Search

This paper seeks to explore the current state of paediatric palliative care in Aotearoa New Zealand. The low priority afforded to paediatric palliative care for more than two decades has had a significant impact on service provision, education and research within this specialty. As a result, provision of specialist paediatric palliative care to children with serious illness and their whānau (family, including extended family) is inequitable and vastly inadequate. This paper considers the consequences of having limited access to specialist palliative care for children and whānau, and outlines what is required for both service development and current priorities for research., Competing Interests: Nil., (© PMA.)

The COVID-19 pandemic has caused an explosive adoption of telehealth in pediatrics . However, there remains substantial variation in evaluation methods and measures of these programs despite introduction of measurement frameworks in the last five years. In addition, for neonatal health care, assessing a telehealth program must measure its benefits and costs for four stakeholder groups - patients, providers, healthcare system, and payers. Because of differences in their role within the health system, each group's calculation of telehealth's value may align or not with one another, depending on how it is being used. Therefore, a common mental model for determining value is critical in order to use telehealth in ways that produce win-win situations for most if not all four stakeholder groups. In this chapter, we present important principles and concepts from previously published frameworks to propose an approach to telehealth evaluation that can be used for perinatal health. Such a framework will then drive future development and implementation of telehealth programs to provide value for all relevant stakeholders in a perinatal health care system., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to declare., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: The COVID-19 pandemic and the measures implemented to stop the pandemic had a broad impact on our daily lives. Besides work and social life, health care is affected on many levels. In particular, there is concern that attendance in health care programs will drop or hospital admissions will be delayed due to COVID-19-related anxieties, especially in children. Therefore, we compared the number of weekly visits to 78 German pediatric institutions between 2019 and 2020., Results: We found no significant differences during the first 10 weeks of the year. However, and importantly, from April, the weekly number of visits was more than 35% lower in 2020 than in 2019 (p = 0.005). In conclusion, the COVID-19 pandemic seems to relate to families´ utilization of outpatient well-child clinics and pediatric practice attendance in Germany.

Zero to 19 year-old children in sub-Saharan Africa bear a disproportionate proportion of the global burden of communicable and non-communicable diseases. Significant public health gains have been made in the fight against these diseases, however, factors such as underequipped health systems, disease outbreaks, conflict, and political instability continue to challenge prevention and control. The novel coronavirus disease (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) introduces new challenges to public health programs in sub-Saharan Africa. Of particular concern are programs targeting major conditions among children, such as undernutrition, vaccine-preventable pneumonia and diarrhea, malaria, tuberculosis, HIV, and sickle cell disease. This article focuses on the impact of the COVID-19 pandemic on child health in sub-Saharan Africa. We review the epidemiology of major pediatric diseases and, referencing modeling projections, discuss the short- and long-term impact of the pandemic on major disease control. We deliberate on potential complications of SARS-CoV-2 co-infections/co-morbidities and identify critical social and ethical issues. Furthermore, we highlight the paucity of COVID-19 data and clinical trials in this region and the lack of child participants in ongoing studies. Lastly, approaches and interventions to mitigate the pandemic's impact on child health outcomes are discussed. IMPACT: Children in sub-Saharan Africa bear a disproportionate burden of communicable and non-communicable diseases globally; this remains true even as the COVID-19 pandemic persists. Amidst the fast-expanding COVID-19 literature, there is little comprehensive coverage of the pandemic's indirect impact on child health in sub-Saharan Africa. This article comprehensively outlines the threat that the pandemic poses to major disease prevention and control for children in sub-Saharan Africa. It discusses the potential impact of SARS-CoV-2 co-infections/co-morbidities, highlights research gaps, and advocates for data and action to mitigate the ripple effects of the pandemic on this population.

Background: Due to low care utilization, a complex intervention was done for two years to optimize the Ethiopian Health Extension Program. Improved quality of the integrated community case management services was an intermediate outcome of this intervention through community education and mobilization, capacity building of health workers, and strengthening of district ownership and accountability of sick child services. We evaluated the association between the intervention and the health extension workers' ability to correctly classify common childhood illnesses in four regions of Ethiopia., Methods: Baseline and endline assessments were done in 2016 and 2018 in intervention and comparison areas in four regions of Ethiopia. Ill children aged 2 to 59 months were mobilized to visit health posts for an assessment that was followed by re-examination. We analyzed sensitivity, specificity, and difference-in-difference of correct classification with multilevel mixed logistic regression in intervention and comparison areas at baseline and endline., Results: Health extensions workers' consultations with ill children were observed in intervention (n = 710) and comparison areas (n = 615). At baseline, re-examination of the children showed that in intervention areas, health extension workers' sensitivity for fever or malaria was 54%, 68% for respiratory infections, 90% for diarrheal diseases, and 34% for malnutrition. At endline, it was 40% for fever or malaria, 49% for respiratory infections, 85% for diarrheal diseases, and 48% for malnutrition. Specificity was higher (89-100%) for all childhood illnesses. Difference-in-differences was 6% for correct classification of fever or malaria [aOR = 1.45 95% CI: 0.81-2.60], 4% for respiratory tract infection [aOR = 1.49 95% CI: 0.81-2.74], and 5% for diarrheal diseases [aOR = 1.74 95% CI: 0.77-3.92]., Conclusion: This study revealed that the Optimization of Health Extension Program intervention, which included training, supportive supervision, and performance reviews of health extension workers, was not associated with an improved classification of childhood illnesses by these Ethiopian primary health care workers., Trial Registration: ISRCTN12040912, http://www.isrctn.com/ISRCTN12040912., Competing Interests: The authors have declared that no competing interests exist.

