An Approach to Family-Centered Electronic Health Records in Pediatrics.

Over the years, family-centered care in the field of pediatrics has become more prevalent and has improved the patient experience. Recent innovations within electronic health records (EHR), such as patient portals, have provided a more "patient-centered" approach by allowing patients to be interactive with the EHR and have greater agency of their own healthcare. There are also ample opportunities within an EHR to improve the patient experience with delivery of family-centered care. In this perspective, we discuss the design and use of a family-centered EHR for the purposes of optimizing the pediatric patient experience.

Preventing Toxic Childhood Stress in the COVID Era: A Role for Telemedicine.

The coronavirus pandemic has resulted in unprecedented stress for families and children. Curve-flattening measures have disrupted the relational networks of millions. Stress in the absence of protective relationships can quickly become toxic, harming mental and physical health. If toxic stress is characterized by an absence of protective relationships, telemedicine may have a role in collective prevention efforts by enabling and preserving patient-provider continuity. Through virtual visits and check-ins, trusted health care providers can serve as a source of emotional support and psychosocial buffering for families under stress. By leveraging technology to deliver care remotely, telemedicine lets patients and providers connect, relate, and engage. Connection enables the conveyance of compassion and empathy. Telemedicine may thus serve as an important conduit for fostering protective relationships, buffering toxic stressors, and promoting safety and healing. Telemedicine will not resolve the needs created by the pandemic, but it may be one component for addressing them.

Can Clinical Empathy Be Communicated by Text Message? A Case Report.

This case report examines a text message communication between a pediatric primary care provider and the mother of a medically complex child for indicators of clinical empathy. First, some clinical background information is provided; second, indicators of clinical empathy are evaluated using a validated instrument; and third, some benefits, limitations, and future directions informed by the case are discussed.

The Relationship Between Housing Instability and Poor Diet Quality Among Urban Families.

OBJECTIVE: To examine associations between housing instability and poor diet quality in a sample of urban parents and children. METHODS: Cross-sectional study of 340 parent/guardian-child dyads visiting a pediatric primary care center in Boston, Massachusetts. The parent/guardian (hereafter, parent) completed 2 Harvard Service Food Frequency Questionnaires, one regarding their own dietary intake and one regarding their child's intake, and an assessment of health-related social needs. Diet quality was measured using the Healthy Eating Index-2010 (HEI-2010; score range 0-100). Housing instability was defined as: 1) homeless or in sheltered housing, 2) doubled up with another family, 3) utilities threatened or shut off, or 4) concerned about eviction. Multivariable logistic regression was used to measure associations between unstable housing and lowest-quartile HEI-2010 scores, adjusting for parent age, race/ethnicity, education, income, and child age. RESULTS: Median (interquartile range) parent and child HEI-2010 scores were 63.8 (56.3-70.8) and 59.0 (54.2-64.7), respectively. Housing instability was found in 136 dyads (40%). In multivariable analysis, it was associated with increased odds of lowest-quartile total parent HEI-2010 scores (adjusted odds ratio [aOR], 1.9; 95% confidence interval [95% CI], 1.1-3.5) but not child scores (aOR, 1.4; 95% CI, 0.8-2.5). It also was associated with increased odds of lowest-quartile parent HEI-2010 dietary component scores for Total vegetables and Greens and beans (aOR, 2.0; 95% CI, 1.1-3.7 and aOR, 2.5; 95% CI, 1.3-4.8, respectively). CONCLUSIONS: In this urban primary care population, housing instability is associated with lower diet quality scores for parents but not children. Lower vegetable consumption appears to drive this association.

Child Life Specialists' Experiences Addressing Social Determinants of Health: A Web-Based Survey.

We used Google Forms to survey 110 child life specialists on their experiences addressing family psychosocial issues. Most respondents were female (99%) and white (95%), with mean age 34 ± 10 years. Ninety-five percent reported addressing family psychosocial issues during the previous 3 months, including parental separation/divorce (71%), poverty/financial needs (64%), parental mental illness (59%), substance abuse at home (54%), homelessness/housing problems (54%), bullying (49%), physical neglect (46%), physical abuse (46%), unemployment (46%), emotional neglect (45%), and hunger/food insecurity (42%). Eighty-five percent of respondents reported addressing family psychosocial issues once per month or more often, with 80% providing coping strategies, 76% providing family support, 66% providing therapeutic play, and 66% providing psychological preparation. These findings indicate that child life specialists frequently address a range of family psychosocial issues. Further research is needed to clarify the role and impact of child life services on social determinants of health.

