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Objective To explore how pediatric hospitalist attendings can recognize, prevent, and mitigate moral distress among pediatric residents. Methods We conducted a qualitative study, utilizing a deductive approach, from August 2019 to February 2020 at 4 university-affiliated, freestanding children's hospitals in the United States using semistructured, one-on-one interviews with pediatric residents and pediatric hospitalist attendings. All transcripts were coded by pairs of research team members. Using constant comparative analysis, codes were categorized into themes and subsequently grouped into domains. We then conceptualized the relationships between the domains. Results We interviewed 40 physicians (18 residents, 22 attendings) and identified specific strategies for attendings to help residents navigate moral distress, which were categorized into 4 proactive and 4 responsive themes. The proactive themes included strategies employed before morally distressing events to minimize impact: ensuring attendings’ awareness of residency factors influencing residents’ moral distress; knowing available support resources; creating a learning environment that lays the foundation for mitigating distress; and recognizing moral distress in residents. The responsive themes included strategies that help mitigate the impact of morally distressing situations after they occur: partnering with the senior resident to develop a team-specific plan; consideration of who will participate in, the timing of, and content of the debrief. Conclusions We present multiple strategies that attendings can implement to learn to recognize, prevent, and mitigate moral distress among residents. Our findings highlight the need for both proactive and reactive strategies and offer a possible roadmap for attending physicians to help their residents navigate moral distress.

BACKGROUND Many children are undervaccinated at the time of hospital admission. Our objective was to explore the facilitators and barriers to vaccinating during hospitalization. METHODS We conducted qualitative interviews of parents, primary care pediatricians, emergency department (ED) physicians, and pediatric hospitalists. Parents of undervaccinated hospitalized children who were admitted through the ED were invited to participate. We used purposive sampling to identify physician participants. Semistructured interviews querying participants' perspectives on hospital-based vaccination were audiorecorded and transcribed. Parent demographics and physician practice characteristics were collected. Transcripts were analyzed for facilitators and barriers to vaccinating during acute hospital visits by using inductive content analysis. A conceptual framework was developed on the basis of the social ecological model. RESULTS Twenty-one parent interviews and 10 physician interviews were conducted. Of parent participants, 86% were female; 76% were white. Physician participants included 3 primary care pediatricians, 3 ED physicians, and 4 hospitalists. Facilitators and barriers fell under 4 major themes: (1) systems-level factors, (2) physician-level factors, (3) parent-provider interactional factors, and (4) parent- and child-level factors. Parent participants reported a willingness to receive vaccines during hospitalizations, which aligned with physician participants' experiences. Another key facilitator identified by parent and physician participants was the availability of shared immunization data. Identified by parent and physician participants included the availability of shared immunization data. Barriers included being unaware that the child was vaccine-eligible, parental beliefs against vaccination, and ED and inpatient physicians’ perceived lack of skills to effectively communicate with vaccine-hesitant parents. CONCLUSIONS Parents and physicians identified several key facilitators and barriers to vaccinating during hospitalization. Efforts to provide inpatient vaccines need to address existing barriers.

Although vaccines are considered one of the most effective medical interventions to prevent vaccine preventable disease and associated morbidity and mortality, a number of recent outbreaks are threatening the gains made by vaccines. Vaccine hesitancy is a key driver of vaccine refusal and has been associated with vaccine preventable outbreaks. While parents seek information from many sources to inform their vaccine decision-making process, they continue to view their child's pediatric provider as a trusted source of vaccine information. The communication that occurs between a provider and parent with regards to vaccination is critical in reducing concerns and nudging parents toward vaccine acceptance. However, vaccine-hesitant parents raise issues in this encounter that many providers feel ill-equipped to answer, due to lack of training on evidence-based communication strategies. We focus on promising approaches related to patient-provider communication within the context of vaccination. We found empirical evidence that the use of a presumptive format to recommend vaccines, motivational interviewing, and tailoring information to increase message salience are approaches that can positively affect vaccine acceptance. As providers continue to serve as important influencers in the vaccine decision-making process, it is evident that there is a need to continue to identify evidence-based, and practically implementable approaches to mitigate parental vaccine hesitancy. Providers play a key role in improving coverage rates, and therefore it is paramount to seek ways to improve how providers communicate about vaccines.