Services aimed at improving the health of infants, children and mothers have developed over the years since the initiation of the Seychelles Child Development Study. This paper describes the policies, procedures and facilities and how they have impacted on service provision. The utilisation of antenatal, perinatal and child health services, both in the hospital and community settings, are described. The successes and challenges are illustrated by describing fertility, abortion, teenage pregnancy and infant mortality. This overview of maternal and child services provides a perspective on an important aspect of health care development and the context in which the SCDS is conducted., (Copyright © 2021. Published by Elsevier B.V.)

Introduction: A wide gap in knowledge exists about the factors associated with newborn care in rural Zambia. In this year of the nurse and midwife, the purpose of this article is to provide transcultural researchers with an example of how Bronfenbrenner's Ecological Systems Theory (EST) can be used to guide an exploration of the cultural practices, knowledge, and beliefs of newborn care and health-seeking behaviors in rural Zambia. Methodology: Based on the EST, maternal knowledge represents the microsystem while family and community members embody the mesosystem. Health care organization denotes the exosystem with culture representing the macrosystem and health policy the chronosystem. Results: Numerous implications for transcultural nursing practice emerged from this adaptation of the ecological systems approach. Findings reveal a maternal dualism faced by Zambian mothers as they navigate the complex interplay between cultural newborn care practices and evidence-based newborn care promoted by the health care system. Discussion: Based on our proposed operationalization of the EST for a transcultural nursing study, the EST can be applied globally, further validating the theory.

Background: Sustainable Development Goal 3 aims at reducing global neonatal mortality to at least 12 per 1000 livebirths, under-five mortality to at least 25 per 1000 livebirths and maternal mortality ratio to less than 70 per 100,000 livebirths by 2030. Considering the achievement so far, many countries in sub-Saharan Africa, including Ghana are not likely to achieve these targets. Low utilization of maternal, newborn and child health (MNCH) services partly account for this predicament. This study explored the trend and correlates of MNCH services utilization in one administrative district in the Volta Region of Ghana., Methods: This is an explorative ecological study employing trend analysis of 2015-2017 data from Ghana Health Service District Health Information Management System II. Univariate Poisson regression models were used to determine the factors associated with MNCH services utilization at 95% confidence level., Results: Cumulative record of 17,052 antenatal care (ANC) attendance and 2162 facility-based spontaneous vaginal deliveries (SVDs) was discovered. Compelling evidence of potential unskilled deliveries was observed in 23% of the 26 facilities reported in the DHIMSII data. High cumulative number of midwives in health facilities associated positively with high records of ANC visits (IRR = 1.30, [95% CI:1.29, 1.32]; p = 0.0001), facility-based SVDs (IRR = 1.30 [95% CI:1.25, 1.35]; p = 0.0001) and BCG immunizations (IRR = 1.32 [95% CI:1.29, 1.34]; p = 0.0001). Likewise, high records of ANC visits correlated positively with high facility-based SVDs and child immunizations records (p < 0.0001)., Conclusion: Targeted health system and community level interventions alongside progressive frontline health staff motivation and retention strategies could further enhance enrollment and retention of mothers in pre-natal and postnatal care services throughout the continuum of care to guarantee better MNCH health outcomes. Investments in universal coverage for quality ANC services has the potential to enhance utilization of supervised deliveries and post-natal care services such as immunizations.

