Availability and utilization of endoscopic retrograde cholangiopancreatography at children's hospitals.

OBJECTIVES: No study has explored whether availability of endoscopic retrograde cholangiopancreatography (ERCP) is adequate and equitable across US children's hospitals. We hypothesized that ERCP availability and utilization differs by geography and patient factors. METHODS: Healthcare encounter data from 2009 to 2019 on children with pancreatic and biliary diseases from the Pediatric Health Information System were analyzed. ERCP availability was defined as treatment at a hospital that performed pediatric ERCP during the year of service. RESULTS: From 2009 to 2019, 37,946 children (88,420 encounters) had a potential pancreatic or biliary indication for ERCP; 7066 ERCPs were performed. The commonest pancreatic diagnoses leading to ERCP were chronic (47.2%) and acute pancreatitis (43.2%); biliary diagnoses were calculus (68.3%) and obstruction (14.8%). No ERCP was available for 25.0% of pancreatic encounters and 8.1% of biliary encounters. In multivariable analysis, children with public insurance, rural residence, or of Black race were less likely to have pancreatic ERCP availability; those with rural residence or Asian race were less likely to have biliary ERCP availability. Black children or those with public insurance were less likely to undergo pancreatic ERCP where available. Among encounters for calculus or obstruction, those of Black race or admitted to hospitals in the West were less likely to undergo ERCP when available. CONCLUSIONS: One-in-four children with pancreatic disorders and one-in-12 with biliary disorders may have limited access to ERCP. We identified racial and geographic disparities in availability and utilization of ERCP. Further studies are needed to understand these differences to ensure equitable care.

Funding Sources and Perceived Financial Insecurity in Pediatric Subspecialty Fellowship Programs.

OBJECTIVE: Shortages of pediatric subspecialists exist in many fields with insufficient recruitment of new fellows. The current system of funding graduate medical education is inadequate. We examined funding sources for trainee salary and educational expenses in pediatric fellowship programs, effects of funding constraints, and program characteristics associated with financial insecurity as reported by fellowship program directors (FPD). METHODS: We conducted a national survey of FPD between November 1, 2016 and February 9, 2017. We used multivariable logistic regression to examine the association between perceived financial insecurity, program characteristics, and funding sources for fellow salary. RESULTS: We obtained data from 519 FPD, representing 14 different pediatric subspecialties. FPD reported that funding limitations restricted program size and educational resources in 22% and 36% of programs, respectively. Nineteen percent of FPD perceived funding of their program to be insecure. Programs with 7 or more fellows (OR .50 [95% CI .27-.90], P = .03) or hospital or graduate medical education/Children's Hospital graduate medical education funding (OR .58 [95% CI .35-.96], P = .04) were less likely to be perceived as insecure. Conversely, programs with extramural (OR 1.74 [95% CI 1.07-2.81], P = .03) or division funding (OR 1.70 [95% CI 1.02-2.82], P = .04) or in subspecialties with more than 25% unfilled positions or programs (OR 1.86 [95% CI 1.11-3.09], P = .02) were more likely to be perceived as insecure. CONCLUSIONS: Perceived financial insecurity of fellowship programs was strongly associated with program size, funding source, and unfilled positions, limiting recruitment and resources. Stable funding of fellowship programs is critical to maintain an adequate pediatric subspecialty workforce.

Risk Factors Associated With Pediatric Acute Recurrent and Chronic Pancreatitis: Lessons From INSPPIRE.