The US response to coronavirus disease 2019 (COVID-19) has been plagued with politics driving public health and messaging. As a result, COVID-19 vaccine rollout is occurring in an environment ill equipped to achieve broad acceptance of the vaccine. Addressing public concerns unlocks the potential for high vaccine coverage; this is best achieved when science and values, not politics, inform public health. A multifaceted and thorough engagement and communication plan that is responsive to the concerns and values of different groups must be swiftly yet carefully implemented in a coordinated manner by federal, state, and local governments. Effective communication will require rapid and rigorous science to promptly differentiate between adverse events following immunization that are causally related versus simply coincidental. Health care providers, in particular, will need support to process the otherwise potentially overwhelming amount of relevant information and effectively integrate it into discussions with their patients to support their decision making. An equitable COVID-19 immunization program could substantively reduce the disproportionate risks associated with this pandemic.

OBJECTIVES: To assess the relationship between vaccination status and clinician adherence to quality measures for children with acute respiratory tract illnesses. METHODS: We conducted a multicenter prospective cohort study of children aged 0 to 16 years who presented with 1 of 4 acute respiratory tract illness diagnoses (community-acquired pneumonia, croup, asthma, and bronchiolitis) between July 2014 and June 2016. The predictor variable was provider-documented up-to-date (UTD) vaccination status. Our primary outcome was clinician adherence to quality measures by using the validated Pediatric Respiratory Illness Measurement System (PRIMES). Across all conditions, we examined overall PRIMES composite scores and overuse (including indicators for care that should not be provided, eg, C-reactive protein testing in community-acquired pneumonia) and underuse (including indicators for care that should be provided, eg, dexamethasone in croup) composite subscores. We examined differences in length of stay, costs, and readmissions by vaccination status using adjusted linear and logistic regression models. RESULTS: Of the 2302 participants included in the analysis, 92% were documented as UTD. The adjusted mean difference in overall PRIMES scores by UTD status was not significant (adjusted mean difference −0.3; 95% confidence interval: −1.9 to 1.3), whereas the adjusted mean difference was significant for both overuse (−4.6; 95% confidence interval: −7.5 to −1.6) and underuse (2.8; 95% confidence interval: 0.9 to 4.8) composite subscores. There were no significant adjusted differences in mean length of stay, cost, and readmissions by vaccination status. CONCLUSIONS: We identified lower adherence to overuse quality indicators and higher adherence to underuse quality indicators for children not UTD, which suggests that clinicians “do more” for hospitalized children who are not UTD.

To understand the influence of a novel infectious disease epidemic on parent general attitudes about childhood vaccines.We conducted a natural experiment utilizing cross-sectional survey data from parents of infants in Washington and Colorado participating in a larger trial that began on September 27, 2019. At enrollment, parents completed the short version of the Parental Attitudes about Childhood Vaccines (PACV-SF), a validated survey scored from 0 to 4, with higher scores representing more negative attitudes. The exposure variable was onset of the SARS-CoV-2 pandemic in the United States, with the before-period defined as September 27, 2019 to February 28, 2020 and the after-period defined as April 1, 2020-December 10, 2020, with the after-period further separated into proximate (April 1, 2020-July 31, 2020) and distant periods (August 1, 2020-December 10, 2020). The outcome variable was parent negative attitudes about childhood vaccines, defined as a score of ≥2 on the PACV-SF. We estimated the probability of the outcome after (vs before) the exposure using log-binomial regression with generalized estimating equations adjusted for demographic confounding variables.Among 4562 parents, the risk of negative attitudes was lower immediately after (vs before) SARS-CoV-2 onset (adjusted risk ratio [aRR] = 0.58; 95% confidence interval [CI], 0.36, 0.94; P = .027), but by August-December 2020, the average rate of negative attitudes was 35% higher than during April-July 2020 (aRR: 1.35; 95% CI: 1.13, 1.61; P = .0009).A reduced risk of negative general vaccine attitudes observed immediately after SARS-CoV-2 onset was quickly attenuated.

The American Society of Transplantation in conjunction with the International Society for Heart and Lung Transplantation released a joint statement on August 13, 2021 in which they strongly recommend that solid organ transplant (SOT) recipients and their eligible household members and close contacts be vaccinated against SARS-CoV-2 with an approved COVID-19 vaccine. Some SOT programs have gone further and will refuse to list or transplant candidates unless the candidate and their household are vaccinated against SARS-CoV-2.Two general pediatrician-ethicists use current best evidence and moral theory to argue why it is unethical to mandate COVID-19 vaccination for pediatric SOT candidates, their primary support person, and their households.Pediatric vaccine mandates are most justifiable when they prevent the harm of a serious vaccine preventable disease (VPD) in children in settings where transmission is highly likely and there are no alternatives that are effective in preventing transmission that intrude less on individual freedom. An additional justification for a vaccine mandate in the SOT context is stewardship of a scarce resource if there is significant risk of graft loss from the VPD to an unvaccinated SOT candidate or recipient. Current evidence does not support fulfillment of these criteria in pediatric solid organ transplantation.Making SOT listing contingent on COVID-19 vaccination is problematic. Though there is some risk of harm to a pediatric SOT candidate in remaining unvaccinated, the risk of harm of not being listed and transplanted is greater and overriding.

