Diversity in the pediatric research workforce: a scoping review of the literature.

The purpose of this scoping review is to determine trends in racial and ethnic representation, identify barriers and facilitators to greater diversity, and assess strategies and interventions to advance diversity among those in the pediatric research workforce in the U.S. We conducted a scoping review of PubMed supplemented with the authors' personal library of papers published from January 1, 2010, to December 31, 2021. To be eligible, papers had to provide original data, be published in English, report information from a U.S. healthcare institution, and report on outcomes of interest relevant to the child health field. The diversity of faculty has modestly increased over the past decade but reflects a worsening representation compared to overall population trends. This slow increase reflects a loss of diverse faculty and has been referred to as a "leaky pipeline." Strategies to plug the "leaky pipeline" include greater investments in pipeline programs, implementation of holistic review and implicit bias training, development of mentoring and faculty programs targeted to diverse faculty and trainees, alleviation of burdensome administrative tasks, and creation of more inclusive institutional environments. Modest improvements in the racial and ethnic diversity of the pediatric research workforce were identified. However, this reflects worsening overall representation given changing U.S. population demographics. IMPACT: Racial and ethnic diversity in the pediatric research workforce has shown modest increases but worsening overall representation. This review identified barriers and facilitators at the intrapersonal, interpersonal, and institutional levels that impact BIPOC trainees and faculty career advancement. Strategies to improve the pathway for BIPOC individuals include greater investments in pipeline and educational programs, implementation of holistic review admissions and bias training, institution of mentoring and sponsorship, alleviation of burdensome administrative responsibilities, and creation of inclusive institutional climates. Future studies should rigorously test the effects of interventions and strategies designed to improve diversity in the pediatric research workforce.

Incidence and risk factors for hypoglycemia during maintenance chemotherapy in pediatric acute lymphoblastic leukemia.

BACKGROUND: Fasting hypoglycemia is a recognized occurrence among pediatric patients with acute lymphoblastic leukemia (ALL) during maintenance therapy. Existing publications describing this finding are limited to small studies and case reports. Our objective was to determine the incidence of hypoglycemia during maintenance chemotherapy and to investigate the association of age, as well as other potential risk factors, with this outcome in pediatric patients with ALL. PROCEDURE: This retrospective cohort study included individuals 1 to 21 years of age with ALL treated with antimetabolite-containing maintenance chemotherapy at a large children's hospital between January 2011 and December 2014. The primary endpoint was time to first documented episode of hypoglycemia during maintenance therapy, defined as single measurement of plasma glucose <60 mg/dL. Cox regression was used to evaluate the association with age and identify other potential risk factors. RESULTS: We identified 126 eligible patients, of whom 63% were documented as White, non-Hispanic, 28% as non-White, non-Hispanic, and 9% as Hispanic. Twenty-eight children (22%) had documented hypoglycemia during maintenance therapy. Younger age at the start of maintenance and hepatotoxicity documented during chemotherapy prior to maintenance initiation were associated with hypoglycemia (adjusted HR age = 0.88; 95% CI, 0.78-0.99; adjusted HR prior hepatotoxicity = 3.50; 95% CI, 1.47-8.36). CONCLUSIONS: Nearly one quarter of children in our cohort had hypoglycemia documented during maintenance chemotherapy. Younger age at maintenance initiation and hepatotoxicity during chemotherapy prior to maintenance initiation emerged as risk factors. These findings highlight the importance of counseling about the risk of, and monitoring for, hypoglycemia, particularly in young children.

Development of a Clinical Prediction Model for Central Line-Associated Bloodstream Infection in Children Presenting to the Emergency Department.

