Pediatrician-Reported Injury Prevention Anticipatory Guidance by Patient Age Group.

OBJECTIVE: Unintentional injuries remain a leading cause of death for children and adolescents older than 1 year. Injury prevention has long been a cornerstone of anticipatory guidance. Previous studies have established the sustained efficacy of injury prevention anticipatory guidance in pediatric primary care. This study examines the topical emphasis of injury prevention anticipatory guidance by patient age, with special attention given to the rate of water safety anticipatory guidance across 4 patient age groups. METHODS: A nationwide, random sample of AAP member pediatricians was surveyed on their experiences, attitudes, and practices related to injury prevention anticipatory guidance, including barriers to delivering anticipatory guidance. RESULTS: Of the respondents who reported providing direct patient care, 92% considered injury prevention anticipatory guidance a priority issue. The content of that injury prevention guidance varied considerably by patient age. Roughly half (53%) reported counseling families with adolescents on water safety/drowning prevention, which represents a statistically significant decrease relative to other patient age groups. CONCLUSIONS: Reported injury prevention anticipatory guidance is high across different mechanisms of injury. However, fewer pediatricians deliver drowning prevention anticipatory guidance to adolescents than to younger patients. Targeted outreach and education to increase injury prevention anticipatory guidance, especially for adolescent patients, should be part of a multipronged approach to decrease drowning and other injury deaths.

Firearm-Related Injuries and Deaths in Children and Youth: Injury Prevention and Harm Reduction.

Firearms are the leading cause of death in children and youth 0 to 24 years of age in the United States. They are also an important cause of injury with long-term physical and mental health consequences. A multipronged approach with layers of protection focused on harm reduction, which has been successful in decreasing motor vehicle-related injuries, is essential to decrease firearm injuries and deaths in children and youth. Interventions should be focused on the individual, household, community, and policy level. Strategies for harm reduction for pediatric firearm injuries include providing anticipatory guidance regarding the increased risk of firearm injuries and deaths with firearms in the home as well as the principles of safer firearm storage. In addition, lethal means counseling for patients and families with individuals at risk for self-harm and suicide is important. Community-level interventions include hospital and community-based violence intervention programs. The implementation of safety regulations for firearms as well as enacting legislation are also essential for firearm injury prevention. Increased funding for data infrastructure and research is also crucial to better understand risks and protective factors for firearm violence, which can then inform effective prevention interventions. To reverse this trend of increasing firearm violence, it is imperative for the wider community of clinicians, public health advocates, community stakeholders, researchers, funders, and policy makers to collaboratively address the growing public health crisis of firearm injuries in US youth.

Firearm-Related Injuries and Deaths in Children and Youth.

Firearms are the leading cause of death in children and youth 0 to 24 years of age in the United States. In 2020, firearms resulted in 10,197 deaths (fatality rate 9.91/100,000 youth 0-24 years old). Firearms are the leading mechanism of death in pediatric suicides and homicides. Increased access to firearms is associated with increased rates of firearm deaths. Substantial disparities in firearm injuries and deaths exist by age, gender, race, ethnicity, and sexual orientation and gender identity and for deaths related to legal intervention. Barriers to firearm access can decrease the risk to youth for firearm suicide, homicide, or unintentional shooting injury and death. Given the high lethality of firearms and the impulsivity associated with suicidal ideation, removing firearms from the home or securely storing them-referred to as lethal means restriction of firearms-is critical, especially for youth at risk for suicide. Primary care-, emergency department-, mental health-, hospital-, and community-based intervention programs can effectively screen and intervene for individuals at risk for harming themselves or others. The delivery of anticipatory guidance coupled with safety equipment provision improves firearm safer storage. Strong state-level firearm legislation is associated with decreased rates of firearm injuries and death. This includes legislation focused on comprehensive firearm licensing strategies and extreme risk protection order laws. A firm commitment to confront this public health crisis with a multipronged approach engaging all stakeholders, including individuals, families, clinicians, health systems, communities, public health advocates, firearm owners and nonowners, and policy makers, is essential to address the worsening firearm crisis facing US youth today.

