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Objective: To compare and contrast notions of ADHD among pediatricians and parents of affected children to understand the perspectives they bring to shared decision making (SDM).Methods: In this freelisting study, 60 parents of children with ADHD and 30 primary care pediatricians listed words reflecting their understanding of (1) Attention Deficit Hyperactivity Disorder (ADHD), (2) getting/offering help for ADHD, (3) talking to doctors/families about ADHD, and (4) "mental health." Smith's salience score established terms that were salient and cultural consensus analysis identified variation within subgroups of participants.Results: Parents' terms reflected ADHD's effects on the child and family, while clinicians often mentioned school. Lists suggested differing needs and goals for clinicians and subgroups of parents in SDM: "time" for clinicians, "learning" and "understanding" for non-college educated parents, and "comfort" and "relief" for college educated parents. Neither parents nor clinicians framed ADHD in the same way as "mental health."Conclusion: Parents and clinicians, who conceptualize ADHD differently, should negotiate a shared understanding of ADHD as a basis for SDM. Treatment discussions should be tailored to encompass families' varied emotional and educational needs.Practice Implications: Fostering SDM in primary care is consonant with notions of ADHD as distinct from mental health. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The goal was to assess the impact of influenza vaccine clinical alerts on missed opportunities for vaccination and on overall influenza immunization rates for children and adolescents with asthma. METHODS: A prospective, cluster-randomized trial of 20 primary care sites was conducted between October 1, 2006, and March 31, 2007. At intervention sites, electronic health record-based clinical alerts for influenza vaccine appeared at all office visits for children between 5 and 19 years of age with asthma who were due for vaccine. The proportion of captured immunization opportunities at visits and overall rates of complete vaccination for patients at intervention and control sites were compared with those for the previous year, after standardization for relevant covariates. The study had >80% power to detect an 8% difference in the change in rates between the study and baseline years at intervention versus control practices. RESULTS: A total of 23 418 visits and 11 919 children were included in the study year and 21 422 visits and 10 667 children in the previous year. The majority of children were male, 5 to 9 years of age, and privately insured. With standardization for selected covariates, captured vaccination opportunities increased from 14.4% to 18.6% at intervention sites and from 12.7% to 16.3% at control sites, a 0.3% greater improvement. Standardized influenza vaccination rates improved 3.4% more at intervention sites than at control sites. The 4 practices with the greatest increases in rates (>or=11%) were all in the intervention group. Vaccine receipt was more common among children who had been vaccinated previously, with increasing numbers of visits, with care early in the season, and at preventive versus acute care visits. CONCLUSIONS: Clinical alerts were associated with only modest improvements in influenza vaccination rates. [ABSTRACT FROM AUTHOR]

OBJECTIVES: We assessed the validity of reported varicella history as a marker for varicella zoster virus immunity among unvaccinated persons 1 to 29 years of age, and we examined varicella disease characteristics associated with varicella zoster virus immunity among those reporting positive histories. METHODS: We conducted a cross-sectional study at 7 community-based sites in Philadelphia, Pennsylvania, between June 2004 and May 2006 and recruited 1476 participants 1 to 29 years of age who had not been vaccinated against varicella. Sensitivity, specificity, and positive predictive value were determined by comparing self-reported or parent-reported varicella histories from a standardized study interview with varicella zoster virus immunoglobulin G serological results for each participant. We performed multivariate logistic regression analyses to determine which disease characteristics best predicted seropositivity. RESULTS: The sensitivity of reported varicella history was highest (81%-89%) among participants > or =10 years of age, whereas specificity was highest among participants 1 to 4 years of age (99%) and > or =20 years (88%). Reported varicella history was highly predictive of seropositivity (>95%) only among participants > or =15 years of age. For participants 10 to 14 years of age, parental reports of a generalized itchy rash with 1 of the following were highly predictive of seropositivity: varicella transmission to another household member or being raised in a household with no other children. Among participants < or =9 years of age, no combination of disease characteristics was both highly predictive of seropositivity and common. CONCLUSIONS: The validity of reported varicella history varies according to age, and a reported history is no longer highly predictive of seropositivity among cohorts born since 1994 (participants < or =9 years of age). Universal varicella vaccination, regardless of history, for these children should be considered, as should simplified criteria for varicella zoster virus immunity among unvaccinated persons born before 1994. [ABSTRACT FROM AUTHOR]

OBJECTIVE: An opportunity exists to use increasingly prevalent electronic health records to efficiently gather immunization, clinical, and demographic data to assess and subsequently reduce barriers to immunization. The objective of this study was to use data entered at the point of care within an electronic health record to identify factors that predispose children in an inner-city population to immunization delay. METHODS: Retrospective cohort data from an electronic health record were used to evaluate the association between demographic, clinical, and immunization variables on immunization delay at 24 months. Patients 2 to 5 years old as of May 31, 2003, with an office visit between May 31, 2002, and May 31, 2003, were selected (N = 5464). Univariate and multivariable models were developed to predict vaccination delay at 24 months per the Advisory Committee on Immunization Practices guidelines. RESULTS: Overall up-to-date immunization rates at 3, 7, 13, and 24 months were 75%, 45%, 82%, and 71%. Multivariable models using electronic health record data showed that early immunization status was the strongest predictor of immunization delay at 24 months. Multivariate analysis revealed that children who were inadequately immunized at 3 months of age were more than 4.5 times as likely to be immunization delayed at 24 months. In this analysis, patient and caregiver factors associated with immunization delay included insurance status and nonparent caregiver. Children who were premature were less likely to be delayed. CONCLUSIONS: Using an electronic health record with information entered at the point of care, we found that early immunization status is a strong predictor of immunization delay for young children that can be identified as early as 3 months of age. Electronic health records may prove useful to clinicians and health systems in identifying children at high risk for immunization delay. [ABSTRACT FROM AUTHOR]

Objectives: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and Supplemental Nutrition Assistance Program (SNAP) provide essential nutrition support for low-income families. However, many eligible families do not receive or fully redeem these benefits. We aimed to understand current and former WIC and SNAP beneficiaries' perceptions of and suggestions for improving both programs., Methods: We conducted semistructured phone interviews with caregivers of pediatric patients who were current or former WIC and SNAP beneficiaries at 2 academic pediatric primary care clinics. Interviews were recorded, transcribed, and coded by 2 independent coders using thematic analysis, resolving discrepancies by consensus. Interviews continued until data saturation was reached., Results: We interviewed 40 caregivers who were predominantly Black (88%) mothers (90%), with 53% and 83% currently using WIC and SNAP, respectively. We identified 4 themes related to participation barriers: (1) limited product variety available through WIC, (2) inconvenience and stigma associated with purchasing WIC products, (3) SNAP income-based eligibility criteria, and (4) burdensome SNAP enrollment and recertification processes. We identified 3 themes related to suggestions for improvement: (a) decreasing stigma associated with participation, (b) allowing online or phone-based enrollment, and (c) improving coordination with health care systems., Conclusions: WIC and SNAP beneficiaries identified several modifiable barriers to enrollment and benefits redemption. Pediatric providers should advocate for programmatic improvements that make it easier for families to access and redeem benefits and should consider implementing innovative cross-sector interventions like medical-financial partnerships, direct WIC and SNAP referrals, and data sharing with government assistance offices., (Copyright © 2024 by the American Academy of Pediatrics.)

