Pediatrics

Research Hospital

New research has shown that childhood cancer survivors (CCSs) with certain germline mutations have higher relative rates (RRs) of secondary neoplasms (SNs) later in life.

Mutation carriers had significantly higher rates of breast cancer and sarcoma if they had received radiation to treat their initial cancer.

Among CCSs who did not receive radiation, the mutations were associated with increased rates of any SN, breast cancer, nonmelanoma skin cancer, and 2 or more histologically distinct SNs.

These findings were reported in the Journal of Clinical Oncology.

Researchers sequenced samples from 3006 CCSs who were at least 5 years from their initial cancer diagnosis as well as 341 samples from cancer-free control subjects.

All subjects were participants in the St. Jude Lifetime Cohort Study, a retrospective study with prospective clinical follow-up.

Thirty-five percent of the CCSs had survived leukemia, and 19% had survived lymphoma.

The CCS’s median age at childhood cancer diagnosis was 7.1 years, and the median follow-up was 28 years. The controls had a median age of 36.4 at follow-up.

Results

There were 1120 SNs diagnosed in 439 CCSs (14.6%). Ninety-one CCSs developed 2 or more histologically distinct SNs. The median time to SN diagnosis was 25.6 years

Non-melanoma skin cancer (580 in 159 CCSs), meningiomas (233 in 102 CCSs), thyroid cancer (67 in 67 CCSs), and breast cancer (60 in 53 CCSs) were among the SNs reported.

There were 15 neoplasms recorded in the control group—14 cases of non-melanoma skin cancer and 1 meningioma.

Pathogenic or likely pathogenic (P/LP) mutations in 32 genes were reported in 175 CCSs. The prevalence in CCSs (5.8%) was nearly 10-fold higher than in controls (0.6%).

The most commonly mutated genes in CCSs were RB1 (n=43), NF1 (n=22), BRCA2 (n=14), BRCA1 (n=12), and TP53 (n=10).

In a multivariable analysis adjusted for sex, age at primary cancer diagnosis, and treatment, P/LP mutation carriers had a significantly higher rate of any SN (RR=1.8).

The rate of subsequent breast cancer was significantly increased among females with a P/LP mutation (RR= 9.4), recipients of chest radiation (RR=7.9), and those with higher anthracycline exposure (RR=2.4).

The rate of subsequent sarcoma was significantly increased for mutation carriers (RR=10.9) and CCSs with greater exposure to alkylating agents (RR=3.8).

Among irradiated CCSs, P/LP mutations were associated with significantly increased rates of breast cancer (RR=13.9) and sarcoma (RR=10.6)

Among non-irradiated CCSs, P/LP mutations were associated with significantly increased rates of any SN (RR=4.7), breast cancer (RR=7.7), nonmelanoma skin cancer (RR=11.0), and 2 or more histologically distinct SNs (RR=18.6).

The researchers said the higher risk of SNs in CCSs with P/LP mutations suggests all CCSs should be referred for genetic counseling.

Research Hospital

New research has shown that childhood cancer survivors (CCSs) with certain germline mutations have higher relative rates (RRs) of secondary neoplasms (SNs) later in life.

Mutation carriers had significantly higher rates of breast cancer and sarcoma if they had received radiation to treat their initial cancer.

Among CCSs who did not receive radiation, the mutations were associated with increased rates of any SN, breast cancer, nonmelanoma skin cancer, and 2 or more histologically distinct SNs.

These findings were reported in the Journal of Clinical Oncology.

Researchers sequenced samples from 3006 CCSs who were at least 5 years from their initial cancer diagnosis as well as 341 samples from cancer-free control subjects.

All subjects were participants in the St. Jude Lifetime Cohort Study, a retrospective study with prospective clinical follow-up.

Thirty-five percent of the CCSs had survived leukemia, and 19% had survived lymphoma.

The CCS’s median age at childhood cancer diagnosis was 7.1 years, and the median follow-up was 28 years. The controls had a median age of 36.4 at follow-up.

Results

There were 1120 SNs diagnosed in 439 CCSs (14.6%). Ninety-one CCSs developed 2 or more histologically distinct SNs. The median time to SN diagnosis was 25.6 years

Non-melanoma skin cancer (580 in 159 CCSs), meningiomas (233 in 102 CCSs), thyroid cancer (67 in 67 CCSs), and breast cancer (60 in 53 CCSs) were among the SNs reported.

There were 15 neoplasms recorded in the control group—14 cases of non-melanoma skin cancer and 1 meningioma.

Pathogenic or likely pathogenic (P/LP) mutations in 32 genes were reported in 175 CCSs. The prevalence in CCSs (5.8%) was nearly 10-fold higher than in controls (0.6%).

The most commonly mutated genes in CCSs were RB1 (n=43), NF1 (n=22), BRCA2 (n=14), BRCA1 (n=12), and TP53 (n=10).

In a multivariable analysis adjusted for sex, age at primary cancer diagnosis, and treatment, P/LP mutation carriers had a significantly higher rate of any SN (RR=1.8).

The rate of subsequent breast cancer was significantly increased among females with a P/LP mutation (RR= 9.4), recipients of chest radiation (RR=7.9), and those with higher anthracycline exposure (RR=2.4).

The rate of subsequent sarcoma was significantly increased for mutation carriers (RR=10.9) and CCSs with greater exposure to alkylating agents (RR=3.8).

Among irradiated CCSs, P/LP mutations were associated with significantly increased rates of breast cancer (RR=13.9) and sarcoma (RR=10.6)

Among non-irradiated CCSs, P/LP mutations were associated with significantly increased rates of any SN (RR=4.7), breast cancer (RR=7.7), nonmelanoma skin cancer (RR=11.0), and 2 or more histologically distinct SNs (RR=18.6).

The researchers said the higher risk of SNs in CCSs with P/LP mutations suggests all CCSs should be referred for genetic counseling.

Research Hospital

New research has shown that childhood cancer survivors (CCSs) with certain germline mutations have higher relative rates (RRs) of secondary neoplasms (SNs) later in life.

Mutation carriers had significantly higher rates of breast cancer and sarcoma if they had received radiation to treat their initial cancer.

Among CCSs who did not receive radiation, the mutations were associated with increased rates of any SN, breast cancer, nonmelanoma skin cancer, and 2 or more histologically distinct SNs.

These findings were reported in the Journal of Clinical Oncology.

Researchers sequenced samples from 3006 CCSs who were at least 5 years from their initial cancer diagnosis as well as 341 samples from cancer-free control subjects.

All subjects were participants in the St. Jude Lifetime Cohort Study, a retrospective study with prospective clinical follow-up.

Thirty-five percent of the CCSs had survived leukemia, and 19% had survived lymphoma.

The CCS’s median age at childhood cancer diagnosis was 7.1 years, and the median follow-up was 28 years. The controls had a median age of 36.4 at follow-up.

Results

There were 1120 SNs diagnosed in 439 CCSs (14.6%). Ninety-one CCSs developed 2 or more histologically distinct SNs. The median time to SN diagnosis was 25.6 years

Non-melanoma skin cancer (580 in 159 CCSs), meningiomas (233 in 102 CCSs), thyroid cancer (67 in 67 CCSs), and breast cancer (60 in 53 CCSs) were among the SNs reported.

There were 15 neoplasms recorded in the control group—14 cases of non-melanoma skin cancer and 1 meningioma.

Pathogenic or likely pathogenic (P/LP) mutations in 32 genes were reported in 175 CCSs. The prevalence in CCSs (5.8%) was nearly 10-fold higher than in controls (0.6%).

The most commonly mutated genes in CCSs were RB1 (n=43), NF1 (n=22), BRCA2 (n=14), BRCA1 (n=12), and TP53 (n=10).

In a multivariable analysis adjusted for sex, age at primary cancer diagnosis, and treatment, P/LP mutation carriers had a significantly higher rate of any SN (RR=1.8).

The rate of subsequent breast cancer was significantly increased among females with a P/LP mutation (RR= 9.4), recipients of chest radiation (RR=7.9), and those with higher anthracycline exposure (RR=2.4).

The rate of subsequent sarcoma was significantly increased for mutation carriers (RR=10.9) and CCSs with greater exposure to alkylating agents (RR=3.8).

Among irradiated CCSs, P/LP mutations were associated with significantly increased rates of breast cancer (RR=13.9) and sarcoma (RR=10.6)

Among non-irradiated CCSs, P/LP mutations were associated with significantly increased rates of any SN (RR=4.7), breast cancer (RR=7.7), nonmelanoma skin cancer (RR=11.0), and 2 or more histologically distinct SNs (RR=18.6).

The researchers said the higher risk of SNs in CCSs with P/LP mutations suggests all CCSs should be referred for genetic counseling.

 

MALMO, SWEDEN – Robust human papillomavirus antibody responses persist through 36 months in boys and girls who received two doses of the 9-valent HPV vaccine known as Gardasil 9 at age 9-14 years, according to an open-label randomized immunogenicity study conducted in 15 countries.

luiscar/Thinkstock

This is reassuring news supportive of regulatory decisions made in 2016/2017 to license the more convenient two-dose schedule in the United States, European Union, Canada, and other countries, Rosybel Drury, PhD, observed in reporting the results at the annual meeting of the European Society for Paediatric Infectious Diseases.

Moreover, HPV type-specific antibody levels at 36 months post vaccination in boys and girls who received two doses were similar to or greater than in the 36-month follow-up of adolescent and young adult females who received three doses at ages 16-26 years.

“This result supports the bridging of efficacy findings in young women receiving three doses to girls and boys receiving two doses,” according to Dr. Drury, a vaccine scientist at Merck Sharp & Dohme in Lyon, France.

Bruce Jancin/MDedge News

She presented an update of a five-cohort study including roughly 1,500 recipients of either two doses of the 9-valent HPV vaccine given 6 or 12 months apart or three doses administered at 0, 2, and 6 months. Four cohorts were composed of 9- to 14-year-olds. The fifth consisted of adolescent girls and young women who got three doses of Gardasil 9 over the course of 6 months at ages 16-26 years. The previous report from this major study provided only short-term data based upon measurements of immunogenicity obtained 1 month after the last dose of vaccine (JAMA. 2016 Dec. 13;316(22):2411-21).

Anti-HPV geometric mean titers were highest 1 month after completing a two- or three-dose series, dropped off sharply during the next 6-12 months, then declined more slowly through 36 months.

While the demonstration of persistent immunogenicity over 3 years of follow-up was reassuring overall, there was a potential hitch: Significantly lower antibody levels for some HPV types were observed in girls who received two doses of the vaccine than in those who got three. Specifically, levels of anti-HPV antibodies to HPV types 18, 31, 45, and 52 were significantly lower in the girls who got two doses of the 9-valent HPV vaccine than in those who got three doses at the same age. Antibody levels directed against HPV types 6, 11, 16, 33, and 58 were similar in the two patient populations.

“The clinical significance of this finding remains unknown,” Dr. Drury said.

Challenged as to why the study didn’t include a single-dose vaccine arm, which would be the preferred preventive strategy in low-income countries where the burden of anogenital cancers and warts due to HPV is greatest, she replied that while there is great interest in this approach, and some modeling studies suggest it would be beneficial, the study she presented was designed to evaluate immunogenicity over time, not clinical efficacy, which needs to be assessed before single-dose public health programs are implemented.

The study was funded by Merck and presented by a company employee.

 

bjancin@mdedge.com

 

MALMO, SWEDEN – Robust human papillomavirus antibody responses persist through 36 months in boys and girls who received two doses of the 9-valent HPV vaccine known as Gardasil 9 at age 9-14 years, according to an open-label randomized immunogenicity study conducted in 15 countries.

luiscar/Thinkstock

This is reassuring news supportive of regulatory decisions made in 2016/2017 to license the more convenient two-dose schedule in the United States, European Union, Canada, and other countries, Rosybel Drury, PhD, observed in reporting the results at the annual meeting of the European Society for Paediatric Infectious Diseases.

Moreover, HPV type-specific antibody levels at 36 months post vaccination in boys and girls who received two doses were similar to or greater than in the 36-month follow-up of adolescent and young adult females who received three doses at ages 16-26 years.

“This result supports the bridging of efficacy findings in young women receiving three doses to girls and boys receiving two doses,” according to Dr. Drury, a vaccine scientist at Merck Sharp & Dohme in Lyon, France.

Bruce Jancin/MDedge News

She presented an update of a five-cohort study including roughly 1,500 recipients of either two doses of the 9-valent HPV vaccine given 6 or 12 months apart or three doses administered at 0, 2, and 6 months. Four cohorts were composed of 9- to 14-year-olds. The fifth consisted of adolescent girls and young women who got three doses of Gardasil 9 over the course of 6 months at ages 16-26 years. The previous report from this major study provided only short-term data based upon measurements of immunogenicity obtained 1 month after the last dose of vaccine (JAMA. 2016 Dec. 13;316(22):2411-21).

Anti-HPV geometric mean titers were highest 1 month after completing a two- or three-dose series, dropped off sharply during the next 6-12 months, then declined more slowly through 36 months.

While the demonstration of persistent immunogenicity over 3 years of follow-up was reassuring overall, there was a potential hitch: Significantly lower antibody levels for some HPV types were observed in girls who received two doses of the vaccine than in those who got three. Specifically, levels of anti-HPV antibodies to HPV types 18, 31, 45, and 52 were significantly lower in the girls who got two doses of the 9-valent HPV vaccine than in those who got three doses at the same age. Antibody levels directed against HPV types 6, 11, 16, 33, and 58 were similar in the two patient populations.

“The clinical significance of this finding remains unknown,” Dr. Drury said.

Challenged as to why the study didn’t include a single-dose vaccine arm, which would be the preferred preventive strategy in low-income countries where the burden of anogenital cancers and warts due to HPV is greatest, she replied that while there is great interest in this approach, and some modeling studies suggest it would be beneficial, the study she presented was designed to evaluate immunogenicity over time, not clinical efficacy, which needs to be assessed before single-dose public health programs are implemented.

The study was funded by Merck and presented by a company employee.

 

bjancin@mdedge.com

 

MALMO, SWEDEN – Robust human papillomavirus antibody responses persist through 36 months in boys and girls who received two doses of the 9-valent HPV vaccine known as Gardasil 9 at age 9-14 years, according to an open-label randomized immunogenicity study conducted in 15 countries.

luiscar/Thinkstock

This is reassuring news supportive of regulatory decisions made in 2016/2017 to license the more convenient two-dose schedule in the United States, European Union, Canada, and other countries, Rosybel Drury, PhD, observed in reporting the results at the annual meeting of the European Society for Paediatric Infectious Diseases.

Moreover, HPV type-specific antibody levels at 36 months post vaccination in boys and girls who received two doses were similar to or greater than in the 36-month follow-up of adolescent and young adult females who received three doses at ages 16-26 years.

“This result supports the bridging of efficacy findings in young women receiving three doses to girls and boys receiving two doses,” according to Dr. Drury, a vaccine scientist at Merck Sharp & Dohme in Lyon, France.

Bruce Jancin/MDedge News

She presented an update of a five-cohort study including roughly 1,500 recipients of either two doses of the 9-valent HPV vaccine given 6 or 12 months apart or three doses administered at 0, 2, and 6 months. Four cohorts were composed of 9- to 14-year-olds. The fifth consisted of adolescent girls and young women who got three doses of Gardasil 9 over the course of 6 months at ages 16-26 years. The previous report from this major study provided only short-term data based upon measurements of immunogenicity obtained 1 month after the last dose of vaccine (JAMA. 2016 Dec. 13;316(22):2411-21).

Anti-HPV geometric mean titers were highest 1 month after completing a two- or three-dose series, dropped off sharply during the next 6-12 months, then declined more slowly through 36 months.

While the demonstration of persistent immunogenicity over 3 years of follow-up was reassuring overall, there was a potential hitch: Significantly lower antibody levels for some HPV types were observed in girls who received two doses of the vaccine than in those who got three. Specifically, levels of anti-HPV antibodies to HPV types 18, 31, 45, and 52 were significantly lower in the girls who got two doses of the 9-valent HPV vaccine than in those who got three doses at the same age. Antibody levels directed against HPV types 6, 11, 16, 33, and 58 were similar in the two patient populations.

“The clinical significance of this finding remains unknown,” Dr. Drury said.

Challenged as to why the study didn’t include a single-dose vaccine arm, which would be the preferred preventive strategy in low-income countries where the burden of anogenital cancers and warts due to HPV is greatest, she replied that while there is great interest in this approach, and some modeling studies suggest it would be beneficial, the study she presented was designed to evaluate immunogenicity over time, not clinical efficacy, which needs to be assessed before single-dose public health programs are implemented.

The study was funded by Merck and presented by a company employee.

 

bjancin@mdedge.com

 

A study published in the British Medical Journal found that women who practiced five healthy habits had children who when they reached adolescence were 75% less likely to be overweight, compared with women who practiced none of the those healthy habits.

 

iStockphoto

The healthy habits were maintaining a healthy weight, eating a nutritious diet, exercising regularly, not smoking, and consuming no more than a moderate amount of alcohol (BMJ 2018;362:k2486). I suspect you aren’t surprised by the core finding of this study of 16,945 female nurses and their 24,289 children. You’ve seen it scores of times. Mothers who lead unhealthy lifestyles seem to have children who are more likely to be obese. Now you have some numbers to support your decades of anecdotal observations. But the question is, what are we supposed to do with this new data? When and with whom should we share this unfortunate truth?