OBJECTIVE: The majority of the children with a central line who present to the emergency department with fever or other signs of bacteremia do not have a central line-associated bloodstream infection (CLABSI). Our objective was to develop a clinical prediction model for CLABSI among this group of children in order to ultimately limit unnecessary hospital admissions and antibiotic use. METHODS: We performed a nested case-control study of children with a central line who presented to the emergency department of an urban, tertiary care children's hospital between January 2010 and March 2015 and were evaluated for CLABSI with a blood culture. RESULTS: The final multivariable model developed to predict CLABSI consisted of 12 factors: age younger than 5 years, black race, use of total parenteral nutrition, tunneled central venous catheter, double-lumen catheter, absence of other bacterial infection, absence of viral upper respiratory tract infection symptoms, diarrhea, emergency department temperature greater than 39.5°C, fever prior to presentation, neutropenia, and spring/summer season. The clinical prediction score had good discrimination for CLABSI with a c-statistic of 0.81 (confidence interval, 0.77-0.85). A cut point less than 6 was associated with a sensitivity of 98.5% and a negative predictive value of 99.2% for CLABSI. CONCLUSIONS: We were able to identify risk factors and develop a clinical prediction model for CLABSI in children presenting to the emergency department. Once validated in future study, this clinical prediction model could be used to assess the need for hospitalization and/or antibiotics among this group of patients.

Evaluation of the PROMIS pediatric global health scale (PGH-7) in children with asthma.

OBJECTIVE: To evaluate the reliability and validity of the PROMIS Pediatric Global Health scale, a 7-item measure of perceived physical, mental, and social health, in children with asthma. METHODS: From February 2014 to February 2015, convenience samples of 8-17 year-old children (n = 182) and parents of 5-17 year-old children (n = 328) visiting an emergency department for treatment of asthma were enrolled. The Asthma Control Test was used to characterize children as controlled versus not controlled, and the PROMIS Asthma Impact Scale was used to assess asthma symptoms' impact on functional status. We conducted longitudinal analyses among 92 children and 218 parents at 3 weeks, and 74 children and 171 parents at 8 weeks after enrollment. RESULTS: The PGH-7 reliability ranged from 0.66 to 0.81 for child-report and 0.76 to 0.82 for parent-proxy. In cross-sectional analyses, children with controlled asthma had PGH-7 scores 0.40-0.95 standard deviation units higher than those who were uncontrolled. The PGH-7 was responsive to changes in overall general health between time points, with moderate effect sizes (0.5-0.6 standard deviation units). In longitudinal analyses, PGH-7 scores were no different between those who stayed uncontrolled versus became controlled at 3 weeks of follow-up; however, by 8 weeks of follow-up, the differences between these groups were 0.7-0.8 standard deviation units, indicative of large effects. CONCLUSIONS: The PGH-7 is a reliable and valid patient-reported outcome for assessing general health among children with asthma. It is a useful complement to other asthma-specific outcome measures.

Pilot RCT of a social media parenting intervention for postpartum mothers with depression symptoms.

Objective: This pilot study describes the adaptation of a parenting group intervention for social media, and examines the feasibility, acceptability and initial outcomes of the adapted intervention for mothers with postpartum depression symptoms. Background: Postpartum depression can negatively affect parenting and the parent-infant relationship. Mothers with postpartum depression symptoms experience barriers to access in-person parenting interventions. Methods: A small, randomised controlled trial was conducted with an adapted parenting intervention delivered via social media (Facebook) or in-person for mothers who screened positive for depression in paediatric clinics. Parenting sense of competence, depression symptoms and intervention attendance and satisfaction were assessed. Twenty-four mothers (mean age 26 years; predominantly African American with limited economic resources) participated in the study. Results: Linear regressions showed that the social media group had significantly improved parenting competence and decreased depression severity when compared to the in-person group. Attendance in the social media group was high (83%), but extremely poor in the in-person group (3%). The mothers rated the intervention positively and the majority of the mothers participated by posting comments on the group page on social media. Conclusion: The findings suggest the feasibility and benefit of delivering a parenting intervention through social media for postpartum mothers with high levels of depression symptoms.

Variation in Positive End-Expiratory Pressure Levels for Mechanically Ventilated Extremely Low Birth Weight Infants.