Academic Careers in Advocacy: Aligning Institutional Values Through Use of an Advocacy Portfolio.

Academic children's hospitals must embrace advocacy as a central component of their missions to discover new knowledge and improve the health of the communities and patients they serve. To do so, they must ensure faculty have both the tools and the opportunities to develop and articulate the work of advocacy as an academic endeavor. This can be accomplished by integrating the work of advocacy at the community and policy-change levels into the traditional value systems of academic medicine, especially the promotions process, to establish its legitimacy. Academic pediatric institutions can support this transformation through robust training and professional development programs and establishing opportunities, resources, and leadership positions in advocacy. The adoption of an advocacy portfolio can be used to align these activities and accomplishments to institutional values and promotion. This alignment is crucial to supporting the advocacy work of pediatricians at a time in which community engagement and systems and policy change must be added to professional activities to ensure optimal outcomes for all children.

A Blueprint for Advocacy in Neonatology.

Advocacy is at the heart of pediatrics and neonatal care. Historically and currently, numerous pediatricians have used their expertise to raise the voices of children and families to promote child health and welfare. Despite a lack of formal training in advocacy and health policy, many of the skills required for daily clinical care can, and ought to, be applied to affect systemic change within neonatology. Advocacy can no longer be considered an optional activity, but rather a core competency and professional responsibility. In this review, the authors describe the necessity and foundational principles for advocacy success as well as provide guidance, resources, and opportunities for neonatologists and clinicians providing newborn care.

Adapting Safety Check as a Universal Suicide Prevention Strategy in Pediatric Primary Care.

OBJECTIVE: The presence of unlocked firearms in the home is associated with increased risk of suicide and unintentional injury in youth. We adapted an evidence-based program for promoting safe firearm storage, Safety Check, to enhance its acceptability as a universal suicide prevention strategy in pediatric primary care. METHODS: We applied ADAPT-ITT, an established adaptation framework, to guide iterative program adaptation with ongoing input from key stakeholders. The present study describes 2 phases of ADAPT-ITT: the Production phase (generating adaptations) and the Topical Experts phase (gathering stakeholder feedback on adaptations). After generating proposed program adaptations based on 3 inputs (stakeholder feedback collected in a prior study, the behavioral science literature, and best practices in pediatric medicine), we elicited feedback from stakeholders with firearm expertise. The adaptations included changes such as clarifying firearm ownership will not be documented in the medical record and offering follow-up reminders. We also crowdsourced feedback from 337 parents to select a new name and program logo. RESULTS: Saturation was reached with 9 stakeholders. Feedback confirmed the value of adaptations that: 1) considered context (eg, reason for ownership), 2) promoted parent autonomy in decision-making, and 3) ensured privacy. The most preferred program name was Suicide and Accident prevention through Family Education (SAFE) Firearm. CONCLUSIONS: Guided by an established adaptation framework that prioritized multistage stakeholder feedback, adaptations to the original Safety Check were deemed acceptable. We plan to test the SAFE Firearm program as a universal suicide prevention strategy in pediatric primary care via a hybrid effectiveness-implementation trial.

Getting Babies Safely Home: A Retrospective Chart Review of Car Safety Seat Tolerance Screening Outcomes.

BACKGROUND: The American Academy of Pediatrics recommends pre-discharge Car Seat Tolerance Screening (CSTS) for all neonates born <37 weeks estimated gestational age (EGA), or otherwise at risk for cardiorespiratory compromise. Screening is burdensome and there remains tremendous variation in testing criteria and methodology. DESIGN/METHODS: We conducted a retrospective chart review of 1,072 infants who underwent CSTS between 11/2013 and 7/2016 at a single academic health center. CSTS outcomes (failure and, separately, significant cardiorespiratory instability (CRI)), including those not meeting failure thresholds) were analyzed for all infants screened, and for preterm infants by screening location (Neonatal Intensive Care Unit (NICU) and Mother/Baby Unit (MBU)). Logistic regression was used to estimate associations between infant characteristics and CSTS outcomes. RESULTS: Overall incidence of CSTS failure was 9.2%. Among all infants, hemodynamically significant congenital heart disease, apnea, chronic lung disease, and being small for EGA were associated with failure. Additionally, those born ≤28 weeks EGA had 2.4 times greater likelihood of failure than those 34-36 weeks EGA. Among preterm infants in the NICU and MBU, those of earlier EGA were also more likely to fail. Almost half (47.5%) of all preterm infants demonstrated CRI during CSTS. CONCLUSION: We found high CSTS failure rates, and identified key infant characteristics that were associated with increased likelihood of failure. Significant CRI events were remarkably common. Larger, prospective studies are needed to elucidate risk factors for instability and failure and define practical criteria for CSTS recommendations.

