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Purpose: The purpose of this DNP project was to increase primary care providers' knowledge of food insecurity in pediatric patients by developing and presenting an evidence-based educational presentation on food insecurity. Background: In the United States in 2021, rates of food insecurity in households with children were reported at 6.1 million. Research suggests that food insecurity can lead to undernutrition, inhibit full growth potential, and permanently impair cognitive development. The American Academy of Pediatrics (AAP) recommends universal screening for food insecurity. Identifying food-insecure households is crucial in promoting connection to nutritional resources that aid in countering pediatric malnutrition and its resulting adverse health outcomes. The review of the literature for this project suggests a need for consistent screening and identification of food insecurity in the pediatric population. Methods: This quality improvement (QI) project used a quantitative pretest, evidence-based educational online presentation, and posttest to evaluate the pediatric primary care provider's (PCP) knowledge of food insecurity in the pediatric population. A follow-up survey was collected two weeks after the presentation inquiring about intent to implement in future clinical practice and barriers the participants may have faced. This project was completed online via Microsoft Sway for the delivery of education and Microsoft Forms for collecting data from the pretest, posttest, and follow-up survey. Data were analyzed using descriptive statistics and paired t-tests. Results: Results showed an increase (23%) in the mean of the test scores from pretest to posttest. Although the data analysis of the results of this project were not statistically significant (p=0.14), the sample size limitation does not exclude the possibility of the occurrence of type II error. Responses from the follow-up survey completed two weeks after the education revealed that participants (n=4) felt knowledge was gained from the presentation and found that 50% of the participants planned to screen for food insecurity in their clinical practice. Conclusions: This project highlighted the need for screening for food insecurity in the pediatric primary care setting. Future studies on providers knowledge of food insecurity in the pediatric patient should include recruitment of a larger sample size to assess effectiveness of the education. [The dissertation citations contained here are published with the permission of ProQuest LLC. Further reproduction is prohibited without permission. Copies of dissertations may be obtained by Telephone (800) 1-800-521-0600. Web page: http://www.proquest.com/en-US/products/dissertations/individuals.shtml.]

Children today are confronted by a wide variety of stressful and traumatic events that may be overwhelming or may hinder their ability to cope and heal in a timely manner before reaching adulthood and becoming effective members of society. Child life specialists are academically trained professionals with expertise in helping children and their families cope with life's challenging events and navigate stressors from healthcare experiences to child welfare experiences. The American Academy of Pediatrics (AAP) and other professional associations have recognized the importance of child life professionals in meeting the psychosocial needs of children and youth in times of healing and crisis, yet there has been little understanding and awareness of child life as a discipline. This research addresses the child life profession and the discipline from an academic perspective as well as its existence as a public good to generate awareness and acknowledgement of it as an essential profession for infants, children, youth, and their families. Limited research has demonstrated a basic knowledge of the value discipline in healthcare and non-healthcare settings; however, there is a lack of research on child life academic programs and their function within higher education. A qualitative research approach was selected as the most appropriate methodology. In doing a case study of a child life academic program, a university that met my criteria was selected to collect my data, which consisted of (a) interviewing 20 participants associated with the university's academic program, (b) observing activities, and (c) reviewing artifacts. Findings demonstrated how the research questions were answered in terms of a child life curriculum designed for community engagement and the academic program existing as a public good. Additional discoveries detailed the tensions that surfaced between the profession and society. Participants' passion for the child life profession was evident through the interview conversations, as was the significance of a child life education in moving the discipline forward and engaging with the community for advancement. The connection between academic presence, the professional practice, and the community exposed the idea that the interdependence of the three were critical for not only the public good, but also for the future of the child life sub-discipline to move to the place where it is no longer considered a shadow discipline. [The dissertation citations contained here are published with the permission of ProQuest LLC. Further reproduction is prohibited without permission. Copies of dissertations may be obtained by Telephone (800) 1-800-521-0600. Web page: http://www.proquest.com/en-US/products/dissertations/individuals.shtml.]

