COVID-19 pandemic related racial/ethnic disparities in the foster care system in the United States.

BACKGROUND: The impact of COVID-19 pandemic on racial/ethnic differences in the US foster care system is unknown. OBJECTIVE: To study the COVID-19 pandemic-related differences in racial/ethnic disparities in entry rates, exit rates, and adverse exits from foster care in US. METHODS: Dataset: Adoption and Foster Care Analysis Reporting System (AFCARS) data from Census Bureau. POPULATION: 1,040,581 children entering and 1,140,370 children exiting foster care between 2017 and 22, under age 25 years. ANALYSES: Age-group, sex, and race/ethnicity-specific entry rates were compared using Fisher's exact test. Exit rates and adverse exits were compared using Cox proportional hazard and logistic regression models respectively using difference-in-difference approach. RESULTS: Entry rates increased for all children <1 year during COVID [entry ratio = 2.75 (2.72, 2.78)], especially American Indian/Alaska Native (AIAN) [entry ratio = 3.00 (2.80, 3.22)]. Exit rates decreased for all children during pandemic [exit ratio (ER) for white children = 0.399 (0.395, 0.403), p < 0.0001] with persistent disparities for AIAN [ER = 0.86 (0.83, 0.90)] and Hispanic children [ER = 0.96 (0.94, 0.97)] compared to white children. Adverse exits increased slightly during pandemic for most racial/ethnic groups [OR for white children = 1.09 (1.06, 1.12), p < 0.0001] with increase in disparities for most children of color, except Asian children. The greatest increase in disparities was for AIAN children [OR for adverse exits compared to white children post pandemic = 9.43 (8.82, 10.07), p < 0.0001]. CONCLUSION: The pandemic adversely affected all children in foster care. Entry rates disproportionately increased for AIAN children. Disparities in exit rates persisted for AIAN and Hispanic children. Disparities in adverse exits increased for most children of color, especially, AIAN children.

A Quality Improvement Initiative to Minimize Unnecessary Chest X-Ray Utilization in Pediatric Asthma Exacerbations.

Background: Current national guidelines recommend against chest X-rays (CXRs) for patients with acute asthma exacerbation (AAE). The overuse of CXRs in AAE has become a concern, prompting the need for a quality improvement (QI) project to decrease CXR usage through guideline-based interventions. We aimed to reduce the percentage of CXRs not adhering to national guidelines obtained for pediatric patients presenting to the Emergency Department (ED) with AAE by 50% within 12 months of project initiation. Methods: We conducted this study at a New York City urban level-2 trauma center. The team was composed of members from the ED and pediatric departments. Electronic medical records of children aged 2 to 18 years presenting with AAE were evaluated. Monthly data on CXR utilization encompassing instances where the ordered CXR did not adhere to guidelines was collected before and after implementing interventions. The interventions included provider education, visual reminders, printed cards, grand-round presentations, and electronic medical records modifications. Results: The study encompassed 887 eligible patients with isolated AAE. Baseline data revealed a mean preintervention CXR noncompliance rate of 37.5% among children presenting to the ED with AAE. The interventions resulted in a notable decrease in unnecessary CXR utilization, reaching 16.7%, a reduction sustained throughout subsequent months. Conclusions: This QI project successfully reduced unnecessary CXR utilization in pediatric AAE. A multi-faceted approach involving education, visual aids, and electronic reminders aligned clinical practice with evidence-based guidelines. This QI initiative is a potential template for other healthcare institutions seeking to curtail unnecessary CXR usage in pediatric AAE.

Platelet parameters as biomarker for bronchopulmonary dysplasia in very low birth weight neonates in the first two weeks of life.

BACKGROUND: The pathogenesis of bronchopulmonary dysplasia (BPD) is attributed to the arrested lung development in premature infants. Studies showed the negative impact of inflammatory markers on the developing lung with higher levels of IL1, 6 and 8. Platelets contribute to the acute phase response of inflammation and are a direct source of IL-1ß. METHODS: We conducted a retrospective data review of all preterm babies with gestational age (GA) <32 weeks admitted to NICU to assess the relationship between platelet parameters in the first 2 weeks of life with the incidence and severity of BPD in very low birth weight (VLBW) neonates. RESULTS: Of 114 screened newborns, 92 were included after exclusion criteria. Of these, 62 (67.3%) developed BPD. Mean platelet count (PC) (P=0.008) and mean platelet mass index (PMI) (P=0.027) were significantly lower and mean platelet volume (MPV) (P=0.016) was significantly higher in the BPD group. The highest difference between groups was observed at 2nd week of life for PC and PMI and at 1st week for MPV. Using multivariate logistic analysis, only PC (P=0.017) showed statistical significance. MPV and PMI showed a positive interaction but did not achieve significance (P=0.066 for both). CONCLUSIONS: We concluded that platelet parameters in the first 2 weeks of life were associated with the incidence of BPD in VLBW neonates. PC may also predict the severity of BPD in these infants.

