height-for-age z score), age, sex, and educational status of the mother were not risk factors for pneumonia.Conclusion: No or nonexclusive breastfeeding, incomplete basic immunizations, indoor air pollution, a history of low birth weight, and severe malnutrition were risk factors for childhood pneumonia. Breastfeeding was the dominant factor, while sex modified the relationship between exclusive breastfeeding and the incidence of pneumonia.

Objective Academic General Pediatrics (AGP) is a pediatric subspecialty with substantial faculty contributions in clinical care, research, education, and advocacy. However, AGP fellowship recruitment challenges exist. We aimed to describe AGP hiring practices from 2014 to 2019 and the role of fellowship training in hiring decisions. Methods We conducted a cross-sectional survey study of AGP Division Directors (DDs) and Fellowship Program Directors (PDs) from US-based academic institutions. Survey questions were developed iteratively and pilot-tested for content validity. Participants were identified from the Association of American Medical Colleges' directory of pediatric departments, Academic Pediatric Association's AGP Accreditation Committee's list of fellowship programs, and institutional websites. Descriptive analysis was used for close ended survey questions. Narrative responses were reviewed for trends. Results Forty-nine DDs (57%) and 22 PDs (73%) responded. All DDs reported at least one available faculty position and 73% reported filling a position with protected time. PDs reported 89 graduating fellows, 88% of whom secured an academic position with protected time. Seventy-percent of DDs and 100% of PDs reported that AGP fellows could secure an academic position with protected time, while only 22% and 1%, respectively, reported a graduating pediatric resident could secure a similar position. DDs indicated AGP fellowship trained candidates are preferable for enhancing research and education programs. Conclusion AGP remains an active subspecialty and the majority of graduating fellows secured faculty positions with protected time. Further studies are needed to understand ways to improve visibility of AGP fellowships.

Background: The clinical significance of lip-tie, or a tethered maxillary frenulum, remains under debate. Clinicians and parents are often perplexed when deciding whether procedures available to relieve a seemingly tight or severe maxillary frenulum are needed.Purpose: No previous studies have assessed the consequences of not subjecting a tethered maxillary frenulum in newborns to surgical intervention. This study aimed to contribute the first prospective trial on this topic with a relatively extended followup of these newborn infants.Methods: This prospective observational questionnaire-based cohort trial was performed in a community setting and aimed to determine whether lip-tie is associated with an increased likelihood of eventual feeding or oral disorders.Results: The convenience sample comprised of 61 consecutively arriving infants with concomitant tethered frenula who were treated at the clinic for various reasons. This cohort was compared with a random sample of 66 age-matched children for a mean follow-up period of 6.42 years. Infants undergoing oropharyngeal procedures were excluded. Awareness of a deviation in oral structures was reported by 18% of the study group versus 0% of the controls. Mothers participating in the study group (24.6%) less frequently recalled painful nipples or discomfort during breastfeeding than those in the control group (47.0%) (P

This study aimed to investigate the effect of maternal smoking during pregnancy (MSDP) on the risk of bone fractures in the offspring through a systematic review and meta-analysis. The PubMed, Web of Science, and Scopus databases were systematically searched for relevant articles published through July 2019. According to heterogeneity, the pooled risk ratio (RR) and odds ratio (OR) and their corresponding 95% confidence interval (CI) were obtained using fixed or random effects models. The heterogeneity and quality of the included studies were assessed by the I-squared (I2 ) statistic and the NewcastleOttawa scale, respectively. Sensitivity analyses were performed to test the effect of MSDP misclassification on the results. The review of 842 search records yielded 5 studies including 8,746 mother-child pairs that were included in the meta-analysis. Pooling adjusted effect measures showed that MSDP was not associated with a later risk of bone fractures in the offspring (pooled RR, 1.15; 95% CI, 0.84–1.58; I2 =66.8%; P=0.049). After the adjustment for misclassification, MSDP may be associated with a 27% increased risk of bone fracture (pooled OR, 1.27; 95% CI, 1.00–1.62; I2 =0%; P=0.537). After the adjustment for misclassification, MSDP is associated with an increased risk of bone fractures among children whose mothers smoked during pregnancy.

Background Despite the assurance of free medical access through the universal health insurance system, over the past three decades Japanese youth have experienced an increase in developmental and behavioral problems, psychosomatic disorders, and psychiatric illnesses. Objectives To identify the challenges in promoting comprehensive preventive health services to adolescents in Japan, specifically in Tokyo. Methods A cross-sectional online survey was conducted of physicians who are members of the Tokyo Pediatric Association. The questionnaire assessed primary care pediatricians’ practice settings and their attitudes toward outpatient services to adolescent patients. Results Out of 617 member pediatricians, 69 valid responses were obtained. Majority were private pediatricians. 52% indicated that they had specialties in addition to general pediatrics; however, no one reported specializing in adolescent medicine. Approximately 70% answered the optimal patient encounter time would be under 10 min. More than 90% of respondents reported challenges providing health services to adolescent patients. Nearly half indicated that they did not routinely evaluate height, heart rate or blood pressure. Few providers asked about reproductive health, violence, or smoking/alcohol use. Conclusion This survey is the first exploration of adolescent health care in an urban area of Japan. While the sample is small, the magnitude of challenges was great with limited training in adolescent medicine, severe time constraints and limited appreciation for the value of health screening at each encounter. Developing a standardized practical assessment tool for adolescent patients may help guide primary care pediatricians to better meet the needs of their adolescent patients.

