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Background: Before the COVID-19 pandemic, telemedicine use for outpatient pediatric specialty care was low. Stay-at-home orders (SHO) prompted rapid upscaling of telemedicine capabilities and upski...

Background. Timely access to pediatric specialty care continues to be a pervasive issue. We aimed to identify factors associated with unmet pediatric specialty care needs by assessing the association with maternal level of education. Methods. A sample was extracted from the 2011-2012 National Survey of Children’s Health, which identified a subset of patients with unmet specialty care needs. Logistic regression models determined the strength of association between our sample and maternal level of education. Results. An estimated 12.5% of US children had unmet specialty care needs. Independent of confounding variables, children with mothers educated at a level of high school or less were 41% more likely to have unmet specialty care needs compared to those with mothers who were educated at a level greater than high school. Conclusions. Maternal level of education can be used as a risk factor to assess whether a child will have unmet specialty care needs.

To describe the distribution of open versus closed treatment and its relationship with the location of care in pediatric specialty versus general hospitals.Patient data were extracted from the Healthcare Cost and Utilization Project's Kid's Inpatient Database for the years 2000-2012. ICD9-CM diagnosis and procedure codes were used to identify open versus closed treatment of closed supracondylar humerus fractures in children younger than 12 years. A multilevel logistic regression model to control for confounders and identify drivers of open treatment was used.An estimated 40,706 inpatient surgical fixation procedures met our inclusion criteria. Overall rate of open treatment was 13.65%. Fractures were less likely to be treated open at pediatric hospitals versus general hospitals 7.61% versus 16.13% (P0.0001). Over the study period, rates of open treatment have fallen at nonpediatric hospitals from 20.21% in 2000 to 17.42% in 2012 (P0.001) but have remained stable at pediatric hospitals: 7.8% in 2000 and 8.62% in 2012 (P = 0.4369). Mean hospital length of stay was higher for patients who had open treatment 1.63 versus 1.20 days (P0.0001), and mean hospital charges were higher for patients who had open treatment $21,465 versus $15,026 (P0.0001). After controlling for time trends as well as demographic and hospital characteristics with a logistic regression model, treatment at a nonpediatric hospital was the single most significant predictor of open treatment for an isolated closed supracondylar humerus fractures with an odds ratio of 1.96 (95% confidence interval 1.56-2.46; P0.001).In this comprehensive population-based study of risk factors for open treatment of supracondylar humerus fractures in the United States, we identified differences in practice patterns by hospital type. Pediatric supracondylar fractures of the elbow have almost twice the odds of open treatment at nonpediatric hospitals.Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Pediatric burn injuries are stressful for parents, yet few burn clinics report screening caregivers. We evaluated psychometric properties of a two-item depression screener administered to parents of children with burns during outpatient clinic visits. We also examined associations between parent depression symptoms and child characteristics. We used a retrospective review of pediatric patients with burn injuries (n = 496, age range: 0–21 years; M = 5.0 years, SD = 4.4 years) from an outpatient specialty burn clinic. Sample was 54.8% male; ethnicity was 42.4% Black/African American and 42.2% White. Most children (94.7%) had a burn TBSA of 10% or less and partial thickness burns (87%). Depression measure was administered at two time points as part of routine care: T1 (n = 496) and T2 (n = 121). Score range was 0 to 8. The means were 1.17 (SD = 1.74) at T1 and 0.81 (SD = 1.40) at T2. The majority scored ≤3 (89.9% caregivers) at T1. The measure demonstrated satisfactory internal consistency at T1 (Cronbach α = .74) and T2 (α = .82). Scores at T1 and T2 for a subsample (n = 121) were related (r = .61, p < .001). Parents of non-White children tended to report higher depression scores at T1. At T2, being female and greater burn degree were associated with higher depression scores. This brief two-item scale used with caregivers of pediatric burn patients is a reasonable method for screening parental depression in this setting. Given the association between parental depression and child characteristics, further studies are needed, including examination of predictive validity of parental depression with pediatric outcomes.

Antecedentes: El síndrome hemofagocítico es una complicación grave que se observa en diversos padecimientos sistémicos. Objetivo: Conocer las características del síndrome hemofagocítico en el Hospital de Especialidades Pediátricas de Tuxtla Gutiérrez, Chiapas, México; se incluyó incidencia, subdiagnóstico y sobrediagnóstico, padecimientos asociados, tratamiento y pronóstico. Métodos: Se analizaron 214 casos probables de síndrome hemofagocítico atendidos entre enero de 2011 y mayo de 2019. Se incluyeron 26 pacientes con diagnóstico de síndrome hemofagocítico y 188 en los que se sospechaba esta entidad o con ferritina > 500 μg/L. Los casos en los que se cumplieron cuatro o más criterios de la Sociedad del Histiocito fueron incluidos en el estudio. Resultados: Se validaron 35 casos (14 con diagnóstico previo, nueve con sospecha y 12 con ferritina > 500 μg/L). No cumplieron con los criterios de la Sociedad del Histiocito, 12 casos diagnosticados previamente (sobrediagnóstico de 46.2 %) ni 21 de los que no habían sido diagnosticados (subdiagnóstico de 60 %). La incidencia anual fue de 2.0/1000 egresos. El virus Epstein-Barr estuvo involucrado en 42 % de los casos. La mortalidad representó 80 %. Conclusiones: El síndrome hemofagocítico fue subdiagnosticado y sobrediagnosticado en el hospital estudiado. Las características clínicas permiten sospecharlo, diagnosticarlo y tratarlo oportunamente. Se identificaron padecimientos específicos y no específicos asociados a síndrome hemofagocítico.

