Assessment of post-concussion emotional symptom load using PCSS and PROMIS instruments in pediatric patients.

OBJECTIVES: The purpose of this study is to evaluate the utility of the Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety and depressive symptom domains in conjunction with the Post-Concussion Symptom Scale (PCSS)for identifying pediatric patients with emotional symptoms following a concussion, and to identify predictors of higher emotional symptom loads. METHODS: We recruited English-speaking patients aged 8-17 years presenting to a tertiary-care concussion clinic from 2014 to 2018 (n = 458). Demographics and clinical data including PCSS, injury date, previous history of anxiety/depression, and Vestibular/Ocular-Motor Screen (VOMS) were collected from patients' electronic medical records. Participants completed surveys in the PROMISTM Pediatric Item Bank v1.1-Anxiety and Depressive Symptoms domains at their initial clinic visit. Multivariable linear regression identified predictors of higher emotional symptom loads. RESULTS: Overall, 425 (92.8%) reported ≥1 emotional symptom on either PROMIS or PCSS. Predictors of higher emotional symptom loads were abnormal VOMS, female sex, history of anxiety or depression, and longer time since injury. CONCLUSION: Our results suggest that adding PROMIS anxiety and depressive symptom surveys to pediatric concussion evaluations may identify more children with emotional symptoms, allowing clinicians to better direct post-concussion treatment and incorporate psychological support for patients if necessary. Future studies should examine whether earlier identification of emotional symptoms with these tools facilitates recovery and improves short- and/or long-term psychological outcomes in pediatric concussion.

Paying Family Medical Caregivers for Children's Home Healthcare in Colorado: A Working Medicaid Model.

OBJECTIVE: To compare the characteristics and healthcare use of children with medical complexity who receive paid certified nursing assistant (CNA) care by a family member (family CNA) and by a traditional nonfamily member (nonfamily CNA). STUDY DESIGN: This was retrospective cohort study of children who received CNA care through Colorado's Medicaid paid family caregiving program between 2017 and 2019 by a home healthcare agency. We compared patient characteristics between the family CNA and nonfamily CNA groups. A multivariable Poisson regression model was used to compare hospitalization rates (days in the hospital per year), adjusting for patient age patient sex, nursing care, and complex chronic condition. RESULTS: Of 861 patients, 79% (n = 680) received family CNA care and 21% (n = 181) received nonfamily CNA care. Patient demographics and hospitalization did not differ between the groups, although patients who had family CNAs were less likely to receive additional nursing-level care (42% vs 60%, P < .01). Family and nonfamily CNA caregivers had similar characteristics, except that family CNA caregivers had substantially better 3-year retention (82% vs 9%, P < .01) despite lower average hourly pay ($14.60 vs $17.60 per hour, P < .01). Hospitalizations were rare (<10% of patients). In the adjusted model, patients who received family CNA care experienced 1 more hospitalized day per year, compared with patients who received nonfamily CNA care (P < .001). CONCLUSIONS: Paid family caregivers provided CAN-level care to children with medical complexity with a greater employee retention compared with nonfamily CNA caregivers, with marginally different hospitalization rates using a family-centered approach. This model may help address workforce shortages while also providing income to family caregivers.

Impact of the Affordable Care Act's Medicaid expansion on tertiary pediatric surgical care.

BACKGROUND: Many children gained insurance with the 2014 Affordable Care Act's (ACA) Medicaid Expansion (ME), yet its impact on access to pediatric tertiary surgical care remains unknown. We examined the effect of ME on rates of elective, ambulatory surgery (EAS), especially among publicly-insured and ethnoracial-minority patients. METHODS: Surgical patients ≤18 years between 2012 and 2018 were identified using the Pediatric Health Information System. Interrupted time series analyses were conducted to predict the monthly proportion of publicly-insured patients and EAS rates in ME and nonexpansion states. RESULTS: 3,270,842 patients were included. Nonexpansion states demonstrated a 1.10% (p<0.05) increase in the proportion of publicly-insured patients at ACA implementation, which then plateaued. No immediate change was observed in ME states, but there was an annual 1.08% (p<0.01) decrease in subsequent years. Publicly-insured EAS rates decreased by 1.09% (p<0.01) in nonexpansion states; no change was observed in ME states. A 3.36% (p<0.01) increase in EAS rates was observed in nonexpansion and ME states. The gap in EAS rates increased between private and publicly-insured patients in nonexpansion, but not ME states. CONCLUSIONS: Increased coverage for children in ME states was not associated with more access to tertiary pediatric surgical care; however, while nonexpansion states saw an increase in insurance-based disparities, ME states did not. Though insurance coverage is critical to access, other factors may be contributing to persistent disparities in access to pediatric surgical care.