BACKGROUND: In 2018, Facebook introduced Ad Archive as a platform to improve transparency in advertisements related to politics and “issues of national importance.” Vaccine-related Facebook advertising is publicly available for the first time. After measles outbreaks in the US brought renewed attention to the possible role of Facebook advertising in the spread of vaccine-related misinformation, Facebook announced steps to limit vaccine-related misinformation. This study serves as a baseline of advertising before new policies went into effect. METHODS: Using the keyword ‘vaccine’, we searched Ad Archive on December 13, 2018 and again on February 22, 2019. We exported data for 505 advertisements. A team of annotators sorted advertisements by content: pro-vaccine, anti-vaccine, not relevant. We also conducted a thematic analysis of major advertising themes. We ran Mann-Whitney U tests to compare ad performance metrics. RESULTS: 309 advertisements were included in analysis with 163 (53%) pro-vaccine advertisements and 145 (47%) anti-vaccine advertisements. Despite a similar number of advertisements, the median number of ads per buyer was significantly higher for anti-vaccine ads. First time buyers are less likely to complete disclosure information and risk ad removal. Thematically, anti-vaccine advertising messages are relatively uniform and emphasize vaccine harms (55%). In contrast, pro-vaccine advertisements come from a diverse set of buyers (83 unique) with varied goals including promoting vaccination (49%), vaccine related philanthropy (15%), and vaccine related policy (14%). CONCLUSIONS: A small set of anti-vaccine advertisement buyers have leveraged Facebook advertisements to reach targeted audiences. By deeming all vaccine-related content an issue of “national importance,” Facebook has further the politicized vaccines. The implementation of a blanket disclosure policy also limits which ads can successfully run on Facebook. Under current policies, improving transparency and limiting misinformation are not separate goals. Public health communication efforts should consider the impact on Facebook users’ vaccine attitudes and behaviors.

It is poorly understood when and how to use shared decision making (SDM) in pediatrics. To address this gap, this chapter presents a practical stepwise framework for putting SDM into practice in pediatrics. This framework includes four steps. The first three steps pose a question to the physician, with the answers directing the physician further along the framework: Step 1 (Medical Reasonableness): Does the decision include more than one medically reasonable option? Step 2 (Benefit-Burden): Does one option have a favorable medical benefit–burden ratio compared to other options? Step 3 (Preference Sensitivity): How preference sensitive are the options? Step 4 (Calibration): This step provides direction on the specific SDM approach to use for the decision under consideration based on the answers to Steps 1 through 3 as well as other decisional characteristics present. For each step, we expound on its rationale, application, and potential issues.

Parental confidence in vaccines is waning. To sustain and improve childhood vaccine coverage rates, insights from multiple disciplines are needed to understand and address the socio-cultural factors contributing to decreased vaccine confidence and uptake. ispartof: J Law Med Ethics vol:49 issue:4 pages:596-598 ispartof: location:England status: published

The Parent Attitudes about Childhood Vaccines (PACV) survey is a validated instrument for identifying vaccine-hesitant parents; however, a Spanish version is not available. Utilizing the WHO framework for translating survey instruments, we used an iterative process for developing the Spanish PACV that included forward translation, expert panel review, back translation and pre-testing that utilized cognitive interviewing. We made revisions to the Spanish PACV at each step, focusing on addressing inclusivity, readability, clarity and conceptual equivalence. The expert panel was comprised of 6 Spanish-speaking medical and research professionals who worked alongside 3 study team members. Pre-testing was conducted using convenience sampling of Spanish-speaking parents (N = 35) who had a child receiving care at the residents’ continuity clinic at Texas Children’s Hospital. Most pre-testing participants were married (80.6%), mothers (97.1%), ≥30 years of age (88.2%) and had a high school education or less (70.6%). While the majority of participants stated the survey was easy to complete, the translation of 5 PACV items was further revised to improve interpretability. We conclude that the final Spanish PACV is conceptually equivalent and culturally appropriate for most Hispanic populations.

