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  Parental Teach Back in the ED setting for Non-English Speaking Families

  Rohan Akhouri

  90 million Americans have low health literacy1.in Missouri 35% of adults have prose literacy at or below basic skill level2. Literacy, more specifically health literacy, is a modifiable social determinant of health that has a large impact on patient care and outcome. Poor health literacy in adults is associated with a higher number of ED visits and worse health outcomes3,4. Teach back is a method used in multiple pediatric and adult settings, shown to improve patient outcomes and comfort with discharge instructions5. There is limited data regarding teach back in non-English speaking patients and its efficacy with this group of patients. Our long-term goal is to address disparity in discharge education for non-English speaking patients in the Emergency Department with the use of the teach back method. Our central hypothesis is that using the “Teach Back” method with non-English speaking patients will improve patient medication compliance, and reduce return to ED. To test our central hypothesis and attain the overall objective, we will pursue the following specific aims: Aim 1. Use teach back with non-English speaking patients for discharge instructions. Our working hypothesis is that using teach back for non-English speaking patients will improve patient understanding of discharge instructions and reduce ED return times. We will complete surveys post-discharge with families via phone Aim 2. Measure patient compliance with medications after discharge. Our central hypothesis is that using teach back in the ED setting at discharge will improve patient medication compliance.

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  Spending on Public Benefit Programs and Exposure to Adverse Childhood Experiences

  Megan Collins, Matt Hall, P J. Chung, Jessica L. Markham, Jessica L. Bettenhausen, L M. Plencer, Molly Krager, Kathyrn Kyler, D Bard, Kayla R. Heller, Roxana Guggenmous, Jordan Keys, and Henry T. Puls

  Background: Adverse childhood experiences (ACEs) have been shown to be associated with poor health outcomes, and children living in poverty are more likely to experience ACEs. Our objective was to estimate the association between spending on benefit programs and cumulative exposure to ACEs among children. Methods: This cross-sectional study examined state and federal spending, at the state-level, on 5 categories of public benefit programs: cash, housing, and in-kind assistance; housing infrastructure; childcare assistance; refundable Earned Income Tax Credit; and Medical Assistance Programs (e.g., Medicaid). The primary exposure was median annual spending per person living below the federal poverty limit across 2010-2017 Federal fiscal years (i.e., one observation per state). The primary outcome was state-level percentage of children aged <18 years having ever been exposed to>≥ 4 ACEs, as reported in 2016-2017 National Survey of Children’s Health. Pearson correlations estimated unadjusted correlations. Linear regression models estimated associations after adjustment for states’ racial and ethnic demographics. A sub-analysis including only children 0-8 years of age was conducted to more closely focus on children who could have been first exposed to ACEs in the 2010-2017 Federal fiscal years. Results: Among the 51 states, a median of 6.3% of children (IQR: 5.2, 7.6) had exposure to ≥4 ACEs. Spending varied between states and was correlated with the percent of children with ≥ 4 ACEs (r= -0.41 [95% CI: -0.62, -0.15, p= 0.003]; Figure 1). Total spending on all benefit categories combined was associated with lower exposure to ≥ 4 ACEs (β coefficient= -0.11 [95% CI: -0.18, -0.04]; p= 0.005). This association suggests that for each additional $1000 spent per person living in poverty, there was an associated -0.7% point difference, or 496,379 fewer children accumulating ≥4 ACEs nationally. Increased spending in each individual benefit category was also associated with decreased reported ACEs exposure (Table 1, Figure 2; all p <0.05). Among children 0-8 years, greater average annual total spending as well as spending on cash, housing, and in-kind assistance; childcare assistance; and Medical Assistance Programs remained significantly associated with decreased reported ACEs exposure (Table 1). Conclusions: Average annual spending on benefit programs was associated with less cumulative exposure to ACEs. Investments in public benefit programs not only decrease childhood poverty but may also have broad positive effects on near- and long-term child well-being beyond the programs’ stated objectives.

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  Rates of Physical Abuse Screening and Detection in Infants with Brief Resolved Unexplained Events (BRUEs)

  Angela Doswell, James Anderst, Joel Tieder, Henry T. Puls, and BRUE Research and Quality Improvement Network

  Background: “Apparent Life-Threatening Events” (ALTEs) have been associated with child physical abuse (CPA). In 2016, “Brief Resolved Unexplained Event” (BRUE) and the development of its clinical guidelines and risk-stratification replaced ALTE. However, it is unknown if there is a similar association between BRUEs and CPA. Hypothesis/Objectives: To determine the rate of CPA in infants presenting with a BRUE, examine differences between infants with and without CPA, and to examine rates of diagnostic testing used to detect CPA. Methods: This study was part of the BRUE Research and Quality Improvement Network, composed of 15 hospitals. Subjects were infants presenting with BRUE in emergency department or inpatient settings. Subjects were followed from BRUE presentation through the first year of life for possible diagnosis of CPA at either initial BRUE or subsequent presentations. The primary outcome was CPA diagnosis at either initial BRUE or subsequent presentations. CPA was the only maltreatment type identified. The secondary outcomes were minor evidence of trauma and diagnostic testing used to detect CPA (head imaging, skeletal survey, and/or liver transaminases) at initial BRUE presentation. Chi-square tests assessed for differences. Results/Conclusion: Of the 2036 infants presenting with a BRUE, 7 (0.3%) were diagnosed with CPA, 5 of whom had findings consistent with abusive head trauma (AHT). Only 1 infant was diagnosed with CPA (cutaneous injury) at initial BRUE presentation (<0.1%). For the remaining cases, 1 infant was diagnosed with AHT within 3 days, 1 with AHT and cutaneous injury within 31-60 days, 1 with abusive fractures within 31-60 days and 3 with AHT more than 60 days after initial BRUE presentation. Infants diagnosed with CPA were more likely to be White (85.7% vs. 48.3%, p<0.05), to exhibit color change (100% vs. 51.1%, p=0.01) and have minor evidence of trauma (14.3% vs. 0.3%, p<0.001) at initial BRUE presentation. There was no difference between CPA diagnosis and BRUE risk stratification. There were 7 (0.3%) infants with minor evidence of trauma: 1 was diagnosed with CPA, 3 were iatrogenic, 1 birth-related and 2 multiple yet nonspecific minor traumas. Of all infants, only 6.2% underwent head imaging, 7% skeletal survey, and 12.1% liver transaminases. Skeletal survey was more likely to be performed if there was minor evidence of trauma (42.9 vs. 6.9%, P <0.001) or a concerning social history (13.9% vs. 5.9%, p <0.05). Head imaging was more often performed if infants had minor evidence of trauma (71.4% vs. 6.0%; p< 0.001), family history of sudden unexplained death (10.2% vs. 6.3%; p= 0.047) or concerning social history (22.8% vs. 5.4%; p< 0.001). There was a lower rate of CPA in infants at initial BRUE presentation (<0.1%) than in infants with ALTE, although testing rates at initial BRUE presentation were also low. Minor evidence of trauma and other clinical features appeared to raise suspicion and initiate diagnostic testing to detect CPA. Further research is warranted to systematically identify and diagnose infants with BRUE at increased risk for CPA.

