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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.

Antibiotics are among the most frequently prescribed drugs in children���s hospitals, which is why regular monitoring of antibiotic use in hospitals is of great importance. This retrospective audit (60 months, January 2014 ��� December 2018) analyzes the antibiotic consumption at a university inpatient department of general pediatrics including neonatal and pediatric intensive care based on pharmacy dispensing data in units of grams per 100 patient days and in Defined Daily Doses per 100 patient days. The results provide potential targets for Antibiotic Stewardship interventions. Conversely, this audit elicits methodological limitations of the method of antibiotic surveillance in pediatrics recommended by the Robert Koch Institute, Berlin.

Purpose To evaluate response process validity evidence for clinical competency committee (CCC) assessments of first-year residents on a subset of General Pediatrics Entrustable Professional Activities (EPAs) and milestones in the context of a national pilot of competency-based, time-variable (CBTV) advancement from undergraduate to graduate medical education. Method Assessments of 2 EPAs and 8 milestones made by the trainees' actual CCCs and 2 different blinded "virtual" CCCs for 48 first-year pediatrics residents at 4 residency programs between 2016 and 2018 were compared. Residents had 3 different training paths from medical school to residency: time-variable graduation at the same institution as their residency, time-fixed graduation at the same institution, or time-fixed graduation from a different institution. Assessments were compared using ordinal mixed-effects models. Results Actual CCCs assigned residents higher scores than virtual CCCs on milestones and one EPA's supervision levels. Residents who graduated from a different institution than their residency received lower milestone ratings than either group from the same institution; CBTV residents received higher ratings on one milestone (ICS4) and similar ratings on all others compared with non-CBTV residents who completed medical school at the same institution. Conclusions First-year residents who graduated from CBTV medical school programs were assessed as having the same level of competence as residents who graduated from traditional medical school programs, but response process evidence suggests that members of CCCs may also draw on undocumented personal knowledge of the learner to draw conclusions about resident competence.

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.

A 15-year-old female with no significant past medical history presented to the emergency department with 1 day of substernal and pleuritic chest pain, chills, cough, and hematuria. She also had swelling of the face and ankles that resolved by presentation. She was found to have elevated troponin and brain natriuretic peptide during initial workup. Electrocardiogram was normal, but there were significant pleural effusions on chest x-ray. She was strep positive and had blood pressure up to 150/90, prompting admission for cardiac monitoring and cardiology consultation. Blood pressure decreased down to 125/72 without intervention. She was afebrile with unlabored breathing and normal saturations. She was clear to auscultation bilaterally, with no abdominal distension or hepatosplenomegaly, and edema was not evident on exam. There was mild erythema to the bilateral tonsillar pillars. Initial considerations included viral myocarditis, pericarditis, and atypical nephritic syndrome. Workup revealed elevated antistreptolysin antibodies, low C3 complement, negative antineutrophil cytoplasmic antibodies, and negative flu testing. Renal sonography was unremarkable. Cardiology recommended echocardiography, which confirmed pleural effusions but revealed no cardiac abnormalities. Urinalysis revealed hematuria and mild proteinuria. Diagnosis was found to be post-streptococcal glomerulonephritis complicated by fluid overload and left ventricular strain secondary to hypertensive emergency. Post-streptococcal glomerulonephritis is the most common cause of acute glomerulonephritis in children. The mechanism of disease is a proliferation and inflammation of the renal glomeruli secondary to immunologic injury, with deposition of immune complexes, neutrophils, macrophages, and C3 after complement activation. This leads to hematuria, proteinuria, and fluid overload. Edema is present in 65%–90% of patients, progressing to pulmonary involvement in severe cases. Cardiac dysfunction secondary to fluid overload is a potentially fatal outcome in the acute setting. Physicians should consider post-streptococcal glomerulonephritis for patients presenting with hypertension, cardiac/pulmonary pathology, or symptoms of acute heart failure in the context of strep infection.