In his introduction, “Anniversaries, ” Alistair G.S. Philip, the editor of NeoReviews until 2017, reminisces about the 1960s to 1990s, highlighting various advances that long ago became a part of the scientific and professional sediment in our field. However, all of these recollections preceded the inception of the all online journal, NeoReviews , one of the first of its kind. At the journal’s 10th birthday, Alistair assembled a collection of “seminal contributions” in neonatal-perinatal medicine that had been published in NeoReviews , (1) which were then subsequently published in a book, Milestones in Neonatal/Perinatal Medicine . (2) Moreover, Alistair’s masterful and judiciously thorough recounting of the history of our field of neonatology was published in 2005, entitled “ The Evolution of Neonatology. ” (3) In this commentary, we wish to acknowledge Alistair’s dedication in informing his readership about the scientific and clinical advances in neonatology. Here, we offer our own perspective on what has transpired over the last 20 years of NeoReview’s life, but with an eye toward the future. As Alistair has pointed out, the subfield of newborn medicine evolved within general pediatrics sometime in the late 1940s and 1950s, an unusual, but remarkable, legacy from Martin A. Couney and Pierre-Constant Budin and their “incubator babies” sideshows at amusement parks, world fairs, and exhibitions. (4) The term “ neonatology ” itself, however, was not introduced until 1960 by Alexander Schaffer (5) in close timing with the advent of intensive care nurseries, which were more than just special facilities for preterm infants. The original research defining the nascent field focused on thermoregulation, nutrition, and growth of a neonate, quickly distinguishing neonatology from general pediatrics because of the unique requirements of the newborn, especially the preterm infant. As survival of preterm infants increased over subsequent decades, advances in cardiorespiratory support and …

Background: The optimal management of perianal abscess in children is controversial.Purpose: To evaluate the efficiency of conservative treatment of perianal abscess in children and identify parameters that predict therapy failure.Methods: All cases of children younger than 14 years of age with perianal abscesses between 2001–2016 were evaluated.Results: Of the 113 enrolled patients, 64 underwent subsequent surgery for advanced disease (primary surgery group). Conservative treatment was initiated in 49 patients (primary conservative group) but was stopped because of inefficiency in 25 patients, who were referred for surgery after a median 7.03 days (range, 2 to 16 days). The other 24 patients (48%) initially achieved complete remission after conservative treatment, but 10 were readmitted after a median 34 months (range, 3 to 145 months) with recurrent disease. There were no significant differences in permanent success after conservative treatment between infants (10 of 29, 34%) and older children (4 of 20 [20%], P=0.122). Overall, conservative treatment alone was effective in only 14 of 113 patients. Recurrence after surgery occurred in 16 patients (25%) in the primary surgery group and 11 patients (22%) in the primary conservative group (P=0.75). Univariate analysis of predictors for conservative treatment failure revealed inflammatory values (C-reactive protein and white blood count, P=0.017) and abscess size (P=0.001) as significant parameters, whereas multivariate analysis demonstrated that only abscess size (odds ratio, 3.37; P=0.023) was significant.Conclusion: Conservative treatment of perianal abscess is permanently efficient in only a minority of children but is not associated with a higher recurrence rate after subsequent surgery. Abscess size is a predictor for therapy failure.

Background: Children today get access to smartphones at an early age. However, their ability to use mobile apps has not yet been studied in detail.Purpose: This study aimed to assess the ability of children aged 2–8 years to perform touchscreen gestures and follow prompting techniques, i.e., ways apps provide instructions on how to use them.Methods: We developed one mobile app to test the ability of children to perform various touchscreen gestures and another mobile app to test their ability to follow various prompting techniques. We used these apps in this study of 90 children in a kindergarten and a primary school in New Delhi in July 2019. We noted the touchscreen gestures that the children could perform and the most sophisticated prompting technique that they could follow.Results: Two- and 3-year-old children could not follow any prompting technique and only a minority (27%) could tap the touchscreen at an intended place. Four- to 6-year-old children could perform simple gestures like a tap and slide (57%) and follow instructions provided through animation (63%). Sevenand 8-year-old children could perform more sophisticated gestures like dragging and dropping (30%) and follow instructions provided in audio and video formats (34%). We observed a significant difference between the number of touchscreen gestures that the children could perform and the number of prompting techniques that they could follow (F=544.0407, PP>0.05).Conclusion: Children gradually learn to use mobile apps beginning at 2 years of age. They become comfortable performing single-finger gestures and following nontextual prompting techniques by 8 years of age. We recommend that these results be considered in the development of mobile apps for children.

ObjectiveWe analyzed the annual prevalence of onset-DKA (diabetic ketoacidosis) from 2012 to 2020 with a sub-analysis for lockdown-periods during the COVID-19 pandemic in 2020.DesignAll newly diagnosed children with type 1 diabetes (T1D) aged Main Outcome MeasuresThe annual DKA prevalence was analyzed using Joinpoint regression. Definition of DKA: pH ResultsIn the years 2012–2020 the mean prevalence for onset-DKA in Austria was 43.6% [95%CI (confidence interval): 41.6, 45.7] and thus above the mean prevalence of previous decades (1989–2011) of 37,1 % (95%CI: 35.6, 38.6). A particularly high prevalence was found among children p = 0.023). During the lockdown in 2020, 59.3% of children were diagnosed with DKA at T1D-onset, compared to 42.1% during the previous 5 years (p = 0.022). Moreover, 20% of children had severe DKA at T1D diagnosis, compared to 14% during the comparison period.ConclusionsThe previously already high prevalence of DKA at T1D-onset has further increased over time. The COVID-19 pandemic has exacerbated the problem of a late or delayed diagnosis of diabetes in children resulting in onset-DKA. The alarmingly increased prevalence of DKA in Austrian children with T1D calls for urgent action.

BackgroundChildren with medical complexity (CMC) have multiple chronic conditions and require a high level of coordinated healthcare. The risk of COVID-19 among CMC is unclear.ObjectivesWe aim to identify and describe the prevalence and experience of COVID-19 among CMC and their caregivers during the initial weeks of the COVID-19 pandemic in the NY metropolitan area.MethodsWe performed a cross-sectional study of children enrolled in a structured clinical program for CMC at a large urban, academic general pediatrics practice in NY.ResultsIn our patient population (n = 132), 16 patients had a known exposure with parents being the most common exposure in 37.5% (n = 6). Two patients were hospitalized for COVID-19 while the remainder of the confirmed or suspected COVID-19 cases were managed as an outpatient.ConclusionsCommon sources of COVID-19 exposure were family members and home care providers. Almost all of our patients experienced interruption of medical care including missed therapies and visits.