OBJECTIVE: To test the hypothesis that significant positive end-expiratory pressure (PEEP) level variation exists between neonatal centers. STUDY DESIGN: We performed a secondary analysis cohort study of the Nasal Intermittent Positive-Pressure Ventilation trial. Our study population was extremely low birth weight infants requiring mechanical ventilation within 28 days of life. The exposure was neonatal center; 34 international centers participated in the trial. Subjects from centers with fewer than 5 eligible cases were excluded. The main outcome was the maximal PEEP level used during the first course of mechanical ventilation. Infant characteristics judged a priori to directly influence clinical PEEP level selection and all characteristics associated with PEEP at P <.05 in bivariable analyses were included with and without center in multivariable linear regression models. Variation in PEEP level use between centers following adjustment for infant characteristics was assessed. RESULTS: A total of 278 extremely low birth weight infants from 17 centers were included. Maximal PEEP ranged from 3 to 9 cm H2O, mean = 5.7 (SD = 0.9). Significant variation between centers remained despite adjustment for infant characteristics (P < .0001). Further, center alone explained a greater proportion of the PEEP level variation than all infant characteristics combined. CONCLUSIONS: Marked variation in PEEP levels for extremely low birth weight infants exists between neonatal centers. Research providing evidence-based guidance for this important aspect of respiratory care in preterm infants at high risk of lung injury is needed. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00433212.

A Toddler Parenting Intervention in Primary Care for Caregivers With Depression Symptoms.

Caregiver depression impacts parenting behaviors and has deleterious effects on child behavior. Evidence-based interventions to address parenting have not been adapted for use with depressed caregivers in pediatric primary care settings. Our study examined the feasibility and explored outcomes of an evidence-based parenting program implemented in primary care and adapted for caregivers with depressive symptoms caring for toddlers. We conducted a randomized controlled trial with a wait-list control. Participants were caregivers who screened positive for depressive symptoms in pediatric settings with a toddler. Our study was implemented from July 2011 to June 2012. We adapted the Incredible Years Parents, Babies and Toddlers program with the addition of depression psychoeducation (12 weekly sessions), and assessed caregivers at baseline and immediately post-intervention. We assessed participation rates, depressive symptoms, parenting discipline practices, social support, and parenting stress. Our results revealed that 32 caregivers participating in the intervention group had significantly greater improvement in self-reported parenting discipline practices compared to the 29 wait-list control group caregivers. We found no differences between groups in depressive symptoms, social support, or parenting stress. Our study demonstrated that the average attendance was poor (mean attendance = 3.7 sessions). We adapted an evidence-based parenting intervention for caregivers with depressive symptoms and toddlers in primary care; however, participation was challenging. Alternative intervention strategies are needed to reach and retain low-income caregivers with depression symptoms as they face multiple barriers to participation in groups within center-based services. Trial Registration Clinical Trials.gov identifier NCT01464619.

Gastric Acid Suppressant Prophylaxis in Pediatric Intensive Care: Current Practice as Reflected in a Large Administrative Database.