Choices in a Crisis As experience with SARS-CoV-2 vaccination accumulates, meaningful differences among vaccines may emerge, making the question of whether individual vaccinees should be able to ch...

* Abbreviation: SNI — : severe neurologic impairment A couple presents to maternal fetal medicine clinic 3 days after a routine prenatal ultrasound at 19 weeks revealed a brain malformation consistent with severe holoprosencephaly in an otherwise normal appearing fetus. Clinicians share with the parents that many families decide to terminate their pregnancy in this situation on the basis of the likelihood that their child will have lifelong severe neurologic impairment (SNI) and require frequent hospital and medicalized home care. Without much further discussion, the couple immediately responds that they will continue their pregnancy. They express hope that their infant’s health will be better than doctors anticipate. Presenting at term in labor with brain abnormalities confirmed on ultrasound, the obstetric clinicians ask the parents about their goals of care. The couple again shares that they remain hopeful and that they would like every intervention done to help their child survive. The infant emerges lethargic and without respiratory effort requiring intubation in the delivery room and admission to the NICU. At the time of birth, the parents share that they are feeling a mix of surprise, anger, joy, and sadness. Over the subsequent months, the infant continues to show signs of SNI, grows well after a gastrostomy tube is placed, and remains intubated for intermittent apnea and airway obstruction. After discussions with the neonatology and surgery teams, the parents … Address correspondence to Jori F. Bogetz, MD, Seattle Children’s Research Institute, 1900 Ninth Ave, M/S: JMB-6, Seattle, WA 98101. E-mail: jori.bogetz{at}seattlechildrens.org

One part of our argument relies on the distinction between requesting inappropriate care (which, per AMA guidance, would make nonacceptance of potential patients permissible) and refusing appropriate care (which would not, by itself, make nonacceptance of potential patients permissible). Vaccine refusers are doing the latter, not the former. Dr. Terk claims this distinction doesn’t make a moral difference. We disagree. First, to be clear, by ‘appropriate care’ we mean the standard of care, defined as minimally competent care; by ‘inappropriate care’ we mean something falling below the standard of care. The distinction we draw—between physicians not offering inappropriate care and physicians tolerating parental … E-mail: navin{at}oakland.edu

The US response to coronavirus disease 2019 (COVID-19) has been plagued with politics driving public health and messaging. As a result, COVID-19 vaccine rollout is occurring in an environment ill equipped to achieve broad acceptance of the vaccine. Addressing public concerns unlocks the potential for high vaccine coverage; this is best achieved when science and values, not politics, inform public health. A multifaceted and thorough engagement and communication plan that is responsive to the concerns and values of different groups must be swiftly yet carefully implemented in a coordinated manner by federal, state, and local governments. Effective communication will require rapid and rigorous science to promptly differentiate between adverse events following immunization that are causally related versus simply coincidental. Health care providers, in particular, will need support to process the otherwise potentially overwhelming amount of relevant information and effectively integrate it into discussions with their patients to support their decision making. An equitable COVID-19 immunization program could substantively reduce the disproportionate risks associated with this pandemic.

This commentary suggests specific strategies and language that clinicians can use to address mistrust of COVID-19 vaccines among racial and ethnic minorities.

Objective Clinicians and healthcare organizations are ethically obligated to treat patients with respect, yet it is not clear what actions best demonstrate respect to patients. This exploratory qualitative study aimed to understand what actions on both an individual and organizational level effectively demonstrate respect for primary care patients. Methods We conducted semi-structured telephone interviews with primary care patients in an integrated healthcare delivery system in Oregon and an integrated safety net health system in Colorado who were participating in a genomics implementation research study of a hereditary cancer screening program. We systematically coded interview transcripts using a coding framework developed based on iterative review of the interview guide and transcripts. We further analyzed the data coded with sub-codes relating to patients’ experiences with respect in healthcare using a descriptive content analysis approach. Results We interviewed 40 English-speaking (n = 30, 75%) and Spanish-speaking (n = 10, 25%) patients. Most interviewees identified as female (n = 35, 88%) and either Hispanic/Latino(a) (n = 17, 43%) or White or European American (n = 15, 38%). Interviewees identified two categories of efforts by individual clinicians that demonstrate respect: engaging with patients and being transparent. They identified five efforts by healthcare organizations: promoting safety and inclusivity, protecting patient privacy, communicating about scheduling, navigating financial barriers to care, and ensuring continuity of care. Conclusions Our findings suggest that patients’ experiences of respect depend on efforts by individual clinicians as well as healthcare organizations. Our findings offer insight into how clinicians can build stronger partnerships with patients and how organizations can seek to promote access to care and patient safety and comfort. They also illustrate areas for future research and quality improvement to more effectively respect patients.

