Clinical Pediatrics

While influenza vaccination in the prior year is a strong predictor of subsequent vaccination, many families do not have static vaccination patterns. This study examined factors guiding influenza vaccination decisions among parents whose children sporadically received the influenza vaccination (flu-floppers). We administered surveys to 141 flu-flopper families. Surveys included 21 factors associated with vaccine decision making. A conceptual framework of “passive” and “active” decision making was used to assess parental motivators behind vaccine decisions. The most common reason for vaccinating was a desire to prevent influenza (45%). The most common reason for not vaccinating was a belief that influenza vaccination is not effective (29%). Most parents (88%) reported an active reason in years when their child was vaccinated, while only 43% reported an active reason when their child was not vaccinated (P < .00001). These findings may guide efforts to increase influenza vaccination rates in children most amenable to vaccination.

The American media often disseminates antivaccination messages. Cinema in particular reaches many individuals and influences attitudes regarding high-risk behaviors such as smoking and alcohol use. We hypothesized that negative cinematic portrayals of immunization have increased over the last 3 decades. Films released in the United States featuring immunization through 2016 were identified on IMDb and viewed in their entirety by 2 reviewers. Themes were recorded, and the portrayal of immunization (positive, negative, or mixed) across each decade was assessed in a logistic regression model. Cultural references attributed to films (eg, television references) were recorded from the “connection” feature on IMDb. Fifty relevant films were identified (1925-2016). Negative/mixed portrayals of immunization were more frequent after 1990 (odds ratio = 4.0, 95% confidence interval = 1.2-13.5), and films with positive immunization portrayals garnered significantly fewer cultural references than films with negative/mixed portrayals (mean = 9.2 vs 56.2, P = .048). American cinema features increasingly negative portrayals of immunization.

Summer camps have a unique supervisory environment that may lead to increased head injury risk for children. The epidemiology of head injuries in camps is unclear. We partnered with CampDoc.com to review head injury reports from camp nurses in 2016 from 197 camps in 36 states. A total of 4290 (92%) reports were coded as definite head injuries, 47% (n = 2002) in female campers, with median camper age of 10 years. Head injury severity was coded as mild (94%, n = 4040), moderate (6%, n = 248), or severe (<1%, n = 2). Only 3% (n = 134) were medically evaluated, and 29% (n = 1221) were sports-related. Head injuries were categorized as definite (3%, n = 137) and probable (13%, n = 572) concussions, with 39% (n = 277) being sports-related and 61% (n = 83) of definite concussions incurred by female campers. Summer camps, while an important location of head injury risk, appear to be a safe environment for youth.

Iron poisoning was a leading cause of pediatric morbidity and mortality. We sought to assess whether the removal of strict iron packaging requirements in 2003 resulted in an increase in iron-related morbidity and mortality in pediatric exposures. We performed a retrospective cohort study utilizing the National Poison Data System from 2000 to 2017. A total of 4110 exposures met inclusion criteria: 847 from before (2000-2003) and 3263 after removal of unit-dose package regulations (2004-2017). The incidence of any marker of severity (7.2% vs 3.8%; odds ratio = 0.51, 95% confidence interval = 0.37-0.69) and frequency of deferoxamine use were both higher in the early time period (2.6% vs 1.0%; odds ratio = 0.38, 95% confidence interval = 0.22-0.66). There was no difference in the frequency of key serious effects (acidosis, elevated transaminases, hypotension). Despite removal of iron packaging regulations in the United States, there continues to be a decrease in the incidence of severe iron exposures in children.

Disadvantaged children often show disparities in early language development. We tested the feasibility, acceptability, and preliminary efficacy of introducing finger puppets in the primary care setting at the 2-month well visit to support caregivers talking with their infants. Caregivers completed a sociodemographic survey and were contacted by phone 2 weeks later to assess initial usage and satisfaction. Ages & Stages Questionnaires (ASQ-3) were independently recorded at well visits. A family cumulative risk score was calculated from the sociodemographic survey. Thirty-four caregiver-child pairs were enrolled. Caregivers reported high satisfaction with the intervention. ASQ-3 Communication and Total scores at 6, 12, and 18 months were significantly higher for high puppet users across all age levels with no significant interactions with age or cumulative risk. Finger puppets provide a low-cost way to promote language-rich interactions. Preliminary evidence suggests that high puppet usage may have long-lasting effects on child development and should be further evaluated.