Objectives: Explore pediatric staff experiences administering the second influenza vaccine dose., Study Design: Qualitative focus groups/interviews., Methods: As part of the National Institutes of Health-funded Flu2Text randomized control trial of text message reminders for second influenza vaccine dose, we conducted seven focus groups and four individual interviews (n = 39 participants total) with clinicians and staff from participating practices from the American Academy of Pediatrics' Pediatric Research in Office Settings (PROS) Network. Of 37 participating practices, 10 were selected through stratified sampling of practices with highest (n = 5) and lowest (n = 5) randomized controlled trial effect sizes. A semi-structured discussion guide included questions that addressed parental, practice, and health system barriers/facilitators to second influenza vaccine dose administration. Using the Systems Model of Clinical Preventive Care as a conceptual framework, two investigators independently coded transcripts (Κ = 0.86, high agreement) with NVivo 12 Plus. Coding inconsistencies were resolved by consensus., Results: Clinicians/staff reported that administering the second influenza vaccine dose in a season was more complex than other childhood vaccines. They highlighted parental uncertainty about the need for the second dose and the difficulty and inconvenience of bringing children back to the office as important barriers. Caregiver-staff relationships were perceived as helpful in getting children vaccinated with their second dose and vaccine reminders were seen as important cues-to-action., Conclusions: Ensuring receipt of two doses of the influenza vaccine in a given season presents unique challenges. Themes identified provide a framework for understanding opportunities to bolster second dose receipt, including explaining why two doses are needed, offering flexible hours for vaccination, and sending vaccine reminders., (Copyright © 2024 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Importance: Lesbian, gay, bisexual, transgender, queer, and/or questioning (LGBTQ+) youth face worse mental health outcomes than non-LGBTQ+ peers. Family support may mitigate this, but sparse evidence demonstrates this in clinical settings., Objectives: To compare depression and suicide risk between LGBTQ+ and non-LGBTQ+ youth in primary care settings and to investigate whether family support mitigates these negative mental health outcomes., Design, Setting, and Participants: This cross-sectional study uses data from well care visits completed by adolescents aged 13 to 19 years from February 2022 through May 2023, including the Patient Health Questionnaire-9 Modified for Teens (PHQ-9-M) and the Adolescent Health Questionnaire (AHQ; an electronic screener assessing identity, behaviors, and guardian support), at 32 urban or suburban care clinics in Pennsylvania and New Jersey., Exposures: The primary exposure was self-reported LGBTQ+ status. Family support moderators included parental discussion of adolescent strengths and listening to feelings. Race and ethnicity (determined via parent or guardian report at visit check-in), sex, payer, language, age, and geography were covariates., Main Outcomes and Measures: PHQ-9-M-derived mental health outcomes, including total score, recent suicidal ideation, and past suicide attempt., Results: The sample included 60 626 adolescents; among them, 9936 (16.4%) were LGBTQ+, 15 387 (25.5%) were Black, and 30 296 (50.0%) were assigned female sex at birth. LGBTQ+ youth, compared with non-LGBTQ+ youth, had significantly higher median (IQR) PHQ-9-M scores (5 [2-9] vs 1 [0-3]; P < .001) and prevalence of suicidal ideation (1568 [15.8%] vs 1723 [3.4%]; P < .001). Fewer LGBTQ+ youth endorsed parental support than non-LGBTQ+ youth (discussion of strengths, 8535 [85.9%] vs 47 003 [92.7%]; P < .001; and listening to feelings, 7930 [79.8%] vs 47 177 [93.1%]; P < .001). In linear regression adjusted for demographic characteristics and parental discussion of strengths, LGBTQ+ status was associated with a higher PHQ-9-M score (mean difference, 3.3 points; 95% CI, 3.2-3.3 points). In logistic regression, LGBTQ+ youth had increased adjusted odds of suicidal ideation (adjusted odds ratio, 4.3; 95% CI, 4.0-4.7) and prior suicide attempt (adjusted odds ratio, 4.4; 95% CI, 4.0-4.7). Parental support significantly moderated the association of LGBTQ+ status with PHQ-9-M score and suicidal ideation, with greater protection against these outcomes for LGBTQ+ vs non-LGBTQ+ youth., Conclusions and Relevance: Compared with non-LGBTQ+ youth, LGBTQ+ youth at primary care visits had more depressive symptoms and higher odds of suicidal ideation and prior suicide attempt. Youth-reported parental support was protective against these outcomes, suggesting potential benefits of family support-focused interventions to mitigate mental health inequities for LGBTQ+ youth.

The Multiphase Optimization Strategy (MOST) is a three-phase iterative framework that could accelerate the development of behavioral interventions. This systematic review and meta-analysis was conducted within the MOST preparation phase and aimed to classify components included in pediatric sleep duration interventions, using the Behavior Change Technique (BCT) Taxonomy. Across 37 interventions, 46 out of 93 BCTs have been used, with an average of 8 techniques used per study. The most common BCTs used were instruction on how to perform the behavior (N = 29; code 4.1), practical social support (N = 22; code: 3.2), and behavioral practice/rehearsal (N = 22; code: 8.1). A latent class analysis identified two classes of interventions, distinguished by the presence of BCTs falling within the following behavior change groups: shaping knowledge, natural consequences, comparison of behavior, and repetition and substitution. Our meta-analysis revealed that interventions belonging to the latent class with these behavior change groups (N = 15) had a pooled positive intervention effect of 14 min (95 % CI: 8-21) versus 8 min (95 % CI: 1-15) for interventions without these behavior change groups (N = 19). This systematic review and meta-analysis will enhance the development of sleep promotion interventions and guide the selection of candidate intervention components for future optimization and randomized control trials., (Copyright © 2024. Published by Elsevier Ltd.)

Importance: Most research to understand postacute sequelae of SARS-CoV-2 infection (PASC), or long COVID, has focused on adults, with less known about this complex condition in children. Research is needed to characterize pediatric PASC to enable studies of underlying mechanisms that will guide future treatment., Objective: To identify the most common prolonged symptoms experienced by children (aged 6 to 17 years) after SARS-CoV-2 infection, how these symptoms differ by age (school-age [6-11 years] vs adolescents [12-17 years]), how they cluster into distinct phenotypes, and what symptoms in combination could be used as an empirically derived index to assist researchers to study the likely presence of PASC., Design, Setting, and Participants: Multicenter longitudinal observational cohort study with participants recruited from more than 60 US health care and community settings between March 2022 and December 2023, including school-age children and adolescents with and without SARS-CoV-2 infection history., Exposure: SARS-CoV-2 infection., Main Outcomes and Measures: PASC and 89 prolonged symptoms across 9 symptom domains., Results: A total of 898 school-age children (751 with previous SARS-CoV-2 infection [referred to as infected] and 147 without [referred to as uninfected]; mean age, 8.6 years; 49% female; 11% were Black or African American, 34% were Hispanic, Latino, or Spanish, and 60% were White) and 4469 adolescents (3109 infected and 1360 uninfected; mean age, 14.8 years; 48% female; 13% were Black or African American, 21% were Hispanic, Latino, or Spanish, and 73% were White) were included. Median time between first infection and symptom survey was 506 days for school-age children and 556 days for adolescents. In models adjusted for sex and race and ethnicity, 14 symptoms in both school-age children and adolescents were more common in those with SARS-CoV-2 infection history compared with those without infection history, with 4 additional symptoms in school-age children only and 3 in adolescents only. These symptoms affected almost every organ system. Combinations of symptoms most associated with infection history were identified to form a PASC research index for each age group; these indices correlated with poorer overall health and quality of life. The index emphasizes neurocognitive, pain, and gastrointestinal symptoms in school-age children but change or loss in smell or taste, pain, and fatigue/malaise-related symptoms in adolescents. Clustering analyses identified 4 PASC symptom phenotypes in school-age children and 3 in adolescents., Conclusions and Relevance: This study developed research indices for characterizing PASC in children and adolescents. Symptom patterns were similar but distinguishable between the 2 groups, highlighting the importance of characterizing PASC separately for these age ranges.