* Abbreviation: AAP — : American Academy of Pediatrics Vaccine refusal forces us to confront tensions between many values, including scientific expertise, parental rights, children’s best interests, social responsibility, public trust, and community health. Recent outbreaks of vaccine-preventable and emerging infectious diseases have amplified these issues. The prospect of a coronavirus disease 2019 vaccine signals even more friction on the horizon. In this contentious sociopolitical landscape, it is therefore more important than ever for clinicians to identify ethically justified responses to vaccine refusal. The American Academy of Pediatrics (AAP) says dismissing families who continue to refuse vaccines is an “acceptable option,”1 but some practices have gone further by not accepting vaccine refusers as patients at all.2,3 The phenomenon of nonacceptance has been underexplored; in both empirical studies and ethics analyses, researchers largely focus on dismissal.4–7 In this article, we first criticize arguments for nonacceptance that invoke a supposed right to choose one’s patients. We then argue that nonacceptance is problematic because (1) some of its motivations are intrinsically immoral, (2) it does not appear to accomplish some of its goals, and (3) even when nonacceptance does accomplish its goals, it fails to appropriately balance the various values it implicates. Throughout the article, we engage with the existing ethics literature about dismissal and conclude that even if dismissal is sometimes justifiable, nonacceptance is not. Some may argue that nonacceptance is ethically justified because they believe the clinical relationship is fundamentally a free association between clinicians and patients, as the American Medical Association Code of Medical … Address correspondence to Mark C. Navin, PhD, Department of Philosophy, Oakland University, 746 Mathematics and Science Center, 146 Library Dr, Rochester, MI 48309-4479. E-mail: navin{at}oakland.edu

Background Health care professionals (HCPs) (eg, nurses, doctors) play a key role in vaccine uptake. Few studies describe HCP influenza vaccine communication with parents of hospitalized children. Methods This study included English- and Spanish-speaking parents of influenza vaccine-eligible children hospitalized at a tertiary care pediatric hospital between October 2018 and May 2019. A survey was completed online or via telephone 2 to 15 weeks (median 4 weeks) after discharge. It examined parental intent to vaccinate their child during hospitalization and parent-reported inpatient HCP communication practices (eg, vaccine recommendation strength, format for initiating the recommendation). Multivariable logistic regression examined the associations between HCP communication practices and influenza vaccination during hospitalization, adjusting for demographic, clinical, and visit characteristics. Results Parents (n = 194; 63.0% response rate) were mostly white (66.8%) and English-speaking (97.4%). Their children were primarily 5 through 17 years (67.0%) with chronic disease (68.6%); 24.7% were vaccinated before discharge. Most parents initially had no plan (55.6%) or planned to decline (31.1%) influenza vaccine for their child during hospitalization. Of these parents, 22.2% decided to accept the vaccine, 66.7% citing a HCP conversation as the main reason for changing their mind. Overall, 75.3% recalled a HCP conversation about influenza vaccination. Of these parents, 61.0% reported a HCP recommendation (53.8% described it as “very strong”; 11.1% noted a presumptive initiation format). A parent-reported HCP conversation (adjusted odds ratio [AOR] 5.23, 95% confidence interval [CI] 1.64–16.68) and recommendation (AOR 5.59, 95% CI 2.01–15.51) were associated with influenza vaccination during hospitalization. Conclusion This study highlights the importance of discussing and recommending influenza vaccination with parents of hospitalized children.

* Abbreviation: VHP — : vaccine-hesitant parent The severe acute respiratory syndrome coronavirus 2 pandemic has put into sharp perspective the paucity of our understanding of how to influence immunization behavior. If we must achieve herd immunity to halt this pandemic, how can that be accomplished? What could we do now to ensure almost universal acceptance of a vaccine determined by the US Food and Drug Administration to be safe and effective in preventing coronavirus disease? Furthermore, recent experience with measles in the United States has demonstrated that even the ready availability of an indisputably effective and demonstrably safe vaccine is no longer sufficient to prevent outbreaks. We need to figure out how to achieve and sustain vaccine acceptance by a high proportion of our population. The investment required to bring a new vaccine to licensure in the United States (estimated to cost ∼$1 billion)1 warrants a substantial commitment to funding research on how and when attitudes and beliefs about vaccines are formed and how best to communicate about vaccines to parents and the public to promote vaccine acceptance. The good news is that this work is well on its way for childhood vaccines. There is a robust literature on parents’ vaccine attitudes … Address correspondence to Edgar K. Marcuse, MD, MPH, FPIDS, Department of Pediatrics, University of Washington School of Medicine, 4800 Sand Point Way NE Seattle, Washington, 98105. E-mail: emarcuse{at}uw.edu