This practicum report describes the development and implementation of a course focused on development of problem-solving skills within a master's program in occupational therapy in pediatrics. The 12-week course was designed to teach students the use of appropriate occupational therapy intervention strategies through the use of case studies and problem-based learning methods. The course included a didactic portion and a clinical fieldwork portion. Structured laboratory experiences occurred weekly. The 12 students in the course determined and directed some of their own learning and laboratory experiences and participated in self-assessment and peer review. Following the course, evaluation data revealed that the students felt more comfortable treating children and youth and were confident in their ability to plan appropriate therapy interventions. They were able to locate the necessary resources needed to meet the unique needs of each patient and could apply problem-solving skills to determine solutions to patient problems with more ease. Students, faculty, and clinical supervisors reported that students were more self-directed in their learning. A faculty, peer, and self-assessment form is appended. (Contains 34 references.) (DB)

Background. Investment in health information technology (HIT) is rapidly accelerating. The absence of contextual or situational analysis of the environment in which HIT is incorporated makes it difficult to measure success or failure. The methodology introduced in this paper combines observational research with time-motion study to measure the impact of new HIT on clinician workflow. Objectives. The purpose of this research is the investigation of nurse workflow before and after the implementation of video care delivery in a telephone care delivery setting. The aims are achieved using a sequential mixed methods protocol that explores the workflow of telephone and video care delivery and uses this information to describe the consequences and measure the efficiency of the two delivery modes. Methods. The first phase is a qualitative exploration of nurse workflow in which ethnographic data is collected from nurse informants at a large, urban general pediatrics clinic. The qualitative data is analyzed within the framework of distributed cognition to identify the activity and interaction themes of telephone and video care delivery. The qualitative themes are connected to the quantitative protocol by developing a data collection instrument for the second phase of the protocol: a time-motion study comparing the time (efficiency) of telephone and video care delivery. Qualitative and quantitative results are merged to identify the consequences of adding video care delivery to nurse workflow. The mixed methods protocol is applied to two settings within the general pediatrics clinic: triage office and care coordination office. Results. The workflow of both triage and care coordination are distributed across time, space, persons and artifacts. In both settings, the primary workflow task is coordinating an episode of care and the primary interactions occur with providers, parents and the electronic medical record. The impact of video care delivery on nurse workflow differs between the two settings. In the triage office, adding video care delivery to the existing workflow is disruptive, requiring significantly more time than telephone care delivery. Despite the disruptive effect, triage nurses rate video care delivery as more useful than telephone. In the care coordination office, video care delivery is a standard component of the workflow. It is not disruptive to nurse workflow and does not require significantly more time than telephone care delivery. Applying the mixed method protocol in similar settings provides initial validation for evaluating the impact of new HIT on nurse workflow. Conclusion. Analyzing the quantitative time-motion data within an interpretive framework provides insight into the consequences of new HIT. Adding video to an existing triage workflow results in positive and negative consequences that increase the time spent on workflow tasks. Video facilitates new interaction and communication patterns with parents and children that allow triage nurses to visually supplement and verify their "telephone" assessment, a positive consequence. The internal network architecture creates unpredictable video transmission errors that cause frequent waiting and video care delivery troubleshooting, a negative consequence. Including video as a standard component of the care coordination workflow has a neutral effect on the time of workflow tasks. Video care delivery supports the proactive interactions and increased nurse scope of practice of care coordination provided by an advanced practice nurse. Use of the mixed methods protocol to evaluate other HIT is a necessary step to ensure the methodologies transferability and applicability for use in meta-analysis. [The dissertation citations contained here are published with the permission of ProQuest LLC. Further reproduction is prohibited without permission. Copies of dissertations may be obtained by Telephone (800) 1-800-521-0600. Web page: http://www.proquest.com/en-US/products/dissertations/individuals.shtml.]

