Enhancing Safe Sleep Counseling by Pediatricians through a Quality Improvement Learning Collaborative.

BACKGROUND: Approximately, 3,500 infants die annually from sleep-related infant deaths in the United States. We sought to improve pediatricians' counseling on safe sleep from birth through 6 months of age through a virtual quality improvement learning collaborative (QILC). Our aim was appropriate screening, counseling, and documentation of safe sleep advice in 75% of eligible patient encounters after the QILC. METHODS: We formed a 9-month QILC for inpatient and outpatient pediatricians. Pediatricians collected data on safe sleep documentation in a newborn discharge or well-child visit note. Data were submitted at baseline and in 9 subsequent phases. Participants met monthly via a webinar, which included a QI presentation, data review, and facilitated discussion among participants. Practices were contacted 12 months after the conclusion of the QILC to assess sustainment. RESULTS: Thirty-four pediatricians from 4 inpatient and 9 outpatient practices participated in the QILC. At baseline, documentation of safe sleep practices varied greatly (0%-98%). However, by the end of the QILC, all participating practices were documenting safe sleep guidance in over 75% of patient encounters. Aggregate practice data show a significant, sustained improvement. The 12-month follow-up data were submitted from 62% of practices, with sustainment of improvement in 75% of practices. CONCLUSION: A facilitated, virtual QILC is an effective methodology to improve safe sleep counseling among a diverse group of pediatric practices. It is one step in improving consistent messaging around safe sleep by healthcare providers as pediatricians work to decrease sleep-related infant deaths.

Radiologic common data elements rates in pediatric mild traumatic brain injury.

OBJECTIVE: The nosology for classifying structural MRI findings following pediatric mild traumatic brain injury (pmTBI) remains actively debated. Radiologic common data elements (rCDE) were developed to standardize reporting in research settings. However, some rCDE are more specific to trauma (probable rCDE). Other more recently proposed rCDE have multiple etiologies (possible rCDE), and may therefore be more common in all children. Independent cohorts of patients with pmTBI and controls were therefore recruited from multiple sites (New Mexico and Ohio) to test the dual hypothesis of a higher incidence of probable rCDE (pmTBI > controls) vs similar rates of possible rCDE on structural MRI. METHODS: Patients with subacute pmTBI (n = 287), matched healthy controls (HC; n = 106), and orthopedically injured (OI; n = 71) patients underwent imaging approximately 1 week postinjury and were followed for 3-4 months. RESULTS: Probable rCDE were specific to pmTBI, occurring in 4%-5% of each sample, rates consistent with previous large-scale CT studies. In contrast, prevalence rates for incidental findings and possible rCDE were similar across groups (pmTBI vs OI vs HC). The prevalence of possible rCDE was also the only finding that varied as a function of site. Possible rCDE and incidental findings were not associated with postconcussive symptomatology or quality of life 3-4 months postinjury. CONCLUSION: Collectively, current findings question the trauma-related specificity of certain rCDE, as well how these rCDE are radiologically interpreted. Refinement of rCDE in the context of pmTBI may be warranted, especially as diagnostic schema are evolving to stratify patients with structural MRI abnormalities as having a moderate injury.

Quality Improvement Learning Collaborative Improves Timely Newborn Follow-Up Appointments.

BACKGROUND: American Academy of Pediatrics guidelines indicate that newborns should follow up with their primary care providers within three days of discharge from the newborn nursery. Many barriers exist to achieving timely follow-up, with potential implications on a newborn's health. The goal of this project was to improve rates of timely newborn follow-up through a nine-month quality improvement learning collaborative (QILC). Timely newborn follow-up was defined as an appointment scheduled within three days of newborn discharge. METHODS: Both inpatient hospitalist and outpatient pediatric practices were eligible to participate. Inpatient and outpatient practices aimed to have 75% of newborns scheduled appropriately by six months into the project. In addition, outpatient practices aimed to have 60% of newborns seen appropriately by their provider. All practices aimed to have their progress sustained at conclusion of the QILC. Practices submitted data at baseline and nine subsequent phases. Monthly webinars featured a quality improvement didactic, data review, and discussion of practices' changes, successes, and challenges. RESULTS: Eleven practices and 24 physicians participated in the QILC. Aggregate data from the practices showed continual improvement in all measured newborn scheduling metrics throughout the nine-month learning collaborative, with sustainment of progress over the last three months of the QILC. CONCLUSION: A QILC is successful for increasing timely newborn follow-up for both the newborn hospitalist and outpatient pediatrician. Pediatric providers can learn from others' strategies and successes to incorporate meaningful changes in their practice.