Background and Objectives: Adolescent strengths and risks are not routinely captured in systematized and actionable ways in pediatric primary care. To address this problem, we developed a comprehensive adolescent health questionnaire (AHQ) integrated within the electronic health record and evaluated the AHQ's impact on collection of information on prioritized health-related domains., Methods: We developed and pilot tested the AHQ. We then scaled and assessed the AHQ's impact on data collection. AHQ development used innovation methods and measured feasibility and acceptability outcomes. Scaling and postscaling outcomes included Reach, Effectiveness, Adoption, Implementation, Maintenance and Sustainability measures: Reach (total questionnaires completed), Effectiveness (capture of key information across health domains pre- vs post-AHQ scaling), Adoption (proportion of practices that adopted the AHQ), Implementation (proportion of eligible adolescents who completed the AHQ), and Maintenance (monthly completion rates)., Results: AHQ development led to a tool that was feasible and acceptable for use. During scaling (October 2020-December 2021), 22 147 questionnaires were completed by 20 749 unique adolescents aged 13 to 21 years at their preventive visit. Comparing pre- versus post-AHQ scaling data, use of the AHQ increased collection of information across domains, especially for strengths, gun safety, substance use, sexual activity, sexual orientation, and gender identity, from ranges of 0%-25% to 92%-95%. All 31 practices adopted the AHQ with completion at 88.7% of visits (n = 24 968). Two years postscaling, completion rates were >91% per month., Conclusions: We successfully developed, scaled, and maintained an AHQ in a widely-used electronic health record system, a model for improving adolescent care and foundation for developing future interventions., (Copyright © 2024 by the American Academy of Pediatrics.)

Objectives: Sleep disorders impact at least 10 % of children, pose risks to overall wellbeing, and are key targets of preventive interventions. The objectives of this study were to describe the prevalence of pediatric sleep disorder diagnoses across sociodemographic characteristics and co-occurring conditions, and to explore potential sociodemographic disparities., Methods: Cross-sectional analysis of 12,394,902 children (0-17 years; 50.9 % Medicaid-insured) in the 2017 MarketScan database. Prevalence was assessed utilizing ICD-10 codes, with multivariate logistic regressions examining disparities (insurance coverage; race and ethnicity in Medicaid-insured) for diagnoses in ≥0.10 % of children., Results: The prevalence of sleep disorder diagnoses was 2.36 %. The most common diagnoses were obstructive sleep disordered breathing (oSDB, 1.17 %), unspecified sleep disorders (0.64 %), insomnia (0.52 %), and other SDB (0.10 %), with <0.10 % for all other diagnoses. Insomnia and parasomnias diagnoses were much lower than diagnostic estimates. Sleep diagnoses were more prevalent in Medicaid versus commercially insured youth, 2-5-year-olds, and in children with co-occurring medical, neurodevelopmental, or behavioral health conditions. Girls and boys were generally equally likely to be diagnosed with any sleep disorder. In Medicaid-insured children, white children were more likely to have any sleep diagnosis compared to all other racial and ethnic groups. Black/African American children were more likely than white children to have oSDB., Conclusions: Compared to diagnostic estimates, claims data suggest sleep disorders are under-diagnosed, with notable sociodemographic disparities. Findings suggest a need for clinical resources to identify and address sleep disorders and to understand biases potentially driving disparities, given that sleep is a modifiable determinant of child wellbeing., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Ariel A. Williamson reports financial support was provided by National Institute of Child Health and Human Development. Jodi A. Mindell reports a relationship with Johnson & Johnson Services Inc, a subsidiary of Kenvue, that includes: consulting or advisory and funding grants. Corresponding author Ariel A. Williamson is an editorial board member for Sleep Health, the official journal of the National Sleep Foundation. - If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

The COVID-19 pandemic has been associated with increases in pediatric obesity and widening pre-existing disparities. To better understand the pandemic's long-term impacts, we evaluated trends in obesity across different demographic groups during the pandemic through December 2022. Using a retrospective cohort design, we analyzed electronic health record data from a large pediatric primary care network. Logistic regression models fit using generalized estimating equations estimated odds ratios (ORs) for changes in the level and trajectory of obesity across 2-year month-matched periods: prepandemic (June 2017 to December 2019) and pandemic (June 2020 to December 2022). Among a cohort of 153,667 patients with visits in each period, there was a significant increase in the level of obesity at the pandemic onset [OR: 1.229, 95% confidence interval (CI): 1.211-1.247] followed by a significant decrease in the trend for obesity (OR: 0.993, 95% CI: 0.992-0.993). By December 2022, obesity had returned to prepandemic levels. However, persistent sociodemographic disparities remain.

Study Objectives: The purpose of this study was to characterize the incidence of pediatric narcolepsy diagnosis, subsequent care, and potential sociodemographic disparities in a large US claims database., Methods: Merative MarketScan insurance claims (n = 12,394,902) were used to identify youth (6-17 years of age) newly diagnosed with narcolepsy ( International Classification of Diseases, 10th revision codes). Narcolepsy diagnosis and care 1 year postdiagnosis included polysomnography with Multiple Sleep Latency Test, pharmacological care, and clinical visits. Potential disparities were examined by insurance coverage and child race and ethnicity (Medicaid-insured only)., Results: The incidence of narcolepsy diagnosis was 10:100,000, primarily type 2 (69.9%). Most diagnoses occurred in adolescents with no sex differences, but higher rates in Black vs White youth with Medicaid. Two thirds had a prior sleep disorder diagnosis and 21-36% had other co-occurring diagnoses. Only half (46.6%) had polysomnography with Multiple Sleep Latency Test (± 1 year postdiagnosis). Specialty care (18.9% pulmonary, 26.9% neurology) and behavioral health visits were rare (34.4%), although half were prescribed stimulant medications (51.0%). Medicaid-insured were 86% less likely than commercially insured youth to have any clinical care and 33% less likely to have polysomnography with Multiple Sleep Latency Test., Conclusions: Narcolepsy diagnoses occurred in 0.01% of youth, primarily during adolescence, and at higher rates for Black vs White children with Medicaid. Only half overall had evidence of a diagnostically required polysomnography with Multiple Sleep Latency Test, underscoring potential misdiagnosis. Many patients had co-occurring conditions, but specialty and behavioral health care were limited. Results suggest misdiagnosis, underdiagnosis, and limited narcolepsy treatment, as well as possible disparities. Results highlight the need to identify determinants of evidence-based pediatric narcolepsy diagnosis and management., Citation: Tang SH, Min J, Zhang X, et al. Incidence of pediatric narcolepsy diagnosis and management: evidence from claims data. J Clin Sleep Med . 2024;20(7):1141-1151., (© 2024 American Academy of Sleep Medicine.)

Objectives: In 2005, the American Academy of Pediatrics founded the Partnership for Policy Implementation (PPI). The PPI has collaborated with authors to improve the quality of clinical guidelines, technical reports, and policies that standardize care delivery, improve care quality and patient outcomes, and reduce variation and costs., Methods: In this article, we describe how the PPI trained informaticians apply a variety of tools and techniques to these guidance documents, eliminating ambiguity in clinical recommendations and allowing guideline recommendations to be implemented by practicing clinicians and electronic health record (EHR) developers more easily., Results: Since its inception, the PPI has participated in the development of 45 published and 27 in-progress clinical practice guidelines, policy statements, technical and clinical reports, and other projects endorsed by the American Academy of Pediatrics. The partnership has trained informaticians to apply a variety of tools and techniques to eliminate ambiguity or lack of decidability and can be implemented by practicing clinicians and EHR developers., Conclusions: With the increasing use of EHRs in pediatrics, the need for medical societies to improve the clarity, decidability, and actionability of their guidelines has become more important than ever., (Copyright © 2024 by the American Academy of Pediatrics.)