OBJECTIVES: Stress-related gastrointestinal bleeding may occur in PICU patients. Raising gastric pH with acid suppressant medications is the accepted treatment. We describe the use of histamine 2 receptor blockers and proton pump inhibitors and associated factors among a national sample of PICU patients. DESIGN: Retrospective cohort analysis using Pediatric Health Information System clinically detailed administrative database. SETTING: Forty-two children's hospitals throughout the United States. PATIENTS: All hospitalizations for all patients 20 years old or younger, admitted directly to a PICU, from January 1, 2007, through December 31, 2011. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The exposure of interest was treatment with a histamine 2 receptor blocker, proton pump inhibitor, or both on the first day of PICU admission. Demographics, principal and additional diagnoses, and procedure codes were assessed. For each hospitalization, principal diagnosis, coagulation disorder, head trauma, spinal trauma, severe burns, sepsis, gastrointestinal hemorrhage, mechanical ventilation, blood product transfusion, and 10 complex chronic conditions were identified. The frequency of principal diagnoses was determined to identify the most prevalent PICU diseases. Acid suppressant use was categorized as high or low. Three hundred and thirty-six thousand ten inpatient hospitalizations were sampled. Histamine 2 receptor blocker or proton pump inhibitor was used in 60.0%, with histamine 2 receptor blocker alone in 70.4%, proton pump inhibitor alone in 17.8%, and both agents in 11.8%. Use increased over the sample years 2007 through 2011. Gastrointestinal bleeding occurred in 1.32% of hospitalizations with transfusion needed in 0.1%. Among most prevalent diagnoses, histamine 2 receptor blocker and proton pump inhibitor use ranged from 33% to 87%. Sepsis, coagulopathy, and mechanical ventilation identified higher use. Use of histamine 2 receptor blocker or proton pump inhibitor among hospitals varied considerably ranging from 28% to 87%. CONCLUSIONS: Histamine 2 receptor blocker and proton pump inhibitor are prescribed in most PICU patients, but significant variation exists across health conditions and hospitals. Institutional preferences likely influence variation. Gastrointestinal hemorrhage is infrequent in the current era. Study data limitations prevent examination of associations between medication use and patient outcomes.

Challenges to implementation of developmental screening in urban primary care: a mixed methods study.

BACKGROUND: Research is needed to identify challenges to developmental screening and strategies for screening in an urban pediatric setting. METHODS: Parents of young children and clinicians at four urban pediatric practices participated in focus groups prior to implementation of screening. Participants were queried regarding attitudes, social norms, and barriers to developmental screening. Using information from the focus groups, workflow strategies were developed for implementing screening. Referral rates and satisfaction with screening were gathered at the conclusion. RESULTS: Six focus groups of parents and clinicians were conducted. Major themes identified included 1) parents desired greater input on child development and increased time with physicians, 2) physicians did not fully trust parental input, 3) physicians preferred clinical acumen over screening tools, and 4) physicians lacked time and training to conduct screening. For the intervention, developmental screening was implemented at the 9-, 18-, 24-, and 30-month well visits using the Ages & Stages Questionnaire-II and the Modified Checklist for Toddlers. 1397 (98% of eligible) children under 36 months old were enrolled, and 1184 (84%) were screened at least once. 1002 parents (85%) completed a survey at the conclusion of the screening trial. Most parents reported no difficulty completing the screens (99%), felt the screens covered important areas of child development (98%), and felt they learned about their child's strengths and limitations (88%). CONCLUSIONS: Developmental screening in urban low-income practices is feasible and acceptable, but requires strategies to capture parental input, provide training, facilitate referrals, and develop workflow procedures and electronic decision support.

Lessons Learned from Remote Assessment of Mother-Infant Interactions Among Women with Postpartum Depression.

Purpose: The COVID-19 pandemic posed challenges to measuring mother-infant interactions, a critical outcome for many interventions to support mothers with postpartum depression symptoms and their new infants. The current study describes the process and lessons learned from implementing a remote assessment of mother-infant interactions during the pandemic. Description: At the onset of the COVID-19 pandemic, we pivoted from in-person to using two different strategies to remotely assess mother-infant interactions: (1) participants independently recorded and uploaded videos of free-play with their child; and (2) research team conducted a live-video recording of the free-play. Assessment: We found initial barriers including technical and video quality issues but overall, a remote option could increase enrollment and retention rates in a sample of postpartum women across various racial/ethnic groups and economic levels. Conclusion: Our experiences in conducting remote assessments with postpartum women add to growing evidence for the feasibility and validity of remote visits. This showed how our methods can be implemented in future research and in practice with postpartum mothers and their infants.

Reducing disparities in behavioral health treatment in pediatric primary care: a randomized controlled trial comparing Partnering to Achieve School Success (PASS) to usual ADHD care for children ages 5 to 11 - study protocol.

