Comparison of Telemedicine Usage at Two Distinct Medicaid-Focused Pediatric Clinics.

Objective: To compare telemedicine versus office visit use at two Medicaid-focused pediatric primary care clinics. Methods: Retrospective cohort study from March 15, 2020 - March 15, 2021 at two Medicaid-focused pediatric primary care clinics. Site A and Site B care for different populations (Site B care for mostly immigrant families with preferred language Spanish). Outcomes included the percent of visits conducted through telemedicine and reason for visit. Descriptive statistics, univariable and multivariable mixed multilevel logistic regression, were used to assess relationship between patient demographics and telemedicine use. Results: Out of 17,142 total visits, 13% of encounters at Site A (n = 987) and 25% of encounters at Site B (n = 2,421) were conducted using telemedicine. Around 13.8% of well-child care (n = 1,515/10,997), 36.2% of mental health care (n = 572/1,581), and 25.0% of acute care/follow-up (n = 1,893/7,562) were telemedicine visits. After adjustment for covariates, there was no difference in odds of a patient having any telemedicine use by preferred language, sex, or payor. Patients 1-4 years of age had the lowest odds of telemedicine use. At Site A, patients who identified as Non-Hispanic Black (odds ratio [OR] = 0.33, 95% confidence interval [CI] = 0.24-0.45), Hispanic/Latinx (OR = 0.40, 95% CI = 0.24-0.66), or other race/ethnicity (OR = 0.35, 95% CI = 0.23-0.55) had lower odds of telemedicine use in comparison to Non-Hispanic White. Conclusions: Telemedicine was successfully accessed by Medicaid enrollees for different types of pediatric primary care. There was no difference in telemedicine use by preferred language and payor. However, differences existed by age at both sites and by race/ethnicity at one site. Future research should explore operational factors that improve telemedicine access for marginalized groups.

Effectiveness of a Pediatric Primary Care Intervention to Increase Maternal Folate Use: Results from a Cluster Randomized Controlled Trial.

OBJECTIVE: To assess the impact of provision of folate vitamins and a preconception health intervention on folate use among mothers bringing infants to pediatric primary care. STUDY DESIGN: We conducted a cluster randomized trial in mothers presenting with their infants (<12 months) at 4 urban pediatric practices in the Baltimore, Maryland, metropolitan area. There were 45 clinicians randomized into an intervention group (15-item preconception health screening and counseling and 90-day multivitamin supply) and control group (preconception health and community resource handouts and 90-day multivitamin supply). Participating mothers were enrolled in the study group assigned to their child's clinician. Baseline and 6-month follow-up interviews were performed. The outcome was daily use of folate, multivitamin, and a prenatal vitamin containing folate. Primary independent variables were time of assessment and mother's study group (intervention or control groups). Covariates investigated were mother's and child's age, race/ethnicity, education, marital status, income, insurance status, previous live births, and intention to have a pregnancy in the next 6 months. RESULTS: We enrolled 415 mothers at baseline who were majority African American and low income. Of the 415 enrolled participants, 352 (85%) completed follow-up interviews. Among all participants, daily vitamin intake increased from baseline to 6-month follow-up (33.8% vs 42.6%; P = .016). After adjustment for covariates and clustered design, there was an augmented effect in the intervention vs control group (aOR, 2.04; 95% CI, 1.04-3.98). CONCLUSIONS: Offering vitamins and recommending folate intake to mothers within pediatric practice can increase use. Pediatric practice is an important contact point and context for improving maternal folate use. TRIAL REGISTRATION: ClinicalTrials.govNCT02049554.

Information and Communication Technology Use Among Low-Income Pregnant and Postpartum Women by Race and Ethnicity: A Cross-Sectional Study.