Evidence from previous studies makes it clear that by the time a child enters grade school the die is cast. Baby fat is neither cute nor temporary. This means that our target audience must be mothers-to-be and women whose children are infants and toddlers. On the other hand, telling the mother of an overweight teenager that her own unhealthy habits have probably contributed to her child’s weight problem is cruel and a waste of time. The mother already may have suspected her culpability. She also may feel that it is too late to do anything about it. While there have been some studies looking for an association between paternal body mass index and offspring BMI, I was unable to find any addressing paternal lifestyle and adolescent obesity.

This new study doesn’t address the unusual situation in which a mother of a teenager sheds all five of her unhealthy habits. I guess there may be examples in which a mother’s positive lifestyle change has helped reverse her adolescent child’s path to obesity. But I suspect these cases are rare.

©monkeybusinessimages/thinkstockphotos.com

So on one hand we would like to get the message out to mothers who still have time to rid themselves of their unhealthy habits, but on the other we must be careful to avoid playing the blame game and giving other mothers a one-way ticket on the guilt train. This is just one more example of the tightrope that we have been walking for generations. Every day in our offices we see children whose health is endangered by their parents’ behaviors and lifestyles. In cases in which the parental behavior is creating a serious short-term risk, such as failing to use an appropriate motor vehicle safety restraint system, we have no qualms about speaking out. We aren’t afraid to do a little shaming in hopes of sparing a family a serious guilt trip. When the threat to the child is more abstract and less dramatic – such as vaccine refusal – shaming and education don’t seem to be effective in changing parental behavior.

Obesity presents its own collection of complexities. It is like a car wreck seen in slow motion as the plots on the growth chart accumulate pound by pound. Unfortunately, parents often are among the last to notice or accept the reality. This new study doesn’t tell us whether we can make a difference. But it does suggest that when we first see the warning signs on the growth chart that we should engage the parents in a discussion of their lifestyle and its possible association with the child’s weight gain. The challenge, of course, is how one can cast the discussion without sounding judgmental.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.

 

A study published in the British Medical Journal found that women who practiced five healthy habits had children who when they reached adolescence were 75% less likely to be overweight, compared with women who practiced none of the those healthy habits.

 

iStockphoto

The healthy habits were maintaining a healthy weight, eating a nutritious diet, exercising regularly, not smoking, and consuming no more than a moderate amount of alcohol (BMJ 2018;362:k2486). I suspect you aren’t surprised by the core finding of this study of 16,945 female nurses and their 24,289 children. You’ve seen it scores of times. Mothers who lead unhealthy lifestyles seem to have children who are more likely to be obese. Now you have some numbers to support your decades of anecdotal observations. But the question is, what are we supposed to do with this new data? When and with whom should we share this unfortunate truth?

Evidence from previous studies makes it clear that by the time a child enters grade school the die is cast. Baby fat is neither cute nor temporary. This means that our target audience must be mothers-to-be and women whose children are infants and toddlers. On the other hand, telling the mother of an overweight teenager that her own unhealthy habits have probably contributed to her child’s weight problem is cruel and a waste of time. The mother already may have suspected her culpability. She also may feel that it is too late to do anything about it. While there have been some studies looking for an association between paternal body mass index and offspring BMI, I was unable to find any addressing paternal lifestyle and adolescent obesity.

This new study doesn’t address the unusual situation in which a mother of a teenager sheds all five of her unhealthy habits. I guess there may be examples in which a mother’s positive lifestyle change has helped reverse her adolescent child’s path to obesity. But I suspect these cases are rare.

©monkeybusinessimages/thinkstockphotos.com

So on one hand we would like to get the message out to mothers who still have time to rid themselves of their unhealthy habits, but on the other we must be careful to avoid playing the blame game and giving other mothers a one-way ticket on the guilt train. This is just one more example of the tightrope that we have been walking for generations. Every day in our offices we see children whose health is endangered by their parents’ behaviors and lifestyles. In cases in which the parental behavior is creating a serious short-term risk, such as failing to use an appropriate motor vehicle safety restraint system, we have no qualms about speaking out. We aren’t afraid to do a little shaming in hopes of sparing a family a serious guilt trip. When the threat to the child is more abstract and less dramatic – such as vaccine refusal – shaming and education don’t seem to be effective in changing parental behavior.

Obesity presents its own collection of complexities. It is like a car wreck seen in slow motion as the plots on the growth chart accumulate pound by pound. Unfortunately, parents often are among the last to notice or accept the reality. This new study doesn’t tell us whether we can make a difference. But it does suggest that when we first see the warning signs on the growth chart that we should engage the parents in a discussion of their lifestyle and its possible association with the child’s weight gain. The challenge, of course, is how one can cast the discussion without sounding judgmental.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.

 

A study published in the British Medical Journal found that women who practiced five healthy habits had children who when they reached adolescence were 75% less likely to be overweight, compared with women who practiced none of the those healthy habits.

 

iStockphoto

The healthy habits were maintaining a healthy weight, eating a nutritious diet, exercising regularly, not smoking, and consuming no more than a moderate amount of alcohol (BMJ 2018;362:k2486). I suspect you aren’t surprised by the core finding of this study of 16,945 female nurses and their 24,289 children. You’ve seen it scores of times. Mothers who lead unhealthy lifestyles seem to have children who are more likely to be obese. Now you have some numbers to support your decades of anecdotal observations. But the question is, what are we supposed to do with this new data? When and with whom should we share this unfortunate truth?

Evidence from previous studies makes it clear that by the time a child enters grade school the die is cast. Baby fat is neither cute nor temporary. This means that our target audience must be mothers-to-be and women whose children are infants and toddlers. On the other hand, telling the mother of an overweight teenager that her own unhealthy habits have probably contributed to her child’s weight problem is cruel and a waste of time. The mother already may have suspected her culpability. She also may feel that it is too late to do anything about it. While there have been some studies looking for an association between paternal body mass index and offspring BMI, I was unable to find any addressing paternal lifestyle and adolescent obesity.

This new study doesn’t address the unusual situation in which a mother of a teenager sheds all five of her unhealthy habits. I guess there may be examples in which a mother’s positive lifestyle change has helped reverse her adolescent child’s path to obesity. But I suspect these cases are rare.

©monkeybusinessimages/thinkstockphotos.com

So on one hand we would like to get the message out to mothers who still have time to rid themselves of their unhealthy habits, but on the other we must be careful to avoid playing the blame game and giving other mothers a one-way ticket on the guilt train. This is just one more example of the tightrope that we have been walking for generations. Every day in our offices we see children whose health is endangered by their parents’ behaviors and lifestyles. In cases in which the parental behavior is creating a serious short-term risk, such as failing to use an appropriate motor vehicle safety restraint system, we have no qualms about speaking out. We aren’t afraid to do a little shaming in hopes of sparing a family a serious guilt trip. When the threat to the child is more abstract and less dramatic – such as vaccine refusal – shaming and education don’t seem to be effective in changing parental behavior.

Obesity presents its own collection of complexities. It is like a car wreck seen in slow motion as the plots on the growth chart accumulate pound by pound. Unfortunately, parents often are among the last to notice or accept the reality. This new study doesn’t tell us whether we can make a difference. But it does suggest that when we first see the warning signs on the growth chart that we should engage the parents in a discussion of their lifestyle and its possible association with the child’s weight gain. The challenge, of course, is how one can cast the discussion without sounding judgmental.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.

TORONTO – Researchers at UCSF Benioff Children’s Hospital in San Francisco implemented a novel intervention that leveraged existing in-room technology to expedite antiepileptic drug administration to inpatients having a seizure.

With the quality initiative, they were able to decrease median time from seizure onset to benzodiazepine (BZD) administration from 7 minutes (preintervention) to 2 minutes (post intervention) and reduce the median time from order to administration of second-phase non-BZDs from 28 minutes to 11 minutes.

©drpnncpp/thinkstockphotos.com

“Leveraging existing patient room technology to mobilize pharmacy to the bedside expedited non-BZD administration by 60%,” reported principal investigator Arpi Bekmezian, MD, a pediatric hospitalist and medical director of quality and safety at Benioff Children’s Hospital. She presented the findings at the Pediatric Academic Societies annual meeting.

“Furthermore, the rapid-response seizure rescue process may have created an increased sense of urgency helping to expedite initial BZD administration by 70%. ... This may have prevented the need for second-phase therapy and progression to status epilepticus, potentially minimizing the risk of neuronal injury, and all without the additional resources of a Code team.”

Early and rapid escalation of treatment is critical to prevent neuronal injury in patients with status epilepticus. Guidelines recommend initial antiepileptic therapy at 5 minutes, with rapid escalation to second-phase therapy if the seizure persists.

Preintervention baseline data from UCSF Benioff Children’s indicated a 7-minute lag time from seizure onset to BZD therapy and a 28-minute lag from order to administration of non-BZDs (phenobarbital, phenytoin, levetiracetam, valproic acid). Other studies have shown significantly greater delays to antiepileptic treatment.

“That was just too long, and it matched our clinical experience of being at the bedside of a seizing patient and wondering why the medication was taking so long to arrive from the pharmacy.”

The researchers set out to reduce time to BZD administration from 7 minutes to 5 minutes or less and to reduce time to second-phase non-BZD administration to less than 10 minutes. To accomplish this, a multidisciplinary team that included leadership from physicians, pharmacy, and nursing defined primary and secondary drivers of efficiency, with interventions targeting both team communication and medication delivery.

The intervention period lasted 16 months, during which time there were 61 seizure events requiring urgent antiepileptic treatment. Complete data were available for 57 seizures.

Among the interventions they implemented was to stock all medication-dispensing stations with intranasal/buccal BZD available on “nursing override” for easy access and administration.

Because non-BZDs require pharmacy compounding, and the main pharmacy receives many STAT orders with competing priorities, they developed a hospitalwide “seizure rescue” (SR) process by using patient-room staff terminals to activate a dedicated individual from the pharmacy, who would then report to the bedside with a backpack stocked with non-BZDs ready to compound. Nurses were trained to press the SR button for any seizure that may require urgent therapy.

“We didn’t want nurses to waste time on the phone [calling pharmacy], and we considered calling a Code, but we couldn’t really justify the resource utilization as most of these patients didn’t have respiratory compromise, and they didn’t need the whole Code team,” said Dr. Bekmezian. She noted that her hospital strongly discourages bedside compounding by nursing staff.

Instead, they realized they could easily reprogram the patient-room electronic staff terminals to have a dedicated SR button that would directly alert a dedicated pharmacist carrying the SR phone. The pharmacist could then swipe and confirm that they received the alert and let the nurse know they were on the way, “and this would free up the nurse to go ahead and obtain the benzodiazepines and administer them as pharmacy made their way to the room.”

“To our knowledge, this is the first study to report expediting antiepileptic drug delivery to patients in the hospital,” said Dr. Bekmezian. She noted that less than 50% of cases actually required pharmacist response, “but the pharmacy staff chose to be activated earlier in the management algorithm to avoid delays in treatment.”

UCSF Children’s Hospital San Francisco campus is a 183-bed, tertiary care, teaching children’s hospital that has pediatric, neonatal, and cardiac intensive care units and set-down units. They provide liver, bone marrow, kidney, and cardiac transplantation and have more than 10,000 annual admissions.

The investigators reported no conflicts of interest.

 

SOURCE: Bekmezian A et al. PAS 2018. Abstract 3545.3.

TORONTO – Researchers at UCSF Benioff Children’s Hospital in San Francisco implemented a novel intervention that leveraged existing in-room technology to expedite antiepileptic drug administration to inpatients having a seizure.

With the quality initiative, they were able to decrease median time from seizure onset to benzodiazepine (BZD) administration from 7 minutes (preintervention) to 2 minutes (post intervention) and reduce the median time from order to administration of second-phase non-BZDs from 28 minutes to 11 minutes.

©drpnncpp/thinkstockphotos.com

“Leveraging existing patient room technology to mobilize pharmacy to the bedside expedited non-BZD administration by 60%,” reported principal investigator Arpi Bekmezian, MD, a pediatric hospitalist and medical director of quality and safety at Benioff Children’s Hospital. She presented the findings at the Pediatric Academic Societies annual meeting.

“Furthermore, the rapid-response seizure rescue process may have created an increased sense of urgency helping to expedite initial BZD administration by 70%. ... This may have prevented the need for second-phase therapy and progression to status epilepticus, potentially minimizing the risk of neuronal injury, and all without the additional resources of a Code team.”

Early and rapid escalation of treatment is critical to prevent neuronal injury in patients with status epilepticus. Guidelines recommend initial antiepileptic therapy at 5 minutes, with rapid escalation to second-phase therapy if the seizure persists.

Preintervention baseline data from UCSF Benioff Children’s indicated a 7-minute lag time from seizure onset to BZD therapy and a 28-minute lag from order to administration of non-BZDs (phenobarbital, phenytoin, levetiracetam, valproic acid). Other studies have shown significantly greater delays to antiepileptic treatment.

“That was just too long, and it matched our clinical experience of being at the bedside of a seizing patient and wondering why the medication was taking so long to arrive from the pharmacy.”

The researchers set out to reduce time to BZD administration from 7 minutes to 5 minutes or less and to reduce time to second-phase non-BZD administration to less than 10 minutes. To accomplish this, a multidisciplinary team that included leadership from physicians, pharmacy, and nursing defined primary and secondary drivers of efficiency, with interventions targeting both team communication and medication delivery.

The intervention period lasted 16 months, during which time there were 61 seizure events requiring urgent antiepileptic treatment. Complete data were available for 57 seizures.

Among the interventions they implemented was to stock all medication-dispensing stations with intranasal/buccal BZD available on “nursing override” for easy access and administration.

Because non-BZDs require pharmacy compounding, and the main pharmacy receives many STAT orders with competing priorities, they developed a hospitalwide “seizure rescue” (SR) process by using patient-room staff terminals to activate a dedicated individual from the pharmacy, who would then report to the bedside with a backpack stocked with non-BZDs ready to compound. Nurses were trained to press the SR button for any seizure that may require urgent therapy.

“We didn’t want nurses to waste time on the phone [calling pharmacy], and we considered calling a Code, but we couldn’t really justify the resource utilization as most of these patients didn’t have respiratory compromise, and they didn’t need the whole Code team,” said Dr. Bekmezian. She noted that her hospital strongly discourages bedside compounding by nursing staff.

Instead, they realized they could easily reprogram the patient-room electronic staff terminals to have a dedicated SR button that would directly alert a dedicated pharmacist carrying the SR phone. The pharmacist could then swipe and confirm that they received the alert and let the nurse know they were on the way, “and this would free up the nurse to go ahead and obtain the benzodiazepines and administer them as pharmacy made their way to the room.”

“To our knowledge, this is the first study to report expediting antiepileptic drug delivery to patients in the hospital,” said Dr. Bekmezian. She noted that less than 50% of cases actually required pharmacist response, “but the pharmacy staff chose to be activated earlier in the management algorithm to avoid delays in treatment.”

UCSF Children’s Hospital San Francisco campus is a 183-bed, tertiary care, teaching children’s hospital that has pediatric, neonatal, and cardiac intensive care units and set-down units. They provide liver, bone marrow, kidney, and cardiac transplantation and have more than 10,000 annual admissions.

The investigators reported no conflicts of interest.

 

SOURCE: Bekmezian A et al. PAS 2018. Abstract 3545.3.

TORONTO – Researchers at UCSF Benioff Children’s Hospital in San Francisco implemented a novel intervention that leveraged existing in-room technology to expedite antiepileptic drug administration to inpatients having a seizure.

With the quality initiative, they were able to decrease median time from seizure onset to benzodiazepine (BZD) administration from 7 minutes (preintervention) to 2 minutes (post intervention) and reduce the median time from order to administration of second-phase non-BZDs from 28 minutes to 11 minutes.

©drpnncpp/thinkstockphotos.com

“Leveraging existing patient room technology to mobilize pharmacy to the bedside expedited non-BZD administration by 60%,” reported principal investigator Arpi Bekmezian, MD, a pediatric hospitalist and medical director of quality and safety at Benioff Children’s Hospital. She presented the findings at the Pediatric Academic Societies annual meeting.

“Furthermore, the rapid-response seizure rescue process may have created an increased sense of urgency helping to expedite initial BZD administration by 70%. ... This may have prevented the need for second-phase therapy and progression to status epilepticus, potentially minimizing the risk of neuronal injury, and all without the additional resources of a Code team.”

Early and rapid escalation of treatment is critical to prevent neuronal injury in patients with status epilepticus. Guidelines recommend initial antiepileptic therapy at 5 minutes, with rapid escalation to second-phase therapy if the seizure persists.

Preintervention baseline data from UCSF Benioff Children’s indicated a 7-minute lag time from seizure onset to BZD therapy and a 28-minute lag from order to administration of non-BZDs (phenobarbital, phenytoin, levetiracetam, valproic acid). Other studies have shown significantly greater delays to antiepileptic treatment.

“That was just too long, and it matched our clinical experience of being at the bedside of a seizing patient and wondering why the medication was taking so long to arrive from the pharmacy.”

The researchers set out to reduce time to BZD administration from 7 minutes to 5 minutes or less and to reduce time to second-phase non-BZD administration to less than 10 minutes. To accomplish this, a multidisciplinary team that included leadership from physicians, pharmacy, and nursing defined primary and secondary drivers of efficiency, with interventions targeting both team communication and medication delivery.

