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Objective: To identify locations with higher need for acute pediatric mental health (MH) interventions or services and describe these communities' socio-demographic characteristics., Methods: This single-center retrospective study included patients 5 to 18 years old with an emergency department (ED) or hospital admission between 2017 and 2019 for a primary known MH diagnosis or symptoms. We extracted visit data from the electronic medical record, mapped patients to their home census tract, calculated normalized visit rates by census tract, and performed spatial analysis to identify nonrandom geographic clusters and outliers of high utilization. Census tract utilization rates were stratified into quartiles, and socioeconomic and demographic characteristics obtained from the US Census Bureau were compared using analysis of variance, chi-square tests, and multivariable analysis., Results: There were 10,866 qualifying visits across 617 census tracts. ED and hospital admission rates ranged from 2.7 to 428.6 per 1000 children. High utilization clusters localized to neighborhoods with lower socioeconomic status (p < .05). Southern regions with high utilizers were more likely to have fewer children per neighborhood, higher rates of teen births, and lower socioeconomic status. Multivariate analysis showed regions with high utilizers had fewer children per neighborhood, lower median household income, and more families that lacked computer access., Conclusion: ED and hospital utilization for pediatric MH concerns varied significantly by neighborhood and demographics. Divergent social factors map onto these locations and are related to MH utilization. Leveraging geography can be a powerful tool in the development of targeted, culturally tailored interventions to decrease acute pediatric MH utilization and advance child MH equity., (Copyright © 2022 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Pediatric palliative home-based care has been shown to improve symptoms, quality of life, and coordination of care. Despite these successes, hospital utilization in our own palliative home-based care population remained high as some caregivers lacked confidence to manage symptoms at home and had difficulty in recalling or accessing "sick care plans." Our team developed the Symptom Management Plan (SMP), a multi-system "sick care plan," as a quality improvement project with the aim of improving caregiver confidence to manage symptoms at home. An Electronic Health Record-based SMP template was created for common symptoms: respiratory distress, seizures, feeding intolerance, and constipation with core subspecialists' input. Individualized SMPs were created and reviewed with caregivers at every subsequent palliative home nursing visit. Caregivers were surveyed on their confidence 3 and 6-months post-implementation. Resource utilization was analyzed throughout implementation. At 6 months, 73% of caregivers reported "better" or "much better" confidence in managing their child's symptoms after using the SMP, and 76% of caregivers perceived the SMP prevented urgent care or emergency department (ED) visits. After the SMP was launched, the rate of ED visits decreased from 0.86 to 0.47 per 100 patient-days, and admissions decreased from 0.56 to 0.39 per 100 patient-days. These rates further decreased to 0.31 ED visits and 0.19 admissions per 100 patient-days within 4 and 6 months. Introducing the SMP for our home-based palliative care patients was associated with improved caregiver confidence in managing acute symptoms at home and a reduction in hospital utilization., (Copyright © 2022 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Background: The US Census confirms a rise in Spanish-speakers, many of whom have limited English proficiency (LEP) and require interpreters. Parent perceptions of interpreter services throughout hospitalization are unknown., Objective: To explore Spanish-speaking LEP parents' views regarding roles of interpreters and providers (attending, resident, or nurse) during a hospital encounter, optimal modalities of interpretation, and barriers to services., Methods: Spanish-speaking LEP parents of children discharged from the hospital medicine service participated in focus groups. Sessions were audio-recorded and transcribed in Spanish, translated into English, and verified for translation accuracy. Qualitative methods were used for thematic analysis., Results: Four sessions (n = 23 participants representing 15 families) were held. Parents felt the interpreter's primary role was to act as a conduit for word-for-word interpretation. They desired kind and trustworthy interpreters with medical knowledge. They saw providers as leaders of the encounter who should allot enough time for interpretation, not use Spanish unless they were fluent, and give frequent medical updates. In-person interpreters were preferred over telephone and video for their ability to convey body language and build relationships. Barriers to requesting interpreters included embarrassment and inability to directly request services, which resulted