The Longitudinal Relation between Infant Feeding Styles and Growth Trajectories among Families from Low-Income Households.

BACKGROUND: Parental feeding styles, including the emotional environment parents create to modify a child's eating behaviors, have been associated with measures of adiposity in cross-sectional studies. The longitudinal relation between parental feeding styles in early infancy and adiposity in later infancy/toddlerhood are scant and have shown mixed results, particularly in families from low-income households. OBJECTIVES: This study examined the relation between parental feeding styles and infant BMI z-score trajectories between 6 and 18 mo in families from low-income households. METHODS: Parent-infant dyads were recruited during the infant's 6-, 9-, or 12-mo well-child visit. Feeding styles were assessed using the Infant Feeding Style Questionnaire (IFSQ). Infant anthropometrics from birth through 18 mo were extracted from the electronic medical record. BMI z-score slopes were estimated for each infant between 0-6 mo and 6-18 mo. Associations between feeding styles and BMI z-score slopes were examined using mixed models controlling for demographic, clinical, and feeding covariates. RESULTS: The final analytic sample included 198 dyads (69% Black; median infant age: 9.0 mo; IQR: 6.8-10.3 mo). The predominant parent feeding styles included the following: laissez-faire (30%), restrictive (28%), responsive (23%), and pressuring (19%). In adjusted models, the predominant feeding style at enrollment was associated with the BMI z-score slope between 6 and 18 mo, with the responsive feeding style exhibiting a steeper increase in BMI z-score than other feeding styles. Infant feeding style was not associated with BMI z-score slope between birth and 6 mo of age. Infants of parents who exhibited restrictive feeding styles were more likely to have a BMI ≥85th percentile at their last measurement. CONCLUSIONS: The predominant parent feeding style during infancy in a low-income population was associated with infant BMI z-score between 6 and 18 mo of age, but not earlier. Further studies are needed to better understand how predictive factors collectively contribute to BMI increase in the first 2 y.

Encouraging Parental Reading for High-Risk Neonatal Intensive Care Unit Infants.

OBJECTIVE: To assess whether a citywide structured book-sharing program (NICU Bookworms) designed to promote reading to infants while admitted in the neonatal intensive care unit (NICU) would increase parental reading behaviors (≥3-4 days/week) in the NICU and after discharge home, including high-risk parents who do not themselves enjoy reading. STUDY DESIGN: The NICU Bookworms program comprised staff training, parent education, and building a literacy-rich environment. In this quasi-experimental intervention study, parents of medically high-risk NICU graduates <6 months of age were administered a questionnaire at their first NICU follow-up clinic visit. The survey incorporated questions from the StimQ-I READ subscale to assess home reading environment and shared reading practices. RESULTS: A total of 317 infants were enrolled, 187 in an unexposed comparison group and 130 in the intervention group. Parents exposed to Bookworms were significantly more likely to read ≥3-4 days per week while in the NICU (34.5% vs 51.5%; P = .002; aOR, 2.2; 95% CI, 1.2-4.0), but reading at home did not differ (67.9% vs 73.1%; P = .28; aOR, 0.99; 95% CI, 0.5-1.8). However, among parents who did not themselves enjoy reading, frequency was significantly higher both in the NICU (18.4% vs 46.1%; P = .009; aOR, 5.0; 95% CI, 1.2-21.5) and at home (36.9% vs 70%; P = .003; aOR, 3.7; 95% CI, 1.1-12.9). A qualitative thematic analysis found that Bookworms decreased parental stress, enhanced bonding, and supported positive parent-infant interactions. CONCLUSIONS: A book-sharing intervention in the NICU increased parent-reported reading aloud during hospitalization and among parents disinclined to read for pleasure, both in the NICU and following discharge. This change may have been mediated by enhancement of parent-infant interactions.

Reading in children with drug-resistant epilepsy was related to functional connectivity in cognitive control regions.

AIM: This study aimed to define whether individuals with drug-resistant focal epilepsy also used regions related to cognitive control to facilitate reading. METHODS: We focused on patients with drug-resistant focal epilepsy in 2011-2014, who were aged 8-20 years and were being treated at the Cincinnati Children's Hospital, USA. They performed a verb generation functional magnetic resonance imaging task known to involve language and cognitive control, as well as a formal reading assessment. The reading scores were correlated with functional connectivity of the anterior cingulate cortex (ACC) using seed-to-voxel analysis. RESULTS: There were 81 potential patients and 13 (seven females) met the inclusion criteria. Their age at seizure onset was 0-13 years, and they had a mean age of 12.66 ± 3.17 years at the time of the study. Individuals with epilepsy demonstrated average intelligence and word reading ability. Their reading scores were positively correlated with functional connectivity between the ACC and regions related to emotional processing (right amygdala), learning and language processing (left cerebellum) and visual processing. CONCLUSION: Our results support the role that the ACC plays in proficient reading among children with drug-resistant epilepsy, even in those with epileptogenic foci in areas related to language.