Perimetry is essential to identify visual field defects in disorders of the visual pathways. In compliant adults, automated static perimetry (ASP) is the preferred method of visual field assessment. However, children under 10 years have difficulty with the visuo-motor task and constant fixation required. Manual kinetic perimetry is often used for children as it can be adapted to a child’s age. However, it suffers from many of the problems inherent to ASP. In infants perimetry is limited to the “confrontation” technique which can be imprecise and does not generate quantitative data. The lack of reliable ASP in children and quantitative perimetry in infants is a longstanding clinical problem. The aims of this research were to (i) develop, and (ii) clinically evaluate, a technique for ASP in children which utilises “eye tracking”. The first part of this research was concerned with the development of the technique, termed “Saccadic Vector Optokinetic Perimetry” (SVOP). The system comprises a personal computer, display screen, and an X50 eye tracker (Tobii Technology, Sweden). The eye tracker is noncontact and provides data on (i) eye position in 3D space, and (ii) the point of gaze. This allows the screen position of “test stimuli” to be calculated, and eye gaze responses to the “test stimuli” to be assessed in “real time”. A software algorithm was developed to determine if “test stimuli” have been perceived based on the direction, amplitude and latency of a subject’s gaze response. A feasibility study was conducted with 29 subjects comprising 4 groups: (i) healthy adults, (ii) healthy children, (iii) adult patients with visual field defects, and (iv) child patients with visual field defects. Subjects performed SVOP tests which replicated the Humphrey Field Analyser (HFA) C-40 screening test with a stimulus size of Goldmann III and intensity of 14dB. Subjects able to do so also performed equivalent HFA C-40 tests for comparison. In healthy subjects 99.1% of SVOP test points were in agreement with a healthy visual field. In patients with visual field defects, 89.8% of test points were in agreement with HFA equivalent tests. The visual field defects identified using SVOP in the child patients were consistent with their clinical findings. A clinical evaluation of SVOP was undertaken in the second stage of this research with 122 subjects comprising the same four subject groups as in the feasibility trial. An “ideal” test protocol resulted in 8 uniocular visual field tests for each subject comprising 4 SVOP tests and 4 HFA tests. In children where uniocular testing was not tolerable, two binocular SVOP tests were performed. The sensitivity and specificity of the SVOP tests were computed using a direct comparison with reliable HFA tests, and repeatability of SVOP and HFA tests were assessed using Cohen’s kappa coefficient. In child patients unable to provide a reliable HFA test, their clinical history, other clinical findings and the repeatability of their SVOP tests were used to assess the SVOP results. The overall sensitivity and specificity of the SVOP testing was 72.7% and 96.8% respectively. The sensitivity had a greater variation than the specificity amongst the different subject groups. The repeatability of SVOP tests was slightly reduced as compared to the HFA tests across all groups with kappa coefficient’s of 0.65 and 0.74 for SVOP and HFA respectively. In child patients without reliable HFA equivalent tests the SVOP results could commonly be associated with other clinical findings and repeatable testing added to the confidence in the reliability of these cases. The developed SVOP technique performs well with accurate eye tracking data and an attentive child. It has proved extremely useful in identifying and monitoring visual field defects in several child patients who required regular visual field assessment.

The importance of monitoring, and where possible reducing, the level of radiation dose from diagnostic X-ray examinations has been recognised for many years and is becoming of increasing concern. Dose reduction is of particular concern in paediatric radiology, and there are specific problems associated with the monitoring and comparison of radiation doses to children. Any optimisation study relies on a framework of good dosimetry. Two techniques have been developed to improve the collection of patient dose data: the automation of survey techniques to increase the quantity of data collected; and a method of correcting for patient size which reduces one source of variability in the data. An optimisation strategy has been developed, consisting of theoretical simulations, experimental verification and clinical implementation. Monte Carlo techniques were used for the theoretical study, which investigated the effect of beam filtration on radiation dose and image quality for a wide range of parameters, specifically for a neonatal size phantom. Simulations included both radiography of bone in soft tissue and fluoroscopy of iodine and barium based contrast media. The results were assessed in terms of the beam spectra and the absorption and transmission characteristics of the phantom and image receptor. Experimental measurements of dose and contrast were made for a simple slab phantom corresponding to that simulated, and results showed good agreement with those predicted. A further set of experimental measurements were carried out using anthropomorphic phantoms in a clinical setting, which demonstrated how the theoretical predictions translated to clinical practice. A clinical trial of the use of a 0.1mm copper filter for fluoroscopic examinations of infants was performed, and the filter shown to give substantial dose reduction with no significant loss in image quality. Some general recommendations on dose quantities and the application of optimisation strategies to paediatric radiology have been made.