BACKGROUND: Integrating behavioral health services into pediatric primary care can improve access to care, especially for children marginalized by poverty and racial/ethnic minority status. In primary care, a common presenting concern is attention-deficit/hyperactivity disorder (ADHD). Services in primary care for marginalized children with ADHD typically include medication alone; therapy to improve skills and build relationships is less available. This study evaluates the effectiveness of a behavioral intervention offered through primary care for marginalized families coping with ADHD (Partnering to Achieve School Success, PASS) compared to treatment as usual (TAU). METHOD: Three hundred participants will be randomly assigned to PASS or TAU. Participants include children ages 5 to 11 who have ADHD and are from economically marginalized families. PASS is a personalized, enhanced behavioral intervention that includes evidence-based behavior therapy strategies and enhancements to promote family engagement, increase caregiver distress tolerance, and provide team-based care to improve academic and behavioral functioning. TAU includes services offered by primary care providers and referral for integrated behavioral health or community mental health services. Outcomes will be assessed at mid-treatment (8 weeks after baseline), post-treatment (16 weeks), and follow-up (32 weeks) using parent- and teacher-report measures of service use, child academic, behavioral, and social functioning, parenting practices, family empowerment, and team-based care. Mixed effects models will examine between-group differences at post-treatment and follow-up. Analyses will examine the mediating role of parenting practices, family empowerment, and team-based care. Subgroup analyses will examine differential effects of intervention by child clinical characteristics and socioeconomic factors. DISCUSSION: This study is unique in targeting a population of children with ADHD marginalized by low socioeconomic resources and examining an intervention designed to address the challenges of families coping with chronic stress related to poverty. TRIAL REGISTRATION: This study was registered on clinicaltrials.gov (NCT04082234) on September 5, 2019, prior to enrollment of the first participant. The current version of the protocol and IRB approval date is October 4, 2023. Results will be submitted to ClinicalTrials.gov no later than 30 days prior to the due date for the submission of the draft of the final research report to the Patient-Centered Outcomes Research Institute.

Parental depressive symptoms and children's school attendance and emergency department use: a nationally representative study.

We sought to assess the association between parental depressive symptoms and school attendance and emergency department (ED) use among children with and without chronic health conditions. Secondary analysis of the 1997-2004 National Health Interview Survey, a nationally representative survey. Parental depressive symptoms were measured by three questions assessing sadness, hopelessness, or worthlessness in the past month. Children with and without asthma or attention-deficit/hyperactivity disorder (ADHD) were identified, and their school attendance and ED visits were reported by adult household respondents. Children with information on parental depressive symptoms, health conditions, and services use were eligible. We incorporated weights available in the survey for each eligible child to reflect the complex sampling design. 104,930 eligible children were identified. The point prevalence of parental depressive symptoms was low (1.8 %, 95 % CI 1.7-2.0), but greater among children with asthma (2.7 %, 95 % CI 2.4-3.0) and ADHD (3.8 %, 95 % CI 3.2-4.4) than among other children (1.6 %, 95 % CI 1.5-1.7). After adjustment for potential confounders, children whose parents reported depressive symptoms most or all of the time were more likely to report an ED visit (adjusted incident rate ratio [IRR] 1.18, 95 % CI 1.06-1.32) or school absence (adjusted IRR 1.36, 95 % CI 1.14-1.63) than children whose parents did not. The effect of parental depressive symptoms was not modified by child health conditions. Parental depressive symptoms were adversely associated with school attendance and ED use in children. These results suggest the importance of measuring depressive symptoms among adult caregivers of children.

Minority Faculty Development Programs and Underrepresented Minority Faculty Representation at US Medical Schools.