Objectives: Neonatal mortality remains persistently high in low-income and middle-income countries. In Cambodia, there is a paucity of data on the perception of neonatal health and care-seeking behaviours at the community level. This study aimed to identify influencers of neonatal health and healthcare-seeking behaviour in a rural Cambodian province., Design: A qualitative study using focus group discussions and thematic content analysis., Setting: Four health centres in a rural province of Northern Cambodia., Participants: Twenty-four focus group discussions were conducted with 85 community health workers in 2019., Results: Community health workers recognised an improvement in neonatal health over time. Key influencers to neonatal health were identified as knowledge, sociocultural behaviours, finances and transport, provision of care and healthcare engagement. Most influencers acted as both barriers and facilitators, with the exception of finances and transport that only acted as a barrier, and healthcare engagement that acted as a facilitator., Conclusion: Understanding health influencers and care-seeking behaviours is recognised to facilitate appropriate community health programmes. Key influencers and care-seeking behaviours have been identified from rural Cambodia adding to the current literature. Where facilitators have already been established, they should be used as building blocks for continued change., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Despite the unparalleled success of immunisation in the control of vaccine preventable diseases, immunisation coverage in South Africa remains suboptimal. While many evidence-based interventions have successfully improved vaccination coverage in other countries, they are not necessarily appropriate to the immunisation needs, barriers and facilitators of South Africa. The aim of this research is to investigate barriers and facilitators to optimal vaccination uptake, and develop contextualised strategies and implementation plans to increase childhood and adolescent vaccination coverage in South Africa., Methods: The study will employ a mixed-methods research design. It will be conducted over three iterative phases and use the Adopt, Contextualise or Adapt (ACA) model as an overarching conceptual framework. Phase 1 will identify, and develop a sampling frame of, immunisation stakeholders involved in the design, planning and implementation of childhood and human papillomavirus immunisation programmes in South Africa. Phase 2 will identify the main barriers and facilitators to, and solutions for, increasing vaccination coverage. This phase will comprise exploratory qualitative research with stakeholders and a review of existing systematic reviews on interventions for improving vaccination coverage. Using the findings from Phase 2 and the ACA model, Phase 3 will develop a set of proposed interventions and implementation action plans for improving immunisation coverage in South Africa. These plans will be discussed, revised and finalised through a series of participatory stakeholder workshops and an online questionnaire, conducted as part of Phase 3., Ethics: Ethical approval was obtained from the South African Medical Research Council (EC018-11/2018). No risks to participants are expected. Various steps will be taken to ensure the anonymity and confidentiality of participants., Dissemination: The study findings will be shared at stakeholder workshops, the website of Cochrane South Africa and academic publications and conferences., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Importance: While many organizations endorse screening for social risk factors in clinical settings, few studies have examined the health and utilization effects of interventions to address social needs., Objective: To compare the acute care utilization effects of a written resources handout vs an in-person navigation service intervention to address social needs., Design, Settings, and Participants: In this secondary analysis of a randomized clinical trial, 1809 adult caregivers of pediatric patients seen in primary and urgent care clinics of 2 safety-net hospitals in northern California were recruited between October 13, 2013, and August 27, 2015. Each participating family was randomly assigned to an in-person navigator intervention vs active control to address the family's social needs. Analyses were conducted between February 28, 2018, and September 25, 2019., Interventions: Caregivers either received written information about relevant local resources related to social needs (active control) or met with a patient navigator focused on helping them resolve social needs (navigator intervention). After an initial in-person visit, navigation services included telephone, email, and/or in-person follow-up for up to 3 months., Main Outcome and Measures: Child emergency department visit or hospitalization within 12 months of study enrollment., Results: Among the 1300 caregivers enrolled in the study without missing follow-up data, most spoke English (878 [67.5%]) and were women (1127 [86.7%]), with a mean (SD) age of 33.0 (9.33) years. Most children were aged 0 to 5 years (779 of 1300 [59.9%]), 723 children (55.6%) had Hispanic ethnicity, and 462 children (35.5%) were in excellent health; 840 families (64.6%) were recruited from urgent care. In total, 637 families (49.0%) were randomized to the in-person navigator group and 663 (51.0%) to the active control group. There was no difference in risk of an emergency department visit between the 2 groups. Children enrolled in the in-person navigator group had a decreased risk of hospitalization within 12 months (hazard ratio, 0.59; 05% CI, 0.38-0.94; P = .03), making them 69% less likely to be hospitalized., Conclusions and Relevance: In this randomized clinical trial evaluating heath care utilization effects of programs designed to address social needs among families, children enrolled in the navigation group were significantly less likely to be hospitalized after the intervention but equally likely to have an emergency department visit. These findings strengthen our understanding of the effects of addressing social needs in clinical settings as part of a comprehensive strategy to improve health and reduce health care utilization., Trial Registration: ClinicalTrials.gov Identifier: NCT01939704.