Abstract: Background: Cardio-metabolic dysregulation (CMD) and sarcopenia have been shown to influence important co-morbid conditions in children after liver transplantation (LTx). In adults with liver disease, suboptimal intake of some nutrients (protein, vitamin D) and high takes of added sugars and saturated fat have been shown to be important contributors to CMD/sarcopenia risk. The influence of dietary patterns, such as high consumption of carbohydrates, fat, and saturated fat as well as low intake of protein and key micronutrients, on CMD and sarcopenia has yet to be explored. The study objectives were to examine the association between dietary intake and the prevalence of sarcopenia and CMD in children (aged 6-18 years) after liver transplant (LTx). Methods: Dietary data (3-day food records) collected in a previously conducted cross-sectional study was analyzed to determine relationships between diet, sarcopenia and CMD risk in children post-LTx (n=22). CMD was defined using three criteria: ATP-III, Magnussen et al. and WHO. Sarcopenia was determined using the European Consensus Working Group Criteria for adults. Results: Sarcopenia and CMD occurred in 36% and up to 50% of LTx children, respectively. Children with sarcopenia had significantly higher protein, and lower fat and PUFA intakes than LTx children without sarcopenia (p103%) and saturated fat (68%) (AMDR>106%). Additionally, 3 participants (13.6%) had a combined diagnosis of sarcopenia and CMD. One of these patients had dietary intakes outside recommended ranges for fat (AMDR>110%), two for saturated fat (AMDR>134%), one for omega-3 (AI=53%), and one for calcium (RDA=61%). Conclusions: Children after LTx should receive a personalized diet to help monitor their intake for fat and saturated fat, particularly those with CMD. Routine follow-ups are an opportunity to monitor for any signs of decreased muscle function, abnormal laboratory values and dietary factors that may contribute to these co-morbid conditions.

Background: Osteoporosis and vertebral fractures are common in patients with Duchenne MuscularDystrophy (DMD) treated with glucocorticoids. Bisphosphonates (BP) have been used in pediatricpatients for treatment of osteoporosis. However, the long-term effects of oral BP therapy on vertebralmorphometry and fractures in patients with DMD and glucocorticoid-induced osteoporosis are notknown.Methods: We retrospectively studied patients with DMD who had been treated with oral BP forglucocorticoid-induced osteoporosis at a tertiary-care pediatric center between 2010 and 2017.Demographic data, and glucocorticoid and oral BP treatment histories were obtained from electronicmedical records. Treatment outcomes were changes in lumbar (L1-L4) vertebral morphometry andfractures, as assessed by the Genant semi-quantitative method. Patients were included if they had bothbaseline, within 6 months prior to start of oral BP treatment, and at least one follow-up spineradiograph available for review. The primary outcome was the prevalence of vertebral fractures and thesecondary outcome was change in Genant grading during treatment.Results: Fifty-eight patients with DMD (median age 12.2 years, range 5.5-19.6 years) were treated withglucocorticoids for a median duration of 4.7 years (range 1.3-12.6 years) and 33% were non-ambulatoryat BP start. Vertebral fractures, defined by Genant grading =1, were present in 6-19% of L1-L4 vertebraeat baseline. Among patients who had radiographs at baseline and 1 year-post BP start, the prevalence ofL1-L4 vertebral fractures remained stable post treatment (n=43; 5-18% at baseline vs 8-18% at 1 year, pvalue 1.00). The prevalence of vertebral fractures at each year up to 5 years was also not statisticallydifferent from that of baseline (p-value 0.08-1.00). Among patients who had serial radiographs forcomparison, longitudinal examination showed no change in Genant grading in the majority of vertebrae(64-80%) up to 5 years of treatment.Conclusions: In our experience of oral BP therapy in patients with DMD, we observed stable prevalenceof lumbar vertebral fractures and unchanged Genant grading in the majority of vertebrae at each yearup to 5 years of treatment. Longer-term data and in-depth quantitative analysis of vertebral fractureseverity are needed to better determine the efficacy of oral BP in children and adolescents with DMD.

