SARS-CoV-2 pandemic effect on pediatric asthma health care utilization in an urban hospital.

Background: The "September epidemic" is a well-described phenomenon of increased pediatric asthma-related health care utilization from August to September each year. The coronavirus disease 2019 (COVID-19) pandemic has brought about significant changes in health care utilization, warranting an investigation into its impact on the September epidemic. Objective: Our aim was to identify the impact of COVID-19 in asthma-related health care utilization, specifically in the September epidemic. Methods: Our study involved a retrospective analysis of data from a Children's Hospital in New York City. We compared the change in asthma-related health care utilization during August and September 2020 with the average change in utilization during the same period in 2017-2019 and 2021-2022. Stratified analyses based on age and sex were conducted by using chi-square tests to determine variations in health care utilization. Results: During September 2020, there was a marked reduction in emergency department (ED) visits related to asthma, with only a 6% rise from the preceding month. This stands in contrast to the observed increases from 89% to 193% in the other years studied (P < .05 for all). This pattern was seen in both sexes and in children under 13 years old (P < .05). No significant variation was found for those older than 13 years (P > .05). Conclusions: Despite an overall reduction in health care utilization over the first year of the COVID-19 pandemic, the decline in ED visits related to asthma during the September epidemic was significantly more pronounced. These results suggest that there may be remediable risk factors contributing to the September epidemic that can be used to guide future interventions for managing pediatric asthma.

Pediatric Faculty Engagement and Associated Areas of Worklife After a COVID19 Surge.

Purpose: Healthcare organizations strive to increase physician engagement and decrease attrition. However, little is known about which specific worklife areas may be targeted to improve physician engagement or retention, especially after stressful events such as a COVID19 surge. Our objective was to identify demographic characteristics and worklife areas most associated with increased physician engagement and decreased intent to leave in pediatric faculty. Patients and Methods: In September 2020, we conducted a cross-sectional survey of faculty at an academic, tertiary-care children's hospital. A convenience and voluntary sampling approach was used. The survey included demographics, Maslach Burnout Index-Human Services Survey (MBI-HSS) and the Areas of Worklife Survey (AWS). The MBI-HSS was used to measure faculty engagement. The AWS measures satisfaction with six worklife areas (workload, control, reward, fairness, community, values). We used bivariate analyses to examine relationships between worklife areas and engagement and between worklife areas and intent to leave. We included multivariate logistic regression models to examine worklife areas most associated with increased work engagement and decreased intent to leave. Results: Our response rate was 41% (113/274 participants). In bivariate analysis, engaged faculty reported higher satisfaction in all worklife areas. In multivariate analyses, positive perceptions of workload (odds ratio (OR) 2.83; 95% confidence interval (CI), 1.2-6.9), control (OR, 3.24; 95% CI 1.4-7.3), and community (OR, 6.07; 95% CI 1.9-18.7) were associated with engagement. Positive perceptions of values (OR, 0.07; 95% CI 0.02-0.32) and community (OR, 0.19; 95% CI 0.05-0.78) were negatively associated with intent to leave. Conclusion: We found that positive perceptions of workload, control, and community were most associated with engagement. Alignment of values and increased sense of community were associated with decreased intent to leave. Our findings suggest specific worklife areas may be targeted to increase faculty engagement and retention.

Screening for Hypertensive Disorders of Pregnancy: US Preventive Services Task Force Final Recommendation Statement.

Importance: Hypertensive disorders of pregnancy are among the leading causes of maternal morbidity and mortality in the US. The rate of hypertensive disorders of pregnancy has been increasing from approximately 500 cases per 10 000 deliveries in 1993 to 1021 cases per 10 000 deliveries in 2016 to 2017. Objective: The US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of screening for hypertensive disorders of pregnancy. Population: Pregnant persons without a known diagnosis of a hypertensive disorder of pregnancy or chronic hypertension. Evidence Assessment: The USPSTF concludes with moderate certainty that screening for hypertensive disorders in pregnancy with blood pressure measurements has substantial net benefit. Recommendation: The USPSTF recommends screening for hypertensive disorders in pregnant persons with blood pressure measurements throughout pregnancy. (B recommendation).

Effectiveness of a School Drinking Water Promotion and Access Program for Overweight Prevention.

