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BACKGROUND AND OBJECTIVES In a previous study of 204 transgender and gender diverse youth in our region, 44% reported being made to feel uncomfortable in the emergency department (ED) because of their gender identity. The objective of our study was to conduct a 2 year quality improvement project to increase affirmed name and pronoun documentation in the pediatric ED. METHODS Using process mapping, we identified 5 key drivers and change ideas. The key driver diagram was updated as interventions were implemented over 3 Plan–Do–Study–Act cycles. Our primary outcome, the percentage of ED visits per month with pronouns documented, was plotted on a run chart with the goal of seeing a 50% increase in form completion from a baseline median of ∼14% over the 2 year study period. RESULTS The frequency of pronoun documentation increased from a baseline median of 13.8% to a median of 47.8%. The most significant increase in pronoun documentation occurred in Plan–Do–Study–Act cycle 3, immediately after ED-wide dissemination of a near-miss case and subsequent call for improvement by ED leadership. Roughly 1.7% of all encounters during the study period involved patients whose pronouns were discordant from the sex listed in their electronic health record. CONCLUSIONS This quality-improvement project increased the frequency of pronoun documentation in the ED. This has the potential to improve the quality of care provided to transgender and gender diverse youth in the ED setting and identify patients who may benefit from receiving a referral to a pediatric gender clinic for additional support.

OBJECTIVE To identify associations between weight status and clinical outcomes in children with lower respiratory tract infection (LRTI) or asthma requiring hospitalization. METHODS We performed a retrospective cohort study of 2 to 17 year old children hospitalized for LRTI and/or asthma from 2009 to 2019 using electronic health record data from the PEDSnet clinical research network. Children RESULTS We identified 65 132 hospitalizations; 6.7% with underweight, 57.8% normal weight, 14.6% overweight, 13.2% class 1 obesity, 5.0% class 2 obesity, and 2.8% class 3 obesity. Overweight and obesity were associated with positive pressure respiratory support (class 3 obesity versus normal weight odds ratio [OR] 1.62 [1.38–1.89]) and ICU admission (class 3 obesity versus normal weight OR 1.26 [1.12–1.42]), with significant associations for all categories of overweight and obesity. Underweight was also associated with positive pressure respiratory support (OR 1.39 [1.24–1.56]) and ICU admission (1.40 [1.30–1.52]). CONCLUSIONS Both underweight and overweight or obesity are associated with increased severity of LRTI or asthma in hospitalized children.

IMPORTANCE: Currently, there is a lack of consensus in the literature on the association between screen time (eg, television, video games) and children’s behavior problems. OBJECTIVE: To assess the association between the duration of screen time and externalizing and internalizing behavior problems among children 12 years or younger. DATA SOURCES: For this systematic review and meta-analysis, MEDLINE, Embase, and PsycINFO databases were searched for articles published from January 1960 to May 2021. Reference lists were manually searched for additional studies. STUDY SELECTION: Included studies measured screen time (ie, duration) and externalizing or internalizing behavior problems in children 12 years or younger, were observational or experimental (with baseline data), were available in English, and had data that could be transformed into an effect size. Studies conducted during the COVID-19 pandemic were excluded. Of 25 196 nonduplicate articles identified and screened for inclusion, 595 met the selection criteria. DATA EXTRACTION AND SYNTHESIS: The study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Extracted variables were child age, sex, and socioeconomic status; informants and measurement type for screen time and behavior problems; study publication year; and study design and quality. Data were extracted by 2 independent coders and were pooled using a random-effects model. MAIN OUTCOMES AND MEASURES: The primary outcome was the association of screen time duration with externalizing (eg, aggression, attention deficit/hyperactivity disorder symptoms) and internalizing (eg, depression, anxiety) behaviors or diagnoses. RESULTS: Of the 595 full-text articles assessed for eligibility, 87 studies met all inclusion criteria, comprising 98 independent samples and 159 425 participants (mean [SD] age, 6.07 [2.89] years; 83 246 [51.30%] male). Increased duration of screen time had a small but significant correlation with more externalizing problems (90 samples; r, 0.11; 95% CI, 0.10-0.12) and internalizing problems (43 samples; r, 0.07; 95% CI, 0.05-0.08) in children. Several methodological moderators explained between-study heterogeneity. There was evidence of significant between study heterogeneity (I(2) = 87.80). CONCLUSIONS AND RELEVANCE: This systematic review and meta-analysis found small but significant correlations between screen time and children’s behavior problems. Methodological differences across studies likely contributed to the mixed findings in the literature.

ObjectiveThis study was conducted to identify rates of pediatric nirmatrelvir/ritonavir (Paxlovid) prescriptions overall and by patient characteristics.MethodsPatients up to 23 years old with a clinical encounter and a nirmatrelvir/ritonavir (Paxlovid, n/r) prescription in a PEDSnet-affiliated institution between December 1, 2021 and September 14, 2022 were identified using electronic health record (EHR) data.ResultsOf the 1,496,621 patients with clinical encounters during the study period, 920 received a nirmatrelvir/ritonavir prescription (mean age 17.2 years; SD 2.76 years). 40% (367/920) of prescriptions were provided to individuals aged 18-23, and 91% (838/920) of prescriptions occurred after April 1, 2022. The majority of patients (70%; 648/920) had received at least one COVID-19 vaccine dose at least 28 days before nirmatrelvir/ritonavir prescription. Only 40% (371/920) of individuals had documented COVID-19 within the 0 to 6 days prior to receiving a nirmatrelvir/ritonavir prescription. 53% (485/920) had no documented COVID-19 infection in the EHR. Among nirmatrelvir/ritonavir prescription recipients, 64% (586/920) had chronic or complex chronic disease and 9% (80/920) had malignant disease. 38/920 (4.5%) were hospitalized within 30 days of receiving nirmatrelvir/ritonavir.ConclusionClinicians prescribe nirmatrelvir/ritonavir infrequently to children. While individuals receiving nirmatrelvir/ritonavir generally have significant chronic disease burden, a majority are receiving nirmatrelvir/ritonavir prescriptions without an EHR-recorded COVID-19 positive test or diagnosis. Development and implementation of concerted pediatric nirmatrelvir/ritonavir prescribing workflows can help better capture COVID-19 presentation, response, and adverse events at the population level.