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  Examining Diagnostic Variability Among Pediatric Subspecialists in Case Examples of Infant Head Injury

  Angela Doswell, Emily Killough, James Anderst, Timothy Zinkus, and Ashley Sherman

  Background: Clinical presentation, imaging, and ophthalmologic findings are important factors in distinguishing between noninflicted and abusive head trauma (AHT) in infants. However, little is known about agreement between pediatric subspecialists regarding diagnosis and timing of AHT in infants. Hypothesis/Objects: The primary outcome was differences in rates of AHT diagnosis among different types of pediatric subspecialists using case examples of infant head injury. The secondary outcome was qualitative trends in clinical reasoning related to injury timing. Methods: Four case examples of infant head injury were developed into an online survey. Cases were categorized as: (1) “bilateral mixed density subdural hemorrhages (SDHs)”; (2) “hyperdense right/interhemispheric SDH”; (3) “bilateral SDHs with membranes”; and (4) “hyperdense right SDH”. Each case assessed diagnosis regarding infant head injury, likelihood of AHT diagnosis, and timing of head injury given clinical presentation, laboratory, neuroradiology, and ophthalmologic findings. Participants evaluated at least 1 possible case of AHT during their career and identified as being a part of 1 (or more) of the following 5 pediatric subspecialties: Child Abuse Pediatrics (CAP), Pediatric Emergency Medicine (PEM), Pediatric Critical Care (PCC), Neurosurgery (NS) and Pediatric Hospital Medicine (PHM). The response selected by most CAPs was the reference and compared across subspecialties using Chi-square or Fisher’s exact tests. Bonferroni corrections were used to determine statistical significance. Qualitative responses were coded individually, with more frequent responses being grouped into such categories as clinical presentation (i.e., symptoms, labs, or other information provided in clinical vignette), neuroimaging findings (i.e., SDH characteristics) and ophthalmologic findings (i.e., presence and/or type or retinal hemorrhages). Results/Conclusion: A total of 288 participants completed at least 1 case. Roughly 26.7% of participants were CAPs, and 64% of participants reported evaluating at least 26 cases of possible AHT during their careers. For case 1, 100% of CAPs diagnosed AHT with no significant difference detected across subspecialties (100% PEM, 83.3% PCC, 100% NS, and 97.1% PHM diagnosed AHT). For case 2, 57.9% of CAPs did not diagnose AHT, but significantly fewer PHM (34.9%, p=0.0061), PEM (28.0%, p<0.0001) and NS participants (24.0%, p=0.0033) did not diagnose AHT. For case 3, 72.2% of CAPs diagnosed AHT with no significant difference detected across subspecialties (73.6% PEM, 66.7% PCC, 80.8% NS, and 84.1% PHM diagnosed AHT). For case 4, 39.4% of CAPs reported uncertainty with AHT diagnosis, with no significant difference detected across subspecialties (34.8% PEM, 50.0% PCC, 42.3% NS, and 34.3% PHM reported uncertainty with AHT diagnosis). In case 1, most participants reported neuroimaging findings as most helpful with injury timing. In cases 2 through 4, most participants reported clinical presentation as most helpful with injury timing. Statistically significant diagnostic variability across pediatric subspecialties was detected in only 1 case example of infant head injury; however, variability persisted across the 3 remaining cases. Further research and/or education regarding the determination of AHT diagnosis and timing of infant head injuries is warranted to aid in the medical decision-making process and decrease diagnostic variability.

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  Implementation of Longitudinal Learning Curricula Results in Improved ITE Scores and ABP Certifying Examination Pass Rates

  Angela Etzenhouser, Emily Killough, and Danielle Reed

  OBJECTIVE: To improve In-Training Examination (ITE) Scores and American Board of Pediatrics (ABP) Certifying Examination pass rates, our program implemented two longitudinal learning curricula; the objective of this study was to evaluate the effectiveness of these curricula. BACKGROUND: In 2018, we developed the “ITE Study Plan” which requires participation for residents whose ITE score falls below the national average. Residents develop a study plan that incorporates a minimum of 10 PREP questions per week along with any additional learning modalities they wish to utilize. Progress and compliance with the study plan is monitored monthly by an Associate Program Director. In 2019, the program implemented the Structured Independent Learner Curriculum (SILC), based on the work of Dr. Kris Rooney at Lehigh Valley Reilly Children’s Hospital. The SILC curriculum is required for all residents in the program and consists of earning “credits” for completing various board-relevant learning objectives each month. For lighter rotations, 6 credits per month are required. For more time-intensive months, 3 credits per month are required. Residents obtain credits for required learning such as conference attendance, online modules, and presentation of Morning Report. Additional credits can be earned according to the resident’s learning preferences and include online questions, articles, and podcasts. METHODS: In-Training Exam scores, ABP Certifying Exam scores, and ABP pass rates were tracked over a five-year period. Program scores were compared with the mean scores of all programs published with the ITE and ABP score reports. RESULTS: Since implementation of these two measures, our program has seen increased compliance with conference attendance and rotation requirements, a 330% increase in completed PREP questions, and an incremental rise in ITE scores above national means for both second- and third-year residents. ITE scores for interns remained stable over the study period. The program also saw an increase in ABP Certifying Examination pass rates, including in 2021 when nationally ABP pass rates were significantly lower. CONCLUSION: Implementation of longitudinal learning curricula improves both In-Training Examination Scores and American Board of Pediatrics Certifying Examination pass rates while reinforcing habits of life-long learning.