Amaç: Pediyatrik kliniklerde bir klinik eczacı tarafından farmakoterapinin değerlendirilmesi, ilaçla ilgili sorunların (İLİS'lerin) saptanması ve önlenmesi açısından önemlidir. Bu çalışma, pediyatrik hastalarda İLİS'lerin prevalansını ve tiplerini iki çalışma aşamasında belirlemeyi ve karşılaştırmayı amaçlamıştır.Gereç ve Yöntem: Bir üniversite hastanesinin pediyatri ünitesinde yürütülen bu gözlemsel çalışma iki aşamadan oluşmuştur: Klinik eczacının klinikte mevcut bulunarak ilaç inceleme hizmetini sunduğu prospektif aşama (Haziran 2019-Şubat 2020) ve klinik eczacının klinikte bulunmadığı dönem aralığından prospektif aşamaya göre yaş-cinsiyet-tanı eşleştirmesiyle elde edilen katılımcılardan oluşan retrospektif aşama (Aralık 2018-Şubat 2019). Avrupa Farmasötik Bakım Ağı'nın yayınladığı sınıflandırma sisteminin V9.1 Türkçe versiyonu İLİS'leri tanımlamak için kullanılmıştır. Lexicomp® ve Micromedex®, potansiyel ilaç etkileşimlerini değerlendirmek için kullanılan kaynaklardır.Bulgular: Çalışmaya katılan 174 hastanın %78,16'sında en az bir İLİS saptanmış ve toplam 527 İLİS tespit edilmiştir. İlaçla ilgili sorunlardan bazıları ilaç-ilaç etkileşimi (%64,90), terapötik ilaç izlemi (%11,39) ve dozlama (%11,01) ile ilgili bulunmuştur. Antienfektifler, bronkodilatörler ve inhale kortikosteroidler en sık kullanılan ilaçlar olmuştur. Çalışma ve kontrol grupları arasında yatış süresi (p=0,025), kullanılan ilaç sayısı (p=0,003) ve toplam İLİS'ler (p=0,019) açısından anlamlı farklılıklar bulunmuştur.Sonuç: Bu çalışmanın bulguları, İLİS'lerin klinik eczacının serviste olduğu dönemde daha fazla oranda tespit edilebildiğini göstermektedir. Objective: Evaluating pharmacotherapy by a clinical pharmacist in pediatric clinics could ameliorate drug-related problems (DRPs). This study aimed to identify and compare the prevalence and types of DRPs in pediatric patients in two study phases.Material and Methods: This observational study consisted of two phases and was conducted in a pediatric unit of a university hospital: The prospective phase (between June 2019 and February 2020) while providing clinical pharmacist-led medication review service with the presence of pharmacist at the clinic and the retrospective phase (between December 2018 and February 2019 which was the period without the presence of pharmacist) among subjects obtained by age-sex-diagnose–matching according to the prospective phase participants. Turkish version of Pharmaceutical Care Network Europe Foundation Classification V9.1 is used to identify DRPs. Lexicomp® and Micromedex® were the resources used to assess the potential drug interactions.Results: Among 174 patients, at least one DRP was seen in 78,16% of the patients, and 527 DRPs were identified. Some of the problems were related to drug-drug interaction (64,90%), therapeutic monitoring (11,39%), and dosing (11,01%). Anti-infectives, bronchodilators, and inhaled corticosteroids were the most frequently used drugs. There were significant differences in duration of hospitalization (p=0,025), number of drugs used (p=0,003), and total DRPs (p=0,019) between the study and control groups.Conclusion: The findings demonstrate the potential to detect DRPs through clinical pharmacist involvement in direct patient care.

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 …

Objective Disparities in adult patient portal adoption are well-documented; however, less is known about disparities in portal adoption in pediatrics. This study examines the prevalence and factors associated with patient portal activation and the use of specific portal features in general pediatrics. Materials and methods We analyzed electronic health record data from 2012 to 2020 in a large academic medical center that offers both parent and adolescent portals. We summarized portal activation and use of select portal features (messaging, records access and management, appointment management, visit/admissions summaries, and interactive feature use). We used logistic regression to model factors associated with patient portal activation among all patients along with feature use and frequent feature use among ever users (ie, ≥1 portal use). Results Among 52 713 unique patients, 39% had activated the patient portal, including 36% of patients aged 0–11, 41% of patients aged 12–17, and 62% of patients aged 18–21 years. Among activated accounts, ever use of specific features ranged from 28% for visit/admission summaries to 92% for records access and management. Adjusted analyses showed patients with activated accounts were more likely to be adolescents or young adults, white, female, privately insured, and less socioeconomically vulnerable. Individual feature use among ever users generally followed the same pattern. Conclusions Our findings demonstrate that important disparities persist in portal adoption in pediatric populations, highlighting the need for strategies to promote equitable access to patient portals.

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.