Children With Special Health Care Needs and Forgone Family Employment.

BACKGROUND: Family income is known to affect child health, but this relationship can be bidirectional. We sought to characterize this relationship by quantifying forgone family employment (FFE) due to a child's health condition in families of children with special health care needs (CSHCN) with updated figures. METHODS: We conducted a secondary data analysis from the 2016-2017 National Survey of Children's Health. CSHCN with previously employed caregivers were included (N = 14 050). FFE was defined as any family member having stopped work and/or reduced hours because of their child's health or health condition. Child, caregiver, and household characteristics were compared by FFE status. Logistic regression analysis was conducted to evaluate the association between hours of medical care provide by a family member and FFE. US Bureau of Labor Statistics reports were used to estimate lost earnings from FFE. RESULTS: FFE occurred in 14.5% (95% confidence interval [CI] 12.9%-16.1%) of previously employed families with CSHCN and was 40.9% (95% CI 27.1%-54.7%) for children with an intellectual disability. We observed disproportionately high FFE among CSHCN who were 0 to 5 years old and of Hispanic ethnicity. We found a strong association between FFE and increasing hours of family-provided medical care, with an adjusted odds ratio (aOR) of 1.72 (95% CI 1.25-2.36) for <1 hour per week (compared with 0 hours), an aOR of 5.96 (95% CI 4.30-8.27) for 1 to 4 hours per week, an aOR of 11.89 (95% CI 6.19-22.81) for 5 to 10 hours per week, and an aOR of 8.89 (95% CI 5.26-15.01) for >10 hours per week. Lost earnings for each household with FFE were estimated at ∼$18 000 per year. CONCLUSIONS: With our findings, we highlight the need to implement programs and policies that address forgone income experienced by families of CSHCN.

Socioeconomic and Familial Factors Associated with Gross Motor Skills among US Children Aged 3-5 Years: The 2012 NHANES National Youth Fitness Survey.

The first aim of this study was to examine the prevalence of below average gross motor skills in a representative sample of US children aged 3 to 5 years. The second aim was to identify socioeconomic and familial characteristics that are associated with below average gross motor skills. Secondary analysis was conducted using the datasets from the 2012 National Health and Examination Survey National Youth Fitness Survey (NNYFS). The NNYFS assessed gross motor skills among 329 children aged 3-5 years, using the Test of Gross Motor Development-Second Edition (TGMD-2). Socioeconomic and familial characteristics of interest, such as family income and family structure, were asked in an in-person interview. This study estimated that one in three US children age 3 to 5 years old (33.9%) scored below average for gross motor quotient. In the gross motor subsets, one in four (24.4%) scored below average for locomotion and two in five (39.9%) scored below average for object control. Children living below the poverty threshold were more likely to have a higher gross motor quotient (odds ratio, OR = 2.76; 95% confidence interval, CI = 1.09-7.00). Girls were more likely to have a higher locomotor score (OR = 2.17; 95% CI = 1.10-4.25). Those living with other child(ren) aged ≤5 years were more likely to have a higher locomotor score (OR = 2.36; 95% CI = 1.01-5.54), while those living with child(ren) aged 6-17 years were more likely to have a higher object control score (OR = 1.83; 95% CI = 1.24-2.69). This study revealed risk factors associated with poor gross motor development, furthering our understanding of gross motor development in early childhood.

Hidden Markov model-based activity recognition for toddlers.

OBJECTIVE: Physical activity has been shown to impact future health outcomes in adults, but little is known about the long-term impact of physical activity in toddlers. Accurately measuring the specific types and amounts of physical activity in toddlers will help us to understand, predict, and better affect their future health outcomes. Although activity recognition has been extensively developed for adults as well as older children, toddlers move in ways that are significantly different from older children, indicating the need for a more tailored approach. APPROACH: In this study, 22 toddlers wore Actigraph waist-worn accelerometers which recorded their movements during guided play. The toddlers were videotaped and their activities were later annotated for the following eight distinct activity classes: lying down, being carried, riding in a stroller, sitting, standing, running/walking, crawling, and climbing up/down. Accelerometer data were extracted in 2 s signal windows and paired with the activities the toddlers were performing during that time interval. MAIN RESULTS: A variety of classifiers were tuned to a validation set. A random forest classifier was found to achieve the highest accuracy of 63.8% in a test set. To improve the accuracy, a hidden Markov model (HMM) was applied by providing the predictions of the static classifiers as observations. The HMM was able to improve the accuracy to 64.8% with all five classifiers increasing the accuracy an average of 1.3% points (95% confidence interval = 0.7-1.9, p  < 0.01). When the three most misclassified activities (sitting, standing, and riding in a stroller) were collapsed together, the accuracy increased to 79.3%. SIGNIFICANCE: Further refinement of the toddler activity recognition classifier will enable more accurate measurements of toddler activity and improve future health outcomes of toddlers.