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  Assessing Early Use and Complications of Gastrostomy Blended Feeds

  James Fraser, Shai Stewart MD, Kristen L. Sayers, Amy L. Pierce, Beth A. Orrick, Kayla B. Briggs, Wendy Jo Svetanoff, Tolulope A. Oyetunji MD MPH, Shawn D. St Peter, and Richard J. Hendrickson

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  Improving Antibiotic Durations for Skin and Soft Tissue Infections in Pediatric Urgent Care Clinics

  Megan Hamner, Amanda Nedved, Holly Austin, Donna Wyly, Alaina N. Burns, Brian Lee, and Rana El Feghaly

  Background: Skin and soft tissue infections (SSTIs) are the second most common diagnosis leading to pediatric antibiotic prescriptions in the outpatient setting after respiratory diagnoses. However, most antibiotic stewardship programs have mainly focused on respiratory diagnoses. Children seen in the ambulatory setting for SSTIs often receive >7 days of antibiotics, although current society guidelines recommend 5-7 days for most diagnoses. Objective: To increase the percentage of patients receiving 5-7 days of oral antibiotics for SSTIs from 58% to 75% by December 31st, 2021, in pediatric urgent care clinics (UCCs). Design/Methods: We formed a multidisciplinary team in April 2020. We completed cause-and-effect analyses and developed a driver diagram (Figure 1). Plan-Do-Study-Act (PDSA) cycle 1 provided an update on current guidelines for UCC providers. PDSA cycle 2 modified the electronic health record to display antimicrobial order sentences from shortest to longest duration. PDSA cycle 3 provided project outcome and balancing measure updates to UCC providers at regular intervals. We created a monthly report of patients 90 days and older seen in UCCs with a final diagnosis of SSTIs including impetigo, abscesses, cellulitis, erysipelas, folliculitis, paronychia, and animal bites. Our outcome measure is the percentage of patients receiving 5-7 days of oral antibiotics for SSTIs. Process measure is the percentage of prescriptions selected from a folder. Balancing measure is the number of patients returning for SSTI within 14 days of their visit. Results are displayed using an annotated control chart. Results: The percentage of patients receiving 5-7 days of oral antibiotics during the baseline period (June 2019-June 2020) was 58%. After project initiation in April 2020, this increased to 68%, and consistently increased following PDSA cycles to a sustainable rate of >80% (Figure 2). A total of 1,971 UCC visits were included in the analysis. Process measure revealed less than 10% of providers utilize prescription folders. There was no change in balancing measure numbers. Conclusion: Prior to our project, only 58% of children seen in pediatric UCCs for SSTIs received the recommended antibiotic duration. By addressing primary drivers uncovered through QI methodology, we surpassed our goal of 75%. Additional PDSA cycles are planned along with expansion to other departments. This work will allow us to expand antibiotic stewardship efforts to other infectious diagnoses as well.

  Presented at 2022 PAS Conference; Denver, CO; April 2022.

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  Financial Outcomes by Severity Across Children's Hospitals

  Jonathan Hartley, Jessica L. Bettenhausen, Matt Hall, James Gay, David C. Synhorst, and Jessica L. Markham

  Background: Hospitalizations represent a significant driver of healthcare costs for children. Little is known about how payor type and the severity of children cared for on the pediatric medical inpatient floor impact a hospital’s financial outcomes. Objective: The primary objective of this study is to compare financial outcomes of pediatric hospitalizations to the medical inpatient floor across patient severity quartiles. Secondary objectives included financial outcomes stratified by payor type across severity quartiles. Methods: Retrospective cohort study included children aged 0-18 years discharged during calendar year 2019 from hospitals that reported clinical information to the Pediatric Health Information System database and financial data to the Revenue Management Program (Children’s Hospital Association, CHA). We excluded newborns, surgical and OB admissions, children requiring PICU or NICU, and transfers in and out. We calculated the ratio of reimbursements to costs (CCR; CCR <1.0 represents a financial liability to hospitals) and compared the CCR across severity quartiles and by payor type. A net margin median was calculated as median reimbursement minus median costs. Severity was determined using the Hospitalization Resource Intensity Score for Kids (H-Risk). Results: This study included 163,656 children within 14 children’s hospitals. Patients were divided equally among four quartiles of H-Risk with quartile 1 being the least severe and quartile 4 the most. The majority of patients had a public payor (54.4%). As severity increased the number of children with chronic complex conditions increased (CCC; 6.8% with 1 or greater CCC for quartile 1 and 78.7% for quartile 4) and length of stay increased (a geometric mean of 1.4 days for quartile 1 and 3 days for quartile 4). Overall, the CCR was 1.1 across all payors and severity levels representing a slight positive margin. Among private payors the CCR varied from 1.6 to 1.7 across severity quartiles which resulted in a median net positive margin $2,544 in quartile 1 and $7,855 in quartile 4. Among public payors the CCR varied from 0.7 to 0.8 across severity quartiles which resulted in a median net negative margin of ($1,404) in quartile 1 and ($905) in quartile 4. Conclusions: Net financial outcomes varied substantially by payor. Utilizing the CCR in conjunction with the patient severity may inform payment models and hospital operations, such as staffing models and patient placement, to ensure financial solvency.