Purpose: We sought to elicit perspectives on HIV and sexually transmitted infection (STI) prevention among adolescents with recent STIs in primary care to optimize acceptability and effectiveness in designing a novel HIV/STI prevention intervention., Methods: We enrolled 13-19 year-olds with recent gonorrhea, chlamydia, trichomonas, and/or syphilis in a multimethods cross-sectional study at two primary care clinics. Participants completed surveys and interviews. We used an integrated analytic approach deductively coding data using the Integrated Behavioral Model, then inductively coding to identify themes not represented in the Integrated Behavioral Model., Results: Participants (n = 35) were 85% cisgender female, 14% cisgender male, 1% transgender female; 25% identified as lesbian, bisexual, or queer. Most (97%) identified as non-Latinx Black. None used condoms consistently, 26% were aware of pre-exposure prophylaxis (PrEP), and 31% were never HIV tested. Five key themes emerged. 1) Mental health was central to HIV prevention behavior uptake and coping with STI diagnosis. 2) Youth desired prevention counseling that allowed decisional autonomy and individualized goal setting. 3) Negative social norms around condoms and absent norms around HIV testing and PrEP limited method uptake. 4) Both confidence and concrete skills were needed to initiate prevention methods. 5) Youth desired education at the time of STI diagnosis to improve subsequent prevention decision making., Discussion: Key intervention design considerations included 1) integrating mental health assessment and referral to services, 2) promoting individualized goal setting, 4) building communication skills, 4) providing navigation and material support for PrEP uptake and HIV testing, and 5) augmenting comprehensive STI and HIV prevention education., (Copyright © 2024 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Importance: The prevalence, pathophysiology, and long-term outcomes of COVID-19 (post-acute sequelae of SARS-CoV-2 [PASC] or "Long COVID") in children and young adults remain unknown. Studies must address the urgent need to define PASC, its mechanisms, and potential treatment targets in children and young adults., Observations: We describe the protocol for the Pediatric Observational Cohort Study of the NIH's REsearching COVID to Enhance Recovery (RECOVER) Initiative. RECOVER-Pediatrics is an observational meta-cohort study of caregiver-child pairs (birth through 17 years) and young adults (18 through 25 years), recruited from more than 100 sites across the US. This report focuses on two of four cohorts that comprise RECOVER-Pediatrics: 1) a de novo RECOVER prospective cohort of children and young adults with and without previous or current infection; and 2) an extant cohort derived from the Adolescent Brain Cognitive Development (ABCD) study (n = 10,000). The de novo cohort incorporates three tiers of data collection: 1) remote baseline assessments (Tier 1, n = 6000); 2) longitudinal follow-up for up to 4 years (Tier 2, n = 6000); and 3) a subset of participants, primarily the most severely affected by PASC, who will undergo deep phenotyping to explore PASC pathophysiology (Tier 3, n = 600). Youth enrolled in the ABCD study participate in Tier 1. The pediatric protocol was developed as a collaborative partnership of investigators, patients, researchers, clinicians, community partners, and federal partners, intentionally promoting inclusivity and diversity. The protocol is adaptive to facilitate responses to emerging science., Conclusions and Relevance: RECOVER-Pediatrics seeks to characterize the clinical course, underlying mechanisms, and long-term effects of PASC from birth through 25 years old. RECOVER-Pediatrics is designed to elucidate the epidemiology, four-year clinical course, and sociodemographic correlates of pediatric PASC. The data and biosamples will allow examination of mechanistic hypotheses and biomarkers, thus providing insights into potential therapeutic interventions., Clinical Trials.gov Identifier: Clinical Trial Registration: http://www.clinicaltrials.gov. Unique identifier: NCT05172011., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: Brett Anderson reported receiving direct support for work not related to RECOVER work/publications from Genentech and the National Institute of Allergy and Immunology. Walter Dehority reported receiving grant support from Merck and participating in research for the Moderna COVID-19 pediatric vaccine trial and the Pfizer Paxlovid trial. Alex Fiks reported receiving support from NJM insurance and personal consulting fees not related to this paper from Rutgers University and the American Academy of Pediatrics. Ashraf Harahsheh reported serving as a scientific advisory board member unrelated to this paper for OP2 DRUGS. Lawrence Kleinman reported serving as an unpaid member of the Board of Directors for the DARTNet Institute, as a principle investigator at Quality Matters, Inc., and as the Vice Chair for the Borough of Metuchen Board of Health. Dr. Kleinman also reported grant support for work not related to RECOVER work/publications from NIH, HRSA, and the Robert Wood Johnson Foundation. Dr. Kleinman also reported minority individual stock ownership in Apple Computer, Sanofi SA, Experion, GlaxoSmithKline, Magyar Bank, Regeneron Pharmaceuticals, JP Morgan Chase, and Amgen Inc. Torri Metz reported participating as a Principle Investigator in the medical advisory board for the planning of a Pfizer clinical trial of SARS-CoV-2 vaccination in pregnancy. She is also a principle investigator for a Pfizer study evaluating the pharmacokinetics of Paxlovid in pregnant people with COVID-19. Joshua Milner reported serving as a member of the Scientific Advisory Board for Blueprint Medicines, in a capacity unrelated to RECOVER work/publications. This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2024 Gross et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objective: The American Academy of Pediatrics recommends that pediatric providers screen families for food insecurity and connect them to appropriate resources. However, it is unclear how clinics can best provide families with resources consistent with their needs and preferences. In this study, we elicited caregiver preferences for clinic-based food assistance., Methods: We conducted a cross-sectional discrete choice experiment in which caregivers at 2 pediatric primary care clinics were asked to choose between hypothetical food programs. Programs varied across 4 categories: 1) resources provided (eg, food delivery, food in clinic, assistance enrolling in benefits); 2) support staff providing resources (eg, social worker, community health worker, physician, or nurse); 3) outreach modality (eg, phone, email, text); and 4) outreach frequency. Multinomial logistic regression was used to assess caregiver preferences within each category and the relative importance of each category to caregiver decisions., Results: We surveyed 142 caregivers who were predominantly Black (87%) and Medicaid-insured (90%). Caregiver preferences for food programs were most strongly influenced by the food resources provided. Caregivers preferred food delivery over other forms of food supports, such as food provided in clinic. They preferred assistance from a benefits enrollment specialist, community health worker, or social worker to assistance from a physician or nurse., Conclusions: Pediatric clinics serving families at risk of food insecurity should use caregiver preferences to inform the design of family-centered interventions. Clinics should consider connecting caregivers with food delivery programs, and pediatric payors should adopt reimbursement models that support multidisciplinary team-based care to address food insecurity., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest relevant to this article to disclose., (Copyright © 2024 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objective: We assessed the impact of an online intervention using clinician prompts for human papillomavirus (HPV) vaccination with a cluster randomized controlled trial., Methods: The randomized trial occurred July 2021-January 2022 in 48 primary care pediatric practices (24 intervention, 24 control) across the US. We trained clinicians via two online learning modules, plus weekly ''quick tips'' delivered via text or email. The training taught practices to implement a staff prompt to the clinician (e.g., printed reminders placed on the keyboard) plus electronic health record (EHR) prompts (if not already done) at well and acute/chronic visits for initial and subsequent HPV vaccination. We assessed missed opportunities for HPV vaccination using logistic regression models accounting for clustering by practice on an intent to treat basis. Surveys assessed facilitators and barriers to using prompts., Results: During the 6-month intervention, missed opportunities for HPV vaccination increased (worsened) in both intervention and control groups. However, at well child care visits, missed opportunities for the initial HPV vaccine increased by 4.5 (95% CI: -9.0%, -0.1%) percentage points less in intervention versus control practices. Change in missed opportunities for subsequent doses at well child care and non-well child care visits did not differ between trial groups. An end-of trial survey found understaffing as a common challenge., Conclusions: Clinician prompts reduced missed opportunities for HPV vaccination at well child care visits. Understaffing related to the COVID-19 pandemic may have led to worsening missed opportunities for both groups and likely impeded practices in fully implementing changes., Competing Interests: Declaration of Competing Interest Dr. Humiston has the following conflicts of interest: until 9/2022, Dr. Humiston’s employer received grant money for her work sponsored by the Pediatric Infectious Diseases Society (PIDS) Foundation, a not-for-profit organization. PIDS is funded for the project through unrestricted joint educational grants from Sanofi US, Merck & Co., Inc., Pfizer, Inc., GlaxoSmithKline, and Seqirus USA, Inc., (Copyright © 2024 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Background: Alcohol and other substance use disorders usually begin with substance use in adolescence. Pediatric primary care offices, where most adolescents receive health care, are a promising venue for early identification of substance use and for brief intervention to prevent associated problems and the development of substance use disorder., Objective: This study tests the effects of a computer-facilitated screening and brief intervention (cSBI) system (the CRAFFT [Car, Relax, Alone, Forget, Family/Friends, Trouble] Interactive System [CRAFFT-IS]) on heavy episodic drinking, riding with a driver who is substance impaired, or driving while substance impaired among adolescents aged 14 to 17 years presenting for a well visit at pediatric primary care practices., Methods: We are conducting a cluster randomized controlled trial of the CRAFFT-IS versus usual care and recruiting up to 40 primary care clinicians at up to 20 pediatric primary care practices within the American Academy of Pediatrics (AAP) Pediatric Research in Office Settings network. Clinicians are randomized 1:1 within each practice to implement the CRAFFT-IS or usual care with a target sample size of 1300 adolescent patients aged 14 to 17 years. At study start, intervention clinicians complete web-based modules, trainer-led live sessions, and mock sessions to establish baseline competency with intervention counseling. Adolescents receive mailed recruitment materials that invite adolescents to complete an eligibility survey. Eligible and interested adolescents provide informed assent (parental permission requirement has been waived). Before their visit, enrolled adolescents seeing intervention clinicians complete a self-administered web-based CRAFFT screening questionnaire and view brief psychoeducational content illustrating substance use-associated health risks. During the visit, intervention clinicians access a computerized summary of the patient's screening results and a tailored counseling script to deliver a motivational interviewing-based brief intervention. All participants complete previsit, postvisit, and 12-month follow-up study assessments. Primary outcomes include past 90-day heavy episodic drinking and riding with a driver who is substance impaired at 3-, 6-, 9-, and 12-month follow-ups. Multiple logistic regression modeling with generalized estimating equations and mixed effects modeling will be used in outcomes analyses. Exploratory aims include examining other substance use outcomes (eg, cannabis and nicotine vaping), potential mediators of intervention effect (eg, self-efficacy not to drink), and effect moderation by baseline risk level and sociodemographic characteristics., Results: The AAP Institutional Review Board approved this study. The first practice and clinicians were enrolled in August 2022; as of July 2023, a total of 6 practices (23 clinicians) had enrolled. Recruitment is expected to continue until late 2024 or early 2025. Data collection will be completed in 2025 or 2026., Conclusions: Findings from this study will inform the promotion of high-quality screening and brief intervention efforts in pediatric primary care with the aim of reducing alcohol-related morbidity and mortality during adolescence and beyond., Trial Registration: ClinicalTrials.gov NCT04450966; https://www.clinicaltrials.gov/study/NCT04450966., International Registered Report Identifier (irrid): DERR1-10.2196/55039., (©Lydia A Shrier, Madison M O'Connell, Alessandra Torres, Laura P Shone, Alexander G Fiks, Julia A Plumb, Jessica L Maturo, Nicholas H McCaskill, Donna Harris, Pamela J Burke, Thatcher Felt, Marie Lynd Murphy, Lon Sherritt, Sion Kim Harris. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 26.03.2024.)