Variation in Car Seat Tolerance Screen Performance in Newborn Nurseries.

BACKGROUND: Currently, car seat tolerance screens (CSTSs) are recommended for all infants born prematurely in the United States. Although many late-preterm infants are cared for exclusively in newborn nurseries (NBNs), data on implementation of CSTS in nurseries are limited. Our objective for this study was to determine management strategies and potential variation in practice of CSTS in NBNs across the nation. METHODS: We surveyed NBNs across 35 states using the Better Outcomes through Research for Newborns (BORN) network to determine what percentage perform CSTSs, inclusion and failure criteria, performance characteristics, follow-up of failed CSTSs including use of car beds, and provider attitudes toward CSTS. RESULTS: Of the 84 NBNs surveyed, 90.5% performed predischarge CSTSs. The most common failure criteria were saturation <90%, bradycardia <80 beats per minute, and apnea >20 seconds. More than 55% noted hypotonia as an additional inclusion criterion for testing, and >34% tested any infant who had ever required supplemental oxygen. After an initial failed CSTS, >93% of NBNs retested in a car seat at a future time point, whereas only ∼1% automatically discharged infants in a car bed. When asked which infants should undergo predischarge CSTS, the most common recommendations by survey respondents included infants with hypotonia (83%), airway malformations (78%), hemodynamically significant congenital heart disease (63%), and prematurity (61%). CONCLUSIONS: There is a large degree of variability in implementation of CSTS in NBNs across the United States. Further guidance on screening practices and failure criteria is needed to inform future practice and policy.

Child Passenger Safety.

Despite significant reductions in the number of children killed in motor vehicle crashes over the past decade, crashes continue to be the leading cause of death to children 4 years and older. Therefore, the American Academy of Pediatrics continues to recommend the inclusion of child passenger safety anticipatory guidance at every health supervision visit. This technical report provides a summary of the evidence in support of 5 recommendations for best practices to optimize safety in passenger vehicles for children from birth through adolescence that all pediatricians should know and promote in their routine practice. These recommendations are presented in the revised policy statement on child passenger safety in the form of an algorithm that is intended to facilitate their implementation by pediatricians with their patients and families. The algorithm is designed to cover the majority of situations that pediatricians will encounter in practice. In addition, a summary of evidence on a number of additional issues affecting the safety of children in motor vehicles, including the proper use and installation of child restraints, exposure to air bags, travel in pickup trucks, children left in or around vehicles, and the importance of restraint laws, is provided. Finally, this technical report provides pediatricians with a number of resources for additional information to use when providing anticipatory guidance to families.

Child Passenger Safety.

Child passenger safety has dramatically evolved over the past decade; however, motor vehicle crashes continue to be the leading cause of death for children 4 years and older. This policy statement provides 4 evidence-based recommendations for best practices in the choice of a child restraint system to optimize safety in passenger vehicles for children from birth through adolescence: (1) rear-facing car safety seats as long as possible; (2) forward-facing car safety seats from the time they outgrow rear-facing seats for most children through at least 4 years of age; (3) belt-positioning booster seats from the time they outgrow forward-facing seats for most children through at least 8 years of age; and (4) lap and shoulder seat belts for all who have outgrown booster seats. In addition, a fifth evidence-based recommendation is for all children younger than 13 years to ride in the rear seats of vehicles. It is important to note that every transition is associated with some decrease in protection; therefore, parents should be encouraged to delay these transitions for as long as possible. These recommendations are presented in the form of an algorithm that is intended to facilitate implementation of the recommendations by pediatricians to their patients and families and should cover most situations that pediatricians will encounter in practice. The American Academy of Pediatrics urges all pediatricians to know and promote these recommendations as part of child passenger safety anticipatory guidance at every health supervision visit.