IMPORTANCE: Pediatric acute recurrent pancreatitis (ARP) and chronic pancreatitis (CP) are poorly understood. OBJECTIVE: To characterize and identify risk factors associated with ARP and CP in childhood. DESIGN, SETTING, AND PARTICIPANTS: A multinational cross-sectional study of children with ARP or CP at the time of enrollment to the INSPPIRE (International Study Group of Pediatric Pancreatitis: In Search for a Cure) study at participant institutions of the INSPPIRE Consortium. From August 22, 2012, to February 8, 2015, 155 children with ARP and 146 with CP (aged ≤19 years) were enrolled. Their demographic and clinical information was entered into the REDCap (Research Electronic Data Capture) database at the 15 centers. Differences were analyzed using 2-sample t test or Wilcoxon rank sum test for continuous variables and Pearson χ2 test or Fisher exact test for categorical variables. Disease burden variables (pain variables, hospital/emergency department visits, missed school days) were compared using Wilcoxon rank sum test. MAIN OUTCOMES AND MEASURES: Demographic characteristics, risk factors, abdominal pain, and disease burden. RESULTS: A total of 301 children were enrolled (mean [SD] age, 11.9 [4.5] years; 172 [57%] female); 155 had ARP and 146 had CP. The majority of children with CP (123 of 146 [84%]) reported prior recurrent episodes of acute pancreatitis. Sex distribution was similar between the groups (57% female in both). Hispanic children were less likely to have CP than ARP (17% vs 28%, respectively; odds ratio [OR] = 0.51; 95% CI, 0.29-0.92; P = .02). At least 1 gene mutation in pancreatitis-related genes was found in 48% of patients with ARP vs 73% of patients with CP (P < .001). Children with PRSS1 or SPINK1 mutations were more likely to present with CP compared with ARP (PRSS1: OR = 4.20; 95% CI, 2.14-8.22; P < .001; and SPINK1: OR = 2.30; 95% CI, 1.03-5.13; P = .04). Obstructive risk factors did not differ between children with ARP or CP (33% in both the ARP and CP groups), but toxic/metabolic risk factors were more common in children with ARP (21% overall; 26% in the ARP group and 15% in the CP group; OR = 0.55; 95% CI, 0.31-0.99; P = .046). Pancreatitis-related abdominal pain was a major symptom in 81% of children with ARP or CP within the last year. The disease burden was greater in the CP group compared with the ARP group (more emergency department visits, hospitalizations, and medical, endoscopic, and surgical interventions). CONCLUSIONS AND RELEVANCE: Genetic mutations are common in both ARP and CP. Ethnicity and mutations in PRSS1 or SPINK1 may influence the development of CP. The high disease burden in pediatric CP underscores the importance of identifying predisposing factors for progression of ARP to CP in children.

Direct Costs of Acute Recurrent and Chronic Pancreatitis in Children in the INSPPIRE Registry.

OBJECTIVE: To estimate selected direct medical care costs of children with chronic pancreatitis (CP) and acute recurrent pancreatitis (ARP). METHODS: We performed a cross-sectional study of data from International Study Group of Pediatric Pancreatitis: In Search for a Cure (INSPPIRE), a multinational registry of children with ARP or CP. We determined health care utilization and estimated costs of hospitalizations, surgical and endoscopic procedures, and medications in our study population. Health care utilization data were obtained from all subjects enrolled in the study, and costs were calculated using national United States costs. RESULTS: We included 224 subjects (median age 12.7 years), 42% of whom had CP. Mean number of hospitalizations, including for surgery and endoscopic retrograde cholangiopancreatography, was 2.3 per person per year, costing an estimated average $38,755 per person per year. Including outpatient medications, estimated total mean cost was $40,589 per person per year. Subjects using surgical procedures or endoscopic retrograde cholangiopancreatography incurred mean annual costs of $42,951 per person and $12,035 per person, respectively. Estimated annual costs of pancreatic enzyme replacement therapy, diabetic medications, and pain medications were $4114, $1761, and $614 per person, respectively. In an exploratory analysis, patients with the following characteristics appear to accrue higher costs than those without them: more frequent ARP attacks per year, reported constant or episodic pain, family history of pancreatic cancer, and use of pain medication. CONCLUSIONS: ARP and CP are uncommon childhood conditions. The severe burden of disease associated with these conditions and their chronicity results in high health care utilization and costs. Interventions that reduce the need for hospitalization could lower costs for these children and their families.

Nonanesthesia magnetic resonance enterography in young children: feasibility, technique, and performance.

OBJECTIVES: The aim of the present study was to demonstrate the effectiveness and cost savings of a nonanesthesia approach to magnetic resonance enterography (MRE) in 14 young pediatric patients (age 4-7 years) with clinically suspected early-onset inflammatory bowel disease using an MRE protocol. METHODS: MRE was performed using a combination of an abbreviated imaging protocol, magnetic resonance imaging video goggles, and Child Life Services support. MRE results were correlated with both colonoscopy and pathology results using Pearson correlation coefficient. Sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS: MRE was performed successfully in 13 of 14 patients (age range 4 years 0 months to 7 years 6 months). MRE findings matched with results in 12 of 13 patients in whom colonoscopy was successfully performed. Both MRE and colonoscopy demonstrated a high specificity (100%) and a positive predictive value (100%), but a low sensitivity (43%) and a negative predictive value (50%). CONCLUSIONS: MRE can be successfully performed in children ages 4 to 7 years using this approach. In addition to decreased risks to the child, the lack of anesthesia also offers a potential overall cost reduction.

