Facilitating coordination between medical and educational systems to improve access to pediatric therapies for preschool children with developmental delays and disabilities.

INTRODUCTION: A large portion of preschool-age children with developmental delays and disabilities (PCw/DD) do not receive recommended therapeutic services, including legally mandated school-based therapies. This study examines the feasibility of a community-clinical linkage using virtual patient navigation and a medical-educational care plan called Preschool and Me (PreM) to connect clinical settings serving historically marginalized communities with early childhood special education (ECSE) services. METHOD: Parents of PCw/DD attending an urban pediatric clinic from January to March 2022 were enrolled to receive PreM which included navigation support for ECSE, overcoming barriers accessing ECSE, and health care provider communication. Families completed measures of demographics and indicators of feasibility at baseline and 4-month follow-up. RESULTS: Of the 34 families referred, 30 were eligible and enrolled. Most parents identified as mothers (97%). Most participant children (70% male, 60% Black, 30% Hispanic) were enrolled in public health insurance (93%) and were not receiving any clinic-based therapies (93%). Parents overwhelmingly found PreM acceptable with the majority stating it would be a strong reason to continue care at the clinic. Among families who received PreM, 26 (96%) completed an individualized education plan (IEP) evaluation (96%). Of these, 24 (92%) children were eligible for an IEP. Nineteen children enrolled in an ECSE program; two families awaited school assignments and three families did not consent to the assigned school placement due to neighborhood safety concerns. DISCUSSION: Our findings suggest PreM was feasible, acceptable, and demonstrated promise in supporting families to navigate the ECSE process. Future studies examining effectiveness are warranted. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Pediatricians as Childhood Development Advocacy Champions in Kenya and Tanzania: A Case Study.

Early childhood development (ECD) is instrumental to shaping educational, emotional, and economic trajectories; alleviating poverty; and achieving gender equality. Pediatricians are experts in children's health and trusted sources of guidance for families and clinicians and thus are optimal ECD champions. This case study describes collaboration by the American Academy of Pediatrics, Kenya Pediatric Association, and Pediatric Association of Tanzania to activate pediatricians as ECD champions in Kenya and Tanzania. From July 2020 through January 2021, the collaborators assessed ECD needs by interviewing 20 key informants per country from governmental ministries, nongovernmental organizations, and clinical practice and assessing datasets and policy documents. In 2021, the societies recruited 15 pediatricians per country as champions; surveyed their knowledge, attitudes, and practices; and trained them on 4 core competencies: understanding early brain development science; developmental and behavioral screening, surveillance, and diagnosis; integration of ECD promotion into clinical practice; and advocacy skills for ECD and nurturing care. In 2021, each society established advocacy-in-action projects to advance ECD. In Kenya, the cohort surveyed clinicians on barriers to ECD, implemented a 2-day in-person training for 90 providers, and developed a 5-week Fundamentals of ECD course, taken by 113 pediatricians from 7 African countries. In Tanzania, champions conducted ECD training workshops for 78 health managers and 189 health care providers in 9 facilities in 7 regions and established 9 ECD corners with toys and information in health care facilities. These results highlight considerations for supporting ECD, including building on existing strengths, infrastructure, and networks; strengthening ECD knowledge among pediatricians; and advocacy skill-building.

Impact of a Brief Healthcare-based Intervention to Support Early Childhood Development in India: A Pilot Randomized Controlled Trial.

OBJECTIVES: To study the impact of a brief early childhood develop-ment (ECD) intervention, Sit Down and Play (SDP), integrated within routine healthcare visits on parent and child outcomes. METHODS: Between April, 2018 and March, 2019, caregivers and their infants aged 5-6 months attending a well-baby clinic were enrolled and randomized to intervention (n=26) or control (n=26) groups. Intervention families received SDP at recruitment and two subsequent immunization visits (8 months and 10 months). Control families received usual care. ECD outcomes were assessed through in-person assessments at the age of 12 months using the Stim Q subscales to assess parenting behaviors, and the Developmental Assessment Scale for Indian Infants (DASII) for neurodevelopment. RESULTS: There was a significant improvement in parent-child stimulation activities and verbal interactions in the intervention group compared with the control group [6.1(1.4) vs 4.9 (1.3); P=0.002]. Infants in the intervention group had significantly higher DASII scores in multivariable analyses [108.0 (103.0-111.3) vs 102.0 (96.8-108.0); P=0.04]. CONCLUSION: Our findings suggest a brief healthcare intervention supports opportunities for early learning among caregivers and neurodevelopmental outcomes in their infants.