in using family members as interpreters. On family-centered rounds, parents preferred professional interpreters over bilingual providers., Conclusions: Modifications are required to improve interpreter services to meet the needs of LEP families. Parents emphasized in-person interpreters' social skills, frequent provider updates, and additional navigation support as essential components of effective care. Next steps include implementing guidelines and interventions to optimize interpreter services., (Copyright © 2021 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Background: Many Americans have limited English proficiency (LEP) and difficulty communicating with health care providers, creating inequitable health care delivery. Despite widespread interpreter availability in hospitals, perceptions of interpreter services in the pediatric inpatient setting are largely unknown., Objective: To investigate staff perspectives regarding: 1) roles of the interpreter and provider (attending, resident, and nurse) during an encounter, 2) modalities of interpretation, and 3) barriers to services., Methods: Focus groups were conducted with: 1) hospital-employed Spanish interpreters, 2) Pediatric Hospital Medicine attendings, 3) pediatric and internal medicine-pediatric residents, and 4) medical unit nurses. Sessions were audio-recorded and transcribed. Using Atlas.ti, 2 investigators created the coding scheme, independently coded the data, and achieved consensus. Qualitative methods were used for thematic analysis., Results: Fourteen groups (n = 59 participants) were held: 3 interpreter groups (n = 10), 3 attending groups (n = 14), 2 resident groups (n = 17), and 6 nurse groups (n = 18). Most believed the interpreter's role was to serve as a conduit (provide word-for-word interpretation), act as a cultural broker, and maintain transparency (not withhold information). All groups felt providers should interact with families as they would with English-speaking families. In-person interpreters were preferred over telephone and video for being more accurate, efficient, and personable. Barriers to accessing services included time needed for interpretation, overconfidence in language skills, variable family dynamics, and identification of LEP families., Conclusions: In-person interpreters are highly valued, fulfilling complex roles. However, operational and human factors limit access to services in the hospital. These findings, along with family perspectives, can be used to optimize interpretation experiences., (Copyright © 2019 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine feasibility of optic nerve head (ONH) imaging and to characterize ONH development in full-term infants without sedation using handheld spectral-domain optical coherence tomography (SD OCT)., Design: Prospective cross-sectional study., Participants: Three hundred fifty-two children aged between 1 day and 13 years., Methods: All participants were imaged using handheld SD OCT without sedation during a single scan session. The percentage of successful scans was calculated. Interexaminer reproducibility and differences between right and left eyes were assessed using intraclass correlation coefficients (ICCs). Images were analyzed using ImageJ software. The developmental trajectories over time for ONH parameters were calculated using fractional polynomial modelling., Main Outcome Measures: Disc and cup diameter (expressed as distance in micrometers and visual angle in degrees), cup depth, Bruch's membrane opening-minimum rim width (BMO-MRW), retinal thickness, and retinal nerve fiber layer (RNFL; 1700 μm and 6° from the disc center)., Results: On average, 70% of participants were imaged successfully. Interexaminer reliability was excellent (ICC, >0.89) for diametric and retinal thickness parameters. Right and left eyes were similar for diametric measurements (ICC, >0.79), but more variable for nasal BMO-MRW, RNFL, and retinal thickness. The mean disc and cup diameter increase by 30% and 40%, respectively, between birth and 13 years of age when expressed as a distance measure, but remained constant (at 5°-5.5° and 2°, respectively) when expressed as a visual angle with reference to the eye nodal point. The peripapillary temporal RNFL demonstrated a marked initial decrease of nearly 35% between birth and approximately 18 months of age. This was followed by a slow increase up to 12 years of age when measured at 1700 μm from the disc center, although there was little change when measured at 6° from the disc center., Conclusions: We demonstrated feasibility of handheld SD OCT imaging of the ONH in full-term infants and children without anaesthesia or sedation. This is the first in vivo handheld SD OCT study to describe the development of ONH parameters during the critical early years of visual maturation. Our results provide a normative database for use in routine practice and further studies of ONH pathologic features., (Copyright © 2016 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Background: Retinal development normally involves migration of the inner retinal layers away from the fovea, migration