Background: Although World Health Organization works to make vaccination service available to everyone everywhere by 2030, majority of the world's children have been unvaccinated and unprotected from vaccine-preventable diseases. In fact, evidences on factors contributing to changes in vaccination coverage across residential areas, wealth categories and over time have not been adequate. Therefore, this study aimed at investigating inequalities in vaccination status of children aged 12-23 months owing to variations in wealth status, residential areas and over time., Methods: Maternal and child health service data were extracted from the 2011 and 2016 Ethiopian Demographic and Health Survey datasets. Then, multivariate decomposition analysis was done to identify the major factors contributing to differences in the rate of vaccination utilization across residences and time variations. Similarly, a concentration index and curve were also done to identify the concentration of child vaccination status across wealth categories., Results: Among children aged 12-23 months, the prevalence of complete childhood vaccination status increased from 20.7% in rural to 49.2% in urban in 2011 and from 31.7% in rural to 66.8% in urban residences in 2016. The decomposition analyses indicated that 72% in 2011 and 70.5% in 2016 of the overall difference in vaccination status was due to differences in respondent characteristics. Of the changes due to the composition of respondent characteristics, such as antenatal care and place of delivery were the major contributors to the increase in complete childhood vaccination in 2011, while respondent characteristics such as wealth index, place of delivery and media exposure were the major contributors to the increase in 2016. Of the changes due to differences in coefficients, those of low wealth status in 2016 across residences significantly contributed to the differences in complete childhood vaccination. On top of that, from 2011 to 2016, there was a significant increment in complete childhood vaccination status and a 59.8% of the overall increment between the surveys was explained by the difference in composition of respondents. With regard to the change in composition, the differences in composition of ANC visit, wealth status, place of delivery, residence, maternal education and media exposure across the surveys were significant predictors for the increase in complete child vaccination over time. On the other hand, the wealth-related inequalities in the utilization of childhood vaccination status were the pro-rich distribution of health services with a concentration index of CI = 0.2479 (P-value < 0.0001) in 2011 and [CI = 0.1987; P-value < 0.0001] in 2016., Conclusion: A significant rural-urban differentials was observed in the probability of a child receiving the required childhood vaccines. Children in urban households were specifically more likely to have completed the required number of vaccines compared to the rural areas in both surveys. The effect of household wealth status on the probability of a child receiving the required number of vaccines are similar in the 2011 and 2016 surveys, and the vaccination status was high in households with high wealth status. The health policies aimed at reducing wealth related inequalities in childhood vaccination in Ethiopia need to adjust focus and increasingly target vulnerable children in rural areas. It is of great value to policy-makers to understand and design a compensation mechanism for the costs incurred by poor households. Special attention should also be given to rural communities through improving their access to the media. The findings highlight the importance of women empowerment, for example, through education to enhance childhood vaccination services in Ethiopia.

Objectives: to understand the practices adopted by relatives regarding ostomized children care., Methods: qualitative approach, conducted with 11 relatives of ostomized children. Methodological framework was used as narrative technique; NVivo® software for data categorization and information analysis; content analysis technique., Results: participants revealed unpreparedness in dealing with children, lack of knowledge about handling materials and equipment inherent to ostomy and challenges faced in the daily life of children in school. They are unanimous in telling they feel encouraged and strengthened by receiving support from nurses in child care. They suggested the development of strategies to guide ostomized children care, such as educational material use., Conclusions: to understand family members' experience made it possible to support training and qualification of nursing professionals, and to establish priorities in care. Evidence found may contribute to reflections that aid health promotion and prevention of complications in ostomized children care.

Competing Interests: Competing interests: Seija Kromm and Deborah McNeil are employees of Alberta Health Services (AHS). David Johnson is remunerated through a contract with AHS. The Merck for Mothers global funding grant is a Merck initiative to reduce maternal mortality; Merck had no role in deciding how the MNCY SCN allocated the funds from that grant support. No other competing interests were declared.

Objective: This study investigated equity in enrollment in a Medicaid waiver program for early intensive behavioral intervention for children with autism spectrum disorder (ASD)., Methods: State administrative, Medicaid, and U.S. Census data for children enrolled in the waiver program between 2007 and 2015 (N=2,111) were integrated. Multivariate and bivariate analyses were used to compare enrollees' neighborhood demographic characteristics with those of the state's general population, with controls for enrollees' age, sex, and race-ethnicity., Results: Findings indicate that in general, enrollment was equitable. During the years in which there were inequities, children who lived in neighborhoods of privilege were favored. These neighborhoods had higher median incomes, lower poverty levels, and fewer female-headed households and were located in urban areas., Conclusions: As states work to provide equitable treatment to children with ASD and their families, it is important to track potential inequities between children who do and do not enroll in services and to use this information to inform outreach efforts. States may turn to South Carolina for insight on how to ensure equity.