BACKGROUND AND OBJECTIVE: Drinking water promotion and access shows promise for preventing weight gain. This study evaluated the impact of Water First, a school-based water promotion and access intervention on changes in overweight. METHODS: Low-income, ethnically diverse elementary schools in California's Bay Area were cluster-randomized to intervention and control groups. Water First includes classroom lessons, water stations, and schoolwide water promotion over 1 school year. The primary outcome was overweight prevalence (BMI-for-age-and-sex ≥85th percentile). Students (n = 1249) in 56 fourth-grade classes in 18 schools (9 intervention, 9 control) from 2016 to 2019 participated in evaluation at baseline, 7, and 15 months. Data collection was interrupted in 8 additional recruited schools because of coronavirus disease 2019. RESULTS: Of 1262 students from 18 schools, 1249 (47.4% girls; mean [SD] age, 9.6 [0.4] years; 63.4% Hispanic) were recruited. From baseline to 7 months, there was no significant difference in changes in overweight prevalence in intervention schools (-0.2%) compared to control schools (-0.4%) (adjusted ratio of odds ratios [ORs]: 0.7 [confidence interval (CI): 0.2-2.9] P = 0.68). From baseline to 15-months, increases in overweight prevalence were significantly greater in control schools (3.7%) compared to intervention schools (0.5%). At 15 months, intervention students had a significantly lower change in overweight prevalence (adjusted ratio of ORs: 0.1 [CI: 0.03-0.7] P = .017) compared to control students. There were no intervention effects for obesity prevalence. CONCLUSIONS: Water First prevented increases in the prevalence of overweight, but not obesity, in elementary school students.

Characterization of Birth Hospitalizations in the United States.

OBJECTIVES: A broad understanding of the scope of birth hospitalizations in the United States is lacking. We aimed to describe the demographics and location of birth hospitalizations in the United States and rank the most common and costly conditions documented during birth hospitalizations. METHODS: We conducted a cross-sectional analysis of the 2019 Kids' Inpatient Database, a nationally-representative administrative database of pediatric discharges. All hospitalizations with the indicator "in-hospital birth" and any categorized by the Pediatric Clinical Classification System as "liveborn" were included. Discharge-level survey weights were used to generate nationally-representative estimates. Primary and secondary conditions coded during birth hospitalizations were categorized using the Pediatric Clinical Classification System, rank-ordered by total prevalence and total marginal costs (calculated using design-adjusted lognormal regression). RESULTS: In 2019, there were an estimated 5 299 557 pediatric hospitalizations in the US and 67% (n = 3 551 253) were for births, totaling $18.1 billion in cost. Most occurred in private, nonprofit hospitals (n = 2 646 685; 74.5%). Prevalent conditions associated with birth admissions included specified conditions originating in the perinatal period (eg, pregnancy complications, complex births) (n = 1 021 099; 28.8%), neonatal hyperbilirubinemia (n = 540 112; 15.2%), screening or risk for infectious disease (n = 417 421; 11.8%), and preterm newborn (n = 314 288; 8.9%). Conditions with the highest total marginal costs included specified conditions originating in perinatal period ($168.7 million) and neonatal jaundice with preterm delivery ($136.1 million). CONCLUSIONS: Our study details common and costly areas of focus for future quality improvement and research efforts to improve care during term and preterm infant birth hospitalizations. These include hyperbilirubinemia, infectious disease screening, and perinatal complications.

Postpartum Family Planning in Pediatrics: A Survey of Parental Contraceptive Needs and Health Services Preferences.