The intervention period lasted 16 months, during which time there were 61 seizure events requiring urgent antiepileptic treatment. Complete data were available for 57 seizures.

Among the interventions they implemented was to stock all medication-dispensing stations with intranasal/buccal BZD available on “nursing override” for easy access and administration.

Because non-BZDs require pharmacy compounding, and the main pharmacy receives many STAT orders with competing priorities, they developed a hospitalwide “seizure rescue” (SR) process by using patient-room staff terminals to activate a dedicated individual from the pharmacy, who would then report to the bedside with a backpack stocked with non-BZDs ready to compound. Nurses were trained to press the SR button for any seizure that may require urgent therapy.

“We didn’t want nurses to waste time on the phone [calling pharmacy], and we considered calling a Code, but we couldn’t really justify the resource utilization as most of these patients didn’t have respiratory compromise, and they didn’t need the whole Code team,” said Dr. Bekmezian. She noted that her hospital strongly discourages bedside compounding by nursing staff.

Instead, they realized they could easily reprogram the patient-room electronic staff terminals to have a dedicated SR button that would directly alert a dedicated pharmacist carrying the SR phone. The pharmacist could then swipe and confirm that they received the alert and let the nurse know they were on the way, “and this would free up the nurse to go ahead and obtain the benzodiazepines and administer them as pharmacy made their way to the room.”

“To our knowledge, this is the first study to report expediting antiepileptic drug delivery to patients in the hospital,” said Dr. Bekmezian. She noted that less than 50% of cases actually required pharmacist response, “but the pharmacy staff chose to be activated earlier in the management algorithm to avoid delays in treatment.”

UCSF Children’s Hospital San Francisco campus is a 183-bed, tertiary care, teaching children’s hospital that has pediatric, neonatal, and cardiac intensive care units and set-down units. They provide liver, bone marrow, kidney, and cardiac transplantation and have more than 10,000 annual admissions.

The investigators reported no conflicts of interest.

 

SOURCE: Bekmezian A et al. PAS 2018. Abstract 3545.3.

As I began my career in pediatric hospital medicine at the Monroe Carell Jr. Children’s Hospital at Vanderbilt in Nashville, Tenn., I knew that I wanted a way to continue my education and to network with other hospitalists with interests in academics and pediatrics.

In 2010, I decided to attend a pre-course to the Society of Hospital Medicine’s annual conference that focused on academic hospital medicine, and my career has never been the same! I am thrilled to say I have found my professional home in SHM.

Here’s a quick list of the reasons SHM has been such a warm, welcoming home for me. I’ve highlighted the few options that stood out to me, but rest assured there is so much more from which to choose:

• Leadership opportunities in our Pediatrics Special Interest Group.
• Representation on the Annual Conference Committee to select pediatric-specific content as well as workshops on leadership, education, patient experience, and quality improvement.
• The Academic Hospitalist Academy, first as a pre-course before the SHM annual conference, and now as its own amazing meeting for academic pediatric hospital medicine providers.
• SHM’s Leadership Academy, a wonderful opportunity to learn leadership skills and network with other leaders. This year, it is in Vancouver!
• Participation in quality improvement initiatives like Pedi-BOOST, a care transitions program that specializes in pediatric patients.
• Traveling to Abu Dhabi and the Middle East Update in Hospital Medicine this March – being able to spread the latest trends in hospital medicine in the USA is one of the best experiences I have had with SHM!

Another reason SHM truly made me feel welcomed was the opportunity to attend the Pediatric Hospital Medicine (PHM) meeting. Each July, SHM helps to put on the largest gathering of pediatric hospital medicine providers. This year, it will be held in Atlanta from July 19-22.

This meeting is organized and supported by SHM, the American Academy of Pediatrics (AAP), and the Academic Pediatric Association (APA), and offers spectacular content in many tracks, including quality improvement, education, research, and the incredibly popular “Top Articles” presentation at lunch on Saturday. This session provides teaching materials that can span the year for Journal Clubs and resident and student education. The abstracts and poster sessions are top-notch and provide an opportunity for young and experienced providers to share their work.

The fourth annual Knowledge Café will be a highlight for me as well, as it allows collaboration and networking experiences in hot topics for early career hospitalists. How to strive for work/life balance, how to get the most out of your first meeting, and techniques for talking with your boss about difficult issues are some of the topics we plan to cover this year.

On top of this, networking and participation on various committees and work groups afforded me the opportunity to join the SHM Board of Directors in May of 2017. Having completed my first year on the Board, I have an even deeper appreciation for the progressive thinking of our leadership team and the amazing work that the staff of SHM does behind the scenes to help us maximize our memberships. I love the continuous process improvement that is happening with every Board meeting.

As a member of the Board, it’s important to keep tabs on the pulse of SHM members and their evolving needs. One way I have really enjoyed getting to learn about our membership is by attending local chapter meetings. I recently traveled to West Virginia and Connecticut, both of which have active, engaged chapters working to improve care in their local communities – it was so inspiring to have the opportunity to represent the organization, and I look forward to more meetings just like this. For our local chapter in Nashville, I have the honor of picking the venue for our meetings, which keeps me on my toes as I look for the latest hot spots in an incredibly happening city!

Last summer, the benefits of membership in SHM and my career choice of hospital medicine took on a whole new meaning. In July, just before PHM 2017, a meeting that I was lucky enough to chair, my husband started to feel the pain of a recurrent kidney stone as he was traveling with our four sons and their three friends. Can you imagine being on an airplane with seven elementary school–age boys when the worst pain EVER strikes?

I was home in Nashville thinking, “Who can I call to help him in Minneapolis?” My first thought was of fellow members of SHM with whom I’ve developed friendships over the years – other hospitalists like you and me. Many people came to mind, all of whom practice hospital medicine! A huge thank-you to our friend Dr. Shaun Frost, who rescued my husband, drove him to a local ED, AND took the seven boys out for lunch. I truly have never been so grateful!

My task for you is simple: Engage with the Society of Hospital Medicine! Come to a meeting, join a special interest group, connect with your local chapter, and make friends who can support you through your career – and, as evidenced by my husband’s experience – even in your personal life. It’s truly a special organization, and I can’t wait to share some experiences just like these with you.


Dr. Rehm is associate professor, pediatrics, and director, division of pediatric outreach medicine at Vanderbilt University and Monroe Carell Jr. Children’s Hospital at Vanderbilt, both in Nashville, Tenn. She is also a member of the SHM board of directors.

As I began my career in pediatric hospital medicine at the Monroe Carell Jr. Children’s Hospital at Vanderbilt in Nashville, Tenn., I knew that I wanted a way to continue my education and to network with other hospitalists with interests in academics and pediatrics.

In 2010, I decided to attend a pre-course to the Society of Hospital Medicine’s annual conference that focused on academic hospital medicine, and my career has never been the same! I am thrilled to say I have found my professional home in SHM.

Here’s a quick list of the reasons SHM has been such a warm, welcoming home for me. I’ve highlighted the few options that stood out to me, but rest assured there is so much more from which to choose:

• Leadership opportunities in our Pediatrics Special Interest Group.
• Representation on the Annual Conference Committee to select pediatric-specific content as well as workshops on leadership, education, patient experience, and quality improvement.
• The Academic Hospitalist Academy, first as a pre-course before the SHM annual conference, and now as its own amazing meeting for academic pediatric hospital medicine providers.
• SHM’s Leadership Academy, a wonderful opportunity to learn leadership skills and network with other leaders. This year, it is in Vancouver!
• Participation in quality improvement initiatives like Pedi-BOOST, a care transitions program that specializes in pediatric patients.
• Traveling to Abu Dhabi and the Middle East Update in Hospital Medicine this March – being able to spread the latest trends in hospital medicine in the USA is one of the best experiences I have had with SHM!

Another reason SHM truly made me feel welcomed was the opportunity to attend the Pediatric Hospital Medicine (PHM) meeting. Each July, SHM helps to put on the largest gathering of pediatric hospital medicine providers. This year, it will be held in Atlanta from July 19-22.

This meeting is organized and supported by SHM, the American Academy of Pediatrics (AAP), and the Academic Pediatric Association (APA), and offers spectacular content in many tracks, including quality improvement, education, research, and the incredibly popular “Top Articles” presentation at lunch on Saturday. This session provides teaching materials that can span the year for Journal Clubs and resident and student education. The abstracts and poster sessions are top-notch and provide an opportunity for young and experienced providers to share their work.

The fourth annual Knowledge Café will be a highlight for me as well, as it allows collaboration and networking experiences in hot topics for early career hospitalists. How to strive for work/life balance, how to get the most out of your first meeting, and techniques for talking with your boss about difficult issues are some of the topics we plan to cover this year.

On top of this, networking and participation on various committees and work groups afforded me the opportunity to join the SHM Board of Directors in May of 2017. Having completed my first year on the Board, I have an even deeper appreciation for the progressive thinking of our leadership team and the amazing work that the staff of SHM does behind the scenes to help us maximize our memberships. I love the continuous process improvement that is happening with every Board meeting.

As a member of the Board, it’s important to keep tabs on the pulse of SHM members and their evolving needs. One way I have really enjoyed getting to learn about our membership is by attending local chapter meetings. I recently traveled to West Virginia and Connecticut, both of which have active, engaged chapters working to improve care in their local communities – it was so inspiring to have the opportunity to represent the organization, and I look forward to more meetings just like this. For our local chapter in Nashville, I have the honor of picking the venue for our meetings, which keeps me on my toes as I look for the latest hot spots in an incredibly happening city!

Last summer, the benefits of membership in SHM and my career choice of hospital medicine took on a whole new meaning. In July, just before PHM 2017, a meeting that I was lucky enough to chair, my husband started to feel the pain of a recurrent kidney stone as he was traveling with our four sons and their three friends. Can you imagine being on an airplane with seven elementary school–age boys when the worst pain EVER strikes?

I was home in Nashville thinking, “Who can I call to help him in Minneapolis?” My first thought was of fellow members of SHM with whom I’ve developed friendships over the years – other hospitalists like you and me. Many people came to mind, all of whom practice hospital medicine! A huge thank-you to our friend Dr. Shaun Frost, who rescued my husband, drove him to a local ED, AND took the seven boys out for lunch. I truly have never been so grateful!

My task for you is simple: Engage with the Society of Hospital Medicine! Come to a meeting, join a special interest group, connect with your local chapter, and make friends who can support you through your career – and, as evidenced by my husband’s experience – even in your personal life. It’s truly a special organization, and I can’t wait to share some experiences just like these with you.


Dr. Rehm is associate professor, pediatrics, and director, division of pediatric outreach medicine at Vanderbilt University and Monroe Carell Jr. Children’s Hospital at Vanderbilt, both in Nashville, Tenn. She is also a member of the SHM board of directors.

As I began my career in pediatric hospital medicine at the Monroe Carell Jr. Children’s Hospital at Vanderbilt in Nashville, Tenn., I knew that I wanted a way to continue my education and to network with other hospitalists with interests in academics and pediatrics.

In 2010, I decided to attend a pre-course to the Society of Hospital Medicine’s annual conference that focused on academic hospital medicine, and my career has never been the same! I am thrilled to say I have found my professional home in SHM.

Here’s a quick list of the reasons SHM has been such a warm, welcoming home for me. I’ve highlighted the few options that stood out to me, but rest assured there is so much more from which to choose:

• Leadership opportunities in our Pediatrics Special Interest Group.
• Representation on the Annual Conference Committee to select pediatric-specific content as well as workshops on leadership, education, patient experience, and quality improvement.
• The Academic Hospitalist Academy, first as a pre-course before the SHM annual conference, and now as its own amazing meeting for academic pediatric hospital medicine providers.
• SHM’s Leadership Academy, a wonderful opportunity to learn leadership skills and network with other leaders. This year, it is in Vancouver!
• Participation in quality improvement initiatives like Pedi-BOOST, a care transitions program that specializes in pediatric patients.
• Traveling to Abu Dhabi and the Middle East Update in Hospital Medicine this March – being able to spread the latest trends in hospital medicine in the USA is one of the best experiences I have had with SHM!

Another reason SHM truly made me feel welcomed was the opportunity to attend the Pediatric Hospital Medicine (PHM) meeting. Each July, SHM helps to put on the largest gathering of pediatric hospital medicine providers. This year, it will be held in Atlanta from July 19-22.

This meeting is organized and supported by SHM, the American Academy of Pediatrics (AAP), and the Academic Pediatric Association (APA), and offers spectacular content in many tracks, including quality improvement, education, research, and the incredibly popular “Top Articles” presentation at lunch on Saturday. This session provides teaching materials that can span the year for Journal Clubs and resident and student education. The abstracts and poster sessions are top-notch and provide an opportunity for young and experienced providers to share their work.

The fourth annual Knowledge Café will be a highlight for me as well, as it allows collaboration and networking experiences in hot topics for early career hospitalists. How to strive for work/life balance, how to get the most out of your first meeting, and techniques for talking with your boss about difficult issues are some of the topics we plan to cover this year.

On top of this, networking and participation on various committees and work groups afforded me the opportunity to join the SHM Board of Directors in May of 2017. Having completed my first year on the Board, I have an even deeper appreciation for the progressive thinking of our leadership team and the amazing work that the staff of SHM does behind the scenes to help us maximize our memberships. I love the continuous process improvement that is happening with every Board meeting.

As a member of the Board, it’s important to keep tabs on the pulse of SHM members and their evolving needs. One way I have really enjoyed getting to learn about our membership is by attending local chapter meetings. I recently traveled to West Virginia and Connecticut, both of which have active, engaged chapters working to improve care in their local communities – it was so inspiring to have the opportunity to represent the organization, and I look forward to more meetings just like this. For our local chapter in Nashville, I have the honor of picking the venue for our meetings, which keeps me on my toes as I look for the latest hot spots in an incredibly happening city!

Last summer, the benefits of membership in SHM and my career choice of hospital medicine took on a whole new meaning. In July, just before PHM 2017, a meeting that I was lucky enough to chair, my husband started to feel the pain of a recurrent kidney stone as he was traveling with our four sons and their three friends. Can you imagine being on an airplane with seven elementary school–age boys when the worst pain EVER strikes?

I was home in Nashville thinking, “Who can I call to help him in Minneapolis?” My first thought was of fellow members of SHM with whom I’ve developed friendships over the years – other hospitalists like you and me. Many people came to mind, all of whom practice hospital medicine! A huge thank-you to our friend Dr. Shaun Frost, who rescued my husband, drove him to a local ED, AND took the seven boys out for lunch. I truly have never been so grateful!

My task for you is simple: Engage with the Society of Hospital Medicine! Come to a meeting, join a special interest group, connect with your local chapter, and make friends who can support you through your career – and, as evidenced by my husband’s experience – even in your personal life. It’s truly a special organization, and I can’t wait to share some experiences just like these with you.


Dr. Rehm is associate professor, pediatrics, and director, division of pediatric outreach medicine at Vanderbilt University and Monroe Carell Jr. Children’s Hospital at Vanderbilt, both in Nashville, Tenn. She is also a member of the SHM board of directors.

LAKE TAHOE, CALIF. – Children with large facial hemangiomas who have S1 involvement, a lesion area greater than 25 cm², or bilateral location should be prioritized for PHACE syndrome work-up.

In addition, children with isolated S2 or parotid hemangiomas should be recognized as having lower risk for PHACE, and specifics of evaluation should be discussed with parents on a case-by-case basis.

Those are key findings from a retrospective cohort study presented by Colleen Cotton, MD, at the annual meeting of the Society for Pediatric Dermatology.

An association between large facial hemangiomas and multiple abnormalities was described as early as 1978, but it wasn’t until 1996 that researchers first proposed the term PHACE to describe the association (Arch Dermatol. 1996;132[3]:307-11). As the National Institutes of Health explain, “PHACE is an acronym for a neurocutaneous syndrome encompassing the following features: posterior fossa brain malformations, hemangiomas of the face, arterial anomalies, cardiac anomalies, and eye abnormalities.” Official diagnostic criteria for PHACE were not established until 2009 (Pediatrics. 2009;124[5]:1447-56) and were updated in 2016 (J Pediatr. 2016;178:24-33.e2).

“A multicenter, prospective, cohort study published in 2010 estimated the incidence of PHACE to be 31% in patients with large facial hemangiomas, while a retrospective study published in 2017 estimated the incidence to be as high as 58%,” Dr. Cotton, chief dermatology resident at the University of Arizona, Tucson, said in an interview in advance of the meeting. “With the current understanding of risk for PHACE, any child with a facial hemangioma of greater than or equal to 5 cm in diameter receives a full work-up for the syndrome. However, there has been anecdotal evidence that patients with certain subtypes of hemangiomas (such as parotid hemangiomas) may not carry this same risk.”

In what is believed to be the largest study of its kind, Dr. Cotton and her associates retrospectively analyzed data from 244 patients from 13 pediatric dermatology centers who were fully evaluated for PHACE between August 2009 and December 2014. The investigators also performed subgroup analyses on different hemangioma characteristics, including parotid hemangiomas and specific facial segments of involvement. All patients underwent magnetic resonance imaging/magnetic resonance angiography of the head and neck, and the researchers collected data on age at diagnosis; gender; patterns of hemangioma presentation, including location, size, and depth; diagnostic procedures and results; and type and number of associated anomalies. An expert reviewed photographs or diagrams to confirm facial segment locations.