IMPORTANCE: Diversity initiatives have increased at US medical schools to address underrepresentation of minority faculty. OBJECTIVE: To assess associations between minority faculty development programs at US medical schools and underrepresented minority faculty representation, recruitment, and promotion. DESIGN: Secondary analysis of the Association of American Medical Colleges Faculty Roster, a database of US medical school faculty. PARTICIPANTS: Full-time faculty at schools located in the 50 US states or District of Columbia and reporting data from 2000-2010. EXPOSURE: Availability of school-wide programs targeted to underrepresented minority faculty in 2010. MAIN OUTCOMES AND MEASURES: Percentage of underrepresented minority faculty, defined as self-reported black, Hispanic, Native American, Alaskan Native, Native Hawaiian, or Pacific Islander faculty. Percentage of underrepresented minority faculty was computed by school and year for all faculty, newly appointed faculty, and newly promoted faculty. Panel-level analyses that accounted for faculty clustering within schools were conducted and adjusted for faculty- and school-level variables. RESULTS: Across all schools, the percentage of underrepresented minority faculty increased from 6.8% (95% CI, 6.7%-7.0%) in 2000 to 8.0% (95% CI, 7.8%-8.2%) in 2010. Of 124 eligible schools, 36 (29%) were identified with a minority faculty development program in 2010. Minority faculty development programs were heterogeneous in composition, number of components, and duration. Schools with minority faculty development programs had a similar increase in percentage of underrepresented minority faculty as schools without minority faculty development programs (6.5%-7.4% vs 7.0%-8.3%; odds ratio [OR], 0.91 [95% CI, 0.72-1.13]). After adjustment for faculty and school characteristics, minority faculty development programs were not associated with greater representation of minority faculty (adjusted OR, 0.99 [95% CI, 0.81-1.22]), recruitment (adjusted OR, 0.97 [95% CI, 0.83-1.15]), or promotion (adjusted OR, 1.08 [95% CI, 0.91-1.30]). In subgroup analyses, schools with programs of greater intensity (present for ≥5 years and with more components) were associated with greater increases in underrepresented minority representation than schools with minority faculty development programs of less intensity. CONCLUSIONS AND RELEVANCE: The percentage of underrepresented minority faculty increased modestly from 2000 to 2010 at US medical schools. The presence of a minority faculty development program targeted to underrepresented minority faculty was not associated with greater underrepresented minority faculty representation, recruitment, or promotion. Minority faculty development programs that were of greater intensity were associated with greater increases in underrepresented minority faculty representation.

Early Literacy Promotion Using Automated Hovering Among Young Minority Children.

OBJECTIVE: To determine feasibility, acceptability, and explore outcomes of behavioral economic (BE) strategies to increase parent-child shared reading within a Reach Out and Read program. METHODS: We conducted rapid-cycle interviews with 10 parents to assess text messages followed by an 8-week randomized controlled trial of 3 BE strategies at 2 urban primary care practices: daily text messages (texting); daily text messages and regret messaging (regret); or daily text messages, regret messaging, and lottery participation (lottery). Parent-child dyads were eligible if children were <24 months old, Medicaid-eligible, and had access to phones capable of receiving and sending text messages. Parents completed the Read Subscale of the StimQ and Parenting Stress Index-short form (PSI-SF) pre- and postintervention, MacArthur Communicative Development Inventory (CDI), Devereux Early Childhood Assessment (DECA), and a satisfaction measure postintervention. Differences between groups were assessed using intention-to-treat analysis. RESULTS: Of 45 dyads randomized, 41 (91%) completed the study. Most participants were Black with incomes <$55,000. Parents reported reading on average 4 d/wk with no change in the reading frequency over time. StimQ scores increased over time, but there were no significant differences in StimQ, PSI-SF, CDI, and DECA scores between groups. Parents in all 3 groups reported satisfaction (3.8/5.0) with the intervention. CONCLUSIONS: Implementation of BE strategies in 2 Reach Out and Read programs was feasible, near acceptable, and improved home reading environment scores. Future study should investigate BE strategies vis-à-vis usual care and be of sufficient duration and intensity to engage participants to assess its impact on patient and parent outcomes.

Social Media-based Parenting Program for Women With Postpartum Depressive Symptoms: An RCT.