Objectives: From a payer perspective, examine the effects of a pediatrician-led care coordination model (PLCM) versus usual, standard pediatric care (SPC) on health utilization and expenditure patterns in a randomized cohort of Medicaid-eligible children with medical complexities (CMC). Methods: Retrospective secondary database analysis of Texas Medicaid administrative medical and prescription claims data of 222 patients previously enrolled in the Specially for Children pilot study from January 1, 2010 to October 31, 2015. Medical diagnoses for 222 patients from inpatient and outpatient claims data were utilized to determine clinical complexity status while bivariate and generalized linear models provided two-year unadjusted and adjusted utilization and expenditures measures. Linear-mixed effects regression models were used to model individual growth curves in medical and outpatient prescription expenditures. Results: A total of 212 patients (95.5%) were identified as having complex chronic medical conditions. Two-year expenditures averaged $217,812 per patient across the study cohort with outpatient medical services accounting for the largest proportion of total healthcare expenditures (64.6%). The inclusion of model covariates resulted in average two-year expenditures of $124,026 in the PLCM and $112,911 in SPC (difference- $11,115 [95% CI -$15,280 to $44,648]). Variability in medical and prescription expenditures were largely due to between-person differences. Rates of change in medical and prescription expenditures were not significantly different from zero. Conclusion: Population-based identification methods exhibited a high level of agreement with prospective, clinician determined classification of children with complex chronic conditions. Total healthcare expenditures and rates of change were not significantly different between the two study groups while significant variability existed between patients. These findings demonstrate similar expenditures among a largely neuro-impaired cohort of CMC cared for under an enhanced care model despite high outpatient medical and prescription expenditure and concentrated spending among relatively few patients.

Introduction: Storybook characters may provide young children with a role model for healthy behaviors and improve their understanding of recommendations for daily physical activity (PA) and sedentary behavior (SB). Purpose: To assess the effect of a character-based intervention on children’s knowledge of recommendations, benefits, and definitions of PA and SB and participation in these behaviors. Methods: All children (6-11 y, N = 21) in an after-school program completed a questionnaire on knowledge, self-efficacy, and habits at pre- and postintervention. A consented subset (n = 6) completed anthropometric measures at baseline and wore an accelerometer for 7 days at both time-points to objectively determine PA. A repeated measures ANOVA assessed changes in knowledge, self-efficacy and behavior from pre- to postintervention by sex, consent status, and program-determined team (based on grade) (p < 0.05). Results: Knowledge increased 14.3% points (p < 0.01) and self-efficacy increased 22.5% points (p = 0.01). Measured PA increased by 7 min/day (p = 0.41), while SB decreased 21 min/day (p = 0.62) and self-reported screen-time decreased by 1.5 hr/day (p = 0.39). Conclusion: This character-based intervention promoted positive changes in knowledge and self-efficacy, with practically important changes in behavior in rural Appalachian youth.

Pediatrics is considered a low-liability medical specialty with respect to the odds of facing a malpractice claim, yet indemnity payments made by pediatricians are among the most expensive of all physicians. Little is known about pediatric malpractice risks from a patient-perspective; especially non-obstetric risks in the infant population, and whether certain pediatric age groups are higher-risk for malpractice injuries. This study uses ten years of malpractice reports from the National Practitioner Data Bank (n = 70,441) to compare pediatric (infant, child, and teenage groups) to adult malpractice events. We compare the severity of injuries and the type of medical errors that were reported, and calculate rates for malpractice reports on a per capita (per 100K population) level for each age group. We found that the pediatric population is a heterogeneous patient population with unique age-specific risk factors. On a per-capita basis, non-obstetric infant malpractice claims were much more common than adult claims, whereas non-infant pediatric claims were less common than in adults. Devastating non-fatal permanent injuries such as brain damage and paralysis were exponentially more common in the infant population across most non-obstetric medical error types. Overall, diagnostic and treatment-related errors were more common among pediatric claims than in adults, whereas surgical and medication-related errors were less common. While previous research has identified the significance of obstetric injuries in the infant population, future safety and training efforts should also focus on reducing the potential for negligence that can lead to non-obstetric paralysis or brain damage injuries in the infant population, particularly in the realms of diagnosis and treatment.