Background Suicide risk screening is recommended in pediatric care. To date, no previous studies illustrate the implementation of suicide risk screening in pediatric subspecialty care, even though chronic medical conditions are associated with a higher risk of suicide. Methods A large multidivision pediatric ambulatory clinic implemented annual suicide risk screening. Patients ages 9-21 years participated in suicide risk screening using the Ask Suicide-Screening Questions during the project. A multidisciplinary team employed quality improvement methods and survey-research design methods to evaluate the feasibility and acceptability of the screening process for patients, families, and medical providers. Results During the quality improvement project period, 1,934 patients were offered screening; 1,301 (67.3%) patients completed screening; 82 patients (6.3% of 1,301 patients) screened positive. The monthly compliance rate held steady at 86% following several Plan-Do-Study-Act cycles of improvement. The survey results demonstrate that providers rated the suicide risk screening process positively; however, a subset of providers indicated that the screening process was out of their scope of practice or impeded their workflow. Conclusions Suicide risk screening is feasible in pediatric specialty care and can identify at-risk patients. Continued efforts are needed to standardize suicide risk screening practices. Future directions include identifying factors associated with suicide risk in patients in pediatric subspecialty care settings.

Objectives: Pediatric specialty care is increasingly regionalized. It is unknown how regionalization affects emergency medical services (EMS) providers' destination decisions for non-trauma pediatric patients. We sought to characterize the rates of bypass of the closest facility, and destination facilities' levels of pediatric care in three diverse EMS agencies. Methods: This is a one-year retrospective study of non-trauma pediatric patients less than 18 years of age transported by three EMS agencies (Baltimore City, Prince George's County, and Queen Anne's County) in 2016. A priori, a bypass was defined as transport to a facility more than 2 km farther than the distance to the closest facility. We calculated rates of bypass and categorized destination and closest facilities by their pediatric service availability using publicly available information. EMS transport distance and time were also compared for bypass and closest facility patients. Results: The three EMS agencies in 2016 transported a total of 12,258 non-trauma pediatric patients, of whom 11,945 (97%) were successfully geocoded. Overall 43% (n = 5,087) of patients bypassed the nearest facility, of which 87% (n = 4,439) were transported to a facility with higher-level pediatric care than the closest facility. Both bypass rates and destination facility pediatric levels differed between agencies. Bypasses had significantly longer transport times and distances as compared to closest facility transports (p < 0.001). For non-trauma pediatric bypasses alone, an additional 41,494 kilometers traveled, and 979 hours of EMS transport time was attributable to bypassing the closest facility. Conclusions: This study reveals a high rate of pediatric bypass for non-trauma patients in three diverse EMS agencies. Bypass results in increased EMS resource utilization through longer transport time and distance. For non-trauma pediatric patients for whom there is little destination guidance, further work is required to determine bypass' effects on patient outcomes.

Introduction The objective of this study was to explore the enablers of and barriers to the contribution of nurse practitioners (NPs) in pediatric specialty care. Method A total of 11 NPs in pediatric medical specialties were interviewed regarding teamwork, communication, documentation, satisfaction, overall role, and perception of the value they contribute to care. Results Themes were identified related to structural and organizational enablers and barriers that facilitate or hinder the NPs’ contribution to pediatric specialty care. Discussion The findings of this study can provide a better understanding of the role of NPs caring for pediatric patients in the specialty setting and can also help guide organizational environments to maximize the potential of pediatric NPs to positively affect patient care.

Services for Children with Special Healthcare Needs (CSHCN) have been challenging in terms of cost and access to appropriate healthcare services.The objectives of this study were to examine cost, caring, and family-centered care in relationship to pediatric specialty services integrating telemedicine visits compared to traditional face-to-face visits only for (CSHCN) in rural, remote, and medically underserved areas.This study used a prospective, quasiexperimental research design with 222 parents or legal guardians of CSHCN receiving pediatric specialty care. The traditional group (n = 110) included families receiving face-to-face pediatric specialty care and the telemedicine group (n = 112) included families who had telemedicine visits along with traditional face-to-face pediatric specialty care.Results indicated no significant differences in family costs when the telemedicine group was compared to traditional face-to-face care. When the telemedicine group was asked to anticipate costs if telemedicine was not available, there were significant differences found across all variables, including travel miles, cost of travel, missed work hours, wages lost, child care cost, lodging cost, other costs, and total family cost (p0.001). There were no differences in the families' perceptions of care as caring. Parents/guardians perceived the system of care as significantly more family-centered when using telemedicine (p = 0.003).The results of this study underscore the importance of facilitating access to pediatric specialty care by use of telemedicine. We endorse efforts to increase healthcare access and decrease cost for CSHCN by expanding telemedicine and shaping health policy accordingly.

A finales del año 2019 China informó a la Organización Mundial de la Salud la presencia de casos de neumonías atípicas en la ciudad de Wuhan. Semanas más tardes se daría conocer a nivel mundial el nombre del agente causal de las mismas, un nuevo coronavirus denominado SARS-CoV-2, y la enfermedad asociada al mismo, la Covid-19. Presentamos la caracterización clínico-epidemiológica de un brote de Covid-19 intrainstitucional en un grupo de residentes de la especialidad de pediatría que la laboran en nuestro hospital.

A web-based survey of pediatric care providers revealed differences in their preference for clinical charts that monitor growth in children with obesity. These findings are attributed to pediatric specialty training. Very few providers believe the currently available Centers for Disease Control and Prevention 2000 body mass index-for-age charts adequately track growth in children with obesity.