OBJECTIVES: To test effects of a social media-based parenting program for mothers with postpartum depressive symptoms. METHODS: We conducted a randomized controlled trial from December 2019 to August 2021 of a parenting program using Facebook. Women with mild-to-moderate depressive symptoms (Edinburgh Postnatal Depression Scale [EPDS] 10-19) were randomized to the program, plus online depression treatment or depression treatment alone for 3 months. Women completed the EPDS monthly and the Parent-Child Early Relational Assessment, Parenting Stress Index-Short Form, and Parenting Sense of Competence pre- and postintervention. Differences among groups were assessed using intention-to-treat analysis. RESULTS: Seventy-five women enrolled and 66 (88%) completed the study. Participants were predominantly Black (69%), single (57%), with incomes <$55 000 (68%). The parenting group reported a more rapid decline in depressive symptoms than the comparison group (adjusted EPDS difference, -2.9; 95% confidence interval, -4.8 to -1.0 at 1 month). There were no significant group X time interactions for the Parent-Child Early Relational Assessment, Parenting Stress Index-Short Form, or Parenting Sense of Competence scores. Forty-one percent of women sought mental health treatment for worsening symptoms or suicidality. Women in the parenting group who exhibited greater engagement or reported mental health treatment had greater parenting responsiveness. CONCLUSIONS: A social media-based parenting program led to more rapid declines in depressive symptoms but no differences in responsive parenting, parenting stress, or parenting competence relative to a comparison group. Social media can provide parenting support for women with postpartum depressive symptoms, but greater attention to engagement and treatment access are needed to improve parenting outcomes.

Neighborhood Social Vulnerability and Interstage Weight Gain: Evaluating the Role of a Home Monitoring Program.

Background Poor interstage weight gain is a risk factor for adverse outcomes in infants with hypoplastic left heart syndrome. We sought to examine the association of neighborhood social vulnerability and interstage weight gain and determine if this association is modified by enrollment in our institution's Infant Single Ventricle Management and Monitoring Program (ISVMP). Methods and Results We performed a retrospective single-center study of infants with hypoplastic left heart syndrome before (2007-2010) and after (2011-2020) introduction of the ISVMP. The primary outcome was interstage weight gain, and the secondary outcome was interstage growth failure. Multivariable linear and logistic regression models were used to examine the association between the Social Vulnerability Index and the outcomes. We introduced an interaction term into the models to test for effect modification by the ISVMP. We evaluated 217 ISVMP infants and 111 pre-ISVMP historical controls. The Social Vulnerability Index was associated with interstage growth failure (P=0.001); however, enrollment in the ISVMP strongly attenuated this association (P=0.04). Pre-ISVMP, as well as high- and middle-vulnerability infants gained 4 g/d less and were significantly more likely to experience growth failure than low-vulnerability infants (high versus low: adjusted odds ratio [aOR], 12.5 [95% CI, 2.5-62.2]; middle versus low: aOR, 7.8 [95% CI, 2.0-31.2]). After the introduction of the ISVMP, outcomes did not differ by Social Vulnerability Index tertile. Infants with middle and high Social Vulnerability Index scores who were enrolled in the ISVMP gained 4 g/d and 2 g/d more, respectively, than pre-ISVMP controls. Conclusions In infants with hypoplastic left heart syndrome, high social vulnerability is a risk factor for poor interstage weight gain. However, enrollment in the ISVMP significantly reduces growth disparities.

Shared decision making and behavioral impairment: a national study among children with special health care needs.