This study demonstrates the challenges of establishing social determinants of health (SDH) screening at well child visits (WCVs) during the COVID-19 pandemic. We conducted a 6-month pre-intervention retrospective chart review (2/2020-8/2020) and 6-month post-intervention prospective chart review (8/2020-2/2021) of an SDH screening and referral protocol at a single suburban academic pediatric clinic. WCVs were screened for food, financial, and transportation needs. With the new protocol, 46% of eligible WCVs (n = 1253/2729) had documented screening results. Self-report of screened visits found 34.6% with financial strain, 32% with worry about food insecurity, 25.1% with food insecurity, 5.3% with medical transportation difficulties, and 6% with daily living transportation difficulties. There was an increase in resources offered during the post-intervention period (OR = 11.5 [7.1-18.6], P

Background: Many children eligible for developmental therapies through early intervention do not receive such services, often due to practical barriers in accessing the early intervention system as well as distrust. In response to these difficulties, we created a Parent Navigator program to provide two full-time parents of individuals with developmental …

Background: Attention deficit hyperactivity disorder (ADHD) symptoms have a major impact on individuals, families, and society. Therefore identification risk factors of ADHD are a public health priority. Purpose: This is meta-analysis evaluated the association between maternal prepregnancy body mass index and the risk of ADHD among the resulting offspring. Methods: The search identified studies published through December 2018 in the PubMed, Web of Science, and Scopus databases. The odds ratios (ORs) or hazard ratios (HRs) with 95 confidence intervals (CI) extracted from eligible studies were used as the common measure of association among studies. Results: A significant association was found between overweight women and the risk of ADHD among children with the pooled HR and OR estimates (HR, 1.27 and 95 CI, 1.17–1.37; OR, 1.28 and 95 CI, 1.15–1.40, respectively). This association was significant between obese women and the risk of ADHD among children and adolescents with the pooled estimates of HR and OR (HR, 1.65 and 95 CI, 1.55–1.76; OR, 1.42 and 95 CI, 1.23–1.61). Conclusion: The current epidemiological studies present sufficient evidence that prepregnancy overweight and obesity are significantly associated with an increased risk of ADHD among children and adolescents. These findings provide a new approach to preventing ADHD by controlling weight gain in the prenatal period, which should be considered by policymakers. © 2019 by The Korean Pediatric Society.

Background Environmental exposures contribute to multiple diseases in children; yet, few pediatricians have training in pediatric environmental health (PEH), and few academic health centers have PEH expertise. To build national capacity in PEH, the Academic Pediatric Association (APA) launched a professional development program that since 2002 has encouraged the establishment of post-residency/post-doctoral training programs, supported a special interest group, and convened an annual mentored retreat for PEH trainees. Objective Describe the APA's professional development program in PEH and assess its impact by tracking careers of former trainees. Methods Careers were tracked through interviews with trainees and program directors supplemented by searches of institutional websites. Publication listings were obtained through PubMed. Publication impact was assessed using bibliometric and altmetric measures. Grant histories were accessed through the National Institutes of Health RePORTER project. Information on advocacy work was obtained through interviews with program directors. Results Fifty-five trainees (36 physicians and 19 health scientists) completed PEH training and attended the APA retreat between 2002 and 2017. Forty-one (75%) are pursuing academic careers, 11 are associate or full professors, 11 are practicing general pediatrics or a pediatric subspecialty, 2 are Centers for Disease Control and Prevention epidemiologists, and 1 is a data scientist. Forty-two former trainees (76%) listed “environment” or “environmental” in their job titles or on their websites. Former trainees have published 632 scientific papers. These papers have been cited 3094times, have a relative citation ratio of 2.97, and have been read or viewed 1,274,388times. Twenty-one former trainees have been awarded 43 National Institutes of Health grants. Trainees have developed education and advocacy skills by teaching medical students and residents, presenting grand rounds, preparing policy papers, presenting legislative testimony, and making presentations to public audiences. Conclusions The APA's professional development program has contributed to the expansion of national capacity in PEH. Former trainees are populating the field, generating new knowledge, and moving into leadership positions.

OBJECTIVE: Despite the need for quality measures relevant to the work residents complete, few attempts have been made to address this gap. Resident-sensitive quality measures (RSQMs) can help fill this void. This study engaged resident and supervisor stakeholders to develop and inform next steps in creating such measures.METHODS: Two separate nominal group techniques (NGTs), one with residents and one with faculty and fellow supervisors, were used to generate RSQMs for 3 specific illnesses (asthma, bronchiolitis, and closed head injury) as well as general care for the pediatric emergency department. Two separate Delphi processes were then used to prioritize identified RSQMs. The measures produced by each group were compared side by side, illuminating similarities and differences that were explored through focus groups with residents and supervisors. These focus groups also probed future settings in which to develop RSQMs.RESULTS: In the NGT and Delphi groups, residents and supervisors placed considerable focus on measures in 3 areas across the illnesses of interest: 1) appropriate medication dosing, 2) documentation, and 3) information provided at patient discharge. Focus groups highlighted hospital medicine and general pediatrics as priority areas for developing future RSQMs but also noted contextual variables that influence the application of similar measures in different settings. Residents and supervisors had both similar as well as unique insights into developing RSQMs.CONCLUSIONS: This study continues to pave the path forward in developing future RSQMs by exploring specific settings, measures, and stakeholders to consider when undertaking this work.