of the cone photoreceptors into the fovea, and elongation of the photoreceptors over time. This process is arrested prematurely in albinism. However, because retinal development continues at least until the age of 4 years, when development arrests in albinism is uncertain. In this study we outlined the time course of retinal development in children with albinism., Methods: We studied 44 children with a diagnosis of albinism and 223 control participants. All participants were aged between 0 and 6 years. We obtained 219 mixed cross-sectional and longitudinal optical coherence tomography examinations in the albinism group and compared them with 558 control examinations. Retinal layer segmentation was performed with ImageJ software. Generalised linear mixed regression modelling was used to analyse group differences in retinal development., Findings: In the albinism group, inner retinal layer migration from the fovea was delayed and arrested prematurely, resulting in a significantly thicker central macular thickness than in the control group (p<0·0001). Whereas the central macular thickness increased with age in the control group, in the albinism group it initially decreased with age as a result of continuing regression of the inner retinal layers (p=0·041). The perifoveal retinal thickness was significantly decreased in albinism from a reduction of both inner (p<0·0001) and outer (p<0·0001) retinal layer thicknesses. There was evidence that the photoreceptor layers across the fovea were elongating in albinism, albeit at a reduced rate, compared with the control group. This difference was most apparent for the foveal photoreceptor inner segment (p=0·001)., Interpretation: Our findings show that perturbations exist in several aspects of retinal development including the migration and differentiation of the neuronal cells within the retina. We showed continuing regression of the inner retinal layers and elongation of the photoreceptor layers suggesting residual plasticity of the developing albino retina. This finding is important because treatment at the earliest stages of the condition might normalise retinal development and optimise vision., Funding: UK Medical Research Council (grant number MR/J004189/1), Ulverscroft Foundation, National Eye Research Centre, Nystagmus Network UK., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Objective: To investigate the feasibility of handheld (HH) ultra-high-resolution spectral-domain optical coherence tomography (SD-OCT) in young children with nystagmus, to determine its sensitivity and specificity in classifying foveal abnormalities, and to investigate its potential to determine the cause of infantile nystagmus with the use of foveal morphology., Design: Prospective, case-control study., Participants and Controls: A total of 50 patients with nystagmus and 50 healthy control subjects (mean age, 3.2 years; range, 0-8 years)., Methods: Each patient was scanned using HH SD-OCT (Bioptigen Inc., Research Triangle Park, NC) without sedation, and foveal morphology was classified into 1 of 4 categories: (1) typical foveal hypoplasia (predicting clinical diagnosis of albinism, PAX6 mutations, or isolated foveal hypoplasia); (2) atypical foveal hypoplasia (predicting achromatopsia); (3) other foveal changes (corresponding to retinal dystrophies); and (4) normal fovea (predicting idiopathic or manifest latent nystagmus). An independent interpretation of the HH SD-OCT scans by masked examiners was performed, and the sensitivity and specificity of the predicted diagnosis were calculated., Main Outcome Measures: The success rate of image acquisition and sensitivity and specificity of the HH SD-OCT in classifying foveal abnormalities., Results: In 94% of examinations, HH SD-OCT was successful. Twenty-three patients had typical foveal hypoplasia (category 1). Of these patients, 21 were diagnosed with albinism and 2 were diagnosed with PAX6 mutations. Five patients were classified as atypical (category 2) and diagnosed with achromatopsia. Six patients had other abnormal foveal morphology (category 3) and were diagnosed with retinal dystrophy. Sixteen patients had normal foveal morphology (category 4). Of these patients, 12 were diagnosed with idiopathic nystagmus and 4 were diagnosed with manifest latent nystagmus. Sensitivities of HH SD-OCT for classifying typical or atypical foveal hypoplasia, other abnormal foveal morphology, and normal morphology were 92.8%, 86.7%, 41.1%, and 88.4%, respectively, with specificities of 91.4%, 94.8%, 97.7% and 95.1%, respectively., Conclusions: We demonstrate excellent feasibility of HH SD-OCT in the diagnosis of conditions associated with infantile nystagmus. The HH SD-OCT classification of foveal abnormalities was highly sensitive and specific. This classification was used to determine the underlying cause of infantile nystagmus. Handheld SD-OCT in early childhood can facilitate focused investigations and earlier diagnosis. This is important in an era when potentially time-sensitive treatment, such as gene therapy, is imminent., (Copyright © 2013 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)