Healthcare-Based Interventions to Improve Parenting Outcomes in LMICs: A Systematic Review and Meta-Analysis.

OBJECTIVES: Although a number of early childhood development (ECD) interventions in healthcare settings in low- and middle-income countries (LMICs) have been developed to improve parent-directed outcomes and support ECD, their impact have yet to be established. This review assesses the effectiveness of healthcare-based ECD interventions in LMICs on the following key evidence-informed parenting outcomes affecting ECD: (1) responsive caregiving (2) cognitive stimulation and (3) parental mental health. Impacts on parental knowledge regarding ECD and parenting stress were also assessed. METHODS: PubMed, PsycINFO, Scopus, CINAHL and Embase were searched. We included randomized controlled trials reporting effects of healthcare-based ECD interventions in LMICs on parent-directed outcomes in the first five years of life. Data extraction included study characteristics, design, sample size, participant characteristics, settings, intervention descriptions, and outcomes. Meta-analyses were conducted using random effects models. RESULTS: 8 articles were included. Summary standardized mean differences demonstrated significant benefits of healthcare-based interventions in LMICs for improving: (1) cognitive stimulation (n = 4; SMD = 0.32; 95% CI: 0.08 to 0.56) and (2) ECD knowledge (n = 4; SMD = 0.44; 95% CI: 0.27 to 0.60). No significant effects were seen on maternal depression and parenting stress; only one study assessed parent-child interactions in the context of responsiveness. Limitations included small number of studies for moderation analysis, high heterogeneity, variability in measures used for outcomes and timing of assessments. CONCLUSIONS FOR PRACTICE: Our results demonstrate statistically significant effects of healthcare-based interventions in LMICs on improving key evidence-based parenting outcomes and offers one promising strategy to support children reach their full developmental potential.

Implementing an early childhood development intervention with routine immunization visits in India: a feasibility trial.

Integrating an early childhood development (ECD) intervention within routine healthcare visits offers an important opportunity for a population-level approach to support ECD in low- and middle-income countries (LMICs) where 250 million children under the age of 5 years fail to reach their full developmental potential. This paper reports on the feasibility of integrating an adapted healthcare-based ECD intervention (Sit Down and Play) in primary health centers (PHCs) serving low-income rural communities in Karnataka, India, and its potential to support research-informed components needed to improve ECD (e.g., opportunities for learning). Using a prospective cluster nonrandomized pilot and feasibility trial, caregivers with infants 6-10 weeks of age were recruited from 2 PHCs: one which delivered the intervention at two subsequent immunization visits (n = 25) and the other as care as usual (n = 28). Feasibility was assessed using the following indicators: implementation, practicality, acceptability, demand, and limited efficacy. Quality of home stimulation and opportunities for learning were explored with key items from the UNICEF Multiple Cluster Index Surveys with generalized estimating equation models. While outcome measures were to be obtained from all participants 3-month post-enrollment, due to COVID19 restrictions, there was variability in timing of follow-up interviews; however, outcome data from all participants were obtained and no significant group differences existed in contact time. Results suggest the feasibility of delivery of SDP during routine immunization visits, high satisfaction with adapted content, and utility of developed training and fidelity measures. Though not powered for hypothesis testing, our exploratory analyses reveal the intervention group demonstrated greater improvements on quality of home stimulation over time than the control group. CONCLUSION: Our findings suggest integrating an ECD intervention with routine healthcare visits is a feasible and promising strategy for supporting ECD in India. Further studies are needed to determine the effectiveness of SDP on children's development. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04167254. WHAT IS KNOWN: • Interventions are increasingly being developed to target responsive caregiving and opportunities for learning because of their potential to support early childhood development (ECD) in low- and middle-income countries where 250 million children under the age of 5 years fail to reach their full developmental potential. • A critical issue in ECD intervention research is the gap between what is known to be effective treatment to protect healthy brain development and what is provided to millions of caregivers during routine care who live in low-income communities. WHAT IS NEW: • We adapted a brief, ECD intervention for use with routine healthcare visits in India as a population-level strategy to support ECD in LMICs. • Our results demonstrate feasibility, acceptability, and improvements in key parenting behaviors that promote ECD.