Here, we describe a transdisciplinary effort to efficiently and equitably improve access to comprehensive evaluations for young children at-risk for autism and related neurodevelopmental disorders in the Austin, Texas community. What emerged from this collaboration between Dell Children’s Medical Group and The University of Texas at Austin is a flexible clinical approach that emphasizes patient-centered care, community partnerships, best practices, and provider satisfaction. This chapter outlines integral components of our (Sin Exclusion) Transdisciplinary Autism Assessment & Resources (S)TAAR model, with the hope of providing an example of early autism assessment that can be implemented in medically underserved communities through pediatric specialty clinics. Future iterations of the model are aimed at increasing professional training opportunities for students and early career clinicians and further increasing post-diagnostic family supports. The benefits and limitations of the current model are discussed and avenues for expansion are considered in greater detail.

As genetic testing is increasingly integrated into medical care, the genetic counselor (GC) has emerged as a key member of multidisciplinary (MD) teams. Prior research has demonstrated the importance of role clarification when subspecialties are introduced to these teams given the potential differences in team member expectations regarding the division of responsibilities in clinic. To assess perceptions of a GC's role in four pediatric hematology/oncology clinics, Accreditation Council for Genetic Counseling (ACGC) competencies were used to develop two separate surveys for providers and patients and their caregivers. Providers (n = 25) perceived roles related to genetic expertise and coordination of care to be primarily the role of a GC significantly more often than psychosocial roles (p

As the landscape of healthcare is shifting from volume-based to value-based practice, organizations are challenged to develop models that promote such changes with current resources while enriching the patient experience. A critical component to be successful, is utilizing an interprofessional team approach. An urban academic pediatric hospital developed such strategies by enhancing the use of Advanced Practice Providers (APPs) to optimize care. Through a series of tactics beginning with the strategic plan, results included an increase in volume, APP productivity, and enhanced satisfaction scores for both providers/patients, and an increase in access to pediatric specialty care.

To examine medication adherence and associated factors among adolescents with bipolar disorder (BP) using both objective and subjective methods.Participants were 21 adolescents with a primary BP diagnosis recruited from a pediatric specialty clinic. All participants were prescribed at least one psychotropic medication. Self- and parent-reported adherence were assessed monthly over 6 months. Objective data on medication adherence were gathered through an electronic weekly pillbox. Demographic and clinical factors were assessed through self, parent, and physician ratings at baseline, 3, and 6 months.Objective data indicate 41.5% of doses (58.6% of days) were not taken as prescribed over a mean of 3 months of follow-up. Subjective reports (patient, parent, and physician) significantly overestimated adherence as compared with objective data. Factors from multiple domains were associated with poorer adherence, including more daily doses, higher weight, dose timing (poorer on mornings/afternoons and weekends), less temporal proximity to medication management appointment, greater self-reported cognitive difficulties with adhering to treatment; the most potent predictor of missed doses was greater overall illness severity.Findings provide further evidence of poor medication adherence among youth with BP, and highlight the limits of subjective report of adherence. Providers should give careful attention to adherence when making decisions regarding treatment response and changes to medication regimen when working with youth with BP.

Objective The purpose of this study was to determine if pediatric specialty pediatric team (SPT) interfacility–transported children from community emergency departments to a pediatric intensive care unit (PICU) have improved 48-hour mortality. Methods This is a multicenter, historic cohort analysis of the VPS, LLC PICU clinical database (VPS, LLC, Los Angeles, CA) for all PICU directly admitted pediatric patients ≤ 18 years of age from January 1, 2007, to March 31, 2009. Categoric variables were analyzed by the chi-square and Mann-Whitney tests for non-normally distributed continuous variables. The propensity score was determined by multiple logistic regression analysis. Nearest neighbor matching developed emergency medical services SPT pairs by similar propensity score. Multiple regression analyses of the matched pairs determined the association of SPT with 48-hour PICU mortality. P values Results This study included 3,795 PICU discharges from 12 hospitals. SPT-transported children were more severely ill, younger in age, and more likely to have a respiratory diagnosis ( P P = .0028). Multiple regressions adjusted for propensity score, illness severity, and PICU site showed no significant difference in 48-hour PICU mortality. Conclusion No significant difference in adjusted 48-hour PICU mortality for children transported by transport team type was discovered.

OBJECTIVES Residency interviews play an integral part in medical residency placement. We aimed to develop and evaluate a mock interview program for fourth-year medical students interested in a pediatric specialty. METHODS A mock interview program for fourth-year medical students interested in pediatrics was developed and implemented. Preinterview quantitative data and postinterview qualitative data were collected. Fifty-nine students completed the program across three consecutive academic years. Preinterview surveys were completed regarding comfort and confidence levels specific to aspects of the interview process. Descriptive analyses were used. In addition, a focus group was held with nine of the participating students to obtain qualitative data via a paper blog process. Themes in student responses were identified through constant comparative analysis. RESULTS Before the mock interview, students were most uncomfortable with introductory and closing remarks and their confidence levels varied by topic. A thematic analysis of focus group data identified five themes (preparation, stress reduction, interview process familiarity, confidence of skills, and receiving feedback) for which the mock interviews were most helpful. CONCLUSIONS Implementation of a mock interview program was feasible and acceptable for senior medical students and may improve comfort and confidence levels in the residency interview process. Further longitudinal research is needed.