Background Mindfulness practices are associated with improved health and well-being for children. Few studies have assessed parents’ acceptance of learning about mindfulness practices. Objective This study aims to assess parents’ beliefs and interest in learning about mindfulness, including from their health care provider, and differences across demographic backgrounds. Methods We conducted a national cross-sectional survey of parents with children aged 0-18 years in October 2018. Measures included beliefs and interest in learning about mindfulness. These measures were compared across demographic backgrounds using chi-square analysis. Multivariate linear and logistic regression analyses were used to perform adjusted comparisons between demographic backgrounds. Results Participants (N=3000) were 87% (n=2621) female and 82.5% (n=2466) Caucasian. Most (n=1913, 64.2%) reported beliefs that mindfulness can be beneficial when parenting, 56.4% (n=1595) showed interest in learning about mindfulness to help their child stay healthy, and 40.8% (n=1214) reported interest in learning about mindfulness from their health care provider. Parents with a college degree 49.6% (n=444) were more likely to report interest in learning about mindfulness from a health care provider compared to those without 37.1% (n=768; P Conclusions This study indicates that many parents believe mindfulness can be beneficial while parenting and are interested in learning how mindfulness could help their child stay healthy. Findings suggest there is an opportunity to educate families about mindfulness practices.

OBJECTIVES Compare lifetime earning potential between academic pediatric and adult medicine generalists and subspecialists. Evaluate the effect of decreasing the length of training for pediatric subspecialties whose length of training is longer than that for the adult medicine counterpart. METHODS Using compensation and debt data from national physician surveys for 2019–2020, we estimated and compared the lifetime earning potential for academic pediatric and adult physicians. RESULTS Lifetime earning potential was higher for adult physicians than for pediatric physicians across all comparable areas of both general and subspecialty academic practice. The lifetime earning potentials for adult physicians averaged 25% more, or $1.2 million higher, than those of the corresponding pediatric physicians. These differences predominantly were not attributable to unequal training length: when we modeled a shortened length of training for pediatric subspecialists, lifetime earning potential for adult subspecialists still averaged 19% more than that for pediatric subspecialists. For both pediatric and adult medicine, the primarily inpatient, procedure-oriented subspecialties had higher lifetime earning potential than the outpatient, less procedure-oriented subspecialties. CONCLUSIONS Wide differences in lifetime earning potential between pediatric and adult physicians reflected lower compensation in pediatrics, rather than any differences in training length. Inpatient-based, more procedure-oriented subspecialties had higher lifetime earning potential than outpatient-based, less procedure-oriented subspecialties. Interventions that improve the lifetime earning potential of general pediatrics and the pediatric subspecialties, as well as the less procedure-oriented subspecialties across both pediatric and adult medicine, have the potential to impact both clinical practice and access to care.

Background The growing prevalence of overweight and/or obese children is an important public health problem in both developed and developing countries. Although the association of obesity between parents and their children is well known, its underlying mechanisms are not well established. Purpose This meta-analysis examined parent-child (PC) relationships in obesity and identified factors such as world region and country income level that may influence this relationship. Methods We identified all related studies published between January 1, 2015 and May 31, 2020 by conducting a literature search using the MeSH terms “obesity,” “overweight,” “body mass index,” “parent,” “child,” “associate,” and “relate” in the PubMed database in English. Results The meta-analysis of 23 studies that reported an odds ratio (OR) for parent and child obesity associations found a significant association between parents and children who were overweight or obese (pooled OR, 1.97; 95% confidence interval, 1.85–2.10). A meta-regression analysis was used to examine the sources of interstudy heterogeneity. The association between parent and child obesity was higher in Asia than in Europe and the Middle East and higher in high-income countries than in middle-or low-income countries. In addition, a higher association between parent and child obesity was found when both parents were obese than when only the father or mother was obese. This study from multiple countries indicates a significant PC relationship in weight status that varies according to PC pair type, parent and child weight statuses, world region, and country income level. Conclusion These results demonstrate that the risk of childhood obesity is greatly influenced by parental weight status and indicate that parents could play an important role in preventing child obesity.

Background/Purpose: Central Diabetes Insipidus (CDI) results from vasopressin (AVP) deficiency following suprasellar surgery, cerebral ischemia, or trauma. Definitive diagnosis of CDI is through fluid deprivation and AVP stimulation testing, but clinical features like polyuria, hypernatremia, high plasma and low urine osmolality are used to diagnose new-onset CDI in critically ill children. Management of new-onset CDI is complex and not standardized. We hypothesized that diagnosis and management of new-onset CDI in critically ill children widely varies …

How quickly the 70 million infants, children, and adolescents living in the United States can reach appropriate levels of hospital care for potentially life-threatening illnesses or injuries is a critical, yet understudied, aspect of our nation’s pediatric public health preparedness.1,2 Although US health planning and policy efforts would benefit from a national understanding of how accessible general types of pediatric hospital services (newborn, emergency, and pediatric inpatient) and their more advanced counterparts (NICU, pediatric emergency, and PICU services, respectively) are, available studies have … Address correspondence to Alyna T. Chien, MD, MS, Division of General Pediatrics, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115. E-mail: alyna.chien{at}childrens.harvard.edu

Background Resident sensitive quality measures (RSQMs) are a new patient-focused approach to performance assessment. Their alignment with existing performance constructs is underexplored. Objective Develop and prioritize RSQMs for outpatient general pediatrics in the areas of well visits (0–2 months, 1, and 5 years) and compare to the existing framework of the Bright Futures recommendations. Methods Categorical pediatric residents, general academic pediatric fellows, and general pediatric faculty participated in nominal group technique (NGT) and Delphi processes to generate and prioritize RSQMs for 3 different well-child visits of interest. The author team then compared the content of the final RSQMs to the American Academy of Pediatrics Bright Futures recommendations. Results From the list of 143 potential measures from the NGT groups, 15 RSQMs were prioritized for each well-child visit. RSQMs prioritized vaccine administration, documentation of screening, and medication management. Overall, RSQMs mapped well to Bright Futures recommendations. Conclusions The alignment of the RSQMs with Bright Futures frameworks supports their contribution as process measures for informing resident performance. RSQMs created from this study should be used for future investigations into resident performance assessment and to drive personal improvement efforts.