Associations Between Patient-Reported Outcome Measures of Asthma Control and Psychosocial Symptoms.

There is growing emphasis on using patient-reported outcome measures to enhance clinical practice. This study was a retrospective review of scores on the Childhood Asthma Control Test (C-ACT) and the Pediatric Symptom Checklist-17 (PSC-17) at a pediatric primary care center in Boston, Massachusetts. A total of 218 patients were selected at random using billing codes for well-child (WC) care and asthma, excluding complex medical conditions. Cutoff scores were used to identify uncontrolled asthma (C-ACT ⩽19) and clinically significant psychosocial symptoms (+PSC-17). Multiple logistic regression was used to measure associations between C-ACT ⩽19 and +PSC-17, adjusting for covariates. In multivariable analysis, C-ACT ⩽19 at WC visits was associated with +PSC-17 at WC visits (adjusted odds ratio = 3.2 [95% confidence interval = 1.3-8.6]). C-ACT ⩽19 at non-WC visits was also associated with +PSC-17 at WC visits (adjusted odds ratio = 3.1 [95% confidence interval = 1.2-8.9]). Patient-reported outcome measures of asthma control and psychosocial symptoms were positively correlated in this sample.

Primary Care Group Visits for Childhood Obesity: Clinical Program Evaluation.

We conducted 29 group visits targeting children with elevated body mass index (BMI) and their families. Visit activities focused on social support, mind-body techniques, exercise, and nutrition. Measures included attendance, family satisfaction scores, and per-patient change in BMI percentile. Ninety-six patients attended ≥1 group visit, mean 2.0 (SD ±1.8; range 1-14). Mean patient age was 9.6 years (SD ±2.4; range 4-15 years); 53.1% were female; 44.8% had a BMI 95th to 99th percentile for age/sex; 35.4% had a BMI >99th percentile. Mean attendance per group visit was 6.8 patients (SD ±3.8; range 1-16 patients). Mean family satisfaction scores were 9.8 (SD ±0.8) with 10/10 "would recommend to family or friends." Of 42 patients who attended ≥2 group visits, 5 (11.9%) experienced a ≥5 BMI percentile reduction between first and last visits; 3 (7.1%) maintained this reduction 2 years later. Group visits were associated with high family satisfaction scores, though few patients experienced a reduction in BMI percentile.

Food Insecurity Screening in Pediatric Primary Care: Can Offering Referrals Help Identify Families in Need?

OBJECTIVE: To describe a clinical approach for food insecurity screening incorporating a menu offering food-assistance referrals, and to examine relationships between food insecurity and referral selection. METHODS: Caregivers of 3- to 10-year-old children presenting for well-child care completed a self-administered questionnaire on a laptop computer. Items included the US Household Food Security Survey Module: 6-Item Short Form (food insecurity screen) and a referral menu offering assistance with: 1) finding a food pantry, 2) getting hot meals, 3) applying for Supplemental Nutrition Assistance Program (SNAP), and 4) applying for Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Referrals were offered independent of food insecurity status or eligibility. We examined associations between food insecurity and referral selection using multiple logistic regression while adjusting for covariates. RESULTS: A total of 340 caregivers participated; 106 (31.2%) reported food insecurity, and 107 (31.5%) selected one or more referrals. Forty-nine caregivers (14.4%) reported food insecurity but selected no referrals; 50 caregivers (14.7%) selected one or more referrals but did not report food insecurity; and 57 caregivers (16.8%) both reported food insecurity and selected one or more referrals. After adjustment, caregivers who selected one or more referrals had greater odds of food insecurity compared to caregivers who selected no referrals (adjusted odds ratio 4.0; 95% confidence interval 2.4-7.0). CONCLUSIONS: In this sample, there was incomplete overlap between food insecurity and referral selection. Offering referrals may be a helpful adjunct to standard screening for eliciting family preferences and identifying unmet social needs.

Associations between Public Library Use and Reading Aloud among Families with Young Children.