A Combined Reach Out and Read and Imagination Library Program on Kindergarten Readiness.

OBJECTIVES: Sharing books with preschoolers is known to improve kindergarten readiness. Both Reach Out and Read (ROR) and Dolly Parton's Imagination Library (DPIL) have shown positive effects on book sharing at home. We developed a novel combined ROR/DPIL program and examined the effect on kindergarten readiness assessment (KRA) scores. METHODS: At urban ROR primary care sites, patients <5 years living in the city school district were enrolled from July 2015 through January 2019 in the ROR/DPIL program when seen for a clinic visit. The literacy subtest of the KRA was examined for participants entering kindergarten in the fall of 2016, 2017, and 2018. The "on-track" rate of participants was compared with nonparticipant groups. RESULTS: A total of 797 kindergarten-aged ROR/DPIL participants were matched to Ohio KRA scores for 2016, 2017, and 2018 school years. The percentages of students "on-track" on KRA literacy subtests increased significantly by cohort (2016, 42.9% [95% confidence interval (CI): 34.9%-50.9%] versus 2017, 50.9% [95% CI: 44.9%-56.9%] versus 2018, 58.3% [95% CI: 53.3%-63.3%], P = .004). ROR/DPIL participants were compared with a proportionate stratified random sample of 1580 non-ROR/DPIL peers. On-track in literacy did not significantly differ between groups (2016 [P = .262], 2017 [P = .653], 2018 [P = .656]), nor did they differ after restricting analysis to economically disadvantaged children (2016 [P = .191], 2017 [P = .721], 2018 [P = .191]). CONCLUSIONS: With these results, we suggest that a program combining literacy anticipatory guidance at clinic visits and more books in the home can potentially improve kindergarten readiness. Pediatric health care providers can play an important role in promoting kindergarten readiness through literacy promotion.

Pediatric education in office settings.

Pediatric training in community office-based settings has been demonstrated to be an effective means of providing "real-world" experiences to students and residents. Although it is often challenging with regards to addressing logistic and conceptual issues, such training provides important practical experiences that may prove critical to the future practice of not only primary care pediatrics but also pediatric subspecialty care. It also may be the key to enhancing the interaction between the two.

The impact of the electronic health record on an academic pediatric primary care center.

Many hospitals and practices are transitioning to electronic health records (EHR), but there is little information on the impact on patient care in a busy pediatric academic setting. The objective of this study was to determine the impacts of EHR on documentation, clinical processes, billing, ancillary staff responsibilities, scheduling, and cycle time. A descriptive study to assess the impact of EHR implementation and subsequent use on documentation, clinical processes, and patient access and flow was performed in a large urban academic pediatric primary care health center. Six months and 2 years after implementation, EHR impact on documentation was collected and compared with baseline value by measuring the percentage of charts with problem lists present. Several clinical improvement processes were collected at baseline and 6 months later including medication refill turnaround time, percentage of charts without attending signature at 3 days, and type of appointment billed on ill visits. The volume of appointments and cycle time were measured at regular intervals from baseline to 2 years after implementation. The percentage of paper charts attempted to be pulled for patient visits was obtained at baseline and 1 year later. Of the 500 charts audited before implementation, and 25 charts audited 6 months and 2 years after the implementation, the percentage of the presence of problem lists improved from 29% to 84%. Medication refill turnaround time improved from an average of 48 hours to 12 hours. Charts with incomplete documentation at 3 days postvisit decreased from 3% to 1.6%. Visit coding for detailed level visits (99214) increased by 13% and for problem-focused visits (99212) decreased by 7%, resulting in increased revenue collected. Medical records support staff needs decreased from 1 full-time equivalent to 0.5 full-time equivalent. One year after the EHR implementation, the medical records staff pulled and refiled 5.2% of paper charts compared with 100% at baseline. Despite plans to return to full volume of scheduling patients by 4 weeks postimplementation, volume continued to be reduced by 10% for 3 additional months because of user inefficiency and high number of new learners/users. Patient cycle time was increased from 76 minutes preimplementation to 119 minutes immediately postimplementation and decreased to 85 to 90 minutes 2 years later. EHR can be successfully implemented in a large urban academic pediatric healthcare center. EHR implementation improved documentation of patient care, improved clinical processes, and resulted in increased revenue. However, the implementation of the EHR also led to short-term decreased appointment availability and a persistent longer cycle time. Ongoing information system training support is a key for maintaining efficiency due to the large number of new learners.