Examining Implementation Outcomes of Sit Down and Play, a Primary Care-Based Intervention, in a Large Urban Primary Care Clinic.

OBJECTIVES: Economical, operational, and employment strains present challenges for widespread implementation of parent-directed interventions. We designed Sit Down and Play (SDP) with the aim of creating a brief primary care-based program that encourages positive parenting practices through take-home play activities. To develop a sustainable model of implementation in real-world settings, we explored the use of university student volunteers as a potential solution for employment strains. Guided by Proctor and colleagues' implementation outcome framework, this study focused on understanding the following implementation outcomes: acceptability, feasibility, fidelity, and service penetration. Exploratory analysis on the limited-efficacy of the program on parental behavior was also assessed. METHODS: Student facilitators were trained utilizing a train-the-trainer model. During the study period, facilitators delivered SDP to caregivers attending their well-child visits (WCVs) in a primary care clinic serving predominantly low-income families. Implementation data was gathered from clinic records, student facilitator surveys, and caregiver surveys. RESULTS: Student facilitators delivered SDP interventions to 99/146 (67.8%) eligible families. Caregivers overwhelmingly found the program helpful (M = 4.70, SD = 0.82), enjoyable (M = 4.88, SD = 0.32), and were highly satisfied with individuals who delivered it (M = 4.97, SD = 0.16). Student facilitators successfully delivered the program with high fidelity. CONCLUSIONS FOR PRACTICE: Implementation findings suggest that delivery of SDP by student volunteers combined with the use of a train-the-trainer model is a feasible model to integrate strategies that support positive parenting behaviors into existing systems, such as the primary care setting. This study yields promising results that suggest the benefit of utilizing university partnerships with healthcare settings for wider dissemination and adaptations for other subgroups and contexts.

Improving Referrals to Preschool Special Education in Pediatric Primary Care.

INTRODUCTION: The American Academy of Pediatrics created evidence-based guidelines that encourage early identification and referral for children with developmental delays. Although pediatric primary care providers are poised to link 3-to-5-year-old children to school-based services, there are gaps in making referrals. METHOD: Educational dissemination of streamlined referral packets was introduced. Knowledge and perceived confidence were measured following an educational presentation. Retrospective chart reviews compared referral rates to preschool special education services when developmental delays were identified. RESULTS: Mean pretest to posttest knowledge and perceived confidence to refer children to preschool special education increased following education. Referral rates for 3-5 years-old by pediatric primary care providers doubled during the initial 8-week implementation period and remained constant 9 months later. DISCUSSION: Educational dissemination of a streamlined referral process in pediatric primary care is a sustainable approach that ensures preschool-aged children with developmental delays receive timely referrals for further school-based evaluations and interventions.

Integrating an Adapted, Low-Intensity Program to Promote Early Childhood Development in Routine Health Visits in Rural India: A Feasibility Study.

OBJECTIVE: More than 200 million children younger than the age of 5 years fail to reach their full developmental potential in low- and middle-income countries (LMICs). The purpose of this study was to describe the feasibility of integrating a brief program to promote early childhood development within a health care setting serving a predominantly rural population in India. METHODS: We conducted a prospective, noncomparative, mixed-methods study. An adapted parent-directed program was administered to caregivers of 2- to 6-month-old children while waiting for their health care provider. Caregivers completed baseline and 4-week follow-up surveys. Thematic analyses and generalized equation estimates were used for analyses in the following feasibility indicators: acceptability, demand, implementation and practicality, and limited efficacy testing. RESULTS: Forty-seven caregivers were recruited; most were women (98%) and had equal to or less than 12 years of schooling (61%). Forty-six of 47 participants completed the follow-up at 1 month. Three administrators were trained to deliver the program over the course of 2 days. Caregivers perceived a need for the program and found the content and structure of the program useful. However, there were important suggestions for improvement, including greater visual content and dissemination to nonparental caregivers and fathers. Significant increases were seen on self-reported parenting behaviors regarding a child's caregiving environment. CONCLUSION: Our findings support the feasibility of integrating an adapted, low-intensity program in a primary care setting in India, but important adaptations and considerations will need to be addressed before effectiveness testing on a wider scale. We discussed implications for offering sustainable population-level interventions to promote early childhood development in LMICs.

