Discrepancies Between Caregiver Reported Early Childhood Sleep Problems and Clinician Documentation and Referral.

OBJECTIVE: The American Academy of Pediatrics recommends routine sleep problem screenings during child well-visits. However, studies suggest a discrepancy between caregiver- and clinician-reported child sleep problems. The present study examines whether caregiver-reported child sleep problems (ie, habitual snoring, insomnia symptoms, poor sleep health) and clinician-documented child sleep problems and management are congruent. METHODS: The sample included 170 caregiver-child dyads (child Mage = 3.3 years, range = 2-5 years; 56.5% girls; 64.1% Black, 20.0% non-Latinx White, and 4.1% Latinx; 86.5% maternal caregiver reporter). Caregivers' questionnaire-based reports of habitual snoring, insomnia symptoms, and sleep health behaviors (nighttime electronics, caffeine intake, insufficient sleep) were compared with clinician documentation in the electronic health record. RESULTS: About 92.3% of children had at least 1 caregiver-reported sleep problem (66% insomnia symptoms, 64% electronics, 38% insufficient sleep, 21% caffeine, 17% snoring). In contrast, a substantially lower percent of children had a clinician documented sleep problem (20% overall; 10% insomnia symptoms, 7% electronics, 0% insufficient sleep, 3% caffeine, 4% snoring), sleep-related referral (1% overall; 0.6% Otolaryngology, 0.6% polysomnogram, 0% sleep clinic), or recommendation (12% overall; 8% insomnia symptoms, 4% electronics, 0% insufficient sleep, 1% caffeine). CONCLUSIONS: There is a vast discrepancy between caregiver-reported child sleep problems and clinician-documented sleep problems and management, with a higher proportion of caregiver reports. To benefit overall child health and well-being, future research and quality improvement initiatives should focus on enhancing screening tools and educational opportunities to improve clinician documentation and enhance family conversations about early childhood sleep problems.

Trends in Positive Depression and Suicide Risk Screens in Pediatric Primary Care During COVID-19.

OBJECTIVE: Adolescent mental health concerns increased during COVID-19, but it is unknown whether early increases in depression and suicide risk have been sustained. We examined changes in positive screens for depression and suicide risk in a large pediatric primary care network through May 2022. METHODS: Using an observational repeated cross-sectional design, we examined changes in depression and suicide risk during the pandemic using electronic health record data from adolescents. Segmented logistic regression was used to estimate risk differences (RD) for positive depression and suicide risk screens during the early pandemic (June 2020-May 2021) and late pandemic (June 2021-May 2022) relative to before the pandemic (March 2018-February 2020). Models adjusted for seasonality and standard errors accounted for clustering by practice. RESULTS: Among 222,668 visits for 115,627 adolescents (mean age 15.7, 50% female), the risk of positive depression and suicide risk screens increased during the early pandemic period relative to the prepandemic period (RD, 3.8%; 95% CI, 2.9, 4.8; RD, 2.8%; 95% CI, 1.7, 3.8). Risk of depression returned to baseline during the late pandemic period, while suicide risk remained slightly elevated (RD, 0.7%; 95% CI, -0.4, 1.7; RD, 1.8%; 95% CI, 0.9%, 2.7%). CONCLUSIONS: During the early months of the pandemic, there was an increase in positive depression and suicide risk screens, which later returned to prepandemic levels for depression but not suicide risk. Results suggest that pediatricians should continue to prioritize screening adolescents for depressive symptoms and suicide risk and connect them to treatment.

Engineering a mobile platform to promote sleep in the pediatric primary care setting.

STUDY OBJECTIVES: Pediatricians lack tools to support families at home for the promotion of childhood sleep. We are using the Multiphase Optimization Strategy (MOST) framework to guide the development of a mobile health platform for childhood sleep promotion. The objective of this study is to demonstrate feasibility of a mobile health platform towards treating children with insufficient sleep. METHODS: Children aged 10-12 years were enrolled (Study #1: N = 30; Study #2: N = 43). Participants wore a sleep tracker to measure sleep duration. Data were retrieved by a mobile health platform, programmed to send introductory messages during run-in (2 weeks) and goal achievement messages during intervention (7 weeks) periods. In study #1, participants were randomized to control, gain-framed incentive or loss-framed incentive arms. In study #2, participants were randomized to control, loss-framed incentive, normative feedback or loss-framed incentive plus normative feedback arms. RESULTS: In study #1, 1514 nights of data were captured (69%) and sleep duration during the intervention was higher by an average of 21 (95% CI: -8, 51) and 34 (95% CI: 7, 61) minutes per night for the gain-framed and loss-framed arms, respectively, compared to controls. In study #2, 2,689 nights of data were captured (81%), with no major differences in average sleep duration between the control and the loss-framed or normative feedback arms. CONCLUSIONS: We have developed and deployed a mobile health platform that can capture sleep data and remotely communicate with families. Promising candidate intervention components will be further investigated under the optimization phase of the MOST framework. CLINICAL TRIALS: Both studies included in this manuscript were registered at clinicaltrials.gov:-Study #1: NCT03263338-Study #2: NCT03426644.

Associations of the residential built environment with adolescent sleep outcomes.