Background: Good quality midwifery care has the potential to reduce both maternal and newborn mortality and morbidity in high, low, and lower-middle income countries (LMIC) and needs to be underpinned by effective education. There is considerable variation in the quality of midwifery education provided globally., Objective: To determine what are the most efficient and effective ways for LMICs to conduct pre-service and in-service education and training in order to adequately equip care providers to provide quality maternal and newborn care., Design: Rapid Systematic Evidence Review METHODS: A systematic search of the following databases was conducted: Medline, CINAHL, LILACs, PsycInfo, ERIC, and MIDIRs. Studies that evaluated the effects of pre-service and in-service education that were specifically designed to train, educate or upskill care providers in order to provide quality maternal and newborn care were included. Data was extracted and presented narratively., Findings: Nineteen studies were included in the review. Of these seven were evaluations of pre-service education programmes and 12 were evaluations of in-service education programmes. Whilst studies demonstrated positive effects on knowledge and skills, there was a lack of information on whether this translated into behaviour change and positive effects for women and babies. Moreover, the level of the evidence was low and studies often lacked an educational framework and theoretical basis. Mapping the skills taught in each of the programmes to the Quality Maternal and Newborn Care framework (Renfrew et al., 2014) identified that interventions focused on very specific or individual clinical skills and not on the broader scope of midwifery., Key Conclusions: There is a very limited quantity and quality of peer reviewed published studies of the effectiveness of pre service and in service midwifery education in LMICs; this is at odds with the importance of the topic to survival, health and well-being. There is a preponderance of studies which focus on training for specific emergencies during labour and birth. None of the in-service programmes considered the education of midwives to international standards with the full scope of competencies needed. There is an urgent need for the development of theoretically informed pre-service and in-service midwifery education programmes, and well-conducted evaluations of such programmes. Upscaling quality midwifery care for all women and newborn infants is of critical importance to accelerate progress towards Sustainable Development Goal 3. Quality midwifery education is an essential pre-requisite for quality care. To deliver SDG 3, the startling underinvestment in midwifery education identified in this review must be reversed., (Copyright © 2019. Published by Elsevier Ltd.)

The targets of the WHO's End TB Strategy and the United Nations' (UN) Sustainable Development Goals (SDGs) have been expanded to"Find. Treat. All #EndTB" with universal access to TB diagnosis, treatment and care by 2022 in an effort to end the global TB epidemic. Trends to achieve the above targets in children have led to greater emphasis on the newer diagnostics paving way to microbiological confirmation and universal drug sensitivity in children., (Copyright © 2019 Tuberculosis Association of India. Published by Elsevier B.V. All rights reserved.)

For 25 years, the American Academy of Pediatrics (AAP) Community Access to Child Health (CATCH) program has supported pediatricians in collaborating within their communities to advance the health of all children. CATCH grants support pediatric residents and pediatricians in planning or implementing community-based child health initiatives. The CATCH program has provided almost 10 million dollars through 842 planning, 585 resident, and 305 implementation grants to >1700 pediatricians. Urban, rural, suburban, and tribal communities in every state as well as the District of Columbia and Puerto Rico have benefited from CATCH-funded projects. Collaborations with community partners such as schools, homeless shelters, and mental health centers have led to programs serving children and families, especially those living in poverty and in minority groups. The most recent program data reveal that 87.5% of the projects are operating 2 years after funding. Many CATCH projects have not only sustained themselves but have grown into larger programs with funding from other sources. CATCH has influenced pediatricians' careers by providing important skills, networking opportunities, career legitimacy, mentoring opportunities, and increased engagement with the AAP. More than 350 pediatricians have served the AAP as CATCH facilitators, the network of physicians that provides technical assistance to applicants and reviews grant applications. Responding to changing trends, CATCH leaders have looked at other funding models and recently launched the CATCH-On initiative. CATCH-On creates and provides templates from successful CATCH projects to busy pediatricians who can then implement the project in their communities with minimal funding., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

Background: The number of EDs visit is on the increase, and the pressure on EDs is of significant concern worldwide. The usage of EDs by parents of children with minor illness is an important and still unresolved problem causing a burden to healthcare services. The aim of this study was to review the literature to summarise parental reasons for visiting ED for children with minor illness., Method: Seven electronic databases (Medline, Embase, PsycINFO, CINAHL, PubMed, Web of Science and Scopus) were comprehensively searched during a 2-week period in August 2016 and updated between 11 and 20 June 2018. The study selection process was undertaken independently by two authors. Qualitative and quantitative studies that focused on the reasons for parents of children with minor illness to attend an ED were included. Studies were assessed for quality and data were analysed by means of narrative synthesis., Results: Twenty-four studies were included. Eleven studies employed quantitative methods, eleven studies used qualitative methods and two studies used mixed methods. Parental reasons for using ED included perceived urgency, ED advantages (eg, faster service, superior ED resources and efficiency), difficulties with getting a general practitioner appointment, lack of facilities in primary healthcare services, lack of health insurance, reassurance, convenience and access., Conclusion: This review identified some of the reasons why parents bring their children to the ED for minor illnesses highlighting the multifaceted nature of this problem. Understanding parental reasons behind their choice to use the ED may help us better design targeted interventions to reduce unnecessary ED visits and alleviate the burden on overstretched healthcare services. This review may help inform emergency care policy makers, researchers and healthcare staff to understand parents' reasons for visiting the ED, to better meet their healthcare needs., Competing Interests: Competing interests: The reviewers declare that there are no conflicts of interest. This review has been completed as part of Butun’s PhD studies at Queen’s University Belfast., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Paediatric organ transplantation today is considered and accepted and widely available therapy in children with end-stage organ failure. It is important to know that in childhood, diseases leading to end-stage organ failure differ from those in adults. Beside this, in children there are different surgical and paediatric challenges before and after transplantation (size differences of the patient and donor organ, special and paediatric infections, different pharmacokinetics and pharmacodynamics of immunosuppressive drugs, noncompliance). However, paediatric organ transplantation in the last decades became a success story of the Hungarian health care owing to several working groups in Hungary and outside the country. Orv Hetil. 2018; 159(46): 1948-1956.