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  Financial Outcomes by Severity Across Children's Hospitals

  Jonathan Hartley, Jessica L. Bettenhausen, Matt Hall, David C. Synhorst, Jessica L. Markham, and James Gay

  Background: Hospitalizations represent a significant driver of healthcare costs for children. Little is known about how payor type and the severity of children cared for on the general pediatric inpatient floor impact a hospital’s financial outcomes. Objective: The primary objective of this study is to compare financial outcomes of pediatric hospitalizations to the general floor across patient severity quartiles. Secondary objectives included financial outcomes stratified by payor type across severity quartiles. Methods: Retrospective cohort study included children aged 0-18 years discharged during calendar year 2019 from hospitals that reported clinical information to the Pediatric Health Information System database and financial data to the Revenue Management Program (Children’s Hospital Association, CHA). We excluded newborns, surgical and OB admissions, children requiring PICU or NICU, and transfers in and out. We calculated the ratio of reimbursements to costs (CCR; CCR <1.0 represents a financial liability to hospitals) and compared the CCR across severity quartiles and by payor type. Severity was determined using the Hospitalization Resource Intensity Score for Kids (H-Risk). Results: This study included 287,658 children within fourteen children’s hospitals. Patients were divided among four quartiles of H-Risk with quartile one being the least severe and quartile four the most. The majority of patients were in quartile one (55.5%) and had a public payor (54.4%). As severity increased the number of children with chronic complex conditions increased (CCC; 19.5% with 1 or greater CCC for quartile one and 88.5% for quartile four) and length of stay increased (a geometric mean of 1.8 days for quartile one and 11.3 days for quartile four). Overall, the CCR was 1.1 across all payors and severity levels representing a slight financial gain. Among private payors the CCR varied from 1.5 to 1.7 across severity quartiles. The median net financial gain ranged from $2,496 in quartile one to $37,257 in quartile four. Among public payors the CCR varied from 0.7 to 0.8 across severity quartiles. The median net financial loss ranged from $1,893 in quartile one to $22,513 in quartile four. Conclusions: Not unexpectedly, the financial gains and losses were higher for patients in higher severity quartiles. However, the net gain or loss varied substantially by payor. Utilizing the CCR in conjunction with the patient severity and payor mix may inform payment models and hospital operations, such as staffing models and patient placement, to ensure financial solvency.

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  Outpatient Emergency Preparedness

  Mary Haywood

  It is commonly believed that medical emergencies do not present to general pediatric offices. However, it has been estimated that 0.9-42 emergencies per office site/year occur. The most common presentations are respiratory in nature. However, children can also present with dehydration, seizure, psychiatric or behavioral complaints. Despite this, most offices are not prepared to handle these presentations for various reasons. Multiple studies have showed that preparedness in inpatient settings is improved with education, implementation, or protocols and deliberate practice with mock codes. However, there have been few studies in the outpatient setting. One study utilized simulation as a tool to improve preparedness in an outpatient setting. This study hopes to improve outpatient preparedness as well as identify latent safety threats in the outpatient setting by utilizing rapid cycle simulation in clinics around the Kansas City area.

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  Get SMART: Implementation of Updated Asthma Guidelines for Pediatric Hospitalists

  Alexander Hogan, Kathyrn Kyler, and Claire Seguin

  Prescription of Single Maintenance And Reliever Therapy (SMART) for moderate and severe persistent asthma is the most important and actionable improvement in the National Heart Lung Blood Institute (NHLBI) asthma guidelines for pediatric hospitalists. SMART is the use of a single inhaled corticosteroid/long acting beta agonist inhaler both as a daily preventive inhaler and as-needed for asthma symptoms. As hospitalists, we treat patients with poorly controlled asthma who will benefit from SMART asthma action plans. Despite ample evidence supporting use of SMART, implementation of such large changes in practice is challenging. Implementation science and quality improvement principles can be used to anticipate barriers and plan effective frameworks for increasing use of new guidelines in practice. Through work at our own institutions, we have identified common barriers to implementing the new SMART guidance. While no single solution is likely to lead to widespread uptake, multi-pronged efforts can support adoption of this practice change. In this session, we will review the new NHLBI asthma guidelines relevant to pediatric hospitalists, focusing on when and how to use SMART for our patients with asthma. Using historical experience in implementation of other care guidelines, we will discuss implementation barriers that have been described and may apply to SMART. We will share the experience with SMART at our own institutions and tools used for inter-disciplinary guideline dissemination and SMART implementation. Our goal is to aid attendees in creating organized changes in local practice. Attendees will receive an actionable toolkit to bolster efforts in implementation of SMART at their institutions. This toolkit will include quality improvement and implementation tools useful for targeting institution-specific barriers and tracking progress of SMART use.

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  Patient Attitudes, Perceptions, Knowledge, and Beliefs Regarding Immigration Status in the Healthcare Setting

  Anik Patel

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  Reducing alarm burden by promoting judicious ordering of continuous pulse oximetry

  Kathleen Berg, David Johnson, Ginny Nyberg, Andrew Ausmus, Christine Claeys, Emily Wilkinson, and Nicholas Clark

  Background: Overutilization of continuous pulse oximetry (CPO) contributes to overdiagnosis and prolonged supplemental oxygen utilization. It may also negatively impact patient sleep, mobility, length of stay (LOS), and cost. Response times to actionable alarms increase with the number of non-actionable alarms. Our baseline data revealed an average of 29.6 pulse oximetry monitor alarms sounded for each admitted patient each day of their hospitalization. Most notably, 38.7% of pulse oximetry alarms were for ≥88% which is generally considered non-actionable.
  
  Objective: We aimed to decrease both total pulse oximetry alarms per patient day and alarms for ≥88% per patient day by 20%, each by September 2020.
  
  Design/Methods: This single-center quality improvement study included patients admitted to inpatient pediatric units from January 2019 to September 2020. Those in intensive care or cardiology units were excluded. Process measures were 1) percentage of patients with CPO order and 2) percentage of LOS with CPO orders in place. Outcome measures were 1) total pulse oximetry alarms per patient day and 2) alarms for ≥88% per patient day. Frequencies of high acuity transfers to intensive care and code blue events without CPO ordered served as balancing measures. Plan-Do-Study-Act cycles included: 1) changing default alarm limits from <90% to <88%, 2) changing pulse oximetry order default to intermittent rather than continuous monitoring, and 3) requiring selection of an indication for CPO from a new list within the order. Statistical process control charts monitored improvement.
  
  Results: Our project included 18,080 patients. Process measures of percentages of patients with CPO order and of LOS with CPO order in place decreased by 29.9% (44.2% to 31.0%; Fig 1) and 29.2% (45.2% to 32.0%; Fig 2), respectively. Outcome measures of total pulse oximetry alarms and alarms ≥88% per patient day decreased by 37.2% (29.6 to 18.6; Fig 3) and by 54.0% (12.4 to 5.7; Fig 4), respectively. Balancing measures were unchanged.
  