BackgroundPrevious studies have suggested that resident physicians are the most meaningful teachers during the clinical clerkships of third-year medical students (MS3s). Unfortunately, residents often feel unprepared for this crucial role. The pediatrics clerkship at our institution identified a paucity in the frequency of resident-led teaching with MS3s. Lack of confidence, suboptimal teaching space, and insufficient time were cited as the most significant barriers. To enhance resident-led teaching of MS3s, we created teaching scripts of general pediatrics topics accessible via a smartphone application (app).MethodsPrior to the implementation of the app, MS3s and pediatric residents were surveyed on clerkship teaching practices. From May 2017 through July 2018, pediatric residents working with MS3s were introduced to the app, with both groups queried on resident teaching habits afterward. We compared pre-intervention and post-intervention data of time spent teaching, teaching frequency, and a ranking of pediatric resident teaching performance compared to residents of other MS3 core clerkships.Results44 out of 90 residents (49%) responded to a pre-intervention survey on baseline teaching habits. 49 out of 61 residents (80%) completed our post-intervention survey. Pre-intervention, 75% (33/44) of residents reported spending less than 5 min per teaching session on average. Post-intervention, 67% (33/49) reported spending more than 5 min (p p = 0.12) post-intervention. Post-intervention data demonstrated a statistically significant correlation between app use and increased frequency of teaching (p p ConclusionsResidency programs looking to reform resident-led teaching, particularly of residents early in their training, should consider our novel approach. In addition to addressing barriers to teaching and creating a platform for near-peer teaching, it is adaptable to any specialty or learner level. Future direction includes developing objective measures for teaching performance and content proficiency to better assess our intervention as an educational curriculum, as well as further investigation of the intervention as a controlled trial.

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 This study examines the practice patterns with respect to the technique of non-oral hydration of infants admitted with bronchiolitis at one Canadian tertiary care institution. Additionally, the authors assess the infants' parents' attitudes regarding hydration through a nasogastric (NG) tube instead of an intravenous (IV) line. Methods A retrospective chart review was conducted for all infants admitted with bronchiolitis from May 1, 2016, to April 30, 2018, with a focus on the method of hydration, investigation with chest radiography, and use of IV antibiotics. Parents of infants who received IV fluids during the admission were surveyed by mail to assess their perceptions surrounding their child's experience with IV fluid therapy as well as their attitudes toward NG hydration, particularly in cases of difficult IV access. Results Of the 101 hospitalized infants, 54 received IV fluids and four received NG fluids. Of the 54 eligible for the survey, 17 completed surveys were returned. Parents were likely to consider NG hydration if suggested by their pediatrician. The proportion was extremely or very likely to consider this intervention increased from 29% in a generic situation to 53% in a scenario where there was more than one unsuccessful IV attempt (p=0.03). Conclusions In the institution studied, NG hydration was rarely used. Parents seemed receptive to the idea of NG hydration as an alternative, particularly when IV access is difficult.

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 …

Adolescent medicine is a subspecialty of pediatrics dedicated to the care and guidance of adolescents as they transition from childhood into adulthood. In this chapter, the authors discuss the history of adolescent medicine and the things that make the subspecialty of adolescent medicine unique from general pediatrics. They also discuss skills that are essential to establishing rapport and improving communication with adolescents. Furthermore, the authors deliberate reasons for choosing a career in adolescent medicine and discuss fellowship training and factors to consider in choosing a fellowship.

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.

BackgroundBronchiolitis is the primary infection of the lower respiratory tract in children under 2 years of age. Although it is generally considered a single nosological entity, recent studies suggested remarkable clinical heterogeneity. To date, no studies have identified classes of children with bronchiolitis within the Italian population. This study aimed to identify discrete profiles of Italian children hospitalized with bronchiolitis using a clustering approach and to compare findings with those obtained in international cohorts.MethodsThis was a retrospective single-centre study conducted on children aged ≤2 years hospitalised with bronchiolitis (n = 401) at the Department of Infectious Diseases and the University Department of General Pediatrics in “Giovanni Di Cristina” Pediatric Hospital of Palermo, Italy, between November 2012 and May 2019. Bronchiolitis profiles were determined by latent class analysis, classifying children based on clinical characteristics at admission and viral aetiology.ResultsThree profiles were identified. Class 1 (49%) was composed of 45% male children; all children were aged ≤6 months at hospitalization; 77% were infected with RSV; 100% had respiratory distress, 11% had apnea and none had cough. Class 2 (77%) was mainly composed of male subjects (51%); 19% were aged > 6 months at admission; 37% were infected with RSV; 12% had respiratory distress, 5% had apnea and 90% had cough. Class 3 (19%) included the largest proportion of male subjects (94%) and was mostly composed of children aged > 6 months at the time of admission (68%); 70% had cough, 12% showed respiratory distress and none presented with apnoea. Children in Class 1 were more frequently born near the epidemic season (p = 0.028); breastfeeding duration was significantly longer for children in Class 3 (p = 0.004).ConclusionsThe study identified distinct clinical profiles of bronchiolitis by a clustering approach in a single-centre study of children hospitalised for bronchiolitis in Italy. The three bronchiolitis profiles share some similarities with those identified in international studies using the same statistical approach. These findings may help to increase the understanding of the phenotypic variability that typically characterizes bronchiolitis, with relevant implications for future research.