Abstract: Parent with children undergoing neurosurgery need access to specialized information as well as support resources. The public is becoming more active in managing their own health care and they often turn to the Internet as a starting point in their quest for health information resources. The Neurosurgery Kids Fund (NKF) in Edmonton, Alberta was created by two pediatric nurse practitioners and launched in 2013 in an effort to help meet the information, support, and resource needs of this unique and special population. Google Analytics, a web analytic software program, an online survey questionnaire, and a focus group interview were used to evaluate parents’ usability and perspectives about a custom designed website about pediatric neurosurgery. Findings included that a health website, if carefully constructed, can meet the information needs and offer support resources to parents with critically ill children. Parents described timing in their child’ illness trajectory as a determinant to when they used the Internet to gain health information about their child’s medical condition or accessing support resources. Factors influencing avoidance of the Internet included fear, uncertainty, and being advised against it by healthcare professionals. The most frequently identified reason for accessing the NKF website was for information on Camp Everest. The next most frequently identified reasons were for medical, social support, and resource information. Parents reported accessing the NKF website regularly and will continue to use it in the future. Nurses and Advanced Practice Nurses (APNs) are now charged with assessing how and what parents are seeking online to meet their needs, and helping to direct them to safe, credible and reliable health websites. Further, issues in the future will revolve around how healthcare professionals are to evaluate health websites to recommend to their patients and parents.

Purpose: To evaluate the effectiveness of a modified Caries Management by Risk Assessment (CAMBRA) model in a clinical trial amongst children between the ages of 5-9 years old, treated in a school-based community pediatric dental clinic setting.Methods: In a one-year, randomized clinical trial, 66 children between the ages of 5-9 years old were randomized into control or intervention groups. The control group received conventional treatment, including exam, prophy, caries risk assessment and fluoride varnish at baseline, 6 months, and one year follow up. The intervention group, in addition to receiving conventional treatment, also received CAMBRA, if considered high caries risk, which consisted of additional fluoride treatments at 3 and 9 months as well as daily xylitol mint consumption. Saliva samples for mutans streptococci (MS) and lactobacilli (LB) enumerations (CFU/ml) and dmfs/DMFS scores were collected from each subject at baseline and one year examinations. Results: Of the 66 participants, 60 subjects completed the study. At baseline there was no statistical differences in subject demographics, MS and LB levels, along with DMFS/dmfs scores between the two groups. At six months and one year, there were no statistically significant differences in logMS and logLB levels between the two groups (Student t- test p>0.05). Also, at one year, we did not find any significant difference in the change of decayed surfaces (DS/ds), smooth surface decay (SS-DS/ds) and overall decayed surfaces (DMFS/dmfs) between the intervention and the control groups (Student t-test, P>0.05). Although the difference is not statistically significant, the change of dental caries at one year in the intervention group displayed a consistent decrease in all scores compared to a consistent increase in the control group with a borderline statistically significant difference in SS-DS/ds (Student t- test, P=0.06). The caries risk assessment tools reviewed the oral habits of the children, such as oral hygiene and diet. An increase in tooth brushing frequency was reported from both control and intervention groups, with a decrease in snacking frequency per day. Although neither was statistically significant, it presents a positive trend towards a reduction of risk factors along with an increase in protective factors for both groups.Conclusions: Although the modified CAMBRA intervention in children did not significantly reduce MS levels or change DMFS/dmfs scores, it did show positive trends towards reducing caries, especially on smooth surfaces. It has also shown decreased lactobacillus levels in children ages 5-9 years old. Due to limitations within the study, we were unable to recruit a sufficient number of subjects to meet the sample-size calculation. Future studies with sufficient number of subjects is needed to validate the success and positive benefits of the modified CAMBRA protocol in young children.

2031-01-01

2031-01-01