Complementary and alternative medicine for children with sickle cell disease: A systematic review.

BACKGROUND: Complementary and alternative medicine (CAM) is a popular alternative to opioid and other analgesics in sickle cell disease (SCD). We review the effectiveness, prevalence, and factors associated with CAM use in the pediatric SCD population. METHODS: The review protocol was created based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A literature search was conducted in MEDLINE, Embase, Cochrane Library, PubMed, and Web of Science. RESULTS: Twenty-four studies were examined. The prevalence of CAM use in pediatric patients with SCD ranged from 36 to 84.5%. Common inpatient CAM interventions were yoga, virtual reality, and acupuncture, which decreased pain scale scores. Outpatient CAMs were consisted of cognitive behavioral therapy, massage therapy, and guided-imagery, which increased pain tolerability and decreased pain scale scores. CONCLUSIONS: CAM modalities can decrease pain scale scores. However, the impact of specific CAM modalities on emergency department visits, hospitalizations, and school absences were inconclusive.

Role of Steroids in Sickle Cell Patients With Acute Chest Syndrome.

Background The role of corticosteroids to treat acute chest syndrome (ACS) in patients with sickle cell disease (SCD) has always been a matter of debate. In clinical practice, systemic steroids were given for ACS with more severe disease. With the lack of standard treatment guidelines, their use to treat ACS is highly physician-dependent and varies widely across different hospitals. The utility of corticosteroids in ACS remains unclear. The objective of our study was to describe the differences between SCD patients treated with corticosteroids for ACS and those who were not and to evaluate the association between corticosteroid use, length of stay, and readmission rates. Methodology We performed a retrospective chart review of patients with SCD ≤18 years of age hospitalized for ACS at Brookdale University Hospital Medical Center between January 2016 and May 2021. Results We identified 43 patients with 60 episodes of ACS (median age was 11 years and 55% were males). In total, 32 such episodes were treated with corticosteroids. The use of bronchodilators (p = 0.23), hydroxyurea (p = 0.13), and the presence of fever (p = 0.86) showed no significant difference between the two groups. The need for blood transfusions (p = 0.005), intensive care unit admission (p = 0.031), respiratory support (p = 0.011), and chest X-ray finding with more than one lobe involvement (p = 0.003) all point to moderate or severe ACS, which has been linked to steroid use. The length of hospital stay (p = 0.07) and the readmission rate (p = 0.31) were not statistically significant between the groups. Even in the subgroup with asthma, the length of stay was not different between the groups (p = 0.44). Conclusions Our results show that treatment with systemic steroids for ACS is associated with more severe disease. The length of hospital stay was not different between the steroid-treated and untreated groups. Corticosteroids were not associated with a higher readmission rate in our study population, even in ACS patients with comorbid asthma. Further adequately powered prospective trials are needed to investigate the efficacy of corticosteroids in ACS.

Asthma Outcome Measures Before and After the COVID-19 Outbreak Among the Pediatric Population in a Community Hospital.

Background The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic is a global health threat that has affected patient care enormously. Moderate to severe asthma was listed as a risk factor for severe SARS-CoV-2 disease by the Centers for Disease Control. Little is known about the impact of the pandemic on asthma control in children, particularly African American children. Objective The present study sought to determine how changes during the coronavirus disease 2019 (COVID-19) pandemic affected asthma metrics in a majority African American pediatric population at a pediatric pulmonology clinic in a community hospital in New York. Methods This is a retrospective, pre-post, comparative cross-sectional study that included children three to 18 years of age with a known diagnosis of asthma followed in a pulmonary clinic. Data were gathered from electronic medical records. Subjects were selected if they presented to a pulmonology clinic within a certain time window both before and after the outbreak of the COVID-19 pandemic. Outcome variables included asthma medication statistics and healthcare utilization statistics. Results Inclusion criteria were met by 104 pediatric patients. The majority were African American. Emergency department visits, primary physician visits, and hospitalizations significantly decreased in the post-COVID study group compared to the pre-COVID control group. Conclusion Among a majority African American pediatric population, there were significant improvements in asthma outcomes after COVID-19 societal changes when compared to before COVID-19 based on outcome variables.