A systematic review and meta-analysis in the effectiveness of mobile phone interventions used to improve adherence to antiretroviral therapy in HIV infection.

BACKGROUND: Antiretroviral therapy is effective in preventing the progression of HIV to AIDS, but adherence to HIV medication is lower than ideal. A previous Cochrane review concluded that SMS interventions increased adherence to HIV medication, but more recent trials have reported mixed results. Our review aims to provide an up-to-date synthesis of the effects of interventions delivered by mobile phone on adherence. METHODS: We searched Cochrane, Medline, CINAHL, EMBASE and Global Health for randomised control trials (RCTs) of interventions delivered by mobile phones, designed to increase adherence to antiretroviral medication. Risk of bias was assessed using the Cochrane risk of bias tool. We calculated relative risk ratios (RR) or standardised mean difference (SMD) with 95% confidence interval (CI). Trials were analysed depending on delivery mechanism and intervention characteristics. We conducted meta-analysis for primary objective outcome measures. RESULTS: We identified 19 trials. No trials were at low risk of bias. Interventions were delivered as follows; nine via text message, five via mobile phone call, one via mobile phone imagery and four via mixed interventions. There was no effect when interventions delivered by text message were pooled in the RR1.25 (CI 0.97 to 1.61) P = 0.08. The SMD 0.42 (0.03 to 0.81) p = 0.04 showed a moderate effect to improve adherence. There was mixed evidence of the effect of text messages delivered daily, weekly, at scheduled or triggered times, however, messages with link to support, interactivity and three or more behavior change techniques (BCTs) all improved adherence. Of the five trials delivered by mobile phone call, one reported a reduction in HIV viral load. One trial using mobile phone imagery reported a reduction in HIV viral load. Three trials that delivered interventions by text message and mobile phone counselling reported improved biological outcomes. CONCLUSION: Specific interventions, of proven effectiveness should be considered for implementation, rather than mobile phone-based interventions in general. Interventions targeting a wider range of barriers to adherence may be more effective than existing interventions. The effects and cost-effectiveness of such interventions should be evaluated in a randomised controlled trial alongside long term objective and clinically important outcomes.

Parental Attitudes and Beliefs Surrounding Play Among Predominantly Low-income Urban Families: A Qualitative Study.

OBJECTIVE: Parents' perceived benefits and barriers to participation in cognitively stimulating activities may help explain why income-related discrepancies in early and frequent participation in such activities exist. We sought to develop an improved understanding of attitudes and beliefs surrounding play among families who live in predominantly low-income urban communities. METHODS: Using qualitative methods, focus groups were conducted with parents of children 2 weeks to 24 months of age who attended a primary care clinic serving predominantly low-income urban communities. Discussions were recorded, transcribed verbatim, and analyzed using thematic analysis. RESULTS: Thirty-five parents participated in 6 focus groups. Participants were 61% female and 94% nonwhite; 71% had children who received public health insurance. Analyses revealed 7 major themes that mapped onto the Health Belief Model's core domains of perceived need, barriers, and cues to action: (1) play as important for developing parent-child relationships, (2) toy- and media-focused play as important for developmental and educational benefit, (3) lack of time due to household and work demands, (4) lack of knowledge regarding the importance of play, (5) media-related barriers, (6) need for reminders, and (7) need for ideas for play. CONCLUSION: Caregivers of young children describe many important benefits of play, yet they have misconceptions regarding use of toys and media in promoting development as well as notable barriers to participating in play, which may be opportunities for intervention. Public health programs may be more effectively implemented if they consider these attitudes to develop new or refine existing strategies for promoting parent-child learning activities.

Encouraging Parenting Behaviors That Promote Early Childhood Development Among Caregivers From Low-Income Urban Communities: A Randomized Static Group Comparison Trial of a Primary Care-Based Parenting Program.

