These slides have been presented at a meetings in Children's Mercy and around the world. They represent research that was done at the time they were created, and may not represent medical knowledge or practice as it exists at the time viewers access these slide presentations.>
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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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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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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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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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Implementation of a Transition Readiness Assessment and Transition Discussion Documentation in a Type 1 Diabetes Clinic
Sonalee Ravi
Background/Objective: Our institution utilizes a general transition readiness assessment to facilitate transition discussions. Patients rate six areas of knowledge, eight skills, and confidence in ability to transfer care successfully prior to age 22, then select a goal for their next visit. Discussions are documented in the medical record. Our aim was to implement this assessment with a 20% documentation rate after six months.
Methods: In March 2021, we trained providers and diabetes educators about the need for transition planning, the differences between transition planning and transfer, and the need for documentation. We added three diabetes-specific questions related to insulin adjustments, sexual function/pregnancy, and diabetes emergencies to the assessment tool. In April 2021, the transition assessment was implemented in clinic visits and all patients aged 17-years and older were asked to complete the assessment prior to their clinic visit. In June 2021, emails were jointly sent to providers and educators the Friday prior to visit indicating patients who needed transition assessments. Monthly data were pulled from the medical record that indicated percentage of eligible patients who had a documented discussion.
Results: Our clinic improved transition assessment documentation from 4.81% to 43.75% after six months. Conclusions: Our clinic successfully increased awareness and use of a general transition readiness assessment to guide transition planning. Future directions include utilizing clinic nurses to provide in-clinic reminders. We will also expand the assessment to younger ages to identify knowledge gaps and provide targeted education videos to improve self-management of diabetes and complete transfer of care.
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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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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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Congenital Abnormalities of the Lower Airways and Lungs
Christopher M. Oermann
Goals and Objectives. Participants will be able to: Describe the 5 stages of fetal lung development. Summarize the prenatal identification and management of congenital abnormalities of the lower airways and lung (CALAL). Explain the classification of CALAL. Compare the clinical characteristics, pathology, and management of common CALAL. Discuss the long-term prognosis of CALAL.
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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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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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Utilization of Enteral Tranexamic Acid To Stabilize Gastrointestinal Hemorrhage in Pediatric Patients on ECMO
Gina Patel, Jenna Miller, Thomas M. Attard, and Asdis Finnsdottir Wagner
Background:
Incidence and management of Gastrointestinal (GI) bleeding on ECMO isn’t well reported Patients on ECMO require systemic anticoagulation making GI bleeding difficult to manage We describe the use of enteral tranexamic acid (TXA) in two pediatric patients with GI hemorrhage on ECMO
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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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Characterization of Comorbidities in Patients with a Dual Diagnosis of Down Syndrome and Autism Spectrum Disorder Using Cerner Health Facts
Michael Slogic, Earl F. Glynn, Cy Nadler, Meredith Dreyer, and Sarah T. Edwards
Background: Up to 19% of patients with Down syndrome (DS) meet diagnostic criteria for autism spectrum disorder (ASD) (Channell, et al, 2019). While the medical and psychological comorbidities for patients with DS or ASD are well characterized, outcomes for patients with a dual diagnosis (DS-ASD) are poorly understood. Large DS-ASD cohorts and comparison samples are needed to fill this gap, as well as methods for grouping and analyzing complex diagnostic phenotypes. Objective: Our objective is to utilize Cerner Health Facts, a multi-institutional healthcare database, to identify large populations with DS, ASD, and DS-ASD, allowing for characterization and comparison of their ICD9/10 diagnoses. A secondary objective is the development of a higher order classification system based on ICD9/10 diagnoses to allow for identification of meaningful differences in body system dysfunction across populations. Design/Methods: Patients birth to 18 years with at least one encounter in Cerner Health Facts and diagnoses of ASD, DS, or both were identified. Medical and psychological diagnoses in the form of ICD9/10 codes were extracted and combined into phenotype codes (Denny, et al, 2013). Phenotype codes were then grouped by physiologic system into compound phenotypes. Prevalence rates for these compound phenotypes were then computed and compared across the DS, ASD, and DS-ASD samples. Results: 1,087 patients with DS-ASD, 22,862 patients with DS, and 98,979 patients with ASD were identified. Thirty-three compound phecode groupings were developed from 1,886 phecodes. As an example, 47.9% of DS-ASD patients were noted to have diagnoses in the Pulmonology/Sleep grouping, similar to those with DS. However, Pulmonology/Sleep diagnoses were over three times more prevalent compared to those with ASD. In the DS-ASD population, Neurologic/Musculoskeletal diagnoses were nearly 2.5 times more prevalent compared to those with DS, and over 1.75 times more prevalent when compared to those with ASD. Conclusion(s): Patients with DS-ASD had higher rates of a wide range of medical and psychological diagnoses compared to those with DS or ASD alone. The compound phenotype classification scheme is a viable method for comparing diagnoses between distinct populations, as well as aggregating differences to produce interpretable phenotypic trends. These trends can both inform clinical practice and provide the basis for future work, such as investigating the link between mortality and comorbidities in those with DS-ASD.