Background: As the largest group of healthcare providers, nurses have many different responsibilities in care provision to child violence victims (CVVs). Yet, their roles in care provision to these victims are poorly known. Objectives: The aim of this study was to explore nurses' experiences of their roles in care provision to CVVs. Methods: This qualitative study was conducted in 2018–2019. Fourteen nurses were purposively recruited from two pediatric specialty hospitals in Tehran and Ardabil, Iran. In-depth semi-structured interviews were held for data collection. Data were analyzed through conventional content analysis. Results: Data analysis revealed that nurses' roles in care provision to CVVs included the four main categories of protective, diagnostic, reporting, and educational roles. Conclusions: Nurses play significant roles in care provision to CVVs through diagnosing violence, reporting it, protecting CVVs, and providing education to CVVs and their families. Nonetheless, they receive limited education, if any, in this area.

[Clinical and epidemiologic characteristics and evolution of patients with stage 5 Renal cronic disease, from year 2005 to 2015 at the Omar Torrijos H. Pediatric Hospital, Panama]ResumenIntroducción: La incidencia y prevalencia de ERC-5 en niños ha ido en aumento. Es poco lo que se conoce respecto a la epidemiología de la ERC en niños y su manejo constituye un reto importante para los sistemas de salud. En Panamá no contamos con estudios que analicen la situación epidemiológica y clínica de niños con ERC. El objetivo del presente estudio es describir las características clínicas, epidemiológicas y evolución de pacientes pediátricos con enfermedad renal crónica estadio 5 atendidos en el servicio de Nefrología del hospital de Especialidades Pediátricas. Metodología: Se realizó un estudio observacional, descriptivo, retrospectivo, de los pacientes con enfermedad renal crónica estadio 5 atendidos en el Servicio de Nefrología del Hospital de Especialidades Pediátricas desde enero de 2005 a diciembre de 2015. Resultados: El promedio de edad al momento de la detección de la ERC-5 fue de 8.4 años. El sexo masculino predominó con una relación 1.4: 1. Predominó el grupo etario escolar de 6 a 10 años, y los adolescentes entre 11 a 15 años, con 14 casos cada uno. La incidencia anual fue de 3.0 casos, o 3.4 por millón de la población relacionada con la edad. La etiología más común fue la glomerulopatía 15 (44.1 %) Todos los pacientes tenían anemia y todos recibieron tratamiento dialítico crónico luego del establecimiento del diagnóstico mayormente diálisis peritoneal. Conclusión: Para Panamá, el promedio de edad al momento de la detección de la ERC-5 fue de 8.4 años, predominando el sexo masculino. La causa etiológica más común fue la glomerulopatía. Todos presentaban anemia al momento del diagnóstico y todos recibieron tratamiento dialítico crónico luego del establecimiento del diagnóstico, mayormente peritoneal.AbstractIntroduction: The incidence and prevalence of CKD-5 in children has been increasing. Little is known about the epidemiology of CKD in children and its management constitutes a major challenge for health systems. In Panama, we do not have studies that analyze the epidemiological and clinical situation of children with CKD. The aim of the present study is to describe the clinical, epidemiological and evolution characteristics of pediatric patients with stage 5 chronic kidney disease treated in the Nephrology service of the Pediatric Specialty Hospital. Methodology: An observational, descriptive, retrospective study of patients with stage 5 chronic kidney disease treated at the Nephrology Service of the Pediatric Specialty Hospital from January 2005 to December 2015 was performed. Results: The average age at the time of The detection of CKD-5 was 8.4 years. The male sex predominated with a 1.4: 1 ratio. The school age group was predominantly between 6 and 10 years old, and adolescents between 11 and 15 years old, with 14 cases each. The annual incidence was 3.0 cases, or 3.4 per million of the population related to age. The most common etiology was glomerulopathy 15 (44.1%). All the patients had anemia and all received chronic dialysis treatment after the establishment of the diagnosis, mainly peritoneal dialysis. Conclusion: For Panama, the average age at the time of detection of CKD-5 was 8.4 years, predominantly male. The most common etiologic cause was glomerulopathy. All had anemia at the time of diagnosis and all received chronic dialysis treatment after the establishment of the diagnosis, mostly peritoneal.

To describe program design, costs, and savings implications of a critical care-based care coordination model for medically complex children with chronic respiratory failure.All program activities and resultant clinical outcomes were tracked over 4 years using an adapted version of the Care Coordination Measurement Tool. Patient characteristics, program activity, and acute care resource utilization were prospectively documented in the adapted version of the Care Coordination Measurement Tool and retrospectively cross-validated with hospital billing data. Impact on total costs of care was then estimated based on program outcomes and nationally representative administrative data.Tertiary children's hospital.Critical Care, Anesthesia, Perioperative Extension and Home Ventilation Program enrollees.None.The program provided care for 346 patients and families over the study period. Median age at enrollment was 6 years with more than half deriving secondary respiratory failure from a primary neuromuscular disease. There were 11,960 encounters over the study period, including 1,202 home visits, 673 clinic visits, and 4,970 telephone or telemedicine encounters. Half (n = 5,853) of all encounters involved a physician and 45% included at least one care coordination activity. Overall, we estimated that program interventions were responsible for averting 556 emergency department visits and 107 hospitalizations. Conservative monetization of these alone accounted for annual savings of $1.2-2 million or $407/pt/mo net of program costs.Innovative models, such as extension of critical care services, for high-risk, high-cost patients can result in immediate cost savings. Evaluation of financial implications of comprehensive care for high-risk patients is necessary to complement clinical and patient-centered outcomes for alternative care models. When year-to-year cost variability is high and cost persistence is low, these savings can be estimated from documentation within care coordination management tools. Means of financial sustainability, scalability, and equal access of such care models need to be established.