Reversal of Opioid Intoxication in an Infant With Intrauterine Growth Restriction With a Single Dose of Naloxone.

Perinatal exposure to opioids might result in opioid intoxication in a newborn infant. The routine use of naloxone in an opioid-exposed newborn infant is discouraged due to the risks of precipitating withdrawal and long-term developmental problems associated with naloxone. We describe a case of respiratory and neurological depression in an infant with intrauterine growth restriction (IUGR) following in utero exposure to an opioid two hours before delivery. The infant was apneic with a poor tone immediately after birth. With positive pressure ventilation, the tone and respiratory effort improved, and the baby was admitted to the neonatal intensive care unit (NICU) on oxygen support via nasal cannula. The baby started having bradypnea with shallow breathing and oxygen desaturation at eight hours of life, most likely secondary to intrauterine exposure to hydromorphone which was successfully reversed with a single dose of intravenous naloxone. The infant was discharged on day of life seven with no further symptoms. Naloxone administration might be considered in an IUGR infant with persistent cardiorespiratory and neurological depression who has a history of intrauterine opioid exposure within four hours before delivery provided the mother is not narcotic dependent.

Assessment of Patient Safety Culture in a Pediatric Department.

Background An assessment of the prevalent culture needs to be the first step when building patient safety programs in healthcare organizations to achieve high-quality health care. Objective To conduct a baseline assessment of patient safety culture, to provide insight into the factors that contribute to patient safety, and to use the information to make improvements.  Methods The Hospital Survey on Patient Safety Culture (PSC) questionnaire was conducted from October through December 2020 at the Brookdale Hospital Medical Center (BHMC) Pediatric departments (Pediatric Inpatient Unit, Neonatal Intensive Care Unit [NICU], Pediatric Intensive Care Unit [PICU], and Pediatric Emergency Department) and four community-based ambulatory pediatric practices (Brookdale Family Care Centers [BFCC]). The percentages of positive responses on the 12 patient-safety dimensions and the summation of PSC and two outcomes (overall patient safety grade and adverse events reported in the past year) were assessed. Factors associated with PSC aggregate score were analyzed. Results From the 385 emails that were sent, 136 surveys were considered for analysis. This gives us a response rate of 35.3%. Most of the participants were nurses (58%) with direct contact with patients (94.2%). Most respondents did not report any events (60.7%), whereas 30.3% reported 1-2 events in the past year. The patient safety composites with the highest positive scores were teamwork within units (78%), supervisor/manager expectations and actions promoting patient safety (71.2%), and organizational learning--continuous improvement (66.8%). The composites with the lowest scores were non-punitive response to error (35.9%) and staffing (38%). Conclusions All of our composite measures, with the exception of teamwork within units, appear to be low, which means that all the other composite measures require interventions for improvement of overall safety culture. In order for healthcare leaders and policymakers to establish a culture of safety and improvement, they must create a climate of open communication, continuous learning, and eliminate the fear of blame and punitive feedback.

Characteristics of Newborns Born to SARS-CoV-2-Positive Mothers: A Retrospective Cohort Study.

OBJECTIVE: The novel virus known as severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has led to a terrifying pandemic. The range of illness severity among children is variable. This study aims to assess the characteristics of newborns born to SARS-CoV-2-positive women compared with those mothers who tested negative. STUDY DESIGN: This was a retrospective cohort study performed at Brookdale Hospital Medical Center in New York City from March to May 2020. Electronic medical records of mother-baby dyads were reviewed. RESULTS: Seventy-nine mothers tested for SARS-CoV-2 were included, out of which 18.98% of mothers tested SARS-CoV-2 positive. We found a significant association between symptoms and SARS-CoV-2 status. We observed a significant association between newborns of SARS-CoV-2 positive and SARS-CoV-2 negative mothers regarding skin-to-skin contact (p < 0.001). Both groups showed significant differences regarding isolation (p < 0.001). Interestingly, regarding SARS-CoV-2 infection in newborns, only one newborn tested SARS-CoV-2 positive and was unstable in the neonatal intensive care unit (NICU). With the multivariable logistic regression model, babies of SARS-CoV-2 positive mothers were three times as likely to have desaturations in comparison to newborns from negative mothers. Also, newborns of SARS-CoV-2-positive mothers were four times more likely to have poor feeding, compared with newborns of SARS-CoV-2-negative mothers. Finally, babies of SARS-CoV-2-positive mothers were ten times more likely to be symptomatic at the 2-week follow-up. CONCLUSION: SARS-CoV-2 has caused major morbidity and mortality worldwide. Neonates born to mothers with confirmed or suspected SARS-CoV-2 are most of the time asymptomatic. However, neonatal critical illness due to SARS-CoV-2 is still a possibility; thus, isolation precautions (such as avoiding skin-to-skin contact and direct breastfeeding) and vertical transmission should be studied thoroughly. In addition, testing these newborns by nasopharyngeal swab at least at 24 hours after birth and monitoring them for the development of symptoms for 14 days after birth is needed. KEY POINTS: · For SARS-CoV-2-positive mothers, reducing transmission of infection to newborns is crucial.. · Newborns of SARS-CoV-2-positive mothers are usually asymptomatic and may not be easily infected.. · Critical illness in the newborn may still happen, so monitoring is needed..