Objectives: Care management programs for medically complex infants interact with parents after complicated pregnancies, when gaps in maternal health care are well documented. These care managers may have the relationships and skills to promote postpartum and interconception health and health care access. It is unknown whether expanding these care management models to address maternal needs would be acceptable., Methods: We conducted qualitative interviews with women with a history of preterm birth and clinicians. For women with a history of preterm birth, additional inclusion criteria were Medicaid-insured infant in one health system and English proficiency. We purposively oversampled women whose infants received care management. Clinicians worked in two geographically adjacent health systems. Interviews explored priorities after preterm birth and perceived acceptability of mother-infant dyad care management. Interviews were audio recorded, transcribed, and coded following an integrated approach in which we applied a priori codes and captured emergent themes., Results: We interviewed 33 women (10/2018-7/2021) and 24 clinicians (3/2021-8/2021). Women were predominantly non-Hispanic Black, and 15 had infants receiving care management. Clinicians included physicians, nurses, and social workers from Pediatrics, Obstetrics, and Family Medicine. Subgroups converged thematically, finding care management acceptable. Tailoring programs to address stress and sleep, emphasizing care managers with strong interpersonal skills and shared experiences with care management users, and program flexibility would contribute to acceptability., Conclusions for Practice: Dyad care management after preterm birth is acceptable to potential program end-users and clinicians. Dyad health promotion may contribute to improved birth outcomes, infant, and parent health., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Pediatric obesity rates in the United States remain at an all-time high. Pediatric primary care clinicians and registered dietitians can help treat childhood obesity, and motivational interviewing (MI) has shown promising effects in prior trials., Methods: We randomized 18 pediatric primary care practices to receive the Brief Motivational Interviewing to Reduce BMI or BMI2+ intervention or continue with usual care (UC). Practices were recruited through the American Academy of Pediatrics Pediatric Research in Office Settings network. The intervention comprised 4 components1: in-person and telehealth MI counseling by pediatric clinicians; 4 recommended sessions,2 6 telephone MI counseling sessions from a registered dietitian,3 text message reminders and tailored motivational messages, and4 parent educational materials. The main outcome was the change in the percentage of the 95th percentile of BMI. The study was conducted 2017 through 2021., Results: There was a significant treatment x time interaction (b = 0.017, 95% confidence interval: [0.0066-0.027]) for the main outcome, favoring the UC group, with youth in the intervention arm showing a greater relative increase in their percent of the 95th percentile., Conclusions: There was no overall benefit of the intervention and, contrary to expectations, youth in the intervention arm gained more weight, based on percent of the distance from the 95th percentile than matched youth from UC practices. The absolute excess weight gain among intervention relative to UC youth was small, approximately 0.5 BMI units and 1 kg over 2 years. We offer several potential explanations for these unexpected findings.

Purpose: Physically or psychologically distressing birth experiences can influence postpartum health, parenting efficacy, and future pregnancy plans. Communication deficits contribute to negative birth experiences. This qualitative analysis explored themes related to communication and negative birth experiences among Black birthing people who experienced preterm birth., Methods: We conducted qualitative interviews with non-Hispanic Black, English language-proficient birthing people with Medicaid-insured preterm infants. Interviews were designed to explore experiences with health care access and well-being after birth. Interviews were audio recorded, transcribed, and coded following an integrated approach where we applied a priori codes and captured emergent themes from the data., Results: We interviewed 30 participants from October 2018 to July 2021. Median gestational age at birth was 30 weeks (range 22-36 weeks). Interviews occurred a median of 7 months postpartum (range 2-34 months). Themes emerged related to negative birth experiences and communication: (1) communication gaps during urgent or emergent intrapartum procedures contributed to negative birth experiences; (2) postpartum opportunities to share birth experiences, particularly with peers, sometimes mitigated the psychological consequences of negative birth experiences; (3) participants did not consistently discuss concerns about future pregnancy risk related to negative birth experiences with clinical teams., Conclusions: Themes from this sample of Black birthing people who experienced preterm birth suggest 3 ways health systems might intervene to improve communication to mitigate the consequences of negative birth experiences. Improvement efforts in these areas may improve postpartum health, future pregnancy outcomes, and long-term health., (© 2024 Annals of Family Medicine, Inc.)