School Bus Transportation of Children With Special Health Care Needs.

School systems are responsible for ensuring that children with special needs are safely transported on all forms of federally approved transportation provided by the school system. A plan to provide the most current and proper support to children with special transportation needs should be developed by the Individualized Education Program team, including the parent, school transportation director, and school nurse, in conjunction with physician orders and recommendations. With this statement, we provide current guidance for the protection of child passengers with specific health care needs. Guidance that applies to general school transportation should be followed, inclusive of staff training, provision of nurses or aides if needed, and establishment of a written emergency evacuation plan as well as a comprehensive infection control program. Researchers provide the basis for recommendations concerning occupant securement for children in wheelchairs and children with other special needs who are transported on a school bus. Pediatricians can help their patients by being aware of guidance for restraint systems for children with special needs and by remaining informed of new resources. Pediatricians can also play an important role at the state and local level in the development of school bus specifications.

Rear-Facing Car Safety Seat Use for Children 18 Months of Age: Prevalence and Determinants.

OBJECTIVE: To examine the prevalence and potential determinants of rear-facing car safety seat use among children approximately 18 months of age born at a university hospital. STUDY DESIGN: We administered a telephone survey to caregivers of children 17-19 months of age who were born between November 2013 and May 2014. The survey was designed to assess the prevalence of rear-facing car safety seat use and estimate the likelihood of rear-facing car safety seat use, compared with forward-facing car seat use, in reference to hypothesized determinants. aORs and 95% CIs were calculated using multivariable logistic regression. RESULTS: In total, 56% of potentially eligible caregivers (491/877) completed the survey; 62% of these reported rear-facing car safety seat use. Race, education, rurality, and household income were associated with rear-facing car safety seat use after controlling for potential confounders. Additionally, caregivers who reported having discussed car seats with their child's provider (aOR 1.7; 95% CI 1.1-2.6); receiving their child's primary care in pediatrics compared with family practice clinics (aOR 2.4; 95% CI 1.1-2.6); and being aware of the American Academy of Pediatrics rear-facing recommendation (aOR 2.8; 95% CI 1.8-4.1) were significantly more likely to report rear-facing car safety seat use. Conversely, caregivers who previously used a car seat with another child were less likely to have their child rear facing at 18 months of age (aOR 0.6; 95% CI 0.4-0.9). CONCLUSIONS: A large proportion of children were forward facing at 18 months of age. Future efforts focused on encouraging providers to discuss car seats during patient visits, increasing awareness of the American Academy of Pediatrics' rear-facing recommendation, and targeting high-risk populations may improve the prevalence of children who remain rear facing until 2 years of age.

How Do US Pediatric Residency Programs Teach and Evaluate Community Pediatrics and Advocacy Training?

OBJECTIVE: In 2013, the Accreditation Council for Graduate Medical Education updated requirements for training in community pediatrics and advocacy in pediatric residency programs. In light of this update, the aim of this study was to better understand how community pediatrics is being taught and evaluated in pediatric residency programs in the United States. METHODS: Cross-sectional exploratory study using a Web-based survey of pediatric residency program directors in September 2014. Questions focused on teaching and evaluation of 10 community pediatrics competencies. RESULTS: Of 85 programs (43% response rate), 30% offered a separate training track and/or 6-block individualized curriculum in community pediatrics or advocacy. More than 75% required all residents to learn 7 of 10 competencies queried. Respondents in urban settings were more likely to teach care of special populations (P = .02) and public speaking (P < .01). Larger programs were more likely to teach (P = .04) and evaluate (P = .02) community-based research. Experiential learning and classroom-based didactics were the most frequent teaching methodologies. Many programs used multiple teaching methodologies for all competencies. Observation was the most frequent evaluation technique used; portfolio review and written reflection were also commonly reported. CONCLUSIONS: Our findings show a strong emphasis on community pediatrics and advocacy teaching among responding US pediatric residency programs. Although respondents reported a variety of teaching and evaluation methods, there were few statistically significant differences between programs.