Pediatric health care providers are in a unique position to discuss the health implications of alcohol, tobacco, and drug use with adolescents and young adults (AYAs) with type 1 diabetes (T1D). This study evaluated the frequency of self-reported substance use and associated demographic and clinical characteristics in a sample of AYAs with T1D and patient-provider discussions of substance use in T1D care. Sixty-four AYAs completed questions about substance use from the Youth Risk Behavior Survey (YRBS). Corresponding diabetes clinic visits were audio-recorded, transcribed, and reviewed to examine substance use discussions. A total of 56.3% of AYAs reported ever engaging in substance use; 40.6% reported substance use within the past 30 days. Five AYAs had discussions about substance use during their most recent diabetes clinic visit. Substance use should be proactively addressed by pediatric health care providers and AYAs should be encouraged to raise questions related to substance use during clinic visits.

The objective of this study was to determine if the use of weight-based criteria to screen for asymptomatic hypoglycemia is consistent with using percentile curves to determine small and large for gestational age status. A retrospective chart review of 892 term infants in the normal nursery was performed. The degree of agreement in screening recommendations between weight-based criteria and the Lubchenco, Oken, and Olsen percentile curves was determined using Cohen’s κ and McNemar’s test. Agreement was lower between Lubchenco and Olsen or Oken (0.470, 0.509, respectively) than with weight-based criteria (Lubchenko = 0.532; Oken = 0.566; and Olsen = 0.582). Weight-based criteria recommended screening 12% and 7% fewer patients than Lubchenko and Oken, respectively (P < .001), but was equally likely to screen infants as Olsen (P = .579). Simple weight-based criteria for asymptomatic hypoglycemia screening can identify infants at risk for hypoglycemia in a manner consistent with current guidelines.

Our objective was to evaluate the risk of short stature in children with attention-deficit/hyperactivity disorder (ADHD) and the effect of ADHD and its treatment on height-for-age z score (HAZ) and body mass index–for-age z score (BMIZ) in early childhood. We evaluated 7603 children from the Early Childhood Longitudinal Study–Kindergarten Cohort 2011 and found that children with ADHD had lower HAZ at second and fourth grades and lower BMIZ at K to fourth grade. Children with ADHD at fourth grade had almost 4 times higher odds of short stature. Children with ADHD at K grew at a slower rate from K to fourth grade (difference in ΔHAZ = 0.23, 95% confidence interval = 0.04-0.42) and had less gain in BMI (difference in ΔBMIZ = 0.16, 95% confidence interval = 0.03-0.29). Longer duration of ADHD medication use was associated with lower HAZ at fourth grade and slower growth from K to fourth grade. These data may assist pediatricians in considering risk of poor growth in children with ADHD.

This article provides recommendations for adapting the pediatric medical home (PMH) model for health care needs of youth in foster care. Recommendations are based on key informant interviews regarding experiences at an established PMH for youth in foster care. Major clinic recommendations include expanding the PMH framework to include proficiency in Medicaid billing, promoting true interdisciplinary care teams, improving care accessibility via phone consultation, providing a stable place for medical records to be housed, delivering services throughout stages of the child welfare case, incorporating all family members, and implementing trauma-informed practice. Preliminary evidence suggests that the PMH model of care may be ideal for addressing the complex and often underserved needs of youth in foster care and their families. The present recommendations provide a logistical framework for establishing a clinic that thoughtfully considers the unique needs of this population. Future research is needed to examine best practices for implementation.

