Prescribing Patterns of Nonrecommended Medications for Children With Acute COVID-19.

OBJECTIVE: Repurposed medications for acute coronavirus disease 2019 (COVID-19) continued to be prescribed after results from rigorous studies and national guidelines discouraged use. We aimed to describe prescribing rates of nonrecommended medications for acute COVID-19 in children, associations with demographic factors, and provider type and specialty. METHODS: In this retrospective cohort of children <18 years in a large United States all-payer claims database, we identified prescriptions within 2 weeks of an acute COVID-19 diagnosis. We calculated prescription rate, performed multivariable logistic regression to identify risk factors, and described prescriber type and specialty during nonrecommended periods defined by national guidelines. RESULTS: We identified 3 082 626 COVID-19 diagnoses in 2 949 118 children between March 7, 2020 and December 31, 2022. Hydroxychloroquine (HCQ) and ivermectin were prescribed in 0.03% and 0.14% of COVID-19 cases, respectively, during nonrecommended periods (after September 12, 2020 for HCQ and February 5, 2021 for ivermectin) with considerable variation by state. Prescription rates were 4 times the national average in Arkansas (HCQ) and Oklahoma (ivermectin). Older age, nonpublic insurance, and emergency department or urgent care visit were associated with increased risk of either prescription. Additionally, residence in nonurban and low-income areas was associated with ivermectin prescription. General practitioners had the highest rates of prescribing. CONCLUSIONS: Although nonrecommended medication prescription rates were low, the overall COVID-19 burden translated into high numbers of ineffective and potentially harmful prescriptions. Understanding overuse patterns can help mitigate downstream consequences of misinformation. Reaching providers and parents with clear evidence-based recommendations is crucial to children's health.

Impact of COVID-19 on the Health of Migrant Children in the United States: From Policy to Practice.

In this article, the authors provide an overview how the COVID-19 pandemic impacted the health and wellbeing of migrant children in conflict zones, in transit and post-settlement in the United States. In particular, the authors explore how policies implemented during the pandemic directly and indirectly affected migrant children and led to widening disparities in the aftermath of the pandemic. Given these circumstances, the authors provide recommendations for child health care providers caring for migrant children to mitigate and bolster resilience and health.

Intraoperative Prophylaxis with Palonosetron for Postoperative Nausea and/or Vomiting in Adults Undergoing Cardiothoracic Surgery Under General Anesthesia: A Single-Center Retrospective Study.

OBJECTIVE: This study assessed the efficacy of palonosetron, alone or with dexamethasone, in reducing postoperative nausea and/or vomiting (PONV) and its impact on hospitalization duration in patients who undergo adult cardiothoracic surgery (CTS) under general anesthesia. DESIGN: This retrospective analysis involved 540 adult patients who underwent CTS from a single-center cohort, spanning surgeries between September 2021 and March 2023. Sensitivity, logistic, and Cox regression analyses evaluated antiemetic effects, PONV risk factors, and outcomes. SETTING: At the Virginia Mason Medical Center (VMMC), Seattle, WA. PARTICIPANTS: Adults undergoing cardiothoracic surgery at VMMC during the specified period. INTERVENTIONS: Patients were categorized into the following 4 groups based on antiemetic treatment: dexamethasone, palonosetron, dexamethasone with palonosetron, and no antiemetic. MEASUREMENTS AND MAIN RESULTS: Primary outcomes encompassed PONV incidence within 96 hours postoperatively. Secondary outcomes included intensive care unit stay duration and postoperative opioid use. Palonosetron recipients showed a significantly lower PONV rate of 42% (v controls at 63%). The dexamethasone and palonosetron combined group also demonstrated a lower rate of 40%. Sensitivity analysis revealed a notably lower 0- to 12-hour PONV rate for palonosetron recipients (9% v control at 28%). Logistic regression found decreased PONV risk (palonosetron odds ratio [OR]: 0.24; dexamethasone and palonosetron OR: 0.26). Cox regression identified varying PONV hazard ratios related to female sex, PONV history, and lower body mass index. CONCLUSIONS: This single-center retrospective study underscored palonosetron's efficacy, alone or combined with dexamethasone, in managing PONV among adult patients who undergo CTS. These findings contribute to evolving antiemetic strategies in cardiothoracic surgery, potentially impacting patient outcomes and satisfaction positively.

Pediatric advocacy: Advancement in academic institutions.