Intrauterine fetal demise or termination for malformation is adverse obstetric outcomes, agonizing for the parents and frustrating for health care providers. These events are often unpredictable and investigation entails not only the evaluation of the fetus/neonate but also the placenta. Though nothing can compensate the bereavement of families who have encountered fetal or a neonatal loss, a meticulous study of the placental, fetal, and neonatal tissues provides succor and help in the healing process. In recent times, with extensive advances in the pediatric specialty, the significance and requirements for perinatal autopsy have also commensurately heightened. There is an inordinate need for an accurate diagnosis in order to render genetic counseling and ascertain the implications of possible recurrence in future pregnancies. A conscientious perinatal autopsy, supplemented by cytogenetic and metabolic evaluation, followed by dissemination of the information to the parents, clinicians, and public health organizations is of paramount importance. This not only assists in the clinical management and bereavement closure but also helps in the reduction of perinatal mortality and morbidity. An autopsy protocol assists in performing an adequate perinatal dissection, facilitates the recognition and documentation of all relevant information and in addition also provides a format for the collection, recording and presenting of data which facilitates collaborative research. A brief account of the benefits and techniques of perinatal autopsy and the protocol are presented.

A quality improvement project intended to promote maintenance of normothermia through active prewarming was carried out at a pediatric specialty hospital. An alternative active, forced-air warming product (Bair Paws warming gowns) was trialed in place of the existing active warming product (Bair Hugger blankets). Converting to the new product was intended to improve patient and staff compliance with prewarming recommendations. The alternative forced air active warming product was favored by both staff and patients, and the rate of compliance with this practice nearly doubled following the change in product. Extensive interprofessional collaboration and problem solving were required to go from an idea to a fully implemented change. The project demonstrated the importance of collaboration among various disciplines and the positive impact interprofessional collaboration can have on compliance with practice changes.

International audience; Until recently, inborn errors of metabolism (IEM) were considered a pediatric specialty, as emphasized by the term "inborn," and the concept of adult onset IEM has only very recently reached the adult medical community. Still, an increasing number of adult onset IEM have now been recognized, as new metabolomics and molecular diagnostic techniques have become available. Here, we discuss possible mechanisms underlying phenotypic variability in adult versus children with IEM. Specifically, phenotypic severity and age of onset are expected to be modulated by differences in residual protein activity possibly driven by various genetic factors. Phenotypic variability may also occur in the context of similar protein expression, which suggests the intervention of environmental, ontogenic, and aging factors.

Fetal medicine programs within children’s hospitals have been developed to ensure access to pediatric specialists across multiple disciplines. The cases that present to these programs are usually complex and require involvement of a multidisciplinary care team. Although some providers on the team limit their focus to their pediatric specialty when counseling patients, the radiologist and genetic counselor have a distinct perspective allowing them to take the larger picture into account in the evaluation of the fetus. As first responders, they come together to review images and identify which consultants are most appropriate to counsel the families, and they can help guide patient discussions. In this paper we demonstrate how the combined expertise of the genetic counselor and pediatric radiologist can facilitate more accurate diagnoses and guide the appropriate management of complex fetal anomalies.

Low- and middle-income countries carry a disproportionate share of the global burden of pediatric surgical disease and have limited local healthcare infrastructure and human resources to address this burden. Humanitarian efforts that have improved or provided access to necessary basic or emergency surgery for children in these settings have included humanitarian assistance and disaster relief, short-term surgical missions, and long-term projects such as building pediatric specialty hospitals and provider networks. Each of these efforts may also include educational initiatives designed to increase local capacity. This article will provide an overview of pediatric humanitarian surgical outreach including reference to available evidence-based analyses of these platforms and make recommendations for surgical outreach initiatives for children.

Through Improve Care Now, a quality improvement and research collaborative for pediatric patients with inflammatory bowel disease, our clinic piloted the feasibility and acceptability of patient-facing electronic technology to enhance engagement. This article qualitatively describes our experience piloting the technology. Participants included 36 families. Tools included a Web-based report pushed to families before office visits explaining current and past results on key health metrics and a mobile app for tracking symptoms and concerns and previsit planning between scheduled office visits. Building technology into clinical care required more support than anticipated. The tools improved collaboration and were well received.

1. Soleil Surette, MLIS* 2. Sunita Vohra, MD, MSc*,† 1. *CARE Program, University of Alberta, Edmonton, Alberta, Canada. 2. †Edmonton General Hospital, University of Alberta, Edmonton, Alberta, Canada. * Abbreviations: ASD: : autism spectrum disorder CAM: : complementary and alternative medicine Whether you believe in the effectiveness of complementary and alternative medicine (CAM) or not, some of your patients and their parents do. As you read this article, please note the number of patients who use CAM. Joseph A. Zenel, MD Editor-in-Chief Health care professionals do not ask consistently about complementary, holistic, and integrative medicine use by their patients, yet it is important to do so because patients and families often pursue this course of therapy for specific medical conditions and do not volunteer this information. No thorough assessment has been made of the literature on the use of pediatric complementary and alternative medicine (CAM) since 1999, when Ernst published a systematic review on this topic. (1) As part of its horizon scanning, the Complementary and Alternative Research and Education (CARE) program (www.care.ualberta.ca) tracks the use of CAM in the pediatric literature and, as of March 2011, has identified 160 English-language studies dating back to 1982. Utilization literature can be a valuable source of information for determining what CAM practices and products warrant further pediatric research. This article explores the 5 most studied pediatric specialty populations: oncology, asthma, autism spectrum disorder (ASD), gastrointestinal diseases (eg, inflammatory bowel disease and irritable bowel syndrome), and pediatric emergency care. The Table lists these studies, with references. View this table: Table. Articles on the 5 Most Studied Pediatric …