Objectives Encouraging key parenting behaviors in early infancy may help decrease income-related developmental disparities. In this study we assessed whether a brief, primary care-based program (Sit Down and Play; SDP) could be successful in impacting key parenting behaviors that promote early childhood development. Methods An ethnically diverse group of predominantly low-income caregivers of children 2-6 months of age were enrolled, interviewed, and randomized to intervention (n = 20) or control (n = 20) groups. Intervention families received SDP at recruitment and the subsequent well-child visit. Control families were provided handouts regarding developmental milestones. One month after the second well-child visit, all families were reinterviewed (n = 34; 85% retention rate). Using open-ended questions and standardized measures (i.e., StimQ), parents were asked about parenting behaviors central to children's development: (1) participation in cognitively stimulating activities, (2) provision of learning materials, and (3) the quality of parent-child verbal interactions. Potential impact on perceived parenting confidence was also explored utilizing The Parenting Sense of Competence Scale. Analyses were conducted using chi square tests and analysis of variance. Results A significant main effect of time, and as hypothesized, an interaction between time and condition emerged that favored SDP on play behaviors (p = 0.03). Post-intervention, SDP families had significantly higher levels of interactional activities between a parent and child that promote cognitive development (p = 0.02). Conclusions for Practice Results appear promising for an accessible, low-intensity program delivered in the primary care setting. Further studies to determine the effectiveness of SDP on parenting behaviors and subsequent developmental outcomes are warranted.

Sit Down and Play: A Preventive Primary Care-Based Program To Enhance Parenting Practices.

The primary care office offers an ideal setting to encourage parenting behaviors that promote early childhood development. We conducted a pilot study to establish feasibility and acceptability of Sit Down and Play (SDP), a brief primary care-based program to facilitate positive parenting behaviors through take-home play activities. A prospective 1-month study was conducted in an urban primary care clinic. SDP was administered to 30 caregivers of 6-12 month old children while they waited for their well-child appointment. Caregivers completed baseline and 4-week follow-up surveys. Open-ended interview questions regarding acceptability and usefulness of SDP were administered and analyzed using content analysis. Parenting practices related to child development were measured with standardized measures and changes analyzed using paired t-test and linear mixed effects models. Most caregivers were mothers (90%) and non-white (97%); the majority of children received Medicaid (87%). There were significant increases in parental reports of practices related to child development (p<0.001), including families who reported low incomes (i.e. <$25,000) and received a high-school education or less (p=0.001). Four main themes emerged from the open-ended interview data: 1) importance of play, 2) noticing a change in their child, 3) reinforcing existing positive parenting behaviors, and 4) satisfaction with the program. This preliminary study suggests that SDP is a feasible and potentially beneficial program that can be delivered during pediatric well-child visits. Further studies are needed to determine the effectiveness of SDP on parenting behaviors and developmental outcomes.

Calcium and Bone Turnover Markers in Acromegaly: A Prospective, Controlled Study.

Context: Acromegaly has been associated with calcium-phosphate and bone turnover alterations. Controlled studies of these interactions are sparse. Objective: To evaluate calcium and bone metabolism in active and treated acromegaly. Design/Setting/Patients: We conducted a controlled, prospective study at a tertiary referral center. We studied 22 patients with acromegaly referred for surgical or medical therapy (ACM) and 22 with nonfunctioning pituitary adenomas referred for surgery (control). Main Outcome Measures: Calcium (serum and urine), phosphorus, parathyroid hormone (PTH), 25-hydroxy- and 1,25-dihydroxy-vitamin D, bone turnover markers [serum C-terminal telopeptide of type 1 collagen (CTX) and procollagen type 1 N-terminal propeptide (P1NP)], and cytokines [receptor activator of nuclear factor κB ligand (RANK-L) and osteoprotegerin (OPG)] at baseline and 3 to 6 months after treatment. Results: At baseline, the ACM group had lower PTH levels than controls (36.3 ± 13.9 pg/mL vs 56.0 ± 19.9 pg/mL) and higher phosphorus (4.34 ± 0.71 mg/dL vs 3.55 ± 0.50 mg/dL) (P < 0.01). Groups had similar levels of serum and urine calcium and 25-hydroxy- and 1,25-dihydroxy-vitamin D. The ACM group had higher bone turnover markers than control; P1NP and CTX were strongly correlated (r2 = 0.82, P < 0.05). CTX was dependent on age and disease group but not on sex or gonadal status. After treatment of acromegaly, serum calcium (9.52 ± 0.43 mg/dL to 9.26 ± 0.28 mg/dL), phosphorus (4.34 ± 0.71 mg/dL to 3.90 ± 0.80 mg/dL), and CTX (0.91 ± 0.75 ng/mL to 0.63 ± 0.68 ng/mL) decreased, while PTH increased (36.3 ± 13.9 pg/mL to 48.9 ± 16.7 pg/mL) (P < 0.01). 25-hydroxy-vitamin D, P1NP, and RANK-L/OPG ratio did not change significantly. Conclusion: Acromegaly patients exhibited PTH-independent calcium-phosphate alterations and enhanced coupled bone formation and resorption. Within 6 months of treatment, bone resorption decreased, whereas RANK-L/OPG changes were inconsistent.

