Oral Health Promotion During Well Visits.

Training pediatric residents in Bright Futures and oral health concepts is critical to improving oral health. This study's objective was to determine the skill level of pediatric residents in integrating oral health promotion during health supervision visits of 12- to 35-month-old children. One hundred forty-three pediatric residents participated in an evaluation of the effectiveness of a Bright Futures oral health curriculum. Competencies assessed preintervention included partnership building, communication, and integration of oral health concepts. Pediatric residents' abilities to integrate oral health promotion into health supervision visits varied considerably. Residents demonstrated greater skill in communication and partnership building compared with oral health promotion behaviors and performance of an oral examination. Further education is needed at a national level if we are to meet Healthy People 2020 goals.

Refusal of Vitamin K by Parents of Newborns: A Survey of the Better Outcomes Through Research for Newborns Network.

OBJECTIVE: To survey newborn clinicians in the United States regarding the frequency of intramuscular (IM) vitamin K refusal by a parent, reasons for refusal, and approaches of clinicians to refusals. METHODS: An electronic survey was administered to the clinician site representative (nursery director or designee knowledgeable about site-specific nursery policies) at all newborn nurseries in the Better Outcomes through Research for Newborns (BORN) network of newborn nurseries. RESULTS: Of 92 BORN sites, 85 (92%) respondents completed the survey. Frequency of IM vitamin K refusal during the past 5 years was reported as increased by 52% of respondents, unchanged by 42%, and 6% did not know. Reported frequencies of refusal of IM vitamin K was weekly (9%), a few times a month (31%), once a month (13%), once every 3 to 4 months (20%), once or twice a year (26%), or never (1%). The overall distribution of the reported frequencies of refusal differed among regions in the United States (higher in the West and the South; P < .05). Reported reasons for refusal by parents included perceptions of parents that the injection was unnecessary, lack of knowledge about vitamin K deficiency bleeding, and concern about preservatives. Approaches to refusal included attempts to educate parents, enlisting support from community clinicians, a state mandate, and prescription of oral vitamin K. CONCLUSIONS: Respondents from a national sample of newborn nursery clinicians reported an increase in refusal of IM vitamin K in the past 5 years with regional variation. Approaches to refusals need further investigation to determine effectiveness.

Utility of Decision Rules for Transcutaneous Bilirubin Measurements.

BACKGROUND: Transcutaneous bilirubin (TcB) meters are widely used for screening newborns for jaundice, with a total serum bilirubin (TSB) measurement indicated when the TcB value is classified as "positive" by using a decision rule. The goal of our study was to assess the clinical utility of 3 recommended TcB screening decision rules. METHODS: Paired TcB/TSB measurements were collected at 34 newborn nursery sites. At 27 sites (sample 1), newborns were routinely screened with a TcB measurement. For sample 2, sites that typically screen with TSB levels also obtained a TcB measurement for the study. Three decision rules to define a positive TcB measurement were evaluated: ≥75th percentile on the Bhutani nomogram, 70% of the phototherapy level, and within 3 mg/dL of the phototherapy threshold. The primary outcome was a TSB level at/above the phototherapy threshold. The rate of false-negative TcB screens and percentage of blood draws avoided were calculated for each decision rule. RESULTS: For sample 1, data were analyzed on 911 paired TcB-TSB measurements from a total of 8316 TcB measurements. False-negative rates were <10% with all decision rules; none identified all 31 newborns with a TSB level at/above the phototherapy threshold. The percentage of blood draws avoided ranged from 79.4% to 90.7%. In sample 2, each rule correctly identified all 8 newborns with TSB levels at/above the phototherapy threshold. CONCLUSIONS: Although all of the decision rules can be used effectively to screen newborns for jaundice, each will "miss" some infants with a TSB level at/above the phototherapy threshold.

Pediatric Residents' Knowledge and Comfort With Oral Health Bright Futures Concepts: A CORNET Study.