IntroductionA key contributor to underimmunisation is parental refusal or delay of vaccines due to vaccine concerns. Many clinicians lack confidence in communicating with vaccine-hesitant parents (VHP) and perceive that their discussions will do little to change parents’ minds. Improving clinician communication with VHPs is critical to increasing childhood vaccine uptake.Methods and analysisWe describe the protocol for a cluster randomised controlled trial to test the impact of a novel, multifaceted clinician vaccine communication strategy on child immunisation status. The trial will be conducted in 24 primary care practices in two US states (Washington and Colorado). The strategy is called Presumptively Initiating Vaccines and Optimizing Talk with Motivational Interviewing (PIVOT with MI), and involves clinicians initiating the vaccine conversation with all parents of young children using the presumptive format, and among those parents who resist vaccines, pivoting to using MI. Our primary outcome is the immunisation status of children of VHPs at 19 months, 0 day of age expressed as the percentage of days underimmunised from birth to 19 months for 22 doses of eight vaccines recommended during this interval. Secondary outcomes include clinician experience communicating with VHPs, parent visit experience and clinician adherence to the PIVOT with MI communication strategy.Ethics and disseminationThis study is approved by the following institutional review boards: Colorado Multiple Institutional Review Board, Washington State Institutional Review Board and Swedish Health Services Institutional Review Board. Results will be disseminated through peer-reviewed manuscripts and conference presentations.Trial registration numberNCT03885232.

Many families are concerned about their child’s risk of concussion, and some seek counsel from clinicians about whether or not to return to contact sports participation postinjury. The present study sought to identify factors that parents weight most heavily in forming their preferences regarding whether their child should return to contact sport after recovering from a concussion. Survey data were collected from 568 parents of youth football players (aged 7–14 years) in the Pacific Northwest region of the United States (73% response rate). Approximately two thirds (63%) of parents preferred that their child retire from football after one or two concussions. Multivariable linear regression indicated parents above the sample mean in terms of how strongly they valued football participation preferred their child stop after more concussions than parents below the sample mean (β = .44, standard error [SE] = 0.06, p < .001). Factors endorsed by the most parents as making them “much more likely” to want their child to stop playing football included the belief that their child will experience cognitive issues later in life as a result of concussions (65.0%) and that their child will get another concussion while playing football (43.5%). Within the context of a clinical visit postconcussion, physicians may need to help families clarify their values related to football participation and provide information about the potential outcomes of returning to contact sport. A formalized shared decision aid could help support consistent implementation of this potentially challenging conversation.

The coronavirus disease 2019 pandemic has affected nearly every aspect of medicine and raises numerous moral dilemmas for clinicians. Foremost of these quandaries is how to delineate and implement crisis standards of care and, specifically, how to consider how health care resources should be distributed in times of shortage. We review basic principles of disaster planning and resource stewardship with ethical relevance for this and future public health crises, explore the role of illness severity scoring systems and their limitations and potential contribution to health disparities, and consider the role for exceptionally resource-intensive interventions. We also review the philosophical and practical underpinnings of crisis standards of care and describe historical approaches to scarce resource allocation to offer analysis and guidance for pediatric clinicians. Particular attention is given to the impact on children of this endeavor. Although few children have required hospitalization for symptomatic infection, children nonetheless have the potential to be profoundly affected by the strain on the health care system imposed by the pandemic and should be considered prospectively in resource allocation frameworks.