Of the 244 patients, 34.7% met criteria for PHACE syndrome. On multivariate analysis, the following factors were found to be independently and significantly associated with a risk for PHACE: bilateral location (positive predictive value, 54.9%), S1 involvement (PPV, 49.5%), S3 involvement (PPV, 39.5%), and area greater than 25cm² (PPV, 44.8%), with a P value less than .05 for all associations.

Risk of PHACE also increased with the number of locations involved, with a sharp increase observed at three or more locations (PPV, 65.5%; P less than .001). In patients with one unilateral segment involved, S2 and S3 carried a significantly lower risk (P less than .03). Parotid hemangiomas had a negative predictive value of 80.4% (P = .035).

“While we found that patients with parotid hemangiomas had a lower risk of PHACE, 10 patients with parotid hemangiomas did have PHACE, and 90% of those patients had cerebral arterial anomalies,” Dr. Cotton said. “However, only one of these patients had an isolated unilateral parotid hemangioma without other facial segment involvement. Additionally, two patients with isolated involvement of the midcheek below the eye [the S2 location, which was another low risk segment] also had PHACE, both of whom would have been missed without MRI/MRA [magnetic resonance angiography].”

She acknowledged certain limitations of the study, including its retrospective design. “Additionally, many of the very large hemangiomas were not measured in size, and so, estimated sizes needed to be used in calculating relationship of hemangioma size with risk of PHACE,” she said.

The study was funded in part by a grant from the Pediatric Dermatology Research Alliance.* Dr. Cotton reported having no relevant financial disclosures.

dbrunk@mdedge.com

Correction, 7/20/18: An earlier version of this article misstated the name of the Pediatric Dermatology Research Alliance.

LAKE TAHOE, CALIF. – Children with large facial hemangiomas who have S1 involvement, a lesion area greater than 25 cm², or bilateral location should be prioritized for PHACE syndrome work-up.

In addition, children with isolated S2 or parotid hemangiomas should be recognized as having lower risk for PHACE, and specifics of evaluation should be discussed with parents on a case-by-case basis.

Those are key findings from a retrospective cohort study presented by Colleen Cotton, MD, at the annual meeting of the Society for Pediatric Dermatology.

An association between large facial hemangiomas and multiple abnormalities was described as early as 1978, but it wasn’t until 1996 that researchers first proposed the term PHACE to describe the association (Arch Dermatol. 1996;132[3]:307-11). As the National Institutes of Health explain, “PHACE is an acronym for a neurocutaneous syndrome encompassing the following features: posterior fossa brain malformations, hemangiomas of the face, arterial anomalies, cardiac anomalies, and eye abnormalities.” Official diagnostic criteria for PHACE were not established until 2009 (Pediatrics. 2009;124[5]:1447-56) and were updated in 2016 (J Pediatr. 2016;178:24-33.e2).

“A multicenter, prospective, cohort study published in 2010 estimated the incidence of PHACE to be 31% in patients with large facial hemangiomas, while a retrospective study published in 2017 estimated the incidence to be as high as 58%,” Dr. Cotton, chief dermatology resident at the University of Arizona, Tucson, said in an interview in advance of the meeting. “With the current understanding of risk for PHACE, any child with a facial hemangioma of greater than or equal to 5 cm in diameter receives a full work-up for the syndrome. However, there has been anecdotal evidence that patients with certain subtypes of hemangiomas (such as parotid hemangiomas) may not carry this same risk.”

In what is believed to be the largest study of its kind, Dr. Cotton and her associates retrospectively analyzed data from 244 patients from 13 pediatric dermatology centers who were fully evaluated for PHACE between August 2009 and December 2014. The investigators also performed subgroup analyses on different hemangioma characteristics, including parotid hemangiomas and specific facial segments of involvement. All patients underwent magnetic resonance imaging/magnetic resonance angiography of the head and neck, and the researchers collected data on age at diagnosis; gender; patterns of hemangioma presentation, including location, size, and depth; diagnostic procedures and results; and type and number of associated anomalies. An expert reviewed photographs or diagrams to confirm facial segment locations.

Of the 244 patients, 34.7% met criteria for PHACE syndrome. On multivariate analysis, the following factors were found to be independently and significantly associated with a risk for PHACE: bilateral location (positive predictive value, 54.9%), S1 involvement (PPV, 49.5%), S3 involvement (PPV, 39.5%), and area greater than 25cm² (PPV, 44.8%), with a P value less than .05 for all associations.

Risk of PHACE also increased with the number of locations involved, with a sharp increase observed at three or more locations (PPV, 65.5%; P less than .001). In patients with one unilateral segment involved, S2 and S3 carried a significantly lower risk (P less than .03). Parotid hemangiomas had a negative predictive value of 80.4% (P = .035).

“While we found that patients with parotid hemangiomas had a lower risk of PHACE, 10 patients with parotid hemangiomas did have PHACE, and 90% of those patients had cerebral arterial anomalies,” Dr. Cotton said. “However, only one of these patients had an isolated unilateral parotid hemangioma without other facial segment involvement. Additionally, two patients with isolated involvement of the midcheek below the eye [the S2 location, which was another low risk segment] also had PHACE, both of whom would have been missed without MRI/MRA [magnetic resonance angiography].”

She acknowledged certain limitations of the study, including its retrospective design. “Additionally, many of the very large hemangiomas were not measured in size, and so, estimated sizes needed to be used in calculating relationship of hemangioma size with risk of PHACE,” she said.

The study was funded in part by a grant from the Pediatric Dermatology Research Alliance.* Dr. Cotton reported having no relevant financial disclosures.

dbrunk@mdedge.com

Correction, 7/20/18: An earlier version of this article misstated the name of the Pediatric Dermatology Research Alliance.

LAKE TAHOE, CALIF. – Children with large facial hemangiomas who have S1 involvement, a lesion area greater than 25 cm², or bilateral location should be prioritized for PHACE syndrome work-up.

In addition, children with isolated S2 or parotid hemangiomas should be recognized as having lower risk for PHACE, and specifics of evaluation should be discussed with parents on a case-by-case basis.

Those are key findings from a retrospective cohort study presented by Colleen Cotton, MD, at the annual meeting of the Society for Pediatric Dermatology.

An association between large facial hemangiomas and multiple abnormalities was described as early as 1978, but it wasn’t until 1996 that researchers first proposed the term PHACE to describe the association (Arch Dermatol. 1996;132[3]:307-11). As the National Institutes of Health explain, “PHACE is an acronym for a neurocutaneous syndrome encompassing the following features: posterior fossa brain malformations, hemangiomas of the face, arterial anomalies, cardiac anomalies, and eye abnormalities.” Official diagnostic criteria for PHACE were not established until 2009 (Pediatrics. 2009;124[5]:1447-56) and were updated in 2016 (J Pediatr. 2016;178:24-33.e2).

“A multicenter, prospective, cohort study published in 2010 estimated the incidence of PHACE to be 31% in patients with large facial hemangiomas, while a retrospective study published in 2017 estimated the incidence to be as high as 58%,” Dr. Cotton, chief dermatology resident at the University of Arizona, Tucson, said in an interview in advance of the meeting. “With the current understanding of risk for PHACE, any child with a facial hemangioma of greater than or equal to 5 cm in diameter receives a full work-up for the syndrome. However, there has been anecdotal evidence that patients with certain subtypes of hemangiomas (such as parotid hemangiomas) may not carry this same risk.”

In what is believed to be the largest study of its kind, Dr. Cotton and her associates retrospectively analyzed data from 244 patients from 13 pediatric dermatology centers who were fully evaluated for PHACE between August 2009 and December 2014. The investigators also performed subgroup analyses on different hemangioma characteristics, including parotid hemangiomas and specific facial segments of involvement. All patients underwent magnetic resonance imaging/magnetic resonance angiography of the head and neck, and the researchers collected data on age at diagnosis; gender; patterns of hemangioma presentation, including location, size, and depth; diagnostic procedures and results; and type and number of associated anomalies. An expert reviewed photographs or diagrams to confirm facial segment locations.

Of the 244 patients, 34.7% met criteria for PHACE syndrome. On multivariate analysis, the following factors were found to be independently and significantly associated with a risk for PHACE: bilateral location (positive predictive value, 54.9%), S1 involvement (PPV, 49.5%), S3 involvement (PPV, 39.5%), and area greater than 25cm² (PPV, 44.8%), with a P value less than .05 for all associations.

Risk of PHACE also increased with the number of locations involved, with a sharp increase observed at three or more locations (PPV, 65.5%; P less than .001). In patients with one unilateral segment involved, S2 and S3 carried a significantly lower risk (P less than .03). Parotid hemangiomas had a negative predictive value of 80.4% (P = .035).

“While we found that patients with parotid hemangiomas had a lower risk of PHACE, 10 patients with parotid hemangiomas did have PHACE, and 90% of those patients had cerebral arterial anomalies,” Dr. Cotton said. “However, only one of these patients had an isolated unilateral parotid hemangioma without other facial segment involvement. Additionally, two patients with isolated involvement of the midcheek below the eye [the S2 location, which was another low risk segment] also had PHACE, both of whom would have been missed without MRI/MRA [magnetic resonance angiography].”

She acknowledged certain limitations of the study, including its retrospective design. “Additionally, many of the very large hemangiomas were not measured in size, and so, estimated sizes needed to be used in calculating relationship of hemangioma size with risk of PHACE,” she said.

The study was funded in part by a grant from the Pediatric Dermatology Research Alliance.* Dr. Cotton reported having no relevant financial disclosures.

dbrunk@mdedge.com

Correction, 7/20/18: An earlier version of this article misstated the name of the Pediatric Dermatology Research Alliance.

 

Concerns about mental health (MH) care delivery for children are repeatedly identified by health care providers, described in the literature, and addressed through advocacy. Unfortunately, health inequities continue to exist, including the social stigma of an MH diagnosis, lower reimbursement for MH compared with medical care, and poor access to expert pediatric behavioral health providers. This is especially true for families living below the poverty line, who are more likely to have MH problems.¹

AlexRaths/Thinkstock

An estimated 50% of primary care (PC) pediatric visits involve an MH or behavioral problem, yet only about 20% of these patients receive services.² According to the Centers for Disease Control and Prevention, one out of seven children aged 2-8 years has a developmental or behavioral disorder.³ In children aged 3-17 years, 7% have ADHD, 2% have depressive disorders, and 3% have anxiety.³ In the 2015 National Youth Risk Behavior Surveillance survey, more than 29% of high school respondents stated that they felt so sad or hopeless during the past 12 months that they had stopped some of their usual activities, and 18% considered suicide.⁴ The incidence of violent acts committed by and affecting teens adds a critical need for creative provision of pediatric MH care.

MH integration in pediatric PC, supported by the National Association of Pediatric Nurse Practitioners, American Academy of Pediatrics, American Psychological Association, and many others is an avenue to provide quality MH services for children.^5,6,7 In a coordinated or colocated model, a behavioral health specialist works with a pediatric provider either in consultation with the practice (coordinated) or in the same practice site where patients are referred (colocated).⁷ The collaborative care model places pediatric medical providers with care managers or behavioral health specialists to deliver care in one practice setting.

The use of pediatric nurse practitioners (PNPs) with advanced training in MH care is described in the literature as a different type of collaborative care model.^8,9,10 PNPs assess, diagnose, and treat using pharmacologic and nonpharmacologic therapies. PNPs may offer evidence-based psychotherapy or refer for psychotherapy or parenting skills development. Those who have added knowledge and skills in MH care may seek validation of these competencies through completion of added certification as pediatric PC MH specialists (PMHS).¹¹ Since 2011, there are more than 400 PMHSs certified in the United States. PNPs with expertise in MH are a solution to addressing the growing need for access to high quality care for children and adolescents in PC settings. We share examples of services provided by PNPs across the United States.
 

At a federally qualified health center

Dawn Garzon Maaks, PhD, CPNP-PC, the current president of the National Association of Pediatric Nurse Practitioners, is certified as a PMHS and works in a federally-qualified health center in southwest Washington State. This center provides lifespan services for patients, with separate office spaces for MH/psychiatric care and PC. Within this colocated environment, Dr. Garzon Maaks spends about 75% of her time caring for children with developmental, behavioral, and MH problems in the MH clinic and 25% in the PC office, providing health maintenance and acute episodic care. She collaborates with psychiatrists and psychiatric mental health nurse practitioners by adding pediatric developmental and medical expertise and is welcomed by providers who have limited experience caring for children. While providing PC, she educates about issues such as resiliency, screening for substance abuse, and treatment of common pediatric mood disorders and ADHD. Her expertise also allows for MH care integration into PC visits, taking away the “stigma” which still is pervasive for patients referred to MH providers.

 

“What my position has taught me is that when primary and mental health care providers work closely, it improves outcomes for all patients seen. Through frequent consultation, our primary care physicians have increasing skills in caring for children with mild mental health issues, thus freeing up the mental health people to deal with the more significant cases. On the other hand, our mental health providers benefit from having the primary care expertise in diagnosing and treating common conditions that mimic mental health issues. This integration also significantly reduces stigma because families see their mental health professional in the primary care setting,” Dr. Garzon Maaks said.
 

At an urban/suburban PC practice

alexsokolov/Thinkstock

Another PNP MH expert, Dr. Susan Van Cleve, is certified as a PMHS and works as a subspecialist within an urban/suburban pediatric PC practice. Her team is composed of two PNPs and one registered nurse who is designated as the full time MH coordinator. This team cares for children and teens with mild to moderate MH disorders from within the practice. The registered nurse performs intake interviews, schedules patients, and sends out screening tools before visits and is available to families and providers in the practice on a dedicated phone line. She refers complex patients to local providers for more comprehensive care and follows them to ensure that appointments and referrals are made. Scheduling with the PNPs allows for longer appointments, comprehensive treatment including medication management if warranted, and close follow-up care. Patient types seen include those with concerns about developmental delays, autism spectrum disorder, disruptive behavior, ADHD, anxiety, and depression. Children or teens with more severe disorders are referred to colleagues in psychiatry or counseling services, or to pediatric or adolescent subspecialists in the community.

“The children and families I see seem to feel comfortable because our behavioral team is embedded in the pediatric practice, and we use the same office space. Families have easy access to our full-time registered nurse who is available to answer questions, provide resources and advice, lend support, or assist navigating the health system. This type of system increases access, enables us to provide comprehensive family-centered care, and supports the child and family,” said Dr. Van Cleve, clinical professor and primary care pediatric nurse practitioner program director at the University of Iowa College of Nursing, Iowa City.
 

As an educator

Naomi A. Schapiro, PhD, CPNP, is a professor of nursing at the University of California, San Francisco, and a PNP at a school-based health center with an integrated behavioral health model, managed by a federally qualified health center in a medically underserved area. She is the principle investigator of an Advanced Nursing Education Health Resources Service Administration grant supporting interprofessional training and practice collaboration to improve care and reduce health inequities for disadvantaged children and adolescents coping with both behavioral health conditions and chronic physical conditions, including obesity.¹¹

Dr. Schapiro collaborates with a multidisciplinary, multi-university team, a local children’s hospital, a social work training program, and the county health care services agency to develop and implement a training program for pediatric PC providers to increase skills and self-confidence implementing American Academy of Pediatrics guidelines assessing and treating depression, ADHD, anxiety and trauma-related symptoms; triaging patients with nonsuicidal self-injury and suicidal ideation; and recognizing and referring patients with bipolar disorder and psychosis. These training modules are currently being recorded for online posting. As part of this interprofessional collaboration, Dr. Schapiro and her colleagues developed a “warmline” for decision support, staffed by a psychiatrist and two nurse practitioners available to PC providers in a network of 29 school-based health centers and two pediatric practices for complex decision making about medications or diagnostic dilemmas. Efforts are underway to continue and expand this program.

 

“As a faculty teaching PNP students enhanced behavioral health assessment skills, I have been proudest when students have been able to apply and disseminate these skills,” Dr. Schapiro said. “One of our recent PNP graduates was in a community primary care practicum when an adolescent thinking about suicide walked into the clinic with her father. Her preceptor wasn’t sure how to proceed, when the student said, ‘Wait! We just practiced this in class.’ The student pulled up her course website, and she and her preceptor walked through the assessment together, developed a safety plan with the teen and her father, and connected the teen with a therapist, avoiding an unnecessary ER visit and potential fragmentation of care.”

The need and expectation that pediatric PC providers incorporate MH services is well documented.^2,12,13 PNPs who have additional training and expertise in assessing, diagnosing, and managing MH care are an excellent solution for addressing this problem. The benefits of this team-based approach to the pediatric health care home include decreasing stigma, increasing access, and providing comprehensive MH care to children and their families.
 

Dr. Haut works at Beacon Pediatrics, a large primary care practice in Rehoboth Beach, Del. She works part-time for Pediatrix Medical Group, serving the Pediatric Intensive Care Unit medical team at the Herman & Walter Samuelson Children’s Hospital at Sinai in Baltimore, and she serves as adjunct faculty at the University of Maryland School of Nursing, also in Baltimore. Other contributors to this article were Dawn Garzon Maaks, PhD, CPNP, PMHS; Naomi Schapiro, PhD, CPNP; Susan Van Cleve, DNP, RN, CPNP-PC, PMHS; and Laura Searcy, MN, APRN, PPCNP-BC. Ms. Searcy is on the medical staff at WellStar Kennestone Regional Medical Center in Marietta, Ga., delivering care to newborns. Dr. Haut and Ms. Searcy are members of the Pediatric News Consultant Advisory Board. Email them at pdnews@mdedge.com.