Primary Care-Based Interventions to Promote Positive Parenting Behaviors: A Meta-analysis.

CONTEXT: Utilization of primary care settings offers a promising approach to enhance parenting practices that are critical for promoting early childhood development. Determining the impact of existing primary care interventions on key parenting behaviors will aid providers and policy makers as they seek strategies to improve early child outcomes. OBJECTIVE: To evaluate the efficacy of primary care-based interventions on parenting practices that promote early child development among children younger than 36 months. DATA SOURCES: PubMed, Excerpta Medica dataBASE, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature databases were searched electronically. STUDY SELECTION: English-language articles that were quasi-randomized or randomized controlled trials, included parents of children <36 months of age, and reported outcomes related to parenting behaviors that promote early child development. DATA EXTRACTION: Two reviewers independently extracted data regarding participants, interventions, and outcomes. Quantitative meta-analyses were conducted with random effects for study and fitted with restricted maximum likelihood methods. RESULTS: The review included 13 studies reporting parenting outcomes in 2 categories: participation in cognitively stimulating activities and positive parent-child interactions. We found a statistically significant positive effect of primary care-delivered interventions and parent-child interactions (summary standardized mean difference 0.29, 95% confidence interval [CI] 0.06-0.52, P < .0001) and participation in cognitively stimulating activities (summary standardized mean difference 0.34, 95% CI 0.03-0.54; summary odds ratio 0.13, 95% CI 0.01-0.25, P < .0001). LIMITATIONS: Limitations included heterogeneity in measures used, outcomes, and timing of assessments. CONCLUSIONS: Primary care-based interventions modestly affect positive parenting behaviors important for early childhood development. Randomized controlled trials with comparable outcome measures using standardized assessments are needed to assess further beneficial impacts.

Positive Parenting Practices, Health Disparities, and Developmental Progress.

OBJECTIVE: To describe interactive activities between parents and young children in a nationally representative sample. We hypothesized that the frequency of participation in interactive activities would be different across economic strata and would be associated with developmental delay. METHODS: Children 4 to 36 months of age were identified by using The National Survey of Children's Health 2011-2012. Interactive caregiving practices were reported by poverty status. Developmental concerns were derived from caregiver responses and scoring of the Parents Evaluation of Developmental Status. Multivariable logistic regressions with weighting were used to explore the effect of interactive practices on risk for developmental delay across poverty levels. Covariates including age, gender, insurance type, maternal education, parenting stress, and ethnicity were adjusted in the models. RESULTS: In our sample (n = 12,642), caregivers with the lowest income versus highest income reported lower participation in reading (33% vs 64%; P < .0001), singing or telling stories (52% vs 77%, P < .0001), and taking their child on an outing (13% vs 22%, P < .0001). Less frequent participation in interactive activities during the week were associated with increased risk of developmental delay among low-income families (Reading odds ratio [OR] 1.57, 95% confidence interval [CI] 1.15-2.13; Singing songs/Telling Stories OR 1.66, 95% CI 1.15-2.40; Outings OR 1.48, 95% CI 1.11-1.97). CONCLUSIONS: Despite evidence emphasizing the protective effects of supportive parenting practices on early child development, our work demonstrates significant disparities in parenting practices that promote early child development between economically advantaged and disadvantaged parents. Innovative population-level strategies that enrich parenting practices for vulnerable children in early childhood are needed.

Pediatricians' knowledge, attitudes, and practice patterns regarding special education and individualized education programs.