Background: Infantile colic (IC) is excessive crying in otherwise healthy children. Despite vast research efforts, its etiology remains unknown.Purpose: Most treatments for IC carry various side effects. The collection of evidence may inform researchers of new strategies for the management and treatment of IC as well as new clues for understanding its pathogenesis. This review and meta-analysis aimed to evaluate the efficacy and possible mechanisms of probiotics for mananaging IC.Methods: Ten papers met the study inclusion and exclusion criteria, and the meta-analysis was conducted using Review Manager (RevMan) software and a random-effects model.Results: This meta-analysis revealed that probiotics are effective for treating infantile colic, while the review showed that this efficacy may be due to their anti-inflammatory effects.Conclusion: Probiotics may be an important treatment option for managing infantile colic due to their anti-inflammatory properties.

BACKGROUND AND OBJECTIVES: To describe the supply, distribution, and characteristics of international medical graduates (IMGs) in pediatrics who provide patient care in the United States. METHODS: Cross-sectional study, combining data from the 2019 Physician Masterfile of the American Medical Association and the Educational Commission for Foreign Medical Graduates database. RESULTS: In total, 92 806 pediatric physicians were identified, comprising 9.4% of the entire US physician workforce. Over half are general pediatricians. IMGs account for 23.2% of all general pediatricians and pediatric subspecialists. Of all IMGs in pediatrics, 22.1% or 4775 are US citizens who obtained their medical degree outside the United States or Canada, and 15.4% (3246) attended medical school in the Caribbean. Fifteen non-US medical schools account for 29.9% of IMGs currently in active practice in pediatrics in the United States. IMGs are less likely to work in group practice or hospital-based practice and are more likely to be employed in solo practice (compared with US medical school graduates). CONCLUSIONS: With this study, we provide an overview of the pediatric workforce, quantifying the contribution of IMGs. Many IMGs are US citizens who attend medical school abroad and return to the United States for postgraduate training. Several factors, including the number of residency training positions, could affect future numbers of IMGs entering the United States. Longitudinal studies are needed to better understand the implications that workforce composition and distribution may have for the care of pediatric patients.

BACKGROUND: Pediatric emergency department (PED) overcrowding and prolonged boarding times (admission order to PED departure) decrease quality of care. Timely transfer of patients from the PED to inpatient units is a key driver that relieves overcrowding. In 2015, PED boarding time at our hospital was 10% longer than the national benchmark. We described a resident-led quality-improvement initiative to decrease PED mean boarding times by 10% (from 173 to 156 minutes) within 6 months among general pediatric admissions. METHODS: We applied Plan-Do-Study-Act (PDSA) methodology. PDSA 1 (October 2016) interventions were bundled to include streamlined mobile communications, biweekly educational presentations, and reminder signs. PDSA 2 (August 2017) provided alternative workflows for senior residents. Outcomes were mean PED boarding times for general pediatrics admissions. The proportion of PICU transfers within 12 hours of admission served as a balancing measure. Statistical process control charts were used to analyze boarding times and PICU transfer rates. RESULTS: Leading up to PDSA 1, monthly mean boarding times decreased from 173 to 145 minutes and were sustained throughout the study period and up to 1 year after study completion. The X-bar chart demonstrated a shift with 57 consecutive months of mean boarding times below the preintervention mean. There were no changes in PICU transfer rates within 12 hours of admission. CONCULSIONS: Resident-led quality improvement efforts, including education and streamlined workflow, significantly improved PED boarding time without causing harm to patients.

* Abbreviations: AAP — : American Academy of Pediatrics EI — : early intervention In this issue of Pediatrics , Lipkin et al1 describe trends in pediatrician-reported developmental screening and referral practices between 2002 and 2016. The authors compare data across serial American Academy of Pediatrics (AAP) Periodic Surveys conducted in 2002, 2009, and 2016. They demonstrate that pediatricians’ self-reported use of formal developmental screening tools increased from 21% in 2002 to 63% in 2016 and that referral of patients identified as at risk for developmental delay to early intervention (EI) services increased concomitantly from 41% to 59%. Their data, however, also suggest that in 2016, more pediatricians considered lack of available treatment options to be a barrier to screening than did so in 2002 (21% vs 9%). Although developmental screening, surveillance, and referral to services has long been an important aspect of pediatric primary care, the AAP issued its first policy statement calling for universal developmental screening in 2001.2 The unique sampling frames queried with each Periodic Survey included in the current study preclude a true longitudinal analysis of individual-level practice changes; however, the current study represents an important barometer of screening and referral practices over the nearly 20 years since the AAP’s initial policy … Address correspondence to Mei Elansary, MD, MPhil, Division of General Pediatrics, School of Medicine, Boston University, 801 Albany St, Boston, MA 02118. E-mail: mei.elansary{at}bmc.org

We report 3 cases of scurvy in children that occurred during a short period (2018) in a general pediatrics unit of a tertiary hospital for children in Paris. All children were around 3 years of age and were admitted for skeletal pain and altered general state, which mimicked infectious or malignant diseases. Their selective diet was not the prominent issue. The diagnosis of scurvy was delayed, after too many unnecessary examinations and medications. Bone imaging findings (X-ray and MRI) were a posteriori considered typical, but lesions were not easily identified as scurvy lesions because scurvy is not well-known by pediatricians and radiologists who should be mindful of this historical diagnosis.