BACKGROUND: The Institute of Medicine has prioritized shared decision making (SDM), yet little is known about the impact of SDM over time on behavioral outcomes for children. This study examined the longitudinal association of SDM with behavioral impairment among children with special health care needs (CSHCN). METHOD: CSHCN aged 5-17 years in the 2002-2006 Medical Expenditure Panel Survey were followed for 2 years. The validated Columbia Impairment Scale measured impairment. SDM was measured with 7 items addressing the 4 components of SDM. The main exposures were (1) the mean level of SDM across the 2 study years and (2) the change in SDM over the 2 years. Using linear regression, we measured the association of SDM and behavioral impairment. RESULTS: Among 2,454 subjects representing 10.2 million CSHCN, SDM increased among 37% of the population, decreased among 36% and remained unchanged among 27%. For CSHCN impaired at baseline, the change in SDM was significant with each 1-point increase in SDM over time associated with a 2-point decrease in impairment (95% CI: 0.5, 3.4), whereas the mean level of SDM was not associated with impairment. In contrast, among those below the impairment threshold, the mean level of SDM was significant with each one point increase in the mean level of SDM associated with a 1.1-point decrease in impairment (0.4, 1.7), but the change was not associated with impairment. CONCLUSION: Although the change in SDM may be more important for children with behavioral impairment and the mean level over time for those below the impairment threshold, results suggest that both the change in SDM and the mean level may impact behavioral health for CSHCN.

Performance measures of the specialty referral process: a systematic review of the literature.

BACKGROUND: Performance of specialty referrals is coming under scrutiny, but a lack of identifiable measures impedes measurement efforts. The objective of this study was to systematically review the literature to identify published measures that assess specialty referrals. METHODS: We performed a systematic review of the literature for measures of specialty referral. Searches were made of MEDLINE and HealthSTAR databases, references of eligible papers, and citations provided by content experts. Measures were eligible if they were published from January 1973 to June 2009, reported on validity and/or reliability of the measure, and were applicable to Organization for Economic Cooperation and Development healthcare systems. We classified measures according to a conceptual framework, which underwent content validation with an expert panel. RESULTS: We identified 2,964 potentially eligible papers. After abstract and full-text review, we selected 214 papers containing 244 measures. Most measures were applied in adults (57%), assessed structural elements of the referral process (60%), and collected data via survey (62%). Measures were classified into non-mutually exclusive domains: need for specialty care (N = 14), referral initiation (N = 73), entry into specialty care (N = 53), coordination (N = 60), referral type (N = 3), clinical tasks (N = 19), resource use (N = 13), quality (N = 57), and outcomes (N = 9). CONCLUSIONS: Published measures are available to assess the specialty referral process, although some domains are limited. Because many of these measures have been not been extensively validated in general populations, assess limited aspects of the referral process, and require new data collection, their applicability and preference in assessment of the specialty referral process is needed.

Perspectives on Breastfeeding from Mothers with Postpartum Depression Symptoms: A Qualitative Assessment of Antecedents, Barriers, Facilitators, and Intervention Suggestions.

Background: Postpartum depression (PPD) is one of the most common birthing complications, and studies negatively associate PPD with breastfeeding initiation and continuation. However, little is known about either the breastfeeding experience of mothers with PPD or what resources mothers need for sustained breastfeeding from their perspectives. This study aimed to identify the antecedents, barriers, and facilitators to breastfeeding for mothers with PPD, understand the relationship between self-efficacy and emergent themes, and generate suggestions to inform supportive interventions. Materials and Methods: Birth mothers who screened positive for PPD and reported breastfeeding were recruited to participate in semistructured interviews. Interviews were transcribed verbatim, and inter-coder discrepancies from double coding were resolved through consensus. Thematic analysis was facilitated using immersion-crystallization methods. Results: Participants identified five antecedent themes that encourage initiation (professional support, infant health, mother's health, cost-effectiveness, and faith), four facilitator themes for sustained breastfeeding (infant connection, decreased stress, personal attributes, and logistical strategies), and seven barrier themes (physical pain, infant nutrition, negative feelings, latching difficulties, medical conditions, public breastfeeding, and sleep). Participants' suggestions fell into three primary themes: supportive services, managing expectations, and respecting self-determination. Conclusion: Antecedent and facilitator themes did not overlap, indicating that factors encouraging breastfeeding initiation differ from sustaining factors. Participant suggestions, barriers, and facilitators did not largely differ from mothers without PPD in other qualitative studies. Therefore, interventions should tailor support to specific breastfeeding phase and may not need to be markedly different for mothers with PPD, in addition to depression management.