OBJECTIVE: To measure public library use in a sample of families with young children and examine associations with reading aloud. STUDY DESIGN: We interviewed 200 parents of 6- to 18-month-old children visiting a hospital-based pediatric clinic. We assessed public library card ownership, public library visitation, and awareness of public library programming. We assessed reading aloud using the StimQ READ questionnaire. We used multivariable logistic and linear regression to examine associations while adjusting for sociodemographic characteristics. RESULTS: In multivariable analysis, parents who owned a public library card had greater odds of reading aloud daily to their 6- to 18-month-old child (aOR, 2.0; 95% CI, 1.0-3.8) and higher StimQ READ scores (ß = 0.9; 95% CI, 0.2-1.6). Parents who visited a public library once a month or more often had greater odds of reading aloud daily (aOR, 3.4; 95% CI, 1.8-6.7) and higher StimQ READ scores (ß = 1.3; 95% CI, 0.6-2.0). Parents whose 6- to 18-month-old child had ever visited a public library did not have greater odds of reading aloud daily (aOR, 1.4; 95% CI, 0.7-2.9), but did have higher StimQ read scores (ß = 1.2; 95% CI, 0.4-2.0). Parents who felt informed about available public library programs for children had greater odds of reading aloud daily (aOR, 2.5; 95% CI, 1.3-5.1) and higher StimQ READ scores (ß = 1.1; 95% CI, 0.4-1.9). CONCLUSION: In this sample of families with young children, we found positive associations between public library use and reading aloud.

Massachusetts Pediatricians' Views Toward Body Mass Index Screening in Schools: Continued Controversy.

Objective Evaluate Massachusetts pediatricians' views toward school-based body mass index screening since its implementation. Methods Survey of 286 members of the Massachusetts Chapter of the American Academy of Pediatrics on attitudes toward screening and perceived impact on clinical practice. Results Overall, 36.3% supported screening, with suburban or rural pediatricians significantly less likely (vs urban) to indicate support. Less than 10% of pediatricians agreed or strongly agreed that screening improved communication with schools (4.2%), communication with families (8.9%), or helped them care for patients (7.0%), with suburban or rural pediatricians significantly less likely to agree. Most pediatricians reported contact from patients regarding screening (59.4%) and identifying concerns from patients regarding screening during office visits (60.4%), including bullying and self-esteem. Suburban or rural pediatricians were significantly more likely to report patient contact and concerns related to screening. Conclusions Support for school-based body mass index screening is low among Massachusetts pediatricians, particularly among suburban and rural pediatricians.

Impact of an Electronic Template on Documentation of Obesity in a Primary Care Clinic.

Identification of obesity at well-child care (WCC) examinations is a step toward intervention. Studies have shown suboptimal documentation in primary care clinics that can improve with the use of electronic health records (EHRs). This study investigated the impact of a standardized EHR template on documentation of obesity at WCC visits and its impact on physician behavior. A cohort of 585 children with severe early onset obesity (body mass index >99th percentile, age <6 years) was identified with an electronic algorithm. Complete records of visit notes were reviewed to extract history taking, counseling, and recording of obesity at a WCC visit. Use of a standardized EHR template for WCC visits is associated with improvement in rates of documentation of obesity (47% vs 34%, P < .01), without interruption of workflow. Documentation of obesity in the chart improved nutritional (66% vs 44%, P < .001) and physical activity counseling (23% vs 9%, P < .001).

Improving immunization rates in a hospital-based primary care practice.

OBJECTIVE: We implemented a quality improvement initiative aimed at reaching a 95% immunization rate for patients aged 24 months. The setting was a hospital-based pediatric primary care practice in Boston, Massachusetts. We defined immunization as full receipt of the vaccine series as recommended by the Centers for Disease Control and Prevention. METHODS: The initiative was team-based and structured around 3 core interventions: systematic identification and capture of target patients, use of a patient-tracking registry, and patient outreach and care coordination. We measured monthly overall and modified immunization rates for patients aged 24 months. The modified rate excluded vaccine refusals and practice transfers. We plotted monthly overall and modified immunization rates on statistical process control charts to monitor progress and evaluate impact. RESULTS: We measured immunization rates for 3298 patients aged 24 months between January 2009 and December 2012. Patients were 48% (n = 1576) female, 77.3% (n = 2548) were African American or Hispanic, and 70.2% (n = 2015) were publicly insured. Using control charts, we established mean overall and modified immunization rates of 90% and 93%, respectively. After implementation, we observed an increase in the mean modified immunization rate to 95%. CONCLUSIONS: A quality improvement initiative enabled our pediatric practice to increase its modified immunization rate to 95% for children aged 24 months. We attribute the improvement to the incorporation of medical home elements including a multidisciplinary team, patient registry, and care coordination.