References

1. “Best principles for integration of child psychiatry into the pediatric health home,” AACAP Executive Summary,2012, pages 1-13.

2. Pediatrics. 2009 Apr;123(4):1248-51.

3. Center for Disease Control and Prevention: Children’s Mental Health Data and Statistics.

4. MMWR Surveill Summ, 2016. doi:10.15585/mmwr.ss6506a1.

5. Pediatrics. 2015;135(5):909-17.

6. JAMA Pediatr. 2015;169(10):929-37.

7. “Integrating child psychology services into primary care,” by Tynan D, Woods K, and Carpenter J. American Psychological Association, 2014.

8. J Am Psychiatr Nurses Assoc. 2005;11(5): 276-82.

9. J Nurse Pract. 2013;9(4):243-8.

10. J Pediatr Health Care. 2013; 27(3):162-3.

11. Advanced Nursing Education Health Resources Service Administration grant (#D09HP26958).

12. J Nurse Pract. 2013:9(3):142-8.

13. Pediatrics. 2018;141(3):e20174082

 

Concerns about mental health (MH) care delivery for children are repeatedly identified by health care providers, described in the literature, and addressed through advocacy. Unfortunately, health inequities continue to exist, including the social stigma of an MH diagnosis, lower reimbursement for MH compared with medical care, and poor access to expert pediatric behavioral health providers. This is especially true for families living below the poverty line, who are more likely to have MH problems.¹

AlexRaths/Thinkstock

An estimated 50% of primary care (PC) pediatric visits involve an MH or behavioral problem, yet only about 20% of these patients receive services.² According to the Centers for Disease Control and Prevention, one out of seven children aged 2-8 years has a developmental or behavioral disorder.³ In children aged 3-17 years, 7% have ADHD, 2% have depressive disorders, and 3% have anxiety.³ In the 2015 National Youth Risk Behavior Surveillance survey, more than 29% of high school respondents stated that they felt so sad or hopeless during the past 12 months that they had stopped some of their usual activities, and 18% considered suicide.⁴ The incidence of violent acts committed by and affecting teens adds a critical need for creative provision of pediatric MH care.

MH integration in pediatric PC, supported by the National Association of Pediatric Nurse Practitioners, American Academy of Pediatrics, American Psychological Association, and many others is an avenue to provide quality MH services for children.^5,6,7 In a coordinated or colocated model, a behavioral health specialist works with a pediatric provider either in consultation with the practice (coordinated) or in the same practice site where patients are referred (colocated).⁷ The collaborative care model places pediatric medical providers with care managers or behavioral health specialists to deliver care in one practice setting.

The use of pediatric nurse practitioners (PNPs) with advanced training in MH care is described in the literature as a different type of collaborative care model.^8,9,10 PNPs assess, diagnose, and treat using pharmacologic and nonpharmacologic therapies. PNPs may offer evidence-based psychotherapy or refer for psychotherapy or parenting skills development. Those who have added knowledge and skills in MH care may seek validation of these competencies through completion of added certification as pediatric PC MH specialists (PMHS).¹¹ Since 2011, there are more than 400 PMHSs certified in the United States. PNPs with expertise in MH are a solution to addressing the growing need for access to high quality care for children and adolescents in PC settings. We share examples of services provided by PNPs across the United States.
 

At a federally qualified health center

Dawn Garzon Maaks, PhD, CPNP-PC, the current president of the National Association of Pediatric Nurse Practitioners, is certified as a PMHS and works in a federally-qualified health center in southwest Washington State. This center provides lifespan services for patients, with separate office spaces for MH/psychiatric care and PC. Within this colocated environment, Dr. Garzon Maaks spends about 75% of her time caring for children with developmental, behavioral, and MH problems in the MH clinic and 25% in the PC office, providing health maintenance and acute episodic care. She collaborates with psychiatrists and psychiatric mental health nurse practitioners by adding pediatric developmental and medical expertise and is welcomed by providers who have limited experience caring for children. While providing PC, she educates about issues such as resiliency, screening for substance abuse, and treatment of common pediatric mood disorders and ADHD. Her expertise also allows for MH care integration into PC visits, taking away the “stigma” which still is pervasive for patients referred to MH providers.

 

“What my position has taught me is that when primary and mental health care providers work closely, it improves outcomes for all patients seen. Through frequent consultation, our primary care physicians have increasing skills in caring for children with mild mental health issues, thus freeing up the mental health people to deal with the more significant cases. On the other hand, our mental health providers benefit from having the primary care expertise in diagnosing and treating common conditions that mimic mental health issues. This integration also significantly reduces stigma because families see their mental health professional in the primary care setting,” Dr. Garzon Maaks said.
 

At an urban/suburban PC practice

alexsokolov/Thinkstock

Another PNP MH expert, Dr. Susan Van Cleve, is certified as a PMHS and works as a subspecialist within an urban/suburban pediatric PC practice. Her team is composed of two PNPs and one registered nurse who is designated as the full time MH coordinator. This team cares for children and teens with mild to moderate MH disorders from within the practice. The registered nurse performs intake interviews, schedules patients, and sends out screening tools before visits and is available to families and providers in the practice on a dedicated phone line. She refers complex patients to local providers for more comprehensive care and follows them to ensure that appointments and referrals are made. Scheduling with the PNPs allows for longer appointments, comprehensive treatment including medication management if warranted, and close follow-up care. Patient types seen include those with concerns about developmental delays, autism spectrum disorder, disruptive behavior, ADHD, anxiety, and depression. Children or teens with more severe disorders are referred to colleagues in psychiatry or counseling services, or to pediatric or adolescent subspecialists in the community.

“The children and families I see seem to feel comfortable because our behavioral team is embedded in the pediatric practice, and we use the same office space. Families have easy access to our full-time registered nurse who is available to answer questions, provide resources and advice, lend support, or assist navigating the health system. This type of system increases access, enables us to provide comprehensive family-centered care, and supports the child and family,” said Dr. Van Cleve, clinical professor and primary care pediatric nurse practitioner program director at the University of Iowa College of Nursing, Iowa City.
 

As an educator

Naomi A. Schapiro, PhD, CPNP, is a professor of nursing at the University of California, San Francisco, and a PNP at a school-based health center with an integrated behavioral health model, managed by a federally qualified health center in a medically underserved area. She is the principle investigator of an Advanced Nursing Education Health Resources Service Administration grant supporting interprofessional training and practice collaboration to improve care and reduce health inequities for disadvantaged children and adolescents coping with both behavioral health conditions and chronic physical conditions, including obesity.¹¹

Dr. Schapiro collaborates with a multidisciplinary, multi-university team, a local children’s hospital, a social work training program, and the county health care services agency to develop and implement a training program for pediatric PC providers to increase skills and self-confidence implementing American Academy of Pediatrics guidelines assessing and treating depression, ADHD, anxiety and trauma-related symptoms; triaging patients with nonsuicidal self-injury and suicidal ideation; and recognizing and referring patients with bipolar disorder and psychosis. These training modules are currently being recorded for online posting. As part of this interprofessional collaboration, Dr. Schapiro and her colleagues developed a “warmline” for decision support, staffed by a psychiatrist and two nurse practitioners available to PC providers in a network of 29 school-based health centers and two pediatric practices for complex decision making about medications or diagnostic dilemmas. Efforts are underway to continue and expand this program.

 

“As a faculty teaching PNP students enhanced behavioral health assessment skills, I have been proudest when students have been able to apply and disseminate these skills,” Dr. Schapiro said. “One of our recent PNP graduates was in a community primary care practicum when an adolescent thinking about suicide walked into the clinic with her father. Her preceptor wasn’t sure how to proceed, when the student said, ‘Wait! We just practiced this in class.’ The student pulled up her course website, and she and her preceptor walked through the assessment together, developed a safety plan with the teen and her father, and connected the teen with a therapist, avoiding an unnecessary ER visit and potential fragmentation of care.”

The need and expectation that pediatric PC providers incorporate MH services is well documented.^2,12,13 PNPs who have additional training and expertise in assessing, diagnosing, and managing MH care are an excellent solution for addressing this problem. The benefits of this team-based approach to the pediatric health care home include decreasing stigma, increasing access, and providing comprehensive MH care to children and their families.
 

Dr. Haut works at Beacon Pediatrics, a large primary care practice in Rehoboth Beach, Del. She works part-time for Pediatrix Medical Group, serving the Pediatric Intensive Care Unit medical team at the Herman & Walter Samuelson Children’s Hospital at Sinai in Baltimore, and she serves as adjunct faculty at the University of Maryland School of Nursing, also in Baltimore. Other contributors to this article were Dawn Garzon Maaks, PhD, CPNP, PMHS; Naomi Schapiro, PhD, CPNP; Susan Van Cleve, DNP, RN, CPNP-PC, PMHS; and Laura Searcy, MN, APRN, PPCNP-BC. Ms. Searcy is on the medical staff at WellStar Kennestone Regional Medical Center in Marietta, Ga., delivering care to newborns. Dr. Haut and Ms. Searcy are members of the Pediatric News Consultant Advisory Board. Email them at pdnews@mdedge.com.

References

1. “Best principles for integration of child psychiatry into the pediatric health home,” AACAP Executive Summary,2012, pages 1-13.

2. Pediatrics. 2009 Apr;123(4):1248-51.

3. Center for Disease Control and Prevention: Children’s Mental Health Data and Statistics.

4. MMWR Surveill Summ, 2016. doi:10.15585/mmwr.ss6506a1.

5. Pediatrics. 2015;135(5):909-17.

6. JAMA Pediatr. 2015;169(10):929-37.

7. “Integrating child psychology services into primary care,” by Tynan D, Woods K, and Carpenter J. American Psychological Association, 2014.

8. J Am Psychiatr Nurses Assoc. 2005;11(5): 276-82.

9. J Nurse Pract. 2013;9(4):243-8.

10. J Pediatr Health Care. 2013; 27(3):162-3.

11. Advanced Nursing Education Health Resources Service Administration grant (#D09HP26958).

12. J Nurse Pract. 2013:9(3):142-8.

13. Pediatrics. 2018;141(3):e20174082

 

Concerns about mental health (MH) care delivery for children are repeatedly identified by health care providers, described in the literature, and addressed through advocacy. Unfortunately, health inequities continue to exist, including the social stigma of an MH diagnosis, lower reimbursement for MH compared with medical care, and poor access to expert pediatric behavioral health providers. This is especially true for families living below the poverty line, who are more likely to have MH problems.¹

AlexRaths/Thinkstock

An estimated 50% of primary care (PC) pediatric visits involve an MH or behavioral problem, yet only about 20% of these patients receive services.² According to the Centers for Disease Control and Prevention, one out of seven children aged 2-8 years has a developmental or behavioral disorder.³ In children aged 3-17 years, 7% have ADHD, 2% have depressive disorders, and 3% have anxiety.³ In the 2015 National Youth Risk Behavior Surveillance survey, more than 29% of high school respondents stated that they felt so sad or hopeless during the past 12 months that they had stopped some of their usual activities, and 18% considered suicide.⁴ The incidence of violent acts committed by and affecting teens adds a critical need for creative provision of pediatric MH care.

MH integration in pediatric PC, supported by the National Association of Pediatric Nurse Practitioners, American Academy of Pediatrics, American Psychological Association, and many others is an avenue to provide quality MH services for children.^5,6,7 In a coordinated or colocated model, a behavioral health specialist works with a pediatric provider either in consultation with the practice (coordinated) or in the same practice site where patients are referred (colocated).⁷ The collaborative care model places pediatric medical providers with care managers or behavioral health specialists to deliver care in one practice setting.

The use of pediatric nurse practitioners (PNPs) with advanced training in MH care is described in the literature as a different type of collaborative care model.^8,9,10 PNPs assess, diagnose, and treat using pharmacologic and nonpharmacologic therapies. PNPs may offer evidence-based psychotherapy or refer for psychotherapy or parenting skills development. Those who have added knowledge and skills in MH care may seek validation of these competencies through completion of added certification as pediatric PC MH specialists (PMHS).¹¹ Since 2011, there are more than 400 PMHSs certified in the United States. PNPs with expertise in MH are a solution to addressing the growing need for access to high quality care for children and adolescents in PC settings. We share examples of services provided by PNPs across the United States.
 

At a federally qualified health center

Dawn Garzon Maaks, PhD, CPNP-PC, the current president of the National Association of Pediatric Nurse Practitioners, is certified as a PMHS and works in a federally-qualified health center in southwest Washington State. This center provides lifespan services for patients, with separate office spaces for MH/psychiatric care and PC. Within this colocated environment, Dr. Garzon Maaks spends about 75% of her time caring for children with developmental, behavioral, and MH problems in the MH clinic and 25% in the PC office, providing health maintenance and acute episodic care. She collaborates with psychiatrists and psychiatric mental health nurse practitioners by adding pediatric developmental and medical expertise and is welcomed by providers who have limited experience caring for children. While providing PC, she educates about issues such as resiliency, screening for substance abuse, and treatment of common pediatric mood disorders and ADHD. Her expertise also allows for MH care integration into PC visits, taking away the “stigma” which still is pervasive for patients referred to MH providers.

 

“What my position has taught me is that when primary and mental health care providers work closely, it improves outcomes for all patients seen. Through frequent consultation, our primary care physicians have increasing skills in caring for children with mild mental health issues, thus freeing up the mental health people to deal with the more significant cases. On the other hand, our mental health providers benefit from having the primary care expertise in diagnosing and treating common conditions that mimic mental health issues. This integration also significantly reduces stigma because families see their mental health professional in the primary care setting,” Dr. Garzon Maaks said.
 

At an urban/suburban PC practice

alexsokolov/Thinkstock

Another PNP MH expert, Dr. Susan Van Cleve, is certified as a PMHS and works as a subspecialist within an urban/suburban pediatric PC practice. Her team is composed of two PNPs and one registered nurse who is designated as the full time MH coordinator. This team cares for children and teens with mild to moderate MH disorders from within the practice. The registered nurse performs intake interviews, schedules patients, and sends out screening tools before visits and is available to families and providers in the practice on a dedicated phone line. She refers complex patients to local providers for more comprehensive care and follows them to ensure that appointments and referrals are made. Scheduling with the PNPs allows for longer appointments, comprehensive treatment including medication management if warranted, and close follow-up care. Patient types seen include those with concerns about developmental delays, autism spectrum disorder, disruptive behavior, ADHD, anxiety, and depression. Children or teens with more severe disorders are referred to colleagues in psychiatry or counseling services, or to pediatric or adolescent subspecialists in the community.

“The children and families I see seem to feel comfortable because our behavioral team is embedded in the pediatric practice, and we use the same office space. Families have easy access to our full-time registered nurse who is available to answer questions, provide resources and advice, lend support, or assist navigating the health system. This type of system increases access, enables us to provide comprehensive family-centered care, and supports the child and family,” said Dr. Van Cleve, clinical professor and primary care pediatric nurse practitioner program director at the University of Iowa College of Nursing, Iowa City.
 

As an educator

Naomi A. Schapiro, PhD, CPNP, is a professor of nursing at the University of California, San Francisco, and a PNP at a school-based health center with an integrated behavioral health model, managed by a federally qualified health center in a medically underserved area. She is the principle investigator of an Advanced Nursing Education Health Resources Service Administration grant supporting interprofessional training and practice collaboration to improve care and reduce health inequities for disadvantaged children and adolescents coping with both behavioral health conditions and chronic physical conditions, including obesity.¹¹

Dr. Schapiro collaborates with a multidisciplinary, multi-university team, a local children’s hospital, a social work training program, and the county health care services agency to develop and implement a training program for pediatric PC providers to increase skills and self-confidence implementing American Academy of Pediatrics guidelines assessing and treating depression, ADHD, anxiety and trauma-related symptoms; triaging patients with nonsuicidal self-injury and suicidal ideation; and recognizing and referring patients with bipolar disorder and psychosis. These training modules are currently being recorded for online posting. As part of this interprofessional collaboration, Dr. Schapiro and her colleagues developed a “warmline” for decision support, staffed by a psychiatrist and two nurse practitioners available to PC providers in a network of 29 school-based health centers and two pediatric practices for complex decision making about medications or diagnostic dilemmas. Efforts are underway to continue and expand this program.

 

“As a faculty teaching PNP students enhanced behavioral health assessment skills, I have been proudest when students have been able to apply and disseminate these skills,” Dr. Schapiro said. “One of our recent PNP graduates was in a community primary care practicum when an adolescent thinking about suicide walked into the clinic with her father. Her preceptor wasn’t sure how to proceed, when the student said, ‘Wait! We just practiced this in class.’ The student pulled up her course website, and she and her preceptor walked through the assessment together, developed a safety plan with the teen and her father, and connected the teen with a therapist, avoiding an unnecessary ER visit and potential fragmentation of care.”

The need and expectation that pediatric PC providers incorporate MH services is well documented.^2,12,13 PNPs who have additional training and expertise in assessing, diagnosing, and managing MH care are an excellent solution for addressing this problem. The benefits of this team-based approach to the pediatric health care home include decreasing stigma, increasing access, and providing comprehensive MH care to children and their families.
 