This retrospective chart review compared the length of stay (LOS) of families with limited English proficiency (LEP) versus English-speaking families seen in 3 pediatric urgent care centers (PUCCs). Visits were included for patients aged 2 months to 17 years seen between January 1, 2016, and December 31, 2016, with 1 of 5 primary diagnoses. For each LEP encounter, we randomly selected 3 English-speaking encounters within the same PUCC and diagnosis class. We compared overall LOS between LEP and English-speaking encounters. Of our entire sample, 184 (1.03%) were LEP encounters, of which 145 (78.8%) preferred Spanish. Comparing the LEP visits to 552 matched English-speaking visits, we found a significant difference in average LOS (LEP 85.5 minutes; English-speaking 76.4 minutes) and in prescriptions provided (P = .005) but not in triaged acuity nor number of medications administered, laboratory or radiological studies, or suction treatments. This study serves as a starting point to better care for patients/families with LEP in PUCCs.

The American Academy of Pediatrics recommends pediatric providers routinely screen for, assess, and treat substance use and substance use disorders among adolescents, a process called “Screening, Brief Intervention, and Referral to Treatment,” or “SBIRT.” Because there are limited data on how Maryland pediatric practices have adopted SBIRT, a quality improvement initiative was developed within the Maryland Adolescent and Young Adult Health Collaborative Improvement and Innovation Network using a “Plan/Do/Study/Act” approach. A 2-part provider training was conducted regarding screening and motivational interviewing, and the “CRAFFT” screening tool was integrated into the practice’s electronic medical record. Results from evaluation demonstrated significant improvements in provider knowledge, attitudes, and screening behavior. The association between substance use and sexual behavior suggests a need for further expansion of this model with inclusion of sexual health screening. Overall, this study demonstrates that SBIRT implementation into a general pediatric practice is highly feasible, acceptable, and shows preliminary effectiveness.

Background. Testicular torsion is a common surgical emergency in children that requires a high index of suspicion, early diagnosis, and exploration. Most children present early to their primary pediatricians or physicians. The aim of this retrospective study is to determine the surgical outcome of testicular torsion with early as well as delayed presentation or referral at our pediatric surgical unit. Methods. Records of 50 patients who presented with testicular torsion at our pediatric surgical unit over the span of 10 years (2007-2017) were reviewed retrospectively. The duration and characteristics of symptoms, initial consultation with primary care health professional, time duration between the initial consultation and referral to a tertiary care center, clinical findings prior to surgery, and operative findings were noted. Results. Fifty patients were in the age group ranging from 38 days to 18 years. All the patients consulted the primary care health professionals within 3 to 6 hours after the onset of testicular pain. The patients presented to our hospital within the range of 3.5 hours to 10 days of onset of initial symptoms. Out of 50 patients who presented to our hospital with torsion testis, 45 (90%) patients underwent orchidectomy as the testicle was gangrenous and 5 patients underwent orchiopexy as the testicle was viable. Conclusion. The risk of testicular loss is very high if there is delay in the initial diagnosis of testicular torsion. Greater effort in educating the primary health care professionals may reduce this delay. Primary objective of treating the acute scrotum should be prevention of testicular loss than treating symptoms.

Nationally recommended universal lipid screening (ULS) in children aged 9 to 11 years is low. Little is known about parents’ understanding of screening. We conducted a survey exploring parental knowledge and attitudes regarding ULS. Of 91 parent respondents, 81.3% were female, 69.2% were non-Hispanic white, 90.1% had a college/graduate degree, and 63.7% had a family history of abnormal cholesterol. Overall, 45.5% agreed that ULS should be done for all children, 30.8% disagreed, and 23.1% were unsure. Parents’ support for ULS was significantly associated with their attitudes toward screening rather than their knowledge about cholesterol, family history of cardiovascular disease or abnormal cholesterol, age, race/ethnicity, or gender. Parents were less likely to agree that ULS should be done if they thought that cholesterol screening should be done based on a child’s health or family history rather than for all children (P < .001), or if they thought that cholesterol screening was unnecessary (P < .001).

Adolescents with diabetes are at increased risk for depression and anxiety, which when untreated negatively affects diabetes control. During a 6-month period, the Patient Health Questionnaire for Depression and Anxiety (PHQ-4) screening tool was utilized. Those with a positive screen then completed the Patient Health Questionnaire for Adolescents (PHQ-A) and the Generalized Anxiety Disorder 7-item (GAD-7) scale. In this article, we report on the correlations in outcomes between the PHQ-4 and the PHQ-A and GAD-7 and its clinical utility for determining the need for standard versus acute behavioral health care. Over 6 months, 77 patients aged 10 to 18 years screened positive on the PHQ-4. Thirty-two patients had positive screening with the PHQ-A and/or the GAD-7. Thoughts of self-harm were reported by 13 (40%), with 1 experiencing current/active symptoms. The PHQ-4 as a screening tool was able to identify adolescents with symptoms of depression and/or anxiety who would benefit from further evaluation by a behavioral health provider.