OBJECTIVE: Training residents in oral health helps eliminate disparities and improves access. The American Academy of Pediatrics Bright Futures Guidelines curriculum is used as a training guide. We assessed knowledge, confidence, and perceived barriers to incorporating Bright Futures oral health concepts into well-child care for children below 3 years in a national sample of pediatric residents. METHODS: A sample of postgraduate year 1 and 2 residents from CORNET sites completed demographic, Bright Futures oral health concepts confidence and knowledge cross-sectional surveys before any intervention. Measures were tested for reliability using Cronbach's alpha coefficient. RESULTS: One hundred sixty-three residents from 28 CORNET sites completed the surveys. One third reported no prior training in oral health. Time (42%) and knowledge (33%) led the perceived barriers to addressing these concepts in well visits. Although 63% rated their confidence as excellent in identifying tooth decay risk factors, a significant percentage rated their oral health risk assessment skills as poor or neutral (64%) and identifying caries at examination (53%). Only 49% conveyed oral health messages during encounters and 80% correctly scored 75% or higher on knowledge questions. CONCLUSIONS: This cross-sectional study shows that residents from a wide geographic range have high self-reported oral health knowledge but low perceived skills and competency in clinical implementation. Lack of time and knowledge in identifying caries led the perceived barriers. Barriers are addressed by implementing oral health curricula that promote competence and skill-development. This study helps programs effectively implement Bright Futures concepts to train graduates to incorporate oral health in well visits.

Prioritizing a research agenda: a Delphi study of the better outcomes through research for newborns (BORN) network.

BACKGROUND: There is a paucity of evidence to guide clinical management for term and late preterm newborns. The Better Outcomes through Research for Newborns (BORN) network is a national collaborative of clinicians formed to increase the evidence-base for well newborn care. OBJECTIVE: To develop a consensus-based, prioritized research agenda for well newborn care. DESIGN: A two-round modified Delphi survey of BORN members was conducted. Round 1 was an open-ended survey soliciting 5 clinical questions identified as important and under-researched. Using qualitative methods, 20 most common themes were extracted and transformed into research questions. Round 2 survey respondents ranked the top 20 questions using a 5- point Likert scale and a quantitative analysis was conducted. RESULTS: Round 1 survey generated 439 unique research questions that fell into 57 themes. In the Round 2 survey, the highest rated questions were: 1) At what weight-loss percentage is it medically necessary to formula supplement a breastfeeding infant? 2) What is the optimal management of infants with neonatal abstinence syndrome? 3) How and when should we initiate a workup for sepsis, and how should these newborns be managed? CONCLUSIONS: Research priorities of clinicians include criteria for medically indicated formula supplementation of the breastfed newborn, management of neonatal abstinence syndrome and management of newborns at-risk for sepsis.

Integrating mental health services in primary care continuity clinics: a national CORNET study.

OBJECTIVE: To determine whether pediatric continuity clinics integrate mental health (MH) services into care delivery; and to determine whether the level of MH integration is related to access to MH services, types of MH screening performed, self-efficacy, satisfaction with referral sites, and communication with the primary care provider. METHODS: Pediatric Residency Integrated Survey of Mental Health in Primary Care (PRISM_PC) is a newly designed cross-sectional, Web-based survey of continuity clinic directors participating in a national network of pediatric continuity clinics (CORNET). Definitions of MH models included integrated or nonintegrated MH models or traditional care. The survey included questions regarding access, screening that was performed at sites, comfort with MH management as well as provider satisfaction and communication with referral sites. RESULTS: Seventy-eight percent (57 of 73) of CORNET site directors responded, representing input from 30% of US pediatric residency continuity programs. Thirty-five percent (n = 20) reported an integrated MH model while 65% (n = 37) reported a nonintegrated MH model. Seventy-nine percent screened for attention-deficit/hyperactivity disorder, 44% for behavioral-emotional issues, and 19% for pediatric depression. No differences were found in terms of screening or tools used on the basis of the level of MH integration. Those with integrated programs were more likely to have access to an on-site psychologist (P = .001) or psychiatrist (P = .006). CONCLUSIONS: Directors from one-third of training programs surveyed reported some level of MH integration in their primary care teaching clinics. Future studies are needed to compare patient and resident education outcomes between integrated and nonintegrated sites.

Evaluation of a national Bright Futures oral health curriculum for pediatric residents.