Objective: There are gaps in receipt of maternal preventive services in the interconception period. Yet mother-infant dyads have frequent health care visits. Health systems have opportunities to better capitalize on existing visits to address dyad needs, but this possibility has not been fully explored., Methods: In this qualitative study we conducted semistructured interviews with clinical team members involved with birthing parents or infants after preterm birth. We conducted snowball sampling from teams in pediatrics, obstetrics, and family medicine at two geographically adjacent health systems. Interviews explored perspectives on existing barriers and facilitators to integrating dyad care across adult and infant teams. Interviews were audio-recorded, professionally transcribed, and coded using an integrated approach., Results: We interviewed 24 physicians, nurses, midwives, and social workers (March-November 2021). Participants identified barriers to integrated care including infrequent communication between clinical teams, which was generalizable to care of the birthing parent or infant as individuals, and additional barriers related to privacy, credentialing, and visit design that were specific to dyad care. To improve integration of dyad care, clinicians proposed adapting a variety tools and procedures currently used in their practices, including electronic health record tools for communication, dedicated roles to support communication or navigation, centralized information on resources for dyad care, referral protocols, identifying dyads for proactive outreach, and opportunities for clinicians to connect face-to-face about shared patients or families., Conclusions: Clinicians believe existing health care structures and processes can be adapted to address current substantial barriers to integrated dyad care., Competing Interests: No competing financial interests exist., (© Emily F. Gregory et al., 2023; Published by Mary Ann Liebert, Inc.)

Background and Objectives: Early detection of health vulnerabilities in adolescents is integral to promoting healthy behaviors into adulthood. Our objective was to quantify the prevalence of health vulnerabilities among adolescents and examine differences by age and neighborhood opportunity., Methods: In a cross-sectional analysis of electronic health record data for adolescents aged 13 to 18 years with preventive visits in a large pediatric primary care network between September 2021 and September 2022, we examined 5 health vulnerabilities: Tobacco use, substance use, firearm access, condomless intercourse, and depressive symptoms. Health vulnerabilities were assessed via self-reported adolescent health questionnaire and the validated Patient Health Questionnaire-Modified. Prevalence of health vulnerabilities were calculated alone and in combination, and compared by age and by quintile of neighborhood Child Opportunity Index (COI) score. Multivariable logistic regression estimated associations of neighborhood COI with reporting ≥2 health vulnerabilities., Results: Among 40 197 adolescents (57.7% aged 13-15 years, 66.3% living in "high"/"very high" COI neighborhoods), 29.7% reported at least 1 health vulnerability and 7.9% reported ≥2 vulnerabilities. Cumulative health vulnerabilities were more prevalent among older adolescents and adolescents from lower opportunity neighborhoods. In adjusted models, lower COI was associated with 65% higher odds of having ≥2 vulnerabilities (odds ratio 1.65, 95% confidence interval 1.43-1.91) compared with adolescents from the highest COI quintile., Conclusions: Understanding the relationship between health vulnerabilities and neighborhood opportunities among adolescents may allow pediatric primary care providers and health systems to offer more tailored community support services and transdiagnostic specialized care navigation to address the health needs of teens with multiple vulnerabilities., (Copyright © 2023 by the American Academy of Pediatrics.)

Objective: In the United States, caregivers of children and youth with special health care needs (CYSHCN) must navigate complex, inefficient health care and insurance systems to access medical care. We assessed for sociodemographic inequities in time spent coordinating care for CYSHCN and examined the association between time spent coordinating care and forgone medical care., Methods: This cross-sectional study used data from the 2018-2020 National Survey of Children's Health, which included 102,740 children across all 50 states. We described the time spent coordinating care for children with less complex special health care needs (SHCN) (managed through medications) and more complex SHCN (resulting in functional limitations or requiring specialized therapies). We examined race-, ethnicity-, income-, and insurance-based differences in time spent coordinating care among CYSHCN and used multivariable logistic regression to examine the association between time spent coordinating care and forgone medical care., Results: Over 40% of caregivers of children with more complex SHCN reported spending time coordinating their children's care each week. CYSHCN whose caregivers spent ≥ 5 h/wk on care coordination were disproportionately Hispanic, low-income, and publicly insured or uninsured. Increased time spent coordinating care was associated with an increasing probability of forgone medical care: 6.7% for children whose caregivers spent no weekly time coordinating care versus 9.4% for< 1 hour; 11.4% for 1 to 4 hours; and 15.8% for ≥ 5 hours., Conclusions: Reducing time spent coordinating care and providing additional support to low-income and minoritized caregivers may be beneficial for pediatric payers, policymakers, and health systems aiming to promote equitable access to health care for CYSHCN., (Copyright © 2023 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Healthy sleep and optimal ventilatory control begin in early development and are crucial for positive child outcomes. This paper summarizes information presented at the Sleep and Ventilatory Control sessions of the National Heart, Lung, and Blood-sponsored 2021 Defining and Promoting Pediatric Pulmonary Health workshop. These sessions focused on pediatric sleep health, screening for sleep health and sleep disorders in primary care using the electronic health record, infant sleep and ventilatory control, and home sleep testing. Throughout this summary, we discuss key gaps in and barriers to promoting sleep and ventilatory health that were identified during the workshop sessions. We conclude with strategies to address these gaps and barriers and directions for future multidisciplinary research, patient care, and training., (Copyright © 2023 by the American Academy of Pediatrics.)

Purpose: The Coronavirus Disease 2019 pandemic disrupted healthcare, but the impact on vaccination missed opportunities (MOs, vaccine-eligible visits without vaccination) is unknown. We evaluated pandemic-related trends in MOs at adolescent well-care visits for three vaccines: human papillomavirus; quadrivalent meningococcal conjugate; and tetanus, diphtheria, and acellular pertussis (Tdap)., Methods: We analyzed electronic health record data from 24 pediatric primary care practices in 13 states from 1/1/2018 to 12/31/2021. Segmented logistic regression estimated risk differences for MOs during the pandemic relative to prepandemic trends., Results: Among 106,605 well-care visits, we observed decreases in MOs prepandemic followed by an increase in MOs during the pandemic for all three vaccines. Relative to prepandemic, MOs increased for human papillomavirus (+15.9%, 95% confidence interval [CI]: 11.7%, 20.1%), meningococcal conjugate (+9.4%, 95% CI: 5.2%, 13.7%), and tetanus, diphtheria, and acellular pertussis (Tdap) (+ 8.2%, 95% CI: 4.3%, 12.1%)., Discussion: Increases in vaccine MOs during the pandemic equaled or exceeded pre-pandemic decreases. Reducing MOs in adolescent well-care could raise vaccine coverage., (Copyright © 2023 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Declaration of Competing Interest No potential conflicts of interest.

Objectives: Describe clinical and epidemiologic patterns of pediatric allergy using longitudinal electronic health records (EHRs) from a multistate consortium of US practices., Methods: Using the multistate Comparative Effectiveness Research through Collaborative Electronic Reporting EHR database, we defined a cohort of 218 485 children (0-18 years) who were observed for ≥5 years between 1999 and 2020. Children with atopic dermatitis (AD), immunoglobulin E-mediated food allergy (IgE-FA), asthma, allergic rhinitis (AR), and eosinophilic esophagitis (EoE) were identified using a combination of diagnosis codes and medication prescriptions. We determined age at diagnosis, cumulative incidence, and allergic comorbidity., Results: Allergic disease cumulative (and peak age of) incidence was 10.3% (4 months) for AD, 4.0% (13 months) for IgE-FA, 20.1% (13 months) for asthma, 19.7% (26 months) for AR, and 0.11% (35 months) for EoE. The most diagnosed IgE-FAs were peanut (1.9%), egg (0.8%), and shellfish (0.6%). A total of 13.4% of children had ≥2 allergic conditions, and respiratory allergies (ie, asthma, AR) were commonly comorbid with each other, and with other allergic conditions., Conclusions: We detail pediatric allergy patterns using longitudinal, health care provider-based data from EHR systems across multiple US states and varied pediatric practice types. Our results support the population-level allergic march progression and indicate high rates of comorbidity among children with food and respiratory allergies., (Copyright © 2023 by the American Academy of Pediatrics.)