BackgroundPost-acute sequelae of SARS-Co-V-2 infection (PASC) is associated with worsening diabetes trajectory. It is unknown whether PASC in children with type 1 diabetes (T1D) manifests as worsening diabetes trajectory.ObjectiveTo explore the association between SARS-CoV-2 infection (COVID-19) and T1D-related healthcare utilization (for diabetic ketoacidosis [DKA] or severe hypoglycemia [SH]) or Hemoglobin (Hb) A1c trajectory.MethodsWe included children ResultsFrom 03/01/2020-06/22/2022, 2,404 and 1,221 youth met entry criteria for the Broad and Narrow cohorts, respectively. The hazard ratio for utilization was (HR 1.45 [95%CI,0.97,2.16]). In the Narrow Cohort, the rate of change (slope) of HbA1c increased 91-180 days after cohort entry for those with COVID-19 (0.138 vs. -0.002, p=0.172). Beyond 180 days, greater declines in HbA1c were observed in the positive cohort (-0.104 vs. 0.008 per month, p=0.024).ConclusionWhile a trend towards worse outcomes following COVID-19 in T1D patients was observed, these findings were not statistically significant. Continued clinical monitoring of youth with T1D following COVID-19 is warranted.Authorship StatementAuthorship has been determined according to ICMJE recommendationsDisclaimerThe content is solely the responsibility of the authors and does not necessarily represent the official views of the RECOVER Program, the NIH or other funders.Funding Source⍰This research was funded by the National Institutes of Health (NIH) Agreement OT2HL161847-01 as part of the Researching COVID to Enhance Recovery (RECOVER) program of research.

BackgroundMulti-system inflammatory syndrome in children (MIS-C) represents one of the most severe post-acute sequelae of SARS-CoV-2 infection in children, and there is a critical need to characterize its disease patterns for improved recognition and management. Our objective was to characterize subphenotypes of MIS-C based on presentation, demographics and laboratory parameters.MethodsWe conducted a retrospective cohort study of children with MIS-C from March 1, 2020 - April 30, 2022 and cared for in 8 pediatric medical centers that participate in PEDSnet. We included demographics, symptoms, conditions, laboratory values, medications and outcomes (ICU admission, death), and grouped variables into eight categories according to organ system involvement. We used a heterogeneity-adaptive latent class analysis model to identify three clinically-relevant subphenotypes. We further characterized the sociodemographic and clinical characteristics of each subphenotype, and evaluated their temporal patterns.FindingsWe identified 1186 children hospitalized with MIS-C. The highest proportion of children (44·4%) were aged between 5-11 years, with a male predominance (61.0%), and non- Hispanic white ethnicity (40·2%). Most (67·8%) children did not have a chronic condition. Class 1 represented children with a severe clinical phenotype, with 72·5% admitted to the ICU, higher inflammatory markers, hypotension/shock/dehydration, cardiac involvement, acute kidney injury and respiratory involvement. Class 2 represented a moderate presentation, with 4-6 organ systems involved, and some overlapping features with acute COVID-19. Class 3 represented a mild presentation, with fewer organ systems involved, lower CRP, troponin values and less cardiac involvement. Class 1 initially represented 51·1% of children early in the pandemic, which decreased to 33·9% from the pre-delta period to the omicron period.InterpretationMIS-C has a spectrum of clinical severity, with degree of laboratory abnormalities rather than the number of organ systems involved providing more useful indicators of severity. The proportion of severe/critical MIS-C decreased over time.Research in contextEvidence before this studyWe searched PubMed and preprint articles from December 2019, to July 2022, for studies published in English that investigated the clinical subphenotypes of MIS-C using the terms “multi-system inflammatory syndrome in children” or “pediatric inflammatory multisystem syndrome” and “phenotypes”. Most previous research described the symptoms, clinical characteristics and risk factors associated with MIS-C and how these differ from acute COVID-19, Kawasaki Disease and Toxic Shock Syndrome. One single-center study of 63 patients conducted in 2020 divided patients into Kawasaki and non-Kawasaki disease subphenotypes. Another CDC study evaluated 3 subclasses of MIS-C in 570 children, with one class representing the highest number of organ systems, a second class with predominant respiratory system involvement, and a third class with features overlapping with Kawasaki Disease. However, this study evaluated cases from March to July 2020, during the early phase of the pandemic when misclassification of cases as Kawasaki disease or acute COVID-19 may have occurred. Therefore, it is not known from the existing literature whether the presentation of MIS-C has changed with newer variants such as delta and omicron.Added value of this studyPEDSnet provides one of the largest MIS-C cohorts described so far, providing sufficient power for detailed analyses on MIS-C subphenotypes. Our analyses span the entire length of the pandemic, including the more recent omicron wave, and provide an update on the presentations of MIS-C and its temporal dynamics. We found that children have a spectrum of illness that can be characterized as mild (lower inflammatory markers, fewer organ systems involved), moderate (4-6 organ involvement with clinical overlap with acute COVID-19) and severe (higher inflammatory markers, critically ill, more likely to have cardiac involvement, with hypotension/shock and need for vasopressors).Implications of all the available evidenceThese results provide an update to the subphenotypes of MIS-C including the more recent delta and omicron periods and aid in the understanding of the various presentations of MIS-C. These and other findings provide a useful framework for clinicians in the recognition of MIS-C, identify factors associated with children at risk for increased severity, including the importance of laboratory parameters, for risk stratification, and to facilitate early evaluation, diagnosis and treatment.

