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Audrey M Uong,1 Michael D Cabana,1 Janet R Serwint,2 Carol A Bernstein,3 Elaine E Schulte1 1Department of Pediatrics, Children’s Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, NY, USA; 2Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA; 3Department of Psychiatry, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USACorrespondence: Audrey M Uong, Department of Pediatrics, Children’s Hospital at Montefiore, 3411 Wayne Ave, Bronx, NY, 10467, USA, Tel +1 718 741-2282, Fax +1 718 920-6506, Email auong@montefiore.orgPurpose: Healthcare organizations strive to increase physician engagement and decrease attrition. However, little is known about which specific worklife areas may be targeted to improve physician engagement or retention, especially after stressful events such as a COVID19 surge. Our objective was to identify demographic characteristics and worklife areas most associated with increased physician engagement and decreased intent to leave in pediatric faculty.Patients and Methods: In September 2020, we conducted a cross-sectional survey of faculty at an academic, tertiary-care children’s hospital. A convenience and voluntary sampling approach was used. The survey included demographics, Maslach Burnout Index-Human Services Survey (MBI-HSS) and the Areas of Worklife Survey (AWS). The MBI-HSS was used to measure faculty engagement. The AWS measures satisfaction with six worklife areas (workload, control, reward, fairness, community, values). We used bivariate analyses to examine relationships between worklife areas and engagement and between worklife areas and intent to leave. We included multivariate logistic regression models to examine worklife areas most associated with increased work engagement and decreased intent to leave.Results: Our response rate was 41% (113/274 participants). In bivariate analysis, engaged faculty reported higher satisfaction in all worklife areas. In multivariate analyses, positive perceptions of workload (odds ratio (OR) 2.83; 95% confidence interval (CI), 1.2– 6.9), control (OR, 3.24; 95% CI 1.4– 7.3), and community (OR, 6.07; 95% CI 1.9– 18.7) were associated with engagement. Positive perceptions of values (OR, 0.07; 95% CI 0.02– 0.32) and community (OR, 0.19; 95% CI 0.05– 0.78) were negatively associated with intent to leave.Conclusion: We found that positive perceptions of workload, control, and community were most associated with engagement. Alignment of values and increased sense of community were associated with decreased intent to leave. Our findings suggest specific worklife areas may be targeted to increase faculty engagement and retention.Plain Language Summary: Physician engagement and retention are growing concerns for healthcare organizations. We conducted a cross-sectional survey of pediatric faculty after a COVID19 surge in 2020 to examine whether there are worklife areas highly associated with physician engagement and decreased intent to leave their current practice. We found that respondents with high positive perceptions of their workload, autonomy and community in their workplace were more likely to be engaged, and that respondents who felt that their values aligned with their organization’s values and felt a positive sense of community were less likely to report intent to leave the organization. Prioritizing improvements in physician workload, autonomy, and community, and recruiting physicians with similar values may be an effective strategy for organizations who desire to increase physician engagement and retention.Keywords: physician burnout, workforce, physician well-being

Background: The “September epidemic” is a well-described phenomenon of increased pediatric asthma-related health care utilization from August to September each year. The coronavirus disease 2019 (COVID-19) pandemic has brought about significant changes in health care utilization, warranting an investigation into its impact on the September epidemic. Objective: Our aim was to identify the impact of COVID-19 in asthma-related health care utilization, specifically in the September epidemic. Methods: Our study involved a retrospective analysis of data from a Children's Hospital in New York City. We compared the change in asthma-related health care utilization during August and September 2020 with the average change in utilization during the same period in 2017-2019 and 2021-2022. Stratified analyses based on age and sex were conducted by using chi-square tests to determine variations in health care utilization. Results: During September 2020, there was a marked reduction in emergency department (ED) visits related to asthma, with only a 6% rise from the preceding month. This stands in contrast to the observed increases from 89% to 193% in the other years studied (P < .05 for all). This pattern was seen in both sexes and in children under 13 years old (P < .05). No significant variation was found for those older than 13 years (P > .05). Conclusions: Despite an overall reduction in health care utilization over the first year of the COVID-19 pandemic, the decline in ED visits related to asthma during the September epidemic was significantly more pronounced. These results suggest that there may be remediable risk factors contributing to the September epidemic that can be used to guide future interventions for managing pediatric asthma.