Objective: The American Academy of Pediatrics recommends routine sleep problem screenings during child well-visits. However, studies suggest a discrepancy between caregiver- and clinician-reported child sleep problems. The present study examines whether caregiver-reported child sleep problems (ie, habitual snoring, insomnia symptoms, poor sleep health) and clinician-documented child sleep problems and management are congruent., Methods: The sample included 170 caregiver-child dyads (child M age  = 3.3 years, range = 2-5 years; 56.5% girls; 64.1% Black, 20.0% non-Latinx White, and 4.1% Latinx; 86.5% maternal caregiver reporter). Caregivers' questionnaire-based reports of habitual snoring, insomnia symptoms, and sleep health behaviors (nighttime electronics, caffeine intake, insufficient sleep) were compared with clinician documentation in the electronic health record., Results: About 92.3% of children had at least 1 caregiver-reported sleep problem (66% insomnia symptoms, 64% electronics, 38% insufficient sleep, 21% caffeine, 17% snoring). In contrast, a substantially lower percent of children had a clinician documented sleep problem (20% overall; 10% insomnia symptoms, 7% electronics, 0% insufficient sleep, 3% caffeine, 4% snoring), sleep-related referral (1% overall; 0.6% Otolaryngology, 0.6% polysomnogram, 0% sleep clinic), or recommendation (12% overall; 8% insomnia symptoms, 4% electronics, 0% insufficient sleep, 1% caffeine)., Conclusions: There is a vast discrepancy between caregiver-reported child sleep problems and clinician-documented sleep problems and management, with a higher proportion of caregiver reports. To benefit overall child health and well-being, future research and quality improvement initiatives should focus on enhancing screening tools and educational opportunities to improve clinician documentation and enhance family conversations about early childhood sleep problems., (Copyright © 2023 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objective: Adolescent mental health concerns increased during COVID-19, but it is unknown whether early increases in depression and suicide risk have been sustained. We examined changes in positive screens for depression and suicide risk in a large pediatric primary care network through May 2022., Methods: Using an observational repeated cross-sectional design, we examined changes in depression and suicide risk during the pandemic using electronic health record data from adolescents. Segmented logistic regression was used to estimate risk differences (RD) for positive depression and suicide risk screens during the early pandemic (June 2020-May 2021) and late pandemic (June 2021-May 2022) relative to before the pandemic (March 2018-February 2020). Models adjusted for seasonality and standard errors accounted for clustering by practice., Results: Among 222,668 visits for 115,627 adolescents (mean age 15.7, 50% female), the risk of positive depression and suicide risk screens increased during the early pandemic period relative to the prepandemic period (RD, 3.8%; 95% CI, 2.9, 4.8; RD, 2.8%; 95% CI, 1.7, 3.8). Risk of depression returned to baseline during the late pandemic period, while suicide risk remained slightly elevated (RD, 0.7%; 95% CI, -0.4, 1.7; RD, 1.8%; 95% CI, 0.9%, 2.7%)., Conclusions: During the early months of the pandemic, there was an increase in positive depression and suicide risk screens, which later returned to prepandemic levels for depression but not suicide risk. Results suggest that pediatricians should continue to prioritize screening adolescents for depressive symptoms and suicide risk and connect them to treatment., (Copyright © 2023 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Importance: Neighborhood conditions are known to broadly impact child health. Research to date has not examined the association of the Childhood Opportunity Index (COI), a multidimensional indicator of neighborhood environment conditions, specifically with pediatric primary care outcomes., Objective: To determine the association of neighborhood opportunity measured by the COI with health metrics commonly captured clinically in pediatric primary care, reflecting both access to preventive care and child well-being., Design, Setting, and Participants: This cross-sectional observational study used electronic health record data from a large pediatric primary care network in the northeastern US. Participants included patients aged 0 to 19 years who were active in the primary care network between November 2020 and November 2022. Data were analyzed in December 2022., Exposure: Census tract-level COI overall score (in quintiles)., Main Outcomes and Measures: Outcomes included up-to-date preventive care and immunization status and presence of obesity, adolescent depression and suicidality, and maternal depression and suicidality. Multivariable mixed-effects logistic regressions estimated associations of these outcomes with COI quintiles, adjusted for age, sex, race and ethnicity, and insurance type., Results: Among 338 277 patients (mean [SD] age, 9.8 [5.9] years; 165 223 female [48.8%]; 158 054 [46.7%] non-Hispanic White, 209 482 [61.9%] commercially insured), 81 739 (24.2%) and 130 361 (38.5%) lived in neighborhoods of very low and very high COI, respectively. Living in very high COI neighborhoods (vs very low COI) was associated with higher odds of being up-to-date on preventive visits (odds ratio [OR], 1.40; 95% CI, 1.32-1.48) and immunizations (OR, 1.77; 95% CI, 1.58-2.00), and with lower odds of obesity (OR, 0.55; 95% CI, 0.52-0.58), adolescent depression (OR, 0.78; 95% CI, 0.72-0.84) and suicidality (OR, 0.79; 95% CI, 0.73-0.85), and maternal depression (OR, 0.78; 95% CI, 0.72-0.86) and suicidality (OR, 0.71; 95% CI, 0.61-0.83)., Conclusions and Relevance: This cross-sectional study of electronic health record data found that neighborhood opportunity was associated with multiple pediatric primary care outcomes. Understanding these associations can help health systems identify neighborhoods that need additional support and advocate for and develop partnerships with community groups to promote child well-being. The findings underscore the importance of improving access to preventive care in low COI communities.

Objective: Neighborhood-level factors, including education, health and environment, and socioeconomic exposures, are important contextual determinants of child health. We explored whether these factors, measured via the Childhood Opportunity Index 2.0, were associated with sleep health in adolescents., Methods: Actigraphy was used to assess sleep duration, timing, and efficiency among 110 adolescents in eighth (13.9 (0.4)) and ninth (14.9 (0.4)) grade. Home addresses were geocoded and linked to Childhood Opportunity Index 2.0 scores (including 3 subtype scores and the 29 individual factor Z-scores). Mixed-effects linear regression was used to determine associations between the Childhood Opportunity Index 2.0 scores and the sleep outcomes, adjusting for sex, race, parent education, household income, school grade and weeknight status. Interactions were also tested by school grade, weeknight status, sex, and race., Results: No associations were observed between overall or subtype scores with sleep outcomes in adolescents. However, we detected associations between select individual Childhood Opportunity Index 2.0 Z-scores, spanning health & environment and education domains, and sleep outcomes. For example, greater fine particulate matter was associated with later timing of sleep onset and offset; ozone concentration was associated with earlier sleep onset and offset; greater exposure to extreme temperature was associated with later sleep onset and offset and increased odds of optimal sleep efficiency., Conclusions: Specific neighborhood factors indexed by the Childhood Opportunity Index 2.0 were associated with sleep health among adolescents. In particular, neighborhood air quality measures were associated with sleep timing and efficiency, warranting further investigation., Competing Interests: Declaration of conflict of interest The authors have no conflicts of interest to report., (Copyright © 2023 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Mobile health (mHealth) is quickly expanding as a method of health promotion, but some interventions may not be familiar or comfortable for potential users. SMS text messaging has been investigated as a low-cost, accessible way to provide vaccine reminders. Most (97%) US adults own a cellphone and of those adults most use SMS text messaging. However, understanding patterns of SMS text message plan type and use in diverse primary care populations needs more investigation., Objective: We sought to use a survey to examine baseline SMS text messaging and data plan patterns among families willing to accept SMS text message vaccine reminders., Methods: As part of a National Institutes of Health (NIH)-funded national study (Flu2Text) conducted during the 2017-2018 and 2018-2019 influenza seasons, families of children needing a second seasonal influenza vaccine dose were recruited in pediatric primary care offices at the time of their first dose. Practices were from the American Academy of Pediatrics' (AAP) Pediatric Research in Office Settings (PROS) research network, the Children's Hospital of Philadelphia, and Columbia University. A survey was administered via telephone (Season 1) or electronically (Season 2) at enrollment. Standardized (adjusted) proportions for SMS text message plan type and texting frequency were calculated using logistic regression that was adjusted for child and caregiver demographics., Results: Responses were collected from 1439 participants (69% of enrolled). The mean caregiver age was 32 (SD 6) years, and most children (n=1355, 94.2%) were aged 6-23 months. Most (n=1357, 94.3%) families were English-speaking. Most (n=1331, 92.8%) but not all participants had an unlimited SMS text messaging plan and sent or received texts at least once daily (n=1313, 91.5%). SMS text messaging plan type and use at baseline was uniform across most but not all subgroups. However, there were some differences in the study population's SMS text messaging plan type and usage. Caregivers who wanted Spanish SMS text messages were less likely than those who chose English to have an unlimited SMS text messaging plan (n=61, 86.7% vs n=1270, 94%; risk difference -7.2%, 95% CI -27.1 to -1.8). There were no significant differences in having an unlimited plan associated with child's race, ethnicity, age, health status, insurance type, or caregiver education level. SMS text messaging use at baseline was not uniform across all subgroups. Nearly three-quarters (n=1030, 71.9%) of participants had received some form of SMS text message from their doctor's office; most common were appointment reminders (n=1014, 98.4%), prescription (n=300, 29.1%), and laboratory notifications (n=117, 11.4%). Even the majority (n=64, 61.5%) of those who did not have unlimited plans and who texted less than daily (n=72, 59%) reported receipt of these SMS text messages., Conclusions: In this study, most participants had access to unlimited SMS text messaging plans and texted at least once daily. However, infrequent texting and lack of access to an unlimited SMS text messaging plan did not preclude enrolling to receive SMS text message reminders in pediatric primary care settings., (©Chelsea S Wynn, Alexander G Fiks, Russell Localio, Justine Shults, Ekaterina Nekrasova, Laura P Shone, Alessandra Torres, Miranda Griffith, Rebecca Unger, Leigh Ann Ware, Mary Kate Kelly, Melissa S Stockwell. Originally published in JMIR Formative Research (https://formative.jmir.org), 30.06.2023.)