No Association between Obesity and Behavior in Low-income, Preschool Latino Children.

BACKGROUND: The relationship between behavioral problems and obesity in early childhood in Latinos is largely unknown. METHODS: Cross-sectional anthropometric and behavioral data of children at three years of age were gathered from a cohort of 174 children of Latina mothers at two San Francisco hospitals. Child behaviors were assessed using the preschool Child Behavior Checklist (CBCL/1½-5). Logistic regression was used to analyze the association between behavior and obesity. RESULTS: At three years, 27.7% were obese. There were no associations between affective (OR = 1.89; 95% confidence interval [CI] 0.42-8.59), anxiety (OR = 1.86; 95% CI 0.53-6.47), pervasive developmental (OR = 0.42; 95% CI 0.13-1.36), attention deficit hyperactivity (OR = 0.58; 95% CI 0.12-2.76), or oppositional defiant (OR = 6.49; 95% CI 0.65-64.49) problems and obesity. CONCLUSIONS: Though psychological problems and obesity are associated among older children and adolescents, there was no association in Latino three-year olds in a low-income sample.

Shooting a moving target: use of real-time cine magnetic resonance imaging in assessment of the small bowel.

The chronic nature of inflammatory bowel disease (IBD) creates a lifelong effect on the morbidity of children affected by the disease. The ability to confidently identify and characterize complications resulting from IBD in the pediatric patient is of critical importance. Magnetic resonance enterography (MRE) is especially valuable in the diagnostic assessment of IBD; however, precise elucidation of complications including strictures can be difficult with standard MRE sequences. The recent development of faster MRI pulse sequences provides rapid, real-time imaging of the intestinal tract. In this review, we describe how the addition of cine MRE confidently pinpoints areas of stricture, aids in lesion detection and diagnosis, and provides valuable information on intestinal motility.

Use of food labels, awareness of nutritional programmes and participation in the special supplemental program for Women, Infants and Children (WIC): results from the National Health and Nutrition Examination Survey (2005-2006).

Use of nutritional labels in choosing food is associated with healthier eating habits including lower fat intake. Current public health efforts are focusing on the revamping of nutritional labels to make them easier to read and use for the consumer. The study aims to assess the frequency of use of nutritional labels and awareness of the United States Department of Agriculture (USDA) nutritional programmes by low-income women including those participating in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) as surveyed in the National Health and Nutrition Examination Survey 2005-2006. Many low-income women do not regularly use the nutrition facts panel information on the food label and less than half had heard of the USDA Dietary Guidelines for Americans (38.9%). In multivariate logistic regression, we found that WIC participation was associated with reduced use of the nutrition facts panel in choosing food products [odds ratio (OR) 0.45, 95% confidence interval (CI) 0.22-0.91], the health claims information (OR 0.54, 95% CI 0.32-0.28) and the information on carbohydrates when deciding to buy a product (OR 0.44, 95% CI 0.20-0.97) in comparison with WIC eligible non-participants. Any intervention to improve use of nutritional labels and knowledge of the USDA's nutritional programmes needs to target low-income women, including WIC participants. Future studies should evaluate possible reasons for the low use of nutrition labels among WIC participants in comparison with eligible non-participants.

The Active Balance Childhood program for improving coping and quality of life in Chinese American children.

BACKGROUND: Interventions to teach children healthy and effective coping skills could help reduce their risk of becoming overweight. However, few studies have examined whether an intervention that teaches coping strategies in weight management can influence children's coping behavior and psychosocial well-being. OBJECTIVE: The purpose of this study was to examine the efficacy of an interactive, a child-centered, and a family-based program in promoting effective coping, behavioral health, and quality of life in Chinese American children. METHODS: This study used a randomized controlled study of behavioral intervention in 67 Chinese American children (ages 8-10 years, normal weight and overweight) and their families. At baseline and 2, 6, and 8 months after baseline, children had anthropometric measurements and completed questionnaires related to coping skills and quality of life, and parents completed the Child Behavior Checklist. RESULTS: Children in the intervention group reported using more active coping strategies and having a higher quality of life in the physical and emotional health domains than did children in the control group during the 8-month study. Children's behavioral problems did not differ between the intervention and the control groups. Changes in coping and psychosocial well-being were not related to change in body mass index in the entire group, except increased body mass index is associated with decreased emotional quality of life. DISCUSSION: This culturally appropriate behavioral intervention was effective in promoting healthy coping and in improving quality of life in Chinese American children. Its utility for both optimal weight and overweight children suggests potential application of the intervention in a broad range of populations.