Pediatricians caring for patients with child abuse or neglect (CABN) may experience secondary traumatic stress (STS) from traumatized patients, or burnout (BO) from workplace stress. This may be buffered by compassion satisfaction (CS), positive meaning from one’s work. For this study, STS, BO, and CS specific to a pediatrician’s care of CABN were assessed for residents, hospitalists, intensivists, and outpatient physicians. Using the Professional Quality of Life Scale modified for CABN experiences, participants (n = 62) had a mean STS score at the 84th percentile, a mean BO score at the 66th percentile, and a mean CS score at the 17th percentile. Reporting one CABN patient as most emotionally impactful predicted STS, caring for all types of CABN predicted BO, and perceived knowledge no longer predicted CS when adjusting for the experience of mandated reporting or CABN fatality. These results highlight the need to support pediatricians involved with CABN.

Incongruent vaccination rates have been found in multiple US cities, one cause possibly being misleading information that is easily available on the internet through text and videos. Health care providers should be aware of the extent and content of online health information available to patients and their guardians to enhance the effectiveness of patient-physician communication. This study obtained data on vaccine-related YouTube videos and analyzed the videos’ content. When misleading information was found in a video, the timing and specific type of misleading information was noted. More than two thirds of the YouTube videos contained some type of unreliable information regarding vaccine safety and effectiveness. Much of the information accessible to patients and parents vaccinating their children is misleading to a potentially dangerous extent. Health care providers should be aware of and able to provide clear counter-evidence to misleading information on YouTube in light of the findings.

Our objective was to assess the association between cigarette smoking and tobacco use screening and advising to quit use by a clinician among adolescents nationwide. We also examined the relationships between smoking and health-related indicators and health care utilization. A secondary analysis of the 2017 National Survey on Drug Use and Health was conducted (N = 11 884). Ever smokers were less likely to be screened for tobacco use. Current smokers and those who were nicotine dependent were more likely to have been advised to quit use. Ever and current smokers were significantly more likely to report good/fair/poor health status, illness-related school absenteeism in the past 30 days, and were more likely to have had an emergency department visit or an overnight hospital stay. Standardized tobacco control efforts are needed in health care settings to support clinicians to screen all adolescents for tobacco use and advise every smoker irrespective of smoking frequency to quit use.

Aim and Objectives. To describe the patient characteristics, clinical-epidemiologic-microbiologic profile, and treatment outcomes, and to draw attention to tuberculosis (TB) in Turkey. Methods. A retrospective, descriptive study was undertaken of 93 children aged 0 to 18 years who were admitted to Hacettepe University Pediatric Pulmonology Department for treatment from January 2005 to December 2015. Review of hospital records was performed for all children diagnosed as having TB. Results. Pulmonary TB was detected in 51.6% of the patients, extrapulmonary involvement in 33.3%, and pulmonary TB with extrapulmonary involvement in 15.1%. The history of contact with an adult with TB was found in 29% of cases. The most common extrapulmonary TB was TB lymphadenitis. The most common symptom was cough followed by fever and night sweats. One fifth of the patients had normal physical examinations at the time of diagnosis. One fifth (20.4%) of the patients had culture, 17.2% had polymerase chain reaction, and 15% had acid-resistant bacillus positivity. In 21.4% of patients with culture growth, at least one anti-TB drug resistance was found. The mean duration of treatment of patients treated according to the national guideline was 8.6 months (range = 6-36 months). Recovery was seen in 91.4% of patients. Conclusion. The most important way to prevent childhood TB is to fight adult TB through early diagnosis and effective treatment. The presence of contact history must direct us to search for TB. While evaluating children with persisted nonspecific symptoms, TB must be kept in mind even if physical examinations are normal.