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

In recent years, there have been significant advances in genetic technologies, evolving the field of genomics from genetics. This has huge diagnostic potential, as genomic testing increasingly becomes part of mainstream medicine. However, there are numerous potential pitfalls in the interpretation of genomic data. It is therefore essential that we educate clinicians more widely about the appropriate interpretation and utilisation of genomic testing., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.

In a Perspective, Lawrence Stanberry and colleagues discuss impacts of climate change on children., Competing Interests: I have read the journal's policy, and the authors of this manuscript have the following competing interests: MCT served as Guest Editor in PLOS Medicine’s Special Issue on Climate Change and Health.

Objectives: Shared care plans play an essential role in coordinating care across health care providers and settings for children with medical complexity (CMC). However, existing care plans often lack shared ownership, are out-of-date, and lack universal accessibility. In this study, we aimed to establish requirements for shared care plans to meet the information needs of caregivers and providers and to mitigate current information barriers when caring for CMC., Methods: We followed a user-centered design methodology and conducted in-depth semistructured interviews with caregivers and providers of CMC who receive care at a tertiary care children's hospital. We applied inductive, thematic analysis to identify salient themes. Analysis occurred concurrently with data collection; therefore, the interview guide was iteratively revised as new questions and themes emerged., Results: Interviews were conducted with 17 caregivers and 22 providers. On the basis of participant perspectives, we identified 4 requirements for shared care plans that would help meet information needs and mitigate current information barriers when caring for CMC. These requirements included the following: (1) supporting the accessibility of care plans from multiple locations (eg, cloud-based) and from multiple devices, with alert and search features; (2) ensuring the organization is tailored to the specific user; (3) including collaborative functionality such as real-time, multiuser content management and secure messaging; and (4) storing care plans on a secure platform with caregiver-controlled permission settings., Conclusions: Although further studies are needed to understand the optimal design and implementation strategies, shared care plans that meet these specified requirements could mitigate perceived information barriers and improve care for CMC., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

This article aims to identify changes in indicators for the organization of children's health services in primary care in the State of São Paulo, Brazil. An evaluative study was conducted with three series of cross-sectional evaluations with participation by 81 services, involving 32 municipalities (counties) in the central-west region of the state, who answered the Quali AB questionnaire in 2007, 2010, and 2014. The analysis used 74 children's health indicators and 7 services indicators. Comparison of the indicators evidenced changes in the organization of children's healthcare, with an improvement in the majority of the indicators in 2010 and maintenance or worsening in 2014, compared to 2007. In conclusion, children's health policy recommendations have not been fully realized in the organization of the supply of comprehensive care, although relevant issues such as childhood obesity and violence have been addressed by a few services.

Background: Electronic health records (EHRs) have been widely proposed as a mechanism for improving health care quality. However, rigorous research on the impact of EHR systems on behavioral health service delivery is scant, especially for children and adolescents., Objective: The current study evaluated the usability of an EHR developed to support the implementation of the Wraparound care coordination model for children and youth with complex behavioral health needs, and impact of the EHR on service processes, fidelity, and proximal outcomes., Methods: Thirty-four Wraparound facilitators working in two programs in two states were randomized to either use the new EHR (19/34, 56%) or to continue to implement Wraparound services as usual (SAU) using paper-based documentation (15/34, 44%). Key functions of the EHR included standard fields such as youth and family information, diagnoses, assessment data, and progress notes. In addition, there was the maintenance of a coordinated plan of care, progress measurement on strategies and services, communication among team members, and reporting on services, expenditures, and outcomes. All children and youth referred to services for eight months (N=211) were eligible for the study. After excluding those who were ineligible (69/211, 33%) and who declined to participate (59/211, 28%), a total of 83/211 (39%) children and youth were enrolled in the study with 49/211 (23%) in the EHR condition and 34/211 (16%) in the SAU condition. Facilitators serving these youth and families and their supervisors completed measures of EHR usability and appropriateness, supervision processes and activities, work satisfaction, and use of and attitudes toward standardized assessments. Data from facilitators were collected by web survey and, where necessary, by phone interviews. Parents and caregivers completed measures via phone interviews. Related to fidelity and quality of behavioral health care, including Wraparound team climate, working alliance with providers, fidelity to the Wraparound model, and satisfaction with services., Results: EHR-assigned facilitators from both sites demonstrated the robust use of the system. Facilitators in the EHR group reported spending significantly more time reviewing client progress (P=.03) in supervision, and less time overall sending reminders to youth/families (P=.04). A trend toward less time on administrative tasks (P=.098) in supervision was also found. Facilitators in both groups reported significantly increased use of measurement-based care strategies overall, which may reflect cross-group contamination (given that randomization of staff to the EHR occurred within agencies and supervisors supervised both types of staff). Although not significant at P<.05, there was a trend (P=.10) toward caregivers in the EHR group reporting poorer shared agreement on tasks on the measure of working alliance with providers. No other significant between-group differences were found., Conclusions: Results support the proposal that use of EHR systems can promote the use of client progress data and promote efficiency; however, there was little evidence of any impact (positive or negative) on overall service quality, fidelity, or client satisfaction. The field of children's behavioral health services would benefit from additional research on EHR systems using designs that include larger sample sizes and longer follow-up periods., Trial Registration: ClinicalTrials.gov NCT02421874; https://clinicaltrials.gov/ct2/show/NCT02421874 (Archived by WebCite at http://www.webcitation.org/6yyGPJ3NA)., (©Eric J Bruns, Alyssa N Hook, Elizabeth M Parker, Isabella Esposito, April Sather, Ryan M Parigoris, Aaron R Lyon, Kelly L Hyde. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 14.06.2018.)