Objectives It is critical to understand what children, and in which context, are at risk for high levels of screen use. This study examines whether child temperament interacts with cumulative social risk to predict young children’s screen use and if the results are consistent with differential susceptibility or diathesis-stress models. Methods Data from 1,992 families in Calgary, Alberta (81% White; 47% female; 94% >$40,000 income) from the All Our Families cohort were included. Mothers reported on cumulative social risk (e.g., low income and education, maternal depression) at Results Children high in surgency (i.e., high-intensity pleasure, impulsivity) had greater screen use than children low in surgency as social risk exposure increased. In line with differential susceptibility, children high in surgency also had less screen use than children low in surgency in contexts of low social risk. Children with heightened negative affectivity (i.e., frequent expressions of fear/frustration) had greater screen use as social risk increased, supporting a diathesis-stress model. Conclusions Young children predisposed to high-intensity pleasure seeking and negative affectivity in environments characterized as high in social risk may be prone to greater durations of screen use. Findings suggest that an understanding of social risks and individual characteristics of the child should be considered when promoting healthy digital health habits.

OBJECTIVES Assess how family stressors (including structural stressors, social determinants of health inequities, and parent psychological distress) relate to media rule implementation and problematic child media use during the coronavirus disease 2019 pandemic. METHODS Nationally representative survey of 1000 United States parents with at least one 6 to 17 year old child was conducted in October through November 2020. RESULTS Problematic use was greater in families where parents were employed full time, present in the home (eg, working from home), had low levels or formal educational attainment, and were experiencing more psychological distress. Although there was a small decline in the number of media-related rules implemented during the pandemic (fewer parents enforced screen limits on weekdays or weekends or limited screen use at mealtimes), there was no association between rule implementation and problematic media use. CONCLUSIONS Family stressors were associated with problematic child media use during the coronavirus disease 2019 pandemic. As we emerge from the pandemic, it will be important to help parents adjust their family’s media practices cognizant of the fact that additional children may have developed problematic screen use behaviors. Such efforts should center the role of structural and social determinants of health inequities on the stressors that families experience and that impact media use.

The impact of post-acute sequelae of SARS-CoV-2 infection (PASC) in children is underrecognized. We developed an EHR-based algorithm across eight pediatric institutions to identify children with COVID-19 based on serology testing from 3/2020 through 4/2022 who had not been identified by PCR. Overall, serology tests were used 100-fold less than PCR. Seroprevalence of IgG anti-nucleocapsid antibodies remained stable, while rates of positive IgG anti-spike antibodies increased in teenagers after COVID-19 vaccine approval. Through data harmonization and after excluding 1,410 serology test results that may have been influenced by vaccines, we identified 2,714 children that were COVID-19 positive exclusively by serology. These patients were frequently tested as inpatients (24% vs. 2%), had chronic conditions more frequently (37% vs 24%), and a MIS-C diagnosis (23% vs.

ImportanceThe post-acute sequelae of SARS-CoV-2 (PASC) has emerged as a long-term complication in adults, but current understanding of the clinical presentation of PASC in children is limited.ObjectiveTo identify diagnosed symptoms, diagnosed health conditions and medications associated with PASC in children.Design, Setting and ParticipantsRetrospective cohort study using electronic health records from 9 US children’s hospitals for individuals ExposureSARS-CoV-2 PCR positivity.Main Outcomes and MeasuresWe identified syndromic (symptoms), systemic (conditions), and medication PASC features in the 28-179 days following the initial test date. Adjusted hazard ratios (aHRs) were obtained for 151 clinically predicted PASC features by contrasting PCR-positive with PCR-negative groups using proportional hazards models, adjusting for site, age, sex, testing location, race/ethnicity, and time-period of cohort entrance. We estimated the incidence proportion for any syndromic, systemic or medication PASC feature in the two groups to obtain a burden of PASC estimate.ResultsAmong 659,286 children in the study sample, 59,893 (9.1%) tested positive by PCR for SARS-CoV-2. Most were tested in outpatient testing facility (50.3%) or office (24.6%) settings. The most common syndromic, systemic, and medication features were loss of taste or smell (aHR 1.96 [95% CI 1.16-3.32), myocarditis (aHR 3.10 [95% CI 1.94-4.96]), and cough and cold preparations (aHR 1.52 [95% CI 1.18-1.96]). The incidence of at least one systemic/syndromic/medication feature of PASC was 41.9% among PCR-positive children versus 38.2% among PCR-negative children, with an incidence proportion difference of 3.7% (95% CI 3.2-4.2%). A higher strength of association for PASC was identified in those cared for in the ICU during the acute illness phase, children less than 5 years-old, and individuals with complex chronic conditions.Conclusions and RelevanceIn this large-scale, exploratory study, the burden of pediatric PASC that presented to health systems was low. Myocarditis was the most commonly diagnosed PASC-associated condition. Acute illness severity, young age, and comorbid complex chronic disease increased the risk of PASC.Key PointsQuestionWhat are the incidence and clinical features of post-acute sequelae of SARS-CoV-2 infection (PASC) in children?FindingsIn this retrospective cohort study of 659,286 children tested for SARS-CoV-2 by polymerase chain reaction (PCR), the symptom, condition and medication with the strongest associations with SARS-CoV-2 infection were loss of taste/smell, myocarditis, and cough and cold preparations. The incidence proportion of non-MIS-C related PASC in the PCR-positive group exceeded the PCR-negative group by 3.7% (95% CI 3.2-4.2), with increased rates associated with acute illness severity, young age, and medical complexity.MeaningPASC in children appears to be uncommon, with features that differ from adults.