National guidelines recommend that providers counsel all patients with sickle cell anemia about hydroxyurea (HU) therapy and screen children with sickle cell anemia annually for the risk of stroke with transcranial Doppler (TCD). We surveyed a national convenience sample of sickle cell disease clinicians to assess factors associated with low adherence. Adherence was 46% for TCD screening. Low adherence was associated with a lack of outcome expectancy (eg, a belief that there would be poor patient follow-up to TCD testing; P < .05). Adherence was 72% for HU counseling. Practice barriers (eg, lack of support staff or time) and a lack of agreement with HU recommendations were associated with low adherence ( P < .05). This study demonstrates that different types of strategies are needed to improve TCD screening (to address follow-up and access to testing) versus HU counseling (to address physician agreement and practice barriers).

We conducted a cross-sectional survey of 1322 parents of children with asthma to measure the prevalence and factors associated with complementary and alternative medicine (CAM) use for pediatric asthma. Multivariate regression techniques were used to determine factors associated with CAM use. Eleven percent (141/1322) of children were given CAM. Parents of children on daily medications who were perceived to have poor asthma control were almost three times more likely to use CAM than parents of children on no daily medications who were perceived to have high asthma control (risk ratio: = 2.81; confidence interval: 1.72, 4.60); age, gender, race, income, and education level were not significant independent predictors. Parent perception of asthma control is significantly associated with CAM use. It is important for providers to elicit information regarding CAM use in the clinic, as this may imply that the asthma symptoms may not be well controlled. [ABSTRACT FROM AUTHOR]

Although asthma quality improvement (QI) programs are common, little is known about the scope and content of QI initiatives in managed care arrangements. The authors conducted a cross-sectional survey of all managed care plans in Michigan serving the pediatric Medicaid population. Using semi-structured interviews, they assessed the comprehensiveness of the asthma QI program regarding provider, allied health professional, pharmacy, and member services. Although all QI initiatives included some type of physician-directed component and patient-directed components, only half included allied health professionals and one quarter included pharmacy-directed components. Interactive physician continuing medical education was associated with plans whose members were concentrated in only 1 or 2 counties. The authors noted wide variation in content, format, inclusion of incentives, inclusion of other health professionals, and outcome goals. The variation in QI approaches by each of the managed care organizations suggests that there is a dearth of information on appropriate and cost-effective methods to improve pediatric asthma quality at the plan level. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Although the Health Plan Employer Data Information Set (HEDIS) is a common method for evaluating the quality of asthma care, its accuracy in characterizing persistent asthma in children is unknown. The objective of this study was to compare the assessment of asthma severity (persistent vs nonpersistent asthma) using the HEDIS criteria versus clinical criteria using National Heart, Lung, and Blood Institute (NHLBI) guidelines. METHODS: In a cross-sectional study, we analyzed baseline data from interviews with the parents of 896 children who had asthma and participated in a randomized controlled trial. Patients had an active clinical diagnosis of asthma, were between 2 and 12 years of age, and had no other pulmonary diseases. Patients had persistent asthma by parent report according to the HEDIS criteria when, within the last year, they had 1 asthma inpatient admission or emergency department visit or 4 asthma medication dispensing events, or 4 outpatient asthma visits and at least 2 asthma medication dispensing events. Patients had persistent asthma by parent report according to the NHLBI criteria when, within the last 2 months, they had nighttime asthma symptoms >2 nights/mo or daytime asthma symptoms >2 days/wk. We calculated the sensitivity of each HEDIS criterion, separately and then combined, using the NHLBI criteria as a gold standard. RESULTS: On the basis of HEDIS criteria, 656 (73%) patients had persistent asthma, compared with 338 (38%) using NHLBI criteria. Although the HEDIS criteria for persistent asthma were fairly sensitive (0.89), they were not very specific (0.70). For children without daily controller medications (n = 346), the sensitivity was even lower (0.45), but the specificity was similar (0.68). We found that the test characteristics were fairly consistent across different age group strata (2-4, 5-9, and 10-12 years of age). CONCLUSIONS: HEDIS criteria used to determine the quality of asthma care should be interpreted with caution. Although the criteria for persistent disease-used to determine which children require daily controller medications-are fairly sensitive, they are not very specific and include children who may not require such medications. [ABSTRACT FROM AUTHOR]