To examine inpatient utilization of pediatric cancer specialty centers (PCSCs) by pediatric oncology patients.We performed a retrospective (1999 to 2010) population-based analysis of oncology hospitalizations for pediatric patients aged 0 through 18 years using the California Office of Statewide Health Planning and Development database. Logistic regression examined hospitalization at 29 PCSCs and variables of age, sex, tumor type, payer, race, income, and distance to admission site.Analysis of 103,961 pediatric oncology discharges revealed that 93% occurred at PCSCs. These sites experienced a 20% increase in pediatric oncology discharges, conversely non-PCSCs exhibited a 70% decrease (P0.0001). Multivariate analyses revealed increased utilization with young age (odds ratio [OR], 4.58; 95% CI, 3.88-5.42), African American (OR, 1.26; 95% CI, 1.11-1.43), and middle income (OR, 1.36; 95% CI, 1.29-1.45). Decreased utilization was seen for females (OR, 0.88; 95% CI, 0.84-0.93) and Hispanics (OR, 0.72; 95% CI, 0.68-0.77). Payer and proximity were not significantly associated with change in utilization. Tumor types less likely to utilize a PCSC included germ cell, solid, and central nervous system tumors. Adolescents were3 times less likely to be treated at a PCSC.Inpatient pediatric oncology care in California has become increasingly regionalized with the vast majority of patients accessing PCSCs. However, variability in hospitalizations of adolescent patients and children not treated in PCSCs deserve further evaluation.

ObjectivesNitrous oxide (N2O) present in anesthetic mixtures (e.g., equimolar mix of oxygen and N2O, EMONO) has been found responsible for various toxicities, including genetic and reproductive toxicities. N2O-containing mixtures are widely used in pediatric care units where most healthcare providers (HCPs) are women of childbearing age. This motivated an investigation of occupational exposure to N2O in search for overexposure and overexposure factors in a pediatric hospital.MethodsThis observational study concerned seven different units. On each of 34 HCPs, air samples were extracted by portable pumps and collected in Tedlar® bags. N2O was quantified by gas chromatography coupled to pulsed discharge ionization detection and infrared spectrometry. The data allowed calculating mainly the instantaneous exposure and the 8 hour time-weighted average (8h-TWA).ResultsThe exposure was four times higher in closed than in open treatment rooms and two times higher in case of use vs. non-use of EMONO. The exposure was significantly higher in junior vs. senior HCPs (by 12%) and higher during presumably short vs. presumably long procedures (by 20%). The mean 8h-TWAs were rather higher than the recommended exposure limit (25 ppm/8 hour) in emergency unit and in day hospital for thoracic and abdominal diseases. Overexposures represented 11% of all measurements but reached substantial levels (up to 3.5 times the recommended threshold).ConclusionsOverexposures to N2O were frequent during short-duration procedures. The causes of overexposure were insufficient air renewal and inappropriate equipment use. This calls for dedicated rooms, more efficient medical/nursing practices, proper training, and regular checks of gas levels.

Neonatal and pediatric specialty transport teams provide an essential link between community referral centers and tertiary care children’s hospitals. These teams bring neonatal and pediatric critical care capabilities to the patient even before arrival at the destination hospital. Beyond the traditional expectations of interfacility transport teams such as intubation and vasoactive medications, many teams now perform advanced care transfers using mobile extracorporeal membrane oxygenation or have taken the leap to performing maternal-fetal transports. Finally, the skill sets and expertise of hospital-based transport team members may allow them to fulfill other roles within their organization, including participation on a rapid response team.

Objective The goal of this publication is to raise awareness of the impact of childhood obesity on the musculoskeletal health of children and its potential long-term implications. Methods Relevant articles dealing with musculoskeletal disorders either caused by or worsened by childhood obesity were reviewed through a Pub Med search. Efforts to recognize and combat the childhood obesity epidemic were also identified through Internet search engines. This case statement was then reviewed by the members of the pediatric specialty group of the US Bone and Joint Initiative, which represents an extensive number of organizations dealing with musculoskeletal health. Results Multiple musculoskeletal disorders are clearly caused by or worsened by childhood obesity. The review of the literature clearly demonstrates the increased frequency and severity of many childhood musculoskeletal disorders. Concerns about the long-term implications of these childhood onset disorders such as pain and degenerative changes into adulthood are clearly recognized by all the member organizations of the US Bone and Joint Initiative. Conclusions It is imperative to recognize the long-term implications of musculoskeletal disorders caused by or worsened by childhood obesity. It is also important to recognize that the ability to exercise comfortably is a key factor to developing a healthy lifestyle and maintaining a healthy body weight. Efforts to develop reasonable and acceptable programs to increase physical activity by all facets of society should be supported. Further research into the long-term implications of childhood musculoskeletal disorders related to childhood obesity is necessary.