Early exclusive breastfeeding and maternal attitudes towards infant feeding in a population of new mothers in San Francisco, California.

BACKGROUND: Positive parental attitudes towards infant feeding are an important component in child nutritional health. Previous studies have found that participants in the Special Supplemental Women, Infants, and Children (WIC) Program have lower breastfeeding rates and attitudes that do not contribute towards healthy infant feeding in spite of breastfeeding and nutrition education programs targeting WIC participants. The objective of this study was to assess the frequency of exclusive breastfeeding in the early postpartum period and maternal attitudes towards breastfeeding in a population of mothers at two San Francisco hospitals and in relation to WIC participation status. METHODS: We interviewed women who had recently delivered a healthy newborn using a structured interview. RESULTS: A high percentage (79.8%) of our sample was exclusively breastfeeding at 1-4 days postpartum. We did not find any significant differences in rates of formula or mixed feeding by WIC participant status. Independent risk factors for mixed or formula feeding at 1-3 days postpartum included Asian/Pacific Islander ethnicity (odds ratio [OR] 2.90, 95% confidence interval [CI] 1.17-7.19). Being a college graduate was associated with a decreased risk of formula/mixed feeding (OR 0.28, 95% CI 0.10-0.79). We also found that thinking breastfeeding was physically painful and uncomfortable was independently associated with not breastfeeding (OR 1.41, 95% CI 1.06-1.89). CONCLUSIONS: Future studies should be conducted with Asian-Americans and Pacific Islanders to better understand the lower rates of exclusive breastfeeding in this population and should address negative attitudes towards breastfeeding such as the idea that breastfeeding is painful or uncomfortable.

Efficacy of a child-centred and family-based program in promoting healthy weight and healthy behaviors in Chinese American children: a randomized controlled study.

OBJECTIVE: To examine the efficacy of an interactive, child-centred and family-based program in promoting healthy weight and healthy lifestyles in Chinese American children. DESIGN: A randomized controlled study of a culturally sensitive behavioral intervention. SUBJECTS: Sixty-seven Chinese American children (ages, 8-10 years; normal weight and overweight) and their families. MEASUREMENTS: Anthropometry, blood pressure, measures of dietary intake, physical activity, knowledge and self-efficacy regarding physical activity and diet at baseline and 2, 6 and 8 months after baseline assessment. RESULTS: Linear mixed modeling indicated a significant effect of the intervention in decreasing body mass index, diastolic blood pressure and fat intake while increasing vegetable and fruit intake, actual physical activity and knowledge about physical activity. CONCLUSION: This interactive child-centred and family-based behavioral program appears feasible and effective, leading to reduced body mass index and improved overweight-related health behaviors in Chinese American children. This type of program can be adapted for other minority ethnic groups who are at high risk for overweight and obesity and have limited access to programs that promote healthy lifestyles.

Maternal knowledge of infant feeding guidelines and label reading behaviours in a population of new mothers in San Francisco, California.

The objective of this study was to evaluate the relationship between maternal nutrition knowledge and maternal socio-demographics including participation in the Special Supplemental Women, Infants and Children's (WIC) Program. A cross-sectional study of new mothers at two San Francisco hospitals was conducted using some of the American Academy of Pediatrics' guidelines in a structured questionnaire to assess maternal nutritional knowledge. Maternal nutritional attitudes towards product nutrient labels were also assessed in a questionnaire format. Logistic regression models were used to evaluate the odds of having high maternal nutrition knowledge and of infrequently reading nutrition labels. In multivariate logistic regression models, higher maternal nutrition knowledge (defined as answering all four nutrition questions correctly) was associated with higher income levels defined as > or =$25 000/year, odds ratio (OR) 10.03 95% confidence interval (CI) (1.51-66.74), and in linear models, higher nutritional knowledge was associated with having more children (P < 0.01), a higher income (P = 0.01) and not being a WIC participant (P < 0.01). Mothers with higher incomes were also more likely to read product nutritional labels OR 4.24, 95% CI (1.24-14.51), compared with mothers with lower incomes as were mothers with higher education levels OR 3.32, 95% CI (1.28-8.63). In San Francisco, lower income mothers are at greatest risk for low maternal nutrition knowledge and not reading product nutritional labels. Higher household income was independently associated with increased maternal nutrition knowledge and likelihood of reading nutritional labels. More comprehensive interventions need to target low-income mothers including current WIC participants to help close the nutritional advantages gap conferred by income and education.