To receive adequate protection against influenza, some children 6 months through 8 y old need two doses of influenza vaccine in a given season. Currently, only half of those receiving the first dose receive a second. Our objective was to assess vaccine hesitancy and influenza disease and vaccine knowledge, attitudes, and beliefs among caregivers of children who received the first of their two needed doses. As part of a national-randomized control trial of second dose text-message influenza vaccine reminders (2017–2018 season), a telephone survey collected caregiver and index child demographic information. Each child had received the first of two needed influenza vaccine doses. Caregivers completed a measure of general vaccine hesitancy – the five-question Parent Attitudes About Childhood Vaccines Survey Tool (PACV-5) – and questions about influenza infection and vaccine. We assessed associations between participant demographic characteristics, vaccine hesitancy, and influenza beliefs and calculated the standardized proportion of caregivers endorsing each outcome using logistic regression. Analyses included responses from 256 participants from 36 primary care practices in 24 states. Some caregivers (11.7%) reported moderate/high vaccine hesitancy and many had misperceptions about influenza disease and vaccine. In multivariable models, no single variable was consistently associated with inaccurate knowledge, attitudes, and beliefs. These results demonstrate that caregivers whose children received the first dose of influenza vaccine may still be vaccine hesitant and have inaccurate influenza beliefs. Pediatricians should consider broadly addressing inaccurate beliefs and promoting vaccination even after caregivers agree to the first dose.

OBJECTIVES:To assess (1) the accuracy of child immunization status documented by providers at hospital presentation for acute respiratory illness and (2) the association of provider-documented up-to-date (UTD) status with immunization receipt during and after hospitalization.METHODS:We conducted a retrospective cohort analysis of children ≤16 years old treated for asthma, croup, bronchiolitis, or pneumonia at a children’s hospital between July 2014 and June 2016. Demographics, clinical characteristics, and provider-documented UTD immunization status (yes or no) at presentation were obtained from the medical record. We compared provider-documented UTD status to the gold standard: the child’s UTD status as documented in the Washington State Immunization Information System (WAIIS). The sensitivity, specificity, and positive predictive value of provider-documented UTD status were calculated. We assessed the association of provider-documented UTD status and immunization during and within 30 days posthospitalization using multivariable logistic regression.RESULTS:Among 478 eligible children, 450 (94%) had provider-documented UTD status at hospital presentation and an active WAIIS record. Overall, 92% and 42% were UTD by provider documentation and WAIIS records, respectively, with provider-documented UTD status having 98.4% sensitivity (95% confidence interval [CI]: 95.4%–99.7%), 12.2% specificity (95% CI: 8.5%–16.8%), and 44.6% positive predictive value (95% CI: 39.7%–49.5%). Per WAIIS records, 20% and 44% of children who were due for vaccines received a vaccine during or within 30 days posthospitalization, respectively. There was no significant association between provider-documented UTD status and immunization during or after hospitalization.CONCLUSIONS:Provider-documented UTD immunization status at hospital presentation for children with respiratory illnesses overestimates UTD status, creating missed opportunities for immunization during and after hospitalization.

Shared decision-making (SDM) is a well-established component of patient-centered care, and yet, its application in pediatrics is poorly understood. Common features of pediatric decision-making are not completely addressed in current SDM models, such as the fact that the principal SDM participant is the patient’s surrogate, who, unlike competent adult patients deciding for themselves, has limitations on decision-making authority. To address this gap and improve the practice of SDM in pediatrics, a practical 4-step framework is presented. In step 1, physicians are posed the following question for any discrete decision: does the decision include >1 medically reasonable option? If the answer is no, SDM is not indicated. If the answer is yes, physicians proceed to step 2 and answer the following question: does 1 option have a favorable medical benefit-burden ratio compared with other options? If yes, physician-guided SDM is appropriate. If no, parent-guided SDM is appropriate. For each SDM approach, the physician proceeds to step 3 and answers the following question: how preference sensitive are the options? This helps to determine the specific SDM approach in step 4, which ranges from a strong or weak version of physician-guided SDM to a strong or weak version of parent-guided SDM. Several decisional characteristics, if present, can also help calibrate the version of SDM used. Additional analyses are needed to consider the inclusion of adolescents into this SDM framework.

OBJECTIVES: Parents frequently decline the influenza vaccine for their child during hospitalization. In this study, we aimed to assess the role of vaccine hesitancy in these declinations. METHODS: This cross-sectional survey study was conducted among English-speaking parents of influenza vaccine-eligible children who were hospitalized between October 2014 and April 2015. Between July 2015 and September 2015, parents were recruited via mail to complete the validated Parent Attitudes about Childhood Vaccines (PACV) survey (modified for influenza vaccination). PACV scores (0–100 scale) were dichotomized into scores of ≥50 (hesitant) and RESULTS: Of 199 parents (18% response rate), 24% were vaccine hesitant and 53% declined the influenza vaccine for their child during hospitalization. Vaccine hesitancy (versus nonhesitancy) was associated with declining influenza vaccination (adjusted odds ratio: 6.4; 95% confidence interval: 2.5–16.5). The declination reason differed by vaccine hesitancy status, with a higher proportion of parents who were hesitant versus nonhesitant reporting “vaccine concern” or “vaccine unnecessary.” CONCLUSIONS: Vaccine hesitancy was prevalent in this limited sample of parents of hospitalized children and associated with influenza vaccine declination. Additional investigation in a large, diverse, prospectively recruited cohort is warranted given the potential sampling bias present in this study.