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

The preventive care chapter of this book examines aspects of a pediatric patient’s well-child care that may be relevant to the general primary care pediatrician in an outpatient setting. It reviews normal growth and nutrition, developmental milestones and how to conduct surveillance and screening, and routine vaccinations, as well as the precautions and special considerations for specific immunizations and diseases. It also reviews common anticipatory guidance and key injury prevention and safety discussions that should take place at each well-child check interval according to the American Academy of Pediatrics recommendations for preventive pediatric healthcare. This chapter is written for pediatric residents who are still in training as well as for the practicing pediatrician who wishes to study and refresh his or her knowledge of updated evidence-based guidelines in primary care pediatrics.

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.

Hemophagocytic lymphohistiocytosis (HLH) is a rare and fatal entity with an incidence rate of 1.2 cases per million people per year. HLH is explained as a highly destructive inflammatory consequence of rampant hypercytokinemia due to excessive lymphocyte-mediated activation of macrophages and histiocytes. Primary HLH is a product of genetic dysfunction and could be familial (five subtypes), syndromic immunodeficiency, or as a consequence of mutations predisposing a person to Epstein Barr Virus (EBV) infection. With secondary HLH, there is an identifiable cause provoking the inflammatory reaction, whether it is an infection, an autoimmune disease, or malignancy (particularly hematological). As a result of widespread cytokine deposition, systemic manifestations are seen with a variety of manifestations that can vary between cases. This is a case of a patient who initially presented to the emergency department with fever, altered mentation, and gastroenteritis. Initial investigations showed non-anion gap metabolic acidosis, high white cell count, and deteriorating renal function. Further laboratory tests, bone marrow biopsies, and neurological imaging were conducted throughout the course of admission as the patient further deteriorated systemically. However, it's important to note the abundant neurological manifestations with a worsening level of consciousness and seizures, some of which were categorized as status epilepticus.

Introduction: Brazilian guidelines for undergraduate medical courses recommend a minimum curricular course load (CL) of 7,200 hours and the Brazilian Society of Pediatrics recommends that 10% of this load be allocated to pediatrics. The aim of this study was to analyze the total course load and the course load in pediatrics of Brazilian medical schools’ curriculum. Method: Cross-sectional and descriptive study. Of the 294 existing medical schools in Brazil in October 2017, those with curricular matrix/grid or political-pedagogical project of the course and pediatrics CL available on their homepage were included. The studied variables included total curricular CL, pediatrics CL and year of inclusion of pediatrics in the curriculum. Data were analyzed using descriptive statistics, calculating absolute and relative frequencies for categorical variables and mean and Standard Deviation (SD) and median and 25-75 percentile (P25-75) for continuous variables. Results: One hundred and fifty-one medical schools were included (51.4% of the total). The curriculum CL median was 7,975 hours (P25-75=7,440-8,550), with a mean of 4,665.7 hours (SD=593.8) before clerkship and 3,388.1 hours (SD=430.3) during clerkship. The mean pediatrics’ CL was 778.2 hours (SD=180.8), with a median CL of 220 hours (P25-75=160-300) before clerkship and 514 (P25-75= 405-640) during clerkship. The median pediatrics practice course load before clerkship (n=70) was 123 (SD=90-180). The mean of the proportion between general pediatrics and the curricular CL was 9.7% (SD= 2,2), and 68.5% schools had a CL >720 hours. The median of the proportion between the CL in pediatrics clerkship and in the course was 16% (P25-75=12.5-18.9), ranging from 6% to 26%. The median of the proportion between pediatrics CL before pediatrics clerkship and course load was 4.7% (P25-75=3.6-6.5), ranging from 1% to 13%. Two schools started the teaching of pediatrics in the first year (1,3%), 19 in the second (12.6%), 63 in the third (41.7%) e 67 in the fourth year of the medical course (44.4%). Conclusions: The schools meet the minimum curricular course load established by the national guidelines, tending to exceed it, and not all of them meet the minimum pediatrics course load requirement of 720 hours recommended by the Brazilian Society of Pediatrics.

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