BACKGROUND: Pregnancy and the postpartum period provide windows of opportunity to impact perinatal and lifelong preventive health behavior for women and their families, but these opportunities are often missed. Understanding racial/ethnic differences in information and communication technology (ICT) use could inform technology-based interventions in diverse populations. OBJECTIVE: The objective of the study was to evaluate differences in the use of ICT between racial and ethnic groups as well as by English language proficiency. METHODS: We conducted a cross-sectional study of 246 women who were aged 18 years or older and pregnant or within 1 year of delivery. They were recruited from 4 hospital-based outpatient clinics and completed a self-administered survey. We used multivariate regression analysis to evaluate the association between race/ethnicity and ICT (mobile phone/short message service [SMS] text message, Internet, and social network) usage by race/ethnicity and perceived English language proficiency after adjusting for age, income, marital status, and insurance status. RESULTS: In all, 28% (69/246) of participants were Latina, 40% (98/246) were African American, 23% (56/246) were white, and 9% (23/246) from other racial/ethnic groups. Of the Latinas, 84% (58/69) reported limited English language proficiency and 59% (41/69) were uninsured. More than 90% of all participants reported mobile phone use, but more than 25% (65/246) had changed phone numbers 2 or more times in the past year. Compared to white women, African American women were less likely to SMS text message (OR 0.07, 95% CI 0.01-0.63) and Latinas were less likely to use the Internet to find others with similar concerns (OR 0.23, 95% CI 0.08-0.73). Women with limited English language proficiency were less likely to use the Internet overall (OR 0.30, 95% CI 0.09-0.99) or use email (OR 0.22, 95% CI 0.08-0.63) compared to women with adequate English language proficiency. CONCLUSIONS: Mobile phones are widely available for the delivery of health interventions to low-income, racially diverse pregnant and postpartum women, but disparities in Internet use and SMS text messaging exist. Interventions or programs requiring Web-based apps may have lower uptake unless alternatives are available, such as those adapted for limited English proficiency populations.

Body Mass Index and Postacute Sequelae of SARS-CoV-2 Infection in Children and Young Adults.

Importance: Obesity is associated with increased severity of COVID-19. Whether obesity is associated with an increased risk of post-acute sequelae of SARS-CoV-2 infection (PASC) among pediatric populations, independent of its association with acute infection severity, is unclear. Objective: To quantify the association of body mass index (BMI) status before SARS-CoV-2 infection with pediatric PASC risk, controlling for acute infection severity. Design, Setting, and Participants: This retrospective cohort study occurred at 26 US children's hospitals from March 2020 to May 2023 with a minimum follow-up of 179 days. Eligible participants included children and young adults aged 5 to 20 years with SARS-CoV-2 infection. Data analysis was conducted from October 2023 to January 2024. Exposures: BMI status assessed within 18 months before infection; the measure closest to the index date was selected. The BMI categories included healthy weight (≥5th to <85th percentile for those aged 5-19 years or ≥18.5 to <25 for those aged >19 years), overweight (≥85th to <95th percentile for those aged 5-19 years or ≥25 to <30 for for those aged >19 years), obesity (≥95th percentile to <120% of the 95th percentile for for those aged 5-19 years or ≥30 to <40 for those aged >19 years), and severe obesity (≥120% of the 95th percentile for those aged 5-19 years or ≥40 for those aged >19 years). Main Outcomes And Measures: To identify PASC, a diagnostic code specific for post-COVID-19 conditions was used and a second approach used clusters of symptoms and conditions that constitute the PASC phenotype. Relative risk (RR) for the association of BMI with PASC was quantified by Poisson regression models, adjusting for sociodemographic, acute COVID severity, and other clinical factors. Results: A total of 172 136 participants (mean [SD] age at BMI assessment 12.6 [4.4] years; mean [SD] age at cohort entry, 13.1 [4.4] years; 90 187 female [52.4%]) were included. Compared with participants with healthy weight, those with obesity had a 25.4% increased risk of PASC (RR, 1.25; 95% CI, 1.06-1.48) and those with severe obesity had a 42.1% increased risk of PASC (RR, 1.42; 95% CI, 1.25-1.61) when identified using the diagnostic code. Compared with those with healthy weight, there was an increased risk for any occurrences of PASC symptoms and conditions among those with obesity (RR, 1.11; 95% CI, 1.06-1.15) and severe obesity (RR, 1.17; 95% CI, 1.14-1.21), and the association held when assessing total incident occurrences among those with overweight (RR, 1.05; 95% CI, 1.00-1.11), obesity (RR, 1.13; 95% CI, 1.09-1.19), and severe obesity (RR, 1.18; 95% CI, 1.14-1.22). Conclusions And Relevance: In this cohort study, elevated BMI was associated with a significantly increased PASC risk in a dose-dependent manner, highlighting the need for targeted care to prevent chronic conditions in at-risk children and young adults.

Maternal folate status and placental vascular malperfusion: Findings from a high-risk US minority birth cohort.