BACKGROUND Access to gender-affirming care services for transgender and gender diverse (TGD) youth is limited, in part because it is currently provided primarily by specialists. Telehealth platforms that facilitate specialist to primary care provider (PCP) education and consultation may help improve access, however little is known about PCPs preferences regarding receiving this support. OBJECTIVE The purpose of this study was to explore pediatric PCPs’ perspectives regarding optimal ways to provide telehealth-based support to facilitate gender-affirming care provision in the primary care setting. METHODS PCPs who had previously requested support from the Seattle Children’s Gender Clinic were recruited to participate in a semi-structured, one-hour interviews over Zoom. Three different PCP-to-specialist telehealth modalities (tele-education, electronic consultation, telephonic consultation) were described and participants were invited to share their perspectives on 1) the benefits and drawbacks of each modality, 2) which modality would be most effective, and 3) the most important characteristics or outcomes of a successful platform. Interviews were transcribed and analyzed using Dedoose qualitative analysis software using an inductive thematic analysis framework. RESULTS Interviews were completed with 15 pediatric PCPs. Benefits of the tele-education platform included developing a network with other PCPs to facilitate shared learning, receiving comprehensive didactic and case-based education, occurring at a scheduled time and increasing provider confidence. Drawbacks included requiring a significant time commitment and not allowing for real-time, patient-specific consultation. Benefits of the electronic consultation platform included convenient and efficient communication, documentation in the electronic health record (EHR), ability to bill for provider time and sufficient time to synthesize information. Drawbacks of this platform included EHR-related difficulties, text-based communication challenges, not receiving an answer in real time, forced conversations with patients about billing and limitations for providers who lack baseline knowledge. With respect to telephonic consultation, benefits included having a dialogue with a specialist, compensation for PCP time and helping with high acuity or complex cases. Drawbacks included challenges associate with using the phone for communication, the limited expertise of responding providers, and lack of utility for non-emergent issues. Regarding the most effective platform, responses were mixed with 27% preferring the electronic consultation, 27% tele-education, 20% telephonic consultation, and the remaining 27% suggesting a hybrid of the three models. The ten factors important to the development of a successful PCP-to-specialist telehealth platform included: reliable, timely, engaging, non-judgmental, scalable, practical, adaptable, comprehensive, integrated and accessible. CONCLUSIONS We must develop a diverse suite of telehealth-based training and consultation services to meet the needs of PCPs with different levels of experience and training in gender-affirming care. Beyond the widely used telephonic consultation model, electronic consultation and tele-education may provide important alternative training and consultation opportunities to facilitate greater PCP independence promote more widespread access. CLINICALTRIAL n/a

IMPORTANCE: A cancer diagnosis can adversely affect other members of the family, including children. However, little is known about the extent to which history of parental cancer affects children’s health. OBJECTIVE: To examine associations of parental cancer with children’s school absenteeism, medical care unaffordability, health care use, and mental health. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional, nationally representative study used data from the 2010-2018 National Health Interview Survey. Statistical analyses were conducted from January to September 2021. Children aged 5 to 17 years living in families with and without a history of parental cancer were identified. Characteristics were grouped into child, parent, and family variables. Sequential multivariable regressions were conducted for unadjusted analyses and with the adjustment of child, parent, and family characteristics to assess associations between parental cancer and child outcomes. EXPOSURES: History of parental cancer. MAIN OUTCOMES AND MEASURES: School absenteeism, medical care unaffordability, health care use, and mental health. RESULTS: A total of 1232 children (mean [SD] age, 11.7 [0.13] years; 579 [48.6%] female; weighted N = 846 730; 3.4% of total sample) were living in families with a history of parental cancer. Compared with 33 870 children without a history of parental cancer (mean [SD] age, 10.8 [0.03]; 16 287 [48.8%] female; weighted N = 24 315 452; 96.6% of total sample), children of cancer survivors were more likely to be older, non-Hispanic White, and living in single parent families. Parents with a history of cancer were more likely to be older, to be female, to have more comorbid conditions, and to have public health insurance compared with parents without a history of cancer. History of parental cancer was adversely associated with school absenteeism, medical care unaffordability, health care use, and mental health among children. Sequential adjustment with child, parent, and family characteristics reduced the magnitude of the associations. For example, the odds ratios for school absenteeism of 1 day or more changed from 1.33 (95% CI, 1.11-1.59; P = .002) to 1.12 (95% CI, 0.93-1.34; P = .23) and for any child hospital emergency department visit from 1.56 (95% CI, 1.31-1.86; P

Cardiac complications, particularly myocarditis and pericarditis, have been associated with SARS-CoV-2 (the virus that causes COVID-19) infection (1-3) and mRNA COVID-19 vaccination (2-5). Multisystem inflammatory syndrome (MIS) is a rare but serious complication of SARS-CoV-2 infection with frequent cardiac involvement (6). Using electronic health record (EHR) data from 40 U.S. health care systems during January 1, 2021-January 31, 2022, investigators calculated incidences of cardiac outcomes (myocarditis; myocarditis or pericarditis; and myocarditis, pericarditis, or MIS) among persons aged ≥5 years who had SARS-CoV-2 infection, stratified by sex (male or female) and age group (5-11, 12-17, 18-29, and ≥30 years). Incidences of myocarditis and myocarditis or pericarditis were calculated after first, second, unspecified, or any (first, second, or unspecified) dose of mRNA COVID-19 (BNT162b2 [Pfizer-BioNTech] or mRNA-1273 [Moderna]) vaccines, stratified by sex and age group. Risk ratios (RR) were calculated to compare risk for cardiac outcomes after SARS-CoV-2 infection to that after mRNA COVID-19 vaccination. The incidence of cardiac outcomes after mRNA COVID-19 vaccination was highest for males aged 12-17 years after the second vaccine dose; however, within this demographic group, the risk for cardiac outcomes was 1.8-5.6 times as high after SARS-CoV-2 infection than after the second vaccine dose. The risk for cardiac outcomes was likewise significantly higher after SARS-CoV-2 infection than after first, second, or unspecified dose of mRNA COVID-19 vaccination for all other groups by sex and age (RR 2.2-115.2). These findings support continued use of mRNA COVID-19 vaccines among all eligible persons aged ≥5 years.