Objectives Calls for pediatricians to tend to children’s psychosocial concerns have existed for decades because they are known to negatively impact child health. Children with chronic illnesses frequently have child- and family-level psychosocial concerns that complicate the care provided by their pediatric subspecialists. This study compares pediatricians who exclusively practice general pediatrics with subspecialists regarding their inquiring/screening and referring for psychosocial concerns. Physician and practice characteristics associated with these behaviors were examined. Methods We conducted a cross-sectional study using the 2013 American Academy of Pediatrics Periodic Survey of Fellows. Respondents included 304 pediatricians who exclusively practice general pediatrics and 147 subspecialists. The primary analysis compared the current practices of generalists vs. subspecialists with regard to inquiring/screening and referring children with 10 different psychosocial concerns. Covariates included socio-demographics, practice characteristics, and training experiences. Weighted univariate, bivariate and multivariable analyses were performed. Results Less than half of all pediatricians in the sample reported routinely inquiring/screening for most psychosocial concerns, and 2/3 of subspecialists failed to routinely inquire/screen for most of these conditions. Pediatricians who practice general pediatrics exclusively were more likely to inquire/screen (incident rate ratio (IRR) 1.41, p

Parotitis is a frequent disease in general pediatrics. Pneumoparotitis is a rare affection that belongs to differential diagnoses of parotitis, along with infections, lymphadenitis, autoimmune disorders, inflammatory conditions, vascular malformations or neoplasms. It is usually described in musicians using wind instruments or in other situations involving a Vasalva maneuver. We report the case of a 12 years old boy with severe idiopathic pneumoparotitis without any of these well-known causes and whose autoimmune familial background of Sjögren syndrome might be relevant.

The novel coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been spreading worldwide since December 2019. Hundreds of cases of children and adolescents with Kawasaki disease (KD)–like hyperinflammatory illness have been reported in Europe and the United States during the peak of the COVID-19 pandemic with or without shock and cardiac dysfunction. These patients tested positive for the polymerase chain reaction or antibody test for SARS-CoV-2 or had a history of recent exposure to COVID-19. Clinicians managing such patients coined new terms for this new illness, such as COVID-19–associated hyperinflammatory response syndrome, pediatric inflammatory multisystem syndrome temporally associated with COVID-19, or COVID-19–associated multisystem inflammatory syndrome in children (MIS-C). The pathogenesis of MIS-C is unclear; however, it appears similar to that of cytokine storm syndrome. MIS-C shows clinical features similar to KD, but differences between them exist with respect to age, sex, and racial distributions and proportions of patients with shock or cardiac dysfunction. Recommended treatments for MIS-C include intravenous immunoglobulin, corticosteroids, and inotropic or vasopressor support. For refractory patients, monoclonal antibody to interleukin-6 receptor (tocilizumab), interleukin-1 receptor antagonist (anakinra), or monoclonal antibody to tumor necrosis factor (infliximab) may be recommended. Patients with coronary aneurysms require aspirin or anticoagulant therapy. The prognosis of MIS-C seemed favorable without sequelae in most patients despite a reported mortality rate of approximately 1.5%.

Background. Observation is necessary following racemic epinephrine (RE) for patients with croup. The ideal length of this observation period is unclear. Objective. To compare the rate of failed outpatient management utilizing different observation times after RE administration for croup. Methods. We performed a retrospective chart review of children with croup who required RE. Failure of treatment was defined as requiring a second RE treatment and/or returning to the pediatric emergency department for croup symptoms within 24 hours of discharge. Results. The primary analysis considered patients observed between 2.1 and 3 hours compared with those observed for 3.1 to 4 hours. The patients in the 2.1- to 3-hour group had a higher rate of treatment failure (16.7% vs 7.1%, OR = 2.44, P < .01). Conclusions. Patients requiring RE for croup are more likely to have treatment failure if observed for between 2.1 and 3 hours as opposed to 3.1 to 4 hours.

Background Traditional half-day per week continuity clinic experiences can lead to fragmented education in both the inpatient and outpatient arenas. Five pediatric residency programs were granted the ability from the ACGME in 2018 to create true X+Y scheduling models where residents see continuity clinic patients in blocks rather than half-day per week experiences. Objective Assess the impact X+Y scheduling has on pediatric faculty perceptions of patient care and other educational experiences. Methods Surveys were sent via REDCap to faculty of the five participating X+Y pilot programs both prior to and 12 months after implementing an X+Y scheduling model. The surveys elicited the clinical focus of the faculty (general pediatrics, hospital medicine, or other subspecialties). Questions were then tailored to the area of clinical focus to determine the impact continuity clinic schedules had on general pediatrics, hospitalist, and subspecialty rotation experiences using a 5-point Likert scale. Data were analyzed using z-tests for proportion differences for those answering Agree or Strongly Agree between baseline and post-implementation respondents. Results 384 faculty members were sent the survey with 51% response pre-implementation and 32% response at 12 months. Each general pediatrics faculty outcome was improved in the X+Y model compared to traditional clinic schedules (p Conclusions General pediatric and hospitalist faculty perceive improved patient continuity and enhanced educational opportunities in X+Y scheduling compared to traditional half-day per week continuity clinics. Hospitalist and other subspecialty faculty note no significant impact on educational time after X+Y schedule implementation.