OBJECTIVE: Infant well-child visits are increasingly being explored as opportunities to address parental postpartum health needs, including those related to reproductive health. To inform potential pediatric clinic-based interventions, this study assessed postpartum contraceptive needs and health services preferences. METHODS: We surveyed postpartum individuals attending 2 to 6-month well-child visits at three Northern California pediatric clinics (2019-20). We examined unmet contraceptive needs; the acceptability of contraceptive education, counseling, and provision at well-child visits; and sociodemographic and clinical correlates. We conducted univariate and multivariable regression modeling to assess associations between sociodemographic and clinical variables, the status of contraceptive needs, and acceptability measures. RESULTS: Study participants (n = 263) were diverse in terms of race and ethnicity (13% Asian, 9% Black, 37% Latinx, 12% Multi-racial or Other, 29% White), and socioeconomic status. Overall, 25% had unmet contraceptive needs. Unmet need was more common among participants who had delivered more recently, were multiparous, or reported ≥ 1 barrier to obtaining contraception; postpartum visit attendance, education, race, and ethnicity were not associated with unmet need. Most participants deemed the following acceptable in the pediatric clinic: receiving contraceptive information (85%), discussing contraception (86%), and obtaining a contraceptive method (81%). Acceptability of these services was greater among participants with unmet contraceptive needs, better self-rated health, and private insurance (all P < .05). CONCLUSIONS: A quarter of participants had unmet contraceptive needs beyond the early postpartum period. Most considered the pediatric clinic an acceptable place to address contraception, suggesting the pediatric clinic may be a suitable setting for interventions aiming to prevent undesired pregnancies and their sequelae.

Effect of Early Infant Lactobacillus rhamnosus GG Supplementation in Preventing Viral Respiratory Illness.

The role of early probiotic supplementation in infants for the prevention of respiratory viral illnesses is unclear. We examined the association of Lactobacillus rhamnosus GG (LGG) supplementation during the first 6 months of life with the frequency and severity of viral illnesses during the first 24 months of life. We conducted a secondary analysis of data from the randomized controlled Trial of Infant Probiotic Supplementation (n = 184). Parents reported the number of respiratory viral illnesses, and a composite severity score was created based on symptoms. A negative binomial regression model and a mixed-effects linear regression model assessed for differences in the number of episodes and severity of episodes between treatment groups, respectively. There was no significant difference in the incidence rate of viral illness episodes or symptom severity between treatment groups. Daily supplementation with LGG in early infancy does not decrease the number or severity of viral illnesses during the first 2 years of life.

Current Use of Probiotics and Prebiotics in Allergy.

The microbiome plays an important role in the pathogenesis of allergic diseases. This review updates the reader on studies aimed at influencing allergic diseases through modulation of the gut microflora. A nonsystematic review of the literature was performed, focusing on relevant trials evaluating the effect of probiotics/prebiotics/symbiotics in the prevention and treatment of allergic disease. For each allergic disease, we were able to find not only a substantial number of clinical trials but also systematic reviews. Specific guidelines, based on systematic reviews and meta-analyses, are available for the prevention of allergic disease and for the treatment of food allergy. In each of the areas examined-allergic rhinitis, allergic asthma, atopic dermatitis, food allergy, and gastrointestinal allergies-there are substantial uncertainties in the efficacy of gut microflora modulation in prevention and treatment. At present, practicing clinicians can avail themselves of intestinal flora modulators as an adjunct in the prevention of atopic dermatitis but not of other forms of allergic diseases. Their effects on the treatment of allergic diseases remain controversial.

Follow-Up After Asthma Emergency Department Visits and Its Relationship With Subsequent Asthma-Related Utilization.

OBJECTIVE: To assess the association between follow-up after an asthma-related emergency department (ED) visit and the likelihood of subsequent asthma-related ED utilization. METHODS: Using data from California Medicaid (2014-2016), and Vermont (2014-2016) and Massachusetts (2013-2015) all-payer claims databases, we identified asthma-related ED visits for patients ages 3 to 21. Follow-up was defined as a visit within 14 days with a primary care provider or an asthma specialist. OUTCOME: asthma-related ED revisit after the initial ED visit. Models included logistic regression to assess the relationship between 14-day follow-up and the outcome at 60 and 365 days, and mixed-effects negative binomial regression to assess the relationship between 14-day follow-up and repeated outcome events (# ED revisits/100 child-years). All models accounted for zip-code level clustering. RESULTS: There were 90,267 ED visits, of which 22.6% had 14-day follow-up. Patients with follow-up were younger and more likely to have commercial insurance, complex chronic conditions, and evidence of prior asthma. 14-day follow-up was associated with decreased subsequent asthma-related ED revisits at 60 days (5.7% versus 6.4%, P < .001) and at 365 days (25.0% versus 28.3%, P < 0.001). Similarly, 14-day follow-up was associated with a decrease in the rate of repeated subsequent ED revisits (66.7 versus 77.3 revisits/100 child-years; P < 0.001). CONCLUSIONS: We found a protective association between outpatient 14-day follow-up and asthma-related ED revisits. This may reflect improved asthma control as providers follow the NHLBI guideline stepwise approach. Our findings highlight an opportunity for improvement, with only 22.6% of those with asthma-related ED visits having 14-day follow-up.