IMPACT: Children are facing many threats to their health today that require system change at a sweeping level to have real-world impact. Pediatricians are positioned as natural leaders to advocate for these critical community and policy changes. Academic medical center (AMC) leaders recognize the importance of this advocacy and clear steps can be taken to improve the structure to support pediatricians in their advocacy careers through faculty development and promotion, including standardized scholarly measurement of the outcomes.

Cancer center-based follow-up among pediatric and adolescent/young adult cancer survivors: the role of a community-based organization and the social determinants of health.

PURPOSE: Adherence to survivorship care is suboptimal among pediatric and adolescent/young adult (AYA) cancer survivors. We evaluated predictors of cancer center-based follow-up among pediatric/AYA cancer survivors, with an emphasis on social determinants of health (SDOH). METHODS: This retrospective cohort study used electronic health record data at an academic medical center to identify patients aged 0-29 years at last cancer treatment who completed treatment 2010-2019. Cancer center-based follow-up was defined by oncology or survivorship clinic visits through 12/31/2022. Multivariate logistic regression models (overall, ages 0-19 [pediatric], 20-29 [YA]) evaluated the association of demographics, clinical/treatment characteristics, and SDOH (insurance type, distance to cancer center, area deprivation index) with clinic attendance. Further modeling accounted for the service area of a community-based organization (CBO) that supports families of children with cancer. RESULTS: A total of 2210 survivors were included (56% pediatric, 44% YA; 66% non-White). Cancer center-based follow-up decreased from 94% 1-year post-treatment to 35% at > 5-7 years. In adjusted analysis, AYAs had the lowest follow-up (5-7 years post-treatment: OR 0.25 [0.15-0.41] for age 25-29; OR 0.25 [0.16-0.41] for age 20-24; OR 0.32 [0.20-0.52] for age 15-19). Survivors residing within the CBO service area were twice as likely to follow-up (OR 2.10 [1.34-3.29]). CONCLUSIONS: Among a diverse population, AYA survivors were vulnerable to loss to follow-up. Other SDOH were not consistently associated with follow-up. Support from a CBO may partly explain these findings. IMPLICATIONS FOR CANCER SURVIVORS: CBOs may strengthen survivorship follow-up within medically underserved communities. More research is needed to understand community support in survivorship.

Making Advocacy Part of Your Job: Working for Children in Any Practice Setting.

Effective child health advocacy is an essential strategy to improve child health, and can improve access to equitable care. It can also be professionally rewarding and improve career satisfaction. However, while advocacy has been a part of pediatrics since its origins as a specialty, many barriers to engaging in health advocacy exist which can be challenging to navigate. There are a wide range of organizational practice settings, which are each accompanied by unique strengths and limitations. No matter the practice setting, pediatricians can be effective advocates for child health through leveraging organizational, professional, and community resources and partnerships.

Sparking a Movement, Not a Moment: Framework and Outcomes From a Pediatrics Department-Wide Coalition to Advance Anti-Racism.

OBJECTIVE: The Stanford Pediatrics Advancing Anti-Racism Coalition (SPAARC) was created to promote a culture of anti-racism through immediate action, development of nimble systems, and longitudinal commitment toward equity. Evaluate gaps in the Stanford Department of Pediatrics (DoP) efforts to advance anti-racism and form a coalition of faculty, staff, and trainees to prioritize, design, and implement targeted activities with immediate and long-term measurable outcomes. METHODS: A needs assessment was conducted across all DoP members in July to August 2020 to identify gaps in anti-racism efforts. Listening sessions were recorded and transcribed to extrapolate key themes and 2 rounds of consensus surveys were done to identify and prioritize actions. Actions teams were created and co-led by faculty-staff dyads with trainee representation. A final activity survey was conducted in January 2021 to determine the specific activities (ie, interventions) each team would design and implement. RESULTS: Ten small group listening sessions (70 participants) and 3 surveys (1005 responses) led to the creation of 7 action teams with associated activities 1) training, 2) community engagement and research, 3) communication, 4) faculty and staff recruitment and advancement, 5) leadership representation, 6) human resources, and 7) staff engagement. Four hundred forty-three (41%) DoP members were directly involved in SPAARC through participation in the needs assessment, action teams, and/or implementation of activities. CONCLUSION: SPAARC can serve as an adaptable framework for how a DoP can create a coalition to identify gaps in anti-racism efforts and create and implement targeted activities with associated outcomes.