The Community Pediatrics Training Initiative Project Planning Tool: A Practical Approach to Community-Based Advocacy.

Introduction: To impact social determinants of health, physicians require knowledge, skills, and attitudes to work with communities beyond the clinical milieu. The American Academy of Pediatrics (AAP) Community Pediatrics Training Initiative (CPTI) project planning tool can guide health care professionals and trainees to identify and define issues, build coalitions, assess interventions, and ensure sustainability of successful programs. The Accreditation Council for Graduate Medical Education guidelines for pediatric training require experiences in community health. To date, there have been no widely available tools to ensure both robust learning and validated assessment for pediatric residents in community pediatrics and advocacy training. Methods: The AAP CPTI project planning tool engages learners with a step-by-step process involving investigation, guided reflection, and structured assessment. Learners practice the skills necessary to plan, implement, and evaluate a community pediatrics/child health advocacy proposal focused upon a learner-defined area of interest. An assessment rubric maps to milestones. Results: This project planning tool has been used in a number of programs with learners at multiple levels, including undergraduate education, graduate education, and practicing health care providers. It can be employed to design and implement a community advocacy intervention or as a thought exercise and can be incorporated in a single block rotation or as a longitudinal experience. It can be used with individual learners or as a group exercise. Discussion: The project planning tool can be used by residency programs to demonstrate resident competence in community health and advocacy, either as a learning exercise or to guide actual implemented projects.

Unsafe from the Start: Serious Misuse of Car Safety Seats at Newborn Discharge.

OBJECTIVE: To estimate prevalence of car safety seat (CSS) misuse for newborns on hospital discharge; and to identify potential risk and protective factors for CSS misuse. STUDY DESIGN: We randomly sampled 291 mother-baby dyads from the newborn unit of an academic health center. Participants completed a survey and designated someone (themselves or another caregiver) to position their newborn in the CSS and install the CSS in their vehicle. Certified child passenger safety technicians assessed positioning and installation using nationally standardized criteria. To examine factors associated with CSS misuse, we used logistic regression to compute ORs and 95% CIs. RESULTS: A total of 291 families (81% of those eligible) participated. Nearly all (95%) CSSs were misused, with 1 or more errors in positioning (86%) and/or installation (77%). Serious CSS misuse occurred for 91% of all infants. Frequent misuses included harness and chest clip errors, incorrect recline angle, and seat belt/lower anchor use errors. Families with mothers of color (OR, 6.3; 95% CI, 1.8-21.6), non-English language (OR, 4.9; 95% CI, 1.1-21.2), Medicaid (OR, 10.3; 95% CI, 2.4-44.4), or lower educational level (OR, 4.5; 95% CI, 1.7-12.4) were more likely to misuse CSSs. However, families that worked with a child passenger safety technician before delivery were significantly less likely to misuse their CSSs (OR, 0.1; 95% CI, 0.0-0.4). CONCLUSION: Nearly all parents of newborn infants misused CSSs. Resources should be devoted to ensuring families with newborns leave the hospital correctly using their CSS.

Toward a centralized database for child safety centers: Results of a feasibility pilot study.

BACKGROUND: Safety centers (SCs) are hospital-affiliated outlets that provide families with safety products and personalized education about preventing injuries. Roughly 40 SCs are in operation across the United States, but no single model for staffing, supplying, or sustaining them has emerged. The project aimed to determine the feasibility of a centralized database for SC evaluation as the first step toward growing this proven intervention. METHODS: An Expert Advisory Committee was convened to determine data collection elements and procedures. Representatives from nine hospital-based SCs collected data about car seat and bike helmet sales and education provided between August 1, 2013, to December 31, 2013. RESULTS: A total of 645 study-related safety products were distributed at cost (72%), below cost (10%), or for free (19%). Education was provided for 96% of all products distributed, including receipt of print materials (81%) and product demonstrations (83%). Visitors to SCs were usually referred by a hospital provider (34%), followed by word of mouth (24%) and walk-in (22%). Seven of nine SCs were able to contribute data. Stability of SCs and capacity of staff emerged as facilitators of centralized data collection feasibility. CONCLUSION: We demonstrate that centralized data collection is feasible and that information to compare centers can be obtained. However, for more meaningful comparisons to emerge and to enable all SCs the ability to participate, support is needed institutionally for staff to be able to capture data and nationally to grow and sustain a database that represents the broader diversity of topics and services offered.