Weight control programs for children monitor BMI changes using BMI z-scores that adjust BMI for the sex and age of the child. It is, however, uncertain if BMIz is the best metric for assessing BMI change.To identify which of 6 BMI metrics is optimal for assessing change. We considered a metric to be optimal if its short-term variability was consistent across the entire BMI distribution.285 643 2- to 17-year-olds with BMI measured 3 times over a 10- to 14-month period.We summarized each metric's variability using the within-child standard deviation.Most metrics' initial or mean value correlated with short-term variability (|r| ~ 0.3 to 0.5). The metric for which the within-child variability was largely independent (r = 0.13) of the metric's initial or mean value was the percentage of the 50th expressed on a log scale. However, changes in this metric between the first and last visits were highly (r ≥ 0.97) correlated with changes in %95th and %50th.Log %50 was the metric for which the short-term variability was largely independent of a child's BMI. Changes in log %50th, %95th, and %50th are strongly correlated.

Background Access to virtual care has increased since the beginning of the COVID-19 pandemic, yet little is known about transgender and gender-diverse (TGD) youth’s experiences and perspectives on receiving care via telemedicine. Objective The purpose of this study was to explore these experiences to (1) inform necessary changes to the provision of pediatric gender-affirming care and (2) help providers and health systems determine if and how telemedicine should be made available post pandemic. Methods Youth (aged 14-17 years) who completed a telemedicine visit in the Seattle Children’s Gender Clinic were invited to participate in a semistructured interview exploring perceived advantages or disadvantages of telemedicine and preferred visit modalities. Interview transcriptions were analyzed by 2 research team members using an inductive thematic analysis framework. Results A total of 15 TGD youth completed an interview. Commonly cited advantages of telemedicine were convenience and comfort with having visits in their own environments. Reported disadvantages included technical issues, discomfort with the impersonal nature, lack of familiarity with the platform, and privacy concerns. Overall, slightly more youth preferred in-person visits over telemedicine, referencing both specific characteristics of the clinical visit (ie, initial vs return and complexity) and proximity to the clinic as reasons for this preference. Although a plurality of TGD youth preferred in-person visits, they also recognized the value of telemedicine and the impact it may have in facilitating access to care. Conclusions Given the variations in needs and visit complexity, our study supports the provision of both in-person and telemedicine modalities as options for pediatric gender-affirming care.

Background Access to gender-affirming care services for transgender and gender-diverse youths is limited, in part because this care is currently provided primarily by specialists. Telehealth platforms that enable primary care providers (PCPs) to receive education from and consult specialists may help improve the access to such services. However, little is known about PCPs’ preferences regarding receiving this support. Objective This study aimed to explore pediatric PCPs’ perspectives regarding optimal ways to provide telehealth-based support to facilitate gender-affirming care provision in the primary care setting. Methods PCPs who had previously requested support from the Seattle Children’s Gender Clinic were recruited to participate in semistructured, 1-hour web-based interviews. Overall, 3 specialist-to-PCP telehealth modalities (tele-education, electronic consultation, and telephonic consultation) were described, and the participants were invited to share their perspectives on the benefits and drawbacks of each modality, which modality would be the most effective, and the most important characteristics or outcomes of a successful platform. Interviews were transcribed and analyzed using a reflexive thematic analysis framework. Results The interviews were completed with 15 pediatric PCPs. The benefits of the tele-education platform were developing a network with other PCPs to facilitate shared learning, receiving comprehensive didactic and case-based education, having scheduled education sessions, and increasing provider confidence. The drawbacks were requiring a substantial time commitment and not allowing for real-time, patient-specific consultation. The benefits of the electronic consultation platform were convenient and efficient communication, documentation in the electronic health record, the ability to bill for provider time, and sufficient time to synthesize information. The drawbacks of this platform were electronic health record–related difficulties, text-based communication challenges, inability to receive an answer in real time, forced conversations with patients about billing, and limitations for providers who lack baseline knowledge. With respect to telephonic consultation, the benefits were having a dialogue with a specialist, receiving compensation for PCP’s time, and helping with high acuity or complex cases. The drawbacks were challenges associated with using the phone for communication, the limited expertise of the responding providers, and the lack of utility for nonemergent issues. Regarding the most effective platform, the responses were mixed, with 27% (4/15) preferring the electronic consultation, 27% (4/15) preferring tele-education, 20% (3/15) preferring telephonic consultation, and the remaining 27% (4/15) suggesting a hybrid of the 3 models. Conclusions A diverse suite of telehealth-based training and consultation services must be developed to meet the needs of PCPs with different levels of experience and training in gender-affirming care. Beyond the widely used telephonic consultation model, electronic consultation and tele-education may provide important alternative training and consultation opportunities to facilitate greater PCP independence and promote wider access to gender-affirming care.