We examined children's Medicaid participation during 2019-21 and found that as of March 2021, states newly adopting continuous Medicaid coverage for children during the COVID-19 pandemic experienced a 4.62 percent relative increase in children's Medicaid participation compared to states with previous continuous eligibility policies.

Objective: A growing evidence base suggests home and neighborhood environmental exposures may influence adolescent sleep, but few studies have assessed these relationships using methods that account for time-varying, location-specific exposures, or multiple neighborhood contexts. This study aimed to assess the feasibility and acceptability of using smartphone global positioning system (GPS) tracking and ecological momentary assessment (EMA) to assess time-varying home and neighborhood environmental exposures hypothesized to be associated with adolescent sleep., Methods: Adolescents aged 15-17 years in Philadelphia completed 7 days of continuous smartphone GPS tracking, which was used to identify daily levels of exposure to geocoded neighborhood factors (eg, crime, green space). Four daily EMA surveys assessed home sleep environment (eg, noise, light), stress, health behaviors, and neighborhood perceptions. Feasibility and acceptability of GPS tracking and EMA were assessed, and distributions of daily environmental exposures were examined., Results: Among 25 teens (mean age 16, 56% male), there was a high level of GPS location data captured (median daily follow-up: 24 hours). Seventy-eight percent of EMA surveys were completed overall. Most participants (96%) reported no privacy concerns related to GPS tracking and minimal burden from EMA surveys. Exposures differed between participants' home neighborhoods and locations visited outside the home neighborhood (eg, higher crime away from home). Sleep environment disruptions were present on 29% of nights (most common: uncomfortable temperature) and were reported by 52% of adolescents., Conclusions: Results demonstrate the feasibility and acceptability of mobile methods for assessing time-varying home and neighborhood exposures relevant to adolescent sleep for up to 1 week., (Copyright © 2023 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Research is needed to identify how clinical decision support (CDS) systems can support communication about and engagement with tobacco use treatment in pediatric settings for parents who smoke. We developed a CDS system that identifies parents who smoke, delivers motivational messages to start treatment, connects parents to treatment, and supports pediatrician-parent discussion., Objective: The objective of this study is to assess the performance of this system in clinical practice, including receipt of motivational messages and tobacco use treatment acceptance rates., Methods: The system was evaluated at one large pediatric practice through a single-arm pilot study from June to November 2021. We collected data on the performance of the CDS system for all parents. Additionally, we surveyed a sample of parents immediately after the clinical encounter who used the system and reported smoking. Measures were: (1) the parent remembered the motivational message, (2) the pediatrician reinforced the message, and (3) treatment acceptance rates. Treatments included nicotine replacement therapy, quitline referral (phone counseling), and/or SmokefreeTXT referral (text message counseling). We described survey response rates overall and with 95% confidence intervals (CIs)., Results: During the entire study period, 8,488 parents completed use of the CDS: 9.3% ( n  = 786) reported smoking and 48.2% ( n  = 379) accepted at least one treatment. A total of 102 parents who smoke who used the system were approached to survey 100 parents (98% response rate). Most parents self-identified as female (84%), aged 25 to 34 years (56%), and Black/African American (94%), and had children with Medicaid insurance (95%). Of parents surveyed, 54% accepted at least one treatment option. Most parents recalled the motivational message (79%; 95% CI: 71-87%), and 31% (95% CI: 19-44%) reported that the pediatrician reinforced the motivational message., Conclusion: A CDS system to support parental tobacco use treatment in pediatric primary care enhanced motivational messaging about smoking cessation and evidence-based treatment initiation., Competing Interests: None declared., (Thieme. All rights reserved.)

Achieving health equity (where every person has the opportunity to attain their full health potential) requires the removal of obstacles to health, including barriers to high-quality medical care. Innovations in service delivery can inadvertently maintain, worsen, or introduce inequities. As such, implementation of innovations must be accompanied by a dual commitment to evaluate impact on marginalized groups and to restructure systems that obstruct people from health and healthcare. Understanding the impact innovations have on access to high-quality care is central to this effort. In this Perspective, we join conceptual models of healthcare access and quality with health equity frameworks to conceptualize healthcare receipt as a series of interactions between people and systems unfolding over time. This synthesized model is applied to illustrate the effects of telemedicine on patient, population, and system outcomes. Telemedicine may improve or worsen health equity by altering access to care and by altering quality of care once it is accessed. Teasing out these varied effects is complex and requires considering multilevel influences on the outcome of a care-seeking episode. This synthesized model can be used to inform research, practice, and policy surrounding the equity implications of care delivery innovations more broadly., (© 2022. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Purpose: Motivational interviewing (MI) is an evidence-based strategy to modify health behaviors, including some risk factors for adverse birth outcomes. Black women, who have disproportionately high rates of adverse birth outcomes, have reported mixed preferences on MI. This study explored the acceptability of MI among Black women who are at high risk for adverse birth outcomes., Methods: We conducted qualitative interviews with women with a history of preterm birth. Participants were English-language proficient and had Medicaid-insured infants. We purposively oversampled women whose infants had medical complexity. Interviews explored experiences with health care and health behaviors after birth. The interview guide was iteratively developed to obtain specific reactions to MI by including videos demonstrating MI-consistent and MI-inconsistent counseling. Interviews were audio recorded, transcribed, and coded following an integrated approach in which we applied a priori codes related to MI and allowed themes to emerge from the data., Results: We interviewed 30 non-Hispanic Black women from October 2018 to July 2021. Eleven viewed the videos. Participants emphasized the importance of autonomy in decision-making and health behavior. Participants expressed a preference for MI-consistent clinical approaches, including autonomy support and building rapport, considering them respectful, nonjudgmental, and likely to support change., Conclusions: In this sample of Black women with a history of preterm birth, participants valued an MI-consistent clinical approach. Incorporating MI into clinical care may improve the experience of health care among Black women, thus serving as one strategy to promote equity in birth outcomes., Competing Interests: No competing financial interests exist., (© Emily F. Gregory et al., 2023; Published by Mary Ann Liebert, Inc.)