Background Assessment using entrustable professional activities (EPAs) is currently under study as a joint effort of the American Board of Pediatrics and program director community. However, limited evidence exists for the feasibility of EPA-based assessment in pediatrics. Aim Among pediatric residency programs that implemented EPA-based assessment over 3 academic years (2015-16, 2016-17, 2017-18), determine how often programs were “unable to assess” a resident on a given EPA. Methods 23 programs reported clinical competency committee (CCC) determined EPA supervision level assignments for all residents in their program for a subset of 5-6 of the 17 general pediatrics EPAs biannually (Fall and Spring), except interns who were only assessed at the end of the academic year (Spring). They indicated “unable to assess” whenever applicable. Results Across the 5 data collection cycles, there were 29,643 opportunities to assign an EPA supervision level to 1987 residents from all three post-graduate years. Of these, 4140 assignments (14%) were deemed “unable to assess.” Across all EPAs, this determination was made less often in mid-year reports than year-end reports (p=.005). Post-graduate year 3 (PGY3) residents and PGY2 residents had significantly lower frequencies of “unable to assess” assignments when compared with PGY1 residents (Figure). EPAs with the lowest rates of “unable to assess” included: EPA 4 (patients with acute, common dx) at 0.4%, EPAs 10 (initial resuscitation/stabilization) and 16 (handovers) at 0.9%, EPA 11 (manage information) at 4%, and EPA 13 (practice management) at 5%. EPAs with the highest rates of “unable to assess” included EPA 8 (transition to adult care) at 43%, EPA 17 (procedures) at 27%, EPA 14 (quality improvement) at 20%, and EPAs 12 (make referrals) and 9 (behavioral and mental health) at 14%. Conclusions “Unable to assess” assignments are related to the given EPA, training year, and timing of assessment within the academic year. CCCs may be less likely to assign EPA supervision levels at timepoints viewed as higher stakes, such as transition from one training year to the next. Future work should explore this further and consider the etiology behind high levels of inability to assess some EPAs in particular.

* Abbreviations: CVAD — : central venous access device MAGIC — : Michigan Appropriateness Guide for Intravenous Catheters miniMAGIC — : Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics PICC — : peripherally inserted central catheter At the interface of clinical practice and medical science, evidence emerges. In domains of clinical practice that lack adequate evidence, clinical decisions are guided by a combination of clinical experience, clinician intuition, and resource availability (material and personnel). Consequently, where evidence gaps exist, clinical care can feel autonomous and innovative but is often inconsistent and may generate adverse outcomes for patients who are underappreciated. For children with serious illness, clinical decisions regarding achieving and sustaining venous access predominantly occur without much evidence, resulting in more variability than predictability in selecting central venous access devices (CVADs). In this supplement, an international group of pediatric experts propose a way forward using the Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics (miniMAGIC) evidence framework,1 which used the RAND Corporation–University of California, Los Angeles Appropriateness Method. miniMAGIC … Address correspondence to Matthew M. Davis, MD, MAPP, Division of Academic General Pediatrics and Primary Care, Ann & Robert H. Lurie Children’s Hospital, 225 E Chicago Ave, Box 162, Chicago, IL 60611. E-mail: mmdavis{at}luriechildrens.org

BACKGROUND AND OBJECTIVES: The American Board of Pediatrics (ABP) certifies that general and subspecialty pediatricians meet standards of excellence established by their peers, immediately after training and over the course of their careers (ie, Maintenance of Certification [MOC]). In 2015–2016, the ABP developed the Maintenance of Certification Assessment for Pediatrics (MOCA-Peds) as an alternative assessment to the current proctored, closed-book general pediatrics (GP) MOC examination. This article is 1 of a 2-part series examining results from the MOCA-Peds pilot in 2017. METHODS: We conducted quantitative and qualitative analyses with 5081 eligible pediatricians who registered to participate in the 2017 pilot; 81.4% (n = 4016) completed a quarter 4 survey and/or end-of-year survey (January 2018) and comprise the analytic sample. RESULTS: The majority of pediatricians considered the MOCA-Peds to be feasible and acceptable as an alternative to the proctored MOC GP examination. More than 90% of respondents indicated they would participate in the proposed MOCA-Peds model instead of the examination. Participants also offered recommendations to improve the MOCA-Peds (eg, enhanced focus of questions on outpatient GP, references provided before taking questions); the ABP is carefully considering these as the MOCA-Peds is further refined. CONCLUSIONS: Pilot participant feedback in 2017 suggested that the MOCA-Peds could be implemented for GP starting in January 2019, with all 15 subspecialties launched by 2022. Current and future evaluations will continue to explore feasibility, acceptability, and learning and practice change as well as sustainability of participation.

The use of telemedicine (TM) to deliver health care has been growing throughout the United States and internationally through asynchronous and synchronous technology. It has proven to be an effective way of delivering health care at a distance. There are multiple ways that a practice can offer these services, from direct-to-consumer to consultations in ambulatory or inpatient services. TM can be used to deliver care in homes, schools, and virtually anywhere that a patient and provider can access technology. For rural communities, emergency departments and inpatient specialty consults that were not available previously are now routine. TM also has been proven to be effective in decreasing costs to patients and increasing access in pediatrics while providing high degrees of satisfaction among patients and providers. [Pediatr Ann . 2019;48(12):e479–e484.]

Food insecurity is an important social determinant of health,1 a key indicator of limited resources and material hardship,2,3 and a source of significant stress as parents and other caregivers seek to provide healthy child nutrition.4 As such, food insecurity would be expected to adversely affect child growth5,6 and health and development more broadly.7,8 However, there has been limited study of associations between food insecurity and child outcomes during the critical period of early childhood.9–11 The authors of “Food Insecurity, Health and Development in Children Under Age Four Years” aim to address this gap by using a large sample of families at high risk for both food insecurity and child health disparities.12 Contrary to the authors’ hypotheses, limited relations between food insecurity and child obesity or other growth parameters were found in the study. The only significant associations were for children between 25 and 36 months old, for whom household food insecurity was associated with increased adjusted odds of obesity. In contrast, no significant associations were found after adjustment for … Address correspondence to Rachel S. Gross, MD, MS, Division of General Pediatrics, Department of Pediatrics, New York University School of Medicine, 462 First Ave, New York, NY 10016. E-mail: rachel.gross{at}nyulangone.org