The current Centers for Disease Control and Prevention (CDC) body mass index (BMI) z-scores are inaccurate for BMIs of ≥97th percentile. We, therefore, considered 5 alternatives that can be used across the entire BMI distribution: modified BMI-for-age z-score (BMIz), BMI expressed as a percentage of the 95th percentile (%CDC95th percentile), extended BMIz, BMI expressed as a percentage of the median (%median), and %median adjusted for the dispersion of BMIs.We illustrate the behavior of the metrics among children of different ages and BMIs. We then compared the longitudinal tracking of the BMI metrics in electronic health record data from 1.17 million children in PEDSnet using the intraclass correlation coefficient to determine if 1 metric was superior.Our examples show that using CDC BMIz for high BMIs can result in nonsensical results. All alternative metrics showed higher tracking than CDC BMIz among children with obesity. Of the alternatives, modified BMIz performed poorly among children with severe obesity, and %median performed poorly among children who did not have obesity at their first visit. The highest intraclass correlation coefficients were generally seen for extended BMIz, adjusted %median, and %CDC95th percentile.Based on the examples of differences in the BMI metrics, the longitudinal tracking results and current familiarity BMI z-scores and percentiles. Both extended BMIz and extended BMI percentiles may be suitable replacements for the current z-scores and percentiles. These metrics are identical to those in the CDC growth charts for BMIs of95th percentile and are superior for very high BMIs. Researchers' familiarity with the current CDC z-scores and clinicians with the CDC percentiles may ease the transition to the extended BMI scale.

Importance: In-person schooling has been disrupted for most school-aged youth during the COVID-19 pandemic, with low-income, Black, and Hispanic populations most likely to receive fully remote instruction. Disruptions to in-person schooling may have negatively and inequitably affected children's mental health. Objective: To estimate the association between school closures and child mental health outcomes and how it varies across sociodemographic factors. Design, Setting, and Participants: This cross-sectional population-based survey study included a nationally representative sample of US adults aged 18 to 64 years with at least 1 child in the household. The survey was administered between December 2 and December 21, 2020, via web and telephone in English and Spanish. Participants were recruited from the NORC AmeriSpeak panel, an address-based panel with known probability sampling and coverage of 97% of US households. Exposures: Schooling modality (in person, fully remote, or hybrid), household income, age. Main Outcomes and Measures: Child mental health difficulties were measured with the parent-report version of the Strengths and Difficulties Questionnaire, with small, medium, and large effect sizes defined as 1.3-, 3.3-, and 5.2-point differences, respectively. Results: A total of 2324 adults completed the survey. Overall, 1671 respondents (71.9%) were women, 244 (10.5%) were Black, 372 (16.0%) were Hispanic, and 421 (18.1%) had a high school education or less. Children attending school in-person had higher household incomes (mean difference, $9719; 95% CI, $4327 to $15 111; P < .001) and were more likely to be White compared with those attending remotely (366 of 556 [65.8%] vs 597 of 1340 [44.5%]; P < .001). Older children in remote schooling had more mental health difficulties than those attending in-person schooling (standardized effect size, 0.23 [95% CI, 0.07 to 0.39] per year older; P = .006), corresponding to small effect sizes in favor of in-person schooling for older children and very small effect sizes favoring remote schooling for younger children. Children from families with higher income benefitted more from attending schools in-person compared with their peers from families with lower income (B = -0.20 [95% CI, -0.10 to -0.30] per $10 000-increase in annual income; P < .001), although this advantage was not apparent for children attending hybrid school (B = -0.05 [95% CI, -0.16 to 0.06] per $10 000-increase in annual income; P = .34), and directionally lower but not significantly different for children attending remote school (B = -0.12 [95% CI, -0.04 to -0.20] per $10 000-increase in annual income; P < .001). Learning pods fully buffered the associations of hybrid schooling (d = -0.25; 95% CI, -0.47 to -0.04) but not remote schooling (d = 0.04; 95% CI, -0.10 to 0.18) with negative mental health outcomes. Conclusions and Relevance: The findings of this study suggest that older and Black and Hispanic children as well as those from families with lower income who attend school remotely may experience greater impairment to mental health than their younger, White, and higher-income counterparts. Ensuring that all students have access to additional educational and mental health resources must be an important public health priority, met with appropriate funding and workforce augmentation, during and beyond the COVID-19 pandemic.

Background: Children with attention deficit hyperactivity disorder (ADHD) are at increased risk for poor health and obesity. The authors describe obesity-related movement behaviors in children with...

IMPORTANCE: Enzyme-inducing antiseizure medications (eiASMs) have been hypothesized to be associated with long-term risks of cardiovascular disease. OBJECTIVE: To quantify and model the putative hazard of cardiovascular disease secondary to eiASM use. DESIGN, SETTING, AND PARTICIPANTS: This cohort study covered January 1990 to March 2019 (median [IQR] follow-up, 9 [4-15], years). The study linked primary care and hospital electronic health records at National Health Service hospitals in England. People aged 18 years or older diagnosed as having epilepsy after January 1, 1990, were included. All eligible patients were included with a waiver of consent. No patients were approached who withdrew consent. Analysis began January 2021 and ended August 2021. EXPOSURES: Receipt of 4 consecutive eiASMs (carbamazepine, eslicarbazepine, oxcarbazepine, phenobarbital, phenytoin, primidone, rufinamide, or topiramate) following an adult-onset (age ≥18 years) epilepsy diagnosis or repeated exposure in a weighted cumulative exposure model. MAIN OUTCOMES AND MEASURES: Three cohorts were isolated, 1 of which comprised all adults meeting a case definition for epilepsy diagnosed after 1990, 1 comprised incident cases diagnosed after 1998 (hospital linkage date), and 1 was limited to adults diagnosed with epilepsy at 65 years or older. Outcome was incident cardiovascular disease (ischemic heart disease or ischemic or hemorrhagic stroke). Hazard of incident cardiovascular disease was evaluated using adjusted propensity-matched survival analyses and weighted cumulative exposure models. RESULTS: Of 10 916 166 adults, 50 888 (0.6%) were identified as having period-prevalent cases (median [IQR] age, 32 [19-50] years; 16 584 [53%] female), of whom 31 479 (62%) were diagnosed on or after 1990 and were free of cardiovascular disease at baseline. In a propensity-matched Cox proportional hazards model adjusted for age, sex, baseline socioeconomic status, and cardiovascular risk factors, the hazard ratio for incident cardiovascular disease was 1.21 (95% CI, 1.06-1.39) for those receiving eiASMs. The absolute difference in cumulative hazard diverges by more than 1% and greater after 10 years. For those with persistent exposure beyond 4 prescriptions, the median hazard ratio increased from amedian (IQR) of 1.54 (1.28-1.79) when taking a relative defined daily dose of an eiASM of 1 to 2.38 (1.52-3.56) with a relative defined daily dose of 2 throughout a maximum of 25 years’ follow-up compared with those not receiving an eiASM. The hazard was elevated but attenuated when restricting analyses to incident cases or those diagnosed when older than 65 years. CONCLUSIONS AND RELEVANCE: The hazard of incident cardiovascular disease is higher in those receiving eiASMs. The association is dose dependent and the absolute difference in hazard seems to reach clinical significance by approximately 10 years from first exposure.