In 2006, the Centers for Disease Control and Prevention recommended discontinuing the use of adamantanes (amantadine and rimantadine) to treat influenza because of high levels of resistance to this class of antivirals. We examined changes in prescribing practices resulting from this recommendation and found that prescribing of adamantanes declined nationwide, with these drugs accounting for approximately 40% of the antivirals prescribed for influenza from 2000 to 2005 and only 2% in 2006. This finding provides evidence of a rapid change in clinical practice associated with the dissemination of treatment guidelines. Evaluating the effectiveness with which public health recommendations are translated into practice is important given the ongoing emergence of resistance to antiviral drugs and a novel H1N1 influenza virus. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Providing asthma education in a primary care setting can be challenging because of time and resource constraints. The purpose of this work was to determine factors associated with the provision of different asthma self-management tools. METHODS: We conducted a cross-sectional survey with 896 parents of children with asthma (age 2-12 years). We collected information regarding demographics and asthma care, including parent receipt of an asthma action plan, a symptom diary, and asthma information materials; whether an asthma management plan was sent to the child's school; and whether the physician reviewed written instructions on use of a metered-dose inhaler. We used multivariate logistic regression methods to determine factors associated with receipt of different asthma self-management tools controlling for demographic factors. RESULTS: For families where parents only completed high school, there was greater likelihood of receipt of an asthma action plan and physician review of written instructions about how to use an inhaler. For families with a household income less than twice the poverty line, there was greater likelihood of receipt of an asthma action plan, the physician sending a letter to the child's school regarding the child's asthma, and receipt of an asthma symptom diary. CONCLUSIONS: In our sample, primary care pediatricians do not routinely provide asthma education in accordance with National Heart, Lung, and Blood Institute asthma guidelines and 'triage' which families receive additional asthma education. We believe that the use of targeted asthma education is a symptom of the limited time and competing demands during a typical visit. As a result, those involved in quality improvement need to help physicians become more efficient and effective at providing asthma education within such time constraints or develop alternative systems of providing asthma education. [ABSTRACT FROM AUTHOR]

Background: Adequate water intake is associated with improved cognitive and physical performance, prevention of dental caries, and overweight and obesity. However, access to free drinking water in schools remains inadequate. Water First, a school-based intervention promoting water consumption, was shown effective in preventing overweight, yet its costs have not been quantified., Objective: To evaluate the costs of Water First from the school's perspective over one academic year., Design: Secondary analysis of a cluster-randomized clinical trial assessing the cost of Water First., Participants/setting: Six public schools in the San Francisco Bay Area in the 2018-2019 academic year, with an average of 578±69 students per school and 110±2 fourth-grade students in intervention schools, and 508±190 students per school and 101±5 fourth-grade students in control schools., Intervention: Schools were randomized to receive water dispensers and stations in cafeterias and high-traffic areas and a schoolwide water promotion campaign (school-level intervention). Fourth-grade students and teachers received reusable water bottles, lessons, and materials for school and home (class-level intervention)., Main Outcome Measures: Activities, resources, and the value needed to implement the school- and classroom-level intervention were systematically captured over one academic year, including labor, materials, and utilities costs., Statistical Analysis: The intervention costs per school and per student were estimated by summing the component-specific costs. Results are presented for both school- and classroom-level interventions in 2023 USD., Results: The Water First intervention costs $20 per student for the school- and $131 per student for the classroom-level intervention over one academic year. Accounting for the useful life of the installed water stations and dispensers beyond one year, the annualized cost of the school-level intervention was $11 per student., Conclusions: These cost estimates provide useful insights for schools and stakeholders to plan and implement effective school-based interventions that promote access to drinking water., (Copyright © 2024. Published by Elsevier Inc.)