Vaccination without Litigation Three times in the past 2 years, the Equal Employment Opportunity Commission has intervened to challenge vaccination mandates for health care workers, causing unease among the growing number of hospitals with mandatory influenza-vaccination policies.

Vaccination over Parental Objection Parents’ resistance to vaccination is leaving more children vulnerable to measles and other preventable illnesses. Most states, however, don’t authorize adolesce...

SummaryBackground Informed consent for pediatric anesthesia is unique because it is (1) obtained from surrogates (ie, parents) rather than from the patient and (2) sought after parents have authorized the surgical intervention. There are limited data on how pediatric anesthesia informed and consent discussions are conducted. The purpose of this study was to characterize the content of preanesthesia informed consent discussions and assess their impact on parent recall and understanding. Methods We conducted a cross-sectional observational study at a tertiary pediatric hospital. We audio-recorded and transcribed preanesthesia consent discussions between pediatric anesthesia providers and parents of children undergoing elective surgery. Parents were recruited on the day of surgery and completed a survey postdiscussion to assess their recall and perceived understanding. We used directed content analysis to identify 7 informed consent elements: (i) description of the plan; mention of (ii) alternatives, (iii) risks, and (iv) benefits; (v) discussion of uncertainties; (vi) assessment of comprehension; and (vii) solicitation of a decision. We used multivariable logistic regression to explore the association between discussions that included 3 informed consent elements (description of plan, mention of risks, and mention of benefits) and parent recall and understanding of these elements. Results We analyzed 97 discussions involving 41 different anesthesia providers. The element most frequently included in preanesthesia discussions was a description of the plan (100%); the least frequently included was decision solicitation (18%). Seventy-one percent of discussions included ≥5 informed consent elements and 70% included a description of the plan, mention of risks, and mention of benefits. Parental recall of these 3 informed consent elements was associated with their inclusion in the preanesthesia discussion (75% vs 34%), and more parents understood all 3 elements if they had reported (vs not reported) recall of all 3 elements (97% vs 53%). Conclusion Most pediatric preanesthesia discussions include ≥5 informed consent elements and describe the plan, mention risks, and mention benefits. Inclusion of these latter 3 consent elements was associated with parental recall of these elements but not understanding.

Objective Moral distress is increasingly identified as a major problem affecting healthcare professionals, but it is poorly characterized among pediatricians. Our objective was to assess the sources of moral distress in residents and pediatric hospitalist attendings and to examine the association of moral distress with reported burnout. Methods Cross-sectional survey from January through March 2019 of pediatric residents and hospital medicine attending physicians affiliated with 4 free-standing children's hospitals. Moral distress was measured using the Measure of Moral Distress for Healthcare Professionals (MMD-HP). Burnout was measured using 2 items adapted from the Maslach Burnout Inventory. Results Respondents included 288 of 541 eligible pediatric residents (response rate: 53%) and 118 of 168 pediatric hospitalists (response rate: 70%; total response rate: 57%). The mean MMD-HP composite score was 93.4 (SD = 42.5). Residents reported significantly higher frequency scores (residents: M = 38.5 vs. hospitalists: M = 33.3; difference: 5.2, 95% confidence interval [CI], 2.9–7.5) and composite scores (residents: M = 97.6 vs hospitalists: M = 83.0; difference:14.6, 95% CI, 5.7–23.5) than hospitalists. The most frequent source of moral distress was “having excessive documentation requirements that compromise patient care,” and the most intense source of moral distress was “be[ing] required to work with abusive patients/family members who are compromising quality of care.” Significantly higher mean MMD-HP composite scores were observed among participants reporting that they felt burned out at least once per week (M= 114.6 vs M= 82.3; difference: 32.3, 95% CI, 23.5–41.2). Conclusions Pediatric residents and hospitalists report experiencing moral distress from a variety of patient-, team-, and system-level sources, and this distress is associated with burnout.