Aims: To explore 40 years of Child Development Centre (CDC) activity and outcomes at Northampton General Hospital 1974-2014., Methods: The study comprises 3 data sets: a published report from 1974 to 1999, an internal audit from 2001 to 2004, and more recent data collected from 2005 to 2014. The medical notes of all children who were assessed by the CDC in 2014 were reviewed, along with referral data collected by the CDC manager from this year and the preceding 10 years., Results: From January 1, 1974 to December 31, 2014, 3,786 children were assessed. The male to female ratio is 2.8:1 from 2005 to 2014. Referrals for behavioural difficulties increased from 10% (10/100 referrals) in 1999-2004 to 17.8% (18/101 referrals) in 2014. Similarly, referrals for social and communication problems, "interaction" increased two and a half fold from 10% (10/100 referrals) in 1999-2004 to 26.7% (27/101 referrals) in 2014. Between 2004 and 2014, numbers of referrals for "developmental delay" halved (22.2% to 12%)., Conclusion: We are aware of no other comparable extant UK CDC database. Services should plan for a referral rate of 6.5 per 1,000 preschool children. Between 1974 and 2014, there has clearly been a change in recorded assessment outcomes. From the mid-1980s, this reflects the change to a preschool assessment role and a shift away from purely educational outcome to include medical conditions. Covering 1974-2014, we demonstrate a clear increase in the number of referrals together with an increasing demand for assessments for social interaction and behavioural difficulties. This reflects the increased awareness of these neurodevelopmental difficulties and the changing diagnostic criteria which will now more likely result in an Autistic Spectrum Disorder diagnosis than previously. Together, these two features are most likely to have considerable implications for service development within Child Development Centres (CDCs) and Child Development Teams (CDTs)., (© 2018 John Wiley & Sons Ltd.)

Objectives: Parents of children with autism spectrum disorder (ASD) face competing demands when caring for their child and fulfilling family commitments. It remains unknown whether family obligations and parental stress might decrease the use of intervention services for young children with ASD., Methods: The current study is a secondary analysis of baseline date from a published randomized control trial with 147 low-resourced caregiver-child dyads. Demographic information, data on service use, maternal employment, parent's perception of their child's development, and parental stress were collected for primary caregivers of 2- to 5-year-old children with ASD from 5 sites. Multiple logistic regressions of accessing any intervention services or more than 1 services on familial characteristics were performed, controlling for demographic and contextual variables., Results: Twenty-five percent of children were receiving no intervention service; 26% were receiving 1 service; and 49% were receiving 2 or more services. Perceived developmental delay and not having a sibling in the home were associated with higher odds of receiving intervention services. Children were more likely to receive more than 1 service if their parents had at least a college education and low levels of stress., Conclusions: Factors including perceived developmental level, parental stress, and caring for siblings may play a role in accessing services for children with ASD. Results reveal that competing family needs may be barriers to service use. Mothers of children with ASD with multiple children in the home, low levels of education, and high levels of stress may need additional supports or alternative service delivery models., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Background: Knowledge has increased regarding the developmental needs and capabilities of infants, and parental behaviours that support optimum infant development. Despite a better understanding of the emotional dysregulation in borderline personality disorder (BPD) and its effects on infants, general practitioners have had few guidelines for how to recognise and help emotionally dysregulated mother-infant dyads., Objective: This article focuses on the behaviours and needs of infants whose mothers have BPD, including knowledge and skills for primary care practitioners to help these troubled families., Discussion: Understanding the adequacy of parenting and troubling infant signs, such as hypervigilance, can potentially lead to either more intervention in primary care, including support, reassurance, guidance regarding development and interaction, and enhanced family support or else specialist referral for enhanced infant care. Infants&rsquo; needs are urgent, and timely intervention can begin a better life trajectory for infant and mother.