The detection of founder pathogenic variants, those observed in high frequency only in a group of individuals with increased inter-relatedness, can help improve delivery of health care for that community. We identified 16 groups with shared ancestry, based on genomic segments that are shared through identity by descent (IBD), in New York City using the genomic data of 25,366 residents from the All Of Us Research Program and the Mount Sinai Bio Me biobank. From these groups we defined 8 as founder populations, mostly communities currently under-represented in medical genomics research, such as Puerto Rican, Garifuna and Filipino/Pacific Islanders. The enrichment analysis of ClinVar pathogenic or likely pathogenic (P/LP) variants in each group identified 202 of these damaging variants across the 8 founder populations. We confirmed disease-causing variants previously reported to occur at increased frequencies in Ashkenazi Jewish and Puerto Rican genetic ancestry groups, but most of the damaging variants identified have not been previously associated with any such founder populations, and most of these founder populations have not been described to have increased prevalence of the associated rare disease. Twenty-five of 51 variants meeting Tier 2 clinical screening criteria (1/100 carrier frequency within these founder groups) have never previously been reported. We show how population structure studies can provide insights into rare diseases disproportionately affecting under-represented founder populations, delivering a health care benefit but also a potential source of stigmatization of these communities, who should be part of the decision-making about implementation into health care delivery.

Lymphadenopathy is a common finding on physical examination in the pediatric population. Although it is often physiologic, lymphadenopathy can also be associated with more serious illnesses and has many possible etiologies. A broad differential diagnosis can be narrowed with a thorough clinical history, physical examination, laboratory studies, and imaging. The goal of this review is to provide a framework for understanding normal physiology, identify when enlarged lymph nodes may be associated with pathology, develop differential diagnoses associated with lymphadenopathy, and apply a systematic approach for diagnostics and appropriate management, with a focus on findings concerning for malignancy and the initial evaluation., (© American Academy of Pediatrics, 2024. All rights reserved.)

Background: The "September epidemic" is a well-described phenomenon of increased pediatric asthma-related health care utilization from August to September each year. The coronavirus disease 2019 (COVID-19) pandemic has brought about significant changes in health care utilization, warranting an investigation into its impact on the September epidemic., Objective: Our aim was to identify the impact of COVID-19 in asthma-related health care utilization, specifically in the September epidemic., Methods: Our study involved a retrospective analysis of data from a Children's Hospital in New York City. We compared the change in asthma-related health care utilization during August and September 2020 with the average change in utilization during the same period in 2017-2019 and 2021-2022. Stratified analyses based on age and sex were conducted by using chi-square tests to determine variations in health care utilization., Results: During September 2020, there was a marked reduction in emergency department (ED) visits related to asthma, with only a 6% rise from the preceding month. This stands in contrast to the observed increases from 89% to 193% in the other years studied ( P  < .05 for all). This pattern was seen in both sexes and in children under 13 years old ( P  < .05). No significant variation was found for those older than 13 years ( P  > .05)., Conclusions: Despite an overall reduction in health care utilization over the first year of the COVID-19 pandemic, the decline in ED visits related to asthma during the September epidemic was significantly more pronounced. These results suggest that there may be remediable risk factors contributing to the September epidemic that can be used to guide future interventions for managing pediatric asthma., Competing Interests: Disclosure of potential conflict of interest: The authors declare that they have no relevant conflicts of interest., (© 2024 The Author(s).)