  Conclusion(s): Change in default pulse oximetry alarm limits was associated with decreased pulse oximetry alarms, particularly of non-actionable alarms. Changes to pulse oximetry order defaults and requirements impacted provider ordering behavior with subsequent decrease in frequency and duration of CPO orders, but had a lesser impact on alarms. Such system-level changes may be applied to reduce non-actionable cardiorespiratory monitor alarms and further reduce overall alarm burden and fatigue.

  Presented at the 2021 PAS Virtual Conference

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  Neurodevelopmental profiles of infants born < 30 weeks' gestation at 2 years of age

  Marie Camerota, Elisabeth C. McGowan, Julie A. Hofheimer, T. Michael O'Shea, Brian S. Carter, Jennifer Helderman, Jennifer Check, Charles R. Neal, Steven L. Pastyrnak, Lynne Smith, Cynthia Loncar, Stephen Sheinkopf, Lynne Dansereau, Sheri A. DellaGrotta, and Barry Lester

  Background: Infants born (PMA) are at increased risk for neurodevelopmental impairment by age 2. Prior studies have tended to examine individual outcomes separately, rather than investigating whether there are subgroups of children with distinct neurobehavioral profiles.
  
  Objective: To determine distinct neurodevelopmental profiles in 2 year old children born cognitive, language, motor, and behavioral characteristics.
  
  Design/Methods: NOVI (Neonatal Neurobehavior and Outcomes in Very Preterm Infants) is a multi-center study of infants born (BSID-III) subscale scores, Child Behavior Checklist (CBCL) syndrome scores, diagnosis of cerebral palsy (CP; Gross Motor Function Classification System and abnormal neurologic exam), and positive screen for autism spectrum disorder (ASD risk; Modified Checklist for Autism in Toddlers, Revised, with Follow-Up [MCHAT-R/F]). Latent profile analysis (LPA) was applied to these measures to group children into mutually exclusive profiles.
  
  Results: Follow-up data were available for N=587/704 (83%) infants. LPA model selection statistics (e.g., Bayesian information criterion [BIC]) were used to identify a four-profile solution (Table 1; Figure 1). Children in profiles 1 (black) and 2 (blue) exhibited the best outcomes at age 2 (e.g., highest Bayley; lowest CBCL scores). Children in profile 3 (red) had the lowest Bayley scores, whereas children in profile 4 (purple) had the highest CBCL scores. Rates of CP diagnosis and ASD risk were highest in profiles 3 and 4 and lowest in profiles 1 and 2. About one-third (27%) of children were classified in one of the atypical profiles (3 or 4).
  
  Conclusion(s): We identified four qualitatively different neurodevelopmental profiles ofcognitive, language, motor, and/or behavioral impairment. The study of profiles offers a nuanced “whole child” approach to understanding outcomes for children born very preterm.

  Presented at the 2021 PAS Virtual Conference

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  Neonatal Gut Microbiota Alterations and Local Inflammation Induced by Escherichia coli Infection are Modified by Lactobacillus rhamnosus Prophylaxis

  Susana Chavez-Bueno, Hao Xuan, Shahid Umar, Concong Zhong, Wei Yu, and Venkatesh Sampath

  Background: E. coli is a leading cause of neonatal sepsis. Newborns ingest E. coli, which transcytoses the gut producing bacteremia. Lactobacillus spp. decrease E. coli gut transcytosis but the mechanisms involved in this protective effect are not well understood.
  
  Objective: To determine the effects of Lactobacillus pretreatment on the intestinal microbiota and inflammation in neonatal rats orally infected with E. coli.
  
  Design/Methods: Newborn rats were orally pretreated on day of life (DOL) 1 and 2 with four doses of 107 colony forming units (CFU) of Lactobacillus rhamnosus GG (LGG) or PBS. On DOL 2, pups received orally 106 CFU of neonatal E. coli bacteremia strain SCB34 or PBS. On DOL 7, distal colon with stool were collected for 16S sequencing. AbundantOTU+ was used to generate de novo operational taxonomic units (OTUs). Observed, ACE, Shannon, and Simpson indices were used for alpha diversity. Bray-Curtis and Jaccard indices were used for beta diversity. Linear discriminant analysis effect size (LEfSe) was used to determine differences at the genus level. Expression of ICAM-1, GRO1, Toll-like receptor 4 (TLR4), and Single-Immunoglobulin Interleukin-1 Related Receptor (SIGIRR) was measured in ileal homogenates by real-time PCR.
  
  Results: Phyla distribution clearly distinguished the SCB34-infected experimental groups (Fig. 1). We also observed greater alpha diversity in the SCB34-infected groups (Fig. 2; A-D). Bray-Curtis analyses showed differences in microbial abundance between the groups receiving LGG pretreatment vs. PBS prior to SCB34 infection. However, the microbial composition of these two groups was similar per Jaccard index (Fig. 2; E-F). LEfSe results showed greater abundance of Lactobacillus in both SCB34-infected groups, and surprisingly, lower abundance of Escherichia-Shigella genera in these groups compared to controls (Fig. 3; A, B). LGG pretreatment produced a significant decrease in anaerobes including Clostridium, Romboutsia and Veillonella (Fig. 3; C-E). LGG prophylaxis significantly suppressed expression of ICAM-1, GRO-1 and TLR4, while inducing the TLR4-inhibitor, SIGIRR (Fig. 4).
  
  Conclusion(s): LGG pretreatment significantly modified clinically relevant microbiota features of neonatal pups orally infected with E. coli, and attenuated E. coli-induced intestinal inflammation. Harnessing these relevant mechanisms afforded by probiotics such as LGG will provide novel preventive and therapeutic interventions against gut-derived neonatal sepsis.

  Presented at the 2021 PAS Virtual Conference

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  The Association Between Age and Unrecognized and Untreated Hypertension in Children with Chronic Kidney Disease

  Chloe Douglas, J Roem, Joseph Flynn, Susan Furth, Bradley A. Warady, and Susan Halbach

  Background: Younger age has been associated with unrecognized hypertension (HTN) in both the general pediatric population and in children on dialysis. An increased lifetime risk of cardiovascular disease and the association of HTN with chronic kidney disease (CKD) progression make optimal treatment of elevated blood pressure (BP) a key component of CKD management. However, the role of age in the recognition and treatment of HTN in non-dialysis pediatric CKD remains unknown.
  