Presented at the 2021 PAS Virtual Conference
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Contraception counseling of adolescents seeking care in pediatric emergency departments
Cynthia Mollen, Romina Barral, Tara Ketterer, Jungwon Min, Laurel Gabler, Lauren Poole, Amber Adams, Elizabeth Miller, Aletha Akers, and Melissa K. Miller
Background: Efforts to increase contraceptive use among adolescents are urgently needed. One approach is to use clinical settings that do not routinely provide contraception services, such as the emergency department (ED). Though many are amenable to ED-based contraceptive care, best practices for providing this care are largely unexplored.
Objective: To assess intention to initiate contraception among adolescent females immediately after receiving ED-based contraceptive counseling, and to assess counseling feasibility, contraception initiation and completion of a follow-up visit for contraceptive care.
Design/Methods: Prospective cohort study in two urban pediatric EDs. Using webinar modules and in-person sessions, advanced practice providers (APPs) were trained to deliver brief contraception counseling. Through a patient-centered approach APPs discussed contraception type, same-day initiation and follow-up needs. Patients aged 15-18 years with any chief complaint were included if they were not currently pregnant and identified as high-risk for pregnancy (reported heterosexual sex within the last 6 months or likely future sexual activity, did not desire pregnancy, were not currently using hormonal contraception/copper intrauterine device). At the index visit we assessed demographics, feasibility of the counseling session (by both participant and APP) and intention to initiate contraception (5-point Likert scales), and contraception initiation/follow-up completion (assessed via medical record review and participant phone interview at 8 weeks post-index visit).
Results: We trained 27 APPs. 62 adolescents have completed study procedures; mean age was 16.6 years, and 26% were White, 55% Black, 16% Hispanic. Counseling lasted a mean of 12 minutes. APPs reported: counseling was easy to deliver (97%); sufficient time to complete the counseling (89%); and feeling competent to provide the counseling (89%). Most adolescents (94%) reported satisfaction with the counseling session. Half (53%) reported high intention to initiate contraception; 13 (21%) were prescribed contraception during the index visit. Seven (11%) completed a follow-up visit.
Conclusion(s): A brief contraception counseling session was feasible during a pediatric ED visit. The majority of those counseled expressed intention to initiate contraception, including some who initiated during the ED visit, but few followed-up after the ED visit. Further efforts to increase contraception access among sexually-active ED patients should include contraception initiation during ED visits.Presented at the 2021 PAS Virtual Conference
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Impact of COVID-19 on Inpatient Utilization and Outcomes for Children with Medical Complexity
Jessica L. Markham, Troy Richardson, Adrienne G. DePorre, Ronald Teufel, Adam Hersh, Eric Feegler, Ryan Antiel, Adam Goldin, Arda Hotz, Jayme Wilder, and Samir Shah
Background: Children with medical complexity (CMC) are a growing subpopulation of children who require intense engagement with the healthcare system including the involvement of multiple subspecialists and ancillary services. CMC often receive definitive care within children’s hospitals where subspecialty services are concentrated. While studies have reported reductions in emergency department visits and hospitalizations for generally healthy children during the COVID-19 pandemic, the overall impact of the pandemic on CMC has not been well described.
Objective: The objective of this study was to describe the impact of the early COVID-19 pandemic on inpatient utilization for CMC presenting to US children's hospitals.