Meeting the Needs of Postpartum Women: Provider Perspectives on Maternal Contraceptive Care in Pediatric Settings.

OBJECTIVE: Closely spaced, mistimed, and unwanted pregnancies are common among postpartum women and can lead to adverse maternal and perinatal outcomes. Women inconsistently attend postpartum obstetric visits, though they reliably interface with pediatric providers during the postpartum months, presenting novel opportunities to identify and address unmet family planning needs. METHODS: We conducted a qualitative study to explore pediatric provider perspectives on addressing maternal family planning in three settings: a neonatal intensive care unit, a primary care clinic, and a high-risk infant follow-up clinic. RESULTS: Pediatric providers were generally open to incorporating postpartum family planning screening and counseling into a pediatric encounter, if given appropriate training and implementation support. Providers largely agreed that contraceptive provision to women was not feasible in their practices, and they shared ideas for utilizing the pediatric encounter to connect women with comprehensive contraceptive care. CONCLUSION: Pediatric providers perceived postpartum family planning screening and counseling, and not contraceptive provision, as potentially acceptable and feasible in their practice settings. These exploratory findings justify further investigation to assess their generalizability and to develop postpartum family planning interventions for pediatrics.

Population health science as a unifying foundation for translational clinical and public health research.

Separated both in academics and practice since the Rockefeller Foundation effort to "liberate" public health from perceived subservience to clinical medicine a century ago, research in public health and clinical medicine have evolved separately. Today, translational research in population health science offers a means of fostering their convergence, with potentially great benefit to both domains. Although evidence that the two fields need not and should not be entirely distinct in their methods and goals has been accumulating for over a decade, the prodigious efforts of biomedical and social sciences over the past year to address the COVID-19 pandemic has placed this unifying approach to translational research in both fields in a new light. Specifically, the coalescence of clinical and population-level strategies to control disease and novel uses of population-level data and tools in research relating to the pandemic have illuminated a promising future for translational research. We exploit this unique window to re-examine how translational research is conducted and where it may be going. We first discuss the transformation that has transpired in the research firmament over the past two decades and the opportunities these changes afford. Next, we present some of the challenges-technical, cultural, legal, and ethical- that need attention if these opportunities are to be successfully exploited. Finally, we present some recommendations for addressing these challenges.

The Impact of Telehealth Adoption During COVID-19 Pandemic on Patterns of Pediatric Subspecialty Care Utilization.

OBJECTIVE: The COVID-19 pandemic prompted health systems to rapidly adopt telehealth for clinical care. We examined the impact of demography, subspecialty characteristics, and broadband availability on the utilization of telehealth in pediatric populations before and after the early period of the COVID-19 pandemic. METHODS: Outpatients scheduled for subspecialty visits at sites affiliated with a single quaternary academic medical center between March-June 2019 and March-June 2020 were included. The contribution of demographic, socioeconomic, and broadband availability to visit completion and telehealth utilization were examined in multivariable regression analyses. RESULTS: Among visits scheduled in 2020 compared to 2019, in-person visits fell from 23,318 to 11,209, while telehealth visits increased from 150 to 7,675. Visits among established patients fell by 15% and new patients by 36% (P < .0001). Multivariable analysis revealed that completed visits were reduced for Hispanic patients and those with reduced broadband; high income, private non-HMO insurance, and those requesting an interpreter were more likely to complete visits. Those with visits scheduled in 2020, established patients, those with reduced broadband, and patients older than 1 year were more likely to complete TH appointments. Cardiology, oncology, and pulmonology patients were less likely to complete scheduled TH appointments. CONCLUSIONS: Following COVID-19 onset, outpatient pediatric subspecialty visits shifted rapidly to telehealth. However, the impact of this shift on social disparities in outpatient utilization was mixed with variation among subspecialties. A growing reliance on telehealth will necessitate insights from other healthcare settings serving populations of diverse social and technological character.

Kinder Ready Clinics: A Collaborative Model for Creating Equitable and Engaged Early Learning Environments for Low-income Families.

Disparities in children's school readiness (SR) in the U.S. are well-documented and have detrimental long-term consequences. Clinic-based early education interventions are limited. This report summarizes collaborative efforts of pediatricians and community stakeholders to develop and implement clinic-based interventions to promote early learning and SR among low-income children.