Dr. Haut works at Beacon Pediatrics, a large primary care practice in Rehoboth Beach, Del. She works part-time for Pediatrix Medical Group, serving the Pediatric Intensive Care Unit medical team at the Herman & Walter Samuelson Children’s Hospital at Sinai in Baltimore, and she serves as adjunct faculty at the University of Maryland School of Nursing, also in Baltimore. Other contributors to this article were Dawn Garzon Maaks, PhD, CPNP, PMHS; Naomi Schapiro, PhD, CPNP; Susan Van Cleve, DNP, RN, CPNP-PC, PMHS; and Laura Searcy, MN, APRN, PPCNP-BC. Ms. Searcy is on the medical staff at WellStar Kennestone Regional Medical Center in Marietta, Ga., delivering care to newborns. Dr. Haut and Ms. Searcy are members of the Pediatric News Consultant Advisory Board. Email them at pdnews@mdedge.com.

References

1. “Best principles for integration of child psychiatry into the pediatric health home,” AACAP Executive Summary,2012, pages 1-13.

2. Pediatrics. 2009 Apr;123(4):1248-51.

3. Center for Disease Control and Prevention: Children’s Mental Health Data and Statistics.

4. MMWR Surveill Summ, 2016. doi:10.15585/mmwr.ss6506a1.

5. Pediatrics. 2015;135(5):909-17.

6. JAMA Pediatr. 2015;169(10):929-37.

7. “Integrating child psychology services into primary care,” by Tynan D, Woods K, and Carpenter J. American Psychological Association, 2014.

8. J Am Psychiatr Nurses Assoc. 2005;11(5): 276-82.

9. J Nurse Pract. 2013;9(4):243-8.

10. J Pediatr Health Care. 2013; 27(3):162-3.

11. Advanced Nursing Education Health Resources Service Administration grant (#D09HP26958).

12. J Nurse Pract. 2013:9(3):142-8.

13. Pediatrics. 2018;141(3):e20174082

 

BALTIMORE – Children who get up to 10 hours of sleep nightly may be more inclined to develop healthy behaviors that reduce their chances of being overweight or obese, a 6-year follow-up of children in the Infant Feeding Practices Study II determined.

deyangeorgiev/thinkstockphotos.com

However, improving health in these children is more than a matter of simply seeing that they get more sleep, said lead investigator Jill Landsbaugh Kaar, PhD, of Children’s Hospital Colorado, Aurora, in presenting the results at the annual meeting of the Associated Professional Sleep Societies. “Perhaps there’s a potential pathway linking healthy eaters and obesity in children that may be mediated through sleep duration.”

The relationship between sleep, diet, and activity level may be more cyclical, rather than linear, Dr. Kaar said. “Poor sleep is typically linked to a poor diet or low levels of physical activity, and then linked to some outcome or disease,” she said. But her research indicates that those three factors – sleep, diet and activity – are more interrelated than one being causative of the others.

Noting that one in three adults and one in six children in the United States are either overweight or obese (JAMA. 2014 Feb 26;311[8]:806-14), Dr. Kaar said, “Childhood obesity prevention has really not been effective in reducing weight or preventing or limiting weight gain.” Such programs typically focus on one health behavior when each child has a unique pattern of health behaviors that influence weight.

Dr. Kaar’s research used data collected by the Centers for Disease Control and Prevention as part of a 6-year follow-up study of women from the Infant Feeding Practices Study II. Some 1,542 women completed mailed questionnaires about their 6-year-olds’ diet, activity, screen time, sleep duration, height, and weight. The statistical analysis grouped the children into health behavior patterns of diet, activity, and screen time and used a three-step mediation regression model to examine their hypothesis.

The analysis characterized children into three health behavior pattern groups: poorest eaters (22%), healthy children (37%), and active supereaters with the highest screen time (41%). The poorest eaters were more likely to be female (58%) and obese (18%) than the other groups, but even 10% of the healthy children group were obese.

In the first model, the poorest eaters had the highest risk of obesity. In the second model, both the poorest eaters and active supereaters had shorter sleep duration than healthy children – 9.46 and 9.59 hours a night, respectively, versus 9.97 hours for healthy children – “thus telling me that sleep was really driving that relationship,” Dr. Kaar said.

“Future interventions should consider that improving health behavior patterns by targeting someone’s diet or physical activity, that you’re also targeting them to improve sleep, and then through increasing sleep you will be influencing obesity,” she said. “Interventions and research studies in general really need to measure all of those health behaviors because they’re all related; it’s not just one of them leading to obesity risk.”

The next step for her research is to branch out beyond a one-center study, Dr. Kaar said.

Dr. Kaar reported having no financial relationships. An American Heart Association Scientist Development Award provided funding for the study.

 

BALTIMORE – Children who get up to 10 hours of sleep nightly may be more inclined to develop healthy behaviors that reduce their chances of being overweight or obese, a 6-year follow-up of children in the Infant Feeding Practices Study II determined.

deyangeorgiev/thinkstockphotos.com

However, improving health in these children is more than a matter of simply seeing that they get more sleep, said lead investigator Jill Landsbaugh Kaar, PhD, of Children’s Hospital Colorado, Aurora, in presenting the results at the annual meeting of the Associated Professional Sleep Societies. “Perhaps there’s a potential pathway linking healthy eaters and obesity in children that may be mediated through sleep duration.”

The relationship between sleep, diet, and activity level may be more cyclical, rather than linear, Dr. Kaar said. “Poor sleep is typically linked to a poor diet or low levels of physical activity, and then linked to some outcome or disease,” she said. But her research indicates that those three factors – sleep, diet and activity – are more interrelated than one being causative of the others.

Noting that one in three adults and one in six children in the United States are either overweight or obese (JAMA. 2014 Feb 26;311[8]:806-14), Dr. Kaar said, “Childhood obesity prevention has really not been effective in reducing weight or preventing or limiting weight gain.” Such programs typically focus on one health behavior when each child has a unique pattern of health behaviors that influence weight.

Dr. Kaar’s research used data collected by the Centers for Disease Control and Prevention as part of a 6-year follow-up study of women from the Infant Feeding Practices Study II. Some 1,542 women completed mailed questionnaires about their 6-year-olds’ diet, activity, screen time, sleep duration, height, and weight. The statistical analysis grouped the children into health behavior patterns of diet, activity, and screen time and used a three-step mediation regression model to examine their hypothesis.

The analysis characterized children into three health behavior pattern groups: poorest eaters (22%), healthy children (37%), and active supereaters with the highest screen time (41%). The poorest eaters were more likely to be female (58%) and obese (18%) than the other groups, but even 10% of the healthy children group were obese.

In the first model, the poorest eaters had the highest risk of obesity. In the second model, both the poorest eaters and active supereaters had shorter sleep duration than healthy children – 9.46 and 9.59 hours a night, respectively, versus 9.97 hours for healthy children – “thus telling me that sleep was really driving that relationship,” Dr. Kaar said.

“Future interventions should consider that improving health behavior patterns by targeting someone’s diet or physical activity, that you’re also targeting them to improve sleep, and then through increasing sleep you will be influencing obesity,” she said. “Interventions and research studies in general really need to measure all of those health behaviors because they’re all related; it’s not just one of them leading to obesity risk.”

The next step for her research is to branch out beyond a one-center study, Dr. Kaar said.

Dr. Kaar reported having no financial relationships. An American Heart Association Scientist Development Award provided funding for the study.

 

BALTIMORE – Children who get up to 10 hours of sleep nightly may be more inclined to develop healthy behaviors that reduce their chances of being overweight or obese, a 6-year follow-up of children in the Infant Feeding Practices Study II determined.

deyangeorgiev/thinkstockphotos.com

However, improving health in these children is more than a matter of simply seeing that they get more sleep, said lead investigator Jill Landsbaugh Kaar, PhD, of Children’s Hospital Colorado, Aurora, in presenting the results at the annual meeting of the Associated Professional Sleep Societies. “Perhaps there’s a potential pathway linking healthy eaters and obesity in children that may be mediated through sleep duration.”

The relationship between sleep, diet, and activity level may be more cyclical, rather than linear, Dr. Kaar said. “Poor sleep is typically linked to a poor diet or low levels of physical activity, and then linked to some outcome or disease,” she said. But her research indicates that those three factors – sleep, diet and activity – are more interrelated than one being causative of the others.

Noting that one in three adults and one in six children in the United States are either overweight or obese (JAMA. 2014 Feb 26;311[8]:806-14), Dr. Kaar said, “Childhood obesity prevention has really not been effective in reducing weight or preventing or limiting weight gain.” Such programs typically focus on one health behavior when each child has a unique pattern of health behaviors that influence weight.

Dr. Kaar’s research used data collected by the Centers for Disease Control and Prevention as part of a 6-year follow-up study of women from the Infant Feeding Practices Study II. Some 1,542 women completed mailed questionnaires about their 6-year-olds’ diet, activity, screen time, sleep duration, height, and weight. The statistical analysis grouped the children into health behavior patterns of diet, activity, and screen time and used a three-step mediation regression model to examine their hypothesis.

The analysis characterized children into three health behavior pattern groups: poorest eaters (22%), healthy children (37%), and active supereaters with the highest screen time (41%). The poorest eaters were more likely to be female (58%) and obese (18%) than the other groups, but even 10% of the healthy children group were obese.

In the first model, the poorest eaters had the highest risk of obesity. In the second model, both the poorest eaters and active supereaters had shorter sleep duration than healthy children – 9.46 and 9.59 hours a night, respectively, versus 9.97 hours for healthy children – “thus telling me that sleep was really driving that relationship,” Dr. Kaar said.

“Future interventions should consider that improving health behavior patterns by targeting someone’s diet or physical activity, that you’re also targeting them to improve sleep, and then through increasing sleep you will be influencing obesity,” she said. “Interventions and research studies in general really need to measure all of those health behaviors because they’re all related; it’s not just one of them leading to obesity risk.”

The next step for her research is to branch out beyond a one-center study, Dr. Kaar said.

Dr. Kaar reported having no financial relationships. An American Heart Association Scientist Development Award provided funding for the study.

 

Greed kills babies. Children’s lives matter. Children over profit.

These were the slogans proclaimed by signs carried by protesters outside of MedStar Franklin Square Medical Center in Baltimore in early May of 2018 to protest the closure of the dedicated pediatric emergency department and inpatient pediatric unit.

But administrators at Franklin Square Medical Center had made their decision long before the glue had dried on the signs, and the protests of patients and community officials fell on deaf ears. Eight doctors and 30 other staff had already lost their jobs, including the chair of pediatrics, Scott Krugman, MD.¹

And this was just another drop in a slow ooze of pediatric inpatient units based in community hospitals that have seen the ax fall on what was thought to be a vital medical resource for their communities – yet not vital enough to survive its lack of profitability. From Taunton, Mass., to Chicago, Ill., to rural Tennessee, pediatric inpatient units in community hospitals have failed to even flirt with breaking even, let alone show profitability. Many community pediatric inpatient units are saddled with rock-bottom reimbursements offered by state Medicaid programs, the overwhelmingly prevalent payer for pediatric hospitalizations, which is compounded by the seasonality and unpredictability of pediatric inpatient volumes, so many have seen a glowing red bottom line lead to their demise.

What does this mean for pediatric health in underserved and rural communities? The closure of the pediatric inpatient unit at MedStar Franklin Square Medical Center meant the loss of physicians and nurses staffing the child protection team helping to assist the local district attorney in child abuse cases. Sometimes described as “secondary care,” community pediatric hospitalists also serve as a link between primary care providers and tertiary care subspecialists; they can serve as pediatric generalists throughout a hospital and provide newborn nursery care, delivery room resuscitations, ED consultations, procedural sedations, psychiatric unit support, surgical comanagement, and informal or formal outpatient consultations.² Losing even a small inpatient pediatric unit can have a ripple effect on inpatient and outpatient pediatric services in a health system and community.

For patients and their caregivers, the loss of pediatric inpatient services in their community hospital can erect additional hurdles to appropriate health care. The need to travel longer distances to urban centers or even the other side of town can be challenging given the difficulties posed by long distances, traffic congestion, public transportation, or just parking.³ For patients suffering from longer hospitalizations caused by medical complexity or chronic illnesses, traveling long distances can exacerbate the caregiver stress from attempting to care for a family at home while participating in the care of a hospitalized child. Longer travel times can also worsen family stress by increasing a caregiver’s absence from home and increased nonmedical expenses, not to mention loss of wages.⁴ Comfort levels with inpatient providers can also suffer because most pediatric units in community hospitals are staffed by either community general pediatricians or very small pediatric hospitalist groups, which breeds familiarity with frequently admitted patients and their caregivers. This familiarity can be lacking in large academic centers, with confusing and ever-rotating teams of academic hospitalists, residents, and medical students.⁵

 

What is driving the slow drumbeat of pediatric inpatient unit closures? On a macroeconomic scale, pediatric hospitalizations have been dropping yearly, driven down by immunizations (despite the best efforts of certain celebrities), antibiotic stewardship, and improved access to outpatient care. In 2006, there were 6.6 million hospitalizations for children aged 17 years and younger,⁶ but by 2012 this had dropped to 5.9 million hospitalizations.⁷ In the same age group, the rate of hospitalization from the ED dropped from 4.4% in 2006 to 3.2% in 2015.⁸

On a hospital level, the presence of multiple small pediatric units in a region may not make sense from a cost standpoint, and a larger, merged unit may provide higher quality because of its higher volumes. On a state and local level, alternative payment models have been implemented with the best of intentions but have led administrators at community general hospitals to look at pediatric units as the lowest hanging money-losing fruit in their efforts to survive a brave new world of hospital payment.

The most extreme (or advanced, depending on your viewpoint) model is in Maryland: Since 2014, acute care hospitals have been only able to receive a fixed amount of revenue from all payers, including Medicare, Medicaid, and commercial insurers.⁹ Known as an all-payer global budget, it incentivizes lowering unnecessary costs of care, such as readmissions, but also encourages cauterization of cost centers hemorrhaging money – such as inpatient pediatrics. Even the venerable Johns Hopkins Children’s Center has seen its profitability pale in comparison to the expansion team Johns Hopkins All Children’s Hospital in St. Petersburg, Fla., which is the second-most profitable hospital in the Hopkins system, only edged out by Sibley Memorial Hospital – which also sports an out-of-state location in the District of Columbia.¹⁰

But all hope is not lost for your comfy local pediatric inpatient unit. In other states and regions where a more favorable (to hospitals) payer mix exists, large pediatric hospitals are still engaged in turf battles with other local competitors to grab market share. In these regions, community pediatric units have survived by partnering with large pediatric institutions, either through affiliations or wholesale transplantation of the larger pediatric institution’s providers, nurses, and EHRs into essentially what is a leased floor. In addition, large pediatric institutions that participate in capitated models such as accountable care organizations have paradoxically found it financially favorable to direct “bread-and-butter” pediatric hospitalizations to community pediatric units, which often provide the same care at a lower cost.

Utilizing community inpatient pediatric units was “initially … a means of expanding their market share and ‘downstream’ revenue from transfers, but more commonly now [is] a way of alleviating the costs associated with admitting low to moderate acuity patients to the main tertiary sites,” said Francisco Alvarez, MD, associate chief of Regional Pediatric Hospital Medicine Programs at Lucile Packard Children’s Hospital in Palo Alto, Calif. “The cost of care provided by pediatric hospitals has always been higher than the average cost for nonpediatric hospitals in regard to caring for pediatric patients due to their highly skilled specialties and services. These have become more scrutinized by private and government insurance plans and, in some cases, have led to lower reimbursements and therefore a lower or deficient net revenue for certain patient populations.”

For community pediatric hospitalists, the shifting sands of reimbursement on which pediatric inpatient care is built can be a motion illness–inducing experience. In addition to concerns over community health care, job security, and population health, care provided in community hospitals can often be subtly undercut by tertiary and quaternary care pediatric hospitals.

“The focus of pediatric residency programs in freestanding children’s hospitals has created a situation where new pediatricians have less opportunity to develop respect for community pediatric hospital medicine,” said Beth Natt, MD, director of pediatric hospital medicine in the Regional Programs at Connecticut Children’s Medical Center, Hartford. “We are the nameless ‘OSH,’ the place that gets ‘Monday-morning quarterbacked’ in resident morning reports without having a voice at the table. Add this to residents learning ‘only’ protocolized care as opposed to a spectrum of appropriate care, and we create a culture of ‘wrong and right’ with the backward nonprotocol driven community docs looking like they are practicing medicine in the Wild West.”

What’s a community pediatric hospitalist to do, faced with an uncertain future and diminishing respect? Continuing to partner with local pediatric providers, community leaders, and local health care advocacy groups will help to enmesh inpatient providers in the fabric of a community’s health care. But making the value case to hospital administrators is critical for community pediatric hospitalists, as adult hospitalists realized soon after the inception of the hospitalist field.

Goals valued by hospital administrators are pursued on a daily basis by community pediatric hospitalists, and these successes need to be brought to light. Achieving value and quality metrics, pursuing high-value care, reducing readmission rates, championing EHRs, and improving documentation are goals that community pediatric hospitalists and hospital administrators can work toward together.¹¹ By pursuing and sharing success in meeting these shared goals, perhaps the local community pediatric inpatient unit can survive – and thrive.