  Objective: Using data from the Chronic Kidney Disease in Children (CKiD) Cohort Study, we examined the relationship between age and recognized vs. unrecognized HTN, and the frequency with which stages I and II HTN are pharmacologically treated. Among children with unrecognized HTN, we also examined the relationship between age and rates of uncontrolled BP.
  
  Design/Methods: Subjects included children <18 years of age with CKD stages>2-4, for whom BP measurements were available. Subjects were stratified by age (0 to <7 >years, ≥7 to <13 >years, ≥13 to ≤18 years) and BP readings were classified by percentile per AAP clinical guidelines. Unrecognized HTN was defined as HTN stage 1 or 2 based on clinic BP measurement without a self-reported diagnosis of HTN. Uncontrolled BP was determined by self-reported lack of antihypertensive treatment among those with HTN. Generalized estimating equations to account for repeated measures were applied to logistic regression analyses to evaluate the associations of age with unrecognized HTN and medication use.
  
  Results: 890 CKiD Study participants with 3,442 annual study visits met inclusion criteria. Children <7 years of age had higher rates of stage 1 or 2 HTN and lower rates of antihypertensive use compared to older children>(Table 1). 46% of children age <7 years with hypertensive BP readings had>unrecognized, untreated HTN compared to 21% of hypertensive children >13 years of age. The youngest age group was associated with higher odds of unrecognized HTN (adjusted OR 2.03) and lower odds of taking antihypertensive medication (adjusted OR 0.48). With the exception of glomerular disease etiology of CKD, other covariates were not associated with unrecognized HTN.
  
  Conclusion(s): Children with CKD younger than age 7 years are more likely to have both underdiagnosed and undertreated HTN compared to older children. Given the impact of hypertension on CKD progression and cardiovascular disease, efforts to improve BP control in these young children are needed.

  Presented at the 2021 PAS Virtual Conference

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  BMI and Associated Variables in A Pediatric Gender Clinic Sample

  Mirae J. Fornander, Christine Moser, Anna Egan, and Timothy A. Roberts

  Background: Studies of transgender/gender diverse (TGD) youth indicate a high prevalence of overweight/obesity and concern for unhealthy weight control behavior.
  
  Objective: Describe BMI and the association of medication use, well-being, and recreational activities in treatment-naïve pediatric TGD patients.
  
  Design/Methods: Chart review of 302 patients (age 3-19, 73.5% sex assigned at birth (SAB) female; 85.8% white) from 2017-2020. BMI was calculated by age and SAB using CDC growth charts. Parents reported medication use; parent and self-reported Pediatric Quality of Life (PEDS-QL) Well-Being and activities were surveyed electronically.
  
  Results: By BMI category, 3.3% were underweight (BMI<5%); 49.4% were >85% and 29.5% fell >95%. Overweight and obesity rates were higher than national norms (31.2% >85%; X2=45.92, p<.01; 16.4% >95%; X2=37.11, p< .01). BMI Z-scores varied by SAB (Female M=0.91, SD=1.18; Male .54, 1.32; F(1, 300)=5.2, p<.05). PEDS-QL parent-reported well-being was a significant predictor of BMI (b=-.018, p<.01, R2=.059); an increase in well-being predicted a decrease in BMI. Parent-reported activities (i.e., participation in performing arts/debate, social/advocacy groups, exercise); creative arts involvement was associated with BMI >85% (M=1.49, .89, t=2, p<.05). Self-reported activities (i.e., creative arts, performing arts/debate, academics, exercise, games, spending time with family/friends, social advocacy); watching/listening to media was associated with BMI >85% (M=1.38,.79, t=3.63, p<.01). Conversely, spending time with friends and family was associated with average BMI (M=.63, 1.04, t=-2.09, p<.05). Medications were used by 55% of patients; gastrointestinal (M=1.91, .77, t=7.69, p< .01), anti-emetic (M=2.29, .78, t=13.12, p< .01), anxiolytic (M=1.43, .79, t=3.11, p<.01), diabetes (M=2.12, .79, t=2.44, p<.01), endocrine (M=1.88, .79, t=1.97, p<.05), mood stabilizer (M= 1.67, .77, t= 2.71, p<.01), norepinephrine/dopamine reuptake inhibitor (M=1.69, .80, t=4.01, p<.05), and SSRI/SNRI (M=1.04, .72, t=2.05, p<.05) were associated with BMI >85%.
  
  Conclusion(s): Obesity is a common problem among TGD youth presenting for gender affirming care. Female SAB, lower well-being, involvement in sedentary recreational activities, and taking medications to treat gastrointestinal, endocrinologic, or psychiatric conditions were associated with elevated BMI. Spending time with family and friends was protective. Providers should address high BMI. TGD youth should be encouraged to decrease sedentary activities and improve connection with friends and family.

  Presented at the 2021 PAS Virtual Conference

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  Umbilical Access in Laparoscopic Surgery in Infants less than 3 months: Single Institution Retrospective Review

  James Fraser, Kayla B. Briggs, Wendy Jo Svetanoff, Rebecca M. Rentea, Pablo Aguayo, David Juang, Jason D. Fraser, Charles L. Snyder, Richard J. Hendrickson, Shawn D. St Peter, and Tolulope A. Oyetunji