Obesity-related behaviors of US- and non-US-born parents and children in low-income households.

OBJECTIVE: To examine differences in obesity-related behaviors by parental US-born status among low-income, minority families participating in Healthy Habits, Happy Homes, an intervention trial to improve household routines for childhood obesity prevention. Evidence suggests lower obesity risk among adult immigrants, but research is inconclusive regarding the influence of having a non-US-born parent on childhood obesity. METHOD: We sampled 57 US-born and 64 non-US-born families of children aged 2 to 5.9 years living in the Boston area. At baseline, parents reported their own screen time, physical activity, diet, and sleep as well as their children's behaviors. We used linear and logistic regression to examine the association of parental US-born status with obesity-related behaviors. RESULTS: Mean (SD) body mass index z score was 0.94 (1.16), and it did not differ between the groups. After adjusting for parental education and child race/ethnicity, children of non-US-born (vs US-born) parents had later bedtimes (0.81 hours later; 95% confidence interval [CI], 0.37-1.25) and wake-up times (0.56 hours later; 95% CI, 0.16-0.95) and engaged in less active play (0.15 fewer hr/d; 95% CI, -0.28 to -0.01). Non-US-born (vs US-born) parents had less screen exposure. CONCLUSION: In this cross-section of low-income, urban families, having a parent born outside the United States was associated with a profile of risk and protective behavior; adjustment for education and race/ethnicity removed the protective associations of parental nativity with child behavior. Obesity-related differences in behaviors and home environments should be considered when designing interventions targeting low-income communities with a high proportion of non-US-born participants.

Healthy Habits, Happy Homes: randomized trial to improve household routines for obesity prevention among preschool-aged children.

IMPORTANCE: Racial/ethnic and socioeconomic disparities exist across risk factors for childhood obesity. OBJECTIVE: To examine the effectiveness of a home-based intervention to improve household routines known to be associated with childhood obesity among a sample of low-income, racial/ethnic minority families with young children. DESIGN: Randomized trial. SETTING: The intervention was delivered in the families' homes. PARTICIPANTS: The study involved 121 families with children aged 2 to 5 years who had a television (TV) in the room where he or she slept; 111 (92%) had 6-month outcome data (55 intervention and 56 control). The mean (SD) age of the children was 4.0 (1.1) years; 45% were overweight/obese. Fifty-two percent of the children were Hispanic, 34% were black, and 14% were white/other. Nearly 60% of the families had household incomes of $20,000 or less. INTERVENTIONS: The 6-month intervention promoted 4 household routines, family meals, adequate sleep, limiting TV time, and removing the TV from the child's bedroom, using (1) motivational coaching at home and by phone, (2) mailed educational materials, and (3) text messages. Control subjects were mailed materials focused on child development. MAIN OUTCOMES AND MEASURES: Change in parent report of frequency of family meals (times/wk), child sleep duration (hours/d), child weekday and weekend day TV viewing (hours/d), and the presence of a TV in the room where the child slept from baseline to 6 months. A secondary outcome was change in age- and sex-adjusted body mass index (calculated as weight in kilograms divided by height in meters squared). RESULTS: Compared with control subjects, intervention participants had increased sleep duration (0.75 hours/d; 95% CI, 0.06 to 1.44; P = .03), greater decreases in TV viewing on weekend days (-1.06 hours/d; 95% CI, -1.97 to -0.15; P = .02), and decreased body mass index (-0.40; 95% CI, -0.79 to 0.00; P = .05). No significant intervention effect was found for the presence of a TV in the room where the child slept or family meal frequency. CONCLUSIONS AND RELEVANCE: Our results suggest that promoting household routines, particularly increasing sleep duration and reducing TV viewing, may be an effective approach to reduce body mass index among low-income, racial/ethnic minority children. Longer-term studies are needed to determine maintenance of behavior change. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01565161.

Healthy Habits, Happy Homes: methods and baseline data of a randomized controlled trial to improve household routines for obesity prevention.