As for Dr. Krugman, he has moved on and is soon to be gainfully employed again. But he continues to be focused, as always, on the health of his patients.

“What are we going to do to take care of kids in their own communities?” Dr. Krugman asked. “It’s going to be an increasing challenge over the next decade due to the consolidation of children’s hospitals and low payments, especially for hospitals that are adult-focused. Unless we find a way to pay for pediatric care as a country.”

 

Dr. Chang is a pediatric hospitalist at Baystate Children’s Hospital in Springfield, Mass., and is the pediatric editor of The Hospitalist.

References

1. McDaniels A. (2018). Protesters denounce reduction in pediatric services at Baltimore’s MedStar Franklin Square hospital. Baltimore Sun. Available at: http://www.baltimoresun.com/health/health-care/bs-hs-franklin-square-hospital-protest-20180508-story.html.

2. Roberts KB. Pediatric hospitalists in community hospitals: Hospital-based generalists with expanded roles. Hosp Pediatr. 2015 May;5(5):290-2.

3. Georgia Health News. (2018). A hospital crisis is killing rural communities. This state is ‘Ground Zero’. Available at: http://www.georgiahealthnews.com/2017/09/hospital-crisis-killing-rural-communities-state-ground-zero/.

4. DiFazio RL et al. Non-medical out-of-pocket expenses incurred by families during their child’s hospitalization. J Child Health Care. 2013 Sep;17(3):230-41.

5. Gunderman R. Hospitalist and the decline of comprehensive care. N Engl J Med. 2016 Sep 15; 375(11):1011-3.

6. Statistical Brief #56. (2018). Retrieved from https://www.hcup-us.ahrq.gov/reports/statbriefs/sb56.jsp.

7. Overview of Hospital Stays for Children in the United States, 2012 #187. (2018). Retrieved from https://www.hcup-us.ahrq.gov/reports/statbriefs/sb187-Hospital-Stays-Children-2012.jsp.

8. Trends in Hospital Inpatient Stays by Age and Payer, 2000-2015 #235. (2018). Retrieved from https://www.hcup-us.ahrq.gov/reports/statbriefs/sb235-Inpatient-Stays-Age-Payer-Trends.jsp.

9. Maryland All-Payer Model | Center for Medicare & Medicaid Innovation. (2018). Retrieved from https://innovation.cms.gov/initiatives/Maryland-All-Payer-Model/.

10. The effects of Maryland’s unique health care system. (2018). Retrieved from https://www.axios.com/johns-hopkins-finances-maryland-1518553853-722c2195-731e-4e02-ab1e-94e4211ba945.html.

11. The Increasing Need for Hospitalist Programs to Demonstrate Value | SCP. (2018). Retrieved from https://www.schumacherclinical.com/providers/blog/the-increasing-need-for-hospitalist-programs-to-demonstrate-value.
 

 

Greed kills babies. Children’s lives matter. Children over profit.

These were the slogans proclaimed by signs carried by protesters outside of MedStar Franklin Square Medical Center in Baltimore in early May of 2018 to protest the closure of the dedicated pediatric emergency department and inpatient pediatric unit.

But administrators at Franklin Square Medical Center had made their decision long before the glue had dried on the signs, and the protests of patients and community officials fell on deaf ears. Eight doctors and 30 other staff had already lost their jobs, including the chair of pediatrics, Scott Krugman, MD.¹

And this was just another drop in a slow ooze of pediatric inpatient units based in community hospitals that have seen the ax fall on what was thought to be a vital medical resource for their communities – yet not vital enough to survive its lack of profitability. From Taunton, Mass., to Chicago, Ill., to rural Tennessee, pediatric inpatient units in community hospitals have failed to even flirt with breaking even, let alone show profitability. Many community pediatric inpatient units are saddled with rock-bottom reimbursements offered by state Medicaid programs, the overwhelmingly prevalent payer for pediatric hospitalizations, which is compounded by the seasonality and unpredictability of pediatric inpatient volumes, so many have seen a glowing red bottom line lead to their demise.

What does this mean for pediatric health in underserved and rural communities? The closure of the pediatric inpatient unit at MedStar Franklin Square Medical Center meant the loss of physicians and nurses staffing the child protection team helping to assist the local district attorney in child abuse cases. Sometimes described as “secondary care,” community pediatric hospitalists also serve as a link between primary care providers and tertiary care subspecialists; they can serve as pediatric generalists throughout a hospital and provide newborn nursery care, delivery room resuscitations, ED consultations, procedural sedations, psychiatric unit support, surgical comanagement, and informal or formal outpatient consultations.² Losing even a small inpatient pediatric unit can have a ripple effect on inpatient and outpatient pediatric services in a health system and community.

For patients and their caregivers, the loss of pediatric inpatient services in their community hospital can erect additional hurdles to appropriate health care. The need to travel longer distances to urban centers or even the other side of town can be challenging given the difficulties posed by long distances, traffic congestion, public transportation, or just parking.³ For patients suffering from longer hospitalizations caused by medical complexity or chronic illnesses, traveling long distances can exacerbate the caregiver stress from attempting to care for a family at home while participating in the care of a hospitalized child. Longer travel times can also worsen family stress by increasing a caregiver’s absence from home and increased nonmedical expenses, not to mention loss of wages.⁴ Comfort levels with inpatient providers can also suffer because most pediatric units in community hospitals are staffed by either community general pediatricians or very small pediatric hospitalist groups, which breeds familiarity with frequently admitted patients and their caregivers. This familiarity can be lacking in large academic centers, with confusing and ever-rotating teams of academic hospitalists, residents, and medical students.⁵

 

What is driving the slow drumbeat of pediatric inpatient unit closures? On a macroeconomic scale, pediatric hospitalizations have been dropping yearly, driven down by immunizations (despite the best efforts of certain celebrities), antibiotic stewardship, and improved access to outpatient care. In 2006, there were 6.6 million hospitalizations for children aged 17 years and younger,⁶ but by 2012 this had dropped to 5.9 million hospitalizations.⁷ In the same age group, the rate of hospitalization from the ED dropped from 4.4% in 2006 to 3.2% in 2015.⁸

On a hospital level, the presence of multiple small pediatric units in a region may not make sense from a cost standpoint, and a larger, merged unit may provide higher quality because of its higher volumes. On a state and local level, alternative payment models have been implemented with the best of intentions but have led administrators at community general hospitals to look at pediatric units as the lowest hanging money-losing fruit in their efforts to survive a brave new world of hospital payment.

The most extreme (or advanced, depending on your viewpoint) model is in Maryland: Since 2014, acute care hospitals have been only able to receive a fixed amount of revenue from all payers, including Medicare, Medicaid, and commercial insurers.⁹ Known as an all-payer global budget, it incentivizes lowering unnecessary costs of care, such as readmissions, but also encourages cauterization of cost centers hemorrhaging money – such as inpatient pediatrics. Even the venerable Johns Hopkins Children’s Center has seen its profitability pale in comparison to the expansion team Johns Hopkins All Children’s Hospital in St. Petersburg, Fla., which is the second-most profitable hospital in the Hopkins system, only edged out by Sibley Memorial Hospital – which also sports an out-of-state location in the District of Columbia.¹⁰

But all hope is not lost for your comfy local pediatric inpatient unit. In other states and regions where a more favorable (to hospitals) payer mix exists, large pediatric hospitals are still engaged in turf battles with other local competitors to grab market share. In these regions, community pediatric units have survived by partnering with large pediatric institutions, either through affiliations or wholesale transplantation of the larger pediatric institution’s providers, nurses, and EHRs into essentially what is a leased floor. In addition, large pediatric institutions that participate in capitated models such as accountable care organizations have paradoxically found it financially favorable to direct “bread-and-butter” pediatric hospitalizations to community pediatric units, which often provide the same care at a lower cost.

Utilizing community inpatient pediatric units was “initially … a means of expanding their market share and ‘downstream’ revenue from transfers, but more commonly now [is] a way of alleviating the costs associated with admitting low to moderate acuity patients to the main tertiary sites,” said Francisco Alvarez, MD, associate chief of Regional Pediatric Hospital Medicine Programs at Lucile Packard Children’s Hospital in Palo Alto, Calif. “The cost of care provided by pediatric hospitals has always been higher than the average cost for nonpediatric hospitals in regard to caring for pediatric patients due to their highly skilled specialties and services. These have become more scrutinized by private and government insurance plans and, in some cases, have led to lower reimbursements and therefore a lower or deficient net revenue for certain patient populations.”

For community pediatric hospitalists, the shifting sands of reimbursement on which pediatric inpatient care is built can be a motion illness–inducing experience. In addition to concerns over community health care, job security, and population health, care provided in community hospitals can often be subtly undercut by tertiary and quaternary care pediatric hospitals.

“The focus of pediatric residency programs in freestanding children’s hospitals has created a situation where new pediatricians have less opportunity to develop respect for community pediatric hospital medicine,” said Beth Natt, MD, director of pediatric hospital medicine in the Regional Programs at Connecticut Children’s Medical Center, Hartford. “We are the nameless ‘OSH,’ the place that gets ‘Monday-morning quarterbacked’ in resident morning reports without having a voice at the table. Add this to residents learning ‘only’ protocolized care as opposed to a spectrum of appropriate care, and we create a culture of ‘wrong and right’ with the backward nonprotocol driven community docs looking like they are practicing medicine in the Wild West.”

What’s a community pediatric hospitalist to do, faced with an uncertain future and diminishing respect? Continuing to partner with local pediatric providers, community leaders, and local health care advocacy groups will help to enmesh inpatient providers in the fabric of a community’s health care. But making the value case to hospital administrators is critical for community pediatric hospitalists, as adult hospitalists realized soon after the inception of the hospitalist field.

Goals valued by hospital administrators are pursued on a daily basis by community pediatric hospitalists, and these successes need to be brought to light. Achieving value and quality metrics, pursuing high-value care, reducing readmission rates, championing EHRs, and improving documentation are goals that community pediatric hospitalists and hospital administrators can work toward together.¹¹ By pursuing and sharing success in meeting these shared goals, perhaps the local community pediatric inpatient unit can survive – and thrive.

As for Dr. Krugman, he has moved on and is soon to be gainfully employed again. But he continues to be focused, as always, on the health of his patients.

“What are we going to do to take care of kids in their own communities?” Dr. Krugman asked. “It’s going to be an increasing challenge over the next decade due to the consolidation of children’s hospitals and low payments, especially for hospitals that are adult-focused. Unless we find a way to pay for pediatric care as a country.”

 

Dr. Chang is a pediatric hospitalist at Baystate Children’s Hospital in Springfield, Mass., and is the pediatric editor of The Hospitalist.

References

1. McDaniels A. (2018). Protesters denounce reduction in pediatric services at Baltimore’s MedStar Franklin Square hospital. Baltimore Sun. Available at: http://www.baltimoresun.com/health/health-care/bs-hs-franklin-square-hospital-protest-20180508-story.html.

2. Roberts KB. Pediatric hospitalists in community hospitals: Hospital-based generalists with expanded roles. Hosp Pediatr. 2015 May;5(5):290-2.

3. Georgia Health News. (2018). A hospital crisis is killing rural communities. This state is ‘Ground Zero’. Available at: http://www.georgiahealthnews.com/2017/09/hospital-crisis-killing-rural-communities-state-ground-zero/.

4. DiFazio RL et al. Non-medical out-of-pocket expenses incurred by families during their child’s hospitalization. J Child Health Care. 2013 Sep;17(3):230-41.

5. Gunderman R. Hospitalist and the decline of comprehensive care. N Engl J Med. 2016 Sep 15; 375(11):1011-3.

6. Statistical Brief #56. (2018). Retrieved from https://www.hcup-us.ahrq.gov/reports/statbriefs/sb56.jsp.

7. Overview of Hospital Stays for Children in the United States, 2012 #187. (2018). Retrieved from https://www.hcup-us.ahrq.gov/reports/statbriefs/sb187-Hospital-Stays-Children-2012.jsp.

8. Trends in Hospital Inpatient Stays by Age and Payer, 2000-2015 #235. (2018). Retrieved from https://www.hcup-us.ahrq.gov/reports/statbriefs/sb235-Inpatient-Stays-Age-Payer-Trends.jsp.

9. Maryland All-Payer Model | Center for Medicare & Medicaid Innovation. (2018). Retrieved from https://innovation.cms.gov/initiatives/Maryland-All-Payer-Model/.

10. The effects of Maryland’s unique health care system. (2018). Retrieved from https://www.axios.com/johns-hopkins-finances-maryland-1518553853-722c2195-731e-4e02-ab1e-94e4211ba945.html.

11. The Increasing Need for Hospitalist Programs to Demonstrate Value | SCP. (2018). Retrieved from https://www.schumacherclinical.com/providers/blog/the-increasing-need-for-hospitalist-programs-to-demonstrate-value.
 

 

Greed kills babies. Children’s lives matter. Children over profit.

These were the slogans proclaimed by signs carried by protesters outside of MedStar Franklin Square Medical Center in Baltimore in early May of 2018 to protest the closure of the dedicated pediatric emergency department and inpatient pediatric unit.

But administrators at Franklin Square Medical Center had made their decision long before the glue had dried on the signs, and the protests of patients and community officials fell on deaf ears. Eight doctors and 30 other staff had already lost their jobs, including the chair of pediatrics, Scott Krugman, MD.¹

And this was just another drop in a slow ooze of pediatric inpatient units based in community hospitals that have seen the ax fall on what was thought to be a vital medical resource for their communities – yet not vital enough to survive its lack of profitability. From Taunton, Mass., to Chicago, Ill., to rural Tennessee, pediatric inpatient units in community hospitals have failed to even flirt with breaking even, let alone show profitability. Many community pediatric inpatient units are saddled with rock-bottom reimbursements offered by state Medicaid programs, the overwhelmingly prevalent payer for pediatric hospitalizations, which is compounded by the seasonality and unpredictability of pediatric inpatient volumes, so many have seen a glowing red bottom line lead to their demise.

What does this mean for pediatric health in underserved and rural communities? The closure of the pediatric inpatient unit at MedStar Franklin Square Medical Center meant the loss of physicians and nurses staffing the child protection team helping to assist the local district attorney in child abuse cases. Sometimes described as “secondary care,” community pediatric hospitalists also serve as a link between primary care providers and tertiary care subspecialists; they can serve as pediatric generalists throughout a hospital and provide newborn nursery care, delivery room resuscitations, ED consultations, procedural sedations, psychiatric unit support, surgical comanagement, and informal or formal outpatient consultations.² Losing even a small inpatient pediatric unit can have a ripple effect on inpatient and outpatient pediatric services in a health system and community.

For patients and their caregivers, the loss of pediatric inpatient services in their community hospital can erect additional hurdles to appropriate health care. The need to travel longer distances to urban centers or even the other side of town can be challenging given the difficulties posed by long distances, traffic congestion, public transportation, or just parking.³ For patients suffering from longer hospitalizations caused by medical complexity or chronic illnesses, traveling long distances can exacerbate the caregiver stress from attempting to care for a family at home while participating in the care of a hospitalized child. Longer travel times can also worsen family stress by increasing a caregiver’s absence from home and increased nonmedical expenses, not to mention loss of wages.⁴ Comfort levels with inpatient providers can also suffer because most pediatric units in community hospitals are staffed by either community general pediatricians or very small pediatric hospitalist groups, which breeds familiarity with frequently admitted patients and their caregivers. This familiarity can be lacking in large academic centers, with confusing and ever-rotating teams of academic hospitalists, residents, and medical students.⁵

 

What is driving the slow drumbeat of pediatric inpatient unit closures? On a macroeconomic scale, pediatric hospitalizations have been dropping yearly, driven down by immunizations (despite the best efforts of certain celebrities), antibiotic stewardship, and improved access to outpatient care. In 2006, there were 6.6 million hospitalizations for children aged 17 years and younger,⁶ but by 2012 this had dropped to 5.9 million hospitalizations.⁷ In the same age group, the rate of hospitalization from the ED dropped from 4.4% in 2006 to 3.2% in 2015.⁸

On a hospital level, the presence of multiple small pediatric units in a region may not make sense from a cost standpoint, and a larger, merged unit may provide higher quality because of its higher volumes. On a state and local level, alternative payment models have been implemented with the best of intentions but have led administrators at community general hospitals to look at pediatric units as the lowest hanging money-losing fruit in their efforts to survive a brave new world of hospital payment.

The most extreme (or advanced, depending on your viewpoint) model is in Maryland: Since 2014, acute care hospitals have been only able to receive a fixed amount of revenue from all payers, including Medicare, Medicaid, and commercial insurers.⁹ Known as an all-payer global budget, it incentivizes lowering unnecessary costs of care, such as readmissions, but also encourages cauterization of cost centers hemorrhaging money – such as inpatient pediatrics. Even the venerable Johns Hopkins Children’s Center has seen its profitability pale in comparison to the expansion team Johns Hopkins All Children’s Hospital in St. Petersburg, Fla., which is the second-most profitable hospital in the Hopkins system, only edged out by Sibley Memorial Hospital – which also sports an out-of-state location in the District of Columbia.¹⁰

But all hope is not lost for your comfy local pediatric inpatient unit. In other states and regions where a more favorable (to hospitals) payer mix exists, large pediatric hospitals are still engaged in turf battles with other local competitors to grab market share. In these regions, community pediatric units have survived by partnering with large pediatric institutions, either through affiliations or wholesale transplantation of the larger pediatric institution’s providers, nurses, and EHRs into essentially what is a leased floor. In addition, large pediatric institutions that participate in capitated models such as accountable care organizations have paradoxically found it financially favorable to direct “bread-and-butter” pediatric hospitalizations to community pediatric units, which often provide the same care at a lower cost.