Parental characteristic patterns associated with maintaining healthy physical activity behavior during childhood and adolescence.

BACKGROUND: Parental characteristics that influence child physical activity (PA) behavior often co-occur. An analytic approach that considers these co-occurring patterns can help researchers better understand the overall context of parental influence. The study aims were to: (1) identify diverse patterns of the relationships among parental characteristics, (2) examine the influence of these parental patterns on child sport participation and moderate-to vigorous-intensity PA (MVPA) trajectories during childhood and adolescence, and (3) examine whether family support mediates the influence of the parental patterns on child sport participation and MVPA trajectories. METHODS: We used data from 408 Iowa Bone Development Study cohort families (97% Caucasians; 65 % mothers with a 4-year college degree). From ages 5 to 19 years, the cohort participated in seven accelerometry assessments, reported sports participation every 6 months, and reported perceived family support for PA at age 15. Parents reported family income, education level, and regular PA participation in high school and adulthood. Structural equation modeling was conducted to identify the latent classes represented among these parental characteristics. Sex-adjusted multivariable logistic regression analyses were conducted to predict sports participation trajectories and MVPA trajectories by latent class and family support. RESULTS: Three parent latent classes were identified: higher family socioeconomic status (SES) and regular PA in both high school and adulthood by both the father and mother (Group 1); lower family SES and regular PA in high school by the father (Group 2); and lower family SES and no regular PA in high school by the father (Group 3). Sex-adjusted ORs of the "drop-out from sports participation" pattern for the children in Groups 1 and 2, compared to Group 3, were 0.38 (95% CI = 0.20, 0.72) and 0.51 (95% CI = 0.26, 1.00), respectively. Sex-adjusted ORs of the "decreasing from moderate MVPA" pattern for the children in Groups 1 and 2, compared to Group 3, were 0.29 (95% CI = 0.11, 0.75) and 1.16 (95% CI = 0.40, 3.37), respectively. Adding family support to the logistic regression model only slightly changed the ORs. CONCLUSIONS: The findings from this study suggest that among lower SES families, the father's role may be important to promote youth to sustain sports participation.

Characteristics of Children Reported to Child Protective Services for Medical Neglect.

OBJECTIVES: Medical neglect can have serious consequences. There is little evidence base to guide medical neglect management and research. Our objective was to describe a group of children reported to child protective services (CPS) for medical neglect to define this population as well as identify prevention and intervention approaches. METHODS: This was a retrospective descriptive study of all patients at a pediatric hospital reported to CPS for medical neglect over a 6-year period. Data about health, health care, CPS involvement, and social history were obtained through medical record review. RESULTS: Of the 154 patients reported for medical neglect, 140 (91%) had chronic illness. The most common diagnoses were type 1 diabetes, organ transplantation, and prematurity-related conditions. Most patients (83%) were black or Hispanic and 90% were publically insured. More than half of patients (54%) had >1 CPS report during the study period. Almost all patients (88%) returned to the hospital for care subsequent to the medical neglect report. Risk factors for child maltreatment, family stressors in the year preceding the report, and practical barriers to care were documented in more than two-thirds of patients. CONCLUSIONS: Overall, children reported for medical neglect have serious chronic medical conditions. There is need and opportunity for improved interventions. Avenues for future study include interventions tailored to the underlying diagnosis, racial/ethnic disparities, effectiveness of CPS interventions, and targeted prevention for at-risk families with medically complex children.

Physical activity of fifth to sixth graders during school hours according to school race/ethnicity: Suburban Cook County, Illinois.