This article, written by a group of experienced parents of children with medical complexity (CMC), provides an overview of the demands of managing care from their unique perspective. The article articulates why attention to understanding the challenges that families of CMC face with a fragmented health care system, inadequate health insurance coverage, deficits in the delivery of medical care, and problems accessing other critical services (as well as lack of support for children and adolescents in developing and exercising self-management skills) are vital to efforts to improve the current system and positively impact the life course of vulnerable populations. The authors discuss the financial and intangible costs experienced by families of CMC and other stakeholders (including providers, payers, and others), as well as the benefits that can result when effective, flexible, comanaged team-based care coordination is provided within the environment that is the most natural locus of care for the family. The authors detail the role of policy strategies that provide protections for CMC and the importance of family-led advocacy and support organizations in helping families "on the front lines." Throughout the article, the case is made that families authentically involved at every level of health care systems are critical partners in designing policies and systems that will improve care for CMC. The experiences of families of CMC should inform and guide efforts to improve systems of care, thus positively impacting the life course of this vulnerable population., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Children with medical complexity (CMC) often require multiple services across the continuum of care, such as therapies and home nursing. However, sufficient access to needed services is not assured and varies considerably by payer, many of whom who face pressures to control health spending. In this article, we review the rights of CMC in Medicaid, the Children's Health Insurance Program, and various forms of private health insurance to receive services that are necessary to promote optimal health, development, and family functioning. Controlling laws such as the Americans with Disabilities Act and the Early and Periodic Screening, Diagnostic, and Treatment provisions of the Medicaid Act are discussed, and precedential court decisions affecting CMC are reviewed. Implications for policy, advocacy, and payment model design are explored in the context of current emphasis on spending reduction., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Discourse about childhood chronic conditions has transitioned in the last decade from focusing primarily on broad groups of children with special health care needs to concentrating in large part on smaller groups of children with medical complexity (CMC). Although a variety of definitions have been applied, the term CMC has most commonly been defined as children and youth with serious chronic conditions, substantial functional limitations, increased health and other service needs, and increased health care costs. The increasing attention paid to CMC has occurred because these children are growing in impact, represent a disproportionate share of health system costs, and require policy and programmatic interventions that differ in many ways from broader groups of children with special health care needs. But will this change in focus lead to meaningful changes in outcomes for children with serious chronic diseases, or is the pediatric community simply adopting terminology with resonance in adult-focused health systems? In this article, we will explore the implications of the rapid emergence of pediatric complex care in child health services practice and research. As an emerging field, pediatric care systems should thoughtfully and rapidly develop evidence-based solutions to the new challenges of caring for CMC, including (1) clearer definitions of the target population, (2) a more appropriate incorporation of components of care that occur outside of hospitals, and (3) a more comprehensive outcomes measurement framework, including the recognition of potential limitations of cost containment as a target for improved care for CMC., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Children with medical complexity (CMC) are a subset of children and youth with special health care needs with high resource use and health care costs. Novel care delivery models in which care coordination and other services to CMC are provided are a focus of national and local health care and policy initiatives. Current models of care for CMC can be grouped into 3 main categories: (1) primary care-centered models, (2) consultative- or comanagement-centered models, and (3) episode-based models. Each model has unique advantages and disadvantages. Evaluations of these models have demonstrated positive outcomes, but most studies have limited generalizability for broader populations of CMC. A lack of standardized outcomes and population definitions for CMC hinders assessment of the comparative effectiveness of different models of care and identification of which components of the models lead to positive outcomes. Ongoing challenges include inadequate support for family caregivers and threats to the sustainability of models of care. Collaboration among key stakeholders (patients, families, providers, payers, and policy makers) is needed to address the gaps in care and create best practice guidelines to ensure the delivery of high-value care for CMC., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Children with medical complexity (CMC) have multiple chronic conditions and require an array of medical- and community-based providers. Dedicated care coordination is increasingly seen as key to addressing the fragmented care that CMC often encounter. Often conceptually misunderstood, care coordination is a team-driven activity that organizes and drives service integration. In this article, we examine models of care coordination and clarify related terms such as care integration and case management. The location of care coordination resources for CMC may range from direct practice provision to external organizations such as hospitals and accountable care organizations. We discuss the need for infrastructure building, design and implementation leadership, use of care coordination tools and training modules, and appropriate resource allocation under new payment models., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Objective: To analyze the care coordination for the child and adolescent in chronic condition and users planning in the Health Care Network., Method: Qualitative study, conducted with 26 health professionals and managers through Focus Groups. Thematic content analysis was used., Results: Care coordination is fragile, with lack of support from the management, and presence of high turnover of managers and professionals. The limits in the network planning are due to frequent changes in the careflow. Communication between levels of care and lack of counter-referral makes network care unfeasible., Final Considerations: There is a need for planning in the Health Care Network and establishment of careflow, as well as the construction of communication channels and tools of referral and counter-referral between professionals and services, for the constitution and integration of the network from the perspective of user-centered care.