Proactive inhibition deficits with normal perfusion after pediatric mild traumatic brain injury.

Although much attention has been generated in popular media regarding the deleterious effects of pediatric mild traumatic brain injury (pmTBI), a paucity of empirical evidence exists regarding the natural course of biological recovery. Fifty pmTBI patients (12-18 years old) were consecutively recruited from Emergency Departments and seen approximately 1 week and 4 months post-injury in this prospective cohort study. Data from 53 sex- and age-matched healthy controls (HC) were also collected. Functional magnetic resonance imaging was obtained during proactive response inhibition and at rest, in conjunction with independent measures of resting cerebral blood flow. High temporal resolution imaging enabled separate modeling of neural responses for preparation and execution of proactive response inhibition. A priori predictions of failed inhibitory responses (i.e., hyperactivation) were observed in motor circuitry (pmTBI>HC) and sensory areas sub-acutely and at 4 months post-injury. Paradoxically, pmTBI demonstrated hypoactivation (HC>pmTBI) during target processing, along with decreased activation within prefrontal cognitive control areas. Functional connectivity within motor circuitry at rest suggested that deficits were limited to engagement during the inhibitory task, whereas normal resting cerebral perfusion ruled out deficits in basal perfusion. In conclusion, current results suggest blood oxygen-level dependent deficits during inhibitory control may exceed commonly held beliefs about physiological recovery following pmTBI, potentially lasting up to 4 months post-injury.

Attention Deficit-Hyperactivity Disorder Group Visits Improve Parental Emotional Health and Perceptions of Child Behavior.

OBJECTIVE: Group visits (GVs) are a promising intervention, but more work is needed to establish intervention effects. The objective was to evaluate the effectiveness of GVs and compare them with individual visits (INDs) for chronic care of attention deficit-hyperactivity disorder (ADHD). METHODS: Caregivers and children (6-12 yrs) with ADHD participated in a comparative effectiveness trial from April 2014 to June 2015. Families were offered ADHD follow-up every 3 months as GVs versus INDs. Outcomes included ADHD core symptoms, child functioning at home, quality of life, perceived social support, and ADHD-related parenting challenges. Change scores from baseline to the study end were examined for parent and child outcomes within and between treatment conditions. RESULTS: Ninety-one children from 84 families participated. Eighteen families withdrew or were lost to follow-up. GV families attended more visits over 12 months, had significant improvement in mean parental emotional health (p = 0.04), and had a greater decrease in challenges related to misbehavior compared with IND families (p < 0.03). GV families experienced significant improvements in child functioning at home (p = 0.01) and reported more time for themselves, other siblings, and routine household activities (p < 0.01). Children receiving care as INDs reported a significant drop in mean emotional health. There were no significant changes in other outcomes. CONCLUSION: Families participating in GVs experienced multiple improvements related to family functioning and attended more follow-up visits. Findings confirm the effectiveness of the GV intervention in delivering critical parenting support as part of ADHD management.

Follow-up of Mothers with Suspected Postpartum Depression from Pediatrics Clinics.

PURPOSE: Pediatric providers are increasingly screening for postpartum depression (PD), yet, it is unknown how often mothers comply with recommendations to seek treatment. The objectives were to describe the rate at which mothers with suspected PD seek treatment and explore factors that predict help-seeking behavior. DESIGN AND METHODS: Mothers were recruited from four pediatric clinics after identification using the Child Health Improvement through Computer Automation (CHICA) system. Mothers with a positive screen were invited to participate in a telephone interview between January 2012 and December 2014. Mothers reported if they sought treatment or called a community resource. RESULTS: 73 of 133 eligible mothers participated (55% response rate). Fifty women recalled a recommendation to seek help. Only 43.8% (32/73) made a follow-up appointment with an adult provider and even fewer kept the appointment. CONCLUSION: A majority of mothers suspected of having PD recalled a referral for further intervention; yet, less than half took action. Further investigation of barriers of help-seeking behavior is warranted.