OBJECTIVE: Training in Bright Futures and oral health concepts is critical for delivery of high-quality primary care and preventive health services by residents, our future pediatric workforce. The goal of this study was to evaluate the effectiveness of an online health promotion curriculum on pediatric residents' confidence, knowledge, and clinical performance in Bright Futures and oral health practice. METHODS: Residents from sites that had been stratified by size and randomized were assigned to the Bright Futures Oral Health curriculum (intervention group) or an active control group. Confidence and knowledge were measured by self-report and multiple-choice questions, respectively. Clinical performance was measured with structured clinical observations, performed by trained faculty, of Bright Futures and oral health performance before and after intervention. Mean scores between intervention and control groups were compared using a 2-tailed, repeated-measures F test. RESULTS: A total of 143 pediatric residents from 27 Continuity Research Network (CORNET) sites participated in the study. At a median of 3 months after intervention, the intervention group demonstrated significant improvement in general Bright Futures confidence (n = 128, F = 6.564, P = .012) and knowledge (n = 102, F = 5.296, P = .023), oral health confidence (n = 123, F = 15.220, P < .001), and clinical performance skills in oral health (n = 96, F = 11.315, P = .001) compared with the control group. CONCLUSIONS: The Bright Futures Oral Health curriculum promoted an increase in confidence and knowledge in Bright Futures concepts and in confidence and clinical performance in oral health concepts among pediatric residents. This online curriculum demonstrated a positive impact on documented resident behavior, maintained for 3 months after intervention, and provides a replicable national training model to advance important elements of primary care pediatrics.

Effects of local institutional review board review on participation in national practice-based research network studies.

OBJECTIVE: To describe the process and outcomes of local institutional review board (IRB) review for 2 Pediatric Research in Office Settings (PROS) studies. DESIGN: Pediatric Research in Office Settings conducted 2 national studies concerning sensitive topics: (1) Child Abuse Recognition Experience Study (CARES), an observational study of physician decision making, and (2) Safety Check, a violence prevention intervention trial. Institutional review board approval was secured by investigators' sites, the American Academy of Pediatrics, and practices with local IRBs. Practices were queried about IRB rules at PROS enrollment and study recruitment. SETTING: Pediatric Research in Office Settings practices in 29 states. PARTICIPANTS: Eighty-eight PROS practices (75 IRBs). Main Exposure Local IRB presence. MAIN OUTCOME MEASURES: Local IRB presence, level of PROS assistance, IRB process, study participation, data collection completion, and minority enrollment. RESULTS: Practices requiring additional local IRB approval agreed to participate less than those that did not (CARES: 33% vs 52%; Safety Check: 41% vs 56%). Of the 88 practices requiring local IRB approval, 55 received approval, with nearly 50% needing active PROS help, many requiring consent changes (eg, contact name additions, local IRB approval stamps), and 87% beginning data collection. Median days to obtain approval were 81 (CARES) and 109 (Safety Check). Practices requiring local IRB approval were less likely to complete data collection but more likely to enroll minority patients. CONCLUSIONS: Local IRB review was associated with lower participation rates, substantial effort navigating the process (with approval universally granted without substantive changes), and data collection delays. When considering future reforms, the national human subject protections system should consider the potential redundancy and effect on generalizability, particularly regarding enrollment of poor urban children, related to local IRB review.

From suspicion of physical child abuse to reporting: primary care clinician decision-making.

OBJECTIVES: The goals were to determine how frequently primary care clinicians reported suspected physical child abuse, the levels of suspicion associated with reporting, and what factors influenced reporting to child protective services. METHODS: In this prospective observational study, 434 clinicians collected data on 15003 child injury visits, including information about the injury, child, family, likelihood that the injury was caused by child abuse (5-point scale), and whether the injury was reported to child protective services. Data on 327 clinicians indicating some suspicion of child abuse for 1683 injuries were analyzed. RESULTS: Clinicians reported 95 (6%) of the 1683 patients to child protective services. Clinicians did not report 27% of injuries considered likely or very likely caused by child abuse and 76% of injuries considered possibly caused by child abuse. Reporting rates were increased if the clinician perceived the injury to be inconsistent with the history and if the patient was referred to the clinician for suspected child abuse. Patients who had an injury that was not a laceration, who had >1 family risk factor, who had a serious injury, who had a child risk factor other than an inconsistent injury, who were black, or who were unfamiliar to the clinician were more likely to be reported. Clinicians who had not reported all suspicious injuries during their career or who had lost families as patients because of previous reports were more likely to report suspicious injuries. CONCLUSIONS: Clinicians had some degree of suspicion that approximately 10% of the injuries they evaluated were caused by child abuse. Clinicians did not report all suspicious injuries to child protective services, even if the level of suspicion was high (likely or very likely caused by child abuse). Child, family, and injury characteristics and clinician previous experiences influenced decisions to report.