STUDY OBJECTIVES: Over 75% of US high school students obtain insufficient sleep, placing them at risk for adverse health outcomes. Identification of modifiable determinants of adolescent sleep is needed to inform prevention strategies, yet little is known about the influence of the built environment on adolescent sleep. METHODS: In this prospective study, actigraphy was used to assess sleep outcomes among 110 adolescents for 14 days each in eighth and ninth grades: duration (hours/night), onset and offset, and sleeping ≥8 hours. Home addresses were linked to built environment exposures: sound levels, tree canopy cover, street density, intersection density, population density, and housing density. Mixed-effects regression estimated associations of built environment measures with sleep outcomes, adjusting for sex, race, parent education, household income, household size, grade, weeknight status, and neighborhood poverty. RESULTS: A 1-standard deviation (SD) increase in neighborhood sound was associated with 16 minutes later sleep onset (ß = 0.28; 95% confidence interval (CI): 0.06, 0.49) and 25% lower odds of sleeping for ≥8 hours (odds ratio (OR) = 0.75, 95% CI: 0.59, 0.96). A 1-SD increase in neighborhood tree canopy was associated with 18 minutes earlier sleep onset (ß = -0.31, 95% CI: -0.49, -0.13) and 10 minutes earlier sleep offset (ß= -0.17, 95% CI: -0.28, -0.05). No associations were observed for density-based exposures. CONCLUSIONS: Higher neighborhood sound level was associated with lower odds of sufficient sleep, while higher tree canopy cover was associated with more favorable sleep timing. Neighborhood sound levels and tree canopy cover are potential targets for policies and interventions to support healthier sleep among adolescents.

A Social Media Peer Group for Mothers To Prevent Obesity from Infancy: The Grow2Gether Randomized Trial.

BACKGROUND: Few studies have addressed obesity prevention among low-income families whose infants are at increased obesity risk. We tested a Facebook peer-group intervention for low-income mothers to foster behaviors promoting healthy infant growth. METHODS: In this randomized controlled trial, 87 pregnant women (Medicaid insured, BMI ≥25 kg/m2) were randomized to the Grow2Gether intervention or text message appointment reminders. Grow2Gether participants joined a private Facebook group of 9-13 women from 2 months before delivery until infant age 9 months. A psychologist facilitated groups featuring a curriculum of weekly videos addressing feeding, sleep, parenting, and maternal well-being. Feasibility was assessed using the frequency and content of participation, and acceptability using surveys. Maternal beliefs and behaviors and infant growth were assessed at birth, 2, 4, 6, and 9 months. Differences in infant growth between study arms were explored. We conducted intention-to-treat analyses using quasi-least-squares regression. RESULTS: Eighty-eight percent (75/85) of intervention participants (42% (36/85) food insecure, 88% (75/85) black) reported the group was helpful. Participants posted 30 times/group/week on average. At 9 months, the intervention group had significant improvement in feeding behaviors (Infant Feeding Style Questionnaire) compared to the control group (p = 0.01, effect size = 0.45). Intervention group mothers were significantly less likely to pressure infants to finish food and, at age 6 months, give cereal in the bottle. Differences were not observed for other outcomes, including maternal feeding beliefs or infant weight-for-length. CONCLUSIONS: A social media peer-group intervention was engaging and significantly impacted certain feeding behaviors in families with infants at high risk of obesity.

Clinical Decision Support Tool for Parental Tobacco Treatment in Hospitalized Children.

OBJECTIVES: To create and evaluate the feasibility, acceptability, and usability of a clinical decision support (CDS) tool within the electronic health record (EHR) to help pediatricians provide smoking cessation counseling and treatment to parents of hospitalized children exposed to secondhand smoke (SHS). METHODS: Mixed method study of first-year pediatric residents on one inpatient unit. Residents received training in smoking cessation counseling, nicotine replacement therapy (NRT) prescribing, and use of a CDS tool to aid in this process. The tool, which alerted when a patient was identified as exposed to SHS based on the history taken on admission or during a prior encounter, had the following capabilities: adding SHS exposure to the patient's problem list; referral to Free Quitline through discharge instructions; and linking to a printable NRT prescription form. We measured feasibility by EHR utilization data. We measured acceptability and usability of the tool by administering questionnaires to residents. RESULTS: From June-August 2015, the alert triggered for 106 patients, and the tool was used for 52 (49%) patients. 41 (39%) patients had SHS exposure added to the problem list, 34 (32%) parents were referred to the Quitline through discharge instructions, and 15 (14%) parents were prescribed NRT. 10 out of 15 (67%) eligible pediatricians used the tool. All clinicians surveyed (9 out of 10) found the tool acceptable and rated its usability good to excellent (average System Usability Scale score was 85 out of 100, 95% CI, 76-93). CONCLUSIONS: A non-interruptive CDS tool to help residents provide smoking cessation counseling in the hospital was feasible, acceptable, and usable. Future work will investigate impacts on patient outcomes.

Imputing Missing Race/Ethnicity in Pediatric Electronic Health Records: Reducing Bias with Use of U.S. Census Location and Surname Data.

OBJECTIVE: To assess the utility of imputing race/ethnicity using U.S. Census race/ethnicity, residential address, and surname information compared to standard missing data methods in a pediatric cohort. DATA SOURCES/STUDY SETTING: Electronic health record data from 30 pediatric practices with known race/ethnicity. STUDY DESIGN: In a simulation experiment, we constructed dichotomous and continuous outcomes with pre-specified associations with known race/ethnicity. Bias was introduced by nonrandomly setting race/ethnicity to missing. We compared typical methods for handling missing race/ethnicity (multiple imputation alone with clinical factors, complete case analysis, indicator variables) to multiple imputation incorporating surname and address information. PRINCIPAL FINDINGS: Imputation using U.S. Census information reduced bias for both continuous and dichotomous outcomes. CONCLUSIONS: The new method reduces bias when race/ethnicity is partially, nonrandomly missing.