Parental intuitive eating behaviors and their association with infant feeding styles among low-income families.

INTRODUCTION: Feeding styles, the attitudes and behaviors parents use to direct their child's eating, shape a child's ability to self-regulate food intake and affects their future risk of obesity. This study examined how parental intuitive eating, where parents follow their own hunger and satiety cues, relates to infant feeding styles in a low-income, predominately Black population. METHODS: Parents of healthy infants aged 5.5-12.5 months were recruited during well-child visits at two urban primary care clinics. Parent's intuitive eating behaviors and infant feeding styles were measured using the Intuitive Eating Scale-2 (IES-2) and the Infant Feeding Style Questionnaire (IFSQ), respectively. Multivariable regression analysis, controlling for maternal and child demographic variables, was conducted to determine the relationship between parent intuitive eating behaviors and five infant feeding styles: restrictive, pressuring, indulgent, laissez-faire, and responsive. RESULTS: 201 parents completed the study, 90% were mothers and 69% were Black. Average infant age was 8.8 ±â€¯2.0 months. Parents who reported relying on their own hunger and satiety cues when eating were more likely to feed their infant in a responsive style (ß 0.10 ±â€¯0.04, p < 0.05). Parents who reported eating unconditionally, not labeling foods as forbidden, were more likely to feed their infant in a laissez-faire (ß 0.16 ±â€¯0.06, p < 0.05) and indulgent (ß 0.09 ±â€¯0.03, p < 0.05) feeding style. CONCLUSIONS: Parental intuitive eating behaviors are associated with both responsive and non-responsive infant feeding styles. Future studies should examine how parental intuitive eating and infant feeding styles affect infant growth trajectories.

Effect of multisource feedback on resident communication skills and professionalism: a randomized controlled trial.

OBJECTIVE: To determine whether augmenting standard feedback on resident performance with a multisource feedback intervention improved pediatric resident communication skills and professionalism. DESIGN: Randomized controlled trial. SETTING: Children's Hospital Medical Center, Cincinnati, Ohio, from June 21, 2004, to July 7, 2005. PARTICIPANTS: Thirty-six first-year pediatric residents. INTERVENTIONS: Residents assigned to the multisource feedback group (n = 18) completed a self-assessment, received a feedback report about baseline parent and nurse evaluations, and participated in a tailored coaching session in addition to receiving standard feedback. Residents in the control group (n = 18) received standard feedback only. The control group and their residency directors were blinded to parent and nurse evaluations until the end of the study. MAIN OUTCOME MEASURES: Residents' specific communication skills and professional behaviors were rated by parents and nurses of pediatric patients. Both groups were evaluated at baseline and after 5 months. Scores were calculated on each item as percentage in the highest response category. RESULTS: Both groups had comparable baseline characteristics and ratings. Parent ratings increased for both groups. While parent ratings increased more for the multisource feedback group, differences between groups were not statistically significant. In contrast, nurse ratings increased for the multisource feedback group and decreased for the control group. The difference in change between groups was statistically significant for communicating effectively with the patient and family (35%; 95% confidence interval, 11.0%-58.0%), timeliness of completing tasks (30%; 95% confidence interval, 7.9%-53.0%), and demonstrating responsibility and accountability (26%; 95% confidence interval, 2.9%-49.0%). CONCLUSION: A multisource feedback intervention positively affected communication skills and professional behavior among pediatric residents.

Strengthening the academic base of general pediatrics fellowship programs: a national program and curriculum development project.