Pilot study of an individually tailored educational program by mail to promote healthy weight in Chinese American children.

PURPOSE: To test the feasibility and impact of an individually tailored educational intervention to promote healthy weight in Chinese American children (ages 8-10). DESIGN: A pre- and post-test study (N = 57) using standardized instruments to measure children's usual food choices, knowledge of nutrition and physical activity needs, and time spent engaging in physical and sedentary activities. RESULTS: We found improvement after the intervention in all three areas. PRACTICE IMPLICATIONS: Healthcare providers need to provide parents and children with specific recommendations regarding children's weight statuses, dietary intake, and levels of activity.

The economic burden of home care for children with HIV and other chronic illnesses.

OBJECTIVES: We compared types, amounts, and costs of home care for children with HIV and chronic illnesses, controlling for the basic care needs of healthy children to determine the economic burden of caring for and home care of chronically ill children. METHODS: Caregivers of 97 HIV-positive children, 101 children with a chronic illness, and 102 healthy children were surveyed regarding amounts of paid and unpaid care provided. Caregiving value was determined according to national hourly earnings and a market replacement method. RESULTS: Chronically ill children required significantly more care time than HIV-positive children (7.8 vs 3.9 hours per day). Paid care accounted for 8% to 16% of care time. Annual costs were $9300 per HIV-positive child and $25,900 per chronically ill child. Estimated national annual costs are $86.5 million for HIV-positive children and $155 to $279 billion for chronically ill children. CONCLUSIONS: Informal caregiving represents a substantial economic value to society. The total care burden among chronically ill children is higher than that among children with HIV.

Economic and psychologic costs for maternal caregivers of gastrostomy-dependent children.

OBJECTIVE: To examine the economic and psychologic costs of care provided by maternal caregivers to children with gastrostomy tube (GT) feedings. STUDY DESIGN: We conducted a 3-site study of primary maternal caregivers of 101 chronically ill children, with (n = 50) and without (n = 51) enteral nutrition support by GT to determine the time spent providing technical care, nontechnical care, and health care management and to assess depressive mood and quality of life. Associated costs were determined. RESULTS: Caregivers spent 339.7 +/- 34.1 (SEM) min/d to provide all care. Children with a GT required more than twice as much care time as children without a GT: 484.5 +/- 54.6 versus 197.8 +/- 30.6 min/d ( P < .0001). The mean annual total value of home care by the primary caregiver for a child with a GT was 37,232 dollars, compared with 15,004 dollars for the child without a GT. Caregivers of children with GT were no more depressed or less satisfied with their lives than caregivers of children without GT. CONCLUSIONS: Use of a GT for enteral nutrition support is associated with significant increased care time by the primary caregiver but not at additional psychologic cost compared with caring for chronically ill children.

Pathophysiologic basis for growth failure in children with ichthyosis: an evaluation of cutaneous ultrastructure, epidermal permeability barrier function, and energy expenditure.

OBJECTIVE: Because an impaired epidermal permeability barrier is present in many of the ichthyoses, we examined the contribution of barrier failure to caloric requirements in children with ichthyosis and growth failure. STUDY DESIGN: Transepidermal water loss (TEWL) and ultrastructural parameters of the permeability barrier were evaluated in 10 hospitalized children with ichthyosis and growth failure. Nutritional intake, resting energy expenditure, and calories lost as heat of evaporation were determined. RESULTS: Mean basal TEWL rates were markedly elevated in all study patients in comparison to the expected upper limit of normal (39.6+/-20.6 vs 8.7 mL/m(2) per hour). The severity of abnormalities in the ultrastructure of permeability barrier-related structures, assessed semiquantitatively, correlated significantly to mean basal TEWL rates (P <.001). Total body daily TEWL was elevated (746 +/- 468 vs 209 mL/d), resulting in a caloric drain of 433 +/- 272 kcal/d (21 +/- 9.8 kcal/kg per day) through heat of evaporation. Nutrient intake exceeded requirements in all, but resting energy expenditure exceeded predicted in 5 of 6 patients and correlated significantly with mean basal TEWL rates (P <.005). CONCLUSIONS: A defective permeability barrier in children with ichthyosis can result in ample chronic losses of water and calories to impair growth.