Collaboration and Shared Decision-Making Between Patients and Clinicians in Preventive Health Care Decisions and US Preventive Services Task Force Recommendations.

The US Preventive Services Task Force (USPSTF) works to improve the health of people nationwide by making evidence-based recommendations for preventive services. Patient-centered care is a core value in US health care. Shared decision-making (SDM), in which patients and clinicians make health decisions together, ensures patients' rights to be informed and involved in preventive care decisions and that these decisions are patient-centered. SDM has a role across the spectrum of USPSTF recommendations. For A or B recommendations (judged by the USPSTF to have high or moderate certainty of a moderate or substantial net benefit at the population level), SDM allows individual patients to decide whether to accept such services based on their personal values and preferences. For C recommendations (indicating at least moderate certainty of a small net benefit at the population level), SDM is critical for individual patients to decide whether the net benefit for them is worthwhile. For D recommendations (reflecting at least moderate certainty of a zero or negative net benefit) or I statements (low certainty of net benefit), clinicians should be prepared to discuss these services if patients ask. More evidence is needed to determine if, in addition to promoting patient-centeredness, SDM reduces inequities in preventive care, as well as to define new strategies to find time for discussion of preventive services in primary care.

SARS-CoV-2 Gastrointestinal Shedding in Hospitalized Children.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a respiratory virus that can cause gastrointestinal (GI) symptoms, with studies demonstrating detection of stool viral RNA weeks after respiratory tract clearance. It is unknown if children who test negative for SARS-CoV-2 on a nasopharyngeal (NP) swab may be shedding the virus in their stool. OBJECTIVE: To measure the prevalence of SARS-CoV-2 stool shedding in children with positive and negative SARS-CoV-2 NP polymerase chain reactions (PCR) tests, and to determine clinical factors associated with GI shedding. METHODS: In this cross-sectional study, we enrolled hospitalized patients 0 to 21 years old with a positive or a negative SARS-CoV-2 NP PCR test who had respiratory and/or GI symptoms. Participants were surveyed, and stool samples were sent for viral PCR testing. Fisher's exact test was used to evaluate bivariate associations of stool PCR test positivity with categorical variables. RESULTS: Sixty-seven patients were consented; 34 patients did not provide stool samples so 33 patients were included: 17 NP-positive and 16 NP-negative for SARS-CoV-2. Eight of the 17 NP-positive patients had a positive stool PCR test for SARS-CoV-2, while none of the 16 SARS-CoV-2 NP-negative patients had a positive result (P < .01). For the 17 SARS-CoV-2 NP-positive patients, GI symptoms were associated with a positive stool PCR test (P = .05) for SARS-CoV-2, but this association was not found for all 33 patients (P = .11). No associations were found with patients in an immunocompromised state or those with a comorbid condition, fever and/or chills, respiratory symptoms, headache and/or myalgias, or anosmia and/or ageusia. CONCLUSIONS: SARS-CoV-2 GI shedding is common and associated with GI symptoms in NP-positive children, with 47% having positive stool PCRs for SARS-CoV-2. GI shedding was not demonstrated in SARS-CoV-2 NP-negative children.

Factors Associated With Hospitalization in Children and Adolescents With SARS-CoV-2 Infection.

In this retrospective study of 319 children with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, we assessed whether age, asthma, obesity, diabetes, and socioeconomic status were associated with hospitalization for coronavirus disease 2019 (COVID-19). Demographic and clinical characteristics were assessed using univariate statistics, excluding incidental or unrelated positives. There was a bimodal distribution of age among hospitalized children. Obesity (P < .001) and a past medical history of diabetes (P = .001) were significantly more prevalent in hospitalized children, including cases of new-onset diabetes and diabetic ketoacidosis. Neither a past medical history of asthma nor lower socioeconomic status was associated with hospitalization. Although limited to a single center, the findings in this study may have important clinical implications. Targeted, proactive health outreach to children with obesity and diabetes, with prioritization of preventative efforts such as vaccination, may be important in preventing worse SARS-CoV-2 infection in this vulnerable group.