Objective: To identify latent classes of adolescents with type 1 diabetes (T1D) based on their interest in receiving diabetes management support from their diabetes care team via social media (SM). Methods: 227 adolescents with T1D (13-18 years old) in Seattle, WA completed a survey about their interest in communicating with their care team over SM. Latent class analysis was used to identify latent groups based on their stated preferences. Results: A 3-class solution was identified that minimized AIC (2042.1), BIC (2131.1), and maximized entropy (0.88) and the value of log-likelihood (-995.0). Over half the sample (n=114, 50.2%) belonged to Class 1, which was defined by a positive view of using SM to support diabetes management and a strong preference for using direct messaging options to communicate over social media (see Figure). Adolescents in Class 2 (n=47, 20.7%) had a similar outlook with respect to impact on communication but reported a preference for private social media communication options. Class 3 (n=66, 29.1%) accounted for adolescents not interested in communicating over SM. Conclusions: The majority of adolescents with T1D endorsed the use of SM communication tools to support diabetes management. Findings from this latent class analysis can be used to provide tailored strategies to meet adolescent preferences for SM use with the diabetes care team. Disclosure F. Malik: None. A. M. Ellyson: None. D. Christakis: None. R. Mangione-smith: None. C. Pihoker: None. M. A. Moreno: None. Funding National Institutes of Health (K23DK119465)

IMPORTANCE: The American Academy of Pediatrics recommends that all families use a family media use plan to select and engage with media rules. To date, the effectiveness of this tool in promoting adolescent media rule engagement is unknown. OBJECTIVE: To test the effect of a family media use plan on media rule engagement in adolescents. DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial with parallel design used the online Qualtrics platform for recruitment, data collection, and intervention delivery. Parents and their children (aged 12 to 17 years) who spoke and read in the English language were recruited, enrolled, and randomized to either the intervention or control group. Parent-adolescent dyads in both groups completed baseline surveys individually, and the dyads in the intervention group completed the family media use plan survey. Baseline recruitment was conducted from April 8, 2019, to May 1, 2019, and follow-up surveys were completed between June 11, 2019, and July 2, 2019. INTERVENTIONS: The American Academy of Pediatrics family media use plan. MAIN OUTCOMES AND MEASURES: The primary outcome was media rule engagement reported by adolescents. Media rules were extracted from the family media use plan, and adolescents rated each rule (using Likert scales) according to whether the rule was present or followed in their home. Secondary outcomes were adolescent-perceived technology importance and changes in sleep, physical activity, and depression. RESULTS: A total of 1520 parent-adolescent dyads were enrolled in the trial and randomized to either the intervention or control group. Adolescents had a mean (SD) age of 14.5 (1.6) years, and 789 were female (51.9%) and 1027 were White (67.6%) individuals. Parents had a mean (SD) age of 44.1 (8.5) years, and 995 were women (65.5%) and 1021 were White individuals (67.2%). For media rule engagement, the between-group difference was –0.1 (95% CI, –1.1 to 0.9). CONCLUSIONS AND RELEVANCE: This randomized clinical trial found that completing a family media use plan did not lead to statistically significant changes in media rule engagement for adolescents in the intervention group. Future studies should consider revising the family media use plan and exploring the importance of technology as an intervention outcome. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03881397

More media exposure and life stressors are associated with higher levels of externalizing behaviors in young children; however, their joint impact on externalizing behavior trajectory is unknown. This study assessed the relationship of stressful life events (SLE), media exposure, and additional demographic and family variables on the trajectory of externalizing behaviors in preschool-aged children.Participants were children ages 3 to 5 years from a large, 18-month duration, randomized control trial to reduce inappropriate media exposure. The sample was recruited from community pediatrics' practices. Intervention and control groups were collapsed, with study arm a covariate. Latent growth modeling (LGM) was conducted, with main outcome of externalizing behaviors at 6, 12, and 18 months after study initiation. Primary exposures of interest were total daily media hours, SLE, intimate partner violence, and harsh parenting.Final analyses included 613 children. LGM without covariates revealed a significant decrease in mean externalizing score between baseline and 18 months. LGM with covariates revealed that individuals with more media exposure exhibited more externalizing behaviors and SLE significantly predicted a slower decline in externalizing behaviors. Externalizing behavior at 18 months was significantly predicted by SLE, child age, white non-Hispanic race, and harsh parenting.Exposure to a greater number of stressful life events appears to slow the age-appropriate decline in externalizing behaviors for preschool-aged children, while harsh parenting and media exposure are associated with more externalizing behavior. Findings highlight the importance of screening and surveillance in primary care and the need for early intervention efforts targeted to these risks.