OBJECTIVE: To develop a home-based intervention for parents of 2-5 year old children to promote household routines to prevent overweight/obesity. METHODS: We recruited 121 children from health centers in Boston between 2011 and 2012 and randomized 62 to intervention and 59 to the control condition. The 6-month intervention included 1) motivational coaching at home and by phone with a health educator, 2) mailed educational materials, and 3) weekly text messages. The intervention promoted three household routines: eating meals as a family, obtaining adequate sleep, and limiting screen time. RESULTS: Of the 121 children, mean (SD) age was 4.0 (1.1) years; 52% were Hispanic, 34% Black, and 14% White/Other. Nearly 60% of the sample had annual household incomes ≤ $20,000. Approximately 64% of families reported eating together ≥ 7 times per week, however, many meals were eaten in front of a TV. Over half of the children slept less than the recommended 11h/night and 78% viewed ≥ 2 h/day of screen time. CONCLUSIONS: Household routines that increase obesity risk were prevalent among low-income families in this study. If proven to be effective, promotion of household routines related to family meals, sleep, and screen time may prevent young children from becoming overweight/obese.

The association of urbanicity with infant sleep duration.

Short sleep duration is associated with multiple adverse child outcomes. We examined associations of the built environment with infant sleep duration among 1226 participants in a pre-birth cohort. From residential addresses, we used a geographic information system to determine urbanicity, population density, and closeness to major roadways. The main outcome was mother's report of her infant's average daily sleep duration at 1 year of age. We ranked urbanicity and population density as quintiles, categorized distance to major roads into 8 categories, and used linear regression adjusted for socio-demographic characteristics, smoking during pregnancy, gestational age, fetal growth, and television viewing at 1 year. In this sample, mean (SD) sleep duration at age 1 year was 12.8 (1.6)h/day. In multivariable adjusted analyses, children living in the highest quintile of urbanicity slept -19.2 min/day (95% CI:-37.0, -1.50) less than those living in the lowest quintile. Neither population density nor closeness to major roadways was associated with infant sleep duration after multivariable adjustment. Our findings suggest that living in more urban environments may be associated with reduced infant sleep.

Unstable distal radial fractures treated with external fixation, a radial column plate, or a volar plate. A prospective randomized trial.

BACKGROUND: Optimal surgical management of unstable distal radial fractures is controversial, and evidence from rigorous comparative trials is rare. We compared the functional outcomes of treatment of unstable distal radial fractures with external fixation, a volar plate, or a radial column plate. METHODS: Forty-six patients with an injury to a single limb were randomized to be treated with augmented external fixation (twenty-two patients), a locked volar plate (twelve), or a locked radial column plate (twelve). The fracture classifications included Orthopaedic Trauma Association (OTA) types A3, C1, C2, and C3. The patients completed the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire at the time of follow-up. Grip and lateral pinch strength, the ranges of motion of the wrist and forearm, and radiographic parameters were also evaluated. RESULTS: At six weeks, the mean DASH score for the patients with a volar plate was significantly better than that for the patients treated with external fixation (p = 0.037) but similar to that for the patients with a radial column plate (p = 0.33). At three months, the patients with a volar plate demonstrated a DASH score that was significantly better than that for both the patients treated with external fixation (p = 0.028) and those with a radial column plate (p = 0.027). By six months and one year, all three groups had DASH scores comparable with those for the normal population. At one year, grip strength was similar among the three groups. The lateral pinch strength of the patients with a volar plate was significantly better than that of the patients with a radial column plate at three months (p = 0.042) and one year (p = 0.036), but no other significant differences in lateral pinch strength were found among the three groups at the other follow-up periods. The range of motion of the wrist did not differ significantly among the groups at any time beginning twelve weeks after the surgery. At one year, the patients with a radial column plate had maintained radial inclination and radial length that were significantly better than these measurements in both the patients treated with external fixation and those with a volar plate (all p < 0.05). CONCLUSIONS: Use of a locked volar plate predictably leads to better patient-reported outcomes (DASH scores) in the first three months after fixation. However, at six months and one year, the outcomes of all three techniques evaluated in this study were found to be excellent, with minimal differences among them in terms of strength, motion, and radiographic alignment.

Biologic therapy for psoriasis: an update on the tumor necrosis factor inhibitors infliximab, etanercept, and adalimumab, and the T-cell-targeted therapies efalizumab and alefacept.

Psoriasis is a chronic skin disorder that affects approximately 2% of the US and European population. Over the last several years, one of the major focuses in psoriasis research has been the development of biologic therapies for this disease. The aim of these therapies is to provide selective, immunologically directed intervention with fewer side effects than traditional therapies. The goal of this article is to update the progress of the tumor necrosis inhibitors which are available, or under investigation, for clinical use in psoriasis: infliximab, etanercept, and adalimumab, as well as the T-cell-targeted therapies efalizumab and alefacept (Table 1).