Facilitators and Barriers to Access to Pediatric Medical Services in a Community Hospital.

Background: Missed medical appointments decrease continuity of medical care, waste resources, and may affect health outcomes. We examined the factors associated with missed children's supervision visits in Eastern Brooklyn, NY, USA. Methods: We surveyed guardians whose children received routine medical care at four pediatric clinics. Participants filled out a questionnaire that queried: demographics, food security, recent relocation, parental support of healthy behaviors, and length of knowing provider. Preexisting disease(s) and missed visits were retrieved from medical records. Regression analyses were used to determine factors that were associated with missing medical appointments. Results: Among 213 families, 33% faced food insecurity and 16.4% reported moving within the past 12 months. Forty percent of children missed at least 1 visit. Food insecurity (adjusted odds ratio [aOR] 2.3, 95% confidence interval [CI 1.0% to 5.2%) and recent relocation (aOR 1.8, 95% CI 1.1-3.4 were associated with missed health supervision visits, whereas greater parental healthy behaviors (aOR 0.5, 95% CI 0.3-0.9) and longer length of knowing provider (aOR 0.8, 95% CI 0.7-1.0) were associated with fewer missed appointments. Conclusion: This study indicates that social inequity may contribute to poor adherence to medical appointments through multiple mechanisms, including food insecurity, lack of social stability, and parental health behaviors. Multidimensional proactive prevention, and reactive tolerance should be considered as opportunities to mitigate the impact of social inequity on health outcomes.

Low Income and Nonadherence to Health Supervision Visits Predispose Children to More Emergency Room Utilization.

Social inequity can have broad health impacts. The purpose of this study was to examine the effects of low income and nonadherence to health supervision visits on emergency room (ER) utilization in Eastern Brooklyn, New York. This study surveyed parents/guardians of children who received routine medical care at Brookdale ambulatory clinics from June 2017 to February 2018. Participants were asked to fill out a questionnaire on social demographics, food insecurity, and relocation. Electronic medical records (EMRs) were reviewed to retrieve numbers of missing health supervision and ER visit in past 12 months. Comorbidity was identified through EMR by International Classification of Diseases. Logistic regression analyses were used to examine the effects of nonadherence to health supervision visits on ER utilization when controlling for demographics, food insecurity, recent moving, and comorbidity. Among 268 participants, 56.0% reported their household income was less than $20,000 annually, 39.6% missed at least 1 health supervision visit, and 31.7% had at least 1 ER visit within the past 12 months. Younger age (adjusted odds ratio [aOR] = 0.92, 95% confidence interval [CI] = 0.86-0.97, P < .01), household income less than $20,000 (aOR = 1.86, 95% CI = 1.02-3.39), preexisting comorbidity (aOR = 2.36, 95% CI = 1.26-4.42), and nonadherence to health supervision visits (aOR = 5.83, 95% CI = 3.21-10.56) were associated with increased ER utilization. Nonadherence to health supervision visits is an independent risk factor and potentially modifiable. Evaluation and remediation should be pursued as a means of improving health outcomes of children in vulnerable circumstances.

A Brief Review of the Pharmacology of Hyperkalemia: Causes and Treatment.

Hyperkalemia is a common problem in both inpatients and outpatients. Many disease states (eg, chronic kidney disease) and medications may precipitate hyperkalemia. There are several drugs now available to treat hyperkalemia. Many of these drugs are relatively new. This review provides information regarding drug-induced causes of hyperkalemia and provides detailed information on the medications used to treat this problem.

Cardiometabolic Risk Factors, Metabolic Syndrome, and Chronic Kidney Disease Progression in Children.