Design/Methods: We performed a retrospective study of CMC using the Pediatric Health Information System. We examined trends in hospitalizations (total hospitalizations [inpatient or observation], length of stay [LOS], costs, and readmissions) overall and by All Patient Refined Diagnosis Related Groups (APR-DRG) in 2020 compared to 2017-2019. We then compared inpatient utilization and clinical outcomes during the COVID period (March 15 to May 29, 2020) to the same timeframe in the prior 3 years (pre-COVID period). Adjusted generalized linear mixed models were used to examine the association of the COVID period with inpatient utilization. All models included a random hospital effect to account for clustering of discharges at the same hospital.
Results: We observed changes in inpatient hospitalizations overall and by APR-DRG for CMC in 2020 compared to 2017-2019 (Figure 1). We identified 19,868 hospitalizations for CMC within our defined COVID period and another 95,575 hospitalizations for the corresponding pre-COVID period (mean: 31,858 hospitalizations per year). Total hospitalizations in the COVID period declined by a median (IQR) of 39.4% (32.6-44.4%) across hospitals. Of the top 10 most prevalent indications for hospitalization for CMC, 8 conditions experienced declines in hospitalizations during the COVID period (eg, hospitalizations for non-bacterial gastroenteritis declined 30.4%) while 2 conditions experienced increases (eg, hospitalizations for diabetes increased 10.7%) (Table 1). Overall outcomes during the COVID period including length of stay, readmission rates, cost, and mortality remained similar to the pre-COVID period (Table 2).
Conclusion(s): Similar to their non-complex peers, hospitalization volumes for CMC declined during the COVID period though hospital-level outcomes remained largely unchanged.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
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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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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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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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Neonatal Neurobehavior, Medical Risk, and 2-year Developmental Outcomes in Infants Born <30 Weeks>Gestation
Elizabeth McGowan, Marie Camerota, Julie A. Hofheimer, Michael O'Shea, Brian S. Carter, Howard Kilbride, Steven Pastyrnak, Charles R. Neal, Lynne Smith, Jennifer Helderman, Jennifer Check, Lynne Dansereau, Sheri A. DellaGrotta, and Barry Lester
Background: Among preterm infants, risk of poor outcomes has been linked to neonatal medical illness and neurobehavior. The combined contribution of neonatal medical morbidities and neonatal neurobehavior to 2 year outcomes has yet to be studied.
Objective: To determine associations between NICU Network Neurobehavioral Scale (NNNS) profiles, medical risk, and 2 year developmental outcomes.
Design/Methods: Multi-center study of 704 infants born <30 weeks gestation enrolled in the Neonatal Neurobehavior and Outcomes in Very Preterm Infants>(NOVI) Study. NNNS were completed prior to NICU discharge and six profiles of neonatal neurobehavior were calculated by latent profile analysis. Two profiles (5 and 6) were considered atypical. Medical risk included brain injury, CLD, ROP, and NEC/sepsis. Outcomes at 2 years were Bayley Scales of Infant and Toddler Development-III (BSID-III) composite scores and Child Behavior Checklist (CBCL) T-scores. Generalized estimating equation (GEE) models were used to test the associations among NNNS profiles, neonatal medical risk, and 2 year developmental outcomes. GEE models accounted for multiple births. Covariates were research site, maternal socioeconomic status (SES), race or ethnicity, maternal primary language, partner status, maternal psychopathology, and infant sex.
Results: Follow-up data were available for 556/704 (78.9%) infants, of which 157 (28.2%) were Profile 5-6. Mother of Profile 5-6 infants were more likely to be non-English speaking and lower SES compared to Profiles 1-4 mothers (Table 1). In a model that included both atypical NNNS and number of medical risks, each independently predicted cognitive and motor composite scores <1 >(mild delay) and <2 SDs>(moderate delay) below the mean (Table 2). Medical risk alone predicted language composite scores <1 SD. Atypical NNNS patterns alone predicted CBCL internalizing and total problems in the clinical range>(Table 2).
Conclusion(s): Neonatal medical risk remains a consistent concern for poor cognitive, language, and motor performance. Atypical neonatal neurobehavioral patterns predicted both adverse developmental outcomes and significant behavioral problems at 2 years, thereby offering an early predictive clinical tool to identify atypical neurobehavior and target NICU and post-discharge interventions.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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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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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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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