  PURPOSE: Umbilical access in laparoscopic surgery has been cited as a potential factor for increased complications in low birth weight infants and those less than three months old. Previous series noted a self-reported complication rate of 10.6% among 329 pediatric surgeons via anonymous survey, citing carbon dioxide (CO2) embolism as the most common complication. We report four-year outcomes with blunt transumbilical laparoscopic access to examine the safety of this technique. METHODS: Following IRB approval, a retrospective database of patients less than three months of age who underwent laparoscopic pyloromyotomy or inguinal hernia repair from 2016-2019 at a tertiary care academic center was reviewed. Operative reports, anesthesia records, post-operative documentation, and postoperative telephone calls were reviewed for complications related to umbilical access. Complications included bowel injury, bleeding umbilical vessels, umbilical vein cannulation, CO2 embolism, umbilical surgical site infection (SSI), umbilical hernia requiring repair, and death. RESULTS: Three hundred sixty-five patients met criteria for analysis (Table 1); 246 laparoscopic pyloromyotomy and 119 laparoscopic inguinal hernia repairs. Median age at operation was 5.9 weeks [4.3,8.8] and median weight was 3.9 kg [3.4,4.6]. Median operative time was 20 minutes [15,28]. Nine complications occurred for a total complication rate of 2.5%; 5 umbilical SSIs (1.4%), 1 bowel injury upon entry requiring laparoscopic repair (0.2%), 1 umbilical hernia requiring repair at 22 days after surgery (0.2%), and 2 cases of severe hypotension and bradycardia upon insufflation that resolved with exsufflation (0.5%). There were no intraoperative mortalities and no signs or symptoms of CO2 embolism. CONCLUSIONS: In this series umbilical access in laparoscopic surgery in neonates less than three months of age and less than 5kg was safe, with minimal complications.

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  Neonatal DNA methylation as a predictor of cognitive, language, and motor performance at 24 months adjusted age, among children born very preterm

  Stefan Graw, Marie Camerota, Brian S. Carter, Jennifer Helderman, Julie A. Hofheimer, Elizabeth C. McGowan, Charles R. Neal, Steven Pastyrnak, Lynne Smith, Michael O'Shea, Barry Lester, Carment Marsit, and Todd M. Everson

  Background: Infants born prematurely are at increased risk for neurodevelopmental impairments during childhood and early neurodevelopment can be influenced by multiple factors (perinatal and environmental exposures, genetics). DNA methylation (DNAm) can also be influenced by these factors and be reflective of health and development, and thus may provide an integrated measure of early life risk for neurodevelopmental outcomes.
  
  Objective: To test whether neonatal DNAm is predictive of cognitive, language, and/or motor performance at 24 months of age in children that were born very preterm.
  
  Design/Methods: We studied 433 neonates born < 30 weeks postmenstrual age in the Neonatal Neurobehavioral Outcomes in Very Preterm Infants (NOVI) study. Neonatal DNAm was measured from buccal swabs at NICU discharge via the Illumina MethylationEPIC BeadArray. Cognitive, motor, and language performance were assessed by the Bayley Scales of Infant and Toddler Development-III (BSID-III) at 24 months adjusted age, with mild and moderate impairment defined as composite scores < 85 and < 70. We used an elastic net regression and leave-one-out cross-validation to limit overfitting and selection bias, to identify sets of DNAm sites that were predictive of composite Bayley scores. For the leave-one-out cross-validation, a model was trained on all but one sample to make a prediction on that held-out sample. This step is repeated until each sample was held out and predicted once. In addition, for a given hold-out sample, all siblings were removed from its training set. The performance of predicted composite scores were evaluated by their correlation with the measured Bayley scores and the area under the receiver operating characteristic (ROC) curve (AUC) based on dichotomized Bayley scores (< 85 and < 70).
  
  Results: We identified sets of DNAm sites (including 33-306 sites) that predicted composite scores for the BSID-III at 24 months of age, which were positively (r>0.3) and significantly (p-value <1e-11) correlated with reported scores (Figure 1A-C). Additionally, neonatal DNAm at these sites was predictive of mild cognitive (AUC=0.68), language (AUC=0.71), and motor impairments (AUC=0.66) (Figure 1D-F), and yielded similar predictive statistics for moderate impairments.
  
  Conclusion(s): DNAm patterns measured at NICU discharge were indicative of cognitive, language, and motor performance at two years of age, among children born very preterm.

  Presented at the 2021 PAS Virtual Conference

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  Getting Back on Track with Cancer Prevention and Adolescent Immunizations

  Sharon Humiston

  Objectives:

  1.Explain why HPV vaccine is important enough to be routinely recommended for young people (i.e., HPV cancer prevention).

  2. Give an HPV vaccination recommendation that is effective and succinct using the same way, same day approach to the introduction of HPV vaccine.

  3. Answer the most frequently asked questions about HPV vaccine accurately and succinctly.

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  HPV Cancer Free: Adolescent Vaccination

  Sharon Humiston

  Objectives:

  1. Explain why HPV vaccine is important enough to be routinely recommended for young people (i.e., HPV cancer prevention).

  2. Give an HPV vaccination recommendation that is effective and succinct using the same way, same day approach to the introduction of HPV vaccine.

  3. Answer the most frequently asked questions about HPV vaccine accurately and succinctly.

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  Reimagining Bioethics Curricula: Centering Antiracism, Diversity, Equity, and Inclusion

  Shika Kalevor, Marie-Laura Allirajah, Isabella Hernandez, and Phoebe Ozuah

  As bioethicists, we engage with social, political, and health care systems that all center on relationality. Part of our responsibility in occupying space within these systems is recognizing where bias, power, and privilege lie, and how our positionality can either contribute to or take away from progress toward a morally conscious society. Bioethicists have the opportunity to remediate preventable harms and address issues of equity, justice, diversity, and oppression. We can also address these issues as core to our growing knowledge base. From our own experiences as bioethics students from multidisciplinary backgrounds, we know that these topics are not sufficiently addressed within academia or they are considered peripheral subjects. Educational institutions can play a role in instituting systemic change, intentional anti-racist practices, and more inclusive frameworks that confront the systems of oppression which contribute to health inequity.Many institutions of higher education released statements committing to address racism and white supremacy in the wake of the pandemic and racial reckoning of 2020. An academic curriculum that reflects these commitments as core to burgeoning bioethicists is a method of action against historical injustice that informs health disparity in care, outcomes, and experiences of the most marginalized.Our purpose is to examine what is included and what is excluded as core learning across three Master of Bioethics programs in the United States. In doing so, we aim to encourage institutions to begin a conversation about the creation of curricula that reflect our priorities as a field moving forward in this new landscape.

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  Obesity does not increase risk for kidney replacement therapy (KRT), but weight reduction improves kidney function in children with chronic kidney disease (CKD)

  Amy Kogon, J Roem, Mark Mitsnefes, Babette Zeme, Bradley A. Warady, Susan Furth, and Nancy Rodig

  Background: Obesity is prevalent in pediatric CKD, but its impact on CKD progression is unclear.
  