Importance: Hypertensive disorders of pregnancy are among the leading causes of maternal morbidity and mortality in the US. The rate of hypertensive disorders of pregnancy has been increasing from approximately 500 cases per 10 000 deliveries in 1993 to 1021 cases per 10 000 deliveries in 2016 to 2017., Objective: The US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of screening for hypertensive disorders of pregnancy., Population: Pregnant persons without a known diagnosis of a hypertensive disorder of pregnancy or chronic hypertension., Evidence Assessment: The USPSTF concludes with moderate certainty that screening for hypertensive disorders in pregnancy with blood pressure measurements has substantial net benefit., Recommendation: The USPSTF recommends screening for hypertensive disorders in pregnant persons with blood pressure measurements throughout pregnancy. (B recommendation).

Objective: Infant well-child visits are increasingly being explored as opportunities to address parental postpartum health needs, including those related to reproductive health. To inform potential pediatric clinic-based interventions, this study assessed postpartum contraceptive needs and health services preferences., Methods: We surveyed postpartum individuals attending 2 to 6-month well-child visits at three Northern California pediatric clinics (2019-20). We examined unmet contraceptive needs; the acceptability of contraceptive education, counseling, and provision at well-child visits; and sociodemographic and clinical correlates. We conducted univariate and multivariable regression modeling to assess associations between sociodemographic and clinical variables, the status of contraceptive needs, and acceptability measures., Results: Study participants (n = 263) were diverse in terms of race and ethnicity (13% Asian, 9% Black, 37% Latinx, 12% Multi-racial or Other, 29% White), and socioeconomic status. Overall, 25% had unmet contraceptive needs. Unmet need was more common among participants who had delivered more recently, were multiparous, or reported ≥ 1 barrier to obtaining contraception; postpartum visit attendance, education, race, and ethnicity were not associated with unmet need. Most participants deemed the following acceptable in the pediatric clinic: receiving contraceptive information (85%), discussing contraception (86%), and obtaining a contraceptive method (81%). Acceptability of these services was greater among participants with unmet contraceptive needs, better self-rated health, and private insurance (all P < .05)., Conclusions: A quarter of participants had unmet contraceptive needs beyond the early postpartum period. Most considered the pediatric clinic an acceptable place to address contraception, suggesting the pediatric clinic may be a suitable setting for interventions aiming to prevent undesired pregnancies and their sequelae., (Copyright © 2023 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Background and Objective: Drinking water promotion and access shows promise for preventing weight gain. This study evaluated the impact of Water First, a school-based water promotion and access intervention on changes in overweight., Methods: Low-income, ethnically diverse elementary schools in California's Bay Area were cluster-randomized to intervention and control groups. Water First includes classroom lessons, water stations, and schoolwide water promotion over 1 school year. The primary outcome was overweight prevalence (BMI-for-age-and-sex ≥85th percentile). Students (n = 1249) in 56 fourth-grade classes in 18 schools (9 intervention, 9 control) from 2016 to 2019 participated in evaluation at baseline, 7, and 15 months. Data collection was interrupted in 8 additional recruited schools because of coronavirus disease 2019., Results: Of 1262 students from 18 schools, 1249 (47.4% girls; mean [SD] age, 9.6 [0.4] years; 63.4% Hispanic) were recruited. From baseline to 7 months, there was no significant difference in changes in overweight prevalence in intervention schools (-0.2%) compared to control schools (-0.4%) (adjusted ratio of odds ratios [ORs]: 0.7 [confidence interval (CI): 0.2-2.9] P = 0.68). From baseline to 15-months, increases in overweight prevalence were significantly greater in control schools (3.7%) compared to intervention schools (0.5%). At 15 months, intervention students had a significantly lower change in overweight prevalence (adjusted ratio of ORs: 0.1 [CI: 0.03-0.7] P = .017) compared to control students. There were no intervention effects for obesity prevalence., Conclusions: Water First prevented increases in the prevalence of overweight, but not obesity, in elementary school students., (Copyright © 2023 by the American Academy of Pediatrics.)