OBJECTIVE: To improve academic general pediatrics (AGP) fellowship programs by 1) developing curriculum guidelines and program standards and 2) creating a process for program review and consultation that might later be used for accreditation of AGP fellowship programs. METHODS: This project of the Ambulatory Pediatric Association (APA) created 4 documents: AGP fellowship program requirements, core curriculum, educational goals and objectives, and a standardized form to describe required program characteristics. Site visits were conducted at 7 volunteer AGP fellowship programs, selected for diversity of content, structure, and location. Evaluations were conducted using a uniform checklist of requirements that combined numerical ratings with a written evaluation summary. Feedback from programs on the review process enabled refinement of the documents. RESULTS: The site visits revealed great variety in emphasis among the 7 programs. In general, faculty were dedicated and capable, and programs showed considerable educational strengths. Typical problems were lack of integration of the program within departmental structures, overburdened faculty, and uncertain funding. Many programs demonstrated suboptimal curriculum planning and weak evaluation methods. Most program leaders felt that the project materials helped to improve the quality of their programs, and 5 of 7 programs expressed willingness to be involved in formal accreditation review in the future. CONCLUSIONS: AGP fellowship programs that volunteered for piloting of an accreditation process were diverse and vital, with rich educational offerings despite a lack of optimal curriculum structure, minimal evaluation, limited faculty resources, and tenuous funding. An APA accreditation process appears to be feasible and may enhance AGP fellowship programs.

Academic general pediatric fellowships: curriculum design and educational goals and objectives.

Academic generalists are unique and important members of the pediatric landscape.(1) Academic general pediatrics (AGP) is not considered a subspecialty, because it adheres to generalist values and embraces a wide range of clinical activities. Nonetheless, academic generalists engage in important scholarly efforts, contribute extensively to the education of new pediatricians, and must be prepared to survive in academia. Academic general pediatric faculty positions are subject to the same appointment and promotion requirements as those of subspecialist faculty.

Securing a faculty position: a practical guide for residents, fellows, junior faculty, and their mentors.

Applying for a faculty position can appear to be a daunting project for many residents, fellows, and junior faculty due, in large part, to the lack of readily available information on the process of interviewing and negotiating for faculty appointment in academic medicine. Although this process may seem mystifying to first-time applicants, it has a structure. This article discusses the framework of the application process and recommends an action plan from initial contact to acceptance of an offer. Each step of the process is discussed. Guidelines are provided to assist applicants and their mentors to successfully manage these important steps.

A Pilot Study of the Creation and Implementation of a Teaching Development Assessment Tool.

BACKGROUND: The importance of effective clinical teaching skills is well established in the literature. However, reliable tools with validity evidence that are able to measure the development of these skills and can effectively be used by nonphysician raters do not exist. OBJECTIVE: Our initiative had 2 aims: (1) to develop a teaching development assessment tool (TDAT) that allows skill assessment along a continuum, and (2) to determine if trained nonphysicians can assess clinical teachers with this tool. METHODS: We describe the development of the TDAT, including identification of 6 global teaching domains and observable teaching behaviors along a 3-level continuum (novice/beginner, competent/proficient, expert) and an iterative revision process involving local and national content experts. The TDAT was studied with attending physicians during inpatient rounds with trained physician and nonphysician observers over 6 months. RESULTS: The TDAT showed emerging evidence of content, construct, and viable validity (the degree to which an assessment tool is practical, affordable, suitable, evaluable, and helpful in the real world) for the evaluation of attending physicians on inpatient rounds. Moderate to near perfect interrater reliability was seen between physician and nonphysician raters for the domains of promotion of clinical reasoning, control of the learning environment, ability to teach to multiple levels of learners, and provision of feedback. CONCLUSIONS: The TDAT holds potential as a valid and reliable assessment tool for clinical teachers to track the development of each individual's teaching skills along the continuum from early development to mastery.

Resident preparedness for practice: a longitudinal cohort study.

OBJECTIVE: To determine whether the perception of preparedness for practice changes over time. DESIGN: Questionnaire survey of University of Massachusetts residents 5 years after an initial survey. Responses to individual questions in the 2 surveys were compared for each graduate and the Wilcoxon rank sum test applied. A supplementary questionnaire addressed current confidence in areas with relatively low scores in both surveys. RESULTS: All 24 eligible graduates responded. The high rating of overall sense of preparedness was identical in the 2 surveys. Differences were statistically significant in only 3 categories: common illnesses, office gastroenterology, and office gynecology-all from a lower estimate of preparedness initially to a higher estimate in retrospect. Six areas continued to receive relatively low scores: nutrition, patient scheduling, cost-effectiveness, telephone management, office gynecology, and office orthopedics. Respondents feel more confident currently with nutrition, patient scheduling, and telephone management but not with cost-effectiveness, gynecology, or orthopedics. CONCLUSIONS: Residents paired with office-based practitioners for their continuity experience report feeling well prepared for practice both on practice entry and 5 to 9 years later. In the 6 areas of relatively low preparedness, experience improved confidence with nutrition, patient scheduling, and telephone management, but not cost-effectiveness, gynecology, or orthopedics. The hypothesis that clinical areas of relative weakness at the end of residency may remain so years later deserves to be tested.