BACKGROUND: The US physician workforce includes an increasing number of women, with pediatrics having the highest percentage. In recent research on physicians, it is indicated that men earn more than women. It is unclear how this finding extends to pediatricians. METHODS: We examined cross-sectional 2016 data on earnings from the American Academy of Pediatrics Pediatrician Life and Career Experience Study, a longitudinal study of early- and midcareer pediatricians. To estimate adjusted differences in pediatrician earnings between men and women, we conducted 4 ordinary least squares regression models. Model 1 examined gender, unadjusted; model 2 controlled for labor force characteristics; model 3 controlled for both labor force and physician-specific job characteristics; and model 4 controlled for labor force, physician-specific job, and work-family characteristics. RESULTS: Sixty-seven percent of Pediatrician Life and Career Experience Study participants completed the 2016 surveys (1213 out of 1801). The analytic sample was restricted to participants who completed training and worked in general pediatrics, hospitalist care, or subspecialty care (n = 998). Overall pediatrician-reported mean annual income was $189 804. Before any adjustment, women earned ∼76% of what men earned, or ∼$51 000 less. Adjusting for common labor force characteristics such as demographics, work hours, and specialty, women earned ∼87% of what men earned, or ∼$26 000 less. Adjusting for a comprehensive set of labor force, physician-specific job, and work-family characteristics, women earned ∼94% of what men earned, or ∼$8000 less. CONCLUSIONS: Early- to midcareer female pediatricians earned less than male pediatricians. This difference persisted after adjustment for important labor force, physician-specific job, and work-family characteristics. In future work, researchers should use longitudinal analyses and further explore family obligations and choices.

Purpose Investigating the prevalence of hyperuricemia and its association with metabolic syndrome (MetS) and cardiometabolic risk factors (CMRFs) in Korean children and adolescents. Methods This cross-sectional survey used data from the 7th Korea National Health and Nutrition Examination Survey (2016–2017); 1,256 males and females aged 10–18 years were included. Hyperuricemia was defined as serum uric acid levels were >6.6 mg/dL at 10–11 years of age (both sexes), >7.7 mg/dL for males at 12–18 years of age and >5.7 mg/dL for females at 12–18 years of age. MetS was defined by the International Diabetes Federation criteria. Logistic regression analysis was used to analyze hyperuricemia-associated risk factors. Results The prevalence of hyperuricemia was 9.4% (male, 8.4%; female, 10.5%) (P

Background: The prevalence and severity of pain, nausea/vomiting, and anxiety (PNVA) among hospitalized children is not well established. We describe the prevalence and severity of PNVA among hospitalized patients from oncology, general pediatrics, and cardiology services in a tertiary care center. Methods: Patients were recruited on admission and enrolled if their caregiver consented, spoke English, and were anticipated to stay 2&ndash, 30 days. Symptoms were measured weekdays using age-validated tools. PNVA symptoms were described and compared. Results: We enrolled 496 (49.4%) patients of 1005 admitted. Patients were predominantly Caucasian (57.9%) on their first admission (53.6%). The average (SD) age was 8.6 years (5.9) in oncology, 4.2 (5.3) in general pediatrics and 2.6 (4.0) in cardiology. 325 (65.6%) patients reported anxiety, 275 (55.4%) reported nausea and 256 (52.0%) reported pain. Mean (SD) severity out of 10 was 3.7 (2.5) for anxiety, 3.2 (2.1) for nausea and 3.0 (1.5) for pain. Prevalence of PNVA was no different between clinical programs, but pain (p = 0.008) and nausea (p = 0.006) severity were. PNVA symptom co-occurrence was positively correlated (p &lt, 0.001). Conclusions: Anxiety was the most common and severe symptom for hospitalized children. Patients in oncology demonstrated the least severe pain and nausea with no difference in anxiety between services.

Sterile pyuria is a common finding in pediatric patients. Literature describing the diagnoses as well as clinical characteristics of children with sterile pyuria is lacking. This review was performed to establish an evidence-based approach to the differential diagnosis by way of an extensive literature search. The definition of pyuria is inconsistent. The various causes of pediatric sterile pyuria identified were classified as either Infectious or Non-Infectious. Sub-categories of Infectious causes include: Viral Infection, Bacterial Infection, Other Infections (tuberculosis, fungal, parasitic), Sexually Transmitted Infections, Recent Antibiotic Therapy. Non-Infectious causes include: Systemic Disease, Renal Disease, Drug Related, Inflammation adjacent to Genitourinary Tract. Clinicians that encounter pediatric patients with sterile pyuria and persistent symptoms should consider the substantial differential diagnosis described in this study.

To investigate whether postponing certification testing, either voluntarily or involuntarily, affects a candidate's performance on pediatric certifying examinations.Both general pediatrics (GP) and pediatric subspecialty (PS) examination candidates were included in the study. Candidates were classified into 3 groups based on time since the completion of training: no delay (12 months), short delay (12-24 months), and long delay (≥24 months). Examination scores and pass rates in the first GP and PS certifying examinations were compared to assess between-group differences.Significant differences in scores and pass rates were found for GP candidates who voluntarily waited 1 year or longer to take the certifying examination. Similarly, PS candidates who opted not to take the first examination available had significantly lower scores and pass rates. However, no significant difference was found for PS candidates who had to wait to take their examination owing to the Board's offered examination schedule.Candidates who postpone taking the certifying examination are less likely to pass the examination. The longer a candidate elects to wait to take the examination, the less likely he or she is to pass. The availability of the PS examinations once every 2 years does not affect pass rates and scores, as long as PS candidates take the first available examinations after completing fellowship.

Background In Turkey, a mandatory referral system is not used. Caregivers, for their children, present directly to health-care providers at all levels. This allows patients to present directly to university hospitals. In this study, reasons for university hospital-treatment seeking by caregivers for child health problems is discussed. Methods This was a cross-sectional descriptive study at Dokuz Eylul University Faculty of Medicine, Izmir, Turkey, of 235 caregivers whose children were admitted to the outpatient clinic of the General Pediatrics Department between 4 and 11 April 2013. They completed a questionnaire on demographic data and reasons for presentation to the university hospital. Mann–Whitney U-test was used to compare group means, and Pearson chi-squared test for ratios between groups. P