  Objective: To determine the relationship between obesity/weight changes with CKD progression among children and adolescents enrolled in the Chronic Kidney Disease in Children (CKiD) study.
  
  Design/Methods: Participants were categorized based on body mass index (BMI) as normal, overweight (OW) or obese and those who were underweight were excluded. Kaplan-Meier survival curves and parametric failure time models determined the association of baseline BMI category on time to KRT stratified by non-glomerular (NG) and glomerular (G) etiology of CKD. The distribution of changes in BMI categories within sequential visit pairs (e.g., obese to OW or OW to normal BMI) and the effect of a one-unit change in BMI category on the annualized change in estimated glomerular filtration rate (eGFR) were determined. Three separate regression models were used for participants with NG and G CKD; each model included all pairs of visits with the same BMI category at the initial visit. Generalized estimating equations, adjusted for age, sex, race, proteinuria and hypertension, were used to account for repeated visit pairs within the same participant.
  
  Results: 160 (27%) of 600 children with NG and 77 (31%) of 246 children with G CKD progressed to KRT. At baseline, 15% of children with NG CKD and 26% of children with G CKD were obese. Times to KRT did not associate with baseline BMI category (Figs 1 and 2). For most, BMI category did not change over time (Figure 3). For those with NG CKD who did not change weight category, there was a similar annualized eGFR change for those who were normal weight, OW and obese. A hypothetical participant with NG CKD who is a 10-year old non-Black female without nephrotic range proteinuria and hypertension and remains obese within a pair of visits has an average annualized eGFR change of -1.0% (95% CI: -3.7%, 1.7%); similar to -1.3% (95% CI: -3.7%, 1.2%) and -0.7% (95% CI: -1.8%, 0.5%) for those who remain OW or normal weight, respectively. Among those with NG CKD who were obese, each decrease in BMI category over time was associated with a concurrent 3.7% increase (95% CI: 0.8%, 6.5%) in annualized eGFR. In those with G CKD, there was no significant difference in annualized change in eGFR by weight category or category change (Fig 4).
  
  Conclusion(s): Baseline obesity does not affect time to KRT, but weight loss in those who are obese may improve kidney survival.

  Presented at the 2021 PAS Virtual Conference

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  Medicaid Expenditures Among Children with Documented Obesity

  Kathyrn Kyler, Matt Hall, Jessica L. Bettenhausen, Sarah Hampl, and Ann M. Davis

  Background: Obesity rates continue to rise among children, but knowledge regarding spending patterns of Medicaid enrollees with documented obesity are lacking.
  
  Objective: We aimed to describe Medicaid expenditure patterns and determine the degree to which specific clinical characteristics and conditions contribute to high expenditures among children with obesity.
  
  Design/Methods: We performed a retrospective cross-sectional analysis of children aged 2-17 years with a diagnosis code (ICD-10) for obesity continuously enrolled in the nationally-representative 2017 Medicaid Marketscan database. Expenditures were measured as median per member per year (PMPY) spending and categorized based on prior literature from low to high PMPY expenditure groups: <80th%, 80-<95th%, 95-<99th%, and ≥99th%. Inpatient, outpatient, and pharmacy expenditures were analyzed. Covariates included demographic factors, common obesity co-morbid conditions (e.g., hypertension), number of complex chronic conditions (CCCs), and number of mental health conditions. Chi square tests were used to compare PMPY spending across expenditure groups and logistic regression analyses were used to measure demographic and clinical characteristics associations for patients in the high spending groups (≥95th%).
  
  Results: We identified 300,286 children with a diagnosis of obesity. Children aged 12-17 years, of non-Hispanic white race/ethnicity, with obesity comorbid conditions, at least 1 CCC, or mental health condition were most likely to be in the highest spending group. (Table 1). The highest overall median PMPY spending was from inpatient and outpatient therapy and treatment ($6,018 and $800, respectively). Mental health therapy and treatment drove the PMPY spending in the higher spending groups (≥99th% group $16,471) (Table 2). Characteristics found to be associated with being in the higher spending groups included: age 12-17 years, having an obesity comorbid condition, having ≥ 1 CCC and mental health condition, with these associations increasing considerably as the number of CCCs or mental health conditions increased (Table 3).
  
  Conclusion(s): Inpatient and outpatient mental health expenditures made up a large proportion of spending among Medicaid-enrolled children with obesity. Important drivers of cost in this population included having obesity comorbid conditions and mental health conditions. Future research is needed to determine if some of these costs are avoidable in children with obesity.
  

  Presented at the 2021 PAS Virtual Conference

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  Lessons From the Pandemic: How a Children’s Hospital Responded to the Challenges of COVID-19

  John Lantos, Paul Kempinski, Laurie Ellison, Jennifer Watts, and Angela Myers

  The COVID-19 pandemic challenged doctors and hospital administrators as did no other event in our lifetimes. Leaders needed to develop a pandemic command structure with the agility to respond to rapidly evolving situations. They had to deal with drastic financial implications, develop new methods of delivering health care, and collaborate regionally. They learned the importance of communication with staff, policy makers, the local medical community, and the public. They had to allocate of scarce resources internally and externally, and balancing rational policy making against irrational fears. For children’s hospitals, some specific challenges included determining our role in a pandemic that predominately affected adults, doing research on the unique pediatric manifestations of disease, and dealing with questions about schools and daycare. In this workshop, leaders from hospital administration, infectious disease, and disaster preparedness will review and analyze some of our experiences and responses at a large quaternary care children’s hospital. We will use specific events and decisions to illustrate the unique challenges and our retrospective analysis of whether we could have done better. The goal of the interactive workshop is to learn together from our collective experience in order to be better prepared for future events.

  Learning Objectives:

  1. Describe the mechanisms that were put in place to respond to the emergent demands of the pandemic

  2. Analyze options that were available to decision makers regarding specific choices, the reasons for the choices that they made, and downstream implications of those choices

  3. Speculate about preparedness for the next phase of this pandemic, or the next major crisis.

  Presented at the 2021 PAS Virtual Conference