Urban elementary school personnel's perceptions of student health and student health needs.

OBJECTIVE: To determine the perceptions of school personnel with regard to urban students' health and health needs as part of a planning process for development and implementation of school-linked health services. METHODS: A self-administered, close-ended questionnaire was given to 294 schoolteachers and school staff to assess school personnel perceptions of 1) health needs of students, 2) priority of need for health services or programs delivered on-site or off-site, and 3) selected factors suspected to affect implementation of new school health services. RESULTS: A total of 72% of teachers and 77% of staff completed the survey. The most highly ranked need by school personnel was mental health, followed by violence and anger management and physical abuse and domestic violence. The most commonly requested services on-site and off-site were for physical abuse or domestic violence, mental health, and drug or other substance abuse. Only 40% of teachers and staff rated current health services as excellent or good. A total of 72% of teachers and staff had some level of discomfort with their current responsibilities regarding the health of students. Parental involvement was reported to be quite low, with only 9% of teachers and staff rating it as excellent or good. CONCLUSIONS: he greatest health care need identified by these elementary school personnel was not for management of chronic or acute physical health conditions, but for mental health services and programs to meet the emotional and psychosocial needs of students. When implementing school-linked or school-based mental health services, focus needs to be placed on 3 areas: 1) education of school health and educational personnel regarding common mental health issues, 2) development of systems that improve knowledge of and connection with mental health resources inside and outside the school, and 3) development of systems that improve communication within the school and between the school and parents regarding health services.

When and how pediatric history and physical diagnosis are taught in medical school: a survey of pediatric clerkship directors.

BACKGROUND: [corrected] History and physical diagnosis skills (HPDS) are required curriculum in medical schools (MS) with pediatric HPDS (PHPDS) necessitating instruction in addition to adult HPDS. Perceived deficiencies in these skills on the pediatric clerkship prompted investigation of when and how other MS taught PHPDS. The concern of whether medical students are adequately taught PHPDS needed to be addressed. METHODS: With the use of the Council on Medical Student Education in Pediatrics listserv, pediatric clerkship directors from 129 US, 15 Canadian, and 2 Puerto Rican MS were contacted via e-mail to complete an anonymous online questionnaire, focused on MS demographics, PHPDS timing, teaching methods, and barriers. RESULTS: Seventy-two (49%) of 146 MS responded to the survey; 18.1% of MS responders did not offer PHPDS in the first 2 years. Methodologies used to educate students included didactic lectures, physician shadowing, hands-on with patients, pairing with preceptor, instructional video, and examination of newborns. Each teaching method had < 3 hours dedicated to medical students during their first 2 years at a majority of the MS. Of the responders, 85.1% concurred that medical students should be exposed to PHPDS before starting the clerkship. Barriers to providing PHPDS included MS time allotment, preceptor availability, and total number of students to accommodate. CONCLUSIONS: This study demonstrated striking variability among MS in how and when medical students were taught PHPDS. Clarification of the role of PHPDS instruction in preclinical years and standardized effective approaches to PHPDS instruction are both needed so that MS curriculum optimizes physician training.

USPSTF perspective on evidence-based preventive recommendations for children.

The development and use of evidence-based recommendations for preventive care by primary care providers caring for children is an ongoing challenge. This issue is further complicated by the fact that a higher proportion of recommendations by the US Preventive Services Task Force (USPSTF) for pediatric preventive services in comparison with adult services have insufficient evidence to recommend for or against the service. One important root cause for this problem is the relative lack of high quality screening and counseling studies in pediatric primary care settings. The paucity of studies limits the development of additional evidence-based guidelines to enhance best practices for pediatric and adolescent conditions. In this article, we describe the following: (1) evidence-based primary care preventive services as a strategy for addressing important pediatric morbidities, (2) the process of making evidence-based screening recommendations by the USPSTF, (3) the current library of USPSTF recommendations for children and adolescents, and (4) factors influencing the use of USPSTF recommendations and other evidence-based guidelines by clinicians. Strategies to accelerate the implementation of evidence-based services and areas of need for future research to fill key gaps in evidence-based recommendations and guidelines are highlighted.