BACKGROUND: We compared moderate-to-vigorous intensity physical activity (MVPA) and inactivity levels among fifth and sixth graders during school hours according to school-level race/ethnicity and income attributes to inform school-based obesity interventions in Illinois Suburban Cook County (SCC). METHODS: Fifth- and sixth-grade students (N = 591) in 14 SCC public schools were asked to wear an accelerometer during school hours for 4 consecutive school days. School-level race/ethnicity was assigned based on the majority (≥ 70%) race/ethnicity of the student population: white (N = 4), black (N = 2), Hispanic (N = 5), or "mixed" (N = 3). All minority schools (N = 7) fell within a low-income category. RESULTS: A total of 538 students (91%) had valid accelerometry data. Average MVPA time during school hours was 20 minutes/day for boys and 11 minutes/day for girls. Multilevel linear regression models showed that compared to peers in white schools, boys, and girls in Hispanic schools engaged in 14 and 10 minutes less MVPA, respectively (p < .01). Girls in black and Hispanic schools had greater inactivity time than girls in white schools (p < .01). CONCLUSIONS: Objectively measured physical activity (PA) data support the need for school-level PA interventions during school hours, particularly in predominantly Hispanic schools.

Initial steps for quality improvement of obesity care across divisions at a tertiary care pediatric hospital.

BACKGROUND: Pediatric subspecialists can participate in the care of obese children. OBJECTIVE: To describe steps to help subspecialty providers initiate quality improvement efforts in obesity care. METHODS: An anonymous patient data download, provider surveys and interviews assessed subspecialty providers' identification and perspectives of childhood obesity and gathered information on perceived roles and care strategies. Participating divisions received summary analyses of quantitative and qualitative data and met with study leaders to develop visions for division/service-specific care improvement. RESULTS: Among 13 divisions/services, subspecialists' perceived role varied by specialty; many expressed the need for cross-collaboration. All survey informants agreed that identification was the first step, and expressed interest in obtaining additional resources to improve care. CONCLUSIONS: Subspecialists were interested in improving the quality and coordination of obesity care for patients across our tertiary care setting. Developing quality improvement projects to achieve greater pediatric obesity care goals starts with engagement of providers toward better identifying and managing childhood obesity.

Tracking of accelerometry-measured physical activity during childhood: ICAD pooled analysis.

BACKGROUND: Understanding of physical activity (PA) tracking during childhood is important to predict PA behaviors and design appropriate interventions. We compared tracking of PA according to PA level and type of day (weekday/weekend) in a pool of five children's cohort studies. METHODS: Data from ALSPAC, CLAN, Iowa Bone Development Study, HEAPS, PEACH were extracted from the International Children's Accelerometry Database (ICAD), resulting in 5,016 participants with age, gender, and accelerometry data at both baseline and follow-up (mean age: 10.3 years at baseline, 12.5 years at follow-up). Daily minutes spent in moderate- and vigorous-intensity PA (MVPA) and vigorous-intensity PA (VPA) was categorized into quintiles. Multinomial logistic regression models were fit to predict follow-up (M)VPA from baseline (M)VPA (reference: 20- < 80%tile), age at follow-up, and follow-up duration. RESULTS: For the weekday, VPA tracking for boys with high baseline VPA was higher than boys with low baseline VPA (ORs: 3.9 [95% CI: 3.1, 5.0] vs. 2.1 [95% CI: 1.6, 2.6]). Among girls, high VPA was less stable when compared low VPA (ORs: 1.8 [95% CI: 1.4, 2.2] vs. 2.6 [95% CI: 2.1, 3.2]). The pattern was similar for MVPA among girls (ORs: 1.6 [95% CI: 1.2, 2.0] vs. 2.8 [95% CI: 2.3, 3.6]). Overall, tracking was lower for the weekend. CONCLUSIONS: PA tracking was higher on the weekday than the weekend, and among inactive girls than active girls. The PA "routine" of weekdays should be used to help children establish healthy PA patterns. Supports for PA increase and maintenance of girls are needed.

Validation of a novel physical activity assessment device in morbidly obese females.

Assessment of physical activity in morbidly obese subjects is important especially in bariatric surgery. We examined the validity of Intelligent Device for Energy Expenditure and Activity (IDEEA) for measuring physical activity and sedentary behavior in morbidly obese women. Activity types, gait counts, and speed detected by the IDEEA monitor were compared to those reported by an observer. The IDEEA monitor detected activity types and gait counts with relatively high accuracy, although slightly lower in extremely obese women than in normal weight controls. The IDEEA monitor accurately estimated gait speeds in both groups. Since gait speed predicts energy expenditure more accurately than gait counts, it is of greater clinical relevance. Reliability of the IDEEA monitor was excellent. The IDEEA monitor is a valid instrument for measuring physical activity and sedentary behavior in extremely obese women, and therefore has potential applications in bariatric surgery both in preoperative evaluation and long-term follow-up.