INTRODUCTION: Maternal folate deficiency was associated with preeclampsia (PE) and PE was associated with placental maternal vascular malperfusion (MVM). However, no study has examined the association of maternal folate status with placental MVM. METHODS: We examined the association of maternal folate status and placental MVM in the Boston Birth Cohort. Primary exposure variables were maternal self-reported multivitamin supplement (<2, 3-5, >5 times/week) per trimester; and plasma folate levels (nmol/L) after birth. Primary outcome was presence/absence of placental MVM defined by the Amsterdam Placental Workshop Group standard classification. Covariates included demographics, chronic hypertension, clinically diagnosed PE, eclampsia and HELLP syndrome, gestational and pre-gestational diabetes, overweight/obesity, maternal cigarette smoking and alcohol use. Associations between folate and placental MVM were evaluated using multivariate logistic regressions. RESULTS: Of 3001 mothers in this study, 18.8% of mothers had PE, 37.5% had MVM. Mothers with the lowest self-reported frequency of folate intake had the highest risk of MVM (OR 1.45, 95% CI 1.03-2.05), after adjusting for the covariates. Consistently, among a subset of 939 mothers with plasma folate levels, folate insufficiency was associated with increased risk of MVM (OR 1.65, 95% CI 1.03-2.63), after adjusting for the covariables. As expected, mothers with low folate and placental MVM had highest rates of PE compared to those of high folate and no MVM (p < 0.001). DISCUSSION: In this high-risk birth cohort, low maternal folate status was associated with increased risk of placental MVM. Further investigation should explore the association between folate status, placental findings and the great obstetrical syndrome.

Maternal vascular malperfusion of the placental bed associated with hypertensive disorders in the Boston Birth Cohort.

INTRODUCTION: The associations of maternal conditions, before or during pregnancy, with placental lesions have not been adequately studied in populations. METHODS: In the Boston Birth Cohort, we evaluated associations between three maternal medical conditions (hypertensive disorders [HDs], gestational/pre-gestational diabetes and obesity), and placental histological findings, using a standardized classification system proposed by the Amsterdam Placental Workshop Group. Placental pathology diagnoses and clinical data from 3074 mothers with clinical indications who delivered singleton live births at the Boston Medical Center between October 1998 and November 2013 were evaluated. Associations between each maternal condition and maternal vascular malperfusion (MVM) of the placental bed and its standardized subgroups were examined using multivariate logistic and multinomial regressions. RESULTS: Women with HDs (chronic hypertension, eclampsia, preeclampsia, HELLP syndrome) had significantly increased odds of MVM lesions when compared to women with no HD (aOR 2.08 95% CI 1.74-2.50), after adjusting for demographics, substance use, diabetes and body mass index. No significant differences in frequencies or aORs were seen in women with and without diabetes, or across body mass index categories. Co-morbid condition patterns that included HDs were more likely to be associated with MVM than those without. DISCUSSION: Using a standardized classification system, we showed that MVM is strongly and specifically associated with maternal HDs, but not other maternal conditions. Additional studies are needed to confirm and validate our findings, and evaluate the role of maternal vascular lesions of the placental bed in relation to postnatal growth and development of the offspring and effect modifiers.

Obesity-Related Dietary Behaviors among Racially and Ethnically Diverse Pregnant and Postpartum Women.

INTRODUCTION: Obesity is common among reproductive age women and disproportionately impacts racial/ethnic minorities. Our objective was to assess racial/ethnic differences in obesity-related dietary behaviors among pregnant and postpartum women, to inform peripartum weight management interventions that target diverse populations. METHODS: We conducted a cross-sectional survey of 212 Black (44%), Hispanic (31%), and White (25%) women, aged ≥ 18, pregnant or within one year postpartum, in hospital-based clinics in Baltimore, Maryland, in 2013. Outcomes were fast food or sugar-sweetened beverage intake once or more weekly. We used logistic regression to evaluate the association between race/ethnicity and obesity-related dietary behaviors, adjusting for sociodemographic factors. RESULTS: In adjusted analyses, Black women had 2.4 increased odds of fast food intake once or more weekly compared to White women (CI = 1.08, 5.23). There were no racial/ethnic differences in the odds of sugar-sweetened beverage intake. DISCUSSION: Compared with White or Hispanic women, Black women had 2-fold higher odds of fast food intake once or more weekly. Black women might benefit from targeted counseling and intervention to reduce fast food intake during and after pregnancy.