Group Visits to Improve Pediatric Attention-Deficit Hyperactivity Disorder Chronic Care Management.

OBJECTIVE: Children with attention-deficit hyperactivity disorder (ADHD) may experience continued impairment at home and school even after medication initiation. Group visits offer a way for pediatricians to provide more time to address ongoing needs. A pilot study was undertaken to examine whether a group visit model improved ADHD management in the pediatric medical home. METHODS: Parents and children aged 6 to 18 years with ADHD were recruited and randomized to group visits or a usual care control. Data included attendance at ADHD follow-up visits, parent-rated ADHD symptoms, adaptive functioning, and quality of life. Longitudinal linear mixed models (continuous variables) and generalized linear mixed models (binary outcomes) were used to compare groups. In our statistical models, child and family were random effects; study assignment was a fixed effect. RESULTS: Twenty families representing 29 children participated (intervention: 9 parents/13 children and control: 11 parents/16 children). Aside from race, baseline characteristics of participants were similar. None of the intervention families missed the expected 5 ADHD follow-up visits over 1 year; control families missed 1 or more visits over the same period. Intervention families reported an improved level of adaptive functioning at 12 months compared with control (mean severity score: 3.7 vs 4.4, p = .003). All families reported greater limitations and poorer quality of life compared with national norms. CONCLUSION: Group visits in the pediatric medical home can improve adherence, and preliminary results show a variety of improvements for the family.

Phenotypic differences in individuals with autism spectrum disorder born preterm and at term gestation.

The objective of the study was to characterize the phenotype of males and females with autism spectrum disorder born preterm versus those born at term. Descriptive statistical analyses identified differences between male and female autism spectrum disorder subjects born preterm compared to term for several phenotypic characteristics and comorbidities. Of the 115 (13.0% of 883) born preterm, a greater percentage of males had sleep apnea (13.8% vs. 2.5%, p < 0.0001), seizure disorders (17.0% vs. 8.5%, p = 0.01), and attention-deficit/hyperactivity disorder (14.9% vs. 6.6%, p = 0.005). Females born preterm were more likely to be nonverbal (22.2% vs. 4.6%, p = 0.001). In summary, phenotypic differences were observed, especially among males. The results may have implications for understanding the underpinnings of a subset of individuals with autism spectrum disorder and contribute to the development of focused treatments for autism spectrum disorder among children born preterm.

Body mass index change in autism spectrum disorders: comparison of treatment with risperidone and aripiprazole.

OBJECTIVE: The purpose of this study was to assess change in body mass index (BMI) and age- and gender-adjusted BMI Z-score in subjects ages 2-20 years with autism spectrum disorders (ASD), who were treated longitudinally with risperidone or aripiprazole at a tertiary care ASD clinic. METHOD: As part of a larger project involving longitudinal drug treatment data in ASD, detailed demographic and treatment data were collected for 142 subjects ages 2-20 years who had been started on risperidone or aripiprazole for treatment of irritability. Mean age at start of treatment, treatment duration, final Clinical Global Impressions-Improvement Scale score, BMI change per year of treatment, and BMI Z-score change per year of treatment (primary outcome measure) were calculated for each drug treatment group. Group means were compared using t tests and Wilcoxon rank sum tests. RESULTS: There was a statistically significant BMI and BMI Z-score increase in the risperidone and aripiprazole treatment groups individually. No statistically significant difference between the two treatment groups was noted in mean BMI change per year of treatment or BMI Z-score change per year of treatment. CONCLUSIONS: In our review of long-term naturalistic treatment of irritability using risperidone versus aripiprazole in persons with ASD, a significant increase in both BMI and age- and gender-adjusted BMI Z-score was noted for each treatment group. No significant difference in BMI or BMI Z-score change was noted when the two treatment groups were compared. We conclude that in our patient population at a tertiary care ASD clinic, the effects of risperidone and aripiprazole on body weight gain in naturalistic long-term treatment are no different.