Fetal Alcohol Spectrum Disorders (FASD) might be 10-15 times more prevalent among foster/adopted children compared to the general population; however, many of these children remain undiagnosed or misdiagnosed. The lack of confirmed prenatal alcohol exposure (PAE) may be a key barrier to diagnosis. Our sample included 681 patients evaluated for FASD, according to the University of Washington 4-Digit Diagnostic Code, at a pediatric specialty clinic. Guardianship status and other patient characteristics were evaluated by multinomial logistic regression as potential predictors of being classified into one of the following FASD groups: 1) full or partial Fetal Alcohol Syndrome (FAS/pFAS; n = 97); 2) Static Encephalopathy/Alcohol-Exposed (SE/AE) or Neurobehavioral Disorder/Alcohol-Exposed (ND/AE) (n = 135); and 3) some features of FASD (equivalent to pFAS, SE/AE or ND/AE phenotypes) but unknown PAE (n = 449). Median age at assessment was 7.0 years, non-Hispanic White constituted the predominant racial/ethnic group (49.5%), and the majority (81.8%) lacked involvement from a biological parent/relative. Many patients (66.0%) had some features of FASD but lacked reliable PAE information. Children classified into the 'some features/unknown PAE' group had higher median age of assessment (8 years) compared to other groups (6 years; p 0.001). No association was observed between race/ethnicity or child's sex and FASD outcomes (p 0.05). Adopted/foster children were 2.8 times as likely (95% CI: 1.6; 4.8) to be classified into the 'some features/unknown PAE' group compared to children living with a parent/relative after adjusting for covariates. This study's findings indicate that adopted/foster children are more likely to have unknown PAE and not receive a FASD diagnosis, potentially denying them access to specialized services, treatment, and rehabilitation.

Objective Describe utilization and satisfaction in a specialty integrated care program for children with severe, chronic respiratory insufficiency (CRI). Subjects Enrollees of the Critical Care, Anesthesia, Perioperative Extension (CAPE) and Home Ventilation Program. Methods Children with CRI received home visits, care coordination, and “on-demand” 24/7 access to physicians. Program activity and outcomes were recorded for 3 years using an adapted Care Coordination Measurement Tool© version. Parents completed the Consumer Assessment of Healthcare Providers and Systems (CAHPS). Patient characteristics, program activity, clinical outcomes, utilization, and satisfaction were summarized using descriptive statistics. Results CAPE provided care for 320 patients from 2012 to 2014 with a median of 7 encounters per year. Neuromuscular (n=132, 41%), chronic lung disease (n=37, 12%), and congenital heart disease (n=13, 4%) represented the majority of underlying conditions. Services included 905 home, 504 clinic, and 3633 telephone encounters, of which 43.6% included a care coordination activity. CAHPS (n=102) revealed that 92.1% (n=93) of children had at least one non-urgent (i.e., routine) visit and nearly two-thirds (64.7%, n=66) reported the need for urgent or emergency care. Overall, parents were highly satisfied with CAPE, with a mean satisfaction rating of 9.3 (±1.3) out of 10. Most parents reported that the CAPE team understood the child’s (96.0%, n=95) and family’s day-to-day life (86.9%, n=86). Conclusions When given open access to an intregated care program, children in our highly complex population required a median of 7 encounters per year. We believe that this experience is scalable and may inform other organizations contemplating similar services.

Purpose: Primary care providers (PCPs) of children with special health care needs (CSHCN) in rural areas face challenges in accessing specialty care to support a patient-centered medical home. This study assessed the practice characteristics and attitudes regarding pediatric specialty care among Montana PCPs of CSHCN. Methods: We surveyed 433 Montana PCPs identified through a statewide registry. Demographic and practice information was collected, including the proportion of time spent on CSHCN care coordination. A 5-point Likert scale was used to calculate mean need scores for each pediatric specialty, access to these specialties, and barriers to care. Results were analyzed separately for pediatricians and family physicians, as well as rural and urban providers, using λ2, t tests, and Mann-Whitney tests. Results: Of the PCPs surveyed, 386 had a valid address and were currently practicing in Montana, 112 (29%) responded, and 91 provided care to CSHCN (averaged 29% of time spent in CSHCN care coordination). Child psychiatry (4.1) and developmental/behavioral pediatrics (3.7) were identified as the most needed specialties, yet they scored lowest in access to care (2.2 and 2.6, respectively). The most important rated specialist characteristics were quality (4.1), availability (3.5), and communication skills (2.8). Among the top barriers to care, lack of appropriate specialists was identified by 82% of PCPs. Conclusions: Specialty care delivery for CSHCN in rural areas such as Montana should focus on matching availability with the identified need for specialty services, and ensuring that systems of communication between PCPs and specialists support the care coordination function of PCPs.

OBJECTIVE: Although the role of reputation in determining the relative standings in the U.S. News & World Report (USNWR) annual rankings of the top 50 hospitals has received analytical attention, the role of reputation in the best children's hospitals pediatric specialty rankings has not been quantified. Our goal was to quantify the role of reputation in determining the relative standings of the top-ranked pediatric specialties and their associated hospitals in the 2008–2010 editions of the USNWR best children's hospital rankings. METHODS: A cross-sectional study of USNWR data collected from the top 30 hospitals in each of 6 (and later 10) specialties was performed. The main outcome measures were rankings based on total USNWR scores and subjective reputation scores. RESULTS: On average, rankings based on reputation scores alone correlated with USNWR overall rankings; correlation coefficients ranged from 0.80 to 0.98 (Spearman Correlation; mean P < .001). This relationship was consistent over all 3 survey years. CONCLUSIONS: The relative standings of the top 30 pediatric hospitals in each of 10 specialties are largely explained by the compelling correlation between subjective reputation scores and ranking scores.