OBJECTIVE: To estimate the prevalence of metabolic syndrome (MetS) and examine its association with chronic kidney disease progression in children enrolled in the Chronic Kidney Disease in Children study. STUDY DESIGN: MetS was defined as being overweight or obese and having ≥2 cardiometabolic risk factors (CMRFs). Incidence and prevalence of MetS were assessed using pairs of visits approximately 2 years apart. RESULTS: A total of 799 pairs of person-visits (contributed by 472 children) were included in the final analysis. Of these, 70% had a normal body mass index (BMI), 14% were overweight, and 16% were obese. At the first visit, the prevalence of MetS in the overweight group was 40% and in the obese group was 60%. In adjusted models, annual percent estimated glomerular filtration rate decline in those who had normal BMI and incident or persistent multiple CMRFs or those with persistent MetS was -6.33%, -6.46%, and -6.08% (respectively) compared with children who never had multiple CMRFs (-3.38%, P = .048, .045, and .036, respectively). Children with normal BMI and incident multiple CMRFs and those with persistent MetS had approximately twice the odds of fast estimated glomerular filtration rate decline (>10% per year) compared with those without multiple CMRFs and normal BMI. CONCLUSION: Children with chronic kidney disease have a high prevalence of MetS. These children as well as those with normal BMI but multiple CMRFs experience a faster decline in kidney function.

Preprocedure prophylaxis against endocarditis among United States pediatric cardiologists.

This study aimed to determine current practices regarding prophylaxis against infective endocarditis among pediatric cardiologists in the United States 5 years after publication of the most recent American Heart Association (AHA) recommendations. A descriptive, analytical, cross-sectional study was conducted from June 2012 to November 2012 in the format of an anonymous self-administered e-mailed questionnaire among pediatric cardiologists across the United States. The questionnaire inquired about demographic information of cardiologists and their current practices of prescribing preprocedure antibiotic prophylaxis against endocarditis to patients with specific preexisting cardiac conditions. Descriptive analyses were done in percentages. Frequency and exploratory statistical analyses were done by the Chi-square method. Of the 980 cardiologists invited, 221 (23 %) responded to the survey. The findings showed that pediatric cardiologists generally follow the AHA guidelines. The most common cardiac conditions in which antibiotics were administered despite AHA guidelines not requiring prophylaxis were rheumatic heart disease with aortic insufficiency, transposition of the great vessels after the Mustard procedure, bicuspid aortic valve with severe aortic stenosis, cardiac transplantation without valvar disease, and bicuspid aortic valve with severe aortic insufficiency. More experienced pediatric cardiologists were significantly more likely to administer prophylaxis to certain patients than their less experienced peers. Many pediatric cardiologists in the United States continue to administer preprocedure antibiotic prophylaxis against endocarditis even when not recommended to do so per the 2007 AHA guidelines. With certain lesions, highly experienced pediatric cardiologists are more likely to administer prophylaxis than their less experienced counterparts.

Incidence of congenital hypothyroidism and congenital adrenal hyperplasia at Flushing Hospital Medical Center.

BACKGROUND: Newborn screening (NBS) program is a simple and inexpensive method for early detection and treatment of over forty conditions as of 2005. Most cases of congenital hypothyroidism (CH) are sporadic and occurs in 1 in 3500 live births. Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders that occurs in 1 in 1600 live births. The detection of CH is determined by either low T4 and/or elevated TSH and the detection of CAH is determined by elevated 17OH progesterone on Guthrie filter paper. Infants who meet the above criteria on NBS for either condition must undergo confirmatory testing. OBJECTIVE: Is the incidence of CH and CAH at FHMC, a community hospital in northern Queens, New York serving a multiethnic population different from theincidence of CH and CAH in New York State (NYS)? DESIGN/METHODS: We reviewed records of the infants recalled and confirmed to have CH and CAH for 2000, 2001 and 2004 and compared with reported incidence of the same conditions in NYS. RESULTS: The total number of live births in NYS was 760,112 and in FHMC 6348 for the three years studied, accounting for 0.7 to 0.8% of total NYS live births. The population served by FHMC included 43% White, 35% Asian, 16% Hispanic, 3% Afro-American and 3% other. A total of 5 patients were identified to have CH in the three years studied, accounting for an incidence of 0.12 (p > 0.05). Three patients were identified to have CAH in 2004 or an incidence of 1.4 (p < 0.05). [Table 1]. CONCLUSIONS: The incidence rate of CH was similar to that of NYS. However, the incidence rate of CAH at FHMC was greater than that reported by NYS. This difference in incidence rate for CAH may be related to the ethnic composition of the population that FHMC serves. Pediatricians and pediatric endocrinologists must be cognizant of the signs and symptoms of CAH in certain populations known to have higher incidence for this condition. Further follow up of incidence rate for CAH at FHMC is indicated since CAH was added to the NBS in 2003.