Poverty Related Education in Pediatrics: Current State, Gaps and Call to Action.

Children are the poorest age group in our country, with 1 in 6, or 12 million, living in poverty. This sobering statistic became even more appalling in spring 2020 when COVID-19 magnified existing inequities. These inequities are particularly important to pediatricians, because poverty, along with racism and other interrelated social factors, significantly impact overall child health and well-being. It is imperative that pediatric educators redouble their efforts to train learners to recognize and address health inequities related to poverty and all of its counterparts. In this paper, we describe the current state of poverty-related training in pediatric undergraduate, graduate, and continuing medical education as well as opportunities for growth. We highlight gaps in the current curricula, particularly around the intersectionality between poverty and racism, as well as the need for robust evaluation. Using a logic model framework, we outline content, learning strategies, and outcomes for poverty-related education. We include opportunities for the deployment of best practice learning strategies and the incorporation of newer technologies to deliver the content. We assert that collaboration with community partners is critical to shape the depth and breadth of education. Finally, we emphasize the paramount need for high-quality faculty development and accessible career paths to create the cadre of role models and mentors necessary to lead this work. We conclude with a call for collaboration between institutions, accrediting bodies, and policymakers to promote meaningful, outcome-oriented, poverty-related education, and training throughout the medical education continuum.

Anti-Poverty Medicine Through Medical-Financial Partnerships: A New Approach to Child Poverty.

Poverty threatens child health. In the United States, financial strain, which encompasses income and asset poverty, is common with many complex etiologies. Even relatively successful antipoverty programs and policies fall short of serving all families in need, endangering health. We describe a new approach to address this pervasive health problem: antipoverty medicine. Historically, medicine has viewed poverty as a social problem outside of its scope. Increasingly, health care has addressed poverty's downstream effects, such as food and housing insecurity. However, strong evidence now shows that poverty affects biology, and thus, merits treatment as a medical problem. A new approach uses Medical-Financial Partnerships (MFPs), in which healthcare systems and financial service organizations collaborate to improve health by reducing family financial strain. MFPs help families grow assets by increasing savings, decreasing debt, and improving credit and economic opportunity while building a solid foundation for lifelong financial, physical, and mental health. We review evidence-based approaches to poverty alleviation, including conditional and unconditional cash transfers, savings vehicles, debt relief, credit repair, financial coaching, and employment assistance. We describe current national MFPs and highlight different applications of these evidence-based clinical financial interventions. Current MFP models reveal implementation opportunities and challenges, including time and space constraints, time-sensitive processes, lack of familiarity among patients and communities served, and sustainability in traditional medical settings. We conclude that pediatric health care practices can intervene upon poverty and should consider embracing antipoverty medicine as an essential part of the future of pediatric care.

A Text-Based Intervention to Promote Literacy: An RCT.

BACKGROUND AND OBJECTIVES: Children entering kindergarten ready to learn are more likely to thrive. Inequitable access to high-quality, early educational settings creates early educational disparities. TipsByText, a text-message-based program for caregivers of young children, improves literacy of children in preschool, but efficacy for families without access to early childhood education was unknown. METHODS: We conducted a randomized controlled trial with caregivers of 3- and 4-year-olds in 2 public pediatric clinics. Intervention caregivers received TipsByText 3 times a week for 7 months. At pre- and postintervention, we measured child literacy using the Phonological Awareness Literacy Screening Tool (PALS-PreK) and caregiver involvement using the Parent Child Interactivity Scale (PCI). We estimated effects on PALS-PreK and PCI using multivariable linear regression. RESULTS: We enrolled 644 families, excluding 263 because of preschool participation. Compared with excluded children, those included in the study had parents with lower income and educational attainment and who were more likely to be Spanish speaking. Three-quarters of enrollees completed pre- and postintervention assessments. Postintervention PALS-PreK scores revealed an unadjusted treatment effect of 0.260 (P = .040); adjusting for preintervention score, child age, and caregiver language, treatment effect was 0.209 (P = .016), equating to ∼3 months of literacy gains. Effects were greater for firstborn children (0.282 vs 0.178), children in 2-parent families (0.262 vs 0.063), and 4-year-olds (0.436 vs 0.107). The overall effect on PCI was not significant (1.221, P = .124). CONCLUSIONS: The health sector has unique access to difficult-to-reach young children. With this clinic-based texting intervention, we reached underresourced families and increased child literacy levels.