Utilizing community inpatient pediatric units was “initially … a means of expanding their market share and ‘downstream’ revenue from transfers, but more commonly now [is] a way of alleviating the costs associated with admitting low to moderate acuity patients to the main tertiary sites,” said Francisco Alvarez, MD, associate chief of Regional Pediatric Hospital Medicine Programs at Lucile Packard Children’s Hospital in Palo Alto, Calif. “The cost of care provided by pediatric hospitals has always been higher than the average cost for nonpediatric hospitals in regard to caring for pediatric patients due to their highly skilled specialties and services. These have become more scrutinized by private and government insurance plans and, in some cases, have led to lower reimbursements and therefore a lower or deficient net revenue for certain patient populations.”

For community pediatric hospitalists, the shifting sands of reimbursement on which pediatric inpatient care is built can be a motion illness–inducing experience. In addition to concerns over community health care, job security, and population health, care provided in community hospitals can often be subtly undercut by tertiary and quaternary care pediatric hospitals.

“The focus of pediatric residency programs in freestanding children’s hospitals has created a situation where new pediatricians have less opportunity to develop respect for community pediatric hospital medicine,” said Beth Natt, MD, director of pediatric hospital medicine in the Regional Programs at Connecticut Children’s Medical Center, Hartford. “We are the nameless ‘OSH,’ the place that gets ‘Monday-morning quarterbacked’ in resident morning reports without having a voice at the table. Add this to residents learning ‘only’ protocolized care as opposed to a spectrum of appropriate care, and we create a culture of ‘wrong and right’ with the backward nonprotocol driven community docs looking like they are practicing medicine in the Wild West.”

What’s a community pediatric hospitalist to do, faced with an uncertain future and diminishing respect? Continuing to partner with local pediatric providers, community leaders, and local health care advocacy groups will help to enmesh inpatient providers in the fabric of a community’s health care. But making the value case to hospital administrators is critical for community pediatric hospitalists, as adult hospitalists realized soon after the inception of the hospitalist field.

Goals valued by hospital administrators are pursued on a daily basis by community pediatric hospitalists, and these successes need to be brought to light. Achieving value and quality metrics, pursuing high-value care, reducing readmission rates, championing EHRs, and improving documentation are goals that community pediatric hospitalists and hospital administrators can work toward together.¹¹ By pursuing and sharing success in meeting these shared goals, perhaps the local community pediatric inpatient unit can survive – and thrive.

As for Dr. Krugman, he has moved on and is soon to be gainfully employed again. But he continues to be focused, as always, on the health of his patients.

“What are we going to do to take care of kids in their own communities?” Dr. Krugman asked. “It’s going to be an increasing challenge over the next decade due to the consolidation of children’s hospitals and low payments, especially for hospitals that are adult-focused. Unless we find a way to pay for pediatric care as a country.”

 

Dr. Chang is a pediatric hospitalist at Baystate Children’s Hospital in Springfield, Mass., and is the pediatric editor of The Hospitalist.

References

1. McDaniels A. (2018). Protesters denounce reduction in pediatric services at Baltimore’s MedStar Franklin Square hospital. Baltimore Sun. Available at: http://www.baltimoresun.com/health/health-care/bs-hs-franklin-square-hospital-protest-20180508-story.html.

2. Roberts KB. Pediatric hospitalists in community hospitals: Hospital-based generalists with expanded roles. Hosp Pediatr. 2015 May;5(5):290-2.

3. Georgia Health News. (2018). A hospital crisis is killing rural communities. This state is ‘Ground Zero’. Available at: http://www.georgiahealthnews.com/2017/09/hospital-crisis-killing-rural-communities-state-ground-zero/.

4. DiFazio RL et al. Non-medical out-of-pocket expenses incurred by families during their child’s hospitalization. J Child Health Care. 2013 Sep;17(3):230-41.

5. Gunderman R. Hospitalist and the decline of comprehensive care. N Engl J Med. 2016 Sep 15; 375(11):1011-3.

6. Statistical Brief #56. (2018). Retrieved from https://www.hcup-us.ahrq.gov/reports/statbriefs/sb56.jsp.

7. Overview of Hospital Stays for Children in the United States, 2012 #187. (2018). Retrieved from https://www.hcup-us.ahrq.gov/reports/statbriefs/sb187-Hospital-Stays-Children-2012.jsp.

8. Trends in Hospital Inpatient Stays by Age and Payer, 2000-2015 #235. (2018). Retrieved from https://www.hcup-us.ahrq.gov/reports/statbriefs/sb235-Inpatient-Stays-Age-Payer-Trends.jsp.

9. Maryland All-Payer Model | Center for Medicare & Medicaid Innovation. (2018). Retrieved from https://innovation.cms.gov/initiatives/Maryland-All-Payer-Model/.

10. The effects of Maryland’s unique health care system. (2018). Retrieved from https://www.axios.com/johns-hopkins-finances-maryland-1518553853-722c2195-731e-4e02-ab1e-94e4211ba945.html.

11. The Increasing Need for Hospitalist Programs to Demonstrate Value | SCP. (2018). Retrieved from https://www.schumacherclinical.com/providers/blog/the-increasing-need-for-hospitalist-programs-to-demonstrate-value.
 

 

Digital technology use by parents during family activities may exacerbate internalizing or externalizing behavior in their children, according to results published in Pediatric Research.

In a study of 183 couples with children aged 5 years or younger, mothers perceived an average of 1.65 devices as interfering in their interactions with their child at least once per day, compared with an average of 1.43 devices per day for fathers. In addition, 56% of mothers and 43% of fathers reported that two or more devices interrupted their parent-child activities on a daily basis.

Higher technology interference (“technoference”) was associated with greater externalizing and internalizing behaviors in children and higher parenting stress for both mothers and fathers. Technoference also was associated with lower coparenting quality in fathers only, and greater parent depressive symptoms in mothers only, reported Brandon T. McDaniel, PhD, of Illinois State University, Normal, and Jenny S. Radesky, MD, of the University of Michigan, Ann Arbor.

Zinkevych/iStock/Getty Images

The parents observed participated in the Daily Family Life Project, a longitudinal study on family relationships from 2014 to 2016. Participants were required to be 18 years of age or older, a parent of a child 5 years of age or younger, an English speaker, and currently living with their partner and child. Participants first completed a baseline online survey via Qualtrics, followed by assessments at 1, 3, and 6 months.

Each follow-up survey included a technoference self-assessment completed by each parent, adapted from the Technology Device Interference Scale. Follow-up assessments included information on parental stress, coparenting quality, depressive symptoms, and child externalizing and internalizing behavior, using scales from the Child Behavioral Checklist. Internalizing was defined by behaviors such as whining, sulking, and easily hurt feelings, whereas externalizing included inability to sit still, restlessness, hyperactivity, being easily frustrated, and having temper tantrums, wrote Dr. McDaniel and Dr. Radesky.

Structural equation modeling was used to test models for child externalizing and internalizing in three hypotheses: more frequent technoference predicting higher ratings of child behavior problems (H1), higher ratings of child behavior problems predicting higher parenting stress (H2), and higher parenting stress predicting more frequent technoference (H3), the authors wrote.

H1 and H2 were supported in the externalizing behavior model but only partially supported in the internalizing model, with technoference predicting greater externalizing behavior at all subsequent time points (betas = 0.11, 0.16, and 0.13, P values less than .01), and child externalizing predicting greater parenting stress (betas = 0.16, 0.15, and 0.12, P values less than .01). H3 was partially supported in the externalizing and internalizing behavior models, with parenting stress predicting later technoference from baseline to month 1 (betas = 0.19 and 0.15, P values less than .01) and from month 1 to month 3 (betas= 0.17 and 0.19, P values less than .001), the authors reported.

The findings suggest that “relationships between parent technoference and child externalizing behavior are transactional and influence each other over time,” Dr. McDaniel and Dr. Radesky said.

“In other words, parents who have children with more externalizing problems become more stressed, which may lead to greater technoference (e.g., withdrawal with technology), which in turn may contribute to more child externalizing problems (and only sometimes internalized problems),” they added.

“Our results suggest that children may be more likely to act out over time in response to technoference as opposed to internalize, although when we examined internalizing subscales, child withdrawal was the most consistently associated with parent technoference over time. This may be due to (1) parents responding to child withdrawal social cues by feeling they too can disengage into their mobile device use, or (2) parent media use precipitating child withdrawal from social interaction,” the authors wrote.

The main limitation of this study was the self-reporting used by parents, which may be more subject to bias compared with observational methods, they added.

“It would be worthwhile to study whether experimental manipulation of parent mobile phone use habits – for example through unplugged family routines or less intrusive digital design – might lead to improvements in the parent-child relationship and child behavior,” Dr. McDaniel and Dr. Radesky concluded.

The study was funded by the College of Health and Human Development, Department of Human Development and Family Studies, and the Bennett Pierce Prevention Research Center at Pennsylvania State University, National Institute on Drug Abuse, and the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Dr. McDaniel and Dr. Radesky had no relevant financial disclosures.

SOURCE: McDaniel B et al. Pediatr Res. 2018. doi: 10.1038/s41390-018-0052-6.

 

Digital technology use by parents during family activities may exacerbate internalizing or externalizing behavior in their children, according to results published in Pediatric Research.

In a study of 183 couples with children aged 5 years or younger, mothers perceived an average of 1.65 devices as interfering in their interactions with their child at least once per day, compared with an average of 1.43 devices per day for fathers. In addition, 56% of mothers and 43% of fathers reported that two or more devices interrupted their parent-child activities on a daily basis.

Higher technology interference (“technoference”) was associated with greater externalizing and internalizing behaviors in children and higher parenting stress for both mothers and fathers. Technoference also was associated with lower coparenting quality in fathers only, and greater parent depressive symptoms in mothers only, reported Brandon T. McDaniel, PhD, of Illinois State University, Normal, and Jenny S. Radesky, MD, of the University of Michigan, Ann Arbor.

Zinkevych/iStock/Getty Images

The parents observed participated in the Daily Family Life Project, a longitudinal study on family relationships from 2014 to 2016. Participants were required to be 18 years of age or older, a parent of a child 5 years of age or younger, an English speaker, and currently living with their partner and child. Participants first completed a baseline online survey via Qualtrics, followed by assessments at 1, 3, and 6 months.

Each follow-up survey included a technoference self-assessment completed by each parent, adapted from the Technology Device Interference Scale. Follow-up assessments included information on parental stress, coparenting quality, depressive symptoms, and child externalizing and internalizing behavior, using scales from the Child Behavioral Checklist. Internalizing was defined by behaviors such as whining, sulking, and easily hurt feelings, whereas externalizing included inability to sit still, restlessness, hyperactivity, being easily frustrated, and having temper tantrums, wrote Dr. McDaniel and Dr. Radesky.

Structural equation modeling was used to test models for child externalizing and internalizing in three hypotheses: more frequent technoference predicting higher ratings of child behavior problems (H1), higher ratings of child behavior problems predicting higher parenting stress (H2), and higher parenting stress predicting more frequent technoference (H3), the authors wrote.

H1 and H2 were supported in the externalizing behavior model but only partially supported in the internalizing model, with technoference predicting greater externalizing behavior at all subsequent time points (betas = 0.11, 0.16, and 0.13, P values less than .01), and child externalizing predicting greater parenting stress (betas = 0.16, 0.15, and 0.12, P values less than .01). H3 was partially supported in the externalizing and internalizing behavior models, with parenting stress predicting later technoference from baseline to month 1 (betas = 0.19 and 0.15, P values less than .01) and from month 1 to month 3 (betas= 0.17 and 0.19, P values less than .001), the authors reported.

The findings suggest that “relationships between parent technoference and child externalizing behavior are transactional and influence each other over time,” Dr. McDaniel and Dr. Radesky said.

“In other words, parents who have children with more externalizing problems become more stressed, which may lead to greater technoference (e.g., withdrawal with technology), which in turn may contribute to more child externalizing problems (and only sometimes internalized problems),” they added.

“Our results suggest that children may be more likely to act out over time in response to technoference as opposed to internalize, although when we examined internalizing subscales, child withdrawal was the most consistently associated with parent technoference over time. This may be due to (1) parents responding to child withdrawal social cues by feeling they too can disengage into their mobile device use, or (2) parent media use precipitating child withdrawal from social interaction,” the authors wrote.

The main limitation of this study was the self-reporting used by parents, which may be more subject to bias compared with observational methods, they added.

“It would be worthwhile to study whether experimental manipulation of parent mobile phone use habits – for example through unplugged family routines or less intrusive digital design – might lead to improvements in the parent-child relationship and child behavior,” Dr. McDaniel and Dr. Radesky concluded.

The study was funded by the College of Health and Human Development, Department of Human Development and Family Studies, and the Bennett Pierce Prevention Research Center at Pennsylvania State University, National Institute on Drug Abuse, and the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Dr. McDaniel and Dr. Radesky had no relevant financial disclosures.

SOURCE: McDaniel B et al. Pediatr Res. 2018. doi: 10.1038/s41390-018-0052-6.

 

Digital technology use by parents during family activities may exacerbate internalizing or externalizing behavior in their children, according to results published in Pediatric Research.

In a study of 183 couples with children aged 5 years or younger, mothers perceived an average of 1.65 devices as interfering in their interactions with their child at least once per day, compared with an average of 1.43 devices per day for fathers. In addition, 56% of mothers and 43% of fathers reported that two or more devices interrupted their parent-child activities on a daily basis.

Higher technology interference (“technoference”) was associated with greater externalizing and internalizing behaviors in children and higher parenting stress for both mothers and fathers. Technoference also was associated with lower coparenting quality in fathers only, and greater parent depressive symptoms in mothers only, reported Brandon T. McDaniel, PhD, of Illinois State University, Normal, and Jenny S. Radesky, MD, of the University of Michigan, Ann Arbor.

Zinkevych/iStock/Getty Images

The parents observed participated in the Daily Family Life Project, a longitudinal study on family relationships from 2014 to 2016. Participants were required to be 18 years of age or older, a parent of a child 5 years of age or younger, an English speaker, and currently living with their partner and child. Participants first completed a baseline online survey via Qualtrics, followed by assessments at 1, 3, and 6 months.

Each follow-up survey included a technoference self-assessment completed by each parent, adapted from the Technology Device Interference Scale. Follow-up assessments included information on parental stress, coparenting quality, depressive symptoms, and child externalizing and internalizing behavior, using scales from the Child Behavioral Checklist. Internalizing was defined by behaviors such as whining, sulking, and easily hurt feelings, whereas externalizing included inability to sit still, restlessness, hyperactivity, being easily frustrated, and having temper tantrums, wrote Dr. McDaniel and Dr. Radesky.

Structural equation modeling was used to test models for child externalizing and internalizing in three hypotheses: more frequent technoference predicting higher ratings of child behavior problems (H1), higher ratings of child behavior problems predicting higher parenting stress (H2), and higher parenting stress predicting more frequent technoference (H3), the authors wrote.

H1 and H2 were supported in the externalizing behavior model but only partially supported in the internalizing model, with technoference predicting greater externalizing behavior at all subsequent time points (betas = 0.11, 0.16, and 0.13, P values less than .01), and child externalizing predicting greater parenting stress (betas = 0.16, 0.15, and 0.12, P values less than .01). H3 was partially supported in the externalizing and internalizing behavior models, with parenting stress predicting later technoference from baseline to month 1 (betas = 0.19 and 0.15, P values less than .01) and from month 1 to month 3 (betas= 0.17 and 0.19, P values less than .001), the authors reported.

The findings suggest that “relationships between parent technoference and child externalizing behavior are transactional and influence each other over time,” Dr. McDaniel and Dr. Radesky said.

“In other words, parents who have children with more externalizing problems become more stressed, which may lead to greater technoference (e.g., withdrawal with technology), which in turn may contribute to more child externalizing problems (and only sometimes internalized problems),” they added.

“Our results suggest that children may be more likely to act out over time in response to technoference as opposed to internalize, although when we examined internalizing subscales, child withdrawal was the most consistently associated with parent technoference over time. This may be due to (1) parents responding to child withdrawal social cues by feeling they too can disengage into their mobile device use, or (2) parent media use precipitating child withdrawal from social interaction,” the authors wrote.

The main limitation of this study was the self-reporting used by parents, which may be more subject to bias compared with observational methods, they added.

“It would be worthwhile to study whether experimental manipulation of parent mobile phone use habits – for example through unplugged family routines or less intrusive digital design – might lead to improvements in the parent-child relationship and child behavior,” Dr. McDaniel and Dr. Radesky concluded.

The study was funded by the College of Health and Human Development, Department of Human Development and Family Studies, and the Bennett Pierce Prevention Research Center at Pennsylvania State University, National Institute on Drug Abuse, and the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Dr. McDaniel and Dr. Radesky had no relevant financial disclosures.

SOURCE: McDaniel B et al. Pediatr Res. 2018. doi: 10.1038/s41390-018-0052-6.