Pediatrics

Planetary Pediatrics: The Next Generation Publication date: Available online 27 April 2019 Source: Academic Pediatrics Author(s): Susan Bennett

Planetary Pediatrics Publication date: Available online 26 April 2019 Source: Academic Pediatrics Author(s): Jeffrey Goldhagen

The challenge of child management during dental care: use of non-pharmacological approaches Publication date: Available online 26 April 2019 Source: Academic Pediatrics Author(s): Marília Leão Goettems, Francine dos Santos Costa, Vanessa Polina Pereira da Costa

Food Insecurity Associated with Underestimation of Weight Status in Children with a Healthy Weight Status Publication date: Available online 25 April 2019 Source: Academic Pediatrics Author(s): Jaclyn M. Dovico, Rebecca J. Palmer, Eliana M. Perrin, Callie L. Brown ABSTRACT Objective Accurate parental weight perception of one's child is an important step in addressing healthy behaviors, but its associations with socioeconomic status (SES) and household food insecurity (HFI) are unclear. We aimed to assess the association of parental weight perception with HFI. Methods This was a secondary data analysis of a cross-sectional study of 284 children ages 2-8 whose parents completed surveys about weight perception, SES, and HFI. Height/weight were measured for child BMI and self-reported in parents. We performed chi-square tests to compare HFI and accuracy of parental weight perception and used logistic regression to assess accuracy, adjusting for significant covariates and stratifying by child weight category. Results Approximately two-thirds of children had healthy weight, 18% had overweight, and 15% had obesity. About one-third of parents inaccurately identified their child's weight category, almost always underestimating weight status. Twenty-eight percent of families were food insecure. HFI was not associated with parental weight perception in bivariate analysis. When stratified by weight status, food insecure families with a child at healthy weight had 0.16 times the odds of accurately perceiving their child's weight status. There was no association between HFI and accuracy of weight perception in children with overweight or obesity. Conclusion Food insecurity was associated with a decrease in accuracy of parental weight perceptions in children with healthy weight. Pediatricians should clearly communicate about weight status, as families with HFI may adopt unhealthy eating behaviors under the incorrect assumption that their child is underweight.

Teaching Students How to Improve Safety and Quality in Two Children's Hospitals: Building a Pediatric Clerkship Patient Safety and Quality Experience Publication date: Available online 25 April 2019 Source: Academic Pediatrics Author(s): Frank J. Genuardi, Maria N. Kelly, Eric I. Rosenberg, Erik W. Black, Kara Dawson

Let them speak for themselves: Improving adolescent self-report rate on pre-visit screening Publication date: Available online 25 April 2019 Source: Academic Pediatrics Author(s): Randall W. Grout, Erika R. Cheng, Matthew C. Aalsma, Stephen M. Downs Abstract Background Adolescent pre-visit screening on patient-generated health data is a common and efficient practice to guide clinical decision making. However, proxy informants (e.g., parents or caregivers) often complete these forms, which may lead to incorrect information or lack of confidentiality. Our objective was to improve the adolescent self-report rate on pre-visit screening. Methods We conducted an interventional study using an interrupted time-series design to compare adolescent self-report rates (percent of adolescents ages 12-18 years completing their own pre-visit screening) over 16 months in general pediatric ambulatory clinics. We collected data using a computerized clinical decision support system with waiting room electronic tablet screening. Pre-intervention rates were low, and we created and implemented two electronic workflow alerts, one each to the patient/caregiver and clinical staff, reminding them that the adolescent should answer the questions independently. We included the first encounter from each adolescent and evaluated changes in adolescent self-reporting between pre- and post-intervention periods using interrupted time series analysis. Results Patients or caregivers completed 2,670 qualifying pre-visit screenings across 19 pre-intervention, 7 intervention, and 44 post-intervention weeks. Self-reporting by younger adolescents nearly doubled with a significant increase of 19.3 percentage points (CI 9.1-29.5) from the baseline 20.5%. Among older adolescents, the stable baseline rate of 53.6% increased by 9.2 absolute percentage points (CI -7.0-25.3). There were no significant pre- or post-intervention secular trends. Conclusions Two automated alerts directing clinic personnel and families to have adolescents self-report significantly and sustainably improved younger adolescent self-reporting on electronic patient-generated health data instruments.