Key Points Question Based on the current understanding of the associations between school disruption and decreased educational attainment and between decreased educational attainment and lower life expectancy, is it possible to estimate the association between school closure during the coronavirus disease 2019 pandemic and decreased life expectancy of publicly educated primary school–aged children in the United States? Findings This decision analytical model found that missed instruction during 2020 could be associated with an estimated 5.53 million years of life lost. This loss in life expectancy was likely to be greater than would have been observed if leaving primary schools open had led to an expansion of the first wave of the pandemic. Meaning These findings suggest that the decision to close US public primary schools in the early months of 2020 may be associated with a decrease in life expectancy for US children., This decision analytical model estimates the potential years of life lost among US primary school–aged children associated with school closures during the coronavirus disease 2019 pandemic., Importance United States primary school closures during the 2020 coronavirus disease 2019 (COVID-19) pandemic affected millions of children, with little understanding of the potential health outcomes associated with educational disruption. Objective To estimate the potential years of life lost (YLL) associated with the COVID-19 pandemic conditioned on primary schools being closed or remaining open. Design, Setting, and Participants This decision analytical model estimated the association between school closures and reduced educational attainment and the association between reduced educational attainment and life expectancy using publicly available data sources, including data for 2020 from the US Centers for Disease Control and Prevention, the US Social Security Administration, and the US Census Bureau. Direct COVID-19 mortality and potential increases in mortality that might have resulted if school opening led to increased transmission of COVID-19 were also estimated. Main Outcomes and Measures Years of life lost. Results A total of 24.2 million children aged 5 to 11 years attended public schools that were closed during the 2020 pandemic, losing a median of 54 (interquartile range, 48-62.5) days of instruction. Missed instruction was associated with a mean loss of 0.31 (95% credible interval [CI], 0.10-0.65) years of final educational attainment for boys and 0.21 (95% CI, 0.06-0.46) years for girls. Summed across the population, an estimated 5.53 million (95% CI, 1.88-10.80) YLL may be associated with school closures. The Centers for Disease Control and Prevention reported a total of 88 241 US deaths from COVID-19 through the end of May 2020, with an estimated 1.50 million (95% CI, 1.23-1.85 million) YLL as a result. Had schools remained open, 1.47 million (95% credible interval, 0.45-2.59) additional YLL could have been expected as a result, based on results of studies associating school closure with decreased pandemic spread. Comparing the full distributions of estimated YLL under both “schools open” and “schools closed” conditions, the analysis observed a 98.1% probability that school opening would have been associated with a lower total YLL than school closure. Conclusions and Relevance In this decision analytical model of years of life potentially lost under differing conditions of school closure, the analysis favored schools remaining open. Future decisions regarding school closures during the pandemic should consider the association between educational disruption and decreased expected lifespan and give greater weight to the potential outcomes of school closure on children’s health.

IMPORTANCE: As schools consider reopening for in-person instruction prior to availability of a coronavirus disease 2019 (COVID-19) vaccine, families may be weighing their priorities regarding school attendance. OBJECTIVE: To characterize the association of planned in-person school attendance during the COVID-19 pandemic with factors, including family socioeconomic characteristics, and parent attitudes and beliefs about their child’s school attendance. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional survey study. Data were collected from June 2, 2020, to June 5, 2020, weighted to reflect population norms, and analyzed using ordered probit regression. A sample of US parents (of children ages 5-17 years) were recruited using a nonprobability survey panel with stratification by socioeconomic characteristics. MAIN OUTCOMES AND MEASURES: The main outcome was parent-reported plan to send their child to school or keep their child home, conditional on their school opening for in-person instruction. Additional measures assessed family socioeconomic characteristics, medical vulnerability, worry about COVID-19 and multisystem inflammatory syndrome, confidence in their child’s school, and homeschooling difficulties. RESULTS: The sample of 730 parents was balanced by parent sex (53% women) with successful oversampling for Black (28%; n = 201) and Hispanic (27%; n = 200) participants. In estimates weighted to US population norms, 31% (95% CI, 27% to 34%) of participants indicated they would probably or definitely keep their child home this fall, and 49% indicated that they would probably or definitely send their child to school this fall. Factors associated with planning to keep children home included lower income (38% with incomes

Objective: To examine adolescent preferences related to the use of social media (SM) as a tool to manage their type 1 diabetes (T1D) with their diabetes care team. Methods: Adolescents with T1D (13-18 years old) in the Seattle, WA area were surveyed from August-December 2019 about their SM use and interest in communicating with their diabetes care team over SM. Results: 232 adolescents with T1D completed the survey (response rate = 53%); mean age 15.1 years, 94% used SM, 85% used SM at least once/day. Approximately 70% indicated that if given the option, they were very likely or somewhat likely to communicate with their diabetes provider on SM. Over 72% shared they were very likely or somewhat likely to use SM direct messaging to ask urgent questions and 64% would use it for non-urgent questions. A majority of participants agreed that they would want to receive educational material (62%) and insulin dose adjustment support over SM (58%); Figure. Most agreed that SM communication would facilitate increased independent communication (61%) and positively impact patient-care team relationships (63%). A minority of participants (38%) reported privacy concerns. Conclusions: Adolescents with T1D expressed interest in using SM to support diabetes management and increase direct engagement with their diabetes care team. Healthcare teams should explore the use of SM to provide tailored support to adolescents with T1D. Disclosure F. Malik: None. M.A. Moreno: None. R. Mangione-Smith: None. C. Pihoker: None. A.M. Ellyson: None. H. Gill: None. K. Chalmers: None. D. Christakis: None. Funding National Institutes of Health (K23DK119465)

This survey study examines cell phone policies at US middle and high schools, practices of students and faculty, and principals’ attitudes about cell phone use during school.