OBJECTIVE: The medical community has called upon pediatricians to be knowledgeable about an individualized education program (IEP). We sought to: 1) evaluate pediatricians' knowledge and attitudes regarding special education; 2) examine the relationship between perceived responsibilities and practice patterns; and 3) identify barriers that impact pediatricians' ability to provide comprehensive care to children with educational difficulties. METHODS: Surveys were mailed to a national sample of 1000 randomly selected general pediatricians and pediatric residents from October 2010 to February 2011. RESULTS: The response rate was 47%. Of the knowledge items, respondents answered an average of 59% correctly. The majority of respondents thought pediatricians should be responsible for identifying children who may benefit from special education services and assist families in obtaining services, but less than 50% thought they should assist in the development of an IEP. The majority of pediatricians inquired whether a child is having difficulty at school, but far fewer conducted screening tests or asked parents if they needed assistance obtaining services. Overall, the prevalence of considering a practice a pediatrician's responsibility is significantly higher than examples of such a practice pattern being reported. Financial reimbursement and insufficient training were among the most significant barriers affecting a pediatrician's ability to provide care to children with educational difficulties. CONCLUSIONS: In order to provide a comprehensive medical home, pediatricians must be informed about the special education process. This study demonstrates that there are gaps in pediatricians' knowledge and practice patterns regarding special education that must be addressed.

Visuomotor performance in KCNJ11-related neonatal diabetes is impaired in children with DEND-associated mutations and may be improved by early treatment with sulfonylureas.

OBJECTIVE: To assess performance on an age-standardized neuromotor coordination task among sulfonylurea-treated KCNJ11-related neonatal diabetic patients. RESEARCH DESIGN AND METHODS: Nineteen children carrying KCNJ11 mutations associated with isolated diabetes (R201H; n = 8), diabetes with neurodevelopmental impairment (V59M or V59A [V59M/A]; n = 8), or diabetes not consistently associated with neurodevelopmental disability (Y330C, E322K, or R201C; n = 3) were studied using the age-standardized Beery-Buktenica Developmental Test of Visual-Motor Integration (VMI). RESULTS: Although R201H subjects tested in the normal range (median standard score = 107), children with V59M/A mutations had significantly lower than expected VMI standard scores (median = 49). The scores for all three groups were significantly different from each other (P = 0.0017). The age of sulfonylurea initiation was inversely correlated with VMI scores in the V59M/A group (P < 0.05). CONCLUSIONS: Neurodevelopmental disability in KCNJ11-related diabetes includes visuomotor problems that may be ameliorated by early sulfonylurea treatment. Comprehensive longitudinal assessment on larger samples will be imperative.

Acromegaly as a cause of 1,25-dihydroxyvitamin D-dependent hypercalcemia: case reports and review of the literature.

Growth hormone excess has been associated with hypercalciuria and nephrolithiasis. Hypercalcemia in acromegaly is rare and usually due to coexistent primary hyperparathyroidism. To report two cases of 1,25-dihydroxyvitamin D (1,25 (OH)(2) D)-dependent hypercalcemia in cromegaly. A 50 year-old female with 2 years history of hypercalcemia presented with features of acromegaly. Serum calcium (Ca) was 10.9 mg/dl (8.6-10.2), parathyroid hormone (PTH) 20 pg/ml (10-65), PTH-related peptide undetectable, and 1,25 (OH)(2) D 119 pg/ml (15-75). Insulin-like growth factor 1 (IGF1) was 911 ng/ml (49-292) and growth hormone (GH) 14.5 ng/ml (0.03-10). MRI showed a 1.7 cm pituitary tumor. Transsphenoidal adenectomy (TSA) resulted in normalization of IGF1, GH, Ca, and 1,25 (OH)(2) D (50 pg/ml) and complete tumor resection. A 52-year-old female was diagnosed with visual field deficits on routine exam. MRI showed a 3 cm invasive pituitary macroadenoma. IGF1 was 416 ng/ml (87-238) and GH 75.8 (0-6.0) ng/ml. Incidentally, she was found with high Ca of 10.8 mg/dl (8.9-10.3) associated with PTH 19 pg/ml and 1,25 (OH)(2) D66 pg/ml. Postoperatively, IGF1 and GH remained abnormal (440 and 12.8 ng/ml, respectively), while MRI showed parasellar tumor residue. Ca remained high (10.1-11.1 mg/dl), along with elevated 1,25 (OH)(2) D level (81.3 pg/ml). In both cases, other causes of hypercalcemia were ruled out. We present 2 cases of 1,25 (OH)(2) D-dependent hypercalcemia associated with growth hormone excess. Complete resection of tumor produced biochemical remission of acromegaly and normalization of calcium and 1,25 (OH)(2) D levels, while incomplete resection was associated with persistent 1,25 (OH)(2) D-dependent hypercalcemia. Acromegaly should be considered a cause of 1,25 (OH)(2) D-dependent hypercalcemia.