Family-Centered Care Across the Border: A Postmortem Reflection Publication date: Available online 25 April 2019 Source: Academic Pediatrics Author(s): Zachary Foughty, Allison Silverstein

A Learning Loop Model of Collaborative Decision Making in Chronic Illness Publication date: Available online 19 April 2019 Source: Academic Pediatrics Author(s): Sarah D. Ronis, Lawrence C. Kleinman, Kurt C. Stange Abstract Shared decision-making is a core attribute of quality healthcare that has proved challenging to implement and assess in pediatric practice. Current models of shared decision-making are limited, including their capacity: to incorporate multiple stakeholders; to integrate downstream effects of subacute or minor decisions; and to account for the context(s) in which such decisions are being made and enacted. Based on a review of literature from organizational psychology, cognitive sciences, business, and medicine, we propose an iterative decision-making model of care planning, and identify targets at several levels of influence warranting measurement in future studies. Our Learning Loop Model posits the relationship between pediatric patients, their parents, and their clinicians as central to the collaborative decision making process in the setting of chronic illness. The model incorporates the evolution of both context and developmental capacity over time. It suggests that "meta-learning" from the experience of and outcomes from iterative decision-is a key factor that may influence relationships and thus continued engagement in collaboration by patients, their parents, and their clinicians. We consider the model in light of the needs of children with special healthcare needs, for whom understanding the ongoing iterative effects of decision making and clinician-parent-child dynamics are likely to be particularly important in influencing outcomes.

Characteristics of High Performing Primary Care Pediatric Practices: A Qualitative Study Publication date: Available online 18 April 2019 Source: Academic Pediatrics Author(s): Sarah L. Goff, Kathleen M. Mazor, Aruna Priya, Penelope S. Pekow, Peter K. Lindenauer Abstract Objective Performance on pediatric quality measures varies across primary care practices. Healthcare quality is associated with organizational factors, but their effect is understudied in pediatric care. This study aimed to develop hypotheses regarding the relationship between organizational factors and composite scores on pediatric quality measures. Methods Using a positive deviance approach, semi-structured interviews were conducted with pediatricians and staff (n=35) at 10 purposively selected high-performing pediatric primary care practices in Massachusetts between September and December 2016. Practices were sampled to achieve diversity in geographic location, size, and organizational structure. Interviews aimed to identify organizational strategies (e.g., care processes) and contextual factors (e.g., teamwork) that may be associated with performance on quality measures. Interviews were audiotaped, transcribed, and analyzed using qualitative content analytic methods. Results We identified four major themes (MT): MT1) Practice Culture; MT2) Practice Structures and Quality Improvement Tools; MT3) Attitudes and Beliefs Related to Measuring Care Quality; and MT4) Perceived Barriers to Achieving High Performance on Quality Measures. MT1 sub-themes included contextual factors such as teamwork, leadership, and feeling respected as an employee; MT2 subthemes included fixed characteristics such as practice size and strategies such as use of an electronic medical record; MT3 and MT4 subthemes linked these constructs to factors external to the practices. Conclusions This study suggested that elements of organizational culture may play as important a role in the quality of care delivered as specific quality improvement strategies. Interventions to further test this relationship may aid practices seeking to improve the care they deliver.

The relationship between housing instability and poor diet quality among urban families Publication date: Available online 13 April 2019 Source: Academic Pediatrics Author(s): Clement J. Bottino, Eric W. Fleegler, Joanne E. Cox, Erinn T. Rhodes ABSTRACT OBJECTIVE To examine associations between housing instability and poor diet quality in a sample of urban parents and children. METHODS Cross-sectional study of 340 parent/guardian-child dyads visiting a pediatric primary care center in Boston, Massachusetts. The parent/guardian (hereafter, parent) completed two Harvard Service Food Frequency Questionnaires, one regarding their own dietary intake and one regarding their child's intake, and an assessment of health-related social needs. Diet quality was measured using the Healthy Eating Index-2010 (HEI-2010; score range 0–100). Housing instability was defined as: (1) homeless or in sheltered housing, (2) doubled up with another family, (3) utilities threatened or shut off, or (4) concerned about eviction. Multivariable logistic regression was used to measure associations between unstable housing and lowest-quartile HEI-2010 scores, adjusting for parent age, race/ethnicity, education, income, and child age. RESULTS Median (interquartile range) parent and child HEI-2010 scores were 63.8 (56.3–70.8) and 59.0 (54.2–64.7), respectively. Housing instability was found in 136 dyads (40%). In multivariable analysis, it was associated with increased odds of lowest-quartile total parent HEI-2010 scores (aOR 1.9 [95% CI 1.1–3.5]) but not child scores (aOR 1.4 [95% CI 0.8–2.5]). It was also associated with increased odds of lowest-quartile parent HEI-2010 dietary component scores for Total vegetables and Greens and beans (aOR 2.0 [95% CI 1.1–3.7] and aOR 2.5 [95% CI 1.3–4.8], respectively). CONCLUSIONS In this urban primary care population, housing instability is associated with lower diet quality scores for parents but not children. Lower vegetable consumption appears to drive this association.

Alexandros Sfakianakis
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