Preventing gun injuries in children.

Firearms are involved in the injury and death of a large number of children each year from both intentional and unintentional causes. Gun ownership in homes with children is common, and pediatricians should incorporate evidence-based means to discuss firearms and protect children from gun-related injuries and violence. Safe storage of guns, including unloaded guns locked and stored separately from ammunition, can decrease risks to children, and effective tools are available that pediatricians can use in clinical settings to help decrease children's access to firearms. Furthermore, several community-based interventions led by pediatricians have effectively reduced firearm-related injury risks to children. Educational programs that focus on children's behavior around guns have not proven effective.

Using self-determination theory to improve residency training: learning to make omelets without breaking eggs.

An inherent tension exists in clinical training between supervising learners to ensure quality and patient safety, and allowing learners to practice independently to gain experience. In this issue of Academic Medicine, Biondi and colleagues discuss this tension, highlighting the disconnect between faculty and resident perceptions of autonomous practice for housestaff. They report that each group perceives itself as more competent in its role than does the other group. Their work leads us to consider how medical educators might safely and effectively transform the learning process. Self-determination theory (SDT) holds that there is a human tendency to develop toward self-directed and autonomous regulation of behavior. This development of intrinsic motivation is governed by the complex relationships among autonomy, competence, and relatedness as well as educational content and the learning milieu. Applying an SDT framework to their findings, Biondi and colleagues report that faculty desire from residents the evidence of internal motivation and demonstration of competence and self-confidence that will allow faculty to entrust learners with autonomy. They conclude, however, that these are qualities that faculty find lacking in many residents. To optimize the balance between autonomy and supervision, this Commentary's author proposes the use of "scaffolding," a construct from developmental psychology. In the scaffolding model, the role of teachers is to support the learner's development and to provide support structures to help the learner get to the next stage of entrustment and competence. Achieving a balance is essential to providing the best patient care now and in the future.

Pediatricians' self-reported knowledge, attitudes, and practices about child passenger safety.

OBJECTIVE: To evaluate pediatricians' self-reported knowledge, attitudes, and dissemination practices regarding the new American Academy of Pediatrics' (AAP) child passenger safety (CPS) policy recommendations. STUDY DESIGN: A cross-sectional survey was distributed to pediatric primary care physicians via AAP e-mail distribution lists. Knowledge, attitudes, and practices related to current AAP CPS recommendations and the revised policy statement were ascertained. RESULTS: There were 718 respondents from 3497 physicians with active e-mail addresses, resulting in a 20.5% response rate, of which 533 were eligible based on the initial survey question. All 6 CPS knowledge and scenario-based items were answered correctly by 52.9% of the sample; these respondents were identified as the "high knowledge" group. Pediatricians with high knowledge were more likely to be female (P < .001), to have completed a pediatrics residency (vs medicine-pediatrics) (P = .03), and have a child between 4 and 7 years of age (P = .001). CPS information was distributed more frequently at routine health visits for patients 0-2 years of age vs those 4-12 years of age. Those with high knowledge were less likely to report several specific barriers to dissemination of CPS information, more likely to allot adequate time and discuss CPS with parents, and had greater confidence for topics related to all CPS topics. CONCLUSIONS: Although CPS knowledge is generally high among respondents, gaps in knowledge still exist. Knowledge is associated with attitudes, practices, barriers, and facilitators of CPS guideline dissemination. These results identify opportunities to increase knowledge and implement strategies to routinely disseminate CPS information in the primary care setting.