Health care transition has been defined as “the purposeful, planned movement of adolescents and young adults with chronic physical and medical conditions from child-centered to adult-oriented health care systems.”1 The 2002 consensus statement on health care transition of the American Academy of Pediatrics, American Academy of Family Physicians, American College of Physicians, and American Society of Internal Medicine mandated that “all adolescents with special healthcare needs should have a written healthcare transition plan by the age of 14 years.”2 In general, studies across various pediatric patient populations have found transition care to be suboptimal. For example, in an analysis of data from the 2000–2001 National Survey of Children with Special Health Care Needs, Scal and Ireland3 found that only about half of the parents of 4,332 children aged 14–17 years had discussed transition needs with their child's provider, and only 16.4% had developed a plan to address these needs. Although there is a paucity of data on diabetes transition practices in the United States, review of the literature and the author's 2009 survey of members of the Pediatric Specialty Practice Group of the American Association of Diabetes Educators (AADE) indicate that many U.S. pediatric endocrine practices struggle with developing workable, effective models for successful transition.4 Of the 176 AADE members surveyed, only 4 of the mere 9 respondents indicated that they had implemented a structured transition program. A 2007 survey by the International Society for Pediatric and Adolescent Diabetes (ISPAD) indicated that, among the 92 responding members representing 36 countries, ∼ 50% had structured transition programs. However, only one of the five respondents from the United States indicated having a transition program and described it as “partial,” further highlighting the need for progress in this area in the United States.5 Most transition research in diabetes …

Background Children’s oral health maintenance are influenced by their parent's knowledge and behaviors. Parents knowledge and attitude play an important role in preventing oral diseases and improving dental health in their children. Aim: to assess the knowledge and behavior of pediatric parent's attending pediatric dental clinics in King Abdul-Aziz University Dental Hospital toward caries prevention. Materials and method Questionnaires consisting of 36 demographic and knowledge and patients’ practices questions were interviewed with All pediatric parent's (549 parents) attending the pediatric specialty clinics with their children during the year 2018 (from 1st of August 2017 to 31st of July 2018). Results There was a total of 283 respondents (51.5% response rate). Out of them, 79.5% were Saudi, 48.4% of children were males with a mean age 8.6 ± 2.54. Their mean knowledge score was 2.29 and 13.8% scored zero. In addition, 66.4% did not take their children to dentist except if there was a dental problem. The most significant factors affecting parental knowledge was maternal occupation and family income. Conclusion Parental dental knowledge and their behavior after their children dental experience were not satisfactory. Anticipatory guidance should be reinforced by oral health providers.

OBJECTIVE:Despite the documented utility of regionalized systems of pediatric specialty care, little is known about the actual use of such systems in total populations of chronically ill children. The objective of this study was to evaluate variations and trends in regional patterns of specialty care hospitalization for children with chronic illness in California.METHODS:Using California's Office of Statewide Health Planning and Development unmasked discharge data set between 1999 and 2007, we performed a retrospective, total-population analysis of variations in specialty care hospitalization for children with chronic illness in California. The main outcome measure was the use of pediatric specialty care centers for hospitalization of children with a chronic condition in California.RESULTS:Analysis of 2 170 102 pediatric discharges revealed that 41% had a chronic condition, and 44% of these were discharged from specialty care centers. Specialty care hospitalization varied by county and type of condition. Multivariate analyses associated increased specialty care center use with public insurance and high pediatric specialty care bed supply. Decreased use of regionalized care was seen for adolescent patients, black, non-Hispanic children, and children who resided in zip codes of low income or were located farther from a regional center of care.CONCLUSIONS:Significant variation exists in specialty care hospitalization among chronically ill children in California. These findings suggest a need for greater scrutiny of clinical practices and child health policies that shape patterns of hospitalization of children with serious chronic disease.

Background: Pediatric hospital medicine is the most rapidly growing site-based pediatric specialty. There are over 2500 unique members in the three core societies in which pediatric hospitalists are members: the American Academy of Pediatrics (AAP), the Academic Pediatric Association (APA) and the Society of Hospital Medicine (SHM). Pediatric hospitalists are fulfilling both clinical and system improvement roles within varied hospital systems. Defined expectations and competencies for pediatric hospitalists are needed. Methods: In 2005, SHM's Pediatric Core Curriculum Task Force initiated the project and formed the editorial board. Over the subsequent four years, multiple pediatric hospitalists belonging to the AAP, APA, or SHM contributed to the content of and guided the development of the project. Editors and collaborators created a framework for identifying appropriate competency content areas. Content experts from both within and outside of pediatric hospital medicine participated as contributors. A number of selected national organizations and societies provided valuable feedback on chapters. The final product was validated by formal review from the AAP, APA, and SHM. Results: The Pediatric Hospital Medicine Core Competencies were created. They include 54 chapters divided into four sections: Common Clinical Diagnoses and Conditions, Core Skills, Specialized Clinical Services, and Healthcare Systems: Supporting and Advancing Child Health. Each chapter can be used independently of the others. Chapters follow the knowledge, skills, and attitudes educational curriculum format, and have an additional section on systems organization and improvement to reflect the pediatric hospitalist's responsibility to advance systems of care. Conclusion: These competencies provide a foundation for the creation of pediatric hospital medicine curricula and serve to standardize and improve inpatient training practices. Journal of Hospital Medicine 2010;5(4)(Suppl 2):82–86. © 2010 Society of Hospital Medicine.

Most pediatric trauma patients are cared for in non-children's hospitals by providers without pediatric specialty training and in facilities that may not be used to caring for children. Children have different physiologic and psychologic responses to injury than adults. Children have different service and evaluative needs. Several studies have shown that pediatric trauma patients have improved outcomes with lower mortality, fewer operations, and improved function when cared for in pediatric facilities or adult trauma centers with pediatric expertise. Differences between injured adults and injured children need to be understood, recognized, and acted upon by care providers to optimize treatment for injured children. Limitations in the availability of pediatric specialists require that all hospitals be prepared to effectively and successfully treat pediatric trauma patients.