The role of early probiotic supplementation in infants for the prevention of respiratory viral illnesses is unclear. We examined the association of Lactobacillus rhamnosus GG (LGG) supplementation during the first 6 months of life with the frequency and severity of viral illnesses during the first 24 months of life. We conducted a secondary analysis of data from the randomized controlled Trial of Infant Probiotic Supplementation ( n = 184). Parents reported the number of respiratory viral illnesses, and a composite severity score was created based on symptoms. A negative binomial regression model and a mixed-effects linear regression model assessed for differences in the number of episodes and severity of episodes between treatment groups, respectively. There was no significant difference in the incidence rate of viral illness episodes or symptom severity between treatment groups. Daily supplementation with LGG in early infancy does not decrease the number or severity of viral illnesses during the first 2 years of life.

Objectives: A broad understanding of the scope of birth hospitalizations in the United States is lacking. We aimed to describe the demographics and location of birth hospitalizations in the United States and rank the most common and costly conditions documented during birth hospitalizations., Methods: We conducted a cross-sectional analysis of the 2019 Kids' Inpatient Database, a nationally-representative administrative database of pediatric discharges. All hospitalizations with the indicator "in-hospital birth" and any categorized by the Pediatric Clinical Classification System as "liveborn" were included. Discharge-level survey weights were used to generate nationally-representative estimates. Primary and secondary conditions coded during birth hospitalizations were categorized using the Pediatric Clinical Classification System, rank-ordered by total prevalence and total marginal costs (calculated using design-adjusted lognormal regression)., Results: In 2019, there were an estimated 5 299 557 pediatric hospitalizations in the US and 67% (n = 3 551 253) were for births, totaling $18.1 billion in cost. Most occurred in private, nonprofit hospitals (n = 2 646 685; 74.5%). Prevalent conditions associated with birth admissions included specified conditions originating in the perinatal period (eg, pregnancy complications, complex births) (n = 1 021 099; 28.8%), neonatal hyperbilirubinemia (n = 540 112; 15.2%), screening or risk for infectious disease (n = 417 421; 11.8%), and preterm newborn (n = 314 288; 8.9%). Conditions with the highest total marginal costs included specified conditions originating in perinatal period ($168.7 million) and neonatal jaundice with preterm delivery ($136.1 million)., Conclusions: Our study details common and costly areas of focus for future quality improvement and research efforts to improve care during term and preterm infant birth hospitalizations. These include hyperbilirubinemia, infectious disease screening, and perinatal complications., (Copyright © 2023 by the American Academy of Pediatrics.)

The microbiome plays an important role in the pathogenesis of allergic diseases. This review updates the reader on studies aimed at influencing allergic diseases through modulation of the gut microflora. A nonsystematic review of the literature was performed, focusing on relevant trials evaluating the effect of probiotics/prebiotics/symbiotics in the prevention and treatment of allergic disease. For each allergic disease, we were able to find not only a substantial number of clinical trials but also systematic reviews. Specific guidelines, based on systematic reviews and meta-analyses, are available for the prevention of allergic disease and for the treatment of food allergy. In each of the areas examined-allergic rhinitis, allergic asthma, atopic dermatitis, food allergy, and gastrointestinal allergies-there are substantial uncertainties in the efficacy of gut microflora modulation in prevention and treatment. At present, practicing clinicians can avail themselves of intestinal flora modulators as an adjunct in the prevention of atopic dermatitis but not of other forms of allergic diseases. Their effects on the treatment of allergic diseases remain controversial., (Copyright © 2022 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)